The Rational Clinical Examination | Clinician's Corner

Has This Prepubertal Girl Been Sexually Abused?

Molly Curtin Berkoff, MD, MPH; Adam J. Zolotor, MD, MPH; Kathi L. Makoroff, MD; Jonathan D. Thackeray, MD; Robert A. Shapiro, MD; Desmond K. Runyan, MD, DrPH
JAMA. 2008;300(23):2779-2792. doi:10.1001/jama.2008.827.
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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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Figure 1. Positions and Techniques for Examination of Genitalia in Prepubertal Girls
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Two examination positions commonly used are the supine frog-leg or butterfly position and the knee-chest position. When findings are abnormal or concerning in the supine position, the examination should be repeated in the knee-chest position to provide additional certainty or clarification. The knee-chest position provides greater visibility of genital structures because gravity may unfold the hymenal tissue. The positions in which findings are observed should be recorded. A, In supine position, the child is examined supine on the examination table or alternatively, sitting on the lap of a trusted adult. Labial separation (performed first) helps the examiner get an initial view of the genital structures. Labial traction permits a complete view of the genital structures. B, To view the genital structures in the knee-chest position, the examiner holds the buttocks apart by pressing laterally and upward.

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Figure 2. Female Prepubertal Genital Anatomy
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A, Inset, The region defined as the posterior hymenal rim, between 4 and 8 o'clock, is shaded blue. B, There is a range of normal anatomical variations in hymenal openings. Crescentic and annular are 2 of the most common shapes. C, The photographs illustrate the range of normal prepubertal hymenal membranes. In most children, the hymen becomes thicker and more redundant during puberty.

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Figure 3. Hymenal Membrane Characteristics
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When considering the possibility of sexual abuse during an examination, the examiner should document pertinent positive and negative findings. In addition to the clinical signs depicted in the figure, other possible findings include prominent hymenal vessels, bumps, tags, longitudinal intravaginal ridge, external ridge, periurethral bands, or vestibular bands.
aPerforation is a finding reported from Berenson et al.28 Perforation of the hymen is not a finding commonly discussed in the literature.

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Figure 4. Study Selection Process
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