Nonpolitically motivated child torture perpetrated by a caregiver is frequently characterized by victim physical abuse, psychological abuse, and neglect (including deprivation of basic necessities), often in settings of social isolation with involvement of multiple household members aware of or perpetrating the abuse. In this article, we review and discuss common features of child torture, components of the medical evaluation, and communication with torture victims and investigators. Unique medico-legal challenges including variability in legal statutes and advocacy opportunities are proposed.
Key points
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Nonpolitically motivated child torture perpetrated by a caregiver is frequently characterized by victim physical abuse, psychological abuse, and neglect (including deprivation of basic necessities) with disregard for the extent or severity of injury. Victims are frequently socially isolated, with other household members commonly aware of the unusual abuse.
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Perpetrators of torture frequently engage in orchestrated, systematic attempts to control the victim, create rules and boundaries to manage the victim’s behavior, and damage the victim’s psyche, rendering torture fundamentally distinct from other impulsive acts of abuse.
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Victims frequently have histories of child welfare involvement for physical abuse and neglect concerns and may interface with pediatric clinicians prior to torture discovery; high level of scrutiny by professionals working with children is needed to ensure early identification and accurate diagnosis.
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Many victims of torture have ongoing medical and mental health needs, requiring care coordination by a pediatric clinician.
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Child torture cases pose unique civil and criminal legal challenges that contribute to varied case outcomes for the victim and perpetrator.
Defining a new category of child maltreatment: a review of the literature
The term “torture” has traditionally referred to deliberate infliction of severe physical and psychological pain and suffering, perpetrated frequently in the context of political conflict by state actors or military dictatorships to extract information from a victim, coerce behaviors, punish, degrade, or for the torturer’s sadistic pleasure. Associated with significant morbidity and mortality, torture victimization has been characterized by detainment against one’s will, exertion of physical control by the perpetrator over the victim (rendering them helpless or powerless), intentional infliction of severe pain and suffering without regard to extent, and dehumanization or psychological “breaking” of the victim’s spirit. , The United Nations defined torture in the Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment as “any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purpose as obtaining from him…information or a confession, punishing him for an act he…has committed, or is suspected of having committed, or intimidating or coercing him…when such pain or suffering is inflicted by, or at least at the instigation of, or with the consent or acquiescence of, a public official or other person acting in an official capacity.”
Torture of children has been long-described among children living in war-torn regions, indigenous children during the colonial era, institutional settings, concentration camps, and those subjected to medical experimentation. Several studies have described enduring torture-related physical and psychological injury among child victims, including scars (resulting from beatings, burns, bullet wounds, walking long distances, carrying heavy loads), oral and dental injuries, visual and hearing impairments, posttraumatic stress, depression, anxiety, and behavioral regression. , , In 2022, the United Nations updated its international guidance document on the evaluation and documentation of torture, known as the Istanbul Protocol, to include special attention to the needs and developmental considerations of child victims.
Emerging in the health sciences and forensic literature in the late 1990s and early 2000s, several publications by pediatric clinicians and legal professionals increasingly drew parallels between the phenomenon of politically motivated torture and cases of severe, bizarre child abuse perpetrated by caregivers. This gave rise to the notion that nonpolitically motivated, intrafamilial torture likely represents a distinct subcategory of child maltreatment. In their 1998 Clinical Pediatrics case report, clinicians David Allasio and Howard Fischer described extensive physical abuse and neglect of a 4-year-old male child who was a victim of torture perpetrated by his caregiver. The victim’s injuries had been perpetrated by his father, and law enforcement investigation yielded that abuse involved the victim being hit with sticks, boards, rubber belts, and a ruler “twice a day or three times a week” for a prolonged time period. Physical examination revealed the victim was dirty, hungry, and thirsty with dozens of bruises, abrasions, and loop marks on his face, chest, back, abdomen, and extremities. Allasio and Fischer suggested some perpetrator behavior may be too extreme to simply be classified as abuse, urging pediatric clinicians, legal, and child protection professionals to consider applying the concept of torture to these unusual cases. Allasio and Fischer highlighted as distinct to these cases the perpetrator’s physical control over the victim and infliction of severe pain and suffering in a cruel, systematic, and protracted manner, proposing these elements may adversely impact victim-perpetrator reunification potential and should influence investigative response.
In 2006, Tournel and colleagues in The American Journal of Forensic Medicine and Pathology similarly described egregious abuse of a 3-year-old child victim of torture by a caregiver; this child experienced penile strangulation inflicted by a hair tourniquet and purposeful, repetitive perforation of his eyes by pocketknife, perpetrated by his mother’s paramour. Barbarity (whose synonyms include extreme cruelty, brutality) and torture were descriptors of these repetitive abusive acts involving reinjury to the same anatomic sites prior to eventual discovery of this child’s bizarre maltreatment.
Similar themes regarding the cruel and unusual nature of child torture perpetrated by a caregiver emerged in Ahan’s 2009 editorial A Road to Hope: The Path to Defining Child Torture to Protect Children. Ahan proposed that a medical definition of child torture include as critical elements intent to cause cruel physical or mental pain and suffering, infliction of serious bodily injury, emotional harm or severe mental pain or suffering, some protraction in time, and infliction of this abuse upon another person within one’s custody or control.
In 2012, Drs Barbara Knox and Suzanne Starling approximated that 1% to 2% of children evaluated for abuse sustain physical and psychological injuries suggestive of torture perpetrated by a caregiver; Knox and Starling later collaborated with fellow national child abuse medical and legal experts to publish the seminal article Child Torture as a Form of Child Abuse in 2014. , A compilation of 28 illustrative cases with similar features, Knox and colleagues used these similarities to establish the basis for a medical definition of child torture perpetrated by a caregiver—namely a longitudinal experience characterized by physical assault, psychological maltreatment, and neglect resulting in prolonged suffering, permanent disfigurement, dysfunction, or death.
Knox and colleagues’ compilation consisted of representative, self-selected cases of child torture across the authorship teams’ clinical institutions in the states of Virginia, Texas, Wisconsin, Utah, and Washington. Child victims ages 9 months to 15 years were evaluated between January 1, 1995 and August 31, 2012. Medical records were reviewed for victim’s age, sex, perpetrator relationship, details of the child’s physical and psychological injuries, abuse methods, duration, and case outcome. Cases involving primarily sexual torture were excluded based on author concerns for differing perpetrator motivation. Victims’ median age was 7.5 years, abuse median duration was 3 years, and all victims were subjected to more than 1 form of physical abuse and neglect; most were deprived of basic necessities. Most victims (93%) had cutaneous injury, were beaten, or had fractures for which medical treatment was not sought. Most experienced food and fluid deprivation; over half were deprived of toilet access or hygienic excretory function. Over one-third of victims died as a result of torture.
A case analysis by Knox and colleagues shed important light on household dynamics involving child torture perpetrated by a caregiver. Notably, most victims (89%) were isolated from people outside of their immediate family, with few individuals besides the perpetrators aware of the child’s existence. Nearly half of the victims (47%) who had attended school were removed under the auspices of homeschooling. Seventy-nine percent of primary perpetrators were not the child victim’s first-degree relative, but rather were paramours of their parent, aunts, uncles, grandparents, adoptive or step parents. For all cases, other adults in the home were aware of the maltreatment and participated to some extent in torture perpetration. Nearly half of victims’ siblings had been coerced into torture participation and over half were identified as abuse victims themselves. Victims appeared to be scapegoated within the household, with perpetrators frequently blaming victims (claiming victim behaviors forced the abuse to be necessary) or utilizing a framework of discipline to justify their abusive acts. For half of all cases, 1 to 15 prior referrals and/or investigations by child protective services had occurred, involving historical concerns for physical abuse, neglect, intentional restriction of food or fluids, and supervision. Investigators frequently misattributed the child’s malnourished state to underlying emotional or behavioral issues, as falsely claimed by the caregivers, and/or accepted the caregiver’s explanations on face value, closing the case without follow-up.
Torture was perpetrated by a caregiver often with the knowledge and/or acquiescence of other caregivers and siblings and with concerted efforts to isolate the child and evade maltreatment detection. Knox and colleagues likened this dynamic of control between torture perpetrator and victim to that of intimate partner violence, highlighting the perpetrator’s often extreme efforts to manipulate the victim’s behavior and threats of harm (to the victim, their loved ones, pets, coveted items) to exert dominance.
Proposed alternative definitions: consistencies and differences
Establishment of a medical definition of child torture by Knox and colleagues enhanced the ability of pediatric clinicians to identify and diagnose this subcategory of maltreatment; however, subsequent critiques have challenged definitional components and proposed modifications. Applicability to infants and those suffering a single catastrophic abuse event (lacking protracted duration) have been questioned. In 2016, Alexander and Pena authored a letter to the editor of the journal that published Knox and colleagues’ manuscript suggesting definitional criteria denote physical torture and might best be labeled as such. Alexander and Pena questioned exclusion of repeated sexual abuse from definitional elements, highlighting sadistic sexual abuse may be profoundly psychologically traumatic but differ so substantially in dynamics to thus warrant an independent definition. They also questioned utilization of “permanent” to refer to bodily dysfunction, suggesting “prolonged” may be preferential for pediatric clinicians and better understood by the legal system. Knox and colleagues issued a response, highlighting complexities of child sexual torture (referencing power/control and ritualistic aspects) and acknowledging future modifications to their definition (such as changes to terminology or timeframe) should appropriately be considered.
The American Professional Society on the Abuse of Children in 2021 proposed an alternative definition, emphasizing torture as the physical and psychological captivity of the child, controlling the child’s psyche to produce subservient beliefs and behaviors to serve the perpetrator’s needs with frequent protracted duration.
Schlatter and colleagues later published a retrospective review of 47 child torture cases evaluated between 2006 and 2021 across Washington State. Similar victim median age and protracted duration were identified; most victims had examination findings concerning for physical abuse with cutaneous injuries again identified most commonly, similar to Knox. , Food and water deprivation were most common types of psychological maltreatment, followed by isolation, experiences similar to Knox and colleagues. Notably, over one-third of children had been evaluated by pediatric clinicians within 1 year of their torture diagnosis; several had been actively followed for poor weight gain despite reported adequate diets, commonly having histories of consumption of nonfood items or stealing food. Despite this, imposed feeding restrictions went unrecognized by the involved clinicians, allowing abuse by torture to continue. Schlatter and colleagues concluded that multiple similarities across both datasets support appropriateness of the Knox definitional criteria, although continued research to refine understanding of torture and aid recognition, diagnosis, and treatment of victims remains needed.
More than just severe abuse: recognition and early identification of torture
Epidemiologic surveillance of child torture perpetrated by a caregiver has been limited by historical lack of formal consensus on the criteria differentiating torture from severe abuse and variable recognition and resultant intervention by medical, legal, and social service professionals. Similar barriers exist among victims of international, politically motivated torture, prompting calls for urgent development of data collection efforts that support identification and diagnosis, documentation, and tracking of treatment outcomes among child torture victims. Incidence of child torture perpetrated by a caregiver is unknown; it is not captured by present federal maltreatment statistical collection methods. Jurisdictional variability in legal approaches to suspected torture additionally hamper efforts to collect data on national trends with fidelity.
While bias in evaluation and reporting of child abuse and neglect has been described, data suggesting disparities involving torture are quite limited. Schlatter and colleagues noted an overrepresentation of Black and Native American torture victims in their single state case series compared with Washington state census data, potentially indicative of localized, regional disparities. Whether disparities exist across the broader population of torture victims nationally is largely unknown.
Emerging themes from child torture literature overwhelmingly support the need to distinguish these cases from simply severe, poly-abuse perpetrated by caregivers. While cases do typically involve multiple abuse types (commonly physical abuse with psychological maltreatment, neglect), cardinal features that should be recognized by pediatric clinicians include concurrent deprivation of basic necessities, elements of domination and control by the perpetrator over the victim’s actions, lack of perpetrator response to a victim’s basic needs, bizarre and unusual maltreatment, and often protracted nature of abuse ( Box 1 ). Most importantly, child torture typically involves planning, orchestration, and systematic attempts by the perpetrator to harm the child victim, opposite that of most acts of impulsive physical abuse resulting from temporary frustration and loss of caregiver control such as infant shaking during crying peaks. Torture differs fundamentally from momentary lapses of judgment and impulse; perpetrators may arrange cameras or other video surveillance equipment to monitor the child victim’s movements and behaviors to record and memorialize their abusive actions, presumably for their own sadistic pleasure, and act at great length to deceive or isolate the child from external observers.
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Single child or select group of children targeted, scapegoated
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Physical abuse
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Food, water, and basic necessity deprivation
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Social isolation
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Psychological/emotional maltreatment
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Protracted duration
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Victim blaming, symptom misattribution
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Profound suffering, serious physical/bodily or emotional injury, fatality
Cases frequently feature astonishing, bizarre, and even shocking elements including prolonged forced exercise, restraint (by ropes, handcuffs, chains), maintenance of uncomfortable positions, ingestion of noxious or dangerous chemicals or substances, imprisonment (in cages or locked spaces), threats of harm (death to oneself, loved ones, or pets), and deprivation of safe and hygienic excretory function (forced to wear diapers, urinate in buckets or bottles) frequently with knowledge and acquiescence of other responsible adults in the home , , ( Box 2 , Fig. 1 A–D ,). Identification of unusual measures occurring in the home (to manage behavior, as punishment, or based on disclosures by the child) or episodes of repeat abuse should be immediately recognized as inappropriate and prompt expeditious consideration of torture as a potential etiology ( Figs. 2–4 ).
“Joseph” is a 12-year-old male with unremarkable past medical history who ran away from home one evening to a friend’s house in his neighborhood ( Fig. 5 A, B ). His friend’s parents contacted law enforcement after seeing Joseph, covered in bruises, and hearing Joseph describe his living conditions. Joseph disclosed to his friend’s parents that he was restricted to a single barren room of his family’s house by his stepmother and forced to sleep on the floor without appropriate bedding, furniture, or toys. Curtain shades covered the windows preventing entrance of sunlight. The room had only a single lamp and a clipboard, on which Joseph was forced to write repeatedly “I will not throw fits” 500 times per day as punishment, ordered by his stepmother. He was locked in this room all day and night, as his stepmother had removed him from school a few months before under the context of homeschooling. His school teachers had previously grown concerned over Joseph’s recent bruising and noticed weight loss, prompting them to contact child protective services on 4 separate occasions. After the third report and outreach by child protective services to their home, Joseph was withdrawn from school by his stepmother. The fourth hotline report called in by Joseph’s schoolteachers was screened out by the child protective service agency. Joseph had limited access to a toilet and was forced to wear a diaper. Joseph was fed a peanut butter sandwich once daily by his stepmother, with limited drinking water. Joseph’s father was aware of what was happening to Joseph but did not stop it and often participated. Joseph was repeatedly ridiculed, called derogatory names, and told he did not deserve any toys. His step siblings who also lived in the home had their own bedrooms with toys and furniture and could eat whatever they wanted; they attended school, and their treatment was very different. Joseph informed his friend’s parents and law enforcement that he escaped from his home through a hole in the wall.
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