Problem - cannot be documented by photography, but only b

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Medical Findings in Sexual Assault of Disabled
Adults
06-04
Diana Faugno, BSN, RN, CPN, FAAFS, SANE-A Palomar
Pomerado Health District Director - Forensic
Health Services dkf_at_pph.org 760-739-3444
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Disability Issues

• Physical issues
• Developmental delay
• Communication tools/or lack of
• Resources available

3
SARTs-Where are they?

• Hospital ERs
• Free-standing facility
• Private
• Combination
• Rural vs. large metropolitan area

4
Move towards free-standing SARTs/DVs

• Provide best practice for victims of violence
• Confidentiality
• Pre-text phone calls
• Customers are??
• Storage of evidence and records

5
Underreporting by Victims

• Incidence studies
• Uniform Crime Reports
• National Crime Victimization Survey
• Only 28 of victims report to police
• Prevalence studies
• Russell (1984) - 1 in 12 reported to police
• Koss (1987) - 8 reported to police

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Goals of the Sexual Assault Medical-Legal
Examination

• Obtain history.
• Identify and document injuries.
• Evaluate and refer for treatment of injuries.
• Follow CDC guidelines for STDs.
• Collect evidence.
• Maintain chain of evidence.
• Refer for follow-up needs.

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Injury Mechanisms

• Blunt Force
• Abrasions
• Contusions
• Laceration
• Sharp force
• Burns
• Bite injuries
• Strangulation injury

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Strangulation Injury

• Form of asphyxia (lack of oxygen)
• Closure of blood vessels and/or air passages in
  the neck
• External pressure on the neck.
• Ligature
• Manual
• Airway obstruction may also result from choking
  (foreign body), smothering, inflammation or
  asphyxiation.

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Nonspecific and Subjective Injury

• Erythema -
• redness of the skin or mucous membranes produced
  by congestion (dilation) of the capillaries.
• Problem - there are many causes other than trauma

• Tenderness - painfulness to pressure of contact
• Problem - cannot be documented by photography,
  but only by examiner
• Victims have different tolerance for pain or
  touch as elicited by exam.

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Nongential Injury

• Head/face/neck
• Thighs/legs/arms

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Incidence of Genital Injury

• Genital examination performed with gross
  visualization and plain light alone.
• Within 72 hours following sexual assault.
• Genital injuries ranged from 16-27
• 5 studies from 1983-1997 - 7,146 subjects.

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Genital Injury Detected Unaided

• Year Study pts Injured
• 1983 Solola 621 22
• 1985 Tintinalli 372 19
• 1986 Carwright 440 16
• 1991 Satin 5,620 21
• 1997 Bowyer 83 27

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Toluidine Blue Aids Injury Detection

• Use of toluidine blue dye in examining female
  sexual assault victims raised the genital injury
  detection rate to
• 45-56 in adult victims
• 28 in adolescent victims
• Consenting controls showed injury also
• 7-10 in adult females
• 28 in adolescent females
• Lauber Soma 1982, McCauley 1986, 1987

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Colposcopy Aids Injury Detection

• Colposcopic exams of sexually assaulted females
  raised genital injury detection rate
• 58-71 in adult female victims
• 63 in adolescent female victims
• There are 2 studies of consenting controls - both
  problematic.
• Slaughter (11) used recanting victims
• Norvel (61) used different methodology
• Norvell 1984, Slaughter 1997, UCDMC/SD unpub
• Chewing, S. 2001 (unpublished)

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Specific Genital Injury Location

• Posterior fourchette is the most common site of
  injury.
• 28-40 using toluidine blue dye
• Lauber Soma 1982, McCauley 1986
• Labia majora and minora is the second most common
  genital injury
• 13
• Adams 1996, Biggs 1998

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Number of Injury Sites

• Multiple genital injury sites following sexual
  assault are more common than after consenting
  contact
• In the study that counted number of genital
  injury sites, only 68 of victims had injuries at
  all.
• Slaughter 1997

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Findings

• The absence of findings does not mean that a
  sexual assault did not occur or is unfounded.
• Cases can also be corroborated by lab work,
  confession, witnesses, etc.

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Injury to the Hymen

• The hymen is more likely to be injured in female
  sexual assault victims who have not had prior
  sexual experience.
• Adolescents 8 transection, 10 bruise
• No prior sexual experience transection 9
• The hymen is not always injured in first sexual
  intercourse, consenting or non-consenting.
• Adams 1996, Biggs 1998, Emans 1994

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Injury to the Cervix

• Injuries to the cervix are uncommon following
  sexual assault but they may occur under certain
  circumstances.
• Forceful digital penetration
• Penetration with a foreign object
• Penile penetration is not likely to cause
  cervical injury
• Slaughter 1991

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Absence of Genital Injury

• All studies of injuries in females who report
  sexual assault include some patients who lack
  genital injuries.
• No genital injury in 31-73
• 5 studies (730 subjects) 1977-1998
• Wide range of lack of injury reflects.
• Exam methodology differences
• Variable examiner experience.
• Everett 1997, Tintinalli 1985, Adams 1996,
• Bowyer 1997, Biggs 1998

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Absence of Genital Injury

• Year Study pts Injured
• 1977 Everett 117 36
• 1985 Tintinalli 372 68
• 1996 Adams 26 31
• 1997 Bowyer 83 73
• 1998 Biggs 132 53

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Non-genital Injury

• Thorough examination often reveals the presence
  of non-genital injury.
• Can be important in corroborating the history of
  use of force
• May give information about incident
• Most injuries minor - dont need treatment
• Non-genital injury rate 23-85
• 5 studies (1972-1997) 2,547 subjects
• Haymen 1972, Solola 1983, Tintinalli 1985,
• Pentilla 72, Bowyer 1997

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Injuries in the Male Victim

• Male sexual assault victims who report anal
  penetration show an anal injury rate of 50-67.
• The nongenital injury rate to male victims ranges
  from 13-57.
• Kaufman 1980, Doan 1983, Hillman 1990,
• Hillman 1991

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Finding Sperm

• Positive sperm recovery confirms recent sexual
  contact.
• Stained slides (crime lab) will detect more sperm
  than the wet mount slide.
• Wet mount preparation at time of exam is the only
  opportunity to detect motility
• Cervical samples may provide recovery of sperm
  longer than vaginal samples.

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Sperm Recovery in Living Victims

• Body Cavity Motile Sperm Non-motile
• Vagina 6 - 28 h 14 h - 10 d
• Cervix 3 - 7.5 d 7.5 - 19 d
• Mouth - - - 2 - 31 h
• Rectum - - - 4 - 113 h
• Anus - - - 2 - 44 h

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Woods Lamp

• Not all that fluoresces is ejaculate.
• Not all ejaculate fluoresces.

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Possible Factors Said to Affect Injury Rate

• Sexual experience
• Relationship of victim to assailant
• Parity
• Human sexual response
• Drugs/Alcohol
• Coital position
• Use/lack of force

• Relaxation
• Genital size match
• Multiple events or partners
• Male sexual dysfunction
• Tissue fragility
• Hormone deficiency
• Inflammation
• Extrinsic lubrication

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Prior Sexual Experience

• Sexual assault victims with prior sexual
  experience sustain genital injuries at a rate of
  25.
• Compared with sexual assault victims without any
  prior sexual experience who sustained genital
  injury at a rate of 65.
• These figures are the result of a study where
  genital exams were done with gross visualization
  and plain light only.
• Biggs 1998

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Victim-Assailant Relationship

• The nature of the relationship between the victim
  and the assailant does not significantly
  influence the genital injury rate.
• Relationship may be Lindsay (unpublished) 1998
• Stranger, Brief encounter, Acquaintance
• More non-genital injuries are likely to occur
  when assaulted by a stranger compared with
  acquaintance.
• Lindsay (unpublished) 1998, Stermac 1995

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Genital Trauma Alcohol Use

• When sexual assault victims were.
• Under the influence of alcohol
• Unconscious due to alcohol use
• There was no significant difference in the
  genital injury rate.
• When compared with sexual assault victims who
  were not under the influence of alcohol.
• Lindsay (unpublished) 1998

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Human Sexual Response

• Sequence of physical/physiologic changes in
  response to sexual stimulation
• 4 Phases
• Excitation
• Plateau
• Orgasm
• Resolution

• HSR in sexual assault has not been studied.
• Anecdotal reports suggest some degree of HSR may
  occur in forced sex as a reflection of normal
  function, not consent or pleasure.

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Questions and Problems with Conclusions/Opinions

• History does not match the examination findings.
• Havent seen this finding before (experience).
• Looks like trauma however, critical thought
  regarding pattern and mechanism of injury need to
  be considered.
• Limitation of scientific foundation in field.
• Thats life.

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Potential Visible Positive Findings

• Examiner summarizes positive findings.
• Any injury sustained during the assault
• Subjective tenderness
• Positive Woods Lamp findings
• Trace evidence
• Wet mount positive for sperm
• Findings match diagram on OCJP 923.
• Photos document and confirm findings.

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Forming a Medical Opinion

• Understand mechanisms of injury and injury
  patterns.
• Know the sexual assault injury literature.
• Be aware of factors that influence the likelihood
  of finding injuries in victims.
• Draw on clinical experience.
• Anticipate prosecution/defense strategy.
• Form responsible conclusion statement.

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Avoid Inappropriate Conclusions

• Both rape and consent are legal principles - not
  medical diagnoses.
• Examiner can verify presence of findings.
• The jury has the responsibility to determine the
  credibility of the history.
• Neither rape nor consent should ever be diagnosed
  from the examination.

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Avoid Problematic Conclusions

• Degree of force used by assailant.
• The presence of an injury speaks for itself
• Consent vs. non-consent.
• The presence or absence of injuries does not
  answer this question
• Traumatic vs. non-consensual penetration.
• These are not synonymous

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Appropriate Conclusions

• Findings of recent trauma.
• Findings of recent sexual contact.
• Consistency between history and findings.
• Consistency is not proof or confirmation of the
  history.
• Consistency means the findings or lack of
  findings could have resulted from the events
  described.

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Significance of Findings

• The examiner will explain the nature and
  specificity of findings based on
• The examiners clinical experience
• The examiners general and forensic training
• The medical and forensic literature
• The experience of the examiners professional
  colleagues

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Medical Concerns

• STD prophylaxis.
• Emergency pregnancy prophylaxis.
• HIV referral/testing.
• Hepatitis B.

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How to Reduce Problems/Prevalence in
Conclusions/ Opinions

• Amass as much experience as possible.
• Develop a consultive/peer review network.
• Maintain an objective demeanor.
• Respect and seek collaboration from law
  enforcement and advocacy.
• Rely on and keep abreast of scientific
  literature.
• Use common sense.

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And You Heard It In Court Under Oath

• I found her clitoris to be larger than normal,
  but shrunken. Also the clitoris that was
  enlarged and shrunk, is the sign of some past or
  previous swelling that happened. It looks like a
  raisin. Its like a grape turns to a raisin.
  The grape is plumpetc.
• Be clear, concise and objective

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True or False?

• 1. Force penetration Rape
• 2. Traumatic intercourse Non-consent
• 3. No human sexual response Non-
• consent
• 4. Human sexual response Consent
• 5. Normal finding - Consent
• 6. Three or more genital lesions Non-
• consent
• 7. The colposcope can diagnose rape

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Obstacles Opportunity to Collaborate

• Financial/cost
• Education/training
• Inability to adapt to advances in forensic and
  clinical medicine
• i.e. primary prevention
• Lack of nurses - health care personnel crisis
• Border issues/USA

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• Always do right. This will gratify some people
  and astonish the rest.
• Mark Twain