Cross Examination of the Medical Expert

Zachary M. Bravos

Medical testimony regarding physical indications of sexual abuse is critical. Testimony that physical findings indicative of sexual abuse exist in the alleged victim is very powerful and cannot be underestimated by the defense. To the fact finder, physical evidence is "real" evidence. While there may be reluctance to find abuse based upon statements alone, there is none when there is corroborative physical evidence.

Generally, there are only two questions for the trier of fact to consider: (1) Was the child sexually abused? and, (2) Who did it? If there is medical testimony asserting physical evidence of abuse, it is just a short step to a finding of abuse if the child is naming the defendant as the abuser. Also, in alleged intrafamilial abuse, corroborative physical findings make it much more likely that criminal charges will be brought. Prosecutors often feel that physical evidence is needed to meet the "beyond a reasonable doubt" burden required for criminal conviction. Without such evidence they are much more likely to allow the case to be handled in family or juvenile court where a "preponderance of the evidence" standard applies.

The defense must be able to objectively evaluate the physical findings. If, in fact, physical findings indicative of abuse are present, they must be faced squarely without hesitation. Sometimes direct confrontation reveals that your client has been less than truthful and is the first step to a negotiated settlement. Sometimes, in cases of intrafamilial abuse, the systems in place are intended to reunite the family if the abuse is admitted. If abuse is real and the perpetrator cooperates in treatment, then reunification is a treatment goal. If abuse is denied, the systems in place generally will seek to destroy the relationship between the alleged perpetrator and the child found to be abused. Usually, there is no provision made for a false allegation or the continuation of a relationship with a child if abuse is denied.

Therefore, if your client insists that abuse did not occur and a trial will be held, the handling of the physical evidence testimony may be determinative of the outcome. The defense cannot rely solely upon cross-examination or arguing alternate causes for the physical findings.

It is also important to be prepared for the unusual circumstances that sometimes surround medical testimony in sex abuse cases. Ideally, doctors come to court in order to give unbiased, accurate information as an aid to the fact finder. Unfortunately, in the area of child abuse, too often the doctor acts as an advocate when delivering an opinion. Doctors will sometimes testify that certain findings are indicative of abuse even though the doctor well knows, or should know, that they are not. In the absence of an informed defense attorney, such evidence is very persuasive and, if the doctor is the only one testifying on the issue, the testimony is likely to be conclusive on the question of whether or not abuse occurred.

In order to deal effectively with medical testimony, the defense lawyer must be completely conversant with the research on what is and is not indicative of abuse. He or she must be aware of the importance of normality and the role of normative studies in medicine. Incredibly, there are still many physicians practicing who are ignorant of such landmark studies as the work by McCann and his colleagues (McCann, Voris, & Simon, 1992; McCann, Voris, Simon, & Wells, 1989; 1990; McCann, Wells, Simon, & Voris, 1990).

In this area, technical terms with exact definitions are needed. There is often some confusion and interchange so that it is important in any cross-examination to make sure that you and the doctor are speaking about the same terms in the same ways. It helps to start with an understanding of the type and degrees of physical evidence which may be encountered. Also, other than the presence of identifiable sperm or a sexually transmitted disease, there are no physical findings that are identifiable with sexual abuse and nothing else (Krugman, 1989). Physical findings are indicative of trauma in general — the source of the trauma may be abuse, self-injury, or other injury. However, do not count on a history of masturbation as a source of physical trauma. Rarely does masturbation proceed to the point of physical injury.

A thorough and searching cross-examination is the best tool for truth seeking, and each and every aspect of the medical evaluation should be carefully analyzed for cross-examination purposes. Let us take a closer look at each aspect which can be the subject of cross-examination.

The attorney must understand that physicians are not trained as scientists. The practice of medicine is an art, not a science, although physicians may be consumers of science. Physicians are often unsophisticated and unskilled in dealing with statistics and causality. Even though medical testimony is often given considerable weight by fact finders, the attorney must make it clear that physicians' expertise is limited and quite narrow.

Do not overlook a complete evaluation of the testifying doctors. Obtain current CVs. Do a complete library search and obtain copies of anything they have written. If you can, find out where and from whom they learned about physical examinations for sexual abuse, who they consider authoritative on the subject and then obtain, read, and understand everything that the doctor, their teachers, or their own recognized authorities have written. In the zeal of advocating their position it is not unusual for doctors to contradict their own printed statements and you must be prepared to take advantage. The following example, as well as the others in this paper, are from actual court testimony:

The doctor has opined after a visual examination without a colposcope that "the history and examination were consistent with sexual abuse." The exact testimony was:

A. The exam was notable for irregularity of the hymen between the 7:00 and 4:00 position.

Q. Can you tell us what that means exactly?

A. The hymen was shaped abnormally in that area. There was asymmetry that was noted. The hymen didn't look like a perfect crescent or a perfect U-shape hymen, or a perfect symmetrical hymen, and there was new blood vessels growing in the left side of the hymen called neovascularity. There was some non-specific discharge noted in the tissue just outside the hymen, and I noted that the diameter of the hymen was three millimeters when the child was relaxed.

Q. Based upon your examination of K___ do you have an opinion now within a reasonable degree of gynecological medical certainty whether or not she was a victim of sexual abuse?

A. The history and examination were consistent with sexual abuse.

This doctor's testimony is subject to attack on many grounds, including her own prior publications. On the subject of the use of the colposcope:

Q. Didn't you indicate in your own book chapter that the use of the colposcope is especially helpful in searching for old wounds?

A. It may be helpful.

Q. Well, you said it was, didn't you, here in your article?

OBJECTION: She answered the question.

OVERRULED, she may answer.

Q. In fact your article says that use of the colposcope is especially helpful?

A. To the untrained observer.

Q. That is not what you said in your article. Your article says a magnifying lens or colposcope is especially helpful. Is that what your article says?

A. That is what you are reading to me, yes.

Q. Well, is that what it says?

A. You read very well.

On the subject of neovascularization, not one of the doctor's own papers or the references cited in her own papers indicated that neovascularization was indicative of sexual abuse. Again, cross-examination in which the witnesses' own words are used against them can be devastating to their opinion if in conflict.

Usually, doctors will be asked if they have an opinion within a reasonable degree of medical certainty as to whether or not the examination did nor did not indicate sexual abuse. Here, on cross-examination you must be very probing. Usually, it turns out that the opinion is based on the totality of the exam which includes an interview of the child or a history from a caretaker. If the history taken indicates abuse, it becomes part of the basis upon which the opinion is formed.

This inclusion improperly slants the testimony. Doctors are seldom expert in interviewing, and often admit on cross-examination that they assume the truth of what the patient tells them. The testimony is presented as if the doctor's opinion is based on physical findings when it is not. It is often largely or wholly based on statements made, a far different basis than objective findings upon examination.

The attorney must sort out all data which contribute to the doctor's opinion and focus in on the objective physical findings which the doctor claims are indicative of abuse. In my experience, such findings in false allegation cases have never been indicative of abuse when examined closely. Instead, they consist of such nonspecific findings as thickened areas of the hymenal edge, vascular changes, nonspecific discharges, irregular hymenal edges, hymenal openings in excess of 4 mm, etc. which are all also found in large numbers of nonabused children.

Continuing with the example above, notice that the doctor's opinion was couched in the terms that the "history and exam" were consistent with sexual abuse. This means that part of the doctor's conclusion of abuse was based on history and not on the physical findings. After determining that the doctor is not qualified to do a sexual abuse evaluation and had no or only limited means to discover if the child knew the difference between fact and fantasy, this history needs to be separated from the objective physical findings.

This particular doctor had previously written that the history was "the most important part" of an examination for sexual abuse. This is a remarkable statement given the fact that the doctor is to give testimony regarding physical findings indicative of abuse:

Q. Actually the taking of the history in one of these cases is the most important part of your evaluation, isn't it?

A. It is one of the very most important parts.

Q. Didn't you say in your own article here that it is "the most important part of any evaluation"?

A. Perhaps I did.

Q. In taking the history of a child in a case like this, isn't it an important part of the history of a child to make as assessment as to whether or not the child knows fact from fantasy or truth from fiction?

A. I guess I assume the child is telling the truth when I take a history like this.

The balance of the doctor's testimony is now easily disposed of. The physical findings of irregularity of the hymen and neovascularization are commonly found in normal, nonabused children. Thus, after cross-examination the doctor's opinion, the most important opinion in the case, amounts to simply this: The exam was within normal limits, all physical findings are commonly found in normal children, and the exam with history, which was assumed to be true, was consistent with abuse. This exam is also "consistent with" no abuse, but the fact that the doctor did not clarify that aspect shows the advocacy position being taken. Incidentally, this testimony was in a criminal case where the defendant was facing an absolute minimum of 6 years and a maximum of 30 years in prison. Probation was not an option.

Unfortunately, doctors testifying for the prosecution will often misrepresent medical facts, especially if defense counsel is not prepared. This has occurred too many times in too many of my trials for me to be able to attribute the behavior to error. For example, a pediatric gynecologist testified with respect to a thickened area of the hymen in a 5-year-old girl:

Q. Did you observe any scarring?

A. The thickening I observed in the posterior aspect of the hymen is a form of scarring.

Q. The only way this sort of hymenal indication would occur would be insertion of some foreign object, is that correct?

A. That's correct, and the opening was larger than it typically is for children of her age; it was 5 millimeters horizontally and 8 millimeters vertically.

Q. What would be considered normal?

A. In general, 4 or 5 millimeters or less would be normal.

At best, this testimony is mistaken, at worst it is intentionally wrong. Thickened areas of the hymen occur in roughly one-half of normal children. A hymenal opening of 5 x 8 millimeters is assertively well within normal limits. There is no research or study which indicates that thickening of the hymen is a form of scarring. The cross-examiner must key in on the specific physical findings made and claimed by the doctor to be indicative of abuse. They must be taken one by one and the doctor must be made to admit that they are also found in normal, nonabused children.

In the example above, the same doctor, after a well-prepared cross-examination in a subsequent trial on the same patient, made the following admission:

Q. Every one of the findings we discussed here this afternoon are found in normal children as well as in abused children, is that correct?

A. They can be found in normal children.

This is a far cry from an unchallenged opinion that "the only way this sort of hymenal indication would occur would be insertion of some foreign object."

Courts are generally receptive to the use of research articles for impeachment purposes. Judges seem to appreciate having the tools to properly adjudicate. One heart-warming exchange (at least to defense counsel) was as follows:

State: The court allowed defense counsel to go on ad nauseam on more than 20 studies.

Defense: I object to the use of the words "ad nauseam."

Court: Well, let me explain one thing about my allowing him to go into this area. The Court has had limited exposure to this particular abuse allegation in-depth. It was by way of the Court's wish to have more knowledge of this and also, I guess, to see a better basis of what the witness was indeed basing her very important determination on. And I also resent the "ad nauseam" characterization.

The use of research studies for impeachment varies from state to state. However, it is often possible to obtain an initial admission that the AMA Journal Pediatrics is considered authoritative. Once that admission is made, impeachment with a recognized and admitted authoritative source should be allowed.

Before a statement can be made that a particular finding is abnormal, there must be an understanding of what normal is. Medicine determines normality by conducting normative studies which look at groups of normal people. Thus, to determine normal body temperature, the body temperature of large numbers of healthy people are taken.

Unfortunately, normative studies as to prepubertal genitalia have only been published since the late 1980s. Many doctors even today remain ignorant of such studies and express opinions that particular findings are indicative of abuse when we now know that they are normal. When the doctor is ignorant of normality, that ignorance needs to be exposed.

When reviewing articles for use as either cross-examination tools or in preparation of the doctor's testimony, be sure to read and understand each article thoroughly. Look at the methodology section of each article. Pay careful attention to the selection criteria of the study groups used. If of abused children, how was the determination that they were abused made? If selected for normality, how was nonabuse determined? In every case you are looking for as little contamination of the study groups as possible.

Often an examination will be said to be "consistent with" abuse. Be very careful of such a statement. The phrase "consistent with" should be probed with vigor. If physicians make statements embodying the concepts of "consistent with" or "typical of" they have exceeded their area of competence. These are issues of probability and the laws of statistical inference. Physicians are not trained in these areas. Almost always, physicians will confuse correlation with causation and assume that if something is associated with something else it is a causal relationship. This is erroneous.

A normal exam is "consistent with" abuse since most sexual abuse leaves no physical findings. We have seen reports which indicate "normal exam, consistent with abuse based on history." Most exams are also "consistent with" nonabuse. The key here is to distinguish between "consistent with" and "indicative of." Certain findings, such as a hymenal tear, healed scars, and the presence of sperm are strongly suspicious for abuse. Most of the findings said to be "consistent with" abuse are, in fact, nonspecific findings which occur in nonabused children as well as abused children. This must be made clear on cross-examination. Sometimes the doctor will go to absurd lengths to maintain the "consistent with" argument and getting what seems a perfectly straight-forward admission can be very difficult. In a case of alleged repeated digital penetration, the following exchange occurred:

Q. If there had been repeated penetration of this child's hymen by an adult male's index finger, you would certainly expect to see loss of hymenal tissue, wouldn't you?

A. Fifty percent of sexual abuse victims have completely normal exams.

Q. Did my question confuse you in any way?

A. Yes.

Q. I didn't ask about sexual abuse victims. I asked you about a sexual abuse victim whose hymen is repeatedly penetrated by an adult male index finger. You understand that?

A. Yes.

Q. In that situation you would expect within a reasonable degree of gynecological certainty to see loss of hymenal membrane, isn't that true?

A. Not necessarily.

Q. More likely than not?

A. If there was only attempted penetration such as may occur with fondling you may not see loss of hymenal tissue.

Q. I didn't ask about attempted penetration — what if there was penetration?

A. For over four or five times you may not see loss of hymenal tissue. You may see a transection of the hymen.

Q. What is a transection of a hymen?

A. A tear.

Q. Did you see such a tear.

A. I didn't see a tear.

Lawyers are used to hearing doctors say that certain examinations are normal; "normal chest," "normal cervical spine," etc. In the strange world of child abuse, the word "normal" is rarely used and some "experts" caution against its use. For example, Dr. Ramona Slupik (1991) writes:

Under no circumstances should the phrase "normal exam" be used, even if both the child and guardian deny the assault. A confession of abuse at a later date may then be impossible to prove. . . .

If an exam is normal then the doctor must be led, by the nose and word-for-word if need be, to admit that fact.

Sometimes, a doctor will testify that, based upon the "constellation of findings," the nonspecific findings found in both nonabused and abused children are, in his or her opinion, indicative of abuse. The cross-examiner must be wary of this ploy. First, there is no research evidence that the presence of more than one or even several of the nonspecific findings somehow add up or give more weight to the opinion of abuse. Thus while thickened areas of the hymen, neovascularization, irregular hymenal edges, etc. are all nonspecific (or variations of normal if you will) there is absolutely no evidence to indicate that the presence of all of these findings in one child somehow indicates abuse. Normal is normal and the presence of more than one of these findings in a child does not add anything to the determination of abuse or nonabuse. The doctor will be unable to put forth any research to support the "constellation" theory.

Every note, mark, drawing, and measurement in the doctor's records must be rigorously checked and re-checked. Fundamental errors are made. If the hymenal opening is stated, find out how was it measured — by eye or ruler, colposcope scale, etc. In one case a doctor reported observing a 5 x 7 mm hymenal opening, well within normal limits. Three days later he changed this to 12 x 20 mm, a very large opening and substantially different. Investigation revealed that he misread the scale on his colposcope. He thought that each "dot" on the scale represented a 5 mm change. Actually, reference to the manufacturer revealed that each "dot" represented a .93 mm change.

In another case, a doctor opined that his examination was "highly suspicious for prior penetrating trauma to the hymen" because the thickness at the posterior rim was .94 mm and "in a study of children selected for nonabuse the posterior rim measurement was greater than 1 mm." Fortunately, included in the case materials were photos with scales which clearly show that the posterior rim thickness varied from 2 mm (supine) to .94 (knee to chest). The exam was well within normal limits.

More troubling is how a doctor can assert that a thickness of .94 mm is abnormal because a study found nonabused children to have posterior rim thicknesses greater than 1 mm. First, the difference of .06 mm is about the width of 2 or 3 human hairs, a very slight difference. Secondly, as shown by the photos, the thickness of the hymen changes according to the examination technique used. The hymen is a stretchable membrane. Thirdly, and more troubling, the examining doctor either did not read or did not understand the study (McCann, Wells, et al., 1990) he was using to determine that his finding was abnormal. Had he read and understood the study he would have seen that the range of posterior rim measurements in children selected for non-abuse was 0 mm to 6 mm (supine) and 1 mm to 8 mm (knee to chest).

Again, it cannot be more strongly urged, examine and question everything about the physical examination.

Deciding cases of child sexual abuse would be much easier if such activities left clear-cut physical evidence. Unfortunately, child sexual abuse often leaves no such evidence. Also unfortunate is the propensity of some doctors to over-estimate the importance of their findings and misinform the court of their significance. In some respects this is understandable since a doctor who believes a child has been abused naturally wants to see justice done and to protect the child from further harm. Such motives, however, are not sufficient to justify departing from the strict truth and honest forthright testimony. The cross-examination of the medical expert is often the key point in a trial and must be prepared for with this fact in mind. Never underestimate the importance of a doctor's testimony.

A listed of selected references is appended. Some are outdated or flawed. Nevertheless, they are often cited by witnesses as authority and you must be familiar with them and their shortcomings. Any medical expert who is not familiar with the current research is not competent. The Committee on Medical Liability (1989) stresses the necessity for physicians who testify in a court of law to be familiar with the research.

Good general and understandable articles with which to begin educating yourself are by Coleman (1989), Gardner (1993), and Fay (1991). The best sources for accurate information on the research on the genital characteristics of nonabused children are the studies by McCann and his colleagues. An excellent discussion of the history and current status of testimony about medical evidence is found in Satan's Silence: Ritual Abuse and the Making of a Modern American Witch Hunt by Nathan and Snedeker (1995). An important and useful book is Evaluation of the Sexually Abused Child (Heger & Emans, 1992); this book contains 120 color illustrations of normal genitalia, normal variants, nonspecific changes, accidental trauma, and changes due to sexual abuse.

Adams, J. A. (1991, June). Common vaginal complaints in prepubertal girls. Medical Aspects of Human Sexuality, pp. 44-49.

Adams, J. A. (1992). Significance of medical findings in suspected sexual abuse: Moving towards consensus. Journal of Child Sexual Abuse, 1(3), 91-99.

Adams, J. A., Harper, K., & Knudson, S. (1992). A proposed system for the classification of anogenital findings in children with suspected sexual abuse. Adolescent and Pediatric Gynecology, 5, 73-75.

Adams, J. A., & Wells, R. (1993). Normal versus abnormal genital findings in children: How well do examiners agree? Child Abuse & Neglect, 17(5), 663-675.

Adams, J. A. (1995). The role of the medical evaluation in suspected child sexual abuse. In T. Ney (Ed.), True and false allegations of child sexual abuse: Assessment and case management (pp. 231-241.). New York: Brunner/Mazel.

Bays, J., & Jenny, C. (1990). Genital and anal conditions confused with child sexual abuse trauma. American Journal of Diseases of Children, 144, 1319-1322.

Bays, J., & Chadwick, D. (1993). Medical diagnosis of the sexually abused child. Child Abuse & Neglect, 17(1), 91-110.

Berenson, A. B., Heger, A. H., Hayes, J. M., Bailey, R. K., & Emans, S. J. (1992). Appearance of the hymen in prepubertal girls. Pediatrics, 89(3), 387-394.

Cantwell, H. B. (1983). Vaginal inspection as it relates to child sexual abuse in girls under thirteen. Child Abuse & Neglect, 7, 171-176.

Cantwell, H. B. (1987). Update on vaginal inspection as it relates to child sexual abuse in girls under thirteen. Child Abuse & Neglect, 11, 545-546.

Committee on Medical Liability (1989). Guidelines for expert witness testimony. Pediatrics, 83, 312-313.

Coleman, L. (1989). Medical examination for sexual abuse: Have we been misled? Issues in Child Abuse Accusations, 1(3), 1-9.

DeJong, A. R., Weiss, J. C., & Brent, R. L. (1982). Condyloma acuminata in children. American Journal of Diseases of Children, 136, 704-706.

Dube, R., & Herbert, M. (1988). Sexual abuse of children under 12 years of age: A review of 511 cases. Child Abuse & Neglect, 12, 321-330.

Emans, S., Woods, E., Flagg, N., & Freeman, A. (1987). Genital findings in sexually abused, symptomatic and asymptomatic, girls. Pediatrics, 79, 778-785.

Emans, S. J. (1992). Sexual abuse in girls: What have we learned about genital anatomy? Journal of Pediatrics, 120(2), 258-260.

Fay, R. (1991). A critical analysis of a medical report in a case of suspected child sexual abuse. Issues in Child Abuse Accusations, 3, 199-202.

Finkel, M. A. (1988). The medical evaluation of child sexual abuse. In D. H. Schetky & A. H. Green (Eds.), Child sexual abuse: A handbook for health care and legal professionals (pp. 82-103). New York: Brunner/Mazel.

Gardner, J. J. (1992). Descriptive study of genital variation in healthy, nonabused premenarchal girls. Journal of Pediatrics, 120(2), 251-257.

Gardner, R. A. (1993). Medical findings and child sexual abuse. Issues in Child Abuse Accusations, 5, 12-23.

Glasson, M., McCrossin, I., & Rogers, M. (1989). Anogenital warts in childhood. Child Abuse & Neglect, 13, 225-233

Heger, A., & Emans, S. (1990). Introital diameter as the criterion for sexual abuse. Pediatrics, 85, 222-223.

Heger, A., & Emans, S. J. (1992). Evaluation of the Sexually Abused Child: A Medical Textbook and Photographic Atlas ()(). New York: Oxford University Press.

Herman-Giddens, M. E., & Frothingham, T. E. (1987). Prepubertal female genitalia: Examination for evidence of sexual abuse. Pediatrics, 80, 203-208.

Kern, D. L., Ritter, M. L., & Thomas, R. G. (1992). Concave hymenal variations in suspected child sexual abuse victims. Pediatrics, 90, 265-272.

Krugman, R. D. (1989). The more we learn, the less we know "With reasonable medical certainty"? Child Abuse & Neglect, 13, 165-166.

Lamb, M. E. (1994). The investigation of child sexual abuse: An interdisciplinary consensus statement. Child Abuse & Neglect, 18, 1021-1028.

McCann, J., Voris, J., Simon, M., & Wells, R. (1989). Perianal findings in prepubertal children selected for nonabuse: A descriptive study. Child Abuse & Neglect, 13, 179-193.

McCann, J. (1990). Use of the colposcope in childhood sexual abuse examinations. Pediatric Clinics of North America, 37, 863-881.

McCann, J., Voris, J., & Simon, M. (1988). Labial adhesions and posterior fourchette injuries in childhood sexual abuse. American Journal of Disease of Children, 142, 659-663.

McCann, J., Voris, J., & Simon, M. (1992). Genital injuries resulting from sexual abuse: A longitudinal study. Pediatrics, 89, 307-310.

McCann, J., Voris, J., Simon, M., & Wells, R. (1989). Perianal findings in prepubertal children selected for nonabuse: A descriptive study. Child Abuse & Neglect, 13, 179-193.

McCann, J., Voris, J., Simon, M., & Wells, R. (1990). Comparison of genital examination techniques in prepubertal girls. Pediatrics, 85, 182-187.

McCann, J., Wells, R., Simon, M., & Voris, J. (1990). Genital findings in prepubertal girls selected for nonabuse: A descriptive study. Pediatrics, 86, 428-439.

Norvell, M. K., Benrubi, G. I., & Thompson, R. J. (1984). Investigation of microtrauma after sexual intercourse. Journal of Reproductive Medicine, 29, 269-271.

Paul, D. (1977). The medical examination in sexual offences against children. Medicine, Science and the Law, 17(4), 81-88.

Paul, D. M. (1986). "What really did happen to Baby Jane?" — The medical aspects of the investigation of alleged sexual abuse of children. Medicine, Science and the Law, 26(2), 85-102.

Paul, D. M. (1990). The pitfalls which may be encountered during an examination for signs of sexual abuse. Medicine, Science and the Law, 30(1), 3-11.

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

Pokorny, S. F. (1987). Configuration of the prepubertal hymen. American Journal of Obstetrics and Gynecology, 157, 950-956.

Reinhart, M. A. (1991). Medical evaluation of young sexual abuse victims: A view entering the 1990s. Medicine, Science and the Law, 31(1), 81-86.

Ricci, L. R. (1988). Medical forensic photography of the sexually abused child. Child Abuse & Neglect, 12, 305-310.

Slupik, R. (1991). Sexual abuse. In J. J. Sciarra (Ed.), Gynecology and obstetrics. Pittsburgh, PA: J. P. Lippincott.

Steward, M. S., Schmitz, D. S., Steward, D. S., Joye, N. R., & Reinhart, M. (1995). Children's anticipation of and response to colposcopic examination. Child Abuse & Neglect, 19, 997-1005.

White, S. T., & Ingram, D. L. (1989). Vaginal introital diameter in the evaluation of sexual abuse. Child Abuse & Neglect, 13, 217-224.

Woodling, B. A., & Heger, A. M. (1986). The use of the colposcope in the diagnosis of sexual abuse in the pediatric age group. Child Abuse & Neglect, 10, 111-114.