Manual final final.doc

Sexual Assault
Of Women and Girl Children
Collection of Medical and Forensic Evidence
Medical treatment and Psycho-social Rehabilitation
A Manual and Evidence Kit for the Examining Physician
Dr. Lalitha D'Souza
(Centre for Enquiry into Health and Allied Themes)
Survey No. 2804 & 2805, Sai Ashray, Aram Society Road,
Vakola, Mumbai - 400055
FAX - (+91) (22) 26673156
Tel: 022 - 26673571/154
November 1998
Updated December 2004
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Acknowledgements

Fund for Global Human Rights
And

Dr Bangal Rajendra, Associate Professor, J J Hospital, Mumbai
Dr Bhate Kamaxi, KEM Hospital, Mumbai
Dr Bwandre S, KEM Hospital, Mumbai
Dr Chaudhar K R, Seth G S Medical College, Mumbai
Dr Chaudhari R S, Professor and Head, KEM Hospital, Mumbai
Dr Dalvie S, FPAI, Mumbai
Dr Desai Janaki, FPAI, Mumbai
Dr Ghodkirekar Madhu, Associate Professor, Goa Medical College, Goa
Gujarathi R D, Forensic Science Laboratory, Mumbai
Dr Gupta A S, KEM Hospital, Mumbai
Dr Gupta M D, Seth G S Medical College, Mumbai
Dr Kadam S S, KEM Hospital, Mumbai
Dr Kapase C S, Professor, D Y Patil Medical College, Pune
Dr Kshirsagar Nilima, Dean, Seth G S Medical College and KEM Hospital, Mumbai
Dr Rukhmini Krishnamurthy, Forensic Science Laboratory, Mumbai
Madhiwalla Neha, Sahyog, Mumbai
Dr Malik Seema, Chief Medical Superintendant, BMC, Mumbai
Dr Samant Padmaja, Associate Professor, KEM Hospital, Mumbai
Dr Mayekar, KEM Hospital, Mumbai
Dr Naidoo Ruben K, South Africa
Dr Nanandkar S D, Govt. Medical College, Aurangabad
Dr Nandanwar Y S, Professor, LTMG Hospital, Mumbai
Dr Narayan Reddy Jagadeesh, Associate Professor, Vydehi Medical College, Bangalore
Dr Parulekar S V, Professor and Head, KEM Hospital, Mumbai
Dr Patil S M, Senior RMO, Police Hospital, Mumbai
Dr Ruia J M, G S Medical College, Mumbai
Dr Roy Nobojit, BARC Hospital, Mumbai
Dr Samuel Anil, KEM Hospital, Mumbai
Dr Thakkar Hardik, KEM Hospital, Mumbai
Dr Vaswani Vina, Professor and Head, Yenepoya Medical College, Mangalore
Dr Vaz Walter, Professor and Head, Nair Hospital, Mumbai
Dr Wase, V V, J J Hospital, Mumbai
Dr Zaveri Kusum, FPAI, Mumbai
PDF created with pdfFactory Pro trial versi Abraham Ammu, Women's Centre, Mumbai.
Advocate Agnes Flavia, Majlis, Mumbai.
Dr Apte V.V., Head of Department of Forensic Medicine, Nair Hospital, Mumbai
Cardoz Sushila, Stree Shakti Sadan, Mumbai.
Currimbhoy Zenia
Duggal Ravi, Swissaid, Mumbai
Dr Franklin C. A. Mumbai
Gavaskar Kalpana, Advocate, Mumbai.
Hanmer Jalna, Research Centre on Violence, Abuse and Gender Relations,LMU, Leeds
Hirekar Sheila, Mahila Nyaya Manch, YWCA, Mumbai
Dr Hobbs James, Community Paediatrics, St James University Hospital, Leeds
Illinois State Police, Department of Forensic Sciences, USA
Dr Jesani Amar, CEHAT
Kadrekar Ujwala, Maharashtra State Commission for Women
Kadri Vipula, PRIDE, India
Dr Lakdawala Hanif, Sanchetna, Ahmedabad.
Manson-Hing Jerilyn, Canada
Mathew Susy, International Women's Welfare Organisation, Mumbai
Dr Mehta Meena, Mumbai
Narula Nandini, Swissaid, Delhi
Ontario Police, Canada
Pandit Purnima, Maharashtra State Commission for Women
Dr Patel Vibhuti, Mumbai
Dr Phatnani Pritam, Mumbai
Rajput Pam, Chandigarh.
Sakhrani Monica, Criminal Lawyer, Mumbai
Sathe Nirmala, Aalochana, Pune.
Sena Sonal, Sakshi, Delhi.
Dr Shatrugna Veena, NIN, Hyderabad.
Saldanha Jean, Human Rights Law Network.
Taskar Jyoti, FMR, Mumbai
Dr Teas Shaku, Physicians for Human Rights, USA
Thombre Mangala, Mantralaya, Mumbai
Welsh James, Amnesty International, UK
Yedekar Savita, Maharashtra State Commission for Women


PDF created with pdfFactory Pro trial versi Introduction

The United Nations Commission on the Status of Women in Article 1 defines violence
against women as any gender based act, which results in or is likely to result in
physical, psychological or sexual harm of women, including threats of such acts,
coercion or arbitrary deprivations of liberty, whether occurring in public or private life.
Gender based violence including rape, domestic violence, mutilation, murder and sexual
abuse, is a profound health problem for women across the globe1. Women who have
been sexually assaulted experience 'the threat of physical injury and death, threats to
their sexual integrity, their personal control, their worthiness as human beings and to
their confidence and trust in others2. Sexual assault3 is a violation of women's bodily
integrity and therefore an abuse of their fundamental human rights. More than merely a
criminal justice issue sexual assault is now viewed an issue of health and human rights4.

Women are in danger of being sexually assaulted throughout their lives. Although
stranger rape is the most feared form of sexual violence, there is alarming evidence to
show that sexual assault by known persons is far more common than has so far been
recognised. The problem exists to a large extent in homes in India, where male family
members are known to abuse women and girl children in the household5. Custodial rape
occurs in police lock-ups, prisons, remand homes and in hospital settings. Rape is also
commonly used as a means of political oppression, in caste wars and war situations and
in refugee camps.
In addition to the direct trauma of such a crime, a survivor must undergo the harassment
that has come to be associated with the law enforcement agencies, and the medical and
legal machinery in the course towards justice. Insensitivity, and lack of empathy and
professionalism among officials of the law enforcement agencies, physicians and
lawyers contribute to the difficulties faced by survivors and their families.
Women's activists and lawyers in India have documented the problems that survivors
and their families face when women are sexually assaulted6. Police do not take prompt
action when cases are reported, causing delays and subsequent loss of valuable medical
and forensic evidence. Staff in police stations, hospital facilities and courts often regard
survivors of sexual assault with scorn and suspicion, making rude remarks about the
woman's character even before investigations begin.
Women's activists also express their inability to proceed with cases at the medical
facility due to their own lack of understanding about the medical and forensic
procedures to be followed while investigating cases of rape and sexual assault.
Questions posed to the examining physicians by women's activists are not welcome. It
is felt that a clear understanding of the medico-legal procedure by support groups will
1 Violence against women: The Hidden Health Burden. Lori L. Heise et al. World Bank Discussion Papers 255. 1994. 2 Care and rehabilitation of rape, torture and other severe traumas of war in the republic of ex-Yugoslavia. Dahl Soherg. 1993. 3 In this document we have used the term sexual assault to include the crimes of rape (IPC 376, 376 A-D) sodomy, buccal coitus ( IPC 377) and outrage of a woman's modesty (IPC 354). Under the current laws, unless the offense fulfills the criteria laid down for rape, sodomy or buccal coitus, any other offense involving sexual touching is classified under IPC 354. Unfortunately a significant number of cases of criminal sexual conduct particularly against minor girls do not fulfill the exact criteria for rape, sodomy and buccal coitus and are therefore labeled as 'Outrage of a woman's modesty i.e. IPC 354. We advise the physician to use this kit for all sex related crimes against women and girl children. 4 The Global Health Burden of Rape. Mary P. Koss, Lori L. Heise and Nancy F.Russo. Psychology of Women Quarterly. 18 (1994). 5 For instance, a rare study conducted with school and college girls in Karnataka, India showed that among those girls who reported molestation and serious sexual abuse, 55 % of the abusers were male family members. Ganesh. 1994. 6 Mathura rape case AIR 1979, S. C. 185; Gunta ben 1987; Jogeshwari rape case 1989; A study of 50 judgments delivered by Sangli district Court in Maharashtra 1990; AWAG, Gujarat 1996; Report on five years of work by Women's Centre, Mumbai 1985. PDF created with pdfFactory Pro trial versi help in reducing the intimidation experienced by activists and survivors while communicating with medical personnel. The emphasis at the medical facility is on collection of forensic evidence. Scant attention is paid to the emergency and long-term medical and psycho-social needs of the woman. Treatment and advice for sexually transmitted diseases and pregnancy takes second place. Often these aspects of medical care are completely overlooked. The examination of survivors of alleged sexual offences is one of the most difficult tasks in forensic medicine. The danger of allowing true offences to go unpunished as well as the injustice of wrong convictions make the responsibility of the examining physician very heavy. In India experts such as Forensic Consultants, Police Surgeons and Gynaecologists are readily available in the cities. But elsewhere, especially in small towns and villages, these facilities are not available and a qualified but inexperienced physician may be asked by the police or the courts to conduct the examination of the woman and/or the accused. Many qualified physicians lack the specialised training required to proceed with the examination and the appearances in court. The medical and forensic examination, the preparation of the report and the subsequent appearances in court are often difficult and thankless tasks7. In the absence of training, doctors may refer to the text. Standard textbooks on Medical Jurisprudence reflect a certain pre-occupation with virginity. This trend is also seen in the courts. In developed countries procedure and laws have changed over the past two decades so as to exclude the need to make references to this aspect of a woman's health. Virginity or the lack of such should not have any bearing on a case of sexual assault. Unnecessary clinical tests like the Finger Test8 are advised as part of the examination. These clinical findings are misinterpreted in the Courts and often used by the defence lawyer to humiliate the survivor and to discredit her evidence. Further, there would appear to be some misunderstanding in important definitions. Standard textbooks on Medical Jurisprudence clearly state that 'the slightest penetration of the penis with the vulva, such as minimal passage of the glans between the labia with or without emission of semen or rupture of the hymen constitutes rape'9. But experience in India shows that frequently this definition is not accepted as evidence of penetration in Courts; only complete penile penetration into the vagina is accepted as evidence of sexual intercourse in cases of alleged rape. Only the most experienced Forensic doctors are able to skilfully field ambiguous questions in Court regarding the medical evidence. But not all survivors have the benefit of a strong medical witness. It is possible for a case to be lost not for lack of actual evidence but for the inexperience of the medical witness. To further complicate the issue, there is inordinate delay before the case comes up for hearing in the court. For instance, statistics show that out of 202 cases of rape registered in 1995 in Greater Mumbai10, 134 cases were still pending in the Courts in late 1997. Delay of this nature does not help the physician to defend the findings of the medical examination, which may have been done years before. This emphasises the need for detailed and lucid medical records. 7 Simpson's Forensic Medicine. Bernard Knight (Ed )Eleventh Edition. 1997. 8 Modi's Medical Jurisprudence and Toxicology 1988 21st edition states that 'it is absolutely necessary to note the distensibility of the vaginal orifice in the number of fingers passing into the vagina without any difficulty'. This constitutes the Finger Test. 9 The Essentials of Forensic Medicine and Toxicology. Dr. K.S. Narayan Reddy. Sixteenth Edition.1997. 10 State Commission for Women. Government of Maharashtra. Unpublished report. PDF created with pdfFactory Pro trial versi
All India statistics show that successful conviction of the accused is less than 30 %11 of
registered cases of rape. Although it is difficult to pinpoint the causes for low rates of
conviction in cases of rape, the role of medico-legal evidence and the value of
experienced medical witnesses is considered most significant. 'Medical evidence
constitutes the most important component of evidentiary material considered in a
prosecution for rape' 12. Many of the essential ingredients of the offence of rape cannot
be proved or disproved without medical evidence.
The role of the physician

Physicians have three well defined and important roles to perform in sexual assault
cases. First, they can provide important evidence of the crime and help judges to
understand the physical and mental condition of the woman. Second, the reports can
serve to corroborate the woman's story and to enhance her credibility. Lastly, but most
importantly, physicians must offer treatment, primary level counselling and referral for
the physical and psychological sequlae of the assault.
In performing a medico-legal examination the physician is performing a public duty and
acting on behalf of the state. However, the role of the physician primarily as a carer is
emphasised in this manual. Caring for survivors of rape and other sexual offences
includes the three roles outlined above and at the same time avoiding any remark during
the examination and writing of the case notes that will in any way lead to secondary
victimisation of the woman. In cases of sexual assault as in all other criminal cases the
doctor-patient relationship takes precedence over any other role a doctor is expected to
take. Duty towards the patient overrules all else. Before proceeding with a medical
examination the sensitive and experienced physician will make a rapid assessment of
the merits of the case and advise the woman or her guardian whether the medical
examination will complement the story or in fact go against it.
'The role and attitude of the doctor immediately after the rape can be vital in the
personal decision made by a victim as to whether to take and follow through legal
action. We know from years of experience that one of the first people that a person
meets who is bringing a rape or sexual abuse case to court is a doctor. And how they are
treated by that doctor can be of immense importance to the way they recover.
While a doctor has a special role in collecting forensic evidence and later being able to
give that evidence in Court, nevertheless he/she is expected to treat the victim with
kindness.until everyone who works with victims can relate to the deep emotional pain
and vulnerability and fear that results from rape, we won't have victims well cared
for'.13
We at CEHAT are happy to put in your hands this manual accompanying the 'Sexual
Assault Care and Evidence Kit'. The kit is a small step towards helping the healing and
seeking of justice, of scores of survivors of sexual violence. It contains all the material
required for the medical as well as forensic examination of survivors of sexual assault
along with the necessary protocol and checklist. This manual gives guidelines regarding
the use of the kit, standard treatment of common problems and collection of evidence.
We are immensely grateful to all those who helped first put together the kit and manual,
and to all the doctors who helped update it more recently.
12 The Offense of Rape and Certain Medico-legal aspects: A Study by P.M. Bakshi. National Commission for Women.1994. 13 Standardising the approach to rape in the EU. Karen Birchard. The Lancet Volume 351, Number 9096. 10 Jan 1998. PDF created with pdfFactory Pro trial versi
Physical and psycho-social effects of sexual assault on women and girl children14
A. Immediate effects of sexual assault on the physical health and well being of a
• Injuries in the form of soreness, bruising, lacerations and bleeding of the external genitalia, introitus and vaginal walls. • Tears, oedema and bleeding of the hymen. • Injuries in the form of bruising, lacerations, bites, scratches, on the head, neck, • Tears and lacerations of the anus and rectal bleeding. • Disturbed eating and sleeping patterns • Risk of sexually transmitted disease including HIV

B. Immediate effects of sexual assault on the psycho-social well-being of a woman
• Shock
• Fear

C. Long term impact of sexual assault on physical health and well-being of a woman
• Dysparunia
• HIV/AIDS infection
D. Long term impact of sexual assault on psycho-social well-being of a woman
• Chronic anxiety
• Feelings of vulnerability
•
Post Traumatic Stress Disorder (PTSD
)
• Nightmares Avoidance of stimuli associated with trauma Intrusive re-experiencing of trauma 14 Adapted from Violence against Women: Relevance for Medical Practitioners. JAMA June 17, 1992- Vol 267. No 23. Council on Scientific Affairs, American Medical Association. PDF created with pdfFactory Pro trial versi • Post traumatic stress disorder (PTSD) • As a result of criminal victimisation there is a lifetime increase in risk of mental PDF created with pdfFactory Pro trial versi
The Sexual Assault Care and Evidence Collection Kit:

The Sexual Assault Care and Evidence Kit formulated by CEHAT, is a scientifically
sound and easy to use model kit for the purpose of examination and collection of
evidence in cases of sexual assault. The kit not only stresses on medical examination
and evidence collection but equally stresses on the importance of the regime of care
both during the process of examination as well as the after care process. The need for
such a kit was felt when a few of our Trustees were involved in the investigation of a
case of sexual assault of a deaf-mute girl in an observation home in Mumbai, by a cook
within the premise. The documentation and investigation related to the case was carried
out in a very shoddy manner. It was then that Dr Lalitha D'Souza, a paediatrician
working with CEHAT, developed the Sexual Assault Care and Evidence Kit. The kit
was first adapted from the kit used by the Ontario Police, Canada, in 1998. Ever since,
the kit has gone through several rounds of review and feedback by forensic doctors,
gynaecologists and obstetricians as well as human rights and women's rights activists
from Mumbai and other parts of India to suit the needs and requirements in the Indian
context.
The main purpose of the kit is to ensure that the whole process of medical examination,
evidence collection and care is done in a systematic, efficient and sensitive manner.
Used with appropriate perspective and training, this could be one step to generate better
quality evidence and better testimony in court. Several studies from the West have also
shown linkages between efficient documentation of evidence with positive legal
outcome in cases of sexual assault. The model 'Sexual Assault Care and Evidence Kit'
consists of the following components:
• A manual to guide the examining doctor • A box containing all equipments required for examination
Model protocol:

The model protocol is a colour-coded document, to be filled by the examining doctor.
The main purpose of the protocol is to help the examining doctor in eliciting history,
examination, and recording the forensic evidence in cases of sexual assault. The
protocol consists of the following main forms:
• Consent (Form 1)
• Medical History (Form 2)
• Sexual Assault History (Form 3)
• Forensic Examination (Form 4)
• Receipt for Medical Evidence (At the end of Form 4)
• General Examination and Age Estimation (Form 5)
• Discharge Slip (Form 6)

While the buff coloured forms are the original forms for the hospital copy, the colour-
coded documents are meant to ensure that each document reaches the concerned
authority as marked in the colour code (Yellow - Police Copy / Pink - Patient Copy /
Blue - Laboratory Copy to be enclosed within the kit). The protocol has paid special
attention to the following aspects:
PDF created with pdfFactory Pro trial versi • Consent of the patient to be taken for the following three purposes: 1. For examination and treatment for effects of the assault, 2. For collection of the evidence 3. For revealing the information to law enforcement officers for purposes of • Medical history and treatment along with history of sexual assault and evidence • Body maps, for both female (including for female children) and male bodies have been provided to record injuries. Therefore this kit can be used in cases of young boys and men survivors. • With some additions it could also be used in case of the accused. • Tables for Tanner Staging for boys and girls are provided for age estimation
Manual:

The manual is a basic guide for the examining doctor. It includes a detailed, step by step
explanation of all the procedures to be followed during examination, as mentioned in
the protocol. It also includes information about appropriate care both during and after
examination, counseling as well as treatment guidelines for STD's, Pregnancy
prophylaxis, Lacerations and Psychosocial trauma. The manual also includes a brief list
of important sections of the Indian Penal Code (IPC) related to Sexual Violence.
Currently, the manual is in the process of being updated.
The Medical And Forensic Examination
Purpose Of Examination
The purpose of the medical and forensic examination of the woman and the accused is to establish the following: 1. A sexual act has been attempted or completed; A sexual act includes rape, which is defined as sexual intercourse by a man of a woman against her will or without her consent. The term rape is limited to penetration of the genitalia of the woman by the penis of the accused. The 'slightest penetration of the penis with the vulva, such as minimal passage of the glans between the labia with or without emission of semen or rupture of the hymen constitutes rape'15. Other sexual acts include non-consensual sexual touching involving genital, anal or oral penetration by the penis, fingers or other objects. 2. The woman has not given consent; Lack of consent may be inferred from history of resistance and/or evidence of struggle and injuries inflicted on her by the accused and by her on the accused. Absence of signs of struggle does not always imply consent. 3. Consent given was not valid e.g. under the influence of alcohol or drugs administered to her, or because she is not mentally sound or because she is a minor. 4. Verifying age of the patient in case of pre-pubertal/adolescent girls
5. Providing treatment, care and appropriate referrals for the patient.
The Venue
The medical examination should, as far as possible, take place in a non-threatening,
pleasant, quiet and private place away from the site of the crime so as to make the
woman comfortable and to provide optimum conditions for observation. Adequate
15 K.R.Narayan Reddy. The Essentials of Forensic Medicine. Sixteenth edition.1997. PDF created with pdfFactory Pro trial versi space for relatives accompanying the survivor, sufficient lighting and a comfortable
examination table is necessary for a thorough examination. Table space should be
arranged for laying out the kit and taking notes. The physician may wait a reasonable
period for adequate arrangements to be made for a detailed examination.
Examining Physician

Usually cases of sexual assault are examined by physicians working for the public
health services. In a city, a Forensic specialist or the Police Surgeon may conduct the
examination. If none of the above are available and the urgency of the case demands so,
a private practitioner may be called upon to complete the examination. Female
physicians are always preferable, although this may not always be possible.

Request For Medical Examination
Request for medical examination will be made by the survivor, her relative, a
representative of the law enforcement agency or by a women's rights organisation. It
can be conducted even before the crime has been reported to the police. No physician
working with the public health services may refuse to examine a survivor of sexual
assault. It is not mandatory for the request to be initiated by the police.
Presence / Absence Of Others
A female medical attendant must be present throughout the medical examination. In
case of a minor girl, her Mother and one other neutral person must be present. A nurse
or the receptionist at the health facility may be available on the premises to fill the role
of the neutral person. The person giving informed consent may take the place of the
Mother in cases of minor girls, if the Mother is not available. Representatives of the law
enforcement agency/police will not be present during the medical examination. In case
of class and caste wars, ensure that persons belonging to the offender's group are not
present. The examining physician must insist that such persons leave the area of
examination.
Recording The Findings

The examining physician or assistant physician will record the findings on the forms
enclosed in the kit. In case the physician herself/himself is not recording notes, it is
advisable to carefully go through the forms before signing and submitting them to the
investigating police officer. A clear and neat record will reduce the need for re-
examination.
Procedure
All supporting medical staff must be familiar with the procedure of examination. The examining physician will need to explain the entire procedure and the purpose of the examination to the team identified as well as to the patient16 and those accompanying her. The patient must be informed that she may if she wishes, ask the doctor to stop proceedings at any point and discontinue the examination. A note to this effect will be included in the record and the implications of the same explained to the patient. 16 We have used the term patient here to emphasise the doctor-patient relationship. In this document the terms patient / woman / survivor are synonymous. PDF created with pdfFactory Pro trial versi Medical needs must first be prioritised. The examination may have to be performed
under general anaesthesia in case of minor girls and when injuries inflicted are severe.
The urgent nature of the examination cannot be overemphasised. Spermatozoa usually
remain motile for 2-3 hours in the vagina, non-motile sperms for 24 hours. However
intact spermatozoa are rarely found in the vagina beyond 72 hours. This forms the basis
for early examination.
A set of spare clothing can be requested from the survivor's relatives, as items of the
survivors clothing will be required to be sent to the forensic laboratory.
The physician is urged to write clearly so as to avoid ambiguity. Clearly written notes
are particularly useful when they are referred to months or years after they have been
written, when the case comes up for hearing in the courts. If feasible, findings may be
typed and read by physician before she / he signs documents. Most forms have multiple
copies for distribution to patient, hospital, police and forensic laboratory. Please use the
carbon paper provided.
There should be no uncomplimentary remarks made by any member of the team
during the examination. It is important to maintain a pleasant and quiet atmosphere.
Requirements for the Medical and forensic Examination:
The kit contains several envelopes and a box containing equipments necessary for
forensic examination. The equipments are available in two sets of envelopes, 2A to 2K
for collection and storing of body evidence, as well as 3A to 3H for collection of genital
and anal evidence. The envelopes used are made of paper and not plastic to ensure that
moisture is not trapped in the collected specimens, thus leading to contamination of
evidence. The steps to be followed during the medical and forensic examination are as
follows:
Step I: Reassure the patient. Assess for medical emergencies and take care of these
immediately.

Step II: Consent

The form number 1 in the protocol will be signed by the patient herself or by the
guardian if the girl is under the age of 12 years or if the patient is unable to give her
consent by reason of mental or physical disability. Consent is sought for medical
examination, treatment for effects of the assault, consent for medico-legal investigation
of the sexual assault and consent to disclosure of the results of the medico-legal
examination in court. Please note that the patient or guardian may refuse to give consent
for any part of the examination. In this case the physician should appraise the patient of
the implications of the refusal. Please note that disclosure of the patient's identity to the
public is not permitted.
Distribution of Form 1: One copy each to the patient/ her guardian and hospital.
STEP III: Medical History
Personal details and medical history including menstrual history and details of
pregnancy are recorded on the form number 2 in the protocol.
Distribution of Form 2: One copy each to patient and hospital.
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STEP IV: Sexual Assault History
Patient's narration of the assault as told/narrated to the physician is recorded on form
number 3 of the protocol. Details of the place of the assault, time, nature of the force
used, areas of contact are recorded here. History of the assault as told to the physician
may be the first opportunity for the patient to tell her story in a relatively secure setting.
In case of minor children, illustrative books or a doll can be used if available, to elicit
the history of the assault. Wherever possible an expert trained in the method of eliciting
the history from a child may be called in to deal with the history in case of a minor
girl/boy.
Distribution of Form 3: One copy each to hospital and police department.
STEP V: Collecting and storing the clothing evidence

To begin with, the patient is requested to stand on a large sheet of paper (Specimen 1)
enclosed with the kit, so as to collect any specimens of foreign material e.g. grass, mud,
pubic hairs or scalp hairs etc. which may have been left on her person from the site of
assault or from the accused. This sheet of paper is carefully folded and preserved in bag
labelled as Specimen 1 for forensic examination.
The patient is then allowed to change into a gown provided by the hospital or an
alternative garment suitable for a complete examination. If the clothing worn at the time
of reporting is the same as those worn at the time of the assault, each item is removed,
allowed to dry in the shade and then packed in separate paper bags (1A, 1B, 1C etc) all
contained in bag labelled as Bag No 1.
Note: Clothing is to be folded in such a manner that the stained parts are not in contact
with unstained parts of the clothing.
STEP VI: Forensic Evidence Record
Collecting And Storing The Body Evidences

The general examination and collection of forensic evidence are carried out
simultaneously and recorded on form number 4 of the protocol. Forensic specimens are
used to establish a) that a sexual act has taken place; b) resistance to the act; iii) identity
of the accused and the woman; and iv) to corroborate the history provided by the
survivor. Examination and collection of specimens from the genitals will be kept to the
end. It is ideal to have a sterilised vaginal speculum for the examination. While
collecting specimens the following points should be taken care of:
1) Always ensure that the samples are air dried before storing them in their respective
containers
2) Always ensure that all the envelopes containing the samples are labeled (Type of
Sample/ Name and Initials of the Examining Doctor / Crime Registration / MLC No. /
Time / Date) and sealed appropriately before handing them over to the concerned
authority (Police/ Laboratory)
§ A general examination begins with the inspection of the body surface for bruises, scratches, bites and other injuries. In cases of sexual assault it is PDF created with pdfFactory Pro trial versi common to find marks on the face, neck, shoulders, breast, upper arms, buttocks and thighs. § Moistened swabs are used to collect smears from the oral cavity (2A),
bloodstains on the body (2B), foreign material on the body surfaces (2C)
seminal stains on the skin surfaces (2D) and other stains (2E). The swabs are air
dried in shade before packing in respective envelopes.
Note: Swabs must not be dried in direct sunlight.
§ The head hair of the survivor is then combed for specimens of any loose hair or debris if present (2F). A sample of 5-10 scalp hairs are then cut and preserved in
an envelope for the purpose of comparison or to serve as control samples (2G).
§ Material from under the survivor's nails (2H Right/2H Left) is collected by
using a moistened and pointed swab. Patient's nail clippings are then collected
and placed in the respective envelopes (2I Right/2I Left).
Note: Underlying tissue contamination is avoided while clipping nails.
§ 7 ml venous blood is collected with the sterile syringe and needle provided. 2ml of this is transferred to an EDTA bulb provided in an envelope (2J). This sample
is kept for blood grouping ABO and advanced grouping and for DNA analysis
when required. The remaining 5 ml is transferred to a bottle provided in an
envelope (2 K) containing 5 mg Sodium Flouride + 50 mg Potassium Oxalate in
solid state. It is shaken thoroughly, sealed and placed back in the envelope. The
second sample of blood is kept for assessing alcohol levels and drugs.

Collection Of Genital And Anal Evidence

Genital area is examined last. A careful observation of the perineum is made for
evidence of injury, seminal stains and stray pubic hair. The vulva and labia are
inspected likewise. Only in case of minor girls it is mandatory to inspect the hymen in
some detail. A note is made of any swelling, bleeding and tearing, these being signs of
recent injury. Examination of the vagina of an adult is done with the help of a sterilised
speculum. Gentle retraction allows for inspection of the vaginal canal. Look for bruises,
redness, bleeding and tears, which may even extend into the perineum, especially in the
case of girl children.
§ In case of any suspected seminal deposits on the pubic hair of the woman, that portion of the pubic hair is clipped, allowed to dry in the shade and placed in an
envelope (3A).
§ Pubic hair of the patient is then combed for specimens of the offender's pubic hair. The kit includes a comb for this purpose and a catchment paper to collect
and preserve the specimens (3B). Cuttings of the pubic hair are also taken for the
purpose of comparison or to serve as control samples (3C).
Note: Mention if pubic hair has been shaved
§ As the examination proceeds, separate swabs are taken from the vulva (3D),
vagina (3E) and anal opening (3G). Cotton tipped swabs enclosed in the kit are
used for this purpose. The swabs are allowed to dry naturally in the shade and
placed in envelopes marked with the numbers. Except in the case of vagina in
which four swabs are used (two from the anterior vaginal wall and two from the
posterior vaginal wall), for all other sites two swabs will be sufficient. Distilled
water is provided (3F). One vaginal smear is to be prepared on a glass slide
provided, air-dried in the shade and placed in an envelope (3H)

Distribution of Form 4: One copy each for, hospital and forensic laboratory (inside the
kit).
PDF created with pdfFactory Pro trial versi STEP VII: General Examination

All injuries are to be noted on the diagrams provided in form number 5 in the protocol.
The colour, shape and size of the injuries should be noted alongside. An assessment of
the emotional and mental state of the woman is made and recorded. Assessment of the
age is included in this Form. It is usually necessary to estimate age when the patient is
around the age of consent. Secondary sex characteristics, dentition and, in selected
cases, ossification tests by radiography are used to estimate age.
Distribution of Form 5: One copy each for, hospital and police department.
STEP VIII: Discharge Slip (Form 6)
At the end of the first examination the patient is assessed and treated, advised or
referred for conditions like injury, sexually transmitted diseases and pregnancy that may
have resulted from the assault. Counselling and psychosocial support is offered. In the
absence of such expertise kindly refer the patient to the nearest competent person.
Follow-up is essential. The patient is called for re-examination 2 days after the assault
to note the development of bruises and other injuries.
Distribution of Form 6: One copy each for patient / her guardian and hospital.

NOTE:
Ensure that all collected items have been included in the kit or packaged
separately as instructed. Do not include unused or extra components. Once all the
sealed specimens are enclosed within the kit, ensure that the kit is sealed and the
information on the outside cover is filled. Also ensure that the receipt of material
evidence at the end of form 4 is duly filled and handed over to the police along with
the kit.
PDF created with pdfFactory Pro trial versi TREATMENTGUIDELINES
Treatment Guidelines
• Urgent medical needs must be prioritised. • If required consider doing the examination under GA Sexually Transmitted Diseases
1. For non-pregnant women, the preferred choice is Azithromycin 1gm stat or
Doxycycline 100mg bd for 7days, with Metrogyl 200mg (7days) with antacid. 2. For pregnant women, the preferred choice is Amoxy/Azithromycin with Metrogyl (NO METROGYL TO BE GIVEN IN THE 1ST TRIMESTER OF PREGNANCY) 3. Hepatitis B. Draw a sample of blood for HBsAg and administer 0.06 ml/kg HB immune globulin immediately (anytime upto 72 hours after sexual act). This is not mandatory and is subject to availability and affording capacity of patient. Pregnancy Prophylaxis (Emergency Contraception)
The preferred choice of treatment is 2 tablets of Levonorgestrel 750 µg (Norlevo), within 72 hours. If vomiting occurs, within 3 hours repeat. Mala/Ovral G => 2 tablets stat repeated 12 hours within 72 hours Novelon/Femilon/Ovral L => 4 tablets stat repeated after 12 hours within 72 hours. Lacerations Clean with antiseptic (Savlon/Dettol) or soap and water. If already
immunised with Tetanus Toxoid or if no injuries, TT not required. If injuries and not immunised administer ½ cc TT IV. If lacerations require repair and suturing, which is often the case in minor girls, refer to the nearest centre offering surgical treatment. Post Exposure Prophylaxis (PEP) for HIV should be treated in the same way as that
for needle stick injuries. If no injuries, treatment to proceed depending upon mucosal Psycho-social Refer to rape crisis centre if such is available. Alternatively refer to
psychologist, psychiatrist or counsellor. Follow-up is essential. PDF created with pdfFactory Pro trial versi Follow-up
• Within 72 hours after initial assessment to record developing bruises • Repeat test for gonorrhoea if possible. • Test for pregnancy. • Repeat after six weeks for VDRL. • Assess for psychological sequelae. PDF created with pdfFactory Pro trial versi IMPORTANT INFORMATION TO NOTE WHEN DEALING WITH
CASES OF SEXUAL ASSAULT
1. Medical needs must be prioritized. The examination may have to be performed
under general anaesthesia in case of minors and when injuries inflicted are severe.
2. Principles for specimen collection:

• Collect specimens as early as possible; 72 hours after the assault the value
of evidentiary material decreases dramatically;

• Collect specimen carefully, change gloves frequently to avoid
contamination;
• Air dry all wet specimens before preserving;
• Label all specimens accurately;
• Ensure specimens are secure and tamper proof;
• Maintain continuity;
• Document details of all collection and handling procedures

3. Oral swabs should be collected first to ensure that the survivor can eat / drink.
4. A top to toe physical examination should be carried out followed by a detailed
genito - anal examination.
5. Early examination is important to ensure detection of sperms. It is best to
examine within 24 to 36 hours.
6. Note the time metabolites remain in the body.

• Alcohol - Found upto 10 hours. The amount of alcohol in the urine
represents the alcohol in the blood half an hour previously.
• Rohypnol (Flunitrazepam) - Found upto 36-72 hours
• GHB (Gamma Hydroxybutyric Acid) - Found upto 10-12 hours
• GLB (Gamma Butyrolactone) - Found in urine upto 6 hours and in the
blood upto 24 hours.
PDF created with pdfFactory Pro trial versi Contents Of The Sexual Assault Forensic Evidence (SAFE) Kit
Ø Manual
Ø Checklist
Ø Paper Envelopes
Ø Sterile Swabs
Ø Comb (Medium /Small)
Ø Nail Cutter
Ø EDTA bulb (2mL)
Ø Double Oxalate Tube (5mL)
Ø Syringe (10cc)
Ø Distilled water (5mL)
Ø Disposable Gloves (Size 6)
Ø Glass slide
Ø Scissors (Small)
Ø Disposable Speculum
PDF created with pdfFactory Pro trial versi Glossary
The sexual act carried out by force or under threat in which the man's erect penis is inserted into the woman's vagina, usually Agreement, permission or approval given by free will A membranous fold connecting the posterior ends of the labia A membranous perforated structure stretching across the vaginal A pair of lip-like folds extending from the mons veneris inferiorly and covering the labia minora (see below) in women A pair of lip-like folds lying within the labia majora in women (Legal) in India male below the age of 16, female below 18 years Penetration.as in Insertion of the penis into the vulva,/vagina of the woman. Legally, minimal contact between the glans with the labia is sufficient to term the act sexual intercourse. Sexual intercourse with a woman against her will or without her Any form of sexual touching without consent and against the will The sexual act whereby the vulva/vagina is penetrated by the The musculo-membranous passage extending from the cervix to The external genitalia of a woman including labia majora & PDF created with pdfFactory Pro trial versi Important IPCs (Revise the laws as per amendments)
• Sexual intercourse by a man with any woman who is not his wife above the age of 16 years, against her will or without her consent; • Sexual intercourse by a man with any woman below the age of 12 • Sexual intercourse by a man with his wife if she is below the age of Sexual intercourse by a man with his wife without her consent or against her will at a time when there exists a legal separation Sexual intercourse by a male public servant with a woman in his custody (consent not in consideration; not rape as in 376) Sexual intercourse by a male superintendent/manager of a jail or other place of custody with a woman in his custody (consent not in Sexual intercourse by a man on the management of a hospital or nursing home with any woman in the precincts of hospital (consent not in Assault or use of criminal force to outrage a woman's modesty Carnal intercourse against the order of nature with any man, woman or Violation of a woman's modesty by word or gesture Rape as in 376 with common intention (gang rape) PDF created with pdfFactory Pro trial versi PDF created with pdfFactory Pro trial versi

Source: http://www.cehat.org/safe%20kit/manual.pdf