Berlin’s forensic medicine community has delivered a sobering message to courtrooms worldwide: in the vast majority of reported sexual assault cases, the body does not show the injuries that investigators, prosecutors, and even the victims themselves might expect to find. A new retrospective cohort study, conducted at the Violence Protection Ambulatory of Charité – Universitätsmedizin Berlin and published in the International Journal of Legal Medicine, analyzed the forensic examination records of 306 adults assessed between January 2016 and December 2023. The researchers, led by Alice Buzzelli and Alberto Amadasi alongside colleagues Julia Babigian, Valentina Bugelli, and Lars Oesterhelweg, set out to answer a deceptively simple question with profound legal consequences: when a person reports a specific sexual act—oral, vaginal, or anal—how often does the medical examination actually reveal a visible injury in the corresponding anatomical region? The answer, quantified with unusual precision, was strikingly and consistently low.
The numbers at the heart of the study tell a story that forensic practitioners have long suspected but rarely been able to express with such statistical clarity. Among the 256 individuals in the cohort who reported at least one oral, vaginal, or anal sexual act, only 72 cases—28.1 percent, with a 95 percent confidence interval of 23.0 to 33.9 percent—showed a visible injury that the researchers had predefined as anatomically or regionally corresponding to the reported act. In the remaining 184 cases, fully 71.9 percent of the subgroup, no corresponding injury could be documented at all, despite specialized examinations that included colposcopy, speculum assessment by gynecologists, and systematic whole-body inspection under both daylight and artificial light by trained forensic physicians. In other words, the most thorough clinical scrutiny available in modern forensic medicine failed to produce a single corroborating visible lesion in nearly three out of four cases.
The asymmetry between extragenital and anogenital findings was itself revealing. Injuries outside the genital region were documented in 216 of the 306 cases, or 70.6 percent of the entire cohort, while anogenital injuries appeared in only 62 cases, or 20.3 percent. This pattern has been observed in earlier studies across different countries and sociocultural settings, but the Berlin team pushed the analysis a step further by asking not merely whether injuries existed, but whether they aligned with the specific acts reported. Extragenital trauma—hematomas, abrasions, petechiae, defensive injuries, strangulation marks, and fixation injuries—was common, yet frequently bore no anatomical relationship to the reported sexual activity. An injury to the forearm, however real, does not corroborate a reported vaginal assault, and the researchers were careful to keep these categories rigorously separated.
When the correspondence was analyzed act by act, further nuances emerged. Reported anal sexual violence was significantly associated with the presence of anal injuries, and reported oral sexual violence was significantly associated with facial injuries—the latter serving as a regional, rather than exact, proxy for the act. Yet even where these statistically significant associations existed, the majority of individuals reporting the relevant acts displayed no corresponding visible injury whatsoever. Corresponding anogenital injuries after reported vaginal acts were uncommon, and the presence of such injuries showed no significant association with reported vaginal acts or with penile-vaginal penetration specifically. The statistical signal, in short, ran in the expected direction but never rose to a level where the absence of a lesion could meaningfully outweigh the reported history.
To understand why injuries are so often absent, the team turned to multivariable binary logistic regression, entering age, the interval between the reported assault and the forensic examination, alcohol involvement, drug involvement, and the number of reported sexual acts into a single model with the absence of a corresponding injury as the dependent variable. One variable emerged as the sole independent predictor: the number of reported sexual acts. Paradoxically, the more acts an individual reported, the less likely it was that any single anatomically corresponding injury would be found—a finding the authors attribute to the dilution effect inherent in their composite endpoint, and one that underscores how insensitive visible injury documentation is as a diagnostic instrument. Notably, neither the delay before examination nor alcohol or drug involvement independently predicted the absence of findings in this model, challenging some widely held assumptions about the sources of negative examinations.
The methodological machinery behind these conclusions deserves attention, because it reflects the practical realities of forensic outpatient care. The Violence Protection Ambulatory operates during regular office hours, and individuals requiring urgent overnight care are first assessed in Charité’s emergency departments by clinical specialists before undergoing dedicated forensic examination, sometimes on the following working day. The researchers drew their data exclusively from finalized forensic reports built on written findings and photographic documentation, coding extragenital injuries by location and morphology—from the neck, face, and thorax to the hands and legs—and grading severity with the Clinical Injury Extent Score. Anogenital injuries were coded across eleven anatomical sites, from the labia majora and posterior fourchette to the hymen and anus, and classified as erythema, edema, hematoma, abrasion, or laceration, without severity grading. Reported acts were categorized into penile, digital, and object-based penetration for both vaginal and anal exposure, as well as oral sexual violence, with categories allowed to overlap.
What elevates this study above its epidemiological predecessors is its deliberate focus on anatomical correspondence—a distinction that matters enormously in court. Previous research comparing consensual and non-consensual intercourse has already demonstrated substantial overlap in genital injury patterns, which severely limits the diagnostic value of genital findings when interpreted in isolation. An injury may be present yet entirely unrelated to the reported assault dynamics, while a reported act may leave no visible trace at all. By systematically pairing each reported act category with a predefined corresponding injury location, the Berlin team converted this clinical intuition into measurable frequencies and confidence intervals, giving judges, prosecutors, and defense attorneys a quantified basis for understanding what a negative forensic examination actually means—and what it does not.
The medico-legal implications ripple outward from the courtroom. Forensic interpretation categories documented in the original records—blunt force from blows or kicks, kissing or sucking injuries, defensive injuries, strangulation marks, undressing injuries, and abutment injuries—illustrate the rich contextual information a forensic physician assembles, far beyond a binary injury checklist. Yet the study’s central warning is unambiguous: the presence of a corresponding injury may support an assessment of consistency with the reported history, but the absence of visible injury must never be interpreted as excluding the reported assault. Given that 71.9 percent of individuals reporting penetrative or oral acts had no corresponding findings, treating a clean examination as evidence against a complainant would misrepresent the evidence base in the overwhelming majority of cases. The researchers frame this as a limitation of sensitivity inherent in visible injury documentation itself, not of the examination technique.
The biological explanation for these findings lies in the anatomy and physiology of the tissues involved. Anogenital mucosa is elastic, distensible, and richly vascularized; microtrauma sustained during penetration often heals within days, produces no bleeding that a victim notices, or simply never manifests as a lesion visible under colposcopy. The timing of examination compounds the problem—petechiae fade, abrasions re-epithelialize, and mucosal fissures close within hours to days—but even in this cohort, examination delay was not the sole independent predictor of absent findings, suggesting that the inherent insensitivity of visual inspection is the dominant factor. Lubrication, position, coercion through intimidation rather than physical force, prior consensual activity, and individual tissue variation all conspire to make the “expected” injury a statistical rarity rather than a forensic norm.
For a study emerging from one of Europe’s largest university hospitals, the public health framing is equally significant. The authors situate their work within the broader landscape of violence against women documented by the European Institute for Gender Equality, where physical and sexual violence remain highly prevalent and are frequently associated with lasting adverse health consequences. With sexual assault consistently recognized as a major global public health and medico-legal issue, the Berlin findings arrive as both a corrective and a safeguard: they arm forensic practitioners with data to defend their negative findings against misinterpretation, and they offer survivors an evidence-based rebuttal to the damaging assumption that “no injury” means “no assault.” As the study enters the citation networks of legal medicine, its central statistic—nearly three-quarters of reported acts leaving no corresponding visible mark—is likely to become a fixture in expert testimony for years to come.
Subject of Research: People
Subject of Research: Medicine
Article Title: Visible injury patterns in relation to reported sexual acts after sexual assault: a retrospective cohort study
Article References: Buzzelli, A., Babigian, J., Bugelli, V., Oesterhelweg, L., & Amadasi, A. (2026). Visible injury patterns in relation to reported sexual acts after sexual assault: a retrospective cohort study. International Journal of Legal Medicine. https://doi.org/10.1007/s00414-026-03941-8
Image Credits: AI Generated
DOI: 10.1007/s00414-026-03941-8
Keywords: sexual assault, forensic medicine, anogenital injury, extragenital injury, anatomical correspondence, forensic examination, International Journal of Legal Medicine, Charité Berlin
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Ophelia Keating. (September 8, 2026). Study links visible injuries to reported sexual acts after assault. Scienmag. https://scienmag.com/study-links-visible-injuries-to-reported-sexual-acts-after-assault/
Ophelia Keating. “Study links visible injuries to reported sexual acts after assault.” Scienmag, 8 September 2026, https://scienmag.com/study-links-visible-injuries-to-reported-sexual-acts-after-assault/. Accessed 8 September 2026.
Ophelia Keating. “Study links visible injuries to reported sexual acts after assault.” Scienmag. September 8, 2026. https://scienmag.com/study-links-visible-injuries-to-reported-sexual-acts-after-assault/
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