Sexual assault in postmenopausal women.

OBJECTIVE: To examine patient characteristics, patterns of injury, forensic evidence, and the frequency of sexual assault in postmenopausal rape victims from 1986-1991. METHODS: Medical and forensic records were reviewed from 129 postmenopausal women (50 years of age or older) and 129 women from a comparison group (14-49 years of age) who reported having been sexually assaulted. Statistical analysis was performed by Student t test, chi 2, multiple logistic regression, or Fisher exact test. RESULTS: Postmenopausal women represented 2.2% of women reporting sexual assault in Dallas County. The postmenopausal victim was more often white (64%), whereas the younger victim was more often black (53%). Drug or alcohol use within the previous 24 hours was more common in the younger group. Trauma, in general, was common, occurring in 67% of the postmenopausal women and 71% of the younger group (P = not significant). Genital trauma was more common in the postmenopausal group (43 versus 18%; P < .001). Nearly one in three postmenopausal women had genital abrasions or edema. Almost one in five older women had genital lacerations, with one in four severe enough to require surgical repair. In contrast, the frequency of extragenital trauma was more common in younger victims (66 versus 49%; P < .01). Forensic findings were similar in both groups; however, in postmenopausal women motile spermatozoa were seen only in those examined within 6 hours of the assault. CONCLUSION: Postmenopausal women who have been sexually assaulted are more likely to sustain genital trauma than younger victims.     

Ultrasound prediction of fetal weight in prolonged pregnancy

In this study we applied two commonly used birth weight prediction equations to a sample of 121 women with prolonged pregnancies. Subjects had sonographic measurements of biparietal diameter and abdominal perimeter taken within 2 days of delivery at Parkland Memorial Hospital. Although the two prediction equations were obtained from a population of women in New Haven, Connecticut, who delivered over a wide range of gestational ages, when the equations were applied to the sample of prolonged pregnancies in Dallas, Texas, there was a strong correlation (0.71) between predicted and actual birth weight. Moreover, reestimation of the New Haven equations with use of the Dallas data yielded similar regression coefficients. Finally, birth weight prediction equations for black, white, and Hispanic patients in Dallas were not significantly different. These findings suggest a remarkably constant relationship between fetal head and abdominal dimensions and birth weight over different gestational ages and for different population groups.     

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.     

Introducing colposcopy and vulvovaginoscopy as routine examinations for victims of sexual assault

Victims of sexual assault require appropriate care, follow-up and information regarding their legal rights. Clinicians are faced with the challenging responsibility of identifying victims and providing effective interventive and preventive counselling. The most pressing medical task is to confirm the assault and to undertake correct documentation and exhibition of biological traces. Performing colposcopy and vulvovaginoscopy does not allow us to diagnose a sexual assault trauma, but it can help us to identify those microscopic lesions (due to the enhanced visualization and the higher resolution under which the genital areas are examined) that may not be seen during a normal clinical examination. The colposcopic and vulvovaginoscopic examination starts from the vulvar region looking for superficial lacerations and ecchymosis; the labia majora and minor are examined scrupulously, then the posterior forchette, the perineum and the hymen where it is possible to report microulcerations, contusions and even possible scars due to a precedent defloration. Recent advances in clinical forensic medicine show that trained examiners using colposcopy obtain evidence of genital trauma in 87% to 92% of rape victims. Colposcopy and vulvovaginoscopy must be performed within 48 hours from the sexual assault, because most of the lesions heal rapidly. Colposcopy and vulvovaginoscopy may be seen as a stressful invasion of a woman who is already vulnerable and at risk of the rape trauma syndrome. Prior information about colposcopy may reduce the level of anxiety experienced by many women undergoing this procedure. Incorporating colposcopy and vulvovaginoscopy into the routine assessment of sexual assault victims could be a valid way of identifying genital injuries; moreover the medical report will be more detailed and precise.     

Legal outcomes of sexual assault

OBJECTIVE: The study was undertaken to better describe the assault characteristics and examination findings in sexual assault victims who pursue legal action. STUDY DESIGN: A case-control study of consecutive women older than 15 years who came to an urban hospital after sexual assault over a 32-month period was conducted. All the women underwent a standardized history and physical examination by a resident in obstetrics and gynecology. Cases were those in which charges were filed against an assailant by the prosecutors' office. The controls were the women assaulted immediately preceding and after each case. RESULTS: Of the 888 women undergoing evaluation in the emergency department, 132 (15%) had charges filed by the prosecutor. Characteristics positively associated with a legal outcome included being examined within 24 hours after assault, partner/spouse as an assailant, oral assault, and anogenital trauma (P <.05,.01,.05,.05, respectively). Amnesia at the time of assault and/or friend/acquaintance as assailant were negatively associated with a legal outcome (P <.01,.05, respectively). CONCLUSION: Although only 15% of sexual assault cases were resolved with a legal outcome, the data support the importance of a physical examination within 24 hours of the assault. Anogenital trauma is associated with, but not a prerequisite for, a successful legal outcome.     

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.     

Adult victims of sexual assault: acute medical response and police reporting among women consulting a center for victims of sexual assault

BACKGROUND: The medical response to adult sexual assault should comprise: the collection of forensic evidence, the treatment of injuries, and follow-up counselling. In the past, victims of sexual assault reporting directly to the police may not have received this total medical care. The Copenhagen Center for Victims of Sexual Assault at Rigshospitalet, Denmark offers a 24-h service. Medical treatment and psychosocial follow up is offered independent of police reporting. The aim of this study was to assess whether adult sexual assault victims who reported to the police differed from those who did not report to the police. METHODS: Using clinical records, sociodemographics, characteristics of the assault, and type of preventive medical treatment received were obtained for 156 consecutive women consulting the Copenhagen Center (March 1st to December 31st 2000). Comparisons between characteristics of victims who reported to the police or not were determined. RESULTS: Ninety-four (60.2%) of the women reported to the police. Women who sought services within 24 h of the assault, had experienced use of force, were subjected to assault outdoors, and among whom nongenital injuries were observed were more likely to report to the police (p < 0.05). However, in the multivariate model these associations fell below significance, and only the type of perpetrator remained significantly related to police reporting. The adjusted odds ratio for police reporting when the perpetrator was a friend was 0.4 (95% CI 0.17-0.94). There was no statistical difference between the victims who did or did not report to the police to request prophylactic antibiotics or emergency contraception. CONCLUSION: Observed injuries and requests for prophylactic antibiotics or emergency contraception were not influenced by whether the woman did or did not report directly to the police. Hence the need for medical treatment appears to be similar in the two groups, and available specialized care for victims of sexual assault should not be restricted to those who immediately report to the police.     

Renal arterial Resistance Index in pregnant and nonpregnant women: evaluation with color and pulse Doppler ultrasound.

The Resistance Index (RI) was studied in the main renal arteries in normal nonpregnant women and its change during normal pregnancy. One hundred and seventy color and pulse Doppler sonographic examinations were performed on 31 nonpregnant and 54 pregnant women. The range of gestation was 5-39 weeks, and patients divided into three groups; 5-12, 13-25 and 26-39 weeks of pregnancy, respectively. The RI was calculated in both main renal arteries. In nonpregnant women the left main renal artery RI mean = 0.587 +/- 0.021, and the right main renal artery RI mean = 0.584 +/- 0.028. In pregnant women the left main renal artery RI mean was 0.681 +/- 0.029, and the right main renal artery RI mean was 0.697 +/- 0.034. There was a significant difference between the main renal artery RI in pregnant and nonpregnant women (P less than 0.01). There was no significant difference between left and right main renal artery in pregnant and nonpregnant women (P less than 0.01). There was no correlation between gestational age and RI in the right main renal artery but a statistically significant correlation with gestational age in the left main renal artery (P less than 0.05).     

Lifetime and current sexual assault and harassment victimization rates of active-duty United States Air Force women

From a stratified random sample, 2,018 active-duty United States Air Force women completed a telephone survey dealing with sexual assault and harassment. The lifetime prevalence of rape among Air Force women (28%) was more than twice as high as the prevalence in a national sample (13%). Nearly half of the military sample had been the victims of rape, molestation, or attempted sexual assault. The majority of both initial rapes (75%) and most recent rapes (56%) involved assault by civilians when the victims were civilians. Family members perpetrated 29% of initial rapes and 33% of most recent rapes. Regarding military status of the perpetrator, 14% of first-time victims were raped by a military member, 26% of multiple-time victims were raped by a military member, 31.8% of military women were sexually harassed by a military supervisor or boss, and 26.7% of military women were sexually harassed by a military coworker.     

Adolescent Sexual Assault: Documentation of Acute Injuries Using Photo-colposcopy

OBJECTIVE: To document the frequency and types of genital injuries in adolescent women examined acutely following a sexual assault, and determine any historical correlates of injury. DESIGN: Retrospective chart review.Setting: Sexual Assault Response Team services at a community hospital in an urban setting. PATIENTS: All female patients aged 14-19 yr who were referred by law enforcement for an acute sexual assault examination and were examined between May 1994 and May 1999. OUTCOME MEASURES: The frequency of signs of genital trauma at various anal and genital sites, as recorded by the examining clinician. RESULTS: Charts of 214 female subjects (mean age 16.3 yr) were reviewed. The most common findings were posterior fourchette tear (36%); erythema of the labia minora, hymen, cervix, or posterior fourchette (18%-32%); and swelling of the hymen (19%). Time to examination was highly correlated with the degree of injury noted (P =.000). The incidence of hymenal tears in self-described virgins was higher than in nonvirgins (19% vs. 3%, P =.008); however, the total number or severity of other injuries was not significantly higher in virgins. Victims reporting anal penetration had a higher frequency of anal injuries than those who denied such contact (14/31, 61% vs. 2/150, 1%; P =.000). CONCLUSIONS: Tears of the posterior fourchette or fossa were the most common findings (40%). Hymenal tears were uncommon, even in self-described virginal girls. Timely examination of adolescent victims is important to document injuries; however, many victims will still not have signs of bruising, abrasions, or tears.     

Adolescent sexual assault: an update of the literature

PURPOSE OF REVIEW: In this review, we examine the most recent literature on adolescent sexual assault, and summarize new findings regarding prevalence, risk factors, sequelae, cultural factors, genital injury, legal issues and practice implications. RECENT FINDINGS: Child and adolescent sexual-assault victims are at risk for a range of negative outcomes, including comorbid post-traumatic stress disorder and major depressive episode, comorbid post-traumatic stress disorder and substance abuse, eating disorders, delinquency, and revictimization. Cultural factors and severity levels of trauma may serve as risk factors to such outcomes in adolescent sexual-assault victims. Compared with adults, adolescent sexual-assault victims have a greater frequency of rape-related anogenital injuries, but data on healing of injuries in this population are lacking. Factors related to a child sexual-assault victim's demeanor and intelligence can influence the perceived credibility of the child as a witness to the abuse. SUMMARY: Recent studies investigating prevalence, risk factors, and sequelae of child and adolescent sexual assault highlight the need for educational programs and primary prevention interventions to educate pre-pubescent children and adolescents about sexuality, including sexual assault. In addition, further research is warranted in the area of statutory rape reporting to determine its effects on adolescent health-service-seeking behaviors and outcomes. Although most adolescent sexual assault victims do not seek acute post-rape medical care, forensic nurse examiners are often the first clinicians to encounter the adolescent sexual assault victim. Nursing protocols that standardize evidence collection as well as psychological support are important in the comprehensive care of these traumatized teens.     

Case Series: Vaginal Rupture Injuries after Sexual Assault in Children and Adolescents

BackgroundVaginal rupture after sexual assault is a rare but life-threatening occurrence requiring prompt recognition and treatment. Herein, we describe four such cases in children. Our purposes are to increase clinicians' awareness of the physical trauma that a sexual abuse victim can suffer and increase recognition that these victims require immediate trauma services.CasesEach patient had obvious hymenal and vaginal lacerations with a vaginal apical rupture injury and secondary acute blood loss. None of the four victims sustained infectious sequelae.Summary and ConclusionProviders should have a low threshold for managing sexual abuse victims as trauma cases when they have obvious hymenal and vaginal lacerations and genital bleeding, proceeding expeditiously to examination using general anesthesia when appropriate.     

Seroprevalence and risk factors for hepatitis C virus antibody in pregnant women.

OBJECTIVE: To better understand hepatitis C viropathies and seroprevalence by performing an epidemiologic analysis of pregnant women seropositive for antibody against hepatitis C. METHODS: We studied 1013 consecutive obstetric patients at Parkland Memorial Hospital who gave informed consent for detailed interviews and serotesting. Sera were analyzed for antibody to the hepatitis C virus using both C100-3 and RIBA-4 assays. Neonatal assessment was carried out in the immediate postpartum period. RESULTS: Hepatitis C antibody was detected in 2.28% (N = 23) of the 1005 women in whom analysis was completed. Factors associated with seropositivity included intravenous (IV) drug use, sexually transmitted diseases, hepatitis B infection, maternal age greater than 22.5 years, increased parity (eg, greater than 2.1), history of transfusion, and three or more different lifetime sexual partners or a sexual partner who used IV drugs. Maternal and neonatal outcome was not different between hepatitis C antibody-positive and -negative groups. CONCLUSIONS: Epidemiologic data are consistent with sexual and parenteral modes of transmission. Women with hepatitis C antibody did not have excessive perinatal complications compared with antibody-negative women. A model protocol and cost analysis for screening pregnant women for hepatitis C infection are presented. However, routine screening for hepatitis C is not advocated.     

Long-term Hospitalization of Women with High-risk Pregnancies A Nurse''s Viewpoint

The addition of high-risk pregnancy units to perinatal care systems provides a setting for daily maternal-fetal surveillance during complicated pregnancies. These units permit safe prolongation of pregnancy when the fetus is immature and timely delivery when either the mother's or infant's health is in jeopardy. Hospitalization also encourages maternal rest with its beneficial effects during complicated pregnancy. Nursing functions and goals as developed in the High-risk Pregnancy Unit at Parkland Memorial Hospital in Dallas, Texas, are presented.     

Prevalence of human papillomavirus infections in term pregnancy

The prevalence of human papillomavirus (HPV) infections in the lower genital tracts of pregnant and nonpregnant women was studied. Cervical and vaginal exfoliated cells were obtained during a routine pelvic examination in 45 pregnant women in early labor, and in 44 nonpregnant women. A detailed questionnaire with emphasis on sexual history and sexually transmitted diseases was administered. The two groups of women were comparable with respect to mean age, prior pregnancy experiences, and number of lifetime sexual partners. Compared with pregnant women, the nonpregnant women had a more frequent history of sexually transmitted diseases (61% versus 39%; p = 0.06), and of genital warts (16% versus 0%; p = 0.01). Utilizing Southern transfer and hybridization with 32P-labeled viral DNA probes for HPV types 6, 11, 16, 18, and 31, DNAs extracted from cervicovaginal exfoliated cells were assessed for HPV genomic sequences. HPV genomic sequences were identified in 25% of nonpregnant women compared with 13.5% of term pregnant women. This difference was not statistically significant (p = 0.26). Six HPV isolates identified in pregnant women were distributed as follows: type 6/11, 1; type 16, 1, type 31, 1; and unknown type, 3. Eleven isolates were identified in nonpregnant women and were distributed as follows: type 6/11, 2; type 16, 6; type 18, 2; and type 31, 1. HPV type 6/11, the type responsible for laryngeal papillomatosis of juvenile onset, was identified in 2% of the pregnant population and accounted for only one of six isolates. HPV DNA-positive pregnant and nonpregnant women were predominantly asymptomatic and had normal Papanicolaou smears and normal clinical examinations.     

Pyelocaliectasis and intrarenal artery doppler indices in uncomplicated pregnancies.

The effect of pyelocaliectasis on intrarenal arterial Doppler indices was evaluated in healthy pregnant women with respect to nonpregnant controls. There was no significant difference between the pregnant and nonpregnant subjects regarding the systolodiastolic ratio, resistivity index and pulsatility index throughout the second and third trimesters (p for all > 0.05). There were 134 kidneys with grade 0, 38 kidneys with grade I and 24 cases with grade II pyelocaliectasis in the pregnant population. Grade II caliectasis was found only in the right kidneys. The nonpregnant women all had grade 0 caliectasis. Doppler indices were not significantly different in various grades of caliectasis, and right and left kidneys had similar Doppler indices. The results of this study suggest that pyelocaliectasis increases with advancing gestational age and is more frequent and prominent on the right side but has no effect on intrarenal Doppler indices in healthy pregnant women. In cases of prominent alterations in Doppler indices, renal pathological conditions should be sought.     

Anogenital Findings in 3569 Pediatric Examinations for Sexual Abuse/Assault

Study Objective

Accurate interpretation of anogenital examination findings in the context of suspected child and adolescent sexual abuse/assault is essential, because misinterpretation has significant child protection and criminal justice implications. A consensus approach to the interpretation of anogenital examination findings is widely used to support accurate diagnosis; however, a large-scale study using this standardized approach is lacking. The objectives of this study were to: (1) determine the proportion of anogenital examinations for sexual abuse concerns with findings diagnostic of trauma and/or sexual contact; (2) determine whether frequency of diagnostic findings varies according to age, gender, and timing of examination; and (3) characterize diagnostic findings.

Different Nordic facilities for victims of sexual assault: a comparative study

BACKGROUND: Open multidisciplinary centers were operated in the mid 1990s for victims of sexual assaults in Oslo and Reykjavik. However, in Copenhagen and Helsinki forensic medical examination was only available to victims who reported directly to the police. One of the main aims of this study was to compare the effect of these different service facilities in four Nordic capitals on the victims' frequency to seek help and report sexual assaults to the police. METHODS: The age and attendance profile of 380 individuals, seeking support after sexual assault, was compared for the four capitals over a period of 1 year. The circumstances and consequences of assault, frequency and time lag of reporting were also compared. RESULTS: Open centers received several times more victims, especially in younger age groups, including more reported cases, when compared with the population at risk than forensic institutes. Victims were seen earlier for examination at forensic institutes that dealt with a more limited spectrum of sexual assaults than the open centers. The proportion of rape was higher amongst victims brought to forensic institutes whereas a higher proportion of victims received at open centers had been exposed to less violent assaults. The frequency of visits was higher at weekends, between 50% and 70% of victims reported consumption of alcohol, and one-third were attacked while sleeping. In the majority of cases only one perpetrator was involved, most often unknown or peripherally known to the victim. CONCLUSION: Open multidisciplinary centers receive and assist considerably more victims, reporting and not reporting sexual assaults than forensic institutes.     

Involvement of drugs in sexual assault

OBJECTIVE: To obtain information about the relationship of alcohol and drug usage in victims of sexual assault, including the newly identified "date rape" drugs gamma hydroxybutyrate and flunitrazepam. STUDY DESIGN: Analysis of urine samples with gas chromatography combined with mass spectrometry can identify alcohol and numerous other drugs with a high degree of specificity. This service was offered to rape treatment centers throughout the United States in May 1996; urine samples obtained from sexual assault victims suspected of drug use by history or physical examination were sent for testing at the discretion of the examiner. RESULTS: As of March 1999, a total of 2,003 specimens were analyzed. Nearly two-thirds of the samples contained alcohol and/or drugs; the predominant substances found were alcohol, present in 63%, and marijuana, present in 30%. A substantial subset of the specimens was found to contain other illicit substances, frequently in combination. GHB and flunitrazepam were found in < 3% of the positive samples. Additionally, over the two-year study period, the use of these two drugs appeared to be declining. CONCLUSION: These findings support prior data indicating that alcohol, marijuana and/or other drugs are important risk factors in sexual assault. Continued monitoring of drug use by victims of sex crimes is important, and programs that serve victims should modify protocols to reflect this.