clinical forensic medicine · forensic science-and- medicinesteven b. karch, md,series editor...

Clinical Forensic Medicine

F O R E N S I CS C I E N C E - A N D - M E D I C I N E

Steven B. Karch, MD, SERIES EDITOR

CLINICAL FORENSIC MEDICINE: A PHYSICIAN'S GUIDE, SECOND EDITIONedited by Margaret M. Stark, 2005

DRUGS OF ABUSE: BODY FLUID TESTINGedited by Raphael C. Wong and Harley Y. Tse, 2005

FORENSIC MEDICINE OF THE LOWER EXTREMITY: HUMAN IDENTIFICATION AND TRAUMAANALYSIS OF THE THIGH, LEG, AND FOOT, by Jeremy Rich, Dorothy E. Dean,and Robert H. Powers, 2005

FORENSIC AND CLINICAL APPLICATIONS OF SOLID PHASE EXTRACTION, by Michael J.Telepchak, Thomas F. August, and Glynn Chaney, 2004

HANDBOOK OF DRUG INTERACTIONS: A CLINICAL AND FORENSIC GUIDE, edited byAshraf Mozayani and Lionel P. Raymon, 2004

DIETARY SUPPLEMENTS: TOXICOLOGY AND CLINICAL PHARMACOLOGY, edited by MelanieJohns Cupp and Timothy S. Tracy, 2003

BUPRENOPHINE THERAPY OF OPIATE ADDICTION, edited by Pascal Kintz and PierreMarquet, 2002

BENZODIAZEPINES AND GHB: DETECTION AND PHARMACOLOGY, edited by Salvatore J.Salamone, 2002

ON-SITE DRUG TESTING, edited by Amanda J. Jenkins and Bruce A. Goldberger, 2001

BRAIN IMAGING IN SUBSTANCE ABUSE: RESEARCH, CLINICAL, AND FORENSIC APPLICATIONS,edited by Marc J. Kaufman, 2001

TOXICOLOGY AND CLINICAL PHARMACOLOGY OF HERBAL PRODUCTS,edited by Melanie Johns Cupp, 2000

CRIMINAL POISONING: INVESTIGATIONAL GUIDE FOR LAW ENFORCEMENT,TOXICOLOGISTS, FORENSIC SCIENTISTS, AND ATTORNEYS,by John H. Trestrail, III, 2000

A PHYSICIAN’S GUIDE TO CLINICAL FORENSIC MEDICINE, edited by Margaret M. Stark, 2000

CLINICAL FORENSICMEDICINE

Edited by

Margaret M. Stark, LLM, MB, BS, DGM, DMJ, DABThe Forensic Medicine Unit, St. George's Hospital Medical School,London, UK

Foreword by

Sir John StevensCommissioner of the Metropolitan Police Service,London, UK

A Physician's GuideSECOND EDITION

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Clinical forensic medicine : a physician's guide / edited by Margaret M.Stark.-- 2nd ed. p. ; cm. -- (Forensic science and medicine) Rev. ed. of: A physician's guide to clinical forensic medicine. c2000. Includes bibliographical references and index. ISBN 1-58829-368-8 (alk. paper) 1. Medical jurisprudence. [DNLM: 1. Forensic Medicine--methods. W 700 C641 2005] I. Stark,Margaret. II. Physician's guide to clinical forensic medicine. III. Series. RA1051.P52 2005 614'.1--dc22 2004024006

DedicationIn memory of Smokey and to Amelia and Feline Friends once again!

v

vii

Foreword

The Metropolitan Police Service (MPS), now in its 175th year, has along tradition of working with doctors. In fact, the origin of the forensic phy-sician (police surgeon) as we know him or her today, dates from the passingby Parliament of The Metropolitan Act, which received Royal Assent in Juneof 1829. Since then, there are records of doctors being “appointed” to thepolice to provide medical care to detainees and examine police officers whileon duty.

The MPS has been involved in the training of doctors for more than 20years, and has been at the forefront of setting the highest standards of work-ing practices in the area of clinical forensic medicine. Only through an aware-ness of the complex issues regarding the medical care of detainees in custodyand the management of complainants of assault can justice be achieved. TheMPS, therefore, has worked in partnership with the medical profession toensure that this can be achieved.

The field of clinical forensic medicine has developed in recent yearsinto a specialty in its own right. The importance of properly trained doctorsworking with the police in this area cannot be overemphasized. It is essentialfor the protection of detainees in police custody and for the benefit of thecriminal justice system as a whole. A book that assists doctors in the field isto be applauded.

Sir John Stevens

ix

The field of clinical forensic medicine has continued to flourish andprogress, so it is now timely to publish Clinical Forensic Medicine: APhysician's Guide, Second Edition, in which chapters on the medical aspectsof restraint and infectious diseases have been added.

Police officers are often extremely concerned about potential exposureto infections, and this area is now comprehensively covered. The results of theuse of restraint by police is discussed in more detail, including areas such asinjuries that may occur with handcuffs and truncheons (Chapters 7, 8, and 11),as well as the use of crowd-control agents (Chapter 6). The chapter on generalinjuries (Chapter 4) has been expanded to include the management of bites,head injuries, and self-inflicted wounds.

Substance misuse continues to be a significant and increasing part of theworkload of a forensic physician, and the assessment of substance misuseproblems in custody, with particular emphasis on mental health problems (“dualdiagnosis”), has been expanded. Substance misuse is too often a cause of deathin custody (Chapter 10).

Traffic medicine is another area where concerns are increasing over theapparent alcohol/drugs and driving problem. There has been relevant researchconducted in this area, which is outlined Chapter 12.

Forensic sampling has undergone enormous technological change, whichis reflected in the chapter on sexual assault examination (Chapter 3).

The chapter on the history and development of clinical forensicmedicine worldwide has been updated (Chapter 1). Chapters on fundamentalprinciples (Chapter 2), nonaccidental injury in children (Chapter 5), and careof detainees (Chapter 8) are all fully revised, as are the appendices (nowcontaining a list of useful websites). Although the subject is constantlyevolving, some fundamental principles remain.

I was very pleased with the response to the first book, and there appearsto be a genuine need for this second edition. I hope the good practice outlinedin this book will assist forensic physicians in this “Cinderella speciality.”

Margaret M. Stark

Preface to the Second Edition

xi

Preface to the First Edition“Clinical forensic medicine”—a term now commonly used to refer to that

branch of medicine involving an interaction among the law, the judiciary, and thepolice, and usually concerning living persons—is emerging as a specialty in itsown right. There have been enormous developments in the subject in the lastdecade, with an increasing amount of published research that needs to be broughttogether in a handbook, such as A Physician’s Guide to Clinical ForensicMedicine. The role of the health care professional in this field must be indepen-dent, professional, courteous, and nonjudgemental, as well as well-trained andinformed. This is essential for the care of victims and suspects, for the criminaljustice system, and for society as a whole.

As we enter the 21st century it is important that health care professionals are“forensically aware.” Inadequate or incorrect diagnosis of a wound, for example,may have an effect on the clinical management of an individual, as well as asignificant influence on any subsequent criminal investigation and courtproceedings. A death in police custody resulting from failure to identify avulnerable individual is an avoidable tragedy. Although training in clinicalforensic medicine at the undergraduate level is variable, once qualified, everydoctor will have contact with legal matters to a varying degree.

A Physician’s Guide to Clinical Forensic Medicine concentrates on theclinical aspects of forensic medicine, as opposed to the pathological, byendeavoring to look at issues from fundamental principles, including recentresearch developments where appropriate. This volume is written primarily forphysicians and nurses working in the field of clinical forensic medicine—forensicmedical examiners, police surgeons, accident and emergency room physicians,pediatricians, gynecologists, and forensic and psychiatric nurses—but such otherhealth care professionals as social workers and the police will also find thecontents of use.

The history and development of clinical forensic medicine worldwide isoutlined, with special focus being accorded the variable standards of care fordetainees and victims. Because there are currently no international standards oftraining or practice, we have discussed fundamental principles of consent,confidentiality, note-keeping, and attendance at court.

The primary clinical forensic assessment of complainants and thosesuspected of sexual assault should only be conducted by those doctors and nurses

xii Preface

who have acquired specialist knowledge, skills, and attitudes during boththeoretical and practical training. All doctors should be able to accuratelydescribe and record injuries, although the correct interpretation requiresconsiderable skill and expertise, especially in the field of nonaccidental injury inchildren, where a multidisciplinary approach is required.

Avoidance of a death in police custody is a priority, as is the assessment offitness-to-be-detained, which must include information on a detainee’s generalmedical problems, as well as the identification of high-risk individuals, i.e.,mental health and substance misuse problems. Deaths in custody include rapidunexplained death occurring during restraint and/or during excited delirium. Therecent introduction of chemical crowd-control agents means that healthprofessionals also need to be aware of the effects of the common agents, as wellas the appropriate treatments.

Custodial interrogation is an essential part of criminal investigations.However, in recent years there have been a number of well-publicizedmiscarriages of justice in which the conviction depended on admissions madeduring interviews that were subsequently shown to be untrue. Recently, aworking medical definition of fitness-to-be-interviewed has been developed, andit is now essential that detainees be assessed to determine whether they are at riskto provide unreliable information.

The increase in substance abuse means that detainees in police custody areoften now seen exhibiting the complications of drug intoxication and withdrawal,medical conditions that need to be managed appropriately in the custodialenvironment. Furthermore, in the chapter on traffic medicine, not only aremedical aspects of fitness-to-drive covered, but also provided is detailedinformation on the effects of alcohol and drugs on driving, as well as anassessment of impairment to drive.

In the appendices of A Physician’s Guide to Clinical Forensic Medicine, therelevant ethical documents relating to police, nurses, and doctors are broughttogether, along with alcohol assessment questionnaires, the mini-mental stateexamination, and the role of appropriate adults; the management of head-injureddetainees, including advice for the police; the Glasgow Coma Scale, and anexample of a head injury warning card; guidance notes on US and UK statutoryprovisions governing access to health records; an alcohol/drugs impairmentassessment form, along with a table outlining the peak effect, half-life, durationof action, and times for detection of common drugs.

Margaret M. Stark

Contents

xiii

Dedication .............................................................................................. vForeword by Sir John Stevens ............................................................. viiPreface to Second Edition .................................................................... ixPreface to First Edition ......................................................................... xiContributors ......................................................................................... xvValue-Added eBook/PDA ................................................................. xvii

CHAPTER 1

The History and Development of Clinical Forensic MedicineWorldwide .......................................................................................... 1

Jason Payne-James

CHAPTER 2

Fundamental Principles ....................................................................... 37Roy N. Palmer

CHAPTER 3

Sexual Assault Examination ................................................................ 61Deborah Rogers and Mary Newton

CHAPTER 4

Injury Assessment, Documentation, and Interpretation ................... 127Jason Payne-James, Jack Crane, and Judith A. Hinchliffe

CHAPTER 5

Nonaccidental Injury in Children ...................................................... 159Amanda Thomas

CHAPTER 6

Crowd-Control Agents ....................................................................... 179Kari Blaho-Owens

Contents xiv

CHAPTER 7

Medical Issues Relevant to Restraint ................................................ 195

Nicholas Page

CHAPTER 8

Care of Detainees ............................................................................... 205

Guy Norfolk and Margaret M. Stark

CHAPTER 9

Infectious Diseases: The Role of the Forensic Physician ................. 235

Felicity Nicholson

CHAPTER 10

Substance Misuse ............................................................................... 285

Margaret M. Stark and Guy Norfolk

CHAPTER 11

Deaths in Custody .............................................................................. 327

Richard Shepherd

CHAPTER 12

Traffic Medicine ................................................................................ 351

Ian F. Wall and Steven B. Karch

Appendices ......................................................................................... 387Index ................................................................................................... 427

Contributors

xv

KARI BLAHO-OWENS, PhD • Research Administration, University of TennesseeHealth Science Center, Memphis, TN

JACK CRANE, MB BCH, FRCPath, DMJ (Clin & Path), FFPath, RCPI • The Queen’sUniversity of Belfast and Northern Ireland Office, State Pathologist’sDepartment, Institute of Forensic Medicine, Belfast, Northern Ireland, UK

JUDITH A. HINCHLIFFE, BDS, DipFOd • School of Clinical Dentistry, Universityof Sheffield, Forensic Odontologist, General Dental Practitioner, andHonorary Clinical Lecturer, Sheffield, UK

STEVEN B. KARCH, MD • Assistant Medical Examiner, City and Countyof San Francisco, CA

MARY NEWTON, HNC • Forensic Sexual Assault Advisor, Forensic ScienceService London Laboratory, London, UK

FELICITY NICHOLSON, MB BS, FRCPath • Consultant in Infectious Diseasesand Forensic Physician, London, UK

GUY NORFOLK, MB ChB, LLM, MRCGP, DMJ • Consultant Forensic Physicianand General Practitioner, Stockwood Medical Centre, Bristol, UK

NICHOLAS PAGE, MB BS, DCH, DRCOG, DMJ, MRCGP • General Practitionerand Forensic Physician, Ludlow Hill Surgery, Nottingham, UK

ROY N. PALMER, LLB, MB BS, LRCP, MRCS, DRCOG • Barrister-at-Law, H. M.Coroner, Greater London (Southern District), Croydon, UK

JASON PAYNE-JAMES, LLM, MB, FRCS, DFM, RNutr • Consultant ForensicPhysician, London, UK

DEBORAH ROGERS, MB BS, DCH, DRCOG, MRCGP, DFFP, MMJ • Honorary SeniorLecturer, The Forensic Medicine Unit, St. George’s Hospital MedicalSchool, London, UK

RICHARD SHEPHERD, MB BS, FRCPath, DMJ • Senior Lecturer, The ForensicMedicine Unit, St. George’s Hospital Medical School, London, UK

MARGARET M. STARK, LLM, MB BS, DGM, DMJ, DAB • Honorary Senior Lecturer,The Forensic Medicine Unit, St. George’s Hospital Medical School,London, UK

SIR JOHN STEVENS • Commissioner of the Metropolitan Police Service, London, UKAMANDA THOMAS, MB BS, DCH, MmedSc, MA, FRCPCH • Consultant Community

Paediatrician, Department of Community Paediatrics, St. James’University Hospital, Leeds, UK

IAN F. WALL, MB ChB(Hons), FRCGP, DMJ, DOccMed • Consultant ForensicPhysician and General Practitioner, Kettering, UK

xvi Contributors

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xvii

History and Development 1

From: Clinical Forensic Medicine: A Physician’s Guide, 2nd EditionEdited by: M. M. Stark © Humana Press Inc., Totowa, NJ

1

Chapter 1

History and Developmentof Clinical Forensic MedicineJason Payne-James

1. INTRODUCTION

Forensic medicine, forensic pathology, and legal medicine are terms usedinterchangeably throughout the world. Forensic medicine is now commonlyused to describe all aspects of forensic work rather than just forensic pathol-ogy, which is the branch of medicine that investigates death. Clinical forensicmedicine refers to that branch of medicine that involves an interaction amonglaw, judiciary, and police officials, generally involving living persons. Clini-cal forensic medicine is a term that has become widely used only in the lasttwo or so decades, although the phrase has been in use at least since 1951when the Association of Police Surgeons, now known as the Association ofForensic Physicians—a UK-based body—was first established. The practitio-ners of clinical forensic medicine have been given many different namesthroughout the years, but the term forensic physician has become more widelyaccepted. In broad terms, a forensic pathologist generally does not deal withliving individuals, and a forensic physician generally does not deal with thedeceased. However, worldwide there are doctors who are involved in both theclinical and the pathological aspects of forensic medicine. There are manyareas where both clinical and pathological aspects of forensic medicine over-lap, and this is reflected in the history and development of the specialty as awhole and its current practice.

2 Payne-James

Police surgeon, forensic medical officer, and forensic medical examinerare examples of other names or titles used to describe those who practice in theclinical forensic medicine specialty, but such names refer more to the appointedrole than to the work done. Table 1 illustrates the variety of functions a forensicphysician may be asked to undertake. Some clinical forensic medical practitio-ners may perform only some of these roles, whereas others may play a more

Table 1Typical Roles of a Forensic Physician a

• Determination of fitness to be detained in custody• Determination of fitness to be released• Determination of fitness to be charged: competent to understand charge• Determination of fitness to transfer• Determination of fitness to be interviewed by the police or detaining body• Advise that an independent person is required to ensure rights for the vulnerable or

mentally disordered• Assessment of alcohol and drug intoxication and withdrawal• Comprehensive examination to assess a person’s ability to drive a motor vehicle,

in general medical terms and related to alcohol and drug misuse• Undertake intimate body searches for drugs• Documentation and interpretation of injuries• Take forensic samples• Assess and treat personnel injured while on duty (e.g., police personnel), including

needle-stick injuries• Pronounce life extinct at a scene of death and undertake preliminary advisory role• Undertake mental state examinations• Examine adult complainants of serious sexual assault and the alleged perpetrators• Examine alleged child victims of neglect or physical or sexual abuse• Examine victims and assailants in alleged police assaults

Additional roles

• Expert opinion in courts and tribunals• Death in custody investigation• Pressure group and independent investigators in ethical and moral issues� Victims of torture � War crimes � Female genital mutilation

• Refugee medicine (medical and forensic issues)• Asylum-seeker medicine (medical and forensic issues)• Implement principles of immediate management in biological or chemical incidents

For all these examinations, a forensic physician must accurately document findings and,when needed, produce these as written reports for appropriate civil, criminal, or otheragencies and courts. The forensic physician must also present the information orally to acourt or other tribunal or forum.

a Expanded and modified from ref. 22. This table illustrates the role of forensic physicians inthe United Kingdom; roles vary according to geographic location.


extended role, depending on geographic location (in terms of country and state),local statute, and judicial systems. Forensic physicians must have a good knowl-edge of medical jurisprudence, which can be defined as the application of medi-cal science to the law within their own jurisdiction. The extent and range of therole of a forensic physician is variable; many may limit themselves to specificaspects of clinical forensic medicine, for example, sexual assault or child abuse.Currently, the role and scope of the specialty of clinical forensic medicine glo-bally are ill defined, unlike other well-established medical specialties, such asgastroenterology or cardiology. In many cases, doctors who are practicing clini-cal forensic medicine or medical jurisprudence may only take on these func-tions as subspecialties within their own general workload. Pediatricians,emergency medicine specialists, primary care physicians, psychiatrists, gyne-cologists, and genitourinary medicine specialists often have part-time roles asforensic physicians.

2. HISTORICAL REFERENCESThe origins of clinical forensic medicine go back many centuries, although

Smith rightly commented that “forensic medicine [cannot be thought of] as anentity…until a stage of civilization is reached in which we have…a recognizablelegal system…and an integrated body of medical knowledge and opinion” (1).

The specific English terms forensic medicine and medical jurisprudence(also referred to as juridical medicine) date back to the early 19th century. In1840, Thomas Stuart Traill (2), referring to the connection between medicineand legislation, stated that: “It is known in Germany, the country in which ittook its rise, by the name of State Medicine, in Italy and France it is termedLegal Medicine; and with us [in the United Kingdom] it is usually denomi-nated Medical Jurisprudence or Forensic Medicine.” However, there are manyprevious references to the use of medical experts to assist the legal process inmany other jurisdictions; these physicians would be involved in criminal orcivil cases, as well as public health, which are referred to frequently andsomewhat confusingly in the 19th century as medical police. There is muchdispute regarding when medical expertise in the determination of legal issueswas first used. In 1975, Chinese archeologists discovered numerous bamboopieces dating from approx 220 BC (Qin dynasty) with rules and regulationsfor examining injuries inscribed on them. Other historical examples of thelink between medicine and the law can be found throughout the world.

Amundsen and Ferngren (3) concluded that forensic medicine was usedby Athenian courts and other public bodies and that the testimony of physi-cians in medical matters was given particular credence, although this use ofphysicians as expert witnesses was “loose and ill-defined” (4), as it was in the

4 Payne-James

Roman courts. In the Roman Republic, the Lex Duodecim Tabularum (lawsdrafted on 12 tablets and accepted as a single statute in 449 BC) had minorreferences to medicolegal matters, including length of gestation (to determinelegitimacy), disposal of the dead, punishments dependent on the degree ofinjury caused by an assailant, and poisoning (5). Papyri related to Roman Egyptdating from the latter part of the first to the latter part of the fourth century ADcontain information about forensic medical examinations or investigations (6).

The interaction between medicine and the law in these periods is undoubted,but the specific role of forensic medicine, as interpreted by historical docu-ments, is open to dispute; the degree and extent of forensic medical inputacknowledged rely on the historian undertaking the assessment.

A specific role for the medical expert as a provider of impartial opinionfor the judicial system was identified clearly by the Justinian Laws between529 and 564 AD. Traill (2) states that: “Medical Jurisprudence as a sciencecannot date farther back than the 16th century.” He identifies George, Bishopof Bamberg, who proclaimed a penal code in 1507, as the originator of the firstcodes in which medical evidence was a necessity in certain cases. However,the Constitutio Criminalis Carolina, the code of law published and proclaimedin 1553 in Germany by Emperor Charles V, is considered to have originatedlegal medicine as a specialty: expert medical testimony became a requirementrather than an option in cases of murder, wounding, poisoning, hanging, drown-ing, infanticide, and abortion (1). Medicolegal autopsies were well documentedin parts of Italy and Germany five centuries before the use of such proceduresby English coroners. The use of such expertise was not limited to deaths or tomainland Europe. Cassar (7), for example, describes the earliest recorded Mal-tese medicolegal report (1542): medical evidence established that the malepartner was incapable of sexual intercourse, and this resulted in a marriageannulment. Beck (8) identifies Fortunatus Fidelis as the earliest writer on medi-cal jurisprudence, with his De Relationibus Medicorum being published inPalermo, Italy, in 1602. Subsequently, Paulus Zacchias wrote QuaestionesMedico-Legales, described by Beck as “his great work” between 1621 and1635. Beck also refers to the Pandects of Valentini published in Germany in1702, which he describes as “an extensive retrospect of the opinions and deci-sions of preceding writers on legal medicine.” In France in 1796, Fodere pub-lished the first edition in three octavo volumes of his work Les Lois eclaireespar les Sciences Physique, ou Traite de Medicine Legale et d’Hygiene Publique.

2.1. Late 18th Century OnwardBeginning in the latter part of the 18th century, several books and trea-

tises were published in English concerning forensic medicine and medical


jurisprudence. What is remarkable is that the issues addressed by many of theauthors would not be out of place in a contemporary setting. It seems odd thatmany of these principles are restated today as though they are new.

In 1783, William Hunter (9) published an essay entitled, On the Uncer-tainty of the Signs of Murder in the Case of Bastard Children; this may be thefirst true forensic medicine publication from England. The first larger workwas published in 1788 by Samuel Farr. John Gordon Smith writes in 1821 inthe preface to his own book (10): “The earliest production in this country,professing to treat of Medical Jurisprudence generaliter, was an abstract froma foreign work, comprised in a very small space. It bears the name of ‘Dr.Farr’s Elements,’ and first appeared above thirty years ago.” In fact, it wastranslated from the 1767 publication Elemental Medicinae Forensis by Fazeliusof Geneva. Davis (11) refers to these and to Remarks on Medical Jurispru-dence by William Dease of Dublin, as well as the Treatise on Forensic Medi-cine or Medical Jurisprudence by O. W. Bartley of Bristol. Davis considersthe latter two works of poor quality, stating that the: “First original and satis-factory work” was George Male’s Epitome of Juridical or Forensic Medicine,published in 1816 (second edition, 1821). Male was a physician at Birming-ham General Hospital and is often considered the father of English medicaljurisprudence. Smith refers also to Male’s book but also comments: “To whichif I may add a Treatise on Medical Police, by John Roberton, MD.”

Texts on forensic medicine began to appear more rapidly and with muchbroader content. John Gordon Smith (9) stated in The Principles of ForensicMedicine Systematically Arranged and Applied to British Practice (1821) that:“Forensic Medicine—Legal, Judiciary or Juridical Medicine—and MedicalJurisprudence are synonymous terms.” Having referred in the preface to theearlier books, he notes, “It is but justice to mention that the American schoolshave outstripped us in attention to Forensic Medicine;” he may have beenreferring to the work of Theodric Romeyn Beck and others. Beck publishedthe first American textbook 2 years later in 1823 and a third edition (London)had been published by 1829 (8). Before this, in 1804, J. A. Stringham, whowas trained in Edinburgh and awarded an MD in 1799, was appointed as aProfessor in Medical Jurisprudence at the College of Physicians and Surgeonsof New York and given a Chair in 1813 (11).

John Gordon Smith (9) wrote that “Every medical practitioner being liableto a subpoena, should make it his business to know the relations of physi-ological and pathological principles to the facts on which he is likely to beinterrogated, and likewise the principal judiciary bearings of the case. Theformer of these are to be found in works on Forensic Medicine; the latter inthose on Jurisprudence.” Alfred Taylor (12) in his A Manual of Medical Juris-

6 Payne-James

prudence defined medical jurisprudence as: “That science, which teaches theapplication of every branch of medical knowledge to the purpose of the law”

There was a clear demand for such books, and Traill’s (2) Outlines of aCourse of Lectures on Medical Jurisprudence, published in 1840 when Traillwas Regius Professor of Jurisprudence and Medical Police at Edinburgh, wasthe second edition of a book initially published in 1834 (13). The first Chair ofForensic Medicine had been established in the United Kingdom in Edinburghin 1803—the appointee being Andrew Duncan, Jr. [although Andrew DuncanSr. had lectured there on forensic medicine topics since 1789 (14)]. Subse-quent nonprofessorial academic forensic medicine posts were established atGuy’s Hospital and Charing Cross Hospital, London. In 1839 and 1875, respec-tively, academic chairs of medical jurisprudence were created in Glasgow andAberdeen (15).

The relevant areas of interest to forensic medicine and medical jurispru-dence were gradually becoming better defined. Table 2 summarizes the chap-ter contents of Principles of Forensic Medicine by William Guy (16), Professorof Forensic Medicine at King’s College, London, in 1844. Much of this mate-rial is relevant to forensic physicians and forensic pathologists working today.

Thus, by the end of the 19th century, a framework of forensic medicinethat persists today had been established in Europe, the United Kingdom,America, and related jurisdictions.

Table 2Chapter Contents of Guy’s 1884 Text, Principles of Forensic Medicine a

1. Medical evidence

2. Personal identityIdentityAgeSex

3. ImpotenceRapePregnancyDelivery

4. Foeticide or criminal abortionInfanticideLegitimacy

5. Life assuranceFeigned diseases

6. Unsoundness of mind

a Adapted from ref. 16.

7. Persons found deadReal & apparent deathSudden dathSurvivorship

8. Death by drowningDeath by hangingDeath by strangulationDeath by suffocation

9. Wounds10. Death by fire

Spontaneous combustionDeath by lightningDeath from coldDeath from starvation

11. ToxicologySpecific poisons


3. CONTEMPORARY CLINICAL FORENSIC MEDICINE

The following working definition has been suggested: “Clinical forensicmedicine includes all medical [healthcare] fields which may relate to legal,judicial, and police systems” (17). Even though medicine and law interactmore frequently in cases of living individuals, forensic pathology has longbeen established as the academic basis for forensic medicine. It is only in thelast two decades that research and academic interest in clinical forensic medi-cine have become an area of more focused research.

The recent growth in awareness of abuses of human rights and civil lib-erties has directed attention to the conditions of detention of prisoners and tothe application of justice to both victim and suspect. Examples of injusticeand failure to observe basic human rights or rights enshrined in statute inwhich the input of medical professionals may be considered at least of poorquality and at worst criminally negligent have occurred and continue to occurworldwide. The death of Steve Biko in South Africa, the conviction of CaroleRichardson in England, and the deaths of native Australians in prison arewidely publicized instances of such problems. Reports from the EuropeanCommittee for the Prevention of Torture and Inhuman and Degrading Treat-ment in the early 1990s drew attention to the problem of lack of indepen-dence of some police doctors. The conflicting needs and duties of thoseinvolved in the judicial system are clear, and it is sometimes believed thatrecognition of such conflicts is comparatively recent, which would be naïveand wrong. In England and Wales, the Human Rights Act 1998, whose pur-pose is to make it unlawful for any public authority to act in a manner incom-patible with a right defined by the European Convention of Human Rights,reinforces the need for doctors to be aware of those human rights issues thattouch on prisoners and that doctors can influence. It is worth noting that thislaw was enacted almost 50 years after publication of the European Conven-tion of Human Rights and Fundamental Freedoms. The future role of theforensic physician within bodies, such as the recently established Interna-tional Criminal Court, is likely to expand.

The forensic physician has several roles that may interplay when assess-ing a prisoner or someone detained by the state or other statutory body. Threemedical care facets that may conflict have been identified: first, the role ofmedicolegal expert for a law enforcement agency; second, the role of a treat-ing doctor; and third, the examination and treatment of detainees who allegethat they have been mistreated by the police during their arrest, interroga-tion, or the various stages of police custody (18). This conflict is well-rec-ognized and not new for forensic physicians. Grant (19), a police surgeon

8 Payne-James

appointed to the Metropolitan Police in the East End of London just more than acentury ago, records the following incident: “One night I was called to Shadwell[police] station to see a man charged with being drunk and disorderly, who hada number of wounds on the top of his head…I dressed them…and when I fin-ished he whispered ‘Doctor, you might come with me to the cell door’…I wentwith him. We were just passing the door of an empty cell, when a police con-stable with a mop slipped out and struck the man a blow over the head…Boilingover with indignation I hurried to the Inspector’s Office [and] told him what hadoccurred.” Dr. Grant records that the offender was dealt with immediately. Dr.Grant rightly recognized that he had moral, ethical, and medical duties to hispatient, the prisoner. Dr. Grant was one of the earliest “police surgeons” in En-gland, the first Superintending Surgeon having been appointed to the Metro-politan Police Force on April 30, 1830. The Metropolitan Police SurgeonsAssociation was formed in 1888 with 156 members. In 1951, the associationwas reconstituted as a national body under the leadership of Ralph Summers, sothat improvements in the education and training for clinical forensic medicinecould be made. The Association of Forensic Physicians, formerly the Associa-tion of Police Surgeons, remains the leading professional body of forensic phy-sicians worldwide, with more 1000 members.

4. GLOBAL CLINICAL FORENSIC MEDICINETable 3 is a summary of responses to a questionnaire on various aspects

of clinical forensic medicine sent in early 2003 to specialists in differentcountries. The selection of countries was intended to be broad and nonselec-tive. It shows how clinical forensic medicine operates in a variety of coun-tries and jurisdictions and also addresses key questions regarding howimportant aspects of such work, including forensic assessment of victimsand investigations of police complaints and deaths in custody, are under-taken. The questionnaire responses were all from individuals who werefamiliar with the forensic medical issues within their own country or state,and the responses reflect practices of that time. The sample is small, but nu-merous key points emerge, which are compared to the responses from anearlier similar study in 1997 (20). In the previous edition of this book, thefollowing comments were made about clinical forensic medicine, the itali-cized comments represent apparent changes since that last survey.

• No clear repeatable patterns of clinical forensic medicine practice may be seenon an international basis—but there appears to be an increase in recognition ofthe need to have appropriate personnel to undertake the roles required.

• Several countries have informal/ad hoc arrangements to deal with medical andforensic care of detainees and victims—this still remains the case—often with


large centers having physicians specially trained or appointed while rural oroutlying areas are reliant on nonspecialists.

• The emphasis in several countries appears to be on the alleged victim rather thanthe alleged suspect—this remains the case, although there are suggestions thatthis approach is being modified.

• The standard of medical care of detainees in police custody is variable—thereappears to be more recognition of the human rights aspects of care of those inpolice custody.

• There are no international standards of practice or training—international stan-dards are still lacking—but more countries appear to be developing nationalstandards.

• There are apparent gaps in the investigation of police complaints in some coun-tries—this remains the case.

• Death-in-custody statistics are not always in the public domain—this remainsthe case—and the investigation of deaths in police custody may still not be inde-pendently undertaken.

There appears to be wider recognition of the interrelationship of the rolesof forensic physician and forensic pathology, and, indeed, in many jurisdic-tions, both clinical and pathological aspects of forensic medicine are under-taken by the same individual. The use of general practitioners (primary carephysicians) with a special interest in clinical forensic medicine is common;England, Wales, Northern Ireland, Scotland, Australasia, and the Netherlandsall remain heavily dependent on such professionals.

Academic appointments are being created, but these are often honorary,and until governments and states recognize the importance of the work by fullyfunding full-time academic posts and support these with funds for research,then the growth of the discipline will be slow. In the United Kingdom andEurope much effort has gone into trying to establish a monospecialty of legalmedicine, but the process has many obstacles, laborious, and, as yet, unsuc-cessful. The Diplomas of Medical Jurisprudence and the Diploma of ForensicMedicine (Society of Apothecaries, London, England) are internationally rec-ognized qualifications with centers being developed worldwide to teach andexamine them. The Mastership of Medical Jurisprudence represents the high-est qualification in the subject in the United Kingdom. Further diploma anddegree courses are being established and developed in the United Kingdom buthave not yet had first graduates. Monash University in Victoria, Australia, in-troduced a course leading to a Graduate Diploma in Forensic Medicine, and theDepartment of Forensic Medicine has also pioneered a distance-learningInternet-based continuing-education program that previously has been serial-ized in the international peer-reviewed Journal of Clinical Forensic Medicine.

10 Payne-James

Many forensic physicians undertake higher training in law or medical eth-ics in addition to their basic medical qualifications. In addition to medical pro-fessionals, other healthcare professionals may have a direct involvement inmatters of a clinical forensic medical nature, particularly when the number ofmedical professionals with a specific interest is limited. Undoubtedly, themultiprofessional approach can, as in all areas of medicine, have some benefits.

5. CONCLUSIONSAs with the previous edition of the book, key areas still need to be

addressed in clinical forensic medicine:

1. It needs to be recognized globally as a distinct subspecialty with its own full-time career posts, with an understanding that it will be appropriate for thoseundertaking the work part-time to receive appropriate training and postgraduateeducation.

2. Forensic physicians and other forensic healthcare professionals must ensure thatthe term clinical forensic medicine is recognized as synonymous with knowl-edge, fairness, independence, impartiality, and the upholding of basic humanrights.

3. Forensic physicians and others practicing clinical forensic medicine must be ofan acceptable and measurable standard (20).

Some of these issues have been partly addressed in some countries andstates, and this may be because the overlap between the pathological and clini-cal aspects of forensic medicine has grown. Many forensic pathologists under-take work involved in the clinical aspects of medicine, and, increasingly,forensic physicians become involved in death investigation (21). Forensic workis now truly multiprofessional, and an awareness of what other specialties cancontribute is an essential part of basic forensic education, work, and continu-ing professional development. Those involved in the academic aspects of fo-rensic medicine and related specialties will be aware of the relative lack offunding for research. This lack of funding research is often made worse bylack of trained or qualified personnel to undertake day-to-day service work.This contrasts more mainstream specialties (e.g., cardiology and gastroenter-ology), where the pharmaceutical industry underpins and supports researchand development. However, clinical forensic medicine continues to develop tosupport and enhance judicial systems in the proper, safe, and impartial dispen-sation of justice. A worldwide upsurge in the need for and appropriate imple-mentation of human rights policies is one of the drivers for this development,and it is to be hoped that responsible governments and other world bodies willcontinue to raise the profile of, invest in, and recognize the absolute necessityfor independent, impartial skilled practitioners of clinical forensic medicine.


11

Tabl

e 3

Clin

ical

For

ensi

c M

edic

ine:

Its

Pra

ctic

e A

roun

d th

e W

orld

Que

stio

ns a

nd R

espo

nses

Jan

uary

200

3

Que

stio

n A

Is th

ere

a fo

rmal

sys

tem

in y

our

coun

try

(or

stat

e) b

y w

hich

the

polic

e an

d ju

dici

al s

yste

m c

an g

et im

med

iate

acce

ss to

med

ical

and

/or

fore

nsic

ass

essm

ent o

f in

divi

dual

s de

tain

ed in

pol

ice

cust

ody

(pri

sone

rs)?

Res

pons

eA

ustr

alia

Yes

(w

ithi

n th

e st

ate)

. Tw

o-ti

ered

sys

tem

add

ress

ing

gene

ral h

ealt

h is

sues

and

for

ensi

c m

edic

al s

ervi

ces.

Eng

land

and

Wal

esY

es. P

olic

e su

rgeo

ns (

fore

nsic

med

ical

exa

min

ers/

fore

nsic

phy

sici

ans)

are

con

trac

ted

(but

not

gen

eral

ly e

mpl

oyed

) by

both

pol

ice

and

cour

ts to

und

erta

ke th

is. T

he P

olic

e &

Cri

min

al E

vide

nce

Act

(P

AC

E)

1984

mad

e pa

rtic

ular

pro

visi

onfo

r thi

s an

d fo

r pri

sone

rs to

requ

est t

o se

e a

doct

or. P

olic

e su

rgeo

ns d

o no

t nec

essa

rily

hav

e sp

ecif

ic fo

rens

ic tr

aini

ng o

rqu

alif

icat

ions

.G

erm

any

Yes

, onl

y af

ter

a co

urt o

rder

has

bee

n gr

ante

d.H

ong

Kon

gY

es.

The

for

mal

and

gen

eric

mec

hani

sm i

s fo

r th

e in

divi

dual

to

be t

aken

to

an e

mer

genc

y de

part

men

t of

a n

earb

yho

spit

al. R

arel

y he

or

she

may

be

sent

for

a s

peci

fic

purp

ose

to a

spe

cial

ist f

oren

sic

doct

or.

Indi

aY

es. U

nder

a S

ecti

on o

f th

e C

rim

inal

Pro

cedu

re C

ode,

a p

olic

e of

fice

r ca

n im

med

iate

ly b

ring

an

arre

sted

per

son

to a

doct

or fo

r exa

min

atio

n. If

the

arre

sted

per

son

is a

fem

ale,

onl

y a

fem

ale

regi

ster

ed m

edic

al p

ract

itio

ner c

an e

xam

ine

her.

The

acc

used

/det

aine

d pe

rson

can

con

tact

the

doct

or a

nd h

ave

him

self

or

hers

elf

exam

ined

.Is

rael

Yes

Mal

aysi

aN

o or

gani

zed

fore

nsic

cli

nica

l se

rvic

es a

vail

able

. Sub

ject

ing

the

deta

inee

s fo

r ex

amin

atio

n is

at

the

disc

reti

on o

f th

eag

enci

es. I

f th

e ne

ed a

rise

s, u

sual

ly d

octo

rs w

ho h

ave

no tr

aini

ng in

cli

nica

l for

ensi

c m

edic

ine

(CF

M)

unde

rtak

e su

chex

amin

atio

ns. I

n la

rger

inst

itut

ions

, sen

ior

doct

ors

and,

at t

imes

, for

ensi

c pa

thol

ogis

ts m

ay e

xam

ine

them

.T

he N

ethe

rlan

dsY

esN

iger

iaY

es (

for

med

ical

rea

sons

) de

pend

ent o

n th

e av

aila

bili

ty o

f th

e ph

ysic

ian.

Sco

tlan

dY

es. P

olic

e re

tain

ser

vice

s of

doc

tors

not

all

nec

essa

rily

qua

lifi

ed in

CF

M.

Serb

iaY

es, v

ia th

e pu

blic

hea

lth

syst

em. G

ener

ally

for t

reat

men

t pur

pose

s. A

lso,

if c

onsi

dere

d ne

cess

ary

for e

vide

nce

coll

ecti

on(b

y th

e in

vest

igat

or a

ppoi

nted

und

er t

he C

rim

inal

Pro

cedu

re A

ct (

CP

A)

the

poli

ce w

ill

refe

r to

pro

secu

tor

in c

harg

ese

ekin

g fo

r hi

s or

her

per

mis

sion

to c

all a

for

ensi

c do

ctor

.S

outh

Afr

ica

Yes

, but

not

in a

ll p

arts

of

the

coun

try.

Spa

inY

es, a

ny i

ndiv

idua

l de

tain

ed i

n po

lice

cus

tody

has

the

rig

ht t

o be

exa

min

ed b

y a

doct

or. I

n ce

rtai

n ca

ses,

one

has

the

righ

t to

have

a f

oren

sic

asse

ssm

ent (

by th

e F

oren

sic

Sur

geon

Cor

ps o

f th

e M

inis

try

of J

usti

ce).

Sw

eden

Yes

Sw

itze

rlan

dY

es

12 Payne-James

12

Que

stio

n B

Who

exa

min

es o

r as

sess

es in

divi

dual

s w

ho a

re d

etai

ned

in p

olic

e cu

stod

y to

det

erm

ine

whe

ther

they

are

med

i-ca

lly f

it to

sta

y in

pol

ice

cust

ody?

Res

pons

eA

ustr

alia

Nur

ses

or m

edic

al p

ract

itio

ners

who

are

em

ploy

ed o

r re

tain

ed b

y po

lice

.

Eng

land

and

Wal

esP

olic

e su

rgeo

ns. R

ecen

t cha

nges

to s

tatu

tory

Cod

es o

f Pra

ctic

e su

gges

t tha

t an

appr

opri

ate

heal

th c

are

prof

essi

onal

may

be c

alle

d.

Ger

man

yN

orm

ally

a p

olic

e su

rgeo

n; if

not

, the

n an

y qu

alif

ied

doct

or.

Hon

g K

ong

Cur

rent

ly, t

he d

uty

poli

ce o

ffic

er lo

oks

and

asks

if m

edic

al a

tten

tion

is r

equi

red.

Mos

t dut

y of

fice

rs a

re q

uite

libe

ral i

nre

ferr

ing

the

indi

vidu

als

to th

e em

erge

ncy

depa

rtm

ent.

Indi

aA

gov

ernm

ent d

octo

r.

Isra

elP

olic

e su

rgeo

ns.

Mal

aysi

aG

ener

ally

not

unl

ess

they

bec

ome

ill.

Any

gov

ernm

ent d

octo

r in

the

near

est h

ospi

tal m

ay u

nder

take

suc

h an

exa

min

atio

n.

The

Net

herl

ands

Gen

eral

ly s

peak

ing:

Pub

lic

heal

th o

ffic

ers,

who

are

qua

lifi

ed in

cli

nica

l for

ensi

c m

edic

ine.

Nig

eria

Any

doc

tor

atta

ched

to p

riso

n se

rvic

es, t

he p

olic

e or

doc

tors

in th

e lo

cal h

ospi

tals

, dep

endi

ng o

n w

ho is

ava

ilab

le.

Sco

tlan

dP

olic

e su

rgeo

ns—

thes

e do

ctor

s ar

e no

t em

ploy

ees.

Nur

sing

sch

emes

hav

e be

en m

oote

d bu

t not

yet

bee

n im

plem

ente

d.

Ser

bia

If th

ere

is a

n ob

viou

s he

alth

pro

blem

or

if th

ey h

ave

cert

ain

dise

ases

that

nee

d m

edic

al a

tten

tion

, pol

ice

wil

l tak

e th

emto

a p

ubli

c he

alth

care

fac

ilit

y or

, in

the

case

of

emer

genc

y, c

all a

n am

bula

nce.

Sou

th A

fric

aN

ot a

lway

s; p

sych

iatr

ist i

n so

me

case

s.

Spa

inW

hen

a pe

rson

is

unde

r ar

rest

(w

itho

ut h

avin

g be

ing

put

unde

r re

gula

tion

), h

e as

ks t

o be

exa

min

ed b

y a

doct

or, h

e is

usua

lly

tran

sfer

red

to th

e S

pani

sh H

ealt

h P

ubli

c S

yste

m d

octo

rs. T

he f

oren

sic

surg

eon

take

s pa

rt e

xcep

tion

ally

.

Sw

eden

So-

call

ed “

poli

ce d

octo

rs,”

who

usu

ally

are

gen

eral

pra

ctit

ione

rs.

Sw

itze

rlan

dT

he “

pris

on d

octo

r”: e

ithe

r a

doct

or o

f in

tern

al m

edic

ine

of u

nive

rsit

y ho

spit

al o

r in

rur

al r

egio

ns th

e di

stri

ct p

hysi

cian

(acu

te c

ases

). A

fore

nsic

doc

tor o

f the

Inst

itut

e of

Leg

al M

edic

ine

of th

e U

nive

rsit

y of

Zur

ich

(not

urg

ent c

ases

, “ch

roni

cca

ses”

).


13

Que

stio

n C

If a

pri

sone

r is

sus

pect

ed o

f bei

ng u

nder

the

infl

uenc

e of

dru

gs o

r al

coho

l in

polic

e cu

stod

y, is

it u

sual

for

him

or h

er t

o be

exa

min

ed b

y a

doct

or (

or o

ther

hea

lth c

are

prof

essi

onal

) to

det

erm

ine

whe

ther

the

y ar

e fi

t to

rem

ain

in c

usto

dy?

Res

pons

eA

ustr

alia

Yes

, but

it

wil

l la

rgel

y de

pend

on

any

heal

th c

once

rns

(e.g

., ab

usiv

e, i

ntox

icat

ed p

erso

n—un

like

ly t

o ac

cess

med

ical

atte

ntio

n, b

ut im

pair

ed c

onsc

ious

sta

te—

alw

ays

acce

ss m

edic

al a

tten

tion

).

Eng

land

and

Wal

esY

es, i

f th

ere

are

asso

ciat

ed h

ealt

h co

ncer

ns, o

r if

ther

e is

a s

peci

fic

need

to d

eter

min

e fi

tnes

s to

inte

rvie

w w

hen

eith

erin

toxi

cati

on o

r w

ithd

raw

al m

ay r

ende

r an

int

ervi

ew i

nval

id.

Spe

cifi

c gu

idel

ines

are

pub

lish

ed o

n ca

re o

f su

bsta

nce

mis

use

deta

inee

s in

pol

ice

cust

ody.

Ger

man

yY

es

Hon

g K

ong

Yes

, the

y w

ill

mos

t ce

rtai

nly

be s

ent

to t

he e

mer

genc

y de

part

men

t. R

egis

tere

d ad

dict

s w

ill

occa

sion

ally

be

take

n to

am

etha

done

cli

nic

if th

ey a

re s

uffe

ring

fro

m w

ithd

raw

al.

Indi

aY

es

Isra

elY

es

Mal

aysi

aN

ot r

outi

nely

.

The

Net

herl

ands

Yes

Nig

eria

No

Sco

tlan

dO

nly

whe

n a

need

is e

stab

lish

ed o

r the

pri

sone

r req

uest

s m

edic

al a

ssis

tanc

e. P

rofo

und

into

xica

tion

or s

uspi

cion

of h

ead

inju

ry w

ould

be

an in

dica

tion

for

exa

min

atio

n.

Ser

bia

Into

xica

ted

deta

inee

s m

ay b

e re

ques

ted

to p

rovi

de a

blo

od o

r oth

er a

ppro

pria

te s

ampl

es fo

r ana

lysi

s. T

he re

ques

t can

be

refu

sed.

Sam

ples

are

arr

ange

d ou

tsid

e po

lice

pre

mis

es, u

sual

ly in

the

publ

ic h

ealt

h in

stit

utio

ns.

Sou

th A

fric

aY

es, b

ut n

ot c

omm

on p

ract

ice.

Spa

inY

es, h

e or

she

is o

ften

exa

min

ed a

nd e

ven

bloo

d sa

mpl

es a

re e

xtra

cted

(wit

h hi

s or

her

pre

viou

s co

nsen

t) if

the

pris

oner

is in

volv

ed in

som

e ag

gres

sion

, hom

icid

e or

car

dri

ving

, for

exa

mpl

e.

Sw

eden

Yes

. In

mos

t cus

tody

sui

tes,

a n

urse

is e

mpl

oyed

nur

se w

ho w

ill c

all a

doc

tor.

Sw

itze

rlan

dY

es, s

eepr

evio

us a

nsw

er to

que

stio

n B

.

14 Payne-James

14

Que

stio

n D

Doe

s yo

ur c

ount

ry/s

tate

hav

e sp

ecif

ic c

odes

/law

s/st

atut

es o

r re

gula

tions

that

mak

e pr

ovis

ion

for

the

wel

fare

of

indi

vidu

als

in p

olic

e cu

stod

y?

Res

pons

eA

ustr

alia

Yes

Eng

land

and

Wal

esY

es

Ger

man

yY

es

Hon

g K

ong

The

re a

re g

ener

ic g

uide

line

s fo

r al

l in

cust

ody;

non

e sp

ecif

ic to

the

poli

ce.

Indi

aT

he P

rote

ctio

n of

Hum

an R

ight

s A

ct 1

993

stip

ulat

es d

etai

led

prov

isio

ns r

egar

ding

this

.

Isra

elY

es

Mal

aysi

aY

es. I

nspe

ctor

Gen

eral

’s S

tand

ing

Ord

er.

The

Net

herl

ands

Yes

Nig

eria

Not

aw

are

of a

ny.

Sco

tlan

dL

ocal

pro

cedu

res

for

each

pol

ice

forc

e ba

sed

on c

entr

al g

uida

nce,

but

ther

e is

no

stat

ute.

Ser

bia

No

Sou

th A

fric

aY

es

Spa

inY

es, t

here

are

spe

cifi

c ru

les

in C

onst

itut

ion

and

in th

e P

enal

Cod

e.

Sw

eden

Not

kno

wn.

Sw

itze

rlan

dY

es


15

Que

stio

n E

Who

und

erta

kes

the

fore

nsic

med

ical

exa

min

atio

n an

d as

sess

men

t of

alle

ged

vict

ims

of s

exua

l ass

ault?

Res

pons

eA

ustr

alia

For

ensi

c m

edic

al o

ffic

ers.

Eng

land

and

Wal

esP

olic

e su

rgeo

ns o

r se

xual

off

ense

exa

min

ers

or d

octo

rs e

mpl

oyed

wit

hin

spec

iali

st s

exua

l off

ense

s un

its.

Ger

man

yE

ithe

r a

gyne

colo

gist

or

a m

edic

oleg

al d

octo

r.

Hon

g K

ong

For

ensi

c pa

thol

ogis

ts/d

octo

rs m

ainl

y. A

ccid

ent a

nd e

mer

genc

y do

ctor

s oc

casi

onal

ly a

nd f

amil

y pl

anni

ng d

octo

rs. T

hela

tter

whe

n th

e vi

ctim

s do

not

wis

h to

rep

ort t

he in

cide

nt to

pol

ice.

Indi

aD

iffe

rent

cen

ters

hav

e di

ffer

ent p

roto

cols

(e.

g., i

n th

is in

stit

utio

n, g

ynec

olog

ists

—m

ainl

y fe

mal

es).

Isra

elF

oren

sic

path

olog

ists

.

Mal

aysi

aIn

maj

or h

ospi

tals

, th

ere

may

be

fixe

d pr

otoc

ols.

Som

e fo

rens

ic p

hysi

cian

s, p

rim

ary

care

phy

sici

ans,

em

erge

ncy

med

icin

e ph

ysic

ians

, and

gyn

ecol

ogis

ts u

nder

take

suc

h ex

amin

atio

ns. I

n sm

alle

r ho

spit

als,

non

spec

iali

st p

hysi

cian

s do

the

exam

inat

ions

. In

som

e ca

ses,

for

ensi

c pa

thol

ogis

ts.

The

Net

herl

ands

Gen

eral

ly p

ubli

c he

alth

off

icer

s, q

uali

fied

in c

lini

cal f

oren

sic

med

icin

e.

Nig

eria

Pri

mar

y ca

re p

hysi

cian

s an

d m

edic

al o

ffic

ers

in lo

cal h

ospi

tals

.

Sco

tlan

dU

sual

ly p

olic

e su

rgeo

n, s

ome

may

be

adm

itte

d to

hos

pita

l and

be

exam

ined

by

hosp

ital

sta

ff.

Ser

bia

The

re is

no

stan

dard

pro

cedu

re f

or th

e ex

amin

atio

n of

all

eged

vic

tim

s of

sex

ual a

ssau

lt. T

here

are

no

prot

ocol

s fo

r th

eex

amin

atio

n of

vic

tim

s, o

r fo

r co

llec

tion

of

fore

nsic

sam

ples

.

Sou

th A

fric

aM

edic

al p

ract

itio

ner.

Spa

inA

fore

nsic

sur

geon

(méd

ico

fore

nse )

and

a g

ynec

olog

ist (

if th

e vi

ctim

is fe

mal

e) o

r a p

roct

olog

ist (

if th

e vi

ctim

is m

ale)

.

Sw

eden

The

pol

ice

are

free

to

enga

ge a

ny d

octo

r to

do

this

. In

cas

es o

f as

saul

t on

adu

lts,

the

exa

min

atio

n is

und

erta

ken

bysp

ecia

list

s in

FM

in a

sm

all f

ract

ion

of th

e ca

ses.

A s

peci

alis

t in

pedi

atri

c m

edic

ine

or s

urge

ry a

lway

s ex

amin

es c

hild

ren,

ofte

n, b

ut n

ot a

lway

s, w

ith

a sp

ecia

list

in f

oren

sic

med

icin

e.

Sw

itze

rlan

dP

hysi

cian

s of

Ins

titu

te o

f L

egal

Med

icin

e of

Uni

vers

ity

of Z

uric

h (D

istr

ict

Phy

sici

an);

Phy

sici

ans

of U

nive

rsit

yD

epar

tmen

t of

Gyn

ecol

ogy,

Uni

vers

ity

Hos

pita

l Zur

ich.

16 Payne-James

16

Que

stio

n F

Who

und

erta

kes

the

fore

nsic

med

ical

exa

min

atio

n an

d as

sess

men

t of

alle

ged

perp

etra

tors

of

sexu

al a

ssau

lt?

Res

pons

eA

ustr

alia

For

ensi

c m

edic

al o

ffic

ers.

Eng

land

and

Wal

esP

olic

e su

rgeo

ns.

Ger

man

yM

edic

oleg

al d

octo

r.

Hon

g K

ong

For

ensi

c pa

thol

ogis

ts/d

octo

rs m

ainl

y.

Indi

aD

iffe

rent

cen

ters

hav

e di

ffer

ent p

roto

cols

(in

this

inst

itut

ion,

for

ensi

c m

edic

ine

spe

cial

ists

). A

biz

arre

sit

uati

on, w

here

the

vict

im g

oes

to th

e gy

neco

logy

dep

artm

ent,

whe

reas

the

accu

sed

in th

e sa

me

case

com

es to

us.

Isra

elF

oren

sic

path

olog

ists

.

Mal

aysi

aS

ame

as f

or a

lleg

ed v

icti

ms

of s

exua

l ass

ault

. See

prev

ious

ans

wer

to q

uest

ion

E.

The

Net

herl

ands

Gen

eral

ly s

peak

ing,

pub

lic

heal

th o

ffic

ers

who

are

qua

lifi

ed in

cli

nica

l for

ensi

c m

edic

ine.

Nig

eria

Sam

e as

for

all

eged

vic

tim

s of

sex

ual a

ssau

lt. S

eepr

evio

us a

nsw

er to

que

stio

n E

.

Sco

tlan

dP

olic

e su

rgeo

n (a

ltho

ugh

expe

rien

ced

poli

ce s

urge

ons

are

not r

eadi

ly a

vail

able

in s

ome

spar

sely

pop

ulat

ed a

reas

, and

the

inex

peri

ence

d ar

e of

ten

relu

ctan

t to

emba

rk o

n su

ch a

n ex

amin

atio

n).

Ser

bia

In p

ract

ical

term

s, r

arel

y do

ne a

ltho

ugh

the

Cri

min

al P

roce

dure

Act

all

ows

exam

inat

ion

of a

lleg

ed p

erpe

trat

ors

of a

nycr

ime

(inc

ludi

ng s

exua

l as

saul

t) f

or f

oren

sic

purp

oses

eve

n w

itho

ut t

heir

con

sent

if

the

exam

inat

ion

itse

lf i

s no

tco

nsid

ered

har

mfu

l to

them

.

Sou

th A

fric

aM

edic

al p

ract

itio

ner.

Spa

inA

for

ensi

c su

rgeo

n.

Sw

eden

Sim

ilar

to th

e pr

oced

ures

of

adul

t vic

tim

s.

Sw

itze

rlan

dP

hysi

cian

s of

Ins

titu

te o

f L

egal

Med

icin

e of

Uni

vers

ity

of Z

uric

h (D

istr

ict P

hysi

cian

).


17

Que

stio

n G

In c

ases

of s

exua

l ass

ault

is it

alw

ays

poss

ible

for

vict

im, p

erpe

trat

or, o

r bo

th to

be

exam

ined

by

a do

ctor

of t

hesa

me

gend

er if

that

is r

eque

sted

?

Res

pons

eA

ustr

alia

Gen

eral

ly, y

es.

Eng

land

and

Wal

esG

ener

ally

, yes

, but

not

alw

ays

poss

ible

.

Ger

man

yY

es

Hon

g K

ong

No,

ther

e is

cur

rent

ly o

nly

one

full

-tim

e fe

mal

e fo

rens

ic d

octo

r ab

le to

do

this

.

Indi

aY

es, i

f req

uest

ed, a

doc

tor o

f the

sam

e ge

nder

wou

ld b

e ar

rang

ed. T

his

wou

ld g

ener

ally

app

ly o

nly

to th

e vi

ctim

(fem

ale

gyne

colo

gist

s ex

amin

e th

e vi

ctim

any

way

). T

he w

ishe

s of

the

accu

sed

are

not a

lway

s ob

serv

ed. I

t is

high

ly u

nusu

al f

ora

fem

ale

to e

xam

ine

a m

ale

accu

sed.

Isra

elN

ot a

lway

s.

Mal

aysi

aIt

may

be

acco

mm

odat

ed if

pos

sibl

e.

The

Net

herl

ands

Usu

ally

but

not

alw

ays.

Nig

eria

No

Sco

tlan

dN

ot a

lway

s, b

ut e

very

eff

ort i

s m

ade

to c

ompl

y w

ith

an e

xam

inee

’s w

ishe

s.

Ser

bia

The

re i

s no

sta

tuto

ry p

rovi

sion

tha

t re

gula

tes

free

cho

ice

of e

ithe

r th

e vi

ctim

or

the

perp

etra

tor

to b

e ex

amin

ed b

y a

doct

or o

f pr

efer

red

(sam

e) g

ende

r.

Sou

th A

fric

aY

es

Spa

inN

o. I

t dep

ends

on

the

doct

or o

n du

ty.

Sw

eden

No

Sw

itze

rlan

dY

es

18 Payne-James

18

Que

stio

n H

Who

und

erta

kes

the

fore

nsic

med

ical

exa

min

atio

n an

d as

sess

men

t of

alle

ged

child

vic

tims

of s

exua

l ass

ault?

Res

pons

eA

ustr

alia

For

ensi

c m

edic

al o

ffic

ers

orpe

diat

rici

ans.

Eng

land

and

Wal

esP

olic

e su

rgeo

ns a

nd/o

r pe

diat

rici

ans.

Ide

ally

join

t exa

min

atio

ns (

guid

elin

es f

or th

e as

sess

men

t hav

e be

en is

sued

).

Ger

man

yE

ithe

r pe

diat

rici

an g

ynec

olog

ist o

r m

edic

oleg

al s

peci

alis

t.

Hon

g K

ong

For

ensi

c pa

thol

ogis

ts/p

hysi

cian

s, p

edia

tric

ians

, obs

tetr

icia

ns, a

nd g

ynec

olog

ists

, som

etim

es jo

intl

y.

Indi

aF

emal

e ch

ildr

en—

gyne

colo

gist

, pre

fera

bly

fem

ale

(whi

ch is

gen

eral

ly th

e ca

se a

nyw

ay).

Mal

e ch

ildr

en—

fore

nsic

per

sonn

el o

f ei

ther

sex

.

Isra

elF

oren

sic

path

olog

ists

and

ped

iatr

icia

ns.

Mal

aysi

aW

here

ver

poss

ible

, by

pedi

atri

cian

s or

gyn

ecol

ogis

ts. S

mal

ler

hosp

ital

s by

non

spec

iali

st p

hysi

cian

s.

The

Net

herl

ands

Gen

eral

ly s

peak

ing,

pub

lic

heal

th o

ffic

ers

qual

ifie

d in

cli

nica

l for

ensi

c m

edic

ine.

Nig

eria

Sam

e as

for

all

eged

vic

tim

s of

sex

ual a

ssau

lt. S

eepr

evio

us a

nsw

er to

que

stio

n E

.

Sco

tlan

dIn

the

larg

er c

ente

rs, j

oint

ped

iatr

ic/p

olic

e su

rgeo

n ex

amin

atio

ns a

re c

omm

on. F

or o

ther

cen

ters

, it v

arie

s.

Ser

bia

Phy

sici

ans

wit

h fo

rens

ic tr

aini

ng a

re r

arel

y in

volv

ed in

init

ial e

xam

inat

ion

and

asse

ssm

ent.

For

ensi

c ph

ysic

ians

tend

toge

t inv

olve

d at

a la

ter

stag

e of

inve

stig

atio

n.

Sou

th A

fric

aM

edic

al p

ract

itio

ner.

Spa

inA

for

ensi

c su

rgeo

n an

d a

pedi

atri

cian

.

Sw

eden

Sam

e as

for

adu

lts.

See

prev

ious

ans

wer

to q

uest

ion

E.

Sw

itze

rlan

dY

oung

er th

an 1

6 yr

: fem

ale

gyne

colo

gist

at U

nive

rsit

y C

hild

ren

Hos

pita

l. O

lder

than

16

yr: e

xam

ined

as

adul

t.


19

Que

stio

n I

Who

und

erta

kes

the

fore

nsic

med

ical

exa

min

atio

n an

d as

sess

men

t of a

llege

d ch

ild v

ictim

s of

phy

sica

l ass

ault?

Res

pons

eA

ustr

alia

For

ensi

c m

edic

al o

ffic

ers

orpe

diat

rici

ans.

Eng

land

and

Wal

esP

olic

e su

rgeo

ns a

nd/o

r pe

diat

rici

ans.

Ger

man

yP

edia

tric

ian

or m

edic

oleg

al s

peci

alis

t.

Hon

g K

ong

Ped

iatr

icia

ns. S

omet

imes

for

ensi

c pa

thol

ogis

ts/p

hysi

cian

s. S

omet

imes

join

tly.

Indi

aF

oren

sic

med

icin

e de

part

men

ts.

Isra

elF

oren

sic

path

olog

ists

and

ped

iatr

icia

ns.

Mal

aysi

aP

edia

tric

ians

in s

mal

ler

hosp

ital

s by

non

spec

iali

st p

hysi

cian

s.

The

Net

herl

ands

Gen

eral

ly s

peak

ing,

pub

lic

heal

th o

ffic

ers

qual

ifie

d in

cli

nica

l for

ensi

c m

edic

ine.

Nig

eria

Sam

e as

for

all

eged

vic

tim

s of

sex

ual a

ssau

lt. S

eepr

evio

us a

nsw

er to

que

stio

n E

.

Sco

tlan

dM

ostl

y pe

diat

rici

ans

but s

ome

evid

ence

is b

ased

on

find

ings

of

fam

ily

phys

icia

ns.

Ser

bia

For

mer

ly, f

ew fo

rens

ic p

atho

logi

sts

wer

e in

volv

ed. S

itua

tion

is s

omew

hat i

mpr

oved

, but

sti

ll p

oor c

oope

rati

on b

etw

een

clin

icia

ns a

nd f

oren

sic

doct

ors.

Sou

th A

fric

aM

edic

al p

ract

itio

ner.

Spa

inF

oren

sic

surg

eon

and

a fo

rens

ic p

edia

tric

ian.

Sw

eden

Sam

e as

for

an

adul

t. Se

epr

evio

us a

nsw

er to

que

stio

n E

.

Sw

itze

rlan

dY

oung

er th

an 1

6 yr

: doc

tors

at U

nive

rsit

y C

hild

ren

Hos

pita

l (T

raum

a-X

gro

up).

Old

er th

an 1

6 yr

: doc

tors

of I

nsti

tute

of

Leg

al M

edic

ine

of U

nive

rsit

y of

Zur

ich

(Dis

tric

t Phy

sici

an).

20 Payne-James

20

Que

stio

n J

Is th

ere

a sy

stem

in y

our

coun

try/

stat

e w

here

by in

divi

dual

s de

tain

ed in

pol

ice

cust

ody

who

app

ear

to h

ave

(or

do h

ave)

psy

chia

tric

dis

orde

r or

men

tal h

ealth

pro

blem

s or

lear

ning

dis

abili

ty m

ay b

e as

sess

ed?

clinical forensic medicine · forensic science-and- medicinesteven b. karch, md,series editor...

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