Comparative analysis of adult versus adolescent sexual assault: epidemiology and patterns of anogenital injury.
Jones JS; et al.
Academic Emergency Medicine: Official Journal Of The Society For Academic Emergency Medicine [Acad Emerg Med] 2003 Aug; Vol. 10 (8), pp. 872-7.
Abstract:
Objectives: To compare the characteristics of sexual assault in pubertal girls (<18 years old) and adults in a community-based population of women presenting to an urban sexual assault clinic.
Methods: This case-series analysis evaluated consecutive female patients presenting to a sexual assault clinic during a three-year study period. The clinic is associated with a university-affiliated emergency medicine residency program and is staffed by forensic nurses trained to perform medicolegal examinations using colposcopy with nuclear staining. Patient demographics, assault characteristics, and injury patterns were recorded using a standardized classification system. Data from the two patient groups (adolescents vs. women > or =18 years of age) were analyzed using chi-square test and t-test.
Results: A total of 766 cases were identified: 43% of the victims were 13 to 17 years old (mean 15.0 years old), and 57% were older than 17 years old (mean 30.8 years old). Adolescents were more likely to be assaulted by an acquaintance or relative (84% vs. 50%, p < 0.001) and to delay medical evaluation (17 hours vs. 12 hours, p < 0.001) than were older women. Adolescent sexual assault was less likely to involve weapons or physical coercion (29% versus 57%, p < 0.001) and was associated with fewer nongenital injuries (33% vs. 55%, p < 0.001). Adolescents had a greater frequency of anogenital injuries (83% vs. 64%, p < 0.001), however, compared with older women. Common sites of injury in adolescents were posterior, including the fossa navicularis, hymen, fourchette, and labia minora. The injuries showed consistent topologic features, varying with the site and nature of tissue. Adult victims of sexual assault had a less consistent pattern of anogenital injuries with fewer hymenal injuries, greater injury to the perianal area, and widespread erythema.
Conclusions: Of women presenting to an urban sexual assault clinic, 43% were adolescents. The epidemiology of sexual trauma and the pattern of anogenital trauma in this age group are unique and may pose special challenges to emergency health care providers.

Healing patterns in anogenital injuries: a longitudinal study of injuries associated with sexual abuse, accidental injuries, or genital surgery in the preadolescent child.
Heppenstall-Heger A, et al.
Pediatrics [Pediatrics] 2003 Oct; Vol. 112 (4), pp. 829-37.
Abstract:
Objective: To study healing patterns of anogenital trauma in prepubescent children.
Methods: A prospective 10-year study was conducted of 94 children who had anogenital trauma and were followed to healing and documented using a colposcope with 35-mm camera attachment.
Results: The 13 boys and 81 girls were referred with injuries as a result of sexual assault or anogenital trauma. Hymenal injuries occurred in 37 cases; 2 transections healed after surgery, and 15 persisted unchanged. Partial tears, hymenal abrasions, or hematomas healed completely or with minor nonspecific changes. Of the 47 injuriesto the posterior fourchette, 22 abrasions, hematomas, or tears healed completely; 12 tears healed with vascular changes; 2 developed labial fusions; 10 lacerations required surgery; and 6 scarred and 4 healed with vascular changes. Only 2 of 39 cases of perihymenal trauma healed with vascular changes. All 17 cases of labial trauma healed completely. Anal trauma healed completely in 29 of 31 with scarring occurring in only 2 cases that required surgery.
Conclusions: Anogenital trauma heals quickly, often without residua. Of the 94 cases, there were diagnostic anatomic changes in the 15 cases of hymenal transections (2 other cases healed completely with surgical reconstruction), 6 cases after surgical repair of posterior fourchette, and 2 cases of anal scarring after surgery.

Validation set correlates of anogenital injury after sexual assault.
Drocton P, et al.
Academic Emergency Medicine: Official Journal Of The Society For Academic Emergency Medicine [Acad Emerg Med] 2008 Mar; Vol. 15 (3), pp. 231-8.
Abstract:
Objectives: Forensic investigators remain unsure exactly why some sexual assault victims display acute injurywhile others do not. This investigation explores potential reasons for these differential findings among female victims.
Methods: This cross-sectional analysis examined data from consecutive female sexual assault victims, at least 12 years old, who agreed to a forensic exam between November 1, 2002, and November 30, 2006. Exams utilized colposcopy, anoscopy, macrodigital imaging, and toluidine blue dye to delineate anogenital injury (AGI), which was defined as the presence of recorded anogenital abrasions, tears, or ecchymosis. Demographic variables of the victim, including sexual experience and reproductive parity, and assault characteristics were recorded in the database for bivariate and multivariate analysis with AGI.
Results: Forty-nine percent of the initial 3,356 patients displayed AGI. Of this total, 2,879 cases included complete data for all variables and were included in the multivariate logistic regression model. A statistically significant increased risk for AGI was noted with: educational status (odds ratio [OR] 1.53, 95% CI = 1.25 to 1.87); vaginal or attempted penetration using penis (OR 2.29, 95% CI = 1.74 to 3.01), finger (OR 1.61, 95% CI = 1.88 to 1.94), or object (OR 3.19, 95% CI = 1.52 to 6.68); anal-penile penetration (OR 2.00, 95% CI = 1.57 to 2.54); alcohol involvement (OR 1.25, 95% CI = 1.04 to 1.50); and virgin status of victim (OR 1.38, 95% CI = 1.11 to 1.71). Victims were less likely to display AGI with a longer postcoital interval (OR 0.50, 95% CI = 0.39 to 0.65) and increased parity (OR 0.76, 95% CI = 0.57 to 0.99).
Conclusions: Approximately half the patients displayed AGI. This rate is higher than earlier studies, but consistent with current investigations utilizing similar injury detection methods. The correlates of injury found reinforce the findings of prior studies, while prompting questions for future study.

Assailants’ sexual dysfunction during rape: prevalence and relationship to genital trauma in female victims.
Jones JS, et. al.
The Journal Of Emergency Medicine [J Emerg Med] 2010 May; Vol. 38 (4), pp. 529-35. Date of Electronic Publication: 2009 Feb 20.
Abstract:
Background: Partial or complete failure to maintain an erection sufficient for coitus is known to occur in a proportion of sexual assailants during the rape episode.
Objective: The purpose of this study was to determine whether the presence of coercion, physical violence, and genital injury associated with sexual assaults is influenced by the assailant’s erectile impotence.
Methods: This prospective, observational study evaluated consecutive female patients presenting to a free-standing urban sexual assault clinic during a 3-year study period. Sexual assault victims presenting directly to four downtown emergency departments (EDs) are routinely referred to the clinic for evaluation after triage and initial assessment. The clinic is associated with a university-affiliated emergency medicine residency program and is staffed by forensic nurses trained to perform medical-legal examinations. The primary outcome was to compare the frequency of anogenital findings documented in women whose assailant experienced no erectile dysfunction vs. those victims who reported erectile impotence in the assailant.
Results: During the study period, 569 sexual assault victims were eligible to participate in the study; 47 (8.3%) reported that their assailants had experienced erectile impotence. Except for assailant age, the two victim groups were comparable in terms of marital status, alcohol and drug use, known assailant, and time to physical examination. In attacks where erectile dysfunction occurred, there was a higher incidence of physical coercion (60% vs. 32% without physical coercion, p < 0.001) and subsequent non-genital trauma (72% vs. 46%, respectively, p < 0.001). Thirty-two women (68%) had documented anogenital trauma despite the assailant having erectile dysfunction. There was no significant difference in the overall pattern of anogenital injury between the two groups (chi (2) = 9.1, p = 0.036).
Conclusion: Erectile impotence occurred in up to 8% of sexual assailants during the rape episode. Despite this erectile dysfunction, the majority of sexual assault victims sustained anogenital trauma. In the attacks with erectile impotence, there was a higher incidence of intra-rape violence and subsequent non-genital injuries.

Anogenital injuries in childhood sexual abuse victims treated in a pediatric Forensic Nurse Examiner (FNE) program.
Campbell R, Patterson D, Dworkin E, Diegel R
Journal Of Forensic Nursing [J Forensic Nurs] 2010 Winter; Vol. 6 (4), pp. 188-95.
Abstract:
Medical forensic exams for victims of childhood sexual abuse (CSA) can be a helpful resource for addressing patients’ complex medical, psychological, and legal needs. These exams can be performed by physicians or forensic nurses to identify and treat injuries, evaluate the risk for sexually transmitted infections and pregnancy, and collect evidence. In this study, we examined CSA cases treated in a midwestern, community-based forensicnurse examiner (FNE) program to document rates of anogenital injury and identify what factors predict the presence of such injuries (N= 203). Overall, 39% of the cases had anogenital injury. Victims who were examined for suspected vaginal and/or anal assault were significantly more likely to have anogenital injuries, and patients examined within 24 hours of an assault were also significantly more likely to have documented injuries. Patients who were seen for vaginal and/or anal assaults and who had bathed since the assault were significantly less likely to have injury. Nurses who had less experience with pediatric medical forensic exams were somewhat more likely to document anogenital injuries. Findings suggest that clinical pediatric practice would benefit from additional practitioner training in injury detection to avoid false positives.

[The prevalence of physical evidence in the anogenital area in sexual assault cases of children in Israel].
Kotik A, et al.
Harefuah [Harefuah] 2011 Dec; Vol. 150 (12), pp. 895-8, 936.
Abstract:
Introduction: Sexual abuse includes obscenity, rape and sodomy. Forensic medical examinations routinely include the genital area, anus and the body of the victims for signs of recent or old injury.
Objectives: To evaluate the incidence of physical evidence in forensic sexual abuse cases and to compare the Israeli findings to data from other countries, including the USA.
Methods: The study was conducted during one calendar year in Israel and included 95 children from infancy to 16 years of age, of whom 83% were females. Examination results were defined by the presence of physical injury or its absence. These findings were classified by their location in the anogenital area or other body areas and findings in the anogenital area were further classified by their likelihood to have been caused by a sexual assault. The results of the examination were related to parameters such as age and sex of the participants, length of time since the last assault, and the degree of proximity between the suspected assailant and the victim.
Results: Evidence of physical abuse was found in 41 patients, in 37 (39%) of these cases physical abuse was detected in the anogenital area. In all these cases of anogenital abuse, 11 (12%) showed clear evidence of sexual assault and five of them had recent signs of injury; 80% of the recent injuries in the anogenital area were identified in patients within the first 24 hours after the assault.
Conclusions: The prevalence of clear evidence of sexual assault in the U.S. ranges from 3-23%, in Italy 9.5%, in Thailand 32% and in Denmark 40%. In Israel, as elsewhere in the world, few cases of sexual assault in children will have clear evidence of a sexual nature. A lack of physical evidence does not rule out sexual assault, therefore, finding physical evidence during an examination is the exception rather than rule. Questioning the victim and investigating the circumstances of the case are crucial elements in all instances of presumed sexual assault on children.

Factors that influence the variability in findings of anogenital injury in adolescent/adult sexual assault victims: a review of the forensic literature.
Laitinen FA, Grundmann O, Ernst EJ
The American Journal Of Forensic Medicine And Pathology [Am J Forensic Med Pathol] 2013 Sep; Vol. 34 (3), pp. 286-94.
Abstract:
Sexual violence is a pervasive problem worldwide. Anogenital injuries are one type of injury that may be present because of sexual violence. A review of the forensic literature yielded 13 published studies from 6 countries between 1987 and 2011 that met the inclusion/exclusion criteria, illustrating that anogenital (anal and/or genital) trauma is observed in 16% to 77% of sexual assault victims. Establishing the reliability of the conclusions of these studies is difficult due to a lack of uniformity in methodology to include detection of injury, injury definition, victim age, time window for examination, injury from consensual sex, and training of examiners. Each one of these factors can change the rate of injury observed. The evaluated studies show a disparity due to a lack of uniformity in examination protocols, injury classification, and examiner qualifications. A current, state of the science, evidence-based standardized protocol should be constructed that promotes objective and accurate parameters including the use of colposcopy, staining techniques, digital photography, and adequate training for examiners of sexual assault victims who present with anogenital injury.

Enhancing the emergency department approach to pediatric sexual assault care: implementation of a pediatric sexual assault response team program.
Goyal MK; et al.
Pediatric Emergency Care [Pediatr Emerg Care] 2013 Sep; Vol. 29 (9), pp. 969-73.
Abstract:
Objectives: The objectives of this study were to describe the experience of a novel pediatric sexual assault response team (SART) program in the first 3 years of implementation and compare patient characteristics, evaluation, and treatment among subpopulations of patients.
Methods: This was a retrospective chart review of a consecutive sample of patients evaluated at a pediatric emergency department (ED) who met institutional criteria for a SART evaluation. Associations of evaluation and treatment with sex, menarchal status, and presence of injuries were measured using logistic regression.
Results: One hundred eighty-four patients met criteria for SART evaluation, of whom 87.5% were female; mean age was 10.1 (SD, 4.6) years. The majority of patients underwent forensic evidence collection (89.1%), which varied by menarchal status among girls (P < 0.01), but not by sex. Evidence of acute anogenital injury on physical examination was found in 20.6% of patients. As per the Centers for Disease Control and Prevention guidelines for acute sexual assault evaluations in pediatric patients, menarchal girls were more likely to undergo testing for sexually transmitted infections and pregnancy (P < 0.01) and to be offered pregnancy, sexually transmitted infection, and HIV prophylaxis (P < 0.01).
Conclusions: In an effort to improve quality and consistency of acute sexual assault examinations in a pediatric ED, development of a SART program supported the majority of eligible patients undergoing forensic evidence collection. Furthermore, a substantial number of patients had evidence of injury on examination. These findings underscore the importance of having properly trained personnel to support ED care for pediatric victims of acute sexual assault.

Debunking three rape myths.
Carr M; et al.
Journal Of Forensic Nursing [J Forensic Nurs] 2014 Oct-Dec; Vol. 10 (4), pp. 217-25; quiz E1-2.
Abstract:
Background: Stereotypes and prejudicial misconceptions are prevalent regarding sexual assaults and victims’ responses. These are collectively referred to as rape myths. This study examines three rape myths purporting that sexual assault victims (1) immediately report the crime, (2) experience severe physical and/or anogenital injuries, and (3) forcefully resist their assailant.
Study Design: This is a cross-sectional descriptive study examining presence of physical or anogenital injury, level of physical resistance during a sexual assault, and time to sexual assault report. Study subjects were female sexual assault victims examined by a sexual assault nurse examiner at Regions Hospital in St. Paul, Minnesota, in 2011 and 2012.
Results: Sexual assault nurse examiner reports for 317 subjects met the inclusion criteria and were reviewed. Twelve (4%) victims experienced physical injury requiring medical intervention. Thirty-four (11%) sustainedanogenital injuries requiring medical intervention. Overall, 253 (81%) victims did not actively resist at some point during the assault, with 178 (57%) victims never actively resisting. Nearly half (129, 43%) did not appear in the emergency department for 12 or more hours from the time of the assault.
Conclusion: Women who seek emergency department assistance after a sexual assault take a variable amount of time to present to the emergency department, rarely experience moderate or severe physical or anogenital injury, and commonly do not exert strong physical resistance against their attacker during at least part of the assault.

Helpfulness of rectoanal endosonography in diagnosis of sexual abuse in a child.
Rostion CG, et al.
Journal Of Pediatric Surgery [J Pediatr Surg] 2016 Jul; Vol. 51 (7), pp. 1151-61. Date of Electronic Publication: 2016 Jan 06.
Abstract:
Background: Clinical importance of sexual abuse in children has rapidly expanded in recent years, but despite of it, the lack of medical signs in the vast majority of sexual abuse cases, makes it difficult to assess. Given that, owing to our prior experience in endosonography (EUS) of the anal canal in child with anorectal malformations, we wanted to test EUS as a diagnostic method of sexual abuse in a child.
Purpose: The purpose of our study is to present our experience in the use of anorectal EUS among children with suspected sexual abuse.
Materials/methods: We present 40 consecutive patients (34 boys and 6 girls, age: 10months-13years) recruited from April 2010 to December 2012, with suspected sexual abuse those made a transrectal EUS.
Results: The procedure was well-tolerated in all patients without complications. Rectoanal EUS findings were normal in 27 patients and showed a partial interruption in the external anal sphincter in 8, scars in 2, double rail image in 2, and rectal wall hematoma in 1.
Conclusions: The interpretation of findings in children depends of historical, physical, and laboratory findings. We believe that anal EUS is another aid in the constellation of clinical factors that could help in diagnostic of sexual abuse.

Child sexual assault reported to an acute sexual assault referral centre in London.
Morgan L; et al.
Archives Of Disease In Childhood [Arch Dis Child] 2017 Feb; Vol. 102 (2), pp. 165-169. Date of Electronic Publication: 2016 Oct 13.
Abstract:
Objective: To describe demographic and assault-related characteristics of children attending an acute sexual assault referral centre in London within a week of alleged sexual assault.
Design: Retrospective case note review of all children aged 12 years and under who reported between 1 January 2008 and 31 December 2013.
Main Outcome Measures: Age, sex, ethnicity, drugs and alcohol around the time of assault, nature of offence, relationship with perpetrator, additional violence, verbal threats, presence of injury.
Results: 176 children attended; 80% were female. Perpetrators were known casually to the victim in almost half of cases (49%) and familial assault was reported in 55 cases (31%). 43% of boys and 28% of girls reported that the perpetrator was under the age of 16 years. Familial domestic violence was reported by 17%, and more boys (26%) than girls (14%) were reported to have a learning difficulty. Extragenital injury was found in 14% and anogenitalinjury in 17%.
Conclusions: This study provides an important overview of young children referred for forensic medical examination in the week following an allegation of sexual assault. Rates of learning difficulty and domestic violence were relatively high, and alcohol and drug use was rare. A large number of alleged perpetrators were young themselves. Additional violence was not common, and rates of injury were low. There may be important differences in sexual offences against boys and girls. Further research is necessary, as is greater case identification and referral for services.