Sexual abuse and assault is common and can affect people of any age. Young women and girls are most at risk, but males are also sexually abused and assaulted.
The diagnosis is complex and has major ramifications; it is therefore important to follow diagnostic guidelines.
Rapid healing of genital tissues and other factors can result in normal findings on exam following sexual abuse. This is particularly true for children, among whom the majority have normal physical exams.
Sexually transmitted infections are uncommon in sexually abused prepubertal children.
The appropriate management strategy is determined by the time elapsed since the sexual assault and the pubertal status of the patient.
The World Health Organization (WHO) 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."
The definitions of child sexual abuse and other sexual offences may vary between countries or within jurisdictions of countries. The WHO defines child sexual abuse as "the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developementally prepared and cannot give consent, or that violate the laws or social taboos of society. Child sexual abuse is evidenced by this activity between a child and an adult or another child who by age or development is in a relationship of responsibility, trust or power, the activity being intended to gratify or satisfy the needs of the other person."
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 their consent. Depending on the jurisdiction, penetration may be of the mouth, vagina, or anus, or only refer to vaginal penetration. The term sexual assault includes other nonconsensual sexual activity.
History and exam
Key diagnostic factors
- disclosure of inappropriate contact
- acute anogenital trauma (any change); transections and absent hymen (in children)
- sexually transmitted infections
Other diagnostic factors
- normal genital findings
- emotional and psychological disorders
- anogenital lesions
- labia and perineum injury
- nongenital injuries
- vaginal or penile discharge
- harmful behaviors
- sexual behavior problems in children
- chronic medical complaints in children
- frequent or persistent genitourinary complaints
- hymenal notches
- sexual abuse of other children in the home
- adolescents and young women
- poverty or homelessness
- sex workers
- living in institutions or areas of conflict
- use of alcohol or other drugs
1st investigations to order
- forensic specimens
- testing for Neisseria gonorrhoeae
- testing for Chlamydia trachomatis
- serologic tests for syphilis
- serologic tests for hepatitis B
- HIV serology
- urine beta human chorionic gonadotropin
- testing for trichomonas
- anogenital culture: herpes simplex virus polymerase chain reaction (PCR)
Investigations to consider
- HIV confirmatory test
- HIV RNA PCR
- Treponema pallidum hemagglutination assay for syphilis
- serum rapid plasma reagin for syphilis
<72 hours since assault: preadolescent
<72 hours since assault: adolescent or adult
>72 hours since assault: preadolescent
>72 hours since assault: adolescent or adult
- Lichen sclerosus
- Urethral prolapse
- Sexually transmitted diseases treatment guidelines, 2021: sexual assault and STIs
- Sexually transmitted infections treatment guidelines, 2021
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