Medicolegal approach to a victim following sexual offenses.

1. Sexual offences
Medicolegal approach to a
victim…
Yapa Wijeratne
Faculty of Medicine
University of Peradeniya
Sri Lanka

2. Introduction

3. Sexual offences include
1. Rape
2. Incest
3. Unnatural offences (eg anal, oral,
intercrural intercourse)
4. Acts of gross indecency
5. Grave sexual abuse
6. Sexual harassment (words/actions)

4. 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.

5. 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 man
b. 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 detention
c. 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

6. 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

7.  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

8. Rape contd…
 Murder is common following rape
 Psychological aspects of rape,
 Rape trauma syndrome
 PTSD
 Social stigma

9. 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

10. 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

11. 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

12. 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

13. 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

14. Sexual Harassment
 Cause sexual annoyance to other
person, by use of criminal force, or by
use of words and action

15. 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

16. Presentation of victims of
sexual offences

17. 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.

18. How will they present
 With a complaint of being sexually
victimised.
 Without a complaint of being sexully
victimised.

19. With a complaint of being
sexually victimised
1.Injuries
 General
 Parasexual
 Genital
2.UTI +/-Vaginal discharge
3.Ulcers-(genital, oral, anal) & Warts(genital)
4.Painful defecation e.g. due to anal fissures
5.Loss of menstrual periods.
6.Without any detectable physical signs.
7.With behavioral abnormalities and emotional
distress

20. Without a complaint of being
sexually victimized
1.Injuries
 General
 Parasexual
 Genital
2.UTI +/-Vaginal discharge
3.Ulcers-(genital, oral, anal) & Warts(genital)
4.Painful defecation e.g due to anal fissures
5.Loss of menstrual periods.
6.Behaviour abnormalities and emotional distress
7.A dead body with injuries.
Thus a detailed Hx & thorough Ex is more crucial.

21. Injuries
 General
Due 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

22. 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

23. 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

24. 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.

25.  Introitus-labia majora and minora
In 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.

26.  Hymen
The 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.
 Vagina
The tip of the penis may also cause abrasions,
contusions and even lacerations when
excessive force is used for penetration.

27. HISTORY

28. PURPOSE OF THE HISTORY
To gather information that will help the
medical and legal management of the case.

29. 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

30. PROCEDURE
1. “CONSENT”
2. HISTORY
3. CLINICAL EXAMINATION
a)General
b)Injuries
4. Collection of trace material
and removal of specimens

31. Why take a history?
 Management of injuries
 Risk of adverse consequences
 Guide specimen collection
 Documentation
 Guide examination

32. BEFORE TAKING THE HISTORY
1. Patient may be distressed-Therefore calm down/ counsel
pt.
2. Give a seat
3. 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.

33. CONSENT.
INFORMED WRITTEN CONSENT
Before Hx & Ex OBTAINED

34. 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.

35. • 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.

36. 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

37. COMPONENTS OF HISTORY
1. Incident
2. Marital history
3. Gynecological history
4. Menstrual history
5. Medical history
6. Family history
7. Social history

38. HISTORY
1) INCIDENT
When? Date and time
Where ? place
Surface
Who? 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?

39. 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
stains
Any foreplay?
Posture adopted for the act?
Was force used to separate thighs ?
any injury ?

40.  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 ?

41.  Events after the act ?
 Activities - bathing , wiping ,changing of
clothes , etc.
 Symptoms - genitourinary , anal , abdominal

42. 2) MARITAL HISTORY
Married / 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 ?

43. Medical history
Natural illnesses / mental illnesses
 General health
 Physical & psychological illnesses
 Surgeries
 Infectious diseases
 Allergies
 Immunization
 Medications

44. Gynecological history
 Complications of pregnancy & delivery
 Pelvic surgery
 Contraception
 Age of puberty
 Last menstrual period
 Regular / Irregular

45. 3. Family history
 Unmarried –father, mother, brother, sister
 Married – husband and children
4. Social history
 Employed / unemployed ?
 Nature of employment ?
 Lodging : staying with parents / relatives /
friends/ boarding , own home etc.
 Associates - friends , parents etc.

46. IF THE HISTORY GIVEN BY THE VICTIM IS
COMPATIBLE WITH EXAMINATION FINDING THAT
WILL BE SUPPORTIVE IN THE CASE.

47. EXAMINATION OF ASSAILANT
IN A CASE OF SEXUAL
ASSAULT

48. IMPORTANCE
1. If known to prove or
to exclude false allegations
2. If suspected to
confirm

49. General Examination
GENERAL
(a) There may be trace material from the victim and from
the 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.

50. 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

51. 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

52. Hymen
know before you examine!

53. The child died unexpectedly of natural causes. Routine examination of
her perineal region revealed textbook normal anatomy. Make note of
the prominent circumferentially intact hymenal ring.

54. The 1-month-old child shows nontraumatized genitalia, with a heart-
shaped variation in hymenal form

55. 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 the
vulva.

56. The genitalia of the 18-year-old female in is fully estrogenized and has
taken adult form.

57. The 2-year-old child was sexually assaulted by a teenage neighbor.
Prior to the retraction of the labia, notice mild generalized erythema
and swelling, the presence of dried blood, and a small laceration at the
12 o’clock position of the anus with surrounding contusion.

58. On further examination, laceration and contusion of the introitus,
particularly between the 1 and 4 o’clock positions, is noted. The hymen
has been obliterated and the vaginal canal is patent. Further trauma to
the perianal margin is also noted.

59. Semilunar variant
This common variant has a cresenteric shape, and has the concavity
turned upward, and minimal tissue anteriorly. When assessing injury to
the hymen, close attention should be paid to the edge, because an
intact hymen has a smooth and sharp border.

60. Septate variant
This hymen has a band of tissue running down the middle, dilatation
on either side of the band of tissue; however, the edges of the rim are
smooth and sharp, indicating an intact hymen.
As an additional note, one must determine if the septate condition
extends through the vagina, resulting in a bifid vaginal canal and more
proximal a bifid cervical canal and bifid uterus. This can either be done
at the time of examination or at a later gynecologic consultation.

61. Cribriform variant
Multiple complete, naturally occurring perforations through to the
vaginal canal are present in this otherwise normal hymen.

62. Microperforate variant
There is a large posterior component, with a tiny (microperforate)
opening into the vaginal canal

63. Heart-shaped variant
The hymen is heart-shaped and longitudinal ridges in the vaginal wall
are visible both anteriorly and posteriorly. There is a bump or mound at
the 4 o’clock position. These are all “normal” findings and have not
been associated with sexual abuse.

64. Keyhole variant
This 1-month-old child died
suddenly of natural causes. At
autopsy, make note of prominent
diaper rash, candidiasis (the white
cheesy material), and what appears
to be a tear at the 3 o’clock
position. This is, in fact, a keyhole-
shaped variation in normal hymen
morphology. This can be
differentiated from actual trauma by
its smooth borders, a lack of
hemorrhage in the region
(hemorrhage meaning acute
trauma), and an apparent lack of
thickened or redundant scar tissue
(scar tissue indicating evidence of
healing).

65. Investigations of Sexual
Offences

66. Objectives
 Confirm the history and examination
findings
 Find out the assailant
 Screening for STDs

67. Collection of Forensic Specimens
Laboratory Investigations

68. 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.

69. 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

70. Collection of Forensic Specimens
 The specimens collected can be used for,
 Visual comparison
 Microscopical examination
 Biochemical investigations
 Serology
 DNA studies

71. 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.

72. 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.

73. 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

74. 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.

75. 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.

76. 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.

77. 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…

78. Laboratory Investigations
 Semen:
 Most conclusive evidence of a sexual assault.
 Can be identified by,
 Presence of spermatozoa
 Biochemical constituents.

79. 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.

80. 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

81. 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,

82. 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.

83. Proper collection,packaging and
storing of evidence in sexual
assault investigations will
effectively support the court
procedures

84. 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

85. How to get...
Vaginal/Oral/Anal swabs
Use sterile cotton swabs
Then air dry
Multiple swabs with a control
swab
Smear slides-Unfixed and unstained using
same swab used above

86.  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

87.  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

88.  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

89. VICTIM SHOULD ALWAYS BE
UNDRESSED OVER AN
EXAMINATION PAPER.

90. 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

91. FEW DON’TS
 Rehydrate the dried samples
 Freeze blood samples
 Use plastic bags

92. Reporting

93. 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

94. 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

95. The Law
 A man is said to commit “rape” when he has
sexual intercourse
a) without the consent even where such women is his wife and she is
judicially separated from the man
b) 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 detention
c) 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 person
d) 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 married
e) 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

96. REPORTING
 AFTER complete
History
Examination
Investigation
 Doctor should fill the MLEF
 On request from the court doctor should
fill and send the MLR

97. CONSIDER
 Should be structured, detailed and
accurate
 Relevant medical history
 Clearly, concisely and completely
 Medical abbreviation should be used with
care

98. MLEF
1. Station
2. Name & address of examinee
3. Date
4. Issued by
5. Hospital
6. Ward number
7. B.H.T number
8. Produced by
9. Date and Time of examination
cont……

99. 10. Injuries
11.Weapon
12.Category of hurt
13.Alcohol
14.Drugs
15.Alcohol / drugs
16.Remarks

100. 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

101. MLR: medico legal report
 Identification
 Short history given by the patient
 Injuries
 Opinion
1. nature of injury
2. injuries caused by
3. patient smelling of liquor

102. 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”

103. 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?

104.  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

105.  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.

106. 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