Objectives. To describe the urologic and sexual complications of male survivors of sexual torture, including
prevalence, sequelae, diagnosis, and treatment.
Methods. Through chart reviews, we identified all male survivors of torture who had been treated for
physical and/or psychological symptoms due to sexual trauma at the Boston Center for Refugee Health and
Human Rights at Boston Medical Center between January 1, 2001 and January 1, 2002. Of the 72 men seen,
20 (28%) were survivors of sexual trauma. Our study focused on genital trauma leading to urologic and/or
sexual dysfunction. Therefore, all cases of male genital trauma that had been referred to the urology
department (3 of 20) were selected for this review.
Results. The patients presented with chronic genital and erectile pain, lower urinary tract symptoms, and
sexual dysfunction. The diagnostic workup included history, physical examination, and ultrasonography.
Treatment included steroid injections for chronic pain and oral erectogenic agents for sexual dysfunction.
Conclusions. The apparent prevalence and severity of the physical and mental sequelae to sexual trauma
make it an important area for screening when treating survivors of torture. Our study is the first of its kind
to document urologic complications of sexual torture in a foreign-born U.S. cohort of tortured men, including
prevalence, diagnosis, and treatment. The proposed use of steroid injections in the clinical treatment of
these patients has not been previously reported.
UROLOGY 65: 28–32, 2005. 2005 Elsevier Inc.
Thousands of asylum seekers and refugees enter hadsufferedfromItisofconcernthathealth
Western countries every year. Between 1991 and professionals often fail to ask about torture or are not 2000, about 1 million people applied for asylum in trained to recognize the physical and psychological the United Among those seeking asylum are torture survivors. In 1999, 400,000 survivors of tor- their history of persecution because of shame or out ture were estimated to reside in the United of fear because the clinical setting is reminiscent of Although not necessarily self-proclaimed, survivors of torture and refugee trauma are consequently ashamed to discuss sexual trauma because of fear of bound to appear in the offices of health professionals.
stigmatization and the shame of a perceived loss of A U.S. study of the prevalence of torture survivors among a random sample of foreign-born patients in The United Nations Convention against Torture primary care in a metropolitan area showed that 25% and Other Cruel, Inhuman and Degrading Treat-ment or Punishment defines torture as “an act by From the Department of Health Law, Bioethics, and Human which severe pain or suffering, whether physical or Rights, Boston University School of Public Health; Boston Center mental, is intentionally inflicted on a person for for Refugee Health and Human Rights, Section of General Internal such purposes as obtaining from him or a third Medicine, and Department of Urology, Boston Medical Center, person information or confession. . . Male sex- Boston, Massachusetts; and Department of Health Services Re-search, Institute of Public Health, University of Copenhagen, ual trauma, which is a form of torture, can be char- Reprint requests: Marie Norredam, M.D., Department of Health Services Research, Institute of Public Health, Univer- 1. Direct genital trauma: hitting, kicking, or ap- sity of Copenhagen, Blegdamsvej 3B, Copenhagen North 2200, plying electric shocks to genitals and/or anus, Denmark. E-mail: Submitted: May 20, 2004, accepted (with revisions): August object inserted into urethral meatus and/or Most common methods of sexual torture and physical sequelae among 20 survivors of
torture treated at Boston Center for Refugee Health and Human Rights at Boston Medical Center
between January 1, 2001 and January 1, 2002
Physical Trauma
Acute Physical Sequelae
Chronic Physical Sequelae
Genital beatings with fists, sticks, or other instruments Forced fellatioInsertion of toothpicks into the penis 2. Nonconsensual sexual acts: pawing, anal rape, genitalia tied to the floor for 12 hours. He was unable to stand upright without painfully stretch- 3. Mental assaults: forced nakedness, sexual hu- ing his genitalia. He presented with complaints of erectile dysfunction and chronic incapacitatinggenital pain. On physical examination, he had di- On the basis of our work with survivors of tor- minished tunica elasticity and compliance, consis- ture and refugee trauma, we report 3 cases of gen- tent with Peyronie’s disease. Penile stretching elic- ital trauma and their physical sequelae, focusing on ited exquisite proximal dorsal penile pain radiating the urologic complications. Our aim was to sensi- to the pubic bone and suspensory ligament. After tize medical professionals to the male genital he provided informed consent, two subcutaneous trauma that occurs in the context of sexual torture steroid injections (triamcinolone 50 mg) on the by discussing the methods of torture and the phys- dorsal aspect of the penis, fundiform ligament, and ical sequelae, diagnosis, and treatment strategies.
pubic tubercles were performed within a 4-monthperiod. After the first steroid injection, the patient MATERIAL AND METHODS
experienced immediate and significant improve- Through chart reviews, we identified all male torture survi- ment of his incapacitating genital pain. After the vors who had been treated for physical or psychological symp- second injection, the pain resolved completely. At toms due to sexual trauma at the Boston Center for Refugee last follow-up, his erectile dysfunction was being Health and Human Rights at the Boston Medical Center. Be-tween January 1, 2001 and January 1, 2002, 20 (28%) of the 72 managed with oral erectogenic agents (sildenafil) men seen were identified as survivors of sexual trauma. The patients were all between 31 and 50 years of age and refugeesfrom African countries in conflict. They had all been impris- CASE 2
oned or captured and had suffered torture, including severe Patient 2 was a 31-year-old man who had also genital beatings. lists the most common methods ofsexual torture, as well as the acute and chronic physical se- been repetitively beaten in the genitals by fists and quelae, among the 20 survivors of torture. Most patients had sticks while imprisoned in an East African country experienced multiple sexual assaults of the same or different for political activities. He also presented with com- kinds. We focus on the genital trauma leading to urologic plaints of erectile dysfunction and severe and and/or sexual dysfunction. Therefore, all cases of male genital chronic genital pain. He had no orgasmic or ejac- trauma that had been referred to the urology department (3 of20) were selected for this review. The cases are presented and ulatory problems, but his erections were reduced serve to illustrate the different aspects of the symptoms, diag- in rigidity compared with previously. The physical nosis, and treatment of male genital trauma. All patients have examination revealed exquisite pubic tubercle, been kept anonymous. The Institutional Review Board at Bos- cord, and suspensory ligament tenderness. Penile ton Medical Center approved the study.
duplex Doppler ultrasonography after intracaver-nosal injection of vasoactive agents revealed de- creased cavernosal systolic velocities and normal CASE 1
end-diastolic velocities. These findings were con- Patient 1 was a 50-year-old man who had fled sistent with pure (no corporeal occlusive dysfunc- from a country in Central Africa after being perse- tion) cavernosal artery insufficiency, most likely cuted by the military for rebel activity and impris- secondary to blunt perineal trauma. No penile oned on 7 occasions between 1996 and 2000. Dur- plaques or tunica thickening were observed. After ing imprisonment, he was repeatedly beaten with he provided informed consent, two steroid injec- fists and sticks all over his body, including the gen- tions (triamcinolone 50 mg) were given into the ital area. On one occasion, he was suspended na- cord, fundiform, and pubic tubercle, with com- ked from the ceiling by his arms with his legs bent, plete resolution of his genital pain. At last follow- his feet secured to the floor wide apart, and his up, he was taking oral erectogenic agents (silde- UROLOGY 65 (1), 2005
nafil) for the management of his erectile refugees, who had been imprisoned, and found a dysfunction, with excellent results.
prevalence of 21%. In a different study, studied 607 men from 45 countries, of whom CASE 3
25% had been sexually assaulted. Of these, 21% Patient 3 was a 39-year-old man who had fled from had been raped, 47% had had assaults to the a West African country after being captured by rebels genitals, 27% had had electric shocks to the gen- and forced to do hard labor. During captivity, he was itals, and/or 21% had had an object inserted in severely beaten in the genital area with fists and sticks the anus or urethral meatus. These prevalence on multiple occasions. He presented with complaints figures may be underestimates because of the ta- of erectile dysfunction and lower urinary tract symp- boo and stigmatization to discussing male sexual toms (International Prostate Symptom Score of 23) trauma inherent in most cultural norms. A study characterized by decreased force of stream, incom- of British male victims of sexual assaults in gen- plete emptying, and urinary frequency. He achieved eral showed that 79% of raped men sought no an approximately 50% erection, which had poor help for a mean time of 16 years after the as- spontaneity and sustaining capabilities. His past medical history was only remarkable for a urethral The sequelae of sexual torture include both psy- stricture managed endoscopically several years previ- ously. His physical examination was unremarkable, In this report, we focused on the physical sequelae.
but urethroscopy revealed a tight bulbar urethral When reviewing published reports, we found few stricture. Penile duplex Doppler ultrasonography af- studies describing the physical sequelae of sexual ter intracavernosal injection of vasoactive agents re- vealed a peak systolic velocity of 31 and 15 cm/s for causes has, however, been documented. Erectile the right and left cavernosal artery, respectively, with dysfunction has resulted from innocent falls or normal end-diastolic velocities. These findings were consistent with pure (no corporeal occlusive dys- erectile dysfunction and groin pain owing to pro- function) cavernosal artery insufficiency, most likely secondary to blunt perineal trauma because of tor- ture. He underwent internal (endoscopic) urethrot- gested that blunt genital trauma may roughly result omy of a long bulbar stricture. However, the stricture in four clinical problems that are not mutually ex- recurred within 6 months, requiring a second inter- nal urethrotomy with excellent results. The patient 1. Chronic genital pain, including erectile pain also began taking sildenafil, with excellent results. A 2. Peyronie’s disease characterized by penile pain, detailed vascular evaluation was obtained to assess penile curvature, and erectile dysfunction the feasibility of penile revascularization from the dorsal to the cavernosal artery in an attempt to re- These clinical problems arise from different pathologic mechanisms. Chronic genital pain may result from injury to the inguinal cord, suspensory Little has been written about the sexual trauma and/or fundiform ligaments, or tunica albuginea, of men within the published medical reports on leading to Peyronie’s Peyronie’s disease torture. Attention has so far mainly been devoted is characterized by decreased tunica elasticity and to female survivors of sexual trauma. The myth compliance secondary to fibrosis and plaque for- that men are only aggressors and not victims mation. Lower urinary tract symptoms may be due to urethral trauma leading to stricture formation.
many countries and in some states in the United Apart from Peyronie’s disease, erectile dysfunction may result from compression injuries of the pu- prevalence of male sexual trauma is uncertain.
dendal arteries as they enter the perineum through Estimates, however, have shown that 5000 to Alcock’s canal and/or corporal damage leading to 8000 men were raped in the former Yugoslavia corporeal veno-occlusive dysfunction (venous and that thousands of men and boys were raped leak). Depending on the symptoms, the diagnosis of male genital trauma is based on the physical ual trauma mostly takes place during detention examination and penile duplex Doppler ultra- and is perpetrated by guards, interrogators, or sound findings. Not yet described in published re- ports, we propose that chronic genital pain due to political prisoners who sought help after torture Peyronie’s disease, pubitis, or suspensory ligament had been sexually abused. Peel et specifi- injury can be successfully treated with steroid in- cally studied male sexual trauma among Tamil jections. Penile curvature can be managed medi- UROLOGY 65 (1), 2005
cally (verapamil, interferon, colchicine, vitamin torture in a U.S. cohort of tortured men, including or surgically (Nesbit plication versus tunica the prevalence, diagnosis, and treatment. The pro- posed use of steroid injections in the clinical treat- tures can be generally treated. The treatments for ment of these patients has not been previously re- erectile dysfunction include oral erectogenic agents (sildenafil, vardenafil, penile re-vascularization procedures, intracavernosal ther-apy, and penile is most common in survivors who have been ex- 1. Available at: posed to sexual trauma, but it may also arise after 2. Piwowarczyk L, Moreno A, and Grodin M: Health care of torture survivors. JAMA 284: 539 –541, 2000.
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blood, anal rape, or unsterile instruments of tor- 8. Peel M: Male sexual abuse in detention, in Peel M, and ture, or when seeking medical care for wounds that Iacopino V (Eds): The Medical Documentation of Torture. Lon- occurred during torture. Thus, all male rape vic- don, Greenwich Medical Media, 2002, pp 179 –190.
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it an important area for screening when treating 17. Eisenman DP, Gelberg L, Liu H, et al: Mental health and survivors of torture and refugee trauma. It is, there- health-related quality of life among adult Latino primary care fore, crucial that health professionals working with patients living in the United States with previous exposure to asylum seeker and refugee populations are aware political violence. JAMA 203: 667– 670, 2003.
of the problem and trained to recognize the phys- 18. Daugaard G, Petersen HD, Abildgaard U, et al: Sequelae to ical and psychological symptoms and make appro- genital trauma in torture victims. Arch Androl 10: 245–248,
priate referrals to knowledgeable providers or 19. Lunde I, Rasmussen OV, Lindholm G, et al: Gonadal treatment centers (National Consortium of Tor- and sexual functions in tortured Greek men. Dan Med Bull 27:
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UROLOGY 65 (1), 2005
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UROLOGY 65 (1), 2005


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