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Forensic practitioners’ willingness to handle sexual assault cases affected by training and experience deficiences: Local study

19 Jan 2022

  •  Finds unfavourable attitudes towards victims influenced by cultural beliefs
BY Ruwan Laknath Jayakody The lack of proper training and inexperience adversely affects the willingness of forensic practitioners to handle cases of sexual assault, while unfavourable attitudes towards victims are influenced by cultural beliefs. Hence, proper training and professional development programmes need to be incorporated into the existing system in order to overcome shortcomings when providing healthcare. These findings and recommendations were made in an original article on “A study on the knowledge, attitudes, and beliefs of Sri Lankan forensic practitioners towards sexual assault survivors” which was authored by W.G.G.B. Kumarasinghe (attached to the Kandy National Hospital’s Judicial Medical Officer’s Office), W.W.J.S.M. Rowel (attached to the Victorian Institute of Forensic Mental Health in Victoria, Australia), and A.N. Vadysinghe (attached to the University of Peradeniya Medical Faculty’s Forensic Medicine Department) and published in the Medico-Legal Journal of Sri Lanka 9 (2) in December 2021. It was found as per a study conducted by the World Health Organisation (WHO) in 2018, which utilised data from 2000 to 2018, and from across 161 countries, that approximately 30% of women have been subjected to sexual and/or physical violence. The Women’s Well-Being Survey done in Sri Lanka in 2019 by the Census and Statistics Department showed that 24.9% of women had experienced physical and/or sexual intimate partner violence or non-partner sexual violence. Sexual assault is a serious public health problem, and causes, per E.C. Neilson, J. Norris, A.E.B. Bryan, and C.A. Stappenbeck’s “Sexual assault severity and depressive symptoms as longitudinal predictors of the quality of women’s sexual experiences” and S.E. Ullman and H.H. Filipas’s “Predictors of post-traumatic stress disorder (PTSD) symptom severity and social reactions in sexual assault victims”, significant mental health problems such as anxiety, depression, and PTSD. Following a sexual assault, survivors would, per A.Y.S. Wong, T.W. Wong, P.F. Lau, and C.C. Lau’s “Attitude towards rape among doctors working in the emergency department” contact several community agencies for assistance, such as the legal, medical, and mental health systems, while in the hospital setting, victims are referred to forensic, medical, and psychological assessment where forensic practitioners take the leading role during the assessment with a forensic examination being carried out as early as possible, following the index event, with the said examination usually taking approximately two hours. Wong et al. have shown that negative attitudes exist towards sexual assault survivors among community groups such as police officers and physicians. Kumarasinghe et al. noted that myths related to cultural beliefs, blame attribution, and core beliefs can result in negative reactions. Per Ullman and Filipas, such negative reactions are associated with more post-traumatic symptoms, stigmatisation, and the secondary traumatisation of the victims. Therefore, Kumarasinghe et al. invited forensic practitioners including postgraduate trainees and medico-legal medical officers to participate in a cross-sectional, anonymous online survey. An online questionnaire was used to gather data. The questionnaire was composed of 22 questions, including six questions on practice and demographics, six questions on the related knowledge, and 10 questions on beliefs and attitudes towards sexual assault survivors. Answers for the questions regarding knowledge, attitudes and beliefs were rated on a scale as “strongly disagree”, “disagree”, “neutral”, “agree”, and “strongly agree”. All the questions related to knowledge carried correct statements. In the questions regarding beliefs and attitudes, the first eight had negative statements and the last two had positive statements. The positive responses for correct and positive statements were correct or favourable while negative responses for the negative and incorrect statements were favourable. The questionnaire was developed with the guidance of the attitudes toward rape victims scale (ARVS) revised by C. Ward (“The ARVS: Construction, validation, and cross cultural applicability” – a 25 item scale which assesses favourable and unfavourable attitudes toward rape victims on victim blame, credibility, deservingness, denigration, and trivialisation) and was modified according to the Sri Lankan context.  Over 100 forensic practitioners were invited to participate in the study but only 51 responded to the survey and 50 completed the questionnaire properly, and one was incomplete. The majority were male (39 – 78%).  The majority were postgraduate trainees (29 – 58%) while 42% were medico-legal medical officers. The majority had work experience of one to four years (23 – 46%), 12 (24%) had more than 10 years of experience, eight (16%) had four to nine years of work experience, and seven (14%) had worked for less than a year. The majority (78%) had examined more than 10 cases in their career. Two participants had never examined any cases of sexual assault. The majority (64%) reported that they had never testified in a legal proceeding for a case of sexual assault. A total of 46% reported that they never had any reluctance to examine sexual assault cases because of the possibility of being required to testify in legal proceedings. A total of 60% of the postgraduate trainees and 15 (30%) of the medical officers reported never being reluctant to examine sexual assault cases. Also, the majority of the forensic practitioners who had more than four years of experience (30 – 60%) never had been reluctant to examine victims of sexual assault and that the value for the same with regard to forensic practitioners with less than four years of experience had been 36.7%. Out of the two participants who claimed that they had never examined any sexual assault cases, one reported being reluctant to examine sexual assault cases virtually all the time while the other reported being reluctant most of the time. The knowledge, beliefs, and attitudes of the participants towards sexual assault victims were thus: 1) Parent’s/Guardian’s consent should be obtained prior to the medico-legal examination of a case of child sexual abuse; 2) Psychiatry referral should be done even though consent is not taken; 3) Sexually transmitted disease referral should be done even though consent is not taken; 4) Clinical case conference should be held for child sexual abuse cases; 5) Institutional case conference could reduce the risk of future abuse; 6) Post-traumatic problems of sexual assault cases should be dealt by linking them with routine social service agencies (psychiatrists, counsellors, the National Child Protection Authority, and probation); 7) Victims increase their likelihood of being attacked by behaviours such as wearing revealing clothes, behaving in a suggestive manner, etc.; 8) During a sexual assault, a woman should do everything in her power to resist; 9) Most sexual assaults involve violence and physical injury; 10) Sexual assaults happen when women go out alone at night and in unsafe places; 11) Most of the perpetrators are strangers; 12) A woman could not be sexually assaulted by someone she previously knew or had sex with; 13) A victim who looks calm is less likely to have psychological problems later on; 14) Commonly, sexual assault victims will be hysterical, shaky, and distraught; 15) If I talked to someone who was sexually assaulted, I would become upset; and 16) Feel the emotional torment a sexual assault victim suffers when dealing with the Police/trial. An average of 35 (70%) responded as “agree” or “strongly agree” for all the correct statements regarding knowledge. The average percentage who responded as “disagree” or “strongly disagree” for the negative statements regarding attitudes and beliefs was 29 (58%). A total of 40% responded as “agree” or “strongly agree” for the two positive statements regarding attitudes and beliefs. Only 12 (24%) disagreed with the statement “During a sexual assault, a woman should do everything in her power to resist”. Only 14 (28%) disagreed with the statement “Victims increase their likelihood of being attacked by behaviours such as wearing revealing clothes, behaving in a suggestive manner, etc.”. There was no significant difference between postgraduate trainees and medico-legal medical officers regarding positive responses to positive statements regarding knowledge, and negative responses for negative statements. Also, there was no significant difference in the responses for the positive and negative statements between those who had less than four years of experience and more than four years of experience in forensics. The WHO, in their “Violence against women – Intimate partner and sexual violence against women” defined sexual assault and sexual violence as “any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic or otherwise directed against a person’s sexuality using coercion, by any person, regardless of their relationship to the victim, in any setting, including but not limited to home and work”, and includes rape, attempted rape, touching, sexual harassment, threatened sexual violence, and sexual slavery. Sexual assaults have been shown to have effects on the mental and physical health of the survivors which include long-lasting difficulties in the quality of their sexual experiences, reproductive or other sexual health problems including sexually transmitted infections, unwanted pregnancies, and mood and anxiety disorders, with depressive disorder and post-traumatic disorder being common among mental disorders. Neilson et al. reported that about one-third of rape victims experience a major depressive episode in their lifetime. Ullman and Filipas revealed that 94% of sexual assault survivors experience post-traumatic symptoms within two weeks of assault and 47% within three months while negative social reactions, including stigmatising responses are associated with more post-traumatic symptoms. Wong et al. whose study was done in Hong Kong involving doctors who work in emergency departments had shown that negative attitudes exist towards sexual assault survivors among community groups such as police officers and physicians, that 36% of them believed that “a woman should be responsible for preventing her rape”, that only 40% of doctors had reported that “they would not avoid handling sexual assault cases if they were given the choice”, that investigators believed that it could be due to the lack of proper training and a lack of experience in handling the above cases, and in turn highlighted the importance of formal training programmes in order to improve the knowledge and attitudes of doctors towards sexual assault survivors so as to prevent secondary victimisation. In Kumarasinghe et al.’s study, only 46% of the forensic practitioners reported that they never feel reluctant to examine sexual assault cases, because of the possibility of being required to testify in legal proceedings whereas 54% had some degree of reluctance in examining sexual assault cases, which could be due to a lack of experience and training. The postgraduate trainees were less reluctant to examine victims of sexual assault compared to the medico-legal medical officers though the difference was not significant. Those who had more years of experience were less reluctant to examine sexual assault cases. These findings, Kumarasinghe et al. pointed out, support that experience and proper training can influence the way in which medical practitioners respond to such victims. The favourable response rate was higher in the knowledge domain and comparatively low in the attitudes and beliefs domain. Thus, the majority were knowledgeable about the correct steps of management; however, they have negative beliefs such as blame towards the victims, where for example, a significantly low percentage of participants had disagreed with the statements, “During a sexual assault, a woman should do everything in her power to resist” and “Victims increase their likelihood of being attacked by behaviours such as wearing revealing clothes, behaving suggestively, etc.”. This, Kumarasinghe et al. observed, could be due to cultural and societal influence where, in the Sri Lankan cultural context, women bear a greater weight on social expectations as they are expected to wear and behave appropriately, in order to maintain dignity. Ullman and Filipas have shown that negative social reactions are associated with more post-traumatic symptoms, secondary victimisation, and the attribution of blame to the sexual assault victims. There was no statistically significant difference between postgraduate trainees and medico-legal medical officers, and those who had less than four years of experience and those who had more than four years of experience, in terms of the response rates to the attitudes, beliefs, and knowledge related domains. Knowledge and attitudes towards sexual assault victims are not affected by their years of experience or seniority. The findings of Kumarasinghe et al.’s study highlight the requirement of interventions so as to address the negative attitudes and beliefs of the forensic practitioners who are the primary contacts of sexual violence survivors in the hospital setting. “These interventions include clinical audits and training activities like lectures and online interactive learning sessions which could be incorporated into the existing training programmes and continuous professional development,” noted the study. If you’re affected by the above content or if you/someone you know may be dealing with a similar situation, the following institutions would assist you:

National Child Protection Authority helpline: 1929

Ministry of Child Development and Women’s Affairs helpline: 1938

Women In Need (WIN) 24-hour hotline: 077 567 6555 Sri Lanka Police Child and Women Bureau: 011 244 4444    

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