Sexual Offence Investigation – The role of the Forensic Medical Examiner

1. Sexual Offence Investigation – The role of the Forensic Medical Examiner Dr Michael O’Keefe Principal Forensic Medical Examiner Strathclyde Police 18 May 2011 drokeefe@ymail.com

2. Sexual Assault - The Role of the FME To provide best professional service to – • Complainer- health needs take absolute priority • Police - collection of trace evidence (secondary) • Fiscal- formal detailed report is required • Court - give witness to findings & opinion

3. Doctor - Patient Relationship • Explain my role of “dual responsibility”- clinical & forensic • Examination can only proceed with consent - only valid if fully informed • Explain procedure and reasons for samples - facilitates consent • Confidentiality issues must be explained i.e. report may be available to police; fiscal; court; “experts” • Patient must be assured she/he is in control (complainer) • Obtain appropriate consent (verbal / written) and proceed

4. The Forensic History • Complaint taken by police officer (SOLO) • Specific enquiries about the complaint made to officer • Recent consensual intercourse • Was force used - type, when, where? (body site) • Was resistance offered - any injuries inflicted on assailant?

5. The Medical History • Medical history – taken by FME • General medical – including prescribed drugs • Obstetric – SVD / CS • Gynaecological – specific procedures • Psychiatric – sensitive enquiry

6. The Forensic Examination • Dr should provide professional courtesy and sensitivity not sympathy – must remain “clinical” and objective • General examn.- note demeanour, mood, sobriety • General -head to toe - complainer may be unaware of injury? • Genitalia - structured & detailed - including negatives • Anal examination - only when appropriate? • Video-colposcopy is now the expected standard

7. General Examination & Injuries Record an accurate description of any injury with - Site of injury - inc anatomical landmarks Specific sites - mouth; lips; throat; wrists; inner thighs & knees Nature of injury - bruises, abrasions, lacerations, incised wounds, restraint injuries Size & shape - measured in cm Age- fresh, healing, old (caution with bruises – “within timescale”)

16. Injuries - Genital (T.E.A.R.S.) • Tears (or lacerations) • Ecchymosis (or bruising) • Abrasions • Redness ? • Swelling ?

17. Genital structures to be examined • Vulva - bruises; abrasions, lacerations ? • Labiae majorae - `` • Labiae minorae - `` • Posterior fourchette - • Vestibule - • Clitoris - • Urethra - • Hymen - • Vagina -

18. Forensic samples in sexual assault • Urine sample - drug assisted sexual assault • Clothing - all clothing - paper bags - trace material • Sheet of paper - complainer stands on - hairs/fibres • Venous blood - toxicology (not DNA) • Saliva and/or mouth swab - spermatozoa; DNA • Skin swabs (UV light - c.f. false positives)

19. Forensic samples in sexual assault contd. • Fingernail scrapings- clippings less popular • Head hair - cut - semen / D.A.S.A. (50 strands) • Pubic hair - combed & cut - (no longer plucked) taped? • Vulval / vaginal swabs- external; low & high vaginal • Anal swabs- only if appropriate • Penile swabs (suspect) - vaginal DNA; faecal; DNA other source (victim) - saliva cf child sexual abuse

20. Forensic Samples - Pubic Hair Pubic hair transfer following intercourse A study (USA) recorded pubic hair transfer in - 17% of cases - female to male in 23% - male to female in 11% (Source – USA student campus volunteers)

21. Vaginal Samples & Forensic Evidence “A low vaginal swab is obtained by passing the swab into the vagina under direct vision avoiding contact with the external genitalia. However even when taken very carefully it is difficult to refute the accusation that in taking the swab contamination (external) had been introduced; its value is therefore questionable” Howitt J, Rogers D “Adult Sexual Offences and Related Matters” in Clinical Forensic Medicine 2nd Ed, 1996, Greenwich Medical Media, 203.

22. Vaginal Samples & Forensic Evidence No internationally agreed format: MPFSL dry swabs - vulval (external) x 2; high vaginal x 2; low vaginal x 2 • Vulval swabs x 2 (wet + dry) • Insert speculum into vagina - 2 dry high vaginal • Speculum almost removed - 2 dry swabs (low) Newton M. “The sexual assault examination kit” in Forensic Gynaecology. 2004. RCOG Press 116. Rogers D, Newton M. “Sexual Assault Examination” in Clinical Forensic Medicine - A Physician’s Guide 2nd Ed. 2005 Humana Press 87,88.

23. Anal & Peri-anal Swabs • Swab area 3 cm radius from anus • If skin appears moist - use dry swab • Skin dry or no obvious stain - use “double swab” technique; moist then dry swab with circular movements rotating tip through its long axis. Pressure light - as care is taken to prevent exfoliation of cells • Anal canal swabs x 2; wet and dry • Rectal swabs x 2 via proctoscope

24. Forensic Report - Genitalia • Location of all abnormalities recorded 12 hour clock • All areas should be examined - vulva, labiae majorae, labiae minorae, fossa navicularis, clitoris, urethra, hymen, vagina and P.F. incl. negative findings • Hymen should be described in detail (in children) • Each structure - signs of injury, recent or old • Anus and peri-anal margin - recent or old injury

25. Detection Time Limits Spermatozoa Seminal Fluid Vagina6 days12-18 hours Anus 3 days3 hours Mouth 24 hrs (max 31) 1 hour Clothing/ until washed until washed Bedding

26. Questions for FME to answer • Has an assault taken place and if so, when? • Is there evidence of restraint or resistance? • Was its nature sexual? • What trace evidence is available? • Was there ejaculation, and, if so, where? • Did intercourse (vaginal/oral/anal) occur ????

27. Points to remember for court ? It might be considered wise to remind the court - It is accepted in enlightened medical circles that further research must be carried out in an attempt to identify clinical findings in the genitaliawhich would be accurate and reliable indicators that intercourse was non-consensual as opposed to consensual.

28. More Points ? Give opinion on any general injuries i.e. • “The injuries are consistent with blunt force trauma” • “These are commonly found on victim of assault” • “Appearance is consistent with time frame alleged” Give opinion on any genital injuries i.e. • “There is no evidence of recent genital trauma” • “There is evidence of recent genital trauma” • “The injuries are consistent with blunt force trauma”

29. Even More Points ? It may be appropriate for the doctor to conclude – “The clinical findings - are consistent with the allegation” Cameron H. “The statement” in Forensic Gynaecology (2004) RCOG Press;169. The doctor should NEVER state – “The medical findings are consistent with rape” since rape is not a medical diagnosis but a legal concept and a determination to be made by the court. Roberts R. “The doctor in court” in Forensic Gynaecology (2004) RCOG Press; 182.