1. Answer: A, B, D
All of the considerations listed are important for effective interviews with the exception of C. All individuals alleging torture, including those in custody, should be informed that they are not required to answer any question that they choose not to.
2. Answer: B, C
Informed consent is required before all medical evaluations and explaining the potential benefits and risks of the evaluation is part of the consent process.
3. Answer: D
Given the possibility of intense shame and ongoing fear, it would be prudent to select a translator who is not related to Mrs. Yousif and is not a member of the refugee community. The clinician should reassure Mrs. Yousif of the measures you will take to ensure confidentiality of the information she provides.
4. Answer: C
Initially, questions should be open-ended, allowing a narration of the trauma with minimal interruptions. Closed questions are often used to add clarity to a narrative account or to carefully redirect the interview if the individual wanders off the subject.
5. Answer: A
Other traumatic experiences may contribute to the psychological symptoms of survivors of torture. In Mrs. Yousif’s case, the killing of her husband and burning of her home and village likely contributed to her psychological symptoms.
6. Answer: C
Inability to protect the ones we love from extreme harm often results in severe and prolonged emotional reactions such as guilt, shame and rage. Mrs. Yousif indicated that she has a profound sense of guilt over what happened to her daughter and is often preoccupied with thoughts of what she should have done differently.
7. Answer: E, F, G
Mrs. Yousif’s trauma history did not included allegations of blindfolding. Although she reported being stuck in the head with the butt of a handgun and kicked in the side of her face, she did not have any lapses in consciousness. The abuses that she described do not suggest significant disorientation that is often associated with prolonged isolation and sleep deprivation. She does have marked symptoms of PTSD, however, and both fear of reprisals and lack of trust in the examining clinician should be anticipated given her previous interactions with police and medical personnel.
8. Answer: A
The content of perpetrators’ verbal remarks often refers to the intent of the abuse and is often relevant to the individual meaning assigned to the torture experience.
9. Answer: E
Moving on with the interview would certainly be appropriate, but the other options listed (B, C and D) also may help to inform the alleged victim’s decision on whether to discuss the allegation of sexual assault further. The option of offering to limit reporting to a judge, only, may depend on the acceptability of this option within the domestic legal system and/or the extent to which absolute confidentiality can be maintained.
10. Answer: H
All of the indirect questions listed may be helpful in assessing the possibility of rape and other forms of sexual assault.
11. Answer: A, C
Mrs. Yousif’s history is highly consistent with a Bell’s Palsy after being kicked on the right side of her face with subsequent swelling, temporarily affecting the right Facial Nerve. Her observation of “tram-track” lines following beating with a hose is also highly consistent with the alleged abuse as it indicates first-hand knowledge of the alleged experience.
12. Answer: F
Mrs. Yousif presented to Nyala Hospital 2 days after the alleged assault. In the acute setting for rape allegations, all of the measures listed should be taken. For CDC recommendations on antiretroviral postexposure prophylaxis after sexual exposure to HIV, see: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5402a1.htm.
13. Answer: A
Mrs. Yousif meets diagnostic criteria for PTSD: She was exposed to multiple traumatic events or experiences involving intense fear, horror, or helplessness and the events or experiences involved threats of death, serious injury, or physical integrity. She has at least one re-experiencing symptom, at least 3 avoidance symptoms, and at least 2 persistent indicators of increased arousal. Since her symptoms have persisted for longer than 3 months, her PTSD should be considered “chronic.”
14. Answer: B
While the content of PTSD symptoms may be consistent or highly consistent with allegations of torture and ill treatment, the diagnosis of PTSD, in and of itself, is not specific for torture and/or ill treatment. On the other hand, there is often a strong relationship between an individual’s psychological symptoms and the individual meaning of torture experiences.
15. Answer: E
All of the traumatic experiences listed likely contribute to Mrs. Yousif’s psychological symptoms.
16. Answer: E
All of the factors listed may help to distinguish cause-specific psychological symptoms.
17. Answer: B
It is rare to find any physical evidence when examining female genitalia more than one week after an assault. For this reason, and the risk re-traumatizing Mrs. Yousif unnecessarily, a pelvic examination is not recommended. The most significant component of a medical evaluation in the chronic phase of rape allegations is the psychological assessment and other, non-gynecologic, physical findings.
18. Answer: E
All of the symptoms of sexual dysfunction listed may be observed following rape.
19. Answer: B
While Mrs. Yousif’s physical findings are consistent with the alleged trauma, they may be the result of other injuries. [Note, the description of the complex, atrophic scar over the dorsum of the left hand is consistent with the history of a laceration that healed by secondary intention; it apparently became infected, formed an abscess and required incision and drainage.]
20. Answer: C
Mrs. Yousif’s psychological symptoms are highly consistent with the torture and ill treatment that she alleged. The severity of her symptoms is consistent with the multiple traumas she reported. In addition to meeting diagnostic criteria for PTSD and Major Depressive Disorder, the content of some of her psychological symptoms refer specifically to the alleged abuse. Her intense feelings of guilt over her daughter’s rape and the consistency between her observed affect during the interview and the content of the evaluation are also highly consistent with the torture and ill treatment she alleged.