Week 3 wrap up
Several of the questions we have discussed are country-specific, but there are always some general principles worth mentioning. Here are some inputs from us on the questions that were discussed:
Step 3.7 When Dr Qureshi suspected that Mrs Abilowale could be a victim of torture, in addition to asking her about this she should have informed her supervisor, Dr Talbot. She should have considered necessary referrals, particularly for psychological assessment, as well as support services or befriending services available. Referral for an independent assessment from a trained professional to complete a medico-legal report in line with the standards set out in the Istanbul Protocol would also be important. Given the indication of recent wounds, dating evidence is particularly relevant, and it is essential that prompt documentation, which may include taking photographs, is carried out. This is necessary to support an asylum application as well as to be used as evidence against alleged perpetrators.
Step 3.9 Health professionals working with patients who have experienced torture must understand that torture strips an individual of their sense of trust and safety. Therefore, a huge part of the medical interview is re-establishing a sense of trust and safety through empathy and human contact. Despite all precautions the physical and psychological examination may re-traumatise the patient. Most clinicians are rightly anxious about opening up agonising memories and re-traumatising the patient. But consider: It is not unique that health professionals cause pain for therapeutic ends, for example by giving an injection (nurse), opening an abdomen (surgeon), or pushing the patient to exercise a frozen shoulder (physio). Inviting a patient to reveal horrible experiences is roughly analogous, and should not be shirked. It is often (but not always) a necessary precondition for helping them to heal. But when this is possible and acceptable to the patient, it should be done gently, patiently, with thought to the distress being caused and attention to the after-effects. If the responsible clinician does not feel able to do this, they should refer to someone who can. There are however some things which can be done to mitigate some of these effects which include:
● Consider the gender of the doctor and patient, for example a female patient may prefer a female examiner, particularly if there has been sexual assault by a male.
● When undertaking the evaluation, provide a clear introduction, including what he/she should expect, and ensure the patient feels in control of the interview, allowing him/her to interrupt the interview at any time.
● Provide a comfortable setting, adequate time for the interview, refreshments and access to toilet facilities.
● Explain at the start that discussing their experiences may be distressing and that these feelings may affect them after the examination as well.
● Arrange a professional interpreter if required. If using an interpreter ensure to maintain eye contact with the patient and use the second person when speaking through the interpreter, for example “what did you do next?”, rather than “ask him what happened next”.
● Trust is an essential component of eliciting an accurate account of abuse. Earning the trust of someone who has experienced torture or other forms of abuse requires active listening, meticulous communication, courtesy and genuine empathy and honesty.
● If enquiring about sexual assault, remember discussing sexual matters is considered taboo in many cultures, and therefore approach with great sensitivity.
● Examine one part of the body at a time so the patient is never fully exposed
● Consider undertaking a suicide risk assessment
● When possible, clinicians who conduct evaluations should have training in forensic documentation of torture and other forms of physical and psychological abuse.
Step 3.11 The key duty for all healthcare professionals is always a duty of care to the patient. According to the Declaration of Tokyo (1975) published by the World Medical Association, physicians have a role in speaking out against human rights violations and supporting colleagues who do so as well as encouraging active review of the human rights situation within their own countries. International Council of Nurses has stated that “the nurse’s primary responsibility is to those people who require nursing care. Nurses have a duty to provide the highest possible level of care to victims of torture and other forms of cruel, degrading and inhumane treatment, and should speak up against and oppose any deliberate infliction of pain and suffering.”