OBJECTIVE: Insufficient training and the absence of guidelines increase the risk of retraumatisation in torture survivors during surgical procedures. This study aims to develop guidelines to mitigate this risk and gather healthcare professionals\' experiences treating torture survivors and insights on the guideline\'s feasibility and acceptability.
METHODS: The study was conducted in two phases. Phase \'a\' involved developing guidelines based on reviews of torture survivors\' encounters in somatic care and potential retraumatisation triggers, as well as a qualitative study on survivors\' experiences during surgical interventions. The development process adhered to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) principles and the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument for methodological rigour. Phase \'b\' involved focus groups and individual interviews with healthcare professionals to explore challenges in caring for torture survivors and to evaluate the guidelines.
METHODS: The study, conducted from May to August 2023, involved participants from surgical departments in three hospitals in southern and southeastern Norway.
METHODS: Twenty-one healthcare professionals, including surgeons, anaesthesiologists, nurses and a dentist, participated in the study. Both focus group interviews and individual interviews were conducted.
RESULTS: Phase \'a\': guidelines comprising six sections were developed: an introduction, general guidelines and four sections covering the preoperative, perioperative and postoperative surgical stages. Phase \'b\': healthcare professionals struggled to understand torture\'s complexities and identify survivors\' unique needs. They faced challenges using interpreters and assisting patients with strong reactions. While the guidelines were viewed as practical and useful for raising awareness, their length was questioned.
CONCLUSIONS: We provide recommendations for preventing retraumatisation in torture survivors undergoing surgical treatment. The guidelines may serve as a starting point for offering safe and individualised care to torture survivors. Teaching institutions and hospitals may incorporate the guidelines into healthcare professionals\' education.

In the United States, clinicians are often called upon to provide their expertise to generate expert evidence in cases of individuals seeking asylum or other forms of international protection. Due to a lack of validated guidelines specific to the U.S. immigration context, clinical evaluations produced for immigration proceedings in the United States vary in their format, structure, and content, which can be confusing for practitioners and for adjudicators assessing the weight these evaluations should be afforded in asylum proceedings. We sought to review critical components of a medico-legal asylum evaluation from an interdisciplinary perspective of key stakeholders, by collecting and synthesizing expert opinions to reach consensus on what constitutes a high-quality, comprehensive medical or psychological affidavit for U.S. immigration cases. The consensus process incorporated a three-step modified Delphi method, which took place between September and December 2021 and consisted of two rounds of online questionnaires and a synchronous video conference meeting. The areas most experts agreed on included, by order of highest agreement (combining answers of \"strongly agree\" and \"agree\"): A narrative form or checklist is preferable to a predetermined template (95%); Primary care physicians should describe their qualifications to diagnose mental health conditions (81%); Use of citation is helpful, with caveats (77%); Clinicians should include an assessment of malingering (72%); Clinicians should include an executive summary/summary of conclusions at the top of the affidavit (72%); Clinicians should reference the Istanbul Protocol and explain its relevance (66%); It may be beneficial for clinicians to describe the anticipated process of healing (57%); Clinicians may include treatment recommendations (52%). Results of this and future consensus-building efforts and resulting guidance should be used to enhance overall quality of medico-legal reports and incorporated in training programs developed for clinicians, attorneys and adjudicators.

The number of torture survivors is on the rise, posing issues for their care in healthcare settings. Even healthcare experts with training in refugee care are unaware of the health difficulties faced by torture survivors. Any medical evaluation or treatment has the potential to re-traumatize torture survivors, thereby reactivating trauma symptoms without applicable guidelines to prevent re-traumatization.
Our objective was to identify, characterize, evaluate, and organize current, available evidence presenting existing recommendations and suggestions to prevent re-traumatization during the treatment of torture survivors\' physical diseases in healthcare services.
A comprehensive search of electronic databases was conducted. Gray literature coverage was obtained by searching for publications from relevant associations and healthcare organizations focusing on torture survivors. Clinical practice guidelines (CPGs) and research focusing on somatic healthcare services for adult torture survivors, regardless of study design, were eligible for review. Studies that concentrated on psychiatric departments were excluded. To conduct an overview of the available research and describe the scope and distribution of evidence, a mapping review methodology was used.
Forty out of 13,111 initial citations met our criteria. There were two guidelines, and text and opinion statements predominated. Two authors independently assessed the risk of bias in each primary research study using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for the research design.
This mapping review identifies triggers that may re-traumatize torture survivors during treatment and makes recommendations for prevention. Only a few studies have considered torture survivors\' perspectives on treatment and re-traumatization. According to the findings of the mapping review, healthcare providers should consider survivors\' biopsychosocial situations, demonstrate cultural sensitivity, and change theirpersonal attitudes . They must also identify tortured patients and determine when professional interpreters should be used.

Healthcare professionals working in somatic departments are not trained to recognise signs of torture or provide appropriate healthcare to torture survivors, which may result in retraumatisation during surgical treatment.
This protocol outlines a four-stage qualitative-method strategy for the development and evaluation of guidelines for prevention of retraumatisation of torture survivors during surgical care. The systematic search for literature review in stages 1 and 2 was conducted in August 2019 and March 2021, respectively, using nine databases. The search strategies employed in stage 1, without imposing any date limits, resulted in the inclusion of eight studies that addressed inadequate healthcare strategies associated with retraumatisation. The clinical guidelines review in stage 2 will include publications from 2000 onwards, which will be appraised using the Appraisal of Guidelines Research and Evaluation Version II instrument. Following multi-institutional recruitment in Norway, stage 3 will explore survivors\' experiences of receiving surgical treatment using indepth interviews (n=8-12), which will be audio-recorded, transcribed verbatim and analysed using the interpretative phenomenological analysis approach. In stage 4a, based on the findings from stages 1, 2 and 3, a set of clinical guidelines for preventing retraumatisation during surgical treatment will be developed. Next, the feasibility and acceptability of the guidelines will be assessed in stage 4b in three interdisciplinary focus group interviews (n=5 per group) and text condensation analyses.
The Regional (South-East C) Committee for Medical and Health Research Ethics approved the study in May 2021 (#227624). In stages 3 and 4, an informational letter and an informed consent form will be distributed to the participants to sign before the interview. The study results will be disseminated through publications, conference presentations, and national and local public forums to healthcare professionals, service managers, policymakers and refugee-supporting agencies.

The documentation of individual cases of child torture is of paramount importance to bring justice to, and help heal, individuals and sensitize societies. Our objective is to systematically review medical guidelines for the recording of individual cases of child torture or cruel, inhuman or degrading treatment (CIDT). We searched CINAHL, Embase, the Guidelines International Network, Lilacs, Medline, the National Guideline Clearinghouse, PsychInfo and all websites of the organizations participating in the updating of the Istanbul Protocol for guidelines or studies on how to document torture, CIDT or abuse in persons under 18 years. We did not find a comprehensive guideline that encompassed all aspects of the documentation of child torture, as does the Istanbul Protocol for adults. An expert opinion guideline on how to document sexual torture in children was found, and in addition we identified 13 consensus-based guidelines for the evaluation of abuse in children or specific aspects thereof. We strongly recommend a child specific, comprehensive guideline on the documentation of torture and CIDT in children.

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Proper forensic documentation of sexual torture in children is crucial. Informed consent for examination and documentation must be sought from the child/accompanying person and the examination conducted in a sensitive and respectful manner. Time should be given to the child to relate the history of torture and the examiner should start with open ended questions. The history of torture should be recorded verbatim as much as possible. The words used to describe the anatomy and the forensic findings have to be precisely defined. The child should be examined from head to toe and should be left partially clothed. Penile, digital or object penetration of the vagina does not always lead to injuries even if the child is seen very soon after the abuse. Genital injuries heal rapidly and can leave no scars. Penile, digital or object penetration of the anus does not always lead to injuries even if the child is seen very soon after the abuse. Sexual torture cannot be disproved by the absence of injuries or scars.

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