Medical documentation of torture must include as much as possible, the following details along with the clinical examination.
These help to correlate the clinical findings with the kind of torture that the person was subjected to. This documentation in turn can help the victim/survivor to access justice and also contributes to holding the police accountable.
Identity of the victim – Full name, gender, age occupation, address, date of birth, description of appearance, photograph, relevant medical files. Was there any process of identification (record of personal information, fingerprint, photograph)?
Identity of the perpetrator – Name (including or even nickname) and rank if possible, connection with the state, Description of uniform/clothing, vehicle, weapon or any other identifying characteristic (scars, birthmark, tattoos, height, weight (relative to the victim), language, accent. Did the person know the perpetrator prior to the events? Was the perpetrator intoxicated? What did the perpetrators speak among themselves?
Description of initial contact with perpetrator – Was it official arrest, time of day or night, reason for taking into custody, date, was there use of violence, threats, abuse, restraints?
Description of location of torture – Prison, police station, lodge, detention centre, military facility, outdoor. Describe the room, what was there in the room, how was the hygiene and lighting, was it an isolated area, who were the visitors to the area, were lawyers permitted, was there access to medical care? Were there insects, rodents? Was there a bed? Was there overcrowding or solitary confinement?
Description of form of torture – Where did it occur? When? How often? By whom? How long did it last? What was the physical and psychological effect immediately and later? Was there anyone else present in the room? Describe. Were instruments used? Was there abusive language? (specify if it was based on a person's gender, caste, religion, sexuality, physical ability, color, occupation etc.) Document the words used. What was the immediate and long term effect of the abuse? Did they receive medical attention? Was it before, during or after the abuse? Did they ask for medical attention? Did they receive it? Were instruments used for abuse? What were the immediate and long-term effects of the abuse? If the victim received medical attention, or requested it and the request was denied, directly before, during, or after the abuse, this should all be detailed. Include date (s) of torture, how many times, for how many days, period of each episode. Describe what they saw, heard and smelt. Were they blindfolded?
Use of instruments or equipment - Rods, pipes, hooks, ropes, barbed wires, water, lighters, matchboxes, electric wires, cords
Was there sexual assault? - Most people will assume that sexual assault is rape or sodomy, but details should be obtained about verbal assault, disrobing, groping, lewd or humiliating acts, injuries or electric shock to the genitals. This has to be sensitive to the person’s gender, sexual orientation, culture, personality etc.
Other witnesses – Were there others present? Who where they? Did they see the person immediately after the attack or during? Was there contact with family, lawyer or health professionals?
Supporting evidence? – Medical record, photos, witness statements, media reports, official complaints. Were they asked to sign any document?
Is there a pattern of abuse? – Are there others who have faced similar abuse and who can come in to give evidence? Any media reports? Any deaths following similar patterns of abuse?
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