The hymen is one of the most misunderstood and misrepresented anatomical structures by physicians and the lay public. In studies of chief pediatric residents, only 59 to 71 percent were able to correctly identify the hymen on a photograph.⁵ Every female, regardless of age, has a hymen. The common misconception is that the hymen acts as a barrier to the vagina and completely covers the vaginal opening. This is just not true. The hymen has an orifice and comes in several shapes and sizes. Common classifications include crescentic, annular, fimbriated, septate, and cribriform. There is a rare anatomical variant where there is no hymenal orifice, called an imperforate hymen. The diameter of the hymenal orifice varies with patient age, examination technique, and state of relaxation of the patient. In addition, the finger size of the examiner can lead to incorrect assumptions. The commonly used term “hymen intact” is anatomically inaccurate and should not be used in medical documentation.

The hymen can provide valuable information in the pediatric sexual assault/abuse medical forensic examination. However, these examinations should be conducted by a child abuse pediatrician or pediatric-trained sexual assault nurse examiner. In the hands of an inexperienced examiner, normal anatomical variants can be misinterpreted as sexual contact or abuse.

Case Resolution

In private, the patient reports being safe and not abused by anyone. She adamantly denies any sexual contact and continues to refuse the pelvic examination. A lengthy discussion occurs with the parents about the lack of their daughter’s assent to examination and the limitations of the physical exam in determining sexual activity. They understand and agree to discharge. Police and CPS are notified.

References

1. Riviello RJ, Rozzi HV. Caring for ED sexual assault victims: common federal and state law requirements. ACEP Now. 2018;37(11):29-31.
2. Mandatory reports of child abuse and neglect. Children’s Bureau website. Available at: https://www.childwelfare.gov/pubPDFs/manda.pdf. Accessed Jan. 11, 2019.
3. SANE program development and operation guide. Office for Victims of Crime website. Available at: https://www.ovcttac.gov/saneguide/identifying-essential-components-of-a-sane-program/informed-consent-and-patient-confidentiality/. Accessed Jan. 11, 2019.
4. United Nations agencies call for ban on virginity testing. The World Health Organization website. Available at: https://www.who.int/news-room/detail/17-10-2018-united-nations-agencies-call-for-ban-on-virginity-testing. Accessed Jan. 11, 2019.
5. Dubow SR, Giardino AP, Christian CW, et al. Do pediatric chief residents recognize details of prepubertal female genital anatomy: a national survey. Child Abuse Neg. 2005;29(2):195-205.