Approach to a Woman with Sexual Assault

Abstract

Examination of a survivor of sexual assault should be performed meticulously. The aim is to confirm whether penetration occurred, document injuries and collect evidence to bring perpetrators to justice. First aid, contraception, preventive measures for Sexually Transmitted diseases and psychological support should be given to the survivor.

Rape is one of the most violent crimes against women resulting in deep and long-lasting physical and psychological trauma.

As doctors it is our professional duty to offer immediate first aid and treatment to survivors of sexual assault, collect evidence meticulously and inform the police for further investigation.

Definition

Under Section 375, I.P.C, a man is said to commit rape if he has sexual intercourse with a woman:

Against her will.

Without her consent.

When her consent has been obtained by threatening her, deception or impersonation.

With her consent, if of unsound mind or intoxicated.

If she is under 16 years of age, irrespective of consent.

Penetration of the penis within the vulva with or without the emission of semen/rupture of hymen is sufficient to constitute rape.

Examination of a survivor of rape.

The survivor should be examined when there is requisition from investigating officer or the Magistrate, or if the survivor goes directly to the doctor.

Objectives

• To search for injuries that will corroborate the history given by the survivor.

• To search for, collect and preserve all physical (trace) evidence for laboratory examination.

• To treat the survivor for any injuries, sexually transmitted infections (STI), prevent pregnancy and to minimize any permanent psychological damage.

General Procedure

Written, witnessed consent of the woman (or parents/guardian if under 12 years of age or of unsound mind) for examination, collection of specimens, taking of photographs, treatment and the release of information to the police must be undertaken.

The survivor should be identified by the escorting police constable and identification marks, constable’s name and number recorded.

The name of the survivor, her parents, marital status, residence, occupation, time, date, year, place of examination and by whom requisition is given should be noted.

The survivor has the right to refuse a medico legal examination or collection of evidence or police investigation but that refusal will not be used to deny treatment. The doctor must inform the police by law. Informed refusal should be documented.

Examination should be carried out promptly as detection of injuries and spermatozoa diminishes with delay.

Statement of the survivor and others with her are recorded separately. It is important to take the signature of the informants especially if they are revealing the identity of the assailant.

Statement of Survivor

Whether she knows the accused, whether she was drugged, or threatened.

Date, time and place of alleged offence.

Number of alleged assailants.

Use of alcohol, drugs or weapons

Details of struggle, injuries sustained by the assailants due to scratching, bites, etc. Calls for help and loss of consciousness.

Type and number of sexual acts.

Use of condoms or lubricant, sanitary pads or tampons.

Did ejaculation take place during the act, either within the vagina or outside.

Was there was pain, discharge or bleeding from the vagina.

Details of events after the alleged assault:

Whether she changed or washed clothing; bathed, douched, defecated/urinated prior to the examination, washed, brushed or combed hair, any treatment, drugs/alcohol taken.

The reason for delay in reporting, if any.

Examination of the Survivor

The survivor is examined in the presence of a female nurse or a relative, whose name should be recorded to avoid the doctor himself being accused.

The age, height and weight should be determined.

The survivor should be requested to undress herself.

If menstruating, a second examination should be done after stoppage of menstruation. Note if she appears under the influence of alcohol or drugs and collect sample of blood and urine.

Examination of the Clothes

Enquire whether she changed her clothes. Each item of clothing worn at the time of assault should be removed by the patient in front of the doctor, standing on a clean sheet of paper and anything that falls, e.g. earth, buttons, hair, fibres, gravel, leaves, etc., should be preserved and compared with those found on the accused or at the crime scene.

Clothes should be examined for stains (blood, seminal, mud, earth, grease, grass, etc.), tears, loss of buttons and the site and type of damage.

Seminal stains are often found on underclothing.

The clothes, sanitary pads and tampons should be dried, stored in a clean paper bag and sent to the forensic laboratory.

Examination of Injuries

Close-up photographs of the injuries, especially the perineal area should be taken.

The entire body must be examined for scratches or bruises, lacerations and areas of tenderness with respect to their appearance, extent, situation and probable age.

Petechiae on the face or conjunctiva indicate partial asphyxia caused during restraint.

Marks of violence may be found:

• Around the mouth and throat.

• Where the wrists and arms were seized.

• On the back, especially shoulders and buttocks from pressure on the gravel.

• On the inner, upper thighs.

• On breasts from rough handling.

True bite marks should be photographed and matched with the perpetrator by a forensic dentist.

Marks of general violence are likely to be found in a third of cases.

The absence usually indicates submission of the survivor due to fear of injury or death. Bruises may not be noticed for 48 h following the assault or fade if reporting delayed.

Examination of Nails

Fingernails should be examined for damage and the debris under nails examined for epidermal cells, blood, hair, fibres, etc. Nails of each hand clipped, labelled and put in separate envelopes.

Examination of Hair

The pubic hair should be combed out as nonmatching male pubic hair and foreign material may be present.15–20 hairs are clipped, not pulled.

The hair over the pubic bone area differs from those around the vulva. Therefore, both the areas should be sampled. Hair samples from the head should be taken from four sides.

All samples should be packed, sealed, labelled and sent to laboratory.

Examination for Seminal Fluid

If the pubic hair is matted, the entire matted hair should be cut as close to the skin as possible.

Three vaginal swabs should be taken prior to digital examination of the vagina.

1. One from the area of the introitus and perineum before examining the hymen.

2. A low vaginal swab after separating the labia.

3. A high vaginal swab after examining the hymen.

Three cervical mucus swabs should be collected if the offence was committed more than 24 h earlier.

1. With the first smears should be prepared.

2. A second swab inserted in a small amount of normal saline to look for motile spermatozoa.

3. A third swab to be air-dried and placed in a clean dry test tube for acid phosphatase determination.

The survivor should be examined using ultraviolet light to detect seminal stains.

Dried seminal stains found on external genitalia and thighs show fluorescence in the presence of ultraviolet light. They should be scraped with a blunt knife, sealed and sent for chemical analysis.

Blood Stains

The presence/absence of blood stains around the vagina, discharge, inflammation or STI should be noted.

Examination of Genitalia

Position: The survivor should be placed on a table in good light in dorsal lithotomy. If separation of thighs is painful, cocaine solution should be applied locally.

Labia majora and minora should be examined for bruises, abrasions and lacerations.

The hymen is usually torn posteriorly. In the absence of frank hymenal tear there may be abrasion and bruising of the hymen and vaginal orifice.

Vaginal lacerations are more frequently seen in the lower third on the anterior vaginal wall and in the upper third on the posterior wall.

Lacerations of the posterior fornix are seen more frequently on the right side than left. They are not seen on the anterior fornix.

Unlike penile penetration, tears due to digital penetration or insertion of tampons do not extend to the margin of the hymen.

The hymen can be closely examined by per rectal examination pushing the posterior vaginal wall forwards and anteriorly.

Two-finger test is to be condemned. Genital injuries are present in only 20% of the cases.

SAFE Kits (also known as Sexual Assault Evidence Kits or SAEK kits) are now available.

Contents

Instructions for doctors.

Informed consent form.

Documentation forms.

Large sheet of paper to undress over.

Paper bags for clothing collection.

Catchment paper.

Sterile cotton swabs and swab guards.

Comb, scissors and nail cutter.

Wooden stick for finger nail scraping.

Urine sample container.

Tubes and vials for blood samples (plain, EDTA and sodium fluoride).

Syringes and needles, distilled water, disposable gloves.

Glass slides.

Envelopes for individual evidence samples.

Labels.

Lac stick for sealing.

Clean clothing to be used after examination.

Treatment

Pain relief, tetanus toxoid injection, hepatitis B vaccination,

emergency contraception, broad spectrum antibiotics and HIV prophylaxis are administered.

Psychological support is Important.

Opinion

The doctor should never make a diagnosis of rape but opine whether there are recent signs of sexual intercourse, vaginal penetration, general physical injuries and/or intoxication and whether the signs are consistent with the history given.

In conclusion, the doctor examining a rape survivor is in a unique position to ensure that the examination is documented and crucial evidence is collected properly. The principal author was instrumental in examining the survivor of a high-profile gang rape case in Mumbai. The meticulous documentation of injuries and collection of 11 specimens helped bring the perpetrators to justice [1, 2].

Dr. Purnima Satoskar

is Professor and Head of Unit, Seth G.S. Medical College. She is Head of Fetal Medicine Department and Fellowship Program (MUHS) at Nowrosjee Wadia Maternity Hospital, Mumbai. She is also a Consultant at Jaslok Hospital and Research Centre, Mumbai. She is an FRCOG and Fellow Representative AICC RCOG Western Zone of India. Dr. Satoskar received the Hargobind Medical Foundation Fellowship in 2000 to study Fetal Medicine at Beth Israel Deaconess Medical Centre, Harvard University, Boston, USA. She is a recipient of FOGSI Ethicon Travelling Fellowship, FOGSI Imaging Science Award and FOGSI Rhogam Grant. She has published over 30 papers in National and International journals.