title: Genito-anal injury patterns and associated factors in rape survivors in an urban province of South Africa: a cross-sectional study.
abstract: 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.
authors.affiliation: School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa. ruxana.jina@gmail.com.
authors.forename: Ruxana
authors.initials: R
authors.lastname: Jina
authors.affiliation: School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa. rachel.jewkes@mrc.ac.za.|Gender and Health Research Unit, South African Medical Research Council, Pretoria, South Africa. rachel.jewkes@mrc.ac.za.
authors.forename: Rachel
authors.initials: R
authors.lastname: Jewkes
authors.affiliation: Wits Institute for Social and Economic Research, Centre for the Study of Violence and Reconciliation, University of the Witwatersrand, Johannesburg, Gauteng, South Africa. lisavetten@gmail.com.
authors.forename: Lisa
authors.initials: L
authors.lastname: Vetten
authors.affiliation: School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa. nicola.chris@gmail.com.
authors.forename: Nicola
authors.initials: N
authors.lastname: Christofides
authors.affiliation: Institute for Security Studies, Pretoria, Gauteng, South Africa. rsigsworth@issafrica.org.
authors.forename: Romi
authors.initials: R
authors.lastname: Sigsworth
authors.affiliation: Gender and Health Research Unit, South African Medical Research Council, Pretoria, South Africa. Lizle.Loots@mrc.ac.za.
authors.forename: Lizle
authors.initials: L
authors.lastname: Loots
mesh_terms: D000293:Adolescent; D000328:Adult; D001003:Anal Canal / Q000293:injuries*; D003430:Cross-Sectional Studies; D005260:Female; D005836:Genitalia, Female / Q000293:injuries*; D006801:Humans; D008875:Middle Aged; D010808:Physical Examination / Q000379:methods / Q000592:standards; D015995:Prevalence; D011902:Rape / Q000175:diagnosis / Q000706:statistics & numerical data; D013019:South Africa / Q000453:epidemiology; D017741:Survivors / Q000706:statistics & numerical data; D014947:Wounds and Injuries / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology