Clinician agreement on physical findings in child sexual abuse cases
S. H. Sinal, M. R. Lawless, D. Y. Rainey, V. D. Everett, D. K. Runyan, T. Frothingham, M. Herman-Giddens and K. St Claire
Department of Pediatrics, Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, NC, USA.
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. DESIGN: 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.
SETTING: All clinicians involved perform child sexual abuse examinations at
tertiary care centers. PATIENTS: 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.
