Sexual abuse of children is alarmingly prevalent. By age 18, 27% of girls and 5% of boys in the U.S. are estimated to have experienced contact sexual abuse.1 Only a small fraction become known and are referred to the public agencies mandated to protect children. The potential short- and long-term consequences of child sexual abuse (CSA) have been amply documented.2, 3, 4 Many parents and caregivers, suspecting abuse, bring children to their primary care professional (PCP), anticipating that they can assess whether abuse occurred. However, in most substantiated cases of CSA, medical evidence is lacking.5 The history is central, and yet PCPs often feel ill-equipped to elicit a report from a child, particularly in young children. Practice guidelines advise pediatricians to conduct “minimal facts” history-taking and ask “open-ended” questions, but clear and consistent guidance is lacking.6, 7 Research has identified the most productive means for questioning children about sexual abuse that can be adapted by PCPs to elicit a minimal facts history and determine whether there is reasonable suspicion of abuse.

PCP’s may be reluctant to assess children when sexual abuse is suspected,8, 9 preferring to refer to an emergency department or medical expert, while reporting the concern to child protective services (CPS) and/or the police. While several factors may contribute to this reluctance, it is often not optimal care, for several reasons. First, in some situations, such as a diaper rash, parental anxiety can be readily allayed. Second, referral to an emergency department often does not lead to an assessment by someone with expertise in this area. Third, data from the American Board of Pediatrics indicate that there were only 336 child abuse pediatricians (CAPs) aged 70 or younger in the U.S. in 2022; the ratio of such professionals varied across states from 0.0 (in four states) to 3.18 per 100,000 children, averaging just 0.5.10 In parts of all states, there are families living over 40 miles from a facility with a CAP.11 Fourth, referral to CPS or the police does not guarantee a medical evaluation. Even if taken to a Child Advocacy Center (CAC) for a forensic interview, only a modest proportion are evaluated medically, just 89,058 out of 247,543 interviewed in 2022.12 Fifth, PCPs usually have long-term trusting relationships with patients and families which are particularly helpful in stressful times.6 Children may be more inclined to share sensitive information with a professional they know and trust.8, 13 Therefore, PCPS can play an important albeit limited role in initially assessing children when CSA is a concern. This assessment guides their decision on whether there is a reasonable basis for referral to CPS and/or the police, the public agencies responsible for investigating abuse and ensuring children's safety.

Our recommendations improve upon the 2013 Clinical Report, “The Evaluation of Children in the Primary Care Setting When Sexual Abuse is Suspected,” regarding how pediatricians should conduct “minimal facts” history-taking, anticipating that a forensic evaluator will conduct “a more detailed interview.”6 First, although the Report recommends that “time should be spent talking about nonthreatening issues, such as schools, friends, or pets,” it fails to discuss the types of questions that increase children’s willingness to report abuse. Our paper gives clear guidance on question types. Second, the Report recommends that pediatricians should “tell children that it is their job as doctors to keep children healthy and that it is okay for children to talk about difficult or uncomfortable subjects with their doctors.” Our paper avoids words like “difficult” or “uncomfortable” that are often misunderstood by young children. Third, the Report warns that “[t]he pediatrician should not ask leading or suggestive questions,” and should begin with “open-ended” questions, but fails to define these terms. Instead the Report provides examples of what it calls open-ended questions, such as “Is anything bothering you?” We explain the problems with yes-no questions, which elicit brief and often erroneous responses. The use of “anything” is particularly problematic, pulling for a “no.” To its credit, the Report recommends “Tell me why you’re here today.” Our paper improves upon this question, discusses how to avoid phrasing it as a yes-no question, and describes what to do if the question is ineffective. Fourth, our paper discusses topics that pediatricians should avoid when conducting “minimal facts” history-taking, including enumeration, dating, and yes-no questions about pain, penetration and ejaculation. The Report is not alone in recommending problematic questions. We routinely see these in practice guides for pediatricians. For example, “The Pediatrician’s Role in Child Abuse Interviewing” recommends “Has something happened to you?” as an open-ended question, not recognizing that it’s yes-no structure and vagueness could lead to false “no” responses.7

The circumstances concerning CSA vary (See Figure). If it is readily evident that abuse likely occurred and local medical expertise is available, PCPs may prefer to minimize their assessment and refer to CPS and/or the police, without obtaining a detailed history or conducting an exam. In some situations, an alternative medical explanation such as a diaper rash can be readily reassuring. At times, there is a need for an urgent medical assessment including gathering forensic evidence and the PCP can facilitate a referral. In some regions, PCPs can directly refer children to a CAP for an expert evaluation. There are also many ambiguous circumstances and a PCP’s limited assessment can clarify how to proceed. This paper focuses on these unclear situations, and offers practical guidance to initially assess possible CSA, without expecting a comprehensive and definitive evaluation. PCPs are clearly not forensic interviewers nor investigators, but they can apply principles of good interviewing techniques in eliciting a limited history, assessing the likelihood of CSA, and determining next steps.7 Their assessment can clarify concerns for a child and family, guide them towards further evaluation if needed, have investigative value, and help protect a child.

In sum, this paper offers PCPs guidance for an initial assessment when concern for CSA arises. Much of this guidance also pertains to emergency medicine professionals, particularly concerning “acute” situations when recent abuse is alleged. It should also be useful to medical professionals in many areas where there is no or limited access to a CAP or similar expert. We focus on the history, typically the critical information in assessing the likelihood of CSA. Guidance on the physical exam and laboratory testing can be found in AAP and CDC publications.14, 15