In crime cases the police and the doctor need to agree on the timing and aims of the examination. Acquaint yourself with the local practices. The physician should examine the victim as soon as possible after an alleged sexual offence.
If the victim has already reported the offence to police, the police investigation should preferably be performed before the medical examination. If not yet done, encourage the victim to report the offence.
The examination includes the documentation of all body injuries, genital examination, gynaecological investigation and taking forensic medical samples.
If the victim is a minor, also contact the child protection authorities.
Find out about and follow local policies and instructions, and utilize relevant materials provided by local authorities or non-governmental organizations.
Clinical examination and forensic medical samples
The doctor should preferably have a nurse assisting in the examination of the patient. Record the persons present at the time of the examination (nurse, family member, police, other accompanying person). Confirm also the identity of the victim in order to be able to write a medical report for possible legal proceedings (if the victim is escorted by a police, the identity has usually already been confirmed).
The patient may have a support person with her/him.
The examination must not be done if the victim refuses.
The examination does not necessitate reporting of the incident to the police. The reporting can be done also after the examination. Local legislation may set limits to the maximum time within which the reporting should be done (e.g. in Finland the limit is 10 years and in aggravated rape 20 years).
Remember to mark all the samples separately and clearly. Unclear markings may hamper the whole investigation.
Document the history precisely. However, an excessively detailed history may result in discrepancies with the police report and can cause problems in criminal proceedings. Record the sources of information: who told or where did you get the information (from the examinee, accompanying person, police; told during the examination or on the phone, written in the referral).
Time of assault
Location of the assault (the home of the victim or the assailant, park, woods, etc.)
Number and identity of the assailants
Type of violence and possible use of weapons
Vaginal, rectal or oral penetration, or an attempt of such
Penetration with an object or with some other body part than genital organs (e.g. bottle, finger, etc.)
Did the victim or some other person present observe an ejaculation?
Did the assailant use a condom?
The victim's body position during the assault
Stripping of clothes, voluntary or forced
Last voluntary sexual intercourse before the offence (when, with whom, vaginal/rectal/oral, use of condom, ejaculation)
Did the victim do something that may have destroyed or altered the evidence after the assault: bathing, douching, wiping, use of tampons, dental hygiene, defecation, changing clothes?
Did the victim possibly induce any injuries to the assailants?
Document in detail, e.g. by drawing, the presence of any physical injuries: bruises, scratches, abrasions, and describe how they arose. Remember careful gynaecological clinical examination.
Specific forms or charts for recording the injuries may be available locally.
Sample taking
To detect seminal fluid, take cotton wool swabs from the posterior vaginal fornix, from lateral walls of the vagina and from the external orifice of the uterus or the uterine cervix. Smear the swabs on microscopic slides and air-dry both the slides and the swabs. Store the swabs in special cardboard boxesor in dry breathable plastic tubes in a refrigerator or freezer.
Depending on the case, swabs are also taken from external genitalia, the anus, the rectum or the pharynx. In addition, swabs should be taken from parts of skin or clothes where there are possible traces of seminal fluid. When taking a sample from the skin, damp a cotton wool swab in sterile water and rub it on the stain; repeat with dry swab and then dry the swabs.
Matted pubic hair is removed into clean bags or tubes.
Clothes can be given to the police for examination.
DNA analyses are performed on the microscopic slides and cotton wool swabs after the semen analyses.
Take reference samples from the buccal mucosa of all persons concerned. Alternatively, take 2-5 ml of venous blood in EDTA-tubes to be used as references in DNA analyses; store in a refrigerator.
In some cases the police ask for hair, pubic hair, fibres or nail samples. Collect hair and fibre samples with a specific adhesive tape or alternatively use a cotton comb and submit the whole comb as a sample.
Reference hair/pubic hair samples are collected by picking, not by cutting. You may place the samples on a clean stationery paper that is folded in the middle. Put the folded paper in a clean envelope and write the identification information of the examined person on the envelope.
Nail samples are cut and each piece of nail is placed in a separate clean test tube.
Samples for alcohol and drugs
Blood and urine samples are taken according to the same instructions as applied in the case of drunken drivers.
Samples to detect the so-called ”knockout drops” are taken at the police's request if there is a suspicion that the victim has been drugged. Report of an offence is required to allow them to be investigated.
Pregnancy test
Ongoing pregnancy of the victim should always be ruled out with a pregnancy test.
HIV and hepatitis C serology and carrier sample for hepatitis B (HbsAg). Hepatitis B vaccination should be offered to victims who wish to have it if they are HbsAg negative.
Treatment
HIV prophylaxis should be considered if the assailant is known to be HIV positive. Always consult the local infectious-disease specialist.
If indicated, a tetanus booster is given to patients with wounds (do not forget vaginal and rectal wounds!).
The victim is instructed to use a condom until all venereal diseases have been excluded.
Follow-up samples: encourage the patient to provide follow-up samples. Note that local variation may exist regarding the timeline presented here.
Chlamydia and gonococcal specimens after 3-4 weeks
Syphilis serology after 4-8 weeks
HbsAg and HBc-IgM after 3 and 6 months
HIV antibodies after 3 and 6 months; if prophylactic treatment has been given, the follow-up should be carried out by a specialist in infectious diseases or according to his/her instructions.
The samples should be stored in a locked space and registered so that the circulation of the samples (chain of custody) can be traced without gaps at all times.
Sending samples to the laboratory
Find out about local instructions on sending the samples or handing them over to the police.
All individual bags, bottles and swabs should be labelled with the type of sample and the person's name. Local practices vary.
The referral should include:
personal data of the patient
a short history and time of the incident
Include also the timing of last sexual intercourses so that the semen sample analyses may be interpreted correctly.
the time and place when the samples were collected and the person responsible
as necessary, the address of the hospital or health centre where the test results should be sent.
Emotional support and follow-up
Every effort should be made from the first beginning to reduce the feeling of guilt in the victim by emphasizing that she is not the guilty party. The assailant is responsible for the incident.
If possible the patient should have an escort when she is discharged.
Give out any written materials available that are directed to victims of violence and to those close to them. Use materials that are written in the native language of the persons involved.
The victim should have an opportunity to express her thoughts and worries soon after the incident, and a further contact to a professional should always be arranged. If possible in practice, an appointment should be booked ready or at least written instructions should be given on whom and how to contact.
A psychological assessment (by a doctor or a psychologist) is indicated within 1-2 weeks. It is very important that the victim is allowed to express her feelings of anger openly.
If the victim is underage, the examination should be performed by a paediatrician or a gynaecologist who is experienced in adolescent gynaecology. A consultation by a child psychiatrist is always indicated.
The patient should preferably be assessed three months after the psychological trauma. A psychiatrist should write a statement on the assessment.