In the interesting forensic work by Stokbaek et al. from Denmark, the problems of the medico-legal examination of sexual abuse (SA) victims are highlighted, in particular late SA reports in young unmarried women where anogenital injuries did not correlate with the SA reported. Considering the problems that are obviously present all over the world [1,2,3,4,5,6,7], this work prompted me to make my own contribution and comment on the matter. Unfortunately, there is no declining trend in sexual violence against women as a gynecological and social-criminological issue does in developing and developed countries, including Croatia. Rape, SA as the most serious form of sexual violence that includes forced vaginal, anal, and/or oral penetration with the penis, other parts of the body, and/or objects, requires an objective gynecological-forensic examination, which is necessary in the evidence procedure [1,2,3,4,5,6,7]. However, although there is an internationally adopted and accepted national protocol on handling a case of sexual violence, with clear goals and procedures during the examination and post-examination for SA, few gynecological forensic experts point to a constant problem that can direct the serious crime of SA during investigation to different short-term and long-term consequences [2]. In Croatia, SA cases are anecdotal situations in hospital gynecological practice and most often occur in the emergency department when the SA victim presents for examination alone for the gynecologist to determine the signs of SA or accompanied by members of the police duty service who bring the victim to the examination with an examination order and declared accessories for confiscation of biological material for forensic evidence of SA, which is most common. In an extremely small number of cases, the victim of SA seeks help from an extra-hospital gynecologist. As proclaimed, the examination is complex and consists of history data, somatic examination, complete gynecological and ultrasound examination, recommended vulvocolposcopy, and taking biological swabs and samples. Medical recommendations emphasize prevention of sexually transmitted diseases, advise against unwanted pregnancy during authentically unprotected vaginal sex, and further supervision by primary gynecology and family physicians, psychiatrists, and, if necessary, social workers [1,2,3, 5, 7, 8].

According to official data from the Government of the Republic of Croatia in 2016, out of 444 victims who reported crimes against sexual freedom, 98% were women, and an average of 105 crimes of rape are reported annually. Between the ages of 18 and 93, 17% of women experienced attempted rape or rape, and only 5% of them reported violence to the police and/or State Attorney Office [2]. A similar problem is mentioned by other authors, such as Jänisch et al., who report on SA to be proven in 171 (56.8%) of the reported 3012 cases of SA [4]. Saint Martin et al. proved SA to be experienced by 31.7% of women from adolescence on, and 36.3% of rapists were accused [5] Table 1.

Table 1 Problems in Croatian forensic gynecological expertise in women with sexual abuses
Full size table

Therefore, in this short report, I would like to point out the mentioned problems from my own 23-year forensic-gynecological expertise practice, along with the results of legally completed examples of SA, as a contribution to clarifying this issue, which is also highlighted in other papers. Of the fully elaborated cases of SA (\(n=31\)) with a median victim age of 37 years, gynecological-forensic expertise proved and confirmed 67.7% of SA criminal cases with a significant problem of inadequate primary gynecological procedure, most often due to insufficient gynecological examination and medical documentation in as many as 64.5% and late SA reports in 51.6% of cases. Of all SA cases, 6 (19.4%) required primary surgical care due to bleeding and lacerations of the genitals. In one case, SA was reported in persons with disabilities, but without visible injury. There were no reported cases of SA in pregnancy and no deaths related to SA. So, the problems that can affect the forensic-gynecological evaluation of SA victims are as follows:

  • Inadequate and insufficient primary medical documentation immediately after SA, which is often unusable (identification, gynecological examination, nomenclature), while it should be necessary, objective, and impeccable

  • Late reports of SA, after several days, weeks, months, or years in the reproductive age of women who are sexually active, with late primary examination when it is difficult to make objective gynecological examination

  • Inadequate education of gynecologists at all levels, family doctors, and pediatricians in SA cases

In addition to inadequate primary medical documentation, which, along with bio-forensic evidence and victim and witness statements, should be the basis of forensic expertise, there is a huge problem of late reporting of SA, which are objectively difficult or even impossible to prove gynecologically, as also stated in other works on significantly larger samples. As the reasons for late reports, the victims most often cite threats from perpetrators or accomplices, or the current emotional situation did not suggest the possibility of SA, but later perception of the event did. Although Croatian algorithms taken from the existing international legal documents recommend support by a psychiatrist, social worker, supervision of a family medicine doctor, and primary gynecologist, such cases of SA often are not completed according to recommendations due to various organizational and communication reasons. The emotional and social context during the processing of a SA victim must not be overcome by professionalism, which can often be read from the findings of individual doctors, so the legal procedure respects doctor’s findings, which can lead to an unwanted, wrong direction. Due to the monitoring and comparability of the procedures and victims of SA, as well as the respective education, it is necessary to have an available register of SA victims with all components including the report, investigation of the criminal offense, forensic expertise, and outcome of the criminal offense. Legislative bodies will judge perpetrators of SA even without gynecological-forensic medical evidence, on the basis of investigative actions, which is within the scope of work of the non-medical part of the investigation [7, 8]. Cook et al. precisely state the problems that I mention, which can direct the investigation and create unintended consequences in further course of investigation and final verdict [7]. In conclusion, it should be noted that the mentioned medical problems can be solved by constant education of all professional medical participants in SA expertise (out-of-hospital and hospital gynecologists), permanent court experts with experience, coordination and subordination of expert gynecological and forensic societies in cooperation with the state attorney office, courts and police, and social service. That is why I wanted to show the problems in Croatian gynecological forensics as the reasons for insufficiently professionally examined cases of SA in women, due to various objective and non-objective reasons which, however, are most amenable to modification.