The Role of the Non-Sexual Abuse Specialist
Community Health Care Professional

Physical Findings in Sexual Abuse

It is a frequently recorded fact that 80 % of children who are victims of a known sexual assault (admitted by the offender) have a normal physical exam (Adams et.al., 1994, Krugman, 1998). This can occur for any of the following reasons:

• There could have been a delay in reporting the incident(s) by the child out of fear or intimidation.
• Small injuries heal rapidly with new epithelial tissue generating in 4 to 7 days.
• Offenders usually do not use enough force to cause tissue trauma.
• The nature of abuse is such that the perpetrator seeks to gain the child's silence and cooperation so that participation is guaranteed over time.
• Behaviors deemed sexually abusive to children extend along a continuum from no touching, to touching, to exploitative behaviors (Robinson & McKenzie, 2000).

Several investigators in the late 1980's made attempts to define characteristics of genitalia of males and females that would be "diagnostic" of abuse. Cantwell (1983), and the team of White, Ingram, & Lyna (1989), described vaginal openings greater than 4 cm as a diagnostic criteria. Hymenal tears and tissue bands inside the vagina were the pathognomonic identifiers in the study by Emans et al. in 1987. Hobbs and Wynne (1989) used the findings of rectal reflex and dilation as their primary focus. In the same year, Hanson and others thought that the definitive diagnostic characteristic was condylomata.

The 1990's brought a series of studies to refute the investigators of the previous years. Surprisingly, little information was actually known about the normal range of genital characteristics in children. What was to be discovered in these newer studies would cast serious doubts on the diagnostic "validity" of those previous genital benchmarks.

McCann et al. (1990), and Berenson, Somma-Garcia, and Barnett (1993) found that by using a control group of pre-pubertal children who had been carefully screened to rule out abuse they were able to identify many hymenal tears, and tissue bands, as well as reflex and anal dilation in the normal population.

The only physical evidence of a definitive sexual assault is the presence of sperm in a pre-pubertal girl (Aiken, 1990). What must be remembered is that even this has a disclaimer. Gardner (1993) reminds us that sperm may be present as the result of consensual intercourse. These studies help show that the diagnosis of child sexual abuse is difficult and the proof of child sexual abuse should not rest on the physical examination alone.