ABSTRACT
An 11-year-old female recently disclosed to her older sister of 19 years that a family member had ‘touched her’ in the bathroom during a family event. The girl came from a large extended family who hosted frequent large gatherings in their home. She was too afraid to tell her sister who had abused her and she did not know exactly when this occurred, but said that it may have happened ‘a few times’. She would not disclose any more information. Her sister brought the child to the emergency department for an evaluation, and findings of the genital exam are shown in Image 19. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig19.jpg"/>
What does the examination show?
Is the physical examination diagnostic of an acute rape?
44Image 19 shows a hymenal transection at the 6:30 o’clock position (large arrow). The hymenal tissue can be followed clockwise from the 1 o’clock position until it becomes completely effaced at 6 o’clock, revealing the posterior rim of the vaginal opening. The tissue then resumes at the 7:00 position and extends anteriorly, where it can be followed until approximately 11 o’clock. There is also a mound or bump at the 4 o’clock position (small arrow) which is a solid elevation of tissue at the site of an attachment to an intravaginal column and is a normal finding. 1
A transection of the hymen is one of the few physical findings with high specificity for abuse; it is diagnostic for blunt force penetration of the vagina. 2 The specific sexual contact, however (e.g. insertion of penis, fingers or foreign body) cannot be ascertained based on physical findings alone. In addition, hymenal tissue is highly vascular and heals quickly (about 3 weeks, some research shows 3 ), so timing of the abuse cannot be ascertained precisely unless the patient presents acutely with bleeding. It is important to remember that the vast majority of children who report sexual abuse have a normal anogenital exam. This occurs because tissues heal very quickly and sexual abuse (even, in some cases, penetration) may not cause damage sufficient to be evident on examination. 2 Any child with a disclosure of sexual abuse should be interviewed by a trained professional and given a complete physical and anogenital examination while reducing the number of interviews to prevent re-traumatization and imprecisions in history.
