Abstract
It was with interest I read Dr Theodore Hariton's Viewpoint piece 1 in which he opines that an erect penis cannot penetrate into a prepubertal girl's vagina without leaving permanent, detectable tissue damage. Experienced clinicians will recognize this as a position occasionally argued in court, though rarely in clinic.
Dr Hariton's website identifies him as a retired gynecologist and forensic consultant with no direct pediatric experience. Nonetheless, his publication raises some forensic questions to which a reasoned response should be made, lest there be further misunderstandings.
Dr Hariton condemns a number of often-cited studies from the child abuse literature, principally the paper by Dr Adams from which he derives his title, 2 for failing to adequately address this question. In doing so, he appears to have misjudged the researchers’ intent. While ‘It's normal to be normal’ is grammatically true enough, it may be more accurate (if not as memorable) to conclude with Adams that ‘… the majority of children with legally confirmed sexual abuse will have normal or nonspecific genital findings.’ Adams, who studied cases in which genital contact was reported, specifically denies being able to know whether that contact actually included penetration past the hymeneal ring in her prepubertal subjects. As reasons, she cites children's lack of familiarity with sexual acts and with their own anatomy, and the demonstrated ability of mucosal tissues to heal quickly-phenomena well known to clinicians who examine children. Instead, Adams’ study addressed a more relevant question and found that, for whatever reason, findings were rare, even after a thorough examination, in this population of children known to have suffered sexual contact.
Dr Hariton goes on to cite several researchers’ conjecture that after violent penile penetration past the hymenal ring ‘there is usually a complete laceration of this membrane,’ 3 or that hymeneal injuries ‘may be found,’ 4 but even these mild assertions are not supported by any cited research, for the reasons cited by Adams.
Dr Hariton mistakenly cites McCann and Kerns’ CD-ROM program, 5 which was largely produced in our institution, as evidence that injuries to the prepubertal hymen, when they occur, should always result in hymeneal change that will be detectable on a subsequent forensic examination. In fact, though many of the tissues in this series were permanently affected by their injuries, few if any of these alterations were distinguishable from normal variants on follow up, despite good, multimethod examination. Demonstrating that a healed hymen may appear normal was, in fact, the intent behind selection of these cases for the teaching program (Dr David Kerns, personal communication). That such repair occurs was also an explicitly stated conclusion of both the McCann and Heger papers on healing cited by Dr Hariton. It is difficult to understand how even a physician with no pediatric experience could have misunderstood this point.
When faced with a normal multimethod examination in a prepubertal child who reports genital penetration of any sort, clinicians familiar with the dynamics of child sexual abuse will recognize several possible explanations, including that penetration may have occurred, but not passed the hymeneal ring; penetration passed the ring, but that tissue's normal elasticity and lubrication minimized damage; or that penetration passed the ring, did some damage, but the mucosal damage healed sufficiently before the examination. Unless the event was witnessed or video-recorded, it will always be impossible to determine the degree of penetration, and thus to learn definitively the amount of damage to be expected. Lawmakers appear to have understood this difficulty: legal definitions of sexual abuse do not in fact specify a necessary degree of genital penetration; neither do punishments depend on the integrity of the hymeneal ring.
Dr Hariton has addressed himself to a question that remains challenging, even to those experienced in the field of child sexual abuse evaluation. It is, however, a question no one has been attempting to answer, and whose eventual answer would have little if any practical value in responding to child sexual abuse.
One other point needs to be addressed. Dr Hariton identifies his (only) professional affiliation as ‘Consultant, California Clinical Forensic Training Center.’ Since 2006, Dr William Green, Medical Director at the California Clinical Forensic Medical Training Center has requested and obtained consultation from time to time regarding adult and adolescent gynecological issues from Dr Theodore Hariton, a forensic gynecologist. However, Dr Hariton has never been employed as a paid consultant to CCFMTC, and consultation has not been requested nor given on issues relating to child sexual abuse (Dr William Green, personal communication).