The immediate role of the forensic medical examiner is to examine and record all the general and genital injuries, collect all available forensic evidence, give a preliminary opinion to the police and provide immediate medical care to the patient. Submitting a comprehensive medico-legal report and appearing in the high court to give oral evidence are also duties of the forensic medical examiner but there usually is enough time to prepare for them.
During the examination the doctor
must remain impartial when dealing with both the alleged victims and suspects
regardless of the nature of allegation.
Whatever the pressure from the
police the doctor should always give priority to the urgent medical needs of
both the alleged victims and suspects.
Examination facilities
Whatever the examination
facilities are the doctor should always have one thing in mind which is to
prevent ‘cross contamination’. The doctor and the examination locus can act as
the vehicle which transfers the forensic evidence from the alleged victim to the
suspect and vice versa unless the doctor is conscious about this possibility. The
unnecessary contact between the alleged victim and the suspect at the
examination facility may also cause cross contamination.
(Cross contamination is transfer
of ‘trace evidence’ between the alleged victim and suspect during the
medico-legal examination. The defence may raise this issue during the trial to make
a reasonable doubt as to how the ‘trace evidence’ had exchanged between the
suspect and the alleged victim. It is the doctor’s duty to show the court (and
the jury) that during his/her examination the possibility of cross
contamination was non-existent.)
In the west, to prevent this, it
is recommended that the alleged victim and the suspect be examined in two different
places or at least in two different times and by two different doctors to
prevent ‘cross contamination’. If it is
not possible to find two different doctors, the doctor should at least go home,
have a shower, change clothes and shoes before examining the second person.
Since this may not be possible in
Sri Lanka the examiner should take maximum precaution possible not to cross
contaminate during the examination. (I am not sure how the doctor does it given
the kind of facilities we have in our hospitals.)
The facility should at least have
necessary equipments and minimum facilities to provide medical care and
undertake adequate forensic assessment. This easier said than done in our part
of the world.
Support for the complainant
In the West a specially trained
police officer of the same sex is allocated to the alleged victim. He/she will accompany the complainant to the
examination facility, obtain details of the allegation in order to determine
the need for forensic samples and further the police investigation and provide
verbal and practical support for the alleged victim.
In Sri Lanka usually the female
victims and small boys are accompanied by the women constables of the ‘women
and children desk’ of the police station. Most of them are not trained to deal
with the sexual assault victims.
Documentation
Suitable proforma should be used
to record the findings.
History Taking
In the west there are qualified police
officers in the police stations to deal with the alleged victims of sexual
assault. They take the detail statement from the alleged victims and suspects
before producing them for medical examination. This process is sometime called
‘interview’. The doctor usually takes a summary of the allegation from the
accompanying police officer in order to determine which forensic samples are
relevant, to tailor the examination and to address the medical and
psychological need of the complaint. The doctor asks the details from the
alleged victim only when the information obtained from the police is not
adequate. The doctor usually limits his/her inquiry to minimum as much as
possible because asking the same question again and again unnecessarily
distresses the alleged victim.
However, in Sri Lanka since the
police is not trained to take details history from the alleged victims it has
become the doctor’s duty to take detailed history, especially from the child
victims of sexual abuse. It is recommended that the doctor should record the
history verbatim in question and answer format and in the same language. They
should avoid asking leading question from the alleged victim as far as possible.
If it is unavoidable it should be limited only to a few pertinent questions.
The doctor should always be mindful of the sensitive nature of the questions
he/she is about to ask. They should never be impatient with their patients and
the pace of the examination should be such that the alleged victim should be
comfortable with it.
Although the alleged victims of
sexual abuse are presented to the doctor with MLEF the report is not usually
written on the Medico-Legal Report (MLR) as it is not adequate for cases of
sexual abuse. Therefore, the preferred style of report is ‘free style’. The
courts usually accept ‘free style’ report as they understand the limitations of
the MLR. The usual headings of the ‘free style’ report may include:
1. History
a.
Obtained from the patient
b.
Obtained from the mother/guardian/father/.....
c.
Obtained from the police
d.
Medical history
e.
Social history
f.
Sexual history
2. Examination
a.
General examination
b.
Examination of systems
c.
External examination
d.
Examination for injuries
e.
Genital and anal examination
3. Investigations
and results
4. Conclusion
(summary of findings)
5. Opinion
6. Referrals
With regard to suspects it is the
usual practice that the doctor does not inquire about the alleged
incident. Instead the doctor should
obtain the details from the police officer before the examination begins and not
in the presence of the suspect.
Important Details of the Allegation
History should include following
salient points about the alleged incident. They may be useful in interpreting
the physical findings, both injuries and forensic evidence.
1. Date
and time of the sexual assault(s)
2. Location:
Inside/outside (weather wet/dry)
3. Number
of alleged assailants
4. Restraints/weapons
and their use
5. Injuries
sustained by the complainant (when, how and where on body?)
6. Injuries
sustained by the suspect (e.g. was the assailant scratched by the complainant?)
7. Type
and number of sexual act(s)/use of condom/lubricant
8. Relative
position during sexual acts
9. Site(s)
of ejaculation
10. Bleeding
from vagina or anus: due to injury or menstruation
11. Use
and disposal of sanitary pads/tampons
12. Other
types of contact (e.g. gripping, kissing, licking, biting, spitting or
scratching)
Since the
incident
Relevant to all recent allegations
1. Manner
of leaving scene and resulting injuries
2. Changed/washed
clothing
3. Bathed/showered
4. Washed/brushed/combed
hair
5. Alcohol/drug
taken
6. Medical
treatment received
Relevant to allegation of oral intercourse
1. Cleaned
teeth/rinsed mouth
2. Drank
any fluid/ate food
Relevant to allegation of vaginal intercourse
1. Consensual
vaginal intercourse
2. Contraception
(particularly) condom used
3. Lubricant
used
4. Douched
5. Vaginal
bleeding /pain
Relevant to allegation of anal intercourse
1. Consensual
anal and/or vaginal intercourse
2. Protection
(condom) used
3. Lubricant
used
4. Anal
bleeding/ pain
5. Bowl
action
(Obtained from Clinical Forensic
Medicine, 3rd Edition, Ed. W.D.S. McLay, Cambridge 2009)
During the examination if
injuries are noted it is appropriate to ask from the patient how they came to
be and their responses should be recorded.
Current Medical Problems
It is important to know the
current medical problems the examinee is suffering from and the medication they
are on. The reasons why the doctor should know about them include:
·
The doctor may misinterpret the injuries if they
does not realize that pre-existing physical conditions might affect their
appearance e.g. patients with bleeding disorders can easily bruise. Even pre-existing
psychological conditions may lead to misinterpretation of the alleged victim’s
or suspect’s behaviour.
·
The doctor can decide on the type of aftercare
required by the patient e.g. suicidal ideations
Past Medical History
Only appropriate past medical
history should be obtained as it is not possible to protect the medical
confidentiality.
Sexual and contraceptive history
Recent sexual and contraceptive
history is important to identify recent sexual activity that could misinterpret
both medical and scientific findings. However, the doctor should avoid asking
about the past sexual history which is not relevant for his or forensic
scientist’s interpretation of physical findings as once obtained they have to be
revealed to the court, which could be a unnecessary distraction for alleged
victim’s cause.
Sometimes sexual and contraceptive
history would determine type of aftercare as suspicion of possible pregnancy
might contraindicate some of the proposed treatment plans.
Suspect should not be asked about
recent sexual experience.
Drugs and Alcohol
In the west it is the usual
practice to take blood and/or urine for toxicological analysis if intoxication
is suspected. In that case a detailed account of the use of drugs or/and
alcohol should be taken either by the doctor or police officer. In out part of
the world this rarely happens. If intoxication due to drug and/or alcohol is
suspected clinical examination is all that required.
Clothing and Jewellery
In the west, interpretation of
the damages to clothing is the responsibility of the forensic scientist.
However, the doctor is required to note the damage to and state of the clothes
and jewelleries. If the doctor feels that there may be forensic evidence in jewelleries
they should swab them.
If the alleged victim or the
suspect is wearing the same clothes they had worn during the incident they
should undress on a sheet of paper (brown paper) in order to collect the loose
foreign material stuck to the clothing. After the undressing is complete the
paper should be folded and kept as a production. The brown paper is preferred
as the tiny pores it contains helps to evaporate the excess moisture, which
otherwise might be collected inside and ruin the quality of forensic evidence.
Each item of clothing should be
placed in brown paper bags, labelled, signed and handed over to the police.
Ideally there should be a Scene of Crime Officer to help the doctor in this
exercise.
After the undressing the patient
should be given appropriate examination gown to wear. The police should provide
suitable alternative clothing they can wear after the examination. In the west
the examination facilities provide showers for the patients’ use.
General Examination
Doctor’s approach must be
sympathetic but professional. They should reassure the examinee without giving
false hope. They should never tell them that everything is going to be alright
without realising that it may not be. They should show them that they are
understanding and sensitive.
The doctor should never rush with
the examination. It should proceed in a pace reassuring the examinee that it
can be stopped at any time. The doctor should be ready to stop the proceeding
if the examinee shows the slightest distress or discomfort. They should always
preserve the dignity of the examinee and minimize any discomfort.
If the incident is suspected to have
occurred within preceding 14 days a comprehensive general examination should be
done, which should include methodical inspection of every body surface and
recessed areas such as behind the ears, axillae, breasts etc.
This is usually done in tandem with
the recovery of forensic evidence. If it is not possible it should always be
done after recovery forensic evidence as the examination may destroy the potential
evidence.
Every significant injuries and
lesions is inspected, measured and recorded (sketched, drawn and
photographed).
Examination of Genitalia and Anus
The doctor is not expected to do
a blanket examination for each and every case of sexual abuse. The examination
and recovery of forensic evidence themselves are traumatic experiences.
Therefore, the extent of examination and forensic sampling should be tailored
to the alleged incident. For instance, if the alleged victim does not complain
about peno-anal contact the doctor is not supposed to obtain the anal swabs and
do a comprehensive anal examination.
The doctor should record the
findings on an imaginary clock face, 12 ‘o’ clock at mons pubis and 6 ‘o’ cock
at coccyx.
The examiner should wear an
examination gown and gloves. Sometimes they should also wear a mask and cover
the head if they feel that they might contaminate the evidence.
To avoid contamination and
destruction of evidence all trace evidence should be retrieved before any
examination.
The recommended position for
examination of female genitalia is ‘partial lithotomy' with knees flexed and
heels on the couch. For the anal examination the preferred position is ‘left
lateral’.
For children ‘frog-leg’ and ‘prone
knee'-chest positions’ are recommended with techniques of ‘labial separation’
and ‘labial traction’.
Examination of ano-genital area
Inspect inner thighs, buttocks
carefully for evidence of injuries and stains. Expose the genial area by
parting the labia or buttocks. Stains should be noted and swabbed.
Pubic hair- note the presence and
length. If secretions noted amongst pubic hair they should be cut/swabbed. Comb
with wide tooth comb and recover loose hair and foreign bodies. Cut pubic hair
for control. Never pluck them. ( How to do them will be discussed in detail
later.)
Female genitalia
Examination
When the alleged victim describes
peno-vaginal penetration inspect the genitalia with a cool light source and
magnifying glass. (Colposcope should be ideal if available)
After all
the forensic samples have been recovered a ‘Foley’ catheter’ or a moistened
swab can be used to inspect the hymenal tissue. In cases of non-virgins
internal examination of the vagina and cervix can be done using an appropriate
size speculum. The injuries, bleeding, source of bleeding etc. should be
recorded.
Male Genitalia
Full examination of the genitalia
should be done. Note whether the body is
circumcised. If not retract the foreskin and inspect the glans. Injuries should
be noted on the foreskin, glans, shaft and scrotal sac. Evidence of vasectomy
should be noted. This should be done after taking the forensic samples.
Perianal Region
If the alleged victim alleges
anal penetration by penis perianal region should be examined after taking
forensic samples with a cool light source and a magnifying glass. (If a
colposcope is available it can be used as well.) Injuries such as lacerations,
swelling, reddening, fissures and abnormalities such as gaping, haemorrhoids,
scars, warts, discharge, venous engorgement, thickening of skin, absence of
puckered anal margin should be observed.
After taking forensic samples an
appropriate sized proctoscope can be used to inspect the interior.
Digital examination should only
be attempted only if clinically indicated. It is no longer considered to be a
valid tool to evaluate the anal tone.
(Theese lecture notes were prepared from two books
1.
The physical signs of child sexual abuse, an
evidence-based review and guidance for best practice, March 2008, Royal College
of Paediatrics and Child Health.
2.
Clinical Forensic Medicine, 3rd
Edition, Ed. W.D.S. McLay, 2009, Cambridge.)
Priyanjith Perera
12/12/12
No comments:
Post a Comment