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SEXUAL ABUSE, GYNECOLOGY, AND SEXUALLY TRANSMITTED INFECTIONS*

*The authors acknowledge the special contributions of Amy Suss, MD, Sarah A. Rawstron, MD, and Konstantinos Agoritsas, MD, to prior edition.

OVERVIEW OF CHILD SEXUAL ABUSE AND ASSAULT

Clinical Summary

Sexual assault is sexual activity for which a victim is unable to or cannot give explicit, informed consent. Sexual assault encompasses child sexual abuse (CSA). CSA is completed or attempted any one of the following: (1) contact involving penetration, however slight, between the mouth, vulva, penis, or anus of a child and a perpetrator’s hand, penis, or object; (2) intentional touching directly or through clothing of the breast, vulva, penis, anus, groin, buttocks, or inner thigh that is not consistent with child’s needs; (3) pornography, voyeurism by an adult, sexual harassment, and commercial sexual exploitation (prostitution, sexual trafficking); (4) confirmed sexually transmitted infections (STIs) in children when perinatal and rare nonsexual transmission has been ruled out. Approximately 1 in 4 females and 1 in 10 males have experienced some form of sexual victimization prior to age 18 years. CSA perpetrators are usually male family members or male acquaintances, not strangers. CSA is most often discovered because of a disclosure by the child weeks to years after event(s). Details are often only incrementally disclosed. Abused children sometimes display explicit or developmentally inappropriate sexual knowledge or behaviors, self-harm, depression, temper tantrums, aggression, phobias, disturbances in sleep and appetite, difficulty in school, abdominal pain, and/or anogenital complaints. The subset of children who have been trafficked (exchanged sexual acts for money, food, shelter, drugs, affection, gifts) often have a history of running away from home, gang involvement, substance use, gender identity concerns, significant nongenital injuries, multiple STIs, and/or current or prior involvement with social services or law enforcement. Adult CSA survivors are at increased risk of sexual dysfunction, depression, and sexual revictimization.

Emergency Department Treatment and Disposition

The diagnosis of suspected CSA is commonly made by careful history taking. History should ideally be obtained from any child older than age 3 years who is willing and able to speak. An open-ended history should begin with an explanation that it is okay for the child to correct the clinician and/or to say the child does not remember or understand. Age-appropriate language and repetition of the child’s words followed by “Tell me more” or “And then what happened?” are suggested approaches to obtain relevant details (Table 4.1). The essential elements that should be asked and documented are who, put what, when, where, and what happened afterward.

FIGURE 4.1

Physical Examination Positions. (A) Frog-leg position. (B) Labial traction. (C) Girl in knee-chest position with elbows resting on examination table. This position is best ...

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