This table lists medical and laboratory findings; however, most
children who are evaluated for suspected sexual abuse will not have signs of
injury or infection. The child’s description of what happened to him or her and
the child’s report of specific symptoms in relationship to the events described
is an essential part of the full medical evaluation.
Findings Documented in
Newborns or Commonly Seen in Nonabused Children
(The presence of these findings generally neither
confirms nor discounts a child’s clear disclosure of sexual abuse.)
NORMAL
VARIANTS
1. Periurethral or vestibular bands
2. Intravaginal ridges or columns
3. Hymenal bumps or mounds
4. Hymenal tags or septal remnants
5. Linea vestibularis (midline avascular area)
6. Hymenal notch/cleft in the anterior (superior) half of the hymenal rim
(prepubertal girls), on or above the 3 o’clock–9 o’clock line with patient
supine
7. Shallow/superficial notch or cleft in inferior rim of hymen below 3
o’clock–9 o’clock line
8. External hymenal ridge
9. Congenital variants in appearance of hymen, including
crescentic, annular, redundant, septate cribiform, microperforate, and
imperforate
10. Diastasis ani (smooth area)
11. Perianal skin tag
12. Hyperpigmentation of the skin of labia minora or perianal
tissues in children of color, such as Mexican-American and African-American
children
13. Dilation of the urethral opening with application of labial
traction
14. “Thickened hymen” (May be due to estrogen effect, folded
edge of hymen, swelling from infection, or swelling from trauma. The latter is
difficult to assess unless follow-up examination is done.)
Findings Commonly Caused by Other Medical Conditions
15. Erythema (redness) of the genital tissues (May be due to
irritants, infection, or dermatitis.)
16. Increased vascularity (“dilatation of existing blood
vessels”) of vestibule and hymen (May be due to local irritants or normal
pattern in the nonestrogenized state.)
17. Labial adhesion (May be due to irritation or rubbing.)
18. Vaginal discharge (There are many infectious and
noninfectious causes. Cultures must be taken to confirm if caused by sexually
transmitted organisms or other infections.)
19. Friability of the posterior fourchette or commisure (May be
due to irritation, infection, or an examiner’s traction on the labia majora.)
20. Anal fissures (Usually due to constipation, perianal
irritation.)
21. Venous congestion or venous pooling in the perianal area
(Usually due to positioning of child. Also seen with constipation.)
Conditions Mistaken for Abuse
22. Urethral prolapse∗
23. Lichen sclerosus et atrophicus∗
24. Vulvar ulcers (May be caused by many types of viral
infections, including Epstein-Barr virus [EBV] and influenza, or by conditions
such as Behcet’s disease or Crohn’s disease.)∗
25. Failure of midline fusion, also called perineal groove∗
26. Rectal prolapse (Often caused by infection, such as Shigella
sp.)∗
27. Complete dilation of the internal and external anal
sphincters, less than 2 centimeters in AP diameter, revealing the pectinate
line∗
28. Partial dilation of the external anal sphincter, with the
internal sphincter closed, causing the appearance of deep folds in the perianal
skin that can be mistaken for signs of injury∗
29. Marked erythema, inflammation, and fissuring of the perianal
or vulvar tissues due to infection with Group A beta hemolytic streptococci∗
INDETERMINATE FINDINGS: INSUFFICIENT OR CONFLICTING DATA FROM RESEARCH
STUDIES, OR NO EXPERT CONSENSUS
(These physical and laboratory findings may support a child’s
clear disclosure of sexual abuse, if one is given, but should be interpreted
with caution if the child gives no disclosure. Report to child protective
services may be indicated in some cases.)
30. Deep notches or clefts in the posterior/inferior rim of hymen that
extend through more than 50% of the width of the hymen
31. Deep notches or complete clefts in the hymen at the 3
o’clock or 9 o’clock location in adolescent girls
32. Marked, immediate anal dilation to an AP diameter of 2 cm or
more, in the absence of other predisposing factors such as chronic
constipation, sedation, anesthesia, and neuromuscular conditions
33. Genital or anal condyloma accuminata in child, in the
absence of other indicators of abuse. Lesions appearing for the first time in a
child older than 5–8 years may be more suspicious for sexual transmission.∗
34. Herpes Type 1 or 2 in the genital or anal area in a child
with no other indicators of sexual abuse. Isolated genital lesions caused by
HSV-2 in a child older than 4–5 years may be more suspicious for sexual
transmission.∗
Findings Diagnostic of
Trauma and/or Sexual Contact
(The following findings support a disclosure of
sexual abuse, if one is given, and are highly suggestive of abuse even in the
absence of a disclosure, unless a clear, timely, plausible description of
accidental injury is provided by the child and/or caretaker. Photographs or video recordings of these findings
should be reviewed by an expert in sexual abuse evaluation for a
second opinion to assure accurate diagnosis.∗)
ACUTE TRAUMA TO EXTERNAL GENITAL/ANAL TISSUES
35. Acute lacerations or extensive bruising of labia, penis,
scrotum, perianal tissues, or perineum (May be from unwitnessed accidental
trauma or from physical or sexual abuse.)
36. Fresh laceration of the posterior fourchette, not involving
the hymen (Must be differentiated from dehisced labial adhesion or failure of
midline fusion; see #25. Posterior fourchette lacerations may also be caused by
accidental injury or by consensual sexual intercourse in adolescents.)
RESIDUAL (HEALING) INJURIES
(These rare findings are difficult to assess unless an acute
injury was previously documented at the same location.)
37. Perianal scar (May be due to other medical conditions such
as Crohn’s disease, accidental injuries, or previous medical procedures.)
38. Scar of posterior fourchette or fossa (Pale areas in the
midline may also be due to linea vestibularis or labial adhesions.)
INJURIES INDICATIVE OF BLUNT FORCE PENETRATING TRAUMA (OR FROM
ABDOMINAL/PELVIC COMPRESSION INJURY
IF SUCH HISTORY IS GIVEN)
39. Extensive bruising on the hymen
40. Laceration (tear, partial or complete) of the hymen (acute)
41. Perianal lacerations extending deep to the external anal
sphincter (Not to be confused with partial failure of midline fusion.)
42. Hymenal transection (healed): An area between 4 o’clock and
8 o’clock on the rim of the hymen, where it appears to have been torn through,
to or nearly to the base, so there appears to be virtually no hymenal tissue
remaining at that location. This finding has also been referred to as a
“complete cleft” in sexually active adolescents and young adult women.
43. Missing segment of hymenal tissue. Area in the posterior
(inferior) half of the hymen, wider than a transection, with an absence of
hymenal tissue extending to the base of the hymen, which is confirmed using
additional positions or methods.
PRESENCE OF INFECTION CONFIRMS MUCOSAL CONTACT WITH INFECTED AND INFECTIVE
BODILY SECRETIONS; CONTACT MOST LIKELY TO HAVE BEEN SEXUAL IN NATURE
44. Positive confirmed culture for gonorrhea, from genital area,
anus, or throat, in a child outside the neonatal period
45. Confirmed diagnosis of syphilis, if perinatal transmission
is ruled out
46. Trichomonas vaginalis infection in a child older than 1 year
of age, with organisms identified by culture or, in vaginal secretions, by wet
mount examination
47. Positive culture from genital or anal tissues for chlamydia,
if child is older than 3 years at time of diagnosis and if specimen was tested
using cell culture or comparable method approved by the Centers for Disease
Control
48. Positive serology for HIV if perinatal transmission,
transmission from blood products, and needle contamination have been ruled out
DIAGNOSTIC OF SEXUAL CONTACT
49. Pregnancy
50. Sperm identified in specimens taken directly from a child’s
body
