Understanding the Sexual Abuse Exam

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)

Nonspecific findings (Class II): May be caused by sexual abuse or other medical conditions.

Suspicious for abuse (Class 3)

Suggestive of Abuse / Penetration (Class 4)

Clear Evidence of Penetrating Injury

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.

They also list the following as unlikely to be due to abuse: