The Presence of Anogenital Injuries in Post-Puberty - Essay Example

Current researches and literature relating to the significance of the presence and absence of ano-genital injuries in post puberty Most organ systems of the body operate almost continuously in order to maintain the well-being of an individual. Each part of our body composed of a well-organized unit by which each of those parts has its own functions and operates as a whole. The relationship between the body parts (anatomy and physiology) is emphasized for us to know its specific operations and functions. (Marieb, 2002) The reproductive system organs will not function unless it reaches the puberty stage. Puberty is the period of life in ages 10-15 years. When the organs grow to their adult sizes and become more functional under any influence of rising levels of gonadal hormones. Male have testosterone while female have estrogen and progesterone. The reproductive stage continues until old age both in male and in female and eventually these are the secondary sex characteristics and events of puberty. It is essential to remember that however, that it is the puberty that represents the beginning period of the reproductive system activity. (Marieb, 2002) The ano-genital area of the human body, sometimes referred to as “genito-anal” includes the anus and the genitals of both sexes. The genito-anal plays a vital role in pre-pubertal and post pubertal stages. Earlier, the certain part of the body is not taken into consideration unlike nowadays where certain diseases can de diagnosed through the examination of the anus and the genitals. The observations can also serve as indicators of the sexual abuse especially in women. Many of the characteristics of the ano-genital areas are further studied to show its significance in many other reproductive processes and development. The ano-genital areas of both male and female can be differentiated if these were abused or not. In pre-pubertal ano-genital area is most likely have the characteristic of none presence of warts, hematomas, and lacerations mostly in children. These are just some of the sign if the certain individual have been sexually abused. In post-pubertal stages, the ano-genital appears to be the opposite of that of the pre-pubertal. In female victims, bleeding and discharge in both genital and anal region are more visible. (Hobbs and Wynne, 1999) Table 1. Summarizes the genital and non-genital injuries of an individuals who are victims of sexual assaults/ rape. The ano-gential index (AGI) or the value of the distance between the anus and the genitals divided the body weight, is primarily the comparative tool between individuals (Barett, 2006). The ano-genital index is commonly used in boys who had been exposed in chemicals. Scientists believed that exposure to chemicals such as phthalates can cause shortening of the ano-genital index which is presumed fertility in males. Furthermore, a disease that involves the ano-genital area of the elderly is specifically significant to study since the it can be only be diagnosed through a biopsy, termed as EMPD or Extramammary Paget’s Disease. It is frequently observed in the penis and the vulva. (Extramammary Paget’s Disease, 2007). Extramammary Paget’s disease arises as a primary cutaneous adenocarccinoma in most cases. The target areas of this are the genital skin, perianal skin, and other sites which are rich in apocrine glands. EMPD is not a common disorder but most likely and an acquired kind of disease. With this certain type of disease, women are more affected than man especially in positively sexually abused women. (Wilde, J.L) In adults, the common considerations are the infections. Vaginal and penile infections are most common in young and elderly individual and in those who have low in resistance. Most common infections were caused by Escherichia Coli. This is a sexually transmitted microorganisms that would be the leading caused for gonorrhea, herpes virus and syphilis and even yeasts which is a type of fungus. Also, Barr (2001) reports the occurrence of over a hundred types of human papillomavirus that can be isolated in the ano-gential region of the body. Papillomavirus is responsible for warts and some types of cancer. In sexually abused clients, they are at least 10 percent of the young women affected by papillomavirus in England. This shows the area of the body so as to put to a stop to the spread of the human papillomavirus believed to be the causative agent of cervical cancer. The virus infects the mucous membrane and the skin of the victim and even the lining of the cervix. The abnormal cells slowly progressing and most of the time are asymptomatic for years before it will be diagnose. In many cases, symptoms cannot be detected unless it will undergo to annual Pap smear by a gynecologists. Male victims can also get penile cancer as well. (Armsstrong, DKB,1197) Meanwhile, rape or sometimes referred to sexual assault can be happen both men and women of any age. Rape is referred to a vaginal penetration of a woman by a male suspect. Sometimes, a male can be victimized too. Sexual assault or violence can be considered as one of the global problems. Sexual violence has a negative impact on the population especially in their health. There a lot potential reproductive a sexual health consequences. (Coomaraswamy, R., 1997) Table 2. Shows some of the potential health risk of a rape victim. Rape cases are happening in millions of the people worldwide. Victims of sexual assaults have already post traumatic disorder which accounts about 33 percent males and 21 percent female on the gathered statistics. Accounted estimations in rape cases are more likely happened in women than men. The majority studies show that 1.5-3 are girls. Men are less likely to be sexually assaulted. Victims of sexual assaults requires a comprehensive study on their health to cope with their consequences physically, emotionally, mentally, and recover from extremely distressing and depressing traumatic event. In sexual activity often times false agreement are obtained in many ways for example, threats to withholding the victim’s benefits, violence in physical, psychological pressure, and even blackmail. (Jewkes, Garcia-Moren,2002) On the other hand, data gathered an estimation of 80-90 percent of individual who were rape victims were really had physical evidences. Legal decisions in this case often the turning point of the evidences if the is sexually abused through the presence and absence of genitor-rectal injury. (Leserman J et al.) A complete physical examination should be dine and should be documented. Numerous samples and specimens should be collected for evidences. These samples and specimens include the fingernails scraping, vaginal samples to examine the presence of the semen of the suspect, and even mouth and anal samples may also be required. The forensic sciences have also set ano-genital examinations one of the key procedures to identify sexual abuse in women victims and other related purposes. It has been one of the important evidence-gathering techniques used currently. However, there are some forensic literatures that do not explain why certain injuries occurred but not a victim of sexual assault. The retrospective law of cross-sectional analysis among the rape victims set a plan for prospective analysis. The researchers had this study telling that those are sexually abused person both in female and male in any age, partial tears, hematomas and hymenal abrasions are commonly seen but some individuals had partial tears, hematomas and hymenal abrasions that does not caused by sexual assault. (Sachs and Chu, 2002). The ano-genital examination of the sexually abused individual is really different from non-abused one. The legal experts told that individual’s history plays an essential role and used as a primary evidence of the abuse. (Am J Obstet ad Gynecol, 2000) Ano-genital injuries have recently become an index for sexual abuse in women. Guardino (2006) describes the characteristics that can be observed in an ano-genital exam. The examinations in pre-pubertal individual must be noninvasive and non-painful. Parts of the Victims to be Examined Girls Boys Both Mons pubis Labia Majora Labia Minora Urethra Clitoris Vaginla Vestibule Hymen Posterior Fourchette Fossa Naviculairs Shaft Gland Fenulum Scrotum Inguinal Region Testicles Epididymis Perineum Ano-rectal canal Anal Verge tissues Glutela Cleft Perianal Region Table 3. Shows the body parts of the victims to be examined through ano-genital examination. Genital bleeding can occur that may be caused by bacterial or viral infections, sclerosis, or by local injury. If bleeding is not present and vaginal discharge is observed, it can be due to abscess, bacterial, viral infection or by chemical and physical irritations. Ano-genital trauma can immediately bring out bruises, inflammation, and redness within the area. Accordingly, genital bleeding, vaginal discharge and other observable forms of ano-genital trauma are directly linked to an occurrence of sexual abuse. It is obvious that detailed and careful examination of the local area speaks a lot about a possible abuse. (Campbell JC,1994) The presence of such injuries distinctions can be used to gather more evidence leading to a formal complaint. But before doing some forensic examinations on the client, the examiner must have a legal consent to the victim that to be examined. The welfare of the client must be a concern primarily for the fact that the client must maintain their self respect and dignity after the assault. Moreover, forensic and medico-legal examinations should be offered in a way to minimize the number of invasive physical exams and legal interviews with the victim. On the other hand, carelessly treated examination procedure may lead to erroneous results and the examiner may be forced to jump into false conclusions., A critical mind is very important in examining the cause and effect of an ano-genital injury especially if it is involved in a criminal case. (Andrist, L.C, 1998) Components in Assessing and Examining for Sexual Assaults and Rape Victims 1. Initial Assessment (Obtaining Informed Consent) 2. Medical History 3. Tip-to-toe Examination 4. A detailed Ano-genital Examination 5. Classifying and Recording types of injuries 6. Collection of Medical Specimens for diagnostic purposes 7. Collection of Forensic Evidences 8. Packaging, Labeling, and Transporting of Forensic Evidences to Chain of Custody 9. Therapeutic/ Medical Opprutunities 10. Follow-up care Visits 11. Storage of Documentation 12. Medico-legal reports provision Table 4. Shows the components in examining and assessing the victims of rape and sexual assaults. The medical and forensic examination must have a proper timing. Delay assessing services may results into the lost of important forensic materials especially the contact with the assailant (blood and semen), changes in physical evidences, and even loss of therapeutic opportunities. (Guardino, 2006) For medical ethics, it is a fundamental duty of the health provider to use their skills in a professional manner. There are several principles in providing the sexual assaults victims in a fundamental and therapeutic way. One is the autonomy of the client wherein the health providers should considered the right of the clients. Every procedure or examination that the health examiner does must have a legal consent signed by the client. Second, is the duty and obligation to act in the interest of the client or what we call the beneficence. Non-maleficence is the term used in protecting the client from harm or danger. Lastly, the fairness and justice in the examination must be clearly emphasized by doing and giving what is due rightfully. (Ingrams Dl. Everist D. Lyna P. et al., 1993) The examiner is supposed to understand the basic anatomy of the human body to be able to understand fully how to describe his observations in the examination. Health professionals must be a skilled in IPPA or the inspection, palpation, percussion, and auscultation are necessary for the examination of physical health. These techniques are used throughout the examination especially to those who are sexual assault and rape victims. According to Kozier (2002), knowledge of the structure and functions (anatomy and physiology) of the system are essential requirements in conducting physical assessment. Pre-pubertal and post-pubertal stages pose a very distinct difference between the normal physiology and physical attributes of the human body. The Tanner scale is used as a tool to categorize a person’s development based on the physical maturity of the primary and secondary sex characteristics. The scale is important to be able to properly interpret findings of the individual under examination relative to the Tanner category. Table 2 shows the category of the Tanner scale. Tanner Scale/ Category Tanner I Tanner II Tanner III Tanner IV Tanner V Female No pubic hair at all. No glandular tissues in the breasts. Widening of the areola and forming of the breast buds. Breasts became more elevated with separation of the contours. The breast increased in size and contour. Final adult size breast with contour and projecting central papilla. Male No pubic hair at all. Testicular volume less than 1.5 ml. Testicular volume is about 1.6-6ml. Thinning of the scrotum’s skin. Enlargement and redness of the penis. Testicular volume about 6 and 12 ml. More largely scrotum. Penis lengthen to 6 cm. Enlarged scrotum and becomes more darken. Increased penis’ size. Testicular volume of 20 ml and greater. Reached the adult size and scrotum. Table 5. Shows the Tanner Classification of Sexual Maturity In post-pubertal stage, the individual has already reached maturity and exhibits the adult sex characteristics. The ano-genital region should also demonstrate the adult stages of sexual maturity. The use of the colposocope in ano-gential examination of gaining scrutiny especially it’s significant use in pre-pubertal against post-pubertal examination. ( Finkelhor D.,1994) Naturally, adult females produce more estrogen as compared to young females it is primarily because active at puberty and start to produce ova, thus ovarian hormones production begins. The production of the estrogens starts in the growing of the mature follicles which causes the secondary sex characteristics appearance in young women. Such changes includes the development of breasts, appearance of the axillary and pubic hair, enlargement of the accessory organs of the female reproductive system (external genitals, vagina, uterus, and uterine tubes), widening of the pelvis, increased deposits of fats particularly in hips and breasts, and onset of menstrual cycle. (Marieb, 2002) These significant characteristics allow adult women to be more resistant against ano-genital injuries. Subsequently, having a higher estrogen level permits them to heal more easily after an injury as compared to pre-pubescent females. Photo-colposcopy is less advised in the post-pubertal stage since older women may use tampons and become involved in sex and these acts can easily cause the colposcope to detect injuries (Norvell 1984). Colposcopy is a procedure performed by the health examiner to a rape or sexual assault victims. It is performed by using a magnified visual inspection of the genitalia (external and internal more specifically in women victims) in the context of the standard gynecologic exam. It will let the user to view the extent of the injury committed by the suspect to the victim by a photograph microscope. (Adams, Harper, et al.,1995) Lots of forensic examiner used this kind of procedure especially in women. The role of the forensic rape examination is essential and most used in United States for health care and criminal justice systems. It is used because it describes the epidemiology of the certain injury whether it was caused by a consensual intercourse or not. Site of the injury The location of the injury should be and must be clearly and directly stated upon examination. Type of the injury Description of the injury. Size of the injury Width and length must be stated. Shape of the injury The shape of injury is patterned similarly to the object or a thing that hit the part of the body. Color of injury Description of the color of the injury indicates the extreme force hit the body parts, the span of time of the injury, and depth of the injury. Table 6. Shows the documentation of injury and its characteristics Interpretation of the injury varies in both complex and challenging manner. It requires a broad-based comprehensive pathological, anatomical, and physiological principles and codes. Without accurate information proper documentation and interpretation of injuries might be seriously flawed. This will have consequences for both the assailant and the victim. Health workers must be skilled enough to undergo such procedures and examination. (Finkelhor D.,1994) Classification and considerations of wounds and injuries Abrasions Scratches Friction Imprint Bruises Bite marks Fingertips Bruises Petechial Bruises Patterned/ imprint Trainline Lacerations Ragged, irregular, inverted Presence of foreign materials Tendons, nerves, and tendons are intact within the wound Blood loss often in small amounts Incised wounds Sharply defined edges Rarely contaminated Minimal damage Blood loss often profuse Table 7. Shows the characteristics and considerations of each injuries brought by the assailant to the victims. The Sexual Assault Nurse Examiner (SANE) programs provides colposcopy as an equipment to use in maximizing the ability and a competent forensic evidences while assisting the requirements of sensitive sexual assault victims. SANE program is included in a pilot studies to enhance a model in diagnostic systems for forensic examination for sexually abused individuals. The program has the potential in assessing and bringing the expertise clinically to every forensic evaluation of sexually abused individuals most especially children regardless of the location of the examination is done. (Andrist, L.C, 1998) By using the procedure colposcopy, a photographic images are taken in viewing evidences instead of using hands in which frees the SANE from contaminating such evidences. In ano-genital exams, as in the previous pages stated that the samples and specimens include the fingernails scraping, vaginal samples to examine the presence of the semen of the suspect, and even mouth and anal samples may also be required. (Andrist, L.C, 1998) Table 8. Shows the Physical and Legal findings on sexually assault victims The external regions of the genital and the anus must be examined. A swab in the region must be taken before doing any speculum exploration and digital examination. The speculum examination allows the examiner to inspect the walls of the vagina and assess any signs of injuries which includes abrasions, bruising, and lacerations. Foreign bodies and hairs should also be collected for the trace evidence. For digital rectal examinations, any insertion of foreign objects in the anal canal may be evident by the proctoscopy or anoscopy. Prostoscopy are needed in cases of anal bleeding or severe anal pain or presence of foreign body in the anus or rectum is suspected. (Burgess AW, 2000) SANE programs merged primarily not because traditional emergency department of several hospitals did not pay attention to the survivors needs. It may be physical, mental, and emotional. The clinical study literature suggests that SANE staffs are not only competent in forensic evidences but they are better at it because of their training and experience. The SANE programs greatly improved the consistency and quality of evidence collected. There are have been few SANE programs that their studies have an empirical hypothesis by which they have increases the prosecution. A stronger methodological design would include a direct comparison for SANE cases versus non-SANE cases in legal outcomes. Significantly, there was much higher percentage of victims treated in the community and more survivors had evidences collected using the rape kits which the SANE created. The SANE programs can have a big impact on the prosecution of rape and sexual assault cases. (Andrist, L.C, 1988) It can be noted that from the earlier example, the practicality of using ano-genital injuries as indicators of sexual abuse may be a little too unnecessary practicality in the sense that some statistics claim a negative psychological effect of the ano-genital tests to the child under examination. Merritt (2004) suggests that the most important factor that can be considered in knowing the cause of a certain injury is the history as stated by the individual. Collecting physiologic data for rape victim’s history does not demand more detailed questioning. Also, the questions asked about the system’s functions directly related to sexuality often provide clients with favourable circumstances to give clues to sexual concerns. A detailed sexual assessment is straightly related to the possible impact of sexuality on the problems of health or vice versa. (Andrist,1988) Psychosexual influences include culture, religion, development, attitudes, and values. The detailed questioning about the case and issues of a rape and sexual assault victims are not necessary in the visual health history unless there are several clues that potential or factual problems or circumstances exist. Diseases, illnesses, and other concerns about health can have a strong influence on sexual concept often possess the first clues of the client’s concerns. (Kozier, Erb, et.al, 2002) For instance, a child is sexually abused and then subjected immediately to ano-genital tests. There are times when a victim show no signs of abuse and ironically appear to be normal in the examinations. The child or the parent concerned should then be questioned if something of abusive nature happened to the child. In this very example, the child was at once subjected to the examination that unfortunately gave no record of physical trauma. That is clear impracticality and waste of money and time. (Emans SJ, Laufer MR, Goldstein DP, 2005) A Recommendation from American Academy of Pediatrics on Sexually Assaulted Children 1. Be knowledgeable on the incident, sexual assault, the victim and the suspect. 2. Rape protocols must be established. 3. Knowledge on legal and forensic aspect of the examination. 4. Preventive counselling, immediate referral, and physiological support must be prioritized. Table 9. Shows the Suggestions and recommendation of American Academy of Pediatrics on Sexually Assaulted Children For post-pubertal adolescents, on the other hand, the use of ano-genital injuries as the main source of evidence in a court trial, for example, can be considered unwise. With the fact stated earlier about post-pubescent adults, the absence of ano-genital injury in women may lead to a conclusion of either having consensual sex or having experienced no abuse at all. This conclusion may be false and misleading. (Emans SJ, Laufer MR, Goldstein DP, 2005) Problems in Forensic Examination 1. Examiners with insufficient experience in conducting the study. 2. Examiners who are improperly trained. 3. Failure of the examiners to recognize and preserve evidences. 4. Lack of equipment in conducting a thorough examination. 5. Failure of the examiners to document some physical findings. Table 10. Shows the Forensic Examination Problems An interdisciplinary team plays a very important role in examining the sexually harassed victims. Counselling staffs are useful in providing information and services socially in these patients. The counselling services include the social workers, community-based support groups, psychologists’ and religious groups. Moreover, laboratories and hospitals are also essentials in dealing with these victims. These teams provide emergency and medical care for the victims. The medical laboratory has the responsibility to take care for the specimens obtained by the practitioner form the victim. The forensic will be the one to examine the specimens for evidence purposes. Also, police plays a main role in investigating the actual criminal activity. Police investigate both the assailant and the victim. Lastly, the criminal justice system will be the one responsible in prosecution. The health workers and other interdisciplinary members of the team will be involved in the court process. Moreover, the law enforcement personnel must be prepared in telling the victim the following issues: The importance and implications of forensic evidences that should be needed to collected as soon as possible. General information about the forensic process of examination The role of the interdisciplinary team that involves in forensic studies, law enforcing, and the rape crisis advocate. The extent of privacy and confidentiality in communications of each professionals involved in the study. The right of the victim to refuse to participate in any aspect of medical procedures and collected evidences. There certain legal issues are also obtained to determine if the medical examinations are comparative to the legal ones. The impartiality of the victim is often happened especially if he or she if emotionally involved with the suspect. Therefore, when providing evidences a court testimony along with the forensic examinations are essential. The forces between the two (the practitioner and the investigator) must be strong and a close relationship with each other should be develop in order to come up a fair result. Fairness may be comprised if either of the shows a unconscious help to each other. In some situations, the investigator and the practitioner may develop a bias and a culture victim-blaming against the victim specifically in women and may often reflect in a judgemental form of questioning. (Leserman J et al., 1998) Guidelines in Providing Medico-legal Evidences Interview with the victim Physical Examination Laboratory Data Diagnostic Procedures and Considerations Filing of Records Treatment Legal Issues Table 11. Shows the Medico-legal Evidences guidelines Alternatively, the presence of ano-genital injury in women can be directly linked to either having consensual sex or having been sexually abused. Both presumptions are inconsistent in nature unless backed upon by supporting evidences and sworn statements. Thus, there is a great danger in the interpretation of findings in an ano-genital examination. Much precaution is needed in declaring the absence or presence of an injury (Norfolk & White 2006). If the presence or absence of an injury is not advised as a major source of evidence and basis for argument in a court trial for sexual abuse, the same goes with the declaration of history by the alleged abused child. Statements and stories can easily be made up to fit the story of both sides of an argument and this is not as reliable as physical evidences. (Leserman J et al., 1998) Some survivors chose to report because: Some survivors chose NOT to report because: 1. To prove that there was really an assault happened. 2. To have justice served. 3. To get revenge. 4. To keep other’s safety. 5. To hold the suspect who is accountable for the assault. 1. Fear of the being blame by others 2. Fear of the assailant 3. Fear of the family assailant’s retaliation 4. Fear of family and friends’ reactions 5. Fear of loss of privacy Table 12. Shows the possible reports and its reasons of sexually assaulted victims Evidences in the rape cases should be reviewed for possible criminal prosecution. The juries and the prosecution may take as many as their decisions relating to the medical records given to them. If the evidences on the said case are extremely strong, there is a great possibility that the assailant may be in responsible for the victim. However, these decision has it’s own disadvantages and advantages. For example, the assailant is unable to post bond then the jury and the medical team have their sufficient time in gathering such criminal laboratories needed on the case such as DNA testing. After appropriate laboratories done, preventive treatment is necessary for the victim. A post-coital contraceptive will be given immediately. (Smithland J.C. and Hogan B., 1973) On the other hand, treatments are provided for rape and sexual assault victims. Treatment for Rape Victims Gonorrhea Cefixime/ Ceftriaxone Vaginosis Metronidazole Chlaymadia Doxycycline Syphilis Tetracycline Table 13. Shows the following specific medications for rape victims Basically, there is a great significance in examining the ano-genital area as enumerated above. Medically, the individual can benefit from detailed knowledge of the ano-genital region because of the possible diagnosis of certain diseases such as the Paget’s disease in men and cervical cancer in women. Researches that focus on the different factors that affect the development of the human body by using the ano-genital index serve a great significance in the sciences as well. Also, knowledge on how to conduct an ano-genital examination properly is very important especially for a child who may perceive it as a negative experience. Reporting to law enforcements and with the used of the rape or evidence kit are the ways in order to detect related ano-genital injuries. (Tjaden P, Thoennes N.,2000) The primary purpose of the medico-legal examination among the sexually assault victims is to obtained general and specific information that assists in the management of the client and help to explain findings. Health practitioners and professionals are suggested to refer on the national guidelines and standards in conducting medico-legal procedures to make sure that they are compliance. (Stevens L., 2000) The medical history of the victim should be covering all known health problems and medications. In obtaining information about the patients’ general medial history, there must be a comprehensive questioning done. If possible, a standard medical examination record will be used in order to prevent some omission of the important details regarding patient’s health conditions. (The British Co- operative Clinical Group., 1997) AIMS FOR OBTAINING MEDICO-LEGAL EXAMINATIONS 1. Search, detect, and treat all injuries brought by the assailants to the victims 2. Assessment for the risk of consequences: Health risk or consequences after an assault 3. Relevant specimen collection 4. Documentation purposes 5. Forensic guidelines procedures and examination Table 14. Shows the main aims for obtaining an account of assault inflicted to the victims from the assailants. Lastly, current literature implies the slight insignificance of the presence or absence of ano-genital injuries in post-pubescent individuals as an indicator of sexual abuse. It is significant though in pre-pubescent individuals, mainly due to the physiological and physical differences they have. Combining physical evidences and data with the history of the individual is still the best way to deduce the possibilities. (Thomas A, Forster G, et.al) References ACOG national officers; ACOGs scope of practice; ACOG governance structure; bylaws; committee descriptions; code of ethics; and history. American College of Obstetricians and Gynecologists American Journal of Obstetrics & Gynecology. 182(4):820-834, April 2000. Sachs C. J., MD, MPH and Lawrence D. Chu, PhD, MS, MPH < ttp://en.wikipedia.org/wiki/Tanner_stage> American Social Health Association P.O. Box 13827 Research Triangle Park, North Carolina.HPV and abnormal cell changes. American Social Health Association website. Available at: . Accessed on February 7, 2003. American Social Health Association P.O. Box 13827 Research Triangle Park, North Carolina Am J Obstet Gynecol 2000” Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy.”;182:820-34. (C) Mosby-Year Book Inc. 2000. All Rights Reserved. Andrews G et al. Comparative risk assessment: child sexual abuse. Final report. Geneva, World Health Organization, in preparation. Andrist, L.C “Blackwell Synergy® is a Blackwell Publishing, Inc. registered trademark Partner of CrossRef, COUNTER, AGORA, HINARI and OARE” December 1988.Taking Care history and Education Clients. Nursing Clinics of North America 23:959-73< http://www.blackwell-synergy.com/doi/abs/10.1111/j.1440- 1800.1997.tb00113.x?cookieSet=1&journalCode=nin > Apgar, M.D., M.S., and G Brotzman, M.D. (American Family Physician May 15, 1999, Human papillomavirus testing.American Academy of Family Physicians website. Available at: http://familydoctor.org/handouts/389.html. Accessed on February 7, 2003 Armstrong DKB. “"Anogenital warts in prepubertal children: pathogenesis, HPV typing and management",”Typing and management Int. STD AIDS 1997:8:78:81 < http://www.ingentaconnect.com/content/rsm/std/1997/00000008/00000002/art00002 > Barr, Eliav 2004, ‘Human papillomavirus and cervical cancer’, U.S. National Center for Infectious Diseases, Nov. 1, 2004, viewed 21 September 2007, < http://www.thefreelibrary.com/Human+papillomavirus+and+cervical+cancer-a0125228857>. Barrett, Julia R. 2006, ‘Fertile grounds for inquiry: environmental effects on human reproduction’, National Institute of Environmental Health Sciences, Nov.1, 2006, viewed 21 September 2007, . Berenson, Abbey B. MD; Chacko, Mariam R. MD; Wiemann, Constance M. PhD; Mishaw, Clifford O. MD; Friedrich, William N. PhD; Grady, James J. DrPH Transactions of the Eighteenth Annual Meeting of the American Gynecological and Obstetrical Society Burgess AW, ed. Violence through a forensic lens. King of Prussia, PA, Nursing Spectrum, 2000. Campbell JC. Health consequences of intimate partner violence. Lancet, 2002, 359: 1331– 1336. Collingwood,L. 21th Century Universal Encyclopedia Edited .1994. Regency publishing Group Pty limited 1994. National Library of Australia Coomaraswamy R. Preliminary report submitted by the Special Rapporteur on violence against women: its causes and consequences. New York, NY, United Nations, 1997 (report number E/CN.4/1997/47). Dickson N et al. First sexual intercourse: age, coercion, and later regrets reported by a birth cohort. British Medical Journal, 1998, 316:29–33. Duncan ME, Tibaus G, Pelzer A. “Prevalence of HIV, syphilis and genital chlamydial infection among women in North-West Ethiopia”et al.First coitus before menarche and risk of sexually transmitted disease.Lancet 1990: 335:338-40< http://journals.cambridge.org/action/displayAbstract;jsessionid=B0E34B116B458B0D93AFF08B141A88B7.tomcat1?fromPage=online&aid=39449 > Emans SJ, Laufer MR, Goldstein DP (primary authors). Pediatric and Adolescent Gynecology. 5th edition. Philadelphia: Lippincott, Williams and Wilkins, 2005 “Reproductive Endocrine Practice” Finkelhor D. The international epidemiology of child sexual abuse. Journal of Child Abuse and Neglect, 1994, 18:409–417. Fuster CD. Neinstein LS. Vaginal C. ”Pediatrics” trachomatis prevalence in sexual abused girls , periatrics 1987:79:235-8 Garden A.S., Nelki J, Stewart F. Growth and psychosexual development . In: Garden AS. ed. Paediatric and Adolescence, gynaecology.London: Arnold . 1998 Giardino, Angelo P. 2006, ‘Child Abuse and Neglect: Sexual Abuse’, eMedicine from WebMD, June 16, 2006, viewed 20 September 2007, . Gostin LO et al. HIV testing, counselling, and prophylaxis after sexual assault. Journal of the American Medical Association, 1994, 271:1436–1444. GreenbergJ, Madger L, Aral S. at first coitus : a marker for risky sexual behavior in Women. Sex Dis 1992: 19:331-4 Halcón L, Beuhring T, Blum R. A portrait of adolescent health in the Caribbean, 2000. Minneapolis, MN, University of Minnesota and Pan American Health Organization, 2000. Hammerschlag MR. Cumming M. Doraiswamy B.et. al. Non specific vaginitis following sexual in children Pediatrics 1985: 75: 1028- 31 Hammerschlag MR, Sexually transmitted disease in sexually abused children : medical and legal implication Sex Transm Infect. 1998:74:167:74 Ingrams Dl. Everist D. Lyna P. et al. Epeidemiology of Adult Sexually transmitted disease agents in Children being evaluated for possible sexual abuse, Pediar Infect Dis 1992:11:945:50 34 Rawstron SA, Bromberg K. HammerschlagMR. STD in children syphilis and gonorrhoea . Genitourin Med 1993:69:66-75 Jewkes R, Garcia-Moren C, Sen P. Sexual violence. In: World report on violence and health. Geneva, World Health Organization, 2002:149–181. Kozier, Erb et. Alo Fundamental of Nursing : concepts process and practice 5th edition 2002, Pearson Education Asia Pre Ltd - Singapore 629733 Leo and Gloria Rosen family. Copyright 2007 © American Cancer Society, Inc. American Cancer Society Leserman J et al. Selected symptoms associated with sexual and physical abuse history among female patients with gastrointestinal disorders: the impact on subsequent health care visits. Psychological Medicine, 1998, 28:417–425. Marieb ,E.n. Essential of Human Anatomy and physiology 6 ed. 2002 Pearson Education Asia Pre Ltd., Singapore 629733 Matasha E et al. Sexual and reproductive health among primary and secondary school pupils in Mwanza, Tanzania: need for intervention. AIDS Care, 1998, 10:571–582. Meritt, Diane F. 2004, ‘Adolescent and pediatric gynecology’, Lippincott Williams & Wilkins, Inc., viewed 20 September 2007, . Murray CJL, Lopez AD, eds. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Geneva,World Health Organization, 1996. Norfolk, G & White, C 2006, ‘Interpreting evidence in court- the dangers and pitfalls’, Sexual Offences Journal of Clinical Forensic Medicine 13 (2006) 160-161, viewed 20 September 2007,. Norvell MK, Benrubi GI, Thompson RJ 1984, ‘Investigation of microtrauma after sexual intercourse’, J Reprod Med 1984; 29 269–71. Rwenge M. Sexual risk behaviours among young people in Bamenda, Cameroon. International Family Planning Perspectives, 2000, 26:118–123. Robinson AJ. Watkeys EM. Ridway GL.unpublished Data. Royal College of pathologists and the Institution of Biomedical Science. The retention and storage of pathological records and archives. Report of the working party of the Royal College Pathologists and the Institution of Biomedical Science 2nd ed. London . 1996 :16 Saltzman LE et al. Intimate partner violence: uniform definitions and recommended data elements,version 1.0. Atlanta, GA, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 1999. Sex Information and Education Council of Canada (SIECCAN) 850 Coxwell Avenue Toronto, Ontario, M4C 5R1 Smithland J.C. and Hogan B., Criminal Law , 3rd Edition 1973 Spataro J, Moss S, Wells D. Child sexual abuse: a reality for both sexes. Australian Psychologist, 2001, 36:177–183. Stevens L. A practical approach to gender-based violence: a programme guide for health care providers and managers. New York, NY, United Nations Population Fund, 2001. Swart LA et al. Rape surveillance through district surgeon offices in Johannesburg, 1996– 1998: findings, evaluation and prevention implications. South African Journal of Psychology,2000, 30:2–10. The BC Cancer Agency, Extramammary Paget’s disease 2007, , viewed 20 September 2007, < http://www.bccancer.bc.ca/HPI/CancerManagementGuidelines/Skin/NonMelanma/ManagementPolicies/ExtramammaryPagets+Disease++.htm>. The British Co- operative Clinical Group. Provision for Sexual Health care of Adolescence in genitourinary medicine clinics in the United Kingdom, Genitourinary Med 1997 :73:453-6 The Society of Obstetricians and Gynaecologists of Canada (SOGC) Sexualityandu.ca Thomas A, Forster G , Robinson A, and Rogstad K “For The Clinical Effectiveness group” (Association of Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases) Tjaden P, Thoennes N. Full report of the prevalence, incidence, and consequences of violence against women: findings from the National Violence Against Women Survey.Washington, DC,Office of Justice Programs, National Institute of Justice, 2000 (report number NCJ 183781). Read More