Prepubertal Female Genitalia: Examination for Evidence of Sexual Abuse

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Prepubertal

Female

Genitalia:

Examination

for

Evidence

of Sexual

Abuse

Marcia

E. Herman-Giddens,

BHS,

PA, MPH,

and

Thomas

E. Frothingham,

MD

From the Department of Pediatrics, Child Protection Team, Duke University Medical Center, Durham, North Carolina

ABSTRACT. 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

ten-sion and timing with the spreading of the labia in the

supine position, the knee-chest position, and lateral

trac-tion 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 ofphysical evidence never rules

out abuse because many sexual acts leave no physical

findings. Pediatrics 1987;80:203-208; sexual abuse,

pre-pubertal female genital examination; hymen.

abnormal findings and examination techniques in

suspected sexual abuse cases.1 Furthermore, these

texts and other published material often give the impression that most young girls can tolerate

vag-inal instrumentation. We have not found this to be the case in our sexually abused patients.

Fortu-nately, however, a thorough external examination is all that is necessary for an accurate diagnosis in

the vast majority of cases.

Data on normal prepubertal male and female

genitalia based on a population of children known to be unabused does not exist. Therefore, interpre-tations of certain findings must be tempered with the knowledge that much research still needs to be done.

Because of social and legal emphasis on physical evidence for sexual abuse, pediatric clinicians must become skilled at conducting forensic genital

ex-aminations ofyoung children. It is equally essential

that they learn how to interpret the findings. Mis-interpretation may doom the child to continued sexual abuse or cause an erroneous charge against a perpetrator. Two of our cases are illustrative.

Our experience with 375 cases of possible sexual abuse has taught us that much is still not known about obtaining and interpreting physical findings related to sexual abuse. The reality of sexual abuse in our society has found most of us without the knowledge and skills needed for adequate physical

assessment of our young patients. Our textbooks

provide little help. In three well-known texts, there

is little to no information relating to normal and

Received for publication May 5, 1986; accepted Aug 15, 1986. Reprint requests to (M.E.H.-G.) Box 3937, Duke University

Medical Center, Durham, NC 27710.

PEDIATRICS (ISSN 0031 4005). Copyright © 1987 by the American Academy of Pediatrics.

CASE REPORTS

Case

1

A 7#{189}-year-old girl came to clinic because of persistent

perineal odor, spotting, and dysuria. She had been seen

for several months for these symptoms at several medical facilities and treated for urinary tract infections, even

though urine cultures were negative. There was no breast development. On genital examination, pubic hair was noted. The vaginal opening was 1#{189}cm in horizontal diameter and had only a remnant of hymenal tissue, which we believed indicated repeated vaginal penetration over a long time (Fig 1). The urethral opening was some-what swollen. When the child was placed in the

knee-chest position, a vaginal foreign body was apparent (Fig

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Fig 1. Case 1: 7#{189}-year-old girl with premature adren-arche, dysuria, and spotting; victim of chronic sexual abuse involving vaginal penetration in supine position.

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The foreign body was removed with complete

resolu-tion of her symptoms. The material was analyzed and

found to contain several adult body hairs. All cultures

were negative. A referral was made to the county’s

de-partment of social services for sexual abuse. The child

later indicated her father had been sexually abusing her for some time.

Case 2

An almost 3-year-old girl was brought to clinic by her

mother and social worker for an evaluation for possible

sexual abuse because of sexual “acting out.” There were

no symptoms. Findings on physical examination were

normal including the genitalia. The prepuce ofthe clitoris

was redundant and somewhat larger than usual (Fig 3).

The annular hymen appeared intact with a pinpoint

opening. A mixture of smegma and powder was present

in the interlabial sulci.

When interviewed, the child demonstrated clearly on

herself and with anatomic dolls how her father had

rubbed her vulva. She did not indicate any type of vaginal penetration but described her father touching his penis

as he rubbed her, and she stated that “there was some

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Fig 3. Case 2: 3-year-old sexually abused girl with nor-mal genitalia.

Examination Position

Prepuc. of clitoris Lss s

-.-- Labls mas

-Hymen Lateral S

posterior traction

(up to 4 nan)

.,.

--

‘ I

--L±

-Fig 4. Genital examination position and anatomy of the prepubertal girl.

I I

I Abnormal

--

-.98-.--pee pee.” The interview in this case provided the

diag-nosis. The normal physical examination findings were

consistent with the child’s account and other information disclosed by the investigation.

EXAMINATION

Adequate genital examinations take time,

pa-tience, and a gentle manner. Unless there is vaginal bleeding, suspicion of a foreign body, or a chronic

unexplained vaginal discharge, an internal pelvic examination, which almost always requires general

anesthesia, is not necessary. The interview and

history, which is the most important diagnostic tool

in possible sexual abuse cases should be done prior

to the examination. The child should be prepared by a careful explanation of the examination proce-dure. Most children are able to cooperate well

enough for an adequate examination, if care has

been taken to establish rapport. A child should never be restrained for the genital examination

(with the possible exception of an infant) for two

reasons: (1) further assault on the child by health professionals is unacceptable and (2) it is

impossi-ble to do an adequate genital examination on a

resisting, frightened, squirming child.

Younger children are best examined in a frog-leg position (Fig 4). They usually do not like to he

draped. Very young children may be examined eas-ily on their mother’s lap and generally prefer that

she be present. Older children usually do well in the standard lithotomy position if a gynecology table is available, but this is not necessary. Older

children generally prefer to be draped. They should

be given a choice regarding their mother or other

supportive person being present. It should not be

assumed that the presence of the primary caretaker

is always comforting. We have found some children

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examination when the mother is present, especially in situations in which the mother knew about the abuse but did nothing to protect the child. Some older children may also prefer to ask or answer questions during the examination in the absence of the primary caretaker.

For adequate exposure of the genital area, the labia majora should be gently spread laterally and dorsally with some pressure against the perineum. Several seconds of tension in this position are usu-ally required for the folds of the hymen to fall apart revealing the size of the vaginal opening and the hymenal shape. The Tanner stage should be noted. Each part of the genitalia (prepuce, labia minora, etc) should be carefully inspected with good lighting and conscious attention to anatomy, the presence of lesions, scars, bruises, changes in pigmentation, discharge, bleeding, and other abnormalities. The urethral opening should be identified and inspected. The type and condition of the hymen should be noted and the hymen carefully inspected for intact-ness, notches, lacerations (fresh or healed), and scars. A magnifying lens is often helpful. Some girls have a deeply recessed hymen which may be over-looked on casual inspection. The size ofthe opening into the vagina should be measured horizontally, in millimeters (Fig 4). An assistant is helpful in han-dling the child and aiding in the procurement of specimens.

Sometimes the anatomy cannot be appreciated with this lateral and dorsal spreading of the labia. Another technique useful in a young child is to gently grasp the lower labia majora and pull toward the examiner and slightly dorsally. At any age, turning the child to the knee-chest position and having her relax with deep breathing and letting her abdomen sag will often cause the hymen to pout outward when the buttocks are spread with dorsal and lateral tension.5 In our series of six episodes of vaginal foreign bodies, three were detected in the supine position and three with the knee-chest man-uever.

Occasionally, especially with the child in the supine position, the thick moist folds of the hymen, particularly a denticulate or annular type, cause it to stick together so that no opening can be seen. If the child can tolerate a gentle teasing of the tissue with a moist Calgiswab the opening may then be discerned. If the hymen is notched, it may be diffi-cult to determine whether the notches are from previous trauma or are a normal variation except, perhaps, with special magnifying equipment.6 If there is not an intact hymen, remnants of hymenal tissue are generally visible, and these should be noted and described.

The anus should be carefully inspected for

fls-sures, scars, hyperpigmentation, thickening of the

skin, skin tags, or other abnormalities. Firm lateral traction on the buttocks may sometimes cause the anus to gape in a child who has been anally pene-trated a number of times.7 We have seen gaping of

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to 1.5 cm in children known to have been subjected to repeated anal intercourse. Gaping of a smaller diameter may or may not be normal and probably should not be considered significant until normative data on an unabused population becomes available. Many children have normal anal and rectal fmdings in spite of a history of anal manip-ulations. Skin tags may be normal at the 12-o’clock position, supine. Ifthey occur elsewhere or are thick and adherent, they may be from anal trauma. When there is a question of anal penetration, a rectal examination for sphincter tone and stool guaiac should be done. If there is blood in the stool or a

history of bleeding, further examination with a

proctoscope or a clean, lubricated glass tube of

appropriate size may be required, as well as a

refer-ral to the appropriate specialist.

Diagrams of the genitalia and anus should be used to record measurements, as well as size and place of scars, lesions, bruises, and other abnor-malities. The mouth, neck, and throat should al-ways be thoroughly examined as well. Bruising and torn frenula may occur from oral-genital contact. Photographs should be taken whenever possible.

Gathering of specimens and samples, as

neces-sary, should be done after thorough inspection of

the genitalia and anus but before any digital ex-amination. Culturing and sampling techniques for secretions and sexually transmitted diseases should be familiar to the examiner.

FINDINGS

There are numerous variations of normal genital anatomy, particularly in girls. Extra folds of the prepuce are common. Labia minora vary greatly in their length and may have extra folds. The urethral opening varies in shape from slit-like to round or triangular with a normal diameter on inspection of not more than several millimeters.

The hymen, contrary to a common notion of being a taut, thin membrane, is usually a thick slack tissue, sometimes in folds, covered with squa-mous epithelium partially occluding the vaginal orifice. We have seen only a few young girls whose hymens were so thin as to be translucent. There are enormous variations in hymenal shape and the

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men-Punctate Annular Denticular

Crescent

Cuff-like

Fig 5. Common normal hymenal variations in prepubertal girls. Less common variations

include: cribiform, imperforate, and septate, as well as hymens with lateral or high anterior or posterior openings.

tioned.8’9 Cantwell’#{176} found a horizontal diameter of the vaginal opening greater than 4 mm correlated with a confirming history of sexual abuse in three

of every four cases. Normative data on nonabused

prepubertal girls needs to be gathered as well as data on hymenal injuries from trauma other than abuse. We have not seen hymenal trauma caused

by legitimate accidents involving the genitalia.

Whether the opening in the hymen slowly

in-creases in diameter several years prior to puberty

is not absolutely known because there are no lon-gitudinal studies on a nonabused population. At

puberty, the vaginal opening is approximately 1 cm

in horizontal diameter. Ascertaining whether there

has been some type of penetration beyond the hy-men by physical examination in a child with a crescent or denticulate type may be particularly

difficult. Sometimes a hymen may appear “intact,”

when, in fact, it has been gradually stretched enough to allow digital or even penile penetration.

Force is rarely used in the sexual use of young

children; therefore, bruises, fresh tears, and

lacer-ations are uncommon findings. In our experience,

hymenal tears and fissures from attempted forced

penile penetration generally occur between the 3-o’clock and 9-o’clock positions and may extend

across the vestibule and fourchette. Digital or object manipulations due to the different angles of thrust may cause trauma anywhere around the introitus, although it frequently seems to be anterior. Also

occurring on occasion is a flat white midline streak

across the posterior vestibule which may be the

result of genital trauma (Fig 6). The frequency of

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ACKNOWLEDGMENTS

This work was supported, in part, by the General

Pediatric Academic Development Program of the Robert

Wood Johnson Foundation.

We thank our colleague, Nancy Berson, for her inter-views, Rob Gordan for his drawings, and Sheree Wheeley and Cheri Junk for manuscript preparation.

oral-genital acts are most common and often leave no physical findings. Therefore, the physical man-ifestations of sexual abuse clearly are not an “all or

nothing” situation. For the same reason, it is never

accurate to say that, because a hymen appears

intact, “no sexual abuse has occurred”;

unfortu-nately, we still see some examiners making state-ments like this. Positive findings are helpful in

establishing the diagnosis and corroborating the child’s account when the child is able to give one. Normal findings do not rule out sexual abuse. The

interview remains the most critical factor in

estab-lishing whether or not sexual abuse or exploitation

has occurred.

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Fig 6. Three-year-old sexually abused girl subjected to

genital digital manipulations showing midline white

streak across posterior vestibule and diagonal hymenal

scar at 4-o’clock position.

known, but it does occur. The fourchette is

some-times thin. We have seen children in whom it has

been confused with the hymen.

DOCUMENTATION

The description of the genital examination

should reflect thoroughness and accuracy in regard to the alleged sexual acts perpetrated against the child. Be specific and avoid terms such as incest or

sodomy that may have more than one meaning.

Terms such as “virginal” or “nonvirginal” are

meaningless. Keep in mind that the genital sexual

acts a child may experience cover a spectrum from

light touching or rubbing of the external genitalia to actual intercourse. Fingering, vulvar coitus, and

REFERENCES

1. Gundy J: The pediatric physical examination, in Hoekelman R (ed): Principles of Pedwtrics, Health Care of the Young.

New York, McGraw-Hill Book Co, 1978, p 65

2. Cowell C: The female reproductive system, in Hockelman R

(ed): Principles of Pediatrics, Health Care of the Young. New York, McGraw-Hill Book Co, 1978, pp 1311-1316

3. Schmitt BD, Kempe CH: Incest, in Behrman RE, Vaughan VC III (eds): Nelson Textbook of Pediatrics, ed 12.

Philadel-phia, WB Saunders, 1983, pp 103

3a.Gordon IB: Examination of the genitalia, in Behrman RE,

Vaughan VC III (eds): Nelson Textbook of Pediatrics. Phil-adelphia, WB Saunders Co, 1983, pp 1515-1516

4. Rowe D: The physical examination, in Rudolph A (ed):

Pediatrics, ed 17. Norwalk, CT, Appleton-Century-Crofts,

1982, p 33,75

5. Emans 5, Goldstein D: Pediatric and Adolescent Gynecology, Boston, Little, Brown and Co, 1982, p 5

6. Woodling B, Heger A: The use of the colposcope in the diagnosis of sexual abuse in the pediatric age group. Child Abuse Negl 1986;10:111-114

7. Paul D: The medical examination in sexual offences against

children. Med Sci Law 1977;17:257

8. Huffman JW, Dewhurst CJ, Caprano VJ: The Gynecology of Childhood and Adolescence. Philadelphia, WB Saunders Co, 1981, p 25

9. Parsons L, Sommers 5: Gynecology. Philadelphia, WB

Saun-ders Co, 1978, p 14

10. Cantwell H: Vaginal inspection as it relates to child sexual

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1987;80;203

Pediatrics

Marcia E. Herman-Giddens and Thomas E. Frothingham

Prepubertal Female Genitalia: Examination for Evidence of Sexual Abuse

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1987;80;203

Pediatrics

Marcia E. Herman-Giddens and Thomas E. Frothingham

Prepubertal Female Genitalia: Examination for Evidence of Sexual Abuse

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Figure

Fig 1.Caseabuse1:7#{189}-year-oldgirlwithprematureadren-arche,dysuria,andspotting;victimofchronicsexualinvolvingvaginalpenetrationinsupineposition.

Fig 1.Caseabuse1:7#{189}-year-oldgirlwithprematureadren-arche,dysuria,andspotting;victimofchronicsexualinvolvingvaginalpenetrationinsupineposition.

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Fig. 2.Casebody1: Top,knee-chestposition.Bottomleft,foreignbodyseeninknee-chestposition.Bottomright,foreigncontainingadultbodyhairs.
Fig. 2.Casebody1: Top,knee-chestposition.Bottomleft,foreignbodyseeninknee-chestposition.Bottomright,foreigncontainingadultbodyhairs. p.2
Fig 3.Casemal2:3-year-oldsexuallyabusedgirlwithnor-genitalia.

Fig 3.Casemal2:3-year-oldsexuallyabusedgirlwithnor-genitalia.

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Fig 4.Genitalexaminationpositionandanatomyoftheprepubertalgirl.

Fig 4.Genitalexaminationpositionandanatomyoftheprepubertalgirl.

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Fig 5.Commonnormalhymenalvariationsinprepubertalgirls.Lesscommonvariationsinclude:cribiform,imperforate,andseptate,as wellas hymenswithlateralor highanteriororposterioropenings.

Fig 5.Commonnormalhymenalvariationsinprepubertalgirls.Lesscommonvariationsinclude:cribiform,imperforate,andseptate,as

wellas hymenswithlateralor highanteriororposterioropenings. p.5
Fig 6.Three-year-oldsexuallyabusedgirlsubjectedtogenitaldigitalmanipulationsshowingmidlinewhitestreakacrossposteriorvestibuleanddiagonalhymenalscarat4-o’clockposition.

Fig 6.Three-year-oldsexuallyabusedgirlsubjectedtogenitaldigitalmanipulationsshowingmidlinewhitestreakacrossposteriorvestibuleanddiagonalhymenalscarat4-o’clockposition.

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