General Injuries
It may not be easy to classify
general injuries of sexual offences as many combinations of different types of
injury may occur. Nevertheless, some types and distributions are commoner than
others.
Contrary to the expectation of
many, most of the alleged victims sexual abuse do not sustain general injuries.
It is good to remember that the absence of injuries does not indicate that the
allegation of sexual assault is false. There are many reasons why a person is
uninjured during a sexual assault.
a. The
victim was sexually assaulted after been subjugated by fear of violence or
death or threats or simple emotional manipulation.
b. The
perpetrator has used force but it was not enough to cause injuries or the
resistance offered by the victim is not enough to cause injuries.
c. The
injuries were healed by the time it is reported.
As mentioned earlier every single
centimetre and recess of the body has to be examined. The most insignificant
injury may have a very significant forensic value.
Exact dating of injuries may be
impossible but it can be used to see whether there is discrepancy between the
history and physical findings.
Attending to the immediate
medical needs of the examinees should always take the priority over examination
for injuries and collection of forensic samples.
Some of the General Injuries of importance
Bite Marks
They are usually found on the
neck, shoulders, and so-called para-sexual areas such as breasts and buttocks.
They are important in identification of the assailant by comparison of the
bite mark and the dentition of the suspect using techniques of forensic
dentistry and by extracting DNA from saliva for ‘DNA Identification’.
Suction bites (sometimes called
‘love-bites’ when sustained during consensual sexual activity) are a variety of
bites and occur as a result of suction of the skin with mouth causing multiple
petechial haemorrhages as a result of the ‘vacuum’ effect caused by ‘sucking’.
They may also present over the upper neck, behind the ear, shoulders and around
the nipple.
The lips may get bruised and lacerated
from forceful kissing by pressing against the teeth and gums.
Finger Nail Abrasions and Finger Tip Bruises
Finger tip bruises are of round
or discoid shape measuring 1 – 2 mm in diameter caused by the pressure
generated by finger tips when used to squeeze or manipulate an area of the
body.
In sexual abuse they may occur on
the buttocks when they are squeezed or manipulated, on the inner aspect of the
things when they are forcefully separated to gain access to the genitalia, on
the buttocks when they are forcefully separated to gain access to the anus or
genitalia during the posterior entry of the vagina.
They may also be present around
mouth in cases where the mouth was forcefully closed to prevent screaming, on
the neck in attempted manual strangulation or around the upper arms, wrists and
ankles when the victim is restrained to prevent struggling.
Finger nail abrasions are linear
abrasions of scratch marks caused by finger nails and usually present on the
areas where the ‘finger tip bruises’ are commonly seen.
The assailant may also sustain
finger nail abrasions on the face, neck and the trunk.
The long and manicured finger
nails of the victims may be broken during the assault and the fractured ends
might contain the fibres and hairs of the assailant, which could be used to
identify the assailant.
General Bruising and Abrasions
The bruises and abrasions may
occur on the back of the victim depending on the type of surface on which the
assault took place. If the assault took place on grass or in a jungle the
victim may have vegetable matter adhered to her wounds.
Sharp Force Trauma
They may occur if the assailant has used sharp
cutting instruments to threaten the victim. They may be present on the face or
neck. In rape-murder cases they may be used to inflict the fatal wound or in
some bizarre cases of ‘sadistic rape-murder’ they may have been used to
mutilate the victim.
Head injuries
Head injuries are not commonly
seen in the clinical cases but they may be present in the rape-murder cases.
Genital and anal findings
It is claimed that less than half
of the alleged victims of sexual assault have injuries to the genitalia and
anal region. The reasons for absence of injuries to these areas may be
a. The
sexual act is such that it would not leave any injuries e.g. touching, kissing
etc.
b. The
alleged victim is sexually experienced
c. The
female genitals especially after puberty has natural elasticity
d. Even
the anus has some degree of natural elasticity
e.
The assailant may have used lubricants
Some of the genital injuries and their significance
Genital erythema/redness/inflammation of external and internal
genitalia
Reddening of the vulva, penis or
anal margin is considered as non-specific finding. It can be a result of wide
variety of causes including consensual sexual intercourse. Especially in
children they may be due to acute trauma, infection, dermatological conditions,
allergies, reaction to chemicals or poor hygiene.
When an alleged victim,
especially a child is present with them, all the possible causes should be
considered in differential diagnosis. Examination should be repeated if the
doctor is doubtful about the diagnosis.
Oedema
It is usually sign of
inflammation, infection or trauma. When a victim is presented with genital
oedema, especially a child all the possible causes should be considered in
differential diagnosis. Examination should be repeated if the doctor is doubtful
about the diagnosis.
Genital Bruising
Most of the time bruises are
caused by trauma. But bruises can also be caused spontaneously due to
haematological conditions, especially in children, who have not been previously
diagnosed. Some of the dermatological conditions such as lichen sclerosis,
localised erythema, haemangioma and pigmented lesions may be confused with
bruises.
When a victim is presented with
genital bruising all the possible causes of bruising and other lesions, which may
mimic bruising, should be considered in differential diagnosis. Examination
should be repeated if the doctor is doubtful about the diagnosis. When bruising
is found in genitalia sexual abuse is always considered, especially in children.
Genital Abrasion
Possible causes of genital
abrasions, especially in children include excoriation of itchy skin and trauma.
When a victim presented with
genital bruising, especially a child, all the possible causes should be
considered in differential diagnosis. Examination should be repeated if the
doctor is doubtful about diagnosis. When abrasions are found in genitalia,
especially in children, sexual abuse should always be considered.
Genital lacerations and tears
Small lacerations or tears (a few
millimetres in length) of the vulva, foreskin, frenulum and anal margin are
likely to be due to stretching of the skin. They may also be due to some local
skin condition or local irritation. They are more commonly seen in the fossa
navicularis and posterior fourchette than in the hymen in sexual abuse,
especially in child victims. When lacerations found on the genitalia sexual
abuse should be strongly suspected in the absence of a convincing history of
penetrating accidental injury especially in children.
Hymenal Tears
Hymen may be lacerated when
stretched. Theses lacerations can be ‘complete’ or ‘incomplete’ depending on
the size of the object and the elasticity of the tissues. Fresh lacerations
bleed but heal rapidly with or without leaving a scar. The healing may complete
within weeks.
They may also heal leaving a ‘v’
shape gap, which is called a transaction if it extends up to the vaginal wall.
If it terminates before reaching the vaginal wall it is called a ‘notch’ which
can be superficial or deep. (Superficial notches only extend less than the 50%
of the hymenal width and the deep notches extends more than 50%).
When describing hymenal
disruption, a uniform and precise terminology should be used. The recommended
terms are as follows. Acute injuries are termed lacerations. They can be
partial or complete (to base of hymen). Non-acute injuries when partial are termed
‘notches’ and when complete are ‘transections’.( Hymenal transection is a
discontinuity of the hymenal tissue which extended to the base. The term should
be limited to healed appearance. )Notches may be ‘deep’ or ‘superficial’.
(>50% of the hymenal width is deep. <50% of hymenal width is
superficial.)
The following appearances on the
hymen are important in ‘child sexual abuse’ as children are generally presented
for medical examination much later than the adult victims of sexual abuse and
therefore, the cases have to be decided on the sequelae of child sexual abuse
and not on acute changes. It is important to appreciate the significance of
these changes or appearances to use them in the diagnosis of child sexual
abuse.
Clefts/notches
They are indentations on the
hymenal membrane. Their shape, depth, location, proximity to hymenal
projection, hymenal configuration and examination position should be considered.
They may be a part of the normal hymenal morphology.
Hymenal transactions/tears can
heal to leave notching/narrowing on the hymen.
The term cleft or notch should be limited to
describe a defect of hymen that does not extend to the base. In fimbriated
hymen technique to separate the hymenal folds will facilitate the visualisation
of cleft/notches. Where deep posterior clefts /notches can be clearly
visualised penetrative injury should be considered.
Hymenal Bumps/mound
A bump or mound is a solid localised
rounded thickened area of tissue on the edge of the hymen. They are commonly
found in the annular or crescentic hymen. The appearance may depend on the
position of examination. Bumps and mounds do not indicate sexual abuse. The
child should be examined in different positions.
Size of the hymenal orifice
The association between the size
of the hymenal orifice and penetrative sex has been debated for many years. It
was the common knowledge that larger hymenal opening indicated penetrative sex.
Now it has been agreed that it is nearly impossible to obtain accurate
measurements of the hymenal orifice size due to the elasticity of the tissue.
The position of examination and even gentle pressure may change the size of the
orifice. Therefore the measurement of hymenal orifice is not recommended.
Hymenal Width
It is the widely held belief that
trauma can ‘attenuate’ the hymenal tissue making it narrow. This is usually
seen at the posterior hymen. The term now preferred is ‘narrow’ and not
‘attenuation’ and described according to the ‘usual’ clock face.
However, measurement of width of
the hymen is not recommended. Absent or narrow posterior hymen should be
confirmed in the knee chest position. In a prepubertal girl penetrative abuse
must be considered where there is complete or almost complete absence of
posterior hymenal tissue. There is insufficient evidence to assess whether a
‘narrow’ posterior hymen indicates sexual abuse in pubertal girls.
Some injuries and changes in anal examination and their significance
Anal / perianal erythema
Erythema is redness of the skin
and mucous membrane. In addition to injury, possible causes in children are
infection, scratching associated with thread worm, poor hygiene including faecal
soiling, lactose intolerance, dermatological conditions and inflammatory bowl
diseases.
All the possible differential
diagnosis should be considered. Examination should be repeated if the doctor is
doubtful about the diagnosis.
Perianal venous congestion
This refers to collection of
venous blood in the perianal venous plexus especially in children. In any child
prolonged traction might lead to appearance of engorged venous plexus. Even if
it appears in a relaxed child who is examined for 30 s it should not be
considered as indicating sexual abuse. It is reported to have been present both
in non-abused and abused children.
Anal/perianal bruising
Apart from trauma spontaneous
bruising due to haematological condition or drugs should also be considered, especially
in children.
If present the child should be
re-examined. All the possible differential diagnosis should be considered. When
bruising is found in the perianal/anal area sexual abuse should always be
considered.
Anal fissures, lacerations, scars and tags
Anal fissure is a break in the
perianal skin, which radiates out from the anal orifice. They are confined to
anal margin and may be superficial or deep.
Chronic fissures are usually deep
and transverse fibres of internal sphincters may be visible.
Perianal lacerations are acute
tears and tissue immediately surrounding anus. They extend beyond anal margin
and are usually longer than 1cm.
Healing of fissures and
lacerations can result in the formation of scars in the anal margin.
Anal tags most often result from
fissures.
In children, presence of anal
fissure with a history of alleged anal abuse may provide some corroboration if
the appearance is consistent with the timing of abuse. However, passing of hard
stool or consistent constipation should always be considered.
In children presenting with anal
laceration the possibility of sexual abuse should always be considered.
In children presenting with anal
scars or tags (outside midline) sexual abuse should be considered. At the same time other possible caused should
also be considered.
Reflex anal dilatation (RAD) in children
Reflex anal dilatation refers to
dynamic action of the opening of the anus due to relaxation of the external and
internal sphincter muscle with minimum buttock retraction (the anus is usually
closed initially, then opens, then closes again over a period of several
seconds)
RAD has been described more in
children who allege anal abuse than those allege sexual abuse. There is
insufficient evidence to determine the significance of laxity or reduced tone
relation to sexual abuse.
If RAD is seen sexual abuse should
always be considered in the context of history, medical assessment and other
anogenital signs.
Precise measurements of diameter
of dilated anal sphincter are not possible.
However doctor should record
details of RAD including approximation of the maximum transverse diameter with
relation to the examination finger, whether the rectum is seen and presence or
absence of stools.
After the examination
The doctor has to fill the MLEF
and apprise the police of the findings relevant to them.
Emergency contraception
If the doctor feels that the
alleged victim has been exposed to pregnancy due to unprotected sexual
intercourse emergency contraception has to be discussed with her. Even if the
perpetrator had not ejaculated in her vagina or ejaculated on the external genitalia
they should be considered as unprotected sex.
Sexually transmitted diseases
Sometimes alleged victims are
much worried about contracting STDs especially HIV if they are knowledgeable
enough to appreciate the danger of unprotected sex. They should be reassured and refer to the STD
clinic for further management.
Psychiatric Referrals
The acute response to sexual
assault differs from patient to patient. While some would demonstrate
stereotype of behaviour of a victim of ‘rape’, a distraught and frightened
individual, others may be calm and controlled. Those who have previous history
of mental health problems may show acute exacerbation of symptoms. Some victims of sexual abuse may end up with
‘post-traumatic stress syndrome’. Some
would show combination of behavioural, somatic and psychological reaction
called ‘the rape trauma syndrome’.
(The lecture
notes were prepared from two books
1.
The physical signs of child sexual abuse, an
evidence-based review and guidance for best practise, March 2008, Royal College
of Paediatrics and Child Health.
2.
Clinical Forensic Medicine, 3rd
Edition, Ed. W.D.S. McLay, 2009, Cambridge.)
Priyanjith Perera
24/12/12
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