Transcript SART - Disability and Abuse Project

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
[email protected]
760-739-3444
Disability Issues:
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Physical issues
Developmental delay
Communication tools/or lack of
Resources available
SARTs-Where are they?
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Hospital ERs
Free-standing facility
Private
Combination
Rural vs. large metropolitan area
Move towards freestanding SARTs/DVs
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Provide best practice for victims of
violence
Confidentiality
Pre-text phone calls
Customers are??
Storage of evidence and records
Underreporting by Victims
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Incidence studies
• Uniform Crime Reports
• National Crime Victimization Survey
• Only 28% of victims report to police
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Prevalence studies
• Russell (1984) - 1 in 12 reported to
police
• Koss (1987) - 8% reported to police
Goals of the Sexual
Assault Medical-Legal
Examination
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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.
Injury Mechanisms
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Blunt Force
• Abrasions
• Contusions
• Laceration
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Sharp force
Burns
Bite injuries
Strangulation injury
Strangulation Injury
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Form of asphyxia (lack of oxygen)
Closure of blood vessels and/or air
passages in the neck
External pressure on the neck.
• Ligature
• Manual
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Airway obstruction may also result from
choking (foreign body), smothering,
inflammation or asphyxiation.
Nonspecific and Subjective
Injury
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Erythema redness of the skin
or mucous
membranes
produced by
congestion
(dilation) of the
capillaries.
• Problem - there
are many causes
other than trauma
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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.
Nongential Injury
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Head/face/neck
Thighs/legs/arms
Incidence of Genital Injury
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Genital examination performed with
gross visualization and plain light
alone.
• Within 72 hours following sexual
assault.
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Genital injuries ranged from 16-27%
• 5 studies from 1983-1997 - 7,146
subjects.
Genital Injury Detected
Unaided
Year
1983
1985
1986
1991
1997
Study
Solola
Tintinalli
Carwright
Satin
Bowyer
# pts
621
372
440
5,620
83
% Injured
22%
19%
16%
21%
27%
Toluidine Blue Aids Injury
Detection
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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
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Consenting controls showed injury
also
• 7-10% in adult females
• 28% in adolescent females
Lauber & Soma 1982, McCauley 1986, 1987
Colposcopy Aids Injury
Detection
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Colposcopic exams of sexually assaulted
females raised genital injury detection rate
• 58-71% in adult female victims
• 63% in adolescent female victims
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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)
Specific Genital Injury
Location
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Posterior fourchette is the most
common site of injury.
• 28-40% using toluidine blue dye
Lauber & Soma 1982, McCauley 1986
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Labia majora and minora is the
second most common genital injury
• 13%
Adams 1996, Biggs 1998
Number of Injury Sites
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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
Findings
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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.
Injury to the Hymen
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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%
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The hymen is not always injured in first
sexual intercourse, consenting or nonconsenting.
Adams 1996, Biggs 1998, Emans 1994
Injury to the Cervix
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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
Absence of Genital Injury
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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
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Wide range of lack of injury reflects.
• Exam methodology differences
• Variable examiner experience.
Everett 1997, Tintinalli 1985, Adams 1996,
Bowyer 1997, Biggs 1998
Absence of Genital Injury
Year
1977
1985
1996
1997
1998
Study
Everett
Tintinalli
Adams
Bowyer
Biggs
# pts
117
372
26
83
132
% Injured
36%
68%
31%
73%
53%
Non-genital Injury
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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
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Non-genital injury rate 23-85%
• 5 studies (1972-1997) 2,547 subjects
Haymen 1972, Solola 1983, Tintinalli 1985,
Pentilla 72%, Bowyer 1997
Injuries in the Male Victim
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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
Finding Sperm
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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.
Sperm Recovery in Living
Victims
Body Cavity
Vagina
Cervix
Mouth
Rectum
Anus
Motile Sperm
6 - 28 h
3 - 7.5 d
-------
Non-motile
14 h - 10 d
7.5 - 19 d
2 - 31 h
4 - 113 h
2 - 44 h
Woods Lamp
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Not all that fluoresces is ejaculate.
Not all ejaculate fluoresces.
Possible Factors Said to
Affect Injury Rate
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Sexual experience
Relationship of
victim to assailant
Parity
Human sexual
response
Drugs/Alcohol
Coital position
Use/lack of force
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Relaxation
Genital size match
Multiple events or
partners
Male sexual
dysfunction
Tissue fragility
• Hormone deficiency
• Inflammation
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Extrinsic lubrication
Prior Sexual Experience
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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
Victim-Assailant
Relationship
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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
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More non-genital injuries are likely to
occur when assaulted by a stranger
compared with acquaintance.
Lindsay (unpublished) 1998, Stermac 1995
Genital Trauma: Alcohol Use
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When sexual assault victims were.
• Under the influence of alcohol
• Unconscious due to alcohol use
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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
Human Sexual Response
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Sequence of
physical/physiologic
changes in response
to sexual stimulation
4 Phases
•
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Excitation
Plateau
Orgasm
Resolution
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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.
Questions and Problems
with Conclusions/Opinions
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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.
Potential Visible Positive
Findings
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Examiner summarizes positive findings.
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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.
Forming a Medical Opinion
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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.
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Draw on clinical experience.
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Anticipate prosecution/defense strategy.
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Form responsible conclusion statement.
Avoid Inappropriate
Conclusions
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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.
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Neither rape nor consent should ever
be diagnosed from the examination.
Avoid Problematic
Conclusions
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Degree of force used by assailant.
• The presence of an injury speaks for
itself
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Consent vs. non-consent.
• The presence or absence of injuries
does not answer this question
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Traumatic vs. non-consensual
penetration.
• These are not synonymous
Appropriate Conclusions
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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.
Significance of Findings
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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
Medical Concerns
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STD prophylaxis.
Emergency pregnancy prophylaxis.
HIV referral/testing.
Hepatitis B.
How to Reduce Problems/
Prevalence in Conclusions/
Opinions
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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.
And You Heard It In Court
Under Oath
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“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
True or False?
Force + penetration = Rape
2. Traumatic intercourse = Non-consent
3. No human sexual response = Nonconsent
4. Human sexual response = Consent
5. Normal finding - Consent
6. Three or more genital lesions = Nonconsent
7. The colposcope can diagnose rape
1.
Obstacles & Opportunity to
“Collaborate”
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Financial/cost
Education/training
Inability to adapt to advances in
forensic and clinical medicine
• i.e.: primary prevention
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Lack of nurses - health care
personnel crisis
Border issues/USA
Always do right. This will gratify some
people and astonish the rest.
Mark Twain