Medical Forensic Exam Research Articles

"This Time It Was Different:" Creating a Multidisciplinary, Trauma-Informed, Victim-Centered Approach to Sexual Assault Cold Case Investigations and Prosecutions.

Police and prosecutors recommend that sexual assault survivors have a medical forensic exam and the collection of a sexual assault kit (SAK; also known as a "rape kit") to preserve biological evidence (e.g., semen, blood, saliva, hair) if they want to pursue criminal prosecution. However, law enforcement personnel do not routinely submit SAKs to crime laboratories for forensic DNA testing. Instead, they often place untested kits in storage and close many of these reported cases after minimal investigation. Current estimates indicate there are 300,000 to 400,000 untested SAKs in law enforcement agencies throughout the United States. In response to this national problem, the U.S. Department of Justice created the Sexual Assault Kit Initiative (SAKI) Project to support kit testing, re-investigation, and prosecution of these "cold case" sexual assaults. The SAKI program also provides training and technical assistance to police, prosecutors, and victim advocates on how to use a multidisciplinary, trauma-informed, and victim-centered approach in cold case prosecutions. This study examined the extent to which one SAKI-funded site implemented these three guiding principles in their interactions with victims while prosecuting cold case sexual assaults. We conducted semistructured qualitative interviews with N = 32 sexual assault survivors from the first cohort of cold cases that were re-opened and prosecuted in this jurisdiction. Nearly all cases (n = 31) ended in a guilty plea or trial conviction, and the vast majority of survivors indicated that they had positive experiences with the SAKI team. Survivors noted that they were listened to, believed, supported, and well-prepared by a multidisciplinary team of practitioners who were personally invested in their cases and in their well-being. Implications for creating multidisciplinary, trauma-informed, and victim-centered approaches with other communities are discussed.

Reasons for Not Reporting Among Sexual Assault Survivors Who Seek Medical Forensic Exams: A Qualitative Analysis.

After a sexual assault, survivors have the option of seeking a medical forensic exam, which includes medical evaluation and treatment, as well as forensic evidence collection. Forensic evidence is collected in a sexual assault evidence kit (SAEK) and typically released to police to aid in the investigation and potential prosecution of the assault. However, 20% to 25% of survivors who have a SAEK collected do not report their assault to police at that time and choose instead to have their SAEK stored for possible future use. This study sought to understand the reasons for not reporting among this group of survivors. We examined medical records of 296 individuals aged 18 and older who had documented their reasons for not reporting to police in their medical record and used a non-theory-driven coding framework to conduct a reflexive thematic analysis based on that data. We identified four themes: Reporting Won't Help, Reporting Will Harm, Not Now, and Not What I'm Here For. These data illustrate that survivors are making an active choice which, for many, was based on concerns that reporting would not meaningfully help their situation or may even make their situations worse. For some survivors, the decision to have forensic evidence collected without a police report was based on their needs at that moment, whereas for other survivors it was based on their desire to move on from the assault more permanently. Practice and policy recommendations are discussed, including the importance of providing survivors information about what police reporting would look like in specific circumstances as well as ensuring that financial concerns are not a barrier to survivors receiving post-assault medical care without forensic evidence collection.

Police Decisions in a Rape Scenario: The Effect of Trauma Response, Forensic Evidence, Stranger-Perpetrators, and Rape Mythology.

This study examined the direct effect of "classic rape" characteristics, and how they were moderated by rape myth endorsement, on the likelihood of arrest, perceived district attorney charge acceptance, and perceived suspect conviction using a formal rape disclosure among a sample of 468 police participants from a sizeable municipal law enforcement agency in one of the fifth largest and most diverse U.S. cities. A randomly assigned, between-subjects factorial vignette design was employed. Manipulations included stereotypical trauma response, forensic medical exam, and perpetrator type. Path modeling revealed statistically significant relations between stereotypical trauma response, forensic medical exam, perpetrator type, and the three outcome variables. Rape myth endorsement moderated the effect of manipulations on the dependent variables. Implications for research and policy are discussed.

“It Made Me Feel Like Someone Wasn’t Doing Their Job:” Sexual Assault Kit (SAK) Victim Notifications and Institutional Betrayal by the Criminal Legal System

ABSTRACT In the United States, sexual assault survivors are advised to have a medical forensic exam and the collection of a sexual assault kit (SAK) to preserve biological evidence (e.g. semen, blood, saliva, hair) if they are considering reporting the assault to the police. Law enforcement personnel are supposed to submit the SAK (also known as a “rape kit”) to a crime laboratory for forensic DNA testing, which can help identify or confirm the identity of the offender. However, police do not routinely submit SAKs for testing, and large stockpiles of untested kits have been found in police storage throughout the United States. Public outrage has prompted many cities to submit these older rape kits for DNA analysis, and this testing has identified thousands of suspected perpetrators. Police and prosecutors are re-opening these older sexual assault cases, which requires reestablishing contact with survivors who made the initial report years ago – a process referred to as “victim notification.” In this study, we conducted qualitative interviews with survivors who received a SAK victim notification and participated in the re-investigation and prosecution of their cases. We explored how survivors reacted to this de facto admission of an institutional betrayal and the emotions they felt during and after the notification. Participants experienced considerable emotional distress (e.g. PTSD, anxiety, fear), anger and betrayal, and hope after they were recontacted by the police. Implications for making victim notifications more trauma informed are discussed.

АНАЛИЗ РЕЗУЛЬТАТОВ СУДЕБНО-МЕДИЦИНСКИХ ЭКСПЕРТИЗ ТРУПОВ, СОДЕРЖАЩИХ ЭКЗОГЕННЫЙ ЭТАНОЛ В БИОЛОГИЧЕСКИХ ЖИДКОСТЯХ

Every year Russia performs about 700’000 forensic medical examinations and postmortem assessments which is about a third of all deaths. In line with the current legislation, suspected violent deaths (due to external causes) are the reason for a forensic medical exam. Determination of the presence and quantitative content of exogenous ethanol in the corpse’s biological fluids is mandatory in all cases of violent death. In turn, alcohol consumption is one of the leading risk factors affecting mortality in Russia, especially among working-age men. Calculating alcohol consumption in population is challenging, since part of the available alcohol is unregistered (moonshine, alcoholic surrogates), yet there are many indicators that are considered reliable and characterize the level of alcohol consumption in population. This study has attempted to analyze causes of death of those with exogenous ethanol in biological fluids. These indicators are necessary for developing and implementing the most effective health policy, saving health and increasing life expectancy in Russia. The purpose of the study is to analyze causes of death based on the results of forensic medical examinations of corpses with ethanol in biological fluids. Material and methods. The material of this paper is data on forensic medical examinations collected by the Russian center of forensic medical examination of the Ministry of Health of the Russian Federation using the statistical observation form #42 “Forensic pathologist’s report, the Burau of forensic medical examination”. The study uses the method of descriptive statistics and correlation analysis. The share of deaths from various causes with ethanol in biological fluids was analyzed based on the results of forensic medical examinations by region and cause of death in 2003-2022. Results. The share of deaths with ethanol in biological fluids equaled to 46% of all forensic medical examinations in 2003, followed by a gradual decrease to 19% in 2022. The maximum was registered in external causes of death. Over the study period (2003-2022) the share of deaths with ethanol in biological fluids among deaths due to external causes decreased from 60% to 47, and from 31% to 14% among non-violent deaths. The share ranged from 36% to 45% among deaths attributed to symptoms, signs and ill-defined conditions without a tendency towards decreasing. For a number of external causes of death, this indicator consistently accounted for more than half of all forensic medical exams. Over the period under study, most regions of Russia witnessed a noticeable decrease in the share of deaths with ethanol in biological fluids, however, in some regions like the Republic of Buryatia, Sakhalin Region, Trans-Baikal Territory, Magadan Region, Nenets Autonomous Area and Murmansk Region, there is no noticeable decrease. The minimum was registered in the Chechen Republic and Republic of Ingushetia. However, in the North Caucasian republics, in general, there are low rates of forensic medical examinations of all deaths (less than 10%). Conclusion. Results of forensic medical examinations can potentially supplement and refine complex estimates of the contribution of alcohol consumption to the Russian mortality.

The ED is not ready for survivors of sexual violence, and especially not survivors like me.

The ED is not ready for survivors of sexual violence, and especially not survivors like me.

Hope Shattered: An Interpretive Phenomenological Analysis of Survivors' Experiences With Untested Rape Kits.

Rape survivors who submit to a medical forensic exam generally expect the resulting rape kit to be tested, but hundreds of thousands of rape kits have been left untested in police storage facilities nationwide. The current study sought to understand what the experience of having an untested rape kit was like for survivors. Using Interpretive Phenomenological Analysis, this study examined narratives of 15 survivors whose rape kits had been part of the rape kit backlog. Analysis suggested that survivors experience an extreme sense of betrayal and loss of faith in the criminal justice system when their kits are not tested. For these survivors, the rape kit was more than just evidence in a box; it was part of them. Implications are discussed.

Post-Assault Health Care for Sexual Assault Survivors During COVID-19: A Mixed Methods Analysis of Service Rates in a Predominately African American Community.

This study examined how the COVID-19 pandemic affected sexual assault healthcare services in a predominately African American U.S. city. In mixed methods research design, we used quantitative interrupted time series modeling to evaluate changes in service rates for three core post-assault healthcare services—medical forensic exams (MFEs), medical advocacy MFE accompaniment, and counseling—from January 2019 through June 2021. We also conducted qualitative interviews with 12 sexual assault advocates to understand how their clients were impacted by COVID and how their agency adapted services to respond to the needs of their community. Both the quantitative and qualitative data revealed marked disruptions in service provision. The number of MFEs, medical advocacy accompaniments, and counseling sessions significantly decreased during the pandemic’s initial surge, and survivors feared seeking hospital-based health care due to concerns that they might contract COVID-19 in hospital emergency departments. The number of MFEs performed by program staff did not return to pre-pandemic levels during this study’s observation period, but the number of medical advocacy accompaniments and counseling sessions did significantly rebound. Counseling services eventually exceeded pre-pandemic levels as agency staff supported clients with both assault- and COVID-related trauma and loss. These results underscore the need for community-based sexual assault healthcare services, so that if public health emergencies limit the availability, accessibility, and safety of hospital emergency department care, sexual assault survivors have other settings for obtaining post-assault health care.

Taking the Test: Participation in a Sexual Assault Medical Forensic Exam as an Indicator of Victim Cooperation with the Criminal Justice System and a Predictor of Suspect Arrest

This study examined indirect effects of sexual assault medical forensic exams (SAMFEs) on suspect arrest, through their effect on criminal justice professionals’ reports of victim cooperation during case investigation and processing. Using a sample of 413 sexual assault case files, we utilized path analysis to model the direct effect of SAMFEs on arrest as well as indirect effects through reports of victim cooperation with law enforcement and prosecution. Cases in which the victim participated in a SAMFE exhibited greater probability of reports that the victim cooperated with law enforcement and prosecution. These reports were, in turn, associated with greater probability of suspect arrest. The direct path between SAMFE participation and suspect arrest was not significant. Findings indicate participation in a SAMFE does not have a direct effect on arrest, but does have an indirect effect on arrest by serving as an indicator of victim cooperation to criminal justice professionals.

Developing Trauma-Informed Research Methods: Using Proxy Respondents to Assess Sexual Assault Survivors' Experiences Seeking Medical Forensic Exams

In research on sexual assault victims' help-seeking, proxy data sources are often utilized because outreach to survivors immediately postassault may increase a study's risk-to-benefit ratio. Victim advocates and services providers are common proxy respondents, but empirical research comparing the accuracy of their information is needed. We collaborated with seven sexual assault nurse examiner (SANE) programs to collect de-identified, paired data from nurses and advocates regarding the help-seeking experiences of N = 744 adult victims. Using pairwise McNemar tests, we found statistically significant agreement on victim demographics, assault characteristics, and victims' decisions regarding medical forensic exams, sexual assault kit (SAK) collection, and release of SAKs for forensic DNA testing. Nurses and advocates had different information regarding victims' disclosure histories and their reasons for seeking SANE care.

The Role of Discrimination Experiences in Postrape Adjustment Among Racial and Ethnic Minority Women.

Although recent studies have linked discrimination frequency among Black and Latinx individuals to PTSD symptom severity, to our knowledge, these associations have yet to be examined among a diverse sample of recent rape survivors. The current secondary analysis of existing data examined the role of discrimination experiences in post-traumatic stress disorder (PTSD) symptoms, depression, and alcohol and drug problems among a racially and ethnically diverse sample of recent rape survivors. Participants were 139 Black (48.2%; n = 67), American Indian (18.7%; n = 26), Hispanic (15.1%; n = 21), and mixed race (17.3%; n = 24) girls and women age 15 or older who presented to the emergency department (ED) for a sexual assault forensic medical exam. They were randomly assigned to one of three intervention conditions, and completed a six-month postrape follow-up, including questions about mental health, substance use problems, and discrimination experiences. Regression analyses revealed that Black women experienced discrimination in significantly more situations and with greater frequency compared to American Indian and Hispanic women. Discrimination frequency was positively associated with PTSD and depression symptoms even after controlling for age, education, race, and intervention condition, but was not associated with alcohol or drug problems. Findings highlight the importance of attending to the heterogeneous experiences of discrimination among racial and ethnic minority women. Future work should adapt evidence-based early interventions to be maximally effective at combating both racial and sexual trauma exposures.

The Geopolitics of “Rape Kit” Protocols

AbstractThis article contributes to historiographies of forensic medicine by examining late twentieth-century women’s rights activism for new clinical standards on medical forensic exams for sexual...

Why do sexual assault survivors seek medical forensic exams and forensic evidence collection? Exploring patterns of service needs in a state-wide study.

Why do sexual assault survivors seek medical forensic exams and forensic evidence collection? Exploring patterns of service needs in a state-wide study.

Racial Disparities in Sexual Assault Characteristics and Mental Health Care After Sexual Assault Medical Forensic Exams

Background: Sexual assault (SA) is common, but Black individuals might be at higher risk of SA and negative health sequalae. Racial differences in SA characteristics and health care utilization after SA are largely unknown. Materials and Methods: We reviewed medical records of 690 individuals (23.9% Black; 93.6% women) who received a SA medical forensic exam (SAMFE) at a southeastern U.S. hospital. We examined bivariate racial differences in SA characteristics and used zero-inflated Poisson regressions to estimate racial differences in mental health outpatient visits at the SAMFE hospital. Results: Among survivors of SA, Black survivors were more likely than White survivors to have been victimized by an intimate partner (odds ratio [OR] = 1.77, confidence interval [95% CI] = 1.02-3.07) and they had more post-SA outpatient mental health visits at the SAMFE hospital (incidence rate ratio [IRR] = 2.05, 95% CI = 1.70-2.47). Black survivors were less likely to report alcohol or drug use before the SA (OR = 0.42, 95% CI = 0.28-0.62). In multivariable models, Black survivors trended toward more mental health visits than White survivors (IRR = 1.63, 95% CI = 0.82-2.44), but intimate partner violence (IPV) significantly moderated that association (IRR = 0.01, 95%CI = ≤0.001-0.03). Black survivors assaulted by an intimate partner were less likely to access mental health care than White IPV survivors. Conclusions: The hospital setting of a SAMFE could be a unique opportunity to serve Black survivors and reduce racial disparities in mental health sequelae, but additional support will be needed for Black survivors experiencing IPV. An intersectional, reproductive justice framework has the potential to address these challenges.

The Link Between the SAMFE and Police Perceptions of Victim Credibility

While research has documented the evidentiary significance of sexual assault medical forensic exams (SAMFEs) to case processing, there has been less focus on SAMFEs’ relevance to extralegal case characteristics. This study, through focus groups with police officers and prosecutors, illuminates the link between two important case processing factors: the SAMFE and perceptions of victim credibility. The majority of respondent narratives about the utility of the SAMFE point to how it strengthens or weakens perceptions of victim credibility. This link points to the SAMFE’s important role in early case processing before investigators send DNA evidence for forensic testing.

009 The Determinants of HIV-Testing Following a Sexual Assault Forensic Medical Exam

009 The Determinants of HIV-Testing Following a Sexual Assault Forensic Medical Exam

New Perspectives on Risk Factors for Non-fatal Strangulation and Post-assault Imaging.

Strangulation has long been associated with death in the context of sexual assault and intimate partner violence (IPV). Non-fatal strangulation (NFS) during sexual assault, which refers to strangulation or choking that does not result in death, is common and has been associated with IPV and with bodily injury; however, other factors associated with NFS are unknown. The current study examined demographic and sexual assault characteristics associated with NFS among women who received a sexual assault medical forensic exam (SAMFE). A second purpose of this study was to explore factors associated with receiving follow-up imaging orders after NFS was identified during a SAMFE. Participants (N = 882) ranged in age from 18 to 81 (M = 28.85), with the majority identifying as non-Hispanic White (70.4%) or Black/African American (23.4%). A total of 75 women (8.5%) experienced NFS during the sexual assault. Of these, only 13 (17.3%) received follow-up imaging orders for relevant scans. Results from a logistic regression analysis demonstrated that NFS was positively associated with report of anal penetration, intimate partner perpetration, non-genital injury, and weapon use during the assault. Results from chi-square analysis showed that among sexual assaults involving women who experienced NFS, those whose assaults involved weapon use were over four times more likely to receive imaging orders compared to assaults without weapon use. These findings have implications for criminal justice, and if incorporated into danger assessments, could potentially reduce fatalities linked to sexual assault and/or IPV. Additional work is needed to ensure that all assaults with NFS trigger a referral for imaging regardless of other assault characteristics.

Beyond Forensic Evidence: Examining Sexual Assault Medical Forensic Exam Mechanisms that Influence Sexual Assault Case Outcomes

Despite the widespread use of sexual assault medical forensic exams (SAMFEs), practitioners and researchers continue to debate the role of SAMFEs and the evidence they provide in the investigation and prosecution of sexual assault cases. Using data from a review of sexual assault cases reported to police between 2015 and 2017 in two jurisdictions (n = 534), we use logistic regression examine whether the presence of a SAMFE predicts the likelihood of achieving criminal case processing outcomes and whether the relationship of the SAMFE with criminal case processing outcomes is moderated by other legal and extralegal case characteristics. We did not find evidence that the presence of a SAMFE in a case significantly predicts whether a suspect will be identified, arrested, or convicted overall, but we did find evidence of the SAMFE's injury documentation value for arrest. Researchers and practitioners should account for the multiple ways SAMFEs can influence decision-making in future research and policymaking.

Factors Associated With Law Enforcement Reporting in Patients Presenting for Medical Forensic Examinations.

Law enforcement reporting following sexual assault is lower than for other violent crimes. Sexual assault nurse examiners (SANEs) provide care for patients in the acute period following sexual assault and are well-positioned to identify and address barriers to reporting. We examined data from medical forensic examination records documented by SANEs for a 5-year period (2011-2015). We examined 347 records of women 18 and older to identify factors associated with law enforcement reporting at the time of the exam using binomial logistic regression to construct odds ratios (OR). A total of 56.5% of patients in the sample reported to law enforcement. Patients who did not voluntarily consume alcohol were more likely to report than those who did (OR = 4.45; p = .001). Patients who were not students were more likely to report than students (OR = 3.24; p = .002). Patients who had a medical forensic exam within 32 hr of the assault were more likely to report than those having exams after 32 hr (OR = 2.68; p = .007). Patients who had anogenital and/or bodily injuries were more likely to report than those who had no injuries (OR = 2.50; p = .008). Patients who were penetrated (vaginally, orally, and/or anally) were more likely to report than those who were not penetrated (OR = 2.50; p = .056). Knowing the assailant, having multiple assailants, and patient and assailant race/ethnicity were not associated with different likelihood of reporting to law enforcement. SANEs and others who work with victims of sexual assault can use data to understand and address barriers to reporting.

Clinical management of patients presenting following a sexual assault.

Sexual assault is a common and distressing occurrence. The medical needs of individuals presenting in the immediate aftermath of an assault may be obvious: addressing injuries and distress and providing the option of a forensic medical exam. However, the initial assessment and response to a disclosure of sexual assault is an important opportunity to address medical, safety and psychosocial concerns. The aim of this article is to discuss the practitioner's response to disclosures of recent sexual assault and the consequent legal, forensic and medical options. In particular, emergency contraception, sexually transmissible infections and management of injuries may be the patient's predominant concerns. Legal concerns, particularly relating to privacy and documentation, are also important inthese cases. Following a disclosure of recent sexual assault, a general practitioner may be juggling many concerns, both medical and legal. This article addresses some of these concerns and considers a medical response to a distressing situation in a way that minimises further trauma to thepatient and the practitioner.