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Boroda

Возможно ли анальное изнасилование при сопротивлении жертвы?

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Boroda

В процессе судебного заседания выясняется следующее:

 

Жертва и насильник знали друг друга давно. Одинокая женщина просила прикрепить ей гардины в её квартире, но просила насильника придти не одному, а с его женой - подругой жертвы. Но насильник явился один и предложил заняться сексом, но женщина отвергла это предложение. В ответ он применил силу...

 

Женщина находилась в положении на животе на кровати. Насильник находился сверху и держал её за голову. Она утверждает, что была вагинальная и анальная пенетрация, но семяизвержения не было. Она сопротивлялась и кричала, что услышали соседи и вызвали органы, которые приехали 30 минут спустя. Насильник скрылся, но позднее был взят под стражу.

 

Гинекологическое исследование дало покраснение в области вульвы и никаких других повреждений. При наружном осмотре области ануса повреждений не обнаружено. В мазках сперматозоидов обнаружено не было.

 

Обнаружены также полосовидные кровоизлияния и царапины на руках и мелкие царапины на лице.

 

Адвокат на судебном заседании заявил следующее: Сфинктер ануса - самый мощный мускул в организме. При сокращении этого мускула анальная пенетрация исключена. Опять же при анальной пенетрации должны были быть в обязательном порядке повреждения. Таковых не наблюдалось.

 

Вагинальная пенетрация при положении на животе исключена из анатомических соображений. Насильник не смог бы достать влагалище.

 

Исходя из вышесказанного никакого изнасилования не было, а была мелкая потасовка с руганью.

 

Суд принял решения вызвать на следующее заседание СМЭ и прояснить ситуацию. Придётся идти и отвечать на вопросы. Есть у кого какие-то лит. источники или идеи как можно было бы ответить адвокату. Был бы благодарен за помощь.

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Stagman
Адвокат на судебном заседании заявил следующее: Сфинктер ануса - самый мощный мускул в организме. При сокращении этого мускула анальная пенетрация исключена. Опять же при анальной пенетрации должны были быть в обязательном порядке повреждения.
А Вы спросите, он-то откуда взял всю эту ерунду просамый мощный мускул и отсутствие повреждений? какой источник?
Вагинальная пенетрация при положении на животе исключена из анатомических соображений. Насильник не смог бы достать влагалище.

Как-так - исключена? :)/> Да это чуть ли не самая любимая моя поза! Очень запросто всё достаётся. Глупость какая-то...

Я б сказал, что "не исключаю". А остальное - пусть сами разбираются.

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Valerich

Не поймите превратно, но это надо бы FILIN'a спросить. Если что-то и есть по теме, то он точно должен знать.

 

Ссылки на российские тюрьмы, где могут не то что, женщину, здорового мужика "опетушить", ваших судей вряд ли убедят. Но в принципе у меня особых сомнений нет, что пенетрация возможна при любом сопротивлении. Но совсем без повреждений, если сопротивление было, а женщина анальный секс не практиковала часто, вряд ли обошлось бы. Про признаки пассивного гомосексуализма, а стало быть и в целом частого анального секса точно что-то было в нашей отечественной литературе, поищу. Кажется, на ФСМ даже учебный фильм выкладывали для студентов, где подробно эти признаки демонстрировались. Правда качество поганое.

 

Что касаемо возможности вагинальной пенетрации на животе, то тут и гадать не надо. Осматриваете обоих, проводите измерения и даёте заключение о принципиальной возможности или невозможности. Тут, конечно, всё будет зависеть от длины полового члена в эрегированном состоянии и габаритов женщины.

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Stagman

Не стоит забывать о том, что эта "самая мощная мышца" от страха у женщины могла стать атоничной и неконтролируемой. Так, извините, и обделаться можно. А это уже спонтанно выделенный любрикант, прости Господи...Так что, я бы и вариант без повреждений не исключал. Плюс учёт измерений...

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Boroda

Надыбал свежую статейку, но на английском. Красным выделил главное.

Forensic Science Internationalб Volume 154, Issues 2-3, 25 November 2005, Pages 200-205

 

Genitoanal injury in adult female victims of sexual assault

 

Malene Hildena, Berit Scheib, c and Katrine Sideniusa

 

aCenter for Victims of Sexual Assault 4031, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen Ш, Denmark

bDepartment of Community Medicine, Norwegian University of Science and Technology, Trondheim, Norway

cCopenhagen University, Denmark

Received 24 June 2004; accepted 20 October 2004. Available online 3 February 2005.

 

Abstract

Objectives:

To evaluate the presence and extFent of genitoanal injury among sexually assaulted women and to estimate the risk of injury in subgroups according to the type of assault and to the sexually assaulted women's susceptibility to injury.

 

Study design:

A case-control study of 249 women exposed to sexual assault. Injury identified by gross visualization. Women with and without injury were compared. Logistic regressions analyses were performed to calculate the risk of injury.

 

Results:

Thirty-two percent sustained genitoanal injury. Anal penetration and assaults on women without prior sexual experience were associated with genitoanal injury.

 

Conclusions:

Most women do not have visible genitoanal injuries. The risk of sustaining genitoanal injury during a sexual assault is higher among women without prior sexual intercourse experience and among women exposed to anal penetration. The severity of the assault is a poor predictor of genitoanal injury.

 

Keywords: Sexual assault; Genitoanal injury; Anal penetration; Gross visualization

 

1. Introduction

Genital and non-genital injuries are not inevitable consequences of sexual assault [1], [2], [3], [4], [5], [6] and [7]. However, the documentation of any genitoanal injuries is an important element in the medico-legal examination; the type and localizations of these injuries are described in several studies [1], [2], [4], [5], [6], [7], [8], [9], [10], [11], [12] and [13]. Three earlier studies indicate an association between genitoanal injury and: age, time between assault and examination, resistance, anal penetration, and the relationship between victim and assailant [1], [3] and [10]. Other studies have examined women after consensual intercourse, and conclude that genitoanal injury can be observed. Two of these studies were comparative studies that reported a higher proportion of women with injury among those who had been sexually assaulted (40–89%) than among those reporting consensual intercourse (5–11%) [1], [14] and [15]. In some studies, the documentation of injury has been associated with pressing charges [11] and [16], and legal prosecution [2], [8], [10] and [17]. Documentation of injury has also been suggested to increase the conviction rate [11] and [17]. Other studies have found no such association [18] and [19]. It is unknown if the documented injuries, both genital and non-genital, is a good indicator of gross violence. It is also unknown if the more frequent prosecution of the assailant in cases where injuries have been documented can be explained by the more serious assaults or the more violent assailants. Little work has been done to determine if any associations exist between the details of the assault and genitoanal injury. Our aim was to evaluate the presence of genitoanal injury in a population of sexually assaulted women, and to relate the injuries to characteristics of the assault in order to estimate the risk of injury in subgroups of sexually assaulted women. We hypothesized that several factors affect the risk of genitoanal injury, as for example, the severity of the assault (extent of violence and number of assailants), the time from assault to examination, whether the incident had been reported to the police, and factors related to the women's susceptibility to injury (age, parity and sexual experience).

 

2. Material and methods

The study was designed as a case-control study at the Center for Victims of Sexual Assault in Copenhagen [20]. The center receives persons who have been referred from other health-care clinics, emergency departments and the police, as well as those presenting themselves. The examination and treatment are independent of the incident having been reported to the police. History taking and results of the examination are standardized in a 20-page form that includes information on: socio-demographics of the assaulted person, information about the assault, the time, the location, and what occurred; alcohol consumption before the assault; relationship to the assailant; age of the assailant; whether the incident has been reported to the police; medical history; and prior sexual experience. The results of the examination and the prescribed medications are also included. Data from all women examined at the center from January 2001 to December 2002 (2 years, n = 406) were recorded in an anonymous database. However, a few cases were excluded, as we were informed by the woman or by the police that the allegations were false.

 

The database has been approved and registered by The Danish Data Protection Agency.

 

Gynecologists examined all patients, and when cases had been reported to the police, the examination was done in collaboration with a forensic pathologist. Signs of violence were described and sketched out during or immediately after the examination. When, in this text, we refer to genitoanal injuries it is implied that these are the injuries that were documented during the examination.

 

We excluded assaults where the reported assault did not involve penetration (n = 46), and among the remaining 360 individuals, 93 were examined later than 72 h after the assault, and a further 18 had no gynecological examination; they were therefore excluded, leaving 249 women included in the study. Fatal cases were not included, as they are not examined at the center (from 0 to 2 per year).

 

Type of sexual coercion and type of violence reported were prioritized for the analyses, according to the order shown in Table 3, with the most serious form first. The location of the assault was categorized as to whether it occurred in a private home (either the victim's or the assailant's), in a public place (restaurant, street, park, stairway, backyard) or other (car, private garden). The relationship between the assaulted woman and the assailant was classified as partner/ex-partner, family (e.g., farther, sibling), friends (known >24 h), acquaintances (known

 

Genitoanal injuries were identified by macroscopic visualization. Internal lesions were examined after insertion of a speculum or anoscope. Injuries were recorded according to their location: the labia majora, labia minora, hymen/hymenal brim, posterior fourchette, vestibulum, perineum and anal/perianal, and type: tears, ecchymoses and abrasions. Women in whom only diffuse, unspecific hyperemia and/or edema were documented (n = 13) were excluded from the group with genitoanal injury because of the lack of specificity of these physical signs.

 

Chi-square tests were performed in univariate analysis; all significant variables were later entered in a logistic regression model. Level of significance: p ≤ 0.05. SPSS 11.0 was used for data-analysis.

 

3. Results

Of the 249 women included, 32 % (n = 80) had a genitoanal injury. The distributions on the anatomical localizations are shown in Table 1. The three most frequent sites of injury were the posterior fourchette, anal or perianal area and vestibulum. Most were single site injuries (67.5%). The type of injury was typically a tear ranging from 2 to 25 mm. No tears needed surgical repair. Tears were found in 87.5% (n = 70) of the 80 women, ecchymoses in 16.3% (n = 13) and abrasions in 10% (n = 8).

 

Table 1. Localization of genitoanal injury in 80 women exposed to sexual assault

————————————————————————————————————————

Number (%)

————————————————————————————————————————

Hymen 14 (17.5)

Labia majora 3 (3.8)

Labia minora 8 (10.0)

Vestibulum 17 (21.3)

Posterior fourchette 39 (48.8)

Perineum 6 (7.5)

Anal/perianal 18 (22.5)

Vagina 4 (5.0)

 

Single site trauma 54 (67.5)

Multiple site trauma 26 (32.5)

 

Table 2 shows the socio-demographic characteristics of the women with and without genitoanal injuries. Only age was significantly related to the occurrence of genitoanal injury (p = 0.04). Women under 19 years of age, and women above 50 years of age had the highest risk of genitoanal injury. Parity was not associated with genitoanal injury. Most victims were students, corresponding with the age dispersion.

————————————————————————————————————————

Table 2.

Socio-demographic information on women seen at the Center for Victims of Sexual Assault, Copenhagen, with and without genitoanal injury, n (%)

 

Genitoanal injury

————————————————————————————————————————

p —- n —- Yes (%) — No (%)

————————————————————————————————————————

Age 0.04

12–19 years 98 39 (39.8) 59 (60.2)

20–49 years 143 37 (25.9) 106 (74.1)

>50 years 8 4 (50.0) 4 (50.0)

 

Occupation 0.48

Employed 37 14 (37.8) 23 (62.2)

Student 104 37 (35.6) 67 (64.4)

Unemployed 20 7 (35.0) 13 (65.0)

Social welfare 48 11 (22.9) 37 (77.1)

Other/no information 40 11 (27.5) 29 (72.5)

 

Nulliparity 0.30

No 73 20 (27.4) 53 (72.6)

Yes 176 60 (34.1) 116 (65.9)

Full-size table

Chi-square tests performed, p-values displayed.

 

Characteristics of the assault were cross tabulated with the presence of genitoanal injury (Table 3). When anal penetration was reported, the frequency of injuries was high (52.6%); the lowest frequency of injuries (5.6%) was found in women reporting only digital penetration or pawing of the genitals. When comparing women exposed to anal penetration (with or without vaginal penetration) with women exposed to vaginal penetration only, excluding the other subgroups in this variable, anal penetration remained significantly associated with an increased risk of genitoanal injury compared with vaginal penetration only, OR 2.4, 95%CI: 1.2–5.0 (not in table). Severe violence reported by the assaulted woman was not associated with an increased likelihood of documenting genitoanal injury; similar, the location of the assault and time of day did not appear to have an impact. Assaults by strangers were less likely to cause genitoanal injury, but this was not statistically significant. Women who reported assaults involving more than one assailant were more likely to sustain injury, but this was not statistically significant (Table 3).

————————————————————————————————————————

Table 3.

Characteristics of the assault and genitoanal injury among 249 women seen at the Center for Victims of Sexual Assault, Copenhagen, n (%)

 

Genitoanal injury

————————————————————————————————————————

p —- n —- Yes (%) —- No (%)

————————————————————————————————————————

Penetration

Anal 38 20 (52.6) 18 (47.4)

Vaginal 150 47 (31.3) 103 (68.7)

Attempted vaginal/anal 14 4 (28.6) 10 (71.4)

Digital/pawing of genitals 18 1 (5.6) 17 (94.4)

No recollection 29 8 (27.6) 21 (72.4)

 

Reported physical violence 0.54

Grievous bodily harm/attempted strangulation 28 9 (32.1) 19 (67.9)

Actual bodily harm 46 11 (23.9) 35 (76.1)

Restrained 104 34 (32.7) 70 (67.3)

None 44 15 (34.1) 29 (65.9)

No recollection 16 5 (31.3) 11 (68.7)

No information 11 6 (54.5) 5 (45.5)

 

Location of assault 0.30

Private home 148 54 (36.5) 94 (63.5)

Public place 82 20 (24.4) 62 (75.6)

Other 15 5 (33.3) 10 (66.7)

No recollection 4 1 (25.0) 3 (75.0)

 

Relationship between assailant and victim 0.16

Partner/ex-partner 35 9 (25.7) 26 (74.3)

Family 12 6 (50.0) 6 (50.0)

Friends 68 23 (33.8) 45 (66.2)

Acquaintances 62 26 (41.9) 36 (58.1)

Strangers 62 14 (22.6) 48 (77.4)

Other 3 – 3 (100)

No information 7 2 (28.6) 5 (71.4)

 

Number of assailants with sexual contact 0.21

1 210 66 (31.4) 144 (68.6)

>1 21 10 (47.6) 11 (52.4)

No recollection/information 18 4 (22.2) 14 (77.8)

 

Time of day of the assault 0.55

4:00 a.m.–11:59 a.m. 65 18 (27.7) 47 (72.3)

Noon–7:59 p.m. 34 13 (38.2) 21 (61.8)

8:00 p.m.–3:99 a.m. 150 49 (32.7) 101 (67.3)

Full-size table

Chi-square tests performed, p-values displayed.

 

In Table 4, the related characteristics of the women are displayed according to the risk of genitoanal injury. Among those women reporting no prior sexual intercourse experience, 69.7% sustained genitoanal injuries, compared to 25% among those with prior sexual experience.

————————————————————————————————————————

Table 4.

Characteristics related to the women and genitoanal injury among women seen at the Center for Victims of Sexual Assault, Copenhagen, n (%)

 

Genitoanal injury

————————————————————————————————————————

p —- n —- Yes (%) —- No (%)

————————————————————————————————————————

Prior sexual intercourse experience

No 33 23 (69.7) 10 (30.3)

Yes 180 45 (25.0) 135 (75.0)

No information 36 12 (33.3) 24 (66.7)

 

Alcohol consumption (victim) 0.55

None 76 23 (30.3) 53 (69.7)

Small quantity (

Large quantity (>5 units*) 73 28 (38.4) 45 (61.6)

Large quantity with amnesia 21 4 (19.0) 17 (81.0)

No information 19 6 (31.6) 13 (68.4)

 

Time from assault to examination 0.15

Less than 24 h 195 67 (34.4) 128 (65.6)

More than 24 h (and less than 72) 54 13 (24.1) 41 (75.9)

 

Non-genital injuries 0.34

Severe 33 12 (36.4) 21 (63.6)

Moderate 67 25 (37.3) 42 (62.7)

Slight 48 16 (33.3) 32 (66.7)

None 95 27 (28.4) 68 (71.6)

No information 6 – 6 (100)

 

Reported to the police 0.75

Yes 196 62 (31.6) 134 (68.4)

No 53 18 (34.0) 35 (66.0)

Full-size table

Chi-square tests performed, p-values displayed.

 

* 1 unit of alcohol equals 12 g of alcohol (4 cl of 40% spirits).

 

Proportionally more victims were found to have injuries when examined within the first 24 h of the assault (n = 195), but this was not statistically significant. No association was found between non-genital injury and genitoanal injury. The quantity of alcohol consumed revealed no significant differences, however, the group who consumed alcohol to a degree where amnesia occurred had proportionally fewer genitoanal injuries compared to the others (not statistically significant). The documentation of genitoanal injuries was not associated with whether or not the woman reported the incident to the police (Table 4).

 

Age, prior sexual experience and type of sexual coercion were entered in a logistic regression model. The association between age and genitoanal injury fell below the level of significance when controlling for the other factors. Prior sexual experience remained statistically associated with genitoanal injury (OR 7.4); anal penetration also remained statistically associated with genitoanal injury, OR 4.0 (Table 5).

————————————————————————————————————————

Table 5.

Crude and adjusted odds ratios of genitoanal injury among sexually assaulted women, n = 249

————————————————————————————————————————

OR crude

————————————————————————————————————————

95%CI

————————————————————————————————————————

OR adjusted

————————————————————————————————————————

95%CI

————————————————————————————————————————

 

Age

12–19 1.9 1.1–3.3 1.5 0.8–2.9

20–49 1 1

50+ 2.9 0.7–12.0 3.6 0.8–16.3

 

Anal penetration

Yes 2.8 1.4–5.7 4.0 1.9–8.6

No 1 1

No recollection 1.0 0.4–2.3 0.9 0.4–2.4

 

Prior sexual intercourse experience

No 6.9 3.1–15.6 7.4 3.1–17.5

Yes 1 1

No information 1.5 0.7–3.2 1.6 0.7–3.7

Full-size table

Binary logistic regression analyses.

4. Discussion

Thirty-two percent of the study population had genitoanal injuries, however, the majority of those exposed to sexual assault had no objective genitoanal findings. Genitoanal injuries were related to anal penetration and assaults on women with no prior sexual intercourse experience.

 

Several limitations to this type of study must be considered when interpreting results. The power of the analyses is affected by the relatively small number of participants; in some of the stratifications with small cell-sizes we might have found a different result if more women had been included. The organization of the center permits inclusion of both cases reported to the police and those not reported, however, the results are still biased by not having any information on women who did not seek any help. It could be argued that the presence of genitoanal injury is an important factor when a woman decides whether or not to report the incident to the police or to contact the health-care system. However, we found no difference in the frequency of injury between women who reported the incident to the police and those who did not. Data on the circumstances of the assault and on personal issues are solely based on information given by the women. Some of this information might not be correct. Finally, it is possible that examiners recorded injuries inaccurately or overlooked some injuries, but as the medical staff had been given repeated instruction and training in the forensic examination we believe that this misclassification is unlikely. However, it might be argued that women who report severe assaults involving, e.g., anal penetration might alert the examiner to look more carefully and thereby cause an observer bias.

 

Lenahan et al. found genital injury in only 6% of 17 women examined by gross visualization, whereas Bowyer et al. reported that 27% of 83 women had genitoanal injury. The latter is in accordance with our findings.

 

The localization of injuries was predominantly found around the introitus vaginae and anus, which is in concordance with previous studies [1], [5], [6], [9], [12] and [21]. Anal penetration and no prior sexual intercourse experience were statistically associated with genitoanal injury, but not all women in these two categories sustained injury. We know that in a few cases the assailant used lubrication, for example, oil, however, we have no information to lead us to believe that this is commonly used.

 

As found in other studies [3], [7], [10] and [22], univariate analyses showed an increased risk of injury in adolescents and women aged over 50 years. However, in the logistic regression analyses, these associations fell below the level of significance. This is probably explained by the susceptibility to genitoanal injury in young women being more a result of no prior sexual experience than of age. Nulliparity was not associated with an increased risk of genitoanal injury. We could not confirm the expected increased risk among the older women being due to lowered estrogenic influence on the mucus membranes in the vagina and vulva, possibly because of the small sample.

 

The type of sexual coercion correlated with genitoanal injury. Anal penetration was a risk factor for injury compared to vaginal penetration only. Pawing of the genitals had an even lower risk. It is important to note than among the group of sexually assaulted women who had no recollection of what had happened to them, 27.6% had genitoanal injuries. This suggests that they had been subjected to consummated or attempted anal or vaginal penetration.

 

We had expected that the more serious type of reported physical violence and the more severe non-genital injuries documented would correlate with the presence of genitoanal injuries but we found no association. This emphasizes the importance of conducting the gynecological examination despite the examination of the body revealing no signs of violence. The relationship between the assaulted woman and the assailant, and the number of assailants has earlier been described as being related to the presence of genitoanal injury. One study has found that assaults by strangers caused more injury [1]. We could not confirm this, which is in concordance with other studies [3] and [10]. It could be argued that these women were in shock or unable to act because of fear of death. Cartwright found no difference according to whether one or more assailants were involved [10]. The number of assaults involving more than one assailant, where the second or third assailant also had sexual contact with the woman, was relatively small in our sample. The percentage of women with injuries was higher than in assaults with just one assailant, but the difference was not statistically significant.

 

More than half of the sexually assaulted women were influenced by alcohol during the assault; those women who consumed quantities sufficient to provoke episodes of amnesia seemed to sustain less injury. An explanation might be that they offered no resistance, or that they were ”asleep” when the assault happened. Sachs and Chu found that women who offered no or little physical or verbal resistance sustained less injury than women who tried to resist the assault [3].

 

The genital mucosa heals quickly and small lesions would be expected to disappear within a few days. Slaughter et al., and Sachs and Chu [1] and [3] found that the documentation of genitoanal injury was associated with examination within 24 h of the assault. Our results also suggest this association, although they are not statistically significant.

 

The frequency of genitoanal injury found among women exposed to sexual assault is dependent on the type of examination used, and the types of injury included. The proportion of women with genitoanal injuries is higher among those examined by colposcope (33–87%) [1], [4], [5] and [8], than among those examined only by macroscopic visualization and/or dye (6–45%) [2], [4], [6], [7], [9], [10], [11] and [23]. The colposcope is widely used in the examination of sexually abused children, but the rationale for the use among adult victims is controversial. Most centers that examine those exposed to sexual assault do not have access to a colposcope, and it has been argued that the colposcopic examination is an unnecessary, stressful invasion [6]. The type of injury included differs between the studies mentioned but there is a tendency towards including redness and swelling as well as microtrauma in studies where the colposcope has been used. This would explain some of the disagreement in results. It seems rational to argue that the smaller lesions detected increase the likelihood of similar lesions being found on women after consensual intercourse. Smaller lesions might enable recent intercourse to be established but their present will not aid in establishing whether intercourse was by common consent. Detection of microtraumas is, therefore, of limited value in legal proceedings.

 

This study emphasizes that genitoanal injuries are not related to any specific type of assault or to the severity of the assault, and in turn outlines that this parameter is a poor guide to determine the severity of the assault.

 

In conclusion, most of those exposed to sexual assault do not have visible genitoanal injuries. Injury seems related to anal penetration and first time sexual intercourse but is otherwise not related to the type or seriousness of the assault.

 

5. Condensation

Factors associated with genitoanal injury in women exposed to sexual assault.

 

References

 

[1] L. Slaughter, C.R. Brown, S. Crowley and R. Peck, Patterns of genital injury in female sexual assault victims, Am. J. Obstet. Gynecol. 176 (1997) (3), pp. 609–616. Article | PDF (3536 K) | View Record in Scopus | Cited By in Scopus (56)

[2] B. Rambow, C. Adkinson, T.H. Frost and G.F. Peterson, Female sexual assault: medical and legal implications, Ann. Emerg. Med. 21 (1992) (6), pp. 727–731. Abstract | PDF (395 K) | View Record in Scopus | Cited By in Scopus (47)

[3] C.J. Sachs and L.D. Chu, Predictors of genitorectal injury in female victims of suspected sexual assault, Acad. Emerg. Med. 9 (2002) (2), pp. 146–151. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (8)

[4] L.C. Lenahan, A. Ernst and B. Johnson, Colposcopy in evaluation of the adult sexual assault victim, Am. J. Emerg. Med. 16 (1998) (2), pp. 183–184. Article | PDF (262 K) | View Record in Scopus | Cited By in Scopus (22)

[5] L. Slaughter and C.R. Brown, Colposcopy to establish physical findings in rape victims, Am. J. Obstet. Gynecol. 166 (1992) (1 Pt 1), pp. 83–86. View Record in Scopus | Cited By in Scopus (42)

[6] L. Bowyer and M.E. Dalton, Female victims of rape and their genital injuries, Br. J. Obstet. Gynaecol. 104 (1997) (5), pp. 617–620. View Record in Scopus | Cited By in Scopus (32)

[7] S.M. Ramin, A.J. Satin, I.C. Stone Jr. and G.D. Wendel Jr., Sexual assault in postmenopausal women, Obstet. Gynecol. 80 (1992) (5), pp. 860–864. View Record in Scopus | Cited By in Scopus (22)

[8] M.J. McGregor, G. Le, S.A. Marion and E. Wiebe, Examination for sexual assault: is the documentation of physical injury associated with the laying of charges? A retrospective cohort study, CMAJ 160 (1999) (11), pp. 1565–1569. View Record in Scopus | Cited By in Scopus (23)

[9] M. Biggs, L.E. Stermac and M. Divinsky, Genital injuries following sexual assault of women with and without prior sexual intercourse experience, CMAJ 159 (1998) (1), pp. 33–37. View Record in Scopus | Cited By in Scopus (21)

[10] P.S. Cartwright, Factors that correlate with injury sustained by survivors of sexual assault, Obstet. Gynecol. 70 (1987) (1), pp. 44–46. View Record in Scopus | Cited By in Scopus (32)

[11] M.J. McGregor, M.J. Du and T.L. Myhr, Sexual assault forensic medical examination: is evidence related to successful prosecution?, Ann. Emerg. Med. 39 (2002) (6), pp. 639–647. Abstract | PDF (86 K) | View Record in Scopus | Cited By in Scopus (33)

[12] J. McCauley, R.L. Gorman and G. Guzinski, Toluidine blue in the detection of perineal lacerations in pediatric and adolescent sexual abuse victims, Pediatrics 78 (1986) (6), pp. 1039–1043. View Record in Scopus | Cited By in Scopus (13)

[13] J. McCauley, G. Guzinski, R. Welch, R. Gorman and F. Osmers, Toluidine blue in the corroboration of rape in the adult victim, Am. J. Emerg. Med. 5 (1987) (2), pp. 105–108. Article | PDF (387 K) | View Record in Scopus | Cited By in Scopus (17)

[14] M.K. Norvell, G.I. Benrubi and R.J. Thompson, Investigation of microtrauma after sexual intercourse, J. Reprod. Med. 29 (1984) (4), pp. 269–271. View Record in Scopus | Cited By in Scopus (29)

[15] A.A. Lauber and M.L. Souma, Use of toluidine blue for documentation of traumatic intercourse, Obstet. Gynecol. 60 (1982) (5), pp. 644–648. View Record in Scopus | Cited By in Scopus (25)

[16] K. Helweg-Larsen, The value of the medico-legal examination in sexual offences, Forensic Sci. Int. 27 (1985) (3), pp. 145–155. Article | PDF (757 K) | View Record in Scopus | Cited By in Scopus (14)

[17] K. Edgardh, G. von Krogh and K. Ormstad, Adolescent girls investigated for sexual abuse: history, physical findings and legal outcome, Forensic Sci. Int. 104 (1999) (1), pp. 1–15. Article | PDF (86 K) | View Record in Scopus | Cited By in Scopus (16)

[18] B. Schei, K.M. Muus and M.H. Moen, Medical and legal aspects of rape. Referrals to a team for care of rape victims at the regional hospital in Trondheim during the period 1989–1992, Tidsskr. Nor. Laegeforen. 115 (1995) (1), pp. 30–33. View Record in Scopus | Cited By in Scopus (7)

[19] J.E. Tintinalli and M. Hoelzer, Clinical findings and legal resolution in sexual assault, Ann. Emerg. Med. 14 (1985) (5), pp. 447–453. Abstract | PDF (650 K) | View Record in Scopus | Cited By in Scopus (32)

[20] B. Schei, K. Sidenius, L. Lundvall and G.L. Ottesen, Adult victims of sexual assault: acute medical response and police reporting among women consulting a center for victims of sexual assault, Acta Obstet. Gynecol. Scand. 82 (2003) (8), pp. 750–755. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (8)

[21] J.S. Jones, L. Rossman, M. Hartman and C.C. Alexander, Anogenital injuries in adolescents after consensual sexual intercourse, Acad. Emerg. Med. 10 (2003) (12), pp. 1378–1383. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (4)

[22] G. Kindermann, P.M. Carsten and V. Maassen, Ano-genital injuries in female victims of sexual assault, Swiss Surg. 1 (1996), pp. 10–13. View Record in Scopus | Cited By in Scopus (3)

[23] M.R. Soules, S.K. Stewart, K.M. Brown and A.A. Pollard, The spectrum of alleged rape, J. Reprod. Med. 20 (1978) (1), pp. 33–39. View Record in Scopus | Cited By in Scopus (11)

 

Corresponding author. Tel.: +45 35453722; fax: +45 35454471.

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Valerich

Спасибо за статью, Борода! Огромную работу коллеги проделали, чтобы в итоге дать нам твёрдую почву под ногами для заявления: "это жизнь, всё может быть" :)/>

 

А кто и как осматривал женщину?

 

Про отсутствие опыта, мы и без исследования больше двух сотен женщин сказали. Кстати, насчёт смазки, использовал или неизвестно?

 

Борода, заметь, они связь между отсутствием предшествующего сексуального опыта и генитально-анальными повреждениями при анальной пенетрации даже в заглавные результаты вынесли (их и можно было красным выделять):

Results:

Thirty-two percent sustained genitoanal injury. Anal penetration and assaults on women without prior sexual experience were associated with genitoanal injury.

Но всё равно ведь сами пишут: not all women in these two categories sustained injury. То бишь, всё может быть... Опять же кто и как искал эти повреждения?

И ещё, может я как-то не так смысл написанного понимаю, но что они имеют в виду под "women without prior sexual experience"? Любой сексуальный опыт? Тогда это некорректно. Опыта может быть завались, а анальный контакт первый раз.

 

Зато слова адвоката про то, что "сфинктер ануса - самый мощный мускул в организме" можно смело этой статьёй хоронить. Примеров, когда женщины сопротивлялись, более чем достаточно.

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svetlanna

А насильника осматривали? Через какое время после предполагаемого контакта? Результаты? Были взяты мазки?

Он ведь скрылся спешно если его быстро выловили, осмотр половых органов на наличие и чистоту даст дополнительную информацию.

Может он импотент или инвалид,тогда все вопросы снимутся.

То что изнасилование в положении женщины на животе невозможно-чушь, коленями ноги ей раздвинуть и ничего сложного. Опять же нужно исходить из анатомо-физиологческих особенностей обоих.

Что касается анального проникновения, то у женщины, не занимавшейся ранее анальным сексом,действительно это практически невозможно осуществить особенно без повреждений, если она сжимает сфинктер.Но вы не можете знать о чем она в этот момент думала и в каком состоянии находился сфинктер, использовалась ли смазка, тогда все проще.

Здесь категоричных ответов нужно избегать. И самое главное ОЧЕНЬ ПОДРОБНЫЙ анамнез.Прямо по секундам и последовательно, какое проникновение было вначале:вагинальное или анальное.Это очень многое проясняет. В общем работать еще с ними нужно. Успехов

Да, кстати, а куда произошло семяизвержение? Были ли обнаружены следы спермы или презерватив на МП?

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Boroda

Нет не осматривали насильника. Позднее поймали. Всё исследование гинекогологом проводилось. Суд уже идёт... и это первый контакт с судебной медициной! Только мазки и трусы в лаборатории осматривались. Всё отрицательно. Так что никакой другой информации окромя как от судьи и меддокументов от гинеколога нет. Анамнез собрать не очень удалось, так как это иностранка и мусульманка, которая категорически отказывается о сексе в прошлом разговаривать. Молится и плачет... Даже переводчик толком не помог.

 

Судья сообщил, что женщины из её культурного круга часто занимаются анальным сексом из двух соображений. Контрацепция и сохранение девственности до момента свадьбы. Т.е. феномен известный, но сама жертва на данные вопросы отвечать и дискутировать отказывается наотрез :)/> Аллах вроде как ей не разрешает.

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Valerich

Ну, тогда вообще всё просто :)/> С вагинальным контаком измерениями всё решится. Если у насильника половой член не 5 см, то, скорее всего, всё возможно окажется. А про анальный контакт отмажетесь: попросите провести осмотр для решения вопроса о функции сфинктра :)/> и возможности насильственной пенетрации без повреждений. Она откажется, вы помянёте, что смотрел гинеколог, да без ректороманоскопа, заднепроходное отверстие тоже, скорее всего не осматривал, а в таких условиях точно говорить ни о чём не возможно :)/>

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Ледигист
Судья сообщил, что женщины из её культурного круга часто занимаются анальным сексом из двух соображений. Контрацепция и сохранение девственности до момента свадьбы. Т.е. феномен известный, но сама жертва на данные вопросы отвечать и дискутировать отказывается наотрез :)/> Аллах вроде как ей не разрешает.

 

Класс! Использовать для "любви" все имеющиеся отверстия АЛЛАХ разрешает, а вот говорить об этом нет. И что за лицемер этот АЛЛАХ или что за лжескромница потерпевшая..... А по делу - может мазочки из влагалища еще взять на бакпосев - если анальный секс был до вагинального, то Е. соli хорошо из влагалища высеется (только тот же результат будет если такое чередование для нашей скромницы не вновь).

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esmero

а вообще если честно, думаю, почему не возможно, насиловали всегда (только вопрос качества износилования, анекдотов много на эту тему), чем зад отличается от переда, да ни чем !!

Но почему-то манит он больше и мужчин и насильников. Гадость, извращение и все синонимы к этому. Если насильник захочет, он это сделает и в зад и в перед и еще туда, куда фантазия позволит !! :)/>

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Stagman

Друзья! Об чём вообще речь то, а!??! Ни её, ни его, как оказывается, эксперт не осматривал! Экспертиза вообще не назначалась, не проводилась - какой-такой допрос в суде тогда? Пришёл, спросил:

- "экспертизу мне назначали?"

- "нет".

- "всего доброго, до новых встреч! назначайте экспертизу"

Для разъяснения заключения - пожалуйста! А так - разговоры ни о чём...Я отказался бы от комментариев. Я сначал подумал, что ув. Борода - автор заключений. А их и не было вовсе.

А назначат экспертизу - осмотрю с участием гинеколога, а может, и проктолога. И дам ответы. Какие - выше сказал. Фиг сожмет она свой "супермощный мускул", когда её в бараний рог скрутят и прикрикнут, что щас шею перережут...Там полнейшее расслабление наступит от страха. Вот и весь фокус.

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esmero
Фиг сожмет она свой "супермощный мускул", когда её в бараний рог скрутят и прикрикнут, что щас шею перережут...Там полнейшее расслабление наступит от страха. Вот и весь фокус.

 

 

сто пудов, согласно полностью и в ту же дырочку, дай бог или АЛЛАХ, чтоб еще и наружу не поперло от страха ......................

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Yablok_By

Насчёт позы при влагалищном введении, можно посоветовать суду посмотреть на иллюстрации книги с тысячелетней историей - Камасутры. Там эта позиция среди самых простейших. Про сфинктер вроде уже все высказались, даже добавлять страшно. :)/>

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Valerich

Stagman, Борода у нас из "Ближней Евразии", ему не только с российскими законами сталкиваться приходится. Но в принципе, подобного рода ситуации возможны и в наших российских судах. Если адвокат будет утверждать, что анальное изнасилование принципиально невозможно, то суд должен будет это утверждение обоснованно опровергнуть иначе приговор вынести не получится. Вот тогда и могут привлечь эксперта в качестве специалиста для разъяснения вопросов, входящих в его компетенцию и не требующих проведения исследования. Правда такая практика у нас практически отсутствует.

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Yablok_By
Stagman, Борода у нас из "Ближней Евразии", ему не только с российскими законами сталкиваться приходится. Но в принципе, подобного рода ситуации возможны и в наших российских судах. Если адвокат будет утверждать, что анальное изнасилование принципиально невозможно, то суд должен будет это утверждение обоснованно опровергнуть иначе приговор вынести не получится. Вот тогда и могут привлечь эксперта в качестве специалиста для разъяснения вопросов, входящих в его компетенцию и не требующих проведения исследования. Правда такая практика у нас практически отсутствует.

 

У меня 50% походов в суд - вот такие вот "разъяснения". Но честно говоря, терпеть это не могу, когда надо чужое заключение пояснять.

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Stagman
У меня 50% походов в суд - вот такие вот "разъяснения". Но честно говоря, терпеть это не могу, когда надо чужое заключение пояснять.

А зачем поясняете? Меня когда вызывают, я в первую очередь интересуюсь - по какой экспертизе. Если не моя, то и разговор закончен: "Не яделал, грите?...А я-то тут тогда причём? Вызывайте эксперта, проводившего экспертизу. Ах, не доверяете и хотите выслушать другого эксперта? Назначайте повторку - это вам в областное бюро".

Занавес.

Более того, если в моём областном бюро узнают, что некто из обычных экспертов в районе ходит по судам и комментирует чужие(коллеги) выводы... :)/> :)/> Короче, лучше сразу после этого идти самому увольняться.

А уж если ВООБЩЕ никто не делал экспертиз по обсуждаемому случаю, то не понимаю, о каком допросе эксперта может идти речь в принципе. Скажете - он вызван в качестве специалиста, а не эксперта? Низзя. Смотрите УПК. Впрочем, мне неизвестны порядки Ближней Евразии...Не знаю, что вкладывает в это понятие Борода. Я вроде тоже в Евразии. Ближней. Смотря к чему(кому). :)/>

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Yablok_By

Тема немного не об этом, но кратко - раньше ходила по экспертизам моего предшественника, сейчас иногда хожу по экспертизам трупов вскрытых в мой отпуск, их в это время возят в областной центр. Часто отказываюсь, но изредка соглашаюсь, скорее от моего настроения зависит и наличия свободного времени. Как правило в таких случаях отвечаю на теоретические вопросы, когда допустим адвокату или судье механизм наступления смерти непонятен. Если просят пояснить что-либо по тексту экспертизы, отсылаю к вскрывавшему эксперту. Выводы не комментирую. :)/>

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Stagman

Надеюсь, ув. Борода расскажет нам о своём выступлении в суде. Очень заинтригован.

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SLeonov
Вагинальная пенетрация при положении на животе исключена из анатомических соображений. Насильник не смог бы достать влагалище.

Как-так - исключена? Все зависит от полноты дамы и расположения интересующих нас отверстий... поддерживаю Stagmana - легко!

А насчет ануса... литературы не читал такой, но ведь на зонах нашей родины как опускали так и опускают и молодых и старых и сильных и больных... наверное можно...

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svetlanna

Дополнительно консультировалась по данному случаю у профи.

Первое.Все должно исходить из "габаритов" нападавшего и потерпевшей, поскольку как и раньше, считается что здоровую сильную женщину изнасиловать практически невозможно.Если женщина в силе, а насильника можно соплей убить, тогда и думать особо нечего.

Второе. Способность насильника к эрекции и размеры и особенности его половых органов.Обязательно.

Как так не осматривали насильника :)/> Это же обязательная процедура, без этого не экспертиза а гадание на кофейной гуще...

Третье. Как показывает практика в 50% случаев повреждения заднего прохода не обнаруживается, поскольку практически всегда используется смазка, чаще всего собственная слюна. Хотя в моей практике в свежих случаях редко не находила повреждений. Если она регулярно занималась анальным сексом, то вероятность обнаружить повреждения мала.

И опять же, анамнез. Ответьте суду что не можете тыкать пальцем в небо и Вам НУЖНО знать подробности для ответа на вопросы. А на нет и суда нет.

Попала бы она мне в руки, я бы ее быстро разговорила :)/>

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Boroda

Вот тут нашёл ещё одну статью на эту тему и выделил красным самое интересное

 

American Journal of Obstetrics and Gynecology - Volume 190, Issue 1 (January 2004) - Copyright © 2004 Mosby, Inc.

Physical injury after sexual assault: Findings of a large case series

N.F. Sugara

D.N. Fine b

L.O. Eckert c

————————————————————————————————————————

Departments of Pediatricsa and Obstetrics and Gynecologyc University of Washington Harborview Medical Center, and the Center for Health Studiesb Seattle, Wash, USA

————————————————————————————————————————

Manuscript received January 17, 2003; revised manuscript received January 6, 2003, accepted January 15, 2003

Reprints not available from the authors.

PII S0002-9378(03)00912-8

————————————————————————————————————————

Objective

This study was undertaken to determine characteristics associated with physical injury in female sexual assault victims.

 

Study design

All females who were 15 years or older presenting after sexual assault to an urban emergency department during a 34-month period underwent standardized evaluation. Analysis was performed by χ2 and logistic regression.

 

Results

Of 819 women, 52% had general body and 20% had genital-anal trauma; 41% were without injury. General body trauma was independently associated with being hit or kicked (odds ratio [OR] = 7.7, 95% CI, 5.1-11.7), attempted strangulation (OR = 4.2, 95% CI, 2.5-7.2), oral or anal penetration (OR = 1.7, 95% CI, 1.2-2.3), and stranger (OR = 2.4, 95% CI, 1.7-3.4) assault. Genital-anal injury was more frequent in victims younger than 20 and older than 49 years (P<.05 in virgins ci and those examined within hours after anal assault>

 

Conclusion

General body injury is primarily associated with situational factors, whereas genital-anal injury is less frequent and related to victim age, virginal status, and time to examination.

————————————————————————————————————————

Keywords

Sexual assault

trauma

female

 

In 1999, an estimated 54,000 women in the United States sought emergency care after sexual assault.[1] This represents a fraction of those women who have been sexually assaulted because the majority do not seek emergency medical care.[2] Emergency care for rape victims includes care for injuries, documentation for legal purposes, and collection of forensic trace evidence.[3] Physicians are often called on to assess the significance of examination findings in the legal arena. The physician may be asked to render an expert opinion whether the sexual intercourse was consensual or forced on the basis of physical findings. Common perception, both in popular and in legal fields, holds that sexual assault is invariably associated with physical injury. A limited number of studies have described the physical injuries associated with sexual assault of adults. In these studies, nongenital injury was found in 40% to 82% of patients,[4] [5] [6] [7] [8] [9] whereas genital-anal injury was documented in 6% to 87%.[4] [5] [6] [7] [8] [9] [10] This broad range in reported trauma may have been influenced by differences in patient population, injury definition, examiner training and experience, and examination technique. Previous studies have correlated injury with victim age,[4] [7] prior sexual intercourse experience,[10] race,[4] and weapon use.[4] However, these studies relied on data sets that contained limited arrays of contextual measures, thus constraining the clinically relevant conclusions that can be drawn.

 

The purpose of this study of consecutive female patients presenting for medical care after sexual assault is to determine which patient factors and specific assault characteristics are related to physical injury. We hypothesized that certain types of assaults, such as stranger assault and multiple assailants, and patient characteristics, such as older age, would be associated with higher frequency of general and genital-anal trauma.

 

Material and methods

 

Patient population

During the study period of 34 months (January 1997–September 1999), 892 women aged 15 years and older presented to an urban hospital emergency department with a complaint of sexual assault. This emergency department is the major referral center for police and other emergency providers in King County, Wash, population 1.73 million (US Census Data 2000). Of these 892 patients, 73 refused all physical examination. The remaining 819 patients are the subjects of this study.

 

Twenty-seven women were seen more than once for sexual assault during this time period. Each visit is included in the analysis. Sixty patients consented to the general physical examination but declined the genital-anal examination. These patient findings were analyzed for general body trauma only. Two hundred eleven women with major psychiatric diagnoses described in detail in a previous report[11] are also included here.

 

Examination and data collection

The patient provided demographic information and assault history, which was recorded by the emergency department social worker. All patients were examined by a second- or third-year resident in obstetrics and gynecology who had received specific training in sexual assault examinations, consisting of a 2-hour introduction and comprehensive chart review and feedback. Emergency department physicians performed additional evaluation as needed. Colposcopy was used only to document grossly visible genital trauma. Providers used a standardized structured sexual assault chart form. Data were abstracted from the emergency department record by an author or research assistant and, for all cases, verified by another author.

 

Toxicology screens and blood alcohol levels were ordered as clinically indicated. Qualitative urine testing for cocaine, opiates, phencyclidine, amphetamine, barbiturates, benzodiazepines, and methadone was performed by immunochemical method and for ethanol by enzymatic method.

 

Definitions

Sexual assault was defined as completed or attempted penetration of the patient's vagina or anus by penis, mouth, fingers, or other object or the patient's mouth by penis. General body injury included any acute injury excluding the genital-anal areas. Injury was defined as bruise/abrasion, laceration, or radiologically defined fracture or intracranial injury Genital erythema, tenderness, or pain without visible tissue injury was not counted as trauma because these findings are subjective and may have poor interrater reliability.[12] The single exception was tenderness on the scalp, where, because of difficulty in visual diagnosis, scalp tenderness was classified as a bruise.

 

The relationship with the assailant was classified as “friend or acquaintance” if the patient reported any social contact, including having a conversation or accepting a car ride before the assault began. The relationship “intimate partner” encompassed current and former boyfriends, live-in partners, and spouses.

 

“Impaired consciousness” was by patient report and was recorded when the patient reported that she was asleep or markedly intoxicated at the onset of the assault; laboratory results of toxicology screens were not used in defining “impaired consciousness.” Amnesia was recorded when the patient specifically reported she could not remember part or all of the assault. Patients who reported no home address or were discharged to a shelter were classified as homeless. Classification of major psychiatric disorder was made when one of the following criteria were met: (1) the patient reported having schizophrenia, schizoaffective disorder, bipolar illness, or psychosis; (2) the patient had a previous inpatient psychiatric hospitalization at this hospital for a suicide attempt or a discharge diagnosis of one of the above psychiatric disorders; or (3) the patient had two or more prior visits to this hospital or mental health center with discharge diagnosis of one of the above psychiatric conditions or of toxic encephalopathy. Patients who reported only a history of depression or who were on antidepressant medication alone were not classified as having a major psychiatric diagnosis.

 

Data analysis

Statistical analysis was performed with χ2 for dichotomous variables and Student t test for continuous variables. Stepwise logistic regression analysis was performed with general body and genital-anal trauma as the endpoints. Measures identified as significant (P<.05 in the bivariate were entered into multivariate analysis. for general body trauma four measures entered: patient report of being hit attempted strangulation substance use by and offender relationship to patient. genital-anal model included age prior intercourse time between assault examination anal rape acute trauma. all statistical analysis used spss software inc chicago ill>

 

This study was approved by the Institutional Review Board of the University of Washington.

 

Results

 

Patient and assault characteristics

The mean age of sexual assault victims was 29.3 years (range 15-87 years, SD 11.7 years). Nearly one fourth (189/819, 23.1%) were adolescents, and almost half (364/819, 44.4%) were between 15 and 25 years of age. Only 15% of patients were aged 40 years or older (124/819). Most patients (63.4%) were white, 20.5% were African American, 4.9% were Hispanic, and 8.2% other ethnic groups. Eighteen patients were pregnant (2.2%). Almost all (96%) were seen within 72 hours after the assault (Table I ). A large majority of patients (87%) allowed forensic evidence to be collected during the examination, and 84% made a police report before or after the examination.

 

Table I. Body trauma–bivariate analyses

Overall rate of body trauma: 51.9% (425 of 819). Factors not related to general body injury: homelessness, race, impaired consciousness at onset of assault, amnesia.

Factor No. Factor % With factor with trauma (%) Without factor with trauma (%) OR (95% CI)

Patient characteristics

Major psychiatric diagnosis 819 211 25.8 59.2 46.9 1.49 (1.09–2.05)

Substance use at time of assault 819 431 52.4 56.4 46.9 1.45 (1.10–1.90)

Assault characteristics

Assailant relationship to patient

Friend/acquaintance 744 464 62.4 46.3 — 1.0 (ref)

Stranger 744 174 23.4 67.2 — 2.38 (1.65–3.43)

Intimate partner 744 87 11.7 62.1 — 1.94 (1.18–3.03)

More than 1 assailant 758 131 17.3 61.1 50.4 1.54 (1.05–2.27)

Hit or kicked 677 214 31.6 84.1 40.6 7.74 (5.13–11.68)

Attempted strangulation 677 99 14.6 80.8 49.8 4.24 (2.51–7.18)

Outdoors 677 166 21.6 69.9 46.4 2.68 (1.86–3.88)

Weapon used 696 164 23.6 68.9 47.4 2.46 (1.70–3.57)

Anal penetration 684 145 21.0 62.8 49.4 1.73 (1.19–2.52)

Oral penetration 684 196 28.7 61.2 48.6 1.67 (1.19–2.34)

Examination within 24 h 783 599 76.5 53.1 46.2 1.70 (1.21–2.38)

 

Twenty-six percent of patients had a major psychiatric diagnosis before presentation and 10% were homeless. More than half of the patients (52%) reported alcohol or substance use in the hours before the assault or had positive toxicology screens. Forty percent of patients (330/819) reported that they had impaired consciousness, either by alcohol or drug use or, less commonly by sleep, at the onset of the assault. Many patients reported that they had partial (126/819, 15%) or total (82/819, 10%) amnesia for the assault. Seventy-one patients (8%) expressed concern that they might have been the victims of surreptitious administration of a “date-rape” drug. Other patients declined to give specific history of the assault. These incomplete histories are reflected in the varying denominators for circumstances of the event.

 

Risk for body injury

General body injury was found in 425 of 819 patients (52%), but serious injury requiring emergency medical intervention was uncommon. Bruises and abrasions were by far the most frequent injuries and were present in nearly all the patients who had identified general body trauma. Intracranial trauma was identified in 11 patients (1.3%) and visceral injury was identified in only 3 patients. Fractures were diagnosed in 18 patients (2.2%); a majority of these patients (12) had facial or skull fractures. Thirty-eight patients (5%) were admitted to medical or surgical services. An additional 31 patients (4%) were admitted to a psychiatric service.

 

Most patients (77%, 599/783) were examined within 24 hours of the assault; these women had a higher rate of body injury than those examined later (odds ratio [OR] = 1.70, 95% CI, 1.21-2.38). The majority of women were assaulted by friends or acquaintances (62%, 464/744). Assaults by either strangers or by intimate partners resulted in more general body injury than those by friends or acquaintances (OR = 2.38, 95% CI, 1.65-3.43; OR = 1.94, 95% CI, 1.18-3.03, respectively). Patients reported a single assailant in 77% (627/758) cases, two assailants in 8% (68/758), and multiple assailants in 8% of cases (range, 3-14). Assault by more than one person resulted in more frequent general body injury (OR = 1.54, 95% CI, 1.05-2.27).

 

Patients who reported they had been hit or kicked (32%, 214/677) had a much higher general body injury rate than those who reported physical restraint or threats only (OR = 7.74, 95% CI, 5.13-11.68). A history of attempted strangulation (15%, 99/677) was also associated with more frequent injury (OR = 4.24, 95% CI, 2.51-7.18). Weapons were used in nearly a fourth of the assaults (164/696, 24%), primarily knives, although victims reported that guns, ropes, and blunt objects were used as well. Use of a weapon and outdoor assaults were both associated with more frequent injury (OR = 2.46, 95% CI, 1.70-3.57; OR = 2.68, 95% CI, 1.86-3.88). Women who reported oral assault (29%, 244/684) or anal assault (21%, 145/684) had a higher frequency of general body injury (OR = 1.67, 95% CI, 1.19-2.34; OR = 1.73, 95% CI, 1.19-2.52, respectively).

 

Increasing age was statistically significantly associated with general body injury. (Figure 1 , P<.001 in the bivariate analysis both preexisting psychiatric diagnosis and recent substance use as determined by history toxicology screen were associated with body injury ci or="1.45," respectively>

 

Figure 1. Age and body trauma (n = 819). Numbers indicate total number of patients in each age group.

 

Risk of genital-anal trauma

The genital examination was completed in 759 of 819 patients (92.7%). Thirty-eight patients (4.6%) reported that the assault did not include vaginal contact; 17 (45%) of these patients had no genital examination. Forty-three additional patients refused the genital examination. Patient refusal was associated with prior psychiatric diagnosis (11% vs 6%, P = .009) and with homelessness (15% vs 7%, P = .004) but was not related to other factors, including substance use, relationship to the offender, or body injury.

 

Twenty percent of those who were examined (165/759) had genital or anal injury. An additional 38 patients (5%) had only erythema of the genital or anal tissues, but this was considered a nonspecific finding. Bruises or abrasions of the vulvar or perineal tissues were noted in 111 (15%) patients; 56 (7%) patients had lacerations of those areas. Anal injury was noted in 33 (4%) patients.

 

Patients examined within 24 hours had a significantly higher rate of genital injury (OR = 1.83, 95% CI, 1.14-2.95). Those patients who reported anal penetration had more frequent genital-anal injury (OR = 1.70, 95% CI, 1.11-2.61). Of the 141 patients who reported anal penetration, 28% had some identified genital-anal trauma, and 16% had anal lacerations. Of the 511 patients who did not report anal contact, 28 (5.2%) had lacerations at this site. Women with trauma to other body areas had a higher rate of genital-anal trauma (OR = 1.63, 95% CI, 1.17-2.27).

 

Genital-anal injury was more prevalent in younger (49 years) women compared with victims between 20 to 49 years old (Figure 2 , P = .005). Those who reported no prior intercourse had a much higher frequency of genital injury (OR = 2.72, 95% CI, 1.38-5.36), but even in this group 60% of patients had no visible injury (Table II Table III ). Multiple other factors, including the relationship of victim to offender and the number of assailants were not associated with frequency of genital-anal injury.

 

Figure 2. Age and genital-anal injury (n = 759). Numbers indicate total number of patients in each age group.

 

Table II. Genital-anal injury–bivariate analyses

Overall rate of genital-anal injury: 20.4% (165 of 759). Factors not associated with genital-anal injury: major psychiatric illness; homelessness; patient's recent use of substances; impaired consciousness; amnesia; relationship to offender, number of assailants, weapon use, choking, oral assault.

Factor No. Factor % With factor with trauma (%) Without factor with trauma (%) OR (95% CI)

Patient characteristics

No prior intercourse 731 28 5.2 39.5 19.3 2.72 (1.38–5.36)

Assault characteristics

Anal penetration 633 141 22.3 28.4 18.9 1.70 (1.11–2.61)

Body trauma 759 388 51.1 24.9 20.8 1.63 (1.17–2.27)

Examination within 24 h 726 533 76.2 22.8 13.9 1.83 (1.14–2.95)

 

Multivariate analysis (Table III )

We used multivariate logistic regression to identify patient characteristics and assault descriptors independently associated with body and genital trauma. Attempted strangulation, being hit or kicked, substance use by the victim, and assault by a stranger were independently associated with general body trauma. Time to examination, psychiatric diagnosis, assault by an intimate partner, and victim age were not independently associated with body injury.

 

Table III. Multivariate analyses: body trauma and genital-anal trauma

Factor Adjusted OR (95% CI)

Body trauma

Hit or kicked 6.72 (4.35–10.38)

Attempted strangulation 3.32 (1.87–5.88)

Substance use 1.52 (1.07–2.18)

Assailant relationship to patient

Friend or acquaintance 1.00 (reference)

Stranger 1.80 (1.18–2.74)

Intimate partner or spouse 1.06 (0.59–1.89)

Genital-anal trauma

Examination within 24 h 2.03 (1.18–3.50)

Age groups

15–19 y 1.00 (reference)

20–29 y 0.46 (0.27–0.78)

30–39 y 0.35 (0.19–0.62)

40–49 y 0.32 (0.15–0.70)

> 49 y 1.42 (0.58–3.48)

No prior intercourse 3.82 (1.65–8.83)

Anal penetration 2.00 (1.26–3.18)

Body trauma 1.58 (1.03–2.41)

 

Genital-anal injury was independently associated with physical examination within 24 hours of the assault, patient age, virginal status, anal penetration, and findings of general body trauma. When other factors were controlled, women between 15 and 19 years old had genital-anal injury more than twice as often as those between 20 and 49 years old. Women older than 49 years sustained genital-anal trauma more than three times as often as than those between 20 and 49 years of age.

 

Comment

Sexual assault is a unique type of interpersonal violence. Sexual assault victims seek medical care not only for care of injuries but also for collection of forensic evidence and to obtain treatment to reduce risk of pregnancy or disease.

 

In this study, we used stringent and reproducible criteria for describing the assault event, relationship to the assailant, and injuries. We systematically included information regarding the patients' prior psychiatric diagnoses and experience of amnesia, factors that have not been considered in prior studies. We used multivariate analysis to determine independent effects. We found that only 60% of patients who presented for medical care after sexual assault had any physical injury. Confirming prior studies,[4] [8] we found that general body injury was more than twice as common as genital-anal injury. General body injury was strongly and independently associated with characteristics of the assault and more often followed assaults by strangers and assaults that included oral and/or anal penetration, use of a weapon, and more violent attacks (strangulation and hitting). We identified genital-anal injury in a minority of patients. Patient age most strongly correlated with genital-anal injury. Those who were virginal sustained genital injury more frequently; however, younger sexually experienced patients also had more frequent genital-anal injury. The finding has not previously been reported. Genital injury, greater on either end of the age spectrum, is consistent with known female physiologic characteristics such as elasticity of the perineum and vagina. Genital-anal injuries were more frequent in patients who were examined within 24 hours after the assault, as well as in those who were subjected to anal assault.

 

Studies that used colposcopy and toluidine blue staining for diagnostic purposes have found a considerably higher rate of genital-anal injury[6] [9] [13] than reported in the current study. The significance of microtrauma and the relationship to grossly visible genital injury after both consensual and nonconsensual intercourse requires further study.

 

Two negative findings in this study were unexpected. Genital injury was not more frequent in those who reported multiple assailants. The reasons for this are unclear but are in concordance with previous findings.[4] Second, anal penetration did not result in visible anal injury in the majority of cases. The external anal examination may be insufficient to visualize anal injury, and anoscopy may be required. Anal injury may be minimized by the use of body fluids or other lubrication. No published studies have evaluated anal trauma resulting from consensual anal penetration.

 

Additional findings bear mention. Even with stringent criteria for diagnosis, we found a very high prevalence of psychiatric diagnosis in this cohort. A previous study in an urban hospital setting found a similar prevalence of psychiatric illness.[14] Women with psychiatric illness are at high risk for victimization, and this group deserves attention in rape prevention strategies. The very high rate of partial and total amnesia in our study has not been previously reported. Although many patients are concerned that they may have been given a “date rape” drug, this suspicion has not been confirmed by toxicology studies.[15] [16] The cause of amnesia in this setting may be multifactorial—psychologic trauma, use of alcohol or recreational substances, and inadvertent mixtures of prescription or over-the-counter medications with alcohol—all may be contributory. Further studies regarding amnesia in victims are warranted.

 

Our study has several limitations. This is an urban hospital that serves as a countywide referral center for sexual assault victims, and the results may not be applicable to other settings. Eight percent of the total number of patients refused the entire physical examination, and 6.2% refused the genital anal examination. The large proportion of victims who do not seek medical care may exhibit a different pattern of injury associations. In the large population-based National Violence Against Women telephone survey, 32% of the women who said they had been raped reported they had physical injury.[2] Of those who said they had been injured, only 36% reported they had received medical care. In the national study, 64% had been raped by an intimate partner, whereas in our study only 11.5% reported this relationship. Women who have been sexually assaulted by an intimate partner may be less likely to obtain medical care than those who are raped by strangers or acquaintances.

 

The history of the assault was exclusively by patient report. It is possible that some of the women in the study were not sexually assaulted or misrepresented facts about the assault. Some women did not recall or were unwilling to relate assault details. Toxicology studies were not obtained in all patients, and our data regarding substance use before the assault are almost certainly an underascertainment. Because alcohol is rapidly metabolized, even universal toxicology testing would not identify all substances used before assault.

 

Data gained this study may be useful for health care providers, providing information for patient counseling and reassurance regarding the prevalence and correlates of trauma in sexual assaults. When the physician is asked to address findings in a legal context, the assessment of the significance of injury or lack of injury should include consideration the patient and event factors examined in this study.

 

References

 

1. Centers for Disease Control. National estimates of nonfatal injuries treated in hospital emergency departments—United States, 2000. MMWR Morb Mortal Wkly Rep 2001;50:340-6.

2. Tjaden P, Thoennes N. Full report of the prevalence, incidence, and consequences of violence against women: findings from the National Violence Against Women Survey. NCJ 183781. National Institutes of Justice, Centers for Disease Control 2000. Available at: http://www.ojp.usdoj.gov/nij/pubs-sum/183781.htm . Accessed July 10, 2002.

3. American College of Obstetricians and Gynecologists. ACOG educational bulletin number 242, sexual assault, November 1997. Int J Gynaecol Obstet 1998;60:297-304.

4. Cartwright PS. Factors that correlate with injury sustained by survivors of sexual assault. Obstet Gynecol 1987;70:44-6.

5. Riggs N, Houry D, Long G, Markovchick V, Feldhaus KM. Analysis of 1,076 cases of sexual assault. Ann Emerg Med 2000;35:358-62.

6. Lenahan LC, Ernst A, Johnson B. Colposcopy in evaluation of the adult sexual assault victim. Am J Emerg Med 1998;16:183-4.

7. Ramin SM, Satin AJ, Stone Jr. IC, Wendel Jr. GD. Sexual assault in postmenopausal women. Obstet Gynecol 1992;80:860-4.

8. Bowyer L, Dalton ME. Female victims of rape and their genital injuries. BJOG 1997;104:617-20.

9. Slaughter L, Brown CR, Crowley S, Peck R. Patterns of genital injury in female sexual assault victims. Am J Obstet Gynecol 1997;176:609-16.

10. Biggs M, Stermac LE, Divinsky M. Genital injuries following sexual assault of women with and without prior sexual intercourse experience. CMAJ 1998;159:33-7.

11. Eckert LO, Sugar N, Fine D. Characteristics of sexual assault in women with a major psychiatric diagnosis. Am J Obstet Gynecol 2002;186:1284-91.

12. Bergeron S, Binik YM, Khalife S, Pagidas K, Glazer HI. Vulvar vestibulitis syndrome: reliability of diagnosis and evaluation of current diagnostic criteria. Obstet Gynecol 2001;9:45-51.

13. Slaughter L, Brown RV. Colposcopy to establish physical findings in rape victims. Am J Obstet Gynecol 1991;166:83-6.

14. Kimerling R, Rellini A, Kelly V, Judson P, Learman L. Gender Differences in Victim and Crime Characteristics of Sexual Assaults. J Interpersonal Violence 2002;17:526-32.

15. El Sohly MA, Salamone SJ. Prevalence of drugs used in cases of alleged sexual assault. J Anal Toxicol 1999;23:141-6.

16. Slaughter LE. Involvement of drugs in sexual assault. J Reprod Med 2000;45:425-30.

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Boroda

Сходил на суд...

Адвокат набросился было с вопросами, но я заявил, что не хочу своего личного мнения выссказывать, а лучше покажу, что в литературе на эту тему нашёл. Вытащил три статьи и подробненько рассказал что там про анальные повреждения и их отсутствие при изнасиловании написано.

 

Адвокат погрузился в недолгие раздумья, а потом парировал, что все исследования не на "тех" женщинах были проведены. Мол то что женщины рассказывали, что они были изнасилованы, так это всё выдумки могли быть. Отсюда и такая масса женщин после анальных пенетраций без повреждений (по первой статье половина, а по второй 72% без повреждений). Ну я так задумчиво сказал, что это не мои исследования и я конечно не могу исключить того, что какая-то часть женщин действительно лишь придумала, что их насиловали, но... тогда в первом исследовании это должна была быть половина, а во втором 72%, что очень маловероятно.

 

Про положение на спине я заявил, что в современных руководствах для супругов типа древней Камасутры поза с женщиной на животе описывается и рекомендуется к использованию. При упоминании про Камасутру все участники заседания заметно оживились и стали усиленно мне кивать. Судья не выдержала и заявила, что вообще-то каждый должен знать, что из-за растяжимости мягких тканей многое возможно...

 

В общем и мучали меня всего минут 40.

 

Весело мне было только в тот момент, где я намекнул на то, что исключить факт пол.акта было бы возможно если бы пол. член у нападающего был очень маленьким или каким-нибудь больным. Насильник мелкий такой южный мужчина, но очень гордый, после перевода ему сказанного мною гордо замотал головой :)/> Т.е, видимо, маленький мужчинка с большой претензией... Потерпевшая тоже маленькая и щупленькая такая. В общем, адвокату трудно будет убедить подзащитного прикинуться мелкочленным или импотентом.

 

Приговора не было ещё, но не думаю что там адвокат пробьётся со своей версией.

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Valerich

Да уж. Ничего не скажешь, Камасутрой кого хочешь можно заинтересовать и убедить. :)/>

 

Не успел ещё поблагодарить за вторую статью. Мало ли чего в экспертной практике встретиться, всегда полезно ссылки на столь серьёзные исследования под рукой иметь.

 

Потом уже вспомнил. Самая известная и самая скандальная киношная сцена изнасилования была сыграна Моникой Белучи в фильме "Необратимость". Длиться оно почти 10 минут без отрыва камеры и с жутким натурализмом, поэтому слухов вокруг него масса (легко можно найти в сети). Так вот изнасилование происходило как раз в этой позе.

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Stagman
Потом уже вспомнил. Самая известная и самая скандальная киношная сцена изнасилования была сыграна Моникой Белучи в фильме "Необратимость". ..

Ох...И правда - чего ж никто раньше не вспомнил...Так натурально. Я был просто шокирован, когда смотрел...Лет 5 назад. До сих пор не понимаю, как это снимали. :)/> Но, думаю, Валерьич, эта сцена не стала бы убедительным аргументом в суде. На месте адвоката я бы сказал: "Ну это ж в кино! Там и черепашки-ниндзя бегают и разговаривают! Не принимается..." :)/>

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esmero

Ребята, Вы плавно ушли от дико интересной обсуждаемой темы ........... :rules:/>

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Stagman
Ребята, Вы плавно ушли от дико интересной обсуждаемой темы ........... :rules:/>

Дык, чего её ещё обсуждать-то? Boroda в суд сходил, литература в тему выложена, мнения высказаны...Усё!

А то, что это обсуждение Вы находите именно дико интересной темой, лично меня в Вас немного пугает и привлекает одновременно. ;)/>

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qwer

Давным-давно мой профессор говорил в подобных случаях: " Поверьте, женщина с поднятой юбкой бегает гораздо быстрее, чем мужчина со спущенными штанами".

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    • Titanic
      Не, это все ПРАВИЛЬНО, просто именно сам процесс "выдергивания" - наиболее физически сложный момент - в целом может сделать и санитар, если он поздоровее: он потом покурит, а СМЭ не будет продолжать вскрытие трясущимися (и отнюдь не от алкашки) руками.  Психологически - для людей в погонах все "штафирки" (как в Царской России называли гражданских) есть люди второго-третьего сорта, такой уж у нас менталитет. В данном случае - СМЭ для них второсортные "смежники"/обслуга из серии "чего изволите".  Для остальных врачей - недоврачи, которым хватает мозгов только на копание в дерьме в сарайке на задворках ЦРБ.  Такова жизнь и тупая российская психология.  А силовикам на это похер. У них логика примерно такая (с их же слов): ваш Минздрав принял на себя эту функцию, пусть крутится как хочет. А мы будем пописывать бумаженции о срыве этой работы в райцентре N. И все. 
    • chemist-sib
      По первоначальной информации, что мне попалась на глаза недели полторы назад, под замес попал, кроме районника, еще и начальник бюры. Ну, здесь-то хоть понятно - именно он отвечает за материальное обеспечение деятельности простого смертного трупореза. И за отсутствие холодильника в отделении, и за логистику доставки материала в лабораторию, и за обучение грамотной оценке полученных результатов допов с учетом состояния этого самого материала... А первый - за собственную глупость - ибо не все надо переписывать в масштабе (1:1)... ИМХО такое.
    • Кузьмич
      Все так. А вот применительно к сабжу. Возбудились они на районного эксперта, дабы "отреагировать" на "общественный резонанс", будь он неладен.  Я правда не понял,  что именно в его действиях " повлекло причинение крупного ущерба или существенное нарушение прав и законных интересов граждан или организаций либо охраняемых законом интересов общества или государства". В чем тут крупный ущерб или какие права и интересы граждан были нарушены тем, что в виду отсутствия холодильных камер в отделении, кровь забродила? Это раз. Еще такой момент. Ребенка сбил водитель. Его даже от работы не отстранили! А виноват опять эксперт! Это два. Ну и наконец. Уволят они этого эксперта. Млядь! А кто там на районе-то работать будет? Или у них там очередь желающих на это место в полтора километра? Очень сильно сомневаюсь.
    • LEX
      в оригинале нет никакого потом ..есть "за тем" и четко указано- "кто был ничем-тот станет всем" применительно к нашим условиям- вместо  сытых комаров прилетят голодные...давно  в медицине  работаю. постулат  -"каждый новый начальник хуже предыдущего" -очень редко  оказывается не совсем верным 
    • Кузьмич
      В такой форме- да. Тебя не раздражает, когда о профессиональных проблемах рассуждают обыватели? И дают советы космической глупости? По известному типу- "все отнять и разделить", "весь мир насилья мы разрушим, до основанья, а потом...."(кстати. А что потом? Как показывает практика, потом становится еще хуже). Меня очень раздражает. А мы даем им пищу для таких суждений. Профессиональные проблемы нужно обсуждать в профессиональном кругу, а не в открытых разделах. 
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