مرکزی صفحہ Clinical Toxicology (Informa Healthcare) Toxicological analysis of blood and urine samples from female victims of alleged sexual assault
Clinical Toxicology (2012), 50, 555–561 Copyright © 2012 Informa Healthcare USA, Inc. ISSN: 1556-3650 print / 1556-9519 online DOI: 10.3109/15563650.2012.702217 CRITICAL CARE Toxicological analysis of blood and urine samples from female victims of alleged sexual assault ALAN W. JONES, ANITA HOLMGREN and JOHAN AHLNER Clinical Toxicology Downloaded from informahealthcare.com by University of Louisville on 12/27/14 For personal use only. Department of Forensic Toxicology, National Board of Forensic Medicine, Linköping, Sweden. Background. The toxicological analysis of blood and urine samples from victims of alleged sexual assault represents a crucial part of the forensic evidence when this crime is investigated. Material and methods. We searched a national forensic toxicology database (TOXBASE) to find cases registered as sexual assault, rape, including date-rape that the police had requested the analysis of ethanol and other drugs. Between 2008 and 2010, N 1460 such cases met this criteria. After immunological screening of urine or blood samples, all positive results were verified by more specific analytical methods, such as gas chromatography-mass spectrometry (GC-MS) for illicit drugs. A large number of prescription drugs and their metabolites were determined by capillary GC with nitrogen-phosphorous (N-P) detector. GC with flame ionization detector (FID) was used to analyze ethanol and gamma-hydroxybutyrate (GHB) in blood at limits of quantitation (LOQ) of 0.1 g/L and 8 mg/L, respectively. Results. The average age ( standard deviation) of all victims was 24 10.3 years and 72% were between 15 and 29 years. Ethanol and other drugs were not detected in 31% of cases (N 459). Blood-ethanol was positive in N 658 cases at mean, median and highest concentrations of 1.23 g/L, 1.22 g/L and 4.3 g/L, respectively. Ethanol plus drugs were present in N 188 cases (13%) and one or more other drugs alone in N 210 cases (14%). Cannabis (marijuana) and amphetamines were the major illicit drugs, whereas diaz; epam, alprazolam, zopiclone as well as newer antidepressants were the major prescription drugs identified. Conclusions. The mean age of victims of sexual assault in Sweden, the proportion of drug positive to drug negative cases, the predominance of ethanol positive cases as well as the types of other drugs showed a remarkably good agreement in two studies spanning a period of 8 years. Keywords Alcohol; Date rape; Drug use; Ethanol; Sexual assault zopiclone) and flunitrazepam is seldom verified.10 – 12 However, because many of these drugs have short elimination half-lives, the concentrations in blood or urine might have decreased below the analytical limits of quantitation by the time specimens were collected from the victims.13 Ethanol is a legal drug, and depending on the dose ingested, the speed of drinking, the person’s age and previous experience with alcohol ethanol-induced effects might range from mild euphoria to unconsciousness.14 Ethanol influences people in different ways from no discernable effects to excitement, loss of inhibitions and dangerous behaviour, including engaging in unplanned sexual activities.15,16 There is often a fine dividing line between consensual sex and sexual assault, especially when both parties are under the influence of alcohol.17,18 Excessive binge drinking resulting in high BAC (2.0 g/L) often leads to gross intoxication and incapacitation in novice drinkers.8,19 This article reports the toxicological results from analysis of blood and urine samples from female victims of alleged sexual assault or rape that came to the attention of the police in Sweden between 2008 and 2010. The victims of this crime are representative of the whole country, and the toxicological results were compared and contrasted with an earlier investigation covering the years 2003–2007.20 Introduction Drug-facilitated sexual assault (DFSA), conjures up the image of a perpetrator adding a chemical substance to a person’s food or drink to render them incapacitated for the purpose of committing an illicit sexual act.1,2 Drug-facilitated crimes attract a lot of attention from the news media, government agencies as well reports in scientific journals.3 When investigating DFSA, it is obviously important to determine whether drugs had been taken voluntarily, which is often the case with the legal drug ethanol.4 –7 Moreover, it is important to establish whether the victims were taking any prescription or recreational drugs at the time the offence was committed. In most of the previous investigations of DFSA, the principal toxicological finding has been a positive blood-alcohol concentration (BAC).8,9 The presence of fast-acting hypnotic or knock-out drugs, as exemplified by chloral hydrate, gamma-hydroxybutyrate, z-hypnotics (zaleplon, zolpidem, Received 8 May 2012; accepted 4 June 2012. Address correspondence to Professor Alan W. Jones, Department of Forensic Toxicology, National Board of Forensic Medicine, Artillerigatan 12, 587 58 Linköping, Sweden. Tel: 46 13 252114. Fax: 46 13 104875. E-mail wayne.jones@LIU.se 555 556 A. W. Jones et al. Materials and methods Clinical Toxicology Downloaded from informahealthcare.com by University of Louisville on 12/27/14 For personal use only. Police procedures When the police authorities investigate crimes of a sexual nature, they have at their disposal a so-called “rape kit” which allows them to collect forensic evidence, including samples of blood and urine for toxicology, and other biological fluids for DNA analysis. Venous blood is taken into evacuated tubes (10 mL) containing sodium fluoride (100 mg) and potassium oxalate (25 mg) as preservatives. Whenever possible a specimen of urine (10 mL) is also collected in a tube containing sodium fluoride (∼1%) as a preservative and enzyme inhibitor. Forensic toxicology Blood and urine samples from victims of alleged sexual assault or date rape in Sweden are sent by express mail for analysis to a central forensic toxicology laboratory. On arrival at the laboratory, the cases are registered using information written on the police report forms that accompany blood and urine samples. This information describes the nature of the case, whether sexual assault or rape, attempted murder, or some other crime in which drugs and alcohol might be involved. The analytical results and demographics of the victims are entered into a national forensic toxicology database TOXBASE, which was used for the present study.21 Analysis of ethanol and other drugs The analytical methods used to determine ethanol and other drugs were the same as those used in our earlier study, which allows a direct comparison of the toxicological results.20 The laboratory work starts with a general screening analysis by immunoassay methods aimed at five classes of drugs (amphetamine analogs, cannabinoids, cocaine metabolite, opiates and benzodiazepines). This initial screening is done on urine specimens if available, otherwise on blood samples after precipitation of proteins. An aliquot of blood (1 mL) is mixed with acetone (3 mL) and then centrifuged to obtain a supernatant, which is carefully removed and used for the immunoassay. After evaporation to near-dryness, the residue is dissolved in methanol (0.5 mL) prior to automated enzyme-multiplied immunoassay (EMIT) and cloned enzyme donor immunoassay (CEDIA). All results from the screening analysis are verified by more specific methods, such gas chromatography-mass spectrometry (GC-MS) or liquid chromatography-mass spectrometry (LC-MS) for illicit drugs and metabolites. Because EMIT and CEDIA are not suitable for analysis of most prescription drugs and metabolites, these were determined after solvent extraction with n-butyl acetate and capillary GC with N-P detector. This analytical method has been used in our laboratory for many years and allows the identification and quantification of about 200 acidic, basic and/or neutral drugs and metabolites, including sedativehypnotics, clonidine and ketamine. Gamma-hydroxybutyrate (GHB) was determined in blood and/or urine by GC and FID detector after conversion into the gamma-butyrolactone (GBL) derivative by acidification. The limit of quantitation (LOQ) for GHB was 8 mg/L.22 The concentrations of ethanol in blood and urine were determined by automated headspace analysis with GC-FID and a method LOQ of 0.1 g/L for reporting positive results.20 Data selection and statistical analysis All requests for toxicological analysis are entered into a national forensic database (TOXBASE). We searched TOXBASE for information on the police request forms indicating that the crime being investigated was of a sexual nature, such as sexual assault, date-rape or DFSA. The search of TOXBASE was restricted to female victims, in part because there are so few male victims and the fact that females were included in our earlier study.20 This furnished results from 8 years of forensic blood and urine samples, 2008–2010 (N 1406) and 2003–2007 (N 1806). Mean, median and highest concentration of ethanol and other drugs were used as descriptive statistics. The mean age of victims was compared by Student t-test and median concentrations of ethanol by Mann–Whitney test. The association between a victim’s age and blood-alcohol concentration was established by calculating the Pearson correlation coefficient. Two percentages, for example, percent drug positive to negative cases were compared by a chi-squared test. Results Trends over time Fig. 1 shows month-by-month changes in the number of alleged sexual assault or date rape cases submitted by the police for toxicological analysis. There were N 538 cases (37%) in 2008, N 470 (32%) in 2009, and N 452 (31%) in 2010. There was an increase in number of cases from May (N 108) to June (N 145), but otherwise monthly variations were unremarkable. Fig. 1 also shows the change in mean age of victims per month, which varied from 23 to 25 years as well as the mean BAC, which ranged from 1.09 g/L (April) to 1.38 g/L (August) with an overall mean of 1.23 g/L. Age distribution of victims Fig. 2 compares the relative frequency distributions of age of sexual assault victims in Sweden in the studies spanning a total of 8 years. The mean ages of 24 10.0 years (2003–2007) and 24 10.3 years (2008–2010) were virtually identical (p 0.05). Moreover, the frequency distributions of age showed remarkably good agreement, both were skewed to the right with 72% of victims aged 15–29 years (2003–2007) compared with 73% within this age range for the period 2008–2010. In 458 of 1460 cases (31%), ethanol and other drugs were negative in blood or urine and the mean age of these victims (23 10.0 years) was not significantly different from the age of drug-positive cases (25 10.4 years) (p 0.05). Clinical Toxicology vol. 50 no. 7 2012 Date-rape drugs 557 1.5 250 Mean BAC 1.0 23 y 150 24 y 23 y 25 y 24 y 24 y 24 y 25 y 24 y 24 y 24 y 25 y 100 0.5 Blood Alcohol Conc., g/L Number of Cases 200 0.0 0 Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Month Fig. 1. Month-by-month variation in number of sexual assault or date rape cases (2008–2010) sent by the police for toxicological analysis. Above each bar the average age of victims is shown along with monthly mean blood-alcohol concentration (BAC). Distribution of blood-ethanol concentration Relative frequency distributions of blood-ethanol concentration (LOQ 0.1 g/L) for the two study periods are compared in Fig. 3. The results show a good agreement, and median BAC of 1.19 g/L (2003–2007) and 1.22 mg/L (2008–2010) were not statistically different (p 0.05). During the period 2003–2007, N 134 cases (11%) had a BAC 2.0 g/L compared with N 83 cases (9%) during the years 2008–2010. The blood-ethanol concentration was positively correlated with victims age r 0.25 (p 0.001), although this association was not as strong as in the earlier study 2003–2007 (r 0.37) (p 0.001). Concentrations of drugs in blood Table 1 shows the frequency of drug positive and drug negative cases in the two studies. There were 31% of cases negative for alcohol and drugs in both time periods. Ethanol was by far the most frequently identified substance and positive results were found in 41–43% of all cases (0.1 g/L). The co-administration of ethanol and other drugs, both licit and illicit, were also common findings (Table 1). Table 1 also attempts to classify the drugs identified, whether illicit or licit (prescription), as shown by the footnotes to the table. Table 2 shows that many more drug-positive cases were identified based on analysis of urine than blood, such as 50 2003-2007, N = 1804 40 Relative Frequency, % Clinical Toxicology Downloaded from informahealthcare.com by University of Louisville on 12/27/14 For personal use only. 50 2008-2010, N = 1460 30 20 10 0 10 20 30 40 Age, y 50 60 70 Fig. 2. Relative frequency distribution of age of female victims of alleged sexual assault in two study periods covering years 2003–2007 and 2008–2010. Copyright © Informa Healthcare USA, Inc. 2012 558 A. W. Jones et al. 15 2003-2007, N = 806 Relative Frequency, % 2008-2010, N = 658 10 5 Clinical Toxicology Downloaded from informahealthcare.com by University of Louisville on 12/27/14 For personal use only. 0 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 Blood Alcohol Conc., g/L Fig. 3. Relative frequency distribution of blood-ethanol concentration in female victims of sexual assault in two studies covering years 2003–2007 and 2008–2010. 791 ethanol positives compared with 658 positives in blood. The individual drugs are also listed in Table 2 and if there were ten or more occurrences the mean, median and highest concentrations in blood are reported. The two principal illicit drugs used by victims of sexual crimes were cannabis (marijuana) and amphetamine, which ranked fourth and fifth, respectively (Table 2). Among prescription medication, sedative-hypnotics, such as diazepam, alprazolam and zopiclone, were common as were the newer antidepressants, exemplified by citalopram, fluoxetine and venlafaxine. The types of drugs and their rank ordering Table 1. Toxicological results from analysis of ethanol and other drugs in blood and/or urine samples from female victims of sexual assault or date rape during two study periods over 8 years. Drugs and drug combinations Ethanol only drug detected Ethanol benzodiazepines* Ethanol prescription drugs (non-sedatives)† Ethanol illicit drugs‡ Ethanol illicit drugs‡ benzodiazepines* Ethanol opiates/opioids¶ Ethanol other drug combinations Benzodiazepines* only Illicit drugs‡ benzodiazepines* Illicit drugs only‡ All other drug combinations† Legal drugs in all combinations No drugs identified ( LOQ) 2003–2007 N 1806 2008–2010 N 1406 772 (43%) 49 (2.7%) 56 (3.1%) 603 (41%) 30 (2.0%) 54 (3.7%) 41 (2.2%) 23 (1.3%) 40 (2.7%) 8 (0.5%) 11 (0.6%) 33 (1.8%) 47 (2.6%) 28 (1.6%) 58 (3.2%) 75 (4.2%) 54 (3.0%) 559 (31%) 10 (0.7%) 46 (3.2%) 29 (2.0%) 13 (0.9%) 36 (2.5%) 81 (5.5%) 51 (3.5%) 459 (31%) LOQ limit of quantification. *Alprazolam, diazepam, clonazepam, nitrazepam, flunitrazepam etc, including zopiclone, zolpidem and zaleplon. †Mainly antidepressants, paracetamol, caffeine, antihistamines and muscle relaxants (non-sedative-hypnotics but excluding opiates). ‡Amphetamine, methamphetamine, ecstasy (MDMA), cocaine and benzoylecgonine, GHB, cannabis (THC and carboxy-THC), 6-acetyl morphine. ¶Buprenorphine, propoxyphene, ethyl morphine, codeine, morphine, methadone, tramadol, oxycodone. showed good agreement between the two studies,20 with two exceptions; fluoxetine replaced sertraline as the 9th most common drug in 2008–2010 and codeine replaced tramadol as the 10th most common drug. The results in Table 2 also suggest that victims with ethanol, fluoxetine and/or THC positive in blood were younger (mean 23–25 years) than those with codeine, zopiclone and/ or amphetamine (mean 34–39 years). The median concentrations of the various prescription drugs in blood were in the therapeutic interval for valid use of this medication. Trends in drug positive cases over time The results from the two study periods 2003–2007 (N 1806) and 2008–2010 (N 1460) are compared and contrasted in Table 3. The annual number of cases increased from 361 per year (2003–2007) to 486 per year (2008–2010) an increase of 36% per year. Otherwise, the mean and median age of victims, the percentage of alcohol and/or drugs positive to negative cases as well as the mean and median BAC agreed well between the two studies. Discussion The relatively few male victims of DFSA in Sweden were not included to allow direct comparison with our earlier work (2003–2007), which only included female victims of this crime.20 In both studies, spanning a total of 8 years and a total of 3266 cases of alleged sexual assault or rape, there was a striking predominance of alcohol positives and elevated BAC.20 The pattern of alcohol and drug use in these victims of sexual crimes is representative for the entire country, which is one of the strengths of the present study. Moreover, the same analytical toxicology was applied in all sexual crimes and not just those cases in which the victim claimed they had been drugged by a perpetrator. In a recent review article, it was noted that in only 2% of cases of alleged DFSA was there evidence of covert Clinical Toxicology vol. 50 no. 7 2012 Date-rape drugs 559 Table 2. The drugs most often identified in blood and/or urine in N 1630 female victims of sexual assault with number of positive cases, mean age ( standard deviation) of victims and the mean, median and highest concentrations of ethanol and drugs in blood. Drugs* Clinical Toxicology Downloaded from informahealthcare.com by University of Louisville on 12/27/14 For personal use only. Ethanol Paracetamol Diazepam Cannabis (THC)¶ Amphetamines Alprazolam Zopiclone Citalopram Venlafaxine Fluoxetine Codeine N† (urine) 791 88 86 85 55 33 33 26 19 18 17 Age, years Mean SD N‡ (blood) Mean drug conc. mg/L Median drug conc. mg/L Highest drug conc. mg/L 25 10.3 29 12.6 33 12.1 25 8.3 30 11.2 32 12.3 34 14.3 28 10.7 29 10.8 23 6.7 39 8.2 658 87 64 33 33 19 13 26 19 14 11 1230 6.5 0.24 0.001 0.35 0.06 0.10 0.11 0.25 0.28 0.07 1220 5.0 0.10 0.0007 0.24 0.04 0.05 0.10 0.10 0.20 0.08 4300 25 1.0 0.006 1.7 0.19 0.40 0.30 0.90 0.70 0.16 conc. concentration. *Included if there was more than ten occurrences of the same substance in blood. †Number of drug positive cases in urine. ‡Number of drug positive cases in blood as well as mean, median and highest concentrations. ¶Cannabis verified as tetrahydrocannabinol (THC) in blood and carboxy-THC in urine. administration of drugs.23 During police investigations, it is obviously important to consider any voluntary use of drugs and/or alcohol when statistics are compiled, including any medication being prescribed to victims. Furthermore, it needs to be established whether alcohol or drugs had been taken after the offence but before sampling blood for toxicology. If victims received an analgesic or an anti-anxiety agent when being examined by a physician, this clearly needs to be considered when analytical results are interpreted. A limitation of the present study, as well as many other investigations of DFSA, is the amount of time that passes after the offence before biological specimens were obtained for toxicological analysis. Much depends on the physical, psychological and emotional state of the victim, the location of the attack, the advice and help given by friends and Table 3. Comparison of toxicological results from analysis of ethanol and/or other drugs in female victims of sexual assault 2003–2007 and 2008–2010. Results Number of cases Cases per year Mean age SD, years Age (median), years Ethanol and drugs negative, N (%) Ethanol positive in blood, N (%)1 Ethanol positive in blood or urine, N (%) Mean BAC SD, g/L Median BAC, g/L‡ Other drugs positive in blood, N (%)¶ Other drugs positive in blood or urine, N (%)¶ Period 2003–2007 Period 2008–2010 1806 361 24 10.1 20 559 (31%) 806 (45%) 952 (53%) 1460 486* 24 10.3† 20 459 (31%)† 658 (45%)† 791 (54%)† 1.24 0.70 1.19 345 (19%) 475 (26%) 1.23 0.65 1.22† 313 (21%)† 412 (28%)† BAC blood-alcohol concentration. *Significantly more cases per year 2008–2010 (p 0.001). †No significant differences for the two study periods (p 0.05). ‡Blood-ethanol 0.1 g/L with or without other drugs present. ¶With or without ethanol present. Copyright © Informa Healthcare USA, Inc. 2012 relatives and transport to a location where a medical examination and sampling of body fluids is possible. Drugs with short elimination half-lives, such as z-hypnotics and GHB, might become eliminated from the body by the time blood and/or urine was taken for analysis. Accordingly, a negative toxicology report for these substances, does not rule out that they had been administered or used by a victim. This is evidenced by zopiclone, with 33 positive findings in urine but only 13 in blood (Table 2). The victims BAC at time of sampling blood will also be lower than the BAC when the crime was committed, although knowledge of ethanol’s pharmacokinetics permits making a back calculation. The elimination kinetics of ethanol from blood is a zero-order process provided BAC exceeds 0.1–0.2 g/L.24 If and when a back calculation is done in DFSA cases, then a good strategy is to use a range of ethanol elimination rates, such as 0.10–0.20 g/L/h or an average of 0.15 g/L/h for moderate drinkers.8,25 Interpreting the BAC in relation to the degree of impairment or incapacitation of the victim is much more difficult and much depends on the person’s age, the dose of ethanol, the speed of drinking and the person’s tolerance to ethanol. The combined effects of alcohol and other drugs, especially sedative-hypnotics, might cause greater impairment than alcohol alone.26 The percentage of drug positive cases was higher in urine than in blood (Table 2), because urine provides a wider detection window in analytical toxicology.27 The use of alternative specimens for toxicology, such as hair, is gaining in importance in DFSA cases, which extends the detection window even further.28 However, interpreting the concentrations of drugs and metabolites in urine or hair in relation to the clinical effects on the individual, such as impairment or incapacitation, is not possible. The presence of drugs or their metabolites in urine verifies prior use of the substances but when they were taken or the effects produced on the individual cannot be determined. Publications on DFSA from several countries confirm that the principal psychoactive substance identified in blood Clinical Toxicology Downloaded from informahealthcare.com by University of Louisville on 12/27/14 For personal use only. 560 A. W. Jones et al. of victims is the legal drug ethanol.9,29 In a small case series (N 135) of sexual assaults in the Netherlands, most victims were women (94%) having a mean age of 25 years and most had consumed ethanol before they were attacked.30 The presence of alcohol and other drugs was negative in 27% of cases and proportion of negative cases increased with longer times before sampling blood and urine for toxicology. The mean BAC in this Dutch study was 1.21 g/L, which is in good agreement with results from Sweden (1.23 g/L). Other common drugs identified in the Dutch study besides ethanol were non-opiate analgesics, illicit drugs and benzodiazepines.30 Cannabis (marijuana) and amphetamine are popular illicit recreational drugs in Sweden, and these substances were among the drugs verified positive in blood or urine (Table 2). It is difficult to envisage surreptitious administration of these drugs; however, their pharmacological effect might have increased the propensity for unplanned sexual encounters. The antidepressants, citalopram, venlafaxine and fluoxetine, were common findings, and this type of medication is often prescribed to young adults in today’s society.31 The presence of codeine in 11 blood samples and paracetamol (acetaminophen) in 87 might have arisen from use of over-the-counter paracetamol-codeine formulations (Table 2). The hypnotic drug, zopiclone, was identified in N 13 blood samples (Table 2), and this substance might render people drowsy making them more susceptible to a sexual crime.13 A likely scenario is that zopiclone was taken as a sleeping aid whereafter victims became vulnerable to sexual advances from an acquaintance or perpetrator.32 The benzodiazepine anxiolytics diazepam and alprazolam were also identified in blood samples, and this medication can alter a person’s awareness and judgement, especially when combined with alcohol.33 The proportions of drug positive to drug negative cases, the high prevalence of ethanol, the high median BAC as well as average age of victims showed very good agreement in two studies spanning a total of 8 years. Ethanol was the psychoactive substance most commonly identified, which agrees with investigations of sexual assaults occurring in other nations, even if drinking habits and use of alcohol as a social drug might be different in Sweden.8,18,34 Because ethanol is a legal drug, many victims probably met their assailant at a bar, a pub or a party where alcohol was served. Elevated BAC leads to excitement, loss of inhibitions, poor judgement and sometimes an increased propensity to take risks, which together might make some people more vulnerable to sexual advances. However, this is a matter for lawyers, expert witnesses and the courts to consider when people are prosecuted for DFSA, although we have no information about how many cases actually went to trial.17,35 The so-called date rape drugs, exemplified by GHB and flunitrazepam, were noticeably absent, which calls into question their use in DFSA crimes in Sweden.5,10,36 The annual number of DFSA cases increased by 35% between the two study periods 2003–2007 and 2008–2010, which either means that date-rape is increasing in frequency or that victims are more likely to make a police report that a sexual crime was committed. The low age of female victims (mean 23–25 years), their relatively high BAC (mean 1.23 g/L), with many above 2.0 g/L, suggests that alcohol intoxicated was an important element in the case. Declaration of interest There was no external funding for this study and none of the authors consider that they have any conflicts of interest by publishing this article. Ethical committee approval for this study was neither applied for nor obtained because the subjects were not identifiable in the data evaluated. References 1. Bechtel LK, Holstege CP. Criminal poisoning: drug-facilitated sexual assault. Emerg Med Clin North Am 2007; 25:499–525. 2. Hall JA, Moore CB. Drug facilitated sexual assault–a review. J Forensic Leg Med 2008; 15:291–297. 3. UNODC. Guidelines for the forensic analysis of drugs fascilitating sexual assault and other criminal acts. Vienna: United Nations Office on Drugs and Crime; 2011:1–46. 4. Scott-Ham M, Burton FC. Toxicological findings in cases of alleged drug-facilitated sexual assault in the United Kingdom over a 3-year period. J Clin Forensic Med 2005; 12:175–186. 5. Djezzar S, Questel F, Burin E, Dally S. Chemical submission: results of 4-year French inquiry. Int J Legal Med 2009; 123:213–219. 6. Grossin C, Sibille I, Lorin de la Grandmaison G, Banasr A, Brion F, Durigon M. Analysis of 418 cases of sexual assault. 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