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Child Abuse Case 9


A 9-year-old girl is brought for examination due to a concern by her primary care provider regarding her examination findings. The girl lives with her mother and mother’s boyfriend and two younger half-siblings. She does well in school and has no genital complaints or behavioral problems.


Case 9

Source: A. S. Botash, MD, used with permission


Which of the following is a true statement regarding the examination of this crescent-shaped hymen?

  1. The hymen edge is less than 1 mm in size at the posterior margin and the finding is suspicious for sexual abuse.
  2. The hymen edge may be rolled under and should be further evaluated with another examination technique.
  3. The examination reveals a healed transection and is clear evidence of past penetrating trauma.
  4. The width of the hymenal opening is larger than normal and is suspicious for sexual abuse.

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The answer is B.

This is a crescent or annular hymen. The area under the clitoral hood is not well seen and therefore the configuration is difficult to ascertain. Medical examiners frequently are only able to achieve a quick glimpse of the hymenal structures in children due to either patient non-compliance or examiner lack of experience. In this case, the posterior area is also slightly covered by the posterior fourchette. The hymen is most likely crescent shaped in configuration based on the age and tanner stage of the patient. As the child matures, the estrogen effect will likely result in thickening and whitening of the hymenal membrane with evolution through stages until a typical fimbriated hymen is observed.

Attention should be given to the edge of the hymen. If the posterior region is less than 1 mm in depth from the edge of the hymen to the vaginal wall, this may indicate that previous trauma has occurred and healed. See reference below. Further evaluation of the edge, using a moistened swab, saline flushes or balloon catheter may be used to assist with visualization. In some cases, examination in the prone knee-chest position will cause the hymen edge to fall forward due to gravity and enable better visualization.

There is no sign of healed or acute hymenal transection on this photograph. Measurement of the vaginal opening width does not correlate with a history of sexual abuse or vaginal penetration and is not recommended.

References:

Adams JA. Guidelines for medical care of children evaluated for suspected sexual abuse: an update for 2008. Curr Opin Obstet Gynecol. 2008 Oct;20(5):435-41.

Starling SP, Jenny C. Forensic examination of adolescent examination of the adolescent female genitalia: the Foley catheter technique. Arch Pediatr Adolesc Med. 1997 Jan;151(1):102-3.


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