J O U R N A L O F

CLINICAL
FORENSIC
MEDICINE
Journal of Clinical Forensic Medicine 13 (2006) 300–303
www.elsevier.com/locate/jcfm

Original communication

Victims of sexual offences:

Medicolegal examinations in emergency settings
Jorge Costa Santos MD, PhD *, Anabela Neves MD,
Marlene Rodrigues PhD, Paula Ferrão MD
Delegação de Lisboa do Instituto Nacional de Medicina Legal, Faculdade de Medicina de Lisboa, Rua Manuel Bento de Sousa,
n° 3, 1150-219 Lisboa, Portugal

Available online 23 August 2006

Abstract

The aim of the study was to present some data concerning the examinations of victims of sexual offences in emergency settings con-
ducted by medicolegal examiners of the Lisbon Department of the National Institute of Legal Medicine (NILM) over a two-year period
(2002–2003).
The study was based on 352 alleged victims of sexual offences referred by investigating police authorities and physicians working at
hospital emergency rooms. Examination records were reviewed and data collected according to the extended medicolegal protocol
adopted by NILM, which includes sociodemographic variables, and medical and laboratory findings.
The results show that examinations in emergency settings represented about 43% of the total examinations of victims of sexual
offences, 44% of them being performed at hospital emergency rooms. Victims’ ages ranged from a minimum of 93 days to a maximum
of 86 years. The mean age was 17.5 years. Females represented about 92% with a large over-representation of those aged from 0 to 19
years (61% of the total). Victims were mainly girls of school age (36%) or under 6 years old (25%). Offenders were male, referred to
mainly, as acquaintances/neighbours (32%), friends (24%) or cohabiting family members (20%), a large majority belonging to the victim’s
social or family circle (85%). Of the examinations requested as ‘‘urgent cases’’ only 61% were reported as having occurred within 72 h
prior to the examination. Traumatic lesions on the whole body were found in only 28% of the cases, while findings on the genitalia and/or
the anus were present in 31%. Medical and laboratory findings were in accordance with some sort of sexual offence in 34% of the cases.
Our findings show the great heterogeneity of the victims, with a high proportion of children as well as the interplay between exam-
ination requests in emergency settings and the need to define more accurate criteria and proceedings for legal authorities and physicians
who are usually the first line of intervention before specialists in legal medicine.
Ó 2006 Elsevier Ltd and AFP. All rights reserved.

Keywords: Victims; Sexual offence; Medicolegal examination; Emergency settings

1. Introduction Lisbon Department of the National Institute of Legal

According to Portuguese law, the examinations of vic-
tims of sexual offences in the Lisbon Metropolitan Area,
which comprises about a million inhabitants, are per-
formed by specialists in legal medicine who work at the
*
Corresponding author. Tel.: +351 2188 11850; fax: +351 2188 64493.
E-mail address: jcsantos@dlinml.mj.pt (J.C. Santos).
Medicine (NILM).1,2
In this geographic area, medicolegal examination
requests have increased greatly in the last few years, and
the objective of this article is to describe certain features
of a consecutive series of these examinations in emergency
settings, either at the Institute itself or at the six hospital
emergency rooms assisted by medical examiners of the
NILM, over a two-year period (2002–2003). Other studies
have shown that this kind of victim has different character-

1353-1131/$ - see front matter Ó 2006 Elsevier Ltd and AFP. All rights reserved.
doi:10.1016/j.jcfm.2006.06.003
 J.C. Santos et al. / Journal of Clinical Forensic Medicine 13 (2006) 300–303 301

istics according to the time between the sexual offence and Table 2
the examination.3–5 Place where examinations were conducted
Place where examinations were conducted n = 352 (%)
2. Material and methods Institute of legal medicine 197 55.97
Hospital emergency room 155 44.03
Among the 820 alleged victims of sexual offences (e.g.
rape, indecent assault and child sexual abuse) examined Table 3
by specialists in legal medicine working at the Lisbon Distribution by sex and age groups
Department of NILM at the request of the investigating Sex 0–9 10–19 20–29 30–39 40–49 50–59 >59
police authorities and physicians between January 1, 2002 n = 101 n = 137 n = 64 n = 28 n = 12 n=5 n=5
and December 31, 2003, there was 352 cases relating to
Male 15 10 2 2 0 0 0
emergency settings. In Portugal, in this setting, ‘‘emer- Female 86 127 62 26 12 5 5
gency’’ is commonly defined as being related to a sexual
offence occurring within 72 h prior to the examination
request. Table 4
These 352 consecutive cases were reviewed, and descrip- Marital status
tive data collected from the medicolegal records according Marital status n = 352 (%)
to the extended protocol adopted by NILM, which Single 306 86.93
includes information provided by authorities; clinical infor- Married 28 7.96
mation supplied by physicians whenever available; general Divorced/separated 12 3.41
Widowed 6 1.70
sociodemographic characteristics (sex, age, civil status,
profession, area of residence); history of sexual offence as
disclosed by the victims (place and details, number of Of the 352 cases considered, 169 in 2002 (60%) and 183
offenders involved, relationship, etc.); general details of in 2003 (34%) were related to emergency settings. Of those,
the victims’ health, mental state, menstrual history, etc.; 197 (56%) were performed at the Institute of Legal Medi-
general details of physical examination (the whole body is cine and 155 (44%) at the hospital emergency rooms situ-
examined for injuries, mud, blood or seminal stains); exam- ated in the NILM geographic area of intervention (Table
ination of the genitalia (bruises, scratches, and stains as 2).
well as other traumatic or natural lesions, state of the About 92% (323/352) of the cases were female victims
hymen and vaginal orifice, etc.); laboratory findings with a sex ratio equal to 0.09 (male:female). Ages ranged
(sperm, pregnancy test, toxicology, etc.), and medicolegal from 93 days to 86 years with a mean age of 17.6, a median
interpretation of the information, findings and injuries.6–8 age of 14.0 years, and a mode of 12.0 years (SD 13.4)
In cases of alleged child abuse, parents and/or other family (Table 3).
members, or caregivers were also interviewed. Descriptive As expected according to the victims’ mean age, the
statistics were created using the Statistical Package for large majority were single (87%) (Table 4). Students and
Social Sciences (SPSS 11) for Windows. children under 6 years represented 67% of the total, which
explains why only 21% of the victims had a professional
3. Results activity (Table 5).
3.1. General characteristics
Table 5
Employment/occupation status
During the years 2002 and 2003, a total of 820 medico-
legal examinations of victims of sexual offences were con- Employment/occupation status n = 352 (%)
ducted by specialists of the Lisbon Department of Children under 6 years 71 20.17
NILM: 284 in 2002 and 536 in 2003, which represent an Students 166 47.16
Employed 75 21.31
increase of about 89% (Table 1). This great and unusual
Housewives 6 1.70
increase was mainly related to a unique paedophilia inves- Other (non-active) 34 9.66
tigation involving more than a 100 male adolescents who
had been allegedly abused in a recent years and examined
by appointment. Table 6
Number of offenders
Table 1 Offenders n = 352 (%)
Number of examinations of victims of sexual offences by year
One 309 87.78
Year Total of examinations In emergency settings Two 26 7.39
n = 820 n = 352 (%) Three 6 1.70
2002 284 169 59.51 Four and more 7 1.99
2003 536 183 34.14 Unknown 4 1.14
302 J.C. Santos et al. / Journal of Clinical Forensic Medicine 13 (2006) 300–303

Table 7 Table 10
Relationship offender/alleged victim Findings related to the genitalia and/or anus
Relationship offender/alleged victim n = 352 (%) Medical and laboratory findings relating n = 352 (%)
to the genitalia and/or anusa
Cohabiting family member 69 19.60
Other family member 34 9.66 Recent penetration of genitalia 47 13.35
Friend/lover 84 23.86 Recent traumatic lesions without penetration 39 11.08
Acquaintance/neighbour 113 32.11 Recent penetration of anus 28 7.96
Stranger 35 9.94 Compliant hymen without traumatic lesions 36 10.23
Unknown 17 4.83 Laboratory findings (spermatozoa, etc.) 81 23.01
Other findings with medicolegal significance 16 4.55
a
In the large majority, the sexual offence will have been Some of these findings were cumulative, which means that one or more
of the items listed above were found in the same victim.
perpetrated by a single offender (88%), although in 11%
of the cases two or more perpetrators were indicated (Table
6). According to the alleged victim’s statement and other Only 61% of the alleged victims reported a consistent
available information, the relationship between the victim history of sexual abuse or assault. The examination showed
and the offender was categorized as: ‘‘acquaintance/neigh- some sort of traumatic lesions on the whole body (bruises,
bour’’ in 32% of the cases; ‘‘friend/lover’’ in 24%; ‘‘cohab- scratches, wounds, etc.), except the genitalia and the anus,
iting family member’’ in 20%; ‘‘other family member’’ in in only 28% of the cases, almost all related to those exam-
10%, and ‘‘stranger’’ in the other 10% (Table 7). The rela- ined within 72 h of the offence (Table 9).
tionship was closely associated with the age groups consid- The medical and laboratory findings related to genitalia
ered. In fact, children of less than 12 years of age were and/or anus are shown in Table 10. Signs of recent penetra-
more frequently abused by single family members, cohabit- tion of the genitalia were identified in 13% of the cases;
ing or not, and neighbours, while in adolescents and adults recent traumatic lesions without penetration in 11%; recent
sexual offences were mainly related to friends, boyfriends penetration of the anus in 8%; compliant hymen without
and lovers, or acquaintances. Unknown and multiple per- traumatic lesions in 10%; positive laboratory findings
petrators were almost exclusively associated with adult (spermatozoa, etc.) in 23%, and other findings (STD, symp-
females. tomatic genital candidiasis, macroscopically visible condy-
lomas and/or specific genital skin disorders, etc.) in 5%.
3.2. Main medicolegal proceedings and findings Medicolegal conclusions resulting from a comprehensive
and integrated interpretation of all the available informa-
As was said before, the reason for and urgency of the tion, victims’ statements of offence and examination, and
medicolegal examination depend on the request of the laboratory findings were categorized as shown in Table
investigating police authorities or the hospital physicians. 11. There was no evidence of sexual offence in 26% of the
On this basis, the time between the sexual offence and the cases, which was admitted as possible in another 39%,
examination showed considerable variability: 27% were and as probable in the remaining 34%, of which 27% pre-
conducted less than 12 h after the alleged offence; 17% sented a clear evidence.
between 12 and 24 h; 11% between 24 and 48 h; 6%
between 48 and 72 h, and 28% more than 72 h. In the 4. Discussion
remaining 11% of the cases there was not sufficient infor-
mation to establish the time (Table 8). This is a preliminary report on the medicolegal examin-
ations of alleged victims of sexual offences in emergency
Table 8 settings. The group is heterogeneous with regard to sexual
Time between sexual offence and examination offence type (child abuse, sexual assault, rape, etc.), under-
Time between sexual offence and examination (h) n = 352 (%) lying circumstances, age of the alleged victims, and the
<12 95 26.99 entity responsible for the examination request (investigat-
12–24 61 17.33 ing police authorities or physicians).
24–48 37 10.51
48–72 22 6.25
>72 99 28.13
Unknown 38 10.79 Table 11
Medicolegal examination conclusion
Medicolegal examination conclusion n = 352 (%)
Table 9
Traumatic lesions to the whole body No evidence of sexual offence 93
26.42
Traumatic lesions to the whole body n = 352 (%) Possible sexual offence 138
(except genitalia and anus) 39.20
Yes (bruises, scratches, wounds, etc.) 97 27.56 Probable sexual offence or clear evidence 121
No 255 72.44 34.38
 J.C. Santos et al. / Journal of Clinical Forensic Medicine 13 (2006) 300–303
Examinations in emergency settings relating to a
two-year period (2002–2003) represented about 43% of
the total examinations conducted on victims of sexual
offences. Of those, 56% were performed at our Institute of
Legal Medicine while the remaining 44% took place at an
emergency hospital room, although they were conducted
by a specialist in legal medicine from our Department.
Victims’ ages ranged from 93 days to 86 years, with a
mean age of 17.6, a median age of 14.0 years, and a mode
of 12.0 years. About 92% (323/352) of the cases were
female victims with a sex ratio equal to 0.09 (male:female)
and a large over-representation of those aged 0 to 19 years
(61%). Victims were mainly girls of school age (36%) or
under 6 years (25%). It must be noted that 53% of the cases
were infants (people under 14 years according to Portu-
guese penal law).
Offenders were male, and were mainly reported to be
acquaintances/neighbours (32%), friends (24%), or cohab-
iting family members (20%). Nevertheless, a large majority
of offenders were reported to belong to the victim’s social
or family circle (85%).
Of the 352 examinations requested as ‘‘urgent cases’’,
only 61% were related to sexual offences allegedly occur-
ring within 72 h prior to examination, which has particular
significance because it is not absolute in concordance with
the time definition more commonly accepted for these
situations. Patient distress, time constraints and lack of
expertise in managing these situations can explain the
false-positive emergencies reported by legal authorities
and hospital physicians.
General body trauma was more frequent in the series by
Riggs et al. (67%)11 and Grossin et al. (44%)12 than in our
study (28%). This difference could be explained by the dif-
ferent characteristics of the victims examined, especially by
a higher number of children in our series. Similar to the
results of Grossin and co-workers, there were more physi-
cal injuries in our study than genital injuries. Vaginal pen-
etration was the most frequent single physical evidence of
sexual assault (13%). Findings in accordance with anal pen-
etration were found in 8% of the cases. As expected, the fre-
quency of genital injuries was low in the allegedly abused
children (2% of the total and 5% of the children under 14
years).
Physical evidence, perineal injury, sexually transmitted
diseases, or seminal fluid was present in only 136 (39%)
of the cases. Detection of spermatozoa was found in 21%
303
of the cases. As has been shown in other studies, physical
findings may be absent or non-specific in nature, superficial
injury may be expected to heal rapidly and without scar-
ring, sexually transmitted diseases are often not present,
and detection of seminal fluid is very time-dependent.9–13
According to the medicolegal reports, conclusions indi-
cated a possible sexual offence in 39% of the cases and a
probable one in 34%. It must be noted that medicolegal
conclusions result not only from the physical evidence,
but also from a comprehensive and integrated interpreta-
tion of all available information, detailed history of the sex-
ual offence, physical examination, and laboratory findings.
Our pilot study illustrates the interplay between forensic
assessment in emergency settings and the need to improve
the legal and medical management of sexually assaulted
or abused victims. They require a degree of expertise not
associated with other offences, which justifies the imple-
mentation of multidisciplinary teams specially trained for
their assessment and management.
References
1. Decreto-Lei n° 96/2001, de 26 de Março.
2. Lei n° 45/2004, de 19 de Agosto.
3. Edgardh K, von Krogh G, Ormstad K. Adolescent girls investigated
for sexual abuse: history, physical findings and legal outcome. Forensic
Sci Int 1999;104:1–15.
4. Adams JA, Harper K, Knudson S, Revilla J. Examination findings in
legally confirmed child sexual abuse: It’s normal to be normal.
Pediatrics 1994;94:310–7.
5. Linden JA. Sexual assault. Emerg Med Clin North Am 1999;17:685–97.
6. American Academy of Pediatrics Committee on Child Abuse and
Neglect. Guidelines for the evaluation of sexual abuse of children:
subject review. Pediatrics 1999;103(1):186–90.
7. Young WW, Bracken AC, Goddard MA, Matheson S. Sexual assault:
review of a national model protocol for forensic and medical
evaluation. Obstet Gynecol 1992;80:878–83.
8. Atabaki S, Paradise JE. The medical evaluation of the sexually abused
child: lessons from a decade of research. Pediatrics 1999;104:178–86.
9. De Jong AR, Rose M. Legal proof of child abuse in the absence of
physical evidence. Pediatrics 1991;88:506–11.
10. Christian CW, Lavelle JM, De Jong AR, Loiselle J, Brenner L, Joffe
M. Forensic evidence findings in prepubertal victims of sexual assault.
Pediatrics 2000;106:100–4.
11. Riggs N, Houry D, Long G, Murkovchick V, Feldhaus KM. Analysis
of 1076 cases of sexual assault. Ann Emerg Med 2000;35:358–62.
12. Grossin C, Sibille I, Grandmaison G, et al. Analysis of 418 cases of
sexual assault. Forensic Sci Int 2003;131:125–30.
13. Banaschak S, Brinkmann B. The role of clinical forensic medicine in
cases of sexual child abuse. Forensic Sci Int 1999;99:85–91.