SEARCH

SEARCH BY CITATION

Keywords:

  • Forensic examination;
  • Injury;
  • Postmenopausal women;
  • Rape

Abstract

  1. Top of page
  2. Abstract
  3. Background and significance
  4. Theoretical perspective
  5. Significance and clinical relevance
  6. Methods
  7. Results
  8. Discussion
  9. Conclusions
  10. Acknowledgments
  11. References

Objective:  To determine whether postmenopausal (age 50 years or older) women would sustain significantly more injury after rape than women younger than 50 and to determine the role of skin pigmentation in the observance of genital injury.

Design and Setting:  Registry data from a sexual assault forensic nurse examiners program.

Participants:  Based on date of examination, records from women of age 50 years or older (n= 40) were matched to two other participants: a premenopausal group younger than 40 years and a perimenopausal group of 40 to 49 years. The final sample consisted of 120 subjects.

Main Outcome Measures:  Number, type, and location of injuries.

Results:  A series of exact conditional logistic regression analyses indicated no significant association between age and genital, nongenital, or head injury. A significant association between race (Black versus White) and genital injury (adjusted odds ratio = 4.30, 95% confidence interval = 1.09-25.98, p= .03) indicated that Whites were more than four times as likely as Blacks to have genital injury.

Conclusion:  Although the primary hypothesis was not supported, the role of racial/ethnic differences and their association with the observance of injury need further exploration to determine whether the standard forensic examination is appropriate for all women. Health disparities may exist if women of color are less likely than others to have genital injuries identified and treated. Alternatively, skin properties may explain racial/ethnic differences in injury prevalence. JOGNN, 35, 199-207; 2006. DOI: 10.1111/J.1552-6909.2006.00026.x

Each year, women older than 50 years of age report 60,000 rapes to the U.S. Justice Department (Illinois Coalition Against Sexual Assault, 2001). Between 1992 and 2000, 59% of the victims of rape whose victimization was reported to the police were treated for their physical injuries (both genital and nongenital), as compared to 17% of rape victims with unreported victimization (Rennison, 2002). A growing number of rape examinations are completed by sexual assault forensic nurse examiners (SAFE) (also known as sexual assault nurse examiners). Rape, therefore, results in a large number of physical injuries to postmenopausal women each year, and many receive treatment from forensic nurse examiners.

Despite the physiological changes that occur as women age, the protocols for a sexual assault examination are not varied based on the adult victim's age (U.S. Department of Justice, Office on Violence Against Women, 2004). In addition, the examination technique is not changed based on the degree of the patient's skin pigmentation (U.S. Department of Justice, Office on Violence Against Women); darker skin may reduce the examiner's ability to observe the type or location of physical injury during the forensic examination, although this clinical observation has not been empirically tested. We have begun a program of research to investigate whether sexual assault examination procedures are appropriate for victims regardless of age or skin pigmentation. The overall objective of this study was to determine the prevalence of physical injury, both genital and nongenital, in women 50 years and older as compared to females ages 14 to 49. More specifically, we tested the following hypothesis: Women aged 50 and older will have significantly more genital and nongenital injury caused by rape than will females between the ages of 14 and 49. A secondary aim was to investigate the role of skin pigmentation in the visual identification of genital injury following rape in females 14 years and older.

Data from a sexual assault registry were used to meet the study aims. Because the registry data did not contain information about menopause, the investigators chose to use age as a proxy for menopause. National Institute on Aging (NIA, 2001) reports that the average age of menopause is 51 years (62-3 years), and therefore women 50 and older were considered postmenopausal. This decision was supported by that of Ramin, Satin, Stone, and Wendel (1992), who classified women 50 and older “postmenopausal” in their work. In addition, the registry data did not provide information on skin pigmentation. Therefore, race/ethnicity (Black, White) was used as a proxy for skin pigmentation with the knowledge that (a) skin pigmentation is a volatile social issue, (b) skin pigment is variable across and within races and ethnicities, and (c) further work is needed to refine the role of race and skin pigmentation in the forensic examination. The investigators are concerned from a clinical standpoint that women with dark skin may be at some disadvantage with current forensic techniques because injuries in women of color may be harder to identify with visual inspection and colposcopy (see 1Table 1). We decided to pursue this sensitive line of investigation to reduce the likelihood of health disparities for women of color.

Table 1.  Definitions of Terms Associated With the Forensic Rape Examination
TermDefinitionCitation
RapeForced sexual intercourse (vaginal, anal, or oral penetration, including incidents where the penetration is from a foreign object) including both psychological coercion as well as physical forceAbbey, Zawacki, Buck, Clinton, & McAuslan (2001); U.S Department of Justice, Bureau of Justice Statistics (2003)
Sexual assaultWide range of victimizations, separate from rape or attempted rape. These crimes include attacks or attempted attacks generally involving unwanted sexual contact between the victim and offender. Sexual assaults may or may not involve force and include grabbing or fondling. Sexual assault also includes verbal threatsU.S Department of Justice, Bureau of Justice Statistics (2003)
Sexual assault forensic examinationHealth care providers assess sexual assault victims for acute medical needs, provide for stabilization and treatment of injury, gather information for the forensic history, and collect and document forensic evidenceSommers, Fisher, & Karjane (2005); U.S Department of Justice, Office on Violence Against Women (2004)
Direct visual inspectionStandard gynecologic and forensic examination unaided by magnification or staining techniquesSommers et al. (2001)
Staining techniques: Gentian violet, Lugol's solution, toluidine blue, fluoresceinStaining techniques make injury more visible to the eye. They allow areas of abraded skin and microlacerations to be highlighted through a variety of techniquesJones et al. (2004); Lauber & Souma (1982); McCauley, Guzinski, Welch, Gorman, & Osmers (1987)
ColposcopyUsed to illuminate, magnify, and photograph external and internal gynecologic structures. Enhances standard examination becauseCrowley (1999); Hobbs & Wynne (1996); Lenahan, Ernst, & Johnson (1998); Sommers et al. (2001)
 –Internal and external structures can be examined microscopically
 –Adequate light source and magnification capability for a detailed examination
 –Repeated examinations are unnecessary because photographs or digital images can be shown to experts or consultants
Genital injuriesTears, abrasions, ecchymosis, redness, or swelling of the external genitalia (labia majora, periurethral area, perineum, posterior fourchette), internal genitalia (labia minora, fossa navicularis, hymen, vagina, cervix), and anus (rectum).Slaughter et al. (1997)
Nongenital injuriesTrauma to the following locations: mouth (including mouth, lips, and tongue), head (including head, face, and neck), upper extremities (including shoulders, arms, hands, and fingers), trunk (including chest, breasts, abdomen, back, and buttocks), and lower extremities (including hips, legs, feet, and toes).Sommers et al. (2001)

Background and significance

  1. Top of page
  2. Abstract
  3. Background and significance
  4. Theoretical perspective
  5. Significance and clinical relevance
  6. Methods
  7. Results
  8. Discussion
  9. Conclusions
  10. Acknowledgments
  11. References

A growing number of SAFE programs exist in the United States. For instance, the U.S Department of Justice, Office for Victims of Crime (2001) reported that 300 programs had been established by 1999 with many more in the planning stages. Understanding the number, type, and location of genital and nongenital injuries following rape is an important part of the nursing forensic examination. The incidence of genital and nongenital injury sustained by women who are raped ranges from 5% to 87% depending on the assessment technique (visual inspection, contrast media, colposcopy) that is used by the examiner (Sommers, Schafer, Zink, Hutson, & Hillard, 2001).

Several investigators have found that older women sustain a higher prevalence of genital injury caused by rape than younger women, but the prevalence of nongenital injury varies. Ramin et al. (1992) studied 129 postmenopausal women (50 years of age or older) and compared them to 129 women aged 14 to 49 years. They found that 67% of the older women had physical injury (both genital and nongenital) as compared to 71% of the younger group. The frequency of nongenital injury was higher in younger women (66% versus 49%, p < .01), but genital injury was more common in the older group (43% as compared to 18%, p < .001). Muram, Miller, and Cutler (1992) also found a higher prevalence of genital injury in older women. They studied 53 women 55 years of age and older, and compared them to 53 controls who were 18 to 45 years of age. The prevalence of nongenital injury was approximately the same in both groups (45% of the older women as compared to 40% of the controls), but 51% of the older women sustained genital injury as compared to 13% of the controls.

Two other groups of investigators using small sample sizes found conflicting results. In a study reviewing 440 reported rapes, Cartwright and the Sexual Assault Study Group (1987) reported that 67% (n= 12) of White women 41 to 50 years old had nongenital injury as compared to 60% of White women older than 50. Genital injury prevalence was 17% (n= 10) for women 41 to 50 years and 30% (n= 10) for women older than 50. In contrast, Tintinalli and Hoelzer (1985) found that older women had more nongenital injuries than younger women, but none of their subjects older than 50 years of age (n= 11) had genital injuries. Genital injury prevalence for the entire sample was 19%.

A landmark study by Slaughter, Brown, Crowley, and Peck (1997) compared patterns of genital injury in female sexual assault victims to females after consensual sexual intercourse. Among 311 sexual assault victims ages 11 to 85 examined with colposcopy technique, 68% had genital trauma and 57% had nongenital trauma. The sample included six postmenopausal women, but the authors did not provide data on injury prevalence of postmenopausal females as compared to the rest of the sample. Injuries following consensual sexual intercourse were reported in 11% of the sample.

If age differences exist in the likelihood of injury, examiners need to understand typical injury patterns attributable to age.

In summary, a confusing picture emerges from literature reporting physical injury sustained during rape. Studies with larger sample sizes reported that women 50 years and older tended to have more genital injuries than their younger counterparts. No consistent patterns of nongenital injury were found for postmenopausal women and little is know about the role of skin pigment in injury identification, although examiners rely heavily on visual inspection of the skin to locate and treat injuries. Nurse examiners have reported anecdotally to the investigative team that they note differences in the ability to identify bruising, abrasions, and redness depending on the degree of skin pigment in their patients, but no literature was available to support the clinical observations that injuries were more difficult to observe in women with dark skin.

Theoretical perspective

  1. Top of page
  2. Abstract
  3. Background and significance
  4. Theoretical perspective
  5. Significance and clinical relevance
  6. Methods
  7. Results
  8. Discussion
  9. Conclusions
  10. Acknowledgments
  11. References

A physiological conceptual framework served as the theoretical perspective for this study. As estrogen levels drop and women age, the vagina gets narrower and shorter. The walls become thin and less elastic, and vaginal glands produce fewer secretions. The external genitalia also change as the labia lose fat and elastic tissue and the vulva thins and flattens because of reduced thickness of the keratin and epithelial layers. In addition epidermal growth rate decreases, and collagen content and thickness diminish with age (Crowley, 1999). Theoretically, these changes may lead to an increased risk of injury to postmenopausal women during rape.

We chose to compare the injury prevalence in postmenopausal women to other females across the life span to understand the phenomenon more fully. Perimenopause is the life phase just before menopause and refers to the transitional period of time before menstruation actually stops. It can last up to 10 years, but generally occurs at approximately 45 years of age (NIA, 2001; Ohio State University, 2005). Therefore, we will compare injury prevalence in postmenopausal females (50 years or older) to injuries in perimenopausal (40 to 49 years) and premenopausal (younger than 40 years) females to better understand the role of injuries after menopause.

Little is known about how menopause might affect susceptibility to genital injury after rape.

Significance and clinical relevance

  1. Top of page
  2. Abstract
  3. Background and significance
  4. Theoretical perspective
  5. Significance and clinical relevance
  6. Methods
  7. Results
  8. Discussion
  9. Conclusions
  10. Acknowledgments
  11. References

Two important goals exist for the forensic examination following rape: assessment/treatment of injuries and evidence collection. Although injuries associated with rape are usually not severe in nature (Tintinalli & Hoelzer, 1985), they do require a thorough examination to allow for assessment, cleansing, and, at times, repair. If indeed, postmenopausal women are more likely to be injured, examiners need to understand common injury patterns in postmenopausal women and be accordingly vigilant during the examination.

No empirical information is available to guide standard protocols for the examination of postmenopausal women at this time. Given that postmenopausal women may have more friable skin, the procedures for the rape examination may need to be altered depending on age. For example, a recent report indicated that in a female whose age was not reported, a new abrasion visible with contrast medium appeared on the labia after speculum insertion. The authors suggested that the new injury was a direct result of speculum insertion use during a rape examination, rather than the rape itself (Jones, Dunnuck, Rossman, Wynn, & Nelson-Horan, 2004). Using the above-mentioned example, the contrast medium may need to be applied and all labial injuries counted prior to speculum insertion in all women and, in particular, postmenopausal women if they are indeed more susceptible to injury. In addition, if as clinicians report to us that women with dark skin are less likely to have their injuries identified and treated because injuries are more difficult to observe than in women with light skin, then health disparities may exist with our current treatment protocols and new examination techniques may be warranted.

Forensic considerations exist as well. The number, type, and location of injuries are linked to the outcome of legal proceedings. McGregor, Le, Marion, and Wiebe (1999) found that the presence of moderate or severe injury was significantly associated with the filing of charges (p < .001) following rape. Rambow, Adkinson, Frost, and Peterson (1992) found evidence that both genital and nongenital injury was significantly associated with a successful legal outcome (p < .01), and Penttila and Karhumen (1990) found that the presence of severe injuries was associated with imprisonment. From a forensic standpoint, it is important that injuries are documented so that those who commit violence against women are brought to trial. Therefore, it is critical from both a health care and legal perspective that all injuries are observed and documented during the forensic examination.

Methods

  1. Top of page
  2. Abstract
  3. Background and significance
  4. Theoretical perspective
  5. Significance and clinical relevance
  6. Methods
  7. Results
  8. Discussion
  9. Conclusions
  10. Acknowledgments
  11. References

Staff from a SAFE program in the Midwestern United States began performing rape examinations in May 1998 at a local level I trauma center. The development of a sexual assault registry was approved by the Institutional Review Board of the affiliated university and hospital, both of whom approved the use of aggregate data from the registry for research purposes. The database included all individuals who signed a consent-to-treat document and who were examined by the program staff between May 1998 and June 2002 and were examined within 72 hours of a rape by the program staff. Registry data were entered by the research assistants affiliated with an Institute for Nursing Research at a health sciences university. All personal information such as birth date and medical record number were removed from the data set so that no individual could be identified.

The examinations were performed by trained nurse examiners, who documented genital and nongenital injuries at the time of the examination. The forensic sexual assault examination is similar to a standard gynecologic examination with the addition of the three techniques defined in Table 1 to identify injury: direct visualization, staining techniques, and colposcopy. The procedure includes a medical forensic history of the event; collection of photographic evidence of injuries and genital structures; visual and microscopic inspection of internal genital, external genital, and anal injuries; treatment of injuries and any sexually transmitted infections; evidence collection; and discharge with follow-up (U.S. Department of Justice, Office on Violence Against Women, 2004).

For the purpose of this study, injury was defined as any tissue trauma visible on inspection including tears, ecchymosis, abrasions, redness, or swelling (TEARS) in the topology proposed by Slaughter et al. (1997). The TEARS classification system uses the following types of injury to organize genital injury: Tears were defined as any breaks in tissue (skin and mucous membranes) integrity including fissures, cracks, lacerations, cuts, gashes, or rips. Ecchymosis was defined as skin or mucous membrane discoloration due to the damage of small blood vessels causing “bruising” or “black and blue” areas. Abrasions (excoriations) were defined as the removal of the epidermis from skin or mucous membranes. Redness was the descriptor for erythematous tissues that are abnormally inflamed because of irritation. Swelling was defined as local edema or transient engorgement of tissues.

The number of injuries was counted and injuries were classified according to anatomic location. Genital injuries included the external genitalia (labia majora, periurethral area, perineum, posterior fourchette), internal genitalia (labia minora, fossa navicularis, hymen, vagina, cervix), and anus (rectum). Nongenital injuries were classified by the following locations: mouth (including mouth, lips, and tongue), head (including head, face, and neck), upper extremities (including shoulders, arms, hands, and fingers), trunk (including chest, breasts, abdomen, back, and buttocks), and lower extremities (including hips, legs, feet, and toes).

Participants

The entire sample was drawn from a larger sample of female rape victims (N= 828) from the sexual assault registry. The postmenopausal age range for this study was considered to be 50 years and more (NIA, 2001; Ramin et al., 1992). The perimenopausal age range for this study was considered to be 40 to 49 years of age, and the perimenopausal group included those women who would either be in the perimenopausal years or entering those years shortly. A comparison group of premenopausal females between the ages of 14 and 39 years who most likely would not have reached the perimenopausal stage were included as a comparison group.

The registry included only 40 female individuals aged 50 or more (females who met our definition of being in the postmenopausal age range). In order to examine the effect of age on injury status, each participant was matched by closest date of examination to two other participants: one younger than 40 years of age and one between the ages of 40 and 49. Matching by date of examination was chosen in order to adjust for the potential confounding influence of examiner or data entry bias, or both. The decision to divide females younger than 50 into two groups was made based on the physiological principles that women 40 to 49 (premenopausal group) would be different hormonally than females younger than 40 (younger female group). The final sample, therefore, consisted of 120 female participants.

Statistical analyses

Four anatomic regions were selected for injury analysis: genital (including external genital, internal genital, and anus), nongenital (trunk, legs, and arms), head (face, neck, and scalp), and all regions combined. Head injury was separated from nongenital injuries because of the findings by Tintinalli and Hoelzer (1985) that injuries of the face, head, and neck are characteristic of the rape syndrome. The presence or absence of injury was noted for each anatomic region. Given the modest size of the current sample and the low frequency of some injury events, tests of exact inference using LogXact-5 software (Statistical Solutions, 2003) were employed in order to obtain the most accurate p values and confidence intervals (CI). Exact conditional logistic regression stratified by examination date was conducted to assess the predictors of injury for each anatomic region. In addition to age group (younger than 40, 40 to 49, older than 49 years), three other main effect covariates were specified a priori and were entered into the exact conditional logistic regression analyses simultaneously in order to adjust for their influence and evaluate their effect on injury detection following rape: race (White/Black), weapon use during assault (yes/no), and the time interval between assault and examination (in hours). Interaction terms were evaluated iteratively along with their main effects. Alternatively, age was entered into the analyses as a continuous, transformed continuous (age squared), and dummy-coded variable.

Results

  1. Top of page
  2. Abstract
  3. Background and significance
  4. Theoretical perspective
  5. Significance and clinical relevance
  6. Methods
  7. Results
  8. Discussion
  9. Conclusions
  10. Acknowledgments
  11. References

The overall injury prevalence for all subjects was 68.9% (see 2Table 2). Demographic and assault-related characteristics are available in 3Table 3. Mean age for the postmenopausal group was 68.25 years with a standard deviation of 14.76. Of the 120 participants, 50% were White and 50% were Black, closely matching the racial composition of the entire sexual assault registry (White: 52.3%, Black: 46.3%, other: 1.4%). There was no association between age and racial groups, χ2(2, N= 120) = 2.40, p= .30. A 3 (age group) × 2 (race group) analysis of variance indicated that the time interval between assault and examination did not differ with respect to age or race, F(5, 113) = 1.39, p= .23 (ranging from an average of 9.9-20.5 hours). There were no significant differences among age or racial groups as to the proportion of cases where the assailant used a weapon during the assault, χ2(2, N= 120) = 4.27, p= .12 and χ2(2, N= 120) = 0.16, p= .69, respectively.

Table 2.  Percent Injury by Anatomic Region Based on Age and Race
 Age Category (years)
Anatomic Region<40 (n =40)40-49 (n =40)>49 (n =40)All Ages (N =120)
All regions 
 White86.450.086.476.7
 Black66.754.264.761.0
 Total77.552.576.968.9
Genital 
 White59.143.863.656.7
 Black44.425.033.333.9
 Total52.532.551.345.4
Nongenital 
 White72.737.572.763.3
 Black38.945.829.439.0
 Total57.542.553.851.3
Head 
 White18.218.831.823.3
 Black16.733.317.623.7
 Total17.527.525.623.5
Table 3.  Sample Demographic and Assault-Related Characteristics
 Age Category
<40 (n =40)40-49 (n =40)>49 (n =40)All Ages (N =120)
VariableM (SD)M (SD)M (SD)M (SD)
Age (years) 
 White22.27 (5.95)43.88 (2.94)72.18 (15.36)46.33 (23.78)
 Black22.67 (8.20)43.37 (2.32)63.44 (12.82)43.18 (17.96)
 Total22.45 (6.96)43.58 (2.56)68.25 (14.76)44.76 (21.04)
Time interval between assault and examination (hours) 
 White12.92 (11.74)15.04 (15.36)10.69 (8.16)12.67 (11.65)
 Black17.78 (19.71)9.90 (10.28)20.53 (25.37)15.37 (18.85)
 Total15.11 (15.79)11.96 (12.63)14.98 (18.22)14.01 (15.63)
Race 
 White55.0%40.0%55.0%50.0%
 Black45.0%60.0%45.0%50.0%
Weapon use (yes) 
 White18.2%37.5%27.3%26.7%
 Black33.3%41.7%11.1%30.0%
 Total25.0%40.0%20.0%28.3%

Exact conditional logistic regression analyses indicated that there was good model fit (discrimination between injury and noninjury) on the basis of four predictors (age group, racial group, weapon use, time interval) in two of the four anatomic regions: genital and head. No interaction terms significantly improved the fit of the models. The pattern of significant predictors did not change when age was entered into the analyses as a continuous or dummy-coded variable. 4Table 4 shows regression coefficients, standard errors, odds ratios (ORs), and 95% CI for ORs for each of the four predictors.

Table 4.  Summary of Exact Conditional Logistic Regression Analyses Predicting Injury
Anatomic RegionPredictor VariableBetaSEOdds Ratio95% Confidence Interval for Odds Ratio 
LowerUpperp
  1. Note. Race = White/Black; Age = categoric age group (<40, 40-49, >49 years); Weapon use = during assault (yes/no); Time interval = hours between assault and examination.

GenitalAge−0.020.250.990.591.66.9974
 Race1.460.684.301.0925.98.0338
 Weapon use−0.710.610.490.111.87.3723
 Time interval−0.050.030.960.901.01.0865
HeadAge0.060.401.060.402.86.9763
 Race0.050.761.050.166.78.9836
 Weapon use1.570.644.811.1734.78.0255
 Time interval−0.076.900.930.840.99.0183

For genital injury, a test of the full model with all four predictors against the null model was statistically significant, χ2(4, N= 120) = 9.74, p= .045, indicating that the predictors, as a set, distinguished between individuals with and without genital injury. Only race predicted genital injury, and the adjusted OR of 4.30 (95% CI = 1.09-25.98, p= .03) indicated that Whites were more than four times as likely as Blacks to have a genital injury observed during the examination (see Table 4).

A statistically significant model also emerged with the aforementioned set of predictors for head injury when compared to the null model, χ2(4, N= 120) = 17.20, p= .002. Weapon use during the assault and a shorter time interval between assault and examination both predicted head injury identification. Although a significant predictor, the adjusted OR for the time interval, indicated little change in the likelihood of head injury identification based on a 1-hour difference in the time between assault and examination (OR = 0.93, 95% CI = 0.85-0.99, p= .02). However, a head injury was nearly five times as likely if a weapon was used during the assault (OR = 4.81, 95% CI = 1.17-34.78, p= .03) (see Table 4).

Discussion

  1. Top of page
  2. Abstract
  3. Background and significance
  4. Theoretical perspective
  5. Significance and clinical relevance
  6. Methods
  7. Results
  8. Discussion
  9. Conclusions
  10. Acknowledgments
  11. References

Overall genital injury prevalence in the postmenopausal group (51.3%) approximated the 51% prevalence found by Muram et al. (1992) and was higher than the prevalence of 43% found by Ramin et al. (1992). Comparable nongenital injury prevalence was found in postmenopausal women in this study (53.8%) as compared to Muram et al. (45%) and Ramin et al. (49%).

Results of the current study departed from prior research, however, because we did not demonstrate an increase in injury with increasing age. By using multivariate statistical procedures that adjusted for factors related to injury (such as weapon use and the interval between assault and examination), we found no relationship between menopausal status and increased risk of injury. Prior research has not used such statistical modeling procedures; adjusting for these potential confounding variables may have clarified the nature of the relationships in question and led to results that differ from prior research. Although not statistically significant, the difference between the percent of the sample sustaining a nongenital, genital, or any injury was consistently higher in both the youngest and oldest groups as compared to the middle-age group (see Table 2), sometimes differing by up to 36%; this trend was also generally apparent when stratified by race/ethnicity. While these differences were not statistically significant, they may be clinically significant and warrant further examination with larger samples of women.

The differences in injury prevalence between Blacks and Whites are puzzling. The rape examinations were performed by trained nurse examiners using a standard protocol for all subjects. It is possible that differences in skin pigmentation altered the ability of the examiners to observe injury regardless of the technique employed, although White and Black participants have a continuum of skin color that is not bound by race and has a wide variation. While we recognize that Whites do not necessarily have low amounts of skin pigmentation and Blacks a high amount of skin pigmentation, the findings suggest that individuals with darker skin may be at a disadvantage for injury identification with the current examination strategies (direct visualization, contrast media, colposcopy). Although skin pigmentation is a socially charged issue, it is critical that further exploration occurs across the continuum of skin pigment to ensure that those with increased skin pigmentation are not placed at a disadvantage during the forensic examination. Our culturally and racially diverse research team is continuing with that work at present.

If women with dark skin are less likely to have their injuries identified and treated, health disparities may exist with our current visualization techniques.

Other explanations for the findings exist as well. Although not reported in the literature, differences may exist that make skin of some populations more resistant to injury than other populations. We were not able to control for underlying properties in the skin that might have made the skin of some subjects more or less friable than others. Although we have no reason to suspect that racial/ethnic bias occurred on the part of the examiners who are multiracial, that possibility exists as well.

On the other hand, the association between weapon use and head injury is not puzzling. It is logical that when a weapon was used during the assault, more violence and head injury occurred as compared to those assaults without weapons. When victims sustained a head injury, one might assume that health providers and police who found the victim would have ensured that rapid transport to a hospital occurred. It is reasonable to expect, therefore, that a shorter time interval between assault and examination was the end result.

The study had several limitations. We chose to match our sample of postmenopausal women to their younger counterparts, but our sample of postmenopausal women is relatively small. We also considered women in the 50+ age group as postmenopausal women, and that cut point might not be the appropriate one nor might the cut point for the perimenopausal group be appropriate. A significant proportion of the postmenopausal women might have had normal levels of estrogen, thereby confounding our results. To our knowledge, no studies that control for menopausal status by hormone testing have been completed, and such procedures would help clarify the issue of injury and menopausal status. In addition, we were not able to control for differences in skin turgor, tissue friability, and skin blood flow, all of which may have affected injury prevalence in all our groups.

Our sample size might have been too small to detect group differences. Studies with larger samples of women, and in particular with more women older than the age of 65, are needed to identify injury prevalence following rape in the older population. We tried to reduce threats to the validity of our results by selecting specialized statistical analysis procedures that are better suited to conditions where sample sizes are small. Our analyses also included age as a continuous covariate and no association was found between age and injury status for any of the anatomic areas under study.

Injury data were documented by practicing expert clinicians who conducted a standard examination, but differences undoubtedly occurred across examiners. During the years of data collection, at least 20 trained forensic nurse examiners were employed at the hospital's emergency department, and although all had intensive training, differences certainly existed in their examination methods. Variability in examination technique and the fact that the data were collected as part of a clinical rather than research protocol both introduce error. However, we tried to mitigate these threats to the internal validity of the study by matching subjects on date of examination. A final limitation was that the data were collected from a retrospective chart review, rather than from prospectively enrolled subjects.

Conclusions

  1. Top of page
  2. Abstract
  3. Background and significance
  4. Theoretical perspective
  5. Significance and clinical relevance
  6. Methods
  7. Results
  8. Discussion
  9. Conclusions
  10. Acknowledgments
  11. References

Our findings did not support the hypothesis that postmenopausal women would have significantly more genital injury caused by rape than would women younger than 50. In fact, the differences in proportions of those participants with a genital injury were larger between racial/ethnic groups than between age groups, with no significant interaction between age and racial/ethnic group. Further prospective work is needed, therefore, to understand the racial/ethnic differences in genital injury prevalence and to explore mechanisms to control for skin pigmentation during the rape examination.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Background and significance
  4. Theoretical perspective
  5. Significance and clinical relevance
  6. Methods
  7. Results
  8. Discussion
  9. Conclusions
  10. Acknowledgments
  11. References

Supported by the National Institute of Nursing Research grant R01 NR05352. The support of Tammy Mentzel and the assistance of Jessica Dillard are acknowledged.

References

  1. Top of page
  2. Abstract
  3. Background and significance
  4. Theoretical perspective
  5. Significance and clinical relevance
  6. Methods
  7. Results
  8. Discussion
  9. Conclusions
  10. Acknowledgments
  11. References
  • Abbey, A., Zawacki, T., Buck, P. O., Clinton, A. M., & McAuslan, P. (2001). Alcohol and sexual assault. Alcohol Research & Health, 25, 43-51.
  • Cartwright, P. S., & Sexual Assault Study Group. (1987). Factors that correlate with injury sustained by survivors of sexual assault. Obstetrics & Gynecology, 70, 44-46.
  • Crowley, S. R. (1999). Sexual assault: The medical-legal examination. Stamford, CT: Appleton & Lange.
  • Hobbs, C. J., & Wynne, J. M. (1996). Use of the colposcope in examination for sexual abuse. Archives of Disease in Childhood, 75, 539-542.
  • Illinois Coalition Against Sexual Assault. (2001). Adult victims of sexual assault. Retrieved April 1, 2005, from http://www.icasa.org/uploads/adult_victimss.pdf
  • Jones, J., Dunnuck, C., Rossman, L., Wynn, B., & Nelson-Horan, C. (2004). Significance of toluidine blue positive findings after speculum examination for sexual assault. American Journal of Emergency Medicine, 22, 201-203.
  • Lauber, A. A., & Souma, M. L. (1982). Use of toluidine blue for documentation of traumatic intercourse. Obstetrics & Gynecology, 60, 644-648.
  • Lenahan, L. C., Ernst, A., & Johnson, B. (1998). Colposcopy in evaluation of the adult sexual assault victim. American Journal of Emergency Medicine, 16, 183-184.
  • McCauley, J., Guzinski, G., Welch, R., Gorman, R., & Osmers, F. (1987). Toluidine blue in the corroboration of rape in the adult victim. American Journal of Emergency Medicine, 5, 105-108.
  • McGregor, M. J., Le, G., Marion, S. A., & Wiebe, E. (1999). Examination for sexual assault: Is the documentation of physical injury associated with the laying of charges? Canadian Medical Association Journal, 160, 1565-1569.
  • Muram, D., Miller, K., & Cutler, A. (1992). Sexual assault of the elderly victim. Journal of Interpersonal Violence, 7, 70-75.
  • National Institute on Aging. (2001). Menopause. Retrieved April 1, 2005, from http://www.niapublications.org/pubs/menopause/menopause.pdf
  • Ohio State University. (2005). Perimenopause. Retrieved April 1, 2005 from http://medicalcenter.osu.edu/patientcare/healthinformation/otherhealthtopics/GynecologicalHealth/Menopause/Perimenopause/
  • Penttila, A., & Karhumen, P. J. (1990). Medicolegal findings among rape victims. Medicine and Law, 9, 725-737.
  • Rambow, B., Adkinson, C., Frost, T., & Peterson, G. (1992). Female sexual assault: Medical and legal implications. Annals of Emergency Medicine, 21, 727-731.
  • Ramin, S. M., Satin, A. J., Stone, I. C., & Wendel, G. D. (1992). Sexual assault in postmenopausal women. Obstetrics & Gynecology, 80, 860-864.
  • Rennison, C. M. (August, 2002). Rape and sexual assault: Reporting to police and medical attention, 1992-2000. Bureau of Justice Statistics Selected Findings, NCJ 194530. Retrieved April 1, 2005, from http://www.ojp.usdoj.gov/bjs/pub/pdf/rsarp00.pdf
  • Slaughter, L., Brown, C., Crowley, S. M., & Peck, R. (1997). Patterns of genital injury in female sexual assault victims. American Journal of Obstetrics and Gynecology, 176, 609-616.
  • Sommers, M. S., Fisher, B. S., & Karjane, H. M. (2005). Using colposcopy in the rape exam: Health care, forensic, and criminal justice issues. Journal of Forensic Nursing, 1, 28-34, 9.
  • Sommers, M. S., Schafer, J., Zink, T., Hutson, L., & Hillard, P. (2001). Injury patterns in women resulting from sexual assault. Trauma, Violence & Abuse, 2, 240-258.
  • Statistical Solutions. (2003). LogXact, version 5 [Computer Software]. Cambridge, MA: Cytel Software Corporation.
  • Tintinalli, J. E., & Hoelzer, M. (1985). Clinical findings and legal resolution in sexual assault. Annals of Emergency Medicine, 14, 447-453.
  • U.S. Department of Justice, Bureau of Justice Statistics. (2003) Criminal victimization in the United States—Statistical tables index; definitions. Retrieved April 1, 2005 from http://www.ojp.usdoj.gov/bjs/abstract/cvus/definitions.htm
  • U.S. Department of Justice, Office for Victims of Crime. (2001). Sexual assault nurse examiner programs (SANE): Improving the community response to sexual assault victims. Retrieved April 1, 2005 from http://www.ojp.usdoj.gov/ovc/publications/bulletins/sane_4_2001/186366.pdf
  • U.S. Department of Justice, Office on Violence Against Women. (2004). A national protocol for sexual assault medical forensic examinations (adults/adolescents). Retrieved April 1, 2005, from http://www.ncjrs.org/pdffiles1/ovw/206554.pdf