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Volume 27, Issue 1, Pages I1-I2, A1-A14, 1-150 (February 2013) Clinical Aspects of Sexual Violence

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1 Aims and Scope/Editorial Board 1st AMEC - Volume 27 (2013) Page iii Anti-aging Volume 27, Issue 4 Medicine pp. A1-A14, 479-640, Show preview | PDF (54 K) | Recommended articles | Related reference work European Congress I1-I2 (August 2013) articles Risk Management in Obstetrics 11–12 Oct 2013 and Gynaecology 2 Preface Paris, France Volume 27, Issue 3 Pages 1-2 pp. I1-I2, A1-A14, Maureen Dalton 21st Annual Cochrane 309-478 (June 2013) Colloquium Show preview | PDF (78 K) | Recommended articles | Related reference work Advances in Gynaecological 19–23 Sep 2013 Surgery articles Québec City, Canada Volume 27, Issue 2 pp. 151-308, I1-I2, 3 Sexual violence against women: The scope of the Canadian problem Original Research Article A1-A14 (April 2013) Association of Caesarean Section – Current Pages 3-13 Ambulatory Practice Elizabeth Dartnall, Rachel Jewkes Care (CAAC) Volume 27, Issue 1 Show preview | PDF (184 K) | Recommended articles | Related reference work 13–14 Sep 2013 pp. I1-I2, A1-A14, 1-150 articles Toronto, Canada (February 2013) Clinical Aspects of Sexual More events » Violence 4 Health consequences of sexual violence against women Review Article Pages 15-26 Volume 26 (2012) Ruxana Jina, Leena S. Thomas Powered by Volume 25 (2011) GLOBALEVENTSLIST Volume 24 (2010) Show preview | PDF (523 K) | Recommended articles | Related reference work Volume 23 (2009) articles Volume 22 (2008) Volume 21 (2007) 5 Psychological consequences of sexual assault Review Article Volume 20 (2006) Pages 27-37 Volume 19 (2005) Fiona Mason, Zoe Lodrick

Volume 18 (2004) Show preview | PDF (161 K) | Recommended articles | Related reference work Volume 17 (2003) articles Volume 16 (2002) Volume 15 (2001) 6 The male victim of sexual assault Review Article

Volume 14 (2000) Pages 39-46 Volume 13 (1999) Iain A. McLean

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7 The role of the sexual assault centre Review Article Pages 47-58 Maeve Eogan, Anne McHugh, Mary Holohan

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8 Problems of capacity, consent and confidentiality Review Article Pages 59-75 Amaboo Dhai, Jason Payne-James

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9 The forensic aspects of sexual violence Original Research Article Pages 77-90 Mary Newton

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10 Forensic medical examination of adolescent and adult victims of sexual violence Review Article Pages 91-102 Ole Ingemann-Hansen, Annie Vesterby Charles

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11 Interpretation of non-genital injuries in sexual assault Review Article Pages 103-111 Jack Crane

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12 Genital injuries in adults Review Article Pages 113-130 Catherine White

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13 Injuries in prepubertal and pubertal girls Review Article Pages 131-139 Jean Price

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14 Immediate medical care after sexual assault Review Article Pages 141-149 Beata Cybulska

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15 Clinical Aspects of Sexual Violence – Multiple Choice Questions for Vol. 27, No. 1 Pages A1-A6

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16 Sub-fertility: Current Concepts in Management – Answers to Multiple Choice Questions for Vol. 26, No. 6 Pages A7-A14

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2 de 2 25/08/13 8:52 Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 1–2

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Preface

The term sexual violence covers a vast array of problems but is also common. Taking just one aspect, Alberti1 suggested that more women are sexually assaulted than develop diabetes or have a stroke in the UK. Yet, in the Western world, more attention is paid to diabetes and stroke victims than sexual assault victims. Meanwhile, the victim suffers the health consequences and we, as health practitioners, manage victims every day, not always aware they are victims and so the care is not always provided very well. In this issue of Best Practice and Research Clinical Obstetrics and Gynaecology, it is not possible to provide a comprehensive guide to the best practice or research in this entire subject. From a worldwide perspective, different issues have different risks, making comprehensive coverage of the subject impossible. Female genital mutilation is not included in great detail, as this is a large and complex problem that could fill a volume on its own. Although various authors have made reference to the law in the country they practise in, it has not been possible to cover all jurisdictions. As sexual assault, in its various forms, is so common, this issue of Best Practice and Research Clinical Obstetrics and Gynaecology covers many of the immediate aspects of care. The terms ‘victim’, ‘complainant’ and ‘patient’ are all used at various points. This is because the individuals studied may be at different points as they travel the path from assault to the start of rebuilding their lives. Many countries are developing special units or ‘sexual assault centres’ to improve the care of the victim and the results of the judicial process. This, in turn, has helped the development of sexual offences medicine as an area of specialism. Within the UK, the diploma of forensic and clinical aspects of sexual assault (DFCASA),2 run by the Society of Apothecaries and open to doctors and nurses, is a confirmation of competence to examine. The Royal college of Obstetrics and Gynaecology have also developed an advanced specialist training module (ATSM) in leadership in the provision of domestic violence and forensic services.3 The issues of consent to examine traumatised acute victims raises many ethical dilemmas, including how it affects a doctor’s need to respect the patient’s confidentiality in health aspects, while not hindering the judicial process; these are considered in more depth. Identifying, recording and interpreting injuries in non-genital and genital areas have both clinical and judicial consequences. So, while injuries to prepubertal and adolescent girls are discussed, the management of the acute victim of child sex abuse is not otherwise considered separately, but is reflected in the scope of the problem and long-term health consequences. Sexual violence also has male victims, including being used as a ‘weapon’ of war. It is under- reported, and victims are even less willing to go to the police. This becomes a challenge where there is statutory reporting to the police, as the chances of improving the care of victims, and so reducing the health consequences, increases. Rape is a crime with an emphasis on confirming that a crime has taken place, and then conducting a police investigation to find the perpetrator. The rapidly expanding world of forensic science makes the environment in which a victim is examined, and which specimens to take, a vital part of the process. The aim is to enable best evidence without leaving the victim feeling they are just a ‘scene of a crime’.

1521-6934/$ – see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bpobgyn.2012.08.005 2 Preface / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 1–2

Many of the long-term health problems relate to, or are a consequence of, the psychological reactions. Understanding why our patients are reacting as they do goes a long way to helping them, and helps us maximise the way we care for them. Sexual violence is an under-recognised area of obstetrics and gynaecology, but it is present in a large number of our patients.

References

1. Alberti G. Responding to violence against women and children: the role of the NHS. The report of the Taskforce on the Health Aspects of Violence Against Women and Children. London: Department of Health, www.dh.gov.uk/; 2010 [last accessed 9.08.12]. 2. The Worshipful Society of Apothecaries of London. Diploma in the Forensic and Clinical Aspects of Sexual Assault (DFCASA); www.apothecaries.org/index.php?page¼120 [last accessed 9.08.12]. 3. Royal College of Obstetrics and Gynecology ATSM; www.rcog.org.uk/curriculum-module/atsm-forensic-gynaecology [last accessed 9.08.12].

Maureen Dalton* Peninsula SARC Board, Oak Centre, Exeter, Devon, UK

Tel.: þ44 392 221163. E-mail addresses: [email protected], [email protected] (M. Dalton) Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 3–13

Contents lists available at SciVerse ScienceDirect Best Practice & Research Clinical Obstetrics and Gynaecology

journal homepage: www.elsevier.com/locate/bpobgyn

1 Sexual violence against women: The scope of the problem

Elizabeth Dartnall, BAppSc, Post-Grad Dip: Counselling, MSc a,b, Rachel Jewkes, MBBS, MSc, MFPHM, MD a,b,* a Gender and Health Research Unit, Medical Research Council, Pretoria, Private Bag X385, Pretoria 0001, South Africa b Sexual Violence Research Initiative, Pretoria, South Africa

Keywords: Rape and sexual violence occur in all societies, and cut across all social sexual violence classes. Prevalence estimates of rape victimisation range between 6 rape and 59% of women having experienced sexual abuse from their intimate partner sexual violence husbands or boyfriends in their lifetime. Two population-based non-intimate partner sexual violence studies from South Africa have found that 28% and 37% of men, prevalence respectively, have perpetrated rape. Estimates of rape perpetration multiple perpetrator rape from high-income countries seem to be lower than those from low- child sexual abuse school based sexual violence and middle-income countries; however, current data make it forced sex impossible to conﬁrm this. Women and girls are much more likely to coerced sex be the victims and men the perpetrators and, in most instances, the research perpetrator is known to the victim. Children are particularly vulnerable to sexual abuse, with girls being at greater risk, especially while at school and at home. High rates of child sexual abuse are emerging from the research, with an increasing understanding of the effect of child sexual abuse on later perpetration and victimisation, highlighting the importance of primary prevention for sexual violence to address childhood exposures to violence. Much of our knowledge about sexual violence has historically been based on research undertaken in high-income countries. This, however, is changing with the emergence of good-quality studies from other settings, particularly in Africa, alongside an increasing number of multi-country studies looking at interpersonal and sexual violence. Most countries lack population data on perpetration of sexual violence, across all categories, including children, and a major gap exists in research on sexual violence among sub-groups and populations. Much of the existing research has limitations thataffect cross-studycomparability, owing to differences in deﬁnitions, research tools, methods and sampling used. Improved research is essential. Research priorities for understanding the magnitude of sexual violence prevalence include assessment of the prevalence and patterns of sexual violence

* Corresponding author. Tel.: þ27 12339 8525; Fax: þ27 12 339 8582. E-mail address: [email protected] (R. Jewkes).

1521-6934/$ – see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bpobgyn.2012.08.002 4 E. Dartnall, R. Jewkes / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 3–13

victimisation and perpetration in a range of settings, across a range of acts of sexual violence, in men and women, in adults and children, using methodologies based on best practice in gender-based violence research and standard measures of different forms of sexual violence; research on the social context of sexual violence perpetration and victimisation by both men and women; and methodological research to measure sexual violence for particular population sub-groups or violence types, such as child perpetrators or young child victims, or sexual harassment at work and school. Ó 2012 Elsevier Ltd. All rights reserved.

Introduction

Sexual violence is a profound human rights violation and public health concern. It cuts across class and race, and occurs in peace and conflict settings. Perpetrators are most commonly men known to the victims, and often an intimate partner or, in the case of child sexual abuse, a trusted family or community member. Perpetrators of sexual violence may also be women and children. Sexual violence has been defined in the World Report on Violence and Health1 as ‘any sexual act, attempts to obtain a sexual act, or acts to traffic for sexual purposes, directed against a person using coercion, harassment or advances made by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work. Sexually violent acts take place in many different circumstances and settings. These include the following: rape in marriage or dating relationships; rape of non-romantic acquaintances; sexual abuse by those in positions of trust, such as clergy, medical practitioners or teachers; rape by strangers; multiple perpetrator rape; sexual contact involving trickery, deception, blackmail or of persons who are incapacitated or are too drugged, drunk or intoxicated to consent; rape during armed conflict; sexual harassment, including demanding sex in return for work, school grades or favours; unwanted sexual touching; rape of men in prisons; unwanted exposure to pornography; sexual abuse of mentally or physically disabled people; sexual abuse of boys and girls; and violent acts against sexual integrity, including female genital mutilation, inspections for virginity, forced anal examination and forced trafficking of people for the purpose of sexual exploitation. Thus, the diversity of sexual violence encompasses a range of different victim perpetrator relationships, a range of different sexual acts, a range of forms of coercion and contexts of vulnerability and it occurs in a range of settings. What these examples have in common is that theyare all sexual acts or acts directed against women and men’s sexuality, and they all occur in circumstances where consent is not given or not given freely. Laws across countries differ in the aspects of sexual violence that they regard as offences. Great variation exists in the scope of legal definitions of ‘rape’, and even though marital rape, for example, is a criminal offence in many countries and a crime under international law, 127 countries fail to criminalise marital rape.2 In this chapter, we review research on the prevalence of sexual violence against women. It does not address all types of sexual violence; for example, it does not discuss sexual harassment or female genital mutilation. Rather, the focus of the paper is on available prevalence estimates on rape and sexual abuse, from peacetime or post-conflict settings. We also discuss some of the challenges experienced when researching sexual violence, provide information on available data sources, and outline what we know about the scope of the problem of rape and sexual violence in terms of victimisation and perpetration of rape. Researching sexual violence: challenges and data sources

‘The measurement of rape or sexual assault represents one of the most serious challenges in the field of victimization research.3 Measuring the extent of sexual violence presents challenges. Sexual violence is an unusual violation in that, irrespective of setting, the victim is often roundly blamed for its occurrence. Furthermore, rape is commonly regarded as defiling. As a result, the experience of sexual violence is seen as stigmatising and shameful, which E. Dartnall, R. Jewkes / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 3–13 5 makes it difficult for victims to share their stories.4 Social consequences of sexual violence may be extreme; for example, a family may feel that the victim has brought dishonour to them and victims may be forced to marry the perpetrator, ostracised, or even killed.5 A further challenge that is rooted in rape stigma, as well as women’s internalisation of strong, culturally rooted ideas about male sexual entitlement, is that they may, after the sexually violent act, reclassify acts of sexual violence as ‘not rape’, and thus avoid perceiving they have to take action against the perpetrator and enable them to pass as ‘not raped’.InSouthAfrica,forexample,itisesti- mated that one in 25 women who have been raped have ever reported it to the police,6,7 compared with the USA, where higher reporting is found, but still only an estimated 40% of rapes are reported.8 Research shows that higher levels of reporting of sexual violence are found when questions are framed around behaviourally specific acts; for example, ‘being forced into sex against your will’.Notionsof‘rape’, ‘violation’ or ‘abuse’ are highly subjective, and questions that use these words always result in low levels of reporting. Considerable debate exists around the use of popular constructions such as ‘having sex’ compared with formal constructions such as ‘sexual intercourse’,withclarification of vaginal and anal penetration. Researchers in the USA have developed and widely used the Sexual Experiences Survey (SES).9 The SES uses precise specification of acts. It seems likely that the acceptability of this may show cultural diversity, as has been seen in South Africa. When the SES was tested in South Africa, men indicated that they found the anatomically precise questions offensive. They preferred to be asked about the vernacular version of ‘having sex’, and indicated that they all interpreted that as an act of vaginal intercourse.10 Questions also need to ask about a range of victim and perpetration contexts, such as when a woman is too drunk to consent, and also multiple perpetrator (gang) rape. Furthermore, they need to be framed around perpetrator type for proper ascertainment. In particular, it is important to ask about sexual violence from intimate partners specifically, as this form is often under-reported unless it is specially asked. The number of questions needed to measure sexual violence exposure will differ, depending on the operational definition; however, all validated scales measuring rape, attempted rape, sexual coercion or sexual harassment use multiple questions. Ascertainment is also sensitive to the contexts in which research is undertaken, particularly when face to face interviews are used, and in the training and support of fieldworkers. Much higher levels of ascertainment are found in surveys that use small numbers of highly trained and supported fieldworkers. For perpetration surveys, the use of computerised technology for questionnaire completion has also been extremely valuable.11 These differences influence our ability to compare prevalence estimates across settings. The figures provided in the literature need to be interpreted with these limitations in mind. The World Health Organization (WHO) Multi-Country Study (MCS) has assisted the field greatly by developing and formalising operational definitions for intimate partner violence.12 It also provides measures of sexual violence by a non-partner and child sexual abuse, although these are limited in scope and thus cannot be seen as gold-standard measures. The operational definitions and question- naires provide us with the tools to compare rates of sexual violence across time and settings. The operational definitions used in this study for the different categories of sexual violence researched in the WHO MCS are presented in Table 1.12 The WHO MCS focused on victimisation, and did not include men. It is increasingly understood, that for us to gain insight into the global scope of the problem, the causes of sexual violence and how best to strengthen prevention programmes, it is important to also include men in our research. A methodology for measuring prevalence of perpetration was developed for research in South Africa,13,14 and has been used in the multi-country IMAGES study15 and further refined for the Change Project run by the United Nations Development Project’s Partners for Prevention.16 It is currently being used in research with over 15,000 men in seven countries in the Asia and Pacific Region (Table 2).17 Country-specific national surveys are also a source of sexual violence prevalence data, as are country-specific studies. For example, the USA has created the National Intimate Partner and Sexual Violence Survey (NISVS). The NISVS was started in 2010 and involves annual interviews with adults in English and Spanish.18 The Demographic and Health Surveys (DHS) and Reproductive Health Surveys19,20 also have country-specific data available on violence against women. The Reproductive Health Survey and DHS data have limitations. For example, DHS data have been shown to under-report violence against women consistently, compared with findings from the WHO MCS and country-based studies specifically looking at violence against women.21,22 Efforts are being made to strengthen the Violence Against Women module in the DHS, but these do not overcome the problems of surveys that 6 E. Dartnall, R. Jewkes / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 3–13

Table 1 Different categories of sexual violence used in the World Health Organization multi-country study on women’s health and domestic violence against women.12

Category Operational deﬁnition

Sexual violence by an intimate partner Physically forced to have sexual intercourse when she did not want to. Had sexual intercourse when she did not want to because she was afraid. Forced to do something sexual that she found degrading or humiliating. Sexual violence from the age of Forced to have sex or to perform a sexual 15 yearsa (by non-partner) act she did not want to. Childhood sexual abuse Touched sexually or made to do something (before age 15 years) sexual that she did not want to Forced ﬁrst sex First sexual intercourse, forced or rape.

a , It is suggested that, in future studies, the 15-year cut-off should be changed to 18 years to reflect legal definition of adulthood, which in most parts of the world is 18 (with some exceptions). have large numbers of fieldworkers who are not particularly well trained and interested in gender, and do not have adequate support for vicarious trauma.

Sexual violence prevalence: what do we know?

Sexual violence is rooted in gender inequality and discrimination.23,24 It occurs at an alarmingly high rate in many settings. The WHO MCS found that between 6 and 59% of women have experienced sexual violence from their husband or a boyfriend in their lifetime12 (Table 3). Prevalence estimates of sexual violence victimisation from other population-based studies from 39 countries estimate that between 0.3% and 39% of women report intimate partner or non-intimate partner sexual violence at some point in their lives.25 A review of violence against women in Latin American and Caribbean countries, using data from Reproductive and Demographic Health Surveys from six countries,c found that between 5.8% and 13.4% of women reported forced intercourse in their lifetime, with up to one-third of first experiences occurring before the age 15 years.22 South African studies estimate prevalence rates for sexual violence across all categories, ranging from between 12 and 28% of women ever reporting rape.26,27 Research from high-income countries also reflects relatively high prevalence of sexual violence. The US NISVS, for example, found almost one in five women (18.3%) reported having been raped in their lifetime compared with one in 71 men.18 A total of 34, 28, 27 and 25% of women in the Australian, Danish, Swiss and Swedish arms of the International Violence Against Women Study, respectively, reported ever having been raped in their lifetime.25,28 As already mentioned, when looking at sexual violence prevalence, we need to distinguish between the different types of rape and their contexts, including sexual violence by intimate partners, sexual violence by non-intimate partners, experiences of first forced sex, childhood sexual abuse and gang rape. Failure to do so are likely to result in an underestimate of sexual violence prevalence.1

Sexual coercion by an intimate partner

Perpetrators of sexual violence are in most cases known to the victim, and rapes mostly occur within intimate relationships. Not surprisingly then, when intimate partner sexual violence is sepa- rated from non-intimate partner sexual violence, we ﬁnd higher prevalence rates. For example, the WHO MCS found that, in all countries surveyed, sexual coercion by an intimate partner was much more common than rape by a non-intimate partner (Table 1),29 dispelling the myth that most rapes occur in dark alleys perpetrated by an unknown assailant. In 10 of the 15 sites in the WHO MCS, more than one

c Paraguay, Nicaragua, Jamaica, Guatemala, El Salvador and Ecuador. E. Dartnall, R. Jewkes / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 3–13 7

Table 2 A new methodology for measuring prevalence of perpetration.17

Category Operational deﬁnition

Rape of a partner (current or previous Forced to have sex with you when she did not want to. wife or girlfriend) Sex when he knew she didn’t want it but believed she should agree because she was a wife or partner. Forced her to watch pornography when she didn’t want to. Forced her to do something sexual that she did not want to do Rape of a non-partner (a woman who Forced to have sex. was not your wife or girlfriend at the time) Sex with a woman or girl when she was too drunk or drugged to say whether she wanted it or not. Multiple perpetrator rape Sex with a woman when she didn’t consent to sex or was forced by ‘you and other men’. Sex with a woman when she was too drunk or drugged to stop it by ‘you and other men’. in ﬁve women had been forced into sex by an intimate partner. Rates of sexual violence by an intimate partner reported by women in the study were as high as 59% in rural Ethiopia.12 Sexual violence within intimate partnerships generally co-occurs with other forms of intimate partner violence.1 This patterning is not always consistent across all cases.1,30 For example, the WHO MCS found that a substantial proportion of women reported experiencing sexual violence only at the hands of their intimate partner: for example, in Thai province, Bangladesh province, and Ethiopia province, 28.9, 49.7, and 58.6% of women reported only sexual violence and very few reported any other form of sexual violence (Table 3). 30 Similarly, physical violence is not always more common than sexual violence. A community-based, cross-sectional survey of 845 ever-married women aged 15–49 years in Southwest Ethiopia reported a life time prevalence of sexual violence of 50.1%, which was much higher than the rates of physical violence (41.1%) found in this study.31 Sexual violence of an intimate partner is also high during pregnancy. A systematic review of African studies on intimate partner violence against pregnant women found prevalence rates ranging between 2.7 and 26.5%.32

Table 3 Prevalence of sexual violence against women and children.29,a

Site Child sexual Forced Sexual coercion Non-partner abuse before ﬁrst sex by an intimate sexual coercion age 15 years partner from the age (best estimate)b of 15 years

% % Ever% Past % 12 months (%)

Bangladesh City 7.4 24.1 37.4 20.2 7.6 Bangladesh province 1.0 29.9 49.7 24.2 0.5 Brazil City 11.6 2.8 10.1 2.8 6.8 Brazil province 8.7 4.3 14.3 5.6 4.6 Ethiopia province 7.0 16.6 58.6 44.4 0.3 Japan City 13.8 0.4 6.2 1.3 3.5 Namibia City 21.3 6.0 16.5 9.1 6.4 Peru City 19.5 7.3 22.5 7.1 10.3 Peru province 18.1 23.6 46.7 22.9 11.3 Samoa 1.8 8.1 19.5 11.5 10.6 Serbia/Montenegro City 4.2 0.7 6.3 1.1 3.9 Thailand City 8.9 3.6 29.9 17.1 6.1 Thailand province 4.9 5.3 28.9 15.6 2.6 United Republic of Tanzania City 12.2 14.3 23.0 12.8 11.5 United Republic of Tanzania province 9.5 16.6 30.7 20.2 9.4

a Based on work from Garcia-Moreno et al.12 b In those sites where anonymous reporting was not linked to the individual questionnaire, the best estimate is the highest prevalence given by either of the two methods of data collection used in the multi-country study (i.e. face-to-face and anonymous report). 8 E. Dartnall, R. Jewkes / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 3–13

Sexual violence in intimate relationships is not unique to heterosexual partnerships.33 Population- based research with adult men in South Africa found that 9.6% of men reported male-on-male sexual violence victimisation and 3.0% reported perpetration; 3.3% had been raped by another man, and 1.2% perpetrated male-on-male rape. Men who have sex with men (MSM) were over four times more likely than non-MSM to disclose sexual violence victimisation (34.4% v 8.1%), and over nine times more likely to have been raped (21.3% v 2.3%).34 A similar rate of 4% experiencing forced sex within their intimate relationships was reported by MSM in a study undertaken in the USA.35 These ﬁndings reﬂect the need for a more nuanced understanding of sexual violence within intimate relationships to help guide service responses and prevention programmes.

Non-partner sexual violence

Non-partner rape is common, although with varying rates of occurrence across settings. This perpetrator group includes a family member, stranger, person known by sight or acquaintance. Comparability of estimates is sometimes hard as some include rape and attempted rape, whereas others focus just on completed rape. According to the WHO MCS, the proportion of women reporting rape by a non-intimate partner since the age of 15years ranged from less than 0.3% in Ethiopia province, up to 11.5% in Tanzania province12 (Table 3). The National Intimate Partner and Sexual Violence Survey found that one in seven female victims (13.8%) had experienced being raped by a stranger.18 The latest estimates of prevalence of non-partner completed rape victimisation from South Africa is 12.2% in a population-based representative sample of adult women living in Gauteng province. In this study, an additional 1.8% had experienced an attempted rape. Overall, 4.9% of women had been raped by a non-partner on more than one occasion.6 This is higher than previous estimates, but the study methodology was stronger and it is compatible with the finding from the 1998 ‘Three Province Study’ that 2% of women had been raped in the past 12 months.36 Again differences in prevalence rates are a reflection of the type of study, the definitions used and the context within which the studies were conducted, as well as true underlying patterns of rape. Prevalence studies, done well, using well-developed research tools and definitions, are of fundamental importance for policy making and service development.

Forced ﬁrst sex

For many young girls and women around the world, their first experience of sex is that of coercion and force. The WHO MCS study, for example, found that, in six of the 15 sites, more than 10% of women reported their first sexual experience was forced. The prevalence ranged from less than 1% in Japan and Serbia and Montenegro, and highest in Bangladesh, where between one-quarter and nearly one-third of women reported that their first experience of sex was forced (Table 3). Forced sex and coercion is more prevalent among girls than boys, and adolescence is a time of risk for experiencing forced first sex.1 Forced sexual intercourse was reported by 45.0% of female students, and 32.0% of male students, in a sample of 2705 pupils from 39 schools in Plateau state, Nigeria.37 A study with young adolescents and adults in Lima Peru, found that 40% of females and 11% of the males reported coercion at sexual initiation.38 In a nine-country study in the Caribbean,d 47.6% female and 31.9% of male sexually active adolescents said their first sexual experience was forced.39 In a multi-country study of school-going children in 445schools across 10 southern African countries,e the overall reported prevalence of forced or coerced sex for 16-year olds was 28.8% for female students and 25.4% for male students.40 The high prevalence of forced sex disclosed by boys largely reflects two social phenomena. One is pressure boys experience to show manliness through having sex at a time in their lives when they do not feel ready for it. This is often pressure from male peers, but it can also be from girlfriends. The other is coercion of boys into sexual acts with older women. In a South African study with a large sample of adolescents, 3.4% of men disclosed being forced into sex by a man, and 9.7% by a woman. Unwanted sexual touching was reported by 7.8%; and 2.3% reported having sex with someone who wasn’t

d Antigua, Bahamas, Barbados, British Virgin Islands, Dominica, Grenada, Guyana, Jamaica and Saint Lucia. e Botswana, Lesotho, Malawi, Mozambique, Namibia, Swaziland, Zambia, Zimbabwe, South Africa and Tanzania. E. Dartnall, R. Jewkes / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 3–13 9 a girlfriend due to being threatened or forced.41 Women who coerced were generally much older and the boys were in their early teens. These acts were clearly distressing for the boys. The context of forced ﬁrst sex needs to be better understood.

Multiple perpetrator rape

Most rape involves only one perpetrator; however, in some settings, rape by more than one man is quite common. This is particularly true in war, but also in some peaceable countries. As with other forms of sexual violence, great variation exists in reported prevalence of multiple perpetrator rape across studies, owing to context and definitions used. Studies from South Africa that have captured data on rapes involving two or more perpetrators report a multiple perpetrator rape population prevalence ranging between 7 and 9%, although one study of adolescent research volunteers found a prevalence of 14% (Table 4). Comparable data from Bangladesh found a population prevalence of 2%.17 A study in the USA on what the researchers described as ‘multiple person sex’ (MPS), was conducted in an effort to gain insight into adolescents having sex with three or more people. Researchers in this study defined MPS as sex involving multiple people that was either consensual (i.e. ‘three-ways’ or ‘group sex’) or forced (i.e. ‘gang rape’). The study sample was 328 females visiting an urban health clinic. Overall, 7.3% reported engaging in MPS, of which just over one-half (52%) said they were coerced and 43% reported having being threatened or forced.43 Rapes involving more than one perpetrator are reportedly more violent than single perpetrator rapes, most perpetrators of gang rape are male,44 and weapons were much more commonly found in rapes involving two or more perpetrators.45 Substantial under-disclosure by women is likely to influence reported figures on multiple perpetrator rape. Such under-reporting is almost certainly caused by considerable stigma associated with having been ‘gang raped’.

Prevalence of rape perpetration

As with victimisation, estimates on perpetration of rape also vary greatly across settings. Most countries lack population prevalence data on perpetration of sexual violence against partners and non- partners.46 Globally, the only population-based data on rape perpetration from large samples of men is from middle- and low-income countries. In this work, South Africa has led the way (Table 4). South Africa has high levels of rape perpetration, with 28–37% of men, aged between 18 and 49 years, interviewed in two large community-based surveys reporting having perpetrated a completed act of rape.13,14 The IMAGES15 study also found high rates of rape perpetration. In India, for example, 24% of all men (and 36% of married men) surveyed disclosed having ever been sexually violent, compared with 9% of men in Chile and Rwanda. Preliminary findings from Bangladesh from the Change Project17 multi- country study found that 10% of urban men, and 15% of rural men, had ever forced their partners into sex.17 As with India, almost all sexual violence identified in Bangladesh occurred within marriage. Estimates from population-based studies and studies with college men from high-income countries on rape perpetration range from between 5.6% and 27% of adolescents and are based on men reporting an act that would meet legal definitions of rape or attempted rape. In a small population-based sample of US men, 24.5% reported perpetration of an act that would meet legal definitions of rape or attempted rape.47 This figure was much higher than that from a national study of US college men, 7.7% of whom reported having engaged in behaviour that met the legal definition or rape or attempted rape,9 or

Table 4 Prevalence of multiple-perpetrator rape in studies conducted in South Africa.42

Country Study Prevalence (%)

South Africa Stepping Stones trial: 1400 men aged 15–26 years from rural Eastern Cape, 14 school going volunteers in HIV prevention trial.14 South Africa Study of men, masculinity and rape: randomly selected general population 9 sample of 1738 adult men from Eastern Cape and Kwa Zulu Natal.13 South Africa Study of GBV in Gauteng province: randomly selected general population 7 sample of 500 men.6 10 E. Dartnall, R. Jewkes / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 3–13 a national study of adolescents, where 5.6% of male adolescents reported they had sexually coerced a romantic partner.48 Perpetration of sexually coercive practices that fall short of rape are much more common in many high-income settings than rape. For example, 15% of men in a study on the prevalence of perpetration among Spanish college men, reported some involvement in sexual behaviours when the woman did not want it, whereas 5.2% had raped or attempted rape.49 Available prevalence estimates indicate that perpetration of rape may be lower in high-income countries than in low- and middle-income countries but, currently, insufﬁcient data conﬁrm this.46

Sexual violence in childhood

Child sexual abuse is global problem.48 A number of reviews and meta-analyses have been undertaken on child abuse victimisation, and have found lifetime prevalence rates ranging from 7–36% – for women and 3–29% for men.50 52 The WHO MCS found that between 1 and 21% of women interviewed reported child sexual abuse before the age of 15 years. In most cases, the perpetrator was a male family member other than the father or stepfather.12 The IMAGES study53 found rates of child sexual abuse against boys ranged, for example, from between 3% in Croatia, 8% in Chile, to 17% in Rwanda and 21% in India. Other data on the history of child sexual abuse (including both forced sexual intercourse and other sex act including such as unwanted touch) reported by adult women sourced from large Reproductive Health national surveys from Latin America and the Caribbean, found prevalence rates among women from 5.8% in El Salvador, 4.0% in Nicaragua, 2.9% in Ecuador, and 2.6% in Paraguay.22 Population-based data on the prevalence of child sexual abuse perpetration are completely lacking. National surveys undertaken in developing countries have found high rates of child sexual abuse. Research from Bangladesh found a high proportion of men interviewed reported experiencing some form of sexual abuse during childhood (37% of urban man and 22% of rural).17 Other recent large studies on child abuse have been undertaken in Swaziland (girls only) and Tanzania. The Tanzanian study found that nearly three out of every 10 girls and three out of every 20 boys reported having experienced sexual abuse.54 The study in Swaziland found that about one in three girls had experienced some form of sexual violence before the age of 18 years. Most perpetrators (75%) were men and boys from the victims’ communities.55 In Switzerland, as survey of more than 6500 school children found that 22% of girls and 8% of boys reported ever having experienced sexual assault at least once in their lives, but only 3–5% of them said they had reported the abuse.56 Data from the US-based Adverse Childhood Experiences study found that 24.7% of girls and 16.0% of boys had experienced sexual abuse during their childhood.57 Estimates for child sexual abuse vary greatly between studies. As with other types of sexual violence, variations in prevalence may be explained by differing methods and deﬁnitions used.51,58 Memory of the abuse may be repressed and thus prevent disclosure or uncertainty about what ‘really happened’. Much of the research has been conducted with adults asking about childhood experiences, and this increases the likelihood of recall bias. If children are interviewed, comparability is hindered by the age structure of the population (i.e. it is not possible to calculate the proportion of children ‘ever’ abused). Similarly, if adults are interviewed a past year prevalence of child sexual abuse cannot be calculated. The estimates cited by research need to be interpreted with these limitations in mind.

Sexual violence in schools

Sexual violence in schools takes a number of forms, and sexual assault and harassment are common in many countries, with perpetrators most often being school teachers, other school administrators and fellow pupils.59 Owing to poverty, many school-going girls are forced into transactional sexual relationships with teachers.60,61 The South African Demographic and Health Survey conducted in 1998 included questions about experience of rape before the age of 15 years, and found that school teachers were the largest group of child rape perpetrators, responsible for 32% of the disclosed child rapes.62 A study undertaken in Kenya with 1206 in-school youth, found that 58% of the children interviewed reported sexual harassment, with most of the perpetrators being peers.59 To accurately gauge the size of the problem is difﬁcult, particularly given the clandestine nature of sexual violence in schools. Disclosing rape and sexual assault within a school setting can be particularly challenging for the victim. Research indicates that disclosure of such abuses is often met with disbelief, E. Dartnall, R. Jewkes / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 3–13 11 denial, or that it is a normal part of life so what is all the fuss about.63 Schools in many countries around the world are failing in their commitment to protect children and provide safe places for learning.

Conclusion

Sexual violence against women and children, and in some instances men, in its many forms is prevalent across all societies. No society is free from rape. Prevalence of sexual violence differs across settings. Reasons may include how sexual violence is measured, the deﬁnitions used, the stigma and shame associated with the act, the extent to which disclosure of abuse and assault is encouraged, and cultural beliefs and the role of women and children in society. Measuring prevalence is, however, important, hence global efforts to strengthen the tools and methodologies to do so. Data are lacking on the various forms of sexual violence, particularly in developing countries, making it difﬁcult to develop appropriate responses and prevention programmes. Prevalence estimates provide policy makers and advocates with information to guide service and policy development and to advocate for resources to do so. It also provides us with insight into where to focus our prevention efforts.

Practice points

Rape-free societies do not exist; depending on setting, between one in 20 and one in two women have been raped by either an intimate or non-intimate partner. Global published research on the prevalence of rape perpetration is limited, but current estimates are that between one in 20 and one in three men have perpetrated a completed act of rape. The proportion of boys and men who have been forced into sex against their will in many settings is quite high, and perpetrators may include women as well as men. Child sexual abuse is common and affects both girls and boys, but girls are more at risk than boys. Perpetrators are usually well known to the victim. Sexual violence often occurs in schools and school health services need to be aware of the potential for problems on school premises as well as likely prevalence of sexual violence among learners of all acts of sexual violence, and put in place school based prevention programmes.

Research agenda

Improved research is essential. Research priorities for the magnitude of sexual violence prevalence needs to include:

Measurement of the prevalence and patterns of sexual violence victimisation in a range of settings, across a range of acts of sexual violence, in men and women using methodologies based on best practice in gender-based violence research and standard measures of different forms of sexual violence. Measurement of the prevalence and patterns of sexual violence perpetration in a range of settings, across a range of acts of sexual violence. Measurement of the prevalence and patterns of sexual violence experienced by children in a range of settings, across a range of acts of sexual violence. Research on the social context of sexual violence perpetration and victimisation by both men and women. Methodological research to reﬁne measures of sexual violence for particular population sub- groups or violence types, such as child perpetrators or young child victims, or sexual harassment at work and school. 12 E. Dartnall, R. Jewkes / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 3–13

Conﬂict of interest

None declared.

References

*1. Jewkes R, Sen P & Garcia-Moreno C. In Krug E et al. (eds.). Sexual violence in world report on violence and health. Geneva: World Health Organization, 2002. 2. Turquet L, Seck P, Azcona G et al. Progress of the world’s women 2011–2012: in pursuit of justice. New York: UN Women, 2012. 3. Truman JL. National crime victimization survey: criminal victimization, 2010. Washington DC: US Department of Justice, 2011. http://bjs.ojp.usdoj.gov/content/pub/pdf/cv10.pdf [last accessed 21.08.12]. 4. Ward C. Attitudes toward rape and rape victims: survey research, Attitudes toward rape: feminist and social psychological perspectives. London, UK: Sage Publications, 1995. 5. Shalhoub-Kevorkian N. Towards a cultural definition of rape: dilemmas in dealing with rape victims in Palestinian society. Women’s Stud Int Forum 1999; 22: 157–173. 6. Machisa M, Jewkes R, Lowe-Morna C et al. The war at home. Genderlinks, and gender and health research unit. Johan- nesburg, South Africa: South African Medical Research Council (MRC), 2011. *7. Jewkes R & Abrahams N. The epidemiology of rape and sexual coercion in South Africa: an overview. Soc Sci Med 2002; 55: 1231–1244. 8. Rennison C. Rape and sexual assault: reporting to police and medical attention, 1992–2000. Washington DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, 2002. *9. Koss MP, Gidycz CA & Wisniewsji N. The scope of rape: incidence and prevalence of sexual aggression and victimisation in a national sample of higher education students. J Consult Clin Psychol 1987; 55: 162–170. 10. Sikweyiya Y, Jewkes R & Morrell R. Talking about rape: men’s responses to questions about rape in a research environment in South Africa. Agenda 2007; 74: 48–57. 11. Langhang LF, Sherr L & Cowan FM. How to improve the validity of sexual behaviour reporting: systematic review of questionnaire delivery modes in developing countries. Trop Med Int Health 2010; 15: 362–381. *12. Garcia-Moreno C, Henrica AFM, Watts C et al. WHO multi-country study on women’s health and domestic violence against women: initial results on prevalence, health outcomes and women’s responses. Geneva: World Health Organization, 2005. *13. Jewkes R, Sikweyiya Y, Morrell R et al. Gender inequitable masculinity and sexual entitlement in rape perpetration South Africa: findings of a cross-sectional study. PloS One 2011; 6: e29590. 14. Jewkes R, Dunkle K, Koss MP et al. Rape perpetration by young, rural South African men: prevalence, patterns and risk factors. Soc Sci Med 2006; 63: 2949–2961. *15. Barker G, Contreras JM, Heilman B et al. Evolving men: initial results from the International Men and Gender Equality Survey (IMAGES). Washington DC and Rio De Janeiro: International Center for Research on Women and Instituto Promundo, 2011. 16. UNDP Partners for Prevention. The change project; http://www.svri.org/partnersprevention.htm or http://www. partners4prevention.org/ [last accessed 20.08.12]. 17. Naved RT, Huque H, Farah S et al. Men’s attitudes and practices regarding gender and violence against women in Bangladesh: preliminary findings. b; Special Publication No. 135. Bangladesh: icddr, 2011. 18. Black MC, Basile KC, Breidling MJ et al. National intimate artner and sexual violence survey (NISVS): 2010 summary report. Atlanta GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2011. 19. Measure DHS. http://www.measuredhs.com/ [last accessed 5.08.12]. 20. Institute for Health Metrics and Evaluation. Surveys families series. http://www.healthmetricsandevaluation.org/ghdx/ series/reproductive-health-survey-rhs [last accessed 5.08.12]. *21. Ellsberg M, Heise L, Peña R et al. Researching domestic violence against women: methodological and ethical considerations. Stud Fam Plann 2001; 32: 1–16. 22. Goodwin M, Guedes A, Bott S, et al. Violence against women in Latin-America and the Caribbean: Comparative findings from recent population-surveys. Presentation made at PAHO's Commemoration of the International Day for the Elimi- nation of Violence Against Women, 2010. http://www.google.co.za/url?sa¼t&rct¼j&q¼&esrc¼s&frm¼1&source¼web& cd¼1&ved¼0CFgQFjAA&url¼http%3A%2F%2Fnew.paho.org%2Fhq%2Findex.php%3Foption%3Dcom_docman%26task% 3Ddoc_download%26gid%3D11530%26Itemid%3D&ei¼AAUyUJKrKcfPhAfqjIHYCw&usg¼AFQjCNHmeRd7cZE7Dsz9YXZYi WCGFU0q4w&sig2¼ElDLgmEMoPXl6_bSz3v9Cg [last accessed 20.08.12]. 23. Abrahams N, Jewkes R, Laubscher R et al. Intimate partner violence: prevalence and risk factors for men in Cape Town, South Africa. Violence Vict 2006; 21: 247–264. 24. General Secretary. The Secretary General’s in-depth study on all forms of violence against women. New York: United Nations General Assembly; 2006. 25. UN Women. Violence against women prevalence data: surveys by country. New York: UN Women, 2011. 26. Dunkle KL, Jewkes RK, Brown HC et al. Prevalence and patterns of gender-based violence and revictimization among women attending antenatal clinics in Soweto, South Africa. Am J Epidemiol 2004; 160: 230–239. 27. Jewkes R, Sikweyiya Y, Morrell R et al. Understanding men’s health and use of violence: interface of rape and HIV in South Africa. Pretoria¼: Medical Research Council, 2009. 28. Mouzos J, Makkai T. Women’s experiences of male violence: findings from the Australian component of the International Violence Against Women Survey (IVAWS). Research and Public Policy Series number 56, ed. Canberra: Australian Institute of Criminology. 29. Jewkes R & Dartnall E. Sexual violence. In Heggenhougen K & Quah S (eds.). International encyclopaedia of public health. San Diego: Academic Press, 2007, pp. 723–731. 30. Ellsberg M & Heise L. Researching violence against women: a practical guide for researchers and activists. Washington DC: World Health Organization and PATH, 2005. E. Dartnall, R. Jewkes / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 3–13 13

31. Deribe K, Beyene BK, Tolla A et al. Magnitude and correlates of intimate partner violence against women and its outcome in Southwest Ethiopia. PLoS One 2012; 7: e36189. 32. Shamu S, Abrahams N, Temmerman M et al. A systematic review of African studies on intimate partner violence against pregnant women: prevalence and risk factors. PLos ONE 2011; 63: e17591. 33. World Health Organization and London School of Hygiene and Tropical Medicine. Preventing intimate partner and sexual violence against women: taking action and generating evidence. Geneva: World Health Organization, 2010. 34. Dunkle KL, Jewkes R, Murdoch D, et al. Consensual male-male sex, male-male sexual assault and prevalent HIV infection in South Africa: results from a population-based household survey. MOPE300 – Poster Exhibition. AIDS 2012 XIX International AIDS Conference July 22-27 Washington DC USA http://pag.aids2012.org/abstracts.aspx?aid¼20124 [last accessed 20.08.12]. 35. Stephenson R, Khosropour C & Sullivan PS. Reporting of intimate partner violence among men who have sex with men in an online survey. West J Emerg Med 2010; 11: 242–246. 36. Jewkes R, Penn-Kekana L, Levin J et al. Prevalence of emotional, physical and sexual abuse of women in three South African provinces. S Afr Med J 2001; 91: 421–428. 37. Slap GB, Lot L, Huang B et al. Sexual behaviour of adolescents in Nigeria: cross sectional survey of secondary school students. BMJ 2003; 4: 15. 38. Cáceres CF, Marín BV & Hudes ES. Sexual coercion among youth and young adults in Lima, Peru. J Adolesc Health Care 2000; 27: 361–367. 39. Halcón LL, Beuhring T & Blum RW. A portrait of adolescent health in the Caribbean, 2000. Minnesota: WHO Collaborating Centre on Adolescent Health, Division of General Pediatrics and Adolescent Health, University of Minnesota, Minneapolis, 2000. 40. Andersson N, Paredes-Solís S, Milne D et al. Prevalence and risk factors for forced or coerced sex among school-going youth: national cross-sectional studies in 10 southern African countries in 2003 and 2007. BMJ Open 2012; Mar; 2: 2– e000754. 41. Sikweyiya Y & Jewkes R. Force and temptation: contrasting South African men’s accounts of coercion into sex by men and women. Cult Health Sex 2009; 11: 529–541. 42. Jewkes R. Streamlining: understanding gang rape in South Africa, 2012. London: Forensic Psychological Services, Middlesex University, 2012. 43. Rothman EF, Decker MR, Miller E et al. Multi-person sex among a sample of adolescent female urban health clinic patients. J Urban Health 2012; 89: 129–137. 44. Woodhams J, Cooke C, Harkins L et al. Leadership in multiple perpetrator stranger rape. J Interpers Violence 2012; 27: 728– 752. 45. Vetten L, Jewkes R, Sigsworth R, et al. Tracking justice: the attrition of rape cases through the criminal justice system in Gauteng, Johannesburg: Tshwaranang Legal Advocacy Centre, 2008. 46. Jewkes R. Rape perpetration: a review. Pretoria Pretoria, South Africa: Sexual Violence Research Initiative, Medical Research Council, 2012. http://www.svri.org/RapePerpetration.pdf [last accessed 20.08.12]. 47. Abbey A, McAuslan P, Zawacki T et al. Cross-sectional predictors of sexual assault perpetration in a community sample of single African American and Caucasian men. Aggressive Behav. 2006; 32: 54–67. 48. Casey EA, Beadnell B & Lindhorst TP. Predictors of sexually coercive behaviour in a nationally representative sample of adolescent males. J Interpers Violence 2009; 24: 1129–1147. 49. Martin AF, Vergeles MR, Acevedo Vde K et al. The involvement in sexual coercive behaviours of Spanish College Men: prevalence and risk factors. J Interpers Violence 2005; 20: 872–891. 50. Finkelhor D. The international epidemiology of child sexual abuse. Child Abuse Neglect 1994; 18: 409–417. 51. Stoltenborgh M, van Ijzendoorn MH, Euser EM et al. A global perspective on child sexual abuse: meta-analysis of prevalence around the world. Child Maltreat 2011; 16: 79–101. 52. Andrews G, Cory J, Slade J et al. Child sexual abuse. In: Comparative quantification of jealth risks: global and regional burden of disease attributable to selected major risk factors. Geneva: World Health Organization, 2004, pp. 1851–1940. 53. Contreras M, Heilman B, Barker G et al. Bridges to adulthood: understanding the lifelong influence of men’s childhood experiences of violence. Washington, DC: International Center for Research on Women (ICRW) and Rio de Janeiro: Instituto Promundo, 2012. 54. United Nations Children’s Fund and Centers for Disease Control. Violence against children in Tanzania: findings from a national survey. Dar es Salam: United Nations Children’s Fund; US Centers for Disease Control and Prevention, Muhimbili University of Health and Allied Sciences, 2011. 55. Reza A, Breiding MJ, Blanton C et al. Violence against children in Swaziland: findings from a national survey on violence against children in Swaziland May 15–June 16. Centers for Disease Control and Prevention and Swaziland United Nations Children’s Fund, 2007. 56. Schmid C. Sexual assault on children and adolescents in Switzerland: forms, extent and circumstances. Switzerland: UBS Optimus Foundation, 2012. 57. Centers for Disease Control and Prevention. Prevalence of individual adverse childhood experiences; Adverse Childhood Experiences (ACE) Study 2011, http://www.cdc.gov/ace/prevalence.htm. 58. Butchart A & Phinney Harvey A. Preventing child maltreatment: a guide to taking action and generating evidence. Geneva: World Health Organization and International Society for Prevention of Child Abuse and Neglect, 2006. 59. Ruto SJ. Sexual abuse of school age children: evidence from Kenya. J Int Coop Educ 2009; 12: 177–192. 60. Human Rights Watch. Scared at school: sexual violence against girls in South African Schools. South Africa: Human Rights Watch, 2001 [last accessed 5.08.12], http://www.unhcr.org/refworld/docid/3bdfdade4.html. 61. Antonowicz L. Too often in silence: a report on school-based violence in West and Central Africa. UNICEF, Plan West Africa, Save the Children Sweden West Africa and Action Aid, 2010. 62. Jewkes R, Levin J, Mbananga N et al. Rape of girls in South Africa. Lancet 2002; 359: 319–320. 63. Pinheiro PS. Violence against children in schools and educational settings. In: World report on violence against children. Geneva: United Nations Secretary-General’s Study on Violence against Children, 2006. Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 15–26

Contents lists available at SciVerse ScienceDirect Best Practice & Research Clinical Obstetrics and Gynaecology

journal homepage: www.elsevier.com/locate/bpobgyn

2 Health consequences of sexual violence against women

Ruxana Jina, MBChB, MMed, FCPHM, MSc (Epidemiology), Dr *, Leena S. Thomas, MBBS, MPH, DOH, MMed, FCPHM, Dr

School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, Johannesburg 2193, South Africa

Keywords: Sexual violence can lead to a multitude of health consequences, sexual violence including physical, reproductive and psychological. Some may be reproductive health fatal, whereas others, such as unhealthy behaviours, may occur mental health indirectly as a result of the violence. In total, these result in post-traumatic stress disorder a signiﬁcant health burden and should be considered by service providers, government authorities and non-governmental agencies. For women who present early, immediate care should be provided with plans for follow up. Mental-health interventions are important, as women who are sexually assaulted have the highest burden of post-traumatic stress disorder. Cognitive– behavioural therapy has been found to be effective for preventing and treating post-traumatic stress disorder, but psychological debrieﬁng for preventing post-traumatic stress disorder is not recommended. Implementing a routine screening and intervention programme in obstetrics and gynaecology departments may be valuable, as reproductive health consequences are common. Ó 2012 Elsevier Ltd. All rights reserved.

Introduction

Sexual violence, in addition to violating a woman’s rights, can result in immediate and long-term health consequences for women.1 These are brieﬂy described in this chapter. Sexual violence includes a range of acts, from rape and genital mutilation to forced marriages, and can occur in contexts such as armed conﬂicts or emergency situations.2 Although the health consequences and health needs resulting from all forms of sexual violence follow a similar pattern, there are some distinguishing features with certain acts of sexual violence that will be elaborated on further in this chapter.

* Corresponding author. Tel.: þ27 11 717 2622; Fax: þ27 11 717 2084. E-mail address: [email protected] (R. Jina).

1521-6934/$ – see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bpobgyn.2012.08.012 16 R. Jina, L.S. Thomas / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 15–26

Sexual violence often occurs with other forms of abuse: physical, emotional and ﬁnancial. In cases of – intimate partner violence, few women suffer from sexual abuse alone.3 5 In South Africa, two separate studies found that only 2% of women experience sexual intimate partner violence exclusively,4,5 whereas, in the USA, 40–50% of women who are physically assaulted by intimate partners have been reported to have also been sexually abused.6 These forms of abuse interact in a complex web of gender-based violence. Although the focus is solely on the health consequences of sexual violence in this chapter, one should remember that women may be facing, or may have faced, multiple forms of abuse in their lifetime. The focus of many investigators working in this ﬁeld has been on wider forms of abuse of intimate partner violence and gender-based violence, and a dearth of information is available on the consequences of sexual violence per se. Women who have experienced physical and sexual intimate partner violence are at a higher risk of experiencing health problems, especially mental, than those facing – physical violence alone.7 9 Women may have also experienced childhood sexual abuse, which has been shown to have longstanding health consequences as well as increasing the risk of intimate partner violence and sexual violence by a non-partner in later life.4,10

Overview of health consequences

Health consequences can be broadly grouped into more immediate effects directly stemming from the incident of sexual violence, whereas medium- to long-term consequences occur in the period after the sexual violation. Indirect health consequences, such as engaging in risky sexual behavior, may occur long after the violent incident. Furthermore, outcomes of sexual violence against women can be fatal or non-fatal, depending on the extent of injuries and health problems. Studies conducted in the USA have shown an increased risk of femicide with sexual violence, with signiﬁcantly more risk factors reported by sexually assaulted women compared with women who were only physically assaulted.6,11,12 A broad overview of the potential health consequences a woman could face from sexual violence is presented in Fig. 1.

Immediate health concerns of the sexual violence survivor

The immediate health concerns of a sexual violence survivor include the management of acute injuries. This may require the survivor to be stabilized, and pain and symptom relief may be necessary with anti-tetanus toxoid for contaminated wounds. If the survivor accesses health services within 3–5 days after the assault, she can be offered care to prevent an unwanted pregnancy, and to prevent sexually transmitted infections, including hepatitis B and human immunodeﬁciency virus (HIV).13 The mental health sequelae of sexual violence may begin from the point of the assault to months and years later. It may be necessary to identify these and provide appropriate care over a longer period. The provision of information to survivors, verbally and in print material, can be valuable, as they may experience symptoms later and be uncertain about how to approach these.13,14 At this point, medico-legal requirements, such as the collection of evidence for DNA analysis, are also important.

Medium- to long-term physical health consequences

A review conducted by the World Health Organization and the Sexual Violence Research Initiative provides an overview of physical and mental health sequelae after sexual violence.15 Gastrointestinal symptoms are found to be common with female survivors of sexual violence.14,16,17 In a random survey of women in Los Angeles, sexually assaulted women had twice the risk of reporting symptoms such as nausea, vomiting, abdominal pain, diarrhoea, and bloatedness (41%) compared with non- assaulted women (26%).16 Furthermore, a study18 conducted with women who were sexually violated found that they were signiﬁcantly more likely to think that they were fat, had sudden weight changes including substantial weight loss, and symptoms of anorexia compared with non-violated women. R. Jina, L.S. Thomas / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 15–26 17

Fig. 1. Health consequences of sexual violence. AIDS, autoimmune deﬁciency syndrome; HIV, Human immunodeﬁciency virus. 18 R. Jina, L.S. Thomas / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 15–26

Chronic conditions are increased in female survivors with much health impairment; they have a poor perception of health and seek medical care more frequently. They are, therefore, either unable to – work or have a high use of sick leave.16,19 23 It has been reported, however, that female survivors have lower rates of mental health service and preventive health care use.14 In addition, survivors are found to have a high reported number of cardiopulmonary and neurologic-type symptoms,16,17 including shortness of breath, palpitations, cardiac arrhythmias, chest pain, asthma, hyperventilation, choking sensation, numbness, weakness or faintness, insomnia and fatigue.15,24,25 In addition, chronic pain with back and facial pain, and ﬁbromyalgia, have been reported.2,14,26 Migraines and other frequent headaches have also been reported.17,20,27

Medium- to long-term reproductive health consequences

Women who are sexually violated may suffer from genital injuries that result in long-term complications. Other gynaecological complaints include vaginal bleeding or infection, genital irritation, fibroids, chronic pelvic pain, pre-menstrual syndrome and urinary tract infec- – tions.19,28 30 In a random survey of 3419 women in two communities in the USA, sexually assaulted women had over twice the risk of reporting painful menstruation (21% v 14%), painful intercourse (6% v 3%), and lack of sexual pleasure (15% v 4%) compared with women without a history of assault.31 Forced sex can also result in an unplanned or unwanted pregnancies, and a large longitudinal study with 4008 women in the USA found that, over a 3-year period, the national rape-related pregnancy rate was 5.0% per rape among victims aged 12–45 years, producing over 32,101 pregnancies nationally among women from rape each year. In this study, 50% of the women underwent an elective abortion, whereas 12% had a spontaneous miscarriage.32 In Ethiopia, 17% of adolescents in a school-based study reported falling pregnant after a rape, whereas two separate studies in crises centres in Mexico reported figures of 15% and 18% for their patients.2 In India, unplanned pregnancies were significantly more common among wives of sexually abusive men (OR, 2.62; 95% CI, 1.91 to 3.60).33 In some areas, women face undergoing backstreet abortions or may be forced to keep the child.2 Sexual assault can also place the women under an increased risk of suffering from sexually transmitted infections.6,30,34

Sexual violence and human immunodeﬁciency virus

Multiple potential pathways exist between sexual violence and human HIV.35 Human immunodeficiency virus can occur directly as result of rape, especially when genital and anal injuries are present. In addition, Jewkes et al.36 have proposed a number of indirect pathways between rape, child sexual abuse and intimate partner violence with HIV. This includes women participating in higher-risk behaviours, such as using condoms less frequently, having more sexual partners, having concurrent relationships, having sex while intoxicated and getting involved in transactional sex. These can occur either as a result of the sexual violence directly or indirectly as a result of psychological distress.37 Women suffering from sexual violence are also prone to have more risky partners with more controlling behaviours. A study conducted in India found that abusive husbands had been married several times, were more likely to be addicted to alcohol or drugs, and suffered significantly more from sexually transmitted infections than non-abusive husbands (P < 0.05).38 In South Africa, sexual intimate partner violence perpetration by men was found to be significantly associated with alcohol, drug use and having more than one current partner, having casual partners, engaging in transactional sex, and perpetrating non- intimate partner sexual assault.39,40 Negotiating for safer sex and condom use is a major challenge for survivors of sexual violence. In a shelter-based sample of women, 67% stated that they used no protection during sexual intercourse, mainly when sex was forced or because their partner insisted on this.28 Women fear that their request for condom use may be considered to imply that either partner is unfaithful or untrustworthy, and that – they would be abandoned.41 43 Additionally, it is feared that this will trigger further violence in the relationship.43 The effect of power dynamics and status in the relationship also plays a role here. R. Jina, L.S. Thomas / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 15–26 19

Studies have found that condoms are inconsistently or never used by women who feel that they have low relationship power.42,44,45

Psychological health consequences

Sexual assault can have immediate and long-term psychological consequences.2,15 Immediate reactions include feelings of shock, denial, fear, confusion, anxiety, panic, phobias, withdrawal, guilt or nervousness. Sleep and eating disorders also occur. Some women may repress their feelings and appear calm and subdued. Symptoms are found to peak at 3 weeks after the sexual violence, remain high for 1 or 2 months, and begin to decline from 2 months onwards.46 More long-term consequences include – anxiety, phobias, panic disorders, depression and suicide.47 49 Post-traumatic stress disorder (PTSD) symptoms can occur immediately, and have been reported up to 1 year after the assault, especially if not treated.25 Women who experience sexual violence as part of intimate partner violence are also reported to be at greater risk of developing PTSD or depression.19 Sexually violated women are more at risk of attempting or committing suicide.50,51 In a studyconducted with women suffering from intimate partner violence, it was found that women reporting sexual violence were 5.3 (95% CI 1.3 to 21.5) times more likely to report threatening or attempt suicide within 3 months compared with women who were only physically abused.6 Similarly, in a national study conducted in the USA with 627 women aged between 15 and 54 years, age of ﬁrst sexual assault was compared with age of ﬁrst suicide attempt, and it was found that both suicidal ideation and suicide attempts were three times more likely to follow a sexual assault as to occur before or within the same year of sexual assault.52

Post-traumatic stress disorder

Studies have shown that rape survivors are the largest group of people to develop PTSD,47 with rates of life-time prevalence of PTSD ranging from 30–94% in sexual assault survivors.15 Sexual violence has also been shown to predict the development of PTSD more strongly than any other trauma, including car accidents, physical attacks, robberies or natural disasters.53,54 Individuals diagnosed with PTSD suffer from disabling symptoms of re-experiencing the traumatic event through ﬂashbacks or recurrent nightmares, avoidance behaviours, and hyperarousal lasting for at least 1 month.55 These symptoms can persist for an extended period, and it has been shown that up to 50% of women retain symptoms of stress even with counselling.56,57 Women in general are twice more likely than men to develop PTSD after traumatic events, and their symptoms also tend to last longer. In addition, sexually assaulted women who develop PTSD are signiﬁcantly more likely than those who do not to have other co-occurring psychological problems.54

Health behaviours

Sexual violence has been linked to high-risk sexual behaviours, such as having unprotected sex, having multiple sexual partners, participating in sex work or transactional sex, having sex while under the inﬂuence of alcohol or drugs, and having high-risk sexual partners.58,59 Eating disorders and unhealthy eating habits associated with sexual violence include fasting, vomiting, abusing diet pills and overeating.60,61 Other unhealthy behaviors found to be associated with sexual violence include the use of cigarettes, heavy alcohol and illicit drug use, and a reliance on prescription medication.23,62 Many of these habits, such as the use of alcohol or high-risk sexual behaviour and substance abuse, can place the survivor at high risk of revictimisation.35 This has especially been reported in women with a history of child sexual abuse.14

Genital mutilation

The cultural practices of partially or totally removing the external female genitalia for non-medical reasons are referred to as female genital mutilation (FGM). It is carried out on infants, girls and women of all ages, and is often linked to cultural practices mainly in Africa, Asia and the Middle East.63 Immigrants from these areas living elsewhere may also continue these practices in their adopted countries. 20 R. Jina, L.S. Thomas / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 15–26

An extensive systematic review conducted by the World Health Organization in 2000,64 and a more recent review conducted in 2008,65 showed that FGM has significant health consequences for a woman’s physical, mental, gynecological and reproductive health. The gravity of the health consequence depends on the type of FGM experienced by the woman. The more severe forms of FGM contribute to serious health consequences, especially if not managed appropriately, such as complications during child birth leading to infant and maternal mortality.65 Short-term health problems include severe pain, bleeding from physical trauma to the genital area, acute urinary retention, infection such as tetanus and urinary infections, trauma to adjacent structures, – such as the urethra and bladder, and the psychological trauma of having one’s genitals cut.63 65 Long- term health consequences include scarring, painful sexual intercourse, strain during urination, recto– vaginal fistulas, anal incontinence, hypersensitivity of the genital area, cysts, painful menstruation, retention of menstrual blood, recurrent infections, pain and difficulty during gynecological examina- – tions, increased risk of sexually transmitted infections and HIV, and even infertility.63 65 Female genital mutilation also doubles the risk of maternal deaths during child birth owing to difficulty during labour. There is more reliance on caesarian sections, and an increased risk of neonatal deaths, stillbirths, and children born with cerebral palsy. Women with FGM may later need surgeries to widen vaginal openings for sexual intercourse and childbirth.63,66 On the contrary, some researchers have reported mixed results on the health consequences of FGM. Obermeyer67 found some associations between circumcision and infections, but no statistically significant associations with other health conditions, such as urinary problems and maternal and infant mortality.67 Another systematic review68 reported that women with FGM were more likely to experience painful sexual intercourse and reduced sexual desire, but that the evidence on psychological and social consequences was inconclusive.

Forced marriages

Forced marriages are often seen in children and women in whom their parents, relatives, or both, force or coerce them into marriages or alliances for monetary, traditional and cultural purposes. This is again common in Africa, the Middle East and Asia.69 When a relationship is forced on the girl child or woman, the ensuing sexual relationship may be physically and mentally traumatic to the female partner. If their husbands or partners are significantly older than them, which is often the case, the risk of sexually transmitted infections and HIV is high. Biological factors, such as hormonal fluctuations, immature genital tracts and permeability of vaginal tissue in young girls, also contribute to increased risk of HIV.70 A recent review, however, reported mixed findings towards HIV transmission risk, calling for more research on the pathways that result in poorer health outcomes.71 Many young girls in these marriages have unintended pregnancies or miscarriages.72 Furthermore, the pelvis of a young girl is not yet fully developed and, if pregnant, can lead to complications during pregnancy and child birth.71 Prolonged and obstructed labour can further lead to haemorrhage, severe infection and maternal death. Young mothers are prone to deliver low-birth-weight babies with neonatal complications.71 The age difference between partners may also cause a power differential in the marriage. A girl child or woman, for example, may be subjected to domestic abuse and intimate partner violence in the relationship.71 The other consequences to health and well-being include having no or poor access to education, which affects the ability of the girl-child to take care of her family.73 A systematic review of 10 studies conducted by Acharya et al.74 looked at factors associated with teenage pregnancy in South Asia. The reviewers found that, owing to poor understanding, poor use of health services, and a lack of empowerment, many girls were falling pregnant at a young age. The review also determined that anaemia, pre-term delivery, neonatal complications, low-birth-weight babies, pregnancy-induced hypertension and spontaneous miscarriages were common.

Sexual violence in complex settings

Complex settings in this context mainly include disasters, armed conflict and migration. Migration or forced displacement can result from disasters or armed conflict, and again women are vulnerable R. Jina, L.S. Thomas / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 15–26 21 and often victims of sexual violence in such situations.75 During periods of armed conflict, rape, sexual exploitation and gender-based violence against women are quite common. The sexual violence is often more aggressive and perverted (e.g. boys being forced to rape their mothers or relatives). Gang rapes are also more common.76,77 It is thus possible that genital trauma is more severe in such scenarios. High rates of psychosocial and mental-health needs have been reported in victims of sexual violence in areas of armed conflict. These include anxiety disorders, substance abuse and PTSD.78 Furthermore, situations in camps can put both the women and their children at risk. Women may be restricted to conduct activities, such as collecting firewood and water out of fear of being raped or assaulted.79 More attention it seems has been given to sexual violence during armed conflict and less to sexual violence during natural disasters such as earthquakes, floods, landslides and the like. Carballo et al.80 studied the effect of the 2004 Tsunami on the reproductive health of women in affected areas. During disaster situations, women, children, sick and elderly people, are often the most at risk. Sexual violence is a real threat for women in such situations. It was shown that the number of reported cases of rape – increased significantly in both Sri Lanka and Indonesia after the Tsunami in 2004.80 82 The lack of or disruption of normal health services in such situations further compounds the problems faced by affected women. Access to condoms and family planning, and even usual health care, may be completely disrupted during periods of armed conflict or disasters. High rates of unplanned and unwanted pregnancies, miscarriages and unsafe abortions may also result.

Social consequences of sexual violence

In this chapter, we deal mainly with the health consequences of sexual violence against women; however, it is well known that social and economic factors have a significant effect on health; therefore, brief mention must be made of the social consequences. Acts of sexual violence can result in stigmatisation by society, health providers and the family, including the intimate partner.2 This puts a strain on marital relations and affects how the woman rears her children. Women may receive minimal support from family and friends and even distance themselves, withdrawing from social activities. Sexual violence can also have harmful consequences for partners, families and the community in general. Women are sometimes perceived as being unfit for marriage, susceptible to further abuse and isolation.77 In some areas, women are married to their rapists.2 Women who marry young and have teenage pregnancies could also have little or no access to education. This can affect their economic ability to take care of themselves and their children as they get older.74 Children born from an incident of sexual violence also face stigma. Finally, providers of post-rape care are known to suffer from vicarious trauma, and even researchers involved in the field can be emotionally affected.83

Management of the health consequences of sexual violence against women

Immediate health problems of sexual violence can be managed with prophylaxis or treatment by providing (1) emergency and long-term care for injuries; (2) pregnancy prophylaxis; (3) tetanus prophylaxis if necessary; (4) managing the transmission risk for hepatitis B, HIV and other sexually transmitted infections; (5) and providing psychological first-aid.84 Follow-up care should be planned with the survivor. Management of medium- to long-term health consequences of sexual violence depends on the specific condition that is diagnosed. For reproductive health care, some treatments that may be required include surgical correction for closed or reduced vaginal openings, episiotomies during child birth, and management of infertility, dyspareunia and dysmenorrhea. Mental health care is required when a diagnosis of PTSD, depression, anxiety or panic disorders is made or where an individual has suicidal ideation. Health consequences of sexual violence against women are often not overt. In a clinical setting, a woman may present to her healthcare provider with vague complaints. Sexual violence may contribute to an underlying fear of sexual intimacy, painful sexual intercourse, infertility or other reproductive health problems. As an obstetrician and gynecologist, medical care should be provided as seen fit, and referral for other identified needs (e.g. mental health) may be necessary. 22 R. Jina, L.S. Thomas / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 15–26

Mental health interventions and their effectiveness

– Research has been conducted on mental-health interventions for sexual-assault survivors85 93; however, as this is limited, we can draw on research into treatment of mental-health conditions and PTSD in general.55 A number of different approaches have been used, and some attempts have been made to assess the effectiveness of these interventions. We present the most recent recommendations and thinking in the field. A description of the different forms of interventions, and the theories behind them, are beyond the scope of this chapter. A glossary of terms is provided by Bisson,55 and details of cognitive– behavioural therapy (CBT) are described by Foa and Rothbaum.94 For the immediate reactions to sexual violence, care and support need to be provided in a non- intrusive manner. Listen to the survivor, comfort her, assess her needs and concerns, provide information on coping mechanisms and support services, and refer if necessary.84 Psychological debriefing should not be used.55 Offer CBT to women with symptoms of PTSD. Assess for other mental-health problems and provide support and treatment as required. Follow up and monitoring is recommended to ensure that PTSD and other mental-health conditions (e.g. depression, suicidal ideation and panic disorders) can be diagnosed early and managed appropriately. Referral for specialist care may be required. For many women, symptoms will improve spontaneously over time without any treatment. A fairly recent systematic review that looked at the effectiveness of interventions to prevent or treat PTSD came to the following conclusions55: for preventing the development of PTSD, multiple-session trauma-focused CBT may be effective in people with psychological distress after a traumatic event, but the value of the treatment is uncertain for people who do not have psychological distress; single- session individual debriefing may actually increase the rate of PTSD compared with no debriefing; and supportive counselling may be less effective than multiple-session CBT. Evidence is insufficient to recommend any drugs for the prevention of PTSD.55 The reviewers found that trauma-focused CBT and eye-movement desensitisation and reprocessing therapy improves symptoms in individuals diagnosed with PTSD compared with stress management and present-centred therapy or no treatment.55 Therapeutic interventions include paroxetine, which may improve symptoms in individuals with PTSD and venlafaxine, which does not seem to be effective; limited evidence shows that sertraline and nefazodone may be effective. A Cochrane review conducted in the same year on psychological treatments for PTSD confirmed these findings.95

Conclusion

Sexual violence can lead to a multitude of health consequences. These are significant and should be considered by service providers, government authorities, and non-governmental agencies. Healthcare providers need to be educated and sensitised to the various health consequences that may result and how to manage them. More training on how to talk to individuals about sexual abuse, including intimate partner violence, is required, and what to do when these are uncovered.15 It has been reported that, although women who have been sexually violated are frequent attendees of health care, they do not necessarily seek care for the sexual violence itself, especially if they are experiencing symptoms after an extended period of time. Women attending health care later may also not disclose the abuse spontaneously, and a high degree of suspicion is required in individuals with non-specific chronic conditions. Screening for sexual violence and other forms of abuse may be of value, but this has to be linked to clearly planned interventions when such women are identified. Several limitations have been identified. Much of the work is based on cross-sectional studies and only a few longitudinal studies. In many of the studies, sample sizes are small. A few randomised- controlled trials have tested the effectiveness of mental-health interventions, but these too were fraught with limitations, again including small sample sizes, lack of blinding, short follow up-periods, and large loss-to-follow up.

Conﬂict of interest

None declared. R. Jina, L.S. Thomas / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 15–26 23

Practice points

Any intervention provided to the sexual assault survivor should consider their rights, needs and wants. Provide immediate care to survivors of sexual violence as required. Monitor and ensure follow-up care for survivors to monitor medical management and to assess their mental health state and other needs. Be alert for individuals who at high risk of suicidality. Do not provide single-session, individual psychological debriefing as a preventative measure, as this may increase the risk of developing PTSD. CBT is effective for the prevention and treatment of PTSD, whereas eye-movement desensitisation and reprocessing can be used for the treatment of PTSD. Maintain a high degree of suspicion in individuals who present with chronic non-specific conditions or where a medical cause cannot be identified. Implementing a routine screening and intervention programme in obstetrics and gynaecology departments may be valuable, as reproductive health consequences are common.

Research agenda

More robust studies are required to build the evidence on the health consequences of sexual violence against women and the interventions to treat these. This is especially important for mental-health interventions. In future studies, there is a need to distinguish between sexual violence, childhood abuse, lifetime trauma and violence, intimate partner violence, and physical and other forms of violence to understand clearly the effect of these factors on health outcomes.

References

1. Koss MP, Heise L & Russo NF. The global health burden of rape. Psychol Women Q 1994; 18: 509–537. 2. Jewkes R, Sen P & Garcia-Moreno C. Sexual violence. World report on violence and health. Geneva: World Health Organi- zation, 2002. p. 47–82. 3. Devries K, Watts C, Yoshihama M et al. Violence against women is strongly associated with suicide attempts: evidence from the WHO multi-country study on women’s health and domestic violence against women. Soc Sci Med 2011; 73: 79. 4. Dunkle KL, Jewkes RK, Brown HC et al. Prevalence and patterns of gender-based violence and revictimization among women attending antenatal clinics in Soweto, South Africa. Am J Epidemiol 2004; 160: 230–239. 5. Jina R, Jewkes R, Hoffman S et al. Adverse mental health outcomes associated with emotional abuse in young rural South African women: a cross-sectional study. J Interpers Violence 2012; 27: 862–880. 6. McFarlane J, Malecha A, Gist J et al. Intimate partner sexual assault against women and associated victim substance use, suicidality, and risk factors for femicide. Issues Ment Health Nurs 2005; 26: 953–967. 7. McFarlane J, Malecha A, Watson K et al. Intimate partner sexual assault against women: frequency, health consequences, and treatment outcomes. Obstet Gynecol 2005; 105: 99. 8. Cole J, Logan TK & Shannon L. Intimate sexual victimization among women with protective orders: types and associations of physical and mental health problems. Violence Vict 2005; 20: 695–715. 9. Bennice JA, Resick PA, Mechanic M et al. The relative effects of intimate partner physical and sexual violence on post- traumatic stress disorder symptomatology. Violence Vict 2003; 18: 87. 10. Watson LF, Taft AJ & Lee C. Associations of self-reported violence with age at menarche, ﬁrst intercourse, and ﬁrst birth among a national population sample of young Australian women. Womens Health Issues 2007; 17: 281–289. 11. McFarlane J, Campbell JC, Sharps P et al. Abuse during pregnancy and femicide: urgent implications for women’s health. Obstet Gynecol 2002; 100: 27. 12. Campbell JC, Glass N, Sharps PW et al. Intimate partner homicide review and implications of research and policy. Trauma Violence Abuse 2007; 8: 246–269. 13. Jina R, Jewkes R, Munjanja SP et al. Report of the FIGO Working Group on sexual violence/HIV: guidelines for the management of female survivors of sexual assault. Int J Gynecol Obstet 2010; 109: 85–92. 14. Astbury J. Services for victim/survivors of sexual assault: identifying needs, interventions and provision of services in Australia. Melbourne: Australian Institute of Family Studies, 2006. 24 R. Jina, L.S. Thomas / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 15–26

*15. World Health Organization. Sexual violence research initiative. Rape: how women, the community and the health sector respond. Geneva: World Health Organization, 2007. 16. Golding JM. Sexual assault history and physical health in randomly selected Los Angeles women. Health Psychol 1994; 13: 130. 17. Leserman J. Sexual abuse history: prevalence, health effects, mediators, and psychological treatment. Psychosom Med 2005; 67: 906–915. 18. Laws A & Golding JM. Sexual assault history and eating disorder symptoms among White, Hispanic, and African-American women and men. Am J Public Health 1996; 86: 579–582. 19. Campbell JC & Soeken KL. Forced sex and intimate partner violence. Violence Against Women 1999; 5: 1017–1035. 20. Golding JM. Sexual assault history and headache: five general population studies. J Nerv Ment Dis 1999; 187: 624. 21. Golding JM, Stein JA, Siegel JM et al. Sexual assault history and use of health and mental health services. Am J Community Psychol 1988; 16: 625–644. 22. Golding JM, Cooper ML & George LK. Sexual assault history and health perceptions: seven general population studies. Health Psychol 1997; 16: 417. 23. Resnick HS, Acierno R & Kilpatrick DG. Health impact of interpersonal violence 2: medical and mental health outcomes. Behav Med 1997; 23: 65–78. 24. Dutton MA, Green BL, Kaltman SI et al. Intimate partner violence, PTSD, and adverse health outcomes. J Interpers Violence 2006; 21: 955–968. 25. Kimerling R & Calhoun KS. Somatic symptoms, social support, and treatment seeking among sexual assault victims. J Consult Clin Psychol 1994; 62: 333. 26. Green CR, Flowe-Valencia H, Rosenblum L et al. Do physical and sexual abuse differentially affect chronic pain states in women? J Pain Symptom Manage 1999; 18: 420–426. 27. Green CR, Flowe-Valencia H, Rosenblum L et al. The role of childhood and adulthood abuse among women presenting for chronic pain management. Clin J Pain 2001; 17: 359. 28. Eby KK, Campbell JC & Davidson II WS. Health effects of experiences of sexual violence for women with abusive partners. Health Care Women Int 1995; 16: 563–576. 29. Collett BJ, Cordle CJ, Stewart CR et al. A comparative study of women with chronic pelvic pain, chronic nonpelvic pain and those with no history of pain attending general practitioners. Br J Obstet Gynaecol 1998; 105: 87–92. 30. Campbell JC & Alford P. The dark consequences of marital rape. Am J Nurs 1989; 89: 946–949. 31. Golding JM. Sexual assault history and women’s reproductive and sexual health. Psychol Women Q 1996; 20: 101–121. 32. Holmes MM, Resnick HS, Kilpatrick DG et al. Rape-related pregnancy: estimates and descriptive characteristics from a national sample of women. Am J Obstet Gynecol 1996; 175: 320–325. 33. Martin SL, Kilgallen B, Tsui AO et al. Sexual behaviors and reproductive health outcomes. JAMA 1999; 282: 1967–1972. 34. Martin SL, Matza LS, Kupper LL et al. Domestic violence and sexually transmitted diseases: the experience of prenatal care patients. Public Health Rep 1999; 114: 262. *35. Campbell JC, Baty ML, Ghandour RM et al. The intersection of intimate partner violence against women and HIV/AIDS: a review. Int J Inj Contr Saf Promot 2008; 15: 221–231. *36. Jewkes RK, Dunkle K & Nduna M. Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study. Lancet 2010; 376: 41–48. 37. Campbell JC & Lewandowski LA. Mental and physical health effects of intimate partner violence on women and children. Psychiatr Clin North Am 1997; 20: 353–374. 38. Salam MA, Alim MA & Noguchi T. Spousal abuse against women and its consequences on reproductive health: a study in the urban slums in Bangladesh. Matern Child Health J 2006; 10: 83–94. 39. Dunkle KL, Jewkes RK, Nduna M et al. Perpetration of partner violence and HIV risk behaviour among young men in the rural Eastern Cape, South Africa. AIDS 2006; 20: 2107. 40. Abrahams N, Jewkes R, Hoffman M et al. Sexual violence against intimate partners in Cape Town: prevalence and risk factors reported by men. Bull World Health Org 2004; 82: 330–337. 41. Kalichman SC, Williams EA, Cherry C et al. Sexual coercion, domestic violence, and negotiating condom use among low- income African American women. J Womens Health 1998; 7: 371–378. 42. Davila YR. Influence of abuse on condom negotiation among Mexican-American women involved in abusive relationships. J Assoc Nurses AIDS Care 2002; 13: 46–56. 43. Davila YR & Brackley MH. Mexican and Mexican American women in a battered women’s shelter: barriers to condom negotiation for HIV/AIDS prevention. Issues Ment Health Nurs 1999; 20: 333–355. 44. Pettifor AE, Measham DM, Rees HV et al. Sexual power and HIV risk, South Africa. Emerg Infect Dis 2004; 10: 1996–2004. 45. Pulerwitz J, Amaro H, De Jong W et al. Relationship power, condom use and HIV risk among women in the USA. AIDS Care 2002; 14: 789–800. 46. Campbell R. Mental health services for rape survivors. Minnesota: Mincava Electronic Clearing House, 2001, http://www. mincava. umn. edu/documents/commissioned/campbell/campbell.html [last accessed 9.08.12]. *47. Foa EB & Riggs DS. Posttraumatic stress disorder and rape. Rev Psychiatry 1993; 12: 273–303. 48. Resick PA. The psychological impact of rape. J Interpers Violence 1993; 8: 223–255. 49. Resnick HS, Kilpatrick DG, Dansky BS et al. Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. J Consult Clin Psychol 1993; 61: 984. 50. Davidson JR, Hughes DC, George LK et al. The association of sexual assault and attempted suicide within the community. Arch Gen Psychiatry 1996; 53: 550. 51. Wiederman MW, Sansone RA & Sansone LA. History of trauma and attempted suicide among women in a primary care setting. Violence Vict 1998; 13: 3. 52. Ullman SE & Brecklin LR. Sexual assault history and suicidal behavior in a national sample of women. Suicide Life Threat Behav 2002; 32: 117–130. 53. Creamer MC, Burgess P & McFarlane AC. Post-traumatic stress disorder: findings from the Australian National Survey of Mental Health and Well-being. Psychol Med 2001; 31: 1237–1247. R. Jina, L.S. Thomas / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 15–26 25

54. Kessler RC, Sonnega A, Bromet E et al. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995; 52: 1048. *55. Bisson JI. Post-traumatic stress disorder. Clin Evid 2010, http://www.ncbi.nlm.nih.gov/pubmed/21718580 [last accessed 9.08.12]. 56. Foa EB, Dancu CV, Hembree EA et al. A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims. J Consult Clin Psychol 1999; 67: 194. 57. Tarrier N, Sommerfield C, Pilgrim H et al. Cognitive therapy or imaginal exposure in the treatment of post-traumatic stress disorder. Twelve-month follow-up. Br J Psychiatry 1999; 175: 571–575. 58. Brener ND, McMahon PM, Warren CW et al. Forced sexual intercourse and associated health-risk behaviors among female college students in the United States. J Consult Clin Psychol 1999; 67: 252. 59. Basile KC, Black MC, Simon TR et al. The association between self-reported lifetime history of forced sexual intercourse and recent health-risk behaviors: findings from the 2003 National Youth Risk Behavior Survey. J Adolesc Health 2006; 39: 752. e1–e7. 60. Faravelli C, Giugni A, Salvatori S et al. Psychopathology after rape. Am J Psychiatry 2004; 161: 1483–1485. 61. Löbmann R, Greve W, Wetzels P et al. Violence against women: conditions, consequences, and coping. Psychol Crime Law 2003; 9: 309–331. 62. Wingood GM, DiClemente RJ & Raj A. Adverse consequences of intimate partner abuse among women in non-urban domestic violence shelters. Am J Prev Med 2000; 19: 270–275. 63. Reyners M. Health consequences of female genital mutilation. Rev Gynaecol Pract 2004; 4: 242–251. 64. World Health Organization. A systematic review of the health complications of female genital mutilation including sequelae in childbirth. Geneva: Department of Women’s Health, Family and Community Health, World Health Organization, 2000. *65. Utz-Billing I & Kentenich H. Female genital mutilation: an injury, physical and mental harm. J Psychosom Obstet Gynaecol 2008; 29: 225–229. 66. Banks E. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet 2006; 367: 1835–1841. 67. Obermeyer CM. The consequences of female circumcision for health and sexuality: an update on the evidence. Cult Health Sex 2005; 7: 443–461. *68. Berg RC, Denison E & Fretheim A. Psychological, social and sexual consequences of female genital; number 13. Oslo: Kunn- skapssenteret, 2010. 69. UNICEF. Early marriage: a harmful traditional practice: a statistical exploration. New York: UNICEF, 2005. 70. Türmen T. Gender and HIV/Aids. Int J Gynecol Obstet 2003; 82: 411–418. *71. Santhya KG. Early marriage and sexual and reproductive health vulnerabilities of young women: a synthesis of recent evidence from developing countries. Curr Opin Obstet Gynecol 2011; 23: 334. 72. Alemu B. Early marriage in Ethiopia: causes and health consequences. Ethiopia: Pathfinder International/Ethiopia 2006. 73. UNICEF. Early marriage: child spouses. Florence: UNICEF, 2001. 74. Acharya DR, Bhattaria R, Poobalan AS et al. Factors associated with teenage pregnancy in South Asia: a systematic review. Health Sci J 2010; 4: 3–14. 75. Vlachova M & Biason L. Women in an insecure world: violence against women: facts, figures and analysis. Geneva: Geneva Center for the Democratic Control of Armed Forces, 2005. 76. Turshen M. The political economy of rape: an analysis of systematic rape and sexual abuse of women during armed conflict in Africa. In Moser CNO & Clark FC (eds.). Victims, perpetrators or actors? Gender, armed conflict and political violence. London: Zed Books, 2001. 77. Josse E. ‘They came with two guns’: the consequences of sexual violence for the mental health of women in armed conflicts. Int Rev Red Cross 2010; 92: 177. 78. Ezard N & van Ommeren M. Responding to the psychosocial and mental health needs of sexual violence survivors in conflict-affected settings. New York: World Health Organization, Stop Rape Now, UNFPA, UNICEF, 2011, http://resourcecentre.savethechildren.se/ content/library/documents/responding-psychosocial-and-mental-health-needs-sexual-violence-survivors- [last accessed 9.08.12]. 79. Nduna S & Goodyear L. Pain too deep for tears: assessing the prevalence of sexual and gender violence among Burundian refugees in Tanzania. New York: International Rescue Committee, 1997. 80. Carballo M, Hernandez M, Schneider K et al. Impact of the Tsunami on reproductive health. J R Soc Med 2005; 98: 400–403. 81. Pikul C. As Tsunami recedes, Women’s risks appear. New York: Global Action on Aging, 2005. 82. del Vecchio D & Gharzeddine O. UNFPA calls for greater security for women affected by Tsunami. UNFPA 2005, http:// www.unfpa.org/public/cache/offonce/home/news/pid/937;jsessionid¼64F33EFC50403DCC090A62811B73E3FD [last accessed 9.08.12]. 83. Campbell R & Wasco SM. Understanding rape and sexual assault. J Interpers Violence 2005; 20: 127–131. *84. World Health Organization, War Trauma Foundation, World Vision International. Psychological first aid: guide for field workers. Geneva: World Health Organization, 2011. 85. Anderson T, Guajardo JF, Luthra R et al. Effects of clinician-assisted emotional disclosure for sexual assault survivors: a pilot study. J Interpers Violence 2010; 25: 1113–1131. 86. Echeburúa E, de Corral P, Sarasua B et al. Treatment of acute posttraumatic stress disorder in rape victims: an experimental study. J Anxiety Disord 1996; 10: 185–199. 87. Foa EB, Rothbaum BO, Riggs DS et al. Treatment of posttraumatic stress disorder in rape victims: a comparison between cognitive–behavioral procedures and counseling. J Consult Clin Psychol 1991; 59: 715. 88. Galovski TE, Monson C, Bruce SE et al. Does cognitive-behavioral therapy for PTSD improve perceived health and sleep impairment? J Trauma Stress 2009; 22: 197–204. 89. Resick PA, Jordan CG, Girelli SA et al. A comparative outcome study of behavioral group therapy for sexual assault victims*. Behav Ther 1988; 19: 385–401. 90. Resick PA, Nishith P, Weaver TL et al. A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. J Consult Clin Psychol 2002; 70: 867. 26 R. Jina, L.S. Thomas / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 15–26

91. Resick PA & Schnicke MK. Cognitive processing therapy for sexual assault victims. J Consult Clin Psychol 1992; 60: 748. 92. Rothbaum BO. A controlled study of eye movement desensitization and reprocessing in the treatment of posttraumatic stress disordered sexual assault victims. Bull Menninger Clinic 1997; 61: 317–334. 93. Rothbaum BO, Astin MC & Marsteller F. Prolonged exposure versus eye movement desensitization and reprocessing (EMDR) for PTSD rape victims. J Trauma Stress 2005; 18: 607–616. 94. Foa EB & Rothbaum BO. Treating the trauma of rape: cognitive-behavioral therapy for PTSD. The Guilford Press, 2001. *95. Bisson J & Andrew M. Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database Syst Rev 2007; 3: CD003388. Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 27–37

Contents lists available at SciVerse ScienceDirect Best Practice & Research Clinical Obstetrics and Gynaecology

journal homepage: www.elsevier.com/locate/bpobgyn

3 Psychological consequences of sexual assault

Fiona Mason, MB BS FRCPsych DFP, Consultant Forensic Psychiatrist and Chief Medical Ofﬁcer a,*, Zoe Lodrick, MSc. BA Hons (1st), Psychotherapist b a St Andrew’s Healthcare, Billing Road, Northampton NN1 5DG, UK b The United Kingdom Council for Psychotherapy, London, UK

Keywords: Sexual violence is an important issue worldwide and can have rape long-lasting and devastating consequences. In this chapter, we sexual assault outline the psychological reactions to serious sexual assault and psychological reactions rape, including development of post-traumatic stress disorder. post-traumatic stress disorder Myths and stereotypes surrounding this subject, and their poten- autonomic nervous system tial effect on the emotional response and legal situation, are discussed. Ó 2012 Published by Elsevier Ltd.

Introduction

The links between traumatic experience and psychological distress have been reflected in art and literature for centuries. Our scientific understanding of these links, however, and the reactions of victims, has only developed over the past 100 years. Victims or survivors, as many would prefer to be known, are just that: people who have experienced adverse circumstance and have lived in spite of the adversity. Rape and serious sexual assault are perpetrated against women and men, boys and girls; considerations such as social status, ethnicity, sexual orientation and religious persuasion are unlikely to affect the likelihood of an individual becoming a victim of such. The research would suggest, however, that most victims are female; therefore, while not forgetting child victims or male survivors, this chapter is written to address primarily (although not exclusively) the psychological consequences of sexual assault on women. Reference will be made to rape and serious sexual assault, as well as the more generic terms of sexual violence, sexual offences, or both; much of the research has focused on the former, although many of the difficulties seen in rape victims are equally applicable to those subject to other forms of serious sexual assault. We will use the terms interchangeably.

* Corresponding author: Tel.: þ44 (0) 1604616000; Fax: þ44 (0) 1604232325. E-mail address: [email protected] (F. Mason).

1521-6934/$ – see front matter Ó 2012 Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.bpobgyn.2012.08.015 28 F. Mason, Z. Lodrick / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 27–37

Sexual violence is a global problem. The lifetime risk of attempted or completed rape is estimated to be 20% for women, and 4% for men.1,2 British Crime Survey data from 20003 indicated that 0.4% of women respondents, aged between 16 and 59 years, disclosed that they had been raped in the preceding year; assuming the findings would be generalisable to the other years, this would equate to one in every 250 women being raped in the UK each year. Of the sexual crimes disclosed by respondents to the above survey, only 18% had been reported to the police. This figure is consistent with other – research, which variously indicates that between 5 and 25% of rapes are reported to police.4 6 Sexual offences are serious crimes with far-reaching consequences. Recently, a plethora of newly published, victim-focused guidance has been published for police,7,8 Crown Prosecution Services Prosecutors,9 Sexual Offence Examiners and Practitioners, Sexual Assault Referral Centres,10 and other professionals11 who come into contact with rape complainants, implementation, of which, has been patchy.12 Baroness Stern’s 2010 review into how rape complaints are handled by public authorities in England and Wales states that: ‘it is time to take a broader approach to measuring success in dealing with rape. The conviction rate, however measured, has taken over the debate to the detriment of other important outcomes for victims. We do not say that prosecuting and convicting in rape cases is in any way unimportant.. But in dealing with rape there is a range of priorities that needs to be balanced. Support and care for victims should be a higher priority.’12 Notwithstanding this, it is essential for those victims who choose to become complainants, that those interacting with them through the criminal justice process understand the significant physical and psychological consequences resulting from issues such as sexually transmitted infections, depression, anxiety and post-traumatic stress disorder (PTSD); conditions that can have a long-lasting effect on people’s well-being and future functioning.13

Myths and stereotypes

When hearing the word ‘rape’, many people will conjure up an image of a stranger attacking a woman at knife point in a dark public place. In reality, this situation is extremely rare. Most rapes, and other sexual assaults, are committed by someone known to the victim. Common categories of perpetrators include current or ex-husbands and partners, recent acquaintances, colleagues and people in positions of trust.6,14,15 This, in turn, means that many assaults take place in private, including inside the victim or perpetrator’s home, and in the context of daily lives. And yet, for some, including the victims themselves,3 such encounters are not always defined as rape; indeed, it was not until 1991 that rape within marriage was criminalised in England and Wales.16 The issue of force is another area around which myths abound. The use of force does not feature in the legal definition of rape in England and Wales,17 and most rapes do not involve overt physical assault or threat. Often, victims do not actively resist and many are not physically injured.18 If the victim themselves, however, or others hearing of the incident, hold the inaccurate assumption that rape always involves violent force, and that a victim of rape will be injured, this may cloud the judgements made about whether an incident was or was not rape. Anyone can be the victim of rape and all have the same rights to protection under the law. Desir- ability, in the way that individuals who engage in consensual sex understand it, has little to do with how and why rapists select their victim. Stereotypically ‘beautiful’ people are not more likely to be raped than stereotypically less beautiful people. Sex offenders, in the main, use the following to select their victim(s): asexual interest criteria; vulnerability; and accessibility. Once the offender has identified people who meet these criteria, they will focus on remaining undetected; perhaps the person they consider will be least likely to disclose, or the person least likely to be considered credible, if they do disclose; in this process sex offenders are very much assisted by the myths, stereotypes and societal judgements being addressed in this section of the chapter. Vulnerable women, such as those with, for example, a history of childhood sexual abuse, mental health problems, or learning disability, are more likely to be targeted by sex offenders, and are more – likely to be subject to repeat victimisation19 23; and yet, multiple reports of rape or sexual assault by an F. Mason, Z. Lodrick / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 27–37 29 individual are, on occasion, used to suggest that they are lying; that they are a serial false complainant; or that they are attention-seeking. Men who are raped, and men who rape men, are often wrongly assumed to be homosexual. On the contrary, both victims and offenders of male rape are frequently heterosexual.24,25 The resulting shame, confusion and sense of isolation, that the effect of such ignorance can have on male victims of rape, are frequently profound. Curiously, victims of rape are often judged as being culpable for the violation they have endured, and their behaviours before the rape perceived as having been ‘risky’. This was illustrated in a 2005 report by Amnesty International,26 and more recently in a 2010 survey,27 of UK residents. Over one-half (56%) of the respondents thought that there were some circumstances where a person should accept responsibility for being raped; for those people, the circumstances were as follows: performing another sexual act on someone (73%); getting into bed with someone (66%); drinking to excess or blackout (64%); going back to someone’s home for a drink (29%); dressing provocatively (28%); dancing in a sexy way with someone at a night club or bar (22%); acting flirtatiously (21%); kissing someone (14%); accepting a drink and engaging in a conversation at a bar with someone (13%). It cannot reasonably be assumed that a woman is consenting to sex from the way in which she is dressed, her reputation, whether she has previously agreed to levels of intimacy or even agreed to sex with the accused on another occasion. Yet, it seems that many of the general public believe that such behaviours make women responsible for being raped. This is clearly at odds with the law as it stands, and can have devastating consequences for recovery as guilt and shame are compounded.

Psychological reactions during rape and serious sexual assault

It is important to understand that it is the perception of threat, not the actual threat, that governs individuals’ responses during an assault. Most will be profoundly affected; fearful, disorientated, and helpless. Others, particularly where repeat victimisation is a factor, may cut off, dissociating from reality. Some women may submit to sexual intercourse from fear of what might happen if they were to resist, or even merely to protest. Most people, when asked to predict how they would react if somebody attempted to rape them, would likely respond that they would actively defend themselves by, for example, screaming, fighting or running. The corresponding reality is that most people faced with such threat do not actively defend themselves. The reason for the mismatch between our predicted reaction and our actual reaction is neurobiological. When imagining our response, we use our higher brain function and think rationally and logically; yet, when the experience actually occurs, our higher brain functions are likely to be impaired (as a result of the threat we are experiencing), and we respond instinctively. When faced with a perceived threat, the human system broadly responds in one (or more) of five predictable ways: ‘fight, flight and freeze’ (well-documented responses to threat), and ‘friend’ and ‘flop’,28 The survival strategy used in any given situation will depend upon a number of factors, namely: what is most likely to ensure survival (and also maintain vital attachments)?; what worked in the past?; and what was unsuccessful in the past? These processes mean that some women resist, run away or cry for help, whereas others will take a far more passive approach; indeed, they may appear frozen and unable to act.29 Submission or taking a passive stance is not, however, the same as consent: consent is actively given and actively reinforced, it is not passively assumed, and yet people might wrongly assume that if there is no injury, torn clothing, struggle or cries for help, then an assault was not committed. Dissociative mechanisms, such as de-realisation (a sense that the world around is not real), de- personalisation (a sense that it is not happening to ‘me’, rather it is occurring to someone else), and dissociation (a sense of being cut off from the actual situation) can result from extreme fear. It is likely that dissociative processes at the time of the trauma will permit the victim to endure the otherwise unendurable29; consequences of dissociation occurring at the time of the trauma include the following: losing track of what was going on; engaging in behaviours without actively deciding to do so; time becoming altered (e.g. things seem to be happening in slow motion, or at speed); sensory disturbances (e.g. moments when one’s body appears distorted or changed)30; and increased likelihood of the individual developing PTSD.31 30 F. Mason, Z. Lodrick / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 27–37

A further, grave, consequence of a victim having dissociated from an experience, and thus not having integrated or ‘owned’ it, is that it limits the individual’s capacity to learn from the experience.31 This, in turn, increases the victims’ vulnerability to future sexual assault. As a result of the impaired brain functioning that perceived threat induces, it is probable that the vital role of the higher brain structures in mediating explicit memory will also be disrupted.32,33 Memories of traumatic experiences are, therefore, more likely to be stored predominantly as implicit memory, which is emotional, sensory, less adaptable, context-free, and concerned with unconscious procedural learning.28 The hippocampus is one of the brain structures whose functions are disrupted under threat conditions. Hippocampi are essentially involved in the storage of explicit memory, and they play a central role in the organisation of spatial and temporal information.32 This means that the threatened individual will potentially perceive the passing of time and concepts such as space, distance and proximity inaccurately. Ultimately, this is likely to affect how such concepts are recalled. For some, the distortion in how they experienced an event will be recognised and they may, for example, declare ‘it felt like hours but, I suppose, it could have been a minute – Idon’tknow’;for others, however, they may not be aware that fear has inﬂuence the objective accuracy of their recollection and, as a result, their recall may be distorted, particularly with regard to spatial and temporal perception. The effect on brain function, as outlined above, can severely impair the person’s ability to recall details of the assault and recall may change over time. Memories of the traumatic event are often initially experienced as fragmented. Thus, for victims, sensory components, feelings and emotions may be more easily recalled while a detailed narrative may not, initially, be accessible. If a victim is to be questioned soon after the assault, questions that focus on perceptions (e.g. what did you feel, smell or hear), will likely yield better evidence than those that demand explicit narrative from the victim. With time, and especially with sleep (speciﬁcally rapid eye movement sleep), the higher brain structures will potentially process memory that has been encoded implicitly and, in doing so, explicit recall may increase. With further questioning and processing of the event (e.g. by sleeping, talking it though, or both), more of the narrative component may become accessible, and the victims’ account will change (usually by becoming more detailed).

Psychological reactions after sexual assault

Many factors will affect an individual’s response to trauma, and psychological reactions vary greatly between individuals. The ‘meaning’ that a victim ascribes to the incident is likely to be significant, a fact that is illustrated by the differences between stranger and acquaintance rape. It might be assumed that the former would be far more traumatic, but this is often not the case, and research has shown that rape victims have similar levels of depression and greater difficulty re-establishing intimate relationships after acquaintance rape.34 A woman raped by an acquaintance potentially has to question everything she ever held ‘true’. If she cannot trust her own judgement, nor her previous positive illusions about the world, and of how she would respond if faced with sexual threat, how can she go about her daily life?35 The world is suddenly a malevolent place where sex offenders are people she knows, and not strangers ‘out there’ to be mistrusted and avoided. Other elements that research indicates will contribute to the victim developing more severe post trauma responses include the following: the victim believes that the rapist will kill them, will sustain physical injury, or both36; the rape is completed (as opposed to attempted)36; the offender is someone known to the victim,37 and thus the element of ‘betrayal’ is significantly greater38; the victim disso- ciates at the time of the incident, exhibits dissociative symptoms immediately afterwards, or both39,40; the victim is unable to move as a result of their own nervous system response,28 or some external restraint41; the victim is very young42 or very old43 at the time of the incident; the victim has previously experienced psychological trauma,44 has prior psychiatric history, or both; the victim is in an environment of captivity at the time of the rape.45 One of the most important factors that predicts severity of post-trauma symptomatology in any rape victim is the post-trauma response received from the environment. For example, where a victims’ F. Mason, Z. Lodrick / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 27–37 31 experience of rape is ignored (deliberately or as a result of people simply not knowing), not recognised, minimised, or both; and where victims are blamed, judged as culpable, met with further violence, violation, or both. Lack of empathy and understanding can, therefore, reduce the prospects for a recovery. Immediate emotional responses will vary between individuals after rape, and should be viewed as a normal reaction to an abnormal event. The victim may be expressive and tearful, quiet and controlled, distressed, shocked or in denial. Early presentation may include anxiety, tear- fulness, shame, physical revulsion and helplessness. Guilt and self-blame are also normal post- trauma reactions. They serve as a means of reinstating positive illusions and defending against the unpredictability and uncontrollability of a world where bad luck can happen.46 In the weeks that follow, symptomatology may become more apparent and severe, symptoms may include anxiety, depression or PTSD, and a wide array of psychosomatic complaints may develop. Most women will experience extreme distress and disruption in many areas of their lives. Originally described as ‘rape trauma syndrome’ by Burgess and Holmstrom,47 many of the more persistent psychological symptoms observed in survivors of rape are now recognised as being compatible with a diagnosis of PTSD.48 Research indicates that most women recover from the acute effects of the attack at between 3 and 4 months. For example, Rothbaum et al.49 found that, soon after the crime (mean 12.64 days), 94% of their sample met symptomatic criteria for PTSD but, at 94 days (mean) after the assault, only 47% continued to do so. Many survivors, however, will experience more prolonged distress and develop difficulties such as persistent PTSD, substance abuse, anxiety, irritability, anger and depression. Kil- patrick et al.50 found that 51% of rape victims had developed PTSD sometime after the assault, and 16.5% still had PTSD when re-assessed some years later. Post-traumatic stress disorder can only be diagnosed after a traumatic incident; diagnostic classification systems vary in defining the nature of stressors that can cause PTSD, but rape and other serious sexual assaults meet the criteria in either system. Post-traumatic stress disorder has three broad symptom groups (as outlined in DSM IV-TR48): (1) persistent re-experiencing of the traumatic event; (2) persistent avoidance of stimuli associated with the traumatic event and numbing of general responsiveness; (3) persistent symptoms of increased arousal. For a formal diagnosis to be made, the symptoms must last for more than 1 month,51 and lead to clinically significant distress or impairment in social, occupational, or other important areas of functioning. Post-traumatic stress disorder is an extremely distressing and disabling condition. Intrusive symptoms such as flashbacks, nightmares and feeling as though the assault is reoccurring are profoundly upsetting to individuals who experience them. Their psychological response is often to become avoidant of thoughts, feelings, places and other reminders of the assault. This, in turn, will mean that individuals with PTSD will not want to talk about what has happened to them; they may also forget important aspects of the events in question. Some individuals present with significant levels of numbing and detachment, a presentation that can lead those observing them to believe that they are not at all distressed, when in fact these symptoms are characteristic of PTSD. Sufferers also experience increased levels of arousal, with difficulty sleeping, poor concentration, anger and irritability, jumpiness and an exaggerated startle response. As a result of these symptoms, many with PTSD (up to 30%) will use substances to cope with the unpleasant feelings; characteristically, depressant drugs, such as alcohol, marijuana or benzodiazepines, are commonly used by survivors of rape to ‘self-medicate’. Additionally, some survivors of rape will injure themselves and engage in other self-harmful behaviours. Other long-term difficulties reported include generalised and phobic anxiety, depression, difficulties with social adjustment and sexual functioning. Kilpatrick et al.52 reported that, of the 507 victims of rape surveyed, 30% had experienced at least one episode of major depression and 21% were depressed at the time of the survey. In contrast, only 10% of women who had never been raped had ever experienced major depression, and only 6% were depressed at the time of survey. Feelings of shame and humiliation are commonly described, often persist and clearly contribute to loss of self- esteem and depression. The level of suicidal ideation and attempts among rape victims is notable. Kilpatrick et al.52 found that 33% of rape victims compared with 8% non-victims had ever 32 F. Mason, Z. Lodrick / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 27–37 contemplated suicide, whereas 13% of rape victims compared with only 1% of non-victims had made a suicide attempt. Burgess and Holmstrom47 found 78% of their sample (n ¼ 81) had been sexually active at the time of rape but, of these, 38% gave up sex for at least 6 months and 33% decreased their frequency of sexual activity after rape. Studies comparing sexual satisfaction of rape victims with non-victims all report that rape survivors experience less sexual satisfaction.

Legal implications

When a victim of rape discloses their experience, it is important, and one determinant of the victim’s future psychological well-being,53,54 that the person receiving the disclosure has an understanding of potential psychological reactions to sexual assault and its aftermath. If the victim has chosen to disclose to the police and thus become a complainant, they are likely to encounter throughout the criminal justice system individuals who will make judgements based on their own, sometimes ignorant, belief systems. Attitudes might affect questioning, evidential acquisition, victim response, decisions about proceeding, and jurors deliberations. Beliefs held, when myth rather than reality, may have a crucial role to play in the victim’s well-being, and achieving justice. Neurobiological phenomena occurring at the time of the incident, as described earlier, can affect the survivor’s ability to give a coherent, consistent account of their experiences, and yet any perceived ‘inconsistencies’ in the victims’ account may be viewed as evidence that they are lying. Ironically, given what we know of the significant effect trauma has on brain functioning, and ultimately on recall, perhaps the opposite should be true (i.e. that the difficulty of a victim to give a coherent narrative of an assault should be deemed to increase their credibility rather than decrease it). Post-trauma symptoms themselves will also potentially affect recall and consistency. Indeed, the inability to recall an important aspect of the event is a characteristic symptom of PTSD, as is avoidance of thoughts that are associated with the trauma. Victims experience feelings of shame and self-blame,55 and this may lead them to give an incomplete or inaccurate account of the circumstances surrounding the rape. Cultural and religious considerations may also have a significant effect on the victims’ ability to disclose the full details of their experience. The survivor will often experience an increase in somatic complaints, such as headaches, muscle tension, and stomach upsets, and research has demonstrated that rape survivors visit their doctors more frequently for such complaints. It may be hard for the individual who has been assaulted to do anything that reminds them of the circumstances of the assault, and simple tasks may become impossible. They may be unable to go to certain areas and may avoid social contact. Home security may be enhanced, and they may be unable to confide in those who love them most. Their ability to access and benefit from support may, therefore, be limited. These factors may lead complainants to seem avoidant, and that avoidance may be wrongly interpreted as indicating that their account was false. The presentation of individuals who are so profoundly affected by the trauma that they appear detached, numb and disconnected, may be misinterpreted, and their complaint taken less seriously as a result.

Late reporting

The timing of reporting has historically influenced conviction rates, and it is important to understand why women may not report immediately. One study has shown that, if the woman made a complaint within 24 h of the rape occurring, and the suspect was subsequently charged, there was a 73% chance of conviction. Women who made a complaint between 24 h and 3 months after the rape, however, saw the conviction rate drop to 38%.56 Complainants are usually aware that, in reporting a rape, they face the risk of not being believed, of being blamed, and of having their behaviour exposed and scrutinised. Many will feel ashamed. For some, the shock, disbelief, and denial that frequently characterise post-trauma response will prevent them from being able to define what has occurred in a timely enough manner to facilitate immediate complaint. Others will need time to consider their experience and to define it, because few rapes fall F. Mason, Z. Lodrick / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 27–37 33 into the category that we might label ‘stereotypical’ and, as such, victims may fail to recognise immediately that their experience was that of rape (despite the fact that what occurred falls squarely within the legal definition of such). Women may fail to report immediately for simple, practical reasons; they may have childcare responsibilities and little social support, they may not have transport, or they may have to remain in the home with the perpetrator.

Re-traumatisation

If a complainant, especially if they have developed PTSD, is required to confront their traumatic experience during the history-taking necessary for the sexual offence examination, police interview and courtroom testimonies will thwart characteristic efforts at avoidance and predictably results in the resurgence of intrusive ideation and increased autonomic nervous system (ANS) arousal. The wish to avoid such distress may lead complainants to avoid court by retracting or altering their account, or not disclosing the full extent of their experiences. On the other hand, it may only be during times of high ANS arousal that the complainant seems able to access the traumatic memories in detail, and therein lies the danger of signiﬁcant re- traumatisation during interview, court appearance, or both. It requires a well-trained, sensitive and skilled doctor, interviewer, or legal counsel to facilitate the balance necessary for the victim to be allowed the time and support needed to disclose the level of detail necessary to meet the demands of the judicial system while ensuring the victim does not experience intolerable levels of ANS activation. If the victim is not sufﬁciently, and actively, supported to manage their ANS response, to that which they are disclosing, there is a real danger that their higher brain functions will become overwhelmed and the archaic structures of the brain that govern survival will become dominant (as they did at the time of the assault). Thus, the victim will likely become ‘compliant’ and ‘passive’, answering questions in the way they believe the interviewer wants them answered as opposed to stating what actually occurred. Arguably, a victim in such a state cannot give their informed consent to the interview or sexual offense examination. It is likely that individuals with heightened ANS arousal will be able to readily access implicit material (which is not usually accessible in a less activated state) and, for this reason, it is sometimes considered desirable. Material accessed in such an activated state, however, is unlikely to be explicitly recallable by the victim. This will result in a victim having disclosed to the doctor or police interviewer details that they do not consciously remember, and will almost certainly result in inconsistencies between the accounts they will give as their complaint proceeds through the criminal justice system. It is also the very process d replaying of ANS activation present at the time of the incident during recall of the incident d that gives rise to the phenomena of revictimisation44 experienced so alarmingly often by survivors of sexual violation. It hardly needs stating that, to reduce the likelihood of a victim of sexual crime becoming a repeat victim of sexual crime, is a priority. To minimise that likelihood, everyone who interacts with the victim after rape must be mindful not to do anything that intends to recreate the ANS high-arousal pattern that the rape itself would have elicited. In other words, victims must always be supported to remain very much in touch with the ‘here and now’ reality while recalling the ‘there and then’ (but not happening now) experience.28

Inconsistencies and lies

As mentioned previously, trauma can lead to extremes of retention and forgetting. Terrifying experiences may be remembered with extreme vividness, or may be totally inaccessible. Amnesia, for all or part of a traumatic experience, is not uncommon. As mentioned earlier, the victim may dissociate when faced with overwhelming threat, and will then be unable to integrate the totality of their experience into consciousness. This, in turn, will hamper their ability to provide a detailed, temporally accurate statement. Victims may, of course, also consciously alter parts of their account, so as to avoid shame, humiliation or possible consequences of their actions. Thus, the woman who has, for example 34 F. Mason, Z. Lodrick / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 27–37 taken illicit substances, may fabricate elements of their account so as to avoid having to disclose their illegal activity. Unless dealt with, such deception may create a false impression in court, in that the victim will be seen as lying in all aspects of the account that they gave.

The trial

Research supports the assumption that jurors are not familiar with typical reactions of rape survivors57 and hold a number of attributional beliefs about the complainant’s responsibility. Jurors tend to identify with a complainant (or defendant), and may have trouble understanding how that person could have felt or acted any differently to how they themselves would have felt or acted in the same situation and, yet, their judgement in this regard will be flawed, unless they understand the issues described. Ellison and Munro58 conducted a study in which volunteers observed one of nine mini-rape trial reconstructions and were asked to deliberate as a group towards a verdict. These deliberations were analysed to further understand what goes on behind the closed doors of the jury room in rape trials and explore the effect of complainant conduct during and post-assault on credibility. Many jurors were influenced by expectations about the instinct to fight back, the compulsion to report immediately, and the inability to control one’s emotions. Many jurors harboured unrealistic expectations about the association of sexual assault and physical injury. Jurors who received educational guidance were less likely to consider the fact of a 3-day delay before reporting or a calm demeanour as necessarily problematic. The authors concluded that concerns about the limits of current public understanding about what constitutes a normal reaction to sexual victimisation seem to be merited.

Treatment

Treatment for clinically signiﬁcant psychopathology is essential, and the general practitioner has an important role in identifying those who require formal treatment and ensuring active follow up. Clear guidance for the management of PTSD has now been published,59 and indicates that all PTSD suffers should be offered a course of trauma-focused psychological treatment (cognitive–behavioural therapy or eye movement desensitisation and reprocessing). These treatments should normally be provided on an individual outpatient basis, and should be offered regardless of the time that has elapsed since the trauma. For PTSD suffers who have no or only limited improvement with such treatment, healthcare professionals should consider an alternative form of trauma-focused psychological treatment, the augmentation of psychological treatment with a course of pharmacological treatment, or both. The use of antidepressant medication is particularly indicated where depressive symptoms are prominent. Given hyperarousal, short- term use of hypnotics and anxiolytics may be of beneﬁt in the immediate aftermath of a rape, but should not be continued for a prolonged period. Treatment requirements may be more complex in individuals with a history of repeat traumatisation, when referral to an appropriate specialist centre should be considered.

Conclusion

Rape and serious sexual assaults are serious crimes with far-reaching consequences, but are under- reported to the police owing to a variety of complex factors. Regardless of whether the perpetrator was a stranger or known to the victim, women can experience profound psychological consequences of this trauma. This can include developing mental illnesses such as depression and PTSD, which require appropriate treatment. A better knowledge of the neurobiological and psychological processes involved will allow professionals and the public to understand women’s reactions to rape. An attempt to dispel societal myths may, in turn, lead to an increase in reporting of rapes and improved conviction rates. F. Mason, Z. Lodrick / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 27–37 35

Practice points

Vulnerable women are more likely to be targeted by sex offenders and are more likely to be subject to repeat victimisation. When faced with a perceived threat, the human system broadly responds in one (or more) of five predictable ways: ‘fight, flight and freeze’ and ‘friend’ and ‘flop’. Memories of traumatic experiences are more likely to be stored predominantly as implicit memory. Immediate emotional responses will vary between individuals after rape, and should be viewed as a normal reaction to an abnormal event. Symptoms may include symptoms of anxiety, depression or PTSD, and a wide array of psychosomatic complaints. Clear guidance for the management of PTSD indicates that all PTSD sufferers should be offered a course of trauma-focused psychological treatment (cognitive–behavioural therapy or eye-movement desensitisation and reprocessing). The use of antidepressant medication is particularly indicated where depressive symptoms are prominent.

Research agenda

Effect of myths and stereotypes on recovery. Effect of myths and stereotypes on the criminal justice process. Effectiveness of early interventions on preventing chronicity. Effective treatments for victims of repeat traumatisation. How to ensure ‘best practice’ in court.

Conﬂict of interest

None declared.

Acknowledgements

The authors would like to thank Dr Clare Oakley for her helpful comments on this chapter.

References

1. Jewkes R, Garcia-Moren C & Sen P. Sexual violence in world report on violence and health. Geneva: World Health Organi- zation, 2002. 149–181. 2. Walker A, Flatley J, Kershaw C et al. Crime in England and Wales 2008/09, volume 1: findings from the British crime survey and police recorded crime. London: Home Office Statistical Bulletin 11/09, 2009. 3. Myhill A & Allen J. Rape and sexual assault of women: findings from the British crime survey. London: Home Office Findings, 2002. 159. 4. HM Crown Prosecution Service Inspectorate and HM Inspectorate of Constabulary (2007). ‘Without consent: a report on the joint review of the investigation and prosecution of rape offences’. London: HMCPSI, 2007. 5. Walby S & Allen J. Domestic violence, sexual assault and stalking: findings from the British Crime Survey. London: Home Office Research, Development and Statistics Directorate, 2004. 6. Povey D, Coleman K, Kaiza P et al. Homicide, firearm offences and intimate violence 2007/08. London: Home Office Statistical Bulletin 02/09, 2009. 7. Association of Chief Police Officers. An assessment of the viability of the dedicated team approach to rape investigation. London: ACPO, 2008. 8. Association of Chief Police Officers and Crown Prosecution Service. Guidance on investigating and prosecuting rape. London: ACPO, 2009. 9. Crown Prosecution Service. CPS policy for prosecuting cases of rape. London: CPS Communication Division, 2009. 36 F. Mason, Z. Lodrick / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 27–37

10. Department of Health, Home Office and Association of Chief Police Officers. Revised national service guide: a resource for developing sexual assault referral centres. London: Department of Health, 2009. 11. Department of Health. Responding to violence against women and children: the role of the NHS. The report of the taskforce on the health aspects of violence against women, 2010; http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_113727 [last accessed 27.08.12]. 12. The Stern Review. A report by Baroness Vivien Stern CBE of an independent review into how rape complaints are handled by public authorities in England and Wales. London: Government Equalities Office and Home Office, 2010. 13. Welch J & Mason F. Rape and sexual assault. BMJ 2007; 334: 1154–1158. 14. McGee H, Garavan R, de Barra M et al. The SAVI Report: sexual abuse and violence in Ireland: a national study of Irish experiences, beliefs and attitudes concerning sexual violence. Dublin Rape Crisis Centre. Dublin: The Liffey Press, 2002. 15. Martin EK, Taft CT & Resick PA. A review of marital rape. Aggress Violent Behav. 2007; 12: 329–347. 16. The marital rape exemption was abolished in England and Wales in 1991 by the Appellate Committee of the House of Lords, in the case of RvR. http://www.official-documents.gov.uk/document/hc9192/hc01/0167/0167.pdf. 17. Sexual Offences Act 2003; http://www.legislation.gov.uk/ukpga/2003/42/contents. 18. Sugar NF, Fine DN & Eckert LO. Physical injury after sexual assault; findings of a large case series. Am J Obstet Gynecol 2004; 190: 71–76. 19. Noll J, Horowitz L, Bonanno G et al. Revictimization and self-harm in females who experienced childhood sexual abuse. Results from a prospective study. J Interpers Violence 2003; 18: 1452–1471. 20. Classen CC, Palesh O & Aggarwal R. Sexual revictimisation. A review of the empirical literature. Trauma Violence Abuse 2005; 6: 103–129. 21. Sarkar NN & Sarkar R. Sexual assault on woman: its impact on her life and living in society. Sexual & Relationship Therapy 2005; 20(4): 407–419. 22. Read J, van Os J, Morrison A et al. Childhood trauma, psychosis and schizophrenia: a literature review with theoretical and clinical implications. Acta Psychiatr Scand 2005; 112: 330–350. 23. Finkelhor D & Yllo K. License to rape: sexual abuse of wives. New York: Holt, Rinehart and Winston, 1985. 24. Abdullah-Kahn N. Male rape. The emergence of a social and legal issue. Hampshire: Palgrave MacMillan, 2008. 25. Groth AN & Birnbaum HJ. Men who rape: the psychology of the offender. New York: Plenum Press, 1979. 26. ICM. Sexual assault research: summary report. Amnesty International UK, 2005. 27. Opinion Matters. Wake up to rape research summary report. Havens (Sexual Assault Referral Centres), 2010. 28. Lodrick Z. Psychological trauma: what every trauma worker should know. Br J Psychother Integr 2007; 4: 18–28. *29. Levine P & Frederick A. Waking the tiger: healing trauma. Berkley, California: North Atlantic Books, 1997. 30. Marmar CR, Weiss DS, Schlenger WE et al. Peritraumatic dissociation and posttraumatic stress in male Vietnam theater veterans. Am J Psychiatry 1994; 151: 902–907. *31. van der Kolk B, van der Hart O & Marman C. Dissociation and information processing in post-traumatic stress disorder. In van der Kolk B, McFarlance A & Weisaeth L (eds.). Traumatic stress: the effects of overwhelming experience on mind, body and society. New York: The Guildford Press, 1996. 32. Cozolino L. The neuroscience of psychotherapy: building and rebuilding the human brain. New York: Norton, 2002. 252. 33. Siegel D. The developing mind: how relationships and the brain interact to shape who we are. New York: The Guildford Press, 1999. 34. Ullman SE & Siegel JM. Victim-offender relationship and sexual assault. Violence Vict 2003; 8: 121–134. 35. Salter AC. Predators, pedophiles, rapists and other sex offenders. New York: Basic Books, 2003. *36. Kilpatrick DG, Saunders BE, Amick-McMullan A et al. Victim and crime factors associated with the development of crime- related post-traumatic stress disorder. Behav Ther 1989; 20: 199–214. *37. Salter A. Transforming trauma. California: Sage, 1995. 38. Freyd J. Betrayal trauma. USA: Harvard University Press, 1996. 39. McFarlane A & Yehuda R. Resilience, vulnerability, and the course of post-traumatic reactions. In van der Kolk B, McFarlance A & Weisaeth L (eds.). Traumatic stress: the effects of overwhelming experience on mind, body and society. New York: The Guildford Press, 1996. *40. van der Hart O, Nijenhuis E & Steele K. The haunted self: structural dissociation and the treatment of chronic traumatization. New York: Norton, 2006. *41. van der Kolk B. Posttraumatic stress disorder and the nature of trauma. In Solomon M & Siegel D (eds.). Healing trauma: attachment, mind, body and brain. New York: Norton, 2003. 42. Schore A. Early relational trauma, disorganized attachment, and the development of a predisposition to violence. In Solomon M & Siegel D (eds.). Healing trauma: attachment, mind, body and brain. New York: Norton, 2003. 43. Briere J & Scott C. Principles of trauma therapy: a guide to symptoms, evaluation and treatment. California: Sage, 2006. *44. van der Kolk B. The compulsion to repeat trauma: re-enactment, revictimization and masochism. Psychiatr Clin North Am 1989; 12: 389–411. *45. Herman J. Trauma and recovery: from domestic abuse to political terror. New York: Basic Books, 1992. 46. Lodrick Z. Victim guilt following experience of sexualised trauma: investigation and interview considerations. The Investigative Interviewer 2010; 1: 54–57. 47. Burgess AW & Holmstrom LL. Rape Trauma Syndrome. Am J Psychiatry 1974; 131: 981–986. 48. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: fourth edition – text revision (DSM- IV-TR). Washington DC: American Psychiatric Association, 2000. *49. Rothbaum BO, Foa E, Riggs DS et al. A prospective examination of post-traumatic stress disorder in rape victims. J Trauma Stress 1992; 5: 455–475. 50. Kilpatrick DG, Saunders BE, Veronen LJ et al. Criminal victimisation: lifetime prevalence, reporting to the police and psychological impact. Crime Delinq. 1987; 33: 479–489. 51. Where symptoms are evident in the initial month following exposure to a traumatic event a differential diagnosis of ‘Acute Stress Disorder’ may be applied. F. Mason, Z. Lodrick / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 27–37 37

*52. Kilpatrick DG, Veronen LJ & Best CL. Factors predicting psychological distress among rape victims. In Figley CE (ed.). Trauma and its wake. New York: Brunner, 1985. 53. Campbell R & Raja S. Secondary victimization of rape victims: insights from mental health professionals who treat survivors of violence. Violence Vict 1999; 14: 261–275. 54. Briere J & Scott C. Principles of trauma therapy: a guide to symptoms, evaluation and treatment. Thousand Oaks, California: Sage, 2006. 55. Dahl S. Acute response to rape: a PTSD variant. Acta Psychiatr Scand 1989; 80: 56–62. 56. Adler Z. Rape on trial. Routledge and Kegan Paul, 1987. 57. Frazier P & Borgida E. Juror common understanding and the admissibility of rape trauma syndrome in court. Law Hum Behav 1998; 12: 101–122. 58. Ellison L & Munro VE. Reacting to rape exploring mock jurors’ assessments of complainant credibility. Br J Criminol 2008; 49: 202–219. 59. NICE, Gaskell and the British Psychological Society. National clinical practice guidelines number 26. The management of PTSD in adults and children in primary and secondary care. National Institute for Clinical Excellence, Gaskell and the British Psychological Society, 2005. Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 39–46

Contents lists available at SciVerse ScienceDirect Best Practice & Research Clinical Obstetrics and Gynaecology

journal homepage: www.elsevier.com/locate/bpobgyn

4 The male victim of sexual assault

Iain A. McLean, PhD, Divisional Research Manager *

Manchester Academic Health Science Centre, University of Manchester and Central Manchester University Hospitals NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK

Keywords: Under-reporting by male victims is more pronounced than for male females victims, and so male victims remain a rarity for most rape sexual assault aftercare service providers. In this chapter, I present sexual assault a review of forensic medical and psycho-social literature on male- forensic medicine on-male rape and sexual assault. Where appropriate, comparison is made with female victims, as that is the context with which most aftercare service providers are familiar. The following aspects are covered: prevalence; deﬁnitions; social perceptions of perpetrators and victims of sexual assault on males; characteristics of victims and assaults; physiological and psychological responses; and implications for forensic medical investigation. Ó 2012 Elsevier Ltd. All rights reserved.

Introduction

Male-on-male rape and sexual assault is still a class of assaults seen less by many forensic physicians and other sexual assault aftercare providers, compared with assaults of women. The issue of under- reporting that afﬂicts all sexual assaults is especially strong in the situation of male victims owing to additional social and cultural factors. The purpose of this review is to help service providers recognise areas in which the experiences of male and female victims more commonly diverge. Naturally, a strong caveat is applied here that generalising the experiences of sexual assault is a limited enterprise and that the story of each individual should be attended to. Discussions of male-on-male compared with male- on-female sexual assault is not intended to say that the male victim is like ‘this’, or the rape of a female happens like ‘that’. Rather, it is that the range of female victim stories are more familiar to most sexual assault aftercare providers and so provides the context in which the more common features in the range of male experiences can be understood. Indicating areas of divergence, but also of similarity, will hopefully emphasise the individual nature of each incident of sexual assault. Although growing, the

* Tel.: þ44 (0) 161 701 2680. E-mail address: [email protected].

1521-6934/$ – see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bpobgyn.2012.08.006 40 I.A. McLean / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 39–46 research speciﬁcally on this subject (e.g. excluding sexual abuse of young boys, or rape and sexual assault in general) is still a relatively small body of work.1,2 For example, in March 2012, a PubMed search of the term ‘rape’ in the title or abstract produced 4767 articles, whereas speciﬁcally ‘male rape’ produced 23. In this chapter, I make reference to key publications on the subject arranged in headings of most interest, hopefully, to its intended audience: forensic physicians.

Legal deﬁnition of rape in England and Wales

Before considering the prevalence of this issue, we should define exactly what the issue is, and that is the phenomenology of rape or sexual assault committed by a male (or males) upon another male. Why this particular phrase is used is discussed in section two below, with reference to social perspectives of, and attitudes to, male-on-male sexual assault. For the purposes of this review, the word ‘rape’ in this phrase is defined according to the current legal definition in England and Wales, although articles under review may have held different interpretations, or collected data under a different definition: A person (A) commits an offence [of rape] if (a) he intentionally penetrates the vagina, anus or mouth of another person (B) with his penis; (b) B does not consent to the penetration; and (c) A does not reasonably believe that B consents.’ (s.1.1, Sexual Offences Act, 2003). This definition and the Act itself were important developments in the legal recognition of rape as a gender-neutral offence in England and Wales. It maintains, however, that rape is only committed by penetration with a penis, not an object or fingers, and therefore can only be committed by males. All other penetration is a separate offence, whereas some other investigators3 and, of course, other jurisdictions, have broader definitions. The Sexual Offences Act 1956 was amended in 1994 to include rape of a male until the 2003 Act overhauled sexual offences law. Before 1994, rape of a male did not exist in English law in those terms, rather there was the crime of buggery (unconsenting penile-anal penetration), which carried a lesser penalty.4 The relatively recent recognition of rape of a male being possible and illegal is reflected in how this issue is denied or misunderstood within society.

Prevalence

The prevalence of male-on-male rape or sexual assault is estimated at around 5–10% of all sexual assaults per year in Western countries, such as the UK, USA3 and the Nordic countries.5 Home Office crime data for England and Wales show that, in financial year 2010–2011, a total of 9901 rapes of victims aged 16 years and above were recorded, of which 9509 victims (96%) were female and 392 (4%) were male.6 This indicates the relative rarity of the issue and how it might be that forensic physicians, counsellors or other service providers do not see many male clients. Although this represents a smaller group compared with female victims, it is one that is, and has been, growing, as represented by the ratio of male–female clients at the St Mary’s Sexual Assault Referral Centre in Manchester, UK. In the first 5 years of its existence (1986–1991), the Centre saw fewer than 20 men who had experienced an acute sexual assault (i.e. not historic or ongoing child sexual abuse), but by 2002 it saw over 40 each year. That growth in referrals was matched in type of referrals; less than 30% of men from those first 5 years were referred by the police (i.e. victim had reported the assault to the police first) whereas, in 2002, it was over 70%.7 Such an increase in disclosure by men, and to the police, not just direct to support services, is a local effect from the presence of an excellent aftercare service and a trend evident across the UK.8 Similar comparative reticence among men who report at all, and especially to the police, was recorded across Norway, Denmark, Iceland, and Finland.5 Such figures are the result of the incidence and types of the assaults themselves, and also the different reactions of men to disclosing what has happened to them. This is discussed below.

Terminology and perceptions

The use of the term ‘male on male rape and sexual assault’ is cumbersome compared with ‘male rape’, but specific. ‘Male rape’ could be construed as rape committed by a male, and of course excludes I.A. McLean / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 39–46 41 other forms of sexual assault. The term is explicit, similar to ‘drug-facilitated rape and sexual assault’ compared with the more sensational but also more vague or misleading ‘drug rape’ or ‘date rape’.In a wider social context, the gendering of the word ‘rape’ by the addition ‘male’ emphasises the sense that this rarely happens to men. For example, the terms ‘male nurse’ and ‘male model’ both indicate that these are professionals traditionally associated with females. Expanding the phrase ‘male rape’ into a brief descriptive sentence, thus presents the issue in detail, rather than lazily labelling it as a subcategory of ‘normal’ rape. The term is also explicitly not about sexuality, in the way the term ‘homosexual rape’9 was. The acts may be described as homosexual, but the implication that either the perpetrator, victim, or both, were also homosexual themselves was, at best, misleading.10 Male-on-male rape, recorded as a form of homophobic punishment,11,12 is well documented in prisons13,14 and as a form of torture visited upon prisoners of war (i.e. former Yugoslavia in the early 1990s).15 With the latter, the exclusive male environment in which rapes occur enables them to be rationalised as being heterosexual masculine behaviour. Consequently, after care service providers should be interested in the effects rape or other sexual assault may have upon victim sexuality rather than seeing it as being a defining aspect of the assault. As can be seen above, even the terms we use to describe a subject are loaded with subjectivity and hidden meanings. In addition, these hidden meanings come from the perceptions and stereotypes prevalent in society about gender roles in general, and rape in particular. Readers may be familiar with the concept of the ‘rape myth’ (the stereotypical rape scenario of an unknown male, probably armed, possibly masked, raping a woman in a dark back street or park), and how victims whose stories vary from that scenario are less likely to be believed as that is the collective perception of what rape is. Our concept of rape and sexual assault informs our perception of rape victims, both in who they are and how deserving of our sympathy they are. Even the concept of rape as primarily a sexual act is refuted by many researchers, who take the perspective that rape is a violent act expressed sexually, rather than a sexual act expressed violently.15,16 Kassing et al.17 discussed rape myths specific to male-on-male rape and sexual assault, and found that widely held beliefs are held in society that male rape is rare, partly because men should be able to resist, but, when it does happen, it is usually in prisons and men should be strong enough to cope with it. The presence of such perceptions of rape, rapists and rape victims in society are, of course, important to understand, as they influence the way in which society and the individuals that compose it then respond to victims. Sleath and Bull18 established that the stronger an individual believes in myths or stereotypes of male rape then the more they will attribute blame to a male victim of such crimes while simultaneously reducing the blame attributed to the rapist. Perceptions of masculinity are, therefore, more influential when considering male-on-male rape than are perceptions of femininity about male- on-female rape. In their review of studies on perceptions of male-on-male rape, Davies and Rogers19 summarised the key perceptions pertaining to male victims as below (with additional supporting citations): males blame victims more than females; male victims are blamed more than females20,21; homosexual victims are blamed more than heterosexual victims22; acquiescent victims are blamed more than resistant victims; and assaults on male (especially homosexual) victims are considered (especially by heterosexual males) less severe than on females.23 With reference to the last point, a study of attitudes to rape by Doherty and Anderson24 found that participants created a ‘hierarchy of suffering’ in which heterosexual men suffered most from rape as it departed more from their typical sexual practices than it did for homosexual males or (heterosexual) women. Part of the additional suffering heterosexual male victims of rape would experience includes a perception in society that their masculinity was diminished. The investigators argue that this hegemonic, phallocentric focus belittles the rape of women and gay men, in turn reducing the opprobrium caused by their rapists.

Service provision

When considering male victims, a feature particular to them, compared with female victims, is the paucity of male-focused services and the lack of rape services prepared to deal with male rather than female victims. It is still a hard ongoing fight to produce sexual assault aftercare services that are 42 I.A. McLean / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 39–46 sensitive to the needs of the victim while collecting high-quality forensic evidence for police investigation and hopefully prosecution. The UK sexual assault referral centre model represents this fight, but over 25 years since the first one opened in Manchester, UK, much of the country’s population still does not have access to such a service, and victims will be typically examined by a male doctor in a police station. That most victims are female, and that a great driver in changing service provision has come from the feminist movement, such as Rape Crisis, the focus in creating an appropriate service response has been on a response appropriate to women. Donnelly and Kenyon’s aptly titled paper ‘Honey, we don’t do men: gender stereotypes and the provision of services to sexually assaulted males’25 discusses this situation in detail. They conclude that a widespread belief exists that male-on-male rape is so rare as to not be a problem; the few victims there are would be homosexual men in a domestic abuse situation; and a denial based on a fear that the existence of male victims could threaten the resources available for female victims. Such views were also held within the feminist-based services reviewed, yet the reality of male victims of male rapists is a further example of how rape is more about control then sexual gratification, and a way to reinforce conformity to the hegemony of heterosexual patriarchy. Indeed, it is the action of patriarchy that contributes to the repression of reporting by male victims26 and contributes to homophobic blame attribution by heterosexual males.27,28

Demographic features of victims

Most studies report the mean age of male victim within a range of 20–30 years; for example, 20,29 21.6,30 26,31 27,32 and 285 years. Although the mean age varies between studies, within studies that report on male and female victim ages, the ages tend to be similar for both sexes; for example, both 25 years33; male 25.5 years and female 25 years.34 Although some do vary more, such as male 20.4 years, female 24.7 years.35 Grossin et al.36 reported on 418 cases of sexual assault recorded in Paris, covering many circumstantial aspects of the victims and assaults. Of these, a relatively high proportion (14%) were male, but only a few circumstances were reported in both male and female terms. No differences were found between male and female victims in age distribution, with both groups close to the overall mean of 15.9 years (which is, as observed above, much younger than usually recorded). One of the other aspects mentioned in this paper that is not often covered elsewhere is that of disability. Although the investigators do not specify what kind or level of disability, nor if it was physical or mental, they recorded disability in 3.4% of the male group examined within 72 h from assault. No figure for the equivalent female group is given, although the same figure of 3.4% is reported for the proportion of disabled victims from the total sample. Those examined over 72 h were more often child sexual abuse cases, and so that proportion could be expected to reflect one-off assault situations. Some studies report on the sexuality of victims, but these figures seem to be especially subject to selection bias based on the nature of the service from which the data are gathered. For example, 3.1% of male victims describing themselves as either homosexual or bisexual among people at a general practice surgery29 compared with 22% at a sexual health clinic.37 Data from the St Mary’s Centre in Manchester, UK, revealed that the most common location at which an assault occurred was a public place, about 30% for both sexes.34 The second and third most common locations for males were assailant’s residence and then their own residence, whereas for females they were transposed. These were statistically significant differences, perhaps suggesting a higher level of domestic abuse of female victims.

Assault type and injuries

The nature of the perpetrators who target males rather than females, their motives and goals, will differ, and rape may not be the principal method by which perpetrators of sexual violence on males seek to achieve their goals. Studies have shown that penile rape is significantly more prevalent in female victims than males, who suffer more digital or object penetration.7 This indicates an important phenomenological difference where the victim is male rather than female. Injury (typically minor laceration or abrasion) to the anal area is comparatively high in males,38 and gross analysis of all forensically examined victims of a sexual assault aftercare service has shown that females receive I.A. McLean / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 39–46 43 significantly more injuries to many body areas than do males, whereas males receive significantly more injuries to the anal area.7 The Nordic survey by Nesvold et al.5 reported 40% of males received ano- genital injuries and 17% to other body areas. It is not easy to make a comparison with female cases in this study, as they have been stratified by country and nature of referral, but no totals given. Ernst et al.31 reported that the use of anoscopy revealed significantly more anal injuries in males than did the use of colposcopy. Caution should be exercised when considering all sexual-assault-related injuries or their absence, as ‘no body area receives an injury in more than one-fifth of cases’, and so ‘injuries are far from certain to result from sexual assault’ (p.169).7

Assailants: their number, relationship to victims, and use of weapon and violence

Kaufman et al.39 and McLean et al.34 found that significantly more male victims had been assaulted by multiple (two or more) assailants than had female victims, suggesting a stronger ‘gang rape’ feature. Nesvold et al.5 reported a difference as wide as 13.4% of female victims and 38.1% of male victims assaulted by multiple assailants in their Nordic study. Findings on the relationship between the assailant and victim varies; for example Pesola et al.40 found that males were half as likely as females to be assaulted by a stranger (or someone known to them for less than 24 h), whereas Mezey and King41 considered it to be a rarity and McLean et al.34 found that it was in fact more common in males. Nesvold et al.5 reported assault by a stranger (or someone ‘peripherally known’) as high as 95% for male victims. About one in 10 of all assailants were found to have possessed a weapon by studies in London42 and Manchester,34 UK, with slightly more where the victim was male. The same studies found that violence additional to that required to subdue the victim was used in over one-half of all cases (but higher when a weapon was present) and slightly less for male victims. The findings on violence were contrary to those by Kaufman et al.,39 who found that males suffered notably more violence. Regardless of the empirical basis of these circumstances, the perception in society is often that they are crucial parts of a believable rape allegation. For example, in their analysis of 801 forensic medical examinations (3% with male victims) in Duval County, Florida, USA, over 2 years, Gray-Eurom et al.43 found that assaults involving victims under 18 years, trauma and a weapon were significantly associated with conviction.

Psychological effect

Kaufman et al.39 found that male victims were more likely to attempt to deny that what had happen to them was rape, and to control their emotional response. This is reflected in the St Mary’s Centre data, which showed that 41.6% of females who attended for a forensic medical examination returned to take part in counselling, whereas only 27.6% of males did so.34 Attempts to control an emotional response, however, is not the same as succeeding, and subsequent suicide attempts may result.44 It may be that it takes males considerably longer to access counselling than females, and more of those males who received an examination may come back to the service in the future. For example, in a study of 115 men at a London counselling service, the mean time elapsed from assault to accessing counselling was 16 years.45 Elliot et al.35 argue that their detailed investigations on adult sexual assault with a representative US population sample show that, contrary to what may be culturally expected, ‘sexual victimization may be especially trauma-producing for men’ because of the conflict with the dominant sex-role presumption that men are aggressive, strong and should avoid any sexual contact with other men. They found that the male participants ‘reported significantly higher levels of distress than female victims’ on most of the Trauma Symptom Inventory,46 and supports some of the beliefs expressed by participants in the Doherty and Anderson24 study discussed above. This is consistent with other findings that most women are more ready to disclose psychological distress than are men.47,48

Erection and ejaculation evidence

Bullock and Beckson’s comprehensive review2 is focused on erection and ejaculation by the male victim of a sexual assault, highlighting evidence that these physiological states and events are not fully under voluntary control49 and can be provoked by high anxiety50 or anal stimulation.51 This is 44 I.A. McLean / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 39–46 especially important for two key reasons. The ﬁrst is that the victim experiencing an erection, ejaculation, or both, is erroneously argued to imply that there had been consent, as it is taken to suggest that the victim enjoyed the experience. Fuchs52 describes examples of how widespread this interpretation is, citing two English cases of a male-on-male rape prosecution dismissed by the trial judge on the basis that the complainant had an erection. As well as pointing out the ordeal that victims face by pursuing their complaints to court and showing why so many victims choose not to disclose at all, this misinterpretation of physical ‘evidence’ highlights the vacuum of objectivity within which rapes often occur. In the absence of eye witnesses, which is usually the case, the substance of an allegation can come down to the word of the accuser against that of the accused. When faced with such subjectivity, it is understandable that the court will seek the comforting certainty of what it considers to be ‘medical fact,’ especially when congruent with ‘common sense’. In other words, this is a perpetuation of the rape myth, and is analogous to the proxy for consent that can and is argued in the absence of injuries. That a complainant does not possess genital injuries has been used by defences to imply consent, despite the reality that most rapes do not result in genital injuries.53 These truths need to be repeated throughout the medical and legal professions so as to negate the disingenuous use of ‘common sense’ to deceive an ignorant jury (or judge). The second reason why the reﬂex actions of erection and ejaculation are important is the effect it can have on the victim. Mezey and King41 found how such an experience can increase the sense of guilt in male victims, based on the same misattribution described above. Furthermore, it can confuse the heterosexual victim’s sense of sexuality and, by extension, identity, by raising the question ‘Did I enjoy it?’ For homosexual or bisexual men, it may negatively effect their perception of future sexual contact with men, as can occur with heterosexual women assaulted by men. The issue of sexuality is particularly important with male victims because, as well as having to cope with the social stigma of being sexually assaulted, the victim faces the implication of homosexuality.3 These compounding prejudices of society inhibit disclosure by male victims even more than is the case for females.

Testing for assailant semen and sperm, and sexually transmitted infections

Sexually transmitted infection screening for rectal and pharyngeal gonorrhoea is suggested for male victims regardless of whether or not unprotected receptive anal intercourse had occurred54 and human immunodeficiency virus at examination and 6-month follow up.55 Forensic tests to establish the presence of seminal fluids based on chemical elements include prostrate-specific antigen and the much cheaper but equally effective acid phosphatse test (acP); however, identification of male and specifically sperm DNA is conducted variously by short tandem repeat analysis, differential lysis, multiple displacement amplification and other tests.56 Evers et al.56 analysed 786 samples from 226 cases of sexual assault, including 11 male victims, in Germany. The findings support the examination strategy of screening with acP test and microscopy and then analysing for DNA only when at least one of those tests is positive. Unfortunately, the samples from the male victims were excluded from most of the analyses that gave rise to that conclusion owing to their small number. How useful this strategy is for male victims is debateable, as the evidence produced would not eliminate traces of seminal fluid originating from the victim. This strategy may then only apply to female victims in gathering evidence, although at least negative results from both acP test and microscopy in male victim cases would save investigation resources by indicating no need for DNA analysis.

Conclusion

British legal systems recognise rape of males as well as females. Reporting by male victims is much lower than that of females: 5–10% of total, although the volume of disclosure is increasing. Societal perception of male rape is influenced by perceptions of masculinity and male power, resulting in additional male-specific rape myths. Male-on-male rape and sexual assault is not confined to prison or homosexual communities. Male, especially homosexual, victims are blamed more than female victims. Direction of improvements in aftercare service provision has generally been female-focused. Male victims are similar in age to female victims, but research varies on differences in male and female I.A. McLean / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 39–46 45 victims’ relationships to assailants. Rape is less common in male victims than females, whereas digital and object penetration is more common. Although injuries are rare in both males and females, anal injury is more common in males but injury to other body areas less common. Assaults by multiple assailants occur more with male, victims and presence of weapons and excessive violence may be slightly more likely with male victims. The effect of assault on sense of sexuality and identity (especially masculinity) may be stronger for men, and are more likely to repress the event or avoid disclosure. Erection and ejaculation are not under full conscious control, and male victims may experience this during an assault as consequences of high anxiety and anal stimulation. These events should therefore not be viewed as indicative of enjoyment and consent.

Practice points

Anoscopy is advised for identiﬁcation of anal injuries. Male victims should be offered screening for rectal and pharyngeal gonorrhoea and human immunodeﬁciency virus. A positive result from either acP test or microscopy may indicate the need for DNA analysis, but does not in itself provide evidence of sexual activity by male victims with another person as it could for female victims. Service provision must be appropriate for males and females.

Research agenda

Further attention to patterns of anal injury, comparison of ﬁndings from consensual and non- consensual anal penetration.

Conﬂict of interest

None declared.

Acknowledgement

Support of the NIHR Manchester Biomedical Research Centre is acknowledged.

References

*1. Davies M. Male sexual assault victims: a selective review of the literature and implications for support services. Aggress Violent Behav 2002; 7: 203–214. *2. Bullock C & Beckson M. Male victims of sexual assault: phenomenology, psychology, physiology. J Am Acad Psychiatry Law 2011; 39: 197–205. *3. Scarce M. Male on male rape: the hidden toll of stigma and shame. New York: Insight, 1997. 4. Rogers P. Male rape: the impact of a legal definition on the clinical area. Med Sci Law 1995; 35: 303–306. 5. Nesvold H, Worm A-M, Vala U et al. Different Nordic facilities for victims of sexual assault: a comparative study. Acta Obst Gynecol Scand 2005; 84: 177–183. 6. Taylor P & Chaplin R. Crimes detected in England and Wales 2010/11. 1st ed. 2011. Home Office Statistical Bulletin 11/11. London: Home Office. *7. McLean I, Balding V & White C. Forensic medical aspects of male-on-male rape and sexual assault in Greater Manchester. Med Sci Law 2004; 44: 165–169. 8. Povey D. Recorded crime: England and Wales, 12 Months to March 2001. Home Office Statistical Bulletin 12/01. London: Home Office Research, Development and Statistics Directorate, 2001. 9. Saum C, Surratt H, Inciardi J et al. Sex in prisons: exploring the myths and realities. J Sex Res 1995; 75: 413–431. 10. Laurent C. Male rape. Nurs Times 1993; 89: 18–29. 11. Harry J. Conceptualizing anti-gay violence. In Herek G & Berrill K (eds.). Hate crimes: confronting violence against lesbians and gay men. Newbury Park CA: Sage, 1992, pp. 113–122. 46 I.A. McLean / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 39–46

12. Hickson F, Davies P, Hunt A et al. Gay men as victims of non-consensual sex. Arch Sex Behav 1994; 23: 281–294. 13. Robertson JE. Rape among incarcerated men: sex, coercion and STDs. AIDS Patient Care STDS 2003; 17: 423–430. 14. Banbury S. Coercive sexual behaviour in British prisons as reported by adult ex-prisoners. Howard J Crim Just 2004; 43: 113–130. 15. Loncar M, Henigsberg N & Hrabac P. Mental health consequences in men exposed to sexual abuse during the war in Croatia and Bosnia. J Interpers Violence 2010; 25: 191–203. 16. Lim LE, Gwee KP, Woo M et al. Men who commit rape in Singapore. Ann Acad Med Singapore 2001; 30: 620–624. *17. Kassing LR, Beesley D & Frey LL. Gender role conﬂict, homophobia, age, and education as predictors of male rape myth acceptance. J Ment Health Couns 2005; 27: 311–328. 18. Sleath E & Bull R. Male rape victim and perpetrator blaming. J Interpers Violence 2010; 25: 969–988. 19. Davies M & Rogers P. Perceptions of male victims in depicted sexual assaults: a review of the literature. Aggress Violent Behav 2006; 11: 357–367. *20. Davies M, Pollard P & Archer J. The inﬂuence of victim gender and sexual orientation on judgments of the victim in a depicted stranger rape. Violence Vict 2001; 16: 607–619. 21. Gerber GL, Cronin JM & Steigman H. Attributions of blame in sexual assault to perpetrators and victims of both genders. J App Soc Psychol 2004; 34: 2149–2165. 22. Burt DL & DeMello LR. Attribution of rape blame as a function of victim gender and sexuality, and perceived similarity to the victim. J Homosex 2002; 43: 39–57. 23. Davies M & Hudson J. Judgments toward male and transgendered victims in a depicted stranger rape. J Homosex 2011; 58: 237–247. 24. Doherty K & Anderson I. Making sense of male rape: constructions of gender, sexuality and experience of rape victims. J Community Appl Soc Psychol 2004; 14: 85–103. *25. Donnelly D & Kenyon S. Honey, we don’t do men: gender stereotypes and the provision of services to sexually assaulted males. J Interpers Violence 1996; 11: 441–448. 26. Calderwood D. The male rape victim. Med Aspects Hum Sex 1987; 21: 181–189. 27. Kite ME & Deaux K. Attitudes toward homosexuality: assessment and behavioral consequences. Basic Appl Soc Psych 1986; 7: 137–162. 28. Anderson I. Explaining negative rape victim perception: homophobia and the male rape victim. Curr Res Soc Psychol 2004; 10: 43–57. *29. Coxell A, King M & Mezey G. Lifetime prevalence, characteristics, and associated problems of non-consensual sex in men: cross sectional survey. BMJ 1999; 318: 846–850. 30. Lacey HB & Roberts R. Sexual assault on men. Int J STD AIDS 1991; 2: 258–260. 31. Ernst AA, Green E, Ferguson MT et al. The utility of anoscopy and colposcopy in the evaluation of male sexual assault victims. Ann Emerg Med 2002; 36: 432–437. 32. Stermac L, Del Bove G & Addison M. Stranger and acquaintance sexual assault of adult males. J Interpers Violence 2004; 19: 901–915. 33. Riggs N, Houry D, Long G et al. Analysis of 1076 cases of sexual assault. Ann Emerg Med 2000; 35: 358–362. *34. McLean I, Balding V & White C. Further aspects of male-on-male rape and sexual assault in Greater Manchester. Med Sci Law 2005; 45: 225–232. 35. Elliot DM, Mok DS & Briere J. Adult sexual assault: prevalence, symptomatology and sex differences in the general population. J Trauma Stress 2004; 17: 208–211. 36. Grossin C, Sibille I, de la Grandmaison G et al. Analysis of 418 cases of sexual assault. Forensic Sci Int 2003; 131: 125–130. 37. Coxell A, King M & Mezey G. Sexual molestation of men: interviews with 224 men attending a genitourinary medicine service. Int J STD AIDS 2000; 11: 574–578. 38. Geist RF. Sexually related trauma. Emerg Med Clin North Am 1988; 6: 439–466. 39. Kaufman A, Divasto P, Jackson et al. Male rape victims: noninstitutionalized assault. Am J Psychiatry 1980; 137: 221–223. 40. Pesola GR, Westfal RE & Kuffner CA. Emergency department characteristics of male sexual assault. Acad Emerg Med 1999; 6: 792–798. 41. Mezey G & King M. The effects of sexual assault on men. Psychol Med 1989; 19: 205–209. 42. Kerr E, Cottee C, Chowdhury R et al. The Haven: a pilot referral centre in London for cases of serious sexual assault. BJOG 2003; 110: 267–271. 43. Gray-Eurom K, Seaberg DC & Wears RL. The prosecution of sexual assault cases: correlation with forensic evidence. Ann Emerg Med 2002; 39: 39–46. 44. Ben-David S & Silfen P. Rape death and resurrection: male reaction after disclosure of the secret of being a rape victim. Med Law 1993; 12: 181–189. *45. King M & Woollett E. Sexually assaulted males: 115 men consulting a counseling service. Arch Sex Behav 1997; 26: 579–588. 46. Briere J. Trauma symptom inventory professional manual. Odessa, Florida: Psychological Assessment Resources, 1995. 47. Hoyenga KB & Hoyenga KT. The question of sex differences: psychological, cultural and biological issues. Boston: Little, Brown,1979. 48. Norris FH. Epidemiology of trauma: frequency and impact of different potentially traumatic events on different demographic groups. J Consult Clin Psychol 1993; 60: 409–418. 49. Huckle PL. Male rape victims referred to a forensic psychiatric service. Med Sci Law 1995; 35: 187–192. 50. Redmond DE, Kosten TR & Reiser MF. Spontaneous ejaculation associated with anxiety: psychophysiological considerations. Am J Psychiatry 1983; 140: 1163–1166. 51. Giuliano F & Clement P. Physiology of ejaculation: emphasis on serotonergic control. Eur Urol 2005; 48: 408–417. 52. Fuchs SF. Male sexual assault: issues of arousal and consent. Clevel State Law Rev 2004; 51: 93–121. 53. McLean I, Roberts S, White C et al. Female genital injuries resulting from consensual and non-consensual vaginal intercourse. Forensic Sci Int 2011; 204: 27–33. 54. McMillan A, Young H & Moyes A. Rectal gonorrhoea in homosexual men: source of infection. Int J STD AIDS 2000; 11: 284–287. 55. Gazi C. HIV testing for rapists. S Afr Med J 2002; 92: 482–483. 56. Evers H, Heidorn F, Gruber C et al. Investigative strategy for the forensic detection of sperm traces. Forensic Sci Med Pathol 2009; 5: 182–188. Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 47–58

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5 The role of the sexual assault centre

Maeve Eogan, MD MRCOG FRCPI, Consultant Obstetrician and Gynaecologist and Medical Director *, Anne McHugh, MSc BSc (Hons) RGN SCM, Project Manager, Higher Diploma in Nursing (Sexual Assault Forensic Examination), Mary Holohan, MB FRCOG FRCPI FFFLM (RCP Lon), Consultant Obstetrician and Gynaecologist

Sexual Assault Treatment Unit (SATU), Rotunda Hospital and National SATU Services, Parnell Square, Dublin 1, Ireland

Keywords: Sexual Assault Centres provide multidisciplinary care for men and sexual assault centre women who have experienced sexual crime. These centres enable multidisciplinary care provision of medical, forensic, psychological support and follow- forensic clinical examination up care, even if patients chose not to report the incident to the police service. Sexual Support Centres need to provide a ring- fenced, forensically clean environment. They need to be appropriately staffed and available 24 hours a day, 7 days a week to allow prompt provision of medical and supportive care and collection of forensic evidence. Sexual Assault Centres work best within the context of a core agreed model of care, which includes deﬁned multi-agency guidelines and care pathways, close links with forensic science and police services, and designated and sustainable funding arrangements. Additionally, Sexual Assault Centres also participate in patient, staff and community education and risk reduction. Furthermore, they contribute to the development, evaluation and implementation of national strategies on domestic, sexual and gender-based violence. Ó 2012 Elsevier Ltd. All rights reserved.

Introduction

In this chapter, we focus on the role of the Sexual Assault Centre (SAC), for the provision of holistic care for adult men and women who have experienced sexual crime. These centres have a broad range

* Corresponding author. Tel.: þ353 18171736. E-mail addresses: [email protected], [email protected] (M. Eogan).

1521-6934/$ – see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bpobgyn.2012.08.010 48 M. Eogan et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 47–58 of titles internationally, but strive to offer a similar model of responsive care for those who need to access services at a time of immense personal crisis. In the Republic of Ireland, they are called Sexual Assault Treatment Units (SATUs) whereas, in the UK, they are generally called Sexual Assault Referral Centres (SARCs). Regardless of the terminology used, it is clear that the ethos must be ﬁrmly patient- focused, providing medical and support services, in conjunction with a co-ordinated justice response. In this chapter, we delineate the necessary components of care provision within SACs, being cog- nisant that many of these will be discussed in greater detail in other sections of this issue of Best Practice and Research Clinical Obstetrics and Gynaecology. It will also focus, therefore, on other aspects of a cohesive service, including infrastructural and funding considerations, guideline development, data collection, strategy implementation, and internal and external education. In view of our familiarity with the model of care available in the Republic of Ireland, much of the detail will pertain to these local services and recent developments. Nevertheless, this model of standardised, patient-focused care is based on best practice and would be eminently reproducible in other jurisdictions. Furthermore, we acknowledge the requirement for standardised and responsive services for children but, in the context of this chapter, we focus on care provision for men and women over the age of 14 years. For the purposes of this chapter, the term SAC will be used throughout, even though it is accepted that a broad range of other descriptive terms (e.g. SATU, SARC) are also used.

History and evolution of sexual assault centres

Before the establishment of a defined service, the forensic medical examination of the complainant was conducted in the police station when an allegation of sexual crime was made. As expertise began to develop in relation to the medical examination, health professionals appreciated the inappropriateness of carrying out the examination in the general environs of a police building. Thus, the provision of an acceptable environment for forensic examination in police presence was the genesis of SACs first seen in the USA and then Australia in the 1970s. The Sexual Assault Treatment Unit of the Rotunda Hospital in Dublin opened in 1985, and was thus the first SAC to provide service in Europe. St Mary’s Unit in Manchester, UK, was established the following year. These hospital-based units were composed of a combined interview and examination room for the purpose of the forensic medical examination, with police interview and aftercare delivered elsewhere. Internationally, in countries where rape is recognised as a criminal act, services are available for the victim who reports the crime. The initial service has most often been led by a committed professional with a support team that has evolved with the developing expertise of the group such that the nominator of ‘centre of excellence’ would be applied. Further development of a national service has often been the result of recognition of local need for a service. Without a strategic approach to service development, other centres have developed, with expertise available locally but not always with all of the core elements of care provided.1 In looking at the current services in a number of European countries,2 Australia3 and the USA,4 service provision is not lacking, but a deficiency can be seen in national, standardised services, such that every person has access to the multidisciplinary expertise of a SAC in all regions of a country. Norway and Ireland have such a national approach to the delivery of care for the adult victim of sexual crime, and new developments in England support the standardisation of SAC services nationally there.5,6 Access to the services of an SAC in many countries is primarily through the police services. Thus, the person must report the crime before having access to the multidisciplinary health, forensic and support services available. Some evidence shows that where access to SAC services does not have the prerequisite of police involvement, that attendance rates are higher,7 potentially reducing the long- term sequelae of the incident. The evolution of SAC care has seen the provision of psychological support and facility for police interview for the complainant at time of initial attendance, as well as the development of comprehensive psychological and sexual health aftercare. Taking social, demographic and geographic considerations into account, a nationally agreed level of service, so that all patients are assured of standard practice, is invaluable.1 Where all the services are delivered within the centre, the term ’one M. Eogan et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 47–58 49 stop shop’ has been used. In areas where SACs have been established, evidence shows improved access to forensic and medical examinations and to psychological support for complainants of rape, together with higher levels of user satisfaction with the services provided.8 Notwithstanding this, it has been acknowledged that ‘SARCs are not the whole answer, but taken together with improvements to the investigation and prosecution of sexual violence cases, and greater investment in the voluntary sector, their development offers a real opportunity to deliver justice to victims’.9 Within the Irish context, an emphasis has been placed on development and standardisation of high- quality accessible care.1 This care is described in detail in a readily available and comprehensive inter- agency document, which aims to ensure that a patient receives similarly responsive and holistic forensic, medical, on-site psychological and follow-up care regardless of which of the six regional SATUs they attend.10 The core agreed model of care in Ireland also includes a multidisciplinary team, close links with the forensic science service and police service (An Garda Siochana). Defined funding streams are provided by Departments of Health and Justice. Similarly, in the UK context, SACs have been defined as a ‘one stop location where victims of sexual assault can receive medical care and counselling while at the same time having the opportunity to assist the police investigation into alleged offences, including the facilities for a high standard of forensic examination.’11 In keeping with this, the Home Office has defined an SAC as ‘a dedicated facility to provide immediate and ongoing victim care within the context of a partnership arrangement between police, health and the voluntary sector’; this document also emphasises that an SAC does not just refer to a building, but embraces a concept of integrated, specialist, clinical interventions and a range of assessment and support services through defined care pathways.5 At present, however, the main difference between the UK and the Republic of Ireland is that, although far more SACs have been established in the UK, services are generally less standardised, with a greater disparity in equity and access in some geographic areas than in others.

Location of sexual assault centres

Victims of sexual crime need to be able to access appropriate care promptly; however, this care should be provided by professionals who are doing this work sufficiently often to maintain competency and skill. For this reason, it would generally be recommended that services would be regionalised. Minimum standards for Ireland recommend that ‘any victim of rape or sexual assault in Ireland is within a maximum of 3 hour drive of a unit,’1 although another report recommended that an SAC be ideally established within 80 km of any given location.12 A report of a UK Department of Health Working group on recommendations for service delivery recommended a model in which a regional SARC, where most examinations would be undertaken) would be assisted by a few Local Sexual Assault Referral Centres for those complainants unable to travel to the RSARC. This report anticipated that such arrangements would ensure that the maximum travelling time for a complainant would be 120 min.13 In the European context, albeit looking at care for women only, it has been recommended that a minimum level of service provision would be one SAC per 400,000 women to enable ease of reporting of recent assaults and to ensure high-quality forensic and medical services.2 The designation of a precise location of a SAC in any country is controversial; although these units need to be relatively local to ensure ease of access, they need be accessed sufficiently often in order to be sustainable and to enable staff to retain and increase all relevant professional competencies.13 Service provision for rural and remote areas is, therefore, inherently difficult. It is important that police services and other agencies in these areas have close links with regional centres to ensure prompt access to care within the SACs. Furthermore, it is important that SACs are not developed as stand-alone projects, but brought into the mainstream and linked to other services through strong partnership across police, health, local authority and independent sector organisations.5 In the UK, the Government response to the Stern Report14 acknowledged that a ‘one size fits all model’ may not be suitable for all local areas, and what matters is that victims receive the comprehensive support they need when they need it, so that that they can take positive steps to recovery. For example, an area may wish to have a small centre of expertise with a high number of follow-up sites because of its geography. Yet again, this report recognises the importance of involving all relevant partners, including voluntary and community sectors, to ensure appropriate referral and follow-up mechanisms. 50 M. Eogan et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 47–58

In providing services in more remote areas of a country, the issue of sustainability of service with low numbers of attendances is suggested to be a limiting factor in development or maintenance of expertise. With more open access to such a service and developing the professionalism of the service providers beyond the core requirements of an SAC, such a service can build capacity and be a valuable, sustainable clinical service within a community.15

Necessary infrastructure

Sexual Assault Centres must provide a ring-fenced, forensically clean environment for examination to avoid contamination of evidence. Changing and showering facilities should be provided for individuals to access after examination. This facility needs to be available and appropriately staffed 24 hours a day, 7 days a week, to ensure that it can be accessed promptly when required.10 The centre must also have an area for provision of follow-up care, so that the forensically clean environment is only used for acute cases.16 Furthermore, individuals can find it difficult to return to the clinic room they attended immediately after the acute event when they come for a return visit, as it may cause them to recall some of the negative feelings they experienced at that time of immense personal crisis. A sufficiently private area for the psychological support worker and crisis worker, with waiting areas for family and members of the police service, must also be considered when developing an SAC. Office space for administrative, nursing and medical staff should also be included, as well access to a meeting room for team or family meetings, peer review meetings and teaching sessions. A secure storage facility for patient records, and forensic samples if a delayed reporting option exists, is also imperative. Access to a secure information technology system and skills enables development and implementation of an electronic database. Anonymised patient records can be completed for each attendance. This allows for collection of a minimum dataset of demographic and other statistics which facilitates data collection and production of key service activity reports. These reports allow for identification of emerging trends between different SACs and over time. This information may be useful for educational strategies and risk reduction, and also for service planning and funding applications. Performance targets such as time (and any delays) between attendance and examination can also be monitored.

Funding considerations

Funding for SAC services should be deﬁned at national level, to allow development and implementation of an integrated strategic plan for service delivery. It is imperative that this care is available free of charge to anyone who wishes to access it. As these services involve close integration and co- ordination of patients’ health and medicolegal needs, funding may have to come through health and justice routes. The set-up and running costs of SACs may, however, be offset against the likely savings to the wider health economy and the long-term costs to the economy as a whole.9 Effective service provision may produce cost savings by reducing multiple assessments and waiting times for individuals who use non-integrated services, and reducing the number of people later referred for specialist services (e.g. mental and sexual health). In addition to this, addressing patient needs early through provision of care within an SAC delivers better health, well-being and quality of life to patients. Long- term productivity savings have been identiﬁed when the immediate aftermath of sexual assault is managed effectively and comprehensively.5

Guideline development

As previously mentioned, development of SACs, ideally in line with a national strategic vision for sexual assault services, also facilitates development and implementation of core agreed models of care. Formal development of inter-agency guidelines and care-pathways facilitates provision of consistent, high-quality care. Preparation of these guidelines needs to include input from SAC staff, rape crisis personnel, the police service and forensic science services, enabling production and dissemination of an accessible, multi-agency document to ensure a responsive, evidence-based and comprehensive response to victims of sexual violence. M. Eogan et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 47–58 51

The experience in the Republic of Ireland has highlighted that the inter-agency links that were established to develop these practice guidelines have ensured an ongoing commitment to an integrated partnership approach to care. On a strategic level, the representatives of the various agencies also contribute to SAC steering groups and management committees, which promote ongoing excellence of service development and delivery of high-quality care.

Role of sexual assault centres

Sexual Assault Centres provide responsive, patient-focused care for men and women over the age of 14 years. They aim to promote recovery and health after a rape or sexual assault, whether or not the individual wishes to report it to the police.5 Indeed, it has been well recognised that SACs also increase access to services and support for those who do not report to criminal justice agencies.8 Whether a rape or sexual assault is reported or not, whether the case goes forward or not, whether there is a conviction or not, victims still have a right to services that will help them recover and rebuild their lives. The criminal justice process is important, but getting support and being believed is as important.17 Seeking support in the aftermath of a rape or sexual assault is a huge challenge, and the work a SAC undertakes plays a vital role in assisting recent victims from a number of perspectives: the collection of forensic clinical evidence for potential future legal cases, the immediate physical and psychological care for the victim, and the referral of victims to appropriate long-term support.10 In the Republic of Ireland, SAC services can be accessed in a variety of ways (Fig. 1). These clearly deﬁned routes through which a patient can approach the various models of care are vital. Furthermore, details of these routes and models must be widely communicated within the broad range of agencies involved in responding to patients after sexual crime (e.g. police services, rape crisis centres, emergency departments, and primary care), so that people are aware of the existence of SACs and the facilities they provide, and to enable full explanation of the available referral options and ease of access in an appropriate timely manner when required.

Care pathways

As shown in Figure 1, a person may choose to report a recent crime to the police service who will arrange for them to attend their local SAC as soon as possible, as forensic evidence deteriorates rapidly (Table 1). For this reason, SACs should be available and staffed 24 hours a day and 7 days a week for care

Fig. 1. Referral to a Sexual Assault Centre (SAC). 52 M. Eogan et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 47–58 of acute cases, although the provision of a timely response must not supercede the victim’s potential need to control the pace of this response. The reporting of sexual crime to criminal justice agencies should always be encouraged; however, if the person chooses not to report the incident, they can still attend an SAC for health and follow-up care. In these situations, the appointment can generally be given for the next working day as there is less urgency when forensic samples are not being taken. Nevertheless, individuals may still need to be seen relatively urgently to ensure that appropriate care of injury and preventative treatment can be given (e.g. emergency contraception and post-exposure prophylaxis for sexually transmitted infections). Another pathway that can be considered is that of collection and storage of forensic evidence without immediate reporting to criminal justice agencies. This option facilitates those who may, for a variety of reasons, be uncertain about whether they wish to report an incident of sexual crime. They may perhaps be concerned about embarking on a potentially lengthy legal process, about the effect of such a course of action on friends and family, they may have issues concerning a previous relationships with the alleged assailant or, very simply, they may just be too traumatised to make such a decision at a time of immense personal trauma. In these situations, in many jurisdictions, two options are available as described above: the ﬁrst is that individuals would report the incident to the police service despite their reservations (in which case forensic samples can be taken); alternatively they can make a decision not to report the event acutely. With this latter option, however, if they initially opt not to report the incident, but subsequently decide to do so, time will have elapsed and forensic evidence, which may have been available had they presented promptly, will have deteriorated. This delay may affect the completeness and success of an investigation and potential prosecution. To counter this, therefore, many services offer a facility for collection and storage (for a deﬁned period of time) of forensic evidence.18 A full explanation of the process, and its potential limitations, is outlined to the individual, and evidence is collected according to best practice. In this context, local protocols must be developed to ensure that the chain of evidence for both collection and storage of samples can be maintained if the individual subsequently chooses to report the incident to criminal justice agencies. If a complaint is ultimately made to the police service, these samples can be released for forensic analysis to assist the investigative process. Provision of this additional option could increase the rates of reporting of sexual crime, as people who may be uncertain about their reporting intentions would not make a rapid decision about not reporting the incident, which they might subsequently regret. There is no ‘statute of limitation’ for serious offences, and delayed reporting should, therefore, not affect the credibility of a complainant or be considered an impediment to prosecution. This is seen as an importantelement in the response to victims of sexual assault because it gives them control over decision making about whether to report to police or not, and allows them to make this decision at some point after the initial crisis.

Care within a sexual assault centre

When a person presents to an SAC, they need to be treated in a caring and non-judgemental manner. Depending on the route the patient took to the service, they may need a further explanation of their options of engaging with police services or otherwise. Clear guidelines for appropriate clinical, psychological and forensic care should be followed.10,19,20 In the Irish context, the individual will generally ﬁrst be met by the forensic examiner (who is either a doctor or clinical nurse/midwife specialist) and a support nurse, who will outline the purpose and progress of the SAC attendance and

Table 1 Sites and time limits for examination for presence of semen in the Republic of Ireland.

Site Time Limits for Examination for Semen Vaginal 7 days Rectum 3 days Mouth 1 day Skin Semen can persist until washing Dead bodies Semen can persist for a much longer period of time Dried seminal staining on clothing Semen persists until clothes are washed

Washing, douching, bathing or menstruation may accelerate the loss of semen. M. Eogan et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 47–58 53 introduce the person to the psychological support worker who provides advocacy, psychological support and crisis intervention. Research has indicated that sexual violence survivors receive more and better legal and medical services when accompanied by rape crisis support.10 It is vital that reassurance is given that nobody deserves to be raped, and that the victim is not responsible for the assault. Even if the person perceives that they made choices they now regret, they need to be reassured that being potentially vulnerable in no way implies culpability.21 Everyeffort should be made to preserve forensic evidence, andideally the patient should not eat, drink, smoke, chew gum or carry out oral hygiene until oral samples are taken, if indicated. Similarly, defecation, urination and showering should be deferred until appropriate samples are obtained. Collaborative working relationships with the police services and other relevant agencies and written inter-agency guidelines will ensure that all those involved in arranging SAC attendances are aware of these recommendations to ensure that the patient receives optimum care. It is important to emphasise that, if a patient presents to a SAC after a rape or sexual assault with significant physical injury, such injury must be dealt with as a priorityand the forensic medical examination can be carried out after stabilisation of the patient. For the same reason, if temporary loss of capacity occurs owing to intoxication from alcohol or drugs, the examination will need to be deferred until capacity to consent has returned. Further description of the precise content and potential findings at forensic clinical examination is outlined elsewhere in this issue of Best Practice and Research Clinical Obsterics and Gynaecology and in other documents;22 in brief this includes the following: (1) full explanation and documentation of witnessed, informed consent; (2) history taking to include medical details that may assist in patient management as well as details of the incident itself to guide examination and evidence collection; (3) general physical examination; (4) appropriate genital and anal examination with collection of relevant forensic samples; (5) classification and documentation of wounds and injuries; and (6) toxicology samples. A member of the police service remains in the clinical room while the history is being taken and proximate to the examination room while samples are being taken. This ensures that they can confirm continuity of evidence. Upon completion of the forensic clinical examination and documentation of findings, collected samples must be given to the police, who will package them in a tamper evident bag and arrange transfer to the appropriate forensic science laboratory for analysis. Relevant items of clothing will also be collected.

Pre-discharge care

After examination, the person is offered a shower and provided with fresh clothes if required. Adjunctive treatment, including emergency contraception, infectious disease prophylaxis (for chlamydia, gonorrhoea and human immunodeﬁciency virus if indicated by risk assessment) and Hepatitis B immunisation is considered for all attendees at SACs in the Republic of Ireland. Further detail on other aspects of holistic immediate after care is discussed elsewhere in this issue.

Follow-up care

A follow-up schedule should be provided to all individuals who attend an SAC before discharge. The routine timeline for sexually transmitted infection prophylaxis and follow up is presented in Table 2.10 The individual also needs to know how to access appropriate post-incident psychological follow up; they should, therefore, be given contact information for SAC personnel and referral or contact information for other locally available services (e.g. Rape Crisis Centre). Written information on all relevant contacts and follow-up arrangements is recommended to avoid further overwhelming people with verbal information and advice (Table 3).10 Even if people do not want to seek counselling in the ﬁrst instance, it is important that they know where to go to seek this at a later point in time. A person who has been sexually assaulted needs to have a safe place to go and a safe way to get there when leaving an SAC; ideally they should be accompanied by a family member, guardian, friend or support person. Consent to contact the person to remind them of future appointments and follow-up arrangements should be conﬁrmed and documented before discharge. 54 M. Eogan et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 47–58

Table 2 Recommended timeline for sexually transmitted infection prophylaxis and follow up in the Republic of Ireland.

Time Treatment or Procedure Rationale 0 1 g Azithromycin orally. Prophylaxis and treatment of Chlamydia trachomatis. First hepatitis B Vaccine. Immunisation against hepatitis B. 1 month First void urine (if nucleic acid Screening for C. trachomatis ampliﬁcation test available). Endocervical culture. Screening for N. gonorrhoeae.* Urethral and endocervical culture. Screening for C. trachomatis.* Serology HIV, Hepatitis B and C, and syphilis. Second hepatitis B vaccine. Immunisation against hepatitis B. 3 months Serology. HIV, hepatitis B, C, and syphilis. 6 months 3rd Hepatitis B Vaccine. Immunisation against hepatitis B. y 8 months Serology. Antibody to hepatitis B surface antigen; ensure hepatitis B immunity.

* All tests of cure if prophylaxis previously given; y Can be checked by general practitioner or local services. HIV, human immunodeﬁciency virus.

Domestic violence and child protection

An awareness of the potential interplay between attendance at an SAC, domestic violence and child protection issues is paramount. If concerns exist about ongoing domestic violence, it may be necessary to offer the person a place of safety as well as offering information and ongoing support about local specialist support services. All SACs should have written information available on local and national services (e.g. Women’s Aid), as well as contact details for local police services. Each SAC also needs to ensure that child protection guidelines appropriate to their jurisdiction are followed.

Risk reduction

Sexual Assault Centres can contribute to educational programmes focusing on both primary and secondary prevention of sexual violence. In providing this education, it is imperative that, although it must be emphasised that being vulnerable to sexual violence is not the same as being culpable, there may be social or behavioural issues that increase a person’s vulnerability, which can potentially be avoided. Although there tends to be signiﬁcant societal awareness of the issue of drug-facilitated sexual crime, there may be less awareness of the fact that alcohol is the most common drug implicated in sexual violence, and that negative consequences can arise from use and misuse of alcohol. Children and

Table 3 Discharge information given to the patient.

Instruction on the care of any injuries. Medication instructions, if applicable. Information leaﬂet issued by the SAC, which will include: Contact numbers for the SAC. Garda’s name, Garda (police) station and telephone number. Information about examination and processing of the forensic samples. Information on medication received and follow-up schedule related to this. Follow-up appointments with place, dates and times. Referral letter, if applicable (e.g. to infectious disease, psychiatry or other required services) Letter for general practitioner, if desired. Letter for work, college, school, if required. Phone number and printed information leaﬂet (if psychological support worker has not spoken with the patient) from the Rape Crises Centre, which offers psychological support for the patient and her or his family. Relevant health promotion information and written information from agencies which deal with issues such as: Domestic Violence. Interpersonal Violence. Drug and Alcohol programmes. Safety Prevention programmes.

SAC, Sexual Assault Centre. M. Eogan et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 47–58 55 young people are drinking earlier and more often; over one-half of Irish 16-year-old children have been drunk, with one in five being a weekly drinker.23 The average age of first alcohol use in children in Ireland has reduced from 15 years for those born in 1980 to 14 years for children born in 1990.23 Research into the link between alcohol and sexual violence, supported by clinical experience, show that considerable quantities of alcohol are often ingested before the incident. Education can also address other vulnerability factors, such as social competence, risk-taking behaviour and other lifestyle factors (e.g. age-appropriate boundaries).12,24 Primary prevention can include community and school-based programmes, with consideration also being given to media campaigns. Secondary prevention (within a patient cohort who have already sought care from an SAC) can be more individualised, focusing on an individual’s specific vulnerability factors and providing appropriate education and care to reduce the possibility of another incident. Establishment of an appropriately staffed SAC network facilitates development and delivery of relevant educational and risk-reduction programmes.

Contribution to national strategies and ongoing educational programmes

Thankfully, in recent years many parts of the world have recognised the significance of sexual violence and how important it is for the multi-agency response to be appropriate and co-ordinated.1,5,9,21,25 Development of SACs was central to the recommendations of many of these reviews. It is, therefore, anticipated that many countries either have, or will have, a network of these high-quality, accessible centres to deliver this clinical, forensic and supportive care. As SACs are commissioned and established, however, it must also be recognised that SACs and their staff are a vital resource in ongoing evaluation and implementation of such national strategies. The staff in an established SAC build up a wealth of experience that aids education of more junior staff, succession planning and indeed education of those interested in becoming involved with the service. Standardised qualification and training requirements for forensic medical examiners, nurse and midwife examiners need to be defined and delivered to ensure consistent provision of high-quality care. Inter-agency educational programmes, between Rape Crisis Centres, police and forensic science services, primary care and SACs allow for a mutual understanding of every step of the victim’s journey and aim to optimise service delivery and care provision by all agencies. Staff are also a resource that can provide ongoing education for other service providers (e.g. emergency departments, prison services, women’s health and voluntary projects), to ensure that these services are aware of SAC facilities and how to access these. In the Republic of Ireland, we have found it useful to develop and distribute a quarterly newsletter, ‘The SAFE Way’. This short newsletter is produced by the National SATU service, with contributions from medical, nursing and support staff from the six SATUs, as well as input from the other public, independent and voluntary agencies. This document ensures dissemination of relevant updates, research findings and information about education and training opportunities.

Vicarious trauma

Vicarious trauma describes the professional’s trauma reactions and response to patients’ traumatic experiences.26 It may result in physical, emotional or behavioural symptoms, work-related issues and interpersonal problems, and can be responsible for a decrease in concern and esteem for patients leading to a decline in quality of patient care.27 Agencies that provide services to patients with traumatic histories have a responsibility to help their employees decrease the occurrence and effects of vicarious trauma.28 Peer supervision groups serve as important resources for normalisation of vicarious trauma experiences, and should be an essential component of an SAC service. This normalisation lessens the effect of vicarious trauma and helps maintain objectivity.29

The future

Aims for the future include an international commitment to continued provision of a standardised package of care regardless of which SAC an individual presents to. This must be underpinned by 56 M. Eogan et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 47–58 cohesive national strategies to ensure appropriate geographical distribution of high-quality, multidisciplinary services responsive to patients needs. Care for those who chose not to report the incident to criminal justice agencies is also imperative. Care for children affected by sexual crime should also be delivered in such a standardised yet responsive manner. Colocation of paediatric services with adult SACs allows for joint assessment if required, and may also contribute to efﬁcient resource utilisation. Quality assurance, monitoring and evaluation must also be integrated into ongoing service development and provision. Indicators and metrics to benchmark the quality of care delivered, as well as objective and subjective patient (e.g. clinical, psychological, forensic and legal) outcomes must be encouraged. This commitment to quality assurance allows the service to deliver a measurable standard of excellence and ensures consistency in service provision for patients regardless of where they present geographically.

Conclusion

In this chapter, we have focused on provision of standardised but responsive care within SACs, and have emphasised the many other aspects of a cohesive service. We must concur with Baroness Vivien Stern who eloquently stated that ‘even in a time of scarce resources there must be a recognition of the need to prevent rape, care for victims, protect the vulnerable and work to reduce the long-lasting harm to individuals and families.’17. We are confident that a well-organised and established SAC network underpinned by strong interagency links and guidelines fulfils these aims. We would argue that to provide best care for all men and women who have experienced sexual violence, we need to embrace a more inclusive and geographically disseminated ‘standard of excellence’ rather than just placing the emphasis on individual ‘centres of excellence’. Furthermore, in more general terms, the availability of such a multi-agency service can raise awareness of sexual violence and abuse which helps boost public confidence in the health and criminal justice systems.5

Practice points

Care for men and women after rape or sexual assault should be delivered in the context of a patient-focused, easily accessible, national, standardised service. Inter-agency guidelines and care pathways should be developed and widely distributed to ensure that care is appropriate and responsive to patients’ needs. People should be able to access care in an SAC even if they choose not to report the incident to criminal justice agencies. SACs also play a role in patient and interagency education, as well as being well placed to contribute to the national strategic vision for prevention of, and care after, sexual violence. Ongoing support for staff in SACs is important to reduce vicarious trauma related to working in this potentially stressful environment.

Research agenda

Mapping of available SAC services in each country to ensure equity of access. Close monitoring of service provision to benchmark quality of care and address any deﬁ- ciencies identiﬁed. Monitoring of subjective and objective patient outcomes to assess service provision from patients’ perspective. M. Eogan et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 47–58 57

References

*1. O’Shea A. Sexual assault treatment services: a national review. National Steering Committee on Violence Against Women, Sexual Assault Review Committee, 2006, www.lenus.ie [last accessed 15.08.12]. 2. Council of Europe; Directorate General of Human Rights and Legal Affairs. Combating violence against women: minimum standards for support services. Kelly, L. Roddick Chair on Violence Against Women, London Metropolitan University and Dubois L, 2008, http://www.coe.int/t/dg2/equality/domesticviolencecampaign/Source/EG-VAW-CONF(2007)Study%20rev. en.pdf [last accessed 01.09.12]. 3. The National Council for Australia. Time for action. The National Council’s plan for Australia to reduce violence against women and children 2009: 75–92, http://www.nasasv.org.au/National_Plan/The_Plan.pdf [last accessed 01.09.12]. 4. US Department of Justice. Office on Violence against Women. National training standards for sexual assault medical forensic examiners. NCJ 213827. Washington DC: US Department of Justice, Office on Violence against Women, 2006, https://www. ncjrs.gov/pdffiles1/ovw/213827.pdf [last accessed 15.08.12]. *5. Revised national service guide: a resource for developing sexual assault referral centres. London: Department of Health, Home Office, Association of Chief Police Officers (DH/HO/ACPO), 2009, http://www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/DH_107570 [last accessed 01.09.12]. 6. Coy M, Kelly L & Foord J. Map of gaps: the postcode lottery of violence against women support services in Britain 2. London: End Violence Against Women in partnership with Equality and Human Rights Commission, 2008, http://www. equalityhumanrights.com/uploaded_files/research/map_of_gaps2.pdf [last accessed 15.08.12]. 7. Goodwach R, Coles J & Casper G. Happy healthy women not just survivors. Consultation report: advocating for a long term model of care for survivors of sexual violence. Australian Women’s Coalition, 2010, http://www.awcaus.org.au/resources/ documents/HHW_Consultation_Report.pdf [last accessed 15.08.12]. *8. Lovett J, Regan L & Kelly L. Child and Woman Abuse Studies Unit London Metropolitan University. In: . Sexual assault referral centres: developing good practice and maximising potentials 2004; 285: Home Office Research, Development and Statistics Directorate: Home Office Research Study, 2004, http://sgdatabase.unwomen.org/uploads/United%20Kingdom% 20-%20SARCs%20-%20developing%20good%20practice%20and%20maximising%20potentials%202004.pdf [last accessed 1. 9.12]. 9. Department of Health/Mental Health Division/Home Office (DH/MH/HO) Developing Sexual Assault Referral centres (SARCs): National Service Guide, 2005, http://webarchive.nationalarchives.gov.uk/20100413151441/crimereduction.homeoffice.gov. uk/sexual/sexual22.htm [last accessed 01.09.12] *10. National SATU Guidelines Development Group. Recent rape/sexual assault: national guidelines on referral and forensic clinical examination in Ireland. 2nd ed. 2010. 11. Public Health Wales: NHS. Specification for services providing care to adults in Wales who have been sexually assaulted. http://apps.bps.org.uk/_publicationfiles/consultation-responses/Sexually%20Assaulted%20&%20Abused%20Adults%20(W)% 20-%20final%20service%20specification%20(Oct%202010).pdf [last accessed 01.09.12]. *12. Hanly C, Healy D & Scriver S. Rape and Justice in Ireland: a national study of survivor, prosecutor and court responses to rape. Dublin: Liffey Press, 2009. Rape Crisis Network Ireland. *13. Report of a DOH Working GroupRecommendations for regional sexual assault referral centres. Department of Health, United Kingdom (DOH UK), https://fflm.ac.uk/upload/documents/1244719631.pdf [last accessed 15.08.12]. *14. HM Government. The Government response to the Stern Review: an independent review into how rape complaints are handled by public authorities in England and Wales. London: Cabinet Office, 2011, http://www.homeoffice.gov.uk/publications/ crime/call-end-violence-women-girls/government-stern-review?view¼Binary [last accessed 15.08.12]. 15. Markowitz J. Sustainability 101: long range thinking for sexual assault nurse examiner program managers. National Sexual Violence Resource Centre (NSVRC), 2009, http://www.vaw.umn.edu/documents/SANELongRangeThinking/SANELongRangeThinking.pdf [last accessed 15.08.12]. 16. Wall IF, Rogers D & Evans V. Operational procedures and equipment for medical rooms in police stations and victim examination suites. Faculty of Forensic and Legal Medicine, 2007, https://fflm.ac.uk/upload/documents/1193757602.pdf [last accessed 15.08.12]. *17. Stern VA. Report by Baroness Vivien Stern CBE of an independent review into how rape complaints are handled by public authorities in England and Wales: the Stern Review 2010, http://www.wrc.org.uk/includes/documents/cm_docs/2011/1/ 100315_stern_review_of_rape_reporting_1final.pdf [last accessed 15.08.12]. 18. Price B. Receiving a forensic medical exam without participating in the criminal justice process: what will it mean? J Forensic Nurs 2010; 6: 74–87. *19. White C. Sexual assault: a forensic clinician’s practice guide. St Mary’s Centre Manchester, 2010. 20. United States Department of Justice, Office on Violence Against Women (USDJ VAW). A National protocol for sexual assault medical forensic examinations: adults/adolescents. USDJ VAW 2004. NCJ 206554. http://www.vaw.umn.edu/documents/ nationalprotocol/nationalprotocol.html; [last accessed 15.08.12]. 21. IACP (International Association of Chiefs of Police). Investigating sexual assaults: concepts and issues paper. Revised ed.. IACP, National Law Enforcement Policy Center, 2005, http://www.theiacp.org/LinkClick.aspx?fileticket¼z5xGuy0ksGo% 3D&tabid¼87 [last accessed 01.09.12] 22. Linden JA. Care of the adult patient after sexual assault. N Engl J Med 2011; 369: 9. 23. Department of Health, Ireland. Steering group report on a national substance misuse strategy. Dublin: Department of Health, Ireland, http://healthupdate.gov.ie/wp-content/uploads/2012/02/Steering-Group-Report-on-a-National-Substance-Misuse- Strategy-7-Feb-11.pdf [last accessed 15.08.12]. *24. Alberti G. Responding to violence against women and children: the role of the NHS. The report of the Taskforce on the Health Aspects of Violence Against Women and Children. UK: Department of Health, 2010, http://www.health.org.uk/media_ manager/public/75/external-publications/Responding-to-violence-against-women-and-children%E2%80%93the-role-of- the-NHS.pdf [last accessed 01.09.12]. 25. KPMG and Queensland Health. Review of Queensland Health responses to adult victims of sexual assault. March 2009. 4769976_1. DOC; http://www.health.qld.gov.au/sexualassault/docs/KPMGreview.pdf; [last accessed 15.08.12]. 58 M. Eogan et al. / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 47–58

26. Trippany RL, White Kress VE & Wilcoxon SA. Preventing vicarious trauma: what counsellors should know when working with trauma survivors. J Couns Dev 2004; 82: 31–37. 27. Racquepaw JM & Miller RS. Psychotherapist burnout: a componential analysis. Prof Psychol Res Prac 1989; 20: 32–36. 28. Pearlman LA & Saakvitne K. Treating therapists with vicarious traumatisation and secondary traumatic stress disorders. In Figley CR (ed.). Compassion fatigue: coping with secondary stress disorder in those who treat the traumatised. Bristol PA: Brunner/Mazel, pp. 150–177. 29. Catherall DR. Coping with secondary traumatic stress: the importance of the support group. In Stamm BH (ed.). Secondary traumatic stress: self care issues for clinicians, researchers and educators. Lutherville, MD: Sidran Press, 1995, pp. 80–90. Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 59–75

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6 Problems of capacity, consent and conﬁdentiality

Amaboo Dhai, MBChB (Natal), FCOG (SA), LLM (Natal), PGDipIntResEthics (UCT), Director and Adjunct Professor and Head of Bioethics Discipline a,*, Jason Payne-James, MB BS, LLM, MSc, FRCS (Eng & Ed), FFFLM, FFSSoc, Consultant Forensic Physician and Honorary Senior Lecturer b,c a 10AO1, Steve Biko Centre for Bioethics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 7 York Road, Parktown, Johannesburg 2193, South Africa b Forensic Healthcare Services Ltd, Leigh-on-Sea, Essex, UK c Cameron Forensic Medical Sciences, Barts and The London School of Medicine and Dentistry, London, UK

Keywords: For the clinician managing a woman who has been violated trust sexually, core values of compassion, understanding and concern mutual respect for the woman’s distress are essential. The nature of the violation voluntariness itself places the woman in a uniquely dependant, anxious, disclosure vulnerable and exploitative state. Capacity, consent and confi- understanding dentiality derive from the principle of autonomy. Informed decision consent entails a process of information sharing and decision authorization making based on mutual respect and participation. Practitioners privacy should have communication, listening and interpretative skills. capacity fi consent One of the greatest challenges is the dif culty in ascertaining confidentiality whether or not the woman truly understands and grasps the nature of her condition. There are many challenges to obtaining a valid consent in the real world. Information obtained from the woman could be shameful and embarrassing, but would be used in a court of law. She should be informed of the potential for breach of confidentiality. These issues are explored and examples of practical application of the relevant themes are given from the England and Wales jurisdiction. Ó 2012 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: þ27 117172718, þ27 824520179; Fax: þ27 117172639, þ27 086 55 32746. E-mail address: [email protected] (A. Dhai).

1521-6934/$ – see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bpobgyn.2012.08.007 60 A. Dhai, J. Payne-James / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 59–75

Introduction

The impact of sexual violence on physical and mental health is profound. It is associated with a range of physical, sexual and reproductive health problems, with both immediate- and long-term consequences. In addition, social well-being can also be overwhelmingly affected, with survivors suffering stigmatisation and ostracism from their families and others as a result. Rape and other forms of sexual assault are frequently used as a weapon of war and as forms of attack on the enemy, where sexual violation typifies the conquest and degradation of its women.1 Where women transgress social and moral codes, it can be used as a punishment against them (e.g. the gang raping of lesbian women in some countries). Although sexual violence is a global phenomenon, research is lacking in this important field. Where research has been conducted on the subject, available data suggest that, in some countries, the sexual violence is by an intimate partner in about one in four cases. In the instance of adolescent girls, the data suggests that nearly one-third describe their first sexual encounter as being coerced.1 Recently, complaints of sexual violation against practitioners during the course of an intimate examination have also been on the increase, bringing to fore the importance of the precautionary measure of having a chaperone present in these settings.2 For the clinician managing a woman who has been violated sexually, core values of compassion, understanding and concern for the woman’s distress are essential. Specifically, the nature of the violation itself places the woman in a uniquely dependant, anxious, vulnerable and exploitative state. She is forced into a position of trusting the clinician in a relationship of relative powerlessness. Moreover, the clinician invites that trust when his or her knowledge and expertise are offered to the service of the woman.3 An extremely high degree of competence is expected and required of practitioners who manage the sexually violated woman. This competence is not limited to scientific knowledge and technical skills, but also includes ethical knowledge and skills and an understanding of the woman’s human rights and how the law applies to, and protects, the woman under these circumstances. Clearly, a significant number of serious and sensitive ethical issues arise when caring for these women. The focus of this paper, however, will be on particular concerns regarding the problems of capacity, consent and confidentiality that emerge in this setting. All these derive from the principle of autonomy. For an understanding of how these difficulties should be addressed, it would be important for the reader to appreciate the principle of autonomy and how it applies in this environment.

Autonomy

Liberty and agency

The traditional Hippocratic belief that one could do almost anything on a patient as long as the principles of beneficence (best interests) and non-maleficence (no harms) were upheld was considerably revolutionised over the past century. Paternalism, the belief that the healthcare practitioner should protect or advance the interests of the patient, even if contrary to the patient’s own immediate desires or freedom of choice, no longer has a place in the healthcare context.4 As a result of the Nur- emburg Trials,5 the Universal Declaration of Human Rights,6 and several other codes and guidelines emanating from international bodies, such as the World Medical Association,7 the value of autonomy and self-determination have been recognised as paramount. Respecting autonomous choices of people is embedded deep in common morality, and in health care it is used primarily to examine decision making, privacy and confidentiality. Decision-making includes informed consent and informed refusal. The word ‘autonomy’ derives from the Greek autos (‘self’) and nomos (‘rule’, ‘governance’ or ‘law’). Initially, it was used to refer to the self-rule or self-governance of independent Hellenic city-states. Today, ‘autonomy’ extends to individuals and has acquired meanings as diverse as ‘self-governance, liberty rights, privacy, individual choice, freedom of the will, causing one’s behaviour, and being one’s own person.’8 Essential to personal autonomy as distinguished from political self-rule is the freedom from controlling interferences by others and from personal limitations that prevent meaningful choice.9 Personal limitations include lack of understanding, low levels of literacy and cultural barriers. Hence, the autonomous person acts freely in accordance with a self-chosen plan whereas, in contrast, A. Dhai, J. Payne-James / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 59–75 61 a person with diminished autonomy is controlled by others in one way or another, or is just not capable of deliberating, acting on the basis of his or her desires or plans, or both. A compelling argument can, therefore, be made that women in situations of gender discrimination, oppressive relationships, and institutions like prisons could have diminished autonomy and, as a consequence, may be constrained from acting on the basis of their desires and plans. Thus, it follows, that for autonomy to be respected, two conditions are essential: liberty (independence from controlling influences); and agency (capacity for intentional actions).8

Autonomous choice

Autonomous choice, on the other hand, is actual self-governance rather that the capacity for self- governance. Capacity refers to the ability to reason, understand and deliberate. Even self-governing people may fail to make autonomous choices, either by waivering their choices or because of temporary constraints imposed upon them by, for example, anxiety, depression or illness. The sexually violated woman, who, in different contexts may have the ability to self-govern, because of physical and mental harms and resultant incapacity, may lack the facilities to make autonomous choices. However, an autonomous person who signs a consent form without reading or understanding the form fails to act autonomously although she is qualiﬁed to do so.8 Furthermore, in the medical world, difﬁculties experienced with autonomous choice could be caused by the nature of the doctor–patient relationship, with the patient being in the dependant position, and the doctor being in a standing of authority.

Degrees of autonomy

In addition, actions can be autonomous by degrees because there are different degrees of understanding and controlling influences that determine actions. A broad continuum exists for both these states, ranging from fully present to wholly absent. For an action to be autonomous, however, a substantial degree of understanding and freedom from constraint are required, and not a full understanding and complete absence of influence, because practically speaking, in the real world, people’s actions are rarely, if ever, fully autonomous. Questions are often raised about what ‘substantial’ and ‘insubstantial’ actually denote, and it can be stated that the line between these two often seems arbitrary. However, ‘thresholds marking substantially autonomous decisions can be carefully fixed in light of specific objectives such as meaningful decision-making’, as seen in accepting of proposed medical interventions and decisions about participation in research.8 In addition, allowing for different degrees of autonomy sanctions a move away from a narrow focus of autonomy that is restricted to independence from others and permits for the introduction of the importance of intimate and dependant relationships between people into the discourse. The crucial role played by communal life and human relationships in providing the matrix for the development of the self should not be underestimated.8

Respecting autonomy

To have the capacity of being an autonomous agent does not equal being respected as an autonomous agent, which, at a minimum, acknowledges the agent’s right to hold views, to make choices, and to take actions based on personal values and beliefs. To respect one’s autonomy involves both respectful attitude and respectful action towards the individual, thereby creating an enabling environment for one to act autonomously. It follows, therefore, that respecting ones autonomy requires more than obligations of non-intervention. Often, autonomous actions depend on material co- operation of others in making options available. Doctors have obligations to disclose information, probe for, and ensure understanding and voluntariness and to facilitate decision-making. Moreover, patients should be equipped to overcome their dependence in the doctor–patient relationship and to achieve as much control as they can or want. This positive obligation on the doctor is a consequence of the special ﬁduciary relationship that practitioners have with their patients.8 To respect autonomy includes obligations to maintain capacities for autonomous choice while allaying fears and anxieties that interfere with, or disrupt, the exercise of autonomous choice; in the case of the sexually violated 62 A. Dhai, J. Payne-James / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 59–75 woman, this must be executed with extreme sensitivity. Correlative to this obligation is the right to self-determination, which supports various autonomy rights, including those of conﬁdentiality and privacy. Although disagreement exists about the scope of these rights, there is agreement that autonomy rights can be constrained by rights of others. Therefore, respect for autonomy has only prima facie ranking, and can be overridden by competing moral considerations.

Autonomy: summary

In summary, autonomous actions are the outcome of deliberations and choices by rational agents as persons in the moral sense. Rational persons meet the criteria necessary to decide what is in their own best interests. Healthcare practitioners have a duty to recognise and respect this value in their patients. Not to do so would not only violate their patients’ autonomy, but would be synonymous with treating them as less than persons.10 An autonomous person is someone who has the ability to deliberate about personal goals and to act under the direction of such deliberation. To respect autonomy denotes valuing autonomous persons’ considered opinions and choices and refraining from obstructing their actions unless they are clearly detrimental to others. Now that the philosophical backdrop to autonomy has been discussed, the rest of the paper will focus on the application of this principle in the healthcare context, with speciﬁc reference to the sexually violated woman. The application applies both to management and research issues.

Informed consent

Over time, patient autonomy has achieved widespread acceptance, with patients being the ultimate decision makers in matters that affect themselves. The clinical autonomy and freedom in determining patient management that medical practitioners traditionally enjoyed has been signiﬁcantly curbed by, inter alia, governments, medical insurers and the economic climate. Hence, autonomy or self- determination, one of the foundational principles in medical practice, has changed to a large extent over the years both for practitioners and patients.11 The basic paradigm of autonomy in the healthcare context is informed consent. Whereas in recent years, the primary justiﬁcation advanced for requiring of informed consent has been the protection of autonomous choice, risk reduction and avoidance of unfair exploitation are still offered as reasons by many professional, regulatory and institutional controls. Consent occurs under varying conditions. It may be perfunctory, made reluctantly or under intense pressures that could render it invalid.

Categories of informed consent

The different categories of informed consent include the following8:

Tacit consent Tacit consent is expressed passively by omissions. The patient remains silent and does not object. Consider when a woman who is sexually violated is asked whether she objects to having her husband present during the consultation. A lack of objection constitutes consent (assuming she understands the question and the need for consent). Silence constitutes valid tacit consent as long as understanding and voluntariness are present.

Implicit or implied consent Implicit or implied consent is consent that is inferred from actions. Consent to one medical procedure is often implicit in a speciﬁc consent to another procedure (e.g. consent to passage of a speculum is implied when the woman consents to undress for an examination).

Express consent Express consent is consent in these circumstances that is articulated implicitly, either verbally or in writing. Express verbal consent will suffice for bladder catheterisation. For surgical procedures, however, express written consent is usually a requisite. Consider the case of a woman who has given A. Dhai, J. Payne-James / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 59–75 63 consent for routine blood tests. Do doctors now have a valid consent for a human immunodeficiency virus (HIV) test? Can appeal be made to a specific consent implicit in the general consent to blood tests? In general, testing for HIV antibodies without specific express consent will be difficult to justify because of the psychological and social risks associated with the test. Psychological risks include anxiety and depression. Social risks include stigma, discrimination and breaches of confidentiality. The category of consent acceptable in clinical practice is usually risk-dependant. Non-express consent is adequate where no risks or low risks are associated with the management proposed. As risk increases, the requirement for obtaining express consent increases. Even in situations where express consent is necessary, with increasing risk, written consent is recommended.

Informed consent as a process

Founded on basic ethico-legal principles, the doctrine of informed consent entails a process of information sharing and decision making based on mutual respect and participation. It should be considered a process and procedure and not merely an afﬁrmation, ritual or signature on a piece of paper at a particular point in time. The idea behind informed consent is that it facilitates the performance of professional tasks in a morally defensible way by bringing the patient’s informed preferences into the healthcare practitioner’s plans. Being well informed on entering the decision-making process protects the patient’s dignity in the healthcare environment.4 Informed consent is typically given over time and can be withdrawn over time. It is essential that informed consent is viewed as a temporal process and the common view that the signed form is the essence of informed consent is recognised as being incorrect.8

Practitioner requirements

The fundamental belief behind informed consent is that trust between the doctor and the patient will be fostered and engendered.12 An obvious requirement for ensuring that consent is truly informed is a practitioner with communication, listening and interpretative skills. In addition, it is an ethical imperative that the practitioner recognises and respects the patient’s choice of decision, which may be that of informed refusal rather than consent. The practitioner that provides information to a patient acknowledges an imbalance of information between them which, if not addressed, will compromise the patient’s autonomy. It is this imbalance of information that is the root of patient vulnerability. Knowledge and information of a patient’s ailment will empower the patient to make the choice most suitable to his or her needs and desires.4

Legal aspects

The requirement for informed consent is not just an ethical one but also a legal one. In law, the doctor–patient relationship is usually a contractual one, with the contract taking the form of an implied agreement that the practitioner will make a diagnosis and treat the patient in accordance with generally accepted standards. A contract implies that the parties involved in the contract have full knowledge of the situation and that they have willingly contracted. All forms of management must be discussed with the patient first. A related legal concept is the idea of a fiduciary relationship, whereby the patient places a special trust or confidence in the doctor. Hence the doctor violates his or her legal duty if information that is necessary for a patient to make a rational decision regarding care is withheld.13 Whether or not there was consent in a particular case is a question of fact. In law, there is no difference between written or oral consent, except that written consent is easier to prove should a dispute ensue.13 It is the duty of the practitioner to ensure that consent has been obtained from the patient. The practitioner cannot only rely on other healthcare professionals, including nursing staff, to ensure that consent has been obtained.14 64 A. Dhai, J. Payne-James / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 59–75

Components of a valid consent process

The ethical and legal components of a valid consent process are divided into three sets of elements (Table 1).8 These elements and sub-elements are viewed as the building blocks in the definition of informed consent, and the threshold elements have to be satisfied first before the other sets of elements can be added on.

Standards of disclosure

The legal doctrine of informed consent has been primarily a law of disclosure based on a general obligation to exercise reasonable care by giving information. Civil litigation has emerged over informed consent because of injury to one’s person or property that is intentionally or negligently inflicted by a doctor’s failure to disclose, with the injury being measured in terms of monetary damage.8 In the past, the accepted standard of disclosure was that of the ‘professional community standard’. How much information to be imparted was largely a matter of the doctor’s discretion as determined by the professional community’s customary practices. This standard assumed that the doctor’s proper role was to act in the patient’s best medical interests. This professional community standard has, in most jurisdictions, been replaced by the ‘reasonable patient’ standard, which entails a patient-centred approach to informed consent.15 Obligations to respect autonomy generally outweigh obligations of beneficence, and, on balance, the reasonable patient standard better serves the autonomy of patients than does the professional community standard. Consent will only be ‘informed’ if the patient has substantial knowledge about the nature, effect, consequences and risks involved in the treatment or procedure consented to. This means that there is a duty on the practitioner to explain the procedures to be followed to the patient, what the alternatives are, the benefits of the treatment, how the patient would fare without treatment, and to warn the patient about the ‘material risks’ involved in the proposed treatment.16 A risk is material if (1) a reasonable person in the patient’s position, if warned of the risk, would attach significance to it; and (2) the doctor should reasonably be aware that the patient, if warned of the risk, would attach significance to it.16 A practitioner, however, need not point out every possible complication that may arise, but where a risk would be considered material by the patient, it would need to be explained to him or her, even though it might be remote. Information overload should be avoided as this could prove an obstacle to adequate understanding. The defence of consent in medical matters applies where the patient has (1) knowledge of the nature or extent of the harm or risk; (2) appreciates and understands the nature of the harm or risk; (3) has consented to the harm or assumed the risk; (4) the consent is comprehensive and extends to the entire transaction, inclusive of its consequences; (5) the person giving the consent is legally capable of giving consent (e.g. not a mentally immature child or a mentally challenged person); and (6) the patient has made the decision freely and voluntarily without being coerced to do so.

Table 1 Ethical and legal components of a valid consent process.

Threshold elements (preconditions) Competence (to understand and decide) Voluntariness (in deciding)

Information elements Disclosure (of material information) Recommendation (of a plan) Understanding (see sections ‘Liberty and agency’ and ‘Autonomous choice’)

Consent and refusal elements Decision (in favour of or against a plan) Authorisation (in favour of or against a plan) A. Dhai, J. Payne-James / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 59–75 65

Consent is a valid defence only if the act consented to is in accordance with public policy, that is, not contrary to good morals (e.g. consent to a consensual sexual relationship with the woman’s doctor would not render the doctor’s conduct lawful).

Capacity and competence

A requisite for the practitioner is the obligation to ascertain the level of a patient’s ability to grasp the information given (i.e. the capacity or competence). One of the greatest challenges to the doctrine of informed consent is the difficulty in ascertaining whether or not the patient truly understands and grasps the nature of her illness and the basis for consenting to, or refusing, the management proposed.4 An experienced and knowledgeable patient is likely to be in a better position to consent than a frightened, sexually violated woman in an emergency room. As the risks to proposed management relative to alternatives increase, so does the need for a greater level of communication, understanding and reasoning skills necessary for competently making the decision increase. When, during the first consultation, it is difficult to determine the level of competence, it is appropriate to evaluate the patient’s understanding, capacity to deliberate, and coherence over time, while supplying counselling and further support and information. Asking questions, bringing out the concerns and interests of the patient, and establishing a climate that encourages questions, all impacts significantly in promoting understanding.8 Of assistance are the four levels of competence that have been proposed by Appelbaum and Grisso.17 Ideally, the patient should have all four levels for optimal competence: (1) the ability to communicate choices; (2) the ability to understand relevant information upon which the choice is made; (3) the ability to appreciate the situation according to the patient’s own values; and (4) the ability to weigh various values to arrive at a decision. In medicine, the motive for determining competence is to protect the patient against decisions they may make that are not in their best interests. Standards of competence are closely connected to levels of experience, maturity and responsibility. Conventionally, age is used as an operational criterion of valid authorisation. Established thresholds of age vary according to a community’s standards, the degree of risk involved, and the importance of prospective benefits (e.g. the minimum age of consent for medical treatment varies between countries and is 12 years in South Africa and 16 in the UK). Information sharing should be in simple language that the patient understands. Differences of language and culture are two major obstacles to good practitioner–patient communication, with differences in cultural understanding of the nature and cause of illness at times impeding the understanding of the diagnosis and treatment options provided by the practitioner.4 Moreover, although the patient may comprehend the information, her ability to make a decision could also be impeded where there is a breakdown in her ability to accepting the information as being true. Furthermore, she could have false beliefs about her condition.8

Legal exceptions to the rule of informed consent

Legal exceptions to the rule of informed consent allow the doctor to proceed without consent in cases of emergency, incompetency, the therapeutic privilege and waiver.8

Emergencies

It has been suggested that, in circumstances where a patient has consented to a specific type of operation, and while being operated upon under general anaesthetic, another serious condition is detected, the practitioner would be justified in trying to remedy such condition if (1) the extension of the operation is in accordance with good medicine; (2) the extension takes place in good faith in order to alleviate the patient’s complaint; (3) the risk to the patient is not materially increased; and (4) it would be against the patient’s medical interests to first allow the person to recover from the anaesthetic in order to give consent to the operation being extended.4 The courts have held that in cases of emergency, an extension of an operation without the patient’s consent may be justified on the basis of necessity.18 66 A. Dhai, J. Payne-James / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 59–75

Both ethics and the law provide that nobody may be refused emergency medical treatment. The sexually violated woman may be so badly injured that she is rendered incapable of giving consent. Emergency medical treatment may be provided without ﬁrst obtaining consent, where patients incapable of giving consent are faced with death or irreversible damage to their health if such treatment is delayed and they have not refused consent. Surrogates may consent on behalf of the patient who is not capable of giving consent, in line with the country’s legal requirements.

Non-disclosure and the therapeutic privilege

A concept that is closely related to informed consent is that of ‘truth telling’. It is always assumed that telling the truth is the right thing to do. Truth telling is aligned to honesty, the moral value of which is unquestionable. Yet, the problem of telling the truth to patients is a topic of controversy, particularly when bad news must be conveyed. In these situations, clinicians make compelling argu- ments that non-disclosure is in the best interests of the patient. Moral acceptability to non-disclosure is permitted when it is used to further the welfare of the patient. Concerns, however, have been raised to whether such intentional non-disclosures are justiﬁable.8 In addition, the long-term threats of non disclosure to trust in the doctor–patient relationship and to the doctor’s moral integrity must be borne in mind. The therapeutic privilege is understandably controversial and allows for a doctor to legitimately withhold information, when, based on sound medical judgement, to divulge the information would be potentially harmful and counter the therapeutic objectives of management. The patient from whom information is withheld is typically depressed, emotionally drained or unstable. Divulging information could endanger life, causing irrational decisions and produce anxiety or stress. Much of this could apply to the woman who has suffered sexual violations.

Waivers of informed consent

A further problem presenting in the clinical situation is the issue of waivers of informed consent. This could be particularly troublesome when managing the woman who has been sexually violated, who is mentally exhausted, and who really does not want to have the additional anxiety of making an informed decision and leaves ‘all in the doctor’s hands.’ When exercising a waiver, the patient voluntarily relinquishes the right to an informed consent and delegates decision-making authority to the doctor or asks not to be informed. Hence, the patient makes a decision not to make an informed decision. Although it is usually appropriate to recognise waivers of rights, the danger of abuse of the waiver in busy clinical settings, together with problems of how to determine the conditions under which a patient can make a voluntary informed decision to waive the right to relevant information, cautions against the indiscriminate implementation of waiver policies. The contemplated management plan could be withheld until sufﬁcient understanding is present, albeit the patient’s autonomously expressed decision not to be informed. In this way, patients will not be coerced or manipulated into receiving undesired information.8

Voluntariness

Voluntariness is satisfied where there is adequate knowledge, and psychological compulsion and external constraints are absent. The patient is not under the control of coercive, persuasive or manipulative influences of others. Some medical conditions diminishing voluntariness include debilitating diseases and psychiatric disorders. Manipulative influences include acts of love, threats, lies, manipulative suggestions and emotional appeals. In the context of health care, informational manipulation is the key form of manipulation. This is a deliberate act of managing information in such a way that it non-persuasively alters the patient’s understanding of the situation and, as a result, she is motivated to do what her doctor intends. The influence of familial preferences and pressures, however, should not be disregarded, and patients should be asked right at the outset about the extent to which she prefers to involve others. A. Dhai, J. Payne-James / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 59–75 67

Challenges to informed consent

Informed consent poses numerous challenges. These are due, for the most part, to resource constraints, understaffing of healthcare facilities and language and cultural barriers, phenomena that are common globally. Often, doctors find themselves faced with patient loads and responsibilities that are all but manageable. This means that, although they wish to provide the best possible treatment for their patients, it is not always possible. Consultation time is limited by the sheer volume of patients awaiting treatment. These time restraints mean that doctors often cannot devote the appropriate amount of time needed to obtain valid informed consent from each patient. In addition, populations across the globe are increasingly becoming culturally diverse. Although doctors recognise that different cultural norms and beliefs should be respected, it is often difficult to establish what these are. Where the doctor cannot speak the patient’s language and where many medical conditions (i.e. HIV and AIDS) are clouded in superstition, it will require ongoing dialogue between healthcare providers and patients to ensure that the patients’ beliefs are recognised. Doctors’ obligations to respect patient autonomy will have to include a recognition of the way patients exercise their autonomy, taking into account socio-cultural contexts, religious and other beliefs. Autonomous patients may choose to delegate decision-making to others besides the doctor, and the right to do so must be respected. Human immunodeficiency virus is another issue that poses a challenge to informed consent. Because of the stigma surrounding the disease, patients are either unwilling to disclose their HIV status to doctors or they are unwilling to consent to HIV testing.4

Conﬁdentiality

Confidentiality is one of the longest standing dictums in healthcare codes of ethics, and has been a cornerstone of healthcare ethics since the time of Hippocrates. According to the Hippocratic Oath, written in the 4th century BC: What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which in no account one must spread abroad, I will keep to myself holding such things shameful to be spoken about.19 Hence, it can be deduced that, through the ages, confidential information has been perceived as sensitive information, as judged by the patient. This sensitive information could be shameful, harmful and embarrassing to the patient, especially where the woman has been sexually violated. Confiden- tiality may be perceived as the need to keep such personal information within proper bounds. The patient, therefore, must have a reasonable expectation that this sensitive information will not be disclosed to others. When doctors obtain confidential information from patients, the latter have a right to expect that the practitioner will honour his or her professional promise of confidentiality.20

Privacy versus conﬁdentiality

The notion of confidentiality is often discussed within the framework of privacy. Although these concepts are closely linked, there are some differences between the two. Privacy relates to aspects of a person’s being into which no one else should intrude. When patients share private information with their practitioners, they choose to relinquish some aspects of their privacy. Patients have a reasonable expectation that such information will only be shared with specific people to further their (the patients’) welfare and with no one else. Confidentiality therefore involves a relationship, whereas privacy does not.21 It is clear that confidential information must be treated with utmost care. The reasons for this are to exclude unauthorised people from being privy to this information, and to facilitate the sharing of sensitive information with the goal of helping the patient. Confidential information may be shared with other healthcare practitioners involved in managing the patient on condition that this information pertains to that aspect of management and has relevance to the case.21 68 A. Dhai, J. Payne-James / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 59–75

Ethical sources

Confidentiality draws such a high value from three sources. These are autonomy, respect for persons and trust.21 The principle of autonomy prescribes that personal information belongs to an individual and should not be made known to others without their consent, except where there is a legitimate requirement to breach confidentiality. Individuals have a right to privacy, and this right allows them autonomy over their personal information. Because people deserve respect, it is essential that the confidences they impart to the doctor are upheld and respected. In this manner, their privacy will be preserved. The doctor–patient relationship is one built on trust. Keeping confidences assist in building that trust, thereby maintaining patient dignity. Eroding that trust will most certainly harm the relationship. Often, practitioners are total strangers to patients who end up revealing their most intimate and personal information to them. Frequently, this information is information that they would not want anyone else to know. If there was no understanding by patients that practitioners have ethical and legal duties to keep their disclosures secret, they would withhold information that would hinder practitioners in their efforts to provide.

Breaching conﬁdentiality

Generally, confidential information cannot be shared with others unless authorised by the patient personally or by the law. In most cases, patients are unaware of the limits to patient confidentiality. Good clinical practice entails that they are advised of this before rather than after their information has been divulged. Where a breach of confidentiality is necessary and justifiable, this should be kept to a minimum and those who gain access to this information should be made aware of the need for them to uphold this information as confidential. In healthcare institutions, breaches may also occur when others (e.g. laboratory technicians, students and interpreters) require access to the patient’s information.22 It should be remembered that breaching confidentiality always involves a harm: that of creating distrust in the doctor–patient relationship. When faced with such a dilemma, it is important that the following questions are asked: does the benefit of breaching confidentiality outweigh the harm of threatening the trust in the doctor–patient relationship? And, how can the amount of harm be kept to a minimum when it is ethically appropriate to breach confidentiality?21 Although questions surrounding the practice of keeping patient confidences are not easily resolved, it is always the duty of the practitioner to ensure that the harms as a result of making disclosures are minimised and patient benefits optimised. In many jurisdictions, according to the law, confidentiality is the duty of healthcare professionals to ensure that all information concerning a patient is not disclosed without the consent of the patient or under the conditions prescribed by law. The common-law right to privacy requires doctors to maintain the confidentiality of their patients unless: (1) a court of law orders them to make a disclosure; (2) an Act of Parliament requires the disclosure to be made; (3) there is a threat to an endangered third party; (4) there is a moral, social or legal obligation to make a disclosure to a person or agency that has a reciprocal moral, social or legal obligation to receive the information; (5) Where patients make complaints against practitioners to their regulatory bodies regarding their treatment and the practitioners are obliged to make certain disclosures as part of their defence; or (6) the patient consents to the disclosure being made.20 These exceptions may be raised as defences to actions for invasion of privacy, defamation or breach of contract arising from a breach of confidentiality.13 A breach of confidentiality may result in an action for invasion of privacy.20 In civil matters, refusal by a health practitioner to comply with a court order will result in prosecution for contempt of court. In criminal matters, such refusal is also contempt and the practitioner could be sentenced to imprisonment. It should also be communicated to women that information that has been collected would be used in a court of law, and therefore the potential for breaching confi- dentially in this context.20 In the US case of Tarasoff23, a student told a university psychologist that he was going to kill his ex-girlfriend because she had left him. The psychologist warned the campus A. Dhai, J. Payne-James / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 59–75 69 security but not the girl or her family. The girl was killed and her family sued the university. The court held that there was a legal duty on the psychologist to warn the girl or her family because she was an endangered third party and ‘the protective privilege ends where the public peril begins.’ The courts treat the relationship between doctors and patients as a qualified privilege, irrespective of whether the relationship involves physical or psychological injuries or illnesses. In cases involving physical injuries or illnesses, even if they are embarrassing (e.g. evidence of sexually transmitted infections in the course of examining the woman who has been sexually violated), the courts will order disclosure if it is necessary in the interests of the administration of justice. In most countries, statutory and civil law impose an obligation on doctors to report child abuse to the relevant authority, or law abiding agency, or both. Hence, the diagnosis of sexual violation in children warrants reporting of this misdemeanour, usually to the police. The court is the upper guardian of all minors, and the best interests of the child (not the parents) is paramount in all activities regarding the child.

Clinical and practical considerations in the forensic setting

The principles espoused in the preceding sections are ones that have great importance in the medical assessment of those who have alleged a sexual assault of some kind. It should also be emphasised that relevant principles should also apply to the signiﬁcant minority of complainants of sexual assault who are male. Medical assessments in this setting will have elements of history-taking, physical examination, sample collection and medical management. The assessment will have therapeutic and forensic elements. Information acquired in this setting may ultimately be used outside the medical setting and in police investigatory and judicial environments. It follows then, that any healthcare professional undertaking such assessments understands the concepts of autonomy, informed consent, capacity and competence, and conﬁdentiality, and can apply them appropriately to each patient that they see. Such principles are universal, but their application and interpretation may alter in subtle ways dependent on the jurisdiction and healthcare professional regulations, which apply locally. Jurisdic- tional issues may, for example, have different ways of managing child patients who disclose any form of abuse. All practitioners should, therefore, make themselves aware and familiar with their own legal framework and local practice and policy. Appropriate application of frameworks, practice and policy will ensure that the evidence retrieved, whether in verbal, written or physical form, is of the best quality, and therefore less likely to be open to legal challenge at a later date.

Practice in England and Wales

England and Wales will be used as an example jurisdiction to show how a number of factors affect and dictate the actions that healthcare professionals may be required to take in relation to capacity, consent and conﬁdentiality. Every jurisdiction will have its own variations on these themes. Healthcare professionals in England and Wales assessing complainants of sexual assault, whether adult or child, must respect the principles described in earlier sections and may have to also adhere to statute, codes of practice, guidelines and other publications designed to assist in their practice. Registered medical practitioners may have to be aware of guidelines from other bodies, such as the General Medical Council (whose declared purpose is to ‘protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine’), and from Royal Colleges or Faculties of Colleges whose membership may be particularly directed at those likely to be involved in such assessments (e.g. the Royal College of Paediatrics and Child Health, the Faculty of Forensic and Legal Medicine of the Royal College of Physicians). Nurses have to adhere to the code of practice produced by the Nursing and Midwifery Council.

Forensic medical assessments

In England and Wales, examination of adult and child complainants of sexual assault may be undertaken by a variety of professionals, predominantly registered medical practitioners (doctors) and 70 A. Dhai, J. Payne-James / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 59–75 nurses. The level of expertise of practitioners will vary, and it is an unfortunate fact that those with less training will be less aware of the importance of appropriately addressing capacity, consent and confidentiality issues, than those who are trained. This lack of awareness is often a reason that evidence may be ruled inadmissible at a later date, as basic safeguards have not been used that result in legal challenge. In essence, an assessment for forensic purposes will require the practitioner to take a full clinical history, which will generally include (over and above medical, surgical, gynaecological, social, substance and psychiatric histories) the following: an account of the allegations (which may be related by a police investigating officer in the case, and clarifications sought by the practitioner); a full head-to-toe physical examination; invasive examinations such as passage of vaginal speculum and proctoscope into the anal canal; and taking of biological samples, which may include blood, urine, hair, nails, and vaginal, anal, oral and skin swabs. Photographic, video or colposcopic images may be required. These may be lengthy and distressing assessments, even in the most sympathetic hands. In addition to the forensic assessment, a therapeutic and prophylactic element may need to be considered. The individual may require treatment for injury (e.g. vaginal or anal tears), for possible infective consequences of contact (e.g. sexually transmitted infection, including hepatitis and HIV), and consideration, when appropriate, for prevention of unwanted pregnancy. Fully informed consent must embrace all these elements, and the emphasis that confidentiality about information disclosed may, despite the practitioner’s best intentions, be limited if the court take the view that disclosure is necessary. Informed consent must, therefore, also indicate that written reports will be made about the assessment, and that such reports and the contemporaneous medical notes and images all have the potential for disclosure to others outside the healthcare field, including police personnel, legal professionals, and judges.

Mental capacity

The complexity of such an assessment, and the implications of disclosure, are great and it is thus extremely important to know that the individual being assessed understands what is being proposed and the potential consequences. The determination of mental capacity of the individual for whom examination is required is thus one that requires consideration before starting the assessment to determine how, and from whom, informed consent should be appropriately sought. The concept of mental capacity is one that has been explored closely in recent years. A new Act, the Mental Capacity Act 200524 now has particular relevance to all those who are involved in the care, treatment or support of people aged 16 years or over who live in England and Wales and who are unable to make all or some decisions for themselves. This is particularly relevant in cases of sexual assault where those who are vulnerable may be over-represented and may thus require additional precautions and safeguards to protect them.25 A Speciﬁc Code of Practice has been published to assist practitioners.26 The Act has ﬁve key principles: (1) every adult has the right to make his or her own decisions and must be assumed to have capacity to do so unless it is proved otherwise; (2) people must be supported as much as possible to make a decision before anyone concludes that they cannot make their own decision; (3) people have the right to make what others might regard as an unwise or eccentric decision; (4) anything done for, or on behalf of, a person who lacks mental capacity must be done in their best interests; (5) anything done for, or on behalf of, people without capacity should be the least restrictive of their basic rights and freedoms. The Mental Capacity Act 2005 determines that a person is unable to make a particular decision if they cannot do one of the four following things: (1) understand information given to them; (2) retain that information long enough to be able to make the decision; (3) weigh up the information to make the decision; (4) communicate their decision – this could be by talking, using sign language or even simple muscle movements such as blinking an eye or squeezing a hand. Lack of mental capacity can be have many causes (some of which are permanent and some temporary), including a mental health problem, learning disability, previous stroke or brain injury, substance misuse, and confusion, drowsiness or unconsciousness. Sexual assault cases may frequently embrace a number of these factors, and lack of capacity may not, in this setting, be permanent. A. Dhai, J. Payne-James / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 59–75 71 Table 2 Paediatric forensic assessment consent form.31

Name ______

Address ______

I, _ [Name of child/young person and/or person with PR]_ consent to a forensic examination, as explained to me by ______, being conducted on ____[Name of child/young person] ______

I understand that the paediatric forensic examination will include (delete if not applicable)

a) A full medical history and complete examination;

b) Collection of forensic and/or medical specimens;

c) Taking of notes, photographs/videos/digital images for recording and evidential purposes (including second opinions from medical experts and peer review). I have been told that any sensitive photographs, videos and/or digital images will be stored securely and only be made available to other non-medical persons on the order of a judge;

d) I understand and agree that the doctor/nurse may provide a statement/report for the police, social services, paediatric services and the patient’s GP;

e) I understand and agree that a copy of the medical notes may be given to professionals involved in the case (e.g. police or lawyers) and may be used in a court;

f) I agree to the use of anonymised photographs/videos/digital images/medical notes for teaching;

g) I agree to the use of my anonymised photographs/videos/digital images/medical notes for audit and research;

h) I have been advised that I may halt the examination at any time Name of child/young person______

Signed ______Date______

Name of person with PR______

Signed ______Date______72 A. Dhai, J. Payne-James / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 59–75

The Mental Capacity Act 2005 introduced a number of changes including: (1) a presumption that people who are being cared for or given treatment have the capacity to make decisions for themselves; (2) a single clear test for assessing whether a person lacks capacity, using the four-point assessment above; (3) a check list of key factors to help determine what is in the ‘best interests’ of a person lacking capacity; (4) an obligation to consult, when practical and appropriate, people who are involved in caring for the person who lacks capacity and anyone interested in their welfare; (5) The creation of the Independent Mental Capacity Advocate service to become involved where there is no one appropriate who can be consulted; (6) A new Court of Protection and a new public ofﬁcial (the Public Guardian) who is supported by the Ofﬁce of the Public Guardian.

Table 3 Adult forensic assessment consent form.32

I, ______consent to a forensic examination, as explained to me by ______

I understand that the forensic examination will include (delete if not applicable)

a) A full medical history and complete examination;

b) Collection of forensic and/or medical specimens;

d) I understand and agree that the doctor/nurse may provide a statement/report for the police ;

e) I understand and agree that a copy of the medical notes may be given to professionals involved in the case (e.g. police or lawyers) and may be used in a court;

f) I agree to the use of my anonymised photographs/videos/digital images/medical notes for teaching;

g) I agree to the use of my anonymised photographs/videos/digital images/medical notes for audit and research;

h) I have been advised that I may halt the examination at any time.

Signed ______Date ______

If verbal consent:

Signature & Name of Witness ______A. Dhai, J. Payne-James / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 59–75 73

For each individual who is assessed and for whom it is determined that they lack capacity to make a decision (e.g. to consent to an examination for therapeutic and forensic purposes), the medical notes should have clear records documenting why the practitioner has come to the conclusion that capacity is lacking at that particular time. If it is believed (e.g. through substance misuse) that lack of capacity is temporary, a plan should be made and recorded for time of review for re-assessment of capacity.

Consent for forensic medical assessment

Mental capacity of the individual to consent should follow Mental Capacity Act 2005 principles and, for doctors, General Medical Council guidance.27 If an individual lacks capacity and, as a result, a delay occurs in obtaining relevant samples, or possible evidential material that may assist with medical treatment or identiﬁcation of an assailant is lost or has deteriorated, then the doctor must consider the possibility of proceeding with a forensic examination without the individual’s consent. The practitioner may then deem an examination is in the individual’s ‘best interests’ having duly considered medical interests as well as emotional, social and welfare considerations. If the incapacity is considered temporary (e.g. due to alcohol or drugs), then forensic assessment should normally be deferred until the effects have worn off and the individual can make their own determination. If the incapacity is considered to be a result of serious physical injury (for whatever reason), and that incapacity will not be short term, a ‘best interests’ examination is undertaken. The practitioner should then (1) inform the consultant who is responsible for the medical care of the patient of the nature and the purpose of the proposed examination to ensure there are no objections to it; (2) consider speaking to people close to the patient about the nature and purpose of the examination to determine their considerations of the patient’s wishes, feelings, beliefs and values so that they can be taken into account (if it is appropriate to do so – this may require consultation with others, such as police investigating ofﬁcers); (3) consider obtaining the views of an attorney or deputy; (4) document all contacts and discussions in the medical records so that the reasons for actions and determinations are clear; and (5) once the patient has recovered, inform them of the actions and reasons why they were undertaken and record their responses.28 For those with mental disorders, and who are considered to lack capacity, similar steps should be taken; however, in addition, it may be appropriate to have a family member or carer present during the examination who may be able to facilitate communication. If the individual being examined does not comply in these circumstances during the examination it must be ceased. In England and Wales, individuals aged 16 or over can give informed consent to surgical or dental treatment,29 and it is presumed (although not explicitly stated) that assessments and examinations for forensic purposes are included. Additionally, in England and Wales, the term ‘Gillick competence’ refers to ‘the ability of a child under the age of 16 to make his own medical decisions is evaluated according to chronological age, considered in conjunction with the child’s mental and emotional maturity, intelligence and comprehension’. A child deemed Gillick competent can consent to such an examination. Provision is made for an examination of individual who is under the age of 18 years who lacks Gillick competence to need consent from either a person who holds parental responsibility for that child or, if such an individual is not available, then a variety of methods, including, local authority seeking a court order under the Children Act 1989, or a relative seeking a residence order and parental responsibility with leave of the court. In such circumstances, copies of such orders should be viewed before starting assessment, and copies retained in the contemporaneous notes. If an apparently competent young person refuses to be assessed or treated in spite of the practitioner’s belief that it is in the individual’s best interests, the General Medical Council advises that legal advice be sought.30 The current view is that doctors cannot be compelled by parents, courts or others, to undertake an examination on a child.28 It is appropriate to have express written consent for both paediatric and adult examinations. Examples of the type of written consent that is appropriate in these settings in order to ensure that any ambiguity is as far as possible avoided are presented in Tables 2 and 3. 74 A. Dhai, J. Payne-James / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 59–75

Conclusion

The effect of sexual violence on physical and mental health is profound. An extremely high degree of competence, including skills in ethics and the law, is expected and required of practitioners who manage the sexually violated woman. Capacity refers to the ability to reason, understand and deliberate. Difﬁculties experienced with autonomous choice could be due to the nature of the doctor– patient relationship, with the patient being in the dependant position, and the doctor being in a standing of authority. Informed consent is a temporal process. In law, there is no difference between written or oral consent, except that written consent is easier to prove should a dispute ensue. The challenges to obtaining a valid consent include multicultural diversity and poor communication. Although personal and sensitive information is divulged by the woman, this will have to be revealed in court, and she needs to be informed of this. Sexual violation of the female child must be reported.

Practice points

Compassion, understanding and concern for the distress of the sexually violated woman are essential. For autonomy to be respected, the woman must be independent from controlling influences and have the capacity for intentional actions. Informed consent is a process that occurs over time and can be withdrawn over time. For informed consent to be valid, threshold, informational and consent and refusal elements have to be satisfied. The woman has to be warned about the ‘material risks’ involved in the proposed treatment. Asking questions, bringing out concerns and interests of the woman, and establishing a climate that encourages questions significantly promotes understanding. Exceptions to the rule of informed consent include the emergency situation, therapeutic privilege, and where the woman waivers her right to make an informed decision. Practitioners should be aware of language, cultural and traditional barriers to obtaining a valid consent. Generally, confidential material cannot be shared with others unless authorised by the patient or by the law. Child sexual violation must be reported to the relevant authorities.

Research agenda

Substantial research is needed on the ethical dilemmas faced by practitioners managing women who have been sexually violated. In addition, understanding how women who have been sexually violated feel about the process of obtaining a valid consent for management and the potential for conﬁdentiality breaches would go a long way in assisting practitioners in how to manage the consultation from an ethical perspective.

References

1. World Health Organization. Sexual violence in World Health Report on Violence and Health. Geneva: WHO, 2002, http:// whqlibdoc.who.int/publications/2002/9241545615_eng.pdf [last accessed 29.08.12]. 2. Dhai A, Gardner J, Guidozzi Y et al. Professionalism and the intimate examination – are chaperones the answer? S Afri Med J 2011; 110: 814–816. *3. Dhai A & McQuoid-Mason D. Professionalism and the healthcare practitioner-patient relationship. In Dhai A & McQuoid-Mason D (eds.). Bioethics, human rights and health law. Principles and practice. 1st ed. Cape Town: JUTA, 2011, pp. 59–68. A. Dhai, J. Payne-James / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 59–75 75

4. Dhai A & McQuoid-Mason D. Consent. In Dhai A & McQuoid-Mason D (eds.). Bioethics, human rights and health law. Principles and practice. 1st ed. Cape Town: JUTA, 2011, pp. 69–85. 5. Nuremberg Tribunal. The Nuremberg Code (1948); http://www.hhs.gov/ohrp/archive/nurember.html [last accessed 29. 08.12]. *6. United Nations. “Universal Declaration of Human Rights”; http://www.un.org/events/humanrights/2007/hrphotos/ declaration%20_eng.pdf. [last accessed 9.08.12]. 7. World Medical Association; http://www.wma.org. [last accessed 29.08.12]. *8. Beauchamp TL & Childress JF. Respect for autonomy. In Beauchamp TL & Childress JF (eds.). Principles of biomedical ethics. 4th ed. New York and Oxford: Oxford University Press, 1994, pp. 120–188. *9. Berlin I. Two concepts of liberty. In Berlin I (ed.). Four essays on liberty. Oxford: Oxford University Press, 1969, pp. 118–172. *10. Munson R. Physicians, patients and others: autonomy, truth telling, and confidentiality. In Munson R (ed.). Intervention and reflection. 7th ed. Victoria: Thomson Leaning, 2004, pp. 101–113. 11. World Medical Association. Medical ethics manual. 1st ed. Ferney-Voltaire Cedex: World Medical Association, Inc, 2004. 36–50. *12. Purtilo R. Informed consent. In: Ethical dimensions in the health professions. 3rd ed. Philadelphia: Saunders, 1999, pp. 185–204. *13. McQuoid-Mason DJ. Legal aspects of medical practice. In Dada MA & McQuoid-Mason DJ (eds.). Introduction to medico-legal practice. Durban: Butterworths, 2001, pp. 5–32. *14. Dhai A. Informed consent. S Afr J Bioethics Law 2008; 1: 27–30 [last accessed 9.08.12], http://www.sajbl.org.za/index.php/ sajbl/article/viewFile/5/9. 15. Lieberman JD & Derse AR. HIV-positive health care workers and the obligation to disclose. J Legal Med 1992; 13: 333–365. 16. Castell v De Greef 1994 (4) SA 408(C) 426. 17. Appelbaum PS & Grisso T. Assessing patients’ capacities to consent to treatment. N Engl J Med 1988; 319: 1635–1638. 18. Carstens P & Pearmain D. Informed consent. In Carstens P & Pearmain D (eds.). Foundational principles of South African Medical Law. Cape Town: Lexis Nexis, 2007, pp. 911–917. 19. Temkin O & Temkin CL (eds.). Ancient medicine: selected papers of Ludwig Edelstein. Boston: The Johns Hopkins University Press, 1967, p. 6. 20. Dhai A & McQuoid-Mason D. Confidentiality. In Dhai A & McQuoid-Mason D (eds.). Bioethics, human rights and health law. Principles and practice. 1st ed. Cape Town: JUTA, 2011, pp. 86–91. 21. Purtilo R. Confidentiality. In: Ethical dimensions in the health professions. 3rd ed. Philadelphia: Saunders, 1999, pp. 147–162. 22. World Medical Association. Medical ethics manual. 1st ed. Ferney-Voltaire Cedex: World Medical Association, Inc, 2005. p. 50–55. 23. Tarasoff v Regents of the University of California 1976. Cal SCt, 17 Cal Rep 3rd series 425 http://www.adoctorm.com/docs/ tarasoff.htm [last accessed 29.08.12]. 24. Mental Capacity Act 2005; www.publicguardian.gov.uk [last accessed 9.08.12]. *25. Payne-James JJ & Beh P. Adult sexual assault. In Gall J & Payne-James JJ (eds.). Current practice in forensic medicine. Chi- chester: Wiley, 2011. 26. The Code of Practice for the Mental Capacity Act; www.publicguardian.gov.uk [last accessed 9.08.12]. *27. General Medical Council. Consent: patients and doctors making decisions together. London: General Medical Council, 2008. 28. Faculty of Forensic and Legal Medicine. Consent from patients who may have been seriously assaulted. Faculty of Forensic and Legal Medicine, 2008. 29. Family Law Reform Act 1969; http://www.legislation.gov.uk/ukpga/1969/46/enacted [last accessed 9.08.12]. 30. General Medical Council. 0-18 years: guidance for all doctors. London: General Medical Council, 2007. 31. Faculty of Forensic and Legal Medicine. Proforma for paediatric forensic examination. Faculty of Forensic and Legal Medicine, 2011. 32. Faculty of Forensic and Legal Medicine. Proforma for adult female and male forensic sexual assault examination. Faculty of Forensic and Legal Medicine, 2010. Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 77–90

Contents lists available at SciVerse ScienceDirect Best Practice & Research Clinical Obstetrics and Gynaecology

journal homepage: www.elsevier.com/locate/bpobgyn

7 The forensic aspects of sexual violence

Mary Newton, Honorary Fellow of the Faculty of Forensic and Legal Medicine *

Best Practice & Research Clinical Obstetrics, Gynaecology 26, Caterham, Surrey CR3 5SY, UK

Keywords: Complainants of sexual assault may disclose to different agencies, forensic medical examiner the police and health professionals being the most likely. It is forensic science provider possible for certain evidence types to be collected before a clinical early evidence forensic assessment takes place that do not require the need for drug facilitated sexual assault a Forensic Medical Practitioner. If the time frames after the incident and the nature of assault warrant the need for a forensic medical examination of either a complainant or a suspect, this should only be conducted by doctors and nurses who have received relevant, up-to-date specialist theoretical and practical training. Clear evidence shows that few other criminal offences require as extensive an examination and collection of forensic evidence as that of a sexual assault. The forensic evidence in a case may identify an assailant, eliminate a nominated suspect(s), and assist in the prosecution of a case. The elements of forensic medical examination, reviewed in this chapter, are those that are the most varied across jurisdictions around the world currently. Key focus points of this chapter are considerations for early evidence collection, utilising dedicated medical examination facilities for sample collection, contamination issues associated with evidence collection and certain practical aspects of forensic sampling methods which have evolved given results identiﬁed by Forensic Scientists processing evidential samples in sexual assault cases, Some of the problems encountered by the forensic science provider will also be discussed. Ó 2012 Elsevier Ltd. All rights reserved.

The initial report and early evidence considerations

The ﬁrst appropriately trained person to encounter the complainant may need to collect certain types of early evidence. These samples may include sanitary wear, urine for toxicology, samples from

* Tel.: þ44 7879 434 406. E-mail address: [email protected].

1521-6934/$ – see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bpobgyn.2012.08.020 78 M. Newton / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 77–90 the oral cavity where oral sex may have been alleged, hand and fingernail samples and non-intimate skin samples. The decision to collect these samples is based on immediate medical needs, the welfare of the patient, availability of a Forensic Medical Practitioner (FMP), or delays in reaching a dedicated forensic examination facility. Ò One of the first dedicated early evidence kits was developed by the Forensic Science Service together with the Metropolitan Police in 2001. The practical nature of the kit was highlighted as good practice by a ‘Her Majesty’s Inspector of Constabulary’ and ‘Crown Prosecution Service ‘ report on the joint inspection into the investigation and prosecution of cases involving allegations of rape, published in April 2002.1 Evidence indicates that the concept of early evidence kits is now more readily available to front-line officers and Accident and Emergency Departments in many jurisdictions.2 As a backup to having kits readily available at exam sites or with examiner programmers, jurisdictions may also want to consider the feasibility of storing a few kits in police patrol cars. Variations in temperature, however, even within one jurisdiction must be born in mind, as heat exposure could affect kit contents before use. It is important that, before an encounter with the woman, an FMP establishes whether any of these samples have already been collected and by whom. Practically, clothing worn by the complainant at the time of an alleged assault is normally seized with their permission, as it may provide useful forensic evidence for contact traces; equally, it may provide important points of reference for the FMP in relation to injuries (e.g. where the clothing is damaged). It is common practice for this clothing to be seized before the FMP examines the complainant. It is good practice for the FMP at the point of call-out to establish if the complainant has presented in the original clothing and if damage or injury has occurred.3 It is advisable in such situations to ask for the woman to remain in the clothing until the FMP has assessed them. It is acknowledged that, if serious injury has occurred, the clothing may have to be cut to facilitate its removal. Any pre-existing damage should be avoided being cut through as it makes it impossible for the FSP to assess the damage in relation to the nature of the assault. It is good practice for the FMP to liaise with the emergency team if clothing has to be removed. Record photography of clothing positions and the extent of any damage before removal are considered useful, as it shows fashion trends and the style of the wearer. As an example, it is difficult to assess damage positions with hosiery once the garment is off the body. Who should take the photo documentation is under debate, but it may be relevant for the forensic scientist to view video or photographic material recorded by the FMP in relation to clothing damage, injury, body mapping in relation to contact traces and body fluid recovery.

Evidence-based sampling time frames

A number of practical guidelines are available to assist the FMP in deciding whether a forensic medical examination of complainant or suspect should be conducted immediately or deferred.4 This is particularly important, as many complainants of sexual assault will report during out-of-ofﬁce hours. The FMP should speak directly with a police ofﬁcer investigating the allegation about time frames and points to prove. Further considerations include post-offence activity of the woman. Local advice may be to speak directly with the FSP about what should be seized according to the crime report.

Contamination issues

Contamination is a crucial issue for everybody involved in the collection of forensic evidence during a sexual assault investigation to be aware of. It is particularly important where the FSP is concerned with the analysis and interpretation of trace DNA. From a theoretical perspective, the forensic scientist considers any DNA deposit identiﬁed that is not immediately relevant to the crime being investigated as potential contamination. Reported evidence shows that contamination has occurred in a number of different ways: (1) before the sexual assault being committed5; (2) in the interval between the crime and a forensic medical examination taking place; (3) during the forensic medical examination6; and (4) within the forensic science provider (FSP) laboratory.7,8,9 Although points (2) and (3) are considered as adventitious transfer and cannot be strictly controlled, the FMP should apply methods to minimise the effect of such contamination occurring. One example of good practice includes the provision of M. Newton / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 77–90 79 dedicated forensic medical examination kits containing disposable equipment and unopened controls. It is crucial that the consumables within the kits do not compromise the integrity of the samples collected or adversely affect the forensic analytical process in any way, and several studies have looked at this problem.8,10,11 The FMP’s use of disposable hospital scrubs when conducting an examination, changing gloves between examination of different body areas, logging all persons in the room at the time of the medical taking place, and staff providing elimination DNA samples can all minimise the occurrence of contamination. Unsolved sexual assault investigations of today may well become the cold-case investigations of the future; as such, potential forensic evidence must be correctly collected, stored and examined with trace DNA detection sensitivities in mind. Any deviations from locally recommended protocols12 must be documented, with clear justiﬁcations recorded (Table 1).

The forensic medical examination facility

Many jurisdictions now have specially designed dedicated examination facilities for the examination of complainants of sexual offenses. These have fixtures and fittings that are durable with washable surfaces, and can be cleaned between forensic examinations. Practically, it is important to monitor equipment and examination areas to identify if any significant levels of DNA are present, and subsequently whether cross-contamination between cases could be considered a possibility.9,11 Evidence has shown that the provision of an environmental monitoring process helps focus how successfully the cleaning procedures are implemented within the facility and identifies any problem areas. Comparison of DNA results obtained from the environmental samples with all relevant staff profiles could also identify any gross contamination seen. Unfortunately, the examination of potential suspects in sexual assault investigations is much more ad hoc, and little information has been recorded on this. Often detainees are forensically examined in cramped medical rooms that are not for dedicated forensic use. Few jurisdictions have dedicated forensic cells. The use of ‘dry’ cells with no provision of toilet or hand-washing facilities within the cell for the detainee to use to remove potential forensic evidence are the defaultable option in many jurisdictions. No studies were found for the recommended standards for forensic facilities available for the examination of suspects in sexual assault investigations. Other issues to consider in reducing cross-contamination include the importance of having examination facilities with a suitable area or at least a non-cluttered wall surface if record photography is required. This includes the ability for total black out where ultraviolet photography is used.

The role of the forensic science provider

Forensic evidence is essential in any sexual assault investigation because it can identify a suspect or a crime scene, or provide corroborative evidence about what sexual acts have occurred. It may also identify possible series links or demonstrate repeat offending by the same suspect. Semen found on intimate swabs may have a more probative value than semen found on clothing or bedding, because it only has a ﬁnite time for survival compared with dried drainage on fabrics. If a sexual assault involves oral, digital or foreign object penetration, then it is useful for the FSP to be provided with as much detail as possible about the alleged offence to process the evidence most effectively. Therefore, in order to

Table 1 Simple steps to reduce contamination issues.

All work areas in the medical examination room must be regularly cleaned before and after patient use. So far as it is possible, work areas should be kept clear. The nature of the cleaning practice between patients must be documented and trained so that a set routine is followed by all operatives. The forensic medical practitioner and other staff assisting with the medical examination process should wear disposable powder free gloves, and these should be changed regularly between examination of body parts or every 20 min for those staff not collecting samples. A log of use of the medical room and those present during each forensic examination should be made. 80 M. Newton / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 77–90 maximise all forensic opportunities and to plan the order of analysis, it is important that the police investigator discusses a forensic strategy with the FMP to ensure relevant forensic evidence is secured at an early stage. Good evidence shows that this occurs when dealing with complainants but is less likely for nominated suspects. Given that the accused suspect will often allege that the complainant has consented to the sexual act, forensic evidence in such cases is more problematic and often requires examination of a large number of exhibits looking at discrepancies between the accounts of those involved. In cases where the complainant is known to the suspect, forensic results have to be interpreted carefully, as legitimate contact could account for some of the ﬁndings. In recent years, in many jurisdictions, victims of sexual assault often report an unclear recollection of what has happened to them. These reports are usually associated with alcohol drug consumption, or both. In many cases, the complainant alleges interference with their drink. The FSP has a dual role here to establish whether sexual activity took place and to conduct toxicology analysis to check for drug or alcohol consumption.

Forensic sample site identiﬁcation

Trace DNA analysis has become an integral part of an FSP’s workload in relation to sexual assault investigation. DNA methodologies based on polymerase chain reaction have allowed the generation of profiles in sexual assault cases in recent years that were not previously examined. This, in turn, has lead to the success of many national offender DNA databases.12,13,14,15,16,17,18,19 When dealing with trace samples from complainants or suspects of sexual assault, it is important to identify which areas to target. By their very nature, such trace samples are not readily obvious. Swabbing an assumed trace sample area that is smaller than the actual deposition area could mean that some of the relevant sample goes uncollected. Alternatively, sampling a much larger area than that of the actual deposit may mean that the sample is spread over a larger surface area and that overall less sample is collected or becomes diluted. Both practical approaches have the potential to give an inaccurate view of where the actual sample was located. The uses of non-invasive detection systems are helpful here and, as such, the Polilight is used to initially examine the patient in a number of jurisdictions. Numerous studies have shown the value of speculative searching scene items and articles of clothing with a Polilight equivalent.20,21,22,23,24,25 Forensic odontologists use ultraviolet photography to document bite marks on skin as the light penetrates the epidermis or upper levels of the skin down to a few hundred microns in depth, which helps to focus on the surface damage while minimising the appearance of visible bruising. Studies looking at traditional photography have shown that these standard methods may interfere with the viewing and characteristics of the injury.26,27 Some studies indicate that ultraviolet light may cause semen and saliva to fluoresce.28,29 Other studies contradict this. For example, Santucci et al.30 identified many creams and ointments that fluoresced on exposure to a Woods lamp (wavelength 360 nm), which is used in a number of countries when examining women who have been sexually assaulted; however, none of the semen samples examined by Santucci et al.30 fluoresced. Other research has shown that ultlraviolet light provides non- ideal results in the examination of women, as many traces accounted in day-to-day situations also fluoresce (i.e. detergents and lubricants that contain petroleum jelly and milk).31 It is possible at higher intensity light sources using goggles to detect semen even when the background surface is also fluorescent, but the perceived impracticality of this method does not make it ideal.32 Nelson and Santucci33 in their study asked FMPs in training to use an alternate light source, the Bluemaxx BM 500, as it gives 100% sensitivity, and to differentiate it from other trace substances. It must be remembered that some fibres may also be visible under ultraviolet light, which enables the FMP to visualise these for collection on skin and within hair. If the FMP is not a regular user of light sources as a means to identify potential contact traces, this does create a practical problem in identifying relevant areas of luminescence, This, however, may be overcome by conducting controlled photographic trials that show different body fluid deposits (including mixtures), commonly applied skin products, and lubricants (e.g. on different skin types), and creating a reference book of standards available for review in the medical examination facility (Miller A, Product Manager at Forensics Source, Jacksonville, Florida, USA, April 2012, personal communication).34 M. Newton / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 77–90 81

In general terms, forensic photography using normal lighting conditions is an important element of a forensic medical examination. Internationally, variation exists on the extent of forensic photography necessary, including when colposcopy of intimate areas is used. Some jurisdictions routinely take photographs of both detected injuries on patients and normal (apparently uninjured) anatomy, whereas others limit photography to detected injuries. It must be born in mind that the photographs may also help the forensic scientist with their interpretation of ﬁndings and, as such, should be made available to them where appropriate. A photographic record of a woman who presents soon after a sexual assault still wearing the same clothing is considered useful if the woman agrees. Pre-printed body diagrams and maps are also useful for recording any injuries and should be used by the FMPs in their assessment of a patient, in addition to the use of photography. It may be beneﬁcial for these records to be forwarded to the FSP to assist in their forensic assessment of any contact traces on the clothing worn at the time of the assault. This is particularly useful when there has been a long delay between the sexual assault and the medical examination taking place, particularly when the complainant has washed in the intervening time.

The forensic medical examination kit

Sexual assault evidence collection kits vary between countries and even between jurisdictions of the same country, so it is not possible within the scope of this chapter to discuss the variations. What is important is that the kit, or its modules, are periodically reviewed for efficiency and usefulness on the basis of evidence-based findings obtained from the FSPs, and any changes are made as needed. In the UK, the Faculty of Forensic and Legal Medicine have a scientific committee that includes FMPs, FSPs, police investigators and forensic kit manufacturers that meet biannually to discuss the content of forensic kits used to sample complainants and suspects of sexual assault. A sampling recommendation document is produced for faculty members after the meetings have taken place with any changes highlighted within it.4 In addition to kit content reviews, it is important to establish mechanisms to ensure that kits at exam facilities are kept up to date (e.g. if a new evidence collection procedure is added, facilities need to know what additional supplies should be readily available to FMPs). Variation also exists in who covers the cost of a forensic medical examination; in some jurisdictions, it can be down to the individual themselves, particularly where the complainant does not wish to involve the criminal justice agency at the outset and as such provide anomalised samples. Elsewhere, the cost of the medical examination and the forensic analysis of the samples is paid for by the local criminal justice agency regardless of whether the police are involved or not. It is not uncommon for a restricted forensic budget to be made available where anomalised reporting applies. Training and policies should actively discourage decision making about evidence collection that is based on extraneous factors, such as reluctance of a criminal justice agency to pay for sexual assault evidence collection or subsequent forensic analysis.

Collection of forensic samples

For forensic sampling from a patient, complainant or suspect of sexual assault, most trace samples are collected using swabs. Some jurisdictions use the medical forensic history, the examination, and patients’ consent to determine whether and where to collect swabs, whereas others collect swabs from all orifices and from the surface of the body (with patients’ consent). In particular, some do not collect anal swabs unless indicated. The swabs and containers differ from those used for clinical purposes. Other methods have also been used practically to recover evidence. These have included the use of surgical gauze pads.35 The swabs should be made of fibres that readily release the collected absorbed material during extraction. In recent years, considerable research has been undertaken into fibre compositions and whether this makes a difference to the amount of collected material subsequently released.36,37,38 Recently, other swab types, such as foam, flock and Dacron, have been introduced.39,40,41 The collection device used for recovery of trace DNA is often a matter of convenience i.e what has always traditionally been used, often based on old research in relation to evidence recovery and the price of the device, rather than what is fit for purpose given more recent research on recovery and findings. 82 M. Newton / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 77–90

Swabbing of a non-genital skin area that is dry has always required moistening of the swab to traverse the sampling area a number of times. Limited pressure is applied to prevent exfoliation of the patient’s own epithelial cells, while rotating the swab so that the whole surface area can be included in maximising the collection process. Research has shown that use of a single moist cotton swab may not pick up all the available material from the surface, and it has been shown that this technique may only remove half of the available material from the sample site.42,43 Few FSPs have undertaken research studies to check the composition of the swab head and whether the swabs being used in forensic medical examination kits are better or worse than alternatives now available on the market. Further research into optimal collection methods and swab types would be beneﬁcial given the tiny amounts of trace evidence recovered in sexual assault investigations.

Skin sampling

Trace DNA is a term used by many to describe minute quantities of DNA transferred thorough skin contact. The small numbers of cells and the nature of the type of transfer make identification of the cellular source of origin (e.g. buccal and epithelial) impractical or impossible as discussed by Wick- enheiser.43 The nature and the extent of the contact from licking, kissing or biting may result in salivary amylase also being transferred, which is the only means for the forensic scientist to identify the presence of the fluid as potentially being saliva. The traditional test used by many FSPs is still the Ò Phadebas amylase test. Specificity, however, is a problem, as amylase can be present in body fluids other than saliva. It is now common practice to carry out a double-swabbing technique as advocated in the research by Sweet et al.,44 who showed that it is possible to obtain a DNA profile from saliva stains (corresponding to a bite mark) on the skin of a cadaver where deposition had occurred up to 48 h earlier. This technique involves moistening the first swab and leaving the second swab dry. It could be argued that by keeping the second swab dry, if the first swab was successful in absorbing all the moisture it deposited onto the skin, then this second swab may not collect as much from the sample site as if it too was moistened before swabbing. It is important that any residues of water are recovered. Where multiple swabs are used, the FSPs look to co-extract the swabs in order to maximise or enhance DNA retrieval.45,46,47,48 Water is still the moistening agent advocated for use by FMPs,39,43 but given that FSPs use other reagents to moisten swabs when retrieving trace DNA from inanimate items,39,49 this is an area of research that may highlight improved recovery. Currently, if the sexual assault involves an unknown assailant, and bite marks or injuries on the skin are present that can be attributed to direct contact by the assailant, then if the complainant has not showered or bathed, some recommendations suggest sampling the area up to 7 days after the incident.4 Control swabs should also be taken from an area adjacent to the site of sampling or the mirror image on the body so that the FSP has access to the level of background DNA at the time of sampling to aid interpretation when the presence of a body fluid or DNA in a specific area is significant. Research is still limited on the persistence of body fluids and cellular material on the skin with these problems in mind. Given that pubic hair is often completely shaved off for hygiene or ethical reasons by women being forensically examined, then logic suggests that if hair is not present, it is more likely for semen to drain and deposit onto the pubic skin or onto the skin of the inner thighs. These uncommon sample sites should be considered as a matter of routine sampling in such situations. In addition, Minitapes are being used to lift potential cellular material from the skin in some jurisdictions, and recent reports have shown that this method is more effective than swabbing for the recovery of salivary DNA.50 Minitapes are small pieces of sterile adhesive clear tape on a plastic backing strip that can be pressed repeatedly onto the surface of skin to collect any loosely adhering cellular material.51 Although the swabbing and taping techniques described above may seem logical and straightforward, inadequate training, combined with the absence of competency testing when an FMP first starts, and a lack of ongoing refresher training, could drastically limit the success rates of the samples collected.12 Consistent initial forensic training and regular forensic update training is, therefore, needed for FMPs. M. Newton / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 77–90 83

Variation exists between jurisdictions about how collected swabs are stored and processed. The ability to properly collect, preserve and analyse the sample is important for preserving the integrity of potential forensic evidence. Stabilisation is a key part of the chain of evidence in sexual assault cases, as it is often biological evidence and DNA tests derived from them that the FSP is considering. Forensic testing of samples is generally not carried out immediately after collection. It is also not uncommon for retesting of stored DNA samples to occur with the advent of further requests as part of an investigation or where new technologies are introduced. Limited research suggests that if biological material is allowed to dry on a swab before extraction, then less DNA is retrieved than if the still moist swab was processed immediately.44 In practical terms, this is because the forensic medical examination facility is not in the same location as the FSP laboratory so, in some jurisdictions, the collected swabs are stored frozen immediately after collection and kept frozen when being transported to the FSP. These storage methods are expensive because of the cost of electricity in a number of countries, the space taken up, and the possibility of breakdown. Research has shown that freezing swabs, rather than drying them before extraction results in DNA recovery rates approaching that of a tested moistened swab.51 Other numerous examples show that degradation occurs during storage, in the cold or at ambient conditions.52 Cotton swabs, being made of a natural fibre, are more likely to go mouldy if left damp without drying or freezing the sample. As already mentioned, environmental temperatures, distances the forensic samples travel, and lack of freezer storage space at the FSPs are, therefore, problematic if cotton swabs are used. These issues have been considered in numerous jurisdictions in terms of fit for purpose swab type and packaging and storage methods. In South Africa, Dacron swabs are used for sampling body fluid traces, and the swabs are placed in triangular suspended boxes and air dried (Steyn P, Senior Technical Officer-Chemistry, University of Stellenbosh, South Africa, April 2012, personal communication).53 This means that a cold chain of evidence is not required. Dacron swabs are also used in Australia (Cooper J, ADF Investigative service Forensic Manager, Australia, April 2012, personal communication). Some new research in the USA has looking at a storage medium SampleMatrixÔ, which is a polymer that protects the sample in storage at room temperature and that completely dissolves after rehy- dration. It suggests that this may be a method that in the future could be applied to sexual assault samples. Variation with sample storage methods, coupled with the associated problems mentioned, warrants further investigation by the forensic science community at an international level.54

Fingernail sampling

Numerous different techniques have described how to sample fingernails where trace evidence may be present. These include clipping nails, and scraping or swabbing with fine-tipped swabs beneath the surface. The fingernail hyponychium is logically an isolated area where biological material may accumulate and can provide a valuable source of evidential material in police investigations. During the course of a sexual assault, trace amounts of skin, body fluids, hairs, fibres and vegetation may collect under the nails of either the complainant or the assailant. It is not uncommon these days for complainants to have well-manicured nails. Artificial nails such as acrylics and gel nails having been popular with women worldwide since the late 20th Century. The FMP, therefore, needs to be mindful that cutting of false nails is very difficult and cutting of real or false nails may cause a complainant additional stress. It is not clear from the research which is the optimal sample type for collection. Considerable research has been undertaken into DNA typing of debris from fingernail samples and the significance of the results. Wiegand et al.55 reported 33% of fingernail samples from casework analysis contained a foreign source of DNA and persistence of foreign DNA tended not to last beyond 6 h. Cook and Dixon,56 on the other hand, conducted a study looking at fingernail swabs from 100 volunteers where foreign DNA was detected in 13% of samples, with only 6% of these giving reportable mixed DNA profiles, suggesting the incidence of foreign DNA under the fingernails was low. A significant proportion of the mixed DNA profiles obtained came from male donors who had given information to indicate some form of physical contact within the 24-h period before sampling. A study by Dowlman et al.57 showed fingernail swabs from donors showed high level DNA profiles with recent intimate contact, but also from samples from individuals who shared accommodation with their partner. The study showed that low-level DNA profiles were associated with all levels of contact. Results have 84 M. Newton / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 77–90 been reported from two homicide cases in New Zealand where the deceased females had been submerged in water. The first in bath water and the second in seawater for 2 and 3 h, respectively, showed that valuable forensic evidence can be obtained from samples that may be considered unlikely given the circumstances. Care must, therefore, be exercised in considering the relevance of fingernail sampling. Research Ò conducted by the Forensic Science Service in 2003 indicated that in one in five (18%) of the sexual assault cases submitted for analysis involved the assailant digitally penetrating the vagina of the complainant as a precursor to another penetrative act (Turton S, Assistant Intelligence Officer, Forensic Ò Science Service March 2003, personal communication).58 A survey of police officers attending custody units around the UK indicated that the hands from detainees are not sampled as a priority and little thought is given to protect loss of potential evidence by the application of gloves or hand protectors before hands and nails being sampled (Newton M, UK Independent Forensic Advisor for Rape and serious Sexual assault, October 2011, personal communication).59 Fingernail samples submitted to the FSP are treated as sets of right and left-hand samples, and are extracted as such owing to the limited amount of material likely to be recovered. It is, therefore, important that fingernails are only collected as two samples only, left and right hand. The exception is where a nail is damaged or broken. These should be packaged separately indicating which finger of which hand the sample has been taken from. It is also recommended practice to photograph the visible damage before taking the sample. Nails that become broken during an assault may involve the FSP carrying out a mechanical fit. This has been conducted on real nails and on false nails. A case from the UK where a false nail was found at the suspect’s home address, processed by the FSS in 2010, provided a mechanical fit to the complainant. Blood and an associated DNA profile matching the suspect, together with fibres from a jumper he wore during the assault, were also detected. The suspect in the case denied ever meeting the complainant Ò (Turton S, Assistant Intelligence Officer, Forensic science Service , March 2010, (personal communication).60

Hair sampling

Hair from a sexual assault complainant or suspect is most likely to be sampled for the FSP to check for body fluids, foreign hairs, fibres or other particulates. Some jurisdictions collect pubic and head hair combings, others collect only pubic combings. Pubic hair combings are typically collected if the assault involved the woman’s genital area. Complainants of sexual assault find the sampling of their pubic hair degrading and, as such, the FMP needs to understand the relevance of collecting the sample. Pubic hair transfer between people that have had sex in the ‘missionary’ position is minimal even when samples are collected a short time afterwards, as demonstrated by research conducted by Exline et al.61 Mann62 and Stone.63 A survey of sexual offence cases examined by FSPs throughout the USA did, however, find pubic hair association between complainants and nominated suspects in 15% of cases.64 Therefore, pubic hair sampling may be of relevance at the time of the medical examination. Although shaving of pubic hair is more widely spread through jurisdictions by the general population for hygiene regions, if pubic hair is present on a patient, it must be borne in mind that the hairs are not subject to as much change as head hairs over time. Because of this, a sample can be taken at a later date for purposes of meaningful comparison. If fibres or particulates are relevant, then the sample should be taken at the time of the forensic medical. An improved method over combing hair samples if fibre exchange is considered relevant is the use of low-tack adhesive tape as mentioned in the study of Salter and Cook.65 They found fibres can remain in hair for up to 7 days if the hair has not been washed.

Toxicology sampling

The FMP needs to be clear about the circumstances in which toxicology testing may be indicated in a sexual assault case for optimal care or when there is a suspicion of drug-facilitated sexual assault (DFSA). Toxicology screening in DFSA cases can help the investigator identifying whether drink spiking may have occurred and whether abuse of legal drugs had occurred and whether illegal drugs were used. Routine toxicology testing in all sexual assault cases is not recommended in some jurisdictions, M. Newton / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 77–90 85 considerations being around the distress to some patients particularly in collecting blood. Other jurisdictions collect toxicology samples from every patient (with permission) and analyse these samples as case facts and jurisdictional policy dictate. In addition to cases of suspected DFSA, however, some jurisdictions may request toxicology samples if patients indicate voluntarily that they have used drugs, alcohol, or both, before the assault or that they did not consume any form of alcohol or drugs. One rationale for such a policy is that prosecutors will want all information on drug and alcohol use to prepare for the case. If samples are not collected at the time of the medical, then critical evidence may be missed. it varies between jurisdictions whether specific drug tests are conducted or whether general screens for all potential ingested drugs and alcohol are undertaken, and where the samples are analysed. It is evident that hospital laboratories do not always have the capability to detect drugs in small quantities, which the FSPs do. Also sensitivity of detection methods may allow for drug metabolites to be detected for longer time frames. The list of drugs that have the potential to facilitate sexual assault are continually growing, which makes the identification of the drug and their effects, particularly with the increase in the number of legal highs coming on the market, a challenge for the FSPs to identify. A legal high is a description given to the influx of designer drugs that have been reported in recent years, including artificial chemicals such as synthetic cannabisand semi-synthetic substances, such as methylhexaneamine. These drugs are primarily developed to avoid being controlled by laws against illegal drugs, thus giving them the label of ‘legal highs’. What is known is that, although the phenomenon of DFSA has been increasingly reported over the – past 15 years, alcohol still plays a major role in these cases.66 70 In some unpublished research conducted by the University Center of Legal Medicine of Geneva in 2008, in a set of 34 cases in which toxicological analyses was conducted, alcohol was found in 12 cases, tetrahydrocannabinol in seven cases, cocaine in two cases, benzodiazepines in two cases and opiates in three cases (Burkhardt S, University Center of Legal Medicine of Geneva, April 2012, personal communication).71 In another study by the Victorian Institute of Forensic medicine reported in 2006, alcohol consumption was reported by 77% of complainants in the study group and alcohol was detectable in 37% of samples from these individuals.72 The types of forensic samples that are appropriate for toxicology examination after a potential DFSA depend on the time frame of presentation for the complainant and the examination time subsequent to the assault for a suspect being examined in custody. If the report is within 4 days, urine and blood can be analysed for the presence of alcohol or drugs. Law enforcement legislation allows for a suspect to refuse blood or urine samples. Saliva can also be used as a forensic sample. Not all drugs, however, partition well into saliva; some drugs have stability problems, and the window of detection is much shorter than urine and modestly lower than blood. Also, concentrations of drugs are lower, so sensitive – testing is needed to obtain results.73 76 In some jurisdictions, point-of-care devices are used for testing purposes (dip stick type devices), but these tend to only test for a limited scope of drugs. For later disclosures, beyond several days since the possible DFSA occurred, hair is the specimen of choice for drug identification.77 Hair testing can provide information on drug history relevant to the time of the alleged assault, even for a single drug dose in many cases. The limitation currently to forensic toxicology of hair, given that alcohol is the main substance being detected worldwide, is that alcohol cannot be reliably tested for in hair.71 What is evident from the research is that the forensic toxicologists face numerous challenges in DFSA cases. It is difficult to collate data in DFSA cases owing to the vague nature of the reports, coupled with the wide range of drugs that could potentially be of interest. As previously mentioned, numerous new psychoactive substances are in circulation, which the FSPs need to be aware of when conducting drug analysis. In the UK, one of the FSPs, LGC Forensics, has played a leading role in identifying new psychoactive substances for the national Forensic Early Warning System project (Ames D, LGC, April 2012, personal communication).78 This project aims to support the UK Government in gaining a better understanding of new, potentially hazardous substances being abused in the UK. It is clear that the practical use of early evidence collection across many jurisdictions has increased, with toxicology collection being a key focus in the past 10–15 years. No obvious research, however, has indicated whether or not this early intervention makes a difference to the number of positive findings, particularly for some drugs, such as gamma-hydroxybutyrate, in which the metabolites are only normally detected for a few hours. 86 M. Newton / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 77–90

Semen identiﬁcation

The persistence of semen is something that is used as a bench mark for whether intimate samples are routinely collected in sexual assault cases. In Hong Kong, for example, routine collection occurs if the woman presents within 24 h of the alleged offence, but samples may be considered beyond these depending on case circumstances (Bah P, Hong Kong, April 2012, personal communication).79 In Romania, vaginal swabs are routinely taken within 48 h and occasionally up to 72 h (Barbu C, Head of Forensic Science of Covasna County, Romania, April 2012, personal communication).80 In several American jurisdictions, 72 h is the standard cut off time frame for collecting evidence, but again the medical forensic history governs whether samples are considered beyond this.81 Modern forensic techniques allow DNA to be extracted from ever decreasing amounts of cellular material. In sexual assault cases, it is often trace amounts that are only ever detected. Also, the DNA derived from haploid cells (semen) contain only half the DNA complement of diploid cells (3 pg compared with 6 pg). Indeed, the smaller the number of cells sampled, the smaller the probability that there is a full representation of the alleles comprising the donor profile. The technique of low copy number profiling enables the production of short tandem repeat DNA profiles from small numbers of cells. It has been reported that it is possible to obtain a DNA profile from as a few as 10 haploid cells. Moreover, a method such as laser micro-dissection, enables forensic scientists to potentially isolate fewer individual cells for olymerase chain reaction (Gill P, Professor of Forensic Genetics Oslo University, April 2012, personal communication).82 Given the sensitivities of DNA profiling and the need for less and less spermatozoa to produce a DNA profile these days, reported case studies on the maximum outliers are somewhat lacking. In some jurisdictions, examiners are required to undertake some identification by using wet mount samples and immediately examining for vaginal and cervical secretions for motile and non-motile sperm. In Denmark, wet mount slides are made from the vagina and possibly the anus and oral cavity, depending on the case circumstances (Lange J, Thomsen, Denmark, April 2012, personal communication).83 In these cases, an optically staining microscope is used to highlight cellular material and facilitate the search for sperm that will provide the only opportunity to see sperm motility. In most cases, sperm becomes non-motile in the vagina within 10–12 h after ejaculation. The presence of motile sperm may help narrow the time frame that the crime could have occurred, which may be useful in cases where the complainant has limited or no memory of what may have happened to them. The preparation of wet mounted swabs does need to be conducted with great care to prevent DNA contamination occurring, as the process involves adding a wetting agent, normally saline, to a slide that the collected swab is then rolled into and then the slide is air dried with a cover slip in place before viewing the slide.84 In other jurisdictions, however, the crime lab is responsible for all analysis of evidence so the swabs are submitted with no prior manipulation or extraction. Although the FSP can reliably identify the presence of sperm on permanent stained slides, they cannot identify motile sperm because of time delays. Information about the presence or absence of sperm and motile sperm obtained at the time of the exam can affect the investigation and patients’ decision making. Concerns related to examiners doing wet-mount evaluations for sperm are twofold: (1) their findings may be different than those of crime labs (e.g. the examiner may not detect sperm, whereas the FSP does); and (2) the FMP may use up material which could be used by the FSP when undertaking DNA analysis of the sample. It is clear from practical reports on methods applied around the world that considerable variation exists in relation to where, how and when sperm visualisation occurs.

Conclusion

Many challenges are faced by the FMP and the forensic scientists working for the FSP when dealing with the forensic aspects of sexual violence. A sound examination strategy noted by the FMP, taking into account pre and post-offence activity by the complainant and suspect, coupled with evidence- based sampling persistence data provided by the local FSP, is important in identifying and maintaining best practice in forensic sampling. M. Newton / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 77–90 87

In recent years the enormous development in DNA proﬁling techniques has resulted in huge advances in sensitivity and, as such, less material is now required to obtain a DNA result. This necessitates a practical appreciation by the FMP of the sampling methods that can be applied, coupled with the FSP’s expertise to estimate the probability that a body ﬂuid or DNA would be transferred, – persist and be detectable.85 88 The other major problem faced by the practitioners is the lack of information in cases where alcohol or drugs by one or both parties is involved which, as a result of the accuracy of events, may limit the sample types collected. It is evident from the research for this chapter that an increase in the collection and analyses of relevant transfer and persistence data from cases received by the FSPs is continually needed.

Practice points

Evidence indicates that the concept of early evidence kits is accepted as best practice, and kits are now more readily available to relevant agencies. Use of dedicated forensic medical examination kits containing disposable equipment and unopened controls reduce the opportunity for DNA contamination occurring with the forensic collection process. Double swabbing is an effective method for recovering body ﬂuid traces from skin Low adhesive tape is a more effective method of recovering ﬁbres from hair than combing or swabbing.

Use of cut-hair sampling in late reporting of DFSA cases if drugs are detected, even at single dose levels, are a consideration.

Research agenda

Effectiveness of the use of early evidence kits to detect drugs and alcohol in potential DFSA cases. Effectiveness of environmental monitoring in preventing DNA contamination at sexual assault examination facilities. Comparison across jurisdictions of forensic facilities available for the examination of suspects in sexual assault investigations, Further comparison of optimal collection methods compared with swab types and storage conditions. Effectiveness of evidence retrieval from false nails compared with human ﬁngernails. Reporting of relevant transfer and persistence data from cases received by FSPs, together with data collected from mock trials, known research sources, or both. Further reporting on low-level detection limits in DFSA cases.

References

1. HM Crown prosecution Service Inspectorate, HM Inspectorate of Constabulary. A report on the joint inspection into the investigation and prosecution of cases involving allegations of rape. London: HMCPSI. 2. HMIC. Forging the links: rape investigation and prosecution; http://www.hmic.gov.uk/media/forging-the-links-rape- investigation-and%20prosecution-20120228.pdf; [last accessed 10.08.12]. 3. Dann TJ, Carr DJ, Laing RM et al. Tearing of knicker fabrics. Forensic Sci Int 2012; 217: 93–100. 88 M. Newton / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 77–90

4. Royal College of Physicians. Recommendations for the collection of forensic specimens from complainants and suspects, July 2102; http://.fflm.ac.uk/library detail/4000068. 5. Balding DJ & Buckleton J. Interpreting low template DNA profiles. Forensic Sci Int Genet 2009; 4: 1–10. 6. Van Ooschot RAH, Treadwell S, Beaurepaire J et al. Beware of the possibility of fingerprinting techniques transferring DNA. J Forensic Sci 2005; 50: 1417–1422. 7. Himmelreich C Germany’s phantom serial killer: a DNA blunder-TIME; http://www.time.com/time/world/article/0, 8599, 1888126,00.html; [last accessed 10.08.12]. 8. Sullivan K, Johnson P, Rowlands D et al. New developments and challenges in the use of the UK DNA database: addressing the issue of contaminated consumables. Forensic Sci Int 2004; 146(suppl): S175–S176. 9. Poy AL & Van Oorschot RAH. Trace DNA presence, origin and transfer within a forensic biology laboratory and its potential effect on casework. J Forensic Ident 2006; 56: 558–576. 10. Gill P, Rowlands D, Tully GG et al. Manufacturer contamination of disposable plastic-ware and other reagents-an agreed position statement by ENSFSI, SWGDAM and BSAG. Forensic Sci Int Genet 2010; 4: 269–270. 11. Ladd C, Adamowicz MS, Bourke MT et al. A systematic analysis of secondary DNA transfer. JForensicSci1999; 44: 1270–1272. 12. Raymond JJ, Van Oorschot RAH, Walsh SJ et al. How far have we come with trace DNA since 2004? The Australian and New Zealand experience. Aust J Forensic Sci 2011; 4: 231–244. 13. Harbison SA, Hamilton JF & Walsh SJ. The New Zealand DNA databank: its development and significance as a crime solving tool. Sci Justice 2001; 41: 33–37. 14. Gunn B. An intelligence-led approach to policing in England and Wales and the impact of developments in forensic science. Aust J Forensic Sci 2003; 35: 149–160. 15. Walsh SJ & Buckleton J. DNA intelligence databases. In Buckleton J, Triggs CM & Walsh SJ (eds.). Forensic DNA evidence interpretation. Florida: CRC Press, 2005, pp. 439–469. 16. Voegeli P, Haas C, Kratzer A et al. Evaluation of the 4-yesr test period of the Swiss DNA database. Int Congr Ser 2006; 1288: 731–733. 17. Walsh SJ, Buckleton JS, Ribauz o et al. Comparing the growth and effectiveness of forensic DNA databases. Forensic Sci Int Genet Suppl Ser 2008; 1: 667–668. 18. National Police Improvement Agency, UK. National DNA database annual report 2007–2009; http://www.npia.police.uk/en/ 14395.htm; [last accessed 10.08.12]. 19. Gill P, Whitaker J, Flaxman C et al. An investigation of the rigor of interpretation rules for STRs derived from less than 100 pg of DNA. Forensic Sci Int 2000; 112: 17–40. 20. Springer E, Almog J, Frank A et al. Detection of dry body fluids by inherent short wavelength UV luminescence: preliminary results. Forensic Sci Int 1994; 66: 89–94. 21. Ben Yosef N, Almog J, Frank A et al. Short UV luminescence for forensic applications: design of a real time observation system for detection of latent fingerprints and body fluids. J Forensic Sci 1998; 43: 299–304. 22. Kobus H, Silenieks E & Scharnberg J. Improving the effectiveness of fluorescence for the detection of seminal stains on fabrics. J Forensic Sci 2002; 47: 819–823. 23. Lennard C & Stoilovic M. Application of forensic light sources at the crime scene. In the practice of crime scene investigation. In Horswell J (ed.). Florida: CRC Press LLC, 2004, pp. 97–124. 24. Vandenberg N & Van Oorschot RAH. The use of Polilight in the detection of seminal fluid, saliva and bloodstains and comparison with conventional chemical-based screening tests. J Forensic Sci 2006; 51: 361–370. 25. Stein C, Kyeck SH & Henssge C. DNA typing of fingerprint treated biological stains. J Forensic Sci 1996; 41: 1012–1017. 26. Krauss TC & Warlen SC. The forensic science use of reflective ultraviolet photography. J Forensic Sci 1985; 30: 262–268. 27. Krauss TC. Forensic evidence documentation using reflective ultraviolet photography. Photo Electron Imaging 1993; 12: 18–23. 28. Girardin BW, Faugno DK, Seneski PC et al. Care of the sexually assaulted patient. In: Color atlas of sexual assault. St. Louis: Mosby, 1997. p. 96. 29. Lynnerup N & Hjalgrim H. Routine use of ultraviolet light in medicolegal examinations to evaluate stains and skin trauma. Med Sci Law 1995; 35: 165–168. 30. Santucci K, Nelson D, Kennedy K et al. Wood’s lamp utility in the identification of semen: pediatrics 1999; 104: 1342–1344. 31. Jones DN. The task of the forensic science laboratory in the investigation of sexual offences. J Forensic Sci Soc 1963; 3: 88–93. Ò 32. Stoilovic M. Detection of semen and blood stains using Polilight as a light source. Forensic Sci Int 1991; 51: 289–296. 33. Nelson DG & Santucci KA. An alternative light source to detect semen. Acad Emeg Med 2002; 9: 1045–1048. 34. Miller A. Product manager at forensics source. Florida, USA: Jacksonville [personal communication]. 35. Sweet DJ. Human bite marks-examination, recovery and analysis. In Bowers CM & Bell GL (eds.). Manual of forensic odontology. Colorado: American Society of Forensic Odontology, 1995. 36. Keating SM & Allard JE. What’s in a name? Medical samples and scientific evidence in sexual assaults. Med Sci Law 1994; 34: 187–201. 37. Benschop CCG, Wiebosch C, KloostermamAD et al. Post coital vaginal sampling with Nylon flocked swabs improves DNA typing. Forensic Sci Int Genet 2010; 4: 115–121. 38. Allard JE, Baird A, Davidson G et al. A comparison of methods used in the UK and Ireland for the extraction and detection of semen on swabs and cloth samples. Sci Justice 2007; 47: 160–167. 39. Wickenheiser RA. Trace DNA: a review, discussion of theory, and application of the transfer of trace quantities of DNA through skin contact. J Forensic Sci 2002; 47: 442–450. 40. Hansson O, Finnebraaten M, Knutsen Heitmann I et al. Trace DNA collection-performance of minitape and three different swabs. Forensic Sci Int Genet Suppl Ser 2009; 2: 189–190. 41. Van Oorshot RAH, Schulz RA, Holding NL et al. Improving collection methods can improve the ability to obtain typings from trace amounts of DNA from touched objects. Proceedings from the XIX International Congress of Genetics, Melbourne 2003. M. Newton / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 77–90 89

42. Van Oorschot RA, Szepietowska I, Scott DL et al. Retrieval of genetic profiles from touched objects. Proceedings of the first International Conference in Forensic Human Identification, London 1999. 43. Wickenheiser RA. Trace DNA. A review, discussion of theory and applications of transfer of trace quantities of DNA through skin contact. J Forensic Sci 2003; 47: 442–450. 44. Sweet D, Lorente M, Lorente JA et al. An improved method to recover saliva from human skin: the double swab technique. J Forensic Sci 1997; 42: 320–322. 45. Sweet D, Lorente JA, Valenzuela A et al. PCR-based DNA typing of saliva stains recovered from human skin. J Forensic Sci 1997; 42: 447–451. 46. Castellan V & Mangin P. DNA profiling success and relevance of 1739 contact stains from casework. Forensic Sci Int Genet Suppl Ser 2008; 1: 405–407. 47. Van Oorschot RAH, Weston R & Jones MK. Retrieval of DNA from touched objects. Proceedings of the 14th International Symposium on the Forensic Sciences of Australian and New Zealand Forensic Science Society. Adelaaide: ANZFSS Oct 12– 16, 1998. 48. Pang BCM & Cheung BKK. Double swab technique for collecting touched evidence. Leg Med 2007; 9: 181–184. 49. Prinz M, Schiffner L, Sebestyen JA et al. Maximization of STR DNA typing success for touched Objects. Int Congress Ser 2006; 1288: 651–653. 50. Collopy C. Mini-popule to maximize DNA recovery for robotic forensic analysis; htttp://www.forensicmag.com/article/ mini-popule-developed-maximize-dna-recovery-robtic-forensic-analysis; [last accessed 10.08.12]. 51. Kenna J, Smyth M, McKenna L et al. The recovery and persistence of salivary DNA on human skin. J Forensic Sci 2011; 56: 170–175. 52. Hall D & Fairley M. A single approach to the recovery of DNA and firearm discharge residue evidence. Sci Justice 2004; 44: 15–19. 53. Cooper J. ADF investigative service forensic manager, Australia, April 2012, [personal communication]. 54. Anchorodoquy TJ & Molina MC. Preservation of DNA, cell preserve. Technol 2007; 5: 180–188. 55. Wiegand P, Rand S & Bajanowski T. DNA typing of fingernails. Int J Leg Med 1993; 106: 81–83. 56. Cook O & Dixon L. The prevalence of mixed DNA profiles in fingernail samples taken from individuals in the general population. Forensic Sci Int Genet 2007; 1: 62–68. 57. Dowlman EA, Martin NC, Foy MJ et al. The prevalence of mixed DNA profiles on fingernail swabs. Sci Justice 2010; 50: 64–71. Ò 58. Turton S. Assistant intelligence officer, forensic science service . United Kingdom March 2003 [personal communication]. 59. Newton M. UK independent forensic advisor for rape and serious sexual assault October 2011 [personal communication]. Ò 60. Turton S. Assistant intelligence officer, forensic science service March 2003 [personal communication]. 61. Exline DL, Smith FP & Drexler SG. Frequency of pubic hair transfer during sexual intercourse. JForensicSci1998; 43: 505–508. 62. Mann MJ. Hair transfers in sexual assault: a six year case study. J Forensic Sci 1990; 35: 951–955. 63. Stone IC. Hair and its probative value as evidence. Tex Bar J 1982; 45: 275–279. 64. Riis R. Sexual assault combing evidence. Presented at the NWAFS meeting. Jackson Hole 1990. 65. Salter MT & Cook R. The significance of transfer of fibres to head hair, their persistence and retrieval. Forensic Sci Int 1996; 81: 211–221. 66. Weir E. Drug-facilitated date rape. CMAJ 2001; 165: 80. 67. Gee D, Owen P, Mclean L et al. Operation MATISSE: investigating drug facilitated sexual assault. London: The association of Chief Police Officers (ACPO), 2006, www.acpo.police.uk/asp/policies/data/Opeatin%20Matisse%20report%20-%20press% 20rel.%2084.doc. 68. Hall J, Goodall EA & Moore T. Alleged drug facilitated sexual assault (DFSA) in Northern Ireland from 1999 to 2005. A study of blood alcohol levels. J Forensic Leg Med 2008; 15: 497–504. 69. Hall JA & Moore CB. Drug facilitated sexual assault-a review. J Forensic Leg Med 2008; 15: 291–297. 70. Scott-Ham M & Burton FC. Toxicological findings in cases of alleged drug-facilitated sexual assault in the United Kingdom over a 3 year period. J Clin Forensic Med 2005; 12: 175–186. 71. Burkhardt S. University Center of Legal Medicine of Geneva, April 2012 [personal communication]. 72. Hurley M, Parker H & Wells D. The epidemiology of drug facilitated sexual assault. J Clin Forensic Med 2006; 13: 181–185. 73. Negrusz A & Gaensslen RE. Analytical developments to toxicological investigation of drug-faciliated sexual assault. Anal Bioanal Chem 2003; 376: 1192–1197. 74. Edinboro LE & Pokis. A detection of benzodiazepines and tri benzazolans by TRIAGEÔ: confirmation by solid-phase Ò extraction utilizing SPEC .3ML.MP3 microcolumns and GC-MS. J Analyt Toxicol 1994; 18: 312–316. 75. Huang W & Moody DE. Immunoassay detection of benzodiazepines and benzodiazepine metabolites in blood. J Analyt Toxicol 1995; 19: 333–342. 76. Marc B. Current clinical aspects of drug-facilitated sexual assaults in sexually abused victims in a forensic emergency unit. Ther Drug Monit 2008; 30: 218–224. 77. Cheze M, Duffort G, Deveaux M et al. Hair analysis by liquid chromatography-tandem mass spectrometry in toxicological investigation of drug facilitated crimes: report of 128 cases over the period June 2003–May 2004 in Metropolitan Paris. Forensic Sci Int 2005; 153: 3–10. 78. Ames D, LGC, United Kigdom, April 2012 [personal communication]. 79. Bah P. Hong Kong, April 2012 [personal communication]. 80. Barbu C. Head of Forensic Science of Covasna County, Romania, April 2012 [personal communication]. 81. US Department of Justice on Violence Against Women. A national protocol for sexual assault forensic examinations adult/ adolescents: presidents DNA initiative. Washington: US Department of Justice on Violence Against Women, 2004. 82. Gill P. Professor of forensic genetics, Oslo University, April 2012 [Personal communication]. 83. Thomsen JL. Denmark, April 2012 [personal communication]. 84. Green W, Kaufhold M & Shhulman E. Sexual assault evidentiary exam training for health care providers (participant manual), module 8. Davis and San Diego: California Medical Training Center at the University of California-Davis, California Medical Training Center and Children’s Hospital of San Diego, 2001. p. 39. 90 M. Newton / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 77–90

85. Hindmarch I & Brinkmann R. Trends in the use of alcohol and other drugs in cases of sexual assault. Hum Psychopharm 1999; 14: 225–231. 86. Hindmarch I, Elsohly M, Gambles J et al. Forensic urinalysis of drug use in cases of alleged sexual assault. J Clin Foren Med 2001; 8: 197–205. 87. Finney A. Alcohol and sexual violence: key forensic findings from the research, number 215. London: Home Office, 2004. 88. Lucy D, Curran JM, Pine AA et al. The probability of achieving full allelic representation for LCN-STR profiling of haploid cells. Sci Justice 2007; 47: 168–171. Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 91–102

Contents lists available at SciVerse ScienceDirect Best Practice & Research Clinical Obstetrics and Gynaecology

journal homepage: www.elsevier.com/locate/bpobgyn

8 Forensic medical examination of adolescent and adult victims of sexual violence

Ole Ingemann-Hansen, MD, PhD, Forensic Pathologist *, Annie Vesterby Charles, MD, DMSc, Professor, Chief Forensic Pathologist, Head of Department

Department of Forensic Medicine, Section of Forensic Pathology and Clinical Forensic Medicine, University of Aarhus, Brendstrupgaardsvej 100, 8200 Aarhus N, Denmark

Keywords: The acute care and examination of a victim of sexual violence must sexual abuse be carried out by a competent forensic examiner in a setting rape appropriate for crisis intervention, forensic evidence collection, forensic examination and medical follow up. The aim of forensic evidence and biological material collection is to document an alleged physical or sexual contact between individuals and to corroborate the victim’s and the assailant’s history. This is why the forensic examiner is expected to be objective and in possession of specialised technical and scientific skills. These skills are addressed and recommendations are made on how to carry out a forensic examination. This includes medical and assault history, top-to-toe examination, biological material collection, and documenting injuries while obtaining the chain of custody. Yet, consensus on time limitations for forensic evidence collection is lacking. Available forensic evidence has been shown to benefit prosecution. To meet the legal system’s needs, an interpretation of the findings in a written legal report is mandatory. Ó 2012 Elsevier Ltd. All rights reserved.

Delineating the purpose

The examination of victims of sexual violence is often located at specialised Sexual Assault Referral Centres (SARC), and is multidisciplinary and public in approach, with free access for every citizens.1,2 The ﬁrst SARC was originally opened in Boston City Hospital in 1972, and was born out of new

* Corresponding author. E-mail address: [email protected] (O. Ingemann-Hansen).

1521-6934/$ – see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bpobgyn.2012.08.014 92 O. Ingemann-Hansen, A.V. Charles / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 91–102 research and understanding of ‘rape trauma syndrome’.3,4 Later, several SARCs were established in the – other Western countries.5 17 The establishment in 1999 of the SARC in Aarhus, Denmark, at the Accident and Emergency department, was based on guidelines stating that every single female who attended the health services should be offered care, treatment, and a medical examination with forensic evidence collection.18,19 In areas with no SARCs, the range of help offered to victims of sexual assault might be accidental or fragmentary, with no continuum and follow up.20,21 The forensic medical examination first described by Paul in 1975,22 and later in the widespread ‘gold standard’ Guidelines for medico-legal care for victims of sexual violence by the World Health Organization,23 however, is a well- known standard protocol. In this chapter, we aim to describe practical issues relating to the forensic medical examination, with emphasis on evidence collection of biological trace material and competence of physicians. The world Health Organization defines sexual violence as: ‘Any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work.’24 In this chapter, we use the terms ‘sexual violence’ and ‘sexual assault’ to denote episodes of involuntary interpersonal hetero- as well as homosexual acts or contacts, such as completed or attempted penile penetration of the vagina, anus, or mouth (irrespective of whether ejaculation of semen takes place); episodes of penetrating the vagina, anus, or mouth with fingers or objects; and episodes in which a person is believed or considers himself or herself to be assaulted. The Danish penal code considers the assault as rape when forced sexual intercourse, completed or attempted, is acquired with violence or threat of violence.25 Victims of such sexual assaults are primary recipients of a forensic examination.

Forensic examination

Main components of a forensic examination

The care and examination of an acute sexual assault victim needs to be carried out by a competent medical doctor with knowledge of the psychological response to sexual assault. They must be a competent communicator so that a relevant history of the assault can be obtained. They must know what to look for, how to document and obtain biological trace evidence, and how to interpret and report the ﬁndings verbally and in writing. Specialists in forensic medicine at Aarhus University carry out the examinations ensuring impartiality. The examination should take place in a quiet setting with access to necessary equipment and assistance. From the victim’s perspective, prompt medical examination by a physician is seen as crises intervention, and injuries can be treated, and sexually transmitted infection and pregnancy risk evaluated and prevented as necessary. The physician is also responsible for collecting trace evidence. From a legal perspective, police reports require the following: accurate history; documentations of observations; forensic trace evidence collection; interpretation of the ﬁndings; a standardised medico- legal report in objective terms; and provision of expert opinion in legal proceedings. From the above, a set of main components can be assembled for a full forensic medical examination. These are presented in Table 1.

Speciﬁc components of the evidentiary examination

Assessment and consent Upon arrival to the SARC or other setting for the examination, the receiving team (nurse or medical doctor) must establish the order of injuries needing acute medical or surgical treatment; hence, treatment takes priority over prompt forensic examination. The forensic examiner should be alerted, and if possible immediately attend, to the victim for parallel examination and securing of evidence (e.g. clothes). The forensic examiner introduces the victim to the examination, informs them of the options, O. Ingemann-Hansen, A.V. Charles / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 91–102 93

Table 1 Essential components of a forensic examination.

Assessment of the victim Informed consent Medical and gynaecological history Assault history Physical top-to-toe examination Genito-anal examination Trace evidence and biological material collection Documenting injuries and findings Securing chain of custody Interpretation and reporting of findings and obtains informed consent by explaining that confidentiality to the police is not possible. It is fundamental that the victim is not pressed to participate in the examination, and written consent is central if the resulting report is to be used legally. It is obligatory for the police to obtain written consent in advance.

History For proper disclosure of the history and alleged assault event, the necessary information is best obtained by using a standardised examination protocol acting as a guide for all relevant details. Simultaneously, a standard protocol makes talk of the sexual activity and inﬂicted coercion more straightforward and less intimidating. Points of forensic medical interest to support subsequent ﬁndings are the victim’s general health, use of prescriptive medication or drugs of abuse, menstrual period, former sexual relationships, time since last voluntary intercourse, and recent genital lesions. It should be explained to the victim that obtaining an assault history is not police questioning, and that the forensic examiner is interested in different aspects of the assaultive episode to the police authorities. Meticulous history taking allows exact documentation and guides the examiner during the following physical examination and trace-evidence collection (Table 2).

Top-to-toe and genito-anal examination It is advisable to conduct the physical examination and the trace-evidence collection simultaneously using the above-mentioned standard protocol, and to also document injuries by using body maps and photography during the examination. The general demeanour and appearance of the victim is noted along with signs of inebriation. The systematic top-to-toe examination should be conducted in the same manner every time, and all parts of the victim’s skin should be inspected. An adequate method is to begin with the head, including the oral oriﬁce and eyelids (petechial bleeding) and the neck. The victim is then asked to recline so that the breast and trunk can be examined followed by the extremities. Remember to cover the victim’s pelvic region and legs while examining the breast and trunk, and vice versa.

Table 2 Taking a meticulous assault history.

When and where the assault happened. What happened. The exact position of the victim and the assailant during the assault. Surroundings. Use of coercion by violence and restraints. Whether weapons were used or neck compression inﬂicted, as these have legal implications.1 Removal of victim’s and assailant’s clothing. Oral, vaginal, rectal, or both, penetration by penis, ﬁngers or objects. Ejaculation. Kissing of the victim’s face or body. Parts of the victim touching the assailant. Aftermath activities such as bathing, changes of clothing, toileting. Genito-anal discharge, bleeding or pain symptoms. 94 O. Ingemann-Hansen, A.V. Charles / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 91–102

With the female victim in supine position, knees drawn and legs apart, inspection of the external genitals and perineum is achieved followed by insertion of a speculum to inspect the vaginal wall and cervix. Trace evidence is collected before insertion of instruments in order to avoid contamination. Specimens from the vagina (i.e. foreign bodies) and samples from the cervix, however, are collected while the speculum is inserted. The anal examination can be carried out with the female victim still in supine position, or turned in the lateral position. After initial inspection and trace-evidence collection, depending on the assault history or signs of profound injury, anoscopy should be carried out. Use of colposcopy is an area of variation and not routine or recommended in all examination programmes.26 The Norwegian Society for Gynaecologist recommends use of a colposcope for diagnostic purposes and documentation.27 In a recent study by Astrup et al.,28 genital lesions were seen with the naked eye in 34% of the cases examined, 49% were seen with colposcopy, and 52% were seen with toluidine blue dye and subsequent colposcopy. As primary intent of the forensic evidence collected is to confirm recent sexual contact, to show if force or coercion has been used (in rape complaints), and to corroborate the victim’s story,29 the intention is to document as many injuries as possible using utensils as colposcope and dye. It is clear, however, that a genital lesion in itself does not corroborate a legal complaint of rape, but the documentation of a genital lesion could be of importance in the individual case whatever the circumstances and explanations.28 The police investigator and legal prosecutor want to know the age of the injury, the way it was inflicted, the type of force used, and the health consequences for the victim. An accurate and complete record of injuries must be compiled, with careful documentation, and proper and rigorous description. Standardised features, such as location, size (continuous use of same unit), shape, colour, and classification, are to be used, allowing correct interpretation and deduction. Classification of injuries should be in accordance with generally used terminology, including bruises, abrasions, contusions, lacerations, sharp-edged wounds, gun wounds and crust-covered wounds. Site of special forensic interest is conjunctiva and neck, where petechiae, bruises, abrasions, and ligature marks indicate a trauma against the neck. Together with sharp-edged wounds and gun wounds indicating use of weapons, these injuries are signs of the victim having been in life-threatening danger. This could be immediate or potential danger, depending on the exact location, spread and depth of injuries. Such injuries or an assault history, including trauma against the neck, use of weapons, or both, have been shown to significantly affect legal outcome.1 Other sites of forensic interest are the face with bruises; haematomas of the periorbital region and inner lips indicating blows; the little finger side of hands and forearms, with bruises indicating warding off injuries; shoulders, upper arms and wrists, with bruising (e.g. fingertip) after possible restraint; and bony prominences with abrasions and bruises as – caused by falls. Bodily (extra-genital) injuries are reported in 25–90% of victims medically examined.30 33 Genital injuries, such as abrasions or lacerations of the fossa navicularis, posterior fourchette, perineum, or perianal region, are possible signs of penetration or attempted penetration by the penis, fingers, or other blunt objects, hence indicating a sexual act. Both positive and negative occurrence of injuries and soiling has to be registered. Remember that description is different from interpretation, and should not be confused in the injury record.

Trace-evidence collection: why, what, where, when, and how? The aim of forensic evidence and biological trace material collection is for use in legal proceedings to document an alleged physical or sexual contact between individuals, objects, or places,23 and to corroborate the victim’s and the assailant’s history. That is why the forensic examiner is expected to be absolutely objective and in possession of specialised technical and scientific skills. A recommended method is to ask the victim to stand on a sheet of paper in order to collect any falling debris, hairs, or fibres while clothing is secured piece by piece in paper bags. During the subsequent top-to-toe and genito-anal examination, all injuries are recorded and documented dia- grammatically. Specimens for DNA and semen are routinely collected with a swab from the face and neck, and both hands, from the gingival margins of the lower jaw, the introitus and fornix vaginae, and the anus. If indicated by the victim’s history, or if visible soiling/contamination, additional samples for semen, blood, saliva, and soiling are taken. Scraping of fingernails with toothpicks (Fig. 1) and a swab from the inside cheek for DNA reference are carried out. Finally, urine and blood samples are collected. O. Ingemann-Hansen, A.V. Charles / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 91–102 95

Fig. 1. Fingernail scraping using utensils from forensic evidence collection the kit box.

Smears on slides are made from the possible semen swabs and stained with haematoxylin-eosin by a laboratory assistant, whereupon the physician looks for spermatozoa under light microscopy. The genetic and toxicological analyses are made on request from the police authorities. The genetic evidence is analysed for semen, blood, saliva, and skin, and DNA type at the Forensic Genetic Department. At the Forensic Chemical Department, specimens are analysed for alcohol and drugs. Forensic scientists at the police department examine the clothing for damage and foreign materials. Biological trace material as foreign DNA can be detected from semen containing spermatozoa, saliva containing epithelial cells, blood, loose epithelial cells, and hair. Conversely, if DNA is detected, the origin as semen, blood, or saliva can be determined. Furthermore, as evidence of the presence of seminal fluid, spermatozoa can be detected by wet-mounted smear or stained smear on light microscopy, or by prostatic acid phosphatise and prostatic specific antigen, with often a higher prevalence of positive test than microscopy.1,34,35 Non-human specimens to be collected are smudges of vegetation or fibres. Biological trace evidence is collected from the skin, body orifices, the penis of male victims, nails, blood, and urine, and clothing are obtained. DNA-free cotton swabs, toothpicks, tweezers, paper bags, needles, and containers are used. In general, it is recommended that moistened (sterile water) swabs are used from dry surfaces and dry swabs from wet material. The World Health Organization recommendation from 2003 is to collect specimens as early as possible because the value of evidentiary material decreases dramatically 72 h after the assault.23 An overview of recommendations of the forensic trace evidence collection procedure is presented in Table 3. In Denmark, the cut-off limit for trace-evidence collection is set to 72 h, partly as a result of a recent study where spermatozoa were found up to 3 days after the alleged assault, but not after.1 On the other hand, injuries stay longer, and use of colposcopy and toluidine blue dye has extended the median survival time for visible injuries from 24–80 h, exceeding the time limit for admission to many SARCs.28 The role of colposcopy and toluidine blue dye is not recommended as a routine procedure until further knowledge is available. 96 O. Ingemann-Hansen, A.V. Charles / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 91–102

Table 3 Recommendations for body locations and time since assault for routine evidence collection.

Site World Health Denmark36 Norwaya37(days) Sweden38 (days) Britain39 (days) USA40,41 Organization23 Gingiva x <3 days <4 <10 <2 <24 hb Palate <4 Lips <10 Face <3 days Genitalia ext. x <4 <10 <3–5 daysb Introitus <3 days <4 <10 <7a <3–5 daysb Vagina middle <4 Fornix post. x <3 days <4 <10 <7a <3–5 daysb Cervix x <4 <10 2–7a <3–5 daysb Perianal <4 <10 <3 <24 hb Penis x <3 days <4 <10 Anus/rectal x <3 days <4 <10 <3a <24 hb Skin x <3 days <4 <10

a Norway recommends an abbreviated examination if the examination is 4–7 days after the alleged assault. b Depending on the assault history, x, recommended before 72 h.

Documenting by securing chain of custody The primary task of the forensic examiner is to obtain accurate documentation of the examination, including the essential forensic examination components mentioned so far. To secure the identity of the victim, it is important to document who has carried out the examination, who assisted, who attended, what information was available, where and how the examination was carried out, what trace evidence was collected, for what purpose, and how it was secured and stored. The procedure for the whole examination, especially the sampling of trace evidence, has legal implications, as the findings could be used in a court of law. The key word is chain of custody. In order to comply, the medical examination would benefit from using a well-equipped rape kit containing utensils needed for the qualified forensic evidence collection. The kit box in Aarhus (Fig. 2), which is now distributed all around Denmark, was made in co-operation with the Danish Technological Institute, and was

Fig. 2. The forensic evidence collection kit box, Aarhus. O. Ingemann-Hansen, A.V. Charles / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 91–102 97 approved by DANAK, the Danish authority tasked with evaluating quality assurance. The box secures the chain of custody because all material necessary for evidence collection is available, sterile or DNA- free, and the clinician is familiar with, and has a thorough knowledge of, the utensils. Furthermore, the person who packed the kit, the nurse opening the kit, and the examiner touching the utensils are all traceable. The handling procedures should be clear from the kit’s guidance or the examiner’s manual on how specimens are collected carefully, contamination is avoided, how to label the material accurately and secure and tamper-proof the specimens. Documentation of the transfer of the kit-box

Fig. 3. Body diagram as used at the Sexual Assault Referral Centre, Aarhus. 98 O. Ingemann-Hansen, A.V. Charles / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 91–102 from the time it is opened until it is sealed and secured is maintained. How to obtain consent, recording assault history and noting ﬁndings on diagrams (Figs. 3 and 4) should be possible in an enclosed protocol or record book. Photography as documentation is mandatory, and knowledge of the capabilities and requirements of the use of photographs in the legal proceeding is necessary. If the kit and manual have been approved by the organisation responsible for standardisation, then doubts

Fig. 4. Genital diagram as used at the Sexual Assault Referral Centre, Aarhus. O. Ingemann-Hansen, A.V. Charles / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 91–102 99 about the validity of DNA material to be used in court are diminished. All information that is registered in accordance with specially designed protocols can be easily transferred to a database for further research.

Interpretation and disclosure of findings: the legal report In the case of a reported assault to the police authorities, a written report is expected to the requester and ‘owner’ of the report. In the case of a non-reported assault, the victim has full self- determination, and the recorded documentations are strictly confidential. To meet the legal system’s needs, an interpretation of the findings is necessary. Even though the objective was clear from the start of the examination, and with the legal implication taken into account, accurate interpretation should be carried out by specialists (e.g. by a forensic physician or pathologist). In order to fulfil this statement, use of standardised forensic evidence collection and examination techniques, based on standard terminology, as described so far, should be carried out. A properly written forensic report should make clear what the examiner was told (from police and victim), observed, and did during the examination, maintaining objectivity using proper terminology. In a conclusion section, the interpretation of findings should make the police investigator and legal prosecutor clearly aware of the age of the injuries and the mechanisms of how the injuries occurred – could they have arisen from the alleged assault, the force by which they were inflicted and whether immediate or potential life-threatening danger was present, together with possible short- or long-term health consequences for the victim. Remember to write and conclude only what could be repeated and explained in court giving testimonial evidence. Guiding principles of what should be documented in the forensic report to the requester of a forensic examination in sexual offences are presented in Table 4. – Genital injuries sustained during assault range from 10–87%.16,42 49 Injuries sustained during – consensual intercourse range from 6–55%.43,50 52 Differences in the use of colposcopy, and inclusion of redness and swelling as an injury are variations, in study methodology. It follows that, genital injuries in itself do not corroborate sexual assault, which have to be interpreted during disclosure. Another example is interpretation of injuries in cases that end up considered baseless or with charges of false allegations.53 Such self-inflicted injuries are characteristically symmetrically distributed and typically avoid the areola of the breasts and the genital area.

Legal outcome

A significantly positive association exists between forensic evidence used to establish physical body and genito-anal injuries, and legal outcome.54 Other studies have shown an association between assault history and legal outcome, whereas others have reported no significant findings (Table 5).

Table 4 Contents in the written forensic report.

Victim demographics Assault history (from victim and police) Alcohol, drug, and medication intake Post-assault activities Medical and gynaecological history (relevant) Victim’s general appearance Signs of inebriation, impairment, and illness Injury description Details of all specimens collected Procedure for examination and material collection Material for laboratory analyses or storage Immediate test results Medications and referrals given Interpretation and conclusion of forensic ﬁndings arising from alleged assault force inﬂiction life threat health consequences 100 O. Ingemann-Hansen, A.V. Charles / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 91–102

Table 5 Studies on forensic evidence documentation and legal outcome.

Country Year Participants Conviction rate (%) Signiﬁcant association to conviction Denmark55 1980 51 24 None Finland31 1984 249 36 Body injuries Norway9 1992 141 29 Severe coercion USA15 1980 372 69 None Canada17 1995 355 23 Injuries, age, weapon Canada56 1997 462 11 Body injuries Denmark1 2005 289 19 Severe coercion

Available forensic evidence beneﬁts prosecution, but attrition represents confounders in studies on legal outcome.57 Furthermore, many victims hesitate to present to SARCs, and these victims might not have forensic evidence collected.58

Conclusion

Medical forensic examination and the resulting legal report beneﬁt the legal procedure and contain ﬁndings and conclusions not otherwise described. It is important to remember that medical examinations are dynamic and, in every single case, are subject to choices of the examiner. Nevertheless, attention should be paid to the fact that sexual assault victims in shock or embarrassment may be unreliable about what happened. Hence, a standardised forensic examination protocol following the mentioned recommendations should work as routine. It is of great importance that the examination is carried out by a specially trained physician accommodating the victim’s needs for crisis intervention and medical treatment and follow up.

Practice points

Treating victims of sexual violence is multidisciplinary and public in approach. The examinator must be a competent communicator with knowledge of psychological reactions. The examination is documented by using a standard protocol. Signiﬁcant association between forensic documentation and legal outcome.

Research agenda

Persistence of foreign DNA on skin and body oriﬁces. Consensus of time limitations for forensic evidence collection. Forensic medical examination and effect on the legal outcome.

Conﬂict of interest

None declared.

References

*1. Ingemann-Hansen O, Brink O, Sabroe S et al. Legal aspects of sexual violence-Does forensic evidence make a difference? Forensic Sci Int 2008; 180: 98–104. *2. Bramsen RH, Elklit A & Nielsen LH. A Danish model for treating victims of rape and sexual assault: the multidisciplinary public approach. J Aggress Maltreat Trauma 2009; 18: 886–905. 3. Burgess AW & Holmstrom LL. The rape victim in the emergency ward. Am J Nurs 1973; 73: 1740–1745. 4. Resnick HS, Kilpatrick DG, Dansky BS et al. Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. J Consult Clin Psychol 1993; 61: 984–991. O. Ingemann-Hansen, A.V. Charles / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 91–102 101

5. Dahl S. Acute response to rape: a PTSD variant. Acta Psychiatr Scand Suppl 1989; 355: 56–62. 6. Bang L. Health services for rape victims. World Health Forum 1991; 12: 184–190. 7. Bang L. Who consults for rape? Sociodemographic characteristics of rape victims attending a medical rape trauma service at the Emergency Hospital in Oslo. Scand J Prim Health Care 1993; 11: 8–14. 8. Bang L. Rape victims: assaults, injuries and treatment at a medical rape trauma service at Oslo Emergency Hospital. Scand J Prim Health Care 1993; 11: 15–20. 9. Schei B, Muus KM & Moen MH. Medical and legal aspects of rape. Referrals to a team for care of rape victims at the regional hospital in Trondheim during the period 1989–1992 [in Norwegian]. Tidsskr Nor Laegeforen 1995; 115: 30–33. 10. Agnarsdóttir G & Skúladóttir S. A new trauma service at the emergency department of the Reykjavik city hospital. Arctic Medical Research 1994; 53: 531–533. 11. Heimer G, Posse B, Stenberg A et al. A national center for sexually abused women in Sweden. Int J Gynaecol Obstet 1996; 53: 35–39. 12. Lacey HB. Sexually transmitted diseases and rape: the experience of a sexual assault centre. Int J STD AIDS 1990; 1: 405–409. 13. Kerr E, Cottee C, Chowdhury R et al. The Haven: a pilot referral centre in London for cases of serious sexual assault. BJOG 2003; 110: 267–271. 14. McGregor MJ, Le G, Marion SA et al. Examination for sexual assault: is the documentation of physical injury associated with the laying of charges? A retrospective cohort study. CMAJ 1999; 160: 1565–1569. 15. Tintinalli JE & Hoelzer M. Clinical findings and legal resolution in sexual assault. Ann Emerg Med 1985; 14: 447–453. 16. Rambow B, Adkinson C, Frost TH et al. Female sexual assault: medical and legal implications. Ann Emerg Med 1992; 21: 727–731. 17. Gray-Eurom K, Seaberg DC & Wears RL. The prosecution of sexual assault cases: correlation with forensic evidence. Ann Emerg Med 2002; 39: 39–46. 18. Vejledning om den fremtidige organisation af sundhedsvæsenets indsats for vold- og voldtægtsramte [in Danish]. Copenhagen: Danish National Board of Health, 1999. 19. Ingemann-Hansen O. The Western Danish Center for prevention, treatment and research of sexual assault. Scand J Forensic Sci 2006; 12: 25–29. 20. Gilles C, Van LC & Rozenberg S. Audit on the management of complainants of sexual assault at an emergency department. Eur J Obstet Gynecol Reprod Biol 2010; 151: 185–189. 21. Hallmann H. Tilbydes voldtaegtsofre i Danmark en psykologisk hensigtsmaessig behandling? [in Danish]. Psykologisk Skriftserie 1997; 22: 1–113. 22. Paul DM. The medical examination in sexual offences. Med Sci Law 1975; 15: 154–162. *23. Guidelines for medico-legal care for victims of sexual violence. Geneva: World Health Organization, 2003. 24. Krug EG, Dahlberg LL, Mercy JA et al. World report on violence and health. Geneva: World Health Organization, 2002. *25. Ingemann-Hansen O. Assessment of the importance of forensic examination for victims of sexual violence – emphasis on legal consequences and prevention of postassault trauma. SUN-TRYK: University of Aarhus, 2008. 26. Anderson SL, Parker BJ & Bourguignon CM. Changes in genital injury patterns over time in women after consensual intercourse. J Forensic Leg Med 2008; 15: 306–311. 27. Hagemann C, Schei B & Finanger T. Seksuelle overgrep [in Norwegian]. Norsk Gynekologisk Forening, 2009. *28. Astrup BS, Ravn P, Lauritsen J et al. Nature, frequency and duration of genital lesions after consensual sexual intercourse: implications for legal proceedings. Forensic Sci Int 2012; 219: 50–56. 29. Tucker S, Claire E, Ledray LE et al. Sexual assault evidence collection. Wis Med J 1990; 89: 407–411. 30. Spears JW & Spohn C. The effect of evidence factors and victim characteristics on prosecutors’ charging decisions in sexual assault cases. Justice Q 1997; 14: 501–524. 31. Penttila A & Karhumen PJ. Medicolegal findings among rape victims. Med Law 1990; 9: 725–737. 32. Avegno J, Mills TJ & Mills LD. Sexual assault victims in the emergency department: analysis by demographic and event characteristics. J Emerg Med 2009; 37: 328–334. *33. Ingemann-Hansen O, Sabroe S, Brink O et al. Characteristics of victims and assaults of sexual violence – improving inquiries and prevention. J Forensic Leg Med 2009; 16: 182–188. 34. Lincoln CA, McBride PM, Turbett GR et al. The use of an alternative light source to detect semen in clinical forensic medical practice. J Clin Forensic Med 2006; 13: 215–218. 35. Talthip J, Chirachariyavej T, Peonim AV et al. An autopsy report case of rape victim by the application of PSA test kit as a new innovation for sexual assault investigation in Thailand. J Med Assoc Thai 2007; 90: 348–351. 36. Behandlingstilbud ved centre for modtagelse af voldtægtsofre [in Danish]. Copenhagen: Danish National Board of Health, 2012. 37. Overgrepsmottak. Veileder for helsetjenesten [in Norwegian]. Oslo: Sosical- og helsedirektoratet, 2007. 38. Nationalt centrum för kvinnofridNationellt handlingsprogram för hälso- och sjukvårdens omhändertagande av offer för sexuella övergrepp [in Swedish]. Edita: Uppsala University, 2010. 39. Guidelines for the collection of specimens. London: Faculty of the Forensic and Legal Medicine, 2010. 40. Department of Justice. A national protocol for sexual assault medical forensic examinations. Adults/adolescents. Washington DC: U.S. Department of Justice, Office on Violence Against Women, 2004. *41. Linden JA. Clinical practice. Care of the adult patient after sexual assault. N Engl J Med 2011; 365: 834–841. 42. Hilden M, Schei B & Sidenius K. Genitoanal injury in adult female victims of sexual assault. Forensic Sci Int 2005; 154: 200–205. 43. Slaughter L, Brown CR, Crowley S et al. Patterns of genital injury in female sexual assault victims. Am J Obstet Gynecol 1997; 176: 609–616. 44. Slaughter L & Brown CR. Cervical findings in rape victims. Am J Obstet Gynecol 1991; 164: 528–529. 45. Slaughter L & Brown CR. Colposcopy to establish physical findings in rape victims. Am J Obstet Gynecol 1992; 166: 83–86. 46. Sommers MS & Buschur C. Injury in women who are raped: what every critical care nurse needs to know. Dimens Crit Care Nurs 2004; 23: 62–68. 47. Sommers MS. Defining patterns of genital injury from sexual assault: a review. Trauma Violence Abuse 2007; 8: 270–280. 102 O. Ingemann-Hansen, A.V. Charles / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 91–102

48. Champion HL, Foley KL, DuRant RH et al. Adolescent sexual victimization, use of alcohol and other substances, and other health risk behaviors. J Adolesc Health 2004; 35: 321–328. 49. Logan TK, Cole J & Capillo A. Differential characteristics of intimate partner, acquaintance, and stranger rape survivors examined by a Sexual Assault Nurse Examiner (SANE). J Interpers Violence 2007; 22: 1066–1076. 50. McLean I, Roberts SA, White C et al. Female genital injuries resulting from consensual and non-consensual vaginal intercourse. Forensic Sci Int 2011; 204: 27–33. *51. Zink T, Fargo JD, Baker RB et al. Comparison of methods for identifying ano-genital injury after consensual intercourse. J Emerg Med 2010; 39: 113–118. 52. Anderson S, McClain N & Riviello RJ. Genital ﬁndings of women after consensual and nonconsensual intercourse. J Forensic Nurs 2006; 2: 59–65. 53. Gibbon KL. False allegations of rape in adults. J Clin Forensic Med 1998; 5: 195–198. *54. Du Mont J & White D. The uses and impacts of medico-legal evidence in sexual assault cases: a global review. Geneva: World Health Organization, 2007. 55. Helweg-Larsen K. The value of the medico-legal examination in sexual offences. Forensic Sci Int 1985; 27: 145–155. 56. McGregor MJ, Du MJ & Myhr TL. Sexual assault forensic medical examination: is evidence related to successful prosecution? Ann Emerg Med 2002; 39: 639–647. *57. Nesvold H, Ormstad K & Friis S. 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. J Forensic Sci 2011; 56: 1156–1162. 58. Nesvold H, Friis S & Ormstad K. Sexual assault centers: attendance rates, and differences between early and late presenting cases. Acta Obstet Gynecol Scand 2008; 87: 707–715. Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 103–111

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9 Interpretation of non-genital injuries in sexual assault

Jack Crane, CBE MB BCh FRCPath DMJ (Clin et Path) FFPathRCPI FFFLM, State Pathologist for Northern Ireland and Professor of Forensic Medicine *

State Pathologist’s Department, Institute of Forensic Medicine, Grosvenor Road, Belfast BT12 6BS, UK

Keywords: The accurate description and interpretation of non-genital injuries injuries may be crucial in cases of alleged sexual assault, and may be bruises important in corroborating a victim’s statement of events. In many abrasions cases of sexual assault, non-genital injuries may be either absent lacerations or trivial; nevertheless, even minor injuries may be of signiﬁcance bite marks and need to be recorded. Injuries may be result from attempts to restrain the victim, whereas others (e.g. bite marks) may have a sexual motive or be part of a sado-masochistic ritual. A standard nomenclature for injuries (i.e. using the terms ‘bruises’, ‘abrasions’, ‘lacerations’, ‘incisions and ‘stab wounds’) should avoid ambiguity between medical examiners. Ó 2012 Elsevier Ltd. All rights reserved.

Introduction

Studies have shown that most victims of sexual assault will have no general injuries or only injuries – that may be categorised as trivial.1 3 The absence of injuries does not preclude a sexual assault having taken place, particularly if threats of violence have been used or the victim is under the inﬂuence of drink, drugs, or both. Similarly, the presence of injuries may indicate violent consensual sexual activity, particularly if the parties indulge in bondage and sado-masochistic acts. In all cases of alleged sexual assault, a complete physical examination must be carried out, and all injuries, no matter how trivial, should be accurately recorded and, if appropriate, photographed. The absence of injuries should also be recorded by the examiner in their notes, as this too may be important in supporting or refuting allegations made by the complainant. A systemic approach to the examination of the victim should be used to ensure that parts of the examination are not omitted. The use of diagrams and body charts are useful for recording injuries, and these, along with photographs, provide a permanent record of the injury as well as being a useful aide-

* Tel.: þ44 (0) 28 9063 4648; Fax: þ44 (0) 28 9023 7357. E-mail address: [email protected].

1521-6934/$ – see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bpobgyn.2012.08.009 104 J. Crane / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 103–111 mémoire when preparing for court. The size, shape and colour of injuries should be recorded, along with non-speciﬁc features such as swelling, localised tenderness and redness. A right-angled ruler is useful for determining the size of an injury, and can be used as a scale when photographs are taken.4

History

Before conducting the physical examination, it is important that the examining physician obtains a detailed history of the precise nature of the alleged assault from the victim directly or from police interview notes. This will provide information that may necessitate modifying the way the examination is conducted (e.g. if it is alleged that the assailant bit the victim), and will also be important in correlating non-speciﬁc injuries with speciﬁc aspects of the history. For example, the victim who alleges she has been forcibly held down on rough ground may have grip-type bruises on the upper arms and streaky abrasions over bony prominences on the back.

Nature of the injury

It is important to appreciate that, on occasions, the only evidence of applied violence may be redness, swelling and tenderness. Such transient lesions, although somewhat non-speciﬁc, should be noted and, if visible, photographed without delay as reddening (e.g. caused by a slap) may disappear within an hour or so after inﬂiction. Transient redness, swelling and tenderness may be a feature of forcible hair pulling, and be associated with localised areas of baldness or hair thinning, on the scalp. In such circumstances, it may be necessary to carefully palpate the scalp to locate areas of swelling and elicit tenderness.

Types of injury

One of the most common reasons why medical evidence on injuries, given in court, is contentious is because of the confusing assortment of terms used by doctors and the inappropriate or inaccurate description of an injury. It is, therefore, essential that for medico-legal purposes, a standard nomenclature is used when describing injuries. The following classiﬁcation is used by forensic physicians and pathologists: (1) bruises, often called contusions; (2) abrasions, also known as scratches; (3) lacerations, sometimes called cuts or tears; (4) incisions, known as slash wounds; and (5) stab wounds, sometimes called penetrating wounds. A variety of wounds or injury types may co-exist after trauma; an apparent ‘single’ injury may also show features of different types (e.g. an area of abrasion within which is a laceration). The purpose of this article is not to discuss the features of particular types of injury, which can be found elsewhere,5 but to consider the interpretation and signiﬁcance of such injuries in cases of alleged sexual assault.

Bruising

Although bruising is perhaps the most non-specific of all the types of injury associated with assault, there are, nevertheless, specific types of bruising that may be of particular significance.

Finger-tip bruising

Finger-tip bruising are discrete areas of ovoid bruising that may result from finger-tip pressure (e.g. on the skin of the neck) if it is forcibly grasped or on the upper arms if there is an attempt to pin a victim down by holding the arms. Typically, when the arms are forcibly gasped, a group of ovoid bruises, caused by the fingers, can be seen on the outer side of the limb, whereas a single ‘thumb’ mark may be identified on the inner side. Similarly, in attempted manual strangulation, a group of bruises on one side of the neck may be associated with a single bruise on the opposite side, often below the angle of the lower jaw. Finger-tip bruising may also be seen on the inner sides of the thighs when the leg or legs is/are firmly grasped in an attempt to forcibly open the legs for access to the genitalia. J. Crane / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 103–111 105

Black eyes

Black eyes are common in all types of assault, not just those of a sexual nature. They are easily sustained, even after relatively minor trauma, caused by a blow to the face such as by punching. Peri- orbital bruising, however, may also result from tracking of blood from injuries to the forehead or scalp or, following severe trauma, from a basal skull fracture (Fig. 1).

Bite marks

Bite marks tend to be of two types. First, there are the typical ‘suction’ type marks, characterised by an area of petechial bruising, and typically seen on the neck or breasts. They are caused by loose skin being sucked into the mouth and then being pressed against the palate by the tongue (Fig. 2). More aggressive biting involves the use of the assailant’s teeth, and these may leave a characteristic, and possibly identiﬁable pattern, on the skin. Such marks need to be carefully photographed, using a rigid L-shaped measuring rule and appropriately swabbed, with plain sterile swabs, moistened if necessary, for residual saliva (and DNA extraction). Consideration should also be given to asking a forensic odontologist to examine the injury. It should also be appreciated that the presence of a single bite mark is likely to be associated with other similar bites on the body (Fig. 3).

Mouth bruising

Victims of sexual assault may attempt to scream or cry out for help and, in order to prevent this, an assailant may apply a hand ﬁrmly over the mouth forcing the buccal mucosal lining of the lips against the teeth. If forcibly applied, such an application of a hand may be associated with bruising of the buccal mucosa of the lips, only visible on careful inspection of the inside of the mouth. Similarly blows to the mouth area (e.g. by punching), may result in bruising, laceration and swelling of the lips, particularly to their mucosal linings.

Fig. 1. Mechanism of peri orbital bruising (black eye). 106 J. Crane / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 103–111

Fig. 2. So called ‘love bites’ on side of neck.

Restraint bruising

Victims of sexual assault who struggle violently with their assailant may demonstrate a variety of injuries sustained while they are being restrained. These may include the ﬁnger-tip bruising characteristically seen on the upper arms as well as circumferential bruising around the wrists owing to the lower arms being forcibly grasped. Similar bruising may also be seen if the arms are tied with a non- abrasive ligature, such as a tie or stocking. Also, defence-type bruising may be found on the ulnar borders of the forearms if the arms are raised to protect the face.

Fig. 3. Two bite marks on the breast of a victim of sexual assault. J. Crane / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 103–111 107

Whipping and beating

Whipping and beating may form part of consensual sexual behaviour; however, they may also be associated with sado-masochistic sexual assault. Whipping and beating with belts, whips or rod-like instruments may produce so-called tramline bruising characterised by an area of central pallor outlined by two narrow parallel bands of bruising (Figs. 4 and 5). Typically, such injuries are usually seen on the buttocks.

Abrasions

As with bruises, abrasions are often of a non-speciﬁc nature and may give no clue as to their causation other than as indicators of contact with a rough surface. Some types of abrasions are, however, worth noting.

Finger-nail marks

Finger-nail marks may be seen in association with finger-tip bruising and typically appear as short crescentic marks or as interrupted linear marks if the finger nails are drawn across the skin surface. They are often seen on the neck when it has been forcibly grasped by an assailant, but it is important to remember that such injuries may be inflicted by the victim themselves while trying to loosen an assailant’s grip. Also, victims of sexual assault may scratch their assailant during a struggle, and the possibility of recovery of evidential material, such as blood from beneath the victim’s finger nails, should be considered and appropriate scrapings taken (Fig. 6).

Ligature marks

Sexual assault victims may occasionally be restrained by the use of ligatures or handcuffs around the wrists and ankles. Also, ligatures may be used as part of a bondage ritual or in association with other sado-masochistic activities. Typically, these marks are streaky abrasions, or sometimes bruises, extending circumferentially around the wrists or ankles. Rarely, if tightly applied, the pattern of the ligature (e.g. of a rope) may be reproduced on the skin (Fig. 7).

Drag marks

Victims may be trailed along the ground or forced to lie on a rough surface during an attack. In such circumstances, streaky linear-type abrasions may be found on the back, particularly over the bony prominences of the shoulders, spine and pelvis.

Lacerations (excluding genital injury)

Lacerations are relatively uncommon in sexual assault; however, when present, they may be an indicator of the degree of physical violence used against the victim. They are caused by blunt force and

Fig. 4. Mechanism of formation of tramline bruise. 108 J. Crane / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 103–111

Fig. 5. Typical bruising caused by blows with a rod like instrument. may involve the delicate skin around the eyes or the lining of the lips due to punching on the face. Lacerations of the scalp are unlikely to be caused by ﬁsts, and are either due to the head striking a hard surface, blows from a blunt object, or possibly kicking with a shod foot.

Sharp force injuries

Sharp force injuries are, fortunately, relatively rare in sexual assaults, although the use of a weapon, such as a knife, to threaten a victim, is not uncommon. The inﬂiction of injuries, for example with knives, may be for deliberate mutilation of the victim as part of a sado-masochistic ritual. In such circumstances, incisions may be found on the face and genitalia, and ‘defence’ type injuries may be seen on the palmar surfaces of the hands or ﬁngers due to an attempt to grasp the weapon.

Changes in appearance of injuries and ageing

Although the size and shape of abrasions remains static, the same cannot be said for bruising. The size and shape of bruises may change in the days after injury, and bruises may appear after a day or two when, on initial examination, no injury was apparent. In view of this, it is advisable to consider re- J. Crane / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 103–111 109

Fig. 6. Crescentic abrasions on neck due to ﬁnger nail marks.

examination of the victim a couple of days later and, if necessary, arrange for injuries to be re- photographed. The accurate ageing of injuries, speciﬁcally bruises, is one of the most contentious areas of forensic medicine, and medical witnesses should be particularly careful in attempting to offer any opinion on the age of a bruise other than to say that it is recent or not recent. Bruises that are reddish-purple or purple-black in colour are almost certainly of recent origin, but occasionally recent deep bruises may be mistaken for an older, more superﬁcial lesion. Bruises resolve over a variable period ranging from days to weeks; the larger the bruise the longer it will take to disappear.6

Injury classiﬁcation and injury scoring

Some investigators advocate the use of an injury classification such as the TEARS system developed by Slaughter et al.7 and based on injury type (T ¼ tears E ¼ ecchymoses A ¼ abrasions R ¼ redness S ¼ swelling) or the Penn Injury Classification System, in which injuries are classified according to anatomical location and graded according to severity.8 Such classification and numeric scoring systems 110 J. Crane / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 103–111

Fig. 7. Streaky linear abrasions caused by a ligature applied. have little merit other than for comparison of data from different investigators. What is, however, crucial is the accurate description, measurement and recording of injuries, of whatever type in cases of alleged sexual assault and a sound opinion given as to how such injuries could have occurred.

Injury interpretation

Although the accurate description of an injury is of crucial importance, the interpretation of how the injury was, or might have been, caused may be particularly relevant in corroborating the victim’s version of events or refuting an allegation made by the assailant. Furthermore, the nature and multiplicity of such injuries may be important in any criminal proceedings as an indicator of the degree of violence used by the assailant. In many instances, the injuries may be of a non-speciﬁc nature, and it may only be possible to state, for example, that they were due to blunt force, such as by a blow or contact with a hard surface. In other cases, it may be possible to suggest possible mechanisms for how an injury may have been sustained or, if the victim states how an injury has occurred, it is entirely reasonable to conclude that the injury is, or is not, consistent with having occurred in the alleged manner.

Self-inﬂicted injuries

It is not unknown for false allegations of sexual assault to be made and with the ‘victim’ displaying injuries alleged to have occurred during the assault. Such injuries typically take the form of scratch- J. Crane / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 103–111 111 type linear abrasions and superﬁcial incisions. The wounds tend to be found in groups, with roughly parallel orientation on easily accessible areas of the body. Superﬁcial bruising is not usually associated with such injuries. The face, breasts, forearms and thighs are the most common sites. Also, the clothing may be deliberately torn, soiled or disarranged. The whole picture is incompatible with a real struggle or assault where a more random picture of injuries is to be expected.

Conclusion

All injuries, including those which might be regarded as trivial, must be accurately recorded and, preferably photographed with a suitable scale. Whilst many injuries e.g. bruises, are of a non-speciﬁc nature, they may nevertheless assist in corroborating a victim's statement of events. Consideration should also be given to a re-examination of a sexual assault victim since (i) bruises may change their size and appearance over time and (ii) bruising which was not apparent at the time of the initial examination may appear some time later.

Practice points

Non-genital injuries may provide corroborative evidence of sexual assault. A proper forensic classiﬁcation of injuries must be used. Suspected bite marks must be appropriately swabbed for recovery of DNA. Injuries may be self-inﬂicted in cases where false allegations of sexual assault are made.

Research agenda

Colour changes in bruising as an indicator of age of injury. Value of injury classiﬁcation and injury scoring.

References

1. Cartwright PS. Reported sexual assault in Nashville-Davidson County, Tennessee, 1980–1982. Am J Obstet Gynecol 1986; 154: 1064–1068. 2. Everett RB & Jimerson GK. The rape victim: a review of 117 consecutive cases. Obstet Gynecol 1977; 50: 88–90. 3. Soules MR, Stewart SK, Brown KM et al. The spectrum of allege rape. J Reprod Med 1978; 20: 33–39. *4. Crane J. Injury interpretation. In Stark MM (ed.). A physician’s guide to clinical forensic medicine. New Jersey: Humana Press, 2000, pp. 100–102. *5. Crane J. Injury. In McLay WDS (ed.). Clinical forensic medicine. Cambridge: Cambridge University Press, 2009, pp. 99–107. 6. Langlois NE & Gresham GA. The ageing of bruises: a review and study of the colour changes with time. Forensic Sci Int 1991; 50: 227–238. 7. Slaughter L, Brown CR, Crowley S et al. Patterns of genital injury in female sexual assault victims. Am J Obstet Gynaecol 1997; 176: 609–616. *8. Sommers MS, Brown KM, Buschur C et al. Injuries from intimate partner and sexual violence: signiﬁcance and classiﬁcation systems. J Leg Med 2012; 19: 250–263. Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 113–130

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10 Genital injuries in adults

Catherine White, MB ChB, MRCGP, FFFLM, FRCOG, DMJ, Clinical Director, St Mary’s Sexual Assault Referral Centre and Vice President Faculty of Forensic and Legal Medicine *

St Mary’s Sexual Assault Referral Centre, St Mary’s Hospital, York Place, Manchester M13 9WL, UK

Keywords: The examination of the rape victim should focus on the thera- ano-genital injuries peutic, forensic and psychological needs of the individual patient. rape One aspect will be an examination for ano-genital injuries. From anatomy a medical perspective, they tend to be minor and require little in the way of treatment. They must be considered when assessing the risk of blood-borne viruses and the need for prophylaxis. From a forensic perspective, an understanding of genital injury rates, type of injury, site and healing may assist the clinician to interpret the ﬁndings in the context of the allegations that have been made. There are many myths and misunderstandings about ano-genital injuries and rape. The clinician has a duty to dispel these. Ó 2012 Elsevier Ltd. All rights reserved.

Introduction

In this chapter, ano-genital injuries in the adult will be reviewed. In this instance ‘adult’ refers to physiological status rather than chronological age. After an allegation of sexual assault, a genital examination might be conducted for several reasons, not just for the detection or otherwise of injuries. It may be, for example, that recovering trace evidence, such as semen, saliva, blood, and lubricant (see chapter on ‘The forensic aspects of sexual violence’ by Mary Newton in this issue of Best Practice and Research Clinical Obstetrics and Gynaecology), may be recovered. Or, it might be as part of the process of providing emergency contraception by way of an intrauterine contraceptive device.

* Tel.: þ44 (0) 161 276 6515; Fax þ44 (0) 161 276 6028. E-mail address: [email protected].

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Why an examination for ano-genital injuries is important

The clinician conducting an examination of a patient (also referred to as victim, complainant or client, but for the purposes of this chapter, patient will be used) who has alleged sexual assault, or where sexual assault is suspected, will undertake a forensic and therapeutic role (Table 1).

The relationship between ano-genital injuries and the criminal justice process

The presence of ano-genital injuries, rightly or wrongly, has been shown to be a major contributing factor in the various decision-making points from a criminal justice perspective.2 One problem with this quest to find even the smallest genital injury to support an allegation is that it may then become a self-fulfilling prophecy. In other words, the situation may arise that the presence of injury leads to increased chance of report, trial and conviction, leading to a skewed evidence base. This skewed evidence base may suggest that injuries are seen in cases that result in conviction (i.e. ‘true allegations’), and those examinations that find no injury suggest the converse. An alternative path is to highlight cases where no ano-genital trauma is detected objectively (by whatever different examination techniques may be used), and yet rape and sexual assault has still been proven by other evidence. This injury evidence base should be used to educate the decision makers (be they victims, healthcare professionals, police, legal profession or members of the public who make up juries). This debate is highlighted by White and Du Mont.3 They raise concerns that micro-visualisation technologies may increase the chances of rape victims experiencing ‘secondary victimisation’, due, in part, to the highly intrusive and potentially humiliating nature of these technologies. They also argue that too much weight is given to the identification of injuries, and that ‘re-defining rape to require physical injury contradicts a growing body of research that shows that most rapes do not result in an injury other than rape itself.’ They argue that it encourages a departure from the historical definitions of rape and the trend in recent years to broaden the definition of rape to include coercion through mental incapacitation and psychological terror. McLean et al.4 looked at 500 allegations of penile vaginal rape and found that, in the cases where an outcome was known (335 cases), no significant associations were found between the presence of genital injury and criminal justice outcome, although the rate was (non-significantly) higher in the small proportion of cases where a conviction was obtained. It is widely appreciated that sexual violence is under-reported. If it is assumed that it occurs at the same rates within different societies (and this may be a huge assumption), a vast difference in reporting rates can be seen. Possibly victims are more likely to report an assault if they have injuries. It could be hypothesised that this is because they think their injuries may require treatment and also they perceive that their allegations are more likely to be believed if they have an injury. Additionally, it may be harder to keep the assault ‘secret’ if physical findings are present that may require explanation.

History taking relevant to the ano-genital examination

Several maxims are useful in any medical history taking, and are particularly true with the sexual assault victim:

Table 1 Examination of ano-genital injuries.

Therapeutic role Forensic role Injuries may require medical treatment Presence and pattern of injuries may support allegations. and possibly surgical repair. Presence of injuries is a factor to consider Absence of injury may refute allegations. when assessing the risk of contracting an infection.1 Psychological reassurance (either about The appearance of any injuries may assist in estimating the absence of injuries or the likely the time of the assault. sequelae of injuries that are present). C. White / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 113–130 115

‘If you interrogate a robin, he will fly away: treelike silence may bring him to your hand.’5 (p. 4). If you only ask questions, you will only receive answers in reply. A full discussion of the history taking for a sexual assault examination will not be covered in this section. Certain aspects, however, are particularly pertinent to the subsequent interpretation of any ano-genital findings. The history taking needs to be: (1) accurate; (2) contemporaneous; (3) comprehensive; (4) objective; (5) respectful and sensitive; (6) paced at the patient’s rate not the clinician’s rate; and (7) intelligent and tailored to the circumstances and to the findings. The history taker must be aware of the following such issues: (1) the legal scrutiny that may befall both the questions asked, and their answers, but also the questions not asked and therefore the answers not given. The clinician wears two hats, therapeutic and forensic; (2) in the complainant’s situation, they may be tired, in pain, and frightened, and this might affect recall; and (3) leading questions should be avoided. Communication needs to be precise, in the accuracy of the words used, and also a common understanding of their meaning. Awareness of how one’s language might be subsequently interpreted is important. An example is the possible confusion that can arise with the use of the word ‘denied’. Clinicians frequently use this term (e.g. ‘patient denies drinking alcohol before the assault’). Other clinicians will understand this as a straightforward question to which the patient has replied in the negative. Non-medics, however, such as police or lawyers, may interpret the use of ‘denied’ as meaning that in fact the doctor ‘suspected’ the patient had drunk alcohol even though he said he had not (i.e. its use is no longer neutral, but pejorative in nature). Particular aspects of the history that might relate to ano-genital findings include menarche; last menstrual period; whether the patient had been sexually active before the alleged assault (including details such as whether this was digital or penile)?; any sexual activity in the last 10 days; and hormonal status. This list is not intended to be exhaustive, and clinicians must tailor their questions on a case by case basis.

Anatomy and embryology

The clinician should have a good understanding of external and internal genital anatomy, including normal variations. This will aid accurate detection of genital injuries, description of their site, and enable the clinician to provide a differential diagnosis. An appreciation of embryology may assist in diagnosis when faced with unusual structural ﬁndings.

Embryology of the genitalia

At day 46 of gestation, a second paired-duct system, the paramesonephric (Müllerian) duct, forms parallel to the mesonephric duct. In male embryos, a cascade of gene activation causes the primitive gonad to become a testis, and the mesonephric duct forms the vas deferens; the paramesonephric duct regresses. In female embryos, the primitive gonad becomes the ovary, the mesonephric duct regresses and the paramesonephric duct forms the fallopian tubes, uterus and upper vagina6 (p. 64). The external genitalia develop from swellings on the ectodermal surface of the embryo (Table 2).7

Histology of female genitalia

Histology of the female genitalia is presented in Table 3.

Table 2 Genital system development.

Embryological origin Female Male Mid-line genital tubercle Clitoris Penis Para-medial genital fold Labia minora Penile urethra Paired lateral genital swellings Labia majora Scrotum 116 C. White / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 113–130

Table 3 Histology of the female genitalia.

Endocervix Simple columnar epithelium Ectocervix Stratified squamous epithelium Vagina Stratified squamous epithelium External genitalia Keritinised stratified squamous epithelium

Anatomy of female genitalia

The vulva is a term that encompasses all the external female genitalia: the mons pubis, the labia majora and minora, the clitoris, and the structures within the vestibule – the external urinary meatus, hymen and fossa navicularis (the furrow between the posterior hymen and the posterior fourchette). The mons pubis is a thickened pad of fat that cushions the pubic bones anteriorly. The labia majora are two folds of skin, covered by keritanised stratiﬁed squamous epithelium, with underlying adipose tissue. They have hair, apocrine sweat glands and sebaceous glands. The labia minora consist of two thin skin folds. They are not so keritanised as the labia majora. They have sebaceous and sweat glands, but no hair follicles or underlying adipose tissue. They are vascular and erectile during sexual arousal. Anteriorly, the folds bifurcate before uniting to form a hood above the clitoris and a frenulum along its dorsal surface. Posteriorly, the labia minora are joined by a ﬁne ridge of skin, the posterior fourchette.

The legal versus the medical vagina

That different medical and legal definitions of the vagina that exist may give rise to confusion and error between professionals involved in dealing with a rape allegation. The medical definition defines the vagina as a muscular tube that has the cervix at its proximal end and the hymen (or hymenal remnants) at the distal end. The legal definition according to s.79(9) of the Sexual Offences Act 2003, has the distal end of the vagina starting with the vulva (i.e. between the labia), with the result that, for legal purposes, penetration of the vagina does not have to involve penetration of the hymen.8

The ano-genital examination

Most women ﬁnd this examination sensitive and possibly intrusive. It is, therefore, incumbent on clinicians to make it as easy as possible and minimise any associated trauma. Clinicians can help in the following ways9: ensure privacy; prepare swabs and equipment before starting; be sensitive to the patient’s ideas and concerns; offer back power and control; and review consent at the start of this part of the examination. The clinician and chaperone should take the lead from the patient on the pace of the examination; who else is present in the room with the clinician and chaperone; where the chaperone is positioned (some patients prefer the chaperone to hold their hand and others to be away from the bed); the amount of conversation and even subject matter; and the extent of the examination.

Examination positions

Most adult female genital examinations will take place in the modiﬁed lithotomy position, with subsequent anal examination in the left lateral position.

Methods of examining

Injury rates in various published studies differ depending on what examination techniques were used. Some used only naked eye inspection; others used the magniﬁcation afforded by colposcopy. Others used toluidine dye with or without colposcopy. This variation means that care has to be given when comparing results of different papers. C. White / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 113–130 117

Toluidine dye Toluidine blue dye is an acidophilic, metachromatic, nucleic stain. It was ﬁrst described in 1963 by Richart10 as a method of highlighting cervical neoplasms. Since then, it has been used as part of the examination of the complainant of sexual violence. It stains the nuclei of damaged epithelial cells, helping distinguish acute injuries or breaks in the skin from non-injured areas. The surface layer of non-traumatised vulvar skin contains no nuclei. Trauma exposes deeper layers of the epidermis where squamae are nucleated and undergoing maturation. Note toluidine blue is spermicidal and therefore could interfere with other forensic tests. Positive stain results may also have causes other than trauma (e.g. any inﬂammatory cause as well as benign or malignant vulvovaginal disease).11

Colposcope The colposcope has several beneﬁts of providing a bright cool light source, magniﬁcation and the ability to obtain photodocumentation.

Foley catheter Use of a catheter balloon can be a helpful technique to demonstrate the hymenal edges of a post- pubertal female. In some post-pubertal females, particularly adolescents, the hymenal edge can be fimbriated, making it difficult to visualise the edge clearly. In order to assess for the presence or not of defects such as a transection, the edge needs to be ‘unfolded’. Passing a catheter into the vagina, inflating the balloon, then slowly withdrawing the catheter, allows the edges of the hymen to fan out over the balloon. This should cause minimal discomfort. Should the balloon ‘pop out’ during the process, a note should be made of the ease with which it did so, and the diameter of the expanded balloon. If something of, for example, 2.5 cm diameter, can pop out easily through the hymen, then it may logically follow that something of similar size could easily pass in through the hymen. If forensic samples are to be taken, then they should be done before the catheter examination. The Foley catheter should be used in post-pubertal females only and after forensic samples have been used. The diameter of the inflated balloon should be recorded9 (p. 58).

Speculum Plastic disposable speculae are suitable for the internal examination of the post-pubertal female. Ensure the appropriate size and correct lubrication is used.

Documenting ano-genital injuries

Several vital points should be considered when documenting any injury: separate out objective ﬁndings and subjective opinion; make clear, comprehensive, contemporaneous written descriptions; make line drawings using body maps if available; consider the beneﬁts or disadvantages of photo documentation; photo documentation of the ano-genital area will require consideration of different issues. These will be ‘highly sensitive images’ and consent must be gained beforehand. The consent process must cover issues such as use, storage, security, ownership and disclosure of these images. For guidance, see the ‘Ethical guidance’ section of the GMC website: ‘Making and using visual and audio recordings of patients.’12 The Faculty of Forensic and Legal Medicine have also produced guidance on the management of such images.13

Face of a clock when documenting ano-genital ﬁndings

The face of a clock is useful to aid description of the site of any ﬁnding. For example, with the patient lying in the supine position (i.e. on their back), the uppermost part of the hymen, nearest the abdomen, would be 12 o’clock, the part nearest the bed would be 6 o’clock etc.

Differential diagnosis of ano-genital ﬁndings

It is important that the forensic clinician is able to formulate a differential diagnosis for any ﬁndings encountered, from a therapeutic perspective and also from a forensic perspective. 118 C. White / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 113–130

Are the genital findings evidence of trauma resulting from the alleged assault or could there be another explanation? Is there an underlying medical problem that would mean that the patient is more prone to show signs of trauma? Examples of conditions that might be confused with injury include the following: allergy; eczema; psoriasis; Lichen sclerosis; infection (e.g. candida); atrophic vaginitis; urethral prolapse; inflammatory bowel disease; and normal anatomical variations. The clinician, upon noting findings where trauma is not the only possible explanation, must be prepared to revisit the history-taking to put the findings into context.

Identiﬁcation of the source of blood: menstrual blood versus blood secondary to trauma

When blood is seen during the genital examination of a complainant of sexual violence, one must consider the differential diagnosis. For example, the blood could either be menstrual in origin or from peripheral blood vessels secondary to trauma. Sometimes, a bleeding point can be identiﬁed, but often this is not the case. Recent research has made progress in producing a method to distinguish menstrual blood from normal circulatory blood reliably using D-dimer assays.14

Healing of genital injuries

Healing of genital injuries is important to consider from a therapeutic and forensic perspective. For example, the clinician may be asked to consider how old a genital injury is, as this may help determine whether it is a result of previous consensual intercourse or a later alleged assault. In some abuse cases, the age of an injury might assist in determining who had access to the victim during the speciﬁed time frame. As well as knowing the evidence base for the time-frames for retrieval of forensic samples, knowledge of injury healing may assist in deciding whether or not to undertake an examination. Each case should be decided on their own merits depending upon the nature of the allegations. Wound healing can be divided into a series of stages as detailed below.15

Immediate reactions

Immediate reactions include vasoconstriction, activation of clotting, platelets and endothelial cells, haemostasis, and clot formation. A fibrin clot forms and fills the gap created by the wound. Fibronectin in the extravasated plasma is cross-linked to fibrin, collagen and other extracellular matrix components by the action of trans- glutaminases. This cross-linking provides a provisional mechanical stabilisation of the wound (0–4 h).

Inﬂammation

Inﬂammation occurs within hours of the injury, and its effect can last for 5–7 days. This phase is characterised by erythema, possibly swelling, slight local increase in temperature and possibly pain.

Proliferation: reconstruction, granulation

In ideal conditions, wound epithelialisation may occur within 48–72 h.

Maturation: remodelling

Wound healing is not a linear process. Intrinsic and extrinsic factors particular for each patient may affect healing, and wounds can progress forwards and back through the different phases. Therefore, consideration must be given to factors such as age, general health, infection, medication, nutritional status, and continence. Kissane,16 quoted by McCann et al.,17 says that the most superficial injuries are known to have their surface recovered with new epithelium at a rate of 1 mm per 24 h. Regeneration of the tissue of deeper injuries is usually well under way in 48–72 h, whereas multiplication and differentiation of cells takes C. White / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 113–130 119 from 5–7 days. Complete restoration of the tissues requires 4–6 weeks. The maturation of scar tissue may take from 60–180 days or longer. Maguire et al.18 looked at women complaining of sexual violence, and found that women examined within 72 h of assault had significantly more injury than those examined after 72 h (40% v 7%, OR 3.70, 95% CI 1.05 to 13.09; P < 0.05). Anderson et al.19 looked at how injury patterns change between the initial pelvic examination (within 48 h of consensual intercourse) and then a second examination 24 h after the first. Thirty-five women aged between 18 and 39 years, completed both examinations. The difference in surface area of abrasions and redness, and also posterior fourchette injuries, were significant between the two examinations. No difference was found in surface area between ‘tears, ecchymosis or swelling’. The actual number of lesions seen in this study was not reported. Astrup et al.20 published a study on injuries after consensual intercourse, and found that median survival time for lesions was 24 h using the naked eye, 40 h using the colposcope and 80 h using toluidine blue dye.

The evidence base for genital injuries after sexual violence

A difficulty in conducting a review of scientific papers looking at genital injury rates is the lack of standardisation. Some papers use the TEARS classification as proposed by Slaughter and Brown21 to document injuries: T ¼ tears, defined as any break in tissue (skin or mucosal membranes) integrity including fissures, cracks, lacerations cuts, gashes or rips; E ¼ ecchymosis, defined as skin or mucous membrane discolouration caused by damage of small blood vessels causing ‘bruising’ or black or blue areas; A ¼ Abrasions (excoriations), defined as the removal of the epidermis from skin or mucous membranes; R ¼ Redness, the descriptor for erythematous tissues that are abnormally inflamed as a result of irritation; and S ¼ swelling, defined as local oedema or transient engorgement of tissues. Many studies, however, exclude erythema and swelling when calculating injury rates, as it is felt that these findings are too subjective. These studies tend to have lower injury rates than those using the TEARS system, making comparison difficult. Many papers do not stipulate the time from assault to examination or they have a very wide window for such. Given that genital injuries tend to heal quickly, this makes comparison of injury rates difficult. Many of the US studies involve the use of nucleic staining and colposcopy allowing the examiner to identify, and therefore include in the figures, cases involving microtrauma. Nucleic staining is not practised in the UK and, rightly or wrongly, colposcopy is not used routinely for adult cases. Hence, another factor when comparing injury rates between studies. Sommers22 makes an argument for the development of a multi-dimensional model when evaluating genital injuries. This would include prevalence, frequency, location, severity and type, and would allow comparison for different studies across consensual and non-consensual populations.

Genital injuries after consensual sexual intercourse

In order to interpret the significance of genital injuries after sexual assault, we need to understand genital injuries with consensual intercourse. On the whole, the evidence base for this area is lacking. Anderson and Sheridan23 reviewed papers that had looked at rates of injury after consensual intercourse, and concluded that too many variables existed between the studies to make comparisons (e.g. subject samples, methodologies, time to examination). It was felt that ‘the presence of even slight genital injuries supported a finding of penetration. The presence or absence of injury, however, cannot be used to determine consensual compared with non-consensual intercourse’. As mentioned previously, the study by Astrup et al.20 looked at the detection rates of genital injuries after consensual intercourse using three different techniques: visualisation with the naked eye, colposcopy and toluidine blue dye followed by colposcopy. Injuries included were abrasions, lacerations or bruises (i.e. not the more subjective findings such as swelling or redness). Ninety-eight women took part. Lacerations were the most prominent lesion. Injuries were predominantly located around the posterior fourchette, the rest in the labia and hymen. No lesions were seen in the vaginal wall or cervix. Seen with the naked eye, 31% of the women had a laceration and 34% had a lesion of any kind. When a colposcope 120 C. White / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 113–130 was used, 42% had a laceration and 49% had a lesion of any kind. With the use of toluidine blue dye, 50% had a laceration and 52% had a lesion of any kind. Abrasions were seen in 2%, 5% and 7%, respectively. Frioux et al.24 described four cases involving vaginal lacerations in adolescents, three of whom gave a history of consensual penile vaginal intercourse. The fourth alleged non-consensual intercourse. Normally, the cervix tends to shield the posterior pericervical vaginal area during intercourse. A retroverted uterus or sexual intercourse with the female supine with hips hyper-flexed, however, tend to expose this area to trauma.25 McLean et al.4 compared genital injury rates between consensual and non-consensual penile vaginal intercourse. Sixty-eight women, all aged over 18 years, were examined within 48 h of having had consensual penile vaginal intercourse. Four out of 68 women had (naked eye examination alone) a genital injury (erythema or swelling not included as injuries). In total, among these four women, only six injuries were sustained. Four of these six injuries were bruises. The injuries in the control group tended to be smaller (no exact sizes given) than those where non-consensual intercourse was alleged.

Genital injury rates after sexual assault

Eckert et al.26 looked at injury rates. The study found that the more experience and training the doctors had, the lower the rate of genital injuries detected (19% for most experienced, 30% for least experienced residents). Gender of the examiner did not affect injury rate detection. The examiners used in this study were either second- or third-year residents in Obstetrics and Gynaecology. They received standardised 2-h training specifically for sexual assault at the beginning of each rotation. This is different to the level of training recommended by the Faculty of Forensic and Legal Medicine.27 Hilden et al.28 looked at injury rates (injuries found in 32% of 249 women alleging sexual assault and examined within 72 h, not including erythema and swelling). They also looked at what factors might affect injury rates. Most were single-site injuries. The type of injury was typically a tear ranging from 2– 25 mm. None of the injuries were severe enough to require surgical repair. McLean et al.4 found that 22.8% of 500 women examined within 48 h of alleged non-consensual penile vaginal sex by one assailant had evidence of at least one genital injury. This study did not include erythema or swelling in the figures, as it was felt that these were too subjective. All examinations were by naked eye alone, without colposcopy or use of nuclear staining. They compared this figure with the 6% of the control group who had engaged in consensual sexual intercourse within 48 h of examination. From this they concluded that ‘neither the presence nor absence of injury can be used to establish the veracity of a rape allegation. However, at the population level, non-consensual intercourse is more likely to cause genital injuries than consensual intercourse.’4

Site of genital injury

Hilden et al.28 reported that, in 249 women alleging sexual assault within 72 h of the examination, the most frequent sites of injury were the posterior fourchette, anal or perianal area or the vestibulum. Jones et al.29 found that common sites of injury were posterior, including fossa navicularis, hymen, fourchette and labia minora. A retrospective review by Morgan et al.30 of postmenopausal women also found that genital injuries in this group were more likely to occur at the fourchette, vestibule, labia minora and fossa navicularis. In a study4 looking at 500 women who were examined within 48 h of an allegation of non- consensual penile vaginal intercourse, 22.8% (95% CI 19 to 27%) had a genital injury. Erythema and oedema were not counted as injuries in this study, and the examinations were naked eye only, no dye or colposcope. Forty-three per cent of these injuries were lacerations, with the posterior fourchette being the site most often injured. The second most frequent site for injury was the labia minora. In this site, abrasions were the injury most often seen It is thought that these figures reflect that most ano- genital injuries tend to be caused by actual or attempted entry, with actual or attempted insertion of the penis into the vagina. The anatomy of this site is such that the muscular attachment of the posterior aspect of the introitus to the perineal body results in it being less able to withstand the force of entry, therefore leading to injury. The perineal body is a tough fibromuscular nodule in front of the anorectal junction. A number of perineal muscles are inserted into the perineal body. C. White / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 113–130 121

Digital vaginal penetration

Rossman et al.,31 in a retrospective study, looked at 53 females (average age not stated but the study included patients aged 13 years or over) where forced digital penetration alone was the basis of the sexual assault (i.e. no penile or object vaginal penetration). Eighty-one per cent (43 of the 53) were reported to have an injury when examined using colposcopy and nuclear staining. The study included erythema as an injury, and indeed this was the most frequently noted injury type at 34% followed by lacerations (29%), abrasions (21%), ecchymosis (11%) and oedema (5%). The investigators reported that the fossa navicularis and labia minora were the most frequently injured sites. They point out that 58% of the patients had been exposed to alcohol or other drugs during the time of assault, and therefore note that the history of digital vaginal penetration as the sole mechanism of injury could be suspect in some of the cases. An audit by Evison32 looked at 47 cases of sexual assault that involved only digital–vaginal penetration. The injury rate here was found to be 29% (erythema was not included nor was nuclear staining used). As with other studies, the posterior fourchette, fossa navicularis and labia minora, were the sites most likely to be injured. In this audit, abrasions were reported to be the most frequent type of injury.

Vaginal penetration by object

Vaginal lacerations have been noted after consensual vaginal intercourse. Although most vaginal lacerations are associated with penile penetration, they have also been seen after brachiovaginal intercourse (‘ﬁsting’), vaginal instrumentation during medical procedures, and the use of plastic tampon inserters33 (p. 96).

Degree of force

When an injury is found, the clinician may be asked to consider what degree of force might have been required to cause it. This may arise where the defence is arguing that the injury was the accidental consequence of consensual activity, whereas the prosecution assert it is proof of lack of consent. Again the evidence base in this area is poor so clinicians should tread carefully when proffering an opinion. The basic equation of ‘force ¼ mass acceleration’ might be considered too simplistic when considering the possible variables involved in any given sexual encounter (e.g. lubrication, position, tissue friability, and body jewellery). The opining clinician might care to reﬂect on the dangers of straying from the known evidence base and relying too heavily on experience and anecdote.34 Hilden et al.28 reported that, when comparing women exposed to anal penetration (with or without vaginal penetration) with women exposed to vaginal penetration only, anal penetration remained signiﬁcantly associated with an increased risk of ano-genital injury compared with vaginal penetration only. Hilden et al.28 also found that severe violence reported by the assaulted women was not associated with increased ano-genital injuries.

Victim factors and genital injuries

Age of victim

The injury rates in post-menopausal women seem to be debatable. Hilden et al.28 reported that age was signiﬁcantly related to the occurrence of ano-genital injury. Women under 19 years and over 50 years had the highest risk. Poulos and Sheridan35 published a literature review examining what was known about postmenopausal women and genital injuries. Of the seven research studies found, they concluded that most studies determined that postmenopausal women were more likely to sustain genital injury after sexual assault than younger women. No studies were found that speciﬁcally investigated genital injuries as a result of consensual intercourse compared with sexual assault. 122 C. White / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 113–130

McLean et al.4 found no difference in injury rates between pre- and post-menopausal women (P ¼ 0.29), although reported numbers in the postmenopausal group were small (29 out of the 500 women). Ramin et al.,36 however, compared injury rates between 129 pre-menopausal and 129 postmenopausal women, and found that the latter were more likely to sustain an injury. Morgan et al.30 conducted a retrospective review of sexual assault of 122 post-menopausal women and compared the results with 130 pre-menopausal women. The two groups had mean ages of 60.52 and 27.36 years, respectively. Most were examined within 48 h of assault (88% of postmenopausal and 81% of pre-menopausal). The two groups combined had a genital injury rate of 26%, with 37% of postmenopausal women and 17% of pre-menopausal women having genital injuries. This difference did not reach statistical signiﬁcance. Erythema and swelling were not included in their ﬁgures, and the investigators wondered if this may account for the difference between their results and that of other studies. Of those who had a genital injury, the mean number of injuries was higher in the postmenopausal group (2.49) than in the premenopausal group (1.69). They also found that, in postmenopausal women, there was a higher rate of verbal threats and a higher presence and use of weapons. It was not felt, however, that this alone accounted for the higher rate of genital injuries. Sommers et al.37 found no difference in injury rates between the pre- and post-menopausal women. Mosqueda et al.38 looked at accidental bruising. The study followed 101 adults, aged over 65 years (average was 83 years), who were examined daily to document the occurrence, progression and resolution of accidental bruises over a 6-week period. Nearly 90% of bruises were on the extremities. No bruises were seen on the neck, ears, genitalia, buttocks or soles of the feet.

Hormonal contraceptives and parity

McLean et al.4 found no link between genital injury rate and parity. Maguire et al.18 reported that women using hormonal contraception had less genital injury, although this ﬁnding was not statistically signiﬁcant. Nulliparity was also not related to an increased risk of genital injury.

Previous sexual experience

Hilden et al.28 found that women who had not previously been sexually active were more likely to sustain ano-genital injuries than those with previous experience (69.7% v 25%). Hwa et al.39 found that age (less than 18 years of age) and virginal status of the victim was signiﬁcantly associated with ano- genital injuries. White and McLean40 looked at injury patterns in virgin and non-virgin adolescent complainants of sexual violence. They compared 81 adolescents who stated that, before the vaginal rape, they had been virgins, with 97 who stated that they had been sexually active before the rape. The virgin group took longer to present (average of 90 h compared with 44 h). Fifty-one per cent of all the adolescents had a non-genital injury, most of which were minor. Thirty-two per cent of the non-virgin group had a genital injury. In the virgin group, 53% had a genital injury; however, only 32% had the type of injury that would leave permanent evidence of penetration (i.e. if examined several weeks or more later). The investigators concluded that genital or body injuries are not routinely found in adolescents after an allegation of rape or sexual assault, even when there has been no previous sexual experience. The absence of injury does not exclude the possibility of intercourse, whether it is with or without consent.

Alcohol

Hilden et al.28 found that more than one-half of the sexually assaulted women in their study were inﬂuenced by alcohol. Where the amount of alcohol drunk was enough to induce amnesia, then the ano-genital injury rate was reduced. One possible explanation for this is that there is less resistance by the victim. Maguire et al.18 reported that body injury in sexual violence, although usually minor, was more prevalent in women under 30 years and strongly associated with alcohol consumption before assault. They concluded that alcohol use had no effect on the frequency of genital injury. C. White / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 113–130 123

Ethnicity of victim

McLean et al.4 found no link between ethnicity and genital injury rate in a study of 500 women alleging penile vaginal rape (P ¼ 0.83). Of these 500 women, 93% were white, 3% black, 2% Asian and 2% other. Sommers et al.37 found a significant association between race (black versus white) and genital injury (adjusted odds ratio ¼ 4.30, 95% CI ¼ 1.09 to 25.98; P ¼ 0.03), and indicated that white people were more than four times as likely as black people to have genital injury identified. The investigators speculate on the reasons for this. One explanation is that injuries in less pigmented skin are easier to see. If this is the case, then they point out that this may put darker- skinned women at a disadvantage, as their injuries will be less likely to be identified and therefore treated. It may also then have a negative influence on the criminal justice process. They also offer, as a possible explanation, the theory that certain types of skin are more susceptible to injury or that there was a bias among the examiners (although they note that the group of examiners was multi-racial).

Assailant factors and genital injury

In one study of 569 female victims of sexual violence,41 over 8% of the male assailants were noted by the complainants to have experienced erectile impotence during the assault. This group of men were noted to be older, more likely to have a weapon, and use physical coercion compared with the women whose assailants did not have a problem with erectile dysfunction. This increased level of physical coercion resulted in the victims in this group having more non-genital trauma than the group of victims whose assailants did not have erectile dysfunction (72% v 46% respectively, P < 0.001). No statistical difference were found in rates of ano-genital injuries between the two groups of victims. In both the groups, the common genital injury sites were posterior (e.g. fourchette, fossa navicularis, hymen and labia minora).

Assailant known to victim

Hilden et al.28 found that assaults by strangers were less likely to cause ano-genital injury, but this was not statistically significant. Cartwright42 found that whether the assailant was a stranger or someone known to the victim made no difference in genital injury rates. A retrospective study by Jones et al.29 looked at 849 females (age range 13–82 years, mean 22.5 years) who presented as victims of sexual assault during a 40-month period. Seventy-two per cent knew their assailants. Strangers used more physical coercion and weapons than known assailants, resulting in a greater number of non-genital injuries. No statistical difference were found, however, in rates of ano-genital injuries between the stranger and acquaintance groups. They did find that the stranger assaults tended to have more anal injuries and fewer injuries to the hymen. Maguire et al.18 found that, among 153 complainants of sexual violence, genital injury was associated with acquaintance assault (48% v 29%, OR 2.33, 95% CI 1.19 to 4.57; P < 0.05). McLean et al.4 found that, if a woman’s assailant was known to her, then there was a statistically significant higher change of her sustaining an injury (91 out of 355 [26%]) compared with women who did not know their assailant (23 out of 145 [16%]; P ¼ 0.019).

Lack of injury: signiﬁcance

From a review of the above cited studies, it can be seen that not all alleged sexual assaults result in genital injury. Absence of injury on ano-genital examination of a complainant of sexual violence could have several possible explanations. As in any other area of medicine, the forensic clinician’s duty will be to consider the differential diagnoses and gather and then assess the evidence available supporting or refuting each option. Ultimately, it will be for others, for example a jury, to determine. 124 C. White / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 113–130

Case study

A 32-year-old woman makes an allegation that her ex-partner has vaginally raped her 3 days ago. On examination no injuries are found. Some of the possible explanations for this are, in no order of likelihood: (1) the allegation is false and no intercourse took place; (2) the allegation is false, intercourse took place, but with consent; (3) the allegation is true, the rape occurred but caused no injury; (4) the allegation is true, the rape took place causing only minor injuries, which have healed in the interim; and (5) the allegation is true, minor injuries were inﬂicted, which the examining doctor has not appreciated.

Infections and ano-genital ﬁndings

Knowledge about infections is important for several reasons. First, it is important in determining whether an examination ﬁnding is caused by trauma or a manifestation of infection. For example erythema of the introitus could be secondary to a candidal infection. Abrasions noted at the examination could be a result of scratching caused by pruritus secondary to infection. Infected tissue may be more friable and therefore more likely to be injured during sexual activity. Infected tissue tends to heal more slowly than healthy tissue, and this should be taken into account when trying to estimate the age of a genital injury. Presence of genital injury may increase the risk of contracting an infection (e.g. blood-borne infections such as human immunodeﬁciency virus or hepatitis B.1

Non-genital body injuries

Care must be taken in assessing the complainant of sexual violence not to restrict the examination to the ano-genital area. Numerous studies4,18 have shown that there is much more chance of ﬁnding an injury on the body surfaces than the ano-genital area.

Female genital mutilation

Female genital mutilation (FGM) is defined by the World Health Organization as ‘all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons. It is also sometimes referred to as female circumcision or female cutting. The World Health Organization has classified FGM into four types. It tends to be practised by specific ethnic groups, particularly within some African countries, although not confined to these areas. With population movement, FGM is being practised outside of these countries. It is estimated that 6500 girls are at risk of FGM within the UK every year, that 100–140 million African women have undergone FGM worldwide and, each year, and a further 3 million girls are estimated to be at risk of the practice in Africa alone. The practice of FGM has long cultural roots. It is considered to be an abuse of human rights and a child protection issue,43 and is outlawed in many countries.44,45 Its relevance to the clinician is in being aware of it, appreciating what it may look like, and also the possible short- and long-term health consequences, including infection, haemorrhage, vesico-vaginal fistulae, complications in pregnancy and labour (Table 4).

Virginity testing

In some countries, the practice of ‘virginity testing’ of women, who are not the victims of sexual assault, still continues. This has been condemned on scientiﬁc grounds as well as from a human rights perspective.46

Male genital injuries

Reported male sexual assaults are much less common than female (see Chapter ‘The male victim of sexual assault’ by Iain McLean in this issue of Best Practice and Research Clinical Obstetrics and C. White / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 113–130 125

Table 4 World Health Organization classiﬁcation of female genital mutilation.

Type I Involves excision of prepuce with or without excision of part or all of the clitoris. Type II Excision of the prepuce and clitoris together with partial or total excision of labia minora. Type III Excision of part or all of external genitalia and stitching or narrowing of the vaginal opening, also known as inﬁbulations. This is the most extreme form and constitutes 15% of all cases. Type IV Includes pricking, piercing or incision of the clitoris, labia, or both: stretching of the clitoris and the labia: cauterisation or burning of the clitoris and surrounding tissues, scraping of the vaginal oriﬁce or cutting (Gishiri cuts) of the vagina and introduction of corrosive substances or herbs into the vagina.

Gynaecology). Few data have been published on genital injury rates. A South African study47 reported that, although 32.4% of female survivors had genital injuries, 43.9% of males had genital or anal injuries. Unfortunately, the paper does not give a breakdown between the genital and anal injuries. McLean et al.48 in their study of 228 men, found that 3.1% were reported to have a genital injury at the time of examination. Norredam et al.49 reviewed 20 cases of male survivors of sexual trauma. They reported that these men presented with chronic genital and erectile pain, lower urinary tract symptoms and sexual dysfunction. Fracture of the penis is an injury associated with sexual activity (usually sexual intercourse but can happen with masturbation). It is caused by the rupture of the tunica albuginea of the corpus cav- ernosum, usually as a result of the abrupt bending of the erect penis (Fig. 1). A review of the condition concluded that it was not a rare occurrence.50

Fig. 1. Male genitalia. 126 C. White / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 113–130

Other injuries may occur with sexual activity. One study by Mehta et al.,51 which was concerned with human immunodeﬁciency virus transmission, looked at the difference between self-reported penile coital injuries in circumcised and uncircumcised men aged 18–24 years old. In this study, self-reported penile coital injuries were deﬁned as penis feeling sore during sex, penis sustaining abrasions or cuts during sex or skin of the penis bleeding after sex. A total of 64.4% of men reported a coital injury of any description. Factors increasing the risk of injury, including being uncircumcised, older or having had multiple recent sex partners.

Anal injuries

Histology

The histology of anal injuries are presented in Table 5.

Anatomy

Normally, the mucosa of the anal margin is reddish brown. It is puckered by the contraction of the external anal sphincter. The anorectal ring is formed by the puborectalis (the innermost fibres of levator ani muscle) and the upper ends of the external and internal anal sphincters. The involuntary internal anal sphincter is the lowermost continuation of the inner, circular muscle layer of the rectum. The external anal sphincter has three parts: subcutaneous, superficial, and deep. The external anal sphincter is under voluntary control. The rectum begins as a continuation of the pelvic colon and ends inferiorly by passing through the pelvic floor to become the anal canal. It measures between 8 and 15 cm long. The anal canal is the most distal part of the large intestine. It lies distal to the rectum and finishes at the anal orifice (e.g. anus, anal verge). Pectinate line is also known as the dentate line.

Anal sexual activity

Agnew52 reviewed the anatomical, physiological and psychological aspects of anal masturbation. The view expressed is that these activities are more widespread than previously thought. Some of these activities are potentially hazardous, producing either internal physical damage or the introduction of pathogenic organisms. The frequency rates of anal assault during sexual violence it is unclear. Many victims ﬁnd it distressing to disclose this type of assault. In one study of 1076 people presenting after sexual assault, anal penetration occurred in 17% of cases.53

Anal stimulation and male sexual response

During a sexual assault, a male victim may develop an erection and even ejaculate. This sometimes leads to others (e.g. investigators) thinking that there could be a consensual element to the sexual

Table 5 The histology of anal injuries.

Perianal skin (Anatomical) anal canal Surgical anal canal Rectum Histology Keritanised, stratified Keritanised, stratified Cuboidal in transition Columnar squamous epithelium squamous epithelium zone then columnar epithelium above. Skin appendages Yes No No No (e.g. hair, sweat glands and sebaceous glands) Nerves Somatic, sensitive Somatic, sensitive Not sensitive to pain Not sensitive to pain to pain to pain Embryology Ectodermal anal pit Endodermal anal rectal canal C. White / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 113–130 127 activity. It can also be distressing for the victim. It should, however, be appreciated that erections and ejaculation are only partially under voluntary control, and can take place during times of extreme stress or duress. In a review of the literature, Bullock and Beckson54 reported that ejaculation is a spinal cord reflex with stimulatory and inhibitory influence from the brain. They reported that electro- ejaculation, a procedure in which an electrical stimulus is applied intra-rectally to obtain sperm samples from male mammals, takes advantage of this physiology.

Examination techniques

Ernst et al.55 carried out a study that looked at the examination techniques for 67 men who reported anal assault. Anoscopy was carried out routinely as well as gross examination. In addition, some of the men were also examined with a colposcope. They found that anoscopy was better at detecting anal trauma than colposcopy.

Anal and rectal injuries

Anal and rectal injuries have been discussed earlier in this chapter where some studies have described ano-genital ﬁndings together. Elam and Gail Ray,56 in their interesting review of sexually related trauma, subdivide anorectal trauma into ﬁve types: traumatic proctitis, non-perforating mucosal lacerations, disruptions of the anal sphincter, tetained foreign bodies, and transmural perforation of the rectosigmoid colon. Two of these are discussed below. Diagnosis of trans-anal rectal injuries may be delayed due to late presentation. Sexual assault should be suspected following rectal injuries.57

Traumatic proctitis Proctitis is inflammation of the rectum. The mucosal inflammation is associated with a burning sensation. Chronic inflammation may occur if the stimulation is repetitive or there is superimposed infection. One should always consider the differential diagnosis (e.g. inflammatory bowel disease, chlamydia, lymphogranuloma venereum).58

Non-perforating mucosal lacerations Non-perforating mucosal lacerations include anal lacerations without sphincter involvement as well as tears of the rectosigmoid mucosa.

Anal assault

Ernst et al.55 studied 67 men who had reported anal assault, and all the assaults involved male assailants. Only one of the assaults involved a female in addition to male assailants. Many did not seek care until more than 24 h after the assault. History of rectal pain was reported in 40 (60%) men, and a history of rectal bleeding in 12 (18%) men. Positive findings were found in some of those without a history of pain or bleeding, as well as those with a history of such. None of the 67 men had gross active bleeding on examination. Sixty-three per cent had at least one anal finding. This study included erythema, tears, abrasions, bleeding, haematoma, discoloration with tenderness, fissures, foreign bodies (i.e. dirt, vegetation or hair), engorgement, and friability as positive findings. In a study looking at the aetiopathogenesis of chronic anal fissures in adults,59 sexual abuse was a factor in a significant number of the cases.

Foreign bodies

One study60 looked at the incidence of injuries related to sexual stimulation devices among US adults between 1995 and 2006. It concluded that these injuries may become more common and disproportionally affect older men. Numerous studies have reported fatalities as a result of trauma sustained from a foreign object as a result of either consensual or non-consensual sexual activity.61,62 A case study by Carey et al.63 described a 17- year old girl who presented 2 years after a sexual assault asking for a foreign body to be removed from her vagina. At surgery, a plastic bottle top was 128 C. White / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 113–130 found. It had eroded the posterior vaginal wall causing a rectovaginal ﬁstula in the upper right vaginal vault. The girl had been seen within hours of the sexual assault, but at the time gave only a history of digital vaginal penetration. It was, therefore, decided that a speculum or bimanual examination was not warranted. The case report discusses the pros and cons of routine speculum examinations for complainants of sexual assault. It stresses the beneﬁt of routine expert follow up and also of oppor- tunistic assessment of adolescents presenting to a clinician with other health concerns. Clinicians are warned to be aware of the frequent habit of the piecemeal disclosure of the details of a sexual assault.

Conclusion

The assessment of a rape victim should focus on the therapeutic, forensic and psychological needs of the patient. Identiﬁcation assessment and treatment of ano-genital injuries will be one aspect of this. There continues to be many myths and misunderstandings about the frequency and nature of ano- genital injuries and sexual violence. Knowledge of these will help the clinician to dispel these. This is an area of medicine where for a variety of reasons the evidence base is minimal and ongoing research is much needed.

Practice points

It is not the norm for victims of rape or sexual abuse to have body injuries or genital injuries. The clinician examining the victim undertakes a therapeutic as well as a forensic role. Care should be taken to give back power and control to the victim and not further ‘objectify’ him or her. When genital injuries in the female are sustained, they tend to be minor and at the posterior part of the vulva. The clinician must consider differential diagnoses objectively, based on the history and examination ﬁndings. Reporting rates are low for female victims of sexual violence and possibly even lower for male victims. Victims may present to clinicians with a variety of signs and symptoms, but no direct disclosure.

Research agenda

Rates of healing for ano-genital injuries. Injury rates, type and sites sustained with consensual sexual activity in different age groups and with different sexual practices. Injury rates, type and sites sustained with non-consensual sexual activity in different age groups and with different sexual practices. Effect of penile size on injury rates. Effect of duration of sexual activity of injury rates. Effect of ethnicity on injury rates. Male rape.

References

*1. Benn P, Fisher M, Kulasegaram R et al. UK guideline for the use of post-exposure prophylaxis for HIV following sexual exposure. Int J STD AIDS 2011; 22: 695–708. 2. Sommers MS, Fisher BS & Karjane HM. Using colposcopy in the rape exam: health care, forensic, and criminal justice issues. J Forensic Nurs 2005; 1: 28–35. 3. White D & Du Mont J. Visualizing sexual assault: an exploration of the use of optical technologies in the medico-legal context. Soc Sci Med 2009; 68: 1–8. C. White / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 113–130 129

*4. McLean I, Roberts SA, White C et al. Female genital injuries resulting from consensual and non-consensual vaginal intercourse. Forensic Sci Int 2011; 204: 27–33. 5. Longmore M, Wilkinson I, Davidson E et al. Oxford handbook of clinical medicine. 8th ed. Oxford: Oxford University Press, 2010. 6. Magowan BA & Drife J. Clinical obstetrics and gynaecology. Philadelphia: WB Saunders, 2004. 7. Universities of Fribourg and Lausanne et Berne. Human Embryology Module 21.5 The external genitalia; http://www. embryology.ch/anglais/ugenital/genitexterne01.html [last accessed 15.08.12]. 8. Rook P & Ward R. Rook and Ward on sexual offences: law and practice. 4th ed. (Section 22.22). London: Sweet and Maxwell, 2010. 9. White C. Sexual assault: a forensic physician’s practice guide. Manchester: St Mary’s Sexual Assault Referral Centre, 2010. 10. Richart RM. A clinical staining test for the in vivo delineation of dysplasia and carcinoma in situ. Am J Obstet Gynecol 1963; 86: 703. 11. Lauber AAMD & Souma MLMD. Use of toluidine blue for documentation of traumatic intercourse. Obstet Gynecol 1982; 60: 644–648. 12. General Medical Council. Ethical guidance: making and using visual and audio recordings of patients. London: GMC, www. gmc-uk.org/recordings. *13. The Faculty of Forensic and Legal Medicine. Guidance for best practice for the management of intimate images that may become evidence in court. The Faculty of Forensic and Legal Medicine 2010, www.fflm.ac.uk [last accessed 15.08.12]. 14. Baker DJ, Grimes EA & Hopwood AJ. D-dimer assays for the identification of menstrual blood. Forensic Sc Int 2011; 212: 210–214. 15. Sephel GC & Woodward SC. Repair, regeneration and fibrosis. In Rubin R & Strayer D (eds.). Rubin’s pathology: clinico- pathologic foundations of medicine. 5th ed. London: Lippincott, Williams and Wilkins, 2007, pp. 71–98. 16. Kissane J. Inflammation and healing. In Kissane J (ed.). Anderson’s pathology. St Louis, MO: Mosby, 1985, pp. 47–53. 17. McCann J, Miyamoto S, Boyle C et al. Healing of nonhymenal genital injuries in prepubertal and adolescent girls: a descriptive study. Pediatrics 2007; 120: 1000–1011. 18. Maguire W, Goodall E & Moore T. Injury in adult female sexual assault complainants and related factors. Eur J Obstet Gynecol Reprod Biol 2009; 142: 149–153. 19. Anderson SL, Parker BJ & Bourguignon CM. Changes in genital injury patterns over time in women after consensual intercourse. J Forensic Leg Med 2008; 15: 306–311. 20. Astrup BS, Ravn P, Lauritsen J et al. Nature, frequency and duration of genital lesions after consensual sexual intercourse: implications for legal proceedings. Forensic Sci Int 2011; 219: 50–56. *21. Slaughter L & Brown C. Colposcopy to establish physical findings in rape victims. Am J Obstet Gynecol 1992; 166: 83–86. 22. Sommers MS. Defining patterns of genital injury from sexual assault. Trauma Violence Abuse 2007; 8: 270–280. 23. Anderson JC & Sheridan DJ. Female genital injury following consensual and nonconsensual sex: state of the science. J Emerg Nurs 2012 [e-pub ahead of print]. 24. Frioux SM, Blinman T & Christian CW. Vaginal lacerations from consensual intercourse in adolescents. Child Abuse Neglect 2011; 35: 69–73. 25. Hoffman RJM & Ganti SM. Vaginal laceration and perforation resulting from first coitus. Pediatr Emerg Care 2001; 17: 113–114. *26. Eckert LO, Sugar N & Fine D. Factors impacting injury documentation after sexual assault: role of examiner experience and gender. Am J Obstet Gynecol 2004; 190: 1739–1743. *27. Stark MM & Wall IF. Quality standards in forensic medicine: general gorensic (GFM) and sexual offence medicine (SOM). London: The Faculty of Forensic and Legal Medicine, http://fflm.ac.uk/upload/documents/1304601986.pdf27 [last accessed 15.08.12]. 28. Hilden M, Schei B & Sidenius K. Genitoanal injury in adult female victims of sexual assault. Forensic Sci Int 2005; 154: 200–205. *29. Jones JS, Wynn BN, Kroeze B et al. Comparison of sexual assaults by strangers versus known assailants in a community- based population. Am J Emerg Med 2004; 22: 454–459. 30. Morgan L, Dill A & Welch J. Sexual assault of postmenopausal women: a retrospective review. BJOG 2011; 118: 832–843. 31. Rossman L, Jones JS, Dunnuck C et al. Genital trauma associated with forced digital penetration. Am J Emerg Med 2004; 22: 101–104. 32. Evison M. Faculty of Forensic and Legal Medicine Annual Conference; 3rd–6th June 2008; Tudor Park Hotel, Maidstone, Kent, 2008. *33. Stark M. Clinical forensic medicine: a physician’s guide. 2nd ed. New Jersey: Humana Press, 2005. 34. Rudin B & Inman K. The experience fallacy. California Association of Criminalists, 2010, www.cacnews.org. 35. Poulos CA & Sheridan DJ. Genital injuries in postmenopausal women after sexual assault. J Elder Abuse Neglect 2008; 20: 323–335. 36. Ramin S, Sati A, Stone I et al. Sexual assault in postmenopausal women. Obstet Gynecol 1992; 80: 860–864. *37. Sommers MS, Zink T, Baker RB et al. The effects of age and ethnicity on physical injury from rape. J Obstet Gynecol Neonat Nurs 2006; 35: 199–207. *38. Mosqueda L, Burnight K & Liao S. The life cycle of bruises in older adults. J Am Geriatr Soc 2005; 53: 1339–1343. 39. Hwa H-L, Chen S-C, Wu M-Z et al. Analysis of cases of sexual assault presenting at a medical center in Taipei. Taiwan J Obstet Gynecol 2010; 49: 165–169. 40. White C & McLean I. Adolescent complainants of sexual assault: injury patterns in virgin and non-virgin groups. J Clin Forensic Med 2006; 13: 172–180. 41. Jones JS, Rossman L, Wynn BN et al. Assailants’ sexual dysfunction during rape: prevalence and relationship to genital trauma in female victims. J Emerg Med 2010; 38: 529–535. 42. Cartwright PS. The Sexual Assault Study Group. Factors that correlate with injury sustained by survivors of sexual assault. Obstet Gynecol 1987; 70: 44–46. 43. Royal College of Obstetricians and Gynaecologists. Green Top Guideline Number 53: Female genital mutilation and its management. London: Royal College of Obstetricians and Gynaecologists. 130 C. White / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 113–130

44. UK Government. Female genital mutilation Act 2003. London: HMSO, 2003. p. 4. 45. Scottish Parliament. Prohibition of female genital mutilation (Scotland) Act 2005. Edinburgh: HMSO, 2005. p. 12. *46. Frank MW, Bauer HM, Arican N et al. Virginity examinations in Turkey: role of forensic physicians in controlling female sexuality. JAMA 1999; 282: 485–490. 47. Lammers K, Martin L, Andrews D et al. Reported rapes at a hospital rape centre: demographic and clinical profiles. S Afr Med J 2010; 100: 362–363. 48. McLean I, Balding V & White C. Forensic aspects of male on male rape and sexual assault in Greater Manchester. Med Sci Law 2004; 44: 165–169. 49. Norredam M, Crosby S, Munarriz R et al. Urological complications of sexual trauma among male survivors of torture. Urology 2005; 65: 28–32. 50. Eke N. Fracture of the penis. Br J Surg 2002; 89: 555–565. 51. Mehta S, Krieger J, Agot K et al. Circumcision and reduced risk of self-reported penile coital injuries: results from a randomised controlled trial in Kisumu, Kenya. J Urol 2010; 184: 203–209. 52. Agnew J. Anal manipulation as a source of sexual pleasure. Venereology 2000; 13: 169–176. 53. Riggs N, Houry D, Long G et al. Analysis of 1076 cases of sexual assault. Ann Emerg Med 2000; 35: 358–362. 54. Bullock CM & Beckson M. Male victims of sexual assault: phenomenology, psychology, physiology. J Am Acad Psychiatr Law Online 2011; 39: 197–205. 55. Ernst AA, Green E, Ferguson MT et al. The utility of anoscopy and colposcopy in the evaluation of male sexual assault victims. Ann Emerg Med 2000; 36: 432–437. 56. Elam AL & Gail Ray V. Sexually related trauma: a review. Ann Emerg Med 1986; 15: 576–584. 57. El-Ashaal Y, Al-Olama A & Abu-Zidan F. Singapore Med J 2008; 49: 54–56. 58. Singhrao T, Higham E & French P. Lymphogranuloma venereum presenting as perianal ulceration: an emerging clinical presentation? Sex Transm Infect :2011; 87 123–124. 59. Nzimbala M, Bruyninx L, Pans A et al. Chronic anal fissure: common aetiopathogenesis, with special attention to sexual abuse. Acta Chirurgica Belgica 2009; 109: 720–726. 60. Griffin R & McGwin Jr. G. J Sex Marital Ther 2009; 35: 253–261. 61. Waraich N, Hudson J & Iftikhar S. Vibrator-induced fatal rectal perforation. NZMedJ2007; 120: U2685. 62. Orr C, Clark M, Hawley D et al. Fatal anorectal injuries: a series of four cases. J Forensic Sci 1995; 40: 219–221. 63. Carey R, Healy C & Elder DE. Foreign body sexual assault complicated by rectovaginal fistula. J Forensic Leg Med 2010; 17: 161–163. Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 131–139

Contents lists available at SciVerse ScienceDirect Best Practice & Research Clinical Obstetrics and Gynaecology

journal homepage: www.elsevier.com/locate/bpobgyn

11 Injuries in prepubertal and pubertal girls

Jean Price, MB.BS, DObs RCOG, DPH, DPM, FRCPCH, Community Paediatrician *

12, Woodview Close, Bassett, Southampton, Hampshire SO16 3PZ, UK

fi Keywords: In this chapter, examination techniques are rst recommended, sexual abuse and then terminology for genital injuries that may occur after child examination techniques sexual abuse or rape (e.g. lacerations, notch, transaction) are injuries in CSA described. Current evidence for these injuries is provided. Areas of controversy (e.g. hymenal diameter, hymenal width) are described and completed with cautionary notes on inflammation, bruising, abrasions, bumps and mounds, tags, labial fusion, lichen sclerosis). The chapter concludes with a debate on normal findings that are reported to occur in up to 99% of children referred for examination. Ó 2012 Published by Elsevier Ltd.

Introduction

When pre-pubertal girls complain of child sexual abuse, it is not unusual for the general public and indeed professionals to expect there to be obvious genital injuries. The fact is that it is much more usual for there to be little or no evidence of injury.1 Signs are subtle and require a careful history to be taken and a full examination to be carried out with the aid of photodocumentation (preferably a colposcope), with a DVD recording made of the examination.2 The doctor must have a good understanding of normal child development and genital anatomy2 (i.e. the normal anatomy, anatomical terminology and the various forms the hymen may take) (Fig. 1). A careful history should be taken and a detailed examination of pubertal girls alleging child sex abuse or rape should take place. Other consensual sexual activity needs to be noted. When was the last sexual intercourse and was this abusive or consensual? This helps with knowing when to take forensic samples (i.e. usually up to 5 days after the alleged event). Menstruation and type of protection used should be noted. Also, was protection (condoms) used during the sexual act? This is an important

* Tel.: þ44 0770 2088 365; Fax: þ44 02380 769 722. E-mail address: [email protected].

1521-6934/$ – see front matter Ó 2012 Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.bpobgyn.2012.08.008 132 J. Price / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 131–139

Fig. 1. Genital anatomy. consideration so that risk of pregnancy can be established and whether the ‘morning after pill’ needs to be provided. All children and young people should be considered for sexually transmitted infections and blood- borne infection screening.

Examination of pre-pubertal girls

Examinations of pre-pubertal girls should be carefully explained in language the child understands, and carried out at the child’s pace.

Supine position

It is usual to ﬁrst examine a pre-pubertal girl in the supine (frog leg) position. This can be with the child on the bed or for younger children on their mother’s lap (Fig. 2). Separation of the labia (by putting two ﬁngers on the labia majora and pressing downwards and laterally) will assist visualisation of the hymen, but if the hymen does not open, then traction may be used (take hold of the labia majora and pull outwards, downwards and laterally) (Fig. 3).

Prone position

The prone position (knee chest) should be used when there is anything unusual, or of concern, seen in the supine position. For this to be effective, the child lies on their front with their head and shoulder girdle ﬂat on the bed. The child’s knees are pulled up under their pelvic girdle so that the child’s bottom is in the air with their back assuming an ‘S’ shape. This allows gravity to pull on the pelvic musculature, which smoothes out any artefacts in the hymen that may have been seen in the supine position. To visualise the hymen, labial separation will need to be used and possibly labial traction, only this time J. Price / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 131–139 133

Fig. 2. Positions. a. Supine frog-leg position. b. Supine lap position. c. Prone knee chest position.

the labia majora will need to be pulled outwards, upwards and laterally (Fig. 3). Dripping warm sterile water or saline over the genitalia may also help to separate tissues that appear adhered together. If all else fails, and you need to check adherence of tissues or smooth out folds, then a small moistened swab (ENT) can be used to run around behind the margin of the hymen, or to tweek a possible tag or adhered tissue.

Examination of pubertal girls

Pubertal girls should also be examined in the supine, frog leg position. By now, oestrogen has made the hymen thick, ﬂeshy and folded. It will not automatically open to reveal the free margin of the hymen, and it is no longer appropriate to expect the young person to adopt the prone position. Other techniques become necessary, as it is essential to visualise the free margin of the hymen, including the area between the folds. In these young people, a moistened swab can be used (as the hymen has lost the sensitivity of the pre-pubertal girl) to run behind the hymen stretching out the folds to look for damage. Alternatively a foley Catheter (size 11) can be used (Fig. 4) 134 J. Price / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 131–139

Fig. 3. Examination techniques. a. Labial separation-supine position. b. Traction-supine position. c. Separation-knee chest position.

Injuries

When injuries are found, they need to be clearly described and the recommended terminology used3 (Table 1).

Fresh injuries: lacerations

Lacerations can be partial or full-thickness tears through the hymen. These injuries will bleed, have raw edges, and may have adjacent bruising, but they will heal remarkably quickly. Examinations should, therefore, be treated as urgent once a child makes an allegation. Hepenstall-Heger et al.4 reported lacerations in prepubertal girls in both penile and digital penetration, but none were found in those girls experiencing straddle injuries. Myhre et al.5 found no lacerations in non-abused 5- and 6-year-old girls. Adams et al.6 reported 6% hymenal tears in those alleging penile penetration and who were examined within 72 h. More were seen in self-reported virgins. Muram7 reported hymenal tears in two out of six pubertal girls where there is perpetrator confession. Palusci et al.8 examined girls alleging sexual abuse within 72 h, and found that 6% had tears greater than 50% of the width of the hymen. This was associated with forensic evidence. Lacerations can also be found in other genital tissues when a girl has been abused, particularly the fossa navicularis and the fourchette. The fourchette and other genital tissues can be injured as a consequence of a straddle injury. A clear history of such an accident is important in differentiating between the two diagnoses.4,6

Fig. 4. a. Catheter insertion. b. Catheter bulb inﬂated. J. Price / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 131–139 135

Table 1 The physical signs of sexual abuse.3

Depth of hymenal disruption Terminology to use with Terminology to use with acute (fresh) injury non-acute (healed) injury Partial (partway through width of hymen) Laceration Notch/concavity Complete to base of hymen Laceration Transection

It is important that when girls present with genital bleeding and are alleging abuse, that they receive an early examination preferably within 24 h. When lacerations are found on the genitalia, then sexual abuse should be strongly suspected provided there is no history of straddle injury.3

Healed injuries

Notch, cleft or concavity Healed injuries are smooth concave deficiencies found on the free margin of the hymen. There are no raw edges. They can be shallow (i.e. less than 50% depth of the hymen) or deep when they are more than 50% of the depth of the hymen. – Berenson et al.9 11 found shallow notches at any point around the hymen in newborn babies and Myhre and Heger also found them in children who were thought not to have been abused.5,12 Some lacerations can heal to leave a shallow notch.3,4 In pubertal girls, shallow notches are difficult to determine in view of the folded, fimbriated nature of the hymenal edge, which must be stretched out using a swab or foley catheter. Deep notches (more than 50%) have only been described in pre-pubertal girls alleging abuse and not in non-abused girls.10 Deep notches in adolescent girls alleging penile penetration have been found in 25%.13 Deep notches have also been found in girls having consensual intercourse and in a small number of girls denying intercourse.14 Deep notches more than 50% width of the hymen are more concerning, and penetrative injury should be considered.3

Transection Transection is a healed, full thickness loss of tissue through the hymen, with no raw edges. Berenson et al.10 found one case in her sexually abused group of pre-pubertal girls, and none in the non-abused group. Hepenstal–Heger et al.4 in her paper on healing, found 12 transections in girls alleging penile penetration, but also found them in four girls with straddle injury. Transections have not been found in non-abused groups of girls, with the exception of one girl whom the authors felt may have been abused.5,11 In the study by Palusci et al.8 of sexually abused girls under the age of 13 years, 3% with transections were reported, whereas in the adolescent group in the study by Adams and Knudson,13 17 transections were reported in the posterior border of the hymen. When a transaction is found, penetrative injury should be strongly suspected.3

Scars

Scars are rarely seen on the hymen and never seen in non-abused girls. Scars have been seen on the posterior fourchette after injury. Scars are clearly signs of previous trauma, and sexual abuse should be considered.3

Width of the hymen

In the past where examination of the width of the hymen found it to be narrow it was referred to as ‘attenuation’. This term, however, implies that a previous examination has been undertaken, with which the current examination can be compared. Usually, this is not the case. The Royal College of Paediatrics and Child Health working party3 decided to use the ‘width’ of the hymen as the preferred description. Some investigators refer to hymenal width as being narrow (i.e. 1 mm). It is incredibly 136 J. Price / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 131–139 difﬁcult to take such small measurements and, in the UK, such measurements are not recommended; however, this may have some signiﬁcance should an area of the hymen be thought to be narrow compared with the rest of the hymen. All newborn babies seem to have hymenal tissue at birth.9,15 If the posterior hymenal rim seems to be narrow or absent in the supine position in a pre-pubertal girl, it is essential that the child is examined in the knee chest position when a rim of hymen is usually found. If the posterior rim remains thin in this position, child abuse must also be considered.3

Hymenal diameter

At one time, the size of the hymenal orifice was thought to be helpful in determining whether penetrative sexual abuse had occurred. On occasions, it is possible to see the margins of the hymen in pre-pubertal girls without using separation or traction. This has been referred to as ‘gaping’ by Myhre et al.5 and Hobbs et al.16 The significance of this is not understood, and Heger et al.12 considers this to be a normal finding. It must be appreciated that the hymen is elastic even in the pre-pubertal girl. This elasticity makes the accurate measurement of the diameter impossible. This elasticity increases with the effect of oestrogens. The hymen can, therefore, stretch with gentle pressure, allowing penetration without tearing even in the pre-pubertal child.7 When the transverse diameter was measured using labial traction, Berenson et al.17 found that girls alleging digital or penile penetration had a larger mean diameter than non-abused girls when examined in the knee chest position but not in the supine position. It was felt that the overlap of measurements was too great to allow this to be helpful in making a diagnosis of child sex abuse. Adams et al.13 also found no significant difference in transverse diameter when comparing children alleging penetration and where there was perpetrator confession compared with published data on normal measurements. Berenson et al.17,18 Found the hymenal orifice increases with age. Myhre et al.5 Found that, in girls thought not to have been abused, the hymenal diameter varied with different examination methods, the skill of the examiner and the degree of relaxation of the child. Height and weight also appeared to make a difference. White and Ingram19 reported larger hymenal diameters in girls reporting penetration than those reporting fondling. It was also larger in girls reporting more than one episode of abuse. The bottom line is that, because so much overlap occurs in the measurements of abused and non- abused girls, and difficulties occur in measurement, the transverse hymenal diameter cannot be used to diagnose child sex abuse. Measurement of the hymenal orifice is not recommended by the Royal College of Paediatrics and Child Health.3

Inﬂammation

Inflammation can be seen on internal and external genitalia as a consequence of rubbing and friction by fingers, penis, or an object during child sexual abuse or by the child rubbing themselves. Inflammation can also be found with overheating, poor hygiene, infection, vulvo vaginitis, skin conditions and thread worn. These must all be eliminated before inflammation can be considered as possibly being a consequence of child sex abuse. Inflammation will fade quickly (2–3 days). Inflammation between the labia or buttocks with clearly demarcated margins may be seen as a consequence of intra-crural intercourse (rubbing of an erect penis against the genitalia or anus). This will, of course, cause pain and discomfort, and may be misinterpreted as penetration by young children when they do not fully understand their anatomy.

Bruising

Bruising can also be found on internal and external genitalia after abuse, but can also be seen as a consequence of straddle injuries (i.e. accidental injuries). Usually, however, straddle injuries are seen J. Price / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 131–139 137 over the anterior parts of the genitalia. They can also be found over the external genitalia more posteriorly, but it is unusual for such accidents to involve internal genitalia, as these structures are generally protected by the labia majora, which generally lie closed together. In exceptional accidents, penetration has been reported of the perineum and even the hymen. A good history of events leading to examination must be taken, and independant observations and reports of the accident sought. Bruising as a consequence of child sex abuse can be found on the hymen and perihymenal tissues as well as the external genitalia. An early examination is recommended. When bruising of the genitalia is found, sexual abuse should be considered.3 Bruising cannot be aged from its appearance or photographs.20 Differential diagnosies to be considered are skin conditions (e.g. Lichen sclerosis, haemangioma, or pigmented lesions). It can be more difﬁcult to see bruising in pigmented skins. Healing of bruises can be rapid, but Finkel21 found a well-marked ecchymosis on the hymen and perihymen still present 10 days after the abuse had occurred. Heppenstall–Heger et al.4 reported all haematomas healing completely. Bruising has not been found in those studies selecting girls for non-abuse. Bruising is a non-speciﬁc sign for sexual abuse.

Abrasions

Abrasions of the external and internal genitalia can be found in sexually abused children and as a consequence of accidents. Heppenstall-Heger4 found abrasions on the hymen, perihymenal tissue, fourchette and labia majora and minora in girls alleging penile or digital penetration. She also described abrasions in similar areas with straddle injuries, but child sex abuse was not robustly excluded in this group. No abrasions have been found in non-abused children examined.5 In adolescent girls alleging penile penetration, abrasions have been reported on the labia minora, fossa navicularis, and fourchette.6 Early examination is recommended. When abrasions are found, child sex abuse should be considered alongside other causes of abrasions.3

Other ﬁndings to be aware of

Hymenal bumps and mounds

Hymenal bumps and mounds are localised thickened areas of hymanal tissue, which usually lie on the free margin of the hymen but they can also be seen in the vestibule. When seen during examination in the supine position, they may or may not smooth out in the knee chest position. They can be associated with intra-vaginal ridges (support bands)4,10 when they are considered to be normal. They can be found at any point on the rim of the hymen. Berenson et al.10 found hymenal bumps in sexually abused and the non-abused pre-pubertal girls. She also found them in her non-abused study,11 as did Myhre et al.5

Hymenal tags

Hymenal tags also consist of hymenal tissue. They are longer than they are wide. They can cause confusion during examinations as they can fall over the hymenal oriﬁce obscuring it. Both examination positions should be used, but it may still be necessary to use a swab to delineate the tag and move it so that the rest of the hymen can be visualised. These are considered a normal variant, and may be the result of a septate hymen breaking down.

Labial fusion

Labial fusion is said to occur when the inner aspects of the labia minora fuse together. This can be seen at various points along the labia minora, or can involve the greater part of their length leaving 138 J. Price / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 131–139 only a small orifice for urine to escape. Such a condition can lead to a child experiencing after drib- bling. As a consequence, they may sit in damp pants leading to sore genitalia, and possibly vulvovaginitis. Labial fusion is seen in younger girls wearing nappies, but it is unusual for it to occur for the first time at 6–7 years of age. Causes are thought to be inflammation from incontinence, vaginitis, poor hygiene, or frictional irritation. Usually, this condition naturally resolves, particularly when a child moves into adolescence with the production of oestrogens. Inflammation was found in abused and non-abused girls by Berenson,10,11 and Myhre et al.5 found labial fusion in his non-abused study. Heppenstall-Heger et al.4 reported that labial fusion could occur after healing of injuries to the posterior fourchette and fossa navicularis. If child sex abuse is suspected, then the fusion may need to be treated so that the hymen can be visualised.

Lichen sclerosis

Lichen sclerosis is an itchy skin condition that can be seen in pre-pubertal girls. The skin is silvery in appearance, usually has clear demarcated margins, and can surround both the anterior genitalia and the anus in a ﬁgure of eight conﬁguration. The skin is friable and easily broken when the child rubs because of the intense itching. This rubbing can be mistaken for excessive masturbation, and when the skin is broken there can be bleeding and the appearance of bruising when child sex abuse is often suspected. This condition should be recognised, as treatment can be very effective.

Normal ﬁndings

The general assumption is that, as an adult erect penis is larger than a small child’s hymenal orifice, penetration will inevitably produce damage. This is not what we find, however. Most examinations have normal findings; Hepenstall-Heger et al.4 have cited 99%. Normal or no clinical findings, however, does not mean that nothing has happened. Healing is rapid, and frequently these children do not come for examination until some time has passed since the last episode of abuse, thus giving ample time for healing to occur. Some children may misinterpret fondling and masturbation for penetration. Although these are still abusive acts, they are more likely to leave minimal or non-specific findings, as will kissing of the genitalia. It is, therefore, important that when a child makes a disclosure, their examination should be treated as urgent. The most important aspect of any investigation is the child’s story. Laming in his two Inquiries stated we should always talk to the child on their own.

Practice points

A clear history of events is essential. Children and young people should be given the opportunity to be spoken to alone (without parents). A careful and thorough examination should always take place even when the allegation is historical. It can provide considerable reassurance to the child and ensure all their needs are met. Different examination positions and techniques should be used to conﬁrm clinical ﬁndings. Consistent terminology should be used. Time from event to examination should be noted. It is now recommended that photodocumentation (DVDs) should take place. J. Price / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 131–139 139

Research agenda

A case-controlled, prospective study of conﬁrmed cases (as far as possible) of child sex abuse, compared with a normal population, in which stringent efforts have been made to exclude child sex abuse. Further studies of healing that clearly differentiates which cases are abused and which are accidental.

References

1. Heger A, Ticson L, Velasquez O et al. Children referred for possible sexual abuse: medical findings in 2384 children. Child Abuse Neglect 2002; 26: 645–659. 2. RCPCH. Guidelines on paediatric forensic examinations in relation to possible child sexual abuse. Royal College of Paedi- atrics and Child Health, and Faculty of Forensic and Legal Medicine October 2007. *3. RCPCH. The physical signs of child sexual abuse: a evidence based review and guidance for best practice. Royal College of Paediatrics and Child Health, and Faculty of Forensic and Legal Medicine March 2008. *4. Hepenstall-Heger A, McConnell G, Ticson LA et al. Healing patterns in anogenital injuries: a longitudinal study of injuries associated with sexual abuse, accidental injuries or genital surgery in the preadolescent child. Pediatrics 2003; 112: 829– 837. *5. Myhre AK, Berntzen K & Bratlid D. Genital anatomy in non-abused pre-school girls. Acta Paediatrics 2003; 92: 1453–1462. 6. Adams JA, Girardin B & Faugno D. Adolescent sexual assault: documentation of acute injuries using photo-colposcopy. J Pediatr Adolesc Gynecol 2001; 14: 175–180. *7. Muram D. Child sexual abuse: relationship between sexual acts and genital findings. Child Abuse Negl 1989; 13: 211–216. *8. Palusci VJ, Cox EO, Shatz EM et al. Urgent medical assessment after child abuse. Child Abuse Negl 2006; 30: 367–380. *9. Berenson AB, Heger A & Andrews S. Appearance of the hymen in newborns. Pediatrics 1991; 87: 458–465. *10. Berenson AB, Chacko MR, Wiemann CM et al. A case control study of anatomic changes resulting from sexual abuse. Am J Obstet Gynecol 2000; 182: 820–831. 11. Berenson AB, Heger AH, Hayes JM et al. Appearance of the hymen in prepubertal girls. Pediatrics 1992; 89: 387–394. *12. Heger A, Ticson L, Guerra L et al. Appearance of the genitalia in girls selected for non-abuse: review of hymenal morphology and non-specific findings. J Pediatr Adolesc Gynecol 2002; 15: 27–35. *13. Adams JA, Harper K, Knudson S et al. Examination findings in legally confirmed child sexual abuse: it’s normal to be normal. Paediatrics 1994; 094: 31 –317. *14. Adams JA, Botash AS & Kellogg N. Differences in hymenal morphology between adolescent girls with and without a history of consensual intercourse. Arch Pediatri Adolesc Med 2004; 158: 280–285. 15. Jenny C, Kuhns ML & Arakawa F. Hymens in newborn female infants. Pediatrics 1987; 80: 399–400. 16. Hobbs CJ, Wynne JM & Thomas AJ. Colposcopic genital findings in prepubertal girls assessed for sexual abuse. Arch Dis Child 1995; 73: 465–469. 17. Berenson AB, Chacko MR, Wiemann CM et al. Use of hymenal measurements in the diagnosis of previous penetration. Paediatrics 2002; 109: 228–235. 18. Berenson AB. A longitudinal study of hymenal morphology in the first 3 years of life. Pediatrics 1995; 95: 490–496. 19. White ST, Ingram DL & Lyna PR. Vaginal introital diameter in the evaluation of sexual abuse. Child Abuse Negl 1989; 13: 217–224. 20. Cardiff Child Protection Systematic Reviews; http:www.core-info.cf.ac.uk; [last accessed 14.08.12]. 21. Finkel MA. Anogenital trauma in sexually abused children. Pediatrics 1989; 84: 317–322. Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 141–149

Contents lists available at SciVerse ScienceDirect Best Practice & Research Clinical Obstetrics and Gynaecology

journal homepage: www.elsevier.com/locate/bpobgyn

12 Immediate medical care after sexual assault

Beata Cybulska, MD, MSc, Dip GUM, MFFLM, Clinical Director of the Sexual Assault Referral Centre and Associate Specialist in Sexual Health *

Central Health Clinic, The Bridge Sexual Assault Referral Centre, Tower Hill, Bristol BS 2 0JD, UK

Keywords: Immediate needs after sexual assault include safety and privacy in fi sexual assault the rst instance, followed by treatment of injuries and prevention forensic examination of unwanted pregnancy and sexually transmitted infections, immediate medical aftercare including human immunodeficiency virus. Management should emergency contraception include risk identification of self-harm and suicide, as well as sexually transmitted infections safeguarding children and vulnerable adults. Pregnancy preven- HIV prophylaxis tion 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. Ó 2012 Elsevier Ltd. All rights reserved.

* Tel.: þ44 0117 342 6999; Fax: +44 0117 3426890. E-mail addresses: [email protected], [email protected].

1521-6934/$ – see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bpobgyn.2012.08.013 142 B. Cybulska / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 141–149

Introduction

Medical care may be offered immediately after a forensic examination. It may also be offered alone in another setting, such as a sexual health clinic, general practice, emergency medicine or gynaecology clinic if forensic medical examination is not carried out or is delayed. It should also be offered to those who do not wish to have a forensic examination as a police or non- police referral, but are concerned about the physical consequences of an assault.1,2

Components of immediate medical care after sexual assault

After a sexual assault, the following immediate care and support can be offered: (1) assuring safety and privacy; (2) treatment of minor injuries by first aid and major injuries in a hospital setting if necessary (3) management of intoxication with, or withdrawal from, alcohol, illicit drugs, or both; (4) management of medical emergencies: asthma, panic attacks, epileptic fits, diabetic hyper or hypo- glycaemia; (5) risk identification and prevention of pregnancy and sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), self-harm and suicide; (6) referrals for sexual health screening, counselling and psychology; (7) safeguarding children and vulnerable adult referrals (e.g. social care, community paediatrics, school or Multiagency Risk Assessment Conference in domestic violence); (8) practical support (e.g. referrals to Independent Sexual Violence Advisor or Child and Young People Sexual Violence Advisor available in the UK; and (9) referrals to voluntary agencies.3,4

Safety and privacy

Safety and privacy are important when dealing with individuals who have been sexually assaulted, some of whom may be distressed and many may feel ashamed5 to talk about what has happened to them. Empathy, sensitivity, a non-patronising attitude and listening skills are paramount in dealing with people who have been sexually assaulted.

Treatment of injuries

Presence of injuries after sexual assault depends on the degree of physical violence and resistance during the assault, as well as level of consciousness, time of presentation and age of complainants, among other factors. Most complainants of sexual assault have no injuries on genital examination. The vast majority of complainants of rape have extragenital injuries found of which head injury is the most dangerous and may require hospital admission.6 Minor extra-genital injuries, such as open wounds and lacerations, bites and minor burns, may be treated using simple ﬁrst aid consisting of sterilisation, sterile dressing and antibiotics. Prophylaxis against tetanus is particularly important in countries in which the vaccination rate for tetanus in childhood is low and tetanus prevalence high. Bites should be treated using topical and oral treatment to prevent the development of local skin infection or, in severe cases, systemic septicaemia. Where high risk exposure occurs (seropositive individual, man having sex with man, intravenous drug user, commercial sex worker, someone from area of high prevalence of HIV infection, in anal penetration and in the presence of genital injury) consider hepatitis B immunoglobulin and HIV post- sexual exposure prophylaxis (HIV PEPSE), particularly if the assailant was known to be seropositive.7 Minor genital injuries are usually superﬁcial and do not require treatment other than saline washing and reassurance, as they heal quickly and spontaneously within days. Major injuries, including head injuries, deep open wounds that require suturing, heavy pelvic bleeding, and rectal bleeding, should be investigated and treated in an emergency department of a hospital.8 This may need to take precedence over forensic examination. Genito-rectal lacerations may require examination and suturing in the theatre under general anaesthesia (Table 1). B. Cybulska / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 141–149 143

Table 1 Treatment of injuries.

Minor injuries First aid: cleaning, dressing. Antibiotics. Tetanus ovoid. Major injuries Hospital admission and observation. Hepatitis B immunoglobulin. Investigations: X-ray, computed Hepatitis B booster or ﬁrst dose of vaccination. tomography and ultrasound scans. Suturing under general anaesthesia. Human immunodeﬁciency virus prophylaxis after sexual exposure. Pain relief.

Prevention of pregnancy

Prevention of pregnancy alongside STI and concern about the possibility of internal injuries is the main reason female complainants of sexual assault seek advice in medical settings after the assault.

Emergency contraception

Prevention of pregnancy consists of the administration of emergency contraception and termination of pregnancy. Emergency contraception comes in two forms: insertion of an intrauterine device (IUD) and hormonal oral methods (e.g. Levonelle or EllaOne). The IUD, an intrauterine device, is the most reliable form of emergency contraception, and should be discussed and offered to those at highest risk and those who choose this method.9 If it is not possible to insert an IUD immediately, smooth referral pathways should be in place. Most complainants of sexual assault prefer to take oral forms of emergency contraception such as Levonelle or Ella One. Levonelle l (Norgestrel) is licensed to be given for up to 72 h after unprotected sexual exposure in females over the age of 16 years. It is most effective in the first 24 h, after which its efficacy diminishes with some residual efficacy after 5 days. Ella One (Ullipristol) is a new oral emergency contraception that is licensed for females 16 years or older for up to 5 days after unprotected sexual exposure.10 The International Federation of Gynecology and Obstetrics guidance 10a states that the victim should be offered a pregnancy test before taking emergency contraception to reduce the chance they are already pregnant with their partner’s child.11 A pregnancy test should be considered 3 weeks after oral emergency contraception in the absence of inter-menstrual bleeding.

Termination of pregnancy

If pregnancy is not prevented by using emergency contraception, women should be offered the option of termination of pregnancy. In some jurisdictions, rape is one of the rare indications for a legal termination of pregnancy. They may, however, wish to continue with the pregnancy, which is not uncommon, and they are referred to an antenatal clinic. The latter usually occurs on religious or moral grounds or when the assailant was a husband or partner. Those who opt out of terminating their pregnancy should be advised about the forensic and evidential signiﬁcance of products of conception, the collection of which should be arranged by liaising with the investigating police ofﬁcers who would collect the samples, exhibit them and store demon- strating chain of evidence of the custody of the samples or dispatch them for forensic analysis. In non-police referrals, local policies should be in place about collection, handling of samples, storage and disposal, in line with local guidelines and policies.12

In-utero paternity testing

A decision whether or not to terminate the pregnancy may be assisted by in-utero paternity testing, using samples obtained during chorionic villous biopsy in cases where there is uncertainty whether the pregnancy resulted from consensual sexual intercourse with a husband or partner, or from rape.13 This is usually arranged on a case-by-case basis, and requires co-ordination of the work of the 144 B. Cybulska / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 141–149 gynaecologist and local DNA experts; in the UK, this is not funded by the National Health Service. Requests should be considered on a case-by-case basis, bearing in mind that alleging rape may be used as a backdoor route to paternity testing.

Risk assessment and management of sexually transmitted infections

Prevention, identification and treatment of STIs represent an important immediate aftercare component of the management of complainants of sexual assault. To offer or not to offer prophylaxis against bacterial or viral STI after sexual assault is a frequently asked question. The decision depends on the local prevalence of STIs, likelihood of the complainant attending for screening, assailant type, assailant’s risk factors, the presence of genital injuries and the complainant’s choice. Benefits of offering prophylaxis against STIs, apart from prevention of infection, include psychological well-being of having done something positive. Many complainants of sexual assault feel dirty and fear acquisition of an infection as much as unwanted pregnancy.14 Irrespective of the choice the complainant makes, STIs screening should be encouraged and referral facilitated to a local sexual health clinic or general practitioner. Taking swabs for STI screening at forensic examination in previously sexually active individuals is controversial, as identification of STI that predated the assault may be used against the complainant in court. This has to be weighed against advantages of early diagnosis and treatment, particularly in symptomatic individuals.

Bacterial prophylaxis against sexually transmitted infections

Gonorrhoea, chlamydia and Trichomonas vaginalis are the most common STIs, each of which can be – prevented using antibiotics as a single dose.15 18 In the UK, the recent emergence of resistance to oral cefixime in the treatment of gonorrhoea has resulted in an intramuscular ceftriaxone becoming the first-line treatment. This, together with the risk of anaphylaxis, may be not available in some non-hospital Sexual Assault Referral Centres. Under such circumstances, in low prevalence areas or when a patient has a needle phobia, oral cefixime 400 mg and azithromycin 1 g as a single dose to cover gonorrhoea and chlamydia infections as well as metronidazole 2 g as a single dose or 400 mg twice a day for 5 days in pregnancy may be offered, followed by STI screening 2 weeks later.

Viral prophylaxis against sexually transmitted infections

Hepatitis B and HIV infections are the two viral STIs that may be prevented by vaccination and administration of antiretroviral combinations after risk assessment.19 Risk factors for hepatitis B and HIV infections include men having sex with men; contact from sub- Saharan Africa, South East Asia and South America; intravenous drug users; commercial sex workers; exchange of blood and body ﬂuids (semen, saliva); anal intercourse; presence of STIs, genital injuries, or both; and multiple assailants (Tables 2–5).

Prophylaxis of hepatitis B infection

Hepatitis B is known to be sexually transmitted and so, particularly in parts of the world where the prevalence is high, a role exists for prophylaxis for hepatitis. In areas of low prevalence of hepatitis B, rapid course of vaccination can be offered in high-risk exposure, which may prevent the development – of acute hepatitis B infection if given for up to 6 weeks after exposure.20 23 Hepatitis B vaccination has been shown to reduce vertical transmission from mother to child, so it is important to consider it in women pregnant after assault who continue with their pregnancy.24 Available options include (1) hepatitis B immunoglobulin 500 iu. intramuscularly when the assailant is known to be hepatitis B positive within 48 h up to 7 days after exposure; rapid course of hepatitis B vaccination 1 ml intramuscularly 1, 2 and 3 weeks for up to 6 weeks after the assault; (3) hepatitis antibody test 6 weeks after vaccination; and (4) hepatitis B booster 1 ml intramuscularly after 12 months. B. Cybulska / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 141–149 145

Table 2 Human immunodeﬁciency virus (HIV) risk assessment of source if HIV status is unknown.

Source community HIV seroprevalence (%) Source community HIV seroprevalence (%) Homosexual men Heterosexual Sub-Saharan Africa >10 London 15 Caribbean <6 Scotland 2.5 South and South East Asia <3 Elsewhere 2.3 Latin America <3 Intravenous drug user North Africa and Middle East <3 London 4.7 East Asia and Paciﬁc <1 Elsewhere UK 0.23 Eastern Europe and Central Asia <1 North America <1 Western Europe <1 UK <1 Australia and New Zealand <1

Human immunodeﬁciency virus prophylaxis after sexual exposure

Human immunodeﬁciency virus prophylaxis after sexual exposure (HIV PEPSE) should be started as soon as possible after high-risk exposure and no later than 72 h; therefore, rapid risk assessment and administration of HIV PEPSE starter packs to those at high risk where this treatment is recommended is paramount.19 Risk assessment and discussion about HIV PEPSE and its efﬁcacy, importance of compliance and side-effects, and follow up should be carried out in every case after sexual assault. In countries where HIV is more common, routine HIV PEPSE should be considered. In low-risk countries, a risk assessment can be carried out, and HIV PEPSE can be given only in high-risk cases. Most cases of HIV PEPSE will not be recommended, and reassurance is what is needed most. Those who are given HIV PEPSE need to have baseline bloods taken and have HIV, syphilis, hepatitis B tests carried out, as well as full blood count, liver function tests, glucose, lipids and amylase, as bone- marrow abnormalities may occur during treatment. Current HIV PEPSE combinations include kaletra (1 tablet once per day) and tenofovir (two tablets twice per day) for 28 days accompanied by symptomatic treatment with loperamide for diarrhoea and domperidone (one tablet three times a day) for nausea and vomiting, which, apart from tiredness and headaches, are the most common side-effects with this treatment. In most cases, side-effects settle with symptomatic treatment, and individuals are able to continue treatment until completion. Referral pathways to clinic where follow up will be carried out should be in place to assure review of compliance, side-effects, and a wish to continue treatment. A follow-up HIV test should be offered from 1 month (for high-risk cases and when new and highly sensitive fourth-generation HIV tests are used) up to 3 months after treatment.

Human immunodeﬁciency virus prophylaxis after sexual exposure in children and young adults

When considering HIV PEPSE in children and young people, it is important to carefully assess risk of transmission by a particular type of assailant and a particular exposure. Local prevalence has to be taken into

Table 3 Exposure risk and recommendation for post-exposure prophylaxis for HIV after sexual exposure where source individual is known to be HIV positive and unprotected sex occurred.

Type of exposure Tick Risk of acquiring HIV per exposure (%) Offer PEPSE? Receptive anal sex 0.1 – 3.0 Recommended Insertive anal sex 0.06 Recommended Receptive vaginal 0.1 – 0.2 Recommended Insertive vaginal sex 0.03 – 0.09 Recommended Fellatio with ejaculation 0 – 0.04 Considered Splash of semen into eye 0.09 Considered Fellatio without ejaculation Not recommended Cunnilingus Not recommended

HIV, human immunodeﬁciency virus; PEPSE, post-exposure prophylaxis for HIV after sexual exposure. 146 B. Cybulska / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 141–149 Table 4 Source individual of unknown status but from a high-risk group (>10%).

Type of exposure Tick Offer PEPSE? Receptive anal sex Recommended Insertive anal sex Considered Receptive vaginal Considered Insertive vaginal sex Considered Fellatio with ejaculation Considered Splash of semen into eye Considered Fellatio without ejaculation Not recommended Cunnilingus Not recommended

PEPSE, post-exposure prophylaxis for HIV after sexual exposure. account, as well as efﬁcacy and short- and long-term side-effects. The same combinations are used as in adults, and dosages are adjusted according to body weight. Specialist advice should be accessed if in doubt.25

Prophylaxis of tetanus

Where bodily wounds occur as a result of physical violence or resistance to violence, prophylaxis of tetanus should be considered. In individuals who have already been vaccinated against it, a booster of tetanus toxoid should be offered.15

Management of medical emergencies after sexual assault

The most common medical emergencies that may have to be dealt with in complainants of sexual assault in an acute stage immediately after assault include the following: anxiety, panic attacks, asthma attacks, epileptic ﬁts, diabetic hypo- or hyperglycaemia and alcohol or drug intoxication or withdrawal, as well as head injury. These emergencies are uncommon and may have to be managed ﬁrst before forensic medical examination is carried out. If necessary, forensic evidence should be gathered in a hospital, particularly when unconscious and hospitalised.

Mental health problems and self-harm after sexual assault

Many complainants of sexual assault have some form of mental health problems, mainly depression, anxiety, schizophrenia, personality disorders or drugs-and alcohol-related problems. Post-traumatic stress disorder has been well recognised as the psychological consequence of sexual assault symptoms, which may be manifested in the acute stage after assault. The most common symptoms are low mood, sleeping difﬁculties, anxiety, low appetite, and feelings of guilt, shame and anger. Emotional numbness and avoidance are common reasons for not seeking help. Most complainants of sexual assault recover with time, but some do not, and those individuals may require – psychological therapy as well as psychotherapy.26 31 Many complainants of sexual assault give a history of self-harm, including cutting or taking over- doses, which in extreme cases may result in deliberate or accidental death. Assessment of the risk of self-harm should be carried around the time of the assault, which itself may act as a trigger to self-

Table 5 Source individual status unknown and not from a high-risk group.

Type of exposure Tick Offer PEPSE? Receptive anal sex Considered Insertive anal sex Not recommended Receptive vaginal Not recommended Insertive vaginal Sex Not recommended Fellatio with ejaculation Not recommended Splash of semen into eye Not recommended Fellatio without ejaculation Not recommended Cunnilingus Not recommended

PEPSE, post-exposure prophylaxis for HIV after sexual exposure. B. Cybulska / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 141–149 147 harming behaviour. Reasons for self-harming include wish to relive anxiety or emotional pain, or to die. Assessment of the nature and severity of it may be conducted by asking questions about frequency and type of self-harm, reasons behind self-harming, and frequency, presence of hopelessness, wish to die, reasons to live and future plans. Carrying out a mental state examination,32 which is a brief measure of cognitive function, will give additional information about mental state at the time of examination (Table 6). Management of self-harmers will depend on the severity of it, and can be divided into mild, moderate and severe, although it is not possible to guarantee that someone with mild self-harm will not go on to commit suicide. It is, therefore, important to assure their safety and support in the immediate aftermath of rape. Available options include, in the immediate term, assuring safety by talking to friends and family to look after them, and information about voluntary organisations such as Samaritans. In the medium term, a referral to a general practitioner or a hospital may be necessary. Individuals classiﬁed as at severe risk of self-harm may have to be referred urgently to a hospital for mental health assessment. Liaise with friends and family, care workers, social workers and general practitioners to alert them to the possibility of self-harm; referral for counselling may be necessary.

Safeguarding children and vulnerable adults

Individuals most at risk include sexually assaulted children (anyone under the age of 18 year of age), children in domestic violence households witnessing the assault/s, and vulnerable adults, such as those with learning difﬁculties, mental disorder and elderly people. Systems should be in place to assure risk assessment and referrals to social care. Other vulnerable groups include sex workers, trafﬁcked women, alcohol, illicit drug users, or both, and ethnic minorities. Access to services and reporting may be delayed or may never happen, as a result of a chaotic lifestyle as well as language and cultural barriers. Building trust and rapport is needed to facilitate appropriate care. Local and national voluntary organisations may be of assistance. Interpreting services may be required in those with language problems.

Practical support

Practical support apart from psychosocial support may be needed, particularly with housing, accessing care and, in particular, follow-up appointments for sexual health screening and counselling. Support through the investigation and trial for the complainant and her or his family members may be required in some cases. In the UK, this role is carried out by Independent Sexual Violence Advisors, who offer their services to sexually assaulted adults and children (Child and Young People Sexual Violence Advisor).

Voluntary organisations

Information about voluntary organisations, such as the Samaritans, Respond, Survivors, Rape Crisis and Victim Support, should be made available to complainants of sexual assault who my wish to contact them when needed.

Table 6 Mental state examination.

Appearance Apparent age, height, weight, and manner of dress, grooming. Attitude Cooperative, un-cooperative, hostile, guarded, suspicious, regressed. Behaviour Eye contact, gait, abnormal movements. Mood Neutral, euthymic, dysphoric, euphoric, angry, anxious or apathetic. Affect Normal, blunted, exaggerated, ﬂat, heightened or overly dramatic. Speech Content, articulation, pitch, loudness, rate, quantity, spontaneity. Thought process Quantity, rate of ﬂow and form of thought. Thought content Delusions, phobias, preoccupations suicidal ideation. Perceptions Hallucinations, pseudo hallucinations and illusions. Cognition Alertness, orientation, attention, memory, functioning. Insight Understanding of mental illness and treatment options. Judgement Capacity to make sound, reasoned and responsible decisions. 148 B. Cybulska / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 141–149

Criminal Injuries Compensation Board

The Criminal Injuries Compensation Board offer ﬁnancial compensation to victims of sexual assault. An application for compensation before the criminal trial is ill-advised, as the Defence may use this fact against the complainant in court.33

Conclusion

What happens to the victim of sexual assault immediately after the incident may affect the individual’s recovery from it, both in physical and psychological terms. Immediate medical and psychosocial care, alongside recovery of forensic evidence and documentation of injuries, affects the well-being of the victims, and recovery from rape and sexual assault and represents an important part of the beginning of the healing process. Prevention of pregnancy as well as STI, including HIV infection, offer reassurance that any potential physical damage will be prevented. Forensic medical examination of those who have been raped or sexually assaulted ought to be managed holistically according to the individual victim’s needs. Being believed, listened to and taken care of may affect reporting the crime to the police. Having forensic evidence gathered and aftercare facilitated may be empowering, and can assist in physical and emotional recovery from rape and sexual assault.

Conﬂict of interest

None declared.

Practice points

Immediate care after rape and sexual assault should include risk assessment and prevention of pregnancy and STIs, including HIV infection. Emergency contraception is not freely available to all victims of rape and sexual assault across the world. Prevalence of mental health problems, including self-harm, is common among victims of sexual assault, and immediate risk must be assessed in all cases. HIV PEPSE should be offered to all victims of rape in areas of high prevalence of HIV infection. Practical and emotional support takes precedence over counselling and psychological treatments immediately after the assault.

Research agenda

Efﬁcacy of bacterial prophylaxis in the prevention of STI after sexual assault. Uptake of bacterial and viral prophylaxis against STI among victims of sexual assault. Availability of emergency contraception to victims of rape and sexual assault. Availability of bacterial and viral prophylaxis against STI to victims of rape and sexual assault. Uptake of emergency contraception and bacterial and viral prophylaxis among victims of rape and sexual assault. Attendance for sexual health screening among victims of sexual assault. B. Cybulska / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 141–149 149

References

*1. Revised national service guide: a resource for developing sexual assault referral centres. Home Office, ACPO and Department of Health, 2009, available from http://www.ccrm.org.uk/images/docs/7.9b_sarc.pdf. *2. Cybulska B & Forster G. Medicine, The Foundation Years. Sexual assault: examination of the victim 2007; 29: 49–54. 3. Steel N, Blakebourough L & Nichols S. Supporting high-risk victims of domestic violence: a review of Multiagency Risk Assessment Conferences (MARACs) 2011 [last accessed 17.08.12], http://www.homeoffice.gov.uk/publications/science- research-statistics/research-statistics/crime-research/horr55/horr55-summary?view¼Binary. 4. Independent Sexual Violence Advisors. March 2011 available from http://www.homeoffice.gov.uk/crime/violence-against- women-girls/sexual-violence/isva/ [last accessed 04.10.12]. *5. Feiring C & Taska LS. The persistence of shame following sexual abuse: a longitudinal look at risk and recovery. Child Maltreat 2005; 10: 337–349. *6. Bowyer L & Dalton ME. Female victims of rape and their genital injuries. Br J Obstet Gynaecol 1997; 104: 617–620. *7. Management of adult patients who attend emergency departments after sexual assault and/or rape. The College of Emergency Medicine, 2011 [last accessed 17.08.12], www.collemergencymed.ac.uk/code/document.asp?ID¼5942. 8. Head injury. NICE Guideline, 2007 [last accessed 04.10.12]. www.nice.org.uk. *9. Faculty of Family Planning and Reproductive Health Care, Clinical Effectiveness Unit. Emergency contraception. FFPRHC Guidance (April 2006). J Fam Plan Reprod Health Care 2006; 32: 121–128. 10. EllaOne - a new emergency contraceptive. MIMS, 2009 [last accessed 17.08.12], http://www.mims.co.uk/Drugs/ contraception/emergency-contraceptives/ellaone/. *11. Jina R, Jewkes R, Munjanja SP et al. Report of the FIGO Working Group on Sexual Violence/HIV: Guidelines for the management of female survivors of sexual assault. Int J Gynaecol Obstet 2010; 10: 85–92. 12. Waye SJ. Prenatal paternity testing following sexual assault: a novel application of forensic DNA typing. Can Soc Forensic Sci 1993; 26: 81–85. 13. Guidelines for handling medico-legal specimens and preserving evidence. The Royal College of Pathologists, 2008 [last accessed 17. 08.12], http://www.rcpath.org/Resources/RCPath/Migrated%20Resources/Documents/G/g047_chainofevidence_jul08.pdf. 14. Petrak J, Doyle AM, Williams L et al. The psychological impact of sexual assault: a study of female attendees of a sexual health psychology service. Sex Marital Ther 1997; 12: 339–345. *15. Cybulska B, Forster B, Welch et al. UK national guidelines on the management of adult and adolescent complainants of sexual assault 2011 [last accessed 17.08.12], http://www.bashh.org/documents/3275. 16. Bignell C & FitzGerald M. UK national guideline for the management of gonorrhoea in adults. Int J STD AIDS 2011; 22: 541–547. 17. 2006 UK National Guideline for the Management of Genital Tract Infection with Chlamydia trachomatis. BASHH Clinical and Effectiveness Group, 2006 [last accessed 17.08.12], http://www.bashh.org/documents/61/61.pdf. 18. United Kingdom Guideline on the Management of Trichomonas vaginalis 2007 [last accessed 17.08.12], http://www.bashh. org/documents/87/87.pdf. *19. Benn P, Fisher M & Kulasegaram R. UK guideline for the use of post-exposure prophylaxis for HIV following sexual exposure. Int J STD AIDS 2011; 22: 695–708. 20. Immunisation against infectious disease. The green book 2006 [last accessed 17.08.12], http://www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_079917. 21. Vaccines and antisera, Hepatitis B vaccine. British National Formulary. March 2010, paragraph 14.4, p. 669. 22. Ahmed SM, Volpellier M & Forster G. The use of the super accelerated hepatitis B vaccination regimen in a North London sexual assault referral centre (SARC). J Forensic Leg Med 2007; 14: 72–74. 23. Crowe C, Forster GE, Dinsmore WW et al. A case of acute Hepatitis B occurring four months after multiple rape. Int J STD AIDS 1996; 7: 133–134. 24. Mosesa J, Tosswillc M, Sudhanva M et al. HIV-1 seroconversion during pregnancy resulting in vertical transmission. J Clin Virol 2008; 41: 152–153. 25. Children’s HIV Association. CHIVA standards for care for infants, children, and young people with HIV (including infants born to mothers with HIV); http://www.chiva.org.uk/professionals/health/guidelines/guidelines/standards.html; [last accessed 17.08.12]. 26. Campbell L, Keegan A, Cybulska B et al. Prevalence of deliberate self-harm in complainants of sexual violence. J Forensic Leg Med 2007; 14: 75–78. *27. Heke S, Forster G & d’Ardenne P. Risk identification and management of adults following acute sexual assault. Sex Relat Ther 2009; 24: 4015. 28. Royal College of Psychiatrists. Managing self harm in young People. London: RCPCH, 1998 [last accessed 17.08.12], www. rcpsych.ac.uk/files/pdfversion/cr64.pdf. 29. National Institute for Clinical Excellence. The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. NICE Guidelines, 2004 [last accessed 17.08.12], http://www.nice.org.uk/ nicemedia/pdf/CG16FullGuideline.pdf. 30. National Institute for Clinical Excellence. Post-traumatic stress disorder (PTSD). The management of PTSD in adults and children in primary and secondary care. Clinical Guideline 26. National Institute for Clinical Excellence [last accessed 17.08. 12], http://publications.nice.org.uk/post-traumatic-stress-disorder-ptsd-cg26. *31. Welch J & Mason F. Rape and sexual assault. BMJ 2007; 334: 1154–1158. 32. Trzepacz PT & Baker RW. The psychiatric mental status examination. Oxford: Oxford University Press, 1993. p. 202. 33. Criminal Injuries Compensation Authority. www.cica.gov.uk; [last accessed 04.10.12]. Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) A1–A6

Contents lists available at SciVerse ScienceDirect Best Practice & Research Clinical Obstetrics and Gynaecology

journal homepage: www.elsevier.com/locate/bpobgyn

Clinical Aspects of Sexual Violence – Multiple Choice Questions for Vol. 27, No. 1

1. The current legal deﬁnition of rape in England and Wales is restricted to the following non- consensual act(s): a) Penetration of the vagina by penis only. b) Penetration of female vagina, anus or mouth by penis only. c) Penetration of male or female vagina, anus or mouth by penis only. d) Penetration of male or female vagina, anus or mouth by penis or digit. e) Penetration of male or female vagina, anus or mouth by penis or digit or object. 2. A male complainant of rape experienced an erection, ejaculation, or both during the assault. Which of the following does this indicates?

a) The complainant gave his consent, therefore no offence was committed. b) The complainant may not have given his consent but enjoyed the experience. c) The complainant is likely to be homosexual. d) That erection and ejaculation are physiological responses that are not fully under conscious control and can be provoked by high anxiety and anal stimulation. e) That it is not possible to achieve an erection during rape because of the fear and therefore the complainant is lying.

3. The following statement(s) is/are true about sexual violence:

a) Sexual violence is an unusual crime because the victim is often to blame for the act. b) A man cannot rape his wife if rape in marriage is not illegal. c) Boys and men may be victims of sexual violence from men and women. d) Most rapes are not reported to the police. e) The most accurate prevalence measures are from research that has questions asking about behaviourally speciﬁc acts.

4. The following statement(s) is/are true ﬁndings from research on the prevalence of sexual violence:

a) In some countries and settings, more than one in two women have been raped by their husband or boyfriend. b) Population-based estimates from the USA are that nearly one in ﬁve women have been raped in their lifetime. c) Male rape by other men is mostly a problem for gay men. d) Except in war, sexual violence always most commonly occurs between intimate partners. e) First sex forced by male partners is chieﬂy a problem for women.

1521-6934/$ – see front matter http://dx.doi.org/10.1016/j.bpobgyn.2012.11.001 A2 Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) A1–A6

5. The following statement(s) is/are true ﬁndings from research on sexual violence:

a) It is not possible to learn the population prevalence of perpetration of sexual violence. b) Gang rape, or rape by more than one man, is a phenomenon conﬁned to criminal gangs. c) Prevalence estimates are sensitive to the methods used in the research and training and support given to interviewers. d) Questions on sexual violence must ask speciﬁcally about experience with intimate partners and non-intimate partners. e) In countries where women are secluded, they are protected from rape.

6. The following statement(s) is/are true for research on child sexual abuse: a) It is difﬁcult to estimate reliably and comparably the proportion of the population who ever experience abuse during childhood without interviewing children. b) Repressed memory of acts of child sexual abuse causes prevalence estimates to be under- estimates. c) Sexual violence in schools is an important problem globally. d) Most child sexual abuse is reported to police and social services. e) If school students willingly have sexual relationships with teachers it is not called abuse.

7. The following statement(s) is/are true about taking skin swabs: a) Ultraviolet light causes all body ﬂuid types to ﬂuoresce so should always be used to identify the sample site. b) Swabs used for clinical purposes are suitable for forensic skin swabbing. c) Cotton swabs are the most suitable to recover trace evidence from skin. d) The double-swabbing technique is widely recognised as a successful method for recovering trace evidence from skin. e) The Forensic Science Provider does not require the Forensic Medical Practitioner (FMP) to take background control swabs when sampling skin.

8. The following statement(s) is/are true in relation to the seizing of clothing from a complainant of sexual assault:

a) Clothing worn by the complainant at the time of the alleged assault is rarely seized. b) Viewing the complainant in torn clothing may provide the FMP with points of reference to injuries on the body. c) The attending staff should be instructed to remove the complainant’s clothing before the FMP assesses them. d) It is acceptable for the FMP to cut through points of existing damage when examining a patient. e) Record photography of clothing in situ is not required.

9. Ideally, the woman should have the following ability(ies) for optimal competence in terms of choice:

a) The ability to communicate choices. b) The ability to keep information conﬁdential. c) The ability to understand relevant information upon which the choice is made. d) The ability to appreciate the situation according to the patient’s own values. e) The ability to weigh various values to arrive at a decision.

10. Exceptions to the rule of informed consent are acceptable in the following situation(s):

a) During an emergency where the woman cannot communicate her wishes to you. b) When exercising the therapeutic privilege. c) When the woman’s husband requests a waiver of consent on her behalf. d) When the woman who is capable of giving consent requests a waiver. e) When the woman’s family usually make decisions on her behalf. Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) A1–A6 A3

11. Which of the following reasons is/are true with regard to why confidential information should be treated with the utmost care: a) To ensure the woman is cared for compassionately. b) To exclude unauthorised people from being privy to this information. c) The information could be embarrassing to the patient. d) To preserve the privacy of the patient. e) To facilitate the sharing of sensitive information with the goal of helping the patient. 12. Which of the following is/are sources from which confidentiality draws such a high value: a) Benevolence. b) Autonomy. c) Trust. d) Respect for persons. e) Malfeasance. 13. The specific evidentiary examination component ‘trace evidence and biological material collection’ has to be carried out:

a) Less than 72 h after the alleged assault. b) With consent. c) Using colposcopy. d) After police reporting. e) Under standardised conditions. 14. The forensic examination has to be interpreted and documented in a written legal report. Which of the following is/are true? a) Interpretations of ﬁndings are a specialist skill. b) Age of injuries and mechanism and force of injury inﬂiction are key issues. c) Standard terminology is essential. d) Conjunctival petechiae with neck injury may be consistent with strangulation. e) Conjunctival petechiae of any aetiology, is a marker of life-threatening injury. 15. Which of the following is/are true about the effect of forensic evidence on legal outcomes in sexual violence?

a) It is signiﬁcantly associated with injuries. b) The correlation to conviction is the best predictor of a proper forensic examination. c) A reduction in negative health consequences for the victim would be an appropriate end point for research as well as conviction rates. d) Forensic examination is carried out to prosecute and convict the alleged assailant. e) Forensic examination is carried out to protect the alleged assailant. 16. A 45-year-old woman has made an allegation of vaginal rape, saying that the assault has happened 4 h ago. Which of the following is/are true about the genital examination?

a) Absence of injury indicates that the allegation is not true. b) Vaginal bleeding is conclusive evidence of the rape. c) Even if she has had consensual intercourse within 24 h, then a genital examination may be warranted. d) This should routinely be done in the left lateral position. e) The posterior fourchette is the site most likely to sustain an injury. 17. Which of the following is/are true about external female genitalia? a) The labia minora contain sebaceous glands. b) The vagina is lined by simple columnar epithelium. c) The fossa navicularis sits distal to the clitoris and anterior to the hymen. A4 Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) A1–A6

d) The lower vagina is formed from the paramesonephric ducts. e) Lacerations are very rare after sexual assault.

18. Which are the following is/are true about conducting a genital examination after an assault:

a) Toluidine blue dye is not good at detecting bruises. b) Photographic images of the genitalia should be discarded if no injuries are seen. c) A catheter balloon can be used to visualise the hymen edges. d) Stranger rapes are more likely to result in genital injuries than acquaintance rapes. e) The legal deﬁnition of the vagina has it as the distal end starting with the vulva.

19. A 23-year old woman has been examined after an allegation of rape. Which of the following is/are true?

a) A vaginal laceration is more likely with an anteverted uterus. b) A vaginal laceration is likely to be due to a sharp object being inserted. c) Injuries to her body surfaces are more likely than genital injuries. d) Intoxication with alcohol by the girl makes her less likely to have sustained genital injuries. e) The risk of blood-borne viruses is unrelated to genital trauma.

20. The following statement(s) is/are true about emergency contraception after sexual assault.

a) An intrauterine device (IUD) is the most reliable form of emergency contraception. b) Most victims of sexual assault prefer to take oral forms of emergency contraception such as: Levonelle or Ella One. c) Levonelle (Norgestrel) is licensed to be given for up to 5 days after unprotected sexual exposure in females under or over the age of 16 years. d) Ella One (Ulipristal) is a new oral emergency contraception that is licensed in women aged 16 years or older for up to 72 h after unprotected sexual exposure. e) The victim should be offered a pregnancy test before taking emergency contraception to reduce the chance they are already pregnant with their partner’s child.

21. The following statement(s) about human immunodeﬁciency (HIV) post-exposure prophylaxis (PEPSE) is/are true:

a) HIV PEPSE should be considered in vaginal penile penetration and high-risk assailants. b) HIV PEPSE is recommended in anal penile penetration and high risk assailants. c) HIV PEPSE can be started for up to 5 days after unprotected sexual exposure. d) HIV PEPSE has no side-effects and is generally well tolerated. e) HIV baseline tests are not required before administration of HIV PEPSE.

22. During an examination of a pre-pubertal girl in the supine position and using separation of the labia, you are unable to see the hymenal edge. Which of the following is/are acceptable ways to manage this?

a) Do nothing and say these were normal ﬁndings. b) Use traction. c) Put the girl in knee chest position. d) Use a Foley catheter. e) Use general anaesthesia to examine her.

23. An adolescent girl alleges rape. At examination, the hymen is folded and ﬂeshy. There are no apparent tears, lacerations or bruises. Which of the following is/are acceptable ways to manage this?

a) Do nothing: state the hymen was normal and there were no injuries to be seen. b) Use a moistened swab to separate the folds. c) Examine in the knee chest position. d) Use a Foley catheter. e) Use general anaesthesia to examine her. Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) A1–A6 A5

24. A pre-pubertal child alleges penetration of genitalia by her uncle 4 weeks previously. At examination, there are no clinical findings. What can you reasonably conclude in this situation? a) Normal clinical findings do not support the allegation. b) The majority of children alleging sexual abuse have no injury so this is expected. c) There may have been signs initially but healing has occurred. d) There may not have been penetration. e) These findings neither support nor negate the allegation.

25. Peri-orbital bruising (black eye) may be caused by: a) Compression of the neck. b) Blows to the frontal region of the scalp. c) Nasal bone fractures. d) Occipital skull fracture. e) Forceful hair pulling. 26. Tram-line bruising is typically associated with: a) The application of a ligature to the wrists. b) Self-inflicted injury. c) Beating with a rod-like weapon. d) Fingertip pressure. e) Whipping with a chain. 27. The following is/are true concerning sexual assault? a) The lifetime rate of sexual assault for women with mental health difficulties is higher than the general population. b) The lifetime risk of being raped for women in the UK is about 20%. c) If a woman is raped by a stranger, rather than someone she knows, she will have less difficulty re-establishing intimate relationships. d) If a woman is raped by someone she knows, rather than a stranger, she will have less difficulty re-establishing intimate relationships. e) For a formal diagnosis of PTSD to be made, the symptoms must be present for 6 months. 28. Which one of the following statements is/are true about the prevention of post-traumatic stress disorder (PTSD)? a) Cognitive–behavioural therapy is effective for preventing PTSD. b) Individual psychological debriefing has been found to reduce the onset of PTSD. c) Symptoms of PTSD can be prevented by using venlafaxine. d) Eye-movement desensitisation and reprocessing therapy is effective for preventing PTSD. e) Expressive writing has been found to be effective in preventing PTSD. 29. Studies have found that women who suffer from sexual abuse are at greater risk of developing HIV because: a) They use condoms inconsistently. b) They have risky sexual partners. c) They tend to have more sexual partners. d) They are more likely to reuse needles when using injectable drugs. e) They are more likely to become involved in transactional sex.

30. Which one of the following statements is/are true about the health consequences of sexual violence against women? a) Women suffering from intimate partner sexual and physical abuse have the same risk of experiencing health problems as women who experience physical abuse alone. b) Mental health symptoms do not improve spontaneously. A6 Appendix / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) A1–A6

c) Women who have experienced sexual violence are found to use preventive health services more frequently. d) PTSD is diagnosed when symptoms are present for at least 2 weeks. e) Eating disorders, including overeating, have been found to be associated with sexual violence.