Improving the forensic genital examination for trans and gender diverse sexual assault complainants: three case reports.

Trans and gender diverse people experience high rates of sexual violence and significant barriers to healthcare, including post-sexual assault healthcare. These barriers could lead to delays in presentations to sexual assault services and a reluctance to having forensic examinations, thereby impacting genital injury assessment and evidence collection. It is therefore important that clinicians working in sexual assault services understand how to best undertake forensic genital examinations, collect forensic genital specimens, and identify and document genital injuries in this population. This case report discusses three trans and gender diverse complainants of sexual assault seen at the Sexual Assault Resource Centre in Western Australia. These cases, along with an accompanying review of the literature, have been used to change the centre's practice towards this community to improve forensic genital examinations. This has included creating specific trans and gender diverse medical and forensic notes, improving clinician knowledge around trans and gender diverse genital examinations and genital injury profiles, creating an inclusive physical environment, improving trans and gender diverse patient knowledge around sexual assault services, and providing options for genital specimen collection.

Patient Query in Adolescent Testicular Torsion Cases: "Was it Necessary to Mention My Scrotal Pain?"

Objective This study investigates the reasons for the failure to diagnose testicular torsion (TT) in different healthcare facilities (HCFs) and by various physicians. Method We retrospectively analyzed all male patients who underwent TT surgery within the adolescent age group between 2015 and 2023. Healthy adolescent patients who initially presented or were referred to an HCF and were subsequently diagnosed at our hospital for TT surgery were analyzed, focusing on why they were not diagnosed earlier. Results A total of 11 patients aged 10 to 17 who were surgically confirmed to have TT at our hospital between 2015 and 2023 were analyzed retrospectively. These patients had been admitted to various public and private HCFs due to the sudden onset of symptoms such as abdominal pain, vomiting, fainting, sweating, and walking difficulties during and after working hours. Four patients had previously been admitted to one HCF, while seven had been admitted two to six times to an HCF. All patients were healthy, and all but one had received age-appropriate education. However, only two of them had reported experiencing scrotal pain. Laboratory tests and/or radiological examinations were conducted on eight patients, and nine patients received medical treatment and/or prescriptions. None of the patients were initially diagnosed with acute scrotum. Conclusion Despite having unrestricted and free access to well-equipped HCFs, the early diagnosis and treatment of TT are not ensured. Factors contributing to this delay include patients' concealment of, or failure to fully disclose, scrotal complaints, as well as physicians' incomplete history taking and genital examinations. The physician's male gender was not found to contribute to an earlier diagnosis of TT. A mandatory genital examination should be included in the emergency assessment protocol for male patients.

Gastrointestinal bleeding caused by metastatic testicular choriocarcinoma: a case report and literature review.

BACKGROUND: Testicular tumor is one of the common solid tumors in young men. Testicular choriocarcinoma is a non-spermatogonial germ cell tumor, which is the rarest of all testicular cancers. Choriocarcinoma usually shows bleeding at the metastatic site, while gastrointestinal involvement is rare. METHODS: Here, we report a case of testicular choriocarcinoma with gastrointestinal bleeding as the first diagnosis and summarize the similar cases all over the world in recent 20 years. RESULTS: A 28-year-old male was treated with repeated melena for 2 months. No bleeding foci of the stomach, duodenum, colon, and rectum were found in endoscopy, and no bleeding foci of digestive tract was found in selective angiography, but a space occupying lesions of the lung, liver, and upper jejunum were found in chest and abdominal CT. Considering the possibility of a metastatic tumor and the ineffectiveness of medical treatment, the patient was converted to surgical treatment. The postoperative pathology was consistent with testicular choriocarcinoma. The patient received a chemotherapy regimen of paclitaxel, ifosfamide, and cisplatin. At present, the chemotherapy regimen is well tolerated. CONCLUSIONS: The case report confirmed that even if we cannot find the logical relationship between clinical manifestations and genital examination, genital examination should also be part of the patient's systematic examination.

Incestuous childhood sexual abuse between siblings resulting in pregnancy without sexual intercourse.

Victims of incest are usually women and children who are mostly girls. The abuse between siblings may remain hidden because of the family's fear of social stigma, though it may result in pregnancy. This article presents a case of incestuous childhood sexual abuse between siblings resulting in pregnancy without intercourse, an event rarely reported in the literature. An 11-year-old girl was brought to the hospital because of a stomachache and was detected pregnancy from examinations. Forensic medicine experts determined that the girl's hymen was still intact and non-elastic in the genital examination. Gynecology and Obstetrics Department confirmed the pregnant compatibility with 14 weeks, 4 days; after ultrasonographic monitoring. She was abused by her 14-year-old brother by rubbing for 1 year and this resulted in pregnancy. During the psychiatric examination, her attitude was negative and symptoms of post-traumatic stress disorder emerged. Medical abortion was applied after psychiatric and gynecological examinations. The girl's brother was confirmed as the biological father after the DNA paternity test was conducted on the fetus. Based on this case, this article aimed to examine the medical, social, and legal problems caused by incestuous childhood sexual abuse and contribute to the literature by emphasizing what forensic medicine and preventive medicine approaches should consider in such cases.

[Prospective forensic study on the characterization of genital examination in women with consented sexual activity]. / Étude médico-légale prospective sur la caractérisation de l'examen génital chez des femmes ayant une activité sexuelle consentie.

OBJECTIVE: The number of women victims of sexual assault remains high, despite prevention and information campaigns. These victims can be adolescent girls, women of childbearing age or postmenopausal women. As part of examinations of victims of sexual assault, the morpho-anatomical diversity of the female genitalia requires knowledge of the physiological variations existing by the practitioners caring for these victims. Our work aimed to describe and characterize the genital examination of women with consented sexual activity. METHOD: Our cohort consisted of 196 women aged 14 to 81, examined in the context of medical gynecology consultations in two French maternity hospitals. RESULTS: Recent genital traumatic injuries were found in 12.8% of women whose last sexual intercourse was less than 5days old. Intact hymens, free from traumatic tearing despite regular sexual activity, were present in 10.7% of these women. CONCLUSION: Thus, in many cases, genital examination alone cannot confirm or deny the existence of prior sexual intercourse, whether or not it was consented to. The development of work on data on female genital anatomy would make it possible to optimize the medico legal care of victims of sexual assault.

Prepubescent Female Genital Examination Images: Evidence-Informed Learning Opportunities.

OBJECTIVES: To determine diagnoses and image features that are associated with difficult prepubescent female genital image interpretations. DESIGN AND SETTING: This was a mixed-methods study conducted at a tertiary care pediatric center using images from a previously developed education platform. PARTICIPANTS: Participants comprised 107 medical students, residents, fellows, and attendings who interpreted 158 cases to derive case difficulty estimates. INTERVENTIONS: This was a planned secondary analysis of participant performance data obtained from a prospective multi-center cross-sectional study. An expert panel also performed a descriptive review of images with the highest frequency of diagnostic error. MAIN OUTCOME MEASURES: We derived the proportion of participants who interpreted an image correctly, and features that were common in images with the most frequent diagnostic errors. RESULTS: We obtained 16,906 image interpretations. The mean proportion correct scores for each diagnosis were as follows: normal/normal variants 0.84 (95% confidence interval [CI] 0.82, 0.87); infectious/dermatology pathology 0.59 (95% CI 0.45, 0.73); anatomic pathology 0.61 (95% CI 0.41, 0.81); and, traumatic pathology 0.64 (95% CI 0.49, 0.79). The mean proportion correct scores varied by diagnosis (P < .001). The descriptive review demonstrated that poor image quality, infant genitalia, normal variant anatomy, external material (eg, diaper cream) in the genital area, and nonspecific erythema were common features in images with lower accuracy scores. CONCLUSIONS: A quantitative and qualitative examination of prepubescent female genital examination image interpretations provided insight into diagnostic challenges for this complex examination. These data can be used to inform the design of teaching interventions to improve skill in this area.

The medical evaluation of prepubertal children with suspected sexual abuse.

Child sexual abuse is an important and not uncommon problem. Children who have been sexually abused may present to a physician's office, urgent care centre, or emergency department for medical evaluation. A medical evaluation can provide reassurance to both child and caregiver, identify care needs, and offer an accurate interpretation of findings to the justice and child welfare systems involved. Given the potential medico-legal implications of these assessments, the performance of a comprehensive evaluation requires both current knowledge and clinical proficiency. This position statement presents an evidence-based, trauma-informed approach to the medical evaluation of prepubertal children with suspected or confirmed sexual abuse.

Preschool Girl With Vaginal Bleeding Due to Pinworm Endometritis.

Genital tract bleeding in prepubertal girls is a rare clinical condition, which can occur for multiple reasons. It frequently generates anxiety in the family and in health care professionals. A thorough anamnesis and careful genital inspection can give important diagnostic hints; however, there are cases in which the cause remains doubtful and a complete gynecological evaluation (including cultures and vaginoscopy) is necessary. Therefore, the attending physician should always consider less frequent diagnoses in order to perform the necessary studies in a sequential and rational manner. We present the case of a preschool girl with vaginal bleeding due to pinworm endometritis, which, to our knowledge, has never been reported before as a cause of genital bleeding in prepubertal girls.

Meaning well while doing harm: compulsory genital examinations in Swedish African girls.

In this article, I discuss compulsory genital examinations in Swedish African, mainly Somali, girls. The discussion is based on data from 122 police files, including criminal investigations regarding suspected "female genital mutilation" (FGM). A growing body of research in European countries indicates that processes of cultural change are occurring among immigrant communities from areas where traditionally girls are subjected to what is construed as "circumcision". Many studies show growing opposition to these practices among people who have migrated to Europe, and there is little evidence to support the assertion that large-scale illegal activities are prevalent. Yet there is a dominant discourse stating that FGM is secretively practised on a large scale among some immigrant groups in Europe, and policies encourage the detection of cases to charge in criminal court. I describe the current situation in Sweden and highlight some of the drawbacks of a very harsh, although well-intended, policy to check for FGM in Europe. While the ultimate aim is to protect girls at risk for FGM, current policies have ramifications that are invasive and sometimes even traumatising for the girls involved. This paper offers an empirical example of how politics in western multicultural societies may negatively influence the sexual health and rights of a target group, in this case, girls and young women whose families originate from countries where circumcision of girls is practiced.

Anogenital Distance in Term Newborns in Kumasi, Ghana.

BACKGROUND: Anogenital distance (AGD) is a simple noninvasive measure of foetal androgen exposure. This study was done to generate normative data on AGD in Ghanaian newborns. METHODS: AGD was measured in 644 male and 612 female term newborns; including the distance between the anterior base of the penis and the centre of the anus, the posterior base of the penis and the centre of the anus, and the posterior base of the scrotum and the centre of the anus (ASD) in males and the distance from the anus to the fourchette (AF) and from the anus to the base of the clitoris in females. Other anthropometric and parental socio-demographic indices were also documented. RESULTS: AGD was sexually dimorphic; with a mean ± SD ASD and AF of 25.5 ± 5.1 and 13.6 ± 2.7 mm, respectively. There was a significant correlation between AGD and birth weight, birth length, and occipitofrontal circumference (p < 0.05). ASD was significantly longer (p < 0.001) in newborns (83/644; 12.9%) of mothers who had ingested herbs during pregnancy. CONCLUSION: AGD was approximately twice as long in males compared to females and can serve as a useful indicator of androgen exposure. Measurements of AGD also need to factor in anthropometric parameters, which are important correlates of AGD.

Unique Presentation of Hematometrocolpos Mimicking Cauda Equina Syndrome: Severe Back Pain and Urinary Incontinence in an Adolescent Girl.

BACKGROUND: Imperforate hymen with hematometrocolpos in adolescent females is a rare pediatric condition. Classical presentation includes abdominal pain or a pelvic mass in female patients with primary amenorrhea. Atypical complaints and reluctance among emergency physicians to perform genital examination in the emergency department or the pediatric emergency department (PED) may delay correct diagnosis. CASE REPORT: We report a unique, cauda equina syndrome-like presentation of hematometrocolpos secondary to imperforate hymen in a 13-year old, previously healthy girl with primary amenorrhea. In the PED, the unusual clinical presentation of severe back pain and urinary incontinence initially mimicked cauda equina syndrome and led to delayed correct diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The novelty of this case is a cauda equina-like presentation of imperforate hymen secondary to hematocolpos. This report illustrates the highly variable clinical presentation of this rare gynecological pediatric entity. It underlines the importance of considering this rare condition in the differential diagnosis of severe upper or lower back pain alongside voiding abnormalities including urinary retention and incontinence in adolescent females with primary amenorrhea. Above all, the importance of performing a thorough history and genital examination in this subgroup early in the investigation process in the PED emerges from this case. Essentially, excellent clinical judgment and genital examination by the emergency physician may minimize unnecessary radiological investigations and ultimately, accelerate correct diagnosis and expedite appropriate surgical treatment. However, not only pediatric and adult emergency physicians, but also pediatricians and general practitioners should be aware of this entity and its diverse clinical presentation.

Abordaje del abuso sexual infantil: combatiendo la revictimizacion / Addressing child sexual abuse: fighting revictimization

Cuando el médico tiene poca experiencia o no suele enfrentarse a este tipo situaciones, el diagnóstico de abuso sexual es difícil y cuando es un niño o una niña es aún más complicado. En la dinámica de estos eventos intervienen diversos factores. Al evaluar al niño o niña afectada es indispensable evitar la revictimización, que al tomar lugar se convierte en una nueva agresión, para lograr lo anterior se requiere que sea un equipo interdisciplinario y con experiencia, el que lleve a cabo la evolución. Se debe evitar la duplicación de interrogatorios, entrevistas y exploración física. En los casos de abuso crónico, se puede prescindir del examen físico. La relación predominante en los casos de abuso es la de padre e hija y el tipo de agresión más frecuente es el tocamiento en casi el 90% de los casos. Premisa que nos lleva a considerar que es frecuente encontrar el área genito-anal totalmente indemne durante la exploración física. Las consecuencias de sucesos como estos dependerán del apoyo familiar, el grado de culpabilidad que se genere en el niño y del abordaje y las estrategias que se pongan en marcha para enfrentar la agresión.

When the doctor has little experience, the diagnosis of sexual abuse is difficult and when the victim is a child, is even more complicated. The dynamic of these events involved several factors. When assessing the affected youth it is essential to avoid re-victimization, which becomes a new aggression. In order to achieve this is required an interdisciplinary and experienced team to develop the analysis. Avoid duplication of interrogations, interviews and physical examination. In cases of chronic abuse, the physicians can dispense physical examination. The predominant relationship in cases of abuse is father and daughter and the most frequent type of aggression is touching, almost in 90% of cases. Reason why is not uncommon to get no abnormal findings in physical examination. The consequences of these kinds of events will depend on family support, the degree of culpability that is generated on the child and the approach and the implemented strategies to deal with aggression.

Vaginal Bleeding in Prepubertal Girls: Etiology and Clinical Management.

STUDY OBJECTIVE: We aimed to investigate the etiology and clinical management of vaginal bleeding in girls aged 0-9 years and to compare our results with previous publications. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: The records of all girls younger than 10 years of age who were seen between 2001 and 2011 at Skåne University Hospital Lund for vaginal bleeding were retrospectively collected. RESULTS: We identified 86 girls with vaginal bleeding. Of those, 47 (54.7%) were diagnosed with a local lesion, the etiology was hormonal in 16 (18.6%), and in 23 (26.7%) the etiology was unclear. Trauma was the most frequent cause of local lesions and hormonal withdrawal of the newborn was the most common hormonal etiology. Two girls were diagnosed with a tumor, 1 with relapse of a vaginal rhabdomyosarcoma, and the other with recurrence of an ovarian granulosa cell tumor. There were large disparities in the clinical management of vaginal bleeding. A genital examination was conducted in 70 of 86 (81.4%), and colposcopy in only 8 of 86 of the patients (9.3%). CONCLUSION: This study confirmed vaginal bleeding as a rare finding in girls younger than 10 years of age. It is usually a benign symptom, but because there might be a serious underlying condition, proper investigation and follow-up are needed. Clinical management varied in our patient cohort. This might be because of insufficient knowledge and might indicate the need for general guidelines.

Labial adhesion and urinary tract problems: The importance of genital examination.

BACKGROUND: Urinary tract infection (UTI) is a common bacterial illness in children. Delay in the treatment of UTI may lead to acute renal parenchymal damage and subsequent renal scarring. It is well established that several risk factors increase the tendency for UTI - one being labial adhesion (LA). OBJECTIVE: The purpose of this study was to emphasize the importance of genital examination in girls with nephrourologic symptoms, particularly UTIs, in order to detect LA. MATERIAL AND METHODS: Data were collected from the files of 46 girls with LA, including: the girl's age, thickness of LA, any recurrence and treatment options of LA, and the reason for admission to hospital. The LAs were grouped in terms of thickness as thin, moderate and dense, and also partial or complete. RESULTS: The average age of the girls at the first visit was 51.9 ± 37.57 months (min-max: 3.5-157 months). Twenty-seven (58.7%) of the girls had history of recurrent UTI. There was a marked association between the presence of UTI and the type of adhesions. The percentages of UTIs in girls with complete and partial LA were 84.0% and 28.6%, respectively (P < 0.05). The percentages of UTIs in girls with thick and thin LA were 100% and 44.1%, respectively (P < 0.05). None of the girls' primary care physicians or pediatricians recognized LA at the time of a periodic health examination. DISCUSSION: In the present study, girls with complete and thick LA had a greater tendency towards having UTIs than those with partial and thin LA, respectively. After treatment of LA, the UTIs did not recur in any girls. None of the girls in this study had undergone a previous genital examination. Therefore, this study suggests that physicians do not often perform genital examinations. Limitations of this study were the small sample size and the short follow-up period. In addition, although all of the girls were examined by the same physician, the thickness of the membrane is subjective and solely depends on the physician's experience. CONCLUSIONS: This study showed that although genital examination is a routine part of a physical examination, it is not always performed. Therefore, it is recommend that genital examination should be performed in girls with nephrourologic complaints, particularly for UTI. By timeously determining the presence of LA, many unnecessary and invasive investigations could be avoided in these children.

Knowledge regarding hymens and the sex education of parents.

The objective of this study was to ascertain beliefs and knowledge of pediatricians and parents regarding the hymen and to evaluate parental and pediatrician attitudes regarding sex education by pediatricians. Surveys were distributed anonymously to parents and pediatricians. Survey questions included knowledge of the female hymen and questions regarding attitudes toward sexual health education. There was a statistically significant difference in mean knowledge scores between pediatricians and parents regarding the hymen (3.7 versus 1.3; p < 0.0001). Almost two-thirds of pediatricians (63%) felt comfortable providing sexual health education directly to their patients, but only 41% felt comfortable educating parents. Pediatricians and parents demonstrate knowledge gaps about the hymen.

Hematocolpos en la infancia. A propósito de un caso / Hematocolpos in Childhood. A case Report

El hematocolpos no es común en nuestro medio, sigue a alteraciones en la génesis del aparato genitourinario femenino; entre las cuales, el himen imperforado es la malformación congénita más frecuente. La sintomatología suele ser variable e inespecífica; el dolor abdominal y los síntomas urinarios es la forma de presentación clínica más usual. La ecografía abdominal-pélvica y la tomografía axial computarizada confirman el diagnóstico y ayudan a descartar otras malformaciones asociadas. Se presentó un caso de una adolescente afectada por esta enfermedad.

The hematocolpos is not common disease. It follow to the alterations in the genesis of female urogenital apparatus among which the imperforate hymen is the most common congenital malformation. The symptoms are variable and nonspecific. The abdominal pain and urinary symptoms is the most common clinical presentation. Abdominal-pelvic ultrasonography and computed tomography help to confirm the diagnosis as well as to find other associated malformations. This article presented a case of an adolescent affected by this disease.