Interpretation of anogenital findings in the living child: Implications for the paediatric forensic autopsy

Postmortem Changes of Female External Genitalia and Their Importance in Suspected Sexual Abuse

Examination of the female external genitalia to assess for sexual abuse is performed in living individuals, and the interpretation of the findings is based on evidence-based studies. However, in the deceased, no such studies are available, and postmortem changes could present as suspicious findings that can be mistaken for trauma. Patches of discoloration in the hymen were reported previously in one case as hypostasis (i.e., livor and lividity), and based on this finding, it was listed as a finding that is not associated with trauma. This was a retrospective study that was conducted in the Center of Forensic and Legal Medicine in Dammam, Saudi Arabia over a 4-year period. The study included 30 deceased women in whom photographic documentation of their external genitalia was assessed for postmortem changes. The postmortem interval ranged from less than 24 h to more than 100 days, and the ages of these deceased women were in the 20-40 year-old age group. In cases where the hymen, vagina, and/or fossa navicularis were clearly visible, none of these areas showed any hypostatic discoloration. A comparison between antemortem and postmortem appearance of the hymen in one case clearly showed the absence of hypostatic changes in the hymen. In conclusion, any discoloration of the external genitalia that is detected in a female decedent requires serious consideration.

Understanding Medical Findings in Child Sexual Abuse: An Update For 2018

When child sexual abuse is suspected, it is important for medical professionals to understand normal as well as abnormal features of the external genital and anal tissues in children. Physicians and other healthcare professionals who rarely perform a detailed examination of these areas may mistakenly interpret normal findings, or findings caused by conditions unrelated to abuse, as signs of injury due to sexual abuse. For this reason, it is important for all medical professionals to have a basic understanding of the appearance of the genital and anal tissues in children. Examples of normal and abnormal genital and anal findings are provided via annotated images. This review presents a research-based summary of how medical findings in children should be interpreted with respect to possible sexual abuse. Resources for obtaining expert review of medical findings are described.

Urogenital tract disorders in children suspected of being sexually abused

INTRODUCTION

Child sexual abuse (CSA) is generally defined as child exploitation that leads to achievement of sexual satisfaction. According to data from European countries, sexual abuse of children affects 10-40% of girls and 5-20% of boys.

MATERIAL AND METHODS

The Medline, and Web of Science databases were searched with no date limitation on May 2015 using the terms 'child abuse' in conjunction with 'urinary tract', 'urologist', 'urological dysfunction', 'urologic symptoms', 'LUTS' or 'urinary infection'.

RESULTS

Awareness of the CSA problem among paediatricians and urologists is very important, because they are often the only physicians who are able to recognize the problem. CSA diagnosis is possible only through the proper collection of a medical history and a thorough physical examination. Urologists have to remember that children exposed to sexual abuse rarely exhibit abnormal genital findings. In fact, absence of genital findings is the rule rather than the exception. In most cases, the final diagnosis of sexual abuse is based on the child's history and behavior, along with the onset and exacerbation of urologic symptoms.

CONCLUSIONS

In this article, we present a review of studies and literature concerning urinary symptoms in sexually abused children to clarify the problem for a broad group of urologists. We present common symptoms and premises that can point to the right diagnosis and basic guidelines of proceeding after suspicion of abuse.

Anal lesions presenting in a cohort of child gastroenterological examinations. Implications for sexual traumatic injuries

The purpose of this study was to describe the anal lesions found in children during a pediatric gastroenterology consultation when the reason for the complaint was related to a digestive disease. This prospective descriptive study included 100 children under 15 years of age over a 13-month period, consulting due to digestive symptoms. The children were under 8 years old (90%) and 25% were under 3.1 years old. Constipation was the most frequent reason for consultation (69%). Fifty-one anal lesions were observed, of which 58.8% were anal fissures, 15.7% were skin tags and 5.8% were venous congestions related to straining. Anal fissures and skin tags were located at the median line, according to the clock-face method in supine position. No child had more than two anal lesions. No anal dilatation, sphincter hypotonia, anal scars, anal lacerations or bruises were found. The two most common anal lesions were anal fissures and skin tags. These anal lesions were mainly observed at the median line and were due to constipation. No cases of multiple anal lesions were found in terms of common digestive diseases.

The risk of misinterpreting genital signs of sexual abuse in cadavers: a case report

The significance of genital findings in a case of suspected child sexual abuse has been widely debated in the past decades, as shown by the different classifications available in literature. In the case of postmortem examination, the search for signs of sexual abuse is considerably more difficult because of the superimposition of postmortem modifications, which may determine tissue modifications that can be mistaken for traumatic lesions. This study aims at reporting a case where presumed findings of the first autopsy were denied by histological analysis; in detail, what looked like a possible bruise of the hymen was correctly recognized as hypostasis (livor) of the hymenal tissue by histological analysis. This case report suggests caution in the analysis and discussion of genital lesions found during postmortem examination since the superimposition of cadaveric modifications may radically modify the morphology of soft tissues.

Characteristics of sex-related homicides in Alaska

The identification and interpretation of anogenital findings postmortem is a critical component of a sex-related homicide investigation. The use of a colposcope to assist in identifying anogenital injuries in living sexual assault victims is well established. The use of a colposcope for postmortem anogenital examination has been briefly mentioned in a few publications, however, no studies were found regarding the types and sites of postmortem anogenital injuries identified with a colposcope in sex-related homicide cases. The purpose of this study was to describe the demographic, physical examination, and victim-suspect relationship characteristics of sex-related homicides in Alaska. Genital findings in living and deceased sexual assault victims in Alaska were compared.

IMPLICATIONS

Given the results of this study, postmortem sexual assault examinations should be conducted in all suspected intimate partner homicides. Further implications for forensic nursing practice and recommendations for future research are discussed.

Partial bowel obstruction in a 2-month-old child. A delayed diagnosis of anal abuse

We present the case of an anal sexual abuse involving a 2-month-old boy, who was admitted to the Pediatric Surgery Unit of the University of Padua for low bowel obstruction. The infant had been already hospitalized for 3 days in a peripheral hospital and treated with daily rectal wash-outs for a fecaloma. Only after a careful interpretation of the plain abdominal radiograph, along with the performance of a rectoscopy and a laparotomy, a vegetable foreign body (about 3 cm in diameter and 7 cm in length) was discovered in the sigma. The morphology and dimensions of the foreign body, as well as its location, left no doubt about the etiology of the partial bowel obstruction, proving that it was clearly related to an anal sexual abuse.

Child sexual abuse in clinical and forensic psychiatry: a review of recent literature

PURPOSE OF REVIEW

To review papers from the recent literature on child sexual abuse and to highlight the clinical and forensic issues raised and how these have been addressed. Also, to identify new demands and recommend future research.

RECENT FINDINGS

The validity of forensic evaluations depends on the quality of the protocols used and the training of the forensic mental health practitioners involved. Diagnosis of child sexual abuse still depends mainly on the child's allegation of abuse, while anogenital examination yields minimal medical evidence of sexual abuse. The relationship between child sexual abuse and victims' mental health is increasingly being proven, underlining the importance of correct clinical and forensic diagnosis of abuse to permit preventive, therapeutic and legal measures. Sexual offences via the internet have raised new demands.

SUMMARY

Forensic child and adolescent practitioners need to be very highly trained. Evaluation of sexually abused children and adolescents must be accurate to ensure legal validity and be performed with diligence so that alleged victims do not experience recurrence. Practitioners' actions must be referenced against appropriate instruments and they must be prepared for the ethical and forensic dilemmas and new demands that arise in this field.