Identifying the prevalence of genital injuries

This month we talk with sexual assault nurse examiner Emily McGrath about injuries following digital-vaginal penetration. The papers discussed are:

Majeed-Ariss, R., Martin, G. P., & White, C. (2024). Identifying the prevalence of genital injuries amongst patients attending Saint Mary’s sexual assault referral centre following an allegation of digital penetration. Journal of Forensic and Legal Medicine, 102. https://doi-org.www.ezpdhcs.nt.gov.au/10.1016/j.jflm.2024.102656

Rossman L, Jones JS, Dunnuck C, Wynn BN, Bermingham M. Genital trauma associated with forced digital penetration. (2004). American Journal of Emergency Medicine, 22(2), 101–104. https://doi-org.www.ezpdhcs.nt.gov.au/10.1016/j.ajem.2003.12.012

Volpellier, M., Hirve, R., & Duckett, C. (2021). Genital injuries and allegation of digital vaginal penetration – A retrospective examination of forensic case notes. Journal of Forensic and Legal Medicine, 80. https://doi-org.www.ezpdhcs.nt.gov.au/10.1016/j.jflm.2021.102154

Host: Assoc Prof Kathy Kramer
Guest: Emily McGrath

www.famsacaustralia.org.au
info@famsacaustralia.org.au

Transcript

SPEAKER_00 0:02

Welcome to Medico-Legal Matters, a podcast where we explore the medico-legal aspects of clinical forensic practice, specifically criminal cases arising from violence, abuse, and neglect.

SPEAKER_02 0:16

Hello and welcome to the latest podcast, season three of FamSakers Podcast, where we interview a committee member about a journal article that piqued their interest. And today, fresh from the Northern Territory, we have our very own secretary, Emily McGrath. Hi everyone. Excellent. What paper are you going to talk about today?

SPEAKER_01 0:34

So today we're going to look at identifying the prevalence of genital injuries amongst patients attending St. Mary's Sexual Assault Referral Centre following an allegation of digital penetration.

SPEAKER_02 0:45

Alright, so pertinent.

SPEAKER_01 0:47

I can see why you were attracted to it, but was there any particular reason that that this paper came across your pathway? So I actually happen to be utilizing the FamSacker research database that is available to all members on the members portal. And I was really quite gobsmacked as to the vast number of research articles that are available. I was actually looking at most recent ones from 2025 and 2024, and then I stumbled across this one because it's quite pertinent to our current practice, particularly if you're presenting data and research within an expert opinion within court. And also to note one of the authors on this article happens to be presenting at our conference in November in NUSA. So Catherine White is one of the authors.

SPEAKER_02 1:31

So if you come to the conference in NUSA, you will not only get to meet Emily, but you will get to meet one of the authors of this paper and you can quiz her directly. All right, so let's unpack it a little bit. What was the sort of study design? How did they go about answering this question?

SPEAKER_01 1:46

A collection was performed retrospectively on paper case files of 120 FEMA adults. These women have presented following an acute sexual assault to the St. Mary's Sexual Assault Referral Centre, which is a major referral centre within Manchester of the United Kingdom.

SPEAKER_02 2:02

So adult women at our large metropolitan centre, and they're presenting after an alleged digital vaginal penetration. But was that just digital penetration or were there digital penetration and other sorts of penetrations in the mix?

SPEAKER_01 2:16

No, they're looking at solely digital penetration in the absence of any other penetration.

SPEAKER_02 2:21

Interesting. Did they also ask about consensual penetration or in the few days beforehand?

SPEAKER_01 2:28

They did ask the question as to whether there's any consensual vaginal penetration within the 10 days preceding the assault. So collectively, 35% patients reported consensual vaginal penetration within those previous 10 days. And of those, five had genital injuries during the FME. As opposed to 77 patients reported no vaginal penetration within 10 days of the assault. And of those, 13 had genital injuries noted. So we're looking at 14% versus 16%, respectively.

SPEAKER_02 2:55

Right. And those numbers don't quite quite add up because there'll be always be a few patients for whom there's missing data. Okay, how were they defining injuries?

SPEAKER_01 3:05

So they were identifying injuries which included bruises, abrasions, and lacerations, which is quite different to how Rossman in 2004 examined their digital penetration study, where they actually included erythema, lacerations, and abrasions. Because why they got get quite a higher rate of incidence of injuries following digital penetration. So in their study, they actually have 81%. Whereas in this study from Majeed Arisatal, we're looking at 18% of that's really helpful because we we might note redness, but we don't consider it an injury because it's so nonspecific.

SPEAKER_02 3:39

So it sounds like their the way they do their examinations kind of quite similar to us, which is good for the relevance of their conclusions to our cohort. I'm just going to double check with you. I'm assuming that this is naked eye examination, they're not using a copuscope.

SPEAKER_01 3:52

Well, interesting you should ask that because no, it actually is using the copuscope for the Majid Iris. But yet in Rosman, they use coposcopy along with the staining, so nuclear staining. There's also another study von Pelia et al. in 2021, which is also a recent study. They identified 11.9% who sustained an injury following digital penetration. And that article is based on data collected from uh retrospectively from sample from files, and that's with the naked eye.

SPEAKER_02 4:25

Okay, so we've got a naked eye finding of um 12%, and we've got this main study we're talking about where they did use coposcopy, but they've still got similar kind of figures, you know, 14 and 16%. Very, very different to the figure uh from the study that included redness and encluridine blue staining, which I think is a study we could now safely ignore and stop quoting because uh they're just not techniques that we use.

SPEAKER_01 4:49

Did the findings surprise you? Well, I guess when you compare it to Rosman, it does surprise you, 81% to 18%, but there is some consistency between volpelio, I would think. The variation between the different studies is it was where they identified the most common site of injury. So they all they all similarly say that abrasions and lacerations are the most common injury that that is found on a genital examination. But in Majid and RS, that this this article, the posterior for shette was the most common site of injury, followed by the lavia minora and the hymen of both 20%. So I think that's kind of interesting as the interpretation. One thing that we should probably be cautious of is that it's still quite a small sample. And also that it's not one singular examiner examining the for the for the forensic examination. So we need to be keep that in mind that there may be some inconsistencies as to who is examining what on a particular particular day.

SPEAKER_02 5:45

Oh man, that's that's been a difficult question that's plagued our profession from the beginning. What is the you know, interrate of variability? Both studies found that abrasions and lacerations were the most common common injury, but the more recent study found the posterior fourchette, is that right, as the main site? And the older study found what was their main site.

SPEAKER_01 6:04

So their most common sites of injury were the fossil nervicularis and the labian menorah.

SPEAKER_02 6:08

But did the authors identify any flaws in the study?

SPEAKER_01 6:11

Yeah, they do identify that the sample is still a relatively small sample recruited from the single SARC service.

SPEAKER_02 6:19

And just out of curiosity, for those examiners who did use a speculum, do they report any vaginal wall or cervical injuries?

SPEAKER_01 6:27

It wasn't mentioned at all in this article.

SPEAKER_02 6:29

But in their limitations, they've said they routinely use coposcopy and they routinely use speculums, but they can't be 100% certain that those modalities got used in every patient. And we know that some patients are going to refuse it. And correct me if I'm wrong, it didn't do any kind of subgroup analysis there. We don't know how many people had a vaginal speculum examination, how many didn't. Is that correct?

SPEAKER_01 6:49

Yeah, that's right. That might be a question we could ask Catherine at the conference.

SPEAKER_02 6:53

Did they do any subanalysis between patients reporting just penetration of the labia with a finger, so essentially fingering, versus penetration of the vagina?

SPEAKER_01 7:05

No, they did haven't identified anything that specific in this study. There were a small number of female alleged perpetrators, so the majority of perpetrators were male, so 95% versus 5%. But interestingly enough, um, the proportion of gentle injuries was significantly higher in patients reporting alleged female perpetrators.

SPEAKER_02 7:24

So I'm thinking that the take-home message here is that once again, the vast majority of patients don't have an injury. And so it's you know, more than 80% of women are going to have a perfectly normal examination.

unknown 7:36

Yeah.

SPEAKER_02 7:37

Would I be right there?

unknown 7:38

Okay.

SPEAKER_01 7:39

Yeah, that's right. Yeah. And also, there hasn't been a study to date that these authors have identified that looks at consensual digital penetration, comparing non-consensual versus non-consensual injury incidents. So there's still probably more work that needs to be done in that area. But as you can imagine, that'd be a very difficult study to do.

SPEAKER_02 7:58

Yes. It's interesting how just how consistent the research findings are. No matter what you're looking at, the majority of women are going to have a normal examination. I think we're gonna have just a lot of confidence going in into court and saying that's what I expect to find.

SPEAKER_01 8:12

Yeah, that's right. Absolutely.

SPEAKER_02 8:13

References to all of those studies in the show notes, and I would encourage everyone to come to the conference. Emily, thank you very, very much for your time tonight, and we'll see you in November.

SPEAKER_00 8:24

Thanks, Kathy. Medico Legal Matters is brought to you by FamSaca, supporting clinicians.org.au