Patterned genital injury in cases of rape – A case–control study

doi:10.1016/j.jflm.2013.03.003

Journal of Forensic and Legal Medicine

Volume 20, Issue 5, July 2013, Pages 525-529

https://doi.org/10.1016/j.jflm.2013.03.003 Get rights and content

Abstract

A pattern of genital injury that separates trauma seen in sexual assault cases from trauma seen following consensual sexual intercourse has been a matter of debate. This study aimed at clarifying the question by eliminating as many confounders as possible in a prospective, case-control setup. A total of 98 controls and 39 cases were examined using the naked eye, the colposcope and toluidine blue dye followed by colposcopy. The overall frequency of having at least one lesion was strikingly similar in the two groups, but cases had significantly more abrasions, a trend towards more haematomas and a higher frequency of multiple lesions. Cases had a higher frequency of lesions in locations other than the 6 o'clock position. Our data suggests that cases have larger, more complex lesions. In conclusion, this study has confirmed the existence of different patterns of genital lesions. Background data for detection of genital lesions using the three most commonly used techniques is provided. These results will aid in the interpretation of findings seen when examining sexual assault victims.

Introduction

The existence of a pattern of genital injury distinguishing trauma seen in rape cases and trauma seen following consensual sexual intercourse has been a matter of debate. Typical different patterns was suggested by Slaughter et al. in 1997 i.e. multiple genital lesions at multiple locations seen in rape victims as opposed to single lesions in the posterior forchette following consensual sexual intercourse.¹ This pattern has to some degree been confirmed in adults² and adolescents,³ whereas a third study could not confirm such a pattern.⁴ A more detailed description of a pattern would aid the medico-legal expert when giving evidence based testimony in court proceedings.

This study aimed to describe the pattern of injury in a prospective, controlled setting using the three most commonly used objective measures worldwide – the naked eye, colposcopy and toluidine blue dye followed by colposcopy.5, 6

Section snippets

Methods

The present study was part of a larger study conducted at the Southern Denmark Sexual Assault Referral Centre (SDSARC) as collaboration between the Institute of Forensic Medicine, University of Southern Denmark and the Department of Gynaecology and Obstetrics, Odense University Hospital. Data and results regarding the control group has been published in detail.⁶ The SDSARC is a 24 h service that receives victims of sexual assault of both sexes, ≥15 years of age, with or without prior police

Study population

A total of 71 women were seen by a forensic physician at SDSARC in the inclusion period. Of these, 32 were excluded: 12 did not wish to participate, 9 were minors accompanied by other than a legal guardian, 8 were excluded due to psychological issues such as psychiatric disease, mental retardation or severe intoxication, and 3 cases due to technical problems. All cases, including minors, had previous sexual experience. After inclusion it was revealed, that 12 of the 110 controls did not fulfil

Discussion

This study is, to our knowledge, the first prospective, case-control study of female genital lesions seen after sexual intercourse. It is also the first study to report results using all three investigative methods in common use around the globe, making the results useful in all settings. We confirmed the differences in genital lesions seen following rape and consensual sexual intercourse proposed in earlier papers.1, 2, 4, 5 The overall frequency of having one or more lesion of any kind was

Conclusion

In this prospective case-control study of genital lesions following non-consensual and consensual sexual intercourse, we have confirmed different patterns of lesions. A single laceration at the 6 o'clock position is the most common finding in both groups, but any other positive finding was more common in the case group. Cases had more complex lesions with a higher frequency of abrasions, haematomas and multiple lesions and a higher frequency of lesion in other locations than the 6 o'clock

Ethical approval

The study was approved by the Medical Research Ethics Committee of Southern Denmark.

Funding

None declared.

Conflict of interest

The authors of this paper hereby declare that we have no conflict of interest regarding the present study.

References (13)

L. Slaughter et al.
Patterns of genital injury in female sexual assault victims
Am J Obstet Gynecol
(1997)
I. McLean et al.
Female genital injuries resulting from consensual and non-consensual vaginal intercourse
Forensic Sci Int
(2011)
B.S. Astrup et al.
Nature, frequency and duration of genital lesions after consensual sexual intercourse-implications for legal proceedings
Forensic Sci Int
(2012 Jun 10)
M.S. Sommers et al.
The effects of age and ethnicity on physical injury from rape
J Obstet Gynecol Neonatal Nurs
(2006)
C. Rechtin et al.
The effects of skin pigmentation on the detection of genital injury from sexual assault: a population-based study
Ann Emerg Med
(2009 Sep)
J.S. Jones et al.
Assailants' sexual dysfunction during rape: prevalence and relationship to genital trauma in female victims
J Emerg Med
(2010 May)

There are more references available in the full text version of this article.

Cited by (27)

Anogenital injury following sexual assault and consensual sexual intercourse: a systematic review and meta-analysis
2023, eClinicalMedicine
Sexual violence is a grave human rights violation and a serious global public health challenge. Rates of reporting of sexual violence and subsequent passage of cases through the criminal justice system are poor all over the world. The presence or absence of anogenital injury following sexual assault may influence survivors in their willingness to report a crime, and law enforcement officers and jurors in their decision making regarding the laying of charges and/or conviction of offenders. The aim of this systematic review was to compare rates of identification of anogenital injury (AGI) in women following sexual assault and consensual sexual intercourse using the same examination techniques.
In this systematic review and meta-analysis, Medline, Embase and Google Scholar were searched for relevant studies (in any language, with no age or sex criteria) published between February 25, 1993, and February 25, 2023, that directly compared AGI between individuals after either sexual assault or consensual sexual intercourse. Abstracts, conference proceedings, and case reports were excluded. The primary outcome of interest was any form of detected AGI. The Mantel-Haenszel method was used for meta-analysis using random effects modelling to determine the risk ratio (RR) of AGI between sexual assault and consensual sexual intercourse. Quality assessment was undertaken using the Newcastle–Ottawa scale tool. The I² statistic was used to determine heterogeneity among studies. An I² >75% was considered high heterogeneity. Funnel plots were used to assess the risk of publication bias, by determining any visually apparent asymmetry. This analysis is registered with PROSPERO, CRD42023402468.
We included 10 studies, accounting for 3165 study participants. All participants were female. AGI was detected in 901 (48%) of 1874 participants following sexual assault and 394 (31%) of 1291 participants following consensual sexual intercourse. Meta-analysis of all included studies demonstrated that the presence of AGI was significantly more likely for participants following sexual assault than consensual sexual intercourse (RR 1.59 (95% CI 1.21, 2.09); p < 0.001). There was a significant heterogeneity among studies and funnel plots suggest that this RR may be an over-estimation. Subgroup analysis including only high-quality studies showed no significant difference between groups.
Although AGI was significantly more likely to be detected after sexual assault than consensual sexual intercourse, more than half of survivors of sexual assault have no detectable injuries. The presence of AGI, therefore, does not prove there has been sexual violence and absence of injury does not refute that sexual assault has occurred.
The University of Birmingham.
Acute concomitant injury and intoxication in complainants of recent sexual assault: A review
2022, Journal of Forensic and Legal Medicine
Sexual assault remains a highly prevalent crime worldwide and has the potential to cause a number of short and longer-term health sequelae. Complainants of recent sexual assault may undergo forensic and/or medical examinations for medical treatment or evidence collection, or both. However, the frequency and severity of acute health concerns requiring medical intervention in these patients at the time of examination is not well understood and has implications for their clinical care and safety.
To examine the frequency and severity of acute concomitant health concerns at the time of forensic examination following an allegation of recent sexual assault in post-pubertal (age >13 years) individuals, through a review of existing literature. Concomitant health concerns considered in this review include ano-genital and extra-genital injury, and acute substance intoxication.
Four online databases (PubMed, Ovid Medline, CINAHL, Embase) were systematically searched with key terms regarding the topics of sexual assault, forensic examination, injury and intoxication. Articles were assessed for relevance based on inclusion and exclusion criteria.
Of 562 titles, 53 full-text publications met the inclusion criteria. Frequency of ano-genital and extra-genital injury was highly variable across studies, and severity was inconsistently assessed and rarely reported. Medical treatment or transfer to acute care settings was more commonly required for extra-genital injuries. Non-fatal strangulation (NFS) was found to represent an increasingly frequent feature of sexual assault cases. NFS complainants often exhibit signs and symptoms of potentially lethal complications requiring urgent review in acute care settings. Substance use around the time of sexual assault was commonly reported by patients and detected in toxicological screens, and could have significant implications on patient and staff safety at the time of examination.
The findings of this review highlight the clinical significance of acute concomitant health concerns following an allegation of recent sexual assault. Ano-genital and extra-genital injury, NFS and both voluntary and involuntary substance use may be more frequent and severe than previously understood. Further investigation into the assessment and management of these acute health needs is required to elucidate their clinical significance and inform evidence-based care for complainants of sexual assault.
The pattern of genito-anal injuries in female sexual assault cases in Mumbai, India
2021, Forensic Science International: Reports
Citation Excerpt :
Injuries were more in those victims who were virgins [1,15,26]. It has been reported that genito-anal injuries are possible after vigorous consensual sex [27,28]. As in most of the cases genito-anal injuries are absent, there is a possibility that the police and court might presume that rape has not occurred [25].
The prevalence of genito-anal injuries in victims of sexual assault depends on several factors. Forensic examination, documentation of injuries and preparing report thus becomes challenging for healthcare providers as the presence or absence of injuries aids in the subsequent laying of charges against the accused. This paper aims to determine the pattern of genito-anal injuries and factors associated with the laying of charges against the accused.
A cross-sectional study of victims of sexual assault (n = 440) was conducted between 2014 and 2017 in a specialized tertiary care center in a Metropolitan city in India. The results were expressed as proportion and percentage. Chi-squared test was used to analyse data using SPSS version 23.0.
There was no statistically significant association between reporting within 72 h of sexual assault and the arrest of the accused. Vaginal and anal bleeding were present in 4.1% cases and 2.7% cases respectively. Genital and anal injuries were present only in 30.9% of cases. The most common genito-anal injury was laceration (72.08%). Posterior fourchette injury (most common site) was present in 27.94% of cases. Extra genital injuries were found in 24.09% of victims. The most common extra genital injury was abrasion (26.42%). Intoxicants were found in the blood of 4.8% of victims and spermatozoa/semen was found in swabs from 3.6% of victims. In this study 25.9% of perpetrators were arrested, out of which 84.37% of adult victim’s cases and 94.23% of minor (<18 years) victims cases went to trial. In 3.12% of adults and 0.6% of minor victims, the accused was found guilty and sentenced to imprisonment. The presence of genital injury, visualization of sperm by direct microscopy, assailant known to the victim and pregnancy of the victim were not significantly associated with the laying of charges (p > 0.05) and were dropped from the model. The odds ratio (OR) for charge-laying associated with the age of the victim < 18 years was 3.02 (95% confidence interval [CI] 1.02–9.14). Arrests in accused of both victims > 18 years age and < 18 years age were more common if the accused was known to the victim. Injuries in victims < 18years of age and > 18 years of age did not appear to have any influence over the arrest. A notable finding was a high proportion (75.51% in <18 years and 77.77% in >18 years) of cases where an arrest was effected in adults and child sexual assault cases where no injuries were described.
This study shows the pattern of genito-anal injuries and factors associated with the laying of charges in sexual assault cases in a developing country. It should be noted that most of those exposed to sexual assault do not have visible genito-anal injuries. We report that age is significantly associated with the presence of genito-anal injuries. However, it is important to note that the presence of injuries does not prove rape, neither its absence disproves the act. The information gathered by a meticulous forensic examination does make a difference in the legal outcome for cases of sexual assault.
Comment to the article: Discriminating between consensual intercourse and sexual assault: Genital-anal injury pattern in females
2021, Journal of Forensic and Legal Medicine
Anal/anogenital lesion revealing child sexual abuse: A case series of an unusual situation in a black African setting
2020, International Journal of Surgery Case Reports
Citation Excerpt :
According to WHO, child sexual abuse (CSA) is the involvement of a child in sexual activity that he/she does not fully understand and/or is unable to give informed consent [1,2]. Globally, the prevalence of genito-anal injuries after sexual abuse is estimated between 9% and 87% depending on the ages of the survivors in the sample, method of examination and the type of injuries included [3–5]. The earliest study of CSA in Africa dates back in 1984 by Westcott et al., who described 18 cases at a Cape Town hospital [6].
Child sexual abuse (CSA) remains a big taboo in black Africa with an underestimated prevalence. In our context, the majority of cases are known by revelations of the child at least one year after the facts.
We report three cases of CSA revealed by an anal/anogenital lesion requiring surgery. All of these patients were female with ages ranging from 20 months to 8 years. The lesions encountered were: an anal abscess, a fissure-in-ano with permanent anal mucosal eversion and a complex perineal tear including partial anal sphincter rupture with partial section of the rectovaginal septum. The outcome was favorable in all cases after surgery. The abuser was subsequently able to be identified after the statements of two of these three children.
Detection of anogenital lesions during a pediatric consultation should make practitioners aware of the possibility of sexual abuse. Surgical repair of these lesions can be simple or complex, requiring major reconstructions. In such cases, it’s important to listening to the child’s voice.
Anogenital lesions discovered during pediatric consultation must evoke sexual abuse. The silence and the taboo surrounding these abuses in Africa must be break down.
Genital and anal injuries: A cross-sectional Australian study of 1266 women alleging recent sexual assault
2017, Forensic Science International
Citation Excerpt :
Of these six, only three [4,19,20] in addition to the Australian study conducted by Lincoln et al. [8] excluded redness and swelling as injuries and therefore are suitable for comparison of genital injury frequency following completed vaginal penetration with our study. A further four more recent studies not reviewed by Lincoln, have significant methodological differences to our study precluding comparisons with our findings [24–27]. Of the four comparable genital injury studies, the earliest study (1992) reported a 9% prevalence of genital injury [4], much lower than our overall prevalence of 22%.
To describe the frequency of genital and anal injury and associated demographic and assault characteristics in women alleging sexual assault.
Cross-sectional study.
Sexual Assault Resource Centre (SARC), Western Australia.
Total of 1266 women attending SARC from Jan-2009 to Mar-2015.
Women underwent a standardised data collection procedure by forensically trained doctors. Multivariate logistic regression analyses were performed.
(1) Frequency of genital and anal injuries by type of sexual assault. (2) Identification of independent factors associated with genital and anal injuries following, respectively, completed vaginal and anal penetration.
Genital injury was observed in 24.5% of all women with reported completed vaginal penetration; in a subset with no prior sexual intercourse 52.1% had genital injury. Genital injury was more likely with no prior sexual intercourse (adjusted odds ratio [adj. OR] 4.4, 95% confidence interval [95%CI] 2.4–8.0), multiple types of penetrants (adj. OR 1.5, 95%CI 1.0–2.1), if general body injury present and less likely with sedative use and delayed examination. Anal injury, observed in 27.0% of reported completed anal penetrations, was more likely with multiple types of penetrants (adjusted OR 5.0, 95%CI 1.2–21.0), if general body injury present and less likely with delayed examination.
This study separately quantifies the frequency of both genital and anal injuries in sexually assaulted women. Genital injuries were absent in a large proportion of women regardless of prior vaginal intercourse status. It is anticipated that findings will better inform the community, police and medico-legal evidence to the criminal justice system.

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Short reportPatterned genital injury in cases of rape – A case–control study

Abstract

Introduction

Section snippets

Methods

Study population

Discussion

Conclusion

Ethical approval

Funding

Conflict of interest

Am J Obstet Gynecol

Forensic Sci Int

Forensic Sci Int

J Obstet Gynecol Neonatal Nurs

Ann Emerg Med

J Emerg Med

Short report
Patterned genital injury in cases of rape – A case–control study