Original Study

Anogenital Findings in 3569 Pediatric Examinations for Sexual

Abuse/Assault
Tanya D. Smith NP-Paediatrics, MN 1,2,*, Sudha R. Raman PhD 3, Sheri Madigan PhD 2,4,
Judy Waldman MN 2, Michelle Shouldice MD 1,2
1
The Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
2
The Suspected Child Abuse and Neglect Program, The Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
3
The Department of Population Health Sciences, Duke University, Durham, North Carolina
4
The Department of Psychology, University of Calgary, and Alberta Children's Hospital, Calgary, Alberta, Canada

a b s t r a c t
Study Objective: Accurate interpretation of anogenital examination findings in the context of suspected child and adolescent sexual abuse/
assault is essential, because misinterpretation has significant child protection and criminal justice implications. A consensus approach to
the interpretation of anogenital examination findings is widely used to support accurate diagnosis; however, a large-scale study using this
standardized approach is lacking. The objectives of this study were to: (1) determine the proportion of anogenital examinations for sexual
abuse concerns with findings diagnostic of trauma and/or sexual contact; (2) determine whether frequency of diagnostic findings varies
according to age, gender, and timing of examination; and (3) characterize diagnostic findings.
Design, Setting, Participants, Interventions, and Main Outcome Measures: Retrospective records of children aged 0-18 years evaluated for
sexual abuse/assault were reviewed. Case details of 3569 patients were extracted and anogenital examination findings were reinterpreted
using a published consensus approach.
Results: Anogenital examination findings diagnostic of trauma and/or sexual contact were present in 173 of 3569 patients (4.8%). The
prevalence of diagnostic findings was significantly higher in adolescents than in children younger than 12 years of age (13.9%, 114/823 vs
2.2%, 59/2657), in female vs male patients (5.7%, 164/2866 vs 1.5%, 9/614), and in examinations within 72 hours for children younger than
12 years (14.2%, 91/643 vs 4.5%, 45/997). Acute injuries were the most common type of diagnostic finding.
Conclusion: Diagnostic findings are present in a small proportion of children and adolescents examined for suspected sexual abuse/assault.
It is essential that practitioners who interpret examination findings be adequately trained and familiar with the current consensus
approach and are aware of case characteristics associated with higher likelihood of findings.
Key Words: Child sexual abuse, Examination findings, Sexual abuse diagnostic findings

Introduction comprehensive empirical documentation of the proportion

The medical assessment of children and adolescents who
might have been sexually abused/assaulted has important
clinical and legal implications. Accurate interpretation of
anogenital examination findings in this context is essential,
because misinterpretation might directly contribute to child
protection and criminal justice outcomes. Therefore, a
standardized, accurate, and evidence-based approach to
diagnostic evaluation is essential.
Adams et al1 examined the available literature and
applied a process of expert consensus review to formulate a
standardized approach to the interpretation of anogenital
examination findings in the context of pediatric sexual
abuse/assault. This rigorous approach has since been regu-
larly updated to facilitate consistent, evidence-based prac-
tice for clinicians.1e5 Although this consensus approach was
developed by experts and is recommended to guide the
practitioner on the interpretation of findings,6 a
The authors indicate no conflicts of interest.
* Address correspondence to: Tanya D. Smith, NP-Paediatrics, MN, The Suspected
Child Abuse and Neglect Program, The Hospital for Sick Children, 555 University
Ave, Toronto, Ontario M5G 1X8, Canada; Phone (416) 813-6275
E-mail address: tanya.smith@sickkids.ca (T.D. Smith).
1083-3188/$ - see front matter Ó 2017 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc.
https://doi.org/10.1016/j.jpag.2017.10.006
of examinations that result in diagnostic findings using this
consensus approach has not been published.
This study capitalizes on a large sample size (N 5 3569)
and a wide age range (0-18 years) to achieve the following
objectives: (1) to determine the proportion of diagnostic
findings of trauma and/or sexual contact resulting from
anogenital examinations for sexual abuse/assault concerns;
(2) to determine whether frequency of diagnostic findings
varies according to child age, gender, and time of exami-
nation; and (3) to characterize the diagnostic findings.
Materials and Methods
A retrospective chart review was conducted of medical
records of children and adolescents evaluated in the Sus-
pected Child Abuse and Neglect Program Outpatient Clinic
and Emergency Department for suspected sexual abuse/
assault between 1995 and 2008. The Research Ethics Board
at the Hospital for Sick Children approved this study.
The Suspected Child Abuse and Neglect Program at the
Hospital for Sick Children provides medical assessments for
approximately 300 child and adolescent victims of sus-
pected acute or historical sexual abuse/assault annually.
80 T.D. Smith et al. / J Pediatr Adolesc Gynecol 31 (2018) 79e83
Standard medical examinations, conducted by nurse prac-
titioners, pediatric sexual assault nurse examiners, or pe-
diatricians, include a medical history, physical examination
including anogenital examination with colposcope, docu-
mentation of findings in writing, and by photographs and/
or video recording. Patients were routinely examined in the
supine position on the examining table. If younger children
could not be examined on the examining table, they were
examined in a semiseated, frog-legged position on the
parent's lap. Throughout this time period, there was a
standard approach to documentation of anogenital exami-
nation findings. Photo documentation was routinely
completed and cases were peer-reviewed. All providers
received training in pediatric sexual assault examinations,
regularly participated in continuing education, and regu-
larly reviewed the literature to maintain expertise.
The study group included all patients younger than the
age of 18 years assessed for suspected sexual abuse/assault
who had documented anogenital examinations. Initial
examinations only were included (ie. no follow-up or sec-
ondary exams were included). Exclusion criteria included
children/adolescents who did not have a genital examina-
tion and/or whose records were not found.
Child age and gender were extracted from each record.
Examination findings, as documented in the medical health
record, were extracted and then classified according to the
“Approach to Interpreting Physical and Laboratory Findings
in Suspected Child Sexual Abuse: December 2007”1 into 3
major categories (normal, indeterminate, or diagnostic).
According to this approach, normal findings include normal
anatomic variants and findings commonly caused by med-
ical conditions. The indeterminate category includes find-
ings with insufficient or conflicting data from research
studies to be clearly categorized as normal or diagnostic.
Diagnostic findings include injuries, infection, pregnancy,
and presence of sperm. When examinations included
findings in more than 1 category, the most diagnostic
category was applied. For example, examinations with
findings diagnostic of trauma and/or sexual contact, as well
as indeterminate or normal findings, were categorized as
diagnostic findings. Medical records with ambiguous or
unclear documentation, and all cases in which findings
diagnostic for trauma and/or sexual contact were docu-
mented, were reviewed independently by 2 research team
clinicians (M.S., T.D.S.) for accuracy, including review of the
written documentation and photo documentation.
Statistical Analyses
Data analysis was performed using SPSS (version 21.0;
IBM Corp). Sample characteristics were described using
frequencies and proportions for categorical variables. Ano-
genital examination diagnostic findings that were deemed
to be not due to accidental or consensual cause were
collated overall and according to subtype of diagnostic
finding. To examine any differences in the proportion of
diagnostic findings according to age and gender, children
(0-11.99 years of age) were compared with adolescents (12-
18 years of age), and male were compared with female
patients using unadjusted odds ratios (ORs) and 95% con-
fidence intervals (CIs).
Results
Study Population
A total of 4987 patient encounters were reviewed, 1418
were excluded, yielding a study sample of 3569 patients.
Primary reasons for exclusion were that an examination
was not completed (due to patient distress, parental
distress, or exam not warranted/necessary), or the medical
record could not be found.
Of the study population of 3569, 2948 (82.6%) were fe-
male and 2749 (76.9%) were younger than 12 years old at
the time of the examination. Reasons for referral for clinical
assessment (more than 1 possible per patient) included: (1)
concerns of sexual abuse (n 5 2758); (2) medical concerns
(such as vaginal bleeding; n 5 815); and (3) sexualized
behaviors (n 5 190).
Anogenital Examination Findings
Anogenital examination findings diagnostic of trauma/
sexual contact were documented in 173 of 3569 patients
(4.8%; Table 1). In addition, 0.9% (n 5 33) of examinations
included findings diagnostic of trauma that were due to
accidental causes, such as household or playground falls
(Table 1). Indeterminate findings were present in 6.9% (247/
3569) of examinations (Table 2). In total, 87.3% (3118/3569)
of examination results were normal, including normal var-
iants and findings commonly caused by other medical
conditions (erythema, increased vascularity, labial adhe-
sion, etc).
Association Between Diagnostic Anogenital Exam Findings and Child
Characteristics
Adolescents 12-18 years of age had a higher proportion
of examination findings diagnostic of trauma and/or sexual
contact (13.9%, 114/823) compared with children younger
than 12 years of age (2.2%, 59/2657; OR, 7.1; 95% CI, 5.1-9.8;
Table 3). Diagnostic findings were also significantly more
common in female (5.7%, 164/2866) compared with male
(1.5%, 9/614) patients (OR, 4.1; 95% CI, 2.1-8.0).
Association Between Diagnostic Anogenital Exam Findings and
Timing of Examination
Diagnostic findings occurred significantly more often when
children or adolescents were seen within 72 hours of the
Table 1
Anogenital Exam Findings Among 3569 Examinations
Category* Exam Findings,
n (%)
Normal/findings documented in newborns/nonabused children 3118 (87.4)
Indeterminate findings 247 (6.9)
Findings diagnostic of trauma due to accidental causes 33 (0.9)
Findings diagnostic of trauma and/or sexual contact 173 (4.8)
* Categories are mutually exclusive.
 T.D. Smith et al. / J Pediatr Adolesc Gynecol 31 (2018) 79e83 81

Table 2 Table 4
Subcategories of Indeterminate Findings Subcategories of Findings Diagnostic of Trauma and/or Sexual Contact (Excluding
Accidental Injuries)
Subcategory of Indeterminate findings* n
Sub-category of Findings Diagnostic of Trauma and/or Sexual contact* n
Deep notches/clefts in the posterior/inferior rim of hymen 30
(O50% of width of hymen) in contrast to transection Acute trauma to external tissue (lacerations/bruising 71
Deep notches/complete clefts in the hymen at the 20 to external anogenital tissue: labia, penis, scrotum,
3 or 9 o'clock position in adolescent girls perianal tissues, posterior fourchette)
Smooth, noninterrupted rim of hymen between 4 and 8 o'clock, 5 Residual (healing) injuries (perianal scar, scar of 1
which appears to be less than 1 mm wide, when examined posterior fourchette or fossa)
in the prone knee-chest position Injuries indicative of blunt force penetrating trauma 119
Wart like lesions in the genital/anal area 70 (lacerations/bruising to the hymen [n 5 91],
Vesicular lesions/ulcers in the genital/anal area 28 perianal laceration [n 5 3], hymenal transection
Marked anal dilation to a diameter of $2 cm, in the 2 [n 5 24], missing segment of hymenal tissue [n 5 1])
absence of other predisposing factors Presence of infection (positive test for gonorrhea, 40
Genital or anal condyloma accuminata 94 chlamydia, trichomonas, syphilis, or HIV)
Herpes type 1 or 2 in genital/anal area with 15 Sperm (identified in specimens taken directly 1
no other indicators of sexual abuse from child's body)
Confirmed Pregnancy 7
* Total N 5 247; categories are not mutually exclusive.
Other (female genital mutilation) 11

* Total N 5 173; categories are not mutually exclusive.

assault (14.2%, 91/643), compared with more than 72 hours

since the assault (4.5%, 45/997; OR, 3.0; 95% CI, 2.1-4.3). findings, and assign a diagnosis accordingly.11e14 In addi-
tion, with advancing knowledge and understanding, inter-
Characterization of Diagnostic Findings pretation of specific findings has evolved. Specifically, very
early studies published before 2000, considered hymenal
Among the 173 children with diagnostic findings, the diameter (a finding previously interpreted as related to
most common types were: (1) injuries indicative of blunt sexual abuse and now known to range widely in nonabused
force penetrating trauma, such as lacerations and/or children), scarring, abrasions, condyloma, and hymenal
ecchymosis of the hymen, perianal lacerations, and healed asymmetry as diagnostic findings, and reported a rate of
hymenal transections; and (2) acute trauma to external diagnostic findings as high as 84%.9,11,12,15e18 These are
genital/anal tissues, including lacerations or extensive findings that would currently be classified as indetermi-
bruising of the labia, penis, scrotum, perianal tissues or nate/lacking expert consensus, or findings commonly
perineum, or fresh laceration of the posterior fourchette caused by other medical conditions2 (ie, not specific for
(Table 4). sexual abuse).
Our diagnostic rate of 4.8% is similar to other studies that
Discussion used early iterations of the evidence-based consensus
approach of Adams et al1 to the categorization of genital
This study provides a description of examination find- examination findings.7e10 Unique to the current study,
ings in a large patient sample of children and adolescents however, is its large sample size and a wide age range, and
with suspected sexual abuse/assault, interpreted using a the application of the comprehensive approach of Adams
standardized, evidence-based approach.1 In this study, 4.8% et al1 to interpretation of exam findings. Previous research,
(173/3569) of examinations of children and adolescents for on a sample of 2384 children that applied an early form of
sexual abuse/assault concerns yielded “positive” findings the Adams classification system in 2001, reported abnormal
that were diagnostic for trauma and/or sexual contact findings among 4% of children referred for diagnostic
(excluding accidental trauma). Over the past 35 years, re- evaluation.10 Kelly et al8 used an approach described as
ported rates of diagnostic findings have varied widely in the “broadly concurrent with” Adams’ classification system
literature, ranging from 2.5%-82%.7e11 The rate of 4.8% in from 200119 and reported a rate of diagnostic findings of 6%
this study is expectedly lower compared with previous in 2134 examinations.
research that relied exclusively on health professionals’ An important contribution of the current study was the
individual clinical judgement to interpret the significance of examination of whether diagnostic findings varied accord-
ing to age, gender, and timing of examination. The impli-
Table 3 cations of these findings for clinical decision-making are
Diagnostic Findings According Patient Characteristics: Age and Gender significant. First, we found that adolescents 12-18 years of
Characteristic N Diagnostic Findings, n (%) OR (95% CI) age were 7 times more likely than children younger than
Child age the age of 12 to have findings diagnostic of sexual abuse/
Younger than 12 2657 59 (2.2) 7.1 (5.1-9.8)* assault. This finding is similar with results reported by Kelly
12 or older 823 114 (13.9) Reference
Gender
et al, who reported a significantly greater likelihood of
Male 614 9 (1.5) 4.1 (2.1-8.0)* diagnostic findings in children older than 10 years of age
Female 2866 164 (5.7) Reference compared with children younger than 10 years of age.8 The
Time to examination
More than 72 hours 997 45 (4.5) 3.0 (2.1-4.3)*
findings of differential results according to child age are not
Less than 72 hours 643 91 (14.2) Reference unexpected for clinicians, because adolescents more
CI, confidence interval; OR, odds ratio. frequently present to sexual assault clinics or Emergency
* P ! .001. Departments for acute penetrative sexual assault, whereas
82 T.D. Smith et al. / J Pediatr Adolesc Gynecol 31 (2018) 79e83
younger children frequently present with delayed disclo-
sure and the nature of abuse that typically is nonviolent
such as touching and/or fondling of the genitals,10,20 acts
that are less likely to result in tissue injury.20e25 Previous
studies describe that up to 68% of genital injury in sexual
assault cases were caused by entry injuries, insertion, or
attempts at insertion of the penis into the vagina,26 which
are more common in adolescents vs children.
Diagnostic findings also differed significantly according
to gender, with female patients being 4 times more likely to
have diagnostic examination findings compared with their
male counterparts. Comparable results were reported by
Heger et al,27 who found that reported penetration was
associated with a higher percentage of abnormal findings in
girls (6%) than in boys (1%). Similarly, Kelly et al8 reported
that more female than male patients (5.9% vs 1%) had exam
findings diagnostic of sexual abuse/assault. These findings
likely reflect the observation that anal penetration typically
results in few to no physical findings, because tissues in the
anus have an intrinsic ability to stretch.20,28e30 In the Hobbs
and Osman study, many injuries remained unexplained
because boys might be more reluctant to disclose abuse.31
Patients seen for an examination within 72 hours of the
assault were 3 times more likely to have diagnostic findings
compared with patients seen 72 hours or more after the
assault. This finding is consistent with those of Adams
et al,17 who also reported a higher incidence of genital in-
juries in female victims examined within 72 hours of the
last assault. Using a longer time frame of within 7 days of
the assault, Watkeys et al32 reported that 50% of patients
seen within 7 days had diagnostic findings compared with
31% seen at more than 7 days. The higher incidence of
diagnostic findings in patients seen soon after the assault is
likely related to the rapid healing of genital mucosal in-
juries. McCann et al24,25 examined healing of hymenal and
nonhymenal genital injuries, and reported that female
genital injuries heal rapidly and leave minimal evidence of
the trauma. Taken together, it is critical that children and
adolescents are seen for anogenital examinations as soon as
possible after a sexual assault event.
Most diagnostic findings were those indicative of blunt
penetrating trauma (laceration and bruising of hymen),
which were more common in our study than healed injuries,
infections, or acute trauma to the external anogenital tissues
(laceration and bruising). This finding highlights the
importance of timing in the detection of genital injuries and
the need for acute examinations when the potential abusive
events are first reported, particularly when genital pene-
tration is described. Our results are aligned with existing
literature that has shown that many types of genital injuries
(lacerations, ecchymosis, abrasions, contusions) heal quickly
and/or completely, without residual scarring,20e24,28 high-
lighting the clinical and forensic importance of conducting
anogenital examinations within 72 hours after the assault.26
The frequency of anal findings, in particular anal lacera-
tions, in our study was 0.08% compared with that in the of
Myhre et al,33 of 0.3% among children without probable anal
penetration and 4.6% among children in whom anal pene-
tration was probable. These results might reflect differences
in the time of examination in the study of Myhre et al, in
which 47% of children were examined within 72 hours
compared with 18% in our study. In addition, anal pene-
tration was reported in 6.2% of cases in our study compared
with 17.8% in the study of Myhre et al. Differences in the
timing of the examination and reported anal contact would
explain why our estimates are less than results reported by
Myhre et al even in a population for whom anal penetration
was believed to not be probable. Conducting anogenital
examinations within 72 hours after the assault is impor-
tant.26,34 The finding of 2 cases of anal dilation is interesting
to note compared with a recent study by Myhre et al,33 who
reported a 5% rate in girls who were examined in the prone
knee-chest position. Patients in our study were routinely
examined in the supine position, which might account for
the difference in our anal findings and those published by
Myhre et al.
The results of this study should be considered in the
context of the following limitations. The Adams et al1
approach to the interpretation of findings was applied in
this study, and has been since updated to reflect the
evolving literature and expert consensus.2 Most of the
changes made in the most recent version of this approach
are within-category refining of terminology and reorgani-
zation of specific injury types, and would not have influ-
enced the diagnostic category assigned in our study. One
noteworthy change in category involves the definition of
healed hymenal transection in the diagnostic category,
which was changed from “to or nearly to the base of the
hymen” to “all the way through the base of the hymen.” It is
possible that application of this change in definition could
result in cases of healed hymenal transection being reas-
signed from diagnostic to indeterminate (updated to “no
expert consensus”) in our study. Twenty-two cases had
“healed hymenal transection,” unfortunately, we were un-
able to further distinguish “to or nearly to the base of the
hymen” vs “all the way through the hymen.” This study is
also limited by the retrospective nature of the data review,
in which written documentation of physical examination
findings were extracted, as recorded by individual clinicians
in the patient chart, and the current consensus approach
applied to the interpretation of the examination findings.
For the purposes of this study, examination findings were
confirmed with photo documentation only in cases with
diagnostic findings. Although this ensured accuracy of the
examinations classified as diagnostic, there is the potential
that examinations without findings were misclassified.
Through the time span of the chart review period, 2 expe-
rienced senior clinical staff (a nurse practitioner and a
pediatrician) were consistently involved in training and
peer-review sessions to create uniformity in the approach
to diagnostic examination, and examination photo docu-
mentation was routinely peer-reviewed, minimizing op-
portunities for inaccuracy.
Conclusions
In this study we applied a published evidence-based
consensus approach to the interpretation of medical find-
ings in sexual abuse examinations among the largest stud-
ied population to date of children and adolescents referred
 T.D. Smith et al. / J Pediatr Adolesc Gynecol 31 (2018) 79e83
for suspected sexual abuse/assault, and confirmed that less
than 5% of examinations result in findings diagnostic of
trauma and/or sexual contact. Diagnostic findings are rela-
tively uncommon, especially among children younger than
12 years of age, and in male children and adolescents.
Despite changes in diagnostic categories with evolving
medical knowledge, the prevalence of diagnostic findings in
children and adolescents is consistent with past studies and
continues to support the importance of not relying on
medical findings to confirm or refute sexual abuse allega-
tions, and of the need for timely examination of all children
especially female children and adolescents with sexual
abuse/assault concerns.
Acknowledgments
The authors thank Karla Wentzel and Amelia Sloan for
their assistance with data collection on this study.
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