Living victims of strangulation: a 10-year review of cases in a metropolitan community

The prevalence of reported domestic violence or intimate partner violence has greatly increased, with approximately 1.5 million women violently assaulted annually in the United States by an intimate partner. Strangulation is often seen in violence against women, including domestic violence cases. Strangulation is defined as "a form of asphyxia characterized by closure of the blood vessels or air passages of the neck as a result of external pressure on the neck." This is a 10-year case review of 102 living victims of strangulation who underwent medicolegal evaluation at the Clinical Forensic Medicine Program at a State Medical Examiner's Office serving Southern Indiana and all of Kentucky. The majority of victims (79%) were strangled by an intimate partner, and manual strangulation was the most common method (83%). A total of 38 victims (38%) described a history of domestic violence, and the same number lost consciousness while being strangled. Nine (9%) women were pregnant at the time of the attack, while 13 (13%) had a history of being sexually abused in addition to being strangled. A paucity of cases involved only strangulation, as most of the victims were subjected to myriad forms of blunt force trauma which included not only the head and neck but also other bodily regions. This is a unique presentation of strangulation of living persons as most evidence of strangulation in the forensic literature has been derived from postmortem examinations of the victims. This comprehensive study discussing the examination of a living strangulation victim offers valuable insight into the mechanism and the physical findings involved in the strangulation process.     

Attempted Drug‐facilitated Sexual Assault—Xylazine Intoxication in a Child

There are only a few cases of drug‐facilitated sexual assaults on children reported in the literature so far. Here, a case of a four‐year‐old boy is presented. He was unconscious, and the accompanying adults reported that the child had been at a playground on his own. Returning home, he complained of having been stung and collapsed immediately. Urine and serum samples of the child were investigated. In the toxicological analysis, xylazine, a sedative and muscle relaxant used in animals, was detected. Subsequent quantification by GC/MS after solid‐phase extraction revealed 0.053 mg/L xylazine in serum and approximately 0.63 mg/L in urine. Furthermore, the child was examined by a forensic medical specialist. Police investigations revealed that the godfather, who had been previously accused of sexual abuse of children, had injected the child with the drug, possibly in preparation for a shared bath.     

Outline Shape Analysis on the Trochlear Constriction and Olecranon Fossa of the Humerus: Insights for Sex Estimation and a New Computational Tool,

Sex estimation through visual analysis of the distal humerus can contribute to establishing the biological profile of an unidentified skeletal individual. Using statistical shape modeling, the trochlear constriction open curves and olecranon fossa closed outlines of 151 humeri were digitized and analyzed. The shape configurations exhibited strikingly different degrees of sexual dimorphism when evaluated using linear discriminant analysis with leave‐one‐out cross‐validation. The trochlear constriction performed poorly, correctly classifying 63.6% of the individuals. However, the olecranon fossa showed high sexual dimorphism, presenting a 94.0% accuracy. A simpler model using only two principal components was also generated. While the accuracy is slightly inferior (88.1%), it has the advantage of being constrained to bidimensional components that were translated into morphoscopic variables within a simulator interface. This allowed us to implement the method through a web application that does not require users to be trained in landmark digitization or have knowledge of geometric morphometrics.     

Developmental validation of the SPERM HY-LITER™ kit for the identification of human spermatozoa in forensic samples

Abstract: With sexual assault evidence, the visualization of spermatozoa confirms that ejaculation has occurred. However, microscopic examination of spermatozoa is a laborious process and can sometimes result in sperm cells being overlooked. Here, we present the developmental validation of the SPERM HY‐LITER? kit, which contains a human sperm–specific mouse monoclonal antibody coupled to a fluorescent Alexa 488 dye. The kit was tested using samples of human semen, saliva, blood, and urine, various animal semen extracts, sexual lubricants, and a commercially available spermicidal film. Postcoital vaginal swabs, degraded semen samples, and samples prepared with sample fixation techniques that deviated from the kit‐provided protocol were also tested. In each case, the SPERM HY‐LITER? kit was demonstrated to bind only to human sperm cell heads. Limitations to this fluorescent staining procedure include nonspecific staining and increased background fluorescence with extreme heat fixation in some samples.     

Factors Influencing the Filing of Complaints,Their Investigation,and Subsequent Legal Judgment in Cases of Sexual Assault

In Geneva, examination of victims of sexual assault is performed by a gynecologist and a medical examiner. 48% of the victims file a complaint and we wanted to investigate the factors leading to file a complaint, those leading the Prosecutor to go to trial, and those influencing a conviction. Between 2006 and 2012, 676 victims of sexual assault were investigated (averaged age 26 year, mean 22). Information on injuries, perpetrators, and circumstances of the assault was collected and analyzed. The attacker being the ex‐spouse or a friend and the presence of semen were factors leading to file a complaint. The assailant being a family member or ex‐spouse and the presence of genital/anal lesions were factors influencing the Prosecutor. The presence of nongenital lesions, the assailant being known by the victim, influenced conviction. This study shows that the medical examiner plays a vital role in the investigation of cases of sexual assault.     

An Investigation into the Relationship between Human Cranial and Pelvic Sexual Dimorphism

When faced with commingled remains, it might be assumed that a more “masculine” pelvis is associated with a more “masculine” cranium, but this relationship has not been specifically tested. This study uses geometric morphometric analyses of pelvic and cranial landmarks to assess whether there is an intra‐individual relationship between the degrees of sexual expression in these two skeletal regions. Principal component and discriminant function scores were used to assess sexual dimorphism in 113 U.S. Black individuals. Correlation values and partial least squares regression (PLS) were used to evaluate intra‐individual relationships. Results indicate that the os coxae is more sexually dimorphic than the cranium, with element shape being more sexually dimorphic than size. PLS and correlation results suggest no significant intra‐individual relationship between pelvic and cranial sexual size or shape expression. Thus, in commingled situations, associations between these skeletal elements cannot be inferred based on degree of “masculinity.”     

Unpredictable Behavior Under the Influence of “Magic Mushrooms”: A Case Report and Review of the Literature

Fatalities implicating psychedelic mushrooms are not a common clinical situation in everyday forensic medicine. Despite classification as an illegal drug in many countries, psilocybin mushrooms have the reputation of being safe. We report the case of a young man who jumped from a second story balcony under the influence of psilocybin mushrooms. The psilocin assay was performed by gas chromatography coupled to an electron‐impact ionization time‐of‐flight detector (GC‐EI‐TOF) after solid‐phase extraction. Total psilocin was quantified in peripheral and cardiac blood as 60 and 67 ng/mL, respectively, and in urine (2230 ng/mL), bile (3102 ng/mL), and vitreous humor (57 ng/mL). This case report and review of literature highlights the danger of psilocybin mushrooms. Isolated use of psilocybin mushrooms by a regular consumer without psychiatric history, even under “safe” circumstances, can lead to a fatal outcome.     

Death by Ram Attack: A Case Report from Greece and a Brief Review of the Literature

A case of a ram attack that caused injuries to a 73‐year‐old man is presented. The deceased survived the attack and had the opportunity to speak with a friend over the phone before being transferred to the hospital. After a 21‐day hospitalization, the patient passed away. A postmortem examination was performed to ascertain the cause of death. The autopsy findings are presented along with a brief review of the literature. Attacks by agricultural animals (or livestock) around the world are reported in the scientific literature. Fatalities from ram attacks are extremely rare. The need to implement specific codes in the ICD system, relevant to each animal attack, appears to be of great importance, in order to allow tracking of animal‐related deaths.     

The Role of Fantasy in a Serial Sexual Offender: A Brief Review of the Literature and a Case Report

Abstract: Extensive research has attempted to elucidate the role of fantasy in sexual offending. In this paper, the authors summarize the main results of the literature, especially the contents, themes, dynamics, etiopathogenesis, and potential functions of fantasy in sexual offending. Further, the authors analyze the case of a serial sexual offender who assaulted 39 women. The forensic‐psychiatric assessment revealed that his fantasies of forced sex, sexual coercion, and dominance, which were linked to narcissistic personality organization and functioning, were the primary drive mechanism in his crimes, because he imagined himself in the role of the aggressor, identified with the power associated with the role of perpetrator, and was sexually aroused by such images of omnipotent control of the victim. In conclusions, the authors suggest that fantasies of sexual aggression, coercion, and dominance of women may stimulate grandiosity and omnipotence and, in a minority of cases, may lead to sexual offending.     

Fatal Fentanyl Patch Misuse in a Hospitalized Patient with a Postmortem Increase in Fentanyl Blood Concentration

Opioid‐related mortality happens, even in healthcare settings. We describe serial postmortem fentanyl blood concentrations in a hospital inpatient who fatally abused transdermal fentanyl. This is a single‐patient case report. A 42‐year‐old man with lymphoma was started on transdermal fentanyl therapy while hospitalized for chronic abdominal pain. The patient was last seen awake 1.3 h prior to being found apneic and cyanotic. During the resuscitation attempt, a small square‐shaped film was removed from the patient's oropharynx. Femoral blood was collected 0.5 and 2 h postmortem, and the measured fentanyl concentration increased from 1.6 to 14 ng/mL. Study limitations include potential laboratory or collection errors and missing data. (i) Providers must be vigilant for signs of fentanyl patch abuse. (ii) Postmortem blood concentrations are not static postmortem, likely secondary to decreasing pH, increased aqueous solubility, and tissue redistribution, and are therefore unlikely to accurately represent antemortem blood concentrations.     

Somnophilia and Sexual Abuse Using Vaginal Administration of Triazolam

Somnophilia is a rare paraphilia, a form of sexual fetishism which is characterized by the desire to have sex with an unconscious human object who is unable to respond. To the author's knowledge, this is the first case study concerning somnophilic sexual abuse associated with vaginal administration of triazolam. The perpetrator video‐recorded his sexual acts with two unconscious female victims with whom he also had normal sexual intercourse and who were unaware of his paraphilic activities. His Internet conversations with other persons whom he thought to be interested in somnophilic sex and his plans to kidnap a child were recorded by the police. It was evident that sex with an unconscious object played a specific fetishistic role for this man. He obviously used a combination of drugs mixed with alcoholic drinks to make his victims fall sleep and videotaped vaginal administration of triazolam used to deepen the victim's unconscious state.     

Sexual Dimorphism of the Fetal Ilium: A 3D Geometric Morphometric Approach with Multislice Computed Tomography

Adult sexual dimorphism is well established. However, data regarding fetuses are sparse with contradictory results. Our study aimed to look for fetal sexual dimorphism. Multislice computed tomography (MSCT) examinations and three‐dimensional (3D) reconstructions were recorded on 93 fetal iliac bones aged between 21 and 40 weeks of amenorrhea (WA). The collection was divided into two age groups, with a cutoff at 30 WA. The 3D geometric morphometric analysis was based on outline analysis. We used elliptic Fourier analysis (EFA) because of the difficulty of landmark positioning. Step‐by‐step reconstructions allowed a better comprehension of the fine shape details. Principal component analysis (PCA) and linear discriminant analysis (LDA) were performed on the two age groups. Results did not show any difference between male and female shapes, in both age groups. We demonstrate the feasibility of outline analysis for immature shapes, but sexual dimorphism has not been established in our collection.     

Comparing Standard and Selective Degradation DNA Extraction Methods: Results from a Field Experiment with Sexual Assault Kits,

A growing number of U.S. cities have large numbers of untested sexual assault kits (SAKs) in police property facilities. Testing older kits and maintaining current case work will be challenging for forensic laboratories, creating a need for more efficient testing methods. Methods: We evaluated selective degradation methods for DNA extraction using actual case work from a sample of previously unsubmitted SAKs in Detroit, Michigan. We randomly assigned 350 kits to either standard or selective degradation testing methods and then compared DNA testing rates and CODIS entry rates between the two groups. Results and conclusions: Continuation‐ratio modeling showed no significant differences, indicating that the selective degradation method had no decrement in performance relative to customary methods. Follow‐up equivalence tests indicated that CODIS entry rates for the two methods could differ by more than ±5%. Selective degradation methods required less personnel time for testing and scientific review than standard testing.     

Sexual Homicide by Older Male Offenders

Recent research has expanded our understanding of sexual homicide offenders (SHOs). However, little exists beyond case reports for older SHOs. We characterized male SHOs ≥ 55 years, comparing them to typical adult male SHOs who are in their 20s. Analysis of 37 years (1976–2012) of US Supplementary Homicide Reports data provided a large SHO sample (N = 3453). Three case reports provide clinical context for the diverse nature and patterns of older SHOs. Only 32 older male SHOs and no older female SHOs were identified. Murders by older SHOs accounted for only 0.5% of US sexual homicides. Unlike typical SHOs that generally target young adult females, over two‐thirds of older SHO victims were ≥40 years, and one‐third were ≥55 years. Sexual homicides by older SHOs, like sexual homicide in general, decreased over the study period. These crimes, while exceedingly rare, do occur, warranting special consideration.     

Persistence of Biological Traces at Inside Parts of a Firearm from a Case of Multiple Familial Homicide

Backspatter from wounds caused by contact shots against a biological target had before been shown to be propelled into firearms' barrels where they can persist and be retrieved from as relevant forensic evidence. Herein, that insight was applied to the investigation of a case of multiple familial homicide with a firearm. Samples of backspatter were collected from the firearm using DNA‐free swabs. DNA was extracted from the swabs, and 16 STR systems were PCR‐amplified to generate DNA profiles of all victims shot by the firearm. The quality of the resulting DNA profiles was sufficient to exclude the perpetrator as donor and to differentiate the three closely related victims thereby proving that all three victims had been shot by the same firearm from very close or contact distance. A key insight gained from this case was that not only a firearms' barrel inside but other inner surfaces may be charged with profilable DNA.     

Medical Findings and Legal Outcomes in Sexually Abused Children*

Abstract: A previous study published in 2000 on a small group of children concluded that the medical examination in cases of sexual child abuse seldom provided legal proof of sexual abuse [J Forensic Sci 45(2000):115–7]. The present consecutive study included children referred to the police for a forensic medical examination. A colposcope was used to evaluate the anogenital findings which were classified as normal, nonspecific, and abnormal. Four hundred and eighty‐two children were included. Abnormal anogenital findings were found in 38% of the girls and 20% of the boys, but there was no relation between abnormal anogenital findings and the two legal outcomes: “appearing in court” and “being convicted.” However, the age of the child turned out to be a more important factor in relation to legal outcome than the physical findings. The results of this study suggest that the child’s statement and not the physical findings were important for legal outcome.     

Complex autoerotic death with full body wrapping in a plastic body bag

Autoerotic deaths are normally classified as accidental deaths occurring during individual, and usually solitary, sexual activity in which a device, apparatus, or prop used to enhance sexual stimulation of the deceased somehow causes unintended death. The most common methods of autoerotic practices are asphyxia by hanging, ligature, plastic bag, chemical substances, or a mixture of these. However, atypical methods such as overdressing/body wrapping have also been reported. In fact, overdressing/body wrapping is so rare that it is implicated in only 1.5% of published cases. Although plastic bags are often implicated in autoerotic deaths, there has been only one previous case that involved a plastic covering the victim's body from head to toe. We here report the case of a 34-year-old man who died due to asphyxia, secondary to body wrapping in the largest and most complex plastic bag ever involved in a published case of autoerotic death.     

Sudden Unexpected Death due to Chiari Type I Malformation in a Road Accident Case

This case concerns a sudden death of a patient with Chiari I malformation. A 17‐year‐old female was seen unconscious then fell off a motorbike during the vehicle acceleration. The girl was confirmed dead on the way to hospital, being previously asymptomatic and with a clean medical record. Autopsy findings showed an extremely extra‐long cerebellar tonsillar herniation in the left side and unexplained multiple small cavities in cerebral hemispheres. Microscopic findings revealed loss and abnormal migration of the Purkinje cells, as well as capillary congestion in the herniated tonsil. The cause and mechanisms of this sudden death are considered as the cardiopulmonary dysfunction and arrest resulted from compression of the medulla and cervical cord, which was induced by both the positional insult and minor head trauma. In addition, this study stresses the importance of cervical cord examination in the case of unexpected sudden death following road accidents.     

Perineal‐Vaginal Injuries in Children: Accident or Abuse?

Abstract: A large number of conditions have been mistaken for abuse. Differentiating accidental injuries from inflicted injuries is important in the management of injured children. In this work, the authors describe two cases of accidental perineal‐vaginal injury in children. In case 1, a 4‐year‐old girl suffered a vaginal tear caused by violent stretching during play; in case 2, a 3‐year‐old girl had minor lacerations of labia minora and majora. The intervention of a multi‐specialist team including a forensic pathologist and forensic psychiatrist was the key factor in being able to exclude abuse by third parties in the described cases.. This leads to the appropriate recommendations to be adopted in the forensic medicine setting.