Female Sexual Violence: A 12-Year Experience at a Single University Hospital in North-East Italy

In our case series, women older than 18 years appeared to be significantly more affected by mental health disorders and had more often experienced SV in the past. In contrast, a history of alcohol and drug abuse and a history of prostitution were not commonly reported. Therefore, they were not significantly different between the groups. A systematic review conducted in 2020 revealed that nearly 40% of individuals seeking assistance at Sexual Assault Referral Centers in England were also receiving care from mental health services [12]. Similarly, a study conducted in the United States identified “major psychiatric diagnoses” in 26% of 819 female patients who presented to an Emergency Department following the report of sexual assault [13]. Moreover, various studies have highlighted the significant prevalence of victimization among individuals with mental illness, including instances of sexual assault [14,15]. These findings confirm that psychiatric conditions increase the vulnerability of women to SV and abuse. In individuals with major depressive disorder, the slowing of thoughts and movement, coupled with feelings of worthlessness and indecisiveness, can significantly impact their ability to perceive and respond to threatening situations. This compromised cognitive and emotional state may hinder the individual’s capacity to identify and appropriately address potential threats [16,17]. On the other hand, episodes of mania, characteristic of bipolar disorder, may manifest with elevated mood, impaired judgment, disinhibition, and hypersexuality, posing a risk of engaging in activities with potentially painful consequences, such as sexual incautions. An impaired perception of the surrounding environment and diminished social functioning during manic episodes may further contribute to difficulties in staying safe, potentially leading to misjudgments regarding trust and increasing vulnerability to violence. Individuals with a history of SV, whether as adults or children, are reportedly at risk of using sex as a form of self-harm, potentially leading to re-victimization. Furthermore, drug abuse can result in a reduced awareness of one’s surroundings, impairing one’s ability to recognize and respond to danger. In the context of personality disorders, varying types may be associated with impulsivity, diminished self-worth, and submissiveness. These characteristics could contribute to challenges in maintaining mindfulness and, consequently, in ensuring personal safety [13,16,17]. Experiences with violence shape human development. Our findings, together with data in the literature, may suggest that being violently victimized, or witnessing serious violence early in life, might increase the risk of victimization later in life because of altered psychological development. Nonetheless, the continuity of adversity throughout life might make early victimization, a marker of social disadvantage, more likely to reproduce also later in life.

Our study showed that adults had bodily injuries more often than minors. This observation could be explained by the fact that sexual assault occurs unpredictably in adult women, and that bodily injuries are the result of their physical resistance against the aggressor or of a deliberate measure by the assailant. Our speculation is further confirmed by the fact that the aggressor was more frequently known among minors than adults, even though this difference was not statistically significant. Interestingly, the perpetrator was a family member in most cases reported in the minor group. These data shed light on the type of SV occurring against minors in our case series, which was nearly always performed in the family environment. Remarkably, our study revealed that the time interval between the SV and the request for medical help (expressed in days) was significantly longer among minors than adults. It is possible that the relationship between the perpetrator and the victim, as well as the victim’s feelings towards the offender, typical features of the family milieu, may lead to a delayed disclosure of SV among young victims [18]. Previous research has indeed demonstrated that victims of intra-familial abuse are more likely to delay disclosure than victims of extra-familial abuse [19]. In instances where the perpetrator is a family member or a trusted adult, a young child might be coerced into silence through threats of punishment, manipulation by instilling a belief that nobody would believe them, or by suggesting that revealing the truth would lead to the abuser going to jail. On the other hand, an older child may internalize the abuse as their own fault, harboring feelings of embarrassment and shame that prevent them from confiding in anyone. It is not uncommon for an older sibling to disclose their abuse only upon discovering that a younger sibling is also being victimized, fueled by a desire to protect their sibling from the same harm. For young adolescents, the fear of disclosing abuse is heightened by the circumstances surrounding the incidents. Instances where the abuse occurred during engagement in high-risk behaviors, against explicit warnings, or in undisclosed and unsafe locations may induce feelings of shame, regret, and apprehension about parental reactions. Consequently, these emotions might lead to a significant delay in disclosing the abuse, sometimes spanning weeks or even months [18,20].

No significant difference was reported regarding the prevalence of genital lesions between the groups. Moreover, in two thirds of young victims, no injuries were detected, likely rejecting an alleged sexual offence. However, it could be hypothesized that the victim might develop a passive behavior toward the sexual offense, mostly if the abuse occurs in the family environment. In rare cases, during the abuse, the victim might develop a set of involuntary responses, including temporary muscular paralysis, lowered body temperature, uncontrollable tremors and analgesia, which is called tonic immobility. Tonic immobility is considered the last chance when other defense attempts have failed [21] and its occurrence during sexual abuse cannot be excluded in the most vulnerable victims, such as minors in our case series.

First, it should be clarified what is meant by genital penetration. The female genital anatomy consists of external structures (labia majora, labia minora and the enclosed vestibule) and internal structures (hymen, vagina, uterus and adnexa). Penetration may be limited to the external genitalia. In this specific situation, it is unlikely that penetration will lead to physical signs, other than transient redness or abrasion, which heals fast. Second, it should be considered that, anatomically, the female genitalia, the anus and the mouth can be penetrated without any visible injuries, thus complicating the medico-legal evaluation. Therefore, the clinical assessment of children who may have been sexually abused can seldom confirm and never exclude sexual abuse. Third, even if false allegations might be commonly reported when a serious conflict exists between parents in the process of separation, the disclosure of sexual abuse against children should never be discouraged. A deferred admission of SV has multiple important negative consequences, such as an increased risk of severe psychological repercussion and a decreased ability to diagnose injuries and to detect biological traces of the violence. In a recent update on the classic interpretation of medical findings related to suspected child sexual abuse, Kellogg and colleagues have brought attention to the evolving understanding of normal genital anatomy [22]. Notably, S. Starling, in an editorial introducing Kellogg’s work, acknowledges that there has been a substantial shift in perspective since 1992, when an enlarged hymenal opening would lead to the suspicion of abuse [23]. Over the years, the definition of normal findings has expanded, while the list of trauma-induced findings has remained largely unchanged. Despite this evolution, certain aspects continue to spark debates among experts. One such point of contention is the interpretation of erythema. The editorial highlights the absence of a consensus on how to categorize erythema, noting that while the interpretation table designates erythema as a normal finding, widely used diagnostic criteria such as TEARS (Tears, Ecchymosis, Abrasions, Redness, and Swelling) consider it as indicative of trauma [24]. According to the TEARS criteria, the presence of redness or any other listed finding results in the examination being recorded as having a positive finding. Moreover, the authors suggest that very few findings are diagnostic of abuse: acute trauma to genital/anal tissues (such as acute laceration(s) or the bruising of different parts of the genitalia or perineum), residual injuries to genital/anal tissues (perianal scar, scar of posterior fourchette or fossa, hymenal transection or cleft, signs of female genital mutilation or cutting) and acute oral trauma (such as unexplained injury or petechiae of the lips or palate, particularly near the junction of the hard and soft palate). The identified findings strongly indicate potential abuse, even when there is no explicit disclosure from the child. However, an exception is made if the child or caretaker promptly provides a plausible explanation involving accidental anogenital straddle, crush, impalement injuries, or verified details of past surgical interventions from medical records. In cases where there are isolated, few, or superficial injuries resembling bruises or petechiae, it should be imperative to validate them as traumatic injuries by observing their resolution during follow-up examinations. To ensure precision in diagnosis, it is recommended that these findings are documented through photographs or video recordings. The evaluation and confirmation of these visual records should be conducted by an expert in sexual abuse assessment, emphasizing the importance of accuracy in the diagnostic process [22,25].

Importantly, an element that the evaluator must take into consideration is the mode in which the minor victim narrates the suspected abuse, especially if pre-adolescent or younger children are involved. Often, these narratives are inconsistent and characterized by bizarre, unusual, or “fantastic” situations that can undermine the credibility of the victim and pose challenges for clinical and forensic interpretation. Longobardi et al. attempted to classify recurring bizarre phrases in the accounts of victims of suspected sexual abuse in particular, highlighting how these are often present in the context of child pornography, and therefore may actually testify to genuinely experienced events. Consequently, it is crucial for the clinician to faithfully report the accounts of younger victims, providing detailed information, including any elements judged as strange, for subsequent evaluation by law enforcement, child neuropsychiatrists, and judges [26].