Sexual abuse is the involvement of children in sexual activities that they cannot understand, for which they are not developmentally prepared, to which they cannot give informed consent, and/or that violate societal norms.
- Ranges from oral, genital, or anal contact; fondling; child pornography; prostitution; exhibitionism; and voyeurism
- 25% of perpetrators are parents, and 30% are nonparental relatives.
- Most children sexually abused will have no discernible physical injury.
- ~150,000 substantiated cases per year; most likely underestimate the incidence as these include only those cases reported
- Prevalence rates between 10% and 30%. The National Violence Survey reported 27% of adult women and 16% of adult men reported sexual abuse during childhood.
- Peak age of vulnerability: 7 to 13 years of age
- Girls are victimized more than boys, although abuse of boys is underreported.
- Single-parent households, domestic violence, parental substance abuse, and mental illness are risk factors.
- Children who experience other types of abuse are also more likely to be victimized sexually.
- Race and socioeconomic status do not appear to be risk factors for child sexual abuse.
- Risk factors for revictimization: younger aged children, more severe maltreatment, families with mental health and substance abuse problems and violence histories
- Diagnosis is made based on the child’s history because abnormal physical findings or lab tests are infrequent.
- Attempt to limit the number of interviews.
- Interview should be detailed enough to know whether a report to child protection or law enforcement is needed.
- If the medical provider is the first person to which the child has disclosed, then that person is an “an outcry witness,” and that disclosure can be used in court testimony.
- Answers from the children that are obtained for the medical diagnosis and treatment may be admitted into evidence. Verbatim documentation is recommended if possible.
- The interview should be conducted with the child separate from family members.
- Ask open-ended, nonleading questions.
- Use developmentally appropriate language.
- Specific questions important to the triage of the child include the following:
- Identity of alleged perpetrator/relationship to child
- Time of last possible contact
- Specific types of sexual contact
- Review of systems including genital pain, bleeding, dysuria, constipation, painful bowel movements, and behavioral changes
- Serves to ensure the overall health of a child after an abusive event and to document any injuries or other forensically relevant evidence
- Most exams are normal.
- An emergency exam is indicated if the most recent assault was within 72 hours or if the patient has complaints of pain, dysuria, or bleeding.
- Beyond 72 hours, the exam can be scheduled at the local child advocacy center.
- A speculum should not be used for a prepubertal sexual abuse exam unless there is acute bleeding, and its origin must be determined.
- Use of the techniques of labial separation and labial traction (gently grasping the posterior portion of the labia majora and pulling laterally, down, and toward the examiner) allows for the best visualization of the hymenal edges.
- Normal hymenal configurations: annular, crescentic, and fimbriated
- Newborn hymen: thickened, pale, and redundant
- Prepubertal hymen: thin, less redundant, with sharp well-defined edges
- Postpubertal hymen: thickened, pale, and redundant
- A few physical findings are diagnostic of abuse:
- Presence of semen or sperm on the victim
- Acute genital/anal injuries without an adequate accidental explanation (bruising, lacerations, complete hymenal transaction between 4 and 8 o’clock along hymenal rim)
- Syphilis and Neisseria gonorrhoeae infection (excluding perinatal infection)
- Chlamydia if the child is >3 years of age
- Trichomoniasis in a child >1 year of age
- Many genital findings are unlikely to be related to abuse:
- Normal variants including intravaginal ridges, hymenal mounds, linea vestibularis, diastasis ani
- Perineal redness
- Labial adhesions
- Anal fissures
- Venous pooling in perianal area
- Any finding on exam thought to be abnormal or diagnostic of child sexual abuse should be reviewed with a child abuse expert for confirmation.
- Photo documentation is recommended as it preserves visual evidence for expert review and legal proceedings.
- Sexualized behaviors
- Normal behaviors for age (e.g., masturbation)
- Exposure to sexual activity (e.g., media)
- Abnormal GU exam
- Normal variations in hymenal anatomy (e.g., septate, cribriform, imperforate)
- Normal variations in perineal anatomy (e.g., hymenal mound, intravaginal ridge, vestibular bands)
- Linea vestibularis: white streaks that run from inferior hymenal border to posterior commissure
- Failure of midline fusion: presence of mucosal surface between fossa navicularis and anus that commonly resolves at puberty
- Irritant, contact, and seborrheic dermatitis
- Labial adhesions
- Lichen sclerosus et atrophicus: thinned white atrophic skin in figure-of-8 appearance which may have bruising or petechiae
- Urethral prolapse
- Pearly pink papules in males
- Balanitis in males
- Phimosis or paraphimosis in males
- Accidental trauma, including straddle and impaling injuries
- Accidental tourniquet of genitals by hair
- Abnormal anal exam
- Diastasis ani: absence of muscle fibers in middle of external anal sphincter
- Anal skin tags
- Anal dilatation from constipation or sedation
- Group A streptococcal perianal cellulitis
- Urethral discharge/bleeding
- Foreign body
- Nonspecific vulvovaginitis
- Group A Streptococcus
- Haemophilus influenzae
- Staphylococcus aureus
- Mycoplasma hominis
- Gardnerella vaginalis
- Shigella flexneri (discharge commonly bloody)
- Genital ulcers
- EBV, herpes simplex virus (HSV)
- Behçet disease
- Inflammatory bowel disease
- Genital irritation
- Candida albicans
Diagnostic Tests and Interpretation
- Forensic evidence collection
- Standard rape kit if the last contact was 72 hours or less
- Always obtain consent.
- In prepubertal children, recovery of useful forensic evidence is rare beyond 24 hours.
- Some experts support forensic evidence recovery up to 5 days from the contact in pubertal children.
- Most positive forensic evidence comes from clothing and linens.
- Sexually transmitted infection (STI) screening:
- For adolescents: Universal screening is recommended.
- For prepubertal children, the Centers for Disease Control and Prevention (CDC) and American Academy of Pediatrics (AAP) recommend STI testing when:
- Child discloses high-risk sexual contact (genital-genital, anal-genital, or oral-genital).
- Child’s symptoms or physical exam suggest presence of STI or anogenital trauma.
- Abuser is known to have an STI or be at risk for STI.
- Abuser is a stranger.
- Community prevalence of STI is high.
- Family member is infected with an STI.
- Patient or family member requests testing.
- Testing for N. gonorrhoeae and Chlamydia trachomatis may be performed with vaginal/urethral culture or nucleic acid amplification techniques (NAATs).
- Cultures have historically been the gold standard method for diagnosing STIs in prepubertal children. NAATs have proven to be sensitive and specific for N. gonorrhoeae and C. trachomatis infection in this age group.
- NAATs are not approved for rectal or pharyngeal specimens.
- NAATs have a higher sensitivity than culture.
- If a NAAT is done, then important not to treat empirically because if the NAAT is positive, the clinician will want to repeat with another NAAT or culture to reconfirm
- Trichomoniasis in a child ≥1 year of age is diagnostic of child sexual abuse; can be tested for by wet preparation, culture, or polymerase chain reaction (PCR). In adolescents, NAAT is the preferred test to diagnose trichomoniasis.
- Screen for syphilis and hepatitis B in any case which meets other screening recommendations.
- HIV screening should also be considered.
- Pregnancy testing should be performed in adolescent girls.
- Genital warts are not diagnostic of child sexual abuse. Neonatal transmission is common and human papilloma virus (HPV) may remain latent for several years. Children who present after age 3 to 5 years should have a complete medical evaluation for sexual abuse.
- Herpes simplex infections in the genital area are most commonly (but not always) caused by sexual contact. Most mouth infections are caused by HSV-1, and most genital infections are caused by HSV-2, but this distinction is not absolute. Culture or PCR can detect HSV when clinically indicated.
- Any positive NAAT needs to be repeated with a different NAAT for confirmation prior to empiric treatment.
- Any positive syphilis screening test should be confirmed with a treponemal test.
- If serologic testing for HIV, HBV, and syphilis is negative acutely, it should be repeated at 6 weeks, 3 months, and 6 months.
Cases of child sexual abuse require a multidisciplinary approach that includes medical, social services, law enforcement, and states attorney expertise.
- Empiric prophylactic antibiotics
- Recommended following sexual abuse/assault in adolescents and adults to prevent N. gonorrhoeae, C. trachomatis, and Trichomonas vaginalis
- Not recommended in prepubertal victims because of the low likelihood of STI and the importance of establishing the diagnosis
- N. gonorrhoeae treatment per CDC guidelines:
- Adolescents: ceftriaxone 250 mg IM once or cefixime 400 mg PO once + azithromycin 1 g PO once
- Prepubertal child: ceftriaxone 25 to 50 mg/kg IM once (not to exceed 125 mg)
- C. trachomatis treatment per CDC guidelines:
- Adolescents: azithromycin 1 g PO one time or doxycycline 100 mg PO b.i.d. × 7 days
- Prepubertal child
- Weight <45 kg: erythromycin 50/mg/kg/24 h divided into 4 daily doses for 14 days
- Weight >45 kg but <8 years: azithromycin 1 g PO × 1; age >8 years: azithromycin 1 g PO one time or doxycycline 100 mg PO b.i.d. × 7 days
- Syphilis treatment per CDC guidelines: parenteral penicillin G; dose depends on stage of disease and child age.
- Trichomoniasis treatment: metronidazole 2 g PO once
- HIV postexposure prophylaxis (PEP)
- Indicated for patients presenting within 72 hours of exposure with high risk of HIV infection (perpetrator with known HIV; high local prevalence of HIV in unknown perpetrator; high-risk sexual contact with anal, vaginal, or oral penetration; or presence of anogenital injuries)
- Recommend consultation with pediatric infectious disease specialist before initiating PEP to determine appropriate medication regimen.
- Discuss risk and benefits of treatments with patient/family including treatment duration of 28 days.
- HIV PEP is not indicated if patient presents >72 hours after the exposure.
- Hepatitis B vaccination for unimmunized patients
- Hepatitis B immune globulin for patients with recent sexual contact with known positive perpetrator
- HPV vaccination for girls ≥9 years who are incompletely immunized or unimmunized
- Consider pregnancy prevention (e.g., emergency hormonal contraceptive) for adolescents after ensuring the patient is not pregnant.
- Tetanus booster for patients with acute, serious genital or other injuries
Consider hospital admission.
- In children with injuries that require operative care
- In cases where the clinician wants to ensure protection of the child and external forces preclude that assurance
- In cases where there is a significant mental health concern
Children should be screened for posttraumatic stress disorder (PTSD) and feelings of self-blame. Most children should be followed by a mental health provider.
Varies greatly depending on specifics of abuse sustained and available support systems
- Domestic violence and revictimization
- Substance abuse
- Chronic pelvic pain
- Males are more likely to have concerns about sexual orientation.
- Adams JA, Kellogg ND, Moles R. Medical care for children who may have been sexually abused: an update for 2016. Clin Pediatr Emerg Med. 2016;17:255–263.
- Berenson AB, Chacko MR, Wiemann CM, et al. A case-control study of anatomic changes resulting from sexual abuse. Am J Obstet Gynecol. 2000;182(4):820–831. [PMID:10764458]
- Christian CW. Timing of the medical examination. J Child Sex Abus. 2011;20(5):505–520. [PMID:21970643]
- Gavril AR, Kellogg ND, Nair P. Value of follow-up examinations of children and adolescents evaluated for sexual abuse and assault. Pediatrics. 2012;129(2):282–289. [PMID:22291113]
- Hammerschlag MR. Sexual assault and abuse of children. Clin Infect Dis. 2011;53(Suppl 3):S103–S109. [PMID:22080264]
- Williams HN, Letson MM, Tscholl JJ. transmitted infections in child abuse (initials lowercase). Clin Pediatr Emerg Med. 2016;17:264–273.
- Workowski KA, Bolan GA; for Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-03):1–137. [PMID:26042815]
995.53 Child sexual abuse
- T74.22XA Child sexual abuse, confirmed, initial encounter
- T76.22XA Child sexual abuse, suspected, initial encounter
700229002 Victim of child sexual abuse (finding)
- Q: How could there have been penetration with a normal physical examination?
- A: The vast majority of child sexual abuse exams are completely normal even with a history of penetration. The healing properties of genital tissues are quick and complete; past injuries are often difficult to detect on physical exam.
- Q: What should I do if I examine a patient with no history of sexual abuse and detect an anatomic abnormality that I think is suggestive of sexual abuse?
- A: Always have exams confirmed by a child abuse expert in your area, as nuances of exams can be hard to discern. Photo documentation can preserve images of findings if a child abuse expert cannot reexamine the patient in a timely manner.
- Q: Is an STI diagnosed in a prepubertal patient always indicative of abuse?
- A: No. All STIs may be transmitted vertically (from mother to infant). The incubation periods of different infections vary, so they are expressed at different ages accordingly. Gonorrhea and syphilis are considered diagnostic of sexual abuse outside of congenital infection. Chlamydia, HSV-2, and Trichomonas are probably due to sexual abuse and should be reported for evaluation. Condyloma acuminata is probably related to sexual abuse in school-aged and older children but may be transmitted to younger children innocently during toileting or diaper changes.
- Q: Why is the physical exam deferred to local child abuse experts if the child presents >72 hours after the exposure?
- A: Unless the child has physical complaints (bleeding, dysuria, pain, etc.), the physical exam can be deferred because its purpose is to collect forensic evidence. In adolescents, beyond 72 hours, the yield for evidence is very low. In prepubertal children, forensic evidence is rarely obtained after 24 hours.
Mitchell Goldstein, MD, MBA
Courtney W. Mangus, MD
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