Child Sexual Abuse

Etiology

Although CSA is not a disease process, one can better understand its etiology by identifying various risk factors and underlying contributing conditions. Most parents genuinely want what is best for their children, including those caregivers who engage in abusive behaviors. The question remains: Why do adults sexually abuse children who are dependent upon them for care?

Risk Factors of Child Sexual Abuse

Risk factors are categorized based on the child, caregiver, home environment, and the broader community. Girls and both girls and boys with chronic mental or physical conditions are at higher risk of sexual abuse, as are children with a history of prior CSA or other forms of victimization.[4] One study of adolescent psychiatric inpatients found high rates of CSA, trauma-related distress, and suicidality.[6]

Dysfunctional family environments, including a caregiver history of abuse, intimate partner or domestic violence, parental mental illness, substance abuse, and the presence of nonbiologically related adult men residing in the home, increase the risk of CSA.[5] Community risk factors for child abuse of any kind include poverty, social isolation, high rates of violent crime, lack of safe childcare, and cultural norms that condone harsh disciplinary measures.[7] These conditions can create an environment where abuse is more likely to occur and less often reported. Identifying and addressing these family and community risk factors is essential for prevention, prompt diagnosis, and effective interventions for vulnerable children susceptible to CSA.

Epidemiology

CSA victims represent diverse social, cultural, and economic backgrounds. Statistics likely underestimate the actual number of victims, as many children never disclose their abuse due to reluctance, worry about punishment, or developmental limitations. Children who do disclose abuse often confide in a same-aged peer who may not share the information with a responsible adult. Victims and their caregivers report fewer than half of all sexual assaults to the police for reasons that include fear, social stigma, and a family's desire for privacy. 

In the United States, >60,000 children endure sexual abuse every year, and approximately 25% of girls and 9% of boys worldwide likely experience CSA. Some studies suggest that boys and men are less likely than girls and women to disclose the occurrence of sexual abuse.[8][9] European studies estimate that 13.5% of girls and 5.6% of boys are CSA victims.[10] These disparities, in all probability, reflect regional differences in definitions and reporting rather than true prevalence. CSA may occur as a single incident or as repeated episodes over weeks or even years.

A particularly alarming global concern is the commercial sexual exploitation of children (CSEC), which is estimated to affect approximately 2 million children annually. Child prostitution is most prevalent in large metropolitan cities, and studies of CSEC survivors reveal that their participation is sometimes driven by the need to escape familial abuse or by coercion from an adult with whom they have an existing relationship.[11] CSA and CSEC affect millions of children worldwide, with most cases remaining unreported, highlighting the critical need for improved detection, reporting, and prevention efforts.

History and Physical

When evaluating a child for possible CSA, obtaining a detailed history and conducting a thorough physical examination using a trauma-informed approach are essential to ensuring accurate diagnosis and appropriate care. Some children reveal the occurrence of sexual abuse to a caregiver and present to a healthcare facility for evaluation. However, more than a third of victims never disclose CSA, especially boys and younger children.[12] Many children present with nonspecific complaints, including abdominal pain, anogenital bleeding, vaginal or urethral discharge, dysuria, or suicidal thoughts. Occasionally, clinicians observe suspicious injuries or disturbing behaviors during a visit for another complaint, including sexually explicit acting out at a young age, using sexual slang or referring to sexual acts, and developmentally inappropriate actions, eg, a child asking to touch an adult's genitalia.[12] 

A thorough, trauma-informed approach to obtaining the history and conducting the physical examination, combined with careful documentation and collaboration with interprofessional teams, ensures that children evaluated for possible CSA receive the compassionate care and protection they need while meeting the requirements of potential investigative and legal processes.

Clinical History

A trauma-informed approach yields the most accurate history from the child and family when gathering information.[10] Clinicians should employ empathetic listening without interrupting, ask open-ended, nonjudgemental questions, and allow a child to use an anatomically correct doll or drawings to describe the incident. Verbal children typically provide more details when their caregiver is absent from the exam room.[13]

Clinicians should address each child's concerns, answer their questions, and offer reassurance to protect them from further harm. Some perpetrators bring the child for medical care, concerned about the severity of the injuries, but are reluctant to provide a reliable account of the events. Other adults or mandated reporters may accompany the child, and clinicians must record the presence and role of these non-family members. A chaperone (eg, a nurse or medical assistant) can validate the medical documentation and address potential future challenges by families or legal system representatives. The written record should include verbatim statements, noting discrepancies between the child's and the adult's accounts without the clinician's opinions or interpretation.[14][10][15][10] When possible, clinicians should review the medical record to obtain as much information as possible before the visit to avoid revictimizing children by asking them to repeat their story multiple times. In some settings, child protection investigators or sexual assault nurse examiners (SANEs), specialists in interviewing CSA victims, obtain the most sensitive information and allow clinicians to focus on the pertinent medical history that addresses the specific clinical presentation. 

Additionally, a thorough clinical history includes inquiries about recent toileting habits, including encopresis or enuresis, sleep problems, and behavioral concerns, as CSA may sometimes trigger these symptoms. Relevant social history details family stressors, individuals living in the home, the details of child supervision, prior law enforcement or Child Protective Services (CPS) involvement, and social barriers of health, eg, housing or food insecurity.

Physical Examination

A clinician with specialized training in sexual abuse evaluation should conduct the physical examination. Families and caregivers must understand that the examination rarely confirms or excludes CSA. The absence of physical evidence does not mean that CSA did not occur. Examiners should note the child's appearance, including emotional state, as they seek to minimize trauma, fear, and distress and respect the child's autonomy and wishes.[14][10][15] The examination includes the mouth, oropharynx, skin, hair, breasts, inner thighs, perineum, anus, buttocks, and genitalia. Checking the mouth first helps put the patient at ease and is less intrusive than beginning with the genitalia. Significant oral findings include palatal petechiae or bruising and frenulum tears caused by forced penetration.

Experienced CSA clinicians examine children in a calm, quiet environment when possible. However, victims may present to emergency services for recent alleged abuse (within 72 to 96 hours) and require immediate assessment and forensic evidence collection. Many hospitals utilize SANEs, who specialize in forensic evidence collection, trauma-informed care, and collaboration with law enforcement and CPS. These nurses play a critical role in assessing injuries, documenting findings, and providing testimony in legal proceedings when necessary. Unfortunately, most examinations do not yield forensic evidence. However, body swabs of vaginal fluid, skin, and fingernail scrapings can recover DNA in the absence of abnormal physical findings, ideally within 24 hours from the time of the assault.[16]

Examination of genitalia

When a patient requires a genital examination, the child and parent or guardian, depending on the child's age, must give consent. A supportive chaperoning adult, not the suspected perpetrator, should be present for the child's comfort. Draping, privacy, and gloves are necessary for all sensitive examinations to protect the child and the clinician.[17] Children cope best when the number of exams is minimized and the clinician explains each step beforehand while using instruments and positions that reduce discomfort and ensure privacy. Documenting findings with detailed drawings or forensic photography has been recommended for decades. However, videography may now be preferred after informed consent to accurately record the patient's findings and reactions to the examination.[18] 

Usually, performing a speculum examination on a prepubertal girl is unnecessary. Clinicians position the child in the supine, frog-leg position, on an adult's lap, or in a prone knee-chest posture to visualize the relevant anatomy, including the labia majora, labia minora, posterior fourchette, clitoris, urethra, hymen, vaginal vault, and fossa navicularis. The presence of erythema, skin lesions, abrasions, tears, discharge, bruises, or bite marks may suggest CSA in both sexes. Inspecting the anus can be done in the lateral recumbent position with the child grasping their knees. Anal laxity indicates the possibility of CSA.[19]

Pubertal girls may require a speculum examination, performed only when necessary to avoid repeated examinations. To minimize physical discomfort and emotional distress, clinicians should prepare the girl beforehand using clear explanations, age-appropriate visual aids, and careful selection of instruments and positions. The clinician should document hymenal findings before inserting a speculum. Measurements of the typical hymenal orifice vary widely and do not indicate penetration, although bruising and lacerations may indicate sexual trauma. Using water or saline as a lubricant helps ensure that any trace evidence (eg, DNA) is not compromised during the examination. Of note is that petroleum-based lubricants can affect sperm motility and culture results. When prepubertal girls need a speculum examination, eg, in cases of vaginal bleeding, the child requires sedation.[14]

Evaluation

During the evaluation, clinicians should aim to achieve 4 main objectives: identify medical conditions and injuries requiring acute treatment, screen for STIs and pregnancy risk, accurately document results with forensic significance, and assess potential mental health consequences associated with CSA. 

Sexually Transmitted Infection and Pregnancy Screening

The prevalence of STIs among child sexual abuse victims is generally reported to be between 4% and 8%.[20] A urine specimen should be analyzed using the nucleic acid amplification technique to test for gonorrhea and chlamydia, and cultures can confirm positive test results in jurisdictions that do not accept nonculture methods as forensic evidence. Clinicians may choose to obtain rectal, urethral, vaginal, or pharyngeal samples if clinically indicated.

Testing for HIV and syphilis requires repeat tests at specified intervals following United States Centers for Disease Control and Prevention (CDC) guidelines. Recommendations include testing for hepatitis B in patients who have not received 3 vaccine doses. For children with vesicular or ulcerative lesions, clinicians should obtain samples for a herpes simplex virus culture. For girls with a vaginal discharge, the evaluation includes specimens to test for bacterial vaginosis and trichomonas vaginalis. Forensic evidence collected within 24 hours yields the most results. Staff must package and label forensic samples carefully and accurately to preserve the evidence chain. They should place clothing worn at the time of the alleged abuse, including underwear, in a labeled, sealed, leak-proof container. 

The American Academy of Pediatrics (AAP) and the CDC recommend pregnancy testing for all postpubertal females evaluated for sexual abuse. In cases where the initial pregnancy test is negative but a high suspicion of pregnancy or ongoing risk is present, a follow-up test is warranted. Subsequent pregnancy testing is critical if the initial evaluation occurs shortly after an alleged assault. Handling pregnancy testing with sensitivity is crucial, as well as ensuring confidentiality and obtaining appropriate consent. Some girls may be candidates for emergency contraception or may have signs or symptoms of pregnancy requiring consultation and further testing by an obstetrician-gynecologist.[14] 

Documentation of Findings

The evaluation of CSA includes accurately recording and interpreting test results that may serve as forensic evidence in future legal proceedings. Precise documentation helps establish the chain of custody, prevents tampering, and provides an objective account that can support or refute allegations. Proper documentation also enhances the credibility of the clinician's testimony if required in court. 

Mental Health Assessment

Clinicians must also assess for potential mental health consequences when evaluating CSA victims at increased risk of psychological issues. Early identification leads to timely intervention, which can improve long-term outcomes by providing access to appropriate mental health support and therapeutic services. Additionally, understanding a child's emotional state and coping mechanisms helps guide trauma-informed care during the evaluation while ensuring comprehensive support for their recovery.

Treatment / Management

Clinicians must tailor treatment plans to each child's clinical presentation and relevant findings. Due to the sensitive nature of CSA, its significant physical and mental health impacts, and its legal implications, providing care for victims requires specialized skills and a trauma-informed approach.[10] Addressing physical trauma and acute injuries is the initial priority when caring for CSA victims. Head injuries, fractures, and other signs of physical abuse may present alongside genital or anal injuries, including lacerations, bleeding, and bruising. Acute psychiatric symptoms, including suicidal ideation, require urgent mental health intervention.(A1)

The CDC and the AAP publish clinical practice guidelines in the United States, including considering infections that mimic CSA, pregnancy testing, and managing STIs.[14] Their recommendations emphasize the importance of obtaining a complete medical history, conducting a detailed physical examination, and employing appropriate diagnostic tests to diagnose treatable conditions. The CDC's Sexually Transmitted Infections Treatment Guidelines provide details for treating STIs in children who may have experienced sexual abuse.[21] The WHO guidelines emphasize a supportive, child-centered, and trauma-informed approach to care, including obtaining a thorough medical history, conducting physical examinations, and documenting physical findings. Several countries and professional societies globally provide evidence-based treatment recommendations, although most European countries lack national clinical practice guidelines.[10](A1)

The CDC recommends empiric treatment for gonorrhea, chlamydia, and trichomoniasis when CSA involves oral, genital, or anal contact. Additionally, HIV postexposure prophylaxis (PEP) should be considered using an algorithm that evaluates the timing and nature of the exposure.[22] Boys and girls who have completed the 3-dose hepatitis B vaccine series and 2-dose human papillomavirus (HPV) vaccine series need no further immunizations. Appropriate vaccines should be administered to unimmunized or underimmunized children, with the HPV vaccine available for boys and girls aged 9 and older.[23] Clinicians should counsel postpubertal girls at risk for pregnancy and offer emergency contraception to them if indicated.[23] 

All victims of CSA require initial psychological assessment and close follow-up. Trauma-focused cognitive-behavioral therapy involving both the child and their caregivers addresses mental health symptoms and reduces symptoms of posttraumatic stress disorder (PTSD), anxiety, and depression.[24] The WHO guidelines highlight the importance of using evidence-based, trauma-focused interventions appropriate to the child's developmental stage to address the complex psychological needs of CSA victims.[25][24](A1)

Differential Diagnosis

When assessing patients for suspected CSA, clinicians must consider other etiologies of genital injuries, infections, dermatologic conditions, and normal anatomic variants in the differential diagnosis. A comprehensive assessment, including history, physical examination, and appropriate diagnostic testing, usually differentiates CSA from medical disorders. Accidental injuries, including straddle injuries, zipper penile entrapment, hair tourniquet, and seat belt bruising in a motor vehicle accident, may all cause genital bruising, abrasions, and lacerations. However, in cases of accidental injuries, the patient or caregiver typically provides a narrative that aligns with the physical findings.

Nonsexually transmitted infections, including streptococcal or candidal vulvovaginitis, urethritis, and pinworm infestation, cause genital irritation, erythema, or discharge. Sexually active adolescents may acquire STIs through consensual sexual activity with a peer rather than as a result of CSA. Medical practitioners should interview teens in a confidential setting to obtain an accurate history, assess for potential coercion or exploitation, and ensure appropriate medical care and support. Clinicians must also distinguish skin conditions associated with CSA from those caused by lichenoid rashes, psoriasis, eczema, and irritant vulvovaginitis due to poor hygiene or bubble baths.[26][27] Normal hymen variations, including ridges, tags, and clefts, may be mistaken for signs of trauma. Deep notches of the hymen may indicate CSA but are not diagnostic, as they may be an anatomic variant or the result of medical or surgical procedures.

Prognosis

CSA, classified as an adverse childhood experience, heightens the risk of developing chronic, life-limiting conditions, including emotional, behavioral, social, and physical health impairments.[17] The overall prognosis varies widely and depends on the severity and duration of the abuse, the relationship with the perpetrator, the presence of supportive caregivers, and access to mental health care. With timely diagnosis and intervention, trauma-informed counseling, and a strong support system, many children demonstrate resilience and recover without long-term psychological harm. However, CSA can adversely affect physical and mental health and lead to life-long complications. Early identification, therapeutic support, and interprofessional care significantly improve the prognosis, helping children heal and regain a sense of safety and well-being.

Complications

Clinicians must promptly diagnose and manage the immediate consequences of CSA, including genital and other physical injuries, STIs, and unintended pregnancies. However, beyond these acute concerns, the trauma of CSA can cause lifelong complications that significantly impact both mental and physical health. CSA survivors experience increased rates of anxiety, depression, PTSD, low self-esteem, social phobias, suicide attempts, and psychiatric hospitalizations.[28] Evidence shows they face a higher risk of lower educational achievement, adult financial instability, and challenges forming and maintaining healthy relationships.[10] Children who have been sexually abused are more prone to substance use disorders, including alcohol and illicit drug dependence, and experience higher rates of STIs, intimate partner violence, and adult sexual assault. Adult survivors often suffer from higher rates of chronic physical health conditions requiring medical care, including irritable bowel syndrome, fibromyalgia, obesity, coronary heart disease, and diabetes.[29][30]

Additionally, CSA can impair adult sexual function, with male and female survivors reporting elevated rates of sexual dysfunction. Women with a history of CSA often experience heightened anxiety and express more difficulties during pregnancy, and pelvic examinations and childbirth can serve as triggering events that recall prior trauma. Postpartum activities like breastfeeding and diapering infants may provoke flashbacks, profoundly impacting parenting abilities. Male CSA survivors also report struggling with tasks involving physical intimacy with their infants, eg, bathing and diapering.[31] 

The long-term complications of CSA, including mental health disorders, chronic physical health conditions, and difficulties with intimate relationships and parenting, require ongoing, specialized care. Clinicians must recognize the lasting impact of CSA and provide continuous support to help survivors manage these lifelong challenges.