Abstract
Background
In the past twenty years, the fight against sexual violence has become a common goal of the entire European Union, due to a greater socio-cultural awareness of the population and the need to create guidelines for common action. Italian Law no. 66 of February 15, 1996, regarding the “Rules against sexual violence” which, with the appropriate amendments, is still in force today, defines 3 types of sexual offenses through the articles 609 of the Penal Code.
Design and methods
This study analyzes the cases relating to one of the hospitals in Northern Italy, during the decade January 2010 - December 2019, relating to suspected/reported cases of sexual violence, group sexual violence and sexual acts with minors. This study was carried out by acquiring information relating to subjects who had been victims of a sexual crime through the analysis of the consultations drawn up by specialist medical staff in the submentioned hospital. These consultations are defined by specific medical protocols that must be activated every time a victim of a suspected sexual offense comes into the Emergency Room (ER). The data were processed with descriptive analyzes, the qualitative variables were synthesized with absolute and percentage frequencies, while the quantitative variables with mean and interpolation of the data, to identify a trend line. In order to hypothesize the possible future trend of the phenomenon, data were collected relating to the type of crime according to the Penal Code, gender and age of the victim. This article also outlines future directions for improving research.
Results
Our data shows that females, of any age, are the most affected in all sexual crimes, often share home with their aggressor, usually a man, and in most cases, they come to the medical observation without any lesion on their body.
Conclusions
In order to provide a global vision of the situation and of the diffusion throughout the territory, studies like this one could be carried out in various Italian provinces. Besides, we hope that the high degree of commitment on the part of society and institutions in combating sexual violence, through information campaigns and incitements to report, will lead in a few years to a reduction in the number of victims of repeated violence (especially in family contexts) and, consequently, also in the total number of acts of violence that comes to the attention of the healthcare facilities. Finally, primary prevention of sexual violence must begin early because a substantial portion is experienced at a young age. It will be necessary to prevent these forms of violence with strategies that address known risk factors for perpetration (e.g., low family support, high poverty, low parental education, absent or single parenting, parental substance abuse, domestic violence, low caregiver warmth), by changing social norms and behaviors and by identifying protective factors that could be strengthened.
Keywords
Introduction
In the past twenty years, the fight against sexual violence (SV) has become a common goal of the entire EU, due to a greater socio-cultural awareness of the population and the need to create guidelines for common action. SV has been described as a worldwide epidemic affecting millions of people. For most reported cases, women and girls are much more likely to be victims, men the perpetrators and, in most instances, the perpetrator is known to the victim. 1 It is estimated that one in four women will experience at least one incident of SV during their lifetime. 2
Significance for public health
The study presented is relevant because it analyzes the ways in which the italian public health daily faces the burdensome problem of sexual violence, in all the forms identified by Italian law, highlighting the characteristics of this crime that involves any gender and age. This article aims to be the starting point for the dissemination of these studies, which cannot be sectoral, in all the provinces of Italy, to highlight the critical issues and to reinforce the process of identification and reporting of these cases.
On April 7, 2011, the Committee of Ministers of the Council of Europe approved the “Council of Europe Convention on preventing and combating violence against women and domestic violence”. Italy ratified this Convention with Law no. 77 of June 27, 2013, rendering its indications active through the approval of the Decree of the President of the Council of Ministers of November 24, 2017, containing the “National guidelines for Health boards and Hospitals on the subject of rescuing and providing sociohealthcare assistance to women who are victims of violence”.
Italian Law no. 66 of February 15, 1996 regarding the “Rules against sexual violence” which is still in force today, defines 3 types of sexual offenses through the following articles of the Penal Code.
Article 609-bis of the Italian Penal Code (IPC) on “Sexual violence” states “anyone who, by violence or threat or by abuse of authority, forces someone to carry out or suffer sexual acts shall be punished (...)”. Any sexual act carried out without consent must therefore be considered SV. The term “sexual act” indicates a direct contact with the victim's body in areas to which an erogenous meaning can be attributed (anogenital area, buttocks, breast area and mouth).3,4
Therefore, according to Italian Law, SV is a flexible concept focused on the violation of consent: the aggression need not necessarily be of such intensity as to annihilate the victim, but it is sufficient that the victim gives herself up only to “put an end to a situation that is distressing and unbearable for her, since this type of consent is not free consent, but forced consent (…)” (Criminal Court November 16, 1988, Official Massimario, 179752, 1988).
According to article 609-octies of the IPC, when SV is carried out by several aggressors it is defined as “group sexual violence” (GSV) and is punished with a consequently greater penalty.
Finally, in the crime of “sexual acts with a minor” (SAM) regulated by Article 609-quater of the IPC, consensual sexual acts committed with persons under the age of 14 are illegal.
Article 609-septies of the IPC defines which situations require the complaint of the offended person to the Judicial Authority or if they are prosecutable ex officio. Crimes of group SV and sexual acts with minors can be prosecuted ex officio. SV can be prosecuted ex officio only if: a) the victim is under the age of 18; b) if it is carried out by his/her parent, even adoptive, or by his/her guardian; c) the offense is committed by a public official; d) the crime relates to another crime punishable ex officio.
This study analyzes the cases relating to one of the hospitals in Northern Italy (the town of Brescia), during the decade January 2010 - December 2019, relating to suspected/reported cases of sexual violence, GSV and SAM.
Design and Methods
This study was carried out by acquiring information relating to subjects who had been victims of a sexual crime through the analysis of the consultations drawn up by specialist medical staff in the submentioned hospital. These consultations are defined by specific medical protocols that must be activated every time a victim of a suspected sexual offense comes into the ER. The data were processed with descriptive analyzes, the qualitative variables were synthesized with absolute and percentage frequencies, while the quantitative variables with mean and interpolation of the data, to identify a trend line.
To hypothesize the possible future trend of the phenomenon, data were collected relating to the type of crime according to the Penal Code, gender, and age of the victim. Based on these data, the cases were divided into 5 categories: SV with an adult female victim, SV with a female victim under the age of 18, SV with a male victim, GSV and SAM.
As regards the age of the victim, a first step defined a cut-off limit of 18 years distinguishing the “adult” (≥ 18y) and “minor” (<18y) ages of the victims, in consideration of the ex officio prosecution of the crime of SV when the victim is a minor. Subsequently, the ages of the adult victims were divided by age groups; minors were divided into two groups, setting 10y as the cut-off. This choice was dictated by the fact that in Italy, carrying out SV against individuals under the age of 10 represents an aggravating factor that determines a doubling of the sentence (article 609-ter of the IPC). Regarding the last 3 categories outlined above, it was considered more useful to describe the phenomena in their entirety, specifying during the dissertation any gender and age differences, due to the small number of cases.
Each category was further examined from various anamnestic points of view. About data relating to the victim: type of prosecution, type and location of the lesions on the body, time interval between assault and consultation, use of alcohol and/or drugs, possible pregnancy or psychiatric illness, statements relating to other episodes of SV suffered in the course of lifetime, conflict with parents; with regard to data relating to the aggressor: type and identity of the aggressor if part of the family, kidnapping and use of a cold weapon.
Regarding the use of alcohol and/or drugs by the victim of violence, the cases considered positive by this study are all those in which a suspicion of use of one of these substances has been proposed based on the immediate medical history provided by the victim (circumstances of the assault), objective examination and laboratory tests. Cases in which there was a reasonable medical doubt about the use of “date rape drugs” by the attacker without the victim's knowledge were also considered positive.
In the analysis concerning the objective injuries on the victims’ bodies, it must be specified that the percentages of the various body areas affected can give a value greater than 100% because it must be considered that a patient may have multiple lesions in different areas.
Lastly, the time interval between the last episode of assault and the medical examiner's consultation was divided into time ranges (< 24 hours, 24-48 hours, 48 hours-5 days, 5-10 days, >10 days).
Results
In the decade under consideration, 253 consultations were carried out concerning suspected sexual crimes perpetrated on victims belonging to the Brescia hospital under study. The number of victims does not reflect the total number of victims of sexual assault in the territory.
The annual average is 25.3 sexual offenses per year. By introducing a trendline can be shown the increase in the annual average number of all sexual crimes, from 24.67 crimes/year in 2010 to 25.92 crimes/year in 2019. For the crime of SV alone, the annual average increase is from 20.87 cases of violence/year in 2010 to 23.92 in 2019. Despite this, certainly the most characteristic data, after analyzing the three sexual offenses separately, is the almost random trend of the cases evaluated in the study (Figure 1).
Trend of the sexual crimes and trend line of the crime of sexual violence.
Subsequently, the consultations by type of crime, gender and age, divided into minors and adults, of the victims were analyzed (Table 1). In most cases they were female victims, of which predominantly victims of SV; only 29 victims were male, none of which were cases of suspected sexual acts with minors. Considering the age of the victims, 52% of the cases of SV against women were committed against adults; 85% of the cases of SV against men were committed on minors. As regards the crime of GSV against women, it was mainly carried out on adults (74% of the total for that crime in that type).
Division of cases based on the type of crime, gender and age of the victim.
About the incidence of the use of psychotropic and narcotic substances by the victim, this affects 22% of the total number of sexual offenses, a percentage which includes: the incidence of alcohol (13%), drugs (2%) and co-administered alcohol and drugs (7%). Analyzing the various crimes separately, alcohol and drugs affect differently; in fact, in GSV (regardless of gender and age) there is a much higher incidence of drug abuse than in cases of SV with a single aggressor. Drug abuse is present in 52% of the cases of GSV and in 19% of the cases of SV with a single aggressor. Regarding the incidence of drug abuse among female victims of SV and between the ages of 13 and 18, this is very close to that of female victims of SV and adults, respectively 27% for minors and 30% for adults.
Sexual violence involving an adult female victim
In the category of the study that is most represented (40% of the total cases considered), in 32% of the cases an ex officio report was made to the judicial authority by the physicians. Among these, 30% of cases were associated with kidnapping and in one case SV was associated with a threat aggravated using a cold weapon, which makes the crime prosecutable ex officio. Seventy-nine percent of the women belong to the younger age group (18-40y); in 6 cases, the victim was over 50 at the time of the assault (Figure 2).
Age groups of the victim for the crime of sexual violence against adult females.
At the time of the medical examination 14% of the subjects stated that they had experienced other episodes of SV in their life or that they had suffered more SV recently; 15% of the subjects were found to be under treatment for psychiatric illness (i.e., major depression or borderline personality disorder) and one woman was pregnant at the time of the assault.
Twenty-six percent of the victims indicated a family member as the alleged aggressor (defined in Figure 3 as “Domestic sexual violence” - DSV); of these, 77% specified that it was the current spouse/partner/cohabitant, while the remaining cases stated that it was the ex-spouse/partner/cohabitant.
Type of the aggressor in the crime of sexual violence against adult females.
Only 2 women refused the general and gynecological examination. In 39% of the cases no lesions were detected, in 59% of the cases at least one perineal, extraperineal or oral lesion was detected. The gynecological seat was affected by at least one lesion in 18% of the cases and the anal seat in 7% of the cases, while as regards bruising and excoriation of the extraperineal skin there was at least one, in 72% of the cases bruising and in 63% of the cases excoriations, respectively.
As for the time interval between the violence and the consultation, 65% of the women went to the hospital within 24 hours of the assault, while only in 10% of the cases had more than 5 days from the event passed.
Sexual violence involving a minor female victim
This category account 37% of the total number of cases considered. In 82% of these, an ex officio report was made to the judicial authorities by the physicians. Respectively, one case of sexual assault took place in a context of child prostitution and one assault was committed during a kidnapping.
In 54% of the cases the victims were post-pubescent minors (10 - <18y) while in 46% of them they were prepubescent minors (<10y), with a prevalence of situations of “child sexual abuse” without penetration.
According to the anamnestic data provided by this category of victims or by those accompanying them at the time of the medical examination, 27% of the subjects had experienced other episodes of sexual violence/sexual abuse during their lifetime or they had recently suffered several episodes; 13% of the victims were under psychiatric surveillance or were being treated by child neuropsychiatrists for psychiatric or mental development disorders. In 19% of the cases there was a conflict between the parents of the minor in the phase of separation or a persistent conflict and a climate of suspicion even after the actual divorce.
In three cases the suspected aggressor was female. In 44% of the cases the alleged aggressor was a member of the family, but also acquaintances (both minor and of the family) represent a good percentage of the cases (22%). In 16% of the cases an unknown person was identified as the perpetrator of the crime. Among the remaining cases, in two suspected abuses, it was assumed that the perpetrator belonged to the school staff or other instructors; in one case, the aggressor was the employer of a teenager and in six cases the aggressor was identified as a friend (Figure 4). In this case, since DSV accounted for a considerable number of cases, the main suspected aggressors within the family were evaluated: in 40% of the cases, it was the father and in 19% of the cases the cohabitant/spouse of the mother (Figure 5).
Type of the aggressor in the crime of sexual violence against underage females.
Identity of the aggressor within the family expressed as a percentage (underage female victims).
The physical and gynecological examination was conducted on all the minors. In 79% of the cases no lesions were found, in 21% of the cases at least one perineal, extraperineal or oral lesion was identified. The gynecological seat was affected by at least one lesion in 50% of the cases and the anal one was affected in only one case, while as regards bruising and excoriation of extraperineal skin, there was at least one, in 25% of the cases for bruising and in 20% of the cases for abrasions, respectively. In one case a so-called “bitemark” was found.
As for the time interval between violence and consultation, in 47% of the cases, the female minors came to the attention of the hospital more than 48 hours after the assault and only in 31% of the cases during the first 24 hours; moreover, in 15% of the cases it was not possible to trace with certainty the time that elapsed between the assault and the consultation.
Sexual violence with a male victim
In 12% of the total number of cases of SV, the victim was a male, and these were committed mostly to the detriment of minors (85% of the total). An ex officio denunciation was made in 78% of the cases. In 26% of the cases, they were post-pubescent minors (10 - <18y) while in 74% of the cases they were prepubescent minors (<10y), where situations of “child sexual abuse” prevailed.
Considering the medical history provided by underage males or those accompanying them and guardians at the time of the medical examination, 26% of the victims had experienced sexual violence/ sexual abuse in their lifetime; in 17% of the cases there was a conflict between the parents of the minor during the phase of separation or a persistent conflict and a climate of suspicion even after divorce.
As for the gender of the suspected aggressor, 26% of the violence was attributable to women. In 43% of the cases, it was assumed that the aggressor was a member of the family, in 35% of the cases an acquaintance of the minor or of the family, in 13% of the cases the school staff or other instructors (including sports instructors). Finally, in one case the offender was defined by the minor as a friend of his/hers and in one case a health professional was accused. Analyzing the aggressors in the family nucleus (DSV) we note a clear prevalence of the father (in 50% of these cases).
At the physical examination there were no lesions in 91% of the cases of underage males; the only lesions found, in two cases, were in the anal area.
As regards the time interval between violence and consultation, in about half of the cases the underage males came to the hospital more than 48 hours after the assault or it was not possible to trace with certainty the time that had elapsed between the assault and the consultation. In the other half of the cases, fewer than 48 hours had passed since the assault.
Group sexual violence
The crime of GSV is an infrequent phenomenon (10% of all the sexual offenses considered). In all cases, an ex officio denunciation was made by the health staff. In only one case the victim was a child, there were no adult male victims, in 68% of the cases the violence was perpetrated on adult females and in 28% of the cases on postpubescent females or males.
In most cases, the victim entered the ER within 24 hours of the violence, even when the victim was a minor. GSV against adult females was mainly perpetrated in the evening and/or at night (76% of the cases) while there was no clear prevalence of a time slot in cases involving minors. The aggressors were known by the victim in 57% of the cases of violence against adult females and in all the cases involving underage victims.
At the physical examination, in 48% of the victims at least one perineal or extraperineal lesion was identified. Although the violence was carried out with more than one perpetrator, the injuries detected were not in proportion higher than those with a single perpetrator.
Sexual acts with a minor
The number of cases of sexual acts with minors is very small, only 4 cases out of 253. The ex officio denunciation by the health staff was made in 3 cases out of 4. The patients, all female, showed up a long time after the event, in only one case it occurs within 24 hours prior to the medical examination.
No lesions of any kind were identified during the physical examination.
Discussion
This study makes it possible to assess the extent of sexual offenses in the reality of an important hospital in Northern Italy, which has a large catchment area. The territory city of Brescia is inhabited by 198,536 people. 5
Analyzing the phenomenon of SV in such a large area of the population enriches the Italian data present so far, which focus mainly on the reports made by the Police forces: in 2018 at the national level, 4,860 reports were made for the crime of SV (Italian Minister of Interior, SDI-SSD database) while 483 reports were made for the crime of sexual acts with minors. 6 Other national data available come from the Central Institute of Statistics 7 which, in 2014, analyzed the SV that occurred on a sample of 25,000 women. This study shows that in 2014, 21% of the women between the ages of 16 and 70 had suffered some form of SV during their lifetime. This violence was committed in 62.7% of the cases by their partner, in 3.6% of the cases by relatives and in 9.4% of the cases by friends. On the other hand, strangers are in most cases (64.9%) perpetrators of sexual harassment. The Italian data available so far refer in the first case to denunciations made by the Police forces and in the second case to self-declarations provided via telephone contacts. Both methods of analyzing the phenomenon suffer from considerable “bias”; in fact, only a small percentage of women report rape (only 12%). In addition, telephone consultations often reveal reports of SV that took place even many decades earlier.
Our study not only allows us to analyze a provincial reality but also to report findings of the clinical physical examination and anamnestic data provided by the victim of SV in the moment of greatest need for medical care, i.e., upon entrance to the hospital regardless of his/her subsequent willingness to report the event to the police.
Time analysis of the phenomenon
The most important data is the annual average number of sexual offenses which is 25.3 sexual offenses per year. Considering the average resident population in the Province of Brescia in the 10 years of our study, it is possible to state that the incidence of sexual crimes that emerges from our case study is 2 cases/100,000 inhabitants if we consider as the area of reference the entire population of the Province of Brescia. However, the incidence of sexual crimes calculated in this way is affected by some selection “biases” as not all the cases analyzed come from the Province of Brescia, many sexual crimes that occur in the provincial territory are managed by other health authorities in the area and, finally, there are some cases involving victims residing outside the region or non-EU citizens. Furthermore, even the absolute number of cases that we have observed is certainly an underestimate of the real incidence of these crimes in the decade, due to the significance of the percentage of submerged crimes of SV that do not come to the doctor's attention. Indeed, the experience of SV is seen as stigmatising and shameful, which makes it difficult for victims to share their stories, out of a sense of fear of a social re-victimization.1,8 Often children are manipulated to feel guilty or responsible for the abuse; these children may fear to disclosure will not be believed, or that it will negatively affect their own well-being and that of their families or they may be concerned about consequences for the perpetrator. 9–10 Sometimes even the victim, more often women, does not consider it a sexual offense (e.g. groping) and some socio-cultural contexts consider sexual exploration with an older person as a neutral or even positive experience, especially for men. 9
Type of crime, gender, and age of the victims
The collection of data shown in Table 1 highlights how SV is the main crime. The small number of cases of sexual acts with minors is intrinsic to the crime itself. This crime, despite being prosecutable ex officio, rarely comes to medical attention for the following reasons: the minor victim has consented to sexual intercourse and consequently has no lesions; moreover, even if the parents/guardians become aware of their children's illicit sexual intercourse, generally they do not contact the doctors, preferring to “manage” the situation inside the family. The most common occurrences that can lead parents to having their minor children undergo a medical examination are generally linked to the fear of an unwanted pregnancy and of having contracted sexually transmitted diseases.
Females are the most affected in all sexual crimes. The expalnation of this difference is given by under-reporting by male victims: boys may be more reluctant to seek support owing to gender norms reinforcing self-reliance. 9 Societal perception of male rape is influenced by perception of masculinity and male power, resulting in additional male-specific rape myths (e.g. prisons or homosexual communities). Moreover, male victims are blamed more than female victims and the direction of improvements in aftercare service provision has generally been female-focused. 11
SV and GSV against women are crimes that mainly affect adult women. Specifically, the victim in GSV is almost exclusively of postpubertal or adult age, frequently weakened using drugs (maximum incidence for this crime), who suffers an assault by a group of men that they often know.
There are many considerations that can be made considering the age groups of the victims. Despite the prevalence of victims in the 18-40 age group, older women can also be affected (6 were over 50y); therefore, although to a lesser extent, it is not correct to consider only women of childbearing age as at risk of SV. 2
Fourteen percent of adult women say they have experienced other incidents of SV in their lifetime or have experienced more SV recently. These women often share home with their aggressor (partner or cohabitant) or live in a sociocultural reality where a woman's attempt to emancipate herself or live in a “Western lifestyle” is severely punished, not only through voluntary personal injury but also through one or more episodes of SV committed by their partner or by other family members.
In SV against underage females there is a significant number of cases of sexual abuse in girls under the age of ten. It is an established fact that in the prepubertal age situations of long-lasting sexual abuse clearly prevail, 3 where the victim is late in confiding with others and revealing what happened, and therefore can suffer more episodes of violence, even for a long time.
In post-pubescent female minors (apart from situations in which the abuse has continued since childhood), it is more frequent that the patient comes to medical observation due to a single assault and that she has not suffered other SV during her lifetime.
In SV against underage males, reaching adolescence leads to a drastic reduction in the incidence of SV (26% males versus 54% females).
SV against men is committed in most cases to the detriment of minors and this category also includes an important share of suspected sexual abuse of prepubescent males.
Type and location of the lesions
A characteristic element of all the cases analysed, in accordance with the most recent literature,12,13 is the high percentage of patients without any objective lesion on their body: in 59% of the total number of cases, no injury attributable to the episode of violence was found, especially when examined non-acutely.
Likewise, the absence of lesions in 39% of the cases of SV against adult females is in line with the scientific literature.3,14 In fact, alongside many women who strenuously defend themselves from aggression, often suffering physically more objective consequences, others for the terror that the unexpected aggression arouses cannot imagine any defensive reaction and so they passively suffer SV, so it is much more difficult to highlight any type of lesion on them. 3 Only some gynecological lesions can be considered a sign of the certainty of a SV, as the presence of genital lesions is not pathognomonic of an episode of SV, while the absence of genital and extraperineal lesions is completely compatible with SV that did, however, occur. 3
Since these are women of age, it is presumable that most of them have already had sexual intercourse in the past, so further injuries due to penetration are in the most cases not to be expected because defloration injuries can only be detected once if the hymen is otherwise intact. However, the discriminating element of a hymenal laceration compared to a possible anatomical variant (fimbriated hymen) is given by reaching the implantation base of the membrane and by locating the lesion in the posterior sectors of the hymen. 3
The data regarding the injuries found on the body of female minors must be critically analyzed. First, it must be considered that non-gynecological and anal lesions are not pathognomonic of SV. The high percentage of the cases where no lesion was identified on any body area could mistakenly lead to believe that SV did not actually occur.
In the last thirty years, medical literature has increasingly analyzed the phenomenon of SV and child sexual abuse.9,15-18 Most of the girls who were sexually abused had no genital or anal lesions, especially if examined some time after the event. Recent studies 13 report that only 2.2% of the girls examined some time after the suspected episode of SV had diagnostic physical findings, a figure which rises to 21% if the event occurred a few hours previously. In fact, the sexual abuse of girls rarely includes penetrating trauma, but more often it takes place with manipulation, touching, oral practices, and the healing processes of lesions in children are very rapid.
The genital lesions found in the adolescent patient victim of SV are identical to those of adult women, the only exception is due to the percentage of “virgo” adolescents is certainly higher than that of adult women and, therefore, it is more common to find lacerations of the posterior sectors of the hymen that reach the base of the implant.
As regards the gynecological lesions found in the pediatric population in cases of suspected sexual abuse, there is an international classification 12 which not only describes the diagnosable findings, but it also provides the levels of evidence of correlation of these lesions to an actual episode of sexual abuse.
SV against underage males is certainly the category with the highest percentage of victims without objective lesions (91%). This is justifiable by the fact that there are fewer victims of SV who are male adolescents (26% of the total) than prepubertal minors and far fewer in percentage than female adolescent victims (54%). In prepubertal males, as in prepubertal females, situations of “sexual abuse” without penetration prevail, which cause less trauma with respect to what occurs in adolescents, where SV with penetration (vaginal or anal) causes greater trauma which can be identified in a clinical examination.
The crime of SAM being a crime where, by definition, the minor has given consent to sexual intercourse, it is typically without trauma and no lesions of any kind are evident. This is demonstrated by our study where none of the cases have any objective lesions. It should be noted that this data is not statistically significant given the small number of these cases in the 10 years of our study.
Abuse of alcohol and/or drugs
Overall, alcohol, drugs and their combination account for 22% of the total number of sexual offenses. This data is particularly alarming considering that the victims are often young or adolescents where the organic damage that these substances induce also at the level of psycho- physical development is well known. Substance abuse also has important medicolegal and social implications as their use could facilitate a sexual assault. In fact, alcohol and drugs share two effects that are capable of facilitating the perpetration of any sexual crime: the first lowers the victim's level of attention, reducing inhibitions and controls up to the point of determining a substantial passivity or acquiescence; the second concerns some side effects of these substances, the most important of which is amnesia, which is obviously an event entirely favorable to the aggressor.
The most interesting fact is that the percentage of cases in which the victim had taken alcohol and drugs (7%) was higher than the use of drugs alone (2%), because as the additive and cumulative effect of the combination of alcohol and drugs on the reduction of the cognitive and defensive abilities of a potential victim facilitates the criminal intent of a potential aggressor.
Time interval between assault and consultation
The anamnestic data regarding the time elapsed between the assault and the consultation reflect the age of the victims very precisely with a net cut-off line between adult victims and minors.
In SV against adult females and in GSV (where most victims are adults) the victim comes to the attention of the health facility mainly within 24 hours of the violence. It is good that the consultation takes place less than 24 hours after the assault; in fact, SV is typically a crime without witnesses, the demonstration of which is the sole responsibility of the victim, and it is essential that she remembers the details of the attack well. Such a short period of time simplifies the work of clinicians, in particular the analysis of the lesions and the collection of biological traces of the aggressor is facilitated: the process of the healing of the wound is only in its initial stages, it is more likely that the clothing worn at the time of the violence was stored without being washed, sperm swabs are more likely to be positive. The possibility for the gynecologist to be able to administer emergency contraception is also greater if the victim shows up shortly after the violence. The discrepancy between the time the violence occurred, and the time of the consultation is because a victim of nocturnal SV often does not go to the ER immediately during the night, except in the bloodiest cases, but she goes when she wakes up the day after or at the end of the effects of having taken any alcohol and drugs. It must also be considered that many women mistakenly believe that they can receive better health care during the daytime hours.
In SV against minors, females or males, the victim goes to the hospital more than 48 hours after the assault. The long-time interval between the aggression and the consultation can be explained by the fact that the cases of SV against a prepubescent underage victim come to the attention of the parent (and consequently the doctor) later; often even adolescents frequently carried out by friends or acquaintances, come late to the health facilities. The child/adolescent cannot accurately provide a temporal reference of the aggression because the story of the incident is often fragmentary or generic also due to the long period of time that elapses between the event and the consultation, while in adolescents, particular states of psychophysical alteration induced by substances or situations where the minor has been unreachable and untraceable for a long time make it difficult to clearly identify the time of the assault.
Type of reports
The ex officio denunciation to the Judicial Authority is carried out in all cases of group SV but in slightly lower percentages, 82% and 78% of the cases, respectively in crimes of SV against underage females and underage males. In these last two situations, although these crimes are always prosecutable ex officio, the discrepancy between the number of consultations carried out and the number of ex officio denunciations is attributable to various factors.
Among the cases where the parents or the treating pediatrician require a specialist hospital evaluation for a suspected abuse of a prepubertal minor, there are some where the medical team can reasonably exclude the possibility that the victim in question was sexually abused. Moreover, it is possibile for the medical examiner to contact the Public Prosecutor on duty by telephone who might express some doubts about the ex officio denunciation. For these reasons, even though the consultation was provided for a suspected SV against minors, it is not necessary to file a complaint.
Similarly, 32% of the cases of SV against women of age, even though this crime is punishable upon complaint by the injured person, required an ex officio denunciation especially due to the connection with other offenses that can be prosecuted ex officio (in our series of cases, kidnapping and the threat aggravated using a weapon stand out) or due to personal injury with a disease prognosis of more than 20 days.
Parental conflict regarding minors
As shown by our data on SV against underage victims (of both sexes) there is often a conflict between separated parents or those in the process of separating. These are, perhaps, the most critical cases and the most difficult to interpret both by the doctor and by the Public Prosecutor responsible for carrying out any preliminary investigations. In these cases, one of the two parents is in a strong emotional state of concern because, on the return of the child from the period where he/she was entrusted to the other parent, they detect organic alterations, often totally non-specific, on the body or, depending on the story, they fear that he/she has suffered sexual assault by the other parent, her/his new partner or other members of his/her family. In these cases, the doctor must avoid “acting” emotionally by supporting or exaggerating the anxieties and expectations of the adult requesting the intervention, avoiding autonomous investigation initiatives that are not the doctor's responsibility. The request for help must never be underestimated, in the belief that there must be at least a situation of deep discomfort or conflict in a family in which the mother and/or father decide(s) to submit the child to a medical examination for suspected sexual abuse. In these cases, it is important to activate psychological support and, possibly, social services.
Information relating to the perpetrator
As shown in the epidemiological data from the Western area, 3 the aggression by a stranger is less frequent than by people known to the victim. If we consider the incidence of violence perpetrated by strangers in the various groups analyzed, we see that it is higher in GSV against adults and SV against adult females, lower in single violence against underage females and it is zero in SV against underage males and in GSV with underage victims.
Most SV involves only one perpetrator; however, most perpetrators, also in gang-rape, are male. 1 Among the perpetrators known to the victim, attention must be paid to so-called DSV because it reflects the social context where the violence took place. Forty-four percent of the cases of SV against underage females and 43% of that against underage males is attributable to a member of the family. More specifically, in these categories there is a clear prevalence of the main male figure of reference which also reflects those situations of conflict between the parents in the phase of separation, but also the cohabitant/spouse of the mother who is often indicated as being responsible for the act by the mother herself.
In SV with female victims and adults, DSV accounts for a smaller percentage of cases (26%) because the incidence of the unknown aggressor or other categories of aggressors, such as acquaintances/friends, is higher. In DSV against adult women, the current or ex-spouse/partner/cohabitant is identified as the alleged aggressor, this latter is the demonstration of the growing number of aggressions, not only sexual, that women can also suffer from people they had removed from their sphere of acquaintances.
Conclusions
In recent decades, episodes of SV have increasingly gained the attention of public opinion and have been the subject of debate and reflections by all those who are involved in combating or preventing the phenomenon. The 253 cases of sexual crimes that have occurred in the last 10 years are an indicator of the incidence of the phenomenon in Brescia. The high number is alarming, since the number of “submerged” phenomena, consisting of those people who do not report the crime and do not come forth for specialist medical observation, might be considerable.
The most recent studies in the literature1–2,9,11,13,15-19 have made important contributions to our knowledge of SV. However, much more is needed to further develop our understanding. One of the limits concerns the cross-study comparability, owing to differences in definitions, research tools, methods and sampling used. To understand the extent of SV prevalence and to implement appropriate service provision, future research will also consider the following: measurement of the prevalence and patterns of SV victimisation/perpetration/ experienced by vulnerable groups (i.e., children, older people, disabled person, etc.) in a range of settings, research on the social context of SV and victimisation, consider the background of the perpetrator and examine the long-term impact of sexual assault via victim follow-up. 1
In addition, the issue of SV is never addressed with an in-depth analysis of the elements related to the context in which it takes place and that characterize actions or events with a strong social impact. The phenomenon is a deep iceberg, whose top represent a picture of relational degeneration and it does not always define the phenomenon. However, two elements that characterize the phenomenon can be outlined: on the one hand the collective decline and on the other fragile subjects, whose personality degenerates into a culmination of both physical and psychological violence.
To provide a global vision of the situation and of the diffusion throughout the territory, studies like this one could be carried out in various Italian provinces. Besides, we hope that the high degree of commitment on the part of society and institutions in combating SV, through information campaigns and incitements to report, will lead in a few years to a reduction in the number of victims of repeated violence (especially in family contexts) and, consequently, also in the total number of acts of violence that comes to the attention of the healthcare facilities.
Finally, primary prevention of SV must begin early because a substantial portion is experienced at a young age. It will be necessary to prevent these forms of violence with strategies that address known risk factors for perpetration (e.g. low family support, high poverty, low parental education, absent or single parenting, parental substance abuse, domestic violence, low caregiver warmth),9,20,21 by changing social norms and behaviors and by identifying protective factors that could be strengthened.9,19
Footnotes
The authors declare no potential conflict.