Coerced anal sex against spouses in Turkey Türkiye ’ de eşe karşı anal yoldan cinsel saldırılar

Objective: The aim of this study was to investigate medicolegal aspects of sexual assaults involving anal penetration against females by their partners. Methods: This study includes 34 females claimed to be exposed to anal sexual assaults and referred to the Department of Forensic Medicine, Kahramanmaraş Sütçü İmam University between January 2007 and June 2012. Data were obtained from physical examination records and a face to face applied questionnaire composed of questions about socio-demographic features. Results: Sexual assaults involving anal penetration were committed against females in all 34 cases included in the study. The mean age of the victims was 23.2±5.2 years. Twenty-four women (70.6%) had a history of physical violence, but 10 (29.4%) did not. Out of all, only four women were presented to hospital because of assault. The rest were noticed to be transferred with conditions other than assaults but they were found out to be exposed to anal assaults on examinations. Most of the cases were young, female and a housewife and were exposed to anal assault. Conclusion: Anal sexual assault against females by their partners is a serious problem in our region. Therefore, screening studies on women should be conducted to determine the frequency of the condition and to provide solutions for the problem. J Clin Exp Invest 2014; 5 (4): 529-533


INTRODUCTION
Partner violence is described as damage to individuals caused by their partners.Partner violence can be experienced by married or engaged couples, partners staying in the same home, partners meet-ing for the first time, couples separated or divorced or heterosexual or homosexual partners [1][2][3][4].A type of intimate partner violence is sexual acts directed to males or females without their consent [5].Today, sexual violence is one of the most serious crimes, the rate of which is increasing rapidly [6].
Sexual violence refers to using sex as a way of threat, oppression and control.It can be against one's partner and can be exemplified as treating partners as if they are sexual objects, being extremely jealous and suspicious, punishing partners through sex, showing an overt sexual interest in people other than partners, deceiving, coercion, emotional oppression for sexual intercourse, raping, forcing partners to have sex in positions they do not want and forcing partners to become prostitutes [2][3][4][7][8][9].
Sexual assaults against partners can be in the form of inserting the penis, fingers/hands, tongue or an object through the vagina or anus by force or threatening and without obtaining consent [4].In a study in the United States, 17.6% of the women reported to have been raped or exposed to attempts of rape throughout their life.In another study from United States, 7.7% of the women noted that they were exposed to sexual violence, at least once, throughout their life [10].Several studies revealed that sexual violence can be in the form of anal assaults.However, anal assaults against female spouses have been disregarded or neglected in many studies although it is known to occur [11,12].To our knowledge, there have not been any studies on anal assaults against female spouses.Therefore, the aim of this study was to investigate medico-legal aspects of anal assaults against females by their intimate partners.

METHODS
Records about 415 cases of sexual assaults in the Department of Forensic Medicine, Kahramanmaraş Sütçü İmam University, between January 2007 and June 2012 were reviewed and 34 cases claimed to be exposed to anal sexual assaults by their partners were included in the scope of the study.Additionally, data was collected with a face to face application of a questionnaire composed of questions about age, sex, education, occupation, period of time partners had been together, history of violence partners were exposed to, time elapsing from anal assaults, causes of assaults, findings from examinations and age of assailants.Informed consent was obtained from the victims themselves for those aged over 18 and from the parents of the victims younger than 18 years.The interviews were conducted by forensic medicine specialists in an appropriate environment.Obtained data were analyzed with descriptive statistics and SPSS 15.0.

RESULTS
Out of 415 sexual assault cases, 34 (8.2%) were found to be exposed to anal sexual assault and were included in the study.All 34 cases of anal assaults (100%) were spousal assaults.The mean age of the victims was 23.2 ± 5.2 years (minimum age: 15 years and maximum age 36 years).The cases were frequently aged 21-30 years (58.8%).The mean age of the assailants was 28.7±6.7 years (minimum age: 18 year, maximum age: 45 years) and they were mostly aged between 21 and 30 years (52.9%).
Twenty-two victims (64.7%) were married, but five (14.7%) were not married, two (5.9%) were separated and five (14.7%) were engaged.Table 1 shows data about education and occupation of the cases.Twenty-four cases (70.6%) noted that they had been exposed to physical violence history before the assult, but ten (29.4%) did not report any history for physical violence.
The cases frequently noted that they had been living with their partners for 2-5 years.Only four cases presented with the complaint of anal assaults.The remaining victims presented with conditions other than anal assaults and were found to be exposed to anal assaults on examinations (Table 2).
Table 3 shows the findings of anal assaults obtained at the examinations.In addition, specimens taken from the anal region showed sperm in one case.Time elapsing from anal assaults was more than seven days in most of the cases (n:21; 61.8%).Eighteen cases were exposed to anal assaults for eleven times or more.Causes or motivation for the assaults were unknown in 28 cases, periods in four cases, virginity in one case and attempt to apply the acts the spouses watched in pornographic movies.

DISCUSSION
We found that the victims of anal assaults were young females and housewives, and anal assaults were persistent.Anal assaults toward victims by their partners do not match exact rape criteria and in general they are forced to have anal intercourse.These acts occur without receiving consent and turn into conditions difficult to bear.It has been reported in the literature that 79.6% and 96.9% of the cases exposed to sexual assaults are female [13][14][15][16][17]. Similarly, all the cases found to be exposed to anal assaults were female, which can be attributed to the fact that all the cases included in the study were married.
The cases were mostly aged between 21 and 30 years.Studies on sexual assaults also showed that young people were frequently exposed to these assaults [15].In a study conducted in Iran, the mean age of the cases exposed to sexual assaults was 34±8 years [18].It may be caused by the idea "as age increases, so does the rate of the cases accepting the condition as it is and not complaining about it".
The median age of the assailant partners was 28.7 years and they were frequently aged within 21-30 years (52.9%).In a study by Janisch, the median age of the sexual assailants was 33.9 years [14].In a study from Iran, the mean age of the assailant husbands was 38 ± 9 years [18].In the present study the finding of young ages of the assailants can be explained by the fact that assaults were committed by partners and that the assaulted partners were young.Besides, it may be that anal assaults are committed by young partners.
Consistent with the literature, half of the cases (50%) had primary education, which suggested that young age is a risk factor for anal assaults [19].The cases were mostly a housewife (n=24; 70.6%).Being a housewife might have caused the women to be more submissive, which might have played a role in anal assaults.In fact, it has been reported in the literature that low education levels, an ineffective role within the family and inability to earn money increase the risk of sexual assaults.
Seventy point six percent of the cases noted that they were exposed to physical violence previously.It has been emphasized in the literature that sexual assaults committed by domestic partners are accompanied by physical violence [14,20,21].Consistent with the literature, the present study revealed that a larger number of the anal assaults were accompanied by physical assaults.
Anal examinations did not reveal any signs of anal assaults in 22 cases.However, eleven victims showed findings such as perianal laceration, loss of tonus and flattening of mucosal folds suggestive of anal assaults and anal swaps showed sperm in only one case.This might have been due to late presentation to hospital, rapid healing of small injuries in the anal mucosa and possibility that there may be any signs of anal assaults in adults.Twentytwo cases presented to hospital at least seven days after the incident.
Out of 34 cases, only four complained about anal assaults, but the remaining victims presented with conditions other than anal assaults and were found to be exposed to anal assaults during examinations.All cases reported that anal injuries occurred during sexual acts without their consent.This can be explained by unwillingness to complain about sexual assaults, pressure from the society and socio-cultural values as barriers.In a study in Nepal, 58% of the women reported that they were exposed to sexual coercion [22].In another study, half of the partners included in the study were found to experience sexual coercion and it was also very common among partners and was rarely reported by partners [23].In a study on 230 women in Iran, 41.8% of the cases were forced to have anal sex [18].
In the present study, 18 cases noted that they experienced anal assaults for 11 times or more, previously.In all studies about spousal violence, an important feature of violence is that it appears repeatedly [4,19,24].Consistent with the literature, the cases had a history of repeated anal assaults.
The cause and motivation of the assaults was unknown in 28 cases, periods in four cases, virginity in one case and desire for applying the acts in a porn film.Anal assault attempts may not only be biologically determined but also result from sociocultural features.
In conclusion, anal sexual assaults comprise a considerable proportion of sexual assaults, and as in the other parts of the world, anal assaults committed by one of the partners against the other is a serious problem in Turkey.Sexual assaults should be kept in mind in examinations of cases of familial violence and history should be taken carefully.Screening programs directed towards married women should be conducted to determine the frequency of and to provide solutions to sexual assaults.It is of great importance that both civil organizations and policy makers should organize education programs for family and sexual health.

Table 1 .
Distribution of cases by education and occupation

Table 2 .
Causes of presentation to hospital

Table 3 .
Findings from anal examinations