Forensic Medicine

1. Examination of a Survivor of Sexual Offence
Dr Nikita Prabhakaran G

2. What is Rape ???

3. Rape- 375 IPC
• A man is said to commit “rape” if he
• (a) penetrates his penis, to any extent,
into the vagina (which term shall include the labia majora)
the anus or urethra or mouth of any woman or child
or makes her to do so with him or any other person
• (b) inserts to any extent any object or a part of the body (other than
the penis) into the vagina(which term shall include the labia majora)
or urethra or anus of a woman or makes her to do so with him or any
other person

4. • (c) manipulates any part of the body of a woman so as to cause
penetration of the vagina (which term shall include labia majora) or
urethra or anus of a woman or makes her to do so with him or any
other person
• (d) applies his mouth to the vagina, anus, urethra of a woman or
makes her to do so with him or any other person
• Under any of the following circumstances…….

5. Under these circumstances
Against her will.
Without her consent
•Will - Psychological desire
•Consent - legal concept (Sec 90 IPC)
permission

6. The Protection Of
Children from
Sexual Offences
Act, 2012
(POCSO)

7. Chapter 1(d)
child means any person below the age of 18 years

8. Classification Sexual offences against children
(Chapter 2)
• Penetrative sexual assault
• Aggravated penetrative sexual assault
(guardian/ public servant/authority)
(gross damage to the child)
• Sexual assault
• Aggravated sexual assault
• Sexual harassment

9. Section 7- Sexual Assault
• Whoever with sexual intent
 touches the vagina/ penis/ anus/ breast of the child
or
makes the child to touch parts of his/ any other person
or
 does any act with sexual intent
which involves physical contact without penetration

10. Section 9 – Aggravated Sexual Assault
• Same as that of section 5
• (a) (u)
• (v) persuades/ induces a child
to get administered any drug / hormone/ chemical substance
to a child with the intent that
such child attains early sexual maturity

11. Section 11- Sexual Harassment
• With sexual intent
(i) utters any word / makes any sound/ gesture/
exhibits any object or part of body
with the intention that it shall be heard by the child
(ii) makes a child exhibit his body / part of his body
so as it is seen by such person/ any other person

12. (iii)Shows any object to a child in any form or media for pornographic
purpose
(iv) Repeatedly or constantly follows or watches or contacts a child
either directly or through electronic , digital or any other means
(v) Threatens to use, in any form of media, any part of the body of the
child
(vi) Entices a child for pornographic purposes

13. • REFERENCE:
• Section 164 A Criminal Procedure Code
• Guidelines and protocols – Medicolegal care for survivors /victims of
Sexual violence  Ministry of Health and Family welfare
• Medicolegal protocol for examination of survivor of sexual offences-
2019- Government of Kerala

14. Duties:
• Whether it be private hospital/ government hospital,
1. Free of cost First aid/primary care
2. Unnecessary referral is not promoted
Po 3. Police intimation
4. Maintenance of absolute confidentiality

15. Prerequisits
• Separate room
• SAFE Kit (Sexual assault forensic examination kit)
• Form of Kerala protocol for survivor examination
• Police intimation
• Register

16. SAFE Kit
• Everything in a hard paper box of size 32x22x24cm.
General items
• 1. One black plastic bag – 100x 50cm, “BIOHAZARD” -for collecting
waste.
• 2. One white plastic bag 100x50cm, labeled “Unused items”.
• 3. Gloves - powder-less (of size 6, 6.5 and 7- 1 pair each)
• 4. Normal saline 10 ml x 2 in plastic containers
• 5. Scissors (4 inches) 1no.
• 6. Cotton roll – as a filler for packing purpose.

17. Contents of the packet
• (1) Step 3 – Clothing
• (2) Step 4 – Debris
• (3) Step 5 – Swabs from stained or grimy areas
• (4) Step 6 – Nail Scrapings and Nail Clippings
• (5) Step 7 – Matted clipped pubic hairs and pubic hair combings
• (6) Step 8 – Cut pubic hairs and scalp hairs Sample seal affixed on
packets

18. • (7) Step 9 – Vaginal smears and swabs
• (8) Step 10 – Vaginal washings
• (9) Step 11 – Anal smears and swabs
• (10) Step 12 – Oral smears and swabs
• (11) Step 13 – Blood for grouping and DNA profiling

19. Extras:
Large sheet of paper size 150x150cm to undress over.
A 4 size sheets to wrap
Self sealing envelopes

20. Strategy
!!!!!Medical duties - priority
•
c
c
Detailed history taking
Medical examination
Documentation
Packing and sealing police
Follow up

21. Ideal person to examine
• Woman survivor (> 18 years)  preferably by a female doctor
• Girl survivor (< 18 years old) should be done only by a woman doctor
(***no case should be redirected for a gynaecologist in another hospital)
Gynaecologist  Lady medical officer
In medical colleges female examiner from Department of Forensic Medicine
***provided there is no urgent medical need

22. • Boy survivor duty medical officer/ casualty medical officer
Transgender  choice is up to them

23. REPORT OF MEDICO-LEGAL EXAMINATION OF
SURVIVOR OF SEXUAL OFFENCE
• Ref. ML./SSO/No : ...………………….. Hospital OP/IP No.:…………….. Date : ………………….…
• I. GENERAL INFORMATION AND CONSENT.
• 1) Name of Medical Institution :…………………………………….…………………………………………
• 2) Name of doctor(s) who conducted the examination :……………………………………………………….
………………………………………………………………………………………………………………….
• 3) Date and time of arrival of the survivor at hospital :…….………………………………………………….
• 4) Survivor is a Woman / Girl / Boy / Man / Transgender / Others………………………………………
• ** 5) Name :…………………………………………………………W/D/S/o………………………………….
• 6) Address :……………………………………………………………………………………………………
……………………………………………………………………………………….……………………….. .
………………………..PIN………………………..Contact phone numbers …………………………………
•

24. 7) Age : …..years……months…….days. (As stated by the…………………………)
8) Date of birth :……………………………………………………………………………………………….
Proof of date birth : School Certificate/Matriculation certificate/Birth Certificate/
Not available anywhere
9) Requisition (if any) from;
.……….………………… vide Crime No. …………… of ………………………….………………
Police station dated …………… and brought/accompanied by (Number if any, name &
designation.)..…………….…...…
10) If not brought with requisition, name, address and relation of the person (if any
brought or is accompanying the survivor.………………………………….

25. A survivor may approach under three circumstances:
a) on his/her own only for treatment for effects of assault;
b) with a police requisition after police complaint; or
c) with a court directive.
11. Informed Consent

26. A) Person coming directly to the hospital
• No police requisition needed
• Medical care and medicolegal examination can be done
With her consent (> 18 years)
If less than 18 years ( with the consent of the guardian/ parent)

27. Special situations :
• > 12 years <18 years
• The consent form must be signed by the person him/herself if s/he is
above 12 yrs. of age
• >12 years willing for examination but parents have given informed refusal
• CWC to be informed they will nominate a person who will give consent
in best interest of the child

28. • Person with mental disabilities
• Consent is taken from guardian
If under the influence of alcohol or other psychotropic
substances
consent is taken from guardian
•

29. • may or may not want to lodge a Complaint
• but requires a medical examination and treatment.
the doctor is bound to inform the police as per law.
ML examination with the informed consent of the survivor/ parent/
guardian

30. *** the survivor does not want to pursue a police case,
a MLC must be made
Duty bound

31. B) With a police requisition
• the information about medico-legal case (MLC) no. &
• police station should be recorded
• Police personnel should not be present during any part of the
examination.

32. • Consent should be taken for the following purposes:
•
1. examination,
2. sample collection for clinical and forensic examination,
3. treatment and
4. police intimation.
!!!! Voluntary not under coercion of any sort
PRINCIPLES OF INFORMED CONSENT

33. • The consent form must be signed by
 the survivor,
 a witness ( should be a major, ‘disinterested’ )and
 the examining doctor.

34. Information to be made clear
while taking consent
• MLE is to assist the investigation, arrest and prosecution of those who
committed the sexual offence.
• involve an examination of the mouth, breasts, vagina, anus and
rectum as necessary depending on the particular circumstances.
• To assist investigation, forensic evidence may be collected

35. • This may include removing and isolating clothing, scalp hair, foreign
substances from the body, saliva, pubic hair, samples taken from the
vagina, anus, rectum, mouth and collecting a blood sample.
• hospital/ examining doctor is required/duty bound to inform the police
about the sexual offence.
• But refusal is her right

36. Refusal
• may refuse to give consent for any part of examination.
• explain the importance of examination and evidence collection, .
• Explain that it will not affect/compromise treatment.
• must be documented
****(again signed by witness along with survivor and doctor)

37. Illiterate or similar reasons?
• 1. Examiner should write it and read it over to them
• “the consent was written by me in …..language and was read over to
the survivor or guardian”
• Sign it
• 2. + signature (if possible) + left thumb impression from the
survivor
• 3. + signature of an independent witness (name and address)

38. Translator / special educator is needed??
• Their name and signature should be included wherever necessory

39. • 13) Date and time of commencement of
examination….………..…………..………………………………..
• 14) Identification marks:
(1)………..…………..….…………………………………………………………..
……………………………………………….…………………………………………………………
………
(2)……….………………...…………………………………………………………………………
………… ………………………

40. Two marks of identification such as moles, scars, tattoos etc.,
preferably from the exposed parts of the body
Description:
size, site, surface, shape, colour, position with respect to a landmark.
Left Thumb impression is to be taken
IDENTIFICATION MARKS

41. Example
• A black mole
• 0.5x0.5 cm ,
• flat, non-hairy,
• On the left side of face
• 4 cm outer to the left angle of mouth

42. • History/Details of stated sexual assault (As stated by survivor/)
• If history was narrated by anyone other than the survivor, name,
address & relation of the person who narrated it:
• State of consciousness and orientation at the time of sexual assault:
• physical and verbal threat/abuse and use of weapons if any
• drugs or alcohol being given to the survivor before or during the
assault:

43. • Pain on urination / defecation since the assault:
• Whether bathed/urinated/defecated/Vomited/
washed the genitals or anus or mouth or the body part on which
the sexual offence has been committed, since the incident:
• Did the assailant use condom or any lubricant: Yes/No/Don’t know
• History of sexual abuse in the past in children
• History and stated cause of injury if any on the body:

44. b) Relevant menstrual and obstetric history (for females only)
1) LMP:…
2) Whether menstruating
(a) at the time of examination :Yes/No/NA
(b) at the time of assault :Yes/No/NA.
3) Whether on any type of contraception at the time of assault :
4) Other relevant history if any
5) Was the survivor pregnant at the time of assault : Yes / No /
NA. If yes, length of gestation…….………..

45. • c) Medical and Surgical history:
1) History of congenital or acquired disability in the past: Present/Not
present/Not available. If present, details
2) History of vaccinations (Tetanus, Hepatitis B)
3) Any other relevant medical or surgical history

46. • III. GENERAL PHYSICAL EXAMINATION
• 1) Pulse:…………………………….. 2) BP:……………………… 3)
Respirations:………..…………….
• 4) Level of consciousness : Conscious/Semi-conscious/Unconscious
• 5) General Mental condition :
……….……………………………..………………………………………..
• 6) Memory : Normal / impaired.
• 7) Orientation of time & space : Normal / impaired/
• 8) Systemic examination (NS, CVS, RS & GIS)
• 9) Examination of clothes (if same as those worn at the time of assault) :
Intact/Disordered/Torn/smearing
• 10) Examination of nails

47. • 11) Evidence or findings suggestive of any disability: Present/Absent.
• 12) Evidence or findings suggestive of administration of intoxicants or
alcohol : Present/Absent.

48. • IV. LOCAL EXAMINATION.
• a) Pubic Hairs. (Relevant / Not Relevant / Not Applicable)
• b) Female External Genitalia. (Relevant / Not Relevant / Not Applicable)
• c) Male External Genitalia. (Relevant / Not Relevant / Not Applicable)
• d) Urethra. (Relevant / Not Relevant / Not Applicable)
• e) Perineum. (Relevant / Not Relevant / Not Applicable)
• f) Anus. (Relevant / Not Relevant / Not Applicable)
1) Anal orifice and peri-anal regions
2) Anal sphincter and rectum

49. • g) Buttocks and Thighs. (Relevant / Not Relevant / Not Applicable)
• h) Breasts (Relevant / Not Relevant / Not Applicable)
• i) Mouth and Oral Cavity (Relevant / Not Relevant / Not Applicable)
• j) Clitoropenis / labioscrotum (Relevant / Not Relevant / Not
Applicable)

50. Examination of Injuries
• The entire body surface should be inspected carefully
• for signs of
 bruises,
 physical torture injuries,
 nail abrasions,
 teeth bite marks,
 cuts,
 lacerations,
 fracture,
 tenderness,
 any other injury, boils, lesions, discharge

51. • specially on the scalp,
• face,
• neck,
• shoulders,
• breast,
• wrists, forearms,
• medial aspect of upper arms,
• thighs and buttocks

52. • Presence of injuries is only observed in one third cases of forced
sexual intercourse.
• Absence of injuries does not mean the survivor has consented to
sexual activity. !!!
• As per law, if resistance was not offered that does not mean the
person has consented.

53. • Describing an injury
• type of injury (abrasion, laceration, incised, contusion etc.),
• site,
• size,
• shape,
• colour,
• swelling,
• signs of healing
• landmark

54. Abrasion 4 x 2 cm on the back
of right forearm 1.5 cm below
elbow.

55. Healing of an abrasion
Fresh- reddish due to exudation of blood
12 to 24 hours – lymph and blood dries up to
form a brownish crust
2 to 3 days – reddish brown scab (adherent)
4 to 7 days – scab becomes loosely adherent
epithelisation from periphery
7 to 10 days- scab dries and falls of leaving a
depigmented area
10 to 12 days- pigmentation gradually occurs

56. Contusion 3x 2.5 cm
(Blue in colour)
on the back and outer aspect of
right forearm
Just below elbow

57. Healing of contusion
Upto 24 hours- red or reddish
2nd to 4th day bluish to bluish black
5th to 7th day- greenish
7th to 12th day- yellow
14th to 18th day - Normal

58. Lacerated
wound
vs
Incised
wound

67. • Mention possible weapon of infliction such as –
hard, blunt, rough, sharp,etc
• Injuries are best represented when marked on body
charts. They must be numbered on the body charts
and each must be described in detail.

71. • Describe any stains seen on the body
the type of stain (blood, semen, lubricant, etc.)
its actual site, size and colour.
Mention the number of swabs collected and their sites.

72. Age estimation
• If requested by police, radiographs of wrist, elbow,
shoulders, dental examination etc. can be advised for age
estimation
Age Area preferred
12 years Hip joint
14 years Hip joint, elbow joint
16 years Hip joint
18 years Shoulder joint, Hip Joint, wrist Joint
21 years Hip Joint

73. Provisional opinion
• !!!! should be done immediately after examination of the survivor
on the basis of
• history and
• findings of detailed clinical examination of the survivor.

74. • The provisional opinion must, in brief, mention
 relevant aspects of the history of sexual violence,
 clinical findings and
 samples which are sent for analysis to FSL.

75. • It should be always kept in mind that normal examination
findings neither refute nor confirm the forceful sexual
intercourse.
• Hence circumstantial/other evidence may please be taken into
consideration.

76. Genital Injuries Physical
Injuries
Opinion
Present Present There are signs suggestive of recent use of force/
forceful penetration of vagina/ anus. Sexual
violence cannot be ruled out.
Present Absent There are signs suggestive of recent forceful
penetration of vagina/anus.
Absent Present There are signs of use of force however
vaginal/oral/anal penetration cannot be ruled out.
Absent Absent There are no signs of use of force however final
opinion reserved pending report of FSL.
Sexual violence cannot be ruled out.

77. Signature and seal
• Document the report, formulate opinion, sign the report and
handover the report and sealed samples to police under due
acknowledgement.
• On the last sheet, mention how many pages are attached. Each page
of the report should be signed to avoid tampering. .

78. • One copy of all documents be given to the survivor as it is his/her
right to have this information.
• One copy to be given to the police and
• One copy must be kept for hospital records

79. • All evidence needs to be packed and sealed
properly in separate envelopes.
• The responsibility for this lies with the examining
doctor.
• All blood samples must be refrigerated until
handed over to next in chain of custody. The
hospital has the responsibility of properly
preserving samples till handed over to police

80. 1. Bite marks present and /or FSL
detects salivary stains
There are signs suggestive of evidence of
bite mark/s on ___________ site(time
the injury)
2. Sucking marks (discoid,
subcutaneous present and /or FSL
detects injury). salivary stains
There are signs suggestive of sucking
extravasation of blood, with or without
mark/s on ___________ site (time the
bite marks)
3. Forceful fondling, with presence of
fingernail marks
. There are signs suggestive of forceful
bruises or contusions with or without
physical injuries on ___________ site
(time the injury) (which may be due to
fondling)

81. 4. Only forceful kissing and FSL detects
salivary stains
There are signs suggestive of salivary
contact (which may be due to
kissing)
5. If the history suggests forced
masturbation of the assailant by the
survivor and seminal stains detected on
the hands
There are signs suggestive of the
survivor of seminal contact (which
may be due to masturbation)
6. In case there are no signs of sucking
licking…… detected, but the history
suggests some such form of assault
It is still important to document a
good history because the survivor
may have had a bath or washed
him/herself.

82. THANK YOU