OBJECTIVE To examine the relationship of behavioral symptoms, interview disclosures, and physical examination findings with changing legal outcomes in child sexual abuse. METHODS Retrospective case series. METHODS Hospital- and community-based multidisciplinary child abuse evaluation teams in the same county in 2 periods. METHODS Children ages 0 to 17 years referred for evaluation of sexual abuse. METHODS Substantiation by child protective services, issuance of a warrant by law enforcement authorities, and criminal penalties were compared with reported changes in behavior, disclosure by the child, and physical evidence on examination. RESULTS Among 497 children evaluated in 1991-1992 and 1995-1996, those with a positive examination finding were 2.5 times more likely to result in a criminal prosecution with a finding of perpetrator guilt (P<.001). Similar rates of disclosure, positive examination findings, child protective services substantiation, and warrant issuance were noted in the 2 periods. Decreasing rates of guilt determination and increasing criminal penalties were identified in 1995-1996 (P<.002). Disclosure of child sexual abuse during medical assessment was significantly associated with a positive physical examination finding, child protective services substantiation, and issuance of a warrant, but not a finding of guilt or criminal penalty. CONCLUSIONS Medical assessment plays an important role in the overall community response to child sexual abuse. While behavioral symptoms and disclosure are important in medical treatment and child protective services investigation, positive physical findings are associated with a finding of guilt. There is a trend toward less finding of guilt and more years of criminal penalty that is not explained by case characteristics.