Freedom from Torture presentation by Susan Munroe

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Freedom from Torture
Susan Munroe
Chief Executive
Defence Nurses Forum Refugee Health Workshop
April 2016
Definition of torture
United Nations definition of torture incorporates these
aspects:
• severe pain and suffering
• physical and/or psychological pain
• intentionally inflicted
• committed for a specific purpose
• committed by an agent of the state, which can
include rebel factions
UN Convention Against Torture, Article 1.1
The Essential Elements:
• The intentional infliction of severe mental or physical
pain or suffering
• By or with the consent or acquiescence of the state
authorities
• For a specific purpose, such as gaining information,
punishment or intimidation
• The infliction of pain or suffering can be an act or an
omission
• Includes rape and sexual violence
• UN Convention Against Torture, Article 1.1

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Where do our clients come
from?
• Sri Lanka
• Iran
• Afghanistan
• DR Congo
• Pakistan
• Turkey
• Cameroon
• Nigeria
• Iraq
• South Sudan
66 different countries of origin in 2015
Top 10
Why are people tortured?
Who
• Teachers
• Lawyers
• Doctors
• Nurses
• Community activists
• Political activists
• Husbands/wives/
children
Why
• Punishment
• Intimidation
• Silencing
• Gaining information
• Wrong place wrong
time
Types of Torture
• Physical – beatings, contortions, suspension,
submersions, ingestion/application of noxious
substances, electric shock, burns
• Psychological – threats/humiliation to self or others,
hearing/witnessing torture of others, mock execution
• Privation – of food, drink, bedding, light, heat, medical
care, solitary confinement
• Sexual torture – up to and including rape, including
with implements such as bottles

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Common Psychological
Responses to Torture
Complex Trauma
a) Re-experiencing the trauma (flashbacks)
b) Avoidance and emotional numbing
c) Hyperarousal
d) Symptoms of depression
e) Damaged self-concept and foreshortened future
f) Dissociation, depersonalisation and atypical behaviour
g) Affect Dysregulation
Istanbul Protocol (2004); Manual on the Effective Investigation & Documentation of Torture
& Other Cruel, Inhuman or Degrading Treatment or Punishment
Common Psychological
Responses To Torture
g) Somatic complaints – pain, paralysis
h) Sexual dysfunction
I) Psychosis (delusions, hallucinations, bizarre ideation and
behaviour, paranoia)
j) Substance abuse
k) Neuropsychological impairment (cognitive, behavioural,
physical)
Istanbul Protocol (2004); Manual on the Effective Investigation &
Documentation of Torture & Other Cruel, Inhuman or Degrading
Treatment or Punishment
Common Physical Responses to Torture
Typical acute symptoms
• Bleeding, bruising
• burns from cigarettes, heated instruments or electricity
• musculoskeletal pain
• Numbness, weakness
• loss of consciousness (Brain injury)
• fractures
Istanbul Protocol (2004); Manual on the Effective
Investigation & Documentation of Torture & Other Cruel,
Inhuman or Degrading Treatment or Punishment

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Common Physical Responses to Torture
Some common chronic symptoms
• Headache
• Back pain
• Gastrointestinal symptoms
• Sexual dysfunction / STDs
• Generalised pain
• Incontinence
• Pregnancy Istanbul Protocol (2004); Manual on the Effective Investigation
& Documentation of Torture & Other Cruel, Inhuman or
Degrading Treatment or Punishment
Transition and change
Adjustment Disorder
• From a familiar to strange and alien environment
• In limbo
• Disorientation
• Confusion
• Coping with changes
• Sense of acute loss and grief
• Cultural displacement
• Uncertainty
• People coming from countries known to have human rights
abuses and civil conflict / history of detention
• Patients with unusual presentations
 Reluctance to be examined
 Repeat presentations for the same complaint
 Patients with medically unexplained symptoms
 Recurrent back pain, abdominal pain, headaches
 Non-compliance / wont engage
Patients most likely to have
experienced torture

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Survivors of torture in the UK
• 55,000 referrals since 1985
• 10% to 30% asylum seekers are torture
survivors
• 22,220 new asylum claims / year stay
• 4,000 extra Syrian refugees / year
• 2,620- 7,870 / year
• 236,000 in total in UK
Refugee Crisis
• Identification is imperative for asylum seekers and
governments, but for two very different reasons:
survivors are in need of protection and rehabilitation
whereas Governments are concerned with the control
of their borders and security issues.
• Identification can create vulnerability: where an
asylum seeker is officially identified as a survivor in one
country, this can be used against them if they claim
asylum in another country, under the Dublin
Conventions.
Refugee Crisis
• Common health problems identified among
migrants arriving into Europe include
hypothermia, influenza and psychological
distress with chronic diseases such as diabetes
also present. Access to medication is a real
problem and conditions on the route make
health conditions worse. Others are caused by
the journey itself including cuts, blisters,
stomach problems, breathing difficulties and
foot pain.

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Survivors seeking protection have a
right to:
• Freedom of movement
• Right to seek asylum
• Non-refoulement
• Right to rehabilitation
• Right to family life
• Right to privacy (including data
protection)
Assessing survivors of torture
• Difficulties in disclosing torture
– Fear
• Who to trust? How will the information be used?
• Re-detention & torture
• Family
• Being seen as a ‘bad person’ (sent back)
– Shame
Barriers to disclosure
As practitioners, we may also
unintentionally hinder disclosure:
• Fear of re-traumatising
• Worry of opening up something we might
not be able to contain (due to time, remit, etc)
• Too much – already heard too many
traumatic stories, can’t handle any more
– Vicarious trauma
• Disbelief

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Consequences of failing to
identify torture
• Psychosis
• Complex PTSD
• Social isolation
• High health
services use
• Suicide attempts
• Homelessness
• Unemployment
• Dependency on
social services and
welfare benefits
• Child safeguarding
issues
• Domestic violence
• Radicalisation
Benefits of early intervention
Early assessment of psychological and
physical health needs and intervention:
• Stabilisation of symptoms
• Engagement – building trust
• Identification of risk
• Referral options to network of support
• Earlier reintegration
Freedom from Torture
outcomes
• ALOS 2 years 8 months
• MOCO (Measurement Of Clinical
Outcomes) tool
• Kolbassia’s story

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Sources of health and support
• Freedom from Torture – training and
capacity building (including on Vicarious
Trauma): www.freedomfromtorture.org
• Doctors of the World (Medicine du
Monde): www.doctorsoftheworld.org.uk
• International Organisation for Migration
(IOM): http://unitedkingdom.iom.int/
Any questions?
• smunroe@freedomfromtorture.org
• @munroeluthra
• www.freedomfromtorture.org