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:


Case 25

Domestic violence against the elderly in Germany


  1. To illustrate that domestic violence can be overlooked due to a lack of knowledge
  2. To show as best case example a succesful intervention of a GP
  3. To demonstrate that it is not always clear – domestic violence case or not?

Narrative cases:

  1. Domestic violence not recognized due to lack of knowledge

During a home visit as a general health practitioner, I saw a family at an isolated rural location (edge of Wuppertal in Germany). A lady of around 80-years of age presented in a weak state [1] with various pains in different places caused by several falls. The patient herself was silent and her home, clothing and family seemed rather neglected. [2]

After writing an admission note for the hospital, I had the vague feeling that something was being withheld from me.  I had asked the family to call an ambulance but should have waited for the ambulance to arrive. I realized this much later when I learnt more about violence against elderly people within the family. [3]

2. Successful intervention of the GP

An 85-year-old woman was said by her family to be unable to pass urine and suffering from severe abdominal pains. This history was given in an excited and wordy account. The patient was very restless, anxious and her bladder clearly full. While writing down the results of my examination, I hear the patient ask her family: “Can I now go to the toilet?” and hear a hissing whispering: “No”!

I wrote a hospital admission note and called the ambulance myself. [4] I had the suspicion that the family had forced the patient not to go to the toilet. I think they did not know how to care for the grandmother and feigned illness in a very clumsy way to bring help from outside. [5] Soon after the visit, I informed my colleague on duty at the hospital about my suspicion. [6] After admission, the patient had been able to pass urine without any problems. Social/familiar background problems could be solved at the hospital by a special care service for needy and lonely patients. [7]

3. Unclear situation- case of domestic violence or not?

A patient on my list  for over 10 years [8], aged 87 years, lived after her daughter’s death with her son-in-law in a detached family house [9]. The patient was suffering from cardiac insufficiency and repeatedly she came with injuries and excoriations on her legs to my private practice. “She is always running down the stairs too quickly!” said the son-in-law who accompanied her. His behaviour was then rather uncooperative and disturbed. The patient insisted that she was kindly nursed by him [10] and a niece with a nurse living nearby looked after her [11].

Until now I have not known what to think about the situation [12]

Learning points

[1] The WHO state there are several risk factors concerning elderly abuse such as illnesses and shared living situations. In addition,  strong dependence on caregivers can make such abuse more likely.

[2] Elderly  abuse can have many different forms and involves more than physical components. The neglect of an elderly person, whether intentional or not, is also considered as abuse. At times, it is difficult to determine whether it is already abuse or still unkemptness.

[3] Here the main problem is described; the general lack of knowledge regarding this topic. The physician did not even think about it! Not only are there few studies on this topic but there are also no reports on this issue worldwide. The topic itself is also regarded as taboo (should stay within the family) and no-one wants to talk about it, which makes recognition even more difficult.

[4] In comparison to the first story, the physician recognized the abuse and decided to intervene. She stayed and made sure that the patient went to hospital.

[5] In this example, the family is clearly overburden with the care of the old lady. They wanted to get help from outside but didn´t know how to do this. The physician was sensitive to the issue but as the awareness is not very high many cases can go undetected. The WHO started preventative programmes for people who are caring for their older relatives. These provided assistance and teaching on how to deal with the situation.

[6] Here we see the positive impact of an intact chain of information between physicians. The physician at the hospital is informed about the suspicion and can further intervene.

[7] This is a best practice example. In most hospitals such a special service is not available. It will assist families that want to get help.

[8] The physician knows the patient for a very long time and the family situation as well. If a relationship like this exists, a physician can recognize changes faster and usually some kind of trust exists between doctor and patient.

[9] Another risk factor is social isolation. It goes together with dependency as the abused person might have only the abuser as their sole contact person.

[10] The physician suspects abuse but does not get a sufficiently detailed answer. Here a standardized sample of questions might help which can be answered with yes or no. Questions like this do already exist such as the H-S/East (Hwalek-Sengstock Elder Abuse) screening test. Recently the WHO has tried to develop a more simple approach using 12 easy to understand questions, EASI – The Elder Abuse Suspicion Index. These questions can be found on the internet (see below). It might also help to question the patient in private. There are many reasons why potential victims do not want to talk about abuse including feeling afraid to be alone or feeling  ashamed.

[11] Once again the importance of a network is seen. The physician could contact this nurse and talk with her about the situation in the patient´s home. In addition, the physician could visit the patient to check the situation for herself.

[12] As already described in [2] it can be rather difficult without screening tools to determine abuse. This underlines the importance of raising awareness and proper training for physicians

Further Information

According to the WHO elder abuse is a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person. It can have many different forms such as physical, psychological or emotional, sexual and financial.

The importance of this topic has long been underestimated but it has gained growing attention. Still elder abuse is believed to be underreported by up to 80% with a prevalence ranging from 1% to 35% according to various questionnaires. There exists a remarkably lack of studies concerning it. The biggest study regarding this topic was in 2002 the Missing voices: views of older persons on older abuse study conducted by the WHO. It was conducted in eight different countries: Argentina, Austria, Brazil, Canada, India, Kenya, Lebanon and Sweden.

This study demonstrated the necessity of addressing this topic. The WHO has started to develop screening tools to make it easier to raise physicians’ awareness and help to detect more cases. Different methods and questionnaires previously used such as the H-S/East but were regarded as taking too much time to ask, were difficult to understand and non specific. Taking these issues into account, EASI the Elder Abuse Suspicion Index was drawn up which consists of only six questions of which five are answered by the patient and the last one by the doctor.


The WHO identified five fields of risk factors:

  1. Individual: illnesses (mental disorders, alcohol abuse), gender (in countries where woman have a lower society status than men, they are more likely to experience elder abuse)
  2. Relationship: shared living situation, dependence, financial dependence of the caregiver on the elderly person, history of poor relationships within the family, overburden of the caregiver
  3. Community: social isolation of the elderly person
  4. Socio-cultural: financial problems, general depiction of old people as weak and helpless, erosion of bonds between the generations, migration of young couples
  5. Institutional: low standards, poorly trained and overworked staff, economic reasons (the economic situation of a home for the elderly is more important than the well-being of its residents)


As with any type of abuse, elder abuse can cause not only physical injuries but may lead to long-lasting psychological problems such as anxiety and depression.

After raising awareness, the WHO proposes various measures to tackle this form of abuse such as a general screening for abuse and better caregiver support and training. They are demanding mandatory reporting on each case, building  safe houses and shelters for victims and the foundation of self-help groups.

All these measures show great similarity to the measures against domestic violence.


Purpose: Screening device for service providers interested in identifying people at high risk of needing protective services.

Instructions: Read the questions and write in the answers. A response of noto items 1, 6, 12, and 14; a response of someone elseto item 4; and a response of yesto all others is scored in the abuseddirection.


  1. Do you have anyone who spends time with you, taking you shopping or to the doctor?
  2. Are you helping to support someone?
  3. Are you sad or lonely often?
  4. Who makes decisions about your lifelike how you should live or where you should live?
  5. Do you feel uncomfortable with anyone in your family?
  6. Can you take your own medication and get around by yourself?
  7. Do you feel that nobody wants you around?
  8. Does anyone in your family drink a lot?
  9. Does someone in your family make you stay in bed or tell you youre sick when you know youre not?
  10. Has anyone forced you to do things you didnt want to do?
  11. Has anyone taken things that belong to you without your O.K.?
  12. Do you trust most of the people in your family?
  13. Does anyone tell you that you give them too much trouble?
  14. Do you have enough privacy at home?
  15. Has anyone close to you tried to hurt you or harm you recently?

EASI Questions

Instruction: Q.1-Q.5 asked of patient; Q.6 answered by doctor

Within the last 12 months:

  1. Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?
  2. Has anyone prevented you from getting food, clothes, medication, glasses, hearing aids or medical care, or from being with people you wanted to be with?
  3. Have you been upset because someone talked to you in a way that made you feel shamed or threatened?
  4. Has anyone tried to force you to sign papers or to use your money against your will?
  5. Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?
  6. Doctor: Elder abuse may be associated with findings such as: poor eye contact, withdrawn nature, malnourishment, hygiene issues, cuts, bruises, inappropriate clothing, or medication compliance issues. Did you notice any of these today or in the last 12 months?



  1. WHO. A global response to elder abuse and neglect. 2008. ISBN: 978924156381 (25.09.2015)
  2. WHO. Discussing screening for elder abuse at primary health care level. 2008. ISBN: 978 92 4 159453 0. (25.09.2015
  3. WHO. Missing voices: views of olfrt persons on elder abuse. 2002. (25.09.2015)
  4. Fact sheet on elder abuse. Dec. 2014. (26.09.2015)
  5. The elder abuse suspicion index. 2015 (28.09.2015)
  6. (28.09.2015)
  7. (28.09.2015)

Case 18

Domestic violence is independent of education, economic situation, social class or culture


  1.  To show that domestic violence is independent of education, economic situation, social class or culture.
  2.  To show that emotional abuse is often a precursor to serious acts of physical abuse.

Narrative Case

Dr. Bob Smith is a general surgeon and his wife, Dr. Carol Jones, is a general practitioner, both practising in an urban setting.  They have been in practice for ten years. They met in medical school and married in their first year of residency.  They have two children, ages 5 and 7.  [1]

Carol took three weeks off on maternity leave with each child, as her practice was still relatively new at that time and she did not feel she could take the year maternity leave that many of her friends in salaried positions could take. [2]

Things are not going well. Bob is on call every second night since the third general surgeon left for the States last year and the hospital has not been able to attract another surgeon.  He is so tired that he wonders at the completion of some surgeries whether he has done his best.  He is currently in the middle of a legal suit, which is taking so much of his time.  He finds that if he comes home at night and drinks vodka, he feels much more relaxed and yet does not have to worry about the smell of alcohol on his breath if he should get called back. [3] He does not want to seek help in case word of his difficulties negatively influences his medical practice.

Carol is becoming increasingly stressed as well.  Her office is always overbooked, as she has had to cut down to 3 days of office work, to be able to take care of the needs of the children.  She still has the office overhead to contend with, but not the volume of patients to justify the costs.  She is feeling more like a single parent, running the two children to lessons and sports by herself as Bob is always either at the office or the hospital.

On one particularly tiring day, Carol comes home after the children’s swimming lesson to find Bob drunk and asleep on the couch.  After putting the children to bed, Carol awakens Bob and confronts him with his increasing use of alcohol and withdrawal from family duties.  Bob is so angry that he hits Carol and blackens her eye.

At the office the next day, Carol makes up an excuse about a household injury to explain her black eye.  She realizes that Bob is a good husband and that the stress of work, the current litigation, both coupled with alcohol, brought out this atypical behaviour. [4]

After repeated episodes of physical abuse, their relationship deteriorates and Carol tells Bob that she is going to leave him and take the children.  Bob pleads for Carol to go to joint counselling, as he has not been himself and really does love them all.

Carol does not have much hope for success from the counselling, but feels guilty about leaving, so she gives counselling a try.  The female counsellor feels threatened dealing with two physicians.  After six sessions, nothing is resolved and Carol makes plans to leave with the children. [5]

Bob finishes his court case and is found guilty of malpractice.  He wonders what is the point in living—his reputation as a surgeon is tarnished, his wife and children are leaving him and he is exhausted and overworked.  He goes home and drinks.  When he hears Carol and the children driving into the garage, he picks up his hunting rifle, killing them and then turning it on himself. [6]

Learning points

[1] Medical marriages are often difficult.  The woman often has to take second place to her husband in career choice and academic advancement.

[2] Women physicians often have an excessive sense of commitment to make their work successful, just to show that they are capable of “having it all”-career, family, husband, etc.

[3] Bob realizes that he is not coping but as a physician and leader in the community does not want to let anyone know that he needs any help.  He turns to substance abuse.

[4]   Despite having counselled patients against staying in a relationship where there has been physical abuse, Carol makes excuses for Bob’s behaviour.

[5]  Being in a position of authority when seeking personal help is not always an advantage.  The male often presents a more threatening figure than the female and this may affect the performance of the caregiver and consequently the outcome.

[6]  Accustomed to being in control and being an authority figure, Bob cannot cope with all these loses and having humbled himself to go to counselling and that failing, he decides that there is only one alternative.  He struggles with feeling powerless in a society that tells him he should be powerful, with the seeming lack of options and with the socialization that has taught him not to seek help.  All this translates into violence against his female partner


Case 6

Case of First Domestic Violence in Pregnancy

Objective: To show that violence during pregnancy may be a more common problem than conditions for which pregnant women are routinely screened

Narrative Case

Mandy was a 23-year old patient currently 28 weeks pregnant.  I had delivered her and was her only doctor since birth.  I knew her quite well as she had asthma and spent more than the usual time in my office.  I also looked after her mother and sister and grandmother.

She did not do well in school and hung with the rough crowd.  Although we had talked about contraception on previous visits, she was unreliable taking her birth control pills.  Therefore, it was not a surprise to find her presenting to my office for pregnancy care.  Her relationship was unstable but at present she was living with the baby’s father, an El Salvadorian immigrant involved in the drug trade. [1]

The pregnancy was progressing uneventfully until one day Mandy presented with facial bruising and abdominal pain.  Through sobs, Mandy told me that her boyfriend had beaten her up because she refused to have sex with him.  He punched her in the face and kicked her in the belly.  She had called the police and they arrested him overnight but he was being released later that morning. She had been to emergency and found to be physically okay.  She did not know what to do. [2]

Pregnancy-wise, she was fine, but was emotionally distraught and not sure of her options.

I was able to put her in contact with the Ending Violence Association, which is an umbrella organization for services available for victims of domestic and sexual violence.  They were able to get her into a safe house, where counselling and social services were available.  She managed to make a clean break from the relationship and went on to deliver a healthy son, with ongoing support from social services and her family. [3]

Learning Points  

[1]  Many women have a longitudinal relationship with a physician, particularly during pregnancy and well baby visits.  This allows for more opportunities for screening and prevention.  Only about 17% of all pregnancy women are screened for domestic violence at their first visit and 10% at subsequent visits.

[2]  Violence during pregnancy may be a more common problem than conditions for which pregnant women are routinely screened.  It is estimated that one in five women will be abused during pregnancy. As homicide during pregnancy now surpasses the previous leading causes of death (automobile accidents and falls), it is more important than ever that we know the signs and properly screen women for domestic violence.  However, the doctors and emergency room providers need to know the signs of abuse and what to do about them.  

[3]  It is important for primary care providers to have easy access to services for victims of domestic and sexual violence.  It is important to make sure that they are safe from further harm and have access to services that allow them to make choices that are best for them and their baby.



Centre for Disease Control
Intimate Partner Violence During Pregnancy, A Guide for Clinicians

Domestic Violence in Pregnancy at