Objective: An estimated 6.8 million rapes and physical assaults occur each year against U.S. women. Of these women, 2.6 million will experience an injury and 792,200 will require health care. On average each year between 1992 and 1996, approximately 12 per 1,000 black women experienced violence by an intimate partner, compared with about 8 per 1,000 white women. The reported incidence of genital injury resulting from sexual assault ranges from 32% on direct visualization to 87% with colposcopy technique (use of an instrument during the forensic exam that allows for magnified visual inspection). The purpose of the study was to compare, with the use of colposcopy technique, genital injury rates in women after consensual and non-consensual sex (rape).
Design: We used a descriptive, comparative design for the study.
Population, Sample, Setting, Years: We established a sexual assault registry in May of 1998. From May 1, 1998 through February 1, 2001, 576 sexually assaulted women were examined by sexual assault nurse examiners at a health sciences center. Their race was 50.1% Caucasian/white, 46.8% African American/black, 1.2% Hispanic/Latino, and <2% other. Mean age was 28.32 years (range 14-95 years). Mean time from rape to examination was 15.99 hours (range 2-68 hours). In January and February of 2001 we also examined 10 healthy volunteers following consensual sexual intercourse. Five were African American/black and 5 were Caucasian/white. Mean age was 35.2 years (range 26-46 years). The mode number of different sexual partners over the lifetime was 6-10.
Outcome Variable(s): Injury was defined as any tissue trauma visible on colposcopic photos including tears, ecchymoses, abrasions, redness, or swelling.
Methods: The colposcopy procedure was established in May, 1999 for all sexual assault survivors, after which 508 women had colposcopic photos as part of their record. An expert in colposcopy technique used the Sexual Assault Injury Scoring Sheet to record information about genital injury as seen on colposcopy photos. A prospective study was then conducted with healthy volunteers to perform a colposcopy examination following consensual sexual intercourse. Following informed consent, subjects were interviewed and then asked to return for a colposcopy exam at a prescribed time (range 2-18 hours) following sexual intercourse. Subjects were asked to avoid showering or douching prior to the exam. When subjects returned, they were interviewed and then examined by a sexual assault nurse examiner using colposcopy technique. An expert in colposcopy technique used the Sexual Assault Injury Scoring Sheet to record information about genital injury as seen on colposcopy photos. We then calculated the number of injuries for those women who were sexually assaulted and those women who had consensual sex.
Findings: Following sexual assault, the cervix was the location most frequently injured site, followed by the labia minora, posterior fourchette, vagina, and mouth. 58% of the women had no genital injury and 42% had injury. One of the ten female subjects (10% injury rate) in the prospective study experienced a single genital injury following consensual sex. The location of injury was on the posterior fourchette.
Conclusions: The literature supports the theory that consensual sex is associated with lower rates of genital injury than that of non-consensual sex. We found similar results in our prospective consensual sample. Following non-consensual sex, women had an injury rate of 42% whereas following consensual sex, women had an injury rate of 10%.
Implications: The intent of the forensic exam after reported sexual assault is two-fold: to determine the extent of injury and to collect evidence for prosecution. Health care providers need to know common locations of injury after sexual assault so that the injuries can be treated. In addition, if experts are able to differentiate consensual versus non-consensual sexual intercourse from the colposcopic photos, juries and judges can have increased confidence in the truthfulness of rape survivors, particularly when the assailant states that sex was consensual. Therefore further work is needed to determine if the colposcopy exam can be used to predict consensual versus non-consensual sex.
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