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Medical Findings in Sexual Assault of Disabled Adults

06-04. Medical Findings in Sexual Assault of Disabled Adults. Diana Faugno, BSN, RN, CPN, FAAFS, SANE-A Palomar Pomerado Health District Director - Forensic Health Services dkf@pph.org 760-739-3444. Disability Issues:. Physical issues Developmental delay Communication tools/or lack of

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Medical Findings in Sexual Assault of Disabled Adults

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  1. 06-04 Medical Findings in Sexual Assault of Disabled Adults Diana Faugno, BSN, RN, CPN, FAAFS, SANE-A Palomar Pomerado Health District Director - Forensic Health Services dkf@pph.org 760-739-3444

  2. 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

  6. 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.

  7. Injury Mechanisms • Blunt Force • Abrasions • Contusions • Laceration • Sharp force • Burns • Bite injuries • Strangulation injury

  8. 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.

  9. 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. Nonspecific and Subjective Injury

  10. Nongential Injury • Head/face/neck • Thighs/legs/arms

  11. 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.

  12. 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%

  13. 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

  14. 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)

  15. 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

  16. 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

  17. 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.

  18. 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

  19. 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

  20. 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

  21. 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%

  22. 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 - don’t 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

  23. 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

  24. 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.

  25. 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

  26. Woods Lamp • Not all that fluoresces is ejaculate. • Not all ejaculate fluoresces.

  27. 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 Possible Factors Said to Affect Injury Rate

  28. 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

  29. 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

  30. 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

  31. 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. Human Sexual Response

  32. Questions and Problems with Conclusions/Opinions • History does not match the examination findings. • Haven’t 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. • That’s life.

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

  34. 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.

  35. 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.

  36. 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

  37. 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.

  38. Significance of Findings • The examiner will explain the nature and specificity of findings based on… • The examiner’s clinical experience • The examiner’s general and forensic training • The medical and forensic literature • The experience of the examiner’s professional colleagues

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

  40. 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.

  41. 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. It’s like a grape turns to a raisin. The grape is plump…etc.” • Be clear, concise and objective

  42. 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

  43. 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

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

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