[Forensic expertise in emergency medicine - clinical examination step by step]. / Rechtsmedizinische Expertise in der Notfallmedizin ­ Klinische Untersuchung Schritt für Schritt.

Victims of violence are not uncommon in emergency medicine. In addition to the medical necessities, the treatment of these patients also requires consideration of their psychological state, as well as the documentation of the findings in a court-approved manner and the securing of evidence, and information about psychosocial care services.

Frequency of Injuries to Women after Sexual Offense - Relevance of a Gynecology Examination.

Introduction Up to a third of women worldwide report having experienced an act of sexual violence during their lifetime. The emergency gynecology department is often the first port of call for affected individuals. The aim of the current study was to evaluate the importance of gynecology examinations for women after a sexual offense and to evaluate the pattern of injuries sustained. Methods This study is a retrospective single center analysis of the gynecology and forensic examination reports of all women examined for a suspected sexual offense in the central emergency department of a university hospital between 2013 and 2017 (n = 692). We evaluated genital and extragenital injury patterns, age, offender profile, time of offense, and substance use, as well as the administration of post-coital contraception and post-exposure prophylaxis for HIV. Results The affected individuals had a mean age of 26 (12 - 91 years). Almost 75% of affected individuals presented within 24 hours of the reported sexual offense. Extragenital injuries were detected in 78.6% of patients and genital injuries in 28.5%. Overall, 20.1% of the women reported complete memory loss and 18.7% partial memory loss of the actual event. Risk factors for memory lapse were the consumption of alcohol and/or the (possibly non-consensual) administration of other substances acting on the central nervous system. A history of alcohol consumption by the victim (hazard ratio [HR] 1.95; 95% confidence interval [CI] 1.21 - 3.12, p = 0.006) and younger victims aged between 25 - 49 years (HR 1.75; 95% CI 1.07 - 2.85, p = 0.025) were associated with the occurrence of extragenital injuries. However, if the perpetrator was someone who was known to the affected individual, fewer extragenital injuries were sustained (HR 0.60; 95% CI 0.36 - 0.99, p = 0.046). Reports of genital injuries, associated with an older age of affected individuals and indications of anal penetration, resulted in more frequent administration of post-exposure prophylaxis (29.1% vs. 19.5%, p < 0.012) and hepatitis B (active) vaccination (40% vs. 28.5%, p < 0.028). Conclusion Emergency gynecology examinations form a fundamental component of the medical care and the assessment of affected women after a sexual offense, since almost a third of victims sustain injuries to the genital region. In addition to a detailed complete physical examination and expert forensic documentation of physical and genital injuries, victims should also be offered psychological support which is easy for them to access.

Males as victims of intimate partner violence - results from a clinical-forensic medical examination centre.

Only few studies have reported on males as victims of intimate partner violence (IPV) so far. The aim of the present study is to analyse frequency and case characteristics of physical violence against male IPV victims examined in a clinical-forensic medical examination centre for victims of violence in Germany over an 11-year period, contributing to a better understanding of IPV in men. Male victims represented 6.2% of IPV cases (n = 167) with a median age of 40 years. Cases were reported to the police in 78.4% before medicolegal examination. In 60.5% of the cases, the perpetrator was the current partner, and 82% occurred in a domestic environment with a predominance of female offenders. In more than half of the cases (57.5%), the victims consulted the examination centre without prior healthcare utilisation. About one-third of the victims reported previous IPV (31.7%). The findings point to the relevance of men as victims of IPV, case group-specific risk factors, injury-dependent behaviour related to healthcare utilisation, the need to establish or strengthen specialised support services for affected men and underscore the importance of clinical-forensic services in documenting and assessing violence-related injuries.

[Child Abuse - Interdisciplinary Collaboration and Child Protection]. / Kindesmisshandlung: interdisziplinärer Kinderschutz.

In Germany, the increasing focus on child abuse led to remarkable changes in recent years. The latest child protection laws (Kinderschutzgesetz, 2012) and the new medical guideline (AWMF S3+ Kinderschutzleitlinie, 2019) provide effective means for child protection services. Sound knowledge of the clinical manifestations, the parties involved, and the legal situation are required in order to provide effective child protection interventions. This article presents an update of the epidemiology, the legal situation, and the clinical manifestations concerning child abuse. With this information it foremost adresses medical professionals seeing children regularly without having a child protection team at disposal.

Interpersonal violence in road rage. Cases from the Medico-Legal Center for Victims of Violence in Hamburg.

Aggressive behavior in traffic is a widespread phenomenon. Up to 90% of the population are involved in mild forms such as shouting or gesturing. More dramatic cases with injury to individuals affect at least 1100 people in the US annually. Certain factors such as a male sex, a young age and an urban residency have been identified to contribute to the likelihood of road rage. Central to this analysis is the determination of specific features regarding the conflicting parties, the crime scene and the injury pattern in violent offenses related to traffic. In a retrospective study spanning 10 years, cases of road rage-linked injuries were identified amongst patients at the Medico-Legal Center of the Institute of Legal Medicine in Hamburg, Germany. The data were digitized and then analyzed using descriptive statistics via SPSS. There are disproportionately large numbers of males (85.7%) and motorists (61.2%) amongst road rage perpetrators. Usually the conflicting parties have no prior relationship (89.7%). In 68.1% of the cases, the violence applied was exclusively physical. Objects were utilized in 31.0% of all cases, and in more than half (55.6%) of these cases the vehicle was used as a weapon. The resulting trauma in road rage is mostly blunt and applied to the face and the extremities. There are characteristic features regarding the demographics, time and place of incident, as well as severity and pattern of injury in road rage associated offenses. Identifying these factors may lead to appropriate measures in the reduction of road rage.

Experiences of health and health care among women exposed to intimate partner violence: qualitative findings from Germany.

Through qualitative interviews with six female survivors of intimate partner violence (IPV) in Germany, we explored their experiences with health and health care within the context of a universal access health system. Using phenomenological analysis, we learned that they view violence as a burden on health; expect health professionals to acknowledge the link between IPV and health with empathy; and experience barriers to acute mental health services despite a lack of financial barriers in seeking treatment. We discuss how our findings compare with other international research, as well as the implications for the health care system's response to IPV.

General practitioners and managing domestic violence: results of a qualitative study in Germany.

A qualitative interview based study on ways of addressing and managing domestic violence (DV) by general practitioners (GPs) is presented. Problem centred semi-structured topic-guided interviews were conducted with 10 male and nine female GPs. Transcribed passages were analysed with the deductive approach of qualitative content analysis. Female doctors gave broader definitions of DV. Addressing of DV by a patient was perceived as a demand to act by all doctors. Documentation of injuries was considered to be important. Time constraints, feelings of being ashamed and helpless were described as barriers in addressing DV. Female doctors reported being anxious about losing their professional distance in cases of female victims. While female participants tend to take an 'acting' role in managing cases of DV by being responsible for treatment and finding a solution in collaboration with the patient, male doctors preferred an 'organising' role, assisting patients finding further help. Definitions of DV and differences in addressing the issue seemed to be strongly affected by personal professional experience. Definitions of DV, personal barriers in addressing the subject and understanding of the own role in management and treatment of DV cases differed between male and female doctors. Pre-existing definitions of DV, personal experience and gender aspects have to be taken into account when planning educational programmes for GPs on the issue of DV.

[Injuries of the female genitalia in cases of sexual assault]. / Verletzungen weiblicher Geschlechtsorgane nach sexualisierter Gewalt.

Sexual violence is a global problem that particularly affects women and children. A retrospective analysis of 390 clinical-forensic examinations and 120 autopsies regarding injuries of the female genitalia in cases of sexual violence was performed. In the majority of cases no injuries of the female genitalia were found. Autopsy cases showed significantly more (and more serious) injuries of the genitalia than clinical forensic examinations (43 % vs. 25 %; p = 0.0004). Predominantly found were injuries of the external anogenital area, mostly tears or soft tissue lesions. In the current literature, data regarding the rate of injuries in victims of sexual violence vary strongly and their comparability is limited. Regarding the reconstruction of an offence, a forensic examination with an appropriate documentation of the injuries is evidently crucial.

Violence against children: further evidence suggesting a relationship between burns, scalds, and the additional injuries.

Up to 22 % of all child maltreatment cases involve non-accidental burns or scalds. In the time period of 2000 until 2007, 20 children with non-accidental burns and scalds in conjunction with other mechanisms of injury were examined at children's hospitals in Hamburg and at the Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, by experts in forensic medicine. The fact that these children presented with additional injuries due to blunt and sharp force and sometimes had signs of neglect emphasize the urgent need for a multidisciplinary cooperation between pediatricians and forensic medical experts to ensure the early identification and prevention of child maltreatment. A new approach for Germany, enforcing mandatory child well-being examinations is discussed.

The organization of autobiographical and nonautobiographical memory in posttraumatic stress disorder (PTSD).

Disorganized trauma memory seems to play an important role in the pathogenesis of posttraumatic stress disorder (PTSD). However, it is unclear whether memory organization of nonautobiographical material (i.e., sequence memory) is also impaired in PTSD. A novel task designed to assess nonautobiographical memory for content and order information was administered to trauma survivors with (n = 26) and without PTSD (n = 55) as well as to nontraumatized healthy adults (n = 30). In addition, traumatized participants were asked to give a detailed narrative of the traumatic event and an unpleasant autobiographical event. Transcripts of both types of narratives were analyzed with regard to disorganization. Results indicated that trauma memories were more disorganized than memories of an unpleasant event in the PTSD group in comparison with the non-PTSD group. However, no differences were found for memory organization of nonautobiographical material among trauma survivors with and without PTSD and nontraumatized controls. With regard to memory accuracy of nonautobiographical material, group differences were more strongly associated with trauma exposure than with PTSD.

Does the evocation of traumatic memories confound subsequent working memory performance in posttraumatic stress disorder (PTSD)?

The role of heightened arousal has been previously discussed as a contributor to neurocognitive impairment in posttraumatic stress disorder (PTSD). To investigate whether psychological effects (distraction, re-location of resources) elicited by the evocation of traumatic memories impact on subsequent cognitive performance in PTSD, two parallel versions of a working memory task were administered to 33 trauma-exposed participants (15 with and 18 without PTSD). Between first and second working memory assessment a trauma-related interview was conducted including the narration of the trauma. Levels of working memory impairment in PTSD patients remained unchanged. This study provides preliminary evidence that neurocognitive impairment is not secondary to psychological effects induced by the evocation of traumatic memories. Nevertheless, it is recommended that future PTSD research should devote more care to the order in which trauma-related and other dependent variables such as cognitive tests are presented to participants.

[A forensic medicine perspective on recurring episodes of intimate partner violence]. / Rezidivgewalt bei Opfern von Partnerschaftskonflikten aus rechtsmedizinischer Perspektive.

During a three year period, 418 victims of intimate partner violence (IPV) were examined and their injuries documented at the Center for Victims of Violence (CVV) in Hamburg, Germany. All victims were questioned if their acute injuries were attributable to recurring acts of violence by the same intimate partner. The victims' experiences with recurring IPV were analyzed and associated risk factors as well as findings of acute physical injuries were integrated into the assesment. Overall, women were significantly more often victims of recurring episodes of IPV than men. In 35.4% of cases, victims of recurring IPV sustained injuries to three or more body regions. However, women who were victimized during a single act of violence, presented with the same distribution of injuries in only 21.1% of cases (p = 0.01). The results emphasize the fact that IPV often manifests itself in a spiraling escalation of physical violence. Furthermore, blunt force trauma to the head was diagnosed significantly more often (p = 0.05). The risk of sustaining a head injury was equally high for women who experienced a first-time violent episode by their ex-partner as it was for married women or women living in a non-marital partnership during recurring episodes of IPV. In an effort to reduce the increased risk for victims of IPV, health care personnel are highly encouraged to partake in forensic medicine based continuing education. This preventative measure may prepare clinicians to recognize IPV earlier as well as to treat and advise clients appropriately.

[Continued physical capacity after head gunshot injury]. / Erhaltene Handlungsfähigkeit nach Kopfschuss.

The human brain shows a very high density of functionally important structures. Even small lesions may therefore cause clinical symptoms. Penetrating gunshots to the head are presumed to cause immediate incapacitation by subsequent disturbance of cerebral functions. The authors discuss anatomical and functional principles of the terms action, capacity to act and incapacitation and report two illustrative cases with lack of incapacitation following gunshots to the head.