Genital examination findings –

“It’s normal to be normal” but

what IS normal?

Dr Jo Tully
VFPMS Seminar2017
The acute SA examination -
• STI/pregnancy
purpose Medic prevention
• Acute injury
al management
and reassurance

• Gatehouse/SECASA
• Empathy with ‘victim’
Psychologic
al and family
Acute • Crisis mental health –
suicide risk
sexual
assault
exam Protectiv • Need for Child
e Protection?

• DNA/evidence collection
connecting alleged
perpetrator with crime
Criminal • Evaluate genital
exam findings in
forensic context –
over-reliance…???
What is normal?
 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
Normal hymens
Normal pre-
pubertal
hymen
Normal post-pubertal hymen
 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
 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; 387-394
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
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: 645-659

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
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
 Where are we now?

Published in J Paed Adolesc Gynecol 29 (2016)

 Non- • Normal variants
abused • Findings caused by medical conditions
• Conditions mistaken for abuse
children

• Anal dilatation
No expert • Notches/clefts
• Genital/anal warts
consensus • HSV

Trauma • Findings indicating acute or healed trauma

• Sexually transmitted infections
+/or sexual • Pregnancy
•
contact Semen
 Non- • Normal
variants
What NOT to worry about abused •Medical
conditions

children •Mistaken
for abuse
1. 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
 Septal remnant

Peri-urethral Hymenal fold

support bands
Septate hymen
Fossa navicularis

Linea vestibularis

Perianal skin tags

Clefts, notches, bumps and
mounds
Non-abused children Non- •Normal
variants

2. Findings commonly caused by

abused • Medical
conditions
•Mistaken for

conditions other than trauma children abuse

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
 Non- • Normal variants
Non-abused children abused • Medical conditions
children • Mistaken for abuse

3. Conditions mistaken
for abuse
• Urethral/rectal
prolapse
• Lichen sclerosis
• Ulcers
• Infection (not STI)
• Peri-anal creases
• Post mortem changes
Conditions mistaken for abuse
 Non-
No expert consensus abused
children
• Anal dilatation
No expert • Notch/clefts
consensus • Genital/anal warts
• HSV 1 or 2
Superficial and deep notches –
but how deep is deep?
 Non-
abused
children

No expert
consensus

• Findings indicating
Trauma acute or healed
+/or trauma
•Sexually transmitted infections
sexual •Pregnancy
•Semen
contact
The ‘abnormal’ hymen….?
Caused by
No expert consensus
trauma/sexual contact
• Notch or cleft at or below • Bruising, petechaie,
3 or 9 o’clock which is abrasions to hymen
deeper than a superficial • Acute laceration – any depth
and may extend nearly to • Healed transection/complete
cleft between 4 and 8 o’clock
the base but is not a extending to base
complete transection • Posterior defect in hymen
• Complete cleft/notch at 3 wider than a transection with
absence of hymen extending
or 9 o’clock position to base
Genital injuries
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
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
“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: 310-317
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
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.
 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
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”.
Summary
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)
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”
Thanks to: Dr Andrea
Smith, Paediatrician,
VFPMS