Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 91–102

Contents lists available at SciVerse ScienceDirect

Best Practice & Research Clinical

Obstetrics and Gynaecology
journal homepage: www.elsevier.com/locate/bpobgyn

Forensic medical examination of adolescent and adult

victims of sexual violence
Ole Ingemann-Hansen, MD, PhD, Forensic Pathologist *,
Annie Vesterby Charles, MD, DMSc, Professor, Chief Forensic Pathologist,
Head of Department
Department of Forensic Medicine, Section of Forensic Pathology and Clinical Forensic Medicine, University of Aarhus,
Brendstrupgaardsvej 100, 8200 Aarhus N, Denmark

Keywords:
The acute care and examination of a victim of sexual violence must
sexual abuse be carried out by a competent forensic examiner in a setting
rape appropriate for crisis intervention, forensic evidence collection,
forensic examination and medical follow up. The aim of forensic evidence and biological
material collection is to document an alleged physical or sexual
contact between individuals and to corroborate the victim’s and
the assailant’s history. This is why the forensic examiner is ex-
pected to be objective and in possession of specialised technical
and scientific skills. These skills are addressed and recommenda-
tions are made on how to carry out a forensic examination. This
includes medical and assault history, top-to-toe examination,
biological material collection, and documenting injuries while
obtaining the chain of custody. Yet, consensus on time limitations
for forensic evidence collection is lacking. Available forensic
evidence has been shown to benefit prosecution. To meet the legal
system’s needs, an interpretation of the findings in a written legal
report is mandatory.
Ó 2012 Elsevier Ltd. All rights reserved.

Delineating the purpose

The examination of victims of sexual violence is often located at specialised Sexual Assault Referral
Centres (SARC), and is multidisciplinary and public in approach, with free access for every citizens.1,2
The first SARC was originally opened in Boston City Hospital in 1972, and was born out of new

* Corresponding author.
E-mail address: oih@forensic.au.dk (O. Ingemann-Hansen).

1521-6934/$ – see front matter Ó 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.bpobgyn.2012.08.014
92 O. Ingemann-Hansen, A.V. Charles / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 91–102

research and understanding of ‘rape trauma syndrome’.3,4 Later, several SARCs were established in the
other Western countries.5–17 The establishment in 1999 of the SARC in Aarhus, Denmark, at the
Accident and Emergency department, was based on guidelines stating that every single female who
attended the health services should be offered care, treatment, and a medical examination with
forensic evidence collection.18,19 In areas with no SARCs, the range of help offered to victims of sexual
assault might be accidental or fragmentary, with no continuum and follow up.20,21 The forensic medical
examination first described by Paul in 1975,22 and later in the widespread ‘gold standard’ Guidelines for
medico-legal care for victims of sexual violence by the World Health Organization,23 however, is a well-
known standard protocol.
In this chapter, we aim to describe practical issues relating to the forensic medical examination,
with emphasis on evidence collection of biological trace material and competence of physicians.
The world Health Organization defines sexual violence as:
‘Any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to
traffic, or otherwise directed, against a person’s sexuality using coercion, by any person
regardless of their relationship to the victim, in any setting, including but not limited to home
and work.’24
In this chapter, we use the terms ‘sexual violence’ and ‘sexual assault’ to denote episodes of
involuntary interpersonal hetero- as well as homosexual acts or contacts, such as completed or
attempted penile penetration of the vagina, anus, or mouth (irrespective of whether ejaculation of
semen takes place); episodes of penetrating the vagina, anus, or mouth with fingers or objects; and
episodes in which a person is believed or considers himself or herself to be assaulted. The Danish penal
code considers the assault as rape when forced sexual intercourse, completed or attempted, is acquired
with violence or threat of violence.25 Victims of such sexual assaults are primary recipients of a forensic
examination.

Forensic examination

Main components of a forensic examination

The care and examination of an acute sexual assault victim needs to be carried out by a competent
medical doctor with knowledge of the psychological response to sexual assault. They must be
a competent communicator so that a relevant history of the assault can be obtained. They must know
what to look for, how to document and obtain biological trace evidence, and how to interpret and
report the findings verbally and in writing. Specialists in forensic medicine at Aarhus University carry
out the examinations ensuring impartiality. The examination should take place in a quiet setting with
access to necessary equipment and assistance. From the victim’s perspective, prompt medical exam-
ination by a physician is seen as crises intervention, and injuries can be treated, and sexually trans-
mitted infection and pregnancy risk evaluated and prevented as necessary. The physician is also
responsible for collecting trace evidence.
From a legal perspective, police reports require the following: accurate history; documentations of
observations; forensic trace evidence collection; interpretation of the findings; a standardised medico-
legal report in objective terms; and provision of expert opinion in legal proceedings.
From the above, a set of main components can be assembled for a full forensic medical examination.
These are presented in Table 1.

Specific components of the evidentiary examination

Assessment and consent

Upon arrival to the SARC or other setting for the examination, the receiving team (nurse or medical
doctor) must establish the order of injuries needing acute medical or surgical treatment; hence,
treatment takes priority over prompt forensic examination. The forensic examiner should be alerted,
and if possible immediately attend, to the victim for parallel examination and securing of evidence (e.g.
clothes). The forensic examiner introduces the victim to the examination, informs them of the options,
 O. Ingemann-Hansen, A.V. Charles / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 91–102 93

Table 1
Essential components of a forensic examination.

Assessment of the victim

Informed consent
Medical and gynaecological history
Assault history
Physical top-to-toe examination
Genito-anal examination
Trace evidence and biological material collection
Documenting injuries and findings
Securing chain of custody
Interpretation and reporting of findings

and obtains informed consent by explaining that confidentiality to the police is not possible. It is
fundamental that the victim is not pressed to participate in the examination, and written consent is
central if the resulting report is to be used legally. It is obligatory for the police to obtain written
consent in advance.

History
For proper disclosure of the history and alleged assault event, the necessary information is best
obtained by using a standardised examination protocol acting as a guide for all relevant details.
Simultaneously, a standard protocol makes talk of the sexual activity and inflicted coercion more
straightforward and less intimidating. Points of forensic medical interest to support subsequent
findings are the victim’s general health, use of prescriptive medication or drugs of abuse, menstrual
period, former sexual relationships, time since last voluntary intercourse, and recent genital lesions.
It should be explained to the victim that obtaining an assault history is not police questioning, and
that the forensic examiner is interested in different aspects of the assaultive episode to the police
authorities. Meticulous history taking allows exact documentation and guides the examiner during the
following physical examination and trace-evidence collection (Table 2).

Top-to-toe and genito-anal examination

It is advisable to conduct the physical examination and the trace-evidence collection simulta-
neously using the above-mentioned standard protocol, and to also document injuries by using body
maps and photography during the examination. The general demeanour and appearance of the victim
is noted along with signs of inebriation. The systematic top-to-toe examination should be conducted in
the same manner every time, and all parts of the victim’s skin should be inspected. An adequate
method is to begin with the head, including the oral orifice and eyelids (petechial bleeding) and the
neck. The victim is then asked to recline so that the breast and trunk can be examined followed by the
extremities. Remember to cover the victim’s pelvic region and legs while examining the breast and
trunk, and vice versa.

Table 2
Taking a meticulous assault history.

When and where the assault happened.

What happened.
The exact position of the victim and the assailant during the assault.
Surroundings.
Use of coercion by violence and restraints.
Whether weapons were used or neck compression inflicted, as these have legal implications.1
Removal of victim’s and assailant’s clothing.
Oral, vaginal, rectal, or both, penetration by penis, fingers or objects.
Ejaculation.
Kissing of the victim’s face or body.
Parts of the victim touching the assailant.
Aftermath activities such as bathing, changes of clothing, toileting.
Genito-anal discharge, bleeding or pain symptoms.
94 O. Ingemann-Hansen, A.V. Charles / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 91–102

With the female victim in supine position, knees drawn and legs apart, inspection of the external
genitals and perineum is achieved followed by insertion of a speculum to inspect the vaginal wall and
cervix. Trace evidence is collected before insertion of instruments in order to avoid contamination.
Specimens from the vagina (i.e. foreign bodies) and samples from the cervix, however, are collected
while the speculum is inserted. The anal examination can be carried out with the female victim still in
supine position, or turned in the lateral position. After initial inspection and trace-evidence collection,
depending on the assault history or signs of profound injury, anoscopy should be carried out.
Use of colposcopy is an area of variation and not routine or recommended in all examination
programmes.26 The Norwegian Society for Gynaecologist recommends use of a colposcope for diag-
nostic purposes and documentation.27 In a recent study by Astrup et al.,28 genital lesions were seen
with the naked eye in 34% of the cases examined, 49% were seen with colposcopy, and 52% were seen
with toluidine blue dye and subsequent colposcopy. As primary intent of the forensic evidence
collected is to confirm recent sexual contact, to show if force or coercion has been used (in rape
complaints), and to corroborate the victim’s story,29 the intention is to document as many injuries as
possible using utensils as colposcope and dye. It is clear, however, that a genital lesion in itself does not
corroborate a legal complaint of rape, but the documentation of a genital lesion could be of importance
in the individual case whatever the circumstances and explanations.28
The police investigator and legal prosecutor want to know the age of the injury, the way it was
inflicted, the type of force used, and the health consequences for the victim. An accurate and complete
record of injuries must be compiled, with careful documentation, and proper and rigorous description.
Standardised features, such as location, size (continuous use of same unit), shape, colour, and classi-
fication, are to be used, allowing correct interpretation and deduction. Classification of injuries should
be in accordance with generally used terminology, including bruises, abrasions, contusions, lacerations,
sharp-edged wounds, gun wounds and crust-covered wounds.
Site of special forensic interest is conjunctiva and neck, where petechiae, bruises, abrasions, and
ligature marks indicate a trauma against the neck. Together with sharp-edged wounds and gun wounds
indicating use of weapons, these injuries are signs of the victim having been in life-threatening danger.
This could be immediate or potential danger, depending on the exact location, spread and depth of
injuries. Such injuries or an assault history, including trauma against the neck, use of weapons, or both,
have been shown to significantly affect legal outcome.1 Other sites of forensic interest are the face with
bruises; haematomas of the periorbital region and inner lips indicating blows; the little finger side of
hands and forearms, with bruises indicating warding off injuries; shoulders, upper arms and wrists, with
bruising (e.g. fingertip) after possible restraint; and bony prominences with abrasions and bruises as
caused by falls. Bodily (extra-genital) injuries are reported in 25–90% of victims medically examined.30–
33
Genital injuries, such as abrasions or lacerations of the fossa navicularis, posterior fourchette, peri-
neum, or perianal region, are possible signs of penetration or attempted penetration by the penis,
fingers, or other blunt objects, hence indicating a sexual act. Both positive and negative occurrence of
injuries and soiling has to be registered.
Remember that description is different from interpretation, and should not be confused in the
injury record.

Trace-evidence collection: why, what, where, when, and how?

The aim of forensic evidence and biological trace material collection is for use in legal proceedings
to document an alleged physical or sexual contact between individuals, objects, or places,23 and to
corroborate the victim’s and the assailant’s history. That is why the forensic examiner is expected to be
absolutely objective and in possession of specialised technical and scientific skills.
A recommended method is to ask the victim to stand on a sheet of paper in order to collect any
falling debris, hairs, or fibres while clothing is secured piece by piece in paper bags. During the
subsequent top-to-toe and genito-anal examination, all injuries are recorded and documented dia-
grammatically. Specimens for DNA and semen are routinely collected with a swab from the face and
neck, and both hands, from the gingival margins of the lower jaw, the introitus and fornix vaginae, and
the anus. If indicated by the victim’s history, or if visible soiling/contamination, additional samples for
semen, blood, saliva, and soiling are taken. Scraping of fingernails with toothpicks (Fig. 1) and a swab
from the inside cheek for DNA reference are carried out. Finally, urine and blood samples are collected.
 O. Ingemann-Hansen, A.V. Charles / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 91–102 95

Fig. 1. Fingernail scraping using utensils from forensic evidence collection the kit box.

Smears on slides are made from the possible semen swabs and stained with haematoxylin-eosin by
a laboratory assistant, whereupon the physician looks for spermatozoa under light microscopy. The
genetic and toxicological analyses are made on request from the police authorities. The genetic
evidence is analysed for semen, blood, saliva, and skin, and DNA type at the Forensic Genetic
Department. At the Forensic Chemical Department, specimens are analysed for alcohol and drugs.
Forensic scientists at the police department examine the clothing for damage and foreign materials.
Biological trace material as foreign DNA can be detected from semen containing spermatozoa, saliva
containing epithelial cells, blood, loose epithelial cells, and hair. Conversely, if DNA is detected, the origin
as semen, blood, or saliva can be determined. Furthermore, as evidence of the presence of seminal fluid,
spermatozoa can be detected by wet-mounted smear or stained smear on light microscopy, or by
prostatic acid phosphatise and prostatic specific antigen, with often a higher prevalence of positive test
than microscopy.1,34,35 Non-human specimens to be collected are smudges of vegetation or fibres.
Biological trace evidence is collected from the skin, body orifices, the penis of male victims, nails,
blood, and urine, and clothing are obtained. DNA-free cotton swabs, toothpicks, tweezers, paper bags,
needles, and containers are used. In general, it is recommended that moistened (sterile water) swabs
are used from dry surfaces and dry swabs from wet material. The World Health Organization recom-
mendation from 2003 is to collect specimens as early as possible because the value of evidentiary
material decreases dramatically 72 h after the assault.23 An overview of recommendations of the
forensic trace evidence collection procedure is presented in Table 3.
In Denmark, the cut-off limit for trace-evidence collection is set to 72 h, partly as a result of a recent
study where spermatozoa were found up to 3 days after the alleged assault, but not after.1 On the other
hand, injuries stay longer, and use of colposcopy and toluidine blue dye has extended the median
survival time for visible injuries from 24–80 h, exceeding the time limit for admission to many SARCs.28
The role of colposcopy and toluidine blue dye is not recommended as a routine procedure until further
knowledge is available.
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Table 3
Recommendations for body locations and time since assault for routine evidence collection.

Site World Health Denmark36 Norwaya 37

(days) Sweden38 (days) Britain39 (days) USA40,41
Organization23
Gingiva x <3 days <4 <10 <2 <24 hb
Palate <4
Lips <10
Face <3 days
Genitalia ext. x <4 <10 <3–5 daysb
Introitus <3 days <4 <10 <7a <3–5 daysb
Vagina middle <4
Fornix post. x <3 days <4 <10 <7a <3–5 daysb
Cervix x <4 <10 2–7a <3–5 daysb
Perianal <4 <10 <3 <24 hb
Penis x <3 days <4 <10
Anus/rectal x <3 days <4 <10 <3a <24 hb
Skin x <3 days <4 <10 <wash
Nails x <3 days <4 <10a <3–5 daysb
Hands <3 days <10
Clothing x <3 days <4 <10 <3–5 days
Blood sample x <24 h <4 Yes Yes <3 daysb
Urine sample x <3 days <4 Yes Yes <3 daysb
a
Norway recommends an abbreviated examination if the examination is 4–7 days after the alleged assault.
b
Depending on the assault history, x, recommended before 72 h.

Documenting by securing chain of custody

The primary task of the forensic examiner is to obtain accurate documentation of the examination,
including the essential forensic examination components mentioned so far. To secure the identity of
the victim, it is important to document who has carried out the examination, who assisted, who
attended, what information was available, where and how the examination was carried out, what
trace evidence was collected, for what purpose, and how it was secured and stored. The procedure for
the whole examination, especially the sampling of trace evidence, has legal implications, as the
findings could be used in a court of law. The key word is chain of custody. In order to comply, the
medical examination would benefit from using a well-equipped rape kit containing utensils needed
for the qualified forensic evidence collection. The kit box in Aarhus (Fig. 2), which is now distributed
all around Denmark, was made in co-operation with the Danish Technological Institute, and was

Fig. 2. The forensic evidence collection kit box, Aarhus.

 O. Ingemann-Hansen, A.V. Charles / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 91–102 97

approved by DANAK, the Danish authority tasked with evaluating quality assurance. The box secures
the chain of custody because all material necessary for evidence collection is available, sterile or DNA-
free, and the clinician is familiar with, and has a thorough knowledge of, the utensils. Furthermore,
the person who packed the kit, the nurse opening the kit, and the examiner touching the utensils are
all traceable. The handling procedures should be clear from the kit’s guidance or the examiner’s
manual on how specimens are collected carefully, contamination is avoided, how to label the material
accurately and secure and tamper-proof the specimens. Documentation of the transfer of the kit-box

Fig. 3. Body diagram as used at the Sexual Assault Referral Centre, Aarhus.
98 O. Ingemann-Hansen, A.V. Charles / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 91–102

from the time it is opened until it is sealed and secured is maintained. How to obtain consent,
recording assault history and noting findings on diagrams (Figs. 3 and 4) should be possible in an
enclosed protocol or record book. Photography as documentation is mandatory, and knowledge of the
capabilities and requirements of the use of photographs in the legal proceeding is necessary. If the kit
and manual have been approved by the organisation responsible for standardisation, then doubts

Fig. 4. Genital diagram as used at the Sexual Assault Referral Centre, Aarhus.
 O. Ingemann-Hansen, A.V. Charles / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 91–102 99

about the validity of DNA material to be used in court are diminished. All information that is
registered in accordance with specially designed protocols can be easily transferred to a database for
further research.

Interpretation and disclosure of findings: the legal report

In the case of a reported assault to the police authorities, a written report is expected to the
requester and ‘owner’ of the report. In the case of a non-reported assault, the victim has full self-
determination, and the recorded documentations are strictly confidential. To meet the legal
system’s needs, an interpretation of the findings is necessary. Even though the objective was clear
from the start of the examination, and with the legal implication taken into account, accurate
interpretation should be carried out by specialists (e.g. by a forensic physician or pathologist). In
order to fulfil this statement, use of standardised forensic evidence collection and examination
techniques, based on standard terminology, as described so far, should be carried out.
A properly written forensic report should make clear what the examiner was told (from police and
victim), observed, and did during the examination, maintaining objectivity using proper terminology. In
a conclusion section, the interpretation of findings should make the police investigator and legal
prosecutor clearly aware of the age of the injuries and the mechanisms of how the injuries occurred –
could they have arisen from the alleged assault, the force by which they were inflicted and whether
immediate or potential life-threatening danger was present, together with possible short- or long-term
health consequences for the victim. Remember to write and conclude only what could be repeated and
explained in court giving testimonial evidence. Guiding principles of what should be documented in the
forensic report to the requester of a forensic examination in sexual offences are presented in Table 4.
Genital injuries sustained during assault range from 10–87%.16,42–49 Injuries sustained during
consensual intercourse range from 6–55%.43,50–52 Differences in the use of colposcopy, and inclusion of
redness and swelling as an injury are variations, in study methodology. It follows that, genital injuries
in itself do not corroborate sexual assault, which have to be interpreted during disclosure. Another
example is interpretation of injuries in cases that end up considered baseless or with charges of false
allegations.53 Such self-inflicted injuries are characteristically symmetrically distributed and typically
avoid the areola of the breasts and the genital area.

Legal outcome

A significantly positive association exists between forensic evidence used to establish physical body
and genito-anal injuries, and legal outcome.54 Other studies have shown an association between
assault history and legal outcome, whereas others have reported no significant findings (Table 5).

Table 4
Contents in the written forensic report.

Victim demographics
Assault history (from victim and police)
Alcohol, drug, and medication intake
Post-assault activities
Medical and gynaecological history (relevant)
Victim’s general appearance
Signs of inebriation, impairment, and illness
Injury description
Details of all specimens collected
Procedure for examination and material collection
Material for laboratory analyses or storage
Immediate test results
Medications and referrals given
Interpretation and conclusion of forensic findings
arising from alleged assault
force infliction
life threat
health consequences
100 O. Ingemann-Hansen, A.V. Charles / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 91–102

Table 5
Studies on forensic evidence documentation and legal outcome.

Country Year Participants Conviction rate (%) Significant association to conviction

Denmark55 1980 51 24 None
Finland31 1984 249 36 Body injuries
Norway9 1992 141 29 Severe coercion
USA15 1980 372 69 None
Canada17 1995 355 23 Injuries, age, weapon
Canada56 1997 462 11 Body injuries
Denmark1 2005 289 19 Severe coercion

Available forensic evidence benefits prosecution, but attrition represents confounders in studies on
legal outcome.57 Furthermore, many victims hesitate to present to SARCs, and these victims might not
have forensic evidence collected.58

Conclusion

Medical forensic examination and the resulting legal report benefit the legal procedure and contain
findings and conclusions not otherwise described. It is important to remember that medical exami-
nations are dynamic and, in every single case, are subject to choices of the examiner. Nevertheless,
attention should be paid to the fact that sexual assault victims in shock or embarrassment may be
unreliable about what happened. Hence, a standardised forensic examination protocol following the
mentioned recommendations should work as routine. It is of great importance that the examination is
carried out by a specially trained physician accommodating the victim’s needs for crisis intervention
and medical treatment and follow up.

Practice points

Treating victims of sexual violence is multidisciplinary and public in approach. The examinator
must be a competent communicator with knowledge of psychological reactions. The examination
is documented by using a standard protocol. Significant association between forensic docu-
mentation and legal outcome.

Research agenda

 Persistence of foreign DNA on skin and body orifices.

 Consensus of time limitations for forensic evidence collection.
 Forensic medical examination and effect on the legal outcome.

Conflict of interest

None declared.

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