Comparative prevalence of anogenital injury following sexual assault in women who have had recent consensual sexual contact.

OBJECTIVE: The purpose of this study was to compare the frequency and types of anogenital trauma in rape victims as a function of the time interval between the assault and recent (72 h) consensual sexual intercourse. METHODS: This retrospective cohort trial evaluated consecutive female patients, age 13 years or older, presenting to a community-based nurse examiner clinic (NEC) during a 5-year study period. The NEC facility is staffed by forensic nurses trained to perform medical-legal examinations using colposcopy with nuclear staining and digital imaging. Eligible patients were classified into five different groups based on the time interval from the last consensual intercourse to the forensic examination (none, 0-24 h, 25-48 h, 49-72 h, 73-96 h). Patient demographics, assault characteristics, and injury patterns were recorded using a standardized classification system. RESULTS: A total of 947 cases of sexual assault met the inclusion criteria and were divided into five groups. The age range was 13 to 87 years (mean, 23.9 years); 78% were examined within 24 h following sexual assault. The five study groups were comparable in terms of demographics, assault history, and incidence of non-genital injuries. The overall frequency, type, or location of anogenital injury did not vary significantly between groups (p > 0.5). CONCLUSION: This is the first clinical study to systematically compare the prevalence and typology of anogenital injuries in sexual assault victims who have had consensual intercourse within four days before a forensic exam. The frequency, type or location of anogenital trauma did not vary significantly based on the time interval from last consensual intercourse to the forensic examination.

Assailants' sexual dysfunction during rape: prevalence and relationship to genital trauma in female victims.

BACKGROUND: Partial or complete failure to maintain an erection sufficient for coitus is known to occur in a proportion of sexual assailants during the rape episode. OBJECTIVE: The purpose of this study was to determine whether the presence of coercion, physical violence, and genital injury associated with sexual assaults is influenced by the assailant's erectile impotence. METHODS: This prospective, observational study evaluated consecutive female patients presenting to a free-standing urban sexual assault clinic during a 3-year study period. Sexual assault victims presenting directly to four downtown emergency departments (EDs) are routinely referred to the clinic for evaluation after triage and initial assessment. The clinic is associated with a university-affiliated emergency medicine residency program and is staffed by forensic nurses trained to perform medical-legal examinations. The primary outcome was to compare the frequency of anogenital findings documented in women whose assailant experienced no erectile dysfunction vs. those victims who reported erectile impotence in the assailant. RESULTS: During the study period, 569 sexual assault victims were eligible to participate in the study; 47 (8.3%) reported that their assailants had experienced erectile impotence. Except for assailant age, the two victim groups were comparable in terms of marital status, alcohol and drug use, known assailant, and time to physical examination. In attacks where erectile dysfunction occurred, there was a higher incidence of physical coercion (60% vs. 32% without physical coercion, p < 0.001) and subsequent non-genital trauma (72% vs. 46%, respectively, p < 0.001). Thirty-two women (68%) had documented anogenital trauma despite the assailant having erectile dysfunction. There was no significant difference in the overall pattern of anogenital injury between the two groups (chi(2) = 9.1, p = 0.036). CONCLUSION: Erectile impotence occurred in up to 8% of sexual assailants during the rape episode. Despite this erectile dysfunction, the majority of sexual assault victims sustained anogenital trauma. In the attacks with erectile impotence, there was a higher incidence of intra-rape violence and subsequent non-genital injuries.

Sexual assault in postmenopausal women: epidemiology and patterns of genital injury.

STUDY OBJECTIVE: Physical abuse of older women, including reports of sexual assault, has risen rapidly for the last decade. The purpose of this study was to compare a group of postmenopausal victims of sexual assault with younger adult women (18-39 years old) by examining patient demographics, assault characteristics, and patterns of physical injury. METHODS: We conducted a retrospective cohort analysis to assess epidemiology and anogenital injuries in consecutive female victims presenting to sexual assault clinics and/or emergency departments within 3 counties of Western Michigan. All patients were examined by forensic nurses trained to perform medicolegal evaluations using colposcopy with nuclear staining. Patient demographics, assault characteristics, and injury patterns were recorded using a standardized classification system. Data from 2 patient groups (women aged 18-39 years vs postmenopausal women >or=50 years) were compared using chi(2) and t tests. RESULTS: During the 5-year study period, 1917 adult sexual assault victims met the inclusion criteria and comprised the study population as follows: 84% of the victims were 18 to 39 years old, and 4% were postmenopausal women at least 50 years old. The 72 postmenopausal victims were more likely to be assaulted by a single assailant, typically a stranger (56% vs 32%, P = .008), in their own home (74% vs 46%, P < .001) and experienced more physical coercion (72% vs 36%, P < .001). In comparison, the younger control group was more likely to have used alcohol or illicit drugs before the assault (53% vs 18%, P < .001) and have a history of sexual assault (51% vs 15%, P < .001). Postmenopausal victims had a greater mean number of nongenital (2.3 vs 1.2, P < .001) as well as anogenital injuries (2.5 vs 1.8, P < .001). The localized pattern and type of physical injuries were similar in both groups, although postmenopausal women tended to have more anogenital lacerations and abrasions. CONCLUSION: The postmenopausal woman is not immune from sexual assault. The epidemiology of sexual trauma in this age group is uniquely different when compared to younger women, which may be useful in planning intervention and prevention strategies.

Why women don't report sexual assault to the police: the influence of psychosocial variables and traumatic injury.

The purpose of this study was to identify the variables that acutely influence reporting practices in female sexual assault victims presenting to an urban clinic or Emergency Department. We conducted a cross-sectional survey of consecutive female victims during an 18-month study period. Patient demographics, assault characteristics, and injury patterns were recorded in all eligible patients using a standardized classification system. At the completion of the forensic examination, victims were asked to complete a psychosocial questionnaire designed to determine specific reasons why women reported or did not report their sexual assault to police. During the study period, 424 women were eligible to participate in the study; 318 (75%) reported the sexual assault to police. One hundred six (25%) did not file a police report, but consented to a medical-legal examination. Women not reporting sexual assault were typically employed, had a history of recent alcohol or drug use, a known assailant, and prolonged time intervals between the assault and forensic evaluation (p < 0.001). There were no differences in the extent of non-genital injuries or anogenital injuries between the two groups. Thirty-six percent (152/424) of the eligible population agreed to complete the questionnaire. Only three of the 20 psychosocial variables examined were found to be significantly different in women not reporting sexual assault compared to reporters. The reasons for not reporting were primarily environmental factors (prior relationship with assailant) rather than internal psychological barriers (shame, anxiety, fear).

Comparison of sexual assaults by strangers versus known assailants in a community-based population.

The medical literature has generally supported the view that sexual assaults by strangers are more serious and more violent than assaults by people known to the victims. This retrospective study was conducted to compare characteristics of sexual assaults by strangers and those by people known to the victims in a community-based population of women. Study patients were consecutive female patients, age 13 years or older, presenting to a sexual assault clinic during a 40-month study period. The clinic is associated with a university-affiliated emergency medicine residency program and is staffed by forensic nurses trained to perform medical-legal examinations using colposcopy with nuclear staining. Case files of 849 patients were reviewed; the age range was 13 to 82 years (mean, 22.5 years). Sexual assault by a person known to the victim accounted for 646 (76%) cases. The majority of these assailants (68%) were described as acquaintances; 139 (21%) were current or previous boyfriends or spouses; 33 (5%) involved other family members. Sexual assault by a stranger was more likely to occur in the home of the victim (43% v 28%, P < .001), involve weapons or physical coercion (58% v 31%, P < .001), and was associated with more non-genital injuries (61% v 40%, P < .001). However, the overall frequency of anogenital trauma (77% v 71%, P = .10), the mean number of anogenital injuries (2.0 v 2.3, P = .05), and the types of genital trauma were similar in both groups of women. These results demonstrated that 71% of the victims of acquaintance rape sustain anogenital trauma and that these injuries may be as extensive as those caused by unknown assailants.

Significance of toluidine blue positive findings after speculum examination for sexual assault.

To determine the incidence of toluidine blue positive findings after speculum examination of sexual assault victims, we performed a prospective before and after study of 27 female patients presenting after sexual assault to a free-standing nurse examiner clinic. Before the insertion of a speculum, a 1% aqueous solution of toluidine blue was applied to the posterior fourchette and photographs were taken using colposcopy with digital imaging (16 x magnification). After the forensic examination was completed, dye was reapplied. Photographs taken before and after speculum examination were reviewed by three EM physicians for superficial lacerations or abrasions. Before speculum examination, genital injuries from sexual assault were documented in 67% of the patients (mean number of genital injuries, 1.4). After speculum examination, one patient (3.7%) demonstrated a new genital injury-an abrasion to the labia. Until further studies are performed, use of a speculum should be delayed until after toluidine dye application.

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.

Anogenital injuries in adolescents after consensual sexual intercourse.

OBJECTIVES: To compare the types and locations of anogenital injuries occurring in adolescent females (13-17 years old) after consensual and nonconsensual sexual intercourse. METHODS: The authors conducted a retrospective, matched case-control study to assess anogenital injuries in female adolescents presenting to a free-standing nurse examiner clinic during a four-year study period. Adolescents were selected for inclusion in the study if they reported consensual sexual intercourse (CSI) and agreed to a medical-legal examination. Control subjects were victims of alleged sexual assault or nonconsensual sexual intercourse (NCSI) matched to cases by age and prior sexual intercourse experience. Genital trauma was documented using colposcopy with nuclear staining and digital photography. Data were analyzed using chi-square and t-tests. RESULTS: Fifty-one cases of CSI were identified; the age range was 13 to 17 years (mean=15.1 years). Overall, 49% (25/51) of CSI subjects reported no prior sexual intercourse experience. CSI and NCSI were comparable in terms of race, time to physical examination, alcohol use, and frequency of genital injuries (73% vs. 85%, p=0.069). The mean number of documented anogenital injuries in CSI subjects was 1.9 +/- 1.5. These injuries commonly involved the hymen, fossa navicularis, and posterior fourchette. CSI subjects had a greater number of anogenital injuries (2.6 +/- 2.0; p=0.02), typically involving the fossa navicularis, labia minora, and hymen. The most common type of injury in both groups was lacerations (39% vs. 41%); however, NCSI subjects had a greater incidence of anogenital abrasions, ecchymosis, and edema (chi2=10.4, p=0.035). CONCLUSIONS: Anogenital trauma was documented in 73% of adolescent females after consensual sexual intercourse versus 85% of victims of sexual assault. The localized pattern and severity of anogenital injuries were significantly different when compared with victims of sexual assault.

Adolescent Foley catheter technique for visualizing hymenal injuries in adolescent sexual assault.

OBJECTIVES: To determine the usefulness of the Foley catheter balloon technique for visualizing injuries of the estrogenized hymen in adolescent sexual assault victims compared with supine labial traction. METHODS: A prospective clinical trial of 20 adolescent (age 13-16 years old) victims of sexual assault evaluated at a free-standing Nurse Examiner Clinic was conducted over a four-month study period. The clinic, affiliated with an emergency medicine residency program, is staffed by registered nurses who have been specially trained to perform medicolegal examinations using colposcopy with digital imaging. The Foley catheter technique uses an inflated balloon in the distal vaginal vault to expand the estrogenized hymen to its full capacity so that the edge may be readily visualized for signs of trauma. The Foley technique was compared with gross inspection, using supine labial traction, to photodocument hymenal abnormalities. Photographs of the hymen were obtained using the labial traction technique and then with the Foley technique. Three emergency physicians independently examined each pair of photographs with high interrater agreement for the presence of injury (kappa = 0.88). RESULTS: Twenty adolescent sexual assault victims volunteered for the study; mean age was 14.8 years. Gross inspection of the hymen using supine labial traction identified hymenal injuries in three patients (15%). Use of the Foley catheter balloon technique allowed identification of hymenal abnormalities in nine additional cases (60%). The common injuries to the hymen included lacerations (30%), followed by ecchymosis and abrasions. One patient (5%) voiced discomfort (mild pressure sensation) during inflation of the balloon. CONCLUSIONS: The Foley catheter balloon technique is a simple method allowing improved photodocumentation of hymenal trauma in adolescent sexual assault victims compared with supine labial traction.

Comparative analysis of adult versus adolescent sexual assault: epidemiology and patterns of anogenital injury.

OBJECTIVES: To compare the characteristics of sexual assault in pubertal girls (<18 years old) and adults in a community-based population of women presenting to an urban sexual assault clinic. METHODS: This case-series analysis evaluated consecutive female patients presenting to a sexual assault clinic during a three-year study period. The clinic is associated with a university-affiliated emergency medicine residency program and is staffed by forensic nurses trained to perform medicolegal examinations using colposcopy with nuclear staining. Patient demographics, assault characteristics, and injury patterns were recorded using a standardized classification system. Data from the two patient groups (adolescents vs. women > or =18 years of age) were analyzed using chi-square test and t-test. RESULTS: A total of 766 cases were identified: 43% of the victims were 13 to 17 years old (mean 15.0 years old), and 57% were older than 17 years old (mean 30.8 years old). Adolescents were more likely to be assaulted by an acquaintance or relative (84% vs. 50%, p < 0.001) and to delay medical evaluation (17 hours vs. 12 hours, p < 0.001) than were older women. Adolescent sexual assault was less likely to involve weapons or physical coercion (29% versus 57%, p < 0.001) and was associated with fewer nongenital injuries (33% vs. 55%, p < 0.001). Adolescents had a greater frequency of anogenital injuries (83% vs. 64%, p < 0.001), however, compared with older women. Common sites of injury in adolescents were posterior, including the fossa navicularis, hymen, fourchette, and labia minora. The injuries showed consistent topologic features, varying with the site and nature of tissue. Adult victims of sexual assault had a less consistent pattern of anogenital injuries with fewer hymenal injuries, greater injury to the perianal area, and widespread erythema. CONCLUSIONS: Of women presenting to an urban sexual assault clinic, 43% were adolescents. The epidemiology of sexual trauma and the pattern of anogenital trauma in this age group are unique and may pose special challenges to emergency health care providers.