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Medical Examination for Sexual Abuse: Have We Been Misled?
Lee Coleman*
ABSTRACT: There are serious difficulties in diagnosing sexual abuse on the basis of an ano/genital examination. Nevertheless, medical conclusions are often used in court to provide evidence for abuse. The
support for the alleged physical indicators of abuse has been based on opinions and claims unsupported by research data. Recent research by John McCann on the ano/genital anatomy in nonabused children has established that
findings often attributed to sexual abuse are found in many normal children. McCann's findings were applied to 158 children who had been medically examined in cases of alleged sexual abuse. Nearly all the findings attributed to sexual abuse were present in McCann's sample of nonabused children. More baseline studies are needed, including those comparing nonabused children to children where there is convincing evidence of abuse. In the meantime, the courts need to modify their current practices concerning evidence from ano/genital examinations.
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McCann and his colleagues are the only ones so far to take on the very necessary task of trying to establish the range of ano/genital anatomy in normal children. Without such data, the "findings" so regularly attributed to molest are essentially meaningless. That there are as yet no published data on this is itself highly significant.
At a meeting in San Diego in January, 1988, sponsored by the Center for Child Protection of the San Diego Children's Hospital, McCann reported on this research.
Three hundred prepubertal children, carefully screened to rule out prior molest, were examined, and it was found that many of the things currently being attributed to molest are present in normal children. Here are some conclusions:
Vaginal opening size varies widely in the same child, depending on how much traction is applied and the position of the child while being examined. Knee-chest position (Emans, 1980) leads to different results from frog position.
Fifty percent of the girls had what McCann calls bands around the urethra. He has heard these described as scars indicative of molest.
Fifty percent of the girls had small (less than 2 mm) labial adhesions when examined with magnification (colposcope). Twenty-five percent had larger adhesions visible with the naked eye.
Only 25 percent of hymens are smooth in contour. Half are redundant, and a high percentage are irregular.
What are often called clefts in the hymen, and attributed to molest, were present in 50 percent of the girls. Commenting on his team's mistaken assumptions at the outset of their study, McCann said, "We were struck with the fact that we couldn't find a normal (hymen). It took us three years before we found a normal of what we had in our minds as a preconceived normal ... you see a lot of variation in this area just like any other part of the body ... We need a lot more information about kids ... we found a wide variety ...
"... in the literature, they talk about ... intravaginal synechiae and it turns out that ... we saw them everywhere ... We couldn't find one that we couldn't find those ridges."
"When does normal (hymenal) asymmetry become a cleft? I don't know."
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Table 3 tabulates those findings said to indicate genital abuse of girls. (As it turned out, all "positive" findings in boys were confined to anal examinations). Because of inconsistent terminology used by different examiners, I have included alternate terms in parenthesis.
Table 3
Frequency of Alleged Indicators of Molest in 109 Girls
Hymenal "scar" (bands, synechia) 45
Rounded hymenal edge 35
"Neovascularization" 27
Dilated vaginal opening 19
Vaginal Erythema 18
Vaginal scar 16
Hymen thickened 10
Healed hymen tear (transection) 9
Hymen redundant 5
Vaginal or labial adhesions 5
Hymen thinned 4
Hymenal tags 3
Labial abrasion 3
Vaginal erosions 2
Hymen absent 1
Labial thickening 1
Condyloma 1
Herpes 1
We see that
nearly all the findings attributed to molest were in fact found by McCann in substantial portions of the normal children he examined. They are also the findings which Emans, et al. (1987) found in children allegedly molested but also found in girls with no evidence of molest but suffering other types of medical problems.
Even the few findings Emans claims distinguish molested from nonmolested but otherwise symptomatic girls, such as hymenal tears and intravaginal synechiae, have been found to be unreliable.
McCann et al. found, as already mentioned, that is was impossible to tell the difference between "normal asymmetry" of the hymen and hymenal "tear," and that he saw intravaginal synechiae "everywhere" when the normal children were examined.
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http://www.ipt-forensics.com/journal/volume1/j1_3_1.htm
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