British Journal of Obstetrics and Gynaecology

May 1997, Vol. 104, pp. 617-620

Female victims of rape and their genital injuries

Lucy Bowyer Registrar, Maureen E. Dalton Consultant (Obstetrics and Gynaecology)
Ellis Fraser Centre, Sunderland District General Hospital, Kayll Road, Sunderland

Objective A minority (some report < 10%) of women report sexual assault. Of those that negotiate the
police process, only a minority will come to a court hearing. It is thought that the courts still rely
upon medical evidence, in particular evidence of genital injury to 'prove' the rape. This study aimed
to ascertain the incidence of genital injury in victims of alleged rape
Design Retrospective review of case records of women who reported they had had been raped, provided
by women doctors on the Northumbrian Police Doctors scheme.
Sample Case records from Newcastle, North and South Tyneside, Sunderland and Northumbria.
Methods Analysis of records in the standardised booklet used by police surgeons to examine women
reporting rape.
Main outcome measures Presence of genital injury, presence of other physical injuries.
Results A minority of women had genital injuries (22/83); the majority had some form of physical injury
(68/83), although most of these were minor.
Conclusion The study shows that only a minority of women examined by specifically trained police
doctors show evidence of genital injury. The absence of genital injury does not exclude rape.

INTRODUCTION New Zealand9 showed that only 28% of reported cases

It is estimated that 1 in 4 to 1 in 6 women is raped dur-
ing her lifetime'-3. The vast majority of victims of sex-
ual assault do not report to the police4v5or consult a doc-
tor. The United States National Crime Survey (1979)6
estimated that only 50% of forcible rapes were reported
to the police. It may be that as few as 1 in 10 women
report sexual assault7.
In English law the accuser bears the burden of proof
of rape. Evidence must support the allegations that 1.
force or threat was involved; 2. the action was against
the will of the accuser; and 3. penetration of the labia or
beyond occurred, with or without ejaculation.
Until recently little sympathy was afforded to women
who were raped, an attitude which contributed to the
under-reporting of cases. In Britain in the early 1980s
there was a public outcry when two particular cases of
rape were publicised: the first was a televised interview
of a rape victim who was treated badly by interviewing
police officers, and the second was the remark of a
judge who said that the woman was guilty of contribu-
tory negligence when she was raped while hitch-hiking.
Following these events the police analysed cases and
found that a large proportion of reported rape allega-
tions did not proceed to trial*; however, this finding was
not specific to this country: a documented series from
Correspondence: Dr L. Bowyer, Research Building, St George
Hospital, Kogarah, NSW 22 17, Australia.
0 RCOG 1997 British Journal of Obstetrics and Gynaecology
proceeded to court.
The need of women reporting rape to be supported by
a more accessible police service began to be realised:
specific interview suites, designed to reduce physical
and psychological trauma, were set up for interview and
examination of the women, while improving the likeli-
hood of collecting and preserving physical evidence for
possible use in a trial.
In the Northern Region of England there has existed
for many years a scheme whereby volunteer women
doctors examine women who report that they have been
raped, sexual assaulted or sexually abused, and varia-
tions of this scheme now exist in other police forces. As
the women are examined in one of two specifically
designed suites where physical examination and coun-
selling take place in relaxed surroundings, it is hoped
that this scheme will encourage more women to report
sexual assault. Doctors are trained how to perform
examinations of the women, write statements and give
evidence in court. Before this scheme was introduced
the police surgeon on duty would examine all those who
reported that they had been raped or who presented as
possible cases of child sexual abuse. At that time there
was no female police surgeon in the Northumberland
region. Several similar schemes have been set up
throughout the world to improve the treatment of rape
and encourage the reporting of rape8JoJ1.
The issue of genital injury and its association with
rape is contentious, but genital injury is still thought to
617
618 L. B O W Y E R & M. E . D A L T O N

carry more weight in the courts to obtain conviction. Table 1. The anatomical location of general injuries, such as bruises,
The following study reports an analysis of the casenotes scratches or grazes, in association with the number of women report-
of 83 women who alleged rape, and in particular ing rape.
describes the genital injuries recorded. Anatomical location of injury n

No injury 15
METHODS Arm 42
Thighhpperleg 36
Examination and interview Neck 22
Breadchest 17
The woman is usually brought to the examination suite Calfhhinilowerleg 16
by a woman police constable (WPC), although those Facehead 15
who do not wish the involvement of the police will be Back 14
seen as self-referrals. Two examination suites exist Knee 14
Shoulder 10
in the Northern Region, both located near or within Hand 13
general hospital grounds. The suite consists of interview Buttock I
rooms, an examination room and bathroom, kitchen and
office where the counsellors are based. The rooms are
furnished in a ‘noninstitutional’ style in order to create a
homelike atmosphere. A brief medical and gynaecolog- After the examination the woman is offered a prelim-
ical history is taken with a detailed description of the inary counselling session, usually a fortnight later to
assault. An account is also provided by the WPC if she allow her time to recover from the initial shock; these
accompanies the woman. Detailed enquiries are made sessions are undertaken by trained autonomous counsel-
concerning the events before, during and after the lors. All women are offered review by the genitourinary
assault, in particular details of micturition, defaecation, medicine clinic approximately two weeks later to
eating, drinking, and washing. If the woman has not discuss screening for HIV, hepatitis and other sexually
changed since the assault she is asked to remove her transmitted diseases.
clothing onto a sheet of brown paper, in order to catch A statement is submitted to the police officer in
any possible items for evidence, such as hairs from the charge, describing the injuries sustained and whether
assailant. Any serious injury is treated as a priority these are consistent with the alleged assault.
before the forensic examination.
RESULTS
Physical examination Eighty-three cases of alleged rape were reviewed from
A thorough physical examination is undertaken ensur- the notes of the women doctors on the scheme. The
ing the dignity of the woman is maintained, with a following details were documented: age; time between
detailed explanation of each element of the examination alleged rape and examination; previous sexual activity;
and her consent at each stage. The woman is carefully assaults in addition to rape; general injuries; genital
examined for evidence of recent injury, such as grazes, injuries.
bruises and scratches and an estimate made of the The mean age of the women reporting rape was 25.3
timing of the injuries. Hair combings and cuttings are years (range 16-48 years). The mean time between the
taken. Her injuries are described in writing and drawn occurrence of the alleged rape and the examination was
with measurements on a body chart. The final examina- 34 hours (range 1 hour to 11 days). The majority of
tion is of the external genitalia and the pelvis. The need women were seen within 24 hours of being raped. Four
to take swabs from the vulva, introitus, low vagina, high women had been virgins.
vagina, cervix, perianal and rectal areas is assessed Implements, such as a fist or clothing, had been
according to the time from the assault. Control swabs inserted into the vaginaof three women, seven had had
(unopened plain swabs from the same batch) are forced anal intercourse, and two had been unsuccess-
included with the specimens. Pubic hair combings and fully strangled. Table 1 shows the associated injuries
cuttings are also taken. Blood samples are taken for and Table 2 the genital injuries.
grouping and DNA and blood alcohol levels. A saliva
specimen is also taken. The woman is examined again DISCUSSION
in one or two days later when new bruising may
be more easily seen, and a comparison of the age of dif- The association of genital injury and rape is question-
ferent bruises can be made. The need for contraception able, the incidence of genital injury varying between 10
is also discussed. and 87% (Table 3).
0 RCOG 1997 Br J Obstet Gynaecol 104, 617-620
 RAPE AND GENITAL INJURIES 619

Table 3. Studies reporting genital injuries in association with rape. Values are presented as n / n (%).
Studies Year No. injured Type of injury

Amir” 1971 38/73 (52) Genital injury

Cameron” 1983 14/33 (42) ‘Slight’ genital trauma
CartwrightI4 1987 70/440 (16) Vulva contusions, hymeneal and vaginal lacerations,
laceration of posterior fomix
Everett & JimersonI5 1977 221117 (19) Minor lacerations/ abrasions of genitalia
8/117 (7) Major vaginal or perineal lacerations
Lauber & Sournalh 1982 10/22 (45) Genital injury with toluidine blue staining
Lloyd & Walmsleyl’
Cases leading to conviction in 1973 49/217 (23) Vaginal cuts and bruises
38/217 (18) Ruptured hymen
17/217 (8) Anal cuts and bruises
Cases leading to conviction in 1985 58/356 (16) Vaginal cuts and bruises
33/356 (9) Ruptured hymen
25/356 (7) Anal cuts and bruises
ManserI8 1992 38/103 (37) : Genital injury
11 1103 (11) Anal injury
Mc Cauley et al. l9 1987 14/24 (58) Genital injury (contusions) with toluidine blue staining
Olusanya et a/.20 1986 53 / 330 (16) Genital injury
Ramin et a/.’’ 1992 561 129 (43) abrasions, haematomas & lacerations
23/129 (18) Premenopausal
Slaughter & Brown 22 1992 114/131 (87) Colposcopic genital injury findings
Solala et al.I’ 1983 137/621 (22) Mostly minor genital injuries

Table 2. Genital injuries sustained by women reporting rape. were examined colposcopically within six hours of
~~~~~ ~

intercourse, and micro-abrasions invisible to the human

Type of injury n
eye were seen only in two cases. Slaughter and Brow#
Tears give the highest incidence of genital injury after rape
Perineal 4 (87%), but examined these women with the colposcope
Hymeneal 3* and included tiny lacerations, abrasions, bruises and
Posterior vaginal wall 1 swelling in this classification. However, it would be
Scratches bruises and grazes
Labia majora
very difficult to perform a controlled observational
Fourchette study comparing the genital injuries sustained by
Vagina women who had been raped with women who had had
Anus vigorous consenting intercourse. Similarly, case series
~ t u d i e s ’ ~ *using
’ ~ . ~dyes,
~ such as toluidine blue, to
*Two in women who had not previously experienced sexual inter-
course.
demonstrate vaginal lacerations invisible to the naked
eye have shown a higher percentage of women with
Most of the genital injuries described in this study genital injuries than those studies in which no dye was
were minor, consisting of tears, bruises, scratches and used. One is inclined to agree with Patel, Courtney and
grazes. If forced anal intercourse had also occurred, ForsteS7 that “Colposcopy may be perceived as a
injury was much more likely. Recent ~ t u d i e s ~ of ~ ~ * ’ stressful invasion of a woman who is already vulnerable
larger series of premenopausal women examined physi- and at risk of the rape trauma syndrome”, and that its
cally only agree that the minority of rape victims sustain routine introduction is undesirable in the management
genital injury, the frequency being < 30%. In our study of rape victims.
the incidence was 27%; we included anal and The presence of genital injury is thought to carry
vulvalhaginal injuries. Postmenopausal women are more weight in obtaining convictions in court, but only
more likely to suffer genital injury after rape; even then, Lloyd and WalmsleyI7 from the home office provide
more than half will have no demonstrable injury. evidence of this: in 1973, of cases leading to conviction
There is anecdotal evidence that consenting 45% had genital injury, and 32% in 1985. These figures
intercourse (the favoured legal term is ‘vigorous con- are slightly higher than those quoted in the studies
senting intercourse’) can lead to the same genital above, indicating that genital injury may be seen as an
injuries as rape23*24. One study25evaluated the effects of important factor by the courts. Helweg-LarsenZR found
consenting intercourse upon the genitalia: 18 women an association between judicial outcome and the result
0 RCOG 1997 Br J Obstet Gynaecol 104, 617-620
620 L. B O W Y E R & M. E . D A L T O N
of the medico-legal examination in most, but not all,
cases of rape and attempted rape in 1975 and 1980.
CONCLUSION
Gynaecologists will usually find no genital injuries
when they examine women reporting that they have
been raped, but this should not influence their opinion in
their legal statement regarding the allegation, nor in
their treatment of the woman. The absence of genital
injury should not be used as pivotal evidence by the
jury, police or the Crown Prosecution Service.
Sympathetic concern in the treatment of women who
come forward to report the experience of rape will
result in more reporting of rape.
Acknowledgements
We are grateful to the following doctors for allowing us
to analyse their data: Dr J. Welbury, Dr E. Fraser and Dr
G. Bannerjee.
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Received I9 April I996
Returnedfor revision 13June 1996 & I 7 October I996
Accepted 5 December 1996
0 RCOG 1997 Br J Obstet Gynaeco2 104, 617-620