Ed Friedlander MD
This site will provide a reliable, truthful to the "why"'s of the pediatric sex abuse exam.
It should assist physicians in evaluating what they see. It will also assist attorneys and members of the public who are required to evaluate reports.
Here is the proposed classification of anogenital findings in children as given by Adams (1994):
Normal (Class I)
Intravaginal ridges or columns
Increased erythema in the sulcus
Hymenal tags, mounds, or bumps
Elongated hymenal orifice in an obese child
Ample posterior hymenal rim (1-2 mm wide)
Estrogen changes (thickened, redunant hymen)
Diastasis ani / smooth area at 6 or 12 o'clock in perianal area
Anal tag /thickened fold in midline
Nonspecific findings (Class II): May be caused by sexual abuse or other medical conditions.
Increased vascularity of vestibule or hymen
Rolled hymenal edges in the knee-chest position
Narrow hymenal rim, but at least 1 mm wide
Flattened anal folds
Thickened anal folds
Anal gaping with stool present
Venous congestion of perianal tissued, delayed in exam
Suspicious for abuse (Class 3)
Immediate anal dilitation of at least 15 mm with stool not visible or palpable in rectal vault
Distorted, irregular anal folds
Posterior hymenal rim less than 1 mm in all views
Condyloa acuminata in a child
Acute abrasions or lacerations in the vestibule or on the labia (not involving the hymen), or perianal lacerations
Scar or fresh laceration of the posterior fourchette with sparing of the hymen
Scar in peri-anal area, must take history into consideration
Hymenal transections or lacerations
perianal laceration extending beyond (deep to) the external anal sphincter
Laceration of posterior fourchette, extending to involve hymen
Scar of posterior fourchette associated with a loss of hymenal tissue between 5 and 7 o'clock.
The authors warn that this classification "does not represent a consensus of medical experts regarding the classification of findings with respect to abuse."
Here is a standard table for evaluating the overall likelihood of sexual abuse.
Notice that this table does not take into account the setting in which accusations are made, i.e., was there a previous custody battle?
In evaluating a report of sexual abuse, look for the following:
How was the exam performed? If the child is not relaxed, or labial traction and separation is not performed, the hymen may seem to be absent. Warm water may need to be applied to see the tissues clearly if they are stuck together. Blood and mucus may need to be wiped away. Was gonorrhea or chlamydia diagnosed? Only confirmed cultures are acceptable in court. Britton and ___ agree. Gram stain is nonspecific in the female at any age. Nonspecific bacterial infection of the vulva can look horrible, but it is quite common in young girls and does not indicate gonorrhea unless there are cultures to prove its cause. Was colposcopy performed? Are there photos? colposcopic examination and photographic documentation of the findings seems to be the standard of practice in the developed world. Adams and colleagues (1994) went through their files of 262 cases since July 1986 with convictions, and found only 18 without photos and 8 with only nonmagnified photos. Nowadays video is available as described by Finkel (1998).
It's normal to be normal. Fondling is not going to leave scars. Penetration of the hymen of a four-year-old girl by an adult man's penis will surely rupture the hymen. The literature is divided on the question of whether the latter can heal without a scar. If this is true, then the most horrible sexual abuse can give a normal exam, and physical findings can never exonerate a defendant. As a pathologist, I don't believe this. It doesn't make sense, and I have been unable to find a follow-up study showing that a Class V laceration has healed without a scar visible on colposcopy. This tells me something.
Some sex-abuse examiners never sign out an exam, "Physical findings do not match the story", although this is routine in forensic pathology of child abuse victims and.
Hymel and Jenny list the differential diagnosos of child sexual abuse.
Seborrheic, atopic, or contact dermatitis
Lichen simplex chronicus
Perianal venous congestion
Prominent medial raphe
Midline anal skin tags
Seat belt or motor venicle accident injry to genitalia
Postmortem anal dilation
Perinatally acquired warts
Gonorrhea or syphilis not transmitted congenitally
HIV not trnasmitted neonatal or intravenously
Pregnancy, not consensual with a peer
Acute unexplainedaotenital injury or isolated hymenal trauma
Definite unexplained hymenal trnasections, healed or acute, "absent hymen"
I would have added bite marks, petechiae, avulsions, hematomas, or contusions in the vulva or the anus, wihtout some good explanation. -- Ed.
Other experts list "absent hymen" as merely "consistent with".
Anogenital herpes herpes, not neonatally transmitted or accompanying stomatitis
Posterior/lateral angular clefts or tears of hymen
Nonmidline anal scars or tags
Dilation of anal opening to >15 mm within 30 sec with no stool present
Suspicious for Sexual Abuse
Posterior narrowing (<1 mm) or asymmetry of hymen
Healed unexplained injry to fossa or posterior fourchette
Decreased thickened anal folds
Thick irregular labial adhesions not related to hygiene or diapering
I'm board-certified in both anatomic and clinical pathology. My primary focus is medical education, helping both student doctors and members of the public understand the "why"'s of tissue injury and disease. I have personally performed eight rape exams on living patients, including two on children. I have reviewed 300 others. I am a good general pathologist, though not a forensic pathologist. The latter certification would require me to devote myself primarily to government work, examining unnatural and questionable deaths. Though I've done this kind of work from time to time, my main interest has always been in teaching. You can visit my main area here.
An enlarged hymenal opening for age with other evidence of hymenal disruption.