Torture survivors: What to ask, how to document

Nearly half of the world’s 200 nations torture their citizens.¹ Although survivors have high rates of physical and psychiatric morbidity, and in coming to this country tend to live in highly concentrated refugee groups, physicians rarely discover torture histories.^2,3

Torture survivors may avoid speaking of it because they do not understand that treatment is available for their physical, psychiatric, and pain disorders. A lack of detection delays the diagnosis and treatment of the sequelae of torture. It may also affect their future safety: Individuals seeking asylum are deprived of the medical documentation needed to support their petitions.

Your involvement in recording histories and exam findings and in referring patients for specialized care can restore lives. It can also aid in reversing the “invisibility” of torture survivors that perpetuates inadequate clinical education, research, and development of appropriate therapies.

Are you caring for a survivor—and don’t know it? Approximately 500,000 torture survivors live in the United States.⁴ This equals the number of individuals with Parkinson’s disease and outnumbers those with multiple sclerosis.^5,6 Physicians may encounter torture survivors in primary care settings, emergency departments, or while consulting with colleagues about patients who have specialized medical needs. There are no evidence-based guidelines for assessing and treating torture survivors. Most studies are from single institutions and have modest sample sizes. Most use univariate analyses, and the effect of confounding variables is often unexamined. Moreover, the diversity of torture survivors’ cultures limits the generalizability of findings from particular groups.

In this article, we propose an approach—based on studies that address cross-cultural issues or use multicenter, multivariate, meta-analytic methods—that can enable you to better identify survivors of torture, assess and document consequent morbidities, and refer them to appropriate treatment programs. We focus on individuals who were tortured months or years earlier rather than on recently traumatized patients.

Facts that justify targeted screening

Although the number of torture survivors is not so high as to warrant population-wide screening, the prevalence of such victims in easily identified refugee groups does justify screening in this setting. Tortured individuals are more likely to emigrate than are their unmolested fellow nationals.⁷ Six percent to 12% of immigrants from countries where torture is practiced say they have been tortured.^2,3 Torture rates are highest in people seeking political asylum. Twenty percent to 40% of asylum-seeking refugees from Somalia, Ethiopia, Eritrea, Senegal, Sierra Leone, Tibet, and Bhutan report being tortured.^7-9 In this context, the lack of data on refugees from countries such as Zimbabwe or Myanmar is not reassuring.

The plight of children. About 4% of torture survivors are children.^10,11 Some are street children brutalized by police; some are tortured to terrorize family members; some belonged to “enemy” communities. Investigation is warranted if an immigrant child comes from a country where torture is common and if the child was old enough to be imprisoned or forced to serve as a child soldier before entering a safe refugee camp prior to immigration.¹² It is more appropriate to screen such children for post-traumatic stress disorder (PTSD) than torture. A meta-analysis found that 11% of refugee children (vs 9% of adults) have PTSD, regardless of whether they were tortured or experienced war or pandemic political violence.¹⁰ The American Academy of Child and Adolescent Psychiatry provides a summary of findings typically seen in children with PTSD.¹³

How to broach the subject with adults. Screening for torture survivors is reliable and takes little time. You might want to ask a question that mentions torture specifically. For example, you might say: “Some people in your situation have experienced torture. Has that ever happened to you?”² Other questions could be less direct and follow the legal definition of torture from the Convention Against Torture: “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?”^14,15 The sensitivity and specificity of screening questions are estimated at 80% and 90%, respectively.⁸ Patient factors that can dampen sensitivity are shame and stigmatization (especially for survivors of sexual torture) and the trauma-amnestic component of PTSD. Secondary gain with regard to immigration appeals, however, rarely causes overreporting.³