The examination of the rape victim should focus on the therapeutic, forensic and psychological needs of the individual patient. One aspect will be an examination for ano-genital injuries. From a medical perspective, they tend to be minor and require little in the way of treatment. They must be considered when assessing the risk of blood-borne viruses and the need for prophylaxis. From a forensic perspective, an understanding of genital injury rates, type of injury, site and healing may assist the clinician to interpret the findings in the context of the allegations that have been made. There are many myths and misunderstandings about ano-genital injuries and rape. The clinician has a duty to dispel these.
Introduction
In this chapter, ano-genital injuries in the adult will be reviewed. In this instance ‘adult’ refers to physiological status rather than chronological age. After an allegation of sexual assault, a genital examination might be conducted for several reasons, not just for the detection or otherwise of injuries. It may be, for example, that recovering trace evidence, such as semen, saliva, blood, and lubricant (see chapter on ‘The forensic aspects of sexual violence’ by Mary Newton in this issue of Best Practice and Research Clinical Obstetrics and Gynaecology ), may be recovered. Or, it might be as part of the process of providing emergency contraception by way of an intrauterine contraceptive device.
Why an examination for ano-genital injuries is important
The clinician conducting an examination of a patient (also referred to as victim, complainant or client, but for the purposes of this chapter, patient will be used) who has alleged sexual assault, or where sexual assault is suspected, will undertake a forensic and therapeutic role ( Table 1 ).
| Therapeutic role | Forensic role |
|---|---|
| Injuries may require medical treatment and possibly surgical repair. | Presence and pattern of injuries may support allegations. |
| Presence of injuries is a factor to consider when assessing the risk of contracting an infection. | Absence of injury may refute allegations. |
| Psychological reassurance (either about the absence of injuries or the likely sequelae of injuries that are present). | The appearance of any injuries may assist in estimating the time of the assault. |
Why an examination for ano-genital injuries is important
The clinician conducting an examination of a patient (also referred to as victim, complainant or client, but for the purposes of this chapter, patient will be used) who has alleged sexual assault, or where sexual assault is suspected, will undertake a forensic and therapeutic role ( Table 1 ).
| Therapeutic role | Forensic role |
|---|---|
| Injuries may require medical treatment and possibly surgical repair. | Presence and pattern of injuries may support allegations. |
| Presence of injuries is a factor to consider when assessing the risk of contracting an infection. | Absence of injury may refute allegations. |
| Psychological reassurance (either about the absence of injuries or the likely sequelae of injuries that are present). | The appearance of any injuries may assist in estimating the time of the assault. |
The relationship between ano-genital injuries and the criminal justice process
The presence of ano-genital injuries, rightly or wrongly, has been shown to be a major contributing factor in the various decision-making points from a criminal justice perspective. One problem with this quest to find even the smallest genital injury to support an allegation is that it may then become a self-fulfilling prophecy. In other words, the situation may arise that the presence of injury leads to increased chance of report, trial and conviction, leading to a skewed evidence base. This skewed evidence base may suggest that injuries are seen in cases that result in conviction (i.e. ‘true allegations’), and those examinations that find no injury suggest the converse.
An alternative path is to highlight cases where no ano-genital trauma is detected objectively (by whatever different examination techniques may be used), and yet rape and sexual assault has still been proven by other evidence. This injury evidence base should be used to educate the decision makers (be they victims, healthcare professionals, police, legal profession or members of the public who make up juries). This debate is highlighted by White and Du Mont. They raise concerns that micro-visualisation technologies may increase the chances of rape victims experiencing ‘secondary victimisation’, due, in part, to the highly intrusive and potentially humiliating nature of these technologies. They also argue that too much weight is given to the identification of injuries, and that ‘re-defining rape to require physical injury contradicts a growing body of research that shows that most rapes do not result in an injury other than rape itself.’ They argue that it encourages a departure from the historical definitions of rape and the trend in recent years to broaden the definition of rape to include coercion through mental incapacitation and psychological terror.
McLean et al. looked at 500 allegations of penile vaginal rape and found that, in the cases where an outcome was known (335 cases), no significant associations were found between the presence of genital injury and criminal justice outcome, although the rate was (non-significantly) higher in the small proportion of cases where a conviction was obtained.
It is widely appreciated that sexual violence is under-reported. If it is assumed that it occurs at the same rates within different societies (and this may be a huge assumption), a vast difference in reporting rates can be seen.
Possibly victims are more likely to report an assault if they have injuries. It could be hypothesised that this is because they think their injuries may require treatment and also they perceive that their allegations are more likely to be believed if they have an injury. Additionally, it may be harder to keep the assault ‘secret’ if physical findings are present that may require explanation.
History taking relevant to the ano-genital examination
Several maxims are useful in any medical history taking, and are particularly true with the sexual assault victim:
‘If you interrogate a robin, he will fly away: treelike silence may bring him to your hand.’ (p. 4).
If you only ask questions, you will only receive answers in reply.
A full discussion of the history taking for a sexual assault examination will not be covered in this section. Certain aspects, however, are particularly pertinent to the subsequent interpretation of any ano-genital findings. The history taking needs to be: (1) accurate; (2) contemporaneous; (3) comprehensive; (4) objective; (5) respectful and sensitive; (6) paced at the patient’s rate not the clinician’s rate; and (7) intelligent and tailored to the circumstances and to the findings.
The history taker must be aware of the following such issues: (1) the legal scrutiny that may befall both the questions asked, and their answers, but also the questions not asked and therefore the answers not given. The clinician wears two hats, therapeutic and forensic; (2) in the complainant’s situation, they may be tired, in pain, and frightened, and this might affect recall; and (3) leading questions should be avoided.
Communication needs to be precise, in the accuracy of the words used, and also a common understanding of their meaning. Awareness of how one’s language might be subsequently interpreted is important. An example is the possible confusion that can arise with the use of the word ‘denied’. Clinicians frequently use this term (e.g. ‘patient denies drinking alcohol before the assault’). Other clinicians will understand this as a straightforward question to which the patient has replied in the negative. Non-medics, however, such as police or lawyers, may interpret the use of ‘denied’ as meaning that in fact the doctor ‘suspected’ the patient had drunk alcohol even though he said he had not (i.e. its use is no longer neutral, but pejorative in nature).
Particular aspects of the history that might relate to ano-genital findings include menarche; last menstrual period; whether the patient had been sexually active before the alleged assault (including details such as whether this was digital or penile)?; any sexual activity in the last 10 days; and hormonal status.
This list is not intended to be exhaustive, and clinicians must tailor their questions on a case by case basis.
Anatomy and embryology
The clinician should have a good understanding of external and internal genital anatomy, including normal variations. This will aid accurate detection of genital injuries, description of their site, and enable the clinician to provide a differential diagnosis.
An appreciation of embryology may assist in diagnosis when faced with unusual structural findings.
Embryology of the genitalia
At day 46 of gestation, a second paired-duct system, the paramesonephric (Müllerian) duct, forms parallel to the mesonephric duct. In male embryos, a cascade of gene activation causes the primitive gonad to become a testis, and the mesonephric duct forms the vas deferens; the paramesonephric duct regresses. In female embryos, the primitive gonad becomes the ovary, the mesonephric duct regresses and the paramesonephric duct forms the fallopian tubes, uterus and upper vagina (p. 64).
The external genitalia develop from swellings on the ectodermal surface of the embryo ( Table 2 ).
| Embryological origin | Female | Male |
|---|---|---|
| Mid-line genital tubercle | Clitoris | Penis |
| Para-medial genital fold | Labia minora | Penile urethra |
| Paired lateral genital swellings | Labia majora | Scrotum |
Histology of female genitalia
Histology of the female genitalia is presented in Table 3 .
| Endocervix | Simple columnar epithelium |
| Ectocervix | Stratified squamous epithelium |
| Vagina | Stratified squamous epithelium |
| External genitalia | Keritinised stratified squamous epithelium |
Anatomy of female genitalia
The vulva is a term that encompasses all the external female genitalia: the mons pubis, the labia majora and minora, the clitoris, and the structures within the vestibule – the external urinary meatus, hymen and fossa navicularis (the furrow between the posterior hymen and the posterior fourchette).
The mons pubis is a thickened pad of fat that cushions the pubic bones anteriorly.
The labia majora are two folds of skin, covered by keritanised stratified squamous epithelium, with underlying adipose tissue. They have hair, apocrine sweat glands and sebaceous glands.
The labia minora consist of two thin skin folds. They are not so keritanised as the labia majora. They have sebaceous and sweat glands, but no hair follicles or underlying adipose tissue. They are vascular and erectile during sexual arousal. Anteriorly, the folds bifurcate before uniting to form a hood above the clitoris and a frenulum along its dorsal surface. Posteriorly, the labia minora are joined by a fine ridge of skin, the posterior fourchette.
The legal versus the medical vagina
That different medical and legal definitions of the vagina that exist may give rise to confusion and error between professionals involved in dealing with a rape allegation. The medical definition defines the vagina as a muscular tube that has the cervix at its proximal end and the hymen (or hymenal remnants) at the distal end. The legal definition according to s.79(9) of the Sexual Offences Act 2003, has the distal end of the vagina starting with the vulva (i.e. between the labia), with the result that, for legal purposes, penetration of the vagina does not have to involve penetration of the hymen.
The ano-genital examination
Most women find this examination sensitive and possibly intrusive. It is, therefore, incumbent on clinicians to make it as easy as possible and minimise any associated trauma.
Clinicians can help in the following ways : ensure privacy; prepare swabs and equipment before starting; be sensitive to the patient’s ideas and concerns; offer back power and control; and review consent at the start of this part of the examination.
The clinician and chaperone should take the lead from the patient on the pace of the examination; who else is present in the room with the clinician and chaperone; where the chaperone is positioned (some patients prefer the chaperone to hold their hand and others to be away from the bed); the amount of conversation and even subject matter; and the extent of the examination.
Examination positions
Most adult female genital examinations will take place in the modified lithotomy position, with subsequent anal examination in the left lateral position.
Methods of examining
Injury rates in various published studies differ depending on what examination techniques were used. Some used only naked eye inspection; others used the magnification afforded by colposcopy. Others used toluidine dye with or without colposcopy. This variation means that care has to be given when comparing results of different papers.
Toluidine dye
Toluidine blue dye is an acidophilic, metachromatic, nucleic stain. It was first described in 1963 by Richart as a method of highlighting cervical neoplasms. Since then, it has been used as part of the examination of the complainant of sexual violence. It stains the nuclei of damaged epithelial cells, helping distinguish acute injuries or breaks in the skin from non-injured areas. The surface layer of non-traumatised vulvar skin contains no nuclei. Trauma exposes deeper layers of the epidermis where squamae are nucleated and undergoing maturation. Note toluidine blue is spermicidal and therefore could interfere with other forensic tests. Positive stain results may also have causes other than trauma (e.g. any inflammatory cause as well as benign or malignant vulvovaginal disease).
Colposcope
The colposcope has several benefits of providing a bright cool light source, magnification and the ability to obtain photodocumentation.
Foley catheter
Use of a catheter balloon can be a helpful technique to demonstrate the hymenal edges of a post-pubertal female. In some post-pubertal females, particularly adolescents, the hymenal edge can be fimbriated, making it difficult to visualise the edge clearly. In order to assess for the presence or not of defects such as a transection, the edge needs to be ‘unfolded’. Passing a catheter into the vagina, inflating the balloon, then slowly withdrawing the catheter, allows the edges of the hymen to fan out over the balloon. This should cause minimal discomfort. Should the balloon ‘pop out’ during the process, a note should be made of the ease with which it did so, and the diameter of the expanded balloon. If something of, for example, 2.5 cm diameter, can pop out easily through the hymen, then it may logically follow that something of similar size could easily pass in through the hymen. If forensic samples are to be taken, then they should be done before the catheter examination.
The Foley catheter should be used in post-pubertal females only and after forensic samples have been used. The diameter of the inflated balloon should be recorded (p. 58).
Speculum
Plastic disposable speculae are suitable for the internal examination of the post-pubertal female. Ensure the appropriate size and correct lubrication is used.
Documenting ano-genital injuries
Several vital points should be considered when documenting any injury: separate out objective findings and subjective opinion; make clear, comprehensive, contemporaneous written descriptions; make line drawings using body maps if available; consider the benefits or disadvantages of photo documentation; photo documentation of the ano-genital area will require consideration of different issues. These will be ‘highly sensitive images’ and consent must be gained beforehand. The consent process must cover issues such as use, storage, security, ownership and disclosure of these images. For guidance, see the ‘Ethical guidance’ section of the GMC website: ‘Making and using visual and audio recordings of patients.’
The Faculty of Forensic and Legal Medicine have also produced guidance on the management of such images.
Face of a clock when documenting ano-genital findings
The face of a clock is useful to aid description of the site of any finding. For example, with the patient lying in the supine position (i.e. on their back), the uppermost part of the hymen, nearest the abdomen, would be 12 o’clock, the part nearest the bed would be 6 o’clock etc.
Differential diagnosis of ano-genital findings
It is important that the forensic clinician is able to formulate a differential diagnosis for any findings encountered, from a therapeutic perspective and also from a forensic perspective.
Are the genital findings evidence of trauma resulting from the alleged assault or could there be another explanation? Is there an underlying medical problem that would mean that the patient is more prone to show signs of trauma? Examples of conditions that might be confused with injury include the following: allergy; eczema; psoriasis; Lichen sclerosis; infection (e.g. candida); atrophic vaginitis; urethral prolapse; inflammatory bowel disease; and normal anatomical variations.
The clinician, upon noting findings where trauma is not the only possible explanation, must be prepared to revisit the history-taking to put the findings into context.
Identification of the source of blood: menstrual blood versus blood secondary to trauma
When blood is seen during the genital examination of a complainant of sexual violence, one must consider the differential diagnosis. For example, the blood could either be menstrual in origin or from peripheral blood vessels secondary to trauma. Sometimes, a bleeding point can be identified, but often this is not the case. Recent research has made progress in producing a method to distinguish menstrual blood from normal circulatory blood reliably using D-dimer assays.
Healing of genital injuries
Healing of genital injuries is important to consider from a therapeutic and forensic perspective. For example, the clinician may be asked to consider how old a genital injury is, as this may help determine whether it is a result of previous consensual intercourse or a later alleged assault. In some abuse cases, the age of an injury might assist in determining who had access to the victim during the specified time frame.
As well as knowing the evidence base for the time-frames for retrieval of forensic samples, knowledge of injury healing may assist in deciding whether or not to undertake an examination. Each case should be decided on their own merits depending upon the nature of the allegations.
Wound healing can be divided into a series of stages as detailed below.
Immediate reactions
Immediate reactions include vasoconstriction, activation of clotting, platelets and endothelial cells, haemostasis, and clot formation.
A fibrin clot forms and fills the gap created by the wound. Fibronectin in the extravasated plasma is cross-linked to fibrin, collagen and other extracellular matrix components by the action of transglutaminases. This cross-linking provides a provisional mechanical stabilisation of the wound (0–4 h).
Inflammation
Inflammation occurs within hours of the injury, and its effect can last for 5–7 days. This phase is characterised by erythema, possibly swelling, slight local increase in temperature and possibly pain.
Proliferation: reconstruction, granulation
In ideal conditions, wound epithelialisation may occur within 48–72 h.
Maturation: remodelling
Wound healing is not a linear process. Intrinsic and extrinsic factors particular for each patient may affect healing, and wounds can progress forwards and back through the different phases. Therefore, consideration must be given to factors such as age, general health, infection, medication, nutritional status, and continence.
Kissane, quoted by McCann et al., says that the most superficial injuries are known to have their surface recovered with new epithelium at a rate of 1 mm per 24 h. Regeneration of the tissue of deeper injuries is usually well under way in 48–72 h, whereas multiplication and differentiation of cells takes from 5–7 days. Complete restoration of the tissues requires 4–6 weeks. The maturation of scar tissue may take from 60–180 days or longer.
Maguire et al. looked at women complaining of sexual violence, and found that women examined within 72 h of assault had significantly more injury than those examined after 72 h (40% v 7%, OR 3.70, 95% CI 1.05 to 13.09; P < 0.05).
Anderson et al. looked at how injury patterns change between the initial pelvic examination (within 48 h of consensual intercourse) and then a second examination 24 h after the first. Thirty-five women aged between 18 and 39 years, completed both examinations. The difference in surface area of abrasions and redness, and also posterior fourchette injuries, were significant between the two examinations. No difference was found in surface area between ‘tears, ecchymosis or swelling’. The actual number of lesions seen in this study was not reported.
Astrup et al. published a study on injuries after consensual intercourse, and found that median survival time for lesions was 24 h using the naked eye, 40 h using the colposcope and 80 h using toluidine blue dye.
The evidence base for genital injuries after sexual violence
A difficulty in conducting a review of scientific papers looking at genital injury rates is the lack of standardisation. Some papers use the TEARS classification as proposed by Slaughter and Brown to document injuries: T = tears, defined as any break in tissue (skin or mucosal membranes) integrity including fissures, cracks, lacerations cuts, gashes or rips; E = ecchymosis, defined as skin or mucous membrane discolouration caused by damage of small blood vessels causing ‘bruising’ or black or blue areas; A = Abrasions (excoriations), defined as the removal of the epidermis from skin or mucous membranes; R = Redness, the descriptor for erythematous tissues that are abnormally inflamed as a result of irritation; and S = swelling, defined as local oedema or transient engorgement of tissues.
Many studies, however, exclude erythema and swelling when calculating injury rates, as it is felt that these findings are too subjective. These studies tend to have lower injury rates than those using the TEARS system, making comparison difficult.
Many papers do not stipulate the time from assault to examination or they have a very wide window for such. Given that genital injuries tend to heal quickly, this makes comparison of injury rates difficult.
Many of the US studies involve the use of nucleic staining and colposcopy allowing the examiner to identify, and therefore include in the figures, cases involving microtrauma. Nucleic staining is not practised in the UK and, rightly or wrongly, colposcopy is not used routinely for adult cases. Hence, another factor when comparing injury rates between studies.
Sommers makes an argument for the development of a multi-dimensional model when evaluating genital injuries. This would include prevalence, frequency, location, severity and type, and would allow comparison for different studies across consensual and non-consensual populations.
Genital injuries after consensual sexual intercourse
In order to interpret the significance of genital injuries after sexual assault, we need to understand genital injuries with consensual intercourse. On the whole, the evidence base for this area is lacking.
Anderson and Sheridan reviewed papers that had looked at rates of injury after consensual intercourse, and concluded that too many variables existed between the studies to make comparisons (e.g. subject samples, methodologies, time to examination). It was felt that ‘the presence of even slight genital injuries supported a finding of penetration. The presence or absence of injury, however, cannot be used to determine consensual compared with non-consensual intercourse’.
As mentioned previously, the study by Astrup et al. looked at the detection rates of genital injuries after consensual intercourse using three different techniques: visualisation with the naked eye, colposcopy and toluidine blue dye followed by colposcopy. Injuries included were abrasions, lacerations or bruises (i.e. not the more subjective findings such as swelling or redness). Ninety-eight women took part. Lacerations were the most prominent lesion. Injuries were predominantly located around the posterior fourchette, the rest in the labia and hymen. No lesions were seen in the vaginal wall or cervix. Seen with the naked eye, 31% of the women had a laceration and 34% had a lesion of any kind. When a colposcope was used, 42% had a laceration and 49% had a lesion of any kind. With the use of toluidine blue dye, 50% had a laceration and 52% had a lesion of any kind. Abrasions were seen in 2%, 5% and 7%, respectively.
Frioux et al. described four cases involving vaginal lacerations in adolescents, three of whom gave a history of consensual penile vaginal intercourse. The fourth alleged non-consensual intercourse.
Normally, the cervix tends to shield the posterior pericervical vaginal area during intercourse. A retroverted uterus or sexual intercourse with the female supine with hips hyper-flexed, however, tend to expose this area to trauma.
McLean et al. compared genital injury rates between consensual and non-consensual penile vaginal intercourse. Sixty-eight women, all aged over 18 years, were examined within 48 h of having had consensual penile vaginal intercourse. Four out of 68 women had (naked eye examination alone) a genital injury (erythema or swelling not included as injuries). In total, among these four women, only six injuries were sustained. Four of these six injuries were bruises. The injuries in the control group tended to be smaller (no exact sizes given) than those where non-consensual intercourse was alleged.
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