OPEN BROMA

Some researchers have extended their prevalence research to also identify factors associated with the presence of genito-anal injuries. Variables that have been considered in such analyses and a summary of the findings are presented in Table 2. However, these studies are plagued by the

38 same limitations as noted for prevalence data, such as small sample sizes. In addition, a number of studies only used bivariate analysis and thus did not adjust for other important variables. The hypothesis or theories for testing some of the variables were also not clear.

Table 2. Factors associated with the presence of genito-anal injuries* Survivor characteristics

Age Eight out of 14 studies showed no association with age (174, 175, 204, 207, 213, 222, 247, 251). One study reported that mean age was greater in patients with injuries but this was marginally significant (13.4 vs. 12.7 years) (221). Another study reported a greater odds of having injuries in survivors between the ages of 12 to 19 years, and in survivors older than 50 years, when compared to survivors aged between 20 to 49 years (223). Similar findings were reported where the prevalence of injuries was greater in adolescents compared to adults (83% vs. 64%) (206). In contrast, a fourth publication reported a greater odds of injuries in survivors 45 years or older

compared to women aged 12 to 24 years (Odds ratio (OR) 2.1, 95% CI 1.4 - 3.2) (215). Almost the same results were reported for women 40 years and older who had significantly more injuries than women between 14 and 19 years of age (OR 5.6, 95% CI 1.6 – 20.2) (227). In a study conducted by Sugar et al (229), survivors between 20 to 29 years of age (OR 0.5, 95% 0.3 – 0.8), 30 to 39 years of age (OR 0.4, 95% CI 0.2 – 0.6), and 40 to 49 years of age (OR 0.3, 95% CI 0.2 – 0.7) had less odds of genito- anal injuries than survivors between the ages of 15 and 19 years.

Menarche One study that was conducted in children found that injuries were more likely to be present among menarchal than premenarchal girls (30% vs. 8%, OR 2.1, 95% CI 1.2, 3.6) (202) and two other studies showed no association with Tanner staging (204, 221).

Menopause Linked to the findings on age above, four out of five studies found an association between survivors who were menopausal and the presence of genito-anal injuries compared to pre-menopausal survivors (209–212). One study reported no association (175).

Race Eight out of 10 studies reported no association between race and the presence of genito-anal injuries (175, 206, 208, 210, 224, 241, 247, 251), while two studies showed an association between being a White survivor and the presence of genito- anal injuries (213, 245) compared to Black/African survivors.

Educational status

In two studies college graduates had significantly more injuries than high school graduates (222, 247). In addition, in the one study survivors who had less than high school education were found to have less injuries than those who were high school graduates (247) but this was not found in the second study (222).

Marital status Two studies reported no association (222, 247). Previous sexual

experience

Seven out of 10 studies reported a significant association between the survivor not having previous sexual experience and the genito-anal injuries (216, 222, 223, 226, 229, 236, 251). In three other studies, no significant association was found with all injuries, but an association was reported with hymenal injuries (204, 205, 252).

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Parity Two out of three studies reported no association with parity (175, 226), whereas one study reported fewer injuries in survivors who had delivered two or more children (222). Another study found fewer injuries in survivors who were pregnant compared to those who were not (239).

Previous experience of violence

Four studies reported no association between previous sexual assault history and genito-anal injuries (206, 210, 224, 241), while one study found that survivors who were involved in fights previously had a higher prevalence of injuries (253). Alcohol/ Drug

use

Eleven out of 12 articles found no association between the use of alcohol and/or drugs and genito-anal injuries (204, 206, 210, 215, 223, 224, 226, 229, 241, 247, 251). One article found more injuries in survivors who had used alcohol (OR 1.3, 95% CI 1.0 - 1.5) but no association was found with drug usage (222).

Medical conditions/ Medicine/ Use of products

Two studies reported no association on the use of lubricants and genito-anal injuries (174, 247), and two other studies found no association with the use of condoms (174). One study reported that patients who were using oral or injected contraception had less genital injuries (OR 2.0, 95% CI 0.9 – 4.6, p value < 0.10) (226). In terms of mental health, one study found no association between psychiatric disorders and the presence of genito-anal injuries (229) while another study reported no association with the use of antidepressants (226). Tampon use was significantly associated with more vulval injuries and less hymenal injuries in one study (252) yet found not to be associated in another study (174). Laboratory evidence of genital infection was also not found to be associated with the presence of injuries in one study (174).

Assault characteristics Relationship

with perpetrator

In seven out of 11 studies there was no association between the relationship of the survivor and the perpetrator and genito-anal injuries (252). In one study this was only true for adult survivors whereas in children, assault by a stranger was associated with more injuries (245). In another study, when further analysis was done, assault by a stranger was associated with more anal injuries (21% vs. 14%) and fewer hymenal injuries (28% vs. 37%) (224). A lower odds of injuries was also reported with known assailants (OR 0.4, 95% CI 0.2 - 0.9) in another study (227). Yet, in contrast, two studies reported that there were significantly more injuries in survivors who were assaulted by known perpetrators (175, 226). Similarly, Möller et al. found no association with genital injuries, but intimate partner (OR 9.3, 95% CI 1.2 - 50) and acquaintance (OR 7.5, 95% CI 1.0 - 56) assault had a greater odds of anal injuries when compared to stranger assault (242).

Number of perpetrators

In all six studies there was no association reported (206, 210, 223, 224, 227, 229). Location of the

assault

In three studies there was no association noted between the location of the assault and injuries (223, 226, 229), whereas one study reported significantly less injuries when assaults occurred outdoors (215).

Time of assault There were two studies that reported no association between the time of day and the presence of injuries (223, 247), and one study that reported no association between the day of the week and injuries (247).

Penetration There were four studies that looked at whether penetration was associated with the presence of genito-anal injuries. In two studies vaginal penetration (199, 222) and

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penetration with a finger (174, 222) was associated with injuries. In another study, penetration with an object was associated with injuries (222). One study reported no association (247) while another reported no association when penetration with a penis was compared to penetration not by a penis (174). Only one study reported on oral penetration and here also no association was found with genito-anal injuries (229). Anal

penetration

Linked to the variable above, all eight studies that looked at anal penetration and injuries reported a significant association (199, 204, 205, 222, 223, 229, 247, 251). Position during

assault

Two studies that tested this found no association between the position during assault and genito-anal injuries (175, 247).

Violence during assault

Four studies reported that physical assault during the rape was not associated with the presence of genito-anal injuries (223, 229, 247, 251).

Threats of violence

One study found a significant association between threats and the presence of injuries (227).

Presence of a weapon

Four studies reported that the presence of a weapon was not associated with genito- anal injuries (213, 222, 227, 229).

Resistance by survivor

In one study physical/verbal resistance was associated with genital injuries when compared to passive resistance or no resistance (247), whereas a second study found no association between verbal resistance and injuries (215).

Non-genital injury

Six out of seven studies reported an association between the presence of non-genital injuries and genito-anal injuries (204, 205, 215, 227, 229, 251), whereas one did not (223).

Loss of consciousness

Two articles reported no association between the loss of consciousness and the presence of genito-anal injuries (222, 247).

Examination characteristics Bath after

assault

One study reported that survivors who had a bath after an assault had less genito-anal injuries recorded (199).

Time between assault and examination

Twelve out of 21 studies found more injuries when survivors were examined closer to the time of assault, but the category of time varied from 24 hours to 72 hours (185, 199, 204, 205, 221, 222, 226, 229, 233, 242, 247, 251). In the remaining 9 studies, no association was found (175, 176, 206, 210, 213, 223, 224, 233, 241).

Examiner One study reported no association between sex of examiner and genito-anal injuries recorded (228). Two studies reported that examiners with less experience recorded more genito-anal injuries (199, 228), but the problem with a high rate of false positives in those less experienced was noted in the one article.

* Only data related to genito-anal injuries are presented and where associations are reported, these were reported to be significant in the study based on a significance level selected by the authors. Where it is reported that there are no associations, this was tested and found to be not significant by the authors based on their significance level in the publication.

Injury prevalence and factors associated with it vary considerably across studies and areas. This is in part difficult to compare due to various differences in the study designs, but most importantly there is no consistent means by which injuries are defined and presented, including a

41 lack of knowledge on injury interpretation (254). Health care providers, as forensically trained, record all clinical signs that survivors present with, yet the relevance especially in the legal field for some (e.g. redness in the genital area) are questionable, and as such they have been excluded from injury prevalence data in certain studies. An injury classification system that includes a severity score, anatomic location and injury type, which is relevant to the health care setting and criminal justice system, has been proposed (255). It would be interesting to see if the research and clinical fraternity will adopt this system if it is found to be valid and reliable in post-rape examinations.

A classification system for child sexual assault has been developed, but of concern to experts is whether health care providers with basic skills are able to identify between normal and abnormal genital findings, where distinctions can be quite subtle and require examination in various positions (256). Misclassification of normal genital variations as abnormal findings by junior or untrained providers is a potential problem. A number of studies have reported on poor knowledge in all health care providers on the genital anatomy in children (257–259) - the hymen was correctly identified by only 59% to 62% of family practitioners, paediatricians, emergency department physicians and paediatric nurse practitioners, and the vaginal opening by 58% to 60% of the sample population (257–259). Physicians and paediatricians who were more experienced (i.e. who had performed a higher total number of child sexual abuse examinations, had testified in more cases, and who conducted a greater number of examinations per month), and examiners who regularly reviewed cases with an expert and who kept up to date with current research were found to be more knowledgeable on anatomy and interpreted photographs and documentation more consistently than less experienced doctors (258, 260, 261).

4. MODELS OF POST-RAPE CARE AND IPV SERVICES, AND INTERVENTIONS TO