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.

Unfounded, Cleared, or Cleared by Exceptional Means: Sexual Assault Case Outcomes From 1999 to 2014

Sexual assault is a highly underreported crime with even fewer cases proceeding to the point of charges and prosecution, suggesting that sexual assault victims have less opportunity for legal justice than other crime victims. Case attrition may, in part, be due to negative attitudes and rape myth acceptance (RMA) in police decision making. Yet, little attention has been paid to examining the evidentiary and extralegal factors surrounding the case that contribute to police decision making and case outcomes through examination of police case files. This examination is necessary to address the issue of differential processing of sexual assault cases in the criminal justice system. This study uses police data of sexual assault case files from 1999 to 2014 (N = 23,525) to examine the assault, victim, and detective characteristics that contribute to case outcomes of unfounded, cleared, and exceptionally cleared through arrest and victim refusal to prosecute. Logistic regression models tested 15 years of reported sexual assault data from one large police department and found that elements that correspond with RMA were predictive of unfounded, cleared, and exceptionally cleared case decisions, providing further indication that officers consider evidentiary but also extralegal factors in decision making. Overall, results support previous contentions that sexual assault victims have unequal access to legal justice, particularly victims possessing demographic and assault characteristics that do not align with stereotypical notions of rape. Implications for future research and policing practices are discussed.

"I never told anyone until the #metoo movement": What can we learn from sexual abuse and sexual assault disclosures made through social media?

BACKGROUND

Social media is providing new avenues for survivors to disclose sexual abuse and/or assault. Since the creation of #MeToo (2017), and the larger MeToo movement founded by American activist Tarana Burke in 2006, millions are disclosing sexual assaults and past childhood sexual abuse on-line.

OBJECTIVE

Social media for disclosing the highly stigmatized problem of sexual abuse/assault was studied to build knowledge about on-line disclosures.

PARTICIPANTS AND SETTING

Participants were tweeters and posters on Twitter and Reddit. Purposive sampling captured on-line sexual abuse/assault disclosures from September 28, 2018 to October 16, 2018 for thematic analysis.

METHOD

Using a phenomenological design 171 social media posts were analyzed for deeper understanding into new options for disclosing sexual abuse and/or sexual assault. Posts were independently coded by the authors. Sampling was stopped when categorical saturation was reached with no new information coming forward on the research question.

RESULTS

Themes that emerged showed the MeToo/#MeToo movement is precipitating sexual abuse/assault disclosures on social media in unprecedented ways; posters identified internal barriers, mixed responses from family, and friends/peers, as well as variable responses from professionals. While some conditions for sexual abuse/assault disclosures have improved, barriers still exist.

CONCLUSION

Social media represents an environmental shift for disclosing sexual violence. Sexual abuse/assault survivors have found voice through social media after periods of silence and being silenced, turning to posting on-line when people and systems have failed to validate and support them. Further investigation is needed on the impacts of on-line sexual abuse and/or assault disclosures.

Factors Predicting Conviction in Stranger Rape Cases

Background: Despite there being no legal distinction between different types of rapes (e.g., those committed by strangers to the victim versus those committed by perpetrators known to the victim), stereotypical beliefs about rape have meant that these can be treated differently by the justice system. The aim is to explore the factors that predict juries' decisions to convict or acquit in stranger rape cases. Methods: We measured the importance of a range of 20 perpetrator-, victim-, and offense-related factors in predicting outcomes for 394 stranger rape cases tried by a jury. A four-stage analytic process was employed: (a) Kendall's tau-b measured intercorrelations among the factors (predictors); (b) Chi-square and Welch t-tests measured associations between factors and verdicts; (c) binary logistic regression measured the power of factors in predicting verdicts; and (d) Stein's formula was used to cross-validate the model. Results: Jury verdicts were predicted by five offense-related factors and one victim-related factor. None of the perpetrator-related factors were significant predictors of convictions for stranger rape. Conclusion: The findings have potential implications for victims of stranger rape, as well as prosecution and courtroom policy. We show that if a perpetrator is identified and charged, the likelihood of securing a conviction by a jury is high for victims of stranger rape. We suggest that prosecutors could gather as much information as possible from victims about the factors found to be of importance to juries, and judges could instruct juries on assumptions about the characteristics of the offense in order to challenge incorrect beliefs and stereotypes. Ultimately, this could be used to encourage victims of stranger rape to report and testify in court.

The Role of “Real Rape” and “Real Victim” Stereotypes in the Police Reporting Practices of Sexually Assaulted Women

Some feminists have argued that rape myths constrain women’s reporting of sexual assault to the police. The authors investigated whether myth-associated characteristics of sexual assaults play a role in police reporting behaviors of women. A sample of 186 sexual assault cases seen at a hospital-based sexual assault care center in 1994 was analyzed using logistic regression. A positive association was found between reporting a sexual assault to the police and two overtly violent components of the “real rape” myth: the use of physical force and the occurrence of physical injury.

A documentation policy development proposal for clinicians caring for people living with HIV/AIDS

In Canada, nondisclosure prosecutions against people living with HIV/AIDS (PHAs) have increased. Nurses who provide services to PHAs could become involved in such criminal cases because they (a) elicit sensitive information about their clients' sexual practices, and (b) adhere to documentation standards. Currently, HIV documentation policies do not exist for clinicians working with PHAs in Canada or abroad. Sexual assault nursing, which includes documentation guidelines, may offer guidance in the creation of a PHA care policy because sexual assault nursing and PHA care both intersect with the justice system. A PHA care policy may have several benefits: It can increase clinician confidence in patient interactions and documentation by clarifying roles and scope of responsibilities, reduce inconsistencies in practice, diminish conflict among professionals, and reduce the stress involved in clinical practice. The outcome of these improvements could be an increase in PHAs' level of comfort with nurses knowing that policies exist.

To be used or not to be used, that is the question: legal use of forensic and clinical information collected in a self-referral sexual assault centre

This study explores how the police select cases for using information from a self-referral Sexual Assault Centre (SAC). The study is retrospective and descriptive: a 2-year series from a Scandinavian SAC and corresponding police files. The police had access to 163 SAC cases, requested 84% of available forensic medical documentation, and had 50% of the trace samples analyzed. The two main predictors of police utilization of forensic evidence were cases the police classified as rape and complaints filed during January to August. Extrinsic DNA was found in 27/60 trace evidence analyses, 21 matching a suspect. For one-third of the suspects who denied sexual acts, the forensic evidence contradicted their denial. Nonuse forfeited this possibility in several cases, and relevant information on injuries was lost. Our results indicate that available medical information is not fully utilized for legal purposes. Main barriers are police classification of cases and insufficient economic funding.

A Socioecological Model of Rape Survivors' Decisions to Aid in Case Prosecution

The purpose of our study was to identify factors underlying rape survivors' post-assault prosecution decisions by testing a decision model that included the complex relations between the multiple social ecological systems within which rape survivors are embedded. We coded 440 police rape cases for characteristics of the assault and characteristics of the rape survivor congruent with rape mythology. In addition, support from friends/family members, social service providers, and police were assessed. Path analysis, using Structural Equation Modeling (SEM) that included a bias-corrected bootstrap resampling procedure, supported our model. As hypothesized, rape survivors' final decisions to aid in case prosecution were predicted by support from the three social ecologies: family/friends, social service providers, and police. Social service provider support, in turn, was predicted by assault characteristics congruent with rape mythology, whereas family/friend and police support were significantly predicted by the interaction between assault and survivor characteristics congruent with rape mythology. Our results show the value of applying a socioecological framework to help understand factors that influence rape survivors' prosecution decisions. Moreover, our results highlight the need to challenge commonly held views of “typical” rape survivors and the “typical” circumstances surrounding their assault.

Visualizing sexual assault: an exploration of the use of optical technologies in the medico-legal context

This article is an exploration of the visualization of sexual assault in the context of adult women. In investigating the production of visual evidence, we outline the evolution of the specialized knowledge of medico-legal experts and describe the optical technologies involved in medical forensic examinations. We theorize that the principles and practices characterizing medicine, science and the law are mirrored in the medico-legal response to sexual assault. More specifically, we suggest that the demand for visual proof underpins the positivist approach taken in the pursuit of legal truth and that the generation of such evidence is based on producing discrete and decontextualized empirical facts through what are perceived to be objective technologies. Drawing on interview and focus group data with 14 sexual assault nurse examiners (SANEs) in Ontario, Canada, we examine perceptions and experiences of the role of the visual in sexual assault. Certain of their comments appear to lend support to our theoretical assumptions, indicating a sense of the institutional overemphasis placed on physical damage to sexually assaulted women's bodies and the drive towards the increased technologization of visual evidence documentation. They also noted that physical injuries are frequently absent and that those observed through more refined tools of microvisualization such as colposcopes may be explained away as having resulted from either vigorous consensual sex or a "trivial" sexual assault. Concerns were expressed regarding the possibly problematic ways in which either the lack or particular nature of visual evidence may play out in the legal context. The process of documenting external and internal injuries created for some an uncomfortable sense of fragmenting and objectifying the bodies of those women they must simultaneously care for. We point to the need for further research to enhance our understanding of this issue.

Cooperation or co-optation?: Assessing the methodological benefits and barriers involved in conducting qualitative research through medical institutional settings

In this article, the authors highlight some benefits of and barriers to doing qualitative research in association with hospital-based services. They first describe an ongoing qualitative research project that involves interviewing women about their post-sexual assault medicolegal experiences in hospital-situated sexual assault centers across a large Canadian province. Their methodological journey led them to engage program coordinators at these centers to assist with locating participants and qualified interviewers, and with negotiating the demands of their respective research ethics boards. They outline the ways in which their project was shaped, positively and negatively, by working with them in medical institutions. They conclude by recommending that hospitals and hospital ethics boards counteract tendencies toward paternalism by recognizing the value of feminist qualitative research contributions to the activities of their own sexual assault centers and to the recovery of sexually assaulted women. Such recognition might be productively engaged by adopting an ethics-in-process approach.

Examining the standardized application of rape kits: an exploratory study of post-sexual assault professional practices

In this exploratory study we examine the practices surrounding with respect to standardization the administration and processing of the Sexual Assault Evidence Kit (SAEK). Despite the presumed scientific objectivity of this protocol, our survey of sexual assault nurses, physicians, police, and forensic scientists found that discretionary practices pervaded the evidentiary process. We argue that there must be greater awareness of the shaping of medicolegal evidence. Given the diverse characteristics of sexual assaults and of the health care needs of sexually assaulted women, we also suggest that it may be unreasonable to apply a single standard model of a rape kit.

Sexual assault forensic medical examination: is evidence related to successful prosecution?

STUDY OBJECTIVE

We describe the medical-legal findings in a population of adult sexual assault cases assessed in an emergency department setting and reported to the police, document the law enforcement and legal disposition of cases seen over the study period, and determine whether medical-legal findings are associated with filing of charges and conviction after adjusting for demographic factors and assault characteristics.

METHODS

This was a retrospective chart review of all police-reported cases seen from January 1993 to December 1997 at the British Columbia Women's Sexual Assault Service, a 24-hour hospital-based emergency service. Information on patient demographics, assault characteristics, and medical-legal findings was merged with data extracted from police and court files on the cases' legal outcomes and sperm-semen test results of collected forensic evidence. Cases were assigned a clinical injury extent score reflecting the degree of documented genital and extragenital injury. The association of medical-legal variables, patient demographics, and assault characteristics with filing of charges (among the subset of cases in which a suspect was identified by police) and conviction (among the subset of cases in which charge were filed) was examined by using logistic regression.

RESULTS

Charges were filed in 151 (32.7%) and a conviction secured in 51 (11.0%) of the 462 cases examined in this study. Genital injury was observed in 193 (41.8%), and sperm-semen-positive forensic results were obtained in 100 (38.2%) of the 262 samples tested. A gradient association was found for injury extent score and charge filing in the following categories: mild injury (odds ratio [OR] 2.85; 95% confidence interval [CI] 1.09 to 7.45); moderate injury (OR 4.00; 95% CI 1.63 to 9.84); and severe injury (OR 12.29; 95% CI 3.04 to 49.65). Documentation on the police file of receipt of forensic samples collected by the Sexual Assault Service examiner was also significantly associated with charges being filed (OR 3.45; 95% CI 1.82 to 6.56). Injury extent score defined as severe was the only variable significantly associated with conviction (OR 6.51; 95% CI 1.31 to 32.32).

CONCLUSION

The finding that documented injury extent had a significant positive association with both filing of charges and conviction is an important step in confirming the value of injury documentation in the forensic examination of sexual assault victims.