Before 1995 examinations of sexually abused children in East Denmark were performed on many different locations and by many different examiner's: Either a medical officer, a forensic pathologist a paediatrician or a gynaecologist.
Since the examinations were performed in different ways, the case reports were heterogeneous and the conclusions were based on the individual examinator's experience. In order to standardize both the examinations and the case reports it was decided to centralize all examinations to one centre. Since 1995 the Institute of Forensic Medicine in Copenhagen has performed allmost all examinations of sexually abused children in East Denmark, a region with a population of 2.3 million.
Material and methods
The material comprises all children suspected of having been sexually abused, examined on the Institute of Forensic Medicine in Copenhagen, over a six year period from January 1st 1995 to December 31st 2000.
A regular physical and a genitial examination were performed on all the children. Furthermore a colposcopic examination of the ano-genetial parts in girls and of the anal region in both girls and boys was performed.
In the six-year period a total of 278 children were examinated, 237 girls and 41 boys. The ages were between 1 year and 15 years with a median age of 9 years 5 month.
Figure 1. Perpetrator.
Figure 2. Type of sexual abuse.
Figure 3. Genetial findings - girls.
62 examinations were performed in close relation to the assult (less than a week after) and in four cases there were traces of semen. The remaining 216 examinations were performed weeks to years after the assult.
The perpetrator was known in 226 cases and was unknown in 52 cases.
The period of sexually abuse varied. In 100 cases there was only one event, in 17 cases the abuse extented over weeks, in 33 cases over months and in 50 cases over years.
In 78 cases the period of abuse was unknown.
In all cases there were normal colposcopic findings regarding the anal region.
In 176 (74%) cases there were normal genetial conditions with an intact hymen. In three cases there were signs of recent penetration with fresh laceration of the hymen and in 23 cases there were signs of earlier penetration with older defects of the hymen or scarring of the hymen. In 8 cases there were normal hymeneal findings but suspicious findings on the labia in shape of condylomas, excoriations or bruises. In 24 cases there were unsepecefic changes or the girls refused to be examined.
A total of 278 children were examined.
The 41 boys had normal anal conditions and there was evidence of semen in one case.
In the 237 girls there were normal conditions in 176 (74%). Signs of recent or earlier penetration were found in 26 cases (11%). There was evidence of semen in three cases.
The type of abuse reported by the girls were vaginal penetration in 59 cases (25%). An explanation for the difference between the reported number and the objective findings of vaginal penetration could be that younger girls would regard an interlabial or interfemoral intercourse intercourse as a vaginal intercourse. In the adolescent girls the hymen gets hyperplastic and elastic due to the rise in estrogen level. This means that in some cases there could be vaginal intercourse without laceration of the hymen.
In total there were only 35 cases (13%) with objective findings raising suspicion of sexually abuse. A large percentage of the reported sexual abuses would not give any physical changes. In addition the majority of the examinations were done a long time after the assault wich diminishes the chances of finding physical evidence.
On the basis of our work it is clear that the medical examination of children suspected of having been sexually abused seldom bring physical evidence of abuse and that the medical examination only is a small part of the investigation.