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12 April 2011

Signs of sexual abuse hard to read

Several genital features of girls that have been interpreted as red flags for sexual abuse may instead be a normal phase of development, a new study has found.

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Several genital features of girls that have been interpreted as red flags for sexual abuse may instead be a normal phase of development, a new study has found.

Dr. Abbey B. Berenson, a professor of obstetrics and gynaecology at University of Texas Medical Branch at Galveston, examined 61 girls periodically between birth and age nine to document their genital development. None of the girls had a history of sexual abuse.

A key feature Berenson looked at was the hymen, the fold of tissue that partially or fully obstructs the external vaginal opening.

In the past, notches and mounds on the hymen or a decrease in hymenal tissue were seen as indicative of abuse, Berenson says.

But her research found notches and mounds can develop on their own after age three. And between the ages of three and five, some of the girls in the study experienced a gradual decrease in the hymenal tissue.

Normal development
"There are some changes that occur in hymenal features as a result of normal aging and development," says Berenson, lead author of the study in today's issue of the Journal of Pediatrics. "In the past, these features were attributed to sexual abuse. However, recent literature has shown that these are normal congenital features."

But despite the new findings, Berenson adds, it's highly unlikely there are many people imprisoned for sex abuse that didn't happen.

"It's been demonstrated the physical exam is rarely a determining factor of whether somebody goes to jail," she says. "The child's history, confessions, the child's version of what happened are stronger determinants than the physical exam."

Berenson is one of the country's foremost researchers of prepubescent genitalia. She began her work in the 1980s when she noticed a dearth of information.

"As physicians, we understand the development of almost every organ in the body, and yet there was almost no data on normal development of the hymen in young girls," Berenson says.

In August 2000, she published a groundbreaking study in the American Journal of Obstetrics and Gynecology that said genital exams were often inconclusive in finding evidence of abuse.

In the study, researchers examined 200 sexually abused children and 200 who had not been abused. Only five percent of the abused children had a genital appearance that was significantly abnormal.

Difficult to distinguish
"In the vast majority of cases, children who have been sexually abused have an exam that is indistinguishable from a child who has not been abused," she says.

Among the reasons: The genitalia can heal rapidly. Previous research has shown it takes an average of six weeks after the last incident of abuse for a child to be brought to the doctor for an exam, she says.

However, there are some cases in which an exam can give important clues about sexual abuse. A child with a sexually transmitted disease is one obvious sign.

So is an actual tear of the hymen, Berenson says.

Other opinion
Dr. Vivian Everett, a member of the American Academy of Paediatrics committee on child abuse and neglect, says Berenson's findings mesh with the academy's guidelines for physicians in examining children suspected of being abused.

However, she says, in some cases a mound or a notch would be a cause for concern.

"This is an evolving field, and more and more research needs to be done," says Everett, director of the child sexual abuse team at WakeMed in Raleigh, N.C.

"We all need to be sure we are in agreement of terminology that are used when describing the anatomy... A hymenal mound in and of itself would not be considered diagnostic. But it would be something that would be documented and used to describe your findings. Some hymenal mounds in little girls are part of normal development, some could be because of abuse," Everett adds.

 
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