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Child Abuse & Neglect xxx (2013) xxx–xxx
Contents lists available at SciVerse ScienceDirect
Child Abuse & Neglect
Anal findings in children with and without probable anal

penetration: A retrospective study of 1115 children referred
for suspected sexual abuse
Arne K. Myhre a,b,∗ , Joyce A. Adams a , Marilyn Kaufhold a , Jennifer L. Davis a ,
Premi Suresh a , Cynthia L. Kuelbs a
a
University of California, San Diego School of Medicine and Chadwick Center for Children and Families, Rady Children’s Hospital, San
Diego, 3020 Children’s Way, MC 5016 San Diego, CA 92123, USA
b
Department of Laboratory Medicine, Children’s and Women’s Health, Norwegian University of Science and Technology and Regional
Resource Center, St. Olav’s University Hospital, Schwach’s Gate 1, 7030 Trondheim, Norway
a r t i c l e i n f o a b s t r a c t
Article history: Interpreting the significance of anal findings in child sexual abuse can be difficult. The
Received 9 November 2012 aim of this study is to compare the frequency of anal features between children with
Received in revised form 21 March 2013
and without anal penetration. This is a retrospective blinded review of consecutive charts
Accepted 22 March 2013
of children seen for suspected sexual abuse at a regional referral center from January 1.
Available online xxx
2005 to December 31. 2009 Based on predetermined criteria, children were classified into
two groups: low or high probability of anal penetration. The charts of 1115 children were
Keywords:
Sexual abuse included, 84% girls and 16% boys with an age range from 0.17 to 18.83 years (mean 9.20 year).
Child 198 children (17.8%) were classified as belonging to the anal penetration group. Bivariate
Anal findings analysis showed a significant positive association between the following features and anal
Anal dilatation penetration: Anal soiling (p = 0.046), fissure (p = 0.000), laceration (p = 0.000) and total anal
Anal penetration dilatation (p = 0.000). Logistic regression analysis and stratification analysis confirmed a
positive association of soiling, anal lacerations and anal fissures with anal penetration.
Total anal dilation was significantly correlated with a history of anal penetration in girls, in
children examined in the prone knee chest position and in children without anal symptoms.
Several variables were found to be significantly associated with anal penetration, including
the controversial finding of total anal dilatation. Due to limitations in the study design, this
finding should still be interpreted with caution in the absence of a clear disclosure from the
child.
© 2013 Elsevier Ltd. All rights reserved.
Introduction
Child sexual abuse is an important part of the child maltreatment spectrum, and in a recent meta-analysis based on
nearly 10 million participants, the overall estimated global prevalence was 127/1000 in self report studies and 4/1000 in
informant studies (Stoltenborgh, van Ijzendoorn, Euser, & Bakermans-Kranenburg, 2011). The medical examination is part
of the multidisciplinary assessment, where both health and forensic concerns can be addressed. To guide the practitioner,
guidelines regarding examination and interpretation of medical findings have been developed and revised (Adams, 2011;
Royal College of Paediatrics and Child Health, 2008).
∗ Corresponding author address: Regional Resource Center about Violence, Traumatic Stress and Suicide Prevention, Schwach’s gt 1, 7030 Trondheim,
Norway.
0145-2134/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.chiabu.2013.03.011
Please cite this article in press as: Myhre, A. K., et al. Anal findings in children with and without probable anal pen-
etration: A retrospective study of 1115 children referred for suspected sexual abuse. Child Abuse & Neglect (2013),
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There is general agreement that among children who are evaluated for suspected sexual abuse, especially for non-acute
examinations of pre-pubertal children, that the percentage of cases showing abnormal medical findings is low (Berenson
et al., 2000; Heger, Ticson, Velasquez, & Bernier, 2002). Further, the absence of signs of genital or anal injuries does not
exclude the possibility of sexual abuse (Adams, 2008), since many types of abuse are not expected to cause injuries, and
most injuries can heal completely by the time the child is brought for a non-acute medical examination (McCann, Miyamoto,
Boyle, & Rogers, 2007a, 2007b).
Since 1990, the publication of several studies of children selected for non-abuse (Berenson, Heger, Hayes, Bailey, & Emans,
1992; McCann, Wells, Simon, & Voris, 1990; Myhre, Berntzen, & Bratlid, 2003), one case-control study (Berenson et al., 2000),
longitudinal studies (Berenson & Grady, 2002; Myhre, Myklestad, & Adams, 2010) and case series reporting the healing of
acute genital trauma (Heppenstall-Heger et al., 2003; McCann et al., 2007a, 2007b; McCann, Voris, & Simon, 1992) have
provided a research basis for the interpretation of genital findings in children with suspected sexual abuse. For anal findings,
there are very few studies of non-abused children (Berenson, Somma-Garcia, & Barnett, 1993; McCann, Voris, Simon, & Wells,
1989; Myhre, Berntzen, & Bratlid, 2001) and no case-control study has been published. For several decades there have been
discussions and controversies related to the interpretation of certain anal findings (Clayden, 1988; Hobbs & Wynne, 1986),
and differences of opinion still exist. Especially for non-acute findings like venous congestion, erythema and anal dilatation,
there seem to be different approaches to interpretation (Adams, 2008; Hobbs & Osman, 2007; Royal College of Paediatrics
and Child Health, 2008).
Purpose of the study
The aim of this study is to provide more information about the frequency of anal findings in children referred for suspected
sexual abuse and to explore whether there is any association of particular findings with anal abuse. As a result we hope
to provide practitioners with information to help in the identification of anal sexual abuse. The study will be done by
comparing anatomical anal features documented during the medical examination between two groups of children; those
with and without a high probability of having experienced anal penetration.
Methods
Inclusion criteria
This is a retrospective cross sectional study of all children evaluated for possible sexual abuse during a 5 year period
from January 1, 2005 to December 31, 2009 at a regional referral center in a large urban area that provides sexual abuse
medical evaluations of 200–250 children yearly. Following approval from the University Institutional Review Board and the
Research Administration office at the Hospital, medical records consisting of photos and charts from the examinations were
reviewed. As criteria for inclusion, all children having their first time examination for an event of suspected sexual abuse
were used. A child was excluded if no anal photos were present or the photos were of insufficient quality.
Follow up examinations were not included. If a child had referrals for several abusive event during this 5 year period,
the child would be included with their first time examination for each event. Since child identification numbers were not
entered into the data system, we have no information about children included more than once.
Review of photographs
First, using the account number from the child’s medical visit, photos from the examinations were retrieved. The pho-
tographs on each case were reviewed first by one of the authors, and anatomical findings were classified and recorded. In
Table 1, the recorded anal features are defined according to the glossary of terms published by the American Professional
Society on the Abuse of Children (APSAC, 1998). An attempt was made, in the case of total anal dilatation, to measure the
diameter of the dilated opening from photographs. This proved difficult because it was not always clear whether the pho-
tograph had been taken at 3.75× or 6× magnification, and the dimensions of the projected image of the digital photos were
not standardized.
Review of complete medical record
After the photographs were reviewed and findings noted, the same author reviewed the medical record of the visit and
recorded the historical information on a data collection sheet. The examiner’s conclusions were not recorded, however the
practice at the center was to only list physical findings, not information from the child’s disclosure, in the interpretation of
findings section of the standardized reporting form.
In addition to information related to the actual alleged abusive event, information like age, sex, ethnicity, Tanner stage,
health problems and symptoms, previous abuse and maltreatment as well as extra-anal findings were recorded from the
chart. Information about examination positions was extracted from both photos and charts. A variable called anal symptoms
was constructed if the child had problems with one or more of the following symptoms: constipation, encopresis or diarrhea.
The examination was classified as acute if done within 72 hours of the episode of abuse.
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Table 1
Definition of terminology.
Erythema: A general or local redness of tissue

Venous pooling: A general or local purple discoloration in the perianal tissue, due to pooling of venous blood.
External anal dilation: A dilatation of the external sphincter, with visualization of the anal canal but not the rectal ampoule.
Total anal dilatation: A dilatation of both the external and internal sphincter, with visualization into the rectum.
Anal fissure: A superficial defect (split) in the perianal skin, located on the anal verge. Not extending into the subcutaneous tissue.
Anal bruising: An injury without a break in the skin. Includes the following features:
Ecchymosis: A flat, hemorrhagic lesion.
Hematoma: A well defined, localized collection of blood.
Petechiae: Pinpoint, purplish spot.
Submucosal hemorrhage: Bleeding into the areolar tissue beneath a mucosal membrane.
Anal laceration: A deep defect (split) in the perianal skin, located on the anal verge. Extending into the subcutaneous tissue.
Anal warts: Any wart (skin wart or condyloma appearance) in the perianal area.
Anal vesicles: Blisters filled with fluid in the perianal area.
Anal tag: A protrusion of the anal verge tissue, which interrupts the symmetry of the perianal skin folds.
Anal scar: White line or whitish area where the tissue has a different consistency (is harder) compared to the perianal tissue. Important to distinguish
from midline structures like perianal raphe.
Soiling: Fecal material covering the anal verge/perianal tissue.
Most photo and chart reviews were done by one of two examiners, JA and AKM, both pediatricians with long clinical
and research experience. A subsample of 10% of the charts was re-reviewed by another pediatrician to assess inter-rater
reliability.
Assignment of each case to group
For the study, criteria listed in Table 2 were used to classify the children into one of two groups: low and high probability
of anal penetration. Physical findings were not used for that purpose. For each case, the same reviewer performed the review
of the photographs and of the medical record. Since the findings on the photographs were recorded before the charts was
reviewed, the reviewer was initially unaware of whether the child had disclosed anal penetration or not. The results of tests
for sexually transmitted infections and the results of recovery of biological fluids from the child’s body were not available
at the time of the child’s examination.
Statistical methods
First bivariate analysis was performed, comparing the frequency of anatomic anal features between the groups where
anal penetration was probable and not. When comparing categorical data, chi-square tests or Fisher exact tests were used.
In order to control for possible bias and confounding factors, we used logistic regression analysis and stratified analysis.
Inter-rater agreement was assessed with kappa statistics.
All analysis was performed with SPSS version 17.0 statistical software. p-Value < 0.05 was used as the level of significance.
No correction for multiple comparisons was made.
Results
Description of the study population
Medical records and clinical photographs from 1231 cases were reviewed. There were 116 cases that were excluded due
to poor photos or lack of photos, leaving 1115 for inclusion. For analytical purposes, one included case is considered as one
child. Of those included, 941 (84%) were girls and 174 (16%) were boys. The girls were significantly older than the boys with
a mean age of 9.67 years (SD: 5.2 range 0.17–18.83 years). The mean age of the boys was 6.26 (SD: 3.9, range 0.33–18.00
years) (p = 0.000). Fifty-seven percent of the children were Tanner stage I. The largest ethnic group was Hispanic children
(35%), followed by white (27%) and African American (13%) children. In 25% of charts, the ethnicity was listed as biracial,
Asian American or not stated. Nearly half of the children (47%) were examined within 72 hours of the episode of sexual
abuse.
Table 2
Criteria used to define if anal penetration was considered highly probable.
• The child in forensic interview or to physician has given a detailed and consistent description of anal penetration.
• The child, when questioned, has acknowledged anal abuse, and described painful defecation or bleeding following the incident.
• Perpetrator confessed to anal penetration.
• Anal penetration documented in photos or videos.
• Anal penetration witnessed by adult observer.
• Detection of anal gonorrhea or chlamydia.
• Finding of anal/rectal sperm.
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Table 3
Comparison of children (N = 1115) with anal penetration probable and not for different anal features. The sample consist of 941 girls (mean age 9.67 years)
and 174 boys (mean age 6.26 years). The denominator tells the number of children where the feature could be assessed. The statistical analysis is done
with Chi-square* or Fisher exact** tests. Level of significance is p < 0.05.
Anal feature Penetration probable (n = 198) Penetration not probable (n = 917) p
Erythema 25/198 (12.6%) 120/907 (13.2%) 0.820*

Venous pooling 70/198 (35.4%) 312/910 (34.3%) 0.774*
Soiling 48/198 (24.2%) 165/912 (18.1%) 0.046*
Anal warts 1/198 (0.5%) 29/911 (3.2%) 0.035*
Anal vesicles 0/198 (0%) 1/911 (0.1%) 1.000**
Anal tags 13/198 (6.6%) 54/911 (5.9%) 0.733*
Anal scar 0/197 (0%) 0/911 (0%)
Bruising 4/198 (2.0%) 10/908 (1.1%) 0.293**
Anal fissure 21/197 (10.7%) 25/908 (2.8%) 0.000*
Anal laceration 9/197 (4.6%) 3/908 (0.3%) 0.000**
External dilatation 30/198 (15.2%) 94/912 (10.3%) 0.050*
Total dilatation 24/198 (12.1%) 33/912 (3.6%) 0.000*
Assignment to penetration probable or not group
Based on information from the charts, anal penetration was considered probable in 198 (17.8%) of the children. In 155
(78%) of these children, the basis for this classification was a history with a detailed and consistent description of anal
penetration given by the child, or an acknowledgment by the child that anal abuse had occurred and a report given by the
child of anal pain, painful defecation or anal bleeding following the incident. For the rest, the classification of anal penetration
was done based on witness observation in 26 children, finding of sperm in the anal canal in 12, documentation that police had
recovered photographs showing the act of abuse in two cases, perpetrator confession in two and culture of anal gonorrhea
in one case.
Bivariate comparison of anal findings
In Table 3, a bivariate comparison of different anal features between children with anal penetration probable and not
was done. As seen, soiling and acute findings of fissures and lacerations were all significantly more common among children
with probable anal penetration. Anal warts were significantly more common among children with a low probability of anal
penetration. The mean age of children with anal warts was 5.7 years (range 1.4–17.9 years). This was significantly lower
than the mean age of children without warts, which was 9.2 years (range 0.2–18.8 years) (p < 0.004). The finding of total
anal dilatation was significantly associated with anal penetration (p = 0.000), while external anal dilatation showed a near
significant association (p = 0.050).
Logistic regression analysis
In order to control for being examined in the prone knee chest position (PKCP), a binary logistic regression analysis was
done for the anal features showing significance in the bivariate analysis (Table 4). Anal penetration and being examined
in PCKP were used as the two independent variables and the different anal features as the dependent variable. Based on
information from photos and charts, 195 examinations could be classified as having been performed in the PKCP. As shown,
soiling, anal fissures, lacerations and total anal dilatation continued to be significantly associated with anal penetration.
Interestingly, for total anal dilatation the odds ratio (OR) for being examined in PKCP is approximately twice the OR for
probable anal penetration (6.47 and 3.17 respectively).
Stratification analysis
As another way of controlling for confounding variables, stratified analyses were done for the following variables: being
examined in PKCP or not, Tanner I or Tanner > I, girls or boys, acute or non-acute examination and having anal symptoms
Table 4
Binary logistic regression analysis looking for associations between significant anal features from bivariate analysis and anal penetration and being examined
in prone knee chest position.
Anal feature Anal penetration OR (95% CI) PCKP OR (95% CI)
Soiling 1.49 (1.03–2.15) 0.74 (0.48–1.12)

Anal warts 0.14 (0.02–1.06) 1.93 (0.84–4.42)
Anal fissure 4.41 (2.40–8.09) 0.57 (0.24–1.40)
Anal laceration 13.68 (3.64–51.33) 1.80 (0.52–6.18)
External anal dilatation 1.40 (0.89–2.21) 2.85 (1.89–4.30)
Total anal dilatation 3.17 (1.79–5.63) 6.47 (3.70–11.29)
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Table 5
Stratification analysis for associations between total anal dilatation and anal penetration. The different strata are shown in the first column consisting of
being examined in PKCP or not, Tanner I or Tanner > I, girls or boys, acute or non-acute examination and having anal symptoms or not. The nominator is the
number with total anal dilatation present, and the denominator tells the number of children where this feature could be assessed. The statistical analysis
is done with Chi-square* or Fisher exact** tests. Anal symptom is the presence of one or more of the following: constipation, encopresis or diarrhea. Level
of significance is p < 0.05.
Total anal dilatation
Strata Penetration probable (n = 198) Penetration not probable (n = 917) p
Not PKCP 7/149 (4.7%) 18/767 (2.3%) 0.162**

In PKCP 17/49 (34.7%) 15/145 (10.3%) 0.000*
Tanner I 12/97 (12.4%) 24/533 (4.5%) 0.002*

Tanner > I 11/97 (11.3%) 7/367 (1.9%) 0.000**
Girls 20/134 (14.9%) 31/803 (3.9%) 0.000*

Boys 4/64 (6.2%) 2/109 (1.8%) 0.196**
Non-acute ex 14/78 (17.9%) 21/509 (4.1%) 0.000**

Acute ex 10/120 (8.3%) 12/397 (3.0%) 0.012*
No anal symptom 17/143 (11.9%) 19/706 (2.7%) 0.000*

Anal symptoms 6/49 (12.2%) 13/190 (6.8%) 0.236**
(constipation, encopresis and diarrhea) or not. In Table 5 the stratified analysis of total anal dilatation is shown, and this
feature was significantly associated with anal penetration for the following strata: children examined in PKCP, Tanner I,
Tanner > I, girls, non-acute examination, acute examination and children with no anal symptoms.
Table 6 is a summary table, showing the results from similar stratified analysis for each anal feature that showed significant
association with anal penetration in the bivariate analysis (Table 3). In the table, only the significant p values are provided.
For all features except anal warts, the association with anal penetration was positive.
In order to assess inter-rater agreement, the photos of 107 cases (9.7%) were reviewed by another physician on the team.
The results are shown in Table 7. Based on kappa statistics, the level of agreement for features like erythema and venous
pooling was fair and for most other features moderate. Interestingly, for total anal dilatation we achieved a 100% agreement,
with a kappa score of 1.000.
Illustrations of findings from the study are provided in Figs. 1–5. Permission to publish the photos has been given in all
cases.
Discussion
In this study of 1115 medical records of children evaluated for possible sexual abuse, anal penetration was considered
highly probable in nearly 18% of children, using predetermined criteria. As displayed in Tables 3–6, several anal features
were significantly associated with probable anal penetration.
The most interesting finding is the association between total anal dilatation and anal penetration, and the fact that
this association persisted after controlling for being examined in PKCP with binary logistic regression analysis. Different
stratification analysis revealed significant associations in a number of strata, among them children examined in the prone
knee position (Table 5).
Fig. 1. Perianal erythema illustrated by two children with streptococcus group A infections. The child in (a) had no history of sexual abuse, but in (b) a
history of digital penetration was given.
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Table 6
Summary table showing associations between different anal features and anal penetration with stratified analyses. Only significant p-values are displayed in figures. The statistical analysis is done with Chi-square1
or Fisher exact2 tests. NS: not significant. Level of significance is p < 0.05.
Strata
Feature No PKCP In PKCP Tanner I Tanner > I Girls Boys Non-acute Acute No anal Anal symptoms
(n = 920) (n = 195) (n = 631) (n = 464) (n = 941) (n = 174) (n = 590) (n = 517) symptoms (n = 239)
(n = 850)
Soiling NS NS p = 0.0321 NS NS NS NS NS p = 0.0071 NS

Warts NS NS p = 0.0141 NS NS p = 0.0272 NS NS NS NS
Fissures p = 0.0001 p = 0.0372 NS p = 0.0001 p = 0.0001 NS NS p = 0.0001 p = 0.0001 NS
Laceration p = 0.0002 NS NS p = 0.0002 p = 0.0002 p = 0.0492 NS p = 0.0002 p = 0.0002 NS
External p = 0.0051 NS NS NS NS NS NS NS NS p = 0.0491
dilatation
Total NS p = 0.0001 p = 0.0021 p = 0.0002 p = 0.0001 NS p = 0.0001 p = 0.0121 p = 0.0001 NS
dilatation
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Table 7
Measurement of inter-rater agreement in 107 cases. The column of concordant findings show that the two examiners agree whether a finding is present
or not (NN: not present from both, PP: present from both). In the column of discordant findings, the nominator express that first reviewer consider the
finding present and the second not (PN). The denominator express that first reviewer consider the finding not present and second present (NP). Kappa
values between 0.21–0.40 is considered fair, 0.41–0.60 moderate, 0.61–0.80 good and 0.81–1.00 very good.
Feature (n = 107) Concordant NN/PP Discordant PN/NP Kappa
Erythema 81/5 12/9 0.209

Venous pooling 57/18 24/8 0.328
Soiling 79/11 15/2 0.480
Anal warts 106/0 0/1 No statistic comp
Anal vesicle 106/0 0/1 No statistic comp
Anal taga 100/2 4/0 0.485
Anal scara 105/0 1/0 No statistic comp
Bruising 107/0 0/0 No statistic comp
Anal fissure 101/2 3/1 0.482
Anal laceration 104/1 2/2 0.493
External dilatation 102/2 1/2 0.557
Total dilatation 102/5 0/0 1.000
N: not present; P: present.

a
n = 106.
Fig. 2. Eleven year old girl showing midline anal fissure and total anal dilatation with stool that developed during the examination. She had a history of
several episodes of anal penetration and was examined non-acutely in prone knee chest position.
Fig. 3. (a) Anal laceration at 11 o’clock and midline tag at 12 in 15 year old girl. The girl was complaining of constipation, but no history of anal penetration
was given. (b) Anal laceration in a girl examined acutely. She was under the influence of alcohol and had no memory of what happened.
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Fig. 4. (a) Two year old constipated girl examined in supine knee chest position. A total anal dilatation with stool present was seen. No history of anal
penetration. (b) 15 year old boy examined acutely after multiple episodes of anal penetration. Except for soiling, no specific anatomical features were seen.
Syphilis serology was positive.
The possible causes of this finding were extensively discussed more than 20 years ago, with some authors suggesting this
to be caused by anal abuse (Hobbs & Wynne, 1986), some suggesting constipation (Clayden, 1988) and another that this was
within the spectrum of normal (McCann et al., 1989). Another study of anal findings in non-abused children demonstrated
an association between total dilatation and being examined in PKCP, and the feature was found to be a very rare finding in
non-abused children examined in the left lateral position (Myhre et al., 2001). In the latest published guidelines, the finding
of total anal dilatation of more than 2 cm, in the absence of pre-disposing factors, is interpreted as an indeterminate finding,
meaning that it is not possible to determine, from the presence of this finding alone, whether it is related to sexual abuse or
not (Adams, 2008; Royal College of Paediatrics and Child Health, 2008). Indeterminate findings are those finding for which
there is insufficient data from research studies, conflicting data, or for which there is a lack of consensus among experts as
to the significance of the finding with respect to sexual abuse.
Although we were not able to quantify the degree of anal dilatation in this retrospective chart review study, our data
suggests that total anal dilatation is potentially an important finding, but we think it is to early to upgrade the finding into
highly suggestive for anal abuse.
Significant associations between acute findings like fissures and lacerations and anal penetration can be explained by
trauma, and stratification analysis showed this to be present in acute cases (Table 6). Also in previous studies such association
has been demonstrated (Pierce, 2004). However, anal fissures can have several causes, like constipation, skin and gut diseases
as well as sexual abuse (Adams, 2008; Royal College of Paediatrics and Child Health, 2008). Soiling showed a weak but
Fig. 5. 17 year old boy examined acutely due to a history of anal penetration. A midline laceration (a) and discharge (b) were seen. Culture for gonorrhea
was positive.
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significant association with anal penetration (Table 3), this being present for Tanner I children and children without anal
symptoms (Table 6). In the literature, possible associations between abuse and gastrointestinal problems are discussed, with
conflicting conclusions (Drossman, 2011; Mellon, Whiteside, & Friedrich, 2006).
Another interesting finding is that anal warts were significantly associated with anal penetration not probable. In the
published guidelines anogenital warts are classified as an indeterminate finding with conflicting research data (Adams, 2008;
Royal College of Paediatrics and Child Health, 2008). A new multicenter study (Unger, Fajman, & Maloney, 2011) reported the
results of testing for Human Papilloma Virus (HPV) DNA in 517 children evaluated for possible sexual abuse, using both urine
and genital swabs. In this group of children, the prevalence of positive tests for HPV was 11.8%. For children without visible
genital warts, 52/503 children (10.7%) were positive for one or more types of HPV. The authors found that the presence of
genital warts, older age of the child, and evidence of child sexual abuse were independently associated with positive tests
for HPV, using an outdated classification system (Adams, 2001). There was a stronger association when the abuse was rated
as “Definite” and “Probable” than when it was classified as “Possible”. Most of the children in the “Probable” category gave
clear, consistent and detailed descriptions of being sexually abused and most of the children in the “Possible” category did
not give a clear history but had genital warts. Although not stated, it is likely that many of these children were pre-verbal.
Four modes of transmission of HPV have been proposed: vertical transmission, autoinoculation from non-genital warts,
innocent hetero-inoculation and sexual transmission. It is suggested that the warts are more likely to be sexually transmitted
in older children (Royal College of Paediatrics and Child Health, 2008; Unger et al., 2011). Looking at the stratification analysis
(Table 6), the association between anal warts and anal penetration not probable were significant for Tanner I children and
boys. Most of the children in our study who had warts were referred for examination because of the presence of anal warts
as the only reason for suspecting sexual abuse. Several of them were very young and without an ability to give a proper
history. Thus, the reason for our finding could be caused by a these children being classified in the “anal penetration not
probable” group due to not being able to tell if abuse actually had happened.
Limitations of the study
First, it was difficult to completely control for the factor of being examined in the prone, knee-chest position (PKCP). Due
to the retrospective design, we had to use information from photos and charts to categorize the examination methods. This
resulted in only 195 (17.5%) of cases being classified as examined in PKCP. From a general knowledge about examination
techniques at the referral center, we would have expected this figure to be higher, and probably the group of “no PKCP” is a
mixture of children examined with and without this technique.
Second, it is reasonable to assume that when a child or adolescent patient gave a history of anal penetration prior to the
examination, the examiner would be more likely to use the prone knee chest position to get a better look at the anal tissues.
Children without a disclosure of anal abuse would then be underrepresented in the population of patients who showed anal
dilatation due solely to being examined in the prone knee chest position.
Another limitation of the study is the lack of information about how long a given child had been in the prone knee
chest position. The form used to document examination findings only asked if the dilatation, if present, was “immediate”
or “delayed”. An earlier study showed an increasing rate of dilatation with increasing time spent in this position (McCann
et al., 1989), and changes in muscular tone and straightening of the anorectal angle have been hypothesized as possible
explanations for this phenomena (Myhre et al., 2001).
In our opinion, in order to properly explore the significance of total anal dilatation in children who may have been sexually
abused, a carefully designed prospective study is needed, so that standardized examination and recording techniques are
utilized.
Most of the limitations of this study are due to the retrospective and cross sectional design, making it prone to bias and
confounding factors. Further, such a design cannot be used to draw conclusions about causality (Bradford Hill, 1965). For
several anal features a low number of positive findings were seen, making the study prone to Type II errors of not being able
to demonstrate true associations. Also, the fact that children exposed to several abusive events were included once for each
episode could confound the findings.
In the study we have chosen to use conservative criteria for classification of the sexual abuse as anal penetration. As
a result, a number of children who had suffered penetration could have been misclassified into the no penetration group.
This phenomenon causes a “dilution” of the differences between the two groups, making it more difficult to demonstrate
statistically significant difference that might exist.
One strength of our study is the use of a blinded design when classifying anal features on photographs. We also had a
very high inter-rater agreement for the controversial finding of total anal dilatation.
Conclusion
In this study reviewing cases of 1115 children examined for a suspicion of sexual abuse, several anal features were found
to be significantly associated with anal penetration. For the controversial finding of total anal dilatation, such an association
was demonstrated, even after controlling for bias and confounding variables.
We recommend caution in interpreting the association of anal dilatation with anal penetration, due to limitations with the
study design. A carefully designed prospective study with standardized examination techniques and use of measurements is
ARTICLE IN PRESS
G Model
a necessary next step to determine whether total anal dilatation should be considered more than an indeterminate finding
in children examined for suspected sexual abuse.
References
Adams, J. A. (2001). Evolution of a classification scale: Medical evaluation of suspected child sexual abuse. Child Maltreateatment, 6(1), 31–36.
Adams, J. A. (2008). Guidelines for medical care of children eveluated for suspected sexual abuse: An update for 2008. Current Opinion in Obstetrics and
Gynecology, 20, 435–441.
Adams, J. A. (2011). Medical evaluation of suspected child sexual abuse: 2011 update. Journal of Child Sexual Abuse, 20(5), 588–605.
American Professional Society on the Abuse of Children. (1998). Glossary of terms and the interpretation of findings for child sexual abuse evidentiary
examinations. Available at www.apsac.org
Berenson, A. B., Chacko, M. R., Wiemann, C. M., Mishaw, C. O., Friedrich, W. N., & Grady, J. J. (2000). A case-control study of anatomic changes resulting from
sexual abuse. American Journal of Obstetrics & Gynecology, 182(4), 820–831, discussion 831–824
Berenson, A. B., & Grady, J. J. (2002). A longitudinal study of hymenal development from 3 to 9 years of age? Journal of Pediatrics, 140(5), 600–607.
Berenson, A. B., Heger, A. H., Hayes, J. M., Bailey, R. K., & Emans, S. J. (1992). Appearance of the hymen in prepubertal girls. Pediatrics, 89(3), 387–394.
Berenson, A. B., Somma-Garcia, A., & Barnett, S. (1993). Perianal findings in infants 18 months of age or younger. Pediatrics, 91, 838–840.
Bradford Hill, A. (1965). The environment and disease: Association or causation. Proceedings of the Royal Society of Medicine, 58, 295–300.
Clayden, G. S. (1988). Reflex anal dilatation associated with severe chronic constipation in children? Archives of Diseases of Children, 63(7), 832–836.
Drossman, D. A. (2011). Abuse, trauma, and GI illness: Is there a link? American Journal of Gastroenterology, 106(1), 14–25.
Heger, A., Ticson, L., Velasquez, O., & Bernier, R. (2002). Children referred for possible sexual abuse: Medical findings in 2384 children. Child Abuse & Neglect,
26(6–7), 645–659.
Heppenstall-Heger, A., McConnell, G., Ticson, L., Guerra, L., Lister, J., & Zaragoza, T. (2003). Healing patterns in anogenital injuries: A longitudinal study of
injuries associated with sexual abuse, accidental injuries, or genital surgery in the preadolescent child. Pediatrics, 112(4), 829–837.
Hobbs, C. J., & Osman, J. (2007). Genital injuries in boys and abuse. Archives of Diseases of Children, 92(4), 328–331.
Hobbs, C. J., & Wynne, J. M. (1986). Buggery in childhood – A common syndrome of child abuse? Lancet, 2(8510), 792–796.
McCann, J., Miyamoto, S., Boyle, C., & Rogers, K. (2007a). Healing of nonhymenal genital injuries in prepubertal and adolescent girls: A descriptive study.
Pediatrics, 120(5), 1000–1011.
McCann, J., Miyamoto, S., Boyle, C., & Rogers, K. (2007b). Healing of hymenal injuries in prepubertal and adolescent girls: A descriptive study. Pediatrics,
119(5), e1094–e1106.
McCann, J., Voris, J., & Simon, M. (1992). Genital injuries resulting from sexual abuse: A longitudinal study? Pediatrics, 89(2), 307–317.
McCann, J., Voris, J., Simon, M., & Wells, R. (1989). Perianal findings in prepubertal children selected for nonabuse: A descriptive study. Child Abuse & Neglect,
13, 179–193.
McCann, J., Wells, R., Simon, M., & Voris, J. (1990). Genital findings in prepubertal girls selected for nonabuse: A descriptive study? Pediatrics, 86(3), 428–439.
Mellon, M. W., Whiteside, S. P., & Friedrich, W. N. (2006). The relevance of fecal soiling as an indicator of child sexual abuse: A preliminary analysis. Journal
of Developmental & Behavioral Pediatrics, 27(1), 25–32.
Myhre, A. K., Berntzen, K., & Bratlid, D. (2001). Perianal anatomy in non-abused preschool children. Acta Paediatrica, 90(11), 1321–1328.
Myhre, A. K., Berntzen, K., & Bratlid, D. (2003). Genital anatomy in non-abused preschool girls? Acta Paediatrica, 92(12), 1453–1462.
Myhre, A. K., Myklestad, K., & Adams, J. A. (2010). Changes in genital anatomy and microbiology in girls between age 6 and age 12 years: A longitudinal
study. Journal of Pediatric & Adolescent Gynecology, 23, 77–85.
Pierce, A. M. (2004). Anal fissures and anal scars in anal abuse – Are they significant? Pediatric Surgery International, 20(5), 334–338.
Royal College of Paediatrics and Child Health. (2008). The physical signs of child sexual abuse. An evidence-based review and guidance for best practice. London:
Royal College of Paediatrics and Child Health.
Stoltenborgh, M., van Ijzendoorn, M. H., Euser, E. M., & Bakermans-Kranenburg, M. J. (2011). A global perspective on child sexual abuse: Meta-analysis of
prevalence around the world. Child Maltreatment, 16(2), 79–101.
Unger, E. R., Fajman, N. N., & Maloney, E. M. (2011). Anogenital Human Papillomavirus in sexually abused and nonabused children: A multicenter study.
Pediatrics, 128, e658–e665. http://dx.doi.org/10.1542/peds.2010-2247

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ARTICLE IN PRESS

Child Abuse & Neglect xxx (2013) xxx–xxx

Contents lists available at SciVerse ScienceDirect

Child Abuse & Neglect

Anal ﬁndings in children with and without probable anal

CHIABU-2562; No. of Pages 10

Purpose of the study

Review of complete medical record

CHIABU-2562; No. of Pages 10

Erythema: A general or local redness of tissue

Assignment of each case to group

Description of the study population

CHIABU-2562; No. of Pages 10

Anal feature Penetration probable (n = 198) Penetration not probable (n = 917) p

Erythema 25/198 (12.6%) 120/907 (13.2%) 0.820*

Assignment to penetration probable or not group

Bivariate comparison of anal ﬁndings

Logistic regression analysis

Anal feature Anal penetration OR (95% CI) PCKP OR (95% CI)

Soiling 1.49 (1.03–2.15) 0.74 (0.48–1.12)

CHIABU-2562; No. of Pages 10

Total anal dilatation

Strata Penetration probable (n = 198) Penetration not probable (n = 917) p

Not PKCP 7/149 (4.7%) 18/767 (2.3%) 0.162**

Tanner I 12/97 (12.4%) 24/533 (4.5%) 0.002*

Girls 20/134 (14.9%) 31/803 (3.9%) 0.000*

Non-acute ex 14/78 (17.9%) 21/509 (4.1%) 0.000**

No anal symptom 17/143 (11.9%) 19/706 (2.7%) 0.000*

CHIABU-2562; No. of Pages 10

Soiling NS NS p = 0.0321 NS NS NS NS NS p = 0.0071 NS

CHIABU-2562; No. of Pages 10

Feature (n = 107) Concordant NN/PP Discordant PN/NP Kappa

Erythema 81/5 12/9 0.209

N: not present; P: present.

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CHIABU-2562; No. of Pages 10

Limitations of the study

CHIABU-2562; No. of Pages 10

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