Distinct age-related differences among victims in cases of suspected child abuse.

Evidence describing age-related differences among children with suspected physical and sexual child abuse is lacking. We describe findings in severe cases of suspected abuse. Cases with 756 children <15 years old were included during 2001-2013 at the Department of Forensic Medicine, Aarhus University, using forensic evaluation documents, medical records, and court proceedings. Eight percent of children <4 years old died from child abuse, 36% through violence resulting in death, and 64% by manslaughter, whereas 1% > 4 years old died, solely by manslaughter. External injuries were mainly located to head and torso in children <4 years old, changing to the upper and lower extremities in older children. Child sexual abuse was suspected in 52% of cases with living children <4 years old, 83% of children 4-7 years of age, 88% of children 8-11 years of age, and 93% of children >12 years old. Anogenital findings were mainly caused by other medical conditions in children <4 years old, hymenal clefts in the superior half of the hymenal rim were almost exclusively found in children between 8 and 11 years of age, whereas both superficial and complete hymenal clefts in the inferior half of the hymenal rim were found in children >12 years old. The present study describes age-related differences in victims of suspected child abuse. Fatal versus nonfatal child physical abuse and the significance of hymenal findings in child sexual abuse could be studied further.

Hymenal transections in children found by photocolposcopy in suspected sexual abuse cases is associated with a history of bleeding.

OBJECTIVE: To investigate the difference in selected variables between children with and without hymenal transection, which is a healed defect that extends through the entire depth of the posterior hymenal membrane to the vaginal wall. MATERIALS AND METHODS: All female children from Southern Denmark who were examined by photocolposcopy in a six-year period were included in a retrospective cohort study. Statistical analyses included a chi-square test and a logistic regression analysis. RESULTS: Eighty girls under 15 years of age who were suspected to have been sexually abused were included. Sixteen of the girls had hymenal transections. There was a statistically significant correlation between the presence of hymenal transections and reported fresh bleeding after the assault. CONCLUSION: Bleeding after an assault could indicate more severe lesions, which might explain why these patients did not heal completely.

Colposcopio para para el examen de alteraciones himeneales en casos de abuso sexual / Colposcope for the examination of hymenal alterations in cases of sexual abuse

INTRODUCCIÓN: Este documento técnico se realiza a solicitud del Instituto Nacional de Salud del Niño - San Borja. A. Cuadro clínico: En los últimos años, las denuncias por delitos sexuales han ido aumentando en su mayoría en menores de edad. El peritaje de víctimas de abuso sexual es un proceso difícil para la víctima, que no sólo tiene que relatar un episodio traumático, sino que se tiene que someter a una serie de pruebas físicas y de laboratorio. Usualmente para evaluar el himen, especialmente en casos pediátricos, se utiliza la visualización directa con la ayuda de una lupa (x40). Este proceso, si bien es inocuo, se tiene que repetir en cada peritaje durante el proceso legal asociado al abuso sexual. Sin embargo, existen tecnologías que podrían hacer grabaciones del examen para que no deba ser repetido por la víctima. B. Tecnología sanitaria: El colposcopio es un dispositivo usado para la evaluación de los genitales femeninos. La magnificación del colposcopio hace mucho más preciso la identificación de anormalidades en los genitales internos tanto como externos. El colposcopio viene acompañado de cámara fotográfica o cámara de video que permite la grabación del examen de alteraciones del himen en el caso de abuso sexual. OBJETIVO: Evaluar la eficacia y seguridad, así como documentos relacionados a la decisión de cobertura del colposcopio para examen de alteraciones himeneales en casos de abuso sexual. METODOLOGÍA: Se realizó una búsqueda en las principales bases de datos bibliográficas: MEDLINE, LILACS, COCHRANE, así como en buscadores genéricos de Internet incluyendo Google Scholar y TRIPDATABASE. Adicionalmente, se hizo una búsqueda dentro de la información generada por las principales instituciones internacionales de ginecología y agencias de tecnologías sanitarias que realizan revisiones sistemáticas (RS), evaluación de tecnologías sanitarias (ETS) y guías de práctica clínica (GPC). RESULTADOS: No se encontraron ensayos clínicos, revisiones sistemáticas de ECAs, evaluaciones de tecnología sanitaria ni evaluaciones económicas que evaluaran la tecnología de interés. Se identificaron cuatro estudios comparativos diagnósticos y cuatro GPC. CONCLUSIONES: • Si bien los estudios no coinciden en que la colposcopía brindaría beneficios en el diagnóstico de alteraciones himeneales en niñas con sospecha de abuso sexual, las GPC recabadas mencionan la importancia de un proceso de documentación adecuado por razones legales y para evitar la reevaluación de pacientes. No se encontraron evaluaciones de tecnología sanitaria que evaluaran la tecnología de interés.

The little tissue that couldn't - dispelling myths about the Hymen's role in determining sexual history and assault.

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.

Impact of mechanical force on posterior hymen - Implications for sexual abuse injury interpretations.

BACKGROUND: Residual anogenital findings following sexual abuse are rare. There is a need for further understanding of the interpretation of hymenal findings. OBJECTIVES: This study evaluates which is more significant with respect to posterior hymenal tissue morphology - previous consensual penile vaginal penetrations or vaginal delivery. DESIGN: A post hoc study comparing nulliparous and parous hymen in heterosexually active female volunteers, with the focus on healed hymenal defects. Adult posterior hymen configuration was evaluated using labial separation or traction. When needed, the hymenal status was evaluated using a swab. A colposcopy with photography was used for documentation. Experts reviewed all taken photographs and recorded the posterior hymenal defects. Photographs were analyzed to determine the level of agreement. PARTICIPANTS: Eighty-seven adult female volunteers were recruited to participate in the study by a personal invitation to a gynecological examination to document anogenital findings. The examination was performed following consensual vaginal intercourse. Age ranged from 20 to 53 (median 26.6years). RESULTS: Single site posterior hymenal transections were significantly more likely in the nulliparous volunteers, compared to the parous volunteers (22/51, 43.1% vs. 4/36, 11.1%, p<0.001). A deep notch, which extends nearly to the base of the hymen was detected in one (2.0%) sexually active nulliparous volunteer, and surprisingly two (3.9%) volunteers had a single, more superficial hymenal notch, that is not considered a sign of previous vaginal penetration. The width of the ridge of the posterior vaginal wall in the vestibule was measured from the anterior part of the navicular fossa to the base of the hymen. The mean width of the ridge of the posterior vaginal wall was 3.1mm (SD2.2, range 0-8) in the photos of 41 nulliparous volunteers. The prevalence of 'double leaf hymen' was 2/87 (2.3%). The inter-rater reliability with a Kappa score of 0.69 indicated strong agreement. CONCLUSION: The myth "hymen is present only in virgins" has now been invalidated. The absence of posterior hymen increases delivery by delivery in adult female volunteers. The space between the anterior part of the navicular fossa and the base of hymen, 'the ridge of the posterior vaginal wall' in the vestibule was evaluated for the first time among studies evaluating hymenal status. Careful assessment of the ridge of the posterior vaginal wall is needed to avoid misinterpretations when evaluating the depth of a hymenal defect.

Child Sexual Abuse Confirmed by Forensic Examination in Salvador, Bahia, Brazil.

Child sexual abuse is a worldwide public health issue. The objective of this study was to describe the demographic and clinical characteristics of children in cases of sexual abuse confirmed by material evidence at forensic examination. Cases of children younger than 12 years examined for suspected sexual abuse at the Institute of Forensic Medicine in Salvador, Bahia, Brazil, were reviewed retrospectively. The period evaluated was between 2005 and 2010. The inclusion criterion was the coroner's confirmation of sexual abuse based on material evidence. The mean age of the children in whom sexual abuse was confirmed was 8.2 (SD, 2.9) years, and 208 cases were female (83.9%). In 94% of the cases, the reason for carrying out the forensic examination was a report of sexual abuse. Less than 1% of the aggressors were female. A ruptured hymen was the finding that confirmed sexual abuse in 172 cases, corresponding to 83% of cases in girls. There were 2 cases of pregnancy. Recent anal or perianal lesions were present in 35 (87.5%) of the confirmed cases involving boys. Laboratory confirmation based on the detection of spermatozoa or prostate-specific antigen occurred in only 4.2% of cases. In all these cases, sample collection was performed within 24 hours of the alleged abuse. Thus, in the majority of cases with material evidence of sexual abuse, the confirmation criteria consisted of a ruptured hymen and recent perianal lesions.

Características y frecuencias de las lesiones genitales, paragenitales y extragenitales en mujeres víctimas de violacion sexual anal y vaginal en la ciudad de Arequipa, 2013 / Characteristics and frequency of genital, paragenital and extragenital lesions in women of anal and vaginal sexual rape in Arequipa city 2013

En la perpetración de la violación se utiliza la violencia física, la amenaza o uso de sustancias tóxicas. La presencia de lesiones indica el uso de violencia física; algunos juristas indican que para poder tipificar la violación es necesaria la presencia de lesiones. Objetivos: Determinar cuáles son las características y frecuencia de las lesiones genitales, paragenitales y extragenitales en mujeres víctimas de violación sexual anal y vaginal. Diseño: Estudio descriptivo retrospectivo, realizado en el Instituto de Medicina Legal de Arequipa (IML). La población de estudio fueron las mujeres que se les realizó examen de integridad sexual, durante el año 2013. Se revisó la base de datos y se seleccionaron las pericias de integridad sexual en las que las victimas refirieron violación, se clasificó según grupo etario, características himeneales, tipo y localización de lesiones. Resultados: En el 2013 se realizaron 27,485 reconocimientos medico legales el 3 .27% fueron exámenes de integridad sexual en mujeres. El grupo etario con mayor vulnerabilidad fue el de 16-20 años (27.8%), solo 445 confirmaron acto violatorio, el 26.07% de himenes fueron complacientes. De las mujeres que referían violación eI 43.8% presentaron lesiones mientras que el 56.2% no presentó lesiones. Fueron más frecuentes las lesiones extragenitales con 49.7% mientras que la presencia de lesiones en las tres áreas fue menos frecuente. Las lesiones contusas fueron de presentación más frecuente, mientras que solo en un caso se encontró herida cortante. Los signos de violación más frecuentes fueron el desgarro himeneal reciente y la hipotonía anal.

Objective: In the commission of the violation is used the physical violence, threat or use of toxic substances. The presence of lesions indicates the use of physical violence; some jurists suggest that to establish the violation is necessary presence of lesions. Objectives: To determine the characteristics and frequency of genital, paragenital and extragenital lesions in women victims of anal and vaginal rape. Design: Retrospective descriptive study at the Legal Medicine Institute of Arequipa. The study population were women who underwent forensic medical examinations of sexual integrity during 2013. The database was reviewed and sexual integrity, and among these, those that reported rape. They were classified far group age, hymenal characteristics, type and location of injury. Results: In 2013, 27.485 forensic tests were performed, with 3.27% for sexual integrity tests in women. The most vulnerable group was 16-20 years (27.8%), only 445 confirmed delict; 26.07% of the hymen were complacent. Of the women who reported rape 43.8% had lesions, while 56.2% had no injuries. Were more frequent extragenital lesions with 49.7%, while the presence of injuries in the three areas was less frequent. Blunt injuries were the most frequent presentation, while only one case was found with stab wounds. The most common signs of rape were the recent hymenal tear and anal hypotonia.

Hymenal lesions and legal outcome in sexually abused girls with a history of vaginal penetration.

PURPOSE: In many cultures, it is commonly accepted that the hymen remains unchanged throughout childhood, until it is torn at the first episode of sexual intercourse. Therefore, the definition of virginity is directly linked to a normal hymen. However, most girls referred for medical forensic colposcopic examination have normal or nonspecific findings, the prevalence of abnormal findings in girls with a history of genital penetration being only 4-6%. The aim of this study was to investigate the relation between hymenal findings seen at the colposcopic examination and the legal outcome: prosecution in court and conviction in court. RESULTS: During the 80-month period of our study, 426 girls with a median age of 9 years (range 0-15 years) were included. A history of at least one vaginal penetration was given in 226 of the girls with a median age of 12 years (range 2-14 years). The hymenal findings were described as normal in 125 of the 226 cases (55%). In 50 cases (22%), hymenal clefts were found, 17 (34%) of which were complete and 33 (66%) incomplete. The finding of hymenal clefts increased with age. Of the 226 cases of girls being sexually assaulted with vaginal penetration, 119 cases (53%) were prosecuted in court, 102 of which (86%) resulted in conviction. Thirty-five (70%) of the cases with hymenal clefts and 100 (57%) of the cases without hymenal clefts were prosecuted in court, showing a correlation between hymenal clefts and conviction; however, the correlation was not significant (χ(2) test=2.1 and P=0.14). In total, 29 (58%) of the cases with hymenal clefts and 88 (50%) of the cases without hymenal clefts were convicted in court, which shows no significance (χ(2) test=1.0 and P=0.33). CONCLUSIONS: The single most important feature for conviction in court is the child's testimony and not hymenal findings seen at the colposcopic examination. Especially the testimony of the older children leads to conviction, raising the question whether the videotaped testimonies are aimed at the court proceedings, or whether hearing the child's testimony directly in court has a more powerful effect. Overall, it is crucial that the videotaped police questioning of the younger children is performed by specialized personnel, with the aim of presenting the testimony in a detailed and credible manner in court, giving children of all ages a fair trial.

[Practical guide to the examination and interpretation of genital lesions of minor female victims of sexual assault]. / Victimes féminines mineures d'agressions sexuelles : guide pratique pour l'examen et l'interprétation des lésions génitales.

Through a comprehensive review of the literature on sexual assault, the authors propose to clarify the different stages of the exam and help the practitioner to the forensic interpretation of lesions. The authors describe the basic principles that make consensus in how to interview victims in order to increase the reliability of the information collected. The various medical data that must be collected allowing to guide diagnosis (urogenital symptoms, sexual behaviour disorder) or facilitate the interpretation of lesions (age of puberty, use of tampons…) are specified as well as the different positions of examination and their association to other complementary techniques (Foley catheter, colposcopy, toluidine blue). The authors present a simple decision tree that can help the practitioner to interpret the laceration of the hymen. They detail the description and forensic interpretation of all genital lesions that may be encountered as a result of sexual assault, and the pitfalls to avoid. Finally, two main problems in the interpretation of lesions are described, the absence of injury after penetration and the accidental genital lesions.

Lesiones del himen en reconocimientos médico legales (RML) ginecológicos por delitos contra la libertad sexual / Hymen injuries in medical legal recognition (MLR) for crimes against gynecological sexual freedom

Determinar las caracteristícas de las lesiones himeneales y lesiones genitales, paragenitales y extragenitales. Material y Métodos: Se realizó un estudio descriptivo prospectivo de enero a diciembre del 2013. Resultados: Se realizaron 47 RML Ginecólogicos por delitos contra la libertad sexual. El 38,29% (18/47) correspondio a peritadas entre 15 a 17 años. Los hallazgos fueron: himen Integro (18,92%), himen complaciente (8,11%), defloración reciente (8,11%) y defloración antigua (72,97%), entre otros hallazgos. Conclusión: Las desfloraciones antiguas pueden tener lesiones himeneales nuevas, ello debido al diámetro del orificio himenal, existiendo mayor frecuencia cuando el orificio himenal es pequeño y mediano; a diferencia de cuando el orificio himeneal es grande o muy elástico (himen complaciente) que crea dificultades en el reconocimiento de lesiones...

To determine hymenal injuries and genital, paragenital and extragenital lesions. Material and Methods: A prospective descriptive study was conducted January to December 2013. Results: 47 MLR were performed gynecological for crimes against sexual freedom; 38.29 % (18/47) corresponded to women between 15-17 years. The findings were: Integro hymen (18.92 %), willing hymen (8.11 %), Recent deflowering (8.11 %) and old deflowering (72.97 %), among others findings. Conclusion: Older Defloration hymens may have new lesions, this due to the diameter of the hymenal orifice, there most often when the hymenal orifice is small to medium; unlike when the hymen hole is large or very elastic we face a complacent hymen which creates difficulties in recognizing injuries...

Hymen Tearing in the Treatment of Vaginal Agenesis: Implications on Women in Turkey.

Rupture of the hymen before marriage is a significant problem for a woman and her family. The purpose of this article is to present a case report where hymen membrane perforation was required for vaginal agenesis in a 13-year-old adolescent, identify psychosocial issues related to the torn hymen in the Turkish culture, discuss gender inequality affecting health care of women with a torn hymen, identify the impact of a torn hymen on a Turkish woman's social status, and discuss health care implications for the woman and her family. The girl could not understand the situation and experienced feelings of guilt. The parents displayed an intense reaction of shock and denial after being informed about the disorder and treatment process and felt a sense of hopelessness about the future of their daughter. Nurses are expected to fulfill their training, counseling, and advocacy roles about this issue.

Injuries in prepubertal and pubertal girls.

In this chapter, examination techniques are first recommended, and then terminology for genital injuries that may occur after child sexual abuse or rape (e.g. lacerations, notch, transaction) are described. Current evidence for these injuries is provided. Areas of controversy (e.g. hymenal diameter, hymenal width) are described and completed with cautionary notes on inflammation, bruising, abrasions, bumps and mounds, tags, labial fusion, lichen sclerosis). The chapter concludes with a debate on normal findings that are reported to occur in up to 99% of children referred for examination.

El himen imperforado como urgencia en ginecología. Caso clínico y revisión de la literatura / Imperforate hymen as a gynecological emergency: case report and literature review

El himen imperforado se presenta en aproximadamente una de cada 2.000 mujeres. Es la causa congénita más común de obstrucción del flujo genital y, por lo general, no suele presentar síntomas hasta la pubertad. Presentamos el caso de una adolescente de 13 años que acudió a nuestro servicio de urgencias refiriendo dolor abdominal y metrorragia. La exploración física reveló un himen íntegro y abombado por el que empezaba a drenar sangre oscura. La ecografía transabdominal era sugestiva de hematocolpos y hematometra. La paciente recibió tratamiento quirúrgico y la evolución postoperatoria fue favorable (AU)

Imperforate hymen occurs in approximately 1 out of every 2000 females. This entity is the most common congenital cause of genital outflow obstruction and does not usually cause symptoms until puberty. We present the case of a 13-year-old girl who attended the emergency department complaining of abdominal pain and metrorrhagia. Physical examination revealed an imperforate and bulging hymen beginning to drain dark blood. Transabdominal ultrasonography was suggestive of hematocolpos and hematometra. The patient was treated surgically and the postoperative outcome was favorable (AU)

Sexual assault in prepubertal girls: 'It is normal to be normal' - or is it? Evidence of vaginal penetration in prepubertal girls.

Study objective The purpose of this study is to evaluate the long-term effects of penile vaginal penetration in prepubertal girls. The specific emphasis is on whether there would be visible identifiable medical evidence of penetration on examinations done months or years after the event. Literature review The medical literature regarding this subject was reviewed specifically for defendable evidence supporting a statement that there would be no findings as well as those that suggested that there would be visible evidence of trauma. Specific definitions of sexual assault, visible anatomic change from trauma, and sexual penetration are established for clarity. The effect of the lack of estrogen on the genital tissue of prepubertal girls is reviewed in relationship to the potential effects of trauma. The average diameters of the hymenal opening in this age group and the diameter of the erect male penis were reviewed. Conclusion The result of the study both from review of the medical literature and an understanding of the anatomy and histology of the unestrogenized genitalia of the prepubertal girl makes it clear that if there has been forceful penile penetration of the hymen there will be both a history of pain and bleeding and healed evidence of this forceful penetration.