Introduction
Since the early 1980s, medical care providers have played a major role in describing physical findings in children and adolescents where sexual abuse or assault is suspected. Initial studies suggested that tissue injury was commonly seen in these patients. The early studies on abused children, however, were done before studies of nonabused children. It was soon discovered that many of these presumed posttraumatic findings were in fact normal or nonspecific findings commonly seen in nonabused children. Over the last 2 decades there have been several studies of genital and anal findings in children carefully screened for nonabuse using screening methods such as sexual behavior inventories, one on one interviews with the child, parental interviews, and medical records searches. There has been a major effort to standardize medical terminology led by the American Professional Society on the Abuse of Children (APSAC), creating more rigorous definitions for anogenital findings in children and adolescents who are suspected victims of sexual abuse.
Importance of Standardization of Examination Techniques
It has become increasingly clear that the use of various examination positions and the use of adjunct techniques affect the results of examinations of children and adolescents for suspected sexual abuse. A recent study by Boyle et al emphasized the importance of using three examination positions: supine labial separation, supine labial traction, and prone knee chest when examining prepubertal and pubertal girls with genital injury. In this retrospective study of 46 prepubertal girls with genital injuries from various causes and 74 pubertal girls with injuries from sexual assault, the investigators found that the use of all three methods was necessary to the ensure successful and adequate visualization of the hymen and to detect all the injuries. No single technique consistently allowed the separation of the hymenal edges for adequate visualization of normal structures and hymenal lacerations and contusions. This was true in both the prepubertal and pubertal populations. The authors concluded that without the combined use of the three methods, a significant number of injuries, particularly hymenal lacerations, could be missed in the child and adolescent.
Studies of injuries have also been enhanced by the use of multiple adjunct techniques to assist in the delineation of injuries to the anogenital tissues, when necessary. This includes the use of cotton-tipped applicators to explore the edge of the hymen, the use of the water or saline to “float” the hymen, and the Foley catheter technique (see Chapter 9 ). Another technique that has been used is the staining of genital and perianal tissues with toluidine blue dye, a nuclear stain taken up by subepithelial layers of disrupted skin to accentuate subtle abrasions of the tissues. , While some practitioners find the use of toluidine blue very helpful in diagnosing acute trauma from assault, its use in children is not standard with all examiners.
Abnormal physical findings in sexually abused/assaulted children and adolescents remain rare. Normal examinations of the genitalia and anus are reported in up to 95% of children evaluated for abuse.
Acute Genital Findings Following Sexual Trauma
If children are seen soon after an abusive episode, they are much more likely to have physical findings corroborating the abuse. Children and adolescents can be exposed to multiple types of trauma during sexual abuse. Friction (rubbing or fondling) often leaves no findings or can result in tissue erythema, abrasions, scratches, bruising, or edema. Penetrating trauma can cause lacerations, fissures, transections, abrasions, or perforations of the vaginal or bowel wall. In some cases of known sexual penetration, no abnormal findings are noted on examination. There also can be extragenital injuries such as bite marks, bruising, suction ecchymoses, and marks from ligatures or strangulation.
Studies of prepubertal victims of acute sexual assault have noted injuries including vaginal lacerations, complete hymenal transections, deep clefts, hymenal bruises, abrasions and tears, bruises or abrasions to the fossa navicularis and posterior fourchette ( Figures 11-1, 11-2, and 11-3 ). A study by Palusci et al of 190 children under the age of 13 seen urgently within 72 hours for evaluation for sexual abuse or assault found that 13.2% had positive examination findings that included a vaginal laceration (1), complete hymenal transections (4), acute hymenal transections through more than 50% of the hymenal width (9), hymenal abrasions (2), and perihymenal bruises (4). Importantly, only vaginal lacerations and hymenal transections greater than 50% of the width of the hymen were statistically associated with positive forensic evidence. In addition, children with positive examination findings were older (8.8 years versus 5.8 years), pubertal (Tanner stage III or greater), and disclosed a history of genital contact or perpetrator ejaculation. The proportion of positive findings was highest in the first 12 hours (29%).
In a study by Christian et al of 293 children younger than 10 years old, most of whom (88%) were evaluated within 24 hours of suspected sexual assault, 23% had anogenital injuries. Injuries were seen in the anus (24%), hymen (16%), labia minora (16%), posterior fourchette (19%) and perineum (9%); 3% had intravaginal injuries. The types of injuries included lacerations or tears (55%), abrasions (38%), and bruises (7%). Erythema was noted in 38% of the acute examinations, as well. The presence of injury was predictive of identifying forensic evidence (odds ratio 3.23).
Another study by Heppenstall-Heger of 94 children with acute anogenital trauma, from both accidents and sexual abuse found 171 injuries : 47 to the posterior fourchette, 37 to the hymen, 39 to the perihymenal tissue, 17 to the labia minora or majora, and 31 to the anus. The 24 children with a history of penile-vaginal penetration had the highest percentage of significant injuries. These included: 12 complete transections of the hymen, 14 injuries to the posterior fourchette, and 2 partial tears of the hymen. Comparing hymenal trauma from sexual assault and accidental injuries, hymenal trauma was associated with a history of sexual assault in 23 of 43 cases (53.4%) versus 8 of 25 accidental injuries (32%). Of the 17 complete hymenal transections, 12 were associated with a history of penile-vaginal penetration, 1 occurred in a preverbal child who gave no history, and 4 were associated with penetrating accidental injuries. All but one tear was located between 4 and 8 o’clock on the hymenal rim.
In the same study, partial tears of the hymen were noted between 4 and 8 o’clock as well. Histories accompanying these injuries included 4 children with digital-vaginal contact, 2 children with penile-vaginal penetration, one child with a straddle injury, and one preverbal child with no history. Injury to the posterior fourchette was most common, found in 58.3% of prepubertal children having sexual abuse trauma, and 51.8% of those children having accidental trauma. Perihymenal injuries were commonly associated with straddle injuries or digital-vaginal penetration. Labia majora/minora trauma was associated with straddle injuries. Very significantly, of the 171 injuries, only 14.6% healed with findings diagnostic of previous trauma. The authors concluded, “There are usually no acute or chronic residua to sexual contact. Most examinations for possible sexual abuse are normal or nonspecific because of the nature of the abuse of children, the child’s perception of the abuse, and a delay in disclosure that allows injuries to heal.” The study also demonstrates an overlap of injury patterns associated with sexual abuse and accidental injury. The history is important to distinguish between these two causes.
There have been multiple studies of acute examination findings in adolescents following genital trauma, although some have included adult subjects. Sugar et al in their study of 819 women coming to an urban emergency department, found that 37% of 15- to 19-year-old female rape victims had bodily injuries other than anogenital trauma including bruises, abrasions, fractures, visceral injuries, attempted strangulation, and intracranial trauma. In the same group, 29% had trauma to the genitals or anus. Girls with no prior history of intercourse had a much higher frequency of genital injury (39.5%) than those who had had prior intercourse (19.3%). A recent study by Drockton et al of colposcopic photos of 3356 acutely sexually assaulted females over 12 years old examined the risk variables that were predictive of acute genital injury. These variables include vaginal penetration or attempted penetration with a penis, finger, or object; alcohol use during the incident; virginal status; and lack of lubricant use. There also was an association between acute genital injury and the inability of the victim to recall a penetration history. Another study by White of 224 adolescents ages 12 to 17 from the United Kingdom having a history of rape or sexual assault compared injury patterns in virginal and nonvirginal girls. Again, those reporting no prior intercourse had more genital injuries than those with prior sexual experience (53% versus 32%). Injuries included lacerations, bruises, and abrasions.
Most studies of adolescents (and adults) agree that the most common acutely injured site after sexual assault is the posterior fourchette and fossa navicularis. Adams et al studied 214 acutely assaulted 14-to 19-year old girls and found that 40% had tears of the posterior fourchette and/or fossa navicularis. This consistent pattern in acutely sexually assaulted adolescents (and adults) strongly suggests that when injury is seen in adolescent rape victims, it occurs as a result of an entry injury, resulting from insertion or attempts at insertion of the penis or other object into the vagina.
Healing of Acute Anogenital Injuries
Prepubertal children rarely present for medical examinations immediately following sexual assault. Although few studies detail the timing and the morphological changes in the healing process following sexual assault, it is clear that healing of hymenal tissue occurs rapidly and often completely, and that hymenal scarring is rare. In a study by Heger of 13 boys and 81 girls with a history of sexual assault or anogenital trauma, there were 171 injuries noted, only 25 of which healed leaving any stigmata of previous trauma (including two hymenal tears requiring reparative surgery). Penile-vaginal penetration was associated with the most significant injuries. This study indicated the importance of prompt examination and the likelihood of complete healing, even in cases of injuries causing pain and bleeding.
John McCann led a multicenter retrospective longitudinal study of 113 prepubertal and 126 pubertal girls with acute hymenal trauma. The healing process was examined in detail to determine factors that might determine the age of a hymenal injury. Prepubertal children had both accidental and assault injuries, while postpubertal children had only assault injuries. The healing patterns and timing of key acute hymenal injuries such as petechiae, blood blisters, contusions, and lacerations were followed using photographs.
Petechiae of the hymen were defined as “pinpoint, nonraised perfectly round, purplish red spots on the hymenal membrane,” and were identified acutely in 60% of prepubertal and 50% of adolescent girls. The authors found that petechiae resolved quickly. None were detected beyond 48 hours in prepubertal girls, or beyond 72 hours in adolescent girls. Hematomas of the hymen were described in the study as a circumscribed area of blood. Hematomas quickly evolved into diffuse submucosal hemorrhages. The authors noted that the submucosal hemorrhages in both prepubertal girls and adolescents were primarily found in the posterior quadrants of the hymen. Hematomas were relatively uncommon (4% in prepubertal girls and 10% in adolescents). Submucosal hemorrhages were common, found in 51% of prepubertal girls and 53% of adolescents.
The McCann et al study documented the healing process in 40 hymenal lacerations in prepubertal girls and 80 hymenal lacerations in adolescents. There was a difference in location of acute injuries between the prepubertal and adolescent population. Prepubertal girls had predominantly posterior injuries (88%), with 8% lateral and 5% anterior injuries. The majority of the posterior injuries in prepubertal girls were midline. Conversely, adolescents’ hymenal injuries were posterior only 61% of the time, with 29% being midline; 23% were at the lateral hymenal wall and 15% were anterior. Visualization of all the anterior findings required an adjunct technique. As healing took place, changes were noted in the depth of the laceration and in the configuration of the laceration. In the prepubertal children, most lacerations became more superficial with healing (e.g., transections with an extension evolved into transections without an extension, deep lacerations evolved into intermediate or superficial lesions). However, 15% of deep lacerations had accompanying swelling of the tissues, which obscured the initial depth of a transection. In adolescents, similar patterns of healing were noted, as some transections became more superficial with healing and other injuries were noted to be deeper after swelling subsided. With regard to timing, the healing of acute hymenal lacerations began quickly and was complete by approximately 3 weeks in the prepubertal girl and 4 weeks in the adolescent girl. In both prepubertal and adolescent girls, the healing process resulted in continuity of the hymenal rim with a smooth edge in all but those with the most severe initial lacerations. Importantly, no scar was noted on any hymens.
McCann’s study noted that the extent of the hymenal injury dictated the final outcome of the configuration of the hymen in both prepubertal girls and adolescents. That is, those who had sustained either a transection or transection with an extension were much more likely to heal into either a transection or into a deep appearing laceration. In 15% of the cases the reverse was seen. When the swelling subsided, deep lacerations were actually complete transections. In prepubertal girls with a superficial, intermediate, or deep laceration, 75% healed to result in smooth hymenal rims with no disruption in contour, and even those with a hymenal transection or transection with an extension, surprisingly resulted in a smooth rim (17%) and continuous hymenal membrane (22%) on healing. Adolescent girls who had a superficial, intermediate, or deep laceration healed 59% of the time to have normally appearing (scalloped) hymenal rims.
This paper further helped clarify the significance of the hymenal rim width of 1 mm in the presence of the history of penetration. Among prepubertal children with acute transections to the base of the hymen or with extensions into the surrounding tissue, 72% eventually healed with a hymenal rim width of greater than 1 mm. In adolescents, only 13% of these transections healed leaving a hymenal rim of less than 1 mm.
The authors noted several findings from their study. First, the study corroborated previous findings that genital injuries heal “… remarkably well and tend to leave little, if any, evidence of the previous trauma.” They also concluded that the presence of petechiae and blood blisters are helpful in determining the age of a genital injury. Finally, they concluded that the rapidity of the healing process reminds us that children and adolescents need to be examined as soon as possible following a suspected sexual assault.
Interestingly, the authors noted that there did not seem to be any difference in the healing process between prepubertal girls and adolescent girls with regards to their hymenal injuries. None of the subjects’ injuries resulted in scar tissue on the hymen. The authors reminded examiners to “… exercise caution before calling a finding normal, without evidence of a previous injury.”
Nonacute Examinations of Prepubertal Children
Most prepubertal children are examined long after the alleged assault. Recent studies have verified that few sexually abused children have abnormal physical findings on their anal and genital examinations. The reasons for this include: (1) in many cases, no physical injury is sustained at the time of the assault; (2) in some cases the genital and anal tissues are sufficiently elastic to distend or stretch without discernible injury during episodes of penetration; and (3) injuries that do occur usually heal quickly and completely.
Occasionally, children will have physical evidence of sexual abuse/assault that occurred sometime in the past including complete hymenal tears, deep hymenal notches, marked narrowing of their hymens, or scars in the posterior fourchette or fossa navicularis ( Figures 11-4, 11-5, 11-6, 11-7, and 11-8 ). Studies on genital and anal findings in normal, nonabused children have contributed greatly to the examiner’s ability to interpret findings in the nonacute setting. One case-control study by Berenson compared vulvar and hymenal features in 192 prepubertal girls ages 3 to 8 with a history of penetration and 200 children who denied prior abuse. The median length of time between the last episode of the abuse and the examination was 42 days. The authors found physical findings strongly suggestive of sexual abuse in less than 5% of prepubertal girls. The findings from this study are detailed in Table 11-1 . Of particular interest were the findings regarding hymenal notches. There was no difference between the abused and the nonabused group in the configuration of the notch (“U” vs. “V”). Likewise, there was no significant difference between these two groups in the prevalence of superficial hymenal notches. Children who reported three or more episodes of abuse were more likely to have a superficial notch (14%) than those who reported fewer episodes (0%) or no abuse (5%). However, deep notches and transections were observed only in abused children. The two deep notches were seen on the inferior rim of the hymen in children who were abused within 7 days of the examination. The authors concluded that a deep notch, a transection, or a perforation on the inferior portion of the hymen could be considered as a definitive sign of sexual abuse or other trauma.
| Hymenal Feature | Abused n = 192 | Nonabused n = 200 | Statistical Significance |
|---|---|---|---|
| Prominent vessels | 15 (8%) | 13 (7%) | p = .70 |
| Periurethral bands | 180 (94%) | 189 (95%) | p = .83 |
| Vestibular bands | 104 (55%) | 120 (60%) | p = .31 |
| Notches | |||
| Superficial | 13 (7%) | 10 (5%) | p = .52 |
| Deep | 2 (1%) | 0 | p = .24 |
| Transection | 1 (1%) | 0 | p = .49 |
| Perforation | 1 (1%) | 0 | p = .49 |
| Longitudinal intravaginal ridges | 170 (89%) | 174 (87%) | p = .65 |
| External ridges | 15 (8%) | 16 (8%) | p = 1.0 |
| Bumps | 87 (46%) | 92 (46%) | p = .92 |
| Tags | 5 (3%) | 10 (5%) | p = .29 |
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