Examination in the Case of Alleged Sexual Assault
Introduction
There is no doubt that examinations of adults in this arena, along with those involving children, can
be the most demanding of circumstances.
The first part of this chapter will deal with the adult. The second with the child where this differs.
This is not to say that other areas of clinical forensic medicine can be approached with less skill and
more superficial knowledge; they cannot. In these areas however, the FME will be faced with
establishing an ambience which will allow the necessary comprehensive examination to take place.
• Whilst preserving the dignity of the examinee as well as the forensic specimens
• By coaxing the patient to be compliant whilst allowing them to regain a control which may have
been severely damaged during any assault
• Whilst accepting the patient's communications with total belief and compassion yet maintaining a
scientific objectivity so that any evidence can be presented without bias or prejudice
"Examination" is a euphemism for the whole doctor/patient interface, involving as it does in good
forensic practice, skills, knowledge and attitudes which go a long way beyond the ability to record
genital findings.
Ideally the "processing" of a complainant, should take place within an organised structure involving
not only appropriately trained and experienced forensic clinicians but also:
1. Trained police officers
2. Trained counsellors
3. Sexually Transmitted Disease (STD) screening facilities and specialist adviser.
4. Obstetric and Gynaecology/Urology/Paediatric specialist back up services
5. Specialist suites.
It is important that where possible the patient has a choice of gender of those who are going to have
intimate contact with them.
In this chapter the use of the term "victim" must be read as "alleged victim". There is no intent that
any forensic clinician should have a prejudicial bias. It is the court that will decide guilt or
innocence, whatever the initial percieved truth of the matter.
Appendix 8a shows a schematic outline of Greater Manchester Services in this field.
General Issues
Medical records are important. Chapter 1 should be read.
Some centres (eg St Mary's Sexual Assault Centre (SMSAC) in Manchester) have developed their
own proformata. If there are confidential notes or common notes which are important for continuing
care such as counselling or STD treatment, it may be a policy that those notes are not removed from
the centre. Otherwise the advice about record responsibility is as discussed in Chapter 1.
Consent has been covered in Chapter 2. Examination of a victim may present forensic and
therapeutic aspects and the doctor must ensure that the appropriate informed consent is obtained.
The police surgeon must be clear in his/her own mind before explaining the features of each to the
examinee.
Though this chapter describes the situation with regard to females, the procedure apart from the
obvious exception of the genital examination applies equally to male complainants. For examination
of the penis, the section in the following chapter should be read.
It is extremely important that the patient understands that any relevant detail of the exchange
between him/herself and the doctor may be discussed in public court.
The Examination
Introduction
The FME should introduce him/herself, explaining what must be done.
The complainant should be asked how they would like to be addressed. It should not be assumed
that they wish to be called by their first name.Sympathy to their plight is important (remembering, but in no way expressing, that this predicament
is only alleged at this stage), it can be expressed whilst the details of the thoroughness of the
examination and sample taking procedure are explained. Attention should be drawn to the way the
evidence can help in court, but additionally the examinee informed that no promises can be given as
regards the outcome of any court case.
The benefit of being able to reassure as to the lack of anatomical damage can be comforting.
Explaining to the patient that they are in control, and even though the examination may be long and
tedious, it should never be more than uncomfortable at the most and that they can call a halt at any
time, may help to dispel some of the feeling of vulnerability which can be left after an assault.
Continuing to converse with or talk to the patient throughout the examination can be reassuring.
Specific medical problems can also be addressed such as STD. It is worth reminding the patient that
this information is not recognised generally as being of value as forensic evidence, and that the
disclosure is covered by law (see Chapter 3). If AIDS is mentioned as a specific concern, then it
must be addressed in superficial general terms and specialist counselling arranged with pre and post
HIV testing counselling sessions provided, otherwise it is best left for any counsellors to deal with
it, if necessary, at a later date.
History of Event
This should be obtained from the sources available. This usually means the reporting police officer
and then the complainant. Detailed notes should be made and checked with the patient with
particular reference to any discrepancies that exist between any versions received (see page 10
"WHAT").
A complainant may not mention all that has happened, and careful probing may be needed to elicit
the full history of events (for example a female may be reluctant to admit buggery). Leading
questions, as always, should be used as a last resort.
The history should also include recent sexual intercourse before and after the event.
General Medical History
Current medical problems, and past medical, surgical, injury (not considered by some to be a
medical problem) and obstetric & gynaecological history should be obtained.
Gynaecological history is important as is history of recent intercourse.Sympathy to their plight is important (remembering, but in no way expressing, that this predicament
is only alleged at this stage), it can be expressed whilst the details of the thoroughness of the
examination and sample taking procedure are explained. Attention should be drawn to the way the
evidence can help in court, but additionally the examinee informed that no promises can be given as
regards the outcome of any court case.
The benefit of being able to reassure as to the lack of anatomical damage can be comforting.
Explaining to the patient that they are in control, and even though the examination may be long and
tedious, it should never be more than uncomfortable at the most and that they can call a halt at any
time, may help to dispel some of the feeling of vulnerability which can be left after an assault.
Continuing to converse with or talk to the patient throughout the examination can be reassuring.
Specific medical problems can also be addressed such as STD. It is worth reminding the patient that
this information is not recognised generally as being of value as forensic evidence, and that the
disclosure is covered by law (see Chapter 3). If AIDS is mentioned as a specific concern, then it
must be addressed in superficial general terms and specialist counselling arranged with pre and post
HIV testing counselling sessions provided, otherwise it is best left for any counsellors to deal with
it, if necessary, at a later date.
History of Event
This should be obtained from the sources available. This usually means the reporting police officer
and then the complainant. Detailed notes should be made and checked with the patient with
particular reference to any discrepancies that exist between any versions received (see page 10
"WHAT").
A complainant may not mention all that has happened, and careful probing may be needed to elicit
the full history of events (for example a female may be reluctant to admit buggery). Leading
questions, as always, should be used as a last resort.
The history should also include recent sexual intercourse before and after the event.
General Medical History
Current medical problems, and past medical, surgical, injury (not considered by some to be a
medical problem) and obstetric & gynaecological history should be obtained.
Gynaecological history is important as is history of recent intercourse.Clinical features should all be recorded. Height, weight, general appearance and demeanour, as well
as any fetor or other stigmata may all be important.
A thorough inspection of the body is necessary. The general body inspection can be done in sections
to preserve the dignity of the patient as much as possible.
Any injury or significant lesion should be notated. See page 92 on examination in cases of assault.
Photography can be useful as an adjunct to the handwritten records and/or sketches and are
extremely useful as a teaching accessory later. Whenever possible a photograph of a lesion, as
opposed to a scene, should contain a scale. If photography is considered necessary for evidential
purposes then the FME should contact the Senior Investigating Officer with regard to use of
the professionally trained police photographer. It helps if female Scenes of Crime Officers
(SOCOs) trained in evidential photography are available.
As well as the general injuries mentioned in the previous chapter there are further specific findings
which may be of evidential value:-
Bite-marks, as well as photography and the referral to a forensic odontologist, should be swabbed.
The swab should be moistened with water from a sterile ampoule, and twisted around on the bite
area. If photography is performed without the presence of the odontologist the views should be
ideally 1:1, with two scales at right angles, and three views perpendicular and either side at 45 ° in
the same plane.
The eyes should be inspected for redness or petechiae.
The scalp may show petechiae, purpura or pin-point haemorrhage at the hair roots when the hair has
been pulled. Hair loss may also be noted. The scalp should be palpated for soft tissue swelling.
The mouth should be inspected as should the auditory meatus and behind the pinnae.
It is possible that fellatio occurred causing petechiae on the palate. 72
As well as soft tissue damage, the nails should be inspected for breaks or possible fibres or skin
from the "assailant".
Genital Examination
The vulva should be inspected, under illuminated magnification, for redness, grazes, splits in the
fourchette and bruising.
External swabs should be taken, including the peri-anal area.
Low vaginal swabs should be taken after gentle separation of the labia. Care must be taken not to
introduce any external contaminant into the vagina.
Introduction
There is no doubt that examinations of adults in this arena, along with those involving children, can
be the most demanding of circumstances.
The first part of this chapter will deal with the adult. The second with the child where this differs.
This is not to say that other areas of clinical forensic medicine can be approached with less skill and
more superficial knowledge; they cannot. In these areas however, the FME will be faced with
establishing an ambience which will allow the necessary comprehensive examination to take place.
• Whilst preserving the dignity of the examinee as well as the forensic specimens
• By coaxing the patient to be compliant whilst allowing them to regain a control which may have
been severely damaged during any assault
• Whilst accepting the patient's communications with total belief and compassion yet maintaining a
scientific objectivity so that any evidence can be presented without bias or prejudice
"Examination" is a euphemism for the whole doctor/patient interface, involving as it does in good
forensic practice, skills, knowledge and attitudes which go a long way beyond the ability to record
genital findings.
Ideally the "processing" of a complainant, should take place within an organised structure involving
not only appropriately trained and experienced forensic clinicians but also:
1. Trained police officers
2. Trained counsellors
3. Sexually Transmitted Disease (STD) screening facilities and specialist adviser.
4. Obstetric and Gynaecology/Urology/Paediatric specialist back up services
5. Specialist suites.
It is important that where possible the patient has a choice of gender of those who are going to have
intimate contact with them.
In this chapter the use of the term "victim" must be read as "alleged victim". There is no intent that
any forensic clinician should have a prejudicial bias. It is the court that will decide guilt or
innocence, whatever the initial percieved truth of the matter.
Appendix 8a shows a schematic outline of Greater Manchester Services in this field.
General Issues
Medical records are important. Chapter 1 should be read.
Some centres (eg St Mary's Sexual Assault Centre (SMSAC) in Manchester) have developed their
own proformata. If there are confidential notes or common notes which are important for continuing
care such as counselling or STD treatment, it may be a policy that those notes are not removed from
the centre. Otherwise the advice about record responsibility is as discussed in Chapter 1.
Consent has been covered in Chapter 2. Examination of a victim may present forensic and
therapeutic aspects and the doctor must ensure that the appropriate informed consent is obtained.
The police surgeon must be clear in his/her own mind before explaining the features of each to the
examinee.
Though this chapter describes the situation with regard to females, the procedure apart from the
obvious exception of the genital examination applies equally to male complainants. For examination
of the penis, the section in the following chapter should be read.
It is extremely important that the patient understands that any relevant detail of the exchange
between him/herself and the doctor may be discussed in public court.
The Examination
Introduction
The FME should introduce him/herself, explaining what must be done.
The complainant should be asked how they would like to be addressed. It should not be assumed
that they wish to be called by their first name.Sympathy to their plight is important (remembering, but in no way expressing, that this predicament
is only alleged at this stage), it can be expressed whilst the details of the thoroughness of the
examination and sample taking procedure are explained. Attention should be drawn to the way the
evidence can help in court, but additionally the examinee informed that no promises can be given as
regards the outcome of any court case.
The benefit of being able to reassure as to the lack of anatomical damage can be comforting.
Explaining to the patient that they are in control, and even though the examination may be long and
tedious, it should never be more than uncomfortable at the most and that they can call a halt at any
time, may help to dispel some of the feeling of vulnerability which can be left after an assault.
Continuing to converse with or talk to the patient throughout the examination can be reassuring.
Specific medical problems can also be addressed such as STD. It is worth reminding the patient that
this information is not recognised generally as being of value as forensic evidence, and that the
disclosure is covered by law (see Chapter 3). If AIDS is mentioned as a specific concern, then it
must be addressed in superficial general terms and specialist counselling arranged with pre and post
HIV testing counselling sessions provided, otherwise it is best left for any counsellors to deal with
it, if necessary, at a later date.
History of Event
This should be obtained from the sources available. This usually means the reporting police officer
and then the complainant. Detailed notes should be made and checked with the patient with
particular reference to any discrepancies that exist between any versions received (see page 10
"WHAT").
A complainant may not mention all that has happened, and careful probing may be needed to elicit
the full history of events (for example a female may be reluctant to admit buggery). Leading
questions, as always, should be used as a last resort.
The history should also include recent sexual intercourse before and after the event.
General Medical History
Current medical problems, and past medical, surgical, injury (not considered by some to be a
medical problem) and obstetric & gynaecological history should be obtained.
Gynaecological history is important as is history of recent intercourse.Sympathy to their plight is important (remembering, but in no way expressing, that this predicament
is only alleged at this stage), it can be expressed whilst the details of the thoroughness of the
examination and sample taking procedure are explained. Attention should be drawn to the way the
evidence can help in court, but additionally the examinee informed that no promises can be given as
regards the outcome of any court case.
The benefit of being able to reassure as to the lack of anatomical damage can be comforting.
Explaining to the patient that they are in control, and even though the examination may be long and
tedious, it should never be more than uncomfortable at the most and that they can call a halt at any
time, may help to dispel some of the feeling of vulnerability which can be left after an assault.
Continuing to converse with or talk to the patient throughout the examination can be reassuring.
Specific medical problems can also be addressed such as STD. It is worth reminding the patient that
this information is not recognised generally as being of value as forensic evidence, and that the
disclosure is covered by law (see Chapter 3). If AIDS is mentioned as a specific concern, then it
must be addressed in superficial general terms and specialist counselling arranged with pre and post
HIV testing counselling sessions provided, otherwise it is best left for any counsellors to deal with
it, if necessary, at a later date.
History of Event
This should be obtained from the sources available. This usually means the reporting police officer
and then the complainant. Detailed notes should be made and checked with the patient with
particular reference to any discrepancies that exist between any versions received (see page 10
"WHAT").
A complainant may not mention all that has happened, and careful probing may be needed to elicit
the full history of events (for example a female may be reluctant to admit buggery). Leading
questions, as always, should be used as a last resort.
The history should also include recent sexual intercourse before and after the event.
General Medical History
Current medical problems, and past medical, surgical, injury (not considered by some to be a
medical problem) and obstetric & gynaecological history should be obtained.
Gynaecological history is important as is history of recent intercourse.Clinical features should all be recorded. Height, weight, general appearance and demeanour, as well
as any fetor or other stigmata may all be important.
A thorough inspection of the body is necessary. The general body inspection can be done in sections
to preserve the dignity of the patient as much as possible.
Any injury or significant lesion should be notated. See page 92 on examination in cases of assault.
Photography can be useful as an adjunct to the handwritten records and/or sketches and are
extremely useful as a teaching accessory later. Whenever possible a photograph of a lesion, as
opposed to a scene, should contain a scale. If photography is considered necessary for evidential
purposes then the FME should contact the Senior Investigating Officer with regard to use of
the professionally trained police photographer. It helps if female Scenes of Crime Officers
(SOCOs) trained in evidential photography are available.
As well as the general injuries mentioned in the previous chapter there are further specific findings
which may be of evidential value:-
Bite-marks, as well as photography and the referral to a forensic odontologist, should be swabbed.
The swab should be moistened with water from a sterile ampoule, and twisted around on the bite
area. If photography is performed without the presence of the odontologist the views should be
ideally 1:1, with two scales at right angles, and three views perpendicular and either side at 45 ° in
the same plane.
The eyes should be inspected for redness or petechiae.
The scalp may show petechiae, purpura or pin-point haemorrhage at the hair roots when the hair has
been pulled. Hair loss may also be noted. The scalp should be palpated for soft tissue swelling.
The mouth should be inspected as should the auditory meatus and behind the pinnae.
It is possible that fellatio occurred causing petechiae on the palate. 72
As well as soft tissue damage, the nails should be inspected for breaks or possible fibres or skin
from the "assailant".
Genital Examination
The vulva should be inspected, under illuminated magnification, for redness, grazes, splits in the
fourchette and bruising.
External swabs should be taken, including the peri-anal area.
Low vaginal swabs should be taken after gentle separation of the labia. Care must be taken not to
introduce any external contaminant into the vagina.
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