Reviewer's report
Title:Genito-anal injury patterns and associated factors in rape survivors in an
urban province of South Africa: a cross-sectional study
Version:1Date:6 December 2014
Reviewer: Dana Kelly
Reviewer's report:
Discretionary Revisions:
First, some comments. In general, I believe this is potentially an important study
in the context of anogenital injury prevalence studies worldwide. The severity
factor of injuries after sexual assault in South Africa is interesting. Centers in
South Africa may want to keep abreast of developing work in the area of severity
scale development. Overall, there are a few methodological problems here which
may not be able to be addressed given the lack of some factors on the J88 form.
From a policy standpoint, it may be time to revise that form.
From the discussion, paragraph 1: Great job associating lack of findings and
false allegation stats.
1. Methods, paragraph 1: Is there an online resource for the J88 form that can be
cited?
2. Methods, paragraph 4: "... J88 form was completed within 10 days of the
rape..." Are the J88 forms always completed at the time of the exam? If so,
perhaps it would be clearer to say "forensic exam was completed within 10 days
of the rape"
3. Results, paragraph 3 (referring to Table 3: What was the reasoning for each
age category?
A few minor corrections:
4. Background, para 2: line 18 "understanding what factors are associated...."
5. Results, para 2: line 8: "...for the clitoris and its frenulum,..."
6. Discussion, para 5: line 17 "... between the ages of 4 and 12 years were more
likely..."
7. Table 2.: what is funelling (& should it be "funneling")? what is tyre sign?
perhaps a small footnote is needed
8. Table 4.: Under Univariate analysis and under Multivariate analysis, should
add label that the values are "OR & 95% CI"
Minor essential revisions
9. Methods, somewhere: From the limitations, I see that there is no actual
knowledge of which injuries were detected macroscopically vs colposcopically vs
with tissue staining (see below). This is a problem and should be mentioned in
the methods. Also, I am assuming that a speculum was used to detect the
vaginal and cervical injuries, but this isn't mentioned. How were the anal
sphincter and anus injures detected? Distraction? Digitally? Anoscopically?
There is no mention of the methods used.
10. Discussion, paragraph 2: "Redness was also frequently reported, yet has a
low sensitivity.." This sentence contradicts itself. I think of redness more in terms
of its subjectivity and nonspecific nature. Is this what you meant?
Major compulsory revisions
11. Discussion, paragraph 6 (limitations): I believe more needs to be discussed
about the lack of knowledge of the injury detection method. This is a huge factor
in the detection rate of anogenital injuries, to the point that it makes the results of
this study bordering on uninterpretable. There are such huge variations in the
detection rates of injuries in the existing literature, based on the detection method
used. In the McCauley paper that you cited (1987), the sensitivity of detecting
injuries using toluidine blue increased from 4% to 58% over gross inspection.
Lenahan, in her 1998 study showed colposcopy alone to increase the detection
of injuries from 6% to 53% over gross inspection, and Astrup's 2013 paper
showed the sensitivity of the combination of colposcopy and toluidine blue raised
from 34% to 52%. Figure 2 in Kelly's 2013 paper shows a comparison of the
various detection methods in the existing literature, controlling for the injury
types, and reporting 95% confidence intervals. There are obviously other factors
that contribute to the sensitivity of detecting findings, that you were able to
analyze or control for, but I really believe that the detection method is major.
Based on this fact, I do not believe that it is valid to analyze factors associated
with presence or absence of injuries when we potentially have a severely skewed
sample, and do not even know in which direction. These factors need to be
emphasized in the limitations of this study.
References for this section
McCauley J, Guzinsky G, Welch R, Gorman R, Osmers F. Toluidine blue in the
corraboration of rape in the adult victim. Am J Emerg Med 1987;5(2):105-08.
Lenahan LC, Ernst A, Johnson B. Colposcopy in evaluation of the adult sexual
assault victim. Am J Emerg Med 1998;16(2):183-84.
Astrup BS, Ravn P, Thomsen JL, Lauritsen J. Patterned genital injury in cases of
rape - A case-control study. J Forensic & Legal Med 2013;20(5):525-29.
Kelly DL, Larkin HJ, Cosby CD, Paolinetti LA. Derivation fo the Genital Injury
Severity Scale (GISS): A concise instrument for description and measurement of
external female genital injury after sexual intercourse. J Forensic & Legal Med
2013;20(6):724-31.
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
I declare that I have no competing interests