1. Dr Jo Tully VFPMS Seminar2017
Genital examination findings – “It’s normal to be normal” but what IS normal?
Dr Jo Tully
VFPMS Seminar2017

2. The acute SA examination - purpose
Medical
STI/pregnancy prevention
Acute injury management and reassurance
Psychological
Gatehouse/SECASA
Empathy with ‘victim’ and family
Crisis mental health – suicide risk
Protective
Need for Child Protection?
Criminal
DNA/evidence collection connecting alleged perpetrator with crime
Evaluate genital exam findings in forensic context – over-reliance…???
Acute sexual assault exam

3. What is normal?

4. Normal Hymens
Hymenaios – the God of marriage/song for delivering bride to marriage bed
Deuteronomy 22:13-21
Appearance of hymen changes with age:
Newborn – maternal oestrogen - swollen, oedematous – labia minora and clitoris often prominent
Up to 2-3 years – gonadal oestrogen – thickened hymen – maybe tube / sleeve like
Pre-pubertal – HPG axis suppressed – tissues thinner and hymenal shape evident, visible capillaries as thin epithelium
Pubertal – oestrogen returns – hymen thick, high elastic and fibre content – extra folds – “hair scrunchy

5. Normal hymens

6. Normal pre-pubertal hymen

7. Normal post-pubertal hymen

8. What IS normal - the changes over time
Evidence of penetration in 1980’s and prior – errors
Belief re “intact hymen”
Variants seen as evidence of recent or healed penetration
Significance/interpretation of
Annular v concentric hymens
Clefts & notches, location, depth
Posterior hymenal rim depth
Hymenal orifice diameter
hymenal bumps, irregularities, vascular markings, rolled edge
fossa navicularis linear vestibularis
Reflex anal dilatation
have changed over time….
Reluctant to rely on child’s testimony alone

9. Studies defining what is normal
McCann 1990 placed hymenal exam on scientific footing
Overturned findings previously cited as evidence of CSA
Non-abused pre-pubertal girls; unexpected genital findings are actually normal
Compare non-abused with abused – clarify the sensitivity and specificity
Longitudinal studies of acute injury healing to confirm link between certain acute findings and “healed” appearance
Problems with methodology – including only truly non-abused
Appearance of the Hymen in Prepubertal Girls
Berenson A, Pediatrics 1992: 89;

10. Findings that remained of concern…
Posterior hymenal clefts/notches
Minimum posterior hymenal depth 1mm
Hymen orifice diameter
Berenson differentiated deep from superficial clefts/notches
All authors commented on examination position/technique influencing findings

11. Studies since have shown much lower rates of abnormal findings:
Children referred for possible sexual abuse: medical findings in 2384 children.
Heger A et al, Child Abuse & Neglect. 2002; 26:
2384 children, 82% girls, mean age (girls) 6.9y, age range 3m – 14y, blinded peer review
3.7% abnormal findings
4.4% - disclosing group (“penetration” = 5.5% abnormal)
2.2% - non-disclosing group
0.2% - behaviour changes / possible exposure to abuse
8% - evaluation of medical findings / conditions

12. What happens when we get it “wrong”?
The Cleveland Enquiry 1989 – Butler-Sloss
Judicial enquiry into 121 children removed from parents care due to concerns re CSA based on RAD (over 2cm)
Over 90 of the children later returned
Subsequent debate on significance of RAD (and other anal findings)
Constipation
Anaesthetic agents
Neuromuscular disease
Sexual abuse? Anal signs of child sexual abuse:
a case–control study Christopher J Hobbs, Charlotte M Wright BMC Pediatrics201414:128

13. Where are we now?
Published in J Paed Adolesc Gynecol 29 (2016)

14. Trauma +/or sexual contact
Normal variants
Findings caused by medical conditions
Conditions mistaken for abuse
Non-abused children
Anal dilatation
Notches/clefts
Genital/anal warts
HSV
No expert consensus
Findings indicating acute or healed trauma
Sexually transmitted infections
Pregnancy
Semen
Trauma +/or sexual contact

15. What NOT to worry about Non-abused children Normal variants
Medical conditions
Mistaken for abuse
Non-abused children
What NOT to worry about
Normal variants
Annular vs crescentic
Congenital 1-3% - septate, micro-perforate, imperforate, redundant
Tags, bumps, mounds, intra-vaginal ridges
Smooth narrow posterior rim of hymen
Any notch or cleft regardless of depth above the 3 and 9 o’clock positions
Superficial notch or cleft at or below the 3 and 9 o’clock positions
Linear vestibularis, diastasis ani, perianal skin tags
Labial hyperpigmentation

16. Septal remnant
Peri-urethral support bands
Hymenal fold
Septate hymen

17. Fossa navicularis
Linea vestibularis
Perianal skin tags

18. Clefts, notches, bumps and mounds

19. Non-abused children Non-abused children
Normal variants
Medical conditions
Mistaken for abuse
Non-abused children
Findings commonly caused by conditions other than trauma
or sexual contact
Red vagina
Labial adhesions
Posterior fourchette friability
Vaginal discharge
Molluscum
Anal ‘fissure’ /laceration
Venous congestion perianal area
Anal dilatation
Constipation
Sedation/anaesthesia
Neuromuscular disease
Post-mortem

21. Non-abused children Conditions mistaken for abuse
Normal variants
Medical conditions
Mistaken for abuse
Non-abused children
Non-abused children
Conditions mistaken for abuse
Urethral/rectal prolapse
Lichen sclerosis
Ulcers
Infection (not STI)
Peri-anal creases
Post mortem changes

22. Conditions mistaken for abuse

23. No expert consensus Non-abused children No expert consensus
Anal dilatation
Notch/clefts
Genital/anal warts
HSV 1 or 2
Non-abused children
No expert consensus
No expert consensus

24. Superficial and deep notches – but how deep is deep?

25. Trauma +/or sexual contact
Non-abused children
No expert consensus
Findings indicating acute or healed trauma
Sexually transmitted infections
Pregnancy
Semen
Trauma +/or sexual contact

26. The ‘abnormal’ hymen….? No expert consensus
Caused by trauma/sexual contact
Notch or cleft at or below 3 or 9 o’clock which is deeper than a superficial and may extend nearly to the base but is not a complete transection
Complete cleft/notch at 3 or 9 o’clock position
Bruising, petechaie, abrasions to hymen
Acute laceration – any depth
Healed transection/complete cleft between 4 and 8 o’clock extending to base
Posterior defect in hymen wider than a transection with absence of hymen extending to base

27. Genital injuries

28. Accidental Trauma
Not from tampons / usual childhood activity/masturbation
Self-inflicted very rare
Usually not hymenal injury
Usually blunt trauma to exterior structures – mons, labia majora, posterior fourchette and inner thigh – crushed between pelvic bones and object
Straddle usually unilateral and anterior, bruising, abrasions, posterior fourchette tears, minor, hymen rarely affected
Direct accidental penetration occurs – history important – vaginal ,hymenal or perianal

29. Factors affecting likelihood and extent of genital injuries
Child:
Anatomy – size and position
Degree of relaxation, stretch, friability
Amount of lubrication (physiological, applied)
Perpetrator:
Object – size and type
Amount of force used, angle
Elapsed time between alleged abuse and examination

30. “It’s normal to be normal”
Examination Findings in Legally Confirmed Child Sexual Abuse: It’s Normal to be Normal Adams JA, et al, Pediatrics. 1994; 94: Review of case files and colposcopic photographs of 236 children with perpetrator conviction for sexual abuse (included many plea bargains) 141 cases – 130 girls,11 boys, Mean age 9.0y (range 8m – 17y 11m), 2/3 > 8y 63% reported penile-genital contact Girls: 28% normal, 49% nonspecific, 9% suspicious, 14% abnormal = 23% Anal penetration: 1% abnormal

31. More literature…
Genital Anatomy in Pregnant Adolescents; “Normal” Does Not Mean “Nothing Happened”
Kellogg N, et al, Pediatrics. 2004; 113: e67-69
36 pregnant adolescent girls, average age 15.1y
56% of pregnancies resulted from sexual assault
1 pregnant with 2nd child, 2 D&C 2w – 2m before
82% normal findings
2/36 complete transections, 4/36 findings suggestive of abuse
Also, Adams (2004) reported 52% normal hymenal findings of 85 adolescent girls, average age 16.5y, with and without a history of consenting sexual intercourse.

32. So why are there so few abnormal findings?
Nothing happened
History not accurate
Absence of injury (likely)
Pubertal hymen able to stretch over objects without being injured
Minor injury missed
Genital mucosal injuries heal quickly
Healed injury results in the same findings as the tissue pre-assault (regeneration vs. repair)
Healed injury looks indistinguishable from average, but may be different compared to the tissue pre-assault

33. Summary of significant findings – take home message
Acute hymenal trauma – abrasions, bruises, lacerations Healed hymenal transections extending to base STIs Positive forensic tests Pregnancy Photographic evidence of actual abuse Berkoff (2008) conducted a systematic review of the literature and concluded that, other than a hymenal transection, genital examination findings “cannot independently confirm or exclude non-acute sexual abuse as the cause of genital trauma in prepubertal girls”.

34. Summary “It’s normal to be normal”
History is the most important aspect
Examine ASAP after alleged assault
Examine in different positions – “multi-method”:
Supine / labial separation
Supine / labial traction
Prone-knee-chest / gluteal lift
Photodocumentation, peer review
Injuries unlikely – examination findings often normal
Few residual abnormalities after injuries heal – examination findings indistinguishable from normal, except
Transection of posterior hymen clear indicator of past trauma
Jury out on deep clefts
“It’s normal to be normal”
(2015 AAP Sexual Assault Guidelines)

35. Conclusions
“Medical professionals must take great care to interpret physical findings using research-derived knowledge concerning the variations of normal and the particular conditions that may be mistaken as abuse” “Since a majority of sexual abuse victims have normal genital examinations, a common theme in testimony is the explanation of the findings and that a physical examination alone does not prove or disprove that sexual abuse occurred.” While interpreting medical findings is an important component of the assessment, “the importance of the child’s history in the diagnosis of sexual abuse cannot be overstated”

36. Thanks to: Dr Andrea Smith, Paediatrician, VFPMS