What is Forensic Medical Documentation?

Forensic Medical Documentation is a core aspect of Synergy for Justice’s work as we help survivors of torture and sexual violence in conflict pursue justice and accountability of their perpetrators. 

Forensic Medical Documentation (FMD) is a process wherein trained clinicians (medical doctors and mental health professionals) conduct a detailed clinical interview of a survivor of torture and/or sexual violence (SV) and examine all signs and sequelae of physical and psychological abuse. “Sequelae” is a clinical term referring to the long-term effects of a difficult experience, event, or injury that affect a person long after the event or injury have occurred. 

The clinical interview includes medical history as well as questions about pre and post torture physical and mental health. The doctor also listens as the survivor shares the narrative of their torture or SV experience. The survivor tells her/his story, and the doctor conducts the forensic medical exam to correlate the story with the evidence of physical and psychological signs and sequelae they see and hear.  The clinician photographs relevant scars or other physical conditions to include in the report. The process of interviewing, examining, photographing, then writing up the report takes several hours. 

The resulting forensic medical reports, which contain the clinician’s expert opinion as to whether the signs and sequelae are consistent with the survivor’s narrative about torture events, serve as key evidence to prosecute perpetrators of torture and inhuman treatment, to help survivors obtain compensation in civil courts, and to substantiate claims of asylum in new countries.

Primary purpose of the FMD:

•To establish the facts relating to alleged torture events; and

•To evaluate and document the level of consistency between these events and the physical and psychological evidence of torture and maltreatment. 

The idea is to complete a full physical and psychological examination of a person to try to  assess if they have indeed experienced torture. A simple way to describe it is to say that doctors listen to their stories and look at their bodies to see if there is alignment. 

Why doctors? What can they see?

• Doctors are able to see and assess physical sequelae (physical consequences of injury) in ways that lay people cannot.
• With proper training, a doctor can identify with some degree of certainty how an injury occurred.
• When they consider and correlate what they are hearing in the form of torture allegation with what they are seeing on the body, the circumstances of torture and ill treatment become clearer.
• Similarly, mental health professionals who perform a psychological evaluation can identify and diagnose certain mental health conditions that could result from torture, ill treatment, or other traumatic experiences. 

What is the Istanbul Protocol? Who developed the protocol? What international justice actors require the protocol to be used for documentation. 

The Istanbul Protocol’s full name is the “Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman and Degrading Treatment or Punishment.” 

Development of the protocol was led by a group of Turkish doctors fed up with the excessive torture that had occurred over the years at the hands of the Turkish authorities, so the nickname Istanbul Protocol, or even shorter - IP - has stuck over the years.

The Istanbul Protocol provides international, legal standards on protection against torture and sets out specific guidelines on how effective legal and medical investigations into allegations of torture and ill treatment should be conducted.

Goals of the Istanbul Protocol: 

• To combat impunity for torture and ill treatment.
• To enable States to address one of the most fundamental concerns in protecting individuals from torture – effective investigation and documentation.
• Forensic medical documentation brings evidence of torture and ill-treatment to light so that perpetrators may be held accountable for their actions and the interests of justice may be served. 
• In many countries, this documentation serves as a basis for asylum seeking.
• The protocol serves as a guide to clinicians detailing best practices for their conduct and documentation of medico-legal assessments of individuals alleging torture and/or ill treatment. 

The original Istanbul Protocol was developed by 75 experts in law, health, and human rights from 40 organisations in 15 countries, and it was officially recognised by the UN High Commissioner for Human Rights in 1999.  The 2022 revised version had 180 expert contributors from 51 countries, including experts from Synergy for Justice.

The protocol is used globally, most commonly for asylum applications because the number of asylum cases is exponential compared to the number of torture prosecutions or civil trials, but increasingly they are being used for case building in the Syria context and elsewhere.

Why is there a significant need for Forensic Medical Documentation globally?

Because torture is used by nearly every state in the world, and there are not enough adequately trained doctors to document all the cases, or even a fraction of them.

How does FMD increase accountability for arbitrary detention, torture and sexual violence?

The idea is that if we as a global society can develop a regular and reliable pattern of global accountability, dictators and others who abuse their power will refrain from using these practices because there will be a reasonable expectation that they might also be held to account one day. 

Unfortunately we are not quite there yet… there is still much work to do. 

How are Forensic Medical Documenters trained?

Some organisations provide only one week of training, but this is wholly insufficient for doctors and mental health professionals to develop the level of skill  and understanding needed to undertake FMD. Synergy for Justice requires and provides a minimum training package that entails 3 weeks of multi-disciplinary training over the course of a few months. This training is backed up by ongoing remote mentoring and case reviews. In order to be effective and engaging, the full 3 weeks of training must be in person with excellent simultaneous interpretation provided by people with deep experience in the subject matter concepts and terminology.

What is the impact of Forensic Medical Documentation on survivors’ well being? Are there additional benefits of FMD beyond accountability? 

 Benefit of Undergoing a Forensic Medical Evaluation

• Validation of the survivor’s experience
• Opportunity to process the experience with an objective, trained professional
• Opportunity for diagnoses and referrals for follow-up treatment
• Potential opportunity to pursue justice and accountability through prosecution of perpetrators
• Potential opportunity to receive reparations for suffering
• Potential evidence for future asylum claim

The validation of the survivor’s experience is extremely important. For many survivors, telling the doctor about their experience would be the first time someone has listened to them without judgment and paid credence to what happened. It can be a very powerful, positive experience. It is also an opportunity to discuss the various physical and psychological sequelae (lasting effects) with a trained medical professional who can diagnose issues and provide referrals for follow-up care.

On the justice side, there are 3 potential avenues of satisfaction, although none is guaranteed. Accountability of the perpetrator, the chance to perhaps receive compensation for suffering, and the basis for a future asylum case in another country are all powerful reasons that many choose to undergo forensic medical evaluation.

Where has FMD been used successfully to prosecute torture and conflict related sexual violence?

Unfortunately successful prosecution of torture and conflict-related sexual violence perpetrators is almost non-existant at the moment, due in part to the protection afforded perpetrators by their positions of power in oppressive, authoritarian governments. However, increasingly Synergy and its partner are asked for FMD to support case-building and investigation that is occurring in the context of the Syrian conflict.

Who pays for the cost of documentation?

In most places where it is available, volunteer networks organise Forensic Medical Documentation for affected populations, but there are never enough trained people, so the problem is less about money and more about finding adequate, qualified people. Synergy partners with Lawyers and Doctors for Human Rights in the Syria context, who provide free documentation and referrals for survivors of torture and sexual violance in Turkey and Syria.

How do doctors feel about being involved in FMD?

The doctors we work with are thrilled to be able to use their clinical training and skills to help vulnerable populations and people who have suffered grievous harm. Most doctors become doctors because they want to help people feel better, but sometimes the substantive work gets lost in the administrative and bureaucratic issues associated with insurance and the business side of medicine. Conducting Forensic Medical Documentations gives them a chance to reconnect with people who require medical care, mental health and psychosocial support, and legal services. Many doctors also enjoy the chance to work with lawyers on the justice side because it is so different from the antagonistic relationship that often develops when they face each other over malpractice or negligence claims in court. And in conflict zones and/or oppressed areas, it’s a chance for doctors to be involved in accountability and justice work, even though they have no legal training. 

There is still, however, risk for burnout and secondary retraumatisation of doctors who hear horrible stories repeatedly and see traumatic injuries and conditions that have resulted from torture and sexual violence, so we advise them to pace themselves and not do too many cases without a break. They need to pay attention to their own physical and mental health so that they can do the work without harming themselves and burning out.

What are Synergy’s plans for expanding the amount of documenters available in the Syria context? Worldwide?

Synergy’s plans include both expanding the numbers of documents in the Syrian context as well as deepening the skills of those who have already been trained as documenters. Last year Synergy completed a 2-week series of training for expert documenters who wanted to learn how to sensitively document the cases of children who have experienced torture and sexual violence. We also offered advanced training on psychological Forensic Medical Documentation because many doctors have less experience in this area than in FMD of physical injuries. We are also hoping to train on FMD and develop a network of documenters in Iraq, where torture and sexual violence have been endemic.