A Critical Analysis of a Medical Report in a Case of Suspected Child Sexual Abuse

Robert Fay^*

ABSTRACT: This is an critical analysis of an actual medical examination and the physician's conclusions, with names and identifying details changed.  The report is based on a review of medical and other records and demonstrates the type of errors which can be made in the interpretation of medical findings.  It also illustrates what to look for when evaluating medical evidence and other documents in cases of alleged child sexual abuse.
  

Comprehensive Report with Interpretation/Comments on Data Concerning the Sexual Abuse Allegation of Heather Shaw

The material on which this report is based includes:

1. A one page history sheet signed by Dr. Fisher with a Lady of Hope Hospital letterhead.

2. Three pages of physical exam findings, also signed by Dr. Fisher, under a Lady of Hope Hospital letterhead.

3. Laboratory data which included blood count, urinalysis and urine culture count results, retic count and sickle test results, chlamydia screening tests from several organs and sources, and gonorrhea culture results from several orifices.

4. A one page anatomic drawing form concerning possible physical trauma, and a two page report of an Interview of Dr. Fisher by a police officer under the letterhead of a General Progress Report/City Police.
  

History

The history by Dr. Fisher relates first that the child primarily in question — Heather Shaw — was first alleged to have been abused by her father on April 8, 1989.  A Dr. Graff apparently examined her at that time and found nothing abnormal.  The vaginal/hymenal opening was 2 millimeters (assertively normal).  I am not aware of whether there was any historical or any other data which would lead anyone to conclude or suspect that abuse had occurred at that time.

It is next stated on this history form that the father was accused of abusing his son Jason, and that the case was "indicated."

I am assuming that there are much more data to which Dr. Fisher is privy, to which I am not at this time privy.  The specific historical and physical findings/details of that situation would be valuable to me.

It is then stated that the father's visits were to be supervised, and were supervised by "mother," and that for one brief moment during an emergency with a flooded appliance, father and child were alone for 5 minutes, and that later the child Heather (age 2 years, 8 months) "complained" of vaginal pain and stated that her father had "touched" her.

I am unable to interpret specifically Dr. Fisher's comment that this happened "last Sunday."  The specific date of "last Sunday" would be relevant and helpful in my evaluating the physical findings as reported on the next several sheets.

I must here interject a very healthy skepticism and caveat based on my fairly extensive experience evaluating these difficult and emotionally wrenching cases.  I think that offering supervised visits under the supervision of an accusing custodial parent (who is already suspicious and disdainful of any contact between the other parent and the child) is fraught with danger and frequent inaccuracy, relative to over worry and indeed over accusation.

The reader of this history is forced to conclude (if indeed an abusive genital act took place) that this child's father, already previously accused of abuse, already under suspicion, supervised at all times under the worried and watchful eye of a hostile custodial parent is going to jump at the chance to disrobe and digitally molest his two-year-old daughter while the mother is very briefly away because of an emergency in the laundry room.  I will he blunt — it stretches my imagination to believe that such an accused and suspected parent would be so incredibly stupid (above and beyond any compulsion and propensity to abuse) that he would commit such an act in such a circumstance.
  

Physical Findings

Dr. Fisher examined Heather in October, 1989 following these allegations.  The child's general examination was normal and the external genitalia were reported as normal.

Starting with the vaginal examination, I will comment individually on the findings mentioned.

There was moderate erythema with slight tenderness on the inside of the labia majora and minora.  Erythema in the genital and the mucosal area of a little girl is so common as to be normal.  It is present probably 50% of the time when any little girl under 5 is examined in a pediatric office.  Causes likely include the loculation of urine in the lower introital area which is somewhat irritating, the use of bubble bath, the common scratching, itching and masturbatory activity which goes on at this age, tight clothing, and strong laundry soap among other factors.  It means, in a word, nothing.  Slight tenderness in this area is also extremely common and difficult clinically to separate from a slight aversion to the doctor who is touching the area.  In medicine unfortunately, slight anything is hard to interpret.

The next finding is a bit hard to interpret because I believe one of the main words is misspelled.  There is a statement that there is one quarter vaginal "synechinite" posteriorly.  I'm almost certain there are mild synechiae in the posterior area of the labia minora, not really a vaginal but a labial finding.  I have never heard of the word synechinite and I'm almost certain it was meant to be synechiae.  If indeed the term is synechiae, that finding (synechiae of the posterior labia minora) is also exceedingly common and found in a large number of absolutely normal children, probably 15 or 20%.

The hymenal area is drawn and stated to be "interrupted" at 12 o'clock.  It is somewhat hard to interpret an "interruption" at that location.  Frankly, many hymens do not go around 360 degrees of the vaginal introitus and frequently the top 15% is absent and the hymen is crescentic.  Occasional hymenal "notches," if indeed such are present, are also difficult to interpret and have been found in up to 5 or 6% of normal children.  The "interruption" or "notch" would frankly be of more concern if it was in another location than 12 o'clock.  I do not consider this conclusive or definitive of abuse at all.

The hymen is said to he adherent to the labia minora at several locations pretty much all around the hymen (at 1 and 3, 7, 8 and 11 o'clock).  The hymen is stated in another place to be flexible and "floppy."  A flexible and floppy hymen is absolutely within normal limits and is a reasonably common finding.  I find the fact that the hymen is floppy to be somewhat helpful in explaining why it might be "adherent."  First of all regarding the "adhesions," experts have shown that when certain movements such as traction of the labia are performed these adhesions usually are not really adhesions at all and are easily separable.

Such adhesions which really are present (hymen to labia minora) are unusual and have not really been explained as to their cause, or indeed whether they are or are not commonly related to abuse.  I find the finding of "adhesions" to be: a) not interpretable or ascribable to abuse, and b) to be known by expert examiners to frequently not be "adhesions" when the labia undergo traction during examination.

The finding on the lower right hand of the examination paper that one could "visualize the vaginal vault which was erythematous" is not unusual or abnormal.  The ability to see the vaginal area or vaginal vaults in this examination varies with: a) the size of the vaginal orifice, b) the cooperation level of the child, and, c) the type of examination done to expose the hymenal/vaginal area.

On the lower left part of the physical exam there is a statement that the edges (this means the hymenal edges) are rounded and irregular.  Several experts have reported on the particular morphology and anatomy of the hymen and they tell us that irregularities are again so common as to be normal (up to 40% of the time) and that rounded or "smooth" edges are also extremely common.  These findings are not of value in evaluating abuse vs. nonabuse.

The findings concerning the diameter of this child's hymen merit substantial comment.  Hymenal diameter — what is normal and what is a problem — has been a great source of controversy for 10 to 15 years.  Very early in abuse investigations a magic number of 4 millimeters horizontal diameter was felt to be significant for judging abuse (above that suggestive of abuse, below that suggestive of normality).  We now know that this was a good effort but untrue and inaccurate.

Hymenal orifices vary with the age of the child, pubertal status, amount of cooperation and tenseness, and type of examination (among many other things).  Also we now look at both horizontal and vertical diameter, although horizontal is the more commonly evaluated and the more commonly reported upon.  I assume that the "opening" reported here is to be interpreted as being a horizontal hymenal opening of 8 millimeters, and I am going to comment on it as if it was that.

It is now known that the type of examination can cause a vast difference in the hymenal diameter of children.  A horizontal diameter of 8 millimeters in a child is therefore hard to interpret without knowing more specifics.  It is high for a child of this age but it is not by any means absolutely or pathognomonically diagnostic of penetration.

In a very recent and very valuable study of normal nonabused children hymenal diameters were reported for children of different ages reflecting different examination techniques (McCann, Voris, Simon, & Wells, 1990).  I do not know whether this child was examined with labial separation technique, labial traction technique or the knee/chest position, or some or all of these three ways.  I do not know, but I assume from the report, that the child was relaxed and totally cooperative.  Therefore my interpretation of the data is somewhat difficult.

The average horizontal diameter of children in this age group varied from roughly 2.5 to 5.5 millimeters, or 3.5 to 6.5 millimeters, or 3.5 to 6 millimeters.  The ranges (including children who are above or below average), with approximately 20 children in each group, were from 1 to 6, 2 to 8, or 2.5 to 7.5, depending type of examination (separation, traction, or knee-chest position).

It is hard to pontificate and be exact, but I think it is obvious that the "opening" reported is large, but not outrageous, when we compare it to the normative data presently known and available.
  

Differences Between Findings in April and October

The considerable differences in the findings April and October of 1989 also deserve substantial comment.  There are two possibilities to be considered here:

1. That both reports are essentially correct and accurate.  In that case, even if we assume that the findings as reported in October 1989 do not necessarily reflect physical abuse, it would still be reasonable to assume that some substantial occurrence or occurrences have occurred between April and October, causing the change in the child's genitalia.

To the extent that one can reconstruct abusive or traumatic genital events (and it's very difficult to do), I think any reasonable examiner/evaluator would conclude either that these substantial changes had to occur over a period of time (the repetitive or masturbatory events) or, if these substantial charges occurred in one brief molestational event (as was apparently alleged here), that such a penetrative and traumatic event would have had to have caused immediate pain and distress and probably bleeding.

We know that skilled or "gentle" molesters can digitally fondle and possibly even penetrate a little girl's hymen slowly and progressively over time, without always or usually causing pain.  We also know, however, that acute digital penetration with acute dilatation or change — especially one performed in 5 minutes — will cause pain and/or bleeding.

If one assertively feels that the findings as reported on October of 1989 are consistent with trauma, and especially so when the examination is compared to the 2 millimeter examination of April 1989, one has to conclude either that frequent "gentle" progressive molestation/penetration has occurred, or that, if indeed only one brief event occurred, something rather significant and nasty and painful, with probable tearing of the hymen, must have occurred.

My feelings then, if we assume that those reports are essentially correct and accurate, and if it is true that this little girl's father had no prior contact with her with the exception of this very clandestine and brief moment, would be that there is no way that this man could have inflicted this kind of change on this little girl's genital area in the brief time he had such an opportunity, unless the child noted immediate pain and unless bleeding (or residual blood) was found on that child or in her panties at that time.  The scenario which these findings would point to simply would not have allowed for a little girl to continue in a loving and pleasant interaction on that afternoon and then suddenly have a sore genital area that night.  It just wouldn't happen.

Of course, if one were to conclude (as we did here in number 1) that both reports were correct, and conclude that molestational trauma caused the changes, then we would have to strongly consider that the molestation occurred at a different time than on the 5 minute time on the date in question.

2. The second possibility is that one of these examinations was inaccurate.  It is perhaps possible that during the first examination, the child's genitalia were inspected but not separated or pulled in such a way as to get a more appropriate evaluation of the hymenal diameter, which might well have been similar to the diameter obtained six months later.

It is also possible that the second examination was somewhat in error, although it is usually more difficult to err when someone sees dilatation of the hymen than when on sees only normal hymenal tissue with a 1 or 2 millimeter opening.  I will say respectfully that the second examiner was very liberal in taking "iffy" and decidedly normal findings (like erythema), and drawing conclusions from this that this examination was consistent with abuse.

The bottom line for me is that the physical findings of this child's genital area are not really helpful in making a decision as to whether or not she was abused.  I will be frank — a lot of very "normal" and very "iffy" findings have been reported assertively.  And I think the bottom line impression which states "vaginal exam consistent with trauma" is unfair.  Without a balancing statement that it is also consistent with normality (which it is), the police department (as well as the accused and the child) are treated unfairly.  Reporting equivocal and iffy findings in an assertive manner often leads to aggressive action by (understandably angry and conscientious) police department, or by an equally conscientious concerned judicial officer.

Destruction of a parent/child relationship, or the financial, emotional and psychological destruction of a father, or the perception by a growing child that a parent abused him or her are all disastrous and are all catastrophic and abusive to the child — perhaps as catastrophic and abusive as an abusive act in itself.  All of the above are repugnant and horrible.

I have not yet commented on the laboratory data which are not helpful.  All of the cultures and screening tests for gonorrhea and chlamydia are negative.  Notice here that I did not say that they proved that the child was not abused.  It is fair and right to say that negative cultures do not exclude abuse — even negative genital findings do not exclude abuse.  The reverse (that certain genital findings do not indicate abuse necessarily) is also true, and has not been mentioned by anyone at any time in these reports.

The chlamydia screening tests done on this child are absolutely contraindicated and should not have been used in other than the vaginal area (and maybe not even in the vaginal area) in this child.  These screening tests were meant for adults and for use mainly on the adult human cervix.  They have been proven to be highly inaccurate with children, with very common false positives.  If indeed any of those tests came up positive I would be assertively stating that they were worthless tests and they mean nothing and they should not have been used.  The main problem is the high frequency of false positives — they react positively to certain bacteria which are normally found in the intestinal tract of children, and have nothing to do with abuse.

This concludes the report.  Should I receive any more data which is relevant or would change my opinions, I will promptly submit another addendum or report.
  

Suggested References for This and Other Cases Involving Medical Reports

Coleman, L. (1989). Medical examinations for sexual abuse: Have we been misled? Issues in Child Abuse Accusations, 1(3), 1-9.

McCann, J., Voris, J., Simon, M., & Wells, R. (1990). Comparison of genital examination techniques in prepubertal girls. Pediatrics, 85, 182-187.

McCann, J., Voris, J., Simon, M., & Wells, R. (1989). Perianal findings in prepubertal children selected for nonabuse: A descriptive study. Child Abuse & Neglect, 13, 179-183.

McCann, J., Wells, R., Simon, M., & Voris, J. (1990). Genital findings in prepubertal girls selected for nonabuse: A descriptive study. Pediatrics, 86, 428439.

Paradise, J. E. (1989). Predictive accuracy and the diagnosis of sexual abuse: A big issue about a little tissue. Child Abuse & Neglect, 13, 169-176.

Paul, D. M. (1977). The medical exam in sexual offenses against children. Medical Science and the Law, 17, 81-88.

Paul, D. M. (1986). "What really did happen to Baby Jane?" The medical aspects of the investigation of alleged sexual abuse of children. Medical Science and the Law, 26, 85-102.