Rape presents a unique problem to physician clinicians in that they often inherit the burden of not only treatment, but proper collection of evidence. For the correct handling of rape cases, both medically and legally, there must be coordination between the physicians examining the victims and the police agency with jurisdiction. It is preferable that victims of rape be examined at one central hospital by experienced physicians trained in the handling and treatment of such patients and in the proper collection of evidence. In a number of areas, rape examination is being conducted by specially trained forensic nurses. If victims are treated at multiple hospitals, by different physicians, documentation of the rape and collection of the evidence will suffer. At the time of examination, the examiner should have a rape examination kit that contains the necessary materials for collection and packaging of the collected evidence. Such kits also contain forms with pertinent questions to be asked and diagrams that can be used to illustrate injuries.
When the victim of a rape is brought into the hospital, she should be triaged ahead of the non-emergency patients. Written, witnessed consent should be obtained before the examination, collection of specimens, release of information to authorities, and taking of photographs. A female chaperone should always be present. The name of the victim is recorded, along with the date and time of the alleged assault, the date and time of the examination, and, if the police have been notified, the attending law officer's name and badge. The law officer is not present at the examination. The only people present should be the examiner and a nurse, one of whom is usually the female chaperone.
Treatment of life-threatening injuries is, of course, given precedence over the collection of evidence. After collection, the chain of evidence must be maintained. The examining physician should either hand the evidence directly over to a police officer or a representative of the crime laboratory, or place it in a secure storage area for subsequent transmittal.
If examination of victims is by physicians, they should preferably be senior staff obstetrician /gynecologists and not residents. Senior staff members are more experienced and their testimony will carry greater weight in court. In addition, a resident might have moved out of the area by the time the case comes to court. In court, the physician or forensic nurse is never expected to state whether the crime of rape has occurred. Rape is not a diagnosis, it is a matter of jurisprudence. All that the examiner can do is document any evidence of trauma, determine, if possible, whether there has been recent sexual intercourse, and collect trace evidence.
The first step is to obtain a history from the patient. This includes a medical history and a brief account of the alleged assault. Three important questions should be asked:
Did the assailant's penis penetrate the vulva? Did the assailant experience orgasm? Did the assailant wear a condom?
Similar questions regarding anal and oral intercourse should also be asked. The victim is asked whether she douched, bathed, showered, defecated, or urinated prior to the examination. All the aforementioned factors can influence whether the physical evidence needed to document sexual intercourse is present. Vertical drainage from the vagina is the worst enemy to the collection of evidence. Because of this, it is recommended that the examiner retain the panty the victim was wearing. Thus, any drainage of semen into the panty can be documented.
After taking a history, the patient is examined. The physician or forensic nurse will conduct the examination in such a manner that objectively acquired evidence can be used to prosecute an assailant in an actual case of rape, or to disprove a false charge of sexual assault. The patient's general appearance and emotional state are noted, as well as whether she is under the influence of alcohol or drugs. The patient's emotional state does not necessarily reflect on the validity of her charges. Some rape victims will appear cold and detached, while others will be hysterical.
All clothing should be examined for stains, tears, missing buttons, dirt, gravel, grease, leaves, etc. The patient herself is then examined. The examiner will look for bruises, bites, and lacerations. He will examine the hands to see if the fingernails are broken. Is the pubic hair matted? Are there any foreign
hairs mixed with the patient's pubic hair? The external genitalia are examined for abrasions, lacerations, and hematomas (Figure 18.1). The vagina and cervix are then examined internally by the use of an unlubricated speculum. All injuries are described.
If there is a bite mark on the patient or if the patient gives a history of the perpetrator's licking a portion of her body (e.g., the nipples), these areas should be swabbed in an attempt to recover saliva. These swabs can then be analyzed for DNA. Positive DNA identification has been made in a number of cases from saliva on the body of the victim. After the swabbing of the bite mark, photographs should be taken. A metric ruler should be included in the photographs. Ideally, one should have a forensic odontologist on call so that they can examine and document the bite mark. They might take casts of the bite mark in addition to photographing it.
During the physical examination, evidence will be collected to document the rape. The only significant differences in the collecting of evidence between the living rape victim and the dead individual are that, in the living individual, a culture will be made from the cervix to detect the presence of venereal disease, and swabs of the mouth and rectum may not be taken if there was no penetration of these orifices.
Absence of trauma to a rape victim does not negate the validity of her claim of rape. Thus, in an analysis of 451 rape victims examined at Parkland Hospital in Dallas by staff gynecologists, Stone found that only 34% showed any evidence of trauma (abrasions, contusions, or lacerations) (I. Stone, personal communication). Of the total number of victims, only 18% had any trauma to the genitalia (reddening, abrasions, contusions, or lacerations). Examination of fluid from the vaginal pool revealed the presence of motile spermatozoa in 19.3% of patients, with motile and non-motile spermatozoa observed in 47% of all patients. Subsequent examination of vaginal smears in the crime laboratory showed spermatozoa present in 62% of all smears.
Following the examination, the patient is treated for her injuries, as well as being given drugs for prevention of pregnancy, and medication for prevention of venereal disease. The patient should be seen 2 weeks after the assault in a follow-up examination. Repeated testing for A.I.D.S. should be performed over the next months.
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