ABSTRACT

Objective

Torture is a violation of human rights which still preserves its importance in today’s world. Istanbul Protocol (IP), is a formative document prepared by many experts working in related fields on the medical reporting of torture and is accepted by United Nations. Our objective in this study was to evaluate the effectiveness of the provision of IP training to students who will probably work as the wardens of the future.

Methods

A survey covering twelve statements structured according to IP was administered to 29 volunteers (17 males, 12 females) who second-year students of Criminal Execution and Security Services Program. Students were asked to respond to the statements in the survey as agree, disagree, or have no idea. The changes in the answers given before and after the training were examined.

Results

A higher rate of correct answers in all statements of the survey was observed after the training and the change acquired in all statements except one was detected to be statistically significant. For instance the rate of those who thought that it would be appropriate for security forces to accompany the examination was 68.9%, and the rate of those who thought that a biological sample could be taken by force was 65.5%. After training, these rates decreased dramatically.

Conclusion

In the struggle against human rights violations and torture, the acquisition of information and sensitivity on these subjects by all addressees of the subject is very important and IP training would constitute good means for this aim.

INTRODUCTION

International law clearly and definitely prohibits torture (1-3). Legal documents accepted by United Nations (UN) member states clearly state no exception for torture prohibition and also the importance of effective investigation and other obligations for protection against similar violations. UN have been carrying out inspections and presenting reports and suggestions against torture and other cruel, inhuman and degrading treatments for years (4). Despite all, torture is a violation of human rights which still preserves its importance in today’s world (5). Human rights violations and their prevention studies are very important in today’s world where wars, forced migrations, illegal immigrants, refugees, concentration camps and death penalties continue to exist. Based on the call by UN on “Support Day for International Torture Victims Day” on June 26, 2023, today, more than 100 armed conflicts are ongoing worldwide, devastating communities, winding back development, and posing severe obstacles to the protection and enjoyment of human rights. UN experts called for states to uphold absolute prohibition of torture in armed conflict (6).

It is one of the most aggravated crimes known to humanity, not only because it involves the intentional infliction of severe physical and mental pain, but also because it is committed by officials or with the acquiescence of a state and is often concealed effectively to prevent justice and accountability. Istanbul Protocol (IP), or “Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment” is a prescriptive document prepared by many experts on medical reporting of torture-related fields and is accepted by UN (7). It covers both medical and legal requirements. All steps to be taken in case of torture claim are explained in detail in IP. The current edition of the document approved in 1999 for the first time was released in 2022. The 2022 Edition of the IP was published in Turkey in accordance with the translation agreement numbered PB/CON2022/25 signed between the UN and the Human Rights Foundation of Turkey on 20 December 2022 (8).

Many studies covering the importance of IP, showing the applications (deficiencies, national policies) and positive results of the training provided (generally for physicians) are available in literature (9-18). Healthcare professionals and especially physicians among the most important figures of torture prevention, detection of evidences and rehabilitation stages acquire information, skill and sensitivity on the subject in later IP trainings and also due to the liabilities of medical ethics (16-19). It is also very important to provide information and awareness on the subject through similar trainings also to security forces, prison employees and lawyers who are other addressees of the subject. Our objective in this study was to evaluate the effectiveness of the provision of IP training to students who will probably work as the wardens of the future. This result will contribute to the literature and international torture prevention programs in terms of guidance.

MATERIALS AND METHODS

Criminal Execution and Security Services Program is a two-year university department aiming to train wardens for prisons. Forensic medicine is among the second-year lessons of the department. IP training covers six hours of forensic medicine syllabus. These classes aim IP identification, acquiring information on subjects structurized in the form of covered titles and gaining experiences on application through case scenarios. The subtopics of the IP lessons were as follows; overview of international human rights law in the context of torture, ethical rules, basic principles in interviewing, physical evidence, mental evidence, documentation. Learning objectives; to be able to define torture, to list the legal bases of the prohibition of torture, to have information about the prevalence of torture, to explain the physical and psychological findings of torture, to explain the documentation of torture, to explain the principles of examination in the context of human rights. The classes were given by the corresponding author of the study holding a IP trainer certificate.

In our study, one of the quasi-experimental design types, the single-group first test-posttest technique, as well as the first test-posttest experimental group design [An initial test is applied to an experimental group without a control group, then it is subjected to intervention (IP training in our study) and the intervention is applied in the last stage. A post-test is applied to measure its effect] was preferred. The survey was checked by two academicians who contributed to IP and their suggestions were considered. The survey started with age and gender information. Afterwards, there was information about the definition of torture, the approach to the allegation of torture, and medical services in the context of human rights. There were four statements for each topic. IP lessons were taught in December 2023. The first test was administered twenty minutes before the first lesson of IP, and the last test was administered in the last twenty minutes of the last lesson of IP. The survey was administered in hard copy. It covered 12 sections of information or scenarios structurized according to IP. The choices of the survey were “I agree”, “I disagree”, “Have no idea”. The correct answers for information and scenarios were determined in line with IP norms and suggestions. The information and scenarios included in the survey are shown in Table 1.

Statistical Analysis

SPSS v.25 (IBM, USA) was used for data analysis. Descriptive statistics were shown as average ± standard deviation or median (minimum-maximum) for constant variables and as frequency and percentage (%) for categorical variables. There were two categories, pre- and post-training, and the compared data were categorical (since it is entered categorically, not as a score pre- and post-training) data. Therefore Pearson chi-square test was used to compare the categorical variables to be compared within the scope of the study and following the calculation of chi-square through the residual values (Z-score) for significant results following the test and the separate calculation of p-values for each group, Bonferroni correction was performed and significance levels were compared. Statistical significance level (Type-1 error level) was accepted as p<0.005 for the analysis covered in the study.

Permission was obtained from the Bandırma Onyedi Eylül University, Health Sciences Non-Interventional Research Ethics Committee (date: 18.10.2023 meeting no.: 2023-8) for this study, and Helsinki Declaration rules were followed to conduct this study.

RESULTS

Gender distribution of participants was detected as 58% male (n=17) and 42% female (n=12). Based on the age distributions of the participants, average age was 19.69 (±0.712), the minimum age was 19 and the maximum age was 21. The gender and age distribution of the participants are shown in Figure 1.

The answers of the participants to the survey and their changes following IP training are shown in Table 2 and Figure 2. Excluding one statement (no. 4), the change in athe answers to all statements was detected to be statistically significant.

The correct answer “I disagree” for statement 1 was detected to increase and “I agree” answer to decrease following the training and these changes were detected to be statistically significant (p<0.001).

“Have no idea” answer in statement 2 was observed to decrease significantly (p=0.001) and “I agree” which is the correct answer to increase following the training.

“I disagree” which is the correct answer for statement 3 was observed to significantly increase (p<0.001) and “Have no idea” answer was observed to significantly decrease (p=0.013) following the training.

A statistically significant result could not be acquired for statement 4 in the survey. However, it was observed that the answer “I agree”, which is the correct answer, increased following the training.

The correct answer “I disagree” for statement 5 was detected to increase and “I agree” answer to decrease following the training and these changes were detected to be statistically significant (p<0.001).

The correct answer “I disagree” for statement 6 was detected to increase and “I agree” answer to decrease following the training and these changes were detected to be statistically significant (p<0.001).

“I disagree” which is the correct answer for statement 7 was observed to significantly increase (p<0.001) and “I agree” answer was observed to significantly decrease (p=0.013) following the training.

“I disagree” which is the correct answer for statement 8 was observed to significantly increase (p<0.001) and “I agree” answer was observed to significantly decrease (p=0.006) following the training.

The correct answer “I agree” for statement 9 was detected to increase and “I disagree” answer to decrease following the training and these changes were detected to be statistically significant (p<0.001).

The correct answer “I disagree” for statement 10 was detected to increase and “I agree” answer to decrease following the training and these changes were detected to be statistically significant (p<0.001).

The correct answer “I agree” for statement 11 was detected to increase and “Have no idea” answer to decrease following the training and these changes were detected to be statistically significant (p<0.002).

“I disagree” which is the correct answer for statement 12 was observed to significantly increase (p<0.001) and “I agree” answer to significantly decrease (p=0.002) following the training.

DISCUSSION

A wide-scale systematical and recent study examining the worldwide prevalence of torture methods showed that torture is applied intensively in almost all regions of the world (20). The first four statements of the survey we use in our study were about the presence of torture in today’s world, definition of torture and, the fact that it should absolutely prohibited. The next four statements were about supervision and the approach to the torture allegation. The results of the surveys performed before the training showed that the students lacked adequate information and awareness on these subjects. Indeed, these were subjects that the students should absolutely have information on to be able to perform their future profession. Lack of knowledge about the definition of torture, what can constitute torture, and its prevalence is very dangerous. Because in this case, the state official does not consider an action or inaction that he/she witnesses or even commits as torture. The rate of those who thought that torture was not common before the training (statement 1) was 58.6%, and the rate of those who had reservations about inspecting places where there may be a risk of torture (statement 5) was 65.5%. After the training, these rates decreased dramatically to 6.9% and 0.0%. Desired changes were acquired at a statistically significant level in all statements excluding fourth statement, following the training as we targeted and predicted. The fourth statement was about torture being a war crime and subject to international jurisdiction. The fact that the students had law lessons may have helped in the answer to this statement. A statistically significant change was not acquired in fourth statement but still an increase was observed in the number of individuals giving correct answer after the training.

A study examining the accordance of the examinations during prisonment to IP revealed the high deficiency in application (9). IP is an important guide for the approach to the claim of human rights violation, examination principles and ethical borders (15, 21, 22). Last four statements of the survey used in our study were related to the general approach to the examinations to be performed in case of torture claim and the medical ethical approach towards prisoners. When medical evaluations are required for the prisoners for health problems, torture claims or other causes, wardens have a very important position at the point of responding to this need and also as the accompanying officer during all these processes. For the successful progress of all these stages, it is very important to provide training on these subjects to future wardens. To that end, this positive change acquired in the last four statements of our survey following IP training constitutes a very important result. The rate of those who did not find it appropriate to remove handcuffs during the examination (statement 9) was 62.0%, the rate of those who thought that it would be appropriate for security forces to accompany the examination (statement 10) was 68.9%, and the rate of those who thought that a biological sample could be taken by force (statement 12) was 65.5%. After the training, these rates decreased to 10.3%, 3.4% and, 13.8%, respectively.

In the third statement, which is related to the definition of torture, the response of “I have no idea”, which was approaching 35%, dropped to zero after the training. Although not at this rate, the response of “I have no idea” decreased similarly in all statements after the training.

Turkish Medical Association, Human Rights Foundation of Turkey and Association of Forensic Medicine Specialists in Turkey made great contributions both institutionally and through experts in the preparation phase, updating and translation of the IP. Afterwards, they supported the process with IP training (23, 24). IP which is the gold standard in the medicolegal evaluation of torture is a very functional resource on torture concept and for future trainings to prevent it (11, 14, 16, 25). It is very important for the staff dealing with groups such as illegal immigrants, prisoners of war, refugees and prisoners and working at environments such as concentration camps or prisons or during wars to take IP training. Thus an awareness will form on torture and a high advantage will be acquired to prevent it. Accordingly, our study has positive results in terms of the information level and awareness acquired after the IP training given to students who will work as wardens in the future.

Statistical Analysis

The limited number of people surveyed, the lack of a more systematic survey and, as a result, the inability to conduct more functional statistical analyzes were considered the limitations of our study. In addition, the fact that it was applied to people who have not yet done their job professionally or even do not plan to do it in the future was considered as a limitation. It is also a limitation that IP training is given by a single trainer.

CONCLUSION

Although torture has been prohibited by the international and humane law, it still continues to exist in today’s world. IP is a very important document for the effective investigation and documentation of torture. It is also a very useful resource for future trainings on torture. IP training is generally associated with trainings for physicians. Although it is a very important subject, it also has many other constituents. Within the context of human rights violations and torture, provision of IP training to lawyers, security forces and prison employees who are other actors of the subject other than physicians is another issue to be considered. Studies to be conducted regarding the awareness of relevant professional groups on the subject will be important in terms of demonstrating the need for IP training. Following the IP training given to the students who will continue their professional lives as wardens, a positive change was observed in subjects such as the concept of torture, evaluation of torture claim, physical examination principles and medical ethical values. It is very important to demonstrate similar changes in other professional groups after IP training and to include them in the literature. In the struggle against human rights violations and torture, the acquisition of information and awareness towards the subjects are very important and thus IP training would constitute good means.

ETHICS

Ethics Committee Approval: Permission was obtained from the Bandırma Onyedi Eylül University, Health Sciences Non-Interventional Research Ethics Committee (date: 18.10.2023 meeting no.: 2023-8) for this study, and Helsinki Declaration rules were followed to conduct this study.

FOOTNOTE

Authorship Contributions

Surgical and Medical Practices: U.A., Concept: U.A., F.A., Design: U.A., F.A., Data Collection or Processing: U.A., Analysis or Interpretation: U.A., F.A., Literature Search: U.A., F.A., Writing: U.A., F.A.

Conflict of Interest: The authors declare that there is no conflict of interest.

Financial Disclosure: No financial support has been taken.