• 1.
  

  a) F b) F c) T d) F e) F

Non-consensual penile penetration of the anus or mouth is also rape. Penetration of the vagina, anus or mouth by penis only refers to both male and female victims. In English and Welsh law, rape is the non-consensual penile penetration of either the vagina, anus or mouth of any individual regardless of gender. Non-consensual digital or object penetration is the offence of sexual assault by penetration.

• 2.
  

  a) F b) F c) F d) T e) F

The experience of an erection or ejaculation does not indicate that the complainant gave his consent as these reactions can occur during rape. The presence of an erection or ejaculation does not indicate that the complainant enjoyed the experience as these reactions can occur in the absence of pleasure. Erection and ejaculation can be stimulated physiologically in men independently of their sexual orientation. Victims may question their sexuality after such an experience because of the presumptions in society that a man responding sexually to a ‘homosexual act’ is also homosexual.

Erection and ejaculation by the victim can occur during male-on-male rape or sexual assault as a result of the physiological effects of ano-genital stimulation and despite the terror of the experience. It is therefore a neutral finding. It is possible to achieve and sustain an erection during rape despite the fear experienced during the event.

• 3.
  

  a) F b) F c) T d) T e) T

Victims of sexual violence do not cause sexual violence and are not to blame, but they are often blamed by their family, community and society. This is a device to deflect blame from those who perpetrate, who are to blame, and is also a powerful deterrent to reporting rape in many settings. Rape in marriage is illegal in 127 countries, but a woman’s experience of rape victimisation by her husband and its effect on her health is not constrained by national laws. She will perceive herself as having been raped if she has been forced into sex against her will and will experience the consequences thereof irrespective of laws. Boys and men may be victimised sexually by both women and men. The stigma attached to disclosing about sexual violence victimisation for men and boys is considerable and a potent barrier to reporting. Only a fraction of rapes are reported to the police because women fear blame, stigma and being re-victimised. In some contexts, women may even be killed if they report rape. When questions are used that ask about behaviourally specific acts, such as ‘forcing a woman to have sex who was too drunk or drugged or otherwise unable to consent,’ it is possible to obtain a much higher prevalence of reports as these questions can be answered irrespective of whether the person being questioned perceived the acts being measured to be ‘rape’ or an act of sexual violence.

• 4.
  

  a) T b) T c) F d) F e) F

The World Health Organization multi-country study found that, in rural Ethiopia, 58.6% of women had ever been raped by their husband or a boyfriend. The 2010 National Intimate Partner and Sexual Violence Survey in the United States found that 18.3% of women had been raped in their lifetime. This figure is compatible with the on population-based prevalence estimate of male rape perpetration, which found that 25% of men had raped. Both gay and straight men may experience sexual violence from other men. Although some research from South Africa suggests that men who have sex with men are at greater risk of rape than other men (one in five in South Africa), the population prevalence of rape among straight men is still quite high in some settings (e.g. one in 50 in South Africa). It is a particular problem in institutions in many countries, including prisons. Available data on sexual violence victimisation indicate that it is much more commonly perpetrated by intimate partners, but research on perpetration does not support this in all settings. In South Africa, more perpetration against non-intimate partners is reported. More research is needed to better understand patterns of rape globally. Forced first sexual experiences are commonly reported by both women and men. The prevalence varies between settings, but in many places men or boys experience coercion from both male peers and from (usually older) women.

• 5.
  

  a) F b) F c) T d) T e) F

Research has been conducted across a range of middle- and low-income countries showing that rape perpetration can be studied in populations by asking direct questions about acts of rape to men. The prevalence of disclosure in these surveys is generally slightly higher than that found in surveys of victimisation among women, suggesting that the method is reliable. Multiple perpetrator rape, often referred to as gang rape, is a feature of rape in all settings, although the prevalence varies. It is not confined to criminal gangs. Estimates from South Africa are that nearly one in 10 men have had sex in such rapes and many more have been otherwise involved. Sexual violence prevalence estimates are highly sensitive to the context in which the research is conducted, and much higher estimates are found in studies with small groups of highly trained and supported field workers. This is critical as intimate partner sexual violence is often not disclosed unless questions specifically ask about it. Women are not protected from rape by seclusion. In highly patriarchal counties where women have little public presence, many are relatively protected from certain types of rape, such as stranger rape, but evidence suggests their risk of rape from their husband is higher than that found in more gender equitable countries. Sub-groups of women who are not secluded in these settings, such as sex workers or market traders, may be at particularly high risk.

• 6.
  

  a) F b) T c) T d) F e) F

Estimates of prevalence in childhood will vary depending on the age structure of a child population if children are interviewed. This is because the annual risk of sexual violence varies depending on the age of the child and the duration of exposure to potential sexual violence (i.e. length of childhood). If interviewees have completed childhood, these factors are no longer considerations. Repressed memory is a recognised reaction to child sexual abuse and will affect prevalence, as some exposed children will have no recall, or long periods of their life with no recall. Sexual violence in mixed gender schools is common and seriously undermines girls’ experiences as school students. In many settings it is an important cause of school-girl drop-out, especially if pregnancy results. In every setting, only a small proportion of child sexual abuse comes to the attention of police and social services. An inherent power differential exists between teachers and their students, irrespective of the age of the students. In many countries, in recognition of this, all sexual contact between teachers and their students of any age is illegal.

• 7.
  

  a) F b) F c) F d) T e) F

Research has shown that not all body fluids fluoresce on the surface of the skin, and other contaminants, such as lubricants and skin products, encountered on a daily basis may also be highlighted with ultraviolet lighting. Clinical swabs do not require the same manufacturing and packaging standards as forensic swabs, and issues such as sample integrity and the nature of the swab composition have to be carefully considered by forensic medical kit manufacturers. Scientific recovery processes and the continued improvements in relation to sensitivity of DNA mean that cotton swabs are no longer necessarily the best swab type for recovery of trace evidence. The composition of the swab head or recovery mechanism should ensure maximum absorption and subsequent extraction. Double swabbing is an effective method to recover body fluid traces, bite marks or skin to skin contact from injuries. The detection limits vary as would be expected in relation to activities such as no further contact or washing of the affected area. Saliva has been detected on skin up to 48 h after an assault and from skin-to-skin contact up to 7 days later. Control swabbing at the time of presentation is advocated as good practice even though there is still limited research on the persistence of body fluids and cellular material recovery from skin surfaces. Control swabs should be taken mirroring the recovery technique used for the forensic sample site, and should be from an adjacent or mirror image site to aid interpretation for the forensic scientist where the presence of a body fluid and DNA in a specific area is significant.

• 8.
  

  a) F b) T c) F d) F e) F

The clothing worn at the time of the alleged assault would normally be seized as it may provide a source of contact traces relevant to the alleged assault. If the FMP is made aware that injuries have occurred to the complainant, then viewing the position of damaged clothing while it is still worn by the patient may provide important points of reference for the injury assessment process. The forensic scientist may be requested as part of the investigation to comment on the nature of damage that has occurred during the alleged assault so it is important that any pre-existing damage is possible if clothing has to be cut to assess serious injury. Photo documentation of how clothing is worn at the point of presentation is very useful, as it will show positions and styles of garments and whether clothing damage mirrors positions of injuries on the body itself.

• 9.
  

  a) T b) F c) T d) T e) T

The four levels of competence that have been proposed by Appelbaum and Grisso and ideally, the patient should have all four levels for optimal competence: the ability to communicate choices; the ability to understand relevant information upon which the choice is made; the ability to appreciate the situation according to the patient’s own values; the ability to weigh various values to arrive at a decision.

• 10.
  

  a) T b) T c) F d) T e) F

Legal exceptions to the rule of informed consent allow the doctor to proceed without consent in cases of emergency, incompetency, the therapeutic privilege and waiver. Husbands and families making decisions for adult women who are in a position to make rational decisions cannot be justified both in law and ethics.

• 11.
  

  a) F b) T c) T d) T e) T

It can be deduced that, through the ages, confidential information has been perceived as sensitive information, as judged by the patient. This sensitive information could be shameful, harmful and embarrassing to the patient, especially where the woman has been sexually violated. It is clear that confidential information must be treated with utmost care. The reasons for this are to exclude unauthorised people from being privy to this information; and to facilitate the sharing of sensitive information with the goal of helping the patient. Confidential information may be shared with other healthcare practitioners involved in managing the patient, on condition that this information pertains to that aspect of management and has relevance to the case. Individuals have a right to privacy and this right allows them autonomy over their personal information. Because people deserve respect, it is essential that the confidences they impart to the doctor are upheld and respected.

• 12.
  

  a) F b) T c) T d) T e) F

There are three sources from which confidentiality draws such a high value. These are autonomy, respect for persons and trust. The principle of autonomy prescribes that personal information belongs to an individual and should not be made known to others without their consent, except where there is a legitimate requirement to breach confidentiality. Individuals have a right to privacy, and this right allows them autonomy over their personal information. Because people deserve respect, it is essential that the confidences they impart to the doctor are upheld and respected. In this manner, their privacy will be preserved. The doctor–patient relationship is one built on trust. Keeping confidences assist in building that trust, thereby maintaining patient dignity. Eroding that trust will most certainly harm the relationship. Often practitioners are total strangers to patients who end up revealing their most intimate and personal information to them. Frequently, this information is information that they would not want anyone else to know. If there was no understanding by patients that practitioners have ethical and legal duties to keep their disclosures secret, they would withhold information which would hinder practitioners in their efforts to provide effective interventions.

• 13.
  

  a) F b) T c) F d) F e) T

Consensus of time limitations for forensic evidence collection is lacking, despite the existence of many recommendations. Time from assault to examination varies from 24 h to 10 days depending on the examination programme, body orifice of interest, and assault history. No examination should be carried out, regardless of police request, without the victim’s consent, especially in legal terms. Colposcopy is not routinely recommended, but can identify more injuries than the naked eye. Genital injury does not itself corroborate a legal complaint of sexual assault. Police involvement is not necessary for the examination, and the evidence collected should be stored, maintaining a chain of evidence, until the complainant has decided to report the incident to the police. In order to maintain a chain of evidence and reduce doubts about the validity of DNA material to be used in court, standardised protocols are recommended.

• 14.
  

  a) T b) T c) T d) T e) F

Interpretation of injuries is a specialist skill as only what can be repeated and explained in court should be concluded. Testimony as expert witness also needs special scientific skills. Use of standard terminology is essential. Conjunctival petechiae without injuries to the neck or a history of strangulation is not to be interpreted as immediate or potential life-threatening danger, as petechiae may arise from cough, defecation, or blunt force to the orbits.

• 15.
  

  a) T b) F c) T d) F e) T

Several studies have shown significantly positive associations to injuries documented at the forensic examination, but other studies have found no association. Conviction should not be the only end point of research (e.g. evaluating fractions that achieve restorative compensation or reduce negative health consequences of the victim could evaluate the forensic examination and the managing of the complainant of sexual assault). The forensic examiner has to be objective and impartial, and conduct the examination to benefit the alleged assailant as well.

• 16.
  

  a) F b) F c) T d) F e) T

Genital injury after rape or sexual assault is not the norm. There may be other explanations for the vaginal bleeding such as menstrual loss and local pathology. Rape is a legal definition, not a medical diagnosis. Examinations, if done well, should attend to the therapeutic, forensic and psychological needs of the patient. The details of the case must be considered. For example, trace material such as DNA and lubricant may be recovered at examination. Trauma sustained may put the patient at increased risk of infection. The usual position for the genital examination is the modified lithotomy, with the left lateral position used for the anal examination. Numerous studies have found that the posterior aspect of the vulva, in particular the posterior fourchette, is the area most likely to sustain an injury, either by actual or attempted penile penetration during non-consensual intercourse.

• 17.
  

  a) T b) F c) F d) F e) F

The labia minora contain both sebaceous and sweat glands but no hair follicles or underlying adipose tissue. The vagina is lined by stratified squamous epithelium. The fossa navicularis is a shallow depressed area or furrow between the posterior aspect of the hymen and the posterior fourchette.

The paramesonephric ducts form the fallopian tubes, uterus and upper vagina, the lower vagina is derived from the vaginal plate from the external surface of the embryo. Although genital injuries are not the norm after sexual assault, when they do occur, lacerations are not infrequent.

• 18.
  

  a) T b) F c) T d) F e) T

Toluidine blue dye is a nucleic stain. It is, therefore, effective where the integrity of the skin has been breached. This is not a feature of bruises unless there is an additional injury. Photographs taken during the medical examination will be part of the medical notes and forensic evidence gathered as objective evidence for the purposes of the court, and should be retained as such. In the post-pubertal female, after any forensic samples have been taken, a Foley catheter balloon can be used to demonstrate the hymenal edges when gently retracted down the vagina. Studies have repeatedly shown that genital injuries are more frequently incurred during reported sexual violence when the assailant is known to the victim rather than being a stranger. The legal definition of the vagina (Sexual offences Act 2003, England and wales) defines the vagina in terms different to the ‘medical’ vagina.

• 19.
  

  a) F b) F c) T d) T e) F

It has been shown that a retroverted uterus seems to increase the risk of vaginal laceration with sexual intercourse. Lacerations are tearing injuries caused by blunt force. Sharp objects are likely to cause incision type injuries such as stabs or slashes. In general, victims of rape are more likely to sustain injuries to non-genital body surfaces than to the genitalia. Intoxication has been shown to be associated with sexual violence. In one study it decreased the risk of injury and in another it was unrelated. Trauma increases the changes of the skin barrier being breached therefore increasing the risk of infection by blood borne viruses.

• 20.
  

  a) T b) T c) F d) F e) T

The IUD is the most reliable form of emergency contraception and should be discussed and offered to all victims for up to 5 days after sexual assault. It can be left in situ as a contraceptive or removed after first menstruation following insertion. Most victims of sexual assault prefer to take oral forms of emergency contraception such as Levonelle or Ella One for convenience and ease of use as opposed to insertion of an IUD. Levonelle (Norgestrel) is licensed for up to 3 days after sexual assault, although it has some efficacy for up to 5 days after the assault in all age groups. Ella One (Ullipristol) is licensed for up to 5 days after sexual assault in women over the age of 16 years.

• 21.
  

  a) T b) T c) F d) F e) F

Risk of HIV transmission in vaginal penile penetration, even if the assailant is from a high-risk category, is not as high as in anal penile penetration; HIV PEPSE is to be considered not recommended. Anal penile penetration by a high-risk assailant is considered as a high-risk act and, HIV PEPSE under the circumstances is recommended. HIV PEPSE should be started as soon as possible after unprotected exposure and no later 72 h after unprotected exposure. A baseline HIV test ought to be done in anyone started on HIV PEPSE to establish whether the individual has already been HIV positive, which would result in not having to taken potentially toxic treatment such as HIV PEPSE.

• 22.
  

  a) F b) T c) T d) F e) T

You should always try to examine a pre-pubertal girl using other techniques to support or confirm clinical findings in one position. Use of a Foley catheter is not usually recommended in pre-pubertal girls because of hymenal sensitivity. It may be possible if the girl is peri-pubertal when a small catheter could be tried. Examination under anaesthetic may be necessary depending upon the clinical circumstances.

• 23.
  

  a) F b) F c) F d) T e) T

An attempt must always be made to visualise the hymen in the depth of the folds. It is not considered appropriate to use a moistened swab to separate the folds for this age group. It is thought to be demeaning, and may mimic the abusive experience. Occasionally, a child might offer to go into this position when it would be considered unusual. Examination under anaesthetic may be necessary depending upon the clinical circumstances.

• 24.
  

  a) F b) T c) T d) T e) T

Up to 99% of children referred for child sex-abuse examination have normal or non-specific findings. Healing occurs remarkably quickly because of good blood supply to this anatomical area. Healing can be complete or leave a very shallow non-specific notch. Penetration can occur leaving no clinical signs, or non-specific signs, or the child may have misunderstood what had happened and mistaken fondling for penetration. Such findings neither confirm nor refute such an allegation.

• 25.
  

  a) F b) T c) F d) F e) F

Black eyes are typically associated with blows to the eye area of the face (e.g. by punching). They may also occur as a result of tracking of blood subcutaneously from blows to the forehead or scalp, or as a result of basal skull fractures. Compression of the neck may be associated with the formation of petechial haemorrhages in the skin and lining of the eyelids.

• 26.
  

  a) F b) F c) T d) F e) F

Tramline bruising is typically associated with blows from cylindrical or rod-like weapons, or by beating with a whip or belt. Bruising of any type is rarely a feature of self-inflicted injury. Ligatures typically cause streaky abrasions or bands of bruising, circumferentially around the wrists or ankles.

• 27.
  

  a) T b) T c) T d) T e) F

Women with mental health difficulties are more vulnerable to sexual assault. According to the British Crime Survey, the lifetime risk of being raped for women in Britain is 20%. For PTSD to be diagnosed, symptoms must be present for 1 month as defined in The Diagnostic and Statistical Manual of Mental Disorders, fourth edition.

• 28.
  

  a) T b) F c) F d) F e) F

A systematic review found that multiple session, trauma-focused, cognitive-behavioural therapy may be effective in preventing post-traumatic stress disorder in people with psychological distress after a traumatic event. This review also found that individual psychological debriefing may increase the rate of PTSD compared with no debriefing. No drugs have been found to be effective for the prevention of PTSD. In addition, venlafaxine has been found to be ineffective for managing PTDS. Eye-movement desensitisation and reprocessing therapy has been found to be effective in treating PTSD but not for prevention. In the systematic review, no comment was made on the evidence of expressive writing owing to insufficient evidence.

• 29.
  

  a) T b) T c) T d) F e) T

Women who suffer from sexual abuse have been found to struggle with negotiating for condom use and safe sex. This is especially true when the sex is forced, even in intimate partnerships. They often fear that their request will be met with more violence. Power dynamics in the relationship also play a role here. It has been shown that women who are sexually assaulted have partners who have other risk behaviours, including having multiple partners, more sexually transmitted infections, more alcohol and drug use, and engaging in transactional sex. Women who are sexually assaulted are known to engage in more risky behaviours, including sexually risky behaviours. This includes having multiple sexual partners, having concurrent relationships, having sex while intoxicated and becoming involved in transactional sex. Although women who are sexually assaulted are known to have high-risk behaviours, including drug and alcohol use, which might place them at high risk of being re-victimised, evidence does not support engagement in more risky practices with drug use (e.g. using contaminated needles), although this is possible.

• 30.
  

  a) F b) F c) F d) F e) T

Studies have found that women suffering from multiple forms of violence, such as sexual and physical abuse in an intimate partnership, have a greater risk of experiencing health problems than women who experience physical abuse alone. It has been found that, in many cases, mental-health symptoms improve spontaneously, and only certain women will require long-term of specialist care. It is, therefore, recommended to support the woman initially, and plan for follow up to monitor symptoms over time. This will indicate women who may need further intervention. Women who have experienced sexual violence are found to use preventive health services less frequently.

According to the Diagnostic and Statistical Manual of Mental Disorders, PTSD is diagnosed when symptoms are present for at least a month. Women who are sexually assaulted are known to engage in more risky and unhealthy behaviours, including having eating disorders with overeating, fasting, vomiting, abuse of diet pills, and symptoms of anorexia being reported.