Medicolegal study of sexual violence cases in Pekanbaru, Indonesia: prevalence, pattern, and Indonesian legal framework

Aim of the work

Pekanbaru is the capital city of the Riau Province, one of the 34 provinces in Indonesia. This city is the third largest (inland) urban area on Sumatra Island, with a population of 1,011,467 people. Pekanbaru is a heterogeneous city with 3 major tribes, namely, Malay, Minang and Batak, and there are also other tribes, such as Java, Bugis, Nias and Tionghoa (Statistic of Pekanbaru City 2015). The principal aim of this study was to identify the prevalence of and pattern of injury in sexual violence based on records from the Forensic Medical Service Center (FMSC) at Bhayangkara Hospital Pekanbaru (BHP). This hospital is a teaching hospital of the Faculty of Medicine, Universitas Riau, and the hospital center for forensic medical services in Pekanbaru. All sexual violence cases reported to the police are referred to BHP. In this paper, sexual violence in terms of the Indonesian legal framework, especially medicolegal procedures and terms of rape, will also be discussed.

Prevalence and pattern of sexual violence cases

The total number of cases was 665 during the five years of the present study. The trend line of number of sexual violence victims decreased across the years, with children composing the majority of sexual violence victims and females outnumbering males in each of the study years (Fig. 1). The average prevalence rate of sexual violence was 13.15/100,000 population/year. Regarding intellectual and developmental disorder evaluation, in our study we found no victims with intellectual and developmental disability among study populated.

Eighty-two percent and 18% of the victims were children and adults, respectively. The ages of victims ranged from 1 to 70 years, with a median age of 16 years. The most affected age groups were aged 5 to 9 years old (38.9%) for males and aged 5 to< 18 years old (44.5%) for females (Table 2). There was no significant difference between gender and age category (P = 0.119). Most of the sexual violence victims were students (75%) (Fig. 2).

Age	Gender		Total n (%)	P-value
	Male n (%)	Female n (%)
Age category
Children	33 (91.7)	512 (81.4)	545 (82)	0.119
Adult	3 (8.3)	117 (18.6)	120 (18)
Total	36 (100)	629 (100)	665 (100)
Age group, year
0–4	3 (8.3)	33 (5.2)	36 (5.4)	0.000
5–9	14 (38.9)	74 (11.8)	88 (13.2)
10–14	10 (27.8)	125 (19.9)	135 (20.3)
15 – <  18	6 (16.7)	280 (44.5)	286 (43.0)
18–24	3 (8.3)	83 (13.2)	86 (12.9)
25–34	0 (0.0)	25 (4.0)	25 (3.8)
35–44	0 (0.0)	7 (1.1)	7 (1.1)
45–54	0 (0.0)	1 (0.2)	1 (0.2)
55–64	0 (0.0)	0 (0.0)	0 (0.0)
65–74	0 (0.0)	1 (0.2)	1 (0.2)
Total	36 (100)	629 (100)	665 (100)

Indonesian legal framework of sexual violence

Based on Indonesian’s Criminal Code Procedure (Act of The Republic of Indonesia, 1981), investigations of suspected sexual violence cases are conducted in Indonesia as follows. Victims or the parents or guardians of a child who has been assaulted report the situation to the police, and the police refer them to the hospital with an official inquiry letter. In this letter, the police investigator writes the type of case (sexual crime). By order from the police’s official inquiry letter, the medical doctor performs a forensic examination of the sexual violence victim. Although a medicolegal examination is based on a request from a police investigator, informed consent should still be made before the examination is performed. This is because the victim is also a patient, and the area to be examined is a “sensitive” area (Gopalakrishnan et al., 2016). A medicolegal report is created by the medical doctor after the medical forensic examination is performed. When a case requires other specialist involvement, the forensic doctor will refer to the appropriate specialist, the victim will be referred to the gynecologist if it requires wound care of the genital area, ensures the pregnancy of the victim or when emergency contraception is necessary to prevent pregnancy; if there is an indication of psychological disorders post trauma or mental health evaluation is required then the victim will be referred to psychiatrist. In addition, the victim may also be referred to pediatrician if the child suspected of being sexually assaulted is found with a growth disorder, a sexually transmitted infection, or an injury requiring treatment (Gopalakrishnan et al., 2016). In the Indonesian legal system, a medicolegal report for legal and judicial interest is called Visum et Repertum (VeR). The main difference between this report and other medical examination reports is the inclusion of the word “Pro Justicia” in front of Visum et Repertum, but the content of the letters is the same. The legal basis of Visum et Repertum is article 133 of Indonesian’s Criminal Act Procedure (Act of The Republic of Indonesia, 1981):

In Indonesia, based on article 133 of Indonesian’s Criminal Act Procedure (Act of The Republic of Indonesia, 1981), forensic doctor is mandated to take a history and perform a general and vaginal examination on any alleged victims of sexual crimes. However, due to the small number of forensic doctors (less than 200) in Indonesia, the law allows for the examination of alleged victims of sexual crimes by general physicians or other specialists. Forensic doctor in Indonesia practice as forensic pathologist and clinical forensic medicine (Gopalakrishnan et al., 2016). It is an obligation for every doctor in Indonesia to make Visum et Repertum if requested by the investigator. Based on Indonesian’s Penal Code article 216, doctors who refuse to conduct medical examinations of crime victims and refuse to make Visum et Repertum at the request of the investigator can be punished by a maximum imprisonment of four months and two weeks or a maximum fine of six hundred rupiahs (Act of The Republic of Indonesia, 1946).

Prevalence and pattern

Sexual violence cases constitute a large proportion of violent crimes and is a serious problem. Many sexual violence cases have been reported in Pekanbaru. This study evaluated the number of sexual violence victims who were examined in FMSC at BHP based on referrals from police investigators. The average prevalence of sexual violence in the study population was 13.15/100,000 population/year. This result is similar to the rate that was recorded for sexual violence victims in Aarhus from 1999 to 2004, which was 14.5/100,000 (Ingemann-Hansen et al., 2009). This proportion is lower than that found in a study by Saltzman et al. in the United States, which reported a rate of 25/100,000 inhabitants (i.e., both sexes and all ages) (Saltzman et al., 2007). This difference may be explained by the Indonesian culture, in which victims feel ashamed to report the sexual violence they experience to the police, or it may be due to the lack of a database, different sources of data collection, different methods of study and different numbers of victims.

Most sexual violence victims are female. In this study, 94.6% of sexual violence victims were female, which is similar to other previous studies that reported that most sexual violence occurs in females, with prevalence’s of 93.9% in Taipei (Hwa et al., 2010), 98.3%) in India (Tamuli et al., 2013), 82.7% in Turkey (Karanfil et al., 2013), 97% in Aarhus-Denmark (Ingemann-Hansen et al., 2009) and 92.6% in the US (Avegno et al., 2009). The results of this study further strengthen the notion that sexual violence is one of the most common crimes against women. The proportion of sexual violence victims in this study who were men was 5.4%. Studies in Taipei (Hwa et al., 2010), India (Tamuli et al., 2013), Aarhus-Denmark (Ingemann-Hansen et al., 2009) and the US (Avegno et al., 2009) also reported male victim proportions to be less than 10%. This number is lower than that found in a study in Turkey by Karanfil et al. (2013), which reported a male victim incidence of 17.3%. This difference may be explained by the cultural norms and gender inequity in the Indonesian legal framework. The findings in this study indicate that both males and females could be victims of sexual violence.

Our study revealed that 82% and 18% of the sexual violence victims were children and adults, respectively. The number of child victims of sexual violence in this study was higher than that in a study conducted in Taipei, who reported a 64% proportion of child victims of sexual violence (Hwa et al., 2010). In contrast to previous studies, other studies reported that most victims were adults, namely, 54% in Spain (Moreno, 2013) and 66% in Aarhus-Denmark (Ingemann-Hansen et al., 2009). This finding may reflect that being young (a child or a teenager) is already a prognostic factor of vulnerability and that children are the main targets of perpetrators (Nannini, 2006). This fact also validates the high level of parental awareness of children at risk for sexual violence and the effects of the mass media influence in combating sexual crimes against children. Our study showed that the most affected age group in boys was the range from 5 to 9 years old (38.9%), and the most affected age group in girls ranged from 15 to < 18 years old (44.5%). This result is of particular concern and demonstrates that parents and the community should pay more attention to the more vulnerable age groups of victims of sexual violence.

Our study reported that 22.4% of sexual violence victims had bodily injury. The results were lower than those of previous studies reporting rates of 30.6% in Spain (Moreno, 2013), 41.8% in Taipei (Hwa et al., 2010) and 42% in Italy (Zerbo et al., 2018). Nevertheless, all of these studies reported similar patterns to those in our study, namely, the incidence of physical injury increased as the victim age increased (Hwa et al., 2010; Moreno, 2013). This study also showed a significant association between bodily injuries in children and adults. The two most common types of injuries found in this study were similar to those found in a study in Spain, namely, bruises and abrasions, with the extremities being the most common site of injury (Moreno, 2013; Zerbo et al., 2018). More child victims had ano-genital injuries compared with adult victims. There was a significant difference between children and adults regarding bodily injury (P = 0.028) and ano-genital injury (P = 0.000).

Regarding forensic examination findings of the ano-genital area, the percentages of victims with genital/anal lesions (75.2%) in our study were higher than those in a previous study by Hwa et al. (2010) (Hwa et al., 2010), which reported a prevalence of 53.3%. This difference may be explained by the different number of victims, different number of male victims and different number of victims in each age category.

In this study, more of the child victims had an ano-genital injury compared with the adult victims. There was a statistically significant difference between children and adults regarding ano-genital injury (P = 0.000) and a significant difference between males and females regarding ano-genital injury (P = 0.000).

Indonesian legal framework of sexual violence

Sexual violence terminology is not found in the Indonesian Penal Code (Act of The Republic of Indonesia, 1946), while sexual violence terminology is contained in The Children Rights Protection Law No.23 Year 2002 (Act of The Republic of Indonesia, 2002) and The Elimination of Violence in Household Law No.23 Year 2004 (Act of The Republic of Indonesia, 2004). The Indonesian Penal Code only mentions two forms of sexual violence: rape and obscenity (Act of The Republic of Indonesia, 1946). The term ‘sexual violence’ is much broader than the term ‘rape’ because sexual violence can include various other forms of sexually lewd acts, sexual harassment and other behaviors. While the term used in the Penal Code is a crime against decency, it does not use the term ‘sexual violence,’ which is defined as a criminal act related to sexuality that can be performed against men or women. The use of the term ‘morality’ causes the public, especially legal professionals, to be trapped in placing the articles of morality solely as a matter of violation of cultural values, religious norms, or courtesy relating to sexual lust, not a crime against one’s body and soul (Novirianti, 2010).

In Indonesian’s Penal Code, the definition of rape solely states that rape occurs in women and is committed by men outside a marriage relationship. Proof of rape in the Indonesian Penal Code requires the occurrence of sexual intercourse between men and women outside of marriage committed by violence and/or threats of violence. Sexual intercourse is defined as the entry of the male genitals into the female genitals with or without ejaculation (Novirianti, 2010).

Thus, the term ‘male rape’ is not present in the Indonesian Penal Code. A crime in which a man who suffers sexual violence committed by men or women is categorized as obscenity. The broader definition of rape began to be adopted by several countries (United Kingdom (UK), US, Australia and others) and stated that rape could be gender-neutral, meaning that it can apply to any person of either sex or gender (Lowe & Rogers, 2017; World Health Organization, 2015).

Another issue related to sexual violence is sexual violence in marriage (marital rape). Although it has been a law for more than a decade, the effectiveness of the law against sexual violence in marriage enacted in The Elimination of Violence in Household Law No.23 Year 2004 is not clearly visible. Similar to most other Islamic countries, it is impossible to define rape in the context of marriage even if it can happen. The Indonesian marriage law has created an unequal position between wives and husbands, as it considers that “husbands are the head of household”. Indonesia makes a similar cultural assumption that marriages are harmonious because husbands and wives agree at all times (Novirianti, 2010; Riggins, 2004; Susila, 2013; Tongat, 2017). The Indonesian Council of Ulama declared that sexual assault in marriage can be considered unlawful sexual violence if the following situation or conditions are present: the wife is in a state of menstruation, at the moment of parturition, during Ramadhan fasting, and/or anal sex (Susila, 2013).

In addition to the developments in the international world and the influence of globalization, Indonesia is currently drafting laws on sexual violence. Indonesia is also amending the Penal Code. The handling of sexual violence cases in the legal context is expected to improve and reduce the incidence of sexual violence in Indonesia.

Our study has some limitations. It was based on medicolegal reports of sexual violence victims. It contains only data relevant to justice and law enforcement. Moreover, the history of perpetrators, living environment of victims, and type of sexual abuse were not available in the medicolegal report. The incidence of male victims was low (5.4%), but they were included in all analyses.