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Received for publication June 7, 1993; accepted Feb. 3,1994.
Reqprint requests to (J.A.A.) Department of Pediatrics, Valley Medical Center, 445 South Cedar Avenue, Fresno, CA 93702.
PEDIATRICS ASSN 0031 40050. Copyright © 1994 by the American Academy of Pediatrics

ABSTRACT. Background. Studies of alleged victims of child sexual abuse vary greatly in the reported frequency of physical findings based on differences in definition of abuse and of "findings." This study was designed to determine the frequency of abnormal findings in a population of children with legal confirmation of sexual abuse, using a standardized classification system for colposcopic photographic findings.

Methods. Case files and colposcopic photographs of 236 children with perpetrator conviction for sexual abuse, were reviewed. The photos were reviewed blindly by a team member other than the examiner, and specific anatomical findings were noted and classified as normal to abnormal on a scale of 1 to 5. Historical and behavioral information, as well as legal outcome was recorded, and all data entered into a dBase Ifl program. Correlations were sought between abnormal findings and other variables.

Results. The mean age of the patients was 9.0 years (range 8 months to 17 years, 11 months), with 63% reporting penile-genital contact. Genital examination findings in girls were normal in 28%, nonspecific in 49%, suspicious in 9%, and abnormal in 14% of cases. Abnormal anal findings were found in only 1% of patients. Using disciminant analysis, the two factors which significantly correlated with the presence of abnormal genital findings in girls were the time since the last incident, and a history of blood being reported at the time of the molest.

Conclusions. Abnormal genital findings are not common in sexually abused girls, based on a standardized classification system. More emphasis should be placed on documenting the child's description of the molestation, and educating prosecutors that, for children alleging abuse: "It's normal to be normal." Pediatrics 1994;94: 310-317; child sexual abuse, genital findings.

ABBREVIATION. CSAEP, Child Sexual Abuse Evaluation Program.

Children who give a history of having been sexually molested, and children in whom abuse is suspected for other reasons, are increasingly referred for medical evaluation. Questions regarding the frequency of abnormal findings in sexually abused children have been difficult to answer with certainty for two reasons: changing definitions of what constitutes an "abnormality," and the lack of a true "gold standard" for proven abuse.

The publication of studies describing the appearance of the genitalia and peri-anal tissues in non-abused prepubertal children,¹"³ and of the hymen in newborns,⁴ have helped examiners to understand which variations should be considered normal, or at least nonspecific for abuse.

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Likewise, there appears to be a growing consensus among researchers in the field of medical examination of sexually abused children as to which findings can be considered conclusive or specific for abuse.⁵"⁷

Two studies reviewing cases in which the alleged perpetrator was convicted of molesting the child reported a frequency of abnormal findings of 45%⁸ and 23%⁹ among the children examined. Again, the definition of genital abnormalities differed, as did the type of examination conducted.

This study was designed in order to determine the frequency of abnormalities among children in whose case the perpetrator was convicted of abusing the child, using a standardized classification system for blindly rating colposcopic photographs for the presence of findings suggestive or conclusive of abuse. The classification scale, which was previously described in detail,¹⁰ was developed using published data on abused and nonabused children.

At the Child Sexual Abuse Evaluation Program (CSAEP) at Valley Medical Center in Fresno, CA, notations have been made on cases in which the alleged perpetrator confessed, plead guilty, or was found guilty in court of sexual abuse. Of the 2732 children evaluated by members of CSAEP between July 1,1986 and July 1,1993, there were 262 cases in which information was obtained confirming that the perpetrator had been convicted.

The case files of patients of patients seen before July 1,1991 were reviewed by one of the authors (who had not been the original examiner), and only those cases with good quality colposcopic photographs were selected for the study. There were 18 cases with no photographs and eight with nonmagnified Polaroid photographs. After excluding these cases, 141 cases (130 girls, 11 boys) of children examined before July 1, 1991 were carefully reviewed. These photographs were all taken using a Cryomedics MM4000 or MM6000 colposcope with a 35-mm Olympus camera attached. The photographs were reviewed without referring to the case history, and the findings were recorded and classified using our previously reported classification scale.¹⁰ Measurements of the hymenal and anal orifice were taken from the photographs using a method described by McCann et al.¹¹ Anal and genital photographs were separately rated as being normal, nonspecific, suspicous, suggestive, or showing clear evidence of penetrating injury, as listed in Table 1. Normal findings are those which have been reported in nonabused children and newborns. Nonspecific findings may be due to abuse, especially if they are found shortly after an abusive episode, but may also have other causes. After the photographs were rated, the complete record was reviewed. An overall assessment of the likelihood of abuse was made, based on the quality and clarity of the child's statement, the reported emotional and behavioral changes in the child, and the presence of laboratory findings, if any. The overall scale is shown in Table 2. Specific details of the molestation were also recorded, if available.

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Normal (Class 1)

Nonspecific findings (Class 2)§

Suspicious for abuse (Class 3)**

Suggestive of Abuse/Penetration (Class 4)

Clear Evidence of Penetrating Injury (Class 5)

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* Table has been modified slightly from that which was published in AdolescPediatr Gynecol (1992;5:73-75).

§ Findings that may be caused by sexual abuse, but may also be caused by other medical conditions. History is vital

in determining significance.

** Findings that should prompt the examiner to quesiton the child carefully about possible abuse. May or may not require a report to Protective Services in the absense of a history.

Class 1: No evidence of abuse

Class 2: Possible abuse

Class 3: Probable abuse

Class 4: Definite evidence of abuse or sexual contact

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* Table reprinted with permission of Springer-Verlag, New York. Publihsed in Adolesc Pediatr Gynecol (1992;5:73-75).

For children seen between July 1, 1991 and July 1, 1993 (n = 770), data cards were completed by the CSAEP examiner within 1 week of the examination. Colposcopic photographs, which were taken on all patients, were reviewed weekly, and a team member other than the examiner "read" the photographs and recorded and coded the findings, without being told the history on the child. The classification scale was then used to give a rating for genital findings and anal findings. The history and laboratory findings were then reviewed, a rating was given for the overall likelihood of sexual abuse, and this information was recorded. There were 95 cases (85 girls and 10 boys) reviewed in this manner in which we were able to determine that the legal outcome was a guilty plea, court conviction, or confession.

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Information regarding legal outcome was provided by the law enforcement agency or District Attorney's office prior to or following the child's examination. Written requests for follow-up on legal outcome, and telephone calls to the District Attorney's office were also made by clerical staff, and by the research assistant. Information was sought concerning the type of criminal count, and whether the sentence included probation, house arrest, jail time, or fines. We were unable to obtain details on counts and sentencing on many cases, due to difficulty in tracking cases decided prior to 1991.

Data from all reviewed cases were entered into a dBase III program, and a BMDP statistical package was used to analyze the data. Discriminant analysis was used to identify variables which could predict the presence of abnormal (Class 4 or 5) genital findings on examination. Chi square analysis was used to compare the proportion of cases with abnormal findings between different groups, and paired t tests were used to compare data between groups with different legal outcomes.

In the final sample of 236 children, the mean age was 9.0 years, with a range of 8 months to 17 years 11 months. The majority of children (63%) were 8 years of age or older. There were 215 girls (91%) and 21 boys (9%). The distribution of racial background of the victims was 49% white, 42% Hispanic, 6% African-American, 1% Asian, and 2% mixed ethnicity. In 98% of cases, the suspected perpetrator was an adult male known to the child, and in 26% of cases was the father.

The type of molestation described by the child was fondling in 36%, oral-genital contact in 31%, digital-vaginal penetration in 44% of girls, and penile-vaginal contact in 63% of girls. Most children described more than one type of contact. Penile-anal contact/penetration was described by 28% of the children. The child reported experiencing pain in 45% of cases, and blood was found or reported at the time of the assault in 43 of 130 cases (34%) in which this information was available. The mean number of episodes of molestation, which were known in 63 cases, was 5.2. These numbers were estimates given by the children, and could not be verified.

The majority of suspected perpetrators (72%) plead guilty immediately prior to the trial or hearing. The court found 34 (14%) guilty following a jury trial, and 32 (14%) of the suspects confessed to varying degrees of sexual abuse. The type of criminal count was known in 172 cases. For the remaining 64 cases, the only information recorded on the chart by our office was that the perpetrator had pled guilty or confessed. We were unable to obtain further details on these cases because of different numbering systems at the police and the district attorney's office. The most common criminal counts were as follows: oral copulation (38%); "lewd and lascivious acts," which involve touching, but not necessarily penetration (15%); child molest, which includes exhibitionism and does not require that the child was touched (10%); other acts, including incest and sodomy (15%); digital penetration (8%); and rape (6%). The criminal counts often did not correlate with the specific acts alleged by the child. Sentencing included jail time in 90%, with a mean sentence of 7 years, as well as probation (30%), and other outcomes, especially fines (12%). Sentences often included probation or fines in addition to jail time.

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Utilizing our classification systrem, we found the cases to break down as follows: 1) No evidence of abuse (4%); 2) Possible abuse (5%); 3) Probable abuse (81%); and 4) Definate evidence (10%). In the probable abuse category, 94% were based on a history of molest alone. Table 3 shows the frequency of normal and abnormal genital findings in girls, and of normal to abnormal anal findings in both girls and boys. None of the boys had abnormal genital findings.

Table 4 shows the frequency of the two or three most common specific findings in each class. Percentages were calculated using a total N = 213 for girls. There were 23 cases in which no anal photos were taken on girls, and two cases where the genital photographs did not show the hymenal rim clearly enough to make an assessment. These percentages do not necessarily correlate with the percentage of cases with overall genital or anal ratings in Table 3, because most patients had a combination of normal and nonspecific findings.

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Figures 1 through 4 provide examples of genital findings using colposcopic photographs, with explanations of how each case was rated using the standard classification scale. For data analysis on genital findings in girls, the 213 cases with classifiable genital photos were studied.

In order to determine which variables predicted the presence of Class 4 or Class 5 (abnormal) genital findings in girls, discriminant analysis was performed using the following variables: age, child or caretaker's report of blood being observed with an episode of molest,

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time since last incident, description by the child of penile-genital contact or penetration, and Tanner genital stage. Of the 213 cases, there were only 90 wth complete data on all five variables. The F value to enter was 4.0, to give a statistical significance of P < .05.

The only variables which significantly discriminated between cases with and without abnormal genital findings in girls were the time since the last episode of molest and the reported presence of blood at the time of the molest. Chi square analysis showed a significantly higher incidence of abnormal genital findings in girls examined within 72 hours of the last episode of molest. Chi square analysis showed a significantly higher incidence of abnormal genital findings in girls examined within 72 hours of the last episode of molest (8/19, 42%) compared to that seen in girls examined 1 month or more after the last episode (7/88, 8%; P = .003). Of 43 cases in which blood was reported in girls, the genital examination was abnormal in 20 (46%), compared to being abnormal in 7 of 87 (8%) cases where no blood was reported. Using chi square, this difference was also highly significant at P = .000. Of the 20 cases with a history of bleeding, 12 had acute trauma, with nine rated Class 5 and three rated Class 4 for genital findings. Eight girls had evidence of prior injury (nonacute), which was healed; five were Class 5 findings, and three were Class 4.

Table 5 shows the probability of finding Class 4 or 5 genital findings in girls, according to time since assault and history of bleeding. Using chi square analysis, the proportion of cases with abnormal genital findings in girls did not vary significantly according to age group, reports of pain, Tanner genital stage, or report of penile-vaginal contact/penetration.

The mean size of the horizontal diameter of the hymenal opening, using labial traction, was compared between 19 Tanner Stage 1 girls, age 8 years to 10 years, 11 months, who had described penile-vaginal contact/penetration (7.7 ± 2.6 mm), and published data on nonabused children of the same age (6.9 ± 2.2 mm²)- There was no significant difference in these measurements. The girls alleging genital-genital contact had all stated: "He touched my private with his private," or some variation. Only one girl (see Fig 3) had an abnormal (suggestive) examination, with increased orifice size (11 mm) and hymenal narrowing to less than 1 mm.

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Because the cases of 129 of the girls were reviewed retrospectively, based on photographs, and 84 were reviewed prospectively, the mean rating of genital findings in girls were compared between the "old" (N = 129) and "new" (N = 84) groups using a pooled t test. The P value was .81, which is not significant. Similarly, the cases (girls only) with a legal outcome of guilty plea (N = 151), confession (N = 29), and court conviction (N = 33) were compared on the following variables: age, history of penile penetration, report of blood, report of pain, time since last incident, and classification of genital findings. Analysis of variance revealed no significant differences between the groups on any of these variables. In a separate analysis of 29 confession cases in girls, details of specific acts confessed to were available in 11 cases. Of six cases in which the perpetrator confessed to digital-vaginal penetration, none had an abnormal examination, while abnormal (Class 4 or 5) findings were seen in four of five cases in which the perpetrator confessed to penile-vaginal penetration.

In order to determine whether cases with legal confirmation differed from cases without such confirmation, the 213 cases (girls) in this study were compared, using paired t tests or chi square analysis, with 157 cases of girls referred to our program in which it was confirmed that no criminal charges were filed. The mean age of the child in the legally confirmed cases was significantly higher than in the "no charges filed" (NCF) group (9.0 vs 7.3 years, P = .000). Descriptions of penile-vaginal contact and pain were more frequent; however, there was no significant difference in reports of bleeding. The mean rating of genital findings was significantly higher in the confirmed cases (2.2 vs 1.8, P = .001), using the paired t test. Using chi square analysis, the frequency of abnormal genital findings was significantly higher in the confirmed, compared to the NCF group (14% vs 2%, P < .005).

The patients in this study were chosen because the legal outcome in each case involved conviction of the alleged perpetrator. This selection method may have inadvertently included children who were not actually molested, therefore, the frequency of abnormal findings may be falsely low. Legal confirmation of sexual abuse was used as a selection criteria in order to obtain the largest undiluted population of referred children who were probably molested. The number of cases in which the perpetrator confessed to specifics acts¹¹ was too small to conduct meaningful statistical analysis.

Since the charges in 170 of the 236 cases were the result of plea bargain agreements, there was no correlation between the acts described by the child (penile-vaginal penetration in 63%) and the specific counts to which the perpetrator plead guilty (rape in 6%). The perpetrator pled guilty to lesser charges, even though vaginal or anal penetration may have occurred. Also, since the examiner testified in court in 34 of the cases in which the perpetrator was convicted following a jury trial, it is possible that testimony concerning medical findings contributed to the conviction. However, the proportion of cases with abnormal genital findings did not differ between those involving confession, court conviction, and guilty pleas.

Child victims in the legally confirmed cases were significantly older, reported penetration

and pain more frequently, and had more abnormal examination findings than children in those

cases in which no charges were filed. These observations reflect the fact that in the six Central

Valley counties that refer patients to our program, decisions whether to proceed with criminal

charges are often based on either physical evidence, the child's ability to describe the abuse in

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detail, or a combination of both factors. In addition, age is very often a factor in whether or not a child is perceived to be a "good witness."

Kerns and Ritter¹⁷ have reported that there was no difference in the likelihood of abnormal genital findings between a group of 83 girls in whose case the perpetrator confessed, and 563 girls with suspected abuse, but no confession. In their study, colposcopic photos were taken on all subjects, and reviewed in a standard manner. Their data also showed that 8 of 13 patients (61.5%) with perpetrator confessions of digital-vaginal penetration had normal examinations, compared to only 4 of 22 (18.2%) in which the perpetrator confessed to penile-vaginal penetration. In our study, the number of cases with specific details was small, however, a large percentage (4/5, 80%) of girls had abnormal findings when the perpetrator.confessed to penile-vaginal penetration.

The classification of genital and anal findings using a standardized classification scale allowed for the independent review and rating of colposcopic photographs of each child, an objective process which has not been applied previously in this type of study. In Muram's study⁸, genital findings were classified using a four-point scale, however, colposcopic photographs were not used.

The frequency of normal or nonspecific genital findings in our study is the same as that reported by DeJong and Rose⁹, who reported that 77% of the 115 subjects whose charts they reviewed had no "physical evidence" of sexual abuse. In their study, colposcopic examinations were not performed, and photographs were not taken. Examinations took place at two or three different centers, and were conducted primarily by residents. The fact that we found the same proportion of normal cases using colposcopy and photographic review suggests that the detection of significant injuries may not necessarily require the use of the colposcope. We utilized measurements of the hymenal rim from the photographs to determine whether areas of apparent narrowing were less than 1 mm wide, and whether apparent enlarged hymenal openings were larger than two standard deviations beyond reported means for age and position. Using this method, many questionable abnormalities on examination were rated as nonspecific, rather than suggestive or clearly abnormal.

Our assessment of genital findings was based solely on review of the colposcopic photographs, and not on reports of what was noted by the examiner during the genital examination. This method may have led to an under-reporting of abnormalities, especially in pubertal females. Changes during a dynamic examination may not be reflected in static photographs. We used photographic findings in an attempt to use more objective criteria for reviewing the cases.

In rating the photographs without knowing the history, it might be possible to underestimate the significance of nonspecific findings such as erythema, superficial abrasions, and venous congestion found immediately after an episode of molest. An overall assessment is alsyas given, however, and if the child's history is clear, the overall rating would still be "probable abuse." In the summary of the evaluation sent to the referring child protection agency, the examiner would comment that, for example: "The marked erythema of the vulva noted two hours after the alleged episode of molest is consistent with the child's history, and most likely reflects residual to such contact." Likewise, if a child describes only fondling and oral

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copulation, the examination would be expected to be normal, and that information is also given to the referring agency. Many kinds of touching leave no signs.

Muram⁸ found a higher frequency of abnormal genital finding (45%) in the 31 cases he reviewed. In his study the suspects confessed to sexually molesting the victims, and 18 of 31 cases, confessed to vaginal penetration. Information as to whether blood was reported, and the time since the last episode of abuse, was not provided in any of the three studies.

In our study, a history of penile-vaginal contact or penetration was not found to correlate with the presence of abnormal genital findings. This contrasts with the data presented by other authors⁸'¹² and even with data from an earlier study by one of us (J.A.A.).¹³ One reason for this difference may be that we grouped together cases where the child described penile-genital contact and penile-vaginal penetration. Our rationale for this was that young children have no concept of what is meant by the term: "in the vagina." A statement such as "He put his thing in my private," may or may not mean that full penetration of the vagina occurred. Also because estrogen changes in the hymen were seen in 42% of the girls in this study, the increased elasticity and distensibility of the hymen may have accounted for the lack of correlation between a history of penetration and the presence of abnormal findings.

The only significant predictors of abnormal genital findings in this study were the time since the last episode and the history that blood was reported or observed at the time of the molest. This finding may have been influenced by the characteristics of the patients referred to our center. Only 10% of the patients in this study were examined within 3 days of the last episode of molest. It is known that acute injuries to the anogenital tissues heal rapidly, and may be difficult to detect after weeks or months.¹⁸"²⁰ The association of abnormal findings with a history of blood being reported or observed is not unexpected, even though it has not previously been reported.

The frequency of abnormal anal findings in our study was 1%. It is difficult to compare these results to other research, because the definition of abnormal findings differs from one study to another and has changed over time. Hobbs and Wynne¹⁶ reported abnormal examination findings in 25% of girls and 83% of boys in their population of patients with suspected abuse, however, findings such as erythema, venous congestion, hyperpigmentation, and intermittent anal dilatation, which were considered abnormal, have subsequently been documented in nonabused children.¹ In addition, most studies do not list individual findings and their frequency, so that a comparison of the frequency of selected findings between studies is impossible.

One limitation of the current study is the lack of certainty regarding the exact type of abuse suffered by the child victims, since most charges were the result of plea bargain agreements. As in the entire area of child sexual abuse evaluation, we must rely upon the child's description of the molestation as the best method of characterizing the abuse.

In this study, 63% of the girls described penile-vaginal penetration as having occurred. There is no way to know whether the penetration was only through the labia, or partially into the vagina, without the events being videotaped or observed by a third party. Using the child's report alone, the only conclusion justified by this data is that the child's description of penetration was not significantly correlated with the presence of abnormal findings, in cases where the perpetrator

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was convicted. In most states, the legal definition of penetration is: "penetration of the female external genitalia or anus, however slight," so that it should not be necessary to prove that penetration beyond the hymen occurred before a child's description of the act is believed. In order to determine the frequency of abnormal genital findings in cases where there is some type of verification that full penile-vaginal penetration occurred, it will be necessary to review colposcopic photographs from cases where the perpetrator has confessed to penile-vaginal penetration. Because the number of cases is relatively small at each institution, a collaborative study is needed to collect sufficient data.

It could be argued that the review of the colposcopic photographs was not completely blinded, as it was known that all children photographed were referred for suspected abuse. However, at the time of the photo review, the findings were documented and classified using our scale before any historical information was reviewed. A truly blinded review would require that photographs of nonabused children as well as photos from legally confirmed cases of abuse be reviewed and rated by an outside consultant.

It should be noted that the classification scale used in this study is currently undergoing revisions as more data are reported on nonabused children and known victims of penetrating genital injuries. This classification system was developed in order to maintain some internal consistency in the review process used at our center, and does not represent a consensus of medical experts regarding the classification of findings with respect to abuse. Although efforts are underway by committees of the American Professional Society on the Abuse of Children to reach a consensus on classification of findings, this will be a lengthy process.

This study provides additional data that the majority of children with legally confirmed sexual abuse will have normal or nonspecific genital findings. Abnormal anal findings are very rarely found. The best predictors of abnormal genital findings in female victims are the time since the assault and a history that blood was reported or observed at the time of the molest. A history of vaginal penetration given by the child did not significantly correlate with abnormal genital findings.

The use of a clearly defined method of classifying the significance of anal or genital findings, and determining the overall likelihood of abuse, allowed for the objective review of a large number of cases. It is hoped that this classification scale, or its revised version, may enable researchers and clinicians at other centers to collaborate effectively in future research endeavors.

This study also reaffirms that the history of the molest provided by the child is probably the most important evidence of sexual abuse. While widely accepted in the medical field, this fact is still not universally accepted in the legal arena. There are many reasons why a child's examination may be normal, as reviewed by Bays and Chadwick⁶, and these reasons need to be reiterated to professionals involved in the assessment of children who have been molested, as well as those who are responsible for decisions regarding legal proceedings.

A comprehensive discussion of the importance of interviewing children in a sensitive manner, as well as a presentation of interviewing techniques, appears in a recent textbook on child abuse evaluation.²¹ This book is an excellent resource for all health professionals working

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with children who may have been abused. When the child makes a statement that is clear, consistent, and detailed, the physical examination should not be relied upon to provide the "proof before proceeding with criminal charges. Health professionals who examine children must be as diligent in obtaining and recording the details of the child's statement as we are in recording the appearance of the hymen, and not be pressured to make a "diagnosis" of sexual abuse based on medical findings alone.

We extend our appreciation to Geni Krogstad, who tracked down information on legal outcome and performed the data entry, and to the University of California Central Valley Medical Education Foundation for supporting her work. Denise Ogan, Lee Vang, and Shari Escareno also assisted in this effort. We also thank Ana Marie Graf for computer services, and Kathy Colone for manuscript preparation.

The Child Sexual Abuse Evaluation Program is supported in part by funding through the California Department of Social Services, Office of Child Abuse Prevention.

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1. McCann J, Voris J., Simon M., Wells R. Perianal findings in perpubertal children selected for non-abuse: a descriptive study. Child Abuse & Neglect. 1989; 13:179-193.

2. McCann J., Wells R., Simon M, Voris J. Genital findings in prepubertal children selected for non-abuse: a descriptive study. Pediatrics, 1990;86:428-439.

3. Berenson A.B., Heger A.H., Hayes J.M., Biley R.K., Emans S.J. Appearance of the hymen in prepubertal girls. Pediatrics. 1992;89:387-394.

4. Berenson A.B., Heger A., Andrews S. Appearance of the hymen in newborns. Pediatrics. 1991;87:458-465.

5. DeJong, A.R. Genital and anal trauma. In: Ludwig S., and Komberg A.E., ed. Child Abuse, A Medical Reference, 2nd ed. New York, Edinburgh, London, Melbourne, Tokyo: 1992; 18:245.

6. Bays J., Chadwick D. Meical diagnosis of the sexually abused child, child Abuse & Neglect. 1993;17:91-110.

7. Adams J. Significance of medical findings in suspected sexual abuse: moving towards consensus. Child Sexual Abuse, 1992;1:91-99.

8. Muram D. Child sexual abuse; relationship between sexual acts and genital findings. Child Abuse & Neglect. 1989;13:211-216.

9. DeJong A.R., Rose M. Legal proof of child sexual abuse in the absence of physical evidence. Pediatrics. 1991;88:506-511.

10. Adams J.A., Harper K, Knudson S. A proposed system for the classification of anogenital findings in children with suspected sexual abuse. Adolesc Pediatr Gynecol. 1992;5:73-75.

11. McCann J., Voris J., Simon M., Wells R. Comparison of genital examination techniques in prepubertal girls. Pediatrics 1992;90:265-272.

12. Kerns D.L., Ritter M.L. Medical findings in child sexual abuse cases with perpetrator confessions. AmerJ Dis Child. 1992; 146:494.

13. Adams J.A., Ahmad M., Phillips P. Anogenital findings and hymenal diameter in children referred for sexual abuse examination. Adol Pediatr Gynecol, 1988;1:123-127.

14. Emans S.J., Woods E.R., Flagg N.T., Freeman A. Genital findings in sexually abused, symptomatic and asymptomatic, girls. Pediatrics. 1987;79:778-785.

15. White S.T., Ingram D.L., Lyna P.R. Vaginal introital diameter in the evaluation of sexual abuse. Child Abuse & Neglect, 1989:13:217-224.

16. Hobbs D.J., wynne J.M. Sexual abuse of English boys and girls: the importance of anal examination. Child Abuse & Neglect. 1989; 13:195-210.

17. Kems D.L., Ritter M.L. Medical findings in child sexual abuse cases with perpetrator confessions. Amer JDis Child 1992; 146:494.

18. McCann J., Voris J., Simon M. Genital injuries resulting from sexual abuse: a longitudinal study. Pediatrics. 1993;91:390-397.

19. Finkel M.A., Anogenital trauma in sexually abused children. Pediatrics. 1989;84:317-322.

20. McCann J., Voris J. Perianal injuries resulting from sexual abuse: a longitudinal study. Pediatrics. 1993;91:390-397.

21. Finkel M.A., DeJong A. Medical findings in child sexual abuse. In: Reece R.M. Child Abuse - Medical Diagnosis and Management. Philadelphia, PA: Lea & Febinger; 1994:185-247.

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Reprinted with permission from:
Sandt, C. (1995). Legal analysis: Understanding medical evidence and how physicians diagnose child sexual abuse. Adapted from Key evidentiary issues in child sexual abuse cases in J. Bulkley & C. Sandt (Eds.), A judicial primer on child sexual abuse. ABA Center on Children and the Law.

I. Introduction

Greater awareness of child sexual abuse is resulting in improved, systematic approaches in the medical field for evaluating the presence and degree of sexual abuse. While certain physical indicators now are known to be definitive of abuse, it is widely recognized that the lack of physical evidence does not mean abuse did not occur.¹ Improvements in medical technology, such as the colposcope and genetic fingerprinting, enhance physicians abilities to examine human genitalia.² Likewise, classification schemes, developed by medical professionals, which rate likelihood of sexual abuse on physical and behavioral indicators, result in more consistent and accurate diagnoses of sexual abuse.³ These improvements are influencing the quality and reliability of medical evidence presented in child sexual abuse cases.

The trier of fact in a child sexual abuse case must understand how physicians make a diagnosis of sexual abuse. Furthermore, the trier of fact should be able to distinguish between physical findings that clearly suggest abuse and those caused by non-traumatic factors.⁴ A familiarity with the important role the child's medical history plays when physical evidence is lacking also is necessary. Medical terminology and procedures used to assess sexual abuse can be technical and difficult for individuals outside the medical community to understand. However, when medical evidence exists, it offers the strongest support for an allegation of child sexual abuse due to its scientific nature. Thus, it is critical that the trier of fact have a basic understanding of the medical issues involved. This article will provide an overview of how physicians, through medical examination, diagnose child sexual abuse. It will also discuss relevant studies, how physical findings are classified, and admissibility of medical evidence at trial.

H. Understanding How Physicians Diagnose Child Sexual Abuse Through Medical Examination

Among physicians, child sexual abuse is recognized as a medical diagnosis.⁵ To arrive at a medical diagnosis, the physician performs a thorough medical examination, which includes a physical examination, medical history and laboratory tests when appropriate. The primary purpose of the medical examination is "to evaluate medical problems, gather evidence and provide the child with a supportive, protective environment where the child can deal with issues that follow sexual abuse." ⁶

*This article was adapted from Key Evidentiary Issues in Child Sexual Abuse Cases, in A Judicial Primer on Child Sexual Abuse (J. Bulkley & C. Sandt eds., 1994), ©ABA Center on Children and the Law. All Rights Reserved. Reprinted with permission.

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In some cases, physician findings may so clearly indicate sexual abuse that laboratory tests and medical history are unnecessary. More often, no physical evidence is found and the physician must make a diagnosis based on the child's medical history. In other cases, physical evidence is questionable and the medical history and lab results are used to support or refute physical findings.⁸

A. Physical Examination

A complete physical examination of the child's entire body is recommended as soon as abuse is suspected; this requires obtaining the child's consent in all cases except medical emergencies.⁹ A prompt examination is critical since physical indicators, when present, usually appear immediately after abuse and heal rapidly.¹⁰ The physical examination includes inspection of genitalia for injury, as well as examination of the outside of the body for physical indicators characteristic of forced abuse or attempts to restrain or silence the child. A variety of extragenital indicators of sexual abuse may exist, including: bite marks, bruises, cuts and scratches, grip marks, hair loss, chipped teeth, injuries to the throat or mouth, suck bruises and suffocation marks.¹¹

Genital Examination: The genital examination involves inspection of the hymen in girls for signs of injury or enlargement. Breaks or bleeding in hymenal tissue is rre, as hymenal tissue is remarkably resistant and elastic in nature. For this reason, any disruption to the hymen is believed to be "significant" or strongly suggestive of abuse.¹² Changes in hymenal size, due to healing and scarring, is also a significant finding.¹³ According to Myers, the most commonly observed site of hymenal injury occurs along the bottom rim of the hymen from the three oclock to nine oclock position; this is explained by the downward deflection of the penetrating object as it strikes the child's small pelvic opening.¹⁴ Injury to the upper rim may occur if the pelvic opening is digitally penetrated and a finger is directed in an upward motion.¹⁵

Changes in the appearance of the hymen in girls may result from a number of nonabusive factors.¹⁶ Normal hormone-induced changes can be easily confused with signs of abuse. For example, in a study of the effects of estrogen on the hymen in young girls during three prepubertal stages (2-4 years, latency, and the onset of puberty), researchers found that estrogen significantly altered the appearance and sensitivity of the hymen during each stage.¹⁷ Thus, since physicians look for changes in the appearance of the hymen during the genital exam, it is important that the physician is careful not to misinterpret normal physical changes with indicators of abuse. Different examining positions and techniques also are known to alter the appearance of the hymen and should also be considered by the diagnosing physician.¹⁸

Anal Examination: An anal examination is performed to assess damage to tissue or muscle in the anal area. Injury caused by anal penetration varies depending on the size of the child, size of the penetrating object, whether force was used and whether any lubrication was used.¹⁹ Damage to the anus by penetration is relatively rare, however, since stools the size of a penis or finger pass regularly through the anus.²⁰ Anal signs of abuse include redness, swelling, change in the color and strength of the sphincter muscle, anal warts, and bruising or hematomas.²¹ As was true in the genital exam, certain nontraumatic factors may explain anal abnormalities and should be considered by the examining physician before making a diagnosis of child sexual abuse.²²

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Trauma to Breasts, Buttocks, Lower Abdomen, or Thighs: Use of force during sexual activity may result in injury to the breasts, buttocks, lower abdomen or thighs. A child's description of abusive events may be corroborated by the presence of injuries to these areas, including: bruises, scratches or abrasions. For example, a physicians discovery of belt marks on a child's buttocks may be used to substantiate a child's report that he was whipped with a belt.

Pregnancy: Pregnancy is an indicator of sexual activity. Most perpetrators are unaware that girls as young as nine years of age may be capable of becoming impregnated. Young girls who become pregnant at a very early age usually do so by accident. While it is customary to assume a girl became pregnant through consenting to sexual intercourse, a physician examining a child for sexual abuse should always consider pregnancy as a possible indicator of sexual abuse in young girls. Special consideration should be given when the girl is particularly young, as the chances that she was pressured or forced to engage in sexual activity are higher.²⁴

Differential Diagnosis: To ensure precision in the diagnosis, the physician forms a "differential diagnosis," which involves comparison of two or more possible diseases or conditions.²⁵ The differential diagnosis allows the physician to screen out any factors which may mimic signs of abuse. During this stage, the history obtained from the parents or caretaker is carefully considered to ensure they have not misinterpreted normal masturbation or sexual play. Other factors also are considered to ensure accurate findings, such as whether the parents are involved in a custody dispute or whether they themselves were abused.²⁶

Classification of Physical Findings: There appears to be general agreement in the medical field that certain physical findings are definitive or clear evidence of sexual abuse.²⁷ A recent classification of anogenital findings in children suspected for sexual abuse characterized definitive findings as: "those explained only by penetrating trauma to the hymen or peri-anal tissues." The following physical indicators have been suggested as clear and convincing evidence of penetrating injury: 1) absence of hymenal tissue in areas of the posterior half of the hymenal rim, observed when the child is in a knee-chest position; 2) obvious hymenal transections; 3) peri-anal lacerations extending beyond the external anal sphincter; 4) recent hymenal-vaginal lacerations; 5) lacerations through the hymen and posterior fourchette or perineum.²⁹ A number of sexually transmitted diseases also were included in the classification for clear and convincing evidence of sexual contact. These include: syphilis, gonorrhea, condylomalata, trichomonas, herpes type II and chlamydia.³⁰

Findings not definitive of or clear evidence of sexual abuse have been classified as: 1) suggestive, suspicious or consistent with sexual abuse;³¹ 2) non-specific or sometimes seen in sexually abused children;³² or 3) normal or unlikely to be caused by sexual abuse.³³

Several factors influence the types of physical evidence discovered during the examination. They include: type of abuse; objects or body parts used; child's age; degree of force used; use of lubricants; number of episodes of abuse; and the amount of time elapsed before the exam.³⁴ The examining physician evaluates the child for these factors during the medical history stage and uses them to help explain physical findings.

B. Medical History

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The purpose of the medical history is threefold: (1) to determine the nature of the abuse; (2) to uncover the frequency of the abuse; and (3) to discover the identity of the perpetrator.³⁵ This is accomplished by interviewing the child, the child's family, and others who may have knowledge about the child and the alleged abuse.³⁶ The interview is usually conducted by a physician, nurse or social worker. A variety of aids, including anatomical dolls and drawings, are used by the interviewer to obtain information about what happened.³⁷

Components of the medical history are: (1) the complaint; (2) the history of the present illness; (3) past medical history; (4) family history; (5) psychosocial history; and (6) a review of body systems.³⁸ Certain trends and patterns may be uncovered in the medical history that are relevant to sexual abuse (e.g., genital trauma, nightmares, signs of suicide or depression, school problems, developmental or behavioral problems, rashes and history of drug/alcohol abuse).³⁹ The history also is important to help the physician recommend further tests or to refer the child to a specialist, both of which can lead to a more accurate diagnosis.

Physical Indicators Lacking: In cases where no physical indicators are found during the medical exam, the physician relies on the medical history to make a diagnosis.⁴⁰ Studies show that in a majority of cases, no physical evidence of sexual abuse exists. It is important that the trier of fact be aware that lack of physical evidence does not mean that sexual abuse did not occur. In the medical community, it is widely recognized that the lack of physical evidence does not rule out the possibility of abuse. For this reason, greater weight is placed on the medical history in making a diagnosis. A summary of data from 12 studies of medical findings in allegedly abused children revealed normal examinations in 26%-73% of girls (mean 50%) and 17-82% (mean 53%) of boys; whereas, findings diagnostic of sexual abuse were found in only 3% to 16% of child victims.⁴¹ These findings suggest that, in most cases, physicians rely heavily on the medical history when diagnosing child sexual abuse.

Several forms of sexual contact leave no physical signs. These include: fondling, kissing, fellatio, cunnilingus and use of children in pornography.⁴² There are a number of other reasons why physical evidence of sexual abuse may be lacking. One reason is that full penetration of the penis may not result in damage to the hymen. As discussed earlier, the hymen is very strong and resistant to injury. Physical evidence also may be lacking because the offender suffers erectile/ejaculatory dysfunction. Healing of genital injuries before the child is medically examined is yet another reason.⁴³ In instances where physical indicators are lacking, a physicians testimony explaining that lack of physical evidence does not rule out the possibility of abuse, followed by the results of the medical history, is critical.⁴⁴

Physical Indicators Present: The medical history plays an equally significant role in the diagnosis when physical evidence is clearly present. In one study of 39 cases of child sexual abuse, in which penetration was proven legally by felony conviction of the perpetrator, the conviction rate was higher in cases where there was no physical evidence (69%), compared with those where physical evidence was present (94%). In the cases where no physical evidence was found, the diagnosing physician relied on the victims medical histories. The conclusion drawn from these findings suggests that an overemphasis on physical evidence "distract[s] from the most important element in child sexual abuse cases, the history." ⁴⁵

Medical history can shed light on and clarify physical findings. In cases where an infection or disease is believed to have been transmitted sexually, the possibility that the child may have acquired a sexual disease by nonsexual means places particular importance on the medical history to help determine the

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likelihood of sexual abuse. In these cases, the history helps identify sources of sexual contact, where the contact took place, and ultimately whether sexual contact did in fact occur.⁴⁷

C. Laboratory Tests

Laboratory tests also may play an integral role in diagnosing child sexual abuse and are especially useful for confirming the presence of physical evidence. Certain tests aid in the discovery of bodily fluids which may have been transmitted sexually. Some tests are useful for identifying the perpetrator. Others reveal injuries too small to be seen with the unaided eye. The absence of laboratory evidence, however, does not mean abuse did not occur.⁴⁹

Genetic Fingerprinting: Genetic fingerprinting is a fairly new technique finding increasing acceptance among medical professionals. The technique is used to identify the perpetratory and Involves comparison of DNA coding material contained in sperm found on the child victims body with a sample from the defendant. The test has been regarded by courts as "sufficientiy reliable" for admissibility purposes because the possibility that DNA coding material could be duplicated in a person other than the defendant is highly unlikely.⁵⁰

Colposcope: Use of the colposcope in medical examinations for child sexual abuse also is gaining recognition among medical professionals. Like the microscope, the colposcope is a magnification device used during the genital examination to make observations that cannot be made with the unaided eye. A 1986 study examining use of the colposcope over a four year period to diagnose child sexual abuse revealed that in 10% of cases, the colposcope identified lesions that otherwise would not have been detected.⁵¹ A photographic device is usually attached to the colposcope to document findings and preserve evidence. Critics argue that the Frye rule excludes findings made with the colposcope because it is a "novel device." This argument has received tittle support however, as courts recognize the colposcope has long been used by the medical community to detect sexual abuse and rape.⁵²

Special Dyes and Solutions. Other laboratory procedures include use of special dyes to identify presence of lacerations and other injuries to the genital area Toluidine blue and Lugols solution are two dyes that help reveal fissures and acute lacerations commonly caused by sexual abuse. Additionally, venereal warts may be identified through application of acetic acid to the genitalia⁵³

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III. Admissibility of Expert Medical Testimony

For the most part, expert testimony regarding medical evidence of sexual abuse is admissible. The guiding principal in determining whether expert testimony is admissible is whether it will assist the jury understand the evidence or determine a fact in issue.

Myers et al. describe four types of expert medical testimony which courts have found admissible.⁵⁵ First, some courts have allowed experts to state a child was sexually abused based on medical findings.⁵⁶ However, such testimony is subject to an ultimate factual inquiring before the court which may limit its admissibility. Other courts limit medical experts to statements of fact that are clearly within their own expertise. Under this reasoning, a physician might be permitted to describe the type of contact or findings made during the physical examination. In cases where the physicians opinion is based on the medical history or laboratory tests, the physician may be permitted to describe how they influenced his opinion. Second, some courts permit physicians to assert that the child has a "diagnosis" of child sexual abuse; this enhances the first type of testimony, as it adds medical certainty to support the assertion that a child was sexually abused. Third, physicians also have been permitted to testify that the child's condition is "consistent with" sexual abuse. And finally, physicians have been permitted to testify that a child demonstrates no physical or medical evidence of child sexual abuse, but that the lack of evidence does not rule out the possibility abuse occurred; this assertion is particularly important in the event the defense argues that lacking physical evidence implies abuse did not occur.

Physicians may be asked to render an opinion regarding the cause of injuries.⁵⁷ Most courts permit physicians to respond to questions concerning whether injuries could have occurred in a particular way,⁵⁸ whether a caregivers explanation of injuries is reasonable,⁵⁹ and whether penetration actually occurred.⁶⁰ In cases requiring that penetration be established, medical testimony is not always necessary. Some courts permit circumstantial evidence, such as the victims testimony, to establish penetration. However, prosecutors must be certain the record contains enough detail to support such a finding, since descriptions of penetration offered by child victims are often incomplete and nonspecific.⁶¹

In state cases, findings made with the aid of new scientific devices and techniques, such as the colposcope and genetic fingerprinting, are admissible if they have gained general acceptance in the medical community. In People v. Mendibles, it was argued that the colposcope was a "novel device;" therefore any findings made with the colposcope were subject to the Frye test, which excludes evidence established through "novel" means. It was further argued that formation of medical judgments regarding sexual abuse, based on physical evidence, was a novel scientific technique. Both arguments were rejected, however, since use of the colposcope and the physical examination have long been recognized as legitimate medical techniques for diagnosing child sexual abuse.⁶⁴

In federal cases, however, and in states which have adopted Rule 702 of the Federal Rules of Evidence, the general standard of relevancy and reliability set forth in the Federal Rules of Evidence 702, not the Frye rule, governs admissibility of scientific evidence. This was recently established by the Supreme Courts opinion in Daubert v. Merrell Dow Pharmaceuticals.⁶⁵

IV. Conclusion

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There is considerable information, often detailed and directed toward medical professionals, about medical evidence in child sexual abuse cases.⁶⁶ The information in this article provides an overview of the medical examination, emphasizing three stages involved in the diagnosis for child sexual abuse: physical examination, medical history and laboratory tests. An understanding of the importance of these three parts, the types of medical evidence obtained by physicians during each stage, and how evidence is classified is useful for determining the reliability of physicians medical testimony and evidence presented in court. New developments will continue to evolve and improve the quality and understanding of evidence in child sexual abuse cases. It is important to note that the information provided here is merely a framework and that, as awareness of child sexual abuse continues to increase, many new techniques for assessing medical indicators of abuse will surely result that will affect how courts address use of medical evidence in child sexual abuse cases.

¹ See Joyce A. Adams, Classification of Anogenital Findings in Children with Suspected Sexual Abuse: An Evolving Process, 6 The Advisor 1 (1993), for classifications of definitive evidence of sexual abuse. See also Jan Bays & David Chadwick, Medical Diagnosis of the Sexually Abuse Child, 17 Child Abuse & Neglect 91 (1993).

² See Martin A. Finkel & Allen R. DeJong, Point/Counterpoint: The Colposcopic Examination, 3 Violence Update 3 (1993), for a detailed discussion of the use of the colposcope in child sexual abuse examinations. See also John E.B. Myers et al., Expert Testimony in Child Sexual Abuse Litigation, 69 Neb. L. Rev. 46 (1989), for further discussion of innovative medical techniques and devices used during the physical exam.

³ See sources cited supra note 1.

⁴ When diagnosing child sexual abuse, a physician must consider a number of nontraumatic factors which may result in findings resembling sexual abuse. These include accidental injuries, and masturbation. Myers et al., supra note 2, at 45.

⁵ Myers et al., supra note 2, at 36.

⁶ Sarah R. Kaplan, American Bar Association, Medical Evidence, in the Child Sexual Abuse Judicial Education Manual 71 (J. Bulkley & C. Sandt eds., 1993).

⁷ Bays & Chadwick, supra note 1.

⁸ See Bays & Chadwick, supra note 1, at 92, for further discussion of the various ways physicians diagnose child sexual abuse.

⁹ Kaplan, supra note 6, at 73.

¹⁰ Id.

¹¹ Id.

¹² Bays & Chadwick, supra note 1, at 105.

¹³ Id.

¹⁴ John E.B. Myers, Evidence in Abuse and Neglect Cases °<y4.22 (2d ed. 1992)

¹⁵ Id.

¹⁶ See sources cited supra note 1.

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¹⁷ Bays & Chadwick, supra note 1, at 97.

¹⁸ Kaplan, supra note 6, at 77.

¹⁹ Myers, supra note 14, "<s>4.22.

²⁰ Id.

²¹ See Myers et al., supra note 2, at 43-45, for complete list of anal indicators of sexual abuse.

²² These may include Crohns disease, hemolytic uremic syndromes, postmortem anal dilation, neurogenic patulous anus, lichen sclerosis and chronic constipation. Bays & Chadwick, supra note 1, at 96.

²³ Suzanne M. Sgroi et al., Validation of Child Sexual Abuse, in Handbook of Clinical Intervention in Child Sexual Abuse (S. Sgroi ed., 1982).

²⁴ Id.

²⁵ See Bays & Chadwick, supra note 1, at 95, for a detailed discussion of conditions which may mimic findings caused by sexual abuse.

²⁶ Id.

²⁷ Joyce A. Adams, Classification of Anogenital Findings in Children with Suspected Sexual Abuse: An Evolving Process, 6 The Advisor 1 (1992); Bays & Chadwick, supra note 1.

²⁸ Adams, supra note 1, at 1.

²⁹ Id.

³⁰ Id.

³¹ These findings may include: 1) presence of sexually transmitted disease (i.e., trichomonas, chlamydia, condyloma acuminata, or herpes II); 2) marked enlargement or dilation of hymenal opening; 3) disruptions of hymen tissue; 4) anal dilation; 5) anal scars or skin tags outside midline. See Adams, supra note 1, at 13, for a complete list of these findings.

³² Non-specific findings include vaginal discharge, anal fissures, and swelling of peri-anal tissues. See Adams, supra note 1, at 12, for a more complete list of these findings.

³³ Normal findings include hymenal changes caused by estrogen, hymenal bumps, and longitudinal vaginal ridges. See Adams, supra note 1, at 12, for a complete list of these findings.

³⁴ Bays & Chadwick, supra note 1, at 103.

³⁵ Kaplan, supra note 6, at 74.

³⁶ Teachers, therapists, neighbors, day care providers, and religious officials are examples of individuals who may posses information about the child relevant to the medical history.

³⁷ Kaplan, supra note 6, at 73.

³⁸ Myers, supra note 14, *^f4.21.

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³⁹ Myers et. al.,supra note 2, at 36.

⁴⁰ Id. at 37.

⁴¹ Bays & Chadwock, supra note 1, at 92 (citing J.E. Paradise, The Medical Evaluation of the Sexually Abused Child, 37 Pediatric Clinics of North America 839-862 (1990)).

⁴² Id.

⁴³ Bays & Chadwick have summarized a number of generally accepted reasons why physical findings may be lacking in sexually abused children. They include: 1) delayed medical examination reduces likelihood of positive findings; 2) semen or evidence of ejaculate is unlikely to be found during examination of sexually abused children, especially when child has washed, urinated or defecated and more than 72 hours have passed since time of assault; 3) anal sphincter allows passage of stools larger than diameter of penis with no damage; and 4) hymen tissue is usually elastic, thus full penetration by finger or penis is unlikely to cause visible trauma. Id.

⁴⁴ Myers et al., supra note 2, at 38.

⁴⁵ Bays & Chadwick, supra note 8, at 102 (citing A.R. DeJong & M. Rose, Legal Proof of Child Sexual Abuse in the Absence of Physical Evidence, 143 Am. J. Of Diseases Of Children 422 (1989)).

⁴⁶ David L. Ingram, Controversies About the Sexual and Nonsexual Transmission of Adult STDs to Children, in Child Sexual Abuse 14-27 (1991).

⁴⁷ Myers, supra note 14, «<v4.21.

⁴⁸ Myers et al., supra note 2, at 45.

⁴⁹ Id. at 46.

⁵⁰ See Andrews v. State, 533 So. 2d 841, 843 (Fla. Dist. Ct. App. 1988).

⁵¹ Woodling & Heger, The Use of the Colposcope in the Diagnosis of Sexual Abuse in the Pediatric Age Group, 10 Child Abuse & Neglect 111,114 (1986).

⁵² Id.

⁵³ Myers et al., supra note 2, at 46.

⁵⁴ Id.at 48.

⁵⁵ Id.

⁵⁶ See State v. Butler, 349 S.E.2d 684, 685 (1986).

⁵⁷ Myers et al., supra note 2, at 49. See People v. Medibles, 245 Cal Rptr. 553, 562 (1988).

⁵⁸ Id. See Owens v. State, 514 N.E.2d 1257 (Ind. 1987).

⁵⁹ Id. See State v. Tanner, 675 P.2d. 539, 544 (Utah 1983).

⁶⁰ Id.

⁶¹ Myers, supra note 14, «^4.28. See Edmonds v. State, 380 So.2d 396, 398 (Ala. Crim App. 1980). See also Davis v. State, 569 So.2d 1317, 1319 (Fla. Dist. Ct. App. 1990); State v. Moore, 404 S.E.2d 695, 698-99 (1991); Vernon

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v. State, 814 S.W.2d845 (Tex. Ct. App. 1991). For an example of a sexual abuse case where a childs testimony was not specific enough to establish penetration, see State v. Oneill, 589 A.2d 999 (N.H. 1991).

⁶² Myers et al., supra note 2, at 50.

⁶³ People v. Mendibles, 245 Cal Rptr. 553, 562 (1988).

⁶⁴ Id.

⁶⁵ 113 S. Ct. 2786 (1993). See also United Stated v. Martinez, 3 F.3d 1191 (8th Cir. 1993) (findings DNA testing reliable under the Daubert standard).

⁶⁶ See, e.g., Joyce A. Adams, Significance of Medical Findings in Suspected Sexual Abuse: Moving Toward Consensus, 1 J. Child Sexual Abuse 91-99 (1992); Jan Bays, Medical Signs Which May Mimic Sexual Abuse, 3 The Advisor 5 (1990); Carol D. Berkowitz, Physical Findings in Sexually Abused Children: What Do We Know in the 1990s?, in Child Sexual Abuse 2-14 (R.D. Krugman & J.M. Levanthal eds., 1991); Allan r. DeJong & Mimi Rose, Frequency and Significance of Physical Evidence in Legally Proven Cases of Child Sexual Abuse, 84 Pediatrics 1022 (1986); Martin A. Finkel, The Medical Evaluation of Child Sexual Abuse, in Child Sexual Abuse: A Handbook for Health Care and Legal Professionals 82 (D. Schetky & A. Green eds., 1988).

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