Genital Findings

High-probability findings specific to the genitalia include the following:

• semen in the vagina of a child,
• torn or missing hymen,
• other vaginal injury or scarring,
• vaginal opening greater than 5 mm, and
• injury to the penis or scrotum.

Semen in the vagina is the highest probability finding, but it is uncommon.

Although there is a fair amount of variability among girl children in the extent, shape, and other characteristics of hymens, the complete absence of or a tear in the hymen of a young girl is indicative of sexual abuse. In older girls, it is important to determine whether other sexual activities may account for the absence or the tear. Conditions such as bumps, friability, and clefts in the hymen may be a result of sexual abuse, but they are also found in girls without a reported history of sexual abuse.

Health care professionals document and describe injuries to or bleeding from the vaginal opening by likening it to a clock face, 12 o'clock being the anterior midline and 6 o'clock the posterior. Abrasions, tears, and bruises to the vagina between 3 and 9 o'clock, or to the posterior, are more likely to be the result of penile penetration, whereas injuries between 9 and 3 o'clock, or anteriorly, are more likely the consequence of digital manipulation or penetration.

There is some controversy regarding what transverse diameter to use as a guideline for differentiating between girls with genital evidence consistent with penetration and those with no genital evidence, with measures ranging from 4 to 6 mm being advocated as indicative of sexual abuse. One factor that may affect findings is the age of the child, with the expectation that older girls will have larger vaginal openings. Heger, an expert in physical findings related to sexual abuse, discounts the importance of hymenal transverse diameter, noting that it varies in size depending on the position in which the child is examined. It is also important to note that not all girls who have a reported history of penetration evidence enlarged vaginal openings, tears, abrasions, or bruising.

Absent another explanation for an injury to the penis, which is consistent with the child's account of the abusive incident, the injury should be considered indicative of sexual abuse. Bite marks, abrasions, redness, "hickeys," scratches, or bruises may be found.

Lower probability genital findings are as follows:

• vaginal erythema,
• increased vascularity,
• synechiae,
• labial adhesions,
• vulvovaginitis, and
• chronic urinary tract infections.

Erythema or redness and swelling might be caused by genital manipulation or intrusion perpetrated by a significantly older person. However, it might also be the result of poor hygiene, diaper rash, or perhaps the child's masturbation. Increased vascularity, synechiae, and labial adhesions may be a consequence of sexual abuse, but they are common findings in children with other genital complaints.

Vulvovaginitis and chronic urinary tract infections can be sequelae of sexual abuse but also can be caused by other circumstances, such as poor hygiene, a bubble bath, or, in the case of urinary tract infections, taking antibiotics.

Anal Findings

The following are high-probability findings:

• destruction of the anal sphincter,
• perianal bruising or abrasion,
• shortening or eversion of the anal canal,
• fissures to the anal opening,
• wasting of gluteal fat, and
• funneling.

Very occasionally there will be a finding of total absence of anal sphincter control, indicative of chronic anal penetration. If there has been forceful anal penetration, it may result in bruising and scrapes. A shortening or eversion of the anal canal has been found in very young children who have been chronically anally penetrated. Perianal fissures and scars from fissures are thought to be indicative of sexual abuse except when they occur at 12 o'clock and 6 o'clock, in which case they may be the result of a large stool. If the fissure is wider externally and narrows internally, this is consistent with object penetration of the anus. The converse finding is consistent with the passage of a large, firm stool. Funneling and wasting of the gluteal fat around the anal opening can occur from chronic anal penetration. This is a rare finding in children but may be found in male adolescent prostitutes. The following anal findings are lower probability:

• perianal erythema,
• increased perianal pigmentation,
• perianal venous engorgement, and
• reflex anal dilatation.

Perianal erythema, increased pigmentation, and venous engorgement are all physical findings noted in children who have a history of anal penetration. However, these conditions also have been reported in substantial numbers of children with no reported history of sexual abuse, suggesting that they can be caused by other conditions. In the case of the first two findings, these conditions could be a consequence of poor hygiene.

A finding that is in some dispute is reflex anal dilatation, that is, gaping of the anus or the twitching of the anal sphincter at the time of physical exam. Some physicians believe that it is a consequence of anal penetration, but others have noted this finding in children whose lower bowel is full of stool. However, gaping of 20 mm or more is thought to be indicative of anal penetration.

Oral Findings

Generally oral sex leaves little physical evidence. The only physical findings that have been noted are the following:

• injury to the palate or
• pharyngeal gonorrhea.

Sometimes the child will sustain an injury to the soft or hard palate from being subjected to fellatio. This may cause bruising, especially pinpoint bruises called petechiae, or abrasions. Children may also contract pharyngeal gonorrhea as a consequence of oral sex, as described above.

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Tags: Sexual Abuse

About the Author

Formerly the National Clearinghouse on Child Abuse and Neglect Information and the National Adoption Information Clearinghouse, Child Welfare Information Gateway provides access to information and resources to help protect children and strengthen families. A service of the Children's Bureau, Administration for Children and Families, U.S. Department of Health and Human Services.