ABSTRACT

Objective:

This study aims to discuss the medicolegal significance of psychological examinations in the documentation of repetitive partner violence by evaluating the results of forensic reports prepared for such cases in detail.

Methods:

Case files those indictments were completed by the Public Prosecutor responsible for the Domestic Violence and Violence Against Women Bureaus in Samsun, were examined retrospectively between June 1, 2020, and December 1, 2020. The forensic reports of 141 women aged 18 and above who had previously reported violence by the same partner were selected and examined.

Results:

The psychiatric examination section of the reports revealed that psychiatric examination was not conducted in 74.5% (n=102) of cases, was recorded only as “normal or N” in 19% (n=26), and was recorded as no psychopathology was found in 2.9% (n=4). Psychiatric examinations were not performed in 72.4% (n=63) of cases with mild injuries that could be treated with simple medical interventions. In cases where the report stated no signs of physical violence, 72.2% (n=13) did not undergo a psychological examination.

Conclusion:

In the medico-legal assessment of women subjected to repeated partner violence who represent a particular group with a high incidence of psychopathologies, appropriate examination conditions are often not provided, and psychiatric examinations are not conducted. A detailed psychological examination can more clearly establish the severity of injuries, and establishing the causality between trauma and psychological findings in the conclusion section of forensic reports will guide the judicial authorities in showing the presence of trauma in case of no physical finding.

Keywords: Repetitive partner violence, forensic report, psychiatric examination

INTRODUCTION

While women are most frequently exposed to violence by men they know, in the case of adult women, these individuals are typically their partners (1,2). Partner violence refers to violent behavior inflicted by an intimate partner or former partner within a relationship. An intimate partner may refer to a legally or religiously married spouse, fiancé, boyfriend, or girlfriend (3). For most women subjected to partner violence, the violence is not an isolated, singular event but rather a recurring and chronic phenomenon (4-7). Experiencing violence once is a significant risk factor for subsequent violence, and it is reported that the intensity of violence increases in repetitive incidents (8,9).

Acts of violence perpetrated by humans can result in various mental health disorders, including post-traumatic stress disorder (PTSD), acute stress reactions and disorders, dissociative disorders, depression, anxiety, substance abuse, sexual disorders, personality disorders, psychotic disorders, as well as sleep and eating disorders (10,11). It has been demonstrated that the rates of depression are higher among women exposed to repetitive violence, and due to the exacerbating effect of the persistence, frequency, and intensity of violence on mental disorders, these conditions tend to be more severe (8,12,13). The repetitive nature of trauma has been identified as a significant risk factor, particularly for PTSD.

In cases of violence against women, physical signs of injury may not always manifest on their bodies, and if they seek medical attention late, any physical evidence of injury may have disappeared. While physical trauma-related symptoms may disappear over time or not manifest at all, psychological trauma-related symptoms can persist for an extended period (14).

The terms included in the conclusion section of forensic reports, which contain answers to questions posed by legal authorities regarding an individual’s medical condition, help to assess the severity of trauma. Including mental health disorders developed in the victim as a result of the incident in the classification of injuries in forensic examinations helps to present the victim’s situation more clearly and accurately (15,16). Early diagnosis and initiation of treatment after psychological assessment are essential for the person’s health, and it can be argued that a proper medico-legal evaluation would lead to a fairer legal process for the perpetrator (14).

Studies on the quality of forensic reports in Turkey have shown that these reports often contain many deficiencies and errors (17-19). However, there has been insufficient research on the psychiatric examination section in Turkey. Addressing violence against women is not only about providing medical care but also about seeking legal remedies, which are crucial for both the rehabilitation of women and the prevention of violence. This study aims to discuss the medical and legal significance of psychiatric examinations in the forensic documentation of women subjected to repetitive partner violence by examining the results of forensic reports prepared for such cases in detail. It is hoped that the findings of this study will emphasize the importance of the issue, and the identified findings can contribute to future research on the medico-legal evaluation of cases involving repetitive trauma against women.

MATERIALS AND METHODS

The study was initiated with the approval of the Samsun Ondokuz Mayıs University Faculty of Medicine Clinical Research Ethics Committee numbered 2021/290.

With the permission of the Samsun Chief Public Prosecutor’s Office, files completed between June 1, 2020, and December 1, 2020, from the bureaus responsible for domestic and gender-based violence within the Samsun Chief Public Prosecutor’s Office were retrospectively examined. During this 6-month period, cases of male victims, cases of domestic violence out of partner relationships, and cases of women who had been subjected to partner violence for the first time were excluded from the sample. A sample of 141 women aged 18 and over, who stated in their initial statements that they had previously been subjected to violence by the same partner, was selected.

Information regarding the relationship between the victim and the suspect, the person/organization to whom assistance was sought, the form of violence, and whether a tool was used has been recorded from the initial statement records in the file. Details about the type of violence previously applied to the victim, whether the victim had been exposed to violence with a tool, and whether the suspect lived in the same house were recorded from the “Violence Against Women Incident Recording and Risk Assessment Form” forms. Additionally, from the general forensic examination forms in the file, details about the examination conditions under which the report was prepared, the history of the incident, physical examination, mental examination, requested consultations, and the evaluations of the physicians were recorded.

Statistical Analysis

The statistical analysis of the data was conducted using the SPSS 21.00 software package. Descriptive findings of the research group, including number and percentage distributions, mean, standard deviation, minimum, and maximum values, were calculated. To determine the relationship between dependent and independent variables, the chi-square test was employed. P<0.05 was considered significant in all statistical analyses.

RESULTS

It was observed that the average age of the 141 women who comprised the study group and were subjected to repetitive partner violence was 35.1±10 years (minimum 19 - maximum 75). All of the perpetrators of violence were male, with an average age of 39.2±11.8 years (minimum 21 - maximum 78).

Looking at the relationship between the perpetrators and the cases, it was found that 80.9% (n=114) were officially married spouses, which was the most common type of relationship, while 14.9% (n=21) were in the process of divorce, ranking second. Furthermore, 83.7% of the cases (n=118) were living in the same house as the perpetrator.

The distribution of the types of violence experienced by the cases during the incidents leading to their applications is provided in Table 1. The distribution of the types of violence they had previously been exposed to is presented in Table 2.

The percentage of cases that had previously experienced violence with any tool was found to be 44.7% (n=63). Among the cases, 31.2% (n=44) had experienced violence with any tool during the incident that led to their most recent application. The rate of experiencing violence with any tool during the most recent incident was found to be significantly higher in cases that had previously experienced violence with any tool compared to cases that had not (p<0.05).

It was observed that in 84.7% (n=116) of the general forensic examination reports, the section regarding examination conditions (whether appropriate conditions were provided, individuals present during the examination, clothing of the examined person) was not marked. Only 5.8% (n=8) of the reports mentioned that all conditions in the examination conditions section were met. In four cases, the used report format did not include the examination conditions section.

When the section of the reports related to the examination of the essential incident (the history of the incident, the complaints of the examined person, the medical history of the examined person) was examined, it was found that in 35.8% (n=49) of the cases, it mentioned forensic examination or examination for assault and violence, in 26.3% (n=36) it only stated that the person was assaulted, and in 5.1% (n=7), this section was left blank.

The identified deficiencies and errors in the sections of the incident history and the medical history of the examined person within the general forensic examination reports are shown in Table 3.

In the psychiatric examination section, it was noted that 74.5% of the cases (n=102) did not undergo an examination, 19% (n=26) were reported as normal, and 2.9% (n=4) showed no signs of psychopathology. Among the 137 cases, detailed information was found in the psychiatric examination section in only 3 cases, and in 2 cases, the report format did not include a psychiatric examination section. The distribution of the presence of psychiatric examination is shown in Figure 1.

Only four cases were referred for consultation, and two of these consultations were from the Department of Orthopedics and Traumatology, while the other two were from the Department of Ophthalmology.

In the conclusion section, it was indicated that there was no vital danger in 64.2% of the cases (n=88), while no assessment of vital danger was made in 35.8% of cases (n=49). Regarding whether the injury was so mild that it could be treated with simple medical intervention, no opinion was given in 34.3% of cases (n=47). In 38% of cases (n=52), signs of assault and violence were reported, while 13.1% (n=18) were reported to have no signs of assault or violence. Among the cases with provisional reports, 10.2% (n=14) expressed the opinion that the final report should be issued by a specialist. There was no specialist in the field of mental health and diseases among the requested experts.

It was found that in 72.4% of cases (n=63) with injuries that could be treated with simple medical intervention, no psychiatric examination was conducted. Among cases in which the conclusion section of the report stated that there were no signs of assault or violence, 72.2% (n=13) also did not undergo psychiatric examination.

DISCUSSION

Violence against women is most commonly perpetrated by men they are familiar with, often their intimate partners. Marital status is an important characteristic that has considerable impact on violence prevalence (20). The finding in our study that the men who are intimate partners and with whom women live in the same household are the most common perpetrators of violence is consistent with the literature (9,21-23). In line with data from a large-scale study conducted in our country, our study also shows that women who are victims of violence tend to be in younger age groups (24).

Studies in the field of violence against women have consistently shown that different forms of violence are often co-occurring (25). In our study, isolated incidents of violence were only found in 10.6% of cases, while previous incidents of violence, like the most recent one, often involved multiple forms of violence occurring together. Healthcare professionals having knowledge of this and receiving training on recognizing co-occurring forms of violence can lead to better patient interviews and more detailed examinations. Additionally, it can help bring to light forms of violence that women may have difficulty describing, such as psychological and economic violence. This, in turn, can contribute to more accurate national data collection and enable the provision of appropriate treatment and qualified forensic medical evaluations for the various consequences of different types of violence.

In our study, only 5.8% of cases had information indicating that appropriate examination conditions were provided in the report forms. However, individuals who have experienced trauma, especially women, may avoid giving a detailed history and may even try to conceal the trauma. Therefore, ensuring a safe environment, adequate time, gaining the patient’s trust, effective listening, and careful communication are essential for an effective evaluation (26). In cases in which appropriate examination conditions are not met, it can be argued that the psychiatric examination may also be incomplete. The low rate of appropriate examination conditions in our study suggests that healthcare professionals may have shortcomings in their approach to trauma patients.

One of the fundamental principles of medicine is that taking a patient’s history is the most crucial step in a medical examination. In our study, we found a relatively high rate of deficiencies in the content of the medical history. Not including the date of the incident in the history content is one of the common deficiencies, and in our study, the prevalence of this deficiency was higher compared to previous studies (19,27). However, determining the age of the wound and the onset of symptoms related to mental illnesses are essential pieces of information for a physician. In forensic medical evaluations, establishing the causality of mental complaints with the incident relies significantly on obtaining a comprehensive medical history.

In our cases, even though they are instances of violence against women, there is no information available about the perpetrators in 77.4% of the reports. Similarly, despite all cases involving recurring violence, 96.4% of them lack information about whether there is a history of violence in the past. However, in cases of violence against women, recurring violence by the same individual is common, and this information is essential both for legal decisions and health outcomes (11,13). The content of the medical history may contain information that can guide judicial authorities regarding the nature of the crime. For example, instead of evaluating only the violence incident that led to the complaint, understanding that the case involves a woman who has experienced violence from the same partner in the medical history, conducting physical and mental examinations in line with the history, and subsequently writing a report can significantly impact the nature and consequences of the injury, potentially transforming the offense from simple assault to torture.

Standard general forensic examination reports have a separate section for psychiatric examination. However, in our study, it was observed that the majority of cases did not undergo a mental examination, with the second most commonly used entry being the letter “N”, which denotes normal. In most of the existing studies, examinations have primarily focused on other system examinations, and since mental examination is considered to be part of other system examinations, the results are similar (28,29). Although forensic report formats have a dedicated section for psychiatric examination, it is evident that the deficiency has not been addressed. A study conducted on 390 forensic cases in our country also showed that 96% of forensic cases did not undergo mental examination (14). However, in cases of trauma caused by human actions, especially when they are recurring in nature, mental symptoms are more pronounced (11,13). Particularly in our study, in which all cases were women who had experienced recurring partner violence, the importance of mental examination becomes more apparent, especially in cases with no physical injuries. In our study, mental examination was not conducted in 72.4% of cases with injuries that could be treated with simple medical intervention. It should be remembered that the failure to conduct a mental examination in cases without physical injury can lead to errors in the evaluation and guidance of women, affecting their rehabilitation and legal process. Because a comprehensive mental examination of women can lead to a diagnosis that will initiate treatment and may alter the report’s conclusion based on the guidelines for the evaluation of post-traumatic mental disorders in the “Evaluation of Bodily Harm Crimes Defined in the Turkish Penal Code (TCK) from the Perspective of Forensic Medicine” (16).

In the guideline, the type of crime described in Article 86/1 of the TCK, which states, “A person who intentionally causes pain to another person’s body or impairs their health or perception ability shall be sentenced to imprisonment for a term of one to three years”, is regulated to include the psychological effects of trauma on the victim. In other words, the mental harm caused to an individual as a result of an event is also considered within the scope of TCK. In this context, Article 86/2 of TCK, which states, “If the effect of the intentional injury act on the person is of a nature that can be remedied with simple medical intervention, and upon the complaint of the victim, a sentence of imprisonment for a term of four months to one year or judicial fine shall be imposed”, emphasizes that when assessing whether there is damage that can be remedied with simple medical intervention, in addition to physical harm, the psychological harm that has occurred in the individual should also be taken into account, and the report’s conclusion should be prepared accordingly.

In a study conducted in Turkey, it was found that out of 164 cases in which a psychiatric disorder was detected, 147 cases (89.6%) had physical effects of trauma categorized as “Not of a Nature That Can Be Remedied with Simple Medical Intervention”. However, considering the psychological effects of trauma, it was determined that their injuries were not “Not of a Nature That can be Remedied with Simple Medical Intervention” (15).

In our study, the rate of requesting consultations was found to be quite low compared to the general literature (30,31). It is believed that the fact that the physical injuries of the cases were categorized as simple injuries may have contributed to this result. Additionally, the low rate of conducting mental examinations, the absence of a psychiatry department among the requested consultations, and the low rate of consultation requests may also be reasons for this low rate.

In addition to the shortcomings and errors identified in all general forensic examination reports, our study revealed several specific issues. These include cases being victims of recurrent partner violence without providing information in the history, medical records, or about the perpetrator, the widespread use of weapons without inquiring about them, and the lack of psychiatric assessments for women exposed to recurrent violence. These findings underscore the importance of examining the adverse consequences resulting from these errors, especially in cases of women who have experienced violence.

CONCLUSION

In cases of partner violence against women, in which physical injuries are often categorized as simple injuries, the significant prevalence of verbal/economic/emotional violence, which does not cause physical injuries, emphasizes the importance of psychological symptoms. A detailed psychiatric assessment can provide a clearer understanding of the severity of the injury, and establishing the causality between trauma and psychological symptoms in the conclusion section of forensic reports can guide the judiciary in cases in which there is no other evidence of trauma. In a particular group, women exposed to recurrent partner violence in which the rate of psychopathology is high, comprehensive forensic psychiatric evaluation is medically, legally, and socially necessary for the well-being of these individuals. Addressing the deficiencies and improving the role of psychological assessments in medical-legal documentation in the fight against gender-based violence, which remains a significant societal issue, should be a subject of further research and effort.

ETHICS

Ethics Committee Approval: The study was initiated with the approval of the Samsun Ondokuz Mayıs University Faculty of Medicine Clinical Research Ethics Committee numbered 2021/290.

Peer-review: Internally peer-reviewed.

Authorship Contributions

Concept: M.G., A.T., Design: M.G., A.T., Data Collection or Processing: M.G., Analysis or Interpretation: M.G., A.T., Literature Search: M.G., A.T., Writing: M.G., A.T.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.

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The Role of Psychiatric Examination in the Forensic Medical Documentation of Repetitive Partner Violence Against Women