The acute care and examination of a victim of sexual violence must be carried out by a competent forensic examiner in a setting appropriate for crisis intervention, forensic evidence collection, and medical follow up. The aim of forensic evidence and biological material collection is to document an alleged physical or sexual contact between individuals and to corroborate the victim’s and the assailant’s history. This is why the forensic examiner is expected to be objective and in possession of specialised technical and scientific skills. These skills are addressed and recommendations are made on how to carry out a forensic examination. This includes medical and assault history, top-to-toe examination, biological material collection, and documenting injuries while obtaining the chain of custody. Yet, consensus on time limitations for forensic evidence collection is lacking. Available forensic evidence has been shown to benefit prosecution. To meet the legal system’s needs, an interpretation of the findings in a written legal report is mandatory.
Delineating the purpose
The examination of victims of sexual violence is often located at specialised Sexual Assault Referral Centres (SARC), and is multidisciplinary and public in approach, with free access for every citizens. The first SARC was originally opened in Boston City Hospital in 1972, and was born out of new research and understanding of ‘rape trauma syndrome’. Later, several SARCs were established in the other Western countries. The establishment in 1999 of the SARC in Aarhus, Denmark, at the Accident and Emergency department, was based on guidelines stating that every single female who attended the health services should be offered care, treatment, and a medical examination with forensic evidence collection. In areas with no SARCs, the range of help offered to victims of sexual assault might be accidental or fragmentary, with no continuum and follow up. The forensic medical examination first described by Paul in 1975, and later in the widespread ‘gold standard’ Guidelines for medico-legal care for victims of sexual violence by the World Health Organization, however, is a well-known standard protocol.
In this chapter, we aim to describe practical issues relating to the forensic medical examination, with emphasis on evidence collection of biological trace material and competence of physicians.
The world Health Organization defines sexual violence as:
‘Any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work.’
In this chapter, we use the terms ‘sexual violence’ and ‘sexual assault’ to denote episodes of involuntary interpersonal hetero- as well as homosexual acts or contacts, such as completed or attempted penile penetration of the vagina, anus, or mouth (irrespective of whether ejaculation of semen takes place); episodes of penetrating the vagina, anus, or mouth with fingers or objects; and episodes in which a person is believed or considers himself or herself to be assaulted. The Danish penal code considers the assault as rape when forced sexual intercourse, completed or attempted, is acquired with violence or threat of violence. Victims of such sexual assaults are primary recipients of a forensic examination.
Forensic examination
Main components of a forensic examination
The care and examination of an acute sexual assault victim needs to be carried out by a competent medical doctor with knowledge of the psychological response to sexual assault. They must be a competent communicator so that a relevant history of the assault can be obtained. They must know what to look for, how to document and obtain biological trace evidence, and how to interpret and report the findings verbally and in writing. Specialists in forensic medicine at Aarhus University carry out the examinations ensuring impartiality. The examination should take place in a quiet setting with access to necessary equipment and assistance. From the victim’s perspective, prompt medical examination by a physician is seen as crises intervention, and injuries can be treated, and sexually transmitted infection and pregnancy risk evaluated and prevented as necessary. The physician is also responsible for collecting trace evidence.
From a legal perspective, police reports require the following: accurate history; documentations of observations; forensic trace evidence collection; interpretation of the findings; a standardised medico-legal report in objective terms; and provision of expert opinion in legal proceedings.
From the above, a set of main components can be assembled for a full forensic medical examination. These are presented in Table 1 .
| Assessment of the victim |
| Informed consent |
| Medical and gynaecological history |
| Assault history |
| Physical top-to-toe examination |
| Genito-anal examination |
| Trace evidence and biological material collection |
| Documenting injuries and findings |
| Securing chain of custody |
| Interpretation and reporting of findings |
Specific components of the evidentiary examination
Assessment and consent
Upon arrival to the SARC or other setting for the examination, the receiving team (nurse or medical doctor) must establish the order of injuries needing acute medical or surgical treatment; hence, treatment takes priority over prompt forensic examination. The forensic examiner should be alerted, and if possible immediately attend, to the victim for parallel examination and securing of evidence (e.g. clothes). The forensic examiner introduces the victim to the examination, informs them of the options, and obtains informed consent by explaining that confidentiality to the police is not possible. It is fundamental that the victim is not pressed to participate in the examination, and written consent is central if the resulting report is to be used legally. It is obligatory for the police to obtain written consent in advance.
History
For proper disclosure of the history and alleged assault event, the necessary information is best obtained by using a standardised examination protocol acting as a guide for all relevant details. Simultaneously, a standard protocol makes talk of the sexual activity and inflicted coercion more straightforward and less intimidating. Points of forensic medical interest to support subsequent findings are the victim’s general health, use of prescriptive medication or drugs of abuse, menstrual period, former sexual relationships, time since last voluntary intercourse, and recent genital lesions.
It should be explained to the victim that obtaining an assault history is not police questioning, and that the forensic examiner is interested in different aspects of the assaultive episode to the police authorities. Meticulous history taking allows exact documentation and guides the examiner during the following physical examination and trace-evidence collection ( Table 2 ).
| When and where the assault happened. |
| What happened. |
| The exact position of the victim and the assailant during the assault. |
| Surroundings. |
| Use of coercion by violence and restraints. |
| Whether weapons were used or neck compression inflicted, as these have legal implications. |
| Removal of victim’s and assailant’s clothing. |
| Oral, vaginal, rectal, or both, penetration by penis, fingers or objects. |
| Ejaculation. |
| Kissing of the victim’s face or body. |
| Parts of the victim touching the assailant. |
| Aftermath activities such as bathing, changes of clothing, toileting. |
| Genito-anal discharge, bleeding or pain symptoms. |
Top-to-toe and genito-anal examination
It is advisable to conduct the physical examination and the trace-evidence collection simultaneously using the above-mentioned standard protocol, and to also document injuries by using body maps and photography during the examination. The general demeanour and appearance of the victim is noted along with signs of inebriation. The systematic top-to-toe examination should be conducted in the same manner every time, and all parts of the victim’s skin should be inspected. An adequate method is to begin with the head, including the oral orifice and eyelids (petechial bleeding) and the neck. The victim is then asked to recline so that the breast and trunk can be examined followed by the extremities. Remember to cover the victim’s pelvic region and legs while examining the breast and trunk, and vice versa .
With the female victim in supine position, knees drawn and legs apart, inspection of the external genitals and perineum is achieved followed by insertion of a speculum to inspect the vaginal wall and cervix. Trace evidence is collected before insertion of instruments in order to avoid contamination. Specimens from the vagina (i.e. foreign bodies) and samples from the cervix, however, are collected while the speculum is inserted. The anal examination can be carried out with the female victim still in supine position, or turned in the lateral position. After initial inspection and trace-evidence collection, depending on the assault history or signs of profound injury, anoscopy should be carried out.
Use of colposcopy is an area of variation and not routine or recommended in all examination programmes. The Norwegian Society for Gynaecologist recommends use of a colposcope for diagnostic purposes and documentation. In a recent study by Astrup et al., genital lesions were seen with the naked eye in 34% of the cases examined, 49% were seen with colposcopy, and 52% were seen with toluidine blue dye and subsequent colposcopy. As primary intent of the forensic evidence collected is to confirm recent sexual contact, to show if force or coercion has been used (in rape complaints), and to corroborate the victim’s story, the intention is to document as many injuries as possible using utensils as colposcope and dye. It is clear, however, that a genital lesion in itself does not corroborate a legal complaint of rape, but the documentation of a genital lesion could be of importance in the individual case whatever the circumstances and explanations.
The police investigator and legal prosecutor want to know the age of the injury, the way it was inflicted, the type of force used, and the health consequences for the victim. An accurate and complete record of injuries must be compiled, with careful documentation, and proper and rigorous description. Standardised features, such as location, size (continuous use of same unit), shape, colour, and classification, are to be used, allowing correct interpretation and deduction. Classification of injuries should be in accordance with generally used terminology, including bruises, abrasions, contusions, lacerations, sharp-edged wounds, gun wounds and crust-covered wounds.
Site of special forensic interest is conjunctiva and neck, where petechiae, bruises, abrasions, and ligature marks indicate a trauma against the neck. Together with sharp-edged wounds and gun wounds indicating use of weapons, these injuries are signs of the victim having been in life-threatening danger. This could be immediate or potential danger, depending on the exact location, spread and depth of injuries. Such injuries or an assault history, including trauma against the neck, use of weapons, or both, have been shown to significantly affect legal outcome. Other sites of forensic interest are the face with bruises; haematomas of the periorbital region and inner lips indicating blows; the little finger side of hands and forearms, with bruises indicating warding off injuries; shoulders, upper arms and wrists, with bruising (e.g. fingertip) after possible restraint; and bony prominences with abrasions and bruises as caused by falls. Bodily (extra-genital) injuries are reported in 25–90% of victims medically examined. Genital injuries, such as abrasions or lacerations of the fossa navicularis, posterior fourchette, perineum, or perianal region, are possible signs of penetration or attempted penetration by the penis, fingers, or other blunt objects, hence indicating a sexual act. Both positive and negative occurrence of injuries and soiling has to be registered.
Remember that description is different from interpretation, and should not be confused in the injury record.
Trace-evidence collection: why, what, where, when, and how?
The aim of forensic evidence and biological trace material collection is for use in legal proceedings to document an alleged physical or sexual contact between individuals, objects, or places, and to corroborate the victim’s and the assailant’s history. That is why the forensic examiner is expected to be absolutely objective and in possession of specialised technical and scientific skills.
A recommended method is to ask the victim to stand on a sheet of paper in order to collect any falling debris, hairs, or fibres while clothing is secured piece by piece in paper bags. During the subsequent top-to-toe and genito-anal examination, all injuries are recorded and documented diagrammatically. Specimens for DNA and semen are routinely collected with a swab from the face and neck, and both hands, from the gingival margins of the lower jaw, the introitus and fornix vaginae, and the anus. If indicated by the victim’s history, or if visible soiling/contamination, additional samples for semen, blood, saliva, and soiling are taken. Scraping of fingernails with toothpicks ( Fig. 1 ) and a swab from the inside cheek for DNA reference are carried out. Finally, urine and blood samples are collected. Smears on slides are made from the possible semen swabs and stained with haematoxylin-eosin by a laboratory assistant, whereupon the physician looks for spermatozoa under light microscopy. The genetic and toxicological analyses are made on request from the police authorities. The genetic evidence is analysed for semen, blood, saliva, and skin, and DNA type at the Forensic Genetic Department. At the Forensic Chemical Department, specimens are analysed for alcohol and drugs. Forensic scientists at the police department examine the clothing for damage and foreign materials.
Biological trace material as foreign DNA can be detected from semen containing spermatozoa, saliva containing epithelial cells, blood, loose epithelial cells, and hair. Conversely, if DNA is detected, the origin as semen, blood, or saliva can be determined. Furthermore, as evidence of the presence of seminal fluid, spermatozoa can be detected by wet-mounted smear or stained smear on light microscopy, or by prostatic acid phosphatise and prostatic specific antigen, with often a higher prevalence of positive test than microscopy. Non-human specimens to be collected are smudges of vegetation or fibres.
Biological trace evidence is collected from the skin, body orifices, the penis of male victims, nails, blood, and urine, and clothing are obtained. DNA-free cotton swabs, toothpicks, tweezers, paper bags, needles, and containers are used. In general, it is recommended that moistened (sterile water) swabs are used from dry surfaces and dry swabs from wet material. The World Health Organization recommendation from 2003 is to collect specimens as early as possible because the value of evidentiary material decreases dramatically 72 h after the assault. An overview of recommendations of the forensic trace evidence collection procedure is presented in Table 3 .
| Site | World Health Organization | Denmark | Norway a (days) | Sweden (days) | Britain (days) | USA |
|---|---|---|---|---|---|---|
| Gingiva | x | <3 days | <4 | <10 | <2 | <24 h b |
| Palate | <4 | |||||
| Lips | <10 | |||||
| Face | <3 days | |||||
| Genitalia ext. | x | <4 | <10 | <3–5 days b | ||
| Introitus | <3 days | <4 | <10 | <7 a | <3–5 days b | |
| Vagina middle | <4 | |||||
| Fornix post. | x | <3 days | <4 | <10 | <7 a | <3–5 days b |
| Cervix | x | <4 | <10 | 2–7 a | <3–5 days b | |
| Perianal | <4 | <10 | <3 | <24 h b | ||
| Penis | x | <3 days | <4 | <10 | ||
| Anus/rectal | x | <3 days | <4 | <10 | <3 a | <24 h b |
| Skin | x | <3 days | <4 | <10 | <wash | |
| Nails | x | <3 days | <4 | <10 a | <3–5 days b | |
| Hands | <3 days | <10 | ||||
| Clothing | x | <3 days | <4 | <10 | <3–5 days | |
| Blood sample | x | <24 h | <4 | Yes | Yes | <3 days b |
| Urine sample | x | <3 days | <4 | Yes | Yes | <3 days b |
a Norway recommends an abbreviated examination if the examination is 4–7 days after the alleged assault.
b Depending on the assault history, x, recommended before 72 h.
In Denmark, the cut-off limit for trace-evidence collection is set to 72 h, partly as a result of a recent study where spermatozoa were found up to 3 days after the alleged assault, but not after. On the other hand, injuries stay longer, and use of colposcopy and toluidine blue dye has extended the median survival time for visible injuries from 24–80 h, exceeding the time limit for admission to many SARCs. The role of colposcopy and toluidine blue dye is not recommended as a routine procedure until further knowledge is available.
Documenting by securing chain of custody
The primary task of the forensic examiner is to obtain accurate documentation of the examination, including the essential forensic examination components mentioned so far. To secure the identity of the victim, it is important to document who has carried out the examination, who assisted, who attended, what information was available, where and how the examination was carried out, what trace evidence was collected, for what purpose, and how it was secured and stored. The procedure for the whole examination, especially the sampling of trace evidence, has legal implications, as the findings could be used in a court of law. The key word is chain of custody. In order to comply, the medical examination would benefit from using a well-equipped rape kit containing utensils needed for the qualified forensic evidence collection. The kit box in Aarhus ( Fig. 2 ), which is now distributed all around Denmark, was made in co-operation with the Danish Technological Institute, and was approved by DANAK, the Danish authority tasked with evaluating quality assurance. The box secures the chain of custody because all material necessary for evidence collection is available, sterile or DNA-free, and the clinician is familiar with, and has a thorough knowledge of, the utensils. Furthermore, the person who packed the kit, the nurse opening the kit, and the examiner touching the utensils are all traceable. The handling procedures should be clear from the kit’s guidance or the examiner’s manual on how specimens are collected carefully, contamination is avoided, how to label the material accurately and secure and tamper-proof the specimens. Documentation of the transfer of the kit-box from the time it is opened until it is sealed and secured is maintained. How to obtain consent, recording assault history and noting findings on diagrams ( Figs. 3 and 4 ) should be possible in an enclosed protocol or record book. Photography as documentation is mandatory, and knowledge of the capabilities and requirements of the use of photographs in the legal proceeding is necessary. If the kit and manual have been approved by the organisation responsible for standardisation, then doubts about the validity of DNA material to be used in court are diminished. All information that is registered in accordance with specially designed protocols can be easily transferred to a database for further research.
