Genital Injury and Human Sexual Response in Sexual Assault. Cheryl Graf, ARNP, MSN
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1 Genital Injury and Human Sexual Response in Sexual Assault Cheryl Graf, ARNP, MSN
2 Reasons to Identify Injury To recognize the need for treatment Refer for further evaluation /treatment Identify a pattern of injury Recognize a patterned injury Appropriate evidence collection Bruises Bite marks Site of injury
3 Medical Conclusions Mechanisms of injury Research Incidence of injury and identification Clinical experience Peer review Medical/Legal conclusions Scope of RN practice Current literature Conclusion of nonconsensual sex Lack of experience Working in isolation Expert or fact witness
4 Injury Types T Tear and Tenderness E Ecchymosis A Abrasions R Redness S Swelling Blunt force Laceration or contusion Burns Bite injury Patterned injury Sharp force Cut or incision
5 Nonspecific/Subjective Injury Erythema redness of the skin or mucous membranes produced by increased blood flow to the capillaries. Note: there are causes other than trauma
6 Nonspecific/ Subjective Injury Tenderness - painfulness to pressure of contact Cannot be documented by photography, but only by examiner observation and victim statement Victims have different tolerance for pain or touch as elicited by exam.
7 Non-genital Injury Head Face Neck Thighs Legs Arms Back Abdomen
8 Objective Genital injury Laceration splitting of skin Contusion Extravasation of blood outside vessels Petechiae Pinpoint contusions pressure, blunt force
9 Genital Injury: Specific Location Posterior fourchette is the most common site of injury Labia majora and minora is the second most common genital injury Adams 1996, Biggs 1998
10 Toulidine Blue Dye Enhances Injury Detection Vital stain, so will not stain keratinized epithelium Will stain underlying tissue, and so delineate abrasions and lacerations Use of toulidine blue dye in examining female sexual assault victims raised the genital injury detection rate to 45-56% in adult victims 28% in adolescent victims Lauber & Soma 1982, McCauley 1986, 1987
11 The presence of findings Does not in itself prove lack of consent Consensual sex can result in injury Can corroborate victim s report
12 The absence of findings Does not mean that a sexual assault did not occur or is unfounded Cases can also be corroborated by lab work, confession, witnesses
13 Injury to the Hymen The hymen is more likely to be injured in female sexual assault victims who have not had prior sexual experience. Adolescents: 8% transection, 10% bruise No prior sexual experience: transection 9%
14 The hymen is not always injured in first sexual intercourse, consenting or non-consenting.
15 Injury to the Cervix Injuries to the cervix are uncommon following sexual assault but may occur under certain circumstances Forceful digital penetration Penetration with a foreign object Penile penetration is not likely to cause cervical injury Slaughter 1991
16 Potential Genital Injury Factors related to the following: Victim Perpetrator Circumstances
17 Factors Related to the Victim Previous child bearing Lubrication Natural or artificial Tissue fragility Hormone deficiency Inflammation
18 Factors Related to the Victim Anatomy and physiology of reproductive structures Positioning Participation Relaxation Cognitions and learned behaviors
19 Factors Related to the Victim Traumatic Stress Response Threat of death or serious injury Intense fear or terror Helplessness Freezing, fight or flight activation
20 Factors Related to the Victim Traumatic Stress initiates the activity of the sympathetic nervous system (SNS) Resulting in: Intensification of genital (physiological) response Increased heart rate, respirations
21 Human Sexual Response Masters and Johnson is NO LONGER an appropriate model: A heterosexual-phallocentric model Does not include the subjective experience of desire Does not accurately reflect arousal in both men and women Stages are linear and prescriptive Overemphasis on physiology
22 Human Sexual Response What is known about HSR: Physical arousal is not always accompanied by subjective desire Genital stimulation can be touch, pressure or rubbing Genital Response is physiological Erection in men, vasocongestion in women Reflexive and involuntary
23 Factors Related to the Use/lack of force Perpetrator Physical force results in injury Male sexual dysfunction Increased duration of tissue friction Nature of penetrating object Inanimate object will result in more injury and pain
24 Factors related to the Circumstances Genital size congruence??? Multiple events or assailants Relationship of victim to assailant
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