The opinion and assertions herein are the private views of the author and are not to be construed as those of the Department of Defense, Air Force, Army, or Navy; the Armed Forces Center for Child Protection; the National Naval Medical Center; or Walter Reed Army Medical Center.
Introduction
The production, collection, distribution, and use of child pornography in this country are major issues affecting many children. The purpose of this chapter is to aid clinicians in assessing the images and videos that are distributed as child pornography, and to provide guidance about making a determination that a person depicted in an image is less than 18 years of age.
Controversy exists regarding morphed or virtual images of child pornography. Advances in technology make it easier to produce images of children that appear real, but may not depict actual children. Virtual child pornography would include modified photographs of real children, images of people older than 18 years of age who appear younger or are made to look younger, and fully computer-generated images.
Computer generated images take a file in one format and use software to manipulate the lighting, reflections, and other features to create a photorealistic image. Age progression and regression software is also used. Current laws attempt to protect children by imposing limits on technological advances that perpetuate child pornography.
The evaluation of an image should include an assessment and documentation of whether the image appears altered or morphed. It is usually difficult to make this determination strictly by viewing the image, though one may consider shadowing, coloring, and proportions which may not appear consistent throughout the image and look obviously mismatched. Computer experts are trained to make determinations regarding the alteration of computer images.
The National Center for Missing and Exploited Children maintains a database of known child pornography victims. This database contains all identified series of a particular victim categorized, indexed, and described in detail. The database is updated annually and can be accessed by law enforcement and other investigative entities to compare seized collections with known underage victims for identification purposes.
Normative Studies of Physical and Sexual Maturation
The Third National Health and Nutrition Examination Survey (NHANES III), conducted from 1988 to 1994, was a study of the health of a nationwide representative sample of children in the United States. Some of the papers generated from this study provide data on the timing of puberty in American children. A second large scale study was conducted in the office-based network of pediatricians participating in research known as the Pediatric Research in the Office Setting Network (PROS). This study specifically looked at sexual maturity ratings (Tanner stages) in girls 3 to 12 years old. All girls presenting to a participating pediatrician’s office for a physical examination or for illnesses requiring a full physical examination were included. Participating providers received special training in assessing sexual maturity rating (SMR).
The aforementioned studies provided valuable datasets that have established a basis for relating SMR to age. For example, the PROS study, which includes more than 17,000 females, shows more than 95% of females have begun breast development by the age of 12 and more than 90% will have at least Tanner stage 2 pubic hair by age 12. These studies established that a white American girl with Tanner 2 breast development is 99.9% likely to be younger than 17.5 years old (and 99.7% likely to be less than 14 years old). The PROS study provided 95% confidence intervals for SMR in girls by mean age. Standard deviations provide the age range for each stage of development African American females are listed separately since they tend to reach puberty earlier than non-Hispanic white American girls.
Papers derived from the NHANES study provide important information for pubertal thresholds in boys and girls. For example, the study reports that the average American boy enters puberty at 9 to 10 years of age and attains full sexual maturity by 14 to 16 years of age. Information is provided for white, African-American, and Hispanic-American males, demonstrating differences in pubertal development. Tables are provided that list the percentage of boys by age that are in a particular stage of sexual development.
Although information from these studies is important in the analysis of pornographic images, SMR were not designed to age children, but to provide a descriptive means of quantifying the development of secondary sexual characteristics. The development of secondary sexual characteristics is an important marker for the transition between childhood, through adolescence, into adulthood. Other factors, discussed below, are also important indicators and supporting factors, but the progression through puberty is an identifiable and quantifiable process. If the person in question has not begun to develop secondary sexual characteristics, then the above studies provide supportive data to assert the person is less than 18 years of age.
It is often argued, particularly in court, that SMR cannot be used to age children. If the provider who is attempting to determine whether a child is less than 18 years old is doing so correctly, that argument has no merit. SMR is not used to determine a child’s age , but to describe the stage of sexual development of an individual depicted in an image. Other studies have correlated the stages of sexual development with age. Therefore, the provider is using SMR as a descriptive means of assessing sexual maturity, and comparing the SMR with population-based data on development by age. SRM is simply a tool, one of many, that aids the provider in making a developmental assessment, which in turn helps determine the likelihood that an individual is less than 18 years old.
Reviewing Images and Videos
When asked to evaluate a series of images or videos of suspected child pornography, the provider should first assess the quality of the material being provided. Size and overall image quality are important considerations. Often images will be salvaged from computers in a thumbnail format. These can vary in size, but are usually very small and difficult to assess. The people in the images are often so small that it is difficult to make any assessments regarding sexual development or other characteristics. Because most images are digital, an attempt can be made to enlarge the image, but quality and resolution is usually lost as the image becomes blurred and pixilated. Even when images are of sufficient size, quality might still be poor. An image should be clear and not blurred or pixilated to an extent that makes it difficult to assess.
Shadows, lighting, and positioning of the individuals in the image can affect the ability to make determinations of sexual and physical maturity. Often body parts that need to be evaluated are covered or not fully seen and determinations cannot be made.
Physical Characteristics and Age Ranges
A variety of physical characteristics can be used to assist in determining whether a child is less than 18 years old. When first assessing an image or video, the overall appearance of the individual in question should be considered. Overall health, nutrition, and the presence of characteristics associated with medical conditions and genetic disorders can affect the appearance of an individual and also affect the onset of puberty. For example, development can be delayed in children who are malnourished, who exercise excessively, or who have severe chronic illnesses. Chromosomal abnormalities can also affect the onset of puberty. Females with Turner syndrome are missing an X chromosome and most will not begin sexual maturation unless hormone replacement is initiated. Girls with Turner syndrome have distinct physical characteristics including short stature, a broad chest with wide spaced nipples, and a webbed neck. Males with Klinefelter syndrome have an extra female chromosome and tend to be tall with small testicles and gynecomastia. The conditions tend to have with characteristic physical features that are easily discernable in an image or video and would not confuse an experienced clinician.
Other physical characteristics that change significantly from childhood to adulthood can be used to support a conclusion that an individual is less than 18 years old. For example, teeth go through a characteristic progression as the smaller baby teeth are lost and replaced by the larger permanent teeth. Size, proportion, and spacing are all obviously different as teeth mature. Age ranges for when particular teeth are lost and permanent teeth erupt are also established. Baby teeth are lost beginning at about 6 years of age until about 12 years of age. Permanent teeth erupt immediately after loss of baby teeth or lag by 4 to 5 months.
Body size and shape change dramatically as children develop. At birth, the head is large compared to the body. As a child grows, the body lengthens and the head becomes less prominent. Leg length also varies considerably with growth. From the age of 1 year, the legs grow faster than the trunk of the body up until puberty. At puberty the trunk then grows more rapidly. Tables have been derived to compare the normal leg length to body length ratios at various ages. For example, in boys at 1 year of age, leg length is 38% of body length, and at 13 years it is 49% of body length.
Body shape also undergoes considerable change. Before the onset of puberty, boys and girls have similar body shapes and proportions with cylindrical trunks and minimal waist indentation. Viewing body habitus from the back, it would be difficult to tell a boy from a girl before puberty. As females go through puberty, the pelvis widens and becomes broader than the shoulders, hips become rounder, and the indentation at the waist becomes obvious. In males the shoulders widen more than the hips and there is not pronounced indentation of the waist.
Muscle development is also a marker of puberty with muscle mass increasing dramatically with puberty. This is much more pronounced in males. Body fat distribution also changes. Female body fat content increases from about 16% to 27% as females go through puberty. Male body fat content increases from about 4% to 11%.
Body hair growth and distribution patterns also vary with age. Younger children have soft downy hair on their bodies that is not particularly visible. With androgens and puberty, hair becomes coarser and darker. In males hair growth is most prominent on the chest, underarms, and face. Hair growth is not as dramatic in females, but changes in axillary and leg hair are obvious. In one study, pubertal changes related to hair growth were noted for American boys and girls. The onset of axillary hair was reported to occur in females between 12 and 14 years of age and in males between 13 and 15 years of age. Facial hair growth in males was reported to first occur between 13.8 and 16 years of age.
Facial characteristics also change with puberty. The jaw becomes longer and thicker. The chin progresses from being small and recessed in childhood to more prominent and adultlike with a larger mouth. The rounded baby-faced appearance disappears to form a more adultlike profile. The nose projects more in adults and sits lower on the face compared with children. In younger children, the nose is smaller in proportion to the rest of the face and turns upright. Facial growth can continue until 21 years of age.
Progression of body changes, such as those listed, can be difficult to assess based on one image. Providers rarely have additional photographs showing changes in an individual with the progression of time. These physical features can be used as an important adjunct with other factors in assessing images, but should not be used as the sole determining factor.
Secondary Sexual Characteristics
Sexual maturity rating (SMR) is a useful tool in evaluating the development of secondary sexual characteristics. SMR in males describes the development of pubic hair and changes in genitalia. In females, pubic hair and breast development are assessed ( Figure 19-1 ).
