Elsevier

Child Abuse & Neglect

Volume 37, Issue 7, July 2013, Pages 465-474
Child Abuse & Neglect

Anal findings in children with and without probable anal penetration: A retrospective study of 1115 children referred for suspected sexual abuse

https://doi.org/10.1016/j.chiabu.2013.03.011Get rights and content

Abstract

Interpreting the significance of anal findings in child sexual abuse can be difficult. The aim of this study is to compare the frequency of anal features between children with and without anal penetration. This is a retrospective blinded review of consecutive charts of children seen for suspected sexual abuse at a regional referral center from January 1. 2005 to December 31. 2009 Based on predetermined criteria, children were classified into two groups: low or high probability of anal penetration. The charts of 1115 children were included, 84% girls and 16% boys with an age range from 0.17 to 18.83 years (mean 9.20 year). 198 children (17.8%) were classified as belonging to the anal penetration group. Bivariate analysis showed a significant positive association between the following features and anal penetration: Anal soiling (p = 0.046), fissure (p = 0.000), laceration (p = 0.000) and total anal dilatation (p = 0.000). Logistic regression analysis and stratification analysis confirmed a positive association of soiling, anal lacerations and anal fissures with anal penetration. Total anal dilation was significantly correlated with a history of anal penetration in girls, in children examined in the prone knee chest position and in children without anal symptoms. Several variables were found to be significantly associated with anal penetration, including the controversial finding of total anal dilatation. Due to limitations in the study design, this finding should still be interpreted with caution in the absence of a clear disclosure from the child.

Introduction

Child sexual abuse is an important part of the child maltreatment spectrum, and in a recent meta-analysis based on nearly 10 million participants, the overall estimated global prevalence was 127/1000 in self report studies and 4/1000 in informant studies (Stoltenborgh, van Ijzendoorn, Euser, & Bakermans-Kranenburg, 2011). The medical examination is part of the multidisciplinary assessment, where both health and forensic concerns can be addressed. To guide the practitioner, guidelines regarding examination and interpretation of medical findings have been developed and revised (Adams, 2011, RCPCH, 2008).

There is general agreement that among children who are evaluated for suspected sexual abuse, especially for non-acute examinations of pre-pubertal children, that the percentage of cases showing abnormal medical findings is low (Berenson et al., 2000, Heger et al., 2002). Further, the absence of signs of genital or anal injuries does not exclude the possibility of sexual abuse (Adams, 2008), since many types of abuse are not expected to cause injuries, and most injuries can heal completely by the time the child is brought for a non-acute medical examination (McCann et al., 2007a, McCann et al., 2007b).

Since 1990, the publication of several studies of children selected for non-abuse (Berenson et al., 1992, McCann et al., 1990, Myhre et al., 2003), one case-control study (Berenson et al., 2000), longitudinal studies (Berenson and Grady, 2002, Myhre et al., 2010) and case series reporting the healing of acute genital trauma (Heppenstall-Heger et al., 2003, McCann et al., 2007a, McCann et al., 2007b, McCann et al., 1992) have provided a research basis for the interpretation of genital findings in children with suspected sexual abuse. For anal findings, there are very few studies of non-abused children (Berenson et al., 1993, McCann et al., 1989, Myhre et al., 2001) and no case-control study has been published. For several decades there have been discussions and controversies related to the interpretation of certain anal findings (Clayden, 1988, Hobbs and Wynne, 1986), and differences of opinion still exist. Especially for non-acute findings like venous congestion, erythema and anal dilatation, there seem to be different approaches to interpretation (Adams, 2008, Hobbs and Osman, 2007, RCPCH, 2008).

The aim of this study is to provide more information about the frequency of anal findings in children referred for suspected sexual abuse and to explore whether there is any association of particular findings with anal abuse. As a result we hope to provide practitioners with information to help in the identification of anal sexual abuse. The study will be done by comparing anatomical anal features documented during the medical examination between two groups of children; those with and without a high probability of having experienced anal penetration.

Section snippets

Inclusion criteria

This is a retrospective cross sectional study of all children evaluated for possible sexual abuse during a 5 year period from January 1, 2005 to December 31, 2009 at a regional referral center in a large urban area that provides sexual abuse medical evaluations of 200–250 children yearly. Following approval from the University Institutional Review Board and the Research Administration office at the Hospital, medical records consisting of photos and charts from the examinations were reviewed. As

Description of the study population

Medical records and clinical photographs from 1231 cases were reviewed. There were 116 cases that were excluded due to poor photos or lack of photos, leaving 1115 for inclusion. For analytical purposes, one included case is considered as one child. Of those included, 941 (84%) were girls and 174 (16%) were boys. The girls were significantly older than the boys with a mean age of 9.67 years (SD: 5.2 range 0.17–18.83 years). The mean age of the boys was 6.26 (SD: 3.9, range 0.33–18.00 years) (p = 

Discussion

In this study of 1115 medical records of children evaluated for possible sexual abuse, anal penetration was considered highly probable in nearly 18% of children, using predetermined criteria. As displayed in Table 3, Table 4, Table 5, Table 6, several anal features were significantly associated with probable anal penetration.

The most interesting finding is the association between total anal dilatation and anal penetration, and the fact that this association persisted after controlling for being

Conclusion

In this study reviewing cases of 1115 children examined for a suspicion of sexual abuse, several anal features were found to be significantly associated with anal penetration. For the controversial finding of total anal dilatation, such an association was demonstrated, even after controlling for bias and confounding variables.

We recommend caution in interpreting the association of anal dilatation with anal penetration, due to limitations with the study design. A carefully designed prospective

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