Abstract
I am writing in response to an article by Dr Hariton, published online in the Viewpoint section of your journal on September 5, 2012. As Dr Hariton referred to a 1994 publication of mine,
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which had as a subtitle ‘It's Normal to be Normal,’ with respect to abnormal genital findings in children who have been sexually abused, I feel it is my responsibility point out some of Dr Hariton's errors of omission and commission.
In my retrospective study
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reviewing medical findings in 236 children in whose case the alleged perpetrator of sexual abuse had been convicted, I acknowledged several of the limitations of the study. The three most important limitations, as pointed out also by Dr Hariton, were: a) the lack of certainty that the child's description of what occurred, often phrased something like ‘he put his thing in my pee pee,’ actually represented penetration of the child's vagina by the adult's penis, or contact that the child perceived as penetration; b) the fact that a guilty plea,- confession or conviction for sexual abuse/assault is not proof that suspect did sexually abuse the child; and c) the fact that both prepubertal girls and adolescent girls were included in the study. He neglected to state, however, that a logistic regression analysis showed that abnormal genital findings were not significantly associated with Tanner Stage. There was one important study that was not mentioned at all by Dr Hariton-the paper by Abbey Berenson MD and associates published in The American Journal of Obstetrics and Gynecology.
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This was the first, and so far only, case control study of genital findings in girls with and without a history of digital-vaginal or penile-vaginal penetration. These were all prepubertal girls, and a very comprehensive method was utilized to rate the likelihood that vaginal penetration had occurred in the 192 subjects in the sexual abuse group. Surprisingly, only 4 girls in the abused group had signs of hymen injury: 2 girls had a deep notch in the hymen, 1 girl had a transection of the hymen, and one girl had a hymen perforation. Superficial hymen notches were found in both the non-abused and abused girls. So, only 2% of the girls in the penetration group had signs of hymen injury. Dr Hariton mentions studies by Dr John McCann several times, but completely misrepresents the findings of his 2007 study
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on the healing of hymeneal injuries in children. This was a descriptive study that analyzed genital injuries in 113 prepubertal girls who had been evaluated acutely following sexual abuse or accidental trauma and had at least one follow-up visit to assess healing of the injuries. He described, from the submitted photographs, lacerations of the hymen as superficial, intermediate, deep, transections, or transections with extension. In the abstract of the paper, he states: ‘Of the girls who sustained superficial, intermediate or deep (hymen) lacerations, 15 of 18 (83%) prepubertal girls had smooth and continuous appearing hymen rims’ at the follow-up visit. An examination of a prepubertal girl that describes the hymen rim as being smooth and continuous would likely be considered as ‘normal’ by most physician experts in this field. For the cases of injuries in prepubertal girls, when there was an acute hymen transection with extension (into the fossa navicularis), 74% healed with a transection or transection with extension. Therefore, in cases where there was a laceration of the hymen acutely, partial tears healed without definitive signs of past injury in 83% of cases, and even in girls who had complete tears all the way through the hymen there were no definitive abnormal findings in 26% of cases.
When evaluating a prepubertal girl who says that someone put something ‘in’ her ‘front privates,’ we will probably never know exactly what happened or how far the object or body part might have been inserted, unless there are clear signs of penetrating trauma: hymen laceration; hymen laceration with extension to the fossa and/or posterior fourchette; or a healed transection presenting as a complete cleft to, or nearly to, the base of the hymen, with virtually no hymen tissue remaining at that location. McCann's study clearly showed that 83% of prepubertal girls who in fact did have partial tears of the hymen when examined acutely did not have ‘Visible Anatomic Change from Trauma’ on follow-up examination.
There are three possible explanations as to why a prepubertal girl who describes penile-vaginal “penetration” could have no signs of residual injury on examination: 1) There was no inappropriate sexual contact; 2) There was penile-vaginal contact perceived by the child as penetration, but it did not cause any injury; or 3) There was contact that caused injury, but the injury has healed without definitive signs of past trauma.
Perhaps ‘It's normal to be normal’ is a misleading phrase that could confuse juries in cases of suspected child sexual abuse and/or assault. A better summary of the evidence concerning examination findings in sexually abused girls would be: ‘Signs of recent or healed injury to the genitalia in prepubertal girls describing penile-vaginal contact are uncommon.’ It is important for judges and juries to understand this fact, and to rely on the clarity, consistency and detail of disclosures given by children about their experience as the most important evidence that sexual abuse has occurred. Whether the sexual contact is called sexual abuse or sexual assault, and whether the penetration was past the hymen or not, the child's disclosure of the events needs to take precedence in the medico-legal arena of pediatric sexual abuse.