CHILD SEXUAL ABUSE

INFANTILE GENITAL ANATOMY

• THE HYMEN: is a thin membrane originating from a relief of the vaginal mucosa that forms a small diaphragm at
the limit of separation of the vaginal canal from the vulva, forming an anatomical barrier of great legal
implication, since its injury is indicative of a carnal act.
• CHARACTERISTICS OF THE HYMEN
o Consistency: It is variable, they can be a thin or resistant membrane (fibrous, tendinous, cartilaginous).
o Elasticity: The elasticity of the hymen membrane depends on its shape, size and consistency.
of the membrane, which is related to the amount of elastic fibers that the tissue contains.
o CHANGES IN THE HYMEN WITH AGE

Infant Teenager
o DIMENSIONS OF THE PREPUBERTAL HYMEN
- A horizontal diameter of the hymenal orifice of up to 5 mm is considered normal up to 5 years of age.
- From 5 to 9 years, 1 additional mm per year is considered.
- In girls before puberty, an average diameter of 1cm to 1.5cm is considered.
- A diameter above these values is SUSPECTED of sexual abuse, and should be evaluated.
together with other findings.

TYPES OF HYMEN
- Annular
- Bilabiate
- Semilunar
- Partitioned
- Cribriform

Annular hymen Bilabiate hymen Lunate hymen Hymenseptate cribriform hymen

GENITAL INJURY MECHANISM

The appearance of lesions depends on two mechanisms:
• The degree of violence of the sexual act
• The anatomical disproportion between the parts involved (penis vagina) (penis anus).

GENITAL DEVELOPMENT AND SEXUAL ACT

• In girls under 6 years of age, vaginal intercourse is practically impossible because the suprapubic angle is very
acute.
• Between the ages of 6 and 11, intercourse is possible, but due to the anatomical disproportion, significant
injuries occur both at the vaginal level and in the rectovaginal septum.
• In girls over 11 years of age, vaginal intercourse is possible due to the development of the hymen (under the
hormonal stimulus of menarche) and the degree of injury will depend on the brutality of the action and the type
of hymen of the victim.
MOST COMMON PLACE OF TEAR ACCORDING TO TYPE OF HYMEN
MEDICAL HISTORY OF THE CHILD VICTIM
• BACKGROUND
A. Previous reports or examinations for sexual abuse.
B. Gynecological history: Previous trauma to the anogenital area, pregnancies, abortions, gynecological
operations, menarche, date of first sexual intercourse, etc.
C. History of behavioral or psychiatric disorders.
D. Existence of potential situations of abuse in the family or social environment.
E. History of antisocial behavior in the minor.

KEY QUESTIONS DURING THE INTERVIEW

• The date, time and place where the events occurred and their circumstances.
• If in addition to sexual violence there was another type of physical violence (extragenital injuries) or
psychological abuse
produced by the aggressor.
• How the victim defended himself from the attack (scratches, bites, etc.).
• If you know the attacker.
• If there was penetration, what was the route, whether there was ejaculation or not
• If I use any type of protection such as condoms.
• Whether it was single or repeated penetration.
• If it was accompanied by physical violence.
• If I use foreign bodies or prostheses.
• If there are stains on clothes or body.
• If personal hygiene or change of clothes was performed.

CLINICAL EXAMINATION
• Characteristics:
either Voluntary, explained, private.
either Avoid traumatizing the patient (re-victimization).
o It must be complete (genital, paragenital, extragenital area).
o Preferably, you should be accompanied by a female staff member at the time of the exam.

• Goals:
o Document sexual abuse: identifying injuries, taking samples of secretions and other tests (DNA).
o Detect sexually transmitted diseases or risk of contracting them for subsequent treatment.
o Detect the possibility of unwanted pregnancies.
o Coordinate psychological support for the
• Use of a gynecological stretcher.
• Use a suitable light source.
• If possible, use colposcopy in doubtful cases.
• If possible, two doctors will do it.
• Have a sampling kit.

• In minors:
o Do it with the mother.
o Lying on your back with your legs apart, touching your chest "Frog
position". This position allows for examination of both the minor's
genitals and anus.

• Teenagers:
o The examination is performed in the gynecological position with the legs
apart.

• Presentation of the hymen:

The labia majora are grasped with the thumb
and index fingers and pulled forward and
outward (reins maneuver), then the patient is
asked to push so that the hymen is exposed.

LACASSAGNE'S HYMENIAL QUADRANT: CLASSIC LOCATION OF TEARS ACCORDING TO THE HOURLY QUADRANT

GENITAL EXAM
In the female victim evaluate:
• Ecchymosis, excoriations at the level of the vulva. Labia minora and majora
• Contused wounds at the level of the vaginal introitus, navicular fossa, and
vulvar fork.
• Lesions in the urinary meatus, clitoris, clitoris, clitoris hood.
• Injuries (tears) in the hymen
EXTRA AND PARAGENITAL EXAMINATION
• Assess the rest of the body for injuries that indicate some degree of violence,
especially the inner area of the legs, buttocks, breasts, and neck.
• Do not forget to evaluate the oral cavity: gums, palate, oropharynx.
DIAGNOSIS OF INJURIES CAUSED BY SEXUAL ABUSE
• HYMEN INJURIES
Generalities:
o The injury occurs due to stretching of its walls beyond their elasticity limit.
o When tears heal, the edges do not join together, meaning the wall of the hymen is not completely
reconstituted.
o Tears can be total or partial.
o Lesions heal over time

RECENT HYMEN INJURIES

either Defloration is considered to be the breaking of the hymen membrane in a virgin woman.
either Recent lesions present acute inflammatory signs and include bleeding, swelling. (Ecchymosis,
bruises, tears).
either They can affect the entire wall of the hymen (total tears) or only a part of it (partial tear).
either The average healing time for hymen tears is ten days.
o Scarring does not reconstruct the original wall of the hymen.
o If there is muscular or rectovaginal septum involvement, healing time is prolonged.

EXCORIATIONS IN VAGINAL INTROITUS RECENT TEAR

RECENT COMPLETE TEARS HOURS 3 AND 7 EXCORIATION OF THE MEMBRANE AT 6 HOURS

OLD HYMEN INJURIES
o It is considered an old tear of the hymen when the initial lesions have healed and do not present signs of
 acute trauma.
either It appears as a discontinuity of the hymen wall with pearly edges.
either It is shaped like fragmented lobes and when joined together they reconstitute the wall of the hymen.
either The minimum age is on average ten days, the maximum age cannot be determined.
either In dilatable hymens with folding of the edges, old lesions may be hidden between
the folds so a thorough examination must be done.
• COMPLACENT HYMEN
It is also called a dilatable hymen, and is a hymen that allows several penetrations (coitus) without its edges
tearing.
o Its main characteristic is the elasticity of the hymen wall.
o It may also present a hymenal opening greater than 3 cm in transverse diameter.

Characteristics:
o Transverse length of the hymenal orifice at presentation greater than 3 centimeters.
o Elastic and expandable edges, allowing the entry of two fingers.
o It occurs in post-pubertal adolescents.

Photo 4. Dilatable hymen. A large hole is evident upon exposure and the internal free edge does not show any lesions.
• DIAGNOSTIC CONCLUSIONS: HYMEN
o Shows signs of recent defloration
o Shows signs of old defloration
o Shows signs of old defloration with recent lesions
either Presents compliant hymen
either Presents a compliant hymen with recent defloration
o Presents a compliant hymen with recent lesions
o Presents a compliant hymen with old lesions
o Presents a compliant hymen with recent and old lesions
o Presents signs of previous vaginal delivery
o Shows signs of recent vaginal delivery
o Does not allow for legal medical examination.
o It does not show signs of defloration

• ANAL LESIONS
o Anal lesions involve the anal mucosa and the external anal sphincter, whose muscle fibers are injured
during anal intercourse.
o This occurs due to the victim's contraction of the sphincter as a defense mechanism against penetration.

CLINICAL EXAMINATION: The anal examination is performed with the patient in the genupectoral position.
In the male victim evaluate:
• Bruised injuries or abrasions to the penis (body and glans), skin, scrotal sacs, testicles, perineum.
• Presence of vesicles, ulcers, warts.
• Presence of urethral discharge.

At the year level evaluate:

o Evaluate perianal skin, condition of folds
o Sphincter tone, anal dilation.
o Recent injuries (cracks, bruises, etc.)
o Old injuries (scars, etc.) tone, etc)
o Other findings: dermatitis, pigmentation, polyps, hemorrhoids, warts, folds, etc.
EXAMINATION
TECHNIQUE

AT REST IT PRESENTS:
• -CLOSED
• -WITH RADIATE FOLDS

SIGNS OF RECENT UNNATURAL COITUS I

• DESCRIBE IN A SIMILAR WAY TO THE HYMEN,
CLOCKWISE ACCORDANCE:
o Decreased hypotonicity (Asym./Eras.).
either Anal spasm.
either Frequent triangular tear in
hours VI.
either Tears of the anal folds.
o Rectus perineal tear (great violence)
either Hemorrhage and perilesional vital signs.

• ANAL LESIONS
o In older girls (adolescents), injuries do not always occur during anal intercourse, especially in consensual
intercourse.
o As with hymen injuries, both recent and old injuries can be found.
of the year.
RECENT INJURIES ASSOCIATED WITH ANAL INTERCOURSE
o At the level of the folds: fissures, irregular swelling of folds,
ecchymosis.
o At the level of the anal sphincter: painful tonic dilation of the
sphincter, decreased sphincter tone.
either ? There may be more serious injuries to the perineal
mucosa and muscle.

OLD INJURIES ASSOCIATED WITH ANAL INTERCOURSE

o Injury to the anal sphincter causes a loss of muscle tone and an
erasure of the perianal folds.
o Fissures heal with pearly scars, which in some cases may go
unnoticed.
• ANAL EXAM DIAGNOSIS
o There are no signs of unnatural intercourse.
o Shows signs of recent unnatural intercourse.
o Shows signs of ancient unnatural intercourse
o Presents signs of old unnatural intercourse with recent lesions.
either Presents signs of an unnatural act.
either Presents infundibuliform anus.
either Presents markedly hypotonic
anus.
either Does not allow for legal medical examination.

PARAGENITAL LESIONS
They are lesions produced in the border areas of the genital apparatus:
vulvar fork, median perineal raphe, inner thigh region, buttocks, mons
pubis region.

• SIGNS OF USE OF VIOLENCE

o These are injuries caused by the aggressor to the victim when the victim resists penetration and the aggressor
attempts to subdue the victim by using force.
o In adolescents, extragenital lesions predominate over genital lesions; in prepubertal girls, genital lesions
predominate over extragenital lesions.

At the extragenital level:

o Lesions on the face, forearms, inner thighs, vulva, buttocks, breasts.
o There may be injuries caused by weapons or blunt objects used to intimidate the victim.
At the genital level:
o There is injury to the labia majora and minora.
o In prepubertal children, lesions of the hymen and anus are pronounced due to anatomical disproportion.
o In post-pubertal girls, the use of violence is associated with anal, hymen and vaginal tears, as well as wounds
bruised navicular fossa.

FREQUENT DIAGNOSTIC ERRORS

• Failure to properly expose the hymen and/or poor cooperation from the victim.
• Lack of knowledge of childhood genital anatomy: there may be congenital alterations in the development of the
hymen that may be mistaken for traumatic origin. Example: confusing congenital notches with partial tears of the
hymen.
• Consider that all genital injuries originate from sexual abuse.
• The absence of genital lesions does not mean that "nothing happened."
• Perform an incomplete examination of the hymen. Not examining elastic hymens properly.
• Too much confidence in the "clinical eye".
• Little experience of the doctor.
• Parental manipulation towards the doctor
 OR PARTIAL TEARS?

LABORATORY TESTS ELASTIC, DILATABLE HYMEN.

INDICATIONS
In the abused minor:
Check for sexual abuse by studying secretions (sperm search).
Check for transmission of venereal diseases.
Check for the presence of pregnancy.
In the abuse suspect:
Blood test: blood type, syphilis, DNA.
Examination of urethral discharge for the detection of venereal diseases.
o Study of spermatozoa and their mobility. o Examination of stains on
clothing: blood, etc.
• SAMPLING
o The sample will be taken with sterile dry swabs, which will be stored in dry, sterile bags that are properly labeled
for later processing. No more than 48 hours should elapse between collection and processing.
o It is recommended to take the sample together with a health professional.
• SPERM SEARCH
o In oral intercourse: behind the upper incisors, up to 8-16 hours after the event.
o In vaginal intercourse: vaginal contents (posterior fornix), vulvar, perivulvar. Up to 72 hours later.
o In anal intercourse: rectal contents. Up to 24 hours after the event.
• EVIDENCE OF VENEREAL DISEASE
o Bacteriological examination and culture of pharyngeal, vaginal or anal secretions to detect: gonococci,
chlamydia, trichomonas, gardenella.
o Blood test for detection of syphilis or other diseases: hepatitis, HIV.
• SEXUAL ABUSE AND DISEASE VENEREAL
o Always associated with sexual abuse: Gonorrhea (oral, anal, vaginal), Syphilis.
o Frequently associated: Herpes simplex, Chlamydia, Trichomoniasis.
o Possibly associated: Condylomatosis, Pediculosis, Gardnerella vaginalis
• PREGNANCY DIAGNOSIS
o - Clinical examination of the pregnant woman.
o -Blood test for human chorionic gonadotropins beta subunit. (Qualitative and quantitative analysis).
o -Transvaginal ultrasound.
• TREATMENT GUIDANCE
1- Treatment of bodily injuries. 4- Pregnancy prevention.
2- Prophylaxis of gonorrhea or other venereal diseases. 5- Hepatitis B vaccination is recommended.
3- HIV study
• MYTHS
either ? Children lie and make up.
either ? The attackers belong to poor socioeconomic strata and people with low educational levels.
either ? Rapists are mentally ill.
either ? The victim always resents his aggressor