Kari Ormstad

Adolescent girls investigated for sexual abuse: history, physical findings and legal outcome

OBJECTIVE The aim of the study was to summarize the history of assault and record the results of medicolegal examination in adolescent girls under investigation for alleged sexual abuse, and to monitor the outcome of the legal process. The investigation period was 1990-94. METHOD A consecutive series of 94 0-para girls, aged 9-22, median age 15.0 years, were examined in the head-to-toe manner including anogenital examination. Girls were referred from investigating police and social authorities. Only non-acute examinations were performed. Findings considered consistent with abusive vaginal penetration were hymenal distortion including deep clefts, hymenal and vestibular scarring, and introital diameter permitting vaginal inspection with a 17 mm speculum in the absence of consensual intercourse. Perianal scarring was recorded. STD sampling was made on indication. Findings were documented on body sketches. Medicolegal conclusions were grouped into three categories according to history and physical findings. Information on the outcome of legal procedures was collected from referring authorities. RESULTS For 82% (77/94) of the girls, referring agencies provided examining physicians with a detailed and consistent history of abuse, presented results comprise these 77 girls. Intrafamiliar abuse was alleged by 81% (62/77), onset prior to menarche by 53% (41/77), and repeated abuse by 74% (57/77) of the girls. Abusive genital penetration was reported by 77% (59/77) and anal penetration by 19% (14/77). Sequelae after admitted self-inflicted injury were found in 15% (12/77). Deep hymenal clefts and/or vestibular scars were found in 59% (35/59) of the girls reporting penetrative abuse, compared with 6% (1/16) when non-penetrative abuse was alleged, P < 0.001. Girls with experience of voluntary intercourse could all be examined with a 25 mm speculum. Of the 17 girls without experience of consensual intercourse but alleging abusive penetration, 47% (17/36) could easily be examined with a 17 mm speculum, compared to none of 13 reporting non-penetrative abuse, P < 0.001. Non-specific anal abnormalities occurred in 10 (13%) girls; more often when anal abuse was reported, P < 0.001. No specific STDs were found. The medicolegal conclusion supported a history of abusive genital penetration in 41 (69%) cases; findings were non-specific in 11 cases and a normal anogenital status was found in 25 cases. The alleged abuse of 34 of the 77 (44%) girls was tried in court. One suspect was acquitted, 32 men were convicted of the abuse of 33 girls. Eleven perpetrators admitted abuse, and their histories were in concordance with the abuse alleged by the victims, as well as with the physical findings. CONCLUSION A medicolegal diagnosis of alleged non-acute cases of sexual abuse relies on a detailed history. Adolescent girls alleging abuse may exhibit signs of admittedly self-inflicted extragenital injury. Our findings confirm that non-penetrative sexual acts leave no lasting genital signs, but that repeated abusive genital penetration significantly more often than non-penetrative abuse leaves deep posterior hymenal clefts and/or vestibular scarring, and a hymenal opening allowing examination with 17-25 mm specula also in girls without experience of voluntary intercourse. In cases with a confessing perpetrator, no discordance was found between the history of the victim, medicolegal conclusion and the history of the perpetrator.

Ethanol and drug findings in women consulting a sexual assault center: Associations with clinical characteristics and suspicions of drug-facilitated sexual assault

The purpose of the study was to describe toxicological findings among women seeking health care after sexual assault, and to assess the relationship with so-called proactive DFSA (drug facilitated sexual assault). We also explored associations between ethanol in blood/urine and background data, assault characteristics, and clinical findings. We conducted a retrospective, descriptive study of female patients ≥ 12 years of age consulting the Sexual Assault Center at St. Olavs University Hospital, Trondheim, Norway. They were examined between July 1, 2003 and December 31, 2010, and urine and/or blood were analyzed for ethanol and selected medicinal/recreational drugs. Among the 264 patients included, ethanol and/or drugs were detected in 155 (59%). Of the 50 patients (19%) testing positive for drugs other than ethanol, benzodiazepines/benzodiazepine-like drugs were found in 31, central stimulants in 14, cannabinoids in 13 and opioids in nine. None tested positive for gamma-hydroxybutyrate (GHB). In total, 57 patients (22%) suspected proactive DFSA, but only five had findings of sedative drugs that were not accounted for by self-reported voluntary intake. No cases could unequivocally be attributed to proactive DFSA. Among the 120 patients tested for ethanol within 12 h after the assault, 102 were positive. The median estimated blood alcohol concentration (BAC) at the time of assault was 1.87 g/L. Patients testing positive for ethanol more often reported a public place of assault and a stranger assailant. Higher estimated BAC at the time of assault was associated with higher frequency of suspecting proactive DFSA. Ethanol was the most prevalent toxicological finding in urine/blood from victims of sexual assault, and high ethanol concentrations were often detected. Among the patients suspecting proactive DFSA, very few had sedative drug findings not explained by voluntary intake. It seems like opportunistic DFSA, rather than proactive DFSA dominate among the sexually assaulted attending our SAC.

Sexual assault centers: attendance rates, and differences between early and late presenting cases.

Objective. Sexual assault centers (SACs) aim at assisting victims and to provide forensic medical examination (FME). This study explores the gap between assaults actually occurring and those seen at SAC; and the characteristics of cases presented in time/too late for FME (early and late cohorts). Design. Retrograde descriptive study. Setting and sample. A two‐year series from a self‐referral SAC; characteristics of victims, assaults, use of services. Methods. Chi‐quadrate, uni‐ and multivariate logistic regression analyses. Main outcome measures. Number of female victims seen/female at‐risk population (attendance rates). Case and service profiles in the two cohorts. Adjusted odds for late presentation. Results. Attendance rates for females were 0.12% (14–55 years); an estimated 4–7% of sexually assaulted females in the catchment area. Two hundred and seventy eight victims arrived in time for FME, 76 later; 6% males. Assaults in the early cohort were more often performed by strangers. Two hundred and thirty‐eight victims underwent FME, 55% complied with follow‐up, 55% reported to the police. The late cohort contained more adolescent victims, more acquainted/partner perpetrators, more verbal coercion; 45% medically examined, 80% follow‐up compliance; 34% reported to police. Further referrals occurred equally often in both cohorts; 12% to somatic and 39% to psychiatric services. Among victims seen, 5% died within 7 years of consultation. Conclusion. Cases seen at SAC are strongly selected. The late cohort seems more representative of the commonly occurring assaults; young victims, known assailants. Even late presenters are in need of a multidisciplinary approach.

Impact of medico‐legal findings on charge filing in cases of rape in adult women

Objective. To assess the impact of the medical documentation and biological trace evidence in rape cases on the legal process. Design. Retrospective descriptive study. Setting and sample. Police‐reported cases of rape of women ≥16 years old in the Norwegian county of Sør‐Trøndelag from January 1997 to June 2003. Methods. Police data were merged with data from the Sexual Assault Center at St Olavs Hospital. Charged and non‐charged cases were compared. Main Outcome Measures. Medico‐legal findings and legal outcome. Results. A total of 185 police‐reported cases were identified. Of the 101 cases examined at Sexual Assault Center, charges were filed in 18 cases. Extragenital injuries were documented in 49 women; five were life threatening. Anogenital injuries were documented in 14 women; eight had multiple anogenital injuries. Documentation of injuries was not associated with charge filing. In only 33% of the cases were swabs collected from womens genitals used as trace evidence by the police. When used, this increased the likelihood for charge filing. A DNA profile matching the suspect was identified in four of the 18 charged cases and in only one among the 54 non‐charged cases. Conclusions. Half of the women had one or more documented injury. Only one‐third of the trace evidence kits collected from the womens anogenital area were analyzed. The analysis of swabs was associated with charge filing, regardless of test results. Increased use of such medical evidence, especially in cases of stranger rape, may ensure womens rights and increase available information to the legal system.

Implementation of medical examination and forensic analyses in the investigation of sexual assaults against adult women: A retrospective study of police files and medical journals

OBJECTIVE To describe the implementation of medical examination and forensic analysis in the police investigation of sexual assaults, and compare police-reported cases with and without medico-legal examination of the victim. METHODS A retrospective study of all police-reported sexual assaults against women in the county of Sør-Trøndelag, Norway, January 1997-June 2003. Information from the police files was merged with information from the only specialized health care system in the region, the Sexual Assault Care Centre (SACC), St. Olavs Hospital, Trondheim. RESULTS Of the 185 police-reported cases identified, 101 (55%) involved women examined at the SACC. A medical report was requested in 83% of the latter, while forensic analyses of biological samples from the victims body were performed in a mere 29%. In cases without examination at the SACC, there was more likely assault outside the city, over one weeks delay between the assault and police-reporting, over one assault reported, and assault coded as attempted rape, while vaginal penetration was less likely. Adjusting for delay of reporting, geographical closeness to health care remained predictive of medical examination. Only 16% of the cases were prosecuted. CONCLUSION The police requested a medical report in most cases where the victim had undergone examination, while a minority of collected biological samples was analyzed. Consequently, a vigilant and thorough documentation of mental state, physical injuries and history of assault should be emphasized.

Sexually transmitted infections among women attending a Norwegian Sexual Assault Centre

Objectives The objective was to describe the prevalence of sexually transmitted infections (STI) and blood-borne viruses (BBV), and prophylactic treatment offered to female postpubertal patients attending a Norwegian Sexual Assault Centre (SAC). We wanted to evaluate whether STIs diagnosed at the initial visit could have been assault-transmitted, and to explore whether background and assault characteristics were associated with diagnosed STI/BBV. Methods We included postpubertal females ≥12 years of age attending the SAC within 1 week of the assault. Data were collected from records. We conducted a retrospective, descriptive study, and used logistic regression analysis. Results Among 412 patients with a median age of 21 years, 35 patients had an STI (8.5%), two of which probably were assault-transmitted. Chlamydia trachomatis was the dominating agent, detected in 25 patients (6.4%). At serology screening, 3.7% tested positive for hepatitis C and/or hepatitis B core antibody. Patient age 16–19 years was associated with STI, while BBV positives were older. Non-Western assailant was associated with STI, while substance abuse was associated with STI and BBV. In order to prevent potential transmission of STI not identified at the initial visit, 91% accepted prophylaxis against bacterial STI, while antiviral prophylaxis was offered to less than one-fifth of the patients. Conclusions The C trachomatis prevalence among the sexual assault patients was lower than in a comparable clinical population. The STI was suspected to be assault-transmitted in only two cases.

To be Used or Not to be Used, that is the Question: Legal Use of Forensic and Clinical Information Collected in a Self-referral Sexual Assault Centre*

Abstract:  This study explores how the police select cases for using information from a self‐referral Sexual Assault Centre (SAC). The study is retrospective and descriptive: a 2‐year series from a Scandinavian SAC and corresponding police files. The police had access to 163 SAC cases, requested 84% of available forensic medical documentation, and had 50% of the trace samples analyzed. The two main predictors of police utilization of forensic evidence were cases the police classified as rape and complaints filed during January to August. Extrinsic DNA was found in 27/60 trace evidence analyses, 21 matching a suspect. For one‐third of the suspects who denied sexual acts, the forensic evidence contradicted their denial. Nonuse forfeited this possibility in several cases, and relevant information on injuries was lost. Our results indicate that available medical information is not fully utilized for legal purposes. Main barriers are police classification of cases and insufficient economic funding.

Sexual Assault Centres and Police Reporting—An Important Arena for Medical/Legal Interaction*

Abstract:  This study explores the usefulness of forensic medical examination (FME) irrespective of police request and police‐reporting practices at a self‐referral Sexual Assault Centre (SAC). The study is retrospective, descriptive: a 2‐year series of cases from a Scandinavian SAC and corresponding police files. Among 354 SAC cases, 180 were reported to the police, comprising 103 of 197 total rapes registered in this police district. Of 278 complainants presenting in time for FME, 55% reported to the police. FME was performed in 238 cases, 142 of these registered by the police. In 24% of the latter, examination preceded reporting by ≥2 days. Thus, substantial amounts of SAC casework remain unavailable to the police owing to nonreporting. However, performing FME regardless of reporting considerably increases the amount of information available to the police in late‐reported cases. Although several factors predict reporting, the predictive power is insufficient for performing FME selectively.

Factors associated with trace evidence analyses and DNA findings among police reported cases of rape

OBJECTIVE The aim of this study was to examine the association between victim, suspect and assault characteristics and (1) forensic analysis of trace evidence, (2) detection of spermatozoa and (3) DNA match in police-reported cases of rape/attempted rape. In addition, we explored whether DNA findings were associated with legal outcome. METHODS We conducted a retrospective, descriptive study based on police-reported rapes and attempted rapes of women  ≥16 years of age in Sør-Trøndelag Police District throughout 1997-2010. Police data were merged with information from the Sexual Assault Centre (SAC) at St. Olavs University Hospital, Trondheim, Norway. We used binary and multivariable logistic regression for the comparisons. RESULTS We identified 324 victims (mean age 24 years). The police requested analysis in 135 (45%) of the 299 collected victim samples. The police decision to analyze was after adjustment associated with the victim being employed or under education, and a public venue, but not with interval from assault to sampling. Spermatozoa were detected in 79 (61%) of the analyzed cases, of which 71 were collected from victims within 24h. Interval from assault being <24h and reporting a penetrative assault remained associated with the findings of spermatozoa after adjustments. Forensic analyses of trace evidence collected from victim, suspect and/or venue disclosed matching DNA profiles in 57 (40%) of a total of 143 analyzed cases. Matching DNA profiles were associated with suspect being known to the victim and with the venue being private. A higher proportion of cases with a DNA match were prosecuted in court: 20 of the 29 cases prosecuted. However, despite a DNA match 35 cases were anyway dismissed because of insufficient evidence. CONCLUSIONS Although many of the associations in our study were expected, it is still important to report the actual numbers to gain insight into the importance of a DNA match in legal proceedings. A substantial proportion of cases with DNA match was dismissed because of insufficient evidence. To strengthen the justice response to sexual assault, it is essential to generate knowledge about the role of medico-legal evidence in such cases, and there are obviously other non-medical factors influencing the legal decisions.