Medico-Legal: The Law and Medicine
Prevention & Treatment. Introduction
Abuse is a combination of two words: “Abnormal” (Ab) and “Use” to form “Ab-use”. For a fact, abuse is rampant. Abuse takes different forms and is everywhere. Abuse occurs in private and public places. Parents abuse children. Strangers abuse others. Spouses abuse each other in the name of love. Various governments at different levels and their agents in different countries abuse the citizens that they are supposed to lead and govern. Religious authorities abuse their followers in the name of God. Some professionals, doctors, accountants, lawyers, teachers, bankers and so forth abuse their clients under the cover of providing services. Brothers and sisters abuse their siblings in the name of families. Friends do abuse each other after all, its familiarity.
However, unknown perhaps to abusers or as a matter of deliberate determination to cause harm, abuse do have consequences, serious consequences. In the coming weeks, we will explore the subject of abuse, in great details.
In any society that is serious enough to want to deal with all or any form of abuse, dealing with abuse cuts across the police, education, social services, healthcare professionals, legal and justice system as well as other relevant professionals.
Forms of Abuse:
Abuse can take different forms: sexual abuse, physical abuse, financial or economic abuse, psychological abuse and abuse of one’s position or authority otherwise called abuse of privileges. Each of these will be explored and what you the reader can do to prevent you from getting into harm will equally be looked into.
For the moment, let us look into the rudiments of what constitute abuse. Before I make my definition, let me state that everything that exists has its own use and has a purpose. Also, the purpose of the thing or mission of a person may not be so obvious at the start. Regardless, some persons are often put in charge of looking after another person or service in as much as a person in adulthood looks after himself or herself. When we are ignorant of the purpose of a thing or person, we say such thing or person is not good. The next step is to devalue or reduce the value of the person or thing. The final phase in the abuse process is to start misusing the person or thing. Thus, apart from an individual or another human beings being abused, a person can abuse himself /herself or misuse parts of his body or entire body to his/her own detriment. One can abuse one’s animal or another animal by mistreating the animal. Example, the owner of a dog (man’s best friend) may deprive the dog of food, beat the dog mercilessly, and ignore the illness that the dog suffers. A person can abuse his own car by misusing the car away from the intended purpose of the car. With these brief explanations, let us now consider what constitute abuse in general.
My definition is that abuse is simply mistreating and misusing an entity such as human beings or a thing or animal. Abuse is also misusing an entity such as power/authority away from its intended purpose.
Let us take an individual who is abusing himself as our starting point. Assuming that in spite of all, he constantly knocks his head on the floor without justifiable reason or believing that such knocking will add any value to his life. Over time, the knocks will have serious effects on his health. Remember, our head is the powerhouse of the human body and is the seat of our bodily control. Someone who is knocking his head on the floor is without doubt misusing and mistreating his body.
Similarly, if a person has a cow and he is in charge of looking after the cow but rather deprived the cow of water, food and proper care, he or she is abusing the cow. If a person has a farm crop put in his care, but does not care for the crop, allow disease to overcome the crop, despite the fact that the crop is in his care and he has a duty to look after it, then he has misused his authority. You can imagine or extrapolate this simple principle to human beings. From this the reader can now see that abuse is a major problem worldwide and more so in societies like ours where injuries from abuse do go unchallenged and unremedied. There are few if any, mostly inaccessible routes to redress in Nigeria. Abuse has serious clinical or medical consequences which are often overlooked by the abuser and the society.
Consequences of Abuse:
Depending on the nature of abuse which I will deal with under the respective form of abuse, abuse has a lot of unpleasant results. For practical reasons, all forms of abuse may lead to the victim seeing a doctor for a short or long term. For example, sexual abuse otherwise called sexual assault, may lead to physical tears of the reproductive organs, bleeding, various forms of infection such as HIV, hepatitis virus infection, herpes infection, gonococcus infection amongst others. Sexual assault may leave a permanent damage on the victim psychologically. Such an abuse may affect the sufferer’s ability to procreate and impair even the next generation. Take another issue of financial abuse for example. Someone who had been so brazenly derived of his money may even commit suicide. If suicide is even put aside, such individual may become anxious and depressed. I will deal these consequences under each heading later in the series.
At this stage, my very strong recommendation is that all forms of abuse should be challenged and perpetrators be pursued for restitution. Injuries should be taken to medical doctors for treatment.
Sexual Abuse: Prevention & Treatment. I
Sexual intercourse is a purposeful biological function. But then, sex in every culture is revered and guided by local customs and laws. In modern and in most decent societies, sex is prohibited under certain age. A child is not competent to consent to sex. In a lot of cultures sexual intercourse is frown upon between close relatives. Therefore, for avoidance of doubt, let us define sex even though the wave for expanded definition is staring down various nations. For our purpose, I will limit my definition of sex being a biological engagement of a male and female whereby the penis of a male enters or attempts to enter the vaginal of the female.
Incest: It’s a taboo in a decent family that siblings should have sex with each other. Father and mother are not allowed to have sex with their children or close relatives of the same biological linage. If this happens, a medical term called incest is said to have occurred.
It’s not for nothing that various cultures and religions prohibit incest. When there is a disease that runs in a family for example, incest may allow such disease to be passed from one family member to the other. This is why intermarriage is encouraged which may neutralise such diseases. Incest is an illegal activity apart from it being morally repugnant. Most good societies frown at it.
Child Sexual Abuse: When incest happens to an underage child be it a girl being sexualised by the father, mother or by siblings or a boy being subjected to forceful male attack or an adult female coercing the male child into sex, such activity is clearly a sexual abuse of the said child.
Without doubt, under the law, a child is someone who is under 18years. We should remember that children are easily led and vulnerable to being deceived because they relate to others and adults on the basis of trust. Sexual abusers simply break such trusts and harm the child.
Rape is a forceful or unconsented sexual intercourse with another individual. For our discussion, this relates to intercourse between a female and a male. Male to male encounter is illegal in Nigeria and if it happens in form of forceful entry, it’s a double criminal offence. Female to Female encounter is also prohibited by law in Nigeria and for that reason; the definition of rape does not extend to such activities. In other climes, definition of rape as I have provided here may not be applicable. A forceful or “consented” sex with a child is child rape. An unconsented sex with adult is rape. The adult may be fully competent or disabled mentally, it does not matter. A forceful male-to male entry either via the mouth or anus against a child or against an unconsented adult male is an abuse. A forceful female to female encounter against a child is an abuse and rape. Also, even if the child consents or “enjoys” to the encounter and the adult does not know or knows that the victim is under age, the perpetrator is abuser and a rapist as the case may be. Rape can also happen between married couples: sex is a matter of consent between mentally competent adults.
A child-to-child case is even more difficult but a male individual being likely to be the aggressor, driven by his testosterone hormone, is likely to be blamed for the sex encounter. That said, females can also instigate sexual encounters. Therefore, child female who abuse male child will be regarded as an abuser. A child cannot consent to sex no matter how physically compelling that such child may be.
Notwithstanding the definition of sex, abuse can take the form of anal or oral “sex”. It may even not take any of these forms but simply invading the victim’s personal space (touching, fondling, and fingering) without consent is enough to lead to being an abuser.
Consequences of Sexual Abuse:
Being an assault, sexual abuse has wide and serious ramifications.
For the child, abuse can leave a permanent scar in the body and the mind of the victim. Physically, there could be tears due to forceful entry during rape. Bleeding could follow. Even if the tear heals, it could leave a permanent scar. For the female with a vaginal scar, future sexual intercourse could become a major problem. Still, for the female, childbirth may be difficult. Transmission of infection is a real possibility. Such infections as HIV, hepatitis, herpes, gonorrhoea, Chlamydia and other deadly diseases may be transmitted to the victim and even vice versa. Forming a legitimate relationship in future may be thrown in doubt. Marriage could end prematurely. Depression, anxiety, frank psychotic illness, sleep disorder, post-traumatic stress syndrome may all set in. Drug and substance misuse such as cannabis, alcohol, and cocaine, heroin misuse may all become difficult problems for the victim. Lack of trust, loss of self esteem, self-abuse and suicide are all likely consequences of sexual abuse.
Prevention of Sexual Abuse: Child:
Proper parenting with love and vigilance is recommended. Knowing the value of human beings and the potential that human beings hold is essential. Parents facing difficulties in child rearing need to seek help from other family members as it’s done in our society and in any loving society. If the parents cannot deal with the child, such child could be considered for adoption rather than abusing the innocent. Sex education should be a compulsory course in primary and secondary schools. A child crying for help or whose behaviour had suddenly changed needs to be listened to, not shouted down to “shut-up” but should be taken for medical assessment. Similarly, vaginal discharge, strange mouth sores, unexplained injuries, suddenly withdrawn child regardless of gender or an apprehensive child in presence of certain individual may indicate an unpleasant relationship going on. A child who suddenly change to start behaving in an adult manner may have been having advanced encounter beyond his or her age. Therefore, guardians and parents need a high index of suspicion to prevent further abuse. Such a child may need to be removed from the focus of danger that she or he may be in to a place of safety.
Adult Abuse: For the adult, male or female, vigilance is the key to it all. Be vigilant against possible attack. Avoid being lured away into danger by greed for money and materials. Learn to say “No”. Avoid walking or being present in lonely dark alley.
Government: However, one of my patients was lured away to be raped in broad daylight under the spell of voodoo hypnosis somewhere in very crowded junction in Lagos. Given the cryptic nature of such hypnosis, and ultimately, the hypnosis will wear off and the victim will come to his or her senses, provided she survives the ordeal. The best advice one may consider here is for police apprehension of the culprits once the victim can identify the location and possible individuals. Very importantly, Police should keep a database of such individual criminals against future prevention strategies. DNA analysis may support the victim’s claim. Samples (hairs, semen) of perpetrator for DNA may be obtained from the victim.
Apart from the above preventive methods, the government at various levels need to start collecting DNA database of sexual abusers. Lagos State government had indicated its intention in this regards. Police is at crucial point in dealing with sexual abuse and not just dismiss the victims with a wave of hand. National DNA database and proper records need to be kept of abusers and matched against future occurrences.
Treatment: Abuse in any form, not the least sexual abuse, doesn’t just go away. I have dealt with a few in recent times. It lingers. For their personal reasons, privacy or need to avoid relationship fractures or by reason of religious beliefs, some perpetrators of abuses may be “forgiven and forgotten” by the victims. This forgiveness does not absolve the architect of their legal guilt. If apprehended, the law should take its full course.
Individuals that may not be able to bear the consequences of sexual abuse need to see a qualified and competent medical doctor/psychiatrist and a psychologist to help deal with effects of sexual abuse. Medication and surgery may be called for. Non-medication therapies may also be used to deal with the huge medical consequences which I discussed earlier. The sooner a sexual abuse is reported to the medical personnel and police the better. To preserve evidence and prevent sexually transmissible diseases, sexual abuse should be reported within 72 Hours of its occurrence. This is crucial.
Very often, the doctor will start the processes of prevention against sexually transmissible diseases which I have mentioned above.
Critically, once sexual abuse occurs, the victim should primarily attend a hospital for immediate care as well as report the same to the police for prosecution. I have seen patients been summarily dismissed by police and the patient was left broken because she had no help that she was expecting. The police should collect relevant samples of semen and genetic material for prosecution evidence.
Sexual abuse is a serious matter and should not be dismissed. It has serious clinical implications and can indeed change the personality as well as the life of the individual victim that is concerned.
Prevention & Treatment.
Verbal Abuse: Most people do not seem to realise that word is the most powerful tool that exists. As any medical doctor especially psychiatrist will tell, word can kill a person and even more importantly word is a powerful healing tool. This understanding of the power of word is deployed in psychological intervention for the good of the patient. Most commonly, most people would have been familiar with prayer, any form of prayer for that matter. The only tool to convey any form of prayer in any religion is by words. Word is a most important instrument to encourage a person in any activity or inactivity.
Yet, when this extremely powerful tool called word, is used in a manner that causes hurt, it can cause unbearable and irreparable destruction that often leads to medical intervention.
Words can be written down, signalled or be spoken. The quickest, the commonest, and perhaps the most immediately active is the spoken words or otherwise called verbal force. When spoken word is deployed in a bad way, to such extent as to cause impairment, feeling of apprehension of threat, anger and destruction in the victim, it’s called verbal abuse and it’s a criminal offence.
When such impairment is applied to a child, it’s called child abuse. That is to say, verbal abuse can retard the growth of a child. Being called different demeaning names may actually stick with such child. Word matters. The child’s future may be compromised by being labelled in a certain way. A child is supposed to be well nurtured in a balanced way along side his/her natural experiences. Silence and refusal to properly direct a child constitute verbal and psychological abuse as well as misdirection is.
On the other hand, adults may also be subject to verbal abuse. This is especially so with husband and wife or a couple in a relationship. When friendship breaks down, the first evidence of being offended is verbal attack on each other. A person may also be bullied verbally. Remember that word can kill or heal.
Consequences of Verbal Abuse: All forms of abuse are forms of demeaning and ridiculing the individual victims. Being devalued, misused, misdirected and misled can have serious impact on the health of the receiver. Lack of progress, lack of trust, anxiety, depression, retarded growth in a child, poor performance at school are some examples of the result of verbal abuse. Self esteem and dignity of the person is diminished. Lack of confidence in self and others may also result from verbal abuse regardless of the age and gender. Verbal abuse may lead to suicide, self-mutilation and depression.
Prevention and Treatment:
Once again, abuse in any form pays no one. It damages the victim and does not esteem the perpetrator in any way. The crucial way to prevent verbal abuse is to recognise that word hurts and though word could hurt, word could also heal. Deploy your words positively and while we could correct an erring person, adult or child, we should be careful what we say and how it’s said. I found leaving the scene of any abuse useful. I could quickly exit a place or event that is degenerating into abuse. On the other hand, trying to retaliate against an abuser with abuse may not be a good strategy. It may simply fuel the verbal war!
Counselling as a form of treatment may reassure the sufferer but it may take a little more than one session to neutralise the damage that has been done to the individual. As I mentioned earlier, both for adult and children, if an abuse is persistent, it may be safer and better to remove oneself and the child from the circumstances of abuse. In that way, the damage will be curtailed. A child or depressed adult may require medications such as anti-depressants as well as other psychological therapies.
Irrational or unreasonable physical chastisement is a physical abuse. Persistent physical beatings also constitute physical abuse. Being subjected to servitude or work without pay is physical and economic abuse. Being burdened unjustly or putting upon a person, disproportionate labour for his or her age and capability is certainly physical abuse (example are children hawkers on the streets). Causing injuries, marks or wounds to a person without legitimate reason is both an assault and an abuse. Denial of food, water and a reasonable environment to thrive to a person under one’s care constitute physical abuse. Illegal and unreasonable restriction of movement to a person is also a form of physical and psychological abuse. Thus in sum: Physical abuse can be defined as any intentional act causing injury or trauma to another person. In most cases, children are the victims of physical abuse, but adults can also be victims, as in cases of domestic violence or workplace aggression. Injuries to any child or mentally impaired person or to any mentally competent person without consent in any part of the body especially if persistent or repeated or multiple is a physical abuse until proven otherwise. Children who are physically abused suffer violence such as being hit, kicked, poisoned, being given medicine that they don’t need, burned, slapped or having objects thrown at them. Shaking or hitting babies can cause non-accidental head injuries.
Consequences of Physical Abuse:
Nowhere else can abuse be more evident and visible as in physical abuse situations. Physical abuse does leave its marks behind: Any good observer could see injuries, scars, fractures, marks such as cigarette burns and open wounds. Physical abuse victims could become emaciated and looking haggard. Also, injuries from physical abuse could cause the death of the child or adult concerned. Physical trauma could also give rise to mental health issues as discussed under verbal and sexual abuses.
Prevention and Treatment: Domestic violence against both women and men are perhaps the commonest form of physical abuse in adults. The other being abuse of mentally incapable adults. On the other spectrum is physical abuse of children. Physical abuse of children especially in Africa and indeed Nigeria is extremely common is a frequent sights in our streets.
The most significant form of prevention, for a child, is for the child to grow in a loving environment with appropriate corrections as may be reasonable. If this fails, government--- and it’s the primary duty of governments at all levels---need to secure the welfare of all children and adults. It’s the failure of the latter that perpetuate abuse in our society. In keeping with this, the government and its law enforcement agencies should enact measures to prosecute offenders and also protect innocent victims. In some societies, victims are taken to refuge or safe homes for their own protection. Mentally and physically capable adults should simply remove themselves from scenes of physical abuse if death and bodily damage is to be avoided.
However, as for treatment, the attending medical officer will treat injuries and incidental diseases such as infections, that are presented to him as may be appropriate. As I mentioned under protection, unless the government has machinery for healthcare practitioners to report abuse especially of children and vulnerable adults, it may be difficult to deal with cases of abuse. In most decent societies, social workers are available and accessible with sound public awareness of their presence or functions, to assess and protect victims and potential victims of abuse. We in Nigeria should do the same.
Other Forms of Abuse: Prevention & Treatment.
There are other forms of abuse that are equally terrifying. This includes psychological (emotional) abuse, economic or financial abuse and abuse of power (abuse of privileges). We shall deal with all these in this concluding part of Abuse, Treatment and Prevention series.
Emotional/Psychological Abuse: The opposite of expression of words is silence. Silence can mean several things. Now take for example, a man who refused to speak to his wife or though they live in the same home, the wife refused to speak with the husband. What if parents refuse to direct and or speak with their children? What if you persistently call someone on the phone: Though the receiver picks the call, the caller kept silent. All these are forms of emotional or psychological abuse. On the other hand, taunting, name calling, abusive signalling, offensive drawing, irritating chanting, refusal to perform one’s duty despite promises to do so are forms of emotional abuse. Any behaviour that may result in mental or emotional impairment is psychological abuse. Take for example: a woman who knowingly exposes herself to a man knowing that the man will have sexual arousal but the woman has no intention to have sex with such a man, the woman is a classic case of emotional abuser.
Constant criticism to more subtle tactics, such as intimidation, manipulation, and refusal to ever be pleased, blaming, shaming, brain-washing, are emotional abuses. Power and control of the victim is a case of such abuse.
Prevention and Treatment: Most often the victim such as children cannot resist the abuser without outsider’s help. Once again, family members, the neighbours, larger society has a big role to play in reporting and preventing abuses. Where the victim has access to escape and or report to responsible outsider such as police, neighbours for intervention, the better.
As for treatment, long-term psychotherapy will be required for victims of emotional abuse. Attending medical doctor will also consider other treatments as may be suitable.
Financial/Economic Abuse: Slavery or servitude is a classic case of economic abuse. Remember that, human resources are important for economic advances. It’s this human resources that financial abuser exploits. On the other hand, parents, due to their poverty unfortunately do abuse their children or ward economically. Examples are the unfortunate children on our streets. There are stories of persons who had been hypnotised and are working tirelessly for another who exploits the labourers. Corrupt government agents can arm twist their subjects for financial advantage. Corrupt established businesses, financial institutions due to poor regulation can subtly exploit their victims for pecuniary advantage. Financial abuse, an illegal or unauthorized activity, is the use of a person’s property, money, pension book or other valuables (including changing the person's will to name the abuser as beneficiary), often fraudulently obtaining power of attorney, followed by deprivation of money or other property, or by eviction of the victim from own home. A key distinction between economic abuse and financial abuse is that economic abuse also includes the control of someone's present or future earning potential by preventing them from obtaining a job or education.
Consequences of Financial Abuse: Clearly, without doubt, the victim of financial abuse, lose money or property. He may also lose future earning potential. The result is that he or she becomes poorer for it. Financial deprivation may lead to illness as the victim may not have enough to take care of himself /herself and his/her family. There are many reports of death of victims who had lost their earning. The victim may become homeless. The victim may become irritable, angry, self-blaming and hostile. Depression, anxiety and suicide are likely consequences. Financial derivation in elderly may be a more complicated event as they may not have recourse to funds other than what had been stolen from them.
Prevention and Treatment: Medical doctors and allied clinicians are not the government to provide remedies for financial abuse. It’s the role of government to provide machinery to address such abuses. That said, individual adults must be vigilant against likely abusers. When papers or alleged profitable proposals are presented by abusers to back up their claims (may be a contract or evidence of their previous accomplishments), I will strongly advise the reader to ask that they be given time or “cool-off period” to consider any proposal. The reader should do own due diligence before parting with hard-earned money. Do nothing is secret. Do not agree not to tell anyone. Abusers prey on secrecy and victim’s vulnerability. Do not believe any evil is going to befall you if you tell anyone. Tell someone anyway. You are even more likely to be worse off or die if you tell no one of what you are being offered by abusers in shape of “419” as we call them in Nigeria. Do not act in haste and do not give in to threats. Do necessary search; ask for hard and proven evidence before giving money away. If necessary, use lawyers and relevant professionals to conduct the due diligence.
However, the consequences of financial deprivation may bring the victim to the doctors who may have to attend to the patient accordingly.
Abuse of Privileges (Power Abuse): All said and done, abuse is about one person exercising his or her power, abusing his/her privileges over another ignorant or vulnerable individual or entity. Abuse of power may occur at any place: be it in public, private, government, business, domestic, professionals and between relationships. One person or party is simply exerting his or her control over the other against known laws, morals and norms. It can be parents overreaching their power or government agent abusing his or her power and privileges against members of the public. The degree of abuse and type does vary depending on the circumstances. The thrust of this analysis is to point to the readers, that notwithstanding, abuse of privileges do have consequences on the victim or public.
Consequences of Abuse of Power: The victim may be killed or maimed, or be abused in other ways, be deprived of money, property, liberty, job and education. The public if applicable, may be underserved or underdeveloped.
Treatment and Prevention: What concerns a clinician is often the result of the abuse. In the end, healthcare practitioners carry the dirty can of results of abuse. All the deprivations that are listed here can result in one form of illness or the other or the society may even be worse off and thus falling into public health catastrophes as a result of a person or persons abusing their power and privileges. The medical profession will deal with what is presented clinically to them but the individual victims and the general public may need to deal with abuse of power in their own terms or as they see it fit.
In summary, the last few weeks have seen us dealing with abuse in its various forms and shapes.
Victims of abuse should primarily endeavour to seek medical and legal help as may be necessary. For me as a doctor, I will strongly recommend that victims of abuse should ask for medical support without delay.