IPT Book Reviews

Title: Evaluation of the Sexually Abused Child  Positive Review Positive Review
Authors: Astrid Heger and S. Jean Emans with Carole Jenny, David Muram, Deborah Stewart, Carolyn Levitt, & Susan Pokorny
Publisher: Oxford University Press, Inc. 1992

Oxford University Press, Inc.
200 Madison Avenue
New York, NY 10016


This 244-page book on high quality glossy paper contains seven brief chapters on the medical aspects of assessing and diagnosing child sexual abuse, a 60-page photographic atlas with 120 color illustrations, a short glossary of terms, and an annotated bibliography of the relevant literature.  Topics covered include interviewing children suspected of sexual abuse, the child protection system, the psychological effects of sexual abuse, sexually transmitted diseases, the forensic evaluation, the role of the physician in court, and the anatomy of the genitals.  Appendices contain different protocols for the physical examination of children suspected of sexual abuse.  The book ends with an index.


The photographic atlas alone is worth the price of this book.  The color illustrations are clearly reproduced and it is extremely useful to see photographs of the types of genitals described in medical reports.  The atlas illustrates the many variations in the genitalia of nonabused children and shows the types of findings in abused children.

The main criticism of this book is its acceptance of many of the myths found in the child sexual abuse system.  For example, Astrid Heger presents the Child Sexual Abuse Accommodation Syndrome, the list of behavioral indicators of sexual abuse, and the classification of pedophiles as "regressed" or "fixed" without qualification.  The chapter by Catherine Koverola, on the psychological effects of sexual abuse, describes Diane Russell's study as "the first truly random sexual abuse study" and implies that Russell's figures (higher than anyone else's) are accurate.

The general assumption of the book, that all allegations of abuse are likely true, is shown in its cautions concerning false negatives in the absence of corresponding cautions about false positives.  I have reviewed countless cases in which an essentially normal genital evaluation is accompanied by a report stating, "nonspecific findings consistent with abuse."  Often, social workers, prosecutors, or mental health professionals reading the report somehow translate this into "physical evidence of abuse" and the case is off and running.  (Obviously, nonspecific findings are also consistent with no abuse, but this is seldom mentioned in medical reports.)  The book would have been improved by a greater recognition of the problem of false allegations and false positives.

An example of this subtle bias is found in the annotated bibliography where the authors state that Paradise, in her 1989 commentary on diagnosing sexual abuse on the basis of the hymenal orifice diameter, concluded that "overreliance on these measurements can result in not protecting the abused child without an enlarged hymenal introital diameter" (p.231).  However, Paradise actually cautions about both false positives and false negatives and concludes that reliance on hymenal orifice diameters results in considerable costs to children in both groups.

Nevertheless some of the chapters are good.  Carolyn Levitt, writing on the medical interview, discusses the dangers in using leading questions and urges caution in technique and interpretation if the anatomical dolls are used.  (In this book Levitt does not discuss her technique of inserting her finger into the child's genitals to see if this elicits memories of someone having done this before.)  The chapters by Carole Jenny and Jean Emans on the physical examination provide practical and specific suggestions that will be helpful in performing an examination or in reviewing a report of an evaluation.

Despite the bias in some of its chapters, this book will be extremely useful not only to physicians, but to attorneys, mental health professionals, and other persons who must attempt to understand and evaluate medical reports of child sexual abuse examinations.


Paradise, J. E. (1989). Predictive accuracy and the diagnosis of sexual abuse: A big issue about a little tissue. Child Abuse & Neglect, 13(2), 169-176.

Reviewed by Hollida Wakefield, Institute for Psychological Therapies, Northfield, Minnesota.

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