Sexual assault in prepubertal girls: ‘It is normal to be normal’ – or is it? Evidence of vaginal penetration in prepubertal girls

Introduction

This viewpoint article is in response to literature discussing the concept that there might be no medical findings in prepubertal girls after traumatic penile vaginal penetration. Since ‘It's normal to be normal’ was published by Dr Joyce Adams ¹ in 1994, her declaration has become the mantra of prosecutors and Sexual Assault Response Team examiners across the country. Her article discussed the lack of visible physical findings from sexual injuries in prepubertal girls who had reported past sexual abuse including penile vaginal penetration. Unfortunately, in many if not a majority of these cases, the reporting did not occur until months or, more often, years after the actual event. Because of this delay and the ages of the putative victims, the statement ‘it's normal to be normal’ takes on real legal importance and is frequently an issue in trials.

The postulate of this article is that after a sexual encounter, a prepubertal girl will not have anatomically normal findings if actual penile vaginal penetration occurred during the event. The prepubertal child will be anatomically normal only if the encounter did not include penile vaginal penetration or if no encounter occurred.

Some arbitrary definitions will be used in this discussion for the sake of clarity. These should be considered for use in the medical literature to help create an unambiguous and consistent dialogue in discussions of sexual abuse, sexual molestation and sexual assault. These definitions and distinctions are essential to an understanding of this issue.

The most important definition is that of sexual assault. In this discussion, sexual assault is defined as actual non-consensual penetration of any orifice. This means actual penile penetration not just to, but partially or completely through, the hymenal ring .

The American Psychological Association statement ‘Understanding Child Sexual Abuse’ ² acknowledges that there is no universal definition of sexual abuse. The terms abuse, assault and molestation are used interchangeably in many articles, and this lack of differentiation often causes difficulty when trying to evaluate the information presented.

The next definition is penetration. The medical definition is used, which is the entering or penetration of the hymeneal ring. The legal definition varies from state to state and is a legal rather than medical issue. Penile contact with the genitals is considered penetration by some states, but for this discussion that would be sexual abuse or sexual molestation, not sexual assault.

Scarring in this discussion is defined as the classic histological and structural changes of healing that can be identified visually and by a microscope on tissue section. It is the current belief that due to the basic histological composition of the hymen, it does not heal with the identifiable histological structural changes that occur in other tissues. Injuries that penetrate through the hymen into the underlying vaginal tissue or penetrating injuries to the fossa navicularis or the posterior fourchette will result in scarring or visible histological verifiable scarring that can be seen under the microscope.

The term Visible Anatomic Change from Trauma, or VACT will be used to describe the changing of shape or contour of the hymen from healed trauma. Hymenal transections and clefts from traumatic damage are evidence of this visible anatomic change in the hymenal anatomy. The purported lack of histological scarring of the hymen is often quoted in court as the reason for not finding evidence of prior penetration.

For consistency and clarity, in this discussion these definitions will be used for assault, penetration and VACT. All assault is abuse but all abuse is not assault.

In many trials the term penetration is used loosely and can give the jury the impression of actual penile vaginal penetration. The medical literature needs to be extremely specific in discussions on this subject. The audience for this medical information now includes the courts as well as medical professionals. In children it is often difficult for the authors/examiners to be specific in their reporting as the children frequently cannot tell them what actually happened. This is why some states require special training to be child sexual abuse interviewers.

This clarity is especially important to learn for the rapidly growing number of sexual assault examiners being trained in the USA. There are now approximately 600 SANE (sexual assault nurse examiner) active programs across the USA. Each program has between one and 20+ sexual assault nurse examiners (Personal Communication, Diana Faugno MSN, RN CPN.SANE-A, 27 September 2010). Many of the new examiners have neither the essential background or training in women's health nor adequate training or experience in the scientific method, research methodology or study design necessary for them to evaluate published research critically. Many of them lack specific training or clinical experience in the area of paediatric anatomy and development.

These new sexual assault examiners will have a major Crime Scene Investigation or ‘CSI effect’ as they testify in courts across the country. Courts qualify these examiners as ‘medical experts’ and juries tend to believe testimony from medical experts, so specific informed accurate medical information is paramount for justice to occur.

The method of genital examination used by these examiners is also extremely important and should be consistent in any study or in any examination report. The use of the multi-method examination approach is a valuable adjunct in the examination of the prepubertal girl. This includes an examination using supine labial separation, supine labial traction and an examination in the prone knee chest position. Boyle ³ has demonstrated the value of this type of examination, especially in identification of hymenal injuries, both acute or in the past.

This article will discuss an evaluation of Dr Adams' original article, ¹ what she based the article on, a review of articles supporting her position and contrary articles that challenge this concept. Most importantly, the anatomy and histology of the prepubertal girl and the size and configuration of the male penis themselves challenge ‘It's normal to be normal’ when penile vaginal penetration has been attempted or occurred.

Literature review

A significant majority of the articles reviewed for this article do not totally separate assault and abuse, either in language or meaning, as we have defined them. They also do not totally separate the examinations and expected findings in prepubertal girls and post pubertal girls. Both what happened (penetration or not) and the estrogen status of the subject are necessary information in any significant study of this subject.

Articles ^1,4 that state that there may not be any physical findings after vaginal penetration in prepubertal girls should be considered. Specifically, Dr Adams’ article ‘It's normal to be normal’ ¹ used, as its study group, case files and colposcopic photos of 236 children in which there was a perpetrator conviction for sexual abuse. The first concern with that study was that the range of ages went from 8 months to 17 years and 11 months, with a mean age of 9. Thus, a certain number of patients were not prepubertal. Dr Adams noted that ‘estrogen changes were seen in 42% of the cases,’ which she states ‘could have accounted for the lack of correlation between a history of penetration and presence of abnormal findings.’

In her article, Dr Adams points out a concern common to the other articles that we have reviewed. That is, there is no clear delineation of what percentage of the girls evaluated in the case studies are prepubertal versus postpubertal. This is extremely important to the understanding of the issues. There is a significant difference in the prepubertal examination findings due to a lack of estrogenation. The mucus membranes of the prepubertal hymen introitus and vagina are thin, pink and atrophic. Therefore, according to Dr Muram, the distensability is limited, with little resistance to trauma and infection. ⁵ The hymeneal examination after puberty and estrogenization presents a totally different state of the anatomy, size, basic histology muscle tone, etc. With the increased size of the hymenal opening, the thickness and elasticity of the hymen, and the ability to lubricate, the post pubertal vagina is prepared to take on its adult role in reproduction and thus responds differently to penetration, consensual or non-consensual.

The second problem with Dr Adams' study ¹ is the use of the term abuse, which does not define whether assault has occurred. In the article's discussion, she stated that ‘This selection method may have inadvertently included children that were not actually molested, therefore the frequency of abnormal findings may be falsely low’.

The author also stated that‘ the number of cases in which the perpetrator confessed to specific acts was too low to conduct meaningful statistical analysis’.

She did refer to perpetrator confession articles by Kerns and Ritter ⁶ and Muram, ⁷ to be discussed later.

The essential core of Dr Adams' results is the statement that ‘The best predictors of abnormal genital findings in female victims are the time since the assault and a history of blood being reported or observed at the time of the molest’. Both of these historical factors are quite significant.

Dr Heger, ⁴ in her 2002 article ‘Children referred for possible sexual abuse: Medical findings in 2384 children,’ states in her abstract that ‘even with a history of severe abuse such as vaginal or anal penetration, the rate of abnormal medical findings is only 5.5%.’ This study included both boys and girls, with the girls’ sexual development ranging from Tanner one to Tanner four. This provides no knowledge as to the percentage of prepubertal versus pubertal girls in the study, with the obvious difference that estrogenization makes to the effect of trauma to the genital area.

Dr Heger ⁴ also describes the challenge to medical examiners to connect a history of abuse from a child with an absence of medical findings. She states that this is particularly true when young children describe penetration and there is no evidence of recent or old injuries. She suggested that perhaps the best explanation is the child's unsophisticated understanding of what happened and the possible misinterpretation by the child of simulated intercourse as genital penetration. The author follows this with the statement that ‘when complete penetration across the hymen has occurred, the hymen does not heal completely unless there has been a surgical repair.’ In this article, Dr Heger also makes the unequivocal statement, ‘Any violent penetrating assault on a prepubescent child will likely lead to significant trauma and discovery.’

Dr Kerns ⁶ and Dr Muram ⁷ have written the two most quoted articles used to support the proposition that there can be penetration without injury in prepubescent girls. These articles compare perpetrator confessions of penetration to physical findings. Both of these articles, along with Dr Adams' article, ¹ rely on confessions that include plea bargains, which are suspect in regard to what actually happened. In many cases the choice a defendant must make is to accept a plea bargain offered by the prosecutor to admit guilt and receive a sentence of probation and/or time served versus taking the chance of going to trial and being sentenced to life in prison. This is a very difficult choice for a young man when his attorney rightfully tells him that no one can predict with accuracy the result of any jury trial (Affidavit, Robert J Hirsh, Pima County Public Defender, 10/2010 – copy available upon request).

In Dr Kerns' 1992 article ⁶ he describes 22 patients with perpetrator confessions of penile vaginal penetration and states that four (18.18%) of these 22 patients did not have findings — however, this also means that 18 of the 22 (81.8%) did have findings. Dr Kerns also described 13 patients with confessions of digital-vaginal penetration of which eight (61.5%) did not have findings. This also means that five of the 13 did have findings. The article also states that ‘there was no significant difference in the likelihood of abnormal genital findings between the two groups’ (confession and no confession). This article states that 81.8% of the girls in which a confession of penile vaginal penetration was obtained had genital findings. This would be more evidence for the expectation of findings in prepubertal girls who have had penile vaginal penetration.

Dr Muram's 1989 study ⁷ is quite interesting because it has been quoted so often by articles written years later. ^1,4 Muram relates that 30 individuals admitted to having sexually assaulted 31 girls. The age range of the girls was from one year to 17 years with a median of 9.1. This range skews the results as it includes post pubertal girls in which less evidence of trauma is expected. There was a division between admitted assault and non-penetrating abuse. In only 18 of the 31 cases did the perpetrator admit to vaginal penetration, and the ages of these girls were not specified. Even in this group of 18 girls in which penetration had been admitted, only two had no findings. The author makes the unsurprising statement that normal appearing genitalia was the most common finding in girls who denied penile and digital penetration. An interesting statistic was that only seven of the 13 girls in which vaginal penetration was denied had normal appearing genitalia. Dr Muram's study was done in 1988 and clearly sent a message that the history was important and more study was needed.

The two methods now used to study the long-term effects of prepubescent assault have shortcomings, including the unreliable accuracy of the history from the child and the obvious problems with the veracity of the confessor when using the confessions of perpetrators.

Longitudinal studies such as Dr McCann's 2007 studies ⁸ dealing with the direct and repeated examinations of injured children are helpful. Hopefully they will eventually create enough data to make the proper conclusions regarding expectations of the appearance of healed injury.

There are several articles that dispute the concept that ‘it's normal to be normal.’ The most declarative belongs to John McCann, MD, ⁹ who states that, ‘When the vagina of a prepubertal girl is penetrated by a large object such an erect male penis, there is usually a complete laceration (tear) of this membrane’.

He marks this with references to four other articles. ^10–13 He also states that ‘with the penetration of the hymenal orifice (vagina) by a relatively small object, such as a finger, the hymen may not be damaged or if injured only partially torn.’ He makes another point as he refers to a Kerns and Ritter article, ¹⁴ that if a child reports pain and/or bleeding the likelihood of detecting abnormal physical findings increases significantly. A corollary to that, which was not discussed, is whether not having a history of pain and/or bleeding would decrease the chances that penetration took place.

In Dr McCann's 1992 article ¹⁰ Genital injuries resulting from sexual abuse: A longitudinal study, he states that injuries heal very quickly. However, in the three cases that they followed in that study, signs of the traumatic penetration persisted and were even found by careful examination after the changes of puberty had occurred. In this article, Dr McCann references the 1993 article by Kerns and Ritter ¹⁴ regarding the increased incidence of abnormal genital findings in cases in which pain and/or bleeding were reported.

In Dr Heger's book ⁵ she states under the heading Chronic Changes Sexual Abuse, ‘In those cases in which painful vaginal penetration or attempted penetration has occurred, healed disruptions of the posterior fourchette or vestibular mucosa as well as transections of the hymen may be found.’ This correlates with her comments in the 2002 article mentioned earlier. ⁴

The most comprehensive review article found in regard to genital findings after assault is the 1998 article by Goodyear–Smith and Laidlaw. ¹⁵ This article makes a clear distinction between actual vaginal penetration and other forms of sexual contact and the expected findings. The article states that ‘a non-scarred hymen that will not admit a finger is ‘intact,’ a hymenal opening accommodating two fingers or a vaginal speculum, with evidence of a deficit or scarring of the lower pole, indicates past sexual or possibly non-sexual penetration. Other findings are not definitive and, at best, can estimate only relative probability of occurrence of penetration.’ The author makes a plea that findings in the normal range be presented as ‘neither confirm nor deny abuse’ rather than ‘consistent with abuse.’ The author states, in response to suggestions that it may be possible for hymenal tears to heal without trace (Adams), ¹ that no longitudinal studies which confirm that speculation have been found to date.

Acute sexual trauma will be obvious during an examination if penile vaginal penetration has occurred. Dr McCann's two 2007 articles, ⁸ on the healing of hymeneal injuries and on the healing of non-hymeneal injuries, deal with this quite well, including the key points of the healing process.

All of the articles above are interesting and informative but only peripherally deal with the real issue, which is the histology and anatomy of the prepubescent child in relationship to the penetrating object – the penis. The most concise description found of the anatomic and physiological changes in children is Dr Muram's section in the Heger textbook. ⁵ He describes the prepubescent child as having minimal separation between the labia minora and majora. The clitoris is hidden in a small cleft of the vulva. He describes the mucus membranes of the introitus and vagina as thin, pink and atrophic. On cross-section they may be only two or three cell layers thick. He goes on to state that the thin vaginal lining has relatively few rugae, and therefore the distensability is very limited. These atrophic tissues have very little resistance to trauma and infection.

With Dr Muram's information as a background and with the knowledge that even with the various methods of measuring the diameter of the hymen in this group of girls, the diameter is small, with one study using 5.6 ± 1.8 mm for girls 5–7.5 years old. ¹⁶ When comparing the diameter of the average adult male penis of 35–39 mm ¹⁷ it is clear that actual penile penetration of the prepubertal vagina without severe trauma is not possible.

A caveat to this discussion is the dynamic changes that occur in late prepubescence as estrogen begins to have its effect on vaginal tissues. This beginning of hymenal estrogenation can occur before actual menarche and begins at different ages for different children, so this effect needs to be considered in regard to the above discussion. Unfortunately, in the delayed reporting of cases there is no way to go back and evaluate the estrogen status at the time of the reported event.

Frequently the prepubertal girl's sexual encounter, abuse or assault is not reported until months or years later. Dr Heger ⁴ points out that ‘frequently these girls do not understand what penetration really is and the examiner has to be quite careful not to lead the child in describing what took place.’ These possible sexual assault episodes usually have taken place some years prior to their reporting, and to expect a child to remember details accurately after this period of time is not always realistic.

Interestingly, the reporting seems to follow some family event – divorce, desertion or other change in family dynamics. A perplexing question is whether the family dynamic, with its anger and dislocation, was the instigator of the report, or whether the change in dynamics now allowed the child to report what she was afraid of reporting earlier. In all this, the one common denominator in the history that suggests findings consistent with penetration or attempted penetration is pain and bleeding.

In the conclusions to the abstract in his 2007 paper, ⁸ John McCann states that hymenal injuries heal rapidly and, except for more extensive lacerations, leave no evidence of a previous injury. He states that no scar tissue was noted. However, in the last sentence of the abstract Dr McCann states that the final width of an injured hymenal rim was dependent on the initial depth of the laceration. This would be consistent with VCAT, because by definition a change in the width of the previously injured hymen could be evidence of prior trauma from penetration.

These findings are consistent with the information from Dr McCann and Dr Kerns' 1999 – A CR-Rom Atlas Reference – The Anatomy of Child and Adolescent Sexual Abuse. ¹⁸ In reviewing the hymenal transection section, 17 cases (of which 11 were of prepubertal girls) of a longitudinal photo evaluation of the original trauma and follow-up photographs as healing occurred, in each of the final exam photos visible changes were noted. The time from the event to the final photo taken was a few days to three years. These final changes were noted as posterior clefts of various sizes and shapes, but the change was noted in each of these cases regardless of the time from the examination. This was also true in reviewing the 19 cases in the section ‘post traumatic posterior clefts’ (which had some crossover from the prior section). No comment was found from the authors that they had evidence that traumatic changes would become invisible over time. From this work one could say that perhaps in some cases the healing changes could make identification of prior trauma difficult. Until more work is done and this is verified, it can be assumed that this will be a rarity, not the norm.

Discussion

It is a fortuitous fact that genital tissues do heal rapidly and well. This fact should not be used to negate the effect that the lack of evidence of genital trauma has on legal proceedings. This search for physical evidence and the significance of the lack of physical evidence of past injury is the major subject of many ongoing legal actions, with prosecutors understandably using the medical literature to justify their positions. Therefore, it is incumbent that the information given in the medical literature be as accurate, understandable and as un-ambivalent as possible. In this context it would be helpful to use the statement that ‘a lack of physical evidence neither confirms nor denies sexual abuse’ rather than the somewhat misleading statement that ‘the findings are consistent with the history.’ Specifying that the word assault means non-consensual penetration of a bodily orifice would give additional clarity and understanding to this literature. The courts need to have clear, accurate and unbiased information to make considered and just decisions.

Conclusion

From the medical literature and an understanding of the anatomy and histology of the prepubertal genitalia, it does seem clear that what can be expected if there has been forceful penile penetration of the prepubescent hymen is: (1) a history of pain and bleeding at the time of the event, and (2) healed evidence of this forceful penetration.