A 12-year-old girl is being seen for chronic abdominal pain by her family physician. The physician asks the mother to step out of the room and does a complete history including the HEADSS (home life, education level, activities, drug use, sexual activity, suicide ideation/attempts) questions. The girl tearfully reports that her stepfather has been touching her in her private areas when her mother is not home. On examination with a female nurse chaperone in the room, the physician finds that the girl’s hymen initially appears normal (Figure 9-1). However, when the girl is more carefully examined with a cotton-tip applicator, a healed posterior hymenal transection is seen (Figure 9-2). When the girl is asked whether any other types of sexual abuse occurred with her stepfather, she admits to repeated penile penetration. Although rare, sometimes the examination reveals more than what the child is willing to disclose about the abuse. Partial disclosures of abuse are common in children. In addition, the findings of sexual abuse tend to be subtle and are easily missed if a careful examination and special techniques are not used. Attempts are made to reassure the girl that this should never happen and that this is not her fault. Her mother is brought back into the room and after a sensitive discussion, the police are called and Child Protective Services (CPS) notified.
Typical appearance of the hymen and perihymenal tissues in a 12-year-old girl. Once females have entered puberty, the hymen becomes redundant with overlapping folds and is more difficult to examine for subtle signs of acute or healed injury. (Used with permission from Nancy D. Kellogg, MD.)
Hymenal cleft visible when the girl in Figure 9-1 is more carefully examined using a saline moistened cotton-tip applicator to gently separate and demonstrate the edges of the hymen. This injury was caused by sexual abuse and may have been missed without the more careful examination. (Used with permission from Nancy D. Kellogg, MD.)
HEADSS is an acronym that provides a framework for interviewing adolescents and children about health risks. The questions start from easiest and least sensitive to more sensitive questions that need to be asked:
D—depression and drugs
S—sex and sexual abuse
The US Department of Health and Human Services compilation of CPS data from 48 states in 2008 indicates there were 772,000 children confirmed as victims of abuse.1 Of these, 9 percent were victims of sexual abuse. Not included in these numbers are several thousand additional victims who are sexually assaulted by nonfamily members; these cases are reported to law enforcement but not CPS.