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By Ruwan Laknath Jayakody The phenomenon of unmarried females who have suffered sexual assault and abuse, presenting to hospitals with pregnancy, requires further evaluation and study, according to local research conducted into the presentations, patterns, and the prevalence of injuries in cases of alleged sexual assault and abuse. This finding was made by B.C.S. Perera (attached to the Office of the Judicial Medical Officer of the District Base Hospital, Dambulla) in an original article on “A retrospective study on the presentations, patterns, and prevalence of injuries in alleged sexual assault cases, presented to the District General Hospital, Gampaha, from July 2018 to April 2019”, published in the Medico-Legal Journal of Sri Lanka’s Ninth Volume’s First Issue on 30 June 2021. Sexual abuse, according to Perera, is sexual behaviour of an undesired nature, inflicted by one person upon another, which, as per P. Cameron, G. Jelinek, A. Kelly, A.F.T. Brown, and M. Little’s “Textbook of adult emergency medicine”, the American Psychological Association, and C.H. Kemp’s “Sexual abuse, another hidden paediatric problem”, is committed by the perpetrators for their stimulation or gratification, and causes physical (including sexually transmitted diseases [STDs], unwanted pregnancy, and sexual dysfunctions) and mental trauma. The majority of the victims are females, but males (men and boys) too, as per the World Health Organisation’s (WHO) “World report on violence and health” and the All Survivors Project”s “Legacies and lessons – sexual violence against men and boys in Sri Lanka and Bosnia and Herzegovina”, are similarly commonly victimised. Hence, Perera conducted a retrospective, descriptive study based on the medico-legal records (medico-legal examination forms, medico-legal reports, bed head tickets) of all the 103 cases with alleged sexual abuse reported to the District General Hospital, Gampaha (this hospital receives referrals for medico-legal examinations from eight divisional secretary divisions in the district), from July 2018 to April 2019. In terms of the socio-demographic characteristics of the victims, 88 were female (almost 90%) and 15 were male. Their ages ranged from three years to 87 years and the median (middle number in a data set) age of the victims was 15 years. A total of 72 victims had completed their secondary education. The vast majority of victims (almost 90%) were unmarried. With regard to the characteristics of the perpetrators, almost all of the perpetrators were male. Their ages ranged from 14 years to 70 years, and the mean (the average of a data set) age was 31 years, while 61% of the perpetrators were between 16 years and 30 years and 5% were over 60 years. A total of 84 abusers were known persons but not relatives (in this instance, those who fall under the incest category by law). There was a 92% probability of the abuser being a known person or a relative. Pertaining to the presentations and patterns of injuries, in 42% of the victims, the nature of the hymen (the commonest site of injury) was of an annular (ring shaped) type, while 11% were fimbriated (having a fringe/border of hair-like/finger-like projections), and 3% were crescentic (curved, sickle shape). Lacerations were the commonest type of injury. A total of 10 victims had sustained non-genital injuries following a sexual assault with injuries in more than one site. The breasts (33%), head and face (28%), and neck (24%) are the commonest sites. Abrasions (35%), bites (18%), and contusions (18%) were the injury types. A total of 11 victims had genital injuries (all at the hymen, with 90% hymenal lacerations and 10% contusions), and 55% of them are less than 15 years old. Of the victims with genital injuries, almost 75% presented within one week or less from the incident. Only three victims had anal and perianal anal injuries (including, among others, abrasions, tears, and lacerations) and all of them were males less than 15 years of age. All three had reflex anal dilatation, which, according to Perera, is – while suggestive of chronic anal abuse – not confirmative of the same (further, history did not support this finding as all denied having had previous anal intercourse). In relation to the nature and location of the sexual abuse, 40 gave a history of repeated abuse (more females than males, almost by just over half), but there was no statistically significant difference among the two biological sexes. A total of one-fifth of the cases of repeated abuse had occurred within one month to six months prior to the presentation. The commonest time per act was 15 minutes to 30 minutes (61%), followed by less than 15 minutes (18%). Almost 90% of the incidents occurred at a location with smooth surfaces (this finding, according to Perera, may be due to abuse being perpetrated by known persons, usually in their home environment). Also, 25 complained of ejaculation. Of the factors associated with the time taken to present to the hospital, almost 60% presented within three days of the incident while the median time for the first presentation from the day of the incident was three days. The duration, however, ranged from one day to 2.7 years. Those who had a history of chronic/repeated abuse and who became pregnant following the abuse were significantly associated with the length of time taken to report, as there was a significant delay in presentation. However, the victim’s age, place of residence, sex, civil status, type of abuser (known, relative, stranger), and the presence of injuries were not significantly associated with the time taken to report to the hospital. Also, the prevalence of genital injuries was almost fourfold among the victims that presented within one week or less from the incident, compared to those who presented after one week. In connection with the health-related impacts on the victims and the medico-legal opinion, all the cases were routinely referred to the venereologist and follow-up human immunodeficiency virus (HIV) and syphilis serology was planned in three months. Baseline syphilis and HIV serology were negative in all cases, but one victim was treated for genital herpes simplex virus. A total of 5% of victims had psychological problems even before the incident/s and seven were found by the psychiatrist to be psychologically disturbed after the incident/s. A total of 13% of unmarried females who were sexually assaulted presented with pregnancy and unmarried females who were sexually assaulted had a 11% chance of presenting with an acute hymenal tear following sexual abuse. In regard to the medico-legal opinion, 35% were reported with no physical or medical evidence, followed by 33% with chronic vaginal penetration and 5% with acute vaginal penetration. According to the Department of Census and Statistics’s (DCS) 2019 “Women’s (including girls) Wellbeing” survey, there was a 2% prevalence of intimate partner sexual violence and 1% of no partner sexual violence among females who were 15 years old and above, during the past year. Perera also noted that the majority of the cases, including incidents of intimate partner violence, remain unreported, including the underreporting of the total number of cases and a markedly low number of cases involving male victims, which were attributed to minor forms of abuse not presenting to the hospital as the victims themselves consider it negligible, societal attitudes towards gender norms and violence against females (in the Women’s Wellbeing survey, 47% women who were interviewed agreed with male superiority), fear of stigmatisation, the lack of social support, the loss of confidence in the justice system, the fear of repercussions to both themselves and to family members, and the absence of social services and support for survivors. According to the WHO, cultural and traditional male superiority and entitlement, the social acceptance of violence against women, inadequate legal and community sanctions against abusers, and areas with social conflicts with increased crimes and poverty are the main risk factors for this type of crime. Further, according to the All Survivors Project, male survivors may be discouraged from coming forward due to the discrimination and criminalisation of same-sex sexual acts. Analysing the findings, Perera explained that males overwhelmingly tend to be the abusers as females are more vulnerable due to their unequal social status. However, male victims tend to underreport when the abusers are females, as most of the time it is considered to be an insult when a male is abused by a female while females, on the other hand, tend to report more due to the fear and stigma over the loss of virginity and the risk of pregnancy. In “Characteristics of victims of alleged child sexual abuse referred to a child guidance clinic of a children’s hospital” by Y.M. Rohanachandra, D.M.A. Dahanayake, P.A.S. Pathigoda, and G.S. Wijetunge, 83% of the abusers were found to be known to the child. This is in part, Perera notes, due to the access that known persons have to minors when compared with strangers. The same reason, Perera observes, may be the cause for the significantly higher number of repeated abuse cases. In the case of sexual abuse and assault in the context of incest, in the majority of such cases, the relative was the victim’s father or a grandfather. In “Development of a screening instrument to detect physical abuse and its use in a cohort of pregnant women in Sri Lanka”, L.N. Moonesinghe, L.C. Rajapaksa, and G. Samarasinghe found that among the 1,200 women surveyed, the father was the abuser in 9%. The majority of the abusers being in the 16-45 years age group, Perera points out, is to be expected, as it reflects the usual range of the age of sexually active males and tallies with the fact that the male sex hormone (testosterone) usually peaks around the age of 20 years and decreases slowly after 30 years. Although the less than 15 years age group had a higher prevalence of genital injuries when compared to the other age groups, this difference was not statistically significant. Younger victims are, as per R.O. Samuel and C.E. Euzebus’s “Prevalence and pattern of genital injuries among adolescent rape victims attending the Enugu State University Teaching Hospital”, more susceptible to genital injuries following abuse. This may also be a question of the limited facilities available for detailed forensic examinations in developing countries, Perera adds. M.S. Sommers, B. Fisher, and H. Karjane’s “Using colposcopy (procedure to visually examine the cervix, vagina, and vulva) in rape exam healthcare, forensic, and criminal justice issues” notes that the use of colposcopy, digital imaging, and staining with contrast media has increased the prevalence of genital injuries by almost 90%. Perera opined that it can also be related to the delayed presentation of victims, as minor injuries can heal with time prior to the conduct of the medical-legal examination. Therefore, Perera called on the Government to establish forensic centres equipped with modern technology and facilities to facilitate detailed forensic examinations, as the lack of data could influence the opinion of the forensic expert and in turn negatively affect the court procedures when it comes to the final judgement in such cases. If you feel that you or someone you know may be dealing with sexual abuse and/or violence, 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