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Appendix 10

Appendix 10. Sexual Assault Forensic Examiners. Assessment and Identification of Genital Trauma. Donna A. Gaffney, RN, DNSc, FAAN The International Trauma Studies Program New York University. Reasons for Identifying Injury . To recognize the need for appropriate treatment

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Appendix 10

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  1. Appendix 10 Sexual Assault Forensic Examiners

  2. Assessment and Identification ofGenital Trauma Donna A. Gaffney, RN, DNSc, FAAN The International Trauma Studies Program New York University

  3. Reasons for Identifying Injury • To recognize the need for appropriate treatment • To refer for further evaluation and treatment if necessary • To identify a pattern of injury as well as patterned injury

  4. As a Result of Injury Identification Although one can not unequivocally establish the use of force based on the presence of the injury . . . it is possible to corroborate the survivor’s history with injury findings.

  5. The Dilemma • Forceful penetration does not always cause injury. As a result. . . Absence of Injury Consent

  6. Types Of Injuries T-Tear (laceration) or tendernessE-Ecchymosis (bruising) A-Abrasion (scrape) R-Redness (erythema) S-Swelling (edema)

  7. Most Common Sites of Injury Related to Penile Penetration • The posterior fourchette (Between 5 and 7 o’clock) • Labia minora • Hymen • Fossa navicularis

  8. Sites and Types of Genital Injury Location:IncidenceTypesPosterior Fourchette 70 % T , AMounting injury, where the penis first touches the perineum, 5-7 o’clock, perpetrator most often in superior position.Labia Minora 56 % A, EHymen 29 % T, ESecondary to penetration, as it is an internal structureFossa Navicularis 25 % T, ECervix 13 % E

  9. What Factors Determine Potential Injury to the Genitalia? There are three categories: • Factors related to the victim, • Factors related to the perpetrator • Factors related to circumstances /environment

  10. Factors Related To The Victim • Lubrication of the vaginal vault (Natural or Artificial) • Condition of genital structures • Anatomy and physiology of reproductive structures • Positioning

  11. Factors Related To The Victim • Participation (Active or Passive) • Health and developmental status • Cognitions and Learned behaviors • Traumatic stress response

  12. Human Sexual Response Human motivation to engage in sexual behavior is due to a complex relationship among several factors. Kelly Johnson, 1997 California State University, Northridge

  13. Phases of Female Human Sexual Response • Excitement:Vasocongestion Vaginal lubrication begins • Plateau: Uterus elevates and tilts back Inner 2/3 of vagina distends Creating a reservoir for sperm Labia minora engorge- Opening vaginal orifice

  14. Phases of Female Human Sexual Response 3. Orgasmic: Regular contractions occur Outer 1/3 of vagina contracts Rectal sphincter contracts • Resolution: Muscle and uterine relaxation Cervical os remains dilated Vaginal wall relaxes Cervix lowers into sperm pool

  15. Without the HSR. . . • There may be poor lubrication of the vaginal vault. . . Resulting in friction from the opposing forces at the labia minora and hymen • Anatomical structures may not beprotected. . . Parts can be pulled inward with the penetrating object. • Result: Abrasions, lacerations and bruising

  16. Lubrication of the Vaginal Vault • What causes lubrication? • Excitement phase of HSR • Lubricant or lubricated condom • Saliva • Cyclical changes in the vaginal environment • Irritation • Infection

  17. What is Protective Positioning? • Facilitates penile insertion • Use of pelvic tilt and partner assistance with insertion • Position of legs and muscle tension in the lower body

  18. Condition of Genital Structures • Engorgement • Trans-sexual surgical procedures • Post-partum changes • Infection or other localized disease • Female Genital Mutilation

  19. Partner Participation • Cooperation and presence/absence of relaxation • Assistance with insertion • Without participation: There is the possibility of creating a less flexible surface against which the penetrating object forces itself.

  20. Health and Developmental Status • Younger victim: Less Injury More resilient tissue Faster healing • Older victim: More injury Less elasticity Less fat tissue Longer healing • Illness-compromises tissue response

  21. Cognitions and Learned Behaviors • Learned experiences and sexual responsiveness • Interpretation of stimuli and HSR • Touch • Odor • Visual • Auditory • Taste

  22. Traumatic Stress Responses • There is the threat of death or serious injury • Feeling of intense fear, terror and helplessness • Normal physiologic functioning shuts down to allow body to defend itself. • Results in one of these behaviors: Fight or flight mechanisms activate resistance behaviors. Tonic Immobility or freezing

  23. Factors Related To Perpetrator • Object of penetration is usually not lubricated causing increased friction • This can result in: Pain, vaginal lacerations or ecchymosis

  24. Factors Related To Perpetrator • Increased force or prolonged contact • consistent with crimes of violence– Result: Increased probability of injury. (especially anal penetration)

  25. Factors Related To Perpetrator • Sexual dysfunction (not uncommon) • Prolongs duration of tissue friction Result: Increased probability of injury.

  26. Factors Related To Circumstances • Relationship between victim and perpetratorvictim/perpetrator with a history of intimacy acquaintance rape situation • Physical surroundings of assault • Objects used during the assault • Location of the assault (surfaces, etc.)

  27. Incidence Of Genital Injury • Injury is not an inevitable consequence of assault. • The absence of genital injury does not prove consent.

  28. Incidence Of Genital Injury • Genital injury occurs in 10-25% of sexual assaults using gross visualization. Lenahan et al, 1998; Slaughter & Brown, 1992; Cartwright et al. 1986; Tintalli et al, 1985. • Serious injury occurs in only 5%, death in 1% may be much lower, as many cases are not reported.

  29. A Critical Question In some cases there is no evidence of genital injury, Why ?

  30. Reasons for Non-identification of Genital Injury • Lubrication of vaginal vault • Anatomical structure and musculature of vagina • Delayed examination Most evidence of injury disappears in 2 weeks

  31. Reasons for Non-identification of Genital Injury • Known relationship (intimate) with perpetratorKinesthetic memory • Minimal force used by perpetrator • Age and Developmental Status Tissue resilience and healing • Elder victim • Child/adolescent victim

  32. Reasons for Non-identification of Genital Injury • Physical health and health history • Athletes, Illness, Surgery, Ob-Gyn history • Absence of vaginal contact • Non-resisting victim • Tonic Immobility and traumatic stress response

  33. Reasons for Non-identification of Genital Injury • Lack of magnification • Drops probability of detecting injury from 50-87 % to 10-30% (gross visualization) • Lack of examiner preparation & education

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