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Objective: To determine the usefulness of measurements of the vaginal opening and amount of hymenal tissue present inferiorly and laterally in the diagnosis of vaginal penetration., Methods: The transhymenal diameters and the amount of tissue present between the hymenal edge and vestibule inferiorly at 6 o'clock and laterally at 3 o'clock and 9 o'clock were measured from photographs of 189 prepubertal children with a validated history of digital or penile penetration and 197 children who denied previous sexual abuse. Statistical analyses were conducted to compare the mean values and hymenal symmetry between groups as well as to determine the sensitivity and specificity of various cutoff points., Results: Comparison of the mean diameters demonstrated that children with a penetration history had a significantly larger transverse opening than nonabused children when examined in the knee-chest position (5.6 vs 4.6 mm). However, there was extensive overlap in measurements between the 2 groups. No significant differences were noted between groups in the size of the vertical diameter, the amount of tissue present inferiorly or laterally, or the symmetry of the hymen in either position. Children with previous penetration were more likely than nonabused children to have a horizontal opening measuring >6.5 mm in the knee-chest position, but the sensitivity and specificity of this test were low (29% and 86%, respectively). Higher values had better specificity but very low sensitivity. Less than 1.0 mm of hymenal tissue was detected at 6 o'clock only in those with a history of penetration (100% specificity), but the sensitivity was low (1%-2%)., Conclusion: Most hymenal measurements lack adequate sensitivity or specificity to be used to confirm previous penetration. Less than 1.0 mm of hymenal tissue at 6 o'clock was detected only in victims of abuse, but the usefulness of this test is limited by the rarity of this finding.

Objective: Because physicians customarily obtain histories before examining children in cases of possible sexual abuse, and because the resulting diagnostic opinions can influence important social and legal decisions, we investigated whether clinical histories influence physicians' interpretations of girls' genital findings., Design: In mailed questionnaires, 1387 randomly selected Fellows of the American Academy of Pediatrics and all 802 members of four professional groups concerned with child abuse or pediatric gynecology were asked to interpret seven simulated cases. Respondents were asked to interpret seven additional cases in separate questionnaires mailed 4 months later. Both sets of cases involved the same seven photographs of girls' external genitalia. However, in six of the seven case pairs, the histories in the two questionnaires differed in the extent to which they suggested sexual abuse. In the remaining (control) pair, the same history was presented in both questionnaires., Results: Of 2189 physicians, 1114 (50.9%) responded. Responses from 604 physicians (54.2%) were eligible for analysis. Overall, the genital findings were interpreted most consistently by the most experienced physicians and least consistently by the least experienced physicians. The proportion of physicians whose interpretations of a photograph reversed in the direction suggested by the change in the associated history from "no indication of abuse" to "probable abuse," or vice versa, ranged for experienced physicians from none to 5.6%; for moderately experienced physicians from 1.6% to 19.8%; and for inexperienced physicians from 3.6% to 27.2%. This difference between the experience groups was statistically significant in four case pairs. Mean interpretation scores for genital findings changed significantly when the histories changed in two case pairs for the experienced physicians, in five pairs for the moderately experienced physicians, and in all six pairs for the inexperienced physicians., Conclusions: In some cases and especially for less experienced physicians, diagnostic expectation appears likely to influence physicians' interpretations of girls' genital findings. Physicians should be alert to the possibility of diagnostic expectation bias and its potentially serious social and legal consequences.

Objective: To determine prevalence, patterns, and correlates of voluntary flunitrazepam use in a sample of sexually active adolescent and young adult women 14 to 26 years of age., Design: Cross-sectional survey., Setting: University-based ambulatory reproductive health clinics., Patients or Other Participants: There were 904 women self-identified as white, African-American, or Mexican-American., Interventions: None., Main Outcome Measure: Lifetime, frequency, patterns, and physical effects of flunitrazepam use., Results: Lifetime use was reported by 5.9% (n = 53) of subjects, with frequency of use ranging from 1 to 40 times. Flunitrazepam was taken most often with alcohol (74%), and 49% took this substance with other illicit drugs. Logistic regression analyses controlling for age and race/ethnicity found that users were significantly more likely than were nonusers to report lifetime use of marijuana (odds ratio [OR] = 3.6) or LSD (OR = 5.2), having a peer or partner who used flunitrazepam (OR = 21.7), pressure to use flunitrazepam when out with friends (OR = 2.7), and a mother who had at least a high school education (OR = 2.6). Finally, 10% of voluntary users reported experiencing subsequent physical or sexual victimization., Conclusions: Voluntary use of flunitrazepam is becoming a health concern to sexually active young women who reside in the southwestern United States. Young women who have used LSD or marijuana in the past or who have a peer or partner who used this drug appear to be at the greatest risk.

Objective: To identify racial/ethnic differences in prevalence and the factors that influence decisions to breastfeed among adolescent mothers., Methods: A total of 696 Mexican-American, African-American, and Caucasian adolescent mothers

Objectives: To identify characteristics of patients 18 years of age and younger who would and would not consider using levonorgestrel implants (Norplant) for contraception and to isolate potential barriers to its use., Study Design: Survey of 323 adolescents attending family planning or obstetrics clinics between April 29 and October 27, 1992. For purposes of analyses, patients were stratified by their willingness to consider using Norplant. Statements about Norplant that differentiated between groups were considered significant barriers. Additional analyses were conducted for the sample, stratified by pregnancy status, race and ethnicity, parity, and Norplant class attendance., Results: Sixty-four percent of participants stated that they would be willing to consider using Norplant. These adolescents were significantly older, were more likely to already have given birth or have had abortions, planned to delay (additional) childbearing for 5 or more years, aspired to receive college educations, and reported lower annual household incomes than did adolescents unwilling to consider using the device. Identified barriers to Norplant use included misinformation, perceived advantages, physical aversions, perceived efficacy, fertility concerns, social influences, and concerns about safety and side effects., Conclusions: Misperceptions and concerns about safety and side effects will prevent many adolescents from using Norplant. Recent negative publicity surrounding its use will intensify this problem. Health care providers must work to remove these barriers so that sexually active adolescents can make informed decisions about contraceptives.

Objective: To document the effects of aging on hymenal morphology during the first 3 years of life in a cohort of nonabused girls., Methods: Using a longitudinal design, we examined and photographed the external genitalia of 134 girls at 2 months or less and near 3 years of age; 42 of these girls were also examined near 1 year of age. The prevalence of each hymenal characteristic was calculated at each time, and differences were analyzed using the z statistic and McNemar change tests. Measurements of transhymenal diameters and the inferior rims were compared using a paired t-test., Results: Hymenal configuration in 65% (87 of 134) of the subjects changed between birth and 3 years, usually from annular or fimbriated to crescentic. External ridges observed at birth usually resolved by 3 years, whereas intravaginal ridges were observed more often in 3-year-olds (P = .00). Analysis by race showed that the prevalence of both superior and lateral notches decreased in whites, whereas the prevalence of intravaginal ridges changed only in blacks (P = .00). Sixty-eight percent (15 of 22) of the tags present at birth were not observed at 3 years, while nine tags formed during this period. Changes observed between 1 and 3 years included increases in the mean horizontal (P = .00) and vertical (P = .02) transhymenal diameters and in the prevalence of the crescentic configuration (P = .04)., Conclusions: Changes in hymenal morphology, which may vary by race, occur in the first 3 years of life. Alterations are more pronounced in the first year than in years 2 and 3. Physicians should understand the effects of aging on the hymen's appearance to differentiate normal development from post-traumatic or infectious changes.

Objectives: Levonorgestrel implants (Norplant) have recently been approved for use in the United States. Adolescents may be especially suited for this method of contraception because of its long duration of action and lack of dependence on patient compliance for efficacy. To date, however, its use in young patients has not been investigated. This study was undertaken to compare side effects and satisfaction with this new method during the first 6 months of use among adolescents and adults., Methods: Twenty-one adolescents 18 years of age or younger and 30 adults 19 years or older participated in this study. Information on side effects and satisfaction was obtained from clinic records and a structured interview conducted 6 months after insertion., Results: The most frequent reason adolescents gave for selecting Norplant was convenience. None of the adolescents were upset by the insertion process or by its appearance in the arm, although 10 (48%) reported that it was visible. The most frequent side effect reported by both adolescents (71%) and adults (53%) was abnormal menstrual bleeding. Weight gain was reported by 8 adolescents (38%), 3 of whom attributed it to an increase in their appetite. Other side effects commonly reported by adolescents included emotional disturbances (33%) and headaches (38%), whereas adults reported acne (27%) and mastalgia (37%). Only 1 adolescent (5%) and 1 adult (3%) reported experiencing no side effects. A similar percentage of adolescents (8%) compared with adults (6%) requested removal of the implant because of side effects during the 6-month period. Overall, satisfaction was expressed by 86% (18/21) of adolescents, all of whom stated that they preferred Norplant to their previous contraceptive method., Conclusions: This investigation demonstrates that levonorgestrel implants are well tolerated by most young patients. Clinicians involved in the care of adolescents should consider Norplant as an appropriate option of birth control for this population.

The increase in the number of prepubertal girls who require evaluation of possible sexual abuse creates a need for detailed information, not previously available from cross-sectional studies, on the influence of aging on the hymen's appearance. This study was undertaken to evaluate and document, using a longitudinal design, changes in the hymen's morphology in 62 girls without a history of sexual abuse between birth and their first birthday. Labial agglutination extensive enough to obscure the inferior half of the hymen was observed in 5 girls (8%) at 1 year of age. Thirty-three (58%) of the remaining 57 infants experienced a marked decrease in the amount of their hymenal tissue between birth and 1 year. Significantly more infants at 1 year of age had a crescentic configuration (0% vs 28%), and significantly fewer had an external ridge (82% vs 14%) as compared to the newborn period. An annular hymen with a central or ventrally displaced opening progressed to a crescentic hymen in 13 children by 1 year, 77% (10/13) of whom were observed to have a notch (cleft) at the 12 o'clock position on the earlier study. A superior notch appeared for the first time in 9 girls. Lateral notches resolved in 5 cases and persisted in 2. Inferior notches between the 4 and 8 o'clock positions were not observed at birth or 1 year. Hymenal tags resolved in 2 instances, persisted in the same location in 2, and appeared for the first time in 4 cases.(ABSTRACT TRUNCATED AT 250 WORDS)

The recent increase in requests for genital examinations in girls who may have been sexually abused has necessitated detailed information not previously available on normal anatomy of the prepubertal girl. This study was undertaken to document the genital anatomy of 211 girls between the ages of 1 month and 7 years who presented for well child care or nongynecologic complaints and who had no history of sexual abuse. Each child's genitalia was examined and photographed, with findings reported reflecting those observed photographically. The study population consisted of 36% blacks, 33.6% white non-Hispanics, 29.9% Hispanics, and 0.5% Asians. Subjects had a mean age of 21 +/- 20.6 (SD) months. Extensive labial agglutination sufficient to obscure the hymen was noted in 5% (10/211) and partial agglutination in an additional 17% (35/211). A significant difference was noted in hymenal configuration by age, with a fimbriated hymen the most common type (46%) in infants aged 12 months or younger and a crescentic hymen the most common (51%) in girls older than 24 months (P less than or equal to .001). No significant difference was noted in hymen configuration by race. Hymenal bumps (mounds) were observed in 7%, hymenal tags in 3%, vestibular bands in 98%, longitudinal intravaginal ridges in 25%, and external ridges in 15% of subjects in whom the anatomy under study could be visualized. Hymenal notches (clefts) occurred superiorly and laterally on the hymenal rim but none were found inferiorly on the lower half of the hymen. A narrow rounded hymenal ring with a transection was observed in only 1 (0.5%) of 201 subjects and was not considered a normal finding.(ABSTRACT TRUNCATED AT 250 WORDS)