title: Clinician agreement on physical findings in child sexual abuse cases.
abstract: OBJECTIVE
  To measure agreement among experienced clinicians regarding the interpretation of physical findings in child sexual abuse cases and to determine whether knowledge of clinical history affects the interpretation of the physical findings.
  
  
  METHODS
  Experienced clinicians rated colposcopic photographs on a scale of 1 to 5 with 1 being normal and 5 being clear evidence of penetrating injury. To answer an additional study question of whether clinical history affected interpretation, 4 clinicians rated 69 cases in which they were blinded to the patients' histories and 70 cases in which the patients' histories were available. The other 3 clinicians then rated the same cases with the presence or absence of history reversed.
  
  
  METHODS
  All clinicians involved perform child sexual abuse examinations at tertiary care centers.
  
  
  METHODS
  A total of 139 girls with Tanner stage 1 or 2 genitalia who were referred to a general pediatric clinic at an academic medical center for examination of possible sexual abuse.
  
  
  RESULTS
  Half of the photographs were interpreted as indicating little or no evidence of abuse. Of those photographic sets that both readers could interpret, 39% were in perfect agreement and 77% disagreed by 1 category or less. Perfect agreement across all possible pairs of readers was 34.5%. Agreement was better when the patient's clinical history was unknown (29.3% vs 38.9%, P = .005). The kappa, a measure of interrater reliability, indicated poor agreement among clinicians. The combined kappa for the first group of clinicians was 0.22 without knowledge of clinical history and 0.11 with knowledge of clinical history. For the second group of clinicians, the kappa was 0.31 without knowledge of clinical history and 0.15 with knowledge of clinical history. The overall kappa across all 7 clinicians disregarding clinical history was 0.20. Agreement was best for categories 1 (normal, kappa = 0.28) and 5 (clear evidence of a penetrating injury, kappa = 0.39).
  
  
  CONCLUSIONS
  Clinicians educated and experienced in assessing child sexual abuse do not agree perfectly on the interpretation of photographs of genital findings in girls with Tanner stage 1 or 2 genitalia. Clinicians agree less when a patient's clinical history is available. Efforts should be directed at standardizing physical findings and avoiding overemphasis on physical findings in child sexual abuse cases.
authors.affiliation: Department of Pediatrics, Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, NC, USA.
authors.forename: S H
authors.initials: SH
authors.lastname: Sinal
authors.forename: M R
authors.initials: MR
authors.lastname: Lawless
authors.forename: D Y
authors.initials: DY
authors.lastname: Rainey
authors.forename: V D
authors.initials: VD
authors.lastname: Everett
authors.forename: D K
authors.initials: DK
authors.lastname: Runyan
authors.forename: T
authors.initials: T
authors.lastname: Frothingham
authors.forename: M
authors.initials: M
authors.lastname: Herman-Giddens
authors.forename: K
authors.initials: K
authors.lastname: St Claire
mesh_terms: D002648:Child; D002650:Child Abuse, Sexual / Q000175:diagnosis*; D003127:Colposcopy; D005260:Female; D006801:Humans; D015588:Observer Variation; D010781:Photography