Analysis of Cases of Sexual Assault Presenting at A Medical Center in Taipei

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.

Clinical and Forensic Aspects of the Management of Child Abuse: The Experience of the Paediatric Emergency Department in Novara, North-West Italy

BACKGROUND

Child abuse is an endemic phenomenon that refers to any form of violence aimed at children and adolescents. The Emergency Room is often the entry point to healthcare for the abused child.

METHODS

This is a cross-sectional study including minors, aged 0-18 years, of all genders, who experienced any form of violence examined at the Paediatric Emergency Department of the 'Maggiore della Carità' Hospital in Novara (North-West Italy) between 1 January 2017 to 31 December 2021. Data were extrapolated by looking at the diagnosis at discharge. A comparison of the different variables collected was made between the pre-COVID-19 period and the COVID era.

RESULTS

120 minors presented to the paediatric emergency room seeking help for violence. The average age was 10 years, 55% of the victims were male and 75% of them were Italian. In the pre-COVID period, the number of presentations for abuse was 62, while in the COVID period it was 58 with an increase of peer violence (from 38.71% to 62.07%) and with a statistically significant impact of the pandemic on the phenomenon (p-value < 0.00001). In general, peer violence accounts for 50% of the cases reviewed and resulted in fewer reports to the judicial authority and requests for forensic advice.

CONCLUSION

The SARS-CoV-2-related pandemic has had an impact on total emergency room admissions and the types of abuse perpetrated.

Similarity and Differences in Sexual Violence Against Adolescents and Adult Women: The Need to Focus on Adolescent Victims

STUDY OBJECTIVE

To explore whether there are differences in characteristics, clinical findings and management in cases of sexual violence in adolescent and adult women.

DESIGN

Retrospective study.

SETTING

SVSeD-Service for Sexual and Domestic Violence, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.

PARTICIPANTS

Female victims of sexual violence aged 10 years and older. Two study groups were analysed: an adolescent group and an adult group.

INTERVENTIONS

None; this was an observational study.

MAIN OUTCOME MEASURES

Characteristics of the perpetrator, time spent between the episode of sexual violence and the access to SVSeD, presence of genital and/or extragenital injuries; tests for sexually transmitted diseases, spermatozoa research; and toxicological screening; RESULTS: Adolescent victims of sexual violence requested help later than the adult victims. The majority of the perpetrators were well known to the victims in both groups. In both groups, we observed genital injuries in 1 of 3 patients. We found a strong association between the presence of genital injuries and a positive screening test for sexually transmitted diseases, in particular with regard to the adolescent victims.

CONCLUSION

Adolescents' delayed disclosure of sexual violence may affect the ability to properly manage these crimes. Prevention programs and public awareness campaigns should be implemented to highlight the importance of a prompt disclosure after sexual assault has occurred. Gynecologists should be made increasingly aware of this delicate issue, to better assist victims of sexual violence, especially adolescent victims.

Age-Related Child Sexual Abuse Experiences

The study aimed to describe differences in the types of sexual abuse injuries between two age groups of children presenting to an emergency department. This descriptive correlational study explored the relationships between sexual abuse type and child's age using data from the hospital health records of 95 children ages 6-14 years. Descriptive analysis indicated that sexually abused child victims' ages were significantly associated with different types of penetrations and mucosal tears or injuries (p < 0.05). These findings highlighted the need for increased awareness about the different types of physical trauma associated with the ages of the child victims.

Characteristics and trends of sexual assaults in Israel - A large cohort study of 3941 victims

INTRODUCTION

To improve care for victims of sexual assault, specialized assault centers have been developed globally, providing medical, psychological and legal care in one place. Our assault center serves a large population in the center of Israel. In 2010, we initiated a program aimed to prevent assaults among minors and to encourage early referral of victims to the center. The goal of the current study was to assess the impact of this program by comparing the characteristics of sexual assaults before and after the program's initiation.

MATERIAL AND METHODS

We conducted a historic cohort study of all victims of sexual assaults who were treated in our center between October 2000 and November 2017. A comparison was performed between victims treated before and after January 2010 (early vs. late study period), when the prevention program was initiated. The program mainly included lectures in middle and high schools, and workshops for police investigators.

RESULTS

Overall, 3941 victims of sexual assault were treated in our center during the study period. Most victims were females (90.5%). Mean age was 23.0 ± 11.0 years. Most victims were single (93.1%), and approximately half knew their perpetrator before the assault. Compared with the early study period, in the late study period we observed a decrease in the rate of minor victims (31.9% vs. 24.7%, respectively, P < .001) and an increase in the rate of victims who arrived to the center within 3 days of the assault (P = .001). However, we observed higher rates of multiple-perpetrator assaults (16.7% vs. 21.9%, respectively, P < .001), alcohol use (29.2% vs. 40.1%, respectively, P < .001), and drug use (7.2% vs. 9.0%, respectively, P = .04). Moreover, in the late study period, fewer victims were willing to press charges (79.5% vs. 64.4%, respectively, P < .001).

CONCLUSION

Our prevention program might have contributed to reducing the rate of sexual assaults among minors and shortened the time interval between the assault and victim's arrival to the center. Nonetheless, more efforts should be taken to reduce the involvement of alcohol and drugs in sexual assaults and to encourage victims to press charges.

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.

Similar mechanisms of traumatic rectal injuries in patients who had anal sex with animals to those who were butt-fisted by human sexual partner

Sexual pleasure comes in various forms of physical play, for many it involves stimulation of the vagina, while the anus for others; some enjoy both. A recent report by Cappelletti et al.¹ shows a meta-analysis of cases describing anal trauma due to sexual fisting in human partners. This clinical article reports four cases of males diagnosed with zoophilia, and who received anal sex from animals, resulting in injuries. Surgical and psychiatric evaluations are summarized. Unusual etiology of sexual activity with animals caused peri-anal trauma in men who engaged in anal sex with dogs and farm animals. Injuries to patients who receive anal sex from animals are mechanistically similar to fisting-induced rectal damage. Among zoophiles, the mode of harm occurs through blood-engorged, interlocked penis that causes tissue lacerations upon retraction from an anus. In people experimenting with fisting, repetitive stretching within anal canal and of external sphincter causes the internal injuries. The mode of physical stimulation explains the extent of injuries in fisters vs. zoophiles: in fisting, the pressure applied by hand is controllable proximally around and within anal sphincter, while penetration by the animal penis is unpredictable and occurs within the proximal anal canal. Forensically, the findings presented in this article describe a significant mechanism of injury in fisters versus passive zoophiles. These descriptions may aid in clinically differentiating pleasurable and pathological rectal stimulation.

Gender-related sexual abuse experiences reported by children who were examined in an emergency department

The purpose of this study was to examine the experiences of sexual abuse by 95 children of two gender groups to determine differences in their reported sexual exploits by perpetrators. Significant differences between female and male children were reported. Male child-victims experienced more anal penetration by penis (54.5%, 10.7% respectively) and finger (27.3%, 2.7% respectively), however; female child-victims experienced more mouth contact to their genitalia (22.7%, 10.0% respectively) and body kisses (47.9%, 9.1% respectively). A more gender-specific approach could help to facilitate prevention, and produce better outcomes.

Genito-anal injury patterns and associated factors in rape survivors in an urban province of South Africa: a cross-sectional study

Background

The prevalence of genito-anal injuries in rape survivors varies significantly and the factors associated with the absence of injuries are not well understood. This plays a major role in the conviction of cases as the absence of injury is equated with a lack of assault. In such cases, health care providers face major challenges in presenting and defending their findings. The aim of this paper is to describe the absence of genito-anal injuries by site in a group of rape survivors and to identify factors associated with the absence of these injuries.

Methods

In a cross-sectional study rape cases reported to the police in one province in South Africa were randomly sampled using a two stage sampling procedure. Data were obtained on the survivor, the circumstances of the rape and the findings of the medicolegal examination. Descriptive statistics were conducted for the prevalence of genito-anal injuries by site and logistic regression models were built to identify factors associated with the absence of genito-anal injuries for all survivors and those reported to be virgins.

Results

In the sample of 1472 women injuries ranged from 1% to 36%. No significant injuries were reported for 749 (51%) survivors. In the multivariable model there was a significantly lower odds of having no injuries in survivors who were virgins, those raped by multiple perpetrators and those examined by a doctor with additional qualifications. In the model for survivors who were virgins, those with disabilities had a greater odds of having no injuries while those between the ages of 8 and 17 years had a lower odds of having no injuries compared to survivors below four years of age.

Conclusions

This study found that being a virgin, multiple perpetration rape and the examiner’s qualifications were significantly associated with the absence of genito-anal injuries. Health providers should thus be aware that in all other respects there was no difference in survivors who had injuries and those who did not. It is important to reiterate the message that the presence of injuries does not necessarily prove that rape occurred nor does the absence disprove the fact.

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.

Complete anal sphincter complex disruption from intercourse: A case report and literature review

INTRODUCTION

Anal sphincter injuries are uncommon injuries outside of obstetric practice - but they may cause disastrous complications.

PRESENTATION OF CASE

We present a case of complete anal sphincter disruption from anal intercourse in a 25 year old woman. Clinical management is presented and technical details of the repair are discussed. She had an uneventful post-operative course and good continence after 154 days of follow up.

DISCUSSION

This is one of a handful of reported cases of anal sphincter disruption secondary to anal intercourse. The established risk factors in this case included receptive anal intercourse coupled with alcohol use. We review the pertinent surgical principles that should be observed when repairing these injuries, including anatomically correct repair and appropriate suture choice. There is little evidence to support simultaneous faecal diversion for primary repair of acute perineal lacerations.

CONCLUSION

Acute post-coital sphincter injuries should be treated operatively on an emergent basis, without diversion because they are low energy injuries with minimal tissue loss and excellent blood supply. Although repair of each injury should be individualized, the majority of these injuries do not require concomitant protective colostomy creation.

Sustainability of an HIV PEP Program for Sexual Assault Survivors: "Lessons Learned" from Health Care Providers

This study explored challenges to continuing an HIV post-exposure prophylaxis (PEP) program of care provided to sexual assault survivors in the province of Ontario, Canada. Data were collected as part of an implementation and evaluation of a universal offering of HIV PEP (known as the HIV PEP Program) at 24 of 34 provincial hospital-based sexual assault treatment centres. Experienced health care providers were surveyed (n = 132) and interviewed in four focus groups (n = 26) about their perceptions of what, if any, factors threatened their ability to maintain the HIV PEP Program. All focus groups were audio-recorded and the recordings transcribed. The transcriptions and open-ended survey responses were analyzed using content analysis. Administrator, nurse, physician, social worker, and pharmacist respondents perceived important barriers to sustainability of the HIV PEP Program. Eight constructs were identified within four broad themes: resources (inadequate funds, overworked and unacknowledged staff), expertise (insufficient external supports, insufficiently trained and knowledgeable staff), commitment (lack of institutional support, physician resistance to offering HIV PEP), and accommodation (lack of flexibility in addressing specific client and community needs, inaccessibility and lack of clarity of tools). We discuss the implications of these findings and the actions that were taken to address the challenges.

Genital trauma in prepubertal girls and adolescents

PURPOSE OF REVIEW

To look critically at recent research articles that pertain to children and adolescents who present with genital injuries.

RECENT FINDINGS

Emerging evidence supports links to long-term psychological sequelae of child sexual abuse. Parents should be educated to instruct their children regarding types of child abuse and prevention. 'Medicalization' of female genital mutilation (FGM) by health providers, including 'cutting or pricking', is condemned by international organizations.

SUMMARY

Genital injuries whether accidental or intentional need to be reported with standardized terminology to allow for comparisons between reported outcomes. Motor vehicle accidents associated with pelvic fractures may result in bladder or urethral trauma. Adverse long-term psychosocial behaviors may be sequelae of child sexual abuse. FGM is willful damage to healthy organs for nontherapeutic reasons, and a form of violence against girls and women. Healthcare providers should counsel women suffering from the consequences of FGM, advise them to seek care, counsel them to resist reinfibulation, and prevent this procedure from being performed on their daughters.