ORIGINAL ARTICLES
Vaginocervical Cytology in Victims of Sexual Assault Michael J. Costa, M.D., Talaat Tadros, M.D., Eva Tackett, and Zuher Naib, M.D., F.1.A.C.
To investigate the role of vaginocervical smears in alleged victims of rape, we reviewed thejndings in 4,220 consecutive rape victims between the years 1982 and 1989. These rape victims showed a slight increase in cellular abnormalities (1.18% vs. .93%) when compared to a group of 17,187 routine smears from an indigent population in 1989. While the differences in the spectrum of cellular abnormalities were not statistically signi$cant, the increase in abnormal smears is remarkable because of the younger age distribution and lower risk factors for cervical cancer in this group of rape victims (41 % of the victims were never seen at our institution before their evaluation for alleged rape and were most probably of higher socioeconomic status and at lower risk for cervical cancer than the indigent population served at our hospital). Thisfinding may reflect the low incidence of vaginocervical cytology screening among the general population of which rape victims are a random sample. Fgty-seven percent of the rape victims with cellular abnormalities who were also regular patients at our hospital returned for follow-up by appropriate repeat smears or biopsies. This was lower than the 95% general follow-up rate of vaginocervicalsmear abnormalities among the rest of the population screened at our hospital. We detected spermatozoa in 56% of the smears from victims who were examined within three days of the alleged sexual assault. Cytology adds to the criminal investigation of rape cases as we detected spermatozoa in four of 16 semen-negative cases from a random sample of 53 cases evaluated by the state crime lab. Diagn Cytopathol 1991;7:337-340. Key Words: Rape victim; Vaginocervical cytology; Dysplasia;
Invasive cancer; Spermatozoa detection In the criminal investigation of alleged rape, statements by victim are frequently the only direct evidence that the crime has occurred.' It is reported that only 20%2 to 45% of raped women suffer physical evidence of bodily harm. For these reasons, medical proof of recent coitus is often an essential part of the investigation of rape cases. The examining physician routinely obtains specialized foReceived June 7, 1990. Accepted September 5 , 1990. From the Department of Pathology, Grady Memorial Hospital and Emory University, Atlanta, GA. Address reprint requests to Michael J. Costa, M.D., Anatomic Pathology, Grady Memorial Hospital, 80 Butler Street, S.E., Atlanta, G A 30335-3801. (cj
1991 WILEY-LISS. INC
M.T.,
A.S.C.P.,
rensic specimens such as vaginal and cervical smears (for acid phosphatase determination, p30 detection, direct examination for spermatozoa, and blood group antigens) and pubic hair brushings. 3,4 In addition, a pelvic examination and a vaginocervical cytology smear (Pap smear) have become part of the accepted practice in our and other institutions. The presence of spermatozoa in alcohol fixed vaginocervical smears produces permanent evidence of recent coitus. 5-7 Screening for epithelial abnormalities provides an opportunity for detecting cervical cancer or its precursors. The purpose of this study is to examine the value of such routine vaginocervical cytologic screening of the alleged rape victims in a busy city/county hospital which handles most of the rape cases of a large metropolis. Currently, our lab expends a large effort to detect spermatozoa in these cases. We wanted to investigate if the cytology lab contributes significantly to the criminal investigation of any cases by detecting spermatozoa when the forensic specimens do not detect semen.
Methods In Atlanta, Georgia, all alleged victims of rape who report to the police within three days are taken to the emergency room of Grady Memorial Hospital. Forensic specimens for semen identification such as vaginal and cervical smears and pubic hair brushings are taken but processed by the state crime lab only when a suspect is identified. A specialized spermatozoa stain (Kernechtrot solution followed by picroindigocarmine) for air-dried vaginal and cervical smears is the first screening test. Only when spermatozoa are not identified morphologically are an acid phosphatase and p304 determination are performed. If semen is identified, the crime lab may then perform more specific determinations such as blood group antigen detection or send the specimen out for the most recent DNA fingerprinting techniques. * A direct vaginal wet prep for the detection of live spermatozoa, pelvic examination, and a vaginocervical cytology smear are also the examining physician's duties. The Diagnostic Cytopathology, Vol 7, No 4
337
COSTA ET AL.
requisition form indicates to the cytology lab by a special code that the smear was taken from an alleged rape victim. The specimen is processed and screened in the same fashion as all routine vaginocervical smears but in addition the presence or absence of spermatozoa is noted.’ We reviewed the findings of all the vaginocervical smears obtained from alleged victims of sexual assault evaluated at Grady Memorial Hospital between the years 1982 and 1989. Using computer assistance, we recorded the number of the cases which showed the presence of spermatozoa and/or cellular abnormalities. Abnormal vaginocervical smears were reported as atypia (inflammatory), mild, moderate, and severe dysplasia, carcinoma in situ, and invasive cancer. This classification system correlates closely to the current proposed Bethesda System for reporting vaginocervical cytology diagnoses. lo We compared the incidence of abnormalities in these smears to the consecutive smears from routine patients seen in our cytology lab between July and December 1989. We excluded all smears originating from the dysplasia and gynecology tumor clinics because these are repeat follow-up smears from patients with known abnormalities and not routine screening. We reviewed the state crime lab findings for semen detection in 130 random victims (with suspects) between the years 1986-1988. Fifty-three of these victims had vaginocervical cytology findings for smears obtained at the same time at our institution. We compared results of the crime lab evaluation for semen to our ability to detect spermatozoa on vaginocervical cytology. The proportion of victims who were previous patients of Grady Memorial Hospital or its clinics was determined by a review of a random sample of 100 laboratory computer files of the rape victims. The laboratory computer files on a random sample of 150 victims with cellular abnormalities were reviewed to investigate the follow-up rate of these patients. At our institution all patients who have dysplasia on a vaginocervical smear undergo a colposcopic-directed biopsy. The patients with inflammatory atypia are given a repeat smear. Two consecutive atypias leads to colposcopic exam. The follow-up rate of our regular patients through our dysplasia clinic is 95%. We used the chi-square statistics to test for differences between vaginocervical cytology results in rape victims and routine patients. A probability of less than 0.05 was considered statistically significant.
’
Results In 4,220 vaginocervical smears from victims of alleged rape seen in our cytology lab between the years 1982 and 1989, spermatozoa were detected in 2,372 or 56% of cases. The state crime lab showed semen in 63% of the random sample of 130 victims (with suspects). A comparison of semen detection by the crime lab to spermatozoa detected 338
Diagnostic Cytopathology, Vol 7, No 4
on vaginocervical cytology obtained at the same time in 53 of these cases is seen in Table I. In four cases spermatozoa were detected only by the cytology lab and in six cases semen was detected only by the crime lab. The combination of cytology and specialized crime lab evaluation increased the sensitivity for semen detection from 70% to 77% in these 53 cases. Table I1 compares the abnormalities found in the smears of 4,220 alleged rape victims to 17,187 routine vaginocervical smears screened in 1989. The age distribution of the rape victims was slightly younger than the routine patients (Fig. 1). The number of severe dysplasia/ carcinoma in situ and moderate dysplasia were slightly higher (Fig. 2), but with no statistical significance ( P > 0.1, P < 0.1 respectively). Invasive cancer was found slightly more commonly in the general population, but again the difference was not statistically significant. The incidence of atypia and mild dysplasia on smears was almost identical (Fig. 3). We found that 59% of the victims overall and 52% of those with cellular abnormalities were previous patients of Table I. Semen Detection by State Crime Lab vs. Spermatozoa Detection by Vaginocervical Cytology in 53 Alleged Rape Victims in Which a Suspect Was Identified Result Cytology
State crime
lab
lab
No.
+ -
= Positive for semen or spermatozoa detection. = Negative for semen or spermatozoa detection.
Table 11. Vaginocervical Cytology Findings for 4,220 Victims of Rape From Years 1982-1989 vs. Routine Smears for the General Population General population
Rape victims Diagnosis
Negative Atypia and mild dys. Mod. dys. Sev. dys. and CIS Invasive cancer Unsat Other Total
No.
(%I
No.
(%)
3,411 720 35 11 4 39 0 4,220
(80.8) (17.0) (33) (.26) (.09) (.92) (0) (100)
13,942 2,956 98 38 24 126 3 17,187
(81.1) (17.2) (.57) (.22) (. 14) (.73) (.01) (100)
Dys. = dysplasia, Mod. = moderate, Sev. = severe, CIS = squamous carcinoma in situ, Unsat = smear unsatisfactory for cytologic evaluation. Cancer includes all invasive cancers including adenocarcinomas and carcinosarcomas. Other includes radiation dysplasia and endometrial hyperplasia. The general population includes all smears interpreted by the cytology lab for July-December 1989 excluding smears obtained in dysplasia and tumor clinic.
VAGINOCERVICAL CYTOLOGY IN SEXUAL ASSAULT VICTIMS PERCENT OF PATIENTS 60
50
=
-’
TYPE OF PATIENTS
.RAPE VICTIMS
0-ROUTINE PATIENTS
~
40 30 20 10 0-
20-29
40+
30-39
]l
AGE
I
,
PATIENT GROUP
=
.RAPE VICTIMS
0-ROUTINE PATIENTS
I
0
Fig. 1. Age distribution of 4,220 alleged rape victims who received vaginocervical cytology between 1982 and 1989 as compared to routine patients from 1989.
1
TYPE OF PATIENT .RAPE VICTIMS .ROUTINE PATIENTS
iI
SEV DYS/CIS
INVASIVE CANCER
o
c
m i
h 0
0.2
0.4
0.8
0.8
1
PERCENT OF PATIENTS Fig. 2. Serious abnormalities found in vaginocervical smears of 4,220 alleged rape victims between 1982 and 1989 as compared to 17,187 vaginocervical smears from routine patients in 1989. MOD DYS = moderate dysplasia; SEV DYS = severe dysplasia; CIS = carcinoma in situ. Invasive cancer includes one adenocarcinoma and one carcinosarcoma. All other invasive cancers were squamous carcinomas.
Grady Memorial Hospital or its clinics. Fifty-five percent of the victims with atypia (inflammatory) or mild dysplasia and 60% of the patients with high grade dysplasia or invasive cancer received appropriate follow-up in our hospital for their abnormalities. None of the victims who were not regular patients in our hospital before the alleged assault received follow-up care at our institution. They most probably went to a private care physician.
Discussion The identification of spermatozoa using vaginocervical smears has been previously studied using volunteers from screening clinics. 5,6 Silverman reported a maximal efficiency of 64% one day after coitus with declining efficiency to about 10% after ten days. Morrison reported
5 10 15 PERCENT OF PATIENTS
20
Fig. 3. Mild abnormalities found in VaginOCerViCal CYtOlogY Smears from 4,220 rape victims between 1982 and 1989 as compared to 17,187 vaginocervical Smears from routine patients in 1989. ATYPIA = inflammatory atypia; MILD DYS = mild dysplasia.
an overall efficiency of 58.4% with an optimum efficiency of 70% within two days of coitus. The identification of spermatozoa in cases of rape has been reported to be from 46%’* to 71%’ The one factor which is universally reported to adversely affect the detection of spermatozoa is the time interval between coitus and collection of the vaginocervical smear. Our observed value of 56% within three days of the alleged assault compares well with the detection rate of 55% among the 287 patients who reported coitus within the last three days in Silverman’s5 study and 58% among the 114 patients who reported coitus within the last seven days in Morrison’s6 study. Our ability to detect spermatozoa in rape victims approaches the reported efficiency in retrospective studies in volunteers. It also approaches the 63% detection rate for semen among rape victims with identified suspects we found by our random review of 130 determinations by the state crime lab. In the 53 cases where a direct comparison could be made, four cases showed spermatozoa in the vaginocervical smear in spite of the fact that the state crime lab could not demonstrate semen. When combined, the sensitivity for semen detection in these 53 cases was increased from 70% (using the state crime lab alone) to 77%. In addition, the police officials involved in rape cases related that on more than one occasion the forensic specimens have been misplaced. The permanent evidence of the presence of spermatozoa in fixed vaginocervical smear was the only physical evidence of recent coitus. These findings reaffirm the importance of the detection of spermatozoa in vaginocervical cytology for the criminal investigation of rape cases. Our detection rate of spermatozoa in vaginocervical smear is below the reported rate of semen detection (97% using acid phosphatase in the first 12 hr ’). Other authors report the sensitivity of acid phosphatase for semen to be Diagnostic Cytopathology, Vol 7, No 4
339
COSTA ET AL.
40% below the 60% detection rate for spermatozoa in their lab.2 The decay of quantitative acid phosphatase determination may correlate with the time passed since the coitus. ' , I 3 However, it goes below the baseline of vaginal acid phosphatase levels in less than 24 hr at which time spermatozoa are still usually detectable in vaginocervical smears. 5-7 The evaluation of blood type group ABO substance shows lower sensitivity for semen (16% in Dahlke et al.'s report 2, but greater specificity in determining blood types of possible suspects. Problems with aberrant group B reaction have been reported. l 4 The current modern technique (DNA fingerprint pattern of detected spermatozoa)8 is more specific for the evaluation of a particular suspect. These techniques add sensitivity in certain cases and some specificity over the morphologic detection of spermatozoa in vaginocervical smears. The slightly higher incidence of abnormal smears in rape victims as compared to a group of 17,187 routine cases from an indigent population screened in 1989 is not statistically significant. However, the indigent comparison group is not the same population as the rape victims because at least 41% of the rape victims are from a population of higher socioeconomic status with a lower incidence of cervical cancer and dysplasia. For this reason, the fact that the incidence of abnormalities is only slightly higher in rape patients speaks for a greater actual difference if the same population were used. A comparable increase of abnormalities in rape victims was reported by Seltzer et al. l 5 These findings become clinically more significant when we consider that rape victims are slightly younger (Fig. 1) and may never have had a chance for screening until it was too late (four cases of invasive cancer were identified, Table 11). Having a Pap smear presupposes that the patient has an active concern for her health. Many alleged rape victims may not have had access or chosen to be screened before their appearance at the rape crisis clinic. An opportunity for a vaginocervical smear examination should never be missed, even in a tragic situation. The significantly lower rate of follow-up of abnormalities detected in the vaginocervical cytology smears of patients seen for the evaluation of rape needs to be further studied. We found that the return rate for follow-up of abnormal findings even in our patients previously seen at Grady Memorial Hospital to be 57% overall (55% in victims with atypia (inflammatory) or mild dysplasia and 60% in victims with high grade dysplasia or invasive cancer). This is much lower than the 95% follow-up reported for regular patients with vaginocervical cytology abnormalities seen in our routine clinics. Possibly the rape vic'
340
Diagnostic Cytopathology, Yo1 7, No 4
~
~
9
'
~
tims are more reluctant to have a pelvic exam even when it is medically indicated. A special technique for the follow-up of these patients seems indicated. The significance of this study is that we showed: 1) screening for spermatozoa on vaginocervical smears is still necessary as it adds to the criminal investigation in rape cases; 2 ) the degree of cellular abnormalities seen in rape victims suggests that many of the patients were previously cytologically unscreened; and 3) the follow-up rate of abnormalities found on vaginocervical smears obtained in the evaluation of rape victims is low.
Acknowledgments The authors acknowledge the Atlanta Police Department, Elizabeth Quarles of the Georgia Bureau of Investigation State Crime Lab, and Peg Zeigler, Ph.D., director of the rape crisis clinic at Grady Memorial Hospital, for the their assistance in correlation and interpretation of findings.
References 1. Ricci LR, Hoffman SA. Prostatic acid phosphatase and sperm in the post-coital vagina. Ann Em Med l982;l l:53O-4. 2. Dahlke MB, Cooke C, Cunnane M, Chawla J, Lau P. Identification of semen in 500 patients seen because of rape. Am J Clin Pathol 1977;68:740-6. 3. Soules MR, Stewart SK, Brown KM, Pollard AA. The spectrum of alleged rape. J Reprod Med 1978;20:33-39. 4. Poyntz FM, Martin PD. Comparison of p30 and acid phosphatase levels in post-coital vaginal swabs from donor and casework studies. Forensic Sci Int 1984;42:17-25. 5. Silverman EM, Silverman AG. Persistence of spermatozoa in the lower genital tracts of woman. JAMA 1978;240:1875-7, 6. Morrison AI. Persistence of spermatozoa in the vagina and cervix. Br J Vener Dis 1972;48:141-3. 7. Short J, Deluca M, DiVasto PV, Kaufman A. Detection of sperm in victims of rape. N Engl J Med 1978;299:424. 8. Gill P, Werrett DJ. Exclusion of a man charged with murder by DNA fingerprinting. Forensic Sci Int 1987;35:145-8 9. Naib ZM: Exfoliative cytopathology. Boston: Little, Brown and Company, 1985. 10. National Cancer Institute Workshop. The 1988 Bethesda System for reporting cervical/vaginal cytologic diagnoses. JAMA 1989;262: 9314. 11. Duncan RC, Knapp RG, Miller MC. Introductory biostatistics for the health sciences. New York: John Wiley and Sons, 1977:137-51. 12. Groth AN, Burgess AW: Sexual dysfunction during rape. N Engl J Med 1977;297:764-6. 13. Findley TP. Quantitation of vaginal acid phosphatase and its relationship to the time of coitus. Am J Clin Pathol 1977;68:238-42. 14. Davies A, Lincoln PJ, Martin P. Aberrant group B reactions detected in mixtures of semen and vaginal secretions possibly due to acquired B. Forensic Sci Int 1984;201-8. IS. Seltzer VL, Hassman H, Bigelow B. Abnormal Papanicolaou smears found in victims of sexual assault. J Reprod Med 1978;20:233.
Vaginocervical Cytology in Victims of Sexual Assault Michael J. Costa, M.D., Talaat Tadros, M.D., Eva Tackett, and Zuher Naib, M.D., F.1.A.C.
To investigate the role of vaginocervical smears in alleged victims of rape, we reviewed thejndings in 4,220 consecutive rape victims between the years 1982 and 1989. These rape victims showed a slight increase in cellular abnormalities (1.18% vs. .93%) when compared to a group of 17,187 routine smears from an indigent population in 1989. While the differences in the spectrum of cellular abnormalities were not statistically signi$cant, the increase in abnormal smears is remarkable because of the younger age distribution and lower risk factors for cervical cancer in this group of rape victims (41 % of the victims were never seen at our institution before their evaluation for alleged rape and were most probably of higher socioeconomic status and at lower risk for cervical cancer than the indigent population served at our hospital). Thisfinding may reflect the low incidence of vaginocervical cytology screening among the general population of which rape victims are a random sample. Fgty-seven percent of the rape victims with cellular abnormalities who were also regular patients at our hospital returned for follow-up by appropriate repeat smears or biopsies. This was lower than the 95% general follow-up rate of vaginocervicalsmear abnormalities among the rest of the population screened at our hospital. We detected spermatozoa in 56% of the smears from victims who were examined within three days of the alleged sexual assault. Cytology adds to the criminal investigation of rape cases as we detected spermatozoa in four of 16 semen-negative cases from a random sample of 53 cases evaluated by the state crime lab. Diagn Cytopathol 1991;7:337-340. Key Words: Rape victim; Vaginocervical cytology; Dysplasia;
Invasive cancer; Spermatozoa detection In the criminal investigation of alleged rape, statements by victim are frequently the only direct evidence that the crime has occurred.' It is reported that only 20%2 to 45% of raped women suffer physical evidence of bodily harm. For these reasons, medical proof of recent coitus is often an essential part of the investigation of rape cases. The examining physician routinely obtains specialized foReceived June 7, 1990. Accepted September 5 , 1990. From the Department of Pathology, Grady Memorial Hospital and Emory University, Atlanta, GA. Address reprint requests to Michael J. Costa, M.D., Anatomic Pathology, Grady Memorial Hospital, 80 Butler Street, S.E., Atlanta, G A 30335-3801. (cj
1991 WILEY-LISS. INC
M.T.,
A.S.C.P.,
rensic specimens such as vaginal and cervical smears (for acid phosphatase determination, p30 detection, direct examination for spermatozoa, and blood group antigens) and pubic hair brushings. 3,4 In addition, a pelvic examination and a vaginocervical cytology smear (Pap smear) have become part of the accepted practice in our and other institutions. The presence of spermatozoa in alcohol fixed vaginocervical smears produces permanent evidence of recent coitus. 5-7 Screening for epithelial abnormalities provides an opportunity for detecting cervical cancer or its precursors. The purpose of this study is to examine the value of such routine vaginocervical cytologic screening of the alleged rape victims in a busy city/county hospital which handles most of the rape cases of a large metropolis. Currently, our lab expends a large effort to detect spermatozoa in these cases. We wanted to investigate if the cytology lab contributes significantly to the criminal investigation of any cases by detecting spermatozoa when the forensic specimens do not detect semen.
Methods In Atlanta, Georgia, all alleged victims of rape who report to the police within three days are taken to the emergency room of Grady Memorial Hospital. Forensic specimens for semen identification such as vaginal and cervical smears and pubic hair brushings are taken but processed by the state crime lab only when a suspect is identified. A specialized spermatozoa stain (Kernechtrot solution followed by picroindigocarmine) for air-dried vaginal and cervical smears is the first screening test. Only when spermatozoa are not identified morphologically are an acid phosphatase and p304 determination are performed. If semen is identified, the crime lab may then perform more specific determinations such as blood group antigen detection or send the specimen out for the most recent DNA fingerprinting techniques. * A direct vaginal wet prep for the detection of live spermatozoa, pelvic examination, and a vaginocervical cytology smear are also the examining physician's duties. The Diagnostic Cytopathology, Vol 7, No 4
337
COSTA ET AL.
requisition form indicates to the cytology lab by a special code that the smear was taken from an alleged rape victim. The specimen is processed and screened in the same fashion as all routine vaginocervical smears but in addition the presence or absence of spermatozoa is noted.’ We reviewed the findings of all the vaginocervical smears obtained from alleged victims of sexual assault evaluated at Grady Memorial Hospital between the years 1982 and 1989. Using computer assistance, we recorded the number of the cases which showed the presence of spermatozoa and/or cellular abnormalities. Abnormal vaginocervical smears were reported as atypia (inflammatory), mild, moderate, and severe dysplasia, carcinoma in situ, and invasive cancer. This classification system correlates closely to the current proposed Bethesda System for reporting vaginocervical cytology diagnoses. lo We compared the incidence of abnormalities in these smears to the consecutive smears from routine patients seen in our cytology lab between July and December 1989. We excluded all smears originating from the dysplasia and gynecology tumor clinics because these are repeat follow-up smears from patients with known abnormalities and not routine screening. We reviewed the state crime lab findings for semen detection in 130 random victims (with suspects) between the years 1986-1988. Fifty-three of these victims had vaginocervical cytology findings for smears obtained at the same time at our institution. We compared results of the crime lab evaluation for semen to our ability to detect spermatozoa on vaginocervical cytology. The proportion of victims who were previous patients of Grady Memorial Hospital or its clinics was determined by a review of a random sample of 100 laboratory computer files of the rape victims. The laboratory computer files on a random sample of 150 victims with cellular abnormalities were reviewed to investigate the follow-up rate of these patients. At our institution all patients who have dysplasia on a vaginocervical smear undergo a colposcopic-directed biopsy. The patients with inflammatory atypia are given a repeat smear. Two consecutive atypias leads to colposcopic exam. The follow-up rate of our regular patients through our dysplasia clinic is 95%. We used the chi-square statistics to test for differences between vaginocervical cytology results in rape victims and routine patients. A probability of less than 0.05 was considered statistically significant.
’
Results In 4,220 vaginocervical smears from victims of alleged rape seen in our cytology lab between the years 1982 and 1989, spermatozoa were detected in 2,372 or 56% of cases. The state crime lab showed semen in 63% of the random sample of 130 victims (with suspects). A comparison of semen detection by the crime lab to spermatozoa detected 338
Diagnostic Cytopathology, Vol 7, No 4
on vaginocervical cytology obtained at the same time in 53 of these cases is seen in Table I. In four cases spermatozoa were detected only by the cytology lab and in six cases semen was detected only by the crime lab. The combination of cytology and specialized crime lab evaluation increased the sensitivity for semen detection from 70% to 77% in these 53 cases. Table I1 compares the abnormalities found in the smears of 4,220 alleged rape victims to 17,187 routine vaginocervical smears screened in 1989. The age distribution of the rape victims was slightly younger than the routine patients (Fig. 1). The number of severe dysplasia/ carcinoma in situ and moderate dysplasia were slightly higher (Fig. 2), but with no statistical significance ( P > 0.1, P < 0.1 respectively). Invasive cancer was found slightly more commonly in the general population, but again the difference was not statistically significant. The incidence of atypia and mild dysplasia on smears was almost identical (Fig. 3). We found that 59% of the victims overall and 52% of those with cellular abnormalities were previous patients of Table I. Semen Detection by State Crime Lab vs. Spermatozoa Detection by Vaginocervical Cytology in 53 Alleged Rape Victims in Which a Suspect Was Identified Result Cytology
State crime
lab
lab
No.
+ -
= Positive for semen or spermatozoa detection. = Negative for semen or spermatozoa detection.
Table 11. Vaginocervical Cytology Findings for 4,220 Victims of Rape From Years 1982-1989 vs. Routine Smears for the General Population General population
Rape victims Diagnosis
Negative Atypia and mild dys. Mod. dys. Sev. dys. and CIS Invasive cancer Unsat Other Total
No.
(%I
No.
(%)
3,411 720 35 11 4 39 0 4,220
(80.8) (17.0) (33) (.26) (.09) (.92) (0) (100)
13,942 2,956 98 38 24 126 3 17,187
(81.1) (17.2) (.57) (.22) (. 14) (.73) (.01) (100)
Dys. = dysplasia, Mod. = moderate, Sev. = severe, CIS = squamous carcinoma in situ, Unsat = smear unsatisfactory for cytologic evaluation. Cancer includes all invasive cancers including adenocarcinomas and carcinosarcomas. Other includes radiation dysplasia and endometrial hyperplasia. The general population includes all smears interpreted by the cytology lab for July-December 1989 excluding smears obtained in dysplasia and tumor clinic.
VAGINOCERVICAL CYTOLOGY IN SEXUAL ASSAULT VICTIMS PERCENT OF PATIENTS 60
50
=
-’
TYPE OF PATIENTS
.RAPE VICTIMS
0-ROUTINE PATIENTS
~
40 30 20 10 0-
20-29
40+
30-39
]l
AGE
I
,
PATIENT GROUP
=
.RAPE VICTIMS
0-ROUTINE PATIENTS
I
0
Fig. 1. Age distribution of 4,220 alleged rape victims who received vaginocervical cytology between 1982 and 1989 as compared to routine patients from 1989.
1
TYPE OF PATIENT .RAPE VICTIMS .ROUTINE PATIENTS
iI
SEV DYS/CIS
INVASIVE CANCER
o
c
m i
h 0
0.2
0.4
0.8
0.8
1
PERCENT OF PATIENTS Fig. 2. Serious abnormalities found in vaginocervical smears of 4,220 alleged rape victims between 1982 and 1989 as compared to 17,187 vaginocervical smears from routine patients in 1989. MOD DYS = moderate dysplasia; SEV DYS = severe dysplasia; CIS = carcinoma in situ. Invasive cancer includes one adenocarcinoma and one carcinosarcoma. All other invasive cancers were squamous carcinomas.
Grady Memorial Hospital or its clinics. Fifty-five percent of the victims with atypia (inflammatory) or mild dysplasia and 60% of the patients with high grade dysplasia or invasive cancer received appropriate follow-up in our hospital for their abnormalities. None of the victims who were not regular patients in our hospital before the alleged assault received follow-up care at our institution. They most probably went to a private care physician.
Discussion The identification of spermatozoa using vaginocervical smears has been previously studied using volunteers from screening clinics. 5,6 Silverman reported a maximal efficiency of 64% one day after coitus with declining efficiency to about 10% after ten days. Morrison reported
5 10 15 PERCENT OF PATIENTS
20
Fig. 3. Mild abnormalities found in VaginOCerViCal CYtOlogY Smears from 4,220 rape victims between 1982 and 1989 as compared to 17,187 vaginocervical Smears from routine patients in 1989. ATYPIA = inflammatory atypia; MILD DYS = mild dysplasia.
an overall efficiency of 58.4% with an optimum efficiency of 70% within two days of coitus. The identification of spermatozoa in cases of rape has been reported to be from 46%’* to 71%’ The one factor which is universally reported to adversely affect the detection of spermatozoa is the time interval between coitus and collection of the vaginocervical smear. Our observed value of 56% within three days of the alleged assault compares well with the detection rate of 55% among the 287 patients who reported coitus within the last three days in Silverman’s5 study and 58% among the 114 patients who reported coitus within the last seven days in Morrison’s6 study. Our ability to detect spermatozoa in rape victims approaches the reported efficiency in retrospective studies in volunteers. It also approaches the 63% detection rate for semen among rape victims with identified suspects we found by our random review of 130 determinations by the state crime lab. In the 53 cases where a direct comparison could be made, four cases showed spermatozoa in the vaginocervical smear in spite of the fact that the state crime lab could not demonstrate semen. When combined, the sensitivity for semen detection in these 53 cases was increased from 70% (using the state crime lab alone) to 77%. In addition, the police officials involved in rape cases related that on more than one occasion the forensic specimens have been misplaced. The permanent evidence of the presence of spermatozoa in fixed vaginocervical smear was the only physical evidence of recent coitus. These findings reaffirm the importance of the detection of spermatozoa in vaginocervical cytology for the criminal investigation of rape cases. Our detection rate of spermatozoa in vaginocervical smear is below the reported rate of semen detection (97% using acid phosphatase in the first 12 hr ’). Other authors report the sensitivity of acid phosphatase for semen to be Diagnostic Cytopathology, Vol 7, No 4
339
COSTA ET AL.
40% below the 60% detection rate for spermatozoa in their lab.2 The decay of quantitative acid phosphatase determination may correlate with the time passed since the coitus. ' , I 3 However, it goes below the baseline of vaginal acid phosphatase levels in less than 24 hr at which time spermatozoa are still usually detectable in vaginocervical smears. 5-7 The evaluation of blood type group ABO substance shows lower sensitivity for semen (16% in Dahlke et al.'s report 2, but greater specificity in determining blood types of possible suspects. Problems with aberrant group B reaction have been reported. l 4 The current modern technique (DNA fingerprint pattern of detected spermatozoa)8 is more specific for the evaluation of a particular suspect. These techniques add sensitivity in certain cases and some specificity over the morphologic detection of spermatozoa in vaginocervical smears. The slightly higher incidence of abnormal smears in rape victims as compared to a group of 17,187 routine cases from an indigent population screened in 1989 is not statistically significant. However, the indigent comparison group is not the same population as the rape victims because at least 41% of the rape victims are from a population of higher socioeconomic status with a lower incidence of cervical cancer and dysplasia. For this reason, the fact that the incidence of abnormalities is only slightly higher in rape patients speaks for a greater actual difference if the same population were used. A comparable increase of abnormalities in rape victims was reported by Seltzer et al. l 5 These findings become clinically more significant when we consider that rape victims are slightly younger (Fig. 1) and may never have had a chance for screening until it was too late (four cases of invasive cancer were identified, Table 11). Having a Pap smear presupposes that the patient has an active concern for her health. Many alleged rape victims may not have had access or chosen to be screened before their appearance at the rape crisis clinic. An opportunity for a vaginocervical smear examination should never be missed, even in a tragic situation. The significantly lower rate of follow-up of abnormalities detected in the vaginocervical cytology smears of patients seen for the evaluation of rape needs to be further studied. We found that the return rate for follow-up of abnormal findings even in our patients previously seen at Grady Memorial Hospital to be 57% overall (55% in victims with atypia (inflammatory) or mild dysplasia and 60% in victims with high grade dysplasia or invasive cancer). This is much lower than the 95% follow-up reported for regular patients with vaginocervical cytology abnormalities seen in our routine clinics. Possibly the rape vic'
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tims are more reluctant to have a pelvic exam even when it is medically indicated. A special technique for the follow-up of these patients seems indicated. The significance of this study is that we showed: 1) screening for spermatozoa on vaginocervical smears is still necessary as it adds to the criminal investigation in rape cases; 2 ) the degree of cellular abnormalities seen in rape victims suggests that many of the patients were previously cytologically unscreened; and 3) the follow-up rate of abnormalities found on vaginocervical smears obtained in the evaluation of rape victims is low.
Acknowledgments The authors acknowledge the Atlanta Police Department, Elizabeth Quarles of the Georgia Bureau of Investigation State Crime Lab, and Peg Zeigler, Ph.D., director of the rape crisis clinic at Grady Memorial Hospital, for the their assistance in correlation and interpretation of findings.
References 1. Ricci LR, Hoffman SA. Prostatic acid phosphatase and sperm in the post-coital vagina. Ann Em Med l982;l l:53O-4. 2. Dahlke MB, Cooke C, Cunnane M, Chawla J, Lau P. Identification of semen in 500 patients seen because of rape. Am J Clin Pathol 1977;68:740-6. 3. Soules MR, Stewart SK, Brown KM, Pollard AA. The spectrum of alleged rape. J Reprod Med 1978;20:33-39. 4. Poyntz FM, Martin PD. Comparison of p30 and acid phosphatase levels in post-coital vaginal swabs from donor and casework studies. Forensic Sci Int 1984;42:17-25. 5. Silverman EM, Silverman AG. Persistence of spermatozoa in the lower genital tracts of woman. JAMA 1978;240:1875-7, 6. Morrison AI. Persistence of spermatozoa in the vagina and cervix. Br J Vener Dis 1972;48:141-3. 7. Short J, Deluca M, DiVasto PV, Kaufman A. Detection of sperm in victims of rape. N Engl J Med 1978;299:424. 8. Gill P, Werrett DJ. Exclusion of a man charged with murder by DNA fingerprinting. Forensic Sci Int 1987;35:145-8 9. Naib ZM: Exfoliative cytopathology. Boston: Little, Brown and Company, 1985. 10. National Cancer Institute Workshop. The 1988 Bethesda System for reporting cervical/vaginal cytologic diagnoses. JAMA 1989;262: 9314. 11. Duncan RC, Knapp RG, Miller MC. Introductory biostatistics for the health sciences. New York: John Wiley and Sons, 1977:137-51. 12. Groth AN, Burgess AW: Sexual dysfunction during rape. N Engl J Med 1977;297:764-6. 13. Findley TP. Quantitation of vaginal acid phosphatase and its relationship to the time of coitus. Am J Clin Pathol 1977;68:238-42. 14. Davies A, Lincoln PJ, Martin P. Aberrant group B reactions detected in mixtures of semen and vaginal secretions possibly due to acquired B. Forensic Sci Int 1984;201-8. IS. Seltzer VL, Hassman H, Bigelow B. Abnormal Papanicolaou smears found in victims of sexual assault. J Reprod Med 1978;20:233.
