Addressing sexual abuse in the primary care setting

Objective. To describe factors that prompt pediatric practitioners to suspe ct child sexual prompt pediatric practitioners to suspect child sexual abus e, the barriers to inquiry, and the approach to management of cases of poss ible abuse. Design. Qualitative, descriptive, and case-based. Methods. Six focus group interviews were conducted. Maternal and Child Heal th Bureau-sponsored collaborative office rounds groups nationwide participa ted in discussions of five vignettes. Each group interview lasted 1.5 hours and had 7 to 16 participants (n = 65). Audiotaped data were transcribed an d analyzed independently for themes by two reviewers. Results. Five themes emerged from the group interviews: anticipatory guidan ce, red flags, approach to management, terminology used in discussions, and barriers to inquiry. All groups discussed giving anticipatory guidance abo ut sexual abuse. Half (3/6) believed girls were more likely to be victimize d, and some (2/6) gave more anticipatory guidance to girls for this reason. Although some groups reported giving anticipatory guidance about sexual ab use, many reported inconsistencies in their practice. All groups identified historical, behavioral, and physical red flags for sexual abuse but believ ed that they were not trained in residency to recognize these signs. There was no consensus regarding the approach to management of cases of possible sexual abuse, and many participants did not know the types of questions tha t they should be asking children when they suspect abuse. Members of all gr oups reported using imprecise terms when they discuss sexual issues with fa milies. Most (4/6) believed that it was a practitioner's responsibility to inquire about abuse but believed that their discomfort with sexual topics w as a barrier to inquiry. All believed that the most significant barrier to inquiry was inadequate training in the area of sexual abuse and that cases ate missed because of lack of training. Conclusions. Highly motivated pediatric practitioners reported that they gi ve anticipatory guidance about sexual abuse inconsistently, that they were not trained to recognize red nags for sexual abuse, and that they do not ha ve a consistent approach to cases of suspected abuse. Additionally, they re ported that they are not comfortable discussing sexual issues and that they miss cases of sexual abuse primarily because of lack of training. Educatio nal interventions that target these themes are essential to improve the abi lity of pediatricians to screen children and to intervene when sexual abuse is identified.