INTRODUCTION — Sexual abuse occurs when a child engages in sexual activity for which they cannot give consent, is unprepared for developmentally, and cannot comprehend. This includes fondling and all forms of oral-genital, genital, or anal contact with the child (whether the victim is clothed or unclothed), as well as non-touching abuses such as exhibitionism, voyeurism, or involving the child in pornography [1-3].
The management and sequelae of childhood sexual abuse will be reviewed here. The epidemiology, evaluation, and differential diagnosis of childhood sexual abuse and human sex trafficking are discussed separately. (See "Evaluation of sexual abuse in children and adolescents" and "Human trafficking: Identification and evaluation in the health care setting".)
MANAGEMENT — The management of sexual abuse involves prevention of sexually transmitted infections (STIs) and pregnancy. Psychosocial support and anticipatory guidance should also be offered to the victims and their non-offending caregivers.
Although evaluation and management of sexual abuse should be performed by an experienced child abuse team (including a child abuse specialist or clinician with similar experience) whenever possible, urgent evaluation is necessary under the following circumstances and typically occurs in an emergency setting (see "Evaluation of sexual abuse in children and adolescents", section on 'Evaluation'):
●The alleged abuse occurred within the previous 72 to 96 hours, depending upon jurisdiction
●There are genital or anal injuries that require treatment
●There is obvious forensic evidence on the patient's clothes or body that must be collected
●There is danger of continued abuse or reprisal by the alleged perpetrator
●The victim has reported homicidal or suicidal ideation or other emergency complaints
Sexually transmitted infection prophylaxis — The need for STI prophylaxis depends upon whether the patient is pre- or postpubertal:
●Prepubertal – We suggest that prepubertal children who have no symptoms of STI not receive antibiotic prophylaxis. STI prophylaxis is not routinely recommended for prepubertal victims for the following reasons [4]:
•The incidence of infections is low after sexual assault in this patient population
•Prepubertal girls have a lower risk of ascending infections
•Follow-up is typically assured
Excessive concern by the caregiver or child concerning STI may make prophylactic treatment appropriate. However, cultures must be obtained prior to treatment whenever prophylaxis is prescribed. (See "Evaluation of sexual abuse in children and adolescents", section on 'Sexually transmitted infection testing'.)
Diagnoses of STIs in prepubertal children have profound consequences for the child, family or caregivers, and alleged perpetrator and are likely to be challenged in court. Because cultures can miss some STIs, prophylaxis can complicate efforts to protect children when initial testing is in doubt. Given the low risk of ascending infection in prepubertal children, it is reasonable to withhold treatment until all follow-up testing is complete and a definitive diagnosis has been established.
●Postpubertal – We suggest that postpubertal children who have been sexually abused receive antibiotic prophylaxis for STIs. Postpubertal females should definitely be offered STI prophylaxis if the assailant is known to be infected, the victim has signs or symptoms of infection, or at the victim's request. Additional considerations are the high prevalence of pre-existing asymptomatic infection, the risk of pelvic inflammatory disease, and the possibility of loss to follow-up. For these reasons, STI prophylaxis is routinely offered even when there are no symptoms and the infection status of the assailant is unknown.
Some experts recommend that all postpubertal patients be screened for STIs, including HIV, because the prevalence of pre-existing asymptomatic infection is high [5]. Others do not routinely test for STI because identification of an infection is unlikely to provide useful evidence and prophylactic treatment is typically prescribed regardless of culture results. Therefore, the decision to test a victim of sexual abuse for STIs should be made on an individual basis [4].
Testing for STIs in pediatric victims of sexual abuse is covered in greater detail separately. (See "Evaluation of sexual abuse in children and adolescents", section on 'Sexually transmitted infection testing' and "Evaluation and management of adult and adolescent sexual assault victims", section on 'Laboratory testing and diagnostic imaging'.)
Almost no clinical trials of STI-related pharmaceuticals include participants younger than 16 years of age, and relatively few include 16- to 17-year-olds. Most data regarding safety and efficacy are extrapolated from late adolescents and young adults. Guidelines for the treatment of specific STIs are regularly updated by the Centers for Disease Control and Prevention (CDC) and are available on its website [4]. The reader may also refer to UpToDate topics on STIs.
HIV prophylaxis — Definitive data concerning the risk of acquiring HIV for sexually abused children and adolescents are lacking, although there have been reports of HIV transmission after rape in adults and from sexual abuse in children [6-8]. The risk of transmission of the virus may be greater in girls than in adult women because vaginal epithelium in children is thin and adolescents have more cervical ectopy than adults. In addition, children may have been exposed to the same perpetrator repeatedly over time.
Recommendations for HIV prophylaxis are generalized from the model for occupational HIV exposure [4]. For adult rape victims, antiretroviral prophylaxis is generally recommended if it can be initiated within 72 hours of exposure, and ideally within four hours. (See "Evaluation and management of adult and adolescent sexual assault victims", section on 'HIV infection'.)
For children and adolescents, decisions regarding HIV prophylaxis are usually made on a case-by-case basis, taking into consideration the following factors [9,10]:
●The likelihood that the perpetrator is HIV positive
●The nature of the sexual contact and its estimated risk for HIV transmission (eg, whether it involved transfer of secretions, injury, or multiple perpetrators)
●The time elapsed since the first contact
●Whether the victim has other ongoing risk factors for HIV infection
Nonadherence to HIV prophylaxis among sexual assault survivors appears to be prevalent. In several retrospective studies describing HIV prophylaxis for pediatric and adult sexual assault victims, between 13 and 24 percent of patients completed the full 28-day prophylaxis regimen [11-13]. Nonadherence to the prophylaxis regimen may limit its effectiveness as well as increase the likelihood that the patient will develop viral resistance. Consequently, the decision to initiate antiretroviral therapy must include counseling for the victim and family or caregivers and close follow-up. Consultation with a specialist in treating HIV-infected children is advised [10]. For clinicians in the United States, the Warmline National HIV telephone consultation service (1-800-933-3413) is also available to provide current HIV clinical and drug information and expert case consultation.
Hepatitis B prophylaxis — Victims of sexual abuse warrant assessment for hepatitis B prophylaxis. The approach depends upon whether the perpetrator is known to be hepatitis B surface antigen (HBsAg) positive and the vaccination status of the victim (table 1) [14]:
●If the perpetrator is not HBsAg positive and the victim is fully immunized, then no action is needed. Unvaccinated or incompletely vaccinated patients should receive hepatitis B vaccine at the initial evaluation with ensured completion of the vaccine series using an age-appropriate dose and schedule (table 2). (See "Hepatitis B virus immunization in infants, children, and adolescents", section on 'Catch-up immunization'.)
●The approach to prophylaxis when the perpetrator is HBsAg positive or status is unknown is similar to exposed adults and is discussed separately. (See "Management of nonoccupational exposures to HIV and hepatitis B and C in adults", section on 'Overview'.)
Pregnancy prophylaxis — Emergency contraception should be offered to all pubertal female patients and should be strongly advised to females at highest risk for pregnancy. Emergency contraceptive preparations and administration are discussed in detail separately. (See "Emergency contraception".)
The overall risk of pregnancy resulting from a sexual assault is 5 percent [15,16]. The highest risk of pregnancy occurs during the three days preceding and including ovulation. Knowing the timing of the event in relation to the patient's ovulatory period is helpful in further assessing risk. (See "Normal menstrual cycle" and "Evaluation of the menstrual cycle and timing of ovulation".)
Human papillomavirus vaccination — For children who have been sexually abused, there is evidence of a higher risk for early sexual debut and therefore, a higher risk of acquiring STIs, including human papillomavirus (HPV) [17]. For this reason, HPV vaccination is recommended at nine years of age or older as a preventative measure among those children who have a known or suspected history of sexual abuse [18]. Recommendations for HPV vaccine administration are discussed in detail separately. (See "Human papillomavirus vaccination", section on 'Administration'.)
Hospitalization — The majority of children who are evaluated for sexual abuse can be discharged with close outpatient follow-up. Indications for hospitalization in child or adolescent victims of sexual abuse include severe injury requiring treatment or when the home environment is unsafe and there are no alternatives for placement.
Psychosocial support — The child's physical and emotional well-being is of primary concern [19]. Whenever possible, involvement of a social worker with experience supporting victims of sexual abuse should occur during the initial evaluation. The child should be reassured that what happened was not the child's fault and that they did nothing wrong. Children in whom sexual abuse is confirmed or suspected should be referred to a mental health professional for evaluation and counseling. The family or caregivers of the victim may also need treatment and support to cope with the emotional trauma of their child's abuse [1].
For children who develop psychological sequelae as the result of sexual abuse, cognitive behavioral therapy (CBT), as part of a broader psychosocial intervention, may be helpful. In a systematic review that described 10 randomized trials, CBT appeared to have a positive, though not statistically significant, impact on immediate and longer-term sequelae among children who had been sexually abused [20].
Anticipatory guidance — For children whose examination is normal, the patient and family or caregivers should be informed that the absence of physical findings does not exclude abuse. For patients with abnormal physical findings, the differential diagnosis must be discussed with the family or caregivers. The child and family or caregiver should be reassured that injuries typically heal rapidly [21]. The potential risks of STIs (including HIV), as well as decisions to perform cultures or provide prophylactic therapy, should also be addressed. (See "Evaluation of sexual abuse in children and adolescents", section on 'Sexually transmitted infection testing' and 'Sexually transmitted infection prophylaxis' above and 'HIV prophylaxis' above.)
The anticipated involvement and intervention of child protective services (CPS) and possible law enforcement should be discussed with the child and parents or caregivers. (See "Child abuse: Social and medicolegal issues".)
Additional concerns that the patient and/or family or caregivers may have about the effects of the abuse (eg, that it has caused the child to lose his or her virginity or may alter the sexual orientation of the child) should be elicited. Listening to family or caregiver concerns and providing reassurance are often the most important aspects of the evaluation [19].
The support that children receive from non-offending caregivers has significant impact on the child's psychological recovery from sexual abuse. The presence of an adult who believes and supports the child is vital to recovery and can have a larger impact than abuse-related factors [22]. Caregivers often struggle with how to best assist a child after sexual abuse. Stressing the importance of their emotional support is beneficial to the caregiver as well as the child.
Parents or caregivers may wonder whether they should attempt to gain further history or details of the assault from their child. Parents or caregivers should be counseled that questioning by an untrained interviewer may complicate further forensic interviews or investigations, but that the child should always feel safe and listened to should they decide to discuss the episode. In short, the parent should be open to any history the child gives but should not attempt to obtain further detail themselves.
Mandated reporting — Physicians in many countries (eg, United States, Canada, Germany, and Japan) are required to report all cases of suspected or known child sexual abuse [1,19]. The designated agency to which sexual abuse should be reported varies by region; physicians should be aware of the local laws. In most jurisdictions, sexual abuse is a criminal offense and must be reported to the police department. If it occurred during a time of inadequate parental supervision, or if the alleged assailant is a family member or caregiver, it may also need to be reported to the regional child welfare agency [23]. The procedure for reporting is discussed in detail separately. (See "Child abuse: Social and medicolegal issues".)
Disposition and safety planning — Regardless of the setting, the health care provider should assess the safety of the patient at disposition by assessing the likelihood of the following circumstances:
●Will the child return to an environment where the suspected perpetrator will still have access to the child?
●Is there a possibility that the child may be punished by caregivers for his/her disclosure of sexual abuse?
●Is there a possibility that the child may be coerced by caregivers to recant his/her disclosure?
If any of the above circumstances are likely, then the health care provider should contact CPS and/or law enforcement to determine a safe environment to which the child can be discharged [19].
SEXUAL ABUSE IN HEALTH CARE SETTINGS — The American Academy of Pediatrics has released a policy to assist health care professionals and organizations in efforts to prevent sexual abuse of children in health care settings and to ensure an appropriate response to allegations of sexual abuse perpetrated by a health care provider. Key actions include [24]:
●Pre-employment screening – All staff and volunteers who have access to children in a health care setting should undergo screening during recruitment and hiring. The screening should consist of any history of child abuse allegations as determined by examination of prior employment and checks of criminal background and child abuse registries. While essential, employment screening alone is insufficient to provide protection because a small minority of people who molest children have a criminal record.
●Culture of safety – Institutional policy must demonstrate zero tolerance of sexual encounters with patients. Health care facilities should also establish a culture of safety that provides training of all employees in the health care setting on their role in preventing sexual abuse and their specific individual duty to report concerns of abuse to Child Protective Services and/or law enforcement according to the laws of their jurisdiction.
●Employee training – All employees warrant education regarding staff-patient boundary setting, chaperone use during the anogenital examination and other sensitive body regions, and their responsibility to report sexual abuse by other health care providers to the proper authorities.
●Provider communication and safe practice – Physicians, advanced practice providers, and nurses who perform examination of sensitive areas such as anogenital examinations or, in adolescent females, breast examinations have the responsibility to explain the purpose of the examination to the patient and family/caregiver. The provider should also obtain consent from the parent/primary caregiver and, for older children and adolescents, the child. Providers should perform the examination with chaperones according to established procedures [25] and in a manner that respects the patient's modesty. The use of chaperones for anogenital examination is described separately. (See "The pediatric physical examination: The perineum", section on 'Use of chaperones'.)
●Response to abuse allegations – All patient, parent/caregiver, or staff allegations of sexual abuse by a health care provider require documentation, timely investigation, and, when there is sufficient suspicion for sexual abuse, adherence to mandated reporting, if not already performed, according to legal requirements of the jurisdiction (see "Child abuse: Social and medicolegal issues"). Institutional and office policies and procedures should delineate an internal confidential investigation process that assists in determining when there is sufficient concern for abuse and ensures that, in addition to reporting to Child Protective Services and law enforcement, sexual misconduct or abuse is reported to licensing authorities such as national or regional medical boards.
SEQUELAE
Abuse victim — Short-term sequelae (ie, those occurring within two years of the assault) of sexual abuse include fear, disturbances in sleep and eating, phobias, guilt, shame, anger, depression, school problems, delinquency, aggression, hostility, antisocial behavior, inappropriate sexual behavior, and running away [26-28]. These sequelae may be the presenting manifestations. (See "Evaluation of sexual abuse in children and adolescents", section on 'Presentation'.)
Longer-term effects include a wide range of medical, behavioral, and psychiatric disorders including depression, sleep problems, eating disorders, obesity, feelings of isolation, stigmatization, poor self-esteem, problems with interpersonal relationships, negative effect on sexual function, revictimization, substance abuse, suicidal behavior, and psychosis [28-35].
Studies that describe factors that may influence long-term effects include the following:
●In a systematic review of the impact of sexual abuse on children, the severity of symptoms was affected by penetration, the duration and frequency of the abuse, force, the relationship of the perpetrator to the child, and maternal support [27].
●In a cross-sectional survey describing adolescents with histories of sexual abuse, favorable social factors (family connectedness, teacher caring, other adult caring, and school safety) were significantly protective for suicide risk [32].
Impact on non-offending caregivers — In the early stages of an assessment about alleged sexual abuse, non-offending caregivers may benefit from guidance as to their role in obtaining the history of abuse. Caregivers should be counseled that it is not their role to conduct a forensic interview of the child, but that they should be open to a child's history or questions, and that they should make the child feel safe in reporting or discussing any abusive activity [19].
Non-offending parents or caregivers often describe the disclosure of child sexual abuse as a major life crisis with a variety of emotional reactions. They may be unsure of how to respond to the child after the disclosure and may be unprepared for the emotional and behavioral sequelae. Caregivers may become isolated from other family members or may experience financial challenges if their partner was the perpetrator of abuse. Thus, support of the non-offending caretakers can be critical to the healing process of the child [22].
RESOURCES — The following resources exist for the management of sexually abused children and adolescents:
●In the United States, many communities have a Children's Advocacy Center that provides expertise in the evaluation and treatment of sexual abuse victims and the prosecution of sexual abuse perpetrators. These centers may provide social services, law enforcement agencies, legal services, and medical evaluation and may be a resource for consultation. There is evidence that Children's Advocacy Centers and the multidisciplinary team approach for child sexual abuse investigations may aid in improving prosecution rates of suspected perpetrators and the experiences of families or caregivers of patients with suspected sexual abuse [36]. Local advocacy centers can be identified on the National Children's Alliance website.
●The World Health Organization (WHO) provides educational materials regarding international policy and program development for addressing child maltreatment, including sexual abuse, at its website.
●The International Society for the Prevention of Child Abuse and Neglect (ISPCAN) provides support for professional development of child abuse and neglect identification and management skills, child protection, and data collection in under-resourced countries where such infrastructure is lacking. Materials are available at its website.
Additional resources that may be helpful in the evaluation and management of suspected child abuse are listed (table 3A-B).
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Sexual abuse in children and adolescents" and "Society guideline links: Sexually transmitted infections".)
SUMMARY AND RECOMMENDATIONS
●The evaluation of sexual abuse in children and adolescents is discussed separately. (See "Evaluation of sexual abuse in children and adolescents".)
●The management of all children who have been sexually abused must include attention to the immediate medical and social needs of patients and families or caregivers as well as to the local requirements for mandated reporting. (See 'Management' above.)
●With regard to prophylactic treatments to prevent sexually transmitted infections (STIs), we offer the following recommendations (see 'Sexually transmitted infection prophylaxis' above):
•We suggest that prepubertal children who have no symptoms of STIs not receive antibiotic prophylaxis (Grade 2C). Children who are prescribed prophylaxis should have specimens sent for culture prior to treatment. (See 'Sexually transmitted infection prophylaxis' above and "Evaluation of sexual abuse in children and adolescents", section on 'Sexually transmitted infection testing'.)
•We suggest that postpubertal children who have been sexually abused receive antibiotic prophylaxis for STIs (Grade 2C). The decision to obtain cultures prior to the initiation of treatment should be made on a case-by-case basis. (See 'Sexually transmitted infection prophylaxis' above and "Evaluation and management of adult and adolescent sexual assault victims", section on 'Sexually transmitted infections'.)
•Clinicians considering prescribing HIV prophylaxis for children who have been sexually abused should consult with a specialist in treating HIV-infected children. (See 'HIV prophylaxis' above.)
•Guidelines for the treatment of specific STIs are regularly updated by the Centers for Disease Control and Prevention (CDC) and are available on its website.
•Victims of sexual abuse warrant assessment for hepatitis prophylaxis. The approach depends upon whether the perpetrator is known to be hepatitis B surface antigen (HBsAg) positive and the vaccination status of the victim. (See 'Hepatitis B prophylaxis' above.)
●Emergency contraception should be offered to all postpubertal female patients and should be strongly advised to females at highest risk for pregnancy. Emergency contraceptive preparations and administration are discussed in detail separately. (See 'Pregnancy prophylaxis' above and "Emergency contraception".)
●Children who have been sexually abused may experience psychological and behavioral sequelae. They and their families or caregivers should be offered a referral to a mental health professional. (See 'Sequelae' above.)
●Physicians in many countries (eg, United States, Canada, Germany, and Japan) are required to report all cases of suspected or known child sexual abuse. The designated agency to which sexual abuse should be reported varies by region; physicians should be aware of the local laws. (See 'Mandated reporting' above.)
