by Valerie Sievers & Diana Faugno
ANYONE WHO REMEMBERS watching the movie My Cousin Vinny (Lynn 1992) knows how a
photograph might provide definitive findings during a trial. In the film, an inexperienced
attorney, Vincent “Vinny” Gambini travels to a small southern town with his
fiancée, Mona Lisa Vito, to represent his cousin in a murder case. Mona Lisa’s continuous
picture taking of the surroundings of the community with an inexpensive pocket
camera causes frustration throughout the film, but eventually produces a photo that
holds the key to the murder case.
on an organization listserv, several questions were posted regarding the
utility and necessity of photo-documentation as part of a medical forensic exam
for patients who have experienced violence, specifically photo-documentation of
genital anatomy and genital injuries. Rationale for omitting or limiting genital
photos included: “I didn’t see any injury when I observed the patient’s genital
region,” “The victim advocate suggested photos of the genital region would be
re-traumatizing,” and “I’m not familiar with the camera system so I don’t use
use of photography in health care is referred to in the literature by several
terms, including clinical photography, medical photography, medical-legal photography,
and forensic photo-documentation. Photo-documentation in health care has been widely
used in a variety of clinical practice areas including dermatology, wound and burn
care, surgery, gynecology, pediatrics, emergency medicine, clinical education,
and research. Reasons for using a camera to address the health-care needs of
patients seen in an acute care setting like an emergency department include:
the last several decades, photo-documentation in the care of patients affected
by sexual abuse and assault has become standard practice and utilized by
forensic-nurse examiners and child-abuse pediatricians to document both body
surface and anogenital injuries.
practice of forensic nursing involves numerous areas of specialization. The key
to excellent practice in these varied areas is proper and complete documentation.
According to Speck & Faugno (2013), complete and accurate identification of
anatomy, of injury, as well as documentation of genital injuries after sexual
assault are three of the most important forensic functions of the forensic
nurse examiner in sexual assault care.
the SANE/forensic-nurse examiner uses photography consistently in the
evaluation of patients affected by violence—for example, taking photographs of
all patients, whether injured or normal—credibility of the documentation
improves and challenges of bias (e.g., denial of important information to the
criminal justice processes) are minimized. However, if the forensic-nurse
examiner determines that there is no injury or has a policy to not photograph
normal genitalia, or deletes “bad” photographs, the credibility of the forensic
nurse and the documentation is undermined and the forensic nurse examiner and
the medical record is open to challenges in criminal justice proceedings (Ernst
et al. 2011).
documentation of physical characteristics, a pattern, or other physical
evidence is required, photography should be used to supplement and enhance
other forms of documentation (Zercie & Penders 2013).
are demonstrative evidence. Demonstrative evidence serves to illustrate, demonstrate,
or help to explain oral testimony. Photographs are not likely to be admitted as
evidence if there is no reference to images in the medical-forensic exam record,
and they may not be admitted as evidence if the medical forensic exam record
does not include narrative and diagrammatic documentation of specific injuries.
The photographs or digital images and the medical-forensic record supplement
and corroborate each other. Photography is a tool that can serve to amplify
nursing documentation (Pasqualone 2011).
are currently several photo-documentation protocols available for use in the
clinical arena which focus on the comprehensive process of photography of body
surface injuries, injuries in older adults, or injuries associated with non-fatal
strangulation (Faugno et al. 2020; Bloemen et al. (n.d.), SDFI
Telemedicine 2020). At present, there is not a standardized protocol that outlines
the detailed anogenital photo-documentation process in a patient who has been
sexually assaulted or abused. The authors intend to propose a
standardized approach to anogenital photography as part of the medical forensic exam for the
adult or adolescent patient who has been sexually assaulted or abused and
develop a photographic protocol for forensic health-care professionals.
a trauma-centered approach to the patient as part of the medical forensic exam
will include obtaining both written and verbal consents to photograph, ensuring
patient privacy and dignity, and communicating about the exam and photographic
process. Appropriate patient identification should include using a label or
book-end cards with the patient’s identifying demographic information at the
beginning and end of the series of photographs. The next steps in comprehensive
anogenital photo-documentation should include:
An “orientation” photograph of the vulva that depicts the entire region from the
mons to the anal area. This photo should be done before any cleaning, swabbing
or manipulation of the genital tissue.
Sequential photos of the vulva in two to three sections. This might also
include several images at varying levels of magnification or distance. Photos should
include both labia majora and minora, and the crease between the majora and
A focused photo of the region of the posterior fourchette and fossa navicularis
(in adolescents). This is the area where subtle injury is often seen, and it
should be photographed prior to rigorous separation and traction
techniques, application of a cell stain as Toluidine Blue, or the insertion of
Applying labial separation and traction, a photo of the clitoris and clitoral
A photo of the urethra and periurethral area.
A photo of the hymen tissue. In the child-bearing patient with estrogenized hymen
tissue, an obstetric swab or air-filled urinary catheter balloon should be
used to evaluate the circumference of the hymen tissue. This step is typically
done after the collection of any specimens.
A photo of the fossa navicularis.
A photo of the posterior fourchette.
A photo of the anus and perianal area.
During speculum insertion, photos should be taken of the vaginal walls
bilaterally, and the cervix and cervical os.
of genital injury taken with a colposcope and attached digital camera should
images at varying levels of magnification, while a digital camera and macro
lens can be used to capture images at mid-distance, close-up, and extreme close-up
photos if needed.
novice forensic clinicians will ask about the specific number or quantity of
digital images that should be taken as part of the sexual assault medical
forensic exam. A good rule of thumb is to take as many pictures as needed to
best represent anatomic findings, as well as any findings of injury. This might
mean that the forensic nurse examiner is taking 12–30 photos or more, depending
on patient presentation. Another good rule of thumb is to never delete a photo,
even if it is out of focus or pixelated. Photographs should not be manipulated,
and if photographic software is used to annotate or describe an image, the
original image should be saved, and for each annotated image there should be an
embedded record of who captured the photograph and annotated the image.
patient who is affected by violence always has the option to decline having
photos taken of body-surface injury or anogenital findings. An important
component of the responsibilities of the forensic nurse examiner is not only to
offer that option to patients as part of a trauma-informed response, but also
to explain to the patient how the photos will be used and how they might be
helpful for diagnosis and potentially in the criminal-justice arena. Since
anogenital photos can be perceived to be graphic or inflammatory, and there is
typically no need for juries to review anogenital photos, the forensic nurse
can review photos prior to testimony and annotate a black and white diagram of
male or female genitalia while objectively describing the anatomy and
identified injury or normal findings. This option should be reviewed in advance
with the attorney.
review of all case photographs and reports is important for learning and
improving patient care. Ernst & Speck (2011) describe seven attributes to
consider when evaluating the quality and consistency of a photograph. These
attributes are highlighted in the chart below.
is an accepted standard of care and essential skill for forensic nurses
responding to patients affected by trauma and violence. Forensic nurses should anticipate
exposure to evidence-based education that includes the essentials of
photo-documentation. The SANE Program Development and Operational Guide (2016) suggests
that photo-documentation creates a mechanism for peer review of exam findings.
It is the only way that a nurse’s evaluation of an injury can be peer reviewed,
which is an essential part of SANE/forensic nurse examiner practice. Clinical
policies for photo-documentation within forensic-nursing practice programs
should include a standardized approach to anogenital photography, expert review
of photos to support quality improvement, and a detailed process for storage
and release of digital images.
summary, photo-documentation and imaging equipment has continued to evolve.
Photographic images can be invaluable and will continue to impact forensic
nursing practice. Keep it simple, know your equipment, follow your procedures
and clinical guidelines, and remember that accurate photo-documentation is a
standard of forensic care. The use of a comprehensive photography protocol
during the medical forensic exam will positively affect health-care services
provided to those affected by crime and violence while serving the interests of
You are called to testify in a domestic
violence/sexual assault case. As the forensic nurse examiner, you saw the
patient two years ago and recall that she had sustained multiple body-surface
and genital injuries. In addition to providing the medical-forensic exam, you
took photographs of her various injuries.
While on the stand, you are shown the
photos and are asked to describe the anatomy and the various injuries to the
is easy for the jurors to see the injuries and consider the demonstrative evidence,
based on your description of the injuries, as well as your ability to identify
the specific injures on the photograph that is displayed for the jury to see.
Guilty on three counts. Sentence, 12 years.
Sievers (MSN, RN, CNS, SANE-A, SANE-P,
DF-AFN) is a Forensic Clinical Nurse Specialist with more than 35 years of
health care experience as a registered nurse, advanced-practice nurse,
educator, and consultant. She is currently owner of MedLaw Consultants, LLC,
editor of Forensic Nursing Exchange, and serves as a board member of the
Academy of Forensic Nursing.
K. Faugno (MSN, RN, CPN, SANE-A, SANE-P,
FAAFS, DF-IAFN, DF-AFN) is a Founding Board Director for End Violence Against
Women International (EVAWI), is the current president of the Academy of
Forensic Nurses, as well as a retired-fellow in the American Academy of
Forensic Science and a Distinguished Fellow in the Academy of Forensic Nursing.
She now works for Life Safe as a forensic nurse in Marietta, Georgia.
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