Female genital mutilation - An overview for forensic practitioners.

Female genital mutilation (FGM) refers to all procedures that partially or totally remove the external female genitalia, or to all other deliberate injuries to the female genital organs for non-medical reasons. It is thought that over 200 million girls and women have had some form of FGM, with more than three million girls being at risk annually. The procedure varies in severity from partial or complete removal of the clitoris (Type 1) to oversewing of the vaginal opening, so-called infibulation (Type 3). There are no medical benefits from FGM, with complications increasing with the amount of tissue damage that has been inflicted. Side effects may be psychological and physical including excessive scarring, pain, infections, sexual dysfunction with significant obstetrical complications such as fistulas and increased risks of stillbirth, as well as increased neonatal and maternal morbidity and mortality. Although primarily originating in countries in Africa, the Middle East and Asia, mass migrations in recent years have made FGM a feature in most societies. For this reason, forensic practitioners and pathologists should be aware of the anatomical features of FGM and the potential medical and psychological side effects. Accurate recording of cases is required to enable appropriate resources to be allocated for instituting preventive measures.

Women's perspectives on disrespect and abuse during facility-based childbirth in Ethiopia: a qualitative study.

BACKGROUND: Disrespect and abuse violates women's basic human rights and autonomy and can traumatize women who are already in a vulnerable position during childbirth and deter them from utilizing skilled care for future childbirth. This study explored women's perspectives on the acceptability of disrespect and abuse during facility-based childbirth in Ethiopia. METHODS: A qualitative descriptive design using five focus group discussions and fifteen in-depth, semi-structured, interviews was conducted with women between October 2019 to January 2020 in north Showa zone of Oromia region, central Ethiopia. Using purposive sampling, women who had given birth at public health facilities of North Showa zone during the twelve months preceding data collection were recruited, regardless of birth outcome. Inductive thematic analysis using Open Code software was used to explore the perspectives of participants. RESULTS: While women reject disrespectful and abusive acts during childbirth generally, they may consider some disrespectful acts as acceptable and or necessary under certain circumstances. Four emerging themes were identified. (1) Disrespect and abuse is not acceptable, (2) Disrespectful and abusive actions are acceptable only if intended to save lives, (3) Disrespectful and abusive actions are an accepted part of everyday practice to prevent complications and adverse outcomes, (4) Disrespectful and abusive actions are necessary to discipline disobedient women. CONCLUSION: Women's perceptions of disrespectful and abusive acts of care providers is deeply rooted within the context of violence in Ethiopia and the societal hierarchies that have systematically disempowered women. Given the pervasiveness of disrespect and abusive actions during childbirth, policymakers, clinical managers and care providers must take these essential contextual and societal norms into account and devise comprehensive clinical interventions that addresses the root causes.

La urgencia de dar respuesta sanitaria a la violencia de género / The urgency of providing a health response to gender-based violence

La violencia por cuestiones de género es un fenómeno histórico, complejo y prevalente a nivel mundial. Definida por la Organización de las Naciones Unidas como 'todo acto de violencia basado en la pertenencia al sexo femenino, que tenga o pueda tener como resultado un daño o sufrimiento físico, sexual o psicológico para la mujer, así como las amenazas detales actos, la coacción o la privación arbitraria de la libertad, tanto si se producen en la vida pública como en la privada', la violencia contra la mujer constituye una violación de los derechos humanos y por lo tanto, una cuestión de Estado. Las autoras de este artículo repasan el marco legal que aborda este problema en la Argentina, las dificultades del sistema sanitario (a nivel institucional e individual) en la detección y asistencia de las personas que lo padecen y la necesidad desensibilización y capacitación de los profesionales de la salud. (AU)

Gender-based violence is a historical, complex and prevalent phenomenon worldwide. Defined by the United Nations as 'any act of female-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, as well as threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or private life', violence against women is a violation of human rights, and therefore a matter of State. The authors of this article review the legal frame that addresses this problem in Argentina, the difficulties of the health system (at institutional and individual level) in the detection and care of people who suffer from it, and the need for raising awareness and training healthcare professionals. (AU)

Conflicto armado, paz y terapia ocupacional en Colombia: recorridos y desafíos / Conflito armado, paz e terapia ocupacional na Colômbia: caminhos e desafios / Armed conflict, peace, and occupational therapy in Colombia: paths and challenges

Resumen Colombia vive un conflicto armado de larga duración, con más de nueve millones de víctimas registradas y daños profundos en la vida de personas, comunidades y en la sociedad misma. El artículo abarca tres temas: primero, una breve contextualización sobre el conflicto armado colombiano y algunos de sus impactos. En la segunda parte, a partir de fuentes documentales, se intentan trazar los recorridos de la aproximación de la terapia ocupacional colombiana al conflicto armado. Se identifican tres momentos: prudente indiferencia, despertar lento y reconocimiento de la responsabilidad ético-política. Finalmente, se presentan algunos desafíos para contribuir como profesión a la construcción de paz en Colombia, entre ellos, la expansión y el fortalecimiento de la profesión para llegar a los territorios más afectados por el conflicto; el mejoramiento de la formación y de la práctica para responder a la complejidad de la situación del país, y la reflexión sobre los objetivos y las implicaciones éticas de las acciones profesionales con víctimas, excombatientes o comunidades afectadas por el conflicto.

Resumo Colômbia vive um conflito armado de longa duração, com mais de nove milhões de vítimas registradas e profundos danos na vida das pessoas, comunidades e na sociedade. Este estudo abrange três tópicos: primeiro, uma breve contextualização do conflito armado colombiano e alguns de seus impactos. Na segunda parte, a partir de fontes documentais, tenta-se traçar as rotas das aproximações da terapia ocupacional colombiana ao conflito armado e identificam-se três momentos: prudente indiferença, despertar lento e reconhecimento da responsabilidade ético-política. Por fim, apresentam-se alguns desafios sobre a contribuição profissional para a construção da paz na Colômbia, entre eles, a expansão e fortalecimento da profissão para chegar até os territórios mais afetados pelo conflito, o aprimoramento da formação de terapeutas ocupacionais e da prática para responder à complexidade da situação do país e a reflexão sobre os objetivos e as implicações éticas da ação profissional com vítimas, ex-combatentes ou comunidades afetadas pelo conflito.

Abstract Colombia experiences a long-running armed conflict, with more than nine million registered victims and profound damage to people, communities, and society. The article covers three topics. First, a brief contextualization of the Colombian armed conflict and some of its impacts. Secondly, based on documentary sources, it attempts to trace how Colombian occupational therapy has approached the armed conflict. It identifies three stages: prudent indifference, slow awakening, and recognition of ethical-political responsibility. Finally, it presents some challenges for the professional contribution to peacebuilding in Colombia, such as expanding and strengthening the profession to reach the territories most affected by the conflict, improving occupational therapists' training and practice to respond to the complexity of the country's situation, and reflecting on the objectives and ethical implications of professional actions for the victims, ex-combatants or communities affected by the conflict.

Understanding the opinion of doctors on obstetric violence in Brazil to improve women's care.

BACKGROUND: Disrespect and mistreatment in childbirth are human rights violations and must be understood by everyone. However, there are many controversies in the use of the term 'obstetric violence' in Brazil. OBJECTIVES: To understand the opinion of residents and specialist doctors about obstetric violence and get a balanced view to improve women's care. SETTING: Public university hospital in São Paulo, Brazil. PARTICIPANTS: Residents in training and specialist doctors in obstetrics and gynecology. MEASUREMENTS: Participants answered an electronic form on obstetric violence opinions. FINDINGS: Of the 60 participants, 33(45%) were specialist doctors and 27(55%) were medical residents in training. Most interviewees (60%) do not agree with the use of the term "obstetric violence" to define mistreatment and disrespectful treatment of women. Regarding situations that characterize obstetric violence, the percentage of residents who agree with the following statements as forms of obstetric violence was significantly (p<0.05) higher than the specialists in the following aspects: episiotomy without consent (78% vs. 15%), episiotomy without indication (100% vs. 64%), episiotomy without anesthesia (96% vs. 76%), not allowing a companion during childbirth (89% vs. 64%), requiring silence from the birthing woman (100% vs. 73%), undergoing vaginal examinations without consent (85% vs. 58%), not allowing the woman to choose childbirth position (82% vs. 58%) and not allowing breastfeeding in the first hour (82% vs. 58%). CONCLUSIONS AND IMPLICATIONS: The resident doctors in training are aware that the Obstetric Violence typifies the mistreatment and abuse of women during childbirth and the same is not true for specialists. Specialist doctors who completed their training longer ago should undergo training programs for a better understanding of Obstetric Violence.

Addressing human rights abuses at mega-sporting events-A shared responsibility in theory and practice.

Mega-sporting events (MSEs) have great potential to promote human rights and be a force for good, not only in the host country or city where the event takes place, but also beyond. At the same time, these events are regularly linked to human rights abuses and this opinion piece provides an overview of MSE-related adverse human rights impacts and discusses how the governance of these events enables these impacts to occur in the context of bidding for, preparing, and delivering these events. At the core of this discussion the paper presents a shared responsibility approach and argues that if applied in a preventative and retrospective way and including the concept of collaborative remedy, it can help address these adverse impacts. This is followed by a reflection on the feasibility of this approach, by considering to what extent current developments in the evolving sport and human rights movement are going in that direction and the paper finishes with a brief discussion on the importance of making the current changes sustainable and how research and education are key elements of this endeavour.

Care Providers' Perspectives on Disrespect and Abuse of Women During Facility-Based Childbirth in Ethiopia: A Qualitative Study.

BACKGROUND: It is increasingly evident that disrespect and abuse of women during facility-based childbirth is a violation of a woman's rights and a deterrent to the use of life-saving maternity care. Understanding care providers' perspectives of disrespect and abuse during facility-based childbirth is an essential element to aid in fully comprehending the problem and its underlying complexities. OBJECTIVE: To explore care providers' perspectives of disrespect and abuse during facility-based childbirth. METHODS: This study used a qualitative descriptive design involving fifteen in-depth, semi-structured, interviews conducted between 5 October 2019 and 25 January 2020 in north Showa zone of Oromia region, central Ethiopia. Purposive sampling enabled health care professionals working in maternity units of health facilities who have direct involvement in care of women during pregnancy and labor to be recruited. Thematic analysis using Open Code software was used to explore the perspectives of participants. RESULTS: Four themes were identified. 1) Disrespect and abuse breaches professional standards, 2) Disrespectful and abusive actions are justified at times to save the mother and her baby, 3) Disrespect and abuse is used as a tool to assert power, and 4) Disrespect and abuse arise from health system deficiencies. CONCLUSION: Disrespect and abuse is triggered by underlying beliefs about risk versus care, provider attitudes, stress and burnout, and health service structural issues including a lack of medicines and supplies. A number of strategies could improve the quality of maternity care, including training providers how to manage difficult and complex situations, addressing root causes of disrespect and abuse, and increasing access to resources.

Acceso a información de los registros sanitarios de medicamentos en el marco del derecho a la protección de la salud / Access to information of regulatory approval of medicines within the framework of the right to health protection / Acesso à informação de aprovação regulatória de medicamentos no marco do direito à proteção à saúde

Introducción: el derecho al acceso a la información administrativa es un derecho fundamental consagrado en la Constitución Política de Costa Rica. La información que presentan las empresas respecto a seguridad, calidad y eficacia para que se otorgue la aprobación para comercializar un medicamento en el país por parte del Estado es necesaria para un usoracional de los medicamentos. Objetivo: determinar si la población costarricense tiene acceso a la información pública del registro sanitario de un medicamento. Metodología: consistió en la revisión detallada de la normativa nacional relacionada con acceso a la información pública y su aplicaciónpara los expedientes de registros sanitarios en el país. Resultados: según la legislación nacional esta información es de acceso público, excepto algunos datos de sustancias nuevas. Sin embargo, el Ministerio de Salud de Costa Rica no permite que la ciudadanía conozca esta información, al no disponer de una base de datos pública, de acceso en tiempo real, a partir de una plataforma digital. Conclusión: existe una violación del derecho fundamental a acceder a la información administrativa por parte del Ministerio de Salud de Costa Rica.

Introduction: the right of access to administrative information is a fundamental right enshrined in the Political Constitution of Costa Rica. The information that companies present regarding safety, quality,and efficacy forthe State to grant approval to market a drug in the country is necessary for a rational use ofdrugs. Objective: To determine if the Costa Rican population has access to the public information of the sanitary registry of a medicine. Methods: a detailed review of the national regulations related to access to public information was made and its application to the records of health records in the country. Results: According to national legislation, this information is publicly accessible, except for data on new substances. However, the Costa Rican Ministry of Health does not allow citizens to know this information, as it does not have a public database, accessible in real time, from a digital platform. Conclusion: there is a violation of the fundamental right to access administrative information by the Ministry of Health of Costa Rica.

Introdução: o direito de acesso à informação administrativa é um direito fundamental consagrado na Constituição Política da Costa Rica. As informações que as empresas apresentam sobre segurança, qualidade e eficácia para que o Estado conceda a aprovação para comercialização de um medicamento no país são necessárias para o uso racional dos medicamentos. Objetivo: determinar se a população costarriquenha tem acesso às informações públicas do registro sanitário de um medicamento. Metodologia: consistiu em uma revisão detalhada das regulamentações nacionais relacionadas ao acesso à informação pública e sua aplicação aos registros dos prontuários de saúde do país. Resultados: de acordo com a legislação nacional, essa informação está acessível ao público, exceto para alguns dados sobre novas substâncias. No entanto, o Ministério da Saúde da Costa Rica não permite que os cidadãos conheçam essas informações, pois não possui um banco de dados público, acessível em tempo real, a partir de uma plataforma digital. Conclusão: há uma violação do direito fundamental de acesso à informação administrativa por parte do Ministério da Saúde da Costa Rica.

Disrespect and abuse during facility-based childbirth in central Ethiopia.

BACKGROUND: Respectful maternity care is a fundamental human right, and an important component of quality maternity care. OBJECTIVE: The aim of this study was to quantify the frequency and categories of D&A and identify factors associated with reporting D&A among women in north Showa zone of Ethiopia. METHOD: A cross-sectional study was conducted with 435 randomly selected women who had given birth at public health facility within the previous 12 months in North Showa zone of Ethiopia. A digital (tablet-based) structured and researcher administered tool was used for data collection. Frequencies of D&A items organised around the Bowser and Hill categories of D&A and presented in the White Ribbon Alliance's Universal Rights of Childbearing Women Framework were calculated. Multivariable logistic regression was used to identify the association between experience of disrespect and abuse and interpersonal and structural factors at p-value <0.05 and odds ratio values with 95% confidence interval. RESULTS: All participants reported at least one form of disrespect and abuse during childbirth. Types of disrespect and abuse experienced by participants were physical abuse 435 (100%), non-consented care 423 (97.2%), non-confidential care 288 (66.2%), abandonment/neglect (34.7%), non-dignified care 126 (29%), discriminatory care 99 (22.8%) and detention 24 (5.5%). Hospital birth [AOR: 3.04, 95% CI: 1.75, 5.27], rural residence [AOR: 1.44, 95% CI: 0.76, 2.71], monthly household income less than 1,644 Birr (USD 57) [AOR: 2.26, 95% CI: 1.20, 4.26], being attended by female providers [AOR: 1.74, 95% CI: 1.06, 2.86] and midwifery nurses [AOR: 2.23, 95% CI: 1.13, 4.39] showed positive association with experience of disrespect and abuse. CONCLUSION: Hospital birth showed consistent association with all forms of disrespect and abuse. Expanding the size and skill mix of professionals in the hospitals, sensitizing providers consequences of disrespect and abuse could promote dignified and respectful care.

"I Would Have Stayed Home if I Could Manage It Alone": A Case Study of Ethiopian Mother Abandoned by Care Providers During Facility-Based Childbirth.

BACKGROUND: Every woman is entitled to respectful care during pregnancy and childbirth as a basic human right. However, not all women are being treated equally well. CASE PRESENTATION: This case study highlights some of the common disrespectful practices that women face. This is a testimony of a 28-year-old mother of two, narrated in her own words. The data were collected during an in-depth interview in November 2019. The interview was conducted in her house and her name has been changed to protect her identity. The interview was audio-taped using a digital voice recorder, later transcribed, and translated verbatim from the local language - Amharic, to English. CONCLUSION: This woman's story highlights the unfortunate reality for some women. Five themes emerged from her narrative: denial of care: the provider left her unattended at a critical moment and denied her the care that she came for; non-consented care: she did not consent to the episiotomy; non-dignified care: she was carried by her arms and legs to the delivery couch, and left naked and bleeding on the couch after birth; taking a sick baby home without medical assistance: she was forced to leave the hospital even though her child had breathing difficulties and was not able to suck or breastfeed; and loss of trust in care providers: for her second birth this woman went to a facility where a relative works, as she no longer trusted these providers.

Interseccionalidade e rupturas dos modos de vida pelos rompimentos de barragem: reflexões a partir de uma mídia em aderência / Intersectionality and the disruption in the way of living by dam's collapses: observations as of the media in adherence / Interseccionalidad y disrupción de formas de vida por ruptura de presas: reflexiones de un medio en adhesión

É um importante desafio a compreensão do ambiente de violação de direitos a que estão submetidas populações atingidas pelo modelo de desenvolvimento extrativista da mineração. Damos foco aos rompimentos das Barragens de Fundão (Mariana) e Córrego de Feijão (Brumadinho), especialmente às mulheres atingidas ­ elo menos visível dessa cadeia. Além de enfrentarem desigualdade calcada nas relações interseccionais, imposta pelo capitalismo patriarcal, são as que mais lutam pela reconstrução dos seus modos de vida. O principal esforço deste artigo é dar visibilidade à realidade vivida por essas mulheres, suas redes de solidariedade e luta. Por meio da mídia aderente e alternativa do jornal A Sirene, análise documental e entrevistas, buscamos ouvir as vozes dessas mulheres que têm seus direitos negados e sua saúde comprometida em função do insistente descaso das empresas mineradoras. Utilizando os conceitos trazidos nos estudos de Veena Das, como conhecimento venenoso e sofrimento social, realizamos a análise dos resultados.

It is an important challenge to understand the environment of violation of rights to which populations affected by the mining extractive development model are subjected. We focus on the disruptions of the Fundão (Mariana) and Córrego de Feijão dams (Brumadinho), especially to the women affected ­ the least visible link in this chain. In addition to facing the inequality based on intersectional relations, imposed by patriarchal capitalism, they are the ones that fight the most for the reconstruction of their ways of life. The main effort of this article is to give visibility to the reality experienced by these women, their networks of solidarity and the fight. Through the adherent and alternative media of the newspaper A Sirene, document analysis and interviews we seek to hear the voices of these women who have their rights denied and their health compromised due to the insistent neglect of mining companies. Using the concepts brought up in the studies by Veena Das, such as poisonous knowledge and social suffering, we performed the analysis of the results.

Es un desafío importante comprender el entorno de vulneración de derechos al que están sometidas las poblaciones afectadas por el modelo de desarrollo minero extractivo. Nos centramos en las interrupciones de las represas Fundão (Mariana) y Córrego de Feijão (Brumadinho), especialmente en las mujeres afectadas, el eslabón menos visible de esta cadena. Además de enfrentar la desigualdad basada en las relaciones interseccionales, impuesta por el capitalismo patriarcal, son ellos los que más luchan por la reconstrucción de sus formas de vida. El principal esfuerzo de este artículo es dar visibilidad a la realidad que viven estas mujeres, sus redes de solidaridad y la lucha. A través de los medios adherentes y alternativos del diario A Sirene, análisis de documentos y entrevistas, buscamos escuchar las voces de estas mujeres a quienes se les niegan sus derechos y se compromete su salud por el insistente descuido de las empresas mineras. Utilizando los conceptos planteados en los estudios de Veena Das, como el conocimiento venenoso y el sufrimiento social, realizamos el análisis de los resultados.

Collision of Fundamental Human Rights and the Right to Health Access During the Novel Coronavirus Pandemic.

Introduction: COVID-19 requires governmental measures to protect healthcare system access for people. In this process, the collision of fundamental rights emerges as a crucial challenge for decision-making. Policy Options and Implications: This policy review analyzes selected articles by the PubMed searcher about extreme measures taken in several countries during precedent pandemics and the current pandemic, and selects hard decisions relating to the exceptional measures taken by judicial departments in Brazil, connecting them to the "collision of fundamental rights and law principles." The collision of rights and principles imposed on decision makers a duty to provide balanced rights, and to adopt the enforcement of some rights prioritization. Ethical concerns were also verified in this field involving rights limitations. During a pandemic, the importance of extreme measures to protect health rights and healthcare systems is instrumental for focused, fast, and correct decision making to avoid loss of life and the collapse of healthcare systems. The main goals of this research are to discuss the implications and guidelines for public health decision making, the indispensable ethical and legal aspects for safeguarding health systems and the lives of people, and the respect of the Justice principle and of fundamental health and dignity rights. We conclude that COVID-19 justifies the prioritization of collective and individual health access rights. Acceptable standards of fundamental rights restrictions are established at the constitutional and international levels and must be enforced by rules and governmental action, to ensure fast and accurate decision making during a pandemic. Freedom rights exercises must be linked to solidarity for the realization of social welfare, for the health rights of all individuals and for health systems to function well during a pandemic. Actionable Recommendations: All individuals are free and equal, therefore social exclusion is prohibited. Institutions must consider social inequalities when discussing public health measures and be guided by ethical standards, by law principles, and rules recognized by constitutional and international law for the benefit of all during a health pandemic. Conclusions: Collective and individual health rights prevail over the collision of rights when facing pandemic occurrences, case by case, in health systems protection, based on the literature, on precedent pandemics and on legitimate Public Health efforts.

Lesiones gravísimas causadas por la actuación ilegítima y el terrorismo de Estado en Uruguay. Reporte de diez años de valoración médico-legal y psiquiátrica a las víctimas / Severe lesions caused by illegitimate acts and state terrorism in Uruguay. 10-year report of the medico-legal psychiatric assessment of victims / Lesões gravíssimas causadas pela ação ilegítima e o terrorismo de Estado no Uruguai. Relato de dez anos de avaliação médico-legal e psiquiátrica das vítimas

Resumen: El rol de la Medicina Legal en derechos humanos y acción forense humanitaria es cada vez más visible. La ley Nº 18.596 indemiza a quienes acrediten haber sufrido lesiones gravísimas por el accionar de agentes del Estado. Objetivo: contribuir al conocimiento público de la actuación ilegítima y el terrorismo de Estado en Uruguay (13/6/1968 y 28/2/1985) y del aporte de la Medicina Legal en materia de verdad, justicia, memoria, reparación y garantía de no repetición. Material y método: se estudiaron las solicitudes de indemnización por lesiones gravísimas recibidas en los primeros diez años de vigencia de la ley. Resultados y discusión: de 166 peticiones, se admitieron 115. En el 95% fue requerido informe médico-legal o psiquiátrico, o ambos. Aunque fue dificultoso demostrar el nexo causal, en 55 casos se estableció un nexo con razonable grado de certeza. La edad media de las víctimas al momento de producirse las lesiones era de 26 años. La edad media al momento de la indemnización fue de 66 años. Las lesiones demostradas se corresponden con la referida en la bibliografía nacional y extranjera. Se destaca el hallazgo de una considerable presencia de trastornos psicóticos. Conclusiones: se indemnizaron 115 víctimas por lesiones gravísimas causadas en su amplia mayoría por prisión política prolongada y tortura. Se observó alta prevalencia de patologías osteoarticulares, trastornos por estrés postraumático crónico y depresión, pero también un alto número de psicosis crónicas. Los informes médico-legales fueron relevantes para demostrar las lesiones gravísimas y su nexo causal con el accionar de los agentes del Estado.

Summary: The role of Legal Medicine in human rights, forensic science and humanitarian action is increasingly visible. Act 18,596 compensates those who prove to have experienced severe lesions by state agents. Objective: to contribute to public awareness of the illegitimate actions and state terrorism in Uruguay (June 13, 1968 to February 28, 1985) and the input of Legal Medicine in terms of truth, justice, memory, reparation and guarantees of non-repetition. Method: the compensation requests for severe lesions received during the first 10 years the law was in force were studied. Results and discussion: 115 out of 166 requests were admitted. In 95% of cases, a medico-legal and or psychological report was requested. Despite it being hard to prove the causal link, a link with a reasonable degree of certainty was found in 55 cases. Average age of victims at the time the lesions were caused was 26 years old. Average age at the time of compensation was 66 years old. Lesions proved match those referred to in the national and international bibliography. The study points out the finding of a considerable number of psychotic disorders. Conclusions: 115 victims were compensated for severe lesions caused, in the wide majority of cases, by long imprisonment and torture. A high prevalence of osteoarticular diseases was observed, chronic post-traumatic stress disorders and depression, although a high number of chronic psychoses, too. Medico-legal reports were relevant to demonstrate severe lesions and the causal link with the action of state agents.

Resumo: O papel da Medicina Legal nos direitos humanos e ação forense humanitária é cada vez mais visível. A Lei Nº 18.596 indeniza aquelas pessoas que acreditem ter sofrido lesões gravíssimas causadas pela ação de agentes do Estado. Objetivo: contribuir para o conhecimento público da ação ilegítima e o terrorismo de Estado no Uruguai no período 13 de junho de 1968 a 28 de fevereiro de 1985 e da contribuição da Medicina Legal em termos de verdade, justiça, memoria, reparação e garantia de não repetição. Material e método: foram estudados os pedidos de indenização por lesões gravíssimas recebidas durante os primeiros dez anos de vigência da lei. Resultados e discussão: das 166 solicitações recebidas, foram incluídas 115. Em 95% dos casos o laudo médico-legal e/ou psiquiátrico foi exigido. Embora fosse difícil demonstrar a relação causal, em 55 casos foi estabelecida com um razoável grau de certeza. A idade média das vítimas no momento em que as lesões foram produzidas era de 26 anos. A idade média no momento da indenização era de 66 anos. As lesões demostradas correspondem às referidas na bibliografia nacional e estrangeira. Destaca-se o achado da presença considerável de transtornos psicóticos. Conclusões: foram indenizadas 115 vítimas por lesões gravíssimas causadas na grande maioria por prisão política prolongada e tortura. Observou-se uma alta prevalência de patologias osteoarticulares, transtornos por estresse pós-traumático crônico e depressão, mas também um número alto de psicoses crônicas. Os laudos médico-legais foram relevantes para demonstrar as lesões gravíssimas e sua relação causal com a ação dos agentes do Estado.

Hospital detention of mothers and their infants at a large provincial hospital: a mixed-methods descriptive case study, Lubumbashi, Democratic Republic of the Congo.

BACKGROUND: The practice of detaining people who are unable to pay for health care services they have received is widespread in many parts of the world. We aimed to determine the proportion of women and their infants detained for inability to pay for services received at a provincial hospital in the Democratic Republic of the Congo during a 6-week period in 2016. A secondary objective was to determine clinical and administrative staff attitudes and practices about payment for services and detention. METHODS: This mixed-methods descriptive case study included a cross-sectional survey and interviews with key informants. RESULTS: Over half (52%) of the 85 women who were in the maternity ward at Sendwe Hospital and eligible for discharge between August 5 and September 15, 2016 were detained for 1 to 30 days for outstanding bills of United States dollars (USD) 21 to USD 515. Women who were detained were younger, poorer, and had more obstetric complications and caesarean sections than other women. In addition, over one quarter of the infants born to these women had died during delivery or in the first three days of life. Key informant interviews normalized detention as an unfortunate but inevitable consequence of patient poverty and health system resource constraints. CONCLUSIONS: Detention of women and their infants is common at this hospital in the DRC. This represents a violation of human rights and a systemic failure to ensure that all people have access to essential health services and that they not suffer financial hardship due to the price of those services.

Métodos de tortura del terrorismo de Estado en Uruguay y valoración médico-legal de su idoneidad para causar lesiones graves o gravísimas / Methods of torture of State terrorism in Uruguay and medical legal assessment of its abililty to cause severe o very severe lesions / Métodos de tortura do terrorismo de Estado no Uruguai e avaliação médico-legal de sua idoneidade para causar lesões graves ou gravíssimas

La Medicina Legal tiene entre sus misiones el diagnóstico de la tortura como forma de contribución a las investigaciones judiciales y a la reparación de las víctimas. En Uruguay se desarrollan numerosos procedimientos administrativos y criminales referidos al período del terrorismo de Estado (entre el 27 de junio de 1973 y el 28 de febrero de 1985). Si bien el delito de tortura es un delito de lesa humanidad imprescriptible, se tipificó en la Ley Nº 18.026 de 26 de setiembre de 2006. La jurisprudencia nacional ha desestimado su tipificación en los casos del período del terrorismo de Estado en base al principio de no irretroactividad de la ley penal. Paralelamente, la Fiscalía Especializada en Crímenes de Lesa Humanidad ha requerido numerosos informes respecto de la posibilidad de que los métodos de tortura aplicados por el terrorismo de Estado en Uruguay pudieran causar lesiones graves o gravísimas. Objetivo general: contribuir al conocimiento de los crímenes del terrorismo de Estado en Uruguay, aportando así a la realización de los estándares internacionales de verdad, justicia, memoria y reparación. Objetivos específicos: 1. Describir los métodos de tortura empleados. 2. Determinar su idoneidad para producir lesiones graves o gravísimas. Metodología: el estudio se basó en las investigaciones históricas nacionales sobre el terrorismo de Estado, así como en la jurisprudencia en la materia, la revisión de la bibliografía internacional, la fisiopatología de situaciones análogas y los actuales consensos nacionales sobre los supuestos fácticos incluidos en los tipos penales de lesiones graves y gravísimas. Resultados: en el período del terrorismo de Estado en Uruguay ha sido característica la aplicación de torturas a gran escala y en forma sistemática. Los métodos más habitualmente aplicados fueron el encapuchamiento, la privación de agua, alimentos y reposo, la exposición al frío, las golpizas, incluido el teléfono, el plantón, el colgamiento, el caballete, el submarino húmedo y seco, la picana eléctrica y las agresiones sexuales. Los distintos métodos de tortura física incluyen un sufrimiento psíquico. A través de mecanismos específicos, todos resultan idóneos para ocasionar daños que encuadran en diversos supuestos de los delitos de lesiones graves y gravísimas. En las mujeres embarazadas, todos estos métodos de tortura son eficaces para provocar el aborto o adelantar el parto. Conclusiones: existió un patrón en los métodos de tortura sistemática empleados por el terrorismo de Estado que incluyó métodos omisivos, posicionales, traumáticos, eléctricos, asfícticos y sexuales. Todos ellos pueden determinar uno o más de los supuestos comprendidos en los delitos de lesiones graves y gravísimas. El peligro de vida y las secuelas psicológicas son inherentes a la tortura. En las mujeres embarazadas, todos los métodos de tortura reseñados son eficaces para provocar el aborto o el adelantamiento del parto. (AU)

Among other missions, Legal Medicine aims to diagnose torture, as a means of contributing to judicial investigations and repair victims. In Uruguay, several administrative and criminal procedures are developed in connection to the times of state terrorism (between June 27, 1973 and February 28, 1985). Despite torture being an indescribable crime against humanity, it was typified in Act 18,026 of September 26, 2006. National jurisprudence has dismissed its classification in the cases that occurred during the times of state terrorism, based on the non-retroactivity principle of criminal law. Simultaneously, the Prosecutor's Office Specialized in Crimes Against Humanity has requested several reports in connection with the possibility that torture methods applied by State terrorism in Uruguay may have caused severe or very severe lesions. General objective: To contribute to learning about state terrorist crimes in Uruguay, thus contributing to the creation of international standards for truth, justice, memory and repair. Specific objectives: 1. To describe the torture methods applied. 2. To determine their ability to cause severe or very severe lesions. Method: The study was based on national history investigations, as well as jurisprudence in the field, review of international bibliography, pathophysiology of similar situtaions and current national consensus on fact assumptions included in the criminal classification of severe and very severe lesions. Results: The times of state terrorism in Uruguay have been characterized by the application of large scale torture in a systematic way. The most frequently used methods were hooding, restriction of water, food and rest, exposure to the cold, beating up, including "the phone", sitting in, hanging, vaults, wet and dry submarine, electric shock baton and sexual assaults. The different methods of physical torture include psychological suffering. By means of specific mechanisms, they are all useful to cause harm that lie within several assumptions of severe and very severe harm crimes. I pregnant women, all of these methods of torture are effective to interrupt pregnancy or anticipate delivery. Conclusions: There is a pattern in the systematic methods of torture used by state terrorism, which included methods involving omissions, positions, trauma, and electrical shocks and, suffocating. All of them may result in one or more of the assumptions included in the severe or very severe lesions crimes. Risk of life and psychological consequences inherent to torture. In pregnant women, all the methods of torture described are effective to interrupt the pregnancy or anticipate delivery.

Entre as missões da Medicina Legal se inclui o diagnóstico da tortura como forma de contribuição às investigações judiciais e a reparação das vítimas. No Uruguai foram desenvolvidos numerosos procedimentos administrativos e criminais referidos ao período do terrorismo de Estado (entre 27 de junho de 1973 e 28 de fevereiro de 1985). Embora o delito de tortura seja um delito de lesa humanidade imprescritível, este foi tipificado na Lei Nº 18.026 de 26 de setembro de 2006. A jurisprudência nacional rejeitou sua tipificação nos casos do período do terrorismo de Estado baseados no principio de não retroatividade da lei penal. Paralelamente, a Procuradoria Especializada em Crimes de Lesa Humanidade solicitou numerosos relatórios sobre a possibilidade de que os métodos de tortura aplicados pelo terrorismo de Estado no Uruguai pudessem ter causado lesões graves ou gravíssimas. Objetivo general: Contribuir ao conhecimento dos crimes do terrorismo de Estado no Uruguai, ajudando dessa forma o estabelecimento de padrões internacionais de verdade, justiça, memoria e reparação. Objetivos específicos: 1. Descrever os métodos de tortura empregados. 2. Determinar sua idoneidade para produzir lesões graves ou gravíssimas. Metodologia: O estudo foi realizado utilizando informação de pesquisas históricas nacionais sobre o terrorismo de Estado, bem como a jurisprudência na matéria, a revisão da bibliografia internacional, a fisiopatologia de situações análogas e os atuais consensos nacionais sobre os supostos fáticos incluídos nos tipos penais de lesões graves e gravíssimas. Resultados: No período do terrorismo de Estado no Uruguai foi característica a aplicação de torturas a grande escala e de maneira sistemática. Os métodos habitualmente mais aplicados foram o "encapuchamiento" (uso permanente de capuz ou venda nos olhos), a privação de água, alimentos e repouso, a exposição ao frio (geladeira), agressões físicas incluindo o "telefone", "plantón" (ficar em pé por períodos prolongados), pendurar pelos membros, "caballete" (montar sobre uma superficie afiada), afogamento úmido e seco, choque elétrico e as agressões sexuais. Os distintos métodos de tortura física incluem sofrimento psíquico. Através de mecanismos específicos, todos resultam idôneos para ocasionar danos que enquadram em diversos supostos dos delitos de lesões graves e gravíssimas. Nas mulheres grávidas, todos estes métodos de tortura são eficazes para interromper a gravidez ou adiantar o parto. Conclusões: Existiu um padrão nos métodos de tortura sistemática utilizados pelo terrorismo de Estado, que incluía métodos omissivos, posicionais, traumáticos, elétricos, asfixiantes e sexuais. Todos podem determinar um ou mais dos supostos compreendidos nos delitos de lesões graves e gravíssimas. O perigo de vida e as sequelas psicológicas são inerentes à tortura. Nas mulheres grávidas, todos os métodos de tortura descritos são eficazes para interromper a gravidez ou adiantar o parto.

Association between bullying and family factors among middle school students in a city of central China / 中国学校卫生

Objective@#To explore the relationship between bullying among middle school students and family factors in a city of central China, so as to provide support for the prevention and reduction of school bullying among middle school students.@*Methods@#The stratified cluster random sampling method was used to investigate the bullying involvement and family factors of 2 996 middle school students from first grade in junior high school to third grade in high school in a city in central China. Chi-square test and Logistic-regression analysis were used to analyze the relationship between family factors and bullying participation of middle school students.@*Results@#Among 2 996 students, 390 students(13.0%) were found of having bullying behavior, and 1 127 students(37.6%) were found of being bullied. Univariate analysis showed that there were statistically significant differences in family factors such as whether she or he is the only child, father-child relationship, mother-child relationship, marital status of parents, whether the mother work away from hometown, education level of father and mother(χ2=8.88, 56.49, 30.85, 30.91, 3.89, 10.36, 11.72；25.00, 69.33, 46.76, 57.09, 3.93, 23.19, 45.49, P<0.05). Logistic regression analysis showed that the only child and mother’s education degree was junior college and below were the risk factors for middle school students’ bullying involvement (OR=1.37，1.39). Parents’ harmonious marital status and father’s not working outside are the protective factors of middle school students’ bullying(OR=0.53, 0.83).The only child is the risk factor of bullying in middle school students (OR=1.42), and good father relationship is the protective factor of bullying in middle school students (OR=0.38).@*Conclusion@#Family factors have a certain impact on the involvement of middle school students in bullying in a city of central China, and corresponding preventive measures should be formulated from the perspective of family to focus on the intervention of high-risk groups.

Eçara: resistência de quem busca e encontra solidariedade na equipe do consultório de rua / Eçara: resistance of those who seek and find solidarity in the team of the office of street

Objetivos: descrever a narrativa de uma usuária-guia e realizar uma análise.Métodos: O presente estudo caracteriza-se como pesquisa qualitativa, do tipo interferência, delineado como estudo de caso, definido a partir da experiência e percurso da usuária-guia. Foram observadas todos as recomendações éticas da Resolução 446/2012.Resultados: Eçara teve nove filhos tendo lhe sido retirado quatro deles. Depois de muitos anos de sofrimento e dor, a usuária encontrou a equipe de consultório de rua, que lhe estendeu pontes para ter uma vaga em abrigo público e começar um novo projeto de vida em família.Conclusões: Concluímos também que o Consultório de Rua investiu seus recursos humanos em Eçara e teceram uma rede de solidariedade, para que nela mãe e filhos pudessem ser acolhidos e a usuária iniciar um projeto de vida, em família. Este dispositivo estendeu pontes para tirar Eçara da invisibilidade das ruas e viadutos, de modo que ela possa continuar indo em busca de uma vida melhor para si e sua família, mesmo que seja num abrigo público. Palavras-chaves: Pessoas em situação de rua; Gravidez; Violações dos Direitos Humanos; Social Vulnerability.(AU)

Objectives: To describe the narrative of a user guide and perform an analysis. Methods: The present study is characterized as qualitative research, of the interference type, delineated as a case study, defined from the experience and path of the user-guide. All the ethical recommendations of Resolution 446/2012 were observed. Results: Eçara had nine children with four of them removed. AGer many years of suffering and pain, the user found the street office staff, which extended bridges to her for a public shelter and start a new family life project. Final Considerations: We also concluded that the Street Office invested its human resources in Eçara and weaving a network of solidarity, so that mother and children could be welcomed and the user to start a life project with the family. This device has extended bridges to take Eçara from the invisibility of the streets and viaducts, so that she can continue to pursue a better life for herself and her family, even if it is in a public shelter.(AU)

A cross-sectional exploratory study of knowledge, attitudes, and practices of emergency health care providers in the assessment of child maltreatment in Maputo, Mozambique.

BACKGROUND: In Mozambique, and other low-income countries (LICs), there is little information on the burden of child maltreatment (CM). Emergency care services (ECS) play an important role in recognizing, treating, and intervening in situations of CM. We aim to identify knowledge, attitudes, and practices regarding CM among health care providers in ECS at Mavalane General Hospital in Maputo, Mozambique. METHODS: This exploratory cross-sectional study evaluates the knowledge, attitudes, and practices of health care providers to diagnose and treat cases of CM. A 25 min, pilot-tested verbal interview questionnaire was administered to 49 physicians and nurses working in ECS at Mavalane General Hospital. Interviews were completed between October-November 2010. Data were managed and analyzed in SPSS 14.0 and descriptive statistics were generated. RESULTS: Of 49 health care providers, 83.6% reporting receiving no, or very little CM education or training. Only 61.2% had knowledge of physical abuse as a main form of child maltreatment and 38.8% were able to identify corresponding symptoms of physical abuse. Sexual abuse as a main form of CM was mentioned by 26.5 and 2% cited its symptoms. While 87.7% of health care providers strongly agreed or agreed that they hold an important role in preventing CM, 51.1% also strongly disagreed or disagreed that they feel confident diagnosing and treating CM cases. In regards to follow-up, 14.3% strongly disagreed or disagreed that they know where to refer victims for further follow-up and an additional 14.3% did not know whether they agreed or disagreed. CONCLUSION: This study revealed knowledge gaps in emergency health care provider knowledge of the main forms of CM and their symptoms. The fact that a majority of health care providers in our sample did not receive information specific to CM in their medical education and training could explain this gap, as well as their unawareness of where to refer victims. Given that health care providers believe they play an important role in identifying and treating CM, future research should focus on raising physician awareness of CM and developing education and training materials grounded in cultural contexts to build response capacity in Mozambique and other LICs.

Explotación sexual comercial de niños, niñas y adolescentes: significados y prácticas de trabajadores/as y residentes del centro de Medellín (Colombia), 2015 / Commercial sexual exploitation of children: Meanings and practices of people who work and reside in downtown Medellin (Colombia), 2015

RESUMEN La explotación sexual comercial es un problema de salud pública y una vulneración de los derechos de niños, niñas y adolescentes. La respuesta a este problema se ha visto afectada por los significados y las prácticas de los actores implicados. Como aporte a una mejor comprensión del problema, entre 2014 y 2015 se realizó una investigación social cualitativa, con el enfoque de la teoría fundamentada, cuyo objetivo fue comprender los significados y las prácticas sobre esta problemática de las personas que permanecen en un sector del centro de la ciudad con alta presencia de explotación sexual comercial de niños, niñas y adolescentes. Las técnicas usadas fueron observación participante y entrevista semiestructurada. Encontramos que predominan concepciones que conducen a prácticas que agravan y perpetúan la vulneración de derechos. Aunque también se identificaron prácticas de protección a las víctimas, estas son limitadas por asuntos críticos del contexto. Las acciones para erradicar la explotación sexual deben trabajar con la comunidad sus significados para potenciar las prácticas protectoras que realizan y reducir las barreras.

ABSTRACT The commercial sexual exploitation of children is a public health problem and a serious violation of the rights of children and adolescents. The response to this problem has been affected by the meanings and practices of the actors involved. In order to contribute to a better understanding of the problem, a qualitative social study using a grounded theory approach was carried out between 2014 and 2015. The aim was to understand the meanings and practices regarding this issue of people who spend time in an area of the city center with a high presence of commercial sexual exploitation of children and adolescents. The techniques used were participant observation and semi-structured interviews. We found that the predominate conceptions lead to practices that aggravate and perpetuate rights violations. Although practices of protection towards victims were identified, these were limited to critical aspects of the context. Actions to eradicate commercial sexual exploitation should work with the community and the meanings within the community regarding sexual exploitation so as to potentiate the victim protection practices carried out and reduce barriers to such practices.

Mistreatment in an academic setting and medical students' perceptions about their course in São Paulo, Brazil: a cross-sectional study / Maus-tratos em um ambiente acadêmico e percepção sobre o curso entre estudantes de medicina em São Paulo, Brasil: um estudo transversal

ABSTRACT: CONTEXT AND OBJECTIVE: High prevalence of mistreatment among medical students has been described in the worldwide literature since the 1980s. However, studies addressing the severity and recurrence of victimization and its effects on students' perceptions of their medical course are scarce. This study had the aim of estimating the prevalence of exposure to mistreatment that was considered to be severe and recurrent and its association with medical students' perceptions about their medical course. METHODS: A cross-sectional study was conducted in a medical school in São Paulo, Brazil. Three hundred and seventeen students from the first to the sixth year answered the online questionnaire. RESULTS: High prevalence of mistreatment during the course was found. Two thirds of the students considered the episodes to be severe, and around one third reported experiencing recurrent victimization. Occurences of mistreatment that the students considered to be severe were correlated with feeling overloaded and wanting to abandon the medical course. CONCLUSIONS: Occurrences of mistreatment within the academic environment are frequent in Brazil. The results suggest that mistreatment that was considered to be severe might negatively affect students' perceptions about their course.

RESUMO CONTEXTO E OBJETIVO: Altas prevalências de maus-tratos entre estudantes de medicina vêm sendo descritas na literatura internacional desde a década de 1980. Estudos sobre a gravidade e recorrência da vitimização e seus efeitos na percepção dos alunos sobre o curso médico são escassos. Este estudo tem por objetivo estimar a prevalência de exposição a maus-tratos considerados graves e recorrentes e sua associação com a percepção dos estudantes de medicina sobre o curso médico. MÉTODOS: Estudo transversal realizado em uma escola médica em São Paulo, Brasil. Trezentos e dezessete estudantes do primeiro ao sexto ano responderam ao questionário online . RESULTADOS: Foram encontradas altas prevalências de maus-tratos durante o curso. Dois terços dos estudantes consideraram os maus-tratos graves e cerca de um terço referiu vitimização recorrente. A ocorrência de maus-tratos considerados graves pelos estudantes esteve associada a sentimento de sobrecarga e desejo de abandonar o curso médico. CONCLUSÃO: A ocorrência de maus-tratos no ambiente acadêmico é frequente no Brasil. Os resultados sugerem que os maus-tratos percebidos como graves podem afetar negativamente a percepção dos estudantes sobre o curso.