Sexual Assault

Journal of Forensic and Legal Medicine 99 (2023) 102590 Contents lists available at ScienceDirect Journal of Forensic and Legal Medicine journal homepage: www.elsevier.com/locate/yjflm Research Paper Addressing sexual assault in Pakistan: Insights from an analysis of female survivors at Lahore General Hospital Faisal Naeem Bandesha a, *, Pervaiz Zarif b, Muhammad Ahmad Faraz a, Fabiha Moeen a, Kanza Ilyas Rehan a, Rida Khalid a a b Post Graduate Medical Institute, Lahore, Pakistan Ameer-ud-Din Medical College, Post Graduate Medical Institute, Lahore General Hospital, Lahore, Pakistan A R T I C L E I N F O A B S T R A C T Handling Editor: Wilma Duijst Background & objective: Rape is a severe kind of sexual violence that represents a significant violation of human rights. The objective was to investigate the demographic and clinical features of female survivors of sexual assault in Lahore, Pakistan. Method: A retrospective study was conducted at the Department of Forensic Medicine of Lahore General Hospital, analysing records of female sexual assault survivors investigated by affiliated police stations from November 2020 to November 2022. Data were collected from medicolegal certificates and medical notes and analysed using SPSS software. Result: 282 female survivors reported to Lahore General Hospital’s Forensic Medicine Department, aged 5–55 years, with a mean age of 22.74 ± 8.30. A significant proportion (50.4%) were aged 16–25 years. Most survivors were examined between 6 and 24 h (34%) and 2–7 days (37.9%) after the assault, with the majority (95%) exhibiting well-developed secondary sexual characteristics. Sexual assault and physical abuse were both reported in 56.4% of cases. In 77% of cases, the perpetrator was known, and in 36.5% of cases, a weapon was used. No external body injury was observed in 74.8% of cases, and 2.8% showed signs of fresh hymen rupture. The study identified 92.2% of cases lost to follow-up. Conclusion: This study highlights the pressing need to implement effective measures to prevent and address rape in Pakistan. The findings emphasise the need for education, improved forensic infrastructure and policy reforms to address sexual assault effectively. Keywords: Rape Sexual assault Medicolegal examination Victim Female 1. Introduction Rape is a severe kind of sexual violence that involves an individual’s forced or intimidated non-consensual sexual encounters. This act is widely recognised as an infringement on human rights, and its victims experience severe physical, psychological, and social ramifications. Women and children are particularly vulnerable to rape, and mostly the perpetrators are men known to the survivors.1 Sexual assault is defined and described differently across nations and segments, including the law, healthcare, and social services. As a result, in underdeveloped nations with inadequate healthcare systems to support sexual assault survivors, the overall incidence of sexual assault is often under-reported. Rape is defined as “physically forced or otherwise coerced penetration - even if slight - of the vulva or anus, using a penis, other body parts, or an object” by the World Health Organization (WHO).2 Rape is defined in the penal code of Pakistan as the act of a man engaging in sexual intercourse with a woman without her consent, against her will, or with her consent obtained through coercion, deception, fear, or misconception of fact or with consent when the woman is under the age of sixteen years.3 Sexual assault is deeply embedded in gender disparity, and United Nations describes gender-based violence as “any act that causes physical, sexual, or psychological harm or anguish to women”.4 Most sexual assaults and rapes are perpetrated by men against women, with men comprising approximately 99% of perpetrators. Furthermore, most survivors of sexual violence know their perpetrator, with an estimated 70% of assaults carried by an individual the survivor knows, such as a family member, intimate partner, or acquaintance.5 Rape occurs at an alarming rate around the globe. According to the UN Office on Drugs and Crime, Botswana has the highest rate, 96.87 per 100,000 people, * Corresponding author. E-mail address: [email protected] (F.N. Bandesha). https://doi.org/10.1016/j.jflm.2023.102590 Received 19 May 2023; Received in revised form 15 August 2023; Accepted 6 September 2023 Available online 7 September 2023 1752-928X/© 2023 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved. F.N. Bandesha et al. Journal of Forensic and Legal Medicine 99 (2023) 102590 while the United States has a rate of 38.2 per 100,000. The Kingdom of Saudi Arabia and Egypt have the lowest rape rates, with 0.09 and 0.12 per 100,000 people, respectively. Regarding statistics, Pakistan ranks 91st globally, with 3.07 reported cases per 100,000 people.6 Unfortunately, rape is a significant problem in Pakistan. According to a report published in 2022 by Pakistan’s Human Rights Commission (HRCP), there were 5279 and 1084 registered cases of rape and child sexual abuse, respectively, in Pakistan in 2021, with the total number of rape cases increasing by 200% over the past decade. The province of Punjab has the highest incidence of rapes, followed by Sindh and Khyber Pakhtunkhwa.7 However, this is likely an underestimation due to societal stigmas, fear of retaliation, and a lack of confidence in the justice system. Despite the intricacies of the problem, these statistics point to the need for increased efforts in Pakistan to prevent and address rape. This study aimed to identify critical denominators and clinical findings in survivors of sexual assault who presented to the Forensic Medicine department of Lahore General Hospital in Lahore. This would assist us in developing prevention strategies by educating the most vulnerable members of society. Chart 1. Time between assault and examination. Table 2 Genital examination. 2. Materials and methods Evidence of Penetration Number Percentage Hymen Number Percentage A cross-sectional retrospective study was conducted at the Department of Forensic Medicine & Toxicology of Lahore General Hospital, Lahore, from November 2020 to November 2022. All the sexual assault cases registered with the police station affiliated with Lahore General Hospital, Lahore, were included in the study. The data was collected from medicolegal certificates and medical notes, entered into a Microsoft Excel worksheet, and analysed using Statistical Package for Social Science (SPSS) version 25. The study complied with the World Medical Association Declaration of Helsinki in Ethical Principles for Research Involving Human Subjects. The ethical review board of the institution approved it. No Yes 15 267 5.3 94.7 Intact Healed Tear Fresh Tear 15 259 5.3 91.8 8 2.8 282 100 Total 282 100 3. Results During the period between November 2020 to November 2022, a total of 282 sexual assault survivors reported to the Forensic Medicine Department of Lahore General Hospital, Lahore. The mean age of survivors was 22.74 ± 8.30 years, with a minimum age of 05 and maximum age was 55 years. Most of the survivors, 142 (50.4%), belonged to the age group of 16–25 years, followed by 26–35 years 68 (24.1%), with 268 (95.0%) survivors having fully developed secondary sexual characters, as shown in Table 1. The survivors reported for the medicolegal examination between 6 h to more than three weeks, with most of the cases, 107 (37.9%) reporting within 2–7 days, followed by 96 (34.0%) within 24 h of the incident, as shown in Chart 1. On genital examination, 267 (94.7%) survivors had evidence of penetration, of which 259 (91.8%) had healed tears, as shown in Table 2. In our study, most of the survivors, 67 (23.8%), were accompanied by their mothers for the examination, followed by police 54 (19.1%), as shown in chart 2. In 159 (56.4%) cases, survivors gave a history of sexual assault and physical abuse, while a history of sexual assault alone was given in 123 (43.6%) cases. On physical examination, no bodily injury was documented in 211 Chart 2. Survivor Accompanied by. (74.8%), and simple injury was noted in 63 (22.3%). One notable finding was that 214 (75.9%) and 261 (92.6%) cases gave a history of changing clothes and using the bathroom before the medicolegal examination. In only 97 (34.4%) cases, a suspected stain could be recovered during a general physical examination. Another striking finding in our study was that in 217 (77.0%) cases of sexual assault assailant was known to the survivor, and 179 (63.5%) of the survivors did not report using any weapon, as shown in Table 3. The maximum number of cases, Table 1 Secondary sexual character and age-wise distribution of survivors. Variables Fully Developed Not Developed Age Number Percentage Number Percentage Number Percentage 5–15 16–25 26–35 36–45 46–55 Total 40 142 68 16 2 268 14.2 50.4 24.1 5.7 0.7 95.0 14 0 0 0 0 14 5.0 0 0 0 0 5.0 54 142 68 16 2 282 19.1 50.4 24.1 5.7 0.7 100 2 Total F.N. Bandesha et al. Journal of Forensic and Legal Medicine 99 (2023) 102590 Table 3 Assailant characteristics. Variables Weapon Used No Weapon Used Assailant Known Number Percentage Number Percentage Number Percentage Yes No Total 72 31 103 25.5 11.0 36.5 145 34 179 51.4 12.1 63.5 217 65 282 77.0 23.0 100 69 (24.5%), were registered at Kahna police station, followed by 68 (24.1%) at Nishtar Colony police station, as shown in Chart 3. A striking finding of our study was that in 260 (92.2%) cases of sexual assault, no final report was established regarding sexual assault and was lost to follow-up. Only 22 (7.8%) cases were declared, of which 3 (13.6%) were confirmed as positive, while 15 (68.2%) reports were inconclusive, as shown in Table 4. Total Table 4 Final report of the cases. Variable a Confirmed Not Confirmed Inconclusiveb Loss to Follow-upc Total 4. Discussion Number Percentage 3 4 15 260 282 1.1 1.4 5.3 92.2 100 a On findings of the medicolegal examination. Ambiguous final report. c Cases where results for the samples sent were not received from law enforcement agencies in the concerned department of Lahore General Hospital. b According to findings, the most likely age group to be sexually assaulted was 5–25 years (69.5%), while survivors ranged in age from 5 to 55 years. This is consistent with research from Pakistan8,9 and Bangladesh10 and findings from some Western countries.11,12 The propensity towards the younger age may be due to females being less knowledgeable and uninformed at this age. They become more cautious of unfamiliar people and acquaintances as they grow and evolve. Because of this, only two (0.7%) women over 46 years of age reported being sexually assaulted in our study. Although the young age group is most vulnerable globally, being a conservative society, cultural and religious taboos make mothers or other older women in the household and community disinclined to converse about the maturation process into the majority, making this age group even more susceptible to such incidents in Pakistan. Only 34.1% of survivors reported for the examination to the hospital within the first 24 h. This finding is consistent with studies in Bangladesh10 and Pakistan1, where only 23.7% and 36.7% were reported during the first 24 h, respectively. However, studies in Portugal,13 Nordic countries,11 and Nairobi14 highlighted that the survivors reported for the examination significantly earlier, with 61–80% reporting within the first 24 h and over 90% if the victim was pre-puberty in the United States.15 Our society’s decision-making process is most likely to blame for the late reporting. Such an occurrence is regarded as an insult to the family’s honour. The unfortunate survivor initially consults with their mother or perhaps another female elder. More indecision and thought to go into the encounter before it is brought for the consideration of the men of the family. Here, too, decision-making is delayed because reporting the incident constitutes being made public and disrespect to the family. There is a need for proper instructions and education for families and victims on reporting these horrific crimes, as early reporting improves the possibility of gathering medical evidence to convict the perpetrator. Furthermore, mechanisms for protecting the complainant’s and family’s confidentiality should be in place, and unwarranted public attention should be avoided. Medical examinations are often conducted not only days but weeks later, losing valuable information. According to reports, 90% of circumstances with positive evidence in the case were seen within 24 h of the offence.15 In 77% of the cases, the perpetrator was known to the victim. This is consistent with global trends in adult and pre-pubertal female victims, where 50–89% of perpetrators were known to the victim at the time of incidence.16,17 This pattern can be explained through the notion that a survivor is more inclined to find herself in a situation in which she is vulnerable to an assault by an individual she knows and, thus, a person with whom the survivor has some confidence. This contradicts the widespread perception that a stranger perpetrates sexual assault.12 In 75.9% of the cases, the victim changed their clothes and bathed before the medical examination, losing valuable information. This is demonstrated by the fact that stains were observed in only 34.4% of cases. This was expected, given that only 34.1% of the survivors sought medical attention within 24 h of the event. An overwhelming 92.2% of cases were lost to follow-up. The reason for so many cases not being followed by the authorities, or the survivor should be a cause for concern. This high ratio can also be attributed to the fact that reports from Forensic Science Authority are not sent directly to the concerned department or medical official but are received by the police department. Only 25.2% of the survivors had physical signs of assault on their bodies. Earlier studies in Pakistan18 and Nigeria19 observed 13.98% and 13.1% of cases with non-genital injuries, respectively. The hymen was ruptured in 94.7% of cases, with 2.9% fresh tears and 5.3% intact hymen. There are several reasons for the absence or presence of injuries. In our study, most reported cases are middle-aged and young female survivors, whereas genital injuries are often more prevalent among post-menopausal women and children. The lack of bodily injuries may not negate the accusation because it can be attributed to the victims’ susceptibility and the likelihood that the victim offered minimal struggle due to ample control by the perpetrator. Minor bodily injuries that heal quickly may be overlooked in cases of late examination, or a false accusation may be made. Several research studies have discovered that proof of physical trauma is neither predictive nor necessary for prosecution; thus, the medical examiner must collect non-medical evidence. The medico-legal report ought to serve as an explanation for the presence or lack of Chart 3. Police station of Registered Cases. 3 F.N. Bandesha et al. Journal of Forensic and Legal Medicine 99 (2023) 102590 physical findings. The implication of differences between an act of sexual assault and examination findings must be carefully assessed.20,21 Pakistan has no legal definitions of sexual assault against children or corresponding laws. The literature lacks actual incidences and prevalence rates. This is a delicate and challenging social issue, but it is not unattainable.22 The definition of sexual assault by WHO appears to be considerably more thorough and unequivocal. The definition states “the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent for, or else acts that violates the laws or social taboos of society".23 Sexual assaults in Pakistan have been underrepresented due to social stigmas and baseless prestige. As a matter of honour, social status discourages guardians and parents from reporting sexual assaults on women and children.1 Department of Forensic Medicine & Toxicology Ameer-ud-Din Medical College/Postgraduate Medical Institute/Lahore General Hospital, Lahore, in conducting this research. References 1. Khan M, Aziz S, Qamar N, Memon JQ. Frequent factors for women and children subjected to sexual assaults presenting at Jinnah Postgraduate Medical center, Karachi. J Pakistan Med Assoc. 2014;64(6):649–652. 2. Organization WH. Violence against women 2021. Available from: https://www. who.int/news-room/fact-sheets/detail/violence-against-women.. 3. Pakistan: penal code [Pakistan], act No. XLV, 6 october 1860. Available from: http s://pakistancode.gov.pk/english/UY2FqaJw1-apaUY2Fqa-apaUY2Npa5losg-jjjjjjjjjjjjj. 4. Organization WH. Addressing Violence against Women and Achieving the Millennium Development Goals. World Health Organization; 2005, 9241593814. 5. RAINN. Perpetrators of Sexual Violence: Statistics 2023. Available from: https ://www.rainn.org/statistics/perpetrators-sexual-violence.. 6. Wisevoter. Rape statistics by country 2023. Available from: https://wisevoter.com/ country-rankings/rape-statistics-by-country/. 7. State of Human Rights in 2021: Human Rights Comission of Pakistan; 2022. Available from: https://hrcp-web.org/hrcpweb/annual-reports/. 8. Hassan Q, Bashir MZ, Mujahid M, Munawar AZ, Aslam M, Marri MZ. Medico-legal assessment of sexual assault victims in Lahore. J Pakistan Med Assoc. 2007;57(11): 539–542. 9. Haider A, Kamran S. A study of female sexual offences in the year 2013 at DHQ Hospital Dera Ismail Khan. Ann Pak Inst Med Sci. 2014;10(4):187–192. 10. Islam MN, Islam MN. Retrospective study of alleged rape victims attended at forensic medicine department of Dhaka medical college, Bangladesh. Leg Med. 2003; 5:S351–S353. 11. Kerr E, Jawad R, Butler B, Welch J. Time to talk about rape. Joint initiatives can improve services for complainants of sexual assault. BMJ (Clinical Research ed). 2001;322(7280):232. 12. Stermac LE, Du Mont JA, Kalemba V. Comparison of sexual assaults by strangers and known assailants in an urban population of women. CMAJ (Can Med Assoc J): Can Med Assoc J. 1995;153(8):1089. 13. Santos JC, Neves A, Rodrigues M, Ferrão P. Victims of sexual offences: medicolegal examinations in emergency settings. J Clin Forensic Med. 2006;13(6-8):300–303. 14. Chaudhry S, Sangani B, Ojwang S, Khan K. Retrospective study of alleged sexual assault at the Aga Khan hospital, Nairobi. East Afr Med J. 1995;72(3):200–202. 15. Christian CW, Lavelle JM, De Jong AR, Loiselle J, Brenner L, Joffe M. Forensic evidence findings in prepubertal victims of sexual assault. Pediatrics. 2000;106(1): 100–104. 16. Koss MP, Dinero TE. Predictors of Sexual Aggression Among a National Sample of Male College Students. Annals of the New York Academy of Sciences; 1988. 17. Lacey H. Sexually transmitted diseases and rape: the experience of a sexual assault centre. Int J STD AIDS. 1990;1(6):405–409. 18. Parveen H, Nadeem S, Aslam M, Sohail K. Female victims of sexual violence: reported cases of in Faisalabad city in 2008. Prof Med J. 2010;17:735–740, 04. 19. Daru P, Osagie E, Pam I, Mutihir J, Silas O, Ekwempu C. Analysis of cases of rape as seen at the Jos University teaching hospital, Jos, north central Nigeria. Niger J Clin Pract. 2011;14(1). 20. Barger E, Wacker J, Macy R, Parish S. Sexual assault prevention for women with intellectual disabilities: a critical review of the evidence. Intellect Dev Disabil. 2009; 47(4):249–262. 21. Garrity SE. Sexual assault prevention programs for college-aged men: a critical evaluation. J Forensic Nurs. 2011;7(1):40–48. 22. Gillani U. Child sexual abuse in Pakistan: the need for an indigenous scientific knowledge base, effective policy making and prevention. Pak J Criminol. 2009;1: 81–96. 23. Srivastava K, Chaudhury S, Bhat P, Patkar P. Child sexual abuse: the suffering untold. Ind Psychiatr J. 2017;26(1):1. 5. Conclusion The age group between 16 and 25 years is most vulnerable, and in 77% of cases, the assailant was known. Only 34% of survivors reported within 24 h for examination, with 92.2% of cases lost to follow-up. Females of a vulnerable age should be better informed of the warning signs of such an altercation to enable them to react accordingly. Survivors and those close to them should be informed about the significance of reporting such an occurrence immediately and having the survivor examined so that appropriate documentation and evidence can be collected. To identify the perpetrator, infrastructures for semen and DNA analysis should be advanced. It would be more beneficial for the families and survivors if the government established rehabilitation centres for them, where besides their physical and psychological wellbeing would be restored, they would also receive proper legal assistance. It is distressing to note that 92.2% of cases were lost to follow-up, highlighting potential gaps in pursuing these reports. This calls for review and reforms in receiving reports from the Forensic Science Authority directly to the concerned Forensic Medicine Department. The findings of our study highlight the necessity for systemic and policylevel changes to address all facets of sexual assault in Lahore, with potential implications for other areas with similar challenges. CRediT authorship contribution statement Faisal Naeem Bandesha: Conceptualization, Methodology, Formal analysis. Pervaiz Zarif: Supervision. Muhammad Ahmad Faraz: Data curation, Writing – original draft, preparation. Fabiha Moeen: Data curation, Writing – original draft, preparation. Kanza Ilyas Rehan: Writing – review & editing. Rida Khalid: Writing – review & editing. Declaration of competing interest None to Declare. Acknowledgement We want to acknowledge the help and support provided by the 4