APPENDIX B: ADAMS C LASSIFICATION SYSTEM FOR A SSESSING P HYSICAL,

LABORATORY, AND HISTORICAL I NFORMATION

in Suspected Child Sexual Abuse

The system to be used for classifying hymenal injury is based upon that found in Joyce Adams’
February 2001 Child Maltreatment publication, entitled “Evolution of a Classification Scale: Medical
Evaluation of Suspected Child Abuse,” in which medical observations are categorized according to
likelihood of abuse. This is a suggested system for classifying medical observations and will likely be
revised in the future as we gain more information from research concerning non-abused and abused
children and adolescents.

Part I: Anogenital Findings on Examination

NORMAL Findings that are observed in newborns.

1. Peri-urethral (or vestibular bands)

2. Longitudinal intravaginal ridges or columns
3. Hymenal tags
4. Hymenal bump or mound
5. Linea vestibularis
6. Hymenal cleft/notch in the anterior (superior) half of the hymenal rim, on or
above the 3 o’clock- 9 o’clock line, patient supine
7. External hymenal ridge

NORMAL 1. Septate hymen (normal variant)

2. Failure of midline fusion (normal variant)
VARIANTS 3. Groove in the fossa in a pubertal female (normal variant)
4. Diastasis ani (normal variant)
5. Perianal skin tag (normal variant)
6. Increased peri-anal skin pigmentation (normal variant)

OTHER 1. Hemangiomas of the labia, hymen, or perihymenal area (may give the
appearance of bruising or submucosal hemorrhage)
CONDITIONS 2. Lichen sclerosus et atrophicus (may result in friability and bleeding)
3. Beche t’s Disease (causes genital and oral ulcers, may be mistakem for Her pes
Simplex lesions)
4. Streptococcal cellulitis of perianal tissues (causes red, inflamed tissues)
5. Molluscum contagiosum (warty lesions)
6. Verruca vulgaris (common warts)
7. Vaginitis caused by streptococcus or enteric organisms
8. Urethral prolapse (causes bleeding, appearance of trauma)
9. Vaginal foreign bodies (may cause bleeding, discharge)
NON -SPECIFIC Findings that may be the result of sexual abuse, depending on the timing of the
examination with respect to the abuse, but which may also be due to other causes,
FINDINGS
or may be variants of normal.

1. Erythema (redness) of the vestibule or peri-anal tissues (may be due to irritants,

infection or trauma)
2. Increased vascularity (dilation of existing blood vessels) of vestibule (may be due
to local irritants)
3. Labial adhesions (may be due to irritation or rubbing)
4. Vaginal discharge (many causes)
5. Friability of the posterior fourchette or commisure (may be due to irritation,
infection, or may be ca used by examiner’s traction on the labia majora)
6. “Thickened hymen” (may be due to estrogen e ffect, folded edge of hymen,
swelling from infection, or swelling from trauma)
7. Apparent genital warts (may be skin tags or warts not of the genital type, may be
Condyloma accuminata which was acquired from perinatal transmission or other
non-sexual transmission)
8. Anal fissures (usually due to constipation or peri-anal irritation)
9. Flattened anal folds (may be due to relaxation of the external sphincter)
10. Anal dilation with stool present (a normal reflex)
11. Venous congestion, or venous pooling (usually due to positioning of child, also
seen in constipation)
12. Vaginal bleeding (may be from other sources, such as urethra, or may be due to
vaginal infections, vaginal foreign body, or accidental trauma)

SUGGESTIVE Findings that have been noted in children with documented abuse, and may be
suggestive of abuse, but for which insufficient data exists to indicate that abuse is
OF ABUSE
the only cause. History is crucial in determining overall significance.

1. Marked, immediate dilation of the anus, with no stool visible or palpable in the
rectal vault, when the child is examined in the knee-chest position, provided there
is no history of encopresis, chronic constipation, neurological deficits, or
sedation
2. Hymenal notch/cleft in the posterior (inferior) portion of the hymenal rim,
extending nearly to the vaginal floor. (Often an artifact of examination technique,
but if persistent in all examination positions, may be due to previous blunt force
or penetrating trauma).
3. Acute abrasions, lacerations or bruising of labia, peri-hymenal tissues, or
perineum (may be from accidental trauma, or may be due to dermatological
conditions such as lichen sclerosus or hemangiomas)
4. Bite marks or suction marks on the genitalia or inner thighs
5. Scar or fresh laceration of the posterior fourchette, not involving the hymen (may
be caused by accidental injury)
6. Perianal scar (rare, may be due to other medical conditions such as Crohn’s
Disease, or from previous medical procedures)
CLEAR Findings that can have no explanation other than trauma to the hymen or perianal
tissues.
EVIDENCE OF
BLUNT FORCE 1. Laceration of the hymen, acute.
OR 2. Ecchymosis (bruising) on the hymen.
PENETRATING 3. Perianal lacerations extending deep to the external anal sphincter.
4. Hymenal transection (healed). An area where the hymen has been torn through,
TRAUMA to the base, so there is no hymenal tissue remaining between the vaginal wall and
the fossa or vestibular wall.
5. Absence of hymenal tissue. Wide areas in the posterior (inferior) half of the
hymenal rim with an absence of hymenal tissues, extending to the base of the
hymen, which is confirmed in the knee-chest position.

Part II: Overall Assessment of Likelihood of Abuse

NO I NDICATION 1. Normal exam, no history, no behavioral changes, no witnessed abuse

OF ABUSE 2. Nonspecific findings with another known or likely explanation and no history of
abuse or behavior changes
3. Child considered at risk for sexual abuse but gives no history and has only
nonspecific behavior changes
4. Physical findings of injury consistent with history of accidental injury that is
clear and believable

POSSIBLE 1. Normal, normal variant or nonspecific findings in combination with significant

behavior changes, especially sexualized behaviors, but child unable to give a
ABUSE history of abuse
2. Herpes Type I anogenital lesions, in the absence of a history of abuse and with an
otherwise normal examination
3. Condyloma accuminata, with otherwise normal examination; no other STDs
present, and child gives no history of abuse (Condyloma in a child older than 3-5
years is more likely to be from sexual transmission, and a thorough investigation
must be done)
4. Child has made a statement but statement is not sufficiently detailed, given the
child’s developmental level; is not consistent; or was obtained by the use of
leading questions concerning physical findings with no disclosure of abuse
PROBABLE 1. Child has given a spontaneous, clear, consistent, and detailed description of being
molested, with or without abnormal or positive physical findings on examination
ABUSE
2. Positive culture (not rapid antigen test) for Chlamydia trachomatis from genital area
in prepubertal child, or cervix in an adolescent female (assuming that perinatal
transmission has been ruled out)
3. Positive culture for Herpes Simplex Type 2, from genital or anal lesions
4. Trichomonas infection, diagnosed by wet mount or culture from vaginal swab, if
perinatal transmission has been ruled out

DEFINITE 1. Clear physical evidence of blunt force or penetrating trauma with no history of accident
2. Finding sperm or seminal fluid in or on a child’s body
EVIDENCE OF 3. Pregnancy
ABUSE OR 4. Positive, confirmed cultures for N. gonorrhea from vaginal, urethral, anal, or
SEXUAL pharyngeal source
5. Evidence of syphilis acquired after delivery (i.e., not perinatally acquired)
CONTACT
6. Cases where photographs or videotape show a child being abused
7. HIV infection, with no possibility of perinatal transmission or transmission via
blood products or contaminated needles