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Medical Examination for Sexual Abuse: Have We Been Misled?
Lee Coleman, IPT Journal 1-1989
There are serious difficulties in diagnosing sexual abuse on the basis of an ano/genital examination. Nevertheless, medical conclusions are often used in court to provide evidence for abuse. The support for the alleged physical indicators of abuse has been based on opinions and claims unsupported by research data.
Recent research by John McCann on the ano/genital anatomy in nonabused children has established that findings often attributed to sexual abuse are found in many normal children. McCann's findings were applied to 158 children who had been medically examined in cases of alleged sexual abuse. Nearly all the findings attributed to sexual abuse were present in McCann's sample of nonabused children.
More baseline studies are needed, including those comparing nonabused children to children where there is convincing evidence of abuse. In the meantime, the courts need to modify their current practices concerning evidence from ano/genital examinations.
The growing recognition of sexual exploitation of children has brought special problems in determining whether an alleged abuse has in fact taken place. Unlike other crimes, the victim may not complain immediately. The victim may be inarticulate, or feel intimidated by the perpetrator. There may be no obvious physical evidence of abuse.
Equally difficult, the "victim" may in truth have been led to believe he or she was abused, through the use of leading and suggestive questioning. In such cases, false accusations are not necessarily lies because improper questioning may lead a child to sincere but incorrect beliefs (Coleman, 1986).
Faced with such problems, police and child protection workers naturally hope for a way to resolve these special difficulties which may protect the child molester in one case and falsely accuse an innocent person in another.
Not for the first time and undoubtedly for the last, we have turned to doctors to relieve us of the uncertainty. And so great has been our desire for resolution, for "science" to come to the rescue, that we have been only too happy to accept whatever the doctors have offered. With few exceptions (Nathan, 1989; Paul, 1977; Paul, 1986; Woodling & Heger, 1986; Zeitlin, 1987) little thought has been given to whether the doctors' offerings are legitimate medical evidence, or mere speculation.
A good beginning is a recognition that sexual abuse is not a "diagnosis" but an event. Even highly suspicious findings, such as the presence of a disease normally transmitted through sexual contact, do not automatically mean sexual abuse. While medical findings may be important in supporting or negating alleged events, a finding of sexual molest is a legal and not a medical conclusion.
The confusion becomes acute when the methods normally used to reach a diagnosis in a nonadversarial, clinical situation are carelessly adopted in a legal investigation. Take, for example, the "history." In medicine, statements made by patients and/or family are generally taken at face value. Allegations of criminal conduct, on the other hand, should be investigated rather than assumed correct.
If a doctor hears an allegation and writes it down as "history," he or she has not made a "finding" but merely repeated the allegation. This might seem obvious, yet it is common for doctors to make a "diagnosis" of sexual abuse, relying heavily on what they call the "history," as given by an accusing adult or by an investigator.
Likewise, it might seem obvious that a normal ano/genital examination is no help in establishing molest. Such normal examinations are, nonetheless, frequently termed "consistent with" sexual abuse. Rarely is this followed by a statement indicating that a normal examination is equally consistent with no abuse. Take, for example, the case in which the doctor wrote, "The normal size of her vagina is not an uncommon finding in girls who have been fondled although not deeply penetrated into the vagina. This finding is still consistent with someone attempting to stick their finger into the vagina."
Given that with many victims of molestation the medical examination will be normal, it follows that every child's anatomy is "consistent with" molest because normal anatomy is also consistent with nontraumatic molest.
The confusion deepens when these two non-findings — "history of molest" and "physical examination consistent with molest" — are combined. Investigators learn that medical examiners have made a "diagnosis" of sexual abuse, based on the "history" and on a medical examination said to be "consistent with the history." With their suspicions confirmed, these investigators are hardly likely to continue with a vigorous and unbiased investigation.
Next, it should be remembered that "normal" always means a range. Parts of the body vary in detail from person to person. Whether examiners may safely equate physical findings with prior trauma will depend on whether controlled studies have documented the range of normal anatomy.
Finally, a note on "experience." Experience, like consensus, is not enough to move from conjecture to science. Feedback, i.e. controlled testing of ideas through research, is necessary to be sure that one's experience is not filled with incorrect notions that go unrecognized. Thousands of women, for example, underwent radical mastectomy because highly experienced surgeons, and doctors in general, believed it was the best way to save lives. Only subsequent research demonstrated that simple mastectomy saved as many lives.
The situation is even worse when the doctor's opinion will itself influence the ultimate findings of the justice system. If Doctor X opines that a child has been molested, based on findings which in truth do not prove molest, a court will frequently rubber-stamp such an opinion. This judicial finding then becomes the confirmation which makes the doctor feel he can rely on his "experience." Such "confirmation" is, of course, scientifically meaningless.
History of Sexual Abuse Examinations
Medical examinations for sexual abuse of children, done long after the alleged fact, are a new phenomenon. All but a handful of the articles on this subject are from the 1980s.
An early but influential article was that of Woodling and Kossoris (1981). A collaboration of a family practitioner and a district attorney, this article listed findings which the authors claimed were indicative of abuse. These included a number of findings which are either extremely nonspecific or open to subjective interpretation by the examining physician, such as perihymenal erythema (redness), tightness (too much or too little) of pubic or anal muscles, anal fissures, and hymenal irregularities interpreted as either "transections" or evidence of scarring.
In support of these alleged indicators of prior sexual contact, Woodling offered only his "experience," which he wrote "suggests that only forced penile penetration causes actual transection of the hymen or perihymenal injuries. Chronic molestation or repeated coitus will result in multiple hymenal transections which eventually heal and leave multiple rounded remnants present between 3 and 9 o'clock ..."
When a growing number of physicians and nurses began to take a special interest in forensic ano/genital examinations of suspected child sexual abuse victims, these new specialists eagerly absorbed such ideas, despite the lack of any research corroboration. Take, for example, Woodling's Training Syllabus: Medical Examination of the Sexually Abused Child (1985). To the above list of supposed indicators of molest he added "rounded scars called synechiae," which "when magnified may show neovascularization." Another unsupported claim: "the rectal sphincter may manifest laxity or may reflexively relax when stimulated by direct contact with an examining finger, perianal stroking with a cotton bud (perianal wink reflex) or by lateral traction of the buttocks."
As trainees went back to their communities, and in turn became the trainers, these uncorroborated claims became the conventional wisdom of the "experts."
This second generation wrote more articles which passed along the same alleged "indicators" of molest, articles which were conspicuous in their absence of any controlled data (Berkowitz, Elvik, & Logan, 1986; Cantwell, 1983; Cantwell, 1987; Chadwick, undated; DeJong, 1985; Elvik, Berkowitz & Smith-Greenberg, 1986; Enos, Conrath, & Byer, 1986; Grant, 1984; Hammerschlag, Cummings, Doraiswamy, Cox, & McCormack, 1985; Heger, 1985; Herbert, 1987; Herman-Giddens & Frothingham, 1987; Hobbs & Wynne, 1986; Hobbs & Wynne, 1987; Jones, 1982; Kerns, 1981; Khan & Sexton, 1983; Levitt, 1986; Levitt, undated; McCann, Voris, & Simon, 1988; McCauley, Gorman, & Guzinski, 1986; Muram, 1988; Pascoe & Duterte, 1981; Ricci, 1966; Seidel, Zonana, & Totten, 1979; Seidel, Elvik, Berkowitz, & Day, 1986; Spencer & Dunklee, 1986; Tilelli, Turek, & Jaffe, 1980).
Pediatricians and other qualified physicians refused to do such examinations, deferring to those few who claimed to be "specialists." Law enforcement and child protection workers quickly learned which examiners were likely to make findings supportive of an allegation of molest. Most often these examiners were attached to a "sex abuse team."
I have had the opportunity to read the reports and testimony of these examiners in cases involving 158 children suspected to have been molested. The confidence expressed, to the effect that findings like those mentioned above are reliable indicators of molest, is usually very high. Rounded hymenal edges and anal relaxation, to mention just two examples, are seen as signs of molest, and only molest.
Behind the scenes, however, doubts were being expressed. Perhaps far fewer doubts than scientific caution dictated, but nonetheless more doubts than law enforcement officials, judges, or juries were hearing. Take, for example, a meeting in April, 1985, during which physicians and nurses came to learn how to examine children who might have been molested.
Dr. Woodling acknowledged that "there is a significant variation in hymenal types ... we need to realize that hymens are like people's faces, there are lots of variations ... there are often times cuts or transections but they're not traumatic, they're just clefts that the child was born with ... and can in fact appear to the untrained eye as an old transection .. " (Woodling & Heger, 1985).
I have seen countless cases in which exactly these findings were said to be unequivocal evidence of molest. Likewise, to take another example, vaginal size may be cited as evidence of molest. A paper by Cantwell (1983) is still cited as support for the proposition that a vaginal opening size above four millimeters is supportive of molest. Woodling nonetheless acknowledged that this had "not held true in our experience" (Woodling & Heger, 1985).
Countless trials have had expert testimony that anal sphincter relaxation was a definite sign of sodomy, but Woodling admitted, "This is not a hard test, that means in fact that you have sexual abuse ..." (Woodling & Heger, 1985).
At the same meeting, the remarks of another specialist, Dr. Astrid Heger, also showed greater willingness to acknowledge uncertainty than I have seen in court trials. "... I think diagnosing sexual abuse on the hymenal diameter alone is a very dangerous thing to do ... the same kid (may have) two different diameters, depending on how you were looking at her" (Woodling & Heger, 1985).
What emerges from these meetings is the fact that these "specialists" have seen a lot of children, and opined on which ones were molest victims, but they have no way of checking the accuracy of their conclusions. Even if they agree on how to interpret a particular finding, this doesn't mean they are correct. Only controlled research will allow them to decide whether a particular finding is indicative of molest.
Dr. Robert ten Bensel, a physician long involved in the effort to increase awareness of child abuse, has commented on the difference between consensus and true scientific evidence. In response to a 1985 Los Angeles conference at which there was an attempt to reach consensus of positive findings among doctors doing these examinations, ten Bensel wrote, "I am not comfortable with the reported 'consensus of positive findings.' This is not the procedure of science; rather, it is simply an agreement among a select group of physicians invited ..." (1985).
Consensus, in other words, is no substitute for research.
In Search of Research
The heightened interest in medical detection of sexual abuse of children has produced lots of articles, but little research. Before discussing what little research exists, let me illustrate how today's "experts" seem to ignore the difference between naked claims and true evidence.
A nurse examiner routinely consulted by law enforcement officials in Northern California county described "a healed V-shaped laceration at the 12 o'clock position in the rectum ... the tip of the V is pointed toward the inside, this indicates penetration from the outside." This nurse was faithfully passing on what she had learned in workshops like those mentioned above. No supportive evidence was cited.
Asked to evaluate these claims, I commented on the lack of data to support such an allegation. In response, lawyers supporting the allegation called on a pediatrician specializing in such examinations. She backed the nurse's findings by citing several articles which made the same claims. None of the articles, however, contained reference to any research. Once again, unsupported claims were being passed 6ff as medical evidence.
Dr. David Paul, one of the most experienced examiners for sexual abuse, has written "... even the most careful examination of a fissure — healed or fresh — by magnifying glass or colposcope, cannot differentiate between a "natural" fissure caused by constipation and one that was caused by anal penetration" (1986).
Clearly, there is a need to get beyond these differences of opinion, into the world of research findings. It is remarkable, considering the attention paid to sexual abuse of children in recent years, how little the doctors examining the children and giving opinions which may send a person to prison for life, have done to validate the claims they so readily make in our courts.
We are not totally without research findings, however. What we do have directly contradicts the claims made in recent years by the small number of examiners so regularly consulted by law enforcement and child protection investigators.
Emans, Woods, Flagg, and Freeman (1987) attempted to compare three groups of girls; abused (group 1), normal girls with no genital complaints (group 2), and girls with other genital complaints (group 3). The study has serious flaws. The examiners were not blind to which category each girl belonged; no information is given on how certain it was that alleged molest victims were true victims; and examiners were not randomly assigned. Instead the lead author was the exclusive examiner of girls assumed to be molested.
Nonetheless, the authors deserve credit for addressing what has been ignored by so many others. They concluded from their literature search, just as I have from my own, that "no previous study has reported the incidence of various genital findings in girls ..."
Presence or absence of twenty genital findings were recorded on each child. These included hymenal clefts, hymenal bumps, synechiae (tissue bands), labial adhesions, increased vascularity and erythema (redness), scarring, friability (easy bleeding), rounding of hymenal border, abrasions, anal tags, anal fissures, and condyloma accuminata (venereal warts). These are the kinds of findings which are being attributed to sexual abuse in courts across the land, despite there having been "no previous study ..."
Emans et al. do claim that only the sexually abused group showed hymenal tears and synechiae (tissue bands) inside the vagina. Doubts about this, however, are raised by the results of the only other research effort done so far. It is not yet in print, but lead investigator, Dr. John McCann, has recently been presenting his team's data before professional audiences.
McCann and his colleagues are the only ones so far to take on the very necessary task of trying to establish the range of ano/genital anatomy in normal children. Without such data, the "findings" so regularly attributed to molest are essentially meaningless. That there are as yet no published data on this is itself highly significant.
At a meeting in San Diego in January, 1988, sponsored by the Center for Child Protection of the San Diego Children's Hospital, McCann reported on this research. Three hundred prepubertal children, carefully screened to rule out prior molest, were examined, and it was found that many of the things currently being attributed to molest are present in normal children.
Here are some conclusions:
Recall that Emans found that while abused (by "history" at least) girls were remarkably similar to nonabused but symptomatic girls (infections, rashes, etc.), hymenal tears and intravaginal synechiae were said to be found only in the abused group. We now see that McCann's findings contradict both these alleged differences between molested and nonmolested children. McCann saw no way to distinguish between a healed hymenal tear and "normal asymmetry." He also routinely saw "intravaginal synechiae" in his population of normal girls.
What little research exists, then, shows that a small group of self-appointed "experts" has been given undeserved credibility by an all-too-eager law enforcement and child protection bureaucracy. This has misled the courts, falsely diagnosed sexual abuse, and damaged the lives of countless nonabused children and falsely accused adults.
The Debacle in England
To illustrate that such an assessment is not an overstatement, let us briefly review what happened in the English town of Cleveland, where two pediatricians relied on their certainty that anal relaxation meant "buggery" (sodomy)
Hobbs and Wynne (1986) had reported in the British medical journal Lancet that "Dilation and/or reflex dilatation of the anal canal" were not seen in normal children, and indicated sodomy. They added that, "In addition to reflex dilatation, we have also seen alternate contradiction and relaxation of the anal sphincter or 'twitchiness' without dilatation. In our experience this also indicates abuse."
Despite the fact that Hobbs and Wynne (like Woodling) presented no controlled data, relying instead on their "experience," their claims were accepted as uncritically in Britain as similar ones are here. This is how Her Majesty's Report of the Inquiry into Child Abuse in Cleveland 1987 (Butler-Sloss, 1988) described what then started to unfold:
Higgs and a colleague (Wyatt) soon were diagnosing children right and left as victims of sodomy. So sure were they of their conclusions that when the finding disappeared and then returned, and the alleged perpetrator had no contact prior to the reappearance, they presumed a second sodomy by a different person! In one case, by the time of the fourth reappearance of the anal relaxation, the grandfather, father and finally the foster parents had all been accused of sodomizing the child.
Before this farce played itself out, Higgs and Wyatt had "diagnosed" sexual abuse in 121 children from 57 families, over a period of 5 months. In the typical case, the child would be removed from the parents and then subjected to regular "disclosure work" interviews.
Eventually, outraged parents were able to arrange second examinations and British courts gradually came to their senses and returned most of the children. Interestingly, these second examinations by highly experienced doctors often differed from the initial examinations. As Her Majesty's investigators wrote, "The signs recorded by Dr. Higgs and Dr. Wyatt were in the main confirmed by Dr. Wynne in those children she examined, but not by Dr. Irvine, Dr. Paul, Dr. Roberts and others in the children they saw."
This should be enough to give readers a sense of the pseudoscience which is presently passing as medical evidence in these cases.
A Review of 158 Examinations
I have as of this writing reviewed 221 cases of alleged child sexual abuse. Some cases have included dozens of children, so the total number of children is much higher. In these cases, 158 children have been examined medically. In all but a handful, only one examiner was permitted to examine the child, a practice which surely needs revising in light of the current state of the art.
Of the 158 children examined, 49 were boys and 109 girls. They ranged in age from one year, 10 months to 13 years old. The age distribution is shown in Tables 1 and 2.
With no scientific way to know which children were in fact abused, we cannot keep score on the percentage of false positive and false negative examinations. We can, however, look to see whether findings described in the single study of normal children (McCann) are being attributed to prior sexual abuse.
Table 3 tabulates those findings said to indicate genital abuse of girls. (As it turned out, all "positive" findings in boys were confined to anal examinations). Because of inconsistent terminology used by different examiners, I have included alternate terms in parenthesis.
Hymenal "scar" (bands,
We see that nearly all the findings attributed to molest were in fact found by McCann in substantial portions of the normal children he examined. They are also the findings which Emans, et al. (1987) found in children allegedly molested but also found in girls with no evidence of molest but suffering other types of medical problems.
Even the few findings Emans claims distinguish molested from nonmolested but otherwise symptomatic girls, such as hymenal tears and intravaginal synechiae, have been found to be unreliable. McCann et al. found, as already mentioned, that is was impossible to tell the difference between "normal asymmetry" of the hymen and hymenal "tear," and that he saw intravaginal synechiae "everywhere" when the normal children were examined.
Turning to the anal findings in the cases I have reviewed, Table 4 tabulates those findings said to indicate anal abuse. Here, both boys and girls were included.
Once again, we should first make use of the only study of normal children available, McCann's, to evaluate these findings. Both hyperpigmentation and anal relaxation were found in many unmolested children. Venous congestion was very common, as was thickening of anal folds. This leaves "scars" and "fissures" as the major finding said to indicate anal abuse in the cases I have studied.
Several factors raise serious questions about whether these findings are reliable. First, it is not uncommon for the scars described to be so small (one or two millimeters) as to be visible only with the use of the colposcope. (I am unable to present here a tabulation of the sizes of the scars in the the cases reviewed, for most often no pictures are taken and no measurement is taken.)
Also, we have no data on how frequently these findings will be found if normal children are examined in this way, particularly if the examiner is not told ahead of time that the child is to be examined is brought in for a sexual abuse examination. Specks of one or two millimeters (about one-sixteenth of an inch) may be easily called "scars" but are hardly reliable indicators of prior trauma.
Paul (1986) has commented forcefully on overinterpretation of such "scars." He writes, "... there is no evidential value in the finding of these tiny areas of scar tissue, for they are certainly not indicative of any form of sexual abuse. To honour them as being indicative of sexual abuse is to dishonour the administration of justice." Clayden (1987), Hey, Buchan, Littlewood and Hall (1987) and Roberts (1986) comment in a similar vein.
Are "fissures" any more reliable as an indicator of molest? Just as in other parts of the body, (take chapped lips, for example) fissures may occur from many causes (Mazier, DeMoraes & Dignan, 1978). Infection and secondary scratching are certainly a prime example. Thus, fissures are too nonspecific to reliably indicate anal abuse.
In those cases I have reviewed where a second examination took place, it was common for the one examiner to describe fissures and/or scars while the next examiner saw none. This was particularly true if the second examiner had not had a chance to see the first examiner's findings.
Overinterpretation of data is not, unfortunately, confined to the physical examination of the child. Laboratory data are frequently being interpreted in ways which are not medically justified.
Gonorrhea of the throat, for example, is easily confused with other organisms which occur normally (Mazier et al., 1978; Whittington, Rice, Biddle, & Knapp, 1988). Even genital gonorrhea, which obviously should lead to the most searching investigation of possible sexual contact, is not inevitably caused by adult sexual contact (Folland, Burke, Hinman, & Schaffner, 1977; Frau & Alexander, 1985; Frewen & Bannatyne, 1979; Gilbaugh & Fuchs, 1979; Gunby, 1980; Lipsitt & Parmet, 1984; Low, Cho, & Dudding, 1977; Neinstein, Goldenring & Carpenter, 1984; Potterat, Markewich, King, & Merecicky, 1986; Shore & Winkelstein, 1971).
Condyloma acuminata (so-called venereal warts) in children do not necessarily prove molest, despite frequent court testimony to the contrary (Bender, 1986; DeJong, 1982; Rock, Naghashfar, Barnett, Buscema, Woodruff, & Shah, 1986; Seidel et al., 1979; Shelton, Jerkins, & Noe, 1986; Stringel, 1985). Chlamydia false-positives are a risk with antigen screening tests, yet many persons have been accused on this basis (Fuster & Neinstein, 1987; Hammerschlag, Rettig, & Shields, 1988). Other organisms, such as Gardenella may infect the genitals of children, but insufficient data exist to automatically assume molest (Bargman, 1986; Bartley, Morgan, & Rimsza, 1987; Kaplan, Fleisher, Paradise, & Friedman, 1984).
The medical community should first speak out forcefully, alerting the community to the fact that unwarranted conclusions are being drawn by a small group of practitioners.
Research which generates controlled data is long overdue. Studies like that of McCann et al. must be replicated for all age groups, so that standards of normal ano/genital anatomy are established. Examiners should not be limited to those with a "special interest" in sexual abuse, for they have already demonstrated a profound bias.
Beyond such studies to establish the range of normal anatomy, we need studies which compare molested with nonmolested children. Those studies which have claimed to do this have in fact simply relied on the judgment of the referring agency as to which children were molest victims (Cantwell, 1983; Cantwell, 1987; Emans et al., 1987; Enos et al., 1986; Grant, 1984; Hammerschlag et al., 1985; Herbert, 1987; Hobbs & Wynne, 1986; Khan & Sexton, 1983; McCann et al., 1988; McCauley et al., 1986; Muram, 1988; Seidel et al., 1986; Spencer & Dunklee, 1986; Tilelli et al., 1980). This ignores, of course, the well established fact that false accusations of molest are a major problem.
Studies which compare molested children with normals must limit themselves to children demonstrated convincingly to have been molested. This will be difficult, for court findings are not necessarily accurate. If, however, this difficulty is ignored, and an unknown number of children examined and assumed to be molested have in fact not been molested, the data will continue to be as meaningless as they are now.
Meanwhile, the courts need to modify their current practice. The current assumption that a second examination is unnecessary must be reevaluated. Opinions not accompanied by photographs should be viewed with suspicion. Serious consideration should be given to the claim that interpretations being currently offered are not yet recognized by the general medical community. Finally, our Appeals Courts should recognize that convictions which relied on these premature medical claims are now suspect.
Physical examiners should not interview the child to get a "history" of possible abuse. This may influence the child and bias the examiner's subsequent findings and interpretations. Examiners should be told only that a careful ano/genital examination is required. When findings are conveyed to family members and/or law enforcement, overinterpretations must be avoided. All parties should be careful to remember that sexual abuse is rarely determined by physical examination alone. Thorough investigation is required.
Only when the medical community recognizes, and speaks out against, the current perversion of medical science, will the Courts and law enforcement respond. No sign of such an outcry from the doctors is on the horizon. Their deep sleep will only end, it seems, when concerned citizens take up the trumpet to awaken them.
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