Sexual assault in pregnancy

Little is known about the acute effects of sexual assault on pregnant victims and the outcome of their gestations. A retrospective review of sexual assault victims in Dallas County from 1983-1988 revealed that 114 of 5734 (2%) were pregnant. There were 0.55 and 0.75 gravid sexual assault victims per 1000 deliveries for Dallas County and Parkland Memorial Hospital, respectively. The purposes of this study were to examine patient demographics, forensic evidence and patterns of injury in pregnant victims compared with 114 matched nonpregnant sexual assault victims, and to compare pregnancy outcome with that of the Parkland Memorial Hospital obstetric population. The typical victim was a black, parous gravida in her twenties at a mean gestational age of 15 weeks, without previous prenatal care. Vulvar (95%), oral (27%), and anal (6%) penetration were reported with similar frequency in both groups. The detection of whole and motile sperm from the vaginal specimens was similar in pregnant and nonpregnant women. Physical trauma was more common in nonpregnant victims (63 versus 43%; P less than .004), especially genital trauma (21 versus 5%; P less than .001). Injury was more common to the head and neck or extremities than to the abdomen, chest, or back in both groups. There was no difference in the pattern of trauma by gestational age, but there were no truncal injuries in women at 20 weeks' gestation or greater. There were no spontaneous abortions or deliveries within 4 weeks of the assault, but low birth weight delivery (24%) and preterm delivery (16%) were common.(ABSTRACT TRUNCATED AT 250 WORDS)     

Providing quality care to the sexual assault survivor: education and training for medical professionals

One in every six women in the United States will be the victim of an attempted or completed rape over the course of their lifetime.³ Health care providers trained in sexual assault examination procedures are not available in all clinical settings. CNMs/CMs have most of the requisite training to provide this service, and they are ideally poised to help women who report sexual abuse. We can assist persons who have been sexually assaulted by becoming educated in sexual assault care, attending specialty training as sexual assault examiners, joining SARTs, and serving as sexual assault response coordinators in our communities. Education about sexual assault care in midwifery programs can facilitate the ability of CNMs/CMs to provide physical assessments and forensic examinations to sexual assault victims.Once training has been obtained, it is essential to stay current about topics such as emergency contraception, STI treatments, and new methods of forensic evidence collection. Sexual assault examiners must have a knowledge of available referral sources and local resources where the person reporting these crimes may receive assistance as needed. Providing medical and forensic care for women who are victims of sexual violence should be considered a core practice within the midwifery scope of practice. CNMs/CMs need to be well prepared to care for sexual assault patients by receiving proper education and training. Specific instruction concerning care for victims of sexual and domestic violence, along with an introduction to serving as an expert witness, should be an integrated into midwifery education programs as part of the core curriculum.     

Intimate partner sexual assault against women: frequency, health consequences, and treatment outcomes

OBJECTIVE: To describe the characteristics and consequences of sexual assault within intimate relationships specific to racial or ethnic group, compare the findings to a similar group of physically assaulted-only women, and measure the risk of reassault after victim contact with justice and health services. METHODS: A personal interview survey of 148 African-American, Hispanic, and white English- and Spanish-speaking abused women seeking a protection order. Extent of sexual assault, prevalence of rape-related sexually transmitted diseases and pregnancy, symptoms of posttraumatic stress disorder (PTSD) and depression, and risk of reassault after treatment were measured. RESULTS: Sixty-eight percent of the physically abused women reported sexual assault. Fifteen percent of the women attributed 1 or more sexually-transmitted diseases to sexual assault, and 20% of the women experienced a rape-related pregnancy. Sexually assaulted women reported significantly (P = .02) more PTSD symptoms compared with nonsexually assaulted women. One significant (P = .003) difference occurred between ethnic groups and PTSD scores. Regardless of sexual assault or no assault, Hispanic women reported significantly higher mean PTSD scores compared with African-American women (P = .005) and White women (P = .012). The risk of sexual reassault was decreased by 59% and 70% for women who contacted the police, or applied for a protection order, after the first sexual assault. Receiving medical care decreased the woman's risk of further sexual assault by 32%. CONCLUSION: Sexual assault is experienced by most physically abused women and associated with significantly higher levels of PTSD compared with women physically abused only. The risk of reassault is decreased if contact is made with health or justice agencies.     

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.     

Sexual assault: review of a national model protocol for forensic and medical evaluation. New Hampshire Sexual Assault Medical Examination Protocol Project Committee.

A national hospital/community model protocol was developed for the forensic and medical examination of victims of sexual assault. This review is designed to assist states in the development of sexual assault protocols. Controversial issues were addressed, including the collection of hair evidence, the importance of semen, mandatory reporting, pregnancy testing and prophylaxis, and sexually transmitted diseases including human immunodeficiency virus. The current role of DNA profiling is reviewed. These issues at the interface of medicine, forensic science, victim advocacy, and the law are analyzed. Representatives of the medical, legal, law enforcement, victim advocacy, and forensic science communities contributed to the development of the protocols at the national and state levels. The importance of a collaborative effort is emphasized. The broad protocol goals are to minimize the physical and psychological trauma to the victim while maximizing the probability of collecting and preserving physical evidence for potential use in the legal system.     

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.     

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.     

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.     

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.     

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.     

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.     

Sexual assault: medicolegal findings and legal outcomes (analysis of 756 cases)

Objectives

We describe the medico-legal findings in a population of sexual assault cases assessed in an urban referral center, analyse the legal outcomes in each case and determine whether the medico-legal findings were associated with conviction of the assailant.

Materials and methods

We performed a retrospective study of medico-legal reports in all the sexual assault cases reported in Tours during a 7-year period. Legal outcomes were obtained from courtroom proceedings. The relationship between the outcomes and the circumstances of the case was analyzed by logistic regression.

Results

756 cases were enrolled. 68.3% of the cases involved children under 15 years old. Genital trauma occurred in 6.8% of the girls and 6% of the boys in this group. 31.7% of all the victims were aged 15 years or more. Genital injury was documented in 11.3% of the women. 36.3% of the assailants were convicted. Examination at the request of the police authorities and previous acquaintance of the assailant by the victim were significantly associated with conviction. The presence of general body and/or genital trauma was not associated with conviction.

Conclusion

Non-medical variables must be thoroughly collected by the medical examiner. Physical evidence of trauma was neither predictive nor essential for conviction.     

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.     

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.     

Data about 154 children and adolescents reporting sexual assault

Sexual assaults on girls occur at an alarming rate representing a significant public health problem, but difficulties in correctly identifying the problem, managing the child and reporting for legal purposes have been recognized. We describe data obtained on 154 recent cases of child and adolescent sexual assault. Results indicate that those at highest risk of sexual assault are girls at age of 11–15 years having a stepfather, although the most girls at age of >15 were assaulted by strange men with higher incidence of cross-race assault. Over a quarter of girls showed signs of physical trauma with face and neck as most common site of contact. A total of 17.5% reported threat of violence or with weapons and 9.7% had alcoholic influence. Pattern and incidence of genital injuries were described. Received: 3 June 1997 / Accepted: 22 August 1997     

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.     

A profile of adolescent females with a history of sexual assault in texas: familial environment, risk behaviors, and health status

STUDY OBJECTIVE: To describe the prevalence and correlates of sexual assault among adolescent females. DESIGN: A cross-sectional study. SETTING: A university family planning clinic in south Texas. PARTICIPANTS: Female adolescents <18 years who initiated care at a university family planning clinic in south Texas between June 28, 1992, and April 28, 1994. The adolescents' lifetime sexual assault experience. MAIN OUTCOME MEASURES: Of the 791 adolescents interviewed, 167 (21%) reported a history of sexual assault. Sexual assault was found to be highly associated with multiple risky behaviors and depressive symptoms. Among assaulted adolescents, nonsexual risk behaviors (e.g., substance use) were more common among those who also experienced physical assault than among those who did not. Sexual risk behaviors (e.g., earlier age at sexual debut) and related gynecological infections (e.g., STDs) were more prevalent among women reporting forced sexual intercourse than in those who reported molestation only. Furthermore, adolescents assaulted by a stranger had participated in the most risky behaviors and reported the worst health status, while those assaulted by a date/acquaintance reported higher rates of inconsistent condom use and gynecological infections but lower rates of substance use and depressive symptoms than those assaulted by a family member. CONCLUSION: A deeper understanding of the links between the characteristics of assault, risk behaviors, and health conditions may provide opportunities to design more individualized interventions.     

Similarity and Differences in Sexual Violence Against Adolescents and Adult Women: The Need to Focus on Adolescent Victims

Study ObjectiveTo explore whether there are differences in characteristics, clinical findings and management in cases of sexual violence in adolescent and adult women.DesignRetrospective study.SettingSVSeD–Service for Sexual and Domestic Violence, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy.ParticipantsFemale victims of sexual violence aged 10 years and older. Two study groups were analysed: an adolescent group and an adult group.InterventionsNone; this was an observational study.Main Outcome MeasuresCharacteristics of the perpetrator, time spent between the episode of sexual violence and the access to SVSeD, presence of genital and/or extragenital injuries; tests for sexually transmitted diseases, spermatozoa research; and toxicological screening;ResultsAdolescent victims of sexual violence requested help later than the adult victims. The majority of the perpetrators were well known to the victims in both groups. In both groups, we observed genital injuries in 1 of 3 patients. We found a strong association between the presence of genital injuries and a positive screening test for sexually transmitted diseases, in particular with regard to the adolescent victims.ConclusionAdolescents’ delayed disclosure of sexual violence may affect the ability to properly manage these crimes. Prevention programs and public awareness campaigns should be implemented to highlight the importance of a prompt disclosure after sexual assault has occurred. Gynecologists should be made increasingly aware of this delicate issue, to better assist victims of sexual violence, especially adolescent victims.     

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.