Prepubertal Vagina Examination Sexual Abuse

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Context:


The legal and social sequelae of interpreting genital findings as indicative of sexual abuse are significant. While the absence of genital trauma does not rule out sexual abuse, the physical examination can identify genital findings compatible with sexual abuse.




Objectives:


To determine the diagnostic utility of the genital examination in prepubertal girls for identifying nonacute sexual abuse.




Data sources:


Published articles (1966-October 2008) that appeared in the MEDLINE database and were indexed under the search terms of child abuse, sexual or child abuse and either physical examination; genitalia; female, diagnosis; or sensitivity and specificity; and bibliographies of retrieved articles and textbooks.




Study selection:


Three of the authors independently reviewed titles of articles obtained from MEDLINE and selected articles for full-text review.




Data extraction:


Two authors independently abstracted data to calculate sensitivity, specificity, and likelihood ratios for the diagnosis of nonacute genital trauma caused by sexual abuse in prepubertal girls.




Results:


Data were not pooled due to study heterogeneity. The presence of vaginal discharge (positive likelihood ratio, 2.7; 95% confidence interval, 1.2-6.0) indicates an increased likelihood of sexual abuse. In the posterior hymen, hymenal transections, deep notches, and perforations prompt concerns for genital trauma from sexual abuse, but the sensitivity is unknown. Without a history of genital trauma from sexual abuse, the majority of prepubertal girls will not have a hymenal transection (specificity close to 100%).




Conclusions:


Vaginal discharge as well as posterior hymenal transections, deep notches, and perforations raise the suspicion for sexual abuse in a prepubertal girl, but the findings do not independently confirm the diagnosis. Given the broad 95% confidence intervals around the likelihood ratios for the presence of findings along with the low or unknown sensitivity of all physical examination findings evaluated, the physical examination cannot independently confirm or exclude nonacute sexual abuse as the cause of genital trauma in prepubertal girls.


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All Journals AAP News AAP Grand Rounds Hospital Pediatrics NeoReviews Pediatrics Pediatrics in Review

Marcia E. Herman-Giddens and Thomas E. Frothingham
Pediatrics August 1987, 80 (2) 203-208;
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Experience with more than 375 cases of possible sexual abuse has taught us that much work still needs to be done in understanding normal prepubertal female anatomy and interpreting findings in sexual abuse cases. Because pediatric clinicians are often called upon to assess possible sexual abuse victims, knowledge of what is known and how best to examine the genitalia of a young girl is essential. Two cases are discussed that involve normal and abnormal anatomy. Examination techniques for adequate visualization include proper tension and timing with the spreading of the labia in the supine position, the knee-chest position, and lateral traction on the buttocks while lying flat on the abdomen to look for anal relaxation. The hymen, contrary to common notion, is often a slack, thick, folded, stretchable tissue which may persist after digital or penile penetration. Findings secondary to sexual abuse are often subtle. Acute tears or bruising are rare because force is seldom a part of the sexual acts committed against a child. A vaginal opening of greater than 5 mm is not common and may indicate vaginal penetration with a finger, object, or penis. An "intact" hymen does not necessarily preclude vaginal penetration. Lack of physical evidence never rules out abuse because many sexual acts leave no physical findings.
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https://pubmed.ncbi.nlm.nih.gov/19088355/
https://pediatrics.aappublications.org/content/80/2/203
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