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They reported that anxiety has a diﬀerent relationship to these two types of pain cheap ampicillin 250 mg without prescription. In terms of acute pain generic 500mg ampicillin, pain increases anxiety discount 500 mg ampicillin with mastercard, the successful treatment for the pain then decreases the pain which subsequently decreases the anxiety. Therefore, because of the relative ease with which acute pain can be treated, anxiety relates to this pain perception in terms of a cycle of pain reduction. Because treatment has very little eﬀect on chronic pain, this increases anxiety, which can further increase pain. Therefore, in terms of the relationship between anxiety and chronic pain, there is a cycle of pain increase. In a recent experimental study participants took part in the cold pressor test which involves placing the hand and arm in icy water as a means to induce pain. Their trait anxiety was assessed and some were actively distracted from thinking about their pain (James and Hardardottir 2002). The results showed that both distraction and low anxiety reduced the pain experience. Fear Many patients with an experience of pain can have extensive fear of increased pain or of the pain reoccurring which can result in them avoiding a whole range of activities that they perceive to be high risk. For example, patients can avoid moving in particular ways and exerting themselves to any extent. However, these patients often don’t describe their experiences in terms of fear but rather in terms of what they can and cannot do. Therefore, they don’t report being frightened of making the pain worse by lifting a heavy object, but they state that they can no longer lift heavy objects. Fear of pain and fear avoidance beliefs have been shown to be linked with the pain experience in terms triggering pain in the ﬁrst place. The participants were then followed up after one year and the occurrence of a pain episode and their physical functioning was assessed. The results showed that 19 per cent of the sample reported an episode of back pain at follow-up and that those with higher baseline scores of fear avoidance were twice as likely to report back pain and had a 1. Some research also suggests that fear may also be involved in exacerbating existing pain and turning acute pain into chronic pain. They argued that pain functions by demanding attention which results in a lowered ability to focus on other activities. Their results indicated that pain related fear increased this attentional interference suggesting that fear about pain increased the amount of attention demanded by the pain. They con- cluded that pain related fear can create a hyper-vigilance towards pain which could contribute to the progression from acute to chronic pain. These conclusions were further supported by a comprehensive review of the recent research. This indicates that treat- ment which exposes patients to the very situations that they are afraid of, such as going out and being in crowds, can reduce fear avoidance beliefs and modify their pain experience (Vlaeyen and Linton 2000). The role of cognition Catastrophizing Patients with pain, particularly chronic pain, in line with many other patients often show catastrophizing. Catastrophizing has been linked to both the onset of pain and the development of longer-term pain problems (Sullivan et al. The results showed some small associ- ations between this and the onset of back pain by follow-up. Their new measure consisted of three subscales reﬂecting the dimensions of catastro- phizing, namely rumination, magniﬁcation and helplessness. They then used this meas- ure to explore the relationship between catastrophizing and pain intensity in a clinical sample of 43 boys and girls aged between 8 and 16. The results indicated that catastro- phizing independently predicted both pain intensity and disability regardless of age and gender. The authors argued that catastrophizing functions by facilitating the escape from pain and by communicating distress to others. Meaning Although at ﬁrst glance any pain would seem to be only negative in its meaning, research indicates that pain can have a range of meanings to diﬀerent people. For example, the pain experienced during childbirth although painful, has a very clear cause and consequence. If the same kind of pain were to happen outside of childbirth then it would have a totally diﬀerent meaning and would probably be experienced in a very diﬀerent way. Beecher (1956), in his study of soldiers’ and civilians’ requests for medication, was one of the ﬁrst people to examine this and asked the question: ‘What does pain mean to the individual? This has also been described in terms of secondary gains whereby the pain may have a positive reward for the individual.
Although the 1967 Sexual Offences Act provided that it was not an offense for two consenting men who had attained the age of 21 to commit buggery in private buy cheap ampicillin 500mg on line, it remained an offense for a man to commit buggery with a woman 250mg ampicillin free shipping, even if both parties consented generic ampicillin 250 mg visa, until 1994. The Criminal Justice and Public Order Act 1994 expanded the definition of rape, which had previously related to only vaginal intercourse, to include nonconsensual penile penetration of the anus independent of the gender of the recipient. The Sexual Offences (Amendment) Act 2000 reduced the minimum age at which a person, whether male or female, may lawfully consent to bug- gery to 16 years. A recent change in English law has defined nonconsensual penetration of the anus by an object or a body part (excluding the penis) as “assault by penetration,” this new offense has the same maximum sentence as rape. In some other jurisdictions, such as Australia, such acts are included in the legal definition of rape (172). Anatomy and Physiology An understanding of the normal anatomy and physiology of the perianal area and anal canal is important for the reliable description and interpretation of the medical findings after allegations of anal penetrative acts. Unfortunately, varying definitions have resulted in considerable confusion, such that there is no consensus among forensic practitioners about the nomenclature that should be used in describing injuries to this area. Therefore, a brief overview of the relevant information is given in the remaining Subheadings, together with ref- erences to more substantive texts. Anus The anus refers not to an actual anatomical structure but to the external opening of the anal canal. The skin that immediately surrounds the anus is variously referred to as the anal verge or anal margin (173). Because the anal canal can evert and invert as the anal sphincters and pelvic floor muscles relax and contract, the anal verge/margin is not a fixed, identifiable landmark. Perianal Area The perianal area is a poorly defined, approximately circular area that includes the folds of skin encircling the anus. It is covered by skin that is often Sexual Assualt Examination 103 hyperpigmented when compared with the skin on the buttocks, although this varies with age and ethnicity (174). Anal Canal Although the anal canal has been variously defined, the definition that has practical clinical forensic value is that of the anatomical anal canal, which extends from the anus to the dentate line. The dentate line refers to the line formed either by the bases of the anal columns (most distinct in children) or, when these are not apparent, by the lowest visible anal sinuses (175). The average length of the anatomical anal canal in adults (age range 18–90 years) is only 2. Between the epithelial zones of the anal canal and the rectum is the anal transitional zone, which is usually located in the region of the anal columns and is purple (177). The anal canal, as previously defined, is lined by nonkeratinized squa- mous epithelium and is salmon pink in the living (174). It is sensitive to touch, pain, heat, and cold to just above the dentate line (175). The anus and lumen of the anal canal usually appear as an asymmetric Y-shaped slit when viewed via a proctoscope (anoscope). The folds of mucosa and subcutane- ous tissue (containing small convulated blood vessels surrounded by con- nective tissue) between the indentations of the Y are referred to as the anal cushions. Although this appearance is usually obscured externally by the folds of skin on the perianal area, it may become apparent if the patient is anesthetized or as the anus dilates. Rectum The rectum extends from the anal transitionary zone to the sigmoid colon and is 8–15 cm long. Anal Sphincters and Fecal Incontinence Although numerous muscles encircle the anal canal, the two that are forensically significant are the internal and the external anal sphincters. Internal Anal Sphincter This sphincter is a continuation of the circular muscle coat of the rectum and extends 8–12 mm below the dentate line. In the normal living subject, the internal anal sphincter is tonically contracted so that the anal canal is closed. The internal sphincter is supplied by autonomic nerve fibers and is not consid- ered to be under voluntary control (3). Thus, although it appears to contract 104 Rogers and Newton during a digital assessment of voluntary anal contraction, it is presumed to result from its compression by the surrounding external sphincter fibers (177). External Anal Sphincter This sphincter encircles the internal sphincter but extends below it, end- ing subcutaneously. The lower edges of the external and internal sphincters can be distinguished on digital palpation. Although this sphincter is tonically contracted in the resting state, this contraction can be overcome with firm pressure (177). If the patient is asked to contract the anus during a digital assessment, the external sphincter can be felt to ensure contraction and clos- ing of the anus tightly. However, because the muscle fibers are predominantly the slow-twitch type, a maximum contraction of the external sphincter can only be maintained for approx 1 minute(178). Fecal continence is maintained by several factors, the relative impor- tance of which has not been fully elucidated. Currently, the most important factor is the angulation between the rectum and the anal canal, which is main- tained at a mean of 92° by continuous contraction of the puborectalis muscles, located above the external sphincter.