Sexual Abuse

Concern for sexual abuse may arise from a child’s spontaneous disclosure, physical exam findings, inappropriate sexual behaviors, behavioral changes, or any combination of the above. Careful and sensitive questioning and a complete physical examination are necessary to evaluate children who may have been sexually abused.

A child’s disclosure of sexual abuse should always be taken seriously and warrants additional evaluation by child protective services, law enforcement, or both. When a child discloses sexual abuse, it can be a gradual process in which they only disclose a small amount of information initially and later disclose additional aspects of abuse. Disclosures are also often delayed by days, weeks, months, or even years. The following are important things to consider when a child discloses sexual abuse:

• Limit repeated questioning: If a child presents to medical care specifically related to disclosure of sexual abuse, the medical team should take steps to limit repeated questioning of the child. Repeated questioning of a child may unintentionally alter the child’s disclosure during forensic or official investigative interviewing. Repeated questioning on the same topic may also increase the likelihood that the child will feel pressured to answer in a given manner, particularly if questions are not asked in open-ended way.

  • When possible, the physician, nurse, and social worker should listen together to the presenting history, rather than obtaining histories sequentially.

  • Interrogation of the child is not recommended, although statements made by the child are important to document accurately.

  • Request for detailed disclosure may be traumatic to a child and should be avoided.

• Clarify medical needs: The role of the medical provider is to clarify the medical needs related to the disclosure of sexual abuse. The clinician should obtain enough information to guide a medical evaluation and determine whether reports to local child protective services and law enforcement are indicated for further investigation (see Legal Mandates for Health Care Providers). The medical provider should clarify from accompanying adults (or an adolescent patient) when the child last had any contact with the alleged perpetrator to determine the need for further acute intervention (see Forensic Evidence Collection and prophylaxis for Sexually Transmitted Infections).

  • Use open-ended questions: If clarification of a disclosure is needed directly from a child, care should be taken to use open-ended questions (e.g., “Tell me why you’re here”).

  • Avoid leading questions (e.g., “Tell me who touched your privates”).

• Investigative or forensic interviewing of the child is not the role of the medical provider and should be deferred to trained specialists.

• Safety assessment: After a disclosure, medical assessment should include immediate safety assessment for the child.

  • One aspect of safety includes the potential for continued exposure to an alleged perpetrator. Depending on the response from the accompanying adults, child protective services, or other investigative agencies, hospital admission may rarely be warranted to ensure physical safety.

  • Another aspect of safety is emotional health and risk of self-harm. A developmentally appropriate behavioral health assessment should be considered for all children who have disclosed sexual abuse to assess emotional health and risk for self-harm behaviors.

Injuries

Presentation to medical care due to injuries related to sexual abuse is not common. More than 90% of children who disclose sexual abuse do not have injuries at the time of physical exam. Furthermore, the likelihood of diagnostic injury on examination is decreased to less than 5% if the disclosure is delayed, which is typical in cases of child sexual abuse. Genitourinary exams are normal in most children who report a history of sexual abuse, for several reasons including:

• Many activities that constitute sexual abuse may not cause physical genital injury or other physical injury to the child.

• Minor mucosal injuries heal rapidly, usually within days.

• In pubertal children, genital structures such as the hymen will stretch during penetration and therefore may not exhibit signs of trauma.

• Medical evaluation findings that are concerning for sexual abuse include:

  • Genital findings that raise suspicion for trauma include genital bruising or bleeding. Differential diagnoses to consider for these findings include foreign body, urethral prolapse, dysfunctional uterine bleeding, or accidental trauma.

  • Pregnancy in a child below the age of legal consent is diagnostic of sexual abuse.

  • Sexually transmitted infections (STIs), including genital, rectal, or pharyngeal Neisseria gonorrhoeae; genital or rectal Chlamydia trachomatis; Trichomonas vaginalis; syphilis; and HIV (in the absence of other mode of known exposure, such as mother-child transmission), are consistent with sexual contact and are either diagnostic or highly concerning (depending on the organism and circumstances) for sexual abuse in children below the age of consent.

Behaviors

No sexualized behaviors are diagnostic of childhood sexual abuse and a variety of sexualized behaviors may actually be normal for a child’s developmental status. However, behaviors that are concerning and warrant additional evaluation include those that are coercive toward another child, sexual behavior that causes pain or injury, or behaviors that explicitly mimic sexual intercourse.

Evaluation

Physical Examination

• General exam: A complete physical examination is warranted to assess for injuries. Clear documentation of findings, both normal and abnormal, is important. When available, photodocumentation in the electronic medical health record of examination findings can be particularly helpful for follow-up. Providers should be aware of institutional practice and security policies regarding genital photography.

• Genital exam: The medical provider should perform the genital examination with a chaperone present. The examination should be explained to the child in developmentally appropriate terms prior to initiation. Children should be allowed to stop any examination unless they are in imminent medical danger.

  • Male genital exam: Genital examination of boys after reported sexual assault includes assessment for injuries such as bruising or lacerations of genital skin, including anus, as well as signs concerning for sexually transmitted infections, such as penile discharge.

  • Female genital exam: Genital examination of girls after reported sexual assault includes assessment for injuries such as bruising or laceration of genital skin, including the anus. Complete assessment requires labial separation by traction to visualize the labia minora, vaginal vestibule, and hymen. For young children, visualization can usually be completed in a frog-leg position with appropriate labial traction. For older children and adolescents, the lithotomy position is used.

• Findings: Findings that are consistent with genital trauma and highly suggestive of abuse in the absence of plausible accidental injury (e.g., straddle or impalement injury) include:

  • laceration or bruising of genitals

  • acute injury to the hymen (including bruising, petechiae, abrasions, or laceration)

  • perianal laceration with exposure of subdermal tissue

Forensic Evidence Collection

• Forensic evidence collection is indicated in cases of acute sexual abuse or assault and should be completed by trained professionals and adhere to local protocols for chain of custody.

  • Pubertal patients: Generally, forensic evidence can be collected up to 72 hours after reported abuse in pubertal patients; some jurisdictions collect forensic evidence up to 96 hours after assault.

  • Prepubertal patients: Forensic evidence collection can also be collected up to 72 hours after reported abuse, although data suggest very low yield after 24 hours.

Testing and Prophylaxis

Sexually Transmitted Infections

• Testing: Children who disclose sexual abuse should be tested by urine nucleic acid amplification test (NAAT) for N. gonorrhoeae, C. trachomatis, and T. vaginalis. Additional swabs from specific genital sites are recommended for children with specific histories of penetration. Children with high-risk exposures (receptive penile-vaginal or penile-anal penetration) and all adolescents should be tested for HIV and syphilis.

  • Confirmation of positive results with forensic implications should be done per local protocol. Options include repeat testing of initial sample, NAAT of alternative site amplicon, or culture.

• Treatment and prophylaxis:

  • HIV: Victims of acute sexual assault should be offered HIV postexposure prophylaxis (HIV PEP) within 72 hours of assault based on an assessment of risk of HIV exposure (see HIV PEP in the IM Infectious Diseases rotation guide). Risk assessment includes factors such as mode of exposure, presence of injuries, and information about potential perpetrator. Highest-risk modes of exposure include receptive penile-anal and penile-vaginal penetration. Treatment regimen should be determined by a local expert in HIV treatment and should consider any preexisting conditions, such as renal or liver disease.

  • Other STIs: In adolescents, empiric antimicrobial prophylaxis for chlamydia, gonorrhea, and trichomonas should be offered after an acute assault. Per the Centers for Disease Control and Prevention (CDC), the recommended regimen for empiric treatment of adolescents is ceftriaxone plus doxycycline plus metronidazole. Tinidazole can be used as a substitute for metronidazole and azithromycin can be used for doxycycline in appropriate patients. (See STIs in the Adolescent Care rotation guide)

    • STI prophylaxis regimen for prepubertal children varies by child age and weight.

    • For younger children who present after an acute assault, the decision to initiate empiric STI treatment can be based on the child’s risk of exposure and physical examination findings.

    • Some prepubertal children who present for care acutely after possible sexual abuse will benefit from HIV prophylaxis, although they do not usually require empiric antimicrobial prophylaxis for other STIs. If this approach is chosen, repeat testing for other infections will be needed, along with interval attention to symptom development and shared decision-making with responsible caregivers.

  • Human papillomavirus (HPV): HPV vaccination series should be initiated if not already done so for any child aged 9 years and older.

• Follow-up: Follow-up with a pediatrician or child abuse specialist is recommended to address medical needs and identify behavioral health needs after trauma.

  • Resources for mental health support should be provided to the patient and family.

  • Recommendations for repeat testing depend on prophylaxis administered.

    • For urine STI testing that occurred within the incubation period for urine STIs, repeat testing should be completed if prophylaxis was not administered.

    • For HIV and syphilis, repeat testing should be completed 4-6 weeks and 3 months after exposure.

  • Children started on HIV PEP should be assessed for adverse effects of medication at 2 weeks.

Pregnancy

• Testing: All peripubertal and adolescent girls should be tested for pregnancy.

• Prophylaxis: Emergency contraception should be considered when an acute assault could result in pregnancy, including in a premenarchal child who is Tanner stage 3 or above.

• Follow-up: Repeat pregnancy testing should be completed 2 weeks after an acute assault regardless of pregnancy prophylaxis administered.