Medical evaluation of sexual abuse in children without disclosed or witnessed abuse

Objectives: To investigate why sexual abuse was suspected and what physical findings were present among children referred for the evaluation of sexual abuse without a verbal disclosure or witnessed abuse, and to determine if the reasons for requesting medical evaluation varied by referral source. Design: Prospective descriptive study. Setting/Patients: Two groups of consecutive children referred to a sexual abuse evaluation clinic. Main Outcome Measure: Categorization of physical examination findings for likelihood of sexual abuse (definite, suggestive, nonspecific, normal, non-abuse-related finding). Results: Of 393 children studied, 190 (48.3%) had a definite or probable history of sexual abuse, 130 (33.1%) had a suspicious history, and 73 (18.6%) had "no history." The no-history group was referred most often for physical findings (42 patients [57%]). Compared with other referral sources, physicians more frequently referred patients for physical findings, parental anxiety, and behavior changes. Regardless of history, examination findings were normal or nonspecific in 83.5% to 94.4% of cases. Suggestive or definite examination findings were more frequent for children with definite or probable histories, while non-abuse-related findings were more common for the no-history group. Only 2 children (3%) with no reported history of abuse had suggestive physical findings, and none had definite findings. Conclusions: Physicians are more likely than public agencies to refer children for sexual abuse evaluation for reasons other than disclosure by the child. For most of these children, examination is unlikely to influence the suspicion of abuse. Improved physician training and selected referrals are indicated.