[This post has been split into two parts because of selfpost character limits.]
It surprises me how often I see discussions involving speculation on whether JonBenet's UTIs, vaginitis, bedwetting, and history of frequent doctor visits indicate sexual abuse or not. These discussions invariably include people chiming in to share how they or someone they know had similar issues but were never abused. From these discussions, one could get the impression that itchy pageant costumes or Mr. Bubble useage are perfectly reasonable explanations for the evidence of sexual abuse.
The fact is, there's no need to speculate based on these things. There is physical evidence that is a significant indicator of prior sexual abuse. This
is the evidence that should be at the forefront of discussions on the question of sexual abuse, not bubble baths or bedwetting. Issues such as vaginitis, UTIs, and bedwetting are not specific to sexual abuse; there are other possible explanations for them. There is no other possible explanation for the physical evidence besides trauma from physical penetration.
In reading discussions on the case over the years, it's always puzzled me how often the evidence of prior sexual abuse gets downplayed or dismissed. In considering why, I believe it is due primarily to these two common misconceptions: Common Misconception 1
(as demonstrated above):
The evidence of sexual abuse = vaginal irritation, UTIs, rashes, bedwetting, soiling, frequent doctor visits Common Misconception 2:
There is a medical debate on the issue and there's evidence to support both sides
Common Misconception 1 is a straw man argument — the actual evidence (the physical findings) is not being addressed or refuted.
Common Misconception 2 is an argument from false equivalence
. An equal, rather than accurate, amount of weight is given to both sides of the issue. People see the mountain of conflicting information and contradicting opinions and think "It looks like expert opinion on this issue is divided; I guess a case can be made for either side." The enormous difference in expertise and experience between the various experts is ignored, as is the level of access they had to the evidence. This misconception gives the impression that all these expert opinions cancel each other out, rendering the issue debatable and open to interpretation. Consequently, the probative value of the evidence is undermined, making it easier for people to feel they can dismiss.
I think several factors have contributed to these two misconceptions:
- Media speculation in reaction to the redacted autopsy report.
A partial autopsy report was released on February 14, 1997, with certain sections having been removed by the coroner. Most of the information detailing the vaginal trauma, for example, was purposefully held back. What did remain was a section that said there was chronic inflammation and epithelial erosion found in the vaginal mucosa. This detail sparked a lot of attention and debate in the media, with various experts weighing in with their opinions on what it could mean. In reaction to speculation from some doctors that the released autopsy report portions indicated chronic sexual abuse, the Ramsey's media consultant Pat Korten made statements such as:
"It is my understanding that this (vaginal inflammation) is not uncommon among children of that age," Korten said. Child abuse experts were asked to join the fray with their own reactions. In a February 20 article, the Daily Camera reported this quote from Dr. Joan Slook, pediatrician with the Baylor College of Medicine in Houston:
"Poor hygiene can cause chronic inflammation," Slook said. "Some little girls don't wash themselves properly." Improper wiping or washing in the vaginal area can introduce bacteria and produce inflammation, she said. In all this media commentary and premature speculation based on incomplete information, chronic inflammation became conflated with evidence of sexual abuse. Even after the full autopsy report was released and information about the evidence of prior abuse came out, Ramsey defense campaign representatives continued to respond to questions about prior sexual abuse with explanations involving poor wiping, bedwetting, and bubble baths. These sneaky answers did the trick — it convinced people who didn't know otherwise that the evidence was something it wasn't.
"Some little girls can have asymptomatic bladder infections that can cause irritation in the vagina," Slook said. "Chronic inflammation is a pretty non-specific thing to say," she said, adding that epithelial erosion also is vague.
- The Ramseys' PR defense campaign efforts. It's not by accident or happenstance that there's a lot of confusion and conflicting information out there on this topic. It's what defense campaigns do — manufacture reasonable doubt and disseminate it in the media. Most of the misinformation in this case can be traced back to Ramseys, their attorneys, their private investigators, Lou Smit, and other defense campaign advocates. They have put out a lot of misleading information which has shaped and controlled the public narrative about this case.
We know the Ramseys were not happy the police had evidence of prior sexual abuse and it was something they wanted to go away — this is mentioned in Steve Thomas's book. Clearly, this evidence is not in their best interest and is something they have actively tried to counter.
- The PBworks wiki page on the evidence of sexual assault. The 'JonBenet Ramsey Case Encyclopedia' is a popular resource online for those searching for information about the case. I've even see some mainstream media outlets use information from it in their articles. Its 'Evidence of Sexual Assault' entry gets referenced and linked online all the time. However, it is very misleading in the way it portrays the evidence and is a good example of false balance/bothsidesism.
- Lawrence Schiller's book. Perfect Murder, Perfect Town is another popular resource on this case. It is regarded as the 'bible' as far as books on this case go. In it, Schiller downplays the evidence of prior sexual abuse, presenting it as something that is wholly uncertain and over which expert opinion evenly divided. On whether JonBenet had been abused prior to her murder, Schiller says: "It was likely that the truth would never be known." That is not an accurate reflection of the value of this evidence in this criminal investigation. Law enforcement accepted that the balance of medical opinion did show JonBenet had been abused prior to her death and considered it a fact of the case. To portray the issue as if there was an equal lack of supporting evidence on both sides to where no conclusions could be drawn is disingenuous.
- Paula Woodward's book. In her book We Have Your Daughter, Woodward misportrays the evidence of prior sexual abuse as well as the opinions of the experts. I have written about this previously in this post.
- Forum discussions. There's a tendency for online discussion on this case to be filled with recycled rumors, misconceptions, opinions, and beliefs which become repeated so often they eventually turn into forum cliches and factoids. I don't know how many times I have seen inaccurate statements like "For every expert that says there was prior sexual abuse, there's another that says there wasn't" get declared as if it were a fact.
However, if one takes a closer look at the evidence, it becomes apparent that it is not
weighted equally on both sides. There is no medical debate, but a medical consensus
. Every child sexual abuse expert who examined the genital findings from JonBenet's autopsy recognized physical signs of sexual abuse that predated her murder.
Despite some objections to their conclusion
, no one has disputed the physical findings of these experts. Their findings are compelling and should be seriously considered. In order to do that, though, one must first understand what the findings are and get acquainted with the doctors who testified to them.
The purpose of this post is to lay out everything that is known about the evidence of prior sexual abuse, but also to put it into a larger context so that hopefully it will be better understood. This will involve delving a bit into the history of child sexual abuse evaluations (it will become relevant later), as well as some background information of the experts involved. I will also go over dissenting opinions and address some common counterarguments and myths.
The evolution of modern pediatric sexual abuse evaluations: A brief historical timeline 1857 -
One of the first known forensic medical studies on child sexual abuse, Étude médico-légale sur les attentats aux mœurs (Forensic study on offenses against morals)
by French medical doctor and pathologist Auguste Ambroise Tardieu, is published. This treatise describes various forms of child abuse and maltreatment and includes anatomical drawings of genital findings which by modern standards are considered surprisingly accurate and ahead of its time. For some reason these efforts are largely ignored and it will be over a century before interest in sexual abuse evaluations from a medical perspective is resurrected. 1940s-50s -
Child sexual abuse remains an unacknowledged taboo. Medical textbooks of this era tell doctors that children can contract STIs like gonorrhea from non-sexual means, such as from toilet seats, sharing towels, or sleeping in the same bed as an infected adult. Such myths will pervade for decades. 1962 -
"The Battered Child Syndrome" by pediatrician C. Henry Kempe is published and physical child abuse is recognized. A watershed moment in pediatrics and child abuse protection. This article is about detecting hidden signs of physical abuse using modern radiological technology and newly proposed evaluation guidelines. Detecting chronic or hidden sexual abuse, however, will prove to be a more enduring challenge. Late 1960s -
By now all 50 states have child abuse protection laws in place. 1970s -
Feminist campaigners and policymakers take up the cause of child sexual abuse. Most child protection workers during this period are social workers and therapists. The field of child abuse protection and evaluation is in its nascency. 1974 -
Congress enacts the Federal Child Abuse Prevention and Treatment Act (CAPTA, P.L. 93-247). CAPTA creates a nationwide focus on establishing standardized protocols for dealing with all forms of child abuse and neglect. Mandatory reporting is one component of CAPTA. Before, only doctors were required to report cases of suspected child abuse; now, it is anyone in a position of authority — teachers, camp counselors, etc. Consequently, there is a significant increase in the reporting of child abuse cases and an increase in the demand of evaluations for suspected sexual abuse. Most of the physicians doing these medical evaluations are not researchers or academics but work with prosecutor's offices and law enforcement. 1975 -
Suzanne M. Sgroi, physician pioneer in the field, publishes an article calling child sexual abuse "the last frontier in child abuse" which "remains a taboo topic in many areas." 1977 -
C. Henry Kempe brings awareness to the issue of child sexual abuse by following up "The Battered Child Syndrome" with a landmark lecture at the Annual Meeting of the American Academy of Pediatrics in New York City. The talk, titled "Sexual Abuse, Another Hidden Pediatric Problem" is published in the journal Pediatrics
the following year. 1980s -
Doctors start examining children's genitals, documenting, cataloging and trying to interpret their findings. Some use a colposcope
, a binocular-like instrument originally used to detect cervical cancer, which magnifies the vaginal canal and tissues up to 4-30x. Some take anatomical measurements which they use to develop criteria for suspected abuse. They know what findings they see in abused children, but there is an acute lack of understanding of what "normal" or nonabused genital findings look like. 1981 -
The article "Sexual Misuse: Rape, Molestation, and Incest" by Dr. Bruce Woodling is published in the journal Pediatric Clinics of North America
Dr. Woodling is a California physician whose area of specialty is in sexual abuse forensics. The paper presents his research on what he has dubbed the "wink response test", a concept borrowed from Tardieu's 19th-century forensic manual. This test involves stroking the area near the anus with a cotton swab and gauging the response — contraction of the sphincter indicates no abuse, while an involuntary opening or 'winking' response indicates prior penetration. It was a test Tardieu developed to diagnose pederasty and Woodling has applied it to children as a way to detect anal abuse. 1982 -
The wave of daycare sexual abuse hysteria
of the 80s begins with the Kern County abuse allegations. The investigation and trial will culminate in the conviction of two couples (the McCuans and Kniffens) for sexually abusing several children. Dr. Woodling's wink response test and testimony play a part in their conviction. Several other similar cases in the same area at the time result in convictions of several others. 1984 -
Daycare abuse hysteria continues with the Fells Acres and McMartin Preschool accusations. In the Fells Acre case, day care teacher Gerald Amirault will be put on trial and convicted of sexually assaulting and raping nine children. Questionable interview methods of the children and unproven genital evaluation criteria form the basis for the conviction.
The McMartin preschool case is the first to receive major media attention in the United States. Pediatrician Astrid Heger, under the tutelage of Dr. Bruce Woodling, conducts many of the evaluations of the McMartin children and diagnoses the majority of them as having been sexually abused. The criteria used for the evaluations are based primarily on Woodling's research as well as other published papers at the time (e.g., Cantwell's 1983 study on hymenal diameter measurements). Many of the children are found to have suspect genital findings such as notches, clefts, bands, tissue tags, ruffled or rolled hymenal edges, 'microtraumas' seen only with magnification, hymenal openings which measure over four millimeters, as well as positive reactions to Woodling's wink response test. mid to late 80s -
More abuse allegations and convictions including Country Walk, Wee Nursery, Bronx Five, Little Rascals day care, Glendale Montessori cases. 1988 -
Dr. John McCann, a pediatrics professor and researcher from UCSF School of Medicine, drops a bombshell at the 18th annual child abuse convention in San Diego. He presents the results of a study he and his colleagues have worked on the past four years. They had gathered a control group of about 300 nonabused/"normal" children and meticulously documented and photographed their anuses and genitals, the first such study to do so. What they learned shocked McCann and everyone else in the field. Many of the anatomic findings which some specialists were claiming to be signs of abuse were commonly found in the nonabused children. The study showed that the large variation of anatomical features of childrens' genitals were, in fact, just that — variations of normal. This meant that parents and caretakers were being reported and convicted based on erroneous unscientific criteria. This presentation, titled "Anatomical Standardization of Normal Prepubertal Children," is a watershed moment in the field. 1989 -
The first paper based on McCann's study ("Perianal findings in prepubertal children selected for nonabuse: a descriptive study
") is published in the journal Child Abuse & Neglect
. Among its conclusions, it shows that Dr. Woodling's wink response test has no scientific basis.
The impact of McCann's study influences leaders in the field to call for an overhaul in the way sexual abuse evaluation criteria are approached: Medical Examination for Sexual Abuse: Have We Been Misled? The more we learn, the less we know "with reasonable medical certainty"? 1990s -
This decade sees an explosion of research and progress. The second paper based on McCanns' landmark study ("Genital findings in prepubertal girls selected for nonabuse: a descriptive study
") is published in the journal Pediatrics
in 1990. The dropping of charges in the McMartin preschool trial, also in 1990, marks the beginning of the winding down of the nation's abuse hysteria. McCann's research is presented as evidence by the defense in some abuse trials, such as the McMartin and Little Rascals daycare cases. 1992 -
A classification system for evaluating children for suspected sexual abuse is proposed by Dr. Joyce Adams, Katherine Harper and Sandra Knudson. This later becomes known as the Adams classification system (keep this system in mind as we will be referring back to it) and will be periodically revised with updated criteria throughout the following decades. It will be adopted and used in the field of child abuse pediatrics and gynecology worldwide. John McCann's research help form a basis for this system. mid to late 90s -
More research based on cross-sectional, case-control, and longitudinal studies of abused and nonabused children are published which improves understanding and accuracy of evaluation criteria: Berenson, Heger, Adams, Emans, Kellogg, Kerns, McCann, Muram, Finkel, etc. Due to the errors of the previous decade, specialists in the field are highly conscientious and prudent about differentiating nonabuse from abuse criteria.
The evidence of prior sexual abuse in the JonBenet Ramsey case: What we know
When Boulder County Coroner Dr. John Meyer performed JonBenet's autopsy, he identified signs of acute vaginal trauma which he believed was consistent with digital penetration. What we didn't find out until the publication of James Kolar's book Foreign Faction
in 2012 is that Dr. Meyer also saw indications of prior sexual contact. Concerned about this possibility, he sought a specialist opinion and brought Dr. Andrew Sirotnak to the morgue to examine JonBenet's genital injuries. Dr. Sirotnak was a child abuse pediatrician who headed the Child Protection Team at Children's Hospital Colorado. He confirmed Meyer's opinion that there were signs of prior sexual contact.
Here are the relevant passages from Kolar's book:
- Dr. Meyer also observed signs of chronic inflammation around the vaginal orifice and believed that these injuries had been inflicted in the days or weeks before the acute injury that was responsible for causing the bleeding at the time of her death. This irritation appeared consistent with prior sexual contact.
[Foreign Faction: Who Really Kidnapped JonBenet?, A. James Kolar, p. 58]
- Following the meeting, Dr. Meyer returned to the morgue with Dr. Andy Sirontak, Chief of Denver Children's Hospital Child Protection Team, so that a second opinion could be rendered on the injuries observed to the vaginal area of JonBenet. He would observe the same injuries that Dr. Meyer had noted during the autopsy protocol and concurred that a foreign object had been inserted into the opening of JonBenet's vaginal orifice and was responsible for the acute injury witnessed at the 7:00 o'clock position. Further inspection revealed that the hymen was shriveled and retracted, a sign that JonBenet had been subjected to some type of sexual contact prior to the date of her death. Dr. Sirontak could not provide an opinion as to how old those injuries were or how many times JonBenet may have been assaulted and would defer to the expert opinions of other medical examiners.
[Kolar, p. 61]
- Dr. Meyer was concerned about JonBenet's vaginal injuries, and he, along with Boulder investigators, sought the opinions of a variety of other physicians in the days following her autopsy. Dr. Sirontak, a pediatrician with Denver Children's Hospital, had recognized signs of prior sexual trauma but neither he nor Dr. Meyer were able to say with any degree of certainty what period of time may have been involved in the abuse.
[Kolar, p. 63]
Boulder Police would later ask several child sexual abuse experts to review the autopsy findings* in order to help them determine if there was evidence of prior sexual abuse. In addition to Andrew Sirotnak
, these are the experts whom we know were consulted: Richard Krugman James Monteleone Valerie Rao John McCann
That's right — that
John McCann. The same John McCann who was responsible for putting child sexual abuse evaluations onto scientific footing and who happened to establish the standards for what is considered normal and abnormal in pediatric genital exams was consulted on the JonBenet Ramsey case.
In Steve Thomas's 2001 deposition for the Wolf v Ramsey civil trial, Thomas says that McCann came recommended by the FBI. There's a reason for that, which is that McCann was regarded as one of the the foremost authorities on interpreting pediatric anogenital findings in cases of suspected abuse. Thomas also refers to McCann, Monteleone, and Rao as the "blue ribbon pediatric panel." Based on various sources, we know that there was at least one meeting in Boulder in September 1997 involving McCann, Rao, Monteleone, and Krugman.
Here is the relevant passage from Thomas's book:
In mid-September, a panel of pediatric experts from around the country reached one of the major conclusions of the investigation - that JonBenet had suffered vaginal trauma prior to the day she was killed.
There were no dissenting opinions among them on the issue, and they firmly rejected any possibility that the trauma to the hymen and chronic vaginal inflammation were caused by urination issues or masturbation. We gathered affidavits stating in clear language that there were injuries "consistent with prior trauma and sexual abuse"...."There was chronic abuse"..."Past violation of the vagina"...."Evidence of both acute injury and chronic sexual abuse." In other words, the doctors were saying it had happened before.
The results, however, were not what is known in the legal world as "conclusive" - which means that there can be no other interpretation - and I would fully expect defense lawyers to argue something different. Nevertheless, our highly qualified doctors had brought in a remarkable finding.
[JonBenet: Inside the Ramsey Murder Investigation, Steve Thomas & Don Davis, p. 253]
The experts expected to testify in court had the case gone to trial. As we know, there was no criminal trial, but we know the experts were called to testify before the grand jury.
*During JonBenet's autopsy, an instrument called a colposcope was used to examine and document her genital injuries. This is standard procedure in forensic pathology in cases of suspected child abuse or sexual assault. Colposcopy illuminates and magnifies the vaginal cavity and is used to identify abnormal changes to tissue and the internal genital structures. The experts would have relied on these colposcopic photos as well as histologic samples of JonBenet's vaginal mucosa in addition to the autopsy report, coroner's notes, and lab results.
The physical findings explained
These are the genital findings we know were discovered at JonBenet's autopsy:
|Ref. no. ||Finding ||Source |
|1 ||Chronic inflammation around vaginal orifice ||FF |
|2 ||Small amount of dried blood on perineum ||AR |
|3 ||Small amount of dried and semifluid blood on skin of fourchette and in vestibule ||AR |
|4 ||Hyperemia of vestibule and vaginal wall ||AR |
|5 ||Abrasion on hymenal orifice at 7 o'clock position, involving the hymen and vaginal wall ||AR |
|6 ||Epithelial erosion with underlying capillary congestion of tissue from 7'oclock ||AR |
|7 ||Hymenal orifice measuring 1cm x 1cm ||AR |
|8 ||A lack of hymenal tissue between the 10 and 2 o'clock positions ||AR |
|9 ||Vascular congestion and focal interstitial chronic inflammation of vaginal mucosa in all sections ||AR |
|10 ||Bruise on hymen ||BP |
|11 ||Three dimensional thickening from inside to outside of inferior hymenal rim ||BP |
|12 ||Narrowing of inferior hymenal rim to base of hymen ||BP |
|13 ||Exposure of vaginal rugae ||BP |
AR = Autopsy Report
BP = Bonita Papers
FF = Foreign Faction What do these physical findings mean?
Here is a quick break down:
- 5, 6, and 10, with corresponding bleeding 2 and 3, are signs of acute trauma from the time of the murder.
- 7 is something that gets brought up as evidence of prior abuse ("enlarged hymenal opening"). However, criteria based on hymenal opening measurements were removed from the Adams classification guidelines in 1996. McCann did not include it in his criteria for abuse, but said it supported the findings for abuse. Since the late 90s/early 2000s, specialists have tried to move away from using measurement-based criteria as it is difficult to do precisely. Research data has shown that measurements can vary with the examination position, technique, age of the child, state of relaxation of the child, and the skill of the examiner.
- 8 describes a crescentic hymen, a common variation of hymen types. This is a normal finding. Generally, discrepancies of the anterior half of the hymen (above the 3 and 9 o'clock positions) are not considered concerning and missing segments, notches, clefts can be normal findings. It is the inferior half of the hymen (below the 3 and 9 o'clock positions) where experts look for indicators of abuse.
- 11-13 are findings observed by John McCann that describe structural changes of the hymen from a prior penetration. 12 describes a transection (a healed laceration) of the inferior portion of the hymen.
- 1, 4, 9 can be caused by a variety of other conditions and on their own are not classified as indicators for abuse. In the case where findings indicating abuse are also present, they need to be considered in context.
The most important of these findings to understand is 12, which is one of McCann's observations outlined in the Bonita Papers.
There was a three dimensional thickening from inside to outside on the inferior hymeneal rim with a bruise apparent on the external surface of the hymen and a narrowing of the hymeneal rim from the edge of the hymen to where it attaches to the muscular portion of the vaginal openings. At the narrowing area, there appeared to be very little if any hymen present. To understand what this means, take a look at the white line segment labeled "Hymenal width" in this colposcopic photo (warning: image of vagina/hymen). It demarcates the length of the hymenal membrane from the rim/edge to the base where it attaches to the vaginal wall.
A narrowing of the hymenal rim means the hymenal membrane is reduced in dimension from the rim/edge toward the base. When the rim is narrowed all the way to the base, that is called a complete cleft or a transection. A transection is a discontinuity of the inferior hymenal rim that extends to or through the base of the hymen. Basically, it is a telltale residual absence of tissue from a healed complete laceration.
If this is difficult to visualize, here is a figure which shows what transections look like:
Figure 3: Hymenal Membrane Characteristics
The Adams classification system
In the fields of child abuse pediatrics and pediatric gynecology, the set of guidelines most widely used in interpreting genital findings is the Adams classification system.
If we were to look at the most recently revised version (2018), we would see that it identifies certain "findings caused by trauma":
These findings are highly suggestive of abuse, even in the absence of a disclosure from the child, unless the child and/or caretaker provides a timely and plausible description of accidental anogenital straddle, crush or impalement injury, or past surgical interventions that are confirmed from review of medical records. Among those findings that are "highly suggestive of abuse" includes point 37, listed in the subsection titled "Residual (healing) injuries to genital/anal tissues" under section E:
Healed hymenal transection/complete hymen cleft, a defect in the hymen below the 3-9 o'clock location that extends to or through the base of the hymen, with no hymenal tissue discernible at that location This is precisely what Dr. McCann described having observed in JonBenet.
A transection in the inferior half of the hymen of a prepubertal child is a significant finding because it is considered a clear indication of a prior penetrating injury:
If any doctor or medical provider today observed a transection on the inferior half of the hymen of a prepubertal female patient, he/she would be required to make a report for suspected sexual abuse and an explanation would be required for how that healed injury got there. In forty years of research, this finding has not been seen in any other instance besides from penetrating trauma. In prepubertal girls, it is indicative of sexual abuse unless it can be shown otherwise.
- Multiple studies have noted the presence of hymenal transections only in prepubertal girls with a history of disclosed sexual abuse.
[ Sara T. Stewart, MD. Hymenal Characteristics in Girls with and without a History of Sexual Abuse, p. 533]
- Hymenal transections are very rarely seen in prepubertal girls who have not been sexually abused. However, a demonstrated transection, based on multiple studies, is commonly viewed as “a clear but uncommon indicator of past trauma.”
[Mishori, R., Ferdowsian, H., Naimer, K. et al. The little tissue that couldn’t – dispelling myths about the Hymen’s role in determining sexual history and assault.]
- Thus a deep notch, transection, or perforation on the inferior portion of the hymen may be considered as a definitive sign of sexual abuse or other trauma.
[Berenson, et al. A case-control study of anatomic changes resulting from sexual abuse, p. 829]
- A transection of the posterior hymen between 4 and 8 o’clock in prepubertal girls suggests genital penetrating trauma; however, the presence of this finding is not confirmatory of sexual abuse. Posterior hymenal findings including transections between 4 and 8 o’clock, deep notches, and perforations were not seen in studies of prepubertal girls without a history of genital trauma from sexual abuse included in this systematic review. Therefore, one can conclude that the posterior hymenal findings of transections, deep notches, and perforations are extremely infrequent findings among children without a history of genital trauma from sexual abuse or other means. [...]
However, because the prevalence of posterior hymenal findings (between 4 and 8 o’clock) such as transections, deep notches, and perforations are near zero in nonabused prepubertal girls, the presence of these examination findings suggests genital trauma from sexual abuse. In the absence of known genital trauma from accidental means, the possibility for sexual abuse must be strongly considered. In a prepubertal girl with a posterior hymenal finding of a transection (between 4 and 8 o’clock), a deep notch (between 4 and 8 o’clock), or a perforation, a report to child protective services should be strongly considered. At a minimum, an examination by a child abuse specialist should occur to confirm these findings and to help provide a careful interpretation regarding the likelihood of sexual abuse.
[Molly Curtin Berkoff, MD, MPH; Adam J. Zolotor, MD, MPH; Kathi L. Makoroff, MD; et al. Has This Prepubertal Girl Been Sexually Abused?, p. 2790]
What the evidence says The evidence says JonBenet had been subjected to at least one penetration of the vagina through the hymenal membrane prior to her murder. The penetration caused a complete laceration of the inferior hymenal membrane. After the laceration healed, a transection and other structural changes of the hymen remained.
The age of the prior injury could not be determined, but based on his research on the healing of hymenal lacerations of prepubertal girls, it was McCann's opinion that it was more than ten days old. His research has shown that "most signs of an acute [hymenal laceration] injury were gone within 7 to 10 days." Some of the experts thought the prior injury could have been weeks or months old.
While the evidence could conclusively prove only one prior penetration, the experts believed there had been more than one instance of penetration/sexual contact and that JonBenet's genital findings indicated abuse that had been repeated or ongoing. They were unable to determine how many incidents over what period of time.
Four of the five experts (Sirotnak, Monteleone, Rao, McCann) were confident in their opinion that JonBenet's genital findings were diagnostic of sexual abuse. One (Krugman) could not disagree with that assessment, but lacking certain forensic evidence (i.e., the victim's testimony, the confirmed presence of sperm, or an STI), was unwilling to assume a sexual motive for the abuse. He felt there was evidence only of physical abuse of the genitals.
What else could explain the prior penetration/ hymenal trauma besides sexual abuse? There are three known causes of transections in the inferior hymenal rim in prepubertal girls — penetrative sexual abuse, accidental penetrating trauma, and surgical intervention.
Most accidental genital injuries sustained by children are straddle-type injuries that involve a fall onto the horizontal bar of a bicycle, jungle gym, or picket fence. This type of accident involves compression of the soft tissues against the bony margins of the pelvic outlet. Trauma is usually limited to the external structures of the genital area (e.g., labia, clitoral hood, fourchette, perineum).
Accidental penetrating or impalement injuries that involve trauma to the hymen are relatively rare:
Of 161 accidental genital injuries reported in the literature, 3.7% involved the hymen. However, they do occur and the resulting injuries can mimic those of sexual abuse. In such cases, it is important that the cause of the injury be confirmed.
[Child Abuse: Medical Diagnosis and Management, 4th ed. Antoinette Laskey and Andrew Sirotnak (eds.), p. 359]
Whether an acute or healed genital or anal injury is identified, it is incumbent on the medical professional to obtain a complete history of the nature of the injury. [...] If JonBenet's prior hymenal injury was the result of an accident or a past surgical procedure, it should be reflected in her medical records and easy to prove. An accidental penetrating injury that results in a complete laceration of the hymen is considered severe, one that would be painful and cause bleeding. It would be expected that most parents or caretakers would seek medical attention for their child's injury.
Key differences in the history of accidental trauma, such as a straddle injury, are that accidental injuries are more commonly observed by a third party, medical attention is sought immediately after the injury, a scene-of-injury visit confirms the plausibility of the injuries and the accompanying history, and the pattern of injury is consistent with the history.
[Child Abuse: Medical Diagnosis and Management, 4th ed. Antoinette Laskey and Andrew Sirotnak (eds.), p. 359]
We know the Ramseys were not timid or frugal when it came to getting medical attention for JonBenet's injuries and ailments. We have records of her being seen by the doctor for various bumps, falls, and injuries, such as a bent fingernail from a fall, a bruised nose from faceplanting at a grocery store, a bump on the brow from a tripping fall, and a small cut to the cheek from a golf club swing. If JonBenet had sustained an accidental genital injury that resulted in a severe laceration, I find it very hard to believe she would not have been taken to the doctor for such an injury when she was taken for lesser injuries and ailments.
Clearly, there was nothing in her medical records that could account for such an injury or the Ramseys would have provided it to police.
(Continue to Part 2: The experts, responses to dissenting opinions and common myths, etc.)