Steven Miles, MD Department of Medicine, Center for Bioethics University of Minnesota Paper pending with Rosa E. Garcia-Peltoniemi, Ph.D., Licensed Psychoanalyst, Center for Victims of Torture, Minneapolis, MN The speaker has no conflicts of interest pertaining to this presentation aside from being a volunteer board member of the Center for Victims of Torture in Minneapolis, a 501c3 organization, www.cvt.org.

• • • • • •

Prevalence Screening Physical sequelae Psychological morbidity Documentation Referral and treatment

Research methods often:

• Underfunded.

• Underpowered.

• Often single institutions.

• Often univariate.

• Lack of controls.

Findings vary with:

• Site and population selection • Historical cohort • Forthrightness of interviewees.

Variance in cross cultural phenomena necessitates careful and difficult validation of instruments.

Torture

. . . any act by which severe pain or suffering, whether physical or mental,  is intentionally inflicted on a person  by, or at the instigation, consent or acquiescence of a person acting in an official capacity. It does not include pain or suffering arising only from, inherent in, or incidental to, lawful sanctions.

 —UN Convention Against Torture (abridged)

Approximate Rates of Methods of Physical Torture

Injurious environments Noise, heat, cold, lack of water/ food/ sanitation/ med care. Beatings, lashings Trunk, extremities, head, genitals, 40% ears, 40% feet.

Suspension, Hyper-flexion/ -extension Ligatures, compression Sexual Torture Men Women Burns, shock Asphyxia Rape

Psychological Torture

Isolation, blindfolding, sleep deprivation. Anticipated Physical Torture Prisoner Humiliation, Degradation Fear (sham execution, being forced to watch torture [including of family]) CBC News 11/19/09

Prevalence of Torture in Some National or Refugee Groups 500,000 torture survivors.

Senegal Algeria

Bosnia?

Gaza Afghanistan Tibet Iraq Bhutan S. Leone Zaire Sudan/Somalia Ethiop/Eritrea Cambodia 75-79 Cohort Timor Zimbabwe 80-100 countries practice torture as policy.

Amnesty International, 2008.

Refugees from a given country have a higher torture prevalence than nationals.

Redface: high but percents are not known.

Miles SH. Compiled from multiple sources.

Prevalence of Torture in Asylum Seekers*

Torture 2008;18:77-86. 142 Danish asylum seekers 2007, Middle east and Africa.

Prevalence was 20% in a population of 3,000 Danish asylum seekers in a private Red Cross study of 1980.

Method

Blows Threats Degradation Isolation Witness others tortured Forced stress positions Foot beating Suspension Mock execution Electric Shock Sexual Abuse 91 88

%

88 65 63 40 40 30 29 25 10 *Asylum seekers is not a synonym for refugee.

   

Torture of Children

About 4% of torture victims are children.

This includes   Street children tortured by police (most common).

Children tortured or kidnapped to terrorize parents.

 Children tortured as subversives or ethnic enemies.

Methods appear to be similar to those used on adults.

 Torture 2009;19(entire issue).

Tuol Sleng, archive The rates of PTSD in refugee children (irrespective of torture) is 11% compared to 9% of refugee adults (irrespective of torture).  Lancet: 2005;365:1309-14. Meta-analysis, 5 studies, 260 child refugees compared to 6,483 adult refugees.

For at-risk children, screen for PTSD rather than torture and refer.

500,000 with Parkinson Disease 500,000 Torture Survivors in US*

400,000 persons with Multiple Sclerosis 300,000 persons with Scleroderma in US

MN: 6,000 - 30,000 torture survivors, most in metro.

* US Dept of Justice: Office for Victims of Crime; 2000

West J Med 2000;172: 301–04. J Gen Int Med 2006;21:764-68.

Consequences to patient Consequences to society

 Delayed referral to therapy.

 Prolonged morbidity.

 Lack of medical documentation in support of asylum petitions.

 Prevalence under-stated.

 Clinical education ignored.

 Treatment infrastructure not developed.

 Social morbidity needlessly high.

Identifying, Assessing, Referring Immigrants for Torture

Yes

• Screening: Have you experienced torture?

6-12% all immigrants.

(>40%, some nations.) Physical

• Exam per reported torture techniques.

Psych/ Soc .

• Screen for Psychosocial Needs.

Refer

• Comprehensive Case Management.

Screening Questions

Simple Screen

  “Have you experienced extreme violence or torture?” “Some people in your situation have experienced torture, has that ever happened to you?”  J Gen Intern Med 2006;21:764-68.

Convention Against Torture Based

 “While in captivity,  did you ever experience physical or mental suffering that was  deliberately and systematically inflicted by a soldier, policeman, or militant or other person acting with government’ approval?”  N Engl J Med 2004; 351:5-7.

Given reluctance to disclose, PTSD amnestic response to torture and psychogenic or instrumental value in falsely claiming torture, structured interview have a sensitivity and specificity of 82% and 92%. to identifying torture survivors. Dan Med Bull 1994;41:588-91.

Torture survivors are • twice as likely to have physical complaints as un-tortured refugees • 2-3 as likely to have psychological complaints. The symptoms and signs of torture are as protean as the methods of injury. THE NEXT SLIDES HAVE GRAPHIC MATERIAL.

Torture 2008;18:77-86. 142 Danish asylum seekers 2007, Middle east and Africa

Bastinado, Falanga, Falaqa

[Foot Caning with batons or electric cables.]

      ~40% of survivors.

Wide global distribution.

80+% have scars, palpable soft tissue irregularities, pigmentations.

Document by photographs, MRI.

Often leads to a chronic disability, polyneuropathic anesthesia or hyperesthesia from heel pad thinning, thickening of the plantar fascia.

Chronicity of the pain and disability strongly correlated with PTSD-constellation symptoms.

  Torture 2009;19:33-40. Torture 2009;19:27-32.

Images: Eur J Rad 2007;63:187-204 and Johannes Wier Foundation.

 

Rattan Caning.

Location: Back, buttocks (back of legs) Straight, dragged skipping lesion.

Note: These lesions may be much deeper, extend to the bone or into viscera.

Old lesions.

Flogging.

  Location: Back.

Lesions curve with body, tend to have depigmented centers and hyperpigmented margins.

Ligatures, shackles, ratchet handcuffs

 Purpose: to inflict pain, mutilate, or restrain for other tortures.

  Location: extremities, genitalia.

Findings: sensory or motor neuropathies or paresthesias, ischemic injuries.

 

Picana [Electric Shock]

Method:  External or subcutaneous anywhere on the body  Intrarectal, vaginal, or rarely ureteral wire.

Pathology:  Burns, then scars, subepithelial collagen and later calcinosis.

 Muscle spasm may cause high vertebral fractures or jaw dislocation.

Eur J Rad 2007;63:187-204.

Crush

Right and Left Index Fingers. Right smashed with rifle butt.

Boston Center for Refugee Health and Human Rights Screw compression of distal finger Eur J Rad 2007;63:187-204.

Strappado

Ligamentous Stress

 Document disability by exam.

 Document soft tissue injuries by MRI.

Parrots Perch

Dislocation Fracture and Callus Eur J Rad 2007;63:187-204.

Gunshot wound to Joint

 Knee, hip, shoulder ankle are most usually involved.

Eur J Rad 2007;63:187-204.

Sexual Torture

~40-60% of tortured women (often concealed).

 Methods are similar to men with addition of rape barracks.

 Women with dependent children may be more vulnerable to torture either because of lack of mobility or attempts to protect children.

 J Adv Nursing 2006;56:577-87. MN 1113 Somali and Ethiopian women in MN.

~ 5-15% of tortured men (Does not include 60-80% receiving genital beatings)

    40-60% Sexual threats (castration, rape) 10% Genital shock 30-40% Rape 5-15% Castration/mutilation   J Interpers Viol 2010;25:191-203.

Repro Health Matters 2004;12:68-77.

Although correlation between method/severity of torture with PTSD are weak, raped torture survivors report significantly higher distress and high levels of sexual dysfunction. Lancet 1990;336(8710):289-91. J Nerv Ment Dis 2006;188-94 .

Goya, Disasters of War Poly Trauma Henry Moore Tw0 Seated Women Social Supports and Stressors Jim Dine June #8 Resilience Photo from Free Tibet.

Therapy Lizbeth Lanpher Head Together

PTSD • Two-thirds of tortured asylum seekers.

• Torture 2008;18:77-86. 142 Danish asylum seekers 2007, Mid-east and Africa.

• 45% of refugees seeking help at a torture treatment center.

• J Nerv Ment Disease 2006;194:188-94.

Depression • Two-thirds of tortured refugees have depression.

• J Nerv Ment Disease 2006;194:725-31.

Baseline PTSD

•

8-10% refugees in developed countries. (1% Non refugees.) Depression

•

4-6% refugees in developed countries.

•

Lancet: 2005;365:1309-14. Meta-analysis, 20 studies, 6,743 refugees from 7 origin countries.

Primary Intake Psychiatric Diagnoses

Chronic Pain and/or Somatizing Syndromes Internat J Ment Health Sys 2010 4:16:4-16. 306 Survivors at 5 well run torture treatment programs in 5 countries.

Such studies generally assess pain as a symptom rather than as a disorder.

Scand J Pub Health 2006;34:496-503 (review); See also Arch Gen Psych 2001:58:475-82 (N=418); JAMA 2003;290:627-34.

*Cumulative Exposures The multiplier effect of poly-trauma justifies increased screening of at risk refugees for torture survivors. Personal Torture General Terror JAMA 2009;302:537-549. Meta-analysis, 161 articles, 81,866 refugees.

War Dislocation Time See also JAMA 2005;294:571 79. N=490.

B. Intrusive flashbacks.

C. Avoiding events, ideas, feelings, people assoc c trauma. Numbing, detachment, apathy.

D. Arousal, insomnia, irritability, ↓concentration ↑ vigilance, anger.

Culture influences how survivors behave (e.g. avoid people) or experience symptoms (e.g. anxiety). Diagnosis requires cultural competence. J Traum Stress 2007;20:271-280.

Marsella AJ et al, APA 1996.

Culturally validated PTSD screening exams, e.g., Harvard Trauma Questionaire-HTQ 16PTSD

Depression

Social, occupational, or academic impairment.

Anxiety

Post-Displacement Stressors on Refugees

• • • • Institutionalized. • Internally displaced within, or repatriated to, their homelands [or threat of repatriation].

Ongoing war.

• Higher socioeconomic status in home country.

• Limited opportunities in destination country.

Older.

Female.

Käthe Kollwitz, self portrait; Miles, refugee camp.  JAMA 2005;294:602-12. Meta-analysis, 56 studies comparing refugees to non-refugee controls, 22,221 refugees, 45,073 non-refugees.

Prefrontal Cortical Thinning in Political Prisoners subject to head trauma vs. those not subject to head trauma  Associated with reported history of prison head trauma but not with reported severity of head trauma.

  Associated with depression (P <.02).

Not Associated with PTSD (perhaps underpowered).

 Lesions appear to involve limbic areas as well.

 Arch Gen Psych 2009;66;1221-32. A sample of 60 prisoners, randomly drawn from 337 prisoners with and without head trauma. Composite brain image of head trauma and not head trauma prisoners where false color is p value of difference in cortical thickness. P<.05, P<.001

Resilience

• Objective severity of torture (including physical vs. psychological techniques does not explain variance in post-torture PTSD / depression. • Arch Gen Psych 2007;64:277-285. 279 Bosnia survivors. See also J Nerv Mental Dis 2006;194:725-31. • The sense of loss of control (e.g., disorientation during torture or never expecting to be subjected to torture) is more predictive. Jacobo Timmerman; torture survivor, journalist author

• • Reduced disability • Less pain.

• • Less psychiatric distress.

Improved musculoskeletal/ orthopedic functioning.

• Improved functioning as a parent, student, citizen, employee.

Fair hearing on asylum requests.

Ten-year mental health of treated tortured immigrants.

80 60 40 20 Baseline 10 year 0 PTSD Depression Anxiety J Nerv Mental Dis 2006;194:725-31. (Recovery similar to SE Asians in Can and MN. J Nerv Mental Dis 1989;177:132-9). See also Internat J Ment Health Sys 2010 4:16:4-16. 306 Survivors at 5 well run torture treatment programs in five countries.

221 at baseline; 139 available at 10 years. Denmark area is 1/5 of MN. This is a well run program. Recovery probably accounts for many lost to follow-ups. Study probably oversamples persisting morbidity.

Even so, torture causes durable and severe psychiatric disability in many survivors.

• • • • • • Physical therapy.

Cognitive behavioral therapy for flashbacks & disabling avoidance.

Psychiatric care for depression.

Interdisciplinary pain desensitization.

Psychosocial supports and interventions.

Assistance with petitions for asylum from persecution.

• J Rehab Med 2009;41:689-96 There are no reliable controlled studies of these standard therapies in torture survivor rehabilitation.

UM has an exceptional opportunity to lead in this area.

Minnesota has 6,000 to 30,000 torture survivors and the US’ largest treatment program.

 A refugee must show a well-founded fear of persecution on account of race, religion, nationality, political opinion, or membership in a particular social group.  Must show objectively reasonable fear.  Claim is stronger if past persecution is demonstrated.  This is a complex law.  Interpreting it is not your job.

 Documenting injuries is.



Fear of repatriation is correlated with increased severity of PTSD symptoms

.

 JAMA 2005;294:602-12. N=22,000 2009: US received 40,000 asylum applications. US DoJ. FFY 2009 Asylum Statistics. J Immigrant Minority Health 2008;10:7-15. N=2400, 2000-2004.

• The Center for Victims of Torture has treatment centers in Minneapolis and St. Paul. CVT cared for 242 US clients (50 new) in 2009, a tiny fraction of the need. • The Center for International Health at Regions Medical Center in St. Paul.

Photo by Swiatek Wojtkowiak, Somali Woman. CVT, Minneapolis

What: A 1 hour orientation for interested clinicians and researchers.

When: Monday, September 13 from 5:00 PM to 6:00 PM. Where: Minneapolis Center for Victims of Torture, 717 East River Parkway, 75 yards from the hospital ER. This is not a fundraiser. Contact Steve for details or RSVP. Steve Miles, MD [email protected]