Toluidine Blue

Toluidine blue stains nuclei and has been used on the posterior fourchette to identify lacerations of the keratinized squamous epithelium that were not apparent on gross visualization (128,129). Use of toluidine blue increased the detection rate of posterior fourchette lacerations from 4 to 58% in adult (older than 19 years) complainants of nonconsensual vaginal intercourse, from 4 to 28% in sexually abused adolescents (11-18 years old), and from 16.5 to 33% in pediatric sexually abused patients (0-10 years old) (129,130).

The same frequency of posterior fourchette lacerations has been identified by use of the stain in adolescents after consensual penile penetration and nonconsensual sexual acts (129). In contrast, adult complainants of nonconsensual vaginal intercourse and sexually abused children had significantly more lacerations demonstrable by toluidine blue staining than control groups (130), although such staining does not identify lacerations that cannot be detected using a colposcope (123). Therefore, if a colposcope is not available, toluidine blue may be an adjunct to the genital assessment of prepubertal and adult complainants of vaginal penetration (129,130). Furthermore, some centers use the stain during colposcopy to provide a clear pictorial presentation of the injuries for later presentation to juries (123).

Vulval swabs for forensic analysis must be taken before the stain is applied. Toluidine blue (1%) is then painted on the posterior fourchette, using a swab, before any instrumentation. After a few seconds, the residual stain is removed with lubricating jelly and gauze (128). The patient may experience some stinging at the application site. The time parameters within which the use of toluidine blue is beneficial in highlighting injuries have not been identified.

8.6.2. Injuries

Little information is available regarding the incidence and type of genital injuries that result from consensual sexual acts involving the female genitalia. Although penile-vaginal penetration is the most frequent sexual act performed by heterosexual couples, anecdotal reports from doctors who regularly conduct nonforensic assessments of the female genitalia (general practitioners, gynecologists, or genitourinary physicians) suggest that injuries resultant from sexual activity are rarely identified. However, this may be explained by the nature of routine assessments, which are usually limited to naked-eye inspection or because of the rapid and complete resolution of minor injuries (90). On the other hand, there are reports describing genital injuries in complainants of sexual assault, although, unfortunately, few have matched the findings with the specific complaint or the subsequent outcome in court. To date, no case-control study has compared the genital findings in complainants of sexual assault with those in a sexually active control population.

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