Rape in the District of Columbia

The prevalence of genital injuries in post-pubertal females presenting for forensic examination after reported sexual violence: a systematic review

BACKGROUND

Sexual violence is a prevalent issue in contemporary society requiring a robust forensic healthcare response. It is critically important that forensic examiners put clinical examination findings into an appropriate evidence-based context. The presence of genital injuries has been shown to increase the likelihood of successful criminal prosecution and report the crime. However, the reported rates of genital injury vary widely in published studies.

AIMS AND OBJECTIVES

We aim to critically evaluate and synthesize existing literature on the prevalence of genital injuries in post-pubertal females, examined following sexual violence, with a view to describing the prevalence and characteristics of genital injuries as well as the range of forensic practices employed.

METHODS

Three online databases (PubMed, Embase, and Scopus) were systematically searched with key terms.

RESULTS

Of the 1224 studies screened, 141 full-text publications met the inclusion criteria. Reported injury prevalence rates varied widely. Details pertaining to forensic examinations included in each study, such as grade of the examiner, type of examination, location of examination, and time interval from assault to examination also varied widely. Injury prevalence was highest in studies where enhanced visualization techniques were utilized.

CONCLUSIONS

This systematic review demonstrates that there is no universally agreed standard for documenting genital injuries in cases of sexual violence and highlights the need for standardized approaches and guidelines for assessing, documenting, and reporting these injuries. The review provides robust evidence to support a call for establishing consistent context, terminology, classification systems, and data collection methods to improve the comparability and reliability of future research findings.

An unusual vaginal injury in a young primigravida patient: A rare case report

INTRODUCTION

Assault with iron made belan causing penetration of it into vagina and perforation of posterior fornix is extremely rare. The commonly used weapon in assault are knife, wood, iron stick, wire, bomb or gun and most commonly affected body parts are cheeck, throat, back, abdomen, chest wall and extremities.

PRESENTATION OF CASE

We report a case of iron made belan penetrated into vagina with posterior fornix perforation and mesenteric tear in a 30 years old lady with history of pregnancy of 14 weeks. She was haemodynamically unstable at the time of presentation. She was treated with advanced trauma life support Protocol (ATLS), taken to operation room where iron made belan was removed with repair of posterior fornix and mesentery was done.

DISCUSSION

Assault to genital organ in female is not uncommon. In present case the offender used the metallic iron made belan for assault which is the house hold material in India. In such situation high degree of suspicion and diagnostic modality are helpful to save the golden hour of patient and save the life of patients. General principles of trauma management is really very helpful to save the life threatening conditions. Urgent exploratory laparotomy with control of bleeding and repair of damaged structures are the cornerstone steps to manage such cases.

CONCLUSION

Assault with iron made belan and its penetration inside vagina is extremely rare mode of injury. Timely intervention, concept of ATLS and definitive surgical interventions are the key steps in managing such patient.

Strategic categorization of available research relating to sexual assault and rape facilitates more accurate interpretation of injury data

The available research evidence pertaining to anogenital injury in victims of sexual violence presents a very wide range of injury prevalence data. As such, it is extraordinarily challenging for health care practitioners involved in clinical forensic examination of victims of sexual violence to place their examination findings in to context. It is generally accepted that the broad range of existing injury prevalence data is reflective of heterogeneous research study methodologies and clinical practice techniques. Thus, health care practitioners should be encouraged to present their evidence in the context of the prevalence data that are most representative of their clinical practice. Presented herein is a simple categorization of existing prevalence data in accordance with national clinical practice guidelines. The range of anogenital injury prevalence is narrower when presented in this manner than when taken as a whole. This will facilitate health care practitioners in presenting their examination findings in the context of research literature that is most representative of their clinical practice.

Forensic sexual assault examination and genital injury: is skin color a source of health disparity?

PURPOSE

The study objectives were to (1) estimate the frequency, prevalence, type, and location of anogenital injury in black and white women after consensual sex and (2) investigate the role of skin color in the detection of injury during the forensic sexual assault examination.

METHODS

A cross-sectional descriptive design was used with 120 healthy volunteers who underwent a well-controlled forensic examination after consensual sexual intercourse.

RESULTS

Fifty-five percent of the sample had at least 1 anogenital injury after consensual intercourse; percentages significantly differed between white (68%) and black (43%) participants (P = .02). Race/ethnicity was a significant predictor of injury prevalence and frequency in the external genitalia but not in the internal genitalia or anus. However, skin color variables--lightness/darkness-, redness/greenness-, and yellowness/blueness-confounded the original relationship between race/ethnicity and injury occurrence and frequency in the external genitalia, and 1 skin color variable--redness/greenness--was significantly associated with injury occurrence and frequency in the internal genitalia.

CONCLUSIONS

Although differences exist in anogenital injury frequency and prevalence between black and white women, such differences can be more fully explained by variations in skin color rather than race/ethnicity. Clinical recommendations and criminal justice implications are discussed.

Defining patterns of genital injury from sexual assault: a review

The forensic examination following rape has two primary purposes: to provide health care and to collect evidence. Physical injuries need treatment so that they heal without adverse consequences. The pattern of injuries also has a forensic significance in that injuries are linked to the outcome of legal proceedings. This literature review investigates the variables related to genital injury prevalence and location that are reported in a series of retrospective reviews of medical records. The author builds the case that the prevalence and location of genital injury provide only a partial description of the nature of genital trauma associated with sexual assault and suggests a multidimensional definition of genital injury pattern. Several of the cited studies indicate that new avenues of investigation, such as refined measurement strategies for injury severity and skin color, may lead to advancements in health care, forensic, and criminal justice science.

Genital findings of women after consensual and nonconsensual intercourse

After a sexual assault, forensic nurses, nurse practitioners, and physicians are called on to collect evidence, document any genital injuries, and testify about the significance of injuries. Recently, the scientific rigor of the research has been challenged in the courts.

Epidemiologic issues of sexually transmitted diseases in sexual assault victims

The objective of this study was to investigate the epidemiologic aspects of sexually transmitted diseases (STDs) in victims of sexual assault and to discuss the methodological issues in determining risk of STD acquisition. We performed a comprehensive review of the medical literature to determine the prevalence of STDs in victims of sexual assault. A MEDLINE search and a search of bibliographies of published manuscripts was performed to discover relevant articles published in the English language. Studies were included in our review if they provided estimates of the prevalence of infection with Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, Trichomonas vaginalis, or human papillomavirus (HPV). The main outcome measure was prevalence rates of STDs in victims of sexual assault. It is difficult to determine the rate of newly acquired STDs from sexual assault. In the populations studied the prevalence of STDs can be summarized as follows: N. gonorrhoeae 0.0 to 26.3 percent; C. trachomatis 3.9 to 17 percent; T. pallidum 0.0 to 5.6 percent; T. vaginalis 0.0 to 19.0 percent; and HPV 0.6 to 2.3 percent. We conclude that prevalence estimates vary widely depending on the population studied and known risk factors for STDs. Given the limited follow-up rates in this population, preventive treatment for STDs in addition to emergency contraception should be offered in most instances.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader will be able to estimate the prevalence of STD transmission from an act of sexual assault, to describe the various types of STDs that a sexual assault victim is at risk for, and to explain the role of preventive therapy in this setting.

Who consults for rape? Sociodemographic characteristics of rape victims attending a medical rape trauma service at the Emergency Hospital in Oslo

OBJECTIVE

To consider the number of victims of rape and attempted rape in a city (Oslo) who sought treatment when medical help had been made available. To examine the sociodemographic characteristics of the patient group that applied for help.

DESIGN

Prospective study.

SETTING

A rape trauma service (RTS) established at the Emergency Hospital in Oslo. The service is free, open around the clock, and independent of police notification.

PARTICIPANTS

All patients attending RTS from 1 January to 31 December.

RESULTS

164 women and four men applied for medical treatment in 1987, four times as many as in 1985, before RTS was started. Their ages varied between 14 and 89 years, with a median of 27 years. Women aged 14-39 years were significantly over-represented in relation to the general female population of Oslo. Married women were significantly under-represented among the female patients, both married women raped by their spouses and married women raped by other men. 45 patients stated that they had been sexually assaulted on a previous occasion without reporting the incident or applying for help.

CONCLUSION

Compared with the police an available medical service for rape victims reached four times as many rape victims as in 1985, from a larger share of the population.

Incubating syphilis in an adolescent female rape victim

The risk of infection after rape is believed to be low. The use of presumptive treatment is, therefore, controversial. Some experts recommend treatment of all patients, and others suggest treatment if the doctor suspects infection, if the patient requests it, if follow-up examination of the victim cannot be ensured, or if the assailant has a known infection. No regimen will cover all possible pathogens. The Centers for Disease Control's empiric regimen for victims of sexual assault is effective against gonorrhea, chlamydia, and, most likely, syphilis. We present a case of incubating syphilis following rape, that did not respond to ceftriaxone.

Sexually transmitted diseases in rape victims

From 1 January 1986 to 1 September 1989 124 women presented to the Ambrose King Centre (the department of genitourinary medicine of the London Hospital) alleging rape. Sexually transmitted diseases were found in 36 (29%) women (excluding candidosis and bacterial vaginosis). The commonest organisms detected were Neisseria gonorrhoeae and Trichomonas vaginalis, each being present in 15 patients. Eleven women had genital warts. Chlamydia trachomatis was isolated in six patients, two had herpes simplex virus infection and one patient had pediculosis pubis. Serological evidence of past hepatitis B infection was detected in five women and one patient had antibodies to human immunodeficiency virus. Eighteen of the 36 women (50%) had multiple infections. Six women had abnormal cervical cytology smears, three being suggestive of cervical intraepithelial neoplasia grades II-III. Although it is rarely possible to attribute infection to an assailant, these patients require further counselling, treatment and review. Rape victims are thus a population at risk of having sexually transmitted diseases and screening should be offered.

Sexually transmitted diseases and rape: the experience of a sexual assault centre

Epidemiological data and rates of sexually transmitted diseases (STDs) are presented from a group of 90 women screened following rape. Forty-eight (53%) women knew their assailant. In 6 cases multiple assailants were involved. In 21 (23%) rapes weapons were used. Of 47 women examined within 48 hours of rape, 17 (36%) had evidence of genital trauma. Anal injury was common (8 of 11, 73%) in those reporting anal intercourse. Anal assault (17 of 90, 19%) and oral assault (16 of 90, 18%) commonly accompanied rape. STDs were diagnosed in 13 (14.4%) women, 3 having mixed infections. Neisseria gonorrhoeae was isolated in 2 women, Chlamydia trachomatis in 7, Trichomonas vaginalis in 6, genital warts in 2 and Pediculosis pubis in 2 women. Five of 16 cervical cytology results showed abnormalities, 2 were suggestive of CIN. Eleven of 13 women with an STD (84.6%) had been sexually active within the 3 months prior to the rape. Previous sexual activity may be the most relevant factor determining those most at risk of harbouring an STD.

Sexually transmitted diseases in victims of rape

The risk of acquiring a sexually transmitted disease as a result of rape is not known, in part because it is difficult to ascertain whether infections were present before the assault or acquired during it. To investigate this question, we examined female victims of rape within 72 hours of the assault and again at least one week after the assault. Of the 204 girls and women initially examined within 72 hours of the rape, 88 (43 percent) were found to have at least one sexually transmitted disease. These diseases included infections caused by Neisseria gonorrhoeae (6 percent of those tested), cytomegalovirus (8 percent), Chlamydia trachomatis (10 percent), Trichomonas vaginalis (15 percent), herpes simplex virus (2 percent), Treponema pallidum (1 percent), and the human immunodeficiency virus type 1 (HIV-1; 1 percent) and bacterial vaginosis (34 percent). Among the 109 patients (53 percent) who returned for at least one follow-up visit (excluding those who were found to be infected at the first visit or who were treated prophylactically), the incidence of new disease was as follows: gonorrhea, 4 percent (3 of 71); chlamydial infection, 2 percent (1 of 65); trichomoniasis, 12 percent (10 of 81); and bacterial vaginosis, 19 percent (15 of 77). There were no new infections with herpes simplex virus, cytomegalovirus, Trep. pallidum, or HIV-1, but follow-up serologic testing was performed in only 26 percent of the patients. On the basis of our assumptions that most venereal infections present within 72 hours of a rape were preexisting and that new infections identified 1 to 20 weeks later were acquired during the assault, we conclude that the prevalence of preexisting sexually transmitted diseases is high in victims of rape and that they have a lower but substantial additional risk of acquiring such diseases as a result of the assault.

Sexual assault patterns

The numbers and types of all sexual offences examined at the Metropolitan Police Forensic Science Laboratory during the years 1978-1986 are presented. The largest number of sexual assaults took place during the month of August; they were mainly intra-racial and between adults of 18 to 30 years of age. A detailed breakdown is given of the offences against females recorded on the Sexual Assault Index. All these assaults were carried out by adult males, mainly strangers. Nearly half the assaults took place indoors, where victims were more likely to be bound and blindfolded, compared with one-third outdoors and one-sixth in vehicles. About one-fifth of the crimes were carried out by two men or more, and in one-third of cases, weapons were carried. Oral intercourse occurred in one-sixth and anal intercourse in one-twelfth of the offences, both performed more by white males and those of Mediterranean origin.

Toluidine blue in the corroboration of rape in the adult victim

Objective physical evidence to corroborate a claim of rape is frequently absent. Genital lacerations are considered evidence that rape has occurred. In this study, toluidine blue dye, a nuclear stain, was used to detect vaginal lacerations. The detection of vaginal lacerations in reported rape victims increased from one in 24 to 14 in 24 with toluidine application. Toluidine blue increases the detection of perineal lacerations in adult rape victims and the presence of lacerations is supportive of the documentation of rape.

[The effects of rape 6 months after the attack and factors associated with recovery]

In this study a group of 27 victims seen approximately 6 months after the assault was compared to a matched control group. The results show significantly higher scores on two subscales of IPAT ("ego weakness" and "disposition to guilt") and on 4 scales of the MMPI ("denial", "hypochondriasis", "depression" and "conversion hysteria"); also, the victims' social adjustment seems inferior and the frequency of sexual relations has been reduced considerably for them. The following factors have been evaluated in order to test their relation to the adjustment to the assault: rape by a stranger versus someone known, degree of violence, feelings of self-blame, problems during the crisis, predominant thoughts, professional help, social support, stable relationship, allusion to victim's responsibility for rape and conviction or not of the aggressor. Even though most of these variables show a significant simple correlation with adjustment to rape only four among them remain significantly associated when sociodemographic variables, pre-rape psycho-social problems and life stressors are controlled; the very subjective variable "predominant thoughts" seems to best explain differences in adjustment. The importance of pre-assault variables and of the subjective reaction to rape is discussed.

Incidence of sexually transmitted diseases in rape victims during 1984

During 1984, 46 women attended the sexually transmitted disease (STD) clinic at St Mary's Hospital alleging that they had been raped. At presentation, 31 (67%) were asymptomatic. Evidence of STD was found in 14 (30%) women, mixed infections occurring in four. Chlamydia trachomatis and Trichomonas vaginalis were each detected in six (13%) patients and Neisseria gonorrhoeae in three (6%). The source of the infection could not confidently be traced to the alleged rapist. Two patients were found to have cervical cytological abnormalities suggestive of cervical intraepithelial neoplasia of grades II or III. One woman became pregnant as a consequence of the sexual assault. Investigations may unveil infection or other abnormalities, which are incidental to the rape but nevertheless require further investigation and treatment.

Reported sexual assault in Nashville-Davidson County, Tennessee, 1980 to 1982

A review of the experience of 440 women reporting they had been raped was made from their initial contact with the police, through their medical-forensic examination at the county hospital emergency room, by any judicial proceedings, and by their longer term psychological counseling. The data were then compared with those from other municipalities. The assailant's use of a weapon seemed the strongest variable correlated with the victim's decision to press for prosecution. Being raped by a stranger or being physically injured did not correlate with this decision. Women most likely to have been victims of a previous rape were over 40 years old, were black, were assaulted by someone well known to them, or had some sort of mental health problem, and these variables were independent of each other. This implies these victims somehow suffer from an increased vulnerability to repeated rape. The data suggest that use of a county hospital emergency room for the medical management of rape victims discourages their reporting the event to the authorities and their seeking medical treatment.