Arne K. Myhre

Genital anatomy in non‐abused preschool girls

Aim: To describe the normal variations in genital anatomy in preschool girls selected for non‐abuse. Methods: A total of 2731 girls aged 5 or 6 y were invited to take part in the study; 195 girls were recruited. Inclusion was based on self‐selection, whereby parents who did not suspect any occurrence of sexual abuse of their children gave informed consent to participate. Several steps were taken to exclude abused girls and girls with previous accidental genital injuries. The genital examination, using a colposcope and a camera, was performed in supine position using a separation and traction technique, and in the prone knee‐chest position. Results: A number of genital anatomical features and hymenal measurements were described and found consistent with previous studies. An important finding was outward folding of the posterior hymenal rim in many girls, a feature that could be difficult to distinguish from attenuation of the posterior hymen. A gaping hymenal orifice, previously suggested to be a supportive sign of sexual abuse, was fairly frequently found and significantly associated with a large horizontal hymenal diameter.

Anogenital human papillomavirus in non-abused preschool children

Aim: To estimate the prevalence of human papillomavirus (HPV) in anogenital samples from children selected for non‐abuse. Methods: A letter of invitation was sent to 2731 girls and 1042 boys, all of them aged 5 or 6 y. Inclusion was based on self‐selection, whereby parents who did not suspect any occurrence of sexual abuse of their child gave informed consent to participate. Several mechanisms were undertaken to exclude abused children. A complete examination was done of each child, including anogenital examination with a colposcope and microbiological sampling from the genitals and anus. Polymerase chain reaction (PCR) using primers MY09 and MY11 was used to identify HPV, and sequencing was done on each positive amplicon. Results: PCR was performed on 325 adequate specimens from 211 children enrolled. Seven samples from 5 girls were HPV‐positive, making 2/161 (1.2%) of the anal and 5/164 (3.0%) of the genital specimens positive. HPV was not detected in any of the boys. In four girls strong associations with HPV 6 genotypes were found, while one girl probably had a mixed infection with HPV 6 and 16. Three girls (1.8%) had clinically detectable anogenital warts.

Perianal anatomy in non-abused preschool children.

The purpose of this study was to describe the normal variation in perianal anatomy in preschool children, selected for non‐abuse, and to compare the findings in two examination positions. A letter of invitation was sent to 3773 children, after which 305 children (103 boys and 202 girls) were recruited. Inclusion in the study was based on self‐selection, whereby parents who did not suspect any occurrence of sexual abuse of their child gave informed consent to participate. The mean age of the children was 5.63 y (range: 5.13–6.75). An anal examination was performed in the left lateral position (LLP) and the prone knee‐chest position (KCP), for approximately 30 s each. A colposcope and a camera were used. All data were systematically analysed for gender differences, and a paired sample test was used to compare findings in LLP and KCP. Venous congestion in LLP and external anal dilatation in both positions were significantly more common in girls, while midline depressions and smooth areas (both positions) were significantly more common in boys. External and total anal dilatation, midline smooth areas and depressions and the occurrence of a prominent anal verge were significantly more common in the KCP. The finding of total anal dilatation was rare.

Previous maltreatment and present mental health in a high-risk adolescent population ☆

Childhood maltreatment is known to increase the risk of future psychiatric disorders. In the present study, we explored the impact of experienced maltreatment on the prevalence and comorbidity of psychiatric disorders in a high-risk population of adolescents in residential care units. We also studied the impact of poly-victimization. The participants of the study were adolescents in residential care units in Norway (n=335, mean age 16.8 years, girls 58.5%). A diagnostic interview (Child and Adolescent Psychiatric Assessment Interview) was used, yielding information about previous maltreatment (witnessing violence, victim of family violence, community violence, sexual abuse) and DSM-IV diagnoses present in the last three months. Exposure to maltreatment was reported by 71%, and in this group, we found significantly more Aspergers syndrome (AS) (p=.041), conduct disorder (CD) (p=.049), major depressive disorder (MDD) (p=.001), dysthymia (p=.030), general anxiety disorder (GAD) (p<.001), and having attempted suicide (p=.006). We found significantly more comorbid disorders in the maltreated group. Poly-victimization was studied by constructing a scale comprised of witnessing violence, victim of family violence, victim of sexual abuse and household dysfunction. We found that poly-victimization was associated with significantly increased risk of MDD, GAD, AS, CD, and having attempted suicide (p<.01). The complexity of the clinical outcomes revealed in this study suggest that longer-term treatment plans and follow-up by psychiatric services might be needed to a greater extend than for the rest of the child and adolescent population, and that trauma informed care is essential for adolescents in residential youth care.

Anal findings in children with and without probable anal penetration: A retrospective study of 1115 children referred for suspected sexual abuse

Interpreting the significance of anal findings in child sexual abuse can be difficult. The aim of this study is to compare the frequency of anal features between children with and without anal penetration. This is a retrospective blinded review of consecutive charts of children seen for suspected sexual abuse at a regional referral center from January 1. 2005 to December 31. 2009 Based on predetermined criteria, children were classified into two groups: low or high probability of anal penetration. The charts of 1115 children were included, 84% girls and 16% boys with an age range from 0.17 to 18.83 years (mean 9.20 year). 198 children (17.8%) were classified as belonging to the anal penetration group. Bivariate analysis showed a significant positive association between the following features and anal penetration: Anal soiling (p=0.046), fissure (p=0.000), laceration (p=0.000) and total anal dilatation (p=0.000). Logistic regression analysis and stratification analysis confirmed a positive association of soiling, anal lacerations and anal fissures with anal penetration. Total anal dilation was significantly correlated with a history of anal penetration in girls, in children examined in the prone knee chest position and in children without anal symptoms. Several variables were found to be significantly associated with anal penetration, including the controversial finding of total anal dilatation. Due to limitations in the study design, this finding should still be interpreted with caution in the absence of a clear disclosure from the child.

Anogenital bacteriology in non-abused preschool children: a descriptive study of the aerobic genital flora and the isolation of anogenital Gardnerella vaginalis

The purpose of the study is to describe the genital aerobic bacterial flora including Gardnerella vaginalis in girls and the occurrence of anal G. vaginalis in both genders. From a group of 3773 children, 278 (99 boys and 179 girls) with a mean age of 5.63 y (range: 5.13–6.73) were recruited. Inclusion in the study was based on self‐selection, whereby parents who did not suspect any occurrence of sexual abuse of their child gave informed consent to participate. Several mechanisms were undertaken to exclude abused children. At least one bacterial species was isolated from the genitals of 59 (33.9%) girls. Most isolates (39 out of 99) were bacteria representing skin flora (staphylococci and coryneform organisms), with viridans streptococci and related organisms as the second most common group of isolates (31 out of 99). S. anginosus was the single most frequent bacterial species identified (17 isolates). Streptococcus pyogenes was isolated from the genitals of two girls, Streptococcus pneumoniae from one girl and Haemophilus influenzae from eight girls. G. vaginalis was not isolated from the genitals in any girl, but the organism was isolated from the anal canal in three children.

Impact of medico‐legal findings on charge filing in cases of rape in adult women

Objective. To assess the impact of the medical documentation and biological trace evidence in rape cases on the legal process. Design. Retrospective descriptive study. Setting and sample. Police‐reported cases of rape of women ≥16 years old in the Norwegian county of Sør‐Trøndelag from January 1997 to June 2003. Methods. Police data were merged with data from the Sexual Assault Center at St Olavs Hospital. Charged and non‐charged cases were compared. Main Outcome Measures. Medico‐legal findings and legal outcome. Results. A total of 185 police‐reported cases were identified. Of the 101 cases examined at Sexual Assault Center, charges were filed in 18 cases. Extragenital injuries were documented in 49 women; five were life threatening. Anogenital injuries were documented in 14 women; eight had multiple anogenital injuries. Documentation of injuries was not associated with charge filing. In only 33% of the cases were swabs collected from womens genitals used as trace evidence by the police. When used, this increased the likelihood for charge filing. A DNA profile matching the suspect was identified in four of the 18 charged cases and in only one among the 54 non‐charged cases. Conclusions. Half of the women had one or more documented injury. Only one‐third of the trace evidence kits collected from the womens anogenital area were analyzed. The analysis of swabs was associated with charge filing, regardless of test results. Increased use of such medical evidence, especially in cases of stranger rape, may ensure womens rights and increase available information to the legal system.

Changes in genital anatomy and microbiology in girls between age 6 and age 12 years: a longitudinal study.

STUDY OBJECTIVE To study changes in genital anatomy and occurrence of human papillomavirus and Gardnerella vaginalis in girls resulting from growth and development. DESIGN At age 11-12 years, an invitation was sent to 180 girls to attend a follow-up examination. All girls had previously participated in a study exploring anogenital anatomy and microbiology in children selected for non-abuse at age 5 and 6. The genital area was examined with a colposcope and microbiological samples for Gardnerella vaginalis (GV) and human papillomavirus (HPV) were collected. GV was identified by conventional criteria and HPV by a PCR method. RESULTS Thirty-one girls were examined twice, at mean age 5.7 and 12.0 years. At first examination all were pre-pubertal. At second examination 21 girls were B2/P2 or above. Significantly more girls had developed a structure called a fossa groove. A thick and redundant hymen with a tendency of folding outward was more common at the second examination. Two girls had GV and one girl had HPV-16 identified. Another girl was classified to have a deep notch and a probable transection in her hymen, and this girl reported a painful insertion of a tampon. All girls denied sexual activity. CONCLUSION The main genital finding in girls entering puberty is the hymen becoming thick and redundant with a tendency of folding out. In the study findings associated with sexual activity were discovered in two girls, and the possibility of alternative explanations is discussed.

Sexually transmitted infections among women attending a Norwegian Sexual Assault Centre

Objectives The objective was to describe the prevalence of sexually transmitted infections (STI) and blood-borne viruses (BBV), and prophylactic treatment offered to female postpubertal patients attending a Norwegian Sexual Assault Centre (SAC). We wanted to evaluate whether STIs diagnosed at the initial visit could have been assault-transmitted, and to explore whether background and assault characteristics were associated with diagnosed STI/BBV. Methods We included postpubertal females ≥12 years of age attending the SAC within 1 week of the assault. Data were collected from records. We conducted a retrospective, descriptive study, and used logistic regression analysis. Results Among 412 patients with a median age of 21 years, 35 patients had an STI (8.5%), two of which probably were assault-transmitted. Chlamydia trachomatis was the dominating agent, detected in 25 patients (6.4%). At serology screening, 3.7% tested positive for hepatitis C and/or hepatitis B core antibody. Patient age 16–19 years was associated with STI, while BBV positives were older. Non-Western assailant was associated with STI, while substance abuse was associated with STI and BBV. In order to prevent potential transmission of STI not identified at the initial visit, 91% accepted prophylaxis against bacterial STI, while antiviral prophylaxis was offered to less than one-fifth of the patients. Conclusions The C trachomatis prevalence among the sexual assault patients was lower than in a comparable clinical population. The STI was suspected to be assault-transmitted in only two cases.

Adhesjon av de små kjønnsleppene – diagnostikk og behandling

BACKGROUND Labial adhesion is relatively common, but the condition is little known among doctors and parents. The article assesses treatment in the specialist health service. MATERIAL AND METHOD The treatment and course are assessed in 105 girls in the age group 0 – 15 years who were referred to St. Olavs Hospital in the period 2004 – 14. RESULTS The majority of the girls (n = 63) were treated topically with oestrogen cream. In 26 of 51 girls (51 %) for whom the final result is known, the adhesion opened after one treatment. When 1 – 4 oestrogen treatments were administered, the introitus had opened completely in two out of three (65 %). Fewer than half of those who received supplementary surgical treatment achieved permanent opening. INTERPRETATION Treatment for labial adhesion had a limited effect in this study. As the literature suggests that the condition results in few symptoms and resolves spontaneously in virtually all girls in puberty, no compelling medical reason exists for opening the adhesion in asymptomatic girls. It is important that doctors are aware of the condition in order to prevent misdiagnosis and to provide parents with adequate information. For parents it is important to know that spontaneous resolution may result in soreness and dysuria. Knowledge of the condition can most likely prevent unnecessary worry.