RESUMEN

El objetivo fue describir las características de la muerte de mujeres por violencia según las necropsias realizadas en la morgue del Callao desde el 2016 al 2018. Se revisaron los registros forenses de 83 mujeres y se encontró que la muerte de mujeres por violencia ocurrió con mayor frecuencia en la etapa adulta, el suceso de tránsito fue el agente causante más implicado, la lesión mortal se ubicó mayormente en el segmento cabeza, se realizaron más levantamientos de cadáveres en la vía pública y el distrito con más casos fue el Callao. Es importante que las autoridades se comprometan a crear, instalar y seguir un plan de acción para prevenir la muerte de mujeres por violencia en el Callao.

Palabras clave:
Autopsia; Causa de Muerte; Violencia; Violencia contra la Mujer; Cadáver; Accidente de Tránsito; Lesiones Craneoencefálicas; Lesiones Múltiples; Homicidio

ABSTRACT

The objective was to describe the characteristics of women’s deaths by violence according to autopsies performed at the Callao morgue from 2016 to 2018. The forensic records of 83 women were reviewed and it was found that women’s deaths by violence occurred most often in adulthood. Traffic accidents were found to be the most common cause. The most frequent location of the fatal injury was in the head segment. Most of the corpse removal took place on the public road. The district with the most cases was Callao. It is important that the authorities commit to creating, installing and following an action plan to prevent women’s deaths by violence in Callao.

Keywords:
Autopsy; Cause of Death; Violence; Violence against Women; Cadaver; Traffic accident; Craniocerebral Trauma; Multiple Trauma; Homicide

INTRODUCTION

Violent death or death from unnatural causes is considered to be of traumatic origin (mechanical factors, physical objects, asphyxia, toxic elements, thermal factors, etc.) and/or when medico-legal etiology corresponds to a homicide, suicide or accident ⁽¹1. Palomo Rando JL, Ramos Medina V, De La Cruz Mera E, López AM. Diagnóstico del origen y la causa de la muerte después de la autopsia médico-legal (Parte I). Cuad med forense [Internet]. 2010 [citado el 9 de enero de 2020]; 16(4):217-29. Disponible en: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1135-76062010000300005&lng=es.
http://scielo.isciii.es/scielo.php?scrip... . Globally, violent events that do not necessarily imply death are at the top of the epidemiological profile in all social strata.

The World Health Organization (WHO) defines violence as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation” ²2. World Health Organization. World report on violence and health [Internet]. Geneva: WHO; 2002 [citado el 7 de enero de 2020]. Disponible en: https://apps.who.int/iris/bitstream/handle/10665/42495/9241545615_eng.pdf?sequence=1.. The WHO also reports that more than 15,000 people die in one day as a result of a violent event, such as road traffic incidents (23%), others (21%) (asphyxiation, poisonous animal bites, hypo- and hyperthermia, and natural disasters), suicide (15%), homicide (11%), falls (8%), drowning (7%), burns (6%), poisoning (6%) and war (3%)³3. World Health Organization. Injuries and violence, the facts. Ginebra: Department of Violence and Injury Prevention and Disability, WHO; 2010 [citado el 7 de enero de 2020]. Disponible en: https://apps.who.int/iris/bitstream/handle/10665/44288/9789241599375_eng.pdf..

In Peru, the most common forms of violence against women are beatings, asphyxiation, use of knives, use of firearms, crushing, decapitation, burns, among others ⁴4. Garmendia F. La violencia en el Perú 2015. An Fac med [Internet]. 2016 [citado el 7 de enero del 2020]; 77(2): 153-161. Disponible en: http://dx.doi.org/10.15381/anales.v77i2.11838.
http://dx.doi.org/10.15381/anales.v77i2.... . All acts of violence constitute a public health problem because they cause physical injury, disability, sequelae, diminished quality of life and finally death ⁵5. López M, Blanco J, Híjar M. La violencia y sus repercusiones en la salud; reflexiones teóricas y magnitud del problema en México. Salud Publica Méx [Internet]. 1997 [citado 16 de enero de 2020]; 39 (6): 565-572. Disponible en: http://saludpublica.mx/index.php/spm/article/view/6046/6951.
http://saludpublica.mx/index.php/spm/art... .

Legal necropsy is a medical, technical and scientific procedure that allows to establish the cause, time, causative agent, manner and mechanisms of death, as well as the identification of the deceased, which will provide evidence that contributes to the proper administration of justice. It is carried out by order of the authority in charge of the investigation (public prosecutor, judge). The autopsy is performed in medicolegal cases, such as violent deaths (unnatural, accidents, suicides and homicides), suspicious deaths (those that may be violent), sudden and unexpected deaths, deaths without medical assistance and deaths in prison ⁶6. Di Maio V, Dana S. Manual de patologia forense. Austin, Texas. M.D. Press; 1998..

It is important to understand the characteristics of violent death in women from a medicolegal point of view. Not only from a gender perspective, nor from the legal figure of femicide, but also in the context of a case series of violent death, in order to understand the causative agents, the most vulnerable body segments, the management of trauma, among others. This will help to identify this problem in the constitutional province of Callao.

Therefore, the objective of this research is to describe the characteristics of women’s death by violence who underwent necropsy at the Callao morgue from 2016 to 2018.

THE STUDY

A case series study was conducted. The first data was obtained from the DICETA statistical report (Callao morgue software). In this system, the general data of the deceased, the requesting authority, the necropsy findings, auxiliary examinations, the cause of death and the causative agent are all registered. A total of 83 cases of women with a violent death were identified. The legal autopsies requested by the authorities in charge of the investigation were carried out between January 2016 and December 2018 in Callao morgue. Necropsy protocols of the selected cases were then reviewed. The reports of the necropsy protocols corresponding to women aged 12 years or older with a violent death were included, and those that did not have a determined cause of death or a definitive causative agent were excluded.

Demographic variables were analyzed by age groups according to the classification of the Ministry of Health’s Comprehensive Care Program ⁷7. Modifican documento aprobado por RM Nº 729-2003-SA/DM en la clasificación de los Grupos Objetivo para los Programas de Atención Integral. Resolución Ministerial Nº 538-2009/MINSA [Internet]. Diario El Peruano. 19 agosto 2009 [citado el 7 de enero de 2020]. Disponible en: https://elperuano.pe/NormasElperuano/2009/08/19/385059-4.html.
https://elperuano.pe/NormasElperuano/200... : adolescent (12-17 years old), young (18-29 years old), adult (30 59 years old) and elderly (over 60 years old). Variables were also analyzed by Callao districts: Bellavista, Callao, Carmen de la Legua Reynoso, La Perla, La Punta, Mi Perú, and Ventanilla; by place of occurrence according to the report on the corpse removal (the forensic document drawn up by the forensic doctor in the presence of the public prosecutor included in the necropsy protocol): house, hospital, hotel, open land, river, public road; by the causative agent of the violent death: contuse agent, cervical constricting element, physical object, liquid, firearm projectile, tip or edge, transit event; and by the topographic anatomy, that is, the segment where the injury causing death was located: abdomen, head, neck, extremities, multiple (three or more body segments), thoracoabdominal and thorax.

This research is of a scientific nature, with statistical and epidemiological purposes, and the identification and reservation of cases is protected. The information found in the database corresponds to the surveillance system of the Institutional Operational Plan of the Institute of Legal Medicine and the Crime Observatory of the Public Prosecutor’s Office.

The corresponding permits were obtained from the Institute of Legal Medicine and Forensic Sciences to access the database and subsequently publish the findings. The data obtained was collected in a template (data collection sheet) designed by the author, and processed in Microsoft Excel program to calculate frequencies and percentages.

RESULTS

The review of Callao morgue’s computer system showed that 571 autopsies were performed in 2016, from which 20 (3.5%) were women’s violent deaths; 520 autopsies were performed in 2017, from which 37 (7.0 %) were women’s violent deaths and it was found that 579 autopsies were performed in 2018, from which 26 (4.5 %) were women’s violent deaths. A total of 83 cases were found in the 3 years. The age group of 30-59 years old was the most frequent with a total of 35 cases (42.2%) (Table 1).

The main cause for women’s violent death were traffic events, that resulted in 26 deaths (31.3%), followed by contusions, which resulted in 21 deaths (25.3%). In accordance with topographic anatomy, the head was identified as the body segment whose injury directly caused the death of 27 (32.5%) women. In accordance with the report on the corpse removal, the most frequent place of occurrence for these deaths were the public roads, with 34 cases (41.0%), and the hospitals, 26 cases (31.3%). In terms of geographical location by district, Callao had 40 cases (48.2%); Bellavista, with 25 (30.1%); Ventanilla, with 11 (13.3%); Carmen de la Legua Reynoso, 4 (4.8%); and finally the district of La Perla, 3 (3.6%).

DISCUSSION

The largest number of cases, during the three years, occurred in 2017, almost three months after the end of the state of emergency in Callao ⁸8. Radio Programas del Perú [Internet]. Lima: RPP; 2016 [citado el 9 de enero de 2020]. El estado de emergencia en el Callao culminó esta medianoche; Disponible en: https://rpp.pe/peru/callao/el-estado-de-emergencia-en-el-callao-culmino-esta-medianoche-noticia-1002563.
https://rpp.pe/peru/callao/el-estado-de-... ; this information shows the dynamic state of violence and its relationship to death.

The most frequent age group was 30-59 years old; which correlates with international investigations of violent deaths in general, with age groups ranging from 18 to 44 years old⁹9. Rozo Lesmes P. Caracterización de la violencia homicida en mujeres en Bogotá 2000-2006 [Tesis de maestría]. Bogotá: Facultad de Medicina, Universidad Nacional de Colombia; 2007. Disponible en: http://bdigital.unal.edu.co/654/.
http://bdigital.unal.edu.co/654/... , from 15 to 34 years old ¹⁰10. Chamizo H. Las muertes violentas en Costa Rica y sus inequidades geográficas. Población y Salud en Mesoamérica [Internet]. 2013 [citado el16 de enero de 2020]; 11(1):1-23. Disponible en: https://www.redalyc.org/articulo.oa?id=44628565006.
https://www.redalyc.org/articulo.oa?id=4... , from 20 to 40 years old ¹¹11. Bandala M, Melo G, Aguirre A. Prevalencia de muertes violentas en el Distrito Judicial X de Veracruz, México. Rev Mex Med Forense [Internet]. 2018 [citado el 9 de enero de 2020]; 3 (1): 19-26. Disponible en: https://www.medigraphic.com/cgi-bin/new/resumen.cgi?IDARTICULO=88225.
https://www.medigraphic.com/cgi-bin/new/... and with what is reported by the Public Ministry’s Office at the national level ¹²12. Ministerio Público. Homicidio y feminicidio en el Perú Setiembre 2008 - Junio 2009 [Internet]. Lima: Observatorio de Criminalidad del Ministerio Público, MINPU; 2009 [citado el 16 de enero de 2020]. Disponible en: https://portal.mpfn.gob.pe/boletininformativo/infoestadfeminicidio..

According to this study, transit events were the main direct cause of death, which coincides with the research carried out in Colombia during 1997-2003 ¹³13. Sánchez R, Tejada P, Martínez J. Comportamiento de las Muertes Violentas en Bogotá, 1997-2003. Rev Salud pública [Internet]. 2005 [citado el 9 de enero de 2020]; 7(3):254-67. Disponible en: http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S0124-00642005000300002&lng=en&tlng=.
http://www.scielo.org.co/scielo.php?scri... , and also correlates with the results of a study in Tijuana (Mexico), where 55% of women died because they were hit by a car ¹⁴14. Molina A, Zonana A, Flores D, Martínez A, Quiroz M. Muertes violentas en Tijuana, Baja California, México. Salud Pública Méx [Internet]. 2008 [citado el 9 de enero de 2020]; 50 (2):105-6. Disponible en: http://saludpublica.mx/index.php/spm/article/view/6807/8564.
http://saludpublica.mx/index.php/spm/art... . This differs from what was reported in Argentina, where transit events were the second most frequent cause of death ¹⁵15. Serfaty E, Foglia V, Masaútis A, Negri G. Mortalidad por causas violentas en adolescentes y jóvenes de 10-24 años Argentina 1991 - 2000. Rev. Vertex. [Internet]. 2003 [citado el 9 de enero de 2020]; 14(2): 40-48. Disponible en: http://www.epidemiologia.anm.edu.ar/wp-content/uploads/2017/12/Mortalidad_Causas_Violentas_2003.pdf.
http://www.epidemiologia.anm.edu.ar/wp-c... . This information varies between countries such as Argentina, Brazil and Colombia, the latter showing an exponential increase in this same cause of death ¹⁶16. Cardona D, Peláez E, Aidar T, Ribotta B, Álvarez M. Mortalidad por causas externas en tres ciudades latinoamericanas: Córdoba (Argentina), Campinas (Brasil) y Medellín (Colombia), 1980-2005. R bras Est Pop [Internet]. 2008 [citado el 9 de enero de 2020]; 25 (2): 335-352. Disponible en: https://doi.org/10.1590/S0102-30982008000200009.
https://doi.org/10.1590/S0102-3098200800... .

The second most frequent cause of violent death found was injury by blunt object. This coincides with what Arias, et al. described in a study on violent deaths in the region of Callao¹⁷17. Arias M, Gutiérrez C. Patrón espacial y temporal de las muertes violentas por homicidios en la región Callao y su distribución según variables sociodemográficas, 2003 - 2012. Rev. Peruana de Epidemiología [Internet]. 2014. [citado el 11 de enero de 2020]; 18 (1): 1-5. Disponible en: http://ateneo.unmsm.edu.pe/bitstream/handle/123456789/3320/rev_peru_epidemiol02v18n1_2014.pdf?sequence=1&isAllowed=y.
http://ateneo.unmsm.edu.pe/bitstream/han... and is related to what Serfaty, et al. found in a study carried out in Argentina that reports violent deaths in adolescents and young adults ¹⁵15. Serfaty E, Foglia V, Masaútis A, Negri G. Mortalidad por causas violentas en adolescentes y jóvenes de 10-24 años Argentina 1991 - 2000. Rev. Vertex. [Internet]. 2003 [citado el 9 de enero de 2020]; 14(2): 40-48. Disponible en: http://www.epidemiologia.anm.edu.ar/wp-content/uploads/2017/12/Mortalidad_Causas_Violentas_2003.pdf.
http://www.epidemiologia.anm.edu.ar/wp-c... . Other injuries were caused by projectiles from firearms. This finding confirms their illegal presence in the streets, which has been described by Meneses ¹⁸18 - Meneses R. Detalles de una muerte violenta: víctimas y circunstancias del homicidio por arma de fuego en el Distrito Federal (2000-2010). Andamios [Internet]. 2013 [citado el 9 de enero de 2020]; 10(23): 257-290. Disponible en: http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S1870-00632013000300011&lng=es&tlng=es.
http://www.scielo.org.mx/scielo.php?scri... in Mexico and by Arias, et al. in the Callao region ¹⁷17. Arias M, Gutiérrez C. Patrón espacial y temporal de las muertes violentas por homicidios en la región Callao y su distribución según variables sociodemográficas, 2003 - 2012. Rev. Peruana de Epidemiología [Internet]. 2014. [citado el 11 de enero de 2020]; 18 (1): 1-5. Disponible en: http://ateneo.unmsm.edu.pe/bitstream/handle/123456789/3320/rev_peru_epidemiol02v18n1_2014.pdf?sequence=1&isAllowed=y.
http://ateneo.unmsm.edu.pe/bitstream/han... . It has also been reported by González, et al. in a Mexican investigation where firearms were reported ¹⁹19. González G, Vega M, Flores M. El incremento de la mortalidad por armas de fuego y su relación con el estancamiento de la esperanza de vida en México. Ciênc saúde coletiva [Internet]. 2017 [citado el 9 de enero de 2020]; 22 (9):2861-72. Disponible en: https://doi.org/10.1590/1413-81232017229.21902016.
https://doi.org/10.1590/1413-81232017229... . In a Colombian study, violent deaths with trauma were caused by projectiles from a firearm, contusions, and stab wounds ²⁰20. Martínez V, Teherán A, Cárdenas W, León L, Pimienta F, Barrera M, et al. Severidad del trauma calculada con registros de necropsia en diferentes tipos de lesión, Bogotá, 2013. Repositorio Institucional EdocUR [Internet]. 2018 [citado el 9 de enero de 2020]. Disponible en: https://repository.urosario.edu.co/handle/10336/18298?locale-attribute=pt.
https://repository.urosario.edu.co/handl... .

During the external and internal examination of the corpse, the head segment was identified as the one with the highest frequency of injury. Similar evidence was found in Mexico in an investigation of violent deaths from firearm projectiles ²¹21. Vega J, Gonzáles L. Determinar la frecuencia de muertes producidas por proyectil de arma de fuego en el SEMEFO de Iguala, Guerrero 2011 [tesis de licenciatura]. Toluca, Estado de México: Facultad de Medicina, Universidad Autónoma del Estado de México; 2014. Disponible en: http://ri.uaemex.mx/handle/20.500.11799/14647.. When reviewing the corpse removal report, it was found that the place of occurrence of these deaths were primary scenarios (where death occurred) and secondary scenarios (where the injury did not occur, but death happened), among them the public road, followed by hospitals.

Between 2014 and 2015, 486 reports of violent death necropsies were reviewed at the Institute of Forensic Medicine in Cuiabá, Brazil. They found that 68.1% of the deaths were people between 20 and 49 years old, information which correlates with data found in Callao. It was also identified that 64.4% of the deaths occurred in public roads, relevant data similar to data obtained in this research. It is described that the most frequent cause of death (74.4%) was traumatic brain injury and hypovolemic shock.

Despite multiple attempts to reduce violence, such as emergency states declared on several occasions by the Peruvian Government, Callao still is a province where citizen security efforts must be redoubled, as reflected in the findings of this study. Similar results have been described in a study conducted with data from 2003 to 2012 in the same province ¹⁷17. Arias M, Gutiérrez C. Patrón espacial y temporal de las muertes violentas por homicidios en la región Callao y su distribución según variables sociodemográficas, 2003 - 2012. Rev. Peruana de Epidemiología [Internet]. 2014. [citado el 11 de enero de 2020]; 18 (1): 1-5. Disponible en: http://ateneo.unmsm.edu.pe/bitstream/handle/123456789/3320/rev_peru_epidemiol02v18n1_2014.pdf?sequence=1&isAllowed=y.
http://ateneo.unmsm.edu.pe/bitstream/han... .

The strengths of the study include working at the institutional headquarters in charge of the necropsies and having experience in forensics. Among the limitations of this study, it must be considered that cases without a definitive diagnosis were not included, neither were deaths that occurred in Callao but were transferred to the Central Morgue of Lima due to police or prosecutorial jurisdiction.

In conclusion, from the 83 cases of women’s violent death, most of them occurred to adults; traffic events were the most frequent causal agents, most of the fatal injuries were located in the head segment; most cases occurred in the public roads and, finally, Callao had the highest number of cases among all districts evaluated. This is the reason why, national authorities should participate creating means to manage integrated public policies; and relay on local authorities, including the fiscal and medico-legal sectors; in order to create, install and follow a plan of action to prevent violence, including a schedule for judicial, educational, health and social welfare activities.

References

Publication Dates

History