Study population

This cross-sectional study analyzed the attendances of all female patients who attended the Dublin SATU for forensic examinations that included a genital and/or anal examination between January 1, 2023 and December 31, 2023. The Dublin SATU, which is part of the national SATU network, is the busiest of the 6 units, seeing 40% of national attendances annually. The unit provides 24/7 care for people of all genders, aged 14 years and over who disclose acute sexual assault. In some circumstances forensic examinations are provided to people under 14 years of age if paediatric services are not available and there is an acute need for a forensic examination.

The inclusion criteria for this study encompassed all females who underwent a forensic examination that involved a genital and/or anal assessment during the study period.

Exclusion criteria applied to individuals who were not female, did not report a sexual assault or express concern that one may have occurred, or did not undergo a genital and/or anal examination.

Ethical approval

Ethical approval was granted by the Research and Ethics Committee, Rotunda Hospital, Dublin 1, Ireland (REC-2022-013). As the data analysed was irrevocably anonymized, the Ethics Committee deemed that individual patient consent was not required. Of note, each patient attending a SATU is asked to sign a consent form at the end of their visit, to allow their data to be used for research purposes.

Forensic examination

Forensic examinations at the Dublin SATU are conducted by doctors or nurses who have received specialized training in sexual assault forensic examintions, with people who attend for a forensic examination choosing between police involvement or a forensic examination without immediate police involvement (evidence storage). Physical examinations are guided by the person’s disclosure and preference, and include comprehensive, but not magnified, physical and genito-anal examinations, using sterile speculum and proctoscope as needed. Forensic samples (DNA and toxicology samples) are collected based on the type of assault and time elapsed. Colposcopy, staining and genital photo-documentation are not used. Forensic examination findings are recorded in a paper medical record contemporaneously.

Standardising genital examination documentation

To standardise comprehensive documentation of genital examinations during forensic assessments, and to facilitate analysis of these, we developed a detailed data collection tool for prospective inclusion in paper medical records (Fig. 1).

Fig. 1

Data collection tool used within the patient’s forensic examination chart

The process of the development of this tool began with a systematic review of existing literature, identifying inconsistencies in injury reporting and a lack of standardised injury definitions when prevalence rates are reported [8]. This review highlighted inter-examiner variability as a key issue. In response, we re-educated our forensic examiners on standardised definitions for various injuries to ensure uniform documentation (Table 1). These definitions were included in the tool and provided to forensic examiners to promote consistency. We also outlined the importance of documenting non-injury-related pathologies (e.g. vulval dermatoses), addressing previous gaps in documentation highlighted by previously published literature.

Table 1 Definitions used during forensic examination for injury findings

The tool featured a detailed diagram of the female genitalia to aid accurate documentation of injury location and type as well as tick boxes for exam types (e.g., external only, speculum exam, proctoscopy) to ensure precise recording (Fig. 1).

Forensic examiners received training on using the tool, focusing on the standardised definitions to ensure consistent documentation. The tool was then integrated into all paper medical records used during examinations. These measures aimed to standardise the accuracy and completeness of genital examination records contemporaneously.

Study protocol and data analysis

After each attendance, anonymised details from the paper medical chart are entered into a national database. This includes patient demographics, incident details (e.g., assailant-victim relationship, location, time), and attendance details (e.g., type, day/time, time from incident to attendance). Injury presence is recorded as a binary metric (yes/no) and includes both genito-anal and extra-genital injury rates.

Patient demographic and incident/attendance details were imported into Microsoft Excel from the national SATU database. Missing data (either due to non-entry or lack of recording by the forensic examiner) were left blank. The proportion of missing data is noted in tables where applicable. A chart review was conducted to collect genital injury details from the contemporaneously completed data collection tool. Extra-genital injuries were also recorded.

This data was irrevocably anonymised, was then coded and imported into SPSS (version 26). Descriptive bivariate analysis using the Chi-Square test examined associations between assault characteristics and demographical details, as well as the presence of injuries. Odds ratios (OR) and 95% confidence intervals were calculated, with statistical significance defined as p-value < 0.05.

Definitions

Genital(non-genito-anal) injury included injuries found on the head (scalp/hair, eyes, ears, face), mouth (lips, teeth and oral cavity), neck, torso (chest, breasts, upper back, abdomen, lower back and buttocks), arms (inner upper arms, remainder of arms, hands, and fingernails), and legs (inner thighs, remainder of thighs, lower legs, feet, knees).

Physical injury types included bruises, abrasions, lacerations, incised wounds, penetrating (stab) wounds and burns. Redness and/or tenderness were not included due to their non-specific nature.

Genital injury included injuries (laceration, abrasion, bruising/ecchymosis) on the mons pubis, internal/external genitalia and perineum. The non-specific finding of erythema/ redness was not included. Specific injury definitions are described in Table 1.

Anal injury included injury (laceration, abrasion, bruising/ecchymosis) to the perianal region, anus and rectum. The non-specific finding of erythema/ redness was not included.

Genito-anal injury is the combination of genital and anal injury.

The Clinical Injury Extent Score (CIES) [10] was utilised to categorise the severity of extra-genital injury as described below:

Mild injury defined as injuries having no discernible impact on the patient’s physical function or not requiring treatment.

Moderate injury defined as impacting on function and/or requiring medical treatment. Patients needed at least one out of seven moderate diagnostic criteria to qualify for allocation to moderate injury category.

Severe injury defined as intensive care unit / high dependency unit admission.

Mental health history

Any women that disclosed that she had a pre-existing mental health condition which had been diagnosed by a health professional, which included any mood disorder (e.g. depression), anxiety, schizophrenia, any type of personality disorder,

Post-menopausal

Women who self-reported that they were post-menopausal, those who had no menstruation for 12 months with associated symptoms of menopause or those who had undergone iatrogenic menopause due to surgery or medical treatment were included in this category.

Absence of previous sexual activity

Those who prior to the reported incident had never been sexually active.