Extragenital Signs of Sexual Abuse
Those signs are infrequent and rather seen in the context of rape: hematomas and bite marks in the so-called erogenous zones, especially the inner thighs, breasts, neck and buttocks; bruising, hematomas and strangulation marks of the neck, the extremities or the flank in the kidney region (due to forceful sodomy); petechiae of the sclerae caused by strangulation; petechiae of the soft palate or tear of the labial frenulum due to forceful oral penetration [Hobbs et al., 1999b; Finkel and De Jong, 2001].
Classification of Findings
In order to categorize anogenital findings, different authors developed classification scales which intend to relate the findings to the probability of their abusive origin. Especially the newest revision of a scale developed by Adams [1992, 2001] is a comprehensive categorization schema for analyzing and interpreting findings. It consists of two parts, the classification of physical findings alone and the overall assessment of the likelihood of abuse. It is of particular value as it interrelates both the physical findings and the historical findings into a diagnostic decision. After measurements of the posterior rim had been removed in a prior version, this version removed enlarged hymenal opening as a criterion for abuse. In a recent review of Adam’s paper, Ricci  cautioned the use of the schema as ‘...it is important to recognize however, that this schema is a suggestion, a way of organizing one’s thoughts about a constellation of findings. Although… in line with much of the current research… it is important to recognize that any schema must be interpreted within the context of each individual case.’ A revised version of the classification is distributed by the author but not yet published [Adams, pers. commun., 2003].
Guidelines for decision-making, especially in respect to mandated reporting of sexual abuse, have been published by the Committee on Child Abuse and Neglect of the American Academy of Pediatrics [AAP, 1999]. Classification scales help to assess probabilities but must never be misinterpreted as rigid instructions how to interpret anogenital findings. The current state of knowledge and its limitations have to be kept in mind and updated continuously as in all other medical disciplines [Kerns, 1998; McCann, 1998] (table 1).
Revision date: June 14, 2011
Last revised: by Andrew G. Epstein, M.D.