Medical Findings and Child Sexual Abuse
Richard A. Gardner
IPT Vol 5, 1993
Richard A. Gardner is a psychiatrist,
author, publisher, and lecturer at 155 County Road, P.O. Box
522, Cresskill, NJ, 07626-0317. This selection is
adapted from his 1992 book, True and False Accusations of
Child Sex Abuse: A Guide for Legal and Mental Health
Professionals. Cresskill, NJ.
Physicians are increasingly being asked to
conduct examinations to determine if there is physical
evidence that a child has been sexually abused.
Unfortunately, a common practice for many physicians has been
to form conclusions about abuse on the basis of vague physical
findings and In the absence of information outside of the fact
that someone believes the child has been abused.
Recently, however, there has been research on the
characteristics of the genitals of normal, non-abused
children. This research provides the baseline
information needed to evaluate physical findings. This research is described, the terms used in medical reports
are defined, and the physical findings which may be indicative
of sexual abuse are discussed.
Up until a few years ago there was very little published in
the medical literature on the physical findings consistent
with child sex abuse. There was even less published on
normal findings in non-abused children.
Moreover, there were no extensive studies on what the hymen
of the non-abused child looks like. Some physicians
claimed that the normal hymen is circular and that any
irregularity meant something had been inserted into the
vaginal canal. Although others maintained that there is
a wide variety of irregularities within the normal range, they
were unable to provide specific experimental data regarding
the frequency of these irregularities.
There was even controversy regarding the size of the normal
hymenal ring at various ages. Until recently, there were
no extensive studies in which measurements were taken.
And even the studies that were done were flawed by the
fact that the investigators failed to consider that the
hymenal orifice varies in size with the position the child
assumes when the examination is being conducted, as well as
with the degree to which the child's legs are spread by the
Similarly, there was no good information regarding the
differences between the normal anus and the anus that has been
subjected to sexual abuse. The necessary baseline
studies had not been done.
In spite of this relative ignorance, physicians have been
asked with increasing frequency to provide the definitive
"proof" regarding whether or not sexual abuse has
taken place. This has been the case even though most
people who are knowledgeable about child sex abuse recognize
that often there will be no physical findings because the
perpetrator has not done anything more than caress and fondle
the child. However, the need for such verification has
been strong, so strong that the objectivity of both those who
make the request and those physicians who have responded has
In response to this need, pediatricians, pediatric
gynecologists, and people from other branches of medicine
(such as internal medicine and family practice) have become
"experts" on child sex abuse in recent years.
Those who generally confirm sex abuse are attractive to
prosecutors, who can rely on them to provide the
"definitive medical evidence," that is, the
"proof" that sex abuse indeed took place.
Those who rarely find sex abuse are likely to be engaged by
defense attorneys who invite them to testify that the child is
"normal" and that there was "no evidence for
sex abuse." Although there are people who claim
that they are completely neutral, my experience has been that
most people who are doing this kind of work have a reputation
(whether warranted or not) for being in either of the two
There are doctors (even pediatricians) who claim that any
inflammation of a little girl's vulva is a manifestation of
sex abuse. Most, however, note that this is an extremely
common finding and can result from sweat, tight pants, certain
kinds of soap, and the occasional mild rubbing (sometimes
masturbatory) activity of the normal girl.
There are some who maintain that the normal hymen is a
perfect circle (or close to it) without any
irregularities. It follows, then, that if any
irregularities are found, these must have been artificially
created by the insertion of something, possibly a finger,
possibly a penis, or possibly something else (like a crayon or
pencil). There are others who claim that the normal
hymen is most often not a circle and there are irregularities,
tags, and bumps. They believe that these irregularities
(sometimes referred to as serrated hymenal orifices) are
within the normal range of hymenal variation.
Some claim that a three-year-old girl's vagina can
accommodate an adult's fingers and even penis without
necessarily showing signs of physical trauma, other than the
production of the aforementioned irregularities, tags, and
bumps. Others maintain that the insertion of an adult
male penis into a three-year-old girl's vagina will produce
severe pain, significant bleeding, and deep lacerations, and
that the insertion of crayons and pencils at that age is
extremely rare because of the pain and trauma that such
insertion will produce.
There are significant differences of opinion regarding what
is the normal size of the hymenal opening, and this, of
course, bears directly on the question of abuse. Most
experts agree that there have not been large studies of many
children at different ages with regard to what the normal
hymen looks like, its size, and whether or not it is indeed
Furthermore, all agree that the older the child, the
greater the likelihood the vaginal opening will accommodate a
penis without significant trauma. Thus, by the age of
nine or ten, one does not get the same degree of trauma that
is found at younger ages.
Most agree, as well, that children of nine and ten, whose
vaginal orifices are still small, could still be brought to
the point of intercourse with an adult by gradual stretching
of the vagina in the course of repeated experiences in which
progressively larger objects (fingers, and ultimately a penis)
Some physicians believe that a certain type of dilatation
("winking") of the anal mucosa is pathognomonic of
penile penetration into the anus. There are others who
claim that such dilatation is normal. (Here I am with
the group that holds that such puckering is most often normal
and is not a manifestation of sex abuse.)
The net result of this situation is that there may be
sharply divided opinions among physicians regarding whether a
particular child has been sexually abused. However, this
does not stop each side from bringing in a parade of adversary
physicians who predictably provide the "proof" that
the child was sexually abused or that there is "no
evidence" of sexual abuse. Another result of this
situation is that many doctors are making a lot of money,
because providing court testimony can be quite remunerative.
Definition of Terms
I will focus here on several terms that are often seen in
reports of physical examinations of children being evaluated
for sex abuse. Because girls are much more frequently
subjected to sex abuse than boys, and because controversies
regarding the signs of sex abuse are much greater in girls
than boys, most of these comments relate to the physical
examination of girls. It is assumed that the reader has
a basic familiarity with the female genitalia and is familiar
with such terms as labia majora, labia minora, clitoris,
urethral meatus (orifice), hymenal orifice, and vaginal walls.
Most often there are two positions described for a girl's
examination, the supine frog-leg position and the prone
knee-chest position. When examined in the supine
frog-leg position, the child is on her back with her legs
spread apart in "frog-leg" fashion. In the
prone knee-chest position, the child's abdomen is close to the
table and she is supported by her knees and chest.
McCann (1988) emphasizes the importance of the child's
chest touching the table and the child's back being in a
relaxed position. Examination of the vagina and cervix
(without the use of a speculum) is more easily accomplished in
young children in the prone knee-chest position.
Sometimes a third position is utilized, the supine knee-chest
position. Here the child lies on her back, puts her legs
together, flexes her thighs at her hips, and is asked to hug
her knees to her chest.
There are a wide variety of hymenal orifices and
configurations. So great is their variation that some
orifices do not easily lend themselves into being
categorized. Furthermore, there is no strict
standardization with regard to the names of the various kinds
of openings. Accordingly, different examiners may use
different names for the same hymenal configuration. The
way in which the child is positioned may affect the hymenal
configuration and thereby affect the name used by the
examiner. I describe here the most common types of
vaginal orifices. Next to each name I have placed in
parentheses other terms that are often used for the same
Annular (Circumferential, Cuff-like, Central) This
is the simplest configuration. The hymenal orifice is
represented by a relatively even circle. Basically, it
is a circular hole that can vary in diameter from almost a
pinpoint to an enlarged orifice that leaves practically no
hymen at all, only a rim. The cuff-like configuration
is also annular, yet there is a thickening at the
circumference of the orifice. Most competent examiners
agree that the perfect circle type of hymen is not common.
Crescentic (Horseshoe, U-Shaped, Posterior Rim,
Semilunar) The hymenal orifice is represented by a
half-moon or crescent. The bottom of the U-shape,
however, is at the posterior position (closest to the
anus). The hymenal tissue, then, can appear as if it
were hanging down from above (the anterior position).
Redundant (Denticular, Folded, Fimbriated, Serrated)
Here the configuration is one in which tooth-like (denticular)
tags of varying size project into the hymenal orifice.
When these are relatively small, they give a saw-tooth
(serrated) appearance. Because they are directed
inward from the hymenal rim, they are called fimbriated
The redundant configuration is quite common. The
hymenal tissue projections are commonly referred to as tags
and bumps. Estrogen has the effect of
thickening the hymen and increasing the formation of these
redundant projections into the hymenal orifice.
Accordingly, the prepubertal girl is likely to have more
such redundancies than younger girls. The spaces
between these projections are often referred to as notches
and clefts. These are to be differentiated from
tears and lacerations, which suggest the
insertion (partial or complete) of some object (animate or
inanimate) beyond the hymen into the vaginal cavity.
Whereas notches and clefts do not extend outward to the base
(or periphery) of the hymen, tears and lacerations
frequently do. And this is one of the important
differentiating criteria between them. Furthermore,
notches and clefts have rounded edges, whereas tears and
lacerations have sharp edges.
Vascularity of the tissue around notches and clefts is
even, smooth, and continuous with the vascularity and color
of the rest of the hymen. Just as estrogen increases
redundancy, it also has the effect of thickening the hymen
and obscuring thereby the fine lacy vascular pattern typical
of younger girls. This thickening also results in a
loss of the translucency of the hymenal tissues, and the
thickening gives the appearance of rounding of the edge of
the hymenal membrane. Tears and lacerations are
surrounded by tissue of different color, depending upon the
period between the trauma and the time of the
examination. The terms healed tears and scars are used
to refer to stages of healing. I will comment further
on these terms in the sections below.
Septate A septum is a partition or a dividing wall
between two spaces or cavities. A septate hymen with
one or more partitions (usually vertical) will result in two
or more parallel (but also vertical) orifices.
Slit-like The hymenal orifice is represented by a
thin slit, almost completely occluding communication between
the vagina and the exterior.
Punctate (Cribriform) In this configuration there
are multiple extremely small (pinpoint) orifices.
Imperforate Here there is no hymenal orifice at
all. This may not cause difficulties prior to
puberty. After the child stats menstruating, however,
incision of the hymen is necessary if there is to be proper
release of the menstrual flow.
The term anterior is used to refer to that past of
the hymen that is closest to the front of the body, and the
term posterior to that part of the hymen that is closest to
the back of the child's body. Commonly, the site of a
particular observation is described by visualizing the hymenal
ring to be like the face of a clock. Accordingly, 12:00
o'clock would be the most anterior position; 3:00 o'clock the
position closest to the child's left side (the examiner's
right); 6:00 o'clock, the position closest to the child's
anus; and 9:00 o'clock the position closest to the child's
right side (the examiner's left). There is a widespread
belief that attempts to insert an object (animate or
inanimate) into the child's vagina is more likely to produce
trauma to the posterior rim of the hymen, namely, in the range
from the 3:00 to 9:00 o'clock position.
Sometimes examination of the hymen may be compromised by
the presence of labial adhesions. These cause a sticking
together of adjacent parts of the labia minora.
Sometimes the attachment is by fibrous bands, and sometimes
merely by a sticking together of labial tissue. These
are so common that they are generally considered to be in the
normal range. Most competent examiners would not
consider them, per se, to be a sign of sex abuse.
Here I define further terms frequently seen in reports by
examiners assessing for sex abuse.
Labial adhesions This term refers to the
"sticking together" of the labia minora and/or
labia majora. Other names for the same phenomenon
include labial agglutination, vulvar fusion, vulvar
synechiae, gynatresia, coalescence of the
labia minora, and occlusion of the vaginal vestibule.
Labial adhesions are usually seen between the ages of two
months and seven years. They are generally considered
to be the result of poor hygiene, a mild vulvitis, or
mechanical irritation along with hypoestrogenism (McCann,
Voris, & Simon, 1988).
Synechiae This refers to a pathological union of
parts. It is synonymous with the word adhesion.
It is best viewed as a sticking together of parts that
should be separate from one another. Infection and
irritation can cause synechiae.
Posterior fourchette A fold of mucous membrane
just inside the point of posterior conversion of the vulva
Because the hymenal structures are so small (the average
normal hymenal orifice of a three-year-old is 4-5 mm) and
because measurements may be difficult, variable, and somewhat
subjective, visualization aids are often used. One such
aid is the traditional otoscope. Although
designed for examination of the ears, it has proven useful in
the genital examination as well. It is basically a
flashlight with a cone-shaped attachment and magnifying glass
that, at the same time, focuses a beam of light on the area to
be examined and allows the examiner to have a magnified view
of what is being seen.
A superior instrument is the colposcope. The
colposcope is a pair of mounted binoculars which can be
mounted on a tripod or suspended from a movable mechanical
arm. It generally magnifies from 10 to 20 times.
The colposcope allows for visualization of structures that may
not be visible to the naked eye. The colposcope is also
equipped with an internal light for better
visualization. It includes a green filter that assists
in the examination of the vascular bed. Finkel (1989)
states: "The green light improves visualization of scar
tissue and alterations in the vascular pattern of the hymenal
membrane and perihymenal tissues." Special cameras
can be used to take photographs through the colposcope. The
terms colposcopy and colposcopic examination
refer to the procedure in which the colposcope is used.
McCann (1990) has written an excellent description of the
colposcope and its use. Muram and Elias (1989) have
reservations about the colposcopy and do not consider it
significantly superior to the unaided eye.
The vaginal speculum is an instrument that allows for
visualization of the vaginal wall and the cervix. It is
best visualized as a split tube with a special handle.
The tube is inserted into the vagina and by squeezing the
handle the tube expands, thereby widening the vagina and
allowing for visualization of the cervix and vaginal wall,
especially while the speculum is being removed. Although
it comes in various sizes, it is rarely used in the
examination of children. The insertion of a vaginal
speculum into the vagina of a child would be very painful, and
even traumatic, especially to the hymenal ring.
The Tanner Stages
The Tanner stages are used to describe objectively the
developmental level of the secondary sexual characteristics in
children and adults. The stage levels are divided into
three categories: breast, genitals, and pubic hair. For
each of these there are five or six stages, ranging from the
most immature to the most mature. For example, Stage I of
pubic hair development is no pubic hair at all. Stage II
of breast development is the presence of a breast bud, with
elevation of the breast and nipple on a small mound.
Stage V of genital development in the male is a penis of adult
size and shape. Although the Tanner stage has little if
anything to do with sex abuse, the term is frequently seen in
the medical reports of children being evaluated for sex abuse.
Although the physical examination in cases of suspected sex
abuse will not be discussed in great detail here, there are
some important areas to consider in evaluating the
significance of such an examination.
According to Muram (1989a), it is important for the
examiner to examine the child within one week of the alleged
assault. It is in that period that residual bruises and
inflammation are more likely to be present. Beyond that
time these associated findings are likely to disappear.
The time between the alleged assault and the examination
should be noted in the report.
A common practice is for the physician who conducts the
examination to form conclusions about sex abuse purely on the
basis of the physical examination. The justification is
that others should be responsible for delving into the
background information, which can shed light on whether the
sex abuse did indeed take place.
The doctor may claim, "I'm a doctor, not a
detective. My job is to describe medical findings;
others concern themselves with the investigation."
I do not agree with this position. When examining for
the presence of other diseases, that same doctor would
certainly ask questions of one or both parents in order to
obtain a "history" and thereby get more information
about the disease under consideration.
Like most things in life, there is a continuum from the
zero-to-hundred level of involvement. A physician who
only is concerned with the physical examination is at the zero
level in terms of getting historical background
information. Most physicians who examine for sex abuse
will go a little beyond that and get some information from the
party who brings the child, most often the mother.
Usually, such data collection does not occupy more than a
minute or two. Accordingly, there is little meaningful
inquiry into the details of the allegation and little
opportunity to assess its credibility and likelihood. I
have never (I repeat never) seen a medical report in which the
examiner has seen fit to invite the alleged perpetrator (even
when the person accused is the father — the most common
case) to provide input.
Most often the examiner will state that the findings are
"consistent with sex abuse." However, I have
seen reports in which the alleged perpetrator is named, even
though that party was not only not seen but there wasn't even
an invitation extended to provide information. Such a
practice is unconscionable and is worthy, in my opinion, of a
malpractice suit. Such a physician is basically making a
diagnosis on a person whom he or she has never seen. I
am certain that the same doctor would be very reluctant to
write any other diagnosis in a chart regarding a person who
was not directly examined.
The failure to get information from available alleged
perpetrators has caused much unnecessary grief. I cannot
criticize such physicians strongly enough. Although
state laws generally require the physician to report suspected
abuse, they do not prevent the physician from speaking with
the alleged perpetrator before making a final decision
regarding whether a referral and investigation are
warranted. Furthermore, many of these physicians do not
appreciate the degree of ineptitude of the "validators"
to whom they are referring their patients. They seem to
be operating under the delusion that these people are
competent in the area of differentiating between true and
false sex abuse accusations.
As physicians they are sworn to subscribe to the
Hippocratic oath in which they vow that they will "above
all do no harm" to their patients. There is no
question that many of the children who are referred to child
protection services, evaluated by "validators," and
others of that ilk are being seriously traumatized and that
the physician has played a role in contributing to such
trauma. I am not suggesting that physicians break the
law. I am only suggesting that they take the time to get
more information before making such referrals. I am also
pointing out the common ineptitude of those people to whom
they are referring their patient for the "final
Physicians must also appreciate how their
"impressions" and statements (for example,
"consistent with sex abuse"), although not
conclusive in their minds, are interpreted by many lay people
as the final "proof." In many cases
"consistent with sexual abuse" becomes transformed
into "physical evidence of sexual abuse."
Perhaps if physicians appreciated this more, they would be
less quick to come to conclusions.
The measurement of the hymenal orifice is considered an
important part of the physical examination of girls suspected
of being sexually abused. It is important to appreciate
how variable this finding can be. It differs according
to the examination technique used (McCann, Voris, Simon, &
Wells, 1990). Yet, there are people who are in jail
because of this one measurement. The horizontal
(transverse) diameter of the hymenal orifice is usually
measured in the supine frog-leg position. Many factors
are operative in determining what this diameter is. If
the child is correctly positioned, the heels will be placed
just below the buttocks. Clearly, if they are in another
position, such as 12 inches below the buttocks, a different
measurement will be obtained.
The examiner must be sure that the child's heels are at the
same position assumed by those children on whom the normative
data were obtained. Then there is the variable of the
degree to which the child's legs are spread. Usually, an
assistant stands next to the child and slowly spreads the
child's legs while distracting and reassuring the child.
Obviously, the greater the degree of spread, the wider will be
the hymenal orifice. However, even when the legs are
extended to the most extreme position that is comfortable, the
labia majora are usually still so close to one another that
the hymen will not be observable. Accordingly, the
assistant generally pulls the labia majora apart laterally and
posteriorly in order to allow hymenal
Obviously, there are varying degrees of such posterolateral
traction, and the greater the traction, the greater the
expansion of the hymenal orifice. Therefore, the
assistant must attempt to apply such traction to the same
degree applied by those collecting the normative data. A
common standard is for the assistant to apply traction at the
mid-point of the labia majora to a point 1-1.5 cm on either
side of the midline.
Furthermore, a lag must be allowed between the time of
retraction and the time of taking the measurement. There
is usually a 1-2-second period during which the hymenal ring
must be allowed to dilate. Competent examiners usually
allow at least a 3-4-second time lag in order to ensure that
the hymenal ring is going to relax into its resting
position. McCann (1988) and McCann, Voris, Simon, &
Wells (1990) emphasize that the greater the traction on the
labia majora, the greater the width the hymenal diameter will
be, and this is one of the explanations for why different
examiners get different results when measuring hymenal
openings. They also point out that the vertical diameter
is smaller in the supine frog-leg position than it is in the
prone knee-chest position.
A small millimeter ruler is then placed very close to the
vaginal opening. Obviously, any squirming by the child
is going to compromise the accuracy of this measurement.
However, even under optimum conditions, and even with strict
reproduction of the positioning used by those collecting the
normative data, there is bound to be some variability of
measurement because of the minuteness of the measurement being
considered here. A millimeter is approximately 1/25 of
an inch. Although the human eye is capable of
discriminating between, let us say, 4 mm and 5 mm, it is
obvious we are dealing here with a discrimination that is
close to the edge of the capability of the human eye (and
brain). One has to consider also that the distance of
the examiner's eye from the hymenal orifice and the distance
of the ruler from the hymenal orifice can very well affect the
measurement perceived by the examiner.
I am convinced that if the same examiner were to examine
the same child on the following day, even when attempting to
reproduce exactly the conditions of the examination, there
would be variability. Furthermore, another examiner,
again under the same circumstances, is also likely to come up
with a different measurement. The American Academy of
Pediatrics (1991) in its statement, "Guidelines for the
Evaluation of Sexual Abuse of Children," emphasizes the
aforementioned variability and impresses upon pediatricians
the importance of taking these variations into consideration
when making decisions regarding the normality or abnormality
of the size of the hymenal orifice.
The prone knee-chest position is generally used to measure
the vertical diameter of the hymen. Here, too, lateral
traction is required if one is to properly visualize the hymen
and there is great variability regarding the child's
positioning and the degree of lateral traction. Again,
standardization is necessary. McCann (1990) states:
"The head is turned to one side with the forearms resting
on either side of the head. The knees are separated 6-8
inches and maintained in 90 degrees of flexion. The
examiner's thumbs are then placed beneath the leading edge of
the gluteous maximus at the level of the vaginal introitus and
the posterior portion of the perineum is lifted, revealing the
Obviously, the examiner who does not follow this procedure
exactly will obtain different measurements of the hymenal
orifice. Examination in the prone knee-chest position
allows the hymenal tissues to fall forward and thereby
provides better visualization of the full circumference of the
hymenal orifice than is generally possible in the frog-leg
position. Horowitz (1987) provides a good general
statement of procedures for conducting a pediatric examination
for sex abuse, as does the American Academy of Pediatrics,
Committee on Child Abuse and Neglect (1991).
What are Normal Genital Medical Findings?
Female Genital Findings
As mentioned above, it has only been in recent years that
extensive studies have been done to determine normal genital
findings in children. This belated interest relates to
the rapid increase in reports of sex abuse and the need for
accurate data in order to differentiate the normal from the
sexually abused child. It is my hope that the reader
will now be impressed with the complexity of the problem of
obtaining normative data with regard to the hymenal orifice,
and will be even more overwhelmed by the complexity of the
problem after a discussion of the wide variety of seemingly
pathological configurations that are found in normal children,
First, with regard to data collection on the size of the
normal hymenal orifice, one of the problems attendant to
conducting such studies is that of knowing with certainty that
the children studied were not abused. It is impossible
to "prove" that "something didn't
happen." The greater the number of children
included in a study, the greater the likelihood the findings
will be credible. However, the greater the number of
such child subjects, the less the likelihood that each of them
was studied in depth with regard to whether or not they were
The fact that children were taken from a "normal
population" of youngsters who were not referred for abuse
is no guarantee that some of the subjects being studied were
not abused. This is one of the criticisms directed at
such studies, especially by those who tend to diagnose sex
abuse in the vast majority of patients refereed to them.
These individuals are likely to use as criteria findings that
other observers would consider to be in the normal
range. This is one of the major problems in this field,
and it is a significant source of controversy.
Goff, Burke, Rickenback, and Buebendorf (1989) studied 273
prepubertal girls as part of their routine health
assessment. They measured horizontal diameters only in
the supine knee-chest position and the supine frog-leg
position. No measurements were made in the prone
knee-chest position. The girls ranged in age from under
age 1 to age 7. This study, as is true of most studies,
confirmed that the vaginal orifice increases in size with
age. The authors found that the horizontal hymenal
diameter was generally larger when measured in the supine
knee-chest position than in the supine frog-leg
position. Interestingly, an orifice greater than 4 mm in
horizontal diameter was rare. The study is a very good
one, especially because the authors describe in great detail
the exact positioning of the children prior to measurement.
McCann, Wells, Simon, and Voris (1990) studied 93 girls
between the ages of 10 months and 10 years. Whereas Goff
et al. (1989) used direct visual measurements, McCann et al.
(1990) used a colposcope. McCann et al. took both
vertical and horizontal measurements in the supine position
with labial separation, the supine position with labial
traction, and the prone knee-chest position. McCann et
al's findings are different from those of Goff et al., in that
the hymenal orifices were typically larger. There was
only one mean measurement below 4.0 mm, and that was the
horizontal measurement in the supine labial separation
position, namely, 3.9 + 1.4 mm. The largest finding was
for the 8-year-old girls in the 8-l0-year group in the prone
knee-chest position, namely, the vertical diameter of 8.7+2.6
mm. Considering these extremes, one can see that the
range of the means goes from 3.9 to 8.7 mm.
Accordingly, physicians who believe that any measurement
over 4 mm is indicative of sex abuse (which would be suggested
by Goff et al.'s studies) would not find support in McCann et
al.'s studies. Both are competent examining teams and
both have written articles that are very impressive.
Yet, they would be quoted by adversaries in a courtroom
dispute regarding whether or not sex abuse took place.
Finkel (1989) holds that a transverse hymenal diameter of
greater than 5 mm is suggestive of sexual abuse.
However, because of the unreliability of such measurements,
repeated measurements must be taken before coming to a
conclusion. He also emphasizes that the position of the
child and the degree of relaxation are important factors in
determining the measurement.
Another reliable study was conducted by White, Ingram, and
Lyna (1989). Their subjects were 242 females, ages
1-12. Three groups were studied: (1) sexually abused,
(2) no history of sexual contact, but at risk, (3) non-abused.
Transverse diameters only were obtained with patients in the
supine frog-leg position. Lateral tension was applied to
the hymenal opening. Measurements were made by
visualization of a measuring tape held over the hymenal
orifice or by a cotton-tipped applicator. They found
that 88% of children who complained of penile/vaginal
penetration had a vaginal introital diameter of greater than 4
mm, as compared to 18% of children who described no such
penetration. They concluded that a vaginal introital
diameter of greater than 4 mm is highly associated with sexual
contact in children less than 13 years of age.
It is important to appreciate that the transverse diameter
of the average adult erect penis is approximately 3.5 cm (35
mm) and an index finger is approximately 1.5 cm (15 mm)
wide. Accordingly, the insertion of either of these into
a hymenal orifice of 5 mm will invariably cause significant
widening and, certainly in the younger girl, pain and
trauma. Accordingly, when a three-year-od girl claims
that an alleged perpetrator inserted his penis into her vagina
and the vaginal examination reveals a diameter of, for
example, 7-8 mm, it is extremely unlikely that the penetration
being described actually took place. The more likely
explanation is either examiner error or the hymenal orifice is
at the upper end of the normal bell-shaped curve of hymenal
McCann, Wells, Simon, and Voris (1990) describe other
observations relevant to the problem of differentiating the non-abused
from the sexually abused children. For example, some
claim that rolled hymenal edges are a manifestation of sex
abuse. However, McCann et al. found that the rolled edge
is much more commonly seen in the supine positions, but tends
to disappear in the knee-chest position. Finkel (1989),
in contrast, states that rounded hymenal edges are one of the
results of the effects of estrogen in the prepubertal girl and
are more likely to be visualized in the knee-chest
position. This not only says something about the
importance of positioning, but also says something about
rolled edges as a sign of sex abuse.
With regard to hymenal configuration, McCann et al. (1990)
concentric [annular] (32%),
In 17% of the subjects he was unable to determine the exact
configuration because of redundancy of hymenal tissues and the
failure of the hymenal orifice to open. These findings
lend confirmation to those who claim that a perfectly circular
hymen is not the only configuration. With regard to the
hymenal edge, he found the following:
redundant (25%), and
Again, these findings lend support to those who hold that
there is great variation in the configuration of the hymenal
orifice. In the traction frog-leg position, with regard
to some of the "abnormalities" sometimes considered
manifestations of sex abuse, he found the following:
thickened hymenal edge (53.8%),
localized roll of the hymenal edge (23.8%),
hymenal mounds (33.8%),
hymenal projections (33.3%),
hymenal tags (24.4%),
peri-hymenal bands (16%),
septal remnants (8.6%),
hymenal septa (2.5%),
hymenal notches (6.6%),
hymenal synechiae [adhesion of the hymen to adjacent
Some claim that the normal hymen is regular in its
vascularity and any areas of vascular irregularity, areas in
which the vascularization is different from surrounding
tissues, is strongly suggestive of healed tears and other
signs of sex abuse.
McCann et al. (1990) found irregular vascularity in
31.3% of those children examined in the separation
30.9% in those children examined in the traction
frog-leg position, and
28.9% of those when examined in the knee-chest
Aside from areas of irregular vascularity, they found areas
of isolated increase in vascularity in
13.9% of those examined in the separation frog-leg
16.0% of those examined in the traction frog-leg
22.8% of those examined in the prone knee-chest
These findings strongly suggest that the vascular
irregularity criterion for sex abuse is improper and risky
(especially for those being falsely accused).
The McCann et al. study directs itself, as well, to the
frequency of other "abnormalities" sometimes
considered manifestations of sex abuse.
he found labial adhesions to be present in 38.9% and
periurethral bands in 50.6% of the children
He found erythema of the vestibule to be present in 56%
of the children examined.
(The vestibule is the portion of the vulva bounded by the
labia minora. At the floor of the vestibule are [from
anterior to posterior] the clitoris, urethral orifice, and
As mentioned previously, vulval rashes are quite common in
children. These relate to poor hygiene, a wide variety
of infections (not necessarily related to sexually transmitted
diseases), tight panties, certain soaps, rubbing, scratching,
and masturbation (to mention the most common). I have
been involved in a number of cases in which these more common
and likely causes of the erythema were ignored and the
examiner concluded that the findings were
"consistent" with sex abuse or even manifestations
of sex abuse.
I have discussed in some detail the McCann, Wells, Simon,
and Voris (1990) research because it provides compelling
evidence that normal children exhibit a wide variety of
variations, many of which have been considered signs of sex
abuse. It is of interest that McCann et al.'s original
group consisted of 114 girls, but 23 were excluded because of
the early onset of puberty and the possibility of undetected
The list of behavioral manifestations that warranted their
exclusion from the study included nightmares, fears,
moodiness, change in school performance, truancy, and acting
out behaviors (among others). All of these could be seen
in normal children (at least on occasion), and many of these
behaviors are manifestations of a wide variety of childhood
problems completely unrelated to sex abuse. There are
sexually abused children, however, who may exhibit one or more
of these behavioral manifestations.
To the best of my knowledge, McCann et al. did not conduct
a detailed inquiry regarding whether these behavioral
manifestations were signs and symptoms of sex abuse, were in
the normal range, or related to other causes. On the one
hand, the exclusion of all these children, simply on the basis
of the presence of one or more of these symptoms, made his
sample "purer" — thereby lessening the likelihood
that sexually abused children were included. On the
other hand, he may have unnecessarily shrunk his patient
population, thereby lessening somewhat the credibility of his
findings and depriving himself of many subjects who were not
Anal Findings (Male and Female)
Anal and perianal findings are also a source of significant
controversy. One of the most widely known such
controversies relates to the anal examinations described by
Hobbs and Wynne (1986, 1987). These examiners claim that
a pathognomonic sign of child sex abuse is "reflex
dilatation and alternate contraction and relaxation of the
anal sphincter or 'twitchiness' without
dilatation." One finding, also referred to as anal
"winking," is considered a pathognomonic sign of
anal intercourse. As a result of using this criterion,
hundreds of children in England were diagnosed as having been
sexually abused, with the result that 121 children were
removed from 57 families. It took a government
investigation to bring society to its senses and return these
children to their families.
McCann, Voris, Simon, and Wells (1989) studied 267 children
(161 girls and 106 boys), ages 2 months to 11 years.
They found anal dilatation in 49% of the children, and the
mean time of the initial dilatation was 65 seconds. The
anus opened and closed intermittently in 62% of the subjects
in which dilatation occurred. Accordingly, about 30% of
all the children studied exhibited the intermittent dilatation
and relaxation of the anal sphincter, which Hobbs and Wynne
considered a sign of sex abuse.
McCann et al. (1989) describe other anal findings in normal
children that are often considered signs of sex abuse.
They found that 41% of their group exhibited erythema.
There is no question that children who have been sexually
molested per anus will exhibit erythema. But in this
study, 41% of normal children exhibited erythema as
well. McCann et al. found increased pigmentation in 30%,
another finding that is often considered a sign of sex
abuse. They found venous engorgement in 52% after two
minutes in the knee-chest position. Again, venous
engorgement has also been considered a sign of sex
abuse. Anal tags and folds are also considered by some
to be indicative of sex abuse. These were found anterior
to the anus in 11% of the children studied. No
abrasions, hematomas, or fissures (common findings in sex
abuse) were found.
What are the Genital Findings in Sexually Abused
Studies of the anogenital findings in sex abuse are beset
by a number of problems. First, all knowledgeable
investigators agree that some children who have been genuinely
abused sexually will exhibit no medical findings. This
relates to the fact that they were caressed and touched in a
way that would not be expected to cause physical trauma.
Another problem relates to the fact that the investigators can
never be sure that all the children in the non-abused group
studied were indeed never abused. There is also the risk
that some of the children in the abused group were indeed not
abused, but this is less likely. A third problem relates
to the fact that a wide variety of abnormalities are seen in
normal children, and the aforementioned studies of McCann and
his colleagues provide good verification of this. What
we are trying to find, then, are specific medical
findings that are seen only in abused children and not in
those who have not been abused.
Female Genital Findings
Emans, Woods, and Flagg (1987) studied 305 girls.
They were divided into three groups:
(1) sexually abused (119 girls),
(2) normal girls with no genital complaints (127 girls),
(3) girls with other genital complaints (59
The abused group was more likely to have
scars on the hymen or the posterior fourchette (9% vs.
1%, p < 0.002),
increased friability (ease of bleeding) of the posterior
fourchette (10% vs. 1%, p < 0.001),
attenuation (stretching and thinning) of the hymen (18%
vs. 4%, p < 0.0003), and
synechiae (adhesions) from the hymenal ring to the
vagina (8% vs. 0%, p < 0.0009).
We see here that we are not dealing with a situation in
which a finding is present in the abused group and not present
in the non-abused. Rather, certain findings are more
likely to be present in the abused group than in the non-abused
group. The obvious problem with this kind of finding is
that its presence then does not necessarily mean that the
particular child being examined was abused.
Interestingly, Emans et al. (1987) found a wide variety of
symptoms to be present with equal likelihood in the abused
group and the non-abused group with other genital
complaints. There was no statistical difference between
groups 1 and 3 regarding the frequency of abrasions, hymenal
tears, intravaginal synechiae, and condyloma acuminata
(venereal warts). This study, then, suggests that these
particular findings are not of diagnostic significance when
attempting to differentiate abused from non-abused
Interestingly, erythema (reddening) was more common in the non-abused
group than in the abused group (68% vs. 34%, p <
0.0001). There was no statistical difference between the
dimensions of the hymenal opening of the abused and the non-abused
group. One would certainly expect a larger average
hymenal opening in the abused group, but this study did not
confirm such a difference. Perhaps there were too few
girls in the 119 abused who had the kind of sexual molestation
that would produce an enlargement of the hymenal
However, as Herman-Giddens and Frothingham (1987) point
"The hymen, contrary to common notion, is often a
slack, thick, folded, stretchable tissue which may persist
after digital or penile penetration."
The same authors hold that
"a vaginal opening of greater than 5 mm is not
common and may indicate vaginal penetration with a finger,
object, or penis."
McCann (1988) states that 85% of preadolescent children who
are being molested are molested on a chronic, ongoing, and
recurring basis. Such molestation should, then, produce
changes indicative of chronic trauma. He emphasizes the
importance of examination for bruises in other parts of
the body, in the nongenital area. The mouth is a common
site of lesions because the perpetrator may have placed his
hand over the child's mouth in order to stop the child from
screaming. Grab marks on the arms and inner thighs are
also strongly suggestive of sex abuse, especially thumb marks
on the inner aspect of the thigh, placed there when the
child's legs were forced apart.
McCann (1988) also observes that labial injury is common at
the time of rape because the labia majora are generally closed
and the perpetrator pushes his penis repeatedly against closed
labia. He believes that the most common area of hymenal
injury is between the 4:00 and 7:00 o'clock positions because
the penis is forced downward and backward. He emphasizes
that children heal quickly and that examinations after the
first few days may not confirm the abuse. Because the
length of the vagina of four- and five-year-old girls is only
4 cm, trauma to the vagina, cervix, and lower part of the
uterus is common.
McCann, Voris, and Simon (1988) studied six sisters, all of
whom had been sexually molested by male family members.
All of these girls had labial adhesions, and four of the six
had changes in the area of the posterior fourchette (a fold of
mucus membrane just inside the posterior commissure of the
vulva). Furthermore, four of the girls' hymens revealed
abnormalities of the hymenal edge (irregular, rolled, or
septum) and three revealed irregularities of the hymenal
membrane (redundant, thick, scarred). Four exhibited
abnormal vascular patterns, and all six exhibited adhesions
and/or scars of the posterior fourchette. The labial
adhesions in these cases were associated with posterior
fourchette changes and other findings consistent with sex
The authors' position is that labial adhesions per se are
not indicative of sex abuse. However, if associated with
other findings suggestive of sex abuse, such as posterior
fourchette trauma, then it should be considered one such
manifestation. We see here, then, a situation in which a
normal finding is considered a sign of sex abuse under certain
circumstances. In these six cases the labial adhesions
were associated with other findings indicative of sex
abuse. Furthermore, labial adhesions usually occur from
ages two to seven. In this case two of the girls were
ages eight and nine, beyond the age at which one usually sees
Muram (1989a) divides the genital findings into four
Abnormalities of the genitalia that could have
been caused by sexual abuse, but also are often
seen in girls who are not victims of sexual abuse
(e.g., inflammation and scratching). These
findings may be the sequelae of poor perineal
hygiene or nonspecific infection. Included
in this category are redness of the external
genitalia, increased vascular pattern of the
vestibular and labial mucosa, presence of purulent
discharge from the vagina, small skin fissures or
lacerations in the area of the posterior
fourchette, and agglutination of the labia minora.
The presence of one or more abnormalities strongly
suggesting sexual abuse. Such findings
include recent or healed lacerations of the hymen
and vaginal mucosa, enlarged hymenal opening of 1
cm, proctoepisiotomy (a laceration of the vaginal
mucosa extending through the rectovaginal septum
to involve the rectal mucosa), and indentations in
the skin indicating teeth (bite) marks. This
category also includes patients with laboratory
confirmation of a venereal disease.
Any presence of sperm.
It is of interest that Muram (1989a) considers labial
agglutination to be a nonspecific finding, in that it does not
necessarily indicate sex abuse. Of importance in the
third category, specific findings, are hymenal tears that
extend to the base of the hymenal ring as to be differentiated
from hymenal clefts which do not extend that peripherally.
Muram believes that an astute examiner will do just as well
with the unaided eye as with the colposcope. Muram
(1989b) studied 31 girls who were assaulted by 30 individuals,
all of whom confessed to having sexually molested them.
Both the girls and the perpetrators were in agreement that the
sex abuse took place. Obviously, this is a good study
sample for ascertaining the physical effects of sex
abuse. It circumvents one of the aforementioned problems
regarding such studies, namely, the uncertainty regarding
whether or not the girl being examined was genuinely abused or
was genuinely in the non-abused category.
In 18 of the 31 cases the offender admitted to vaginal
penetration. However, specific findings were only to be
found in 11 of these 18 girls (61%). In those girls in
which penetration was denied only 3 of 13 (23%) provided
specific findings. However, the girls ranged in age from
2 to 15, so it is not surprising that some of the teenagers
who experienced penile penetration did not have physical
findings of abuse.
It is of Interest that of the 31 girls, inflammation,
bruising, and irritation were seen in only 9, all of whom were
evaluated within one week of the assault. None of the
girls evaluated one week after the abuse had findings
suggestive of inflammation. Muram states: "If no
tear of the hymen occurred, the examination will fail to
detect any abnormalities." This is an important
point. According to Muram, the most important specific
sign of sexual molestation Is hymenal tear, to the base,
especially extending into the vaginal canal. Other
abnormalities, such as inflammation and bruising, tend to heal
within a week.
The most important observation Muram makes is that the most
consistent finding in bona fide sex abuse is laceration or
tear of the hymenal ring, down through the base, and extending
often into the adjacent vaginal wall. This sign is one
of the most important for differentiating genuine from
On occasion, a child may sustain significant genital
injuries associated with trauma to the perineal area as a
result of falls and fence or straddle injuries (Behrman &
Vaughn, 1983; Paul, 1986). Here one may see the kinds of
lacerations seen in sexual abuse. One may also see
abrasions and other forms of injury to the perivaginal
area. However, the time of the trauma is generally well
known to the child (and usually an adult), and there is
nothing else in the history to suggest sexual
Paul (1977, 1986) claims that penile penetration in younger
children will cause widespread injuries, including lacerations
of the hymen, vagina, and labia. There will be profuse
bleeding and the child will experience excruciating
pain. This is an important point because in many cases
of fabricated sex abuse, the child will describe no pain or
McCann (1988) observes that children who have been
subjected to anal intercourse on repeated occasions suffer
with a relaxation of the external anal sphincter, but not of
the internal anal sphincter. Accordingly, there is a
typical funnel-like appearance of the anus on physical
Finkel (1989) reports on seven children who had experienced
acute genital and anal trauma in association with sexual
abuse. Some of the more superficial manifestations of
the trauma (abrasions, superficial lacerations, contusions,
and bleeding) were not apparent after four days. In two
of Finkel's seven cases, penile-anal penetration was
involved. In one case, Finkel described
"superficial lacerations of the anal verge tissues in
anterior and posterior midline positions each measuring 2 mm
circumferentially and 3 mm in length." In the
second case he described five mucocutaneous superficial
lacerations, some of which extended from the external anal
mucosa down into the anal canal.
Paul (1990) observes that, even with the use of a
lubricant, penile penetration of the anus will almost
invariably result in some injury to the anal verge. He
stresses the importance of the history, from the child, of
severe pain — not only during the abuse, but when the child
next attempts to have a bowel movement. He states: "This
exacerbation of pain on defecation is an almost invariable
'story' and is so impressed on the child's mind that it is
rarely forgotten" (p. 6).
Sexually Transmitted Diseases
The presence of a sexually transmitted disease (previously
referred to as venereal disease) is generally considered
definitive evidence for sex abuse. Of the wide variety
of such diseases, the most commonly found in sexually abused
children are gonorrhea, syphilis, Chlamydia, condyloma
acuminatum, Trichomonas vaginalis, and herpes 1
(genital). However, it is important to appreciate that
gonorrhea, syphilis, and Chlamydia can be acquired perinatally
from the mother, and this must be given consideration before
deciding that the presence of such a disease automatically
indicates sex abuse (American Academy of Pediatrics, Committee
of Child Abuse and Neglect, 1991).
The material for gonorrhea culture is generally obtained
from cotton swabs of the vagina, throat, and rectum. The
organism may sometimes be grown from cultures of the urine of
suspected boys. The urine can also be examined for
Trichomonas infection. Tests for syphilis are usually
obtained from a blood sample. Vaginal secretions can
also be cultured for the presence of Chlamydia, herpes, and
Trichomonas. Vaginal secretions can be examined directly
(microscopically, with proper staining) for gonorrhea and
Condyloma acuminatum is also referred to as genital warts
and venereal warts. It is caused by a virus called the
human papilloma virus (HPV). It is the most common viral
sexually transmitted disease in the United States and is now
more common than herpes (due to the recent rapid increase in
its incidence). Because the incubation period is
approximately one month (Stewart, Stewart, Guest, &
Hatcher, 1987), the genital warts will not be observable
immediately after a child has been abused. The diagnosis
is made generally by direct observation, the warts usually
appearing like warts on other parts of the body, but they do
extend into the vaginal canal, cervix, and rectum.
Sometimes the warts are inconspicuous or completely invisible
to the naked eye. Horowitz (1987) provides an excellent
protocol for the examination for sexually transmitted
Although the presence of a sexually transmitted disease is
strongly suggestive of sex abuse, the disease may have been
acquired by the child in a nonsexual way. The problem in
such situations is that the suspect may also have the sexually
transmitted disease but did not have a sexual encounter with
the child. Rather, the disease was transmitted
nonsexually. Clearly, an accused who is trying to deny a
sexual encounter will give strong support to this theory.
Support for this can be found in the medical literature,
where there are many articles providing instances of just such
a method of transmission. For example, Shore and
Winklestein (1971) claim that 50% of their sample of children
contracted their gonococcal infection in the absence of sex
abuse and that only one-fifth acquired the gonorrhea through a
sexual experience. Kaplan (1986) claims that the
gonococcus can survive outside the human body for up to 24
hours and cites a 1929 study in which several newborns in the
same hospital nursery were found to have gonococcal
infections. It was believed that the organism was
transferred with thermometers. Wakefield and Underwager
(1988) refer to studies in which gonorrhea was found to have
been transmitted nonsexually among peers, via close physical
contact with infected adults or indirect contact through
bedclothes or hands. They also refer to the work of
DeJong et al. (1982), who report that venereal warts can be
transmitted through close nonsexual contact, during delivery,
and by sexual encounters.
Sperm in the Vagina and the Pregnancy Test
The presence of sperm in the vagina of a prepubertal child
is obvious evidence for sex abuse. It is proof that a
postpubertal male has sexually penetrated the prepubertal
girl. The presence of sperm in the vagina of a
postpubertal girl is not necessarily evidence of sex abuse, in
that she may have voluntarily had sexual relations without in
any way being abused.
Fresh sperm can be examined directly under the
microscope. After 24 hours sperm may not be viable
enough for such direct examination. Sperm may be
visualized with Wood's light, under which it becomes
fluorescent. These fluorescent "tear drops"
shine dramatically in contrast to other vaginal secretions
that are examined under Wood's light (McCann, 1988). The
examiner must take care to question the parents regarding
whether the child has taken a bath between the time of the
alleged abuse and the time of the examination.
Obviously, if the sperm has been washed out, the Wood's light
test will not be positive. The sperm sample can also be
tested for the presence of acid phosphatase, an enzyme that is
secreted by the prostate gland and is to be found in the
ejaculate. Acid phosphatase is not normally found in the
In association with the examination for sperm, one must
consider the pregnancy test. Obviously, the pregnancy
test is not viable for prepubertal children, although there
are reports of pregnancy in girls as young as eight and many
examiners will routinely do them for children of that age and
above. Although conducting a pregnancy test on a
prepubertal child may seem unnecessary and even absurd, it is
not completely so. There are children who are capable of
becoming pregnant who have exhibited few, if any, signs of
sexual maturity. And this is where the Tanner level of
sexual development may provide information regarding whether
or not the child could indeed be pregnant. An eight- or
nine-year-old, exhibiting Tanner II and III levels, may very
well be capable of pregnancy.
Although physicians have been performing medical
examinations and drawing conclusions about sex abuse, their
conclusions have often been ill-considered and unsupported by
empirical data. The recent research on the
characteristics of the genitals of normal, non-abused children
provides the baseline information needed to evaluate physical
findings. This research indicates that many of the
physical findings often claimed to indicate probable sexual
abuse are found frequently in non-abused children. This
research must be taken into account when evaluating reports of
medical examinations of children in cases of suspected sex
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