Sexual abuse and assault

The classification scheme proposed by Joyce Adams et al may be used to determine the significance of physical findings.

Normal variants include:

A range of hymenal configurations such as annular, crescentic, imperforate, micro-perforate, septate, and redundant hymens; hymens with tags, mounds, bumps, or notches (above 3 and 9 o’clock regardless of depth, or below these positions if not extending to the base); a smooth or asymmetric posterior rim; and a hymen that appears narrowed but is normal. Additional normal findings include periurethral or vestibular bands, intravaginal or external hymenal ridges, diastasis ani, perianal skin tags, hyperpigmentation of genital or perianal tissues, and dilation of the urethral opening. Midline features such as a groove in the fossa, perineal groove, median raphe, and linea vestibularis are also normal. The pectinate/dentate line may be visible during full anal dilation caused by flatus or stool, and reflex anal dilation can occur during examination due to positioning or traction. Anal dilation may reveal normal structures like the dentate line, anal columns, and crypts, which can be mistaken for injury but are not indicative of trauma.

Findings commonly caused by conditions other than trauma or sexual contact include:

Erythema, inflammation, fissuring, and maceration of the perianal, perineal, or vulvar tissues, often related to poor hygiene or irritant dermatitis; increased vascularity of the vestibule and hymen; labial adhesions; and friability of the posterior fourchette. Other findings include non-sexually transmitted infections (non-STI)-related vaginal discharge, anal fissures, venous congestion or pooling in the perianal region, and complete or immediate anal dilation. The latter may occur in children with predisposing factors such as constipation or encopresis, children under sedation or anaesthesia, or children with impaired neuromuscular tone.
Infections not related to sexual contact include erythema, inflammation, and fissuring due to bacterial, fungal, viral, or parasitic infections acquired through non-sexual routes. Common pathogens include Streptococcus (Groups A and B), Staphylococcus sp., Escherichia coli, and Shigella. Genital ulcers may also result from viral infections such as Epstein-Barr virus.

Findings due to other conditions which can be mistaken for abuse include:

Erythema, inflammation, and fissuring, of the perianal, perineal, or vulvar tissues due to irritant dermatitis (e.g., Jacquet’s); inflammatory findings such as aphthous ulcers, inflammatory bowel disease (anal fissures or tags, rectal discharge), and Behçet’s disease (painful ulcers); and dermatological conditions such as lichen sclerosus, folliculitis, vitiligo, angiokeratomas, and haemangiomas. Painful ulcers may result from immunological causes such as pyoderma gangrenosum. Multifactorial or idiopathic findings include urethral or rectal prolapse and anal funnelling.

Indeterminate findings include:

Complete and immediate anal dilation involving both sphincters without other predisposing factors (e.g., constipation or encopresis, sedation or anaesthesia, or impaired neuromuscular tone), and a notch or cleft in the hymen ring, at or below the 3 or 9 o’clock positions. Specifically, notches or clefts that nearly reach the base of the hymen but are not complete transections, and complete clefts or suspected transections to the base of the hymen at the 3 or 9 o'clock location. These findings have been associated with a history of sexual abuse in some studies, but at present, there is no expert consensus as to how much weight they should be given with respect to abuse. The final two findings listed should be interpreted with caution and confirmed through additional examination techniques.
Infections that can be spread by both sexual transmission and non-sexual transmission include molluscum contagiosum in the genital or anal area, condyloma acuminatum (human papillomavirus) in the genital or anal area, and herpes simplex virus types 1 and 2, diagnosed by culture or nucleic acid amplification testing (NAAT) in oral, genital, or anal sites. Gardnerella vaginalis, though associated with sexual activity, is also found in pre-pubertal and adolescent vaginal flora. Mycoplasma genitalium and Ureaplasma urealyticum are typically sexually transmitted in adolescents, but their prevalence and transmission in younger children are not well understood.

Findings caused by trauma (suggestive but not diagnostic of abuse) include:

Acute trauma to genital or anal tissues: Lacerations or bruising of the labia, penis, scrotum, or perineum; lacerations of the posterior fourchette or vestibule (not involving the hymen); hymenal bruising, petechiae, abrasions, or partial/complete lacerations of any depth; vaginal lacerations; and perianal bruising or lacerations exposing tissue below the dermis.
Residual or healing injuries: Scarring of the perianal area or posterior fourchette/fossa (rare and difficult to diagnose without prior documentation of a previous injury at the same location); healed hymenal transections or complete clefts (a defect below the 3 to 9 o’clock location extending to or through the base with no tissue remaining); and signs of female genital mutilation, such as loss of clitoral or labial structures or characteristic scarring.
Acute oral trauma: Unexplained injuries or petechiae to the lips or palate, especially near the junction of the hard and soft palate.

Infections caused by sexual contact, if confirmed by testing and perinatal transmission has been ruled out, include:

Genital, rectal, or pharyngeal infection with Neisseria gonorrhoeae or Chlamydia trachomatis; Trichomonas vaginalis detected in vaginal secretions or urine; syphilis; and HIV (if other routes of transmission such as through blood or contaminated needles have been excluded).

Findings diagnostic of sexual contact include:

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Criteria