Valuable time should not be lost when a woman complains of rape. She should be brought immediately for medical examination.

The police should bring the alleged rape victim as soon as possible. Detail statements may be taken by the police after the medical examination.

Medical evidence is very important in cases of rape,as there should be “independent corroboration” of the victims story by other evidence.

ii)Being Sensitive:

One should be very sensitive while examining a rape victim. The examiner should realize the gravity of the situation. The woman may even need psychological/psychiatric care later in life.

iii)Must be examined only if referred properly:

Any medico legal examination should be undertaken only when there is proper referral (such as MLEF issued by the police or court/magistrate in Sri Lanka).

It is not necessary for the doctor to examine a rape victim brought by her husband or relative without reporting it to the police.

Alternatively the emergency unit of the nearest police station can be called to the hospital/clinic if she presents there first (done in some countries).All these measures are to reduce the delay in examining the patient.

iv) Presence of a female chaperone during examination:

It is unethical for a male doctor to examine a female patient in the absence of a female chaperone. In the absence of a hospital nurse a female relative or a female friend of the woman should be present. However it is not suitable to have a female police officer as admissibility of evidence obtained may be challenged.

v)Obtain written consent:

Written consent should be obtained. The examnation the doctor is going to conduct should be explained in detail to the victim. She should also be informed that the reports will be issued to the police/courts and she also has a right to refuse examination.

Her consent should not be influenced by others.The victim must be mentally capable (incapable persons/mentally retarted/psychiatric individuals cannot give valid consent). In such cases the consent of the parents or guardian is essential. For girls below 18 years of age ,consent of the parents/guardian is essential.

vi) History:

History should be obtained separately from the victim, witnesses, police,parents etc.

It should include the full name ,age address, national id card no. The correct age is very important, to determine if she is a minor.

A quick assessment of her mental state should be done, so that one can decide if she is of sound mind to give a reliable history.

Important aspects of the history include the history of the act (eg how many assailants ,is the assailant known to her,was he under alcohol,were any weapons used, was a condom used,was she forced to do oral sex,any anal intercourse etc), menstrual and sexual history.

The time of the incident should be noted ,as it is important as the signs expected on examination may vary as time passes.

To be continued in the final part :Rape Management Part 3

References:

Pages 758 to 759. Chapter 17. Rape.Gynaecology. CMDT 2006. Current Medical Diagnosis and Treatment 2006.45 th Edition. Edited by Lawrence M. Tierney,Jr. Stephen J McPhee, Maxine A. Papadakis.

Pages 122 to 134.Chapter 19 .Sexual offences. Forensic Medicine and Medical Law. Notes on Forensic Medicine and Medical Law.Dr Hemamal Jayawardena .2nd edition. Former lecturer in charge.Department of Forensic Medicine.University of Kelaniya.Sri Lanka.

i) Analgesics or sedatives should be administered if indicated.

ii) Tetanus toxoid should be given if deep lacerations are present.

iii)Antibiotic -Ceftriaxone, 125mg intramuscularly to prevent gonorrhea.

-Give metronidazole 2 g (single dose) and azithromycin 1g orally (or doxycycline 100mg twice daily-for 7 days) to prevent chlamydial infection.

Syphilis: The above antibiotics will probably eliminate incubating syphilis. However the VDRL test should be repeated 6 weeks after the assault.

iv)Vaccinate against hepatitis B

v)Consider HIV prophylaxis (covered under a different post).

vi)Pregnancy can be prevented by using any of the methods discussed under emergency contraception (covered in another post).

Medico-legal aspects of investigating a victim of sexual violence

The aim of the examination is to gather evidence regarding:

i)Penetration/ejaculation

ii)Force/lack of consent

iii)Identification of the assailant

iv)Question of age.

v)Other corroborating evidence-This will help establish links among the victim, assailant ,scene etc.( Lochard’s Principal)

References:

Pages 758 to 759. Chapter 17. Rape.Gynaecology. CMDT 2006. Current Medical Diagnosis and Treatment 2006.45 th Edition. Edited by Lawrence M. Tierney,Jr. Stephen J McPhee, Maxine A. Papadakis.

Pages 122 to 134.Chapter 19 .Sexual offences. Forensic Medicine and Medical Law. Notes on Forensic Medicine and Medical Law.Dr Hemamal Jayawardena .2nd edition. Former lecturer in charge.Department of Forensic Medicine.University of Kelaniya.Sri Lanka.

1)Written consent must be obtained for the gynaecological examination.

Photographs may also be taken if they are to be used as evidence. The written consent may be obtained either from the patient or guardian/next of kin.

The police should also be notified as soon as possible.

2)History should be obtained from the patient. Ideally it must be recorded in her own words. Important aspects of the history include the time, place, circumstances ,last menstrual period (LMP). It is also important to ask if she is pregnant and the time of the most recent coitus prior to the sexual assault.

Other details should include, which of the orifices were penetrated, use of foreign objects, number of assailiants.

Did the victim come directly to the hospital or did she bathe and change her clothing.

3)What is the general appearance of the victim? do you think drugs or alcohol may be involved? Is the victim calm, agitated or confused?

The patient should disrobe while standing on a white sheet. Any hair,dirt, underclothing must be kept as evidence. Torn and stained clothing should also be kept as evidence. The pubic hair should be combed for evidence. Material should also be scraped from beneath the finger nails. All evidence must be placed in separate bags/envelopes and labeled carefully.

The patient should be examined ,and traumatized areas should be photographed.

The body and genitals should be examined with wood’s light to identify semen. Positive areas will fluoresce .These areas should be swabbed with a moisened swab and air-dried in order to identify acid phosphatase.

Colposcopy may be used to identify small areas of trauma eg in the posterior fourchette.

4)A pelvic examination should be performed after explaining the procedure and obtaining the patients consent.

Only a narrow speculum should be used. In rape victims one should only use water as a lubricant.Sterile cotton swabs should be used to collect material from the cervix and upper vagina. These should be air dried on two glass slides after smearing.

Wet and dry swabs should also be collected and refrigerated for subsequent DNA and acid phosphatase evaluation.

If appropriate the mouth and the anus must be swabbed (eg in anal rape).

Secretions from the vagina,mouth,anus may be collected by a swab and placed on a slide. A drop of saline should be added and covered with a coverslip. This should be examined for motile and non motile sperms. The finding must be recorded. The percentage of motile forms must be noted.

5)Laboratory tests should be done to identify sexual transmitted diseases. Swabs may be taken from the vagina, anus or mouth and cultured for N Gonorrhoea and chlamydia. A wet mount for trichomonas vainalis and a papanicolaou smear should be done. A VDRL test (for syphilis) and a pregnancy test should be done.

A HIV antibody test should be done and repeated  after 2 to 4 months later, if the initial test was negative.The  pregnancy test must be repeated if the next menses is missed. Ideally the VDRL should be repeated in six weeks time.

Blood(without anticoagulant) and urine specimen should be obtained if there is a history of forced ingestion or injection of drugs .

6) Laboratory specimens should be transferred to the responsible clinical pathologist/technician in the presence of witnesses and never via a messenger, so that evidence is not breached.

Treatment /drugs administered to rape victims will be addressed in a subsequent post.

References:

Pages 758 to 759. Chapter 17. Rape.Gynaecology. CMDT 2006. Current Medical Diagnosis and Treatment 2006.45 th Edition. Edited by Lawrence M. Tierney,Jr. Stephen J McPhee, Maxine A. Papadakis.

About 95% of rape victims are women. It is also essential to note that people involved in the management of rape victims understand and recognize the violent nature of the crime.

Penetration of which orifice constitute rape?

It is important to note that the penetration may be vaginal,anal or oral.

The penetration may be by the hand,penis or by a foreign object.

It is also important to note that the absence of genital injury does not mean that the individual has given consent.

The rapist (assailant) may be a stranger or more frequently an acquaintance or even the spouse.

What is statutory rape?

Statutory or “unlawful sexual intercourse” is intercourse with a female before she reaches the age of majority, even with her consent.

Who are rapists?

Rapists are usually hostile men that terrorize and humiliate women by raping them. It is important to note that women do not want to be raped or even enjoy being raped under any circumstances.

What are the physical and psychological consequences of rape?

In 5 to 10% of cases rape involves severe physical injury. Women are terrified for their lives.

It is also important to note that all victims suffer some psychological aftermath.

Some rape victims may acquire sexually transmitted diseases (such as AIDS) or become pregnant.

What is the rape trauma syndrome?

Each person deals with rape differently, because it is a personal crisis.

There are two principal phases in the rape trauma syndrome:

1)Immediate or acute phase: Here there is sobbing, shaking and restless activity. This phase may last from a few days to a few weeks. The patient may experience anger,guilt or shame.The victims personality and circumstances of the attack may determine the reaction by the victim.

2)Late or chronic: This may change the work pattern and lifestyle of the individual. This develops several weeks or months later.Victims may develop phobias or sleep disorders. Rare cases of suicide have been reported during the chronic phase.

What are rape crisis centers?

These are centers created to provide information for clinical and emergency department personnel. They can also provide ongoing support and counseling for rape victims.

References:

Pages 758 to 759. Chapter 17. Rape.Gynaecology. CMDT 2006. Current Medical Diagnosis and Treatment 2006.45 th Edition. Edited by Lawrence M. Tierney,Jr. Stephen J McPhee, Maxine A. Papadakis.

Sexual offences include the following:

i) Rape

ii)Grave sexual abuse

iii)Sexual exploitation of children

iv)Incest

v)Unnatural offenses like gross indecency between persons and intercourse against the nature with man, woman or animal.

What is Rape?

It must be emphasized that rape is a legal concept and not a medical diagnosis. The definition of rape depends on the law of the country.

The law regarding rape:

The law regarding rape varies slightly from one country to another. The Sri Lankan law regarding rape is given in section 363 of the penal code.

A man is said to commit rape ,if he has sexual intercourse with a woman under the following five circumstances:

1)Without her consent even where such a woman is his wife and she is judicially seperated from the man.

2)With her consent when her consent has been obtained ,by use of force, threats, intimidation, or by putting her in fear of death or of hurt while she was in unlawful detention.

3)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.

4)With her consent when the man knows that he is not her husband,and that her consent is given because she beleives that he is another man to whom she is or beleives herself to be,lawfully married.

5)With or without her consent, when she is less than 16 years of age, unless the woman is his wife, who is over twelve years of age and is not judicially seperated from the man.

It must be emphasized that only penetration is sufficient to constitute rape. Physical evidence of resistance is not essential to prove rape. Only inter labial penetration is adequate to constitute sexual intercourse, ejaculation,rupture of the hymen,orgasm ,full penetration or pregnancy is not essential.

Most women that are raped do not report the incidence, due to the social stigma attached to rape. Repeated rape may happen in certain situations eg house maids.

False aligations of rape can also be made by the girls parents, girl , girls other relativves or even the girls friends.This situation may occur after a broken love affair.

What is grave sexual abuse?

Grave sexual abuse is defined as an abuse,committed by an individual for sexual satisfaction, 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, being an act which does not amount to rape under section 363 (Sri Lanka), in circumstances which fall under any of the following descriptions,that is to say:

a)Without the consent of the other person

b)With the consent of the other person, where the consent has been obtained by force, threat or intimidation or putting such other person on fear of death or of hurt or while such other person was in unlawful detention.

c)With the consent of the other person where such consent has been obtained at a time the other person was of unsound mind or was in a state of intoxication induced by alcohol or drugs.

Refrences :

Pages 120 and 121 -Chapter 19-Sexual Offences -Notes on Forensic Medicine and Medical Law by Dr Hemamal Jayawardena (Attorney at Law)MBBS,DLM,MSc,LLM,MD. 2nd edition. Former lecturer in charge, Department of Forensic Medicine, University of Kelaniya, Sri Lanka.