Journal of Forensic and Legal Medicine 34 (2015) 127e132

Contents lists available at ScienceDirect

Journal of Forensic and Legal Medicine

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / j fl m

Clinical practice

Prevention of violence in prison e The role of health care professionals

€rg Pont a, Heino Sto
Jo taz c, Alejandra Casillas c, *, Hans Wolff c
€ ver b, Laurent Ge
a
Medical University of Vienna, Austria
b
University of Applied Sciences, Faculty Health and Social Work, Frankfurt am Main, Germany
c
Division of Medicine and Psychiatry, Department of Community Medicine, Primary Care and Emergency Medicine, University Hospitals of Geneva and
Faculty of Medicine, University of Geneva, Switzerland

a r t i c l e i n f o a b s t r a c t

Article history: The World Health Organization (WHO) classifies violence prevention as a public health priority. In
Received 15 October 2014 custodial settings, where violence is problematic, administrators and custodial officials are usually tasked
Received in revised form with the duty of addressing this complicated issue-leaving health care professionals largely out of a
12 February 2015
discussion and problem-solving process that should ideally be multidisciplinary in approach.
Accepted 29 May 2015
Available online 9 June 2015
Health care professionals who care for prisoners are in a unique position to help identify and prevent
violence, given their knowledge about health and violence, and because of the impartial position they
must sustain in the prison environment in upholding professional ethics. Thus, health care professionals
Keywords:
Prevention
working in prisons should be charged with leading violence prevention efforts in custodial settings.
Prison violence In addition to screening for violence and detecting violent events upon prison admission, health care
Health care professional duty professionals in prison must work towards uniform in-house procedures for longitudinal and systemized
Harm reduction medical recording/documentation of violence. These efforts will benefit the future planning, imple-
Medical ethics mentation, and evaluation of focused strategies for violence prevention in prisoner populations.
© 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.

1. Introduction: Prevention of violence in prison- A call to
action for health care professionals
In accordance with worldwide laws,1,2 rules, recommendations
and declarations3e6 prisoners have the “right to a safe and healthy
environment”7- this includes the right to protection from all
aspects of violence. Despite international consensus on various
position documents, and contributions from prison law enforce-
ment officials, custodians, and guardians, violent perpetration and
victimization continue to be an everyday reality in many prisons all
over the world. For one, many prisoners already possess risk factors
that are associated with being a perpetrator and/or victim of
violence. They include: young age, male, family history of abuse or
neglect, low socio-economic and educational status, unemploy-
ment, mental illness and drug dependency.8 Next, these already
vulnerable individuals enter the context of a “total institution”9
(prison) which can be further de-stabilizing. The prison environ-
ment has been well documented as a trigger for violent behavior.
* Corresponding author. Tel.: þ41 766735915.
E-mail addresses: joerg.pont@meduniwien.ac.at (J. Pont), hstoever@fb4.fh-
€ver), Laurent.Getaz@hcuge.ch (L. Ge
frankfurt.de (H. Sto taz), Alejandra.Casillas@
hcuge.ch, Doctorale05@gmail.com (A. Casillas), Hans.Wolff@hcuge.ch (H. Wolff).
Deprivation of liberty, oppressive conditions, overcrowding10,11 and
impunity of violence (in some penitentiary systems) have been
known to be associated with violent incidents.
The WHO Report on Violence8 sheds light on the victimization of
certain vulnerable groups like children, adolescents, women and the
elderly. However, little, if any mention, is made about imprisoned
persons, a particularly vulnerable population with respect to violence.
As reflected in current theories that address the issue of prison
violence, approaches for violence prevention up until this point
have really only dissected this issue as a subject which solely
concerns custodial officials, instead of including a role for health
partners in the discussion.12,13 The scope of this paper is to examine
the role that health care professionals can take for the prevention of
violence in prison and other custodial institutions. This perspective
actually mirrors the community-based Global Campaign for
Violence Prevention, which advocates for a close partnership
between public health services and police/criminal justice systems
for community violence prevention.14 Prison policies for violence
prevention should closely model community policies, which
already value the role of the health care professional and mean-
ingful partnership between public health and custodial officials.
Like for any other health care promotion/preventive activities, the
ethical medical principle of equivalence of health care applies.

http://dx.doi.org/10.1016/j.jflm.2015.05.014
1752-928X/© 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
128 J. Pont et al. / Journal of Forensic and Legal Medicine 34 (2015) 127e132
2. What do we know? Definition, prevalence, and the impact
of interpersonal violence in prison
The WHO defines violence as “the intentional use of physical
force or power, threatened or actual, against oneself, another per-
son, or against a group or community, that either results in, or has a
high likelihood of resulting in injury, death, psychological harm,
mal-development, or deprivation.”15 To clarify the scope of this
paper, we should mention that suicide and other “self-harm” pre-
vention efforts in prison have been thoroughly addressed by WHO
documents and other publications,16e18 while “collective violence”
(prison riots), is outside the likely sphere of influence for many
health care providers. Thus, to simplify, we confine this present
discussion to interpersonal (person-to-person) violence by phys-
ical, sexual and/or psychological attack, and abuse/neglect.
Data on the prevalence of prison violence have been obtained
mostly by anonymous surveys of current or former prisoners.
However, the interpretations of these surveys are limited by
low/modest response rates, varying methodologies and different
definitions (inclusion criteria) for violent events. Because inter-
personal violence is the result of a complex interplay between in-
dividual, socio-cultural and environmental factors, the results of
the limited available studies are not fully representative of the
complete issue. Nevertheless, they can begin to outline the
magnitude of the problem.
A prior survey of 13 American state prisons (7221 male and 564
female participants, out of roughly 19,000 prisoners), reporting on
the past six-month period, found that inmate-on-inmate physical
violence was experienced by 13%e35% of all prisoners; staff-on-
inmate violence was reported by 8e32%.19 Sexual victimization
was reported by 4% (inmate-on-inmate) and 8% (staff-on-inmate)
of male prisoners; among female prisoners, sexual violence was
21% (inmate-on-inmate) and 8% (staff-on-inmate).20 In addition,
inmates with a prior history of mental health disorders had a higher
risk for physical21 and for sexual victimization.22
Results of roughly the same magnitude were found in a recent
survey of 33 prisons in north and east Germany: more than 25% of
males and females of the 6384 participants (nearly 12,000 pris-
oners total) reported being physically victimized in the prior four-
week prison period. Among males, 5% reported sexual assault,
with 4% among women. Indirect (i.e. non-physical) victimization
included verbal/psychological assault or theft, and was experienced
by more than half of the respondents in the past 4-week period. The
authors estimated that their results, at best, shed some light on the
lower limit of prison violent events; the numbers in reality, are
likely much higher.23
The United States Bureau of Justice Statistics via the Prison Rape
Elimination Act of 2003 administers the largest surveys on
violence- but these are, of course, limited to reports of only sexual
violence. In its most recent National Inmate Survey, 4% of the more
than the 92,000 participating inmates reported that they experi-
enced at least one incident of sexual victimization by another
inmate or facility staff member in the past 12 months.24 In the
National Former Prisoner Survey, based on over 18,000 interviews,
9.6% of former state prisoners reported at least one incident of
sexual victimization during their most recent period of incarcera-
tion in a jail, prison, and/or post-release community-treatment
facility.25 In the National Survey of Youth in Custody, an estimated
9.5% of the 8707 adjudicated youth in state juvenile facilities and
state-contract facilities who participated in the survey reported
experiencing one or more incidents of sexual victimization by
another youth or staff member in the past 12 months.24
There is a scarcity of medical reports on injuries suffered at the
hands of prison violence.26,27 The “enhancement of capacity for
collecting data on violence” by health care staff (as recommended
by the WHO8) and the “systematic recording and compiling of
periodic statistics” on violence by health care professionals work-
ing in prisons (as proposed by the European Committee for the
Prevention of Torture and Inhuman or Degrading Treatment and
Punishment (CPT),3 are lacking in most correctional facilities. As
one unique example, the 2010 Clinical Indicators of Sexual Violence
in Custody study (U.S. National Institute of Justice and the Centers
of Disease Control and Prevention) did propose the use of medical
indicators and medical surveillance methodologies for the collec-
tion of sexual assault data in prison on a national level. However,
the study was later deemed “not feasible” by the U.S. Bureau of
Justice Statistics, and henceforth, has not been pursued since.24
Physical injuries have been reported for 40% of physical
assaults,23,28 and 67% of sexual assaults.28 Data on the psychologi-
cal/emotional short and long-term trauma of interpersonal prison
violence are also important. These include pathological anger
(instigating further violent behavior), depression, post-traumatic
stress reactions, fear, “fight or flight” maladaptive responses, and
inescapable paranoia/insecurity for one's welfare.23,28,29 In two
studies, psychological trauma developed in over half of all vic-
tims.23,28 Transmission of sexually transmissible infections in
prison, through sexual assault, is a common report in many parts of
the world.30 However, less than a third of the assaults received
medical attention or were brought to the attention of medical
authorities28 (the numbers are actually lower for staffeon-prisoner
sexual assaults).28
3. Challenges for prison administration and custodial staff
colleagues
The inherent structures within prison pose a serious problem for
prison staff trying to address violence prevention solely through
the legal/custodial perspective. For example, following trauma in
prison, victims of violence tend to seek protection through alliance
with a gang for protection (these individuals then fight violently for
power and influence in prison against other gangs, as part of the
group).31 In addition, several penitentiary systems passively
enforce unofficial prisoner hierarchies, organized in cast-like
structures, where certain individuals control money, goods and
drugs in prison by violent means, often with tacit acquiescence by
prison staff and administration.32 Clearly, it is a complicated and
multifaceted issue where one act of violence begets more violence.
Although various theory models on the response to violence in
prison exist, prerequisites for any prevention programs will require
the engagement from multiple parties. Health care professionals
can help in the partnering discourse. This engagement includes a
strong commitment to the defense of human rights by all stake-
holders, a sufficient number of staff in relation to the number of
inmates, appropriate staff training and supervision, and a policy
and everyday practice of non-tolerance of violence among all staff
and inmates within the prison.12,13
4. A new source of aid in the prison violence prevention
model-why health care professionals should partner
Until recently, health professionals in the community and in
prison limited their violence role to the medical care of victims post
a violent event: diagnostic examination, treatment, documentation
of trauma in the individual patient file and reporting the case to the
authorities for prosecution (with or without consent of the victim,
depending on the national law). Today, the WHO stresses an active
role for the health sector in the prevention of violence in the
community.8 Similarly, health care professionals working in prison
should prioritize this mission, particularly because, according to
 J. Pont et al. / Journal of Forensic and Legal Medicine 34 (2015) 127e132
international standards, prevention of violence is an implicit part of
health care worker's professional obligations:
1) The 1982 United Nations Principles of Medical Ethics Relevant to
the Role of Health Personnel, particularly Physicians in the
Protection of Prisoners and Detainees against Torture and Other
Cruel, Inhuman or Degrading Treatment or Punishment state
that “Health personnel, particularly physicians, charged with
the medical care of prisoners and detainees have a duty to
provide them with protection of their physical and mental
health …”.4
2) According to the United Nations (UN) Standard Minimum Rules,
“the medical officer shall have the care of the physical and
mental health of the prisoner …” and “shall report to the di-
rector whenever he considers that a prisoner's physical or
mental health has been or will be injuriously affected … by any
condition of imprisonment.”5 Since physical and mental
victimization are explicitly linked to interpersonal violence,
prevention of interpersonal violence should therefore fall under
the auspices and obligations of prison health care professionals.
3) The Committee on the Prevention of Torture (CPT) standards
state that prison health care services in relation to violence
prevention should be performed through (but not limited to)
high quality medical screenings and data collection. Medical
documentation and record services should concentrate on the
detection of markers/signs of violence, a systematic and
continuously updated database about related injuries, and lon-
gitudinal data (follow-up) on all recorded injuries that are sec-
ondary to all forms of violence. These periodic data would then
be reviewed by prison health officials, prison management,
penitentiary authorities, and community public health officials.3
A similar approach is recommended by the World Medical As-
sociation in a web-based course for prison physicians.33
Overall, medical professionals caring for prisoners are in a
particularly unique position to prevent violence in prison. First,
they are usually the first-line responders to a violent situation
when treating and documenting suffered injuries. This simple and
immediate association provides these professionals with access to
information and data that facilitates research and prevention.8
Second, health care professionals who maintain the principles of
medical ethics in prison (professional independence, confidenti-
ality, respect for patient autonomy and humanitarian assis-
tance),3,4,6 develop relationships with victims and potential victims
that may lead to new information about violence triggers in the
prison. However, since less than 30% of events of violent events are
brought to the attention of a medical professional,28 doctors still
have much work to do in gaining these patients' trust. Third, within
the confines of the total and repressive institution9 -that is prison-
the doctor's office might just be the only space where any com-
plaints about abuse (and particularly, victimization of prisoners by
staff), can be expressed by inmates without the fear of retribution,
given the ethics of medical confidentiality and professional inde-
pendence of health care workers (which custodial guardians and
prison staff are not obligated to adhere to).
Nevertheless, the protected role of the prison health care worker
(medical confidentiality and professional independence from the
custodial authorities) is not yet respected in many custodial set-
tings. There are well-documented reports of health care workers
who succumb to custodial pressures and avoid reporting incidents
of violence, thus becoming complicit in the original abuse.34,35
Health care professionals in these settings frequently face the
ethical dilemma of dual loyalty and are in a vulnerable position if
they are not sufficiently trained in medical ethics and are working
under unorganized organizational structures with shady policies
129
and no clear chain-of-command. Actually, it has been shown that
an almost “military-like” organizational structure is detrimental in
protecting the role of the prison health care worker: this type of
work environment impinges on the health professional's rights and
due boundaries, inevitably affecting the best interests of the
patient/prisoner. Health care workers integrated in these hierarchal
structures have less professional independence and suffer much
more under the dual loyalty dilemma, thus impairing the rights of
their patients.36,37
The extent of this crisis is exemplified in the numerous inves-
tigative country reports from the European Committee on the
Prevention of Torture (CPT) which highlight the lack, delay and/or
cursory medical examinations of inmates and complete omission of
violence signs/symptoms screens at admission, and the lack of
systematic statistical recordings for injuries/signs of violence
during the period of incarceration.7,38
But even in the most professional prison settings, health care
professionals must be prepared for conflicting ethical obligations
with regards to prison violence. The physician's obligation towards
the victimized patient is, indeed, to respect confidentiality and
his/her consent to report the violent crime. However, the physi-
cian's obligation to society is to follow the law-a lawful citizen
would alert the authorities about a violent individual, in order to
prevent further harming of innocents. This is of particular impor-
tance in cases of torture and abuse. The Istanbul Protocol39 and the
World Medical Association quoting the Istanbul Protocol in its
Resolution on the Responsibility of Physicians in the Documenta-
tion and Denunciation of Acts of Torture or Cruel or Inhuman or
Degrading Treatment or Punishment provide the following advice
for dealing with this ethical dilemma:40
“Health professionals should seek solutions that promote justice
without breaching the individual's right to confidentiality,”
“… they may discover evidence of unacceptable violence, which
prisoners themselves are not in a realistic position to denounce.
In such situations, doctors must bear in mind the best interests
of the patient and their duties of confidentiality to that person,
but the moral arguments for the doctor to denounce evident
maltreatment are strong, since prisoners themselves are often
unable to do so effectively.”
In the end, how to resolve this ethical dilemma rests solely on
the physician after conducting a careful assessment, evaluation and
ethical consideration of the individual case. Nevertheless, in the
spirit of shared decision-making, the medical provider should keep
the victim informed at all points of the decision-making process.
Ideally physician and patient should share in the final decision
about reporting a violent event, should an ethical dilemma initially
exist.
5. Action items e Prevention of violence in prison by health
care professionals
5.1. Medical screening on admission
Violence prevention by prison health professionals starts with
the medical examination of a prisoner on admission. A carefully
obtained history permits screening for particular risk factors-
mental impairment,21,22 drug dependence, and other socio-
cultural characteristics associated with vulnerability and victimi-
zation.8 If appropriate and with consent of the patient, health pro-
fessionals should assist and advise the prison administration
regarding treatment and placement plan of a vulnerable inmate. For
example, prisoners diagnosed with antisocial personality disorders
130 J. Pont et al. / Journal of Forensic and Legal Medicine 34 (2015) 127e132
(impulsive, reckless and irresponsible behavior) should be referred
to undergo group-based cognitive and behavioral interventions.
These patients should also be placed in a more controlled envi-
ronment that will not trigger violent and harmful behavior. The
physical examination on admission should also pay attention to
signs/symptoms of violence that may have occurred at arrest/
holding (before admission to the prison), and should be thoroughly
documented and reported.
In addition, the admit exam is a key opportunity to build initial
trust with a new prisoner by informing him/her about the health
care professionals' commitment to confidentiality, respect for the
patient's autonomy, professional independence and humanitarian
assistance. It is as well an opportunity to invite the new inmate to
address the health care team if they at all ever feel threatened or
victimized during their stay.
5.2. Post-violence
Medical examination and documentation after incidents of
violence are fundamental safeguards against abuse, impunity and
future inter-prisoner violence. Any allegation of violence or abuse
and any observation/suspicion of violence in the prison community
should be brought forward, without delay, to the attention of the
health care professionals and investigated fully. Authorities should
also ensure that every victim be fully examined right way under the
sole care of health professionals.3,36,39
In order for these efforts to have an effective impact, medical
documentation of violent events should be performed in a manner
that is valid before a court. According to the Istanbul Protocol this
document must contain a) the detailed record of the victim's report
and complaints b) the exact documentation of the physician's
findings c) the physician's interpretation of the consistency be-
tween a and b and d) the current course or recommended treat-
ment plan.39 As many health professionals have no formal forensic
training, the World Medical Association recommends the dissem-
ination of the Istanbul Protocol (which is helpful for health pro-
fessionals working in prison).40 However, in keeping with medical
ethics, a physician caring for prisoners must remember to not
abandon his professional role as caregiver by switching to the role
of a forensic expert.37
Medical documentation of any violent event should also be
made available to the victim and forwarded to the relevant prose-
cuting authority with his/her consent.
In cases of sexual violence, secondary prevention measures
should be in place immediately after the event is reported or
observed. This includes counseling and voluntary testing about
HIV, hepatitis B and other sexually transmitted infections. If
appropriate, post-exposure prophylaxis should be offered. For the
victim's psychological benefit, re-assignment of perpetrators and
victims in terms of placement/accommodation should be consid-
ered and discussed with the custodial staff.
5.3. Systematic statistical recording
Given the scarcity of medical data on prison violence, systematic
statistical recording and periodic statistics about violence pro-
cessed through the prison health service could reveal key infor-
mation about how to reduce the number of violent acts,3 Routine
data collection by health professional would help to assess inci-
dence, risk factors and identify persons at risk for injury by inter-
personal violence. These data, acting as a “needs assessment,”
would facilitate future implementation for targeted interventions
in preventing or reducing violent injuries. The Geneva model for
systematic violence screening, to the best of our knowledge, is
currently the only systematic violence detection program in prison,
and may serve as a practicable and feasible example to others
(Box1):
Systematic statistical recording is best performed by standard-
ized injury surveillance systems that use international classifica-
tions of injuries such as the chapters XIX and XX of ICD-1042 and/or
the International Classification of External Causes of Injury ICECI.43
These systems facilitate international data exchange and compa-
rability. The WHO/CDC publication “Injury Surveillance Guide-
lines”44 is a good tool for implementing a passive surveillance
system that collects, codes and processes data in settings where
resources (like trained staff and electronic equipment) are limited.
Implementing such systems would likely require just a few extra
steps on top of routine medical recording, and little additional
financial cost.
Periodic analysis and reporting of collected data to prison and
health authorities help in the longitudinal real-time assessment of
current interventions. In addition, sharing de-identified informa-
tion about violence-related harm between health services, execu-
tive bodies and the community in an interdisciplinary, data driven,
The Geneva experience of systematic screening for
violence
The medical unit of the Geneva prison, attached to the
Geneva University Hospitals and completely independent
of the prison administration, offers a low-threshold primary
care approach to prison health care. The facility operates
24 h/day with a nurse present at all times. All detainees who
complain about violence, or present with a traumatic lesion
on admission or during their prison course are immediately
brought to a primary care physician who documents on a
standardized form. Required data include the alleged time,
place and perpetrator(s) as well as the extent and localiza-
tion of any traumatic lesions. Whenever appropriate,
photos or results of additional examinations are enclosed.
If the detainee consents, the medical certificate and a copy
are sent to the head of the responsible service (head of the
police or prison warden) and to the commissioner of
deontology (who is in charge of surveillance and detection
of incorrect and violent behavior of police and prison ser-
vices in Geneva). This commissioner (in place after severe
allegations of police violence in the 1990's), reports annually
to Geneva's minister. If the detainee refuses, the certificate
is only kept in the medical record, but violence complaints
are reported to the authorities by the medical unit in a de-
identified manner.
A peak value of 297 illegitimate violence allegations was
reported in 2004e2005. This corresponded to 2% of the
prison population, with 85% concerning a police officer
during arrest or custody. Ten percent of the official certifi-
cates were related to violence between detainees and less
than 5% were related to violence by prison officers.41 A
remarkable drop in allegations against the police have
occurred since 2011, after the modification of the Swiss
Criminal Procedure Code which permits the presence of a
lawyer at arrest. Of the 125 reports in 2013, 70 (56%)
involved allegations against the police, 16 (12.8%) against
prison officers and 39 (31.2%) against co-detainees. For
2013 as well, 27.2% of cases refused to be identified
(violence complaint was reported in a de-identified
manner).
 J. Pont et al. / Journal of Forensic and Legal Medicine 34 (2015) 127e132
organized partnership has been shown to have a substantial and
sustained effect for preventing violence related injury at the com-
munity level.45 There is no obvious reason why this should not be
accomplished also in the prison setting.
Analyzed data should be regularly submitted to the National
Preventive Mechanism as established by the Optional Protocol to
the Convention against Torture (OPCAT).46 These statistics should
be kept ready for visits from international monitoring bodies like
the CPT3 and the UN Subcommittee on Prevention of Torture.46
6. Conclusion
This “call to action” is a starting point which very simply relies
on implementing the basic tools of medical practice, as a way to
address the epidemic of violence in prison. In reality, it is difficult to
predict what effects the health care system can project onto the
violence crisis in prison. However, the data does show that indis-
pensable components of basic health care delivery are not being
carried out in prison with regards to violence, a public health issue.
Therefore, these health care gaps must be filled by way of thorough
medical screenings and examinations, timely treatment and sys-
tematic reporting of incident cases-tools that are used to address
any other public health issue.
Identifying violent acts and classifying the effects of violent
trauma is of major importance in custodial settings. Health care
professionals who already treat prisoners are in a favorable place
for violence prevention given their ethical and legal obligation to
the patient's best interest. This relationship is the “best shot” that
inmates may have to express their experiences with violence
(particularly staff-on-inmate violence) without the fear of punish-
ment or retribution.
We strongly recommend systematic medical recording of
violence-induced injuries in detention settings. There is great
wealth of information to be collected for the use of planning,
implementing, and evaluating targeted strategies on prisoner
violence prevention. Public health advocates should expand their
violence prevention endeavors to detained populations. Prison
health services should be urged to produce systems for statistical
recording and periodic statistics on violence. Prison and police
administrations should make use of these data for the design,
evaluation, comparison and improvement of their violence pre-
vention strategies. Such strategies not only protect detainees and
help to defend prisoner/patient rights, but these efforts also sup-
port police and prison authorities to properly and transparently
investigate allegations of abuse. The end result is that such pro-
grams improve mutual respect and collaboration in total in-
stitutions, ultimately supporting the realization of human rights
standards in custodial settings.
Conflict of interest
We wish to confirm that there are no known conflicts of interest
associated with this publication and there has been no significant
financial support for this work that could have influenced its
outcome.
Funding
We have no funding sources to disclose and no conflicts on in-
terests. All participants who have contributed work towards this
project have been included in the author byline.
Ethical approval
None.
131
References
1. International Covenant on Civil and Political Rights http://www.ohchr.org/EN/
ProfessionalInterest/Pages/CCPR.aspx.
2. International Covenant on Economic, Social and Cultural Rights http://www.
ohchr.org/EN/ProfessionalInterest/Pages/CESCR.aspx.
3. European Committee for the Prevention of Torture and Inhuman or Degrading
Treatment and Punishment. The CPT standards. Council of Europe CPT/Inf/E;
2002. 1-Rev. 2011, http://www.cpt.coe.int/en/docsstandards.htm.
4. Office of the UN High Commissioner on Human Rights. Principles of medical
ethics relevant to the role of health personnel, particularly physicians, in the
protection of prisoners and detainees against torture and other cruel, inhuman or
degrading treatment or punishment. 1982. www2.ohchr.org/english/law/
medicalethics.htm.
5. United Nations. Standard minimum rules for the treatment of prisoners. 1955.
www2.ohchr.org/English/law/treatmentprisoners.htm.
6. Council of Europe. The ethical and organizational aspects of health care in prison.
Recommendation No. R (98) 7. Council of Europe Publishing; 1998.
7. CPT Database, Council of Europe. http://hudoc.cpt.coe.int/eng#.
8. WHO WRVH. World report on violence and health. Geneva: WHO; 2002. http://
whqlibdoc.who.int/publications/2002/9241545615_eng.pdf.
9. Goffman E. Asylums: essays on the social situation of mental patients and other
inmates. New York: Anchor Books; 1961.
10. Yuma Y. The effect of prison crowding on prisoners' violence in Japan: testing
with co-integration regression and error correlation models. Jpn J Psychol
2010;81(3):218e25.
11. Council of Europe. Recommendation R(99)22 concerning prison overcrowding
and prison population inflation. Strasbourg. 1999.
12. Bottoms AE. Interpersonal violence and social order in prisons. Crime Justice
1999;26:205e81.
13. Homel R, Thomson C. Causes and prevention of violence in prison. In:
O'Toole S, Eyland S, editors. Corrections criminology. Sydney: Hawkins Press;
2005. p. 101e8.
14. Violence prevention alliance: Global campaign for violence prevention, plan of
action 2012e2020. Geneva: WHO; 2012. http://www.who.int/
violenceprevention.
15. WHO. Global consultations on violence and health. Violence: A public health
priority. Geneva: World Health Organization; 1996 (Document WHO/EHA/
SPI.POA.2).
16. WHO/International Association for Suicide Prevention (IASP). Preventing suicide
in jails and prisons. Geneva: Department of Mental Health and Substance
Abuse, WHO; 2007. http://www.who.int/mental_health/prevention/suicide/
resource_jails_prisons.pdf.
17. WHO. Preventing suicide. A resource for prison officers. Mental and behaviour
disorders. Geneva: Department of Mental Health, WHO; 2000 (Document
WHO/MNH/MBD/00.5), www.who.int/mental_health/media/en/60.pdf.
18. Anasseril ED. Preventing Suicide in prison: a collaborative responsibility of
administrative, custodial and clinical staff. J Am Acad Psychiatry Law
2006;34(2):165e75.
19. Wolff N, Blitz CL, Shi J, Siegel J, Bachman R. Physical violence inside prisons.
rates of victimization. Crim Justice Behav 2007;34(5):588e99.
20. Wolff N, Blitz CL, Shi J, Bachman R, Siegel JA. Sexual violence inside prisons:
rates of victimization. J Urban Health 2006;83(5):835e48.
21. Blitz CL, Wolff N, Shi J. Physical victimization in prison: the role of mental
illness. Int J Law Psychiatry 2008;31(5):385e93.
22. Wolff N, Blitz CL, Shi J. Rates of sexual victimization in prison for inmates with
and without mental disorders. Psychiatr Serv 2007;58(8):1088e94.
23. Bieneck S, Pfeiffer C. Viktimisierungserfahrungen im Justizvollzug. Forschungsbericht
Nr. 119. Kriminologisches Forschungsinstitut Niedersachsen; 2012.
24. U.S. Department of Justice. Office of justice programs, Bureau of Justice Statistics:
PREA data collection activities. 2013. www.bjs.gov/content/pub/pdf/pdca13.pdf.
25. U.S. Department of Justice. Office of justice programs, Bureau of Justice Statistics:
PREA data collection activities. 2012. www.bjs.gov/content/pub/pdf/pdca12.pdf.
26. Ludwig A, Cohen L, Parsons A, Venters H. Injury surveillance in New York city
jails. Am J Public Health 2012;102:1108e11.
27. Butler T, Azar K. Prison violence: perspectives and epidemiology. NSW Public
Health Bull 2006;17(1e2):17e20.
28. Wolff N, Shi J. Contextualization of physical and sexual assault in male prisons:
incidents and their aftermath. J Correct Health Care 2009;15:58e77.
29. Wolff N, Shi J. Feelings of safety inside prisons among male inmates with
different victimization experiences. Violence Vict 2009;24:800e11.
30. WHO/UNAIDS/UNODC. Effectiveness of interventions to manage HIV in prisons e
provision of condoms and other measures to decrease sexual transmission. WHO;
2007. www.who.int/hiv/idu/Prisons_condoms.pdf.
31. Skarbek D. Prison gangs, norms and organization. Duke University, Department
of Political Science; 2011. http://sites.duke.edu/psworkshops/files/2011(08/
skarbek_Prison-Gangs-Norms_Organization.pdf.
32. Reyes H. SIZOs, colonies and prisons: an introduction to the penitentiary system of
the Russian federation. International Committee of the Red Cross; 1997 [internal
document].
33. McManus J. Violence in prisons: the role of the medical professional. In: Doc-
tors working in prison: Human rights and ethical dilemmas. www.wma.net/en/
70education/10onlinecourses/20prisons/.
132 J. Pont et al. / Journal of Forensic and Legal Medicine 34 (2015) 127e132

34. Iacopino V, Heisler M, Pishevar S, Kirschner RH. Physician complicity in degrading treatment or punishment. 2003. amended 2007, www.wma.net/en/
misinterpretation of evidence of torture in postdetention medical examina- 30publications/10policies/t1.
tions in Turkey. JAMA 1996;276:396e402. 41. Bugnon G. Le constat me dical peut-il mettre a  l’e
preuve les frontieres de la
35. Heisler M, Moreno A, DeMonner S, Keller A, Iacopino V. Assessment of torture re le
force policie gitime? Enque ^te sur un dispositif me dico-le
gal de de pistage
and ill-treatment of detainees in Mexico: attitudes and experiences of forensic des violences policieres de
viance et socie te
 2011;35(1):113e36.
physicians. JAMA 2003;289:2135e43. 42. WHO. International statistical classification of diseases and related health prob-
36. Physicians for Human Rights and School of Public Health and Primary Health lems. 10th revision, ICD-10 Version 2010. World Health Organization; 2011.
Care. Dual loyalty and human rights in health professional practice. Proposed http://apps.who.int/classifications/icd10/browse/2010/en.
guidelines and institutional mechanisms. University of Cape Town, Health Sci- 43. WHO. International Classification of External Causes of Injury (ICECI). http://
ences Faculty; March 2002. http://physiciansforhumanrights.org/library/ www.rivm.nl/who-fic/ICECIeng.htm.
report-dualloyalty-2006.html. 44. Holder Y, Peden M, Krug E, et al., editors. Injury surveillance guidelines. Geneva:
€ver H, Wolff H. Dual loyalty in prison health care. Am J Public Health
37. Pont J, Sto World Health Organization; 2004. http://whqlibdoc.who.int/publications/
2012;102(3):475e80. 2001/9241591331.pdf.
38. Lehtmets A, Pont J. Prison health care and medical ethics. Council of Europe; 45. Florence C, Shepherd J, Brennan I, Simon T. Effectiveness of anonymous in-
2014. http://www.coe.int/t/dgi/criminallawcoop/Presentation/Documents/ formation sharing and use in health service, police, and local government
Publications_HealthCare_manual_Web_A5_E.pdf. partnership for preventing violence related injury: experimental study and
39. Office of the United Nations High Commissioner for Human Rights. Professional time series analysis. BMJ 2011;342. d3313.
training series no. 8/Rev. 1. Istanbul protocol. Manual on the effective investigation 46. Office of the United Nations High Commissioner for Human Rights. Optional
and documentation of torture and other cruel, inhuman or degrading treatment or Protocol to the Convention Against Torture (OPCAT) Subcommittee on preven-
punishment. New York and Geneva. 2004., www.ohchr.org/Documents/ tion of torture. 2006. http://www.ohchr.org/English/bodies/cat/opcat/index.
Publications/training8Rev1en.pdf. htm.
40. World Medical Association. Resolution on the responsibility of physicians in the
documentation and denunciation of acts of torture or cruel or inhuman or