Medical Considerations in the Diagnosis of Child Sexual Abuse
ABSTRACT: There are no medical signs in the vast majority of
abuse cases. Many findings promoted as physical indicators of
been shown to be present in nonabused children. In particular hymenal
openings said to measure more than 4 mm, genital rashes and redness, and
anal reflex dilatation have been demonstrated to be unreliable medical
indicators. Children can be harmed both by unnecessary invasive investigation
(including general anesthesia) and by subsequent
interventions if the allegations are false. Doctors must insure that
they have an empirical basis for the interpretation of their findings,
and that they do not allow someone else's belief that a child has been
abused to color their clinical judgment. Describing normal findings as
"consistent with abuse" is decried. This practice is likely to
mislead a court to erroneously believe that there is physical evidence
supportive of abuse.
Most cases of sexual abuse are diagnosed on historical and behavioral
evidence and not on physical findings (Kivlahan, Kruse, & Furnell,
1992). However, investigation of sexual abuse will often involve a
medical examination to look for physical evidence of abuse. Such
information will be eagerly sought by the prosecution, as physical
findings represent relatively "hard" evidence compared to
psychological assessment and "disclosure" interview findings.
Also, the courts will generally give considerable weight to a physician
testifying in support of an abuse allegation.
The majority of sexual abuse cases involve activities such as genital
fondling and not penetration of the vagina or anus, and do not cause any
marks or damage to the tissues. A diagnosis of sexual abuse is therefore infrequently made solely on medical findings (Lawton,
Goodyear, & Stringer, 1987; Royal College of Physicians, 1991).
Sexual activity can be proved if an underage pregnancy has occurred, or
if a sexually transmitted disease is detected, but these are relatively
rare events. Finding semen on the genital area also indicates sexual
contact, but this is only possible if the child is examined soon after
the alleged event (within 72 hours at the outside) (Gabby, Winkleby,
Boyce, Fisher, Lanchester, & Sensabaugh, 1992). In reality, the
vast majority of alleged abuse cases present weeks, months or years
If a young child does have the vagina or anus penetrated by fingers
or a penis, bruising, tearing and bleeding are likely. It seems probable
that the child would also suffer considerable discomfort for the next
couple of days or so, especially when urinating or defecating. Anal
penetration by the penis results in severe exacerbation of pain when the
child next attempts to defecate (Paul, 1990). The perineal region has a
good blood supply, and usually heals rapidly.
Whether such injuries cause permanent scars detectable months or
years later is currently being researched. McCann, Voris and Simon
(1992) studied three children who had suffered genital lacerations from
a single isolated episode of assault, one requiring suturing. They used
a camera and colposcope to record their findings and followed up the
appearance of the injuries for up to three years. They found that in these
cases, there was very little scar formation and signs of damage were
difficult to detect after a couple of months.
Children who have bee n sexually abused on an ongoing basis may well
show more obvious signs of trauma. The vaginal and anal orifices might
remain more open and show signs of scarring, although research evidence
in this area is still sparse also.
Children's genital regions have not been routinely examined in
medical examinations, and until the last decade virtually nothing was
written on what normal vaginas and anuses looked like in childhood (Pokorny,
Pokorny, & Kramer, 1992; McCann, Voris, Simon & Wells, 1989;
McCann, Wells, Simon, &Voris, 1990).
In 1983, Cantwell examined and measured the hymens of nearly 250
girls under 13 years of age who were treated at a Crisis Care Unit in
Denver. She reported that 75% of those with horizontal openings greater
than 4mm had been sexually abused. Four years later she amended this
figure to 80% (Cantwell, 1987). This paper is often quoted by medical
experts in court rooms and in the absence of any other studies, a
horizontal hymen size greater than 4mm has been considered an indicator
of sexual abuse.
Examination of this study reveals it seriously flawed, however.
First, the method of substantiating abuse was not made clear, and
appears to include a number of girls who denied that they were victims.
Second, measuring hymenal size is not a simple procedure, and
different examiners are likely to get different results. To establish
the diameter, a child's legs must be spread at the hips and the vaginal
lips gently parted to expose the hymen. Varying the amount of lateral
pressure used to part the lips will distort the shape of the hymen and
change the apparent diameter. In addition, the method used for
examination supine with labial separation, supine with labial traction,
or knee-chest affects the measurement of the hymenal orifice diameter
(McCann, Voris, Simon, & Wells, 1990).
Hymenal shape is very variable (Heger, 1985; Hyden, & Gallagher,
1992). Some have several openings, they may be crescent-shaped,
slit-shaped (horizontal or vertical), or very irregular. The hymen might
be thick and fleshy or a very thin membrane. Not only is measurement
impossible with any degree of accuracy, but Dr. Raine Roberts,
Manchester, reported in the British Medical Journal in 1989 that
"the hymen ... can vary, in the same child, from a pinhole to a
centimeter, depending on whether she is relaxed or apprehensive, warm or
cold." A medical finding of a dilated hymenal opening must therefore be interpreted
with great caution.
The diameter of an average index or middle finger is about 15 to
20mm. An erect penis is 25 to 40mm in diameter. The hymen is not a very
elastic tissue, but even allowing for some stretching, the belief that
any hymenal diameter greater than 4mm is an indicator of abuse is not
commonsense. The Royal College of Physicians (1991) states that a
hymenal diameter of 15mm is supportive of abuse, although it should not
be used as the sole basis for a diagnosis.
Unfortunately, the belief that hymenal diameters greater than 4mm
indicate sexual abuse has permeated the field. I have examined a number
of medical reports of vaginal examinations where hymenal sizes less than
10mm have been reported by the examining physician as indicating
In one particular case, a woman doctor in Christchurch, New Zealand,
examined three sisters and gave the opinion that they had all probably
been molested. She claimed that her examination of the 5-year-old
revealed "a transverse vaginal diameter of 5mm, and no evidence of a
hymen" which she found "highly suggestive of penetration."
The 9-year-old had a transverse vaginal opening of 3.5mm, with hymenal
remnants, which she concluded was "suggestive of some
interference to the vagina," and the 10-year-old had a transverse
opening of 6mm, with no definite hymen, which she believed was
"strongly indicative of vaginal penetration."
The three girls were then subjected to a number of sexual abuse
assessments. In her first interview session, the eldest girl was told
that the doctor's examination showed that she had been the victim
of "bad touching" and had a "hurt between her legs."
Despite being repeatedly questioned about who had caused the
"hurt," she continued to deny any molestation. Even after two
counselors performed a role play with her about a "father who hurts
kids between their legs" she was adamant that nothing like that had
happened to her. Sadly she was not believed and all three children were
placed in a foster home. Their father was charged with sexual violation
of all his daughters, especially the eldest. It was a year and a half
before his case was heard in court, where he was acquitted on all
Other Female Genital Findings
Examining doctors often claim that rashes and redness around the
vaginal area are "consistent with sexual abuse." While this
may be technically true, there are so many other common causes of such
findings that such a claim is likely to mislead a court into believing
these findings mean sexual abuse has probably occurred. In fact, such
genital irritation is also consistent with no sexual abuse. Scratching,
masturbating, inadequate washing, irritating soaps and bubble baths,
tight-fitting underpants, threadworm, thrush and other nonsexually
transmitted infections can all result in redness and irritation. So can
a number of less common causes such as foreign bodies inserted in the
vagina (Emans & Goldstein, 1980).
Genital examination of little girls is generally done with the child
in one of two positions: knee-chest, where the child is asked "to
lie on her tummy with her bottom in the air," or the frogleg
position, where she lies on her back, sometimes propped up with her
parent sitting behind her, with her legs spread open. In my experience,
once good communication and rapport has been established, most children
will tolerate such an examination with little complaint.
There are a few situations, however, where an examination needs to be
carried out under a general anesthetic. In 1984, in conjunction with an
Auckland pediatrician specializing in sexual abuse work, I established
guidelines in New Zealand for when examination under anesthetic (EUA) is
It was emphasized that examination under general anesthetic should be
a very rare occurrence. These guidelines were distributed to all New
Zealand registered medical practitioners (Lawton et al, 1987).
Unfortunately, these guidelines are not always adhered to, and it
appears that children undergo general anesthetics for what I believe are
unjustifiable reasons. In one particular case, a 3-year-old girl in my
care was the subject of a custody dispute. Her father was seeking to
return to his home in Europe with his daughter, and alleged that her new
stepfather had sexually abused her. A Family Court hearing did not
uphold the allegation, and joint custody was awarded. The father was
upset at the decision, and continued to present the child at several
Auckland agencies dealing with sexual abuse. Often these centers were
unaware of previous proceedings, and therefore this child had continuing
assessments and interventions for alleged abuse, despite the court
On one occasion when the child was staying with him, her father
noticed a small warty lesion on her mons pubis, in the area just above
and to the right of the clitoris. Without informing her mother, he took
her immediately to the Child Protection Team at the Children's Hospital.
The Team rapidly decided that this child had almost certainly been
sexually abused, and that the wart should be removed under a general
anesthetic to be sent to the virology lab for typing (to see if it was
of a sexually transmitted type). They were not going to tell the child's
mother, as she was considered to be a "colluder" with her
current husband, the alleged offender. Fortunately, she was informed by
a social worker who knew her, and she was able to be present while her
daughter underwent this procedure. I discussed the case with the
hospital doctors, who informed me that if the wart was of a sexually
transmitted type, the child would undergo a diagnostic interview by the
hospital social worker. The stepfather was also a patient of mine.
had no history of genital warts, and a genital examination confirmed
that none were now present. Even if the wart was thought to be a
sexually transmitted type, therefore, he could not be suspected of
Previous discussions with the hospital virologist had assured me that
even if a wart was identified as a sexually transmittable type, there
are nonsexual ways by which it can be transmitted. Its presence is therefore not
definitive evidence of sexual abuse. Review of recent literature in fact
demonstrates that only a minority of children with anal-genital warts
have been sexually abused (Derksen, 1991; Gutman, Herman-Giddens, &
Phelps, 1992). I believed that a general anesthetic was not warranted in
this child's case.
Despite my expressed concerns, the little girl duly underwent a
general anesthetic during which her wart was cut off, her hymen measured
and swabs taken for STD testing. No abnormalities were detected, and
typing of the wart did not suggest sexual transmission. The hospital
informed me that they still wished to refer her for further sexual abuse
assessment. I made some of the workers aware of how much intervention
this child had already undergone, and eventually no further action was
A month later the little girl's mother brought her to my surgery.
warty lesion had regrown and was now larger than the original (about 2
mm diameter). It had the appearance to me of a benign wart-like
infection called molluscum contagiosum. The child attended a preschool
where this condition was common. Naked play between the children made
this a very likely source of the infection. I treated the lesion with a
brief application of liquid nitrogen, which caused the little girl
slight discomfort but which she tolerated well without any anesthetic.
few days later the wart dropped off and has not recurred. I also
inspected her hymen at that time with no discomfort to her. She would
have easily tolerated my taking of swabs if this had been required.
I believe this child was subjected to an unnecessary general
anesthetic, which was not required for either diagnosis of sexual abuse
or for treatment of her wart. She underwent a potentially
life-threatening procedure as well as suffering the distress of hospital
intervention. It seems likely that too many children's lives are being
put at risk from undergoing general anesthetics for which there are
The other area of contention in medical examination is the physical
signs of anal abuse. In particular, the argument centers around a
phenomenon of anal gaping called reflex anal dilatation (RAD). Briefly, this involves
gently parting the buttocks and observing the anus for half a minute.
Usually, the sphincter on the outside of the anus will contract and then
dilate, as pressure is maintained. Sometimes the inside sphincter will
then also relax giving a view right into the rectum. It is this response
that has been named RAD.
British pediatricians Drs Hobbs and Wynne reported that RAD was
present in 42% of anally abused children they examined, and claimed that
it was an important indicator of abuse (Hobbs & Wynne, 1986, 1989).
They stated that they had not witnessed RAD in nonabused children.
also claimed that splits or fissures around the anus are very rare in
the nonabused child.
These findings became the basis of a belief in some circles that RAD
is proof of anal abuse. More recent studies and observations, however,
refute Hobbs and Wynne's findings. One study observed the phenomenon in
nearly half of the nonabused children they examined (McCann et al,
1989). It also appears to be more common when a child is constipated and
has feces sitting higher in the bowel (Sunderland, 1987; Royal College
of Physicians, 1991). Many doctors also report that they have commonly
seen anal fissures in nonabused children (Freeman, 1989; Kean, 1989;
Royal College of Physicians, 1991).
Unfortunately, Hobbs and Wynne's theories regarding the relevance of
anal reflex dilatation was taken to be established fact by a number of
doctors examining children. In some centers it became policy for all
children to undergo genital and anal examinations, no matter what
medical problem they had come with.
This practice resulted in the false epidemic of sexual abuse cases in
Cleveland, England, which was to receive worldwide attention from the
media. In 1987, two pediatricians working at the Middlesbrough General
Hospital in Cleveland, Drs. Marietta Higgs and Geoffrey Wyatt, diagnosed
121 cases of alleged sexual abuse of children in the space of five
months. Their diagnoses were made largely from medical examination
findings of reported hymenal irregularities and RAD. Many of these
children had come to the hospital for treatment of complaints such as
asthma, and there was no other evidence suggesting that they had been
abused (Bernard, 1988; Woods, 1988). Dr.
Higgs held the view that one in ten children are sexually abused, and
sincerely believed that her findings proved the abuse.
Despite denials from bewildered and distraught parents, the children
were immediately taken from their homes, initially to a hospital and
later into care by the social services. As the numbers escalated,
distressed parents sought media and political support. Eventually a
public inquiry was called. The Cleveland inquiry, headed by Lord Justice
Butler-Sloss, found that most of the allegations were unfounded, and the
children were returned to their families (Butler-Sloss, 1988). The
process was, however, very traumatic to all concerned, and the children
and their parents did not emerge unscathed by the experience.
Despite the findings of the inquiry, and the evidence coming forward
from a number of reputable medical sources regarding the unreliability
of relying on medical signs, such as RAD, to diagnose abuse, many
agencies still maintain their use is valid. Dr. Higgs still has many
supporters within the field who believe her diagnoses were justified.
Some books written about the Cleveland affair (Campbell, 1988; La
Fontaine, 1990) present the view that the allegations in the Cleveland
case were founded, despite overwhelming evidence that abuse was not
substantiated in the vast majority of the cases.
There are no physical signs of abuse to be found in the vast majority
of sexual abuse cases. Medical findings supporting or proving abuse are
not as clear cut as may be expected. Many of the medical indicators
advocated are frequently found in non-abused children. The ubiquitous
practice of describing completely normal examination findings as being
"consistent with abuse" is likely to be misunderstood in a
courtroom as evidence supporting an allegation. Lay people serving as
jurors are particularly apt to be misled by medical experts giving such
Physicians examining a child for possible sexual abuse are likely to
have been briefed by other workers who have already decided that the
child has been sexually abused. Many social workers and psychologists
believe that false allegations are extremely rare and that "children never lie about abuse," and see
their role as a "validator" that the abuse has occurred.
a belief that sexual abuse has taken place has become entrenched, very
little can be done to sway the believers otherwise. To even suggest the
possibility of a false allegation is often to invite an emotional
outburst and accusations of condoning or even colluding with abuse.
Actions and decisions may subsequently be made without scientific
substantiation of the allegations.
Doctors called upon to perform forensic sexual abuse examinations
should have up-to-date information on the range of normal for nonabused
children. They should be very cautious on how they interpret their
findings, and insure that they have an empirical basis for their claims.
Children can be seriously harmed both by invasive investigative
practices and by subsequent interventions when the allegations are
unfounded. Physicians must always have in mind the Hippocratic vow,
primum non nocere: first do no harm.
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| * Felicity
Goodyear-Smith is a family physician at Wrights Road, RD2,
Albany, New Zealand. This article is adapted from a section of her book,
First Do No Harm: The Sexual Abuse Industry (), 1993,
Publishers, Auckland. [Back]