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.     

Sexual Assault Nurse Examiner (SANE) Program Goals and Patient Care Practices

PURPOSE: To examine Sexual Assault Nurse Examiners (SANE) programs' goals and guiding philosophies and how they influence patient care practices for sexual assault victims. DESIGN: Data were collected from a national random sample of SANE to examine whether programs differed significantly in their goals and patient care practices. METHODS: Iterative cluster analysis was used to identify types of programs distinct in their stated goals. FINDINGS: Three types of emphasis in SANE programs were identified: (a) prosecution of cases as a primary goal; (b) attending to patients' emotional needs, supporting feminist values, empowering patients, and changing the community response to rape; and (c) least importance on prosecution of cases and average importance on the other goals. Programs that were more focused on prosecution goals provided less comprehensive patient services. CONCLUSIONS: Programs focused on prosecution as a primary goal were less likely to provide comprehensive services, especially those involving patient education. Such information is important for patients because their health concerns (e.g., pregnancy, STIs) have long-term implications for their well-being. Historical and structural differences among SANE programs might explain these different patient care practices. Researchers should examine the underlying processes in SANE programs that shape both their goals and patient care approaches.     

Predictors of injury associated with rape

The purpose of this study was to assess predictors of injury in a preliminary model with victim and forensic characteristics as variables. Assessment of predictors will fill gaps in the literature, help clinicians improve data-gathering methods, and identify characteristics associated with rape-related injury of women who may be at higher risk for subsequent poor health.     

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.     

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 (χ² = 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.     

Organizational characteristics of Sexual Assault Nurse Examiner programs: results from the national survey project

A random sample of representatives from Sexual Assault Nurse Examiner (SANE) programs throughout the United States were contacted to participate in in-depth telephone interviews about program operations and services for sexual assault patients. Programs that had been in operation 5 years or less at the time of this study are compared to older programs to examine trends.     

Health Care Seeking and Engagement After Sexual Assault

Sexual assault (SA), which affects up to 20% of women, is associated with chronic physical and emotional health disorders. Although SA victims/survivors are less likely to seek health care, less is known about the specific barriers and facilitators in health care seeking and engagement. The purpose of this study was to learn the barriers and facilitators from victims/survivors. Data were collected using semistructured interviews. Constructivist coding was used in data analysis. Barriers were reminders of sexual assault, male health care providers, and loss of control with disclosures. Facilitators were health care providers who were empathetic, knowledgeable, and female.     

Emergency Department Characteristics of Male Sexual Assault

OBJECTIVE: To characterize the nature, frequency, and treatment of male sexual assault encountered by physicians in an ED. A minor objective compared the lengths of time the victim knew the assailant between males and females to determine whether there were differences between male and female victims. METHODS: Retrospective review over four years of all male patients with a diagnosis of sexual assault presenting to an urban academic ED in New York City. Demographics, types of injury, assailant/victim information, and treatment of the assault were obtained. RESULTS: Twenty-seven male sexual assaults (approximately 12% of all sexual assaults) were documented during this time period. Forcible rectal, oral, or both rectal and oral intercourse occurred 14, 4, and 9 times, respectively. Documented physical trauma occurred in nine of 27 visits, with two admissions for head trauma. Five additional patients complained of rectal pain with no independent objective evidence of trauma. Prophylactic treatment with antibiotics for the prevention of Neisseria gonorrhoeae and Chlamydia trachomatis was offered in 26 of 27 episodes and prophylactic HIV protection was given to only two of 21 eligible patients. Documentation of HIV status and HIV counseling occurred only in ten and five visits, respectively. The male-to-female odds ratios for whether the assailant was unknown, known less than 24 hours, or known more than 24 hours were 0.43 (95% CI = 0.15 to 1.26), 2.48 (95% CI = 0.94 to 6.53), and 0.92 (95% CI = 0.31 to 2.71), respectively. CONCLUSIONS: The percentage of total sexual assaults occurring in males who present to an ED is now more than 10% of all sexual assaults seen in this urban ED. These assaults are associated with a high proportion of patients with documented trauma. Although the treatment of traditional sexually transmitted diseases appears to be covered well, the need for HIV documentation, counseling, and possible HIV prophylaxis should be addressed more aggressively. In comparing the lengths of the relationships between the victim and the assailant, it appears twice as likely that the female victim will not know her assailant compared with the male, and twice as likely that the male victim will know his assailant less than 24 hours compared with the female.     

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.     

Genital findings of women after consensual and nonconsensual intercourse

After a sexual assault, forensic nurses, nurse practitioners, and physicians are called on to collect evidence, document any genital injuries, and testify about the significance of injuries. Recently, the scientific rigor of the research has been challenged in the courts.     

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.     

HIV Postexposure Prophylaxis in Sexual Assault: Current Practice and Patient Adherence to Treatment Recommendations in a Large Urban Teaching Hospital

Background: Although rare, HIV transmission is one of the most feared consequences of sexual assault. While availability of medications to prevent HIV transmission (HIV nonoccupational postexposure prophylaxis [HIV nPEP]) is increasing, little is known about emergency department (ED) prescribing practices and patient adherence to treatment recommendations. Objectives: To determine factors associated with offering, following up with, and adhering to treatment when HIV nPEP is initiated for sexual assault victims. Methods: This was a retrospective chart review of female patients presenting with complaint of sexual assault to an urban ED from October 1, 1999, to September 30, 2002. HIV nPEP medications and/or follow‐up were provided without charge. Chi‐square analysis identified factors associated with being offered or referred for nPEP and follow‐up. Variables significant at the p < 0.10 level were entered into logistic regression analysis. Results: Two hundred twenty‐nine charts were reviewed. The final sample size was 181. Mean age was 29.1 years; median time from assault to presentation was 10.1 hours; 51.5% of the assailants were known to the victims. HIV nPEP was offered to 89 (49%) patients, and 11 patients were referred to an HIV nurse. Eighty‐five (85%) patients accepted, 38 of these 85 (45%) followed up, and 18 of the 85 (21%) completed treatment. In multivariate analysis, three variables were statistically significantly associated with increased likelihood of referral or being offered HIV nPEP: unknown assailant, having insurance, and younger age. Treatment was completed by 15 of 82 (18%) of ED‐initiated patients, versus three of three (100%) referred for initiation. The authors were unable to identify factors associated with completing treatment. Conclusions: HIV nPEP was offered to less than half of sexual assault patients, and few completed treatment. Further studies are needed to evaluate and improve appropriateness of HIV nPEP administration and follow‐up.     

Using Trauma-Informed Care to Address Sexual Assault and Intimate Partner Violence in Primary Care

Interpersonal trauma has long-lasting effects on mental and physical health and is associated with acute and chronic negative health outcomes. Primary care providers can improve health care outcomes by using trauma-informed care to recognize, acknowledge, and respond appropriately to trauma survivors. Routine trauma screening in the primary care setting should be done in a safe environment and with a team approach. This article will offer guidance on screening for and responding to sexual assault and intimate partner violence using trauma-informed principles with the goal of promoting health and healing for survivors.     

Preventing Sexual Abuse and Assault

This article reviews prevention of sexual abuse and assault from a public health approach. The public health approach identifies three levels of prevention: primary, secondary, and tertiary. Several programs are reviewed in the area of primary prevention. The article discusses the efficacy of different approaches. Information from offenders and victims is reviewed to gain insight into primary prevention approaches. Review of innovative approaches to secondary prevention are introduced. This section focuses on changing the behavior of potential offenders rather than changing the behavior of potential victims. Special consideration is given to the role of alcohol in abuse and possible prevention strategies to reduce abuse risk by reducing high-risk alcohol use. Discussion of intervention strategies and offender characteristics are reviewed to address tertiary prevention.     

Exploring the similarities and differences amongst service users with and without learning disabilities attending Saint Marys Sexual Assault Referral Centre

Background

People with learning disabilities are over-represented amongst Sexual Assault Referral Centre service users. This work aims to explore the similarities and differences between service users with and without learning disabilities.

Method

Medical notes of 52 service users likely to have a learning disability were compared with 52 service users not likely to have a learning disability (according to the Learning Disability Screening Questionnaire); all of whom attended Saint Marys SARC for a forensic medical examination during a 12-month period.

Results

Significant associations were found between the likelihood of learning disability and relationship to perpetrator; location of assault; alcohol use; time taken to present to SARC; domestic violence; self-harm; suicide attempts and mental health service involvement.

Conclusions

People with learning disabilities in the sexually assaulted population are more likely to present with intersecting vulnerabilities emphasising the need for timely, accessible and appropriate patient-centred care for this group.