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Overview of clinical forensic services in various countries of the European Union

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Examination of a person who has been a victim of a physical or sexual assault may be very important for upcoming legal proceedings. In the context of a clinical forensic examination, physical findings are recorded and biological trace material is gathered and secured. Ideally, all forensic findings are documented in a detailed report combined with photographic documentation, which employs a forensic scale to depict the size of the injuries. However, the integrity of such forensic findings depends particularly on two factors. First, the examination needs to be conducted professionally to ensure that the findings are properly admissible as court evidence. Second, the examination should take place as soon as possible because the opportunity to successfully secure biological samples declines rapidly with time. Access to low-threshold clinical forensic examinations is not evenly provided in all member states of the European Union (EU); in some states, they are not available at all. As part of the JUSTeU! (Juridical standards for clinical forensic examinations of victims of violence in Europe) project, the Ludwig Boltzmann Institute for Clinical Forensic Imaging in Graz, Austria created (in cooperation with its international partner consortium) a questionnaire: the purpose was to collect information about support for victims of physical and/or sexual assault in obtaining a low-threshold clinical forensic examination in various countries of the EU. Our paper provides a summary of the responses and an overview of the current situation concerning provided clinical forensic services.
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Overview of clinical forensic services in various
countries of the European Union
Sophie Kerbacher, Michael Pfeifer, Reingard Riener-Hofer, Andrea
Berzlanovich, Maeve Eogan, Anita Galić Mihic, Gregor Haring, Petr Hejna,
Johannes Höller, Sorin Hostiuc, Michael Klintschar, Peter Kováč, Astrid
Krauskopf, Simone Leski, Michal Malacka, Thorsten Schwark, Hanna
Sprenger, Andrea Verzeletti, Duarte Nuno Vieira, Sylvia Wolf & Kathrin Yen
To cite this article: Sophie Kerbacher, Michael Pfeifer, Reingard Riener-Hofer, Andrea
Berzlanovich, Maeve Eogan, Anita Galić Mihic, Gregor Haring, Petr Hejna, Johannes Höller,
Sorin Hostiuc, Michael Klintschar, Peter Kováč, Astrid Krauskopf, Simone Leski, Michal Malacka,
Thorsten Schwark, Hanna Sprenger, Andrea Verzeletti, Duarte Nuno Vieira, Sylvia Wolf & Kathrin
Yen (2019): Overview of clinical forensic services in various countries of the European Union,
Forensic Sciences Research, DOI: 10.1080/20961790.2019.1656881
To link to this article: https://doi.org/10.1080/20961790.2019.1656881
© 2019 The Author(s). Published by Taylor &
Francis Group on behalf of the Academy of
Forensic Science
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ORIGINAL ARTICLE
Overview of clinical forensic services in various countries of the
European Union
Sophie Kerbacher
a
, Michael Pfeifer
a
, Reingard Riener-Hofer
a
, Andrea Berzlanovich
b
, Maeve Eogan
c
,
Anita Gali
c Mihic
d
, Gregor Haring
e
, Petr Hejna
f
, Johannes H
oller
a
, Sorin Hostiuc
g
, Michael Klintschar
h
,
Peter Kov
a
c
i
, Astrid Krauskopf
j
, Simone Leski
a
, Michal Malacka
k
, Thorsten Schwark
l
,
Hanna Sprenger
a
, Andrea Verzeletti
m
, Duarte Nuno Vieira
n
, Sylvia Wolf
a
and Kathrin Yen
j
a
Ludwig Boltzmann Institute for Clinical Forensic Imaging, Ludwig Boltzmann Gesellschaft, Graz, Austria;
b
Center of Forensic
Medicine, Medical University of Vienna, Vienna, Austria;
c
Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin,
Ireland;
d
Institute of Forensic Medicine and Criminalistics, School of Medicine, University of Zagreb, Zagreb, Croatia;
e
Department
for Forensic Medicine and Deontology, University of Ljubljana, Ljubljana, Slovenia;
f
Department of Forensic Medicine, Charles
University and University Hospital, Hradec Kralove, Czech Republic;
g
Department of Legal Medicine, National Institute of Legal
Medicine, Bucharest, Romania;
h
Department for Legal Medicine, Hannover Medical School, Hannover, Germany;
i
Forensic.sk,
In
stit
ut Forenzn
ych Medic
ınskych Expert
ız, Bratislava, Slovakia;
j
Institute of Forensic and Traffic Medicine, University of
Heidelberg, Heidelberg, Germany;
k
Faculty of Law, Palack
y University Olomouc, Olomouc, Czech Republic;
l
Department of
Forensic Medicine, Laboratoire National de Sant
e, Dudelange, Luxembourg;
m
Department of Medical and Surgical Specialties,
Radiological Sciences and Public Health, University of Brescia, Brescia, Italy;
n
Department of Forensic Medicine, Ethics and
Medical Law, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
ABSTRACT
Examination of a person who has been a victim of a physical or sexual assault may be very
important for upcoming legal proceedings. In the context of a clinical forensic examination,
physical findings are recorded and biological trace material is gathered and secured. Ideally,
all forensic findings are documented in a detailed report combined with photographic docu-
mentation, which employs a forensic scale to depict the size of the injuries. However, the
integrity of such forensic findings depends particularly on two factors. First, the examination
needs to be conducted professionally to ensure that the findings are properly admissible as
court evidence. Second, the examination should take place as soon as possible because the
opportunity to successfully secure biological samples declines rapidly with time. Access to
low-threshold clinical forensic examinations is not evenly provided in all member states of
the European Union (EU); in some states, they are not available at all. As part of the JUST
e
U!
(Juridical standards for clinical forensic examinations of victims of violence in Europe) pro-
ject, the Ludwig Boltzmann Institute for Clinical Forensic Imaging in Graz, Austria created (in
cooperation with its international partner consortium) a questionnaire: the purpose was to
collect information about support for victims of physical and/or sexual assault in obtaining a
low-threshold clinical forensic examination in various countries of the EU. Our paper pro-
vides a summary of the responses and an overview of the current situation concerning pro-
vided clinical forensic services.
ARTICLE HISTORY
Received 18 December 2018
Revised 12 August 2019
Accepted 13 August 2019
KEYWORDS
Forensic sciences; clinical
forensic services; violence;
JUST
e
U!; Directive 2012/29/
EU; victim; examination
Introduction
In November 2016, the European Commission pub-
lished a Special Eurobarometer Report on gender-
based violence [1]: the aim was to assess the percep-
tion of citizens in the 28 member states of the
European Union (EU) on the topic. In the report,
gender-based violence is defined as violence
directed towards a person on the basis of their
gender, and violence that disproportionately affects
persons of a particular gender; it therefore encom-
passes physical, sexual and psychological abuse. Any
person, regardless of gender, can become a victim of
gender-based violence, but women are particularly
affected by this kind of violence [1,p.3]. In 2014, a
survey by the EU Agency for Fundamental Rights
(FRA) about violence against women found that one
in three women in the EU older than 15 years had
suffered from physical or sexual violence. The sur-
vey concluded that, violence against women is
an extensive and wide-ranging fundamental rights
abuse.Moreover, the survey determined that the
majority of women never report violence to the
police or a victim-support organization. Therefore,
such cases of violence may not appear in official
criminal justice data, which results in a general lack
of comprehensive data. The FRA recommends that
CONTACT Sophie Kerbacher sophie.kerbacher@cfi.lbg.ac.at sophie.kerbacher@uni-graz.at
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/tfsr.
ß2019 The Author(s). Published by Taylor & Francis Group on behalf of the Academy of Forensic Science.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
FORENSIC SCIENCES RESEARCH
https://doi.org/10.1080/20961790.2019.1656881
health-care professionals should play an important
role in countering the under-reporting of violence,
encouraging victims to come forward, report their
experience, and seek help. Health-care professionals
need to be alerted about identifying violence and be
able to recognize such cases. Hence, a questioning
routine for health-care practitioners should be
developed and include appropriate checks to clarify
suspected abuse. If a patient has characteristic inju-
ries that may have resulted from violence, 87% of
questioned women indicated that they would con-
sider it acceptable for an examining doctor to ask
routinely about violence [2,p.7,11,15].
For the Special Eurobarometer Report on gender-
based violence (2016), face-to-face interviews with
over 27 000 EU citizens were conducted [1]. Over
three-quarters of the respondents believed that
domestic violence against women was common in
their country; fewer than one-third considered that
in their country, domestic violence against men was
common. More than 90% of the respondents
declared that domestic violence was unacceptable
either against women or men. In both cases, a large
majority (around 80%) believed that the perpetrators
should be punished by law. Regarding personal
experience, almost one-quarter stated that they
knew a family member or friend who was a victim;
70% of the respondents, who personally knew a vic-
tim, had talked to someone about the violent event;
however, only one in ten disclosed the matter to the
police, 8% spoke to health-care professionals, and
only 7% contacted support services. As to the main
reasons for 30% of the respondents not talking to
anyone about the violent event, the survey found
the following: they believed that it was none of their
business; they lacked proof; they did not want to
create trouble; or they stayed silent for no particular
reason. The survey concluded that most cases con-
cerning domestic violence affected women.
To tackle this issue, the Special Eurobarometer
Report recommends further action against gender-
based violence in the EU. Among other measures, it
states that the Council of Europe Convention on
preventing and combating violence against women
and domestic violence, referred to as the Istanbul
Convention, should be implemented by the member
states [1,p.2,6,8,10,1215,33,34].
Legal regulations in connection with gender-
based violence
In the preamble to the Istanbul Convention, it is
stated as fact that women and girls are at greater
risk of falling victim to gender-based violence than
men. Article 2 Section 2 of the convention particu-
larly recommends tackling gender-based violence.
One provision is laid down in Article 25 concerning
support for victims of sexual violence: it states that
countries should take responsibility to set up
appropriate, easily accessible rape crisis or sexual
violence referral centres for victims in sufficient
numbers to provide for medical and forensic exam-
ination, trauma support and counselling for victims
[3]. The Explanatory Report to the Istanbul
Convention specifies that these sexual violence refer-
ral centres can be specialized, for example in high-
quality forensic practice (Recital 141). Moreover, the
report emphasizes the good practice to carry out
forensic examinations regardless of whether the
matter will be reported to the police, and to offer
the possibility of having samples taken and stored
so that the decision as to whether or not to report
the rape can be taken at a later date[4,p.26].
Accordingly, clinical forensic services should not be
dependent on the victim making a formal complaint
to the police regarding a criminal offence: a low-
threshold access to clinical forensic examinations
should be ensured [5].
The European legislator addresses gender-based
violence in its Directive 2012/29/EU of the
European Parliament and of the Council of 25
October 2012 establishing minimum standards on
the rights, support and protection of victims of
crime(ABl L 315, 57)the so-called victimsrights
directive. In this context, Recital 17 states, Women
victims of gender-based violence and their children
often require special support and protection because
of the high risk of secondary and repeat victimiza-
tion, of intimidation and of retaliation connected
with such violence.In particular, Articles 8 and 9
of the directive are dedicated to victim support serv-
ices. Article 8 (Right to access victim support serv-
ices) stipulates in Section 1 that member states
have to provide access to confidential victim sup-
port services, free of charge. Article 9 (Support
from victim support services) details in Section 1
the services to be offered as a minimum standard
for victim support [6].
In advising European member states about imple-
mentation of the victimsrights directive, the
Directorate-General (DG) Justice Guidance
Document regards Article 8 as one of the core rights
of that directive. The document emphasizes that vic-
tim support plays a large role in helping victims in
the process of their recovery. Support offers should
be confidential, free of charge, available from the
earliest possible moment after a crime has been
committed, and irrespective of whether the crime
has been reported. This is due to the fact that access
to support services at an early stage can lower long-
term consequences, such as suffering and loss of
income. In addition, the DG Justice Guidance
2 S. KERBACHER ET AL.
Document advises that the specific needs of a victim
should be determined. For example, to process the
circumstances of the crime, victims of sexual vio-
lence and domestic violence may require psycho-
logical support. Additionally, reliable support
services may encourage a victim to make a formal
complaint regarding the crime [7,p.2426].
Thus, Article 8 Section 3 of the victimsrights
directive obliges member states to establish free of
charge and confidential specialist support services;
Article 9 Section 3 specifies which special services
should be provided as a minimum. According to
Article 9 Section 3 Littera b, victims with specific
needs are victims of sexual violence, victims of gen-
der-based violence and victims of violence in close
relationships. Recital 38 recommends that among
other victims, victims of gender-based violence
should have special support services at their disposal
as immediate medical support, referral to medical
and forensic examination for evidence in cases of
rape or sexual assault[6]. This is particularly
important given that physical and sexual violence
often goes unreported. Statistics reflect only
reported cases of violence and so may just indicate
the tip of the iceberg. There is also a link between
citizensperception of domestic violence and their
behaviour regarding formal complaints to the police:
women in European states where domestic violence
is considered less unacceptable are less likely to
report such violence[8,p.13].
In consideration of all these matters, the Ludwig
Boltzmann Institute for Clinical Forensic Imaging in
Graz, Austria initiated the international JUST
e
U!
(Juridical standards for clinical forensic examina-
tions of victims of violence in Europe) project [9].
JUST
e
U! project
The European Commission provides financial con-
tributions in the form of grants to projects, which
help implement EU programmes or policies. To
apply for grant funding, a project proposal has to be
submitted under a specific call for proposals. In the
case of the JUST
e
U! project, it was the Joint Justice
& Daphne call Actions grants to support national
or transnational projects to enhance the rights of
victims of crime/victims of violence (JUST/2015/
SPOB/AG/VIC). The project was awarded a grant
and co-funded by the Justice Programme of the EU
[10]. The JUST
e
U! project started in February 2017
for a 2-year period: it addressed access to specialist
support services, especially for clinical forensic
examinations (Article 9 Section 3 Littera b in com-
bination with Recital 38 of the victimsrights direct-
ive) [5]. The project sought to reinforce the legal
position of victims of sexual and/or physical
violence: during a clinical forensic examination,
injuries are documented in detail on a documenta-
tion form as well as with a camera and a forensic
scale; trace evidence is collected and stored. These
evidentiary findings can then be used in future legal
proceedings [11].
To enhance victim support in this field on a
European level, the project consortium involved the
following: the Institute of Forensic and Traffic
Medicine at the University Hospital Heidelberg [12]
and Institute for Forensic Medicine at the Hannover
Medical School [13] (Germany); the Department of
Medical and Surgical Specialties, Radiological
Sciences, and Public Health at the Universit
a degli
Studi di Brescia [14] (Italy); and the Department of
Forensic Medicine at the Faculty of Medicine in
Hradec Kr
alov
e[15] and Faculty of Law at Palack
y
University Olomouc [16] (Czech Republic). The
Ludwig Boltzmann Institute for Clinical Forensic
Imaging [17] was the project leader.
One main part of the project focussed on dissem-
ination and awareness-raising activities to expand
understanding (among the public as well as among
experts) of the importance of access to clinical
forensic examinations for victim support.
Accordingly, a project website [9] was established,
and national symposia were hosted in each project
partner country. Further, a 2-day workshop [18] for
experts in clinical forensic medicine was organized
by the Ludwig Boltzmann Institute for Clinical
Forensic Imaging in early June 2018 in Graz. At
that JUST
e
U! workshop, all project partners partici-
pated, and each recruited one additional forensic
expert. In that way, it was possible to gather forensic
expertize from 11 European countries: Austria,
Croatia, Czech Republic, Germany, Ireland, Italy,
Luxembourg, Portugal, Romania, Slovakia and
Slovenia. The goals of the JUST
e
U! workshop were
to discuss a future Clinical Forensic Network for
Europe (CFN Europe) and a European-wide min-
imum standard for clinical forensic examinations.
To assess the starting point for the discussions,
the Ludwig Boltzmann Institute for Clinical
Forensic Imaging created in advance (in cooperation
with its international partner consortium) two ques-
tionnaires. One questionnaire was dedicated to ana-
lyze the legal framework concerning clinical forensic
examinations: Questionnaire concerning the legal
framework for doctors when dealing with a case of
physical violence. The results of the survey were
analyzed by the project partner from the Faculty of
Law at Palack
y University Olomouc; they were sum-
marized as a legal opinion, which was forwarded as
a part of a compilation to European decision makers
at the end of the project. Through the second sur-
vey, questions concerning the availability of clinical
FORENSIC SCIENCES RESEARCH 3
forensic service offers were addressed: Questionnaire
concerning national victim supporting low-threshold
clinical forensic examination offers (QCFN). Both
questionnaires were drafted by the Ludwig
Boltzmann Institute for Clinical Forensic Imaging
and revised by all project partners. They were sent
to all medical project partners via email in elec-
tronic form with input fields. In an effort to distrib-
ute the questionnaires on a European-wide basis,
the questionnaires were also dispatched to about
180 relevant stakeholders, such as ministries of just-
ice and health, medical associations, members of the
European Council of Legal Medicine [19], and
experts in law and forensic medicine.
QCFN
The questionnaire comprised 32 items and was div-
ided into three parts: Part I enquired about the cur-
rent status of clinical forensic examination services;
Part II covered routine clinical forensic examination
practice; and Part III dealt with the expectations
towards a future CFN Europe. The survey was car-
ried out from May 2017 till January 2018. The first
responses were received in July 2017 and the last
responses in March 2018. Responses from 13
European countries were obtained: Austria, Croatia,
Czech Republic, Germany, Greece, Ireland, Italy,
Luxembourg, Poland, Portugal, Romania, Slovakia
and Slovenia. The following results are based on the
survey responses.
Part I: current status of clinical forensic
examination services
With the initial questionnaire items (Appendix I),
the general availability of clinical forensic examin-
ation provided in each country was assessed. In
brief, 12 of the 13 countries offered clinical forensic
examinations (Austria, Czech Republic, Germany,
Greece, Ireland, Italy, Luxembourg, Poland,
Portugal, Romania, Slovakia and Slovenia). Nine of
those countries offered examinations on a low-
threshold basis: a person could be examined without
having filed a complaint to the police regarding a
criminal offence. That service was available in
Austria, Germany, Ireland, Italy, Luxemburg,
Poland, Portugal, Romania and Slovenia. The Czech
Republic, Greece and Slovakia offered clinical foren-
sic examinations, but not on a low-threshold basis.
Those three countries considered the low-threshold
service useful. In Croatia, the Institute of Forensic
Medicine and Criminalistics at the University of
Zagreb [20] did not offer clinical forensic examina-
tions at the time of the study (July 2017); however,
it plans to establish a clinical forensic unit in
the future.
Service availability to victims
Another question asked whether the availability of an
examination service was dependent on such factors as
age,sex,orthetypeofviolence(Appendix I). As
indicated in Figure 1, nine countries answered that
question in the affirmative: Austria (Graz and
Vienna); Germany (Hannover and Heidelberg);
Figure 1. Service availability to victims. FOKUS: Forensische Kinder- und Jugenduntersuchungsstelle (in German, Forensic
Outpatient Centre for children and adolescents); SATUs: sexual assault treatment units.
4 S. KERBACHER ET AL.
Greece; Italy (Brescia); Poland (Lublin); Portugal;
Romania (Bucharest); Slovakia; and Slovenia
(Ljubljana). In Austria, the situation depended on the
institution. There were no restrictions with the exam-
ination services in hospitals in Graz and Vienna; how-
ever, restrictions existed with an other institution in
Vienna regarding the age of victims. The latter was
the case for the Forensic Outpatient Centre for
Children and Adolescents (FOKUS, in German:
Forensische Kinder- und Jugenduntersuchungsstelle)
in Vienna, which is an outpatient centre available
only to children and adolescents aged up to 18years
[21]. In Lower Saxony in Germany, the Network
ProBeweis (in German: Netzwerk ProBeweis) con-
sisted of 36 hospitals and offered clinical forensic
examinations only in cases of domestic violence and
sexual abuse [22]. In Hannover, a special centre for
the assessment regarding possible child abuse (in
German: Kinderschutzambulanz) was available [23].
In Ireland, six Sexual Assault Treatment Units
(SATUs) were subject to two restrictions: the units
were accessible only to women and men older than
14 years and in cases of suspected sexual violence.
Some services for children younger than 14 years
existed in Ireland, but at the time of the question-
naire, they were dispersed over a wider geographical
area and were generally not standardized [24]. In
Luxembourg, it should be noted that children could
not be examined on a low-threshold basis by the Unit
for Medico-legal Documentation of Injuries
(UMEDO) owing to reporting obligations [25]. No
questionnaire response about a low-threshold service
availability was received from Slovakia.
On-call service
The survey included questions about the availability
of an on-call service and on-call hours.
As Figure 2 demonstrates, six European states
(Austria, Germany, Ireland, Italy, Luxembourg and
Portugal) provided a 24-h on-call service. In Austria,
this service was provided through the Womenshelp-
line against violence (in German: Frauenhelpline gegen
Gewalt) [26]. In Germany, the two cities offered con-
tinuous accessibility by telephone: Hannover estab-
lished a hotline within Network ProBeweis; and
Heidelberg offered a hotline within its Clinical
Forensic Outpatient Clinic (in German: Klinisch-
Forensische Ambulanz) [27]. A 24-h on-call service
was available in Ireland through SATUs [24], in
Luxembourg through the UMEDO [25], and in
Portugal through the National Institute of Legal
Medicine and Forensic Sciences (NILMFS, in
Portuguese: Instituto Nacional de Medicina Legal e
Ci^
encias Forenses) [28]. In Italy, such a service was
available through the Spedali Civili di Brescia, a hos-
pital in Brescia [29]. An on-call service was not avail-
able in Lublin (Poland) [30], Bucharest (Romania) [31]
and Slovakia. In Bratislava (Slovakia), an on-call ser-
vice was organized on an informal base that included
11 qualified forensic pathologists. In Ljubljana
(Slovenia) [32], an on-call service was available, but
the on-call hours were not specified. No data about an
Figure 2. On-call service. SATUs: sexual assault treatment units.
FORENSIC SCIENCES RESEARCH 5
on-call service were received from Greece and
Czech Republic.
Provision of clinical forensic services
With regard to the nationwide provision of clinical
forensic services (Appendix I), the responses appear
in Figure 3.
With Heidelberg (Germany), the clinical forensic
examinations took place within a radius of 200 km
from the city [27]; Hannover operated the Network
ProBeweis, which covers the whole state of Lower
Saxony with its partner hospitals [22]. The UMEDO
and its four partner hospitals provided clinical
forensic examinations throughout Luxembourg. In
Ireland, every person was able to reach one of the
six SATUs within 3-h driving time [24]. In Portugal,
the NILMFS [28] covered the whole country with its
33 service facilities.
In Austria, the service was more or less restricted to
some larger cities (Graz, Innsbruck, Linz, Salzburg and
Vienna) [33]. In Greece, forensic services were available
only on the mainland. The forensic service through the
hospital Spedali Civili di Brescia in Italy was limited to
the city of Brescia and its suburbs [29]. That situation
was similar for the service of the Institute of Forensic
Medicine for the city of Ljubljana (Slovenia) and its
suburbs [32]. Likewise in Lublin (Poland) [30] and in
Bratislava [34] and Ko
sice (Slovakia) [35], the service
was provided only through the department of forensic
medicine. No data about regional service limitations
were received from Romania and Czech Republic.
Access to clinical forensic services
Regarding clinical forensic examination services, the
survey also included a question about how a victim
could contact a clinical forensic service facility at a
low-threshold level (Appendix I). The situation var-
ied from country to country and was sometimes not
even consistent within the same country. One possi-
bility for the victim to gain access to an examination
was through self-referral via the Internet, email, or
an on-call service. For example in Heidelberg
(Germany), the victim could directly call the
Clinical Forensic Outpatient Clinic [27]. In Ireland,
the SATUs, contacted directly by a patient, offered
victims a choice between a health check (e.g. provid-
ing emergency contraception and sexually transmit-
ted infection (STI) prophylaxis) or a forensic
examination (also including emergency contracep-
tion and STI prophylaxis) [24]. In Portugal, the
NILMFS could be contacted directly, and it for-
warded a complaint to court if the victim consented
[28]. Another approach was to establish contact
through the hospital emergency room, which was
the routine procedure in Brescia (Italy) [29], or
through partner hospitals if such a service has been
established (e.g. within the Network Pro Beweis in
Lower Saxony, Germany [22]). In some countries, it
was possible to contact the clinical forensic service
facility through victim support groups, other physi-
cians or such authorities as the police and youth
welfare authority.
Dissemination of clinical forensic services
In the survey, respondents made the following rec-
ommendations about further disseminating low-
threshold clinical forensic examinations (Appendix I).
The provided responses could be summarized in
three categories: raising public awareness; political or
state support; and training. However, some answers
did overlap and sometimes fitted all categories.
Raising public awareness related to recommendations
Figure 3. Regional service limitations. SATUs: sexual assault treatment units.
6 S. KERBACHER ET AL.
to promote clinical forensic examinations among the
general public. More coverage should be sought in
the media, such as through TV and radio, as well as
announcements in public bulletins and social media
channels. Such moves should be accompanied by
public information in the form of seminars
and promotions.
The second category (political or state support)
emphasized the importance of legal regulations (which
would secure the funding of clinical forensic examina-
tionsonalong-termbasis)aswellasthatofpolitical
support. A main demand made by respondents was
that the reimbursement of examination costs to vic-
tims and institutions should be resolved. In general,
fundingshouldberaisedfortheworkofphysicians
when dealing with victims of sexual and/or physical
violence. The state and political forces should aim to
increase awareness among health-care providers
regarding clinical forensic examinations. Such moves
could be executed by introducing official recommen-
dations through national health authorities or legal
regulations. Finally, to enhance telemedicine, a major
impact could be achieved by improving access to
services via the Web and phone.
The third category (training) emphasized the need
for all kinds of teaching activities. Forensic training
sessions should be offered for all relevant occupational
groups, such as victim support groups, teachers,
physicians, nursing staff, midwives and youth welfare
authorities. To avoid and identify violence, improving
knowledge at school plays a key role. Where networks
are already established in a country, the aim should
be to increase the number of partner hospitals
involved in the network and expand training.
Examining person
The survey included questions about assessing the role
of the person who conducts the clinical forensic exam-
ination. As Figure 4 shows, in most countries, all types
of physicians (family doctors, obstetricians, paediatri-
cians, emergency physicians, court-appointed physi-
cians) were allowed to conduct a clinical forensic
examination. These countries were Austria, Germany,
Italy, Ireland, Luxembourg, Poland, Portugal and
Slovenia. In Ireland, forensic nurses were trained to
conduct clinical forensic examinations on men and
women aged over 14 years [24]. In Greece and
Romania, only a physician specialized in forensic medi-
cine was allowed to conduct such an examination.
Special training for clinical forensic examinations
The questionnaire enquired whether medical staff
(physicians and forensic nurses) had received special
training for such examinations (Appendix I). That
was answered in the affirmative for Austria,
Germany, Greece, Ireland, Poland, Portugal,
Slovenia and Romania. In Italy, no special training
was available; thus, physicians had to rely on self-
study, lectures, and seminars. Likewise in
Luxembourg, no special training was available; clin-
ical forensic examinations were performed only by
board-certified forensic pathologists.
Special training for performing clinical forensic
examinations has both advantages and disadvantages
Figure 4. Type of examining physician.
FORENSIC SCIENCES RESEARCH 7
(Appendix I). One advantage is that forensic find-
ings may have a higher admissibility rate as evi-
dence in legal proceedings. Accordingly, the victims
legal status is enhanced; the court is able to assess
the case on a more objective basis, thereby promot-
ing legal certainty [5,36]. Another advantage is that
training guarantees a higher quality standard for
clinical forensic examinations and assures that the
examination can be conducted in a timely manner.
For example, a victim can be examined instantly by
a trained physician without having to wait for a spe-
cialist to arrive. When taking into account that in
rural areas no forensic physicians are usually avail-
able, it is very important that general practitioners
should be empowered to perform such examina-
tions. In addition, trained personnel are best for
ensuring that a patient (or rather a victim) receives
the appropriate care. Moreover, training in general
increases the awareness of possible violent cases,
which may have otherwise remained unnoticed, as
physicians gain knowledge about identifying eviden-
tial traces and prevent their destruction. In this con-
text, written guidelines for physicians are of great
value [37,38]. Finally, training also optimizes com-
munication among the institutions concerned with
victims of sexual and/or physical violence. The dis-
advantages of special training concern time and cost
factors: training is rather time consuming and
expensive because it needs to be undertaken regu-
larly to ensure a consistent quality level.
Part II: clinical forensic examination routine
Part II of the questionnaire obtained information
about the clinical forensic examination routine. Of
particular interest was the availability of a standardized
examination kit and standardized documentation form
(Appendix I). The answers varied from country to
country. The SATUs in Ireland [24]andtheNILMFS
in Portugal [28] were best-practice examples: they pro-
vided a standardized examination kit and standardized
documentation form for the whole of the country. In
Austria, a standardized kit was available, which con-
tained a standardized documentation form called
MedPolform for the examination to document inju-
ries (in German: MedPolUntersuchungsbogen zur
Verletzungsdokumentation). The MedPol documenta-
tion form was developed by Andrea Berzlanovich
within the MedPol project by the Federal Criminal
Police Office of the Ministry of the Interior in cooper-
ation with the Austrian Medical Association and
Austrian Society for Forensic Medicine; it can be
downloaded from the Internet [39]. The Network
ProBeweis in Lower Saxony [22] and Clinical Forensic
Outpatient Clinic in Heidelberg (Germany) [27]both
used a standardized kit and documentation form;
however, the documentation form was not standar-
dized for the whole country. The same applied to the
UMEDO in Luxembourg [25]. The Spedali Civili di
BresciainItaly[29] had a standardized kit, but it did
not use a documentation form. The departments of
forensic medicine in Lublin (Poland) [30]and
Ljubljana (Slovenia) [32] did not have examination
kits; however, each used a documentation form that
was not standardized for the whole country. The
National Institute of Legal Medicine Mina Minovici in
Bucharest (Romania) [31] also lacked an examination
kit, but it included standardized elements in the docu-
mentation form. Different regions in Romania could
produce their own documentation form, which had to
contain the standardized elements. No responses were
obtained from Greece and Slovakia about the clinical
forensic examination routine.
One interesting aspect about the course of a clin-
ical forensic examination was photographic docu-
mentation and storage of evidence (Appendix I). At
the institutions in Austria [40], Germany [22,27],
Italy [29], Luxembourg [25], Portugal [28] and
Slovenia [32], photographs were routinely taken and
evidentiary findings were stored. Ideally, a forensic
colorimetric scale should be used when taking the
images to best depict the size and colour of the inju-
ries. The period of time for storing evidence varied
among the institutions and also depended on legal
regulations: it was from 6 months to 30 years. At the
institutions in Ireland [24], Poland [30] and
Romania [31], no photographs were taken, but evi-
dentiary findings were stored. No data about this
question were obtained from Greece and Slovakia.
Part III: expectations towards a future
CFN Europe
To conclude the survey, Part III contained questions
about a future CFN Europe (Appendix I). Fortunately,
all respondents from Austria, Croatia, Czech Republic,
Germany, Greece, Italy, Ireland, Luxembourg, Poland,
Portugal, Romania, Slovenia and Slovakia expressed
their interest in joining such a network to promote
the spreading of clinical forensic services in Europe.
A European-wide network could offer many
advantages for victims and medical staff. Both would
benefit from such a network, because it would present
a strong common voice at the European level towards
implementing guidelines and standards as well as
funding for examination services. Further, victims
would benefit by having equal rights and receive
equal support and protection regardless where they
are in the EU. In a clinical forensic examination, evi-
dentiary findings have higher value if the evidence
was properly obtained, which serves to strengthen the
legal position of a victim in court. Another advantage
is that through an interdisciplinary network, more
8 S. KERBACHER ET AL.
systemic problem solving could be achieved.
Moreover,throughaCFNEurope,victimscould
access up-to-date and easily obtain information about
whom to contact and where to find a specialist for a
clinical forensic examination. A CFN Europe could
help raise public awareness about the issue of domes-
tic and sexual violence, which could encourage vic-
tims to come forward and report their cases. Further,
a CFN Europe would encourage mutual learning
among medical staff by enabling networking and
research opportunities with international experts.
Throughsuchanetwork,expertsandothermedical
staff could easily keep in contact, share their experien-
ces and address urgent matters. Another advantage
would be that a European network could establish
standardized guidelines for examination procedures,
thereby facilitating the conduct of such examinations.
Thenetworkwouldbeabletooffertrainingformed-
ical staff and other occupational groups in close con-
tact with victims of physical and/or sexual violence.
Through such training, medical personnel could
become aware of the importance of securely and
adequately storing forensic findings.
Conclusions and outlook
The responses obtained from the QCFN question-
naire, which was developed within the JUST
e
U! pro-
ject, provided a first insight into the current situation
about clinical forensic services in the EU. The data
from Part I of the QCFN indicated that clinical foren-
sic examinations are of great relevance for victim sup-
port. The clinical forensic services offered were
specialist support services in the sense of Article 8
Section 3 of the victimsrights directive. Therefore, it
isnecessarytosettheaimoffurtherestablishingor
expanding such services in all European countries. To
facilitate implementation of those services and based
on the QCFN responses, the Ludwig Boltzmann
Institute for Clinical Forensic Imaging developed a
concept about expanding national clinical forensic
examinations. The concept was included in the final
compilation, which was forwarded to European deci-
sion makers at the end of the JUST
e
U! project in
January 2019. As noted above, clinical forensic serv-
ices should be built on three pillars: raising public
awareness; political or state support; and training. To
guarantee adequate support for victims of all forms of
violence, it is important to provide an on-call service,
ideally on a 24-h basis.
From the responses to Part II of the QCFN, it
was evident that standardized examination kits and
documentation forms would be greatly beneficial in
best securing forensic findings and recording those
findings. Within the JUST
e
U! project, recommenda-
tions relating to a European-wide standard for
clinical forensic examinations were drafted and
included in the final compilation, which can be
downloaded from the JUST
e
U! homepage [41].
The responses to Part III of the QCFN revealed
that there was considerable interest in a joint future
CFN Europe. Such a CFN Europe could serve med-
ical staff and victims of violence. As a first step
towards establishing such a network, forensic
experts from 11 European countries discussed stat-
utes for a CFN Europe at the JUST
e
U! workshop in
June 2018. The revised statutes were also included
in the projects final compilation and can be down-
loaded from the JUST
e
U! homepage [42]. In conclu-
sion, it should be said that the JUST
e
U! project was
a starting point for giving clinical forensic medicine
a voice at the European level. Nevertheless, more
data have to be collected to elaborate and improve
the current situation about accessing clinical foren-
sic examinations in the EU.
Acknowledgements
The authors thank Viktoria Moser for her contribution to
the revision.
Authorscontributions
Sophie Kerbacher, Michael Pfeifer and Reingard Riener-
Hofer carried out the survey, participated in the analysis
and drafted the manuscript; Johannes H
oller, Simone
Leski, Hanna Sprenger and Sylvia Wolf supported the
process of drafting and carrying out the survey; Andrea
Berzlanovich, Maeve Eogan, Anita Gali
c Mihic, Gregor
Haring, Petr Hejna, Sorin Hostiuc, Michael Klintschar,
Peter Kov
a
c, Astrid Krauskopf, Michal Malacka, Thorsten
Schwark, Andrea Verzeletti, Duarte Nuno Vieira and
Kathrin Yen participated in the survey and provided the
relevant data. All authors contributed to the final text and
approved it.
Compliance with ethical standards
This article does not contain any studies with human par-
ticipants or animals performed by any of the authors.
Disclosure statement
No potential conflict of interest was reported by
the authors.
Funding
This work was supported by the Justice Programme of
the European Union [grant number: JUST/2015/SPOB/
AG/VICT] (Action grants to support national or trans-
national projects to enhance the rights of victims of
crime/victims of violence). The contents of this publica-
tion are the sole responsibility of the authors of this pub-
lication and can in no way be taken to reflect the views
of the European Commission.
FORENSIC SCIENCES RESEARCH 9
ORCID
Peter Kov
a
chttp://orcid.org/0000-0002-2895-4127
Thorsten Schwark http://orcid.org/0000-0002-7522-8646
Duarte Nuno Vieira http://orcid.org/0000-0002-7366-6765
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FORENSIC SCIENCES RESEARCH 11
... National and regional medical academic societies also publish guidelines. [16][17][18][19][20] However, the nature of CSA guidelines varies in content and detail. HCPs in many countries do not have access to guidelines addressing CSA, due to lack of resources at the local, national or geographical regional level and lack of awareness of the WHO guidelines. ...
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Introduction Childhood sexual abuse (CSA) is a global public health problem with potentially severe health and mental health consequences. Healthcare professionals (HCPs) should be familiar with risk factors and potential indicators of CSA, and able to provide appropriate medical management. The WHO issued global guidelines for the clinical care of children with CSA, based on rigorous review of the evidence base. The current systematic review identifies existing CSA guidelines issued by government agencies and academic societies in the European Region and assesses their quality and clarity to illuminate strengths and identify opportunities for improvement. Methods and analysis This 10-database systematic review will be conducted according to the Centre for Reviews and Dissemination guidelines and will be reported according to The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Guidance for HCPs regarding CSA, written by a national governmental agency or academic society of HCPs within 34 COST Action 19106 Network Countries (CANC) and published in peer-reviewed or grey literature between January 2012 and November 2022, is eligible for inclusion. Two independent researchers will search the international literature, screen, review and extract data. Included guidelines will be assessed for completeness and clarity, compared with the WHO 2017/2019 guidelines on CSA, and evaluated for consistency between the CANC guidelines. The Appraisal of Guidelines for Research and Evaluation II tool and Grading of Recommendations Assessment, Development and Evaluation methodology will be used to evaluate CANC guidelines. Descriptive statistics will summarise content similarities and differences between the WHO guidelines and national guidelines; data will be summarised using counts, frequencies, proportions and per cent agreement between country-specific guidelines and the WHO 2017/2019 guidelines. Ethics and dissemination There are no individuals or protected health information involved and no safety issues identified. Results will be published in a peer-reviewed medical journal. PROSPERO registration number CRD42022320747.
... Only a few publications deal with partial aspects of the usability of medical reports in criminal proceedings [14][15][16][17][18][19]; comprehensive analyses have not been found in the international scientific community. ...
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Introduction The Istanbul Convention calls for comprehensive care for victims of violence while maintaining forensic standards. After violent crimes, court usable documentation of injuries and securing of evidence is essential to avoid disadvantages for those affected in criminal prosecution. Material and methods This retrospective study compares forensic relevant aspects in clinical forensic examination of victims of physical and sexual violence conducted by clinicians and forensic examiners. Forensic medical reports based on clinical documentation of individuals of all ages in the period from 2015 to 2018 (n = 132) were evaluated in comparison to a control group of examinations conducted by forensic specialists. A comparative statistical evaluation was performed. Results The study revealed statistically significant differences in forensically relevant aspects. In the clinical examinations, full-body examination was performed in only 37.9%, and concealed body sites were examined in 9.8%. Photo documentation was often incomplete (62.4%), without scale (59.1%), blurred (39.7%), or poorly exposed (31.2%). Information on size, color, shape, and texture of injuries was often missing. In about every third examination, the findings were not described purely objective. A body scheme was used only in 8.3% of the clinical cases. Discussion In order to establish nationwide care structures and the forensic standard required in criminal proceedings, intensive involvement of forensic medicine is essential. Standardized examination materials, regular training of medical staff, and telemedical approaches can improve the care for victims of violence regarding criminal prosecution.
... Implications Based on Victims' Perceptions general availability, low-threshold access, availability of oncall service, special training of the examining person and standardization of the clinical forensic medical examination (FME) (8). In Germany as well, the acute medical care situation paints a heterogeneous picture as there is no nationwide standardized care pathway and regional differences in quality and access are evident. ...
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Background/aim: The objective of this study was to assess the perception of the forensic medical examination (FME) by victims of sexual violence. Based on patient-related outcomes gained in terms of personnel, chronological and spatial parameters, an additional aim was to derive improved examination procedures. Patients and methods: A total of 49 sexually assaulted women were enrolled in this study. After standardized FME by a forensic doctor followed by a gynecologist, women were asked to complete a questionnaire addressing general perception, preferences regarding attending staff's sex, sequence and time frame of the examinations performed. The attending gynecologist also completed a questionnaire addressing demographic and medical parameters of the patient as well as assault-related information. Results: The examination setting in general was evaluated positively. Nevertheless, 52% of examined victims perceived the FME as an additional psychological burden. Overall, 85% of the affected women preferred a female forensic physician and 76% a female gynecologist to perform the examination. When women said they experienced a violation of their privacy during the gynecological examination, a male was more often present (60% vs. 35%, p=0.0866). Regarding the sequence of the examination components, 65% of the victims preferred to start with their medical history followed by the forensic and then the gynecological examination. Conclusion: Forensic medical and gynecological examination after sexual assault is an essential procedure, yet it is a potentially further traumatizing experience for the victim. The identified patient preferences should be taken into account in order to diminish further trauma.
... The article about the "Overview of clinical forensic services in various countries of European Union" [1] is an important milestone in the field of clinical forensic medicine in so far that one of the main proposals would be to set up a Clinical Forensic Network for Europe. This network could be held under the umbrella of the European Council of Legal Medicine. ...
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Forensic pathology is the discipline of anatomic pathology that deals with the investigation of sudden and unexpected death. This article provides a brief overview of the work required to provide an informed opinion on the cause and manner of death, from the death scene examination to the interpretation of ancillary studies.
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Background Global studies on adolescent victims of violence require serious attention due to the possibility that underreported cases may be higher than official records indicate. Since Indonesia expects to witness a demographic bonus, extensive research is needed to strengthen early detection, case handling, and prevention. Here, we report the outcomes of a survey on physical, verbal, and sexual violence experienced by adolescents in West Java, an Indonesian province inhabited by 18% of the country’s total population. Methods We conducted a cross-sectional survey in 2017 using the International Society for the Prevention of Child Abuse and Neglect (ISPCAN) Child Abuse Screening Tool for Children (ICAST-C) questionnaire for detecting child abuse; an expert panel translated, simplified, and validated it based on a theoretical framework that combines paediatrics, public health, and medicolegal perspectives. We aimed to cover a large sample size and explore three types of violence (physical, verbal, and sexual) that have high evidentiary value in the forensic context. The respondents were adolescents in the first and second grades of middle school (12 to 14 years old) and high school (15 to 17 years old) in seven cities/municipalities in the province, selected through several stages of simple random sampling (N = 3452). We analysed the samples through univariate (percentage), odds ratio (OR), comparison, correlation, and correspondence analyses. Results The results showed that 78.7% of the adolescents experienced violence in 2017, comprising those who encountered at least one incidence of physical violence (43.1%), verbal violence (12.2%), and sexual violence (4.5%). Data overlap includes 14.3% who experienced one type of violence in 2017, 7.4% who experienced two forms of violence, and 1.4% who underwent all three kinds of violence. The offenders were mainly adolescents across all types of violence, except for being forced to engage in sexual intercourse. Several victims of sexual violence did not state who the offenders were. Further, several characteristics showed a higher chance of experiencing violence than other characteristics, especially for adolescents who were still in middle school and those who lived only with their mothers. Correspondence analysis suggested subtle differences between characteristics. Conclusion We expect this study to help identify risk and protective factors that are essential to strengthening early detection efforts, decisive medicolegal examinations, case handling, and policy-making.
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Historically, some forensic practitioners and policy makers have viewed the use of photography in forensic documentation for adult victims of sexual assault as controversial. Some argue that diagrams and verbal descriptions of injury are sufficient, suggesting that sexual assault victims are so traumatised at time of examination that they are not able to provide valid consent, that the imaging process itself is humiliating, and that any decision to have photographs taken might be later regretted. Objectively, a patient capable of consenting to a forensic examination has an equal capacity to consent for forensic imaging, even when this involves sensitive areas of the body, and the process of forensic photography is not inherently problematic. Literature on forensic photography is sparse, particularly from the patient perspective. Our Forensic Medical Unit is in an excellent position to investigate this issue, as it is one of the few services in Australia that routinely offers sexual assault forensic photography, including genital, as part of its standard procedures for injury documentation. Photographs, in adult sexual assault cases, are not routinely taken of normal anatomy nor are they ever taken without patient consent. This study explores the immediate and short-term experiential impacts of forensic photography from the victims’ perspective. Capacity to consent was assessed using a trauma informed, evidence-based interviewing tool at the start of their forensic assessment. Participants also completed questionnaires at the conclusion of their examination and on follow-up. Results show that victims not only have the capacity to provide informed consent but also found forensic photography, and the reasons for it, quite acceptable. A majority [80%; n = 87/108] indicated the photographic process had either been not at all or only a little embarrassing. When asked how they felt about having photographs taken, the majority 93.4% [n = 99/106) indicated that as well as having no regrets they were also happy with the way the images had been taken. 4.7% [n = 5] expressed some doubt about whether they had made the right decision. A similar pattern of responses was observed at follow-up which occurred, on average, seven weeks post examination. 72% [n = 26/36] said they did not think about the photographs at all or did so rarely. While 14% [n = 5/36] said they thought about them a fair bit or a lot of the time, most stated they had no concerns regarding the images that had been taken. Given its evidentiary salience and other benefits, such as its potential to promote greater transparency in the provision of forensic opinions and its usefulness in teaching, this study supports the case for the routine use of forensic photography in adult Sexual Assault Units more broadly.
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Sexual assault is a complex situation with medical, psychological, and legal aspects. Forensic experts play a major role in terms of forensic and gynecological medical examination and evidence collection in order to maintain the chain of custody. Victims should be examined by a specially trained medico-legal examiner in order to avoid multiple examinations in the surroundings that do not meet minimum health standards. The evolution and treatment of sexual assault victims are time-intensive and should optimally be provided by a team that includes a forensic medical doctor. These guidelines will be of interest to forensic medical doctors who will have responsibility for the examination and assessment of victims of sexual violence and can be used as a day-to-day service document and/or a guide to develop health service for victims of sexual violence.
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Clinical forensic imaging encompasses the diverse application of imaging procedures that serve the same purpose: to enable the analysis and investigation of criminal activities and consequences of a crime. All kinds of imaging techniques and their corresponding images can be subsumed under “forensigraphy”, a more comprehensive term for forensic imaging created by the Ludwig Boltzmann Institute for Clinical Forensic Imaging in Graz, Austria. As the word forensigraphy suggests, criminal imaging material should be of use in forensic investigations. Ideally, this can lead to new findings that would not have been revealed without the application of imaging techniques and are moreover admissible as evidence in criminal proceedings. However, the admissibility of evidence can only be facilitated through the implementation of clinical forensic imaging techniques into the forensic routine case work, which requires a precise pre-analysis of the corresponding legal framework. Because taking and displaying internal images of a person's body touches upon various aspects of one's physical and psychological integrity, imaging methods in general and clinical forensic imaging methods especially have a strong impact on and interfere regularly with the fundamental rights of the concerned person. Particularly with regard to a possible medical context, certain legal regulations have to be taken into account. Therefore, this paper examines forensic imaging in the field of radiological forensigraphy, specifically its in vivo (i.e. clinical) application. It is designed to enlighten readers as to the great significance of legal barriers that emerge from fundamental rights, as laid down in the European Convention on Human Rights (ECHR), when dealing with clinical forensic imaging. As a result, the legal framework of clinical forensic imaging procedures are comprehensively described, the relevant fundamental rights, especially the right to respect for private and family life, the right to data protection and certain procedural guarantees, are concisely presented to further raise awareness regarding the importance of fundamental rights.
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