Colposcopy in evaluation of the adult sexual assault victim

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.

Frequency of Injuries to Women after Sexual Offense - Relevance of a Gynecology Examination

Introduction Up to a third of women worldwide report having experienced an act of sexual violence during their lifetime. The emergency gynecology department is often the first port of call for affected individuals. The aim of the current study was to evaluate the importance of gynecology examinations for women after a sexual offense and to evaluate the pattern of injuries sustained.

Methods This study is a retrospective single center analysis of the gynecology and forensic examination reports of all women examined for a suspected sexual offense in the central emergency department of a university hospital between 2013 and 2017 (n = 692). We evaluated genital and extragenital injury patterns, age, offender profile, time of offense, and substance use, as well as the administration of post-coital contraception and post-exposure prophylaxis for HIV.

Results The affected individuals had a mean age of 26 (12 – 91 years). Almost 75% of affected individuals presented within 24 hours of the reported sexual offense. Extragenital injuries were detected in 78.6% of patients and genital injuries in 28.5%. Overall, 20.1% of the women reported complete memory loss and 18.7% partial memory loss of the actual event. Risk factors for memory lapse were the consumption of alcohol and/or the (possibly non-consensual) administration of other substances acting on the central nervous system. A history of alcohol consumption by the victim (hazard ratio [HR] 1.95; 95% confidence interval [CI] 1.21 – 3.12, p = 0.006) and younger victims aged between 25 – 49 years (HR 1.75; 95% CI 1.07 – 2.85, p = 0.025) were associated with the occurrence of extragenital injuries. However, if the perpetrator was someone who was known to the affected individual, fewer extragenital injuries were sustained (HR 0.60; 95% CI 0.36 – 0.99, p = 0.046). Reports of genital injuries, associated with an older age of affected individuals and indications of anal penetration, resulted in more frequent administration of post-exposure prophylaxis (29.1% vs. 19.5%, p < 0.012) and hepatitis B (active) vaccination (40% vs. 28.5%, p < 0.028).

Conclusion Emergency gynecology examinations form a fundamental component of the medical care and the assessment of affected women after a sexual offense, since almost a third of victims sustain injuries to the genital region. In addition to a detailed complete physical examination and expert forensic documentation of physical and genital injuries, victims should also be offered psychological support which is easy for them to access.

Vaginal injuries after consensual sexual intercourse - a survey among office-based gynecologists in Hamburg, Germany

Studies on the occurrence of injuries following consensual sexual intercourse (CSI) among patients treated by office-based gynecologists are lacking. This survey aimed to assess the presence and medical relevance of vaginal injuries after CSI in gynecological office-based practice, associated risk factors, and their significance for forensic medical assessment practice. All office-based gynecologists in Hamburg, Germany (n = 316), were asked to fill in a one-page questionnaire via a fax survey. The questionnaire covered various aspects such as having observed CSI-related injuries, injury severity, risk factors, and concomitant factors (bleeding, need for surgical care, hospitalization). Response rate was 43.2% (n = 115). Overall, 83.5% of office-based gynecologists reported having observed vaginal injuries after CSI at least once and 59.1% repeatedly. Regarding maximum injury severity, 52.1% observed mucosal erosions, 32.3% mucosa penetrating injuries, and 14.6% injuries penetrating the vagina. Having observed bleeding was reported by 56.3%, 28.1% had to perform surgical suture care, and hospital admission was initiated by 20.8%. Menopause (37.5%), use of objects (19.8%), alcohol, and/or drug use (16.7%) were reported as the most frequently observed associated risk factors. Vaginal injuries after CSI have been observed by the majority of office-based gynecologists in Hamburg involving a wide spectrum of severity, including the necessity of surgical care and hospital admission. Complementing published work in clinical and emergency medicine, these findings are highly relevant to the forensic evaluation of injuries in an allegation of sexual assault, as the severity of a vaginal injury in this setting does not necessarily support a conclusion on the issue of consent.

[Prospective forensic study on the characterization of genital examination in women with consented sexual activity]

OBJECTIVE

The number of women victims of sexual assault remains high, despite prevention and information campaigns. These victims can be adolescent girls, women of childbearing age or postmenopausal women. As part of examinations of victims of sexual assault, the morpho-anatomical diversity of the female genitalia requires knowledge of the physiological variations existing by the practitioners caring for these victims. Our work aimed to describe and characterize the genital examination of women with consented sexual activity.

METHOD

Our cohort consisted of 196 women aged 14 to 81, examined in the context of medical gynecology consultations in two French maternity hospitals.

RESULTS

Recent genital traumatic injuries were found in 12.8% of women whose last sexual intercourse was less than 5 days old. Intact hymens, free from traumatic tearing despite regular sexual activity, were present in 10.7% of these women.

CONCLUSION

Thus, in many cases, genital examination alone cannot confirm or deny the existence of prior sexual intercourse, whether or not it was consented to. The development of work on data on female genital anatomy would make it possible to optimize the medico legal care of victims of sexual assault.

Prevalence of Adult Female Genital Trauma After Acute Sexual Assault: The Need for a Universal Definition of Genital Trauma

BACKGROUND

Examination of the adult female genitalia after an acute sexual assault may reveal findings interpreted by the examiner as injuries, which may be linked to later legal outcomes. There is no consistent definition in the literature regarding what findings constitute genital trauma after sexual assault. We studied how the prevalence of genital trauma is impacted by the inclusion/exclusion of various genital findings reported in the literature.

METHODS

A retrospective descriptive chart review of the sexual assault forensic records from a provincial regional sexual assault treatment center was conducted over a 4-year period and included 67 female patients, 12 years old and over, who reported being sexually assaulted in the previous 72 hours and received a complete forensic examination. We studied the prevalence of genital trauma, using eight definitions of trauma, as well as the percentage of each type of genital finding within this population.

RESULTS

The prevalence of genital trauma in this population ranged from 52%, the majority, to 31% of women, depending on the definition of trauma utilized. Forty-one percent of the findings, the greatest number overall, were redness. Bruises, abrasions, and tears (lacerations), the components of blunt force trauma, accounted for 4%, 15%, and 14% of the findings, respectively.

INTERPRETATION

A universal definition of what findings constitute genital trauma after acute sexual assault is required if the examiner, as expert witness, is to compare findings in a given case with the broader literature and assist the court in ensuring an informed process of decision making.

Genital injuries and allegation of digital vaginal penetration - A retrospective examination of forensic case notes

OBJECTIVE

To determine the prevalence of genital injuries following alleged sexual assault by digital penetration of the vagina in the absence of penile penetration of the vagina or anus in women age 16 and over; and to compare with the prevalence of genital injuries following alleged sexual assault by penile vaginal penetration in the absence of penile penetration of the anus or digital penetration of the vagina and/or anus.

POPULATION

1428 adults and children attending a forensic medical examination between September 2017 and January 2020 at the Haven sexual assault referral center situated in Paddington, London, UK.

DESIGN

Retrospective review of forensic notes.

METHODS

Eligible cases were identified through the standardized forensic notes and relevant data was extracted.

RESULTS

109 cases of women 16 years and over alleging digital penetration only and 110 cases of women 16 years and over alleging penile vaginal penetration only were included. The 110 cases of penile vaginal penetration only were randomly selected for comparison purposes. 7.6% of Haven attenders fulfilled the digital penetration only category. In this category, the patients mean age was 27.2 years. Thirteen patients (11.9%) sustained genital injuries; of those with genital injuries, eleven (84.6%) sustained one or more abrasions. The most common site of injury was the labia minora (46.2%). There were no significant differences between the 2 groups (digital penetration only and penile vaginal penetration only) in terms of number of patients with genital injuries, type or location of injury. There were differences regarding the relationship between patient and assailant: more stranger assaults in the digital penetration group 27/109 (29%) vs 13/110 (12%) in the penile penetration group. There was one assault by multiple assailants in the digital penetration group and 8 (7.3%) in the penile penetration group. In the digital penetration group there was more alcohol use [71/109 (65.1%) vs 62/110 (56.4%)] but less drug use [21/109 (19.3%) vs 30/110 (27.3%)] than in the penile vaginal penetration group.

CONCLUSION

The majority of patients examined following an allegation of digital vaginal penetration without penile penetration sustained no injuries. Of those who did, abrasions were the most common type of injury, with the inner labia minora being the most common location for injury. There were no significant differences with the injuries seen in the penile vaginal penetration group in terms of number of patients with genital injuries, type or location of injury.

Comparison of Injury Patterns in Consensual and Nonconsensual Sex: Is It Possible to Determine if Consent was Given?

Matters of sexual consent and sexual assault are hotly debated issues among professionals and laypersons alike. A widespread misconception of sexual assault is that most victims of sexual assault sustain significant physical trauma. It is the purpose of this review article to compare the patterns of physical injury (both genital and extragenital) in victims of sexual assault and participants of consensual sex to conclude if physical injury alone can indicate whether consent was given. Interpretations of injury have great forensic significance as it can influence the outcome of sexual assault cases. Several articles indicate that extragenital injuries are commonly found in sexual assault victims (46%-82%) and that most of such injuries are deemed minor. Articles report a wide range of genital injury detection rates in both sexual assault victims (6%-87%) and consensual sex participants (6%-73%). Usage of different examination techniques may partly explain the wide range of detection rates reported. Out of all those who sustained genital injuries, only a small portion of people required hospitalization. In both consensual and sexual assault cases, genital injuries in the 6 o'clock position were most common. Studies of genital injury lacked standardization of factors that significantly influence the results, such as time to examination after sex, examination techniques, and injury severity scales. Therefore, medicolegal personnel should be aware that sexual assault victims can present with a wide range of physical trauma and should avoid relying on physical trauma alone to conclude whether consent was present.

Care of the Adolescent After an Acute Sexual Assault

Sexual violence is a broad term that encompasses a wide range of sexual victimizations. Since the American Academy of Pediatrics published its last policy statement on sexual assault in 2008, additional information and data have emerged about sexual violence affecting adolescents and the treatment and management of the adolescent who has been a victim of sexual assault. This report provides new information to update physicians and focuses on the acute assessment and care of adolescent victims who have experienced a recent sexual assault. Follow-up of the acute assault, as well as prevention of sexual assault, are also discussed.

Strategic categorization of available research relating to sexual assault and rape facilitates more accurate interpretation of injury data

The available research evidence pertaining to anogenital injury in victims of sexual violence presents a very wide range of injury prevalence data. As such, it is extraordinarily challenging for health care practitioners involved in clinical forensic examination of victims of sexual violence to place their examination findings in to context. It is generally accepted that the broad range of existing injury prevalence data is reflective of heterogeneous research study methodologies and clinical practice techniques. Thus, health care practitioners should be encouraged to present their evidence in the context of the prevalence data that are most representative of their clinical practice. Presented herein is a simple categorization of existing prevalence data in accordance with national clinical practice guidelines. The range of anogenital injury prevalence is narrower when presented in this manner than when taken as a whole. This will facilitate health care practitioners in presenting their examination findings in the context of research literature that is most representative of their clinical practice.

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.

The relationship of victim injury to the progression of sexual crimes through the criminal justice system

A number of factors are known to influence the progression of sexual crimes through the criminal justice system. The role of victim injury in influencing decision-making at pivotal stages has been addressed by a number of separate research projects. This article consolidates existing research evidence in order to highlight the important role that victim injury plays at each step of the legal process. The importance of accurate diagnosis and recording of victim injury is highlighted. Furthermore, by describing the significant impact that the presence of victim injury can have on the legal outcome, the importance of ensuring that cases without victim injury are correctly interpreted by the police, legal professionals, judiciary and the jury is heavily emphasised.

Injuries from intimate partner and sexual violence: Significance and classification systems

While intimate partner violence (IPV) and sexual violence (SV) are highly associated with injury, the healthcare and legal significance of these injuries is controversial.

PURPOSE

Herein we propose to explore the significance of injury in IPV and SV and examine the current status of injury classification systems from the perspectives of the healthcare and criminal justice systems. We will review current injury classification systems and suggest a typology of injury that could be tested empirically.

FINDINGS

Within the published literature, we found that no commonly accepted injury typology exists. While nuanced and controversial issues surround the role of injury detection in the sexual assault forensic examination, enough evidence exists to support the continued pursuance of a scientific approach to injury classification. We propose an injury typology that is measurable, is applicable to the healthcare setting and criminal justice system, and allows us to use uses a matrix approach that includes a severity score, anatomic location, and injury type. We suggest a typology that might be used for further empirical testing on the validity and reliability of IPV and SV injury data.

CONCLUSION

We recommend that the community of scientists concerned about IPV and SV develop a more rigorous injury classification system that will improve the quality of forensic evidence proffered and decisions made throughout the criminal justice process.

A pilot study to test the differential validity of a genital injury severity scale, in development for use in forensic sexual assault examinations

Methods of examining the sexual assault patient are not standardized and a definition of what constitutes significant genital injury after sexual assault (SA) remains controversial. This pilot study tests the empirical validity (initial differential validity) of a genital injury severity scale (GISS) under development by the authors with the hypothesis that women who report SA have more severe external genital injuries than those who engage in consensual intercourse (CI). In this observational, prospective study, an initially developed GISS is applied and the exam results of 59 CI volunteers and 185 SA patients are compared. All examinations were performed by experienced sexual assault forensic examiners (SAFE) using toluidine blue (TB) and colposcopy. The Independent Samples Median Test indicates a significant difference in median genital injury type between CI and SA subjects (p < 0.0001). There is a significant difference in the prevalence of Class A (less severe) and Class B injuries (more severe) between the SA and the CI groups (SA: Class A 60%/Class B 40%; CI: Class A 90%/Class B 10% (p= 0.0001)). This initial validation study shows effectiveness in using magnification and TB, combined with a standardized injury severity scale, in describing external genital injury in women after sexual intercourse.

Characteristics of sex-related homicides in Alaska

The identification and interpretation of anogenital findings postmortem is a critical component of a sex-related homicide investigation. The use of a colposcope to assist in identifying anogenital injuries in living sexual assault victims is well established. The use of a colposcope for postmortem anogenital examination has been briefly mentioned in a few publications, however, no studies were found regarding the types and sites of postmortem anogenital injuries identified with a colposcope in sex-related homicide cases. The purpose of this study was to describe the demographic, physical examination, and victim-suspect relationship characteristics of sex-related homicides in Alaska. Genital findings in living and deceased sexual assault victims in Alaska were compared.

IMPLICATIONS

Given the results of this study, postmortem sexual assault examinations should be conducted in all suspected intimate partner homicides. Further implications for forensic nursing practice and recommendations for future research are discussed.

Visualizing sexual assault: an exploration of the use of optical technologies in the medico-legal context

This article is an exploration of the visualization of sexual assault in the context of adult women. In investigating the production of visual evidence, we outline the evolution of the specialized knowledge of medico-legal experts and describe the optical technologies involved in medical forensic examinations. We theorize that the principles and practices characterizing medicine, science and the law are mirrored in the medico-legal response to sexual assault. More specifically, we suggest that the demand for visual proof underpins the positivist approach taken in the pursuit of legal truth and that the generation of such evidence is based on producing discrete and decontextualized empirical facts through what are perceived to be objective technologies. Drawing on interview and focus group data with 14 sexual assault nurse examiners (SANEs) in Ontario, Canada, we examine perceptions and experiences of the role of the visual in sexual assault. Certain of their comments appear to lend support to our theoretical assumptions, indicating a sense of the institutional overemphasis placed on physical damage to sexually assaulted women's bodies and the drive towards the increased technologization of visual evidence documentation. They also noted that physical injuries are frequently absent and that those observed through more refined tools of microvisualization such as colposcopes may be explained away as having resulted from either vigorous consensual sex or a "trivial" sexual assault. Concerns were expressed regarding the possibly problematic ways in which either the lack or particular nature of visual evidence may play out in the legal context. The process of documenting external and internal injuries created for some an uncomfortable sense of fragmenting and objectifying the bodies of those women they must simultaneously care for. We point to the need for further research to enhance our understanding of this issue.

Forensic sexual assault examination and genital injury: is skin color a source of health disparity?

PURPOSE

The study objectives were to (1) estimate the frequency, prevalence, type, and location of anogenital injury in black and white women after consensual sex and (2) investigate the role of skin color in the detection of injury during the forensic sexual assault examination.

METHODS

A cross-sectional descriptive design was used with 120 healthy volunteers who underwent a well-controlled forensic examination after consensual sexual intercourse.

RESULTS

Fifty-five percent of the sample had at least 1 anogenital injury after consensual intercourse; percentages significantly differed between white (68%) and black (43%) participants (P = .02). Race/ethnicity was a significant predictor of injury prevalence and frequency in the external genitalia but not in the internal genitalia or anus. However, skin color variables--lightness/darkness-, redness/greenness-, and yellowness/blueness-confounded the original relationship between race/ethnicity and injury occurrence and frequency in the external genitalia, and 1 skin color variable--redness/greenness--was significantly associated with injury occurrence and frequency in the internal genitalia.

CONCLUSIONS

Although differences exist in anogenital injury frequency and prevalence between black and white women, such differences can be more fully explained by variations in skin color rather than race/ethnicity. Clinical recommendations and criminal justice implications are discussed.

Care of the adolescent sexual assault victim

Sexual assault is a broad-based term that encompasses a wide range of sexual victimizations including rape. Since the American Academy of Pediatrics published its last policy statement on sexual assault in 2001, additional information and data have emerged about sexual assault and rape in adolescents and the treatment and management of the adolescent who has been a victim of sexual assault. This report provides new information to update physicians and focuses on assessment and care of sexual assault victims in the adolescent population.

Sexual assault nurse examiner program characteristics, barriers, and lessons learned

Sexual Assault Nurse Examiner (SANE) programs have been developed throughout the United States to better meet the needs of sexual assault survivors. This study builds upon three previously published national surveys of SANE programs, with a random sample of 243 SANE programs surveyed. Results are discussed along with implications Jbr SANE program practice.

The medical and ethical aspects of photography in the sexual assault examination: Why does it offend?

This paper reviews the literature in respect to the photo-colposcopic examination of anogenital injury in the sexually assaulted child, considered to be the 'gold standard' of examination, and how this compares with gross visualisation, still the standard procedure in adult examinations. It then examines the claim that, because the presence of injury does not provide a distinction between consensual and non-consensual intercourse in adults, photo-documentation is unnecessary medically and constitutes an invasive procedure which is ethically unacceptable. The paper questions whether the unwillingness of forensic physicians to extend photo-colposcopy to the examination of adult victims is related more to political and gender issues than to claims made on ethical and medical grounds, and concludes that any move to ban anogenital photography in adult forensic examinations (currently under consideration in the author's own jurisdiction) would possibly constitute an interference with independent clinical judgment and an incursion into the patient's right to evidence-based medicine.

The Effects of Age and Ethnicity on Physical Injury from Rape

OBJECTIVE

To determine whether postmenopausal (age 50 years or older) women would sustain significantly more injury after rape than women younger than 50 and to determine the role of skin pigmentation in the observance of genital injury.

DESIGN AND SETTING

Registry data from a sexual assault forensic nurse examiners program.

PARTICIPANTS

Based on date of examination, records from women of age 50 years or older (n = 40) were matched to two other participants: a premenopausal group younger than 40 years and a perimenopausal group of 40 to 49 years. The final sample consisted of 120 subjects.

MAIN OUTCOME MEASURES

Number, type, and location of injuries.

RESULTS

A series of exact conditional logistic regression analyses indicated no significant association between age and genital, nongenital, or head injury. A significant association between race (Black versus White) and genital injury (adjusted odds ratio = 4.30, 95% confidence interval = 1.09-25.98, p = .03) indicated that Whites were more than four times as likely as Blacks to have genital injury.

CONCLUSION

Although the primary hypothesis was not supported, the role of racial/ethnic differences and their association with the observance of injury need further exploration to determine whether the standard forensic examination is appropriate for all women. Health disparities may exist if women of color are less likely than others to have genital injuries identified and treated. Alternatively, skin properties may explain racial/ethnic differences in injury prevalence.

Current issues in the use of colposcopy for examination of sexual assault victims

Colposcopic examination is considered the gold standard in child sexual abuse evaluations in Australia. However, there remain contentious issues with its use, especially in adult victims, which we sought to address by a review of the literature. Colposcopy has been shown to be a sensitive and acceptable tool for detection of anogenital abnormalities in children. The significance of some genital findings remains controversial, especially when images are interpreted by inexperienced clinicians. Its use in adult assessments is hampered by a lack of comparative studies on colposcopically detected genital injuries in adults following consensual v. non-consensual sexual intercourse. Further research is urgently needed before the use of colposcopy can be routinely recommended for adult victims.

Genitoanal injury in adult female victims of sexual assault

OBJECTIVES

To evaluate the presence and extFent of genitoanal injury among sexually assaulted women and to estimate the risk of injury in subgroups according to the type of assault and to the sexually assaulted women's susceptibility to injury.

STUDY DESIGN

A case-control study of 249 women exposed to sexual assault. Injury identified by gross visualization. Women with and without injury were compared. Logistic regressions analyses were performed to calculate the risk of injury.

RESULTS

Thirty-two percent sustained genitoanal injury. Anal penetration and assaults on women without prior sexual experience were associated with genitoanal injury.

CONCLUSIONS

Most women do not have visible genitoanal injuries. The risk of sustaining genitoanal injury during a sexual assault is higher among women without prior sexual intercourse experience and among women exposed to anal penetration. The severity of the assault is a poor predictor of genitoanal injury.

Using colposcopy in the rape exam: health care, forensic, and criminal justice issues

In the setting of a forensic examination following rape, colposcopy allows practitioners to identify and photograph genital injury not readily visible to the unaided eye, thereby clarifying the location and extent of injury as well as providing evidence for court proceedings. Since the 1980s, the technique once reserved for victims of child abuse has been used across the lifespan and has been shown to identify genital injury in up to 87% of women who have been raped. The role of colposcopic findings as evidence in court testimony, however, remains controversial. This paper explores the history of colposcopy in the rape exam and describes the epidemiology of genital injury in consensual sex as well as rape.

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

OBJECTIVE

This study was undertaken to determine whether physician gender or level of experience is associated with the prevalence of trauma documented in victims after sexual assault.

STUDY DESIGN

All female patients 15 years or older reporting to an urban hospital with a complaint of sexual assault between January 1997 and September 1999 underwent a standardized history and physical examination by a second- or third-year resident in obstetrics and gynecology. Data were abstracted and verified. A chi(2) or Fisher exact test was used for categoric analysis.

RESULTS

The overall prevalence of genital trauma was 21% in the 662 patients available for analysis. The prevalence of genital trauma documented by second- and third-year residents was 50 of 191 patients (26.2%) and 90 of 471 patients (19.1%), respectively (P=.04), despite similar assault characteristics between the 2 groups. The prevalence of genital trauma documented by male examiners (105/499 [21.0%]) and female examiners (35/160 [21.9%]) did not differ (P=.8). All examiners documented a similar prevalence of body trauma (52%).

CONCLUSION

This study supports the hypothesis that the examiner's experience level may influence the prevalence of genital trauma documented after a sexual assault. Genital trauma documented was not associated with examiner gender in this study.

Genital trauma associated with forced digital penetration

Clinicians may not perform a medical-legal examination in cases in which a sexual assault was attempted but no penile-vaginal contact occurred. This retrospective study was conducted to document the frequency and type of genital injuries in women in whom forced digital penetration was the only reported type of assault. Study patients were consecutive female patients presenting to an urban sexual assault clinic during a 3-year study period. The clinic is associated with a university-affiliated urban hospital and is staffed by registered nurses trained to perform forensic examinations using colposcopy with nuclear staining. Case files of 941 patients were reviewed; 6% (53) reported only digital-vaginal contact. Genital injuries were documented in 81% of the patients (mean number of genital injuries, 2.4). Fifty-six percent of the injuries occurred at four sites: fossa navicularis, labia minora, cervix, and posterior fourchette. The most common type of injury was erythema (34%) followed by superficial tears (29%) and abrasions (21%). Colposcopy with nuclear staining was useful in detecting these injuries--and can provide valuable legal information in sexual assault victims reporting only digital-vaginal penetration.

Injury in Women Who Are Raped

Sexual assault is considered the silent, violent epidemic. However, many critical care nurses are unaware of the injury patterns that may indicate that their patient has been sexually assaulted. In addition, critical care nurses are often uncertain how to proceed when caring for someone with a suspected sexual assault. This article provides both background information about sexual assault and guidance to critical care nurses on how to manage this difficult situation.

Physical injury after sexual assault: Findings of a large case series

OBJECTIVE

This study was undertaken to determine characteristics associated with physical injury in female sexual assault victims.

STUDY DESIGN

All females who were 15 years or older presenting after sexual assault to an urban emergency department during a 34-month period underwent standardized evaluation. Analysis was performed by chi(2) and logistic regression.

RESULTS

Of 819 women, 52% had general body and 20% had genital-anal trauma; 41% were without injury. General body trauma was independently associated with being hit or kicked (odds ratio [OR]=7.7, 95% CI, 5.1-11.7), attempted strangulation (OR=4.2, 95% CI, 2.5-7.2), oral or anal penetration (OR=1.7, 95% CI, 1.2-2.3), and stranger (OR=2.4, 95% CI, 1.7-3.4) assault. Genital-anal injury was more frequent in victims younger than 20 and older than 49 years (P<.05), in virgins (OR=2.7, 95% CI, 1.4-5.4) and those examined within 24 hours (OR=1.7, 95% CI, 1.2-2.4) and after anal assault (OR=1.7, 95% CI, 1.1-2.6).

CONCLUSION

General body injury is primarily associated with situational factors, whereas genital-anal injury is less frequent and related to victim age, virginal status, and time to examination.

Evaluation and management of the sexually assaulted woman

The evaluation and management of the sexually assaulted woman is a challenging task that emergency physicians frequently face. The physician must assume dual roles as advocate for the patient and as an agent of the government. While caring for the immediate physical and emotional well being of the victim, the physician also must be diligent in the forensic evaluation and evidence collection. To receive quality care, the victim should receive a thorough history and physical examination with appropriate diagnosis and treatment of injuries, a thorough evidentiary examination, counseling and treatment for prevention of pregnancy and STDs, provisions for initial and ongoing mental health evaluation, and appropriate follow-up. To provide this high quality care, the physician must be familiar with the process of the evidentiary examination, have knowledge of the current recommendations for pregnancy and STD prophylaxis. and have thorough knowledge of the community resources that are available.

Sexual assault forensic medical examination: is evidence related to successful prosecution?

STUDY OBJECTIVE

We describe the medical-legal findings in a population of adult sexual assault cases assessed in an emergency department setting and reported to the police, document the law enforcement and legal disposition of cases seen over the study period, and determine whether medical-legal findings are associated with filing of charges and conviction after adjusting for demographic factors and assault characteristics.

METHODS

This was a retrospective chart review of all police-reported cases seen from January 1993 to December 1997 at the British Columbia Women's Sexual Assault Service, a 24-hour hospital-based emergency service. Information on patient demographics, assault characteristics, and medical-legal findings was merged with data extracted from police and court files on the cases' legal outcomes and sperm-semen test results of collected forensic evidence. Cases were assigned a clinical injury extent score reflecting the degree of documented genital and extragenital injury. The association of medical-legal variables, patient demographics, and assault characteristics with filing of charges (among the subset of cases in which a suspect was identified by police) and conviction (among the subset of cases in which charge were filed) was examined by using logistic regression.

RESULTS

Charges were filed in 151 (32.7%) and a conviction secured in 51 (11.0%) of the 462 cases examined in this study. Genital injury was observed in 193 (41.8%), and sperm-semen-positive forensic results were obtained in 100 (38.2%) of the 262 samples tested. A gradient association was found for injury extent score and charge filing in the following categories: mild injury (odds ratio [OR] 2.85; 95% confidence interval [CI] 1.09 to 7.45); moderate injury (OR 4.00; 95% CI 1.63 to 9.84); and severe injury (OR 12.29; 95% CI 3.04 to 49.65). Documentation on the police file of receipt of forensic samples collected by the Sexual Assault Service examiner was also significantly associated with charges being filed (OR 3.45; 95% CI 1.82 to 6.56). Injury extent score defined as severe was the only variable significantly associated with conviction (OR 6.51; 95% CI 1.31 to 32.32).

CONCLUSION

The finding that documented injury extent had a significant positive association with both filing of charges and conviction is an important step in confirming the value of injury documentation in the forensic examination of sexual assault victims.

Characteristics of sexual assault in women with a major psychiatric diagnosis

OBJECTIVE

In a previous study of women who had been sexually assaulted, we reported a 26% prevalence of a major psychiatric diagnosis. The purpose of this study was to better characterize sexual assaults in women with a major psychiatric diagnosis.

STUDY DESIGN

All female patients >or=15 years old with a complaint of sexual assault underwent a standardized history and physical examination by an upper-level resident in obstetrics and gynecology. Data were abstracted and verified. A psychiatric diagnosis was determined by history and by use of computer-linked medical records. Chi-square or Fisher exact test was used for categoric analysis.

RESULTS

Of the 819 women who were examined, 211 women (26%) had a major psychiatric diagnosis. In these 211 women, the prevalence of solely mood, thought, or substance use disorders were 26%, 14%, and 16%, respectively, whereas 44% had >or=2 diagnoses. Having a psychiatric diagnosis was associated with increasing age (P =.001), homelessness (P =.001), and incarceration (P =.001). In comparison with women with no psychiatric diagnosis, sexual assaults in these 211 women occurred more frequently outdoors (P =.007), by a stranger (P <.001), or by >or=2 assailants (P =.02). Being assaulted with a weapon (P =.04) and being hit (P =.01) were more prevalent in assaults against women with a psychiatric diagnosis, as was anal contact (P =.03), contact to >or=2 body orifices (P =.001), and body trauma (P =.01).

CONCLUSION

Sexual assaults in women with a major psychiatric diagnosis are common. These assaults are more violent and result in body trauma more frequently than do sexual assaults in women without a psychiatric diagnosis. Prevention and treatment strategies should target this vulnerable population.

Management of sexual assault

The incidence of sexual assault continues to escalate, and it is under-reported. Victim care requires special attention in the emergency department because the history and physical examination are unique and frequently time consuming. The victim should receive counseling and treatment for potential STDs, HIV, and hepatitis exposure, while stressing the importance of follow-up care. The emergency department physician must fulfill obligations not only to the patient but also to law enforcement. To be done well, documentation of findings and the completion of the evidentiary portion of the exam require a familiarity with the process.

Genital injury: is it significant? A review of the literature

The purpose of this review was to critically evaluate the available literature on genital injury in order to facilitate an understanding of its significance in relation to sexual offence trials. Wide variation exists in research objectives, study populations and methodology, hindering interpretation considerably. The most valuable research in this field identifies the range of normal genital findings and those associated with consensual sexual intercourse, to enable interpretation of genital findings in sexual assault victims. However, there are, unfortunately, few studies of this nature. Difficulties arise when examining doctors are not experienced in the genital examination of those other than sexual assault victims, limiting their ability to draw conclusions about genital injury if it is detected. If the methods of genital examination employed are not the same as those used to examine a wide range of non-sexual assault victims, comparison and thus valuable interpretation is further limited. This review of the literature finds that the most appropriate genital examinations and indeed the most legally valuable as far as interpretation is concerned, are done macroscopically by doctors with considerable experience in the examination of normal, diseased and traumatized genitalia, and a sound knowledge of the principles of injury interpretation. A deficiency exists in the literature in relation to macroscopic genital examination findings in consensually sexually active women who have been examined by forensically trained doctors. This deficiency must be addressed before the medicolegal significance of genital injury relating to sexual assault can be accurately interpreted, and before any decision is made to incorporate colposcopy or staining techniques into the routine assessment of sexual assault victims.

Care of the adolescent sexual assault victim

Sexual assault is a broad-based term that encompasses a wide range of sexual victimizations, including rape. Since the American Academy of Pediatrics published its last policy statement on this topic in 1994, additional information and data have emerged about sexual assault and rape in adolescents, the adolescent's perception of sexual assault, and the treatment and management of the adolescent who has been a victim of sexual assault. This new information mandates an updated knowledge base for pediatricians who care for adolescent patients. This statement provides that update, focusing on sexual assault and rape in the adolescent population.

The utility of anoscopy and colposcopy in the evaluation of male sexual assault victims

STUDY OBJECTIVE

We sought to compare the use of anoscopy and colposcopy in examinations of male sexual assault victims and to characterize the demographics of male sexual assault victims.

METHODS

This is a case series of 67 male sexual assault victims evaluated over an 8-year period by the Sexual Assault Forensic Examination team. The setting is a university-based emergency department serving as the primary site for examination of sexual assault victims by trained nurse practitioners and physician's assistants. Police and victims' advocates are available at the time of the examination. Anoscopy was done routinely over the entire study period in all patients with any anal penetration or involvement. Colposcopy use started in 1994 to magnify and take pictures. Patients were categorized into 2 groups. Group 1 consisted of subjects receiving only anoscopy, and group 2 consisted of subjects receiving initial colposcopy. Anoscopy in group 1 and colposcopy in group 2 were compared for positive results. A positive result was defined as an additional finding to those obtained by means of gross examination by using the test being evaluated (anoscopy versus colposcopy). Colposcopy and anoscopy were also compared among the subjects receiving both tests. Groups were compared by using a Pearson chi(2) test.

RESULTS

Sixty-seven male sexual assault victims were evaluated between 1991 and 1998. The average age was 26+/-8 years, and the distribution of races was 30% black, 62% white, and 8% Hispanic. Results of gross examination were positive in 42 (63%) subjects. Four patients did not receive either anoscopy or colposcopy. Of the remaining 63, 25 patients had anoscopy only (group 1), and 38 patients had initial colposcopy (group 2). There were no significant differences in age, race, or rate of positive gross examination results between groups. Findings in addition to those obtained by means of gross examination were revealed by means of anoscopy in 8 (32%) of 25 subjects in group 1 and colposcopy in 3 (8%) of 38 subjects in group 2 (P =.03, difference 24%, 95% confidence interval 4% to 44%). In the 36 subjects who had both examinations, the gross examination revealed at least one finding in 22 (61%). The combination of anoscopy and colposcopy yielded positive findings in 17 subjects, including 4 subjects who had no findings on gross examination (increasing the positive rate to 26/36 [72%]).

CONCLUSION

In male sexual assault victims with anal penetration, anoscopy is significantly better for gathering evidence than is colposcopy. The addition of colposcopy and anoscopy increased the rate of cases with positive findings from 61% to 72%. These 2 methods together may be a valuable adjunct in gathering evidence of damage.

Sexual Assault Nurse Examiner programs in the United States

STUDY OBJECTIVE

We sought to provide a descriptive study of the Sexual Assault Nurse Examiner (SANE) programs and their characteristics in the United States.

METHODS

A confidential survey addressing patient and staff demographics, administration attributes, examination procedures, and medical and legal issues was mailed to SANE programs in the United States.

RESULTS

Sixty-one (66%) of 92 programs responded. More than half of the programs (32/58 [55%]) had been in operation for less than 5 years. Thirty (52%) of the 58 programs performed the initial sexual assault examination in hospital emergency departments. Written consent (57/59 [97%]) was obtained for the initial examination, and most (51/59 [86%]) programs used preprepared commercial sexual assault kits. Program directors were predominately registered nurses. All but one program mandated specific training requirements for their staff, with a median requirement of 80 hours. Procedures used for initial examinations varied; most offered pregnancy testing (56/58 [97%]), pregnancy prophylaxis (57/59 [97%]), and sexually transmitted disease (STD) prophylaxis (53/59 [90%]). HIV testing was not offered in 32 (54%) of 59 programs. Almost all programs used Wood's lamp (51/59 [86%]), colposcopes (42/59 [71%]), and photographs (46/59 [78%]) for documentation. Median time required per patient for initial examination and evidence collection was 3 hours (range, 1 to 8 hours). Follow-up is consistently offered to the survivor. Most programs (45/61 [74%]) could report the number of survivors treated, but few could provide information on survivor medical follow-up or the number of prosecutions by survivors and their outcomes.

CONCLUSION

This survey provided an overview of SANE programs. SANE programs are similar across the country with regard to staffing, training, STD and pregnancy prophylaxis, and documentation techniques. They are inconsistent in the use of STD cultures, HIV testing, and alcohol and drug screening. SANE programs were unable to provide data regarding survivor follow-up and legal outcomes. This information is essential to evaluate the programs' effectiveness and to improve performance. The need for better outcome data should be addressed to define success or failure of SANE programs.

Analysis of 1,076 cases of sexual assault

STUDY OBJECTIVE

Rates of sexual assault are increasing, and evidence exists that its demographics and characteristics are changing. The purpose of our study was to describe victim, assailant, assault, and treatment characteristics for sexual assault victims and to provide descriptive data on the evidentiary examination.

METHODS

Prospective data were collected on all sexual assault victims presenting to an urban Level I trauma center from January 1992 to December 1995 for treatment and evidentiary examination. Data from crime laboratory records were retrospectively reviewed.

RESULTS

One thousand one hundred twelve patients presented after a sexual assault. A total of 1,076 (97%) patients consented to the medical and evidentiary examination and were enrolled in the study. Age ranged from 1 to 85 years (mean, 25 years; median, 23 years), with 96% (1,036/1,076) female and 4% (41/1,076) male victims. The number of assailants was greater than 1 in 20% (208/1,044) of cases, and the assailant was a stranger only 39% (409/1,094) of the time. Force was used in 80% (817/1,027) of reported assaults, and in 27% (275/1,014) of cases a weapon was present. Vaginal intercourse was involved in 83% (851/1,023) of female victims. Oral assault was involved in 25% (271/1,053) of all cases, and anal penetration was involved in 17% (178/1,058) of all cases. Overall, general body trauma was seen 67% (621/927) of the time, and genital trauma occurred in 53% (388/736) of cases. Twenty percent (147/1,712) of patients had no trauma noted on examination. Sperm were noted on the emergency department wet mount in only 13% (93/716) of the victims, and of the 612 cases with both ED sperm data and crime laboratory semen data available, evidence of sperm and semen were found 48% (296/612) of the time by either.

CONCLUSION

Health care professionals should be aware that general body trauma is common, that the assailant is often someone known to the victim, and that evidence of semen is commonly found by the crime laboratory even when it is not found in the ED analysis of a wet mount.

Sexual assault

According to recent national studies, one in six women and one in 33 men will experience an attempted or completed rape during their lifetime. Although most rapes are never reported, victims that do report them often present to the emergency department for intervention. The emergency physician must be able to treat acute injuries, accurately collect and record evidence, offer STD and pregnancy prophylaxis, offer emotional support (with the social worker and rape crisis advocate), and provide appropriate referrals for follow-up care. The emergency physician can play a crucial role in easing the transition from victim to survivor with initial treatment. This article summarizes current recommendations for evaluation and treatment of sexual assault victims.

Evaluation of the adolescent rape victim

Adolescents are frequently victims of sexual assault, often by a previously known assailant. This article discusses the initial management of adolescents who have been sexually assaulted, including obtaining the history and performing a careful physical examination, forensic evidence collection, and medical and psychologic therapy.