Child sexual abuse in the U.S. affects 100,000 to 500,000 children annually. Increased reporting of this crime to authorities has augmented the number of requests for medical evaluations of victims. In court, the examining physician may be the only adult who can substantiate the child's story by reporting on the injuries observed during the physical examination. Clinicians need accurate information on the appearance of the external genitalia, including the hymen, in non-abused female children and how it differs in those who have been sexually molested. However, there are almost no data on this topic. The studies published have numerous methodologic flaws, which leads to discrepancies in literature and, therefore, a poor understanding by clinicians of which hymenal findings are associated with abuse. The only evidence that frequently is available in child abuse cases is the victim's report. Relying on the child's testimony, however, may increase the trauma experienced by the victim and frequently results in acquittal of the perpetrator. Incorrect information on hymenal anatomy may lead to the traumatization of non-abused children if they are incorrectly diagnosed by physicians and are referred to Child Protective Services. We must obtain accurate information on the hymen's appearance in non-abused children and how it differs in abused children. To meet this need, we will compare the hymen's morphology in 200 girls between 3 and 8 years who do not have assault histories to 200 subjects with histories of penetrating abuse. Subjects will be recruited from patients who present for sexual abuse evaluation at the Child Protective Health Clinic at Baylor College of Medicine, Houston, and controls from those attending well child care clinics at The University of Texas Medical Branch, Galveston, or from a large pediatric practice in Houston. Controls will be screened for undetected abuse by direct interview of child and parent and by use of the Child Sexual Behavior Inventory. For Consistency and verification of findings, all characteristics reported will be evaluated from photographs taken during the exam, which will be reviewed by two experts of hymenal anatomy. Differences in each characteristic between the two groups will be assessed using bivariate and multivariate analyses. We hypothesize that there will be features specific to the anatomy of an abused child. Specifically, notches on the inferior half of the hymen and a transverse transhymenal diameter >6.5 mm will be observed only in sexually abuse victims, and an inferior rim measuring <1.0 mm will be observed more often in victims than in non-abused girls. We further hypothesize that the hymen's appearance in abused and non-abused children will not significantly differ on the following characteristics: prevalence of extensive or partial labial agglutination, prevalence and location of ridges, bumps and bands, and vascularity. The information gained from this study will establish criteria for the diagnosis of sexual abuse based on physical examination. Clinicians can then make more appropriate referrals to CPS and provide expert testimony to convict perpetrators of child sexual abuse. Ultimately, this project will benefit all female children.
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