Rape and sexual assault

Adult Sexual Assault Patients' Experience of the Physical Examination Component of the Medical Forensic Examination: A Scoping Review to Identify Gaps in the Research Literature

We undertook a scoping review of published research literature that reported on adult sexual assault patients' experience of the physical examination component of the medical forensic examination (MFE). Eligible papers were those reporting data about the physical examination component of the MFE from the adult patient's perspective, published in the period January 2000 to March 2022 in peer reviewed journals and reports containing original research data published from a tertiary institution. Twelve papers were identified. The review identified a gap in the literature regarding the patient's experience of the physical examination component of the MFE. The existing literature is limited but suggests that some patients find the examination empowering and reassuring, restoring a sense of bodily control; however, for others it is an intrusive, violating experience that they endure. A more patient-centered sexual assault service appears to have a therapeutic value in itself, but more research is warranted as existing research is very limited and often from a proxy. In particular, more research on patients' self-reported experience of the MFE, including specific aspects of the examination and the experience of male and gender nonconforming victim-survivors, is needed. A better understanding, from the point of view of the patient, of the benefits of attending, may encourage victim-survivors to seek a health response and, possibly, report to police. It may also be time to assess the impacts of certain aspects of the forensic examination, rethink standard evidence collection processes, and consider enabling more acceptable options for victim-survivors including self-collection of intimate samples.

Risk for dating violence and sexual assault over time: The role of college and prior experiences with violence

Objective: Despite increased research on emerging adults and interpersonal violence, evidence on the role of college attendance in risk for dating violence and sexual assault is mixed. We examined the role of college attendance on victimization risk in emerging adulthood. Participants: Participants were a diverse longitudinal sample of 630 emerging adults. Methods: We conducted regression analyses to examine the association of college attendance by type (community and public/private four year) with subsequent victimization, controlling for prior victimization and other factors. Results: Participants who attended public and private four-year colleges had significantly less risk for physical dating violence (OR = 0.35, p < 0.001), but not prior sexual or psychological dating violence or other sexual assault. Prior victimization was the most significant predictor of victimization in emerging adulthood. Conclusions: The context of higher education and prior victimization experience should be considered for addressing dating violence and sexual assault in emerging adulthood.

Analysis of aborted fetal material using autosomal STR markers in forensic cases of sexual assault

Sexual violence represents a widespread social problem associated with serious lifelong consequences. In many cases, an outcome of sexual violence is the victim's unwanted pregnancy, usually ended in an abortion. The objective of this paper is to report five rape cases, including rapes of a minor and young woman, two incest cases and a case of human trafficking for sexual exploitation, where every case resulted in the victim's pregnancy. In each case, pregnancy was terminated in the first trimester or at the beginning of the second trimester in the relevant medical center or clinic. Fresh fetal blood or aborted tissue samples were delivered to our laboratory in order to perform paternity testing for the purpose of proving the crime. DNA extraction using Qiagen Dneasy™ Tissue Kit was optimized according to the sample type. Amplification of autosomal STR (Short Tandem Repeat) markers was performed using the PowerPlex®16 System. In two cases, mixtures of maternal and fetal DNA in the aborted fetal material were found. Using the LRmix Studio v.2.1.5 Software for interpreting DNA mixtures based on a probabilistic model, the likelihoods of maternal contribution and presence of fetal allelic variants inherited from the alleged father/suspect were calculated. Based on these results, we confirmed the presence of assumed fetal fractions (determined before software analysis) in the mixtures. In all cases, positive paternity proved the crime (probabilities of paternity >99.9999%). This cases report once again pointed out the importance of DNA analysis in the process of clarifying and solving forensic cases and demonstrated that the LRmix Studio v.2.1.5 Software can deal with complex cases such as sexual assaults.

Conceptual Framework for Rape Survivors Diagnosed with PTSD in the North West Province of South Africa

The lack of a conceptual framework that can be utilized to manage rape survivors diagnosed with Post-Traumatic Stress Disorders presents a challenge in the North-West province. The study aims to provide a conceptual framework for managing rape survivors with PTSD in the province of the North-West using Practice-Oriented Theory and Donabedian's Structure Process Outcome Model Features. The research was conducted using an explanatory, sequential and mixed-methods approach. Additionally, used was the descriptive and explorative programme evaluation design. The results of the study demonstrated the significance of PTSD assessment before management interventions for rape survivors. The study findings outlined and designed a framework to assess and manage PTSD among rape survivors consulting at Thuthuzela Care Centre and those referred to hospitals for further management. The Practice-Oriented theory by Dickoff, James and Wiedenbach, and the Structure Process Outcome model by Donabedian served as points of reference for the development of the conceptual framework. The study is limited to North-West provincial healthcare facilities and Thuthuzela care centres (TCCs), however, it highlights the lack of a conceptual framework pertaining to the psychological management of PTSD rape survivors in the province and South Africa.

Sexually transmitted infections among patients attending a sexual assault centre: a cohort study from Oslo, Norway

OBJECTIVES

We estimate the prevalence of sexually transmitted infection (STI) among patients after sexual assault, assess the possible value of azithromycin prophylaxis, and identify risk factors for assault-related STI and for not presenting at follow-up.

DESIGN

Prospective observational cohort study.

SETTING

Sexual assault centre in Oslo, Norway.

PARTICIPANTS

645 patients, 602 (93.3%) women and 43 (6.7%) men, attending the centre from May 2017 to July 2019.

OUTCOME MEASURES

Microbiological testing at the primary examination and at follow-up consultations after 2, 5 and 12 weeks. Estimated relative risk for assault-related STI and for not presenting at follow-up.

RESULTS

At primary examination, the prevalence of genital chlamydia was 8.4%, Mycoplasma genitalium 6.4% and gonorrhoea 0.6%. In addition, the prevalence of bacterial STI diagnosed at follow-up and possibly from the assault was 3.0% in total: 2.5% for M. genitalium, 1.4% for genital chlamydia and 0.2% for gonorrhoea. This prevalence did not change when azithromycin was no longer recommended from January 2018. There were no new cases of hepatitis B, hepatitis C, HIV or syphilis. We found no specific risk factors for assault-related STI. Patients with previous contact with child welfare service less often presented to follow-up (relative risk (RR) 2.0 (95% CI 1.1 to 3.5)), as did patients with a history of sex work (RR 3.6 (1.2 to 11.0)) or substance abuse (RR 1.7 (1.1 to 2.7)).

CONCLUSIONS

Most bacterial STIs were diagnosed at the primary examination, hence not influenced by prophylaxis. There was no increase in bacterial STI diagnosed at follow-up when azithromycin prophylaxis was not routinely recommended, supporting a strategy of starting treatment only when infection is diagnosed or when the patient is considered at high risk. Sex work, substance abuse and previous contact with child welfare services were associated with not presenting to follow-up.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03132389).

Statement of the DGGG - Recommendations on the Care and Support of Female Minors Suspected of Having Been Subjected to Acute Sexual Violence or Rape

Ziele Die vorgelegten Empfehlungen sollen zur weiteren Verbesserung und Standardisierung der ärztlichen Versorgung von Betroffenen sexualisierter Gewalt, insbes. von einer Vergewaltigung betroffenen weiblichen Minderjährigen in Deutschland beitragen. Sie wendet sich vor allem an Frauenärztinnen und Frauenärzte in der Klinik und in der Niederlassung und ergänzt die umfangreiche Kinderschutzleitlinie der Bundesrepublik Deutschland.

Methoden Unter Einbeziehung der Ergebnisse einer umfassenden selektiven Literaturrecherche wurden von einer interdisziplinär besetzten Gruppe von Expertinnen und Experten in einem 3-stufigen Verfahren im Auftrag des Vorstands der DGGG diese Empfehlungen erarbeitet und im Konsens verabschiedet.

Zusammenfassung Diese DGGG-Stellungnahme ist entsprechend dem Alter der Betroffenen (ca. 14 bis 17 Jahre/pubertär; 0 bis ca. 13 Jahre/präpubertär) zweigeteilt. Dies hat medizinische, strukturelle und forensische Gründe. Es werden zahlreiche Empfehlungen zum Umgang mit den mutmaßlich von akuter sexualisierter Gewalt bzw. einer Vergewaltigung betroffenen Minderjährigen, zur Erstversorgung, zu Versorgungsformen (z. B. Vertrauliche Spurensicherung), zur Anamneseerhebung, zur medizinisch-forensischen Untersuchung, zur medizinischen, psychischen und psychosozialen Versorgung sowie zur Nachbetreuung gegeben.

Recommendations for Care and Support of Female Rape Victims

Introduction According to prevalence studies, at least 5% of all women in the Federal Republic of Germany experience rape during their lifetime. While the effects vary according to the individual, rape has serious consequences for the somatic, psychological, and psychosocial health of the victim. The medical care that is provided to presumed rape victims is of special importance, as this care can have a positive influence on the patient's ability to process their experience and engage in healing following such a traumatic event. Furthermore, doctors are the professionals whose help is most often sought in this context. Primary care following rape consists of three aspects: the forensic medical examination, medical care, and psychological care. In this position paper, each of these aspects are discussed in detail. Recommendations for follow-up care are also provided. Methods In a multi-tiered process, a selective literature review was performed and a consensus among representative experts from different areas of specialization was formulated. Goals The goal of this paper is to contribute to the further improvement and standardization of the medical care provided to women who are presumed rape victims.

HIV/AIDS post-exposure prophylaxis knowledge and uptake among health professionals in Africa: Systematic review and meta-analysis

BACKGROUND

Healthcare workers in developing countries are at particularly increased risk of infections from blood-borne pathogens because of the high prevalence of such pathogens in their communities as well as the lack of basic personal protective equipment, such as gloves, gowns and goggles. For those exposed healthcare workers, the immediate administration of antiretroviral drugs following exposure to potentially infected blood or other bodily fluids is essential in order to minimize the risk of acquiring HIV infection. This review is aimed at estimating the pooled prevalence of knowledge and uptake of post-exposure prophylaxis among healthcare providers in Africa.

METHODS

We accessed PubMed, Science Direct, Google Scholar, SCOPUS, African Journals Online (AJOL), Journal Storage (JSTOR) and EMBASE. The search for unpublished studies included Google and institutional repositories were also used. This meta-analysis follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The quality of studies was assessed using the modified Newcastle-Ottawa Scale (NOS). Meta-analysis was carried out with a random-effects method using STATA v.14 software.

RESULTS

Out of 654 692 studies retrieved, 37 studies from four African regions involving 6482 healthcare providers were included in this meta-analysis. The overall estimated pooled uptake and knowledge of HIV/AIDS post-exposure prophylaxis among healthcare providers in Africa using a random-effects model were 40.09% (95% CI: 30.14-50.04) and 57.67% (95% CI: 44.32-71.01) respectively, whereas the highest uptake and knowledge were 45.48% (95% CI: 24.79-66.17) and 61.37% (95% CI: 46.39-76.36) in the southern and eastern regions, respectively.

CONCLUSIONS

The results of this meta-analysis indicated that the knowledge and uptake of post-exposure prophylaxis, one of the best approaches to tackling HIV/AIDS transmission, are significantly low. Therefore, healthcare organizations should work on strategies to increase knowledge and uptake of post-exposure prophylaxis among healthcare providers.

REGISTRATION

Prospero (ID: CRD42021244003).

Hormonal response to perceived emotional distress in incarcerated men with sexual sadism

Sexual sadists derive pleasure from humiliation, domination and infliction of pain on victims. They display increased penile arousal and activation of brain regions involved in sexual arousal and emotional states when viewing stimuli depicting individuals in physical distress. Neuroactive hormones modulate these regions, but it is unknown if sexual sadists also have endocrine responses to depictions of individuals in distress. The present study examined endocrine responses, elicited by viewing a video depicting an individual in extreme emotional distress, in incarcerated adult male sexual offenders (n = 23) with varying levels of sadistic traits. Sadism, was measured by the Severe Sexual Sadism Scale (SeSaS). Testosterone (T), adrenocorticotropic hormone (ACTH), and oxytocin (OT) were assayed before and after participants watched a video depicting an individual in emotional distress. T responses to the video were significantly and positively associated with SeSaS scores. There were no significant associations between sexual sadism and OT or ACTH. Our findings provide physiological evidence of atypical processing of distress cues in sadism consistent with the role of testosterone in sexual arousal and aggressive behaviors. These findings have implications for the evaluation and treatment of sexual sadists.

Care of women and girls after sexual assault in Geneva: A descriptive study between 2005 and 2014

BACKGROUND AND PURPOSE

We aimed to examine epidemiological data and identify risk factors for sexual assault. This study included women seeking care at the Geneva University Hospitals emergency obstetrics and gynaecological unit.

METHOD

Retrospective, sociodemographic, and clinical data were collected from the medical reports.

RESULTS

We reviewed 836 medical charts and registered 92.8 women and girls per year who consulted the emergency department after sexual assault. The average age was 26 (±12) years, with a median of 23 years. Body lesions were reported in 525 patients (63%) and genital traumatic lesions were reported in 230 (28%) patients. Sexual assault by a stranger was reported in 436 cases (52%). Thirty percent of patients knew their aggressor. Aggressions were predominantly committed on the weekend, accounting for 367 cases (46%), with nearly two-thirds (65%, n = 474) occurring between 10 pm and 6 am. In total, 399 (48%) patients who were sexually assaulted reported having consumed alcohol and 102 (12%) reported having taken drugs prior to the aggression; 80 (10%) patients had consumed both and 286 (34%) had amnesia. Half of the sample sought and received medical care within 24 h from the time the aggression took place.

CONCLUSION

Sexual assault risk factors in our study population in Geneva included use of drugs and alcohol, with amnesia. Future prevention and education interventions should target these areas.

Intimate Partner Violence and Completion of Post-Sexual Assault Medical Forensic Examination Follow-Up Screening

Sexual assault is a major public health concern associated with significant mental health and medical symptoms. Follow-up screening post-sexual assault medical forensic examination (SAMFE) can be one method of determining needs and providing targeted prevention of mental health and medical symptoms among individuals who experienced a recent sexual assault. However, the factors associated with engagement in post-SAMFE follow-up screening have not been identified. The current study examined the association between intimate partner violence victimization and sexual assault-related characteristics and engagement in post-SAMFE follow-up screening. Participants were 193 individuals who received a SAMFE and indicated at the time of SAMFE that they were interested in follow-up by the hospital. It was found that individuals were less likely to engage in follow-up screening if the assault was perpetrated by an intimate partner. These findings suggest that other resources are needed to reach individuals who experience sexual assault perpetrated by an intimate partner due to the unique needs of that population.

Determinants of HIV and Sexually Transmitted Infection Testing and Acquisition Among Female Victims of Intimate Partner Violence

The purpose of this study was to identify determinants of HIV and sexually transmitted infection (STI) testing and acquisition among female victims of intimate partner violence (IPV). Data were abstracted from intake and HIV/STI testing forms from a family justice center, to identify the socioeconomic and abuse characteristics associated with requesting and obtaining an HIV/STI test (n = 343) and acquisition of HIV/STIs (n = 111). Multiple logistic regression using forward selection was used to identify predictors of HIV/STI testing and acquisition. Females experiencing greater risk of lethality were at higher odds of requesting an HIV/STI test; however, risk of lethality did not predict the receipt of an HIV/STI test. A history of sexual assault was associated with higher odds of acquiring HIV/STIs in the past year. Interventions are needed to facilitate HIV/STI testing among female victims of IPV, especially those with higher risk of lethality and a history of sexual assault.

Evaluation of the relationship between the detectability of seminal stains on laundered fabric and stain age

In some cases of sexual assault that are not reported to judicial authorities within a certain time, it is important to detect and identify seminal stains on laundered fabrics. In this study, we aimed to reveal the effect of the time from staining to laundering on the detectability and identification of seminal stains on laundered clothes. A total of 180 pieces of fabric (four different colours and five different types) were stained with seminal fluids, and three different lag times (12 hours, 1 week and 1 month) from staining to laundering were used. Three different laundering protocols were applied to these fabrics after staining. The built-in camera of the Mobile Multispectral UV-VIS-IR Imaging System® was used to take photos (1260 in total) of the stains with seven different wavelength and filter options, and the obtained images were evaluated. The Seratec® PSA Semiquant test was used to analyse the presence of prostate-specific antigen (PSA) in the seminal stains laundered after different lag times. We observed that in examining with the forensic light source (FLS) system, the time from staining to laundering affected the detectability of seminal stains on pieces of cloth. The best fluorescence was obtained in the examination of semen-stained fabric with FLS, particularly when the fabric was not laundered for one month after staining. On the other hand, the time from staining to laundering had a more limited effect on PSA test positivity than on the results of the examination with FLS.

Intersections between Young Women's Racial/Ethnic Identities and Sexual Orientation on Rates of Sexual Violence and Substance Use

Background

Little is known about whether there are differences in rates of sexual violence and its association with substance use based on women's identities, specifically the intersection of their race/ethnicity and sexual orientation.

Method

Women (N = 546; 18 to 29 years of age) recruited from a reproductive healthcare clinic reported their race, ethnicity, sexual orientation, sexual violence history and substance use. Five logistic regressions examined (a) rates of sexual violence, and (b) the strength of the associations between sexual violence and four substance use outcomes (heavy alcohol use, marijuana use, cigarette use, number of cigarettes used) based on sexual orientation. Subsequent logistic regressions examined race/ethnicity as a moderator of the associations between sexual orientation and (a) rates of sexual violence and (b) substance use.

Results

Most women surveyed were heterosexual (64%), and 35% of all women reported unwanted sex. Sexual minority women (SMW) reported higher rates of sexual violence and substance use than heterosexual women. Sexual violence was more strongly associated with heavy alcohol use, but not with marijuana or cigarette use, for SMW than heterosexual women. Rates of sexual violence varied based on the intersection of sexual orientation and race/ethnicity. Although SMW were more likely to report sexual violence than heterosexual women, this association was weaker for Black/Latinx women than for non-Hispanic White women (aOR = 0.39, 95%CI [0.18, 0.82]). Race/ethnicity did not moderate the strength of associations between sexual violence and substance use.

Conclusions

SMW exhibit increased risk for sexual violence and substance use, and victimization was associated with heavy alcohol use. Few racial/ethnic differences emerged as a function of sexual orientation, so SMW are a group with unique needs around sexual violence experiences and substance use, regardless of race/ethnicity. Healthcare providers should be aware of the link between substance use and prior victimization when treating SMW.

Psychopathology, perceived social support, and coping in survivors of adult sexual assault: A cross-sectional hospital-based study

BACKGROUND

Adult sexual assault (ASA) is often associated with negative mental health consequences. The psychological needs of ASA survivors are overlooked while the legal and social needs focused on.

METHODOLOGY

It is a cross-sectional study. The ASA survivors who came for medical evaluation were included in the study after obtaining consent. Fifty ASA survivors were interviewed for the study. Psychopathology, perceived social support, and coping mechanisms were assessed during interview using especially designed semi-structured pro forma.

RESULTS

The mean age of participants was 25.6 ± 7.2 years. Forty-one of 50 survivors suffered from major depressive disorder or posttraumatic stress disorder or both with 33 expressing suicidal ideas. Maximum social support was perceived from family and least from significant others such as health-care workers, police, and judiciary. Problem solving and expressive action are associated with better perceived social support by family as well as friends.

CONCLUSION

Depression and suicidal ideas among majority the survivors of ASA highlight the mental devastation the sexual assault causes to a woman. Although family is primary social support to them, health-care workers and law enforcement officials are not perceived as supportive toward the survivors. Routine mental health assistance and empathetic approach by all parties involved in the management of survivors are needed in these cases.

Evaluating the persistence of laundered semen stains on fabric using a forensic light source system, prostate-specific antigen Semiquant test and DNA recovery-profiling

Semen stains on the clothes of victims of sexual assault can remain as evidence even after garments have been laundered. In this study, we aimed to investigate the effectiveness of commonly preferred methods to detect semen stains in two different fabric types that were laundered with different washing machine programmes and washing powders, and to obtain a DNA profile from the semen stains. For this purpose, a comprehensive study was performed on semen-stained underwear using three different methods for stain detection, confirmation and identification: a forensic light source (FLS) system, the prostate-specific antigen (PSA) test and DNA recovery profiling. With FLS applications, stronger fluorescence was achieved in wash protocols performed at a low temperature (30°C) on semen-stained cotton underwear. DNA recovery between 13.45 and 55.00 ng/µl was obtained by modifications in the DNA extraction step when the effect of temperature and washing powder on DNA recovery was evaluated, and these were enough for short tandem repeat (STR) typing in all samples. This study shows that when semen-stained underwear is washed after a month, some semen stains can be determined by FLS and PSA, and all stains can be identified by STR analyses.

Current care for victims of sexual violence and future sexual assault care centres in Belgium: the perspective of victims

Background

Sexual violence is a global health problem. After ratifying the Convention of Istanbul in 2016, this Belgian study was set up to map the perspective of victims of rape on the current sexual violence care provision in Belgium and to inquire on their need for more specialised and holistic care in future Sexual Assault Care Centres.

Methods

Sixteen rape victims participated in this sub-study. A mixed-method design (questionnaire, in-depth interview or small focus group) was applied depending on the time elapsed between rape and participation. Descriptive Thematic Framework Analysis was performed in duo.

Results

The participants thought it of utmost importance that every victim should receive all medical, psychological and forensic care without necessarily having to involve the police first. They stated that the current Belgian sexual violence care provision could be much more patient-centred, specifically the forensic examination and psychological care. Alongside medical and psychological consequences, victims emphasised the high personal financial and relational burden of sexual violence.

The holistic care offered in Sexual Assault Care Centres was perceived to enhance the recovery process of victims of sexual violence. Their doors should be open to all victims and their relatives. They should not only provide acute care for the victim, but also improve victims’ reintegration into society while reducing their personal costs significantly.

Conclusion

All care for victims of sexual violence, especially forensic and psychological care, needs drastic improvement in Belgium. All participants agreed that having specialised, multidisciplinary and longitudinal care in a Sexual Assault Care Centre that would be open 24/7 for everyone, victims and their significant others, would be an improvement to the currently available care all over Belgium.

Trial registration

This research was registered on April 1st 2016. Registration number B670201628242.

Sexual assaults in individuals with visual impairment: a cross-sectional study of a Norwegian sample

OBJECTIVE

To examine the prevalence of sexual assaults among individuals with visual impairment (VI) compared with the general population and to investigate the association between sexual assault and outcomes of self-efficacy and life satisfaction.

DESIGN

Cross-sectional interview-based study conducted between February and May 2017.

PARTICIPANTS

A probability sample of adults with VI (≥18 years) who were members of the Norwegian Association of the Blind and Partially Sighted. A total of 736 (61%) members participated, of whom 55% were of female gender. We obtained norm data for sexual assaults from a representative survey of the general Norwegian population.

OUTCOME MEASURES

Sexual assaults (Life Event Checklist for DSM-5), self-efficacy (General Self-Efficacy Scale) and life satisfaction (Cantril's Ladder of Life Satisfaction).

RESULTS

The prevalence of sexual assaults (rape, attempted rape and forced into sexual acts) in the VI population was 17.4% (95% CI 14.0 to 21.4) among women and 2.4% (95% CI 1.2 to 4.7) among men. For women, the VI population had higher rates of sexual assaults across age strata than the general population. For men, no significant differences were found. In the population of people with VI, the risk of sexual assault was greater for those having other impairments in addition to the vision loss. Individuals with VI who experienced sexual assaults had lower levels of self-efficacy (adjusted relative risk (ARR): 0.18, 95% CI 0.05 to 0.61) and life satisfaction (ARR: 0.31, 95% CI 0.19 to 0.50) than others.

CONCLUSIONS

The risk of experiencing sexual assault appears to be higher in individuals with VI than in the general population. Preventive measures as well as psychosocial care for those who have been exposed are needed.

The use of HIV post-exposure prophylaxis in forensic medicine following incidents of sexual violence in Hamburg, Germany: a retrospective study

In Hamburg, Germany, the initiation of HIV post-exposure prophylaxis (HIV PEP) in cases of sexual violence is often carried out by forensic medical specialists (FMS) using the city's unique Hamburg Model. FMS-provided three-day HIV PEP starter packs include a combination of raltegravir and emtricitabine/tenofovir. This study aimed to investigate the practice of offering HIV PEP, reasons for discontinuing treatment, patient compliance, and whether or not potential perpetrators were tested for HIV. We conducted a retrospective study of forensic clinical examinations carried out by the Hamburg Department of Legal Medicine following incidents of sexual violence from 2009 to 2016. One thousand two hundred eighteen incidents of sexual violence were reviewed. In 18% of these cases, HIV PEP was initially prescribed by the FMS. HIV PEP indication depended on the examination occurring within 24 h after the incident, no/unknown condom use, the occurrence of ejaculation, the presence of any injury, and the perpetrator being from population at high risk for HIV. Half of the HIV PEP recipients returned for a reevaluation of the HIV PEP indication by an infectious disease specialist, and just 16% completed the full month of treatment. Only 131 potential perpetrators were tested for HIV, with one found to be HIV positive. No HIV seroconversion was registered among the study sample. Provision of HIV PEP by an FMS after sexual assault ensures appropriate and prompt care for victims. However, patient compliance and completion rates are low. HIV testing of perpetrators must be carried out much more rigorously.

Child and Adolescent Sexual Abuse in Women Seeking Help for Sexual and Reproductive Mental Health Problems: Prevalence, Characteristics, and Disclosure

This is a multicentric, descriptive, cross-sectional study of child and adolescent sexual abuse in women over 18 years in 24 primary care sexual and reproductive health centers in Catalonia. A total of 1,013 women were recruited; 345 (37.6%, 95% CI: 34.6-40.9) reported exposure to child sexual abuse: 32.4% disclosed being touched in a sexual way, and 9.6% reported completed sexual intercourse. Abuse occured before the age of 13 in 63.4% of respondents. The perpetrator was a relative or an acquaintance in almost 80% of cases. The risk was higher among women of Central or South American origin (OR: 2.86; 95% CI: 1.33-6.12). Only 31.9% of women disclosed the abuse and 17.3% were blamed. Abuse that involved attempted or completed sexual intercourse was significantly associated with recurrence, physical violence, and revictimization in adulthood.

Postrape care services to minors in Kenya: are the services healing or hurting survivors?

Child sexual abuse is a global problem and a growing concern in Sub-Saharan Africa. It constitutes a profound violation of human rights. To address this problem, Kenya has established the Sexual Offences Act. In addition, Kenya has developed national guidelines on the management of sexual violence to grant minors access to health care. However, little is known about the experiences of sexually abused minors when they interact with the health and legal system. Accordingly, this study uses a triangulation of methods in the follow-up of two adolescent girls. Health records were reviewed, interactions between the girls and service providers were observed, in-depth interviews were conducted with the girls, and informal discussions were held with guardians and service providers. Findings indicated that the minors’ rights to quality health care and protection were being violated. Protocols on postrape care delivery were unavailable. Furthermore, the health facility was ill equipped and poorly stocked. Health providers showed little regard for informed assent, confidentiality, and privacy while offering postrape care. Similarly, in the justice system, processing was met with delays and unresponsive law enforcement. Health providers and police officers are in grave need of training in sexual and gender-based violence, its consequences, comprehensive postrape care, and sexual and reproductive health rights to ensure the protection of minors’ rights. Health administrators should ensure that facilities are equipped with skilled health providers, medical supplies, and equipment. Additionally, policies on the protection and care of sexually abused minors in Kenya require amendment.

Nonoccupational Postexposure Human Immunodeficiency Virus Prophylaxis: Acceptance Following Sexual Assault

BACKGROUND

Nonoccupational postexposure prophylaxis (nPEP) for HIV following sexual assault may decrease the likelihood of HIV transmission.

OBJECTIVE

The purpose of this exploratory chart review study was to examine factors associated with patients accepting post-sexual assault nPEP at three forensic nurse examiner programs in urban settings.

METHODS

Forensic nursing charts of patients presenting for acute sexual assault care were reviewed as part of a mixed-methods study.

RESULTS

Patients assaulted by more than one or an unknown number of assailants were over 12 times more likely to accept the offer of nPEP (adjusted odds ratio [aOR] = 12.66, 95% CI [2.77, 57.82]). In cases where no condom was used (aOR = 8.57, 95% CI [1.59, 46.10]) or when any injury to the anus or genitalia was noted (aOR = 4.10, 95% CI [1.57, 10.75]), patients were more likely to accept nPEP. Patients with any injury to the face or head were less likely to initiate nPEP (aOR = 0.32, 95% CI [0.11, 0.97]).

DISCUSSION

This study is an important first step in understanding factors associated with nPEP acceptance after sexual assault.

Sexual offending runs in families: A 37-year nationwide study

BACKGROUND

Sexual crime is an important public health concern. The possible causes of sexual aggression, however, remain uncertain.

METHODS

We examined familial aggregation and the contribution of genetic and environmental factors to sexual crime by linking longitudinal, nationwide Swedish crime and multigenerational family registers. We included all men convicted of any sexual offence (N = 21,566), specifically rape of an adult (N = 6131) and child molestation (N = 4465), from 1973 to 2009. Sexual crime rates among fathers and brothers of sexual offenders were compared with corresponding rates in fathers and brothers of age-matched population control men without sexual crime convictions. We also modelled the relative influence of genetic and environmental factors to the liability of sexual offending.

RESULTS

We found strong familial aggregation of sexual crime [odds ratio (OR) = 5.1, 95% confidence interval (CI) = 4.5-5.9] among full brothers of convicted sexual offenders. Familial aggregation was lower in father-son dyads (OR = 3.7, 95% CI = 3.2-4.4) among paternal half-brothers (OR = 2.1, 95% CI = 1.5-2.9) and maternal half-brothers (OR = 1.7, 95% CI = 1.2-2.4). Statistical modelling of the strength and patterns of familial aggregation suggested that genetic factors (40%) and non-shared environmental factors (58%) explained the liability to offend sexually more than shared environmental influences (2%). Further, genetic effects tended to be weaker for rape of an adult (19%) than for child molestation (46%).

CONCLUSIONS

We report strong evidence of familial clustering of sexual offending, primarily accounted for by genes rather than shared environmental influences. Future research should possibly test the effectiveness of selective prevention efforts for male first-degree relatives of sexually aggressive individuals, and consider familial risk in sexual violence risk assessment.

A systematic review of training interventions addressing sexual violence against marginalized at-risk groups of women

Women from marginalized groups working in occupations such as domestic work are at increased risk for sexual violence. Scarce evidence exists about training interventions targeting such groups. The article aims to identify community and workplace-based training interventions aiming to increase capacity among marginalized at-risk women to deal with sexual violence. A systematic review was applied. Inclusion criteria were English language published between 2003 and 2013; reporting on delivery and/or evaluation; focusing on any form of sexual violence; delivered to professionals, affected or at-risk women; targeting migrant, at-risk women or domestic workers. Data were extracted on the setting, content, evaluation process and target population. Four studies which focused on prevention or responding to sexual violence were included. One study provided sexual violence training to vulnerable female and one provided a HIV prevention intervention to marginalized women. Learning objectives included increasing knowledge around issues of sexual violence and/or gender and human rights, prevention and response strategies. Two studies aimed to train trainers. All studies conducted an outcome evaluation and two a process evaluation. It seems there is a gap on participatory empowerment training for marginalized women. Community train-the-trainer interventions are imperative to protect themselves and deal with the risk of sexual violence.

Comparative study of spermatozoa detection using the genital swab versus bedside smear slide technique in sexual assault patients

BACKGROUND

Specimen collection from sexual assault victims is an essential part of practice in forensic medicine. Semen analysis is a forensic test used to confirm sexual contact. Two methods of specimen collection were compared in this study: the genital swab and bedside slide smear.

MATERIALS AND METHODS

A retrospective chart review was performed in the Division of Clinical Forensic Medicine, Siriraj Hospital, Thailand. Data were collected on microscopic spermatozoa detection in the external and internal genitalia, the time interval from assault to visit, and the history of condom use and genital cleansing. McNemar's test was used for comparison between the genital swab and bedside slide smear techniques.

RESULTS

In total, 724 case files from 2009 to 2013 were reviewed. The genital swab technique yielded a higher detection rate than did the bedside slide smear technique in both the external genitalia (37.0% vs. 31.8%, respectively) and internal genitalia (40.8% vs. 34.1%, respectively). Collection of a genital swab only missed positive cases in 4%-6% of negative swabs. When considering both the external and internal genitalia, the genital swab still yielded a higher rate of positive results than did the slide smear (45.9% vs. 39.0%, respectively). Examination of the victim within the first 3 days produced the highest spermatozoa detection rate (46.3%).

CONCLUSIONS

The genital swab is the preferred specimen collection method for spermatozoa detection in adult sexual assault victims. However, collection of both a swab and slide specimen may be considered in some cases. Collection of specimens later than 3 days after the assault greatly decreases the rate of spermatozoa detection.

The influence of prior rape on the psychological and physical health functioning of older adults

OBJECTIVES

Older adults who have experienced traumatic events earlier in life may be especially vulnerable to additional challenges associated with aging. In a cross-sectional study of older females, the present study examines whether a history of rape is associated with current psychological and health problems.

METHOD

This study used existing data from the female respondents (N = 1228) in the National Social Life, Health, and Aging Project (NSHAP), a national probability sample of adults between the ages of 57 and 85 interviewed in their homes. It was determined whether or not the participant experienced forced sexual contact since the age of 18. Measures of psychological health (e.g., scales of depression, anxiety, and loneliness), the presence or absence of a number of serious health problems, and a one-item measure of self-esteem were obtained.

RESULTS

Adult rape occurred in 7% of the sample. On average, 36 years had elapsed since the rape had occurred. Using structural equation modeling (SEM), rape was associated with lower self-esteem, psychological, and physical health functioning. Self-esteem partially mediated the association between rape and psychological functioning, but not health functioning. These associations were significant even after controlling for participant characteristics and risky health behaviors.

CONCLUSIONS

Mechanisms linking prior rape to psychological and health problems in older age are discussed, as well as treatment recommendations for symptomatic older adults.

"Not used but almost…"--a gender and agency analysis of the grey zone between consensual and nonconsensual sexual intercourse

Rape is a widespread but underreported problem among women. In this article I explore the complexities surrounding the fine line between consensual and nonconsensual sexual intercourse, by studying a rape through which a young woman was infected with HIV. I provide an analysis of how to understand and interpret this episode by applying a gender perspective based on patriarchy-namely, women's submissive position in heterosexual situations compared with men-and the concept of agency, that is, the individual's own decision-making ability, own choices, and different courses of action available, to outline the frame of action available to the informant. The inclusion of agency and a gender perspective offers new dimensions on how to understand and give meaning to narratives that are seldom told.

The recovery of semen from bathwater using the Evidence Recovery System (ERS)

Sexual offences are under-reported and ascertaining accurate offence numbers is difficult. Any methods which could increase the ability to obtain biological evidence or reduce the additional distress associated with reporting a sexual offence may result in an increase in reporting this crime type. The Evidence Recovery System (ERS) is designed to collect trace evidence, including hairs, fibres and biological evidence, from bath or shower water in a non-invasive manner. Initially, samples of semen were placed in baths filled with water, and washing was simulated using a range of body wash products. The water was then drained through the ERS before its filters were subjected to acid phosphatase testing and haematoxylin and eosin staining of spermatozoa. Recovered spermatozoa were then graded accordingly. Following this, the experiment was repeated with the addition of dirt/dust particulates during the washing stage, to simulate recovery of biological evidence in a more realistic environment. The results showed that spermatozoa considered 'easy to find' could regularly be obtained from bathwater using the ERS. It appeared that this recovery was not affected by the presence of different body wash products. When dust/dirt particles were added, the number of spermatozoa recovered increased at two of the evidence collection stages. The difference in recovery was considered to be statistically significant. This study provides evidence to suggest the feasibility of use of the ERS as a method to collect semen evidence from individuals subjected to sexual offences. The recovery of spermatozoa does not appear to be affected by the presence of a body wash, but does appear to be improved when skin cells, hair and other debris are transferred into the water, as would be likely during a bath/shower. Further to this, the possibility of obtaining spermatozoa from the home bath or shower of a victim following a post-offence bathing experience is implied.

Immediate medical care after sexual assault

Immediate needs after sexual assault include safety and privacy in the first instance, followed by treatment of injuries and prevention of unwanted pregnancy and sexually transmitted infections, including human immunodeficiency virus. Management should include risk identification of self-harm and suicide, as well as safeguarding children and vulnerable adults. Pregnancy prevention can be achieved through oral or mechanical methods of emergency contraception. Availability of emergency contraception may vary between districts and countries, depending on local laws and cultural or religious beliefs. Sexually transmitted infections, including gonorrhoea, chlamydia, hepatitis B and human immunodeficiency virus, represent an important part of management of victims of sexual assault. They can be prevented immediately by offering bacterial and viral prophylaxis followed by sexual health screening 2 weeks later unless symptomatic. In deciding what antibiotics to use as prophylaxis, local prevalence of infections and resistance to antibiotics should be considered. Prophylaxis against human immunodeficiency virus infection after sexual exposure should be discussed and offered in high-risk cases for up to 72 h after exposure. This should be accompanied by baseline human immunodeficiency virus test and referral for follow up. In high prevalence areas, prophylaxis against human immunodeficiency virus infection after sexual exposure should be offered as a routine. Psychosocial support and risk assessment of vulnerabilities, including self-harm or domestic violence and practical support should be addressed and acted on depending on identified needs.

Psychological consequences of sexual assault

Sexual violence is an important issue worldwide and can have long-lasting and devastating consequences. In this chapter, we outline the psychological reactions to serious sexual assault and rape, including development of post-traumatic stress disorder. Myths and stereotypes surrounding this subject, and their potential effect on the emotional response and legal situation, are discussed.

Sexual assault and coincident alcohol use in attendees at a genitourinary medicine clinic in the south of England

To investigate the relationship between alcohol consumption and the experience of sexual assault, either as victim or perpetrator, among genitourinary (GU) medicine department attendees in Portsmouth, UK, we carried out a cross-sectional survey of consecutive patients attending the walk-in service when a researcher was available. Self-completed questionnaires were used and anonymized data were collected from 1186 participants (response rate 34%). Responses showed that 15.6% of female and 3.7% of male participants had ever being sexually assaulted. Women who reported sexual assault drank more on a heavy night out than those who did not report sexual assault (mean 21.3 versus 17.0 units, P = 0.041). Over half of the victims had been drinking prior to the relevant assault. Twenty-seven participants (2.3%) admitted to having sex with a person who was not fully willing. Of these, 59% had been drinking prior to the assault, and the majority believed alcohol had contributed to the assault. Any strategies aiming to reduce the incidence of sexual assault must address hazardous drinking as a high priority.

Availability of services for subjects of sexual assault in genitourinary medicine clinics

The aim of this study is to gain an understanding of the services available to subjects of sexual assault at genitourinary medicine (GU medicine) clinics throughout the United Kingdom, and to determine whether these services are adequate. By means of a questionnaire, consultants in 106 clinics provided information on the number of patients who reported sexual assault and the services available to them. The study found a marked regional variation in attendances by subjects of sexual assault. However, only a minority of clinics kept accurate data (36.7% regarding female victims and 37.75% regarding male victims). The number of subjects who were aged under 16 years was disproportionately high (under 16s: 6.9% of female victims and 1.2% male victims; 16 and over: 1.3% of female victims and 0.14% of male victims). This survey highlights deficiencies in services that need to be addressed by clinics, management and the speciality.

Management of female genital trauma

The management of female genital trauma is complex and should be performed by a well-trained team of health care professionals. It is important to remember that many female genital injuries will cause not just physical injury, but also significant psychological and emotional distress that may lead on to future physical dysfunction. The approach of any health care professional in the immediate diagnosis and management of females with a genital injury must be aimed at getting the best and most appropriate care to the patient as soon as possible. It is also important to remember that many of these injuries are the result of crimes and careful documentation is required so as not to remove or invalidate evidence that may later be required by the courts. This article is aimed at non-specialist healthcare providers who may find themselves faced with a female genital trauma patient. It will cover the range of injuries and conditions that should be expected and describes the treatment that should be given for the best possible physical and psychological outcomes. At all times it should be remembered that the patient should be assessed and resuscitated in accordance with recognised ATLS protocols.

Sex-trafficking, violence, negotiating skill, and HIV infection in brothel-based sex workers of eastern India, adjoining Nepal, Bhutan, and Bangladesh

A community-based cross-sectional study was conducted among brothel-based sex workers of West Bengal, eastern India, to understand sex-trafficking, violence, negotiating skills, and HIV infection in them. In total, 580 sex workers from brothels of four districts participated in the study. A pretested questionnaire was introduced to study their sociodemography, sex-trafficking, violence, and negotiating skills. Blood sample of 4-5 mL was collected from each sex worker using an unlinked anonymous method to study their HIV status. Data were edited and entered into a computer using the Epi Info software (6.04d version). Both univariate and multivariate analyses were done to find out any association between HIV and relevant risk factors. Results of the study revealed that a sizeable number of the participants were from Nepal (9%) and Bangladesh (7%). The seroprevalence of HIV was strikingly higher among Nepalese (43%) than among Bangladeshis (7%) and Indians (9%). Almost one in every four sex workers (24%) had joined the profession by being trafficked. Violence at the beginning of this profession was more among the trafficked victims, including those sold by their family members (57%) compared to those who joined the profession voluntarily (15%). The overall condom negotiation rate with most recent two clients was 38%. By multivariate analysis, HIV was significantly associated with sexual violence (odds ratio=2.3; 95% confidence interval 1.2-4.5). The study has documented that the trafficked victims faced violence, including sexual violence, to a greater magnitude, and sexual violence was associated with acquiring HIV in them. There is a need for an in-depth study to understand the problem of trafficking and its consequences.