Sexual Assault: A Color Atlas

Barbara W. Girardin, RN, PhD

Forensic Health Care

Palomar Pomerado Health

Escondido, California

Diana K. Faugno, RN, BSN, CPN, FAAFS, SANE-A

District Director

Pediatrics/Nicu

Forensic Health Service

Palomar Pomerado Health

Escondido, California

Mary J. Spencer, MD

Clinical Professor of Pediatrics

University of California San Diego

School of Medicine

Medical Director

Child Abuse Prevention and Sexual Assault Response Team

Palomar Pomerado Health

Escondido, California

Angelo P. Giardino, MD, PhD

Associate Chair - Pediatrics

Associate Physician-in-Chief

St. Christopher’s Hospital for Children

Associate Professor in Pediatrics

Drexel University College of Medicine

Philadelphia, Pennsylvania

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Copyright © 2003 by G.W. Medical Publishing, Inc.

All Rights Reserved. This material may not be reproduced, sold or used in any other format; it may not be stored in a retrieval system or transmitted in any form, print or electronic, including, but not limited to, posting on web sites or on the Internet. Unauthorized duplication, distribution, or publication is a violation of applicable laws.

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Library of Congress Cataloging-in-Publication Data

Sexual assault victimization across the life span : a color atlas /

Barbara W. Girardin … [et al.].-- 1st ed.

            p. ; cm.

Includes bibliographical references and index.

ISBN 1-878060-61-9 (hardcover : alk. paper)

  1. Rape--Atlases. 2. Generative organs--Atlases.

[DNLM: 1. Sex Offenses--Atlases. 2. Forensic Medicine--Atlases. 3.

Genitalia--injuries--Atlases. W 617 S518 2003] I. Girardin, Barbara W.

        RA1141 .S45 2003

        616.85’83--dc21

2002013041

CONTRIBUTORS

Joyce A. Adams, MD

Clinical Professor of Pediatrics

Division of General Academic Pediatrics and Adolescent Medicine

University of California, San Diego Medical Center

San Diego, California

Eileen Allen, RN, BSN, DABFN

SANE Program Coordinator

Monmouth County Prosecutor’s Office

Freehold, New Jersey

Joanne Archambault

Sergeant (SDPD retired)

San Diego Police Department

Sex Crimes Unit

San Diego, California

Training Director

SATI, Inc.

Sexual Assault Training and Investigations

El Cajon, California

Patrick E. Besant-Matthews, MD

Forensic Pathology and Forensic Medicine

Legal and Law Enforcement Consultations

Private Practice

Dallas, Texas

Susan Chasson, MSN, CNM, JD

Lecturer

College of Nursing

Brigham Young University

Provo, Utah

Sue Dickinson, RN, BSN, PHN, CEDN, SANE-A

Forensic Nurse Examiner

Palomar Pomerado Health

Escondido, California

Colette M. Eastman, DO

Obstetrics, Gynecology, and Reproductive Medicine

Physician Consultant/Instructor, Sexual Assault Response Team

Poway, California

Diana K. Faugno, RN, BSN, CPN, FAAFS, SANE-A

District Director

Pediatrics/Nicu

Forensic Health Service

Palomar Pomerado Health

Escondido, California

Anne B. Finigan, RN, MScN, ACNP

Forensic Clinical Nurse Specialist/Nurse Practitioner

Regional Sexual Assault and Domestic Violence Treatment Centre

St. Joseph’s Health Care London

London, Ontario

Canada

Angelo P. Giardino, MD, PhD

Associate Chair - Pediatrics

Associate Physician-in-Chief

St. Christopher’s Hospital for Children

Associate Professor in Pediatrics

Drexel University College of Medicine

Philadelphia, Pennsylvania

Barbara W. Girardin, RN, PhD

Forensic Health Care

Palomar Pomerado Health

Escondido, California

Carolyn J. Levitt, MD

Assistant Professor of Pediatrics

Department of Pediatrics

University of Minnesota

Director

Midwest Children’s Resource Center

Children’s Hospitals and Clinics

St. Paul, Minnesota

Claire Nelli, RN, SANE-A

Manager—SART Department

Villa View Community Hospital

San Diego, California

Jason Payne-James, LLM, FRCS (Edin & Eng), DFM, RNutr

Forensic Physician

Forensic Medical Examiner - Metropolitan Police Service

and City of London Police

Director - Forensic Healthcare Services, Ltd.

Editor-in-Chief, Journal of Clinical Forensic Medicine

London, England

UK

Dawn Rice, RN, BSN, FNE

Executive Director

Fort Wayne Sexual Assault Treatment Center

President

Indiana Chapter of the IAFN

Fort Wayne, Indiana

Diana Schunn, RN, BSN, SANE-A

SANE/SART Manager

Via Christi Regional Medical Center

Wichita, Kansas

Deborah K. Scott, RN-C, BSN, ARNP, FNS

Child Protection Team

Howard Phillips Center for Children and Families

Orlando, Florida

Patricia M. Speck, APRN, MSN, BC

Coordinator of Nursing Services and Interim Manager

City of Memphis Sexual Assault Resource Center

Division of Public Services and Neighborhoods

Memphis, Tennessee

Mary J. Spencer, MD

Clinical Professor of Pediatrics

University of California San Diego

School of Medicine

Medical Director

Child Abuse Prevention and Sexual Assault Response Team

Palomar Pomerado Health

Escondido, California

Norman D. Sperber, DDS

Chief Forensic Dentist, San Diego and Imperial County

Diplomate, American Board of Forensic Odontology

Distinguished Fellow, American Academy of Forensic Sciences

San Diego, California

Malinda Waddell, RN, MN, FNP

Director-Forensic Nurse Specialists

Long Beach, California

FOREWORD

Whether in the pediatric emergency room, the adult sexual assault clinic, the nursing home or even the morgue, high quality photography of visible lesions remains an essential documentation and investigation tool. The value of photographic documentation cannot be overstated. Indeed, all medical providers who evaluate sexual assault victims should be familiar with the basic principles and techniques of clinical photography and should assure adequate photographic documentation of visible lesions. Such images, whether still or video, may be used in court, although less commonly than photographs of physical abuse (sometimes judges and juries have a hard time understanding the significance of, for example, a subtle hymenal tear). Photographs are also important for peer review, peer consultation and teaching. Perhaps most significantly, photographs may allow a second opinion by opposing council experts without subjecting the victim to a repeat examination.

The evolution in photodocumentation techniques in sexual assault has often followed, sometimes paralleled, and even sometimes led the evolution in the medical examination and interpretation of sexual assault injuries. Early published photographs of anogenital trauma were of such poor quality as to be virtually uninterpretable. At the same time clinical interpretation of findings were based on limited empirical research. With the advent of close-up photographic techniques such as 35mm camera macro lenses and colposcopes, the quality of published images increased dramatically. It was as if a shroud had been removed from the eyes of the examiner, who could now finally see and document microtrauma. Unfortunately at that time, the research base for interpreting these new findings was still undeveloped. It has only been in the last several years that well controlled studies, often using close-up photography to collect and analyze data, have clarified what is and what is not trauma. Only now have visualization techniques and interpretive skills found equivalency.

The variety of sexual assault photodocumentation tools in use today is astonishing: 35mm cameras, instant processing cameras, digital cameras, video cameras, colposcopes and most recently specialized stand alone, base mounted cameras. In virtually every case, however, where a new photodocumentation technology has developed, sexual assault documentation has been an afterthought. Close-up 35mm photography was first used in plastic surgery. Colposcopic photography, a combination of magnification, lighting, and photography, was, of course, first developed for gynecologic use. Even the latest trend in stand alone, base mounted, still and video cameras with attached light sources first saw their use in the dental office. Perhaps the next generation of photodocumentation tools—the combination of high quality digital video with high quality digital still imaging suitable for telemedicine consultation—will be developed specifically with the sexual assault victim in mind.

Though not demonstrated in this text, digital photography will soon equal if not exceed 35mm film photography in resolution, ease of use, and cost. Even then, still photography remains potentially limited since still images can easily miss significant findings and in some cases appear to show findings that are not present, all depending on when the shutter is released. Video photography represents still another advance, taking a 2 dimensional image and virtually creating 3 dimensions by recording the entire examination. Perhaps the next version of this text will have CD or web based digital video examples of traumatic findings.

Sexual trauma, whether at age 6 months or at age 60 years, demands the best skills of the best available examiner, the most sensitive and caring approach, and in virtually all cases the highest quality photodocumentation available. Not only does this text amply illustrate the variety of findings at each age group, but it also illustrates the similarities and differences across the lifespan. This text is a testament to the skill of the many examiners who took these excellent photographs. Discerning readers should come away from viewing these images with a clearer sense of how to document and how to interpret anogenital findings in sexual assault victims of all ages.

Lawrence R. Ricci, MD

Director, The Spurwink Child Abuse Program

Portland, Maine

Clinical Assistant Professor of Pediatrics

University of Vermont College of Medicine

Clinical Assistant Professor of Pediatrics

University of New England College of Osteopathic Medicine

FOREWORD

Healthcare professionals have a unique opportunity in making a difference in how a victim of sexual assault will assimilate that event into the rest of their lives. The primary purpose of the sexual assault examination by the healthcare professional is to provide for medical diagnosis and treatment. To appropriately provide this care, the professional needs an understanding of the anatomical and physiological changes through the life span and how those changes will effect the observations made in a sexual assault examination.

These observations are important. The examiner needs to keep in mind that observations may be the result of normal development, a result of trauma caused by accident or abuse, or the result of a disease condition. The evidence collection portion of the examination will assist law enforcement in linking the victim, the suspect, the crime scene, and the evidence. Documentation of this portion of the examination is just as important as documenting the history and the physical assessment. The text provides photographic examples of evidence as well as the anatomical observations intertwined in the discussion of the many unique situations in which a sexual assault may occur.

The examiner that is aware of and sensitive to the patient and their response to the examination process will go a long way in beginning the emotional healing process necessary to integrate the events. Giving control back to the victim of rape is therapeutic and should be utilized all through the examination.

This text shows a wide variety of findings and variations that illustrate the observations and histories in sexual assault examinations. It provides a base of observations that sexual assault examiners can utilize as they provide details necessary for the thorough medical forensic examination.

Kathy Bell, RN, BLS, SANE-A

Forensic Nurse Examiner

Tulsa Police Department

Tulsa, Oklahoma

PREFACE

Moses identified the presence of sex crimes among the Israelites 3500 years ago: If a man meets a girl and rapes her, the man who has done this shall die (Deuteronomy 22:25). Accountability was instituted for different situations by death, required marriage, or a fine, but it is not clear how the crime was discovered or evidence established.

Sex crimes still exist today with all the morbidity that they bring to individuals, families and society. However, identifying and documenting the presence of physical injury has helped in corroborating the victim’s history, contributing to the investigation of possible sexual abuse or assault and holding offenders accountable for their crime. The quality of photographic, colposcopic, video and narrative documentation continues to improve. Secured computer programs are being used to transmit photographs for consultation on injury. Crucial research is being conducted into assault injury that continues to support that the presence of injury does not prove assault, nor does the absence of injury prove consent. The interdisciplinary Sexual Assault Response Team (SART) approach with an expert nurse examiner or physician, a sex crimes detective, an advocate, and an experienced, specialized prosecutor has streamlined the process for the victim. Emotional care beginning at the time of the examination has softened the blow and helped to jettison the victim towards recovery. More efficient and better funded DNA profiling at the local, state, and national level is allowing for more timely identification of stranger and serial offenders.

This color atlas complements volume one, Sexual Assault Victimization Across the Lifespan: A Clinical Guide as a photographic elaboration including over 1600 photographs arranged by cases of injury, nonassault, and normal findings. The chapters follow the developmental stages of infancy (0–3 years), childhood (4–8 years), preadolescence, Tanner stage 1 (9–12 years), adolescence (13–17 years), adulthood (18–39 years), middle-age (40–64) and the elderly (65 and older). Many of the photographs show Hispanic victims or perpetrators because some of the contributing SARTs are located along the southern border of the United States. This does not imply that victims or sexual predators are more typically Hispanic. The photographs that show ungloved hands were drawn from archived records before gloves became the standard of practice. The adult chapter includes photographs not typically found in a text on sexual abuse or assault: findings following consensual intercourse and findings of the genitalia in the sexually inexperienced female, in females after sexual experience, and after one to multiple vaginal deliveries. This serves as a valuable basis of comparison for assault injury. Cases are presented of victims who were drugged and then raped, victims who were raped and sodomized in prison, as well as cases when DNA was used in the investigation. The goal of the text is to provide better care to victims of sexual violence and to hold offenders accountable to society for their crimes.

Barbara W. Girardin, RN, PhD

Diana K. Faugno, RN, BSN, CPN, FAAFS, SANE-A

Mary J. Spencer, MD

Angelo P. Giardino, MD, PhD

TABLE OF CONTENTS

CHAPTER 1:INFANT SEXUAL ABUSE (0–3 YEARS)

CHAPTER 2:YOUNG CHILD SEXUAL ABUSE (4–8 YEARS)

CHAPTER 3:PRE-ADOLESCENT (TANNER STAGE 1) SEXUAL ABUSE (9–12 YEARS)

CHAPTER 4:ADOLESCENT SEXUAL ABUSE AND ASSAULT (13–17 YEARS)

CHAPTER 5:ADULT SEXUAL ASSAULT (18–39 YEARS)

CHAPTER 6:MIDDLE-AGED ADULT SEXUAL ASSAULT (40–64 YEARS)

CHAPTER 7:ELDERLY SEXUAL ASSAULT (65 AND OLDER)

CHAPTER 1: INFANT SEXUAL ABUSE (0–3 YEARS)

History of Sexual Abuse

Acute Findings

Normal and Nonspecific Findings

Special Cases

Males

Disabled

Nonassault Variants

Accidents

Labial Adhesions

Foreign Object Penetration

Infection

Viral

Bacterial

Fungal

Breech Delivery

Friable Fourchette

Scratches

Urethral Prolapse

Balanitis

Constipation

Normal Findings

Annular Hymens

Crescentic Hymens

Septate Hymen

Median Raphe Ridge

CHAPTER 2: YOUNG CHILD SEXUAL ABUSE (4–8 YEARS)

History of Sexual Abuse

Acute Findings

Penile Penetration of the Vagina

Digital Penetration of the Vagina

Cunnilingus

Normal and Nonspecific Findings

Penile Penetration of the Vagina

Digital Penetration of the Vagina

Special Cases

Males

Revictimization

Incest

Adolescent Perpetrators

Healing

Nonassault Variants

Accidents

Labial Adhesions

Infections

Viral

Bacterial

Fungal

Parasitic

Friable Fourchette

Failure to Fuse

Urethral Prolapse

Oral Findings

Anal Findings

Skin Findings

Normal Findings

Hymen

Annular

Crescentic

Septate

Anus

CHAPTER 3: PRE-ADOLESCENT (TANNER STAGE 1) SEXUAL ABUSE (9–12 YEARS)

History of Sexual Abuse

Friend of the Family Perpetrator

Incest

Incest Involving Multiple Victims

Adolescent Perpetrator

Stranger Perpetrator

Nonassault Variants

Infection

Viral

Bacterial

Spirochetal

Parasitic

Normal Findings

Varied Examiner Technique

Hymen

Annular

Crescentic

Sleeve-like

Redundant

Septate

Failure to Fuse

Anus

CHAPTER 4: ADOLESCENT SEXUAL ABUSE AND ASSAULT (13–17 YEARS)

History of Sexual Abuse or Assault

Penile-Vaginal Penetration

Characteristics of the Injury

Acute Findings

Healing Injury

Revictimization

Characteristics of the Victim

Alcohol-related

Not Previously Sexually Active

Stated Bisexual

Prostitute

Developmentally Disabled

Pregnant

Characteristics of the Assault

Foreign Object

Internet-related

Drug-facilitated

Characteristics of the Perpetrator

Incest

Gang-related

Multiple Perpetrators

Adolescent Perpetrators

Victim and Perpetrator Photodocumentation

Digital-Vaginal Penetration

Sodomy

Fellatio

General Injuries

Nonassault Variants

Consenting Sexual Intercourse

Previously Sexually Active

Not Previously Sexually Active

Skin-Related

Lichen sclerosus

Folliculitis

Scratching

Accidents

Labial Adhesions

Vaginal Ridge

Cervical Polyp

Infection

Viral

Bacterial

Fungal

Normal Findings

Hymen

Previously Sexually Active

Never Sexually Active

Septate

Bands

Labia

Asymmetrical Labia

Clitoris

Vagina

Cervix

Anal/Rectal

Mouth

CHAPTER 5: ADULT SEXUAL ASSAULT (18-39 YEARS)

History of Sexual Assault

Alcohol-Related

Bites

Clothing Evidence

Debris

Torn or Displaced

Crime Scene

Deceased Victims

Defense Injury

DNA-Related Cases

Digital Penetration

Disabled Victims

Domestic Violence

Drug-Facilitated Rape

Emotionally Disabled Victims

Foreign Object

Gay and Lesbian Victims

Homeless

Internet-Related Assault

Male Victims

Military

Multiple Perpetrators

Oral Injury

Prison Rape

Psychic Healing

Revictimization

Self-Inflicted

Sexually Inexperienced

Stranger Perpetrator

Strangulation

Suspects

Trace Evidence

Victim and Perpetrator

Nonassault Variants

Findings in Consenting Intercourse

Not Previously Sexually Active

Unknown Previous Sexual Experience

Previously Sexually Active

Skin-Related Findings

Marks on the Neck

Slash Marks

Tire Abrasion

Gunshot Wound

Poison Oak

Irritation of the Medial Thighs

Cesarean Section Scar

Folliculitis

Piercings

Labial and Vaginal Findings

Folliculitis

Lichenification

Crust and Erythema

Transection of the Labium Minus

Vulvectomy

Vaginal Band

Vaginal Septum

Post-Hysterectomy

Cystocele/Rectocele

Episiotomy

Post-Speculum Examination

Breast Findings

Breast Augmentation Scars

Birthmark

Burns

Breast Reduction Scars

Nipple Erythema

Perineum and Perianal Findings

Skin Irritation

Hemorrhoid and Perianal Tag

Perianal Abscess

Oral Findings

Infection

Viral

Bacterial

Fungal

Techniques

Genital Examination

Probe/Balloon

Toluidine Blue Dye

Photographic Techniques

Avoiding Pitfalls of Examination

Normal Findings

Anatomy of the Female Genitalia

Tanner Stages in the Female

Tanner Stage 1

Tanner Stage 2

Tanner Stage 3

Tanner Stage 4

Tanner Stage 5

Labia Majora

Clitoral Hood and Clitoris

Labia Minora

Vestibule

Inferior to the Anterior Commissure

Vestibular Papillations

Open Bartholin Duct

Periurethral and Perihymenal Bands

Hymenal Tag

Crescentic Hymen

Tampon Within the Vagina

Hymens Related to Sexual Experience, Pregnancy, and Number of Vaginal Deliveries

Sexually Inexperienced Women

Sexually Experienced Women

Never Been Pregnant

Pregnant Once or More, No Vaginal Deliveries

One Vaginal Delivery

Two Vaginal Deliveries

Three Vaginal Deliveries

Four Vaginal Deliveries

Five and Six Vaginal Deliveries

Vaginal Wall

Cervix

General Findings

Intrauterine Device (IUD) String

Anus and Rectum

Perianal

Rectal

Oral

Other

CHAPTER 6: MIDDLE-AGED ADULT SEXUAL ASSAULT (40–64 YEARS)

History of Sexual Assault

Characteristics of the Victim

Alcohol-related

Homeless

Developmentally Disabled

Revictimization

Characteristics of the Perpetrator

Acquaintance

Stranger

Intimate Partner

Nonassault Variants

Consenting Intercourse

Nevus

Nabothian Cyst

Post-Vulvectomy

Vulvar Dystrophy

Breasts

Eyes

Normal Findings

Genital

Anal/Rectal

CHAPTER 7: ELDERLY SEXUAL ASSAULT (65 AND OLDER)

History of Sexual Assault

Nonassault Variants

Friable Fourchette

Rectal Polyp

Normal Findings

Smooth Vaginal Wall

Perianal Laxity

Chapter 1

INFANT SEXUAL ABUSE: 0–3 YEARS OLD

Barbara W. Girardin, RN, PhD

Diana K. Faugno, RN, BSN, CPN, FAAFS, SANE-A

Carolyn J. Levitt, MD

Malinda Waddell, RN, MN, FNP

Mary J. Spencer, MD

This chapter consists of cases of very young children within the approximate age range of newborn to 3 years. Sexual abuse in this age group often goes unreported. When it is reported, weeks or months may have passed since the abuse occurred. There are rarely conclusive physical findings, even in witnessed abuse, not only because of delays in reporting, but also because the sexual abuse of the young child is more often related to fondling than penetration. When there is acute injury, as would be more likely in attempted penetration of the infant’s vagina with the adult penis, it resolves quickly, without significant scarring of the mucous membranes. Nonspecific findings, such as erythema, often resolve even sooner than conclusive findings do. And if parents do notice redness in their child’s genital area, they may relate it to diaper irritation or skin tenderness. Because injuries in this age group often go unnoticed or are healed before abuse is reported, a normal medical examination is common in child victims of sexual abuse. This means that there may be no findings to corroborate the history. It is important to note, however, that a normal physical examination does not rule out sexual abuse.

A medical examination should be performed as soon as possible after an abuse is reported, even if weeks or months have passed since the incident. An examination with colposcopy and photodocumentation provides vital evidence for the current report and a baseline for the future. Photodocumentation also helps avoid repeated examinations. If photographs are available, Child Abuse Team members and consulting examiners can discuss the findings without re-traumatizing the child. To accurately interpret the findings, the medical examiner must be familiar not only with the signs of abuse, but also nonassault variants and normal findings.

There are three sections in this chapter: cases with a history of sexual abuse, cases of nonassault variants, and cases of normal findings. Each section includes brief case histories and key photographs. The cases with abuse histories include both females and males, a developmentally disabled female, and an abusive injury that occurred on a surgical scar. Nonassault variants of the genitalia include accidental injury, labial adhesions, injury from foreign object penetration, infection, edema secondary to breech delivery, friable fourchette, and others. Perianal injury from constipation is also shown. The chapter concludes with normal findings in this age group, including annular, crescentic, and septate hymens, and the median raphe.

Most photographs are magnified from 6 to 16x. Those photographs not magnified are listed as 35mm. The designation of body parts as left and right is from the point of view of the patient, not the examiner.

HISTORY OF SEXUAL ABUSE

ACUTE FINDINGS

Case Study 1-1

This 5-month-old female was brought to the emergency department the day after the perineal bruises were found by the mother. The day-care provider had sent her home with thick diaper cream completely covering these bruises. The mother noticed the bruises while changing the baby.

Figure 1-1-a. 24 hours postassault shows ecchymosis posterior to the labia majora (35mm).

Figure 1-1-b. General erythema of the hymen, periurethral area and medial labia minora. She has a patulous urethra.

Figure 1-1-c. Five days after the first examination, there is resolution of the erythema.

Key Point:

Examination of the child in the first 24 hours reveals more physical and forensic evidence of assaults than examinations done after this time.

Case Study 1-2

This 8-month-old female was cared for by a neighbor while the mother ran an errand. The neighbor was high on cocaine and attempted to penetrate the infant’s vagina with his penis.

When the mother returned, the infant was crying and fussy. The mom found blood in her diaper.

Figure 1-2-a. Hymenal ecchymosis, edema, and erythema are evident. An avulsion is present, midline at the base of the hymen, giving the appearance of a puncture wound.

Figure 1-2-b. A laceration of the posterior fourchette from the perineum to the anus.

Figure 1-2-c. Five days postassault, erythema of the vestibule persists. The cavity at the base of the hymen is filling with granulation tissue.

Figure 1-2-d. Four months postassault. The injury at the base of the hymen has completely healed, and the annular hymen is thick. The erythema persists and is normal for this diapered infant.

Case Study 1-3

This is an 8-month-old Caucasian female, Tanner stage 1, examined within six hours of digital penetration of the anus and spanking. The 25-year-old male babysitter explained the baby wouldn’t stop crying. The first four photographs show the acute findings; the fifth photo was taken three months later.

Figure 1-3-a. There is perianal ecchymosis and ecchymosis on the left buttock from 1 o’clock to 4 o’clock and on the posterior and lateral left thigh (35mm).

Figure 1-3-b. Perianal ecchymosis is evident on both sides, lateral to the anus. There is ecchymosis on the right and left lateral thighs (35mm).

Figure 1-3-c. This photo shows perianal ecchymosis, focal erythema superior to the anus, and lacerations at 12 and 6 o’clock.

He was sentenced by court-martial to 8 years in prison.

Figure 1-3-d. Toluidine blue dye uptake affirms the presence of the perianal lacerations.

Figure 1-3-e. This photo was taken on recheck, three months later. The thigh, buttocks, and perianal ecchymoses are resolved. The lines along the thighs are from the diaper and are not scars (35mm).

Key Point:

Photographs are invaluable in aiding the examiner’s recollection of what was seen at the time of the examination.

Case Study 1-4

This 18-month-old African-American male returned from the babysitter with excoriations on his right and left buttocks. His mother found the lesions within 2 hours of returning from the sitter. He was examined within 24 hours. There was no history of diarrhea. The child was unable to tell what happened. The case was inactivated because the leads were exhausted.

Figure 1-4. There are 2 vertical and 1 circular areas of peeling, denuded skin. There is a wider circular area surrounding the 3 lesions where the top layer of skin has peeled off (35mm).

Case Study 1-5

This 18-month-old Caucasian was observed by her 6-year-old sister being touched by her mother’s boyfriend. She was examined within 24 hours from the time of touching. There was a history of constipation.

Figure 1-5-a. An annular hymen with symmetrical normal clefts at 3 and 9 o’clock. The vaginal wall is obvious within the hymenal opening.

Figure 1-5-b. A perianal laceration at 12 o’clock which may be related to constipation.

Case Study 1-6

This 25-month-old was examined within 24 hours after the foster mother brought her home from a day visit with her natural parents who were drug abusers. There was blood found in her diaper and a red vagina. She had a history of constipation.

Figure 1-6-a. A wide pocket-like laceration of the fossa navicularis and posterior fourchette extending from 6 to 8 o’clock. A second laceration extends from the posterior fourchette down the perineum.

Figure 1-6-b. The perineal laceration extending downward to the anal tag at 12 o’clock.

Figure 1-6-c. A coarse, kinky brown hair found on the genitalia. Cultures of the vaginal secretions revealed light staphylococcus species.

The child was referred for a surgical consult. The mother, who gave several histories, was convicted by a bench trial and is serving a 2 year prison term.

Case Study 1-7

This 30-month-old Hispanic female was fondled by a friend of the family. She was examined in a supine, frog-leg position, 12 hours afterwards. Follow-up photographs are indicated to determine the significance of these acute findings. However, the mother refused to bring the child back.

Figure 1-7-a. Edema of the clitoral hood and at the superior ends of the labia minora.

Figure 1-7-b. Punctate erythema at 1 o’clock in the periurethral area. The erythema at the anterior commissure is evident as the labia are separated.

Figure 1-7-c. An abrasion on the medial aspect of the labium minus.

Case Study 1-8

The child care provider found redness on the bottom of this nonverbal 24-month-old Caucasian female. Her older sibling (next case) revealed to the provider, Daddy touches us. The father cares for the children while the mother attends an in-patient drug recovery program. The child was examined within 48 hours of the disclosure.

Figure 1-8-a. A large clitoral hood with focal erythema at 2 and 3 o’clock. Vaginal cultures demonstrated normal flora.

Figure 1-8-b. Erythema from 3 to 9 o’clock in the vestibule.

Case Study 1-9

This 3-year-old child, sister of the child in the previous case, is developmentally delayed. She was born full-term at 4 pounds. Her mother used cocaine while she was pregnant. She was examined 24 hours after she disclosed to the child care provider that Daddy touches us.

Figure 1-9-a. A large clitoral hood.

Figure 1-9-b. Erythema from 6 to 9 o’clock on the vestibule, medial to the right labium minus.

Key Point:

Erythema is a nonspecific finding, but that does not rule out sexual abuse.

Case Study 1-10

The mother of this 17-month-old Hispanic female found a tear on her daughter. She was examined within 24 hours using minimal separation in a supine, frog-leg position.

Figure 1-10. There is a laceration of the posterior fourchette at 6 o’clock, extending down the perineum.

Case Study 1-11

This 2-year-old Caucasian female has a history of being touched under her clothes by a 16-year-old neighbor. She was examined within 24 hours of the disclosure.

Figure 1-11. Minimal separation shows a laceration of the posterior fourchette. This laceration was apparent before the examiner separated the tissue.

Key Point:

A photograph prior to manipulation during the examination is an essential baseline in ruling out iatrogenic injury.

Case Study 1-12

This 3-year-old Hispanic female was found by her 4-year-old brother in the next apartment with a 40-year-old neighbor. The neighbor had his pants down and the 4-year-old brother said, I saw his pee-pee, and, He sucked her. The 3-year-old does not give a history. The child was examined within 24 hours of the incident.

Figure 1-12-a. Blood in the anterior part of the crotch of the underwear (35mm).

Figure 1-12-b. Abrasions superior and lateral to the clitoral hood.

Figure 1-12-c. Erythema medial to the labia minora, lacerations at 6 o’clock in the posterior fourchette and lacerations at the posterior ends of both right and left labium minus. There is an abrasion on the right labium majus.

Figure 1-12-d. Toluidine blue dye uptake of the lacerations in the posterior fourchette and at the posterior end of the left labium minus. The toluidine blue dye in the medial labia has been blotted off. The extensive dye uptake is consistent with the history of cunnilingus. Clitoral hood edema is present as compared to the follow-up figure 1-12-g.

Figure 1-12-e. Focal erythema at anus between 6 to 10 o’clock and at 12 o’clock.

Key Point:

Oozing injuries may not take up toludine blue dye even though breaks in the skin are apparent.

Figure 1-12-f. Dye uptake on two of the perianal lacerations at 8 and 9 o’clock. There are multiple other sites of dye uptake. Note the erythema of the surrounding tissue (following the examination) compared to photograph 1-12-e (prior to the examination).

Figure 1-12-g. This photo was taken at a 2 week follow-up examination. There is healing of the labial lacerations with only a small laceration remaining. The erythema of the labia may be typical to this child. There is no distinct dye uptake.

Key Point:

Follow-up photographs provide a comparison that clarifies what is a normal finding for a particular patient.

NORMAL AND NONSPECIFIC FINDINGS

Case Study 1-13

This 22-month-old Caucasian female was brought in by her mother over 72 hours after the alleged incident. The mother reported that the child told her that her fraternal grandmother touched me, as she pointed to her genitalia. On interview the child failed to repeat her complaints of touching.

Figure 1-13-a. A normal exam.

Figure 1-13-b. Labial separation shows erythema around the outer perimeter of the hymen, which is likely normal for this diapered infant. There is a periurethral band at 1 o’clock.

Case Study 1-14

This 23-month-old Caucasian’s father saw blood in her underwear. The child gave no history of being touched on or in her privates. The Emergency Department physician saw tears on the hymen, which were not evident to the Child Abuse Physician who also saw the child within hours of the Emergency Department examination.

Figure 1-14-a. Erythema at the opening of the clitoral hood and on the medial labium minus, which may be normal for this child.

Figure 1-14-b. A normal, symmetrical, vascular pattern on the medial labia and hymen. The hymenal tag with its base at 8 to 9 o’clock is adhered at 5 o’clock. A swab might be used to lift this tag from its 5 o’clock position, showing that it is indeed a tag and not a band. A band that has torn loose from its attachment may have explained the bleeding.

Case Study 1-15

This 2-year-old was brought by her mother because the mother suspected that the child’s father had fondled her. Older siblings had reported this repeated occurrence over time. The most recent incident was over 72 hours before the time of the examination. Other female children in this family had also been rubbed by their natural father. Disclosure occurred because an older sibling saw a program at school.

Figure 1-15. There is a normal color pattern throughout. The hymen is redundant. The continuity of the hymenal rim cannot be assessed in this view (supine position).

The perpetrator pled guilty to child molestation of 2 children and was sentenced to 2 years in prison and registration as a child sex offender. The mother of the children divorced the father.

Case Study 1-16

This 2-year-old Hispanic child stated that the babysitter’s boyfriend reached into her panties. The mother brought the child for an examination within 24 hours of the incident.

Figure 1-16. Erythema of the fossa navicularis at 5 to 7 o’clock. The sleeve-like hymen with a ventral opening has a normal vascular pattern.

Case Study 1-17

This 28-month-old Asian female complained of pain on urination. In explaining the complaint, the child said that one of her mother’s employees, a 22-year-old male, had touched her under her clothes.

Figure 1-17-a. A laceration of the right labium minus. The vestibule is homogeneous and pink.

Figure 1-17-b. Lacerations on the right and edema on the lower half of the left labium minus. Toluidine blue dye would help demonstrate if lateral to the left labium minus is also a laceration.

Figure 1-17-c. A normal anus. The blue-gray ring around the anus is normal as is the median raphe ridge. Fecal and tissue particles are common in children who do their own toileting. The dark fibers are consistent with the black pants she was wearing.

Case Study 1-18

This 30-month-old was brought to the Emergency Department by her mother who saw vaginal bleeding several days before she brought the child for an examination. There is no history of vaginitis, itching, urinary tract infections, or previous abuse.

Figure 1-18. Normal findings: pink medial labia minora, redundant, annular hymen, and a labial adhesion at 6 o’clock.

Case Study 1-19

This 3-year-old Caucasian female was fondled by a 30-year-old friend of her father’s. The father drove while the child was sitting on the perpetrator’s lap in the back seat of the car. Her mother noted blood in her underwear and the child revealed he touched me under my dress. She was examined within 72 hours of the touching.

Figure 1-19-a. Erythema from the base of the clitoral hood down the medial aspects of the labia majora (35mm).

Key