Sexual abuse and assault - Symptoms, Causes, Images, and Treatment Options

Diseases

Highlights & Basics

Key Highlights

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.

Quick Reference

History & Exam
- Key Factors
- Other Factors
More information...
Diagnostics Tests
More information...
Treatment Options
More information...

Definition

Epidemiology

Etiology

Pathophysiology

Images

Absent hymen from 4 to 7 o'clock position in a sexually active 14-year-old girl
Acute vaginal trauma in an 11-year-old victim of abduction and rape
Supine frog-leg position for exam of a prepubertal girl
Knee-chest position for exam of a prepubertal girl
Labial traction technique
Normal annular hymen
Example of the use of a body diagram to record injuries
Sexual assault exam patient handout form

Citations

Key Articles

Jenny C, Crawford-Jakubiak JE; Committee on Child Abuse and Neglect, American Academy of Pediatrics. The evaluation of children in the primary care setting when sexual abuse is suspected. Pediatrics. 2013 Aug;132(2):e558-67.[Abstract][Full Text]
American College of Obstetricians and Gynecologists. ACOG committee opinion no. 777: sexual assault. Obstet Gynecol. 2019 Apr;133(4):e296-302.[Abstract][Full Text]
Workowski KA, Bachmann LH, Chan PA, et al; Centers for Disease Control and Prevention. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187.[Abstract][Full Text]
Adams JA, Kellogg ND, Farst KJ, et al. Updated guidelines for the medical assessment and care of children who may have been sexually abused. J Pediatr Adolesc Gynecol. 2016 Apr;29(2):81-7.[Abstract][Full Text]
World Health Organization. Health care for women subjected to intimate partner violence or sexual violence: a clinical handbook. Nov 2014 [internet publication].[Full Text]

Other Online Resources

Canadian Paediatric Society: the medical evaluation of pre-pubertal children with suspected sexual abuse

Referenced Articles

1. World Health Organization. Understanding and addressing violence against women: sexual violence. 2012 [internet publication].[Full Text]
2. World Health Organization. Report of the consultation on child abuse prevention, 29-31 Mar 1999, WHO, Geneva. 1999 [internet publication].[Full Text]
3. United Nations General Assembly, 61st session. Report of the independent expert for the United Nations study on violence against children. 2006: A/61/299.[Full Text]
4. Hussey JM, Chang JJ, Kotch JB. Child maltreatment in the United States: prevalence, risk factors, and adolescent health consequences. Pediatrics. 2006 Sep;118(3):933-42.[Abstract]
5. Finkelhor D, Turner HA, Shattuck A, et al. Prevalence of childhood exposure to violence, crime, and abuse: results from the National Survey of Children's Exposure to Violence. JAMA Pediatr. 2015 Aug;169(8):746-54.[Abstract]
6. Finkelhor D, Dziuba-Leatherman J. Children as victims of violence: a national survey. Pediatrics. 1994 Oct;94(4 Pt 1):413-20.[Abstract]
7. Feldman W, Feldman E, Goodman JT, et al. Is childhood sexual abuse really increasing in prevalence? An analysis of the evidence. Pediatrics. 1991 Jul;88(1):29-33.[Abstract]
8. Finkelhor D. Improving research, policy, and practice to understand child sexual abuse. JAMA. 1998 Dec 2;280(21):1864-5.[Abstract]
9. Hay T, Jones L. Societal interventions to prevent child abuse and neglect. Child Welfare. 1994 Sep-Oct;73(5):379-403.[Abstract]
10. Leventhal JM. Have there been changes in the epidemiology of sexual abuse of children during the 20th century? Pediatrics. 1988 Nov;82(5):766-73.[Abstract]
11. World Health Organization. Violence against women prevalence estimates, 2018: executive summary. Mar 2021 [internet publication].[Full Text]
12. Mueller-Johnson K, Eisner MP, Obsuth I. Sexual victimization of youth with a physical disability: an examination of prevalence rates, and risk and protective factors. J Interpers Violence. 2014 Nov;29(17):3180-206.[Abstract]
13. Christoffersen MN. Sexual crime against schoolchildren with disabilities: a nationwide prospective birth cohort study. J Interpers Violence. 2022 Feb;37(3-4):NP2177-205.[Abstract]
14. Tyler KA, Whitbeck LB, Hoyt DR, et al. Risk factors for sexual victimization among male and female homeless and runaway youth. J Interpers Violence. 2004 May;19(5):503-20.[Abstract][Full Text]
15. Malloy LC, Sutherland JE, Cauffman E. Sexual abuse disclosure among incarcerated female adolescents and young adults. Child Abuse Negl. 2021 Jun;116(Pt 1):104147.[Abstract][Full Text]
16. Assink M, van der Put CE, Meeuwsen MWCM, et al. Risk factors for child sexual abuse victimization: a meta-analytic review. Psychol Bull. 2019 May;145(5):459-89.[Abstract]
17. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The adverse childhood experiences (ACE) study. Am J Prev Med. 1998 May;14(4):245-58.[Abstract][Full Text]
18. Dube SR, Anda RF, Felitti VJ, et al. Exposure to abuse, neglect, and household dysfunction among adults who witnessed intimate partner violence as children: implications for health and social services. Violence Vict. 2002 Feb;17(1):3-17.[Abstract]
19. Connor J, You R, Casswell S. Alcohol-related harm to others: a survey of physical and sexual assault in New Zealand. N Z Med J. 2009 Sep 25;122(1303):10-20.[Abstract]
20. Littleton H, Grills-Taquechel A, Axsom D. Impaired and incapacitated rape victims: assault characteristics and post-assault experiences. Violence Vict. 2009;24(4):439-57.[Abstract]
21. Marc B. Current clinical aspects of drug-facilitated sexual assaults in sexually abused victims examined in a forensic emergency unit. Ther Drug Monit. 2008 Apr;30(2):218-24.[Abstract]
22. Davis MK, Gidycz CA. Child sexual abuse prevention programs: a meta-analysis. J Clin Child Psychol. 2000 Jun;29(2):257-65.[Abstract]
23. Bolan RM. Child sexual abuse: prevention or promotion. Social Work. 2003 Apr;48(2):174-85.
24. Mikton C, Butchart A. Child maltreatment prevention: a systematic review of reviews. Bull World Health Organ. 2009 May;87(5):353-61.[Abstract][Full Text]
25. Walsh K, Zwi K, Woolfenden S, et al. School-based education programmes for the prevention of child sexual abuse. Cochrane Database Syst Rev. 2015 Apr 16;(4):CD004380.[Abstract][Full Text]
26. Finkelhor D. The prevention of childhood sexual abuse. Future Child. 2009 Fall;19(2):169-94.[Abstract]
27. Wacker J, Macy R, Barger E, et al. Sexual assault prevention for women with intellectual disabilities: a critical review of the evidence. Intellect Dev Disabil. 2009 Aug;47(4):249-62.[Abstract]
28. Bair-Merritt MH, Jennings JM, Chen R, et al. Reducing maternal intimate partner violence after the birth of a child: a randomized controlled trial of the Hawaii Healthy Start Home Visitation Program. Arch Pediatr Adolesc Med. 2010 Jan;164(1):16-23.[Abstract][Full Text]
29. Centers for Disease Control and Prevention. STOP SV: a technical package to prevent sexual violence. 2016 [internet publication].[Full Text]
30. Jina R, Jewkes R, Munjanja SP, et al; FIGO Working Group. Report of the FIGO Working Group on Sexual Violence/HIV: guidelines for the management of female survivors of sexual assault. Int J Gynaecol Obstet. 2010 May;109(2):85-92.[Abstract]
31. Kellogg ND; Committee on Child Abuse and Neglect, American Academy of Pediatrics. Clinical report: the evaluation of sexual behaviors in children. Pediatrics. 2009 Sep;124(3):992-8.[Abstract][Full Text]
32. National Institute for Health and Care Excellence. Child abuse and neglect. Oct 2017 [internet publication].[Full Text]
33. Jenny C, Crawford-Jakubiak JE; Committee on Child Abuse and Neglect, American Academy of Pediatrics. The evaluation of children in the primary care setting when sexual abuse is suspected. Pediatrics. 2013 Aug;132(2):e558-67.[Abstract][Full Text]
34. Greenbaum J, Crawford-Jakubiak JE; Committee on Child Abuse and Neglect. Child sex trafficking and commercial sexual exploitation: health care needs of victims. Pediatrics. 2015 Mar;135(3):566-74.[Abstract][Full Text]
35. American College of Obstetricians and Gynecologists. ACOG committee opinion no. 777: sexual assault. Obstet Gynecol. 2019 Apr;133(4):e296-302.[Abstract][Full Text]
36. Chen LP, Murad MH, Paras ML, et al. Sexual abuse and lifetime diagnosis of psychiatric disorders: systematic review and meta-analysis. Mayo Clin Proc. 2010 Jul;85(7):618-29.[Abstract]
37. World Health Organization. Clinical management of rape and intimate partner violence survivors: developing protocols for use in humanitarian settings. 2020 [internet publication].[Full Text]
38. Marsac ML, Kassam-Adams N, Hildenbrand AK, et al. Implementing a trauma-informed approach in pediatric health care networks. JAMA Pediatr. 2016 Jan;170(1):70-7.[Abstract][Full Text]
39. Substance Abuse and Mental Health Services Administration. SAMHSA's concept of trauma and guidance for a trauma-informed approach. Jul 2014 [internet publication].[Full Text]
40. Kellogg ND, Menard SW, Santos A. Genital anatomy in pregnant adolescents: "normal" doesn't mean "nothing happened". Pediatrics. 2004 Jan;113(1 Pt 1):e67-9.[Abstract][Full Text]
41. Adams JA, Harper K, Knudson S, et al. Examination findings in legally confirmed child sexual abuse: it's normal to be normal. Pediatrics. 1994 Sep;94(3):310-7.[Abstract]
42. Heger AH, Ticson L, Guerra L, et al. Appearance of the genitalia in girls selected for nonabuse: review of hymenal morphology and nonspecific findings. J Pediatr Adolesc Gynecol. 2002 Feb;15(1):27-35.[Abstract]
43. White C, McLean I. Adolescent complainants of sexual assault; injury patterns in virgin and non-virgin groups. J Clin Forensic Med. 2006 May;13(4):172-80.[Abstract]
44. Sugar NF, Fine DN, Eckert LO. Physical injury after sexual assault: findings of a large case series. Am J Obstet Gynecol. 2004 Jan;190(1):71-6.[Abstract]
45. Muram D, Miller K, Cutler A. Sexual assault of the elderly victim. J Interpers Violence. 1992;7(1):70-6.
46. Workowski KA, Bachmann LH, Chan PA, et al; Centers for Disease Control and Prevention. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187.[Abstract][Full Text]
47. British Association of Sexual Health and HIV; Ashby J, Browne R, Dwyer E, et al. BASHH national guideline on the management of sexually transmitted infections and related conditions in children and young people. 2021 [internet publication].[Full Text]
48. Faculty of Forensic and Legal Medicine. Recommendations for the collection of forensic specimens from complainants and suspects. Jan 2023 [internet publication].[Full Text]
49. Adams JA, Kellogg ND, Farst KJ, et al. Updated guidelines for the medical assessment and care of children who may have been sexually abused. J Pediatr Adolesc Gynecol. 2016 Apr;29(2):81-7.[Abstract][Full Text]
50. Adams JA. Guidelines for medical care of children evaluated for suspected sexual abuse: an update for 2008. Curr Opin Obstet Gynecol. 2008 Oct;20(5):435-41.[Abstract]
51. Berkoff MC, Zolotor AJ, Makoroff KL, et al. Has this prepubertal girl been sexually abused? JAMA. 2008 Dec 17;300(23):2779-92.[Abstract]
52. Fischer GO. Vulval disease in pre-pubertal girls. Australas J Dermatol. 2001 Nov;42(4):225-34.[Abstract]
53. Brown MR, Cartwright PC, Snow BW. Common office problems in pediatric urology and gynecology. Pediatr Clin North Am. 1997 Oct;44(5):1091-115.[Abstract]
54. Stricker T, Navratil F, Sennhauser FH. Vaginal foreign bodies. J Paediatr Child Health. 2004 Apr;40(4):205-7.[Abstract]
55. World Health Organization. Health care for women subjected to intimate partner violence or sexual violence: a clinical handbook. Nov 2014 [internet publication].[Full Text]
56. US Preventive Services Task Force, Curry SJ, Krist AH, et al. Screening for intimate partner violence, elder abuse, and abuse of vulnerable adults: US Preventive Services Task Force final recommendation statement. JAMA. 2018 Oct 23;320(16):1678-87.[Abstract][Full Text]
57. Thackeray J, Livingston N, Ragavan MI, et al. Intimate partner violence: role of the pediatrician. Pediatrics. 2023 Jul 1;152(1):e2023062509.[Abstract][Full Text]
58. CommonSpirit Health, HEAL Trafficking, Pacific Survivor Center. PEARR tool: trauma-informed approach to victim assistance in health care settings. 2020 [internet publication].[Full Text]
59. International Society for the Prevention of Child Abuse and Neglect. Manual for administration: the ISPCAN child abuse screening tool (ICAST). Aug 2015 [internet publication].[Full Text]
60. American College of Obstetricians and Gynecologists. Committee opinion no. 498: adult manifestations of childhood sexual abuse. Obstet Gynecol. 2011 Aug;118(2 pt 1):392-5.[Abstract][Full Text]
61. Brown SJ, Carter GJ, Halliwell G, et al. Survivor, family and professional experiences of psychosocial interventions for sexual abuse and violence: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2022 Oct 4;10(10):CD013648.[Abstract][Full Text]
62. Centers for Disease Control and Prevention. Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection drug use, or other nonoccupational exposure to HIV: United States, 2016. Apr 2016 [internet publication].[Full Text]
63. British HIV Association. UK guideline for the use of HIV post-exposure prophylaxis. 2021 [internet publication].[Full Text]
64. Schillie S, Vellozzi C, Reingold A, et al. Prevention of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2018 Jan 12;67(1):1-31.[Abstract][Full Text]
65. Markowitz LE, Dunne EF, Saraiya M, et al. Human papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2014 Aug 29;63(RR-05):1-30.[Abstract][Full Text]
66. Faculty of Sexual and Reproductive Healthcare, Royal College of Obstetricians and Gynaecologists. Clinical guidance: emergency contraception. Dec 2017, amended December 2020 [internet publication].[Full Text]
67. American College of Obstetricians and Gynecologists. Practice bulletin no. 152: emergency contraception. Obstet Gynecol. 2015 Sep;126(3):e1-11.[Abstract]
68. World Health Organization. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. 2013 [internet publication].[Full Text]
69. American College of Obstetricians and Gynecologists. ACOG committee opinion no. 554: reproductive and sexual coercion. Obstet Gynecol. 2013 Feb;121(2 pt 1):411-5.[Abstract]
70. American College of Obstetricians and Gynecologists. ACOG committee opinion no. 518: intimate partner violence. Obstet Gynecol. 2012 Feb;119(2 pt 1):412-7.[Abstract][Full Text]
71. Hailes HP, Yu R, Danese A, et al. Long-term outcomes of childhood sexual abuse: an umbrella review. Lancet Psychiatry. 2019 Oct;6(10):830-9.[Abstract][Full Text]
72. Stock JL, Bell MA, Boyer DK, et al. Adolescent pregnancy and sexual risk-taking among sexually abused girls. Fam Plann Perspect. 1997 Sep-Oct;29(5):200-3, 227.[Abstract][Full Text]
73. Welch J, Mason F. Rape and sexual assault. BMJ. 2007 Jun 2;334(7604):1154-8.[Abstract][Full Text]
74. National Institute for Health and Care Excellence. Post-traumatic stress disorder. Dec 2018 [internet publication].[Full Text]
75. Kendall-Tackett KA, Williams LM, Finkelhor D. Impact of sexual abuse on children: a review and synthesis of recent empirical studies. Psychol Bull. 1993 Jan;113(1):164-80.[Abstract]
76. Lloyd S, Operario D. HIV risk among men who have sex with men who have experienced childhood sexual abuse: systematic review and meta-analysis. AIDS Educ Prev. 2012 Jun;24(3):228-41.[Abstract][Full Text]
77. Arriola KR, Louden T, Doldren MA, et al. A meta-analysis of the relationship of child sexual abuse to HIV risk behavior among women. Child Abuse Negl. 2005 Jun;29(6):725-46.[Abstract]
78. Taylor JE, Harvey ST. Effects of psychotherapy with people who have been sexually assaulted: a meta-analysis. Aggress Violent Behav. 2009;14(5):273-85.