Heterogeneity of existing research relating to sexual violence, sexual assault and rape precludes meta-analysis of injury data

Topical Tranexamic Acid to Control Vaginal Laceration Bleeding after Sexual Assault

BACKGROUND

Sexual assault survivors may sustain vaginal trauma that requires intervention in the emergency department, or operating room.

CASE REPORT

We describe the case of a 16-year-old female who was referred to the emergency department for evaluation of continued bleeding from a vaginal laceration following sexual assault 38 h prior. The bleeding limited the medical forensic medical examination, but she was hemodynamically stable. After the application of tranexamic acid (TXA)-soaked gauze, the patient's bleeding was controlled and the wound was able to be evaluated and the examination completed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To our knowledge, this is the first case in the literature that describes the use of topical TXA in a patient to achieve hemostasis in a vaginal laceration sustained from sexual violence.

Differences in patterns of sexual assault among female victims preceding and during the COVID-19 pandemic: an analysis of encounters in an emergency department

The aim of this study was to evaluate how the COVID-19 pandemic may have impacted the number and patterns of sexual assault victims within a German metropolitan city. A retrospective single center analysis of the gynecology examination reports of all women presenting to the emergency department of a university hospital after a sexual offense between 03/2013 and 02/2021 (n = 1167). Comparison of the first year of the pandemic 03/2000-03/2021) to previous years (03/2017-02/2020) and comparison of periods of government-imposed social distancing (03/12/2020-05/23/2020 and 10/23/2020-02/28/2021) with corresponding periods of pre-pandemic years. The overall number of sexual assault cases did not change during the first year of the COVID-19 pandemic. However, during the stay-at-home orders, the number of women presenting to the emergency department decreased by 38% (n=45 vs. 72). Fewer victims filed a police report during the pandemic (49.5% vs. 73.9%, p<0.001) and the lockdown period (50% vs. 76.5%, p<0.001). Less genital injuries after sexual assault were detected during the pandemic (14.3% vs. 25.2%, p<0.02), but there was an increase of illegal substance abuse (19.5% vs. 9.3%, p<0.003). During the stay-at-home orders fewer victims reported alcohol consumption (42.4% vs. 62.5 %, p<0.023). Despite the decrease in sexual offense related police reports, the number of sexual assault cases remained consistent, and the usage of illegal drugs increased during the COVID-19 pandemic. These findings represent the importance of providing support to sexual assault victims, as well as the implementation of preventative measures, especially in times of crisis.

The prevalence of genital injuries in post-pubertal females presenting for forensic examination after reported sexual violence: a systematic review

BACKGROUND

Sexual violence is a prevalent issue in contemporary society requiring a robust forensic healthcare response. It is critically important that forensic examiners put clinical examination findings into an appropriate evidence-based context. The presence of genital injuries has been shown to increase the likelihood of successful criminal prosecution and report the crime. However, the reported rates of genital injury vary widely in published studies.

AIMS AND OBJECTIVES

We aim to critically evaluate and synthesize existing literature on the prevalence of genital injuries in post-pubertal females, examined following sexual violence, with a view to describing the prevalence and characteristics of genital injuries as well as the range of forensic practices employed.

METHODS

Three online databases (PubMed, Embase, and Scopus) were systematically searched with key terms.

RESULTS

Of the 1224 studies screened, 141 full-text publications met the inclusion criteria. Reported injury prevalence rates varied widely. Details pertaining to forensic examinations included in each study, such as grade of the examiner, type of examination, location of examination, and time interval from assault to examination also varied widely. Injury prevalence was highest in studies where enhanced visualization techniques were utilized.

CONCLUSIONS

This systematic review demonstrates that there is no universally agreed standard for documenting genital injuries in cases of sexual violence and highlights the need for standardized approaches and guidelines for assessing, documenting, and reporting these injuries. The review provides robust evidence to support a call for establishing consistent context, terminology, classification systems, and data collection methods to improve the comparability and reliability of future research findings.

Anogenital injury following sexual assault and consensual sexual intercourse: a systematic review and meta-analysis

Background

Sexual violence is a grave human rights violation and a serious global public health challenge. Rates of reporting of sexual violence and subsequent passage of cases through the criminal justice system are poor all over the world. The presence or absence of anogenital injury following sexual assault may influence survivors in their willingness to report a crime, and law enforcement officers and jurors in their decision making regarding the laying of charges and/or conviction of offenders. The aim of this systematic review was to compare rates of identification of anogenital injury (AGI) in women following sexual assault and consensual sexual intercourse using the same examination techniques.

Methods

In this systematic review and meta-analysis, Medline, Embase and Google Scholar were searched for relevant studies (in any language, with no age or sex criteria) published between February 25, 1993, and February 25, 2023, that directly compared AGI between individuals after either sexual assault or consensual sexual intercourse. Abstracts, conference proceedings, and case reports were excluded. The primary outcome of interest was any form of detected AGI. The Mantel-Haenszel method was used for meta-analysis using random effects modelling to determine the risk ratio (RR) of AGI between sexual assault and consensual sexual intercourse. Quality assessment was undertaken using the Newcastle-Ottawa scale tool. The I2 statistic was used to determine heterogeneity among studies. An I2 >75% was considered high heterogeneity. Funnel plots were used to assess the risk of publication bias, by determining any visually apparent asymmetry. This analysis is registered with PROSPERO, CRD42023402468.

Findings

We included 10 studies, accounting for 3165 study participants. All participants were female. AGI was detected in 901 (48%) of 1874 participants following sexual assault and 394 (31%) of 1291 participants following consensual sexual intercourse. Meta-analysis of all included studies demonstrated that the presence of AGI was significantly more likely for participants following sexual assault than consensual sexual intercourse (RR 1.59 (95% CI 1.21, 2.09); p < 0.001). There was a significant heterogeneity among studies and funnel plots suggest that this RR may be an over-estimation. Subgroup analysis including only high-quality studies showed no significant difference between groups.

Interpretation

Although AGI was significantly more likely to be detected after sexual assault than consensual sexual intercourse, more than half of survivors of sexual assault have no detectable injuries. The presence of AGI, therefore, does not prove there has been sexual violence and absence of injury does not refute that sexual assault has occurred.

Funding

The University of Birmingham.

Frequency of Injuries to Women after Sexual Offense - Relevance of a Gynecology Examination

Introduction Up to a third of women worldwide report having experienced an act of sexual violence during their lifetime. The emergency gynecology department is often the first port of call for affected individuals. The aim of the current study was to evaluate the importance of gynecology examinations for women after a sexual offense and to evaluate the pattern of injuries sustained.

Methods This study is a retrospective single center analysis of the gynecology and forensic examination reports of all women examined for a suspected sexual offense in the central emergency department of a university hospital between 2013 and 2017 (n = 692). We evaluated genital and extragenital injury patterns, age, offender profile, time of offense, and substance use, as well as the administration of post-coital contraception and post-exposure prophylaxis for HIV.

Results The affected individuals had a mean age of 26 (12 – 91 years). Almost 75% of affected individuals presented within 24 hours of the reported sexual offense. Extragenital injuries were detected in 78.6% of patients and genital injuries in 28.5%. Overall, 20.1% of the women reported complete memory loss and 18.7% partial memory loss of the actual event. Risk factors for memory lapse were the consumption of alcohol and/or the (possibly non-consensual) administration of other substances acting on the central nervous system. A history of alcohol consumption by the victim (hazard ratio [HR] 1.95; 95% confidence interval [CI] 1.21 – 3.12, p = 0.006) and younger victims aged between 25 – 49 years (HR 1.75; 95% CI 1.07 – 2.85, p = 0.025) were associated with the occurrence of extragenital injuries. However, if the perpetrator was someone who was known to the affected individual, fewer extragenital injuries were sustained (HR 0.60; 95% CI 0.36 – 0.99, p = 0.046). Reports of genital injuries, associated with an older age of affected individuals and indications of anal penetration, resulted in more frequent administration of post-exposure prophylaxis (29.1% vs. 19.5%, p < 0.012) and hepatitis B (active) vaccination (40% vs. 28.5%, p < 0.028).

Conclusion Emergency gynecology examinations form a fundamental component of the medical care and the assessment of affected women after a sexual offense, since almost a third of victims sustain injuries to the genital region. In addition to a detailed complete physical examination and expert forensic documentation of physical and genital injuries, victims should also be offered psychological support which is easy for them to access.

Sexual violence in adult women and adolescents: a narrative review

Sexual violence is a widespread phenomenon, as it has been estimated that about 35.6% of women have experienced some forms of sexual abuse, with variable prevalence estimates worldwide. Sexual violence has remarkable negative consequences on women's health and quality of life, with a specific harmful impact on women's psychological well-being and sexuality. In this narrative review, we provide an overview on the phenomenon of sexual violence against adult women and adolescents, discussing its associated multiple negative consequences with a specific focus on clinical and sexological aspects. ''Women centered care'' and a multidisciplinary approach appear of pivotal importance when working with sexual violence survivors. Woman should be engaged in all the clinical activities as equal partners in the decision-making process, and should be supported by multiple and different professional figures (i.e. gynecologists, psychologists, sexologists, forensic medical doctors, lawyers) working within the framework of a cooperative integrated model.

A retrospective observational study of genital findings in adult women presenting to a New Zealand Adult Sexual Abuse Assessment and Treatment Service following an allegation of recent sexual assault

OBJECTIVE

The aim of this study was to report on the prevalence of genital findings documented in women attending a forensic examination following an allegation of recent sexual assault. A secondary aim was to investigate for any associations between genital findings and variables related to population demographics and clinical factors.

STUDY DESIGN

A retrospective review of clinical records was undertaken for 593 women, aged between 17 and 45 years of age, who underwent a forensic examination within 72 h following an alleged sexual assault at the Pohutukawa clinic, adult Sexual Abuse Assessment and Treatment Service (SAATS) in Auckland, New Zealand over a four-year period. Statistical analysis to examine for any associations between any documented genital findings and subject variables was performed.

RESULTS

The key finding was that 66.4% (394/593) of the women had a normal genital examination. Of the 182 women with genital findings the presence of skin disruption and/or bruising was noted in 21.1% (125/593) and non-specific findings in 9.6% (57/593). 17 women were not included as the genital examination was incomplete. For 9.5% (56/593) of women the presence of abnormal genital skin was documented. From the adjusted odds ratios obtained by multivariate analysis there was a statistically significant association between the presence of genital findings and abnormal skin condition (OR 3.13, p = 0.0004).

CONCLUSION

The study demonstrated that the majority of women seen within 72 h of an alleged sexual assault had a normal genital examination. Given the strength of the association between the presence of genital findings and skin condition, we recommend that documentation of the genital skin condition should become a routine part of a forensic examination following sexual assault. This is particularly important if genital findings are present, in order to present the full complexity of clinical examination findings to the court and provide an expert opinion regarding the limitations of attributing causation.

Discriminating between consensual intercourse and sexual assault: Genital-anal injury pattern in females

BACKGROUND

Assessment of genital-anal (GA) injuries following sexual assault promotes health and assists prosecutors to build a case. The pattern of injuries may help differentiate between consensual and non-consensual intercourse, bolster the survivors' credibility, and increase prosecutions in sexual assault cases.

OBJECTIVES

To identify the constellation of G-A injury-related characteristics that most effectively discriminated between consensual sexual intercourse and sexual assault in females when controlling for intercourse-related variables.

METHODS

We employed a comparative study with two groups: a prospective cohort group with consensual participants and a group derived from an existing sexual assault registry. In the prospective cohort, we performed a sexual assault forensic examination at baseline and following consensual sexual intercourse with females ≥21 years. We compared their injury patterns to the injury records of females ≥21 years who were sexual assaulted.

RESULTS

We enrolled a sample of 834 females: 528 consensual (63.3%) participants and 306 non-consensual (36.7%) registry cases. After controlling for race/ethnicity, age, and time between intercourse and examination, logistic regression analyses showed that the presence of an external genital tear increased the odds of non-consensual intercourse more than two times (adjusted odds ratio [AOR] = 2.70, 95% CI = 1.28-5.56). Logistic regression analyses also showed that the odds of non-consensual sexual intercourse were significantly greater with a lower prevalence and frequency of external and internal genital redness, lack of condom use and lubrication, and presence of anal penetration. Latent class analysis identified high and low G-A injury prevalence subgroups among both consensual and non-consensual samples. One subset of results emerged that may be indicative of non-consensual as compared to consensual intercourse: a higher prevalence of external genital and anal tears.

CONCLUSION

External genital tears occurred more frequently in the non-consensual sample and increased the odds of non-consensual intercourse more than two times. Anal tears, swelling, and ecchymosis and anal penetration were markers for non-consensual intercourse and should increase suspicion for lack of consent.

Coding of Sexual Assault by Emergency Physicians: A Nationally Representative Study

Introduction

Sexual assault is a public health problem that affects many Americans and has multiple long-lasting effects on victims. Medical evaluation after sexual assault frequently occurs in the emergency department, and documentation of the visit plays a significant role in decisions regarding prosecution and outcomes of legal cases against perpetrators. The American College of Emergency Physicians recommends coding such visits as sexual assault rather than adding modifiers such as “alleged.”

Methods

This study reviews factors associated with coding of visits as sexual assault compared to suspected sexual assault using the 2016 Nationwide Emergency Department Sample.

Results

Younger age, female gender, a larger number of procedure codes, urban hospital location, and lack of concurrent alcohol use are associated with coding for confirmed sexual assault.

Conclusion

Implications of this coding are discussed.

Forensic medical results and law enforcement actions following sexual assault: A comparison of child, adolescent and adult cases

BACKGROUND

In sexual assault cases, little research has examined differences in forensic medical findings and law enforcement response by victim age across the entire age range.

OBJECTIVE

This study addressed this gap by comparing four victim age groups: adults, adolescents over the age of consent, adolescents under the age of consent, and children under 12.

PARTICIPANTS AND SETTING

Cases were randomly sampled from a statewide database of medical reports on sexual assault examinations conducted in hospital emergency departments, including only cases reported to law enforcement (N = 563).

METHODS

Data were combined from a medical report database, from coding of medical documentation and crime laboratory reports, and from case data provided by law enforcement.

RESULTS

Rates for both younger and older adolescent victims and adult victims were comparable, with no statistically significant differences on most variables: penetration, perpetrator use of force, non-genital and genital injuries, presence of biological evidence, generating assailant DNA profiles, DNA match to suspect, hits in the FBI's DNA database, and law enforcement unfounding (i.e., determining allegations to be false or baseless). Child victims were significantly less likely to have a non-genital injury, and their cases were significantly more likely to be founded by law enforcement. Arrests were significantly more likely when victims were under the age of consent.

CONCLUSIONS

Despite significant differences by victim age, similarity between adolescent and adult cases was substantial. Both younger and older adolescents may be at higher risk of physical violence during sexual assault than previously recognized, and need greater attention in response systems.

A retrospective study of sexual offences in Zambia

Zambia has recently reported high incidences of sexual abuse against women and children. Zambian law categorises sexual offences into rape, defilement, incest and others, with defilement constituting the majority of the reported cases (>89%). Between 2010 and 2012, convictions of defilement cases were achieved in only 13% of cases reported to the police. DNA evidence has shown prominence in resolving crimes, specifically as an identification tool in sexual offences. Currently there is no empirical evidence describing the role of forensic evidence in sexual crimes in Zambia; as such a retrospective study was conducted to evaluate this between 2007 and 2014 (n = 1154). Only 14 (0.1%) of the cases had forensic samples collected in the form of a vaginal swab for semen analysis. In all cases where a suspect was identified (60%), identification was based on the witness/victim testimonies, and in no case, was forensic DNA evidence used to assist in identification or corroborate the testimonies. Overall, 28.1% of cases were taken to court and the conviction rate was 12.4%. These findings support the use of employing DNA evidence in sexual offence cases to aid the identification of suspects, which is hypothesised to increase the number of cases prosecuted in Zambia.

A data model for clinical legal medicine practice and the development of a dedicated software for both practitioners and researchers

OBJECTIVE

To present a data model for clinical legal medicine and the software based on that data model for both practitioners and researchers. The main functionalities of the presented software are computer-assisted production of medical certificates and data capture, storage and retrieval.

METHODS

The data model and the software were jointly developed by the department of forensic medicine of the Jean Verdier Hospital (Bondy, France) and an bioinformatics laboratory (LIMICS, Paris universities 6-13) between November 2015 and May 2016. The data model was built based on four sources: i) a template used in our department for producing standardised medical certificates; ii) a random sample of medical certificates produced by the forensic department; iii) anterior consensus between four healthcare professionals (two forensic practitioners, a psychologist and a forensic psychiatrist) and iv) anatomical dictionaries. The trial version of the open source software was first designed for examination of physical assault survivors.

RESULTS

An UML-like data model dedicated to clinical legal practice was built. The data model describes the terminology for examinations of sexual assault survivors, physical assault survivors, individuals kept in police custody and undocumented migrants for age estimation. A trial version of a software relying on the data model was developed and tested by three physicians.

DISCUSSION

The software allows files archiving, standardised data collection, extraction and assistance for certificate generation. It can be used for research purpose, by data exchange and analysis. Despite some current limitations of use, it is a tool which can be shared and used by other departments of forensic medicine and other specialties, improving data management and exploitation. Full integration with external sources, analytics software and use of a semantic interoperability framework are planned for the next months.

Attrition and Rape Case Characteristics: A Profile and Comparison of Female Sex Workers and Non-Sex Workers

The attrition of rape cases from the criminal justice system (CJS) remains high and there is a paucity of research in relation to marginalized groups. Sex workers (SWs) are vulnerable to sexual violence due to the nature of their work. They are also unlikely to report such violence to police for a range of reasons. Two stages of research sought to describe the victim, perpetrator, and offense characteristics of SW rape and to examine the attrition of these cases. All rapes and attempted rapes (N = 1,146) reported to police in a large city in the South West of England over a 21-year period were examined; 67 cases involved SWs. Data were extracted from police files in line with the variables of interest. Secondary analysis of the total number of SW rapes (n = 67) resulted in a profile of these cases. A matched pairs study revealed significant differences in victim, perpetrator, and assault characteristics between SW (n = 62) and non-sex-worker (NSW) samples (n = 62). Although no significant difference was found in terms of attrition from the CJS, SW cases were observed to secure more convictions for rape than NSW cases. The implications of the findings for practice and future research are discussed.

The (in)significance of genital injury in rape and sexual assault

The forensic significance of genital injury following rape and sexual assault has been the subject of considerable academic and research interest, in terms of the contribution it may provide to the body of evidence in criminal proceedings. This essay takes a critical look at such research, in the context of modern understandings of what actually constitutes rape and sexual assault. Written from the author's perspective as a forensic physician practising in Scotland, it illustrates the fascinating interface between medical evidence and the legal system.

Strategic categorization of available research relating to sexual assault and rape facilitates more accurate interpretation of injury data

The available research evidence pertaining to anogenital injury in victims of sexual violence presents a very wide range of injury prevalence data. As such, it is extraordinarily challenging for health care practitioners involved in clinical forensic examination of victims of sexual violence to place their examination findings in to context. It is generally accepted that the broad range of existing injury prevalence data is reflective of heterogeneous research study methodologies and clinical practice techniques. Thus, health care practitioners should be encouraged to present their evidence in the context of the prevalence data that are most representative of their clinical practice. Presented herein is a simple categorization of existing prevalence data in accordance with national clinical practice guidelines. The range of anogenital injury prevalence is narrower when presented in this manner than when taken as a whole. This will facilitate health care practitioners in presenting their examination findings in the context of research literature that is most representative of their clinical practice.

Men victim of sexual assault of concern into the first Emergency Medical Unit for Victims of Assaults in France

Although it accounts for only a small part of activity in the field of victimology, the provision of support for male victims of sexual assault is regularly discussed in the literature. Authors, English-speaking for the most part, all agree that this phenomenon has been largely underestimated, owing to the stigmatization victims suffer after the facts have been disclosed. The same authors agree that this type of assault is far from being inconsequential, from both a physical and a psychological perspective. The following retrospective and descriptive study, conducted at the Bordeaux CHU (Bordeaux University Hospital), aims to draw a comparison between the distinctive characteristics of male sexual assault victims treated at the CAUVA (Centre d'Accueil en Urgence des Victimes d'Agression - Emergency Medical Unit for Victims of Assaults) on the one hand, and, on the other hand, those identified in the existing scientific literature. The victims are predominantly young men, unconnected with their attackers, and more often than not the attacks take place on the public highway. Forensic treatment is provided within the seven days following the assault, which raises the question of the assessment of infection risks, including HIV transmission. Most of the time, the victims will not undergo a full psychological appraisal, though authors are unanimous that such assaults do indeed have heavy repercussions. Improving our services for such victims will require suitable training for staff, covering initial reception, general assessment and the drafting of the forensic medical report, as well as encouragement to lodge a complaint. This process should give priority to multidisciplinary centers, especially dedicated to shelter-providing, information, counseling and victim support. This will also entail information and awareness campaigns for the general population, and the homosexual community in particular. Finally, we should not be afraid to envisage an investigation into this subject at an international level.

How teaching on the care of the victim of sexual violence alters undergraduate medical students' awareness of the key issues involved in patient care and their attitudes to such patients

Sexual violence is known to be highly prevalent, albeit the majority of incidents are not reported to the authorities. It is therefore likely that medical students will encounter very many patients who have experienced sexual violence during their postgraduate careers, although this history may never be disclosed to them. Numerous highly regarded sources have advocated for the inclusion of instruction on the care of the victim of sexual violence in undergraduate medical curricula. Moreover, there has been a call for research to measure the effectiveness of educational strategies addressing the issue of sexual violence at undergraduate level. We present an evaluation of the effectiveness of a reproducible teaching session on care of the victim of sexual violence appropriate for undergraduate medical students, looking specifically at alterations in students' awareness of the key issues involved in patient care and their attitudes to such patients. This research demonstrates that such an educational intervention significantly enhances undergraduate medical students' awareness of the issues involved in patient care and their insight in to myths surrounding sexual violence.