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False Allegations of Child Abuse

Child abuse is a problem that is frequently underdiagnosed. Recognition that underdiagnosis of abuse exists has produced a high zeal for identifying cases of child abuse, which has inevitably produced cases of overdiagnois. Overdiagnosis of child abuse is as catastrophic as underdiagnosis.

-- Am. J. Clin. Path. 123 (S) : S-119, 2005

When I was an associate medical examiner for Jackson County, I got a lot of enjoyment from assisting with the prosecution of real criminals, and putting bad people where they belong.

When child abuse has really occurred, it is a dreadful thing, and the perpetrators deserve to be punished as examples to others.

It is not my purpose to address, here, the custody-battle tactic of making a groundless accusation of sexual abuse or domestic violence. Click here for information and get a good lawyer. One group that handles this sort of case is. ("No charge is easier to make against an innocent person and more difficult to disprove. The word of a child, whether mistaken, coached, or the result of a deliberate lie, is all that it takes to ruin lives.") Click, and for accounts of men who are still incarcerated despite the children having later admitted that their testimony was false. Click for the American Academy of Child and Adolescent Psychiatry practice parameters, which acknowledges that children sometimes lie and are sometimes coached. Click for the National Center for Reason and Justice, a group that helps people false accused of sex crimes. Click for the 2000 Harvard Law School conference on the 1980's Day Care Child Sex Abuse Phenomenon. Click for the conference notes. It is very easy to find accounts of children who made coached or malicious accusations online. Click to see how many ordinary citizens reading an obscure blog know someone to whom this has happened. Click for Law Hum. Behav. 30:561-70, 2006, in which a group found that in a simulation, adult jurors could not tell whether a child was telling the truth or had been intact hymenal ring photo coached to lie. Link is now down, let me know if there is another version posted: A prosecutor's digest, including an 2009 appeals court opinion, "If the only evidence of guilt is a child victim's out-of-court statement admitted under section 90.803(23), and if the child has recanted the accusation in court, the trial court must grant a motion for judgment of acquittal." Click for the report following the Wenatchee fiasco, documenting extensive unprofessional conduct by police and social workers. Click for "All parents are liars until proved otherwise", the mentality that I have found pervasive in child-protection circles. Click for the conservative "Renew America" -- "Yes, some chidren do lie." Social workers and child protection people see their role as "validators" -- all accusations are assumed to be true. Click for an account of inappropriate techniques used by "therapists" and "investigators" to get children to lie. ("Draw a picture of how you feel about Pa's genitals.")

Click for the Journal of the American Medical Association's review of criteria for sex abuse in prepubertal girls.

My concern is with errors by examining physicians and sex-abuse nurse examiners (SANE nurses). The system is imperfect, and occasionally an innocent person is accused on bad medical evidence. Once the initial error is made, it is very hard to stop the process.

The refereed medical literature recognizes the Alice-in-Wonderland nature of many sexual abuse workups in today's world, even in oh-so-proper England. ("Claims of innocence [are] taken as evidence of guilt, and information [is] interpreted in a manner that fit[s] only this presumption while factual evidence to the contrary [is] ignored." -- Medicine, Science & the Law 42(2): 149-59, 2002). In 1997,Professor Vidmar at Duke Law School documented how many jurors acknowledge that they cannot be impartial or ignore the presumption of the defendant's guilt in a sex abuse trial (Law & Human Behavior 21(1): 5-25, 1997).

In late March, 1996, I went to court in another state to help a working-class family which had contacted me through this home page. A 2 1/2 year old girl had obvious nonspecific vulvovaginitis, with a mix of flora on gram stain which included some gram-negative diplococci, mostly extracellular. The child was just getting over chickenpox, which might have triggered the vulvovaginitis. The pediatrician, a self-styled expert on child sexual abuse, found an "apparent healed laceration" at the 2-3 o'clock position in the hymen, no further description. Cultures and DNA probes were negative for gonorrhea. Cultures of all family members, including the grandfather, a former chief flight mechanic on a Navy ship, were negative for gonorrhea. The child denied any sexual stuff during the medical exams. The child struggled and cried a lot during the child abuse exams and cultures. A smear of the "purulent" exudate showed no white cells, only a lot of epithelial cells. Afterwards, she talked about "monster(s)" and "doctor monsters", and said, "The monster(s) put a bone in my mouth and the hair choked me" (the cotton-tipped swabs, dummies) and said "the monster had a mask" (duh).

On the strength of this evidence, the Department of Human Services told the court, "The perpetrator has been identified" as the grandfather, the evidence being that he owned a Hallowe'en mask. They told him that if he admitted his crime and got counselling, the child would be restored to the mother. The entire family refused. I was the sole medical witness for the defense, which I took for free.

I poked around the medical library, confirmed and improved on what I already knew, and was able to testify that (1) 3% of girls had a little nick in the hymen at the 2-3 o'clock position, just naturally, and around 20-30% of three-year-old girls have such innocent nicks ("apparent healed lacerations", I thought), which are no more indicative of trauma than is a double-chin; (2) relying on a gram stain in this situation was totally unacceptable as a means of diagnosing gonorrhea, and the bugs were probably Neisseria sicca or one of it kin, common commensals, which tend to be extracellular while gonorrhea bacteria are usually mostly intracellular; (3) the CDC guidelines specifically direct physicians NOT to rely on a gram stain in this situation; (4) if this were gonorrhea, there would have been white cells in the exudate, and the abundance of epithelial cells suggested "resolving chickenpox" to me; (5) the negative culture and DNA probes satisfied me that this was almost certainly not gonorrhea; (6) there are published, empirical criteria for the physical examination of a girl suspected of having been sexually abused, and the "expert" had utterly failed to address or meet these; (7) often you never find the cause of vulvovaginitis in a child. (I should have had the statistic, which is 70%; I'm sorry I didn't.)

We won.

The sexual abuse exam is now recognized as the business of the pathologist, whether the patient is alive or dead. A major review of the situation in Italy appears in Am. J. For. Med. Path. 28: 163, 2007, and there's a chapter in Dolinak's textbook.

From now on, I am available as a medical expert in other cases in which I'm convinced that an allegation of child abuse is false. I do not charge for an initial chat, and I do the cases where the person is clearly innocent pro bono. Please place links to my page as you think would be useful.


Gary Preble is an attorney at 2120 State Avenue NE, Olympia, WA 98506, 360-943-6960,.

Yet another resources is Tony Barreira, and Parents Helping Parents, 35 Tallmara Street, Winnipeg MB R2R 2G1 CANADA 204-256-8912.

Men's HOTLINE : 512-472-3237 :
807 Brazos, Suite 315 : Austin, Texas 78701
A service of the Men's Health Network : Washington, D.C.

Men's Health Network:
Edward Nichols MSW: a social worker with an interest in false allegations of sexual abuse >. To Receive Free Report: Email: and request "Free Report" Report will be sent by return email as an attached file.

Wayne Gossman MD, a psychiatrist and internet friend of mine, practices in Alabama. His phone number is 205-313-7246.

-- attorneys specializing in false sex abuse accusations by children, in Seattle.
, Los Angeles
Addendum: I receive many inquiries as a result of this page. Regrettably, many of the charges turn out (in my opinion, after considering the evidence) to be true. (If you're a "child protection activist" planning to send me one of those anonymous E-mails, please be reassured that I'm really not a "butcher", "murderer", "idiot" or whatever.)

I cannot help you unless the case against you is based on bad medical testimony.

From working in this area, I've reached the conclusion that most doctors don't want to go against the local prosecutors, or defend somebody accused of a vile crime, no matter how silly the charges. Since I'm not a family or political man, I can do this more freely than others, and enjoy the challenge.

Since I posted this, I've had additional cases of false accusations, including:

  • A case of a baby who was killed when another child jumped off a bed and by a freaky but plausable mechanism, already known from other cases, ruptured the baby's heart. The autopsy matched the family's story perfectly (even elegantly), but the case was unusual and there was dissension in the scientific literature about this kind of injury. I submitted a written report, and following the local medical examiner's testimony and cross-examination, and prior to the defense's time, the judge dismissed the case.
  • A teenaged boy who apparently had common jock itch, which was mistaken by a paraprofessional for herpes, and an adult was charged with causing this by sodomizing the boy; I wrote a letter and have heard no more since.
  • A young teenaged girl made assorted accusations, some clearly untrue, against her natural father, who was in a custody battle with the mother. The local child-protection expert evidently mistook the white line that sometimes runs from from the posterior aspect of the vulva to the anus as a healed laceration. This is the linea vestibularis, present in 10% of young women. After I pointed this out, I heard nothing more.
  • Not child abuse, but similar... A man died of a heart attack while smoking in his chair, and burned after he died. Sonja Casey, was wrongfully (and ridiculously) convicted of a torch murder. My letter written in an attempt to obtain her release got me a paragraph in the Wall Street Journal. She was released.
  • Not child abuse, but similar... A woman died with extremely advanced Alzheimer's, who had been fed by gastrostomy for 7 years (she hadn't known to eat for all this time), Finally she developed the cachexia that happens to these people at the very end. Death was actually due to heart failure, and it was inevitable considering the extremely advanced Alzheimer's. Although there was food in the gut, plenty of feces in the colon, and plenty of inner bodyfat, an activist pushed and the pathologist was willing to call it death by intentional starvation. Incredibly, the state prosecuted the caretaker for murder. The trial was highly political, with a state legislator at the prosecutor's table. I got to tell the court that the medical examiner had also overlooked two obvious brain infarcts that most second-year medical students would spot easily. The defendant was acquitted of the murder charge.
  • Not child abuse, but similar... A teenaged boy argued with his girlfriend's father in a weightroom. Later that day, the father complained of chest pain and died. A huge blood clot was found in a major coronary artery. The local medical examiner took a photograph of what appeared to be a normal skull marking which happened to be a bit prominent in the dead man, and a bit of blood from the extraction of the brain. He called the marking a fracture, though he did not give evidence that the bone fragments were separable, and called the death a murder from being struck on the head. As a result of this travesty, the teen did two years in jail. My consultation on the case helped with his ultimate acquittal.
  • A baby who died of SIDS also had a full diaper and was not found for 8 hours. Some red apparent abrasions were identified by the nurses when the body was undressed and washed. These were not in an assaultive pattern. Microscopy showed these to be the work of fecal clostridia, which were obvious on the slide, where they formed a bacterial lawn over the lesion. I was shocked and dismayed that the local pathologist wouldn't recognize this. I decided that he was either incompetent or just crooked. The prosecutor had nothing to say about the scientific stuff, but actually screamed at me because I read "Playboy", complained about my link to VOCAL, and made the false allegation that I was linked directly to sites for pedophiles. I asked to show the court that this was not true, but was not allowed to do so. This is how low some prosecutors can sink in a politicized case. For some reason, my testimony was eventually ruled inadmissable and the defendant was convicted.
  • I have reviewed two cases from Rhode Island in which a nurse-activist has testified, falsely, that her review of the literature indicates (in one case) mere failure of the anus to wink when the buttocks are spread (curiously she calls this the "relaxation response") is a good indicator for buggery, and (in the other case) labial adhesions are a strong sign of abuse. At the time she gave testimony in each case, the actual refereed medical literature indicated both claims were NOT true. This is at best a surprising display of ignorance from somebody who should know better, and at worst criminal perjury. On the evidence I have seen so far, this has resulted in one wrongful, and one dubious, conviction. Both men are in prison.
  • A man, also in Rhode Island, has served 11 years in prison because of testimony by a pediatric resident. Errors included saying that an opening in the hymen of 1 cm was excessively large for a six year old girl (it's just within the 2 SD), that scarring could be produced by rubbing, that a child who easily accepted an examiner's digital anal penetration had probably been abused, and that skin tags on the anus suggested sexual abuse. The child had a groin rash, which I thought was a better explanation for the "scarring" (sounded like dermatitis) on the perineum. And she had been receiving suppositories, which explained why she permitted anal digital penetration more easily than did other children. He tells me the accusation followed his finding his wife in bed with another man. I wrote him explaining the mistakes, and I have asked him to have the physician who testified against him review her testimony and reconsider in light of today's improved knowledge.
  • A man in the southern US was accused by his sixteen-year-old daughter of many episodes of penetration. The examiner testified that a pattern of scarring was seen at the edges of the ruptured hymen which indicated that intercourse was not consensual. She could not describe the identifying features of this pattern. During cross-examination, she admitted this was not something she could find in a textbook, but became very indignant, saying her education was not on trial here, that she doesn't memorize textbooks, and so forth. Of course, you can't tell from a physical exam whether consent was given. I told this to the interested parties. Outcome unknown.

Except for two cases which went through a referral agency, I've handled these pro bono.

Addendum: July 2003.
Understanding the Sex Abuse Exam

This is offered with the hope of helping both prosecutors and defense attorneys recognize errors by physicians that might cause a miscarriage of justice either way.

My focus is on tissue reactions. I have performed eight clinical rape exams as a team member, including two on children, while a resident. I think I am current in my reading on how to interpret physical findings in suspected abuse. Unlike two decades ago, there are clear standards, and they match what I know about disease and injury. And I probably have a better grasp of how tissue responds to injury than do the clinicians who have made the clinical guides.

Here is a list of Adams proposed classification of anogenital fidnings in children, from Pediatrics 94: 310, 1994. I chose this because it's been available for almost a decade and ought to be familiar to anybody claiming to be an expert. I have added my notes on WHY these make sense.

In May, 2007, the distingished journal Pediatrics published online (e1094) an article about the ability of the hymen to heal. The authors are John McCann and his teammates at the Child and Adolescent Research and Evaluation center at UC Davis. If you e-mail me, I will be glad to send you a copy. It seems to be a good study, with many photos, and I believe it will be of great importance in these trials in the years to come. The authors emphasize the remarkable ability of the hymen to heal, and show a photo of an 8-month-old baby with a transection which healed with only some neovascularity. (Notice that this is not "normal", any more than a flat red scar on a face after a knife wound is "normal"). You do need to examine all the data, including what the authors themselves do not point out. Among 39 prepubertal girls, 16 had full transections of the hymen that extended into the surrounding tissue. (This is what a reasonable person would expect after full penetration of a prepubertal child.) There were only 4 transections without such extension.) Among these, the vast majority of hymens ring that had healed were not "smooth", not "continuous", and not "delicate". This supports the common-sense idea that if a prepubertal girl is fully penetrated by an adult's penis, the hymen is unlikely to appear normal.

Some other recent articles that have bearing and that you may encounter are:

  • Pokorny and colleagues from Rutgers / Robert Wood Johnson, "Circumferential hymen elasticity: A marker for physiologic maturity", J. Repro Medicine 43(11): 943, 1998. The hymen becomes more elastic after adolescence is underway, as measured by the sizes of the speculums that the young woman can take. This further confirms for me the unlikelihood that an normal adult man's erect penis can fully penetrate a prepubertal girl without doing damage.
  • Hobbs and colleagues from Leeds, UK, "Colposcopic genital finings in prepubertal girls assessed for sexual abuse", Arch. Dis. Child. 73(5): 465, 1995. From the era in which attenuation of the rim of the hymen was considered evidence of penetration and a diameter of the orifice greater than 4 mm was also, all but two out of 109 girls had findings. The authors went on to say that "physical findings including normality are consistent with abuse and even minor anogenital findings should be documented." By this time, colposcopy and photography were obviously considered standard.
  • Lillibridge and Kappes, private practitioners in Anchorage, "Quantitative observations of hymens in prepubescent females selected for non-abuse", Alaska Medicine 35(2): 160-7, 1993. The authors took a different approach and concluded that regardless of age, height, or weight, the mean area of the orifice of the hymen for "non-abused, non-masturbate" was 6.4 square millimeters, the upper limit of mean being 24.1 square millimeters, and also concluded somehow that an opening diameter of 6.94 or less meant that the child was 99% likely not to have been abused.
  • Myhre, Berntzen, and Bratlid, Norway, "Genital anatomy in non-abused preschool girls", Acta Paed. 92(12): 1453, 2003. This paper completely discredited the old idea that a large diameter to the opening of the hymen suggested previous sexual abuse. The authors also noted that the old classic finding of "thinning of the posterior hymen" often just reflected it being folded over on iself (!) -- suggesting just how good the older sex abuse exams had been. A few drops of saltwater clarifies things.
  • Pugno, Perry A., "Genital Findings in Prepubertal Girls Evaluated for Sexual Abuse: A Different Persective on Hymenal Measurements", Arch. Fam. Med. 8: 403-406, 1999. This is a study by a resident who concluded that girls being examined for sexual abuse without other signs had a mean transhymenal diameter of 2.3 mm (at what age?) and "in general showed an increase of approximately 1 mm per year of age" (how can this be? I don't see that it's even supported by the data) By contrast, girls with "definitive signs of genital trauma" had average diameters of 9.0 mm "and no significant variance wtih age" even in babies. Since definitive signs usually means the hymen has been pierced, it is no wonder that none of the author's mentors wanted to be co-author. I am more surprised that this passed peer-review. The newer articles discredit the author's conclusions.
  • Ingram, Everett and Ingram, from Chapel Hill. "The relationship between the transverse hymenal orifice diameter by the separation technique and other possible markers of sexual abuse", Child Abuse & Neglect 25: 1109-20, 2001. The authors found the number to be worthless in distinguishing girls at low and high risk of having been sexually abused. The article includes large numbers of children, including hundreds of girls, many as young as 3-4, in which the authors thought vaginal penetration was likely; however this was based on interviews, considered positive if the interviewer was merely suspicious, and did not distinguish between fingers and penises. Further, there's nothing in any of the data to suggest that any child known to have been penetrated by a penis had an otherwise-normal hymen. There are also a huge number of girls with "narrowed posterior hymenal rim", now clearly a bogus finding. The authors discussed in great detail the likelihood that not all histories are true. They admit that "interviewing is as much an art as a science [and] attorneys, for one, are quick to question the reliability of the testimony of young children." In other words, this isn't and can't be about determining for certain what really happened in an individual case. Most sensibly, the authors concluded that sexual abuse would only increase the diameter of the hymen if it had been torn, lacerated, clefted between 5 and 7 o'clock (i.e., an old posterior tear), or "narrowed posterior rim". At the time, the American Academy of Pediatrics recommended using the diameter to confirm sexual abuse, and this helped discredit the claim.
  • Berenson and colleagues, Galveston, "Use of Hymenal Measurements in the Diagnosis of Previous Penetration", Pediatrics 109(2): 228-35, 2002. This group found the measurements not to be helpful. There are no measurements for different ages.
  • Berenson AB and colleagues, Baylor & Mayo. "A case-control study of anatomic changes resulting from sexual abuse." Am. J. Ob. Gyn. 182: 820-34, 2000. This study was the first to try to sort out girls between ages 3 and 8 who had been penetrated vaginally by finger or penis from those who had merely had their labia touched. The authors freely acknowledge that this had been a problem in previous "it's normal to be normal" studies. They also affirm that the literature is full of contradictions. Unfortunately, almost none of the girls were examined within the first week after the last episode of abuse. The girls in the abuse group came from DFS sources. The authors did use an instrument to assess the likelihood of penetration, especially noting pain and bleeding, and seem to have used great care. We don't know how many girls were exluded because their stories seemed not to be true, but there must have been a fair number. The authors examined variations in the anatomy of the hymen and found almost no significant differences between groups in bumps, vascularity, friability, bands, or superficial notches. Only four children had transections, perforations, or deep notches, and all had been penetrated.

Life has taught me to trust physical evidence above what anybody tells me, no matter how seemingly "sincere". You'll have to ask somebody else how often a child is coached to tell a fabricated story during a divorce or custody battle.

Although this is mainstream... as of this writing (July 2003), the criteria for the physical exam in suspected child abuse have been almost impossible to find online. (It's no surprise that most people who post on the internet are concerned with politics instead of with truth.) For example, the 2001 proposed classification was only located at a relatively obscure Filipino site. The Filipinos included a much-deserved thank-you to Dr. Joyce Adams.

Proposed Classification of Anogenital Findings in Children (1994)

Normal: Class I

  • Periurethral bands

  • Intravaginal ridges or columns

  • Increased erythema in the sulcus []

  • Hymeneal tags, mounds, or bumps []

  • Elongated hymeneal orifice in an obese child

  • Ample posterior hymenal rim (1-2 mm wide) []

  • Estrogen changes (thickened, redundant hymen) []

  • Diastasis ani / smooth area at 6 or 12 o'clock in perianal area []

  • Anal tag / thickened fold at midline []

  • []

Nonspecific findings (Class II).

  • "Findings that may be caused by sexual abuse, but may also be caused by other medical conditions. History is vital in determining significance.
  • Erythema of vestibule or perianal tissues []

  • Increased vascularity of vestibule or hymen []

  • Labial adhesions []

  • Rolled hymenal edges in the knee-chest position []

  • Narrow hymenal rim, but at least 1 mm wide []
  • Vaginal discharge []

  • Anal fissures
  • []
  • Flattened anal folds []

  • Thickened anal folds []

  • Anal gaping with stool present []

  • Venous congestion of perianal tissues, delayed in exam []

Suspicious for abuse (Class 3)

  • "Findings should prompt the examiner to question the child carefully about possible abuse. May or may not require a report to Protective Services in the absence of a history."
  • Enlarged hymenal opening -- greater than two SD's [standard deviations] from nonabused study (McCann et al.)[]

  • Immediate anal dilitation of at least 15 mm with stool not visible or palpable in rectal vault []

  • Immediate, extensive venous congestion of perianal tissues []

  • Distorted, irregular anal folds []

  • Posterior hymenal rim less than 1 mm in all views []

  • Condyloma acuminata in a child []

  • Acute abrasions or lacerations in the vestibule or on the labia (not involving the hymen), or perianal lacerations []

Suggestive of Abuse / Penetration (Class 4)

  • Combination of two or more suspicious anal findings or two or more suspicious genital findings

  • Scar or fresh laceration of the posterior fourchette with sparing of the hymen []

  • Scar in perianal area (must take history into consideration) []

Clear Evidence of Penetrating Injury (Class 5)

  • Areas with an absence of humenal tissue, (below the 3 o'clock to 9 o'clock line with patient supine) which is confirmed in the knee-chest position

  • Hymenal transections or lacerations

  • Perianal laceration extending beyond (deep to) the external anal sphincter

  • Laceration of posterior fourchette, extending to involve hymen

  • Scar of posterior fourchette associated with a loss of hymenal tissue between 5 and 7 o'clock

Note 1: The sulcus is the area around the glans of the clitoris. Redness here means nothing.

Note 2: These are common normal variants, like having a split in your chin. If the bump is about the same color as the nearby tissue, it can't be a scar. I would have added that notches in the anterior half of the hymen (i.e., 9 o'clock to 3 o'clock with the patient supine) mean nothing.

Note 3: The anterior hymenal rim may be very slim or absent as a normal variant; this was the case with and the pathologist recognized it as normal.

Note 4: I read testimony of one examiner who said that thickening implied scarring and thus prior abuse. This flunks introductory "Pathology" in medical school. Scar usually contracts. Estrogen renders the hymen thicker and more redundant / wrinkly so it stretches easier.

Note 5: Diastasis ani means the visible portion of the anal opening appears slightly open when the buttocks are spread. This means nothing. The mucosal folds (i.e., the little stretchable wrinkles that are present when the anus is not distended by stool) in front and back are often much more shallow than elsewhere, and this is a normal variation. I have seen both of these called evidence of sexual abuse.

Note 6: A tag is a bit of redundant skin. You can see skin tags around the anus on anybody, or on the necks or elsewhere on the skin especially of older folks. I have had two cases of physicians calling anal skin tags evidence of anal penetration. You have to wonder whether they've done many rectal exams on normal people. A "sentinal pile" is edema or venous dilation just below a fissure. If somebody has a fissue, it'll be obvious already.

A white line running posteriorly from the posterior forchette, over the skin in the midline, is a normal variant. As I noted above, I've seen this called a "scar" and thus proof of severe abuse. It is a normal anatomic variant.

A crescentic hymen, i.e., with no tissue at all between 11 o'clock and 1 o'clock or thereabouts in the supine position, is a perfectly normal variant. So is a cribriform ("sieve-like") with several openings.

I am not aware of any reason to believe that if the anal sphincter relaxes but only after one second following spreading of the buttocks, this indicates anal intercourse. However, as I've noted, this was stated as fact in court, leading to what seems to me to be a faulty conviction.

In one case, Division of Family Services people stated that since the suspect had been given a routine urinalysis during a doctor's office visit, it was proof that the doctor suspected venereal disease. I hope nobody who lives in your community is this ignorant.

One of the toughest calls is the "normal" exam when the child claims abuse. In evaluating these claims, there are a couple of things to consider.

First, the tissues of the vulva, including the hymen, can heal minor trauma after a few weeks with no scar.

Second, the ring around the hymen is quite sensitive in a pre-pubertal girl, and touching it will hurt considerably.

Third, fondling and digital penetration of just the vestibule (a girl will probably still call this the vagina) and/or anus isn't going to leave any physical changes except perhaps transient redness.

Fourth, despite "it's normal to be normal", I cannot believe, and am not aware of any evidence, that penetrating a girl of any age with an erect normal-sized penis is likely to leave the hymen intact.

I've seen a few cases in which an examiner finds no abnormality whatsoever, and signs the case out, "Normal examination, consistent with sexual abuse." In pathology (and so far as I know, in every other branch of real medicine), when I say "consistent with", I mean there is some solid physical evidence that this is the case. I was taught to sign out a negative rape / sex abuse exam, "No physical evidence of..." If these examiners were honest (and I use this word after reflection), they would say instead, "No physical evidence of abuse. NOTE: A normal exam does not rule out fondling or some other forms of sexual abuse."

Note 8. Erythema simply means increased blood flow, as when in blushing or exercise or after scratching. In 1988, a sex abuse examiner in Rhode Island noted erythema of the posterior mucosal surface of the vulva on a six year old girl. She testified that this was likely the result of digital penetration of the vulva six months previously. This is even stupider because the child had a groin rash, likely from poor hygiene.

Note 9. Increased vascularity means that the blood vessels, i.e., the surface veins, are easier to see. This usually reflects the changes of chronic inflammation, in which the epithelium may be thickened and the mucosa may be edematous and infiltrated by white cells. On the skin, we call this a chronic dermatitis. Increased vascularity is also seen in a healing true scar. The two are easy to confuse, especially if the examiner doesn't reflect that a scar must be localized and must have been preceeded by abundant hemorrhage. Rubbing could produce a dermatitis / mucositis, as could any other kind of irritation, inflammation, or infection. However, this won't last more than a few days.

Note 10. Labial adhesions are fibrin or other condensed protein connecting the labia. It's fairly common in young girls and evidently "just happens". Of course, scabbing following severe abuse could do the same thing. One of our medical students has a daughter who was diagnosed as an intersex by the family doctor and the family was on its way to genetic counselling. Asked for my opinion first, I demonstrated the ease with which labial adhesions could be separated with a wet Q-tip. The term "friability" has different meanings in clinical medicine ("bleeds easily when manipulated") and pathology ("crumbly").

Note 11: There's more tissue here than usual. This can be normal, or the result of inflammation from another cause, or the result of deformation of the hymen from trauma.

Note 12: I believe the authors are referring to the posterior portion of the hymen.

Note 13: Nonspecific vulvovaginitis in children can result from systemic illness, poor hygiene, or "just happen". Finding gram-negative diplococci on gram smear is not evidence of gonorrhea in the female. A negative culture / gene probe rules out untreated gonorreha.

Note 14: A genuine anal fissure is very painful. This will not be a surprise finding on examination. Resources suggest all fissures are longitudinal, i.e., radiating out from the anal opening; however, deep ones can be transverse.

Note 15: Flattened anal folds would only result from abuse which would produce additional evidence trauma, with deformation of the underlying connective tissue (marked remodelling in a scar) or marked associated local edema (obliterating the folds by stretching). The idea that fondling will flatten mucosal folds is as ridiculous as claiming that rubbing your lips will lead to an area that doesn't wrinkle when you pucker your mouth.

Note 16: Thickening (i.e., increased prominence) of the anal folds would be typical of a chronic dermatitis / mucositis. The trauma would have to be equivalent to what would produce a rash or signs of injury on the lips.

Under development

Overall Assessment of the Likelihood of Sexual Abuse (1994)

Class 1: No evidence of abuse

  • Normal exam, no history, no behavioral changes, no witnessed abuse

  • Nonspecific findings with another known etiology, and no history or behavioral changes

  • Child considered at risk for sexual abuse, but gives no history and has nonspecific behavior changes

Class 2: Possible abuse

  • Class 1, 2, or 3 findings in combination with significant behavioral changes, especially sexualized behaviors, but child unable to give history of abuse

  • Presence of condyloma or herpes 1 (genital) in the absence of a history of abuse, and with otherwise normal exam

  • Class 3 findings with no disclosure of abuse

Class 3: Probable abuse

  • Child gives a clear, consistent, detailed description of molestation, with or without other findings present

  • Chass 4 or 5 findings in a child, with or without a history of abuse, in the absence of any convincing history of accidental penetrating injury

  • Culture-proven infection with Chlamydia trachomatis (child over 2 years of age) in a prepubertal child. Also culture proven herpes type 2 infection in a child, or documented Trichomonas infection

Class 4. Definite evidence of abuse or sexual contact

  • Finding of sperm or seminal fluid in or on a child's body

  • Witnesed episode of sexual molestation. This also appplies to cases where pronographic photographs or videotapes are acquired as evidence

  • Nonaccidental, blunt penetrating injury to the vaginal or anal orifice

  • Positive, confirmed cultures for Neisseria gonorrhoeae in a prepubertal child, or serologic confirmation of acquired syphilis

By the time these were written, the literature shows they were common knowledge. In my opinion, any physician or other examiner offering medical testimony substantially at variance from these proposed standards after the year 1994 was doing sub-standard work.

Development of the scheme continued. Here is the 2001 version, from Child Maltreatment 6(1): 31. 2001.

Anogenital Findings on Examination (2001)

Normal

  • Peri-urethral or vestibular bands

  • Longitudinal intravaginal ridges or columns

  • Hymenal tags

  • Hymenal bump or mound

  • Linea vestibularis

  • Hymenal cleft/notch in the anterior (superior) half of the hymenal rim, on or above the 3 o'clock-9 o'clock line, patient supine

  • External hymenal ridge

Normal Variants

  • Septate hymen

  • Failure in midline fusion

  • Groove in the fossa in a pubertal female

  • Diastasis ani

  • Perianal skin tag

  • Increased peri-anal skin pigmentation

Other Conditions

  • Hemantiomas of the labia, hymen, or perihymenal area (may give the appearance of bruising or submucosal hemorrhage)

  • Lichen sclerosus et atrophicus (may result in friability and bleeding)

  • Behcet's disease (causes genital and oral ulcers, may be mistaken for herpes simplex lesions)

  • Streptococcal cellulitis of perianal tissues (causes red, inflamed tissues)

  • Molluscum contagiosum (warty lesions)

  • Verruca vulgaris (common warts)

  • Vaginitis caused by streptococcus or enteric organisms

  • Urethral prolapse (causes bleeding, appearance of trauma)

  • Vaginal foreign bodies (may cause bleeding, discharge)

Non-Specific Findings

  • Erythema (redness) of the vestibule or perianal tissues (may be due to irritants, infection or trauma)

  • Increased vascularity (dilation of existing blood vessels) of vestibule (may be due to local irritants)

  • Labial adhesions (may be due to irritation or rubbing)

  • Vaginal discharge (many causes)

  • Friability of the posterior fourchette or commissure (may be due to irritation, infection, or may be caused by examiner's traction on the labia majora)

  • "Thickened hymen" (may be due to estrogen effect, folded edge of hymen, swelling from infection, or swelling from trauma)

  • Apparent genital warts (may be skin tags or warts not of the genital type, may be condyloma accuminata which was acquired from perinatal transmission or other non-sexual transmission)

  • Anal fissures (usually due to constipation or peri-anal irritation)

  • Flattened anal folds (may be due to relaxation of the external sphincter)

  • Anal dilation with stool present (a normal reflex)

  • Venous congestion, or venous pooling (usually due to positioning of child, also seen in constipation)

  • Vaginal bleeding (may be from other sources, such as urethra, or may be due to vaginal infections, vaginal foreign body, or accidental trauma)

Suggestive of Abuse

  • Marked, immediate dilation of the anus, with no stool visible or palpable in the rectal vault, when the child is examined in the knee-chest position, provided there is no history of encopresis, chronic constipation, neurological deficits, or sedation

  • Hymenal notch/cleft in the posterior (inferior) portion of the hymenal rim, extending nearly to the vaginal floor. (often an artifact of examination technique, but if persisting in all examination positions, may be due to previous blunt force or penetrating trauma)

  • Acute abrasions, lacerations or bruising of labia, peri-hymenal tissues, or perineum (may be from accidental trauma, or may be due to dermatological conditions such as lichen sclerosus or hemangiomas)

  • Bite marks or suction marks on the genitalia or inner thighs

  • Scar or fresh laceration of the posterior fourchette, not involving the hymen (may be caused by accidental injury)

  • Perianal scar (rare, may be due to other medical conditions such as Crohn's disease, or from pervious medical procedures)

Clar Evidence of Blunt Force or Penetrating Trauma

  • Laceration of the hymen, acute

  • Ecchymosis (bruising) on the hymen

  • Perianal lacerations extending deep to the external anal sphincter

  • Hymenal transection (healed). An area where the hymen has been torn through, to the base, so there is no hymenal tissue remaining between the vaginal wall and the fossa or vestibular wall.

  • Absence of hymenal tissue. Wide aeras in the posterior (inferior) half of the hymenal rim with an absence of hymenal tissues, extending to the base of the hymen, which is confirmed in the knee-chest position.

Overall Assessment of Likelihood of Abuse (2001)

NOTE by me: This seems much more helpful to me than simply writing, "Normal exam consistent with sexual abuse." I think that these criteria should now be considered standard, and I would question the integrity of an examiner who deviates substantially from this outline.

No indication of abuse

  • Normal exam, no history, no behavioral changes, no witnessed abuse

  • Nonspecific findings with another known or likely explanation and no history of abuse or behavioral changes

  • Child considered at risk for sexual abuse but gives no history and has only nonspecific behavior changes

  • Physical findings of injury consistent with history of accidental injury that is clear and believable

Possible abuse

  • Normal, normal variant or nonspecific findings in combination with significant behavior changes, especially sexualized behaviors, but child unable to give a history of abuse

  • Herpes type I anogenital lesions, in the absence of a history of abuse and with an otherwise normal examination

  • Condyloma accuminata, with otherwise normal examination; no other STDs present, and child gives no history of abuse. Condyloma in a child older than 3-5 years is more likely to be from sexual transmission, and a thorough investigation must be done.

  • Child has made a statement but statement is not sufficiently detailed, given the child's developmental level; is not consistent; or was obtained by the use of leading questions concerning physical findings with no disclosure of abuse

Probable abuse

  • Child has given a spontaneous, clear, consistent, and detailed description of being molested, with or without abnormal or positive physical findings on examination

  • Positive culture (not rapid antigen test) for Chlamydia trachomatis from genital area in prepubertal child, or cervix in an adolescent female assuming that perinatal tarnsmission has been ruled out

  • Positive culture for herpes simplex type 2, from genital or anal lesions

  • Trichomonas infection, diagnosed by wet mount or culture from vaginal swab, if perinatal transmission has been ruled out

Definite evidence of abuse or sexual contact

  • Clear physical evidence of blunt force or penetrating trauma with no history of accident

  • Finding sperm or seminal fluid in or on a child's body

  • Pregnancy

  • Positive, confirmed cultures for N. gonorrhea from vaginal, urethral, anal, or pharyngeal source

  • Evidence of syphilis acquired after delivery (i.e., not perinatally acquired)

  • Cases where photographs or videotape show a child being abused

  • HIV infection, with no possibility of perinatal transmission or transmission via blood produts or contaminated needles

Please click to see the Adams 2003 classification, as it was originally placed online by the medical students at Harvard.

Normal hymen anatomy: Pediatrics 89: 387, 1992.




. Outstanding review.

Elaine Lehman, FAST, False Allegations Solutions Team, 4514 Baptist Road, Taneytown, Maryland 21787, Phone 410-756-9067; FAX 410-756-9068. I am told the group does not charge. Click for their website.

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