Statement of the Independent Forensic Expert Group on Conversion Therapy.

Conversion therapy is a set of practices that aim to change or alter an individual's sexual orientation or gender identity. It is premised on a belief that an individual's sexual orientation or gender identity can be changed and that doing so is a desirable outcome for the individual, family, or community. Other terms used to describe this practice include sexual orientation change effort (SOCE), reparative therapy, reintegrative therapy, reorientation therapy, ex-gay therapy, and gay cure. Conversion therapy is practiced in every region of the world. We have identified sources confirming or indicating that conversion therapy is performed in over 60 countries. In those countries where it is performed, a wide and variable range of practices are believed to create change in an individual's sexual orientation or gender identity. Some examples of these include: talk therapy or psychotherapy (e.g., exploring life events to identify the cause); group therapy; medication (including anti-psychotics, anti- depressants, anti-anxiety, and psychoactive drugs, and hormone injections); Eye Movement Desensitization and Reprocessing (where an individual focuses on a traumatic memory while simultaneously experiencing bilateral stimulation); electroshock or electroconvulsive therapy (ECT) (where electrodes are attached to the head and electric current is passed between them to induce seizure); aversive treatments (including electric shock to the hands and/or genitals or nausea-inducing medication administered with presentation of homoerotic stimuli); exorcism or ritual cleansing (e.g., beating the individual with a broomstick while reading holy verses or burning the individual's head, back, and palms); force-feeding or food deprivation; forced nudity; behavioural conditioning (e.g., being forced to dress or walk in a particular way); isolation (sometimes for long periods of time, which may include solitary confinement or being kept from interacting with the outside world); verbal abuse; humiliation; hypnosis; hospital confinement; beatings; and "corrective" rape. Conversion therapy appears to be performed widely by health professionals, including medical doctors, psychiatrists, psychologists, sexologists, and therapists. It is also conducted by spiritual leaders, religious practitioners, traditional healers, and community or family members. Conversion therapy is undertaken both in contexts under state control, e.g., hospitals, schools, and juvenile detention facilities, as well as in private settings like homes, religious institutions, or youth camps and retreats. In some countries, conversion therapy is imposed by the order or instructions of public officials, judges, or the police. The practice is undertaken with both adults and minors who may be lesbian, gay, bisexual, trans, or gender diverse. Parents are also known to send their children back to their country of origin to receive it. The practice supports the belief that non-heterosexual orientations are deviations from the norm, reflecting a disease, disorder, or sin. The practitioner conveys the message that heterosexuality is the normal and healthy sexual orientation and gender identity. The purpose of this medico-legal statement is to provide legal experts, adjudicators, health care professionals, and policy makers, among others, with an understanding of: 1) the lack of medical and scientific validity of conversion therapy; 2) the likely physical and psychological consequences of undergoing conversion therapy; and 3) whether, based on these effects, conversion therapy constitutes cruel, inhuman, or degrading treatment or torture when individuals are subjected to it forcibly2 or without their consent. This medico-legal statement also addresses the responsibility of states in regulating this practice, the ethical implications of offering or performing it, and the role that health professionals and medical and mental health organisations should play with regards to this practice. Definitions of conversion therapy vary. Some include any attempt to change, suppress, or divert an individual's sexual orientation, gender identity, or gender expression. This medico-legal statement only addresses those practices that practitioners believe can effect a genuine change in an individual's sexual orientation or gender identity. Acts of physical and psychological violence or discrimination that aim solely to inflict pain and suffering or punish individuals due to their sexual orientation or gender identity, are not addressed, but are wholly condemned. This medico-legal statement follows along the lines of our previous publications on Anal Examinations in Cases of Alleged Homosexuality1 and on Forced Virginity Testing.2 In those statements, we opposed attempts to minimise the severity of physical and psychological pain and suffering caused by these examinations by qualifying them as medical in nature. There is no medical justification for inflicting on individuals torture or other cruel, inhuman, or degrading treatment or punishment. In addition, these statements reaffirmed that health professionals should take no role in attempting to control sexuality and knowingly or unknowingly supporting state-sponsored policing and punishing of individuals based on their sexual orientation or gender identity.

A Fatal Outcome of Pica Syndrome: An Unusual Case of Delayed Mortality.

We present the case of a 42-year-old man, with a medical history of schizophrenic psychosis, who was found dead on the floor of his bedroom. At the autopsy, a bottle lid with a notched edge was found in the lower pharynx, partially obstructing the larynx and thus keeping the epiglottis in an open position. Airway obstruction was caused by edema and inflammation of the surrounding tissue. After removal of the foreign body, the tissue of the larynx was left with an impression of the bottle lid. The adjacent mucosa was swollen, hyperemic, partly necrotic, and covered with fibrin deposits. Also, foreign bodies were found in the stomach. The histological analysis of the hypopharynx showed severe nonspecific inflammation and necrosis of epithelium. The cause of death was a complication of subacute laryngeal obstruction caused by a foreign body.

A posttraumatic pseudoaneurysm of the left radial artery as a result of a stab wound in an 8-year-old girl.

Pseudoaneurysms arise from a disruption of arterial wall continuity and are most commonly related to a penetrating trauma, an arterial wall inflammation or iatrogenic causes. They differ from real aneurysms due to a lack of one or more layers of the arterial wall. The frequency of peripheral artery pseudoaneurysms in the upper extremities is less than in the lower extremities and its most common cause is a gunshot or a stab wound. The risk of a rupture is higher than in true aneurysms due to a lack of wall layers, therefore requiring surgical treatment in most cases. Here we describe an unusual case of an 8-year-old girl who presented to the emergency department complaining of swelling and pain in her left distal forearm. One month before admission she experienced a penetrating trauma in the same area due to a self inflicted stab wound. After clinical and duplex ultrasonography evaluation the tumefaction proved to be a posttraumatic pseudoaneurysm of the left radial artery.

Unusual venous bullet embolism - Case report.

Bullet embolism is rare complication of penetrating gunshot trauma. We are presenting a case of a single gunshot with entrance wound located on external side of a left thigh. The upward directed trajectory extends to the left lateral side of the neck, but the bullet has been recovered from right external iliac vein. The bullet migration was explained due to one rare variation of the mouth of vena cava superior and inferior.

Accurate Completion of Medical Report on Diagnosing Death.

Diagnosing death and issuing a Death Diagnosing Form (DDF) represents an activity that carries a great deal of public responsibility for medical professionals of the Emergency Medical Services (EMS) and is perpetually exposed to the control of the general public. Diagnosing death is necessary so as to confirm true, to exclude apparent death and consequentially to avoid burying a person alive, i.e. apparently dead. These expert-methodological guidelines based on the most up-to-date and medically based evidence have the goal of helping the physicians of the EMS in accurately filling out a medical report on diagnosing death. If the outcome of applied cardiopulmonary resuscitation measures is negative or when the person is found dead, the physician is under obligation to diagnose death and correctly fill out the DDF. It is also recommended to perform electrocardiography (EKG) and record asystole in at least two leads. In the process of diagnostics and treatment, it is a moral obligation of each Belgrade EMS physician to apply all available achievements and knowledge of modern medicine acquired from extensive international studies, which have been indeed the major theoretical basis for the creation of these expert-methodological guidelines. Those acting differently do so in accordance with their conscience and risk professional, and even criminal sanctions.

[Death caused by heat stroke: case report].

INTRODUCTION: Heat stroke is the most dangerous among numerous disorders caused by elevated environmental temperature. It is characterized by an increased body temperature of over 40 degrees C, the dysfunction of the central nervous system and the development of multiple organ failure. The aim of this paper was to highlight problems in the clinical and post-mortal diagnosis of fatal heat stroke. CASE OUTLINE: A 20-year-old male was found unconscious on the street; on admission at the Emergency Center, Clinical Center of Serbia, Belgrade, he was in a coma. The body temperature of 40 degrees C was maintained despite the applied therapy, meningeal signs were negative, tachycardia with gallop rhythm, hypotension, bleeding from the nose and mouth, and presence of skin bruises. LABORATORY FINDINGS: highly elevated LDH and creatine kinase, elevated serum creatinine, AST, and signs of DIC. Lethal outcome occurred 6 hours after admission, and the case remained clinically unsolved. Autopsy showed signs of hemorrhagic diathesis, brain and pulmonary edema, and microscopic examination revealed general congestion, internal bleeding in various organs, cerebral edema, massive blood aspiration and pulmonary edema. Toxicological and bacteriological examinations were negative. Based on these findings and subsequently obtained data on the conditions at the workplace where the young man had a part-time job, it was concluded that the violent death was caused by heat stroke. CONCLUSION: Since heat stroke is associated with a high mortality rate and high incidence of serious and permanent organ damage in survivors, it is important to make the diagnosis of heat stroke as quickly as possible and apply appropriate treatment. Misdiagnosis of heat stroke, and consequently inadequate treatment, with a potential fatal outcome for the patient, can be the reason for blaming doctors for the legal offense of medical malpractice in failing to administer first aid.

Traumatic testicular displacement in motorcycle drivers.

Testicular displacement is a rare clinical presentation of blunt scrotal injury that may take place in road traffic accidents involving motorcycle occupants. We are presenting two cases of motorcycle occupant fatalities, 21 and 24 years of age, where testicular displacement and other signs of groin trauma have been determined. In both cases, discrete external signs of scrotal trauma were noted on examination, while unilateral and bilateral traumatic testicular displacement, respectively, have been documented at autopsy. For motorcycle occupants involved in collision, it is necessary to perform a thorough analysis of injuries, in particular to look for specific trauma arising from fuel-tank impact to genitalia and/or groin. These injuries are of great medico-legal importance both at postmortem and in clinical cases involving motorcycle occupants involved in collision.

Ethical and legal consideration of prisoner's hunger strike in Serbia.

Hunger strike of prisoners and detainees remains a major human rights and ethical issue for medical professionals. We are reporting on a case of a 48-year-old male sentenced prisoner, intravenous heroin user, who went on a hunger strike and died 15 days later. Throughout the fasting period, the prisoner, who was capable of decision making, refused any medical examination. Autopsy findings were not supporting prolonged starvation, while toxicology revealed benzodiazepines and opiates in blood and urine. Cause of death was given as "heroin intoxication" in keeping with detection of 6-MAM. Legal and ethical issues pertinent to medical examination and treatment of prisoners on hunger strike are explored in accordance with legislation and professional ethical standards in Serbia. A recommendation for the best autopsy practice in deaths following hunger strike has been made.

Amniotic fluid embolism-apropos two consecutive cases.

Amniotic fluid embolism (AFE) is a sporadic, unpredictable, and usual fatal obstetric complication. The paper deals with two cases of maternal deaths because of AFE verified by medicolegal autopsy. In both the cases, several known risk factors associated with AFE, such as increased maternal age (41 and 35 years), diabetes, augmented labor, and cesarean delivery, were identified. Clinical features were typical, including sudden onset of cardiovascular and respiratory symptoms. In the patient who survived longer, both clinical and autopsy signs of disseminated intravascular coagulopathy were present, while they were absent in the case where death occurred rapidly. This paper describes briefly the particular features to look for at autopsy and stresses the importance of histology examination and staining techniques.

Divergent patrilineal signals in three Roma populations.

Previous studies have revealed that the European Roma share close genetic, linguistic and cultural similarities with Indian populations despite their disparate geographical locations and divergent demographic histories. In this study, we report for the first time Y-chromosome distributions in three Roma collections residing in Belgrade, Vojvodina and Kosovo. Eighty-eight Y-chromosomes were typed for 14 SNPs and 17 STRs. The data were subsequently utilized for phylogenetic comparisons to pertinent reference collections available from the literature. Our results illustrate that the most notable difference among the three Roma populations is in their opposing distributions of haplogroups H and E. Although the Kosovo and Belgrade samples exhibit elevated levels of the Indian-specific haplogroup H-M69, the Vojvodina collection is characterized almost exclusively by haplogroup E-M35 derivatives, most likely the result of subsequent admixture events with surrounding European populations. Overall, the available data from Romani groups points to different levels of gene flow from local populations.

Child homicide on the territory of Belgrade.

OBJECTIVE: This study examines the incidence and other epidemiological and medico-legal characteristics of child homicide in the territory of Belgrade, Republic of Serbia. METHODS: We performed a retrospective analysis of all autopsies carried out at the Institute of Forensic Medicine in Belgrade during a 15 year period between 1991 and 2005, focusing on homicide cases of victims aged 0-14 years. These were then analyzed in terms of number of deaths, mortality rates, age, and sex of the victim, relation to the perpetrator, and cause of death and injury. RESULTS: Forty-six homicides were identified where the victims were aged 0-14 years. These included 24 girls and 22 boys. In 32 cases (69.6%) the perpetrator was one of the child's birth parents, more frequently the mother. Blunt head trauma was the most frequent cause of death, followed by exsanguination. In 9 cases (19.5%) there was evidence of physical abuse; 16 children died in the setting of multiple homicide and/or murder/suicide. In 4 cases (8.7%) there was evidence of neglect which contributed to the fatal outcome. There were 10 cases of neonaticide within the 46 homicides. There were, however, 49 further cases where bodies of newborn infants were discovered after having been disposed of in suspicious circumstances. CONCLUSIONS: Proportionally, the largest number of victims fell within the 1-4 years age group, with a slight preponderance of females, most of them killed at home by a close family member, usually the mother. Blunt head trauma was the single most frequent cause of death. Injury patterns consistent with child abuse were identified among 20% of the study group.

[Vasculature of the distal part of optic nerve].

BACKGROUND/AIM: Vascularisation of the distal, namely intracranial and intracanalicular parts of the optic nerve have not been explained in conventional textbooks of anatomy, while there have been explanations of proximal, that is intraorbital segment. The aim of this research was to study the pattern of arterial supply of the intracranial and intracanalicular part (the distal part) of human optic nerve. METHODS: The optic nerve and the ophthalmic artery (OA), predominately in their intracranial and intracanalicular parts, were investigated in 25 human specimens by three different methods: macroscopic, stereomicroscopic, and histological observations. Mixture with 10% of India ink and gelatin was injected through the intracranial part of the internal carotid artery, and the most proximal part of the OA. Each optic canal specimen was fixed in formaldehyde and finally paraffin embedded, sectioned, and stained with Masson trichrome, Azan, Toluidin blue, and Van Gieson methods. RESULTS: OA passed through the optic canal within the dural sheath of the optic nerve. In 44% of our specimens the OA was on the inferomedial side of the optic nerve at the entrance point to the optic canal. OA left the optic canal at its lateral border in the apex of the orbit in 72% of our specimens. The intracanalicular portion of the optic nerve receives arterial blood principally from the intracanalicular part of OA. OA gives one (72% of the specimens) to two branches that supply the intracanalicular part of the optic nerve. Each branch pierces the dura mater from below and then supplies the nerve through the pia mater. These arteries then terminate in a pial vascular network of continuous transverse centripetal arterioles and capillaries that surround each optic nerve. The rich anastomoses with branches of superior hypophyseal artery, from the cranial cavity, which take part in the optic nerve vascularization in its hole length, was observed. There were no intraaxial vessels in the intracranial and intracanalicular parts of the nerve in our specimens. CONCLUSION: These anatomical data offer important informations for understanding the variety of the pathology in the region of optic canal and orbito-cranial junction, and is also useful for designing operative strategies. This report indicates the delicacy and vulnerability of the intracranial and intracanalicular capillary network to traumatic disruption.

In the absence of dental records, do we need forensic odontologists at mass grave sites?

With the exception of exhumations of mass graves in Latin America, forensic dentists and odontologists are rarely involved in the examination of mortal remains recovered from mass graves. The cited reason is often that "there are no dental records-so what is the point"? In this presentation we review the published accounts of examination of remains arising from the conflict in the former Yugoslavia between 1991 and 1999 in which dental examinations are reported. There are roughly 30,000 missing persons of which more than 15,000 mortal remains have been identified, mostly based on DNA. There are 9 sources which describe postmortem dental examinations of 3919 sets of remains; of these, 23% were purported to have been identified specifically from dental information. Of the 8100 listed missing persons from the Srebrenica mass killings in 1995, we located 600 dental records. A sample of 263 charts was examined for information about first molar treatment as we are concerned that dental charting of individuals who lose their first molars may be incorrectly done if allowance is not made for mesial drift of the remaining molars. We found that of all the first molar extractions that are ever going to occur according to these dental charts, 63% have taken place by age 18. The majority of extracted first molars have a functional age of 17 years. We observe that an adult's remains from Srebrenica usually have only second and third molars, which have often drifted forward to occupy the position of the first molar creating the appearance of third molar agenesis. We conclude: that, since dental identifications of victims in mass graves and mass disasters is the exception rather than the rule, even in the absence of DNA-based identifications, international forensic odontologists have an ethical obligation to become more involved in examination of mass grave victims, that there must be more determined searches for antemortem dental records; that local dentists should be approached to participate in the examination of remains and lastly that dental examination and charting by anthropologists and pathologists may be grossly inaccurate. Furthermore, even in the absence of dental records, there is significant information about the individual to be obtained by an oral biologist since many families have useful memories about the oral status of their loved ones who went missing.

Medicolegal aspects of post-traumatic gastroduodenal ulcers: a retrospective study.

Retrospective examination of 5-year autopsy material showed the presence of posttraumatic gastroduodenal ulcers (PGDU) in 17.7% of decedents deemed to be at risk. They were more common in males (77%) and in patients aged over 50. In the majority of cases (76%) the survival period was < 12 days; in 16.5% it was < 48 h. PGDU developed most commonly in victims of polytrauma and isolated craniocerebral injury, with ISS values > or = 16; patients with spinal cord injuries were at greatest risk. Most frequently affected was the stomach, exhibiting numerous, usually superficial lesions, while solitary acute and exacerbated chronic peptic ulcers were more common in the duodenum. Complications of PGDU developed in 40% of cases, mostly in the form of hemorrhage; in 20% of cases PGDU have contributed to death. Medicolegal aspects of PGDU are, most frequently, concerned with the causal relationship between trauma, PGDU, and fatal outcome, as well as the potential for allegations of medical negligence.

[Did we forget tetanus?]. / Da li smo zaboravili tetanus?

INTRODUCTION: Currently, in our country (Republic of Serbia) tetanus is a rarely occurring disease, mainly affecting people older than 65 years of age. A small number of reported cases is mainly due to appropriate immunization. Therefore, each case of tetanus may be considered as failure of health care system to provide adequate immunization. CASE OUTLINE: A 71-year-old woman was injured in her garden. She sustained laceration in the left coccygeal region. The next day the wound was treated by a surgeon, but tetanus postexposure prophylaxis was not administrated. On the fifth day following the incident, the symptoms and signs of tetanus became apparent, and the patient died two days later. Postmortem examination revealed the wound that was not adequately treated, since there was a foreign body and a dressing inserted in the wound. Signs of acute (aerobic) infection were also present. CONCLUSION: Tetanus is a severe, potentially lethal disease that is absolutely preventable. Mistakes in immunization and surgical treatment of the wound can be considered as medical malpractice.

Death caused by a signal rocket--not an isolated case*.

Fatalities related to sporting events are predominantly caused by blunt force injuries especially due to the emotional involvement of crowd, but occasionally other types of trauma are reported as well. A case of very rare trauma caused by shooting with a hand-held parachute signal rocket during a football match is presented. A 17-year-old football fan sustained fatal injuries, a combination of mechanical trauma caused by rocket penetration, as well as extensive thermal burning of the thoracic viscera. Analysis of the event was based on autopsy findings and evidence produced by medicolegal and ballistic experts. Improper use of a hand-held signal rocket, designed for marine distress signals, may cause serious injuries either mechanically, due to explosion, or as a result of thermal discharge. In the reported case, pattern of injuries is discussed, and medical finding corroborated to other available evidence. The presented case is a reminder that the forensic pathologist should be informed accordingly on the type and features of weapon suspected to produce injury, to be able to understand traumatic changes, and look for potential presence of foreign bodies at postmortem examination.

[Drug facilitated sexual assault].

In line with the fact that there is little information regarding drug facilitated sexual assault in national medical literature, the authors aimed to prepare a review of the phenomenon based on available international references. Therefore we offered a definition of the concept of sexual assault, and rape in particular. Consent and ability for valid consent for sexual intercourse were defined as well. A review contains discussion about the basic elements of a concept of drug-facilitated sexual assault. There is also available information in regard to pharmacology of common data rape drugs, i.e. flunitrazepam, gamma-hydroxybutyrate (GHB), and ketamine. We indicate the utmost importance of prompt collecting of biological samples for toxicological screening in patients who are suspected victims of drug facilitated sexual assault.

Severity of injuries among sexual assault victims.

It is generally accepted that victims of sexual assault sustain bodily injury. This study's objective was to determine specific characteristics and severity of injuries among victims of sexual violence in Belgrade. Retrospectively, we analyzed a subgroup of victims of sexual violence that was legally processed over a five-year period. We evaluated 113 cases of sexual crimes selected from the District Court of Belgrade in order to analyze the medical records. All victims were female, at average 24.1 years old (range 5-80 years). In more than half of the cases (52%) evaluated, a medical examination was completed on the day of assault, while 84% took place within 72 hours post-assault. Due to delayed referral, body examination was not conducted on 12 victims (10.6%). We noted one or more extra-genital injuries in 64 victims (63.4%), no injuries in 36 victims (35.6%), whereas for one victim the medical records were inconclusive. Injuries, predominantly bruises, were located on limbs (32%), face (23%), and torso (7%). Abrasions and contusions were less frequently present, while two victims sustained lacerations. The Clinical Injury Extent Score was used to rate the physical severity of the assault. The majority of victims (44%) sustained light injuries, 18% were moderate, while one victim had severe injuries.

[Physical examination of sexual assault victims in Belgrade area].

INTRODUCTION: Sexual crimes represent various forms of contact of perpetrator's genitals, lips, tongue, and fingers with genitals, lips and/or anus of the victim, in order to achieve sexual satisfaction, without victim's consent. OBJECTIVE: The aim of this work was to analyze the type of medical institution in which victims of sexual assaults are being examined in Belgrade area, to assess the quality of these examinations and medical records, as well as to control whether standardized protocols are followed. METHOD: Data were obtained through analysis of 113 cases of sexual assaults prosecuted in the District Court of Belgrade. RESULTS: All victims were females with mean age of 24.1 years. The majority of victims (85%) were examined in one medical institution, most often in the Institute of Gynecology and Obstetrics, Clinical Center of Serbia, and only by one medical doctor (81.4%). Gynecologists were most frequently included in examination, while specialists of forensic medicine were engaged in only 9 cases (7.9%). In 84% of victims, the examination was performed during the first three days after the assault, and in 52% of cases on the first day. Standard techniques of clinical and gynecological examinations were applied only, without following any protocols, so the reports were made exclusively on individual basis. In no case an informed consent by victim was obtained before examination. Anamnestic data were collected in only 15.9% of cases, and they were generally incomplete. CONCLUSION: The results of investigation show that the quality of examination of sexual assault victims in Belgrade area is not adequate. Therefore, such negative practice should be changed in future through introduction of standardized protocols for examination of victims, as well as development of clinical forensic medicine.