The sexual violence is an umbrella term that refers both violent acts that cause sexual harm psychologically, physically, and illegally to others and the sexual approaches against the other party’s will. The sexual assault and forced indecent are representative cases of sexual violence, and also include quasi-rape and quasi-indecent act by compulsion, which commit crimes using victim’s state of insanity or inability to protest. The rape, also called sexual assault, means forced sexual insertion without consent of the other party. The Korean Criminal Law, article 297 and 297-2 define rape and imitative rape, respectively. A person who committed rape, under Korean Criminal Law, article 297, shall be punished by imprisonment for a limited term of at least three years. A person who inserts one’s sexual organ into another’s mouth or anus, or inserts one’s finger or other bodily part or any instrument into another’s genital organ or anus shall be subjected to imitative rape an punished by imprisonment for a limited term of at least two years. The punishments for quasi-rape and quasi-indecent act by compulsion are same for that of rape and indecent act by compulsion, and any attempted criminals are also punished. The crime to compliant for sexual crimes was abolished in June, 2013, and the victim of rape has been revised from ‘women’ to ‘people’ to include the sex crimes against man into the subject of punishment.

A person who has sexual intercourse with whom under thirteen years of age is punished as rape regardless of the earlier consent of victim. Any person who commits rape against under nineteen years of age is under the Act on the Protection of Children and Juveniles from Sexual Abuse, article 7, punished by imprisonment with labor for an indefinite term or for at least five years, and rape against under thirteen years of age punished by imprisonment with labor for an indefinite term or for at least five years, respectively [1].

As of 2014, the data reported by investigation agencies such as Prosecution Service, Korean National Police Agency, and Special Judicial Police showed that the number of cases of sexual violence in Korea has been steadily increasing since 2005. The number of sexual violence crime was reported to increase from 11,757 in 2005 to 22,034 in 2013 and 29,863 in 2014, indicating that, even after the Special Act on the Punishment of Sexual Crimes was enacted in 2013, the crime rate continues to increase. Sexual violence against minors increased 3.3 times from 2904 cases in 2005 to 9530 cases in 2014, and as of 2014, 31.9% of the total number of sexual violence were against minors [2]. Given that the hidden crime rate of sexual violence is 87.5%, the actual number of sexual assault crime is estimated to be more than six times [3].

Sexual crime victims may contact the police (112), region one-stop support Centers, emergency telephone for women (1366 without area code), Korean Sexual Violence Counseling Center, and the Sunflower Center, and is eligible to receive medical support from a dedicated medical institution. The primary role of a dedicated medical institution is to collect evidence and include sexually transmitted infections test, pregnancy reaction test, treatment of physical injury, prescribing prophylactic antibiotics and contraceptives, and psychiatric support. Evidence collected by a physician when the victim of sexual violence victim visits the hospital is an important legal data for punishment of the perpetrator, and is collected, using a standardized ‘emergency kit for victim of sexual violence’, with the consent of the victim. The ‘emergency kit for victim of sexual violence’ was developed for the purpose of facilitating the collection of evidence of sexual violence from the victim, and consists of necessary tools to collect evidence by stages and a checklist form to simplify the investigation process. Items include paper bags of various sizes to keep the victim’s underwear or foreign objects, sterile cotton swab, slide, tube for blood collection, and nail clippers. The evidences collected in the dedicated medical institution using the kit is handed over to an investigative agency. The case is sent to the prosecutor’s office based on the results of the investigation of the evidences by the National Institute for Scientific Investigation, and the court ultimately decides the guilt or innocence.

As of 2016, there are 348 dedicated medical institutions for sexual violence victims nationally. The most common department is obstetrics and gynecology, occupying 235 institutions including general hospitals (n = 82) and private obstetrics and gynecology clinics (n = 153), and other departments such as neuropsychiatry (47) and public health centers (21) have also been designated as dedicated medical institution.

The purpose of this study was to investigate the actual status and characteristics of sexual violence committed in one area in Republic of Korea, and to discuss the points to be considered in treating victim of sexual violence by analyzing the medical records of patients who visited an university hospital located in one area in Republic of Korea with sexual violence as main complaint.

This study compared the characteristics of cases by age groups by classifying victims into three groups of child group under 13 years old (n = 21, 6.3%), adolescent group between 13 and 20 years old (n = 86, 25.9%), and adult group over 20 years old (n = 225, 67.8%). The largest age group was in their 20s (n = 142, 42.8%) and was followed by adolescent group (n = 86, 25.9%) (Table 1).

In this study, the overall rate of victims under influence of alcohol at the time of case was 52.1% (n = 173), and this rate for adolescent victims was 46.5% (n = 40). 26 victims (66.7%) from 39 ones without record about types of sexual violence were unable to remember that moment due to influence of alcohol. Jänisch et al. [4] reported that alcohol is the most commonly used material in date rape. In the case of a quasi-rape in which the victim was sexually assaulted in a state of inability to protest such as heavy drinking, and especially when the victim is unconscious, the drug detection test may be considered.

It has been reported that sexual violence occurs most frequently in the summer from Jun. to Aug. [5], and in this study, the cases occurring in summer from Jun. to Aug. accounted for 32.8%, higher than that of other seasons. The most frequent time of occurring sexual violence was dawn time from 0:00 to 6:00 in both adolescent and adult groups, occupying 37.2% and 58.2%, respectively, being consistent with the results of study on other region study [5, 6, 7]. A previous study that analyzed the medical records of 70 patients who visited the emergency unit of tertiary university hospital located in one area in Republic of Korea for sexual violence from April 2001 to May 2006 with sexual violence as main complaint, showed that the most frequent conditions for sexual violence were summer (61.4%), evening (25.7%) and night (45.7%), being consistent with result of this study [8]. The most frequent (38.1%) time in child group was 12:00–18:00. This is consistent with the results that most frequent time of occurring sexual violence toward children was 14:00–18:00 in a study on other region [5] and was 12:00–14:00 and 16:00–19:00 in a study on another region [9]. The reason of these differences in the time of occurring sexual violence among age groups was that children and infants have lower risk of being exposed to crime during night or early morning and higher risk at daytime because of coming home from school.

The rates of occurring in accommodate facility were 39.5% and 38.2% for adolescent and adult groups, respectively, in this study. 42.9% of cases where the victims are under the age of 13 occurred at outside places such as apartment, rooftops, toilet, and academies. The studies in other regions [5, 7] reported that 31.9% and 25.1% of sexual violence occurred at victim’s home, being inconsistent with the result of this study. A study on one area in Republic of Korea from 2001 to 2005 also reported that the most common places of occurring sexual violence were victim’s home (32.9%) and accommodation facility (28.6%) [8]. Another study [6] reported that the most common place of occurring sexual violence was hotel or motel when victim was adolescent and victim’s home when victim was in other age group. The hotel or motel were also places where sexual violence occurred he most in this study for both adolescent and adult groups, necessitating further studies on this theme.

For the relationship with perpetrator, the stranger occupied 66.7% and 55.4% in other studies [6, 7], and in this study, stranger or a person whom the victim met for the first time accounted for 45.5%. In particular, victims in their 10s and 20s were likely to be raped by someone they met for the first time through cell phone application, internet chatting, or at bar [6, 7]. The Korean Sexual Violence Counseling Center reported in 2015 that the acquaintance was perpetrator in 78.4% of all 1308 sexual violence counseling cases, being inconsistent with result of this study. Other studies showed that when the perpetrator was acquaintance, most of them were those from work in adult victims [10], those from school or academies in adolescent victims [11], and relatives in child victims [12], being consistent with the results of this study. In this study, most of perpetrators were father, brother, or step-brother in child victims and teacher, acquaintance older than victim, someone they met through chatting application in adolescent victims. Notably, among 42 middle-aged women older than 40 years old, six were sexually committed by customer at bar or restaurant they were operating and three were raped by ex-husband or lover. Adult women were reported to be more likely to be sexually assaulted by their spouse or ex-spouse [13]. One victim in this study, for example, was consistently sexually committed by her ex-husband in the oral, genitals, and anus, and visited emergency unit complaining that it is hard to sit down due to fecal incontinence and anal pain.

The cases with two or more perpetrators are classified as group sexual violence. A 2013 study analyzed 25-year criminal records in the US and Europe and reported that 10–20% of sexual assault were group rape [14]. It was reported that the perpetrators of group sexual violence were likely to be younger and to use alcohol or drugs and that victims were suffered from severe physical and psychological damages [10, 11]. In this study, 19 (5.7%) victims were sexually committed by two or more perpetrators, and 11 of them were adolescents. Even two children under 13 years old were victims of group sexual violence. A 12 years old girl, for example, was sexually committed by oral, genital, and anal sex after drinking with a boy older than her and seven friends. She visited emergency unit 48 hours after the case. 15 from 19 victims of group sexual violence were under influence of alcohol, and two of them went to psychiatry for anxiety disorders.

The results of vaginal discharge showed that the Klebsiella pneumoniae was detected in four victims and two of them were positive in the pregnancy test. Klebsiella pneumoniae is known to be the main cause of pneumonia and, in addition to respiratory tract, may cause urinary tract infections. This is also known to be strongly related to premature labor in vaginal infections [15]. In this study, Klebsiella pneumoniae was detected in two victims with positive in pregnancy test. They showed no special in the urine test. Both did not revisited though they were required to receive additional examination.

The sexually transmitted disease test for victims of sexually violence include HIV, hepatitis B, and syphilis and the U.S. Centers for Disease Control and Prevention in 2015 added tests for chlamydia, gonorrhea, and trichomonas infections. According to the guidelines for the treatment of sexually transmitted diseases published by U.S. Centers for Disease Control and Prevention in 2015 though there may be slight difference among hospitals, the standard treatment for gonococcus and chlamydia is one oral administration of Ceftriaxone 250 mg intramuscularly and 1 g of Azithromycin (Pfizer Inc., New York, NY, USA). As a prevention of infection with Trichomonas, Metronidazole 2 g is administered once orally. Those who have no hepatitis B antibodies should be inoculated with hepatitis B vaccine and additional vaccinations should be given after one and six months [16]. For those with history of exposure to HIV (Human Immunodeficiency Virus), antiviral drugs should be administered within four hours of the occurrence of sexual violence, though it should not be administered if more than 72 hours have passed. The fact that anal sex or group rape increases the risk of HIV infection should be considered during the interview [17]. The human papillomavirus (HPV) vaccine is recommended for women victims aged 9 to 26 years and men victims aged 9 to 21 years and booster vaccination after one and six months are needed. Although the likelihood of being pregnant due to rape depends on the menstrual cycle of victim, all victims should take emergency contraceptives. Ulipristal (HRA Pharma, Paris, France) and Levonorgestrel (HRA Pharma, Paris, France) are used as emergency contraceptives. Ulipristal is effective up to 120 hours after intercourse and is recommended particularly when 72 hours after ejaculation have been passed or for obese women. Levonorgestrel (0.75 mg twice every 12 hours, or 1.5 mg once) is widely used because of less side effects, and its effect is expected when it is taken within 72 hours and the effect is less for obese women.

The hepatitis B antibody vaccination is one of the mandatory vaccinations in Korea, and according to the statistics published by the Korea Disease Control and Prevention Agency, 94.3% of 480,000 children born in 2012 completed three hepatitis B vaccinations [18]. It is known that more than 90% of those who have been vaccinated with hepatitis B vaccine three times have antibody. In this study, 168 (50.6%) victims of sexual violence who visited the hospital had hepatitis B antibodies. In particular, 11 (52.4%) victims from children group and 45 (52.3%) victims from adolescent who did not carry hepatitis B antibodies are required to be vaccinated with Hepatitis B vaccination and additional booster vaccinations in outpatient setting. Discussion on the hepatitis B antibody retention rate and sexual violence victims has not been reported in Korea, meaning that further studies should be conducted based on data from each dedicated medical institution for sexual violence victims.

Victims of sexual violence are at higher risk of pregnancy or being exposed to sexually transmitted infections, thus are required follow-up. The World Health Organization (WHO) recommends for the victims of sexual violence to visit hospital three times, one to two weeks, three months, and six months after the case. When the victims revisit hospital one or two weeks after the case, the results of the test conducted at first visit are explained, and if necessary, a picture of the injured part is taken. The victims who have not taken prophylactic antibiotics are tested for sexually transmitted infections and, if necessary, a pregnancy test is performed. The victims who did not carry hepatitis B antibody should be given with explanation on the need for hepatitis B vaccination at first visit and after 1 month and 6 months. When three months have been passed after the case, HIV test and pregnancy test are required and those who have not taken prophylactic antibiotics should be tested for syphilis. Six months after the case, HIV test and hepatitis B vaccination should be performed [19]. A study that investigated the follow-up treatment rate of victims of sexual violence reported that the actual follow-up treatment rate was around 31% [20], and Korean previous reports reported follow-up treatment rate was 11.3% [11], 11.6% [21], and 28.7% [6], which were lower than others. The antibiotics and contraceptives were also prescribed to victims who visited emergency unit in this study and were educated to re-visit the obstetrics and gynecology after one week, only 133 from 332 victims (40.1%) revisited, which is similar to 42.9% reported in a study from 2001–2005 [8]. Although this rate is relatively higher compared to those in other regions, education on the need for revisiting to manage physical and mental sequela in the future should be conducted more actively.

Many of sexual violence victims complain of post-traumatic stress disorder, anxiety, and depression and, in severe cases, suicide is attempted [22]. In addition, they suffered from insomnia, anorexia, and nightmares, making them to return to normal life [23]. It is recommended to start psychiatric counseling in earlier time and follow-up psychiatric as well as obstetrics and gynecology examination should be performed one or two weeks after the visit [24]. The psychiatric follow-up examination rates were reported as 5.4% [6] and 13.5% [5], and in this study, only one patient was followed up as receiving psychiatric treatment at same hospital. The physicians, in treating victims of sexual violence, should pay attention so that they visit not only obstetrics, but also psychiatry.

The victims in this study were those who visited the emergency unit in person or with accompanying police, and when the emergency unit contacted the obstetrics and gynecology department, they knew that the patients is a victim of sexual violence and practiced examination accordingly. It can be reasonably expect that, however, there are a number of victims of sexual violence who visited the emergency unit for vaginal bleeding or trauma, without reporting the fact of sexual violence and thus were overlooked. In particular, children are likely to be unaware that they have been sexually committed and the perpetrator is often a relative [11], meaning that the crime is often concealed. Sexual violence against children is defined as “rape or forced indecent against persons under the age of 13”, and even with the consent of the victim, all sexual acts against children are regarded sexual violence. For a child who visits the emergency unit with the vaginal bleeding or trauma to the vulva ascomplaint, the obstetrician and gynecologist should always take care of the possibility of sexual violence in mind.

No previous domestic studies on sexual violence, in their reports, subdivided the number of perpetrators, rate of carrying hepatitis B antibody in victims of sexual experience before case. In this study, the overall rate of carrying hepatitis B antibody in victims of sexual violence was 50.6%, and 65.1% of adolescent victims reported previous sexual experience. Further epidemiological studies, based on accumulated data of each dedicated medical institution for sexual violence victims, are necessary in order to derive statistically significant results. In addition, it is suggested that doctors who exam victims of sexual violence should be familiar with the kinds of medical examination for victims of sexual violence, and should pay careful attention not only for collecting legal evidence but also, from medical perspective, for physical and psychological treatment of them.

GEH performed the research and analyzed the data. JHS wrote the manuscript and reviewed relevant literature. THK designed the research study. HHL reviewed relevant literature and revised the manuscript. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript.

The article does not contain any studies with human participant or animal performed by any of the authors.

Thanks to all the peer reviewers for their opinions and suggestions.

This research was supported in part by the Soonchunhyang University Research Fund (grant number: 11-20210831).

The authors declare no conflict of interest. THK is our Guest Editor, given his role as Guest Editor, had no involvement in the peer-review of this article and has no access to information regarding its peer-review.