Exam Findings in Child Sexual Abuse
Prepared by Satish Jetty, MD and Mark Feingold, MD for the AAP Ohio Chapter Committee on Child Abuse & Neglect, revised July, 2000.
1. Adams, J. A.; Harper, K.; Knudson, S.; Revilla, J. Examination findings in legally confirmed child sexual abuse: It's normal to be normal. Pediatrics. 1994; 94: 310-317.
This is a review of cases of sexual abuse with perpetrator convictions. Adams and colleagues report on 213 female sexual abuse victims between the ages of 8 months and 17 years 11 months, all of whose perpetrators were convicted of sexual abuse. Seventy-seven percent of the children had either a completely normal or non-specific genital exam, and only 23% had either suspicious or abnormal physical findings. In an analysis of the 29 cases in which the perpetrator confessed, there were 6 cases in which there was an admission of digital-vaginal penetration but none of these children had an abnormal exam. In contrast, abnormal findings, according to authors' strict criteria, were found in 4 of the 5 cases in which the perpetrator confessed to penile-vaginal penetration. The proportion of children with abnormal genital findings did not differ between those whose perpetrator had confessed, had pled guilty, or had been convicted at trial. The authors conclude that abnormal genital findings are not common among girls who have been sexually abused.
2. Adams, J. A.; Knudson, S. Genital findings in adolescent girls referred for suspected sexual abuse. Arch Pediatr Adolesc Med. 1996; 150: 850-857.
In this later study of 204 adolescent girls examined because of probable or definite sexual abuse, Adams found that normal or nonspecific findings were common, unless the abuse was recent. The authors further analyzed two subgroups. The first subgroup was made up of 25 girls who had never been sexually active, and in whose case the perpetrator confessed to molestation but not to intercourse, or where the accused was convicted by jury trial. Only 40% of these girls had abnormal genital findings. The second subgroup was made up of 37 girls who had been molested and who had experienced vaginal intercourse, either because they gave history of having had consensual sexual activity, or because they had a sexually transmitted disease, or because they were pregnant, or because their perpetrator admitted to having had sexual intercourse with them. Of these 37 girls, all of whom had been sexually penetrated (either voluntarily or abusively), only 49% had positive genital findings; the majority had normal or inconclusive exam findings. The authors conclude that "It is important for medical professionals who examine adolescent girls for possible abuse to educate the patient, the parents, and the law enforcement agencies that investigate these cases that physicians may not be able to tell, with certainty, whether a girl has had sexual intercourse, and that normal results of genital examination do not invalidate the patient's allegation of abuse." The authors urge us to dispel "the myth of the hymen."
3. Bays, J.; Chadwick, D. Medical diagnosis of the sexually abused child. Child Abuse Negl. 1993; 17: 91-110.
In a detailed literature review, Bays and Chadwick analyzed 21 different published studies. They point out that in these studies between 26% and 73% of girls, and between 17% and 82% of boys, who had been sexually abused had a normal physical exam. The exam may be normal even when the offender has confessed to penetration. They conclude that not only is a normal exam common in child sexual abuse victims even when the offender has confessed, but that healing of injuries due to abuse may be rapid and complete. Bays and Chadwick explain that a normal exam after sexual abuse can be due to a variety of causes: a long delay before seeking medical attention; forms of sexual contact that do not leave physical findings; the natural elasticity of the hymen and vaginal tissues; and different definitions of what constitutes an abnormal exam.
4. McCann J, Voris j, Simon M. Genital injuries resulting from sexual abuse: a longitudinal study. Pediatrics. 1992; 89: 307-317
McCann has documented that genital healing after sexual abuse may be rapid, which helps to explain why there may be no physical changes on a later examination.
5. DeJong A. R.; Rose, M. Legal proof of child sexual abuse in the absence of physical evidence. Pediatrics. 1991; 88: 506-511.
DeJong reviewed 115 child sexual abuse court cases from a 12 month period to determine the frequency and significance of physical evidence. A charge of vaginal rape was made in 88 cases, and of oral and/or anal sodomy in 67 cases. Eighty-seven cases (76%) resulted in felony convictions, even though physical evidence was present in only 23%. Felony convictions were actually obtained more often (79% of 85 cases) when there was no physical evidence than in cases where physical evidence was present (67% of 30 cases). Eight of the 10 cases without physical evidence that failed to result in conviction involved children younger than 7 years old, and the authors note that even with physical evidence available, cases involving the youngest victims had a significantly lower conviction rate (52%). They conclude that "Physical evidence was neither predictive nor essential for conviction. Successful prosecution, particularly in cases involving the youngest victims, depended on the quality of the verbal evidence and the effectiveness of the victim's testimony."
6. Levitt, C. J. Medical evaluation of the sexually abused child. Prim Care. 1993; 20: 343-355.
Levitt, commenting on the pressure put on the medical community to provide "hard proof" of sexual abuse, emphasizes that what the child says about what happened is often the most useful part of the total sexual abuse evaluation. Levitt supports the need to be cautious in drawing definitive conclusions based on very small differences in the hymnal opening. Minor differences can often be due to differences in examination technique or relaxation of the patient. The author supports using a conservative definition of a genital exam that is strongly suggestive or specifically positive for sexual abuse.
7. Muram, D. Child sexual abuse: Relationship between sexual acts and genital findings. Child Abuse Negl. 1989; 13: 211-216.
In this study, Muram reported on 205 girls 1 to 16 years old in whom abuse was believed to have occurred either because the perpetrator confessed, or the event had been witnessed, or the child had given a detailed history or had a positive psychological evaluation. Muram found abnormal genital findings in 46% of these children, but the majority, 54%, had neither definitive nor specific physical evidence of abuse. Sixty-five girls (32%) had normal-appearing genitalia, 45 (22%) had non-specific changes and only 95 (46%) had findings considered specific for sexual abuse. In this study, normal-appearing genitalia were found more often after digital-vaginal penetration, and specific positive changes were found more often after penile-vaginal penetration. Muram concluded that "Failure to document specific findings in half of these girls highlights the limitations of the medical evaluation in validating sexual abuse. Many victims of sexual abuse do not have physical injuries."
8. Paradise, J. E. The medical evaluation of the sexually abused child. Pediatr Clin North Am. 1990; 37: 839-863.
Paradise emphasizes that if the single finding of an enlarged hymenal opening is used to define sexual abuse, then many unnecessary investigations will be undertaken. On the other hand, many abused children, who happen to have a small hymenal opening, will go uninvestigated and unprotected. Like other authorities in this field, Paradise concludes that the diagnosis of sexual abuse often rests not on genital measurement but on descriptive statements made by the child.
9. Berenson, A. B. A case-controlled study of anatomic changes resulting from sexual abuse. Am J Obstetrics and Gynecology. 2000; 182: 820-834.
The authors performed a careful case-control study of prepubertal girls who were three to eight years old. 192 had a history of sexual abuse and 200 had no history of sexual abuse. Girls were excluded from the (normal) control group if there was a confirmed or suspected history of sexual, any current genitourinary complaints, a prior vaginal speculum examination, or an injury that had caused vaginal bleeding. Photographs were reviewed by two physicians, and a 10% sample rechecked to verify high consistency for scoring of physical findings. Twenty-one different genital features were evaluated using specific definitions to describe each finding. Appropriate statistical methods were used to compare the abused and nonabused groups. Vaginal discharge was more frequent in abused girls (11% vs. 4%). A septate hymen was more common in abused girls (4% vs. 1%). No difference was found between the two groups in the frequency of labial agglutination, increased vascularity, friability, perineal depression, hymenal bumps or tags, longitudinal intravaginal ridges, external ridges or bands, or superficial hymenal notches. No statistical difference was noted between the groups in terms of type, number or shape of hymenal notches, although the four girls who had deep hymenal notches, transection, or perforation were all in the abused group. The authors conclude that the genital examination of the abused girl rarely differs from that of the nonabused girl, and that legal experts should focus on the child's history as the primary evidence of sexual abuse.
