Violence and bullying at school: 10-year data from the Forensic Medicine Department of a University Hospital in Türkiye

ABSTRACT

BACKGROUND:

Violence at school is broadly defined as a range of acts including physical, psychological, and sexual violence, as well as bullying. These can occur at school, in the school environment, on the way to school, or in any school-related environment. Considering the school environment as the place where a child spends most of their daily life, its impact on the child’s life cannot be underestimated. This study aims to contribute to the literature by sharing characteristics of school violence and bullying cases with forensic reports prepared in our department, and by presenting solution suggestions for detecting and preventing these issues.

METHODS:

Between January 1, 2012 and December 31, 2022, a total of 14,330 forensic reports issued by the Dokuz Eylül University Faculty of Medicine, Department of Forensic Medicine, were analyzed. It was found that 125 cases involved school violence. Five cases involving non-students were excluded, leaving 120 student cases for inclusion in the study. Sociodemographic data, type of violence, incident location, educational stage, injury origin, and psychiatric assessment results were assessed. Statistical analysis of the data was performed using the SPSS 29.0 package.

RESULTS:

Of the 120 cases analyzed, 90 (75%) were male, and 30 (25%) were female. The cases were most frequently subjected to violence at the secondary education stage (n=73, 60.8%) and, secondarily, at the primary education stage (n=36, 30%). When the type of violence was analyzed, it was found that physical violence was the most common (n=96, 80%), followed by sexual violence (n=21, 17.5%). Among these, 91.1% (n=82) of males and 43.3% (n=13) of females were exposed to physical and sexual violence, respectively. A statistically significant relationship was found between the type of violence and gender (p<0.001). Post-traumatic stress disorder (PTSD) was the most common diagnosis among those who underwent psychiatric assessments after experiencing violence (n=15, 45.5%).

CONCLUSION:

To effectively combat violence and bullying, we believe that strategies based on analyzing the causes of bullying in schools across different cultures, planning and implementing appropriate interventions tailored to the problem area, and preventing recurrence by disseminating the results will yield more effective outcomes.

INTRODUCTION

As social beings, humans are constantly engaged in cycles of communication and interaction with others as a condition of living together.[1] As a result of this cycle, individuals sometimes experience conflicts with those they interact with, and these conflicts can sometimes escalate into violence.[2] The World Health Organization (WHO) defines violence as “intentional physical, psychosocial, and sexual behaviors that cause injury and death to an individual or hinder their development.”[3,4] Although violence has various causes, such as stress, anxiety, and depression, children and young people have consistently been the demographic most affected by violence throughout human history.[4,5]

Considering the school environment, where a child spends most of their daily life with friends and adults, the impact of school on a child’s life cannot be underestimated. At this point, various sources indicate that the issue of violence and bullying in schools has been recognized as a field of study and research since the early 1970s.[6]

Violence at school is commonly defined as a spectrum of behaviors that includes physical, psychological, and sexual violence, as well as bullying. This violence occurs at school, around the school, on the way to school, or in any environment related to the school.[7,8] (Fig. 1) All violent and bullying behavior perpetrated by students, teachers, administrators, and school staff is included.[4,9]

Figure 1.

School violence and bullying.[8]

Bullying is a form of violence characterized by repetitive and intentional aggressive behavior that uses force, intimidation, threats, or coercion against a victim where there is a real or perceived power imbalance, establishing pressure and superiority.[8,10,11]

Peer bullying refers to physical, verbal, and emotional/behavioral harmful behavior perpetrated by one or more individuals of the same age group against each other or an individual. This behavior must be continuous to be considered peer bullying.[10]

There are basically three groups in the bullying cycle: those who exhibit bullying behavior, those who are subjected to bullying behavior, and bystanders.[10]

Bullying behavior is divided into two categories: direct and indirect.[11] Direct bullying behavior includes punching, shoving, pushing, hitting, shouting, biting, spitting, swearing or insulting, threatening, making embarrassing or cruel jokes, making fun of religion, social inability, financial situation, or social status, and teasing. Indirect bullying behavior includes refusing or not accepting, blackmailing, giving hateful looks or making gestures with curses, writing insulting or humiliating notes, spreading damaging rumors or gossip, using friends for one’s own interests, writing defamatory articles on websites, pretending to be absent, and excluding someone from the group.[10]

Although the issue of violence and bullying in schools has been recognized for many years, it has only been studied worldwide since the early 1970s and has gained significant attention in the past two decades.[11,12] In recent years, due to the increase in incidents of violence in schools, more attention has been paid to this area, and more research has been conducted to prevent and reduce violence in schools.[9,13] Nevertheless, many sources indicate that awareness of the issue remains insufficient.[7,14]

This study aims to contribute to the existing literature on school violence and bullying by sharing the characteristics of school violence and bullying cases, for which forensic reports were prepared, observed in our department, and by proposing solutions for their detection and prevention.

MATERIALS AND METHODS

A total of 14,330 forensic reports prepared by the Department of Forensic Medicine of Dokuz Eylül University Faculty of Medicine between January 1, 2012 and December 31, 2022, were examined, and it was determined that a total of 125 cases were subjected to violence at school. Since the focus was on cases of school violence that students were exposed to, 5 cases involving non-students were excluded from the analysis, and only 120 cases involving students were included in the study. The analysis covered sociodemographic data, type of violence, crime scene, educational stage, perpetrator of violence, tool used, injury origin, injury area, wound type, presence of mental retardation, and psychological evaluation results.

Statistical Analysis

Statistical analysis of the data was performed using the SPSS 29.0 (Statistical Package for the Social Sciences) package program. Descriptive analyses were conducted. Means and standard deviations of continuous variables and percentages of categorical variables of the participants are shown. Categorical dependent and independent variables were analyzed using the Pearson Chi-square test and Fisher-Freeman-Halton Exact Test. For statistical significance, a p-value of less than 0.05 was considered significant.

RESULTS

Of the total 120 cases, 90 (75%) were male and 30 (25%) were female. The mean age was found to be 14.89±4.75 years (the youngest is 6, the oldest is 45; the mean age of women is 14.26; the mean age of men is 15.10).

When examining the distribution of cases exposed to violence according to educational stage, it was determined that 73 (60.8%) cases were in secondary education, 36 (30%) in primary education, 6 (5%) in university, 4 (3.3%) in special education, and 1 (0.8%) in kindergarten. When the types of violence experienced were examined, the most common was physical (n=96, 80%), followed by sexual (n=21, 17.5%). Three cases (2.5%) were subjected to psychological violence.

In analyzing the type of violence by gender, it was found that 91.1% (n=82) of the males were exposed to physical violence and 8.9% (n=8) to sexual violence. For females, 46.7% (n=14) were exposed to physical violence and 43.3% (n=13) to sexual violence. Of the patients exposed to psychological violence (2.5% of the total), all three were female (Table 1). A statistically significant relationship was found between the type of violence exposed to and gender (p<0.001).

Table 1.

Distribution of gender, educational stage, and type of violence exposed by the cases.

Types of violence	Kindergarten Education	Primary Education	Secondary	University	Special Education	Total* (%)
Physical
Male	0	18	58	5	1	82 (91,1)
Female	0	3	10	0	1	14 (46,7)
Sexual
Male	1	4	1	0	2	8 (8,9)
Female	0	11	2	0	0	13 (43,3)
Psychological
Male	0	0	0	0	0	0
Female	0	0	2	1	0	3 (10)
Total
Male	1	22	59	5	3	90 (75)
Female	0	14	14	1	1	30 (25)

^*Column percentages are shared as stated in the text.

In 18 (15%) cases, the place of violence was not specified and was reported in the history as “at school.” It was observed that the most common area of exposure to violence was classified as “other,” with 33 (27.5%) cases, including areas outside the school boundaries such as the service area, the bus stop near the school, and the park next to the school. 31 (25.8%) cases were exposed to violence in the school garden, 28 (23.3%) in the classroom, 7 (5.8%) in the toilet, and 3 (2.5%) in the corridor (Fig. 2).

Figure 2.

Distribution of type of violence by location of incident.

Out of a total of 62 cases, 55 (88.7%) were subjected to physical violence in areas within the teacher’s control, such as the classroom, corridor, and school garden. Out of a total of 21 cases of sexual violence, 8 (38.1%) occurred in areas described as “other,” and 3 (14.3%) in the toilet. There was no statistically significant relationship between the type of violence and the location of the incident (p=0.121).

The gender of 54 (45%) alleged perpetrators was not specified. Of the 66 (55%) patients, 9 (13.6%) were female and 57 (86.4%) were male. The perpetrators of violence were primarily 73 (60.8%) peers of those exposed to trauma. Fifteen (12.5%) perpetrators of violence were from the upper classes of those exposed to trauma. Eighteen (15%) individuals were observed to have used violence against the pupils they were teaching. All four cases in special education were subjected to violence by their educators. In the group classified as “other,” 14 (11.7%) were subjected to violence within the school boundaries by parents of other pupils, neighbors, and strangers.

It was found that physical violence was mostly perpetrated by peers (n=68, 70.8%) and sexual violence was mostly perpetrated by older individuals (n=17, 81%) (Table 2). A statistically significant relationship was found between the type of violence and the perpetrator (p<0.001).

Table 2.

Trauma perpetrators, educational stage of cases, and the type of violence they were exposed to.

Educational stage	Peer	Upper	Instructor	Other	Total
Kindergarten
Sexual	0	1	0	0	1
Primary Education
Physical	14	2	3	2	21
Sexual	3	4	3	5	15
Secondary Education
Physical	50	7	6	5	68
Sexual	1	1	0	1	3
Psychological	1	0	0	1	2
University
Physical	4	0	1	0	5
Psychological	0	0	1	0	1
Special Education
Physical	0	0	2	0	2
Sexual	0	0	2	0	2
Total
Physical	68	9	12	7	96
Sexual	4	6	5	6	21
Psychological	1	0	1	1	3
Total* (%)	73 (60,8)	15 (12,5)	18 (15)	14 (11,7)	120 (100)

When the origin of injury was analyzed, it was found that most of the patients (n=91, 94.8%) who were subjected to physical violence were exposed to blunt trauma. Two (2.1%) patients were injured by sharp objects. Of the 3 cases (3.1%) classified in the “other” group, 2 were injured as a result of falls, and 1 was injured as a result of a rope around the neck.

Sixty-two (64.6%) cases who were subjected to physical violence were injured in the head/face/neck region, and fifteen (15.6%) cases were injured in the upper extremities. It was observed that 45 (72.6%) of the head/face/neck injuries were caused by punching. Nasal bone fractures occurred in one-third of these cases (n=15, 33.3%) (Table 3).

Table 3.

Distribution of wound type according to the injury region in physical violence

	Type of wound from physical violence					Total*(%)
	Ecchymosis/Abrasion	Laceration/Sharp İnjury	Fracture	Other	Multiple
Injured body region
Head/Face/Neck	26	8	15	2	11	62 (64.6)
Chest/Abdomen/Back	3	2	0	1	0	6 (6.2)
Upper Extremity	7	1	5	2	0	15 (15.6)
Lower Extremity	1	1	0	0	0	2 (2.1)
Multiple Region	8	0	1	0	2	11 (11.5)
Total	45	12	21	5	13	96 (100)

^*Column percentages are shared as stated in the text.

Physical violence occurred in 2 (2.1%) cases involving the use of sharp objects, and in 8 (8.4%) cases, various tools such as a tennis racket, rope, dustbin, pencil, and door were used, which were classified in the “other” group.

Three (14.3%) cases who were subjected to sexual violence were verbally or visually harassed without any physical contact. Twelve (57.1%) cases had been subjected to sexual abuse at the level of touching, such as kissing, touching, and taking off their clothes. In 6 (28.6%) cases, 3 were exposed to vaginal and 3 to anal penetration. It was found that the majority of the cases who were subjected to physical violence (n=94, 97.9%) did not have mental retardation, whereas the majority of the cases who were subjected to sexual violence (n=11, 52.4%) had mental retardation. A statistically significant relationship was found between the type of violence and the presence of mental retardation (p<0.001).

It was observed that the majority of the cases (n=87, 72.5%) were not assessed psychologically after the violence. In 32 (26.7%) cases, consultation was requested from the Child and Adolescent Psychiatry Clinic, and in 6 (5%) cases, from the Psychiatry Clinic. After excluding cases that did not attend their appointments, 33 (27.5%) patients were assessed psychologically. The most common diagnosis was post-traumatic stress disorder (PTSD) (n=15, 45.5%), followed by acute stress disorder (ASD) (n=8, 24.2%) (Table 4). In 1 case of sexual abuse where no psychological effects were reported, it was concluded that the phenomenon of the “sleeper effect” should be considered.

Table 4.

Distribution of psychiatric diagnoses according to type of violence.

	Psychiatric Diagnosis						Total
	ASD*	PTSD**	Adjustment Disorder	Other	No Diagnosis	No Evaluation
Type of Violence
Physical	7	3	4	0	1	81	96
Sexual	1	12	0	3	1	4	21
Psychological	0	0	1	0	0	2	3
Total	8	15	5	3	2	87	120

^*ASD: Acute Stress Disorder,

^**PTSD: Post-traumatic Stress Disorder

DISCUSSION

Violence at school, which includes physical, sexual, and psychological violence as well as bullying, is an issue that has received increasing attention in recent years throughout the world, especially in Europe and America.[15] Violence may have serious and long-term negative consequences for students’ physical and mental health, as well as for their education and thus their future.[7,14] At this point, it is clear that in order to solve the problem, it must first be revealed in the light of the data.

Although the incidence of violence at school varies by gender, studies in the literature show that boys are more likely than girls to engage in aggressive behavior and more likely than girls to be involved in bullying as bullies or victims.[15-17] In the study by Kim YS. et al., in which they investigated bullying at school in 1,756 secondary school students, it was reported that 40% of the students were exposed to bullying, and male (43.7%) students exposed to bullying were significantly more than female (35.8%) students.[18] According to the 2018 data of the Programme for International Student Assessment (PISA), it was reported that the rate of being exposed to bullying at least several times a month on average across Organisation for Economic Co-Operation and Development (OECD) countries was higher in schools where more than 60% of the students were male than in schools where more than 60% of the students were female.[19] In the study by Bulut S., in which he analyzed the incidents of violence reflected in the visual and written media at the primary and secondary education stages, it was reported that 78% of the victims of violence were male and 22% were female.[20] In our study, 75% (n=90) of the patients were male and 25% (n=30) were female. The results of our study are in line with the literature.

In the analysis carried out according to the stage of education in our study, it was found that the most common stage of exposure to violence was secondary education (n=73, 60.8%), followed by primary education (n=36, 30%). In the study by Bulut S., it was reported that violence occurred at similar rates in primary education (51%) and secondary education (49%).[20] In the Youth Risk Behavior Survey (YRBS) conducted by the Centers for Disease Control and Prevention (CDC) in 2019, which included 13,677 students, approximately 1 out of every 5 high school students was reported to have been exposed to bullying at school.[21] Additionally, there are studies in the literature reporting that violence and bullying occur mostly at the secondary school stage.[22,23] It can be said that our study is similar to literature in this respect.

Studies indicate that the most traditional forms of bullying are direct physical behavior and verbal aggression.[24] Studies show that the most common reasons for violence incidents at school, as reported in the press, include arguing, swearing, and physical hitting.[20] In the study by Kim YS. et al., analyzing 1,756 secondary school students, physical violence was reported at 16% and verbal aggression at 22%.[18] In our study, the most prevalent type of violence was physical (n=96, 80%), followed by sexual (n=21, 17.5%), and psychological (n=3, 2.5%).

Literature shows that boys are more often exposed to direct bullying acts, including physical violence compared to girls, who are mostly subjected to emotional bullying indirectly [15,18,20,25]. According to the 2019 data from the National Center for Education Statistics, boys are more frequently exposed to physical violence than girls.[26] Bilgin NG. et al. examined the sociodemographic characteristics of children exposed to physical and verbal violence at school and reported that 58% of those exposed to physical violence were male.[27] Fineran S. stated in his study that boys were predominantly bullies, while girls were more often victims of sexual violence.[28] In our study, it was found that male cases (n=82, 91.1%) were exposed to physical violence at a much higher rate than female cases (n=14, 46.7%), and female cases (n=13, 43.3%) were exposed to sexual violence at a higher rate than male cases (n=8, 8.9%). All 3 (2.5%) cases exposed to psychological violence were women. A statistically significant relationship was found between the type of violence experienced and gender (p<0.001).

It was also found that cases in secondary education (n=68, 93.2%) were exposed to physical violence at a much higher rate than those in primary education (n=21, 58.3%), and sexual violence was observed at a higher rate in primary education (n=15, 41.7%). In the study by Bilgin NG. et al., the rate of physical violence at the secondary education stage was reported to be 38.9%.[27] In a study conducted in Australia, it was reported that physical violence occurred at a higher rate at the secondary school level.[29] In the study by Kapıcı EG., it was reported that 40% of primary school students were exposed to physical, verbal, emotional, and sexual bullying.[30] Pişkin M. reported in his study on school bullying that the rate of exposure to sexual violence was 9% at the high school level.[31]

Studies show that most bullying behavior and direct bullying acts at school occur during breaks, outside school, on the way to and from school, in the garden, and in the classroom.[32,33] When analyzing the distribution of places where violence occurred in our study, the most common place of violence (n=33, 27.5%) was in areas classified as ’other’, which included areas outside the school boundaries such as service areas, bus stops near the school, and parks near the school. Thirty-one (25.8%) cases were exposed to violence in the school garden, and 28 (23.3%) cases were exposed to violence in the classroom. In 18 cases (15%), the place of violence was not specified.

Out of a total of 62 cases who were subjected to violence in places open to teacher supervision, such as classrooms, corridors, and school gardens, 55 (88.7%) were subjected to physical violence. Out of a total of 21 cases of sexual violence, 8 (38.1%) occurred in places indicated as “other.” There was no statistically significant relationship between the type of violence and the location of the incident (p=0.121).

In our study, the gender of 54 (45%) alleged perpetrators of violence was not specified. Of the 66 (55%) cases where gender was specified, 9 (13.6%) were female and 57 (86.4%) were male. Studies in the literature indicate that boys exhibit more aggressive behaviors than girls.[15-17] In a study by Bulut S., it was reported that the majority of the aggressors who committed acts of violence were men (90%).[20] Kim YS. et al. reported that 54.4% of the perpetrators of violence were male and 45.6% were female students.[18]

Studies in the literature show that the rate of students subjected to violence by their peers at school varies between less than 10% and more than 65%.[34] According to data from the Ministry of Education in Botswana in 2007, 92% of students were exposed to violence by their teachers.[35] In a thesis study conducted by İrfaner S. on 673 students, it was reported that students were mostly (71.3%) exposed to bullying by their own peers and then by students in the upper classes (22.5%).[36]

In line with the literature, our study found that most perpetrators of violence (n=73, 60.8%) were peers of the traumatized cases and a smaller proportion (n=15, 12.5%) were from upper classes. It was found that 18 (15%) individuals were subjected to violence by their educators and all 4 cases in special education were exposed to violence by their educators. Although the number of cases receiving special education was not very high in our study, these findings underscore the necessity for proper and effective supervision of special education centers and trainers in preventing violence.

It was found that physical violence was mostly perpetrated by peers (n=68, 70.8%) and sexual violence was mostly perpetrated by older individuals (n=17, 81%). A statistically significant relationship was found between the type of violence and the perpetrator (p<0.001).

An analysis of the tools used in cases of violence at school shows that knives are the most common (90%), followed by sticks, stones, iron bars, etc.[20] In their study analyzing school-related homicides in the United States, Holland KM et al. reported that more than 70% of school-related homicides among adolescents were caused by gun-related injuries.[37] In our study, it was found that most of the cases were exposed to blunt trauma due to violence (n=91, 94.8%), and only 2 (2.1%) cases were injured due to sharp objects. It was observed that 8 out of 91 cases (8.8%) who were exposed to blunt trauma due to violence were injured using various tools classified as other (tennis racket, dustbin, door, etc.). It cannot be said that our study is compatible with the literature in this respect.

In our study, it was found that the most common site of injury in cases subjected to physical violence was the head, face, and neck region (n=62, 64.6%); most of these cases (n=45, 72.6%) were injured by punching, and one-third (n=15, 33.3%) had a nasal bone fracture.

In our study, it was observed that the most common type of violence (n=12, 57.1%) was at the degree of touching (kissing, taking off clothes, etc.), and 6 cases (28.6%) were subjected to sexual assault, 3 of which were vaginal and 3 of which were anal penetration. The U.S. Government Accountability Office (GAO) reported 7,000 cases of sexual assault in public schools in the 2017-2018 academic year. Additionally, research shows that 26% of female students and 6.8% of male students are exposed to sexual assault at the higher education level in the USA.[38] Özcebe et al. reported that 15.8% of the young people in their study were exposed to sexual violence, and Bulut S. reported that 21% of the cases were exposed to sexual assault at the degree of harassment/swearing.[20,39]

In our study, it was found that the majority of cases who were subjected to physical violence (n=94, 97.9%) did not have mental retardation, whereas the majority of cases who were subjected to sexual violence (n=11, 52.4%) did have mental retardation. Our findings suggest that mental retardation may be a risk factor for exposure to sexual violence. A statistically significant relationship was found between the type of violence and the presence of mental retardation (p<0.001).

In our study, the majority of cases (n=87, 72.5%) could not be assessed psychiatrically after the violence. In 32 (26.7%) cases, a consultation with child and adolescent psychiatry was requested, and in 6 (5%) cases, a psychiatric consultation was requested. After excluding patients who did not attend their appointments, 33 (27.5%) patients were assessed psychiatrically. A study conducted in Mersin reported that 6.5% of children exposed to physical violence and 6.6% exposed to verbal violence were taken by their families to child psychiatry for a mental health assessment. A diagnosed mental disorder was reported in 3.5% and 3.9% of these cases, respectively.[27] In our study, it was observed that 31 (94%) of 33 patients assessed for psychiatric aspects following violence were diagnosed with a mental disorder.

In our study, post-traumatic stress disorder (PTSD) was the most common diagnosis (n=15, 45.5%), and acute stress disorder (ASD) was the second most common (n=8, 24.2%). It was reported that the “sleeper effect” phenomenon[40] should be considered for 1 case of sexual abuse that was reported to have no psychiatric effects. Houbre et al. reported that symptoms compatible with PTSD were present in approximately 66% of bullied students.[41] In a study examining the relationship between bullying victimization and post-traumatic stress disorders among Chinese adolescents, it was reported that exposure to bullying had a direct and positive relationship with PTSD in adolescents.[42] Studies in the literature show that victims of violence and bullying often experience somatic symptoms such as headache, abdominal pain, and chest pain, as well as psychological symptoms such as loss of self-esteem, post-traumatic stress, anxiety, feeling isolated from society, and depression.[27,43-45]

CONCLUSION

Given the position of the child as the future building block of society, in civilized countries the family, society, and the state have certain responsibilities towards the child. Perhaps the most important of these responsibilities is to teach the child human rights approaches and to provide an environment in which the child can enhance and develop their own expressive abilities, self-esteem, and self-worth. It is clear that one of the greatest threats to providing such an environment is violence and bullying in schools. At this point, in the fight against violence and bullying acts, it is necessary to analyze the causes of bullying in schools before such situations occur by revealing the data in different societies and cultures. With this perspective, we believe that strategies based on the prevention of recurring incidents through planning and implementing appropriate interventions related to the problem area and disseminating the results will produce more effective outcomes in preventing violence and bullying in schools.