A recent review in JAMA, titled “Primary Care Management of Non-English-Speaking Refugees Who Have Experienced Trauma” contains a Table labeled “Physical Torture Techniques (August 7, 2013, Vol 310, Number 5).
Most of us have heard of some of these “techniques,” but when spelled out in a bland table in a medical journal, as it is in this article, it is simply appalling. These are things that man does to his fellow man. I think it is instructive to reproduce the list here because we need to know that these things happen to people that we clinicians care for in the everyday practice of medicine.
Physical Torture Techniques
Conditions of Detention:
- Containment in a cage
- Deprivation of food and water
- Deprivation of sanitary conditions (no toilet)
- Crowded cells
- No windows or ventilation
Methods of Physical Torture:
- Fists, kicks, canes, sticks, rifle butts
- Head trauma
- Falanga (beating to soles of feet)
- Blunt trauma to soles of feet with batons, canes
- Acute bruising, swelling, severe pain fractures
- Chronic pain, neuropathy, deformities
- Examination: pain on palpation on ball of foot, heel pad destruction)
- “Necklacing” – placement of gasoline-filled tire around neck and lighting it on fire [Although all these forms of torture are abhorrent, this one shocked me the most]
- Hot liquids
- Heated plastic
- Heated metal
- Dental trauma
- Suspension (suspended from arms or legs)
- Administration of electric shocks
- Cutting wounds from knife, bayonet or other sharp instrument
- Insertion of pins under nails
- Simulated drowning- e.g., “waterboarding” or “submarino” (head placed in water that may be contanimated with substances such as feces)
- Stress positions – forced unnatural positions for prolonged periods of time
- Sensory deprivation
- Prolonged isolation
- Sensory stimulation
- Temperature extremes (cold or hot)
- Continuous loud noises
- Continuous lights
- Sleep deprivation
- Sexual trauma
- Female genital mutilation
- Sodomy with instruments
- Direct genital trauma (blunt trauma, use of instruments such as pliers, weights applied to the scrotum)
- Mental assaults (forced nakedness)
- Forced to drink urine or human blood or eat human flesh
Nine academic references were cited as sources of this information – a number of them in a journal named simply “Torture.”
What PCPs need to know about torture
This article focused on primary care physicians taking care of non-English speaking refugees, but ordinary folks from the “civilized world” are also being subjected to these abuses – example: the kidnapping victims of Ariel Castro.
The JAMA article has another table that is instructive – a list of medical conditions and symptoms related to torture and “ill-treatment.” It ranges from chronic pain syndromes to sexually transmitted diseases to fractures and amputations. Interestingly, PTSD and other mental health conditions and symptoms do not appear in this list although we know these sequelae are common.
There are many unanswered questions when it comes to the impact of violence on human health:
- Why do we inflict violence on our fellow human beings?
- Can we prevent it? Are there effective methods of violence prevention that physicians and other clinicians ought to be applying?
- How can we recognize when someone is a victim of violence, in particular, a victim of torture?
- What are the short and long-term sequelae – both physical and psychological?
- How can we intervene to help with relief of symptoms related to the torture?
I remember a young Vietnamese refugee I took care of in the Kaiser Permanente SanFrancisco Emergency Department years ago. He lay rigidly on the gurney avoiding eye contact. Even with an interpreter, it was difficult to make any sense out of his constellation of symptoms. It wasn’t until I pulled back the sheet to do an exam and saw he was wearing his army boots that I had an inkling of what he had lived through.
Man’s inhumanity to man – all too common – is incomprehensible to most of us.