Advancing research on femicide prevention: A mixed methods approach

Abstract

Femicide, the killing of women, girls, and infants, is a pervasive problem affecting all global societies. Policy and research are impeded by inaccurate and missing prevalence data, gaps in understanding of femicide, especially for hard-to-reach marginalized populations, and conflicting perceptions between jurisdictions. Leveraging on a combined socio-ecologic model and Public Health approach, the paper spans the methods of a computed tomography-based injury study, an in-depth media-analysis, a legislation evaluation study, and a data barriers’ study. Injury patterns, media depiction, and end-user consultations will close the loop on residual problems such as implementation, data gaps, and cultural perceptions. By mixed methods research representing multiple regions, and stakeholders, this project will enhance knowledge on interpersonal, institutional, and societal factors of femicide, advancing the humanitarian forensic discipline. The research method will identify emerging trends and facilitate improvements in tertiary prevention of femicide, specific to resource settings.

Keywords

Coroner forensic medicine human rights legal system

Introduction

Significant parts of the world are battling with issues of gender-based violence and femicide; a humanitarian crisis. Femicide, defined as the murder of women, girls, and infants with a gender-based intent, can be either direct or indirect.^1,2 Direct femicide types are sex motivated homicide, dowry related homicide, intimate partner homicide, killings due to perceived slights to honor, acid attacks, genital mutilation leading to death, alleged witchcraft related homicide, violence directed against sex workers; hate crimes such as trans femicide; sex selective abortions and infanticide; and maternal homicide.^3–7 Indirect femicide encompasses human trafficking, armed conflict, gang-related activities or feminicide. Feminicide is the act of the state's direct commission of unlawful killings or tolerance of perpetrators’ acts of violence.⁸

Commensurate policy warrants a clear understanding of the specific acts that are gender related. Various administrative and community-based measures include femicide-specific legislation, social media advocacy, and data informed initiatives (e.g. femicide observatory and Femicide Watch). Critical data gaps, lack of implementation of laws, and gender discrimination potentially increase the risk of an inadequate femicide response.^1,2,9

A key gap in comprehending femicide burden is that the definition of femicide is ad-hoc and inconsistent between jurisdictions. Femicide reporting rates are low and record keeping is not standardized.¹⁰ Data frameworks such as mortuary-based surveillance,¹¹ International Classification of Diseases (ICD) 11,¹² and the International Classification of Crime, United Nations,¹³ are thus far in-transition or possess insufficient evidence regarding their usability for the representation of femicide injury/context. Accurate numbers on femicide variants are difficult to source, thus undermining targeted intervention.¹⁴

Humanitarian forensic medicine represents an intersection of human rights and forensic medicine in societal issues such as violent deaths, homicide including femicide, sexual crimes, gender-based violence, different forms of child abuse, torture, and deaths in custody.¹⁵ Transdisciplinary research is a relatively new and upcoming method in homicide studies¹⁶ and could be applied in humanitarian issues. Existing research such as the Preventing and Assessing Intimate Partner studies, though led by a team of transdisciplinary researchers, only address domestic variant of femicide and individual-risk characteristics.^17,18 A 2018 literature analysis¹⁹ on femicide recommended case control studies, person-based research (conviction rate, restraining order) or (proxy) next-of-kin interviews as methods. Health-service contact was one institutional measure discussed in that review.

Each of the four disciplines covered in the literature review below contribute towards a complete understanding of femicide and societal/agency response. However, each discipline appears siloed, and none displays a shared perspective.

Literature review

Injuries

Skeletal injuries, may be indicative of mechanisms associated with hate and gender-based femicide, in particular, overkill.²⁰ The Safarik and Jarvis study reported injury severity to be predictive of offender characteristics such as, demographic profile and drug usage,²¹ however, recent empirical research proposes that this observation may be valid at group level only.²² According to the Flieger study, skeletal damage is observed to occur in many femicide cases. Injuries to the skeleton can be caused by blunt force, sharp force, gunshot, or application of compressive forces to the neck.²³ Of 151 family homicide cases, an Australian population study reported fractures of facial skeleton and or dental injuries in 31.8%, a significant burden,²⁴ however the injuries were not disaggregated by sex.

Skeletal injury patterns in femicide are not that dissimilar to injuries in women who have experienced near-fatal violence. Computed tomography (CT) scans have played a significant role in identifying cases of nonaccidental trauma in children.²⁵ Thus, it has the potential to enable the identification of injuries resulting from femicide. Although domestic femicide is usually preceded by a history of previous partner violence, it is not uncommon to encounter cases that would not be picked during risk assessments.²⁶ An in-depth study of fatal injury patterns may provide insights on risk factors, data bias, and aid in supporting forensic pathologist's court testimonials.

Media representation

Media reporting is a barometer of social and cultural standards that reinforce or challenge violence against women in societies.²⁷ While news coverage of a femicide incident reportedly trigger an increase in help seeking in gender-based violence survivors,²⁸ such news may also incite discriminatory narratives and biased representations of victims/perpetrators.²⁹ A greater foreshadowing of victim's background and a limited discourse of perpetrator-related characteristics in media reports tends to absolve the perpetrators of their share of responsibility.³⁰

Media reporting may be biased with regional variations in the type of femicide discussed in social media. For example, studies show that media coverage was not representative of the various types of non-intimate femicide in South Africa,³¹ and that the Spanish press was mostly prone to covering non-intimate femicide, often caused by strangers.³² Accurate media reporting holds the power to shape societal perceptions especially for younger adults.³³

Legislation

Despite acknowledged challenges in influencing law reform, femicide criminalization is attributed to raising social and administrative awareness for gendered killings.³⁴ Legislative reforms can be traced to Latin American countries where femicide or feminicide has been a specific criminal offence since 2007. Although that law uses the term femicide for both forms, there is no clarity about state accountability.³⁵ Besides the legal mandate, additional institutional measures include the establishment of medicolegal death investigative guidelines, and injury surveillance systems. These actions have reportedly decreased homicide numbers to some extent in countries such as Colombia.³⁶ The femicide law tends to criminalize different types of femicide subject to regional settings. For example, the Argentinian legislation recognizes hate crimes due to the gender identity of victims as femicide, however, Brazil excludes transgender women from its legal mandate.

In India, dowry related killings were specifically criminalized in 1986,³⁷ but the legislation usage has not been researched. In European law, gender related factors are usually considered as aggravating circumstances. To address hidden issues of cultural diversity, the Inter-American Model Law was approved in December 2018, however to date, the law is not widely recognized in the region. International human rights law has been successfully adapted for justice delivery in Mexico and Honduras killings, for example the Cotton Field case vs Mexico State, and Vicky Hernandez, a trans femicide trial at the Inter-American Court of Human Rights.³⁸

Data reporting

The methods of investigation and data reporting in femicide observatories and Femicide Watch organizations display wide variations. These observatories are largely academic and/or community-based initiatives with their success contingent on local circumstances and resources. Although the observatories capture the local picture, they may lack the judicial framework ensuring their long-term status. To date, there is no standardized guidance for depicting gender indicators in data.³⁹ Medicolegal data is crucial for public health responses to issues such as violent deaths including femicide. Although the World Health Organization (WHO)-specified medical cause of death is routinely recorded in several prescribed parts by forensic pathologists, the information is inconsistent in terminology/detail/style. Though aligned to statistical purposes, ICD coding lacks specificity and does not necessarily represent the pathologists’ reporting of cause of death.

Project rationale

Interdisciplinary approach, increasingly used in South-African and Latin American initiatives for femicide data standardization,^40,41 indicates that the most effective measures are a combination of responses from social work, healthcare, and the justice system. Whilst a quantitative study in the current project, will analyze skeletal injury patterns in female killings using CT scans, three qualitative studies (media-, legislation-, and data-based) will explore stakeholder sentiments on femicide perception, investigation, and reporting. The studies span different world regions (Australia, Africa, Asia, and Latin America). Evidence supports the use of multi-country qualitative research for addressing global health problems.⁴² The research purpose is to enhance knowledge of gender indicators, informing humanitarian forensics, and agency/community response.

Theoretical framework

The project's theoretical framework is based on the socio-ecological model (SEM) and the Public Health Approach encompassing individual, institutional, and community-based protective/risk factors.⁴³ The SEM will unpack the complex interaction between institutional (forensic doctors, women's rights organizations, medical coders, and data managers) and individual (risk of injury) factors. A similar theoretical framework was adopted in a 2019 South African PhD project on femicide that combined crime statistics, mortuary based and media based studies.⁴⁴ The Public Health approach will guide the identification of residual problems in the extent and nature of femicide responses by legal and administrative institutions.

Aims

The study aims are: (a) to identify the skeletal injury patterns inflicted in a representative population of women, girls and infants in an Australian state; (b) to identify the role of the Australian news media in shaping civil society perception of femicide; (c) to explore the effects and challenges associated with the legislative requirements in a Latin American state; and (d) to describe the barriers in femicide data reporting (multi-country). Table 1 lists research questions of all studies.

Table 1.

Research questions.

Study	Research questions
Skeletal Injury	What are the skeletal injury patterns of the head, face and neck region in femicide? What are the incident, socio-demographic, and clinical characteristics, and underlying cause of death mechanisms associated with femicide? What is the severity of all skeletal head, face and neck injuries and are they associated to cause of death?
Media-based	How is femicide reported on by the Australian media, including incumbent understandings and attitudes? Is the media's representation of femicide an accurate reflection of the state of femicide in Australia, and known attitudes and understandings of gender-based violence of the Australian population? What responsibility does the Australian news media have in its portrayal of femicide? What role does the Australian news media play in influencing attitudes and understandings of femicide in the Australian population?
Legislation-based	What elements of the femicide law and investigation guides in Colombia are reflected in practice? What is the extent of consistency between the femicide law, guides, and user understanding?
Data Barriers’	What procedures should epidemiologists, medical coders, and forensic doctos adopt to ensure optimum collection, coding, and standardized reporting of femicide injury data?

Methods

The project design is mixed methods. All four studies are based at the Department of Forensic Medicine of an Australian University, co-located with the state forensic institute. At the institute, all admitted deceased persons undergo a full body high resolution postmortem computed tomography scan (PMCT). Approximately 50% undergo an autopsy to determine the cause of death, with 50% having their cause of death reliably determined by imaging, body inspection/examination, and related documentation. This repository contains more than 100,000 medicolegal reports of death, PMCT scans, and toxicology/DNA samples. The database increases at a rate of approximately 7000 scans annually.

Proof of concept was established by empirical studies (Australian) on family violence homicide,^24,45 which has some overlap with femicide.

The units of analysis are service/community response or person based. The 4 studies are:

Skeletal injury study (Study 1): A retrospective cross sectional blinded study (Australia) to determine the characteristics of skeletal injuries in all female homicide using source data (postmortem CT scan and autopsy reports).

Media analysis (Study 2): A content and discourse analysis of Australian media depictions of femicide to describe their role in shaping civil society attitudes and understandings.

Legislation and administrative protocol analysis (Study 3): A qualitative analysis of the Colombian forensic doctors and women's rights organization to explore the service impact of femicide-specific legislative/administrative guidelines.

Data barriers’ study (Study 4): A multi-country qualitative analysis to identify the barriers in the representation of gender-based indicators in femicide data.

Data sources, case selection

Case selection/sampling methods, and variables are described in Table 2, and Online Resource Table A. Qualitative data will be reported using the COREQ and quantitative data will be based on the STROBE guidelines. Qualitative instruments of studies are included in the Online Resource.

Table 2.

Case selection/sampling methods

Study	Country setting	Data source	Inclusion	Exclusion
Skeletal Injury	Australia	family violence homicide data^a PMCT, photographs	All age groups Sex: Female (State population) Period: 2006–2018 external cause deaths (assault) closed cases	PMCT not available No autopsy reports Body not received Extensive decomposition, severe effects of fire/human remains with no detectable skeletal injuries in PMCT
Media-based	Australia	Factiva	Search string: “femicide* or (female* near3 homicid*)” Published in Australia English articles Period: 11/04/2020 to 11/04/2023	Non-Australian articles Duplicate articles (same article published online and in print, and in sibling papers) Articles with an irrelevant article style (e.g., Television guide stating a femicide program or female perpetrators)
Legislation-based	Colombia	interviews	Interviewees: forensic doctors; human rights experts and Non-Government Organization employees
Data Barriers’	Multi-country	Interviews, web survey	Interviewees: epidemiologists, practitioners (forensic doctors, researchers and managers) of the 2012 Fatal Injury Mortuary Surveillance Tool (WHO); Medical coders at a Statistical agency, and a Data Register

Note: Family violence is defined in Australia as any threatening, coercive, dominating or abusive behavior that occurs between people in a family, intimate or family-like relationship that causes the person experiencing the behavior to feel fear. PMCT = Postmortem Computed Scan; WHO = World Health Organization.

^aCases established in PhD studies of primary author.

Ethics approval

All four studies have been granted ethics committee permissions by the relevant Institutional Review Boards.

Data gathering

Study 1

Study 1 is an analysis of CT scans of female homicide skeletal injuries in an Australian state. The list of closed (coroner's investigation complete) cases was established by a standardized methodology.^24,45,46 A researcher will classify the skeletal injury patterns of the head and neck, remaining masked to the victim perpetrator relationship and case circumstances. Once injury analysis is completed, the blinds will be removed, and skeletal injury disaggregated by relationship (victim-perpetrator) type. Relationship types will be classified as domestic femicide (e.g. intimate partner, parent child) or non-domestic femicide (e.g. stranger). A modified injury severity scale²¹ will establish correlation to the cause(s) of death, underlying mechanism (e.g. weapon use, manual neck compression), and overlying/surrounding soft tissue injury, for example contusion, laceration (see Online Resource).

Study 2

This study will identify the manner of femicide reporting in the Australian news media, and related implications. A dual content and discourse analysis of recent news articles will be conducted. Findings will be benchmarked against known attitudes and understandings of femicide from the 2021 National (Australia-wide) Community Attitudes towards Violence against Women Survey.⁴⁷ In doing so, this study will determine if the news media is an objective reflection of the femicide incident including promulgation of myths and of Australian population's attitudes.

Study 3

To assess legislation implementation, interviews will be conducted with frontline staff/community groups (forensic doctors and women's rights organization members) impacted by femicide law. Based on the size and field reputation of their forensic institute and the availability of femicide law and investigative guidelines, Colombia is selected.

Study 4 (data barriers’ study)

A qualitative analysis will draw on best practice recommendations for gender-sensitive data recording and injury classification. Convenience sampling will include experts using surveillance systems, and observatorial methods. These experts have more than a decade of experience in working with mortality datasets and or using observatorial study methods. Observatorial design uses multiple data sources to enhance case frequencies and address incomplete data.⁴⁸ The surveillance systems are:

A fatal mortuary injury surveillance tool trialled by six African and Southeast Asian Countries under a WHO 2012 initiative.⁴⁹

A Colombian epidemiologic surveillance system

Two mortality registers (the Australian Bureau of Statistics⁵⁰ and a state Homicide Register⁵¹).

Data analysis

The quantitative results will be reported by the Statistical Package for Social Sciences version 28⁵² and descriptive results expressed as medians and interquartile range and or percentages and proportions. Braun and Clarke's analysis method⁵³ and NVivo⁵⁴ will be used for the qualitative studies. Content and discourse analysis will be analyzed in excel.

Reflections on the process

Although the results of the four studies will be reported separately, an integration exercise will be performed using a side-by-side joint display under the convergent mixed methods design.^55,56 Integrated findings will be reported in a separate paper. That paper will draw a composite picture across various death investigations and data management systems.

Major patterns of interrelatedness are expected across the studies. Contextual injury patterns (Study 1) may be mirrored by the media and data studies (Studies 2, 4). Injury variables such as underlying mechanisms, injury severity (Study 1), and correlation of skeletal injuries to coexistent injuries describe the potential correlation to typical femicide injuries. These typical injuries are described in the Colombian guideline on femicide and feminicide.

Discussion

To date, no single approach has managed to decrease the incidence of femicide or modify the beliefs that propitiate femicide. An interdisciplinary method underpinned by the socio-ecological model and the Public Health approach will interpret the key risk factors and attitudes associated with femicide. Leveraging on a mixed methods design, and multi-country data, the methods will unmask gender-based perspectives, and region-based best practice.

Significance

Study 1

Potential correlations of skeletal injuries with overkill, mechanism of injury and overlying soft tissue injury is a research question that is relevant in criminal court proceedings in intentional deaths. An injury-informed approach will enable an objective injury severity assessment of all female homicide (and not just femicide). The study, guided by forensic pathologists and injury researchers, will facilitate high quality ascertainment of injuries.

Study 2

News media reports are pivotal for community information and are drivers of change. The media has a responsibility to educate and move the needle on sentiments of civil society. Determining biases is essential as attitudes and understandings are indicative of deep-seated patriarchal sentiments in the community. A content and discourse analysis of the media articles in a high development index country will unpack the intrinsic systemic beliefs of patriarchy.

Study 3

Law efficacy will be determined by querying the ease of interpretation and application of femicide definition, and convictions based on the usage of femicide law. To this effect, the inclusion of women's organizations will represent female population experiencing gender-based violence.

Study 4

The data barriers study will collate the experiences of medical coders, epidemiologists, and forensic doctors regarding the success and limitations of different data coding practices. Considering varying resources, a data management tool tailored for one setting may be less effective in another. Hence, region-specific measures will be gathered.

Strengths

Study bias will be minimal as source (injury) data will be assessed in a blinded study. Use of blinding is a recommended means of mitigating risk of observer bias.⁵⁷ All professional networks at the forensic institute will be used to maximize participant recruitment and overcome sampling difficulties encountered with hard-to-reach target populations. Through its enhanced experimental design, the mixed methods approach will provide input or reinforce the findings of multiple experts and contribute to a better understanding of the bigger picture (via joint display).

Limitations

Some participants may not be English speakers, mandating translations services. Convenience sampling of the qualitative study participants may lead to selection bias. Data on primary perpetrators and their characteristics is beyond the scope of the current victim-based project. Given the administrative and resource barriers (e.g. ethical approval, cost of linkage), linkage studies will not be pursued.

Visions for future

The study could culminate in a separate research on mental health issues in perpetrators substantiated by existing evidence that psychiatric disorders, and previous suicidal ideation, are important indicators for predicting and possibly preventing intimate partner femicide.⁵⁸ Similarly, environmental pressors, such as influence of pandemic closedowns on femicide prevalence, could be explored.

Conclusion

This unique mixed methods project introduces a novel research approach to studying femicide, addressing limitations imposed by cultural perceptions, and gaps in data, legislation, and injury patterns. The study will lead to comprehensive knowledge gain on the global issue of femicide and will inform multiple original studies in future.

Supplemental Material

sj-docx-1-msl-10.1177_00258024241270818 - Supplemental material for Advancing research on femicide prevention: A mixed methods approach

Supplemental material, sj-docx-1-msl-10.1177_00258024241270818 for Advancing research on femicide prevention: A mixed methods approach by Reena Sarkar, Nicholas Dempsey, Clare Toulmin, Joel Forthun, Annika Spiers, Chloe Dalla-Fontana and Richard Bassed in Medicine, Science and the Law

Footnotes

Acknowledgments

The authors acknowledge Professor Morris Tidball Binz, (United Nations Special Rapporteur for Extrajudicial, Arbitrary and Summary Executions), Professor Emeritus Stephen Cordner (Head of International Programs, Victorian Institute of Forensic Medicine, Australia), Professor Emeritus Joan Ozanne-Smith (Head of Injury Prevention Research Unit, Department of Forensic Medicine, Monash University Australia), and Dr Michael Burke (Senior Forensic Pathologist, Victorian Institute of Forensic Medicine, Australia) for sharing their expertise. They thank the Victorian Institute of Forensic Medicine, Australia for their invaluable data.

Author contributions

Conceptualization and methodology were done by Professor Richard Bassed, Dr Reena Sarkar, Dr Nicholas Dempsey; formal analysis and investigation were done by Clare Toulmin, Joel Forthun, Annika Spiers, Chloe Dalla-Fontana; writing the original draft preparation was done by Dr Reena Sarkar; writing the review and editing were done by all authors; Professor Richard Bassed provided resources; supervision was done by Professor Richard Bassed and Dr Reena Sarkar.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical approval

Skeletal injury study: Victorian Institute of Forensic Medicine ethics committee (2023 - 1259 −2386/3/dated 28/02/2023, and 2023 - 1259 - 2390/1/dated 4/04/2023).

Media based study: Monash University Human Research Ethics Committee, 38172/2023.

Legislation study: Monash University Human Research Ethics Committee, 37826/2023.

Data Barriers study: Monash University Human Research Ethics Committee 37846/2023.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Reena Sarkar

Supplemental material

Supplemental material for this article is available online.

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