Child Abuse Pocket Atlas Series

WARNING — This excerpt is intended for use by medical, legal, social service, and law enforcement professionals. It contains graphic images that some may find disturbing or offensive. Minors and/or nonprofessionals should not be allowed to access this material.

Volume Two Sexual Abuse

TM Learning, Inc. eai Publiser o Scietiic ecical a eical ucatioal esources Saint Louis www.stmlearning.com

Saint Louis i www.stmlearning.com Our Mission

To become the world leader in publishing and

information services on child abuse, maltreatment, diseases, and domestic violence.

We seek to heighten awareness of these issues

and provide relevant information to

professionals and consumers.

A portion of our profits is contributed to nonprofit organiza- tions dedicated to the prevention of child abuse and the care of victims of abuse and other children and family charities. Child Abuse Pocket Atlas Series

Volume Two Sexual Abuse

Randell Alexander, Jonathan D. Thackeray, David L. Chadwick, MD MD, PhD MD, FAAP Director Emeritus Professor of Pediatrics and Chief Physician Chadwick Center for Children and Division of Child Protection and The Center for Family Safety and Healing Families Forensic Pediatrics Division of Child and Family Advocacy Children’s Hospital - San Diego Department of Pediatrics Department of Pediatrics Adjunct Associate Professor University of Florida Nationwide Children’s Hospital Graduate School of Public Health Jacksonville, Florida Columbus, Ohio San Diego State University San Diego, California Angelo P. Giardino, Joyce A. Adams, MD Professor of Clinical Pediatrics Rich Kaplan, MD, PhD † Vice President/Chief Medical Officer Division of General Academic Pediatrics MSW, MD, FAAP Medical Affairs and Adolescent Medicine Child Abuse Pediatrician Texas Children’s Health Plan School of Medicine Children’s Hospitals and Clinics of Clinical Professor, Pediatrics and University of California, San Diego Minnesota Section Chief Specialist in Child Abuse Pediatrics Associate Professor of Pediatrics Academic Pediatrics Rady Children’s Hospital University of Minnesota Medical Department of Pediatrics San Diego, California School Baylor College of Medicine Medical Director Houston, Texas Suzanne P. Starling, The Center for Safe and Healthy MD, FAAP Children Debra Esernio-Jenssen, Professor of Pediatrics University of Minnesota Amplatz Eastern Virginia Medical School Children’s Hospital MD, FAAP Associate Medical Director Professor of Pediatrics Division Director, Child Abuse Pediatrics Midwest Children’s Resource Center University of Florida at Gainesville Medical Director, Child Abuse Program Children’s Hospitals and Clinics of Medical Director Children’s Hospital of the The King’s Minnesota Child Protection Team Daughters Minneapolis, Minnesota Gainesville, Florida Norfolk, Virginia

iii Publishers: Glenn E. Whaley and Marianne V. Whaley Graphic Design Director: Glenn E. Whaley Managing Editor: Paul K. Goode, III Print/Production Coordinator: Jennifer M. Jones and G.W. Graphics Cover Design: Jennifer M. Jones and G.W. Graphics Color Prepress Specialist: Kevin Tucker Acquisitions Editor: Glenn E. Whaley Developmental Editor: Paul K. Goode, III Copy Editor: Paul K. Goode, III Proofreader: Paul K. Goode, III Editorial/Publishing Consultant: Kerry Blasingim

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopy- ing, recording, or otherwise, without prior written permission from the publisher.

Printed in the United States of America.

Publisher: STM Learning, Inc. Saint Louis, Missouri Phone: (314) 434-2424 Fax: (314) 434-2425 http://www.stmlearning.com [email protected]

The Library of Congress has cataloged the printed edition as follows:

Names: Alexander, Randell, 1950- , editor. Title: Sexual abuse / [edited by] Randell Alexander, Angelo P. Giardino, Debra Esernio-Jenssen, Jonathan D. Thackeray, Joyce A. Adams, Suzanne P. Starling, David L. Chadwick, Rich Kaplan. Other titles: Sexual abuse (Alexander) | Child abuse pocket atlas series ; v. 2. Description: Florissant, MO : STM Learning, Inc., [2016] | Series: Child abuse pocket atlas series ; volume 2 | Includes bibliographical references and index. Identifiers: LCCN 2016006971 (print) | LCCN 2016007656 (ebook) | ISBN 9781936590599 (pbk. : alk. paper) | ISBN 9781936590643 (ebook) Subjects: | MESH: Child Abuse, Sexual--diagnosis | Infant | Child | Adolescent | Case Reports | Atlases | Handbooks Classification: LCC RC560.C46 (print) | LCC RC560.C46 (ebook) | NLM WS 17 | DDC 616.85/836--dc23 LC record available at http://lccn.loc.gov/2016006971 iv Contributors Joyce A. Adams, MD Professor of Clinical Pediatrics Division of General Academic Pediatrics and Adolescent Medicine School of Medicine University of California, San Diego Specialist in Child Abuse Pediatrics Rady Children’s Hospital San Diego, California

Randell Alexander, MD, PhD Professor of Pediatrics and Chief Division of Child Protection and Forensic Pediatrics Department of Pediatrics University of Florida Jacksonville, Florida

Debra Esernio-Jenssen, MD, FAAP Professor of Pediatrics Child Protection Team University of Florida at Gainseville

Lori D. Frasier, MD Clinical Professor University of Utah School of Medicine Director of the Fellowship in Child Abuse Pediatrics University of Utah Salt Lake City, Utah

Kristi A. Green, MSN, ARNP Advanced Registered Nurse Practitioner Department of Pediatrics University of Florida

Jason Schulman, MD Pediatrician Miami, Florida

v Preface The concept of medical care for children who are possible victims of child sexual abuse is relatively new. In the recent past, we have seen the medical care for these children undergo a significant evolution, in which we now view these children as patients who require medical attention and care. The focus of this book is to address the medical care for these children from a variety of perspectives. In creating this book, our goal has been to demystify the medical care of sexually abused children. When caring for a child who is a possible survivor of child sexual abuse, the essential principles and standards of medical care apply, such as obtaining a complete and well-documented history and physical examination, performing an appropriate and scientifically driven laboratory evaluation, and forming a medical diagnosis to guide the ongoing care needs of the patient. It should be clear that the medical component is simply one part of the response to maltreatment. While legal issues certainly are important for the safety and well-being of children, the focus of this text primarily will be on the medical and therapeutic care these children need to heal and, hopefully, to have a happy and productive life. This book, the second volume of the Child Abuse Pocket Atlas Series, brings together experts and scholars with a variety of expertise related to the care of young survivors. While the focus of this book is medical care, it is our hope that other members of the multidisciplinary team will find this a useful reference.

Rich Kaplan, MSW, MD, FAAP† Joyce A. Adams, MD Suzanne P. Starling, MD, FAAP Angelo P. Giardino, MD, PhD

This page intentionally left blank vii Contents in Brief

Chapter 1: Basic Anogenital Anatomy 1

Chapter 2: Equipment for the Documentation of Sexual Abuse 39

Chapter 3: Interpretation of Anogenital Findings 55

Chapter 4: Sexual Abuse 107

This page intentionally left blank ix STM Learning, Inc.

We’ve partnered with Copyright Clearance Center to make it easy for you to request permissions to reuse content from STM Learning, Inc.

With copyright.com, you can quickly and easily secure the permissions you want.

Simply follow these steps to get started:

— Visit copyright.com and enter the title, ISBN, or ISSN number of the publication you’d like to reuse and hit “Go” — After finding the title you’d like, choose “Pay-Per-Use Options” — Enter the publication year of the content you’d like to reuse — Scroll down the list to find the type of reuse you want to request — Select the corresponding bubble and click “Price & Order” — Fill out any required information and follow the prompts to acquire the proper permissions to reuse the content that you’d like

For questions about using the service on copyright.com, please contact: Copyright Clearance Center 222 Rosewood Drive Danvers, MA 01923 Phone: +1-(978) 750-8400 Fax: +1-(978) 750-4470

Additional requests can be sent directly to [email protected].

About Copyright Clearance Center Copyright Clearance Center (CCC), the rights licensing expert, is a global rights broker for the world’s most sought-after books, journals, blogs, movies, and more. Founded in 1978 as a not-for-profit organization, CCC provides smart solu- tions that simplify the access and licensing of content that lets businesses and academic institutions quickly get permission to share copyright-protected materials, while compensating publishers and creators for the use of their works. We make copyright work. For more information, visit www.copyright.com.

x Contents in Detail

Chapter 1: Basic Anogenital Anatomy ...... 1 Embryology ...... 4 Normal Variations ...... 5 Effects of Puberty 8 The Hymen 8 The Vagina ...... 9 The Cervix ...... 9 The Anus ...... 9 Conclusion ...... 11 Features of Genital and Anal Anatomy ...... 12 References ...... 37

Chapter 2: Equipment for the Documentation of Sexual Abuse ...... 39 Photodocumentation 40 Laboratory Specimens ...... 41 Forensic Evidence Collection 42 Medication ...... 43 Telemedicine ...... 43 Sexual Abuse Documentation Equipment ...... 45 Photodocumentation ...... 45 Laboratory Specimens 46 Forensic Evidence Collection ...... 49 Medication ...... 52 Telemedicine ...... 52 References ...... 53

Chapter 3: Interpretation of Anogenital Findings 55 History ...... 55 Studies in Genital and Anal Findings in Children and Adolescents With Suspected Sexual Abuse 56 Research ...... 56 Hymenal Data ...... 57 Sexually Transmitted Infections ...... 59 Mimics ...... 59 Anal Dilation ...... 60 Injuries ...... 60 Conclusion ...... 61 Normal Variations and Forensic Photography ...... 62 References ...... 104

xi Chapter 4: Sexual Abuse ...... 107 Techniques and Basic Skills 108 Hymenal Configurations ...... 115 Findings Confused With Abuse 120 Imperforate Hymen 120 Prolapsed Uterus ...... 120 Lichen Sclerosis ...... 121 Urethral Prolapse ...... 122 Failure of Midline Fusion ...... 123 Labial Fusion ...... 123 Straddle Injury ...... 123 Vaginal Duplication 124 Vitiligo ...... 124 Foreign Body ...... 125 Toxic Shock 126 Hymenal Projection 128 External Hymenal Midline ...... 128 Extensive Labial Fusion ...... 129 Failed Midline Fusion 129 Possible Foreign Body 130 Lichen Sclerosis Causing Bleeding 132 Labial Bruising ...... 133 Duplication of Reproductive Structures 133 Pinworm ...... 134 Hemangioma ...... 134 Perianal Vitiligo 134 Vaginal Discharge 135 Normal Findings ...... 137 Crescentic Hymen 137 Annular Hymen 137 Large Urethral Opening Above Normal Hymen 137 Normal Intact Hymen ...... 138 Anal Tag 138 Normal Intact Annular Hymen ...... 139 Intravaginal Ridge 139 Normal Examination ...... 140 Normal Anal Findings 141 Thickened Crescentic Hymen 141 Circumferential or Annular Hymen 142 Anterior Anal Venous Pooling 142 Extensive Anal Pooling ...... 142 Midline White Line 143 Normal Examination After Sexual Assault 143 Smooth Avascular Posterior Area ...... 144 Hymenal Projection 144 xii Integrity of Hymen ...... 145 Hymenal Mound ...... 145 Anterior Intravaginal Ridge ...... 145 Knee-Chest Position 146 Intact Posterior Rim 146 Prominent Urethral Support Structures ...... 146 Hymenal Tag ...... 147 Normal Posterior Hymenal Rim ...... 147 Hymenal Projection 147 Intravaginal Rugae and Normal Hymen 148 Estrogenized Hymen in Abused Girl ...... 148 Normal Hymenal Mound 148 Posterior Mound With Cleft ...... 149 Possible Precocious Puberty ...... 149 Cribriform Hymen ...... 150 Estrogenized and Intravaginal Rugae ...... 150 Vascularization ...... 151 Examination With and Without Traction 151 Hymenal Pit 152 Normal Cribriform Hymen in Alleged Abuse 152 Penetration ...... 153 Acute Findings ...... 154 Hematoma and Hymenal Tear ...... 154 Partial Healing After Transection of the Hymen 154 Anal Tears 155 Lacerations ...... 156 Unexplained Genital Bleeding 158 Acute Penetration ...... 160 Traumatic Superficial Hymenal Laceration ...... 160 Anal Laceration ...... 161 Laceration With Bruising ...... 162 Perianal Laceration ...... 163 Acute Laceration After Penile Penetration 163 Vaginal Bleeding After Penile Penetration 164 Vaginal Bleeding ...... 164 Anal Tear ...... 168 Linear Abrasions ...... 168 Hymenal Transections 170 Hymenal Septum ...... 171 Hymenal Transection ...... 172 Vaginal Discharge 173 Digital Penetration ...... 174 Penetration ...... 175 Anal Abuse ...... 176 Complete Disruptions 178

xiii Contents in Detail

Discontinuity of Hymen ...... 179 Labial Intercourse ...... 179 Straddle Injury-Related Bruising ...... 180 Alleged Rape ...... 180 Perianal Bruising ...... 181 Bruising of Penis ...... 181 Burned Penis ...... 181 Perianal Laceration Caused by Penetration ...... 182 Accidental Anal Hematoma 182 Sexually Transmitted Diseases 183 Herpes Simplex Virus Type 1 ...... 183 Syphilitic Lesion 183 Genital Warts ...... 184 Perianal Herpes ...... 185 Condyloma Acuminata ...... 185 Hemorrhagic Herpes ...... 185 Scrotal Condyloma Acuminata ...... 186 Cylindrical Perianal Condylomata 186 Perianal Streptococcal Infection 187 Penile Lichen Planus ...... 187 Flatwarts ...... 187 Molluscum contagiosum ...... 188 Genital Warts ...... 188 Old Injuries 189 History of Penile Penetration ...... 189 Previous Vaginal Penetration ...... 189 Digital Penetration ...... 190 Healed Transection ...... 190 References ...... 190

xiv Child Abuse Pocket Atlas Series

Volume Two Sexual Abuse

TM Learning, Inc. eai Publiser o Scietiic ecical a eical ucatioal esources Saint Louis www.stmlearning.com

Saint Louis xv www.stmlearning.com Chapter 1

Basic Anogenital Anatomy Joyce A. Adams, MD

In order to recognize signs of child sexual abuse, it is necessary to first be familiar with normal genital anatomy, its variations, and its development. While this may seem obvious, the lack of understanding of the many variations in normal appearance of the genital and anal tissues in children has led to misunderstandings among medical and nonmedical professionals alike. Even after the publication of the first detailed descriptions of anal and genital anatomy in nonabused prepubertal children,1-3 some physicians and nurses who perform child sexual abuse medical evaluations are not familiar with the findings from those and subsequent studies.4-9 When a child’s examination is thought to show signs of injury or abuse but actually represents normal findings or evidence of another medical condition, the medical provider may contact child protection and/or law enforcement officials to report the suspicions. The child and family would then be unnecessarily traumatized by a referral and investigation of those suspicions. It is also important for medical and nursing professionals, as well as nonmedical professionals, to be able to speak the same language when describing features of genital and anal anatomy in children and adolescents. Anatomy courses in medical and nursing school rarely provide the necessary detail about the features of genital anatomy in children, usually focusing on adults and on pathology common to adult patients. In the early 1990s, a group of physicians met at conferences to agree on proper terminology for describing features of genital and anal anatomy, and the results of a 4-year consensus development process was published by the American Professional Society on the Abuse of Children in 1995. Some of the definitions were taken from standard medical dictionaries and anatomy textbooks, but out of necessity, other definitions were created by specialists working in the field of sexual abuse medical evaluation. Table 1-1 is a list of terms and definitions from that publication.10

1 Child Abuse Pocket Atlas Series, Volume 2: Sexual Abuse

Table 1-1. Basic Genital Anatomy, Related Terminology, and Definition of Terms.10

Anatomical Structures in the Female

— Mons pubis: The rounded, fleshy prominence, created by the underlying fat pad that lies over the symphysis pubis (pubic bone). — Vulva: The external genitalia or pudendum of the female. Includes the anterior commisure, clitoris, labia majora, labia minora, vaginal vestibule, urethral orifice, vaginal orifice, hymen, and posterior commisure. — Anterior commisure: The union of the 2 labia minora anteriorly/superiorly. — Clitoris: A small, cylindrical, erectile body, situated at the anterior (superior) portion of the vulva, covered by a sheath of skin called the clitoral hood; homologous with the penis in the male. — Labia majora (singular: labium majus): Rounded folds of skin forming the lateral boundaries of the vulva. — Labia minora (singular: labium minus): Longitudinal thin folds of tissue enclosed within the labia majora. In the prepubertal child, these folds extend from the clitoral hood to approximately the midpoint on the lateral walls of the vestibule. In the adult, they enclose the structures of the vestibule. — Vaginal vestibule: An anatomic cavity containing the opening of the vagina, the urethra, and the ducts of Bartholin’s glands. Bordered by the clitoris superiorly, the labia minora laterally, and the posterior commisure inferiorly. — Urethral orifice: External opening of the canal (urethra) from the bladder. — Vestibular bands: Small bands of tissue lateral to the urethral orifice that connect the periurethral tissues to the anterior lateral walls of the vestibule (urethral support ligaments), or bands of tissue lateral to the hymen connect- ing to the vestibular wall. — Vaginal orifice: The opening to the uterovaginal canal. — Vagina: The internal structure extending from the uterine cervix to the inner edge of the hymen. — Hymen: A membrane that partially, or rarely completely, covers the vaginal orifice. — Fossa navicularis/posterior fossa: Concavity on the lower part of the vestibule situated inferiorly to the vaginal orifice and extending to the posterior commisure or posterior fourchette. — Posterior commisure: The union of the 2 labia majora inferiorly (toward the anus). (continued)

2 Chapter 1: Basic Anogenital Anatomy

Table 1-1. Basic Genital Anatomy, Related Terminology, and Definition of Terms.10 (continued)

Anatomical Structures in the Male

— Penis: Male sex organ composed of erectile tissue through which the urethra passes; homologous with the clitoris in the female. — Glans penis/balanus: The cap-shape expansion of the corpus spongiosum at the end of the penis. It is covered by mucous membrane and sheathed by the prepuce (foreskin) in uncircumcised males. — Scrotum: The pouch that contains the testicles and their accessory organs. — Median raphe: A ridge or furrow that marks the line of union of the 2 halves of the perineum.

Descriptive Terms Related to the Perineum and Anus

— Perineum: The external surface or base of the perineal body, lying between the vulva and the anus in the female and the scrotum and the anus in the male. Underlying the external surface of the perineum is the pelvic floor and its associated structures occupying the pelvic outlet, which is bounded anteriorly by the pubic symphysis (pubic bone), laterally by the ischial tuberosity (pelvic bone), and posteriorly by the coccyx (tail bone). — Perineal body: The central tendon of the perineum located between the vulva and the anus in the female and between the scrotum and anus in the male. — Anus: The anal orifice, which is the lower opening of the digestive tract, lying in the fold between the buttocks through which feces is extruded. — Anal skin tag: A protrusion of anal verge tissue that interrupts the symmetry of the perianal skin folds. — Anal verge: The tissue overlying the subcutaneous division of the external anal sphincter at the most distal portion of the anal canal (anoderm) and extending exteriorly to the margin of the anal skin. — Pectinate/dentate line: The sawtoothed line of demarcation between the distal (lower) portion of the anal valves and the pectin, ie, the smooth zone of stratified epithelium that extends to the anal verge. This line may be apparent when the external and internal anal sphincters relax and the anus dilates.

Definitions taken from “Practice Guidelines: Descriptive Terminology in Child Sexual Abuse Medical Evaluations” published by the American Professional Society on the Abuse of Children, 1995. Adapted and reprinted with permission from the American Professional Society on the Abuse of Children.

3 Child Abuse Pocket Atlas Series, Volume 2: Sexual Abuse

Embryology An appreciation of the wide variation in the appearance of the genital and anal tissues in children requires an understanding of embryology and how the external genital tissues develop. For the first 6 weeks of development, the genital structures of the human embryo are in an undifferentiated state. In males, a transcription factor encoded on the sex-determining region of the Y chromosome (SRY) is produced during the seventh week, which triggers male development. In the absence of a Y chromosome and SRY production, female development progresses. From the indifferent stage (4 to 7 weeks) through the 12th week, the genital tubercle differentiates into the glans and shaft of the penis in the male and into the glans and shaft of the clitoris in the female. The definitive urogenital sinus develops into the penile urethra in the male and the vestibule of the vagina in the female. The urethral fold becomes the penis surrounding the penile urethra in the male or the labia minora in the female. The labioscrotal fold develops into either the scrotum in the male or the labia majora in the female.11 A detailed study of the development of the perineum was published in 2005, which provided a new understanding of the formation of the vagina and hymen.12 In the undifferentiated state, the distal ends of the fused paramesonephric ducts are separated from the urogenital sinus by the dense stroma of the Mullerian tubercle. In females, the mesonephric ducts regress and the fused paramesonephric ducts form the uterus and vagina. The mesonephric orifices are incorpo- rated into the orifice of the developing vagina, and the epithelium is replaced by the epithelium from the Mullerian tubercle. The vagina expands and extends downward to bulge into the vestibulum, and the paramesonephric epithelium is transformed into vaginal epithelium. The glycogen-filled cells begin to disintegrate, which forms the lumen of the vagina. The data from the study by van der Putte provide support for the theo- ry that the vagina is formed mainly from paramesonephric epithelium, not from the urogenital sinus.12 Alternate theories postulated prior to this study held that the inferior portion of the vagina was formed from a portion of the urogenital sinus called the sinuvaginal bulb.11 The lengthening of the vagina into the vestibulum, where it meets the dense stromal tissue of the Mullerian tubercle, forms the hymen.12 Folds in the urogenital sinus contribute to the lateral folds of the hymen. The deepening of the dorsal vestibular groove accentuates the dorsal segment of the hymen, which in clinical terms is referred to as the posterior or inferior rim. Both the inner side and the outer side of the hymen are

4 Chapter 1: Basic Anogenital Anatomy made up of sinus epithelium. Van der Putte reports that primordial urethral glands were occasionally found on the inner side of the hymen, which he believes could be the origin of the hymenal cysts described by Merlob et al.13 Another finding from this study is that the hymen itself is “… built of finely fibrillar connective tissue without the smooth muscle element predominant in all of its surrounding tissues.”12 The opening in the hymen develops as the stromal tissue between the descending vagina and the urogenital sinus regresses. It is postulated that the denser the column of stromal tissue, the more likely it is that the tissue will not completely regress, which leads to a microperforate or imperforate hymen. See Figure 1-1 for details of female external genital anatomy. If the tissue is denser in some areas than others, the uneven regression could also produce a septate or cribriform hymen. Normal Variations The increasing societal awareness of the problem of child sexual abuse, beginning in the 1980s, and the involvement of physicians in the evaluation of children with suspected child sexual abuse stimu- lated interest in the appearance of the hymen in neonates. A study by Jenny et al14 identified the presence of a hymen in all 1131 neonates examined, and Berenson et al15 described the morphology of the hy- Figure 1-1. Labeled anatomical men and anatomical variations in 449 neonates who were examined structures in the and photographed in the first week of life. Table 1-2 summarizes female. Photograph terminology related to the hymen.10 of a 5-year-old girl examined in the The neonates were found to have primarily annular hymens; that supine position using labial separation. is, the hymenal tissue extended 360 degrees around the opening (See Table 1-1 for to the vagina. Hymenal clefts, cysts, tags, mounds, external ridges, definitions.)

Clitoral Hood

Labium Minus (plural is labia minora)

Opening to the Vagina

Hymen

Fossa Navicularis

Posterior Commisure Figure 1-1

5 Child Abuse Pocket Atlas Series, Volume 2: Sexual Abuse

Table 1-2. Descriptive Terms and Definitions Related to the Hymen.10

Anatomical Structures in the Female:

— Annular: Variation in morphology where the hymenal membrane tissue extends completely around the circumference of the vaginal orifice. — Crescentic: Hymen with attachments at approximately the 11 and 1 o’clock positions with no tissue present between the 2 attachments. — Cribiform: Hymen with multiple small openings. — Imperforate: Hymenal membrane with no opening. — Septate: Hymen with 2 or more openings, caused by bands of tissue that bisect the opening. — Fimbriated: Hymen with multiple projections and indentations along the edge, creating a ruffled appearance. — Redundant: Abundant hymenal tissue that tends to fold back upon itself or protrude. — Hymenal mound or bump: A solid elevation of hymenal tissue that is wider or as wide as it is long, located on the edge of the hymenal membrane. This structure may be seen at the site where an intravaginal column attaches to the hymen. — Hymenal tag: An elongated projection of tissue arising from any location on the hymenal rim. — Hymenal cyst: A fluid-filled elevation of tissue, confined within the hymenal tissue. — Hymenal cleft: An angular or v-shaped indentation on the edge of the hymenal membrane. — External hymenal ridge: A midline longitudinal ridge of tissue on the external surface of the hymen. May be either anterior or posterior and usually extends to the edge of the hymen.

and intravaginal ridges were noted. See Figures 1-2 through 1-21 for examples of anatomical variations of the hymen. The location of various features was described using a clock face, with the 12 o’clock position defined as directly below the urethra and the 6 o’clock position in the midline above the posterior commisure. In

6 Chapter 1: Basic Anogenital Anatomy a follow-up study of 62 infants examined at 1 year, Berenson et al4 noted that 10 of 13 infants who had an annular hymen with a notch in the 12 o’clock position as neonates had a crescentic hymen at 1 year. A crescentic hymen is defined as a configuration in which the attachments of the hymen are at the 1 to 2 o’clock and 10 to 11 o’clock positions, with an absence of hymenal tissue in between. At 1 year, 28% of infants had crescentic hymens, compared to none in the neonate period; the frequency of external hymenal ridges decreased from 82% to 14% at 1 year. Table 1-3 summarizes the changes in the frequency of various features of hymenal morphology among the children who were followed by Berenson et al from birth to 3 years5 and those followed from 3 to 9 years.6

Table 1-3. Changes in Hymenal Features by Age.4-6,10,14,15

Percentage of Subjects Having Specific Hymenal Features Listed by Age

Newborn 1 year 3 years 5 years 7 years 9 years Feature n=486 n=57 n=134 n=93 n=80 n=61

Annular hymen 100 52 41 23 18 10 Crescentic hymen 0 28 50 77 82 90 Redundant hymen 100 42 25 N/A N/A N/A Hymen tags 13 10 7 13 10 10 Hymen bump/mound 0 5 44 53 78 69 Intravaginal ridges 54 66 83 86 90 92 External hymenal ridge 82 17 7 3 1 0 Notch/cleft 38 19 14 7 9 11 Mean horizontal dia- N/A 3.8 4.7 4.6 5.5 6.1 meter of opening (mm) +/- 1.1 +/- 1.2 +/- 1.6 +/- 1.9 +/- 2.3 Range of horizontal N/A 2.5 - 2.8 - 1.0 - 1.75 - 1.75 - diameter of opening 6.0 mm 8.0 mm 8.0 mm 10.5 mm 12.25 mm Width of posterior N/A 2 - 2.5 - 1.0 - 0.75 - 1.25 - hymenal rim, range 4 mm 4.0 mm 6.5 mm 5.5 mm 4.75 mm

7 Child Abuse Pocket Atlas Series, Volume 2: Sexual Abuse

The longitudinal study supported the clinical observation that hymenal opening width increases with the age of the child. The mean horizontal diameter of the opening increased from 3.8 mm at 1 year to 6.1 mm at 9 years, with the width of the hymenal opening ranging from 2.5 to 6.0 mm at 1 year to 1.75 to 12.25 mm at 9 years. The other trend noted in the follow-up study was the decrease in the mean width of the posterior/inferior rim of hymen. The range of measurements of the posterior rim was 2 to 4 mm at 1 year but changed to 0.75 to 5.5 mm at 7 years. Cross-sectional studies of children selected for nonabuse, examined using colposcopy and photographs, reported a similar range of measurements of the diameter of the hymenal opening and the width of the posterior rim of hymen. McCann et al1 reported measurements of the horizontal diameter of the hymenal opening, using labial traction, of 2 to 8 mm in girls 2 to 5 years, 1 to 9 mm in girls 5 to 7 years, and 2.5 to 10.5 mm in girls 8 years through Tanner Stage 2 development. While there were not enough girls in each age group to compare width of the posterior hymenal rim by age, researchers reported that among girls who were examined in the prone knee-chest position, the range of posterior rim width was 1 to 8 mm, with a mean of 2.8 mm. A cross-sectional study of 211 girls from 1 month to 7 years by Beren- son et al2 also found that the mean horizontal diameter of the hymenal opening varied significantly by age (2.5 +/- 0.8 mm to 3.6 +/- 1.2 mm) and that the measurement of the posterior rim of the hymen was as small as 0.9 to 1.0 mm in girls between 1 and 7 years who were consid- ered to be nonabused. A study of 195 nonabused girls between 5 and 7 years by Myhre et al7 also found that the range of measurement of the posterior hymenal rim, using labial traction, was 1.1 to 7.9 mm wide. Figures 1-22 and 1-23 are examples of cases where the opening in the hymen may seem wide and the posterior rim relatively narrow, but in both cases the measurements from the photographs showed that they were within the normal range for a child of that age. Effects of Puberty The Hymen With the onset of puberty, the hymen and other genital tissues show the effects of hormonal influence, especially estrogen. The hymen becomes thicker, paler, less sensitive to touch, and more likely to fold upon itself. These changes are illustrated in the following 3 cases. In a follow-up study of girls examined at 5 to 7 years,7 Myhre et al re-examined a subset of subjects at 10 to 13 years. The hymen, vagina, and labia show the effects of development, as seen in Figures 1-24 through 1-26.16

8 Chapter 1: Basic Anogenital Anatomy

Adolescent girls, from 13 to 19 years, with and without a history of penile-vaginal intercourse, were examined in a study to compare the appearance of the hymen.17 Figures 1-27 through 1-30 show some of these variations, from a very thick, tulip-shaped hymen with an anterior opening (Figures 1-27-a and b) to a relatively narrow rim of hymen in a girl who denies intercourse (Figure 1-30). Because estrogen causes the tissues of both the hymen and vagina to thicken and become pale, it is sometimes difficult to identify the edge of the hymen. The use of a large swab covered by a balloon for color contrast (Figure 1-28) or a regular cotton-tipped applicator to stretch out the edge of the hymen (Figures 1-29 and 1-30) can assist the examiner in determining the integrity of the hymenal rim.

The Vagina As pubertal development progresses, all the tissues and structures of the vaginal vestibule show the effects of estrogen. The external surface of the labia affected by androgenic hormones in the same way the scrotal skin changes in males. The skin becomes darker, thicker, and develops folds or rugae. For reasons not fully understood, the labia minora can be affected on one side more than another, which causes an asymmetry that can be quite pronounced (see Figures 1-31 and 1-32).

The Cervix The cervix may also take on a different appearance as puberty progresses (Figure 1-33). In the younger adolescent, the columnar epithelium of the endocervix is visible on the outer surface, which gives it a darker red, sometimes pebbled appearance (Figure 1-34). This pattern changes as the neck of the cervix lengthens and the endocervical tissues regress inward.

The Anus The skin around the anus, when the external anal sphincter is contract- ed and the anus is closed, takes on a wrinkled appearance. The tighter the contraction of the sphincter, the more wrinkles or folds are seen. In some children, there is a gap in the subcutaneous division of the external sphincter muscle, which causes an area in the midline, usually at the 6 o’clock position, to be smooth and free of folds. This condition was named diastasis ani (Figure 1-35) by Dr. John McCann3 who observed this finding in 26% of the children in his study of perianal findings in nonabused children. Berenson et al,8 in a study of 89 female infants under 18 months, also noted this smooth area in 26% of subjects. Myhre et al9 studied children 5 to 7 years with no history or suspicion of sexual abuse and noted that more boys than girls were found to have diastasis ani and that it was more commonly observed in the prone knee-chest position than in the left lateral position. In the knee-chest position, 12% of subjects had the finding.

9 Child Abuse Pocket Atlas Series, Volume 2: Sexual Abuse

Anal tags and thickened midline skin folds are common findings in children who have not been abused. Tags were seen in 11% of the subjects in the study by McCann et al3 and in 6% of subjects in the study by Myhre et al.9 Figure 1-36 is an example of a midline tag. The skin in the perianal area may have darker pigmentation than elsewhere on the body. This was first described in the study by McCann et al,3 where the prevalence varied by ethnicity. Among white children, 22% had hyperpigmentation of the perianal skin, compared to 53% of the African American children and 58% of the Hispanic children (Figures 1-37 and 1-38-a). When the external anal sphincter relaxes but the internal sphincter re- mains closed, the anal opening may have an irregular appearance. This is shown in Figure 1-38-b. When both the internal and external anal sphincters relax, the anal canal is visualized, and in some views, the pectinate line can be seen. The pectinate line is the line of demarcation between the skin of the anal canal (pectin) and the anal mucosa, which can have a jagged appearance due to the anal columns and crypts. These structures are shown in Figure 1-39. Anal dilation, with both internal and external sphincters relaxed, was found in 49% of 267 children selected for nonabuse in the study by McCann et al3 in which all children were examined in the prone knee-chest position, some for as long as 4 minutes (Figure 1-40). A smaller number of children showed complete anal dilation within 30 seconds (14.6%). Myhre et al9 reported the frequency of complete anal dilation seen in 100 boys and 167 girls between the ages of 4 and 6 years who were examined in the prone knee-chest position for 30 seconds as part of a study of findings in nonabused children. Com- plete anal dilation was seen in 3% of the boys and 5.6% of the girls, for a rate of 4.7% overall. In the Myhre study, complete anal dilation was very rare (0.7%) when the child was examined in the left lateral position. Another feature described in the studies by McCann et al3 and Myhre et al9 is that of venous pooling or venous congestion of the blood vessels in the perianal area. McCann et al reported that at the midpoint of the examination in the knee-chest position, 52% of the subjects had venous pooling. In the Myhre et al study, children were not kept in the knee-chest position as long as in the McCann et al study (average time 30 seconds, compared to up to 4 minutes), and venous congestion was documented in 20% of subjects. The perianal area has a rich blood supply, and the veins become engorged when the child is positioned so that venous return from the plexus is im- paired. This can lead to a rather alarming purple/blue coloration of the surrounding skin, which should not be mistaken for trauma. See Figures 1-41 through 1-42 for examples of venous pooling.

10 Chapter 1: Basic Anogenital Anatomy

The congenital defect known as failure of midline fusion, or perineal groove, is another finding on anogenital examination that may cause concern if it is not recognized. In 1984, Dr. Anthony Shaw published photos of 6 children with this defect in the “Picture of the Month” section of the American Journal of Diseases of Childhood.18 His report stated that the condition required no treatment and that the defect would eventually fill in. The defect was also described in a textbook of surgery19 as having the following features: “normal formation of the vestibule, urethra and vagina, hypertrophic minoral tails which skirt the perineum and course posteriorly to join at the anus or surround it, and a wet groove in the perineum between the fourchette and the anus.” A 2006 report described the results of a surgical correction of a perineal groove in a 6-month-old girl.20 Histological analysis of the excised tissue revealed squamous epithelial tissue at both ends, with rectal mucosa in between. There was also edema, patchy hem- orrhage, and scattered inflammatory cell infiltrate in lamina propria surrounding normal rectal crypts. The authors postulate that the anomaly represents an embryologic remnant of the urorectal septum rather than a failure of midline fusion. Conclusion It should not be surprising that there is considerable variation in the appearance of the structures of the external genitalia and anal tissues in nonabused children. Every child is a unique individual, and while there may be common patterns in how tissues develop, there is much not understood about anatomic variations. For example, it is not clear exactly why the hymen changes from primarily annular to primarily crescentic as a child grows and estrogen effect regresses or what factors are involved in the development of the septate, microperforate, or imperforate hymen. Additional studies of children with no history or concern for abuse are needed, especially studies of the appearance of the genital tissues in girls between 9 and 13 years. Further studies are also needed of the appearance of the anal tissues in children of different ages and of the prevalence of dilation in children with and without a history of constipation. Further research will help to answer some of the remaining questions regarding what is normal when it comes to the appearance of the genital and anal tissues in children.

11 Child Abuse Pocket Atlas Series, Volume 2: Sexual Abuse

Features of Genital and Anal Anatomy

Figure 1-2-a. Eight-year-old girl examined in the supine position, using labial traction. Arrows point to intravaginal ridges at 6 and 9 o’clock, which are normal structures that can be seen in up to 92% of nonabused girls this age who are examined using labial traction (see Table 1-2). Figure 1-2-a

Figure 1-2-b. Same patient examined in the prone, knee-chest position. Arrow points to an intravaginal ridge. The hymen is smooth and without interruption. This type of normal examination is common in children who describe being molested and are examined some time distant from the last episode of abuse. Touch- ing or rubbing of the genital area, contact between a perpetrator’s hand or penis and the external genital structures, and oral-genital contact would not be expected to cause any injury.

Figure 1-3-a. Two-year-old girl examined using labial separation. The hymen at 7 o’clock location is thick and shows the effects of estrogen. The hymen is redundant and folded, and in this view, neither the hymenal edge nor the hymenal opening can be seen.

Figure 1-2-b

Figure 1-3-a

12 Chapter 1: Basic Anogenital Anatomy

Figure 1-3-b. Using labial traction, with the examiner grasping the labia majora and gently pulling forward, the hymen at 7 o’clock opens, as does the urethral orifice shown at 12 o’clock, and an intravaginal ridge at 5 o’clock can be visualized extending into the vagina at the 8 o’clock location.

Figure 1-4-a. Six-year-old girl with no suspicion of sexual abuse. The photograph shows an annular hymen with tissue all the way around the hymenal opening, including at the 12 o’clock position. This is the most common hymen configuration in newborns and girls up to age 3 years from the longitudinal stud- Figure 1-3-b ies by Berenson et al (see Table 2-2).

Figure 1-4-b. In the prone knee-chest position, the smooth, noninterrupted edge of the hymen is clearly demon- strated.

Figure 1-4-a

Figure 1-4-b

13 Child Abuse Pocket Atlas Series, Volume 2: Sexual Abuse

Features of Genital and Anal Anatomy

Figure 1-5. Eleven-year-old girl with no history of sexual abuse. This photo shows a normal, crescentic hymen, with attachments at the 2 o’clock and 10 o’clock position. The arrow points to periurethral support bands, which are normal structures.

Figure 1-6. Two-year-old Hispanic girl brought for suspicion of sexual abuse. The hymen is sleeve-like, with a ventral opening and an external hymenal ridge in the midline at 6 o’clock. The redness in the fossa is not specific for sexual abuse.

Figure 1-5

Figure 1-6

14 Chapter 1: Basic Anogenital Anatomy

Figure 1-7. Annular hymen in a 6-month-old Caucasian female, showing the thick appearance typical of estrogen effect.

Figure 1-8. Annular hymen in a 16-month-old girl, shown using labial separation.

Figure 1-7

Figure 1-8

15 Index A abrasions, linear, 168–169 anus, 3, 34–36 abused girl, estrogenized skin tag, 3 hymen in, 148 verge, 3 accidental anal hematoma, 182 acute laceration, 163 B acute penetration, 160 bleeding, 55, 120–122, 132 alleged abuse, cribriform genital, 158–159 hymen in, 152 lichen sclerosis causing, 132 alleged rape, 180 vaginal, 74, 164–167 Bowenoid papulosis, 186 anal abuse, 176–177 bruising of penis, 181 anal anatomy, features of, 1, 12–36 burned penis, 181 anal dilation, 60 buttocks lesion, 183 anal erythema lacerations, 77 anal findings in children, 56 C anal folds, venous pooling and Candida albicans, 61, 78 flattening of, 36 cervical ectropion, 33 anal hematoma, accidental, 182 cervix, 9, 33 anal laceration, 87, 161 child sexual abuse, 5 anal polyp, 95 signs of, 1 anal tag, 10, 138 societal awareness of, 5 anal tear, 155, 168 children anatomy cross-sectional studies of, 8 anogenital, 1–3 genital and anal findings in, 56 courses, 1 genital and anal tissues in, 4 genital and anal, 12–36 injuries, 60–61 structures in female, 2 medical examination of, 107 structures in male, 3 sexual abuse. See sexual abuse annular hymen, 13, 15 Chlamydia, 167 anogenital anatomy, 1–3 circumferential/annular hymen, 142 effects of puberty, 8–11 cleft, posterior mound with, 149 embryology, 4–5 clitoris, 2 genital and, 12–36 condyloma acuminata, 185, 187 normal variations, 5–8 crescentic hymen, 7, 14, 28, 137 anterior anal venous pooling, 142 defined, 7 anterior commisure, 2 cribriform hymen, 150 anterior intravaginal ridge, 145 in alleged abuse, 152 cylindrical perianal condylomata, 186

191 Child Abuse Pocket Atlas Series, Volume 2: Sexual Abuse

D H diastasis ani, 9, 34 healed transection, 190 digital penetration, 162, 174, 190 healing after transection of hymen, discontinuity of hymen, 179 154 disruptions of posterior hymen, 178 hemangioma, 134 documentation of sexual abuse, hematoma, 154 39–40 hemorrhagic herpes, 185 forensic evidence collection, 42, herpes simplex virus (HSV-1), 185 49–51 type 1, 183 laboratory specimens, 41–42, HPV. See human papillomavirus 46–48 (HPV) medication, 43, 52 HSV-1. See herpes simplex virus photodocumentation, 40–41, 45 (HSV-1) telemedicine, 43–44, 52 human embryo, 4 human papillomavirus (HPV), 187 E infections, 184 embryology, 4–5 hymen, 2, 5, 28–31 erythema, 101 anatomical structures in estrogenization, 115–116, 149, 150 female, 6 estrogenized hymen, 92 anatomical variations of, 6 in abused girl, 148 circumferential/annular, 142 extensive anal pooling, 142 crescentic, 7, 137 extensive labial fusion, 129 cribriform, 150, 152 external hymenal midline, 128 external hymenal ridge, 6 discontinuity of, 179 disruptions of, 178 F dorsal segment of, 4 failed midline fusion, 129 estrogenized, 30, 92 fimbriated hymen, 6 features by age, 7 flatwarts, 187 focal erythema of, 83 focal erythema of hymen, 83 hematoma and tearing of, 154 foreign body, 125, 130–131 imperforate, 120 forensic evidence collection, 42, in adolescents, 31 49–51 in neonates, 5 forensic photography, normal integrity of, 145 variations and, 62–103 irregular, 89 fossa navicularis/posterior fossa, laceration of, 165 2, 91 microperforate, 25 morphology of, 5 G normal, 137, 148 Gardnerella vaginalis, 78, 90 partial notch in, 86 genital anatomy, features of, 1, petechial hemorrhages on, 166 12–36 posterior rim of, 8 genital bleeding, 158–159 septate, 22 genital findings in children, 56 thickened crescentic, 141 genital herpes, 185 transection of, 154 genital warts, 184, 188 tulip-shaped, 9 glans penis/balanus, 3

192 Index hymenal cleft, 6 laboratory specimens, 41–42, 46–48 hymenal configurations, 115–119 laceration, 156–157 hymenal cyst, 6 with bruising, 162 hymenal data, 57–58 lichen planus, 187 hymenal laceration, traumatic lichen sclerosis, 100, 121, 132 superficial, 160 linear abrasions, 168–169 hymenal morphology, 7 features of, 7 M hymenal mound/bump, 6, 145, median raphe, 3 148 medication, 43, 52 hymenal orifice, 176–177 microperforate hymen, 25 hymenal pit, 152 midline fusion, failure of, 123 hymenal projection, 128, 144, 147 midline white line, 143 hymenal septum, 171 Molluscum contagiosum, 188 hymenal tag, 6, 147 mons pubis, 2 hymenal tear, 154 Mullerian tubercle, 4 hymenal transection, 170, 172 Myhre study, 10 hymeneal notch, 84 hypertrophic papillary lesions, 183 N NAATs. See nucleic acid I amplification tests (NAATs) imperforate hymen, 6, 120 neonates, hymen in, 5 injuries, 60–61, 130, 189–190 normal cribriform hymen, in alleged straddle, 123 abuse, 152 intact hymen, 138 normal hymen, 148 intact posterior rim, 146 normal variations, and forensic intercourse, labial, 179 photography, 62–103 intravaginal ridge, 139 nucleic acid amplification tests intravaginal rugae, 148, 150 (NAATs), 167 irregular hymen, 89 P K pectinate/dentate line, 3 knee-chest position, 146 penetration, 153, 175 digital, 174, 190 L penile, 189 labia majora, 2 perianal laceration caused by, labia minora, 2, 28–29 182 asymmetric development of, 32 vaginal, 189 thickness and pigmentation of, penile lichen planus, 187 24 penile penetration, 163–164, 189 labia, external surface of, 9 penis, 3 labial bruising, 133 bruising of, 181 labial fusion, 123 burned, 181 labial intercourse, 179 perianal bruising, 176, 181 labial separation, 12 perianal herpes, 185 labial traction, 12, 17, 26, 27, 64 perianal laceration, 163 examination using, 16, 18–21 caused by penetration, 182 labium minus, 29 perianal streptococcal infection, 187

193 Child Abuse Pocket Atlas Series, Volume 2: Sexual Abuse

perianal vitiligo, 134 sexually transmitted diseases, perineal body, 3 183–188 perineal groove, 11 suspicion of, 9 perineal lacerations, 85 techniques and basic skills, perineum, 3, 4 108–114 photodocumentation, 40–41, 45 sexual assault, 55 pinworm, 134 normal examination after, 143 possible precocious puberty, 149 sexually transmitted diseases posterior commisure, 2, 6 condyloma acuminata, 185 posterior hymenal rim, 147 cylindrical perianal posterior mound with cleft, 149 condylomata, 186 primordial urethral glands, 5 flatwarts, 187 prolapsed uterus, 120 genital warts, 184, 188 prominent urethral support hemorrhagic herpes, 185 structures, 146 herpes simplex virus type 1, 183 puberty, effects of Molluscum contagiosum, 188 anus, 9–11 penile lichen planus, 187 cervix, 9 perianal herpes, 185 hymen, 8–9 perianal streptococcal vagina, 9 infection, 187 scrotal condyloma acuminata, R 186 rape, alleged, 180 syphilitic lesion, 183 redundant hymen, 6 sexually transmitted infections, 59 reproductive structures, smooth avascular posterior area, 144 duplication of, 133 straddle injury, 123 research design, “gold standard” related bruising, 180 for, 56–57 syphilitic lesion, 183 Rett’s syndrome, 176 T S Tanner Stage 2 development, 8 scrotal condyloma acuminata, 186 telemedicine, 43–44, 52 scrotum, 3 thickened crescentic hymen, 141 septate hymen, 6, 22 toluidine blue dye uptake, 61, 75, sexual abuse, 14, 107–108 77, 85–87 acute findings, 154–182 toxic shock, 126–127 documentation of. traction, examination with and See documentation of without, 151 sexual abuse transection, healed, 190 examination positions, 108–114 traumatic superficial hymenal findings confused with, laceration, 160 120–136 tulip-shaped hymen, 9 hymenal configurations, 115–119 U injuries, 189–190 urethral orifice, 2 normal findings, 137–153 urethral prolapse, 122

194 Index

V vagina, 2, 41–42 vaginal bleeding, 164–167 after penile penetration, 164 vaginal discharge, 135–136, 173 in children, 115 vaginal duplication, 124 vaginal orifice, 2 vaginal penetration, 189 vaginal vestibule, 2 vascularization, 151 vestibular bands, 2 vitiligo, 124 vulva, 2, 31, 34, 113

195