The Rational Clinical Examination
Clinician's Corner
December 17, 2008

Has This Prepubertal Girl Been Sexually Abused?

Author Affiliations

Author Affiliations: Division of General Pediatrics (Drs Berkoff and Runyan) and Department of Family Medicine (Dr Zolotor), University of North Carolina, Chapel Hill; Center for Safe and Healthy Children, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (Drs Makoroff and Shapiro); and Center for Child and Family Advocacy, Nationwide Children's Hospital, Columbus, Ohio (Dr Thackeray).

JAMA. 2008;300(23):2779-2792. doi:10.1001/jama.2008.827

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.