The number of children affected by sexual abuse is high. Sexual abuse was reported in 1995 to involve more than 100,000 children as new unsubstantiated victims in the United States. There are significant limitations in the ability of experts to perform all medical examinations for suspected child sexual abuse victims, and defining outcomes is a critical issue in these examinations. Consequently, guidelines need to be developed to assist in determining which children need a medical examination and when and what level of expertise is optimum given a set of clinical circumstances. In developing policies for triage and referral for child sexual abuse medical examinations, current practices and beliefs about the medical examination need to be understood. The health system structure of care includes such characteristics as the organization of care, specialty mix and support services, financial incentives, provider workload and demographics, specialty training, beliefs and attitudes related to child sexual abuse, and individual preferences and satisfaction. Sociolegal structure of care issues include case and witness characteristics, child protective services, law enforcement, prosecutors, and juvenile and criminal court systems. The process of care must also be addressed in triage and referral policy development, along with outcome and methodological issues. The author concludes triage and referral decisions for medical examination of alleged child sexual abuse encompass an extensive array of patient, provider, sociolegal, community, and financial considerations. 21 references