Article, Forensic Medicine

Sexual assault in postmenopausal women: epidemiology and patterns of genital injury

Original Contribution

sexual assault in Postmenopausal women: epidemiology and patterns of Genital injury?,??

Jeffrey S. Jones MD a,?, Linda Rossman MSN a,b, Renae Diegel RN c,

Phyllis Van Order RN d, Barbara N. Wynn MD a,b

aGrand Rapids MERC/Michigan State University Program in Emergency Medicine, Spectrum Health Hospital-Butterworth Campus, Grand Rapids, MI 49503-2560, USA

bNurse Examiner Program, YWCA West Central Michigan, Grand Rapids, MI 49503, USA

cTurning Pointe SANE Program of Mount Clemens, MI 48046, USA

dSexual Assault Services of Calhoun County SANE Program, Battle Creek, MI 49037, USA

Received 21 June 2008; revised 13 July 2008; accepted 13 July 2008

Abstract

Study objective: Physical abuse of older women, including reports of sexual assault, has risen rapidly for the last decade. The purpose of this study was to compare a group of postmenopausal victims of sexual assault with younger adult women (18-39 years old) by examining patient demographics, assault characteristics, and patterns of physical injury.

Methods: We conducted a retrospective cohort analysis to assess epidemiology and anogenital injuries in consecutive female victims presenting to sexual assault clinics and/or emergency departments within 3 counties of Western Michigan. All patients were examined by forensic nurses trained to perform medicolegal evaluations using colposcopy with nuclear staining. Patient demographics, assault characteristics, and injury patterns were recorded using a standardized classification system. Data from 2 patient groups (women aged 18-39 years vs postmenopausal women >=50 years) were compared using ?2 and t tests.

Results: During the 5-year study period, 1917 adult sexual assault victims met the inclusion criteria and comprised the study population as follows: 84% of the victims were 18 to 39 years old, and 4% were postmenopausal women at least 50 years old. The 72 postmenopausal victims were more likely to be assaulted by a single assailant, typically a stranger (56% vs 32%, P = .008), in their own home (74% vs 46%, P b .001) and experienced more physical coercion (72% vs 36%, P b

.001). In comparison, the younger control group was more likely to have used alcohol or illicit drugs before the assault (53% vs 18%, P b .001) and have a history of sexual assault (51% vs 15%, P b .001). Postmenopausal victims had a greater mean number of nongenital (2.3 vs 1.2, P b .001)

? Presented at the Society of Academic Emergency Medicine Annual meeting in New York, May 22-25, 2005.

?? Blodgett Butterworth Foundation, Grand Rapids, Mich #2003-180.

* Corresponding author. Department of Emergency Medicine, Spectrum Health-Butterworth Campus, Grand Rapids, Mich 49503-2560. Tel.: +1 616 391 3587; fax: +1 616 391 3674.

E-mail address: [email protected] (J.S. Jones).

0735-6757/$ – see front matter (C) 2009 doi:10.1016/j.ajem.2008.07.010

as well as anogenital injuries (2.5 vs 1.8, P b .001). The localized pattern and type of physical injuries were similar in both groups, although postmenopausal women tended to have more anogenital lacerations and abrasions.

Conclusion: The postmenopausal woman is not immune from sexual assault. The epidemiology of sexual trauma in this age group is uniquely different when compared to younger women, which may be useful in planning intervention and Prevention strategies.

(C) 2009

Introduction

Physical abuse of older adults, including reports of sexual assault, has risen rapidly for the last decade [1]. The true extent of this problem is difficult to determine. Reluctance to report sexual abuse, relative isolation of elderly victims, and lack of public and professional awareness undoubtedly contribute to many cases of undetected assault. In addition, rape committed against women older than 50 years has been the subject of only scattered and limited scientific study. The National Crime Victimization Survey estimates that the incidence of rape committed against older adults at 50 per 100 000 per year, representing about 3% of all sexual assault victims [2].

Older rape victims who seek medical treatment may be particularly susceptible to physical injury because of declining health and strength, decreased levels of estrogen, comorbidity, Cognitive impairments, and psychopathologic condition in the offender [3-7]. In a small study done by Pollock [8], assaults on older women were more violent, brutal, and sadistic when compared to assaults on younger women. If age differences exist in the likelihood of injury, clinicians need to understand typical injury patterns attributable to age.

The purpose of this study was to determine the epidemiological characteristics, as well as the type, frequency, and severity of anogenital injuries in postmeno- pausal victims after sexual assault. Perimenopausal is the life phase just before menopause and refers to the transitional period before menstruation actually stops. It can last up to 10 years but generally occurs between 40 and 49 years of age [7]. A comparison group of premenopausal females between the ages of 18 and 39 years who most likely would not have reached the perimenopausal stage were included as a comparison group.

Methods

Study design

This was a retrospective cohort analysis to assess epidemiology and anogenital injuries in postmenopausal women (>=50 years old) in 3 Michigan counties for a 5-year study period. More specifically, we tested the following hypothesis: women aged 50 and older will have

significantly more genital and nongenital injury caused by rape than will females between the ages of 17 and 39. The study protocol was approved by the institutional review board at Spectrum Health Hospital.

Study setting

The Nurse Examiner Program (NEP) is a community- based program that provides 24-hour comprehensive response to adolescent and adult victims of sexual assault. Three NEPs participated in this study–YWCA West Central Michigan, Kent County; Sexual Assault Services of Calhoun County SANE Program; and Turning Pointe SANE Program of Malcomb County. These NEPs serve as the major referral centers in West Central Michigan for police and other emergency providers in Kent, Calhoun, and Malcomb counties with a total population of 1.57 million [9]. Those sexual assault victims presenting directly to the emergency departments (EDs) in the 3 Michigan counties are referred to an NEP for evaluation after triage and initial assessment. Trans- portation is provided if needed or requested. Approxi- mately 10 to 12 ED patients each year are too severely injured to be transferred to the NEP for evaluation [10]. Nurse examiners have completed a credentialing process that allows them to go into the hospital ED and perform the evaluation and collection of evidence. Education of the nurse examiner consists of approximately 40 hours of training in all aspects of caring for this population, including physical examination, forensic preservation of evidence, documentation, and courtroom testimony.

Study population

Female sexual assault victims who presented to EDs or directly to the NEPs for treatment between January 1, 1998, and December 31, 2003 (60 months), were eligible for inclusion in the study. For comparison in data analysis, we chose premenopausal victims of sexual assault (aged 18- 39 years of age) and postmenopausal women (>=50 years). Postmenopausal status was defined by the absence of menstrual periods within the previous 12 months with natural menopause or had bilateral oophorectomy and was not receiving estrogen or progestin hormone therapy. Women who refused forensic examination, could not recall details of

the assault (eg, intoxication), had missing or incomplete documentation, or if examined at least 72 hours after the assault were excluded from the study sample.

Study protocol

The Forensic sexual assault examination is similar to a standard gynecologic examination with the addition of the 3 techniques to identify injury as follows: direct visualization, nuclear staining, and colposcopy. The procedure includes a medical forensic history of the event; gynecologic history (including timing of last menstrual period and menopausal status); collection of photographic evidence of injuries and genital structures; visual and microscopic inspection of internal genital, external genital, and anal injuries; treatment of injuries and any sexually transmitted infections; evidence collection; and discharge with follow-up. The following Anatomical sites are routinely evaluated and photographed for the presence and type of injury: External genitalia (thigh, mons, labia majora, and perineum), Internal genitalia (labia minora, periurethral area, posterior fourchette, fossa navicu- laris, hymen, cervix, and vagina), and anus. Anoscopy is performed at the examiner’s discretion.

The number of genital and nongenital injuries was determined by simply counting each injury occurrence and totaling the count for each individual. Injury frequency was the number of genital or nongenital injuries sustained by each woman. Injury prevalence was the number of survivors with one or more injuries divided by the total number of survivors. For the purposes of this study, injury was defined as any tissue trauma visible on inspection including tears, ecchymosis, abrasions, redness, or swelling (TEARS) in the topology proposed by Slaughter et al [11]. The TEARS classification system uses the following types of injury to organize genital injury. Tears were defined as any breaks in tissue (skin and mucous membranes) integrity including fissures, cracks, lacerations, cuts, gashes, or rips. Ecchymo- sis was defined as skin or mucous membrane discoloration due to the damage of small blood vessels causing “bruising” or ” black and blue ” areas. Abrasions (excoriations) were defined as the removal of the epidermis from skin or mucous membranes. Redness was the descriptor for erythematous tissues that are abnormally inflamed because of irritation. Swelling was defined as local edema or transient engorge- ment of tissues.

Standardized abstraction forms were used to guide data collection. Demographic information, sexual assault history, and clinical findings were obtained from NEP records using appropriate safeguards to protect patient confidentiality. Medical records were reviewed by one research nurse who was trained using a set of “practice” medical records. One of the investigators (LR) met frequently with the abstractor to resolve questions. A second investigator (JSJ) performed a blinded critical review of a random sample of 10% of the charts to determine reliability. The Interrater agreement for this sample of charts was excellent (? statistic = 0.97).

Data analysis

The primary outcome of interest was used to determine the frequency of anogenital injuries documented in sexual assault victims from each age group. Secondary outcomes were used to identify any differences in demographics, assault characteristics, or injury patterns in postmenopausal victims compared with women 18 to 40 years old. A power analysis determined that at least 40 patients were needed in each group to detect an absolute difference in genital injuries of 20% with a power of 0.8 and an ? of .05.

Data were entered into a Microsoft Excel database (version 2003; Microsoft, Redmond, Wash).

Analyses were performed using SPSS statistical soft- ware (version 14.0, SPSS Inc, Chicago, Ill). Descriptive statistics were used to describe the demographic variables, perpetrator factors, and assault characteristics. The mean number of documented anogenital and nongenital injuries for each group was determined, as were the typical locations and type of Anogenital injury (abrasion, lacera- tion, erythema, ecchymosis, edema). To compare 2 means, t tests were used. Discrete variables were analyzed using the ?2 test. To determine the correlations between various historical factors and the number of anogenital injuries, Pearson correlations using the 2-tailed t test were calculated. To reduce the inflated risk of a type I error that occurs when a large number of statistical analyses are conducted, we chose a P value of less than .01 for statistical significance [12,13].

Results

During the 5-year study period, 2188 adult women presented after a sexual assault. Two hundred seventy-one cases were excluded because the victims could not recall details of the assault (104), were examined at least 72 hours after the assault (88), refused forensic examina- tion (51), had incomplete documentation (14), or were older women who did not meet the postmenopausal criteria

(14). These exclusions resulted in a final sample size of 1917. Of these victims, 84% (1610) were 18 to 39 years old, and 3.8% (72) were postmenopausal women at least

50 years. These 2 groups comprised the final study population described in Table 1.

Of the study patients, 59% (992) presented directly to 1 of 3 participating NEPs for evaluation and treatment; 38% (640) were triaged in 1 of 19 local EDs and transferred to an NEP; and 3% (50) of patients were evaluated in a hospital by NEP staff because of the severity of their injuries. Not surprisingly, postmenopausal women were more likely to present to the ED and be admitted to the hospital than younger victims. We examined the medical records of the 12 postmenopausal women who were admitted. Eight were admitted for trauma evaluation

Table 1 Patient demographics

Premenopausal

(n = 1610), n (%)

Postmenopausal (n = 72), n (%)

Age of victim, mean (SD) ?

Age range Ethnicity (% white)

marital status (% single) ?

Presentation for treatment ?

Direct to NEP ED triage to NEP

Hospital admission psychiatric history Cognitive disability ?

Physical disability ?

alcohol or drug use

b24 hrs ?

History of sexual assault ?

Last consensual intercourse b72 h ?

time interval to examination, mean (SD) ?

police report filed

26 +- 9 y

63 +- 14 y

19-39

50-96

1190 (73.9)

57 (79.2)

1115 (69.3)

22 (30.6)

958 (59.5)

34 (47.2)

611 (38.0)

29 (40.3)

41 (2.5)

9 (12.5)

241 (15.0)

8 (11.1)

29 (1.8)

10 (13.9)

81 (5.0)

11 (15.3)

855 (53.1)

13 (18.1)

818 (50.8)

11 (15.3)

409 (25.4)

3 (4.2)

18 +- 11 h

12 +- 8 h

1269 (78.8)

65 (90.3)

* Indicates significance at the P b .01 level.

(fractures, head injuries, vaginal wall perforation), 2 for urinary tract infections, 1 patient for pneumonia, and 1 patient for nontraumatic chest pain.

Postmenopausal women were more often married (69.3% vs 30.6%, P b .001) and likely to have a history of cognitive and/or physical disability (23.6% vs 6.1%, P b .001). In comparison, younger women were more likely to have used alcohol or illicit drugs before the assault (53.1% vs 18.1%, P b .001) and have a history of sexual assault (50.8% vs 15.3%, P b .001). Younger women were also more likely to delay seeking care after rape compared with older women (18 hours vs 12 hours, P b .001) and more reluctant to file a police report (78.8% vs 90.3%, P = .027).

Assault-related characteristics are listed in Table 2. The

percentages add to more than 100% because more than one type of assault was documented in 35 (48.6%) postmeno- pausal women and 749 (46.5%) controls (P = .82). In all ages of women, penis to vagina contact was the most prevalent type of contact. However, older women reported significantly less vaginal penetration (P b .001) and more hand to vagina contact (P = .006). Use of an object or foreign body as instrument of rape happened rarely in this study population.

The location of assault was significantly different for

the 2 age groups. In postmenopausal women, three fourths of assaults occurred in the patient’s own home and 8.3% in a care facility. Few occurred in another’s home, outdoors, or a vehicle. In contrast, for the younger women, 24.8% of assaults occurred in a home other than the patient’s, 7.2% occurred outdoors, and 13% in a

vehicle. Most women in all age groups reported a single assailant, approximately just 2 (2.8%) postmenopausal women had 2 or more assailants compared with 12.8% of younger women.

The assailant was rarely an intimate partner in either age group. For older women, most (55.6%) of assailants were strangers. Most assailants of younger women were acquaintances (eg, date rape). Report of the assailant as a service provider (9.7%) was more common in the older women. The assailant’s racial distribution was similar in

Table 2 Sexual assault characteristics and physical injuries

Premenopausal Postmenopausal (n = 1610), n (%) (n = 72), n (%)

Type of sexual assault

Vaginal ? 1467 (91.1) 54 (75.0)

Oral 447 (27.8) 22 (30.6)

Anal 255 (15.8) 13 (18.1)

Digital ? 460 (28.6) 32 (44.4)

Foreign body 11 (0.7) 0 (0) Location of assault ?

Victim’s home 736 (45.7) 53 (73.6)

Assailant’s home 400 (24.8) 6 (8.3)

Vehicle 209 (13.0) 2 (2.8)

Outdoors 116 (7.2) 0 (0)

extended care facility 4 (0.3) 6 (8.3)

Other/combination 145 (9.0) 5 (7.0)

Ethnicity of assailant 742 (46.1) 37 (51.4) (% white)

Multiple assailants ? 206 (12.8) 2 (2.8)

Relationship to victim ?

Stranger 516 (32.0) 40 (55.6)

known assailant 1094 (68.0) 32 (44.4)

Acquaintance/date 929 (57.7) 15 (20.8)

Previous boyfriend/ 102 (6.4) 4 (5.5) spouse

Current spouse/partner 36 (2.2) 3 (4.2)

Relative 16 (1.0) 2 (2.8)

Employer/authority 9 (0.6) 1 (1.4) figure

Caregiver/service 2 (0.1) 7 (9.7) provider

type of coercion

Verbal threats 881 (54.7) 35 (48.6)

Physical force ? 577 (35.8) 52 (72.2)

restraint used 430 (26.7) 11 (15.3)

Victim sleeping/drugged 274 (17.0) 4 (5.6)

Use of weapons 311 (19.3) 9 (12.5)

Prevalence of 701 (43.5) 44 (61.1) nongenital trauma ?

Non-genital injuries, 1.2 +- 0.9 2.3 +- 1.3 mean (SD) ?

Prevalence of 1014 (62.9) 61 (84.7) anogenital trauma ?

Anogenital injuries, 1.8 +- 1.1 2.5 +- 1.5 mean (SD) ?

* Indicates significance at the P b .01 level.

both groups; 51.4% of the attackers in the postmenopausal group were white and 46.1% of the attackers in the younger group were white. Many of the victims had difficulty estimating the assailant’s age, so this variable was not included in Table 2.

Postmenopausal victims were more likely to be assaulted by a single assailant, typically a stranger (55.6% vs 32%, P b .001), in their own home (73.6% vs 45.7%, P b .001). The type of coercion was found to be related to the victim’s age. Less physical force was reported by young women (35.8% vs 72.2%, P b .001). These younger women subsequently had fewer nongenital injuries (mean injuries, 1.2 vs 2.3; P b .001). There were a total of 2098 nongenital injuries recorded including contusions (57%), abrasions (37%), lacerations (5%), and fractures (1%). Intracranial injury was uncommon but twice as prevalent in older women (4.2%) compared to younger victims (1.8%).

A total of 3078 anogenital injuries were documented in the study population; the overall prevalence was 63.9%. Three hundred twenty (19.0%) had single and 801 (47.6%) had multiple sites of trauma. Fig. 1 summarizes the location and frequency of injury for the 1075 victims with anogenital injuries. Although younger victims had fewer anogenital injuries, the patterns of injuries were similar in both cohorts (P = .06). Most genital injuries (80%) occur at

1 of 3 anatomical sites as follows: labia minora, fossa navicularis, and posterior fourchette. Ethnicity, alcohol, or drug use by the victim, multiple assailants, time interval to examination, and a history of sexual assault were not associated with the number of anogenital injuries noted on examination.

Significant signs of injury were defined as abrasion, bruising, tissue edema, erythema, and tears or lacerations (Fig. 2). The most common injuries in postmenopausal women were lacerations, typically noted at the fossa navicularis and posterior fourchette. Abrasions commonly were noted on the labia minora and fourchette. In younger

Fig. 1 Location of injury in postmenopausal (n = 61) and premenopausal victims (n = 1014) with anogenital trauma.

Fig. 2 Types of genital trauma documented in sexual assault victims.

women, erythema was the most common injury, typically noted on the labia and fossa navicularis. However, these differences in the types of injuries were not statistically significant between the 2 age groups (P = .51).

Discussion

In this 5-year community-based study of women present- ing to local EDs or sexual assault clinics, approximately 3.8% of the victims were 50 years or older. Other major US studies of sexual assault reveal similar figures for age distribution of victims. Eckert et al [4] reported a sexual assault frequency of 4% in women older than 55 years, whereas Muram [14] found a 3% incidence in the same age group. This age group is vulnerable for sexual assault because of declining health and strength, housing conditions, financial limitations, limited sensory capacity, cognitive impairments, dependence on caregivers, and increased burdens on family members [15]. These increased risk factors also present unique challenges for older survivors of sexual assault, family members, social workers, and medical professionals.

Cartwright and Moore [16] performed a 2-year retro- spective review of rape victims treated in one Nashville ED. They found that in 1 year, 21 (4%) of 493 patients were older than 60 years. However, they found no older women among the 247 victims treated in the following year. To explain this yearly variance, they suggested that rapes in the community were of a serial nature and involved relatively few rapists.

The present study took place in 3 counties in West Central Michigan comparing rape injuries sustained by older and younger sexual assault victims. We found that a most older women (ie, >=50 years) sustained physical injury from their assault compared with their younger counterparts (ie, ages 20-40). Most assailants were complete strangers to the victims, and most assaults occurred in the women’s homes. This finding was in contrast to the younger victims

in the study, for whom most assailants were known to them and most assaults occurred outside the women’s homes. Overall, these demographics and assault characteristics are very similar to postmenopausal victims treated at a Dallas ED [17] as well as a sexual assault resource center in Memphis, Tennessee [14].

Younger victims were more likely to report a previous sexual assault–50.8% of the younger women compared to 15.3% of the postmenopausal victims. Muram [14] con- cluded that this discrepancy may reflect a trend in today’s society where women are likely to become victims of sexual assault. However, since 1994, violent crime rates have declined each year, reaching the lowest level ever recorded in 2005 [18]. This difference may instead reflect cultural differences between the 2 groups of women. A 60-year-old woman, raised in the 1940s and 1950s, was exposed to different cultural norms, sexual education, dating patterns, and significantly less media attention than the 19-year-old woman raised in the 1990s. As a result, it is possible that women older than 50 years interpret the term sexual assault differently from younger women. It is then likely that some forms of sexual assault, such as child abuse and date rape, were perceived only by the younger women as representing previous assault, explaining the significant difference in the prevalence of previous Sexual assaults [18].

Younger women were also more likely to delay seeking care after sexual assault compared with older women and were less likely to report the assault to police. It has been hypothesized that older women experiencing the most severe assaults may present earlier for treatment than younger victims who have fewer injuries [19]. However, a recent study by Jones et al [20] found no differences in the extent of nongenital injuries or anogenital injuries between reporters and nonreporters or in those sexual assault victims who delayed seeking medical care. Their results suggested that the primary reasons for delays in seeking medical care after a sexual assault were (1) a known assailant and (2) a history of recent alcohol or drug use during the time of the assault. In our study, both of these demographic characteristics were clearly more evident in the younger cohort and likely contributed to the 6-hour delay in seeking medical treatment.

Our cohort of postmenopausal women had a greater number of anogenital injuries compared with younger women. Advances in clinical forensic medicine show that trained examiners using colposcopy obtain evidence of anogenital trauma in 58% to 87% of rape victims [3,7,11,19]. Although this is a significant improvement over protocols relying on gross visualization or Toluidine blue dye enhancement, little has been written about the extent, or types of anogenital injury seen in older women. Although some physical findings such as redness and swelling could be physiologic responses and/or due to unrelated conditions, Ramin et al [17] found that nearly 1 in 5 postmenopausal victims of sexual assault had perineal or vaginal lacerations. Surgical repair was required in 6 of

24 women with lacerations. According to Geist [21] in a review of sexually related trauma, most genital injuries occur in young children and older women. Postmenopausal victims may be more susceptible to genital trauma as a consequence of atrophy of connective tissue, loss of soft tissue elasticity, and atrophy of vaginal epithelium. Although our older subjects tended to have more anogenital lacerations and abrasions, the overall injury pattern was not statistically different (Figs. 12).

The most common sites of anogenital injury our population were the labia minora, fossa navicularis, and posterior fourchette (Fig. 1). This pattern is consistently reported in studies of sexual assault in adult women [3,4,7,11,14] and provides further evidence that the major cause of genital trauma seen in rape victims occurs as an entry injury, with insertion or attempts at insertion of the penis into the vagina, regardless of the victim age. Our study population did have more labial injuries than documented in other clinical studies. This difference is likely due to the consistent use of nuclear staining and colposcopy as a routine part of our forensic examination. Small lacerations to the external genitalia that might not be obvious on gross visual inspection are easily visualized after application of toluidine blue. McCauley et al [22] demonstrated that the use of toluidine increased the detection of genital lacerations in reported rape victims from 1 (4%) in 24 to 14 (58%) in 24.

Other investigators have concluded that injury in the rape of older women was likely due to higher levels of violence rather than simply because of the postmenopausal status of the genital anatomy. In 1978, Groth [23] first highlighted the exceptional violence of these assaults, causing serious injury or death, and concluded that the rape was the perpetrator’s means of expressing hostility and power, of inflicting pain and degradation. The comparison by Pollack [8] of men who had sexually assaulted older vs younger women also reported that “these individuals are not simply antisocial people with deviant sexual interests but that they evince more debilitating psychopathology.” More recent studies of sex offenders and their elderly victims had similar conclusions [6,24].

Physical force was documented more often in our postmenopausal victims compared to controls (72% vs 36%). This higher level of violence, usually inflicted by an unknown assailant who forcibly entered the victim’s home, might be the best explanation for the greater number of physical injuries noted in our population of older women. It is also important to recognize that less Serious injuries have more serious consequences in morbidity and mortality among older adult patients. Schwab and Kauder [25] report that outcome differences between older and younger trauma patients are most disparate at the lower end of the injury scale. Thus, it is seemingly inSignificant injuries that may need increased attention. Evidence of bruising to the perineum, pain with micturation, Vaginal bleeding, and discharge are all ominous signs [27]. In addition to physical

trauma, postmenopausal women who have been assaulted may also have major psychologic trauma, which is no different from younger women after assault. These victims may have posttraumatic stress disorder and rape-trauma syndrome for years after the assault [6,15,19,21].

Limitations

Several limitations are noted in this retrospective study, including the small number of postmenopausal women evaluated during the study period. Studies with larger samples of women, and in particular with more women older than the age of 65, are needed to identify injury prevalence after rape in the older population. During the years of data collection, at least 18 trained forensic nurse examiners evaluated victims of sexual assault. Although all had a similar level of training, differences certainly existed in their examination methods. Variability in examination technique and the data that were collected as part of a clinical rather than research protocol both introduce error. The findings of the examiners were recorded on state- mandated reporting forms and were taken as the most accurate representation of the actual physical findings. Finally, colposcopic photographs, although generally are reliable at showing acute trauma such as abrasions and lacerations, may not show the more subtle findings of erythema, ecchymosis, or swelling of tissues [26].

Almost 50% of all patients had been exposed to alcohol or other drugs during the time of assault. It is unknown what impact this might have had on the accuracy of the history or the degree of genital injuries. This study, like all studies of rape victims, is vulnerable to sample bias. Feldhaus et al [27] reported that fewer than half of rape victims reported the assault to the police or sought medical care. Because the data in this study are based on victims presenting for medical evaluation, they may not be completely generalizable to all cases of sexual assault. Therefore, it is possible that the proportion of rapes involving significant force and injuries may be overrepresentative.

Finally, as mentioned in the discussion, it is possible that women older than 50 years interpret the term sexual assault differently from younger women. It is then likely that older women with less injury, and those assaulted by intimate partners, may not have reported the rape at all. The resulting data would then be skewed–showing older victims to appear that they have more injury and were less likely to be raped by partners or former partners. However, we feel that useful conclusions can still be drawn on the basis of the differences between the 2 groups.

How we understand and respond to sexual assault of older women becomes increasingly important as the population of the United States continues to age. Existing social services for sexual assault victims are generally not designed to meet the needs of older adults and therefore

need to be investigated in ongoing research. These investigations will facilitate our understanding of the vulnerabilities, exposure patterns, and physical and emo- tional responses that are unique to older victims. Clear definitions of elder sexual assault and more precise data collection methods would provide a greater understanding of the scope of the problem. More important, however, emergency physicians and nurse examiners would benefit from new knowledge in caring for these victims, particu- larly focusing on prompt detection as well as the resources available for victims and their families.

Conclusions

Approximately 4% of the adult women referred to

3 sexual assault clinics in West Central Michigan were aged 50 years or older. These findings confirm and further elucidate that vulnerabilities and assault characteristics in this older population differ from those of younger women and that prevention and treatment strategies should be tailored to the specific population.

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