Abstract Torture is widely practiced throughout the world. Recent studies indicate that 50% of all countries, including 79% of the G-20 countries, continue to practice systematic torture despite a universal ban. It is well known that torture has numerous physical, psychological, and pain-related sequelae that can inflict a devastating and enduring burden on its victims. Health care professionals, particularly those who specialize in the treatment of chronic pain, have an obligation to better understand the physical and psychological effects of torture. This review highlights the epidemiology, classification, pain sequelae, and clinical treatment guidelines of torture victims. In addition, the role of pharmacologic and psychologic interventions is explored in the context of rehabilitation.
Keywords Torture · Chronic pain · Pain sequelae · Refugee · Posttraumatic stress disorder · Psychological stress · Epidemiology · Rehabilitation · Treatment · Cognitive behavioral therapy
Torture, despite how one feels about its justification, is one of the most brutal and perverse aspects of humanity. A common definition of torture, and one that is often used in the literature, is provided by the United Nations Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, which defines torture as ". . . any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for any act he committed, or intimidating or coercing him or a third person, or for any reason . . .". National and international legal prohibitions on torture derive from a consensus that torture and ill-treatment are immoral. Despite this general sentiment, torture is widely practiced throughout the world. For instance, according to the 2009 annual report by Amnesty International, which documents the state of human rights in 157 countries for the period of January to December 2008 (the most recent time period for which data is available), 50% of all countries continue to practice systematic torture . Moreover, the same study indicates that 79% of the G-20 countries also continue to engage in torture despite a universal ban on this practice. Unfortunately, torture is not a new phenomenon, as exemplified by a long history of torture both within the United States and throughout the world, with antecedents dating from ancient Egyptians, Romans, and Jews . In the United States, the subject of torture has recently come to the forefront of national discussion within the context of interrogation of suspected terrorist suspects.
Health care professionals are most likely to encounter torture survivors as refugees and asylum seekers [4··]. In 1999, 400,000 survivors of torture were estimated to reside in the United States alone . Based on more recent data and the fact that more refugees come to the United States every year, it is now believed that the number of torture survivors living in the United States is in excess of 500,000 . It is well known that torture has numerous physical, psychological, and pain-related sequelae that can inflict a devastating and enduring burden on its victims [7-9]. Health care professionals, particularly those who specialize in the treatment of chronic pain, thus have an obligation to better understand the physical and psychological effects of torture. This article reviews the epidemiology, classification, pain sequelae, and clinical treatment guidelines of torture victims.
Most studies have examined the sequelae of torture as it relates to displaced and refugee populations. Primary caregivers are the points of first contact and important gatekeepers to recognizing victims and initiating or referring for treatment of specialized centers [10, 11]. However, specialists most often field these referrals and are responsible for initiating specialized treatment regimens.
The available data indicate that torture is fairly common in modern society. In general, the prevalence rates vary widely due to differences in the type of study conducted, the country of origin of the population studied, the gender of the participants, and the type of torture examined. A Danish study on adult Middle Eastern refugees concluded that 30% had been exposed to torture . More striking in this study was the male to female predominance in that 55% of male refugees were exposed to torture compared with only 12% of female refugees. A more recent study from Denmark indicated that 45% of asylum-seeking immigrants, representing 33 different countries, had been subjected to torture in their countries of origin . A cross-sectional, community-based, epidemiological study of Somali and Ethiopian refugees indicated torture prevalence ranged from 25% to 69% . Crosby et al.  examined the prevalence of torture among foreign-born patients, representing 35 different countries, who presented to urban medical clinics . The authors concluded that among foreign-born patients presenting to an urban primary care center (Boston), approximately one in nine reported a history of torture that was consistent with the United Nations' definition. Sexual torture has also been studied. For instance, Agger  found that 52% of male political prisoners who sought help after torture had been sexually abused, and a study by Peel et al.  indicated that 21% of Tamil refugees who had previously been imprisoned had experienced various forms of sexual torture. Moreover, a recent study by Norredam et al.  found that in a subset of male patients treated for torture, 28% were survivors of sexual trauma.
The literature indicates a high prevalence of persistent pain among survivors of torture. A comprehensive review in 2007 by Williams and Amris [4··] indicated that estimates vary based on the country and type of torture studied. Headache ranged from 39% in Uganda  to 93% in Denmark . Musculoskeletal pain, including back and neck pain, ranged from 60% in Turkey  to 87% in Uganda . Chest or thoracic pain ranged from 19%  to 37% , joint pain from 17%  to 43% , foot pain from 28%  to 72% , and pelvic pain 17% .
In 2008, Masmas et al.  compared tortured to nontortured asylum seekers arriving in Denmark. The study demonstrated that physical symptoms were approximately twice as frequent and psychological symptoms were approximately two to three times as frequent among torture survivors compared with nontortured asylum seekers. Also, among the torture survivors, 63% fulfilled the criteria for posttraumatic stress disorder (PTSD), and 30% to 40% of the torture survivors were depressed, in anguish, anxious, and tearful in comparison to 5% to 10% of the nontortured asylum seekers. Lastly, the study noted that 42% of torture survivors had torture-related scars.
The aim of torture is to obtain information or a confession to incriminate a third person, take revenge, or establish a reign of terror within a community. The classification of torture into physical, psychological, and sexual categories is somewhat academic because most victims often endure all of them simultaneously. However, the most common types of torture can be classified and summarized as indicated in Table 1 .
The most frequent physical torture method is blunt trauma or beating of all parts of the body with blunt instruments. Olsen et al. [28, 29] followed 139 previously tortured refugees for 10 years and showed that they all had persistent body pain even years later. The pain reported on follow-up closely related to the pain at baseline in terms of description, character, location, and severity. The most frequent physical torture method identified by Olsen was generalized beating. A similar interview conducted by the same researchers on 220 refugees showed that chronic pain in specific body parts was closely associated with specific torturing methods and frequency, For example, refugees with chronic foot pain had endured systematic application of blunt trauma to the soles of the feet or falanga torture. This might be of importance in managing torture survivors when early identification of certain kinds of torture methods could guide development of effective treatment programs for these survivors. Moisander and Edston  compared 160 victims from six different nations and concluded that falanga was the most commonly used method of torture. Prip and Persson  studied 11 falanga torture victims and concluded they all had chronic heel pain, compensated gait, and impaired neurological sensations as compared with controls.
Another common method of torture involves suspension of the body. Victims are usually suspended above the ground by their wrists and ankles for hours or days [31-36]. In addition, they may also be released, suddenly causing various forms of blunt trauma upon contact with the ground. The "Palestinian suspension," for example, consists of suspending the victim with one hand facing forward and other facing backward. Common injuries after these suspensions involve various brachial plexus injuries resulting in chronic, often life-long, neurogenic pain . Furthermore, suspension-type torture typically results in a stretch arthritis syndrome, a form of polyarthritis that affects the wrist and ankle joints in a characteristic pattern, often incapacitating the victim .
Knowledge of the type of torture employed can aid in evaluating injuries, scars, and other chronic sequelae. Thomsen et al.  studied common torture methods used on 18 Middle Eastern victims and concluded that each particular method of torture had an associated corresponding painful neuropathy. Such examples include Palestinian hanging associated with brachial plexus injury; falanga associated with peripheral neuropathy of feet; leg suspension associated with lumbosacral plexus injury; and positional torture associated with chronic low back pain.
Sexual torture includes sexual humiliation, genital trauma, castration, and rape. Norredam et al.  identified chronic genital and erectile pain, recurrent lower urinary tract infections, and chronic sexual dysfunction in survivors of sexual torture. Psychological torture involves direct threat to the victim or his/her relatives, sensory deprivation, mock executions, or witnessing torture. Sensory deprivations include detention in darkness, exposure to bright lights, and poor living conditions [39-41].
Whether the torture method is physical, psychological, or sexual, psychological sequelae are nearly universally present in victims, even in situations in which physical sequelae may be absent. For example, PTSD has been well described in almost all torture survivors [10, 42]. A full spectrum of psychogenic manifestations from generalized anxiety to major depression has been described . Suicidal tendencies can be more common with associated sexual torture methods, and sequelae such as unwanted infections, pregnancy, and social stigma often ensue . Previous torture, trauma, lower educational status, fewer social contacts, and unemployment represent some of the predictors of chronic distress in torture victims .
Dr. Adam J Carinci, MD, is a nationally recognized and sought after clinician, expert witness, and speaker with over a decade of Pain Medicine experience. He is double-board certified in both Anesthesiology and in Pain Medicine and maintains an active, full time medical practice. Dr. Carinci is Chief of the Pain Management Division and Director of the Pain Treatment Center at the University of Rochester Medical Center and an Associate Professor at the University of Rochester School of Medicine.
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