Mahjabeen Khan ( School of Public Health, Dow University of Health Sciences, Pakistan. )
Sina Aziz ( Depatrment of Paediatrics, Karachi Medical and Dental University, Abbasi shaheed Hospital, Karachi, Pakistan. )
Nasreen Qamar ( Medicolegal Department, Jinnah Postgraduate Medical Center, Karachi, Pakistan. )
Jalil Qadir Memon ( Medicolegal Department, Jinnah Postgraduate Medical Center, Karachi, Pakistan. )
Objectives: To determine the frequent factors in women and children subjected to sexual assaults seeking medical care at Jinnah Postgraduate Medical Center, Karachi.
Methods: A cross sectional study was conducted in the Medico legal Department of Jinnah Postgraduate Medical Center, Karachi, Pakistan. Sexual assault victims seeking medical care and medico legal reports from Jan 2007-June 2010 were included in the study. The sampling technique was non-probability purposive. All women were informed regarding the confidentiality of their records and written informed consent was taken. In case of female children the consent was taken from both parents / guardians. The data was analyzed on statistical package for social sciences version 15.
Results: There were 180 women and children examined and interviewed after the Sexual assault. The mean age (years) was 19.24±7.33. Mostly reported victims were raped and abused both 162 (90%) and only rape was reported in 18 (10%).The physical, local, Abdominal and Pelvic examination showed fresh act of violence in sexual assault victims in 83 (46.1%) cases. The sexual assault was confirmed in 75 (41.7%) cases.
Conclusion: The fresh sexual assault acts confirmed in 41 %. The frequent factors in women and children subjected to sexual assaults were adult women (18-40 Years), two third victims brought by police after 6-24 hours of rape, 90 % reported both sexual assault and physical violence, in two third cases no weapon used and no external marks of body injuries observed.
Keywords: Rape, Sexual Assault, Victim, Women, Children, Medicolegal. (JPMA 64: 649; 2014).
Globally, sexual assault (rape) in women and children is a serious health, social and religious concern, as a violation of women and children\'s human rights. Sexual assault is defined as any undesired physical contact of a sexual nature committed against another person.1 Sexual assault has a demoralizing effect on children and women\'s sexual and reproductive health. The Sexual assault occurrences are more common in developed countries and according to world rape statistic 2008; a woman is raped in South Africa at every 17th second. A woman is raped every 2 minutes, according to the U.S. of America, Department of Justice.2 According to United Nations Office on Drugs and Crime, 2012; Lesotho is the country with the highest rate, 91.6 per 100,000 people while the rate in America is 28.6 per 100,000 people. The lowest rate of sexual assault recorded is in Egypt 0.1 and Armenia 0.3 per 100,000 people.3
Sexual assault has been a sociocultural, legal and societal sensitive issue in all the communities. However, not all countries define sexual assault in the same way. One of the major determinants is the definition and description of sexual assault variations in the law, health and social sectors. Child rape/ or rape occurred in victim married to the perpetrator is not considered as sexual assault in some communities. The actual incidence of sexual assault has been severely under-reported in most of the developing countries with poor health care system to support the sexual victims.
Sexual assault is basically rooted in gender inequality. The United Nation provides a broad framework for gender-based violence (GBV). GBV is defined as any act resulting in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty in public or private life.4,5 Sexual violence against women include acts that take place in home/community and at working places.6 The Millennium Declaration (2000), aimed the promotion of gender equality and empowerment of women. The eighth Millennium Development Goals (MDG) is to combat all forms of violence against women. This goal is to implement elimination of all forms of discrimination against women and children. Pakistan is one of the signatory but non-achievers countries of MDG.7 The actual and reported data is scarce for sexual assault and victims have not been given sociocultural, legal, psychological and health care support even for very few reported cases in urban and rural areas of Pakistan.
This study was conducted to determine the frequent factors in women and children subjected to sexual assaults seeking medical care at Jinnah Postgraduate Medical center, Karachi.
A cross sectional study was conducted in the Medico legal Department of Jinnah Postgraduate Medical Center (JPMC), Karachi, Pakistan. Sexual assault victims seeking medical care and medico legal reports were included in the study. The study was conducted during the period Jan 2007-June 2010. The sample size for the research is 180. According to the Grossin study8 at 12% of incidence examined in emergency at 95% level of significance with margin of error at 5% the sample size was 163. The loss for follow-up and refusal added and the final total sample size was 180. (OpenEpi, Version 3, open source calculator-SSPropor). The sampling technique was non probability purposive. Sexual assault victims were referred from investigating police authorities. All women were informed regarding the confidentiality of their records and written informed consent was taken. Women and children were given full coverage for their medical management. The informed consent for female children was taken from both parents/guardians. A structured Performa was used for the record of the demographics and medico legal examination report.
Initially women and children were physically examined; treatment given and reports were provided for further proceedings. Women and children with stable health status were given information regarding the study objectives and an informed written consent was taken. Women and children not in stable conditions and refusing for the medical examination and informed consent were excluded from the study. The data was analyzed on statistical package for social sciences version 15.
There were 180 women and children reporting at Medico Legal Department, Jinnah Postgraduate Medical Center from January 2007 to June 2010. Mean age was 19.24±7.33 years. The minimum age of rape victim was 5 years. The reporting time after the event of rape varied from 6 hours to 2 months. Mostly victims were examined by woman medico legal officer after 1-2 months 67 (37.2%) and within 6-24 hours 66 (36.7%) respectively. Mostly rape victims were brought by police 133(73.9%). Women and children mostly reported for sexual assault and abused both 162 (90%) and only sexual assault in 18 (10%). Women had well developed secondary sex characters 162 (90%) as shown in Table.
There was no external body injuries observed in 141 (78.3%) cases. The Physical, local, Abdominal and Pelvic examination showed fresh act of sexual assault in 83 (46.1%) cases. In more than three quarter cases (77.3%) no weapon was used. The sexual assault was confirmed in 75 (41.7%) cases as shown in Table. Rape and physical abuse in the form of burn and mutilation was found in 83(46%) sexual victims. The study reported morbidity in 3 children and 2 women. There were 13 cases brought by husband directly for the medico legal examination and report.
Sexual assault is a problem of all socioeconomic classes and impacts the physical, mental, social, psychological and spiritual health status of women and children throughout their life. Mostly sexual assault has been underreported, underrated and unsupported worldwide. The evidence and possible legal ramifications for affected women and children has not been managed properly in legal and health care system of Pakistan.
Mostly sexual assault victims were referred from investigating police authorities. Only few 09 cases were self-reported and police authorities were informed by the medico legal department. The medical report and chemical analysis confirmed sexual assault in 75(41.7%) cases only.
All sexual assault victims were seen by the senior women medico legal officers in emergency room of JPMC. The history taking, physical examination, evidence of chemical and pathological sample collection, medical treatment, and appropriate follow-up were provided at JPMC on behalf of Government of Sindh, Health Department. Grosin also analyzed 418 cases of sexual assault and found that victims had different characteristics according to the time between the sexual assault and the examination similar to our analysis.8 Medical management of the sexually assault victims needs both physical and psychological support in emergency room.
The place of the sexual assault occurrence was not reported in the medico legal forms. The gap between the medical and crime scene evidence to establish the final report require joint investigation by the prosecution to provide justice to the victims. This study showed that weapon used for harassment and physical abuse was sharp in 17(4.4%) and hard in 24(3.3%) cases. On medical examination there was simple injury in 33 (18.3%) and grievous in 06(3.3%) cases. There was no injury in 141(78.3%) sexual assault victims however, the absence of injury does not exclude the possibility of sexual act, whether with or without consent.9 Saint Martin analyzed that the medico-legal findings were associated with conviction of the assailant. The presence of general body and/or genital trauma was not associated with conviction10,11 similar to our study.
The minimum age of sexual assault victim was 5 years. This study revealed morbidity in 3 children and 2 women due to haemorrhage.
The frequent factors in this study found were time of medical examination after the sexual assault and increased length of time after the assault and examination. The victims were brought after 1-2 weeks 67(36.7%) and after 6-24 hours in 66(36.7%) cases. This delays the justice for the victims. Christian also reported the same in their study and reasoned that mostly sexually abused women and children were not identified immediately after assault. The timing of the examination require provision of physical and emotional support by the availability of standard medical examination.12 The minimization of time is dependent on the victims and their relatives’ decision for the timely report of sexual assault, police authority and role of medico legal officers in collecting the evidence. After the sexual assault the medico legal examinations has been focused on specific hymenal findings that suggest a child/woman has been sexually abused. The healing of genital injuries may occur before the medico legal examination. Therefore the interpretation of medical findings may be difficult/misguided.13-15
Several studies have found that the physical evidence of trauma was neither predictive nor essential for conviction; therefore non-medical evidence must be collected by the medical examiner. The medico legal report should be an instrument to explain the presence or absence of physical findings. The significance of discrepancies between an act of assault and clinical findings require careful evaluation.16-18
Mostly the victims were brought by police 120(66.6%), brother 18(10%) and husband 13(7.22%). The study found that trauma may range from minimal physical injury to death particularly as seen in other developing countries.19
The key part of the medical assessment of an act of sexual assaulted child is the medical history which requires a nonjudgmental approach by the woman medico legal officer.20 In this study medical history has been taken in detail and physical examination has been conducted in emergency department with the collection of maximum evidence at the time of examination.
In Pakistan there is absence of legal definitions regarding Child Sexual Assault and accompanying laws. The true prevalence and incidence rates lacks in literature. This social issue is sensitive and difficult, but certainly not impossible.21
The definition of sexual assault provided by the World Health organization (WHO) seems to be more comprehensive and unambiguous. The accepted definition is "the involvement of a child in sexual activity that he or she does not fully comprehend, unable to give informed consent, or else act that violates the laws or social taboos of society.22
In Pakistan, sexual assaults have been under reported because of social taboos, false prestige. The social status as matter of honour prevent parents/guardians to report occurrence of sexual assaults in women and children.23 There has been no national survey or official statistics available in Pakistan.24 In this study quarter of the victims had previous history of sexual assault by family members which were never reported.
The fresh sexual assault acts confirmed in 41%. The frequent factors in women and children subjected to sexual assaults were adult women (18-40 Years), two third victims brought by police after 6-24 hours of rape, 90% reported both sexual assault and physical violence, in two third cases no weapon used and no external marks of body injuries observed.
1. Marc B. Current clinical aspects of drug-facilitated sexual assaults in sexually abused victims examined in a forensic emergency unit. Ther Drug Monit 2008; 30: 218-24.
2. World rape rates. (Online) (Cited 2012 Jun 10). Available from URL: http://www.emergencypreparednessdepot.net/v/WORLD-RAPE-RATES/.
3. Rapes (per capita) - Nation Master. (Online) (Cited 2012 Jun 10). Available from URL: http://www.nationmaster.com/graph/ cri_rap_percap-crime-rapes-per-capita.
4. World Health Organization. Addressing violence against women and achieving the millennium development goals. Geneva, Switzerland: Department of Gender, Women and Health, World Health Organization; 2005.
5. United Nations Division for the Advancement of Women. Violence against women: a statistical overview, challenges and gaps in data collection and methodology and approaches for overcoming them. Report of the expert group meeting. Geneva, Switzerland: United Nations Division for the Advancement of Women; 2005.
6. Ampbell JC, Webster D, Koziol-McLain J, Block C, Campbell D, Curry MA, et al. Risk factors for femicide in abusive relationships: results from a multisite case control study. Am J Publ Health 2003; 93: 1089-97.
7. DeVore HK, Sachs CJ. Sexual assault. Emerg Med Clin North Am 2011; 29: 605-20.
8. Grossin C, Sibille I, Lorin de la Grandmaison G, Banasr A, Brion F, et al. Analysis of 418 cases of sexual assault. Forensic Sci Int 2003; 131(2-3): 125-30.
9. White C, McLean I. Adolescent complainants of sexual assault; injury patterns in virgin and non-virgin groups. J Clin Forensic Med 2006; 13: 172-80.
10. Saint-Martin P, Bouyssy M, Jacquet A, O\'Byrne P. Sexual assault: medicolegal findings and legal outcomes (analysis of 756 cases. J Gynecol Obstet Biol Reprod (Paris) 2007; 36: 588-94.
11. Lincoln C. Genital injury: is it significant? A review of the literature. Med Sci Law 2001; 41: 206-16.
12. Christian CW. Timing of the medical examination. J Child Sex Abus 2011; 20: 505-20.
13. Alexander RA. Medical advances in child sexual abuse. J Child Sex Abus. 2011; 20: 481-5.
14. Riggs N, Houry D, Long G, Markovchick V, Feldhaus KM. Analysis of 1,076 cases of sexual assault. Ann Emerg Med 2000; 35: 358-62.
15. Avegno J, Mills TJ, Mills LD. Sexual assault victims in the emergency department: analysis by demographic and event characteristics. J Emerg Med 2009; 37: 328-34.
16. Wacker J, Macy R, Barger E, Parish S. Sexual assault prevention for women with intellectual disabilities: a critical review of the evidence. Intellect Dev Disabil 2009; 47: 249-62.
17. Garrity SE. Sexual assault prevention programs for college-aged men: a critical evaluation. J Forensic Nurs 2011; 7: 40-8.
18. Finkel MA. Putting it all together. J Child Sex Abus 2011; 20: 643-56.
19. Nadesan K. Victims of violence: an Asian scenario. J Clin Forensic Med 2000; 7: 192-200.
20. Finkel MA, Alexander RA. Conducting the medical history. J Child Sex Abus 2011; 20: 486-504.
21. Gillani U. Child Sexual Abuse in Pakistan: The Need for an Indigenous Scientific Knowledge Base, Effective Policy Making and Prevention. Pak J Criminology 2009; 1: 81-96.
22. Preventing child maltreatment: A guide to taking action and generating evidence. Geneva: World Health Organization, 2006.
23. Child sexual abuse. (Online) (Cited 2013 Jun 12). Available from URL: http://www.pakistansocietyofcriminology.com/Admin/articles/ChildSexualAbuse.doc.
24. The state of Pakistan\'s children 2008. Islamabad, Pakistan: Society for the Protection of the Rights of the Child. SPARC, 2008.