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Keywords:

  • Colposcopy;
  • consensual intercourse;
  • forensic examination;
  • forensic nursing;
  • genital injury severity scale;
  • pattern of injury;
  • sexual assault;
  • toluidine blue

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Study objectives
  5. Sexual assault research
  6. Consensual intercourse research
  7. Methods
  8. Genital injury severity scale
  9. Data analysis
  10. Results
  11. Discussion
  12. Limitations
  13. Conclusions/Clinical implications
  14. Acknowledgments
  15. References

Methods of examining the sexual assault patient are not standardized and a definition of what constitutes significant genital injury after sexual assault (SA) remains controversial. This pilot study tests the empirical validity (initial differential validity) of a genital injury severity scale (GISS) under development by the authors with the hypothesis that women who report SA have more severe external genital injuries than those who engage in consensual intercourse (CI). In this observational, prospective study, an initially developed GISS is applied and the exam results of 59 CI volunteers and 185 SA patients are compared. All examinations were performed by experienced sexual assault forensic examiners (SAFE) using toluidine blue (TB) and colposcopy. The Independent Samples Median Test indicates a significant difference in median genital injury type between CI and SA subjects (p < 0.0001). There is a significant difference in the prevalence of Class A (less severe) and Class B injuries (more severe) between the SA and the CI groups (SA: Class A 60%/Class B 40%; CI: Class A 90%/Class B 10% (p= 0.0001)). This initial validation study shows effectiveness in using magnification and TB, combined with a standardized injury severity scale, in describing external genital injury in women after sexual intercourse.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Study objectives
  5. Sexual assault research
  6. Consensual intercourse research
  7. Methods
  8. Genital injury severity scale
  9. Data analysis
  10. Results
  11. Discussion
  12. Limitations
  13. Conclusions/Clinical implications
  14. Acknowledgments
  15. References

Sexual assault forensic examiners (SAFE) are rapidly becoming the first line healthcare providers for survivors of interpersonal violence and sexual assault. In 2009, there were approximately 126,000 incidents or threats of sexual assault reported to U.S. law enforcement agencies (Rand, 2010). The physical examination of these patients has both medical and legal implications.

In the last two decades, the increasing use of DNA testing coupled with the renewed emphasis on physical evidence have highlighted the medical examination, evidence collection and documentation of injuries, as critical to the prosecution of perpetrators of sexual assault (Gray-Eurom, Seaberg, & Wears, 2002; McGregor, Dumont, & Myhr 2002; Sachs & Chu, 2002). Inconsistencies persist in the methods employed to examine SA patients and the interpretation of what constitutes genital trauma and its ultimate significance. These inconsistencies have resulted in legal challenges, which have compromised the admissibility of evidence and, at times, the credibility of the forensic examiner (Gaffney, 2001; People vs. Hatch, 1997).

The Federal Rules of Evidence delineate the criteria that govern the admissibility of scientific evidence. They stipulate that for methods to be considered valid, they should be scientifically tested, i.e., have a known rate of error, have established standards, and be subjected to peer review and scientific rigor (U.S. Supreme Court, 2000). Future research must meet these benchmarks to ensure a legally defensible, scientific basis for opinions regarding the significance of genital injury. An initial step in this process is to standardize the examination method of sexual assault patients and increase the objectivity of the interpretation of examination findings.

Study objectives

  1. Top of page
  2. Abstract
  3. Introduction
  4. Study objectives
  5. Sexual assault research
  6. Consensual intercourse research
  7. Methods
  8. Genital injury severity scale
  9. Data analysis
  10. Results
  11. Discussion
  12. Limitations
  13. Conclusions/Clinical implications
  14. Acknowledgments
  15. References

The objective of this study was to perform the initial test of differential validity of a genital injury severity scale (GISS) derived by the authors, using a standardized examination method to differentiate the genital findings of consensual intercourse (CI) subjects versus sexual assault (SA) patients. The instrument was derived with operational definitions of genital injury findings (DeVellis, 2003) based on severity. The authors could find no such validated severity scale in existence in the current literature. Therefore, the hypothesis of interest in this initial validation study (Streiner & Norman, 2008) is the fundamental, resultant hypothesis of the scale application: that the external genital findings of women after SA will be more severe than after CI. The outcomes of interest were the prevalence differences in Class A (none or less severe injury) vs. Class B (more severe injury) findings in the CI and SA groups, as well as differences in central tendency of the ordinal variable between the SA and CI groups, as defined by the scale.

Sexual assault research

  1. Top of page
  2. Abstract
  3. Introduction
  4. Study objectives
  5. Sexual assault research
  6. Consensual intercourse research
  7. Methods
  8. Genital injury severity scale
  9. Data analysis
  10. Results
  11. Discussion
  12. Limitations
  13. Conclusions/Clinical implications
  14. Acknowledgments
  15. References

The existing research that looked at prevalence of genital findings in SA exams, and did not utilize adjuncts (colposcopy and toluidine blue), had a detection rate that ranged from 6% to 53% (Cartwright, Moore, Anderson, & Brown, 1986; Eckert & Sugar, 2008; Gray-Eurom et al., 2002; Lenehan, & Johnson, 1996; Palmer, McNulty, D’Este, & Donovan, 2004; Rambow, Anderson, Frost & Peterson, 1992; Riggs Houry, Long, Markovich, & Feldhaus, 2000; Sugar, Fine, & Eckert, 2004; Tintanelli & Hoelzer, 1985; Wiley, Sugar, Fine, & Eckert 2003). Previous studies that have utilized either colposcopy alone or TB alone to detect genital injury have shown an improved ability to consistently identify injuries in both adolescents and adults when compared with studies using gross visual inspection alone. Injury prevalence rates from these studies ranged from 46% to 68% (Lauber & Souma, 1982; Lenahan et al., 1996; McCauley, Gorman, & Guzinsky, 1986; McCauley, Guzinsky, Welch, Gorman, & Osmers, 1987; Slaughter, Brown, Crowley, & Peck, 1997). Several studies report that the concurrent use of magnification and TB by trained forensic examiners increases the ability to identify and confirm the presence of genital injuries. Prevalence from these studies ranged from 32% to 87% (Anderson, McClain, & Riviello, 2006; Drocton, Sachs, Chu, & Wheeler, 2008; Jones, Rossman, Hartman, & Alexander, 2003; Jones, Wynn & Koeze, Dunnick, & Rossman, 2004; Jones, Rossman, Wynn, Dunnick, & Schwartz, 2003; Jones, Rossman, Diegel, Van Order, & Wynn, 2009; Read, Kufera, Jackson, & Dischinger, 2005; Sachs & Chu, 2002). Injuries were defined typically as abrasions, tears, ecchymosis, redness and swelling. Studies consistently regarded the presence of any of these findings as a positive result. Some researchers quantified the frequency and location of injury but did not consider severity in their analysis. The Department of Justice (2004) strongly suggests the use of the colposcope and also recognizes that toluidine blue can be useful in identifying recent genital and perineal injuries in sexual assault patients.

Although there is wide agreement with Cartwright's assertion that genital injury is not an inevitable consequence of sexual assault (Cartwright et al., 1986), there is significant variation in the literature regarding the absence of genital injury findings in women undergoing sexual assault examination, with the frequency ranging from 13% to 68% (Lauber & Souma, 1982; Lenahan et al., 1996; McCauley et al., 1987; Read et al., 2005; Sachs & Chu, 2002; Slaughter & Brown, 1992; Templeton & Williams, 2006). This wide variation may be the result of disparate research methods, examination techniques, and definitions of injury and study populations.

Consensual intercourse research

  1. Top of page
  2. Abstract
  3. Introduction
  4. Study objectives
  5. Sexual assault research
  6. Consensual intercourse research
  7. Methods
  8. Genital injury severity scale
  9. Data analysis
  10. Results
  11. Discussion
  12. Limitations
  13. Conclusions/Clinical implications
  14. Acknowledgments
  15. References

There are six frequently cited studies that examined the genitalia of women who reported recent consensual intercourse. These studies utilized tissue staining dye, colposcopy or a combination of both methods. Positive findings were described as tears, abrasions, ecchymoses, redness, swelling, tissue-stain uptake and hypervascularity. The rate of positive genital findings in these consensual cohorts ranged from 5% to 55%. When the CI subjects with positive genital findings were compared with sexual assault patients in these studies, the CI subjects’ findings were consistently less frequent in all studies, though the frequency variation in one study was not statistically significant (Anderson et al., 2006).

It should be noted that the number of consensual cohorts with genital findings after sexual intercourse in these studies was lower than sexually assaulted subjects, but was not zero. Interpreting the significance of these results is challenging in the absence of consistent examination techniques and without defined ranges of genital findings that are commonly observed after consensual intercourse, as demonstrated in Figure 1. Further exploration into the characteristics of injury and the range of genital injury findings noted after consensual intercourse is essential in defining what constitutes significant injury after sexual assault.

image

Figure 1. CI sample literature review. This figure illustrates the difficulty in comparing genital findings after CI and SA in the literature.

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Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Study objectives
  5. Sexual assault research
  6. Consensual intercourse research
  7. Methods
  8. Genital injury severity scale
  9. Data analysis
  10. Results
  11. Discussion
  12. Limitations
  13. Conclusions/Clinical implications
  14. Acknowledgments
  15. References

The study was conducted in the emergency department of a large urban county teaching hospital and Level II trauma center using a sexual assault response team (SART) medical examiners. The team, established in 1994, performs more than 300 sexual assault forensic exams each year for 23 police jurisdictions (Departmental Statistics, 2008). The team is staffed with 10 midlevel practitioners (physician assistants and nurse practitioners). Examiners have completed 40 hours of forensic training and have between 5 and 17 years of experience performing SA forensic examinations. Examiners routinely participate in ongoing sexual assault education, literature review, and chart and colposcopic image review. The authors obtained institutional review board approval from both the participating academic institution and medical center.

The consensual intercourse (CI) portion of the study was an observational, prospective investigation to assess the effects of consensual sexual activity on the genitalia of adult women. The CI participants were recruited using flyers and electronic announcements. Emergency department research staff interviewed prospective study participants to determine eligibility. Study participants were women, aged 18 to 46 years, must have been sexually active for more than 6 months, must have had a current partner with whom they have had vaginal intercourse with at least twice, must have demonstrated adequate mental capacity to provide consent, and the ability to read, write and understand English. Potential study subjects were excluded if they were pregnant, less than 6 weeks postpartum, postmenopausal, had known or suspected vaginitis, PID or perineal infection, were currently menstruating (or within two days of completion), or reported recent genital injury, douching or tampon use within the previous 72 hours. Informed consent for participation was obtained and an intake questionnaire including demographic information, gynecologic history, information regarding sexual partner and recent sexual activity was completed.

CI participants underwent a genital examination within 72 hours of consensual sexual (penile-vaginal) intercourse. The examiner performed an external genital examination (no speculum exam) using toluidine blue dye applied to the labia minora and posterior fourchette. Excess dye was then removed with a water-soluble lubricant. Colposcopic images before and after the application of toluidine blue were taken. The examiner recorded the site, type and severity of observed genital injuries on a standardized physical exam form and completed the genital injury severity scale (GISS). Examiners were blinded to all information collected on the questionnaire. Participants were paid $20 at the completion of the visit to compensate for travel and parking.

The Sexual Assault patient data were collected prospectively from consecutive sexual assault exams completed in the Emergency Department from January 2007 to September 2008. Consent for the anonymous use of the SA data for research purposes is part of the standard consent on the California Emergency Management Agency, Office of Emergency Services 923 (2002) forms signed by the SA patient at the time of the forensic exam. Included SA cases were matched to CI cohort variables of age between 18 and 46 years, examination within 72 hours of assault, reported penis to vagina contact only, not currently pregnant or currently menstruating, and with no observed or reported genital infection or lesions. The SA forensic examination included the use of colposcopy and toluidine blue dye in each case. The examiners completed the GISS at the time of SA exam.

The final consensual intercourse cohort consisted of 59 women, ages 18 to 46 years, 50 of whom reported consensual intercourse occurring in the preceding 72 hours. The SA cohort was comprised of 185 sexual assault examinations of patients treated at the emergency department from 2007 to 2008.

Genital injury severity scale

  1. Top of page
  2. Abstract
  3. Introduction
  4. Study objectives
  5. Sexual assault research
  6. Consensual intercourse research
  7. Methods
  8. Genital injury severity scale
  9. Data analysis
  10. Results
  11. Discussion
  12. Limitations
  13. Conclusions/Clinical implications
  14. Acknowledgments
  15. References

The authors developed the genital injury severity scale (GISS) in an attempt to quantify and qualify the severity of external genital injuries. The scale employs five physical examination variables and five injury severity categories. The scale identifies criteria that characterize a range of observed findings for each of the following variables: 1) swelling, 2) color change, 3) tissue injury in the labia minora or posterior fourchette, 4) hymenal injury, and 5) toluidine blue uptake. Figure 2 is a schematic of the GISS employed for this study. Injury characteristics and severity categories were selected to represent the continuum of physical examination findings most commonly reported by experts in the field of sexual assault forensic examinations and the sexual assault literature. The scale creates measurable categories, identified as “Type” of genital findings based on degrees of severity. Types 1 and 2 (Class A: none or less severe injury) reflect no disruption to minor disruption of genital tissue integrity. Types 3, 4 and 5 (Class B: more severe injury) examination findings represent swelling, color change, tissue disruption and specific toluidine blue uptake. The “type” is the most severe finding selected at the time of the exam.

image

Figure 2. Genital injury severity scale, developed by the authors.

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Figure 3 summarizes the initial testing of the instrument in development, including content and construct validity, inter-item, test-retest, and inter-rater reliability methods and results.

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Figure 3. Review of instrument development methods and results for a genital injury severity scale under development by the authors.

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Data analysis

  1. Top of page
  2. Abstract
  3. Introduction
  4. Study objectives
  5. Sexual assault research
  6. Consensual intercourse research
  7. Methods
  8. Genital injury severity scale
  9. Data analysis
  10. Results
  11. Discussion
  12. Limitations
  13. Conclusions/Clinical implications
  14. Acknowledgments
  15. References

Power analysis indicated that a minimum of 50 consensual intercourse subjects were required to detect a statistically significant difference of 5% in injury prevalence and central tendency values of the genital severity dependent variables. Using SPSS (Statistical Package for Social Science, IBM, Chicago) version 18, χ2 tests were conducted to evaluate the differences in categorical variables. All sample distributions were nonparametric, requiring tests for the difference in medians. The differences in medians between the SA and CI groups were evaluated with The Independent Samples Median Test. Significance was declared at 0.05.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Study objectives
  5. Sexual assault research
  6. Consensual intercourse research
  7. Methods
  8. Genital injury severity scale
  9. Data analysis
  10. Results
  11. Discussion
  12. Limitations
  13. Conclusions/Clinical implications
  14. Acknowledgments
  15. References

Fifty subjects from the 59 CI enrollees completed the examination within 72 hours of CI. Table 1 demonstrates the demographic of each group. Both the CI and SA groups demonstrated a median of 2 for the injury type variable, which ranged from type 1 to type 4. However, significance testing that compared the prevalence of Class B (more severe) injuries in the two samples determined them to be significantly different (p < 0.0001). A significantly higher proportion of SA survivors had Class B injuries compared to the CI group (Class B injury: SA 40% vs. CI 10%, χ2 stat = 15.875, p= 0.0001, df = 1). See Figure 4. Ninety percent of the CI participants’ exams were categorized as Class A (none or less severe injury) whereas 60% of the SA survivors’ exams were categorized as Class A. The 10% of CI participants with Class B findings reported having intercourse more than three times a week, with a mean vigorousness score of 2.6 (Likert scale 1–5), and three reported “sometimes” having painful intercourse. When comparing the two groups for the presence or absence of any injury, there was no significant difference in the proportion of SA survivors compared to CI participants who had any finding (GISS Type 2–5; SA 63% vs. CI 58%) vs. no findings (GISS Type 1; SA 37% vs. CI 42%) (χ2 stat = 0.368, p= 0.544, df = 1). Table 2 demonstrates these results in comparison form.

Table 1.  Sample characteristics (age and race) for sexual assault and consensual intercourse samples
 Sexual assault patients (n= 185)CI subjects (n= 59)
Mean age (SD) range25.5 (13.4) 18–4632.6 (8.1) 19–48
Race/ethnicity (%)
 African American48%34%
 Caucasian24%50%
 Hispanic13% 3%
 Asian/Other 6% 7%
 Unknown10% 5%
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Figure 4. Proportions of Class A vs. Class B GISS findings in SA and CI cases.

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Table 2.  Differential validity statistical analysis. Comparing CI vs. SA groups for “no findings” vs. “any findings” (p= 0.544). Comparing CI vs. SA groups for Class A vs. Class B findings (p < 0.0001). Comparing medians of CI vs. SA groups (p < 0.0001). Prevalence of “types” and “classes” for CI vs. SA groups.
  1. 1Per authors’ definitions, “injury” only found with types 3,4,5.

  2. 2 Per Independent Samples Median test.

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Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Study objectives
  5. Sexual assault research
  6. Consensual intercourse research
  7. Methods
  8. Genital injury severity scale
  9. Data analysis
  10. Results
  11. Discussion
  12. Limitations
  13. Conclusions/Clinical implications
  14. Acknowledgments
  15. References

This study compared ethnically diverse cohorts of adult women who reported sexual assault within 72 hours of examination and those who reported consensual intercourse within the same time period. A standardized examination method using both colposcopy and toluidine blue was employed and a prospectively applied standardized injury scoring scale was utilized. Utilizing a GISS to analyze both the prevalence and severity of genital injury, the results demonstrated that women in this study who reported recent sexual assault consistently had more severe injuries than those who reported recent consensual intercourse.

The GISS utilized in this study provided a standardized tool that allowed quantitative evaluation and documentation of genital examination findings using five exam variables, which included both the enumeration of genital findings and a mechanism to describe the severity of injury. Utilizing the Class A and B divisions to compare the CI and SA groups, the concept of the continuum of injury based on severity is best illustrated. In this study, the most common level of genital findings observed in women who engaged in consensual intercourse was Class A (90%). This delineation demonstrated that while it is possible to have a full spectrum of findings in both consensual subjects and sexually assaulted subjects, the prevalence of the severity of injury was significantly higher in the sexually assaulted group. This highlights why the future research of physical findings on genital exam should not be limited to “presence or absence” of injury. Figure 5 illustrates the difference in prevalence of findings categories between the SA and CI data when the GISS method replaces the previous method of “findings present” or “findings absent.”

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Figure 5. Comparing proportions of findings based on severity class vs. “presence” or “absence.” Class comparison p < 0.0001. “Presence” vs. “absence”p= 0.544 (Pearson χ2).

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Limitations

  1. Top of page
  2. Abstract
  3. Introduction
  4. Study objectives
  5. Sexual assault research
  6. Consensual intercourse research
  7. Methods
  8. Genital injury severity scale
  9. Data analysis
  10. Results
  11. Discussion
  12. Limitations
  13. Conclusions/Clinical implications
  14. Acknowledgments
  15. References

Readers should consider the findings of this study in light of several limitations. First, the researchers assumed that a patient seen in the Emergency Department for a police-authorized forensic examination was a sexual assault patient. Police will typically authorize a forensic medical exam when the facts of the case meet an established credibility threshold and there is a reasonable belief that a crime has occurred. The researchers chose not to track criminal prosecution outcomes in this study.

Second, this study is limited to menstruating-aged adult women, 18 to 46 years old and cannot be generalized to the adolescent (13 to 17 years) or postmenopausal population. Previous research conducted on adolescents and women in these age groups have demonstrated distinctly different profiles with increased genital injuries associated with both consensual and nonconsensual intercourse (Eckert & Sugar, 2008; Jones, Rossman, Wynn, et al., 2003; McCauley et al., 1987; McCauley et al., 1986; Ramin, Satin, Stone, & Wendel, 1992; Sugar et al., 2004). For this reason these groups were omitted from the study.

Third, this study cannot be generalized to findings obtained without the concurrent use of both magnification (photography with magnification or colposcopy) and TB for tissue staining. The authors consider both adjuncts to be an integral part of the examiners’ ability to identify and characterize existing genital injuries and are essential to the use of this scoring scale. Additionally, the genital injury findings are limited to the external genitalia. Previous studies that utilized magnification and/or TB reported the vast majority of injuries to be on the external structures (Anderson et al., 2006; Jones, Rossman, Wynn et al., 2003; Lauber & Souma, 1982; Slaughter & Brown, 1992; Slaughter et al., 1997).

The process of instrument development is both complex and lengthy. Figure 3 shows our initial development testing. The results of the inter-item reliability and inter-rater reliability for this iteration of the scale indicate that further refinement is warranted. The ultimate establishment of validity of a scale is an ongoing process (Streiner & Norman, 2008) and will be advanced by testing a GISS with varying populations using a variety of SA forensic examiners. Construct validity of any instrument is a lifelong process. However, in the case of a scale where the theory is the division is between SA and CI, the requirement of construct validity that the theory is the best explanation for the results can never be fully realized in testing. In practice, a SAFE cannot ethically perform an exam without prior knowledge as to whether they are examining a consensual intercourse subject or a sexual assault patient, so prospectively scoring a GISS such as one that is in development by the authors will always be biased by this fact.

Conclusions/Clinical implications

  1. Top of page
  2. Abstract
  3. Introduction
  4. Study objectives
  5. Sexual assault research
  6. Consensual intercourse research
  7. Methods
  8. Genital injury severity scale
  9. Data analysis
  10. Results
  11. Discussion
  12. Limitations
  13. Conclusions/Clinical implications
  14. Acknowledgments
  15. References

This study found a statistically significant difference in the genital findings of consensual intercourse subjects and sexual assault patients using a standardized exam method with colposcopy and toluidine blue and a standardized genital injury severity scale. Ninety percent of the CI subjects had Class A findings (none or less severe injuries) which are defined as mild erythema, nonspecific TB uptake and superficial skin disruption, compared to 60% of sexual assault survivors in this study. Ten percent of the CI subjects had Class B findings (more severe) including identifiable tears, redness, and/or specific TB uptake, compared to 40% percent of SA subjects.

By using a standardized examination method and severity scale, the forensic examiner is better able to tangibly categorize a continuum of external genital findings. At the conclusion of every SA forensic examination, the ultimate question asked of the forensic examiner is, “are the physical findings consistent with the history given?” The experienced examiner is aware that a sexual assault examination may have three potential outcomes: 1) “no findings,” or a normal exam; 2) “nonspecific” findings that could be a normal variant or the result of consensual or nonconsensual intercourse; or 3) “definite” findings which would constitute and be documented as injury. Any of these outcomes could be “consistent with the history” of a sexual assault, however, none of these outcomes can prove that a sexual assault occurred.

There is an immediate need to create and adopt a more scientific basis for decisions regarding observed injuries in SA survivors. This begins with a standardized method of examination and an agreed-upon taxonomy. In 2007, Sommers called for “a common definition for genital injury pattern,” which includes genital injury prevalence, frequency, location and severity, to guide future research parameters in both consensual and sexually assaulted subjects (Sommers, 2007). The authors agree that the need for standardization of examination techniques and common definitions of genital injury are needed to meet the demanding legal requirements for admissibility of scientific evidence and will ultimately provide a consistent framework for research in this area. The process of developing a common definition of injury and testing an objective injury severity scale and its validation will require a concerted effort on the part of forensic examiners, but it is the necessary first step in fully understanding the continuum of injury. With these factors in place, the potential to do scientific and reliable research with valid results in the future will be greatly enhanced.

Importantly however, both the research and clinical experience underscore that the absence of trauma does not prove consent, nor does consent preclude physical trauma. No scale, regardless of how refined, will be able to answer the ultimate legal question of whether or not a sexual assault has occurred. That question must be left to the jury. As Catherine Lincoln (2001) stated, “the significance (in a legal case) of most genital injury findings can only contribute to the “balance of probabilities.” It is not possible for the disciplines of law and medicine to reconcile on this issue”(p. 214). In the future, the use of a standardized exam method and an objective injury severity scale will better substantiate the forensic examiner's conclusion as to whether or not an “exam is consistent with the history given” and provide a scientific rationale for making this determination.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Introduction
  4. Study objectives
  5. Sexual assault research
  6. Consensual intercourse research
  7. Methods
  8. Genital injury severity scale
  9. Data analysis
  10. Results
  11. Discussion
  12. Limitations
  13. Conclusions/Clinical implications
  14. Acknowledgments
  15. References

This work is dedicated to Andrew Levitt, DO. Grant support from Samuel Merritt College and the California Clinical Forensic Medical Training Center. Statistical support from SMC: Nandini Dasgupta, MA, Cheryl Zlotnick, PhD; CCFMTC: Sonia Jain, DPH; ACMC: Harrison Alter, MS, MD; Alameda County Public Health: Janet Brown, MSC. Research support: ACMC: Lance Smith, Research Assistant. This work was presented at the International Association of Forensic Nurses “Scientific Assembly”: November 2006, Vancouver, BC, Canada and Clinical Forensic Medical Institute: September 2006–2009, University of California, Davis.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Study objectives
  5. Sexual assault research
  6. Consensual intercourse research
  7. Methods
  8. Genital injury severity scale
  9. Data analysis
  10. Results
  11. Discussion
  12. Limitations
  13. Conclusions/Clinical implications
  14. Acknowledgments
  15. References
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