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 Case Report: Fatal Neglect of the Elderly by a Spouse
Case Reports
Fatal Neglect of the Elderly by a Spouse: A case report
A SAUVAGEAU, MD MSc
S RACETTE, BSc
Laboratoire de sciences judiciaires et de m6decine 16gale, Edifice Wilfrid-Derome 1701, Parthenais
Street, 12th floor, Montreal (Quebec) Canada H2K 3S7
Correspondence: Anny Sauvageau. Tel: (514) 873-3300 Fax: (514) 873-4847
Email: a.sauvageauqmsp.gouv.qc.ca
ABSTRACT
Neglect is one of the most common forms of elder
abuse, along with physical and psychological abuse.
It is defined as an elderly person alone who is not
able to provide for him or herself the services
necessary to maintain physical and mental health,
or who is not receiving those services from a
responsible carer. We present an unusual case of
neglect where a 69-year-old diabetic man was left
lying on the ground by his spouse after a sudden fall
from a cerebral stroke. The man was not able to move
or to get up and his spouse, unable to lift him up, did
not seek help. Although the victim's spouse reported
having taking care of him, the man died four days
later from a fatal hyperglycaemia.
INTRODUCTION
The problem of elder abuse was introduced in
1975 with the notion of 'granny-battering'
(Baker, 1975; Burston, 1975). In 1987, the
American Medical Association's (AMA) Coun-
cil on Scientific Affairs defined elder abuse and
neglect as actions or the omissions of actions
that result in harm or threatened harm to the
health or welfare of the elderly (AMA, 1987).
Today, elder abuse can be divided into six
categories: (1) physical abuse, (2) sexual abuse,
(3) neglect, (4) psychological abuse, (5) finan-
cial and material exploitation and (6) violation
of rights (Program Resources Dept. AARP and
AOA, 1993). It has been estimated that 3 to
10% of adults older than 65 years of age
experience a form of abuse (AMA, 1987;
Pillemer and Finkelhor, 1988; Kurrle et al.,
1992; Tsokos et al., 2000; Vida et al., 2002).
173
Although the medical profession has come
to recognise the problem of elder mistreat-
ment, it is still thought that the reported cases
are only the tip of a much larger unidentified
and unreported problem (Kleinschmidt, 1997).
This situation is referred to as the iceberg
theory of elder abuse (Tatara et al., 1998).
We report an unusual case of neglect of an
elderly man, left lying on the ground by his
spouse after a sudden fall.
CASE REPORT
A 69-year-old man with a history of diabetes
mellitus was found dead, lying in the corridor,
in his apartment.
During the night, the man got up from bed
to go to the bathroom. When he came back, he
was walking with difficulty and suddenly fell
on the floor lying flat on his stomach, slightly
on his left side. He was not able to move nor to
get up. Yet he was able to talk and say to his
spouse that he was not feeling any pain. His
spouse, unable to lift him up, decided to leave
him in place, on the floor, not knowing what
else to do. She did not call the emergency
services nor any other kind of help. She took
care of him in this position, feeding him and
covering him with a blanket. The man died
about four days later. However, it was only on
the next morning that the lady got out of the
house to ask for help at the local presbytery.
174 Med. Sci. Law (2006) Vol. 46, No. 2
Figures 1A and 1B. Victim's body showing bearing points, all compatible by localisation with the history
of a fall.
The spouse was known to suffer from
psychological problems. No further details
could be obtained, since accessing the spouse's
medical records was not possible.
The autopsy showed a white man of
72.73 kg and 1.73 m, well-nourished, present-
ing numerous bearing points. Localisation of
those points was compatible with the history of
the previously described fall: left cheek, left
elbow, left thorax and both knees (Figures 1A
and 1B).
At internal examination, subacute cerebral
infarct was seen, extending through the right
fronto-temporal and left frontal regions, as
well as the cerebellum. According to micro-
scopical observations, infarct could have
occurred one to four days prior to death, thus
being compatible with the reported history. An
aspiration pneumonia from feeding in a lying
position was also found. Other autopsy find-
ings included a moderate to severe cardiac
atherosclerotic disease, severe atherosclerosis
of the aorta and the presence of an endovenous
filter in the inferior vena cava, suggesting
previous emboli.
No alcohol or drugs were detected by
toxicological exam. However, significant glu-
cose and lactic acid concentration of the ocular
fluid led to the conclusion of fatal hypergly-
caemia as the cause of death.
It was later found that, although the spouse
took care of the victim, feeding and nursing
him in the corridor, she had failed to admin-
ister his insulin.
The manner of death was ruled homicide by
neglect. However, legal pursuits were with-
drawn since it was judged that the spouse did
not intend to harm nor was she fully aware,
considering her psychological problems, of the
life-threatening situation.
DISCUSSION
Victims of abuse are usually older than 60
years of age and often present with cognitive
impairment, minimal social interaction and
low self-esteem. Proximity and demanding
attitudes towards the caregiver are also very
typical characteristics of the victims (Lachs
and Pillemer, 1995; Lett, 1995; Kleinschmidt,
1997; Tatara et al., 1998). As for the abuser,
typical risk factors include mental illness,
alcoholism and substance abuse, legal difficul-
ties and violence or antisocial behaviour (Lett,
1995; Kleinschmidt, 1997). Abuse is even more
strongly correlated with the emotional and
financial dependence of the caregivers on the
elderly (Kleinschmidt, 1997).
It has been evaluated that in 90% of cases,
the perpetrator was known to the victim,
typically being a family member such as an
adult child or spouse with whom they lived
(Kleinschmidt, 1997; Tatara et al., 1998). A
retrospective study of 125 fatal abuse cases
revealed that the most common perpetrator
was the victim's son, followed by a grandchild,
daughter-in-law or son-in-law (Akaza et al.,
2003).
Elder abuse usually occurs in the context of
 Case Report: Fatal Neglect of the Elderly by a Spouse 175

long-term care (Kosberg, 1988; Meier- chemic/hypertensive heart disease and trauma
Baumgarther and Ptischel, 1996); neglect, from a fall (Shields et al., 2004).
physical and psychological abuse being the Here reported is the case of a 69-year-old
most common forms of mistreatment (Jones et man who suffered from a sudden fall in his
al., 1997). Neglect is defined as an elderly residence and was left on the floor by his spouse
person living alone who is not able to provide for about four days before his death. This case is
him or herself with the services necessary to a very unusual and atypical case of neglect.
maintain physical and mental health, or who is Indeed, most cases of neglect of the elderly occur
not receiving those services from a responsible in the context of long-term care, which is not the
carer (Lachs et al., 1998). situation here. In fact, there was no evidence
that the victim had been abused or neglected
In the forensic setting, some cases of elder
prior to his fatal sudden incident.
abuse by neglect have been reported. Collins et
Our case is an example of acute medical
al. (2000) reported the case of an elderly white
neglect. Medical neglect, a particular form of
woman found dead in her soiled bed in the care
neglect, has been defined as failure to seek
of a male friend. The cause of death was
medical care appropriate for the patient's
related to pseudomonas sepsis with dehydra-
condition (Collins et al., 2000). As a matter of
tion secondary to deep purulent decubitus
fact, the victim's spouse did present the
ulcers over the sacral and inferior buttocks
intention to care for her male companion by
regions (Collins et al., 2000). Ortmann et al.
covering him with a blanket and trying to feed
(2001) presented two cases of neglect. In the
him. However, she failed to provide the needed
first case, a 82-year-old bedridden woman was
insulin pharmacotherapy and to call for help.
neglected by her son and finally died from
During the spouse's interrogation, she
septic-toxic heart failure from surinfected
claimed that the victim told her he was well,
pressure sores and purulent bronchitis with
though not able to move, and didn't want her to
bronchopneumonia. The second case was one
call emergency help. Thus, she stated having
of a 72-year-old-man also dying from septic-
only followed his instructions. This element
toxic heart failure, from infected pressure
brings the perspective of self-neglect, where
sores of the right arm, with maggots infesta-
help is declined by the elder in need (Lachs et
tion, leading to osteomyelitis (Ortmann et al.,
al., 1998). Nevertheless, even though a person
2001). Again in the same year, an unusual case
can decline medical help for himself, lack of
of neglect in an 80-year-old woman looked
seeking such help by the caregiver in a life-
after by her son was reported by Rickert et al.
threatening situation constitutes severe
(2001). Autopsy revealed the presence of
medical neglect. However, to what extent can
Marchiafava-Bignami disease in a non-
someone force a person to receive treatment or
alcoholic woman. It was actually presumed
help, especially since abusive negligent care-
that malnutrition associated with neglect was
givers are known to be often emotionally and
related to the disease (Rickert et al., 2001).
financially dependant on the abused elder
More recently, Akaza et al. (2003) reported 15
(Kleinschmidt, 1997)? Therefore, dissociating
cases of fatal elder mistreatment, including
respective weights of neglect and self-neglect
four cases of neglect, all but one in combination
can be rather complex.
with other forms of abuse. In the one pure
neglect case, the victim's son forced the man to
eat food, but the latter died from choking on ACKNOWLEDGEMENTS
The authors would like to thank M. Thierry Marcoux
aspirated food. The son left the corpse in place
for technical support.
for 19 days (Akaza et al., 2003). Finally,
Shields et al. (2004) realised a ten-year retro-
spective review of morbidity and mortality REFERENCES
Akaza K, Bunai Y., Tsujinaka M., Nakamura I.,
among elders. They found 22 fatal cases of Nagai A., Tsukata Y. and Ohya I. (2003) Elder
suspected neglect, with victims dying from abuse and neglect: social problems revealed from
bronchopneumonia, sepsis, dehydration, is- 15 autopsy cases. Leg. Med. (Tokyo). 5 (1), 7-14.
176 Med. Sci. Law (2006) Vol. 46, No. 2
A.M.A. (1987) Council on Scientific Affairs: elder
abuse and neglect. J.A.M.A. 257 (7), 966-71.
Baker A.A. (1975) Granny battering. Mod. Geriatr. 5,
20-4.
Burston G.R. (1975) Granny-battering. B.M.J. 3
(5983), 592.
Collins K.A., Bennett A.T. and Hanzlick R. (2000)
Elder abuse and neglect. Autopsy Committee of
the College of American Pathologists. Arch.
Intern. Med. 160 (11),1567-8.
Jones J.S., Veenstra T.R., Seamon J.P. and Krohmer
J. (1997) Elder mistreatment: National survey of
emergency physicians. Ann. Emerg. Med. 30 (4),
473-9.
Kleinschmidt K.C. (1997) Elder abuse : a review.
Ann. Emerg. Med. 30 (4), 463-72.
Kosberg J.I. (1988) Preventing elder abuse: identifi-
cation of high risk factors prior to placement
decisions. Gerontologist. 28 (1), 43-50.
Kurrle S., Sadler P. and Cameron I. (1992) Elder
abuse - an Australian case series. Med. J. Aust.
155 (3), 150-3.
Lachs M.S. and Pillemer K. (1995) Abuse and neglect
of elderly persons. N. Engl. J. Med. 332 (7),
437-43.
Lachs M.S., Williams C.S., O'Brien S., Pillemer K.A.
and Charlson M.E. (1998) The mortality of elder
mistreatment. J.A.M.A. 280 (5), 428-32.
Lett J.E. (1995) Abuse of the elderly. J. Fla. Med.
Assoc. 82 (10), 675-8.
Meier-Baumgartner H.P. and Puschel K. (1996) Old
age and violence. J. Gerontol. Geriatr. 29 (3),
167-8.
Ortmann C., Fechner G., Bajanowski T. and Brink-
mann B. (2001) Fatal neglect of the elderly. Int. J.
Legal Med. 114 (3), 191-3.
Pillemer K. and Finkelhor D. (1988) The prevalence
of elder abuse: a random sample survey. Geron-
tologist. 28 (1), 51-7.
Program Resources Department, American Associa-
tion of Retired Persons (AARP), and Administra-
tion on Aging (AoA), US Department of Health
and Human Services (1993) A Profile of Older
Americans. Washington, DC: American Associa-
tion of Retired Persons.
Rickert C.H., Karger B., Varchmin-Schultheiss K.,
Brinkmann B. and Paulus W. (2001) Neglect-
associated fatal Marchiafava-Bignami disease in
a non-alcoholic woman. Int. J. Legal Med. 115 (2),
90-3.
Shields L.B., Hunsaker D.M. and Hunsaker J.C. 3rd.
(2004) Abuse and neglect: a ten-year review of
mortality and morbidity in our elders in a large
metropolitan area. J. ForensicSci. 49 (1), 122-7.
Tatara T., Kuzmeskus L.B., Duckhorn E., Bivens L.,
National Center on Elder Abuse (NCEA)., Amer-
ican Public Human Services Association
(APHSA)., Thomas C., Gertig J., Jay K., Hartley
A., Rust K. and Croos J., Westat Inc. (1998) The
National Elder Abuse Incidence Study: final
report. Washington D.C., Administration on
Aging, p 136.
Tsokos M., Heineman A. and Pdischel K. (2000)
Pressure sores: epidemiology, medico-legal impli-
cations and forensic argumentation concerning
causality. Int. J. Legal Med. 113 (5), 283-7.
Vida S., Monks R.C. and Des Rosiers P (2002)
Prevalence and correlates of elder abuse andne-
glect in a geriatric psychiatry service. Can. J.
Psychiatry 47 (5), 459-67.

Air Gun - A Deadly Toy?: A case report
F S KULIGOD, MD DFM
Professor
PRASANNA S JIRLI, MD
Assistant Professor
PRADEEP KUMAR, MV MBBS (MD)
Post Graduate Student
Department of Forensic Medicine, K.L.E. Society's Jawaharlal Nehru Medical College, BELGAUM 590
010, Karnataka State, India
Correspondence: Dr. F.S. Kuligod. Tel: (0)91-0831-2473777 Extn. 1538 Fax: 91-0831-2470759
Email: drfskuligodrediffmail com
ABSTRACT
Air guns (air rifles) are used throughout the world as
instruments of amusement such as toys in funfairs,
for bird hunting and firearms training. In India and
in many other countries, this instrument neither
comes under the purview of the Arms Act, nor is
there is any restriction on the user's age. This
enables a person to gain access to this instrument
quite easily. Sometimes serious and fatal injuries
result when it is used by an ignorant person or by a
criminal. There are reports which suggest that these
'toys' can cause painful injuries but only a few cases
of death have been reported. There is no literature
about the features of injuries that help to establish
the range of fire by an air gun. Here we report a case
where a boy was accidentally shot to death while
watching bird shooting. We attempt to correlate the
injury with the range of fire.
INTRODUCTION
Many people fantasize about handling guns.
They try to make it come true by playing with
air guns (air rifles) at funfairs, by target
shooting, or bird hunting in the fields. As
there is no age restriction in most countries to
have or handle air guns, they are easily
accessible to children who, due to their
ignorance, handle them inappropriately.
The air gun is a simple yet ingenious and
effective weapon based on fundamental me-
chanics. The gun primarily employs a very stiff
compression spring to transmit momentum to
a light pellet. Here, a very clever method of
transmitting energy to the pellet is used. It is
not by collision but using the dynamics of
Case Report: Air Gun - A Deadly Toy? 177
compressed air. Most modern air guns are
inexpensive BB guns (named for the size of the
shot fired) (Di Maio, 1985). The best of these
employ about half the muzzle velocity of a light
firearm, are accurate enough for marksman-
ship training at ranges up to 40 metres and can
cause serious injuries (Reddy, 2003)
An air rifle is distinguished from an air gun
as the former is a rifled weapon and the latter
is a smooth bore. Air pistols may be either
rifled or smooth bore. The weight of an air
weapon pellet is concentrated in the head; with
a hollow body. Its centre of gravity is well
forward from the mid point. Hence, these slugs
are not subject to the tendency of tumbling.
This is an important factor in a projectile of low
energy contributing to its capability to pene-
trate a target (Ravindra,1999).
There are three basic power systems for
air-powered guns. They are pneumatic type,
spring air compression system, and gas
compression type (Di Maio, 1985). Death from
an air-powered gun is rare. A review of
English language literature reveals only a
few deaths. Most involved children (Green,
1982). In most of the cases the point of entry
was in the head.
CASE REPORT
A 12-year-old shepherd boy was accidentally
shot while he was watching someone bird
hunting with an air gun. The person who was
178 Med. Sci. Law (2006) Vol. 46, No. 2
Figures 1 and 2. X-rays (AP view and lateral
view).
shooting the birds, while reloading, acciden-
tally shot the boy. After the injury, the boy was
admitted to hospital, and the presence of the
pellet was confirmed by means of suitable
diagnostic techniques (X-rays - Figures 1 and
2 - and CT scan). Due to financial constraints,
Figure 3. Showing entry wound.
no effort was made by the treating surgeons to
retrieve the pellet. The boy was treated
symptomatically and he survived for four days.
On post-mortem examination the deceased
was a moderately built and reasonably well-
nourished male dead body. The remaining
external features were unremarkable. With
the help of X-rays taken during diagnostic
procedures (lateral and AP view) the position
of the pellet was confirmed.
External injuries
The pellet entrance wound was in the middle
third of the right upper eyelid, 0.5 cms below
the right eyebrow and 4 cms to the right of the
root of the nose. The wound measured 7 mm in
diameter, with a 4 mm central perforation. The
pellet travelled through the roof of the right
eye orbit into the cranial cavity, without
causing any injury to the right eye globe. The
edges of the wound were dark brown in colour
and inverted (Figure 3).
Internal injuries
Bruising of the scalp measuring 4 x 3 cms was
present, corresponding to the external injury
(entry wound). There was a penetrating frac-
ture of the middle third of the roof of the right
orbit. The pellet entered the cranial cavity
through the right orbital plate (roof of right
orbit) adjacent to the cribriform plate. It
entered the front right half of the brain, below
the surface, travelled inbetween the halves of
the brain, towards the back and to the left and
finally lodged in the back of the left half of the
brain (left occipital lobe). Multiple lacerations

were present along the whole length of the
wound track. A deformed lead pellet of an air
gun was recovered at the end of the wound
track. The recovered pellet weighed 0.78 gms.
Diffuse subdural and subarachnoid haemor-
rhages were present. Both lateral ventricles
were filled with dark brown blood clots. The
brain weighed 1,764 gms. The cause of death
was given as 'cerebral oedema due to brain
injury as a consequence of an air weapon
pellet'.
DISCUSSION
A traditional firearms gun is one that
launches a projectile (i.e. a bullet) down the
barrel by using the energy generated from the
burning of gunpowder. Non-powder guns
utilize the power of compressed air to launch
a projectile (Lawrence, 1990) These non-
powder firearms have been in use since the
16th century in warfare and to kill animals as
large as deer (Milroy, 1998). Air-powered guns
were originally considered as weapons, cap-
able of causing lethal injury. The increased
power of powder firearms relegated air-
powered guns to the status of a toy in modern
society. Unfortunately, a minor or a parent,
many of whom do not understand their
destructive potential, typically buy these guns
(Bond, 1996).
Air-powered guns utilize compressed air or
carbon dioxide rather than gunpowder to
propel a pellet or ball bearing. The most
common sizes of ammunition available are
0.177 calibre, 0.22 calibre and 5 mm (Di Maio,
1985). Three mechanisms for compressing the
gas are in widespread use (Lawrence,1990).
Modern air guns are capable of muzzle
velocities of 400 to 900 ft/sec. By comparison,
an M16 military rifle has a velocity of 3,250 ft/
sec; a 0.30-06 hunting rifle, 2,500 ft/sec; a 0.38
calibre pistol, 870 ft/sec; and a 0.22 calibre
pistol, 800 ft/sec (Morgan, 1984).
Therefore, it can be said that air guns
produce muzzle velocities equal to, or in excess
of, small calibre handguns. The injuries pro-
duced by an air gun can mimic those injuries
produced by handguns. In this particular case,
the injuries found on the middle third of the
upper eyelid of the right eye were the same as
Case Report: Air Gun - A Deadly Toy? 179
if a handgun been used at close range. In cases
of handguns, the size and density of the area of
blackening varies with the calibre of the
weapon, the barrel length, the type of propel-
lant powder and the distance from muzzle to
target (Di Maio, 1985). Within the penetrating
range, the injury produced by an air gun will
be an oval or round entry wound, irrespective
of the distance of fire, and without any change
in the size and density of the area of black-
ening as it lacks propellant powder.
However, the range of fire does affect the
tissue penetration. Reports of ballistics studies
carried out by Di Maio et al. (1985) described
the minimum velocities required to penetrate
the skin as well as primary penetration of
bone. The speed at which tissue penetration
occurs is easily attainable with virtually all
types of air gun. It has also been proved by
studies that a larger calibre pellet will pene-
trate the body (e.g, skin, bone) at lower
velocities because of its increased mass. Pellets
have different designs. Each is suited to a
different purpose. Hollow points are used for
hunting and the pellets' diameter increases on
impact to cause maximum damage. The de-
formed pellet in our case weighed 0.78 gm.
Most pellets weigh in the range of 0.7 to 1.0 gm
(Ravindra, 1999) So while assessing the range
of fire, it has to be kept in mind that injuries by
hand guns and air guns can mimic each other.
The difference can be established from the
presence of singeing of the hair or the presence
of soot particles at the wound entry, or
tattooing by partially burnt and unburnt
propellants, all of which are more suggestive
of a shot by a hand gun.
Lethal injuries caused by air-powered guns
are well described. A literature search sug-
gests that the majority of these fatalities were
injuries to the brain. In a series of 101 cases, 49
had injuries to the head, including 38 with
injuries to the eye, ten with intracranial
injuries and one with a skull injury. Three
out of ten children with intracranial injuries
died (Bratton, 1997) When we consider the
treatment aspect, it has been suggested to
clean out the missile tract with the removal of
the pellet, and to give prophylactic antibiotics
and anticonvulsants.
180 Med. Sci. Law (2006) Vol. 46, No. 2
In the present case, due to financial con-
straints, no effort was made by the treating
surgeons to retrieve the pellet from the brain.
The boy was treated symptomatically. He
survived for four days. It is therefore essential
to remove the pellet as soon as possible and to
prevent hydrocephalus, ventriculities or intra-
cranial haemorrhage. Furthermore, if the
pellet is left in place, it can act as a nidus of
infection.
A decade ago there were an estimated
31,547 pellet gun-related injuries in the Uni-
ted State of which 2,047 required hospitaliza-
tion (Annest et al., 1995) These figures are
increasing day by day. Operating a gun with-
out care or knowledge is the reason behind
such increasing numbers. In a study of 1,004
eligible participants, 67% believed that it was
never 'OK for a child to play with toy guns' and
66% stated that they never let their child play
with toy guns (Cheng et al., 2003). Our case is
rare because in a country like India very few
cases of injury with an air gun are reported as
these 'toys' are used in funfairs for target
shooting or by high-class people for hunting
birds. A literature search through textbooks of
Indian authors suggest only few fatalities from
air guns (Subrahmanyam, 1999; Reddy, 2003).
CONCLUSION
Air guns, although considered as toys, can
cause injuries ranging from trivial to fatal. The
type and severity of injuries depend on the
type of air gun used, the range at which it is
fired, and the anatomical site at which the
pellet hits. A fair degree of comparison
between injuries by hand guns and air guns
can be made by careful examination of the
entry wound. Lack of care, supervision and
unstructured use are the risk factors contri-
buting to the incidence of fatal injury from air
guns. Even in developing countries proper
laws should be enforced regarding their sale
and use.
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 Case Report: HIV/AIDS, Psychiatric Disorder and Sexual Assault in Transkei 181

HIV/AIDS, Psychiatric Disorder and Sexual Assault in Transkei: A case

report.
B L MEEL, MBBS MD DHSM (Natal) DOH (Wits) M.Phil HIV/AIDS Management
(Stellenbosch).
Professor and Head, Department of Forensic Medicine, Faculty of Health Sciences, Walter Sisulu
University for Technology and Science, Mthatha 5100, South Africa
Correspondence: Prof Meel. E-mail: meelfgetafix.utr.ac.za

ABSTRACT tion, with a general trend for increased

HIV infection and psychiatric disorders have a
complex relationship. HIV infection could lead to
psychiatric disorders, and psychiatric patients are
more vulnerable to HIV infection. HIV is not only
an illness which is associated with stigmatization
and discrimination, but also has several risks
attached including physical and sexual abuse.
There is a scarcity of literature on HIV, mental
illness and sexual assault although they are a
common trio.
The author describes an HIV-positive woman
with a psychiatric disorder. She suffered from AIDS
and periodic psychotic epidsodes. On a day when
she had such an episode she became a rape victim.
The history, and physical and genital examination
has been described. The need for further research
in the area of HIV/AIDS and mental health has
been discussed. Preventive strategies have been
recommended for HIV-infected individuals in poor
health resource settings.
INTRODUCTION
HIV/AIDS is a double-edged sword. On the one
hand a mentally ill person is more vulnerable
to HIV infection, and on the other hand, the
HIV-infected person is more prone to mental
disorders. Men and women who have a severe
and persistent mental illness are vulnerable to
infection with HIV (Carey et al., 1997). People
who suffer from mental disorders are at
increased risk of becoming infected with HIV
There have been studies which show that
psychiatric disorders present an increased risk
for those with an HIV infection (Hoff et al.,
1997).
Phobias related to HIV and AIDS have been
reported early in the history of HIV infection
(Faulstich, 1987). Anxiety disorders may be
manifest throughout the course of HIV infec-
prevalence of these disorders as the illness
progresses (Chandra et al., 2005). Researchers
have reported a prevalence range of 2-38%
depending upon the stage of illness (Perkins
et al., 1994). Depression is the commonest
psychiatric syndrome reported in studies
among HIV-infected individuals. Major de-
pression in the HIV-positive population is
elevated to about twice the level of occurrence
in the general population. Rates of depression
have ranged from 5-25% or even higher
(Chandra et al., 1998). The risk of suicide
has been reported as 20 to 36 times higher
than in the general population (Meel and
Leenaars, 2005).
South Africa is a country with a rapidly
escalating HIV/AIDS epidemic. There are also
high levels of rape reported from various
sources (Kim et al., 2003). Here, as elsewhere,
statistics capturing the true magnitude of
sexual violence are difficult to obtain, espe-
cially among the victims who are living with
HIV/AIDS. Those released by the South
African Police Service note that in 2001,
52,860 rapes and attempted rapes were
reported (Kim et al., 2003). Only about 15%
of women who were forced to have sex against
their will reported the incident to the police
(Department of Health, 1998).
There are several gaps in the understanding
of HIV and mental health. The serious psycho-
tic problems have scarcely been reported in the
literature, and therefore the purpose of this
case report is to highlight the problem of HIV-
182 Med. Sci. Law (2006) Vol. 46, No. 2
related psychotic behaviour and its conse-
quences.
CASE REPORT
On 18 December 2004, NL, a 29-year-old
woman from Mthatha presented with a history
of rape to the accident and emergency section
of Nelson Mandela Academic Hospital. She
was living with HIV/AIDS.
On the day in question the patient had
developed a psychotic episode in town and
damaged a vehicle parked there. The owner of
the vehicle had become furious, grabbed her in
the car, driven away and raped her. While her
relatives were searching for her, information
was received of her whereabouts. The owner of
the vehicle had dropped her at her house and
demanded a cash payment of R1200/- for
repairs, which had been paid by a cousin.
NL reported that she was raped by the
driver and the passenger. She had been
assaulted by both of them. The rape and
assault were reported to the police and they
brought her to hospital accompanied by her
sister. She was very traumatized, and not
responding to verbal commands. On physical
examination, there were multiple bruises on
the face and body. There was a whitish
discharge visible on genital examination but
no blood. She was treated with antibiotics.
Unfortunately she died two months after the
incident.
DISCUSSION
This is first case report regarding HIV and
psychiatric disorder in the region of Transkei.
The Transkei was one of the former black
homelands, now part of Eastern Cape
Province. It is one of the poorest rural regions
in South Africa. Mental health care services
are not available in the majority of remote
rural areas. HIV/AIDS is on the increase and
there is poor support for these individuals.
There is an increasing incidence of HIV
infection among victims of sexual assault
(Meel, 2003) and no studies have been carried
out on the relationship between HIV infection
and psychiatric disorders. However, there is a
very high prevalence of HIV/AIDS and psychi-
atric disorders, including a moderate prev-
alence rate of alcohol use/misuse in this less
affluent community (Sebit et al., 2003).
NL was a young women living with HIV/
AIDS. She was living with her sister who is
also HIV-positive, and getting support from
her. NL was a victim of rape as a result of her
HIV illness. About 10% of victims are HIV-
positive at the time of the incident (Meel,
2005). This may be because of their psychiatric
manifestation, such as in LN's case. They
should have been put on antiretroviral treat-
ment.
Psychiatric disorders are common in HIV
patients, and previous work suggests that
these patients experience delays in treatment
with highly active antiretroviral therapy
(HAART). HAART is beneficial to these
patients as they are able to reap the survival
benefit by remaining on it (Himelhoch et al.,
2004). Therefore, the training of HIV clinicians
needs to increase their expertise in the
management of these co-morbid conditions
and help develop systems of care that better
address the special needs of this population
(Friedland, 2002).
HIV/AIDS is one of the major issues to be
faced by mental health care sectors over the
next decade. Many mentally ill people already
have, or will, become infected with HIV due to
a range of factors including lack of information
and poor risk prevention skills (Luckhurst,
1992). Others, like LN, without a previous
history of mental illness, will develop mental
health problems because of the effects of HIV
on the central nervous system (Luckhurst,
1992). LN was suffering from a serious
psychiatric disorder of self-harm. The care-
giver is her sister, and she is unemployed, and
also HIV-positive. She is faced with multiple
problems. The rapist was unaware of LN's
disease status and may pay a heavy price with
his own life.
In an African study on 194 subjects, of
whom 101 (52.1%) knew about their sero-
status, over two-thirds (71.3%) of the HIV-
positive subjects suffered from psychiatric
disorders, against those who were HIV-nega-
tive (44.3%). There was a higher prevalence
rate of alcohol use/misuse (24.3%) among HIV-
positive subjects. The commonest psychiatric
 Case Report: HIV/AIDS, Psychiatric Disorder and Sexual Assault in Transkei
symptoms/signs were emotional withdrawal,
depression, suspiciousness, apparent sadness,
reduced sleep, psychotic disorders and suicidal
thoughts especially among women (Ruiz et al.,
2000; Sebit et al., 2003).
Preventive interventions are urgently
needed for HIV-infected psychiatric patients.
However, it is not clear that at what stage of
HIV infection, these neuropsychiatric symp-
toms are more predominant. LN was HIV-
infected but there were no visible signs of
AIDS. It is important too that psychiatrists
collaborate very closely with HIV/AIDS
clinicians in the management of HIV/AIDS
and the psychological sequelae (Ruiz et al.,
2000).
Integrating psychiatric and psychosocial
interventions along with antiretroviral
therapy should benefit both the mental and
physical health of people living with HIV/AIDS
in this region. Whether the mental health
problem preceded HIV infection or vice versa
needs to be assessed. Public health laws need
to change so that those infected with HIVenjoy
legal protection. Nurses in rural areas should
be trained in dealing with HIV-infected people
as a priority. Wider research is urgently
needed to adequately assess HIV/AIDS-related
psychiatric disorders.
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