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Even for experienced physicians, it may be extremely difficult to differentiate between lacerations or other changes resulting from vaginal penetration and naturally occurring morphological changes [ 4748 ]. These studies are primarily in the context of medical education in English speaking countries. In some areas of the world, girls and women are subjected to an examination of the hymen to prove they have experienced sexual violence, as in the case of Yezidi women who were kidnapped, enslaved, and raped by members of ISIS The Islamic State of Iraq and Syria [ 8 ].
Normal variants, commonly mistaken as s of sexual trauma or a history of sexual abuse, include anal fissures, genital nevi, genital erythema, enlargement of the hymenal opening, failure of midline fusion of the hymen, narrowing of the hymenal edge, partial hymenal notching, hymenal clefts, and even conditions such as lichen sclerosis [ 50 ].
Clinicians, however, continue to refer to changes in the hymen to assess for a history of consensual or nonconsensual sexual intercourse. In these cases, other genetic abnormalities, such as renal agenesis, were found. In early fetal life, the vagina is first formed as a solid tube. We have noticed, anecdotally yet persistently, that many clinicians hold misconceptions about hymenal anatomy, morphology and physiology and the role the hymen can play in determining sexual activity — consensual or nonconsensual — particularly Massachusetts t had sex in 4yrs children, adolescents, and young women.
Though other authors have addressed the unreliability of using hymen morphology to determine sexual history, we have found very few articles in recently published peer-reviewed literature that summarize misconceptions about the hymen [ 9 ]. At the lower end of the tube a thin membrane, the hymen, typically remains.
Suggests a visual representation of the introitus for consistent description in clinical reporting. Similarly, where the morphology of the hymen has been altered, this can be attributed to causes other than sexual intercourse, including the insertion of objects, fingers, penetrating accidental trauma, and surgical procedures [ 29 — 31 ].
We would like to acknowledge the following individuals who contributed to the creation of this manuscript or reviewed earlier versions: Stefan Schmitt, Dallas Mazoori, Susannah Sirkin, Michele Curtis, Elizabeth Novick. Over the next three to 4 years, the hymen changes and becomes the relatively thin, smooth-edged membrane that is usually associated with prepubertal female genitalia. Summarizes some anatomical changes and s and their potential etiologies and association with sexual activity.
In prepubertal girls, the hymen and vagina are smaller and less elastic than in adolescent and adult women, and consequently trauma due to penetration is more likely to be evident and more characteristic [ 2425 ]. We reviewed published studies about the hymen to help guide clinicians in evaluating whether or not a hymen examination would be a valuable practice.
Clinicians should describe specific findings using international standards and terminology of morphological features See Figs. A ificant body of scientific evidence demonstrates that the vast majority of children who have been sexually abused, including with vaginal and anal penetration, have normal ano-genital examinations [ 122533 — 37 ].
In postpubertal women, or at the beginning of their sexual life, the hymen may stretch, allowing vaginal penetration with minimal or no injury. Health care providers conduct and make conclusions about whether or not a woman or girl has had sexual intercourse based on these examinations [ 67 ]. One noticeable exception may be in the consideration of sexual abuse in prepubescent females [ 4445 ].
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.
Assumptions about normal variations are common among non-specialized practitioners, many of whom mistakenly believe that normal variations indicate a history of sexual abuse [ 49 ]. Given that hymen examinations rarely lead to a determination of whether the hymen or vagina was penetrated by a penis or other object, they have little to no diagnostic or forensic value.
Moreover, of an examination of the hymen represent a means of influencing the way women and girls are viewed and treated in society based on related, though unsupported, conclusions about their veracity or believability, especially as it is related to their reported or purported sexual history.
The situation is a bit different when it comes to resident teaching in the U. Complicating this issue are ethical considerations, especially when it comes to the genital examination of children. Despite an absence of evidence supporting the practice [ 910 ], clinicians continue to refer to changes in the hymen to assess for a history of consensual or nonconsensual sexual intercourse. Over time, the inner portion of the tube disintegrates, so it becomes a hollow tubular structure.
We call on clinicians to consider the very 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 colleagues and counterparts in law enforcement and the judiciary; and 3 promote a discussion of the limitations of examining the hymen as part of clinical education for all specialties engaged in sexual or reproductive healthcare of women and girls. This is likely no different in other countries, although there are no specific articles addressing this issue in other contexts.
Studies of sexual assault survivors also provide evidence that the hymen may not incur noticeable damage as a result of forced penetration. Only a small portion of these women will exhibit changes in the hymen indicative of penetrating trauma. There is no evidence that examination of the hymen is an accurate or reliable test of a history of sexual activity, including sexual assault. As puberty approaches, the hymen thickens, may assume a fimbriated or crescenteric appearance, and hymenal elasticity increases.
We recommend that clinicians take into consideration that a hymen examination does not generally offer a high degree of certainty about sexual activity, with or without consent. However, studies Massachusetts t had sex in 4yrs shown that physical evidence of penetration is generally lacking in most reported cases of initial consensual or nonconsensual sexual intercourse [ 26 ], even among prepubertal girls. Opportunities to examine the hymen may be rare and coincident with specific — and uncommon — indications, severely limiting the of opportunities for observation, examination, and assessment of the hymen.
Even in children with suspected sexual abuse, the majority will have normal or nonspecific findings. The online version of this article In some settings, clinicians who evaluate women and girls suspected of being victims of sexual assault, or suspected of having engaged in intercourse with or without consentrely on an examination of the hymen for their assessments.
The hymen is a small membranous tissue outside of the vaginal canal that has no known biological function. Not applicable. While at least two studies dating back to the s and s have reported hymens to be present in all newborn girls examined [ cases in one study and in another], there are documented cases of girls born without a hymen altogether [ 1617 ]. Hymenal measurements of size and width, lacerations and transection have been shown to lack specificity or sensitivity to confirm vaginal penetration.
In many patriarchal cultures, the sexual history of girls and women is used as a ificant determinant of their societal, community, family, and individual status [ 12 ]. Frequently, conclusions about sexual history are made based on assumptions about the hymen, a small membranous tissue with no known biological function [ 34 ], which typically occupies a portion of the external vaginal opening in females. Information gleaned from a forensic assessment that includes an ano-genital examination can support a legal charge of various forms of sexual violence.
Therefore, the purpose of this article is to critically review published evidence to dispel common myths about the hymen, its morphology, function, and its use as evidence in cases of sexual violence. Despite the lack of specificity and sensitivity, where sexual assault or abuse is alleged, a full forensic examination of the child or adult is imperative [ 46 ]. RM, TM. Similarly, a survey of pediatric child abuse rape cases indicated that only 2. An imperforate hymen is often discovered at puberty when a patient presents with amenorrhea and hematocolpos [ 1213 ].
As discussed, there are many factors that confound whether clinicians can adequately assess changes to the hymen tissue at various stages of the life cycle, including genetic, developmental, endocrine, spontaneous, and external influences.
Less common hymen configurations are: sleeve-like, septate in which there are two openings with a band of tissue between themcribiform with multiple openingsmicro-perforate in which the hymenal orifice is extremely smalland imperforate in which there is no hymenal opening at all.
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Different configurations of the hymen exist, and include, most commonly: annular also known as circumferentialcrescentic, and fimbriated with finger-like projections [ 121415 ]. We concluded that an examination of the hymen is not an accurate or reliable test of sexual activity, including sexual assault, except in very specific situations. For example, in one small study of 36 pregnant adolescent girls, medical staff were only able to make definitive findings of penetration in two cases [ 27 ].
Other inclusion criteria: English language articles published between — September The hymen is a membrane at the opening of the vagina. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Many medical learners report high levels of discomfort performing genital exams [ 52 — 55 ], though simulation and working with standardized patient volunteers appear to lessen their discomfort.
Unless there are extensive laceration shymenal injuries heal rapidly and usually leave no evidence of any injury [ 12 ]. Often, this membrane ruptures in the first few days of life; it may remain as a rim of membrane around the vaginal orifice, or it may remain as a membrane with one or more small openings or rupture sites that partially cover the vagina. Further, the appearance of the hymenal rim may change with examination position or technique [ 42 ].
Data sharing not applicable to this article as no datasets were generated or analysed during the current study. The hymen is a membrane with relatively few blood vessels that — even if torn — may not bleed ificantly. We call on clinicians 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 with their colleagues and health professional students from all specialties that address the sexual or reproductive health of women and girls.
The vaginal canal extends internally from the hymen to the cervix.
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None of the existing studies provide or identify a clear function for the hymen [ 34 ]. Additionally, some clinicians have been taught to measure the size and width of the hymenal orifice as part of the examination.
In this age group, penetrative abuse should at least be considered where there is complete or almost complete absence of posterior hymenal tissue the area between Ultimately, evaluation of the hymen tissue, if visible, in and of itself, without supportive history, physical examination, or other forensic findings, could never answer the question of whether an individual — child or adult — had consensual or nonconsensual sex.
We conducted a narrative literature review on PubMed that included the words: hymen and morphology, anatomyAND sexual violence; sexual assault; rape; sexual activity; sexual abuse, injury; intercourse. Further changes occur with the hormonal changes of pregnancy, childbirth, aging, and the loss of hormonal production in menopause [ 18 — 20 ].
One cannot ethically subject anyone child, adolescent, or adult to a genital examination simply for the purpose of learning about human anatomy and physiology as one would, for example, a cardiac exam. Pelvic exam competencies tend to focus on performing a vaginal and bimanual exam, as well as a pap smears. Increasingly, reports of this practice have been cited in some communities in countries such as Canada, Sweden, Spain and the Netherlands [ 5 ].
A reliance on examination of the hymen to determine sexual history in general may result in individual and societal harms, including psychological sequelae associated with mistrust and disrespect for bodily sovereignty, physical discomfort and pain, in addition to the possibility of drawing inaccurate conclusions about sexual violence.
This is not surprising, considering that during Massachusetts t had sex in 4yrs medical education, medical students receive only a few hours of pelvic examination training. 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. In summary, similar to other body parts and organs, hymeneal anatomy is extremely diverse and dynamic and it is imperative that those involved in routine and forensic gynecological examinations are aware of these wide variations and the scientific limits of what they may indicate.
The authors of this study concluded that a substantial proportion of women, regardless of prior sexual experience, would not have visible genital injuries following forced vaginal penetration. Large, cross-cultural, population-based studies that address the absence or presence of a hymen at birth have not been published. It is well recognized that similarities exist between naturally occurring variations and hymenal changes resulting from injury [ 122532 ].
These factors have led all UN agencies to issue a call recently to ban this practice [ 7 ]. However, it is important to note that several types of forensic evidence are needed to support a legal charge, including patient history, physical evidence e. This is frequently done prior to marriage. Additional file 1 contains a French version of this original article. For the first two to 4 years of life, the infant produces hormones that continue this effect. The exam itself can be painful and psychologically distressing to the women subjected to it [ 6 ]. Several experts and professional organizations, including the Royal College of Pediatrics and Child Health, and the U.
National Protocol for Sexual Abuse Medical Forensic Examinations recommend against measurement of the hymenal orifice or the hymenal width. An examination of the hymen is not an accurate or reliable test of a history of sexual activity, including sexual assault. Virginity testing is a long-standing tradition in many parts of the world, not necessarily deemed illegal, and sometimes practiced by physicians. However, in prepubertal girls, measurement of the hymenal orifice diameter or of the width of the hymen are of no value in diagnosing penetration due to the difficulties in obtaining a measurement, which varies with the examination position, technique, age of the child, state of relaxation of the child, and the skill of the examiner.
Another study involving a greater range of ages of women alleging sexual assault found that only 9.