Hymen 24 Clocks

Hymen 24 Clocks

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The hymen must be examined in detail after an allegation of a nonconsensual penetrative act. When the hymen is fimbriated, this assessment may be facilitated by the gentle use of a moistened swab to visualize the hymenal edges. When the hymenal opening cannot be seen at all, application of a few drops of warm sterile water or saline onto the hymen will often reveal the hymenal edges. Foley catheters are also a useful tool to aid hymenal visualization in postpubertal females (138). A small catheter is inserted through the hymenal opening, the balloon is then inflated with 10-20 mL of air, and the catheter is gently withdrawn so that the inflated balloon abuts the hymen. The balloon is deflated before removal. This procedure is well tolerated by the examinee. Obviously, in the acute setting, none of these maneuvers should be attempted until the relevant forensic samples have been retrieved.
There is little specific information available regarding the type and frequency of acute hymenal injuries after consensual sexual acts, particularly regarding the first act of sexual intercourse. Slaughter et al. (90) conducted colposcopic examinations of the genitalia of 75 women who had experienced "consensual" vaginal intercourse in the preceding 24 hours. They found lacerations (tears) with associated bruising at the 3-o'clock and 9-o'clock positions on the hymen of a 14-year-old and bruises at the 6-o'clock and 7-o'clock positions on the hymens of two other females (aged 13 and 33 years). No other hymenal injuries were detected. Unfortunately, no details regarding previous sexual experience are recorded on their pro forma.
In the same article, the hymen was noted to be one of the four most commonly injured genital sites among 311 postpubertal complainants of nonconsensual sexual acts. The hymenal injuries detected colposcopically were bruises (n = 28), lacerations (n = 22), abrasions (n = 13), swelling (n = 10), and redness (n = 4). The hymenal lacerations were either single (n = 12), nine of which were at the 6-o'clock position, or paired around the 6-o'clock position (n = 10). The authors found that hymenal lacerations were four times more common in the younger age groups. Again, there was no information regarding previous sexual experience. Bowyer and Dalton (133) described three women with hymenal lacerations (detected with the naked eye) among 83 complainants of rape who were examined within 11 days of the incident; two of the three women had not previously experienced sexual intercourse. One retrospective survey of the acute injuries noted among adolescent complainants of sexual assault (aged 14-19 years) found that hymenal tears were uncommon, even among the subgroup that denied previous sexual activity (132). Bruises, abrasions, reddening, and swelling completely disappear within a few days or weeks of the trauma (90,139). Conversely, complete hymenal lacerations do not reunite and thus will always remain apparent as partial or complete transections (123), although they may be partially concealed by the effects of estrogenization (140). However, lacerations that do not extend through both mucosal surfaces may heal completely (2). There is one case report of a 5-year-old who was subjected to penile penetration and acquired an imperforate hymen resulting from obliterative scarring (141).
On the basis of the current literature, complete transections in the lower margin of the hymen are considered to provide confirmatory evidence of previous penetration of the hymen. However, it is not possible to determine whether it was a penis, finger, or other object that caused the injury, and there is an urgent need for comprehensive research to determine whether sporting activities or tampon use can affect hymenal configuration. Although partial or complete transections of the upper hymen may represent healed partial or complete lacerations beyond the acute stage, there is no method of distinguishing them from naturally occurring anatomical variations.
Goodyear and Laidlaw (142) conclude that, "it is unlikely that a normal-looking hymen that is less than 10 mm in diameter, even in the case of an elastic hymen, has previously accommodated full penetration of an adult finger, let alone a penis." However, there is no objective evidence on which to base this conjecture, and it is not known whether measuring the hymenal open ing using a digit, or other previously measured object, in the clinical setting when the practitioner is particularly anxious not to cause the patient any distress accurately reflects what the hymen could have accommodated during a sexual assault.
On the other hand, it is now generally accepted that postpubertal females can experience penile vaginal penetration without sustaining any hymenal deficits; this is attributed to hymenal elasticity (142,143). Furthermore, the similarity between the dimensions of the hymenal opening among sexually active and nonsexually active postpubertal females (96) makes it impossible for the physician to state categorically that a person has ever had prior sexual intercourse unless there is other supportive evidence (pregnancy, spermatozoa on a high vaginal swab; see Subheading 8.5.; Forensic Evidence) (96,142,144).
Lacerations and ruptures (full-thickness lacerations) of the vagina have been described in the medical literature after consensual sexual acts (145147). They are most commonly located in the right fornix or extending across the posterior fornix; this configuration is attributed to the normal vaginal asymmetry whereby the cervix lies toward the left fornix, causing the penis to enter the right fornix during vaginal penetration (147). Factors that predispose to such injuries include previous vaginal surgery, pregnancy, and the puerperium, postmenopause, intoxication of the female, first act of sexual intercourse, and congenital genital abnormalities (e.g., septate vagina) (145). Although most vaginal lacerations are associated with penile penetration, they have also been documented after brachiovaginal intercourse ("fisting") (147), vaginal instrumentation during the process of a medical assessment (147), and the use of plastic tampon inserters (148).
Vaginal lacerations have been documented without any direct intravaginal trauma after a fall or a sudden increase of intra-abdominal pressure (e.g., lifting a heavy object) (147).
Injuries of the vagina have been noted during the examinations of complainants of sexual assault. Slaughter et al. (90) describe 26 colposcopically detected vaginal injuries among the 213 complainants who had genital trauma identified. These were described as "tears" (n = 10), bruises (n = 12), and abrasions (n = 4). Other articles that considered only macroscopically detectable lesions found vaginal "injuries" in 2-16% of complainants of noncon-sensual penile vaginal penetration (133,134). However, one study included "redness" as a vaginal injury when, in fact, this is a nonspecific finding with numerous causes.
When a vaginal laceration may have been caused by an object that has the potential to fragment or splinter, a careful search should be made for foreign bodies in the wound (145) (this may necessitate a general anesthetic), and X-rays should be taken of the pelvis (anteroposterior and lateral), including the vagina, to help localize foreign particles (149). Any retrieved foreign bodies should be appropriately packaged and submitted for forensic analysis.
Bruises and lacerations of the cervix have been described as infrequent findings after nonconsensual sexual acts (90,150,151). In one article, the injuries related to penetration by a digit and by a "knife-like" object. There are no reports of cervical trauma after consensual sexual acts.
Norvell et al. (126) have also documented areas of increased vascularity / telangiectasia (n = 7), broken blood vessels (n = 2), and microabrasions (n = 2) during colposcopic assessment of the introitus , hymen, and lower 2 cm of the vagina of 18 volunteers who had participated in consensual sexual activity within the preceding 6 hours. However, the areas of increased vascularity may have been normal variants (90), and the precise location of the other findings was not described. Fraser et al. (152) describe the macroscopic and colposcopic variations in epithelial surface of the vagina and cervix in healthy, sexually active women (age 18-35 years). They documented changes in the epithelial surface in 56 (17.8%) of the 314 inspections undertaken; six were located at the introitus, 26 in the middle or lower thirds of the vagina, eight on the fornical surfaces of the cervix, 14 in the vaginal fornices , and two involved generalized changes of the vaginal wall . The most common condition noted was petechiae . The more significant conditions noted were three microulcerations, two bruises, five abrasions, and one mucosal tear. The incidence of these conditions was highest when the inspections followed intercourse in the previous 24 hours or tampon use.
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Obstet Gynecol Sci

v.60(6); 2017 Nov

PMC5694739

Obstet Gynecol Sci. 2017 Nov; 60(6): 612–615.
Published online 2017 Oct 24. doi: 10.5468/ogs.2017.60.6.612
1 Daegu Child Sexual Abuse Response Center, Daegu, Korea.
2 Department of Forensic Medicine, Kyungpook National University School of Medicine, Daegu, Korea.
3 Department of Obstetrics and Gynecology, Kyungpook National University School of Medicine, Daegu, Korea.
Corresponding author: Taek Hoo Lee. Department of Obstetrics and Gynecology, Kyungpook National University School of Medicine, 130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea. rk.ca.unk@eelht
Received 2017 Mar 23; Revised 2017 May 19; Accepted 2017 Jun 12.
Copyright © 2017 Korean Society of Obstetrics and Gynecology
Articles published in Obstet Gynecol Sci are open-access, distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/ ) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Keywords: Rape, Child, Hymen, Genitalia
1. Kim HK. Reforming the law of rape in Korea. J Crim Law. 2013; 25 :81–103. [ Google Scholar ]
2. Ministry of Justice (KR) Article 307 of the Criminal Procedure Act (No evidence no trial principle) [ Google Scholar ]
3. Heppenstall-Heger A, McConnell G, Ticson L, Guerra L, Lister J, Zaragoza T. Healing patterns in anogenital injuries: a longitudinal study of injuries associated with sexual abuse, accidental injuries, or genital surgery in the preadolescent child. Pediatrics. 2003; 112 :829–837. [ PubMed ] [ Google Scholar ]
4. Sommers MS, Zink T, Baker RB, Fargo JD, Porter J, Weybright D, et al. The effects of age and ethnicity on physical injury from rape. J Obstet Gynecol Neonatal Nurs. 2006; 35 :199–207. [ PubMed ] [ Google Scholar ]
5. Cartwright PS. Factors that correlate with injury sustained by survivors of sexual assault. Obstet Gynecol. 1987; 70 :44–46. [ PubMed ] [ Google Scholar ]
6. Heger AM, Emans SJ, Muram D. Evaluation of the sexually abused child: a medical textbook and photographic atlas. 2nd ed. New York (NY): Oxford University Press; 2000. [ Google Scholar ]
7. Berenson AB. Appearance of the hymen at birth and one year of age: a longitudinal study. Pediatrics. 1993; 91 :820–825. [ PubMed ] [ Google Scholar ]
8. Park HT. Evaluation and management of vulva-vaginal symptoms in children; 100th Korean Society of Obstetrics and Gynecology Conference; 2014 Sep 26??7; Seoul. Seoul: Korean Society of Obstet Gynecol; 2014. pp. 228–231. [ Google Scholar ]
9. Slaughter L, Brown CR. Cervical findings in rape victims. Am J Obstet Gynecol. 1991; 164 :528–529. [ PubMed ] [ Google Scholar ]
10. Hegazy AA, Al-Rukban MO. Hymen: facts and conceptions. TheHealth. 2012; 3 :109–115. [ Google Scholar ]
11. Slaughter L, Brown CR, Crowley S, Peck R. Patterns of genital injury in female sexual assault victims. Am J Obstet Gynecol. 1997; 176 :609–616. [ PubMed ] [ Google Scholar ]
12. Berkoff MC, Zolotor AJ, Makoroff KL, Thackeray JD, Shapiro RA, Runyan DK. Has this prepubertal girl been sexually abused? JAMA. 2008; 300 :2779–2792. [ PubMed ] [ Google Scholar ]
13. Faller KC. Child sexual abuse: an interdisciplinary manual for diagnosis, case management, and treatment. New York (NY): Columbia University Press; 1988. [ Google Scholar ]
14. Son H. Normal penile size and self esteem about penile size of the third decade men in Korea. Korean J Urol. 1999; 40 :1037–1042. [ Google Scholar ]
15. World Health Organization. Guidelines for medico-legal care for victims of sexual violence. Geneva: World Health Organization; 2003. [ Google Scholar ]
Articles from Obstetrics & Gynecology Science are provided here courtesy of Korean Society of Obstetrics and Gynecology
1. Kim HK. Reforming the law of rape in Korea. J Crim Law. 2013; 25 :81–103. [ Google Scholar ] [ Ref list ]
2. Ministry of Justice (KR) Article 307 of the Criminal Procedure Act (No evidence no trial principle) [ Google Scholar ] [ Ref list ]
3. Heppenstall-Heger A, McConnell G, Ticson L, Guerra L, Lister J, Zaragoza T. Healing patterns in anogenital injuries: a longitudinal study of injuries associated with sexual abuse, accidental injuries, or genital surgery in the preadolescent child. Pediatrics. 2003; 112 :829–837. [ PubMed ] [ Google Scholar ] [ Ref list ]
4. Sommers MS, Zink T, Baker RB, Fargo JD, Porter J, Weybright D, et al. The effects of age and ethnicity on physical injury from rape. J Obstet Gynecol Neonatal Nurs. 2006; 35 :199–207. [ PubMed ] [ Google Scholar ] [ Ref list ]
5. Cartwright PS. Factors that correlate with injury sustained by survivors of sexual assault. Obstet Gynecol. 1987; 70 :44–46. [ PubMed ] [ Google Scholar ] [ Ref list ]
6. Heger AM, Emans SJ, Muram D. Evaluation of the sexually abused child: a medical textbook and photographic atlas. 2nd ed. New York (NY): Oxford University Press; 2000. [ Google Scholar ] [ Ref list ]
7. Berenson AB. Appearance of the hymen at birth and one year of age: a longitudinal study. Pediatrics. 1993; 91 :820–825. [ PubMed ] [ Google Scholar ] [ Ref list ]
8. Park HT. Evaluation and management of vulva-vaginal symptoms in children; 100th Korean Society of Obstetrics and Gynecology Conference; 2014 Sep 26??7; Seoul. Seoul: Korean Society of Obstet Gynecol; 2014. pp. 228–231. [ Google Scholar ] [ Ref list ]
9. Slaughter L, Brown CR. Cervical findings in rape victims. Am J Obstet Gynecol. 1991; 164 :528–529. [ PubMed ] [ Google Scholar ] [ Ref list ]
10. Hegazy AA, Al-Rukban MO. Hymen: facts and conceptions. TheHealth. 2012; 3 :109–115. [ Google Scholar ] [ Ref list ]
11. Slaughter L, Brown CR, Crowley S, Peck R. Patterns of genital injury in female sexual assault victims. Am J Obstet Gynecol. 1997; 176 :609–616. [ PubMed ] [ Google Scholar ] [ Ref list ]
12. Berkoff MC, Zolotor AJ, Makoroff KL, Thackeray JD, Shapiro RA, Runyan DK. Has this prepubertal girl been sexually abused? JAMA. 2008; 300 :2779–2792. [ PubMed ] [ Google Scholar ] [ Ref list ]
13. Faller KC. Child sexual abuse: an interdisciplinary manual for diagnosis, case management, and treatment. New York (NY): Columbia University Press; 1988. [ Google Scholar ] [ Ref list ]
14. Son H. Normal penile size and self esteem about penile size of the third decade men in Korea. Korean J Urol. 1999; 40 :1037–1042. [ Google Scholar ] [ Ref list ]
15. World Health Organization. Guidelines for medico-legal care for victims of sexual violence. Geneva: World Health Organization; 2003. [ Google Scholar ] [ Ref list ]

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1 Daegu Child Sexual Abuse Response Center, Daegu, Korea.
1 Daegu Child Sexual Abuse Response Center, Daegu, Korea.
1 Daegu Child Sexual Abuse Response Center, Daegu, Korea.
2 Department of Forensic Medicine, Kyungpook National University School of Medicine, Daegu, Korea.
3 Department of Obstetrics and Gynecology, Kyungpook National University School of Medicine, Daegu, Korea.
Children who have been raped some years back may have hymenal scars. However, medical professionals are not accustomed in assessing these scars because of the lack of experience in performing physical examinations of the external genitalia of children who suffered from rape some years back. Moreover, the importance of physical examination of the victim's external genitalia is sometimes overlooked. Two cases of rape victims with hymenal scars who visited Daegu Child Sexual Abuse Response Center several years after their first sexual abuse along with a literature review are presented here.
Child sexual abuse is a sexual crime against children aged less than 13 years. Rape is defined as committing forced sexual intercourse by violence or threat [ 1 ]. Children lack the capacity to consent; therefore, heavy sentences are imposed on the offenders, regardless of consent. Nevertheless, the Korean Criminal Procedure Act is based on the evidence submitted during the trials [ 2 ] and the physical evidence that supports the victim's statement is crucial in proving the crime committed by the defendant. Medical professionals provide not only medical treatment for the physical injuries on the
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