Genito-anal injury patterns and associated factors in rape survivors in an urban province of South Africa: a cross-sectional study.

BACKGROUND: The prevalence of genito-anal injuries in rape survivors varies significantly and the factors associated with the absence of injuries are not well understood. This plays a major role in the conviction of cases as the absence of injury is equated with a lack of assault. In such cases, health care providers face major challenges in presenting and defending their findings. The aim of this paper is to describe the absence of genito-anal injuries by site in a group of rape survivors and to identify factors associated with the absence of these injuries. METHODS: In a cross-sectional study rape cases reported to the police in one province in South Africa were randomly sampled using a two stage sampling procedure. Data were obtained on the survivor, the circumstances of the rape and the findings of the medicolegal examination. Descriptive statistics were conducted for the prevalence of genito-anal injuries by site and logistic regression models were built to identify factors associated with the absence of genito-anal injuries for all survivors and those reported to be virgins. RESULTS: In the sample of 1472 women injuries ranged from 1% to 36%. No significant injuries were reported for 749 (51%) survivors. In the multivariable model there was a significantly lower odds of having no injuries in survivors who were virgins, those raped by multiple perpetrators and those examined by a doctor with additional qualifications. In the model for survivors who were virgins, those with disabilities had a greater odds of having no injuries while those between the ages of 8 and 17 years had a lower odds of having no injuries compared to survivors below four years of age. CONCLUSIONS: This study found that being a virgin, multiple perpetration rape and the examiner's qualifications were significantly associated with the absence of genito-anal injuries. Health providers should thus be aware that in all other respects there was no difference in survivors who had injuries and those who did not. It is important to reiterate the message that the presence of injuries does not necessarily prove that rape occurred nor does the absence disprove the fact.

Medico-legal findings, legal case progression, and outcomes in South African rape cases: retrospective review.

BACKGROUND: Health services for victims of rape are recognised as a particularly neglected area of the health sector internationally. Efforts to strengthen these services need to be guided by clinical research. Expert medical evidence is widely used in rape cases, but its contribution to the progress of legal cases is unclear. Only three studies have found an association between documented bodily injuries and convictions in rape cases. This article aims to describe the processing of rape cases by South African police and courts, and the association between documented injuries and DNA and case progression through the criminal justice system. METHODS AND FINDINGS: We analysed a provincially representative sample of 2,068 attempted and completed rape cases reported to 70 randomly selected Gauteng province police stations in 2003. Data sheets were completed from the police dockets and available medical examination forms were copied. 1,547 cases of rape had medical examinations and available forms and were analysed, which was at least 85% of the proportion of the sample having a medical examination. We present logistic regression models of the association between whether a trial started and whether the accused was found guilty and the medico-legal findings for adult and child rapes. Half the suspects were arrested (n = 771), 14% (209) of cases went to trial, and in 3% (31) of adults and 7% (44) of children there was a conviction. A report on DNA was available in 1.4% (22) of cases, but the presence or absence of injuries were documented in all cases. Documented injuries were not associated with arrest, but they were associated with children's cases (but not adult's) going to trial (adjusted odds ratio [AOR] for having genital and nongenital injuries 5.83, 95% confidence interval [CI] 1.87-18.13, p = 0.003). In adult cases a conviction was more likely if there were documented injuries, whether nongenital injuries alone AOR 6.25 (95% CI 1.14-34.3, p = 0.036), ano-genital injuries alone (AOR 7.00, 95% CI 1.44-33.9, p = 0.017), or both nongenital and ano-genital injuries (AOR 12.34, 95% CI 2.87-53.0, p = 0.001). DNA was not associated with case outcome. CONCLUSIONS: This is the first study, to our knowledge, to show an association between documentation of ano-genital injuries, trials commencing, and convictions in rape cases in a developing country. Its findings are of particular importance because they show the value of good basic medical practices in documentation of injuries, rather than more expensive DNA evidence, in assisting courts in rape cases. Health care providers need training to provide high quality health care responses after rape, but we have shown that the core elements of the medico-legal response require very little technology. As such they should be replicable in low- and middle-income country settings. Our findings raise important questions about the value of evidence that requires the use of forensic laboratories at a population level in countries like South Africa that have substantial inefficiencies in their police services. Please see later in the article for the Editors' Summary.

Injury patterns of female homicide victims in South Africa.

BACKGROUND: Injury patterns and interpretation of injuries in homicidal deaths are important components of medicolegal autopsies. The objective of this article is to describe the incidence of female homicides and their related injury patterns with reference to autopsy practices in South Africa. METHODS: A national retrospective mortuary-based study of homicides in women of 14 years and older in 1999 was conducted. Data were gathered from medical legal laboratory records, autopsy reports, and police interviews from a stratified multistage sample of 25 mortuaries. RESULTS: The most common cause of homicide was a gunshot wound injury, with a firearm mortality rate of 7.5/100,000 women, 14 years and older, in 1999, followed by sharp force injury (6.8/100,000) and blunt force injury (6.1/100,000). Gunshot victims were more likely to be African, and those killed by sharp force injury were more likely colored. Significantly, blunt force injury deaths occurred predominantly in intimate partner homicides. A full autopsy was performed only in 70% of cases. An assessment of postmortem reports revealed poor descriptions of the anatomic location of injuries and the specifications of wound dimensions. CONCLUSIONS: South Africa has a high female homicide rate that exceeds reported rates with the cause of homicide varying by social group. Assessment of injury description suggests weaknesses in the documentation of injuries at autopsy. This weakens the forensic investigation and undermines the strength of evidence presented in court. Further measures are needed to strengthen forensic pathology services in South Africa.

Mortality of women from intimate partner violence in South Africa: a national epidemiological study.

The purpose of this article is to describe mortality of women from intimate partner violence (IPV) in South Africa using a retrospective national study in a proportionate random sample of 25 mortuaries. Homicides identified from mortuary, autopsy, and police records. There were 3,797 female homicides, of which 50.3% were from IPV. The mortality rate from IPV was 8.8 per 100,000 women. Mortality from IPV were elevated among those 14 to 44 years and women of color. Blunt force injuries were more common, while strangulation or asphyxiation were less common. The national IPV mortality rate was more than twice that found in the United States. The study highlights the value of collecting reliable data across the globe to develop interventions for advocacy of which gender equity is critical.

Intimate femicide-suicide in South Africa: a cross-sectional study.

OBJECTIVE: To examine the incidence and patterns of intimate femicide-suicide in South Africa and to describe the factors associated with an increase in the risk of suicide after intimate femicide (i.e. the killing of an intimate female partner). METHODS: A cross-sectional retrospective national mortuary-based study was conducted at a proportionate random sample of 25 legal laboratories to identify all homicides committed in 1999 of women aged over 13 years. Data were collected from the mortuary file, autopsy report and a police interview. FINDINGS: Among 1349 perpetrators of intimate femicide,19.4% committed suicide within a week of the murder. Suicide after intimate femicide was more likely if the perpetrator was from a white rather than an African racial background (odds ratio, OR: 5.8; 95% confidence interval, CI: 1.21-27.84); was employed as a professional or white-collar worker rather than a blue-collar worker (OR: 37.28; 95% CI: 5.82-238.93); and owned a legal gun rather than not owning a legal gun (OR: 45.26; 95% CI: 8.33-245.8). The attributable fraction shows that 91.5% of the deaths of legal gun-owning perpetrators and their victims may have been averted if this group of perpetrators did not own a legal gun. CONCLUSION: South Africa has a rate of intimate femicide-suicide that exceeds reported rates for other countries. This study highlights the public health impact of legal gun ownership in cases of intimate femicide-suicide.

The epidemiology and the pathology of suspected rape homicide in South Africa.

OBJECTIVE: To describe the epidemiology and forensic management of suspected rape homicide in South Africa, with the aim of promoting the recognition of this form of violence against women amongst forensic pathologists during post-mortem examination. METHODS: A retrospective national study in a proportionate random sample of 25 medico-legal laboratories was carried out to identify all homicides in 1999 of women over the age of 13 years. Data was collected from the mortuary file, autopsy report, police record and during interviews with police. FINDINGS: A rape homicide was suspected in 16.3% (95% confidence intervals (CI): 10.6-22.3) of the female homicides which gave a rape homicide rate of 3.65/100,000 women over 13 years. Rape homicides were more likely to than other female homicides to be crimes where the perpetrator and victim were strangers, where the crime happened in public spaces and the victim older than the perpetrator. In addition to genital injuries, injuries associated with this crime included those of head and face, legs, neck and injuries caused by bites. Victims had larger numbers of injuries, and more often a mechanism of death due to strangulation asphyxiation, or blunt trauma, rather than gunshot. CONCLUSION: Rape homicide is an extreme form of violence against women and the prevalence in South Africa is higher than that of all female homicides in the United States. The particular pattern of injury found in these cases should be used to develop protocols for autopsies on murdered women to ensure that crucial evidence is not lost and the victims' and their families claim to justice is not compromised.