Case 38

Violence Against Women


  1. To review the Istanbul Protocol
  2. To illustrate an application of the Istanbul Protocol

Narrative Case

A young recently married woman (31 years old) asked for divorce after 3 months of marriage. She complained that her husband frequently attacked her and physically hurt her. On examination, 2 months later, she was found pale, slimy and depressed. More than 20 skin lesions were seen, in the form of abrasions, bruises and lacerations, widely distributed on both upper limbs. Most of them were rounded or elliptical and some were brush-shaped indicating dragging of teeth on soft tissues of skin. The pattern of teeth marks were compared to bite marks of the wife to exclude being self-inflected bite-marks. A cast was prepared to the victim’s teeth while the husband refused to be examined for comparison. All lesions were old, dating to more than 3 weeks, showing discolored scars, brownish, coppery or paler than the surrounding normal skin. They appeared neglected, infected or badly treated and showed different stages of healing, and some showed keloid formation (massive fibrous tissue formation) with loss of sensation at certain parts of injured areas. All injuries were photographed with a scale to document these injuries with the proper measurements.


It was concluded that these bite marks dated back to the time of marriage, about 2 months before examination, and they were neglected. Healing was by secondary intension and there was keloid formation. These bite-marks were not self-inflicted. As the husband refused being examined for comparison, the victimized wife got divorced by the court considering his refusal as a confession of guilt and was convicted.  So, effective investigation and documentation according to Istanbul Protocol are important to prevent torture and abuse.

Learning Point

  1. The Istanbul Protocol can be an effective tool in clinical decision making, including appropriate investigations and record keeping in cases of Wife Abuse.


Background Information

The Manual of Effective Investigation and Documentation of Torture, and other Cruel, Inhuman or Degrading Treatment or Punishment, commonly known as the Istanbul Protocol, sets the international standard for legal and medical investigations of torture and other mistreatment, including intimate partner violence. Its development was the work of more than 75 physicians, lawyers, mental health professionals and human rights monitors from 15 nations representing 40 agencies or organizations. In 1999, the Istanbul Protocol became an official United Nations document.

The standard set by this document, when adhered to, ensures that the physician’s medical record can be used in the prosecution of crime.


  1. The Manual of Effective Investigation and Documentation of Torture, and other Cruel, Inhuman or Degrading Treatment or Punishment: