Patterns of Injuries in Domestic Violence in a Romanian Population

Abstract

In Romania, the quantification of traumatic injuries is achieved in medical- legal services; therefore, each domestic violence (DV) victim needs a medical-legal certificate to prove in a court of law the presence of traumatic injuries. In this study, we aimed to determine the pattern of traumatic injuries in DV. A total of 219 consecutive DV cases were included. For each victim, a detailed medical-legal examination was performed, including specialized consults, if needed. Results were analyzed statistically using the SPSS software. Traumatic injuries in DV cases were usually located in the head, face, and neck areas and had a low severity index. Severe lesions were found in less than 10% and no sexual aggression was found. The severity increases with age and is higher for males than females. The pattern of DV–associated injuries we have encountered is similar to the one found in other similar studies. Knowing this pattern may be useful in clinical practice to detect cases of DV.

Keywords

domestic violence trauma lesions

Introduction

According to the “United Nations Declaration on the Elimination of Violence against Women,” and “EU guidelines on violence against women and girls and combating all forms of discrimination against them,” domestic violence (DV) is defined as

any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life. (García-Moreno, 1999; Ruiz-Pérez, Plazaola-Castaño, & Vives-Cases, 2007)

DV has a highly variable incidence (20% in Thailand, 25% in the United Kingdom and Russia, 26% in Chile, 28% in the United States, 35% in Egypt, 42% in Kenya, and 45% in India; Curca et al., 2008), being highly conditioned by (a) population characteristics—higher in rural, low-income, illiterate populations, and so forth; and (2) measurement methods—for example, in Romania official statistics counted 50,604 reported DV cases between 2004 and 2009 (1st trimester; a total incidence of 0.00043%/year), whereas a sociological study conducted in Bucharest in 2003 found a prevalence of 21%, value confirmed by similar studies performed in other counties (Buhas, Mihalache, & Radu, 2007; Popa, Covaciu, Gisca, & Botez, 2007).

World Health Organization (WHO, 2009) classifies the effects of violence against the woman in direct and cumulative. Direct effects are those directly connected to a specific violent act (bruises, abrasions, sexual assaults, etc.) and are easier to identify, quantify, and link to a specific cause. Cumulative effects are those determined by repeated violent acts (physical, psychological, or sexual); they are harder to quantify as they often lead to behavior changes or psychiatric consequences. Main consequences of DV on women’s health can be summarized into the following:

Traumatic lesions (physical or sexual abuse);

Reproductive health—STD’s (gonorrhea, syphilis, AIDS), unwanted pregnancies, abortions, fetal or pregnant woman pathology, and the like;

Psychiatric pathology—depressive disorders, posttraumatic stress disorder, sleep disturbances, anorexia, bulimia, anxiety, obsessive-compulsive disorder, and the like;

Associated physical symptoms—headache, back pain, fibromyalgia, abdominal pain, intestinal disorders, and the like;

High-risk behaviors—sexual abuse during childhood leads to increased risk-taking behaviors in adult life (early start of sexual activity, multiple partners, and unprotected sex), alcohol and drugs consumption, smoking, and the like; and

Death—HIV infection, honor crimes, suicide, female infanticide (frequent in India), septic abortion, and the like. (Ciobanu et al., 2007; Curca et al., 2008; Gracia & Herrero, 2006; Hadareanu, Cocora, & Nistor, 2007; WHO, 2009)

In Romania, the quantification of traumatic injuries is achieved in medical-legal services. These medical-legal services are organized in a hierarchical structure, with one national institute of legal medicine, six regional institutes, and, under their jurisdiction, local medical-legal services. They are purely expertal services and have departments for clinical-legal medicine (from which the cases presented in this study were obtained), forensic pathology, forensic toxicology, genetics, forensic psychiatry, and so forth. The medical-legal services functions outside the clinical health service system. If injuries needing specialized medical care are diagnosed in a medical-legal service, the patient is directed toward a clinical institution. Each DV victim needs a medical-legal certificate to prove in a court of law the presence of traumatic injuries. In these services, each lesion is carefully analyzed, dated, classified, and causally linked (or not) with the declared traumatic event. A study regarding the pattern of injuries associated with DV has not yet been conducted in Romania; therefore, there is no way of knowing whether this pattern is similar to the one found in other parts of the world or whether it has unique features. In this study, we aimed to determine the main characteristics of traumatic injuries in DV in a Romanian population. If a pattern is found and made known to other physicians, it might increase the awareness regarding this phenomenon and the percentage of DV victims identified in hospitals/medical offices, as it is known that they are extremely reluctant in divulging being aggressed by a close family member.

Materials and Method

From a consecutive number of 4,540 clinical legal medicine cases on a 2-year period, 788 declared to be victims of DV and 219 agreed to be included in the medical-legal study and to fill in a short questionnaire. The medical-legal study consisted of trauma analysis and was conducted during the medical-legal examination by medical-legal physicians. Age limits were not used as exclusion criteria. The main activity of clinical legal medicine in Romania is to objectify and quantify the severity of traumatic lesions in living persons, including trauma related to road traffic accidents, beating, work-related incidents, sexual assaults, and so forth. Medical-legal services are present in each county (more than one if the county is very large), have an administrative independence from other local authorities, but are subordinated to regional medical-legal institutes (six), which in turn are subordinated to a national medical-legal institute.

For each victim, a detailed medical-legal examination was performed, including specialized consults, if needed. Data were included in a *sav database and analyzed throughout the SPSS software. The study was conducted in the clinical medical-legal department; therefore, deaths due to DV were not included in the study.

Results

Only 27.8% (219 out of 788) of the victims agreed to be included in the medical-legal study when asked to participate, most frequent reason for refusal being fear of retaliation from the perpetrator or fear not to cause them a legal harm. Most cases were women (195 cases, 89%). Mean age for DV victims was 40 ± 12.754 years, higher for men (44.12 ± 19.583) than women (39.49 ± 11.611). Analyzing case distribution according to victim’s sex, we found a leptokurtic distribution in women (kurtosis = 0.244), with a maximum incidence around the mean (40 years) whereas male distribution, due to a decreased number of cases, could not be properly analyzed.

Out of 219 patients, only 9 declared victims of DV and did not have any signs of trauma when examined; 69.5% presented head or neck lesions (152 cases), 24.2% had thoracic or abdominal lesions (53 cases), and 58.9% had traumatic lesions on the upper and/or lower limbs (129 cases). Of the victims, 47.95% had lesions involving only one part of the body whereas 46.58% had injuries in more than one body part.

Table 1 presents the most frequent types of traumatic lesions. None declared or presented lesions typical for sexual aggressions (vaginal or anal traumatic injuries, grasping lesions on the inner side of the thighs, bite marks on the neck, breasts, or buttocks, and the like). Hematomas were strongly associated with head injuries (significant at p = .000), abrasions were strongly associated with limb injuries (significant at p = .006), whereas bruises had a more homogenous distribution.

Table 1.

Types of Traumatic Injuries

Type	Number of Cases	%
Bruises	179	81.7
Abrasions	92	42
Wounds	31	14.2
Fractures (nasal, maxilla, ribs) and dental trauma	23	10.5

By correlating the pattern of injuries (type, location) with the sex of the DV victim, we have identified a strong association between male sex and open wounds and between female sex and bruises. The severity of injuries affecting male victims was significantly increased compared with women victims, with a mean CD value of 6.50 (mean female CD value was 4.29).

The victims usually came to the medical legal service one day after the assault (101 cases, 46%); only 16% came on the same day (35 cases) and another 16% on the 3rd day (36 cases). The presence of limb injuries was positively correlated with an increased number of days between assault and the medical legal consult (Pearson’s r = .158, significant at the .05 level). There is a strong correlation between male sex and open wounds (Kendall’s τ = .235, significant at the .01 level) and between female sex and bruises (Kendall’s τ = .137, significant at the .05 level).

Usually DV victims are seeking medical-legal assistance the next day following a traumatic event (46%). The main reasons for this behavior are (a) in the day of the traumatic act, the perpetrator is at home, (b) the aggression usually occurs late, after work, and (c) the act is often associated with alcohol consumption (personal, unpublished data). Twenty-six percent came at the medical-legal service in the 3rd or 4th day, this behavior being usually associated with aggressions occurring during the weekend.

Severity of traumatic injuries was analyzed by two methods: (a) the need for specialized medical services and (b) a synthetic parameter, care days (CD), used in Romanian medical-legal service to quantify the severity of injuries. From the statements of the respondents, 96 needed basic medical care (43.84%)—pain medication, Band-Aids, and the like, and 41 needed specialized medical care (18.72%), of which 26 (11.87%) needed 1 or more days of hospitalization.

CD values were divided into four classes as presented in Table 2. The distribution of CDs revealed two peak values (0 and 4), and a very low number of cases with value 1 (Figure 1). The cause for the latter is the fact that usually CD is given as a range (e.g., 1-2 CDs), and in our study we only took into account the highest value. The only situation where a range is not given is at 0, meaning either the absence of traumatic injuries or the presence of traumatic injuries with absolutely no clinical consequences. Most injuries were caused by low/medium intensity assaults, as suggested by the prevalence of bruises and abrasions. Wounds and fractures were rare and with a moderate severity index (CDs above 20 were only quantified in three cases). Most were caused by impact with a blunt object (usually hands/fists but sometimes other household objects like plates or glasses).

Table 2.

Distribution of CD Values According to the Sex of the Victim and Sample Traumatic Lesions From Each CD Group

		Number of Cases
		Male		Female		Total
CD	Severity	No.	%	No.	%	No.	%	Examples
0	No traumatic lesion or very minor traumatic lesions	1	0.45	36	14.43	37	16.89	Small bruise
1-5	Minor traumatic injuries	11	5.02	112	51.14	123	56.16	Small abrasion, small hematoma, large bruise
6-19	Medium traumatic injuries	11	5.02	45	20.57	56	25.59	Large hematoma, nasal fracture, dental avulsion
>20	Severe traumatic injuries	1	0.45	2	0.91	3	1.36

Figure 1.

Care days frequencies

The severity of injuries affecting male victims was significantly increased (Kendall’s τ = .136, significant at p < .01) compared with women victims, with a mean CD value of 6.50 (mean female CD value was 4.29). Using the ANOVA test, we identified a positive correlation between the age group of the patient and the severity of traumatic injuries (p = .015, see Table 3).

Table 3.

CD Values in Different Age Groups

Age Group	M	N	SD
Below 20 years	3.90	10	3.510
20-29 years	3.97	35	3.831
30-39 years	4.19	69	3.953
40-49 years	4.16	48	4.692
50-59 years	5.45	47	5.012
60-69 years	3.00	4	0.816
70-79 years	13.00	4	12.570
80-89 years	2.00	1	—
Total	4.53	219	4.659

Discussions

The victims were most often hit in the head, face, neck (HNF) area (69.4%), a result similar to other studies regarding DV; for example, Brink et al. (Brink, Vesterby, & Jensen, 1998), in a study regarding the prevalence and pattern of injuries due to interpersonal violence in Accident & Emergency Departments in Denmark, found that HFN injuries represented 69% of all injuries. Ochs et al. found that patients who came in the emergency department for head, neck, and face injuries are 11.8 more likely to be victims of DV than individuals seeking treatment for other injuries (Ochs, Neuenschwander, & Dodson, 1996). Muelleman et al. found that battered woman are more likely to be hit in the face, neck, and torso, whereas other injured women are more likely to be injured in the spine and lower extremities (Muelleman, Lenaghan, & Pakieser, 1996). From a psychological point of view, the perpetrator attacks most often the HNF area as a means to depersonalize the victim. This type of traumatic act can continue after the victim is left unconscious which leads to an increased lethality. Other studies found a high tendency of the aggressor to strangle the victim (Brink, 2009). Even if we have not included in our study deceased victims of DV, we have encountered this behavior often in DV murder cases, especially associated with two circumstances—old-aged parents, with severely debilitating afflictions, usually psychiatric, murdered by their sons/nephews, and during crimes of passion. However, the overall severity of HFN injuries in our study is low, with a mean CD value of 4.97. A low HFN severity index was found to be associated with DV (Muelleman et al., 1996; Ochs et al., 1996; Seifert, Lambe, Anders, Pueschel, & Heinemann, 2009).

Limb injuries are also very frequent and often associated with head trauma (defense lesions) or falls, wherein the victims are pushed, leading to injuries (often abrasions) on prominent surfaces like the knees or elbows. Blunt force trauma of the upper extremities is a known indicator of DV, suggesting repetitive aggressive DV—the victim anticipates the aggressive act and tries to defend her or her vulnerable areas (Seifert et al., 2009).

Thoracic and abdominal injuries are less frequent (24.2%) and are usually less severe than both head and limb injuries. The aggressor hits these areas when he or she feels the victim is an equivalent adversary, which must be annihilated and not humiliated. Even if the force applied by the perpetrator is high, injuries often seem less severe than those from other areas as the victim usually wears clothes, decreasing the impact strength. Analyzing the distribution of different traumatic lesions, we found hematomas to appear more frequently in the cephalic region (the most frequent being palpebral lesions, followed by lip and scalp hematomas). Both orbit and lips contain a very lax subcutaneous tissue, favoring the appearance of hematomas; therefore, even if they are more severe than bruises on other parts of the body, they do not necessarily suggest a higher energy trauma. Cut or lacerated wounds have a random distribution.

The fact that DV victims are seeking medical assistance the next day following a traumatic event was identified by other authors as well and was positively correlated with DV (Christiano et al., 1986; Flitcraft, 1993) or sexual assaults with the perpetrator being a close relative (McCall-Hosenfeld, Freund, & Liebschutz, 2009). Ideally, to maximize injury identification, the victim must come to the medical legal service as fast as possible after a traumatic act; this is especially important for sexual assault victims as forensic sampling, emergency contraception, and HIV chemoprophylaxis must be conducted ideally within the first 72 hr but is almost equally important in nonsexual injuries as well, as some lesions fade or disappear after only a few days, decreasing characterization accuracy and dating.

Reijnder et al. found that 85% of all intimate partner victims had injuries in multiple parts of the body and 79% of the injuries were located on visible parts of the body (Reijnder, Van der Leden, & De Bruin, 2006). Petridou found that women with multiple injuries were 15 times more likely to have been aggressed by their partner compared with women with a single injury (odds ratio [OR] = 15.15, 95% confidence interval [CI] = [11.61, 19.77]; Petridou et al., 2002). Our study has showed that only 46.58% of DV victims had lesions on more than one body part; a possible cause may be the inclusion in our study of other types of DV as well, as the studies presented above specifically targeted intimate partner violence.

A CD range between one and four is associated with small bruises or abrasions, usually nonfacial. A CD of 5 to 20 suggests moderate intensity traumas, including most HFN lesions. CD was found to be higher in males, elderly, and especially in elderly males, an atypical pattern without an obvious explanation. From discussions with patients in this age and sex group, the main cause seemed to be alcohol consumption (by the victim, which seem to increase spouse’s aggressivity), and their health problems (incontinence, Alzheimer’s or vascular dementia), which seems to increase their sons’/nephews’ aggressiveness. A detailed research of the causes has not been conducted as this study was designed to analyze only the medical-legal consequences of DV.

The correlations between male DV and open wounds, females sex and bruises, and increased severity and male sex were found by other authors as well; for example, Brink found male DV victims to be more frequently associated with open wounds in head-neck area whereas females usually had less severe injuries (especially bruises; Brink, 2009).

Most of the DV victims in our study are female, around 40 years old and were hit usually in the HFN area, often presenting defense injuries on the upper limbs and/or fall-related injuries on the prominent parts of the body; injuries were with a mild-moderate severity and the victims usually came to the medical-legal service 1 day after the aggression (more if the aggressive act occurred during the weekend). Recognizing injury patterns in battered woman can aid the diagnosis of DV and subsequently allows sending them toward specialized social services (Danis, 2003; McCaw, Berman, Syme, & Hunkeler, 2001). Recognizing a DV victim may be extremely difficult as they often deny being aggressed by a family member (Kocacik & Dogan, 2006; Mayda & Akkus, 2004; Roberts, Otoole, Lawrence, & Raphael, 1993; Siemieniuk, Krentz, Gish, & Gill, 2010); therefore, to identify it, the physician must often rely on injury pattern analysis and other circumstantial proofs. Other elements have been cited to aid the diagnostic of DV as well: a reported cause of injury incompatible with the actual pattern of injuries, differences between the actual date and the reported date of injuries (more obvious in child abuse but also present in adult DV; Fulga, Musat, Crassas, & Ceavdari, 2008), familial excuses to explain the injuries (the patient claims to have fallen and hit his or her face; Le & Blum, 2011; Ochs et al., 1996; Sims et al., 2011), coexistence with pregnancy (Garabedian et al., 2011; Hostiuc, Curca, & Dermengiu, 2011), drug abuse and, alcohol consumption (Angelucci, 2008; Bhatt, 1998; Fonseca, Fernandes Galduroz, Tondowski, & Noto, 2009; Jewkes, Levin, & Penn-Kekana, 2002; Livingston, 2011; Maffli & Zumbrunn, 2003; Moreira et al., 2011; Tauser, 2009), an alcoholic husband (Ochs et al., 1996), depressive disorders and suicide attempts (Espinoza-Gomez et al., 2010; Karmaliani et al., 2008), violent behaviors against male hospital personnel (Christiano et al., 1986; Flitcraft, 1993), and so forth.

Most of the results obtained by our study are in accordance with others regarding DV, suggesting that this phenomenon has a set of common injury types which may be helpful in identifying DV victims. The particularities of DV in different parts of the world, like honor crimes using jambia in Yemen (Dermengiu, Naji, Curca, & Hostiuc, 2011) or aggressive acts against women carrying female children in India (Luthra, 1993; Mankekar, 1988), do not seem to significantly change the overall morphological pattern of injuries even if they are prone to increase the severity of DV acts.

Limitations

The study was limited by the small size of the male group. The circumstances or the consequences of the aggressive acts could not be properly objectified, as they were out of our control and could only be partially obtained through a questionnaire.

Footnotes

Declaration of Conflicting Interests

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

Funding

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

Bios

George Cristian Curca is associate professor of legal medicine and bioethics at the Carol Davila University of Medicine and Pharmacy, Bucharest, Romania (from 2005), vice president of the Bioethical Committee of the Romanian College Board, and deputy manager of the National Institute of Legal Medicine, Romania. His scientific activity is directed toward studies regarding sudden cardiac death and interpersonal violence (especially domestic violence and violence against physicians).

Dan Dermengiu is professor of legal medicine and bioethics at the Carol Davila University of Medicine and Pharmacy, Bucharest, visiting professor of forensic pathology at the University of Huddersfield, and general manager of the National Institute of Legal Medicine Romania. His main area of scientific activity is directed toward studies regarding sudden cardiac death and toxicology (drugs of abuse, alcoholism, and their consequences).

Sorin Hostiuc is assistant professor of legal medicine and bioethics at the Carol Davila University of Medicine and Pharmacy, Bucharest. His scientific activity is directed toward bioethics (especially reproductive bioethics), interpersonal violence (especially domestic violence and violence against physicians), and molecular biology (studies in the area of sudden cardiac death and interstitial cells of Cajal).

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