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Moussaoui D, Abdulcadir J, Yaron M. Hymen and virginity: What every paediatrician should know. J Paediatr Child Health 2022; 58:382-387. [PMID: 35000235 PMCID: PMC9306936 DOI: 10.1111/jpc.15887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/22/2021] [Accepted: 12/28/2021] [Indexed: 11/30/2022]
Abstract
Paediatricians may face the notion of 'virginity' in various situations while caring for children and adolescents, but are often poorly prepared to address this sensitive topic. Virginity is a social construct. Despite medical evidence that there is no scientifically reliable way to determine virginity, misconceptions about the hymen and its supposed association with sexual history persist and lead to unethical practices like virginity testing, certificate of virginity or hymenoplasty, which can be detrimental to the health and well-being of females of all ages. The paediatrician has a crucial role in providing evidence-based information and promoting positive sexual education to children, adolescents and parents. Improving knowledge can help counter misconceptions and reduce harms to girls and women.
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Affiliation(s)
- Dehlia Moussaoui
- Division of General Paediatrics, Department of Woman, Child and Adolescent MedicineGeneva University HospitalsGenevaSwitzerland,Present address:
Department of Paediatric and Adolescent GynaecologyThe Royal Children's Hospital MelbourneParkvilleVictoriaAustralia
| | - Jasmine Abdulcadir
- Division of Gynaecology, Department of Woman, Child and Adolescent MedicineGeneva University HospitalsGenevaSwitzerland
| | - Michal Yaron
- Division of Gynaecology, Department of Woman, Child and Adolescent MedicineGeneva University HospitalsGenevaSwitzerland
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Rastogi R, Rome ES. Adolescent Gynecology in the Office Setting. Pediatr Rev 2021; 42:427-438. [PMID: 34341084 DOI: 10.1542/pir.2019-0122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Ensuring open communication, partnership with patient and parent, and clarification of confidentiality during an adolescent gynecologic visit helps establish an environment in which a history and physical examination can be performed safely and with a focus on prevention, recognition of disease, and treatment as necessary. The history should include the menstrual status and gynecologic review of systems. The examination should document Tanner staging (sexual maturity rating) and be otherwise symptom guided. Similarly, testing in the office is largely risk and symptom related. Contraceptive counseling is an important component of the office visit, as well. Long and short curricula for teaching pediatric and adolescent gynecology have been developed by the North American Society for Pediatric and Adolescent Gynecology and are readily available for use. (1)(2) Although state-based variation in consent and confidentiality exists, pediatric practices should aim to protect patient confidentiality and transition to more independent health-care decision making.
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Affiliation(s)
- Radhika Rastogi
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Ellen S Rome
- Center for Adolescent Medicine, Cleveland Clinic Children's Hospital, Department of Pediatric Endocrinology, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, OH
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Collins JA, Maney JA, Livingstone A. Fifteen-minute consultation: Apparent vaginal bleeding in the pre-pubertal girl. Arch Dis Child Educ Pract Ed 2021; 106:142-148. [PMID: 32859737 DOI: 10.1136/archdischild-2018-316218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 04/23/2020] [Accepted: 07/03/2020] [Indexed: 11/04/2022]
Abstract
A parent or carer's observation of blood in a child's nappy or underwear can be quite alarming for both parent and child and may indicate vaginal bleeding. At first glance, it may be difficult to ascertain whether the bleeding is from the skin, genital tract, urinary tract or anus. Confirmed vaginal bleeding in a pre-pubertal girl is rare but always abnormal and requires comprehensive assessment to determine the cause. Recognition of normal female pre-pubertal anatomy is essential to detect any abnormalities. Appropriate action should be taken according to findings on initial inspection of the ano-genital area. The possibility of child sexual abuse and the need for specialist paediatric sexual offences medicine examination by an FME (Forensic Medical Examiner) or specialist paediatrician should always be considered. This article offers a systematic approach to assessment in pre-pubertal girls with apparent vaginal bleeding which will benefit general paediatricians, emergency department practitioners and GPs.
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Affiliation(s)
- Julie-Ann Collins
- Emergency Department, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Julie-Ann Maney
- Emergency Department, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Alison Livingstone
- Community Paediatrics, Northern Health and Social Care Trust, Antrim, UK.,The Rowan SARC, Antrim Area Hospital, Antrim, UK
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Hadley J, Moore J, Goldberg A. Sexual Abuse as a Cause of Prepubertal Genital Bleeding: Understanding the Role of Routine Physical Examination. J Pediatr Adolesc Gynecol 2021; 34:288-290. [PMID: 33482332 DOI: 10.1016/j.jpag.2021.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 12/18/2020] [Accepted: 01/08/2021] [Indexed: 11/19/2022]
Abstract
Although accidental trauma is the most common mechanism for genital bleeding, sexual abuse should be considered when the patient is prepubertal and/or a vague history of bleeding is provided. Prepubertal female genital exams should be completed routinely; this clinical technique is critical for pediatricians to assess pubertal progression, to identify pathologies or differences in sexual differentiation, and to narrow a broad differential diagnosis of bleeding. Physical evidence of sexual abuse on exam is rarely found, and therefore the diagnosis relies on a child's disclosure. Physicians should be cognizant of barriers to patient disclosure. In this commentary we aim to provide general pediatricians and trainees with a framework for evaluating genital/vaginal bleeding in prepubertal girls, by discussing the following: (1) the importance of a complete anogenital exam in generating a differential diagnosis; and (2) the possibility of sexual abuse as an etiology with recognition that the disclosure process is complex.
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Affiliation(s)
- Julia Hadley
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Jessica Moore
- Hasbro Children's Hospital, Providence, Rhode Island
| | - Amy Goldberg
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island; Hasbro Children's Hospital, Providence, Rhode Island.
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Fan SM, Grigorian A, Chaudhry HH, Allen A, Sun B, Jasperse N, Albertson S, Nahmias J. Female pediatric and adolescent genitalia trauma: a retrospective analysis of the National Trauma Data Bank. Pediatr Surg Int 2020; 36:1235-1241. [PMID: 32851470 PMCID: PMC7449526 DOI: 10.1007/s00383-020-04736-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE Pediatric genitalia injury represents 0.6% of all pediatric trauma. It is crucial for providers to understand whether pediatric patients are at risk for violent mechanisms, such as rape, assault, or other abuse. Therefore, we sought to perform a large database analysis of pediatric and adolescent female genitalia trauma, comparing mechanisms of injury (i.e., sexual abuse) and need for operative intervention between adolescent and pediatric cohorts. METHODS The National Trauma Data Bank was queried (years 2007-2015) for female patients ≤ 16 years old with external genitalia (vaginal or vulvar) trauma. Two groups were compared: pediatrics (< 12 years old) and adolescents (12-16 years old). RESULTS Out of 303,992 female patients, 3206 (1.1%) were identified to have genitalia trauma with the majority being pediatric patients (92.1%) and with injury to the vagina (62.6%). Pediatric patients with vaginal injury were less likely to be victims of rape (4.1% vs. 17.3%, p < 0.001) and assault (2.1% vs. 7.2%, p < 0.001) but more likely to be victims of other abuse (9.5% vs. 3.4%, p = 0.003). More of the adolescent patients with vaginal trauma required repair (58.7% vs. 43.2%, p < 0.001). Pediatric patients with injury to the vulva were less likely to be victims of rape (0.7% vs. 2.8%, p = 0.01) and motor vehicle accidents (4.2% vs. 11.0%, p < 0.001). CONCLUSION Genitalia trauma occurs in 1.1% of pediatric and adolescent trauma cases with the vagina being more commonly injured compared to the vulva. Adolescent patients with vaginal injuries were more likely to be victims of rape and assault and required repair more often, while those with vulvar injuries were more likely due to motor vehicle accidents. Health care providers must be aware of these at-risk populations and the differences between them to identify female victims of violence and provide resources to assist with recovery.
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Affiliation(s)
- Shannon M. Fan
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, 333 The City Blvd West, Suite 1600, Orange, CA 92868-3298 USA
| | - Areg Grigorian
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, 333 The City Blvd West, Suite 1600, Orange, CA 92868-3298 USA
| | - Haris H. Chaudhry
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, 333 The City Blvd West, Suite 1600, Orange, CA 92868-3298 USA
| | - Angela Allen
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, 333 The City Blvd West, Suite 1600, Orange, CA 92868-3298 USA
| | - Beatrice Sun
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, 333 The City Blvd West, Suite 1600, Orange, CA 92868-3298 USA
| | - Nathan Jasperse
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, 333 The City Blvd West, Suite 1600, Orange, CA 92868-3298 USA
| | - Spencer Albertson
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, 333 The City Blvd West, Suite 1600, Orange, CA 92868-3298 USA
| | - Jeffry Nahmias
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, 333 The City Blvd West, Suite 1600, Orange, CA 92868-3298 USA
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Northridge JL. Adnexal Masses in Adolescents. Pediatr Ann 2020; 49:e183-e187. [PMID: 32275763 DOI: 10.3928/19382359-20200227-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Adnexal masses in adolescents, such as functional cysts, are often benign and can usually be managed expectantly since they typically regress on their own. The most common ovarian neoplasm in adolescents is a benign cystic teratoma. Both functional cysts and benign cystic teratomas are associated with ovarian torsion. Of concern, ovarian torsion requires a high level of suspicion when adolescents present with acute abdominal pain, as almost one-half of cases have no associated adnexal masses. The most common malignant adnexal masses in this age group include germ cell tumors, followed by epithelial cell tumors. Finally, ectopic pregnancy and tubo-ovarian abscesses must be considered in the differential diagnosis of adnexal mass, as delays in treatment may seriously affect an adolescent's health and future fertility. Obtaining an accurate history, including a sexual history, requires reviewing this history with the adolescent privately. Management of adnexal mases should prioritize fertility preservation. [Pediatr Ann. 2020;49(4):e183-e187.].
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Lazanyi M, Grover SR. Imperforate hymen: Retrospective review from a single tertiary centre of presenting symptoms and diagnostic process. J Paediatr Child Health 2020; 56:90-93. [PMID: 31144364 DOI: 10.1111/jpc.14501] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 12/29/2022]
Abstract
AIM To review presentations, diagnostic processes and time to diagnosis of presentations of imperforate hymen at one tertiary paediatric hospital over a 10-year period. The aim was to improve knowledge, enable targeted education and reduce unnecessary tests and diagnostic delay for this congenital obstructive disorder of the female reproductive tract. METHODS A pragmatic, retrospective, observational study was conducted of all female patients, aged younger than or equal to 18 years of age, presenting to the Royal Children's Hospital, Melbourne, over an 18-year period. Presenting symptom(s), time to diagnosis, investigations ordered and number of health-care professionals consulted prior to diagnosis were recorded. RESULTS A total of 27 patients met eligibility criteria, and 85% presented with pain (23/27). Pain was frequently associated with other symptoms (15/23). Over three quarters of patients consulted more than one health-care professional prior to diagnosis (22/27). Of the 27 patients, 19 had imaging undertaken prior to diagnosis. CONCLUSIONS Paediatric and adolescent females managed at our tertiary paediatric hospital are experiencing diagnostic uncertainty and the unnecessary ordering of imaging prior to a diagnosis of imperforate hymen. Targeted education is recommended to health professionals managing female paediatric and adolescent patients.
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Affiliation(s)
- Mikhaila Lazanyi
- Department of Gynaecology, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Sonia R Grover
- Department of Gynaecology, Royal Children's Hospital, Melbourne, Victoria, Australia
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Mishori R, Ferdowsian H, Naimer K, Volpellier M, McHale T. The little tissue that couldn't - dispelling myths about the Hymen's role in determining sexual history and assault. Reprod Health 2019; 16:74. [PMID: 31159818 PMCID: PMC6547601 DOI: 10.1186/s12978-019-0731-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 05/02/2019] [Indexed: 11/10/2022] Open
Abstract
Conclusions about women's and girls' sexual history are made in some settings based on assumptions about the hymen, a small membranous tissue with no known biological function, which typically occupies a portion of the external vaginal opening in females. Clinicians, however, continue to refer to changes in the hymen to assess for a history of consensual or nonconsensual sexual intercourse. We reviewed published evidence to dispel commonly held myths about the hymen and its morphology, function, and use as evidence in cases of sexual violence.An examination of the hymen is not an accurate or reliable test of a previous history of sexual activity, including sexual assault. Clinicians tasked with performing forensic sexual assault examinations should avoid descriptions such as "intact hymen" or "broken hymen" in all cases, and describe specific findings using international standards and terminology of morphological features.We call on clinicians to consider the low predictive value of a hymen examination and to: 1) avoid relying solely on the status of the hymen in sexual assault examinations and reporting; 2) help raise awareness of this issue among their peers and counterparts in law enforcement and the judicial system; and 3) promote fact-based discussions about the limitations of hymenal examinations as part of clinical education for all specialties that address the sexual or reproductive health of women and girls.
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Affiliation(s)
- Ranit Mishori
- Department of Family Medicine, Georgetown University School of Medicine, Washington, DC, USA.
| | - Hope Ferdowsian
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Karen Naimer
- Physicians for Human Rights, Program on Sexual Violence in Conflict Zones, Boston, MA, USA
| | - Muriel Volpellier
- Sexual Assault Referral Centre, The Havens Paddington, Kings College Hospital NHS Trust, London, UK
| | - Thomas McHale
- Physicians for Human Rights, Program on Sexual Violence in Conflict Zones, Boston, MA, USA
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Manning S. Genital Complaints at the Extremes of Age. Emerg Med Clin North Am 2019; 37:193-205. [DOI: 10.1016/j.emc.2019.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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