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

Characterization of male sexual assault in the state of São Paulo, Brazil: an epidemiological study from 2014 to 2017

Sexual violence is a pervasive global issue that affects individuals of all genders. However, the experiences of male survivors have often been marginalized and inadequately represented. Male rape, which encompasses several forms of sexual violence against men, remains a sensitive and under-discussed topic in academic literature and public discourse. This study presents a descriptive cross-sectional analysis based on data collected from the Legal Medicine Institute (IML-São Paulo, Brazil) between 2014 and 2017. The analysis includes 7386 reports of sexological examinations performed on male victims of alleged rape. The analysis reveals that a significant majority of rape reports involved victims under the age of 12 or 14, which is considered vulnerable rape by the Brazilian legislation. Regarding the examination of reported cases of abuse against men, it was observed that only the minority of these cases exhibited visible injuries consistent with rape or tested positive for the presence of spermatozoa in the perianal region. Since the absence of visible injuries or spermatozoa does not negate the possibility of rape, this work highlights the challenges in obtaining conclusive evidence, necessitating a comprehensive approach to investigate and prosecute these crimes, creating a more inclusive and supportive environment for all survivors of rape, irrespective of their gender.

Physical evidence of rape against children and adolescents in Brazil: Analysis of 13,870 reports of sexual assault in 2017

Introduction:

The medical literature reports child and adolescent maltreatment since the 8th century. Unfortunately, even today, the incomplete knowledge of this event persists. Several forms of violence are applied to children and adolescents, mainly sexual violence including rape and sexual assault. Forensic medical examinations routinely include the genital area, anus, and the body of the victims for signs of a recent or old injury. The main goal of this study is to show the results of physical and sexual examinations regarding confirmation of rape in children and adolescents, based on the medicolegal reports.

Methods:

We made a descriptive cross-sectional study conducted by collecting data from Medicolegal Institute (IML-São Paulo, Brazil) in 2017. We examined 13,870 reports of sexological examinations of victims of the alleged rape. The variables analyzed were age; sex; physical examination; sexological examination; and direct search for sperm in the vaginal, anal, or oral cavity. We selected 11,725 reports from victims under 18 years.

Results:

As for the medical-legal findings, only 1735 reports (14.8%) confirmed sexual abuse. The most affected ages were between 3 and 5 years in the male group and 11 to 14 years in the female group. The most frequent injuries were bruises and abrasions, fissures in the anal region. In 96.2% of the examined males and 85.8% of the females under 14 years old, the examination was inconclusive, and somebody cannot prove the alleged rape. Only 1735 reports (113 from men and 1622 from women) concluded beyond any doubt the alleged rape (14.8%). The search for sperm was positive in only 1582 cases (13.5%).

Conclusion:

This study shows that the results of the medicolegal examinations were quite limited in recording evidence. Sexual violence against children and adolescents reaches mostly females under 13 years of age. Besides, it is a complicated crime to prove, as 85.8% of female examinations and 96.2% of male exams revealed: “no supporting elements” or “undetermined” to characterize the felony. Therefore, to prevent it, the communication of the alleged rape must be made as quickly as possible.

Intra- and inter-rater agreement of the Genital Injury Severity Scale

INTRODUCTION

The Genital Injury Severity Scale (GISS) is a clinimetrically-tested tool in use for quantifying and qualifying external genital injury after sexual intercourse.

PURPOSE

To evaluate inter- and intra-rater agreement of the GISS amongst examiner/raters in an urban, ethnically diverse, emergency department based sexual assault center.

METHODS

The study was conducted in three phases. Six examiners with various years of experience rated their own cases and each others' cases greater than one year after the initial exam. They rated the photographs and documentation of each case at least one year apart. Another six raters utilized a combination of the photos and documentation simultaneously from the same cases. The evaluation method was the completion of the GISS for each phase.

RESULTS

Based on the experience level of the rater, the differences in overall agreement were not significant. Strength of agreement was highest with the combination of photos and documentation with W ranging from 0.60501 (substantial) to 0.91056 (almost perfect). The GISS variables with the highest level of agreement were tissue break type and toluidine blue uptake type, both with photo evaluation alone and combination of documentation and photos (W = 0.72051 and 0.74599, respectively).

CONCLUSION

The Genital Injury Severity Scale is a reliable tool to quantify and qualify the severity of external genital injury when used to evaluate a combination of photos and documentation utilizing midlevel providers trained as sexual assault forensic examiners with various years of experience.

[Practical guide to the examination and interpretation of genital lesions of minor female victims of sexual assault]

Through a comprehensive review of the literature on sexual assault, the authors propose to clarify the different stages of the exam and help the practitioner to the forensic interpretation of lesions. The authors describe the basic principles that make consensus in how to interview victims in order to increase the reliability of the information collected. The various medical data that must be collected allowing to guide diagnosis (urogenital symptoms, sexual behaviour disorder) or facilitate the interpretation of lesions (age of puberty, use of tampons…) are specified as well as the different positions of examination and their association to other complementary techniques (Foley catheter, colposcopy, toluidine blue). The authors present a simple decision tree that can help the practitioner to interpret the laceration of the hymen. They detail the description and forensic interpretation of all genital lesions that may be encountered as a result of sexual assault, and the pitfalls to avoid. Finally, two main problems in the interpretation of lesions are described, the absence of injury after penetration and the accidental genital lesions.

Non-obstetric vulval trauma

OBJECTIVE

To describe the mechanism, injury pattern and management of women who present to the ED with non-obstetric vulval trauma.

METHODS

A retrospective, single-institution case series was carried out. Data were sourced from medical records of women who presented to the ED and Royal Brisbane and Women's Hospital between 2007 and 2011. Records of possible injuries to the vulva were assessed to determine incidence, age, site, type of injury, mechanism of injury and whether urinary retention required treatment. This information was analysed using the computer software Statistical Package for the Social Sciences 11.0.

RESULTS

Vulval non-obstetric trauma was found in 19 of 519 cases, resulting in haematoma formation, lacerations, tears or a combination of the three in 16 of the 19 cases. Injuries were due to falling astride a firm object, consensual coitus, sexual assault, cold waxing and tight clothing. Urinary retention occurred in three cases. Site of injury, whether anterior or posterior, was evenly distributed irrespective of the mechanism of injury. Haematomas were treated conservatively and bleeding lacerations sutured. None required resuscitation.

CONCLUSIONS

Non-obstetric vulval injuries are uncommon (incidence 3.7%). All cases require assessment for vaginal, urethral, anal and bony pelvis injuries. This might require examination under anaesthesia. Conservative management of haematomas in the absence of acute haematoma expansion is favoured. The need to screen for sexually transmissible infections and pregnancy is important. Social worker and psychological support is important to reduce the incidence of long-term psychological problems.

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.

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.