Title: Sexual Assault of Women in the region of Kairouan, Tunisia: An eight-year retrospective
study on epidemiological and medicolegal characteristics
Version: 0 Date: 28 Jan 2022
Reviewer's report:
The manuscript entitled “Sexual Assault of Women in the region of Kairouan, Tunisia: An eight-
year retrospective medico-legal and forensic approach” analyzed the pattern of female casualties
of sexual assault in the region of Kairouan, Tunisia over an eight years period.
It was a descriptive study admittedly from a region of the World where such data remains scarce;
However, the results are superficial and non-representative to the country level or to the Arab
Region.
General comments:
The English language needs proof editing. Not being a native English-speaking person, I still
had difficulties understanding part of the manuscripts.
Specific comments:
Abstract:
1- The introduction is to be rephrased without statements not supported by previous reports in
the manuscript.
2- The objective is complex and lacks accuracy.
3- The conclusion would fit better to the introduction part. The second sentence remains vague
4- Keywords: I do not think “Characteristic” is a relevant Key world.
Manuscript
Introduction
5- The background lacks data from Tunisia and the Arab World although data are not extensive
from this region of the World.
Some references would add useful figures from Tunisia :
- Doi: 10.1016/j.avb.2018.10.005 ;
- Doi: 10.1016/j.encep.2018.07.004
- National Office of family and population (2010). Enquete Nationale sur la Violence a l'Egard
des Femmes en Tunisie.
Likewise, previous studies from the Arab Region would add a more contextualized background.
e.g. Doi: 10.1097/01.EPX.0000471671.51800.34 ; Doi: 10.1186/s12914-019-0215-5
6- The objective should be better framed for more accuracy.
Methods
7- The inclusion criteria were totally unclear. The rimary study outcome was not clear either.
What was defined as sexual assault? Which reference was used (a legal definition, casualties
allegations, judicial/Police authorities assumption?…).
Why were female victims classified according to hymen tears? What was considered physical
or biological proof of sexual assault?
What about sexual assault without physical contact or without vaginal/anal penetration?
What were the context and the framework of the medical examination?
How many Forensic specialists were involved in the Follow-up? How many disparities were
there in the health services?
What were the criteria to refer casualties to the Gynecology Department?
What were the data sources for assailants?
8- The Chi-square test was not used in any of the results you have presented, the statement in
Line 139/140 should be deleted
Results
The general comments about the results are that they remained superficial without any in-depth
analysis. Several results remained abstracted.
9- When we try to apply the inclusion criterion, we cannot understand for example how the
sample comprises victims aged 60 years old or more.
10- How did you define the “vulnerability factors” other than mental disorders and physical
disabilities?
11- It was not clear when you had missing data. Having only percentages does not help
understand when the figures represent the whole sample or if there were missing data and the
potential magnitude of the statistics gap.
12- In the cases of multiple aggressors, what kind of aggression was reported (A group rape?
Successive assaults.)
13- Several changes of denominators were observed without a clear explanation, which results
in inaccuracies. One example : Line 189 speaks about 41.4% of victims with injuries during
the medical examination; Whereas the percentages of each type of injury are counted with as
a denominator not all the sample but presumably the number of victims with injuries. This had
to be explained in the text, or in the Table with adding the total number of cases for each sub-
category.
14-  What are “superficial abrasions”? What kind of “Wound”?
15- Line 192, what are the denominator for these percentages?
16- Line 194, how do you define a “tear in the hymenal membrane”? For the consistency and
coherence of the text, what is the difference between “Hymen tear” and “hymeneal transection”
as stated in Line 197 and in Table 2?
17- Here again, the 69.4% of victims with old hymen tear (Line 197) were supposed to be
excluded as stated in the Methods section (Line 126)?
18- How do you define a “complacent hymen”?
19- The paragraph 4th paragraph in the section 3.4. (Line 197 to 202) need to be better clarified.
For example, what was described as “multiple tears”? What was the position of examination
sustaining the hourly orientation you described (this had to be explained in the Methods section)
20- What do you describe as “old and healed anal lesions”. To which extent did that “evoke
signs of recurrent anal penetration” (especially that such a diagnosis is complicated to confirm
and do not rely necessarily on anal injuries as such.
21- Line 2005-206, I am curious to better understand this statement “The presence of both recent
and old lesions to the anal area was seen in 5 examined victims (13%).”
22- Line 209, how was sperm detected? (Histopathology examination with Christmas tree
staining? H&E staining? DNA analysis?)
Discussion
The discussion was very long with some explanation not supported by the results. I will raise
only the major comments here as I strongly recommend to rephrase the discussion by focusing
on the most relevant points (for example the discussion about the months of the year (Line
287-295) is extremely useless here.
23- A more contextualized discussion would add value to the manuscript. Comparing with Data
from the Arab World and discussing the particularities related to the culture in the country would
be recommended.
24- Line 255 “Mentally handicapped” and “physically handicapped” are words that should be
replaced.
25- Line 327: Non-consented (rather than non-consensual). Do the authors aim to confirm that
non-consented vaginal intercourse might not induce injuries only in the case of “complacent
hymen” (a highly debatable concept) or in the case of “previously torn hymen”? What about
drug-induced assaults just to name this other potential situation among other possibilities!
26- In the discussion, the authors compared their results with previous reports of  "Rape"
casualties series. However, this study did not include only Rape casualties, which create
inaccuracies in the data interpretation and proposed explanations.
27- Line 337 to 352: a very theoretical discussion not sustained by the results and with debatable
comparability of the results
28- Line 375-377 how did this study “highlighted a relatively high number of female sexual
assaults”?
29- Table 3 is not relevant and should be deleted
30- Figure 3: I would recommend  a histogram  rather than a sector graph