GUIDELINES FOR COMPLETING POLICE FORM 3B FOR MEDICAL EXAMINATION OF VICTIMS OF SEXUAL ASSAULT.

Table of Contents

Place of medical examination:......................................................................................... 1

Handling victims of sexual violence: useful techniques ........................................ 1

COMPLETING THE POLICE FORM: .................................................................................... 2

Section 1: Particulars of the request .......................................................................... 2

Section 2: Place of medical examination .................................................................... 2

Section 3: Demographic information (particulars) of the victim. ............................... 2

Section 4: Apparent age of the victim based on medical examination ...................... 3

Section 5: Description of circumstances/ history of the incident(s) as told to the

health worker. ........................................................................................................... 3

Section 6: Relevant gynaecological and obstetric history .......................................... 4

General principles in medico-legal examinations. ................................................ 4

Section 7: General examination of the victim. ........................................................... 5

Section 8: Mental Examination .................................................................................. 5

Examination of the genital area, anus and rectum ............................................... 7

Section 10: Estimation of the ages of wounds and injuries: ..................................... 10

Section 11: Collection of materials/samples for purposes of evidence:................... 10

Section 11: Any other relevant information. ............................................................ 13

Section 12: Concluding remarks ............................................................................... 13

INTRODUCTION:

Proper documentation of medical evidence of sexual assault and the timely collection of

the relevant samples are vital for effective prosecution of such cases. The health worker,

through the medical examination and the documentation of the findings therefore, helps

the Courts of Law to establish whether a sexual act took place between the victim and

the suspect, and the circumstances surrounding it.

Place of medical examination:

Examinations of victims of sexual assault may be carried out in out-patient clinics.

Some health units, however, examine the victims in the gynaecological units, while

others use side rooms of the wards. The most important features of a place for such

medical examinations are the following;

a) There should be adequate visual and auditory privacy

b) The room should be well lit

c) There should be an examination couch and preferably one with

lithotomy poles.

d) Adequate supply of gloves and swabs

The clinic should, in addition, have tape measures and rulers, a source of running water,

a screen and a changing room where possible.

When handling a victim of sexual assault, it is very important for the health worker to

create a good interpersonal relationship with the victim right from the beginning.

Handling victims of sexual violence: useful techniques

You may find the following strategies and techniques helpful when dealing with victims

of sexual violence:

• Greet the victim by name. Use her preferred name. Make her your central

focus.

• Introduce yourself to the victim and tell her your role.

• Have respect for victim at all times.

• Be professional.

• Have a calm demeanor and use a gentle tone of voice A victim who may

been frightened is in need of people who will understand and support her.

Avoid expressions of shock or disbelief

• Do not perform the examination in haste.

• Maintain as much eye contact as is culturally appropriate especially during

history taking.

• Have an empathetic and non-judgmental attitude while the victim recounts

her experiences.

• Always address the victims questions and concerns.

• Avoid using victim-blaming statements such as, “What did you think would

happen?”, “What were you doing out alone?”, “What were you wearing?” or

“You should have known better.”

COMPLETING THE POLICE FORM:

Upon receipt of the request to examine the victim by the police, the health worker

should fill the sections on the police form as follows.

Section 1: Particulars of the request

• Use the information provided by the police on the request form to record the

particulars of the request

• This information is useful when testifying in the Courts of Law. It forms the

legal basis of the examination.

Section 2: Place of medical examination

• Indicate the place where the examination is being carried out. This should be

the name of the particular health unit.

Section 3: Demographic information (particulars) of the victim.

• Interview the victim or the accompanying person to provide the particulars

of the victim.

• The particulars of the victim identify who that person is and is used to

contact the victim when the need arises.

Section 4: Apparent age of the victim based on medical examination

The age of a person can medically be determined using:

1) Physical development

2) Dentition (Eruption of teeth).

3) Radiology.

• State the estimated age of the victim.

• Indicate how you have estimated the age.

Section 5: Description of circumstances/ history of the incident(s) as told to

the health worker.

Interview the victim or the accompanying person to establish when the sexual assault

occurred and the circumstances thereof. This is to guide the health worker to examine

the relevant areas and document appropriate injuries of the particular sexual act.

The following details about the alleged assault should be documented where applicable.

• The date, time and location of the assault, including a description of the type

of surface on which the assault occurred.

• Description and number of assailants.

• The nature of the physical contacts and detailed account of violence

inflicted.

• Use of weapons and restraints if any.

• Use of medications/drugs/alcohol/inhaled substances.

• How clothing was removed (where applicable).

• Details of actual or attempted sexual activity should also be carefully

recorded, in particular whether or not the following occurred:

 Vaginal penetration of victim by offender’s penis, fingers or objects;

 Rectal penetration of victim by offender’s penis, fingers or objects;

 Oral penetration of victim by offender’s penis or other object;

 Oral contact of offender’s mouth with victim’s face, body or ano-

genital area;

 Forced oral contact of victim’s mouth with offender’s face, body or

ano-genital area.

 Ejaculation in victim’s vagina or elsewhere on the victim’s body or

at the scene.

• Activities performed by the victim after the assault such as bathing and

douching.

Section 6: Relevant gynaecological and obstetric history

A victim’s recent gynaecological and obstetric histories are of particular relevance in

some cases of sexual assault. Care should, however, be taken to document what is

relevant to that particular case. The health worker should inquire about:

● The first day of the last normal menstrual cycle.

● The age at which the first menstrual cycle was seen

● Past and present pregnancies

● Any ano-genital surgery

● Contraceptive history

● Last consensual sex, as details of this may be required if DNA analysis is to be

performed.

General principles in medico-legal examinations.

• Make sure the equipment and supplies are prepared and available.

• Do not ask the victim to undress or uncover completely. Examine the upper half

of her body first, then the lower half; or give her a gown to cover herself.

• Examine the victim’s clothing under a good light before she undresses. Collect

any foreign debris on clothes and skin or in the hair (soil, leaves, grass, foreign

hairs). Ask the victim to undress while standing on a sheet of paper to collect any

debris that falls.

• Systematically examine the victim's body. Start the examination by taking the

vitals (pulse, blood pressure, respiratory rate and temperature) as this is more

reassuring for the victim. Do not forget to look in the eyes, nose, and mouth (inner

aspects of lips, gums and palate, in and behind the ears, and on the neck. Check

for signs of pregnancy.

• Take note of the pubertal stage where applicable.

• Look for signs that are consistent with the victim's story, such as bite and punch

marks, marks of restraints on the wrists, patches of hair missing from the head, or

torn eardrums, which may be a result of being slapped. If the victim reports being

throttled, look in the eyes for petechial haemorrhages. Examine the body area that

was in contact with the surface on which the violence occurred to see if there are

injuries.

• Take the samples, as provided in section 10, during the examination.

• Record your findings and mark/ illustrate them carefully on the body figure

pictograms in the form, in legible hand writing.

Section 7: General examination of the victim.

Note the physical condition of the victim including:

• Whether the victim is frail, is sickly, is disabled or strong and capable of

putting up resistance.

• The gait and especially whether the victim walks with difficulty.

• Whether the clothing is soiled or torn.

Section 8: Mental Examination

The aim of a mental examination is to establish the emotional and psychosocial effects

of the sexual assault on the victim and to establish if the victim had a mental illness. The

mental examination is carried out through observation of the victim, a clinical interview

with the victim, taking of collateral history and a formal assessment of the victim’s

current thinking, mood (feeling) and behaviour. The health worker needs to establish

history of previous mental illness, family history of mental illness and the past and

immediate medical history of the victim.

The mental examination of the victim will include evaluation of:

Appearance, Behavioral activity and Speech:

• Observe whether the victim is alert or appears restless, sad, crying or any

other abnormal or inappropriate behavior especially when talking about the

incident.

• Note if the volume of speech is low or high, if it’s fast or slow, coherent or

difficult to understand.

Mood (Affect or demeanor)

This evaluates the victim’s inner emotional state and is noted from the facial expression,

body posture and vocal tone. The mood may be elated or depressed.

Thoughts, Perception and Cognitive Functioning

These will be assessed by establishing rapport with the victim.

Assess whether the victim has:

• Ideas that are linked, logical and goal directed and the victim is well oriented

in person, place and time.

• Delusions, obsessions, thought insertions, thought withdrawals and thought

broad casting.

• Hallucinations and illusions.

• The ability to concentrate and recollect events.

Section 9: Examination of the regions of the body:

The findings of the physical examination will depend on how soon after the sexual

violence took place, the victim presents to the health worker. The health worker should

endeavor to examine all the regions of the body systematically as outlined and

document the findings on the police form. The objective of the physical examination is

to determine the nature, number, position and dimensions of all injuries.

An injury is tissue damage resulting from any of the following; physical force, heat,

cold, chemicals electricity or radiation. Most of the injuries are wounds. A wound is

defined as a disruption of the continuity of tissues as a result of a mechanical force. The

following is a brief description of the types of wounds encountered in forensic

examinations.

An abrasion is a superficial injury in which the skin or mucous membrane has been

crushed or removed by rubbing. These may be scratches, grazes (or scrapes) friction

abrasions or imprint (patterned) abrasions.

A bruise is a wound resulting from the escape of blood into tissue from raptured small

blood vessels with a resultant discoloration and/or swelling of the overlying intact skin

or membrane. They are also known as contusions. The appearance of bruises may be

delayed up to 24 hours.

A laceration is a tear in the tissues. It usually has irregular edges and is normally

caused by crushing or blunt force trauma. It is usually associated with bruising.

An incised wound is also known as a cut. There is full thickness breech of the skin and

the wound has regular edges. It is caused by a shape edged object and it may bleed

profusely. Chop wounds are gapping wounds caused by heavy, sharp-edged objects.

A stab wound is a wound produced by a piercing object or made by driving into a body

a pointed object. A fatal complication of stab wounds is hemorrhage which is

characteristically internal. The edges and depth of the wound may correspond to the

shape and length respectively of the offending object.

Examination of the genital area, anus and rectum

Even when female genitalia are examined immediately after a rape, there is injury may

only be identified in less than 50% of cases. A genital examination should be carried out

as indicated below.

• Systematically inspect, in the following order, the mons pubis, the inner aspects of

the thighs, the perineum, the anus, the labia majora and minora, the clitoris, the

urethra, the introitus and hymen: Note any scars from previous female genital

mutilation or childbirth.

Look for

 Any signs of infection, such as ulcers, vaginal discharge or warts.

 Injuries to the hymen (these are more common in children and

adolescents).

 Injury at the introitus, often located in the posterior fourchette

 Injury to the vaginal walls, cervix and fornices.

• Always endeavor to take samples for laboratory analysis. When collecting samples

for DNA analysis, take swabs from around the anus and perineum before taking

the samples from the vulva, in order to avoid contamination.

• For the anal examination the victim may have to be in a different position than for

the genital examination. In suspected cases of anal penetration, note the shape and

dilatation of the anus. Note any fissures around the anus, the presence of faecal

matter on the perianal skin, and bleeding from rectal tears. If indicated by the

history, collect samples from the rectum.

• If there has been vaginal penetration, gently insert a speculum, lubricated with

water or normal saline. Do not use a speculum when examining children, virgins

and when the victim has fresh tears. Under good lighting inspect the cervix, then

the posterior fornix and the vaginal mucosa for trauma, bleeding and signs of

infection. Take vaginal swabs at this stage.

• If indicated by the history and the rest of the examination, do a bimanual

examination and palpate the cervix, uterus and adnexae, looking for signs of

abdominal trauma, pregnancy or infection.

• Perform a recto-vaginal examination and inspect the rectal area for trauma, recto-

vaginal tears or fistulas, bleeding and discharge if indicated. Note the sphincter

tone. If there is uncontrollable bleeding or suspected presence of a foreign object,

refer the victim to a specialist.

Special considerations for elderly women

Elderly women, like children, are at increased risk of vaginal tears and injury, and

transmission of STI and HIV when vaginally assaulted. Decreased hormone levels after

the menopause result into atrophy of the vagina, thereby making the vagina prone to

injuries. Use a thin speculum for genital examination. If the only reason for the

examination is to collect samples or to screen for STIs, consider inserting swabs only

without using a speculum.

Special considerations for boys.

• For the genital examination:

 Examine the scrotum, testicles, penis, periurethral tissue, urethral

meatus and anus.

 Note if the victim is circumcised.

 Look for hyperaemia, swelling and tenderness Distinguish these from

inguinal hernias, hydroceles and haematoceles and torsion of testis.

 Torsion of the testis is a surgical emergency that requires immediate

intervention.

 If the urine contains large amounts of blood, look for penile and

urethral trauma.

 Perform a rectal examination in cases of anal sex and look for trauma

and signs of infection of the prostate and rectum.

 If relevant, collect material from the anus for examination for

spermatozoa under a light microscope.

Special considerations for examination in children

• Note the child's weight, height, and pubertal stage.

• Ask girls whether they have started their menses. If the girl has attained her

menarche, she may be at risk of pregnancy.

• Small children can be examined on the mother's/guardian’s lap. Older children

should be offered the choice of sitting on a chair or on the mother's lap, or lying on

the bed.

• Examine the hymen. Note the location of any fresh or healed tears in the hymen

and the vaginal mucosa.

• A digital examination is not recommended in young children (below 10 years

unless there is a strong clinical indication).

• Examine for vaginal discharge. In prepubertal girls, vaginal specimens can be

collected with a dry sterile cotton swab.

• Do not use a speculum to examine prepubertal girls as this is extremely painful

and may cause serious injury.

• A speculum may only be used when you suspect a penetrating vaginal injury and

internal bleeding. In this case, a speculum examination of a prepubertal child is

usually done under general anesthesia.

• In boys, examine the frenulum of the prepuce for injuries and the anus and urethra

for any discharge.

• Reflex anal dilatation can be indicative of anal penetration, but also of

constipation.

• Do not carry out a digital examination to assess anal sphincter tone.

• If the child is highly agitated, and cannot be calmed down, and physical

examination is vital, the examination may be performed with the child under

sedation. Oral diazepam may be given in the doses of 0.15 mg/kg or alternatively

promethazine syrup in doses of 15-20 mg for children between 2-5 years.

Section 10: Estimation of the ages of wounds and injuries:

The age of a wound is estimated by observing its colour, the state of bleeding, scab

formation and stage of healing.

• A fresh wound is a wound that has been caused within the last 2 days. This is

a wound that is red and easily bleeds.

• A wound caused within 2 and 5 days is dry and does not bleed actively and

is pale or brown in appearance

• A wound that more than 5 days will shows obvious signs of healing such as

epithelial growth and granulation tissue formation. Initially it is of a paler

colour than the surrounding skin.

Section 11: Collection of materials/samples for purposes of evidence:

It is essential that the collection, labeling, storage and transportation of specimens

follow legally and scientifically acceptable standards and procedures.

When collecting specimens for forensic analysis, the following principles should be

strictly adhered to:

• Collect samples for DNA analysis from all places where there could be saliva

(where the attacker licked or kissed or bit the victim) or semen on the skin or

clothes.

• The victim’s pubic hair should be combed for foreign hairs.

• If ejaculation took place in the vagina or anal area or mouth, swabs should be

taken for examination for spermatozoa and for DNA and acid phosphatase

analysis. In children, the anus and the vulva should always be inspected.

• Label clearly and accurately all specimens with the victim’s name/ identifying

codes and date of birth, the health worker’s name, the type of specimen, and the

date and time of collection.

• Ensure safety of the samples and maintain the chain of custody of the evidence.

The table below lists the range of forensic specimens that are typically of interest

in cases of sexual violence, together with notes about appropriate collection

techniques and comments on their relevance.

Forensic specimens

SITE

MATERIA

EQUIPMEN

SAMPLING

INSTRUCTION

Anus

(rectum)

Semen

Cotton swabs and

microscope slides

Use swab and slides to collect

and plate material; lubricate

instruments with water, not

lubricant.

Lubricant

Cotton swab

Dry swab after collection

Blood

Drugs

Appropriate tube.

Collect 10 ml of venous blood

DNA

(victim)

Appropriate tube

Collect 10 ml of blood.

Clothing

Adherent

foreign

materials

(e.g. semen,

blood,

hair, fibres)

Paper bags

Clothing should be placed in a

paper bag(s). Collect paper sheet

or drop cloth. Wet items should

be bagged separately.

Genitalia

Semen

Cotton swabs and

microscope

Use separate swabs and slides to

collect slide and plate material

collected from the

external genitalia, vaginal vault

and

cervix; lubricate speculum with

water not

lubricant or collect a blind

vaginal swab

Hair

Comparison

hair found at

scene

Sterile container

Cut approximately 20 hairs and

place hair in sterile container.

Mouth

Semen

Cotton swabs,

sterile container

(for oral

washings)

or dental flossing

Swab multiple sites in mouth

with one or more swabs To obtain

a sample of oral washings, rinse

mouth with10 ml water and

collect in sterile container.

DNA

(victim)

Cotton swab

Nails

Skin, blood,

fibres, etc.

(from

assailant)

Sterile toothpick

or similar or nail

scissors/clippers

Use the toothpick to collect

material from under the nails or

the nail(s) can be cut and the

clippings collected in a sterile

container.

Sanitary

pads/ampon

Foreign

material e.g.

semen,

blood, hair)

Sterile container

Collect if used during or after

vaginal or oral penetration.

Skin

Semen

Cotton swab.

Swab sites where semen may be

present

Saliva (e.g.

at sites

of kissing,

biting or

licking),

blood

Cotton swab

Dry swab after collection.

Foreign

material

(e.g.

vegetation,.

matted hair

foreign

hairs)

Swab or tweezers

Place material in sterile

container(e.g. envelope, bottle)

Urine

Drugs and

HCG

Sterile container

Collect 100 ml of urine.

Samples should be dispatched to the laboratory immediately.

Section 11: Any other relevant information.

Report any relevant information in regard to the case that may not have been reported in

the rest of the above sections. Such information may include;

a) Serious complications diagnosed which need immediate attention.

b) Any treatment given or procedure done like PEP and any surgery. These should

include those administered even before the case was reported to police.

c) Any referrals made or required.

Section 12: Concluding remarks

Summarise your findings and relate them to the sexual assault under investigation.

Particulars of the Heath worker.

The particulars of the health worker are important for purposes of identification and

communication with other investigators and the Courts of Law. The qualifications of the

health worker are what makes him or her a professional or expert witness.