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Child Abuse Case 12


Which of the following statements regarding child sexual abuse findings in prepubertal girls is true?

  1. Transections to the posterior hymen are consistent with sexual abuse.
  2. Perforations of the hymen are a common finding due to sexual abuse.
  3. Vaginal discharge is a frequent finding among non-abused girls.
  4. The absence of a deep notch suggests a decreased likelihood of abuse.

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The answer is A.

A comprehensive summary of the literature regarding findings in prepubertal girls is reviewed in the JAMA article listed below. Evidence–based studies of findings in sexual abuse are limited. This limits the clinical interpretation of findings using specificity, sensitivity and negative or positive likelihood ratios. Further studies might help support the impression of experts regarding specific findings.

According to Berkoff et al, only two articles meet criteria for quality at Level 3 (independent, blind comparison of physical examination findings with a reference standard among non-consecutive patients). These studies included cases and non-abused controls. One of these studies, the Berenson article listed below, reports the association of genital trauma with high likelihood ratios for transections, hymenal perforations and deep notches. These findings were not reported in girls without a history of genital trauma, suggesting that these findings are very unlikely in non-abused girls. Due to the low numbers studied, confidence intervals are wide. The presence of any of these findings is not confirmatory of sexual abuse. The absence of these findings is not helpful in determining whether the girl has been sexually abused.

Perforations of the hymen are infrequent findings due to trauma and are extremely infrequent in girls without a history of trauma.

The presence of a vaginal discharge is unusual in non-abused girls. The finding of a discharge should prompt evaluation for sexual abuse.

In the absence of a history of accidental genital trauma, the presence of transections, perforations and/or deep notches is consistent with sexual abuse and highly suspicious for abuse. A report should be made to child protective services if these findings are observed.

Berenson AB, Chacko MR, Wiemann CM, Mishaw CO, Friedrich WN, Grady JJ. A case-control study of anatomic changes resulting from sexual abuse. Am J Obstet Gynecol. 2000 Apr;182(4):820-31.

Berkoff MC, Zolotor AJ, Makoroff KL, Thackeray JD, Shapiro RA, Runyan DK. Has this prepubertal girl been sexually abused? JAMA. 2008 Dec 17;300(23):2779-92.


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