sommers rev oct 19 ppt

Pathway to Discovery: Building on Unexpected Findings: 

Pathway to Discovery: Building on Unexpected Findings Sensitivity of the Colposcopy Exam after Sexual Assault…… and beyond…… Marilyn S. Sommers, PhD, RN, FAAN Associate Dean and Professor, University of Cincinnati, Cincinnati, OH Visiting Professor, School of Nursing, University of Pennsylvania, Philadelphia, PA

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Sensitivity of the Colposcopy Exam after Sexual Assault Funding: National Institute of Nursing Research, R01 NR05352 Role: Principal Investigator Research Team: Therese Zink, MD, Olmsted Med Center, Rochester, MN; Family Medicine, Colposcopy Technique John Schafer, PhD, University of Cincinnati Statistical Agreement, Intimate Partner Violence Jamison Fargo, PhD, Utah State Data Base Management and Analysis Donna Shambley-Ebron, PhD, RN University of Cincinnati, Africana culture and health disparities Rachel Beekman Baker, RN, MSW Doctoral Student and Pre-Doctoral Fellow Genital Injuries in Adolescents after Sexual Assault, F31NR009727, NINR

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Sensitivity of the Colposcopy Exam after Sexual Assault Background ● Estimated 6.8 million rapes and physical assaults in the U.S. each year; 2.6 million rapes and physical assaults will result in an injury to the woman; almost 800,000 will result in the survivor receiving some type of health care ● Most sexual assault survivors receive health care interventions during a sexual assault examination in a clinic or emergency department

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Sensitivity of the Colposcopy Exam after Sexual Assault Background ● Genital injury prevalence generally approaches 90% after sexual assault ● Number, type, location, and severity of genital injury can enhance the government’s case in allegations of sexual assault and allow the jury or judge to make an informed decision. ● Presence and moderate severity of injury is positively associated with conviction for sexual assault

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Sensitivity of the Colposcopy Exam after Sexual Assault Significance: The intent of a forensic examination after reported sexual assault is two-fold: to determine the extent of injury and to collect evidence for prosecution. Healthcare significance: Physical injuries need assessment and treatment Of the estimated 6.8 million rapes and physical assaults in the U.S. each year, 2.6 million will result in an injury to the woman and almost 800,000 will result in the survivor receiving some type of health care (Tjaden andamp; Thoennes, 1998). Legal and judicial significance: Evidence needs to be collected Little is known about the role of colposcopy in the forensic testimony during adult female rape cases; both genital and non-genital injury is significantly associated with successful prosecution (Pentillila andamp; Karhumen, 1990; Rambow et al., 1992)

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Sensitivity of the Colposcopy Exam after Sexual Assault Specific Aim: To determine the sensitivity and specificity of the forensic examination with colposcopy to predict consensual versus non-consensual sex Can experts differentiate between colposcopic photos of two groups of women: those who have experienced consensual vs. non-consensual sex? When viewed as colposcopic photos, what is the difference in number, type and location of injury to the female genitalia and/or anus after consensual versus non-consensual sex? What are the differences in the sensitivity and specificity of colposcopic photos in detecting injury to the female genitalia and/or anus in African-American/Black and Caucasian/White women?

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Sensitivity of the Colposcopy Exam after Sexual Assault Specific Aim: To determine the sensitivity and specificity of the forensic examination with colposcopy to predict consensual versus non-consensual sex Theoretical Framework: Human sexual response as described by Masters and Johnson (1966, 1970); the physiologic dynamics that constitute consensual female sexual behavior provide a framework to explain local or microscopic tissue injury during non-consensual sex. The female response to the sexual cycle is comprised of four phases, including excitement, plateau, orgasm, and resolution; lack of progression through these phases during forced sex leads to injury.

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Colposcope is an instrument for magnified visual inspection of anogenital structures. It has a binocular system and an internal light source and allows for examination of internal and external structures; camera captures digital images of injury Target Population: Community volunteers, women 21 and older Exclusions: Pregnancy, sexually transmitted illnesses, surgical procedures

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Sensitivity of the Colposcopy Exam after Sexual Assault: Methods ▪ Prospective enrollment of control subjects who will undergo an exam including visual inspection, colposcopy, and toluidine blue contrast following consensual sex. Subjects are recruited to fill cells with age and time between consensual sex and exam based on retrospective review of records of 587 sexual assault survivors from our Sexual Assault Registry

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Sensitivity of the Colposcopy Exam after Sexual Assault: Methods ▪ 100 control participants will be enrolled. 200 participants will comprise sample, 100 in survivor group (non-consensual) and 100 in consensual control. We have sufficient power (80%) to detect a difference in proportions between 95% and 83%. For the condition in which we divide the sample by ethnicity yielding our smallest groups of 50 each, we will have sufficient power (80%) for detecting a difference between the areas under Receiver Operating Characteristic (ROC) curves of 0.08 NOTE: Ultimately we enrolled 120 participants

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Sensitivity of the Colposcopy Exam after Sexual Assault: Methods ▪ Chart records and colposcopic photos of sexual assault survivors will be reviewed retrospectively and matched to control subjects by ethnicity, age, and time from assault to exam. ▪ A panel of five gynecologic and forensic experts will attempt to differentiate between the photographs of women with consensual (n=100) and non-consensual (n=100) sex.

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Sensitivity of the Colposcopy Exam after Sexual Assault: ▪ Primary response variables: Frequency, type and location of injury to the female genitalia and/or anus after consensual versus non-consensual sex. TEARS classification: Tears, Ecchymosis, Abrasions, Redness, Swelling (Slaughter et al., 1997) ▪ Explanatory variables: length of encounter, nature of encounter, partner size, degree of lubrication, pariety, smoking history, age, race/ethnicity

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Findings to Date ● 253 women screened, 132 women met inclusion criteria and were enrolled ● Characteristics of sample were selected based on race/ethnic identification, age, and time between sex and examination; matched characteristics of total sample of women from sexual assault registry ● 132 women were enrolled, 4 did not return for exam; data from 8 were excluded from analysis due to serving as pilot participants (n = 2), pregnancy (n = 3), or other complications (n = 3); final sample of 120 women examined following consensual sexual intercourse

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Findings to Date ● 46% were White, 50% were Black, and 2% were classified as Other ● Mean age was 32.5 years (SD = 9.0, Min = 21.1, Max = 68.0 years). ● 55% were single, 43% were married, and 2% were in other types of relationships ● 81% indicated that they engaged in sexual intercourse at a frequency of at least once per week and 19% indicated a frequency of less than once per week but at least once per month

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Findings to Date ● 11% of sample indicated that they had been sexually assaulted, but none had been sexually assaulted in the last 6 months ● Mean time between intercourse and examination was 8.23 hours (SD = 6.33, Min = 1, Max = 23 hours) ● Proportion of White participants who reported being married (58%) was significantly larger than the proportion of the non-White participants (42%) (p = .05) ● Level of self-reported lubrication during intercourse and duration of penetration in minutes were both higher among non-White (respectively, M = 7.5, SD = 2.3 and M = 19.1, SD = 16.6) as compared to White participants (respectively, M = 5.9, SD = 2.2 and M = 12.9, SD = 8.5) (p andlt; .05 for both analyses)

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Injury prevalence in women following sexual assault

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Considerations related to findings New theoretical framework Help from consultants (Brian Barford, David Sullivan) New measurement strategies Rethinking methods and long term plans Consideration of racial/ethnic differences in injury prevalence

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Where do we go from here? Conclusions and Future Directions ▪ Rates of injury after consensual sex are higher than anticipated (literature and pilot work indicated rates of 10%) ▪ We have found ethnic/racial differences in a retrospective sample of older women from data in the sexual assault registry (In Press, JOGNN)

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Conclusions and Future Directions Small Business Innovative Research (SBIR) Award submission to NIH; testing several innovative techniques to detect injury across the continuum of skin tones; ($100,000) David Sullivan, PI. M.S. Sommers, Co-PI Reducing Health Disparities in the Sexual Assault Exam using Fluorescence Imaging

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Conclusions and Future Directions Competitive continuation July 1, 2005 to NINR Injury from sexual assault: Addressing health disparity (R01 NR05352-04; $2,058,984)