Forensic gynaecologyBMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7476.s207-a (Published 20 November 2004) Cite this as: BMJ 2004;329:s207
- Jan Welch, clinical implementation lead
Emily Weston-Price, Alex Dill, Kerry Parton, and Jan Welch from the Haven Sexual Assault Referral Centres outline what is involved in this much needed and expanding specialty
Forensic gynaecology includes obtaining evidence of a sexual crime by forensic examination, immediate medical aftercare, long term follow up, and court appearances.
What is sexual assault?
Rape is defined as non-consensual penetration of the vagina, mouth, or anus by the penis. Assault by penetration is non-consensual, intentional insertion of objects, such as bottles, or body parts other than the penis, into the vagina or anus.
The legal emphasis lies in “consent,” which is defined as agreement by choice and freedom, and capacity to make that choice.
People will be considered most unlikely to have willingly agreed to sex if they were unconscious, drugged, abducted, subject to threats or fear of serious harm, or incapable of giving consent because of a learning disability or mental disorder.
Options after sexual assault
After a sexual assault, the victim will have many concerns including personal safety, police involvement, and possible pregnancy or infection. Victims of sexual assault come to the Havens, either via the police, by self referral, or by referral from elsewhere, for example, from their general practitioners.
After a sexual assault, there are two key priorities—firstly, to obtain evidence to possibly identify the assailant and use in a later court case, and secondly, to provide immediate medical care such as emergency contraception, antibiotic prophylaxis, hepatitis B vaccination, post-HIV exposure prophylaxis, and arrange follow up and counselling.
The forensic examination involves performing a detailed physical and genital examination and documenting any injuries found. DNA sampling involves taking swabs from different sites of the body and/or genital area and these are either given to the police or, in the case of a self referral who does not yet want to report, the samples can be kept at the Haven for storage and future analysis.
Careers in forensic gynaecology
Being involved in forensic gynaecology is an opportunity to do something completely different and is an attractive full time or part time career choice for general practitioners, and doctors specialising in genitourinary medicine or gynaecology (see box 2).
There are close links to different specialties, such as paediatrics, genitourinary medicine, accident and emergency, family planning services, and psychiatry, and there are opportunities for research, training, and special interests. Much of the job also involves working with non-medical agencies, such as the police.
Junior clinical fellow posts
We (Emily and Alex) work as junior clinical fellows in the Havens at St Mary's Hospital and King's College Hospital. These are two year rotations, which involve one year in forensic gynaecology, with various sessions a week in genitourinary medicine and gynaecology. This year can be viewed as the “elective” year required by the Royal College of Obstetrics and Gynaecology. We will spend the second year as senior house officers in obstetrics and gynaecology.
Box 1: Statistics from British Crime Survey 2002
About one in 20 women in Britain said they had been raped since the age of 16—an estimated 754 000 victims. About one in 10 women said they had experienced some form of sexual victimisation, including rape, since the age of 16.
Each Haven also employs a full time staff physician or associate specialist. The remainder of the out of hours rota is covered by hospital practitioners, who work one or two daytime sessions in the Haven as well.
Haven doctors are trained at the beginning of their post in how to perform a forensic examination. This involves a mentoring system by more senior doctors, experienced in dealing with victims of sexual assault.
To work at a Haven you must attend the adult and paediatric forensic courses. These are two day courses, held at New Scotland Yard and include lectures and practical modules featuring speakers from the Forensic Science Service, the police, and an expert witness. A barrister goes through the legal side of sexual assault.
Currently there is no formal court training course, but the police offer a one day “Orientation” and “Question and Answer” session at the crown court. This is particularly useful for those doctors who have not had any court experience.
There is also a one day child protection course, which the trust organises, which is vital, as some of the clients will be under 16 years of age.
The job can be upsetting and demanding, with the added pressure of the constant demand for police statements, which may require a quick turn around.⇓
Many doctors find attending court as a professional witness quite intimidating, and other than good preparation there is nothing else you can do to prevent a “grilling” from an aggressive defence barrister. As sexual assault is classed as a serious crime, the court appearance will be in the crown court and this can also be a source of stress.
The job requires you to have a strong character and the ability, perhaps more than in other parts of medicine, to dissociate work from your personal life. Establishing a rapport with a client is obviously important, but it is also essential to remain clinically objective. Documenting injuries and making statements requires an attention to detail. In addition, you have to be confident in dealing with other services, particularly the police.
Typical (fictitious) situations
A self referral
A 20 year old woman said that she had been forced to have oral and vaginal intercourse with a male acquaintance. She first went to her general practitioner for emergency contraception. She did not go into details about what had happened to her.
Later a friend told her about the Haven, so she contacted us. We arranged a time for her to come and talk to us about having a forensic examination. We explained that we would take her history first, followed by a general physical examination and then a genital examination. We would also take some swabs.
After discussing the options with her, she decided to have the examination, but did not want the police to be involved at that time. All forensic samples are anonymously labelled and can be sent to the Forensic Science Service for analysis if the client wishes.
Box 2: Experience of a hospital practitioner*
I entered forensic gynaecology accidentally when I attended the forensic course as part of career grade training in community gynaecology. I did not expect to be transfixed but I had never been on such a stimulating course, real detective stories! Overnight, having convinced myself I had the right experience for the job, I applied for a post at the Haven the following day. After two years the job still supplies the slight adrenalin rush and sense of purpose and achievement I had hoped for.
I am currently a part time hospital practitioner at the Haven. The main purpose of my job is being part of the 24 hour on-call rota for the Metropolitan Police, who can bring victims—male or female, old or young, for a forensic medical examination. I do one 12 hour stint about every 10 days.
I also work two daytime sessions each week, which enables me to follow up clients by appointment and see new clients for medical examination. The principal benefits, however, are being able to share the burden of difficult experiences with my colleagues and to form part of the team making ongoing adjustments to protocols and improvements to the service in general, as this method of dealing with sexual assault is still in its infancy.
It might seem strange to say that you “enjoy” this line of work as obviously it can be extremely harrowing at times, particularly seeing children or young vulnerable teenagers, but it is one of the few specialties of the NHS where you are expected to spend two or more hours with a client. If you aim to turn a mentally and physically traumatised young person back into someone who can go out and face the world again, then the job can be very satisfying.
The intellectually stimulating part of the work is mixing with other disciplines, not only from other medical fields such as paediatrics, but also police officers and lawyers. I need to be very sure of my ground when writing a statement, or when my presence in court is required for questioning about the examination.
We then started her on antibiotics and an immunisation course against hepatitis B. She was offered, but declined, post-exposure prophylaxis against HIV.
Her follow-up care included a sexual health screen and an appointment to meet a SOIT officer (a specially trained police officer) to discuss her experience informally. After this meeting, she decided to pursue the case and reported it to the police.
A 40 year old nurse was on her way home from work when a stranger threatened her at knifepoint, dragged her into bushes, and vaginally raped her. She returned home before dialling 999. Officers from a special police unit took her report and bought her to the Haven three hours after the assault. She was examined and provided with emergency contraception, antibiotic prophylaxis, post-exposure prophylaxis for HIV, and a tetanus vaccination. She later returned for follow up, screening for sexually transmitted infections, and counselling.
While doing my obstetrics and gynaecology training I was involved in the care of a pregnant woman who had been assaulted. During this time it struck me how little people knew about the management of these complex presentations and whom to contact to ask for advice. A team from the Haven Camberwell carried out a forensic examination on the woman and following this I attended the Adult Forensic Examiners course at New Scotland Yard, where I met other doctors working in this field. I wanted to learn more about forensic gynaecology and expand my skills in this area.
As I proceed with my training I would like to continue to include forensic gynaecology in my work, as it provides something different within the NHS and I enjoy being part of an evolving specialty. I find it a privilege to have the opportunity to be a part of a system that offers people the chance to take control of their life after a disempowering event such as sexual assault.⇓
I find forensic gynaecology an important addition to obstetrics and gynaecology training, especially in combination with genitourinary medicine training. Experience in both specialties offers several interesting options for my future career. My personal career plan includes refugee health and international women's health, where sexual assault during and after a disaster or displacement is common, is used as humiliation and punishment, and has major implications on women's status in society. Having worked at the Haven at junior clinical fellow level also leaves the option to return part time and for on-calls during a career break or further study.
Relevance to trainees
Most incidents of sexual assault are not reported to the police and the lifetime risk of rape for women in the United Kingdom is thought to be at least 5%. It is therefore likely that many gynaecologists are seeing cases of assault without the woman disclosing it. It is important therefore to recognise the acute and chronic clinical signs of sexual assault, and to know what the management options are and how to discuss these appropriately.
Trainees in gynaecology should also be familiar with taking a sexual history and pre-test (HIV) counselling, how to manage sexually transmitted infections, and organise health promotion and contact tracing.
Of course, doctors in other specialties, such as general practice, may be the first point of contact for people who have been sexually assaulted so should also know how to manage them and when to refer if necessary. Referral is straightforward if there is a local Sexual Assault Referral Centre (SARC) such as the Havens in London, the St Mary's Centre in Manchester, or Reach in Newcastle or Sunderland. Elsewhere, forensic examinations are arranged by the police, who will contact a specialist doctor (forensic medical examiner or sexual offences examiner) for this. Additional referral is likely to be required for needs such as sexual health assessment and counselling.
The Havens help anyone in London who has been raped or sexually assaulted—www.thehavens.org.uk
Contactfor details on training in adult rape examination.
Dalton M (ed.).
Wilken J, Welch J. Management of people who have been raped.
Victim support is an independent charity that helps people cope with the effects of crime—www.victimsupport.org.uk
The British Crime Survey 2002. London: Home Office—www.homeoffice.gov.uk/rds/bcs1.html
External evaluations have shown that SARCs can offer optimal care to victims of sexual assault. Unfortunately most areas of the United Kingdom do not have access to SARCs, although it is a government priority to develop more. More doctors will be needed to staff SARCs; in the meantime, those interested in forensic gynaecology can obtain experience by working in sexual health services or with the police as sexual offences examiners. Forensic gynaecology is evolving as a subspecialty and work is ongoing to define aspects such as training and accreditation.