Table 2.

Classification systems used by investigators studying genital and non-genital injury prevalence following consensual sexual intercourse and sexual assault, 1990-2010

Authors	Country of Sample	Classification of Injury	Sample	Findings
Adams et al., 2001	USA	0: None; 1: Redness or swelling 2: Bruising or abrasion; 3: Tears Subset of injured victims 0: None; 1: Redness and/or swelling; 2: Bruising 3: Abrasion and/or tear	Females 14 to 19 years of age (N=214) who were sexually assaulted; 55% White, 9% African American, 8% Mexican American	36% of victims had no signs of injury; 25% injured at one site; 21% injured at 2 sites; 11% 3 sites; 5% injured at 4 or 5 sites
Ahnaimugen & Asuen, 1980	Nigeria	Lacerations Tears	Females 15 to 51 years of age following consensual sexual intercourse (N=15)	Ten females had single tears; five had multiple tears/lacerations
Anderson etal., 2008; 2009	USA	TEARS Pain	Healthy females 18 to 40 years of age within 48 hours after consensual sexual intercourse (N= 40); 31 White; African American 3; Asian 1; Pacific Islander 1; Hispanic 3; Other 1	No report of injury prevalence. Significant decrease in injury surface area and redness over time as injuries healed in the first 72 hours after sexual intercourse.
Anderson etal., 2006	USA	TEARS	Health females following consensual sexual intercourse (n=46; ages 21 to 45 years of age) and females after sexual assault (n=56; ages 16 to 54 years of age); 19 Black; 73 Caucasian; 6 Hispanic; 3 Asian; 1 unknown	30.4%of consensual participants (n=30) and 32.1% of nonconsensual participants (n=56) had injury present (n.s.)
Baker & Sommers, 2008	USA	TEARS	Females 14 to 29 years of age (N=234) who were sexually assaulted; African American 50%; White 49%; Other 1%	When considered as a group, adolescents were not more likely to sustain an injury than adults; mean number of genital injuries was 1.81
Baker et al., 2010	USA	TEARS	Females 14 to 29 years of age (N=234) who were sexually assaulted; African American 50%; White 49%; Other 1%	Overall injury prevalence was 62.8%. Race was significantly associated with frequency of injuries in several anatomical locations, with White/Caucasian participants having a higher frequency of injuries than Black/African American participants.
Beh, 1998	China	Bodily injury: Bleeding genital injury; vulval injury; recent hymenal injury	Females 4 to 66 years of age (N=350) who were sexually assaulted; 169 were sexually active; no race/ethnicity identified	Bleeding genital injury 12% Vulval injury 8% Recent hymenal injury 10% 35% showed signs of bodily injuries (likely defined as genital injury)
Biggs et al., 1998	Canada	Non-perforating soft tissue injuries (bruises, bites, redness, swelling) Lacerations (tears, cuts abrasions) Current bleeding (history or evident on exams; healed hymenal perforations) Locations: labia majora and minora, posterior fourchette and introitus, hymen, vagina, cervix, anus	Females 15 to 64 years of age (N=132); no race/ethnicity identified	Overall genital injury 45% with 65% in those with no previous sexual intercourse history and 26% in those previously sexually active
Bowyer & Dalton, 1997	Great Britain	Tears: perineal, hymeneal, posterior vaginal well Scratches, bruises, and grazes	Females 16 to 48 years of age who were sexually assaulted (N=83); no race/ethnicity identified	22 of 83 women had genital injuries; 68 of 83 had some form of physical injury but most injuries were minor
Drocton et al., 2008	USA	Injury and no injury	Females 12 years of age and older who were sexually assaulted (N=3,356); 39.6% White; 37.7% Hispanic; 16.6% African American; 8% Asian and other	49% sustained ano-genital injury; increased risk for injury occurred with penetration or attempted penetration using penis, finger, or object
Everett & Jimerson, 1977	USA	Genital: Minor lacerations or abrasions; major lacerations Nongenital: Abrasions and contusions; choke-related; lacerations; stab wounds; gunshot wounds	Females 2 to 71 years of age who were sexually assaulted (N=117); 70% White; 73% Black; 7% Indian	15 of 117 patients sustained serious physical injury and 60 of 117 sustained minor injury; 19% sustained minor genital lacerations or abrasions; 7% sustained major genital lacerations; 38% had minor non- genital abrasions or contusions, 2% had strangulation injury; 2% had non-genital lacerations
Fraser et al., 1999	Australia Dominican Republic Finland USA	Genital: Micro-ulcer, abrasion, petechial haemorrhage, sub- epithelial haemorrhage and swelling, erythema, oedema, epithelial tear	Healthy sexually active females 18 to 35 years of age undergoing a gynecologic examination (N=107); no race/ethnicity identified	In 107 sexually active women with a total of 314 inspections, 56 injuries were found, most commonly petechiae (n=13) and redness (n=4)
Goodyear-Smith, 1989	New Zealand	Injury: any type of bruising, inflammation, tenderness, abrasions, lacerations, or fractures Location: genital, anal, body (face, head, trunk, arms, legs)	Victims (91% female) 2 to 83 years of age (N=190) following sexual assault; 76% European; 8% Maori; 11% Pacific Islander; 4% other	19.5% of children and 40.5% of adults sustained genital injury; 9.0% of children and 64% of adults sustained body injury
Grossin et al., 2003	France	Genital lesions: tears, abrasions General body trauma: bruises, scratches, abrasions, cuts, bites	Victims (86% female) 1.5 to 79 years of age (N=418) following sexual assault; no race/ethnicity identified	General body trauma was found in 39.1% examined within 72 hours of sexual assault and 6.3% examined after 72 hours; genital trauma was found in 35.7% examined within 72 hours of sexual assault and 19.5% examined after 72 hours
Helweg-Larsen, 1985	Denmark	No injuries Minor injuries Severe injuries	Victims of sexual assault 14 to 67 years of age (N=74); no race/ethnicity identified	Immediate reaction of the legal system to the offense (filing of charges) was related to injury but there was no relationship between the grade of the injury and the severity of the penalty
Hilden, 2004	Denmark	Genital: tears, ecchymoses, abrasions Non-genital injury: Slight, moderate, severe	Females 12 to 50 years of age (N=249) following sexual assault; no race/ethnicity identified	32% sustained genital injury; no association found between genital and non-genital injury
Hillman, 1991	Great Britain	Skin and mucosal damage	Males 16 to 43 years of age (N=28) following sexual assault; no race/ethnicity identified	57% reported skin or mucosal damage
Jones et al., 2009	USA	TEARS	1,917 records from sexual assault victims; 84% 18-49 years; 4% ≥ 50 years 74% of younger group and 79% of older group were White	Postmenopausal victims had a greater mean number of non- genital (2.3 versus 1.2, p<.001) and genital injuries (2.5 versus 1.8, p<.001)
Jones et al., 2003	USA	Abrasion Ecchymosis Edema Erythema Tears/Laceration	766 records of female sexual assault victims; 42% 13-17 years; 53% ≥ 18 years; 75% of younger group and 74% of older group were White	Adolescents (13-17 years of age) were more likely to be injured than older (>17-82) females (83% versus 64%)
Jones & Worthington, 2009	USA	Grade I: Isolated genital laceration below hymen Grade II: Isolated genital laceration including hymen Grade III: Isolated genital laceration including vagina Grade IV: Grades II or III injury plus partial tear of anorectum Grade V: Grade III injury plus complete tear of anorectum	44 girls under 21 years of age with genital injuries requiring surgical repair; 11 had been sexually assaulted	Injuries of 9 of 11 of sexually assaulted girls (82%) involved hymen, vagina, anus, or rectum and had average severity scores of 2.1
Lenahan et al., 1998	USA	Ecchymosis Abrasions Lacerations	Females 15 years if age or older (N=17) following sexual assault;	53% had genital trauma ;76% had evidence of extra-genital trauma
Light et al., 2009	USA	Physical injury or no physical injury	Males 18 years of age and older from the Violence and Threats of Violence Against Women and Men in the United States Survey (N=219) following sexual assault; 80% White; 10% African American/Black, 10% other	11% reported physical injury
Maguire et al., 2009	Ireland	Bruises Abrasions Lacerations Burns Stab wounds Redness and swelling were excluded	Sexual assault victims ages 13 to 74 (N=164); no race/ethnicity identified; two victims refused examination	Injury was detected in 80%; 99 of 162 had body injury and 60 of 162 had genital injury
Manser, 1992	Great Britain	Injured or not injured Anal abrasion, laceration, bruising, redness, scarring, edema	Sexual assault victims (N=153); no race/ethnicity identified	74% sustained injuries
McCauley etal., 1987	USA	Lacerations visualized with and without toluidine blue contrast	Females ages of 19 and older (N=24) following sexual assault; 20 African American/Black; 4 White	Detection of injury increased from 1 in 24 to 14 in 24 with toluidine blue application; hypervascularity as a was considered a non-injury finding
Olusanya et al., 1986	Nigeria	Bruising Laceration Tear Contusion	Sexual assault victims ages 2 to 33 years of age (N=330); no race/ethnicity identified	44.7% of the children and 16.4% of the adults had genital injury; 9.4% of the children and 22.8% of the adults had non-genital injury
Palmer et al., 2004	Australia	Non-genital (bruises, abrasions, lacerations, and fractures) classified as minor; moderate; severe Genital (abrasions, bruises, lacerations, other) classified as minor, moderate; severe	Sexual assault victims 14 to 73 years of age (N=153); no race/ethnicity identified	Genital injuries occurred in 22%; non-genital injuries occurred in 46%; women 40+ had 3.1 times the odds of non-genital injury and 5.6 times the odds of genital injury compared to those 14-19 years of age
Ramin et al., 1990	USA	Genital trauma: abrasions/edema, hematomas, lacerations Extra-genital trauma: hematoma/ecchymosis, scratches, lacerations	Cases from a sexual assault registry included 129 females 50 years of age and older and were compared to 129 females 14 to 49 years of age; older group was 32% African American/Black, 64% White, 4% other; younger group was 53% African American/Black, 38% White, 9% other	In postmenopausal women, 32% had abrasions, 3% hematoma, and 19% lacerations; in the under-50 females, 16% had abrasions, 2% hematomas, and 5% lacerations
Riggs et al., 2000	USA	General body trauma: Lacerations, abrasions, contusions Genital trauma (no classification)	Female and male (n=41) sexual assault victims (N=1,076) ages 1 to 85 years of age; 26.1% were younger than 18 years of age; no race/ethnicity identified	Overall general body trauma was 67% (extremities were most common followed by head and neck); genital trauma was 53%; 20% had no trauma
Sachs & Chu, 2002	USA	Abrasions Tears Ecchymosis Redness and swelling were excluded	Females less than 15 years of age to 40 and older (N=209); Injured: 67 African American, 55 other, 46 White; No injury: 11 African American, 14 other, 15 White	169 with injury, 40 without injury; white women were more likely to sustain injuries than African American women; an increased likelihood for females less than 15 years of age to have injury
Sau et al., 1993	India	Vaginal bleeding Introital injury Lower vaginal injury	Admission to hospital for non-obstetric injuries (N=31); no race/ethnicity identified	Injury to vaginal vault most common consensual injuries; despite need for blood transfusions and surgery for some women, authors did not attribute any injury to sexual assault
Sill, 1987	Papau New Guinea	Laceration Hematoma Tear	Females (N=25) admitted to hospital for non-obstetric injuries	Females (n=13) following consensual sexual intercourse had lacerations to the posterior fornix; 3 of 5 females injured after rape were children
Slaughter et al., 1992	USA	Lacerations Abrasions Ecchymosis Swelling Hymenal tears Microabrasions with use of a colposcope	Females 13 to 85 years of age (N=131) following sexual assault; 113 White, 5 Black, 11 Hispanic, 2 Asian	114 of the 131 had positive injury findings with colposcope examination
Slaughter et al., 1997	USA	TEARS	Females 11 to 85 years of age (n=311) after sexual assault and healthy women (n=75); of women who were injured (n=213): 189 White, 6 Black, 17 Hispanic, 1 Asian	After sexual assault, 213 had genital trauma; 162 had 3.1 mean sites of injury; after consensual intercourse, 11% had injury all occurring at a single site
Sommers et al., 2008; 2009	USA	TEARS	Females after consensual sexual intercourse ages 21 to 68 years of age (N=120); 50% White or other, 50% African American	55% had at least one ano-genital injury; while Black and White participants had significantly different genital injury prevalence (43% and 68% respectively), dark skin color rather than race was a strong predictor for decreased injury prevalence.
Sommers et al., 2006	USA	TEARS	Females after sexual assault 14 to 76+ years of age (N=120); 50% White or other, 50% African American	Significant association between race/ethnicity (White and Black) and genital injury indicating that Whites were more than four times as likely as Blacks to have genital injury
Sturgiss et al., 2010	Australia	Abrasions Lacerations Redness Tenderness	Of 826 cases of sexual assault, 20 (19 females and 1 male) had penetration with foreign object; no race/ethnicity given	Foreign object assaults may be more violent with multiple assailants than other assaults; 75% of victims had genital injury and 91% of victims had non- genital injury
Sugar et al., 2004	USA	Bruise/abrasion Laceration Radiologically defined fracture or intracranial injury Visible tissue injury Not counted as trauma: genital erythema, tenderness, or pain without visible tissue injury because were considered “subjective”	Female sexual assault victims 15 to 87 years of age (N=819); 63.4% White, 20.5% African American, 4.9% Hispanic; 8.2 other	General body injury occurred in 52%; anal or genital injury occurred in 20%; attempted strangulation occurred in 99 out of 677. Females 15 to 19 years of age had more than twice the genital injuries as women 20 to 49; females over 49 had three times the genital injuries as women 20 to 49 years of age
Teixeira, 1981	Brazil	Incomplete or complete rupture of hymen	Female sexual assault victims 4 to 51 years of age (N=500); 78.2% White; 14.6% Tawny; 5.4% Black; .8% Yellow; 1% other	11.8% of the cases showed additional trauma when using colposcopy as compared to standard visual inspection
White & McLean, 2006	Great Britain	Laceration Abrasion Bruise Burn Subjectively reported or potentially normal physiological features were excluded: reddening (erythema), swelling, tenderness	Sexual assault victims 12 to 17 years of age (N=224); 90.2% White, 10.8% Non-White	32% of non-virgin group had genital injury; 53% in the virgin group had genital injury; 51% of both groups had non-genital injury
Zink et al., 2010	USA	TEARS	Females after consensual sexual intercourse ages 21 to 68 years of age(N=120); 50% White or other, 50% African American	55% had at least one genital injury; direct visualization and colposcopy yielded similar genital injury findings; more tears were identified with toluidine blue than with direct visual inspection or colposcopy

USA: United States of America; TEARS: tears, ecchymoses, abrasions, redness, swelling