Child Abuse Pocket Atlas, Volume 2: Sexual Abuse

By Randell Alexander, MD, PhD, Angelo P. Giardino, MD, PhD, Debra Esernio-Jenssen, MD and 5 more

212 pages, 445 images, 11 contributors

Sexual abuse of children is an especially delicate matter, and each reported case should be treated with exacting care. Accurate identification and appropriate response to symptoms of sexual maltreatment in children is essential to the resilient, long-term recovery of survivors. Therefore, it is incumbent upon those professionals who care for and represent the interests of survivors to recognize cases of childhood sexual abuse and to respond expediently, in the survivors’ best interest.

Child Abuse Pocket Atlas Series, Volume 2: Sexual Abuse, the second addition to an ongoing series on child abuse, will support medical practitioners and other affiliated sexual assault response providers in identifying and interpreting the physical signs and symptoms of sexual abuse in children.

• Language: English
• Publisher: STM Learning
• Release date: Mar 15, 2016
• ISBN: 9781936590643

Randell Alexander, MD, PhD

Randell Alexander is a professor of pediatrics at the University of Florida and the Morehouse School of Medicine. He currently serves as chief of the Division of Child Protection and Forensic Pediatrics and interim chief of the Division of Developmental Pediatrics at the University of Florida-Jacksonville. He is the statewide medical director of child protections teams for the Department of Health's Children's Medical Services and is part of the International Advisory Board for the National Center on Shaken Baby Syndrome. He has also served as vice chair of the US Advisory Board on Child Abuse and Neglect, on the American Academy of Pediatrics Committee on Child Abuse and Neglect, and the boards of the American Professional Society on the Abuse of Children (APSAC) and Prevent Child Abuse America. He is an active researcher, lectures widely, and testifies frequently in major child abuse cases throughout the country.

Book preview

Chapter 1

Basic Anogenital Anatomy

Joyce A. Adams, MD

In order to recognize signs of child sexual abuse, it is necessary to first be familiar with normal genital anatomy, its variations, and its development. While this may seem obvious, the lack of understanding of the many variations in normal appearance of the genital and anal tissues in children has led to misunderstandings among medical and nonmedical professionals alike. Even after the publication of the first detailed descriptions of anal and genital anatomy in nonabused prepubertal children,¹-³ some physicians and nurses who perform child sexual abuse medical evaluations are not familiar with the findings from those and subsequent studies.⁴-⁹

When a child’s examination is thought to show signs of injury or abuse but actually represents normal findings or evidence of another medical condition, the medical provider may contact child protection and/or law enforcement officials to report the suspicions. The child and family would then be unnecessarily traumatized by a referral and investigation of those suspicions.

It is also important for medical and nursing professionals, as well as nonmedical professionals, to be able to speak the same language when describing features of genital and anal anatomy in children and adolescents. Anatomy courses in medical and nursing school rarely provide the necessary detail about the features of genital anatomy in children, usually focusing on adults and on pathology common to adult patients.

In the early 1990s, a group of physicians met at conferences to agree on proper terminology for describing features of genital and anal anatomy, and the results of a 4-year consensus development process was published by the American Professional Society on the Abuse of Children in 1995. Some of the definitions were taken from standard medical dictionaries and anatomy textbooks, but out of necessity, other definitions were created by specialists working in the field of sexual abuse medical evaluation.

Table 1-1 is a list of terms and definitions from that publication.¹⁰

Embryology

An appreciation of the wide variation in the appearance of the genital and anal tissues in children requires an understanding of embryology and how the external genital tissues develop. For the first 6 weeks of development, the genital structures of the human embryo are in an undifferentiated state. In males, a transcription factor encoded on the sex-determining region of the Y chromosome (SRY) is produced during the seventh week, which triggers male development. In the absence of a Y chromosome and SRY production, female development progresses.

From the indifferent stage (4 to 7 weeks) through the 12th week, the genital tubercle differentiates into the glans and shaft of the penis in the male and into the glans and shaft of the clitoris in the female. The definitive urogenital sinus develops into the penile urethra in the male and the vestibule of the vagina in the female. The urethral fold becomes the penis surrounding the penile urethra in the male or the labia minora in the female. The labioscrotal fold develops into either the scrotum in the male or the labia majora in the female.¹¹

A detailed study of the development of the perineum was published in 2005, which provided a new understanding of the formation of the vagina and hymen.¹² In the undifferentiated state, the distal ends of the fused paramesonephric ducts are separated from the urogenital sinus by the dense stroma of the Mullerian tubercle. In females, the mesonephric ducts regress and the fused paramesonephric ducts form the uterus and vagina. The mesonephric orifices are incorporated into the orifice of the developing vagina, and the epithelium is replaced by the epithelium from the Mullerian tubercle.

The vagina expands and extends downward to bulge into the vestibulum, and the paramesonephric epithelium is transformed into vaginal epithelium. The glycogen-filled cells begin to disintegrate, which forms the lumen of the vagina.

The data from the study by van der Putte provide support for the theory that the vagina is formed mainly from paramesonephric epithelium, not from the urogenital sinus.¹² Alternate theories postulated prior to this study held that the inferior portion of the vagina was formed from a portion of the urogenital sinus called the sinuvaginal bulb.¹¹

The lengthening of the vagina into the vestibulum, where it meets the dense stromal tissue of the Mullerian tubercle, forms the hymen.¹² Folds in the urogenital sinus contribute to the lateral folds of the hymen. The deepening of the dorsal vestibular groove accentuates the dorsal segment of the hymen, which in clinical terms is referred to as the posterior or inferior rim. Both the inner side and the outer side of the hymen are made up of sinus epithelium. Van der Putte reports that primordial urethral glands were occasionally found on the inner side of the hymen, which he believes could be the origin of the hymenal cysts described by Merlob et al.¹³ Another finding from this study is that the hymen itself is … built of finely fibrillar connective tissue without the smooth muscle element predominant in all of its surrounding tissues.¹²

The opening in the hymen develops as the stromal tissue between the descending vagina and the urogenital sinus regresses. It is postulated that the denser the column of stromal tissue, the more likely it is that the tissue will not completely regress, which leads to a microperforate or imperforate hymen. See Figure 1-1 for details of female external genital anatomy. If the tissue is denser in some areas than others, the uneven regression could also produce a septate or cribriform hymen.

Normal Variations

The increasing societal awareness of the problem of child sexual abuse, beginning in the 1980s, and the involvement of physicians in the evaluation of children with suspected child sexual abuse stimulated interest in the appearance of the hymen in neonates. A study by Jenny et al¹⁴ identified the presence of a hymen in all 1131 neonates examined, and Berenson et al¹⁵ described the morphology of the hymen and anatomical variations in 449 neonates who were examined and photographed in