According to data available in the international literature, men are less affected by sexual violence than women. Our study confirms this observation: Over a four-year period, between 2018 and 2021, in the Department of Forensic Medicine of Paris, 12.5% of all victims of sexual violence were male. Sexual violence is also thought to be particularly under-reported by men [14]. Males represented 10.6% of all victims of rape or suspected rape, aged 15 years of age and older. In France, according to the report of the survey “Cadre de vie et sécurité” (living conditions and security), 16.1% of the adults (18–75 years old) that reported a rape or an attempted rape were men [4]. Our results confirm the under-reporting of sexual violence among men. Male victims of rape or suspected rape were mostly young, with an average age of 28.8 years. These results are consistent with the existing literature in France: the mean ages were 25 and 29.5 years in two similar studies in Bordeaux and Bondy, France, respectively [15,16]. Most of the patients reported anal penetration, committed by a single male assailant, whom they met on the day of the assault, often in a festive context. Victims more rarely reported being forced to commit penile penetration on the assailant. Since the reform of August 03, 2018, changes in French legislation allow for the circumstance of having been forced to commit a sexual act on the perpetrator to be taken into account [17]. This modification allowed the filing of a complaint for 13 patients in our study.

Most patients were examined shortly after the assault (median delay of 1 day). An early examination allows for better detection of possible lesions, especially in the anal mucosa, which heals rapidly. For superficial lesions such as peri-anal abrasions, the reconstruction of the epithelium can be complete within 24 h in children, thus masking the lesions [18]. Healing of superficial lesions is generally effective within a few days. In our study, anal lesions were found on examination in more than one-third of patients reporting anal penetration (penis or object) regardless of the time frame. However, the presence of anal lesions was statistically higher when patients were examined within 48 h of the assault. The presence of anogenital injuries does not provide a diagnosis of rape. These injuries are not specific to traumatic intercourse and can be found after consensual intercourse in both males and females [19]. Nevertheless, the identification of anogenital or general lesions is generally associated with a higher rate of conviction of the aggressor [20]. In the literature, the prevalence of anogenital injuries in male victims of sexual assault varies between 15% and 61.4% [19]. A timely examination also allows for better medical management, as the initiation of a HIV post-exposure prophylaxis is most effective within 48 h after the event, according to the current French recommendations [13]. In our study, ten patients could have benefited from a HIV post-exposure prophylaxis in the emergency room during the initial examination. This finding illustrates the lack of information among emergency physicians regarding the management of rape victims.

Among the patients in our study, 17.5% were vulnerable (psychologically, socially, or economically). As previously described in the literature, vulnerable patients were more likely to have been assaulted by someone they knew [21]. They were less likely to report an associated suspicion of proactive DFSA, their vulnerability having itself facilitated the crime of the aggressor.

From other studies, psychological vulnerability seems to be associated with a higher risk of sexual violence. A study in Sweden showed that diagnosis of psychotic, bipolar, stress anxiety disorders, and depression were more common among patients with a diagnosis of sexual abuse [22]. A study carried out in Seine-Saint-Denis, France, showed that male victims were more frequently disabled or vulnerable than were female victims, and that vulnerable male victims reported previous sexual assaults more frequently than other male victims [15]. More than one-fifth of patients in our study also reported the use of psychiatric medication (antidepressants, anxiolytics, etc.). France is a country with a high consumption of antidepressants and anxiolytics; a report by the French National Agency for the Safety of Medicines and Health Products (ANSM) estimated that 13.4% of the French adult population had taken a benzodiazepine at least once during the year of 2015 [23]. The consumption of psychiatric drugs is also on the rise, particularly in connection with the COVID-19 pandemic [24]. In our study, vulnerable patients were more likely to take psychiatric medication, which is consistent with psychological vulnerability. Psychiatric medication intake was not associated with a higher consumption of alcohol or illicit drug on the day of the assault.

Vulnerability related to living conditions is not traditionally investigated in studies of male victims of sexual violence. In France, social and economic vulnerability was recently added to the aggravating circumstances of sexual violence by the law as of 3 August 2018 [17]. In our study, nearly one-tenth of the victims reported a social or economic vulnerability linked to their living condition. Being homeless has been proven to be associated with a high risk of rape in the United State [25,26]. Sexual violence may be particularly under-reported by this population, especially as homeless people are afraid of being discriminated against by the police [27]. If social workers are aware of the link between homelessness and sexual violence, preventative actions on this theme should be carried out with police officers.

More than sixty percent of the patients of our study reported the voluntary consumption of alcohol and/or illicit substances prior to the assault, characterizing a potential opportunistic DFSA. Opportunistic DFSA is often confused with proactive DFSA, in which the administration of the psychoactive substance is done by the assailant without the victim’s knowledge in order to facilitate a sexual assault [28]. In line with the international literature, the report of an opportunistic DFSA was associated with a higher suspicion of proactive DFSA in our study [29,30,31,32,33]. In other studies, in France and in the UK, a recent psychoactive substance use (including alcohol) was reported by, respectively, 26% and 58% of male victims of a sexual assault [8,15]. Our study found a higher proportion of recent psychoactive substance use (including alcohol). This finding may be related to the more festive Parisian population, as well as to the significant proportion of assaults that took place in a chem-sex or a slam-sex context. It was not possible to characterize the actual proportion of proactive DFSA, as the samples for toxicological purposes are analyzed in expert laboratories under the responsibility of the judicial authority.

More than half of the patients reported the consumption of alcohol (53.5%). The median alcohol consumption was over 60 g of pure alcohol, three times greater than the recommended amount as a daily maximum in France [9]. Ethanol will decrease the vigilance of victims who will be less able to identify the administration of a substance without their knowledge. It can also potentiate the effects of other psychoactive substances. Alcohol consumption, in the form of alcohol use disorder (AUD) or binge drinking, has been proved to be associated with sexual violence [34]. In another French study, 22% of the male victims of sexual violence reported an alcohol consumption before the assault [15]. AUD was not explored in our study, but in other cohorts of male victims of sexual assault, addictive disorders were reported by 22% of the patients in France and 19.2% in Italy [15,20]. These results underline the importance of prevention strategies and information on the risks associated with ethanol consumption, especially for a young and festive population.

The use of illicit substance(s) use was reported in one-quarter of the patients. The primary substance used was cannabis, which is the most-consumed illicit substance in France [35]. France is also the European country where cannabis consumption is the most prevalent among young adults [35]. The intake of cannabinoids can induce neuropsychic disorders (euphoria, imaginative exaltation with impaired judgment, and potential drowsiness) and variable sensory manifestations that can go as far as hallucinations or cognitive disturbances [36]. This symptomatology can, therefore, induce an opportunistic DFSA. Almost one-tenth of the patients reported the use of other illicit substances in the context of chem-sex or slam-sex. Chem-sex is defined as the absorption of psychoactive substances during sexual intercourse, which can be swallowed, snorted, or inserted rectally. Slam-sex is a variant where the substances are injected [37]. These practices are carried out mainly by men who have sex with men (MSM). The main substances used are cathinone, methamphetamine, GHB/GBL, or ketamine. These sexual practices are considered particularly risky. The combination of several substances is frequent, increasing the risk of potentially lethal overdose and of substance use disorder. The risk of infection is also often less controlled during these practices [37]. Our study underlines the fact that, in addition to the toxic and infectious risks, chem-sex can lead to sexual violence. There is likely a significant under-reporting of this type of incident. These victims may fear that they will not be believed by the judicial authorities, or even that they will be prosecuted for the use of illicit substances. Most of the substances involved in chem-sex are indeed under international control and scheduled under the Convention of Psychotropic Substances of 1971. In practice, in France, patients filing a complaint in a chem-sex context are not prosecuted for substance use. The question of reception at the police station and the establishment of absence of consent is more complex. With the use of psychoactive substances, it is indeed sometimes complex to identify what the victim may have consented to, as well as what was understood by the assailant(s). Nevertheless, not respecting a change of mind or a limit established by a partner, regardless of his or her state of impregnation with a substance, is constitutive of sexual violence. People practicing chem-sex should be more informed about the particularity of consent in this context. It also seems essential to reinforce prevention and information actions, to help them assert their rights in cases of sexual violence. Informational materials could be shared through social networks, specific associations, or even dating applications.

In our study, more than one-third of the patients suspected a rape but could not recall it. These patients had more frequently consumed alcohol and/or illicit drugs, but not necessarily in a chem-sex context. They were more likely to suspect a proactive DFSA and reported more frequently an associated theft. Although there was no difference in terms of delays of examination, fewer anogenital lesions were found in these patients. Total amnesia can often be explained by alcohol intoxication and/or proactive DFSA. In most studies, total amnesia is reported by less than 10% of the victims [38,39,40]. The large percentage of victims who reported alcohol and/or illicit substances use might explain the higher prevalence in our study.

Finally, our study explored the existence of aggravating circumstances. These could be related to the victim (vulnerability) or the circumstances of the aggression. We noted only one perpetrator in the family context and only three marital rapes. The under-reporting of sexual violence perpetrated by a known perpetrator is a well-described phenomenon, which our work confirms [41]. Unknown perpetrators are more likely to be reported, as there is less fear of reprisals or of upsetting the family environment. This phenomenon is described similarly in the two other French studies on the subject, with most perpetrators being male and unknown in 38.4% of cases in Bordeaux and 39.8% of cases in Seine-Saint-Denis. Most assaults occurred in the victim’s home (23.1%) or on the public space (21%). According to some authors, assaults on the public space are more frequent among homosexual men, in connection with sexual encounters in parks [16]. Although nearly 20% of the victims reported having met the perpetrator on the public space and 13% via dating applications, this hypothesis was not explored in our study, as sexual orientation is not discussed during the examination. Our study also found six rapes during deprivation of liberty. All these patients reported digital anal penetration during body searches by police officers. These acts were probably more akin to humiliation than to sexual gratification for the perpetrators. Acts of rape in prison or police custody are well-described in the literature [1]. The absence of reported rapes in prisons in our study is likely related to its geographical specificity as there is only one prison in Paris, the Santé prison. It was closed in 2018 and housed a maximum of 920 inmates, which, combined with a probable under-reporting of rapes in prisons, may explain the absence of cases in our study. Among the aggravating circumstances, our study found 7% of prostitutes, often transgender or transsexual. Sex workers represent a category of patients particularly exposed to sexual violence. The 2016 law, aimed at reinforcing the fight against the prostitution system and supporting prostitutes, abolished the offense of passive soliciting and prohibited the purchase of sexual acts by clients [42]. This law, intended to protect prostitutes, ultimately exposes them to more sexual violence. Indeed, to maintain a clientele, prostitutes will tend to carry out their activities in more isolated places and will, thus, be particularly vulnerable. It seems essential to reinforce the protection of prostitutes and their support in case of sexual violence. Overall, apart from suspected proactive DFSA, we found a high proportion of aggravating circumstances (40.5%). Including suspected proactive DFSA, one or more aggravating circumstances were found in the files of 141 victims (70.5%).

Our study presents the characteristics of male victims of rape or suspected rape, examined following a complaint in Paris between 2018 and 2021. It has certain limitations, inherent to its retrospective and mono-centric methodology. There is a significant risk of under-reporting of certain data, notably on alcohol or illicit substances consumption. Our sample size is also limited, and the Parisian population may have certain specificities, making the results difficult to extrapolate to a rural population, for example. Finally, the forensic Department of Paris receives patients only after a formal report to the police which. This may explain the high percentage of associated aggravating circumstances, as victims often feel that their chances of being believed increase when the facts are perceived as more serious. This factor could also limit the representativeness of the results. Finally, it would be interesting to confront the results of our study to the judicial follow-up of the investigations, notably to establish whether the presence of injury leads more often to a conviction of the assailant.