Gynecological health and uptake of gynecological care after domestic or sexual violence: a qualitative study in an emergency shelter.

BACKGROUND: Domestic and sexual violence have been linked to adverse gynecological and obstetric outcomes. Survivors often find it difficult to verbalize such violence due to feelings of shame and guilt. Vulnerable or socially excluded women are frequently excluded from research, particularly qualitative studies on violence. This study aimed to characterize the perceived impact of domestic or sexual violence on the gynecological health and follow-up among women with complex social situations. METHODS: We analyzed the data following inductive thematic analysis methods. RESULTS: Between April 2022 and January 2023, we conducted 25 semi-structured interviews, lasting on average 90 min (range: 45-180), with women aged between 19 and 52, recruited in an emergency shelter in the Paris area. The women described physical and psychological violence mainly in the domestic sphere, their altered gynecological and mental health and their perception of gynecological care. The levels of uptake of gynecological care were related to the characteristics of the violence and their consequences. The description of gynecological examination was close to the description of coerced marital sexuality which was not considered to be sexual violence. Gynecological examination, likely to trigger embarrassment and discomfort, was always perceived to be necessary and justified, and consent was implied. CONCLUSION: This study can help question the appropriateness of professional practices related to the prevention of violence against women and gynecological examination practices. Any gynecological examination should be carried out within the framework of an equal relationship between caregiver and patient, for the general population and for women with a history of violence. It participates in preventing violence in the context of care, and more widely, in preventing violence against women.

Low uptake of gynecological consultation following domestic or sexual violence: A case-control study during pregnancy follow-up.

OBJECTIVE: The aim of this study was to examine the association between exposure to domestic and sexual violence and low uptake of gynecological consultation. STUDY DESIGN: Between October 2021 and October 2022, a case-control studywas conducted in mother andchild centers and sexual health centers in the Paris, France area. The case group included pregnant women who did not have a scheduled gynecological consultation in the past two years. The control group included pregnant women who had a scheduled gynecological consultation in the past two years. Pregnant women were interviewed using a standardized questionnaire about a history of domestic and sexual violence, the date of their last gynecological consultation and the gynecological health. RESULTS: A total of 405 pregnant women were included in the case group (n = 129) or in the control group (n = 276). After adjustment for age, couple, social security, supplementary health insurance, dyspareunia, abnormal vaginal discharge, dysmenorrhea, regular pelvic pain, mastodynia, vulvodynia and history of difficult delivery, a history of intimate partner violence was associated with the absence of a gynecological consultation in the past two years (OR 2.13; CI95% 1.21-3.73, p = 0.008). A history of sexual violence, regardless of age, was associated with the absence a gynecological consultation in the past two years (OR 1.92; CI95% 1.05-3.49, p = 0.03). The absence of a gynecological consultation was associated with dyspareunia and domestic or sexual violence (p < 0.0001 and p < 0.0001, respectively). CONCLUSIONS: This study highlighted the association between domestic and sexual violence and the absence of gynecological consultations in the past two years. It underlines the importance of screening for domestic and sexual violence during gynecological consultations and its impacts on mental health, in particular psychotraumatic symptoms, and on gynecological health, in particular dyspareunia.

[Pelvic exam in gynecology and obstetrics: Guidelines for clinical practice]. / Examen pelvien en gynécologie et obstétrique : recommandations pour la pratique clinique.

OBJECTIVE: To provide guidelines for the pelvic clinical exam in gynecology and obstetrics. MATERIAL AND METHODS: A multidisciplinary experts consensus committee of 45 experts was formed, including representatives of patients' associations and users of the health system. The entire guidelines process was conducted independently of any funding. The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. METHODS: The committee studied 40 questions within 4 fields for symptomatic or asymptomatic women (emergency conditions, gynecological consultation, gynecological diseases, obstetrics, and pregnancy). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. RESULTS: The experts' synthesis work and the application of the GRADE method resulted in 27 recommendations. Among the formalized recommendations, 17 present a strong agreement, 7 a weak agreement and 3 an expert consensus agreement. Thirteen questions resulted in an absence of recommendation due to lack of evidence in the literature. CONCLUSIONS: The need to perform clinical examination in gynecological and obstetrics patients was specified in 27 pre-defined situations based on scientific evidence. More research is required to investigate the benefit in other cases.

Intimate partner violence against ever-partnered women in Europe: Prevalence and associated factors-Results from the violence against women EU-wide survey.

Study questions: To describe the prevalence of physical, sexual, and psychological intimate partner violence (IPV) against women in the European Union (EU) and to search for their determinants among demographic, socioeconomic, health-related factors, and partner characteristics. Methods: Observational study. Data from the violence against women survey, the first study conducted in the EU, which simultaneously measured all dimensions of IPV and many characteristics. The EU Agency for Fundamental Rights randomly conducted face-to-face interviews among the 28 countries with 42,002 women aged 18-74 who resided in the survey country and spoke the language. IPV is defined by a positive answer to at least one question about physical, sexual, or psychological violence perpetrated by a current or ex-partner. Findings: Among the 40,357 women having already been in a relationship, 51.7% (51.2-52.2) reported having been victims of violence in their lifetime. The prevalence of physical, sexual, and psychological IPV was, respectively, 20.0% (19.6-20.4), 8.4% (8.2-8.7), and 48.5% (48.1-49.0). Women, who were younger, employed, had highly qualified work, had at least one immigrant parent, lived in an urban setting, were unmarried, separated, divorced, widowed, childless, cohabited with a partner, and others over the age of 18, had worse self-perceived health, or a history of violence before the age of 15 were more likely to report IPV. It was the same when their partners had a lower level of education, no work, were home staying, earned less than they did, were involved in 10 years of relationship, were frequently drunk, or were violent otherwise. Major implication: The lifetime prevalence of reported IPV among women in Europe is high and likely underestimated. The results emphasize the importance of a comprehensive definition of IPV and partners' characteristics. They highlight socioeconomic differences and poorer health status for victims of IPV.

Screening for domestic violence during pregnancy follow-up: evaluation of an intervention in an antenatal service.

To assess the impact of a brief training for obstetricians and midwives about screening for domestic violence during pregnancy follow-up and to identify barriers to a routine enquiry. A monocentric quasi-experimental study was performed in an obstetrics department in Paris, France. We asked patients during their pregnancy follow-up to complete a survey describing their demographic characteristics. They were also asked if a health professional had screened them for domestic violence during the current pregnancy. Exclusion criteria were refusal and inability to complete the survey alone. Health professionals attended a brief training about domestic violence. The intervention provided general information about domestic violence to alert health professionals (prevalence, risk factors, consequences on women's health, pregnancy, and children) and guidelines on screening and how to deal with women disclosing domestic violence. They also had to complete a survey about their knowledge and practice concerning domestic violence. Two months later, patients consulting for their pregnancy follow-up completed the same survey. Health professionals were not aware of the study's aim throughout its course. The primary outcome was the rate of patients screened for domestic violence during pregnancy follow-up. The secondary outcome was the identification of barriers to a routine enquiry. Four hundred ninety-five patients completed the first survey (control group): 21 patients (4.8%) had been screened for domestic violence. Twenty-one health professionals attended the intervention. Eight (38.1%) stated that they never screened for domestic violence, and 3 (14.3%) stated that they always did. Three hundred ninety-five patients completed the second survey (experimental group): 17 patients (4.3% vs 4.8%, p = 0.53) stated that they had been screened for domestic violence. The main barriers to screening mentioned by health professionals were the presence of the partner, the lack of awareness of the need to screen, uncomfortable feelings, and the difficulty to identify victims. There was no increased screening for domestic violence during pregnancy follow-up after a brief training of obstetricians and midwives. An early training during medical studies or more extensive training for professionals could be more efficient.

A roadmap to the safe practice of forensic medicine in the COVID-19 pandemic.

The COVID-19 pandemic has forced forensic practitioners to consider how we perform our normal duties, especially when those duties involve humans. The potential for contracting the virus from working in close contact with living sufferers is high, and we have yet to fully determine the risk of infection from the deceased. In an attempt to support the community, the Journal of Forensic & Legal Medicine has drawn together three articles which underline the importance of continued forensic medical practice during the pandemic and highlight some factors to consider in a Roadmap towards safe practice. Our Roadmap has intentionally taken an international perspective and supports other work we have published in the Journal on our collective response to the COVID-19 crisis.

Adolescent arrestees detained in police cells: an observational study in the Paris, France, area.

OBJECTIVE: Custody conditions in police cells are often demeaning and considered inappropriate for human beings. The detention of young adolescents in police custody has received little attention. Our study aimed to describe the characteristics of adolescents under 18 detained in custody. METHODS: We studied all arrestees aged 13-17 examined in 1 year (January 01-December 31, 2014) in a suburban district near Paris. We evaluated the proportion of adolescents under 18 among all arrestees detained in custody and their medical history, addictive behaviors, perceived health status, and opinion on custody. RESULTS: Arrestees aged 13-17 accounted for 1859 individuals. They were predominantly males (94%) and accounted for 19% of all examinations in custody. Nearly half of the arrestees aged 13-15 (42%), and two thirds of those aged 16-17 (65%) had been previously detained in police cells. Somatic and psychiatric disorders were reported by 7% and 4%, respectively, of arrestees aged 13-17. Alcohol, tobacco, and cannabis consumption were reported by 5%, 24%, and 12%, respectively, of arrestees aged 13-15. These proportions were lower than the 16%, 50%, and 35%, respectively, reported by arrestees aged 16-17 (p < 0.0001). Assaults were reported by 18% of arrestees aged 13-17. They had a fair, bad, or very bad opinion on custody in 43% of cases. CONCLUSION: The detention of adolescents in police stations is commonly associated with assaults at the time of arrest. High proportions of adolescent arrestees smoke tobacco or cannabis. We suggest that the medical examination in custody could be an opportunity for adolescents to initiate access to health care.

Male sexual assaults in the Paris, France area: An observational study over 8 years.

BACKGROUND: Male sexual assaults were long ignored, possibly because of the myth acceptance that a man can only be the perpetrator of sexual assaults. It is increasingly admitted that all males can be victims of rape. We described the characteristics of a series of male adolescent and adult victims of sexual assault who had a forensic medical examination. METHODS: We conducted an observational study over 8 years. RESULTS: We included 98 male patients aged 15 years and older (range 15-66, median 25) at the time of a reported sexual assault. Assailants were known by the victim in 59 cases (60%). Forty-four patients (45%) had physical or mental vulnerability. Anal penetration was reported in 49 cases (50%). Genital examination showed abnormalities compatible with traumatic injuries in 23 cases (24%). Psychological symptoms were found in 81 victims (83%), including shame (39, 40%) and anxiety (38, 39%). Of 98 victims, sperm could be detected in 6 cases (6%) (anal, 4; oral, 1; skin, 1). Male victims were more frequently disabled or vulnerable than female victims examined in the same centre (45% vs. 13%, p<0.001). At the one-month follow-up consultation, psychological symptoms, including sleep disorders and fear, were observed in most patients and the proportions of physical and psychological complaints were similar among male and female victims. CONCLUSION: Male victims of sexual assault experienced high level of psychological trauma and felt more ashamed than women, which suggests that sexual assaults should be considered as severe among men as among women.

Multiple brief interventions in police custody: The MuBIC randomized controlled study for primary prevention in police custody. Protocol and preliminary results of a feasibility study in the Paris metropolitan area, France.

BACKGROUND: The 15- to 35-year-old population has little contact with the health care system and is exposed to risk factors. Several studies demonstrated the feasibility of brief interventions (BIs) in different settings, e.g., in addiction medicine during police custody, where arrestees are entitled to a medical examination. Approximately 700,000 individuals are detained in police custody in France annually, and custody is an opportunity for young people to be medically examined. The characteristics of the detainees and previous experience with BIs suggest that custody is an opportunity to contribute to primary prevention. We propose to investigate the feasibility of such a contribution. OBJECTIVES: The aim of this article is to present a study protocol and some preliminary results. The primary research objective is to assess the feasibility of performing brief interventions without a specific topic in police custody settings in arrestees aged 15-35 years. The secondary research objectives include i) testing four strategies for engaging in BIs that maximize the chances of success of the BI; ii) identifying the determinants that can orient the practitioner's choice to use a specific strategy over another one; and iii) analysing the differences between individuals who engage in BIs and those who do not and, in those who do engage, the determinants of success of the intervention. METHODS: A two-step randomized and prospective study: i) randomization of eligible patients into 4 groups of 500 patients each; analysis of the response rates for each strategy; performance of the BI; and analyses of the associated factors and ii) a real-life, full-scale phase study evaluating the effectiveness of BIs performance of the BI; and analyses of the interventions. Analyses of the determinants of a positive response to BI, of success and of the topic of intervention will be conducted. EXPECTED RESULTS: The rates of BI performed, rates of success, and characteristics associated with response and with success are the main expected results. Additionally, the development and assessment of filter questions and an improved BI dedicated to primary prevention for police custody settings will be attained.

Healthcare and forensic medical aspects of police detainees, suspects and complainants in Europe.

Death and harm is well-recognised in detainees in police custody worldwide. Based on the results of previous global surveys and the CPT (European Committee for the Prevention of Torture) recommendations a questionnaire was developed to summarise the current medical aspects of police custody in European countries. The survey was distributed to named contacts in all European countries. Data from 25 European countries was obtained. The results reveal significant differences in the regulations among the different countries, with nothing close to a harmonised European standard in place at present. This study has identified interesting variations in the methods and standards of healthcare and forensic medical services to detainees in police custody (e.g. quantitative mode of monitoring, qualification of the doctors, maximum time allowed for holding a detainee in police custody, body or an organisation that investigates complaints against the police). There are both very detailed legal regulations in some countries while in others there are only generally observed provisions that sometimes are only given in the form of recommendations. A multinational, multiprofessional expert group is required to identify best practices, recommend basic standards of care and identify qualifications which would be appropriate for healthcare professionals working in this field.

Doctors' attendance with arrestees in police custody: Physicians' representations.

Police custody is detention in response to a suspicion of crime. In France, it lasts less than 24 h, in most cases. According to French law, any individual placed in police custody may, at the individual's request, be examined by a doctor. The doctor decides whether the detainee's state of health is compatible with detention in a police station. Our objective was to assess the attending physicians' representations of police custody and medical intervention in this setting. In this study, physicians were asked to report on their own practice in custody and the way they perceived arrestees. We conducted face-to-face semi-structured interviews with 22 physicians who attended arrestees in police custody. For some doctors, the doctor-patient relationship is unconventional because arrestees may want to cheat them and because doctors feel that they have minimal duties that are limited to keeping arrestees alive. Most doctors consider the conditions of examination markedly unsatisfactory, similar to the material conditions of detention in police cells. Some physicians are reluctant to describe traumatic injuries so that they do not appear to support the arrestees over the police. Although all doctors determine whether a detainee is fit to be detained in police cells, the rationale for this decision differs from one physician to another. Physicians consider a medical prescription legitimate when it fits with their own representation of the needs of arrestees. Physicians delimit the framework of their relationship with arrestees and restrict the requests that they consider acceptable. They have limited knowledge of the conditions of detention and show little interest in this matter. Physicians manifest a simplistic, usually negative view of the individuals that they examine in custody. However, some are aware of the deleterious effects of custody conditions on arrestees.

The health of female arrestees in police cells: A descriptive study.

INTRODUCTION: Little information is available regarding the medical status and health care needs of female arrestees. Our objective was to evaluate the perceived health and somatic or psychiatric disorders reported by female arrestees in police cells. MATERIAL AND METHODS: We conducted an observational study in a regional reference department of forensic medicine in France. We studied female arrestees examined in police cells (01/01/2013-06/30/2013). Data were collected regarding individuals' medical characteristics, addictive behaviours, and perceived health status, as well as reported assaults or recent traumatic injuries. We recorded medical decisions regarding fitness for detention in police cells. RESULTS: A total of 438 women (median age, 29; range, 13-67) accounted for 5% of the 7408 examined arrestees. Females considered their overall health as good or very good in 314/395 cases (70%). Women reported chronic somatic or psychiatric disorders more frequently than men (89/379, 23% vs. 757/6,135, 12%, p < 0.001 and 59/379, 15% vs. 392/6319, 6%, p < 0.001, respectively). Daily tobacco consumption and cannabis use were reported by 255/403 (63%) and 98/438 female arrestees (22%), respectively. Physical assaults were reported in 113/415 cases (27%). Female arrestees were considered fit for detention in 92% of cases. Among 24 pregnant arrestees, 6 (25%) were unfit for detention, 2 (8%) were fit for custody during daytime only and 16 (67%) were fit for detention if certain conditions were met. CONCLUSIONS: Detention in police custody involves a minority of females. Females are older and report somatic or psychiatric disorders more frequently than males.

[Violence for educational purpose: Representations of general practitioners in the Paris area, France. A qualitative study]. / La violence éducative : représentations des médecins généralistes en Île-de-France. Étude qualitative.

BACKGROUND: Violence for educational purpose refers to a modality of education that includes threats, verbal abuse, physical abuse and humiliations. Twenty European countries, not including France, have abolished corporal punishment through explicit laws and regulations. The position of general practitioners in the screening and care of violence for educational purpose in France is unknown. In this study, we aimed to assess the representations of this form of violence among general practitioners. METHODS: We have performed semi-directed interviews of general practitioners in the Paris, France region (Île-de-France). Interviews were conducted until data saturation was achieved. Interviews were recorded, transcribed and analysed by two investigators. RESULTS: Interviews were conducted with 20 physicians (November 2015-January 2016). General practitioners considered that physical, verbal or psychological abuse had possible negative consequences on children. Uncertainty regarding the consequences of violence was a cause of tolerance towards violence for educational purpose, depending on the act committed and the context, as perceived by nearly all practitioners. General practitioners expressed interest in the field. They cited their own education and experience as the main obstacles to action. Most of them expressed a feeling of failure when they screened or took care of violence for educational purpose. CONCLUSION: This study suggests that doctors can participate in supporting the parents in the prevention of violence for educational purpose. Support to parents would need specific medical training as well as a societal change.

Children detained in French police cells.

AIM: Police custody is detention in response to a suspicion of crime. In France, until the age of 13, pre-trial detention and police custody are not allowed. We aimed to evaluate the practical implementation of police detention of children aged between 10 and 12 years and describe the medical characteristics and history, perceived health status and opinion on custody of the potentially affected children. METHODS: A descriptive study was conducted in a French reference regional department of forensic medicine at the time of medical examination in police cells among arrestees younger than 13 years old examined over a 5-year period (1 January 2011-31 December 2015). RESULTS: Children aged 10-12 years (n = 60; males, 48, 80%), accounting for 60 of 57 687 examined arrestees (0.1%), were examined over the study period. Six individuals (10%) were arrested twice or more times during the study period (for a total of 76 detentions analysed). The most common suspected crimes were theft or robbery (42/76, 55%) and physical assault (22/76, 29%). Arrestees had a favourable opinion of custody in 33 of 76 cases (43%). Children reported physical assault by the police in 6 of 76 cases (8%), and the physicians observed recent traumatic injuries in 7 of 76 cases (9%). Daily tobacco consumption was reported by 4 of 60 children (7%). No child was considered unfit for detention by the physician. CONCLUSIONS: Children aged 10-12 years suspected of serious crimes accounted for 0.1% of detained individuals in police cells. Although infrequent, such situations are a matter of concern.

[Forensic medical examination of adolescent and adult victims of sexual assault or intimate partner violence who do not complain to the police - An observational study in Seine-Saint-Denis, France]. / Accueil en médecine légale des adolescents et adultes victimes de violences sexuelles ou de violences dans le couple n'ayant pas déposé plainte ­ étude observationnelle en Seine-Saint-Denis.

OBJECTIVES: to identify characteristics of victims of sexual assault or domestic violence who consulted in a Department of Forensic Medicine without a formal complaint to the police. METHODS: observational study (03/01/2014-08/31/2015) of individuals (age>15years) consulting in a Department of Forensic Medicine near Paris, France, after a sexual assault or domestic violence. Among the individuals who were examined in the department of Forensic Medicine, we compared the individuals who had not complained to the police to those who had complained to the police. RESULTS: A hundred and nine individuals have consulted without a prior complaint to the police, including 73 persons after domestic violence (i.e. 4% of all persons examined with or without a complaint to the police) and 36 persons after a sexual assault (i.e. 8% of all persons examined). Regarding domestic violence, the proportion of persons presenting recent traumatic injuries was lower among those who did not complain to the police than among those who did (64% vs. 78%, P=0.008). Regarding sexual violence, the persons who did not complain to the police were more frequently uncertain about the assault (42% vs. 13%, P<0.001), reported more frequently a recent alcohol or drug intake (42% vs. 26%, P=0.039) and less frequently showed extragenital traumatic injuries than the persons who did complain to the police (22% vs. 43%, P=0.016). CONCLUSION: the persons examined who had not complained to the police accounted for less than one in 20. The extension of the activity of a Department of Forensic Medicine to persons who do not want to be involved in a judicial process is not sufficient for the majority of victims to consult a forensic physician.

Social vulnerabilities and health conditions of arrestees in the Greater Paris area, France, in 2013: a multicentre cross-sectional study.

OBJECTIVE: The aim of this study was to describe the health and social conditions of arrestees, as compared to the general population. METHODS: We studied a sample of 600 adult arrestees in three locations in the Greater Paris area, prospectively included (February-May 2013). A descriptive analysis has been performed, then prevalence was estimated using an indirect standardisation according to age, based on data from a population-based, representative survey in the same area. RESULTS: Arrestees had a median age of 31 years; 92% were males. As compared to the general population, arrestees had a lower level of education (8.6 vs. 7.6%, p < 0.001), were more frequently unemployed (42.0 vs. 11.9%, p < 0.001) and in a difficult financial situation (43 vs. 11%, p < 0.001) and had less significant social support (48.1 vs. 87.9%, p < 0.001). They reported also more frequently a chronic health condition (54 vs. 36%, p < 0.001) and a limited health insurance coverage (36 vs. 15%, p < 0.001). CONCLUSION: Comparative analysis of male arrestees and males from the general population showed that the former had worse social and health conditions. These results argue for widespread medical interventions on all arrestees. Medical examination during detention could act as a gateway to health care and social support.

Self-reported Mental Health Issues Among Arrestees in the Paris, France Area.

We studied (May-September 2014) all arrestees who reported mental health issues during the medical examination performed by a forensic physician for the assessment of fitness for detention. Among 4814 arrestees, 420 (9%) reported a current mental health issue. The suspected crimes among arrestees reporting a current mental health issue were more often related to violent behaviors (physical assault, 23% vs. 16%, p < 0.001, sexual assault, 3% vs. 1%, p = 0.01) and less often drug offenses (18% vs. 29%, p < 0.001). Among arrestees reporting mental health issues, 80% reported psychiatric or psychological care, of whom 33% reported previous mental health care. Decisions of unfitness for detention were more frequent among arrestees reporting mental health issues than in other detainees (3% vs. 1%, p < 0.001). The high proportion of patients with interrupted mental health care among those reporting mental disorders suggests that the medical examination during custody could be a significant opportunity to restore psychiatric care.

Unfitness for Detention Among Arrestees with Suspected Mental Disorders in Paris, France.

In this retrospective study (11/2013-04/2014), we aimed to identify the factors associated with psychiatric hospitalization among detainees in police custody. We included 137 patients (M/F, 74%/26%; median age, 37 years), and 125 (91%) had a mental disorder. Seventy-seven patients (56%) had involuntary hospitalization. Sixty patients (44%) were declared fit for detention, and 48 (80%) of these patients had a mental disorder. All patients who required urgent psychiatric care and could not provide valid consent for care were declared as requiring involuntary hospitalization. Forty-nine of the 62 patients (79%) who required urgent psychiatric care and were suspected to have committed serious crimes were involuntarily admitted. In conclusion, we commonly found that some individuals with mental disorders were considered fit for detention in police cells.