|Year : 2014 | Volume
| Issue : 1 | Page : 122-129
A prospective study of some medicolegal aspects of physical and sexual family violence cases at Menoufia University hospital over 2 years
Samy M. Badawy, Naira F. Gergis, Amira M. El-Seidy, Fatma S. Kandeel
Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||12-Sep-2013|
|Date of Acceptance||04-Dec-2013|
|Date of Web Publication||20-May-2014|
Fatma S. Kandeel
MBBCh, MSc, Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Menoufia University, Menoufia
Source of Support: None, Conflict of Interest: None
To study some medicolegal aspects of family violence cases at Menoufia University hospital beginning from 1 June 2009 to 31 May 2011 in terms of sociodemographic pattern, injuries pattern, relation between family violence and substance abuse, and outcome of these cases.
Family violence occurs in all socioeconomic groups, in every race, ethnic group, religion, and also in same-sex relationships and it can be perpetrated by both men and women. It may be called battery, child abuse, elder abuse, intimate partner violence, family violence or domestic violence, and other violent acts between family members.
Patients and methods
This was a prospective study including all family violence cases after obtaining their written valid consents, and clinical sheets were obtained including assessment of history and examination.
A total of 472 cases were studied. Physical violence constituted 98.5% (465 cases) and sexual violence constituted 1.5% (seven cases) of cases. Most violence occurred indoor (84.7%) and in a repeated manner (80.7%). Social causes of violence (50.2%) outnumbered other causes, followed by economic causes (28.2%). The most common assailants in family violence were husbands (23%), followed by brothers (16%). Most of the assailants were men (89.2%), from rural areas (71.8%), of low socioeconomic standard (53.2%). Sexual violence was significantly associated with lower age of victims and assailants.
Family violence was mainly of the physical type. Most of the assailants were men. Social and economic causes were the main causes. Sexual violence was significantly associated with lower age of victims and assailants.
Keywords: Domestic violence, family violence, physical abuse, sexual abuse
|How to cite this article:|
Badawy SM, Gergis NF, El-Seidy AM, Kandeel FS. A prospective study of some medicolegal aspects of physical and sexual family violence cases at Menoufia University hospital over 2 years. Menoufia Med J 2014;27:122-9
|How to cite this URL:|
Badawy SM, Gergis NF, El-Seidy AM, Kandeel FS. A prospective study of some medicolegal aspects of physical and sexual family violence cases at Menoufia University hospital over 2 years. Menoufia Med J [serial online] 2014 [cited 2017 Dec 14];27:122-9. Available from: http://www.mmj.eg.net/text.asp?2014/27/1/122/132781
| Introduction|| |
Family violence is defined as any act of physical, sexual or psychological abuse, or the threat of such abuse, inflicted against an individual by an individual intimately connected to them through marriage or family relation .
In all societies, domestic violence is difficult to study because it occurs primarily within the private sphere of the family . Scientific investigations of family violence began in the USA and they have only been in existence since the 1960s .
Findings from selected Arab countries between 2004 and 2012 suggest increasing rates of domestic violence . Egypt's Demographic and Health Survey found that almost half of ever-married women of reproductive age had experienced violence since the age of 15 years; one in five reported exposures to violence in the preceding year and one in three reported that they had been subjected to physical violence at least once by their current or most recent husband . In the study of the causes and patterns of domestic violence toward pregnant women in Alexandria, Egypt, results showed that 80.7% had faced physical abuse, 67.3% had faced psychological abuse, and 70% had faced sexual abuse .
Types of family violence include physical violence, which is defined as intentional use of physical force with the potential for causing injury, harm, disability, or death , sexual violence refers to any sexual act, attempt to perform a sexual act, unwanted sexual comments, or advances directed against an individual's sexuality using coercion , and emotional violence can include humiliating the victim privately or publicly, name-calling, blaming, controlling what the victim can and cannot do, and withholding information from the victim .
| Patients and methods|| |
Clinical sheets were filled after obtaining written valid consents from cases or their guardians including all required data on sociodemographic data, causes of violence, relation between family violence and substance abuse, examination of injuries, required radiological investigations, and outcome of these cases.
Statistical analysis 
- Descriptive statistics were described as %, mean (x), and SD.
- Analytic statistics: Z-test and χ2 -test were used with a level of significance of P value less than 0.05 as significant, P value less than 0.001 as highly significant, and P value more than 0.05 as insignificant.
| Results|| |
The total number of family violence cases was 472. The majority of cases were of physical type (98.5%) and occurred mainly indoor (84.7%), in repeated attacks (80.7%), and mainly because of social (50.2%) and economic causes (28.2%). It was noted that 56.4% of the victims were women and 43.6% were men. Sexual violence was highly significantly associated with lower age of victims (Z = 3.6, P < 0.001). Cases were mainly from rural areas (68.2%). Most of the assailants were men (89.2%), from rural areas (71.8%), mainly of middle age (99.2%). In terms of substances of abuse, there was no history of tobacco smoking and use of other substances of abuse in 58.1 and 85.8% of cases, respectively, whereas there was a positive history of tobacco smoking, cannabis, drug, and alcohol abuse in 39.9, 10.4, 2.8, and 1.1% of the assailants, respectively. Sexual violence was highly significantly associated with lower age of assailants (Z = 3.2, P < 0.001) [Table 1] and [Table 2].
|Table 2: Relationship between victim and assailants' age and type of violence|
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The most common assailants were husbands in 23% of cases, followed by brothers (16%) and the least were mothers, 0.4% each [Figure 1].
There was a statistically significant difference between types of injurious agents among different sexes, as sharp instruments and poison were more commonly used by men (P < 0.05). All firearm injuries were found in men [Table 3]. The most common type of injuries in male victims was contused wounds in 51.5% of cases, followed by a combination of abrasions and contusions, incised wounds, abrasions, stab wounds, and contusions, found in 22.8, 9.4, 4.9, 4.5, and 3.5% of cases, respectively. Then firearm wounds were restricted to male victims. Considering the types of injuries in female victims, contusions were the most common type (40.4%) followed by a combination of abrasions and contusions, contused wounds, abrasions, and incised wounds, found in 21.2, 17.3, 13.1, and 5% of cases, respectively. The lowest percentage was chemical or thermal burns and stab wounds, which constituted 1.5% of cases each [Table 4]. The most common site of fracture was the fracture of the hand bones (25%), followed by fracture of the long bones of upper limbs (21.9%). Internal soft tissue injuries occurred in 1.7% (eight cases) of cases. Pleural and lung injuries were the most common internal soft tissue injuries, which constituted 37.5% of these injuries, followed by spinal cord contusion, nerve injury,, rupture uterus, rupture intestine, and peritoneal injury with minimal intraperitoneal fluid collection, found in 12.5% of cases each [Table 5].
|Table 3: χ2-Test of the physical family violence cases in relation to types of injurious agents and sex|
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|Table 4: Distribution of physical family violence cases in relation to types of wounds and sex|
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|Table 5: Distribution of the physical family violence cases in terms of the type of injuries|
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There were seven cases of sexual violence cases , and all showed positive local findings in the form of contusions around the anus, and dilated anal opening and stool incontinence [Table 6].
|Table 6: Findings of examination of sexual family violence cases studied in relation to sex (N = 7)|
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The majority of the cases were cured without disfigurement or permanent infirmity, 97.2%, whereas 2% of the cases were cured with permanent infirmity or disfigurement. The mortality rate was 0.6% of cases. Unknown outcome was found in 0.2% of cases as follow-up was not complete. There was a difference between different age groups in the outcome of family violence cases, where the majority of cases cured with disfigurement or permanent infirmity were of middle age and more cases of deaths were found in children; this difference was statistically significant (P < 0.05) [Table 7] [Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6] and [Figure 7].
|Table 7: Outcome of family violence cases in relation to different age groups|
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| Discussion|| |
The current study showed that more than half of the victims and assailants were of low socioeconomic standard and were mainly from rural areas. This may indicate that although domestic violence occurs across all socioeconomic classes, poorer victims are more likely to be victims of domestic violence than wealthier ones as victims are economically dependent on their abusers and assailants may be more violent because of economic stresses. Rural areas may be associated with different cultural concepts and different thinking. These findings were in agreement with the results of a study carried out by Mouzos and Makkai , who indicated that low income status and residence in a rural area were found to be significant risk factors for family violence.
The majority of assailants were men (89.2%). Many people may find the concept of women perpetrating violence difficult to believe as it is against the stereotype of the passive and helpless woman. This was in agreement with the results of a study by Abdel Salam  that showed that 76.8% of the assailants were men and 32.2% were women.
There was a positive history of tobacco smoking in 41.9% (cigarette and goza smoking), cannabis abuse in 10.4%, drug abuse in 2.8%, and a history of alcohol abuse in 1.1% of the assailants. These findings might indicate that use of substances of abuse may lead to an increase in domestic violence, partially because of their negative effects or because of the economic burden to obtain these substances. These findings were in agreement with the results of Chermack et al. , who suggested that use of illicit drugs, tobacco, marijuana, and alcohol consumption in particular may lead to an increase in the risk of domestic violence. This is because the negative effect of alcohol and illicit drugs on individuals' perceptions and judgments interact with a complex set of social and psychological factors to result in violence in certain cases. In contrast, the results of Jeyaseelan et al.  indicated that in Egypt, regular consumption of alcohol by husbands was not a significant risk factor contributing toward abuse of wives in the village of El-Sheik Zayed, Ismailia.
In terms of type of wounds, the present study showed that the most common injuries were external soft tissue injuries caused by blunt instruments in the form of contused wounds (32.3%), contusions (24.2%), combination of abrasions and contusions (21.9%), abrasions (9.5%), and punctured wound (0.2%), followed by those caused by sharp instruments in the form of cut wounds (7%), stab wounds (2.8%), thermal and chemical burns (1.5%), and firearm wounds (0.6%). These findings could be explained by the fact that assailants may prefer to use blunt instruments rather than sharp or firearm ones as they want to abuse, terrify, or inflict pain on the victims and not to kill them as they are usually of the same family. Considering the types of injuries in female victims in the current study, contusions were the most common type (40.4%), followed by a combination of abrasions and contusions (21.2%), contused wounds (17.3), and abrasions (13.1%). The most injuries in men were contused wounds (51.5%), followed by a combination of abrasions and contusions (22.8%) and then incised wounds (9.4%). Men suffered from wounds because of sharp instruments (stab and incised wounds) more than female victims and firearm wounds were found only in male victims. This indicated that sharp instruments and firearm weapons were more commonly used in violence against male victims rather than female ones as men are usually strong physically and put up more resistance; thus, assailants may use such weapons to inflict major injuries in a short duration of time. These findings were almost in agreement with those of a retrospective study carried out by Bach et al. , who found that 91.8% of cases had contusions and abrasions and 27.2% had lacerations, and with those of the study of Mouzos and Makkai , who showed that injuries were minor in nature, with bruises and associated swelling sustained by 77% of cases, and incised wounds, scratches, and burns found in 25% of cases.
Bone fractures were found in 13.6% of cases. Fractures were found in 62.5% of male victims and 37.5% of female victims. The most common fractures were of the hand bones (25% of fracture cases), long bones of the upper limbs (21.9%), fracture of the nose (20.3%), and fracture of the skull (7.8%). These findings can be attributed to the fact that the upper limbs and face bones were the most common sites of fractures as trauma was mainly directed to these parts. These percentages of fracture cases were almost in agreement with those found by Mouzos and Makkai , who found that 10% of cases had broken bones or a broken nose. However, these percentages were less than those reported by Bach et al. , who found that 36.2% of cases had fractures and dislocations and 30% of cases sustained facial fractures. Most facial fractures were nasal fractures (40%). This difference may be because of differences in the environment and culture.
Internal soft tissue injuries occurred in 1.7% of cases (eight cases) and they were pleural and lung injuries (three cases), rupture uterus (one case), rupture uterus (one case), small spinal cord contusion (one case), nerve injury (one case), and minimal intraperitoneal fluid collection (one case). These were less than those reported in the study of Mouzos and Makkai , who found that 6% of cases had internal injuries.
In the present study, there were seven cases of sexual violence (1.5% of all cases of family violence). This may not represent the actual prevalence as sexual violence may be underreported. The relation of sexual assaults to a man's honor and dignity - especially in Egypt - make it a shameful situation about which neither the victims nor the families want to talk or victims were terrified and under blackmailing so did not inform about that assault. Doctors and other health professionals should be aware of the high prevalence rate of child abuse and its potential for initial and long-term deleterious outcomes.
In terms of the sex of assailants and victims of sexual violence, the present study showed that all assailants were men, whereas women constituted 71.4% of victims and men constituted 28.6%. Among victims of child abuse, females represented 60% and males represented 40% of cases (ratio 3 : 2). Thus, the percentage of female victims was higher than that of male victims of sexual abuse, and this could be explained by the fact that all assailants were men so it is logic to have sexual desire towards the opposite sex. These findings were in agreement with those of other studies carried on an Egyptian population such as those carried out by Hagras et al. , who showed that girls represented 70.6% and boys represented 29.4% of these cases. However, Pereda et al.  reported a higher number of male victims and this difference could be attributed to environmental and cultural differences, with more acceptance of same-sex relationships.
In terms of the age of the victims of sexual violence, the current study showed that most of the cases were younger than 7 years of age (71.4% of all sexual cases and 100% of child abuse cases), and the other two cases were in the age range between 21 and 30 years. This finding may be because of the fact that young children rarely understand sexual relations and will not inform their parents about the assault, especially if they are terrified, beside sexual perversion of the assailants to prefer to have sex with a child. Other studies have reported variable percentages such as Hagras et al. , who reported that 11.7% of assaults were on children younger than 10 years old, whereas 88.3% were older than 10 years, and Metwaly et al. , who showed that 45% of victims were in the age range of 7-13 years. Findings from researches were often not comparable across studies because of different age categories used to differentiate childhood and adolescence, and varying study populations.
In terms of the type of sexual violence, the present study indicated that all cases of sexual violence involved anal intercourse in the form of buggery (anal intercourse with a female partner), represented by 71.4% of cases, and sodomy (anal intercourse with a male partner), constituting 28.6% of cases, and there were no cases of rape. So male assailants prefer to have sexual enjoyment with female partner but he prefer unnatural orifice and this may be due to sexual perversion of assailants or may be to avoid severe bleeding with vaginal intercourse as most of female victims were of young age with delicate genital organs. These results were partially in agreement with those of Metwaly et al. , who reported that anal intercourse constituted 80% of cases in the form of sodomy, which constituted 57.5% of cases, and buggery, which represented 22.5% of cases, whereas vaginal intercourse (rape) constituted 20% of cases.
In terms of the relation of assailants to victims, the present study showed that cousins represented 57.1%, husbands represented 28.6%, and stepfathers represented 14.3% of assailants. The results of other studies showed some differences as Olsson et al.  reported that the most common perpetrators of abuse on children younger than 12 years of age were male family members including uncles, cousins, and fathers (66%), Cohen et al.  showed that sibling incest may be more common than other types of incest, which was reported twice as often as incest perpetrated by fathers/stepfathers, and Jeffrey  reported that the most-often reported type of incest is father-daughter and stepfather-daughter incest, with most of the remaining reports consisting of mother/stepmother-daughter/son incest. The difference might be because of differences in culture and environment.
In terms of injuries in cases of sexual violence, the present study showed that positive local findings in all cases of assault were of a repetitive nature, and they were in the form of contusions around the anus, anal fissures and dilated anal opening, stool incontinence, and loss of anal sphincter function. None of the cases showed general injuries on the body. This could be explained by the fact that most victims were children with no previous sexual experience and they usually do not offer resistance. A study carried out by Hagras et al.  reported that external injuries were found in 36.4% of cases in the form of bruises on the arms and lips. Genital injuries were of a recent hymen tear in 18.2% and a recent anal tear in 18.2%; there were no cases of pregnancy among girls. Ingemann et al.  found that 78% of the victims in their study had injuries: 58% had skin injuries, 19% had extragenital and genital injuries, and showed greater presence of external injuries; this may be because victims in these studies were older and thus they may have offered more resistance to assailants; examinations showed less percentage of cases with genital injuries, perhaps because of incomplete intercourse.
The two adult wives who were victims of sexual violence in the present study had dilatation of the anus and loss of corrugations as they were forced to have repeated anal intercourse with their husbands and their husbands isolated them from sources of support and help by limiting their communication with their relatives. Clayton et al.  also showed that women may engage in sexual intercourse with their husbands because of a sense of obligation or guilt and not because of their own desire. Elnashar et al.  reported that 11.5% of married Egyptian women admitted to being victims of sexual abuse and Bakr et al.  found that 17.1% of married Egyptian women were forced to engage in sex.
The majority of the cases were cured without disfigurement or permanent infirmity, represented by 97.2% of cases, whereas 2% of cases were cured with disfigurement in the form of ugly scars after healing of chemical burns or permanent infirmity in the form of skull bone defects, loss of vision in one eye after destruction of its tissues by corrosive material, and limitation of hand movement. The mortality rate was 0.6%, and 0.2% (one case) had unknown outcome because of incomplete follow-up. These findings indicated that family violence in the current study was less than that reported in other Egyptian studies as in the study carried out by Abdel Salam  on family violence cases in greater Cairo governates over 6 years, which found that death occurred in 56% of cases, permanent infirmity constituting 18.5%, and complete recovery occurred in only 25.5% of cases; these differences may be because of the wide area covered in that study, which included greater Cairo with much increased stress in such crowded industrialized governates beside the site of collection of data in greater Cairo department and morgue, so violence may be expected to be of severer form.
| Conclusion|| |
Violence occurs in all socioeconomic groups. However, evidence shows strong relationships between levels of violence and potentially modifiable factors such as low socioeconomic standard, low level of education, and unemployment. Sexual violence was associated significantly with lower age of victims and assailants.
Violence is preventable. Thus, fostering of safe, stable, and nurturing relationships between children and their parents and caregivers and promoting sex equality can prevent violence.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
| References|| |
|1.||Watts C, Zimmerman C. Violence against women: global scope and magnitude. Lancet 2002; 359:1232-1237. |
|2.|| Rodriguez M, Bauer H, Mcloughlin E, et al. Screening and intervention for intimate partner abuse. JAMA 1999; 282:468-474. |
|3.|| Kempe C, Silverman F, Steele B, et al. The battered child syndrome. J Am Med Assoc 1962; 181:107-112. |
|4.|| Day V. Violence against women - take action. Available at: http: // vday.org/take action/violence against women/battery-abus e [Last accessed on 2013 April 1] |
|5.|| El Zanaty F, Way A. Egypt demographic and health survey 2005. Cairo, Egypt: National Population Council, Ministry of Health & Population, El Zanaty Association & Macro International; 2006. 222-230. |
|6.|| Abd Elrahman H. Causes and patterns of domestic violence toward pregnant women (Master thesis); 2002; Faculty of Nursing, University of Alexandria. |
|7.|| Jackson N. Encyclopedia of domestic violence. New York, NY: Rutledge; 2007. 327-333. |
|8.|| Beh P, Payne J. Adult sexual assault. In: Gall J, Payne-James J, editors Current practice in forensic medicine. London: Wiley; 2011. 5:pp. 345-372. |
|9.|| Follingstad D, Dehart D. Defining psychological abuse of husbands toward wives: contexts, behaviors, and typologies. J Interpers Violence 2000; 15:891-920. |
|10.||1Elliott A, Woodward W. SPSS (statistical package for the social sciences). California, London and New Delhi: SAGE Publications; 2007. |
|11.||1Mouzos J, Makkai T. Women′s experiences of male violence: findings from the Australian component of the International Violence Against Women Survey (IVAWS), Australian Institute of Criminology; 2004 (research and public policy series no. 56) |
|12.||1Abdel Salam Y. Study on family violence: partner and child abuse cases reported to the greater Cairo Department and Morgue from January 1998 to December 2003 (Master thesis); 2005; Faculty of Medicine, Zagazig University |
|13.||1Chermack S, Wryobeck J, Walton M, et al. Distal and proximal factors related to aggression severity among patients in substance abuse treatment: family history, alcohol use and expectancies. Addict Behav 2006; 31:845-858. |
|14.||1Jeyaseelan L, Sadowski L, Kumar S, et al. World studies of abuse in the family environment - risk factors for physical intimate partner violence. Inj Control Saf Promot 2004; 11:117-124. |
|15.||1Bach T, Eric J, Brett A, et al. Maxillofacial injuries associated with domestic violence. Oral Maxillofac Surg J 2001; 59:1277-1283. |
|16.||1Hagras A, Mustafa S, Barakat H, et al. Medico-legal evaluation of child sexual abuse over a six-year period from 2004 to 2009 in the Suez Canal area, Egypt. Egypt J Forensic Sci 2011; 1:58-66. |
|17.||1Pereda N, Guilera G, Forns M, et al. The prevalence of child sexual abuse in community and student samples: a meta-analysis. Clin Psychol Rev 2009; 29:328-338. |
|18.||1Metwaly M, Abd Elhay M, Sherif M. Study about sexual offences in Qena governorate. Zagazig Univ Med J 2013; 19:276-289. |
|19.||1Olsson A, Ellsberg E, Berglund S, et al. Sexual abuse during childhood and adolescence among Nicaraguan men and women: a population-based anonymous survey. Child Abuse Negl 2008; 24:1579-1589. |
|20.||2Cohen J, Perel J, DeBellis M, et al. Treating traumatized children: clinical implications of the psychobiology of post-traumatic stress disorder. Trauma Violence Abuse 2002; 3:91-108. |
|21.||2Jeffrey T. Encyclopedia of relationships across the lifespan. Greenwood Publishing Group, Greenwood International, Oxford, UK; 1996:92. |
|22.||2Ingmann O, Brink O, Sabroe S, et al. Legal aspect of sexual family violence - Does forensic evidence make a difference? Forensic Sci Int 2008; 180:98-104. |
|23.||2Clayton A, Pradko J, Croft H, et al. Prevalence of sexual dysfunction among newer antidepressants. J Clin Psychiatry 2002; 63:357-366. |
|24.||2Elnashar A, Ibrahim E, Eldesoky M, et al. Sexual abuse experienced by married Egyptian women. Int J Gynaecol Obstet 2007; 99:216-220. |
|25.||2Bakr I, Ismail N. Domestic violence among women attending out-patient clinics in Ain Shams University Hospitals, Cairo, Egypt. J Egypt Public Health Assoc 2005; 80:629-650. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]