1. Examination
of
“The RAPE VICTIM”
Dr. Sharda Jain
Director :-
To be presented AOGD annual Conference
on 25th october 2014

2. DEDICATED
W
to
NIRBHAYA
of INDIA

3. Our Promise
W
Teach every Doctor
Exam. Of Rape VICTIM
Rape Free India !!
Looks
a Dream

4. Black
Day
Dec. 2012
Shook conscience of
Every Indian
16th
NIRBHAYA

5. Total Failure of Mother India to protect
Honor & Dignity of W

6. India's Biggest Shame

7. M
WHY r Becoming BEAST
HORRIBLE
Weapon to
torment
W

8. PUBLIC FURY & PROTEST
UNPRECEDENTED

9. Centre’s Stage

10. We all Realised !!

11. Rape
W
First
Shatter
Beyond
your & mine
imaginations

12. Rape Need to be
STOPPED
Second

13. Third
Societies Views on
Rape Victims Need to change

14. Fourth
Rapist
Should
Not
Go
Scot Free

15. Time
BOUND
Fifth

16. Victims Need to Speak Up
SPEAK - Up
Sixth

17. Culture of
Lousy
Medical
Exam.
Of Rape
Victim
has to change
!!
Seventh

18. Total Apathy & Collective
NEGLECT of Rape Survivor’s
Exam. Can’t be IGNORED any further

19. Eighth
Every Lady Doctor Has to Get Trained in
Rape Victim Exam & Care

20. WHY
?

21. & Can Happen
to anyone
Rape
is
Increasing
You , Me Our Daughter, Sister,
Friend & Even Mother !!)

22. 2001
N.C.W.
Marked Deficiency Noted
In medical exam / Evidence Collection / std. care
&
No Rape crisis cell & centres

23. Manual, Film & Kit
2004
IMA, MOWCD, UNICEF
Ignored by Medical
Fraternity till 2011

24. 2011 DELHI HIGH COURT
Land Mark
judgment
• Directing uniform examination
protocol
• Use a standard kit
• Uniform Protocol of treatment
• Uniform Training Module based on
IMA
FILM MANUAL
THE MAKING OF NEW INDIA

25. 2013
RAPE Law amendment
Thanks to Justice Verma Committee
Gave us
Much Hope

26. DELHI HIGH COURT - JUDGMENT
justice sh. D Murgeshan and justice sh.V.K. Jain
2013
Directed Delhi government to issue all hospitals
including those in Private sector
Examination, FIRST AID & EMERGENCY TREATMENT
to RAPE Victims - Free of Cost.
Dept of Health and Family welfare NCT of
Delhi has directed nursing homes and private
hospital not to refuse emergency treatment
to rape Victims / give care
Failing which - face punishment.

27. PUNISHMENT FOR NON COMPLIANCE
for we doctors –
Exam/ Care/ Evidence collection
Whoever, being in charge of a hospital , public
or private , whether run by the central
Government, local bodies or any other person,
contravenes the provisions of sections 357c of
the code of criminal procedure , 1973(2 of
1974), shall be punished with imprisonment for
a term which may extend to one year or with
fine (166B – IPC)

28. Lets Know the LAW
New Definition Of RAPE
(According to 2013 amendment)
•Penetration of penis, to any extent, into the
vagina, mouth, urethra or anus of a women
or makes her to do so with him or any other
person; or
•Insert, to any extent, any object or a part of the
body, not being the penis, into the vagina, the
urethra or anus of a women or makes her to do
so with him or any other person;

29. Lets Know the LAW Cond.
New Definition Of RAPE
(According to 2013 amendment)
•Manipulation of any part of the body of a
women so as to cause penetration into the
vagina, urethra, anus or any part of body of
such women or makes her to do so with him
or any other person
Or
•Applies his mouth to the vagina, anus urethra
of a women or makes her to do so with him or
any other person, under the circumstances
falling under any of the following seven
descriptions:

30. Lets Know the LAW Cond.
New Definition Of RAPE
(According to 2013 amendment)
FIRST – Against her will
SECONDLY – without her consent
THIRDLY – with her consent, when her consent has
been obtained by putting her or any person in
women she is interested in fear of death or of hurt.
FOURTH – with her consent, when the man knows
that he is not her husband and that her consent is
given because she believes that he is another man to
whom she is or believes herself to be lawfully
married.

31. Lets Know the LAW Cond.
New Definition Of RAPE
(According to 2013 amendment)
FIFTHLY – with her consent when, at the time of giving such
consent, by reason of unsoundness of mind or intoxication or the
administration by hem personally or through another of any
stupefying or unwholesome substance, she is unable to
understand the nature and consequences of that to which she
gives consent.
SIXTHLY – with or without her consent, when she is under
eighteen years of age
SEVENTHLY – when she is unable to commutate consent
2.INJURIES ON VICTIMS BODY HAS NO RELEVANCE

32. 3 Most Important
Things Needed
•Trained Doctor & her team
• Special safe kit for examination
• Std. Protocol of Collection &
Treatment to prevent STD/
Pregnancy is crucial

33. What You Can do
Before Reaching
Hospital ?
As soon as one comes across a victim
Of Sexual assault, the first step is to
ensure SAFETY
• Take her to safe and secure place call the POLICE
if danger from the assailant is still there.
• Call a CLOSE FRIEND or RELATIVE-someone
who will offer unconditional support.

34. INSTRUCTIONS TO THE VICTIM
What You Can Do Before
Reaching Hospital ?
• One must take care not to clean up before
taking them to hospital. The victim should
not bath, go to the bathroom, comb hair,
change clothes or brush teeth before
undergoing a medical examination.
• This will help to preserve all the evidence.

35. Principle of Emergency Care
The doctor’s job at the emergency room is not to
determine if the rape has happened or not.
Rape is a legal term
– a crime –
and whether this crime has been committed or
not will be decided by the Honorable court.

36. APPEA
L SURVIVOR
of Sexual Assault to be used
& not the VICTIM of Sexual
Assault so as to eliminate the
stigma associated with
word Victim.

37. Principle of Emergency Care of Rape
Survivor Exam. & care
• The attitude of the medical staff
should be compassionate and not
judgmental
• Life threatening emergency, if
present needs urgent attention

38. POLICE REQUISITION /FIR
is not mandatory for seeking
medical care and treatment of
the victim.
Guidelines for Medical Examination
As per new law 2013

39. The GOALS of
Medical Examinations
• MEDICAL ASSESSMENT ,
documentation & TREATMENT of
injuries and PREVENTION of
pregnancy & STD
• Collection of FORENSIC evidences
• PSYCHOLOGICAL support

40. CAUTION
If the ATTENDING DOCTOR FAILS TO
COLLECT EVIDENCES PROPERLY,
he / she may face the charges of
DESTROYING THE EVIDENCES which
is PUNISHABLE in India panel code

41. WHO should do the examination ?
New law 2013
Medical examination of a female victim shall
be conducted by a FEMALE REGISTERED
MEDICAL PRACTITIONER, in absence
there of , in presence of a female registered
medical practitioner
If the child age less then 12 years
Pediatrician should perform the general examination and
PSYCHOLOGIST should be called for
PSYCHOLOGICAL support of the survivor

42. Place of Examination
RMP employed in a HOSPITAL RUN BY
GOVT. or a LOCAL AUTHORITY and , in
the absence of such a practitioner by any
other RMP within in the radius 16 Km From
The Place where the offence has been
committed on the Request Of A Police
Officer not below the rank of a sub
inspector

43. INFORMED CONSENT
CONSENT IS ESSENTIAL AND NOBODY CAN
FORCE A VICTIM TO UNDERGO A MEDICAL
EXAMINATION WITHOUT HER CONSENT ,
NOT EVEN THE COURT .
•IT RECOGNISES HER RIGHT TO CONSENT FOR
PARTIAL EXAMINATION - she may also decide to
undergo partial physical examination and / or genital
examination and allow the collection of bodily evidence.,
•It is purely her wish whether to file a police complaint
and initiate criminal proceedings against the accused.

44. Many Hospitals make these cases
MLC & Inform the police
• In that case police comes in to actions
• But no body can examine her without her consent
if she is under the age of 12 years or a
mentally subnormal person, the written
consent of the parents

45. Medical Examination
• ABSOLUTE PRIVACY
• Medical Exam.-should be treat as an EMERGENCY
• EMERGENCY MEDICAL CARE is a
priority over collection of evidence
THE ATTITUDE towards patients should be
Nonjudgmental , Empathetic and Reassuring

47. EVERY CONTACT LEAVES A TRACE

48. PRELIMINARY
DATA

50. The statement of the victim in her words must be written down
as much as possible “WORD FOR WORD”. The amount of
violence used, the position of the assailant, and the mode of
attack should be elicited. It is necessary to inquire if vaginal,
oral, or rectal contact occurred. Her statement should be
noted with reference to:-
•Pain
•Haemorrhage
•Sensation as to penetration and emission and
•The appearance of discharge
•If she cried for help, or was too terrified to do so, or she
fainted
Enquiry should be made of the events after the all eged
assault, e. g, if she has changed her clothing, bathed or
passed urine. Any delay in making complain to the authorities
should have a proper explanation. A record should be made of
the statement of others who accompany her. The degree of
agreement of the various statements is important.

51. Collection of OUTER Clothes & INNER
clothes
of Survival of Sexual Assault
separately
Separately on big piece of paper wrap & seal
fresh set of clothes provided

52. The Principal Features of the
Examination are:-
1. Mouth, breast , genital and rectum are
examined closely. Injury markers on body
are described and documentation clearly.
Drawings should be used to described
injuries.
2. Debris from any is collection in a separate
envelop, labeled and sealed
3. Loose debris from finger nails and
scrapings collection in envelops sealed and
marked.

54. Guidelines for Injuries
As per new law 2013
• SIGN OF STRUGGLE on Clothes & Body
are IRRELEVANT according to New Law
• Injuries are seen in only one third cases.
• Common sites of extra genital trauma are
mouth, throat, wrists, arms, breast and
thighs. It is essential to do a careful
recording of the findings if there
presents.

55. The women usually
scratches the assailant
during the struggle and
this may result in injury
to her nail which should
be recorded. The debris
under nail should be
removed and examined
for the presence of tags
of epithelium, blood,
fibers, etc, of the
assailant
Nails Scrapping

56. The Principal Features of the
Examination are:-
4. Any suspected stain on body collected by
putting distil water rolling the swab stick
over it and the stick placed in an envelop.
5. A paper placed under the buttocks of the
patient, comb the patient’s public hair,
collect loose hair in the same paper and seal
it
6. Patient’s Public hair, which appear matted,
to be cut and sealed in another envelop.

57. The Principal Features of the
Examination are:-
7. VULVA examined for signs of injury and the
finding noted down.
8. SPECULUM EXAMINATION AFTER
EXPLAINING THE PROCEDURE – swab
collection from slides two are handed over to the
accompanying police constable and rest two sent
to the forensic lab. The swab is put separately in
the tube.
9. FLUID AND MUCUS FROM CERVIX collection
& slide prepared. The swab is placed in a tube
sealed. Another swab collection from cervix and
streaked on chocolate agar plate and the swab
discarded.

60. The Principal Features of the
Examination are:-
• 10. washing the vagina by saline from a
preloaded syringe, stirred by speculum, fluid
drawn, put on the slide & examined under
microscope for spermatoa
• Rectal examination is performed if suspected
– proctoscopy performed by surgeon using
smallest size proctoscope , any injury noted,
swab collected and put in a tube
• Examination of oral cavity : swabs taken
from sides of molar teeth slide prepared and
swab kept in the tubes.

61. Two finger admissibility Test
• On a women victim shall not be
performed (As per Guidelines for Medical
Examination As per new law 2013 & WHO
guidelines.
and
• Recording of “victim is habituated to
sexual inter course or not” shall not form
a part of report at all.

62. Menstruation is not a bar
for Examination
“MENSTRUATION IS NOT
BAR TO ILLEGAL
SEXUAL INTERCOURSE”.

63. Body fluids samples collection and
radiological examination
1. BLOOD : for ABO grouping and Rh typing
HIV, Hepatitis , Syphilis
2. URINE : For alcohol intoxication and
pregnancy test.
3. X RAY : wrist, pelvis, shoulder and knee for
confirmation of age.
4. Sample for GONORRHEA is already taken
on chocolate agar plate
No specimen should be left alone at any time . All specimens are placed in
yellow bag which is kept in locked refrigerator till the time samples are
handed over to police constable who would take them to forensic science
laboratory

65. Motility of Sperm – Prepare a
hanging drop Preparation
Motile sperms can visualized up
to four – five hours
The smears are fixed with drop of alcohol

66. Collection of Evidence
• Even if the victim is NOT SURE, whether she
wants to report the attack, it is still important
to collect and preserve evidence so it can be
accessed at a later date, if necessary.
• Evidence if not collect within 48 to 72 hours
of the incident is often unrecoverable or
invalid.

67. SPECIAL TESTS , if Required
• COLPOSCOPY for Examination microtrauma
• TOLUDINE BLUE : Stains microtrauma area
& better visualized. It is than washed with
water
• WOODS LAMP EXAMINATION may help
identify semen, which will fluoresce ,. The
flurescent area should br swabbed with
cotton tipped applicator moistened with
sterile water.
• BITE MARK CASTING can be done by
unwaxed dental floss

68. Optional in Virgins & Children

69. Rape is a Rape !!

70. Hard to disprove

71. Treatment AIM
• Pregnancy prevention
• Sexually Transmitted
Disease Prevention
• Emotional Support

72. Prophylactic treatment for all patients
• Injection tetanus toxoid 0.5 mL SC
• EMERGENCY CONTRACEPTION
offered
Tab Levonorgestrel 75 microgram with in
72 hours & to be repeated after 12
hours or
Tab Mala N 2 tab stat follwed by 2 tab
after 12 hours
UPT : to be repeated at 1,2 weeks MTP : if need be

73. Sexually transmitted diseases
Incubation period of common infections
• Gonorrhea 3-4 days
• Trichomonas 1-4 weeks
• Chlamydia 7-14 days
• Warts several months
• Herpes 2-14 days
• Herpes vaginosis 2-14 days
• Syphilis 3 months

74. Universal STD Prophylaxis
Metrogyl 2gm orally - single dose
Azithromycin 1g - orally single dose
Oral Cefixime 400 mg orally single dose

75. Prophylactic treatment for all
patients
1) For GONORRHEA
Oral azithromycin 1 gm orally single dose
Oral Cefixime 400 mg orally single dose
2) For CHLAMYDIA
Oral azythromycin 1 gm single dose
Or
Oral DOXYCYCLINE 100 mg twice daily for 7 days

76. Prophylactic treatment for all patients
3) For HIV
(Initiate within 4hr for maximum benefits),
the basic regiman includes:
Oral Zidovudine 300 mg twice daily for 4
weeks plus oral Lamivudine 150 mg twice
daily for 4 weeks

77. HIV
If the transmission risk for HIV is perceived to
be high (bleeding the assailant was at high of
having HIV): example regima to be given which
includes:
• Basic regimen plus
• Indinavir 800mg thrice daily for 4 weeks or
Nelfinavir 750 mg thrice daily for 4 weeks

78. Optional
• Hepatitis B vaccination

79. Emotional Support
Sexual assault victim need unconditional
emotional support as they may be struggling
with emotions of
Anger,
Fear,
Guilt,
Shame and anxiety

80. Emotional Support
The Victim May Suffer From
• Sleep disturbances
• Lack of appetite
• Depression and nightmare
• Physical pain

81. Counseling
Most victims find counseling helpful in
the process of recovering and moving
on with their life.
The care a patients initially receives -
influences her recovery from the
trauma suffered due to rape
Follow up is must

82. RAPE CRISIS CENTRE

83. SAFE (Sexual assault Evidence collection) Kit
Help Collect different Evidences
Contents:
Mannual to guide doctos – 21 pager
document to guide the doctor protocol
book containing forms
Form 1 : consent
Form 2 : medical history
Form 3 : sexual assault history
Form 4 : forensic examination

84. SAFE (Sexual assault Evidence collection) Kit
Help Collect different Evidences
Form 5: General exam & age estimation
Form 6 : Discharge slip
All forms have 2 copies
4 envelopes containing envelops –
11 Envelops (2A to 2K): body samples
8 envelopes (3A to 3H) : genital and
anal samples
Step – wise arrangement of all
envelops to prevent omissions

85. FILM
On Medical Examination of Rape
Victim Prepared by MOWCD/
IMA Youtube
https://www.youtube.com/watch?v=0MAwMISPYt0

86. 2013
RAPE Law amendment
at one year
No doubt picture will be
different 5 yrs hence
No Monitoring
Mechanism onground
No Attempt to Prevent
Failure of
Prosecution
No
Accountability
No
women Safety
Review
of

87. Please Remember
Girls can not stop rape just by changing
their own behavior
violent people never stop unless they are
Punished
Please join hands with Delhi
Gynaecologists forum’s campaign to
do great medical examination & care

88. Girls must learn
self defense
self defense
self defense

90. Thank You