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Medical Evaluation of
Medical Evaluation of Child Sexual Abuse A PRACTICAL GUIDE

Medical Evaluation of
Child Sexual Abuse
A PRACTICAL GUIDE 4th Edition
Child Sexual Abuse
A PRACTICAL GUIDE 4th Edition
Editors: Martin A. Finkel, DO, FACOP, FAAP,
and Angelo P. Giardino, MD, PhD, MPH, FAAP
The fourth edition of this best-selling reference is a valuable resource to

clinicians and child advocates serving children and families affected by
suspicions of child sexual abuse.
Fully updated and revised by leading experts on child abuse, this resource
covers what a complete and comprehensive medical evaluation entails,
when to seek an examination, the importance of conducting a medical
history, how discrepancies between a child’s history and physical findings
can be explained, how the child’s medical record should be structured,
what types of documentation should be expected, and how a medical
4th Edition
diagnosis is formulated.
NEW TOPICS INCLUDE

• Telemedicine and the child sexual abuse medical evaluation
• Human trafficking
• International issues in child sexual abuse
• Enhanced focus on findings that mimic sexual abuse and on
developmental considerations
Medical Evaluation of Child Sexual Abuse is an invaluable resource for

medical professionals, child protection workers, mental health clinicians,
investigators, and the courts.
For other pediatric resources, visit the American Academy of Pediatrics

Giardino
Finkel
at shop.aap.org.
ISBN 978-1-61002-295-8
Martin A. Finkel, DO, FACOP, FAAP
90000>
Angelo P. Giardino, MD, PhD, MPH, FAAP
AAP
9 781610 022958
Medical Evaluation
of
Child Sexual Abuse
A Practical Guide
4th Edition
Edited By
Child Abuse Research Education and Service Institute
School of Osteopathic Medicine
Rowan University
Stratford, NJ

University of Utah School of Medicine
Intermountain Primary Children’s Hospital
Salt Lake City, UT
American Academy of Pediatrics

345 Park Blvd
Itasca, IL 60143
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and well-being of infants, children, adolescents, and young adults.
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contributors are expert authorities in the field of pediatrics. No commercial involvement of any kind
has been solicited or accepted in the development of the content of this publication. Disclosures: Drs
Christian and Melville disclosed that they provide expert testimony in child abuse cases.
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ISBN: 978-1-61002-295-8
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Cover design by Linda Diamond
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About the Editors

Dr Finkel is a professor of pediatrics and the medical director and cofounder
of the Child Abuse Research Education and Service (CARES) Institute at the
Rowan University School of Osteopathic Medicine. The CARES Institute is a
statewide resource to inform best practices in the delivery of medical and
mental health diagnostic and treatment services. Dr Finkel is an internationally
recognized authority on the medical evaluation and treatment of children who
have been alleged to have been sexually abused. Dr Finkel has been instrumen-
tal in developing the New Jersey statewide network of regional child abuse
diagnostic and treatment centers. These centers of excellence provide services
for children who have been sexually and physically abused and educate profes-
sionals within the medical, child protection, law enforcement, and mental
health communities on the evaluation of children who have been victimized.
He has been a pioneer in the use of video colposcopy for the assessment and
documentation of residua from sexual abuse. In the medical literature, he is the
author of the first scientific paper published on the healing and interpretation
of acute genital and anal trauma and the first paper on signs and symptoms
associated with genital contact in girls. He has published numerous articles,
authored chapters, and coedited 3 previous editions of Medical Evaluation of
Child Sexual Abuse: A Practical Guide.
Dr Finkel was appointed by 9 governors to cochair, with the commissioner
of the Department of Children and Families, the New Jersey Task Force on
Child Abuse and Neglect and 2 governor blue ribbon panels to review child
protection practices. He is a founding commissioner of the New Jersey
Children’s Trust Fund to prevent child abuse. Dr Finkel has been on the
National Board of the American Professional Society on the Abuse of Children
(APSAC), where he had oversight for the development of national standards
regarding medical terminology and the interpretation of medical findings. He
is a founding member of the Ray E. Helfer Society, the American Academy of
Pediatrics Section on Child Abuse and Neglect, and the APSAC. He served a
6-year term on the National Board of Prevent Child Abuse America. He is
former president of the American College of Osteopathic Pediatricians.
Dr Finkel is a member of the Executive Committee and Council of the
International Society for the Prevention of Child Abuse and Neglect.
In 2012, he received the Ray E. Helfer Society lifetime achievement award
and the US Department of Health and Human Services, Administration
for Children and Families, commissioner award. In 2016, he received the
Leonard Tow Humanism in Medicine Award presented by the Arnold P.
Gold Foundation.
iv
About the Editors

Dr Giardino is the Wilma T. Gibson Professor and chair of pediatrics at
the University of Utah School of Medicine and chief medical officer at
Intermountain Primary Children’s Hospital in Salt Lake City, UT. Immediately
before this, Dr Giardino had been professor and section chief of academic gen-
eral pediatrics at Baylor College of Medicine and senior vice president and chief
quality officer at Texas Children’s Hospital in Houston, TX. While there, he
served on the hospital Child Protection Team and helped staff the local child
advocacy center. Dr Giardino earned his doctorates of medicine and philoso-
phy at the University of Pennsylvania and his master of public health from the
University of Massachusetts. Dr Giardino completed his pediatric residency
and child maltreatment fellowship training at the Children’s Hospital of
Philadelphia (CHOP) and also completed training in secondary data analysis
related to child maltreatment through the National Data Archive on Child
Abuse and Neglect Summer Research Institute at Cornell University.
Dr Giardino’s clinical work focuses on child maltreatment, and in 1995,
he collaborated with a multidisciplinary team to develop and lead the Abuse
Referral Center for Children with Special Health Care Needs at the Children’s
Seashore House, which was funded by a 3-year grant from a local philanthropy
in Philadelphia. This program was designed to provide medical evaluations of
children with developmental disabilities who were suspected of having been
abused or neglected. In 1998, he was appointed associate chair for clinical
operations in the Department of Pediatrics at CHOP and also served with the
hospital child abuse evaluation service. In 2002, Dr Giardino joined the
Department of Pediatrics at Drexel University College of Medicine as the asso-
ciate chair for clinical affairs and was appointed associate physician in chief at
St. Christopher’s Hospital for Children, where he also served as the medical
director for the hospital Suspected Child Abuse and Neglect Program. This
program collaborated with the Institute for Safe Families and Lutheran
Settlement House to secure a Pennsylvania Children’s Trust Fund grant, which
supported a community-based Intimate Partner Violence Screening Program
at St. Christopher’s aimed at identifying at-risk families and working to prevent
child maltreatment. In addition, while at St. Christopher’s, Dr Giardino collab-
orated with colleagues at the Drexel University School of Public Health to
launch the Philadelphia Grow Project, which provided clinical care to children
with the diagnosis of failure to thrive and also conducted policy research on the
issues surrounding food insecurity and childhood hunger.
Dr Giardino is board-certified in pediatrics and is a fellow of the American
Academy of Pediatrics. His academic accomplishments include published arti-
cles and textbooks on child abuse and neglect, contributions to several national
curricula on the evaluation of child maltreatment, presentations on a variety
of pediatric topics at both national conferences and regional conferences. Most
recently, he completed 2 terms on the National Review Board (NRB) for the
v
About the Editors
US Conference of Catholic Bishops, providing advice on how best to protect

children from sexual abuse. While on the NRB, Dr Giardino served as the
chair for its Research Committee. Currently, Dr Giardino serves on the
national boards of directors for Prevent Child Abuse America and the US
Center for SafeSport.
About the Contributors
Alexander Butchart, PhD

Dr Butchart is the prevention of violence coordinator in the Department for
Management of Noncommunicable Diseases, Disability, Violence and Injury
Prevention at the World Health Organization (WHO) in Geneva, Switzerland.
His responsibilities include coordinating the Global Campaign for Violence
Prevention, the development of policy for the prevention of interpersonal
violence, preparation of guidelines for the prevention of specific types of inter-
personal violence, and the coordination of research into various aspects of
interpersonal violence and its prevention. His postgraduate training includes
a master’s degree in clinical psychology and neuropsychology and a doctoral
degree for work examining the history and sociology of Western medicine and
public health in southern Africa. Before joining WHO, he worked mainly in
southern and East Africa, where he was lead scientist in the South African
Violence and Injury Surveillance Consortium, and in collaboration with
the Uganda-based Injury Prevention Initiative for Africa, he participated in
training violence and injury prevention workers from a number of African
countries. He has been a visiting scientist at the Swedish Karolinska Institutet
Division of Social Medicine and is a widely published social scientist.
Cindy W. Christian, MD, FAAP

Dr Christian holds the Anthony A. Latini Endowed Chair in the Prevention
of Child Abuse and Neglect at the Children’s Hospital of Philadelphia (CHOP).
She is a professor of pediatrics at the Perelman School of Medicine at the
University of Pennsylvania and serves as associate dean of admissions at the
Perelman School of Medicine. Dr Christian completed her pediatric residency
and child abuse pediatrics fellowship at CHOP, where she has spent her career.
For more than 2 decades, she directed the child protection program at CHOP.
She is a faculty director of the Field Center for Children’s Policy, Practice and
Research at the University of Pennsylvania. Dr Christian is a past chair of the
American Academy of Pediatrics Committee on Child Abuse and Neglect and
past chair of the Subboard of Child Abuse Pediatrics for the American Board
of Pediatrics. From 2010 to 2015, Dr Christian served as the first medical direc-
tor for the Philadelphia Department of Human Services, leading the develop-
ment of policies and strategies to improve the health of dependent children
in Philadelphia.
Rachel A. Clingenpeel, MD, FAAP

Dr Clingenpeel received her bachelor of science from Duke University in 1998
in psychology and biology with a certificate in neuroscience. She then com-
pleted a 2-year postbaccalaureate research program at the National Institutes of
Health before attending medical school at the University of Virginia, from
viii
which she graduated in 2004. She completed her pediatric residency training
and chief residency at Tulane University in New Orleans and fellowship in
child abuse pediatrics at Brown University in Providence, RI. Dr Clingenpeel
joined the faculty at University of Arkansas for Medical Sciences (UAMS)
in fall 2012. She now serves as assistant professor of pediatrics at UAMS, as
well as associate director for the Team for Children at Risk at Arkansas
Children’s Hospital.
Dr Clingenpeel’s practice as a child abuse pediatrician includes duties such
as inpatient and outpatient evaluation of suspected child abuse and neglect,
medical directorship of the new Emergency Department Sexual Assault
Response Team, and education of other health care professionals as well as
community partners regarding all aspects of child abuse and neglect.
Sharon W. Cooper, MD
Dr Cooper is a developmental and forensic pediatrician who cares for children
and select adults with different abilities as well as those who have been victims
of maltreatment. Dr Cooper retired from the US Army with the rank of colonel
and holds adjunct faculty positions at the University of North Carolina at Chapel
Hill School of Medicine and the Uniformed Services University of Health
Sciences in Bethesda, MD. She has provided numerous lectures to medical, nurs-
ing, mental health, judicial, social science, and investigative agencies, including
the National Judicial College, the Federal Bureau of Investigation, the Australian
Federal Police, and INTERPOL. Her primary areas of expertise include all areas
of child maltreatment, child torture, and child sexual exploitation.
Dr Cooper has published numerous chapters on the subject of child sexual
exploitation and is the lead editor of one of the most comprehensive texts in the
United States on this subject. She works with victims and families of children
who have been the prey of all types of online and off-line exploitation. She is a
board member of and consultant to the National Center for Missing and
Exploited Children and has taught several thousand special victim unit and
vice investigators for over a decade, on the victim vulnerability, health impact,
and diverse forms of exploitation in sex trafficking.
Dr Cooper has served as an expert witness in several hundred cases of child
maltreatment and numerous cases within the past several years on behalf of
victims of sex trafficking. Dr Cooper served as a task force member for the US
attorney general on Defending Childhood, Children Exposed to Violence; was
an invited speaker to the White House Summit on the United State of Women;
and recently presented at the World Congress on Child Dignity in the Digital
World, sponsored by the Vatican. She has provided testimony before the US
Congress, the Italian Senate, the Russian Parliament (Duma), and the Ottawa
House of Commons on child sexual exploitation.
ix
Esther Deblinger, PhD, CPC-CBT

Dr Deblinger is cofounder and codirector of the Child Abuse Research
Education and Service Institute and a professor of psychiatry and psychology at
Rowan University School of Osteopathic Medicine. Her clinical research on the
impact and treatment of child sexual abuse and other childhood traumas has
been supported by funds from the National Center of Child Abuse and Neglect,
the National Institute of Mental Health, and the Rowan University Foundation.
In collaboration with Judith A. Cohen, MD, and Anthony P. Mannarino, PhD,
she developed and extensively tested Trauma-Focused Cognitive Behavioral
Therapy, a treatment approach that has evolved as the standard of care for
youths and families affected by trauma. Introductory training for this treat-
ment model has been available online since 2005, and this training has been
accessed by more than 300,000 therapists across more than 120 countries
worldwide. Dr Deblinger also successfully collaborated with Melissa K.
Runyon, PhD, on the development and evaluation of another evidence-based
treatment model for families at risk for physical abuse. She has served 2 terms
on the board of the American Professional Society on the Abuse of Children,
served as a founding fellow of the Academy of Cognitive Therapy, and currently
serves on the advisory board for the Moore Center for Child Sexual Abuse
Prevention at John Hopkins University. Dr Deblinger has coauthored numer-
ous scientific publications, several widely acclaimed professional books, and a
number of children’s books about body safety. Most recently, Dr Deblinger was
recognized by the Association for the Advancement of Behavioral and
Cognitive Therapies as a pioneer in the field.
Karen J. Farst, MD, MPH, FAAP

Dr Farst is a child abuse pediatrician at Arkansas Children’s Hospital. She is
an associate professor in the College of Medicine, Department of Pediatrics, at
the University of Arkansas for Medical Sciences (UAMS) and director for the
university Center for Children at Risk. She is a past president of the National
Children’s Alliance Board of Directors. She earned her bachelor of arts and
doctorate of medicine from Texas Tech University and then completed a
residency in internal medicine and pediatrics at UAMS. Following a child
abuse fellowship at Cincinnati Children’s Hospital, she completed a master of
public health at Fay Boozman College of Public Health at UAMS.
Lori D. Frasier, MD, FAAP

Dr Frasier graduated from the University of Utah School of Medicine and com-
pleted a residency in pediatrics and fellowship in child abuse at University of
Washington/Children’s Hospital of Seattle. She completed a fellowship in child
abuse at University of Washington/Harborview Medical Center. She has been
on the faculties of the University of Missouri/Columbia, the University of Iowa,
and the University of Utah. Dr Frasier is board-certified in general pediatrics
x
and child abuse pediatrics. Dr Frasier has served as the chair of the Section on
Child Abuse and Neglect of the American Academy of Pediatrics and was on
the first Subboard of Child Abuse Pediatrics at the American Board of
Pediatrics, where she served as chair of the subboard and immediate past chair.
She has been on the Board of Directors of the American Professional Society on
the Abuse of Children and is current chair of the Board of Directors of the
National Center for Shaken Baby Syndrome. Dr Frasier is vice president/presi-
dent elect of the Ray E. Helfer Society. She is currently a professor of pediatrics
at Penn State Milton Hershey Children’s Hospital and division chief of child
abuse pediatrics. She is medical director of the UPMC-Pinnacle Health
Children’s Resource Center, an accredited children’s advocacy center (CAC)
in Harrisburg serving 7 counties in central Pennsylvania, and provides peer
review via telehealth at several additional CACs. Dr Frasier has an interest in
telehealth in child abuse and sexual abuse physical findings and has lectured
nationally and internationally on the topic of child abuse.
Eileen R. Giardino, PhD, RN, APRN, NP-C

Dr Giardino is an associate professor of clinical nursing in the Department
of Family Health at the University of Texas Health Science Center at Houston
(UTHealth). She earned a bachelor of science and doctorate of philosophy in
education from the University of Pennsylvania, a master’s degree in nursing
from Widener University, and family and adult nurse practitioner certificates
from La Salle University in Philadelphia. Dr Giardino is board-certified as an
adult nurse practitioner and as a family nurse practitioner. Academic accom-
plishments include authoring textbooks in the areas of child maltreatment and
intimate partner violence, as well as advanced nursing practice. She presents at
professional meetings on issues related to physical assessment and interper-
sonal violence. Dr Giardino currently teaches in the Doctor of Nursing Practice
program and was former track director of the Family Nurse Practitioner
program. She is the nursing core faculty for the Leadership Education in
Neurodevelopmental Disabilities program at UTHealth to provide the nursing
perspective on caring for children on the autism spectrum.
Jordan Greenbaum, MD
Dr Greenbaum is a child abuse physician who received her degree from Yale
School of Medicine. She is the medical director of the Global Health and
Well-being Initiative with the International Centre for Missing and Exploited
Children and the medical director of the Institute on Healthcare and Human
Trafficking at the Stephanie Blank Center for Safe and Healthy Children
at Children’s Healthcare of Atlanta. She cochairs the Human Trafficking
Committee for the Ray E. Helfer Society and the Education/Training
Committee for HEAL Trafficking, an organization of medical professionals
working on human trafficking issues. Dr Greenbaum has served on national
xi
committees and work groups regarding human trafficking and has testified for
congressional committees. She coauthored a clinical report and a policy state-
ment regarding child trafficking for the American Academy of Pediatrics. Dr
Greenbaum provides trainings on child trafficking and exploitation and other
aspects of child maltreatment for medical and nonmedical professionals. She
trains locally, nationally, and internationally, working with child-serving pro-
fessionals to prevent, identify, and intervene in cases of suspected abuse and sex
trafficking. Her research focuses on developing and validating a screening tool
to identify suspected child sex trafficking in the health care setting and on
global health care for survivors of child trafficking.
Kristine Hodshon, PsyD

Dr Hodshon is a child and adolescent psychologist at the Child Abuse Research
Education and Service (CARES) Institute at the Rowan University School of
Osteopathic Medicine. At the CARES Institute, Dr Hodshon provides treat-
ment of children who have experienced maltreatment and is a certified
Trauma-Focused Cognitive Behavioral Therapy clinician. She also provides
brief mental health assessments of children entering the foster care system in
New Jersey and comprehensive psychological/sexual abuse evaluations when
there continue to be questions regarding potential sexual abuse despite comple-
tion of investigations. Dr Hodshon is involved in several statewide training and
quality initiatives in New Jersey, including serving as faculty on NJ Finding
Words, which provides training to multidisciplinary teams throughout New
Jersey on forensic interviewing of children. She also serves as a consultant for
the New Jersey Coordination Center for Child Abuse & Neglect Forensic
Evaluation and Treatment at Rutgers University, which is charged with imple-
menting statewide quality improvement programs that promote advances in
knowledge, policy, and practice within the field of child abuse and neglect
forensic evaluation and treatment.
Berit Sabine Kieselbach, MPH, MSc

Berit Sabine Kieselbach works as technical officer on the Prevention of Violence
team in the Department for Management of Noncommunicable Diseases,
Disability, Violence and Injury Prevention at the World Health Organization
(WHO) in Geneva, Switzerland. She is coordinating the development of nor-
mative guidelines on the health sector response to child maltreatment and pro-
vides technical support to countries in the development of policies and
programs addressing violence against children. She also manages the secretar-
iat of the Violence Prevention Alliance, a network of governments, interna-
tional agencies, nongovernmental organizations, and academic institutions
supporting evidence-informed violence prevention. Berit has an academic
background in psychology (master of science) and public health (master of
public health). Before joining WHO, she worked as health advisor for German
xii
Development Cooperation and various humanitarian agencies, supporting

cooperation programs in Asia, Africa, and Latin America, with a focus on
health systems development, mental health, and violence prevention.
Megan M. Letson, MD, MEd, FAAP

Dr Letson is the division chief of the Division of Child and Family Advocacy,
program director of the Child Abuse Pediatrics Fellowship Program, and
medical director of the Center for Family Safety and Healing at Nationwide
Children’s Hospital in Columbus, OH. She is also an associate professor of
clinical pediatrics at the Ohio State University College of Medicine. Dr Letson
received her medical degree from the University of Cincinnati College of
Medicine and completed her general pediatrics residency and child abuse pedi-
atrics fellowship at Cincinnati Children’s Hospital Medical Center. Dr Letson is
board-certified in both child abuse pediatrics and general pediatrics. Her pro-
fessional interests include resident and fellow medical education, and she has a
master’s degree in education from the University of Cincinnati. She is an active
member of the American Academy of Pediatrics Ohio Chapter Committee on
Child Abuse and Neglect and serves on several national committees, including
the program, education, and program director committees of the Ray E. Helfer
Society. She has held several national leadership roles, including past chair of
the scholar, program, and education committees of the Ray E. Helfer Society.
Dr Letson was recently appointed to the Subboard of Child Abuse Pediatrics
for the American Board of Pediatrics.
Michelle A. Lyn, MD, FAAP

Dr Lyn is an associate professor of pediatrics at Baylor College of Medicine
and the medical director of care management/patient flow at Texas Children’s
Hospital in Houston. She received her medical degree from the State University
of New York at Buffalo School of Medicine and completed her residency in
pediatrics at Albert Einstein College of Medicine-Montefiore Medical Center
in Bronx, NY. After serving an additional year as chief resident, she moved to
Texas to complete her postgraduate fellowship in pediatric emergency medicine
at Baylor College of Medicine. Dr Lyn holds board certifications in pediatrics,
pediatric emergency medicine, and child abuse pediatrics.
Dr Lyn is an administrator, an educator, and a clinician. She previously
served as the chief of child protection in the Section of Emergency Medicine.
Her academic accomplishments include published chapters, development of
curricula on the evaluation of child maltreatment, and presentations on a vari-
ety of pediatric topics related to evaluation and treatment of children in a
health care crisis. She has participated in numerous radio and television broad-
casts to discuss topics of injury prevention, child maltreatment, and emergency
medicine. Dr Lyn is the recipient of the Baylor College of Medicine Department
of Pediatrics Award of General Excellence in Teaching and the Baylor College
of Medicine Fulbright and Jaworski Excellence in Teaching Award. She is also
xiii
the recipient of several Houston community awards, including the Breakthrough

Women Award from Texas Executive Women and the Houston Chronicle and
the Unstoppable Leader Award from the Greater Houston Women Chamber
of Commerce.
Kathi Makoroff, MD, MEd, FAAP

Dr Makoroff is medical director and fellowship director of the Mayerson
Center for Safe and Healthy Children at Cincinnati Children’s Hospital
Medical Center and associate professor of pediatrics at the University of
Cincinnati College of Medicine.
Dr Makoroff earned her bachelor of arts from the University of Pennsylvania
and graduated with honors from the University of Pittsburgh School of
Medicine. After completing a residency in pediatrics at Children’s Hospital of
Pittsburgh, Dr Makoroff came to Cincinnati in 1997 for training in child abuse,
including a research fellowship in child abuse pediatrics. Dr Makoroff received
her master’s degree in education from the University of Cincinnati in 2010.
Lauren Maltby, PhD

Dr Maltby is a board-certified child and adolescent psychologist and works
as the supervising forensic psychologist at the Harbor-UCLA K.I.D.S. (Kids in
Dependency Systems) Clinic, where she conducts forensic interviews and
supervises other interviewers. Dr Maltby provides training to professionals
throughout California regarding forensic interviewing of children and provides
expert testimony in cases of suspected child abuse. She is an assistant professor
in the Department of Pediatrics at the David Geffen School of Medicine at
UCLA and an infant-parent and early-childhood mental health specialist
(California endorsement).
John D. Melville, MD, MS, FAAP

Dr Melville is an associate professor of pediatrics at the Medical University of
South Carolina, where he also serves as chief of the Division of Child Abuse
Pediatrics. Trained as both a computer scientist and a physician, Dr Melville’s
research interests include informatics, photography, and image processing as
applied to child abuse evaluations.
Stacey A. Mitchell, DNP, MBA, RN, SANE-A, SANE-P,

DF-AFN, FAAN
Dr Mitchell holds a doctorate in forensic nursing from the University of
Tennessee Health Science Center. Her master’s degree in nursing has a focus in
trauma and forensic nursing from the University of Virginia in Charlottesville.
Dr Mitchell’s bachelor’s degree is in nursing from the Medical College of
Virginia. Her nursing career spans over 27 years, with experience in critical
care, emergency nursing, forensic nursing, risk management, and patient safety.
xiv
Dr Mitchell began her forensic nursing career as the coordinator of the

Forensic Nurse Examiners of St. Mary’s Hospital in Richmond, VA. She has
served as a director at large for 2 terms, treasurer, president-elect, and president
on the Board of Directors of the International Association of Forensic Nurses.
Currently, Dr Mitchell is a clinical associate professor at Texas A&M University
College of Nursing and program coordinator for the Forensic Health Care
Program. In 2016, she was appointed by Houston Mayor Annise Parker to the
Board of Directors of the Houston Forensic Science Center. She held the posi-
tion of deputy chief forensic nurse investigator at the Harris County Medical
Examiner’s Office in Houston, TX, for 6 years. From 2008 to 2017, she was the
administrative director of forensic nursing services and risk management and
patient safety for the Harris Health System.
Recently, Dr Mitchell was honored as one of the Top 20 Outstanding Nurses
by the Texas Nurses Association District 9. In October 2017, she was inducted
as a fellow into the American Academy of Nursing. She also received the
Virginia Lynch Pioneer in Forensic Nursing award in 2015.
John E.B. Myers, JD

John E.B. Myers is professor of law at the University of the Pacific, McGeorge
School of Law, in Sacramento, CA, and visiting professor at the University of
California Hastings College of the Law. John is an authority on legal and his-
torical aspects of child maltreatment, intimate partner violence, stalking,
sexual assault, elder abuse, family law, and mental health law. John has written
or edited 14 books and 146 articles and chapters on subjects related to interper-
sonal violence. His writing has been cited by more than 200 courts, including
the US Supreme Court. John has given than more than 400 presentations
across the United States and abroad. John represents children in juvenile court
dependency proceedings and high-conflict custody trials, as well as victims of
domestic violence in restraining order trials.
Vincent J. Palusci, MD, MS, FAAP

Dr Palusci is professor of pediatrics at New York University School of Medicine
in New York City, where he is a board-certified general and child abuse
pediatrician at the Bellevue Hospital Frances L. Loeb Child Protection and
Development Center. During his career, he has provided care in a number
of settings for children who have been maltreated; taught medical students,
residents, fellows, and the community; and has developed a research program
focusing on violence epidemiological issues, systems, health services, and
training for professionals.
Dr Palusci was a Benjamin Franklin Scholar, graduating with distinction in
chemistry at the University of Pennsylvania. He received his doctorate of medi-
cine from the University of Medicine and Dentistry of New Jersey, New Jersey
xv
Medical School in Newark and completed his internship and residency in pedi-
atrics at New York University School of Medicine and Bellevue Hospital in New
York City.
Dr Palusci currently serves as program chair for the American Academy
of Pediatrics (AAP) Section of Child Death Review and Prevention. He has
served in leadership positions for the AAP Section on Child Abuse and Neglect,
the Subboard of Child Abuse Pediatrics at the American Board of Pediatrics,
and the American Professional Society on the Abuse of Children (APSAC). He
has been editor of the APSAC Advisor and the APSAC Alert. He has edited a
number of books and more than 100 articles, chapters, and reports, lecturing
nationally and internationally. His publications address medical, epidemiologi-
cal, reporting, and prevention issues, as well as education and training.
Dr Palusci received the Christine Nelson Outstanding Professional Award
for Service to Children in Kent County in 2001, the Ray E. Helfer Award for
child abuse prevention in 2004 from the AAP and the National Alliance for
Children’s Trust and Prevention Funds, and the Outstanding Service Award in
2018 from the APSAC.
Elisabeth Pollio, PhD

Dr Pollio is the director of mental health administration at the Child Abuse
Research Education and Service Institute and a member of the faculty at
Rowan University School of Osteopathic Medicine. Her responsibilities include
overseeing the administrative aspects of the institute mental health services;
the institute foster care program, which provides mental health screenings and
medical evaluations of children entering foster care; and the institute post-
doctoral fellowship program, which provides specialized trauma training.
She participates in research at the institute as well. Dr Pollio has provided and
supervised Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and
assists with the coordination and implementation of TF-CBT learning collab-
oratives, particularly through her work with agency leaders.
Lawrence R. Ricci, MD, FAAP

Dr Ricci is a clinical professor of pediatrics at the Tufts Maine Medical Center
College of Medicine. He is a board-certified child abuse pediatrician specializ-
ing in the evaluation and treatment of children who have been abused, as
medical director of the Spurwink Child Abuse Program, in Portland, ME. The
Spurwink Child Abuse Program is a multidisciplinary statewide referral center
for Maine children with satellites in Waterville, Lewiston, and Bangor, ME. He
is on the consulting staff at Barbara Bush Children’s Hospital (BBCH), where he
spends time training pediatric residents in clinical settings and monthly didac-
tic sessions. He also performs inpatient child abuse consultations at BBCH. He
is in addition the director of the Pediatric Advocacy Program at BBCH.
xvi
Melissa K. Runyon, PhD

Dr Runyon is a licensed psychologist who began her career in 1997 at the
Miami University School of Medicine as part of the Child Protection Team in
Florida, where she founded and directed the Family and Child Treatment
Services (FACTS) program. In 1999, she took a position as treatment services
director of the Child Abuse Research Education and Service (CARES) Institute,
now part of Rowan University School of Osteopathic Medicine, where she
achieved the rank of professor of psychiatry. For nearly 16 years, Dr Runyon
provided oversight of all clinical activities, including offering training and
clinical supervision to staff and trainees in the evidence-based therapies,
Combined Parent-Child Cognitive Behavioral Therapy (CPC-CBT), and
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), developed at the
CARES Institute.
Dr Runyon has been the principal or coinvestigator on grants supporting
research or services from the National Institute of Mental Health, the
Substance Abuse Mental Health and Services Administration, and private
foundations. Dr Runyon developed, with Esther Deblinger, PhD, CPC-CBT,
an evidence-based treatment of children and families who are at risk for or
who have experienced child physical abuse. Dr Runyon conducts national and
international trainings and provides consultation to disseminate CPC-CBT
and TF-CBT to professionals. Dr Runyon has coauthored numerous journal
articles and book chapters in the areas of child abuse and domestic violence
and coauthored a book about CPC-CBT and a book about the application of
TF-CBT to children who have been sexually abused, respectively.
Philip V. Scribano, DO, MSCE, FAAP

Dr Scribano graduated from Rutgers University and the University of Medicine
and Dentistry of New Jersey School of Osteopathic Medicine. He also received
a master of science in clinical epidemiology at the University of Pennsylvania.
He is the section chief of Safe Place: Center for Child Protection and Health
at the Children’s Hospital of Philadelphia and professor of clinical pediatrics at
the Perelman School of Medicine at the University of Pennsylvania.
Dr Scribano has devoted his scholarly efforts to the areas of epidemiology and
prevention of child maltreatment and intimate partner violence, technology
use in health care, and health services to children in foster care. He is the recip-
ient of multiple research and program grants, including awards from the
Administration for Children and Families, US Department of Justice, Agency
for Healthcare Research and Quality, and Centers for Disease Control and
Prevention.
Dr Scribano is an active member of the American Academy of Pediatrics in
the Section on Child Abuse and Neglect and the Council on Foster Care,
Adoption, and Kinship Care. He currently serves on the Board of Directors of
Prevent Child Abuse America and is the chair of its Programs, Research, and
Policy Committee.
xvii
Natalie Stavas, MD
Dr Stavas graduated from Creighton University with her bachelor’s degree in
nursing and then went on to medical school at the University of Nebraska
Medical Center. She received a master of science and health policy research at
the University of Pennsylvania.
She completed her pediatric residency at the Boston Combined Residency
Program and her child abuse pediatrics fellowship at the Children’s Hospital
of Philadelphia (CHOP). Dr Stavas has devoted her scholarly efforts toward
improving access and quality of care for children who are vulnerable. She has
been the recipient of multiple awards for her work in the community, including
the Change Maker Award and Bostonian of the Year Award. She received Best
Abstract Award by a fellow at the 2018 Pediatric Academic Societies conference
for her research in telehealth.
Dr Stavas has accepted a position at CHOP as a child abuse pediatrician
and as an assistant professor in pediatrics at the University of Pennsylvania
Perelman School of Medicine. Dr Stavas is an active member of the American
Academy of Pediatrics, the Ray E. Helfer Society, and the Academic Pediatric
Association.
Raquel Vargas-Whale, MD, MS, MSc, FAAP

Dr Vargas-Whale serves as the medical director and child abuse pediatrician
with the CARE (Child Abuse Resource & Evaluation) Team at Driscoll
Children’s Hospital in Corpus Christi, TX. Dr Vargas-Whale primarily pro-
vides medical and forensic services to families of children in south Texas with
concerns for any type of child maltreatment. She is also responsible for resident
and medical student education related to advocacy and child maltreatment and
provides community education and outreach. Dr Vargas-Whale graduated
from the University of Texas Medical Branch in 2005 and completed her pedi-
atric residency in 2008 at the Cleveland Clinic in Ohio. After graduation,
Dr Vargas-Whale served as an Indian Health Services scholar and staff pedia-
trician for the Choctaw Nation Health Service Authority in Oklahoma. Her
practice emphasis was in the area of behavioral health and child development.
Dr Vargas-Whale completed fellowship training in child abuse pediatrics
at the University of Utah and at the same time completed a master’s degree
in clinical science investigation, graduating in July 2015. Dr Vargas-Whale is
board-certified in both general pediatrics and child abuse pediatrics.
Thank you…
To the children, parents, and professionals
who have entrusted me to help
To my colleagues with whom shared insights have
helped build the foundation of our understanding
of meeting the medical needs
of children suspected of being sexually abused
To my child protection, mental health,
and legal colleagues
for teaching me how the system can
and must work to help children
To my codirector, Esther Deblinger, PhD, CPC-CBT, of 30 years
for being a kindred spirit and partner
in building the Child Abuse Research Education
and Service (CARES) Institute
To the faculty and staff of the CARES Institute
for their tireless dedication and professionalism
To the administration of the School of Osteopathic Medicine
at Rowan University for providing
the environment and tools to succeed
To my wife, Bonnie, and our children, Benjamin and Julia,
for their encouragement, understanding, and support
To the following colleagues, who over the past 3 decades

have graciously shared their
teaching materials and wise counsel:
Carol D. Berkowitz, MD, FAAP, FACEP
Allan R. DeJong, MD
Robert M. Reece, MD
Contents
Foreword Carol D. Berkowitz, MD, FAAP, FACEP....................... xxiii

Preface Martin A. Finkel, DO, FACOP, FAAP, and
Angelo P. Giardino, MD, PhD, MPH, FAAP................... xxv
Chapter 1 The Problem.. . . . . . . . . . . . ........................................ 1
Angelo P. Giardino, MD, PhD, MPH, FAAP, and
Michelle A. Lyn, MD, FAAP
Chapter 2 The Evaluation.. . . . . . . . . ...................................... 21
Appendix.. . . . . . . . . . . . . . . ...................................... 42
Obtaining the Medical History in Suspected Child
Sexual Abuse: Suggested Rationale and Questions
Chapter 3 Physical Examination.. . ...................................... 59
Appendix 1.. . . . . . . . . . . . . ..................................... 104
When Sexual Abuse Is Suspected: Common Concerns
About the Medical Examination
Appendix 2.. . . . . . . . . . . . . ..................................... 107
Colpophotographic Case Studies
Chapter 4 Documentation of Physical Evidence
in Child Sexual Abuse.. . ..................................... 135
John D. Melville, MD, MS, FAAP, and
Chapter 5 Sexually Transmitted Infections in Child and
Adolescent Sexual Assault and Abuse...................... 147
Karen J. Farst, MD, MPH, FAAP, and
Rachel A. Clingenpeel, MD, FAAP
Chapter 6 Forensic Evidence in Child Sexual Abuse................... 171
Vincent J. Palusci, MD, MS, FAAP, and
Cindy W. Christian, MD, FAAP
Chapter 7 Adolescent Issues in Sexual Abuse.......................... 197
Kathi Makoroff, MD, MEd, FAAP, and
Megan M. Letson, MD, MEd, FAAP
Chapter 8 Mimics of Sexual Abuse. . .................................... 211
Lori D. Frasier, MD, FAAP, and
Raquel Vargas-Whale, MD, MS, MSc, FAAP
xxii
Contents
Chapter 9 Telemedicine and the Child Sexual Abuse

Medical Evaluation. . . . . . . . . . . . . . ............................. 247
Natalie Stavas, MD, and
Philip V. Scribano, DO, MSCE, FAAP
Chapter 10 The Roles of Nursing in Issues of Child Sexual Abuse...... 265
Eileen R. Giardino, PhD, RN, APRN, NP-C, and
Stacey A. Mitchell, DNP, MBA, RN, SANE-A, SANE-P,
DF-AFN, FAAN
Chapter 11 Developmental Considerations When
Interviewing Children and the Forensic
Evaluation Process.. . . . . . . . . . . . . ............................. 277
Kristine Hodshon, PsyD, and Lauren Maltby, PhD
Chapter 12 Child Sexual Abuse Education and Treatment
for Youth................................................................. 303
Melissa K. Runyon, PhD; Esther Deblinger, PhD, CPC-CBT;
and Elisabeth Pollio, PhD
Chapter 13 Interdisciplinary Approaches to Child Maltreatment:
Accessing Community Resources............................... 331
Philip V. Scribano, DO, MSCE, FAAP, and
Chapter 14 Legal Issues in the Medical Evaluation
of Child Sexual Abuse............................................ 355
John E.B. Myers, JD
Chapter 15 Child Sexual Exploitation: Recognition
and Prevention Considerations................................. 393
Sharon W. Cooper, MD
Chapter 16 Child Sex Trafficking.............................................. 417
Jordan Greenbaum, MD
Chapter 17 Documentation, Report Formulation,
and Conclusions................................................... 439
Chapter 18 Child Sexual Abuse: An International Perspective.......... 455
Berit Sabine Kieselbach, MPH, MSc, and
Alexander Butchart, PhD
Index ......................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
Foreword
In preparation for crafting the foreword to the fourth edition of Finkel &
Giardino’s Medical Evaluation of Child Sexual Abuse: A Practical Guide,
I reviewed what I had written for its predecessor. I recalled the 1980s and the
explosion of cases of child sexual abuse, some involving multiple victims and
many cases sensationalized by headlines in the media or lead stories on the eve-
ning news. Many of us became involved in assessing those children, admittedly
in the face of an emerging research agenda and a paucity of studies. We did not
even have data on normal prepubescent female anatomy and common variants.
I mentioned the skepticism that surrounded the abuse disclosed by young chil-
dren and that the average time interval between abuse and disclosure had been
8 years. Some of the more notorious cases were very polarizing. Bumper stickers
appeared, declaring, “We believe the children.” But neither we physicians nor
the children were uniformly believed, and many alleged perpetrators were
found not guilty. I can still remember the gasp that that filled the ballroom in
San Diego at the child maltreatment meetings in 1990 when David Chadwick
announced the startling “not guilty” verdict in the McMartin Preschool case.
No doubt, science and forensic assessment of cases of child abuse has pro-
gressed significantly since then. The 18 chapters that follow this foreword are a
testimony to ongoing scholarly work to help the children as well as the commu-
nity. And though we have made significant progress in some domains of child
sexual abuse, we are still confronted with victim shame and secrecy and a
public that all too often fails to believe those who experienced sexual abuse and
assault, be it by a friend, family member, or stranger.
It is hard as a child abuse pediatrician not to feel disappointed and discour-
aged by high-profile stories in which alleged perpetrators of sexual assault have
escaped justice and even attained high levels of power and prestige, while the
victims have been disbelieved and pushed aside. Many of us deal daily with
young people who have experienced violent assaults. The feelings of many clini-
cians caring for these patients was eloquently articulated in an article in STAT
by child abuse pediatrician Nina Agrawal, MD. She wrote:
I see teenage girls every day who have been sexually assaulted, often
by older teenage boys. Sadly, very few of the perpetrators are ever held
accountable for the crimes they have committed. Why? The victims
have everything to lose by coming forward.
A quote commonly attributed to Yogi Berra sums it up: “It’s déjà vu all over
again.” Unfortunately, not that much has changed about the credibility afforded
to victims of sexual abuse.
But now, the good news. We as professionals continue to learn, grow, and
improve the care we give our patients. Our successes have been significant.
xxiv
Foreword
Reported child sexual abuse has declined by 65% between 1990 and 2015. There
does not seem to be a single attributable reason for the decline but rather multi-
ple factors including economic prosperity and interventions that are more
social and therapeutic.
In addition to the reappearance on our radar screens of overt discounting of
the claims of survivors of sexual assault is the reframing of “prostitution” not as
a crime by the individual but as a crime to the individual. Even for a seasoned
child abuse pediatrician, it is shocking to see the violence, abuse, and control to
which these young people, both boys and girls, are subjected. And so we have
articles, book chapters, mandated educational modules, and webinars gearing
us up to recognize and intervene in the lives of these trafficked patients.
But before we pat ourselves on the back too much, let me share a brief story
I heard recently. A colleague told me about a 15-year-old who was being traf-
ficked, was arrested, and was brought to the emergency department for medical
clearance on her way to jail. When the arresting officer was told by the clinician
seeing the girl that the teen was being trafficked, the officer replied he had to
arrest her, because that was the law. If the clinician wanted things to be differ-
ent, the law had to be changed. It is entirely appropriate for pediatricians and
others involved in the care of children and teens to embrace our role as advo-
cates and lobby to change laws.
Despite what may seem disheartening, we can celebrate the opportunity to
advance and refine our knowledge and the care that we provide to these chil-
dren. The opening chapter to this fourth edition expertly describes the problem
with delineating definitions and paradigms. Even a seasoned child abuse pedia-
trician will find this to be an excellent framing of the multiple dimensions of
child sexual abuse and a directive for the future. And while the basic mechanics
of the assessment have not changed significantly over the past 25 years, emerg-
ing science and technology has helped make the evaluation more patient
focused, and this new edition reflects these developments. Even the notion of
the “disease of sexual victimization” reframes the role of the clinician, who was
once a collector of swabs and slides to assist law enforcement, to that of a healer.
Newer technologies have had an impact on the forensic assessment, and the
wide-scale use of telemedicine continues to provide rural areas with expertise
that would otherwise be lacking. As we continue to improve the services we
provide to the children and teens of the United States, it is important to have an
international perspective: it is estimated that about 12% of the world’s children
experience child sexual abuse. We have an obligation to share what we have
learned with those who are still developing programs globally.
Sexual abuse is not limited by national boundaries, nor is it a partisan issue.
We need to empower our patients, their families, and the communities in
which we live to be part of the public chorus that validates the stories of our
patients and creates a safe place for disclosure, treatment, and healing.
Carol D. Berkowitz, MD, FAAP, FACEP
Preface
We are very pleased to offer a revised and expanded fourth edition of Medical
Evaluation of Child Sexual Abuse: A Practical Guide. This edition reflects
almost 30 years of collaboration of the coeditors of this book. We have been
very fortunate to see our baby grow from a small manual to a comprehensive
and yet practical clinical resource. Our book has stood the test of time and
matured into what we believe to be one of the few books that could be said to be
a standard reference text for the field. Its strength is rooted in the exceptional
contributors who all are experts in the field of child maltreatment and bring
great academic and clinical expertise to their chapters. As coeditors, we made
a decision that the fourth edition will set the stage for the next generation of
child abuse pediatricians (CAPs) to share their expertise. Readers will see new
names paired with the familiar as this book transitions to the next generation
of leaders in our field.
There have been significant changes in the format of this edition with major
revisions throughout. We are honored to have this book published by the
American Academy of Pediatrics (AAP). In 1991, our first guide and precursor
to this textbook on the medical evaluation of children who have been sexually
abused was published. At that time, our understanding of the sexual victimiza-
tion of children was still in its infancy. And although we have made great
strides in public awareness of child sexual abuse (CSA), the problem is still of
epidemic proportions. The provision of anticipatory guidance by primary care
physicians is still not routine. Communities are much more resourced around
the country to respond to allegations of sexual abuse, but those resources are
limited and need to be bolstered. There is now the recognition that CSA is an
adverse childhood experience and that there is clearly not just a cost to the
child but also an economic cost to society when we fail to provide the diagnos-
tic and treatment services that children who have been victimized need and
deserve. We hope that this edition will provide new insights into how best to
meet the needs of children when CSA is suspected and respond in a way that
meets the diagnostic and treatment needs of child victims.
Since the time of the last edition, child abuse pediatrics has been established
as a recognized subspecialty of pediatrics. Child abuse pediatricians have
become integral to the work of child protection, but many communities lack
access to this level of expertise. We have enhanced our collective understanding
of the sexual victimization of children and our response when these concerns
arise. The impact of our increasing evidence base and professional skill devel-
opment has dramatically improved our diagnostic acumen, improved the pro-
tection and prevention of CSA, and refined our therapeutic intervention. It is
truly heartening to see the systems designed to recognize sexual abuse and
then investigate allegations in a manner that is informed and sensitive to vic-
tims’ special needs becoming steadily more accessible throughout the United
xxvi
Preface
States and beyond. As the field of child maltreatment has matured, pediatri-
cians continue to play a leading role in defining and meeting the specialized
medical needs of sexually abused children, and today, board certification is
available in child abuse pediatrics. The multidisciplinary landscape has contin-
ued to change over time as well: a spectrum of strategies has evolved to coordi-
nate investigations, collect forensic evidence, and meet the medical and mental
health needs of sexually abused children. With all these changes and the diffi-
culty in meeting the clinical demands for medical services, pediatricians in the
vanguard, along with the AAP, remain very important sources of the multidis-
ciplinary expertise necessary to meet all the needs of child victims. We believe
that when children enter a system designed to assess and then, if needed, pro-
tect those children should have access to the most knowledgeable, skilled, and
sensitive clinicians. This book brings together the collective expertise of skilled
clinicians whose vast experience in addressing the needs of sexually abused
children is shared in a manner that we hope readers will find practical and
easily applied.
This edition reflects the continued refinement of our knowledge of the sci-
entific foundation of the medical diagnosis of CSA and our roles as medical
professionals in diagnosing and treating children who have experienced sexual
abuse. Medical professionals, whether physicians or nurses, are on the front
lines, and their clinical expertise is critical to addressing residua from sexual
contact. A medical professional’s opinion is one of the many important pieces
of the diagnostic puzzle that leads ultimately to a fuller understanding of what
a child may have experienced. A well-documented medical diagnosis and opin-
ion often contributes to the substantiation of allegations, protection from fur-
ther abuse, and referral for treatment of the psychological sequelae. Few aspects
of medical practice require a multidisciplinary approach and cooperation
with professionals of other disciplines more than the field of maltreatment.
Throughout this text, the important contributions of the many disciplines that
comprise the child protection system are emphasized.
This text is written not only for medical professionals but also as a reference
for child protection workers, mental health clinicians, investigators, and the
courts. It is incumbent on professionals in each of the disciplines to understand
what a complete and comprehensive medical evaluation entails, when to seek
an examination, the importance of a medical history, how discrepancies
between a child’s history and the child’s physical findings can be explained,
how the medical record should be structured, what types of documentation
should be expected, and how a medical diagnosis is formulated.
This latest edition includes new chapters on the burgeoning problem of
child pornography and the risks of the Internet. Because the primary impact
of any form of sexual victimization is psychological, a new chapter has been
added to complement the chapter on psychological evaluation and thus help
CAPs understand the spectrum of mental health therapy choices as well as the
xxvii
Preface
latest on the prevention of sexual abuse. We hope that readers will find this
fourth edition to be practical, providing both the knowledge and the skills
necessary to readily translate new information into clinical practice. We are
pleased as well to have added more information about primary prevention and
a chapter on an international perspective from the World Health Organization,
Department for Management of Noncommunicable Diseases, Disability,
Violence and Injury Prevention, continuing with the recognition of the inter-
national importance of CSA that began with publication of the previous edition
in Chinese, Japanese, and Spanish, as well as in Pakistan.
The contributors hope that this text will enhance professionals’ working
knowledge of how to establish the diagnosis of CSA, resulting in objective,
balanced, and defensible medical diagnoses. We salute professionals who select
this very rewarding field and hope that each author’s contribution to this text
will assist you in providing the best of care. Children will be the beneficiaries
of all our efforts.

Another random document with
no related content on Scribd:
Possibly the environmental feature of greatest value to cultural
progress in Middle America was its diversity. Mountain and coast,
temperate highland and hot lowland, humid and arid tracts, tropical
jungle and open country, were only a few hours apart. In each
locality the population worked out its necessary adaptations, and yet
it was near enough others of a different adaptation for them to trade,
to depend on one another, to learn. Custom therefore came in
contact with custom, invention with invention. The discrepancies, the
very competitions, would lead to reconciliations, readaptations, new
combinations. Cultural movement and stimulus would normally be
greater than in a culturally uniform area.
Be that as it may, Middle America took the lead. It is in the region
of southern Mexico that a wild maize grows—teocentli, “divine
maize,”[25] the Aztecs called it. From this, in a remote archaic period,
the cultivated plant was derived. At least, such seems to be the
probability in a somewhat tangled mass of botanical evidence. Here
then the dominant plant of American agriculture was evolved: with it,
very likely, the cultivated beans and squashes that are generally
associated in native farming even in parts remote from Mexico.
Pottery has so nearly the same distribution as maize agriculture,
as to suggest a substantially contemporaneous origin, probably at
the same center. This is the more likely because the art is of chief
value to a sessile people, and farming operates more strongly than
any other mode of life to bring about a sedentary condition.
Agriculture almost certainly increased the population. The food
supply was greater and more regular; people got used to living near
each other where before they had unconsciously drifted apart
through distrust; and the proximity in turn, as well as the new
stability, would lessen many of the local famines, hostilities, and
other hardships to which the smaller and less settled communities
had been exposed. As the death rate went down and numbers
mounted, specialization of labor would be first made possible, and
then almost forced. A self-contained community of a hundred cannot
permit much specialization of accomplishment and none of
occupation. Every man must be first of all an immediate food getter.
On the other hand a community of a million inevitably segregates
somewhat into classes, trades, guilds, or castes. The individual with
decided tastes and gifts in a particular direction finds his products in
enough demand to devote himself largely or wholly to their
manufacture. The very size of the community as it were forces him to
specialization, and thus diversity, with its train of effects leading to
further stimulation, is attained independently of environment.
184. Tobacco
For some culture elements, the evidence of early origin in Middle
America is less direct. The use of tobacco, for instance, is as widely
spread as agriculture, but is not necessarily as ancient. Its diffusion
in the eastern hemisphere has been so rapid (§ 98) as to make
necessary the admission that it might have spread rapidly in the New
World also—faster, at any rate, than maize. Moreover, a distinction
must be made between the smoking or chewing or snuffing of
tobacco and its cultivation. There are some modern tribes—mostly
near the margins of the tobacco area—that gather the plant as it
grows wild. It is extremely probable that wild tobacco was used for
some time before cultivation was attempted. Nevertheless tobacco
growing, whenever it may have originated, evidently had its
beginning in the northern part of Middle America, either in Mexico or
the adjacent Antillean province. It is here that Nicotiana tabacum
was raised. The tribes to the north contented themselves with allied
species, mostly so inferior from the consumer’s point of view that
they have not been taken up by western civilization. These varieties
look like peripheral substitutes for the central and original Nicotiana
tabacum.
The Colombian and Andean culture-areas used little or no
tobacco, but chewed the stimulating coca leaf. This is a case of one
of two competing culture traits preventing or perhaps superseding
the other, not of tobacco never having reached the Andes. Most of
the remainder of South America used tobacco.
185. The Sequence of Social Institutions

The most peripheral and backward peoples of both North and
South America even to-day remain without clans, moieties,
hereditary totems, or exogamic groupings (§ 110). Some of these,
like the Eskimo and Fuegians, live at the extreme ends of the
continents, under conditions of hardships which might be imagined
to have directed all their energies toward the material sides of life
and thus left over little interest for the development of institutions.
But this argument will not apply to the many clanless tribes of the
California, Plains, and Tropical Forest areas. It must accordingly be
concluded that those American nations that show no formal
organization of society on a hereditary basis—or at least the more
primitive ones who possess no equivalent or substitute—do without
this organization because they never acquired it. This negative
condition may then be inferred as the original one of the whole
American race.
Somewhat more advanced culturally, on the whole, and less
definitely marginal, at any rate in North America, are several series
of tribes that do possess exogamic groups—either sibs or moieties—
in which descent goes in the male line and is generally associated
with totemic beliefs or practices. These comprise the tribes of one
segment of the Northwest Coast area; those of one end of the
Southwest with some extension into California; and those of most of
the Northern Woodland, with some extension into the Plains.
Another series of tribes live under the same sort of organization
but with descent reckoned in the female instead of the male line.
These comprise the peoples of one end of the Northwest Coast;
those of one portion of the Southwest; and those of the Southeast,
with some extensions into the Northeast and Plains.
These exogamic-totemic series of tribes average higher in their
general culture than the clanless and totemless ones. On the whole,
too, they are situated nearer the focus of civilization in Middle
America. As between the two exogamic-totemic series the
matrilinear tribes must be accredited with a more complex and better
organized culture than the patrilinear ones. The finest carving in
North America, for instance, is that of the Northwest—totem poles,
masks, and the like. Within the Northwest, the Tlingit, Haida, and
Tsimshian—matrilinear tribes—excel in the quality of this work. They
far surpass the patrilinear Kwakiutl and Salish. So in the Southwest:
the matrilinear Pueblos build stone towns, obey a priestly hierarchy,
and possess an elaborate series of cult societies. The patrilinear
Pimas and southern Californians live in villages of brush or earth-
covered houses, are priestless, and know at most a single religious
society. Again, the matrilineal Southern Woodlanders had made
some approach to a system of town life and political institutions, the
patrilineal Northern Woodlanders did without any serious institutions
in these directions. The one Northeastern group that established a
successful political organization, the Iroquois with their League of the
Five Nations, were matrilinear among patrilinear neighbors and
possessed positive affiliations with the Southeast.
It would be extravagant to maintain that throughout the North
American continent every matrilineal tribe was culturally more
advanced than every patrilineal one. But it is clear that within each
area or type of culture the matrilineal tribes manifest superiority over
the patrilineal tribes in a preponderance of cultural aspects. The
matrilineal clan organization thus represents a higher and
presumably later stage in North America than patrilineal clan
organization, as this in turn ranks and temporally follows the clanless
condition.
With one exception, the distribution of the same tribes with
reference to the South Mexican center agrees with their
advancement. The Northeast is distinctly peripheral, the Southeast a
half-way tract connected with Mexico by way both of the Southwest
and the Antilles. The matrilineal Pueblo portion of the Southwest
occupies part of the plateau backbone near the southern end of
which the Mexican culture developed. It was along this backbone
that civilization flowed up through northern Mexico. The coasts
lagged behind. They were marginal in Mexico, more marginal still in
the Southwest, where the patrilineal tribes lived on or near the
Pacific.
The one exception is in the Northwest Coast, where the more
remote northerly tribes are matrilinear, the nearer southerly ones
patrilinear. This reversed distribution raises the suspicion that the
Northwestern social organization may have had nothing to do with
Mexico, but may be a purely local product. This suspicion is
hardened by the fact that the Northwest shows a number of other
culture traits—some peculiar to itself, others recurring in well
separated areas—which it seems impossible to connect with Mexico.
Several of these traits will be discussed farther on. For the present it
is enough to note their existence as an indication favorable to the
interpretation of the Northwest social organization as unrelated to
Mexico. Thus the abnormal matrilineal-patrilineal distribution in the
Northwest is no bar to the generic finding for North America that
clanless, patrilinear, and matrilinear organizations of society rank in
this order both as regards developmental sequence and distance
from Middle America.
For South America the data are too scattering to discuss profitably
without rather detailed consideration.
The distributional facts outside Middle America thus point to this
reconstruction of events. The original Americans were non-
exogamous, non-totemic, without sibs or unilateral reckoning of
descent. The first institution of exogamic groups was on the basis of
descent in the male line, occurred in or near Middle America, and
flowed outwards, though not to the very peripheries and remotest
tracts of the continents. Somewhat later, perhaps also in Middle
America, possibly at the same center, the institution was altered:
descent became matrilinear. This new type of organization diffused,
but in its briefer history traveled less far and remained confined to
the tribes that were in most active cultural connection with Middle
America.
Now, however, a seeming difficulty arises. Middle America, which
appears to have evolved patrilinear and then matrilinear clans, was
itself clanless at the time of European discovery.[26] The solution is
that Middle America indeed evolved these institutions and then went
a step beyond by abandoning or transforming them. Obviously this
explanation will be validated in the degree that it can be shown that
probable causes or products of the transformation existed.
186. Rise of Political Institutions:
Confederacy and Empire
In general, the transformation would seem to have been along the
line of a substitution of political for social organization. Struggling
villages confederated, with a fixed meeting place and established
council; the authority of elected or hereditary chiefs grew, until these
gave the larger part of their time to communal affairs; towns
consolidated. Public works could thus be undertaken. Not only
irrigating ditches and defenses, but pyramid temples were
constructed. In Middle America this condition must have been
attained several thousand years ago. The Mayas had passed
beyond it early in the Christian era. They were then ruled by a
governing class and priesthood, and were erecting dated
monuments that testify to a settled existence of the more successful
of their communities.
In the area of the United States, which may be reckoned as
perhaps two thousand years more belated than southern Mexico,
political organization was still in the incipient stage at the time of
discovery. The Pueblos of the Southwest had achieved town life and
considerable priestly control. They had not taken the further step of
welding groups of towns into larger coherent units. In the Southeast,
however, while the towns were less compact physically, and
probably less populous, political integration on a democratic basis
had made some headway. The institution evolved was essentially a
confederacy of the members of a language group, with civil and
military chiefs, council houses, and representation by “tribes” or
towns and clans. From the Southeast the idea of the confederacy
was carried into the Northeast by the Iroquois, whose famous
league, founded perhaps before Columbus reached America,
attained its culmination after the French and English settlement and
the introduction of firearms. The Iroquois league was an astounding
accomplishment for a culturally backward people. Its success was
due to the high degree of political integration achieved. Yet it did not
destroy the older clan system, in fact made skilful use of it for its own
purposes of political, almost imperialistic, organization.[27]
Some stage of this sort the Mexican peoples may have passed
through. The Maya form of political organization was evidently
similar to that of the Pueblos, the Aztec development more like that
of the Muskogeans and Iroquois. A thousand years before Columbus
the Maya cities were contending for hegemony like the Greek city-
states a millenium earlier. Then the Nahua peoples forged to the
front; and about two centuries before the invasion of Cortez,
Tenochtitlan, to-day the city of Mexico, began a series of conquests
that ended in some sort of empire. It was a straggling domain of
subjected and reconquered towns and tribes, interspersed with
others that maintained their independence, extending from middle
Mexico to Central America, containing probably several million
inhabitants paying regular tribute, held together by well-directed
military force, and governed by a hereditary line of half-elected or
confirmed rulers of great state and considerable power. The
exogamic clan organization as such had disappeared. Groups called
calpulli were important in Aztec society, but they were local, or based
on true kinship, and non-totemic. They may have been the made-
over survivals of clans; they were not clans like those of the
Southwest, Southeast, or Northwest.
Five successive stages, then, were probably gone through in the
evolution of south Mexican society. First there was the pre-clan
condition, without notable organization either social or political; next,
a patrilinear clan system; third, a matrilinear clan system, with more
important functions attaching to the clans, especially on the side of
ceremonial; fourth, the beginnings of the state, as embodied in the
confederacy, the clans continuing but being made use of chiefly as
instruments of political machinery; fifth, the empire, loose and simple
indeed, judged by Old World standards, but nevertheless an
organized political achievement, in which the clans had disappeared
or had been transformed into units of a different nature.
187. Developments in Weaving

In the textile arts, since the successive stages rank one another
rather obviously, and the distributions coincide well with them, the
course of development is indicated plainly.
The first phase was that of hand-woven basketry, which has
already been accredited to the period of immigration, and is beyond
doubt ancient. All Americans made baskets at one time or another.
The few tribes that were not making them at the time of discovery
had evidently shelved the art because their environment provided
them with birch bark, or their food habits with buffalo rawhide, with
exceptional ease, and because their wants of receptacles and
cooking utensils were of the simplest. That basket making goes back
to a rudimentary as well as early stage of civilization is further
suggested by the fact that perhaps the finest ware is made in the
distinctly backward areas, such as the Plateau and California.
A second and a third phase, which are sometimes difficult to
distinguish, are those of loose suspended warps and of a simple
frame or incomplete loom. Pliable cords of some sort, or coarse bast
threads, are employed. The objects manufactured are chiefly wallets
or bags, blankets of strips of fur or feathers, hammocks, and the like.
These two processes are widely spread, but not quite as far as
basketry; the northern and southern extremes of the double
continent do not know them. Occasionally, very fine work is done by
one or the other of these two methods. The most striking example is
the so-called Chilkat blanket of the Northwest Coast, a cloth-like
cape, woven, without a complete loom, of mountain goat wool on
cedar bark warps to a complicated pattern—a high development of a
low type process.
The fourth stage is that of the true or complete loom. In America
the loom is intimately associated with the cultivation of cotton. The
two have the same distribution, except for some use of the plant for
the twining of hammocks on a half-loom in portions of the Tropical
Forest area. Disregarding this case as a probable part adaptation of
a higher culture trait to a lower culture, we may define the distribution
of both loom and cotton as restricted to the Middle American areas,
the adjacent Southwest, and perhaps the adjacent Antilles. This is
certainly central.
The fifth stage is the loom with a handle or mechanical shedding
device, obviating tedious hand picking of the weft in and out of the
warps. The heddle is proved only for Peru. It was probably used in
Mexico. It may therefore be tentatively assumed to have been known
also in the intervening Chibcha area. It is used to-day in the
Southwest, but may have been introduced there by the Spaniards.
This stage accordingly is limited even more strictly to the vicinity of
Middle America.
The sixth stage, that of the loom whose heddles are operated by
treadles, and what may be considered a seventh, the use of multiple
heddles to work patterns mechanically, were never attained by any
American people.
The best and finest fabrics were made in Peru, in part probably as
consequence of the addition of wool to the previous repertory of
cotton. This addition in turn probably followed the domestication of
the llama by the Peruvians. The Mexicans had no corresponding
animal to tame, and their textiles lagged behind in quality.
188. Progress in Spinning: Cotton

Spinning and weaving are interdependent. Baskets are made of
woody rods, cane splints, root fibers, or straws, all untwisted, but it is
probable that the ability to twist cordage is about equally old as
basketry. At any rate there is no American people ignorant of cord
making. The materials are occasionally sinews, more frequently bast
—that is, bark fibers. These are rolled together, almost invariably two
at a time, between the palm and the naked thigh. Cordage is used
for the second and third stages of weaving. The cotton employed in
loom weaving does not spin well by this rolling method. It was
therefore spun by being twisted between the fingers, the completed
thread being wound on a spindle. This spindle served primarily as a
spool or bobbin. In the Old World the distaff has been used for
thousands of years. This is a spindle with a whorl or flywheel. It is
dropped with a twirl, giving both twist and tension to the loose roving
of linen or wool and thus converting it into yarn by a mechanical
means. The New World never fully utilized this device. The
Southwest to-day uses the wheeled spindle, but evidently as the
result of European introduction. Old Mexican pictures and modern
Maya photographs show the spindle stood in a bowl, not dropped.
The whorl which it possessed was therefore little more than a button
to keep the thread from slipping off the slender spindle. For Peru this
is established. Thousands of spindles have been found there,
normally with whorls too small and light to serve as an effective
flywheel. It may then be concluded that all American spinning was
essentially by hand; which is in accord with the absence from all
America of any form of the wheel. The Indian spinning methods were
only two: thigh rolling for bast, finger twisting for cotton.
The origin of the higher forms of spinning and weaving in Middle
America is confirmed by the tropical origin of cotton, on which these
developments depend. The cotton of the Southwest, for instance,
was introduced from Mexico as a cultivated plant. It is derived by
some botanists from a Guatemalan wild species. This may well have
been the first variety to be cultivated in the hemisphere.
189. Textile Clothing

Clothing in general is too much an adaptation to climate to render
satisfactory its consideration wholly by the method here followed. But
clothing of textiles shows a distribution that is culturally significant.
The distribution is that of loom-woven cotton; the salient
characteristic is rectangular shape: the blanket shawl, the poncho,
the square shirt and skirt. In the Northwest Coast region hand and
half-loom woven capes and skirts of bast were worn more or less.
But these were flaring—trapezoidal, not rectangular—and thus
evidently represent a separate development.
In all the cloth weaving areas, and in them only, sandals were
worn. The spatial correlation is so close that there must be a
connection. It may be suggested that the sandal originated, or at
least owed its spread, to textile progress. Again the Northwest Coast
corroborates by being unique; it is essentially a barefoot area.
To summarize. The original textile arts of the race were probably
first advanced to the stages intermediate between basket and cloth
making in Middle America. Thence they spread north and south, but
not quite to the limits of the hemisphere, being retained in special
usage chiefly in the Northwest. With the cultivation of cotton in
Middle America, spinning and the loom came into use, and were
ultimately carried to the Southwest, but not beyond. Cloth garments
and sandals promptly followed. The heddle was evidently devised
last, and did not diffuse beyond Middle America.
190. Cults: Shamanism

In the matter of religious cults, seven entries have been included
in Figure 35: (1h) shamanism, and (1i) crisis ceremonies, especially
for girls at puberty and the whipping of adolescent boys, two more or
less synchronous traits; (6a) initiating societies, and (6b) masks—
also about contemporaneous; (16) priesthood; and (22) human
sacrifice and (23) temples.
The shaman is an individual without official authority but often of
great personal influence. His supposed power comes to him directly
from the spirits as a gift or grant. He himself, as a personality, has
been able to enter into a special relationship, denied to normal
persons, with the supernatural world or some member thereof. The
community recognizes his power after it is his: the community does
not elect him to his special position, nor accept him in it by
inheritance. His communion with spirits enables the shaman to
foretell the future, change the weather, blast the crops or multiply
game, avert catastrophes or precipitate them on foes; above all, to
inflict and cure disease. He is therefore the medicine-man; a word
which in American ethnology is synonymous with shaman. The
terms doctor, wizard, juggler, which have established themselves in
usage in certain regions, are also more or less appropriate: they all
denote shamans. When he wishes to kill his private or public enemy,
the shaman by his preternatural faculties injects some foreign object
or destructive substance into his victim, or abstracts his soul. To cure
his friends or clients, he extracts the disease object, sometimes by
singing, dancing, blowing, stroking, or kneading, most often by
sucking; or he finds, recaptures, and restores the soul. Of the two
concepts, that of the concrete disease object is more widely spread;
that of the soul theft is apparently characteristic of the more
advanced tribes; but the exact distribution remains to be worked out.
The territorial extent of shamanistic ideas and practices is from the
Arctic to Cape Horn. The method of acquiring power from spirits, the
nature of the disease object and its process of extraction, the
conviction that sickness must be caused by malevolent shamanistic
power, there being no such thing as natural death; these and other
specific features of the institution are sometimes surprisingly similar
in North and South America. In fact, they recur in peripheral parts of
the eastern hemisphere—Siberia, Australia, Africa—with such close
resemblance as strongly to suggest their being the remnants of a
once world-wide rudimentary form of religion or religious magic.
191. Crisis Rites and Initiations

Crisis rites are of equally broad diffusion and apparent antiquity.
They concern the critical points of human life: birth, death,
sometimes marriage and childbirth; but most frequently, or at least
most sacredly, they are wont to concern themselves with maturity.
They are thus often puberty ceremonials, made for the welfare both
of the individual and of the community, and fitting him or her for
reproductive functions as well as for a career as a useful and
successful community member. The girls’ adolescence rites have
been described (§ 154) in some detail for California. With but minor
variations, the account there given applies to the customs of many
American and in fact Old World peoples. The boys’ rites come at the
corresponding period of life, but their reference to sex and marriage
is generally less definite. Fortitude, manliness, understanding are the
qualities they are chiefly intended to test and fix. Privations like
fasting, ordeals of pain, admonitions by the elders, are therefore
characteristic elements of these rites. It is thus not as surprising as it
might seem at first acquaintance that identical practices, such as
having the boys stung by vicious ants, are occasionally found in
regions as remote as California and Brazil: even the particular
method may be a local survival of a wide ancient diffusion. Perhaps
most common of all specific ingredients of the rite in America is a
whipping of the boys. Possibly this commended itself as combining a
test of fortitude and an emotional memento of the counsel imparted.
At any rate it evidently became an established part of the puberty
rites thousands of years ago, and thus acquired the added social
momentum of an immemorial custom in many parts of both North
and South America.
192. Secret Societies and Masks

Out of the puberty crisis rite for boys there grew gradually a
society of initiates who recruited their ranks by new initiations. As
emphasis shifted from the individual to the community as
represented by those already initiated, the ceremony came to be
performed less for the benefit of the individual than for the
maintenance of the group, the society as such, with its rites, secrets,
and privileges. Very often, no one was excluded but immature boys
and females; yet, if the act of admittance was to have any psychic
significance, the exclusion of these elements of the community had
to be made much of. Thus secrecy toward women and children was
emphasized, although often the secrets simmered down largely to
the fact that there were secrets.
The girls’ adolescence ceremony does not seem to have taken
this course of growth, because of its more personal and bodily
character, puberty in women being so much more definite a
physiological event. There are women’s societies among some
American tribes. But they seem to be generally a weaker imitation of
the men’s societies after these were fully developed, not a direct
outgrowth of the original girls’ rite.
Shamanism entered as another strain into the formation of the
secret society. Medicine-men often would come to act for the public
good, the occasion would be repeated regularly, and a communal
ceremony with an esoteric nucleus resulted. Also, the shamans at
times helped the novice shamans train and consolidate their spiritual
powers. The extension of this habit perhaps sometimes led, or
contributed, to the establishment of a secret society (§ 158).
Masks are closely associated with secret societies. They disguise
the members to the women and boys, who are told, and often
believe, that the masked personages are not human beings at all. Of
course this adds to the mystery and impressiveness of the initiations,
especially when the masks are fantastic or terrifying. Masks and
societies thus are two related aspects of one thing. But they are by
no means inseparable. There are tribes, like some of the Eskimo,
who use masks but can scarcely be said to possess societies, while
in the Plains and elsewhere there are definite societies that initiate
without masks. Physical and economic conditions in the Arctic
operating against large-scale community life or social elaboration,
the masks of the Eskimo may represent merely that part of a mask-
society “complex” which these people could conveniently take over
when the complex reached them.
In the Southwest, among the Pueblos, there are two types of
societies. There is a communal society, embracing all adult males,
who are initiated at puberty by whipping and who later wear masks
to impersonate spirits and dance thus for the public good. There are
several smaller societies, also with secret rites, which cure sickness,
recruit their membership from the cured, and use masks little or not
at all. It is clear here how the two component strains, namely crisis
rites and shamanistic practices, have flowed into the common mold
of the society idea and become patterned by it without quite
amalgamating.
193. Priesthood
This, then, was the second general stage of American religion.
The third is marked by the development of the priesthood. The priest
is an official recognized by the community. He has duties and
powers. He may inherit, be elected, or succeed by virtue of lineage
subject to confirmation. But he steps into a specific office which
existed before him and continues after his death. His power is the
result of his induction into the office and the knowledge and authority
that go with it. He thus contrasts sharply with the shaman—logically
at least. The shaman makes his position. Any person possessed of
the necessary mediumistic faculty, or able to convince a part of the
community of his ability to operate supernaturally, is thereby a
shaman. His influence is essentially personal. In actuality, the
demarcation cannot always be made so sharply. There are peoples
whose religious leaders are borderline shaman-priests. Yet there are
other tribes that align clearly. The Eskimo have pure shamans and
nothing like priests. The Pueblos have true priests but no real
shamans. Even the heads of their curing societies, the men who do
the doctoring for the community, are officials, and do not go into
trances or converse with spirits.
Obviously a priesthood is possible only in a well constructed
society. Specialization of function is presupposed. People so
unorganized as to remain in a pre-clan condition could hardly be
expected to have developed permanent officials for religion. As a
matter of fact they have not. There are not even clear instances of a
full fledged priesthood among patrilinear sib tribes. The first
indubitable priests are found among the matrilinear Southwesterners
and a few of their neighbors. Thence they extend throughout the
region of more or less accomplished political development in Middle
America. Beyond that, they disappear.
Here once more, then, we encounter a trait substantially confined
to the area of intensive culture and evidently superimposed upon the
preceding stages. This makes it likely that the second stage, that of
societies and masks, originated in the same center, but so long ago
as to have been mostly obliterated by later developments, while
continuing to flourish half way to the peripheries.
Even the priesthood is old in Middle America. This seems
reasonably demonstrable. We do not know its actual beginnings
there. But its surviving conditions at the edge of its area of
occurrence may be taken as roughly indicative of its origin. Among
the Pueblos, each priest, with his assistants, is the curator of a
sacred object or fetish, carefully bundled and preserved. The fetish
serves the public good, but he is its keeper. In fact he might well be
said to be priest in virtue of his custodianship thereof. Associated is
the concept of an altar, a painting which he makes of colored earth
or meal. In the Plains area, some tribes may be somewhat
hesitatingly described as having a priest or group of old men as
priests. Wherever such is the case, these half-priests are the
keepers of fetish-bundles; usually they make something like an altar
of a space of painted earth. Areas as advanced as the Northwest
Coast, where distinctive priests are wanting, lack also the bundles
and altars. It looks, therefore, as if the American priesthood had
originated in association with these two ceremonial traits of the fetish
bundle and painted altar—both of which are conspicuously unknown
in the eastern hemisphere.
194. Temples and Sacrifice

In Middle America the fetish bundle and picture altar do not
appear, apparently through supersedence by elements characteristic
of the next or fourth cult stage, characterized by the temple and the
stone altar used in sacrifice. Temples, however, were already in
luxuriant bloom among the Maya in their Great Period of 400 to 600
A. D. The beginnings of their remarkable architecture and sculpture
must of course lie much farther back; certainly toward the opening of
the Christian era, very likely earlier. Before this came the
presumptive initial stage of priesthood, with bundles and altar
paintings or some local equivalent. If a thousand years be allowed
for this phase, the commencement of the priesthood would fall in
southern Mexico or Guatemala at least three thousand years ago;
possibly much longer. Peru, perhaps, did not lag far behind.
Temples mark the last phase of native American religion, but the
most purely religious characteristic of the period, independent of
mechanical or æsthetic developments, is human sacrifice. This had
long been practised by the Mayas and in Peru, but reached its
culmination in the New World and probably on the planet, at least as
regards frequency and routine-like character, among the Aztecs.
These were a late people, by their own traditions, to rise to culture
and power, attaining to little consequence before the fourteenth
century. It looks therefore as if human sacrifice had been a
comparatively recent practice, perhaps only one or two thousand
years old when America was discovered, and still moving toward its
peak.
Outside Middle America, human sacrifice was virtually
nonexistent. There was considerable cannibalism in the Tropical
Forest and Antilles, but no taking of life as a purely ceremonial act.
For the Pueblos of the Southwest, there are some slight and doubtful
suggestions, but it appears that such deaths as were inflicted were
rather punishments than offerings. The one North American people
admittedly sacrificing human life were the Pawnee, a Plains tribe,
who once a year shot to death a girl captive amid a ritual reminiscent
of that of Mexico. This has always been interpreted as suggestive of
a historical connection with Mexico. In fact, the Pawnee appear to
have moved northward rather recently, and most of their Caddoan
relatives had remained not far from the Gulf of Mexico when
discovered.
The precise origin of sacrifice is obscure, although it is significant
that it was restricted to the area of concentrated population and
towns. In Mexico at least there were no domesticated mammals
available. The ultimate foundation of human sacrifice is no doubt the
widespread and very ancient custom of offerings. It is, however, a
long leap from the offering of a pinch of tobacco, a strew of meal, an
arrowpoint or some feathers, or even a few bits of turquoise, to the
deliberate taking of a life. Possibly the idea of self-inflicted torture
served as a connection. The Plains tribes sometimes hacked off
finger joints as offerings, and in their Sun Dance tore skewers out of
their skins. In the northern part of the Tropical Forest knotted cords
were drawn through the nose and out of the mouth—a sufficiently
painful process—in magico-religious preparation. In Mexico it was
common for worshipers to pierce their own ears or tongues, the idea
of a blood offering combining with that of penance and mortification.
It may seem strange that so shocking a custom as human sacrifice
represented the climax of American religious development. Yet in a
few thousand years more of undisturbed growth, it would probably
have been superseded. This is precisely what happened in the Old
World, which may be reckoned as about four to five thousand years
ahead of the New. In the Old World also the really lowly and
backward peoples did not sacrifice men. The practice is a symptom
of incipient civilization.
195. Architecture, Sculpture, Towns

To construct stone-walled buildings seems a simple
accomplishment, especially in an environment of stratified rocks that
break into natural slabs. Such flat pieces pile up into a stable wall of
room height without mortar, and a few log beams suffice to support a
roof. Yet the greater area of the two continents seems never to have
had such structures. Stone buildings are confined to Middle America
and the Southwest. Outside these regions only the wholly timberless
divisions of the Eskimo make huts of stone, and for their winter
dwellings they are limited to choice of this material or blocks of snow.
The Eskimo hut is tiny, not more than eight or ten feet across, and
the weather is kept out not by any skill in masonry or plastering, but
by the rude device of stuffing all crevices with sod. The Eskimo style
of “building” in stone would be inapplicable in a structure of
pretension. Made larger, the edifice would collapse.
The art of masonry, like agriculture, pottery, and loom weaving,
may therefore be set down as having had its origin in Mexico or
Peru, or possibly in both. It shows, however, this peculiarity of
distribution: at both ends of the area, among the Pueblos of the
Southwest in North America and among the Calchaqui of northwest
Argentina in South America, living houses were stone-walled. In the
intervening regions, most dwellings were of thatch or mud, public
buildings of stone. The Aztec, Maya, and Inca areas have therefore
left stone temples, pyramids, palaces, forts, and the like, but few
towns; the Pueblo and Calchaqui, only towns.[28] How the Middle
Americans were first brought to use stone is not known; but a temple
built as such being a more specialized, decorative, organized edifice
than a dwelling, as well as involving some degree of communal
coöperation, it can safely be regarded as a later type than private
dwellings. The occurrence of the stone living houses at the
peripheries confirms their priority. Evidently masonry was first
employed in Middle America for simple public structures: chiefs’
tombs, water works, platforms for worship. In its diffusion the art
reached peoples like the Pueblos, who lived in small communities,
interred their leaders without great rites, and offered no sacrifices in
sight of multitudes. These marginal nations therefore took over the
new accomplishment but applied it only to their homes. Meanwhile,
however, the central “inventors” of masonry had grown more
ambitious and were rearing ever finer and larger structures, until the
superb architecture of the Mayas and the consummate stone fitting
of the Incas reached their climax.
Stone sculpture grew as an accompaniment. It remained rude in
Peru, and chiefly limited to idols, in keeping with the simple, massive
style of architecture. But the Mayas covered their structurally bolder
and more diversified religious buildings with sculpture in relief and
frescoed stucco, and between them set up great carvings of animal
and mythical divinities, as well as luxuriantly inscribed obelisks. Their
sculpture is æsthetically the finest in America and compares in
quality with that of Egypt, India, and China.
Recent excavations in the Southwest have revealed a succession
of stages as regards buildings. The first houses in this region may
have been thatched or earth-roofed. The earliest in which stone was
used were small, dug out a few feet, the sides of the excavation lined
with, upright rock slabs, and a superstructure of poles or mud-filled
wattling added. Then followed a period of detached one-room
houses, with rectangular walls of masonry; and finally the stage of
drawing these together in clusters and raising them in terraced
stories. This whole development can be traced within the area. Yet it
by no means follows that it originated wholly within the area. The
knowledge of laying stone in courses, the impulse or habit of doing
so, might, theoretically, just as well have come from without; and
evidently did actually come into the Southwest from Mexico.
This is a type of situation frequently encountered in culture history
problems. A group of data seem to point to a spontaneous origin on
the spot so long as they are viewed only locally, whereas a broader
perspective at once reveals them as merely part of a development
whose ultimate source usually lies far away. For instance, the
backward Igorot tribes of the interior Philippines rear imposing
terraces for their rice plots; their more advanced coastal neighbors
do not. It has therefore been debated whether the Igorot invented
this large-scaled terracing or learned it from the Chinese. Yet the
terracing is only an incident to rice culture, which is widespread in
the Orient, ancient, and evidently of mainland origin. The knowledge
of terracing was therefore no doubt long ago imported into the
Philippines along with rice cultivation, and the Igorot only added the
special local development of carrying the terraces to a more
impressive height. There is no question that the increase and better
concatenation of knowledge is gradually leading to more and more
certain instances of wide diffusions and fewer and fewer cases of
independent origin.
Town life possesses a material aspect—that of the type and
arrangement of dwellings—as well as the social and political aspects
already touched on. The largest towns in America were those of
Mexico and Peru, whose capitals may have attained populations of
fifty to a hundred thousand. The Maya towns were smaller, in
keeping with the Maya failure to develop an empire. The largest
towns of the Chibcha of Colombia may have held ten or twenty
thousand souls. The most flourishing pueblos of the Southwest seem
never to have exceeded three thousand inhabitants. The Calchaqui
towns in Andean Argentina were no larger, probably smaller.
Southeastern and Northwest Coast towns ran to hundreds instead of
thousands of population. These figures tell the usual story of thinning
away from center to peripheries.
But local differences were sometimes significant. The
Southeastern town, except for its court and rude public buildings,
was straggling and semi-rural compared with the compact, storied,
and alleyed Southwestern pueblo; often it was less populous. Yet its
political and military development was more advanced, at any rate
as a unit in the larger group of the confederacy.
196. Metallurgy

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The fourth edition of this best-selling reference is a valuable resource to

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Medical Evaluation of Child Sexual Abuse is an invaluable resource for

For other pediatric resources, visit the American Academy of Pediatrics

Angelo P. Giardino, MD, PhD, MPH, FAAP

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Martin A. Finkel, DO, FACOP, FAAP

Angelo P. Giardino, MD, PhD, MPH, FAAP

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Alexander Butchart, PhD

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Karen J. Farst, MD, MPH, FAAP

Lori D. Frasier, MD, FAAP

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the recipient of several Houston community awards, including the Breakthrough

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To the following colleagues, who over the past 3 decades

Foreword Carol D. Berkowitz, MD, FAAP, FACEP....................... xxiii

Chapter 9 Telemedicine and the Child Sexual Abuse

Martin A. Finkel, DO, FACOP, FAAP

185. The Sequence of Social Institutions

187. Developments in Weaving

188. Progress in Spinning: Cotton

189. Textile Clothing

190. Cults: Shamanism

191. Crisis Rites and Initiations

192. Secret Societies and Masks

194. Temples and Sacrifice

195. Architecture, Sculpture, Towns

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