Anal Findings

The other area of contention in medical examination is the physical signs of anal abuse. In particular, the argument centers around a phenomenon of anal gaping called reflex anal dilatation (RAD). Briefly, this involves gently parting the buttocks and observing the anus for half a minute. Usually, the sphincter on the outside of the anus will contract and then dilate, as pressure is maintained. Sometimes the inside sphincter will then also relax giving a view right into the rectum. It is this response that has been named RAD.

British pediatricians Drs Hobbs and Wynne reported that RAD was present in 42% of anally abused children they examined, and claimed that it was an important indicator of abuse (Hobbs & Wynne, 1986, 1989). They stated that they had not witnessed RAD in nonabused children. They also claimed that splits or fissures around the anus are very rare in the nonabused child.

These findings became the basis of a belief in some circles that RAD is proof of anal abuse. More recent studies and observations, however, refute Hobbs and Wynne's findings. One study observed the phenomenon in nearly half of the nonabused children they examined (McCann et al, 1989). It also appears to be more common when a child is constipated and has feces sitting higher in the bowel (Sunderland, 1987; Royal College of Physicians, 1991). Many doctors also report that they have commonly seen anal fissures in nonabused children (Freeman, 1989; Kean, 1989; Royal College of Physicians, 1991).

Unfortunately, Hobbs and Wynne's theories regarding the relevance of anal reflex dilatation was taken to be established fact by a number of doctors examining children. In some centers it became policy for all children to undergo genital and anal examinations, no matter what medical problem they had come with.

This practice resulted in the false epidemic of sexual abuse cases in Cleveland, England, which was to receive worldwide attention from the media. In 1987, two pediatricians working at the Middlesbrough General Hospital in Cleveland, Drs. Marietta Higgs and Geoffrey Wyatt, diagnosed 121 cases of alleged sexual abuse of children in the space of five months. Their diagnoses were made largely from medical examination findings of reported hymenal irregularities and RAD. Many of these children had come to the hospital for treatment of complaints such as asthma, and there was no other evidence suggesting that they had been abused (Bernard, 1988; Woods, 1988). Dr.

Higgs held the view that one in ten children are sexually abused, and sincerely believed that her findings proved the abuse.

Despite denials from bewildered and distraught parents, the children were immediately taken from their homes, initially to a hospital and later into care by the social services. As the numbers escalated, distressed parents sought media and political support. Eventually a public inquiry was called. The Cleveland inquiry, headed by Lord Justice Butler-Sloss, found that most of the allegations were unfounded, and the children were returned to their families (Butler-Sloss, 1988). The process was, however, very traumatic to all concerned, and the children and their parents did not emerge unscathed by the experience.

Despite the findings of the inquiry, and the evidence coming forward from a number of reputable medical sources regarding the unreliability of relying on medical signs, such as RAD, to diagnose abuse, many agencies still maintain their use is valid. Dr. Higgs still has many supporters within the field who believe her diagnoses were justified. Some books written about the Cleveland affair (Campbell, 1988; La Fontaine, 1990) present the view that the allegations in the Cleveland case were founded, despite overwhelming evidence that abuse was not substantiated in the vast majority of the cases.

Anal/rectal sample[27] Collect swabs from the anal cavity. [28] Avoid contact with external skin surfaces. Optionalsmear swabs on microscopic slides, according to jurisdictional policy. Air-dry swabs and slides. Package swabs and slides, place in envelope, label, seal, and initial the seal.

At this time, any additional examinations or tests involving the anus should be conducted.