Has this prepubertal girl been sexually abused?
BACKGROUND
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.


OBJECTIVE
To determine the diagnostic utility of the genital examination in prepubertal girls for identifying nonacute sexual abuse.


METHODS
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.


METHODS
Three of the authors independently reviewed titles of articles obtained from MEDLINE and selected articles for full-text review.


METHODS
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.
Berkoff
Molly Curtin
MC
Division of General Pediatrics, University of North Carolina, 231 MacNider, CB #7225, Chapel Hill, NC 27599, USA. molly_berkoff@med.unc.edu
Zolotor
Adam J
AJ
Makoroff
Kathi L
KL
Thackeray
Jonathan D
JD
Shapiro
Robert A
RA
Runyan
Desmond K
DK
D002648:Child; D002650:Child Abuse, Sexual / Q000175:diagnosis*; D002675:Child, Preschool; D005260:Female; D005836:Genitalia, Female; D006801:Humans; D007223:Infant; D008487:Medical History Taking; D010808:Physical Examination; D012680:Sensitivity and Specificity; D012749:Sexually Transmitted Diseases / Q000175:diagnosis