Assessment of Torture and Ill Treatment of Detainees in Mexico: Title and subTitle BreakAttitudes and Experiences of Forensic Physicians

Torture and ill treatment of detainees commonly occur in more than half of the world's countries and have devastating physical, psychological, and social health consequences.^{1 - 2} In response to this problem, physicians and other health professionals worldwide are playing crucial roles in efforts to investigate and document medical evidence, treat torture survivors, prevent torture, and oppose any form of physician involvement in torture.^{3 - 7} Because many countries in which torture occurs require or allow medical examinations of detainees by forensic physicians, ensuring that these physicians have adequate training, resources, and autonomy is critically important to hold perpetrators accountable and end the practice of torture. Toward this end, more than 75 physicians, psychologists, human rights experts, and lawyers representing 40 organizations from 15 countries worked together to develop international standards for the effective investigation and documentation of torture and ill treatment.⁵ The guidelines are now published by the United Nations (UN) as the Manual on Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (ie, the "Istanbul Protocol"),⁸ along with a set of principles outlining minimum standards for state adherence to ensure the effective documentation of torture.⁵ The UN Commission on Human Rights has unanimously annexed these principles to several UN resolutions.^{9 - 11}

Mexico's Constitution explicitly prohibits "all incommunicado detention, intimidation or torture."¹² Mexico's Federal Law to Prevent and Sanction Torture defines torture as a public servant's infliction on another person of "severe pain or suffering, be it physical or psychological, with the aim of obtaining from the victim or a third party information or a confession; or of punishing him or her for having committed or being suspected of having committed an act; or with the aim of forcing them to behave or stop behaving in a particular way."¹³ Mexico is also a signatory to the UN Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment.¹⁴ Despite these formal measures, however, international and Mexican human rights organizations have documented torture in all 31 states and the Federal District of Mexico and at all levels of federal, state, and municipal law enforcement systems.^{15 - 19} Those who have reported experiencing torture include criminal suspects, political detainees, and members of indigenous communities in areas of significant military presence. In addition, it has been reported that torture is committed by law enforcement agents in the context of the administration of justice to secure confessions later used in court as evidence.²⁰

Responsibility for Mexico's public security and judicial systems is divided among relatively autonomous federal, state, and municipal administrative entities. At the federal level, the Office of the Attorney General (la Procuraduria General de la Republica—PGR) is mandated to prosecute a variety of crimes, including drug-related offenses, arms trafficking, kidnappings, and immigration-related crimes. A range of other crimes are handled at the state level by separate prosecution services and their supporting judicial police forces. These federal- and state-level entities each employ a corps of forensic physicians (ie, physicians trained in the legal applications of medicine and in investigating causes, mechanisms, and consequences of inflicted injuries). These physicians are required under law to examine detainees. There are approximately 130 000 state prisoners and 47 000 federal prisoners in the total prisoner population in Mexico. Of the federal prisoners, approximately 13 000 are detainees (ie, those held in detention centers who are indicted but not sentenced), as are 62 000 of the state prisoners.²¹ A corps of 115 federal forensic physicians is assigned to examine federal detainees, and approximately 310 state forensic physicians examine state detainees (with an additional 120 physicians assigned to the Federal District). Thus, in a country in which there was approximately 1 physician per 500 people in 1990,²² there is 1 federal forensic physician per 113 federal detainees, and 1 state forensic physician per 200 state detainees.

In addition to medical examinations when detainees are first detained and when they are taken to court, governmental authorities must provide an examination by an official physician to any detainee who requests it.^{20 ,23} Even in cases in which other independent physicians have documented evidence of torture, however, the official forensic medical report included in the legal records of these detainees often reports no evidence of torture.²⁰ As in other countries in which torture occurs and forensic examinations of detainees are required by law,³ inadequate official medical examinations may serve as impediments to defendants making claims of torture. Because judges require an official medical certificate documenting evidence of torture, a medical certificate with no information regarding torture is used as conclusive evidence that no torture occurred.²⁰

The election of President Vicente Fox in July 2000, ending 7 decades of 1-party rule in Mexico, created a historic opportunity to address the country's human rights problems, including torture. President Fox has pledged his government to fully respect human rights and the rule of law and has promulgated a series of reforms to fulfill this pledge.¹⁷ In the context of these reforms, in December 2001, the Mexican government signed an agreement with the UN High Commissioner for Human Rights to strengthen judicial and police procedures to prevent torture, including improving forensic medical investigation and documentation.²⁴

To further these aims, in December 2001 the Mexican Federal Attorney General's office consulted Physicians for Human Rights (PHR) to help design a model training program for all physicians with the PGR's Federal Forensic Service, assist in standardizing medical examinations and documentation of detainees, and develop specific recommendations on prevention and accountability measures. This consultation represents the first comprehensive initiative to implement governmental reforms in accord with the Istanbul Protocol and its related principles. In March 2002, a team of PHR experts (including V.I. and A.M.) met with PGR officials, physicians, and representatives of independent Mexican human rights organizations. Because little is currently known about the prevalence of torture and ill treatment in Mexico and the attitudes and experiences of forensic physicians examining detainees, participants agreed that an important first step for efforts to improve forensic documentation would be to conduct a comprehensive survey of federal- and state-level forensic physicians.

Accordingly, we designed and conducted a survey to answer the following research questions: (1) What is the frequency of medical examinations and autopsies in which torture is alleged, suspected, or documented? (2) What problems do forensic physicians encounter in conducting thorough and impartial medical examinations? and (3) What are forensic physicians' attitudes regarding the practice of torture in Mexico and measures to improve forensic investigation and documentation? This assessment of Mexican forensic physicians, undertaken with the full support of the Mexican government, is the first initiative of this kind and will be used to inform subsequent efforts to implement the Istanbul Protocol in other countries.

In May 2002, all 115 physicians listed on the PGR's nationwide Federal Forensic Service employee roster were hand-delivered a written survey with a return envelope and cover letter from the General Director for the Protection of Human Rights in the Mexican Federal Attorney General's office requesting their participation. To ensure anonymity, respondents could either mail the completed survey inside the envelope without identifiers to a PHR representative in the United States or place the anonymous survey in a plain sealed envelope in the mailbox of a person designated by the regional PGR delegation to collect and mail the envelopes to the PHR representative. Because there is no reliable central list of state-level forensic physicians employed with state attorney general offices, we surveyed state forensic physicians attending the annual national forensic medicine conference organized by the PGR and held in Mexico City in August 2002 to assess experiences and attitudes among state-level physicians. A PHR representative attending the meeting (A.M.) distributed the questionnaire to all 99 state forensic physicians participating in the conference (32% of an estimated 310 forensic physicians associated with state attorney general offices). All questionnaires were self-administered in private and returned to the PHR representative in a sealed, blank envelope.

To further ensure confidentiality, the only personal information requested of respondents was medical specialty and approximate years of forensic medicine training and practice. Since individuals' responses were not tracked, only 1 wave of surveys was distributed to each group. Moreover, because responses were anonymous, no data are available on nonrespondents. Participants received no compensation. The research protocol was reviewed and approved by an independent group of individuals with expertise in clinical medicine, public health, bioethics, and international human rights research, and conducted in accord with the Declaration of Helsinki, as revised in 2000.²⁵ The data analysis plan was reviewed and approved separately by the Ann Arbor Veterans Affairs Medical Center's institutional review board. Data collection occurred between June and August 2002.

The questionnaire consisted of 80 items developed both to address the particular Mexican context and to cover areas necessary to assess the extent to which practices and attitudes corresponded with international standards for forensic investigation and documentation of torture. The survey was composed of the following sections: (1) medical training and practice information; (2) attitudes about the definition of torture and the extent of the problem of torture in Mexico; (3) estimated numbers of cases of alleged, suspected, or documented torture among detainees examined in the previous year; (4) trends in rates of suspected and documented torture in the past year compared with 5 years before; (5) assessment of problems forensic physicians encounter in investigating and documenting torture; and (6) recommendations for reforms. While all forensic physicians in Mexico are supposed to use the definition of torture and ill treatment provided in the Federal Law to Prevent and Sanction Torture,¹³ an aim of the survey was to ascertain respondents' working definitions of torture and ill treatment. Thus, the terms "torture" and "ill treatment" were not defined in the survey. Because legal definitions of torture usually include both "torture" and "ill treatment,"¹⁴ survey questions asked about "torture and/or ill treatment" (tortura y/o maltrato). "Alleged" torture and/or ill treatment was defined as a verbal claim of these by a detainee. "Suspected" torture and/or ill treatment was defined as cases in which the physician had reason to believe that the detainee may have experienced torture and/or ill treatment in the absence of verbal allegations by the detainee or clear evidence of such abuse. For questions requesting respondents to estimate numbers of medical evaluations conducted and cases of alleged, suspected, and documented torture in the past 12 months, response categories with ranges of numbers were provided in the survey.

The survey questionnaire was first written in English and then translated into Spanish. Some questions were adapted from earlier extensively field-tested PHR surveys of forensic physicians who examine detainees.^{3 - 4} The Spanish-language questionnaire was pilot tested among 5 physicians and human rights experts in Mexico, 2 of whom were fluent in both Spanish and English. The wording was compared in the English- and Spanish-language versions, and suggestions from the pilot test were incorporated into the final questionnaire.

Descriptive statistics were generated using STATA 7.²⁶ Since our objective was to describe the attitudes and experiences of this population of forensic physicians, rather than comparing groups of physicians on the basis of training, practice, or caseload variables, we did not conduct comparative statistical analyses. Moreover, because of the differences in the sampling frames for federal and state forensic physicians, we do not present statistical comparisons between these 2 groups of physicians. We calculated ranges of total numbers of medical evaluations of detainees conducted by respondents in the previous 12 months and cases of alleged, suspected, and documented torture among detainees in the past 12 months as reported by the respondents. Total ranges for alleged and documented cases were determined by multiplying the low and high end of each range category by its frequency of responses and then summing all range categories for overall low and high range totals. For suspected cases the ranges were calculated by multiplying the top and bottom range number of cases each individual reported for the past 12 months by the top and bottom percentages of cases in which each individual reported they suspected torture.

Practice, Training, and Case Load Characteristics. Although 103 federal forensic physicians returned surveys, 10 of these were only partially completed. Thus, the effective sample of respondents consisted of 93 federal forensic physicians (81% response rate). As Table 1 shows, almost all survey respondents (96%) had at least 1 year of formal training in forensic medicine and of practice in the field. Approximately half of the federal physicians (56%) had been practicing forensic medicine more than 10 years. The predominant medical specialty was general practice (76%). Other specialties represented included general surgery (6%), internal medicine (4%), pathology (1%), gynecology (2%), and psychiatry (1%).

Ninety-eight percent of federal respondents had conducted forensic examinations of detainees in the past 12 months. Forty-nine percent of federal physicians reported having conducted more than 400 evaluations in the past 12 months. The 93 federal forensic physicians responding to this survey estimated conducting 26 445 to 30 650 or more medical evaluations of 13 000 federal detainees in the past 12 months.

Attitudes About Torture. The majority of federal forensic physician respondents defined torture in a manner consistent with Mexican and international legal definitions of torture and ill treatment, including both physical and psychological forms of abuse (Table 2). Forty-nine percent of federal forensic physician respondents reported that torture is a severe problem for detainees in Mexico. An additional 30% considered torture to be a problem of moderate importance. Seven federal physician respondents, however, indicated their belief that torture and/or ill treatment can help to obtain the truth from detainees, and 12 agreed that it is appropriate for law enforcement officials to be present during medical evaluations of all detainees.

Estimates of Number of Cases of Torture and/or Ill Treatment. Sixty-three percent of federal forensic physician respondents (58 of 91) reported having examined detainees in the past 12 months who alleged that they had experienced torture and/or ill treatment while in police custody (Table 3). The highest percentage of these physicians (43%) reported examining between 1 and 50 detainees who alleged that they had experienced torture and/or ill treatment. Thirteen percent had examined between 51 and 100 individuals who alleged torture and/or ill treatment, and 7 physicians reported examining between 101 and 300 individuals who alleged torture and/or ill treatment. Respondents reported that they had examined a total ranging from 1658 to 4850 individuals who alleged torture and/or ill treatment, or 5% to 18% of the total number of evaluations of federal detainees reported in the past 12 months.

Forty percent of respondents (37 of 92) had suspected torture and/or ill treatment in detainees examined during the previous 12 months, in the absence of verbal allegations of abuse from the detainees (Table 3). These 37 federal physicians reported that they had examined between 131 to 678 detainees in which they suspected torture and/or ill treatment in the absence of allegations from the detainees. A majority of respondents (51 of 79, or 65%) reported a decrease in the number of cases in which they suspected torture in the past year compared with 5 years before. Twenty percent of these respondents (16 of 79), however, reported an increase in such cases.

Forty-nine percent of respondents reported documenting forensic evidence of torture and/or ill treatment in examinations of detainees in the past 12 months. These 45 physicians reported documenting torture and/or ill treatment in 285 to 1090 cases (Table 3). These cases of documented torture or ill treatment represent 1% to 3.5% of the estimated range of numbers of evaluations of detainees conducted by the federal forensic physicians. Finally, 20% of respondents (18 of 90) reported documenting evidence of torture and/or ill treatment in autopsies in the past 12 months.

Problems in Documenting Torture or Ill Treatment. Respondents reported a number of obstacles to their efforts to provide thorough and impartial documentation of physical and psychological evidence of torture (Table 4). Seventy-three percent of respondents stated that forensic evidence of torture was limited in most cases, and 60% agreed that police refinement of torture methods minimizes physical signs. Twenty-nine percent of respondents reported that forensic physicians' inadequate documentation of evidence contributed to torture and ill treatment of detainees in Mexico, and 36% cited insufficient monitoring and accuracy of medical examinations as a problem. Additional obstacles included coercion by police officials or the presence of superiors during examinations (18%), and forensic physicians' fear of future reprisals if they document torture (23%). Eighteen percent of respondents reported that law enforcement officials had attempted to be present during their examinations of detainees in the past year, and 6 physicians stated that this presence had influenced their medical examinations and/or reports.

Respondents cited a number of resource and training constraints impeding their ability to document forensic evidence of torture (Table 4). Seventy-five percent of respondents (66 of 88) reported never using photographic documentation, and 58% indicated that they did not have photographic equipment or services available to document physical findings. Twenty-eight percent (26 of 92) reported that their forensic training had provided little or no preparation to document forensic evidence of torture.

Only 60% of the physicians surveyed (55 of 93) answered the question asking whether a judge had ignored at least 1 of their medical reports of examinations of detainees who had alleged torture and/or ill treatment. Eighteen physicians stated that their reports had sometimes been ignored because of the absence of physical findings, 15 because they had not established a cause-and-effect relationship between alleged torture and physical findings, and 12 because they had not identified an alleged perpetrator in their reports. Thirty-five physicians (38% of respondents) agreed that police officers had ignored evidence of torture or ill treatment of detainees.

Measures to Improve Forensic Documentation. While only 23% of respondents (21 of 93) reported that their forensic medicine colleagues at least occasionally fail to document forensic evidence of torture (Table 2), almost all respondents (98%) agreed that forensic physicians need additional training in the effective documentation of torture (Table 5). Most (81%) also stated that a standard evaluation form for forensic physicians to use in cases of alleged or suspected torture and/or ill treatment would be useful. Moreover, 95% supported enhanced measures to monitor the quality and accuracy of medical reports in cases in which torture and/or ill treatment is alleged. When asked what should happen to physicians who misrepresent, omit, and/or falsify information in reports of torture or ill treatment, 21% indicated that such physicians should be given a warning, 42% supported criminal sanctions, 35% supported administrative sanctions, and 44% indicated that such physicians should be discharged from employment. Finally, high percentages of the surveyed federal forensic physicians cited a range of judicial and law enforcement deficiencies contributing to torture and ill treatment of detainees in Mexico (Table 6).

The sample of respondents consisted of 91 state forensic physicians (92% response rate among the 99 physicians given the survey). Ninety-one percent of respondents had 1 or more years of formal training in forensic medicine, and 76% were general practitioners. Thirty-one percent had conducted more than 400 forensic or medico-legal evaluations of detainees in the past 12 months. Table 7 summarizes state-level respondents' estimates of the numbers of their medical examinations of detainees during the past 12 months in which torture and/or ill treatment was alleged, suspected, or documented. In addition, 36 respondents had conducted at least 1 judicial autopsy over the prior 12 months with forensic evidence of torture or ill treatment. Fifty-eight percent of the state-level respondents reported that torture is a severe problem for detainees in Mexico. Sixty-six percent cited inadequate monitoring and accuracy of medical examinations, and 49% cited inadequate forensic physician documentation as problems that may contribute to torture and/or ill treatment of detainees in Mexico. Ninety-nine percent of respondents endorsed the need both for additional training in effective documentation of torture and ill treatment and for increased monitoring of medical report accuracy and quality. Seventy-seven percent of state-level respondents endorsed the use of a standard evaluation form for cases in which torture and/or ill treatment were alleged.

Our findings suggest that torture and ill treatment of detainees continue to be pervasive problems in Mexico. It is encouraging that a majority of federal forensic physician respondents reported a decrease in medical examinations in which they suspected or documented torture, compared with 5 years before. However, from respondents' survey responses, we calculated that the federal and state forensic physicians in the prior 12 months had examined between 5017 and 11 800 or more detainees who alleged torture and documented evidence of torture and/or ill treatment in 806 to 2440 cases or more. These estimates, which represent only those cases in which these physicians were directly involved, certainly exceed the 6 documented cases of torture and/or ill treatment reported by the Mexican National Commission on Human Rights for both 2000 and 2001.²⁷ It is not clear whether the gap between allegations of torture by detainees and the number of cases of torture and ill treatment respondents reported documenting is due to deficiencies in documentation skills, the lack of physical and/or psychological evidence among detainees, or other factors.

Our study findings further suggest that forensic physicians in Mexico face significant obstacles to their efforts to effectively document alleged or suspected torture. Almost all respondents defined torture in a manner consistent with definitions promulgated in international human rights conventions and in Mexican laws.^{14 ,23} Yet, while half of respondents stated that torture is a severe problem for detainees in Mexico, they also reported that monitoring and accuracy of medical examinations are inadequate. Besides enumerating external pressures on forensic physicians to ignore evidence of abuse, respondents noted the need for specialized training, standardized protocols, and material resources to increase detection and documentation of evidence of torture and ill treatment. In the absence of physical findings from torture, training and effective documentation of psychological sequelae of torture are also important. Most respondents (99% of federal physicians and 92% of state physicians) recognized psychological forms of abuse as torture. However, 99% of the federal forensic physicians were not trained as psychiatrists, and as a result, they may need additional assistance in detecting and documenting psychological evidence of torture.

The duties and obligations of physicians in the face of torture are clearly defined in international human rights instruments.^{28 - 30} Among these, the Declaration of Tokyo, adopted by the World Medical Association in 1975, states, "The doctor shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures, whatever the offense of which the victim of such procedures is suspected, accused or guilty, and whatever the victim's beliefs or motives, and in all situations, including armed conflict and civil strife."³¹ Failure to investigate and to document evidence of torture and ill treatment among detainees indeed constitute forms of "countenancing" or being complicit with torture.^{32 - 33} Yet, as the case of forensic physicians in Mexico exemplifies, translating principles into practice may be difficult. Among these difficulties, as the forensic physicians in this study reported, are the conditions of material scarcity in which they often work, lacking even basic ancillary equipment such as cameras to document external injuries, as well as the large case loads of many forensic physicians. Moreover, as government employees, they may not only face coercion by the presence of police officials in their medical examinations of detainees, but also legitimately fear physical and/or employment-related reprisals for documenting evidence of torture and/or ill treatment.

Our findings reinforce the need for 3 specific measures to improve forensic investigation and documentation of abuse among detainees. The first is a program of specialized training for forensic physicians that focuses on investigating and documenting evidence of physical and psychological torture and ill treatment. In this study, 17% of federal physician respondents reported believing that it is appropriate for law enforcement officials to be present during a medical examination and 8% agreed with the contention that torture or ill treatment can help obtain the truth (Table 2). Thus, an essential component of such training is to reinforce international standards on the privacy of forensic examinations and norms against the use of torture for any reason. Second, the development and use of standardized protocols and documentation procedures may help ensure greater uniformity of medical examinations and documentation. Third, the institution of monitoring of the quality and accuracy of medical evaluations in cases of alleged torture and ill treatment is necessary to hold forensic physicians accountable for documenting torture and ill treatment.

In Mexico, as elsewhere, effective documentation of torture represents just one of the necessary measures to prevent torture and hold perpetrators accountable. As the respondents indicated, improved forensic medical examinations and documentation must be linked with adequate legal investigations and protections, independent monitoring of police practices, punitive sanctions for perpetrators, and stronger measures prohibiting judicial acceptance of confessions extracted under torture as evidence. Federal and state forensic physicians in Mexico are in a position to bear witness to the human suffering caused by torture and ill treatment and, through their investigations and documentation, to help end these practices. To fulfill this role, they need sufficient autonomy and procedural safeguards within a broader judicial system in which respect for human rights is enforced.

Several limitations of this study should be noted. We have emphasized the results of the federal forensic physician survey because we surveyed the total population of federal forensic physicians, with an 81% response rate. In contrast, at the state level, we surveyed a convenience sample of approximately one third of the forensic physicians associated with state attorney general offices; our findings for that group may not generalize to other state-level forensic physicians. It is worth noting, however, that even if the remaining two thirds of state forensic physicians were to report absolutely no cases of torture and ill treatment, the numbers would still be alarmingly high. Second, this study did not include any forensic physicians at the municipal or Federal District level or those associated with human rights commissions, the military, or prisons. Thus, our findings may not generalize to these other groups. Third, our data collection strategy, as is the case for all surveys requiring respondents to report on past events, was subject to respondents' self-report and recall biases. In addition, respondents' own subjective views on the topics covered in the survey may have biased their reports. For example, although forensic physicians in Mexico have been trained in legal definitions of torture and ill treatment, we did not provide an operational definition of these terms in the survey. On this point, however, it is reassuring that more than 90% of respondents defined torture and ill treatment in a manner consistent with national and international law. Finally, we did not verify respondents' estimated ranges of their cases in which there was alleged, suspected, or documented torture and/or ill treatment over the prior year. Thus, we cannot determine whether respondents underreported or overreported the number of these cases.

In conclusion, torture and ill treatment of detainees continues to be a significant problem in Mexico and is facilitated by a number of factors. Forensic physicians support measures to improve forensic documentation of torture and ill treatment of detainees, including specialized training, standardized protocols, and documentation procedures, as well as monitoring of the quality and accuracy of medical evaluations in cases of alleged torture and ill treatment. Such measures must be integral components of broader efforts to hold perpetrators accountable and eliminate torture.