A/HRC/22/56 and damage to the shoulders or wrists including dislocation, chronic pain and restriction of movement. Ten cases manifested physical symptoms associated with rape and sexual torture including anal bleeding and pain, vaginal bleeding and discharge, pain and swelling in the genitals, lower abdominal pain, pain on passing urine and sexual dysfunction of various kinds. 72. According to available information, 36 cases (72%) had either been referred to or had been medically treated by statutory health care providers for acute and chronic physical symptoms associated with torture in detention. In most cases treatment had occurred in the UK, although a few people had also been treated in Iran immediately on release from detention. Many people were treated for chronic pain symptoms, but others had been referred for acute injuries or symptoms related to these. Most of those who had been raped had either been screened for sexually transmitted diseases or were referred for such screening. Psychological impact of torture 73. Psychological findings for the 50 cases in this study included 45 people (90%) with symptoms of Post Traumatic Stress Disorder (PTSD) related to the history of torture in detention. Of these, 32 (64% overall) had symptoms reaching the diagnostic threshold according to the ICD-10 Classification of Mental and Behavioural Disorders. In addition, ongoing symptoms of depression directly related to the history of detention and torture were reported by 42 people (84%), of which 27 (54% overall) had symptoms reaching the diagnostic threshold for depression. According to available information, 39 cases (78%) were in treatment for depression and/or PTSD symptoms at the time of the documentation process, receiving medication and/or psychological therapies from statutory health care providers. A total of 11 cases were receiving treatment services from Freedom from Torture during the period when their MLR was being prepared. 74. Signs and symptoms associated with PTSD were reported and observed to a very high level across the sampled cases and included flashbacks (84%) and intrusive memories and thoughts (68%) where traumatic events are repeatedly re-experienced even when the individual is awake and conscious. Recurrent nightmares including elements of the traumatic events in actual or symbolic form and fear and severe anxiety responses to cues that trigger an association with the trauma were reported and/or observed during clinical sessions (94% and 56% respectively). Other typical symptoms included avoidance of thoughts, feelings and activities associated with the trauma, signs of which were observed in half the cases (50%). Some people also reported and demonstrated a marked emotional restriction or dissociation when recalling events related to their torture and a difficulty recalling these events (20%). A marked diminished interest, detachment and social withdrawal was also documented in 62% of cases, while almost all reported that they had difficulties sleeping (96%). 75. Other depressive features of PTSD and depression signs and symptoms documented in these cases included a persistently low mood in most cases (80%), increased fatigue (38%), as well as diminished appetite (60%). Difficulties with concentration and recall and scattered thoughts were also commonly reported and observed (70%), while feelings of worthlessness and guilt and a bleak or pessimistic view of the future were very commonly expressed (56%). Some individuals, particularly those who were raped, expressed a feeling of being irreparably damaged and a sense of their self identity having been permanently altered as a result of the torture, with devastating impact. Particular psychological responses to sexual torture and rape documented in those cases subjected to this included: intense and overwhelming feelings of shame; feelings of anger towards the abuser and/or internalised anger expressed as self hatred; fear and severe anxiety symptoms either generalised or related to those who remind the person of their abuser; avoidance of anything associated with the trauma, including being unable to remember anything or remember details of what occurred or to make a full 42