Case 28

A 12-year-old girl was brought to your office with concerns from her mother that ‘her opening is too big’. The mother reported that she and the father had separated, contemplating divorce, and the girl stayed with her father on alternative weekends. The child denied that he has ‘done anything’ to her and she also denied any other sexual contact with anyone else. She had complained of vaginal discharge and her mother ‘checked her down there’ to see if she was having her first period. As a primary care physician, you explain you are not a paediatric gynaecologist but offer to do an examination as she was due for her routine well-child exam for sports in school. She was Tanner stage III. With her lying on the examination table on her back and her mother at her side, you see the image as presented (Image 28). https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig28.jpg"/>

What does the image show?

Do these findings indicate sexual abuse and/or trauma?

64The image depicts a view of the hymen and vagina without much estrogenization. The hymen is crescentic in shape and does not extend completely around the genital opening. The posterior fourchette and fossa navicularis are not visible. The depicted labia minora has increased vascularity and mucus membranes are erythematous, but this may be nonspecific and artefactual from the lighting. There is no visualized vaginal foreign body, discharge or trauma. The posterior rim of the hymen is thin and there appears to be a bump at the insertion of an intravaginal ridge in the inferior half at 5 o’clock with her in the supine position. Based on the size of the examiner’s fingers, the rim appears to be at least 1 mm in thickness in all locations on the posterior half of the hymen. ¹

These findings should be interpreted with caution. Historically, expert opinion has suggested that the thinness of the hymen rim was indicative of sexual abuse and/or trauma to this area; however, the paucity of research evidence in this area has more recently made this finding more indeterminant. ² Girls with complete transections of the hymen or bruises and lacerations are more easily found to have been abused, but the smoothness and otherwise normal appearance of the hymenal tissues in this image suggest that this finding is a normal variant. The bump is an accepted normal finding when associated with an intravaginal ridge. In the absence of disclosure or other evidence, these physical findings do not currently indicate sexual abuse or trauma.