Practice Essentials
Child sexual abuse has been defined by the American Academy of Pediatrics as the engaging of a child in sexual activities that the child cannot comprehend, for which the child is developmentally unprepared and cannot give informed consent, and violate the social taboos of society. [1, 2]
It is important to know the risk factors for sexually abused children in order to recognize victims.
Children suspected of being sexually abused require thorough history taking, including presenting symptoms and general medical, social, behavioral, gynecologic, and family histories.
Physical examination includes a complete head-to-toe examination including external genitalia. It is important to differentiate between a child who needs to be seen and examined emergently, urgently, or electively scheduled for a later time with his or her own physician or referred to a child abuse evaluation center as an outpatient.
All evidence pertaining to the current event of abuse needs to be collected appropriately.
It is important to remember that physical findings of sexual abuse are often not present, especially when examined nonacutely.
Further management includes treatment for identified sexually transmitted diseases (STDs), prophylaxis for adolescents, HIV prophylaxis (if exposure was within 36 hours), discussion of possible pregnancy, and any other workup or treatment that is required for physical trauma. Referral to mental health or other counseling is imperative. Consult a medical team on call for sexual abuse evaluations if available.
Always notify Child Protective Services and/or law enforcement.
Child sexual abuse affects more than 100,000 children a year. Many of these children present to the emergency department (ED). The following article outlines triage determinants for examinations, examination techniques, and interpretations of genital findings of sexual abuse.
Pathophysiology
In general, children cannot consent to any sexual activity, but the legal age of consent may vary by state.
Sexual activities involving a child may include activities intended for sexual stimulation, such as those involved in contact sexual abuse (eg, touching the child's genitalia or the child touching an adult's genitalia), penetrating injury (eg, penile, digital, and object insertion into the vagina, mouth, or anus), and nonpenetrating injury (eg, fondling, sexual kissing).
Noncontact sexual abuse, which may include exhibitionism, voyeurism, and the involvement of a child in verbal sexual propositions or the making of pornography, often occurs.
Physical findings of sexual abuse are often not present. The most important determinant for abuse is the child's (or a witness's) account of the incident. Physical indicators may be present, such as bruises to the skin (eg, on the arms and legs from pinch marks or force), abrasions to wrists and ankles (eg, from tethering), bruises to the genital area and mucosa, oral palatal bruises and/or petechiae, and rectal abnormalities. Hymenal abnormalities may be present from chronic abuse or acute injury. Sexually transmitted diseases (STDs) may be present in sexually abused children and teenagers.
Etiology
Risk factors for child sexual abuse are as follows:
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Family structure: Children who live with both biological (married) parents are at lowest risk. Children who live with step-parents or single parents are at higher risk (especially children who live with a single parent with a live-in partner). Children living without either biological parent (ie, foster care) are also at higher risk.
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Parent abused as a child: Most perpetrators are not strangers but are known to the child (eg, stepfathers, uncles, mother's paramour). Female perpetrators are reported less often. Parents who have been abused do not always abuse their own children, but the risk for continued familial abuse is present.
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Girls are at higher risk than boys
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Multiple caretakers for the child
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Caretaker or parent who has multiple sexual partners
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Drug and/or alcohol abuse
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Stress associated with poverty
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Social isolation and family secrecy
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Child with poor self-esteem or other vulnerable state
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Other family members (eg, siblings, cousins) abused
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Gang member associations
Epidemiology
United States statistics
In 2016, 57,329 children in the United States reported to Child Protective Services were determined to be suspected victims of child sexual abuse. The actual number is likely to be higher because these numbers reflect only children whose cases are investigated by Child Protective Services. [3] Also, the majority of child abuse victims never report their abuse.
From 2010 to 2016, the number of emergency department (ED) admissions for child sexual abuse increased from 5138 to 8818. About 85% of the children admitted for confirmed sexual abuse were girls. [4]
Sex-related demographics
It is estimated that 1 in 4 girls and 1 in 6 boys will have experienced an episode of sexual abuse while younger than 18 years. The numbers of boys affected may be falsely low because of reporting techniques.
Mortality and Morbidity
Although perforation of the vagina or viscera could result in injury and death, death resulting from sexual abuse is unusual.
Most of the morbidity associated with sexual abuse is a result of emotional and psychological trauma.
Reactions to sexual abuse can include posttraumatic stress disorder, depression, anxiety, anger, impaired sense of self, dissociative phenomena, suicidal behavior, sexually reactive behaviors that are beyond the scope of normative child sexual development, and indiscriminate sexual behavior.
STDs may result in further morbidity. However, the prevalence of STDs in sexually abused children varies with geographic location and with the child's age. Most STD prevalence rates in prepubertal children tend to be below 5%; in adolescents, the prevalence rate is approximately 14%.
Prognosis
Sexually abused children have significantly higher occurrences of the following:
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Eating disorders
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Suicidal behaviors
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Self-injury
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Psychosis [5]
Children who are sexually abused may be at increased risk of reabuse.
Ongoing emotional/psychological problems may be indicative of abused children's false beliefs about themselves and the sexual abuse experience.
Complications
Complications of sexual abuse may include infection and psychological/social problems.
Patient Education
Families are usually concerned about injury in the child. Reassurance may involve an explanation that children can be sexually abused and have no physical findings to support their allegations.
For patient education resources, see the Children's Health Center. Also see the patient education article Child Abuse.
