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53. Examination of Sexual Assault Victim
53.1 Introduction
Sexual abuse is a serious infringement of one’s rights to health and protection. It is not only a particular nation’s problem but has become global public health issue. Sexual abuse until 1970 was restricted to poor economy class of people only and was rarely found. Now the cases are seen in all socioeconomic groups. Sexual abuse includes genital–genital, genital–rectal, oral–genital, hand–breast, hand–rectal, and hand–genital contact, exposure of sexual anatomy, forced view of sexual anatomy, and using a victim in the production of pornography or showing pornography.
Sexual assault is cognizable, non-bailable offence under the criminal law, and the offender is liable for punishment that includes imprisonment of varying duration, fine, and even death penalty. It is one of the serious crimes in India.
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Natural offences: Sexual offences which are performed in the order of nature, i.e., by penetration of the female organ (vulva) by the male organ (penis), are called as natural offences.
Examples: (1) Incest, (2) adultery, and (3) rape
- 2.
Unnatural offences: Sexual offences where intercourse is performed against the order of nature, i.e., when the act does not involve penetration of a woman’s vagina by the penis of a man, are included under unnatural offences.
Examples: (1) Bestiality, (2) buccal coitus, (3) tribadism, and (4) sodomy
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Sexual perversions: These are the sexually perverted acts such as (1) necrophilia, (2) sadism, (3) masochism, (4) transvestism, (5) fetichism, (6) masturbation, (7) voyeurism, (8) frotteurism, (9) undinism, and (10) exhibitionism.
Rape as said by the UN ’s human-rights chief is a “national problem” and is regarded as one of India’s most common crimes against women. A new case is reported every 20 min even in developed countries. Among Indian cities, New Delhi has the highest rate of rape cases. Rape cases in India have doubled between 1990 and 2008. 24,206 rape cases were registered in India in 2011 (National Crime Records Bureau) although experts agree that the number of unreported cases is much higher. Considering the magnitude, seriousness of the offence, and its long-term impact on the life of the victim, it is the obligatory duty of the medical and paramedical personnel to help the judiciary and crime department to convict the offender by collecting evidence against him by doing proper examination of the sexual assault victim.
Sexual Assault Victim
53.2 Examination of the Alleged Case of Sexual Assault Victim
The comprehensive forensic medicolegal examination of the victim is very important in the full investigation of the case and the building of an effective prosecution in the court. It should be conducted without unnecessary delay so that the findings should not disappear or mislead. For example, spermatozoa, if present in the vagina, should not disintegrate [1]. The alleged victim of sexual assault should be protected from any additional emotional trauma during physical examination. The details of medical examination of the victim are as follows.
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Look for physical signs (injuries) that will corroborate the history given by the victim.
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Collect and preserve all physical (trace) evidence for laboratory examination.
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Offer treatment to the victim for injuries and against venereal disease or pregnancy.
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Prevent or minimize permanent psychological damage.
General Method [2]
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Authorized person either a magistrate or the officer in charge of a police station should send a requisition for examination of the victim in connection with the alleged incident of rape.
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To identify the victim before the medical officer, an authorized person should be there about whom there should be mention in the requisition.
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The woman cannot be forced for medical examination against her will by the court or the police. Therefore prior written consent in the presence of a witness should be obtained before the start of medical examination of the alleged victim if she is 12 years or above and of parents or guardians (about whom there should be mention in the requisition) if her age is below 12 years or if the alleged victim is mentally unsound or intoxicated. So as to avoid subsequent criminal charge of indecent assault against the examining doctor, consent for examination is a must.
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It is necessary to note down identification marks of the alleged victim.
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The rape victim should be allowed to give her own account of the act without any questions being put to her.
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The name of the victim and her parent/husband if married, age, height, weight, residence, occupation, date, time and place of examination, and name of the police station by whom the requisition is given should be accurately recorded.
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The developmental, behavioral, mental, and emotional status in the case of the child/adolescent victim should also be briefly assessed.
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Medicolegal examination is one of the star evidences in the judicial proceeding that should not be ignored. The tenderness and swelling of the vulva may disappear after some hours. The possibility of finding spermatozoa from the genital tract also decreases with delay. Therefore it is advisable to examine and collect all relevant and feasible materials from a victim at the earliest after the incident, to achieve the above goal.
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Record statements of the victim and of others with her separately. They should include:
- (a)
Preliminary affairs
- (b)
Date, time, and place of the offence alleged
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Parties’ exact relative positions
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Evidence of struggle or resistance
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Calls for help
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Whether she experienced any pain then and afterwards
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Was there ejaculation during the act, either within the vagina or outside
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Any associated discharge
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Whether she had any bleeding from the vagina
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Whether there was loss of consciousness anytime during the attack
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Any other events after the alleged assault
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When the first complaint was filed and if there was undue delay, the reason for that.
All this must be taken down verbatim.
- (a)
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It is important to note down previous history with regard to sexual experience, menses, vaginal discharge, venereal disease, pregnancies, pelvic operations, etc. Children who are subjected to sexual assaults may not be able to give proper history. So the examiner must have high degree of suspicion. Many times a sexually assaulted victim might have been brought to a gynecologist, only with the history of trauma and bleeding per vagina or inability to pass the urine or loss of appetite. Hence, a medical practitioner is not only morally but also legally bound to take detailed history from the child, guardian, accompanying person, and police inspector and document it.
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The victim is examined in the presence of an adult mentally sound female attendant, either hospital nurse or a female relative of the alleged victim. This applies specially to male medical officer.
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Note down the physical development in order to determine her capacity to struggle and resist.
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Her general behavior and mental status should be observed, while she narrates her story.
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Her gait should be observed, and specific questions related to pain while walking, on micturition, or defecation should be asked. We can notice guarded gait due to pain, the victim walking with legs apart and slow steps(women should not be made naked to test the gait).
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The removal of dress should be done by the victim herself or by the female attendant and not by the male doctor himself. No force to undress her should be made by the attendant.
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A second examination should be done after stoppage of menstruation if the victim is in menstrual period.
The identity of the victim against whom an offence is alleged to have been committed should not be disclosed and is not permitted [3].
Evaluation of Mental Status [1]
The victim should subsequently be referred to a psychiatrist if mental unsoundness is doubted. Note down if she appears to be intoxicated and under the influence of drugs or alcohol, and her blood and urine samples should be preserved after necessary physical examination.
Evaluation of Developmental Status of Secondary Sex Features [1]
The appearances and growth of breasts, axillary, and pubic hair should be noted. The sexual habit of the woman can be guessed from the appearance of the breasts. The breasts will be hemispherical, firm, and spongy with similar nipples and have pinkish areola in a woman not accustomed to sexual practices. The breasts will be larger, lax, and slightly pendulous with larger raised nipples in women habituated with sexual practices. The areolar color may not change before pregnancy.
Examination Proper [2]
- 1.
Examination of the clothes:
Inquiry about the change of clothing and a bath or wash should be made. Attempt should be made to find out whether the clothes of the victim are those worn at the time of sexual assault or changed. Each item of the clothing should be examined for stains (blood, seminal, mud, grass, etc.), soiling, tears and loss of buttons, and the site and type of damage. If the offence has been committed in an open place, corroborations can sometimes be obtained by finding grass, leaves, mud, etc. on the buttocks or on the back. In certain cases stains may be present on pieces of material or handkerchief used by the victim after assault for cleaning purpose. Vulval pads and vaginal tampons whether worn at or after the time of the incident should be preserved. Clothes play very important role in corroborating or contradicting her story. Foreign hair, fibers, etc. found on the clothes or on the skin surface must be preserved and compared with those found on the accused.
- 2.
General examination:
It includes inspection of the whole body for marks of violence resulting from struggle, their appearance, situation, extent, and probable age. They can be found around/on (1) the mouth and throat, produced while preventing her from calling for help, (2) wrists and arms, (3) the inner side of thighs and knees, (4) the back from pressure on hard ground, and (5) the breasts by rough handling. True bite marks and love bites are usually found on the breasts, neck, chest wall, lower abdomen, and upper parts of the thighs. The nature and situation of the general injuries should correspond with the victim’s description of the assault. Marks of violence are likely to be found in one-third cases. The absence of general injuries may be due to: (1) Submission of the victim due to fear of injury or death, etc. (2) Insufficient force to produce an injury. (3) After 48 h bruises may not be noticed. (4) Delayed reporting of the incident during which minor injuries will heal.
General injuries are observed only in 1/5th cases because of (1) alleged sexual act consisting of only rubbing or touching the genitalia, (2) sexually experienced victim, (3) elasticity of genitalia and hymen in a post-pubertal female, and (4) the use of lubricants. The victim usually scratches the assailant during the struggle. Debris under the nails should be removed and examined for epidermal cells, blood, fibers, etc. At the same time, any damaged fingernails should be noted.
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Special local examination [2]:
After completing the consent formalities depending upon the age of the alleged victim, she is placed on an examination table in good light with her legs drawn up and widely opened (lithotomy or knee-chest position). If possible, a vaginal speculum should be used. Vaginal lining should be examined to see any abrasion, bruises, erosions, or vault tears. Digital examination may show (1) areas of pain and tenderness in the vagina, (2) some laxity of the vaginal orifice (indicating previous penetration), or (3) elongation of the posterior fornix of the vagina (indicating frequent sexual intercourse).The size of the vagina should be noted as admitting one, two, or three fingers as the case may be(Pl refer Supreme Court Judgment quoted later on).
The police or court has no power of compelling a woman to submit the private part of her person to the examination of a medical practitioner [3].
The local findings may change depending upon the type of victim as below.
- (a)
Rape on a virgin [2]: The hymen is examined by gently separating the labia. Rupture of the hymen occurs with the first intercourse, which is the main evidence of rape in a virgin. The nature and extent of injury varies in different cases depending upon (1) disproportion between male and female parts, (2) extent of penetration, (3) the nature of the hymen, and (4) amount of force used. Tearing usually occurs posteriorly at the sides in the 4 or 8 o’clock position or in the midline of the hymen. More than one tear may occur. Several hymenal lacerations indicate first intercourse. Tears usually occur in the posterior midline of the hymen because the hymen lies suspended across a potential space, whereas anteriorly the periurethral tissues buttress the hymen. Any object passing through the hymenal orifice which is larger than its original opening will cause a V-shaped cleft or clefts. One deep tear may be seen at 6 o’clock position or a number of tears usually in the posterior half of the membrane. With healing over a period of months, V-shaped tear becomes rounded and appear as U-shaped defects. In pre-pubertal children, the posterior tear of the hymen may involve fourchette producing a deep U-shaped defect. The margins of the torn hymen are sharp and red which bleed on touch; the tissues around about them are swollen and tender soon after the act. The edges of laceration are congested and swollen after 3–4 days of an offence and get healed completely in a week, but they do not unite. Rupture of the hymen due to sudden stretching can be caused by agents other than male genital organ such as fingers, and therefore, evidence of local injury is not proof of penetration. Many a times, in the absence of hymenal tearing, there is abrasion and bruising of the hymen and the vaginal orifice.
For close examination of the hymen, Glaister-Keen glass rod, warmed to body temperature, should be passed through the hymenal orifice. Then it is passed around the posterior surface of the hymen, which is slightly stretched by separation of labia minora. The edges of the hymen become slightly everted by this procedure. By slowly rotating the sphere around the edges, natural notches are easily differentiated from tears, recent or old. This method does not cause any injury or pain. Another method is to pass a finger into the rectum above the perineal body and push the posterior vaginal wall forwards and downwards. This pushes the hymen forwards which is clearly seen entirely, lying against the posterior vaginal wall.
Injury to the labia is not common, but fingernail scratches may be present on the labia, particularly the labia minora. The labia may be red and inflamed with slight edema of the vaginal introitus if it is the first sexual act. Bruising and lacerations of external genitals may be present with redness, swelling, and inflammation if there is disproportion between the male and female genitals. Swelling and congestion of the mucosa at introitus, the clitoris, and the labia minora are caused by genital stimulation, but they may also be caused by digital stimulation or masturbation. These signs usually fade in 1 or 2 h. Swelling and tenderness of the labia minora may indicate sexual activity. The posterior commissure is usually intact in the virgin and often ruptures at first intercourse, especially if there is much disparity in the size of the penis and vagina. The fourchette is fragile and often tears during the first intercourse. Fossa navicularis disappears. Bruising of the vagina is seen as dark-red areas against the overall redness of the vaginal mucosa, and within 24 h, the color becomes deep red or purple. It is more frequently seen on the anterior vaginal wall in the lower third and on the posterior vaginal wall in the upper third. Bruising of this nature is more consistent with penile penetration than with digital penetration. These types of injuries can occur during consenting sexual intercourse. In rape or digital penetration without consent, where preliminary stimulation has not taken place, initial lubrication will be lacking, due to which more severe local bruising or abrasion can result. In women of childbearing age, frank laceration of the vaginal wall or vault is rare following sexual intercourse, but it can occur in very young children and in the atrophic post-menopausal vagina. Posterior laceration of the vaginal wall occurs with violent intercourse or where there has been considerable disproportion between the penis and the vagina. Severe stretching/tearing of the vagina and labia may occur even with slight entry of the penis. Some degree of local injury may be caused by sudden forcible dilatation of the vagina in majority of adult rapes. But one should keep in mind that even with consenting woman, bruising, laceration, or abrasion are at times seen with forceful intercourse that does not indicate rape. In all cases where there are no marks of fresh injury, one should do vaginal examination to assess (1) the laxity of the vaginal orifice, (2) the length of the vagina into the posterior fornix, (3) the number of fingers that can be introduced through the hymenal orifice, and (4) the areas and the degree of tenderness complained of by the patient. All these should be attempted if the state of the hymen permits. A finger may be inserted into the vagina in most young women although the hymen is intact, which is felt as a constricting ring around the tip of the finger. Vaginal examination helps the examiner to assess the elasticity of the hymen and to determine the degree of penetration which would be possible without its rupture. The possibility of sexual intercourse may be inferred if the vaginal opening easily admits two fingers (as per the present laws of evidence, two-finger test has no special importance). The vagina needs to be inspected for signs of bruising, abrasion, and laceration by introducing speculum.
- (b)
Rape on Deflorate Women [2]:
The hymen is completely destroyed, the vaginal orifice dilated, and the mucus membrane wrinkled and thickened in the case of deflorate women, even without childbirth. Complete penetration can occur in such women without any evidence except semen. The presence of spermatozoa in the vagina is the only proof that penetration has occurred. Therefore, the absence of injuries under certain circumstances does not exclude even complete penetration. In a married woman though, marks of violence to the genitalia are less likely to be found, but they must be looked for because rape is associated with greater violence than sexual intercourse with consent. The vagina may show laceration, bruising, deep injury with effusion of blood, swelling, and inflammation of the vulva even when no marks of violence indicating a struggle may be found externally. Tearing or perforation of the vagina may occur when it is thin or fragile. When older women are raped, senile atrophy and friability of their genitalia result in extensive vaginal lacerations and perineal trauma. In women who have been used to sexual intercourse, injuries from rape usually disappear or become obscure in 3–4 days. When there has been much violence, they may persist for longer duration. The chief evidence of crime may be found on other parts of the body in the form of injury marks.
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