Forensic examination of suspected child victims of sexual abuse in the UK: a personal view.

Expert opinion in child abuse has received considerable bad press and currently public confidence in this area of medical practice is low. Media interest has focused most on the diagnosis of factitious illness. However doctors who examine children in respect of proceedings arising from suspected sexual abuse should be mindful this area is potentially just as problematic. Widely different rates of abnormal findings have been reported. At least in part this has reflected inconsistency in interpretation. Findings once assumed diagnostic of penetration are now recognised to occur in non-abused children. The practical difficulties of examining a reluctant child and achieving adequate visualisation of the hymen in relaxed state, are frequently underestimated. Where normal or non-specific findings are presented as "consistent with the alleged event" there is a high risk the court will perceive them to be significant. Guidelines have tended to lag behind existing knowledge and made inadequate differentiation between prepubertal and adolescent cases. They have also placed a high degree of reliance on statements from children without regard to the context in which any "disclosure" had arisen. Photodocumentation has important benefits, and limitations. Images may not display the true depth of field and are not the same as examining the child directly. Examination must remain the gold standard. There is a moral duty of care on the examining doctor to understand and clarify the status of findings dispassionately and with due regard to the level of the evidence base.