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

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Presentation on theme: "Assessment and Identification of Genital Trauma Donna A. Gaffney, RN, DNSc, FAAN The International Trauma Studies Program New York University."— Presentation transcript:

1 Assessment and Identification of Genital Trauma Donna A. Gaffney, RN, DNSc, FAAN The International Trauma Studies Program New York University

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

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

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

5 Types Of Injuries T -Tear (laceration) or tenderness E -Ecchymosis (bruising) A -Abrasion (scrape) R -Redness (erythema) S- Swelling (edema)

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

7 Sites and Types of Genital Injury Location: Incidence Types Posterior Fourchette 70 % T, A Mounting injury, where the penis first touches the perineum, 5-7 o’clock, perpetrator most often in superior position. Labia Minora 56 % A, E Hymen 29 % T, E Secondary to penetration, as it is an internal structure Fossa Navicularis 25 % T, E Cervix 13 % E

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

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

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

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

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

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

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

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

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

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

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

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

20 Cognitions and Learned Behaviors Learned experiences and sexual responsiveness Interpretation of stimuli and HSR –Touch –Odor –Visual –Auditory –Taste

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

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

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

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

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

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

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

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

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

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

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

32 Reasons for Non-identification of Genital Injury Lack of magnification –Drops probability of detecting injury from % to 10-30% (gross visualization) Lack of examiner preparation & education


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