The accurate description and interpretation of non-genital injuries may be crucial in cases of alleged sexual assault, and may be important in corroborating a victim’s statement of events. In many cases of sexual assault, non-genital injuries may be either absent or trivial; nevertheless, even minor injuries may be of significance and need to be recorded. Injuries may be result from attempts to restrain the victim, whereas others (e.g. bite marks) may have a sexual motive or be part of a sado-masochistic ritual. A standard nomenclature for injuries (i.e. using the terms ‘bruises’, ‘abrasions’, ‘lacerations’, ‘incisions and ‘stab wounds’) should avoid ambiguity between medical examiners.
Introduction
Studies have shown that most victims of sexual assault will have no general injuries or only injuries that may be categorised as trivial. The absence of injuries does not preclude a sexual assault having taken place, particularly if threats of violence have been used or the victim is under the influence of drink, drugs, or both. Similarly, the presence of injuries may indicate violent consensual sexual activity, particularly if the parties indulge in bondage and sado-masochistic acts.
In all cases of alleged sexual assault, a complete physical examination must be carried out, and all injuries, no matter how trivial, should be accurately recorded and, if appropriate, photographed. The absence of injuries should also be recorded by the examiner in their notes, as this too may be important in supporting or refuting allegations made by the complainant.
A systemic approach to the examination of the victim should be used to ensure that parts of the examination are not omitted. The use of diagrams and body charts are useful for recording injuries, and these, along with photographs, provide a permanent record of the injury as well as being a useful aide-mémoire when preparing for court. The size, shape and colour of injuries should be recorded, along with non-specific features such as swelling, localised tenderness and redness. A right-angled ruler is useful for determining the size of an injury, and can be used as a scale when photographs are taken.
History
Before conducting the physical examination, it is important that the examining physician obtains a detailed history of the precise nature of the alleged assault from the victim directly or from police interview notes. This will provide information that may necessitate modifying the way the examination is conducted (e.g. if it is alleged that the assailant bit the victim), and will also be important in correlating non-specific injuries with specific aspects of the history. For example, the victim who alleges she has been forcibly held down on rough ground may have grip-type bruises on the upper arms and streaky abrasions over bony prominences on the back.
History
Before conducting the physical examination, it is important that the examining physician obtains a detailed history of the precise nature of the alleged assault from the victim directly or from police interview notes. This will provide information that may necessitate modifying the way the examination is conducted (e.g. if it is alleged that the assailant bit the victim), and will also be important in correlating non-specific injuries with specific aspects of the history. For example, the victim who alleges she has been forcibly held down on rough ground may have grip-type bruises on the upper arms and streaky abrasions over bony prominences on the back.
Nature of the injury
It is important to appreciate that, on occasions, the only evidence of applied violence may be redness, swelling and tenderness. Such transient lesions, although somewhat non-specific, should be noted and, if visible, photographed without delay as reddening (e.g. caused by a slap) may disappear within an hour or so after infliction. Transient redness, swelling and tenderness may be a feature of forcible hair pulling, and be associated with localised areas of baldness or hair thinning, on the scalp. In such circumstances, it may be necessary to carefully palpate the scalp to locate areas of swelling and elicit tenderness.
Types of injury
One of the most common reasons why medical evidence on injuries, given in court, is contentious is because of the confusing assortment of terms used by doctors and the inappropriate or inaccurate description of an injury. It is, therefore, essential that for medico-legal purposes, a standard nomenclature is used when describing injuries. The following classification is used by forensic physicians and pathologists: (1) bruises, often called contusions; (2) abrasions, also known as scratches; (3) lacerations, sometimes called cuts or tears; (4) incisions, known as slash wounds; and (5) stab wounds, sometimes called penetrating wounds.
A variety of wounds or injury types may co-exist after trauma; an apparent ‘single’ injury may also show features of different types (e.g. an area of abrasion within which is a laceration).
The purpose of this article is not to discuss the features of particular types of injury, which can be found elsewhere, but to consider the interpretation and significance of such injuries in cases of alleged sexual assault.
Bruising
Although bruising is perhaps the most non-specific of all the types of injury associated with assault, there are, nevertheless, specific types of bruising that may be of particular significance.
Finger-tip bruising
Finger-tip bruising are discrete areas of ovoid bruising that may result from finger-tip pressure (e.g. on the skin of the neck) if it is forcibly grasped or on the upper arms if there is an attempt to pin a victim down by holding the arms. Typically, when the arms are forcibly gasped, a group of ovoid bruises, caused by the fingers, can be seen on the outer side of the limb, whereas a single ‘thumb’ mark may be identified on the inner side. Similarly, in attempted manual strangulation, a group of bruises on one side of the neck may be associated with a single bruise on the opposite side, often below the angle of the lower jaw. Finger-tip bruising may also be seen on the inner sides of the thighs when the leg or legs is/are firmly grasped in an attempt to forcibly open the legs for access to the genitalia.
Black eyes
Black eyes are common in all types of assault, not just those of a sexual nature. They are easily sustained, even after relatively minor trauma, caused by a blow to the face such as by punching. Peri-orbital bruising, however, may also result from tracking of blood from injuries to the forehead or scalp or, following severe trauma, from a basal skull fracture ( Fig. 1 ).
Bite marks
Bite marks tend to be of two types. First, there are the typical ‘suction’ type marks, characterised by an area of petechial bruising, and typically seen on the neck or breasts. They are caused by loose skin being sucked into the mouth and then being pressed against the palate by the tongue ( Fig. 2 ). More aggressive biting involves the use of the assailant’s teeth, and these may leave a characteristic, and possibly identifiable pattern, on the skin. Such marks need to be carefully photographed, using a rigid L-shaped measuring rule and appropriately swabbed, with plain sterile swabs, moistened if necessary, for residual saliva (and DNA extraction). Consideration should also be given to asking a forensic odontologist to examine the injury. It should also be appreciated that the presence of a single bite mark is likely to be associated with other similar bites on the body ( Fig. 3 ).
