Torture survivor: exam and Istanbul Protocol

In a health unit that serves refugees, a middle-aged man comes for a consultation about back pain and difficulty sleeping. He speaks little, prefers to stay near the door and asks twice who will read the medical record. When the doctor asks about the history of the pain, he says he was imprisoned in his country before fleeing and that "things happened" in there. He gives no details, and the dates he mentions shift a little over the course of the conversation. The first reaction of the person attending may be to look for signs in the body that confirm the account. The scene is fictional and was written for teaching. This text uses that picture as a scenario for clinical reasoning: how to open space for the story, how to conduct an examination that does not repeat the trauma, how to interpret findings and gaps, and what the international manual called the Istanbul Protocol teaches about all of this.

NEXO is a daily medical diagnosis game: one clinical case a day, up to six progressive clues, and ICD-10 proximity feedback across five levels.

The text is not a course in forensic documentation. The formal assessment of allegations of torture requires specific training and follows the laws and procedures of each place. The interest here is the reasoning of the person attending: why consent organizes every step, why a normal examination does not close the question and why a story with gaps can be perfectly reliable. If you play the case of the day in NEXO, you will recognize the move: the complaint the person brings is not always the whole story.

Key points

• The Istanbul Protocol, revised in 2022 by the United Nations, is the reference manual for investigating and documenting torture and ill-treatment.
• Consent must be free and informed, and the person may interrupt the interview or the examination at any time.
• Gaps and inconsistencies in the story are common in people who have suffered trauma and, on their own, do not indicate that the account is false.
• Most acute injuries heal within weeks, so a normal physical examination does not rule out torture.
• Psychological sequelae usually last longer than physical ones, and chronic pain is frequent.

Why the torture survivor is a reasoning scenario

People who have suffered torture arrive at ordinary health services, not only at specialized centers. They arrive at primary care units, emergency departments and outpatient clinics, often with complaints that seem unrelated to what they lived through: body pain, headache, insomnia, fatigue. Crosby reviewed primary care for torture survivors and noted that many of these patients do not spontaneously tell what happened, and that the professional needs to know how to ask and how to receive them (Crosby, 2013).

In a classic study with refugees from Somali and Oromo communities in the United States, Jaranson and colleagues found torture frequently reported, and women were tortured as much as men (Jaranson and colleagues, 2004). This finding corrects a narrow image of who may have lived through this experience. A meta-analysis by Steel and colleagues with populations exposed to conflict and displacement showed that torture was the factor most strongly associated with post-traumatic stress disorder (Steel and colleagues, 2009).

What the scene teaches

The scene has three important clues. The first is the vague physical complaint, which may be only the entry point. The second is the concern about who will read the medical record, which suggests fear of exposure and calls for a clear conversation about confidentiality. The third is the story with dates that shift, which may provoke distrust in the person attending. The manual teaches how to treat these three clues with care, and clinical reasoning gains when it recognizes that haste to confirm or rule out can get in the way as much as inattention.

The post about signs, symptoms and history shows how the way of asking changes what the patient is able to tell.

What the Istanbul Protocol is

The official name is Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. The first version was published in 1999, the result of work by health professionals, jurists and human rights advocates. Iacopino and colleagues presented the manual at the time as a tool to standardize medical and legal documentation (Iacopino and colleagues, 1999). In 2022, the Office of the United Nations High Commissioner for Human Rights published a broad revision, which is the version used in this text (United Nations High Commissioner for Human Rights, 2022).

The manual covers ethical and legal principles, the interview, the physical examination, the psychological assessment and report writing. Furtmayr and Frewer discussed how documenting torture became a medical task with its own ethical dimension, in which care and evidence must coexist (Furtmayr and Frewer, 2010).

Who the manual was written for

The manual was designed for professionals who carry out formal assessments, but its principles serve anyone who treats survivors. The text acknowledges that many clinicians will meet these patients without having been trained as experts, and that even so they have an ethical duty to record what they observe. In paragraph six hundred and twenty-one, the manual recalls that the principle of doing no harm and the duty to document go together.

Consent, privacy and the limits of confidentiality

Before any difficult question, the person needs to know why they are there, what will happen to what they say and who will have access to the record. The manual insists that consent be voluntary and informed, and recalls that consent obtained under pressure is not valid. This applies to the interview, to the examination and to photographs.

The conversation about confidentiality must be honest. In paragraphs two hundred and seventy-three to two hundred and seventy-eight, the manual asks the professional to explain the limits of confidentiality, including when the assessment may be read by an authority or a court. In the opening scene, the question about who will read the medical record deserves a direct answer, without promises that cannot be kept.

Control returns to the person

One of the manual's central ideas is to give the person some control over the situation. They decide the pace, can ask for pauses and can end the consultation. Paragraph two hundred and ninety-nine recalls that the person can leave and be offered a new consultation. Paragraph four hundred repeats the idea for the physical examination: the person can stop at any time.

Disclosing sexual violence is often especially difficult. The manual acknowledges this difficulty and says the person keeps control over what they wish to tell. The post about empathy and clinical reasoning in the consultation discusses how attentive listening improves the quality of clinical information.

Explain before asking

A good start is to say in simple words who the professional is, what the purpose of the consultation is and how long it should last. Many survivors have been through interrogations, and a sequence of questions without explanation can recall that experience. Saying that the person may decline to answer a question, may ask for it to be repeated or may correct something said earlier helps distinguish the clinical consultation from any interrogation setting.

It is also worth asking what the person expects from that meeting. Sometimes they only want to treat the pain and sleep better, and do not wish to talk about what they lived through. Sometimes they need a report for an asylum process. These expectations change the focus of the consultation, and respecting them is part of consent.

Interpreters, gender and the setting of the consultation

Many survivors do not speak the language of the service. The manual recommends professional interpreters and recalls that family members, friends or members of the same community can inhibit the account and put the person at risk. In paragraph two hundred and ninety-seven, it recommends that the professional speak directly to the person, looking at them, and not to the interpreter. The question is "what happened to you?", not "ask him what happened".

The person can choose the gender of the examiner and of the interpreter whenever possible. This choice is especially important when there is a history of sexual violence or when cultural aspects make examination by someone of another gender unacceptable.

The place also communicates

A room with a closed door, no interruptions, with chairs arranged so that the person does not feel cornered, helps build trust. In the scene, the patient prefers to stay near the door, and respecting that preference is a clinical gesture. Moreno and Grodin, when describing care for survivors, highlighted the building of trust and empathy as the basis of care (Moreno and Grodin, 2002).

The story: gaps and inconsistencies are not lies

Anyone who does not know the effect of trauma on memory may distrust a story with dates that change or details that are missing. The manual addresses this point clearly. In paragraphs three hundred and thirty-one and three hundred and thirty-two, it explains that a lack of detail does not mean a lack of truthfulness. In paragraphs three hundred and forty-two to three hundred and fifty-one, it lists reasons for difficulty remembering: fear, shame, effects of head trauma, sleep deprivation, disorientation during detention, cultural differences in how time is told, and the psychological impact itself.

Herlihy and colleagues studied refugees interviewed more than once about the same events and showed that discrepancies were common, more frequent in peripheral details and, in those with symptoms of post-traumatic stress, greater the longer the time between interviews (Herlihy and colleagues, 2002). The manual adds that, when there is an adequate explanation for the inconsistencies, this may even strengthen the reliability of the account.

How to ask without retraumatizing

Telling the story can reactivate painful memories. The manual calls this the risk of retraumatization and suggests ways to reduce that risk: pauses, breathing exercises, a temporary change to less loaded subjects, the presence of support and referral when necessary. Open questions, without pressure for details, help more than an interrogation.

In paragraph four hundred and ninety-seven, the manual recommends an attitude of informed learning, instead of haste to diagnose. This sentence sums up the reasoning of the scene well: the first consultation may serve more to build trust than to complete the story. The post about narrative medicine explores how to listen to the story the way the person can tell it.

The physical examination in parts and without haste

The physical examination of a torture survivor follows the logic of any careful examination, with one important difference: each step must be explained and consented to. Paragraph four hundred of the manual recommends examining the body in parts, keeping covered what is not being examined. This protects dignity and reduces the feeling of exposure.

The examination begins with what the person reports and with current complaints. The manual calls for a detailed record of each finding: location, shape, size, color and characteristics. Paragraph two hundred and thirty-four advises that photographs be taken with consent and with a scale alongside, so that they can be interpreted later.

What to look for beyond the marks

Chronic findings deserve attention. Paragraph three hundred and ninety-eight recalls that many survivors are assessed months or years later, when there are no longer acute injuries. At this stage, the examination may show scars, limitations of movement, neurological changes, pain on palpation and signs of diseases worsened by detention. The neurological and musculoskeletal examination is often as important as inspection of the skin.

The post about how to organize clinical reasoning in the medical record shows how to record findings so that another professional can understand the path taken.

The record that protects

A careful record serves the person in several ways. It helps in continuous care, because another professional understands what has already been seen. It can be useful in a request for protection or in legal proceedings, if the person wishes. And it protects against the loss of information that time erases. The manual recommends noting the person's own words when possible, separating what was reported from what was observed and describing findings without adjectives that anticipate conclusions.

When the consultation is not for forensic purposes, the record still matters. An objective description of the complaints, the examination and the emotional state, made with consent, may be the first documentation this person receives.

A normal examination does not rule out torture

This may be the most important point in the text. Paragraph 399 of the manual explains that most injuries heal within weeks, often leaving no marks, and states that a normal physical examination in no way negates the allegation. Paragraph 417 repeats the idea: the absence of physical findings does not exclude torture.

The same applies to complementary tests. Paragraph 401 notes that a negative test does not mean torture did not happen. Many methods are chosen precisely because they leave few marks, and the time between the event and the consultation erases much of the evidence.

The mistake of looking only for confirmation

In the scene, the doctor may fall into a cognitive trap: looking in the body for proof of the account and, failing to find it, concluding that nothing happened. Croskerry described common cognitive errors in diagnosis, such as premature closure and the selective search for information that confirms a hypothesis (Croskerry, 2003). Here, the correct reasoning is different: the absence of findings is compatible with the history and must be recorded as such.

The post about implicit biases in diagnosis discusses how expectations about who the patient is can distort the interpretation of data.

The degrees of consistency

When a trained professional evaluates a finding, the manual asks them to state how consistent that finding is with the reported history. Paragraph 418 defines five degrees, from weakest to strongest. This scale helps communicate the interpretation precisely and avoids absolute statements.

Degree	What it means	How to think about it
Not consistent	The finding could not have been caused by what was described	Rare, and calls for a careful review of the history and the examination
Consistent	The finding could have been caused by what was described, but also by other causes	Many findings fall here, and that has value
Highly consistent	The finding could have been caused by what was described, and there are few other possible causes	Strengthens the link between finding and account
Typical of	The finding is usually found in this type of trauma, but there are other possible causes	Brings the finding closer to a known pattern
Diagnostic of	The finding could not have been caused in any other way	Rare, reserved for very specific patterns

What counts is the whole picture

Paragraph 383 notes that the final assessment considers the body of evidence, not each injury in isolation. Several findings that are merely consistent, added to a coherent history and compatible psychological sequelae, can form a strong conclusion. The report's conclusion uses the highest degree of consistency the whole picture allows.

This reasoning resembles that of any difficult diagnosis: no single piece of data decides, and the weight comes from the combination. The post about diagnostic uncertainty discusses how to decide well when no single finding is conclusive.

Psychological sequelae and chronic pain

Paragraph 491 of the manual notes that psychological sequelae are often more persistent than physical ones. Post-traumatic stress, depression, anxiety, insomnia, nightmares and difficulty concentrating are common. The psychological assessment is part of the Istanbul Protocol and can be as informative as the physical examination.

Paragraphs 541 to 544 ask that the psychological assessment also state how consistent the findings are with the account. And they carry an important reminder: not meeting criteria for a psychiatric diagnosis does not mean the person was not tortured. Some survivors have great capacity for adaptation, and culturally different reactions may not fit the usual classifications.

The pain that does not go away

Chronic pain is one of the most frequent complaints. Paragraph 507 cites somatic pain and headaches among the common manifestations. Amris and colleagues reviewed the assessment and management of pain in survivors and described it as a complex problem, in which physical injuries, changes in pain processing and psychological distress add up (Amris and colleagues, 2019). In the opening scene, back pain may be the possible way of asking for help.

What is known about treatment

The evidence on treatment is still limited. A Cochrane review by Baird and colleagues found insufficient evidence to recommend specific interventions for chronic pain in torture survivors (Baird and colleagues, 2017). Hamid and colleagues reviewed psychological interventions and found a reduction in post-traumatic stress symptoms at the end of treatment, an effect that did not hold at follow-up, and no clear benefit for depression (Hamid and colleagues, 2019). These results reinforce the importance of referral to specialized services and of continuous, multidisciplinary and culturally appropriate care.

Those who examine also feel

Hearing accounts of torture affects those who listen. Paragraphs three hundred to three hundred and two of the manual describe transference and countertransference: the survivor may project onto the professional feelings linked to whoever hurt them, and the professional may feel anger, helplessness, disbelief or a wish to rescue. Recognizing these reactions helps keep the assessment balanced.

Paragraph six hundred and twenty deals with vicarious trauma, the cumulative impact of hearing stories of violence. The manual recommends supervision, support among colleagues and attention to one's own limits. It is not a sign of weakness, but part of responsible care.

Emotion and judgment

Emotion also enters reasoning. Disbelief can lead to underestimating the account, and indignation can lead to conclusions beyond what the findings allow. The post on affective bias shows how emotion influences clinical decisions and how to notice that influence. For those who go through difficult experiences at work, the post on the second victim discusses the emotional impact on professionals.

How NEXO helps train this reasoning

In NEXO, the case of the day is fictional, with a real clinical presentation and up to six progressive clues. You propose a diagnosis by looking for the code in ICD-10 and receive proximity feedback at five levels, which shows whether the guess landed on the exact code, the same category, the same group, the same chapter or a different chapter. This format speaks to the theme of this text: the first complaint may be just the doorway into the story.

To use the case of the day as training, try three habits. Before each guess, ask what story could explain a vague complaint. When a piece of data seems contradictory, ask what explanation would make that data compatible. After the result, note which clue changed your interpretation.

Three exercises with cases

Look for the story behind the complaint. In each case, ask what experience could explain diffuse pain, insomnia or fatigue.

Separate absence of a finding from a negative finding. Faced with a normal exam, ask whether it really rules out the hypothesis or merely does not confirm it.

Grade the consistency. For each clue, say whether it is consistent, highly consistent or typical of the main hypothesis.

The post on case-based learning in clinical practice shows how cases help fix patterns that rarely appear in daily practice.

The limits on using the game are described on the NEXO economy page. If you research the teaching of clinical reasoning, the page for researchers explains how to get in touch. Professionals who write or review cases find information under curation and under creators, and institutions can learn about the proposal on the partnerships page.

Frequently asked questions

What is the Istanbul Protocol?

It is the United Nations manual for investigating and documenting torture and ill-treatment, published in 1999 and revised in 2022.

Can any health professional use its principles?

Yes. Formal assessment requires training, but consent, careful listening, respectful examination and detailed recording apply to any care.

Can the person interrupt the consultation?

Yes. They can ask for pauses, end the interview or the examination at any time and be offered a new appointment.

Is a normal exam compatible with torture?

Yes. Most injuries heal within weeks, and the manual states that a normal exam does not deny the allegation.

Are inconsistencies in the history expected?

Yes. Trauma, fear, shame and time affect memory, and discrepancies in peripheral details are common in true accounts.

Is psychological assessment part of the protocol?

Yes. Psychological aftereffects often last longer than physical ones and are part of the conclusion along with the physical examination.

Final checklist

• I explained the purpose of the consultation and the limits of confidentiality.
• I asked for consent for the interview, the examination and each photograph.
• I offered a professional interpreter and respected the gender preference.
• I listened to the history without rushing and without treating gaps as lies.
• I examined by parts, keeping the body covered and recording each finding.
• I recorded the absence of findings as compatible with the history, when that was the case.
• I assessed sleep, mood, pain and psychological distress and referred the person for support.
• I noticed my own reactions and sought supervision.

Want to practice your reasoning with progressive clues? Play the case of the day.

References

1. United Nations High Commissioner for Human Rights. Istanbul Protocol: Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. Professional Training Series No. 8/Rev.2. 2022. Document.
2. Amris K, Jones LE, Williams AC de C. Pain from torture: assessment and management. Pain Rep. 2019. PMID 31984299.
3. Baird E, Williams AC de C, Hearn L, Amris K. Interventions for treating persistent pain in survivors of torture. Cochrane Database Syst Rev. 2017. PMID 28820231.
4. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003. PMID 12915363.
5. Crosby SS. Primary care management of non-English-speaking refugees who have experienced trauma: a clinical review. JAMA. 2013. PMID 23925622.
6. Furtmayr H, Frewer A. Documentation of torture and the Istanbul Protocol: applied medical ethics. Med Health Care Philos. 2010. PMID 20419473.
7. Hamid A, Patel N, Williams AC de C. Psychological, social, and welfare interventions for torture survivors: a systematic review and meta-analysis of randomised controlled trials. PLoS Med. 2019. PMID 31550249.
8. Herlihy J, Scragg P, Turner S. Discrepancies in autobiographical memories: implications for the assessment of asylum seekers: repeated interviews study. BMJ. 2002. PMID 11834558.
9. Iacopino V, Ozkalipci O, Schlar C. The Istanbul Protocol: international standards for the effective investigation and documentation of torture and ill treatment. Lancet. 1999. PMID 10509518.
10. Jaranson JM, Butcher J, Halcon L, et al. Somali and Oromo refugees: correlates of torture and trauma history. Am J Public Health. 2004. PMID 15054011.
11. Moreno A, Grodin MA. Torture and its neurological sequelae. Spinal Cord. 2002. PMID 11987003.
12. Steel Z, Chey T, Silove D, et al. Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. JAMA. 2009. PMID 19654388.