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Doctoral theses at NTNU, 2014:317

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 Olav’s Hospital. Charged and non-charged cases were compared.Main OutcomeMeasures. Medico-legal findings and legal outcome.Results.Atotal 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 hadmultiple anogenital injuries.Documentation of injuries was not associatedwith charge filing. In only 33%of the cases were swabs collected fromwomen’s 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 women’s 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 women’s rights and increase available information to the legal system. (c) 2011 The Authors

Bakgrunn Hyperaktiv bekkenbunn er en lite studert tilstand med kompleks etiologi og sykdomsbilde. Pasienter har gjerne en kombinasjon av urologiske, gastrointestinale, gynekologiske, muskel- og skjelett-, og psykologiske symptomer og tilstander. På grunn av det heterogene sykdomsbildet kan det være vanskelig å identifisere pasienter. Det er ingen diagnose i ICD-10 for hyperaktiv bekkenbunn, og prevalensen i den norske befolkningen er ukjent. Et nederlandsk forskerteam har utviklet et selvrapporteringsskjema, kalt Amsterdam Hyperactive Pelvic Floor Scale (AHPFS), rettet mot kvinner og foreslått en klinisk cut-off verdi for hyperaktiv bekkenbunn basert på skåringen på dette spørreskjemaet. Mål Hovedmålet i denne studien var å utforske alvorlighetsgraden av symptomer ved hyperaktiv bekkenbunn hos pasienter og friske frivillige. Forskningsspørsmålene var: 1) Er det noen forskjeller i skåringen på AHPFS blant forskjellige grupper av kvinner?, og 2) Er det noen sammenheng mellom skåringen på AHPFS og forskjellige bakgrunns- og kliniske forhold? Materiale og metode Dette er en deskriptiv tverrsnittstudie med data fra spørreskjemaer fra tre forskjellige grupper av kvinner: 1) pasienter henvist til gynekologisk poliklinikk (generell gynekologi, urogynekologi, eller vulvateam) eller til bekkenbunnfysioterapeut på St. Olavs hospital; 2) medlemmer av Vulvodyni- eller Endometrioseforeningen; og 3) friske frivillige. Deltakerne ble invitert til å fylle ut en nettbasert utgave av den norske versjonen av AHPFS, i tillegg til validerte spørreskjemaer om symptomer relatert til hyperaktiv bekkenbunn og noen bakgrunnspørsmål. Dataene ble samlet inn våren 2022. Pearsons khikvadrattest og Fishers eksakte test ble brukt i sammenligningene. Resultater Totalt 397 kvinner ble inkludert i studien. Gjennomsnittpoengsum på AHPFS blant alle kvinnene var 12.4 (SD 3.9) (range 6-30). Det var signifikante forskjeller i skåringene mellom de ulike gruppene av kvinner. Medlemmer fra pasientforeninger skåret høyest (gjennomsnitt 15.5, SD 3.8), deretter pasienter fra St. Olavs hospital (gjennomsnitt 12.7, SD 4.0), og lavest skåret friske frivillige (gjennomsnitt 10.7, SD 2.8). Vi fant større sykdomsbyrde og flere tilstander relatert til hyperaktiv bekkenbunn hos pasienter henvist til St. Olavs hospital og medlemmer av pasientforeninger, og bedre mental helse og seksualfunksjon blant friske frivillige. Vi fant høyere skåring på AHPFS blant kvinner som ikke var i arbeid, kvinner med kroniske bekkensmerter og vulvodyni samt kvinner som oppga at de hadde opplevd seksuelt overgrep. Konklusjon Vår studie viser at hyperaktiv bekkenbunn var en hyppig forekommende tilstand blant pasienter henvist for bekkenbunnslidelser og kvinner med vulvodyni og endometriose, men også blant friske kontroller. Kunnskap om symptombilde og tilknyttede risikofaktorer ved hyperaktiv bekkenbunn hos kvinner kan være nyttig for bedre å identifisere de kvinnene som er rammet. Background Hyperactive pelvic floor is a sparsely investigated condition with a complex aetiology and symptom presentation. Patients often present with a combination of urological, gastrointestinal, gynaecological, musculoskeletal, and psychological symptoms and conditions. Due to its heterogenous symptom presentation, it can be difficult to identify the patients. There is no definite diagnosis in ICD-10 for hyperactive pelvic floor, and the prevalence in the Norwegian population is unknown. A Dutch researcher team has developed a self-report questionnaire called Amsterdam Hyperactive Pelvic Floor Scale (AHPFS) for women and proposed a clinical cut-off value for hyperactive pelvic floor based on scores from this questionnaire. Objectives The primary aim of this study was to explore the symptom severity of hyperactive pelvic floor among patients and healthy volunteers. The research questions were: 1) Are there any differences in the scores of the AHPFS between different groups of participants?, and 2) Are there any associations between scores of the AHPFS and different background and clinical characteristics? Methods This is a descriptive cross-sectional study with questionnaire data from three different samples of women: 1) patients referred to the gynaecological outpatient clinic (general gynaecology, urogynaecology, or vulvar team), or to a pelvic floor physiotherapist at St. Olavs hospital; 2) members of the Vulvodynia or the Endometriosis Patient Associations; and 3) healthy volunteers. The participants were invited to fill out a web-based version of the Norwegian AHPFS, in addition to validated questionnaires addressing symptoms related to hyperactive pelvic floor, and sociodemographic background data. The data were collected in the spring of 2022. Pearson’s chi square test and Fisher’s exact test were used for the comparisons. Results A total of 397 women were included in the study. For all participants, we found a mean score of 12.4 (SD 3.9) on the AHPFS (range 6-30). There were significant differences in the scores between the different groups of participants. Members of the patient associations scored highest (mean 15.5, SD 3.8), then patients from St. Olavs hospital (mean 12.7, SD 4.0), and lowest scores were found among healthy volunteers (mean 10.7, SD 2.8). We also discovered a greater symptom burden and more related conditions to hyperactive pelvic floor in patients referred to St. Olavs hospital and members of the patient associations, and better mental health and sexual functioning among the healthy volunteers. The AHPFS scores were higher among unemployed women, women with chronic pelvic pain and vulvodynia, and women who had experienced sexual assault. Conclusion We found that hyperactive pelvic floor is prevalent in patients referred for pelvic floor disorders and in women with vulvodynia and endometrioses, but also among healthy controls. Knowledge about symptom severity and associated risk factors of hyperactive pelvic floor in women can be useful to better identify affected women.

Bakgrunn Siden problembasert læring (PBL) ble innført på 60-70 tallet har det vært et økt søkelys på å innføre studentaktiviserende undervisningsformer ved medisinsk utdanning i Norge. Teamba-sert læring (TBL) er en slik undervisningsform som gradvis er blitt faset inn ved universitetene her til lands. Det er få publiserte studier om læringsutbytte og studenttilfredshet med TBL i høy-ere utdanning i Norge. Formålet med studien var derfor å evaluere TBL som undervisnings-form. Dette har jeg valgt å gjøre ved å bruke TBL i gynekologiundervisningen ved NTNU som studieobjekt. Materiale og metode Studien er en multimetodisk retrospektiv observasjonsstudie med både kvalitative og kvantitati-ve data. Materialet skriver seg fra tidsrommet 2013 til 2021 og omfatter data fra undervisningen, eksamensresultater, spørreundersøkelse, samt referansegrupperapporter med gynekologi som tema ved NTNU. Fra undervisningen ble det benyttet individuelle- og gruppebesvarelser på flervalgsoppgaver. Disse ble vurdert i forhold til type forberedelsesmateriale gitt før sesjonene. Eksamensresultater (flervalgsoppgaver) ble analysert før og etter innføringen av TBL for temae-ne abnormale uterine blødninger og gynekologisk cancer. For å vurdere om det var systematiske forskjeller i vanskelighetsgrad på eksamensoppgavene før og etter innføring av TBL, trakk jeg et tilfeldig utvalg av oppgavene og testet på et eksternt testpanel av medisinstudenter og leger i spesialisering. For å evaluere den samlede gynekologiundervisningen ble det sendt ut et spørre-skjema til medisinstudentene etter endt undervisning. Kvantitative data ble oppsummert og pre-sentert deskriptivt. Kvalitative data ble analysert med metoden systematisk tekstkondensering. Resultater Under TBL-sesjonene gjorde studentene det best på de individuelle flervalgsoppgavene når de hadde brukt videoforelesning og lysbildepresentasjon som forberedelsesmateriale, og de skåret høyere på gruppebesvarelsene framfor de individuelle uavhengig av forberedelsesmateriale. Det var små forskjeller i studentenes eksamensresultater før og etter innføringen av TBL for temaene abnormale uterine blødninger og gynekologisk cancer, og vi kunne ikke påvise noen sikre for-skjeller i vanskegrad mellom eksamensoppgaver gitt før og etter innføring av TBL. Studentene mente aktiviserende undervisningsformer som TBL ga høyest læringsutbytte, og de forberedte seg også i større grad til denne typen av undervisning. Studentene ga uttrykk for å ønske seg enda mer studentaktiviserende undervisning. Fortolkning/konklusjon Innføringen av TBL i gynekologiundervisningen har blitt godt mottatt blant studentene uten no-en påviste negative konsekvenser. Studentene ser ut til å forberede seg best når de tilbys video-forelesning og kopi av lysbildepresentasjonen som forberedelsesmateriale. Tilbakemeldingene fra studentene tyder på at det er rom for å øke andelen TBL i undervisningen ytterligere. Background Since problem-based learning (PBL) was introduced in the 60s and 70s, there has been an increased focus on introducing student-activating teaching methods in medical education in Norway. Team-based learning (TBL) is one such form of teaching that has been gradually phased in at the universities in this country. There are few published studies on learning outcomes and student satisfaction with TBL in higher education in Norway. The purpose of the study was therefore to evaluate TBL as a form of teaching. I have chosen to do this by using TBL in gynecology teaching at NTNU as a study object. Material and method The study is a multimethodical retrospective observational study with both qualitative and quantitative data. The material is written from the period 2013 to 2021 and includes data from the teaching, exam results, questionnaire, and reference group reports with gynecology as a theme at NTNU. From the teaching, individual and group answers were used for multiple-choice assignments. These were assessed in relation to the type of preparation material given before the sessions. Exam results (multiple-choice assignments) were analyzed before and after the introduction of TBL for the topics of abnormal uterine bleeding and gynecological cancer. To assess whether there were systematic differences in the degree of difficulty of the exam assignments before and after the introduction of TBL, I drew a random sample of the assignments and tested on an external test panel of medical students and doctors in specialization. In order to evaluate the overall gynecology teaching, a questionnaire was sent out to the medical students after the end of the teaching. Quantitative data were summarized and presented descriptively. Qualitative data were analyzed using the systematic text condensation method. Results During the TBL sessions, the students did best on the individual multiple-choice tasks when they had used video lecture and slide presentation as preparation material, and they scored higher on the group answers rather than the individual independent of preparation material. There were small differences in the students' exam results before and after the introduction of TBL for the topics of abnormal uterine bleeding and gynecological cancer, and we could not demonstrate any definite differences in degree of difficulty between exam assignments given before and after the introduction of TBL. The students believed that activating teaching methods such as TBL gave the highest learning outcomes, and they also prepared to a greater extent for this type of teaching. The students expressed a desire for even more student-activating teaching. Interpretation / conclusion The introduction of TBL in gynecology teaching has been well received among students without any proven negative consequences. The students seem to prepare best when they are offered a video lecture and a copy of the slide presentation as preparation material. The feedback from the students indicates that there is room to increase the proportion of TBL in the teaching further.

Sammendrag Bakgrunn Kroniske bekkensmerter (CPP) er en vanlig, kompleks og ofte belastende smertetilstand. Det er begrenset kunnskap om tilstandens etiologi og den optimale håndteringen av bekkensmertepasienter. For kroniske smertetilstander generelt, har tverrfaglige tilbud vist seg å være effektive, og forskning indikerer at slike tilbud også kan være nyttige for bekkensmertepasienter. Det er imidlertid få studier som har evaluert bekkensmertepasienters nytte av slik utredning og behandling. Ettersom tverrfaglige tilbud er tids- og ressurskrevende, er evaluering nødvendig, både fra et pasientperspektiv og et samfunnsøkonomisk perspektiv. Eksisterende forskning understreker behovet for å evaluere nytteverdien av et tverrfaglig tilbud, faktorer som kan påvirke dets effektivitet, samt tidlig identifisering av bekkensmertepasienter som kan dra nytte av et slikt tilbud. Formålet med studien var å øke kunnskapen om utredning, behandling og selvrapporterte utfall blant bekkensmertepasienter som fikk helsehjelp fra et regionalt, tverrfaglig smertesenter. Vi ønsket å sammenligne kroniske bekkensmertepasienter med andre kroniske smertepasienter (CNPP), vedrørende andel som; mottok utredning- og behandlingskonsultasjoner; hadde fullført utredning i løpet av ett år; og som mottok tverrfaglig kontra ikke-tverrfaglig utredning. I tillegg ønsket vi å sammenligne pasientenes opplevelse av helserelatert livskvalitet før og etter, og global opplevelse av endring (Patient Global Impression of Change, PGIC) etter ett år. Videre ville vi undersøke hvordan bekkensmertepasienters globale opplevelse av endring, var assosiert med andel som mottok utredning- og behandlingskonsultasjoner; andel som hadde fullført utredning i løpet av ett år; andel som mottok tverrfaglig kontra ikke-tverrfaglig utredning; pasientenes bakgrunnskarakteristika før oppstart, samt pasientenes symptomskårer før oppstart og ved ett års oppfølging. Avslutningsvis ønsket vi å beskrive og sammenligne bruk av smertestillende medikamenter blant bekkensmertepasienter og andre kroniske smertepasienter. Metode En prospektiv kohortstudie basert på pasientrapportert og behandlerregistrert informasjon fra tre, regionale, tverrfaglige smertesentre i Norge. Pasientrapporterte data ble samlet inn via nettbaserte spørreskjema en måned før og ett år etter første konsultasjon ved smertesenteret. Før-konsultasjonsdata omfattet bakgrunnskarakteristika, symptomskårer og livskvalitet, mens etter-konsultasjonsdata omfattet livskvalitet og global opplevelse av endring. Behandlerregistrert informasjon inneholdt opplysninger fra (opp til) fire konsultasjoner per pasient, og ble hentet ut fra lokale kvalitetsregistre ved hvert senter. Resultater Blant 934 samtykkende pasienter i studien, besvarte 687 (74 %) pasienter spørreskjema ved ett års oppfølging. Av disse, hadde 84 (12 %) pasienter kroniske bekkensmerter. Blant alle kroniske smertepasienter, mottok 52 % utredning (ingen behandling), mens 48 % mottok både utredning og behandling; 78 % hadde ikke fullført utredning i løpet av ett år; og 42 % mottok tverrfaglig utredning. Det var ingen signifikante forskjeller mellom bekkensmertepasienter og andre smertepasienter med hensyn til nevnte utrednings- og behandlingskarakteristika. Vedrørende helserelatert livskvalitet, var det ingen endringer i domeneskårer blant bekkensmertepasientene ved ett års oppfølging, og heller ikke forskjell mellom bekkensmertepasienter og andre smertepasienter. Det var imidlertid en forskjell mellom pasientgruppene når det gjaldt global opplevelse av endring, hvor en større andel bekkensmertepasienter rapporterte forbedring. Hele 36 (43 %) bekkensmertepasienter følte seg «bedre» etter ett år, i motsetning til 154 (26 %) av andre smertepasienter (p

To increase our knowledge about sexual violence against women, the three studies in this thesis aimed at analyzing and comparing subgroups of both victims and assailants, as evidence-based research on these topics is limited. This thesis examines how sexual assaults committed against women with certain vulnerability factors differ from assaults against women who do not have such vulnerability characteristics. Further, the quality of police investigations of these crimes is studied with regard to differences between the corresponding cases of victims with and without vulnerability. Finally, three categories of rape suspects are examined to detect differences in assault characteristics and police investigations depending on the category of the suspect involved. The basis for Paper I was a relatively large collection of data from the Sexual Assault Center (SAC) at St. Olavs University Hospital in Trondheim, Norway, from the period 2003–2010. These SAC data (Paper I) were then merged with corresponding data from police files at the Sør-Trøndelag Police District (STPD), and Papers II and III were based on data from the merged data sources, but then with different perspectives. All three papers in the thesis have a retrospective and descriptive design, although Papers II and III could be seen as having qualities of a historical prospective cohort design. There are four main themes: (a) the association between victim vulnerability and assault characteristics, (b) the association between victim vulnerability and police investigation, (c) the association between suspect category and assault characteristics, and d) the association between suspect category and police investigation. Vulnerable groups of victims constituted the majority of women contacting the Trondheim SAC and the STPD after being sexually assaulted. There were obvious patterns of difference in characteristics of sexual assaults committed against women with vulnerability compared to those without vulnerability. Victims without any of the vulnerability factors were more often young students and assaulted during or after social settings where alcohol, and relatively large amounts of it, was served. In the cases of vulnerable victims, and presumably by the nature of these victims’ inherent vulnerability, alcohol seemed to a lesser degree “to be needed” in order to attract, mislead, and abuse them. We found a trend showing less thorough police investigation of rape cases if the victims had vulnerability than in cases where victims did not have vulnerability. The police less often interrogated witnesses other than the victim and suspect, and they also less often secured biological material from the crime scene in cases involving victims with vulnerability than in cases involving non-vulnerable victims. Patterns of rape were different depending on the categories of suspects involved. Cases involving suspects who had a criminal record as a former suspect of a sexual/violent crime (recidivist suspects), were investigated more thoroughly by the police and were more often prosecuted than cases where suspects did not have a record of such crimes. More knowledge is needed in the future to improve preventive and protective means toward groups of women who are at increased risk of being sexually assaulted. Future research should explore the presence of eventual rape myth endorsement among law enforcement personnel, and whether such preconceived attitudes bias police investigations in rape cases depending on the characteristics of victims and suspects.

Materiale og metode Studien var en tverrsnittstudie der helsepersonell med rett til å forskrive prevensjon ble bedt om å svare på et web-basert spørreskjema. Alle helsesøstre som arbeidet med ungdom i skolehelsetjenesten, samt alle fastleger, gynekologer og jordmødre som jobbet i Trondheim kommune ble invitert til å delta. Spørreskjemaet bestod av totalt 29 spørsmål som omhandlet demografiske variabler som kjønn, aldersgruppe og yrke, dessuten vurderinger av egne kliniske ferdigheter og kunnskap om prevensjon, anbefalingspraksis og materielle arbeidsforhold. I tillegg ble deltakerne bedt om å ta stilling til 14 påstander som tok for seg holdninger, fordommer og personlige meninger rundt prevensjon. Spørreskjemaet inneholdt også et åpent svarfelt der deltagerne kunne komme med innspill i fritekst. Programvaren Select Survey ble benyttet til å samle inn svarene, som ble analysert i statistikkprogrammet SPSS. Resultater I alt fullførte 105 av de 408 (25,7 %) inviterte personene spørreskjemaet. Av disse var 41 fastleger, 25 gynekologer, 29 jordmødre og ti helsesøstre. Hele 65 % av alle studiedeltakerne var < 50 år og 79 % var kvinner. Totalt oppga 46 av 104 forskrivere at de ikke kjente til Helsedirektoratets endrede retningslinjer for prevensjonsforskrivning fra 2010, der Helsedirektoratet fremmet ønsket om en dreining i prevensjonsbruken til fordel for LARC. Legene i undersøkelsen vurderte i stor grad både sine teoretiske kunnskaper om prevensjon og sine praktiske ferdigheter i innsetting og uttak av spiral og p-stav som gode eller svært gode, mens ikke-legene vurderte disse oftest som lavere. Henholdsvis 17 og 19 av 87 LARC-forskrivere oppga at de aldri satte inn henholdsvis spiral eller p-stav, de fleste av disse var ikke-leger. Manglende mengdetrening ble oppgitt av henholdsvis ni og ti forskrivere som hovedårsaken til dette. Halvparten av gynekologene og omtrent tre av fire fastleger, helsesøstre og jordmødre i studien, kunne tenke seg mer opplæring i forskrivning og administrasjon av prevensjonsmidler. Av de som satte inn spiral og p-stav minst én gang årlig, oppga 18 av LARC-forskriverne, at de én eller flere ganger ikke hadde forskrevet LARC på grunn av mangel på tid. I alt 13 forskrivere (tolv av disse jordmødre/helsesøstre) ville ikke gitt prevensjonsveiledning til en kvinne under 16 år. Gynekologene var den yrkesgruppen som var mest skeptiske til å tilby LARC til kvinner i alderen 16-19 år, omtrent 25 % av gynekologene var uenig i at LARC bør være et førstevalg i denne aldersgruppen. To leger og syv ikke-leger mente at nullipara ikke burde bruke spiral. Jevnt over vurderte alle yrkesgruppene sine egne ferdigheter som prevensjonsveiledere som gode, mens de samtidig nedvurderte de andre yrkesgruppenes ferdigheter. Unntaket var gynekologer, som i stor grad ble vurdert som godt egnede prevensjonsveiledere av de andre yrkesgruppene også Halvparten av legene ønsket ikke at helsesøstre og jordmødre skulle få rett til å forskrive prevensjon til kvinner under 16 år og mente at jordmødre burde bruke mer tid på kjerneoppgaver som veiledning av gravide. Konklusjon Sett under ett var det tre temaer fra denne spørreundersøkelsen som skilte seg ut, og som potensielt kan være til hinder for Helsedirektoratets ønske om økt bruk av LARC. Det eksisterte til en viss grad feilaktige oppfatninger om LARC hos helsepersonellet i studien, som at kvinner som ikke har født, ikke bør bruke spiral eller at LARC er uegnet til de yngste aldersgruppene. Disse feiloppfatningene kan potensielt medvirke til at noen kvinner ikke får tilstrekkelig prevensjonsveiledning. Noen forskrivere oppga at ytre faktorer har forhindret dem fra å forskrive LARC. Hele 20 % av deltagerne med forskrivningsrett for LARC oppga at manglende tid i konsultasjonen hadde forhindret dem i å forskrive LARC, og mangel på gynekologisk undersøkelsesutstyr ble trukket frem som et hinder for å tilby spiral på kontroll etter fødsel. Resultatene i denne undersøkelsen tyder på at mange leger er skeptisk til at ikke-leger skal kunne forskrive prevensjon til kvinner under 16 år. Per i dag har kun leger forskrivningsrett til kvinner under 16 år. Om det skulle bli tillatt for helsesøstre og jordmødre å forskrive prevensjon til denne aldersgruppen, er det likevel lite trolig at en leges personlige oppfatning av en ikke-lege vil forhindre en kvinne fra å oppsøke en ikke-lege for å få prevensjon. Likevel er ikke holdningene mellom leger og ikke-leger uten betydning. Før en eventuell lovendring kan tillate ikke-leger å forskrive prevensjon til kvinner under 16 år, vil uttalelser fra ekspertise bli vektlagt i det politiske arbeidet. Det politiske arbeidet vil kunne påvirkes dersom legene – som fremstår som de fremste fagpersonene på området – er negative til å utvide forskrivningsretten til helsesøstre og jordmødre. Background The Norwegian Directorate of Health has introduced several programs in order to reduce the number of unwanted pregnancies and abortions throughout the last few years. Increasing the use and the availability of Long-Acting Reversible Contraceptives (LARCs) have been some of the most important measures. The purpose of this study was to describe the different prescribers in Trondheim and their attitudes towards prescribing LARC. We wanted to find out whether the prescribes were aware of the change in LARC policy from the Norwegian Directorate of Health, and whether attitudes, knowledge, practical skills or external factors, such as lack of counseling time or medical equipment, could be a limiting factor for prescribing LARC, especially for young women. We would also investigate possible differences in the prescribing pattern between different health occupational groups. Method We performed a cross-sectional study in which health care providers with the rights to prescribe contraceptives were asked to respond to a web-based survey. All general practitioners (GPs), gynecologists, school nurses and midwives working in the municipality of Trondheim were invited to participate. The survey consisted of a total of 29 questions dealing with demographic variables such as gender, age group and occupation. The survey also contained the prescriber´s self-assessed practical skills and knowledge of the different contraceptive methods, recommendation practices and their working conditions. In addition, the participants were asked to comment on 14 statements addressing attitudes, prejudices and personal opinions on contraception. The survey also had an open-ended question for the participants to freely comment their opinion on the topic. The software SelectSurvey was used to collect the answers, which were analyzed with IBM SPSS statistics program. Results In total, the survey was completed by 105 (25.7%) of the 408 health care providers invited. Of these, 41 were GPs, 25 were gynecologists, 29 were midwives and ten were school nurses. As many as 65% of all contestants were < 50 years of age and 79 % of them were women. In total, 46 out of the 104 prescribers stated that they did not know about the change in prescribing guidelines of 2010 from the Norwegian Directorate of Health, recommending LARC. The physicians considered both their theoretical knowledge of the different contraceptive methods as well as their practical skills in insertion and removal of intrauterine devices (IUDs) and subdermal contraceptive implants as good or very good, while the nurses in general considered their knowledge on these matters as lower than the physicians. 17 and 19, respectively, of the 87 LARC prescribers (most of whom were nurses), stated that they never performed insertion or removal of IUDs or implants. Nine and ten prescribers, respectively, stated that the main reason for this was the lack of extensive practical experience. Half of the gynecologists and about three out of four GPs and nurses wished for more theoretical and clinical training opportunities for contraceptive methods. Of those whom performed stating to perform insertion procedures of IUDs or implants at least once a year, 18 stated that they had at least once failed to offer LARC due to lack of time. A total of 13 providers (twelve of whom were nurses) would not offer any contraceptive device for woman under the age of 16. The gynecologists were the most hesitant in offering LARC to women aged 16-19 , Around 25% of the gynecologists disagreed that LARC methods should be considered first-line options for this age group. Two physicians and seven nurses considered nulliparity to be a contradiction to IUDs. Throughout the occupational groups the prescribers considered their own skills as contraceptive counselors as good, and better than the other groups. Except for the gynecologists, which the other groups largely considered as well-suited contraception counselors. Half of the physicians did not want school nurses and midwives to be given the possibility to prescribe contraceptives to women under the age of 16, and believed that midwives instead should spend more time on their core tasks such as examining and monitoring pregnant women. Conclusion All in all, this survey has pointed out three matters that could potentially slow down the efforts in increasing LARC use in young women. To some extent, the prescribers had misconceptions about LARC, i.e. nulliparous women cannot use IUDs, or that LARC is unsuited for the youngest women. Potentially, these misconceptions may hinder some women from receiving sufficient contraceptive counseling. Some prescribers stated that external factors have prevented them from prescribing LARC. A total of 20% of the providers with formal LARC training stated that lack of consultation time had prevented them from prescribing LARC, and that lack of gynecological examination equipment could be an obstacle for IUD insertions post-natally. The results of this study indicate that many physicians are sceptic to school nurses and midwives getting the possibilities to prescribe contraception to women under the age of 16As of today, only physicians in Norway have such rights. If in the future nurses were allowed to prescribing contraceptives for this age group, it is however, unlikely that a physician’s opinion would prevent a woman from seeking contraceptive counseling from a nurse. Nevertheless, physicians’ and nurses’ attitudes towards each other are not negligible. Before any legal changes allowing nurses to prescribe contraception to women under the age of 16 can happen, statements and attitudes from medical expertise will be emphasized in the political work. The political work could be affected if the foremost expertise on the topic – the physicians – are hesitant in expanding the rights to provide LARC to other occupational groups.

Background Female genital mutilation (FGM) is a harmful traditional practice comprising procedures involving partial or total removal of external female genitalia and/or narrowing of the vaginal orifice for non-medical reasons. Due to migration pattern, it is estimated to be approximately 17,300 girls and women subjected to FGM currently living in Norway. A number of publications over the last decades have reported long-term health complications after FGM. However, there is a lack of publications on characteristics and quantitative findings in a Norwegian health care setting, especially concerning gynecological impacts of FGM. The aim of this study was to explore the gynecological complaints, treatment interventions and management of women subjected to FGM in a Norwegian health care setting. Methods We conducted a retrospective, descriptive study based on medical records of women with FGM who had been in contact with St. Olavs Hospital, University Hospital of Trondheim, Norway, throughout 2004 - 2016. A total of 158 cases were included. Results Among the 158 women in this study (mean age 26.9, SD = 6.5 years), the majority were from Somalia (n = 96, 60.8%) and Eritrea (n = 32, 20.3%). 125 women (79.1%) presented with FGM type III, 16 (10.1%) with type II and 10 (6.3%) with type I. 69 (55%) women discussed a possible deinfibulation with a gynecologist. At first gynecological examination, FGM was not described for 20% of the women. Gynecological complaints were described among 119 (75%) women. The most common gynecological complaints were abdominal and pelvic pain (n = 70, 44%), dyspareunia, apareunia (n = 60, 38%) and dysmenorrhea (n = 49, 31%). 86 women (69%) with FGM type III underwent deinfibulation. 20 of the procedures (23%) were performed during vaginal delivery. Conclusion Our study describes health complaints, treatment interventions and management of women who have been subjected to FGM. We have shown that a substantial part of these women have a high prevalence of gynecological pain conditions, and that this applies to all types of FGM. Healthcare-workers should be aware of these women’s need for medical care, 2 and to a greater extent document their complaints and findings in their contact with women subjected to FGM. Denne masteroppgaven vil bli tilgjengelig 9.6.2019

Background: The medical examination after rapes has two main goals: to provide high-quality care for the victim and to collect evidence to be used in the crime investigation. Collected samples are sent for forensic analysis upon police request. However, little is known about how the police select cases to be submitted for analysis. Furthermore, few studies report the DNA findings and associated factors. The aim of this study was to examine whether victim-, suspect- and assault characteristics, were associated with (1) forensic analysis of trace evidence, (2) detection of spermatozoa and (3) DNA match in police-reported cases of rape/attempted rape. In addition, we explored whether DNA findings were associated with police investigations and legal outcome. Methods: We conducted a retrospective, descriptive study based on police-reported rapes and attempted rapes of female victims (≥ 16 years of age) in Sør-Trøndelag Police District throughout 1997 – 2010. Police data were merged with information from the Sexual Assault Centre (SAC) at St.Olavs University Hospital, Trondheim, Norway. Altogether 324 cases were included. We applied Pearson’s x2 tests for the analyses. Statistical significance was assumed when p < 0.05. Results: Among 324 victims (mean age 24.2 ± SD 8.4 years), swabs and/or clothes were collected from the victim in 299 cases, of which 135 were sent for forensic analysis. The police decision to analyze the forensic material was associated with a public venue (p = 0.006) and interval from assault to sampling < 24 h (p = 0.033). Trace evidence analyses could be evaluated in 129 of the cases, and were positive for spermatozoa in 79 cases. Among samples collected within 24 h, 90 % were positive for spermatozoa (p = 0.003). In addition, detection of spermatozoa was associated with a reported penetrative rape (p = 0.006). The police requested forensic analyses of available trace evidence collected from the victim and/or the suspect (swabs and/or clothes) and/or the venue in 143 cases. The forensic analyses disclosed matching DNA profiles in 57 cases (40 %) and no matching DNA profiles in 50 cases (35 %), whereas 36 cases (25 %) were classified as “other”. DNA match was associated with absence of victim vulnerability factors (p = 0.001), victim being known to the suspect (p = 0.013) and a private venue of the assault (p = 0.013). In addition, interrogation of the suspect (p < 0.001), crime scene examination (p = 0.013) and the suspect admitting sexual contact (p = 0.003), were associated with a DNA match. A higher proportion of cases with DNA match were prosecuted in court (p < 0.001). Discussion: The police requests more analyses and detects spermatozoa in 90 % of the cases when the interval from assault to sampling is < 24 h. Spermatozoa is an evidence that gains further importance with the increased availability and progressive advances in DNA-profiling techniques. When there was a DNA match between the victim and the suspect, a higher proportion of the cases was taken to court. Nevertheless, DNA evidence should always be considered in the scope of other evidence. Conclusions: Our study provides descriptive data regarding trace evidence analyses and DNA findings and identifies potential factors that influence the analyses and DNA findings. These results may improve the quality of medico-legal care.