a note to the prosecution service.318 That note was received at 5:33 p.m. the same day.319 At 7 p.m., the “complete calcified placenta” was extracted from Manuela, a curettage was performed, and her “perineal tear” was sutured.320 The Court notes that the State has not presented arguments to justify this delay. To the contrary, the Court emphasizes that during this time, the treating physician gave priority to filing a complaint before the prosecution service concerning a presumed abortion.321 196. Second, the Court recalls that, since 2007, Manuela had visible lumps in her neck. 322 Nevertheless, the general examination performed on the presumed victim at 6:40 p.m. on February 27 indicates that she had a symmetrical neck.323 In fact, during the seven days that Manuela remained hospitalized, the medical record reveals that the treating personnel never examined or recorded the lumps in Manuela’s neck. On this point, expert witness Guillermo Ortiz indicated that, once the emergency had been attended to, a complete physical examination should have been performed. In this regard, he indicated that by “conducting a more thorough, more meticulous examination, the tumor in her neck would have been diagnosed,” and this could have changed the course of the treatment provided to Manuela. 324 197. Third, the Court notes that, according to Manuela’s father, his daughter was handcuffed in the San Francisco Gotera Hospital.325 This assertion concurs with the practice of handcuffing women suspected of abortion, and the Court has considered this proved by the contextual facts of the case (supra para. 46). In cases such as this one, where there is no direct proof of the actions of the state agents, the Court has stressed that it is legitimate to use circumstantial evidence, indications and presumptions as grounds for a judgment, provided that conclusions consistent with the facts can be inferred from them. 326 The Court considers that the statement of Manuela’s father, assessed in light of the context in which the facts of the case occurred, makes it possible to presume that Manuela was handcuffed to the hospital bed, at least on February 28, 2008. 198. Handcuffs or other similar devices are frequently used as instruments of physical coercion for people who are detained and deprived of liberty. This Court has indicated that any use of force that is not strictly necessary due to the behavior of the person detained constitutes an attack on human dignity, in violation of Article 5 of the American Convention.327 The Court recalls that numerous decisions of international bodies cite the United Nations Standard Minimum Rules for the Treatment of Prisoners (hereinafter “Rules for the Treatment 318 Cf. Record of the interview of the treating physician (evidence file, folio 16). 319 Note addressed to the prosecution service dated February 27, 2008 (evidence file, folio 22). Communication issued by the director of the San Francisco Gotera National Hospital of February 29, 2008 (evidence file, folio 58). 320 321 Note addressed to the prosecution service dated February 27, 2008 (evidence file, folio 22). Cf. Medical appraisal in the case of Manuela. Review of clinical and hospital treatment in the Cacaopera Health Unit and the San Francisco National Hospital” (evidence file, folios 186 and 187); Sworn statement of Manuela’s mother on September 3, 2017 (evidence file, folio 2281), and Sworn statement of Manuela’s father on September 3, 2017 (evidence file, folio 2288). 322 Communication issued by the director of the San Francisco Gotera National Hospital of February 29, 2008 (evidence file, folio 58). 323 324 Cf. Expert opinion provided by Guillermo Antonio Ortiz Avendaño during the public hearing held in this case. 325 Sworn statement of Manuela’s father on September 3, 2017 (evidence file, folio 2288). Cf. Case of Velásquez Rodríguez v. Honduras. Merits, supra, paras. 130 and 131, and Case of Valenzuela Ávila v. Guatemala, supra, para. 163. 326 Cf. Case of Loayza Tamayo v. Peru. Merits. Judgment of September 17, 1997. Series C No. 33, para. 57, and Case of Azul Rojas Marín et al. v. Peru. Preliminary objections, merits, reparations and costs. Judgment of March 12, 2020. Series C No. 402, para. 158. 327 57