Medical Care
Medical treatment is guided by any conditions uncovered. The incidence of STDs in child sexual abuse (CSA) is low. In prepubertal children, asymptomatic vaginal infections are thought to be increasingly uncommon. Therefore, the Centers for Disease Control and Prevention (CDC) does not recommend prophylaxis for STDs in asymptomatic prepubertal children who are evaluated for possible CSA. In contrast, the CDC recommends that teenaged patients and adults who are sexually abused or assaulted should receive antibiotic prophylaxis for STDs. For more information, see MMWR Recommendation and Report Sexually Transmitted Diseases Treatment Guidelines.
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Treat STDs with appropriate medications based on the infection and the child's age and weight.
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In postmenarcheal children, consider the possibility of pregnancy.
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Recognize the overriding need for emotional support and attention to the psychosocial crisis in which the child and family now find themselves.
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Health care providers are mandated reporters in all 50 states; once sexual abuse seriously is suspected or diagnosed, a report to the appropriate child protective services (CPS) agency is necessary. Attention to the safety of the child is essential. The AAP recommends reporting in the following situations:
When a child makes a clear disclosure of abusive sexual contact, with or without specific findings
When individuals present with STDs (see Workup section)
When physical examination findings are believed to be the result of abusive sexual contact
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When sexual abuse is being considered, the AAP suggests the possibility of reporting, depending on the perceived risk to the child. In such cases, discussion with members of an interdisciplinary team may be helpful.
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Cases of sexual abuse may result in law enforcement action against the alleged perpetrator and possible criminal court proceedings. Well-documented medical records are essential, since legal proceedings may occur over long periods of time. The health care provider cannot rely solely on recollection of the case.
Consultations
Mental health consultation is warranted to evaluate and treat acute stress reaction and, later, posttraumatic stress disorder (PTSD).
Expert mental health management of stress disorders is warranted because of the burgeoning evidence that psychic trauma in young children has a significant effect.
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Possible factors influencing the decline in substantiated cases of child sexual abuse. Courtesy of David Finkelhor, PhD.
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Adverse Childhood Experience (ACE) Pyramid. Courtesy of the Centers for Disease Control and Prevention (CDC) [https://www.cdc.gov/violenceprevention/aces/about.html].
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Infant girl in frog-leg supine position. Genital examination reveals translucent hymenal membrane with significant redundant tissue making hymenal orifice difficult to appreciate in this photo. With further traction applied to both labia majora, the hymenal orifice could be observed. Courtesy of Carol D. Berkowitz, MD.
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Infant girl in frog-leg supine position. Hymenal orifice is crescentic (little tissue is present at 12-o'clock posterior). Hymen is thin and translucent with vessels visible. Hymenal edge is regular and without interruption. Courtesy of Carol D. Berkowitz, MD.
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Girl in knee-chest position. Hymenal orifice is crescentic, thin, translucent, and without interruption or scarring. Courtesy of Carol D. Berkowitz, MD.
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Infant girl in frog-leg supine position. Hymenal orifice is annular, with tissue present around entire opening. Some redundancy is present. Courtesy of Carol D. Berkowitz, MD.
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Infant girl in frog-leg supine position. Hymenal orifice is annular with a "bump" at 1-o'clock position and a small "notch" at 10-o'clock position. Hymenal membrane is thin and translucent, with no interruption or scarring. Courtesy of Carol D. Berkowitz, MD.
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Girl in frog-leg supine position, exhibiting annular hymenal orifice. Tissue is thin and translucent without disruption or scarring. Courtesy of Carol D. Berkowitz, MD.
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Girl in frog-leg supine position exhibiting hymenal orifice, which is crescentic and has symmetric attenuation at lateral margins. No scarring is present. Courtesy of Carol D. Berkowitz, MD.
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Girl in frog-leg supine position exhibiting hymen. Hymen is septate; a band of tissue crosses the hymenal orifice. Tissue is thin with no scarring present. Courtesy of Carol D. Berkowitz, MD.
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Adolescent girl in supine position demonstrating estrogenized tissue. Hymen is thicker, pink, and fairly opaque with no vessels visible. Tissue is redundant. Courtesy of Carol D. Berkowitz, MD.
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Genital examination of adolescent girl revealing estrogenized hymenal tissue that is pink, thick, and opaque. Orifice appears irregular, secondary to significant redundancy of tissue. Courtesy of Carol D. Berkowitz, MD.
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Genital examination of adolescent girl demonstrating estrogenized hymenal tissue that is pink, thick, and opaque. Orifice is irregular due to areas of redundancy, especially at the 9-o'clock position. Courtesy of Carol D. Berkowitz, MD.
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Prepubertal girl with foul-smelling bloody discharge. On examination, a foreign body in the vagina was found just past the hymenal orifice. The foreign body is lodged in vagina and appears to be toilet tissue that is colonized with bacteria, causing a vulvovaginitis. The foreign body was dislodged with gentle water flushing during examination. Courtesy of Carol D. Berkowitz, MD.
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Genital examination of prepubertal girl with foul-smelling bloody discharge. On examination, a foreign body in the vagina was found lodged just past the hymenal orifice and appears to be toilet tissue that is colonized with bacteria, causing a vulvovaginitis. The foreign body was dislodged with gentle water flushing during examination. Courtesy of Carol D. Berkowitz, MD.
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Infant girl with imperforate hymen and absence of a hymenal orifice. Courtesy of Carol D. Berkowitz, MD.
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Genital examination of girl revealing bruising on medial aspects of labia minora, hymenal trauma with disruption of hymenal tissue, and fresh blood. Courtesy of Carol D. Berkowitz, MD.
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Infant girl with significant bruising that involved labia minora and labia majora, hymenal trauma with disruption of hymen, and fresh blood. Courtesy of Carol D. Berkowitz, MD.
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Genital examination 10 days after infant girl presented with significant bruising that involved labia minora and labia majora, hymenal trauma with disruption of hymen, and fresh blood. Bruising on vulvar structure is nearly resolved. Hymen is healing and no blood is observed. Courtesy of Carol D. Berkowitz, MD.
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Genital examination of girl in frog-leg supine position after genital trauma. Examination reveals suture in place at 6-o'clock position to stop bleeding from injury. Hymenal edge is irregular and asymmetric. Courtesy of Carol D. Berkowitz, MD.
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US Maltreatment Trends, 1990-2019. Courtesy of David Finkelhor, PhD [Finkelhor D, Saito K, Jones L. Updated Trends in Child Maltreatment, 2019. Crimes Against Children Research Center, University of New Hampshire. February 2021. Online at: http://unh.edu/ccrc/pdf/CV203%20-%20Updated%20trends%202019_ks_df.pdf.].
