The most frequent injuries that are documented after allegations of nonconsensual anal penetration are anal fissures, tears, and lacerations. Use of these different terminologies is confusing and makes comparing the different data impossible. A consensus should be reached among forensic practitioners worldwide regarding what terms should be used and what they mean.
Clinically, an anal fissure refers to a longitudinal laceration in the perianal skin and/or mucosa of the anal canal. Anal fissures may be acute (usually healing within 2-3 weeks) or chronic and single or multiple. Most fissures will heal by first intention and not leave a scar. However, after healing, the site of some fissures may be apparent as a fibrous skin tag (183). Manser (134) described the medical findings in only 16 of 51 complainants (15 males and 36 females) of anal intercourse (21 were categorized as child sexual abuse). The majority (61%) of this study population was examined at least 72 hours after the sexual contact. Fissures were found in eight cases (16%).
A major problem in the forensic interpretation of anal fissures is that they may result from numerous other means that are unrelated to penetrative trauma, including passage of hard stools, diarrhea, inflammatory bowel disease, sexually transmitted diseases, and skin diseases (183,184).
In the study by Manser (134), lacerations were documented as being present in only one of the 51 complainants of anal intercourse and five of 103 females complainants of nonconsensual vaginal penetration aged between 12 and 69 years, some of whom complained of concurrent nonconsensual anal penetration with either an object or a penis (the majority of whom were examined within 24 hours of the sexual assault). It may be that these "lacerations" were long or deep anal fissures, but because the parameters of length or depth of an anal fissure have not been clinically defined, the distinction may be arbitrary. Conversely, these "lacerations" may have been horizontally or obliquely directed breaches in the epithelium (185), which would immediately differentiate them from anal fissures and render them highly forensically significant because of the limited differential diagnoses of such injuries compared with fissures.
Slaughter et al. (90) described the gross and colposcopic findings in 311 females aged from 11 to 85 years who reported nonconsensual sexual acts, 55 of whom described anal contact. The majority (81%) of the population was examined within 72 hours of the sexual assault. They found "anal findings" in 56% of the 55 patients who reported anal contact. The anal injuries were categorized as tears in 19 of the cases. Although elsewhere Slaughter has qualified the term "tear" to mean "laceration" (186), this was not done in this article and again means that interpretation of the forensic significance of these injuries may be limited.
Because a significant percentage of the heterosexual and male homosexual population has engaged in consensual anal penetration, anecdotal accounts suggest that resultant injuries, such as fissures, are rare. This could be because the injuries do not warrant medical attention or because patients are not specifically questioned about anal intercourse when the causative factors for anal abnormalities/complaints are considered. However, one study that specifically attempted to address this issue documented that among 129 women who gave a history of anal intercourse, only one patient described anal complications, namely proctitis and an anal fissure; both these signs related to a gonococcal infection (80). However, because this study was limited to the medical history, it is not possible to rule out the presence of minor asymptomatic conditions or injuries in this study population.
Whether an injury heals by first or secondary intention, the latter resulting in scar formation, depends on several factors, including the width and depth of the breach in the epithelium. Manser (134) reported scarring in 14% of the people examined because of possible anal intercourse. The Royal College of Physicians working party stated that in children, "The only specific indicator of abuse is a fresh laceration or healed scar extending beyond the anal margin onto the perianal skin in the absence of reasonable alternative explanation, e.g., major trauma" (173). Disappointingly, this report does not clarify how they differentiate between lacerations and fissures.
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