Sexual offences include1. Rape2. Incest3. Unnatural offences (eg anal, oral, intercrural intercourse)4. Acts of gross indecency5. Grave sexual abuse6. Sexual harassment (words/actions)
Rape Not a medical diagnosis but a legal concept. Definition depends on the law of the country. In section 363 of penal code in Sri Lanka.
A man is said to commit rape who has sexual intercourse with a woman under the following.a. With out her consent even where such a woman is his wife and she is judicially separated from the manb. With her consent when her consent has been obtained by the use of force or threats or intimidation or by putting her in fear of death or of hurt or while she was in unlawful detentionc. With her consent when her consent has been obtained at a time when she was of unsound mind or was in a state of intoxication induced by alcohol or drugs, administered by the man or by some other person
d. With her consent when the man knows that he is not her husband and that her consent is given because she believes that he is another man to whom she is , or believed herself to be lawfully married.e. With or without consent when she is under 16 years of age and unless the woman is his wife who is over 12 years of age and is not judicially separated from the man
Inter labial penetration is sufficient to constitute intercourse Boy under 12 years of age is incapable of committing rape ( Section 113 of Evidence Ordinance) Gang rape
Rape contd… Murder is common following rape Psychological aspects of rape, Rape trauma syndrome PTSD Social stigma
Incest Having sexual intercourse with another who stands towards him in any of the following enumerated degrees of relationship, a. Either party is directly descended from the other, or is the adoptive parent, adopting grand parent of the other b. The female is the sister of the male, either by full blood/ half blood or by adoption or is the daughter of his brother or of his sister, or is a descendent from either of them, or is the daughter of his wife by another father, or is his son’s, grandson’s or father’s or grandfather’s widow
c. The male, is the brother of the female either by full/half blood or by adoption, or is the son of her brother or sister, or is a descendent from either of them, or is the son of her husband by another mother, or is her deceased daughter’s or grand daughter’s or mother’s or grandmother’s husband Children whose mothers have gone abroad are the most common victims
Unnatural Offences Having intercourse against the order of nature with any man, woman or animal Includes genital fingering, intra crural penile friction, penile substitutes, cunnilingus, fellatio, anal intercourse…. Based on the religious views that sex should only be meant for reproduction and not for pleasure This has been criticized
Acts of gross indecency between people Section 365 A Commits or is a party to the commission of , or procures or attempts to procure the commission by any person of, any act of gross indecency with another person
Grave sexual abuse Section 365 B Doing any act, by the use of his genitals or any other part of the human body or any instrument on any orifice or part of the body, of any person for sexual gratification Act does not amount to rape
Sexual Harassment Cause sexual annoyance to other person, by use of criminal force, or by use of words and action
Sexual exploitation of children Genital fingering Intra crural penile friction Penile or penile substitutes Lingual stimulation Oral penile sexual abuse Digital penetration of anus Anal sex Obscene photographs depicting children
To whom will they commonly present To the police -children with their parents/guardian -adults (mainly women) To a doctor-children (GP,Pediatric physician/surgeon/psychiatrist, JMOs) - adults (GP, VOG, Physician, Surgeon, Venerologist, Dermatologist, Psychiatrist, JMOs) To school teachers/principals. To parents/guardians.
How will they present With a complaint of being sexually victimised. Without a complaint of being sexully victimised.
With a complaint of being sexually victimised1.Injuries General Parasexual Genital2.UTI +/-Vaginal discharge3.Ulcers-(genital, oral, anal) & Warts(genital)4.Painful defecation e.g. due to anal fissures5.Loss of menstrual periods.6.Without any detectable physical signs.7.With behavioral abnormalities and emotional distress
Without a complaint of being sexually victimized1.Injuries General Parasexual Genital2.UTI +/-Vaginal discharge3.Ulcers-(genital, oral, anal) & Warts(genital)4.Painful defecation e.g due to anal fissures5.Loss of menstrual periods.6.Behaviour abnormalities and emotional distress7.A dead body with injuries.Thus a detailed Hx & thorough Ex is more crucial.
Injuries GeneralDue to threatening behaviour by assailant and struggling and restraining the woman-Gripping marks on the arms at the wrists-Injuries at the back of shoulders, elbows,thighs,calves and buttocks from being forcibly held down on a rough surface.-Grazed abrasion at the back by a struggle or being dragged on the ground
General injuries cont…-injuries around the mouth due to forcibly closing her mouth to prevent victim shouting-Imprint of muzzle when threatened by a gun.-imprint abrasions & contusions of nails including thumb marks due to holding woman by neck.-punch marks /slaps-Torn clothes
Para-sexual injuries These areas includes the lips, breasts and the thighs.-swelling of the lips from passionate kissing-love bites and hostile bites on the face, neck and the breast or any area.-finger tip contusions on the breasts from squeezing-nail marks, thumb impressions and other injuries on the thighs following forcible separation
Genital injuries Perineum-injuries include abrasions and contusions in an adult, caused by the assailant trying to forcibly insert the penis into the introitus.In children, in addition, there will be lacerations.They are extensions of the hymenal tears and may extend into vaginal canal or the anus.
Introitus-labia majora and minoraIn inter labial penetration there may be reddening or an abrasion or a contusion.At times a vaginal discharge my indicate inter labial penetration.Pressure exerted on the labia majora and minora by the male organ will cause abrasions and contusions and lacerations.
HymenThe position of the tear is indicated as on the face of a clock.In fresh tears there is swelling ,tenderness and bleeding.In not so fresh tears there will be tenderness and contact bleeding. VaginaThe tip of the penis may also cause abrasions, contusions and even lacerations when excessive force is used for penetration.
PURPOSE OF THE HISTORY To gather information that will help the medical and legal management of the case.
When to deal with victims, With a proper referral such as an “MLEF” (Medico Legal Examination Form) issued by police, court/ magistrate order. A patient referred by a physician even with out “MLEF” or magistrate order
PROCEDURE1. “CONSENT”2. HISTORY3. CLINICAL EXAMINATION a)General b)Injuries4. Collection of trace material and removal of specimens
Why take a history? Management of injuries Risk of adverse consequences Guide specimen collection Documentation Guide examination
BEFORE TAKING THE HISTORY1. Patient may be distressed-Therefore calm down/ counsel pt.2. Give a seat3. Introduce your self, note the name & designation of the officer producing the victim & others accompanying her. (WPC, POLICE MATRON, MOTHER, etc. )4. Note the date & time and the place where the victim is produced.5. Note the MLEF number, date of issue & the police area.6. Take down the name, age, marital status, employment etc. Of the victim.
CONSENT. INFORMED WRITTEN CONSENT Before Hx & Ex OBTAINED
THIS INCLUDES • Describing the purpose and nature of the ex the doctor is proposing to conduct. •That reports will be issued to police/ courts. •That the woman has the right to refuse ex • If over 16 years, consent of victim. • If less than 16 years or not in sound mind – parent or guardian, if neither available magistrate order.
• Victims of sexual offence is already traumatized and will need all the support that can be provided to over come their fears.• Doctors are at risk of allegations of patients that they have been indecently assaulted during the course of consultation. Therefore the doctor need to have a female chaperone.History should be documented in victim’s own words. Otherwise discrepancies may occur in courts.
Do s & Don’t s……. Victims own words….. Avoid unnecessary interruptions Open ended , non leading questions Be thorough! Empathize Tone of voice Eye contact DO NOT show shock or disbelief ABOVE ALL BE SENSITIVE & NON JUDGEMENTAL
COMPONENTS OF HISTORY1. Incident2. Marital history3. Gynecological history4. Menstrual history5. Medical history6. Family history7. Social history
HISTORY1) INCIDENTWhen? Date and timeWhere ? place SurfaceWho? Name of the assailant ( if known ) whether can recognize or not.How? HELD BY HANDS/ CARRIED/ DRAGGED etc. Did victim struggle or shout ? did she sustain injuries? Which part of the body?
Was she assaulted? Injuries ? where?Who removed clothing? Victim/ assailant? Torn ?What were the clothing at the time of act did they get soiled ? mud ? dirt ? blood ? seminal or other stainsAny foreplay?Posture adopted for the act?Was force used to separate thighs ? any injury ?
Was condom used ? Sense of penetration ? Pain during penetration ? Bleeding during or after act ? How many times assailant had intercourse with her ? Anal/ oral/ inter-crural inter course ? LOC ? Was the victim intoxicated ? Assailant drunken ? Was she menstruating at the time ? Did she struggle / resist ? any defensive injuries ?
Events after the act ? Activities - bathing , wiping ,changing of clothes , etc. Symptoms - genitourinary , anal , abdominal
2) MARITAL HISTORYMarried / unmarried ?If married - how long ? children ? how they were delivered? Age of last child ?If unmarried- previous intercourse with any man ? how many times ? when was the last act ?If divorced/ separated / widowed- Was there intercourse recently ?
Medical historyNatural illnesses / mental illnesses General health Physical & psychological illnesses Surgeries Infectious diseases Allergies Immunization Medications
Gynecological history Complications of pregnancy & delivery Pelvic surgery Contraception Age of puberty Last menstrual period Regular / Irregular
3. Family history Unmarried –father, mother, brother, sister Married – husband and children4. Social history Employed / unemployed ? Nature of employment ? Lodging : staying with parents / relatives / friends/ boarding , own home etc. Associates - friends , parents etc.
IF THE HISTORY GIVEN BY THE VICTIM IS COMPATIBLE WITH EXAMINATION FINDING THAT WILL BE SUPPORTIVE IN THE CASE.
EXAMINATION OF ASSAILANT IN A CASE OF SEXUAL ASSAULT
IMPORTANCE1. If known to prove or to exclude false allegations2. If suspected to confirm
General ExaminationGENERAL(a) There may be trace material from the victim and fromthe scene on the clothes and the body of the assailant. 1. Blood from the victim following a hymenal tear on the penis or on the clothes of the assailant. 2. Victims pubic hair among the pubic hair/ underwear of the assailant. 3. Victims head hair on the body / clothes of the assailant 4. Victims vaginal epithelial cells on the assailants glans penis 5. Cosmetics(lipsticks) from the victim on the assailant. 6. Victims epidermal tags in the nail scrapings of the assailant 7. Dust, weed etc from the locus similar to those found on the victim ,on the assailants body or clothing.
EXAMINATION (General) contd…..(b) The assailant may show evidence of recent sexual intercourse. 1. Clean glans penis with absence of smegma. 2. Recent penile injuries. (c ) The assailant may be suffering from venereal diseases -Gonococcal infection
EXAMINATION (Injuries) (a) The victim may have inflicted injuries on the assailant. 1. Bite injuries on the assailant can be compared with the victims dentition. 2. Scratch marks inflicted by the victim on the assailant. (b) The assailant may sustain injuries during the act of penetration -injuries to the prepuse,frenulum or even to the glans penis -injuries to the body depending on the surface on which the act took place
The child died unexpectedly of natural causes. Routine examination ofher perineal region revealed textbook normal anatomy. Make note ofthe prominent circumferentially intact hymenal ring.
The 1-month-old child shows nontraumatized genitalia, with a heart-shaped variation in hymenal form
12-year-old female featured in more subtle nature of the labia majora,and the evidence of scant pubic hair along the upper margin of thevulva.
The genitalia of the 18-year-old female in is fully estrogenized and hastaken adult form.
The 2-year-old child was sexually assaulted by a teenage neighbor.Prior to the retraction of the labia, notice mild generalized erythemaand swelling, the presence of dried blood, and a small laceration at the12 o’clock position of the anus with surrounding contusion.
On further examination, laceration and contusion of the introitus,particularly between the 1 and 4 o’clock positions, is noted. The hymenhas been obliterated and the vaginal canal is patent. Further trauma tothe perianal margin is also noted.
Semilunar variantThis common variant has a cresenteric shape, and has the concavityturned upward, and minimal tissue anteriorly. When assessing injury tothe hymen, close attention should be paid to the edge, because anintact hymen has a smooth and sharp border.
Septate variantThis hymen has a band of tissue running down the middle, dilatationon either side of the band of tissue; however, the edges of the rim aresmooth and sharp, indicating an intact hymen.As an additional note, one must determine if the septate conditionextends through the vagina, resulting in a bifid vaginal canal and moreproximal a bifid cervical canal and bifid uterus. This can either be doneat the time of examination or at a later gynecologic consultation.
Cribriform variantMultiple complete, naturally occurring perforations through to thevaginal canal are present in this otherwise normal hymen.
Microperforate variantThere is a large posterior component, with a tiny (microperforate)opening into the vaginal canal
Heart-shaped variantThe hymen is heart-shaped and longitudinal ridges in the vaginal wallare visible both anteriorly and posteriorly. There is a bump or mound atthe 4 o’clock position. These are all “normal” findings and have notbeen associated with sexual abuse.
Keyhole variantThis 1-month-old child diedsuddenly of natural causes. Atautopsy, make note of prominentdiaper rash, candidiasis (the whitecheesy material), and what appearsto be a tear at the 3 o’clockposition. This is, in fact, a keyhole-shaped variation in normal hymenmorphology. This can bedifferentiated from actual trauma byits smooth borders, a lack ofhemorrhage in the region(hemorrhage meaning acutetrauma), and an apparent lack ofthickened or redundant scar tissue(scar tissue indicating evidence ofhealing).
Objectives Confirm the history and examination findings Find out the assailant Screening for STDs
Collection of Forensic Specimens Laboratory Investigations
Collection of Forensic Specimens The primary aim is to collect evidence that may help prove or dispose a link between individuals and/or individuals and objects or places.
Collection of Forensic Specimens Close encounter of assailant, victim and crime scene may result in an interchange of traces of evidence. Victim Assailant Locard’s Principle Scene
Collection of Forensic Specimens The specimens collected can be used for, Visual comparison Microscopical examination Biochemical investigations Serology DNA studies
Collection of Forensic Specimens Principles for specimen collection: Avoid contamination Collect as early as possible. (Better to collect before 24hrs of crime. After 72 hrs, value of specimens decreases dramatically.) Label accurately Dry all wet specimens Ensure the security Document all collection and handling procedures.
Collection of Forensic Specimens From the victim: Seminal stains Blood Hairs: pubic/head Saliva Nail scrapings Foreign material like mud, vegetations, clothing Any other stains on the body Smears from the glans penis Examination Paper They should be collected from clothing, vaginal canal, vulva, perineum, thighs, pubic area, bite injuries and finger nails.
Collection of Forensic Specimens How to collect… Swabs – A swab from vulva is taken before taking vaginal swabs. Two swabs taken from lower vagina and upper vagina or posterior fornix. Smears are prepared from them immediately. If there was an oral or anal intercourse, additional swabs should be taken. Saliva can be obtained by taking swabs from the bite wounds. Swabs taken from perineum and thigh if there are seminal stains
Collection of Forensic Specimens How to collect… Pubic hair - Combing will bring out hairs which may have come from the assailant. If there is dried seminal stains in the pubic hair, they will be matted cut and removed for examination. Nail scrapings – Nail beds may contain epidermal debris of the assailant.
Collection of Forensic Specimens In addition, 5ml of venous blood A few plucked pubic hairs. A few plucked head hairs. Taken for comparison with blood stains and hairs found on the assailant.
Collection of Forensic Specimens From the assailant: Blood Pubic hairs Head hairs Nail scrapings Smear from glans penis Any other stains on the body Clothing Vaginal epithelial cells may be left on the glans penis of the assailant, so a smear is taken.
Collection of Forensic Specimens From the scene Blood stains, seminal stains, condoms, hairs, etc… Clothes, buttons, safety pins dropped off from the victim or assailant, hair pins/clips. Samples of mud, weeds, etc…
Laboratory Investigations Semen: Most conclusive evidence of a sexual assault. Can be identified by, Presence of spermatozoa Biochemical constituents.
Laboratory Investigations Spermatozoa: Motile up to 3hrs from the crime in the living. Unlikely to find living sperms after 10hrs. After 16hrs only the heads are visible difficulty in identification. Smears are stained with methylene blue or H&E. Using DNA techniques assailant is positively identified.
Laboratory Investigations Biochemical investigations: Identification of acid phosphatase – Good test in the absence of sperms (vasectomised or azoospermic assailants). Creatinine phosphokinase – Increased levels found in seminal fluid (a positive reaction may occur even after 6 months). Serology Seminal blood group antigens
Laboratory Investigations Vaginal epithelial cells: Rich in glycogen stains dark brown with lugol’s iodine. Saliva: Identified by the amylase activity Contains blood group antigens in about 80% of Sri Lankans. Hairs (pubic and head): Morphological comparison to identify the origin. Hair bulbs can be used for DNA studies,
Laboratory Investigations Blood stains: To detect blood group – ABO, Rh DNA studies Nail scrapings: Specific identification by DNA studies Foreign material: Comparison with those at the scene, on the victim and the assailant.
Proper collection,packaging and storing of evidence in sexual assault investigations will effectively support the court procedures
oWhen to get….. As early as possible Any sample to prove circumstantial evidence(Grass,soil,etc.)DON’T NEED EVERY SAMPLE IN EACH AND EVERY CASE
How to get...Vaginal/Oral/Anal swabs Use sterile cotton swabs Then air dry Multiple swabs with a control swabSmear slides-Unfixed and unstained using same swab used above
Pubic/Head hair combings To find foreign hairs and fibres Comb the area submit the comb and any debris in sealed envelop If matted cut and place in envelop
Scraping under finger nails/clippings dried semen/blood –scrape from the body into specimen envelopes Saliva –wet -spit into filter paper and air dried -Dried- wet sterile pad
Blood sample -By a court order -Victim,assailant,any person had sexual contact with victim -EDTA bottle and a Plain bottle -If needed for toxicology NaF bottle+urine sample -All refrigerated,Not frozen
VICTIM SHOULD ALWAYS BE UNDRESSED OVER AN EXAMINATION PAPER.
Preservation and packaging Wet samples must be completely dried After drying use paper bags/envelops Frozen or refrigerated until sending to laboratory Properly labelled(dated,initialed) Hand over to the responsible person Samples should be send with facts about crime,incident,samples collected,required investigations and other relevant facts
FEW DON’TS Rehydrate the dried samples Freeze blood samples Use plastic bags
Documentation medical records are used in courts as evidence Help the courts in decision making and provide information about past and present sexual activities Appropriate and sympathetic follow up care Estimate the incidence of sexual violance and guide policy making
What should be documented ? what was said (by the patient, in her own words) What was seen and done ( by the health worker) Documentation should include the following - Demogarphic info (i.e. name, age, sex) - Consents obtained - History ( general medical and gynaecological) - An account of the assault - Results of physical examination ( injuries and their description) - Tests and their results - Treatment plan - Medications given - Pt. education and referrals
The Law A man is said to commit “rape” when he has sexual intercoursea) without the consent even where such women is his wife and she is judicially separated from the manb) with her consent when the consent has been obtained, by use of force, or threats or intimidation, or by putting her in fear of death or of hurt or while she was in unlawful detentionc) with her consent when her consent has been obtained at a time when she was of unsound mind or was in a state of intoxication induced by alcohol or drugs, administered to her by the man or by some other persond) with her consent when the man knows he is not her husband, and that her consent is given because she believes that he is another man to whom she is, or believed to be, lawfully marriede) with or without her consent when she is under sixteen years of age, unless the women is his wife who is over twelve years of age and is not judicially separated from the man
REPORTING AFTER complete History Examination Investigation Doctor should fill the MLEF On request from the court doctor should fill and send the MLR
CONSIDER Should be structured, detailed and accurate Relevant medical history Clearly, concisely and completely Medical abbreviation should be used with care
MLEF1. Station2. Name & address of examinee3. Date4. Issued by5. Hospital6. Ward number7. B.H.T number8. Produced by9. Date and Time of examination cont……
10. Injuries11.Weapon12.Category of hurt13.Alcohol14.Drugs15.Alcohol / drugs16.Remarks
16.REMARKS After completing the injury cages of the MLEF the remarks column(16) should be filled with information, which are materially relevant to the police.E.g. 01.evidence of penetration 02.evidence of ejaculation 03.evidence of force and resistance MLRF should be handed over to the police and the signature obtained
MLR: medico legal report Identification Short history given by the patient Injuries Opinion1. nature of injury2. injuries caused by3. patient smelling of liquor
Rape The conclusion “rape” strictly a legal matter Solely decided by the courts The doctor does not see a “ rape victim”. He sees a victim of “alleged sexual assault”
Questons to be answered! Has sexual penetration taken place? *supporting evidence – injuries *absence of injuries ? does not rule out If sexual penetration has taken place is it of recent origin?
If sexual penetration has taken place, by whom and by what (penile or other) has the penetration been done? *presence of sperms in genital tract identification *absence of sperm cannot rule out penile penetration
consent / was force used or not? *supporting – injuries offering resistance force used on the victim *no injuries! Cannot say consent was given Whether the victim was of unsound mind or evidence of loss or diminished level of consciousness? *alcohol, drugs, head injury etc.
Writing reports – a few points Explain what you were told and observed Use precise terminology Maintain objectivity Stay within your field of expertise Distinguish findings and opinions Detail all specimens collected Only say what you would be prepared to repeat under oath in court