Pattern of Injuries in Genito-Anal Area in Cases of Sexual Assault: A Cross Sectional Study

Aim: To determine the pattern of injuries in the genito-anal area in cases of sexual assault Study Design: Cross-sectional study Place and Duration: This study was conducted at Liaquat University of Medical and Health sciences Jamshoro, Pakistan from June 2020 to July 2021 Methodology: A total of 96 victims of assault, who survived rape, were incorporated. The victims were from all groups of ages. All the patients considered in this study were both male and female. All of them had reported the case to the police and community. Results: There were 84.5% cases of penile-anal penetration, 76% of penile-oral penetrate and 48% of assault victims presented with ano-genital bleeding. Most of the cases of sexual assault considered in this study were not completely investigated previously. Original Research Article Aslam et al.; JPRI, 34(22B): 39-43, 2022; Article no.JPRI.84354 40 Conclusion: The study concludes that the most common pattern of injury after sexual assault was penile-anal penetration. Penile-oral penetration was the second most common injury. Nothing can undo whatever a sexual assault victim has to go through but catching and punishing the perpetrator is a necessary step. Genital injuries are not proof of a sexual assault. A sexual assault does not necessarily leave the genital area injured.


INTRODUCTION
Sexual assault is an important concern of public health with almost one in three women. In the case of men, the ratio is less than women and it is one in four men. Any form of physical contact with an intention of sexual assault can be categorized as sexual violence. The survivors of sexual assault need immediate health care to deal with their physical injuries, sexually transmitted infections, and risk of pregnancy. There is a need for an assessment of the victim to collect forensic evidence to catch the accused. Psychological and emotional support for the trauma of the patient should also be dealt with timely and compassionately [1]. Sexual violence is a common practice done globally. Consent has an important value worldwide. Without agreement or consent of the receipt of sexual contact is considered to be a violent act.
Sexual torture includes rape, drug-assisted sexual violence, forcible sodomy, child abuse, vaginal penetration and oral penetration. Rape is legal terminology that means sexual penetration without the agreement of the victim. This definition is irrespective of the extent of force and damage to the vaginal, anal or oral area [2]. The physical or emotional pressure put by the perpetrator is called force. A perpetrator can be a close relative, friend and a stranger. In the case of a stranger perpetrator, the rape is termed stranger rape. It is of three types; contact sexual assault, blitz sexual assault, and home invasion sexual assault [3].
DNA evidence of the crime is collected from the crime scene, the clothes of the victim, from the body of the victim and other surrounding objects. A 'rape kit' can be used to collect and preserve DNA evidence. Showering, changing clothes, cleaning the area, bathing, using a restroom and combing of hair can damage the evidence. The process can take a few minutes to a few hours depending on the case [4].
Generally, the process of forensic investigation of rape begins with the immediate care of the victim. Then the history of the case is recorded by taking the statement of the victim. The medical history of the patient is also collected. After that, a head-to-toe examination of the victim is performed. This component of the examination is specific depending on the experience of the victim. Internal and external examination of the vagina, anus and mouth are a part of this step. Samples of urine, blood, swabs from the surface of the body, and hair are collected. Photographs of the affected areas are collected. With the permission of the victim, their clothes, undergarments and related objects are also collected. Other objects related such as torn parts of clothes of the perpetrator or hair of the perpetrator during the crime are collected and packed for the sake of forensic analysis [5]. Necessary medical and psychological support is given to the victim after the collection of the evidence. However, medical attention is not enough for a sexual abuse victim. The intervention of the judicial system is important for the punishment of the perpetrator [6].
There are a few studies done about the association of injuries of the extra-genital and genital region with actual assault and those have been reported [7]. It should be noted that the experience of the examiner, style of examination and the setup in which examination is being conducted is significant in the documentation of the injuries. If the examination and reporting are delayed, results can differ due to the healing of injuries [8].
The present study aims to identify the pattern of genito-anal injuries in the victims of sexual assault and the elements associated with filing charges on the perpetrator [9].

METHODOLOGY
This is a cross-sectional study conducted at Liaquat University of Medical and Health sciences Jamshoro, Pakistan from June 2020 to July 2021. A total of 96 sexual assault victims had been considered in the study, irrespective of the ages of the victim. Victims were previously marked as raped and had reported to a police station or community. Both male and female victims who were sexually assaulted and had injured genito-anal areas were considered. Total 90 (93.75%) were female and 6 (6.25%) were male. Intoxicated cases and those who had extra genital injuries were excluded from the study. The assent of the casualty was acquired from them straightforwardly. The casualties had been analyzed in the presence of a female attendant with the aid of a specialist.
The victim was asked for a history, clinical record and a copy of the first information report (FIR). Permission from the ethical committee and moral panel was taken to carry out the study. They have explained the method of the study. The data was analyzed by IBM SPSS Version 26.

RESULTS
The mean age of the victims was 27.2 years (range, 13 years to 79 years). The mean age of the perpetrators was 32.8 years. Two victims (2.08%) had a psychiatric disorder. One had depression and one suffered from schizophrenia.
The most commonly observed type of assault was penile-anal penetration. 88 (91.66%) victims complained of penile-anal penetration. The second most common type of assault was penileoral penetration. Vaginal penetration was reported by 46 (47.19%) of the cases and digital penetration was reported by 52 (54.16%) of the victims. Total 82 (85.41%) presented with penileoral penetration (As shown in Table 1). Total 54 (56.25%) victims of assault were found with anogenital bleeding. 48 (50%) victims reported physical assault along with sexual assault (As shown in Table 3). Total 45 (46.87%) of the cases had an incomplete investigation.

DISCUSSION
The present study deals with the understanding of the happenings and pattern of sexual assault done in a genito-anal manner and its pattern. It also includes the study of the statistics of physical injuries the victim received during a sexual assault. Extra genital injuries the victims received are also studied. Moreover, the issues of underreporting and reporting were also keenly seen. The collection of prevalence data accurately was a challenge. Getting hold of the general public is also difficult. Not much research has been done in this regard. Standardized definitions of sexual assault, physical assault and abuse are also not available [10].
Penetration other than the anal orifice of the body such as oral and vaginal orifice is also considered a serious sexual offense. Consent and force issues are still in the phase of evolution. According to the study of Debby et al. at a college campus, 15.8% of women experienced forced sexual activities without consent and 7.7% of males experienced the same. Also, the students who had experienced sexual assault did not report the case to the administration of the college [10]. Another study done by Zinzow et al. suggests that the definition of consent should be made clear to the masses in order to reduce the risk of sexual assault and for the improvement of sexual communication [11].
The legislation and laws about sexual assault and rape are ambiguous and complicated. Different terms of sexual abuse such as rape, assault, abuse, etc. can also be confusing because they all are taken in different contexts in different regions of Pakistan. The same is the case with the 'consent' term which is why it is not given significance. It should be explained to the masses to be aware that sexual touch and exposure at any level is sexual abuse. Moreover, different terminologies are used in different regions about male and female penile penetration [12]. According to the study conducted by Kumar-Pal et al, 1225 victims of rape, physical assault, child abuse and sexual assault were assaulted by 120 perpetrators. This accounts for 5.8% rapes done by one perpetrator [13].

CONCLUSION
The study concludes that the most common pattern of injury after sexual assault was penile-anal penetration. Penile-oral penetration was the second most common injury. Whatever happens with a victim during a sexual assault is not undoable, however, catching the perpetrator and a valid punishment is necessary. If the victim was not sexually active before the assault, the genital injury would not necessarily be there contrary to the myths. Hence, the presence of injuries in genital areas is not proof of assault and the absence of injuries does not rule out an assault. The forensic examiner should keenly conduct the examination of the assault and report carefully for an accurate investigation.

DISCLAIMER
The products used for this research are commonly and predominantly use products in our area of research and country. There is absolutely no conflict of interest between the authors and producers of the products because we do not intend to use these products as an avenue for any litigation but for the advancement of knowledge. Also, the research was not funded by the producing company rather it was funded by personal efforts of the authors.

CONSENT
Written informed consent was signed by the victims and their attendants after a counseling session.

ETHICAL APPROVAL
As per international standard or university standard written ethical approval has been collected and preserved by the author(s).