Visible injury patterns in relation to reported sexual acts after sexual assault: a retrospective cohort study

Sexual assault may result in visible anogenital and extragenital injuries, but the absence of such findings remains a major challenge in forensic interpretation. This retrospective forensic outpatient study analyzed 306 adults examined after reported sexual assault at the Violence Protection Ambulatory of Charité - Universitätsmedizin Berlin between January 2016 and December 2023. Demographic, assault-related, and injury-related variables were extracted from finalized forensic examination reports. The primary aim was to assess the frequency of predefined anatomically or regionally corresponding visible injuries in relation to reported oral, vaginal, and anal sexual acts. Extragenital injuries were documented in 216/306 cases (70.6%), whereas anogenital injuries were documented in 62/306 cases (20.3%). Among 256 individuals reporting at least one oral, vaginal, or anal sexual act, predefined corresponding visible injuries were present in 72 cases (28.1%, 95% CI 23.0-33.9) and absent in 184 cases (71.9%). Corresponding anogenital injuries were uncommon after reported vaginal acts and were not significantly associated with reported vaginal acts or penile-vaginal penetration. Reported anal sexual violence and oral sexual violence were significantly associated with anal and facial injuries, respectively; however, corresponding injuries were still absent in most cases. In multivariable logistic regression, the number of reported sexual acts was the only variable independently associated with absence of corresponding visible injury. These findings demonstrate the limited sensitivity of visible injury documentation after reported sexual assault. The presence of a corresponding injury may support the assessment of consistency with the reported history, but the absence of visible injury must not be interpreted as excluding the reported assault.