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 - Initial suspicion and legal outcome.

OBJECTIVES: To evaluate the association of primary reason to suspect child sexual abuse with the legal end-point in medically examined, police reported cases. STUDY DESIGN: Observational post hoc analysis of retrospective review of records of 155 medically examined, police reported alleged child sexual abuse (CSA) cases during 2001-2009. Primary referral indications for medical examinations or criminal investigations were analyzed with an end-point in the legal process. The data consists of official investigation documents from University Hospital records, police, crime laboratories, state prosecutor, and courts of Law. RESULTS: The median age of the children was 7.1 years (range 11 months-17.5 years) at the time when suspicion of sexual abuse was reported to police. Conviction of the alleged perpetrator was significantly more likely in cases where the child's disclosure was the reason for the initial suspicion of CSA, compared to cases with referrals for "suspicious circumstances" (39/92, 42.4% vs. 7/37, 19%, p<0.001). In 92 (59.5%) cases the initial suspicion of CSA arose from child's disclosure. The forensic interviewer's report supported more likely CSA allegations where the suspicion of CSA arose by child's clear, detailed and credible disclosure of what had happened, compared to the other initial reasons of suspicion (35/61, 57.4% vs. 13/42, 31.0%, p=0.001). In child's age category of 4-9 years conviction was significantly more likely where the initial suspicion of CSA arose with child's disclosure, compared to other reasons of suspicion (21.45, 46.7% vs. 5/27, 16.7%, p=0.001). No association was found regarding to whom the initial suspicion of CSA arose and legal outcome. Forensic interviewer's report supported the allegation of CSA more often if the suspicion was arose first to a neutral person (p=0.019). Legal outcome of conviction was associated with child's disclosure of perpetrator's physical contact regardless of how the suspicion arose (45/99, 45.5% vs. 10/46, 21.7%, p<0.001). CONCLUSION: The reason which initially arise a suspicion of child sexual abuse plays an important role in the criminal investigation. Initial suspicion of CSA by child's disclosure, an eyewitness or objective material may lead to higher conviction rates. If a concerning physical symptom or finding arise the suspicion of CSA, referral to expert consultation is recommended to prevent unnecessary allegations and investigations. Other possible differential diagnostic medical conditions need to be evaluated. Furthermore, when child's disclosure arise a suspicion of CSA, it needs to be thoroughly investigated, regardless to whom the child discloses to.

Urine specimen collection following consensual intercourse - A forensic evidence collection method for Y-DNA and spermatozoa.

The purpose of the prospective research was to evaluate the benefit of urine specimen as a collection technique for biological forensic evidence in adult volunteers following consensual intercourse. For detecting Y-chromosomal material Buccal Swab Spin Protocol(®) was used in DNA extraction and purification and samples were analysed with Quantifiler Y Human Male DNA Quantification Kit(®). The time frame for positive Y-DNA was evaluated. Immediate microscopy for detection of spermatozoa was performed. Y-DNA was detected in 173/205 (84.4%) urine samples. Of the 86 first post-coital void urine samples available, Y-DNA was detected in 83 (96.5%) specimens. Of the 119 urine samples from volunteers with post-coital activities Y-DNA was still measurable in 70 (58.8%) urine specimens. The male DNA amount was below 0.023 ng/µl in 28/153 (18.3%) urine samples. Of the 22 urine samples obtained after 24 post-coital hours, 9 (40.9%) were still Y-DNA positive. No associations were found between coital durance, coital frequency during the past two weeks prior to the study intercourse, post-coital activities, and the urine sample Y-DNA positivity. Of the 111 urine samples where the immediate microscopy was performed, in 66 (59.5%) samples spermatozoa were verified and one sample even contained motile spermatozoa. Microscopy detected 66 (67.3%) and failed to detect spermatozoa in 32 (32.7%) of Y-DNA positive samples. In addition to conventional invasive swab techniques, urine samples seem to be an effective biological trace collection method for Y-DNA and spermatozoa within 24 h following penile-vaginal penetration. Furthermore, it may be considered as a non-invasive collection method in suspected acute child sexual abuse cases to diminish time delay in forensic evidence collection and to improve patients' positive attitudes towards evidence collection.

[When suspicion of child sexual abuse is raised--what to do?]. / Lapseen kohdistuneen seksuaalisen väkivallan epäilyn herätessä--mitä tulee huomioida?

Upon a raised suspicion of child sexual abuse, time must be taken to control and calm down tne situation. It is important for those working with children to take actions without causing problems to the course of the possible criminal process. Advance issue with treatment guidelines is a good way to confirm adequate basic information about the phenomenon. Hearing the child and detailed documentation of the information are essential. Excessive questioning may have a negative impact on the criminal process. The urgency of somatic investigations is determined by the last possible time of occurrence of the suspected abuse.

Clinical forensic sample collection techniques following consensual intercourse in volunteers - cervical canal brush compared to conventional swabs.

The purpose of the research was to evaluate gynecological evidence collection techniques; the benefit of cervical canal brush sample compared to vaginal fornix and cervical swab samples and the time frame for detecting Y-chromosomal material QiAmp DNA Mini Kit(®) and Quantifiler Y Human Male DNA Quantification Kit(®) in adult volunteers following consensual intercourse. Eighty-four adult female volunteers following consensual intercourse were recruited for the study. By combining all sample collecting techniques, 81.0% of the volunteers were Y-DNA positive. Up to 60 h the conventional swab sampling techniques detected more Y-DNA positive samples when compared to the brush technique. However, after 60 h, the cervical canal brush sample technique showed its benefit by detecting 27.3% (6/22) of Y-DNA positive samples, which were Y-DNA negative in both conventional swab sampling techniques. By combining swab and brush techniques, 75% of the volunteers were still Y-DNA positive in 72-144 post-coital hours. The rate of measurable Y-DNA decreased approximately 3% per hour. Despite reported consensual intercourse, 6.8% (3/44) of volunteers were Y-DNA negative within 48 h. Y-DNA was not detected after 144 post-coital hours (6 days). In conclusion, the brush as a forensic evidence collection method may provide additional biological trace evidence from the cervical canal, although the best biological trace evidence collection can be obtained by combining all three sampling techniques. The time frame for gynecological forensic evidence sample collection should be considered to be at least a week if sexual violence is suspected.

Evaluation of anogenital injuries using white and UV-light among adult volunteers following consensual sexual intercourse.

OBJECTIVES: New clinical forensic examination techniques for sexual assaults have not been introduced over the last few decades. We evaluated the benefit of ultraviolet light compared to white light for detecting minor anogenital injuries and scars, following consensual sexual intercourse among adult volunteers. DESIGN: A prospective study comparing female genital findings utilising white and ultraviolet light. A colposcopy with photographic documentation was used. SETTING: Personal invitation to healthcare students, hospital employees or acquaintances to volunteer for a gynecological examination, with a focus on clinical forensic aspects. PARTICIPANTS: Eighty-eight adult female volunteers were recruited for the study. The examination was performed after consensual intercourse. Age ranged from 20 to 52 years (median 26.5 years). MAIN OUTCOME MEASURES: Presence of acute findings and scars in the genital area using white and UV-light. RESULTS: Acute genital injury rate was 14.8% under white light colposcopy and 23.0% using UV light. Submucosal hemorrhages in the genital area were documented significantly better under UV-light than white light (14.9% vs. 6.8%; p=0.016), whereas petechiaes (4.5%) and abrasions (2.3%) were detected using either method. UV-light revealed significantly more often delivery-associated genital scars compared to white light (39.8% vs. 31.8%; p=0.016). Furthermore, 10 out of 31 (33.3%) women had no residual anogenital skin or mucosal surface findings, despite a prior episiotomy or rupture of the vaginal outlet wall during delivery, supporting its enormous ability to heal even after major trauma. CONCLUSIONS: UV-light may provide additional value for the evaluation of physical findings in clinical forensic examinations after sexual assault, and is especially useful in detecting otherwise invisible early submucosal hemorrhages and scars.

Child sexual abuse--Medical statement conclusions in criminal legal process.

OBJECTIVES: To evaluate medical statement conclusions in the criminal-legal process in suspected cases of child sexual abuse (CSA). STUDY DESIGN: An observational study of a random sample of 130 medically examined, police reported CSA suspected cases during 2001-2009. Medical statements were evaluated and their conclusions were analyzed with an end-point in the legal process. The data consists of official investigation documents from the University Hospital records, the Police, crime laboratories, the State Prosecutor, and the Courts of Law. RESULTS: The median age of the children was 5.3 years (range 11 months-17.3 years) at the time of the suspected sexual abuse. In most cases (76.2%, 99/130) medical statement conclusions neither supported nor excluded the suspicion of CSA. Twenty-one (16.2%) medical statements supported and in 10 cases (7.7%) the conclusion did not support the suspected CSA. Of the suspected CSA cases a hundred (76.9%) proceeded to the Prosecutor. The charge filing rate was 41.5% (54/130). The final conviction rate was 30.8% (40/130) and 74% in the charged cases. Medical statements were mentioned as evidence in the Prosecutor's decision to file charges in 18 (33.3%) of suspected CSA cases and in 15 (36%) of verdicts. A child's clear disclosure of CSA (p<0.001) and medical statements (p=0.037) had a significant role in decision making on convictions. CONCLUSION: In medical statement conclusions, physical findings with proper documentation and interpretation are needed to avoid misunderstandings in the legal process. The present study supports a routine medical statement peer review to minimize the risk of neglect caused by lack of knowledge among authorities working with sexually abused children.

[Update in Current Care guidelines. Evaluation of a suspected child sexual abuse]. / Lapsen seksuaalisen hyväiksikäytön epäilyn tutkiminen.

According to Finnish Child Welfare Law, the authorities are obligated to report suspicions of child sexual abuse immediately to the police and to social services to ensure the well being of the child. The investigating police may request assistance for forensic interviews and medical assessments from specialized units. The child's disclosure is often the most important part of the evaluation. The timing of medical examination is crucial to obtain biological trace of evidence and to document evidence of acute injury or infection. The need for crisis support must be evaluated.

Childhood lichen sclerosus--a challenge for clinicians.

Childhood lichen sclerosus (LS) is a rare and often misdiagnosed inflammatory dermatitis with an unpredictable course. The complications of LS are architectural changes of the vulva; malignant transformation is possible. The objective of our study was to define the background and the long-term course of childhood LS. A registery study identified 44 children with LS treated at Tampere University Hospital, Tampere, Finland, from 1982 to 2010. A questionnaire was sent to the identified patients and 15 responded. The clinical depiction of LS varied significantly. LS was diagnosed in only 16% of the patients at the referring unit. Autoimmune disorders were observed in 6 of the 44 patients. High prevalences of Turner's syndrome (2/44) and kidney disease (2/44) were noted. The majority of the patients were treated with topical corticosteroids. Eight developed architectural changes of the vulva. The questionnaire revealed that three of six patients who were asymptomatic at the end of the registery study follow-up experienced a recurrence of symptoms. None of them were undergoing follow-up. Nine of the 15 patients reported reduced quality of life. Childhood LS is a heterogeneous disease with a remarkable effect on quality of life. The misdiagnosis of childhood LS is common. The association between LS and autoimmune diseases should be noted. The high prevalence of Turner's syndrome raises questions regarding the influence of low estrogen levels on the development of LS. The prognosis cannot be predicted, so long-term follow-up is recommended. New tools for diagnosis and surveillance are needed.

Presenting and long-term clinical implications and fecundity in females with obstructing vaginal malformations.

OBJECTIVE: To evaluate presenting and long-term clinical consequences in females with obstructing vaginal anomalies. DESIGN: A retrospective study. SETTING: A university hospital in southern Finland. PARTICIPANTS: Twenty-six females with obstructing vaginal malformations. The conditions were classified into transverse vaginal obstruction (transverse septum or imperforate hymen) and longitudinal vaginal obstruction (longitudinal vaginal septum). INTERVENTIOS: 13 out of 16 women with transverse vaginal obstruction underwent incision of the imperforate hymen and three underwent excision of a complete transverse vaginal septum. Ten patients with obstructing hemivagina had incision of the longitudinal vaginal septum. MAIN OUTCOME MEASURES: Presenting symptoms and delay in diagnosis, outcome of primary surgical treatment, possible late complaints associated with obstruction, fecundity, perinatal outcome, and presence of other anomalies were studied. The mean followup period in the transverse and longitudinal obstruction group respectively was 13 years (range 1-29) and 16 years (range 1-44). RESULTS: Transverse vaginal obstructions were diagnosed within less than a month from the primary symptoms, while the diagnosis of longitudinal obstruction was delayed for an average of 27 months. Two out of three females with transverse vaginal septum underwent re-operation for vaginal constriction and three out of 10 with longitudinal vaginal septum had re-excision of the septum. All females with longitudinal obstruction had uterine and renal malformations as opposed to those with transverse vaginal obstruction. In the transverse vaginal obstruction group, two out of the six females who had their renal status assessed had double ureters. Dysfunctional uterine bleeding (19% in the transverse and 40% in the longitudinal obstruction group), dyspareunia (30% and 0%) and dysmenorrhea (19% and 20%) were the most common complaints during the followup. No endometriosis was found in the group that underwent a subsequent laparotomy or laparoscopy (18/26). Female infertility was not found in those 14 females who were attempting to conceive. Twenty-five (89%) out of 28 pregnancies ended in delivery, the live birth rate being 82% in the longitudinal and 94% in the transverse obstruction group. CONCLUSION: Accurate diagnosis together with adequate treatment may reduce the need for re-operations in cases with obstructing vaginal malformations. No specific gynecologic long-term clinical symptoms were identified in obstructing vaginal anomalies.

Gonadoblastoma and dysgerminoma associated with XY gonadal dysgenesis in an adolescent with chronic renal failure: a case of Frasier syndrome.

STUDY OBJECTIVES: To report a rare reason for primary amenorrhea, a Frasier syndrome, XY gonadal dysgenesis associated with renal failure with eventual development of gonadoblastoma. To study immunohistochemical analysis of gonadoblastoma and dysgerminoma. To analyze the possibility of androgen receptor mutation in this rare syndrome. METHODS: We report a case of a 16-yr-old female with this syndrome. She underwent a laparoscopic bilateral gonadectomy and salpingectomy. A histopathological examination revealed gonadoblastoma with focal malignant dysgerminoma in the left dysgenetic gonad and an immunohistochemical of these fairly rare, malignant tumors. An androgen receptor was coded. Analysis was done. RESULTS: Immunohistochemical analysis showed that inhibin was strongly positive in gonadoblastoma but negative in dysgerminoma. No mutations of the androgen receptor gene were found. CONCLUSIONS: Inhibin positivity in gonadal stroma and in gonadoblastoma may indicate hormonal activity causing advanced puberty in patients with XY gonadal dysgenesis.