Health disparities in the forensic sexual assault examination related to skin color

Abstract

Little is known about the role of skin color in the forensic sexual assault examination. The purpose of this study was to determine whether anogenital injury prevalence and frequency vary by skin color in women after consensual sexual intercourse. The sample consisted of 120 healthy (63 Black, 57 White) women who underwent a forensic sexual assault examination following consensual sexual intercourse. Experienced sexual assault forensic examiners using visual inspection, colposcopy technique with digital imaging, and toluidine blue application documented the number, type, and location of anogenital injuries. Although 55% of the total sample was observed to have at least one anogenital injury of any type following consensual intercourse, the percentages significantly differed for White (68%) and Black (43%) participants (p 0.02). When the presence of anogenital injury was analyzed by specific anatomical region, a significant difference between White and Black participants was only evident for the external genitalia (White = 56%, Black = 24%, p = .003), but not for the internal genitalia (White = 28%, Black = 19%, p = .20) or anus (White = 9%, Black = 10%, p = 0.99). A one standard deviation-unit increase in L* values (lightness) was related to a 150% to 250% increase in the odds of external genitalia injury prevalence (p < 0.001). While Black and White participants had a significantly different genital injury prevalence, dark skin color rather than race was a strong predictor for decreased injury prevalence. Sexual assault forensic examiners, therefore, may not be able to detect injury in women with dark skin as readily as women with light skin, leading to health disparities for women with dark skin.

Making Sense of Skin Color in Clinical Care

“…Investigators describe differences in injury patterns, types, severity, and number between people of different races and/or ethnicities with respect to sexual assault, childbirth-related injury, pressure ulcer formation, and healing (Baumgarten et al, 2004; Fogerty et al, 2008; Saladin & Krause, 2009; Sommers, 2007; Sommers et al, 2008). For example, in a population of women studied after consensual sexual intercourse, Sommers et al found that not only was injury prevalence significantly higher in White as compared with Black/African American women, but the effect of race/ethnicity became nonsignificant after adding skin color values to the model predicting occurrence of genital injury (Sommers et al, 2008, 2009). These findings indicated the spurious nature of the relationship between race/ethnicity and injury prevalence and demonstrated that skin color rather than race/ethnicity is likely the important variable in injury prevalence.…”

“…Clinicians and researchers have published findings relating the importance of skin color in health care. These include differences in the potential for injury when faced with forces associated with trauma (soft tissue injury), friction/shearing (pressure ulcers), and stretching (childbirth; Howard, Davies, DeLancey, & Small, 2000; Robinson, Norwitz, Cohen, McElrath, & Lieberman, 1999; Saladin & Krause, 2009; Sommers et al, 2009). Accurate evaluation of skin color is important in both clinical and research settings (Bennett, 1995; Berardesca, Derigal, Leveque, & Maibach, 1991; Ha et al, 2009; Lindholm et al, 2008).…”

Sexual Assault: Disparities Within Health Care and the Criminal Justice System for Minority Women

“…Even with higher reports of sexual assault, African American women are less likely to report being sexually assaulted and received less support than White women (Tillman et al, 2010).…”

“…Many of the differences have been attributed to cultural norms, help-seeking behaviors, and availability of accessible services (Cuevas & Sabina, 2010;Tillman, Bryant-Davis, Smith, & Marks, 2010). Ethnic minority victims report more undesired social reactions from others than do White victims (Ullman & Filipas, 2001).…”

Strangulation Forensic Examination

“…Petechiae may also be present on the skin on the victim's neck, head, face, forehead, around eyes and ears, conjunctivae, and buccal mucosa (Clarot et al, 2005;Dix & Calaluce, 1998;. Physical findings on the skin may be more difficult to identify in patients with darker skin; one study found that it was more difficult to find anogenital injuries in patients with darker skin than in those with lighter skin when they were examined after consensual intercourse (Sommers et al, 2009). This is an area for further research as far as its application to strangulation injuries.…”