Knowledge and Perception of Gynecologist Against Sexual Assault-Multi Center Trial

Sexual harassment is a global phenomenon. Sexual Assault is highly emotive subject and still reporting of the act is limited. Awareness of women rights has increased reporting of sexual assault requiring forensic evidence. The health care professionals required to document assault are hesitant to report assault largely due to limited knowledge and training to deal with such situations. The objective of this study was to assess knowledge and perception of Gynaecologists working in Tertiary Care Hospitals of Lahore, Pakistan who have been dealing with women with sexual assault. This is a prospective cross sectional study and a questionnaire about knowledge and perception of sexual assault was used for assessment. This prospective study was carried out in Department of Obstetrics and Gynaecology in three tertiary care hospitals of Lahore from May to June 2021 by filling a questionnaire, after verbal informed consent and obtained data was analyzed by SPSS 26. 166 doctors working at different levels answered a confidential and anonymous written questionnaire. Out of 166, 63.9% were 25-30years, 94% were females and 62.7% were married. 98.8% were Pakistanis while 72.3% belonged to urban areas of Pakistan. 53% participants had basic medical qualification (MBBS) and 41% were post graduate residents.50.6% strongly disagreed that women who wear certain types of clothing are responsible for their own rape.60.2% disagreed that rape cannot occur within marriage. 42.2% agreed upon victim not knowing the attacker. 47% disagreed that a woman can't be raped by someone she has a sexual relationship with. 30.1% strongly disagreed that a woman should feel guilty while 39.8% strongly agreed that a raped woman should do everything she can do to resist. Only 41.5% knew what to do when someone disclosed their rape. 65.1% felt uncomfortable listening to rape history of patients. 32.5% agreed that rape victim had alcohol prior to rape, 43.3% say rape victims become pregnant and 51.3% agreed that sexual violence is a very common cause of post-traumatic stress disorder while 45.8% said that rape victim may need HIV preventive measures. Laws against sexual violence and workplace harassment are in place in Pakistan but there is limited knowledge and awareness in Gynaecologists reporting sexual assault. Awareness of social rights and laws is necessary to improve diagnosis and management of this pressing problem, so this should be a part of basic medical curriculum in Pakistan


Introduction:
exual harassment is a global issue that is affecting S 1 millions of men and women psychologically. It is said that worldwide, one out of three women experiences either physical or sexual violence. Sexual assault is an unwanted sexual activity in which an individual feels 2 uncomfortable and threatened or frighten. It could be of different forms including Rape, non-consensual (enforced or unwanted) sex or sexual actions. Sexual assault can be of different types and forms, but one perspective of our society remains same: "it's never the 3 victim's fault".
The term sexual assault can be defined as any sexual interaction or behavior that happens without the consensus of victim. Some forms of sexual assault are: attempted rape, unwanted touching to private areas of body, forcing a victim to perform sexual acts, such as oral sex and 4 penetration in the victim's body, also known as rape .
Despite of the fact that sexual assault is highly emotive subject, its disclosure is low. The crime survey in England and Wales (2015) revealed that only a small minority of people who had experienced a sexual assault had reported it to the police. Embarrassment and the fear of 5 further humiliation were listed as barriers for disclosure .
Following a sexual assault, there can be a high level of anxiety in addition to the risk of pregnancy and transmission of infections will be issues of concern to the victim. Hence, timely and appropriate management of these post-assault medical issues is crucial. However, the safety and forensic issues surrounding sexual assault can create clinician anxiety, resulting in delay in the administration of appropriate medical care. So, in conclusion, assessment of a victim's overall mental health 6 and referral for emotional support should be considered .
Different countries have different laws to oppose sexual harassment, as in Pakistan according to section 376 of penal court of Pakistan the punishment of rapist is depen-7 dent on the nature of crime. Punjab Projection acts for women rights like The Punjab Protection of Women against Violence Act-XVI 2016, is an Act to establish an effective system for the protection, relief and rehabili-7 tation of women against violence and according to the Act IV 2010 the basic rights were provided to women to protect themselves from harassers. The Punjab government also launched a helpline 1043 under Punjab commission on the status of women to assist women. After all these preventive measure and efforts by government the crimes stats of Punjab police in last 07 months (01-01-21 to 21-07-21) shows 2292 registered rape cases that include 104 gang rape cases ( Figure 1). The Harassers, are punished differently depending on the 8 nature of case, witnesses, and type of court. Due to social dilemma, many cases are not reported because of the consequences that women may face, which include being viewed negatively by family members and by 9 society.
According to the annual statutory report of crime 2019-2020, the percentage of atrocious crimes like rape, gang rape and dacoity with rape increased by 21%, 9% and 11 9%, respectively as compared to 2018. The dramatic increase in the reports of sexual abuse incidents has placed demands on physicians especially Gynecologist to examine women for possible sexual abuse. Mostly Gynecologist have partial knowledge about the social and medical aspects of sexual abuse. Due to the lack of this knowledge, they do not recognize sexual abuse 8 and many cases remains unreported.
There is a frequent hesitance amongst healthcare professionals when dealing with sexual assault. Often, this comes from a lack of training and a fear that one might document information incorrectly or lose forensic evidence. It is vital to remember that a patient's primary concern should always be their healthcare and any urgent 12 treatment of injuries. As healthcare professionals, we should not lose sight of this. So, it is the most important step by the Gynecologist to have some knowledge and information on how to best preserve forensic evidence whilst providing timely medical care for sexual assault 13 victims.
The approach to the patient should be non-judgmental, supportive and includes training in communication skills amongst all staff groups, encourage all staff dealing with sexual assault to have the knowledge of forensic time frames, as well as child protection, domestic vio-14 lence and self-harm risk identification issues. It is essential that Gynecologist must improve their knowledge and skills in the diagnosis of sexual abuse so that its serious consequences can be minimized and they can 15 treat victims in best possible way. The objective of this study is assess the perception of the female doctors who are working with women who have been victim of sexual assault and also to assess their knowledge about this pressing problem. The clear knowledge of female doctors is important for better management of victims of sexual assault, also knowing perception of the treating female doctors would show us areas of lack of awareness and expertise.

Methods
It was a prospective and cross-sectional study that was conducted in the Departments of Obstetrics and Gynecology in three tertiary care teaching hospitals of Lahore, Pakistan from May 2021 to June 2021. The study was approved by the ethical committee of Post Graduate Medical Institute, Lahore General Hospital, Lahore Pakistan. Total of randomly selected 83 doctors of the Gynecology Departments of Lahore General Hospital, Jinnah Hospital and Services Institute of Medical Sciences participated in this study. These doctors included in this study were from all levels from house officers, post graduate trainees, registrars, senior registrars, assistant professors and associate professors of the respective departments. Sampling technique used was non probability convenient sampling.
A confidential and anonymous written survey was conducted. All the participating doctors were briefed about the study after taking informed consent. A questionnaire was distributed among all the participating doctors. It has 2 parts. The first part was about the demographic details, including the age, gender, marital status, qualification, working designation, affiliated hospital. nd The 2 part was to be filled by the doctor without any instruction or formal training given to them, in order to know their basic level of knowledge and perception about sexual assault against women.

Statistical Analysis:
Data was tabulated and further analyzed in SPSS version 25.0. Detail analysis was done to find out the frequency and percentage of all the variables.

Results:
Total of 83 respondents are the part of this study. According to age most of the participants 53 (63.9%) were belong to age category 25-30 years. Regarding to demographic variables; 78 (94.0%) were female, 52(62.7%) were married, 82 (98.8%) were belonged to Pakistan and 60(72.3%) were resident of Lahore. According to qualification; most of the participants 44 (53%) did MBBS, 54 (65.1) were trainee and 34 (41%) were affiliated with Lahore general hospital. (Table 1) According to the perception ; Out of 83 participants 78(50.6%) were strongly dis-agreed with women who say that women wearing certain types of clothes are responsible for their own rape, 50 (60.2%) were disagreed that rape cannot occur within marriage, 35 (42.2%) were agreed that victim does not know about the assaulter, 39 (47.0%) were dis-agreed that a women cannot be raped by somebody with whom she is in a sexual relationship, 25 (30.1 %) were strongly dis-agreed that a woman should feel guilty, 33 (39.8%) were strongly agreed that a rape women should do everything she can to resist. (Table 2)

b)qualification (c) occupation (d) affilitaed hospitals
In addition, 26 (31.3%) participants were agreed that mostly people know how to protect themselves from rape, 34 (41.5%) were agreed that they know what to do if somebody disclosed about their rape, 29 (34.9%) were dis-agreed that they feel uncomfortable listening to the rape history of the patient, similarly 32 (38.6%) were dis-agreed that they feel uncomfortable asking patient about rape. (Table 2) According to 35 (42.2%) respondents most of rape happens when women are alone outdoors at night, 30 (36.1%) were neutral about Allegations of rape are false, 29(34.9%) were agreed that rapist must be sent to prison, 40(48.2%), 35(42.2%) were agreed that rape always involve physical force, when taking a medical history from a new patient in General Practice, one should routinely ask about a history of rape. When talking about Men cannot be raped 41 (49.4) were strongly disagreed. (Table 2) According to knowledge; 32(38.6%) were agreed that Rapist frequently use medication, 27 (32.5%) were agreed that It is very common for a rape victim to have consumed significant amounts of alcohol in the hours leading up to the incident, 32(38.6%) were agreed that Rape is a serious health issue, 36(43.3%) were agreed that rape victim frequently become pregnant, 43(51.3%) were agreed that sexual violence is a very common cause of post-traumatic stress disorder, similarly 38 October -December 2022 | Volume 28 | Issue 04 | Page 445 (45.8%) were agreed that rape victims need proper treatment to avoid HIV infection. (Table 3) Mostly, 33(39.8%) participants were disagreed that DNA and Semen can be obtained for several weeks after an incident of sexual violence, 49 (59%) were agreed that rapist DNA can be obtained from a rape victim, 37(44.6%), 57(68.7%), 51(61.4%), 43(51.6%) were agreed that genital injuries do not tend to heal well in a rape victim, victims of rape will have a genital injury, a rape victim will be shaky, hysterical and distraught. On the other hand, 31(37.3%) were neutral that rape victim should be examined forensically irrespective of their wishes. (Table 3)

Discussion:
The Gynecologist are the one who are in direct contact with the rape victims while doing treatments or analyzing the situation. They should know the details of harassment, assault and abuse. If they know better they can treat better, most of the studies in literature related to sexual assault are with reference to ethnicity, uneducated and low income participants but our studies focuses on welleducated community of the nation, i.e. doctors especially Gynecologist. This study focuses on their knowledge and attitudes towards sexual assault & violence.
Most of the participants were of age group 25-30, minimum qualification is MBBS and most of them were house officers and trainees in three major tertiary care hospitals. All participants are dealing with majority of the sexual assault victims in government sectors, were eagerly involve in this study and shows a positive approach towards this study.
The social dilemma of Asian countries like Pakistan focuses on victim blaming especially if victim is female. The dress code is the first question raised by all the first responder, judicial personals and society. If the woman is wearing moderately modern clothes, they will never blame victim and always consider rape as her fault. It's common in society when a woman is raped the rather than consoling her someone always ask what she was 16 wearing , what time it was, she is involved in some way, she is faking and many other victim blaming statements. The participants were provided with all these questions to check the perception of sexual assault, so one can relate with doctors and victims and according to the survey (indicated in Figure 3) out of 83 participants 78(50.6%) were strongly dis-agreed clothing of women October -December 2022 | Volume 28 | Issue 04 | Page 446 shows they have least knowledge of marital rape but current studies shows that 50 participants (60.2%) disagrees that rape cannot occur within marriage and it need to be taken seriously. The victim blaming is common all around the world and in recent studies it is discussed that individual, situational, and cultural factors contribute to victim blaming, particularly in the case of acquaintance 18 rape . The current studies showed also relates with literature as only 35(42.2%) participants agrees that victim does not know about the attacker, 39(47.0%) were disagreed that a women cannot be raped by the person with whom she is in a sexual relationship. The guilt factor is human psychology but in sexual assault or rape 19 it leads to depression and sometime suicide . In this study all the participants strongly dis-agreed that a woman should feel guilty, 33 (39.8%) were strongly agreed that a rape women should do everything she can to resist.
The sexual assault or rape is not by choice and victim blaming makes the condition worst20, 26 (31.3%) participants were agreed that everybody is responsible for 21 preventing their own rape. Due to societal pressure , mostly victims don't disclose about rape as in this study 34(41.4%) participants thinks same but 29(34.9%) participants discussed that they are comfortable in listening rape history of patients to help them, similarly 32 (38.6%) were dis-agreed that they feel uncomfortable asking patient about rape.
The timing of sexual assault or rape is of utmost importance in present study according to 35(42.2%) respondents mostly rapes occur when women go alone outside at night, 30(36.1%) were neutral about Allegations of rape are false. In literature it is reported that most of the 22 perpetrators are convicted once they are reported but in our study lack of trust in justice system is visible as only 29(34.9%) thinks that rapists are sent to prisons. 35(42.2%) were agreed that Rape almost always involve physical force, and 41(49.4) strongly disagreed that men cannot be raped.

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The sexual assault and rape is least discussed norm , the attitude of doctors towards it is compared by checking their knowledge in this study and as indicated in Figure 4, 32(38.6%) participants agreed that Rapist frequently use medication. 27(32.5%) participants agrees that victims have consumed significant amounts of alcohol that resulted the incident. Pregnancy resulting from rape 24 is more prevalent than generally recognized and as per 32(38.6%) respondents rape should be considered as serious medical conditions. 36(43.3%) were agreed that rape victim frequently become pregnant, this is not the only medical condition victim suffered as per respondents 43(51.3%) agreed that sexual harassment is a common cause of a well-known disorder i.e., posttraumatic stress and 38 (45.8%) were agreed that rape victims may need treatment to prevent HIV infection ( Figure 4) The admissibility of DNA and semen evidence is really 25 important and only applicable after certain period of time, 33(39.8%) participants disagreed that these evidences can be obtained even after several weeks of sexual harassment, but collection is possible as 49(59.0%) were agreed that rapist DNA can be obtained from victim, 37 (44.6%), 57 (68.7%), 51 (61.4%), 43 (51.6%) were agreed that the injury of genital area do not heal soon in a rape victim. They will have genital injuries; a rape victim will be quivery and hysterical but 31(37.3%) victims remain neutral. The rape victim should be examined properly by forensic methods irrespective of their wishes (Figure 4).

Limitations
This study was difficult to approach women and getting their opinions. A future research is planned to cater knowledge and perception of women rights in difference groups of women.

Conclusion
This study concludes sexual assault is still believed to be victim's fault widely by society. Victims are not related to the offenders usually. Societal pressure plays negative role in reporting of the sexual assault and women affected by sexual assault not only undergo physical injures but also psychological harm. This study depicts perception of educated young females of urban society about sexual assault. The public awareness and realization of women's right in Pakistan is of utmost importance. Due to limited knowledge of an important public dilemma, a significant problem is being brushed under the carpet. Hence the lack of adequate knowledge and wrong perception of even gynecologists working in Tertiary care centers about sexual assault represents our society as a whole.