Case 12

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. American Journal of Obstetrics and Gynecology. 2000; 182 (4) : 820-834

  DOI • PubMed
  

  OBJECTIVE: Our goal was to identify vulvar and hymenal characteristics …

  OBJECTIVE: Our goal was to identify vulvar and hymenal characteristics associated with sexual abuse among female children between the ages of 3 and 8 years. STUDY DESIGN: Using a case-control study design, we examined and photographed the external genitalia of 192 prepubertal children with a history of penetration and 200 children who denied prior abuse. Bivariate analyses were conducted by X2, the Fisher exact test, and the Student t test to assess differences in vulvar and hymenal features between groups. RESULTS: Vaginal discharge was observed more frequently in abused children (P = .01). No difference was noted in the percentage of abused versus nonabused children with labial agglutination, increased vascularity, linea vestibularis, friability, a perineal depression, or a hymenal bump, tag, longitudinal intravaginal ridge, external ridge, band, or superficial notch. Furthermore, the mean number of each of these features per child did not differ between groups. A hymenal transection, perforation, or deep notch was observed in 4 children, all of whom were abused. CONCLUSION: The genital examination of the abused child rarely differs from that of the nonabused child. Thus legal experts should focus on the child's history as the primary evidence of abuse. \textcopyright 2000 Elsevier Science B.V.
• Berkoff MC, Zolotor AJ, Makoroff KL, Thackeray JD, Shapiro RA, Behavioral BS. CLINICIAN'S CORNER Has This Prepubertal Girl Been Sexually Abused ? EXAMINATION FOR SEXUAL. 2008; 300 (23)