False Allegations of Child Abuse

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:

  • A case of a baby who was killed when another child jumped off a bed and by a freaky but plausable mechanism, already known from other cases, ruptured the baby's heart. The autopsy matched the family's story perfectly (even elegantly), but the case was unusual and there was dissension in the scientific literature about this kind of injury. I submitted a written report, and following the local medical examiner's testimony and cross-examination, and prior to the defense's time, the judge dismissed the case.
  • A teenaged boy who apparently had common jock itch, which was mistaken by a paraprofessional for herpes, and an adult was charged with causing this by sodomizing the boy; I wrote a letter and have heard no more since.
  • A young teenaged girl made assorted accusations, some clearly untrue, against her natural father, who was in a custody battle with the mother. The local child-protection expert evidently mistook the white line that sometimes runs from from the posterior aspect of the vulva to the anus as a healed laceration. This is the linea vestibularis, present in 10% of young women. After I pointed this out, I heard nothing more.
  • Not child abuse, but similar... A man died of a heart attack while smoking in his chair, and burned after he died. Sonja Casey, was wrongfully (and ridiculously) convicted of a torch murder. My letter written in an attempt to obtain her release got me a paragraph in the Wall Street Journal. She was released.
  • Not child abuse, but similar... A woman died with extremely advanced Alzheimer's, who had been fed by gastrostomy for 7 years (she hadn't known to eat for all this time), Finally she developed the cachexia that happens to these people at the very end. Death was actually due to heart failure, and it was inevitable considering the extremely advanced Alzheimer's. Although there was food in the gut, plenty of feces in the colon, and plenty of inner bodyfat, an activist pushed and the pathologist was willing to call it death by intentional starvation. Incredibly, the state prosecuted the caretaker for murder. The trial was highly political, with a state legislator at the prosecutor's table. I got to tell the court that the medical examiner had also overlooked two obvious brain infarcts that most second-year medical students would spot easily. The defendant was acquitted of the murder charge.
  • Not child abuse, but similar... A teenaged boy argued with his girlfriend's father in a weightroom. Later that day, the father complained of chest pain and died. A huge blood clot was found in a major coronary artery. The local medical examiner took a photograph of what appeared to be a normal skull marking which happened to be a bit prominent in the dead man, and a bit of blood from the extraction of the brain. He called the marking a fracture, though he did not give evidence that the bone fragments were separable, and called the death a murder from being struck on the head. As a result of this travesty, the teen did two years in jail. My consultation on the case helped with his ultimate acquittal.
  • A baby who died of SIDS also had a full diaper and was not found for 8 hours. Some red apparent abrasions were identified by the nurses when the body was undressed and washed. These were not in an assaultive pattern. Microscopy showed these to be the work of fecal clostridia, which were obvious on the slide, where they formed a bacterial lawn over the lesion. I was shocked and dismayed that the local pathologist wouldn't recognize this. I decided that he was either incompetent or just crooked. The prosecutor had nothing to say about the scientific stuff, but actually screamed at me because I read "Playboy", complained about my link to VOCAL, and made the false allegation that I was linked directly to sites for pedophiles. I asked to show the court that this was not true, but was not allowed to do so. This is how low some prosecutors can sink in a politicized case. For some reason, my testimony was eventually ruled inadmissable and the defendant was convicted.
  • I have reviewed two cases from Rhode Island in which a nurse-activist has testified, falsely, that her review of the literature indicates (in one case) mere failure of the anus to wink when the buttocks are spread (curiously she calls this the "relaxation response") is a good indicator for buggery, and (in the other case) labial adhesions are a strong sign of abuse. At the time she gave testimony in each case, the actual refereed medical literature indicated both claims were NOT true. This is at best a surprising display of ignorance from somebody who should know better, and at worst criminal perjury. On the evidence I have seen so far, this has resulted in one wrongful, and one dubious, conviction. Both men are in prison.
  • A man, also in Rhode Island, has served 11 years in prison because of testimony by a pediatric resident. Errors included saying that an opening in the hymen of 1 cm was excessively large for a six year old girl (it's just within the 2 SD), that scarring could be produced by rubbing, that a child who easily accepted an examiner's digital anal penetration had probably been abused, and that skin tags on the anus suggested sexual abuse. The child had a groin rash, which I thought was a better explanation for the "scarring" (sounded like dermatitis) on the perineum. And she had been receiving suppositories, which explained why she permitted anal digital penetration more easily than did other children. He tells me the accusation followed his finding his wife in bed with another man. I wrote him explaining the mistakes, and I have asked him to have the physician who testified against him review her testimony and reconsider in light of today's improved knowledge.
  • A man in the southern US was accused by his sixteen-year-old daughter of many episodes of penetration. The examiner testified that a pattern of scarring was seen at the edges of the ruptured hymen which indicated that intercourse was not consensual. She could not describe the identifying features of this pattern. During cross-examination, she admitted this was not something she could find in a textbook, but became very indignant, saying her education was not on trial here, that she doesn't memorize textbooks, and so forth. Of course, you can't tell from a physical exam whether consent was given. I told this to the interested parties. Outcome unknown.
  • Except for two cases which went through a referral agency, I've handled these pro bono.

    Addendum: July 2003.
    Understanding the Sex Abuse Exam

    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

    Nonspecific findings (Class II).

    Suspicious for abuse (Class 3)

    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.

    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.

    Under development

    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 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?"
    American Family Physician
    James K. Ribe, Pathologist. Outstanding review.

    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.


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