Tanner Staging and Pornography

To the Editor. This letter is in response to a recently published letter by Drs Rosenbloom and Tanner regarding Tanner staging and child pornography. Their letter states that chronologic age cannot be accurately determined via Tanner staging. Therefore, physicians should refrain from testifying in court as to chronologic age based on Tanner staging.If anyone has testified to a specific chronologic age based on Tanner staging, Drs Rosenbloom and Tanner's letter is appropriate criticism. However, one should not conclude that Tanner staging is not useful in child pornography cases.According to revised federal statutes regarding child pornography, an individual in question need only have the appearance of a minor.1 “Minor” is further defined as <18 years of age.In assessing an individual as having the appearance of a child, it is reasonable to use an assessment of the individual's general appearance as well as breast, genital, and pubic hair Tanner stage. An assessment of upper to lower body segment ratio can also be attempted.Dr Tanner published an article regarding height velocities that contained centiles for age of onset of various maturational stages.2 These centiles were superimposed on the chronologic age axis of the height velocity charts. Related data was also published by Barnes.3 From this data one gets a fairly good idea as to the age of a child who has not yet experienced the onset of a given maturational characteristic.Most colleagues are very conservative regarding making statements about individuals who appear to be Tanner stage 3 or above. The difficulty of distinguishing between breast stage 3 and 5 in pornographic photos is recognized. It is also understood that Tanner staging does not apply to populations not evaluated and described by Dr Tanner.1,4,5There is, however, data regarding children in Singapore.6Finally, assessments are not typically made if images do not adequately depict critical aspects of an individual's body.Much discussion has centered on the ability to alter an individual's physical appearance or their photographic image. Understanding that images and individuals can be altered was the primary reason for modification of federal statutes.With all this in mind, physicians can give the courts valuable and accurate information regarding whether an individual has the appearance of a child—which, after all, is what is really being asked in the US federal cases to which Drs Rosenbloom and Tanner refer.To the Editor. The recent letter by Drs Rosenbloom and Tanner regarding use of Tanner puberty stages to estimate chronologic age highlighted the difficulty in using data derived from longitudinal studies by Marshall and Tanner1,2 and others for this purpose. It is curious that neither author identified himself as the expert witness and whether this was prosecution or defense testimony. It is disturbing that the letter never acknowledges the international problem of child pornography as a form of child sexual abuse. It should be clear to the reader that pornographers do not use “standardized” photographs of their victims to ensure accuracy of their salacious product.As a child abuse pediatrician, I have been asked to objectively review suspected child pornography and to give an expert medical opinion within reasonable medical certainty regarding the age of individuals in the material. I appreciate the caution to refrain from providing “expert testimony,” but I also voice support for those pediatricians who dedicate clinical and academic career time to the care of abused children who know what the legal standards of evidence are in both civil and criminal child abuse cases.In reviewing such material, the medical standards that I can easily defend in these cases are twofold. First, the pediatric experience of providing medical care to this age range of patients absolutely allows us to state when looking at an adequately depicted image, which can be confirmed not to have been technologically altered, that the image is that of a person with little or no pubertal changes. Second, given that first assessment, and using such published statements as “the first sign of puberty appeared between ages 8.5 and 13 years in girls,”1 it can be stated with reasonable medical certainty that the person is likely to be under a legal adult age. I agree that estimating the exact chronological age is not accurate science. What a jury needs to understand is how a physician looking at a child or a photo can reasonably explain it is indeed a child.Perhaps the authors are simply disturbed either by the appropriation of Tanner staging to estimate pubertal development of individuals depicted in graphic pornographic acts or by the realization that children are so heinously violated.To the Editor. I would like to express my concern over reading Drs Rosenbloom and Tanner's recent letter, which represented an extremely brief rendering on an extremely complicated issue, namely, the use of sexual maturity rating to determine probable age ranges for potential child pornography victims.Why was this letter published without any accompanying commentary from recognized pediatric authorities? Raising questions and calling for rigorous study on how practicing pediatricians arrive at age ranges for children maltreated via child pornography is a valid use of the editorial pages of Pediatrics. However, the 23 lines in the Rosenbloom and Tanner letter go beyond raising questions and, instead, cast the issues surrounding the use of the sexual maturity rating scales to approximate age ranges in such absolute language that it would appear that academic study is not needed. Such unrefereed statements, which use absolute language, leave children who are victimized by pornography poorly served because responsible, clinically astute pediatricians can now be discredited by quotes from the pages of their very own prestigious journal, Pediatrics. The letter provides nonpeer-reviewed “sound bites” which will be echoing within our nation's court rooms for many years to come by those who would work against the interests of children.Once again, why would such an unbalanced rendering of assigning age ranges in child pornography cases be rushed to print without an accompanying commentary which could, at least, frame the issue in a more scholarly manner? Are the absolute truths on this topic really known as certainly as Drs Rosenbloom and Tanner contend?In Reply. I will begin responding to the preceding letters and other letters and calls that I have received about our brief letter, by conveying Professor Tanner's last word on the use of the sexual development scale he developed: “Chronologic age cannot be accurately estimated from Tanner stage.” Here is an example of the kind of egregious misuse of Tanner staging that led to our letter, which comes from an expert's report about a photograph: “Tanner 4 late, has heavy hair at base of penis and up over pubis… Testes well developed in full scrotum, penis long and broad. No hair on thighs or up to inguinal area or up linea alba. Age 16–17.” An example from a report in another case: “Three of those [Asian] females had Tanner stage 4 sexual characteristics, which again is consistent with a young girl of 13 to 15 years of age… 1 young Asian girl appeared to be late Tanner stage 4 and within reasonable medical probability, she is 15 or 16 years of age.”I am pleased that all who have written or called about our letter are uniformly not misusing Tanner staging to make more or less precise chronologic age estimates in this manner. As noted by Dr Kutz, Tanner staging does not apply to populations not evaluated by Tanner, particularly those that may have sparse pubic hair, on which much of the staging depends, such as Asians. These correspondents appear to be using Tanner stage as a convenient reference terminology for clinical judgment, which raises the question of the need to use it at all. As many have pointed out, the expert pediatrician comes to the evidence with an ability to estimate age based on facial appearance, body shape, muscular development, and sexual maturation. To determine whether an individual is sufficiently mature from this evidence to be 18 years old does not, of course, require Tanner staging. Invocation of Tanner staging, with its population specificity, wide age range for timing of maturational features, unreliability of staging from visual materials, and dependence on clues that can be altered (shaving), may weaken rather than strengthen the straightforward authority of the experienced pediatrician.I trust that Dr Kutz would agree that the examples above justified our criticism. I would again question, however, the need for or value of Tanner data from English children, useful as they might be for clinical record-keeping and research, for determining whether an individual is a minor or a mature person. Dr Kutz's suggestion that estimating the ratio of the upper to the lower body segments be considered is surprising. By age 10 most children have adult proportions, and already by age 6 are within 10% of unity.Our letter did not state or imply that physicians should refrain from providing expert testimony in suspected child pornography, as suggested by Dr Sirotnak, only that they should refrain from providing testimony as to chronologic age based on Tanner staging. I certainly share his admiration and respect for those pediatricians who are committed to the protection of abused children in the medical and legal settings. I do not know of a tougher or more noble task in pediatrics. Dr Sirotnak's statement of medical standards that he can defend in these situations, which makes no mention of Tanner staging, is reasonable, astute, and a welcome addition to my brief.Dr Giardino gives a draconian interpretation of our letter. I do not think it inappropriate for Professor Tanner to make absolute statements about what Tanner staging was and was not designed to do! There is nothing in our letter to preclude testimony based on sound clinical judgment by expert pediatricians. The use of Tanner staging to label such judgment could be a distraction and be more vulnerable to legal attack, even without our letter, than is personal experience and expertise.An especially lucid interpretation of our letter came from a detective who works on child pornography on the Internet. He recognized that what we were saying did “not interfere with a pediatrician forming an opinion regarding the age of the subject in a photograph(s), relying on their experience of examining children. You want this expert not to form an opinion based using the Tanner scale, but on other factors such as their clinical experience.”