Investigating obstetrics and gynecology forensic cases at a tertiary health center in Turkey to demonstrate the significance of forensic evaluation

Summary

Objectives: To assess the diagnostic rates of forensic case patients who sought gynecological and obstetrics care, as well as the differences in forensic report production based on the event. Study design: The following factors were looked into: age of the patients, time between the incident and consultation, reason for consultation (pregnancy determination during the post-divorce waiting period, sexual assault, hymen examination, physical violence, other), time of the consultation (in-hours or out-of-hours), place of referral (prosecutor’s office/court, police station, own request), and type of report (final or preliminary). The data were obtained retrospectively. Results: When 651 forensic cases admitted to the emergency department were examined, 234 (36%), 199 (30.6%), 66 (10.6%), and 34 (5.2%) requested waiting period removal, physical assault against women, sexual assault, and hymen examination, respectively. The study revealed that 62.1% of sexual assault incidents were perpetrated by an acquaintance, 19.1% by a distant relative, and 12.1% by a first-degree family member. It was determined that the patient’s partner was responsible for 63.8% of the physical violence against women, while 24.6% was committed by a first-degree relative and 6.5% was perpetrated by other acquaintances. Conclusion: If the legislator revises the provision on the modern legal system’s waiting period, which prevents women from remarrying, judicial reports may drop rapidly. Examining cases referred to gynecologists and obstetricians in centers with forensic medicine specialists and medical staff trained in forensic medicine will ensure safer forensic examinations and medical investigations.

Keywords:

Obstetrics and gynecology – forensic case – sexual assault – violence against women

Introduction

Forensic cases involve situations where there is suspicion that an individual or others may be accountable for the circumstances that led to harm of the person’s health [1]. The phrase liability encompasses the concepts of intent, negligence, carelessness, and recklessness. Forensic cases, regardless of whether they arise from negligence or intentional actions, exhibit variations based on the country and the corresponding legal framework, but they unequivocally necessitate criminal accountability [1]. Health professionals in our country (Turkey) may receive referrals from prosecutors’ offices, courts, and police station authorities to compile a forensic report for forensic cases. Gynecologists and obstetricians have a higher patient load than most other branches, with the exception of a few, when conducting forensic investigations [2,3].

Gynecologists and obstetricians are frequently requested to compile forensic reports on various matters. For divorced women who are considering remarriage, it is legally necessary to get a pregnancy test if the divorce occurred recently (within the waiting period) and the result of the test must be documented. This term lasts from 100 to 310 days, depending on the country [4]. The legislator intends to use this interval to avoid any ambiguity concerning the custody of the future child’s paternity.

Sexual assaults are among the most critical forensic examinations that practitioners should prioritize. Almost one in every five women is affected by sexual assault or sexual contact, which can range from touching without consent to intercourse without consent [5]. The increasing frequency of sexual assaults is particularly concerning due to their profound psychological and traumatic effects on survivors [6].

The presence of penetration is important in women who are victims of sexual assault, especially in childhood. The criminal law of many countries, as in Turkey, emphasizes the existence of penetration [7]. For this, hymen examination reporting is needed. This examination should be performed by qualified experts as close to the time of the incident as possible. Although there is limited information in the literature, the only finding that can be confirmed during examination is the injury that can be detected in the posterior part of the hymen [7].

The global prevalence of physical or sexual violence is not yet definitively established, but it is a significant public health issue that is generally on the rise worldwide, with many countries seeing higher rates than others [8]. Only 40 percent of women are estimated to seek assistance following an occurrence of physical or sexual abuse, or domestic violence. Furthermore, only 10% of these incidents are reported to the police [8].

This study includes a retrospective analysis of 651 forensic cases admitted to a tertiary care center, which is a branch hospital in the field of gynecology and obstetrics, and the approach of gynecologists and obstetricians to these cases.

Materials and methods

The research was conducted within the scope of 651 patients who applied to the emergency department of the University of Health Sciences Etlik Zübeyde Hanım Gynecology Training and Research Hospital between 1. 1. 2021 and 1. 1. 2022 and were evaluated as forensic cases. The data in the study were obtained retrospectively from the forensic case registry and hospital automation system. The study’s inclusion criteria were patients who had been registered as forensic cases. Exclusion criteria included all patients who have not been diagnosed as forensic cases. The study received approval from the Local Council of the Etlik Zübeyde Hanım Gynecology Training and Research Hospital (Approval No. E-900057706-799; 19,08,2022/10).

The information required includes age of the patients, time interval between the incident and consultation, reason for consultation (pregnancy determination during the post-divorce waiting period, sexual assault, hymen examination, physical violence, pregnancy + trauma, other), time of consultation (in-hours or out-of-hours), place of referral (prosecutor’s office/court, police station, own request), type of report (final report or preliminary report), and relationship of the perpetrator in cases of sexual assault or physical violence (first-degree relative, distant relative, acquaintance, stranger). In addition, data on the length of time between the event and subsequent assessment were documented.

Informed consent: In this retrospective study, informed consent is routinely obtained during the patient’s admission to our healthcare institution. Patients are required to confirm and provide their signature, acknowledging that all information pertaining to their examination, treatment, and interventions falls within the purview of the training and research hospital. Furthermore, patients acknowledge that this information may be utilized anonymously by medical specialty students or academicians for scientific research purposes. Data were collected by anonymizing the patient’s identifying information during the research.

Statistical analysis: Since the variables discussed in the study are categorical variables, frequency (N) and percentage (%) values are given in descriptive analyses. The data were analyzed in the SPSS.25 program.

Results

Age distribution of the admitted patients was determined to be 29 (4.5%) under the age of 15 years, 86 (13.2%) between the ages of 15 and 18 years, including these ages, and 535 (82.5%) over the age of 18 years (Tab. 1).

When 651 forensic cases admitted to the emergency department were examined, the number of reports requested for the removal of the waiting period was 234 (36%), the number of cases admitted due to physical assault against women was 199 (30.6%), the number of cases accepted due to sexual assault was 66 (10.6%), and the number of reports requested for hymen examination was 34 (5.2%). The time between the onset of the complaint and examination was as follows: 21.5% of patients applied within the first 24 hours, 13.2% of patients applied between 24–72 hours, and 22.3% of patients applied after 72 hours. About 90.5% of the patients were admitted in-hours and 9.5% were admitted out-of-hours (Tab. 1).

The prosecutor’s office/court referred 74.2% of the patients, while the police station referred 7.1%. The study revealed that 62.1% of sexual assault incidents were perpetrated by an acquaintance, 19.1% by a distant relative, and 12.1% by a first-degree family member. It was determined that the patient’s partner was responsible for 63.8% of the physical violence against women, while 24.6% was committed by a first-degree relative and 6.5% was perpetrated by other acquaintances. Gynecologists and obstetricians provided the final report for 92% of all instances and a preliminary report for 8% of all cases (Tab. 1).

Discussion

When examining the connection between forensic cases and fields of gynecology and obstetrics, research on the circumstances that give rise to medical malpractice lawsuits is prominent in the literature [3,9]. On the other hand, there is a scarcity of research on the examination and documentation of forensic cases that are specifically referred to gynecologists and obstetricians for direct assessment and report generation.

This research, conducted in a center with the highest number of outpatient patients in the field of gynecology in Turkey, reveals that the highest workload expected from gynecologists and obstetricians in terms of forensic cases is the preparation of reports for pregnancy determination regarding the cancellation of the waiting period after divorce. The medical need and biological validity of the waiting time in the Turkish Civil Code, which prohibits women from getting married within 300 days after their divorce or the death of their spouse, remain a subject of ongoing discussion [4,10]. According to the Constitution of the Republic of Turkey, women and men have equal rights. The civil law, on the other hand, was drafted against the possibility of “a woman remarrying and giving birth without complying with the waiting period”. There is no reason to justify this prohibition of marriage, which is specific to women only [11]. In addition, other articles of the same law define the offence as ’the act of concealing the paternity of the child’. In this case, actions that may inadvertently incriminate the woman during the waiting period can be easily expressed [12]. According to the modern legal system, the same waiting periods are also included in the legal systems of Germany, France, and Switzerland; however, Switzerland has cancelled this article of law in its legal system for similar reasons explained above [13]. It has been observed that these simple pregnancy tests (beta-hCG) and ultrasound applications made by obstetricians and gynecologists to shorten the waiting period make up the majority of forensic reports, as shown in our study. We believe that such examinations will rapidly decrease as a result of legislative changes in the modern legal system in relation to the limited marriage ban regarding the waiting period for women.

Due to the rising incidence of sexual assault, a thorough definition of rape has been formulated, encompassing any form of penetration of a bodily orifice (such as the vagina, anus, or mouth) without consent, using either a sexual organ or an instrument [14]. Approximately 50 to 80% of instances of sexual assault are perpetrated by an individual who is acquainted with the victim [14,15]. Upon examining the patients admitted for sexual assault in our study, we found that over 90% of the cases involved perpetrators who were known by the victims. The frequency and incidence estimates of sexual assault are significantly impacted by the widespread underreporting of such incidents. Our investigation revealed that the proportion of applicants resulting from sexual assault in all forensic cases was 10% (Tab. 1). Sexual assault has short- and long-term consequences on women’s physical, mental, sexual, and reproductive health. Short-term health effects include physical injuries, sexually transmitted infections (STIs), and pregnancy [16]. In forensic reports prepared in such cases, findings regarding these issues should be carefully evaluated, and the health sequelae of sexual assault should not be overlooked. Prevention of sexual violence requires a comprehensive approach that includes interventions that address individual, relational, community, and societal factors [17].

Rape is the most underreported criminal offense. Approximately 16% to 38% of individuals who have experienced rape inform law authorities about the assault, and a comparable proportion seek medical assessment [17]. Legislators regard the issue of penetration in cases of rape to be significant, since it might affect the nature of the crime. As a result, gynecologists and obstetricians are asked to do hymen examinations. The majority of scars resulting from rape are typically located in the posterior region of the vagina, namely between the 3 and 9 o’clock positions [18]. If a child or adolescent is raped, the hymen is more likely to be damaged than in adults, and the injury is more serious. These scars may remain permanently even after several years [19]. In our study, the rate of a definitive doctor’s report was over 90%. This was 100% for the hymen examination. We believe that the primary reason for this is that the majority of patients who undergo hymen examinations are children and adolescents, and the results of the examination can be more easily discerned.

The United Nations defines violence against women as “any act of gender--based violence that results in, or is likely to result in, physical, sexual, or mental harm or suffering to women, including threats of such acts, coercion, or arbitrary deprivation” [20]. In our study, we also looked at the rate of those diag- nosed with physical violence against women only. The majority of physical violence against women, such as sexual assault, was perpetrated by people the women knew. About 65% of them were partners. Physical violence against women increases as age increases, education level decreases, and socio-economic level decreases. Compared to previous studies, this increase emphasizes more cases of intimate partner violence [21]. Cases of violence against women outside of partners are mostly caused by people who have addiction problems such as drugs [22].

In the study, we observe that the majority of the female patients examined as forensic cases, except for a very small number, applied within in-hours and only one third of these applications could be evaluated within the first 24 hours after the forensic event. The remaining patients were evaluated after 24 hours. We suggest that this situation is related to the time and process of the prosecutor’s office/court and police units to evaluate the incident. The quality and validity of forensic evidence, especially in sexual crimes, is seriously affected both physically and chemically by the victim’s actions after the incident and the passage of time [23]. Completing the forensic examination procedure of patients classified as forensic cases promptly is crucial for ensuring the accuracy and reliability of the forensic investigation [24].

Conclusion

We emphasize that the cases of pregnancy detection during the waiting period (iddah), which constitute the majority of patients referred to obstetricians and gynecologists, especially by legal and judicial units, for the preparation of forensic reports, can be significantly reduced if the legislator reorganizes this requirement in accordance with universal legal norms. In addition, instead of gynecologists and obstetricians alone preparing forensic reports for many forensic patients, such as sexual assault, violence against women, and hymen exams in cases of rape, the establishment of specialized centers with forensic experts, psychologists, and staff trained in combating forensic crime will be an approach that both shares the workload and achieves safer investigation results.