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Assessment and Identification of Genital Trauma

Assessment and Identification of Genital Trauma. Donna A. Gaffney, RN, DNSc, FAAN The International Trauma Studies Program New York University. Reasons for Identifying Injury . To recognize the need for appropriate treatment To refer for further evaluation and treatment if necessary

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Assessment and Identification of Genital Trauma

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  1. Assessment and Identification ofGenital Trauma Donna A. Gaffney, RN, DNSc, FAAN The International Trauma Studies Program New York University

  2. Reasons for Identifying Injury • To recognize the need for appropriate treatment • To refer for further evaluation and treatment if necessary • To identify a pattern of injury as well as patterned injury

  3. As a Result of Injury Identification Although one can not unequivocally establish the use of force based on the presence of the injury . . . it is possible to corroborate the survivor’s history with injury findings.

  4. The Dilemma • Forceful penetration does not always cause injury. As a result. . . Absence of Injury Consent

  5. Types Of Injuries T-Tear (laceration) or tendernessE-Ecchymosis (bruising) A-Abrasion (scrape) R-Redness (erythema) S-Swelling (edema)

  6. Most Common Sites of Injury Related to Penile Penetration • The posterior fourchette (Between 5 and 7 o’clock) • Labia minora • Hymen • Fossa navicularis

  7. Sites and Types of Genital Injury Location:IncidenceTypesPosterior Fourchette 70 % T , AMounting injury, where the penis first touches the perineum, 5-7 o’clock, perpetrator most often in superior position.Labia Minora 56 % A, EHymen 29 % T, ESecondary to penetration, as it is an internal structureFossa Navicularis 25 % T, ECervix 13 % E

  8. What Factors Determine Potential Injury to the Genitalia? There are three categories: • Factors related to the victim, • Factors related to the perpetrator • Factors related to circumstances /environment

  9. Factors Related To The Victim • Lubrication of the vaginal vault (Natural or Artificial) • Condition of genital structures • Anatomy and physiology of reproductive structures • Positioning

  10. Factors Related To The Victim • Participation (Active or Passive) • Health and developmental status • Cognitions and Learned behaviors • Traumatic stress response

  11. Human Sexual Response Human motivation to engage in sexual behavior is due to a complex relationship among several factors. Kelly Johnson, 1997 California State University, Northridge

  12. Phases of Female Human Sexual Response • Excitement:Vasocongestion Vaginal lubrication begins • Plateau: Uterus elevates and tilts back Inner 2/3 of vagina distends Creating a reservoir for sperm Labia minora engorge- Opening vaginal orifice

  13. Phases of Female Human Sexual Response 3. Orgasmic: Regular contractions occur Outer 1/3 of vagina contracts Rectal sphincter contracts • Resolution: Muscle and uterine relaxation Cervical os remains dilated Vaginal wall relaxes Cervix lowers into sperm pool

  14. Without the HSR. . . • There may be poor lubrication of the vaginal vault. . . Resulting in friction from the opposing forces at the labia minora and hymen • Anatomical structures may not beprotected. . . Parts can be pulled inward with the penetrating object. • Result: Abrasions, lacerations and bruising

  15. Lubrication of the Vaginal Vault • What causes lubrication? • Excitement phase of HSR • Lubricant or lubricated condom • Saliva • Cyclical changes in the vaginal environment • Irritation • Infection

  16. What is Protective Positioning? • Facilitates penile insertion • Use of pelvic tilt and partner assistance with insertion • Position of legs and muscle tension in the lower body

  17. Condition of Genital Structures • Engorgement • Trans-sexual surgical procedures • Post-partum changes • Infection or other localized disease • Female Genital Mutilation

  18. Partner Participation • Cooperation and presence/absence of relaxation • Assistance with insertion • Without participation: There is the possibility of creating a less flexible surface against which the penetrating object forces itself.

  19. Health and Developmental Status • Younger victim: Less Injury More resilient tissue Faster healing • Older victim: More injury Less elasticity Less fat tissue Longer healing • Illness-compromises tissue response

  20. Cognitions and Learned Behaviors • Learned experiences and sexual responsiveness • Interpretation of stimuli and HSR • Touch • Odor • Visual • Auditory • Taste

  21. Traumatic Stress Responses • There is the threat of death or serious injury • Feeling of intense fear, terror and helplessness • Normal physiologic functioning shuts down to allow body to defend itself. • Results in one of these behaviors: Fight or flight mechanisms activate resistance behaviors. Tonic Immobility or freezing

  22. Factors Related To Perpetrator • Object of penetration is usually not lubricated causing increased friction • This can result in: Pain, vaginal lacerations or ecchymosis

  23. Factors Related To Perpetrator • Increased force or prolonged contact • consistent with crimes of violence– Result: Increased probability of injury. (especially anal penetration)

  24. Factors Related To Perpetrator • Sexual dysfunction (not uncommon) • Prolongs duration of tissue friction Result: Increased probability of injury.

  25. Factors Related To Circumstances • Relationship between victim and perpetratorvictim/perpetrator with a history of intimacy acquaintance rape situation • Physical surroundings of assault • Objects used during the assault • Location of the assault (surfaces, etc.)

  26. Incidence Of Genital Injury • Injury is not an inevitable consequence of assault. • The absence of genital injury does not prove consent.

  27. Incidence Of Genital Injury • Genital injury occurs in 10-25% of sexual assaults using gross visualization. Lenahan et al, 1998; Slaughter & Brown, 1992; Cartwright et al. 1986; Tintalli et al, 1985. • Serious injury occurs in only 5%, death in 1% may be much lower, as many cases are not reported.

  28. A Critical Question In some cases there is no evidence of genital injury, Why ?

  29. Reasons for Non-identification of Genital Injury • Lubrication of vaginal vault • Anatomical structure and musculature of vagina • Delayed examination Most evidence of injury disappears in 2 weeks

  30. Reasons for Non-identification of Genital Injury • Known relationship (intimate) with perpetratorKinesthetic memory • Minimal force used by perpetrator • Age and Developmental Status Tissue resilience and healing • Elder victim • Child/adolescent victim

  31. Reasons for Non-identification of Genital Injury • Physical health and health history • Athletes, Illness, Surgery, Ob-Gyn history • Absence of vaginal contact • Non-resisting victim • Tonic Immobility and traumatic stress response

  32. Reasons for Non-identification of Genital Injury • Lack of magnification • Drops probability of detecting injury from 50-87 % to 10-30% (gross visualization) • Lack of examiner preparation & education

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