Forensic nursing care for adult male victims of sexual violence: a scoping review

Abstract

Objective

To map and synthetize evidence on forensic nursing care for adult men victims of sexual violence.

Methods

A scoping review in accordance with JBI method. The eligibility criteria included: Population - adult men aged 18 to 59 years old; Concept - forensic nursing care; and Context - sexual violence against an adult man treated in health services. The search was carried out in three stages by two researchers, with the participation of a third reviewer to solve doubts. Data collection was carried out from data sources using descriptors and keywords. For this review, the temporal and idiomatic cut-off was not updated. The Virtual Health Library (VHL), Nursing Database (BDENF), Medical Literature Analysis and Retrieval System Online (MEDLINE) via PubMed, CINAHL via Ebsco databases and gray literature were used. Data were systematically spread sheeted, and inductive content analysis was carried out on 16 included studies. Synthesis of results was presented using charts, infographics and diagrams.

Results

It focused on compassionate care and helping relationship, subjective data recording, need to remove the victim’s clothes, head-foot examination, injury recording on body diagrams, photographic records, forensic trace collection and preservation, oropharyngeal collection, penile, scrotal and anorectal swabs. Care related to colposcopy, use of Wood’s lamp and anoscopy was mapped.

Conclusion

Situations of sexual violence against men, although little addressed, can occur frequently in everyday life, which implies the recognition of care that can promote welcoming in order to preserve their integrity and reduce trauma arising from this situation as well as guaranteeing forensic trace recording.

Forensic nursing; Sex offenses; Men’s health; Crime victims

Resumo

Objetivo

Mapear e sintetizar evidências sobre a assistência de enfermagem forense a homens adultos vítimas de violência sexual.

Métodos

Scoping review de acordo com o método JBI. Os critérios de elegibilidade incluíram: População – homens adultos com idade entre 18 e 59 anos; Conceito – assistência de enfermagem forense; e Contexto – violência sexual contra homem adulto atendido em serviços de saúde. A busca foi realizada em três etapas por dois pesquisadores, com a participação de um terceiro revisor para sanar dúvidas. A coleta de dados foi realizada a partir de fontes de dados por meio de descritores e palavras-chave. Para esta revisão, o corte temporal e idiomático não foi atualizado. Foram utilizadas as bases de dados Biblioteca Virtual em Saúde (BVS), Base de Dados de Enfermagem (BDENF), Medical Literature Analysis and Retrieval System Online (MEDLINE) via PubMed, CINAHL via Ebsco e literatura cinzenta. Os dados foram sistematicamente divulgados e foi realizada análise de conteúdo indutiva em 16 estudos incluídos. A síntese dos resultados foi apresentada por meio de gráficos, infográficos e diagramas.

Resultados

Centrou-se no cuidado compassivo e na relação de ajuda, registro de dados subjetivos, necessidade de retirada da roupa da vítima, exame de cabeça e pés, registro de lesões em diagramas corporais, registros fotográficos, coleta e preservação de vestígios forenses, coleta de orofaringe, swabs penianos, escrotais e anorretais. Foram mapeados cuidados relacionados à colposcopia, ao uso da lâmpada de Wood e à anuscopia.

Conclusão

Situações de violência sexual contra homens, embora pouco abordadas, podem ocorrer com frequência no cotidiano, o que implica o reconhecimento de cuidados que possam promover o acolhimento, a fim de preservar sua integridade e reduzir traumas decorrentes dessa situação, bem como garantir o registro do rastreio forense.

Enfermagem forense; Delitos sexuais; Saúde do homem; Vítimas de crime

Resumen

Objetivo

Mapear y sintetizar evidencias sobre la atención de enfermería forense a hombres adultos víctimas de violencia sexual.

Métodos

Scoping review de acuerdo con el método JBI. Los criterios de elegibilidad incluyeron: población (hombres adultos entre 18 y 59 años), concepto (atención de enfermería forense) y contexto (violencia sexual contra hombres adultos atendidos en servicios de salud). La búsqueda fue realizada en tres etapas por dos investigadores, con la participación de un tercer revisor para aclarar dudas. La recopilación de datos se llevó a cabo a partir de fuentes de datos, mediante descriptores y palabras clave. Para esta revisión, no se actualizó el corte temporal e idiomático. Se utilizaron las siguientes bases de datos: Biblioteca Virtual en Salud (BVS), Banco de Datos de Enfermería (BDENF), Medical Literature Analysis and Retrieval System Online (MEDLINE) vía PubMed, CINAHL vía Ebsco y literatura gris. Los datos se difundieron sistemáticamente y se realizó un análisis inductivo en los 16 estudios incluidos. La síntesis de los resultados se presentó por medio de gráficos, infográficos y diagramas.

Resultados

Se centró en el cuidado compasivo y en la relación de ayuda, el registro de datos subjetivos, la necesidad de remoción de ropa de la víctima, examen de cabeza y pies, registro de lesiones en diagramas corporales, registros fotográficos, recopilación y preservación de vestigios forenses, toma de muestras orofaríngeas, hisopados peneanos, escrotales y anorrectales. Se mapearon los cuidados relacionados con la colposcopía, el uso de la lámpara de Wood y la anoscopía.

Conclusión

Situaciones de violencia sexual contra hombres, a pesar de ser poco abordadas, pueden ocurrir con frecuencia en la vida cotidiana, lo que implica el reconocimiento de cuidados que puedan promover la acogida, a fin de preservar su integridad y reducir traumas resultantes de esta situación, además de garantizar el registro del rastreo forense.

Enfermería forense; Delitos sexuales; Salud del hombre; Víctimas de crimen

Introduction

Sexual violence is a complex, multifactorial phenomenon that affects individuals, regardless of age group, social, economic and political status, and geolocation. Access to legal and security services is considered a serious public health problem, whose records have been increasing significantly.(¹-³)

Sexual violence consequences include the development of harm, such as genitoanal injuries, sexually transmitted infections (STIs), pregnancy, psycho-emotional harm, alcohol and drug use, prostitution, developmental harm and death.(⁴-⁶)

The World Health Organization recognizes sexual violence as attempts to obtain a sexual act or consummation of a non-consensual act, harassment and/or sexual advances against an individual. It should be noted that this nature of violence presents polysemic conceptual constructions depending on the scope, whether it is health, legal, social, psychological, anthropological and political, which can generate epistemological tensions for its understanding, reverberating in the construction of coping strategies.(⁴)

In this context, men are often represented as the dominating agent and, therefore, considered as offenders. This social construction supports a stereotype that they cannot be identified as victims of this type of violence. This process of social invisibility of this phenomenon also occurs in the epistemic field, as, over the centuries, efforts have been made in scientific investigations into sexual violence against women, children, adolescents and older adults. However, there are few investigations to understand this nature of violence in relation to adult men, and there are several gaps in knowledge that need clarification.

It is understood that epidemiological data on sexual violence against men is incipient, which tends to strengthen the hypothesis that such cases do not occur or that they are very rare, supporting a camouflage process regarding how these individuals experienced sexual violence situations.(⁶-⁹) Thus, the process of construction, support and social dissemination of the idea of hegemonic masculinity that adult men are strong, inviolable and that only homosexuals suffer sexual violence contributes to limiting the understanding of this phenomenon.(⁶-⁹)

Due to this problem, victims can resort to health services to receive support and multidisciplinary clinical care for injury diagnosis and treatment, STI examinations and treatment.(¹,¹⁰)

Since forensic nurses are in a prime position to promote user care in health services at the primary, secondary and tertiary levels, which have a theoretical-scientific and pragmatic framework, their practices are supported by the legal apparatus of the country in which the specialty of forensic nursing is implemented. It is understood that this professional will be able to provide qualified and safe care to people affected by sexual violence, including adult men.

Thus, it is defended that forensic nurses must be prepared to establish safe and qualified care for adult men affected by sexual violence, providing forensic trace collection, preservation and storage to contribute to identifying perpetrators and adopting secondary prevention measures and rehabilitation of individuals, and may even contribute with their technical-specialized testimony in courts.(¹¹,¹²)

Considering the above, the need to amplify the debate on sexual violence against men is identified, as it is a topic that is little explored and requires intervention and prevention of dysfunctional health patterns resulting from this problem.

In light of the foregoing, in order to support this scoping review, a preliminary search was carried out between May and July 2023 in the Medical Literature Analysis and Retrieval System Online (MEDLINE) via PubMed, International Prospective Register of Systematic Reviews (PROSPERO), Cochrane Library and JBI Evidence Synthesis databases, opportunity in which no current or ongoing scoping or systematic reviews on this topic were identified. The review question established was as follows: what is the forensic nursing care provided to adult men who have experienced sexual violence? This review aimed to map and synthetize forensic nursing care for adult men victims of sexual violence.

Methods

This is a scoping review carried out in accordance with JBI method, which was registered in the Open Science Framework with DOI 10.17605/OSF.IO/QJH9U. For transparency and epistemological vigilance, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA–ScR) recommendations.(¹³,¹⁴)

The eligibility criteria followed the PCC mnemonic: “P” (Population) – adult men aged 18 to 59 years old;“C” (Concept) - forensic nursing care;(¹¹,¹²) and “C” (Context) - sexual violence against an adult man treated in health services.(⁴)

It is noteworthy that no temporal and idiomatic cut-offs or open access definition of sources were defined, in order to amplify the searches and avoid the risk of bias when locating and analyzing data with a temporal and idiomatic cut-off. Primary and secondary studies of any type of approach and design were considered sources of technical-scientific information. In addition to these sources, which were accessed through databases, searches were also carried out in gray literature. The search was carried out in three stages by two reviewers, and had the support of a third reviewer to solve any disagreements. It is noteworthy that the blinding process was maintained among reviewers, and had the support of a librarian. The first stage comprised a primary search in Medical Literature Analysis and Retrieval System Online (MEDLINE), through which an analysis of titles, abstracts and descriptors was carried out. The second stage involved a complete search in all selected databases, using Boolean operators “AND” and “OR” along with keywords and descriptors (Chart 1).

Chart 1
Search strategy

Search strategy

((“Sex Offenses”[mh] OR Sex Offense*[tiab] OR Sexual Abuse*[tiab] OR “Sexual Injuries”[tiab] OR Sexual Violence*[tiab] OR “Sexual injury”[tiab] OR “Sexual violence”[tiab] OR “Child Abuse, Sexual”[mh] OR “Child Molestation”[tiab] OR “Sexual Abuse”[tiab] OR “Rape”[mh] OR Rape[tiab])) AND ((“Forensic Nursing”[mh] OR Forensic Nursing*[tiab] OR “Forensic care”[tiab] OR “Forensic Nurse”[tiab] OR “Forensic Nurses”[tiab] OR forensic practice*[tiab] OR forensic technique*[tiab] OR “Nurse Examiner”[tiab] OR “Forensic Examinations”[tiab] OR “Forensic Examination”[tiab] OR “Sexual Assault Nurse Examiner” OR “Sexual Assault Nurse Examiners” OR ((forensic[tiab]) AND (nursing*[tiab] OR nurse*[tiab])) OR (“Expert Testimony”[mh] OR “Expert Testimonies”[tiab] OR “Expert Witness”[tiab] OR “Expert Witnesses”[tiab] OR “Expert Opinion”[tiab] OR “Expert Opinions”[tiab] OR Photography[mh] OR Photograph*[tiab] OR Fingerprinting[tiab] OR Fingerprint*[tiab] OR “Justice Administration System”[tiab] OR “Equal Protection”[tiab] OR trace collection[tiab] OR “collection of evidence”[tiab] OR “collection of evidence”[tiab] OR collection of information[tiab] OR identifying of evidence[tiab] OR collecting of evidence[tiab] OR preserving of evidence[tiab] OR “chain of custody”[tiab] OR evidence tracking[tiab] OR “evidence screening”[tiab] OR death risk scenario*[tiab] OR “death investigation”[tiab] OR “death investigations”[tiab] OR “bodily injury”[tiab] OR cadaver preservation*[tiab] OR “Victims Identification”[tiab] OR “trace preservation”[tiab]) AND (forensic[tiab] OR nursing*[tiab] OR nurse*[tiab]))).

The third stage comprised tertiary search through analysis of reference lists of studies. This review also included the search for more information through contact with the authors of primary studies.

Searches were carried out in data sources and gray literature such as: Virtual Health Library (VHL) Regional Portal; Latin American and Caribbean Literature in Health Sciences (LILACS); Índice Bibliográfico Español em Ciencias de la Salud (IBECS); Nursing Database (BDENF); Medical Literature Analysis and Retrieval System Online (MEDLINE) via PubMed; Scientific Electronic Library Online (SciELO); Embase; SciVerse Scopus via Elsevier; CINAHL via Ebsco; and ASP. A search was also carried out on the reference supplier in CAB Direct and in the APA PsycInfo database. The integrative and gray literature portal Science.gov: USA.gov was also used. Furthermore, searches included websites about forensic nursing, legislation, digital libraries of theses and dissertations and internet search engines.

The process to select sources involved analyzes by two reviewers regarding title, abstracts and descriptors. Excluded studies were registered, and the reasons for exclusion were described. To organize references and identify duplicate studies, EndNote Web^® and Rayyan^® were used.

Texts were read in full by two reviewers, with the support of an instrument adapted from PRISMA-ScR proposed by JBI.(¹³,¹⁴)Disagreements among reviewers were solved by discussion among them, with the participation of a third reviewer.

The extraction instrument previously tested was composed of study title, country/language, study design, context in which it occurs, profile of men, type of violence and forensic nursing care for men affected by sexual violence.

Data were organized for content analysis inductively, and results were presented using infographics and diagrams, seeking proper alignment with the objective and research question. The study was carried out from February 2022 to July 2023. This study stands out for being a scoping review that used public domain publications, and it was not necessary for the study to be assessed by a Research Ethics Committee (REC).

Results

A total of 5,248 studies were retrieved from the databases, and new studies were identified using other methods such as websites of forensic nursing associations and societies, reverse search, protocols, dissertations and theses, 681 on websites and 778 in reverse searches. After the identification and screening steps, 16 studies were included for final analysis (Figure 1).(¹⁵-³⁰)

Figure 1
Flowchart of the stages of study selection for the scoping review, adapted from the PRISMA-ScR model

The first study was carried out in 1980 (6.25%). In 1999, 2000, 2002 and 2003, there was one (6.25%) study per year. A wide range of studies was noted in subsequent years, with two (12.5%) in 2013, 2019 and 2022, and one (6.25%) in 2014, 2016, 2018, 2020 and 2023 (Chart2). As for the country, 14 (87.5%) were published in the United States of America (USA), one (6.25%) in Geneva and one (6.25%) in South Africa. Regarding language, the 16 (100%) studies were written in English (Chart 2).

Chart 2
Synthesisof results (year, authors, country, language and forensic nursing care)

Authors/years	Country	Language	Forensic nursing care
Groth N, Burgess A W 1980(15)	USA	English	Collect and preserve all clothes in paper bags
LedrayLE 1999(16)	USA	English	Perform colposcopy
Ernst AA, Green E, Ferguson MT, Weiss SJ, Green WM 2000(17)	USA	English	Obtain history collection; Perform a head and foot examination; Inspect the victim’s body; Perform colposcopy; Use Wood’s lamp; Perform anoscopy; Carry out laboratory and toxicological tests; Carry out screening and prophylaxis for sexually transmitted infections (STI); Administer vaccine doses
Ellis CD 2002(18)	USA	English	Helping relationship; Provide explanations about examination; Carry out laboratory and toxicological tests; Carry out screening and prophylaxis for sexually transmitted infections (STI); Provide care and legal support; Assess and carry out therapies; Provide counseling
World Health Organization 2003(19)	CHE	English	Sign the Informed Consent Form; Obtain history collection; Perform a head and foot examination; Inspect the victim’s body; Inspect the genito-anal area; Carry out laboratory and toxicological tests; Carry out screening and prophylaxis for sexually transmitted infections (STI); Administer vaccine doses; Assess and carry out therapies; Provide counseling
Riviello RJ, Rozzi HV 2013(20)	USA	English	Helping relationship; Sign the Informed Consent Form; Obtain history collection; Record the victim’s narrative; Completely undressing the victim on a sheet; Inspect the victim’s body; Document it in body diagrams; Perform an oropharyngeal examination; Collect oropharyngeal swabs; Inspect the genito-anal area; Collect swabs from the penis and scrotum; Collect swabs from the anorectal region; Use Wood’s lamp; Carry out screening and prophylaxis for sexually transmitted infections (STI); Administer vaccine doses; Assess and carry out therapies; Provide counseling
BurgessAW,Slatterry DM, Herlihy PA 2013(21)	USA	English	Perform a head and foot examination; Inspect the victim’s body; Provide counseling
Sutherland JL, Amar AF, Sutherland MA 2014(22)	USA	English	Inspect the victim’s body
Central Minnesota Sexual Assault Center(CMSAC) 2016(23)	USA	English	Obtain history collection; Perform a head and foot examination; Inspect the victim’s body; Inspect the genito-anal area; Collect swabs from the penis and scrotum; Collect swabs from the anorectal region; Perform anoscopy
Porta CM, Johnson E, Finn C. 2018(24)	USA	English	Compassionate care; Helping relationship; Obtain history collection; Perform a head and foot examination; Inspect the victim’s body; Carry out screening and prophylaxis for sexually transmitted infections (STI); Provide care and legal support
Charlies L, Mitchell S. 2019(25)	USA	English	Sign the Informed Consent Form; Record the victim’s narrative; Document it in body diagrams; Collect oropharyngeal swabs; Nail debris; Collect swabs from the penis and scrotum; Collect swabs from the anorectal region; Objects or any material present in the rectum; Carry out screening and prophylaxis for sexually transmitted infections (STI); Provide care and legal support; Provide counseling
Mgolozeli, SE, Duma SE. 2019(26)	ZAF	English	Carry out screening and prophylaxis for sexually transmitted infections (STI)
Prince M 2020(27)	USA	English	Compassionate care; Document it in body diagrams; Carry out screening and prophylaxis for sexually transmitted infections (STI)
Colorado Sexual Assault Evidence Collection Protocol 2022(28)	USA	English	Compassionate care; Document it in body diagrams; Collect swabs from the penis and scrotum; Collect swabs from the anorectal region; Carry out screening and prophylaxis for sexually transmitted infections (STI)
Charlies L, Mitchell S, Texas A&M Health Center of Excellence in Forensic Nursing College of Nursing 2022(29)	USA	English	Sign the Informed Consent Form; Record the victim’s narrative; Document it in body diagrams; Collect oropharyngeal swabs; Nail debris; Collect swabs from the penis and scrotum; Collect swabs from the anorectal region; Objects or any material present in the rectum; Carry out screening and prophylaxis for sexually transmitted infections (STI); Provide counseling
Moret JD, Choe L, Anderson JC 2023(30)	USA	English	Compassionate care; Helping relationship; Carry out screening and prophylaxis for sexually transmitted infections (STI); Provide counseling

Regarding context, 12 (75%) were in general, two (12.5%) in the community, one (6.25%) in the military, one (6.25%) in the university. Regarding research methods, it was identified that seven (43.75%) are protocols, four (25%) are case studies, two (12.5%) are cross-sectional descriptive studies and one (6.25%) is phenomenological and retrospective review. Figure 2 presents the results regarding the profile of adult men who experienced situations of sexual violence, perpetrators as well as type of sexual violence committed against adult men.

Figure 2
Infographic mapping the profile of victims, perpetrators and type of violence

Aggression motives and styles varied. It was identified that six studies highlighted power relations,(¹⁵,¹⁸,²²,²⁴,²⁶,²⁷) two referred to affirmation of strength and masculinity.(¹⁵,¹⁸) Three studies pointed to retaliation/revenge.(¹⁵,²¹,²⁶) Three other studies highlighted degradation, humiliation, sadism and torture,(¹⁵,¹⁸,²⁶) and one, coprophilic acts.(¹⁵)

Two studies explained motivations, such as status, maintenance of social ties (group rape),(¹⁵,²⁶) initiation of a prisoner into a gang,(²⁶) transactional rape (exchange of favors, food),(²⁶) attempt by a homosexual victim to change his sexuality.(²⁶) Three studies(¹⁵,¹⁶,¹⁸) showed that this violence against men is not sexually motivated, being misinterpreted as a sexually motivated crime.

With regard to consequences, it was identified that such occurrences affect biological aspects(¹⁵,¹⁸,²⁶-³⁰) through injuries resulting from choking,(²⁴) bleeding,(¹⁷) anorectal and perianal injuries,(¹⁶-¹⁸,²²,²⁴,²⁶,²⁷,³⁰)trauma physical injuries such as abrasions on wrist and ankles, development of sexually transmitted infections (STI),(¹⁷,¹⁸,²¹,²²,²⁶,²⁷) increased use of alcohol and drugs,(¹⁹,³⁰)smoking,(³⁰) sexual dysfunction.(¹⁶,¹⁸,¹⁹,²¹)

With regard to psycho-affective impacts,(¹⁶,²²,²⁶,²⁷,³⁰) it was identified post-traumatic stress disorder (PTSD).(¹⁶,²¹,²⁴,²⁷,²⁸,³⁰)rape trauma syndrome (RTS),(¹⁵,¹⁶,¹⁸,¹⁹,²¹,²⁴,²⁷,²⁸,³⁰) difficulty speaking and dealing with social meaning, anguish, psychophysiological consequences resulting from erection and ejaculation during sexual violence.(¹⁵,¹⁶,¹⁸,²⁴)

With regard to forensic nursing care for male victims of sexual violence, it was identified that it can be divided into 3 major phases: 1. Welcoming and forensic interview; 2. Forensic examination and trace collection and preservation; and 3. Complementary exams and follow-up care (Figure 3).

Figure 3
Mapping forensic nursing care for men victims of sexual violence

Discussion

The topic of forensic nursing care for adult men affected by sexual violence is still incipient. Evidence points to the need to invest in more scientific production, as the male population has unique human needs that supports the urgency of a forensic nursing approach based on compassionate care.(⁶,¹¹,¹⁵,¹⁶,²⁵,²⁹,³¹)

Regarding study years, it is identified that it is a problem that has occurred since antiquity, but it was in the 1980s that this phenomenon began to receive greater notoriety and scientific investigations began, which is in line with the discussions presented by different authors. It was identified that different countries must, therefore, invest in research and models of forensic nursing care for men who are victims of sexual violence.(²,⁶,⁸,⁹,³¹)

Regarding the publication method, it was identified that these are protocols and case studies that present a low level of evidence. There is a need for studies with more robust methods, exploring gaps evidenced by this review, such as carrying out welcoming and forensic examinations, colposcopy and anoscopyuse, alcohol, drugs or medication consumption, counseling and therapeutic techniques, STI and continuity of prophylaxis, violence with a female perpetrator and rape trauma syndrome (RTS) and post-traumatic stress disorder (PTSD)diagnostics.(¹⁵-¹⁸,²²,²⁴,²⁶,²⁷,³⁰,³¹)

It became clear that many cases may be underreported and that records may have inconsistencies supported by challenges such as the existence of myths, taboos and stereotypes built, supported and socially disseminated. They represent men as strong, capable of fighting, unlikely to suffer sexual violence, and that they are always the perpetrators and that individuals affected by sexual violence are homosexuals. Moreover, there is fear of having their identity and confidentiality damaged, of having the essence of their masculinity attacked and of suffering secondary victimization in health and police services.(¹,⁷,⁸,¹³,¹⁵-²¹,²⁴-²⁷,²⁹-³³)

The absence of injuries can contribute to delays in seeking health services, ranging from one day, six months to years after suffering the aggression. Men are more likely to mischaracterize the fact that they were victims of sexual violence. It is necessary for forensic nurses to develop strategies to encourage men to seek health services immediately after the occurrence of violence.(¹⁵-²⁰,²¹,²⁴,²⁵,²⁷,²⁹-³¹,³³)

It should be noted that, with limited studies on this phenomenon and low number of participants, it becomes a challenge to have accurate statistical data on victim and aggressor characteristics. Forensic nurses play an important role in helping victims to break the silence and identify and recognize their trauma when working in different care spaces.(²¹,³¹)

It is necessary to take a holistic approach in forensic care management. A history of sexual trauma in men of any age should be suspected, establishing compassionate care, (re)affirming that it is never the victims’ fault, not making judgments, promoting active listening, maintaining focus on individuality and establishing a helping relationship so that men feel more comfortable, safe and receptive to forensic nursing care.(⁴,¹²,¹⁵,¹⁶,¹⁸,²⁴,²⁵,²⁷-³¹)

It is noteworthy that forensic nurses must assess verbal and non-verbal communication to identify signs and symptoms of rape trauma syndrome (RTS) and post-traumatic stress disorder (PTSD) arising from neuroendocrinometabolic response to trauma.(¹²,¹⁸,³¹)

The need for multidisciplinary monitoring and ensuring emotional and physical safety is highlighted, as it is necessary to stabilize victims, first solve the emergency or life-threatening condition, assess emotional state and then explain procedures and forensic examinations that will be carried out.(¹⁵,¹⁸,²⁰,²⁴,³¹)

Men must sign the Informed Consent Form (ICF) before any nursing history searches and forensic examinations are conducted. Thus, the principle of autonomy for any interventions is maintained, as that have the right to refuse any part of the investigation, and it is also worth highlighting the need to preserve privacy.(¹⁸-²⁰,²³-²⁵,²⁹)

Forensic nurses must dedicate time and sensitivity to collecting history and explain in clear language the physiology of erection and ejaculation, because rectal penetration can generate prostate stimulation, which in response can cause erection and ejaculation, which does not presuppose consent, as victims may become confused and fear that their sexuality has been shaken.(¹⁶-²⁰,²³-²⁵,²⁸,²⁹,³¹)

It is important to record victims’ narrative, investigate the last consensual sexual practices, hygiene, urination, defecation. History will indicate the sites to be examined. Understanding in detail how sexual violence occurred can help forensic nurses connect legal resources and health.(²⁰,²³,²⁵,²⁷,²⁹,³¹,³²,³⁴)

Sequentially, men must undress completely on a sheet, and forensic nurses must collect and preserve all clothing in paper bags and, preferably, to prevent microbial proliferation.(²⁰,²⁵,²⁹,³⁴)

Forensic nurses must perform a head and foot examination, as macroscopic examination is the gold standard. Propaedeutic and semiological techniques must be carried out in accordance with victims’ report, inspecting the body and assessing signs of injuries and changes, which must be documented in body diagrams and photographed.(¹⁷,¹⁹-²⁵,²⁷,²⁹,³²,³⁴)

It is pointed out that oropharyngeal examination should be carried out in cases of oral penetration to investigate labial and lingual frenulum laceration, mucosal abrasions, contusions, petechiae on the posterior wall and soft palate, which may occur days later. The genito-anal region, inner thighs and perineum and places where aggressors may have grabbed or ejaculated are inspected as well as the presence of saliva on the penis, vaginal fluids, feces or lubricants, fissures, bruises, anal sphincter reduction.(¹⁹,²⁰,²³,²⁸,³¹,³²,³⁴,³⁵)

Based on forensic nursing history, bite mark, suction mark and semen stain swabs should be collected, as spermatozoa can last from 72 to 96 hours at the site. The need to obtain an oropharyngeal and anorectal swab is assessed if there is a history of contact, collecting a swab or nail spatula to collect debris.(²⁰,²⁵,²⁹,³¹,³²,³⁴)

Penis and scrotum swabs must be collected, taking care to change gloves, pre-moisten two swabs in sterile saline solution, without saturating. It is necessary to let swabs dry, place them in a box at the ends and label, seal the envelopes with examiners’ initials and label with site identification. Care must be taken not to take a swab from the urethral meatus, as this may result in deoxyribonucleic acid (DNA) samples from victims and not perpetrators.(²⁰,²³,²⁵,²⁸,²⁹,³¹,³²)

Swab collection from the anorectal region must be carried out, in addition to inspecting and taking care to changing gloves, pre-moistening two swabs in sterile saline solution, collecting 2cm from the rectum gently in circular movements and rubbing around from the anus.(²⁰,²³,²⁵,²⁸,²⁹,³²)

Retained objects or any material present in the rectum are collected, leaving to dry in open air, placing them in secretions/dry residue envelope, labeling collected objects and sealing the envelopes.(²⁵,²⁸,²⁹)

Regarding complementary forensic exams, forensic nurses can perform colposcopy, which enlarges the anogenital area and allows photography.(¹⁷) Using a Wood^® lamp allows to identify semen residues that become fluorescent and perform anoscopy (wait 2 to 3 minutes for the anal sphincter to relax).(¹⁶,¹⁷,²⁰,²³,³²)

It is noteworthy that anoscopy should be performed in victims with a history of anal penetration. It is an uncomfortable exam, and victims may report intense pain and inability to tolerate it due to rectal injuries and hematomas that may require consultation and surgical hospital admission. In cases of memory lapses, anoscopy is indicated, in addition to carrying out blood and urine laboratory and toxicological tests. All traces must be collected and preserved, maintaining rigor in maintaining the chain of custody.(¹⁷-²⁰,³⁴)

Studies highlight the need to promote comfort care by relieving pain and anxiety. Forensic nurses must monitor wound healing and use/effects of medications. Therefore, consecutive consultations are necessary to monitor biological and psycho-affective damages.(¹⁷,¹⁹,²⁰,²⁵,²⁹)

Screening and repeat tests for STIs should be carried out, offering prophylaxis for STIs. Doses of immunobiological agents for hepatitis B and tetanus should be administered.(¹⁷-²⁰,²⁴-³⁰)

It is necessary to provide care and legal support and establish measures to prevent vicarious trauma and reconnect survivors to the support network, as sexual aggression can affect the family nucleus, who are secondary victims, and can express similar feelings. It is important to assess and carry out therapies, according to the individuality of survivors and the case.(¹⁵,¹⁸-²⁰,²⁴,²⁵,²⁸,³⁰,³¹)

It is necessary to review legislation(¹⁵,¹⁸,²⁶,³¹,³⁶) and invest in forensic nurses’ education and testify in court if necessary. It was identified that it is necessary to develop public policies, protocols, guidelines and programs for prevention and treatment.(¹⁵-¹⁸,²¹,²²,²⁴,²⁶,³⁰,³²,³⁶)

Study limitations concerned access to studies unavailable for online access and the fact that it was carried out with studies using different methods and scenarios of sexual violence against adult men. However, it is believed that it was possible to map forensic nursing care for this population. As a limitation of this study, despite the broad and systematic search carried out in different databases, other possible sources of information may not have been mapped, which may not completely reflect the diversity of approaches and practices in forensic nursing in different regions of the world, which may have limited a broader understanding of practices.

The study provides opportunities for contributions to the advancement of science in the field of forensic nursing and care practices developed with male victims of sexual violence. Comprehensive mapping and synthesis of evidence related to the forensic care provided to these men fills a gap in existing literature on the topic, providing a basis for developing clinical guidelines and health policies that aim to improve the care and protection of these victims.

Conclusion

The scoping review made it possible to map the care that forensic nurses can perform to promote welcoming, immediate and continuous care for men who are victims of sexual violence. There are many physical and psycho-affective disorders presented by men resulting from this problem, which therefore reinforces the importance of establishing a supportive relationship to offer judgment-free care, maintaining privacy, dignity and respect. Furthermore, forensic trace collection and adequate recording are essential for the pursuit of justice and protection of victims. Gender stereotypes and prejudices need to be considered in order to promote a more inclusive and compassionate care environment for these men. Summing up, the study highlighted the need for advances in research, education, legislation and awareness about the problem, which has the potential to improve quality of care and guarantee justice for these victims who are often silenced.

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Edited by

Associate Editor (Peer review process): Alexandre Pazetto Balsanelli (https://orcid.org/0000-0003-3757-1061) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil

Publication Dates

• Publication in this collection
  08 July 2024
• Date of issue
  2024

History

• Received
  4 Oct 2023
• Accepted
  24 Jan 2024