Forensic Medical Examination After Sexual Violence: Implications Based on Victims’ Perceptions

Discussion

The mean age of the study population was 31 years. This is well in accordance with the results of other investigations defining young age as a risk factor for becoming a victim of sexual violence (19-21). Some of these studies reported a slightly younger mean age, which might be due to their retrospective design including patients irrespective of age, whereas in our study age <16 years was an exclusion criterion. Notably, the oldest woman included was 95 years. This finding underlines the observation that sexual violence is not a phenomenon confined to young people. Sexual abuse of the elderly is even expected to increase due to demographic change and has been described as more violent, resulting in more severe injuries (28, 29).

It is widely accepted that alcohol and drug abuse are risk factors for sexual abuse (30). Studies addressing the frequency of alcohol intake prior to an assault vary in their results. However, to a large extent, they report higher percentages of women being under the influence of alcohol than in our study population (19-21, 26, 31). In our study, the estimation of alcohol intake was based on self-reporting and, if available, information provided by the criminal police but not generally assessed via a breath or blood test. Therefore, non-disclosure regarding alcohol consumption, especially regarding small amounts causing no physical impairment, might have been possible. Notably, there is a correlation between being assaulted by a stranger and higher levels of alcohol consumption during the time of the incident (26, 32). As in our study a relatively high percentage of women reported familiarity with the perpetrator, the generally low level of observed alcohol intake would be in line with these publications. Moreover, women who consumed alcohol on the day of the incident are less likely to report their assault to the police (20). Therefore in our study the comparatively low percentage of women who reported alcohol intake can also be explained by the fact that the vast majority of women presented at our hospital shortly after they had reported to the police.

The seemingly high rate of total and partial amnesia in our study is in accordance with the results of other studies (21, 32, 33). Since the involvement of ‘date rape’ drugs were only reported by a very small minority, the amnesia might have been due to a combination of alcohol intake on the day of the incident along with psychological reactions. The high percentage of amnesia is a disquieting finding as according to the literature, victims may question the credibility of their own experiences due to impaired consciousness, reducing the likelihood of reporting the incident to the police (34) with a hence negative impact on a successful legal outcome (27).

Regarding familiarity with the perpetrator, previous studies report known perpetrators in 44% to 61% of cases − the latter equaling the result of our study (19-21, 31). However, those studies undertook a more detailed differentiation concerning the relationship to the perpetrator and, for example, distinguished them as strangers, loose contacts, acquaintances and partners/former partners. Due to the lack of such classification in our study, the assignment as to whether the perpetrator was familiar or not was up to the woman and the physician’s interpretation and therefore to some extent was arbitrary. The comparably high percentage of multiple-incident victims in our study can be explained by the high percentage of known perpetrators because having a close relationship or living in the same household with a perpetrator increases the likelihood of repeated assaults (21).

In our study, half of the surveyed women stated that they had filed a complaint to the police. This is well in line with the data published by La Harpe et al. (35). As one-fifth of our study population reported they did not file a complaint and one-quarter said they only might do so, it is important to understand this subgroup. It is known that several factors contribute to this reluctant behavior, including presentation to the hospital more than a week after the incident, a shared home with the perpetrator, consumption of alcohol, amnesia and a lack of knowledge of the victim as to whether there was penetration (35).

The assessment and management of pregnancy and STIs are relevant aspects of post-assault care. This comprises performing a pregnancy test to exclude a pre-rape pregnancy and counselling for emergency contraception. Additionally, it is important to provide information regarding frequently contracted STIs and to encourage the victim to undergo screening, as well as to offer prophylactic treatment in high-risk cases (11, 13). In our study, almost one-third of the women stated they were not informed about the option of using emergency contraception. This is a remarkable finding because at the same time, 45% of the women in our study population declared they did not use any contraception. It was not assessed whether those predominantly not informed ensured that they used a safe method of birth control and therefore might not be considered at risk for an unintended pregnancy. However, due to inherent contraceptive failure rates, every victim should be informed about the use of emergency contraception. In our study, almost all women were informed about the option of STI screening, yet only half of them stated they would make use of it. It is important to keep in mind that for a significant proportion of victims, the primary motive for presenting at a hospital is the fear of STIs or a pregnancy. Understandably, this fear and the resulting desire to receive testing and treatment are greater if the perpetrator is a stranger (17, 36). This circumstance may explain why more than a third of the women refused to undergo testing, as the percentage of familiar perpetrators in our study was comparably high.

As the quality of the immediate care after a sexual assault can affect physical and emotional recovery from the incident, it is important to optimize the examination conditions as much as possible (13). Conversely, if victims fail to receive empathetic and supportive care, the examination can be perceived as re-traumatization and re-victimization and can even be experienced as a ‘second rape’, reinforcing feelings of powerlessness, shame and guilt (4, 17, 37). Even though the examination conditions (represented by the protection of privacy, the adequacy of premises and the feeling of preparedness for the examination) in our study were evaluated as positive by the majority of the women, the examination was still considered to be an additional psychological burden by more than half of the victims. Similar observations were made in a study by DuMont et al., in which despite a general satisfaction with the staff interaction and the way the examination was performed, many women felt distressed during the examination (17). Consistent with this, Lovett et al. reported that even though most women felt treated with kindness and respect, many stated they felt “upset”, “afraid”, “ashamed” and “shocked” before the forensic examination (38). Reducing the potential trauma caused by an examination can be achieved through precise explanation of the examination process, giving the victim the feeling of having control over the process and protection of privacy (11, 38). As the association between the physical injury found during the examination and the legal resolution of a sexual assault case is not as clear as one might expect (27, 39), it is important to provide honest information about the value of the examination so that victims can make an informed decision whether to undergo the examination or not. Taking into account that the examination was considered to be an additional psychological burden and that 40% of the women in our study reported a pre-existing mental illness, low-threshold referrals for professional psychological counseling and support to prevent the onset or worsening of mental health conditions are recommended, as well as the implementation of a staff training for greater sensitivity and improved communication (40, 41). Moreover, exploring the specific reasons why women experienced an additional burden during the examination and analyzing the sources of stress and discomfort is a worthwhile focus for further research efforts.

When the women were asked about their preferred sequence of the examination components, there was a clear majority favoring medical history first, then performing the clinical forensic examination and concluding by performing the gynecological examination. According to the literature, active listening, not blaming the women for what has happened and affirming the women’s strength for having endured the assault should be employed to build trust and confidence in the beginning during the patient–doctor conversation (40). After having obtained informed consent for the upcoming examination procedure and collection of forensic specimens, a head-to-toe physical examination to document any injuries present is conducted. By finishing with the gynecological examination, the most challenging and potentially onerous part is placed at the end of the examination process. In this way, the women have had time to accommodate to the examination setting, settle down and build confidence with the examining physician.

Chowdhury-Hawkins et al. found that 76.8% of the victims attending sexual assault referral centers in the UK preferred the staff to be female (16). Our data are well in accordance with these results as in our collective, a similar number of women generally preferred female staff. Notably, almost half of the women (43.6%) in the UK study stated they would not have had an examination if they had to see a male forensic physician (gynecologists were not part of the survey) (16). Overall, 54.3% of the women in the investigation by Chowdhury-Hawkins et al. stated they felt strongly about the issue of staff sex (16). Likewise, 55% of the women in our investigation explicitly preferred a female forensic physician and 58% a female gynecologist. As might be expected, the preference for a female criminal police officer, who is usually not present in the examination room, was not as clear. Notably, due to the strong preference for female staff in general, there is a female-only recruitment policy at some of the UK sexual assault referral centers. In cases in which this policy cannot be realized, an appropriate training of all staff addressing established standards, i.e. showing a professional attitude towards sexual assault issues and treating victims with dignity, sensitivity and without prejudice should be emphasized (16, 18). Chowdhury-Hawkins et al. argue that the women with a lack of sex preference (comparable with the respondents in our study answering with “neutral”) might want to undertake the examination as quickly as possible due to the previous emotional trauma so that they would tolerate whatever is involved to achieve that. Such tolerance has to be rated differently from a genuine lack of preference (16). Moreover, in our study it was shown that when women said they experienced a violation of their privacy or an additional psychological burden during the examination, male personnel were present more frequently and the average number of males was higher. If possible, the examination should therefore be performed by a female doctor. In cases where there is only a male doctor on duty, even greater emphasis should be placed on empathic and sensitive interaction and the presence of a female chaperone as a third party is advisable (11).

Our study has several limitations which should be noted. Firstly, the number of women included is limited and participants were recruited at only two nearby hospitals. Therefore, the findings of this study only depict the experiences of a certain population of sexually assaulted women and generalizability might be reduced. Furthermore, the vast majority of the women in our study presented at the hospital after they had reported to the police, therefore the results might be biased due to the over-representation of this subgroup. Another matter to be taken into account is that data collection was based on the women’s statements during the post-assault period and might therefore be affected by acute trauma, emotional stress or intoxication.

However, this study explored a research area that has gained little attention so far as it focuses on the perceptions of those directly affected by a sexual assault. As our insights regarding women’s perceptions and experiences grow, translation of this newly gained knowledge into specific steps to improve and optimize the examination setting is essential.