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Evaluation and Management of the
Sexually Assaulted or Sexually Abused Patient
Chapter 7
Injury in Sexual Assault
Monique Sellas, MD
A primary role of the forensic examiner is to identify and document injuries while
remaining mindful that the absence of objective physical or genital injury does not preclude
the possibility of sexual assault, including genitoanal penetration.
Physical Injury
Physical injuries in the sexual assault patient vary from the more common minor to the rare life-threatening. The
trauma patient should be managed in accordance with ATLS trauma protocols while paying attention to preserving
potential forensic evidence during the trauma evaluation.
The reported incidence of nongenital physical injuries ranges from 23–85% of patients based on published studies
with varying methodologies.1 The majority of these injuries are mild and self-limited, requiring only basic wound
care. A smaller percentage (2–17%) suffer moderate injuries while only 1–2% of sexual assault patients suffer severe
injuries requiring hospitalization.1 When injuries are sustained, the most commonly seen are soft tissue injuries
involving the head, face, neck, and extremities. Blunt force trauma, including a penetrative blunt mechanism, may
produce contusions, associated with swelling, pain, tenderness, and discoloration, and lacerations from a tearing of
the tissues. A friction mechanism may cause abrasions. Sharp force trauma may produce incised wounds. Bites may
involve multiple mechanisms of injury. Patterned injuries suggest the specific object, weapon, or mechanism used to
produce its characteristic shape.1,2
The physical exam should be dictated by the history of the events. Close attention should be paid to the skin for
signs of victim resistance, applied restraints, or defensive wounds. Patterned injuries should be documented. The
oral cavity should be inspected for a torn lingual or labial frenulum or contusions to the palate with report of an
oral assault. With a report of strangulation, the exam should focus on assessing for and documenting abrasions or
contusions of the neck, dysphonia or dysphagia, facial petechiae, and subconjunctival hemorrhage.2
Nearly 20% of sexual assault victims require medical procedures or interventions.3,4 Such injuries should be treated
and managed as per usual emergency care.
Genital Injury
The prevalence of genital injury following sexual assault varies greatly between different studies depending on
the methodology used for the study, how injury is defined, on the experience of the examiner, and on the type of
examination used.
From a research methodology perspective, the inclusion criteria can drastically affect estimates of injury. Some
studies include sexual assault patients without penetration in their measurement of genital injury while others only
include those with self-report of penetration and exclude assaults where penetration did not occur.5–12 Some studies
include patients presenting within a specific time window after the assault, such as 48 or 72 hours, while others
include those evaluated at much later times, some as late as 10 days out.5–12 One study examined the genitals of
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Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient | ACEP
Injury in Sexual Assault
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