Sexual abuse and assault

Last reviewed: July 2019

Last updated: May 2018

Summary

Sexual assault is common and can affect adults of any age. Young women are most at risk, but males are also sexually violated.

The majority of children presenting for a sexual abuse evaluation have normal findings on physical examination.

Sexually transmitted infections are uncommon in sexually abused pre-pubertal children.

Time elapsed since the most recent sexual assault, and the pubertal status of the child, determine the appropriate management strategy in the acute setting.

Girls have a higher risk than boys of victimisation such as sexual abuse.

Definition

The World Health Organization defines sexual violence as "any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic or otherwise directed against a person's sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work". [1]

The definitions of child sexual abuse and other sexual offences may vary between countries or within jurisdictions of countries. A current definition from the American Academy of Pediatrics (AAP) is that: "Sexual abuse occurs when a child is engaged in sexual activities that he or she cannot comprehend, for which he or she is developmentally unprepared and cannot give consent, and/or that violate the law or social taboos of society." [2] The AAP further specifies that the "activities may include all forms of oral-genital, genital, or anal contact by or to the child or abuse that does not involve contact, such as exhibitionism, voyeurism, or using the child in the production of pornography." [2]

In most jurisdictions, rape is defined as sexual intercourse or other forms of penile sexual penetration, by one person (the perpetrator) of another person without his or her consent. Depending on the jurisdiction, penetration may be of the mouth, vagina or anus, or may only refer to vaginal penetration. The term sexual assault includes other non-consensual sexual activity.

History and exam

Key diagnostic factors

disclosure of inappropriate contact
acute anogenital trauma (any change); transections and absent hymen (in children)
HIV infection

Full details

Other diagnostic factors

normal genital findings
depression
anogenital lesions
labia and perineum injury
non-genital injuries
vaginal or penile discharge
self-destructive behaviour
sexualised behaviours in children
chronic medical complaints in children
frequent or persistent genitourinary complaints
hymenal notches

Full details

Risk factors

sexual abuse of other children in the home
adolescents and young women
disability
poverty or homelessness
sex workers
living in institutions or areas of conflict
use of alcohol or other drugs
lack of community services

Full details

Diagnostic investigations

1st investigations to order

forensic specimens
culture for Neisseria gonorrhoeae
culture for Chlamydia trachomatis
nucleic acid amplification for Chlamydia trachomatis and Neisseria gonorrhoeae
serological tests for syphilis
HIV serology
urine beta human chorionic gonadotrophin
testing for trichomonas
anogenital culture: herpes simplex virus polymerase chain reaction (PCR)
LFT
creatinine
urea
FBC

Full details

Investigations to consider

HIV confirmatory test
HIV RNA PCR
Treponema pallidum haemagglutination assay for syphilis
serum rapid plasma regain for syphilis

Full details

Treatment algorithm

ACUTE

≤72 hours since assault: pre-adolescent

≤72 hours since assault: adolescent or adult

>72 hours since assault: pre-adolescent

>72 hours since assault: adolescent or adult

Disclosures

MM declares that she has no competing interests.

Acknowledgements

Dr Sheela Lahoti, Dr Rebecca Girardet, Dr Shaina Groisberg, Dr Michelle Ruda, and Dr Margaret McNeese would like to gratefully acknowledge Dr Zoe O'Connor, paediatric resident from Niklaus Children’s Hospital in Miami, Florida, for her contribution to this topic, and Dr Christopher Greeley and Dr Jan Welch, previous contributors to this topic. CG and JW declare that they have no competing interests.

Peer reviewers VIEW ALL 

James Lukefahr, MD

Professor of Pediatrics

Child Abuse Division

Department of Pediatrics

University of Texas Health Science Center

San Antonio

Disclosures

JL declares that he has no competing interests.

Suzanne Starling, MD

Medical Director

CHKD-CAP

Professor of Pediatrics

Eastern Virginia Medical School

Norfolk

Disclosures

SS is an author of a reference cited in this topic. SS declares that she has no other competing interests.

Angelo P. Giardino, MD, PhD

Clinical Associate Professor

Pediatrics

Baylor College of Medicine

Medical Director

Texas Children's Health Plan

Houston

Disclosures

APG declares that he has no competing interests.

Ruth Gilbert, MD, MSc, MB ChB

Professor of Clinical Epidemiology

UCL-Institute of Child Health

London

Disclosures

RG declares that she has no competing interests.

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