Published online May 1, 2007
PEDIATRICS Vol. 119 No. 5 May 2007, pp. 997-999 (doi:10.1542/peds.2006-3677)

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COMMENTARY

Healing of Hymenal Injuries: Implications for Child Health Care Professionals

Howard Dubowitz, MD, MS

Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland

The article by McCann et al¹ in this issue of Pediatrics Electronic Pages provides additional information on the natural course of hymenal injuries in both prepubertal and pubertal girls. In general, they heal rapidly and often completely, confirming similar findings in earlier studies.^2,3 This new study raises several implications for pediatricians and other health care professionals who examine children and youth.

It is noteworthy that it took this major US (and Australian) effort involving 25 medical centers to gather retrospective information on 239 girls, both prepubertal and postpubertal, with hymenal trauma. This largely reflects how unusual these injuries are; relatively few girls evaluated for sexual abuse have abnormal findings on physical examination.^4–6 Fortunately, most sexually abused girls do not experience serious physical trauma, primarily because of the nature of the abuse. The low base rate of physical injuries, however, has been a challenge for research in this area. Even in this study of 239 girls, there were few girls with certain injuries (eg, 7 prepubertal girls with "transection only"). Small numbers always demand cautious interpretation. It is noteworthy that none of the girls in this large series had any hymenal scarring, as reported by others.^2,7 However, these other authors did note occasional scarring of adjacent structures (eg, the posterior fourchette); the McCann et al article is limited to hymenal findings.

Previous studies have reported that hymenal trauma mostly occurs posteriorly.⁷ McCann et al¹ document hymenal lacerations occurring anteriorly in 5% of prepubertal and 15% of pubertal girls. It seems that none of those girls also had posterior injuries. Thus, McCann et al recommend that medical evaluations for sexual abuse in girls should always include both the prone knee-chest and supine positions, because some anterior and lateral lacerations were found only in the prone position. This finding may be explained by their method of reviewing photodocumentation rather than performing actual examinations. It is probable that the anterior aspect of the hymen may not have been readily visualized in images taken in the supine position because of the positioning of the camera. Examining girls in the prone position is thought to be potentially embarrassing; this position is often only used when the examination in the supine position raises concerns. Acute trauma is invariably visible in the supine position, making the prone examination usually unnecessary. Beyond the "acute" period, many nonabused girls normally have clefts and areas of "missing" hymen anteriorly. This makes the prone examination redundant unless an additional view is necessary to clarify uncertain findings in the supine position.

A goal of the article was to assist with the timing of the hymenal injuries. The retrospective design, with varying periods to follow-up, made this difficult. The authors found, however, varying patterns of healing that suggest timing these injuries was difficult and of limited forensic value. Of note, they do report that petechiae had all disappeared within 2 to 3 days and that blood blisters lasted up to 1 month. These findings may help corroborate histories of when the alleged abuse occurred.

It has long been thought that estrogen-induced changes of the hymen usually mask previous evidence of trauma. The McCann et al ¹ study highlights the potential for complete healing in prepubertal girls. In addition to the customary caution that a "normal" examination does not rule out sexual abuse, there is the need to acknowledge that current hymenal normalcy does not preclude earlier injury. Even many of the more serious injuries healed without leaving a trace. Their study confirms the need for considerable constraint in interpreting the physical findings (ie, likelihood of abuse) beyond the acute period.

The medical evaluation is one component of the comprehensive assessment of children suspected of having been sexually abused. Questions remain as to where, when, and by whom these evaluations should be performed. Pediatricians might even question whether the medical piece is really necessary given that so few children are injured and have medical evidence of abuse. First, even if only a few have findings, the medical evidence can make a significant difference in helping protect a child, identifying those responsible, and protecting other children.⁸ In addition, some, particularly adolescents, have sexually transmitted infections that need to be treated.^9,10 Perhaps most importantly, the medical evaluation can provide immense comfort to a child and parents that they are normal, without any residual defect. Children and parents may have an array of fears about being "damaged," infections, future sexuality, and childbearing. Allaying such anxiety is very important; parents have reported much satisfaction with interdisciplinary evaluations for sexual abuse.¹¹

When and where should the medical evaluations be conducted? McCann et al¹ have demonstrated that the physical evidence may disappear within a few days, especially petechiae, the most common finding. Christian et al¹² also reported that forensic evidence, including blood and semen, is mostly found within the first 24 hours, a finding that was confirmed recently by Young et al.¹³ Thus, the medical evaluation should be conducted soon after the alleged abuse occurred. Children often delay reporting their abuse, which makes this difficult; once several days or weeks have elapsed, the likelihood of finding clear physical evidence is very slim. Ideally, all communities should have resources for a skilled medical evaluation to be made available quickly (within a day of the alleged abuse). At the same time, it does not mean that these children must be examined immediately unless there is a compelling medical indication (eg, active bleeding, suicidal ideation). Too often, the perceived need for an immediate evaluation leads to an emergency department, in the middle of the night, with staff not trained to evaluate these children and in a setting that may exacerbate their stress.

The concern of acute or recent sexual abuse raises legal issues and the possible need to gather forensic evidence. Few primary care pediatricians are likely to feel comfortable in this role; time demands are an added barrier. A few pediatricians, however, do set aside regular time to provide this service in their offices. North Carolina, for example, has a network of primary care physicians who perform these evaluations on a fee-for-service basis.¹⁴ Within the United States, approximately 600 child advocacy centers have been developed to comprehensively evaluate possible sexual abuse, although many do not have a medical component.¹⁵ Pediatricians can play a valuable role in collaborating with other professionals in these centers. Currently, however, there is a shortage of physicians who are trained and willing to conduct these evaluations, which has contributed to forensic (or sexual assault) nurse examiners often filling this gap, usually in emergency departments. Nurses started these programs to serve adult rape victims, and some of them have received special training to evaluate children. There are a variety of models. Some nurse examiners are supervised by pediatricians; they conduct the evaluations but do not interpret the findings or render a definitive opinion as to the likelihood of abuse. Others function quite independently. There is debate among pediatricians as to the appropriateness of nurses in these roles; research is needed to evaluate these models of care. At least until there are enough physicians able and willing to evaluate these children, nurses will likely continue to provide this service.

The McCann et al¹ study is interesting, because it indirectly shows where earlier thinking turned out to be erroneous. For example, until recently, the diameters of the hymenal opening were examined and reported.^5,6,16 We have since learned that the size of the hymenal opening is mostly meaningless; McCann et al appropriately do not even report those data. This is important for pediatricians to be aware of, especially when faced with a presenting complaint such as "she looks so big down there." There may still, however, be a need to probe the concern of possible sexual abuse. Their article does describe thinning (<1 mm) of the hymen in some girls. It is difficult to measure this thinning; hence, there is questionable significance to this finding.¹⁷

It is the nature of science that knowledge evolves. However, there is an ethical concern here if such previous knowledge contributed to a finding of sexual abuse, a child being removed from the home, and someone being incarcerated.¹⁸ In general, these decisions were based on more than 1 physical finding. Nevertheless, there may be a need to "set the record straight" despite the logistic challenges of whom to contact, how to reach them, and over what period of time.

The McCann et al¹ article also illustrates the importance of precise terminology to help us speak a common language.^5,19 The authors offer useful guidance by carefully defining their terms. Nevertheless, even with their glossary, some terms are used interchangeably. For example, why have both "hymen" and "hymenal membrane" or "complete tear (or laceration)" and "transection?" "Cleft" and "notch" are also very similar terms. Having just one term for each finding would facilitate communication for medical, legal, and research purposes.

The article by McCann et al reinforces a lesson we have learned: the child's history is the most important aspect of evaluating possible sexual abuse.⁶ Physical findings are few and, once the wounds heal, are often subtle and ambiguous or entirely gone. Girls who have been sexually abused generally have the same physical appearance as girls who have not been abused. Thus, although these children need a skilled and early medical evaluation, it is especially important that a detailed history be obtained. The physician's history can complement the forensic interview conducted by law enforcement or child protective services.²⁰ The optimal evaluation of children suspected of having been sexually abused demands interdisciplinary collaboration, which should include mental health colleagues for providing treatment.

	FOOTNOTES

 
Accepted Dec 27, 2006.

Address correspondence to Howard Dubowitz, MD, MS, University of Maryland School of Medicine, Department of Pediatrics, 520 W Lombard St, Baltimore, MD 21201. E-mail: hdubowit{at}peds.umaryland.edu

The author has indicated he has no financial relationships relevant to this article to disclose.

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

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