Introduction

Sleeping childOne of the most difficult aspects of child sexual abuse to read about (or write about) is the physical injuries that may result from the sexual abuse.  Studies regarding children’s sexual abuse injuries are few and far between and there is much debate as to what types of injuries result, how severe those injuries may be, and how much, if any, permanent damage can result from the sexual abuse of a child.

Contrary to what most will believe, physical indicators of sexual abuse are not always present and in fact, most examinations of sexually abused prepubertal girls result in normal examination findings due to the elasticity of the hymenal tissue and rapid healing of any injuries that may have occurred during the sexual abuse.  In addition, many sexual abuse cases do not involve vaginal or anal penetration (e.g. fondling), nor was the victim physically forced or restrained, and hence no physical injuries would be have occurred.  And finally, children often wait for quite some time after the sexual abuse incident before disclosing.  Hence, any physical evidence of the abuse will have long healed.  The fact is, typically no physical or medical evidence will be found that indicates that a child has been sexually abused.

If the examination can be done immediately after the sexual abuse incident then there is a much better chance of finding evidence such as tears and bruising the labia, vaginal walls, and hymen.  Regardless, when evidence is found , it is frequently ambiguous and may be argued that the injury occurred as the result of some other type of physical trauma.

“The human body is an incredible machine and the anal and vaginal cavities have a remarkable ability to heal rapidly.  Injuries to the genital and anal tissues not only heal quickly, but often times they heal completely.  Furthermore, many types of sexual contact do not cause apparent physical injury.  Studies since 2000 indicate that only 4 percent to 5 percent of children giving a history of sexual abuse have physical signs of the assault.  A case review of 36 pregnant adolescent girls was conducted to determine the presence or absence of medical evidence indicating trauma as a result of penetration.  Although pregnant, only 2 of the 36 subjects had definitive findings of penetration.  Most children have no physical indications as a result of sexual abuse.  Often times the lack of injuries may be viewed as a negative indicator of sexual abuse when in reality it is more a neutral finding, unable to definitively prove or negate the allegation.  The exam may be able to help children and their families address their concerns and provide reassurance that the children are physically OK.”

Just as physical injuries are typically not produced during the sexual abuse of a child, long term problems resulting from sexual abuse are rare but may include gastrointestinal disorders such as irritable bowel syndrome, non-ulcer dyspepsia, or chronic abdominal pain.  Occasionally gynecological disorders may persist such as chronic pelvic pain, dysmenorrheal, or menstrual irregularities.

Still, evidence of physical injury is rare.  The best indicator of a sexual abuse incident is the child’s or a witness’s account of the sexual abuse.

Physical injuries that may result from child sexual abuse

If physical indicators are present they may include bruises to the arms or legs or pinch marks resulting from force.  Abrasions to the wrist and ankles may result if the perpetrator forcefully held the victim down during the assault.  Grab marks on the arms or inner thighs are strongly suggestive of sexual abuse, especially thumb marks on the inner aspect of the thigh placed there when the child’s legs were forced apart.

Bruises to the genital area are also possible.  For girls, redness or adhesions may not be indicative of sexual abuse and could in fact be the result of poor hygiene, diaper rash, child masturbation, or injurious activities such as a straddle injury.  Genital bruises are common and may not necessarily result from sexual abuse.

Bruises to oral palate, the soft or hard palate, can occur during sexual abuse.  Sometimes the oral bruises that result from sexual abuse are pinpoint type bruises called petechiae.  In addition, bruising around the mouth may occur if the perpetrator forcefully closes the child’s mouth to stop them from screaming.

Bruising or abrasion of the rectal area can occur by typically only occurs if penetration was forceful (and in family related sexual abuses cases the molestation act is rarely forceful).  Other rectal abnormalities such as tears, distorted or irregular folds, or poor anal tone can be indicative of sexual abuse.  Destruction of the anal sphincter may be possible if sexual abuse was chronic (repeated over time).

Tears, fissures, or scars around the anal opening will typically be found at the 12 o’clock and 6 o’clock positions.  Tears could be the result of a large stool though.  In sexual abuse cases, the tears are wider externally and narrower internally, especially if the penetration occurred with a foreign object.  If tears resulted from large stools then the tear pattern is inverse (narrower externally and wider internally).

Rarely found in children (other than young male prostitutes) is the wasting of the gluteal fat (the fat around the buttocks) around the anal opening but this can occur from repeated anal penetration.  Another rare occurrence is total lack of sphincter control that can result from repeated anal penetration.  In cases where sexually abused children often soil their pants, it is caused more by the child purposefully soiling their pants in order to deter the offender from further acts of sexual abuse, and not as a result of damaged or weakened sphincter muscles.

An item of dispute is the gaping of the anus or twitching of the anal sphincter at the time of a physical exam.  Gaping can be the result of anal penetration but can also occur if the lower bowel is full of stool.  Some doctors argue that lax sphincter muscles or enlarged openings may not indicate sexual abuse at all because penetration by an adult male would result in tearing injuries instead.

Males may incur injuries to the shaft of the penis or scrotum although this too is rare.  More telling will be surface injuries to the penis such as bite marks, abrasions, redness, scratches, or bruises.

Hymenal abnormalities in young girls are a hotly disputed and misunderstood topic.  The hymen is the membrane that surrounds or partially covers the external vaginal opening.  In young girls it is often crescent shaped.  Hymenal tears may be found but they may also heal completely leaving no signs of trauma or scarring.  Hymenal injuries may be present from chronic abuse and may show up as bands, ridges, notches, bumps, tags, tears, or a even a missing hymen.  The shape of the hymen after repeated sexual abuse may be altered too.

A couple of myths regarding the hymen are mentioned below:

FACT: The hymen does not cover the opening of the vaginal cavity and it is not “lost” when vaginally penetrated.  Many myths regarding female genital anatomy are based solely on dogma and lack of research.  However, in the last 25 years, many research studies have expanded medical knowledge and debunked old myths.  It is a common myth that the hymen is a sheet of tissue covering the vaginal opening that is broken open during sexual intercourse.  This is untrue.  The hymen is in fact a collar or partial collar of tissue that surrounds the vaginal opening, but rarely covers it.  In the rarest of cases, when a hymen does cover the vaginal vault, the opening would need to be medically opened to release menstrual blood or insert a tampon.

FACT: The hymeneal tissue experiences changes during birth and the prepubescent and pubescent years.  In addition, estrogen plays an important role in the physiological changes of the hymen during the lifespan.  For instance, since newborn babies are still under the influence of the mother’s estrogen the hymen is thick and elastic.  Newborns may continue to produce increased levels of estrogen for the first two to four years.  When estrogen levels increase again during puberty, the hymen becomes thick and elastic again.  However, after estrogen leaves the newborn’s body and before a child becomes pubescent, a girl’s body has decreased levels of estrogen.  Without estrogen, the hymen becomes smooth, thin and without any elasticity.  During this stage, the hymen is extremely sensitive and delicate.

Remember that a torn or missing hymen in a young girl may not necessarily be indicative of sexual abuse.  In older girls, other sexual activity may account for a torn or missing hymen.  Bumps and clefts in the hymen may be the result of sexual abuse but are also found in girls with no history of sexual abuse.

Sexually transmitted diseases or pregnancy are of course a physical indicator that almost always points to sexual abuse, especially if the victim was a young child.  STDS such as gonorrhea, rectogenital chlamydial infections, herpes simplex, venereal warts and syphilis have been found in sexually abused children.

Findings are categorized as “high probability” and “low probability” findings.  A combination of several high probability findings lends credence to the sexual abuse incident while low probability findings may easily be the result of something other than sexual abuse.

High probability findings include

  • Semen in the vagina
  • Torn or missing hymen
  • Vaginal injury or scarring
  • Vaginal opening greater than 5mm
  • Injury to penis or scrotum

Low probability findings include

  • Labial adhesions
  • Urinary tract or vaginal infections.  Due to the anatomy of the vagina in young girls (lacking pubic hair, vagina lying close to the anus, lack of labial fat pads) in conjunction with poor hygiene, leads to vaginal infections
  • Redness or swelling

In reality, most problems that result from sexual abuse are related to psychological trauma.  Complaints from the child or actions they take may make can indicate the child has experienced a sexual abuse incident.  The child may insert foreign bodies into the vagina or rectum or they may complain of pain while defecating or urinating.  Children who are sexually abused may complain of itching in the vaginal area or mouth.  Other more general complaints that could indicate sexual abuse include headaches, abdominal pain, constipation, diarrhea, encopresis (voluntary or involuntary passage of stools in a child who had already been toilet trained), or general fatigue.

How sexual abuse examinations are conducted

Many times the sexual abuse examination is conducted well after the fact since children generally do not disclose the incident immediately.  More often the child will not disclose at all and your only indicator that sexual abuse has occurred will be changes in the child’s pattern of behavior.

Preparing the child for a sexual abuse physical examination

For prepubertal children, the physical examination will of course include an examination of the external genitalia.  Parents should prepare the child beforehand.  This will help ease the child’s fears and make the examination quicker and easier for all.  Explain to the child what the examination will entail and why it is needed (to make sure the child is OK).  Typically the doctor will do a head to head examination and include the genitalia examine along with the complete body examine so as to not draw too much attention to that part of the exam.

Explain to the child that cotton swabs may be used to pick up test indicators and that the doctor will be inserting the swabs into various parts of their bodies.  The child will be tested for STDs and cotton swabs may be used for this procedure.  This is often scary for the child.

Sometimes scopes will be used so the doctor can look inside the vagina or rectal area.  Ask the doctor if the child may use the equipment beforehand so they understand what it does and why it is not to be feared.  Water may also be used to “float” the hymen so it is easier for the doctor to examine.  If the hymen is missing entirely, it may be adhered to the side of the vaginal wall.  The doctor may use water or moist swabs to loosen the edges in order to clarify the finding of sexual abuse.

Other examination considerations

Parents will need to consider that photographs will be taken and that they must first consent to this.  Photographs are of course confidential but may be used in future court proceedings.  You must also explain to the child why the doctor is photographing their “private parts”.

If the child is bleeding, they will be treated as an emergency and examined immediately.  The location of the bleeding or injuries will use a clock metaphor such as “bruises to the vagina between the 3 and 9 o’clock positions”.

The opening of the vagina will typically not be measured for stretching although some studies have found that stretching may indeed occur.  This type of measurement is typically too subjective to be of any use in the exam and there is some controversy in this area regarding what diameter to use as a guideline for young girls.  In young girls, a vaginal opening diameter between 4 to 6 mm may be an indicator of sexual abuse.  The size varies with age and even varies with the position of the child during the examination.  It is believed that a 3mm diameter is normal but the diameter increases by about 1mm each year.

After the physical exam

Once the examination is complete and the results have been passed on, let the child know what the results of the examination were.  Ensure them that everything is OK and that there was no permanent damage.  And as always, reassure them that the sexual abuse act was not their fault.