Forensic Science International 242 (2014) 293–298

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Forensic Science International

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Technical note

Evaluation of anogenital injuries using white and UV-light among adult

volunteers following consensual sexual intercourse
Minna Joki-Erkkilä a, * , Juha Rainio b , Heini Huhtala c , Aki Salonen d, Pekka J. Karhunen e
a
Departments of Gynecology and Obstetrics and Forensic Child Psychiatry, Tampere University Hospital, Finland
b
Department of Forensic Medicine, School of Medicine, University of Tampere, and Institute for Health and Welfare, Finland
c
School of Health Sciences, University of Tampere, Finland
d
Crime Scene Investigation Unit, Pirkanmaa Police Department, Tampere,Finland
e
Department of Forensic Medicine, School of Medicine, University of Tampere and Fimlab Laboratories, Tampere University Hospital Region, Finland

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: New clinical forensic examination techniques for sexual assaults have not been introduced
Received 23 September 2013 over the last few decades. We evaluated the benefit of ultraviolet light compared to white light for
Received in revised form 20 December 2013 detecting minor anogenital injuries and scars, following consensual sexual intercourse among adult
Accepted 4 June 2014
volunteers.
Available online 12 June 2014
Design: A prospective study comparing female genital findings utilising white and ultraviolet light. A
colposcopy with photographic documentation was used.
Keywords:
Setting: Personal invitation to healthcare students, hospital employees or acquaintances to volunteer for a
Consensual intercourse
Submucosal hemorrhages
gynecological examination, with a focus on clinical forensic aspects.
Genital scars Participants: Eighty-eight adult female volunteers were recruited for the study. The examination was
Genital injuries performed after consensual intercourse. Age ranged from 20 to 52 years (median 26.5 years).
Ultraviolet (UV)-light Main outcome measures: Presence of acute findings and scars in the genital area using white and UV-light.
Sexual assault Results: Acute genital injury rate was 14.8% under white light colposcopy and 23.0% using UV light.
Submucosal hemorrhages in the genital area were documented significantly better under UV-light than
white light (14.9% vs. 6.8%; p = 0.016), whereas petechiaes (4.5%) and abrasions (2.3%) were detected using
either method. UV-light revealed significantly more often delivery-associated genital scars compared to
white light (39.8% vs. 31.8%; p = 0.016). Furthermore, 10 out of 31 (33.3%) women had no residual
anogenital skin or mucosal surface findings, despite a prior episiotomy or rupture of the vaginal outlet
wall during delivery, supporting its enormous ability to heal even after major trauma.
Conclusions: UV-light may provide additional value for the evaluation of physical findings in clinical
forensic examinations after sexual assault, and is especially useful in detecting otherwise invisible early
submucosal hemorrhages and scars.
ã 2014 Elsevier Ireland Ltd. All rights reserved.

1. Introduction intercourse in these studies is unbelievably wide: 5–61%. This may

When evaluating and analyzing physical findings in victims of
sexual assault for clinical forensic purposes, it is very important to
know how often lesions occur through consensual intercourse. To
our knowledge, the current literature contains eight studies
investigating external genital injuries after consensual intercourse
[1–8]. Variation in genital injury prevalence after consensual
* Corresponding author at: Departments of Gynecology and Obstetrics and
Forensic Child Psychiatry, Tampere University Hospital, P.O. Box 2000, Tampere
33521, Finland. Tel.: +358 500 5557760.
E-mail address: minna.joki-erkkila@pshp.fi (M. Joki-Erkkilä).
partly result from heterogeneous participant recruitment, due to
examination timing, misreporting other medical conditions as
acute genital findings, a lack of follow-up, and the use of different
examination and visualization techniques. Furthermore, injury
definition, participant inclusion and exclusion criteria were not
always clear.
Three clinical forensic medical examination methods are
currently used for the evaluation of the external genitalia and
hymen in sexual crime allegations: (1) direct visual inspection with
labial separation and labia traction, (2) colposcopy (use of a
binocular magnifying microscope with a light source and attached
camera for photographic documentation), which improves
microtrauma identification [9], and (3) the application of contrast

http://dx.doi.org/10.1016/j.forsciint.2014.06.005
0379-0738/ ã 2014 Elsevier Ireland Ltd. All rights reserved.
294 M. Joki-Erkkilä et al. / Forensic Science International 242 (2014) 293–298

media to identify microscopic injuries [1,10]. For example toluidine
blue, a nuclear stain, adheres to abrasions and microlacerations
and highlights acute mucosal or skin injuries during forensic
examinations [10].
Over the last few decades, no new clinical forensic examination
methods have been introduced for identifying physical anogenital
trauma in sexual assault cases. In the 1990s, UV-light was
suggested to become a routine part of medico-legal examinations
to evaluate stains and skin trauma [11], but its use has not caught
on. Recently, crime scene investigators have applied UV-light to
provide forensic evidence of physical skin traumas not be seen
under white light at autopsies of crime victims.
UV-light is electromagnetic radiation with a shorter
wavelength than visible light. UV-light is either absorbed or reflected
by various biochemical compounds that are part of the healing
process in skin tissue [12,13]. Some bruises deep in the tissue, or
under thick areas of skin, cannot be seen under inspection with white
light. UV-light detects the release of blood cells and shows bruises in
a dark colour. The possibility of using UV-light in surviving sexual
assault victims has not yet been exploited.
The aim of this study was to determine whether UV-light might
be a useful tool in clinical forensic evaluations and evidence, for the
documentation of acute and old trauma in the anogenital area. The
primary end point was to compare the presence or absence of
injury under white or UV-light. Some associated factors possibly
influencing these physical findings are also analysed.
2. Material and methods
2.1. Participant recruitment
Female volunteers, comprising medical or laboratory students,
hospital personnel or acquaintances, were invited to participate in
a gynecological examination from May 2008 to December 2009,
after consensual intercourse, through personal invitation or
collective invitation after a lecture. Inclusion criteria were age
18 years or more, heterosexual intercourse, willingness to fulfil a
detailed questionnaire (25 questions) on personal and sexual life,
and signed consent to photography. Ninety caucasian women
volunteered, but two declined the use of photography and were not
included in the study. Finally, 88 participants were included in the
study.
The study protocol was approved by the Pirkanmaa District
Hospital’s Ethics Committee (R08018). Written consent was
required for attendance in the study, photography and the use
of photographs for teaching or publication purposes. No data from
patient’s medical records were collected.
2.2. Data collection and analysis
All 88 volunteers were examined in the supine position using
separation and traction technique of the external genitalia. For the
colposcopy, Olympus OCS-500 colposcope and white light source
was used with the magnification at 3.7. In 86 volunteers the
colposcope attached camera (4 Olympus high quality ED wide
zoom lens, Olympus C-5060 wide zoom, 5.1 megapixels) was used
for the photographic documentation. In two volunteers a Canon EOS
5D camera was used for documentation due to technical problems.
One gynecologist (MJ-E) performed all medical examinations.
Colposcopy under white light was performed, followed by UV-light
(368 nm) examination. During the UV-light examination the lights in
the examination room were turned off. The extragenital area and
hymen were photographed and the findings were filled separately on
the study information form. The detected anogenital injuries were
categorized into submucosal hemorrhages, petechiaes, ecchymosis,
bruises, abrasions, fissures, lacerations, and scars (Table 1).
Medical and sexual history was collected via a form filled by the
volunteer. The time of the intercourse and the medical examination
were recorded. Information about sexual activity in the last two
weeks and in general, contraception use, last menstrual cycle and
length, and the use of tampons, as well as the duration of the studied
intercourse, use of different positions, lubricants, and possible
discomfort in the genital or other parts of the body were all recorded.
Additionally, information about parity, obstetrical procedures
during delivery(-ies), past occurrences of genital-anal trauma, and
medical gynecological operations were gathered. Former sexual
victimisation was recorded if answered in the questionnaire.
2.3. Technical details and precautions of UV-light
White and ultraviolet (UV) light (368 nm, prototype, Obelux)
were used to detect physical findings during UV-light use, the
volunteer either wore eyeglasses, or kept her eyes shut to avoid
exposure to the UV-light. The radiation exposure varies by
distance; 1 m: 6.7 mW/cm2, 0.5 m: 27 mW/cm2, 0.1 m: 677 mW/
cm2. According to regulations by the Social and Health Ministry of
Finland, the current recommendation (294/2002, 4:11) for the
maximum length of exposure to this type of UV-light is 50 J/m2
(180–400 nm) per day. Anogenital UV-light examination was
accomplished within a minute for all cases.
2.4. Statistical considerations
Categorical variables are given as frequencies and percentages.
Mean, range and SD are given for age and time variables.

Table 1
Anatomic structures and definitions for physical findings.

Finding or anatomic Definition

structure

Submucosal hemorrhage A small hemorrhage under mucous membrane

Petechiae A pinpoint, flat, round spot of blood under mucosa or skin, caused by intradermal or intramucosal bleeding
Ecchymosis A mucous membrane or skin discoloration caused by the escape of blood into the tissues from ruptured blood vessels
Bruise or "contusion" An traumatic injury of the soft tissues which results in breakage of the local capillaries and leakage of red blood cells
Abrasion A mucous membrane or skin excoriation caused by the removal of epidermal layer and with defined edge
Fissure A superficial partial split in mucous membrane or skin, which does not extend to subcutaneous tissue
Laceration A skin or mucosal wound with separation of the connective tissue elements and it may extend to subcutaneous tissue. None of the skin or
mucosa is missing, but it is just separated
Scar An area of fibrous tissue that replaces normal skin after injury
Hart's line A line between non-keratinized and keratinized squamous epithelium
Vestibule The area between hymen and Hart's line
 M. Joki-Erkkilä et al. / Forensic Science International 242 (2014) 293–298
Photo 1. In our study, this was the biggest submucosal haemorrhage (black arrow) detected on the right vestibulum, which was not seen under white light and detected with
UV-light nine hours and 45 min after consensual intercourse. Residual anatomic changes and a white scar (white arrow) from an episiotomy were detected under UV-light but
only the residual anatomic changes inside the Hart’s line were seen under white light.
Categorical associations were assessed using Fisher’s exact test.
Differences in the ability to detect scars with UV-light and white
light were analyzed using the McNemar test, after combining
responses of “no” and “unspecified findings”. PASW Statistics v18.0
was used for data analysis.
3. Results
3.1. Participant characteristics
The median age of the 88 participants was 26.5 years (range 20–
52 years). All volunteers had penile vaginal penetration. Only one
sexual position was used in 57% of the volunteers’ studied
intercourse situations. One volunteer had anal penetration. The
median examination time from the consensual intercourse studied
was 42 h (range 1.5–183.2 h).
3.2. Presence of acute anogenital injuries under white and UV-light
The acute genital injury rate was 14.8% (13/88) under white
light colposcopy and 23.0% (20/87) using UV light. One volunteer
could not be evaluated by UV light, due to vulval erythrasma, which
caused excessive coral red fluorescence. Submucosal hemorrhages
were documented under white light in 6.8% (6/88) of cases, and
14.9% (13/87) under UV-light (Photo 1). Seven out of thirteen
(53.8%) submucosal hemorrhages would have been missed
without the UV-light (p = 0.016) (Fig. 1, Photo 2). Petechiaes were
detected in four (4.5%) volunteers using both white and UV-light.
Four participants had unspecific mucosal redness. Mucosal
Fig. 1. Genital acute injuries and scars detected by white and UV-light.
295
abrasions were documented in 2/88 (2.3%) participants, one in
the labia minora and the other in the posterior fourchette. One
small superficial acute laceration (4 mm) was documented in the
posterior fourchette. UV-light showed no advantages over white
light in detecting abrasions. Condyloma accuminatum was not
highlighted or illuminated under UV-light. No bruises, ecchymosis
or deep lacerations in the genital area, nor acute or residual injuries
in the anal area were documented.
Submucosal haemorrhages were detected on average 49.0 h
(range 13.5–133.25) following intercourse under white light and
45.5 h (8.75–133.25) under UV-light, suggesting haemorrhages
were seen slightly (n.s.) earlier with UV-light than white light. UV-
light did not detect petechiaes earlier than white light, but
confirmed their existence more definitively after several days.
Positive findings for genital hemorrhages within 24 h were 12%
(3/25) in white light and 24% (6/25) in UV-light; within 24–48 h
14.3% (3/21) in white-light and 19% (4/21) in UV-light, within 48–
72 h 2/16 in white light and 4/16 in UV-light, within 96–120 h 1/8 in
UV-light and within 120–144 h 2/4 in both lights.
3.2.1. Possible factors affecting acute genital findings
The median coital duration was 15 min (range 2–60). All acute
findings under either white or UV-light were detected in cases
where the intercourse lasted less than twenty minutes. Coital
frequency per week (mean 3.2, range 1–6; SD 1.2) did not influence
the frequency of acute mucosal findings, even when age was
considered. Lubricants were used in 9% (n = 8) volunteers, and none
showed acute findings in the anogenital area. Delivery pathway or
former episiotomy did not have an effect on acute findings. No
submucosal hemorrhages were identified in the 30–39 age
category after consensual intercourse under white light. Submu-
cosal hemorrhages were more prevalent in over 49 year old
women after consensual intercourse under white light (Fig. 2).
Submucosal hemorrhages were more commonly seen among
users of progestagen contraceptives (pills or intrauterine device)
compared to non-hormonal and combined oral contraceptives, but
with no statistically significant difference.
3.3. Genital scars under white and UV-light
Scars in the genital area were visible in 35 (39.8%) volunteers
under UV-light and 28 (31.8%) under white light (p = 0.016). Of the
scars, 7 (20%) would have been missed without the use of UV-light
(Fig. 1, Photo 3). Six of these seven scars had an even, regular
mucosal surface and no residual anatomical changes detected
under white light.
 296 M. Joki-Erkkilä et al. / Forensic Science International 242 (2014) 293–298

Photo 2. Thirteen and a half hours after consensual intercourse, submucosal haemorrhages (black arrows) were detected in the vestibulum using both lighting methods, but
seen much clearer under UV-light.

same colour as the mucosa, and 5 (13.9%) observed with vascular

changes.

3.3.1. Possible causes for genital scars

Fig. 2. Percentages of genital submucosal hemorrhages detected under white and
UV-light after consensual intercourse according to age.
Genital scars differed in colour. Under white light in mucosal tissue
inside the Hart’s line, scars were seen as white, redder than mucosa
with vascular changes, or the same colour as the mucosa. Outside
the Hart's line, skin tissue scar colour varied from white, darker
than, or the same colour as the skin, or a combination of these in
the genital area. Under UV-light, scars were seen as either white or
darker than the mucosal or skin tissue, regardless of the Hart's line
location. Of all scars, 13 (36%) were white in colour, 12 (33.3%) the
Fifty-two volunteers were nulliparous (59.1%), 36 (40.9%)
parous with one to five deliveries, of which two vaginal deliveries
were without episiotomy and 3 Caesarean sections. Genital scars
were detected in one (1.9%) nulliparous woman and 34 (94.4%)
parous women. A regular or normal appearing mucosal surface
was seen in all nulliparous females. Ten out of thirty-one (33.3%)
women with a history of episiotomy or ruptured vaginal outlet wall
during delivery, had complete healing based on the presence of a
regular anogenital skin and mucosal surface. In two volunteers,
one with a history of a vaginal delivery without episiotomy and
another with episiotomy, visible scars were not detectable under
either white or UV-light.
Prior accidental genital trauma with bleeding was reported by
16 (18.2%) of the 88 volunteers. Two of these were cycling traumas,
one straddle injury, one coital injury and one rape, and the
remaining 11 did not specify the cause of the trauma. Of these, 6/16
had a scar. Apart from delivery-associated scars, one scar was
caused by a vaginal operation and one scar by a previous trauma. In
nulliparous female, 10 reported genital traumas did not leave
residual genital findings.

Photo 3. An old episiotomy scar showed only some vascular changes under white light. The scar is observed using UV-light (white arrows).
 M. Joki-Erkkilä et al. / Forensic Science International 242 (2014) 293–298 297

Prior anal trauma with bleeding was reported in six (6.9%)
volunteers. Two of these were victims of sexual abuse, of which
one reported violent anal penetration. None had visible scarring
under white or UV-light.
Former sexual assault was reported in 7/87 (8%) of the
volunteers. One volunteer did not answer the question. At the
time of the sexual assault, five out of seven participants were under
18 years old, and two were adults (20 and 23 years). In three cases
of child sexual abuse, the victimization of sexual abuse lasted over
a long period of time (3–6 years). Both adult victims suffered
penetrative rape. Additionally, two volunteers were unsure
whether they were sexually assaulted as teenagers.
4. Discussion
To our knowledge, this is the first comparative study
investigating the use of white and UV-light for acute findings
and scars in the anogenital area after consensual intercourse.
4.1. Acute genital findings after consensual intercourse using white or
UV-light
More than half (53.8%) of submucosal hemorrhaging after
consensual intercourse would have been missed without the use of
UV-light. UV-light tended to detect submucosal hemorrhages a bit
earlier than white light. UV-light may detect haemorrhages earlier
due to the rupture of veins and release of blood cells into tissue,
which remains deep under the mucosa or skin for some time, and is
invisible under white light. All acute petechiaes were visible under
both lighting methods, but UV-light was helpful after several days.
As previously mentioned, submucosal hemorrhages and genital
ecchymosis are difficult to see without careful inspection and
magnification [3], thus according to our results the use of UV-light
may help in observing these findings in the genital area.
Our study identified submucosal hemorrhages up to 5.6 days
after consensual intercourse under white and UV light. In a recent
study, systematic follow-up of healing was able to detect genital
lesions for 4.5 days [8]. This supports the inclination that clinical
forensic examination and documentation of acute findings should
be done up to 6 days after a suspected sexual assault in adults.
Our rate of minor acute anogenital injuries after consensual
intercourse is consistent with some earlier reported studies [1–3,7]
using white light colposcopy, although some studies report higher
acute genital injury rates of 30–61% [1,4,6,8] (Table 2). This higher
prevalence could be due to the inclusion of unspecific acute genital
injuries, as concluded by Sommers’ review [14] that suggested a
lack of consensus in defining lesions, variation in defining injury
sites and furthermore a deficiency in differential diagnostics may
cause these discrepancies.
Recent adult studies comparing examination techniques after
consensual intercourse revealed direct visualization almost as
good as colposcopy for detecting abrasions (2–8% vs. 5–8%), but
less effective than colposcopy detecting tears or lacerations
(18–32% vs. 17–42%) [6,8]. The high prevalence of genital tears
and lacerations in some earlier studies may be due to insufficient
differential diagnostics of extragenital mucosal findings, a lack of
follow-up or inaccurate definitions. Genital mucosal findings
caused by some gynecological, gastrointestinal, or dermal
diseases may be difficult to distinguish from fissures or
lacerations caused by sexual intercourse and should be
re-evaluated in a follow-up visit. Future studies require consen-
sual intercourse follow-ups and more accurately defined severity,
depth and size measurements of specific lesions after consensual
and non-consensual intercourse.
4.2. Genital scars detected using white and UV-light
In our study, scars were detected significantly more often under
UV-light than white light, resulting in every fifth genital scar
potentially being missed if white light alone was used. In a study by
Slaughter et al. [3], anogenital scarring from detected genital
lacerations in sexual assault follow-up visits (average 25 days;
range 4–56) was not observed. Our study is the first to present a
new forensic purpose for the use of UV-light: anogenital scar
detection.
Surprisingly, every third (10/31) vaginal delivery and episiot-
omy had a regular mucosal surface. Of the scars missed in white
light, only one out of seven (14.3%) evoked a suspicion for a scar
because of the irregularity of the mucosal surface or residual
anatomic changes. Two participants who had undergone vaginal
deliveries had no visible scars under white or UV-light,
supporting earlier studies documenting the enormous healing
abilities of genital mucosal and skin tissue after documented
trauma [15–19]. This should be taken into account in the

Table 2
List of previous studies with acute external genital findings after consensual vaginal intercourse, compared to the present study.

n Age range, Time frame, Acute genital Acute genital findings (n) Clinical examination methods
years hours trauma rate (n)

Lauber et al. 22 women 48 4.5% Laceration (1) Toluidine blue technique
1982a
Norvell et al. 18 23–35 72 11.1% (2) Teleangiectasia (7), broken blood vessels Colposcope and Lugol's solution
1984a 6 61.1% (11) (2), microabrasions (2)
Slaughter et al. 75 18–48 24 11% (7) Ecchymosis, tear, abrasion Colposcopy and photography
1997b
Anderson et al. 46 21–45 24 30% Abrasions, tears, ecchymosis, redness Colposcopy, toluidine blue technique
2006a
McClean et al. 68 30 48 6% (4) Bruises (3), Laceration (1), abrasion (1) Wall mounted circular magnifying glass with
2010a incorporated lamp surround
Zink et al. 120 >20 24 55% Tears, abrasions, ecchymosis, redness Visual inspection, colposcopy, toluidine blue
2010a technique
c d
Astrup et al. 98 29–40 <48 34%, 49% , 52% Lacerations (49)d , abrasions (7)d, Naked eye, colposcopyc , or toluidine blued
2012a hematoma (3)c
Present studya 87 20–52 <184 14.8%, 23.0%e Submucosal hemorrhage, Petechiae, Colposcopy and photography either by white or
abrasions, laceration UV-lighte
a
Prospective study.
b
Retrospective study.
c
Colposcopy.
d
Toludine blue.
e
UV-light.
298 M. Joki-Erkkilä et al. / Forensic Science International 242 (2014) 293–298
criminal–legal process to avoid misunderstandings in sexual
assault cases.
Scars differed in colour depending on the light detection method
used and the site of the lesion. One third of extra genital mucosal
tissue scars were the same colour as the mucosa, revealing UV-light
as a useful tool for identifying these lesions. We also observed that
stretching the tissue made the scar appear more apparent.
4.3. Alternative medical or non-medical considerations of physical
findings under UV-light
Interpretation of UV-light physical findings requires discretion, as
alternative medical or non medical causes must be considered. A
physical finding such as accentuation in the mucosal or skin area can
be caused by sexual abuse, trauma, medical operations, shadows,
blood, moles, venous enlargements, or healed infections (e.g.,
Varicella). Additional considerations are that UV-light causes the
skin to fluoresce a coral red color in erythrasma, and the fluorescence
of pubic hair may interfere with interpretation of physical findings. In
sexual assault cases, follow up examinations are recommended to
evaluate the cause(s) of acute and intermediate medical findings also
in UV-light. Consideration of differential diagnosis is essential for any
physical finding.
4.4. Study limitations
Limitations to our study include the small number of
participants, lack of follow-up and independent peer-review.
One examiner provided study consistency, but the lack of a
comparative interpretation is definitively a limitation. Only one
female with a submucosal hemorrhage had a control visit in a week
for another reason, and the earlier identified submucosal hemor-
rhage had disappeared, but another one was seen in a different
location. There is also a need for further studies to compare UV-
light on different skin pigments.
5. Conclusion
UV-light may provide additional help for visualising and
documenting acute submucosal hemorrhages, petechiaes and
scars in the anogenital area. When sexual assault is suspected, it is
important to consider doing an acute clinical examination up to 6
days because injury can still be present.
Acknowledgements
The authors thank Mervi Seppälä and Sari Tuomisto for their
assistance during the examinations and Eloise Mikkonen for
editing English.
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