Sexual abuse and assault

The classification scheme proposed by Joyce Adams et al may be used to determine the significance of physical findings.

Normal variants include:

Periurethral or vestibular bands, intravaginal ridges or columns, hymenal bumps or mounds, hymenal tags, septal remnants, linea vestibularis, hymenal notch or cleft (regardless of depth) above the 3 and 9 o’clock location of the hymen, superficial notch of the hymen at or below the 3 and 9 o’clock location of the hymen, external hymenal ridge, congenital variations in hymenal appearance (crescentic, annular, redundant, septate, cribriform, microperforate, imperforate), diastasis ani, hyperpigmentation of labia minora or perianal tissues, dilation of the urethral opening with labial traction, thickened hymen.

Findings commonly caused by other medical conditions include:

Erythema, increased vascularity, labial adhesions, vaginal discharge, friability of the posterior fourchette or commissure, excoriations, bleeding or vascular lesions, perineal groove (failure of midline fusion), molluscum contagiosum, anal fissures, venous congestion or venous pooling in the perianal area, flattened anal folds, partial or complete anal dilation.

Indeterminate findings include:

Deep notches or clefts in the posterior/inferior rim (between 3 and 9 o'clock) of the hymen in prepubertal girls
Deep notches or complete clefts in the hymen at 3 or 9 o'clock in adolescent girls
Complete clefts/transections at 3 or 9 o’clock
Wartlike lesion in the genital or anal area
Vesicular lesions or ulcers in the genital or anal area
Marked, immediate anal dilation.

Findings suggestive but not diagnostic of sexual contact include:

Genital or anal condyloma acuminatum: the specificity for sexual transmission is indeterminate if there are no other indicators of abuse. Lesions appearing for the first time in a child older than 5 years of age may be more likely to be the result of sexual transmission.
Herpes type 1 or 2 in the genital or anal area: may be innocently transmitted, autoinoculated, or sexually transmitted. The presence of the infection is not diagnostic of sexual contact in a child with no other indicators of abuse.

Findings diagnostic of trauma and/or sexual contact include:

Acute trauma to external genital or anal tissues, such as acute lacerations or extensive bruising of labia, penis, scrotum, perianal tissues, or perineum and fresh laceration of the posterior fourchette, not involving the hymen.

Residual (healing) injuries include:

Injuries indicative of blunt force penetrating trauma (or abdominal/pelvic trauma) include:

Laceration of the hymen
Acute ecchymosis, petechiae, or abrasion on the hymen
Hymenal transection (healed) between 4 and 8 o'clock of the hymenal rim, and missing segment of hymenal tissue
Perianal laceration with exposure of tissue below the dermis.

Presence of infection confirms mucosal contact with infected and infective bodily secretions, contact most likely to have been sexual in nature:

Positive confirmed test for gonorrhea from genital area, anus, or throat outside the neonatal period.
Positive test from genital or anal tissues for chlamydia, if child is older than 3 years at time of diagnosis and specimen was tested using cell culture or comparable method approved in the US by the Centers for Disease Control and Prevention.[46]
Confirmed Trichomonas vaginalis infection in a child older than 1 year of age.
Confirmed syphilis if perinatal transmission is ruled out.
Positive confirmed serology for HIV if perinatal transmission, transmission from blood products, and needle contamination have been ruled out.

Other laboratory findings diagnostic of sexual contact include:

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Criteria