Factors impacting injury documentation after sexual assault: role of examiner experience and gender

The prevalence of genital injuries in post-pubertal females presenting for forensic examination after reported sexual violence: a systematic review

BACKGROUND

Sexual violence is a prevalent issue in contemporary society requiring a robust forensic healthcare response. It is critically important that forensic examiners put clinical examination findings into an appropriate evidence-based context. The presence of genital injuries has been shown to increase the likelihood of successful criminal prosecution and report the crime. However, the reported rates of genital injury vary widely in published studies.

AIMS AND OBJECTIVES

We aim to critically evaluate and synthesize existing literature on the prevalence of genital injuries in post-pubertal females, examined following sexual violence, with a view to describing the prevalence and characteristics of genital injuries as well as the range of forensic practices employed.

METHODS

Three online databases (PubMed, Embase, and Scopus) were systematically searched with key terms.

RESULTS

Of the 1224 studies screened, 141 full-text publications met the inclusion criteria. Reported injury prevalence rates varied widely. Details pertaining to forensic examinations included in each study, such as grade of the examiner, type of examination, location of examination, and time interval from assault to examination also varied widely. Injury prevalence was highest in studies where enhanced visualization techniques were utilized.

CONCLUSIONS

This systematic review demonstrates that there is no universally agreed standard for documenting genital injuries in cases of sexual violence and highlights the need for standardized approaches and guidelines for assessing, documenting, and reporting these injuries. The review provides robust evidence to support a call for establishing consistent context, terminology, classification systems, and data collection methods to improve the comparability and reliability of future research findings.

Cinsel Saldırı - İstismar Olguları Üzerine Retrospektif Bir Çalışma

Objective: In this study; it is aimed to analyze the sexual attack-abuse cases that occurred in Bolu province and were judged by the High Criminal Court. Methods: A total of 148 cases of sexual assault - abuse decided by the Bolu High Criminal Court between 2007 and 2016 were analyzed retrospectively. Results: This study included 148 cases: 131 (88.5%) cases were female and 17 (11.5%) were male. The mean age was 18.6 ± 11.6 (min:4, max:83). The highest number of cases was in the 13-15 age group (n=52, 35.2%). Sexual abuse most frequently occurred through vaginal penetration (n=72: 48.6%). The most common psychiatric diagnosis was acute stress disorder (n:12, 10.8%) and post-traumatic stress disorder (n:12, 10.8%). Physical violence was found to be statistically effective (p = 0.008) in the occurrence of mental disorders after the event. The victim recognized 81.8% of the attacker. Conclusion: We think that more effective sexual attack-abuse prevention strategies can be developed at the national level by determining the risk factors of sexual assault-abuse in our country through wider research to be conducted across the country.

The significance of the forensic clinical examination on the judicial assessment of rape complaints - developments and trends

OBJECTIVE

The aim of this study was to investigate the role of the forensic clinical examination in the judicial assessment made by the Prosecution Service in cases of rape.

METHODS

All cases of police-reported sexual assault in the county of Funen, Denmark in a six-year period were reviewed, and the retrospective data was collected. Cases in which a forensic clinical examination was performed were included.

RESULTS

The Prosecution Service in the county of Funen received 348 police-reported rape cases and of these 184 cases were included. The Prosecution Service stated that the forensic clinical examination (FCE) was important for the decision-making process in approximately half of the cases. The Prosecution Service finding an FCE important due to the presence of relevant findings was significantly associated with the case going to trial, whereas importance due to absence of relevant findings was significantly associated with the cases not going to trial. The only single factor associated with a case going to court and a guilty verdict was an FCE of the alleged perpetrator. There were no crude associations between any other factors i.e. the type of assault, victim injuries or alcohol consumption. In a logistic regression model, however, it was significantly more likely (p < 0.05) that a forensic clinical examination of the victim was used in the Prosecution Service's decision if there were both anogenital and extra-genital injuries documented, that could originate from the alleged crime. The odds were 7.83 times higher compared to if no injuries were detected. The Prosecution Service's use of the clinical examination in their argumentation of the decision of a rape complaint has been significantly increasing from 2003 to 2015.

CONCLUSION

The results of the first in-depth analysis of the overall importance of a forensic clinical examination in cases of rape and sexual assault shows that we need to continuously focus on the documentation of sexual assault, as documentation is part of the decision-making process at all stages of the judicial process.

Genito-anal injury patterns and associated factors in rape survivors in an urban province of South Africa: a cross-sectional study

Background

The prevalence of genito-anal injuries in rape survivors varies significantly and the factors associated with the absence of injuries are not well understood. This plays a major role in the conviction of cases as the absence of injury is equated with a lack of assault. In such cases, health care providers face major challenges in presenting and defending their findings. The aim of this paper is to describe the absence of genito-anal injuries by site in a group of rape survivors and to identify factors associated with the absence of these injuries.

Methods

In a cross-sectional study rape cases reported to the police in one province in South Africa were randomly sampled using a two stage sampling procedure. Data were obtained on the survivor, the circumstances of the rape and the findings of the medicolegal examination. Descriptive statistics were conducted for the prevalence of genito-anal injuries by site and logistic regression models were built to identify factors associated with the absence of genito-anal injuries for all survivors and those reported to be virgins.

Results

In the sample of 1472 women injuries ranged from 1% to 36%. No significant injuries were reported for 749 (51%) survivors. In the multivariable model there was a significantly lower odds of having no injuries in survivors who were virgins, those raped by multiple perpetrators and those examined by a doctor with additional qualifications. In the model for survivors who were virgins, those with disabilities had a greater odds of having no injuries while those between the ages of 8 and 17 years had a lower odds of having no injuries compared to survivors below four years of age.

Conclusions

This study found that being a virgin, multiple perpetration rape and the examiner’s qualifications were significantly associated with the absence of genito-anal injuries. Health providers should thus be aware that in all other respects there was no difference in survivors who had injuries and those who did not. It is important to reiterate the message that the presence of injuries does not necessarily prove that rape occurred nor does the absence disprove the fact.

Macroscopically detected female genital injury after consensual and non-consensual vaginal penetration: a prospective comparison study

OBJECTIVE

The aim of this study was to compare the prevalence, type and pattern of macroscopically detected female genital injury after consensual and non-consensual vaginal penetration to further an understanding of the forensic significance of genital injury in women reporting sexual assault. A secondary aim was to identify any effect of a range of possible variables upon the likelihood of genital injury resulting from vaginal penetrative sexual intercourse.

STUDY DESIGN

Two groups of reproductive age women (aged 18-45 years) were prospectively recruited within 72 h of a single episode of vaginal penetrative sex, and macroscopically examined for the presence of bruises, abrasions and lacerations at twelve external and internal genital sites. Forty one women who presented for forensic examination after reporting a sexual assault to police were recruited to the non-consensual group and 81 women who presented for routine cervical screening or with sexual health concerns to a primary health care service to the consensual group. Each group was examined by a different group of doctors, all of whom were experienced in both forensic genital examination and gynaecological examination of healthy and diseased sexually active women. Data collection and examination protocols were the same for both groups.

RESULTS

The key finding was a statistically significant difference in genital injury prevalence between women who were vaginally penetrated non-consensually and consensually; 53.7% of the non-consensual group (22/41) and 9.9% of the consensual group (8/81) were found to have at least one genital injury [OR 10.57, CI (4.07, 27.42), p < 0.00001]. Penetration with finger/s and possible pre-existing genital 'infection' were found to be significantly associated with the presence of injury in the univariate analysis after adjusting for consent. Logistic regression demonstrated that women penetrated without consent were 19.5 times more likely to sustain at least one genital injury, than those penetrated consensually [OR 19.53, CI (6.03, 63.24)] and that a penetration scenario that included finger/s was 4.2 times more likely to result in at least one genital injury than penetration without finger involvement [OR 4.25, CI (1.42, 12.78)], when controlling for other variables in the model. Whilst a comparatively low injury prevalence in the consensual group limited interpretation, results revealed possible differences in genital injury typology and pattern resulting from non-consensual and consensual vaginal penetration. Lacerations were seen after both consensual and non-consensual vaginal penetration, while abrasions and bruises were seen exclusively in the non-consensual group.

CONCLUSION

This study demonstrated a significant consent group difference in genital injury prevalence and the highest macroscopically detected genital injury prevalence rate resulting from non-consensual vaginal penetration identified to date. Results also indicate that vaginal penetration with finger/s increases the likelihood of sex-related injury. The difference in type of injury sustained as a result of non-consensual and consensual vaginal penetration was an unexpected finding, and warrants further investigation. These results highlight the importance of a standardised means of detecting genital injury based on consistent injury definitions, examination protocols, and examiner experience and suggest that macroscopic genital examination may be uniquely placed to detect consent group differences in injury typology and pattern if they exist.

Multiple perpetrator sexual assault: how does it differ from assault by a single perpetrator?

Research that attempts to identify characteristic features of multiple perpetrator sexual assault (MPSA) is limited. This study compared demographic and assault related characteristics of 135 cases of MPSA with 139 cases of single perpetrator sexual assault (SPSA) reported to the Haven sexual assault referral centre, Camberwell, London, over a 4-year period, and aimed to identify any unique features of MPSA victims, perpetrators and assault type. Victims of MPSA were younger, less likely to be White, more likely to report previous self-harm and more likely to sustain injuries than victims of SPSA. Multiple perpetrators were younger, less likely to be White and more likely to be strangers to the victim than single perpetrators. The nature of the assault was different in single and multiple perpetrator cases; in MPSA, there were more completed rapes and more multiple rapes, and perpetrators were more likely to meet the victim in an outside location before carrying out the assault in a place of residence that was not the victim's. These findings add to a scant but growing evidence base.

Reliability of female genital injury detection after sexual assault

OBJECTIVE

To establish inter-rater reliability for genital injury detection among experienced forensic sexual assault (SA) examiners.

METHODS

Cross-sectional observational study testing inter-rater agreement of injury assessment among eight experienced SA examiners who each viewed 2-4 digital images from 50 cases. Each case was rated by 4 examiners and included images before and after toluidine blue dye application. We calculated overall agreement and kappa (κ).

RESULTS

Examiners had perfect agreement in 60 cases; in 24 cases 3 examiners agreed; in 5 cases 2 agreed and 1 was unsure; and in 9 cases there were 2 "yes" and 2 "no" ratings or 1 "yes," 1 "no," and 2 "unsure" ratings. Overall agreement was 82% (κ, 0.57) when yes|unsure and no|unsure combinations equaled disagreement and 86% (κ, 0.66) when only yes|no dyads equaled disagreement. Neither the number of images nor any single examiner fundamentally influenced results. Highly experienced examiners tended to agree with each other (86%) slightly more often than moderate examiners agreed with each other (75%).

CONCLUSIONS

Our set of experienced forensic examiners achieved moderate inter-rater agreement in assessment of the presence of female genital injury on selected digital images obtained during SA examination.

Rectal perforation secondary to rape and fisting in a female adolescent

We present the case of a 16-year-old girl who was sexually assaulted with transanal forearm penetration resulting in rectal perforation. She required a sigmoid colostomy that was later reversed. The patient's history and physical examination was complicated by multiple factors: she was intoxicated at the time of presentation as well as during the assault; her presentation fluctuated over time, she was obese, and she carried a psychiatric diagnosis. This case report documents a rare injury caused by sexual assault in the adolescent population and also serves as a platform to discuss the evaluation and management of pediatric victims of sexual assault. We support a collaborative model of care including qualified sexual assault pediatricians, sexual assault nurse (or forensic) examiners, medical specialists, and the criminal justice system. The importance of developing updated sexual assault protocols, ensuring their implementation, and maintaining continuous quality assurance cannot be overemphasized.

Relationship of genital injuries and age in adolescent and young adult rape survivors

OBJECTIVE

To examine the associations between age and genital injuries in adolescent and young adult women examined following rape.

DESIGN & SETTING

A retrospective review of 234 medical records from an emergency department sexual assault program.

SAMPLE

Women aged 14 to 29 years. Fifty percent of the sample was African American, 48% was White, and 2% was either Asian or an "other" race.

MAIN OUTCOME MEASURES

Genital injury was described by injury prevalence, frequency, and anatomical locations of injuries.

RESULTS

Overall genital injury prevalence was 62.8%. Younger age was not significantly associated with the presence or absence of genital injury. However, younger age was significantly associated with an increased number of genital injuries overall and to the thighs, labia minora, periurethral area, fossa navicularis, and vagina.

CONCLUSION

These findings support the need for further research to determine if the current care provided to rape survivors is age appropriate.

Sexual assault victims in the emergency department: analysis by demographic and event characteristics

The objective of this study was to analyze demographic and event characteristics of patients presenting to the Emergency Department (ED) for evaluation after sexual assault, using a Sexual Assault Nurse Examiner standardized database. Data were prospectively collected as part of the Sexual Assault Nurse Examiner program at an urban teaching hospital. This study reviewed all ED patient records with a complaint of sexual assault between January 1, 2000 and December 31, 2004. Data were collected on 1172 patients; 92.6% were women, with a mean age of 27 years. The sample was 59.1% black, 38.6% white, and 2.3% "Other." Black victims of sexual assault were significantly more likely to be young (25 years or less) than Whites. Over half (54%) reported involvement of drugs or alcohol during the event. Fifty-three percent knew their assailant(s), and black and young patients were significantly more likely to know the perpetrator(s). Threats of force were common (72.4% of sample), and multiple assailants were uncommon (18.1% of sample). Physical evidence of trauma was present in more than half (51.7%), with increased rates among Whites and older persons. Multivariate analysis showed that race, age, threats, and substance use during the event were independent risk factors for evident trauma on physical examination. Survivors of sexual assault who present to the ED are overwhelmingly female, relatively young, often know the perpetrator of the event, and are likely to be threatened and show signs of physical trauma. Differences between patients according to demographic and event characteristics may have important implications for ED management and treatment plans.

Validation set correlates of anogenital injury after sexual assault

OBJECTIVES

Forensic investigators remain unsure exactly why some sexual assault victims display acute injury while others do not. This investigation explores potential reasons for these differential findings among female victims.

METHODS

This cross-sectional analysis examined data from consecutive female sexual assault victims, at least 12 years old, who agreed to a forensic exam between November 1, 2002, and November 30, 2006. Exams utilized colposcopy, anoscopy, macrodigital imaging, and toluidine blue dye to delineate anogenital injury (AGI), which was defined as the presence of recorded anogenital abrasions, tears, or ecchymosis. Demographic variables of the victim, including sexual experience and reproductive parity, and assault characteristics were recorded in the database for bivariate and multivariate analysis with AGI.

RESULTS

Forty-nine percent of the initial 3,356 patients displayed AGI. Of this total, 2,879 cases included complete data for all variables and were included in the multivariate logistic regression model. A statistically significant increased risk for AGI was noted with: educational status (odds ratio [OR] 1.53, 95% CI = 1.25 to 1.87); vaginal or attempted penetration using penis (OR 2.29, 95% CI = 1.74 to 3.01), finger (OR 1.61, 95% CI = 1.88 to 1.94), or object (OR 3.19, 95% CI = 1.52 to 6.68); anal-penile penetration (OR 2.00, 95% CI = 1.57 to 2.54); alcohol involvement (OR 1.25, 95% CI = 1.04 to 1.50); and virgin status of victim (OR 1.38, 95% CI = 1.11 to 1.71). Victims were less likely to display AGI with a longer postcoital interval (OR 0.50, 95% CI = 0.39 to 0.65) and increased parity (OR 0.76, 95% CI = 0.57 to 0.99).

CONCLUSIONS

Approximately half the patients displayed AGI. This rate is higher than earlier studies, but consistent with current investigations utilizing similar injury detection methods. The correlates of injury found reinforce the findings of prior studies, while prompting questions for future study.