- Email: [email protected]
Victims of violence: an Asian scenario
Journal of Clinical Forensic Medicine (2000) 7, 192±200 ß APS/Harcourt Publishers Ltd 2000
ORIGINAL COMMUNICATION
Victims of violence: an Asian scenario K. Nadesan Department of Pathology (Forensic Section), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia SUMMARY. The term `violence' is difficult to define. Aggressive behaviour with actual use of physical force may result in some form of physical and emotional trauma to an individual and this could be considered as violence against the person. The trauma may range from minimal physical injury to death. It is also relevant to note that in some jurisdictions if members of the law enforcement agencies with appropriate authority resort to certain acts of `violence' for lawful purposes, then such acts of violence may be excluded from this category. However, if the law enforcement personnel exceed their limits of authority, or resort to various unacceptable and unauthorized methods of violence, then certainly such acts will become violence against the person. In today's context the word violence has expanded to encompass many issues, besides the usual physical violence such as assault. Rape, child sexual abuse, other forms of sexual abuse, non-accidental injury to children, battered wife, assault in custody, torture, victims of war, civil unrest and ethnic violence are all considered under `violence'. While general violence is almost endemic in many countries, assault in custody, torture, political and ethnic violence are serious problems in some of the developing world. In these countries, particularly, the law enforcement agencies and other unlawful groups who are backed by politicians may in¯ict politically motivated violence against its citizens. In such cases attempts are often made to cover up such crimes. Forensic physicians and forensic pathologists who examine these cases may be placed in dif®cult positions at times owing to various `pressures' being brought upon them to issue `favourable' reports. On the other hand there is also a general dearth of suitably trained forensic physicians and forensic pathologists in many of these countries. Medical of®cers without any training in forensic medicine often undertake the examination of victims of violence, both living and fatal cases. Lack of training makes them more vulnerable to political and other forms of `pressure'. The objective of this article is to highlight some of the common problems that are encountered, particularly in developing countries. ß APS/Harcourt Publishers Ltd 2000 Journal of Clinical Forensic Medicine (2000) 7, 192±200 LEGAL DEFINITIONS OF HURT, INJURY AND WOUND
any harm whatever illegally caused to any person, in body, mind, reputation or property.' The word `wound' generally means a breach of the skin or the mucous membrane and therefore this de®nition does not include contusions, abrasions or fractures and other wounds. Unfortunately there is no statutory de®nition of a wound.1 In medical parlance, however, abrasions, contusions, lacerations, incised wound, stab wound, fractures and so on are considered as wounds. Rolland's Medical Dictionary de®nes a wound as an injury to the body caused by physical means, with disruption of the normal continuity of body structures. `Hurt', `injury' and `wound' need not be synonymous. `Wound', however, comes within the de®nition of `injury' according to the penal code, that is any harm whatever illegally caused to body and mind and hence a wound is an injury. But on the other hand an injury need not always be a wound because
Section 319 of the Malaysian penal code and Section 300 of the Sri Lankan penal code deal with hurt. According to these sections `whoever causes bodily pain, disease or in®rmity to any person is said to cause hurt.' Section 44 of the Malaysian penal code and Section 45 of the Sri Lankan penal code de®ne an injury. According to these sections, `the word injury denotes
Correspondence to: Dr Kasinathan Nadesan MBBS, MD (Forensic), MRCPath, FRCPA, DMJ(Path), DMJ(Clin), Dip in Legal Med, Professor, Department of Pathology (Forensic Section), Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia, Tel: 603 7950 2912; Fax: 603 7955 6845. 192
Victims of violence: an Asian scenario according to the same sections in the penal code an injury could be caused to a person by in¯icting harm to his reputation or property without in¯icting a wound. According to the de®nition in the penal code, `hurt' is the unlawful causation of bodily pain, disease or in®rmity to any person and therefore it involves both wound and an injury. However, the hurt does not involve all that is covered by the term injury, namely the harm in¯icted on mind, reputation or property. But in practice, the term `hurt' is more widely used as a parameter to de®ne the seriousness of the offence. Therefore, the court is more concerned about hurt than a `wound' and the responsibility of de®ning a wound is more a medical issue than a legal issue and perhaps this explains why there is no legal de®nition of wound. Seriousness of an offence depends not only on the seriousness of the actual wound that was being in¯icted and its outcome but also on the intention of the assailant. However, establishing the intention is a matter for the court. As a matter of fact the court deliberates often to establish the intention of the assailant, because imposing the appropriate punishment depends on the intention. Besides other evidence that is made available to a court of law, the nature of the weapon used, the part of the body that was wounded together with the actual wounds in¯icted, will assist the court in establishing the intention of the assailant. Therefore it is evident that a thorough medicolegal examination of the victims of violence contributes greatly in the administration of justice. The following types of hurt are dealt under the offences affecting the human body in chapter 16 of the Malaysian and Sri Lankan penal code: 1. 2. 3. 4. 5.
Simple hurt Grievous hurt Injury that endangers life Injury that is fatal in the ordinary course of nature Deliberately fatal injury.
It is a matter for the court to decide whether a wound is grievous or not. However, a doctor by his description and documentation should be able to categorize the hurt as to whether it is a simple or a grievous hurt so that the court may make the ®nal decision based on the doctor's report. Section 320 of the Malaysian penal code and section 311 of the Sri Lankan penal code de®ne grievous hurt.2,3 The following types of wounds only are designated as `grievous' according to section 320 of the Malaysian penal code: FirstÐEmasculation SecondlyÐPermanent privation of the sight of either eye ThirdlyÐPermanent privation of the hearing of either ear
193
FourthlyÐPrivation of any member or joint. FifthlyÐDestruction or permanent impairing of the powers of any member or joint SixthlyÐPermanent dis®guration of the head or face SeventhlyÐFracture or dislocation of a bone EighthlyÐAny hurt which endangers life, or which causes the sufferer to be, for the period of 20 days, in severe bodily pain, or unable to follow his ordinary pursuits. Until 1995 both the Sri Lankan and Malaysian sections regarding grievous hurt were similar. However, after the penal code (amendment) act, No. 22 of 1995, the Sri Lankan de®nition of grievous hurt became clearer and some of the practical confusions that existed were recti®ed.4 Sub sections two and three were rephrased to be read as `permanent privation or impairment of the sight of either eye and permanent privation or impairment of hearing of either ear' respectively. Privation meant a total loss and when a person loses 80% of his eyesight or hearing, according to an earlier section it was only an impairment and therefore not grievous. Sub section six was changed to `cut or fracture, of bone, cartilage or tooth or dislocation or subluxation of bone, joint or tooth'. Sub section eight was divided into two, the ®rst part `any injury which endangers life or in consequence of which an operation involving the opening of the thoracic, abdominal or cranial cavities is performed'. For example, prior to the 1995 amendment, an exploratory laparotomy performed for suspected bowel rupture was non-grievous in nature if no rupture was found at surgery, but after the 1995 amendment, however, the necessity for the surgery, even though no internal injury was found later, still made it a grievous hurt. The second part was like this: `any injury which causes the sufferer to be in severe bodily pain or unable to follow his ordinary pursuits, for a period of 20 days either because of the injury or any operation necessitated by the injury'. Victims of violence may present as non-fatal or fatal cases. The acute non-fatal cases may be seen by general practitioners or at the accident emergency departments. Fatal cases very often will be subjected to an inquest and a medicolegal post mortem. There are instances where the victims of violence are prevented from seeking medical help when the perpetrators are the law enforcement personnel or persons who are backed by governments or terror groups. This appears to be a serious problem in many Asian and other developing countries, particularly in the Latin American region. In many instances, by the time they are seen by a doctor, several months have already elapsed. Hence one can appreciate the dif®culties encountered in examining and assessing these persons
194
Journal of Clinical Forensic Medicine
who are traumatized both physically and emotionally. On the other hand the bodies of fatal victims are disposed of in several ways without any inquiries being held and if the remains are discovered they are already decomposed or even skeletonized. In many instances persons are arrested in the night and are kept in custody without any documentation in order to avoid accountability. Often they are tortured and if they die during the process, the bodies may be secretly disposed of without any inquiry. Burning appears to be a popular method of surreptitious disposal of such bodies in Asia. The victims of violence may present in different ways including 1. physical assault and other forms intentional violence 2. rape, child sexual abuse and other forms of sexual abuse 3. non-accidental injury to children 4. battered wife, battered employees and other similar situations 5. battering in custody, victims of torture 6. victims of war, civil unrest, ethnic violence, terrorism etc. OBJECTIVES OF MEDICOLEGAL EXAMINATION The responsibility lies with the doctor to correctly identify and interpret the wounds (Fig. 1). Only then will the report be of bene®t to the victim, the court and the community at large. Knowledge, skill and experience in handling the victims of various types of violence must be acquired before a doctor can considered an expert.
Fig. 1 The deceased was attacked with a sword, which was a long straight-bladed heavy cutting weapon, which in Malay is termed a `Parang'. The injuries consist of incised wounds, linear abrasions and a grazed abrasion in the mid right chest. The different types of wounds have resulted because of the varying manner in which the weapon had been used. The contour of the body also alters the appearance of the wounds. A guarded opinion about the profile of the causative agent/agents is always necessary
The doctor who examines the injured person should document the wounds and look actively for the following: 1. Accurately identify and describe the wounds. 2. Establish if possible the causative agent or agents that caused the wounds. 3. The mechanism of causation and reconstruction of the event. The latter will help to accept or refute the account given by the injured or an eyewitness. 4. Determine as to whether the wounds were self in¯icted or fabricated? 5. Try to establish the approximate age of the wounds, and this issue may become important in cases of battered children, battered wives and victims of torture. 6. Look for speci®c wound pattern, which may help in identifying battered children, battered wives, victims of torture, etc. In Asian countries, through fear or for social and cultural reasons, battered wives and victims of torture may not voluntarily admit to abuse and sometimes may even deny it. 7. Look for any underlying conditions and diseases that may have aggravated the original wound. 8. Try to ascertain whether any disease process has developed subsequent to trauma. Reference should be made to Ewing's postulate regarding trauma and disease.5 9. Classify and categorize the wounds in a medicolegal context. 10. Write a legally valid report to court. Comment on what was actually found and try to interpret the ®ndings in an acceptable, objective and factual mannerÐthere is no room for speculation. Valid consent should be obtained from the injured person prior to medical examination. However, with a court order in some jurisdictions a person could be examined without a consent. Similarly, a new prisoner at the time of admission to prison too could be examined without consent. A detailed history has to be obtained from the injured person prior to examination. If the injured person is a suspect and is produced by the police or any members of the law enforcement, history taking and examination should ideally be undertaken in private without the presence of any of®cials in the examination room. All wounds must be carefully documented with sketches and photographs. A complete physical examination should always be performed. Wherever possible con®dentiality has to be maintained. SEXUAL OFFENCES Sexual violence forms an important group amongst the victims of violence. Sexual offences include an
Victims of violence: an Asian scenario in®nite variety of physical acts, either executed or attempted, in the furtherance of sexual grati®cation, by a person or persons, of differing or similar genders, without the lawful consent of those offended, and having regard also to considerations of age, mental development, physical development, kinship and species. Rape is dealt with under section 375 of the Malaysian penal code.6 According to this section a man is said to commit `rape' who, except in the case hereinafter excepted, has sexual intercourse with a woman under the circumstances falling under any of the following descriptions: FirstÐAgainst her will. SecondlyÐWithout her consent. ThirdlyÐWith her consent, when her consent has been obtained by putting her in fear of death or hurt to herself or any other person, or obtained under a misconception of fact and the man knows or has reason to believe that the consent was given in consequence of such misconception. FourthlyÐWith her consent, when the man knows that he is not her husband, and her consent is given because she believes that he is another man to whom she is or believes herself to be lawfully married or to whom she would consent. FifthlyÐWith her consent, when, at the time of giving such consent, she is unable to understand the nature and consequences of that to which she gives consent. SixthlyÐWith or without her consent, when she is under 16 years of age. Section 363 of the Sri Lankan penal code and section 375 of the Indian penal code deal with the de®nition of rape.7,8 Until the Sri Lankan penal code (amendment) act, No.22 of 1995, came into force, Malaysian, Sri Lankan and Indian laws regarding the de®nition of rape were almost similar.9 After the 1995 amendment to the Sri Lankan penal code, the sub section `against her will' was removed. The sub section `without her consent' was replaced by `without her consent even where such woman is his wife and she is judicially separated from the man'. Also, the age of consent for sexual intercourse was raised from 14 to 16 years. This amendment was a major step forward because `against her will' arose from the early 19th century English Common Law which looked for evidence of struggle and resistance on the rape survivor as proof of rape.10 The word rape is probably derived from the Latin `rapere' to snatch; it literally means a forcible seizure. This led to a misconception in the minds of many that one has to always ®nd some evidence of a struggle before establishing rape. However, it is very well known that under many situations a woman will be compelled to yield to a rapist without offering any
195
resistance. Hence the main issue in the offence of rape is the question of consent. Under English Law, the Sexual Offences (Amendment) Act 1976 de®nes rape. According to this section, a man commits rape if: 1. there is unlawful sexual intercourse with a woman who at the time of the intercourse does not consent to it and 2. at that time he knows that she does not consent to the intercourse or he is reckless as to whether she consents to it or not. Rape is the fastest growing violent crime in many parts of the world. In spite of heavy punishment including death sentence and many law reform initiatives, rape still remains a serious problem all over the world. It is also important to remember that there are many reported cases of rape that are found to be false.11 On the other hand many genuine cases of rape are not reported because of fear, damage caused by publicity to the victims and often the cases cannot be proved and so no justice seems to be done to the rape victim. A thorough medical examination often provides an independent, scienti®c and a corroborative evidence. However, corroboration is not essential to prove a case of rape.9 The 1995 amendment act on rape laws in Sri Lanka, in its procedural law, had described that `evidence of resistance such as physical injuries are not essential to prove that there was no consent'. It is also the responsibility of the trial judge to explain this aspect to the jurors during the commencement of the trial. A negative medical ®nding, therefore, does not rule out the possibility of rape. Medical examination and expert opinion will also save an innocent person who may have been wrongly implicated. The doctor should have special expertise in performing the examination, collecting the relevant specimens and in interpreting the ®ndings. Finally, a comprehensive report has to be submitted to court.12 At no stage should the doctor comment about rape in his report or evidence, as this will be a matter for the court. Unfortunately in many Asian countries there are no speci®cally trained, full time forensic physicians to ef®ciently deal with these cases. There are also no Scene of Crime Of®cers in the police force to assist the doctors. Hence the quality of medical examinations conducted is questionable in many instances. Child sexual abuse is another issue that causes grave concern. It is believed that virtually every child is vulnerable to sexual abuse. According to researchers one out of every four children will be the victim of sexual abuse in the West. No such details are available for the Asian region. In many instances, unfortunately, the perpetrators are immediate family members. For various reasons, including fear of reprisals, these
196
Journal of Clinical Forensic Medicine
Fig. 2 A nine-year old boy who was subjected to repeated buggery by his uncle over a period of time. Note the gaping, somewhat funnel shaped anus with flattening of the surrounding skin and the absence of normal puckered appearance. A partially healed laceration is visible at the 12'o clock position
offences are usually not reported immediately. Sexual abuse can be physical, verbal or emotional. There is a whole spectrum of activities that range from touching and fondling, exhibitionism, masturbation to even rape and buggery. However, the experience at the University Hospital is that the incidence of rape of small children including statutory rape is very rare. But buggery appears to be a serious problem amongst the victims of child sexual abuse. Unless the victim of buggery is examined immediately or shortly after the act there will be less chance of detecting any positive evidence at a clinical examination. However, if buggery had been committed repeatedly over a period of time, then there may be speci®c changes found which may support chronic abuse (Fig. 2). Unfortunately most of the cases of child sexual abuse that come before the doctors for examination are not `fresh cases'; that is the offence had been committed some time prior to actual examination. The doctor who examines these cases should have specialized knowledge and experience because, on the one hand, the
children have to be handled gently and tactfully and, on the other hand, there could be false positive and false negative ®ndings, which need careful interpretation. Super®cial anal ®ssures are not an unusual ®nding in small children. It may be useful to feel for hard faecal matter in the rectum during digital examination because constipation may be the cause of the ®ssure. Worm infestation in children is a common problem in the tropics and pinworm causes severe irritation and itching at the anus. Such children often scratch their anal verge, particularly in the nights, and this may cause reddening, abrasions and even swelling and that can be easily mistaken for sexual abuse. It is useful to carry out routine stool examination for worm infestation. It is also not uncommon to ®nd reddening of the anal verge and the perianal skin in children who lack personal hygiene. Wherever possible, seek the assistance of a paediatric surgeon while examining the rectum, particularly when a proctoscopic examination is carried out. Very often small children may not cooperate with the rectal examination. It is the author's view that it is the children who have had a traumatic experience or who have experienced a tactless medical examination previously who resist the most. In such cases examination may have to be conducted under anaesthesia. It is often possible to examine such children using ketamine sedation in the ward itself. It is also important to remember that children can make false and fabricated stories of physical and sexual abuse.13 Non-accidental injury to children The other area of concern is the non-accidental injury to children. At one time it was believed that nonaccidental injury to children was very uncommon in the Asian region owing to the existence of extended families. However, that is now proved to be wrong, and physical and sexual abuse of children appear to be serious problems in Asian countries. `Non-accidental injury to children' refers to a child usually under 3 years of age, who suffers repeated nonaccidental injuries, sometimes fatal, caused by episodes of violence by a parent or guardian.14 Various social, economic, personal and other factors are attributed to this problem. The pointers to true battering are: 1. variation and inconsistencies in the parental explanation of how the child sustained the injuries 2. delay in seeking medical advice 3. injuries and the explanations are inconsistent 4. multiple injuries in different stages of healing 5. presence of `classic' lesions 6. repeated visits to different doctors.
Victims of violence: an Asian scenario
197
VICTIMS OF TORTURE
Fig. 3 A 12-year old boy was brought in dead to hospital by the uncle who was looking after him, with a history of fall from a tree. He had multiple soft tissue injuries in different stages of healing, including cigarette burns. A granulating lacerated wound is seen on the mucosal aspect of the lower lip. The cause of death was closed haemopericardium and cardiac tamponade due to ruptured pulmonary artery. The mid front of chest wall had an irregular contusion, possibly caused by stamping with bare foot while the boy was lying on the ground
Doctors, especially in the paediatric, surgical, accident and emergency and primary care departments, and in the general practice, should be alert to this problem of child abuse. If they are watchful, then cases of child abuse could be easily identi®ed (Fig. 3). Johnson et al. (1966), said `The skin and bones tell a story that the child is either too young or too frightened to tell'. Skin bruising is the common injury that is seen in battered children. These contusions are often con®ned to certain areas of the body and also they exhibit certain characteristics. Besides, they may be of different ages and particularly in light complexioned children the colour changes that take place with ageing can easily be identi®ed. Skin bruises of different ages are strongly suggestive of physical abuse. It may be useful to carry out a complete skeletal survey in suspected cases, particularly when the parent or guardian claim accident proneness as an explanation for repeated trauma. Detailed description of injury pattern is beyond the scope of this article. It is important to remember that the doctors need to have a clear knowledge about the various presentations and tact in handling not only the children but also the parents and guardians. Failure to identify early may lead to a tragic outcome. On the other hand over enthusiasm or unwarranted suspicion too can be counterproductive and may even land the doctor in litigation. It is ideal to have a child abuse team in each institution that is represented by various medical experts, child psychologists and social welfare of®cials, and decision-making, especially in dif®cult cases, should be collective. Regular case conferences should be held before crucial decisions are made.
Torture and battering in custody is another major problem encountered especially in some of the developing countries. In many instances, members of the police force and armed services are responsible for these crimes, often committed in the course of crime investigation and for political reasons. Torture is de®ned as the deliberate, systematic or wanton in¯iction of physical or mental suffering by one or more persons acting alone or on the orders of any authority, to force another person to yield information, to make a confession, or for any other reason.15 The Congress of the World Medical Association (WMA) in Tokyo in 1975 adopted the above de®nition. It was mainly applicable to medical personnel. Torture has been known throughout the history of man. In modern times, the Second World War is one example of where doctors were involved in torture and using prisoners and others for various unethical researches. The doctors who take part in any form of torture are acting against the Hippocratic oath.16 The Declaration of Tokyo forbids doctors from taking part in torture and other forms of cruel, inhuman or degrading procedure.17 Victims of torture may present as living or dead victims. Torture takes the form of physical or emotional abuse, often it is a combination of both. Survivors of torture may come to a doctor on their own, brought by police, by prison of®cials, or on a magistrate's order. Physical abuse often presents as blunt weapon trauma, in¯icted over the soft tissues. Hitting on the soles of feet with baton or plastic pipes ®lled with sand is a common method employed by police, which is referred to falanga or bastonade. Some of these victims may end up with permanent malfunction of gait.18 However, there are all possible varieties and variation of acts of physical torture such as suspension by thumbs, wrists and feet, burning, pricking under ®nger nails, traumatization of genitals, immersion and near drowning, sexual abuse, sexual humiliation and so on, to name a few since the list is endless (Figs 4 & 5). Unless the survivors are examined early, most physical signs and symptoms may disappear except where intense and cruel physical violence had been used.19,20 Many victims who have survived the initial ordeal may subsequently develop anxiety, depression, post traumatic stress disorder and suicidal tendencies.21 The doctor who examines these patients should interview them in the absence of any law enforcement of®cials. Fatal cases may present with multiple contusions, especially with subcutaneous bleeding resulting in hypovolaemic shock, muscle damage and acute renal failure or trauma to fatty tissues, resulting in fat
198
Journal of Clinical Forensic Medicine Ethnic violence and terrorism
Fig. 4 A victim of police torture. Note the parchmented abrasions encircling both thumbs and lower part of both forearms. He was suspended by his thumbs at the police station to extract information and to force him to make a confession. The abrasions around both forearms were caused by a rough ligature material, such as rope. The wound caused by the knot is visible in the front of the left forearm
Fig. 5 Another victim of police tortureÐmultiple partially healed contusions placed parallel to one another on the back of trunk towards the lumbar area. The victim was forced to lie face downwards over a table before being beaten with a thin wooden rod. Some of the wounds are spindle shaped because of the contour of the body. Over the lower lumbosacral area the wound is showing a typical `tram line' because that area is almost flat
embolism syndrome, such as cerebral fat embolism. Rarely, injury to vital organs is demonstrated. Clinical examination and autopsy examination should be thorough and the doctor should be familiar with the special techniques of examination and the various ways in which these cases may present.1,22 His report should be unbiased and impartial. In certain situations `pressure' may be brought upon doctors to suppress facts and to issue `favourable' reports. A doctor should, under all circumstance, resist such `pressures', and must be courageous enough to make a true and genuine report following the ethical standards.23 The WMA will stand by the doctors when they are under threat.24
Sadly, ethnic violence has become a way of life in many countries. In several Asian and African countries ethnic violence has not only affected the entire lifestyle of the people but has even affected the neighbouring states. In most instances when violence breaks out, people are beaten up with hands and legs or with weapons such as clubs, knives and swords. The victims often end up with multiple blunt weapon traumas, slash, cut and stab wounds. Looting and arson is another common manifestation of ethnic violence. Undesirable elements use these situations for their advantage. Firearms too are being used during ethnic violence. Police and military may be called upon to maintain law and order during such crises and this also results in various types of wounds. Terrorism is an equally serious problem in many countries. Ethnic, religious and political differences are the main causes that can ®nally lead to terrorism. This is the reason why de®ning `terrorism' is sometime dif®cultÐfor a particular ethnic group the violent acts of a militant group may appear as terrorism where as for the other ethnic group it will appear as a freedom struggle. Nowadays the violent groups use modern and sophisticated weapons and explosive devices; in addition, they also use various improvised devices. Explosives are increasingly used in the Indian subcontinent. Land mines, Calymore mines and grenades are commonly used to attack armed forces and other opponents. In Sri Lanka, the `human bomb' is the most deadly explosive out®t that is increasingly used by the Liberation Tigers of Tamil Eelan. Referred to as `suicidal bombers', they strap `plastic explosives' on to their body and detonate them at selected targets, which results in death and destruction, including the person carrying the bomb. The explosives used are always very powerful and that results in extensive damage to the victims. The bodies of persons who were close to the explosive device are usually badly mangled up and sometimes visual identi®cation may be a problem. Identifying the suicide bomber is an important part of the forensic investigation. Invariably the body of the bomber is severely fragmented, but, interestingly, in many instances the head is spared. Due to the powerful explosion taking place around the area of the chest and the abdomen the head gets separated and thrown a long distance, e.g. heads of bombers have been recovered from rooftops of high rise buildings. In one instance crows gathering at the roof of a tall building a day after the explosion ®nally led to the discovery of the head. Such explosions often occur in crowded areas and that results in several deaths, with many more injured. The doctors who examine the injured and the dead have to be very
Victims of violence: an Asian scenario cautious and thorough Ðthere will be always allegations and counter allegations, therefore the medical examination reports have to be very objective and unbiased. In most of these situations the armed forces also exceed their limits and resort to various acts of violence, including torture and extra-judicial killings. Worse still, the bodies are disposed of by burning or buried in mass graves. The author was involved in a mass grave exhumation in 1994 and 31 skeletonized remains of young males were recovered. Each victim had a single bullet wound, either on the side or the back of the head and they were restrained and blindfolded. The victims were suspected militants and the perpetrators were armed forces. During such crisis, a doctor may be caught up in a dif®cult situation and will be `pressurized' from both sides. TRAINING OF UNDERGRADUATES AND DOCTORS Clinical forensic medicine is not included in the undergraduate medical curriculum in Malaysia. General pathologists who have no special training in forensic pathology perform medicolegal autopsies in many large hospitals. Medical of®cers who have no training in this ®eld handle clinical forensic cases. Some of them are quite incompetent, particularly in handling cases of sexual abuse, child abuse, victims of torture, battery and so on and hence their examinations and reports may lack the necessary objective ®ndings. There is also a severe dearth of forensic experts in Malaysia trained to undertake good quality post mortem and clinical examinations on a countrywide basis. In all the medical schools in Malaysia, forensic medicine is a sub unit in the department of pathology and very little emphasis is given to this subject. To be precise, these units are in fact departments of forensic pathology rather than departments of forensic medicine, because, as already referred to, there is no teaching in clinical forensic medicine. On the other hand, in Sri Lanka and India, the medical undergraduate curriculum provides reasonable recognition of forensic medicine and there is invariably a separate department. Both forensic pathology and clinical forensic medicine are taught and the undergraduates are tested in them, which include practical and viva-voce in addition to two theory papers. In Malaysia the undergraduates are required to take a 2 h theory examination only. In Malaysia postgraduate course is available in forensic pathology, which is a 3 year full time course leading to a Masters in Forensic Pathology. The trainee has to ®rst successfully complete the part-I
199
examination, and the duration of the part-I course is 1 year. However, in India and Sri Lanka, there is an MD programme in forensic medicine, which is a 3-year full time course and it involves both forensic pathology and clinical forensic medicine. In Sri Lanka, the Postgraduate Institute of Medicine of the University of Colombo has a separate board of study for forensic medicine, which controls the selection, training and conduct of the postgraduate examination.25 After the MD examination, there is a compulsory 1 year attachment overseas in a recognized forensic institution before the graduates are board certi®ed as specialists.26 The University of Malaya has just approved a proposal to start a department of clinical forensic medicine, which will join the department of forensic pathology and will function somewhat similar to an Institute of Forensic Medicine. It will be the ®rst of its kind in this country and is certainly a major step forward towards developing this specialty. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.
Pounder D. Wounds. Torture 1997; Suppl 1: 34±38 Grievous hurt, section 320 of the Malaysian Penal Code Grievous hurt, section 311 of the Sri Lankan Penal Code Grievous hurt, section 311 of the Sri Lankan Penal Code (amendment) act, No. 22 of 1995 Gee DJ. Lecture Notes on Forensic Medicine, 3rd edn. London: Blackwell Scientific 1979, Ch 8 Rape, section 375 of the Malaysian Penal Code Rape, section 363 of the Sri Lankan Penal Code Rape, section 375 of the Indian Penal Code Rape, section 363 of the Sri Lankan Penal Code (amendment) act No: 22 of 1995 Nadesan K. Management of rape survivors. Ceylon Medical J 1999; 44(3): 109±113 Kanin EJ. False rape allegations. Archives of Sexual Behaviour 1994; 23: 81±90 Doney IE. Police surgeons of the United Kingdom. Practitioners of clinical forensic medicine. Am J Forensic Med Pathol 1984; 5(2): 185±188 Chariot P, Rey C, Watson P. Pitfalls in the diagnosis of child sexual abuse. J Clin Forensic Med 1999; 6(1): 35±38 Knight B. The battered child. In: Tedeschi CG, Eckert WG, Tedeschi LG (ed) Forensic Medicine Vol I, 3rd edn. London: WB Saunders 1977, Ch 10 Jacobsen L, Smidt-Nielsel K. Torture survivorÐtrauma rehabilitation, 1st edn. Copenhagen: International Rehabilitation Council for Torture Victims 1997 ch I Mason JK, McCall Smith RA. Law and Medical Ethics. London: Butterworth, 1994, Appendix 1 International declarations and conventions. Declaration of Tokyo 1975. Copenhagen: International Rehabilitation Council for Torture Victims 1996 Skylv G. FalangaÐdiagnosis and treatment of late sequelae. Torture 1993; 3(1): 11±15 Adhikari KK. Torture methods prevalent in Bhutan. Torture 1999; 9(1): 9±10 Ivanov K, Dimitrova M. Current dimensions of torture in Bulgaria: an attempt to assess the rehabilitation needs. Torture 1998; 8(4a): 17±19 Zeeberg NS. TortureÐa public health puzzle in Europe. Torture 1997; 8(4a): 25±43 Jehuda H, Tzipi K. Medicolegal investigation of death in custody: a postmortem procedure for detection of blunt force injuries. Am J Fore Med Pathol 1996; 17(4): 312±314
200
Journal of Clinical Forensic Medicine
23. Rasmussen OV, Rehof LA, Kendal D et al. Ethical and legal aspects of working as a doctor in the Danish prison system. Torture 1990; Suppl 1: 41±50 24. Medical aspects of torture. Danish Medical Bulletin 1990; 37(1): 43±47
25. Salgado MSL. Forensic medicine and medicolegal investigation in Sri Lanka. Am J Forensic Med Pathol 1986; 7(2): 137±145 26. Prospectus of the Postgraduate Institute of Medicine, University of Colombo 1992
ORIGINAL COMMUNICATION
Victims of violence: an Asian scenario K. Nadesan Department of Pathology (Forensic Section), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia SUMMARY. The term `violence' is difficult to define. Aggressive behaviour with actual use of physical force may result in some form of physical and emotional trauma to an individual and this could be considered as violence against the person. The trauma may range from minimal physical injury to death. It is also relevant to note that in some jurisdictions if members of the law enforcement agencies with appropriate authority resort to certain acts of `violence' for lawful purposes, then such acts of violence may be excluded from this category. However, if the law enforcement personnel exceed their limits of authority, or resort to various unacceptable and unauthorized methods of violence, then certainly such acts will become violence against the person. In today's context the word violence has expanded to encompass many issues, besides the usual physical violence such as assault. Rape, child sexual abuse, other forms of sexual abuse, non-accidental injury to children, battered wife, assault in custody, torture, victims of war, civil unrest and ethnic violence are all considered under `violence'. While general violence is almost endemic in many countries, assault in custody, torture, political and ethnic violence are serious problems in some of the developing world. In these countries, particularly, the law enforcement agencies and other unlawful groups who are backed by politicians may in¯ict politically motivated violence against its citizens. In such cases attempts are often made to cover up such crimes. Forensic physicians and forensic pathologists who examine these cases may be placed in dif®cult positions at times owing to various `pressures' being brought upon them to issue `favourable' reports. On the other hand there is also a general dearth of suitably trained forensic physicians and forensic pathologists in many of these countries. Medical of®cers without any training in forensic medicine often undertake the examination of victims of violence, both living and fatal cases. Lack of training makes them more vulnerable to political and other forms of `pressure'. The objective of this article is to highlight some of the common problems that are encountered, particularly in developing countries. ß APS/Harcourt Publishers Ltd 2000 Journal of Clinical Forensic Medicine (2000) 7, 192±200 LEGAL DEFINITIONS OF HURT, INJURY AND WOUND
any harm whatever illegally caused to any person, in body, mind, reputation or property.' The word `wound' generally means a breach of the skin or the mucous membrane and therefore this de®nition does not include contusions, abrasions or fractures and other wounds. Unfortunately there is no statutory de®nition of a wound.1 In medical parlance, however, abrasions, contusions, lacerations, incised wound, stab wound, fractures and so on are considered as wounds. Rolland's Medical Dictionary de®nes a wound as an injury to the body caused by physical means, with disruption of the normal continuity of body structures. `Hurt', `injury' and `wound' need not be synonymous. `Wound', however, comes within the de®nition of `injury' according to the penal code, that is any harm whatever illegally caused to body and mind and hence a wound is an injury. But on the other hand an injury need not always be a wound because
Section 319 of the Malaysian penal code and Section 300 of the Sri Lankan penal code deal with hurt. According to these sections `whoever causes bodily pain, disease or in®rmity to any person is said to cause hurt.' Section 44 of the Malaysian penal code and Section 45 of the Sri Lankan penal code de®ne an injury. According to these sections, `the word injury denotes
Correspondence to: Dr Kasinathan Nadesan MBBS, MD (Forensic), MRCPath, FRCPA, DMJ(Path), DMJ(Clin), Dip in Legal Med, Professor, Department of Pathology (Forensic Section), Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia, Tel: 603 7950 2912; Fax: 603 7955 6845. 192
Victims of violence: an Asian scenario according to the same sections in the penal code an injury could be caused to a person by in¯icting harm to his reputation or property without in¯icting a wound. According to the de®nition in the penal code, `hurt' is the unlawful causation of bodily pain, disease or in®rmity to any person and therefore it involves both wound and an injury. However, the hurt does not involve all that is covered by the term injury, namely the harm in¯icted on mind, reputation or property. But in practice, the term `hurt' is more widely used as a parameter to de®ne the seriousness of the offence. Therefore, the court is more concerned about hurt than a `wound' and the responsibility of de®ning a wound is more a medical issue than a legal issue and perhaps this explains why there is no legal de®nition of wound. Seriousness of an offence depends not only on the seriousness of the actual wound that was being in¯icted and its outcome but also on the intention of the assailant. However, establishing the intention is a matter for the court. As a matter of fact the court deliberates often to establish the intention of the assailant, because imposing the appropriate punishment depends on the intention. Besides other evidence that is made available to a court of law, the nature of the weapon used, the part of the body that was wounded together with the actual wounds in¯icted, will assist the court in establishing the intention of the assailant. Therefore it is evident that a thorough medicolegal examination of the victims of violence contributes greatly in the administration of justice. The following types of hurt are dealt under the offences affecting the human body in chapter 16 of the Malaysian and Sri Lankan penal code: 1. 2. 3. 4. 5.
Simple hurt Grievous hurt Injury that endangers life Injury that is fatal in the ordinary course of nature Deliberately fatal injury.
It is a matter for the court to decide whether a wound is grievous or not. However, a doctor by his description and documentation should be able to categorize the hurt as to whether it is a simple or a grievous hurt so that the court may make the ®nal decision based on the doctor's report. Section 320 of the Malaysian penal code and section 311 of the Sri Lankan penal code de®ne grievous hurt.2,3 The following types of wounds only are designated as `grievous' according to section 320 of the Malaysian penal code: FirstÐEmasculation SecondlyÐPermanent privation of the sight of either eye ThirdlyÐPermanent privation of the hearing of either ear
193
FourthlyÐPrivation of any member or joint. FifthlyÐDestruction or permanent impairing of the powers of any member or joint SixthlyÐPermanent dis®guration of the head or face SeventhlyÐFracture or dislocation of a bone EighthlyÐAny hurt which endangers life, or which causes the sufferer to be, for the period of 20 days, in severe bodily pain, or unable to follow his ordinary pursuits. Until 1995 both the Sri Lankan and Malaysian sections regarding grievous hurt were similar. However, after the penal code (amendment) act, No. 22 of 1995, the Sri Lankan de®nition of grievous hurt became clearer and some of the practical confusions that existed were recti®ed.4 Sub sections two and three were rephrased to be read as `permanent privation or impairment of the sight of either eye and permanent privation or impairment of hearing of either ear' respectively. Privation meant a total loss and when a person loses 80% of his eyesight or hearing, according to an earlier section it was only an impairment and therefore not grievous. Sub section six was changed to `cut or fracture, of bone, cartilage or tooth or dislocation or subluxation of bone, joint or tooth'. Sub section eight was divided into two, the ®rst part `any injury which endangers life or in consequence of which an operation involving the opening of the thoracic, abdominal or cranial cavities is performed'. For example, prior to the 1995 amendment, an exploratory laparotomy performed for suspected bowel rupture was non-grievous in nature if no rupture was found at surgery, but after the 1995 amendment, however, the necessity for the surgery, even though no internal injury was found later, still made it a grievous hurt. The second part was like this: `any injury which causes the sufferer to be in severe bodily pain or unable to follow his ordinary pursuits, for a period of 20 days either because of the injury or any operation necessitated by the injury'. Victims of violence may present as non-fatal or fatal cases. The acute non-fatal cases may be seen by general practitioners or at the accident emergency departments. Fatal cases very often will be subjected to an inquest and a medicolegal post mortem. There are instances where the victims of violence are prevented from seeking medical help when the perpetrators are the law enforcement personnel or persons who are backed by governments or terror groups. This appears to be a serious problem in many Asian and other developing countries, particularly in the Latin American region. In many instances, by the time they are seen by a doctor, several months have already elapsed. Hence one can appreciate the dif®culties encountered in examining and assessing these persons
194
Journal of Clinical Forensic Medicine
who are traumatized both physically and emotionally. On the other hand the bodies of fatal victims are disposed of in several ways without any inquiries being held and if the remains are discovered they are already decomposed or even skeletonized. In many instances persons are arrested in the night and are kept in custody without any documentation in order to avoid accountability. Often they are tortured and if they die during the process, the bodies may be secretly disposed of without any inquiry. Burning appears to be a popular method of surreptitious disposal of such bodies in Asia. The victims of violence may present in different ways including 1. physical assault and other forms intentional violence 2. rape, child sexual abuse and other forms of sexual abuse 3. non-accidental injury to children 4. battered wife, battered employees and other similar situations 5. battering in custody, victims of torture 6. victims of war, civil unrest, ethnic violence, terrorism etc. OBJECTIVES OF MEDICOLEGAL EXAMINATION The responsibility lies with the doctor to correctly identify and interpret the wounds (Fig. 1). Only then will the report be of bene®t to the victim, the court and the community at large. Knowledge, skill and experience in handling the victims of various types of violence must be acquired before a doctor can considered an expert.
Fig. 1 The deceased was attacked with a sword, which was a long straight-bladed heavy cutting weapon, which in Malay is termed a `Parang'. The injuries consist of incised wounds, linear abrasions and a grazed abrasion in the mid right chest. The different types of wounds have resulted because of the varying manner in which the weapon had been used. The contour of the body also alters the appearance of the wounds. A guarded opinion about the profile of the causative agent/agents is always necessary
The doctor who examines the injured person should document the wounds and look actively for the following: 1. Accurately identify and describe the wounds. 2. Establish if possible the causative agent or agents that caused the wounds. 3. The mechanism of causation and reconstruction of the event. The latter will help to accept or refute the account given by the injured or an eyewitness. 4. Determine as to whether the wounds were self in¯icted or fabricated? 5. Try to establish the approximate age of the wounds, and this issue may become important in cases of battered children, battered wives and victims of torture. 6. Look for speci®c wound pattern, which may help in identifying battered children, battered wives, victims of torture, etc. In Asian countries, through fear or for social and cultural reasons, battered wives and victims of torture may not voluntarily admit to abuse and sometimes may even deny it. 7. Look for any underlying conditions and diseases that may have aggravated the original wound. 8. Try to ascertain whether any disease process has developed subsequent to trauma. Reference should be made to Ewing's postulate regarding trauma and disease.5 9. Classify and categorize the wounds in a medicolegal context. 10. Write a legally valid report to court. Comment on what was actually found and try to interpret the ®ndings in an acceptable, objective and factual mannerÐthere is no room for speculation. Valid consent should be obtained from the injured person prior to medical examination. However, with a court order in some jurisdictions a person could be examined without a consent. Similarly, a new prisoner at the time of admission to prison too could be examined without consent. A detailed history has to be obtained from the injured person prior to examination. If the injured person is a suspect and is produced by the police or any members of the law enforcement, history taking and examination should ideally be undertaken in private without the presence of any of®cials in the examination room. All wounds must be carefully documented with sketches and photographs. A complete physical examination should always be performed. Wherever possible con®dentiality has to be maintained. SEXUAL OFFENCES Sexual violence forms an important group amongst the victims of violence. Sexual offences include an
Victims of violence: an Asian scenario in®nite variety of physical acts, either executed or attempted, in the furtherance of sexual grati®cation, by a person or persons, of differing or similar genders, without the lawful consent of those offended, and having regard also to considerations of age, mental development, physical development, kinship and species. Rape is dealt with under section 375 of the Malaysian penal code.6 According to this section a man is said to commit `rape' who, except in the case hereinafter excepted, has sexual intercourse with a woman under the circumstances falling under any of the following descriptions: FirstÐAgainst her will. SecondlyÐWithout her consent. ThirdlyÐWith her consent, when her consent has been obtained by putting her in fear of death or hurt to herself or any other person, or obtained under a misconception of fact and the man knows or has reason to believe that the consent was given in consequence of such misconception. FourthlyÐWith her consent, when the man knows that he is not her husband, and her consent is given because she believes that he is another man to whom she is or believes herself to be lawfully married or to whom she would consent. FifthlyÐWith her consent, when, at the time of giving such consent, she is unable to understand the nature and consequences of that to which she gives consent. SixthlyÐWith or without her consent, when she is under 16 years of age. Section 363 of the Sri Lankan penal code and section 375 of the Indian penal code deal with the de®nition of rape.7,8 Until the Sri Lankan penal code (amendment) act, No.22 of 1995, came into force, Malaysian, Sri Lankan and Indian laws regarding the de®nition of rape were almost similar.9 After the 1995 amendment to the Sri Lankan penal code, the sub section `against her will' was removed. The sub section `without her consent' was replaced by `without her consent even where such woman is his wife and she is judicially separated from the man'. Also, the age of consent for sexual intercourse was raised from 14 to 16 years. This amendment was a major step forward because `against her will' arose from the early 19th century English Common Law which looked for evidence of struggle and resistance on the rape survivor as proof of rape.10 The word rape is probably derived from the Latin `rapere' to snatch; it literally means a forcible seizure. This led to a misconception in the minds of many that one has to always ®nd some evidence of a struggle before establishing rape. However, it is very well known that under many situations a woman will be compelled to yield to a rapist without offering any
195
resistance. Hence the main issue in the offence of rape is the question of consent. Under English Law, the Sexual Offences (Amendment) Act 1976 de®nes rape. According to this section, a man commits rape if: 1. there is unlawful sexual intercourse with a woman who at the time of the intercourse does not consent to it and 2. at that time he knows that she does not consent to the intercourse or he is reckless as to whether she consents to it or not. Rape is the fastest growing violent crime in many parts of the world. In spite of heavy punishment including death sentence and many law reform initiatives, rape still remains a serious problem all over the world. It is also important to remember that there are many reported cases of rape that are found to be false.11 On the other hand many genuine cases of rape are not reported because of fear, damage caused by publicity to the victims and often the cases cannot be proved and so no justice seems to be done to the rape victim. A thorough medical examination often provides an independent, scienti®c and a corroborative evidence. However, corroboration is not essential to prove a case of rape.9 The 1995 amendment act on rape laws in Sri Lanka, in its procedural law, had described that `evidence of resistance such as physical injuries are not essential to prove that there was no consent'. It is also the responsibility of the trial judge to explain this aspect to the jurors during the commencement of the trial. A negative medical ®nding, therefore, does not rule out the possibility of rape. Medical examination and expert opinion will also save an innocent person who may have been wrongly implicated. The doctor should have special expertise in performing the examination, collecting the relevant specimens and in interpreting the ®ndings. Finally, a comprehensive report has to be submitted to court.12 At no stage should the doctor comment about rape in his report or evidence, as this will be a matter for the court. Unfortunately in many Asian countries there are no speci®cally trained, full time forensic physicians to ef®ciently deal with these cases. There are also no Scene of Crime Of®cers in the police force to assist the doctors. Hence the quality of medical examinations conducted is questionable in many instances. Child sexual abuse is another issue that causes grave concern. It is believed that virtually every child is vulnerable to sexual abuse. According to researchers one out of every four children will be the victim of sexual abuse in the West. No such details are available for the Asian region. In many instances, unfortunately, the perpetrators are immediate family members. For various reasons, including fear of reprisals, these
196
Journal of Clinical Forensic Medicine
Fig. 2 A nine-year old boy who was subjected to repeated buggery by his uncle over a period of time. Note the gaping, somewhat funnel shaped anus with flattening of the surrounding skin and the absence of normal puckered appearance. A partially healed laceration is visible at the 12'o clock position
offences are usually not reported immediately. Sexual abuse can be physical, verbal or emotional. There is a whole spectrum of activities that range from touching and fondling, exhibitionism, masturbation to even rape and buggery. However, the experience at the University Hospital is that the incidence of rape of small children including statutory rape is very rare. But buggery appears to be a serious problem amongst the victims of child sexual abuse. Unless the victim of buggery is examined immediately or shortly after the act there will be less chance of detecting any positive evidence at a clinical examination. However, if buggery had been committed repeatedly over a period of time, then there may be speci®c changes found which may support chronic abuse (Fig. 2). Unfortunately most of the cases of child sexual abuse that come before the doctors for examination are not `fresh cases'; that is the offence had been committed some time prior to actual examination. The doctor who examines these cases should have specialized knowledge and experience because, on the one hand, the
children have to be handled gently and tactfully and, on the other hand, there could be false positive and false negative ®ndings, which need careful interpretation. Super®cial anal ®ssures are not an unusual ®nding in small children. It may be useful to feel for hard faecal matter in the rectum during digital examination because constipation may be the cause of the ®ssure. Worm infestation in children is a common problem in the tropics and pinworm causes severe irritation and itching at the anus. Such children often scratch their anal verge, particularly in the nights, and this may cause reddening, abrasions and even swelling and that can be easily mistaken for sexual abuse. It is useful to carry out routine stool examination for worm infestation. It is also not uncommon to ®nd reddening of the anal verge and the perianal skin in children who lack personal hygiene. Wherever possible, seek the assistance of a paediatric surgeon while examining the rectum, particularly when a proctoscopic examination is carried out. Very often small children may not cooperate with the rectal examination. It is the author's view that it is the children who have had a traumatic experience or who have experienced a tactless medical examination previously who resist the most. In such cases examination may have to be conducted under anaesthesia. It is often possible to examine such children using ketamine sedation in the ward itself. It is also important to remember that children can make false and fabricated stories of physical and sexual abuse.13 Non-accidental injury to children The other area of concern is the non-accidental injury to children. At one time it was believed that nonaccidental injury to children was very uncommon in the Asian region owing to the existence of extended families. However, that is now proved to be wrong, and physical and sexual abuse of children appear to be serious problems in Asian countries. `Non-accidental injury to children' refers to a child usually under 3 years of age, who suffers repeated nonaccidental injuries, sometimes fatal, caused by episodes of violence by a parent or guardian.14 Various social, economic, personal and other factors are attributed to this problem. The pointers to true battering are: 1. variation and inconsistencies in the parental explanation of how the child sustained the injuries 2. delay in seeking medical advice 3. injuries and the explanations are inconsistent 4. multiple injuries in different stages of healing 5. presence of `classic' lesions 6. repeated visits to different doctors.
Victims of violence: an Asian scenario
197
VICTIMS OF TORTURE
Fig. 3 A 12-year old boy was brought in dead to hospital by the uncle who was looking after him, with a history of fall from a tree. He had multiple soft tissue injuries in different stages of healing, including cigarette burns. A granulating lacerated wound is seen on the mucosal aspect of the lower lip. The cause of death was closed haemopericardium and cardiac tamponade due to ruptured pulmonary artery. The mid front of chest wall had an irregular contusion, possibly caused by stamping with bare foot while the boy was lying on the ground
Doctors, especially in the paediatric, surgical, accident and emergency and primary care departments, and in the general practice, should be alert to this problem of child abuse. If they are watchful, then cases of child abuse could be easily identi®ed (Fig. 3). Johnson et al. (1966), said `The skin and bones tell a story that the child is either too young or too frightened to tell'. Skin bruising is the common injury that is seen in battered children. These contusions are often con®ned to certain areas of the body and also they exhibit certain characteristics. Besides, they may be of different ages and particularly in light complexioned children the colour changes that take place with ageing can easily be identi®ed. Skin bruises of different ages are strongly suggestive of physical abuse. It may be useful to carry out a complete skeletal survey in suspected cases, particularly when the parent or guardian claim accident proneness as an explanation for repeated trauma. Detailed description of injury pattern is beyond the scope of this article. It is important to remember that the doctors need to have a clear knowledge about the various presentations and tact in handling not only the children but also the parents and guardians. Failure to identify early may lead to a tragic outcome. On the other hand over enthusiasm or unwarranted suspicion too can be counterproductive and may even land the doctor in litigation. It is ideal to have a child abuse team in each institution that is represented by various medical experts, child psychologists and social welfare of®cials, and decision-making, especially in dif®cult cases, should be collective. Regular case conferences should be held before crucial decisions are made.
Torture and battering in custody is another major problem encountered especially in some of the developing countries. In many instances, members of the police force and armed services are responsible for these crimes, often committed in the course of crime investigation and for political reasons. Torture is de®ned as the deliberate, systematic or wanton in¯iction of physical or mental suffering by one or more persons acting alone or on the orders of any authority, to force another person to yield information, to make a confession, or for any other reason.15 The Congress of the World Medical Association (WMA) in Tokyo in 1975 adopted the above de®nition. It was mainly applicable to medical personnel. Torture has been known throughout the history of man. In modern times, the Second World War is one example of where doctors were involved in torture and using prisoners and others for various unethical researches. The doctors who take part in any form of torture are acting against the Hippocratic oath.16 The Declaration of Tokyo forbids doctors from taking part in torture and other forms of cruel, inhuman or degrading procedure.17 Victims of torture may present as living or dead victims. Torture takes the form of physical or emotional abuse, often it is a combination of both. Survivors of torture may come to a doctor on their own, brought by police, by prison of®cials, or on a magistrate's order. Physical abuse often presents as blunt weapon trauma, in¯icted over the soft tissues. Hitting on the soles of feet with baton or plastic pipes ®lled with sand is a common method employed by police, which is referred to falanga or bastonade. Some of these victims may end up with permanent malfunction of gait.18 However, there are all possible varieties and variation of acts of physical torture such as suspension by thumbs, wrists and feet, burning, pricking under ®nger nails, traumatization of genitals, immersion and near drowning, sexual abuse, sexual humiliation and so on, to name a few since the list is endless (Figs 4 & 5). Unless the survivors are examined early, most physical signs and symptoms may disappear except where intense and cruel physical violence had been used.19,20 Many victims who have survived the initial ordeal may subsequently develop anxiety, depression, post traumatic stress disorder and suicidal tendencies.21 The doctor who examines these patients should interview them in the absence of any law enforcement of®cials. Fatal cases may present with multiple contusions, especially with subcutaneous bleeding resulting in hypovolaemic shock, muscle damage and acute renal failure or trauma to fatty tissues, resulting in fat
198
Journal of Clinical Forensic Medicine Ethnic violence and terrorism
Fig. 4 A victim of police torture. Note the parchmented abrasions encircling both thumbs and lower part of both forearms. He was suspended by his thumbs at the police station to extract information and to force him to make a confession. The abrasions around both forearms were caused by a rough ligature material, such as rope. The wound caused by the knot is visible in the front of the left forearm
Fig. 5 Another victim of police tortureÐmultiple partially healed contusions placed parallel to one another on the back of trunk towards the lumbar area. The victim was forced to lie face downwards over a table before being beaten with a thin wooden rod. Some of the wounds are spindle shaped because of the contour of the body. Over the lower lumbosacral area the wound is showing a typical `tram line' because that area is almost flat
embolism syndrome, such as cerebral fat embolism. Rarely, injury to vital organs is demonstrated. Clinical examination and autopsy examination should be thorough and the doctor should be familiar with the special techniques of examination and the various ways in which these cases may present.1,22 His report should be unbiased and impartial. In certain situations `pressure' may be brought upon doctors to suppress facts and to issue `favourable' reports. A doctor should, under all circumstance, resist such `pressures', and must be courageous enough to make a true and genuine report following the ethical standards.23 The WMA will stand by the doctors when they are under threat.24
Sadly, ethnic violence has become a way of life in many countries. In several Asian and African countries ethnic violence has not only affected the entire lifestyle of the people but has even affected the neighbouring states. In most instances when violence breaks out, people are beaten up with hands and legs or with weapons such as clubs, knives and swords. The victims often end up with multiple blunt weapon traumas, slash, cut and stab wounds. Looting and arson is another common manifestation of ethnic violence. Undesirable elements use these situations for their advantage. Firearms too are being used during ethnic violence. Police and military may be called upon to maintain law and order during such crises and this also results in various types of wounds. Terrorism is an equally serious problem in many countries. Ethnic, religious and political differences are the main causes that can ®nally lead to terrorism. This is the reason why de®ning `terrorism' is sometime dif®cultÐfor a particular ethnic group the violent acts of a militant group may appear as terrorism where as for the other ethnic group it will appear as a freedom struggle. Nowadays the violent groups use modern and sophisticated weapons and explosive devices; in addition, they also use various improvised devices. Explosives are increasingly used in the Indian subcontinent. Land mines, Calymore mines and grenades are commonly used to attack armed forces and other opponents. In Sri Lanka, the `human bomb' is the most deadly explosive out®t that is increasingly used by the Liberation Tigers of Tamil Eelan. Referred to as `suicidal bombers', they strap `plastic explosives' on to their body and detonate them at selected targets, which results in death and destruction, including the person carrying the bomb. The explosives used are always very powerful and that results in extensive damage to the victims. The bodies of persons who were close to the explosive device are usually badly mangled up and sometimes visual identi®cation may be a problem. Identifying the suicide bomber is an important part of the forensic investigation. Invariably the body of the bomber is severely fragmented, but, interestingly, in many instances the head is spared. Due to the powerful explosion taking place around the area of the chest and the abdomen the head gets separated and thrown a long distance, e.g. heads of bombers have been recovered from rooftops of high rise buildings. In one instance crows gathering at the roof of a tall building a day after the explosion ®nally led to the discovery of the head. Such explosions often occur in crowded areas and that results in several deaths, with many more injured. The doctors who examine the injured and the dead have to be very
Victims of violence: an Asian scenario cautious and thorough Ðthere will be always allegations and counter allegations, therefore the medical examination reports have to be very objective and unbiased. In most of these situations the armed forces also exceed their limits and resort to various acts of violence, including torture and extra-judicial killings. Worse still, the bodies are disposed of by burning or buried in mass graves. The author was involved in a mass grave exhumation in 1994 and 31 skeletonized remains of young males were recovered. Each victim had a single bullet wound, either on the side or the back of the head and they were restrained and blindfolded. The victims were suspected militants and the perpetrators were armed forces. During such crisis, a doctor may be caught up in a dif®cult situation and will be `pressurized' from both sides. TRAINING OF UNDERGRADUATES AND DOCTORS Clinical forensic medicine is not included in the undergraduate medical curriculum in Malaysia. General pathologists who have no special training in forensic pathology perform medicolegal autopsies in many large hospitals. Medical of®cers who have no training in this ®eld handle clinical forensic cases. Some of them are quite incompetent, particularly in handling cases of sexual abuse, child abuse, victims of torture, battery and so on and hence their examinations and reports may lack the necessary objective ®ndings. There is also a severe dearth of forensic experts in Malaysia trained to undertake good quality post mortem and clinical examinations on a countrywide basis. In all the medical schools in Malaysia, forensic medicine is a sub unit in the department of pathology and very little emphasis is given to this subject. To be precise, these units are in fact departments of forensic pathology rather than departments of forensic medicine, because, as already referred to, there is no teaching in clinical forensic medicine. On the other hand, in Sri Lanka and India, the medical undergraduate curriculum provides reasonable recognition of forensic medicine and there is invariably a separate department. Both forensic pathology and clinical forensic medicine are taught and the undergraduates are tested in them, which include practical and viva-voce in addition to two theory papers. In Malaysia the undergraduates are required to take a 2 h theory examination only. In Malaysia postgraduate course is available in forensic pathology, which is a 3 year full time course leading to a Masters in Forensic Pathology. The trainee has to ®rst successfully complete the part-I
199
examination, and the duration of the part-I course is 1 year. However, in India and Sri Lanka, there is an MD programme in forensic medicine, which is a 3-year full time course and it involves both forensic pathology and clinical forensic medicine. In Sri Lanka, the Postgraduate Institute of Medicine of the University of Colombo has a separate board of study for forensic medicine, which controls the selection, training and conduct of the postgraduate examination.25 After the MD examination, there is a compulsory 1 year attachment overseas in a recognized forensic institution before the graduates are board certi®ed as specialists.26 The University of Malaya has just approved a proposal to start a department of clinical forensic medicine, which will join the department of forensic pathology and will function somewhat similar to an Institute of Forensic Medicine. It will be the ®rst of its kind in this country and is certainly a major step forward towards developing this specialty. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.
Pounder D. Wounds. Torture 1997; Suppl 1: 34±38 Grievous hurt, section 320 of the Malaysian Penal Code Grievous hurt, section 311 of the Sri Lankan Penal Code Grievous hurt, section 311 of the Sri Lankan Penal Code (amendment) act, No. 22 of 1995 Gee DJ. Lecture Notes on Forensic Medicine, 3rd edn. London: Blackwell Scientific 1979, Ch 8 Rape, section 375 of the Malaysian Penal Code Rape, section 363 of the Sri Lankan Penal Code Rape, section 375 of the Indian Penal Code Rape, section 363 of the Sri Lankan Penal Code (amendment) act No: 22 of 1995 Nadesan K. Management of rape survivors. Ceylon Medical J 1999; 44(3): 109±113 Kanin EJ. False rape allegations. Archives of Sexual Behaviour 1994; 23: 81±90 Doney IE. Police surgeons of the United Kingdom. Practitioners of clinical forensic medicine. Am J Forensic Med Pathol 1984; 5(2): 185±188 Chariot P, Rey C, Watson P. Pitfalls in the diagnosis of child sexual abuse. J Clin Forensic Med 1999; 6(1): 35±38 Knight B. The battered child. In: Tedeschi CG, Eckert WG, Tedeschi LG (ed) Forensic Medicine Vol I, 3rd edn. London: WB Saunders 1977, Ch 10 Jacobsen L, Smidt-Nielsel K. Torture survivorÐtrauma rehabilitation, 1st edn. Copenhagen: International Rehabilitation Council for Torture Victims 1997 ch I Mason JK, McCall Smith RA. Law and Medical Ethics. London: Butterworth, 1994, Appendix 1 International declarations and conventions. Declaration of Tokyo 1975. Copenhagen: International Rehabilitation Council for Torture Victims 1996 Skylv G. FalangaÐdiagnosis and treatment of late sequelae. Torture 1993; 3(1): 11±15 Adhikari KK. Torture methods prevalent in Bhutan. Torture 1999; 9(1): 9±10 Ivanov K, Dimitrova M. Current dimensions of torture in Bulgaria: an attempt to assess the rehabilitation needs. Torture 1998; 8(4a): 17±19 Zeeberg NS. TortureÐa public health puzzle in Europe. Torture 1997; 8(4a): 25±43 Jehuda H, Tzipi K. Medicolegal investigation of death in custody: a postmortem procedure for detection of blunt force injuries. Am J Fore Med Pathol 1996; 17(4): 312±314
200
Journal of Clinical Forensic Medicine
23. Rasmussen OV, Rehof LA, Kendal D et al. Ethical and legal aspects of working as a doctor in the Danish prison system. Torture 1990; Suppl 1: 41±50 24. Medical aspects of torture. Danish Medical Bulletin 1990; 37(1): 43±47
25. Salgado MSL. Forensic medicine and medicolegal investigation in Sri Lanka. Am J Forensic Med Pathol 1986; 7(2): 137±145 26. Prospectus of the Postgraduate Institute of Medicine, University of Colombo 1992