From the Experts: Nancy Kellogg

This month, Dr. Nancy Kellogg--Professor of Pediatrics at the University of Texas Health Science Center at San Antonio, Chief of the Child Abuse Division, and contributor to G.W. titles such as Child Sexual Exploitation and the forthcoming Child Sexual Abuse--was generous enough to provide an article about changes in the interpretation of examination findings in children and adolescents evaluated for sexual abuse.

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Why “Normal” does not mean “Nothing Happened”

Over the past several years, there have been significant changes in the interpretation of examination findings in children and adolescents evaluated for sexual abuse. Specifically, the proportion of sexual abuse examinations with injuries indicative of penetrative trauma has declined, ranging from as high as 80%[1,2] to as low as 4%[3] over a 20-year period. While the medical diagnosis and criminal investigation now focus on the child’s history, many still find the concept of a normal examination in which a child describes multiple incidents of penetration incomprehensible.

The medical professional is often called upon to educate the judge and jury about the significance of the physical examination findings, or lack thereof, in child sexual abuse assessments. Many of the jurors come armed with factoids gleaned from watching “CSI” and other fictional crime shows. They believe DNA is as ubiquitous and durable as superglue. They believe that doctors are experts at detecting breaches in virginity. The lack of material evidence is not something they expect, and although they are told that the child’s history is “the most important evidence,” this leaves some with a nagging sense of uncertainty: “Can I REALLY convict a man that raped an 8-year-old almost daily for 2 years and left no mark?”

The medical professional can provide important information to help resolve this paradox. There are at least 4 situations where normal genital examinations have been documented despite indisputable evidence for sexual contact:

1. Most acute injuries due to sexual assault heal quickly and completely back to normal.[4]

2. Most children and adolescents with sexually transmitted diseases have otherwise normal examinations.[5]

3. Many children who were abused by individuals that confessed to specific acts, or who were videotaped during the sexual acts, have normal examinations.

4. Most pregnant adolescents have normal, “intact” hymens.[6]

A normal examination means one of three things: 1) abuse occurred, resulted in visible tissue damage, and injuries healed completely; 2) abuse occurred but did not result in tissue damage; or 3) no abuse occurred. As with other medical diagnoses, such as migraines and pain syndromes, the diagnosis of child sexual abuse relies primarily on the patient’s history. If the medical professional provides effective testimony, the jurors will consider the child’s statement carefully…and perhaps “CSI” will cease to be regarded as a reputable source of fact.

References

1. Cantwell H. Vaginal inspection as it relates to child sexual abuse in girls under 13. Child Abuse & Negl. 1983;7:171-176.

2. Hobbs CJ, Wynne JM. Child sexual abuse: an increasing rate of diagnosis. Lancet. 1987;1:837-841.

3. Heger A, Ticson L, Velasquez O, et al. Children referred for possible sexual abuse: medical findings in 2384 children. Child Abuse & Negl. 2002;26:645-659.

4. McCann J, Voris J, Simon M. Genital injuries resulting from sexual abuse: a longitudinal study. Pediatrics. 1992;89:307-317.

5. Kellogg ND, Baillargeon J, Lukefahr JL, et al. Comparison of nucleic acid amplification tests and culture techniques in the detection of Neisseria Gonorrhoeae and Chlamydia Trachomatis in victims of suspected child sexual abuse. J Pediatr & Adolesc Gynecol. 2004;17:331-339.

6. Kellogg ND, Menard SW, Santos A. Genital anatomy in pregnant adolescents: “normal” does not mean “nothing happened.” Pediatrics. 2004;113:e67-e69.