Child abuse is a problem that is frequently underdiagnosed. Recognition that underdiagnosis of abuse exists has produced a high zeal for identifying cases of child abuse, which has inevitably produced cases of overdiagnois. Overdiagnosis of child abuse is as catastrophic as underdiagnosis.
-- Am. J. Clin. Path. 123 (S) : S-119, 2005
When I was an associate medical examiner for Jackson County, I got a lot of enjoyment from assisting with the prosecution of real criminals, and putting bad people where they belong.
When child abuse has really occurred, it is a dreadful thing, and the perpetrators deserve to be punished as examples to others.
It is not my purpose to address, here, the custody-battle tactic of making a groundless accusation of sexual abuse or domestic violence. Click here for information and get a good lawyer. One group that handles this sort of case is Stuckle and Ferguson. ("No charge is easier to make against an innocent person and more difficult to disprove. The word of a child, whether mistaken, coached, or the result of a deliberate lie, is all that it takes to ruin lives.") Click here, and here for accounts of men who are still incarcerated despite the children having later admitted that their testimony was false. Click here for the American Academy of Child and Adolescent Psychiatry practice parameters, which acknowledges that children sometimes lie and are sometimes coached. Click here for the National Center for Reason and Justice, a group that helps people false accused of sex crimes. Click here for the 2000 Harvard Law School conference on the 1980's Day Care Child Sex Abuse Phenomenon. Click here for the conference notes. It is very easy to find accounts of children who made coached or malicious accusations online. Click here to see how many ordinary citizens reading an obscure blog know someone to whom this has happened. Click here for Law Hum. Behav. 30:561-70, 2006, in which a group found that in a simulation, adult jurors could not tell whether a child was telling the truth or had been coached to lie. Link is now down, let me know if there is another version posted: A prosecutor's digest, including an 2009 appeals court opinion, "If the only evidence of guilt is a child victim's out-of-court statement admitted under section 90.803(23), and if the child has recanted the accusation in court, the trial court must grant a motion for judgment of acquittal." Click here for the report following the Wenatchee fiasco, documenting extensive unprofessional conduct by police and social workers. Click here for "All parents are liars until proved otherwise", the mentality that I have found pervasive in child-protection circles. Click here for the conservative "Renew America" -- "Yes, some chidren do lie." Social workers and child protection people see their role as "validators" -- all accusations are assumed to be true. Click here for an account of inappropriate techniques used by "therapists" and "investigators" to get children to lie. ("Draw a picture of how you feel about Pa's genitals.")
Click here for the Journal of the American Medical Association's review of criteria for sex abuse in prepubertal girls.
My concern is with errors by examining physicians and sex-abuse nurse examiners (SANE nurses). The system is imperfect, and occasionally an innocent person is accused on bad medical evidence. Once the initial error is made, it is very hard to stop the process.
The refereed medical literature recognizes the Alice-in-Wonderland nature of many sexual abuse workups in today's world, even in oh-so-proper England. ("Claims of innocence [are] taken as evidence of guilt, and information [is] interpreted in a manner that fit[s] only this presumption while factual evidence to the contrary [is] ignored." -- Medicine, Science & the Law 42(2): 149-59, 2002). In 1997,Professor Vidmar at Duke Law School documented how many jurors acknowledge that they cannot be impartial or ignore the presumption of the defendant's guilt in a sex abuse trial (Law & Human Behavior 21(1): 5-25, 1997).
In late March, 1996, I went to court in another state to help a working-class family which had contacted me through this home page. A 2 1/2 year old girl had obvious nonspecific vulvovaginitis, with a mix of flora on gram stain which included some gram-negative diplococci, mostly extracellular. The child was just getting over chickenpox, which might have triggered the vulvovaginitis. The pediatrician, a self-styled expert on child sexual abuse, found an "apparent healed laceration" at the 2-3 o'clock position in the hymen, no further description. Cultures and DNA probes were negative for gonorrhea. Cultures of all family members, including the grandfather, a former chief flight mechanic on a Navy ship, were negative for gonorrhea. The child denied any sexual stuff during the medical exams. The child struggled and cried a lot during the child abuse exams and cultures. A smear of the "purulent" exudate showed no white cells, only a lot of epithelial cells. Afterwards, she talked about "monster(s)" and "doctor monsters", and said, "The monster(s) put a bone in my mouth and the hair choked me" (the cotton-tipped swabs, dummies) and said "the monster had a mask" (duh).
On the strength of this evidence, the Department of Human Services told the court, "The perpetrator has been identified" as the grandfather, the evidence being that he owned a Hallowe'en mask. They told him that if he admitted his crime and got counselling, the child would be restored to the mother. The entire family refused. I was the sole medical witness for the defense, which I took for free.
I poked around the medical library, confirmed and improved on what I already knew, and was able to testify that (1) 3% of girls had a little nick in the hymen at the 2-3 o'clock position, just naturally, and around 20-30% of three-year-old girls have such innocent nicks ("apparent healed lacerations", I thought), which are no more indicative of trauma than is a double-chin; (2) relying on a gram stain in this situation was totally unacceptable as a means of diagnosing gonorrhea, and the bugs were probably Neisseria sicca or one of it kin, common commensals, which tend to be extracellular while gonorrhea bacteria are usually mostly intracellular; (3) the CDC guidelines specifically direct physicians NOT to rely on a gram stain in this situation; (4) if this were gonorrhea, there would have been white cells in the exudate, and the abundance of epithelial cells suggested "resolving chickenpox" to me; (5) the negative culture and DNA probes satisfied me that this was almost certainly not gonorrhea; (6) there are published, empirical criteria for the physical examination of a girl suspected of having been sexually abused, and the "expert" had utterly failed to address or meet these; (7) often you never find the cause of vulvovaginitis in a child. (I should have had the statistic, which is 70%; I'm sorry I didn't.)
We won.
The sexual abuse exam is now recognized as the business of the pathologist, whether the patient is alive or dead. A major review of the situation in Italy appears in Am. J. For. Med. Path. 28: 163, 2007, and there's a chapter in Dolinak's textbook.
From now on, I am
available as a medical expert in other cases in which I'm convinced
that an allegation of child abuse is false.
I do not charge for an initial chat, and I do the cases where the
person is clearly innocent pro bono.
Please place links to my page as
you think would be useful.
Dean Tong
False Allegations
Family
Rights Organization National Taskforce
Gary Preble is an attorney at 2120 State Avenue NE, Olympia, WA
98506, 360-943-6960, preble@olywa.net.
Yet another resources is Tony Barreira, barr@mail.autobahn.mb.ca and Parents Helping Parents, 35 Tallmara Street, Winnipeg MB R2R 2G1 CANADA 204-256-8912.
Men's HOTLINE : 512-472-3237 : men@menhotline.org
807 Brazos, Suite 315 : Austin, Texas 78701
A service of the Men's Health Network : Washington, D.C.
Men's Health Network: mensnet@CapAccess.org
Edward Nichols MSW: a social worker with an interest
in false allegations of sexual abuse EZTherapy@aol.com>.
To Receive Free Report:
Email: eztherapy@aol.com and request "Free Report"
Report will be sent by return email as an attached file.
Wayne Gossman MD, a psychiatrist and internet friend of mine, practices in Alabama. His phone number is 205-313-7246.
Merihew
Law Group -- attorneys specializing in false sex abuse accusations by children, in Seattle.
Alec Rose, Los Angeles
Addendum: I receive many inquiries as a result of this
page. Regrettably, many of the charges turn out (in my opinion,
after considering the evidence) to be true. (If you're a
"child protection activist" planning to send me one of those
anonymous E-mails, please be reassured that I'm really not
a "butcher", "murderer", "idiot" or whatever.)
I cannot help you unless the case against you is based on bad medical testimony.
From working in this area, I've reached the conclusion that most doctors don't want to go against the local prosecutors, or defend somebody accused of a vile crime, no matter how silly the charges. Since I'm not a family or political man, I can do this more freely than others, and enjoy the challenge.
Since I posted this, I've had additional cases of false accusations, including:
Except for two cases which went through a referral agency, I've handled these pro bono.
This is offered with the hope of helping both prosecutors and defense attorneys recognize errors by physicians that might cause a miscarriage of justice either way.
My focus is on tissue reactions. I have performed eight clinical rape exams as a team member, including two on children, while a resident. I think I am current in my reading on how to interpret physical findings in suspected abuse. Unlike two decades ago, there are clear standards, and they match what I know about disease and injury. And I probably have a better grasp of how tissue responds to injury than do the clinicians who have made the clinical guides.
Here is a list of Adams proposed classification of anogenital fidnings in children, from Pediatrics 94: 310, 1994. I chose this because it's been available for almost a decade and ought to be familiar to anybody claiming to be an expert. I have added my notes on WHY these make sense.
In May, 2007, the distingished journal Pediatrics published online (e1094) an article about the ability of the hymen to heal. The authors are John McCann and his teammates at the Child and Adolescent Research and Evaluation center at UC Davis. If you e-mail me, I will be glad to send you a copy. It seems to be a good study, with many photos, and I believe it will be of great importance in these trials in the years to come. The authors emphasize the remarkable ability of the hymen to heal, and show a photo of an 8-month-old baby with a transection which healed with only some neovascularity. (Notice that this is not "normal", any more than a flat red scar on a face after a knife wound is "normal"). You do need to examine all the data, including what the authors themselves do not point out. Among 39 prepubertal girls, 16 had full transections of the hymen that extended into the surrounding tissue. (This is what a reasonable person would expect after full penetration of a prepubertal child.) There were only 4 transections without such extension.) Among these, the vast majority of hymens that had healed were not "smooth", not "continuous", and not "delicate". This supports the common-sense idea that if a prepubertal girl is fully penetrated by an adult's penis, the hymen is unlikely to appear normal.
Some other recent articles that have bearing and that you may encounter are:
Life has taught me to trust physical evidence above what anybody tells me, no matter how seemingly "sincere". You'll have to ask somebody else how often a child is coached to tell a fabricated story during a divorce or custody battle.
Although this is mainstream... as of this writing (July 2003), the criteria for the physical exam in suspected child abuse have been almost impossible to find online. (It's no surprise that most people who post on the internet are concerned with politics instead of with truth.) For example, the 2001 proposed classification was only located at a relatively obscure Filipino site here. The Filipinos included a much-deserved thank-you to Dr. Joyce Adams.
Proposed Classification of Anogenital Findings in Children (1994)
Normal: Class I
Suggestive of Abuse / Penetration (Class 4)
Clear Evidence of Penetrating Injury (Class 5)
Note 1: The sulcus is the area around the glans of the clitoris. Redness here means nothing.
Note 2: These are common normal variants, like having a split in your chin. If the bump is about the same color as the nearby tissue, it can't be a scar. I would have added that notches in the anterior half of the hymen (i.e., 9 o'clock to 3 o'clock with the patient supine) mean nothing.
Note 3: The anterior hymenal rim may be very slim or absent as a normal variant; this was the case with JonBenet Ramsey and the pathologist recognized it as normal.
Note 4: I read testimony of one examiner who said that thickening implied scarring and thus prior abuse. This flunks introductory "Pathology" in medical school. Scar usually contracts. Estrogen renders the hymen thicker and more redundant / wrinkly so it stretches easier.
Note 5: Diastasis ani means the visible portion of the anal opening appears slightly open when the buttocks are spread. This means nothing. The mucosal folds (i.e., the little stretchable wrinkles that are present when the anus is not distended by stool) in front and back are often much more shallow than elsewhere, and this is a normal variation. I have seen both of these called evidence of sexual abuse.
Note 6: A tag is a bit of redundant skin. You can see skin tags around the anus on anybody, or on the necks or elsewhere on the skin especially of older folks. I have had two cases of physicians calling anal skin tags evidence of anal penetration. You have to wonder whether they've done many rectal exams on normal people. A "sentinal pile" is edema or venous dilation just below a fissure. If somebody has a fissue, it'll be obvious already.
Note 7: I would have added a few others. These should be
known to every physician, but evidently aren't.
A crescentic hymen, i.e., with no tissue at all between 11 o'clock and 1 o'clock
or thereabouts in the supine position, is a perfectly normal variant.
So is a cribriform ("sieve-like") with several openings.
I am not aware of any reason to believe that if the anal sphincter
relaxes but only after one second following spreading of the buttocks,
this indicates anal intercourse. However, as I've noted,
this was stated as fact
in court, leading to what seems to me to be a faulty conviction.
In one case, Division of Family Services people stated that
since the suspect had been given a routine urinalysis during
a doctor's office visit, it was proof that the doctor suspected
venereal disease. I hope nobody who lives in your community is this ignorant.
One of the toughest calls is the "normal" exam when the child claims
abuse. In evaluating these claims,
there are a couple of things to consider. Second, the ring around the hymen is quite sensitive in a
pre-pubertal girl, and touching it will hurt considerably.
Third, fondling and digital penetration of just the vestibule (a girl will
probably still call this the vagina) and/or anus isn't going to leave
any physical changes except perhaps transient redness.
Fourth, despite "it's normal to be normal",
I cannot believe, and am not aware of any evidence, that penetrating
a girl of any age with an erect normal-sized
penis is likely to leave the hymen intact.
Note 8. Erythema simply means increased blood
flow, as when in blushing or exercise or after scratching.
In 1988, a sex abuse examiner in Rhode
Island noted erythema of the posterior mucosal surface of the vulva
on a six year old girl. She
testified that this was likely the result of digital penetration of
the vulva six months previously. This is even stupider because
the child had a groin rash, likely from poor hygiene.
Note 9. Increased vascularity means
that the blood vessels, i.e., the surface veins, are easier to see.
This usually reflects the changes of chronic inflammation,
in which the epithelium may be thickened and the mucosa may be edematous
and infiltrated by white cells. On the skin, we call this a chronic
dermatitis. Increased vascularity is also seen in a healing true scar.
The two are easy to confuse, especially if the examiner doesn't reflect
that a scar must be localized and must have been preceeded by abundant hemorrhage.
Rubbing could produce a dermatitis / mucositis, as could any other kind
of irritation, inflammation, or infection. However, this won't last more than
a few days.
Note 10. Labial adhesions are fibrin or other
condensed protein connecting the labia. It's fairly common in young girls
and evidently "just happens". Of course, scabbing following severe abuse
could do the same thing.
One of our medical students has a daughter who was diagnosed as an intersex
by the family doctor and the family was on its way to genetic counselling.
Asked for my opinion first, I demonstrated the ease
with which labial adhesions could be separated with a wet Q-tip. The term
"friability" has different meanings in clinical medicine ("bleeds easily
when manipulated") and pathology ("crumbly").
Note 11: There's more tissue here than usual.
This can be normal, or the result of
inflammation from another cause, or the result of deformation
of the hymen from trauma.
Note 12: I believe the authors are referring
to the posterior portion of the hymen.
Note 13: Nonspecific vulvovaginitis in children
can result from systemic illness, poor hygiene, or "just happen".
Finding gram-negative diplococci on gram smear is not evidence
of gonorrhea in the female. A negative culture / gene probe rules
out untreated gonorreha.
Note 14: A genuine anal fissure is very painful.
This will not be a surprise finding on examination. Resources suggest
all fissures are longitudinal, i.e., radiating out from the anal opening;
however, deep ones can be transverse.
Note 15: Flattened anal folds would only result
from abuse which would produce additional evidence trauma, with deformation
of the underlying connective tissue (marked remodelling in a scar)
or marked associated local edema (obliterating
the folds by stretching).
The idea that fondling will flatten
mucosal folds is as ridiculous as claiming that rubbing your lips will
lead to an area that doesn't wrinkle when you pucker your mouth.
Note 16: Thickening (i.e., increased prominence) of the
anal folds would be typical of a chronic dermatitis / mucositis.
The trauma would have to be equivalent to what would produce a rash
or signs of injury on the lips.
Overall Assessment of the Likelihood of Sexual Abuse (1994)
Class 1: No evidence of abuse
Class 2: Possible abuse
Class 3: Probable abuse
Class 4. Definite evidence of abuse or sexual contact
By the time these were written, the literature shows they were common knowledge.
In my opinion, any physician or other examiner
offering medical testimony substantially
at variance from these proposed standards after the year 1994 was doing sub-standard work.
Development of the scheme continued. Here is the 2001 version, from Child Maltreatment 6(1): 31. 2001.
Anogenital Findings on Examination (2001)
Normal
Normal Variants
Other Conditions
Non-Specific Findings
Suggestive of Abuse
Clar Evidence of Blunt Force or Penetrating Trauma
Overall Assessment of Likelihood of Abuse (2001)
No indication of abuse
Possible abuse
Probable abuse
Definite evidence of abuse or sexual contact
Please click here to see the Adams 2003 classification,
as it was originally placed online by the medical students at Harvard.
Normal hymen anatomy: Pediatrics 89: 387, 1992.
"Have we been misled?"
Elaine Lehman, FAST, False Allegations Solutions Team, 4514 Baptist Road, Taneytown, Maryland 21787, Phone 410-756-9067; FAX 410-756-9068. I am told the group does not charge.
Click here
for their website.
A white line running posteriorly
from the posterior forchette, over the skin in the midline, is
a normal variant. As I noted above, I've seen this called a "scar" and thus
proof of severe abuse. It is
a normal anatomic variant.
First, the tissues
of the vulva, including the hymen, can heal minor trauma
after a few weeks with no scar.
I've seen a few cases in which an examiner finds no abnormality whatsoever,
and signs the case out, "Normal examination, consistent with sexual abuse."
In pathology (and so far as I know, in every other branch
of real medicine), when I say "consistent with", I mean there is some
solid physical evidence that this is the case. I was taught to sign
out a negative rape / sex abuse exam, "No physical evidence of..."
If these examiners were honest (and I use this word after reflection),
they would say instead, "No physical evidence of abuse. NOTE:
A normal exam does not rule out fondling or some other forms of sexual abuse."
NOTE by me: This seems much more helpful to me than simply writing, "Normal exam consistent with sexual abuse."
I think that these criteria should now be considered standard, and I would
question the integrity of an examiner who deviates substantially from this outline.
falseallegations.com
American Family Physician
James K. Ribe, Pathologist. Outstanding review.