Telltale signs, history help diagnose sexual abuse. (Anogenital Lesions in Children).

ASPEN, COLO. -- Often it takes a good medical detective to determine if anogenital lesions in children are the result of sexual abuse, according to Dr. Elaine C. Siegfried.

Many cases lack absolute diagnostic signs of abuse, so the diagnosis must be based on a carefully directed history gleaned from the child, whenever possible, and the caregiver, as well as telltale characteristics that distinguish abuse from biologic conditions, Dr. Siegfried said at a clinical dermatology seminar sponsored by Medicis.

When speaking to parents or caregivers, ask who else cares .for the child, how the, child is cared for, and whether the parents themselves suspect any inappropriate contact.

Parents who become angry or defensive when questioned, or who insist on a second opinion, should raise suspicions because most parents become genuinely concerned when the possibility of abuse is raised, she said.

As for physical evidence, a geometric, nonbiologic distribution of lesions is one sign of possible abuse. Sparing of the skin folds is another, as this suggests the problem is occurring outside the skin and does not reach protected areas. Often the giveaway is a history that doesn't match the examination. For example, she described a child who presented with a scald. injury on his penis. The parents claimed they had no idea how the injury occurred--it just appeared one day when they removed his diaper. That's a highly questionable explanation, Dr. Siegfried said.

Doctors whose suspicions are confirmed should contact their local family services office for further intervention. Many communities have 24-hour hot lines for immediate referral.

On the other hand, many innocently acquired conditions can be mistaken for sexual abuse, so the doctor must proceed with ...