Istanbul Protocol for toddlers and children

The Istanbul Protocol (full title: Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment) represents the United Nations’ standard for training professionals to appraise persons who make allegations of having been tortured or mistreated, for examining cases of alleged torture and for reporting such findings to the judiciary and other investigative authorities.

75 doctors, psychotherapists, lawyers and human rights activists, together representing forty organisations from fifteen different countries, worked on the protocol. In August 1999, they gave the fully worked out Istanbul Protocol to the UN High Commissioner for Human Rights. The numerous authors include, among others, amnesty international, Human Rights Watch, the International Red Cross, Physicians for Human Rights, the Lawyers Committee for Human Rights, the Treatment Centre for Torture Victims in Berlin, as well as other therapy centres in South Africa, Chile and the USA, various university institutes, the Turkish, Danish, British, Indian and German Chambers of Medicine, as well as the World Medical Association, and, last but not least, the IRCT.

In mid-2004, the Istanbul Protocol was published as part of the UN’s Professional Training Series at the office of the UN High Commissioner for Human Rights as a manual for effective medical examination, and is meanwhile available in several languages. The Istanbul Protocol presents the current possibilities for verifying the traces of torture, thereby differentiating between methods of diagnosing physical symptoms of the skin, face, teeth, chest, abdomen, muscles, skeletal system, urogenital tract and nervous system resulting from various forms of abuse, and the verification of the psychological consequences of torture.

Despite the painstakingly compiled, well laid-out and detailed information which it contains, this manual for conducting examinations is virtually never used in cases (of suspicion) of the rape and torture of (very young) children. Having combed through the Protocol in detail, the network has compiled a rapidly readable document offering procedural guidelines for lawyers, doctors and parents protecting their children.


Recommended procedure for conducting a visual examination of the child in a case of suspected torture/sexual abuse

Before beginning a thorough visual examination of the child’s body, you should take the following steps:

First, acquire a precise overview of any illnesses, medical interventions or accidents that the child has had before you definitely suspect an assault. Safeguard the relevant documents, as pieces of evidence that will be needed later on, from being accessed by outside parties.

Think about what clothes the child was wearing during the abuse. Keep safe any pieces of clothing that the child may have been wearing.

If you suspect that your child has been abused using specific everyday objects from your home, you should likewise safeguard these pieces of evidence from getting lost and manipulated.

Having taken the above steps, you can now examine the child in an unclothed state. You should conduct this examination in a systematic way, and thereby try to convey a sense of calm to the child. Record the entire examination on video. In addition, take photographs of any signs of abuse found on the child’s body in a full-body shot and a close-up shot.

Bring in at least one witness of as impeccable repute as possible. For example, persons with expertise in the field of medicine (doctors, nurses) or in criminalistics (police, lawyers) will, as expert witnesses, be regarded as particularly credible when they later testify in court.


Examining the Skin

Bear in mind that generalised skin diseases in a child can be caused by torture, heat, the effects of deliberate exposure to very strong light or the forced consumption of toxic substances. As soon as you discover a skin disease, take a close-up photograph of it. Measure the skin anomaly. Record a detailed description of the location, shape, size and surface structure of the findings. Look out for injury patterns such as grazes, abrasions, contusions, lacerations, puncture wounds and burns (which can be caused by cigarettes, heated instruments and electrical diodes). Examine the scalp of your child for hair loss, and inspect their fingers for pulled-out fingernails. Take into account that skin damage can heal in 6-8 weeks.

Changes in the skin show up in the form of scratches and abrasions. If, on the other hand, contusions and bruises are visible, these are signs of burst blood vessels. Contusions may have a visible pattern and may thus even show the outlines of the object used to abuse the child. As soon as contusions cause bruises and subside, they go through a series of changes in colour. Most bruises initially appear dark blue, violet or crimson. If the child attests to having been abused, but you cannot yet establish the existence of a contusion during the visual examination of the child, then examine the child again a few days later: because contusions that lie deeper under the tissues of the skin surface do not become visible until later on.

If the abuse of a child has caused a laceration, it will usually be possible to verify scarring. The same applies to burns.

This is the type of torture which most frequently leaves permanent changes in the skin. Burns caused by cigarettes often leave 5-10 millimetre circular or oval scars with indistinct edges. A burns inflicted with a pre-heated object causes a scar which frequently reflects the shape of the instrument of torture. If the nail bed has been burned, that will cause the subsequent growth of thin, striated and deformed nails.

Traumatic injuries from skin punctures or cuts come about when the surface of the skin is pierced or slit open with a sharp object. Look out for even the tiniest puncture wounds, deep scratches or cuts.









Examining the face

Palpate the tissue of the face to find evidence of a possible fracture, swelling or the crunching of bones (crepitation). If the child complains of pain anywhere, document the site concerned with photographs, accompanied by measurements. A subsequent computer tomography (CT) is the best way of diagnosing broken bones in the face.


Examining the ears

Eardrum injuries, in particular, are the subsequent result of violent blows to the child’s head. One form of this type of torture is the so-called “telefono”, in which both ears are simultaneously dealt a blow with the palms of both hands. The pressure on the outer ear canal can thereby cause the eardrum to burst. Liquid may be found in the middle ear or the outer ear of the child. An ear specialist can diagnose such a discharge from the ear through a laboratory analysis and offer diagnostic confirmation of the suspicious nature of these injury patterns. At the same time, it is essential to test the child for possible hearing loss. The fracture site can be located later on through MRT or CT.

Examining the eyes

A wide variety of eye injuries can occur during the torture of the child. Look out for bleeding and redness, and to a possible dislocation of the lens.

Document this suspicion and then get it confirmed through a diagnosis from an eye specialist. In addition, a computer tomography (CT) can diagnose eye-socket fractures. Magnet resonance tomography (MRT) can verify injury to the soft parts of the eyeball through a high-resolution sonogram.



You should carefully examine the child’s nose for any misalignment, crunching and displacement of the nasal cartilage. In a case where there is suspicion of a simple nasal fracture, having a standard X-ray done can provide firm proof. In the case of a complicated nasal fracture, you should at least have a CT carried out.


Jaw, oral cavity and neck

Fractures and dislocations of the lower jaw can be caused by violent blows to the child’s head. If blows have been inflicted on the lower half of the face or the jaw, the result can be a jaw joint syndrome (disorder of the masticatory apparatus). Indicators of this are headaches, toothache or cracking sounds when chewing. Look into the open mouth of the child, watching out for any injuries in the oral cavity and any bleeding of the gums. In particular, the pain caused by the electrical current may have made the child bite their tongue, gums or lips.

In case of suspicion, one should then get a dental anamnesis drawn up. Fractures of the lower jaw can be precisely diagnosed through X-rays and MRT.


Ribcage and abdomen

Carefully palpate the ribcage and abdomen, both in front and over the back. Blows and kicks can cause not only injuries and tearing of the inner organs, but also internal haematomas. In case of suspicion, you should get an ultrasonic test, CT and bone scintigraphy (examination of areas with increased bone metabolism by a medical specialist) carried out.


Musculoskeletal system

Carefully carry out a mobility test on each of the child’s joints. Complaints of pain when moving, as well as any suspicion of dislocations and fractures, justify subsequently getting an X-ray done. Injuries to tendons, ligaments and muscles, on the other hand, are best verified through an MRT.


Central and peripheral nervous System

If possible, you should document any disruptions of motor function, gait and coordination that you detect. The same applies to wristdrop and to weakness of the arms (caused by disorders of the tendon reflexes). Arrange for a radiological examination of the brain and the posterior cranial fossa to be carried out through MRT.



Any fractures found involve injury to the bone substance caused by a blunt mechanical force. An x-ray examination of newly fractured sites should be carried out by a specialist in trauma radiology.


Traumatic brain injury

Traumatic brain injury is one of the most common consequences of the use of violence.

Signs of this are, for example, bruises on the scalp. After a child has been subjected to blows to the head, they may subsequently complain of prolonged headaches. Carefully palpate the child’s scalp and the nape of the neck to detect local swelling. Swelling of soft tissue can be diagnosed through CT or MRT.

Violently shaking a child’s body can cause brain injuries, although it usually leaves no visible signs of injury. Try to recall whether, in the past, the child ever complained of recurring headaches or whether you noticed any deficits, for example in the form of disorientation. Document the period(s) concerned. If these types of symptoms recur, record them on video. As far as possible, you should ensure that you always have your video camera ready to hand for this purpose. Bear in mind the risk of a cerebral oedema, subdural haematoma (bleeding between the meninges and the brain) or retinal bleeding caused by the use of violence.


Trauma to the chest and Abdomen

Fractured ribs in the child can be a sign of blows to the chest. Here, tears in the lungs or what is called “pneumothorax” (air in the pleural cavity) can arise. Violence inflicted on this region of the body can also cause fractures of the spine. A CT can diagnose bleeding caused by a lung fracture, or an accumulation of fluid in the abdomen. Other potential injuries to the abdomen are haematomas of the spleen or acute kidney failure. An ultrasonic examination is particularly helpful for verifying any haematomas of the spleen.


Blows to the feet

Blows to the feet are often inflicted by means of a club or cane. As applying blunt force to the feet is meanwhile a recognised method of torture, the technical term “falanga” (trauma to the feet) has become established. The most severe consequence of falanga is compartment syndrome (disordered blood flow to the tissue) in the foot. Damage to muscles or vascular obstruction can, however, also occur. As these injuries are usually limited to soft tissue, CT or MRT represent the surest methods for carrying out a subsequent radiological documentation of such injuries. Blows to the feet can ultimately cause chronic disability. As a result, not only can walking itself be chronically painful, but the tarsal bones themselves can also become either fixed and immobile (spastic) or too loose. You should therefore carefully palpate the sole of each foot, paying attention to any hardened areas in the foot, as well as to any tearing, scarring and discolouration of the skin. Document all your findings. Try to recall whether, in the past, the child ever complained of pain when walking, or wanted to be carried to an abnormal extent, and whether you noticed any injuries to the soles of the feet.




Torture by Suspension

Suspending (hanging up) victims is a frequently encountered method of torture that causes extreme pain but leaves hardly any visible evidence. Different forms of this torture are practised. Often, victims are thereby hit or mistreated in other ways. Possible complications that can subsequently arise include weakness of muscles of the arms or hands, deafness, loss of tendon reflexes, pain sensitivity or insensitivity to touch. In addition to neurological injury, torn ligaments in the shoulder joints, dislocation of the shoulder blade or injury to the shoulder muscles can also occur. Similar patterns of injury can result if the victim is not suspended but is instead held fast to force them to hold a certain position (bent over, overstretched) for a prolonged period.

Source: Lynn Schirmer

Carefully move the shoulders, arms and wrists of the child. Look out for any disruptions of motor function and any swelling. In case of suspicion, arrange for a neurological examination of the muscle tissue to be carried out.


Torture by electric shock

Here, an electrical current is passed through electrodes that are attached to a place on the body. The most usual points of contact used for this purpose are the hands, feet, fingers, toes, ears, nipples, the mouth, the lips and the genital area. Particularly in the genital area, the resulting pain is known to be unbearable. As all the muscles located along the flow of the current contract in a cataleptic-like manner, shoulder dislocations and diseases of the nerve roots (radiculopathy) can occur. However, the type and time of the torture, the strength of the current and the electric power cannot be determined with certainty through physically examining the victim. The traces of burns caused by electrical current are usually reddish-brown, circular wounds with a diameter of only 1-3 mm. You should therefore pay particularly close attention to the surface of the child’s skin.

Torture inflicted on the teeth

Torture inflicted on the teeth can take the form of tooth fracture, drilling the roots of teeth or pulling teeth out. It can also take the form of electric shocks to the teeth. Basically, when examining the child, you should always check the oral cavity. Use a torch or other additional source of light for doing this. Take photographs of any injuries to the gum and inflammations of the oral mucosa that you discover. Try to recall whether, in the past, the child ever complained of pain while chewing. Violent blows to the head can cause restrictions of jaw movement and muscle spasms.



Torture by near-suffocation (“submarino“)

This method of torture normally leaves no visible traces and the child recovers physically from it quite quickly. Common methods include:


– Putting a plastic bag over the head

– Forcibly blocking the nose and mouth

– Strangulation, with subsequent inhalation of pepper, dust or cement

This torture can cause various subsequent complications. Known complications in this context are nosebleeds, bleeding from the ears, facial bleeding due to congestion, acute or chronic respiratory problems. Look out for what are called “petechiae” (pinhead-sized spots of bleeding) on the surface of the skin. Forcibly ducking the head under water, which is often intentionally contaminated with faeces or vomit, can likewise be the cause of a child fearing suffocation. The inhalation of water can subsequently lead to pneumonia. You should therefore pay close attention to any skin abrasions, strangulation marks and contusions on the neck.




Sexual torture, including rape

Sexual torture already begins with the forced nakedness of the child. Furthermore, verbal sexual threats, verbal abuse and mockery are likewise one component of sexual torture, as they debase the victim still more as a human being. Subsequent penetration of the child always involves the risk of infection with sexually transmitted diseases. In the event of sexual violence, electric shocks and blows are specifically inflicted on the genitals of male children.

Remember that the sexual assault may also have occurred a considerable time ago. Look out for any bleeding in the anal area, to pain when the child passes stool, to sudden incontinence (weakness of the bladder/intestine), and to the occurrence of dysuria (pain when passing urine), diarrhoea or constipation.


It is a different story if you are unexpectedly faced with the suspicion of a recent assault. In such a case, you should additionally look out for bruises and petechiae, which can be caused by sucking or biting the child. If sexual torture is perpetrated using relatively large objects, particularly in order to penetrate the anus, the probability of verifiable injury is very strong.

Contact a forensic laboratory and have a smear test carried out. Sperm can be identified for up to five days on materials, and for up to three days using material obtained from the rectum. Take photographs of any patterns of injury that you discover and, above all, safeguard these records from being accessed by outside parties.


Examining the genitals of male children

Torture in the genital region by pinching, twisting (torsion) of the scrotum, or by directly inflicting trauma in this region, is always particularly painful for the child. Here, vasodilation (hyperaemia), visible swelling and bleeding of the skin over larger areas (ecchymosis) can be observed.

Accumulations of fluid due to decreased drainage of the urine around the testicles (hydrocele) may also occur. Try to recall whether, in the past, your child ever experienced severe pain when passing urine or had to have medical treatment for a urinary tract infection. Remember that scars on the skin of the scrotum and the penis may be difficult to discern. The presence of scarring thus usually indicates that the child has suffered considerable trauma. Take photographs of the scarring and later get these indications confirmed through a urological diagnosis by a children’s urologist.


Examining the anal region

After an anal rape or the introduction of objects into the anus, the child can suffer bleeding for days or weeks. This can subsequently lead to constipation and other gastrointestinal problems for the child. Look out for any tearing of the mucus membrane in the child’s anus (known as “anal fissures”).



Further signs of past anal penetration are also rectal tearing, with or without bleeding. Pay close attention to any scarring and a purulent discharge from the child’s anus. Take photographs of these findings and, in the event of significant indications, get a diagnosis from a dermatologist and a doctor who specialises in gastroenterology.


Evidence of psychological damage to the child

A child who has been tortured can experience vivid flashbacks, both when fully conscious and in their sleep. Where possible, record these by video and get a witness to be present.


Bear in mind that witness statements have markedly more power if the persons concerned are not members of your family. If you are ready to consider having an unknown person as a witness to a flashback, try to ascertain their identity and to ensure their willingness to make a subsequent statement. Consider further whether your child has displayed any behavioural changes such as:


– Flat affect (social withdrawal, memory gaps, avoidance of certain places and people)

– Extreme excitability (sleep disorders, irritability, outbreaks of rage, startle responses)

– States of fear and sudden concentration problems

– Shortness of breath, feelings of dizziness, sweating

– Appetite disorders, sudden loss of interest in hitherto regular activities

– Feelings of worthlessness and personal guilt

– Tiredness, loss of energy, deficits in motor function and a general slowing-down

– Somatic complaints (headaches, backache)

– Psychotic reactions (delusions, auditory, optical and olfactory hallucinations)

– Having bizarre ideas, paranoia, fear of being stalked or pursued

– PTSD (post-traumatic stress disorder)




It is important to be aware that torturers may try to conceal their actions. In order to avoid leaving physical evidence of blows, the torture is often inflicted using wide, blunt objects, and torture victims are sometimes covered with a carpet or, in the case of falanga, are wearing shoes in order to distribute the force of individual blows. The twisting of limbs, crushing injuries and suffocation are likewise forms of torture intended to create maximum pain and maximum suffering with minimum detectability. This is also the reason why wet handkerchieves are used when administering electric shocks.





Andreas Frewer; Holger Furtmayr; Kerstin Krása; Thomas Wenzel (Ed.)

Istanbul Protocol. The Investigation and Documentation of Torture and Human Rights Violations. Published by V&R unipress: Göttingen, 2015 (2nd revised edition)

Wikipedia: (Accessed on 31.07.2017)

Photographs: Internet



Translation by Verity Speedwell.

Translate »