C/u/c/ -I~IISF & Neg/cw, Vol. 16. pp. 533-540. Printed in the U.S.A. All rights reserved.
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MEDICAL EVALUATION REFERRAL PATTERNS FOR SEXUAL ABUSE VICTIMS
Department of Pediatrics, Indiana University School of Medicine, Indianapolis
Indiana University School of Public and Environmental Affairs, Indianapolis
Abstract-It has been recommended that all children suspected of being sexually abused should have medical evaluations. To better understand practices and perceptions of child sexual abuse medical evaluations, a survey was conducted of 579 professionals attending educational programs on child sexual abuse; 85.8% (N = 497) responded. Half (50%) of the respondents reported no previous training in child sexual abuse. Of the 336 nonphysician professionals, 194 (57.7%) were in positions where they make referrals ofthe victims, and 69% ofthese did not refer ali of the children they saw for medical evaluations. The first referral choice for medical evaluation was most often to the victim’s primary physician (57%). For those professionals who did not refer all alleged victims for medical evaluation, neither the victims’ age, gender, nor accessibility to care were generally considered relevant in determining the decision to refer. However, the type of abuse and presence of physical and psychological symptoms were considered relevant in making the decision. The majority indicated that the findings of the medical exam were very useful in substantiating or refuting the allegation of abuse. Further training for both medical and nonmedical professionals is needed to increase awareness of the need for and implications of the medical evaluation if children are to receive comprehensive assessments. Physicians may play an active role in this process through education of professionals and provision of care. Kq Wovds-Sexual
abuse, Medical evaluations, Referral patterns.
INTRODUCTION INCREASED AWARENESS OF the problem of child sexual abuse has resulted in increased numbers of children presenting to both medical and nonmedical professionals for the evaluation of possible sexual victimization. It has been emphasized that all children suspected of being sexually abused require medical evaluations (Kempe & Kempe, 1984; Sgroi, 1978; Sgroi, Porter, & Blick, 1985). While this is a strong recommendation, the complicance with it is not often addressed. The purpose of this medical evaluation is to ascertain the medical history and conduct a complete physical examination, identify and treat any medical conditions, determine the plausibility of sexual abuse, and to reassure the child and family regarding possible physical sequelae (Muchlinski, Boonstra, & Johnson, 1989). While most physical examinations of alleged sexual abuse victims are normal. the physical examination can proThis research was supported by Indiana State Board of Health Project #290, 1985-1987. Received for publication October 20, 1990; final revision received June 10, 199 1; accepted for publication June 13, 1991. Requests for reprints may be sent to Roberta A. Hibbard, M.D., Department of Pediatrics, IU Medical Center, Riley Clinic C., 702 Barnh~ll Drive, Indiana~lis, IN 46202-5200. 533
534
R. A. Hibbard and T. W. Zollinger
vide reasonable evidence of sexual abuse (Claytor, Barth, & Shubin, 1989), and physicians are often expected to provide essential forensic information (Abright, 1986). However, they are admonished to “exercise extreme care in their examinations of allegedly sexually abused children,” because of the possibility of significant false positive findings when using commonly accepted indicators to determine if abuse has occurred (Paradise, 1989). The medical evaluation is an important component of a complete evaluation. Others have examined professionals’ reluctance to report possible abuse (Chang, Oglesby, Wallace, Goldstein, & Hexter, 1976), physician recommendations for intervention in abuse cases (Anglin, 1983) and professionals’ compliance with legal mandates regarding child abuse (Saulsbury & Campbell, 1985). Attias and Goodwin (1985) suggest that physicians have the most to teach others about the necessity of the medical examination as part of a comprehensive approach to evaluation. Child abuse is recognized as a multidisciplinary matter, requiring professionals from many disciplines to work together and draw on the expertise of the medical professionals to determine the most appropriate care for the victims (Oates, 1989). To better understand practice and perceptions of child sexual abuse medical evaluations, social, legal, and medical professionals were surveyed to assess medical examination referral patterns and knowledge about child sexual abuse. Professional knowledge about child sexual abuse has been reported elsewhere (Hibbard & Zollinger, 1990). This report addresses referral patterns for medical evaluations of alleged child sexual abuse victims.
METHOD Physicians, nurses, child protective workers, lawyers, law enforcement officers, and psychologists who professionally interact with child sexual abuse were invited to participate in professional educational programs on child sexual abuse. They were identified and invited through state and local child protective services (CPS), hospitals, law enforcement agencies, professional newsletters, medical and legal professional society memberships, and personal professional contacts. Throughout the year, 579 professionals from eight geographic areas in Indiana attended day-long multidisciplinary educational programs on the evaluation of alleged sexual abuse victims. These programs were an outreach effort from an educational program previously reported (Hibbard, Serwint, & Connolly, 1987). There was no requirement or fee for participation. Prior to the educational programs, subjects were asked to respond to two questionnaires: one regarding experience and training in the evaluation of alleged sexual abuse victims, and one assessing knowledge about child sexual abuse. Based on the professionals’ responses to the knowledge questionnaires, a knowledge score was developed (Hazzard, 1984; Hazzard & Rupp, 1986) and used in this study to relate to referral patterns of the professionals. The experience questionnaire addressed issues of previous training, number of children evaluated, referral practices for medical examinations, and perceived usefulness of the medical examinations in supporting or refuting allegations of sexual abuse. The physician questionnaires were not included in this study of referral patterns because many of the referral questions were not appropriate for them, thus the term “Professionals” used throughout the remainder of this paper will refer to those other than physicians. The professionals who did not refer all of the child victims of sexual abuse for medical evaluation were asked the relevance of 15 factors such as the child’s demographics, the abuse characteristics, and accessibility to medical care in determining their decision to refer the child for medical evaluation. A relevancy score was constructed by assigning the value of “1” when the respondent indicated the factor was “not relevant,” “2” for “somewhat relevant,” and “3” for “very relevant,” and summing the values for the 15 factors. Thus the relevancy
Medical referral for sexual abuse victims
535
score could range from 15, in the event the professional felt all of the factors were not relevant, to 45 if they considered all of the factors relevant. The experience, practices, and perceptions of professionals attending the programs were described and differences examined among professional groups using contingency tables (chisquare), and analysis of variance. The Duncan’s multiple-range test procedure was used to identify the nature of the significant relationships identified in the analysis of variance results. The number of victims referred per month, the proportion of those seen who were referred, and the relevancy score interrelationships were identified using correlation analysis.
RESULTS Of the 579 who attended the programs in 1987,497 (85.8%) completed the questionnaires. The study group was comprised of 135 social work professionals (predominantly child protective caseworkers), 107 nurses, 57 law enforcement officers, 36 psychologists, 157 other professionals (ministers, educators, attorneys, and personnel from mental health and other agencies), and 5 who did not indicate their profession. The sample was 24% male, with a mean age of 37.0 years (SD = 10.35) and reported a mean of 10.4 (SD = 9.29) years of professional practice. Half (50%) of the respondents reported no previous formal training in the evaluation of alleged sexual abuse victims. The training for many of the respondents (46%) consisted of continuing education they received after they entered their profession. The professionals averaged 28.5 hours (SD = 52.32) of training on this topic. Of the group who see victims of child abuse professionally (N = 336), 194 (57.7%) were in professional positions where they made referrals of child sexual abuse victims they see for medical evaluations. Most (85%) of this subgroup reported seeing an average of five or fewer alleged victims per month over the previous year. About a third (31%) of those who see victims refer most or all of the victims they see for medical evaluation. The males who saw victims referred a significantly (x2 = 10.44, p = 0.033) higher proportion of the victims they saw for medical evaluations compared to the females, although there was not a significant difference in the average number of victims they referred per month. The nurses referred a significantly (x2 = 37.12, p = 0.002) higher proportion of the victims they see for medical evaluations as compared to the other professional groups, even though the nurses see (and refer) less victims per month as compared to the social workers and law enforcement professionals. Those with formal training dealing with child sexual abuse referred significantly (t = 1.99, p = 0.048) more children per month for medical evaluation, however, the type of the training was not an important factor. The age, number of years of practice, number of hours of training, knowledge score, relevancy score and number of victims seen per month were not related to the number or proportion of victims referred fo: medical evaluation per month. The professionals who reported referral patterns (N = 180) indicated they most often referred children to their regular primary physicians (40.6%) for medical evaluations. Emergency rooms (22.2%) were other common sources of care. Significant (x2 = 36.54,~ = 0.0003) differences existed among the professional groups related to their first referral choice. The majority of all the professional groups except for law enforcement listed the child’s regular physician as the first referral choice. Law enforcement officers were more likely than the other professionals to refer the victims to emergency rooms. Social workers and professionals in the “other” category were more likely than the rest of the professionals to utilize the services of a consultant specifically for abuse. The most common second referral choice for all the professional groups, except those in law enforcement, was the emergency room. Law enforcement professionals more often listed the child’s regular physician as the second referral choice.
536
R. A. Hibbard and T. W. Zollinger Table 1. The Relevancy of Case Characteristics in Determining Which Victims Were Referred for Medical Evaluations (N = 158) Number (Percent) Indicating Factor Was: Factor Age of Victim Sex of Victim If Offender Was Known to the Victim Chronicity of Abuse Time Since Last Abuse Physical Force Used Type of Abuse Who Gives History Behavior Problems Psychological Symptoms Physical Complaints Physician Availability Cost of Exam Parent Willing Custody/Separated Family
Not Relevant
Somewhat Relevant
Very Relevant
68 (43.6%) 96 (60.8%)
33 (21.2%) 34 (21.5%)
55 (35.3%) 28 (17.7%)
101 (65.6%) 41 (26.3%) 29 (18.6%) 26 (16.6%) 23 (14.6) 50 (32.7%) 40 (26.0%) 28 (18.2%) 12 (7.7%) 85 (55.6%) 127 (81.9%) 88 (57.1%) 93 (60.8%)
29 ( 18.8%) 42 (26.9%) 52 (33.3%) 31 (19.7%) 42 (26.8%) 61 (39.9%) 65 (42.2%) 64 (41.6%) 24 (15.5%) 40 (26.1 W) 21 (13.5%) 39 (25.3%) 38 (24.8%)
24 (15.6%) 73 (46.8%) 75 (48.1%) 100 (63.7%) 92 (58.6%) 42 (27.5%) 49 (31.8%) 62 (40.3%) 119 (76.8%) 28 (18.3%) 7 (4.5%) 27 (17.5%) 19 (12.4%)
Those professionals who referred for medical evaluation some of the victims they saw were asked the relevancy of 15 factors in determining their decision to make the referrals. Their responses to this question are summarized in Table 1. The age, gender, and whether the perpetrator was known to the victim were generally considered not relevant or only somewhat relevant decision factors by the professionals. However, most of the professionals felt the characteristics of the abuse (chronicity of abuse, time since last abuse, and use of physical force) were important factors in making the decision to refer the victim. The professionals indicated mixed reactions to the factors: who gives the history of abuse (parent vs. child), and the presence of behavior problems. Almost equal numbers of respondents indicated these two factors were very relevant and were not relevant. However, ifthe victims displayed psychological symptoms or physical complaints, most of the professionals indicated these factors were very relevant in their decision to refer the victim for medical care. Lastly, the majority of the professionals indicated physician availability, cost of the exam, willingness of the parent, and who has custody in a separated family were generally not relevant or only somewhat relevant in determining their decisions to refer the victims for medical evaluations. Analysis of the responses to these questions using a composite relevancy score compared to other characteristics of the professionals was conducted with the results shown in Tables 2 and 3. The nurses indicated significantly more of the factors were relevant in the decision to refer as compared to the social workers and “other” professionals. Male professionals more often than females indicated the factors listed were relevant in the decision. The relevancy score was not related to the proportion of victims referred for medical evaluation, the first referral choice, or the type of training of the professionals. The relevancy score was positively related to the age of the professionals, the number of years they have been in practice, and their perception of the usefulness of the exams. There were no relationships between relevancy score and the number of hours of training pertaining to the evaluation of child sexual abuse victims, the number of victims they see, the number of victims they refer for medical evaluation, and knowledge score. The professionals were asked, based on their experience, in what percentage of the children is the medical exam useful in determining whether abuse may have occurred. Of the 163
537
Medical referral for sexual abuse victims Table 2. Relevancv Scores bv Characteristics
of Studv Group (N = 142)
Characteristic
M
SD
Total Group Profession Social work (65) Nurse’ ( 12) Law enforcement (25) Psychologist (13) Other (27) Gender Males (53) Females (89) Proportion of Children Referred for Exams None (8) Some (63) Half(l9) Most (29) All (12) First Referral Choice Regular MD (77) ER(19) Consultant (26) Other ( 12) Formal Training No (31) Yes (110) Type of Training Courses (5) Prof-CEU (53) Community (1) Other (4) Multiple (47)
27.29
6.65
26.1 32.5 28.1 28.5 26.5
6.41 6.75 6.68 7.37 5.92
29.3 26.1
5.93 6.78
27.8 26.5 27.8 26.4 29.3
5.36 6.48 8.17 4.73 9.15
27.3 27.7 26.5 24.6
6.51 7.36 5.83 6.13
25.4 27.8
5.38 6.29
31.6 27.1 37.0 29.0 27.9
7.50 6.47
F-value
p-value
2.77
.0298
8.31
.0046
0.60
.6618
0.65
.5856
3.26
.0730
0.99
.4161
3% 7.50
a Nurses scored significantly (p < .05) higher than the social workers and “other” professionals.
responding to this question, the mean response was 54.5% (SD = 3 1.74). There was a highly significant (Y= 0.5353, F = 40.94, p
1992 CopyrIght
0
014%?l34/92 1992 Pergamn
$5.00 + .CO Press Ltd.
MEDICAL EVALUATION REFERRAL PATTERNS FOR SEXUAL ABUSE VICTIMS
Department of Pediatrics, Indiana University School of Medicine, Indianapolis
Indiana University School of Public and Environmental Affairs, Indianapolis
Abstract-It has been recommended that all children suspected of being sexually abused should have medical evaluations. To better understand practices and perceptions of child sexual abuse medical evaluations, a survey was conducted of 579 professionals attending educational programs on child sexual abuse; 85.8% (N = 497) responded. Half (50%) of the respondents reported no previous training in child sexual abuse. Of the 336 nonphysician professionals, 194 (57.7%) were in positions where they make referrals ofthe victims, and 69% ofthese did not refer ali of the children they saw for medical evaluations. The first referral choice for medical evaluation was most often to the victim’s primary physician (57%). For those professionals who did not refer all alleged victims for medical evaluation, neither the victims’ age, gender, nor accessibility to care were generally considered relevant in determining the decision to refer. However, the type of abuse and presence of physical and psychological symptoms were considered relevant in making the decision. The majority indicated that the findings of the medical exam were very useful in substantiating or refuting the allegation of abuse. Further training for both medical and nonmedical professionals is needed to increase awareness of the need for and implications of the medical evaluation if children are to receive comprehensive assessments. Physicians may play an active role in this process through education of professionals and provision of care. Kq Wovds-Sexual
abuse, Medical evaluations, Referral patterns.
INTRODUCTION INCREASED AWARENESS OF the problem of child sexual abuse has resulted in increased numbers of children presenting to both medical and nonmedical professionals for the evaluation of possible sexual victimization. It has been emphasized that all children suspected of being sexually abused require medical evaluations (Kempe & Kempe, 1984; Sgroi, 1978; Sgroi, Porter, & Blick, 1985). While this is a strong recommendation, the complicance with it is not often addressed. The purpose of this medical evaluation is to ascertain the medical history and conduct a complete physical examination, identify and treat any medical conditions, determine the plausibility of sexual abuse, and to reassure the child and family regarding possible physical sequelae (Muchlinski, Boonstra, & Johnson, 1989). While most physical examinations of alleged sexual abuse victims are normal. the physical examination can proThis research was supported by Indiana State Board of Health Project #290, 1985-1987. Received for publication October 20, 1990; final revision received June 10, 199 1; accepted for publication June 13, 1991. Requests for reprints may be sent to Roberta A. Hibbard, M.D., Department of Pediatrics, IU Medical Center, Riley Clinic C., 702 Barnh~ll Drive, Indiana~lis, IN 46202-5200. 533
534
R. A. Hibbard and T. W. Zollinger
vide reasonable evidence of sexual abuse (Claytor, Barth, & Shubin, 1989), and physicians are often expected to provide essential forensic information (Abright, 1986). However, they are admonished to “exercise extreme care in their examinations of allegedly sexually abused children,” because of the possibility of significant false positive findings when using commonly accepted indicators to determine if abuse has occurred (Paradise, 1989). The medical evaluation is an important component of a complete evaluation. Others have examined professionals’ reluctance to report possible abuse (Chang, Oglesby, Wallace, Goldstein, & Hexter, 1976), physician recommendations for intervention in abuse cases (Anglin, 1983) and professionals’ compliance with legal mandates regarding child abuse (Saulsbury & Campbell, 1985). Attias and Goodwin (1985) suggest that physicians have the most to teach others about the necessity of the medical examination as part of a comprehensive approach to evaluation. Child abuse is recognized as a multidisciplinary matter, requiring professionals from many disciplines to work together and draw on the expertise of the medical professionals to determine the most appropriate care for the victims (Oates, 1989). To better understand practice and perceptions of child sexual abuse medical evaluations, social, legal, and medical professionals were surveyed to assess medical examination referral patterns and knowledge about child sexual abuse. Professional knowledge about child sexual abuse has been reported elsewhere (Hibbard & Zollinger, 1990). This report addresses referral patterns for medical evaluations of alleged child sexual abuse victims.
METHOD Physicians, nurses, child protective workers, lawyers, law enforcement officers, and psychologists who professionally interact with child sexual abuse were invited to participate in professional educational programs on child sexual abuse. They were identified and invited through state and local child protective services (CPS), hospitals, law enforcement agencies, professional newsletters, medical and legal professional society memberships, and personal professional contacts. Throughout the year, 579 professionals from eight geographic areas in Indiana attended day-long multidisciplinary educational programs on the evaluation of alleged sexual abuse victims. These programs were an outreach effort from an educational program previously reported (Hibbard, Serwint, & Connolly, 1987). There was no requirement or fee for participation. Prior to the educational programs, subjects were asked to respond to two questionnaires: one regarding experience and training in the evaluation of alleged sexual abuse victims, and one assessing knowledge about child sexual abuse. Based on the professionals’ responses to the knowledge questionnaires, a knowledge score was developed (Hazzard, 1984; Hazzard & Rupp, 1986) and used in this study to relate to referral patterns of the professionals. The experience questionnaire addressed issues of previous training, number of children evaluated, referral practices for medical examinations, and perceived usefulness of the medical examinations in supporting or refuting allegations of sexual abuse. The physician questionnaires were not included in this study of referral patterns because many of the referral questions were not appropriate for them, thus the term “Professionals” used throughout the remainder of this paper will refer to those other than physicians. The professionals who did not refer all of the child victims of sexual abuse for medical evaluation were asked the relevance of 15 factors such as the child’s demographics, the abuse characteristics, and accessibility to medical care in determining their decision to refer the child for medical evaluation. A relevancy score was constructed by assigning the value of “1” when the respondent indicated the factor was “not relevant,” “2” for “somewhat relevant,” and “3” for “very relevant,” and summing the values for the 15 factors. Thus the relevancy
Medical referral for sexual abuse victims
535
score could range from 15, in the event the professional felt all of the factors were not relevant, to 45 if they considered all of the factors relevant. The experience, practices, and perceptions of professionals attending the programs were described and differences examined among professional groups using contingency tables (chisquare), and analysis of variance. The Duncan’s multiple-range test procedure was used to identify the nature of the significant relationships identified in the analysis of variance results. The number of victims referred per month, the proportion of those seen who were referred, and the relevancy score interrelationships were identified using correlation analysis.
RESULTS Of the 579 who attended the programs in 1987,497 (85.8%) completed the questionnaires. The study group was comprised of 135 social work professionals (predominantly child protective caseworkers), 107 nurses, 57 law enforcement officers, 36 psychologists, 157 other professionals (ministers, educators, attorneys, and personnel from mental health and other agencies), and 5 who did not indicate their profession. The sample was 24% male, with a mean age of 37.0 years (SD = 10.35) and reported a mean of 10.4 (SD = 9.29) years of professional practice. Half (50%) of the respondents reported no previous formal training in the evaluation of alleged sexual abuse victims. The training for many of the respondents (46%) consisted of continuing education they received after they entered their profession. The professionals averaged 28.5 hours (SD = 52.32) of training on this topic. Of the group who see victims of child abuse professionally (N = 336), 194 (57.7%) were in professional positions where they made referrals of child sexual abuse victims they see for medical evaluations. Most (85%) of this subgroup reported seeing an average of five or fewer alleged victims per month over the previous year. About a third (31%) of those who see victims refer most or all of the victims they see for medical evaluation. The males who saw victims referred a significantly (x2 = 10.44, p = 0.033) higher proportion of the victims they saw for medical evaluations compared to the females, although there was not a significant difference in the average number of victims they referred per month. The nurses referred a significantly (x2 = 37.12, p = 0.002) higher proportion of the victims they see for medical evaluations as compared to the other professional groups, even though the nurses see (and refer) less victims per month as compared to the social workers and law enforcement professionals. Those with formal training dealing with child sexual abuse referred significantly (t = 1.99, p = 0.048) more children per month for medical evaluation, however, the type of the training was not an important factor. The age, number of years of practice, number of hours of training, knowledge score, relevancy score and number of victims seen per month were not related to the number or proportion of victims referred fo: medical evaluation per month. The professionals who reported referral patterns (N = 180) indicated they most often referred children to their regular primary physicians (40.6%) for medical evaluations. Emergency rooms (22.2%) were other common sources of care. Significant (x2 = 36.54,~ = 0.0003) differences existed among the professional groups related to their first referral choice. The majority of all the professional groups except for law enforcement listed the child’s regular physician as the first referral choice. Law enforcement officers were more likely than the other professionals to refer the victims to emergency rooms. Social workers and professionals in the “other” category were more likely than the rest of the professionals to utilize the services of a consultant specifically for abuse. The most common second referral choice for all the professional groups, except those in law enforcement, was the emergency room. Law enforcement professionals more often listed the child’s regular physician as the second referral choice.
536
R. A. Hibbard and T. W. Zollinger Table 1. The Relevancy of Case Characteristics in Determining Which Victims Were Referred for Medical Evaluations (N = 158) Number (Percent) Indicating Factor Was: Factor Age of Victim Sex of Victim If Offender Was Known to the Victim Chronicity of Abuse Time Since Last Abuse Physical Force Used Type of Abuse Who Gives History Behavior Problems Psychological Symptoms Physical Complaints Physician Availability Cost of Exam Parent Willing Custody/Separated Family
Not Relevant
Somewhat Relevant
Very Relevant
68 (43.6%) 96 (60.8%)
33 (21.2%) 34 (21.5%)
55 (35.3%) 28 (17.7%)
101 (65.6%) 41 (26.3%) 29 (18.6%) 26 (16.6%) 23 (14.6) 50 (32.7%) 40 (26.0%) 28 (18.2%) 12 (7.7%) 85 (55.6%) 127 (81.9%) 88 (57.1%) 93 (60.8%)
29 ( 18.8%) 42 (26.9%) 52 (33.3%) 31 (19.7%) 42 (26.8%) 61 (39.9%) 65 (42.2%) 64 (41.6%) 24 (15.5%) 40 (26.1 W) 21 (13.5%) 39 (25.3%) 38 (24.8%)
24 (15.6%) 73 (46.8%) 75 (48.1%) 100 (63.7%) 92 (58.6%) 42 (27.5%) 49 (31.8%) 62 (40.3%) 119 (76.8%) 28 (18.3%) 7 (4.5%) 27 (17.5%) 19 (12.4%)
Those professionals who referred for medical evaluation some of the victims they saw were asked the relevancy of 15 factors in determining their decision to make the referrals. Their responses to this question are summarized in Table 1. The age, gender, and whether the perpetrator was known to the victim were generally considered not relevant or only somewhat relevant decision factors by the professionals. However, most of the professionals felt the characteristics of the abuse (chronicity of abuse, time since last abuse, and use of physical force) were important factors in making the decision to refer the victim. The professionals indicated mixed reactions to the factors: who gives the history of abuse (parent vs. child), and the presence of behavior problems. Almost equal numbers of respondents indicated these two factors were very relevant and were not relevant. However, ifthe victims displayed psychological symptoms or physical complaints, most of the professionals indicated these factors were very relevant in their decision to refer the victim for medical care. Lastly, the majority of the professionals indicated physician availability, cost of the exam, willingness of the parent, and who has custody in a separated family were generally not relevant or only somewhat relevant in determining their decisions to refer the victims for medical evaluations. Analysis of the responses to these questions using a composite relevancy score compared to other characteristics of the professionals was conducted with the results shown in Tables 2 and 3. The nurses indicated significantly more of the factors were relevant in the decision to refer as compared to the social workers and “other” professionals. Male professionals more often than females indicated the factors listed were relevant in the decision. The relevancy score was not related to the proportion of victims referred for medical evaluation, the first referral choice, or the type of training of the professionals. The relevancy score was positively related to the age of the professionals, the number of years they have been in practice, and their perception of the usefulness of the exams. There were no relationships between relevancy score and the number of hours of training pertaining to the evaluation of child sexual abuse victims, the number of victims they see, the number of victims they refer for medical evaluation, and knowledge score. The professionals were asked, based on their experience, in what percentage of the children is the medical exam useful in determining whether abuse may have occurred. Of the 163
537
Medical referral for sexual abuse victims Table 2. Relevancv Scores bv Characteristics
of Studv Group (N = 142)
Characteristic
M
SD
Total Group Profession Social work (65) Nurse’ ( 12) Law enforcement (25) Psychologist (13) Other (27) Gender Males (53) Females (89) Proportion of Children Referred for Exams None (8) Some (63) Half(l9) Most (29) All (12) First Referral Choice Regular MD (77) ER(19) Consultant (26) Other ( 12) Formal Training No (31) Yes (110) Type of Training Courses (5) Prof-CEU (53) Community (1) Other (4) Multiple (47)
27.29
6.65
26.1 32.5 28.1 28.5 26.5
6.41 6.75 6.68 7.37 5.92
29.3 26.1
5.93 6.78
27.8 26.5 27.8 26.4 29.3
5.36 6.48 8.17 4.73 9.15
27.3 27.7 26.5 24.6
6.51 7.36 5.83 6.13
25.4 27.8
5.38 6.29
31.6 27.1 37.0 29.0 27.9
7.50 6.47
F-value
p-value
2.77
.0298
8.31
.0046
0.60
.6618
0.65
.5856
3.26
.0730
0.99
.4161
3% 7.50
a Nurses scored significantly (p < .05) higher than the social workers and “other” professionals.
responding to this question, the mean response was 54.5% (SD = 3 1.74). There was a highly significant (Y= 0.5353, F = 40.94, p
