Article

Differences in Hymenal Morphology Between Adolescent Girls With and Without a History of Consensual Sexual Intercourse

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Abstract

To compare the morphology of the hymen in adolescent girls who have and have not had sexual intercourse involving penile-vaginal penetration. Female patients aged 13 to 19 years, recruited from an urban adolescent medicine practice. Subjects were interviewed in private after completing detailed questionnaires and then underwent a physical examination. External genital inspections were performed using a colposcope with an attached 35-mm camera to document the appearance of the hymen. The presence of notches or clefts was recorded during the examination, and photographs taken at x10 magnification were used to take measurements of the width of the posterior hymenal rim. Posterior hymenal notches and clefts were more common among girls admitting past intercourse (13/27 [48%]) than in girls who denied intercourse (2/58 [3%]; P =.001), but the mean width of the posterior hymenal rim was not significantly different between the 2 groups (2.5 mm vs 3.0 mm; P =.11). Two subjects who denied intercourse but had posterior hymenal clefts described a painful first experience with tampon insertion. Deep notches or complete clefts in the posterior rim of the hymen were rare in girls who denied intercourse. Subjects who admitted past intercourse still had nondisrupted, intact hymens in 52% of cases.

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... La littérature rapporte de nombreuses données quant à l'examen gynécologique génital des femmes victimes d'agression sexuelle [71,72,73,74], notamment chez les jeunes enfants ou adolescentes. ...
... La position d'examen gynécologique peut conditionner la mise en évidence de lésions ou non : toutes les femmes de l'étude ont été examinées en position gynécologique, sur une [79,91]. Et de façon plus générale, chez les adolescentes, l'absence de déchirures hyménales ne signifie pas l'absence de pénétration vaginale pénienne [73,20]. ...
... De même, en cas de vie sexuelle active, les femmes peuvent consulter à distance de leur dernier RS. Pour De nombreuses études existent sur l'examen génital des adolescentes et des jeunes filles pré-pubères [71,72,73,80,88]. Notre travail apporte des données sur l'examen génital des femmes non vierges, ayant déjà une activité sexuelle [34,37]. ...
Thesis
De nos jours, le nombre de femmes victimes d'agression sexuelle reste élevé, malgré l'amélioration de la prévention et de l'information. Ces victimes sont aussi bien des jeunes enfants, des adolescentes, des femmes en âge de procréer, que des femmes ménopausées. La diversité morpho-anatomique de l'appareil génital féminin impose une acquisition des connaissances de toutes les variations physiologiques existantes, par l'ensemble des praticiens prenant en charge ces victimes. Notre travail a pour objectifs de décrire l'examen gynécologique génital des femmes ayant une activité sexuelle consentie, et de comparer l'examen gynécologique normal de ces femmes à celui de victimes d'agression sexuelle.Les lésions traumatiques génitales d'allure récente sont retrouvées chez 14,2% des femmes victimes d'agression sexuelle contre 7,3% des femmes normales, avec une différence non significative. La littérature précise que les lésions traumatiques sont plus fréquentes en cas de pénétration vaginale non consentie : la confusion entre des encoches hyménales physiologiques et des déchirures traumatiques incomplètes est possible, surtout chez des praticiens peu expérimentés.Les hymens intacts, indemnes de déchirure traumatique, sont présents chez 12,7% des femmes normales (qui ont toutes débutées une vie sexuelle) contre 13,3% des victimes d'agression sexuelle. L'hymen intact est possible chez des femmes ayant une vie sexuelle régulière. Il n'existe pas de gold-standard pour déterminer la virginité.Dans de nombreux cas, l'examen génital seul ne permet ni d'affirmer, ni d'infirmerl'existence d'un rapport sexuel, et ce d'autant qu'il est avéré non consenti. Les objectifs de l'ensemble des travaux concernant les données sur l'anatomie génitaleféminine, cherchent à optimiser la prise en charge des victimes d?agression sexuelle, à réduire leur nombre, et tentent d'éradiquer les récidives.
... First, it is neither possible nor desirable to create a medical standard for determining virginity by inspection-so-called virginity testing. Being a virgin is not about whether or not the hymen is intact, because the hymen varies in its flexibility and can appear "intact", or free of clefts, after onset of vaginal intercourse, even through a colposcope [2,4]. The appearance and diameter of a "normal" hymen also varies [2,4,5]. ...
... Being a virgin is not about whether or not the hymen is intact, because the hymen varies in its flexibility and can appear "intact", or free of clefts, after onset of vaginal intercourse, even through a colposcope [2,4]. The appearance and diameter of a "normal" hymen also varies [2,4,5]. ...
... Including perineoplasty as part of hymenoplasty to create "tightness" in nulliparous women seeking the procedure with no history of sexual violence or other indication is somewhat problematic. The relative sizes of the erect penis and the vaginal introitus (with or without an intact hymen) in such nulliparous women defy logic in such requests [2,4,5,10]. ...
Article
This Special Editorial questions whether hymenoplasty ("re-virgination") before marriage, where lawful, is ethically or medically appropriate, recognizing that in some cultures, the lives or well-being of patients may be at stake.
... Therefore by the time the JMO examines the child, the injuries are most likely to heal to a certain extend thereby the interpretation of the non-acute findings of sexual abuse becomes debatable. Also, the interpretation of injuries on hymen is influenced by a variety of factors including the age, hormonal effects, individual variations, time interval between the assault and the evaluation and the examination techniques or has non-disrupted intact hymen 8 . But the review of these literature revealed that the findings of the hymen of adolescents following rape have been interpreted differently. ...
... . The hymenal rim is traced with a cotton tipped applicator moisten with water when the child is in the supine position while a large cotton swab covered by a latex balloon can also be used 8 . The use of a colposcope is a standard at present as it has many advantages like good lighting, magnification and the fact that findings can be documented by obtaining a high quality photographs or video recording with a camera attached to it. . ...
... The study on morphology among adolescent girls with and without a history of consensual sexual intercourse revealed that the adolescent girls who have no deep notches in the hymen could still have experienced penile-vaginal penetration, because 52% of the subjects in the study did not have deep notches or complete clefts in the lateral or posterior locations in the hymen. The study concludes that the absence of notches does not rule out previous penetration in an adolescent therefore the term intact should be avoided when describing a hymen that is free of clefts 8 . McCann is of the same opinion stating that calling a hymen 'normal, without evidence of previous injury' need to be exercised with caution 1 . ...
... Assessment of the hymen cannot be used to establish whether or not previous penetration has occurred. [33][34][35][36][37][38][39] Congenital absence of a hymen in girls with a normal Müllerian system has not been described. [40][41][42] The use of the term "hymen intact" is not recommended because of the lack of specificity. ...
... The most important concept pertaining to child sexual abuse is that a normal examination is expected, and that child sexual abuse can never be excluded, and seldom confirmed, on clinical grounds. 16,[36][37][38][50][51][52] ...
Article
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This is Part 3 of a three-part series on medico-legal documentation. Part 1 addressed the knowledge and skills necessary to complete a legal J88 document. Part 2 provided practical guidance on completion of the J88 form in the case of assault. This article will focus on pages 2 and 3 of the J88 document, which deals with the alleged sexual offences of both adults and children. The assumption may exist that the J88 is the only significant document with respect to medical findings in alleged rape and child sexual abuse cases, and that the court needs this information to make a decision on the medical aspects of a case. However, the court needs the information to be interpreted by a medical practitioner, who must indicate the significance of the findings, determine who should supply relevant additional information, and then place the entire picture in context. This article attempts to highlight the value of the relevant aspects, while raising awareness of an unscientific interpretation of clinical examination.
... The finding of a deep notch/cleft in the hymen at or below 3 and 9 o'clock is listed in the "No expert consensus/ findings inconclusive for abuse" section of Table 1, because this is a rare finding that has been reported in a few prepubertal 20 and pubertal patients 21 with a history of sexual abuse, or consensual intercourse. 22 However, current studies do not show a consistent pattern of whether lacerations of the hymen heal 23 to a transection, a deep notch, or a nonspecific finding. Complete clefts/healed transections Fig. 4. ...
... .01) in one study. 22 All notches/clefts that are not deep, as defined previously, are considered normal variants. Notches or clefts, of any depth, above 3 and 9 o'clock, are also considered normal variants. ...
Article
Full-text available
Most sexually abused children will not have signs of genital or anal injury, especially when examined non-acutely. A recent study found that only 2.2% (26/1160) of sexually abused girls examined non-acutely had diagnostic physical findings, while among those examined acutely, the prevalence of injuries was 21.4% (73/340). 1 It is important for health care professionals who examine children who may have been sexually abused to be able to recognize and interpret any physical signs or laboratory results that may be found. This review will summarize new data and recommendations concerning documentation of medical examinations, testing for sexually transmitted infections, interpretation of lesions caused by Human Papilloma Virus and Herpes Simplex Virus in children, and interpretation of physical examination findings. Updates to a table listing an approach to the interpretation of medical findings2 will be presented, and reasons for changes will be discussed.
... and minors victims of ascertained sexual abuse show non-specific, or even normal, genital and/or anal evidence. 21,22 Hence, the outcome of many cases of alleged sexual assault requires not only specialized and thorough anatomical-clinical knowledge, [23][24][25] but also specific forensic medicine skills so to acquire any evidence of committed crime. 26 The complexity of sexual assault cases requires the consequential collection of medical documentation in order to collect information on case history, on description of clothes and any traumatic lesion in genital and anal areas, supplied with iconographical reproductions in order to collect biological "evidence", which is crucial in the subsequent judicial procedure as proof of the violence suffered. ...
... Sometimes, negative or non-specific physical examination findings are ascribable to the lack of experience of health operators (traumatic lesions erroneously classified as inflammatory lesions, anatomical anomalies). 24,30 Sometimes, on the opposite way, misinterpretations lead to inevitable judicial repercussions. 31 The medical investigation carried out to substantiate violence suffered is further complicated when physical examination results are totally negative; in those cases, the testimony of minor plays a significant role, as it is the only evidence of the existence of crime. ...
Article
Full-text available
Sexually transmitted diseases (STDs), with special emphasis to HIV infection, involve legal and ethical issues regarding informed consent to submit to a diagnostic, observance of professional secrecy in regard to partner(s) and community; legal troubles of particular difficulties are related to STD involving minors; lastly, physicians must be able to recognize the state of so called medical necessity. Knowledge and awareness of these related obligations are crucial to STD in medical practice; it is also important to allow for proper protection of victims of suspected sexual abuse under observation of healthcare. With regard to this aspect should be emphasized that violence against women and minors is a worldwide problem that has not yet been sufficiently acknowledged. Italian legislation (Law n. 96/1996) against rapes finally gave significant relevance to sex crimes. When sexual abusers have to be evaluated some obstacles may arise for lack of appropriate interdisciplinary approach, with insurance of the collection of biological samples, also related to STD diagnosis and alerts of legal authorities. Personal preconceptions may interfere with investigation if the biological evidences in children are few. In this regard, rules of document "Carta di Noto" drafted in 1996 and reviewed in July 2002 include some specific indications aiming to grant the reliability of the results of technical investigations and authenticity of the statements of the alleged victims.
... The finding of a deep notch/cleft in the hymen at or below 3 and 9 o'clock is listed in the "No expert consensus/ findings inconclusive for abuse" section of Table 1, because this is a rare finding that has been reported in a few prepubertal 20 and pubertal patients 21 with a history of sexual abuse, or consensual intercourse. 22 However, current studies do not show a consistent pattern of whether lacerations of the hymen heal 23 to a transection, a deep notch, or a nonspecific finding. Complete clefts/healed transections Fig. 4. ...
... .01) in one study. 22 All notches/clefts that are not deep, as defined previously, are considered normal variants. Notches or clefts, of any depth, above 3 and 9 o'clock, are also considered normal variants. ...
Article
Full-text available
The medical assessment of children and adolescents for suspected sexual abuse or assault includes gathering a history from the child, examination and photodocumentation of bodily and anogenital findings, forensic evidence collection, and testing for sexually transmitted infections, when indicated. Most children will not have signs of injury or infection, and the child and family need to be reassured that an absence of injury does not mean the abuse did not happen. This article provides an overview of current recommendations concerning the medical assessment, including recent updates in the interpretation of examination findings, sexually transmitted infection testing methods, follow up examinations or testing, and practice recommendations for quality improvement. Changes in the approach to interpretation of anogenital findings table are also reviewed.
... Although there are many papers and textbooks discussing the anogenital findings in abused and nonabused living children (81)(82)(83)(84)(85)(86)(87)(88)(89)(90), the medical literature shows a surprising dearth of evidence regarding the postmortem anogenital findings in cases of acute or chronic sexual abuse. Very few papers deal with the specific issues involved in the investigation of possi- ...
Article
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Certain conditions have been considered hallmarks of child abuse. Such pathognomonic conditions have led to an inevitable diagnosis of inflicted injury. Forensic pathologists are faced with complex analyses and decisions related to what is and what is not child abuse. In this review, we examine the literature on the specificity of five conditions that have been linked to inflicted injury to varying degrees of certainty. The conditions examined include tears of the labial frena (frenula), cigarette burns, pulmonary hemorrhage and intraalveolar hemosiderin-laden macrophages as markers of upper airway obstruction, intraabdominal injuries, and anogenital injuries and postmortem changes. Analysis of the literature indicates that frena tears are not uniquely an inflicted injury. Cigarette burns are highly indicative of child abuse, though isolated cigarette burns may be accidental. Pulmonary hemorrhage is seen more commonly in cases with a history suggestive of upper airway obstruction, but is not diagnostic in an individual case. Hemosiderin-laden macrophages may be seen in cases with inflicted injuries and in natural deaths. Abdominal injuries may be seen in accidents and from resuscitation, though panreatico-duodenal complex injuries in children under five years of age are not reported to be seen in falls or resuscitation. The understanding of anogenital injuries is increasing, but misunderstanding of postmortem changes has led to miscarriages of justice.
... It must also be remembered that a genital examination is normal in more than 50% of children suspected of having been abused, and that less 10% of these will present characteristic lesions; more than 90% of children aged between 3 and 8 years that describe vaginal penetration (fingers, penis) do not exhibit signs of genital lesions. The absence of physical signs neither excludes nor confirms a diagnosis of abuse [50][51][52]. Furthermore, the morphological aspect of the genitals as the only present indicator is not sufficient to confirm sexual abuse. ...
Article
The aim of this work is to propose a comment on the impact of different forms of child abuse. A multidisciplinary approach (gynecological, psychological and pediatric) is important for an adequate diagnosis and an early recognition of the abuse in order to minimize the serious impact of child abuse on the physical and psychological wellbeing of the victims.
... Lateral hymenal signs at or below the three or nine o'clock position were more commonly seen than in other studies, which predominantly describe posterior signs. 26 We note that the recent US guidelines published by Adams et al acknowledge the difficulties faced by experts in interpreting such signs, as there is no consensus on their significance with respect to sexual contact. 27 Given that the cases we report were supportive of CSA in the context of the allegations and following peer review, it may be that in future, more consideration should be given to the significance of lateral signs. ...
Article
Introduction Police-recorded sexual offences against children and young people (CYP) increased 85% in the UK between 2010/2011 and 2014/2015. Many children delay disclosure, but little data are available regarding characteristics of CYP presenting with historic child sexual abuse (CSA). Aim To identify the clinical and CSA-related characteristics of CYP presenting with a suspicion or allegation of historic CSA. Method Data were collected on all CYP<17 years presenting with suspected or alleged historic CSA (ie, >3 days since last sexual assault in prepubertal children, >7 days pubertal girls) between October 2009 and November 2014. Data collected: source and indication for referral, alleged perpetrator, physical findings. Findings supportive of CSA were peer reviewed for consensus agreement. Analysis: χ² test, Fisher’s exact test and logistic regression. Results Among 249 CYP, presentation with physical/behavioural symptoms was associated with age <13 years (p<0.01), and alleged penetration with ages 13–17 years (p<0.01). Where known, time since alleged CSA ranged from 1 week to 13 months. Anogenital findings supportive of CSA were present in 7% of examined children (16/233), significantly associated with alleged penetration (p<0.01) and more likely with increasing age (OR 1.46, 95% CI 1.23 to 1.72). Additionally, where tested, sexually transmitted infections (STI) were detected in 2.6% CYP (3/116). Alleged perpetrators were intrafamilial in 66% (126/190). No associations were identified between perpetrator type and gender (p=1.0), age (p=0.7) or indication for referral (p=0.35). Conclusions Despite significant time delay since the alleged CSA, this study highlights the persistence of anogenital findings supportive of CSA in 7% and STIs in 2.6% of CYP.
... Medical evidence from previous studies supports our position that hymenal physical examination is an unreliable indicator of prior sexual intercourse (Anderst et al., 2009;Mishori et al. 2019;Olson & García-Moreno, 2017;Pillai, 2008). One study reported that 52% of cases of women who admitted having past intercourse still had intact hymens (Adams et al., 2004). ...
Article
Full-text available
Virginity is the nullity of sexual experience in females. However, the use of virginity testing as proof of previous involvement in sexual relations is dependent on having an intact hymen, which refers to a hymen with no signs of previous penetrating injury. Although the quality of this evidence in questioned virginity is extremely poor and considered a violation of human rights, it still constitutes a major facet in medicolegal investigations of sexual assaults. This work evaluates virginity testing as currently practiced in many countries, including Egypt, in terms of medical and legal considerations.
... During adolescence, the hymen changes from a sensitive, inelastic structure to being elastic and redundant, forming a structure that has a high probability not to be torn by penetration. [22][23][24] Complete clefts in the 3 o'clock and 9 o'clock positions of the adolescent hymen may be a normal finding, but there is no consensus among the experts due to insufficient research on the feature. 19 The area behind the 3 to 9 o'clock line should, in addition, preferably be examined with the aid of toluidine blue 1%, a tissue stain with affinity for cell nuclei. ...
Article
Full-text available
The management of a rape case in the emergency department is shrouded in an unacceptable level of lack of confidence. Since South Africa has a high incidence of rape, the contribution of health practitioners in addressing the crime successfully is essential. The medical management of such cases carries a high level of uncertainty with an accompanying element of not feeling in control. The intimidation associated with the responsibility of being an expert witness complicates the matter further. This article attempts to address the reluctance to get involved in medico-legal cases and emphasises the holistic management of survivors of rape.
... These conclusions are in line with those of the Physical Signs of Child Sexual Abuse published by the Royal College of Pediatrics & Child Health (2008), which at the time of writing are being updated. Adams et al. (2004) compared the morphology of the hymen in adolescent girls who have and have not had sexual intercourse involving penile-vaginal penetration. ...
Article
It is widely assumed outside the forensic medical arena that sexual assault of any nature will result in anogenital injury. This is only the case in a minority of assaults. Appropriate assessment, documentation, and interpretation of findings in complainants and suspects will best allow the court to determine appropriate outcomes. Consistency and quality of examination and sample taking and an understanding of the current medical evidence-base related to injuries and findings after sexual assault is key to appropriate assessment in adults and children. Examples are given of the types of injuries that may be sustained.
... Sometimes, instead, negative or non-specific physical examination findings are ascribable to the lack of experience of health operators (traumatic lesions erroneously classified as inflammatory lesions, anatomical anomalies) (Adams et al. 2004;Stewart 2011). Inquiry into sexual abuse in children is particularly complicated, as many children do not report the abuse (Lanzarone et al. 2017 The new Adam's classification unify the third and fourth classes as they are now comprise in the type "findings diagnostic"; so they are concretely more clear for medical examiner. ...
Article
Full-text available
Background: Sexual assault is a worldwide problem that has not yet been sufficiently acknowledged as confirmed by the literature. Italian law n.96, 1996, foreseeing norms regarding rape and sexual abuse, finally gave significant relevance to sex crimes. In 2004, the European Commission for Justice Internal Affairs and Social Politics promoted the Daphne II program to support victims of rape and abuse, and the Violence and Operative Healthcare Networks (Ve.R.S.O.) project started at the Policlinico “P. Giaccone” University Hospital of Palermo in 2006. Aim: data analysis emerging from 10 years experience of Daphne protocol utilization for the management of sexual assault victims. Methods: From October 2006 since December 2016 a total of 90 victims of sexual assault were retrospectively investigated. Patients are divided into groups in relation to: gender, age, place of SA, number and type of assailant, nature of sexual assault, presence/absence of physical or genital injuries. Results: Among victims 88 were females (97%) and 2 males (3%); 68 Italians (75.5%) and 22 foreigners (24.5%). At the time the events occurred, 42% (n = 38) of the victims were minors aged less than 16 years. In 11 cases, the age of the victim is not indicated. The assailant was an acquaintance of the victim in 65% of the cases (in 73% of these cases, the assailant was a family member). In 26 cases (28%) happened indoor, 44 cases happened outdoor and in 20 cases there were no data. Evidence of recent acute general body trauma (abrasions, bruises, lacerations) was found in 38 cases (42%); other types of injuries include: genital trauma (14 cases, 15%), genital and body traumas (49 cases, 54%) (tab. 1–2-). In 24 cases (26%) there were no injuries. Among genital trauma, we distinguished vulvo-vaginal lesions (68.5%) and anal lesions (31.5%). We have classified the minor victims using first Adam’s classification and based on Adam’s classification revised in 2015. Conclusion: Application of the Ve.R.S.O project protocol changed and greatly improved health management of victims of violence. By following these procedures, violence and abuse are analyzed from every point of view, also for an appropriate assessment of the medium and long term health consequences of sexual assault. Only in this way are citizens provided with a high level of protection against gender violence, psychological support and prevention from any form of violence which takes place in respect of such vulnerable people.
... The widespread assumption of a correspondence between hymen, virginity, and blood on bed sheets has been called the "the myth of the intact hymen" (Van Moorst et al., 2012:94) because of its biological implausibility: the form taken by the membranous fold of tissue at a woman's vaginal opening varies greatly among individuals, and often wears significantly away during childhood, even in the absence of sexual relations (Adams et al., 2004). Virginity, moreover, is defined differently by different cultures and women, and vaginal sexual penetration cannot be medically or informally ascertained with certainty (Gay-y-Blasco, 1997;Boddy, 1989). ...
... Dieser Saum ist vom Aussehen her nicht einheitlich, sondern zeigt vielfältige anatomische Variationen. Daher erstaunt es nicht, dass bereits erfolgter Geschlechtsverkehr nicht immer zu nach weis baren Veränderungen des Hymens führt und dass ge wisse Veränderungen wie Furchen oder Kerben des Hymens auch bei Frauen nachweisbar sind, die keinen Geschlechts verkehr hatten (Adams et al. 2004). Studien zeigen, dass es aufgrund der unterschiedlichen Beschaffen heit des Hymens bei weniger als 50% der Frauen zu einer Blutung beim ersten Geschlechtsverkehr kommt (Amy 2008). ...
... A review of the literature produced only one study that performed an agreement assessment among clinical examiners. In a study to determine hymenal injury in adolescents, Adams, Botash, and Kellogg (2004), each a medical doctor, examined, photographed, and documented a clinical judgment regarding the hymenal rim of 85 female subjects. Due to poor photographic quality, 18 of the cases were not sent out for review. ...
... These conclusions are in line with those of the Physical Signs of Child Sexual Abuse published by the Royal College of Pediatrics & Child Health (2008), which at the time of writing are being updated. Adams et al. (2004) compared the morphology of the hymen in adolescent girls who have and have not had sexual intercourse involving penile-vaginal penetration. ...
Article
Full-text available
IntroductionSexual assault settings and characteristicsFindings after sexual assaultToxicology and sexual assaultForensic science and sexual assaultTreatment after sexual assaultSummaryReferences
... Participants' reference to the hymen as an anatomical structure that "breaks" and "bleeds" reifies constructions of the hymen as a corporeal membrane. This discursive construction is problematic, however, as the hymen is not a reliable indicator of prior sexual experience (Adams, Botash, & Kellogg, 2004;Edgardh & Ormstad, 2002), nor is it a physical structure covering the opening of a woman's vagina. Women may damage the hymen in other nonsexual activities (Essén MIGRANT van Dijken, & Salvatore, 2012). ...
Article
Full-text available
Constructions of normative sexuality shape the sexual scripts that women are permitted to adopt and the manner in which such sexuality can be expressed. We explored experiences and constructions of premarital sexuality among migrant and refugee women recently resettled in Sydney, Australia, and Vancouver, Canada. A total of 78 semistructured individual interviews and 15 focus groups composed of 82 participants were undertaken with women who had migrated from Afghanistan, Iraq, Somalia, South Sudan, Sudan, Sri Lanka, and South America. We analyzed the data using thematic decomposition. Across all cultural groups, women’s premarital sexuality was regulated through cultural and religious discourse and material practice. Such regulation occurred across three main facets of women’s lives, shaping the themes presented in this article: (1) regulating premarital sex—the virginity imperative; (2) regulation of relationships with men; and (3) regulation of the sexual body. These themes capture women’s reproduction of dominant discourses of premarital sexuality, as well as women’s resistance and negotiation of such discourses, both prior to and following migration. Identifying migrant and refugee women’s experiences and constructions of premarital sexuality is essential for culturally safe sexual health practice, health promotion, and health education.
... Sometimes, instead, negative or non-specific physical examination findings are ascribable to the lack of experience of health operators (traumatic lesions erroneously classified as inflammatory lesions, anatomical anomalies) (Adams et al. 2004;Stewart 2011). Inquiry into sexual abuse in children is particularly complicated, as many children do not report the abuse (Lanzarone et al. 2017 The new Adam's classification unify the third and fourth classes as they are now comprise in the type "findings diagnostic"; so they are concretely more clear for medical examiner. ...
... The widespread assumption of a correspondence between hymen, virginity, and blood on bed sheets has been called the "the myth of the intact hymen" (Van Moorst et al., 2012:94) because of its biological implausibility: the form taken by the membranous fold of tissue at a woman's vaginal opening varies greatly among individuals, and often wears significantly away during childhood, even in the absence of sexual relations (Adams et al., 2004). Virginity, moreover, is defined differently by different cultures and women, and vaginal sexual penetration cannot be medically or informally ascertained with certainty (Gay-y-Blasco, 1997;Boddy, 1989). ...
... Among the medical profession, hymen reconstruction receives particular attention and is debated because the surgery is not medically indicated and reveals contradictory social norms regarding virginity and marriageability for girls/women [8,9]. The belief that bed sheets must be stained with blood after first intercourse during the wedding night, as a sign of virginity, contradicts with the medical evidence that blood loss after first coitus does not always occur [10][11][12], and with the fact that there is a wide variety of appearances of the hymen in virgin girls and women [13,14]. Moreover, an 'intact hymen' is not always a sign of not having engaged in sexual activity as there are other ways of preserving virginity while at the same time having engaged in sexual intercourse [15]. ...
Article
Full-text available
Background: Hymen reconstruction (HR) involves the restoration of the hymeneal membrane's gross anatomical integrity. Among the medical profession, hymen reconstruction receives particular attention and its necessity is debated because the surgery is not medically indicated, and often reveals conflicting social norms on virginity and marriageability between health professionals and their patients. The focus of this paper is not to address the many open questions that the ethics and politics around HR reveal, but rather aims at contributing to the much-needed empirical evidence. It presents findings of a study conducted in Belgium (Flanders region), among gynaecologists that aimed at assessing their knowledge, views, and experiences on hymen reconstruction. Methods: A digital self-administered questionnaire-based survey was sent to Flemish gynaecologists and trainees in Flanders registered with the Flemish Society of Obstetrics and Gynaecology (VVOG). Results: Hundred-and-nine questionnaires were completed. The majority of the respondents (73%) had requests to perform HR. Knowledge and technical skills about HR were considered to be sufficient (69%), even though HR does not seem to be integrated in medical curricula or post-graduate training. Most respondents (72%) would favour the publication of a guideline by their professional organisation. Few respondents discuss alternative options with the patient (19%) and half of the respondents reject to perform HR (49%). The majority of our respondents are against reimbursement of the surgery (70%). Not even half of our respondents believes that a patient is at risk of further violence (47%). 7% of the respondents mentioned complications, but the majority was able to perform a follow up consultation. Conclusions: The responses of this survey cannot be generalised to the entire population of gynaecologists in Flanders, but do provide insights in how gynaecologists confronted with HR are approaching such requests, and thus contributes to the empirical evidence. Our paper showed that many Flemish gynaecologist are likely to encounter requests for hymenoplasty, but that a majority would not perform the surgery. There seems to be a lack of guidance and debate in Flanders on the social and moral dimensions of HR, and a number of complexities were revealed when gynaecologists address HR that need further research.
... During adolescence, the hymen changes from a sensitive, inelastic structure to being elastic and redundant, forming a structure that has a high probability not to be torn by penetration. [22][23][24] Complete ...
Article
Full-text available
The management of a rape case in the emergency department is shrouded in an unacceptable level of lack of confidence. Since South Africa has a high incidence of rape, the contribution of health practitioners in addressing the crime successfully is essential. The medical management of such cases carries a high level of uncertainty with an accompanying element of not feeling in control. The intimidation associated with the responsibility of being an expert witness complicates the matter further. This article attempts to address the reluctance to get involved in medico-legal cases and emphasises the holistic management of survivors of rape. (Full text of the research articles are available online at www.medpharm.tandfonline.com/ojfp) S Afr Fam Pract 2017; DOI: 10.1080/20786190.2017.1280900
... Similarly, it is also reported that the hymen can sometimes not be torn, even after penetration of the penis into the vagina, while on other occasions a torn hymen is unable to provide a clue regarding fresh coition. [16][17][18] In Pakistan the MLO/CMO performs the two-finger test to determine the virginity of the victim. In this process, she tries to insert two fingers into the victim's vagina to check the rupture of the hymen. ...
Article
Sexual assault is becoming a global epidemic, affecting close to a billion women throughout the world. This paper explores the challenges in the admissibility of DNA evidence in rape cases in Pakistan. Delays in the medical examination of victims, and improper collection and packaging of evidentiary material, compromise the probative biological evidence. In the last few years, existing laws have been amended to increase the utility of DNA evidence during criminal trials. However, various issues – for example lack of proper knowledge of DNA evidence by lawyers and judicial officers, inadequacies in existing laws and conflicting decisions of apex courts – can affect the admissibility of DNA evidence during criminal trials.
... Another study comparing hymenal morphology in adolescent girls with and without a history of consensual sexual intercourse found that 52% of those who admitted to having had prior intercourse, had no identifiable changes to the hymenal tissue [28]. Similarly, where the morphology of the hymen has been altered, this can be attributed to causes other than sexual intercourse, including the insertion of objects, fingers, penetrating accidental trauma, and surgical procedures [29][30][31]. ...
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Conclusions about women’s and girls’ sexual history are made in some settings based on assumptions about the hymen, a small membranous tissue with no known biological function, which typically occupies a portion of the external vaginal opening in females. Clinicians, however, continue to refer to changes in the hymen to assess for a history of consensual or nonconsensual sexual intercourse. We reviewed published evidence to dispel commonly held myths about the hymen and its morphology, function, and use as evidence in cases of sexual violence. An examination of the hymen is not an accurate or reliable test of a previous history of sexual activity, including sexual assault. Clinicians tasked with performing forensic sexual assault examinations should avoid descriptions such as “intact hymen” or “broken hymen” in all cases, and describe specific findings using international standards and terminology of morphological features. We call on clinicians to consider the low predictive value of a hymen examination and to: 1) avoid relying solely on the status of the hymen in sexual assault examinations and reporting; 2) help raise awareness of this issue among their peers and counterparts in law enforcement and the judicial system; and 3) promote fact-based discussions about the limitations of hymenal examinations as part of clinical education for all specialties that address the sexual or reproductive health of women and girls.
... Nevertheless, hymenal injury is not always present, as 40 to 80% of women do not bleed in the initial coitus, 6 and the hymen was observed intact in 52% of adolescents who admitted past intercourse. 30 Indeed, when pregnant adolescents were examined for sexual abuse, 82% of the examinations were normal and only 7% were definitive for penetrating trauma. 31 Hence, the likelihood of sustaining a genital injury is not related to the consent, resistance or prior sexual experience. ...
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Genital injury has a forensic relevance after a sexual assault and it has been discussed and investigated among professionals who work in this field. To analyze the studies published in the last decades, the present review examines different factors that may influence this finding, first clarifying terms of the forensic field, such as the peculiarity of the legal medical examination, and the distinction of the terms “legal” and “anatomical” vagina. Finally, it analyses if it is possible that the existence of these injuries in victims explain the lack of consent in sexual contact, and to clarify the meaning of the absence of injuries.
... Of 383 CM cases examined in the Forensic Medicine Center, 276 According to Adam's classification, which is based on anogenital findings in children with suspected sexual abuse (14), 26 (17%) victims had indeterminate non-specific findings, while 82 (55%) had signs of abuse, and 42 (28%) had overt evidence of blunt force or penetrating trauma to or beyond the hymen (Table 2). ...
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Child maltreatment (CM) exists throughout the world, including within the Arab region. However, the resources addressing CM in Saudi Arabia remain limited. The study described the medico-legal characteristics of CM victims referred to the Saudi Forensic Medicine Center during the years 2015 and 2016. There were 385 cases of CM included in the study. Most cases involved boys (72.1%) who experienced sexual assaults (98%), for which forensic evidence was non-conclusive (59.2%). These findings represent the tip of the iceberg regarding the magnitude of CM in the Kingdom and should compel child protective authorities to develop effective strategies to minimize it.
Article
Child sexual abuse is a common form of child maltreatment that can leave a broad range of residual evidence. This chapter will define child sexual abuse and then will explore the various findings that should be collected as evidence. It will contrast the relative increasing indicia of reliability in interpreting a child's behavior, trace evidence, victim's statements, trauma, sexually transmitted infections (STIs), presence of seminal products, witnesses, suspect statement, presence of somatic DNA, presence of sperm, pregnancy, and video/photographic evidence. Suggested guidelines are offered with respect to purpose of sexual abuse exams, STI testing, and prophylaxis for possible medical consequences. Entities that may be mistaken for sexual abuse will also be discussed. © 2014 Springer Science+Business Media New York. All rights are reserved.
Article
The female vulva is an intricate structure comprising several components. Each structure has been described separately, but the interplay among them and physiologic significance remain controversial. The structures extend inferiorly from the pubic arch and include the mons pubis, labia majora, labia minora, vestibule, and clitoris. The clitoris is widely accepted as the most critical anatomic structure to female sexual arousal and orgasm. The female sexual response cycle is also very complex, requiring emotional and mental stimulation in addition to end organ stimulation.
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Prostitution involves the exchange of sexual services for economic compensation. As sexual behaviour is an important determinant in transmitting HIV and sexually transmitted diseases (STDs), sex workers (SWs), transgenders and clients are often labeled as a "high risk group" in the context of HIV and STDs. It has been documented that female sex workers in particular have an increased prevalence of untreated STDs and have been hypothesized to affect the health and HIV incidence of the general population. People involved in prostitution are a cause for concern from both public health and economic perspectives. However, little is known about why they remain in this type of activity given the risks prostitution presents, and even less is known about how to intervene and interrupt the complex cycle of prostitution. The aim of this paper is to provide a clinical and epidemiological analysis of the relationship between prostitution, sexual behavior and outbreaks of STDs; to assess the role that migrants, transgenders and clients of SWs have in prostitution and in the outbreaks of STDs. In addition, we also want to highlight how new sexual networks, like the Internet, have become an increasingly important vehicle to sharing information about prostitution, sexual behavior and STDs. Finally we present what may be the prevention strategies and the goals in order to stem the spread of STDs among these hard-to-access groups.
Article
Acute salpingitis is an uncommon cause of an acute surgical abdomen, especially in an adolescent who is not sexually active. The following is a case of a 12-year-old girl who denied sexual activity, had a remote history of an appendectomy, and a recent diagnosis of a large, right-sided ovarian cyst, who presented with acute abdominal pain, urinary symptoms, and fever. The patient was ill-appearing and progressed to uncompensated septic shock in the emergency department despite aggressive fluid resuscitation and empiric antibiotics. She ultimately underwent an exploratory laparotomy and was diagnosed with acute bilateral salpingitis. This case highlights the diagnostic dilemmas facing those caring for an adolescent girl with abdominal pain and presents an extremely rare etiology for abdominal pain in a nonsexually active adolescent.
Chapter
The medical and forensic evaluation of victims of child sexual abuse (CSA) is complex. Steps include careful medical history taking, physical and anogenital examination, consideration of differential diagnoses, diagnostic testing, and/or collection of forensic evidence, treatment of injury or disease, consideration of post-exposure prophylaxis, and mandated reporting based on professional practice guidelines and jurisdictional policies. Among children evaluated for CSA, only a minority of anogenital examinations have physical findings at the time of examination. Emphasis must be placed on listening and asking open-ended questions of the child and/or caregiver(s). The physical examination should be done by or in consultation with available local experts such as Child Abuse Pediatricians. A comprehensive examination may reveal non-genital findings related to sexual abuse or assault such as intraoral injuries, subtle signs of strangulation, or bite marks and cutaneous injuries inflicted by the suspected perpetrator. When performing the anogenital exam, clinicians should carefully inspect for hymenal, anal, and other non-hymenal injuries while keeping in mind that there is a wide range of normal anatomical variants and that some medical conditions and injuries can mimic signs of sexual trauma. Likewise, a normal examination does not mean sexual victimization has not occurred; definitive physical findings of anogenital trauma are only seen in a minority of child victims. Screening for sexually transmitted infections (STIs) is an important part of treatment of children suspected to have been abused. Confirmation of HIV, gonorrhea, syphilis, chlamydia, trichomonas, herpes, and genital warts in children beyond the neonatal period must prompt serious consideration of child sexual abuse. Prophylactic antibiotics after potential exposure are recommended for teens following acute sexual victimization that has the potential for transfer of biologic fluids. In addition to STI post-exposure prophylaxis for teens, there needs to be consideration of post-exposure pregnancy prophylaxis for post-pubescent girls. In most jurisdictions in the United States, forensic evidence collection is generally recommended for all children who present within 72 h of sexual victimization that has the potential for physical transfer of biologic secretions. Forensic evidence collection kits are self-contained with fairly standard instructions for clinicians across most jurisdictions in the United States.
Article
Introducción: la apendicitis aguda es causa frecuente de dolor abdominal. Su complicación más frecuente es la infección del sitio operatorio, siendo el compromiso pélvico muy raro. Presentamos el caso de una paciente sin vida sexual activa, con una enfermedad pélvica inflamatoria como complicación posoperatoria de una apendicitis aguda. Esta ingresó por dolor abdominal, varias semanas después de una apendicetomía, sin signos de infección incisional, pero con una tomografía que reportaba un hidrosalpinx izquierdo. Evolucionó hacia el deterioro clínico a pesar de la reanimación con cristaloides y antibióticos de amplio espectro. Fue llevada a laparotomía para control del foco. Se encontró un hidrosalpinx izquierdo y necesitó de una segunda cirugía por el compromiso anexial derecho. Luego de estas intervenciones hubo recuperación. Conclusión: la enfermedad pélvica inflamatoria es una etiología poco frecuente (aunque posible) de abdomen agudo en pacientes sin vida sexual activa.
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Chapter review of the evolution in the field of the diagnosis and management of possible child sexual abuse as referred from parents, law enforcement and social services. The review includes an overview of the importance of history, impact of testimony by both the child victim and the medical professional on the outcome of the legal intervention. Conclusions focused on the importance of outcomes for children and families and child protection as the most important measurement of effective and appropriate interventions as well as maintaining a professional, research-based foundation for diagnosis and treatment. Additional information is provided on the current standards for (1) Interviewing and (2) Medical diagnosis and includes a summary of the challenges to professionals as they continue to research and diagnosis cases of child sexual abuse.
Chapter
Die gynäkologische Untersuchung von Kindern ist an sich schon eine Herausforderung für die durchführende Ärztin bzw. für den durchführenden Arzt. Nicht nur die Angst vor dem Unbekannten, vor möglichen Schmerzen bei der Untersuchung, sondern auch die ungewohnte Situation, sich unbekleidet vor Fremden zeigen zu müssen, führen naturgemäß häufig zu einer Anspannung auf Seite des zu untersuchenden Kindes. Es erfordert daher nicht nur von den untersuchenden Ärztinnen eine entsprechende Empathie, sondern auch ein möglichst entspanntes ruhiges und beruhigendes Umfeld bei der Konsultation.
Chapter
Bei der überwiegenden Mehrzahl sexuell missbrauchter Kinder lassen sich keine auffälligen körperlichen Befunde erheben. Die korrekte Erhebung, Dokumentation und auf aktueller Evidenz basierende Interpretation der Gesamtsituation kann dennoch erhebliche Implikationen für den Schutz und die umfassende ärztliche Betreuung betroffener Kinder haben. Die medizinische Untersuchung kann dazu beitragen, ein durch den Missbrauch verursachtes pathologisches Körperselbstbild durch die ärztliche Bestätigung körperlicher Normalität und Integrität zu entlasten. Voraussetzung für eine fachgerechte medizinische Betreuung sind kinder- und jugendgynäkologische und forensische Kenntnisse. Dazu kommt die Kenntnis der methodischen Einschränkungen und Aussagefähigkeit medizinischer Befunde und die Berücksichtigung aktueller Empfehlungen, Leitlinien und Klassifikationen. Die Gründe für die hohe Rate an Normalbefunden (> 90%) bei sexuellem Kindesmissbrauch müssen jedem Arzt bekannt sein, um Fehleinschätzungen der Aussagen der Opfer aufgrund fehlender Verletzungsbefunde zu vermeiden. Beweisend sind massive, akute anogenitale Verletzungen, die nicht akzidentell erklärbar sind, eine gesicherte Gonorrhö, Syphilis oder HIV-Infektion (nach Ausschluss einer angeborenen Infektion), eine Schwangerschaft oder der Nachweis von Sperma in oder auf dem Körper eines Kindes. Für eine Reihe von Befunden, die als missbrauchsverdächtig gelten, ist die Zuordnung mit Unsicherheiten behaftet, da die Datenlage für eine definitive Bewertung noch unzureichend ist. Trotz des hier skizzierten Stellenwertes der medizinischen Diagnostik beruht die Diagnose des sexuellen Missbrauchs von Kindern nach wie vor in erster Linie auf einer qualifiziert erhobenen Aussage des Kindes.
Article
Hymenoplasty is surgery to alter the shape of the hymen membrane in the vaginal canal, commonly performed to minimise the aperture. This medical operation is often requested by women who expect that their virginity will be under scrutiny, particularly during their first sexual encounter on their wedding night. Despite increasing demand for the surgery all over the globe, there is no one standard of practice in performing hymenoplasty. In the Netherlands, the manner in which medical consultations concerning the procedure take place depends heavily on the consulting physician. This paper looks at two different approaches to hymenoplasty consultation in the Netherlands: a pedagogical philosophy adopted in a public hospital and a practical approach employed by a private clinic. Each approach culminates in a contrasting result: patients in one medical establishment are twice as likely to undergo hymenoplasty than those visiting the other.
Article
This paper provides new perspectives on the scholarship on medicalization and demedicalization, building on an ethnography of hymenoplasty consultations in the Netherlands. By examining how doctors can play an active role in demedicalization, this paper presents novel insights into Dutch physicians' attempt to demedicalize the “broken” hymen. In their consultations, Dutch doctors persuade hymenoplasty patients to abandon the assumed medical definition of the “broken” hymen and offer nonmedical solutions to patients' problems. Drawing from unique ethnographical access from 2012 to 2015 to 70 hymenoplasty consultations in the Netherlands, this paper's original contribution comes from closely examining how demedicalization can be achieved through the process of medicalization. It investigates how Dutch physicians go even further in their efforts to demedicalize by medicalizing “cultural” solutions as an alternative course of action to surgery.
Chapter
Sexual assaults create significant health and legislative problems for every society. All healthcare professionals who have the potential to encounter victims of sexual assault should have some understanding of the acute and chronic health problems that may ensue from an assault. The primary clinical forensic assessment of complainants and suspects of sexual assault should only be conducted by healthcare professionals (doctors, nurses and paramedics) who have acquired specialist knowledge, skills, and attitudes during theoretical and practical training.
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Mittlerweile gibt es eine Fülle von klinischen Daten über medizinische Befunde bei sexuell missbrauchten Kindern aus zahlreichen Fallkontrollstudien und Kasuistiken. Hinweise zu ihrer Beurteilung und Klassifizierung und zu ihrer Differenzierung von Normvarianten und anderen Differenzialdiagnosen existieren entsprechend. Dennoch ist der forensische medizinische Beweis eines sexuellen Missbrauchs die Ausnahme. Beweisend sind massive, akute anogenitale Verletzungen, die nicht akzidentell erklärbar sind, eine gesicherte Gonorrhö oder Syphilis (nach Ausschluss einer angeborenen Infektion), eine Schwangerschaft oder der Nachweis von Sperma in oder auf dem Körper eines Kindes. Für eine Reihe von Befunden, die als missbrauchsverdächtig gelten, ist die Zuordnung mit Unsicherheiten behaftet, da die Datenlage für eine definitive Bewertung noch unzureichend ist.
Article
Learning objectives: After studying this article and viewing the video, the participant should be able to: 1. Accurately describe the relevant aesthetic anatomy and terminology for common female genital plastic surgery procedures. 2. Have knowledge of the different surgical options to address common aesthetic concerns and their risks, alternatives, and benefits. 3. List the potential risks, alternatives, and benefits of commonly performed female genital aesthetic interventions. 4. Be aware of the entity of female genital mutilation and differentiation from female genital cosmetic surgery. Summary: This CME activity is intended to provide a brief 3500-word overview of female genital cosmetic surgery. The focus is primarily on elective vulvovaginal procedures, avoiding posttrauma reconstruction or gender-confirmation surgery. The goal is to present content with the best available and independent unbiased scientific research. Given this relatively new field, data with a high level of evidence are limited. Entities that may be commonly encountered in a plastic surgery practice are reviewed. The physician must be comfortable with the anatomy, terminology, diagnosis, and treatment options. Familiarity with requested interventions and aesthetic goals is encouraged.
Article
Résumé Objectif: Le nombre de femmes victimes d’agression sexuelle reste élevé, malgré les campagnes de prévention et d’information. Ces victimes peuvent être des adolescentes, des femmes en âge de procréer ou des femmes ménopausées. Dans le cadre des examens de victimes d’agression sexuelle, la diversité morpho-anatomique de l’appareil génital féminin impose une connaissance des variations physiologiques existantes par les praticiens prenant en charge ces victimes. Notre travail avait pour objectif de décrire et de caractériser l’examen génital des femmes ayant une activité sexuelle consentie. Méthode: Notre cohorte était constituée de 196 femmes âgées de 14 à 81 ans, examinées dans le cadre de consultations de gynécologie médicale de deux maternités françaises. Résultats: Les lésions traumatiques génitales d’allure récente étaient retrouvées chez 12,8% des femmes dont le dernier rapport sexuel datait de moins de 5 jours. Les hymens intacts, indemnes de déchirure traumatique malgré une activité sexuelle régulière, étaient présents chez 10,7% de ces femmes. Conclusion: Ainsi, dans de nombreux cas, l’examen génital seul ne permet ni d’affirmer, ni d’infirmer l’existence d’un rapport sexuel antérieur, qu’il soit ou non consenti. Le développement de travaux sur les données de l’anatomie génitale féminine, permettrait d’optimiser la prise en charge médico-légale des victimes d’agression sexuelle.
Chapter
Mittlerweile gibt es eine Fülle von wissenschaftlichen Daten über medizinische Befunde bei sexuell missbrauchten Kindern. Hinweise zu ihrer Beurteilung und Klassifizierung und zu ihrer Differenzierung von Normvarianten und anderen Differenzialdiagnosen existieren entsprechend. Dennoch ist der forensische medizinische Beweis eines sexuellen Missbrauchs die Ausnahme. Dies gilt für massive, akute anogenitale Verletzungen, die nicht akzidentell erklärbar sind, sowie bei einer gesicherten Gonorrhö oder Syphilis (nach Ausschluss einer angeborenen Infektion), bei einer Schwangerschaft oder beim Nachweis von Sperma in oder auf dem Körper eines Kindes. Für eine Reihe von Befunden, die als missbrauchsverdächtig gelten, ist die Zuordnung mit Unsicherheiten behaftet, da die Datenlage für eine definitive Bewertung noch unzureichend ist.
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This chapter provides an overview of an increasingly specialised and complex area where the understanding of physical signs is advancing and opinions changing. Detailed guidance on the assessment of children and young people for CSA is described in the RCPCH document ‘The Physical Signs of Child Sexual Abuse – an evidence based review and guidance for best practice’ [1].
Chapter
Die Hymenrekonstruktion ist ein wichtiger Bestandteil, wenn es um die Rekonstruktion der Jungfräulichkeit geht. In vielen Kulturen, in der die Jungfräulichkeit vor der Ehe eine sehr entscheidende Bedeutung hat, geraten viele junge, aufgeklärte und sexuell aktive Frauen in Not, den Familientraditionen besonders in muslimischen Kulturkreisen Genüge zu tun. Häufig wird dann eine chirurgische Intervention als einzig sinnvolle Möglichkeit gesehen, um die Familie nicht in „Unehre“ zu stürzen. In diesem Kapitel werden die psychosozialen Hintergründe, anatomische Grundlagen sowie die operative Technik der Hymenrekonstruktion dargelegt.
Article
To review data from patients who have undergone hymenoplasty with a novel surgical technique, termed the STSI (suture three stratums around the introitus) method. In a retrospective study, data were reviewed from patients who underwent hymenoplasty by STSI at a center in Beijing, China, between January 2010 and January 2014. Patients were scheduled to attend a follow-up appointment 1month after surgery. Long-term follow-up was conducted by telephone. Follow-up data and preoperative and postoperative photos were assessed. Overall, 125 patients had undergone hymenoplasty using the STSI method. Only 1 (0.8%) patient had an early postoperative complication (uncontrolled bleeding). Among the 99 patients who returned for follow-up at 1month, healing was recorded for 91 (91.9%). Long-term follow-up suggested that no patient had persistent dyspareunia, menstruation changes, or other health problems after the surgery. Among 51 patients who reported sexual intercourse since the surgery, 47 (92.2%) were satisfied with the outcome and 28 (54.9%) reported blood loss during the first intercourse. The STSI method seems to be an effective, enduring, and safe technique of hymenoplasty. Copyright © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Article
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To determine which type or types of childhood abuse are associated with adolescent pregnancy and other adverse health outcomes. 100 females between the ages of 12 and 24 years of age, attending either an adolescent/young adult clinic (for ages 12 to 24), or teen obstetrics clinic (for ages 13 to 18) at an urban academic medical center, were recruited to participate in an interview study during their clinic visit. The clinician or research assistant used a 186-item structured interview form to record answers to detailed questions on abuse, in addition to traditional questions about the patient's feelings on home, education, activities, drugs and depression, sex and suicide (HEADS). 32% of subjects reported a history of sexual abuse, 29% reported physical abuse, and 46% reported past emotional abuse. The frequency of any past abuse was significantly higher in girls who had ever been pregnant (29 of 50, 58%), compared with "never pregnant" girls (19 of 49, 38%)( P < .05). A past history of physical abuse (P = .04), but not sexual or emotional abuse, was significantly associated with pregnancy as a teen. Other factors significantly correlated with teen pregnancy were: frequent alcohol use, older age, and Mexican-American or African-American ethnicity. Past history of abuse was significantly correlated with depression, suicidal thoughts, absent father, school failure, alcohol and tobacco use, and delinquency. A history of past physical abuse is strongly associated with adolescent pregnancy, and questions about all types of abuse should be routinely asked of adolescent patients.
Study Objectives: To determine the frequency with which various examination methods and techniques are being used in the medical evaluation of suspected child sexual abuse and how medical examiners interpret the significance of physical and laboratory findings with respect to sexual abuse. Design: An 8-page, 68-item survey was mailed to physicians with a possible interest in sexual abuse evaluation. Participants: One hundred forty-one health professionals (90% pediatricians) who returned the completed surveys. Methods: Tabulations of responses to questions regarding the frequency of examination methods, use of magnification, culturing practices, measurement of orifice size, and interpretation of 57 physical and laboratory findings as normal to abnormal on a 5-point scale. Results: The overall response rate was 44%, after excluding 56 responses from the group with only a 12% response rate. A colposcope was used by 45% of respondents; 51% obtained cultures for sexually transmitted diseases on an female patients, and 42% on an male patients. Findings rated as abnormal by more than 90% of respondents were the presence of sperm or semen; confirmed positive culture for Neisseria gonorrhea; a positive culture for Chlamydia; lacerations of the hymen, posterior fourchette, and perianal tissues; and hymenal transections. Experience level significantly (p < 0.05) affected responses on 15 of the 68 items on the survey (22%). Conclusions: There is a high level of agreement among examiners on the significance of certain findings in suspected sexual abuse. Higher experience level was associated with the rating of several findings as nonspecific rather than abnormal.
Article
We undertook a prospective study of 300 postmenarcheal female subjects (median age, 18.0 years) to examine (1) the relation of tampon use, sports participation, prior gynecologic examination, and consensual sexual activity to hymenal anatomy, (2) the factors leading to choice of tampons by girls not sexually active, and (3) factors related to ease of gynecologic examination. The sample included 100 subjects in group 1, who denied sexual intercourse and used only pads for menses; 100 subjects in group 2, who denied sexual intercourse and had used tampons; and 100 subjects in group 3, who gave a history of sexual intercourse. Sexually active subjects (81%) were significantly more likely than tampon users and pad users to have "complete clefts" in the lower hymen between the 2 o'clock and 10 o'clock positions (p < 0.001); tampon users were not significantly different from pad users (11% vs 5%). In subjects who were not sexually active, the presence of these complete clefts was not related to participation in sports or to prior pelvic examination. Although median hymenal opening diameter differed in the three groups (1.2 cm for group 1 vs 1.5 cm for group 2 vs 2.5 cm for group 3; p < 0.0001), the ranges of measurements were wide. Tampon users were significantly more likely than pad users to have mothers and friends, but not sisters, who had a favorable attitude toward tampon use. The best predictors of tampon use in a multivariate model were a favorable maternal attitude (odds ratio (OR), 5.3; 95% confidence interval (CI), 2.4, 12.1) and friends' use of tampons (OR 7.9; 95% CI 3.5, 18.1). Only 26% of speculum examinations in pad users were rated as easy compared with 56% of examinations in tampon users and 81% in sexually active young women (p < 0.001). The best predictors of ease of speculum examination were sexual activity (OR 15.9; 95% CI 1.9, 135.3) and tampon use (OR 3.6; 95% CI 1.0, 12.7). This large sample should provide useful data for physicians who testify in sexual assault cases and gives new information on the predictors of tampon use and ease of gynecologic examination in young women.
Inspection of female adolescent genitalia for the evaluation of suspected sexual abuse is often a difficult task for the examiner. The hymens of Tanner III through Tanner V adolescents are normally estrogenized and, therefore, often thickened and redundant on examination. Examination of the margins of the hymen is difficult by visual inspection alone. Many authors1-5 recommend the use of a cotton-tipped swab to explore the hymenal margin. Even this technique can offer little advantage if the hymen is excessively redundant. One purpose of the sexual abuse examination is to examine the margins of the hymen for disruptions. These are especially concerning if the clefts extend to the hymental base, defined as the junction of the hymen and the vestibule.6 In the case of redundant tissue, it can be impossible to fully explore the entire hymen with use of a swab, because the tissue often folds back on itself
Article
Our goal was to identify vulvar and hymenal characteristics associated with sexual abuse among female children between the ages of 3 and 8 years. Using a case-control study design, we examined and photographed the external genitalia of 192 prepubertal children with a history of penetration and 200 children who denied prior abuse. Bivariate analyses were conducted by chi(2), the Fisher exact test, and the Student t test to assess differences in vulvar and hymenal features between groups. Vaginal discharge was observed more frequently in abused children (P =.01). No difference was noted in the percentage of abused versus nonabused children with labial agglutination, increased vascularity, linea vestibularis, friability, a perineal depression, or a hymenal bump, tag, longitudinal intravaginal ridge, external ridge, band, or superficial notch. Furthermore, the mean number of each of these features per child did not differ between groups. A hymenal transection, perforation, or deep notch was observed in 4 children, all of whom were abused. The genital examination of the abused child rarely differs from that of the nonabused child. Thus legal experts should focus on the child's history as the primary evidence of abuse.
Article
The genital examination is not a routine part of health maintenance assessment in prepubertal and pubertal girls. However, evaluation of minors for suspected sexual abuse has been addressed extensively in the last two decades. In spite of this, normal anatomic variations and developmental changes are not fully investigated. This paper reviews current knowledge about the hymen, with a focus on puberty and adolescence. More is known about the external genitals of prepubertal children than of adolescent girls. No longitudinal studies have been performed among girls older than age 3. Tanner staging does not include detailed genital development. A variety of terms have been used to describe the configuration and/or distortion of the hymen: attenuation, clefts, tears and transections, bumps and notches. No studies have been published on the normal variations of the width of the hymenal rim, although an attenuated and/or narrow rim is categorized as consistent with penetrative sexual abuse according to an international consensus statement. Critiques of the literature on the hymen have been published by experts on forensic medicine, emphasizing the fact that the normal hymenal appearance in adolescents still is not well documented. Few studies on hymenal configuration in nonabused adolescent girls have been performed, including girls with and without experience of consensual vaginal intercourse and use of tampons. Longitudinal investigations are required for a better knowledge of female genital development during puberty, with a special focus on vulvar and hymenal anatomy.