How can signs of deliberate physical injury be detected years after they were caused? What are the physical and psychological ramifications of torture for its victims? How can we cope with the moral dilemmas raised by treating captives and prisoners? Physicians who attended the first workshop in Israel devoted to locating and treating torture victims share their insights.
“I must admit that the issue of torture kind of passed me by,” says Dr. Revital Arbel, a senior gynecologist at a hospital in Jerusalem. “It was always out there somewhere, but I guess that I preferred not to see it. Then I monitored the pregnancy and labor of an Eritrean refugee who was raped in Sinai. Although I have been involved in these issues for years, working with victims of sexual assault, this was the saddest birth I have ever seen. I will never forget the sadness in this mother’s eyes when her son was born.
“I monitored the entire pregnancy not knowing she had been raped. When she came in to deliver the baby she was accompanied by an interpreter for the first time, and they told me the story. Slowly the things she had been through in Sinai began to sink in. Like other refugee women imprisoned in Saharonim, she had not been able to undergo a termination of pregnancy at an early stage. It’s hard to realize that women who arrive there pregnant are not given the opportunity to undergo termination. This causes appalling suffering. However late it is, it is always possible to stop a pregnancy in these circumstances – anything rather than see the face of a woman giving birth to her rapist’s child.”
Just as Arbel realized that eventually this suffering would not forever pass her by unnoticed, she received an invitation to participate in the first-ever training program in Israel for physicians and psychologists teaching ways to locate and diagnose torture victims. She accepted the invitation and became one of the first 16 participants to undergo training from foreign experts in working according to the Istanbul Protocol. The workshop is an ongoing project of the Public Committee Against Torture in Israel (PCATI), in cooperation with the International Rehabilitation Council for Torture Victims (IRCT). It provides training in the forensic aspects of torture. The knowledge is used to identify victims and mainly to provide evidence in court or in other formal examinations, such as applications to the United Nations to receive refugee status.
Arbel now knows much more about torture in Israel and around the world than she ever wanted to know. She can diagnose a person who underwent torture many years ago, offer legal confirmation (or non-confirmation) of their story, and sometimes even ensure that they receive treatment or that justice is done. “Torture leaves marks,” she explains, “and these remain in the body many years after the event. The interrogators may be careful not to leave blue bruises, but today we can also identify what’s under the skin – what the bones remember.”
The bones of clinical psychologist Dr. David Senesh remember all too well. If the human body were able to remember generations back, Senesh would also remember the torture suffered by his aunt, Hannah Senesh, the Jewish parachutist who was captured by the Nazis. But Senesh and his body make do with the 40 days spent in an Egyptian jail during the 1973 Yom Kippur War, after he was taken prisoner from one of the Israeli outposts along the Suez Canal. “I’m post-traumatic,” he says openly. “The guys who were held prisoner with me can’t figure out what I’m doing; how what we went through brought me to identify with the experience of occupation and treat Palestinians who have undergone torture. But from my perspective it’s a logical continuation.”
“Torture violates the victim’s humanity and destroys him,” says Dr. Bettina Birmanns, a neurologist at the same hospital in Jerusalem, as she attempts to explain why she repeatedly finds herself dealing with this subject. “I’m increasingly convinced that when a state permits torture, it damages the fabric of the state and destroys trust between citizens the authorities. Even if ‘regular’ citizens do not believe that they will be affected, the fact that someone in an official position is allowed to use serious violence and deliberately cause someone else pain and suffering, damaging their inner kernel and soul – and we know that this happens – that destroys society. I cannot accept that.”
The two physicians and the psychologist admit that they paid a heavy emotional price for their participation in the series of workshops. Alongside theoretical sessions discussing methods of torture around the world, trainee participants also diagnosed actual cases, engaged in role-playing exercises, and confronted professional and personal dilemmas. “It always takes me a week or two to calm down after all the things I’ve heard,” Senesh reveals.
“There’s a reason why the training program attracted relatively long-serving physicians,” Arbel suggests. “I think this work demands maturity, and I’m glad that I didn’t suggest that any of our interns join it. Maturity is important in order to act properly and cope with the difficult exposure to the people involved and their stories. You also require moderation – you cannot be too extreme in either direction, but need a mature view of life.”
Birmanns: “One is exposed to stories where the only possible reaction is to say: ‘it’s unreal.’”
Birmanns was born in Germany, fell in love with Israel, converted to Judaism, married and is raising her children in Israel. She is an experienced physician and an active member of PCATI. Among other areas of activity, Birmanns wrote a neurological opinion for PCATI about the damages of “painful shackling,” which can cause paralysis and intolerable pain. Holding to a purely humanistic worldview, Birmanns is a natural candidate for the training program. By contrast, Arbel would probably not have found herself in the program if she hadn’t been signed up by her friend Birmanns. Arbel is one of the pioneers in the treatment of the victims of sexual assault in Israel. Among other things, she is a specialist in identifying forensic signs years after the assaults. In recent years she has volunteered to examine refugee women with Physicians for Human Rights-Israel. Nevertheless, she in no way considers herself a human rights activist. “Medicalization,” she repeatedly asserts, batting off political and moral dilemmas. “It all has to be totally medical, scientific, and substantiated.”
You were already working in some very difficult fields, why go as far as torture?
“You reach a point where you just can’t ignore it anymore. You examine one person and then another, and another, and you realize that there’s a pattern. You hear the traumatic stories, and you see the victims after they were tortured – what they experienced has an impact on their health, their psychological condition, and their relations with their wives, children, and with society at large.”
“People undergo personality changes. They’ll never be the same as they were before they were tortured. They were all imprisoned afterwards and didn’t receive treatment. So first they are tortured during interrogation, which results with various kinds of problems. And then their imprisonment kind of freezes the situation, and when they are released all kinds of issues and experiences erupt and those around them don’t know how to cope with it. People are happy to see them out of jail, but they are not really the same people who went into jail, partly because of the torture. It’s hard for them to talk about it because it floods their emotions, plus their friends and family don’t always want to hear about it. There’s also an element of lost dignity, similarly to sexual assault. In fact, in many cases the torture includes an element of sexual assault. You then meet people without any ambitions. Empty people.”
How do your colleagues at the hospital react?
“We do not talk about politics at the hospital and I can’t discuss this with anyone. I couldn’t even talk about it with my husband at first. We grow up here with the constant threat of the ‘ticking bomb’ so the whole subject is very sensitive. There are people among us who lost their loved ones in terrorist attacks. That’s clear to me. I don’t talk to people about it. Not about refugees nor Palestinians – I just don’t talk about it!”
Asylum seekers, too? Isn’t that a less sensitive issue than the torture of Palestinians?
“Well, some physicians were not willing to write a professional opinion for a refugee who sued the state because they didn’t allow her have an abortion in jail. That’s the way things are here.”
And you are taking a stand, just like those physicians, aren’t you?
“I stand as a physician. I don’t get into political questions but consider what I can do as a person who has expertise in this field. It’s about taking cases and ensuring they get appropriate attention and evaluation. Someone I wrote an opinion for then gets treatment, and so do his wife and children. Personally, when I write an opinion one of my goals is to allow them to choose the right treatment – and that’s a physician’s function.”
Don’t you feel that your empathy for the person complaining of torture could influence your professionalism?
“I do not feel sympathy towards them. This is not the case. I examine a complaint.”
‘We don’t ask why they were tortured’
“One must understand,” says Birmanns, “that as physicians we look at any individual as a human being, and there are certain things that one human being must not do to another. We never ask why they tortured someone, whether it was necessary, or how loudly was the bomb ticking. I don’t care whether he has three children or if he kidnaps children. It does not matter.
“In some countries torture – the official definition is ‘the deliberate causing of pain or suffering by an official body’ – is completely forbidden. Such is the case with Germany. A well-known case involved a German policeman who threatened a suspected kidnapper who was refusing to reveal the whereabouts of a kidnapped boy. The policeman threatened to slap him – he was desperate to get the information. The kidnapper sued the state for torture and won the case. His admission was ruled inadmissible.”
This is a difficult story, and the Israeli context might be even more so – the person under interrogation who possibly knows the whereabouts of a suicide bomber on his way to carry out an attack, and the chance to extract information from him and save lives. Torture would seem to be almost unavoidable in this kind of situation.
“In many cases the state defines torture as saving human lives. We talked a lot about the ‘ticking bomb’ – this is repeatedly mentioned when one discusses torture in Israel. Well, first of all, there’s no certainly that the information cannot be secured by other means without smashing someone’s head into a wall. And in the case of many victims nothing came of it: they went through abuse or humiliating treatment without providing any information or leading to the saving of any lives.”
But what about the one instance – and there have been more than one – when torture does save life?
“I still believe that a law-abiding state should not deliberately cause pain and suffering and ruin someone’s life. There should be a border that remains uncrossed, beyond any discussion. That’s also what the international Convention against Torture says, and Israel signed the convention.” Dr. Arbel believes that “it is all very complicated, but the good thing is: it’s irrelevant. You must draw a line, as the establishment keeps causing extremely severe suffering to defenseless individuals over days and days, and that is very bad.”
Still you’re an Israeli, you know the context, you do not come from classical Europe. Didn’t you have any doubts?
“At the beginning of the training some physicians wondered whether it might not be permissible to torture detainees in certain cases. But after what we heard we reached the clear conclusion that it isn’t permissible. There’s a very strong process in Israel that turns the Palestinians into the ‘other’ – it’s ingrained in the education system, and it allows people to imagine that torturing might be okay. But we reached the conclusion that we do not take an interest in the question of why the person was interrogated: just as I wouldn’t ask a woman who was assaulted why she was walking down a dark alley. It doesn’t matter why he was interrogated and what he had done. And it goes both ways: Just because I write an opinion, it doesn’t mean I agree with the deeds that led a suspected victim to trial. The two things are completely separated. It’s irrelevant. There’s no sympathy here, just a total separation between your human emotions and thoughts and your duty as a physician.
“I remember one incident during my medical studies while I was working as a nurse; I must have been about 22. A policeman arrived with a beaten detainee and I treated the man. The policeman said, ‘Why are you treating him so well? Do you know what he had done?’ I was a polite, well-behaved girl and I respected the policeman, so I replied: ‘We’re a hospital and I do what needs doing. I’m going to be a physician and care for people.’ I wasn’t even aware of the subject of torture, but something about the situation was very clear to me.”
Being together with the patient
“Over years I have treated children and applied my profession to protect them,” tells Dr. Senesh. “That wasn’t to escape from my own trauma, on the contrary. What many do not understand – the Rehabilitation Department of the Defense Ministry included – is that the trauma of captivity is nothing like battle trauma. There’s an essential difference between the two. The trauma of captivity is injury within an ongoing relationship. Over time the captive regresses and becomes helpless and dependent on his captor. It is very similar to the trauma children experience. We were also tortured [in Egypt], of course. In fact the training workshops we attended made me recognize some of the things they did to me, and wonder about the way we were treated.”
Senesh recalls that while he was in captivity “captives used to return from investigations after they suffered head injuries, and then lose consciousness. I remember that they made us lose consciousness and then brought us round again countless times. It’s very easy to do with a soft, deliberate blow. The objective was to faze us during interrogation, and sometimes simply to have fun. This causes medical damage, let alone the psychological impact – the knowledge that you can easily be knocked out and removed. When I hear about this from a patient it reawakens my own injury, for sure, but it doesn’t paralyze me. I don’t treat captives, by the way.”
Senesh recalls that when he went in for the first time to diagnose a refugee who had been tortured in Sinai, together with a physician, “I saw the doctor go up to the patient, touch him, examine him, and extract his story – not in order to write his opinion, but first of all just to hear it. That took me back to the medical committees I had to satisfy after we returned to Israel from captivity. The doctors would sit behind a desk, always opposite us. I always had to prove that I had been injured. I felt as if they were toying with us. It really impressed me to see a doctor abide with the patient who was telling his story, and sometimes reliving what he had experienced. That’s my part in the verification process – looking for the source of the injury, like a detective.”
And what about the personal dilemma when you face someone who was tortured under interrogation? No-one knows better than you that the other side would treat you at least as badly under similar conditions.
“For me the easier situation is when you’re dealing with refugees, because then the evil was committed elsewhere. He suffered in his own country, and then on the way to Israel, particularly in Sinai. As a Jewish, Israeli, male diagnostician you don’t belong to the side that inflicted the pain, you are the savior. When you interview a Palestinian, however, you represent someone who has come to help, but also those who hurt him. Maybe he was a terrorist who was a threat to you, and when he’s released he’ll be a threat to you again. That’s a possibility. But once he has undergone torture he is transformed from an attacker to a victim, and you have to hold to this realization.
“It’s something that’s hard to do. It is easier for a doctor – he examines the hand that struck a blow or threw a grenade, while as a psychologist I also have to examine the head that gave the order. This can come up in a conversation: He might ask me ‘do you know what I was accused of?’, and I may reply that I’m not interested, or I may address the matter and see where that leaves me. We discuss this dilemma, but I can’t tell you what is the right thing to do. To me, it is an unfamiliar field of experience.”
Doesn’t all this influence the professional opinion you write?
“It is not our job to say whether or not the torture happened. We weren’t there. All I can say without moving beyond my professional field and becoming someone’s legal counsel, is that ‘the symptoms and aspects I identify are consistent with the results of torture.’ I also have to separate things. Whether I examine what happened in Sinai or during an interrogation where the use of torture is suspected, I have to put aside all the background information. Whatever the details, the refugee in any case came from a situation of distress, poverty, and war, possibly human trafficking and slavery. There’s a good chance that he is already post-traumatic. In the case of a Palestinian who was tortured, I ignore the arrest, the children who may have been crying in the middle of the night, possible threats to hurt his dear ones, sometimes the practice of undressing the prisoner in front of his family. I examine the aspect of torture and strive to do justice.
“I can state that if someone who has been tortured is sent back to prison, or to Holot camp for refugees, for that matter, there is a good chance that this will reawaken his trauma. Once again he will find himself in a camp in the desert where others control his routine, disconnection from life. So you get a chance of writing an opinion that may prevent detention and get him out of that. But how can we avoid the temptation of doing that en masse? By bearing in mind that this would turn us into a rubber stamp and lose our professional standing.”
Pushing away the truth
During the training course the participants wrote opinions that helped release or prevent the detention of two asylum seekers. They also prepared an opinion that was attached to a petition, in a case in which the state admits that a Palestinian man was tortured but refuses to open a criminal investigation, as in many similar cases. Birmanns, Arbel, and Senesh will now work as part of the team of trainers for the next program for physicians, which will be run in cooperation with the Israel Medical Association (IMA).
The three participants pay far more attention to professional and moral dilemmas than the system in which they operate. The obligation incumbent on a physician to report suspected cases of torture (along the lines of the obligation to report the abuse of children, women, or legally incompetent persons) is a relatively new concept in Israel and has not yet been implemented in practice. In January 2012 Boaz Lev, the Deputy Director-General of the Ministry of Health, appointed a committee to which medical staff are supposed to report cases of interrogees who show signs of damage to their health. The committee is also supposed to receive and process complaints about physicians who fail to report torture. To date the committee has only received a handful of complaints.
“The committee was appointed in 2012 and has not since received any reports from medical personnel about the suspected abuse of detainees,” a Health Ministry spokesperson said in a statement, more than two weeks after the request for comment was made. “The committee will soon be reappointed and the Health Ministry will work to increase awareness of its existence among medical staff in the health system.”
“If a prisoner comes to the emergency room bearing signs of violence, the Istanbul Protocol requires the recording of his complaints and the examination and documentation of the symptoms,” Birmanns explains. “But that’s in theory. In practice, in the case of a prisoner – and particularly a Palestinian detainee – even obvious marks on the body are often ignored. If he comes in with a broken hand they put a plaster cast on it and release him home or back to whoever is holding him. According to the Declaration of Tokyo it is forbidden to return a person to those who are torturing him.”
I have collected numerous testimonies concerning the abuse and rape of asylum seekers from Eritrea held in the Bedouin camps in Sinai. At some point I started to feel that it couldn’t be real. All the stories seemed very similar, and instead of seeing this as proof to their credibility, it made me wonder whether they have made up some fairy tale that is passed around by word of mouth, thus serving their general “story.”
“We all do that,” says Birmanns with a smile. “When you encounter a torture victim you do everything possible to push away the truth. Your brain hunts for every possible explanation why it can’t actually be the truth.”
So did the torture in Sinai actually happen?
“Yes,” reply both physicians. Arbel leaves no room for doubt: “We have seen the photographs of people who had boiling plastic poured on their backs. It cannot be anything else. We met them. Unlike those who torture on behalf of the Israeli authorities, the Bedouin don’t care about leaving marks.
“Here in Israel part of the method of operation is to leave as few marks as possible on the skin – no bruises and certainly no scars. When they handcuff someone’s arm they put a handkerchief underneath. But neither they nor the victims realize that these actions leave neurological marks – damage to the nerves. These are things that can be seen under bone scanning or brain imaging, and certainly by means of psychological diagnosis. Today there are all kinds of ways to follow these tracks and to get closer to the truth.”