Journal of Forensic and Legal Medicine
Volume 14, Issue 8 , Pages 482-488 , November 2007

Interpretation of anogenital findings in the living child: Implications for the paediatric forensic autopsy

  • Dawn E. Elder, MB ChB, FRACP

      Affiliations

    • Corresponding Author InformationTel.: +64 4 3855999; fax: +64 4 3855898.

Received 5 November 2006 ,Revised 4 January 2007 ,Accepted 5 March 2007.

References 

  1. Kempe C, Silverman F, Steele B, et al. The battered-child syndrome. JAMA. 1962;181:105–112
  2. Fergusson D, Lynskey M, Horwood L. Childhood sexual abuse and psychiatric disorder in young adulthood: I. Prevalence of sexual abuse and factors associated with sexual abuse. J Am Acad Child Adolesc Psychiatry. 1996;35:1355–1364
  3. Fleming J. Prevalence of childhood sexual abuse in a community sample of Australian women. Med J Aust. 1997;166:65–68
  4. American Professional Society on the Abuse of Children . Glossary of terms and the interpretation of findings for child sexual abuse evidentiary examinations. Chicago: American Professional Society on the Abuse of Children; 1998;
  5. Jenny C, Kuhns M, Arakawa F. Hymens in newborn female infants. Pediatrics. 1987;80:399–400
  6. Mor N, Merlob P, Reisner S. Types of hymen in the newborn infant. Eur J Obstet Gynecol Reprod Biol. 1986;22:225–228
  7. Berenson A, Heger A, Andrews S. Appearance of the hymen in newborns. Pediatrics. 1991;87:458–465
  8. Berenson A. Normal anogenital anatomy. Child Abuse Negl. 1998;22:589–596
  9. Berenson A. Appearance of the hymen at birth and one year of age: a longitudinal study. Pediatrics. 1993;91:820–825
  10. Berenson A, Grady J. A longitudinal study of hymenal development from 3 to 9 years of age. J Pediatr. 2002;140:600–607
  11. Berenson A. A longitudinal study of hymenal morphology in the first 3 years of life. Pediatrics. 1995;95:490–496
  12. Berenson A, Heger A, Hayes J, et al. Appearance of the hymen in prepubertal girls. Pediatrics. 1992;89:387–394
  13. Gardner J. Descriptive study of genital variation in healthy, nonabused premenarchal girls. J Pediatr. 1992;120:251–257
  14. Heger A, Ticson L, Guerra L, et al. Appearance of the genitalia in girls selected for nonabuse: review of hymenal morphology and nonspecific findings. J Pediatr Adolesc Gynecol. 2002;15:27–35
  15. Myhre A, Berntzen K, Bratlid D. Genital anatomy in non-abused preschool girls. Acta Paediatr. 2003;92:1453–1462
  16. McCann J, Wells R, Simon M, et al. Genital findings in prepubertal girls selected for nonabuse: a descriptive study. Pediatrics. 1990;86:428–439
  17. Kellogg N, Parra J. Linea vestibularis: a previously undescribed normal genital structure in female neonates. Pediatrics. 1991;87:926–929
  18. Kellogg N, Parra J. Linea vestibularis: follow-up of a normal genital structure. Pediatrics. 1993;92:453–456
  19. Leung A, Robson W, Tay-Uyboco J. The incidence of labial fusion in children. J Paediatr Child Health. 1993;29:235–236
  20. Berkowitz C, Elvik S, Logan M. Labial fusion in prepubescent girls: a marker for sexual abuse?. Am J Obstet Gynecol. 1987;156:16–20
  21. McCann J, Voris J, Simon M. Labial adhesions and posterior fourchette injuries in childhood sexual abuse. Am J Dis Child. 1988;142:659–663
  22. Cantwell H. Vaginal inspection as it relates to child sexual abuse in girls under thirteen. Child Abuse Negl. 1983;7:171–176
  23. White S, Ingram D, Lyna P. Vaginal introital diameter in the evaluation of sexual abuse. Child Abuse Negl. 1989;13:217–224
  24. Goff C, Burke K, Rickenback C, et al. Vaginal opening measurement in prepubertal girls. Am J Dis Child. 1989;143:1366–1368
  25. Ingram D, Everett V, Ingram D. The relationship between the transverse hymenal orifice diameter by the separation technique and other possible markers of sexual abuse. Child Abuse Negl. 2001;25:1109–1120
  26. Berenson A, Chacko M, Wiemann C, et al. Use of hymenal measurements in the diagnosis of previous penetration. Pediatrics. 2002;109:228–235
  27. McCann J, Voris J, Simon M, et al. Perianal findings in prepubertal children selected for nonabuse: a descriptive study. Child Abuse Negl. 1989;13:179–193
  28. Berenson A, Somma-Garcia A, Barnett S. Perianal findings in infants 18 months of age or younger. Pediatrics. 1993;91:838–840
  29. Myhre A, Berntzen K, Bratlid D. Perianal anatomy in non-abused preschool children. Acta Paediatr. 2001;90:1321–1328
  30. Suarez L, Belanger-Quintana A, Escobar H, et al. Suspected sexual abuse: an unusual presentation form of congenital myotonic dystrophy. Eur J Pediatr. 2000;159:539–541
  31. Hobbs C, Wynne J. Buggery in childhood – a common syndrome of child abuse. Lancet. 1986;2:792–796
  32. Clayden G. Reflex anal dilatation associated with severe chronic constipation in children. Arch Dis Child. 1988;63:832–836
  33. Harvey I, Nowlan W. Reflex anal dilatation: clinical epidemiology evaluation. Paediatr Perinat Epidemiol. 1989;3:294–301
  34. Adams J. Approach to the interpretation of medical and laboratory findings in suspected child sexual abuse: a 2005 revision. APSAC advisor. 2005;17:7–12
  35. Adams J, Botash A, Kellogg N. Difference in hymenal morphology between adolescent girls with and without a history of consensual sexual intercourse. Arch Pediatr Adolesc Med. 2004;158:280–285
  36. Pokorny S, Murphy J, Preminger M. Circumferential hymen elasticity. A marker of physiologic maturity. J Reprod Med. 1998;43:943–948
  37. McCann J, Reay D, Siebert J, et al. Postmortem perianal findings in children. Am J Forensic Med Pathol. 1996;17:289–298
  38. Muram D. Child sexual abuse-genital tract findings in prepubertal girls. Am J Obstet Gynecol. 1989;160:333–335
  39. Claytor R, Barth K, Shubin C. Evaluating child sexual abuse: observations regarding ano-genital injury. Clin Pediatrics. 1989;28:419–422
  40. Muram D. Child sexual abuse: relationship between sexual acts and genital findings. Child Abuse Negl. 1989;13:211–216
  41. Adams J, Harper K, Knudson S. A proposed system for classification of anogenital findings in children with suspected sexual abuse. Adolesc Pediatr Gynecol. 1992;5:73–75
  42. Hobbs C, Wynne J, Thomas A. Colposcopic genital findings in prepubertal girls assessed for sexual abuse. Arch Dis Child. 1995;73:465–471
  43. Berenson A, Chacko M, Wiemann C, et al. A case-control study of anatomic changes resulting from sexual abuse. Am J Obstet Gynecol. 2000;182:820–834
  44. Heger A, Ticson L, Velasquez O, et al. Children referred for possible sexual abuse: medical findings in 2384 children. Child Abuse Negl. 2002;26:645–659
  45. Kellogg N, Parra J, Menard S. Children with anogenital symptoms and signs referred for sexual abuse evaluations. Arch Pediatr Adolesc Med. 1998;152:634–641
  46. Adams J. Evolution of a classification scale: medical evaluation of suspected child sexual abuse. Child Maltreatment. 2001;6:31–36
  47. Finkel M. Anogenital trauma in sexually abused children. Pediatrics. 1989;84:317–322
  48. Heppenstall-Heger A, McConnell G, Ticson L, et al. Healing patterns in anogenital injuries: a longitudinal study of injures associated with sexual abuse, accidental injuries, or genital surgery in the preadolescent child. Pediatrics. 2003;112:829–837
  49. Muram D, Levitt C, Frasier L, et al. Genital Injuries. J Pediatr Adolesc Gynecol. 2003;16:149–155
  50. Berkowitz C, Elvik S, Logan M. A simulated “acquired” imperforate hymen following the genital trauma of sexual abuse. Clin Pediatrics. 1987;26:307–309
  51. Botash A, Jean-Louise F. Imperforate hymen: congenital or acquired from sexual abuse. Pediatrics. 2001;108:e53
  52. Kellogg N, Parra J. A rectovaginal fistula in a sexually assaulted child. Clin Pediatrics. 1996;35:369–371
  53. Lahoti S, McNeese M, McClain N, et al. Two cases of anal fistula in girls evaluated for sexual abuse. J Pediatr Surg. 2002;37:132–133
  54. Marconi J, Turow V, Esernio-Jenssen D, et al. Ruptured ectopic pregnancy complicating sexual abuse in an 11-year-old girl. J Pediatr. 1990;117:739–741
  55. Muram D. Anal and perianal abnormalities in prepubertal victims of sexual abuse. Am J Obstet Gynecol. 1989;161:278–281
  56. De Jong A, Emmett G, Hervada A. Epidemiologic factors in sexual abuse of boys. Am J Dis Child. 1982;136:990–993
  57. Bruni M. Anal findings in sexual abuse of children. J Forensic Sci. 2003;48:1343–1346
  58. Ameh E. Anal injury and fissure-in-ano from sexual abuse in children. Ann Tropical Paediatr. 2001;21:273–275
  59. Pierce A. Anal fissures and anal scars in anal abuse – are they significant?. Pediatr Surg Int. 2004;20:334–338
  60. McCann J, Voris J. Perianal injuries resulting from sexual abuse: a longitudinal study. Pediatrics. 1993;91:390–397
  61. Loredo-Abdala A, Trejo-Hernandez J, Monroy-Villafuente A, et al. letter. Clin Pediatrics. 2000;39:131–132
  62. Adams J, Knudson S. Genital findings in adolescent girls referred for suspected sexual abuse. Arch Pediatr Adolesc Med. 1996;150:850–857
  63. Edgardh K, Ormstad K. The adolescent hymen. J Reproduct Med. 2002;47:710–714
  64. Adams J, Girardin B, Faugno D. Adolescent sexual assault: documentation of acute injuries using photo-colposcopy. J Pediatr Adolesc Gynecol. 2001;14:175–180
  65. Kellogg N, Menard S, Santos A. Genital anatomy in pregnant adolescents: “Normal” does not mean “nothing happened”. Pediatrics. 2004;113:e67
  66. Herman-Giddens M, Berson N. Harmful genital care practices in children. JAMA. 1989;261:577–579
  67. Jones L, Bass D. Perineal injuries in children. Br J Surg. 1991;78:1105–1107
  68. Elder D. Inflicted anogenital injury in children: physical abuse or sexual abuse?. Forensic Med Sci Pathol. 2006;2:25–28
  69. Angel C, Shu T, French D, et al. Genital and perineal burns in children: 10 years of experience at a major burn center. J Pediatr Surg. 2002;37:99–103
  70. Lukschu M, Bays J. Inflicted incision of the penis. Child Abuse Negl. 1996;20:979–981
  71. Feldman K. Letter. Child Abuse Negl. 1997;21:253–254
  72. Slosberg E, Ludwig S, Duckett J, et al. Penile trauma as a sign of child abuse. Am J Dis Child. 1978;132:719–720
  73. Merritt D. Vulvar and genital trauma in pediatric and adolescent gynecology. Curr Opin Obstet Gynecol. 2004;16:371–381
  74. Elmusharaf S, Elhadi N, Almroth L. Reliability of self reported form of female genital mutilation and WHO classification: cross sectional study. BMJ. 2006;333:124–128
  75. West R, Davies A, Fenton T. Accidental vulval injuries in childhood. BMJ. 1989;298:1003–1004
  76. Boos S. Accidental hymenal injury mimicking sexual trauma. Pediatrics. 1999;103:1287–1290
  77. Dowd M, Fitzmaurice L, Knapp J, et al. The interpretation of urogenital findings in children with straddle injuries. J Pediatr Surg. 1994;29:7–10
  78. Bond G, Dowd M, Landsman I, et al. Unintentional injury in prepubescent girls: a multicenter prospective report of 56 girls. Pediatrics. 1995;95:628–631
  79. Hostetler B, Muram D, Jones C. Sharp penetrating injuries to the hymen. Adolesc Pediatr Gynecol. 1994;7:94–96
  80. Herrmann B, Crawford J. Genital injuries in prepubertal girls from inline skating accidents. Pediatrics. 2002;110:e16
  81. Ameh E. Anorectal injuries in children. Pediatr Surg Int. 2000;16:388–391
  82. Vinsant G, Buntain W. Blunt anorectal injuries in children. J Tenn Med Assoc. 1985;78:158–160
  83. Scheidler M, Shultz B, Schall L, et al. Mechanisms of blunt perineal injury in female pediatric patients. J Pediatr Surg. 2000;35:1317–1319
  84. Boos S, Rosas A, Boyle C, et al. Anogenital injuries in child pedestrians run over by low-speed motor vehicles: four cases with findings that mimic child sexual abuse. Pediatrics. 2003;112:e77
  85. Baker R. Seat belt injury masquerading as sexual abuse. Pediatrics. 1986;77:435
  86. Aho T, Upadhyay V. Vaginal water-jet injuries in premenarcheal girls. NZ Med J. 2005;118;http://www.nzma.org.nz/journal/118-1218/1565/
  87. Gray M, Norton P, Treadwell K. Tampon-induced injuries. Obstet Gynecol. 1981;58:667–668
  88. Wood P, Bevan T. Child sexual abuse enquiries and unrecognised vulval lichen sclerosus et atrophicus. BMJ. 1999;319:899–900
  89. Levine V, Sanchez M, Nestor M. Localized vulvar pemphigoid in a child misdiagnosed as sexual abuse. Arch Dermatol. 1992;128:804–806
  90. Bays J, Jenny C. Genital and anal conditions confused with child sexual abuse trauma. Am J Dis Child. 1990;144:1319–1322
  91. Young S, Wells D, Ogden E. Lichen sclerosis, genital trauma and child sexual abuse. Aust Fam Phys. 1993;22:729–733
  92. French G, Johnson C. Genital bleeding: two uncommon causes in patients referred to a sexual abuse clinic. Clin Pediatrics. 1994;33:38–41
  93. Dodds M. Vulvar disorders of the infant and young child. Clin Obstet Gynecol. 1997;40:141–152
  94. Al-Khenaizan S, Almuneef M, Kentab O. Lichen sclerosus mistaken for child sexual abuse. Int J Dermatol. 2005;44:317–320
  95. Stratakis C, Graham W, DiPalma J, et al. Misdiagnosis of perianal manifestations of Crohn’s disease. Clin Pediatrics. 1994;33:631–633
  96. Sellman S, Hupertz V, Reece R. Crohn’s disease presenting as suspected abuse. Pediatrics. 1996;97:272–274
  97. Porzionato A, Alaggio R, Aprile A. Perianal and vulvar Crohn’s disease presenting as suspected abuse. Forensic Sci Int. 2005;155:24–27
  98. Darmstadt G. Perianal lymphangioma circumscriptum mistaken for genital warts. Pediatrics. 1996;98:461–463
  99. Christian C, Singer M, Crawford J, et al. Perianal herpes zoster presenting as suspected child abuse. Pediatrics. 1997;99:608–610
  100. Simon H, Steele D. Varicella: pediatric genital/rectal vesicular lesions of unclear origin. Ann Emerg Med. 1995;25:111–114
  101. Hanks J, Venters W. Nickel allergy from a bed-wetting alarm confused with herpes genitalis and child abuse. Pediatrics. 1992;90:458–460
  102. Huppert J, Gerber M, Deitch H, et al. Vulvar ulcers in young females: a manifestation of aphthosis. J Pediatr Adolesc Gynecol. 2006;19:195–204
  103. Herman-Giddens M. Vaginal foreign bodies and child sexual abuse. Arch Pediatr Adolesc Med. 1994;148:195–200
  104. Stricker T, Navratil F, Sennhauser F. Vaginal foreign bodies. J Paediatr Child Health. 2004;40:205–207
  105. Kellogg N, Menard S. Violence among family members of children and adolescents evaluated for sexual abuse. Child Abuse Negl. 2003;27:1367–1376
  106. Pollanen M, Smith C, Chiasson D, et al. Fatal child abuse-maltreatment syndrome. A retrospective study in Ontario, Canada, 1990–1995. Forensic Sci Int. 2002;126:101–104
  107. Schmidt P, Madea B. Rape homicide involving children. J Clin Forensic Med. 1999;6:90–94
  108. Deming J, Mittleman R, Wetli C. Forensic Science Aspects of fatal sexual assaults on women. J Forensic Sci. 1983;28:572–576
  109. Kellogg N, Lukefahr J. Criminally prosecuted cases of child starvation. Pediatrics. 2005;116:1309–1316
  110. Crowley S. A mobile system for postmortem genital examinations with colposcopy: SART-TO-GO. J Forensic Sci. 2004;49:1299–1307
  111. Orr C, Clark M, Hawley D, et al. Fatal anorectal injuries: a series of four cases. J Forensic Sci. 1995;40:219–221
  112. Kirschner R, Wilson H. Pathology of fatal abuse. In:  Reece R,  Ludwig S editor. Child abuse: medical diagnosis and management. Philadelphia: Lippincott Williams & Wilkins; 2001;p. 467–516

PII: S1752-928X(07)00038-8

doi: 10.1016/j.jflm.2007.03.005

Journal of Forensic and Legal Medicine
Volume 14, Issue 8 , Pages 482-488 , November 2007