Concept – Please do not quote until draft has been completed and published
Visualizing the unseen scars and silent narratives of torture1
Janus Oomen2 (Medical Anthropological and Sociological Unit, University of Amsterdam,
the Netherlands).
Abstract
How telling are scars of torture? Can photographs grasp the evidence? In the restrictive
socio-political context of Fortress Europe, medical clinicians volunteer, on behalf of Amnesty
International (Netherlands), to make photographs of torture victims because the immigration
authority denied them asylum and threatened to extradite. This paper reviews interactions
between medical and human rights actors on individual asylum cases and in particular the use
of photographs in support of claims against the immigration authority. I will discuss the
evidencing through the means of photography as a focus in the documentation of the late
torture sequels and the role of the photographer in visualization. Scars are body memory and
signifiers of pain and suffering, impossible to understand out of context. The medical
practititioner meets difficulties in representing victims confronting asylum procedures. Some
tortures leave physical evidence, but many do not, and all victims have a combination of
significant mental, physical and emotional scars, they want to forget and try to avoid
speaking about. In procuring safety and healing, however, the story and the scars are all they
have and medical photographs can visualize the evidence.
The medical professional wants to make an irreproachable record. What links the visual with
the medical and can be applied for a proper account of the narrative? What photograph is a
striking one? How does one get to the point? How should the photograph be made and
described with the assistance of victims? The social, anthropological and ethical aspects of
traumatization and representation are important factors. Why are pictures interesting in
relation to torture? How are they politicized in the attempts towards a „Medical Atlas of
Torture‟?
1
Draft of the paper presented at the European Association of Social Anthropologists, Workshop 32, Processing
trauma in (post-) conflict societies, Ljubljana, Slovenia, on August 28-29, 2008.
2
Medical anthropologist and physician (non-practicing internist), member of the medical examination group of
Amnesty International, Amsterdam, and guest researcher in the University of Amsterdam Master’s of Medical
Anthropology(AMMA), oomen@xs4all.nl.
Introduction
This paper reflects, from a medical anthropological point of view, on the attempts towards a
„Medical Atlas of Torture'. What discourse connects the visualization with the narratives of
victims? Susan Sontag wrote:
Photographs furnish evidence. Something we hear about, but doubt, seems proven when we're
shown a photograph of it („On Photography‟ 1977: 5)
The author has been involved in that kind of photography. Since 1996 he volunteered as
member of a „scarring from torture‟ project group of Dutch medical professionals on behalf
of the local branch of Amnesty International. The photography of scars is one form of applied
expertise, providing a professional assessment on behalf of the asylum seeker. Before dealing
with a medical anthropological discernment („what is at stake‟), I will first describe the Dutch
medical context, exemplified by case histories, and then outline the impact, individually and
on an epidemiological scale, on the asylum conditions in the Netherlands. We will return
repeatedly to one salient IND3 stipulation in the asylum procedure, which is, that medical
expertise has no role because it cannot contribute to verification. What conflict is played out
here? I review several medical publications for a comparison. Can the officialized looking
away from scars as a narrative manifestation be counteracted by the photographs?
Cases, causes and contexts of photographing torture survivors
Only a tiny minority of torture survivors flee, from their country of origin to other countries,
to the European Union (EU) to obtain asylum. Taking the Netherlands as an example, the
total number of applications for asylum in the period from 2003 - 2007 is approximately
60.000 and varied around 10.000 annually on a population of 16,5 million (UNHCR). The
rates of admission are very low: less than 5% in the official procedure. The rules governing
the asylum policy in W. Europe aim at restriction, notwithstanding the fact that all EU-
members support the international asylum conventions. Several non-government human
rights organizations have voiced grave concerns about those policies of restriction.
As one Dutch lawyer and refugee expert formulated on behalf of Amnesty-Netherlands:
3
The Immigration & Naturalisation Department (IND) is the Dutch service assessing asylum requests on the
basis of the Aliens Act (2001).
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Janus Oomen - Visualizing the unseen scars and silent narratives of torture
Europe fears asylum seekers. For many years now they are the subject of a political discourse with
the emphasis on their numbers and not the persons. Media are reporting daily on war and
persecution in faraway places, but personal nearby narratives, of victims trying to survive that
violence, remain untold. Some of those victims seek protection in our backyard. Their dossiers are
stored in the Ministry of Justice (Busser 2007).
The admittances to asylum are never argued. Beyond words, one cause for Amnesty‟s active
local intervention is the fact that asylum requests by victims of torture are refused for
inscrutable reasons. In the IND‟s negative decisions, their stories were deemed either
„inveracious‟ (untrue) or „invalid‟ (according to instructions defining the trauma refugees
deserving protection). After the negative decision a long procedure develops, in which the
concerned, aided by solicitor and Refugee Council, appeals, adds arguments and involves
Amnesty in the validation of the request. In cases, where torture stories failed to convince the
IND, Amnesty offers the medical affidavit in support of the claim. On retrospect (evaluating
outcomes of Amnesty aided cases several years afterwards) a majority of rejections are
reverted in some way or other and a residence permit is achieved. In hind view, the initial
rejections were ill-informed and resulted from the manner in which, during the asylum
hearing, interrogations are conducted and decided upon. One cause for evidentiary
photography is the fact that the IND does not see the scars of torture (‘unseen’). Another
cause for Amnesty involvement is that the scars are not shown. More often than not, the
asylum seekers are, initially, unaware what is expected, or feel unable to speak about the
torture, due to the setting, the approach, or being in post-traumatic turmoil mentally (‘silent’).
Avoidance or denial of the torture trauma thus becomes reciprocal, because interrogators and
victims collude to keep out the painful events, which have led to the request and should result
in asylum. Consequently, it is only during the later development of the procedure, after the
negative decision, on instigation by solicitor, or by fellow-victims, refugee councillors and
(para)medical caregivers, that the person concerned realises „what narrative‟ („what truth‟) is
the key to asylum. However, immigration authorities refuse belated narratives, keeping
decisions as they stand on the principle that the „truth‟ is to be given at the 1st opportunity.
The judiciary actions to deny asylum aim at extradition, „refoulement‟, a forced return to the
country where the torture occurred. The fact that the asylum seeker runs the risk to be
subjected to torture again is the mainspring of the Amnesty intervention. The medical
disposition on the preceding torture is one way to counteract the effect of the narrative
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remaining ‘unseen and silent’. In the moment of need Amnesty is requested for assistance.
The need is the threatening refoulement and the necessity of a last effort to revert that
decision by convincing the judge of appeal. On the average, the asylum procedure has then
lasted two years or more. The person concerned has told the story of trauma more than once
and feels in a blind alley. At that stage, the medical sequels of the torture (be they present or
absent, and physical, mental or both) have remained „out of sight‟. They are new again -
‘nova’ in the asylum jargon. Since 1996 a „scarring from torture‟ project was initiated, as the
medical volunteers realized that photographs support the claim and extend the evidence of
late sequels of torture in the judicial documentation. In the hearings by Dutch asylum
officials, questions are asked about torture and the replies are recorded, but signs or scars are
not interpreted nor considered indication for medical consultation.
“Scars are of no account” (Oomen 2007). The interrogators do not look at the scars, even
when they are mentioned during the hearing. The looking away from clearly visible signs of
torture is perceived by Amnesty as being an officialized denial of proper asylum proceedings.
Though in itself a belated correction on the procedure, Amnesty‟s doctors are the only resort
for medical assessment tolerated by the immigration authority for the purpose. Since 2002,
the period I will review in this paper, an annual number of approximately 100 clients are
examined, by one or more physicians from a pool of 50 trained and ready. Their task is to
give a medical version of the narrative, and if scars are observed, to relate these to the torture
allegation, according to the instructions of the Istanbul Protocol as „best practice‟ guideline.
The IND and solicitor‟s dossier, Amnesty‟s human rights appreciation and medical data in
the correspondence with attending medical practitioners, are carefully studied beforehand.
The photographer, a volunteering non-medical professional, comes in only if visible scars or
handicaps are recorded during screening by Amnesty‟s refugee experts consulting with one
experienced physician of their group. Photographs are made in the setting of medical
examination and illustrate what the examiner considered significant to support or contradict
allegations of torture. Prior to examination, a written informed consent is obtained from the
client. The pre-examination information emphasizes that the client can withdraw the medical
report from the asylum assessment procedures at all times.
As to the photographs, Amnesty ensures that, when making public use of reports, the identity
of the client is in no way disclosed. As „lawfully‟ medical expertise is to play no role,
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Janus Oomen - Visualizing the unseen scars and silent narratives of torture
question is, in what way photographs can be turned against the authority‟s denial of the
victim‟s disclosure.
Case Histories
Excerpts of the medical reports illustrate the context and the role of the photographs4.
Achmed is a 30 years old male office employee, who was refused in the Netherlands and one other
European state after his flight from N. Africa. According to his allegations, he had been arrested two years
earlier and tortured (sticks, whips, one arm broken) by the secret police on the unfounded suspicion of
aiding anti-government actions. He escaped from hospital shortly after surgery for the arm. On physical
examination the scars were consistent with blunt trauma and upper arm fracture. The synchronicity of
surgery and alleged torture could not be ascertained: the scar could have occurred at an earlier date. As
Achmed told us that prosthetic material was present, we suggested a radiological examination and
consultation by an orthopedic. However, before the additional investigation could be arranged, the asylum
authority decided to grant the client asylum, not on the basis of procedural results, but as a part of a general
pardon, politically motivated, due to the enormous backlog (26.000) of cases since 2002.
Babür is a 36 years male ex-soldier, who was refused asylum in the Netherlands notwithstanding the fact
that 5 previous family members received permits based on the same background narrative in the Middle
East. Significantly Amnesty found no signs that the archived records of the client and his family had been
compared by the IND! His own story covered many traumatic episodes in different detentions: blunt and
electrical tortures, nail and tooth extraction and a knifing which left a large scar on the leg. He told us, that
he deserted from the army, was caught and detained in the capital, but escaped during a new war. On
examination the scars were consistent with the alleged forced teeth extractions, and the knifing had caused
atrophy and dysfunction of one leg. Posttraumatic mental signs were present. *The large scar on the leg
was without signs of surgical intervention (e.g. stitches) and thus consistent with spontaneous healing, as he
alleged, but the cause could have been another sharp injury, for instance in war actions.
Cassim is a 35 y. old male, whose asylum request was refused in 2003 after an inappropriate hearing, in our
view, due to the fact that he was in severe stress and unable to speak out. In all, two medical examinations
were performed by Amnesty (at an interval of 2 years) as the 1st had to be reviewed due to PTSD being a
hindrance in speaking out. He told us about several traumas starting 5 years earlier. The tortures had been
blunt, by sticks, whips and severe falaka. Other tortures, he remembered, were with hot and cold water and
suspension. In his African home country, the client was related to a politician in disgrace and belonged to
„the wrong tribe and job (physician)‟ in the eye of the torturers. He escaped from a detention hospital. Our
findings (*scars) were very consistent with the alleged falaka as were the burn marks of cigarettes and hot
4
Names, backgrounds and visually identifying particulars are changed to ensure that persons concerned are
unrecognizable.*Select photographs of the scars on the workshop presentation.
5
fluids. The client had suffered since a pain, ascending from the feet to the upper parts, both in rest and
during exertion. He experienced difficulty in standing and walking. “He walks as if on hot coals; the gait is
underdeveloped in the rolling movements towards the toes. He is unable to climb a chair unsupported. The
complaints of painful walking are increased without shoes”. After his partial recovery from the psychiatric
disorder we found these observations, twice, to be very consistent with severe scarring due to falaka, a
permanent specific handicap, as demonstrated in the international centers for the rehabilitation of the
tortured (in Copenhagen: Jacobsen & Smidt-Nielsen.,„Torture Survivor‟, ICRT, 1997). Photographs were
taken to demonstrate the similarities with that publication. In the photographs the eyes were masked on
request of the client. In due course, after the appeal procedure, asylum was granted one year later.
Dio is a 29 y. old male, arrested after protesting in a N. African country by posters against mistreatment.
During detention he was hit, while blindfolded, by a jailer with a heavy object (metal?) on the back of the
head. He remembered that bleeding resulted, which was treated by another jailer with coffee dregs, which
our client recognized on smell. He escaped from detention helped by corrupt jailers. We observed scars on
the back of the head consistent with the alleged head wound and also confirming his account that the
wound had not been properly medically attended – no stitches. The Arabic interpreter explained that the
„wound treatment‟ was a known „home panacea‟ in that country and we accepted his „cultural‟ insight (as a
context missing in the IND hearing). The narrative contributed to our interpretation to call this scar, shown
in a photograph, consistent with the alleged mistreatment. His asylum request had been refused 5 y. earlier,
but two years afterwards the negative decision was revoked without further explanation: possibly an
extradition was deemed inadvisable in view of the political enmity between the Netherlands and the
country of origin or he was „pardoned‟ due to the length of procedure.
Efraim was referred by his solicitor because the IND paid no attention to his physical and mental condition,
even while this client pointed at his scars. The story of the 25 y. old W.African man was that, during a
period of months, he had been traumatized in detention after a mass arrest of bystanders in a local political
upheaval. He was helped by a soldier of his own tribe to escape and arrived shortly afterwards in the
Netherlands. The then recent scarring could easily have been ascertained by the IND and in fact was
documented by the medical services within the asylum center. At our examination, two years later, the
findings included *scars on the shins in particular, interpreted as very consistent with the alleged kicks by
military shoes with metal noses and subsequent inflammation. One shin defect measured 10 cm and showed
distinctive features such as tissue loss, star shape and variably pigmented areas, interpreted as very
consistent with allegations of kicks on the vulnerable area of the shin. From a dermatological point of view
another „tropical‟ pathological agent could have caused a scarring skin disease, but not with the same
appearance. The pattern (type, localization and distribution) of scars was demonstrated by photographs. The
appeal judge instructed the IND to reconsider his request and he received a provisional permit to stay.
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Janus Oomen - Visualizing the unseen scars and silent narratives of torture
Francis was a 28 y. old male when asylum was refused to him and 4 y. later he was still appealing that
decision. A 2d asylum procedure was initiated by Amnesty, the outcome of which is still pending in 2008.
In his asylum tale the *1st photograph was taken by the client himself before self-treatment of scars with
anti-inflammatory ointment. The photograph showed extensive festering scars. When he was examined by
us several years later the scars had changed due to the treatment. In his allegations he had been detained
and mistreated in an African civil war situation and tortured (belted and burned) by „revolutionaries‟, who
had since moved into a government position. The client escaped because his knowledge of local area was
better than that of the rebels. He fled to the adjacent country and from there, assisted by a travel agent, by
air to the Netherlands. Our findings of the multiple scars were interpreted as very consistent with the
alleged whipping on his back, while being blindfolded, and the pattern matched that of the earlier
photograph. Several coin-like bleached skin areas would have been difficult to interpret without that 1st
photograph, but could now be explained as cigarette burns. Military belts with heavy buckles („cordelette‟)
had left distinctive scars on his back, of a type described in the literature (Peel 2000: 12). Still other scars
showed the typical „tramline-contours‟ known to be caused by the „sjambok‟ (whip).
Gian had fled from a W. African country after detention and torture during several months in different
locations, because he belonged to a tribe, suspected of hiding rebels. The history of this 26 y. old man was
difficult to translate and understand. He was an uneducated farmer, who had never been outside his village
before and was completely bewildered by what had happened since. Most of the many scars, he carried, he
could not explain to himself, because he had lost consciousness on several occasions. His skin was a
landscape of scars of different origins, but several of these – in particular in the genital area – were clearly
due to the traumatic episodes he was unable to remember in detail. The making of the photographs and
showing these to him for explanation made him recall and tell the interpreter what could have happened. As
an inventory, the photographs aided greatly – in showing the extent of traumatization also.
Hawa was seen by us as a 21 y. old female, who had requested asylum, but was refused forthwith (within
48 h.) and had appealed one year later, when her solicitor discovered irregularities in the 1st procedure and
requested a medical examination. As she retold us, she witnessed the killing of her father when she was 16
and was then abducted and raped by the rebel leader in a W. African country. This man kept her as a sex
slave in his bush camp during 3 years. While in this camp, she became pregnant and delivered a baby girl.
During a pacification period she fled back to her village, but was rejected. She was helped by a Red Cross
refugee worker to escape as a stowaway in a ship that brought her to Rotterdam. On our medical
examination, the findings were interpreted as consistent with the alleged mistreatment, but were difficult to
attribute to specific torture occurrences. A female circumcision scar was confirmed by photograph
(excision of clitoris and vulva in „tribal fashion‟). Findings were consistent with the narrative and time
setting. The important feature in the subsequent asylum procedure was her circumcision. She had been
rejected from her village, because she resisted giving her 1st daughter up for circumcision and, allegedly,
the girl was taken away from her. While expecting asylum, she delivered a 2d daughter. The risk for
7
circumcision of that girl, if both were extradited, was made much of in the procedures and for that reason
she received asylum „on humanitarian grounds‟.
Purpose and method of the examinations
The extensive archive of Amnesty, having thousands of similar affidavits on file since the
seventies, shows that the above cases were not chosen because of their exceptionality, but
simply for the fact that the demonstration of torture included the making of photographs, two
or more years onwards in the asylum procedure.
At first sight, the photographic documentation aims at a visualization of what was not
observed during the asylum hearing, versus what was observed during medical examination.
Scars and handicaps become pictorial in the process of demonstrating and interpreting the
individual traumatization. Additionally, the physician is enabled to state in what ways the
photographic details are consistent with allegations about the torture. The reporting takes into
account the guidelines of the Istanbul Protocol and also the similarity to scars and handicaps
associated with similar tortures as referenced in the human rights literature and in the
repositories of Amnesty International, the centers for rehabilitation of the tortured (CRT‟s)
and related forensic and medical public archives.
The medical examiners are trained to observe and reason from the trauma narrative to a
purposive, reproducible and systematic approach solving the focal query: how are the
observed scars, symptoms and signs consistent with the torture as stated by the victim. The
reporting is to be done is such way that the report is understood and accepted by the victims,
their solicitors, but also by the appeal judges, who will deal with the report as that of an
expert witness. The report also has to match Amnesty‟s expectations as a neutral non-
governmental organization, keen on their own independent mandate on what constitutes
torture in implementing the international Declarations and Agreements.
A closer look is necessary to specify the photographic application of medical diagnostics to
the late sequels of torture. Taking the medical history, a body scheme (provided by the
Istanbul Protocol) is used to ask the client to clarify, where what signs of torture are to be
expected, how they originated, what initial suffering they caused, if any treatment was
applied, how healing occurred and what sequels are experienced. Often other, non-torture
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Janus Oomen - Visualizing the unseen scars and silent narratives of torture
related, scars have to be explained too (differential diagnosis). As the next step, during
physical examination, a careful inspection is made of all exposed body areas and a systematic
assessment performed of the scars, allegedly caused by torture. If possible a forensic
examination and measurement is attempted and the affected areas are marked and
systematically recorded in their anatomical positions. The third step is to call the
photographer in and do a series of takes (overview, detail, close up). This includes an
identifying overview, and if possible, views connecting between the pattern and details of
scarring (or handicaps) – keeping in mind that too narrow a view could be dismissed as a
manipulation or undue magnification of the observation. The fourth step is to discuss the
record on digital camera with the client, often necessary when scars are on the back or in
other places inaccessible for the clients‟ perception, and additions. The fifth step is
integrating selected photographs in the draft-report.
Photography evidencing torture
The photographing simplifies the task of storing and describing observations in a system of
findings and facilitates clear and evidence based interpretations. A dermatologist can help as
a consultant. The draft is mailed to one experienced colleague, to the solicitor and to
Amnesty experts for further consultation and improvement of conclusions. Following
correction, the final document is signed personally by the doctor taking full professional
responsibility for all the report contains. The last step, after the original is sent to the client, is
to store a copy, with a written permission of the concerned, in a well-organized archive,
affording easy retrieval for the purpose of future reference, training and in the collection for
an „atlas of torture‟.
Painstaking as the routine seems, the real problems of evidencing torture to be the cause of
scars are not solved by a strategy as that. The approach imitates the bio-medical and forensic
methodology customary to a crime scene. True, in torture crimes are committed. In many
other ways however the investigation differs from those in medical criminology. The purpose
in asylum settings is to relay medical evidence on „ways the subject is a victim in accordance
with human rights in the Netherlands‟. Means for objectification are often weak and can fail:
A history of torture is one factor in making a case for asylum under the terms of the United
Nations 1951 Convention on Refugees, but it is a powerful one which can greatly influence the
9
decision. However, though patients and solicitors often expect it, it is almost never possible to
prove that torture has taken place once about 6 months has elapsed. Late physical after effects of
torture enable to give credence to an allegation, but only if the level of proof required is simply the
balance of probability (Forrest 2006: 31).
How to be convinced or not, on a case-by-case basis, is fundamental in the discourse. In the
examinatory setting this means, from a medical perspective, that the „alleged victim‟ and the
„intended diagnostician‟ join forces to „extract evidence‟ and „test consistency‟ to salvage
whatever can be reconstructed of the trauma. The systematization applied is to start by an
inventory from the narrative, translating events into injuries, locating sites where the skin
could bear traces and estimating effects of healing. One tenet in forensic technology is that
crimes leave traces, even if margins of probability have to be taken into consideration. A
matching conviction in (Western) medical psychology is that trauma runs a recognizable
course, as exemplified in the psychiatric criteria of the post-traumatic stress disorder (PTSD)
of the American Psychiatric Association‟s Diagnostic Statistical Manual. Attribution can be
assisted by independent observations, either made in previous cases, in the medical literature,
by the means of „magnification technology‟ (imaging or pathology), triangulation with the
observations on the same client by others and so on. If the query is the right one, the
interrogation can proceed in a manner, which is „acceptable to medicine as the best practice‟.
Another factor, not unimportant, is that the prolonged interval between trauma and
examination has the advantage of „longitudinal‟ coping with the torture reminiscences and
the adaptation of the victim to the new surroundings. Physicians are accustomed to be at one
time empathic, analytic and probabilistic in their diagnostic approach. They learn to make the
best of whatever clues they are offered. Torture is a pathological agent profoundly affecting
life, the human organism and the individual‟s mental balance. The assumption, that a trauma
so pervasive is untraceable on careful observation, is to be discarded from a physician‟s point
of view.
In medical photography this translates in attempts to visualize a pattern relating to the injuries
as to location, arrangement, extent, form, color and „typical‟ features resembling familiar
images („tramline‟ for the parallel stripes caused by whipping). Patterns are connected with
distinctive impacts, blunt, sharp, burning; in extent, direction in 3 dimensions; depending on
the underlying structure (bone) and initial qualities (genetic, age, sex) of the skin site
affected. Some injuries are more probable causes of secondary complications (infection,
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Janus Oomen - Visualizing the unseen scars and silent narratives of torture
inflammation, contraction) adding features to the image. The nature of the injury – and the
resulting image – depends on the position of victim and attacker during torture provided by
the narrative („defense wounds‟). Even though scarring is regarded as common pathway for
different injuries, external or internal (diseases), patterns still differ to the extent that they talk
to the initiated.
Ethnology proves that skin artifacts function in communication (scarifications, ornamental
changes, tattoos). In medicine, surgeons can see who operated and what operation was
performed, and dermatologists too can, recognize, differentiate and explain a scar‟s clinical
history from experience, on sight. However, to amplify the earlier citation:
All signs disappear unless there has been a breach of the full thickness of the skin. There are some
exceptions to this rule: in dark-skinned people even superficial injury may result in permanent
increase or decrease in pigmentation. Occasionally injury causing no breach may leave [visible
and palpable] changes [by compression, under the skin or in] soft tissue or bone. There is no
recovery of hair [or skin accessories as sweat glands] in a full-thickness injury (Forrest 2006: 31).
With respect to torture „breaching the skin‟, all the above arguments help to demonstrate that
narrative informs on scar and in return scar informs on narrative. Many torture scars are of a
certain type associated with similar narratives. Highly prevalent are the cigarette burns,
falaka handicaps from the soles upwards, ligature strictures on ankles, tramlines on the back.
Another type is made on purpose as signature in the flesh, the half-moon or cross-like
burnings. Other scars are distinguished by a modus operandi: shin scars by military boots,
whipping by cordelettes and specific dislocations of shoulder joints due to the „Palestinian
hanging‟. These scars all share, that they can be ascertained in an expert photograph.
Visualizing however is by no means limited to the technically detailed and measurable
imprint of the torture weapon or mode. Observing behavioral, non-verbal effects of events,
on the victim, is important in medical examination. As mutual trust is an asset of their
communication, interactions between patient and physician are purposive language. Reaching
a diagnosis is to the advantage of both. The patient speaks out and the physician asks for
more. Making photographs is by definition transgressive if victimization is involved, but
within the medical relation it is acceptable and the recording of an image is expected and
appreciated. Explaining the pattern of scars is a joint, mutual, cooperative undertaking.
11
The production of the image is one way to provoke memory. The still camera captures what is
seen by the human eye and creates visual information used for later analysis. Photography is
side by side qualitative and quantitative visualization, offering a closer look and
verisimilitude to lived experience in comparison to other reporting. The role of imagery vis-
à-vis text is clear in issues such as the ability to contextualize findings for evidentiary
purposes. Photographs have evidentiary value in their scale, focus and exposure, when
narratives are contested in court. In torture crimes, scar photographs can provide an entry
otherwise impossible. In facing ethical, political and emotional concerns (Abu Ghraib!)
photographs are experienced as more convincing than eye witness reports and have more
impact. By reproduction and data analysis, by categorizing and selecting, specific images
have an ethnographic „richness‟ for in depth discussion.
Comparing and contrasting alternative explanations with the help of photographs provides
arguments for a medical decision. Images can be clarifying and confusing at the same time:
numerous injuries (accidental, surgical, auto-mutilatory), other than torture, cause what may
appear a similar scar, but they are linked to different narratives, told with non-verbal behavior
incomparable to the tortured. Images demonstrate allegations of intentionality to be
consistent with a modus operandi and in what degree. Tortures are often classifiable by their
purpose to exert the most pain, shame and fear. Also by their aim to cause the least lasting
externally visible marks (on the genitals, soles; by submersion or „water boarding‟; mock
execution). Torturers wish to remain unidentified (blind folding) or keep the deed out of sight
(on the back). The impact is adapted to the victim‟s sensitivities (rape, disfigurement on the
face) or related to professions (breaking the fingers of a journalist) and political convictions
(branding a cross or a half-moon). Once the torture narrative is understood, an intention of
faking a torture memory to an experienced medical observer is improbable.
Experienced physicians are aware of the mental and somatic equivalents of anguish and
shame. Patterns of torture are the signatures of the perpetrators and scars are reminders of
their contempt. An evil and degrading intention has affected both mind and body. It is, in
fact, exactly the very individual magnitude of human degradation, which gave rise to the
solemn human rights conventions, forbidding torture as the very worst that people could do to
each other. If one has an eye for that consideration, scars of torture are body memory and
signifiers of a quite specific nature in the narrative of suffering. The victims have experienced
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Janus Oomen - Visualizing the unseen scars and silent narratives of torture
a mental and physical shock, considered to be extreme in all clinical studies. Conditions of
verification may be difficult or exacting, but, if medical professionals share the anguish,
forgoing on it is simply no option. The deliberate setting of the examination for late sequels is
indeed incomparable to that of crime forensics. As a rule, the perpetrators will not be
apprehended and their handbooks of torture are unavailable for reference. Neither will there
be public records of consequences of torturing. By keeping sight, however, of the emotional,
personal, political and cultural context, physicians have substitutes for that concealed
information. Would it not be a poor physician then, who is unable to tell the difference?
Front and backyard view on asylum healthcare
As seen from the previous paragraphs, the involvement of the medical professional in the
assessment of torture allegations depends on the task the profession sets to itself, above and
beyond the assignment by governments, clients or any other agency. Remarkably, the history
of revealing torture shows doctors to be bystanders more often than not, notwithstanding their
„Hippocratic instructions‟ (under oath!) and the participation of medical organizations in anti-
torture lawgiving. The Declaration of Geneva by the World Medical Association is one such
moment of verification (or golden standard) in medical ethical traditions. However, it is safe
to say that in common medical practice, in the Netherlands, torture is perceived as a „human
rights issue elsewhere, unknown to these parts: a matter out of place‟. In asylum countries, in
particular those where torture is not practiced, in the public domain, the narratives are
perceived as incomprehensible. Both officials and doctors tend to declare themselves
„incompetent assessors‟ even if they fully apprehend the individual consequences to the
victim. In EU-countries and their allies, physicians at work to examine or offer treatment to
the late survivors of torture, are few. They work on an „ad hoc‟ basis mostly. Only when the
workload requires a more formal arrangement they organize themselves, and these
organizations look for „natural allies‟ more to human rights NGO‟s (HRNGO) than for
support and integration under medical (para-) governmental professional umbrellas. In
addition, standing apart from the international executive organizations, such as the UNHCR,
these HRNGO‟s and action groups are critical of „appearance in front, but not in the back‟.
Most doctors live in front.
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Demographically, that fact is interesting to the medical anthropologist, by virtue of the offer
of a backyard view on health, as it is affected by human rights perceptions in a post-conflict
society. While, since the 1948 Universal Human Rights Declaration, in the front view,
asylum carries a stamp of positive, permanent and global acceptance, local implementations,
on an individual and regional basis, are obscure, variable, temporary or simply unattainable
from the HRNGO perspective. Asylum – a socio-cultural phenomenon – subserves
governmental policies of the day and the protection promised is a strictly controlled gift of
great rarity. As to the medical perspective, McGorry stated (1995: 463):
The health and welfare needs of refugee survivors of torture and trauma have in recent years belatedly
found a prominent place on the policy agendas of Federal and State Governments. The development of
a statewide service to meet these needs provides an opportunity to illustrate some of the general issues
in developing a model specialist community health service, as well as the specific and complex
elements involved in the care and resettlement of refugee survivors of torture and trauma.
Healthcare associated with asylum is perceived as „statist‟. Accordingly, in Dutch asylum
conditions, the provisions are fully controlled by the IND and function as part of the
restricted admittance. The „specific and complex‟ elements, McGorry referred to, sound as
considerate care, in front, but in the Dutch backyard they appear as carefully measured
deterrence. One overall feature is the lack of agency allowed to the target groups, asylum
seekers and medical caretakers. Another feature is the extensive and intricate detailing of
„what to do and what not‟. The services to asylum seekers are tight, clients having no choice
and the regulations with respect to prevention aiming at „quarantining‟ (such as screening for
tuberculosis to preserve the local population against infections). No screening is done for
typical medical origins of an asylum request, other than a self-assessment-questionnaire,
which is put on record by a nurse, and, as far as asylum procedure is concerned, shelved. The
IND instruction reads that „on the basis of medical examination, no firm pronouncements can
be made as to the cause of complaints or scars‟. So instructed, the official, hearing the asylum
request, is interdicted to rely on medical expertise for the purpose of assessing traumatization,
even if that information is readily available in the asylum seekers‟ medical dossier.
Medical information is pronounced irrelevant to the asylum decision. Even more to the point,
medical staff are prohibited to bring the trauma to the attention of the IND on their own
accord, due to medical confidentiality – an anti-client interpretation of an ethical tradition
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Janus Oomen - Visualizing the unseen scars and silent narratives of torture
which is intended to favor the client. The medical services are further instructed that,
depending the outcome of the asylum request, only urgently necessary (lifesaving) medical
interventions are allowed. Once the negative decision is made (within 48 „office hours‟) – by
far the most common occurrence – the client is an „illegal person‟ in the Netherlands, to be
extradited immediately if possible, and otherwise left to his resources to leave the country on
his own, under threat to be forcefully detained and removed to the country of origin if not.
During „illegality‟, the means to obtain medical services are limited to the barest necessities
and in fact quite often refused by hospital facilities as „irrecoverable‟. One recent outcome,
emphasizing how inconvenient asylum seeking has become in this country:
Each year some 20,000 irregular migrants and asylum-seekers are detained in the Netherlands, where
the use and duration of detention and other restrictive administrative measures is increasing. A June
2008 Amnesty report examines how far these measures have led to a deterioration in the human rights
situation of irregular migrants and asylum-seekers. The report examines how far Dutch immigration
policy conforms with international human rights law, which considers that immigration detention
should be an extreme measure of last resort. It looks at the effect on vulnerable groups of increasingly
restrictive measures, and considers whether Dutch law and practice allow for sufficient and effective
accountability, transparency and accessibility for irregular migrants and asylum-seekers to seek redress
and enjoy the protection of their human rights, despite their irregular status (Amnesty Report 2008).
In tracking the discourse on asylum we meet this revealing figure: every year 10 percent of
refugees, from a dynamic pool of approximately 200.000 „illegals on flight‟ in the
Netherlands, stay in prison because they are refugees. At this point, the annual number of
those imprisoned in 2008 is greater than that of asylum requests, due to arrears. It is
unknown, „unseen and unheard‟, what proportion of the prisoners has a history of torture, and
an important reason for that is an absence of medical insight in their plight. A further
exploration of circumstances, the torture victims are in, will show that at the one hand
policies of asylum restriction and deterrence cannot be applied to them fully and at the other
hand the aftermath of torture generates an avoidance to speak. Combined, these causes give
rise to a range of conflicts and contradictions, affecting the visualization.
Conflicts and contradictions
Quite in contrast to the formal denial of medical information when advantageous to the
allegation of torture, the IND applies medical technology when the claim on asylum can be
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contradicted. The estimation of „biological‟ age by the means of radiology and physical
anthropology is an IND procedure. This method entails that the claim of being an underage
asylum seeker (under international agreements owed special care) is to be verified by an
assessment of bone maturation. Several authors, both medical and legal, have criticized the
validity and ethics of the procedure (Smeets 2004: 32; Keunen 2004). The scientific criticism
is that stages of maturation are too variable to furnish certainty in such dispute. Significantly,
radiologists involved in assessment refused to countersign reports, distancing themselves
from a personal relationship with the examined person. This was unacceptable to legal
judgment, demanding signature responsibility (van Es 2003). The exchange of arguments in
the discourse demonstrates that medical imaging in asylum claims is not a freestanding
instrument for neutral reproduction and judgment, but deeply politicized.
The application of medical photography is a project useful in making trauma manifest.
Advantage is that the documentary evidence in the hands of photographers can follow the
golden standard of a guideline (‟color photographs of all physical evidence as a routine part
of examinations using accepted forensic methods‟– Istanbul protocol). As the case histories
exemplify, pictures contribute by demonstrating that significant injuries have been missed at
the time of the IND hearings. Due to the superiority of photography, details and patterns of
the injuries are an eye witness report providing a testimony supporting remembrance. From
that angle, photography surpasses the limitations of narrative by being a completely faithful
or consistent re-enactment. Memory is malleable but scars persist. During traumatic events,
stress and chaos prevail, and torturers take precautions, such as blindfolding. Victims lose
consciousness. The fear and the shock of degradation blocks perception and recollection.
Shame, guilt and self-preservation are important considerations, particular in sexual tortures.
As one survivor formulated: “I could not defend myself against the torture, but now I can
refuse to relive the event”.
Quite often, the client has no words for the experience: many females from traditional
societies do not know how to describe rape in their language. Post-traumatic coping differs
strongly between cultures and individuals. Constructing an image can often clarify what is
lost in translation or where words fail. There is the agent of time, the post-traumatic interval
at the IND hearing, and, again much later, the belated medical examination. Worn out, clients
lose faith in their ability to convince and give up, because the burden in giving evidence is
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Janus Oomen - Visualizing the unseen scars and silent narratives of torture
overwhelming. Even then, scarring remains a link, overlooked, but which cannot be made to
disappear. Within the population, seen by Amnesty‟s doctors, at several instances the
presence of scarring occasioned the reopening of asylum procedure, when, meeting the scars
by accident, the commiseration of attending physicians or refugee workers was aroused and
their questions and reports rekindled the investigations. These incidents mark the fact how
little is known, recorded, revealed and understood about survivors of torture, at least in the
asylum countries. The medical examination is only one opportunity enabling asylum seekers.
Photographs are a „Western‟ approach of signifying and naming an injury. The imaginary is
made concrete. Medical science transforms the visualization into the perception and the
acknowledgement of trauma, which can be important to the victims as they feel revictimized
by the misinterpretations during the asylum procedures.
On the other hand there is a contradictory danger of retraumatization by the medical
photograph. Scars are not only signifiers of an event, but also identify the person. Amnesty-
Netherlands promises, as part of the informed consent, to prevent the identification of the
client in public. The photograph risks an improper usage, if publicized. Clients still have
reason to fear the torturer or an abuse of medical information. From collecting a „scarring
from torture‟ inventory Amnesty-Netherlands learned that the practical problems in achieving
a forensic level – to achieve an „atlas of torture‟ – are manifold. The photographs which
could be borrowed from HRNGO collections were unclear, descriptions absent and matching
medical documents unavailable either due to informed consent or the lack of it. As we have
seen, effective visual medical representation is also difficult by virtue of the fact, that many
physical traumata cause injuries, which, after healing, are hard to visualize or specify. It
happens, that scars, when they are clearly visible, cannot be differentiated from other injuries,
unrelated to torture, with confidence. In search of objectification and consistency, a
photograph of a scar by itself is a poor substitute, rarely communicating the severity – in
particular the mental anguish – of trauma. To find an approach, which carries the verification
of torture scars to the professional level of medical forensic photography, is an exacting job.
The ‘Atlas of Torture’ and the photographic assumption of truth
Summing up the torture experience in a photograph is a task of extraordinary difficulty. To
assist a visual medical documentation of torture, an atlas compiling all useful material in the
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professional media will be welcome, but how to reach that goal against the odds described?
There is only one recent example in Turkish, which deals extensively with the documentation
of more recent injuries and which has been collected in a state, where torture is still rampant.
The Turkish forensic authors, also the initiators of the Istanbul Protocol, have succeeded in
setting an example to the profession, and done so under great personal risk. On the subject of
the late sequels of torture, more isolated case studies are appearing in the medical literature,
and a few dedicated dissertations, monographs or human rights manuals. Only few contain
pictures, which comply with professional standards. Other material has to be collected from
internal publications, handbooks or by courtesy of rehabilitation physicians, dermatologists,
surgeons and forensic pathologists, who kept illustrations for their own purpose of reference
and training. A limited number of professional publications are now publicly available
(Bloemen 2004: 556; Brogdon 2003, Peel & Iacopino 2002, Jacobsen 1997, Basoglu 1992).
Opening the eyes is what is necessary (Ford 2002):
Photography is also a metaphor and symbol: it is a representation and in that it stands for
something. The picture you create is not the same as the thing you photographed. William Wylie
said “I want the reverberation of the photograph, as an image of a subject that matters, to expand
out to all aspects of our feelings and experience”.
Sontag, clear-sighted, teaches us that making photographs, as attempts of truth finding by
actors and bystanders on the issue of torture in the asylum procedure, requires the company
of a political gaze, informed and willing to see:
The possibility to be morally touched by a certain photograph is completely dependent on the
presence of a relevant political consciousness (Sontag 1977: 21).
Notes
The author is indebted to the clients for their consent; to Mireille van der Linden, Pascale Diederen,
dermatologists; to Milette Raats, and Kees Hummel, photographers and to the volunteers in the medical
examination group for professional cooperation and to Marc Stolwijk and Heleen Tiemersma, staff of
Amnesty International Amsterdam, who coordinated the medical examination group and supervised the
case procedures.
References [to follow with the definitive manuscript]
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