Sexual violence is a human rights abuse.1,2 The majority of sexual assaults are committed by someone known to the victim.3,4 Intimate partners perpetrate a significant proportion of rapes.3–8 A multicountry study showed that 30–60% of battered women were also sexually assaulted.9 Since 1994, violence committed by intimate partners has been recognized as an aggravating circumstance of assault under French Law.10 However, Assize Courts (courts in France that are competent to try cases involving major felonies, including rape) have adjudicated intimate partner rape only in exceptional circumstances,11 reinforcing the view that intimate partner sexual violence is less serious than assaults by unknown individuals.12 In the United States, marital rape was not a crime in all 50 states until 1993 and provisions exempting husbands from prosecution for rape remain common.13,14
Analyses of physical violence associated with sexual assaults by intimate partners compared with assaults committed by other types of assailants have yielded conflicting results.3,6,8 Data regarding the histories of assaults are scarce and follow-up is lacking. Although intimate partner violence is a global health issue,1 published studies are limited to physical findings3,6–8,12 or refer to psychological disorders in assault survivors.15,16 Population-based surveys have shown that a majority of victims told no one about the assault.4 The disclosure of a sexual assault can be an additional stressful experience for victims, who are frequently blamed and stigmatized.17–19
To properly characterize intimate partner sexual violence, we compared the physical and psychological symptoms observed among victims assaulted by an intimate partner with those assaulted by unknown individuals or by acquaintances as reported at a large referral center. We also recorded the social reactions reported by the victims when the assault was disclosed. We hypothesized that sexual violence is not less serious when the perpetrators are intimate partners than when they are unknown individuals or acquaintances.
MATERIALS AND METHODS
We conducted an observational and prospective study. We consecutively included all eligible individuals aged 15 years and older at the time of a reported sexual assault who were referred to the Department of Forensic Medicine (Bondy, France) over a 3-year period. The Department is the referral center for all sexual assaults survivors of the Seine-Saint-Denis area, which accounts for approximately 1.5 million inhabitants. Victims were excluded from our sample if they refused to undergo clinical examination, if their clinical examination was delayed for more than 1 year after the reported assault, or if they had insufficient knowledge of French or English for a medical interview.
Examinations were performed by trained forensic physicians after patients had reported the assault to the police or when they planned to do so shortly after the medical examination. Twelve forensic physicians were involved in data collection. All follow-up examinations were performed and psychological scales administered by two of them (M.S. and P.C.). An ethics approval of the project (No. 10-005) was given by the institutional review board (00006477) of Paris North Hospitals.
All patients had similar general, genital, and anal examinations. Gynecologic examination included a visual examination of external genitalia. Hymenal injuries were scrutinized using a Foley catheter in victims without prior sexual intercourse experience.20 Colposcopy and anoscopy were used at the examiner's discretion. No dyes were used. Inspection of the vagina and cervix was performed using a speculum in victims reporting prior sexual intercourse experience. Lacerations, bruises, abrasions, and scars were recorded. Relevant forensic and toxicology samples were collected. Trace samples were collected using swabs. The external genitalia were swabbed before insertion of a single-use speculum. In case of anal assault, swabbing was performed before and at the time of insertion of a single-use anoscope. Water was used as a lubricant. Swabs were also collected from the mouth and the surface of the body when indicated. Swabs were collected for spermatozoa, DNA, and sexually transmitted infection (Chlamydia trachomatis and Neisseria gonorrhoeae) testing. The slides were prepared immediately by direct smearing of the swab, left to dry, and frozen. When the victim reported partial amnesia or when the police requested toxicology sampling, blood and urine were analyzed for the presence and concentrations of alcohol and illicit psychoactive substances, including cannabis, cocaine, opiates, and amphetamines, tested by gas chromatography–mass spectrometry.21
Patients were examined for the first time on the day of referral. The follow-up included a second examination scheduled 1 month later. The sample period ran from January 1, 2008, to March 1, 2011. Victims of assault by intimate partners (group 1) were compared with victims of assault by acquaintances (ie, individuals who were previously known to the victims; group 2) and victims of assault by strangers (ie, individuals previously unknown to the victims; group 3). Unknown individuals were defined as persons the victim had never met or met for the first time within the 24 hours preceding the assault. Previously known individuals were defined as persons known to the victim for more than 24 hours before the assault. Data collected at the examination included the following: descriptions of the patients, the assailants, and the assault (Box 1); descriptions of the events after the assault; and medical examination results (Appendices 1–3, available online at http://links.lww.com/AOG/A776). Data were collected at the follow-up examination regarding 1) the events occurring before the second examination, including social reactions perceived by the victims after the assault (eg, support, negative reactions, mixed reactions, downplaying the importance or seriousness of the experience, or the absence of reactions) (Appendix 4, available online at http://links.lww.com/AOG/A776); and 2) the results of the clinical examination, including the evaluation of psychological status (Appendices 1–3, http://links.lww.com/AOG/A776). All variables are categorical, except the ages, the times to examination, and the Impact of Event Scale–Revised and General Health Questionnaire scales. Ages and times to examination were divided into quartiles when used in multinomial models.
Box 1 Characteristics of the Victim and Reported Assailant at Time of Presentation Cited Here...
- Age: Years (whole)
- Psychological disorders: Yes or No
- Use of psychoactive treatment: Yes or No
- Substance use: No or Yes (if yes, specify alcohol, cannabis, cocaine, heroin, tranquilizers)
- History of prior assaults: No or Yes
- If yes, by the same assailant: No or Yes
- Characterize assault: Physical assault only, sexual assault only, both sexual and physical assault
- Prior assault in the past 12 mo: Yes or No
- Estimated or known age: Years (whole)
- Gender: Male or Female
- Known recent use of psychoactive drug: No or Yes (if yes, name substance)
- How long victim knew assailant: No prior knowledge, Acquaintance, Current or former intimate partner
- Known substance use: No or Yes (if yes, specify alcohol, cannabis, cocaine, heroin, tranquilizers)
Physical assault characterization was based on patient report and recorded as binary (yes or no) answers. These included the following: Was the patient threatened? Did she make any self-defensive reactions? Was she confined? Was a weapon used? Was she drugged by the assailant or others? Did she recently take a psychoactive substance? If so, was this induced by the assailant? Which substances were involved (alcohol, cannabis, heroin, tranquilizers)? Was she punched? Slapped? Knocked to the ground? Kicked? Did she have her hair pulled? Was she scratched? Was she bitten? The characteristics of the sexual assault were reported as binary (yes or no) answers to the following: Did she report vaginal penetration? Anal penetration? Oral penetration? Any unsuccessful attempts of any or all of aforementioned penetrations? Was there sexual touching? Use of a condom? If the assailant was male, did he ejaculate and where?
Data were collected on the different events that could have occurred after the assault independently of the medical examinations conducted in our unit. Each victim was asked whether any other assault may have occurred since the one she reported, whether she had reported the assault to law enforcement, whether she had withdrawn her complaint, whether she reported any absence from work or interruption of studies, whether she had sought any medical or psychological opinion, and whether she had undergone any psychoactive treatment.
In the first examination, data were collected about the different kinds of symptoms reported by the victim (somatic and psychological symptoms), the time of examination (within 3 days and actual time), the presence of recent traumatic injuries, and the types and locations of these injuries. Victims were also asked whether they had sought a prior medical opinion. Somatic symptoms included reports of fatigue, pain, and functional impairment, defined as an inability to fulfill daily activities. Presence of psychological symptoms was reported. If present, these were categorized as anxiety, fear, shame, sadness, disgust, sleep disorders, depressive symptoms, intrusive images or revivification, self-blame, eating disorders, social withdrawal, and suicidal ideation. The different types of injuries reported were bruises, hematomas, wounds, sprains, and bone fractures. Locations of injuries were categorized as extragenital injuries (limbs, head or neck, trunk) and genital injuries (anus, vulva, hymen, and vagina).
During the second medical examination, somatic and psychological symptoms were noted the same way they were during the first examination. Variables were also the same. The time between the two examinations was noted. During the second examination, posttraumatic stress symptoms were evaluated with the French Impact of Event Scale–Revised, a validated scale that measures intrusion, avoidance, and arousal within the last 7 days.22 We considered the common cutoff score of 33 indicative of posttraumatic stress disorder (PTSD).23 Mental health disorders were screened with the French version of the General Health Questionnaire, a validated scale that measures social dysfunction, anxiety, depression, and somatic symptoms.24 We considered the common cutoff point of 4 out of 5 indicative of minor psychiatric disorder.24 We recorded the victim's report of the first person whom she informed of the assault (a family member, a friend, an intimate partner, another person) and the reactions from the intimate partner, the family members, and from other people around (support, negative, mixed, or absent). Negative reactions included blame, denial, relationship breakdown, threat, and violence.
We conducted descriptive analyses and searched for overall and pairwise differences among groups. Statistical tests included the χ2 and Fisher and Kruskal-Wallis tests. Results were considered significant for P≤.05. As commonly considered in observational settings, the lower the P values, the better. Multivariable models were built to control for potential biases and provide measures of association (odds ratios) for several variables of interest with respect to a reference group. Namely, we used multinomial regression models with the three different groups as the outcome, variables considered relevant with respect to statistical significance, and the age of the victim as adjustment variables in each model. Variables were included in these models if statistically significant for P<.1 in univariate analysis or based on the analysis of vulnerability and the history of characteristics of psychological disorders, including the General Health Questionnaire or Impact of Event Scale–Revised scales. For specific medical outcomes such as somatic symptoms, psychological symptoms, or the presence of traumatic injuries, models were additionally adjusted on the time to the first and second examinations, as appropriate, because time can influence the appearance of the injury, the resolution, or the intensity of symptoms at the time of examination.
Our sample consisted of 797 patients (female:male, 767:30; 96%:4%). Figure 1 shows a flowchart of inclusion. We excluded the 30 male patients, leaving 767 female patients. Groups 1, 2, and 3 included 263, 229, and 275 patients, respectively. Table 1 shows the characteristics of the victims, the assailants, and the assaults. The forensic examination was performed within 3 days of the assault for 473 of the 767 patients (62%).
A total of 294 patients (38%) attended the 1-month follow-up consultation. Patients with a history of sexual or physical assaults attended the follow-up consultation more frequently than other patients (56% [95% confidence interval (CI) 50–62] compared with 45% [95% CI 41–49]; P=.002). Attendance rates at the second examination were similar regardless of their age (median 23 compared with 23 years; P=.246); whether the patients had a history of psychological disorders (31% [95% CI 26–36] compared with 25% [95% CI 21–29]; P=.792) or vulnerability (12% [95% CI 8–16] compared with 13% [95% CI 10–16]; P=.792); whether they sought medical advice after the assault (28% [95% CI 23–33] compared with 22% [95% CI 18–26]; P=.080); whether they reported associated physical assaults (38% [95% CI 32–42] compared with 41% [95% CI 37–45]; P=.492), presented recent traumatic injuries (49% [95% CI 43–55] compared with 52% [95% CI 47–57]; P=.483), or psychological symptoms (85% [95% CI 81–89] compared with 84% [95% CI 81–87]; P=.491); and whether they were given antiretroviral therapy at the time of the first medical examination (26% [95% CI 21–31] compared with 32% [95% CI 28–36]; P=.070).
In group 1, the victims and their assailant were a couple in 161 cases (61%) and were separated in 102 cases (39%). A total of 376 patients (49%) reported previous sexual or physical assaults, including 235 cases (31%) within the last 12 months. Previous assaults were more frequently reported by victims assaulted by intimate partners than by other types of victims (71% [95% CI 65–77] compared with 49% [95% CI 45–53] and 28% [95% CI 22–34] for groups 2 and 3, respectively; Tables 1 and 2). A total of 304 victims (40%) reported physical assaults; these were reported more frequently in intimate partner assaults (55% [95% CI 49–61] for group 1 compared with 32% [95% CI 26–38] and 31% [95% CI 26–36] for groups 2 and 3, respectively). Punches, slaps, and kicks were more frequent in intimate partner assaults (Tables 1 and 3).
Somatic symptoms were reported by 532 patients (69%) and mainly included fatigue and pain. We found recent traumatic injuries in 388 victims (51%). Extragenital traumatic injuries were more frequent in intimate partner assaults (52% [95% CI 48–56] compared with 33% [95% CI 27–39] and 43% [95% CI 37–49] for groups 2 and 3, respectively). No extragenital physical assaults were reported, and there were no traumatic injuries in 314 cases (41%), including 30% of intimate partner assaults (78/263). Among victims reporting extragenital physical assaults who were examined within 72 hours after the assault, there were no traumatic injuries in 43 of 200 cases (22%). No intergroup differences were observed with respect to this measure (Table 4; Appendix 2, http://links.lww.com/AOG/A776).
Psychological symptoms were found at the time of the first examination (Table 4; Appendix 3 [http://links.lww.com/AOG/A776]) in 84% of the patients. The most frequent symptoms included anxiety (50%), fear (34%), shame (25%), and sadness (22%). Fear was reported more frequently in victims assaulted by intimate partners (46% [95% CI 39–52] compared with 30% [95% CI 24–36] and 25% [95% CI 20–30]). At follow-up (Table 5; Appendix 3 [http://links.lww.com/AOG/A776]), psychological symptoms were noted in 271 of the 294 follow-up patients (92%). The most frequent symptoms included sleep disorders, depressive symptoms, self-blame, fear, intrusive images or reliving of the trauma, shame, anxiety, eating disorders, and social withdrawal. Scores obtained in scales suggested that most victims presented a PTSD or minor psychiatric disorders (79% and 89%, respectively). Results were similar across the three groups. After the consultation (Appendix 5, available online at http://links.lww.com/AOG/A776), the physicians referred the patients to other professionals in 63% of cases. Victims assaulted by intimate partners were more frequently referred to lawyers, social workers, and victim support associations than other victims.
In the 131 cases (45%) in which the assault was reported to the police more than 48 hours after it occurred, victims related the delayed disclosure to fear (42%), physical or mental inability (36%), threats by the assailant (18%), attempts to forget (15%), and incomplete information (13%) (Appendix 6, available online at http://links.lww.com/AOG/A776). Victims perceived emotional support from their spouse or romantic partner, family members, and other individuals in 25%, 52%, and 60% of cases, respectively. Victims assaulted by former intimate partners perceived support from their spouse or romantic partner less often than other types of victims (6% [95% CI 3–9] compared with 26% [95% CI 17–35] and 32% [95% CI 22–42]). The proportions of perceived positive reactions from family members and others were similar in all groups (Table 4; Appendix 4 [http://links.lww.com/AOG/A776]).
Supplementary results are available in Appendices 1 and 5–7 online, including drug prescriptions after the medical examination (Appendixes 1 and 7, available online at http://links.lww.com/AOG/A776), assault disclosure to the police (Appendix 6, http://links.lww.com/AOG/A776), and referral to other professionals after the second examination (Appendix 5, http://links.lww.com/AOG/A776).
Sexual assault by a current or past intimate partner is often treated by law enforcement, the judiciary system, and the public as somehow less of crime than sexual assault by a stranger or nonintimate acquaintance. This study demonstrates that extragenital physical assaults coincident with the sexual assault are more commonly perpetrated by intimate assailants than either strangers or acquaintances. Additionally, there is no difference in the victim's psychologic symptoms nor in the reaction to reports of the assault to family and friends.
We found evidence of recent traumatic injuries in just more than half the victims, a lower proportion than the 80% reported in victims examined in an emergency department.25 The absence of visible injuries may be related to the long interval between the assault and the medical examination. The absence of visible injuries does not necessarily indicate the absence of physical assault.25,26 We found traumatic injuries in only 76% of victims reporting recent physical extragenital assaults. The absence of physical extragenital assaults and of traumatic injuries has major implications for victims and the response of the criminal justice system. Victims are more likely to report a rape if they have physical injuries that support their allegations.27,28 Police are more likely to investigate sexual crimes in cases with recorded injuries.28 A common myth is that rape requires the use of physical force.29 The absence of physical extragenital assaults can originate from a psychological control by the assailants threatening the victims verbally or with a weapon. The higher frequency of physical extragenital assaults in victims of intimate partners, as reported in a previous study from Sweden8 but not in earlier studies,3,6,15 may be related to such assaults commonly being committed at home, potentially making it easier for the assailant to confine the victim.
Disclosing sexual assault is a stressful experience. In a French national survey, 38% of sexual assault victims who told someone about the assault did not do so immediately, similar to the 44% of victims in our sample who told the police more than 48 hours after the assault.30 In these cases, most victims related the delayed disclosure to fear, physical or mental inability, or threats by the assailant. We observed a 38% attendance rate at 1-month follow-up, similar to the 31–35% reported in previous studies.31,32 Some victims who did not attend the follow-up consultation might have been silenced by negative reactions to the disclosure of the assault by professionals, friends, or family.18 Previous research has shown that negative social reactions are related to greater PTSD severity.15,17 We found only minor differences between the patients' general characteristics or their distribution among the three groups at the time of the initial examination and at follow-up.
We found evidence of psychological disturbance in most cases, including 84% of patients at the time of the first examination and 92% of patients reexamined 1 month later. Responses to the Impact of Event Scale–Revised and General Health Questionnaire at follow-up showed that victims of intimate partner assaults had rates of disturbance similar to other types of victims. More than half of the victims had some form of sleep disorder and depressive symptoms. Previous research has shown that 80–90% of victims of sexual assaults present with PTSD 1 month after the assault.33
This study has certain limitations. First, all patients included had complained to the police or planned to do so. Because only a minority of sexual assault survivors file complaints, the data cannot be considered representative of all sexual assaults.34 Victimization surveys and reports from sexual assault centers, which receive victims who file complaints and others who do not, have shown that the propensity to report was higher if the perpetrator was unknown.27,28,35 However, no significant difference was found in a report from Sweden.36 Second, the time to examination varied among individuals, making traumatic lesions difficult to interpret in some cases. The broad inclusion criteria were a methodologic option that may make this study more representative of the subset of victims who complained to the police. Third, we had no access to data from judicial investigations or to offender statements. Most data, including characteristics of the assault or of the assailants, were obtained from patients. Without other evidence regarding the assaults such as evidence from police investigators and assailants, we cannot be sure that all allegations were founded. A participant with an assailant who was a complete stranger could not knowledgeably report that the assailant had an addictive disorder.
We searched the PubMed database without any language, publication date, or article type filter and used the following search words: 1) “psychological AND injury AND social reaction AND (sexual assault OR sexual violence)”; and 2) “psychological AND injury AND (sexual assault OR sexual violence).” This study is the first to jointly consider traumatic injuries, psychological symptoms, and perceived social reactions after sexual assaults.
Our results show that women who were assaulted by an intimate partner experience the same degree of psychologic distress and lack of support by their friends and families as victims of stranger or acquaintance rape and a greater rate of extragenital trauma. This challenges law enforcement, judiciary, and public opinion that seem to underestimate the seriousness of intimate partner sexual assaults. The high frequency of repeated assaults in which the assailant is an intimate partner confirms the substantial difficulties experienced by patients in breaking the silence surrounding domestic violence.
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