‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

DOMESTIC VIOLENCE &

ABUSE OF HUMAN
2024/2025
RIGHTS 2024/2025 2024/2025

STAFF MEMBERS OF FORENSIC MEDICINE AND

CLINICAL TOXICOLOGY DEPARTMENT
FACULTY OF MEDICINE - TANTA UNIVERSITY

Page 1 of 49
 An Introduction to Domestic Violence

Objectives
*Define domestic violence and abuse of human rights.
*Outline the types of domestic violence.
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

Definition of domestic violence

It is violence or other abuse by one person against another in a domestic setting,
such as in marriage or cohabitation.
Criteria of domestic violence
• Is carried out in private domain.
• The abuser and victim usually live within the same domestic setting and may be
dependent on each other.
• Is insidious and continues over a period of time (chronic)
2024/2025 Types of domestic
2024/2025 violence 2024/2025

• Child abuse • Intimate partner violence • Elderly abuse

Forms of domestic abuse
• Physical • Emotional • Neglect
• Sexual • Economic/financial
I) Physical abuse:
• Physical abuse happens when a person uses physical force against another
person with the intent to cause fear, pain or injury.
• Usually abuse involves multiple episodes but may be a single event.
• Most injuries are non-fatal (but death may occur).

Page 2 of 49
 Common forms of physical abuse:
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

Figure (1): Common forms of physical abuse. Source: https://www.slideshare.net/DivyaGaur3/child-

abuse-and-neglect-56040202

Injuries due to abuse have suggestive patterns: multiple injuries, in multiple body sites, with
different ages (denoted by healing) and usually take the shape of the instrument.
II) Sexual abuse:
2024/2025 2024/2025 2024/2025
• Coercing or attempting to coerce any sexual contact or behavior without consent.
III) Emotional (psychological) abuse:
• Perpetrators of emotional abuse use it to take away a person’s independence,
confidence and self-esteem.

Figure (2): Common forms of emotional abuse.

Source:https://www.slideshare.net/DivyaGaur3/child-abuse-and-neglect-56040202

Page 3 of 49
 IV) Economic or financial Abuse:
• Making or attempting to make an individual financially dependent by
maintaining total control over financial resources, e.g. withholding one's
access to money or forbidding one's attendance at employment.

Risk factors for victimization

‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

I) The abuser:
✓ Young age
✓ Poverty and unemployment
✓ Feels overwhelmed or stressed
✓ Has mental health problems
✓ Has a history of substance abuse or criminal history, came from single
parent homes/broken homes, raised in a household of domestic violence.
✓ Social isolation (e.g. lacking an emotional support network)
✓ May be dependent on the victim for housing or other needs
II) The victim:
Factors differ according to age (child, middle aged adult, elderly and his/her
relation with the abuser.
The effects of domestic violence
I)
2024/2025 Psychological effects: 2024/2025 2024/2025

✓ Depression
✓ Post-traumatic,,stress,,disorder
✓ Dissociative & anxiety disorders
✓ Eating disorders, sleep disturbances, somatization.
✓ Tendency to further victimization in adulthood.
II) Physical effects:
✓ Injury: Depending on the age and size of the victim, and the degree of force used,
child abuse may cause internal lacerations and bleeding. In severe cases, damage
to internal organs may occur, which, in some cases, may cause death.
✓ Infections: sexually transmitted diseases.
✓ Neurological damage: It has deleterious effect on brain development of children.
✓ Malnutrition & dehydration
References
✓ Clinical forensic medicine, a physician guide: non acidental injury in child:
2nd edition ,Chapter 5 pages 161:175.
✓ Forensic encyclopedia of forensic sciences: child abuse:pages 362-386.
✓ Clinical forensic medicine: Child abuse: physical, 3 rd edition chapter 11.

Page 4 of 49
 Assignment on Topic 1

1. Which of the following is an act of financial abuse?

A. Depriving victim of money.
B. Minimizing
C. Online humiliation
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

D. Unrelenting criticism

2. Which of the following is an act of child neglect?

A. Use of restraints
B. Kicking child’s body
C. Slapping the face
D. Food deprivation

3. Which of the following is a serious psychological effect of domestic

violence on victims?
A. Malnutrition and dehydration
2024/2025 2024/2025 2024/2025
B. Neurological disorders
C. Post-traumatic stress disorders
D. Injuries to vital viscera

Page 5 of 49
 Physical Child Abuse

Objectives
*Define physical child abuse.
*Recognize characteristic signs that indicate physical child abuse.
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

*Explain the mechanism of infliction of injuries in child abuse and common causes of death.
*Differentiate physical child abuse from accidental childhood injuries, murder & mimicking
clinical conditions
Definition of physical child abuse
⎯ It is a form of child maltreatment, usually induced by parents or caregivers.
⎯ Also called non-accidental childhood injury (NAI).
⎯ It is usually in the form of episodes of violence but may present as a single event

N.B. Fatal child abuse differs from common murder, in that:

⎯ It is usually the culmination of repeated injury, rather than a single episode of
deliberate killing by stabbing, shooting,
2024/2025 2024/2025strangulation, etc. 2024/2025
⎯ In child abuse weapons are rarely used and manual violence being offered in most
cases.
Risk factors for child abuse
- Abuser: Look introduction lecture p 2.
- Children:
✓ Female sex (though in some developing countries male children constitute a large proportion
of child victims)
✓ Unaccompanied children, children in foster care, adopted children, stepchildren
✓ Children with physically or mentally handicap, learning difficulties, & behavioral problems.
Common features of physical child abuse
1. History
⎯ Delay in reporting, for hours or days.
⎯ Discrepant or absent history (as the child has been taken to different doctors
or hospitals at each episode of violence).
2. Examination:
⎯ History incompatible with the injury type or date.
⎯ Pattern of injury more suggestive of abuse.

Page 6 of 49
 3. Behavioral signs:
⎯ Unusual parental behavior or mood.
⎯ The behavior of the child may be significant: Shows fear of the abuser or is
unwilling to make eye contact (eye avoidance). He may cringe with a distrustful and
hunted look (the look of frozen awareness).
Common injuries in physical child abuse
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

The most common physical lesions are the skin and skeleton (the skin and
bones tell a story that the child is either too young or too frightened to tell).
❑ Skin lesions. ❑ Eye & ear injuries.
❑ Skeletal lesions ❑ Mouth & lips injuries.
❑ Head injuries. ❑ Visceral injuries.
I) Skin lesion (bruising & burns):
A- Bruising
• Is the cardinal sign particularly those of different ages (as demonstrated by color changes).
• Common bruises highly suggestive of abuse are:
1. Patterned bruises:
⎯ They imprint the shape of the instrument, so they give out the shape &/or size
of the object used to inflict injury.
2024/2025 2024/2025 2024/2025
⎯ Examples include:

Figure (3): Common patterned injuries in physical child abuse

Page 7 of 49
 Bites should be differentiated from other children’s which has a narrow arch &
is smaller than one made by an adult) or domestic pets’ (parallel rows of bruises that
may be associated with puncture wounds). Must be matched with a suspected
assailant by swabs (may recover saliva which can be blood then grouped if the
person was a secretor or tested for DNA printing), photography, measurements or
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

Latex casts.

2. Pinprick bruises: from ruptured capillaries (e.g., suction bruises, squeezing,

strangulation, suffocation. Also, a common example is pinch mark which is a
butterfly-shaped bruise with one wing (caused by the thumb) larger than the other.

Differential Diagnosis of Bruising in a child

1. Congenital or pathological conditions:

• Pigment anomalies, birthmarks and skin disorders.

• Benign tumors as nevus, or hemangiomas.
2024/2025 2024/2025 2024/2025

• Vascular and bleeding disorders— e.g. purpura, hemophilia.

2. Accidental or self-inflicted injuries in older children:

- Clues to distinguish bruises due to abuse from accidental bruising:
❑ Patterns: finger/hand marks (finger-tip, pinch, slap) or patterned instrumental
marks (e.g. tram-line, loops, shoe sole pattern, ligature mark).
❑ Sites: In abuse, injuries appear in multiple sites. The most common are:
Facial: soft tissues of the cheek, eye, mouth, ear, lower jaw, and neck.
Chest wall, Abdomen.
Inner thighs and genitalia (strongly associated with sexual abuse).
Buttock and outer thighs (commonly associated with punishment injuries).
Accidental injuries are more common over bony prominences and on the front of
the body.

Page 8 of 49
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

Figure (4): comparison of common sites of bruises between child abuse and accidental injuries in
children. Source:https://slideplayer.com/slide/12684698/
❑ Numbers:
• More than 10 bruises in an actively mobile child should raise concern.
• Multiple bruises in multiple sites often raise suspicion of abuse.
B- Burns:
2024/2025 2024/2025 2024/2025
Burn is either dry (flame or contact) or wet (i.e immersion scald burn).
1. Contact Dry burn:
- Produced by flame or heated solid object
- Examples:
- Hot irons, grill or spoons applied to the skin.
-Cigarette burns: circular (perpendicular) or triangular (oblique).When fresh, they
are pink or red. After healing, they had silvery center with a narrow red rim.

Figure (5): patterns of bruises and burns seen in NAI of children. Source:
http://www.atuder.org.tr/FileOut.aspx?url=ic36CIoeC4ej6DkE63I7.

Page 9 of 49
 Contact burns due to abuse are more severe, deeper (due to long contact) and larger and
uniform depth than accidental burns. It can occur in covered areas of body.
2. Immersion scalds
- They result from dipping into hot liquid.
- Site: commonly found on hands, buttocks, upper thighs (gloves & stokes).
- They are often symmetrical, uniform depth, deep, more severe, no trickle pattern.
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

- Clear demarcation line between burned and healthy skin.

2024/2025 2024/2025 2024/2025

Figure (6): comparison of common sites of burns between NAI and accidental injuries in children. Source:
https://www.slideshare.net/Medifix/safe-guarding-children

II) Skeletal lesions:

• Common sites: skull and limbs.
• Fractures may be either fresh or old healing
• Spiral fractures of limb bones are of great significance, resulting from limb
twisting (e.g. twisting at the elbow → spiral fracture of the humerus)
• Evidence of previous damage (vital in confirming long- term abuse) includes the following:
a. Callus formation at previous fracture sites. A classical radiological picture is multiple callus
formation on the ribs, in the paravertebral gutters, giving a string of beads appearance, indicating
healing fractures following squeezing of the chest by adult hands.

b. Chipped epiphyses near large joints such as elbow and knee.

c. Metaphyseal damage.
N.B. Skeletal survey is essential in all cases as not all fractures are apparent on clinical examination.

Page 10 of 49
 III) Head injuries:
• The most frequent cause of death in child abuse or may result in severe permanent
neurological disability.
• Caused by blows from a punch or heavy slap or vigorous shaking.

• Head injuries may include:

‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

- External head injury (may be absent, though a haematoma is often found under the scalp in
case of blows).
- Skull fracture: Commonly caused by direct blunt trauma. It is usually a fissure fracture across
the temporal or parietal bone. Less often in occipital, frontal or basal bones.
- Subdural hematoma: may arise from direct impact or from vigorous shaking (causing
shearing stresses to the cranial contents → rupture of bridging veins in the subdural space).
- Cerebral oedema and diffuse axonal damage.
IV) Eyes:
• Up to 70% of battered infants have eye lesions
• They include vitreous hemorrhage, dislocated lens and detached retina, (resulting
from violent shaking or impact upon the head).
• 2024/2025
Permanent loss of vision is possible2024/2025
in such cases. 2024/2025

V) Ear
Cauliflower ear & slap marks caused by slapping by open hand.
VI) Mouth
- Lip abrasions, bruises or lacerations by blows to the face
- Torn frenulum of the upper lips (characteristic lesion) caused by tangential blow
across the mouth or by a feeding bottle being forced between lip and gum.

VII) Visceral injuries:

They are the second most frequent cause of death. They include:
- Intestine: In infants with thin anterior abdominal wall, blows on the front can sandwich
the duodenum and jejunum between the impact and the lumbar spine, crushing or even
cleanly transecting the gut, with consequent peritonitis and shock.
- Liver & spleen: Liver can be ruptured by frontal blows. The spleen is rarely damaged due
to its sheltered position from frontal trauma
References
✓ Clinical forensic medicine: Child abuse: physical, 3rd edition chapter 11.

Page 11 of 49
 ✓ Toskos, M., (2015): Diagnostic criteria for cutaneous injuries in child abuse: classification,
findings, and interpretation; Forensic Science, Medicine, and Pathology;11(2):235-242.

Assignment on Topic 2
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

1. Which of the following is rarely seen in battered baby syndrome?

A. Adult bite marks
B. Several burn marks
C. Skin bruises of various ages
D. Stab penetrating wounds

2. Which of the following is a characteristic oral lesion in child abuse in

infants?
2024/2025 2024/2025 2024/2025
A. Lacerated palate
B. Lip contusions
C. Missed tooth
D. Torn frenulum

3. Which of the following is characteristic regarding immersion scalds?

A. Asymmetrical distribution
B. Line of demarcation
C. Non-Uniform depth
D. Trickle pattern

Page 12 of 49
 CHILD SEXUAL ABUSE
Objectives
*Define sexual and emotional child abuse.
*Recognize characteristic signs that indicate sexual child abuse.
*Outline the steps of diagnosis of sexual child abuse.
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

Definition
It is the involvement of a child in sexual activity that he or she does not fully comprehend, is
unable to give informed consent to, or that violates the laws or social taboos of society.
Forms of sexual abuse
I) Contact activities:
❑ Penetrative: such as rape, buggery, oral sex or sexual penetration with an object.
❑ Non penetrative acts: as kissing, fondling one’s own or another person’s genitals, genital viewing,
exhibitionism & voyrism.
II) Non-contact activities:
❑ Sexual exploitation: a term defining offenses in which an adult victimizes a minor for sexual
gratification, or profit; for example, prostituting
2024/2025 2024/2025 a child, and in production
2024/2025 or watching

pornographic materials.
❑ Sexual grooming: making a child think that sex with the offender is normal or that they have
no choice. Offenders do this by building a relationship and emotional connection with the
child, for example in an online chat room.
N.B: Child marriage is one of the main forms of child sexual abuse; UNICEF has stated that child
marriage "represents perhaps the most prevalent form of sexual abuse and exploitation of girls"
Who commits the abuse?

Page 13 of 49
 Features that characterize child sexual abuse
• Physical force/violence is very rarely used; rather the perpetrator tries to
manipulate the child’s trust and hide the abuse.
• The perpetrator is typically a known and trusted caregiver.
• Child sexual abuse often occurs over many weeks or even years.
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

• Perpetrators usually engage the child in a gradual process of sexualizing the

relationship over time (i.e. grooming).
• The sexual abuse of children frequently occurs as repeated episodes that become
more invasive with time.
Behavioral indicators of sexual child abuse
• Regression in behavior, school performance or attaining developmental milestones.
• Sleep disturbances • Social problems
• Inappropriate sexualized behaviors • Depression
• Eating disorders • Poor self esteem
2024/2025 2024/2025 2024/2025

Findings that are suspicious of abuse or sexual contact include

1) Infections in genital areas:
• Recurrent vulvovaginitis.
• Vaginal or penile discharge
• Recurrent UTI
• STD or condyloma in children over the age of 2 years
2) Injuries in genital areas:
• Acute abrasions, lacerations or bruising of the labia, penis, scrotum or perineum.
• Hymenal notch/cleft
• Scarring or fresh laceration of the posterior fourchette.
• Anal complaints (e.g. fissures, pain, bleeding)
• Significant anal dilatation or scarring.
Findings that are definitive evidence of abuse or sexual contact
• Sperm or seminal fluid in, or on, the child’s body.
Assessment and examination of children with sexual abuse
• Where? at ER in acute cases, family physician center in non-acute cases.
• When? Within 72 hours of abuse.
Page 14 of 49
 • Who will examine? (SAFE CARE providers)
- Sexual assault forensic examination child abuse resource & education.
- By a specialist in clinical forensic medicine in co-operation with a
gynaecologist and/or a paediatrician.
• Why?
- Identify injuries & infections.
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

- Make good documentation of injuries.

- Collect forensic evidence (if recent abuse).
- Screen for STD & pregnancy
- Assess child and parents mental & emotional state.
- Reassurance & rehabilitation.
- Be available for court testimony.
N.B: Multiple examinations of the suspected victim must be avoided
Steps of examination of sexual child abuse
1. Taking consent & explain.
2. Interviewing the Child:
• The child’s disclosure is often the most important piece of information in determining the
likelihood of abuse. The child should be interviewed, preferably alone.
2024/2025 2024/2025 2024/2025
• Use open ended questions. Questions and answers should be recorded verbatim.
• A history should include information about the assault, including the use of a
condom or lubricants. Whether the victim has eaten, washed, voided, defecated,
bathed or douched since the contact.
3. Physical examination:
• Should be done gently
• Explain the examination beforehand to the patient and caretaker.
• A complete physical examination, including careful documentation of any
lacerations, ecchymoses or petechiae, is critical.
• Make good documentation of injuries: by sketches or photos.
• Examination of female child:
⎯ Choice of proper position: frog leg, knee chest & supine position
⎯ Magnification and illumination are essential.
⎯ The use of labial traction can greatly enhance visualization of the hymen.

Page 15 of 49
 ⎯ Locations of abnormalities should be described as on a clock face with the
urethra in the 12-o’clock position and the anus at the 6-o’clock position.
• Examination of prepubertal boys:
⎯ The physician should examine the penis, testicles and perineum for bite
marks, abrasions, or bruising.
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

⎯ Evaluation of the anus may be performed with the patient in the supine, lateral
recumbent or prone position with gentle retraction of the gluteal folds.
4. Evidence collection:
• It includes blood, semen, sperm, hair or skin fragments related to assailant or
debris (e.g., carpet fibers) that could link the assault to a location.
• Use of a Wood’s lamp may be useful in the detection of semen:
Areas that fluoresce should be sampled with a moistened cotton swab, and the
specimen sent for laboratory analysis.
• Maintain chain of custody.
5. Interpretation of Physical Findings:
Results of a physical examination will be within normal limits in 80% of child
2024/2025 2024/2025 2024/2025
victims of sexual abuse. Many forms of sexual abuse do not cause physical injury.
N.B. Why examination is often normal?
• It depends on: type of contact, force used and time interval between abuse and examination.
• Female adolescent victims of sexual assault are less likely to show signs of acute
trauma or evidence of old injuries than pre-pubescent girls.
N.B: Normal genital examination does not, therefore, preclude the possibility of sexual abuse.
6. Follow up
a) Plan for follow-up visits for STD assessment and pregnancy.
b) Assessment of psychological state of family
c) Plan for psychological support & rehabilitation.

References
✓ Guidelines for medico-legal care for victims of sexual violence. Clinical forensic
medicine: Child abuse: Sexual, 3rd edition chapter 12.
✓ Hornor, G., (2011): Medical Evaluation for Child Sexual Abuse: What the PNP
Needs to Know:J Pediatr Health Care; 25, 250-256.

Page 16 of 49
 Medicolegal Aspects of Female Genital Mutilation/Cutting (FGM/C)

− More than 230 million girls and women alive today have undergone
FGM in 30 countries in Africa, the Middle East and Asia.
− FGM is mostly carried out on young girls between infancy and age 15.
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

− FGM is a violation of the human rights of girls and women and

considered a form of physical, sexual and psychological abuses.
Definition of FGM:

According to WHO: Female genital mutilation (FGM) comprises all procedures

that involve partial or total removal of the external female genitalia, or other injury
to the female genital organs for non-medical reasons.

According to Egyptian Penal Code 58/1937 amended by law 10/2021

‫سنوات كل من أجرى ختانًا ألنثى بإزالة أي جزء‬
‫من‬2024/2025 ‫ُعاقب بالسجن مدة ال تقل عن خمس‬
2024/2025
‫ ي‬:‫ مكررا‬٢٤٢ ‫مادة‬
2024/2025

‫ و تكون العقوبة السجن‬،‫أعضائها التناسلية الخارجية بشكل جزئي أو تام أو ألحق إصـابات بتـلك األعضاء‬
.‫المشدد لمدة ال تقل عن خمس سنين إذا كان من أجرى الختان طبيبا ً أو ُمزاوالً لمهنة التمريض‬

Types of FGM according to WHO classification:

Type 1: This is the partial or total removal of the clitoral glans, and/or the
prepuce/clitoral hood.
Type 2: This is the partial or total removal of the clitoral glans and the labia
minora, with or without removal of the labia majora.
Type 3: Also known as infibulation, this is the narrowing of the vaginal opening
through the creation of a covering seal.
Type 4: This includes all other harmful procedures to the female genitalia for non-
medical purposes, e.g., pricking, piercing, incising, scraping and cauterizing the
genital area

Page 17 of 49
 Complications of FGM:
Physical problems
✓ Immediate Complications
Severe pain - Excessive bleeding (hemorrhage) - Infections e.g., cellulitis,
abscess, hepatitis C and tetanus - Urinary retention - Hemorrhagic shock -
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

Neurogenic shock - Death.

✓ Long-term Consequences
• Scarring leading to urethral stricture, labial fusion and keloid
• Urinary problems (painful urination, urinary tract infections)
• Future childbirth complications like difficult delivery, excessive bleeding,
tears and lacerations, caesarean section, need to resuscitate the baby and
newborn death
• Need for later surgeries: for example, type III may need to be cut open later
2024/2025 2024/2025 2024/2025
to allow for sexual intercourse and childbirth.
Psychological Problems
Post-traumatic stress disorder, anxiety, depression, and low self-esteem.
Long Term Sexual Problems
• Fear of sexual intercourse
• Vaginismus which is the involuntary spasm or contraction of muscles
around the vagina whenever penetration is attempted preventing it.
• Dyspareunia (pain during intercourse)
• Decreased sexual pleasure and satisfaction
References
✓ WHO 2024: https://www.who.int/news-room/fact-sheets/detail/female-
genital-mutilation
✓ UNICEF 2017: Proposal For Phase Iii Of The Unfpa-Unicef Joint
Programme Elimination Of Female Genital Mutilation: Accelerating Change
https://www.unicef.org/media/71786/file/JP-FGM-Phase-III-Proposal.pdf

Page 18 of 49
 Assignment on Topic 3
1. Which of the following is true regarding child sexual abuse?
A. Commonly inflicted by females
B. Occurs in repeated episodes
C. Physical force is a common practice
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

D. The perpetrator is commonly stranger

2. Which of the following is an unusual position for examination of sexually

abused female child?
A. Frog leg
B. Knee chest
C. Knee elbow
D. Supine
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3. Which of the following specimens is NOT a collected evidence in child sexual

abuse?
A. Blood
B. Hair
C. Semen
D. Stool

4. Which type of female genital mutilation involves partial removal of the

clitoral glans, or the clitoral hood?
A. One.
B. Two
C. Three
D. Four

Page 19 of 49
 Intimate Partner Abuse

Objectives
*Define intimate partner abuse and outline its forms.
*Recognize characteristic signs that indicate intimate partner abuse.
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

*Explain the mechanism of infliction of injuries in intimate partner abuse.

Definition
• Intimate partner abuse is a form of domestic violence by a current or former spouse or
partner in an intimate relationship against the other spouse or partner.
• Victims can be male or female, but females are victimized more often and sustain
more severe injuries than males.
What are the causes of and risk factors for intimate partner violence?
 Related to abuser (commonly male) :-
✓ Look introduction lecture p2.
2024/2025
Related to victim (commonly female):- 2024/2025 2024/2025

✓ Young female.
✓ Females with disabilities.
✓ Female has a higher level of education than her male partner.
✓ Exposure to domestic violence during childhood (e.g. females who are beaten in
childhood by parents are also more likely to be abused by intimate partners as
adults)
 Community & Social factors
✓ Lack of family, social and legal support for female.
✓ Lack of women’s civil rights, including restrictive divorce and marriage laws.
✓ Concepts such as female should tolerate violence in order to keep her family; male
has a right to assert power over a woman.
✓ Social acceptance of violence as a way to resolve conflict in a relationship and
high levels of general violence in society.
✓ Experiences of violence at home in childhood teach children that violence is
normal in certain settings. In this way, men learn to use violence and women learn
to tolerate it or at least tolerate aggressive behavior.

Page 20 of 49
 Forms of intimate partner abuse
I) Physical Abuse
- Physical Abuse injuries
✓ Skin (common)  Skeletal Visceral

✓ Skin injuries
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

- Bruises at different stages, multiple sites, patterned. Examples: pinch mark,

slap mark, bite mark and ligature marks around the wrists, ankles or neck.
- Dry burns (e.g. cigarette burns, burns from appliances) or Scalds.
✓ Skeletal injuries
- Fracture bones, sprains and dislocated joints.
✓ Visceral injuries

II) Sexual abuse:

• Is forcing or attempting to force a partner to take part in a sex act without partner
consent (not fully conscious or afraid to say no).
• Sexual abuse includes acts such as:-
✓ Intentional hurting to his partner2024/2025
2024/2025
during sex. 2024/2025
✓ Assaults upon the genitals including use of objects intravaginally or anally.
✓ Forcing his partner to have sex without protection against STDs.
✓ Forcing his partner for prostitution.
N.B. Marital rape or spousal rape is considered a form of domestic
violence and sexual abuse and defined as the act of sexual intercourse with one's
spouse without the spouse's consent. The lack of consent is the essential element
and need not involve physical violence.

III) Financial abuse:

Look introduction p 2.

IV) Emotional (Psychological) abuse:

• Look introduction p 2.

Page 21 of 49
 What are the consequences of intimate partner violence?
IPV affects women’s physical and mental health directly through injury and
indirectly via chronic health problems that arise from prolonged stress.
I) Effects on physical health:
✓ Multiple physical injuries that may even result in infirmity.
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

✓ Stress-related conditions such as irritable bowel syndrome, gastrointestinal

symptoms, chronic pain syndromes and exacerbation of asthma
II) Psychological and behavioral effects:
✓ Emotional distress, depression, anxiety, phobias, smoking, alcohol and drug
abuse, thoughts of suicide and attempted suicide.
III) Sexual and reproductive health effects:
Negative sexual and reproductive health consequences for women, including
unintended and unwanted pregnancy, sexually transmitted infections including
HIV and pregnancy complications such as abortion, stillbirth, premature labour
and low-birth-weight infants.
IV) Effects on children:
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There is association between IPV and negative social and health consequences
for children including anxiety, depression, poor school performance and negative
health outcomes. Also, exposure to IPV against the mother is one of the most
common factors associated with male perpetration and female experience of IPV
later in life.
References
✓ Forensic encyclopedia of forensic sciences: recognition of pattern injuries in
domestic violence victims: pages 384-390. W S Smock
✓ Heise L, Garcia Moreno C. Violence by intimate partners. In: Krug EG et al.,
eds. World report on violence and health. Geneva, World Health Organization,
2002:87– 121.
✓ Garcia-Moreno C et al. WHO multi-country study on women’s health and
domestic violence against women: initial results on prevalence, health
outcomes and women’s responses. Geneva: World Health Organization, 2005

Page 22 of 49
 Assignment on Topic 4

1. Which of the following is the most common type of injuries in cases of

intimate partner abuse?
A. Skeletal
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

B. cutaneous

C. Visceral

D. Vascular

2. Which of the following is rarely found in cases of intimate partner abuse?

A. Cigarette burns

B. Slap marks

C. Torn frenulum
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D. Black eyes

3. Which of the following is considered a psychological consequence of

intimate partner abuse?
A. Habitual miscarriage

B. Chronic pain syndrome

C. Permanent infirmity

D. Thoughts of suicide

Page 23 of 49
 Elderly Abuse

Objectives:
*Define elderly abuse and outline its forms.
*Recognize characteristic signs that indicate elderly abuse.
*Explain the mechanism of infliction of injuries in elderly abuse.
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

*Differentiate elderly abuse from accidental injuries.

Definition
Elderly abuse is a term referring to any intentional or negligent act by a caregiver
or family member that causes harm or distress to older people.
Who commits elderly abuse? (Perpetrators)
✓ Both men and women ✓ Caregivers
✓ Family members (Common) ✓ Strangers

Why are older people more vulnerable to abuse? (Risk factors)

• Abuser: See introduction lecture.
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• Elderly individuals:
✓ Has physical disabilities, dementia or mental illness
✓ Has depression or lack of social support
✓ Cannot fend for themselves emotionally or physically
Forms of elderly abuse
I) Physical Abuse
Physical abuse of the elderly involves the application of non-accidental physical
force against an elder that results in physical injury, pain or impairment.
• Physical abuse injuries
- Visceral injuries - Skeletal injuries - Skin injuries
✓ Skin injuries
- Abrasions, bruises at different stages, pinch mark, slap mark, bite mark
- Scalding burns, cigarette burns, burns from appliances
✓ Skeletal injuries
Fracture bones, sprains and dislocated joints.
✓ Visceral injuries: As rupture liver

Page 24 of 49
 II) Sexual Abuse
When an older person is forced to have sexual contact with another person when they are
unable to understand, unwilling to consent, threatened, or physically forced into the act.
• Sexual Abuse examples
✓ Forcing elder to watch sex acts and pornography.
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

✓ Forcing the elder to take off his clothes.

✓ Unwanted touching.
✓ All types of sexual assault such as rape and sodomy.
• Signs of sexual Abuse
✓ Torn or bloody clothes, especially underwear.
✓ Bruises, especially on the inner side of thigh or around the breasts or genitals.
✓ Bleeding from the vagina.
✓ Sexually transmitted diseases.
III) Emotional Abuse
✓ The infliction of anguish, anxiety, distress, fearfulness or withdrawn behaviors
to elder through verbal or nonverbal acts.
✓ Emotional abuse is the most under
2024/2025
reported abuse of elder abuse
2024/2025 2024/2025
but can have
the most damaging effects because it leads to more physical and mental health
problems.
IV) Neglect & Abandonment
✓ Neglect is a form of abuse where the perpetrator who has assumed
responsibility for providing care and support for an elder, do not provide the
elder with necessities of life
✓ Abandoning the person completely is also a type of abuse.

 Neglect examples
Refusal or failure to provide an older person with food, water, clothing, housing,
personal hygiene, medication or personal safety.
V) Financial abuse
 Financial abuse examples
✓ Using an older person's credit cards, cheques or bank accounts without his permission
✓ Deceiving an older person into signing any document (e.g., contracts)
✓ Forging an older person's signature
✓ Misusing or stealing an older person's money

Page 25 of 49
 ✓ Overpayment for goods or services
✓ Charging too much for services or billing for a service that he never received.
Warning signs of physical elder abuse
✓ Past history of hospitalizations, often for injuries that are similar.
✓ Attendance to various emergency rooms to avoid detection of abuse.
✓ A delay in receiving medical care for an injury the elder receives.
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

✓ Unreasonable explanations as to how the elder received an injury

✓ Strained relationships between caregiver and elder.
✓ Unexplained bruises, pressure marks, fracture bones, abrasions and burns
especially when present at sites which are difficult to be reached by accidental
injuries.
Warning signs of other forms of elder abuse
- Unexplained withdrawal of elder from normal activities, sudden change in alertness, unusual
depression and hesitant to speak freely (emotional abuse).
- Bruises around the breasts or genital area can occur from sexual abuse.
- Bedsores, untreated medical conditions, poor hygiene & unusual weight loss (neglect).
- Sudden changes in financial situations may be indicator of financial abuse.
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Differentiate elderly abuse from accidental injuries
Generally, it is difficult to distinguish between accidental and intentional
causes of injury in the elderly, because changes that occur with aging (e.g.
osteoporosis and brain atrophy) predispose to injury from relatively minor
trauma such as falls.
However, repetitive injuries (different ages), pattern and site of injuries may
suggest physical elderly abuse.

References

✓ Carolyn J. Hildreth, MD, Writer; Alison E and Burke, MA (2011): Elder

Abuse. JAMA ; 306(5):568.

✓ Donna M. Hunsaker and John C. Hunsaker III. (2006): Elder Abuse:

Challenges for Clinical Forensic Specialists and Forensic Pathologists in the
21st Century, edited by: Forensic pathology review volume 4 edited by
Michael Tsokos: pages 25:64.
Page 26 of 49
 Assignment on Topic 5

1. Which types of elderly abuse are characterized by the presence of bruises?

A. Emotional & physical
B. Physical & financial
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

C. Physical & sexual

D. Sexual & neglect

2. Which of the following is a most characteristic finding in cases of elder

abuse?
A. Bruises of different ages
B. Multiple deep cut wounds
C. Multiple stab wounds
D.
2024/2025 Hand and glove burns 2024/2025 2024/2025

3. Which of the following is considered a warning sign of emotional elder

abuse?
A. Bedsores & unusual weight loss

B. Hesitation of an elder to speak freely

C. Sudden changes in financial situations

D. Skin bruises in multiple body regions

Page 27 of 49
 Torture and abuse of human rights
Objectives
*Define abuse of human rights and outline its forms.
*Recognize characteristic signs that indicate physical abuse of human rights (torture).
*Explain the mechanism of infliction of injuries in physical abuse of human rights (torture).
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

Definition
- Torture is any act by which severe pain or suffering, whether physical or mental,
is intentionally inflicted on a person for such purposes as obtaining information
from him or punishing him.

- Most torture cases do not result in death. However, some cases progress to
fatality.
Problems
- The authorities in the state where it occurred may be totally uncooperative.
2024/2025 2024/2025
- In the living, they may have been retarded for months or years 2024/2025
after by time acute
injuries will have healed, bruises absorbed, and wounds and burns scarred over.

Features of torture & fatal physical abuse

Repetition of a particular injury is a common feature, because in ordinary assaults
and homicides such excessive and regularly repeated lesions would be unusual.

Common mechanisms include

I) Physical torture
1. Beating (Blunt injuries):

- It is one of the most common forms of torture.

- Weapons are more commonly used than hands or feet, such as whip, metal bars,
rifle butt or belts.

Page 28 of 49
 - Targets: The back is the most frequent target, but whipping and beating may be
applied to the buttocks, thighs, front of chest, breasts and abdomen, lower legs,
soles of the feet, and even perineum and genitals.
- Beating of the soles of the feet with canes or rods is commonly done and this
called 'falanga' which is extremely painful and do not readily reveal bruising.
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

However, bruising may be found on deep dissection in victims who have been
killed by some other means.
 Injuries include:
❑ Abrasions
❑ Bruises:
- A single- or double-edged linear bruise (tramline bruise)
- Intradermal bruising can reproduce the pattern of the weapon well.
However, deeper bruising can't reproduce the shape of the weapon.
❑ Lacerations
2024/2025 2024/2025 2024/2025

- If injuries were inflicted months before examination, only the scars can be found.
2. Burns:
- All kinds of burns may be suffered
- Burns are unfortunately common and may be either the actual cause of death or
visible as evidence of previous torture.
- Methods of inflicting burns: variable and may include:
• Extensive burns from molten rubber dripped into victims from motor tyres suspended
overhead.
• Hot irons applied to skin.
• Ignited kerosene-soaked rags wrapped around limbs and numerous burns from
cigarettes pressed into the skin.
• Acid and caustic liquids especially, battery fluid in the form of sulphuric acid.

Page 29 of 49
 3. Cutting and stabbing:

- With sharp instruments, commonly knives and bayonets are most common.
- The site may be anywhere but are common on the chest and upper arms.
- The scars of old wounds may show the shape of the instrument even to the extent
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

of revealing whether it was a single or double- edged blade.

4. Electrical torture:

- Electrical torture is common. It is painful and leaves little permanent signs.

- Carries risk of local burn and fatal cardiac arrhythmia.
- Targets: The current may be applied anywhere, but the genitals are sites favored
by torturers (especially the penis and scrotum) and female nipples.
- The later demonstration of electrical injury is difficult, as healed lesions have
few characteristic features. Special histological techniques in the dead body can
detect electrical injuries.
2024/2025 2024/2025 2024/2025

5. Suspension:

- It is common, but not often fatal in itself, can cause extreme pain with little
evidences.
- Abrasion, bruises may be found in ligature sites usually on arms, legs, sometimes
genitalia.

- Permanent brachial plexus injury even if short period of suspension with

peripheral neuropathy.
- The victims are often beaten during suspension with associated injuries.
- Pain & tenderness around shoulder joint with muscle wasting, atrophy, tears in
ligaments, dislocation of scapula.

Page 30 of 49
 6. Suffocation and drowning:

- Repeated dipping of the victim's head under water or even foul liquid such as
sewage and may cause drowning, or a later pneumonia.
- Enveloping the head in an opaque plastic bag is more a means of disorientation
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

than physical torture, but partial suffocation by similar means may cause death.

7. Water boarding:

- Consists of immobilizing individual and pouring water over his face to simulate
drowning, which produces a severe gag reflex, making the subject believe his
death is imminent while ideally not causing permanent physical damage.
Prolonged water- boarding can also result in death.

8. Sexual abuse:

- Is common in women, rape sometimes multiple, others include forced

2024/2025 2024/2025 2024/2025
homosexuality, trauma to genitalia.
- May leave physical signs.

II) Psychological (Mental) torture

 Direct threats, being forced to torture another person, witness the torture of
another person, or watch killings and rapes.
 Sensory deprivation includes detention in complete darkness, exposure to
bright lights and constant noises. Deprivations of food, potable water, sleep,
toilet, aeration, medical care, and communication.

✓ Reference:
D J Pounder (2005): Torture: physical findings and psychological assessment.
In: encyclopedia of forensic and legal medicine. Elsevier Ltd.1st edition:297-
308.

Page 31 of 49
 Assignment on Topic 6

1. "Immobilizing individual and pouring water over his face to simulate

drowning, but without submersion under water". This statement refers
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

to which of the following?

A. Suffocation
B. Suspension
C. Water boarding
D. Falanga

2. What is true about the bruises that result from falanga?

A. Readily seen under normal light

B. Deep and may not be seen

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C. Superficial and discoid

D. Single, butterfly in shape

3. Which type of torture can result in joint dislocation and ligament tears?
A. Burning

B. Cutting

C. Electrocution

D. Suspension

Page 32 of 49
 Role of physicians in cases of domestic violence
Objectives
*Identify the role of physician in cases of domestic violence and abuse of human rights

- Physicians are called on to play a large role in identifying, intervening in, and
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

following up cases of abuse.

- The physicians provide medical care but rely on community or in-house experts on
domestic violence to do most of the intervening.
- The physicians’ tasks can be summarized to the following 4 areas (AVDR): Asking
patients about abuse; Validating the message that battering is wrong and confirming
the patient’s worth; Documenting presenting signs, symptoms, and disclosures; and
Referring victims to domestic violence specialists.

Asking
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- When physicians routinely ask about domestic violence, they are successfully
fulfilling a major part of the intervention. Screening sends the message that battering
is wrong and is a health care issue.
- Making the question a normal part of the history taking helps to reduce discomfort.
Asking about abuse should be in a private, confidential setting, using nonjudgmental
tones and language. Family members should never be used as translators.
- Physicians need to develop their own way of asking patients about abuse. “How are
things at home?” is a standard screening question that can be embedded in other
questions on safety and used as an opening to more specific questions about abuse.
- Adding one question about domestic violence to the routine health assessment is an
important first step in improving health care.

Page 33 of 49
 Validating

- When asking patients about domestic violence, physicians must acknowledge that
battering is wrong and also confirm their patients’ worth.
- Clear, validating messages include compassionate statements that take the blame off
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

the victim: “You didn’t cause this; it isn’t your fault.” “You do not deserve to be hit or
hurt, no matter what happened.”
- Physicians should periodically revisit the topic of domestic violence, expressing
concern for the patient’s health and safety and offering hope for the future.

Documenting

- Physicians must document the presenting signs and symptoms of abuse as well as
any disclosures about the abuse by the victim. Notations in the medical record should
be specific and detailed. The victim’s direct words should be denoted with quotation
marks; a patient’s own words.
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- The physician may need to complete body maps and take photographs to document
specific injuries. Cameras that develop pictures instantly should be readily available
in all health care settings because pictures offer a firm record of the abuse.

Referring

- Physicians should refer abused patients to community advocates or on-site

specialists.
- Physicians working with no resources on site could refer the patient to an
advocate for victims of domestic violence at a local agency or hot line.
- If the patient is not ready to speak with a specialist in domestic violence, the
physician must offer the patient telephone numbers for referrals and try to
assess her immediate safety needs.

Page 34 of 49
 - These specialists would take complete histories of the abuse, thoroughly document
additional disclosures of the abuse, maintain the medical record, assess for safety and
develop a safety plan if indicated, refer to community services, develop a follow-up
plan, report to the police if required to by law, and inform the physician about all
interventions.
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

- If the identifying physician is the patient’s primary care physician, he/she would
follow up on domestic violence as a health issue in the patient’s life and provide
ongoing validation to lay the groundwork for change.

✓ Reference:
Clinical forensic medicine, a physician guide: non accidental injury in child: 2nd
edition, Chapter 5 pages 161:175

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Page 35 of 49
 Assignment on Topic 7

1. Reporting domestic abuse is a must in which of the following cases?

A. Any type of domestic abuse
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

B. Child and elderly persons

C. Female intimate partner

D. Intimate partner & child

2. Regarding the role of physician with a female victim of intimate partner

abuse; Which of the following statements is correct?
A. Ignore reporting detected injuries in female’ body.

B. Reporting after she consents to hospital authorities

C. Using statement like” all females are usually hurt”

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D. Reporting this abuse to the authorities is a must

3. X- rays can show characteristic signs for diagnosis of which cases of

domestic violence ?
A. Adult female abuse
B. Physical Elderly abuse
C. Physical child abuse
D. Sexual child abuse

Page 36 of 49
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

‫‪2024/2025‬‬ ‫‪2024/2025‬‬ ‫‪2024/2025‬‬

‫‪Page 37 of 49‬‬
 Physical Child Abuse: Cutaneous Injuries

Objectives
• Identify early warning signs of physical child abuse.
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

•Mechanism of infliction of injuries in child abuse.

•Differentiate physical child abuse from accidental injuries, murder and some similar clinical
conditions.

For each injury you should know:

–Type of injury
–Why it is probably a case of abuse
–Mechanism or circumstances of infliction
–Differential diagnosis

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Cutaneous injuries in child abuse are either bruises or burns.

Bruises are the most common sign.
Bruises are:
- Patterned wounds: caused by an object with specific pattern such as
o Discoid (fingertip)
o Tram line
o Knuckle bruises
o Pinch mark
o Slap marks
o Bite mark
o Black eyes.
o Others: e.g., restraint marks, sole of shoe marks, etc.
- Pinprick bruises: result from ruptured capillaries as suction bite or from
ligature.

Page 38 of 49
 Burns may be
- Dry burn (flame or contact) as hot irons (applied on the hands, buttocks or
legs). Taking shape of heated metal.
- Wet burn ( scald) resulting from dipping into hot liquid. Commonly found on
hands, buttocks, upper thighs (gloves & stokes).
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

Assignment on practical lesson 1

1. Differentiate between accidental and abusive scalds in children.

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Page 39 of 49
 Physical Child Abuse: Skeletal & Visceral Injuries
Objectives
• Identify types of skeletal & visceral injuries
•Mechanism of infliction of injuries in child abuse.
•Differentiate physical child abuse from accidental injuries, murder and some similar clinical
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

conditions.

Limb fractures include:

- Metaphyseal fractures: Common in tibia, distal end of femur and
humerus. They are caused by either traction & twisting of limbs or
limb-swinging during shaking a baby
o Corner s fracture: separation of corners of long bones.
o Bucket handle fracture: Epiphysis can separate from the
metaphysis as an arc.
- Spiral fracture: It results from limb twisting.
Rib fractures
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Commonly due to adult squeezing tightly of the chest during violent shaking
or direct trauma to the ribs.
Posterior & lateral rib fractures are highly specific for abuse. They are often
multiple in number and bilateral.
When fresh rib fractures heal by callus formation, a specific radiological
finding is seen (string of beads appearance) due to sequential callus formation
seen in vertical line down one or both paravertebral gutters.
Head injuries
Commonly caused by direct trauma: blows from a punch or heavy slap. It
may occur also indirectly by shaking the child’s head.
The commonest head injuries include:
- Fissure fracture: commonly at the temporal or parietal bone. Fractures
crosses sutures (diastatic).
- Subdural hematoma: It may arise from
o direct impact with or without skull fractures. Or

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 o vigorous shaking causing shearing stresses to the cranial
contents and rupture of bridging veins in the subdural space.
Ocular injuries
Abusive ocular injuries include:
- Black eye, scleral and conjunctival hemorrhages.
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

- Dislocated Lens
- Vitreous Hemorrhage
- Retinal Hemorrhages
- Detached retina.
They result from:
- Violent shaking of the head
- Direct impact upon the head.
Ear injuries
The pinna may be bruised or even lacerated usually by a slap.
Internal ear damage also may occur.
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Oral injuries
They include:
- Lip bruises or abrasions: They are caused by blows to the face: the
inner side of the lips may be bruised or lacerated by contact with the
tooth edges.
- Lacerations of soft palate.
- Torn frenulum: a characteristic lesion of physical child abuse. It is
caused either by a tangential blow across the mouth or forcing an
object as feeding bottle into the mouth between the lip and gum.
Visceral injuries
They include:
- Small intestine injuries: usually affecting the duodenum or jejunum.
The mechanism is a blow to the thin anterior abdominal wall that
sandwiches the intestinal loops between the impact and the lumbar

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 spine, crushing or even cleanly transecting the gut, with consequent
peritonitis and shock.
- Liver: frequently injured by frontal blows, even by deep prodding by
adult fingers
- Spleen is rarely damaged due to its sheltered position from frontal
trauma.
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

Assignment on practical lesson 2

Search for a picture representing one of the visceral or skeletal injuries
you learned and write a short paragraph about it explaining:
a) The type of injury

b) The probable mechanism(s) for its occurrence

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c) How you can differentiate it from an accidental injury to the same

body region

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 Sexual Child Abuse
Objectives
• Outline the steps of diagnosis of sexual child abuse.
• Identify characteristic signs of sexual child abuse.
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

Steps of examination
- Step 1 : Consent taking & explain
- Step 2 : Interviewing the Child
- Step 3 : Physical examination
- Step 4 : Evidence collection
Physical examination
It includes general and local examination
In general examination, the following signs are suggestive of sexual abuse:
- Love bites & Bites in buttocks, thighs, genitals.
- Discoid bruises &/or fingernails abrasions on inner & posterior
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thighs and genitalia (strongly associated with sexual abuse).
- Lips & mouth bruises and lacerations & around mouth.
In local examination, ensure the following factors:
- Good illumination
- Proper position
o In female children: examination of the hymen in frog leg, prone
knee chest, or supine positions
o In male children: examination of anus in supine, lateral
recumbent, or prone positions.
- Local findings suggestive of abuse:
o In female children: hymen is edematous & ecchymotic. Acute
laceration &bruising of posterior fourchette
o In male children: examine the penis, testicles and perineum for
bite marks, abrasions, or bruising. The anal opening may show
lacerations, bruises, dilatation and loss of normal anal shape.

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 Assignment on practical lesson 3
A three-year old female child was brought by her mother with complaints of
fever, vomiting, seizures, and disturbed consciousness She had allegedly
sustained a fall 20 days back and had fractured her left femur for which a cast
was applied, but her mother had removed it after a week without medical
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

consultation. There was no history of bleeding manifestations, easy

bruisability or family history of bleeding disorders.
At admission, the child was in early shock and had multiple healed scars and
multiple bruises at different ages of healing all over her body. Her left thigh
was swollen with abnormal mobility and crepitus. Radiograph of the left thigh
revealed a displaced fracture femur. CT scan of the head showed multiple
infarcts with edema and midline shift to left. There was no evidence of sexual
abuse.
The child had a progressive course with features of raised intracranial tension
and deteriorating hemodynamic status. She died due to her injuries on day
eleven of hospital admission. Her autopsy revealed diffuse subdural
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haemorrhage over the left hemisphere and congested brain with no evidence
of skull fracture.
1. Discuss circumstances this case had been exposed?

2. Justify your answer?

3. Outline the role of physician in this case?

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 Intimate Partner Abuse & Elderly Abuse
Objectives
• Identify signs of intimate partner abuse.
• Identify early warning signs of elderly abuse
• Differentiate physical elderly abuse from accidental injuries and some medical conditions.
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

Intimate partner abuse is a form of domestic violence by a current or former

spouse or partner in an intimate relationship against the other spouse or
partner.
Elderly Abuse is any intentional or negligent act by a caregiver, family
member or any other person who stands in a trust relationship to the elder that
causes harm or distress to older people.
Physical abuse:
- The use of non-accidental physical force against the partner or
elderly that results in physical injury, pain or impairment.
- Examples: Beating, Slapping,
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Burning
- Injuries:
o Skin injuries (common)
▪ Abrasions, specially dragging abrasions
▪ Pinch mark
▪ Slap mark
▪ Bite mark
▪ Ligature marks around the wrists, ankles or neck.
▪ Scalding burns
▪ Cigarette burns
▪ Burns from appliances

o Skeletal injuries
▪ Fracture bones
▪ Sprains
▪ Dislocated joints

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 o Visceral injuries
- In elderly people, some medical conditions and accidental injuries
may resemble abusive injuries.
Sexual abuse:
- It is forcing or attempting to force a person to take part in a sex act
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

without consent (not fully conscious or afraid to say no).

Financial abuse:
- It is restricting access to resources such as bank accounts, spending
money, funds for household expenses, employment, education, or
medical care.
Emotional (Psychological) abuse:
- The use of verbal and non-verbal acts with the intent to harm the
victim emotionally.
Neglect:
- This occurs particularly in2024/2025
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in partner
abuse if the victim has some disability that prevents the victim
from caring for oneself.

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 Assignment on practical lesson 4
A 25-year-old married pregnant woman arrived in a state of shock. She was
immediately moved to the operation theatre and intubated. Cardiopulmonary
resuscitation was performed for 10 minutes. The physical examination had
also revealed a bruised and oedematous left eye, bleeding from the mouth and
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

gums, and bruise marks on the left hand, with evidence of a wrist fracture.
Her abdomen was tense and tender, and she had vaginal bleeding. A
provisional diagnosis of uterine rupture was made. On laparotomy, around 1.5
litres of blood were found in the peritoneal cavity and a stillborn baby was
delivered. A vertical tear was identified in the left fornix of the vagina and
the lower uterine segment.
After the surgery, the woman was transferred to the intensive care unit, but
she died 24 hours later. On questioning the patient’s husband, he denied that
there had been any physical abuse and claimed that he did not know how it
had happened.
1.2024/2025
Discuss circumstances this case had been exposed?2024/2025
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2. Justify your answer?

3. Outline the role of physician in this case?

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 Abuse of Human Rights (Torture)
Objectives
• Identify different forms and types of torture.
• Outline the consequences of torture
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

Torture is any act by which severe pain or suffering , whether physical or

mental, is intentionally inflicted on a person for to obtain a confession
and/or information, or to punish.
Physical torture
It may be in the form of:
1) Beating by blunt or sharp instruments
2) Phalanga / falanga
3) Suspension (positional torture)
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Electric torture 2024/2025 2024/2025

5) Burns: dry or scalds

6) Asphyxiation procedures
7) Dental torture

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 Assignment on practical lesson 5
Search for a picture representing a form of physical torture that you
learned and write a short paragraph about it explaining:
a) The type of torture
‫ﻧﺪﻯ ﺍﺑﺮﺍﻫﻴﻢ ﻋﺒﺪﺍﻟﺮﺣﻤﻦ ﺍﻟﺸﺮﻧﻮﺑﻲ‬

b) The resulting injuries/consequences.

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c) The probable mechanism(s) of resulting injuries

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