Professional Documents
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O F
CLINICAL
FORENSIC
MEDICINE
Journal of Clinical Forensic Medicine 13 (2006) 172180
www.elsevier.com/locate/jcfm
Original communication
a,*
, Iain McLean
St. Marys Sexual Assault Referral Centre, St. Marys Hospital, Hathersage Road, Manchester M13 0JH, UK
b
Academic Unit of Obstetrics and Gynaecology and Reproductive Healthcare, University of Manchester, UK
Available online 27 March 2006
Abstract
Introduction: Misconceptions about the likelihood of sustaining injuries following rape or sexual assault can have a detrimental eect on
the justice process. This is particularly noticeable with regard to rst time intercourse. Forensic physicians have a duty to put any examination ndings in context. This study sets out to compare the ndings in virgin and non-virgin adolescents seen at the St Marys Sexual
Assault Referral Centre, after an allegation of non-consensual intercourse.
Methodology: The records of all females aged 1217 years old, examined in an 18 month period were reviewed.
Results: Two hundred and twenty-four clients tted this group with a mean age of 14.8 years. Eighty-one were virgins and 97 had been
sexually active prior to the assault. The virgin group took longer to present for examination then the non-virgin group (90 h compared to
44 h). Of all clients 51% had a non-genital injury. These tended to be minor. 32% of the non-virgin group had a genital injury.
In the virgin group, 53% had a genital injury, however only 32% had the type of genital injury that would leave permanent evidence of
penetration (i.e. if examined several weeks or more later).
Alcohol use prior to assault was common.
Conclusions: Genital and or body injuries are not routinely found in adolescents after an allegation of rape or sexual assault even when
there has not been previous sexual experience. The absence of injury does not exclude the possibility of intercourse, whether with or without consent.
2006 Elsevier Ltd and AFP. All rights reserved.
Keywords: Sexual assault; Adolescents; Virgins; Injuries
1. Introduction
1.1. Forensic medical examination
One of the roles of the forensic physician in cases of sexual assault is to record the history of the allegations and to
document injuries found. However, there are still many
misconceptions about the likelihood of sustaining injuries
after a rape or sexual assault that, potentially, can have a
negative impact on the justice process. For example, the
q
This paper is part of the special issue entitled Sexual Oences, guest
edited by Dr. Guy Norfolk and Dr. Cath White.
*
Corresponding author. Tel./fax: +44 0161 276 6515.
E-mail address: cathswhite@hotmail.com (C. White).
1353-1131/$ - see front matter 2006 Elsevier Ltd and AFP. All rights reserved.
doi:10.1016/j.jcfm.2006.02.006
173
174
Table 1
Ethnicity of participants, excluding unknowns
3. Results
Ethnic group
All, n = 210
British
Irish
White Black Caribbean
White Asian
Other Dual Heritage
African
Pakistani
199
3
2
1
1
2
2
94.8
1.4
1.0
0.5
0.5
1.0
1.0
72
2
2
1
0
0
1
92.3
2.6
2.6
1.3
0.0
0.0
1.3
88
1
0
0
1
1
0
96.7
1.1
0.0
0.0
1.1
1.1
0.0
Virgins,
n = 78
Nonvirgins,
n = 91
Table 2
Crosstabs analyses of demographic data and referral source by virginity status
Status
Ethnicity White
Menarche
Tampon use
Police referral
In-care
a
Virgin, n = 81
Non-virgin, n = 97
N positive
% Positive
N totala
95% CI
Low
Up
74
74
27
76
5
94.9
94.9
40.3
93.8
6.2
78
78
67
81
81
0.377
1.148
0.925
0.378
0.942
1.229
2.942
1.875
1.023
4.500
Fisher exact
P (2-tailed, a < 0.05)
N positive
% Positive
N totala
95% CI
Low
Up
89
96
37
95
16
97.8
99.0
53.6
97.9
16.8
91
97
69
97
95
0.524
0.061
0.551
0.598
0.503
5.123
2.054
1.072
6.321
0.889
0.416
0.173
0.127
0.248
0.036
Excluding unknowns.
Table 3
Crosstabs analyses of genital injuries by tampon use
Status
Tampon users, n = 78
N positive
Genital injury
Hymen injury
Vulva injury
Fourch-ette injury
Vagina injury
26
13
10
10
0
% Positive
51.0
17.8
13.7
13.7
0.0
Non-tampon users, n = 78
N
51
73
73
73
73
total*
95% CI
N positive
Low
Up
0.736
1.265
0.425
0.668
1.693
3.360
0.853
1.782
39
33
3
12
4
% Positive
55.7
43.4
3.9
15.8
5.3
70
76
76
76
76
total*
Fisher exact
P (2-tailed, a < 0.05)
95% CI
Low
Up
0.678
0.435
0.852
0.608
0.421
1.255
0.779
6.352
1.404
0.585
1.000
0.001
0.044
0.819
0.120
175
Table 4
Criminal justice outcomes, all participants, n = 224
Outcome
Valid %
Undetected
Trial, but result unknown
Retracteda
No caseb
No crimec
Conviction
Self-referral
No record of outcome
55
30
23
18
12
9
5
72
24.6
13.4
10.3
8.0
5.4
7.1
2.2
32.1
37.4
20.4
15.6
12.2
8.2
6.2
a
b
c
Table 5
Crosstabs analyses of assault types data
Status
Virgin, n = 81
N positive
Penile-vaginal
Digital-vaginal
Penile-anal
Digital-anal
Object-anal
Fellatio
Cunnilingus
a
% Positive
70
8
3
0
0
5
1
92.1
10.4
3.8
0.0
0.0
6.3
1.3
Non-virgin, n = 97
a
N total
76
77
80
80
80
80
80
95% CI
N positive
Low
Up
0.276
0.849
0.410
0.609
0.232
1.053
2.794
2.099
2.503
3.773
73
17
3
2
1
8
1
% Positive
82.0
19.3
3.3
2.2
1.1
8.8
1.1
N total
89
88
92
91
91
91
91
Fisher exact
P (2-tailed, a < 0.05)
95% CI
Low
Up
1.053
0.544
0.476
0.456
0.459
0.542
0.264
1.927
1.022
2.417
0.608
0.610
1.345
4.289
0.068
0.131
1.000
0.499
1.000
0.577
1.000
Excluding unknowns.
Table 6
Crosstabs analyses of alcohol and drug use prior to assault
Status
Virgin, n = 81
N positive
Alcohol use
Drug use
a
30
5
Excluding unknowns.
% Positive
37.0
6.2
Non-virgin, n = 97
a
N total
81
81
95% CI
N positive
Low
Up
1.415
0.630
2.800
2.671
66
9
% Positive
68.0
9.3
N total
97
97
Fisher exact
P (2-tailed, a < 0.05)
95% CI
Low
Up
0.404
0.551
0.749
1.265
0.000
0.579
176
Table 7
Alcohol units consumed by those that had been drinking, excluding
unknowns
Frequency
All, n = 96
Virgins, n = 23
Non-virgins, n = 60
Mean
Median
Mode
St. Dev.
Minimum
Maximum
7.26
6.00
6
4.463
1
22
6.35
6.00
3 and 6
4.302
1
15
7.82
6.50
5
4.742
1
22
Stranger
Friend
Acquaintance over 24 h
Acquaintance under 24 h
Family member
Acquaintance time unknown
Current partner
Former partner
Authority gure
Mothers partner
Unknown
66
45
32
29
10
6
6
1
1
1
27
29.5
20.1
14.3
12.9
4.5
2.7
2.7
0.4
0.4
0.4
12.1
Table 9
Crosstabs analyses of injury data
Status
Self-harm evident
Old self-harm
Fresh self-harm
Body injury
Genital injury
Hymen injury
Vulva injury
Fourch-ette injury
Vagina injury
a
Virgin, n = 81
Non-virgin, n = 97
N positive
% Positive
N totala
95% CI
Low
Up
4
2
2
39
43
40
5
13
2
5.3
50.0
50.0
49.4
62.3
50.6
6.3
16.5
2.5
75
4
4
79
69
79
79
79
79
0.877
0.696
0.073
0.851
0.508
0.317
0.654
0.609
0.348
5.105
17.589
2.036
1.630
1.025
0.570
2.769
1.419
2.536
% Positive
N totala
95% CI
Low
Up
14
12
3
54
31
11
9
13
2
14.9
85.7
21.4
56.8
46.3
12.4
10.1
14.6
2.2
94
14
15
95
67
89
89
89
89
0.510
0.214
0.665
0.662
0.985
1.803
0.532
0.708
0.394
0.909
1.590
2.992
1.149
1.951
5.298
1.229
1.619
2.857
Excluding unknowns (and for old/fresh self-harm also excluding cases of no self-harm).
Positive
Positive
5 / 6%
16 / 16%
Missing
2 / 2%
Negative
76 / 94%
Fisher exact
P (2-tailed, a < 0.05)
N positive
Negative
79 / 81%
0.049
1.000
0.533
0.362
0.085
0.000
0.416
1.000
1.000
177
68
37
9.3
6.2
Alcohol
Drug
Virgin
Non-virgin
Fig. 2. Bar chart of alcohol and drug use by virgin and non-virgin participants.
50.6
12.4
6.3 10.1
Hymen
16.5 14.6
2.5 2.2
Vulva
Fourchette
Genital area
Vagina
Non-genital injuries tended to be fairly minor, including bruises, abrasions. None of the observed injuries
(genital and non-genital) were severe enough to require
referral to hospital for continued care. Most of the virgin
hymen injuries (26/40, 65%) were full thickness lacerations and all were in the posterior portion between 3
and 9 oclock, with 18 of the 26 (69%) more narrowly
placed between 5 and 7 oclock. The other virgin hymen
injuries were bruises, abrasions or less than full thickness
lacerations (see Fig. 4).
Missing
5 / 2%
4. Discussion
4.1. Demography
4.1.1. Ethnicity and age
Ethnic dierences were not statistically signicant but
the virgin group was on average 1 year younger than the
non-virgin group. This age dierence may be responsible
for some of the statistically signicant ndings between
the groups, e.g., older adolescents have greater access to
Missing
16 / 7%
Positive
90 / 40%
Negative
105 / 47%
Negative
118 / 53%
178
alcohol and a higher proportion of non-virgins had consumed alcohol (see Tables 1012).
4.1.2. Menarche, tampon use, and parity
Tampon users were less likely to have hymenal injuries than non-tampon users. This could have a variety
of explanations. It may be that using tampons
stretches the hymen therefore making penile penetration less likely to cause an injury. It could also be that
those girls with a larger hymenal orice or stretchier
hymen are more likely to nd tampon use acceptable
than those where the hymen is less accommodating to
tampon insertion. The question have you ever tried to
use tampons? is not routinely asked but may shed some
light on this.
4.1.3. Being looked after (in-care)
There was a higher proportion of non-virgins in-care. As
this group was also older it may just reect the fact that
they have had more time to be exposed to the sort of diculties that lead to care orders rather than represent genuinely increased sexual activity amongst those in-care.
Table 10
Summary of presence and absence of injuries for all participants, n = 224
Finding
Body area
Body
Yes
No
Not examined
Not known
Genital (all)
Hymen
Vulva
Four-chette
Vagina
114
105
5
0
50.9
46.9
2.2
0.0
90
120
0
14
40.2
53.6
0.0
6.3
62
148
14
0
27.7
66.1
6.3
0.0
19
191
14
0
8.5
85.3
6.3
0.0
32
178
14
0
14.3
79.5
6.3
0.0
6
204
14
0
2.7
91.1
6.3
0.0
Table 11
Summary of presence and absence of injuries for all known virgins, n = 81
Finding
Body area
Body
Yes
No
Not examined
Not known
Genital (all)
Hymen
Vulva
Four-chette
Vagina
39
40
2
0
48.1
49.4
2.5
0.0
43
36
0
2
53.1
44.4
0.0
2.5
40
39
2
0
49.4
48.1
2.5
0.0
5
74
2
0
6.2
91.4
2.5
0.0
13
66
2
0
16.0
81.5
2.5
0.0
2
77
2
0
2.5
95.1
2.5
0.0
Table 12
Summary of presence and absence of injuries for all known non-virgins, n = 97
Finding
Area
Body
Yes
No
Not examined
Not known
Genital (all)
Hymen
Four-chette
Vagina
Vulva
N
54
41
2
0
55.7
42.3
2.1
0.0
31
58
0
8
32.0
59.8
0.0
8.2
11
78
8
0
11.3
80.4
8.2
0.0
9
80
8
0
9.3
82.5
8.2
0.0
13
76
8
0
13.4
78.4
8.2
0.0
2
87
8
0
2.1
89.7
8.2
0.0
179
sion making regarding progression of a case. Any uncertainty regarding medical ndings should be discussed at
pre trial conference.
5. Conclusion
5.1. Summary
The numbers of people coming forward to make
complaints of rape and sexual assault has increased year
on year since the opening of St. Marys centre. The proportion of these that are adolescents has also increased. But
also over this time the national conviction rate for rape
has fallen: in 1977 it was 32%, decreasing to 5.6% in
2002.9
This study of adolescents presenting during an 18month period established three key ndings:
a. Genital injury is not the norm following sexual
assault, even when there is a history of not having
been sexually active prior to the alleged assault.
b. Nearly 50% will have no body injuries.
c. The majority of the complainants knew their alleged
attacker prior to the assault.
Some issues highlighted by these results raise more questions that may be worth further study:
a. The high proportion of alcohol consumption prior to
the alleged assault in these young girls. It would be
interesting to see if the alcohol is a confounder rather
than a causal factor in sexual assault/rape.
b. The high rate of self-harm in the non-virgin group.
Are there issues of self-esteem, self worth that need
exploring?
5.2. Recommendations
1. Forensic physicians need to be aware of the myths and
stereotypes that surround rape and sexual assault.
2. Forensic physicians need to raise these issues at every
opportunity (e.g. in statements and witness testimony)
to try to get the correct information to the decision makers (police, lawyers and juries) so that they can base their
decisions on facts not ction.
3. It is arguable that every rape examination should be followed swiftly be a statement which would put ndings in
context and aid decision making by the investigative
team. This has time issues for the doctor and nancial
implications for the police.
4. Rape specialist lawyers should be routinely used for
these cases.
5. Precourt conferences involving the forensic physician
and counsel should be routine practice.
6. Rape specialist police ocers should always be involved
in these cases.
180