Patterns of genital injury in female sexual assault victims

doi:10.1016/S0002-9378(97)70556-8

American Journal of Obstetrics and Gynecology

Volume 176, Issue 3, March 1997, Pages 609-616

https://doi.org/10.1016/S0002-9378(97)70556-8 Get rights and content

Abstract

OBJECTIVE: New colposcopic protocols allow examiners to better document genital trauma in rape victims. We report our findings on the locations and types of genital injury seen in female assault victims versus women engaging in consensual sex.

STUDY DESIGN: Physical examinations were performed on 311 rape victims seen by San Luis Obispo County's Suspected Abuse Response Team between 1985 and 1993 and contemporaneously on 75 women after consensual sexual intercourse.

RESULTS: Among 213 (68%) victims with genital trauma, 162 (76%) had 3.1 mean sites of injury. Comparatively, 8 (11%) consenting women had just single-site trauma. Two hundred (94%) victims had trauma at one or more of four locations, as follows: posterior fourchette, labia minora, hymen, fossa navicularis. Trauma types varied by site; tears appeared most often on the posterior fourchette and fossa, abrasions appeared on the labia, and ecchymosis was seen on the hymen.

CONCLUSION: A localized pattern of genital trauma can frequently be seen in women reporting nonconsensual sexual intercourse; such findings are useful for the clinical forensic examiner.(Am J Obstet Gynecol 1997;176:609-16.)

Section snippets

Sexual assault population

For 10 years, in San Luis Obispo (California) County, all sexual assault examinations have been performed by Suspected Abuse Response Team (SART) examiners using the colposcope to evaluate anogenital trauma.

Examiners are medical doctors and nurse examiners specifically trained in the forensic evaluation of sexual assault victims according to the State of California Training Curriculum.¹ For this study we reviewed the initial and follow-up SART evaluations, including colposcopic photographs, of

Results

Of the 311 assault victims, 213 (68%) had anogenital trauma. Those with trauma included 189 white, 6 black, 17 Hispanic, and 1 Asian. The mean age was 24 years, with a range of 11 to 85 years; all were postpubertal and 6 were postmenopausal. Those with normal findings on physical assessment had the same mean age (24 years) and proportionate racial distribution.

Among the 178 (57%) patients with nongenital trauma, 132 (74%) also had genital injury. The proportion with genital injury was

Comment

Our findings show that genital trauma is common in victims of sexual assault, occurring in 68% of all patients, and is more commonly observed than injury associated with complaints of sodomy (56%). Moreover, our data confirm prior information showing that the prevalence of genital injury in rape is greater than in those women engaging in consensual intercourse.10, 11 The severity and extent of trauma in rape victims appear, as well, to differ from changes after consensual sex.

In our population

Acknowledgements

We thank Margaret Nalley, RN, and Christine Clickard, RN, FNP, for their help in this study and for their continued work with SART. We also acknowledge the support of the San Luis Obispo County SART and the San Luis Obispo General Hospital; thanks to Sexual Assault Victim Education and to Mary Kennedy Eggan, RN, whose dedication to the treatment of assault victims inspired the establishment of the SART program.

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Cited by (223)

Anogenital injury following sexual assault and consensual sexual intercourse: a systematic review and meta-analysis
2023, eClinicalMedicine
Sexual violence is a grave human rights violation and a serious global public health challenge. Rates of reporting of sexual violence and subsequent passage of cases through the criminal justice system are poor all over the world. The presence or absence of anogenital injury following sexual assault may influence survivors in their willingness to report a crime, and law enforcement officers and jurors in their decision making regarding the laying of charges and/or conviction of offenders. The aim of this systematic review was to compare rates of identification of anogenital injury (AGI) in women following sexual assault and consensual sexual intercourse using the same examination techniques.
In this systematic review and meta-analysis, Medline, Embase and Google Scholar were searched for relevant studies (in any language, with no age or sex criteria) published between February 25, 1993, and February 25, 2023, that directly compared AGI between individuals after either sexual assault or consensual sexual intercourse. Abstracts, conference proceedings, and case reports were excluded. The primary outcome of interest was any form of detected AGI. The Mantel-Haenszel method was used for meta-analysis using random effects modelling to determine the risk ratio (RR) of AGI between sexual assault and consensual sexual intercourse. Quality assessment was undertaken using the Newcastle–Ottawa scale tool. The I² statistic was used to determine heterogeneity among studies. An I² >75% was considered high heterogeneity. Funnel plots were used to assess the risk of publication bias, by determining any visually apparent asymmetry. This analysis is registered with PROSPERO, CRD42023402468.
We included 10 studies, accounting for 3165 study participants. All participants were female. AGI was detected in 901 (48%) of 1874 participants following sexual assault and 394 (31%) of 1291 participants following consensual sexual intercourse. Meta-analysis of all included studies demonstrated that the presence of AGI was significantly more likely for participants following sexual assault than consensual sexual intercourse (RR 1.59 (95% CI 1.21, 2.09); p < 0.001). There was a significant heterogeneity among studies and funnel plots suggest that this RR may be an over-estimation. Subgroup analysis including only high-quality studies showed no significant difference between groups.
Although AGI was significantly more likely to be detected after sexual assault than consensual sexual intercourse, more than half of survivors of sexual assault have no detectable injuries. The presence of AGI, therefore, does not prove there has been sexual violence and absence of injury does not refute that sexual assault has occurred.
The University of Birmingham.
Analysis of injuries in 702 cases of sexual assault in Alicante (Spain) during the years (2016-2020)
2023, Revista Espanola de Medicina Legal
el objetivo principal de este trabajo es analizar las características de las víctimas y circunstancias de la violencia sexual asociadas con un mayor riesgo de presentar lesiones físicas, así como determinar la frecuencia y severidad de las mismas.
estudio descriptivo retrospectivo de 702 casos de violencia sexual atendidos en el Instituto de Medicina Legal y Ciencias Forenses de Alicante entre 2016 y 2020. Se ha realizado un estudio comparativo entre las víctimas de violencia sexual con lesiones físicas y sin lesiones, para analizar las variables asociadas que pueden influir en su presentación.
del total de 702 víctimas de violencia sexual, 314 casos (44,8%) presentaban lesiones físicas. Las víctimas con lesiones físicas la mayoría eran mujeres (95,5%), entre 18 y 27 años (31,3%), que referían un consumo voluntario previo de sustancias, fundamentalmente de alcohol (50%). Las lesiones físicas más frecuentes fueron a nivel extragenital (38,6%), seguidas de lesiones a nivel anogenital (15%), de carácter leve en la mayoría de los casos (97,5%). Los días totales de curación fueron menores o iguales a una semana (83,4%). La mayoría se curó sin secuelas (97,1%). Las víctimas que presentaron secuelas (9 casos), las más frecuentes fueron de carácter psíquico (1,6%).
la violencia sexual en el grupo de víctimas con lesiones físicas se asocia a factores de vulnerabilidad para la víctima: sexo femenino, edad entre 18 y 27 años y consumo previo de alcohol.
Nuestro estudio confirma que las lesiones anogenitales son poco frecuentes en la mayoría de las víctimas de violencia sexual, por lo que su ausencia no puede descartar el haber sufrido violencia sexual. Las lesiones físicas encontradas fueron de carácter leve en la mayoría de los casos. La ausencia de secuelas psíquicas en muchas de las víctimas puede estar condicionado por el escaso seguimiento de las mismas.
The aim of this paper is to analyze the characteristics of the victims and the circumstances of sexual violence related with the risk of physical lesions, as well as to determine the frequency and severity of the injuries.
Descriptive study of 702 cases of sexual assault attended at the Institute of Legal Medicine and Forensic Sciences of Alicante between the years 2016–2020. A comparative study was carried out between victims with and without injuries, to identify the variables associated to their presentation.
314 victims attended showed physical injuries (44,8%). Profile of the victims with injuries were women (95.5%), aged 18 to 27 years (31.3%), and previous alcohol consumption (50%). Injuries physical were mainly extragenital (38.6%), anogenital (15%), or both, and most cases were mild in severity (97.5%). Recovery was less to one week (83.4%) and without aftermath (97.1%). When the victim showed aftermath (9 cases), the most frequent were psychological type (1.6%).
Physical injuries in sexual violence is related with circumstances of victim vulnerability: women, age between 18 to 27 years, and previous alcohol consumption.
Our study shows that anogenital lesions are absent in a significative number of victims of sexual assault, so this absence cannot exclude sexual violence. The lesions found are mild in severity, and the absence of physical aftermath in most of the victims may be conditioned by the scarce follow-up of them.
Comparative prevalence of anogenital injury following sexual assault in women who have had recent consensual sexual contact
2022, American Journal of Emergency Medicine
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.
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.
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).
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.
The pattern of genito-anal injuries in female sexual assault cases in Mumbai, India
2021, Forensic Science International: Reports
The prevalence of genito-anal injuries in victims of sexual assault depends on several factors. Forensic examination, documentation of injuries and preparing report thus becomes challenging for healthcare providers as the presence or absence of injuries aids in the subsequent laying of charges against the accused. This paper aims to determine the pattern of genito-anal injuries and factors associated with the laying of charges against the accused.
A cross-sectional study of victims of sexual assault (n = 440) was conducted between 2014 and 2017 in a specialized tertiary care center in a Metropolitan city in India. The results were expressed as proportion and percentage. Chi-squared test was used to analyse data using SPSS version 23.0.
There was no statistically significant association between reporting within 72 h of sexual assault and the arrest of the accused. Vaginal and anal bleeding were present in 4.1% cases and 2.7% cases respectively. Genital and anal injuries were present only in 30.9% of cases. The most common genito-anal injury was laceration (72.08%). Posterior fourchette injury (most common site) was present in 27.94% of cases. Extra genital injuries were found in 24.09% of victims. The most common extra genital injury was abrasion (26.42%). Intoxicants were found in the blood of 4.8% of victims and spermatozoa/semen was found in swabs from 3.6% of victims. In this study 25.9% of perpetrators were arrested, out of which 84.37% of adult victim’s cases and 94.23% of minor (<18 years) victims cases went to trial. In 3.12% of adults and 0.6% of minor victims, the accused was found guilty and sentenced to imprisonment. The presence of genital injury, visualization of sperm by direct microscopy, assailant known to the victim and pregnancy of the victim were not significantly associated with the laying of charges (p > 0.05) and were dropped from the model. The odds ratio (OR) for charge-laying associated with the age of the victim < 18 years was 3.02 (95% confidence interval [CI] 1.02–9.14). Arrests in accused of both victims > 18 years age and < 18 years age were more common if the accused was known to the victim. Injuries in victims < 18years of age and > 18 years of age did not appear to have any influence over the arrest. A notable finding was a high proportion (75.51% in <18 years and 77.77% in >18 years) of cases where an arrest was effected in adults and child sexual assault cases where no injuries were described.
This study shows the pattern of genito-anal injuries and factors associated with the laying of charges in sexual assault cases in a developing country. It should be noted that most of those exposed to sexual assault do not have visible genito-anal injuries. We report that age is significantly associated with the presence of genito-anal injuries. However, it is important to note that the presence of injuries does not prove rape, neither its absence disproves the act. The information gathered by a meticulous forensic examination does make a difference in the legal outcome for cases of sexual assault.
Comment to the article: Discriminating between consensual intercourse and sexual assault: Genital-anal injury pattern in females
2021, Journal of Forensic and Legal Medicine
Genital injuries and allegation of digital vaginal penetration – A retrospective examination of forensic case notes
2021, Journal of Forensic and Legal Medicine
To determine the prevalence of genital injuries following alleged sexual assault by digital penetration of the vagina in the absence of penile penetration of the vagina or anus in women age 16 and over; and to compare with the prevalence of genital injuries following alleged sexual assault by penile vaginal penetration in the absence of penile penetration of the anus or digital penetration of the vagina and/or anus.
1428 adults and children attending a forensic medical examination between September 2017 and January 2020 at the Haven sexual assault referral center situated in Paddington, London, UK.
Retrospective review of forensic notes.
Eligible cases were identified through the standardized forensic notes and relevant data was extracted.
109 cases of women 16 years and over alleging digital penetration only and 110 cases of women 16 years and over alleging penile vaginal penetration only were included. The 110 cases of penile vaginal penetration only were randomly selected for comparison purposes. 7.6% of Haven attenders fulfilled the digital penetration only category. In this category, the patients mean age was 27.2 years. Thirteen patients (11.9%) sustained genital injuries; of those with genital injuries, eleven (84.6%) sustained one or more abrasions. The most common site of injury was the labia minora (46.2%). There were no significant differences between the 2 groups (digital penetration only and penile vaginal penetration only) in terms of number of patients with genital injuries, type or location of injury. There were differences regarding the relationship between patient and assailant: more stranger assaults in the digital penetration group 27/109 (29%) vs 13/110 (12%) in the penile penetration group. There was one assault by multiple assailants in the digital penetration group and 8 (7.3%) in the penile penetration group. In the digital penetration group there was more alcohol use [71/109 (65.1%) vs 62/110 (56.4%)] but less drug use [21/109 (19.3%) vs 30/110 (27.3%)] than in the penile vaginal penetration group.
The majority of patients examined following an allegation of digital vaginal penetration without penile penetration sustained no injuries. Of those who did, abrasions were the most common type of injury, with the inner labia minora being the most common location for injury. There were no significant differences with the injuries seen in the penile vaginal penetration group in terms of number of patients with genital injuries, type or location of injury.

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^☆: From the San Luis Obispo County Sexual Assault Response Team, the San Luis Obispo General Hospital, and California Polytechnic State University.

^☆☆: Reprint requests: Laura Slaughter. MD, Department of Anesthesiology, Oregon Health Sciences University, UHS-2, 3181 S.W. Jackson Park Road, Portland, OR 97201-3098.

^★: 0002-9378/97 $5.00 + 0 6/1/79147

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Abstract

Section snippets

Sexual assault population

Results

Comment

Acknowledgements

Am J Obstet Gynecol

Am J Emerg Med

Am J Obstet Gynecol

Ann Emerg Med

Ann Emerg Med

Adolesc Pediatr Gynecol

California medical protocol for examination of sexual assault and child sexual abuse victims: training curriculum

Management of the patient with the complaint of sexual assault

Ann Emerg Med

Sexual assault

Care of the woman who has been raped

N Engl J Med

Epidemiology and management of sexual assault victims

Obstet Gynecol