How we can approach survivors of torture

Abstract

The Constitution of the World Health Organization (WHO) was the first international instrument to enshrine the enjoyment of the highest attainable standard of health as a fundamental right of every human being (‘the right to health’). The right to health in international human rights law is a claim to a set of social arrangements – norms, institutions, laws and an enabling environment – that can best secure the enjoyment of this right. The Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, adopted in 1984 by the UN, is entirely devoted to banning these practices and provides for the liability to punishment before all courts where the perpetrator is, regardless of the place where torture was committed. In addition, no exceptional circumstances whatsoever, whether a state of war or a threat of war, internal political instability or any other public emergency, may be invoked as a justification of torture. The debate on torture probably dates as far back as the origin of humankind. This issue was discussed by philosophers since the Classical Age, Modern Age and in the 20th and 21st centuries. Torture is usually associated with slavery and genocide and, along with them, it is condemned as a crime against humanity. There is a crucial common ground between these crimes, which explains and justifies why they are commonly abhorred. However, in some legal systems, the power of torture was legalized to the point that the person resisting torture was considered innocent, and hence released, and torture coincided with the judicial process and the punishment. In this issue, Clarysse et al. approached the crucial relevance of the right understanding and clinical value of the lesions likely due to violence or torture. Dermatologists may be the first and only physicians to find a lesion potentially due to torture, considering that the skin alterations may be the most evident sign of torture. But each physician should be able to correctly provide diagnosis of torture and to differentiate it from dermatological or systemic diseases. At the same time, lack of adequate knowledge may lead to underestimation of Post-Traumatic Stress Disorder (PTSD). The authors offer a clear classification and presentation of acute and chronic lesions, all supported by the related differential diagnosis. Finally, they provide a useful flow chart adapted to clinical practice. According to the Istanbul protocol, the authors underlined that the complete skin assessment is a crucial step in the overall approach to the people who are survivors of torture, as dermatologist expertise is complementary to the coroner one. The current limit is the overall poor access of the victims of torture to the health system for several different reasons. The sense of shame, the fear of being misunderstood, the fear of revealing what they were forced to endure, not knowing whether they can receive help, and the fear of retaliation; all of these represents a true hindrance for the patients to make complaints, thus for the physicians to properly ‘take care’ of them. The approach to the possible victims of torture should be a holistic approach, where alongside the need to make a diagnosis, which has in any case a crucial practical and legal value, the person must regain confidence in himself/herself and he/she must trust the interlocutor. This process takes time. It requires willingness to listen, and sometimes even silence. However, this process is the only way for these people to regain their dignity. As clearly indicated by the authors of this article, the treatment must be individualized. ‘Taking care’ is a more complex clinical and anthropological experience than ‘caring’.