Article psychosocial

Sexual Abuse in Children

Charles Felzen Johnson,
Objectives After completing this article, readers should be able to:
MD*
1. List three reasons why children may not reveal sexual abuse.
2. Be familiar with a normal hymen in a preadolescent and adolescent female.
Author Disclosure 3. Recognize a laceration of the hymen rim.
Dr Johnson did not 4. Describe the immediate and long-term adverse behavioral consequences and the
disclose any financial physical consequences of sexual abuse.
relationships relevant 5. Discuss why results of the genital examination may be normal after sexual abuse.
to this article. 6. Appreciate the importance of a properly conducted forensic interview in sexual abuse.

From the Editor: This comprehensive review of sexual abuse offers insights into every aspect
of management. Some general pediatricians are better equipped than others to deal with
sexual abuse, depending on training, experience, and the availability of community
resources. Recognizing the value of a multidisciplinary team approach, each pediatrician
must decide what his or her role should be and at what point a referral is necessary.—LFN

Case Study
Mary, a normal and healthy 5-year-old, is the only child in a recently divorced family. The
mother has custody of Mary, and the father has weekend visitation. The father is remarried to
a woman who has two children. Mary has been objecting to her weekend visits with her father.
She is masturbating “frequently” according to the mother, who isolates Mary for this behavior.
Mary has complained about burning when she urinates. The mother has noted that Mary’s
genital area is red. She concluded that this was due to the masturbation. Mary has begun to
suck her thumb. The preschool teacher called the mother to report that Mary was inviting boys
to touch her genitalia. Mary also is refusing to do her school work. When her mother questioned
her, Mary replied that her stepbrother had touched her privates and told her not to tell anyone
or he would be in trouble. The mother comes to your office for guidance.

Definition
Sexual abuse may be defined as any activity with a child before the age of legal consent or
beyond the child’s comprehension that is for the sexual gratification of an adult or a
significantly older child. These activities include oral-genital, genital-genital, object-
genital, genital-rectal, object-rectal, hand-genital, hand-rectal, or hand-breast contact;
exposure of sexual anatomy; and forced viewing of sexual anatomy, showing pornography
to a child, and using a child in the production of pornography. The child may be a victim
of the act or perform the act on the adult or significantly older child. Viewing or touching
of the genitalia, buttocks, or chest by normal preadolescent children, separated by no more
than 4 years of age, in which there has been no force or coercion, is termed sexual play. The
4-year age difference is arbitrary. The more important variable is whether there is a
significant size, status, or developmental difference between the perpetrator and victim.
Intentional failure, on the part of a caretaker, to shield an immature child from exposure to
sexual acts or sexual information may be considered sexual neglect or a failure to protect
the child. Although the physician may have no doubt about the diagnosis of sexual abuse,
the ultimate conclusion is made in a court of law after a judge or jury weighs the evidence
provided by those who testify for the prosecutor and defense.

*Professor of Pediatrics, The Ohio State University School of Medicine and Public Health, Child and Family Advocacy Program,
Children’s Hospital, Columbus, Ohio.

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psychosocial sexual abuse

Surveys of Adults or Adolescents to

Table 1. theory that part of the decrease is
due to perpetrators choosing
Determine Prevalence of Sexual Abuse younger and less communicative
victims and a possible decrease in
Females Males Study Location Publication Date
children’s services resources. The
10% to 20% 3% to 10% Europe 2002 Clearinghouse data reveal that of all
54% — San Francisco, California 1983 perpetrators of sexual abuse, ap-
15% to 32% — United States 1999
35.7% to 42.3% — Australia 2001 proximately 3% were parents and
20.4% 3.3% Geneva, Switzerland 1996 29% were other relatives. For a va-
33% — South Africa 2002 riety of reasons, only a fraction of
children who are sexually abused
are discovered or reported.
Epidemiology Such underreporting may have serious adverse conse-
The actual number of victims of sexual abuse is un- quences for the child or adult victim who is not provided
known, and estimates vary as a result of different defini- protection and therapy. Thus, it is important for the
tions, the age and sex of the individuals surveyed, and pediatrician, often the only professional to have contact
personal and cultural variables that may influence the with younger children, to be aware of the behaviors,
desire to answer survey questions. Younger children or symptoms, and signs that suggest sexual abuse. A suspi-
children who have significant developmental delays may cion of abuse by a pediatrician or other professional
not have the communication skills needed to answer requires a report to be made to local authorities. In most
questions. They may not recognize acts as being im- communities, such reports are made to children’s protec-
proper, especially if performed by a female caretaker tive services or social services and to law enforcement.
involved in the maintenance of the child’s hygiene. Chil- Each region should have an agency whose purpose is to
dren and adults may forget or repress memories, cooper- provide protection for children; information on the re-
ate with demands for secrecy, or fear threats and retribu- sponsible agencies in specific areas can be obtained from
tions from perpetrators or the systems to which the local chapters of the American Academy of Pediatrics.
victims are referred for diagnosis and treatment. Chil- Children’s services must investigate a report to assure
dren who are related to the perpetrator, as well as the that a child is safe from harm. Community agreements
relatives of the perpetrator, may not want the perpetrator assure sharing of information with law enforcement be-
to be discovered and punished. More specifically, if the cause a report of sexual abuse must be investigated
father has sexually abused a family member and is the further to determine if a crime has been committed.
breadwinner, the mother may fear the adverse economic
consequences that may arise if the father is incarcerated. Pathogenesis
The results of surveys of adults to determine the preva- Sexual abuse can be described as a disease process that
lence of sexual abuse are shown in Table 1. Variations are involves a vulnerable child host and a perpetrator or
due to differing definitions of what acts constitute abuse “pathologic agent” (PA) who is attracted to children for
and willingness to participate and disclose. sexual gratification. Studies of perpetrators indicate that
The National Clearinghouse on Child Abuse and they seek out specific physical characteristics in their
Neglect issues annual statistics collected from state child victims and locations where they have access to children
protective services agencies. In 2002, about 10% of the
estimated 896,000 children who were determined to be
victims of child maltreatment were victims of sexual
Agency Reports of Sexual
Table 2.

abuse. As with prevalence studies, data from incidence Abuse (Incidence)

studies vary by city, state, and country (Table 2). The
incidence of victimization in the United States for all Study Publication
Females Males Location Date
types of maltreatment fell from 13.4 per 1,000 children
in 1990 to 12.3 per 1,000 children in 2002. This was due 8% 3% Greenland 2002
primarily to a decrease in reports of sexual abuse. The 36% 1% to 15% Europe 2002
.17% .04% United States 2000
causes for such a decrease are being debated and include
.07% (both males and Denmark 1998
incarceration of perpetrators, successful prevention females)
methods, and changes in the economy. Of concern is the

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 psychosocial sexual abuse

with minimal opportunity for detection. The reasons that such as anxiety, enuresis, encopresis, decrease in school
PAs gave for their behavior are varied. For example, a PA performance, regression, depression, and behavior prob-
might describe a certain child as being seductive, the PA lems are nonspecific, but the possibility that child mal-
may have experienced sexual abuse as a child and become treatment is the cause of the behavior must be ruled out.
a “reactive” abuser, or the PA may have experienced a The verbal child can be questioned about domestic vio-
loss or the unavailability of a mate. The child, usually a lence, physical abuse, and sexual abuse when he or she is
daughter, becomes a substitute as a way of maintaining not in the presence of the caretakers. In a forensic inter-
the family unit. Some PAs are attracted only to children, view, no caretaker is allowed in the interview room. This
perhaps because of limited skill or confidence in relating practice is intended to minimize verbal or nonverbal
to age mates. A young child may be perceived as being coaching by the caretaker or nonsupportive statements
easier to seduce and manipulate, less likely to become about the child’s veracity. This experience may be due to
pregnant, more easily bribed and threatened, unsophis- exposure to pornography, adult sexual activity, or sexual
ticated about proper sexual behavior, and less likely to abuse. Unless a history of sexual abuse is obtained from
transmit a sexually transmitted disease (STD) to the PA. the child or there are physical or laboratory findings of
The portrayal of children or childlike-appearing adoles- sexual abuse, behaviors are not considered of sufficient
cents and young adults in sexually provocative advertis- diagnostic specificity to warrant a report. The misbehav-
ing or in pornography presents the child as interested in ing child who does not respond to behavior management
and available for sex. These materials may be used by PAs methods suggested by the pediatrician should be referred
to increase their attraction to children, rationalize their for behavior therapy. In the course of therapy, when
behavior as being acceptable to society, and convince comfortable with the examiner, a past history of sexual
children that the behavior is normal. The vulnerable and abuse may be revealed.
attractive child may be “groomed” with gifts and atten-
tion that proceed to pornography viewing, touching the Physical Findings
clothing, and frank sexual contact (oral-genital, hand- Sexual and nonsexual trauma to the genital area can
genital, or oral-oral). Such acts do not produce any result in erythema, abrasion, bruising, and laceration. As
physical findings. with physical abuse, if the caretaker is the perpetrator, a
Convicted PAs may deny the use of force, but their history of accidental injury may be offered to explain the
larger size and psychological power over trusting chil- trauma. The child may not be brought to the physician
dren is a form of force. Once the child has participated in until intentional trauma has healed. The child may not
a sexual activity and accepted gifts, the PA can use these reveal a history of abuse immediately after the experi-
behaviors to convince the naı̈ve child that the actions ence(s). This delay can allow physical trauma such as
were the child’s fault. Supplementing this approach are a erythema to heal completely. Tears through the hymen
panoply of threats to the safety, reputation, and welfare edge and anal fissures also heal over a period of weeks.
of the child, the child’s family, and pets. To be successful Long-term follow-up studies indicate that even severe
and avoid detection, PAs develop skills in communicat- trauma that required surgical intervention may not be
ing with children and determining their vulnerability. detectable over time. If skin or mucous membranes are
They may seek out children who have emotional or eroded by rubbing, the clinician can expect to see ery-
behavioral problems, mental retardation, communica- thema.
tion problems, single parents, or who are experiencing If an opening such as the anus, vestibule, or hymen is
failure. The PA befriends the child and asks for sexual penetrated by a blunt object larger than the maximum
favors in return. size of the opening, a tear with bleeding is expected.
Tears of the hymen opening can occur in any part of the
Clinical Aspects hymen rim but are more likely to occur from the 3 to 9
Behavior Changes o’clock positions (Fig. 1). A common hymen variant
Sexual acting out; masturbation that is excessive, public, lacks tissue above the 3 and 9 o’clock positions, which
and unresponsive to behavior modification; and sophis- can make interpretation of narrowing or missing tissue
ticated questions about sex or questions not expected for difficult unless the child has been examined previously
the child’s developmental level are likely to be related to and found to have tissue in that area. A tear results in
an inappropriate sexual experience. bleeding. Urine passing over a tear in the hymen or
Children who have been sexually abused may develop vestibule or abrasions in these areas results in dysuria.
behavioral and physical symptoms. Behavioral changes Hard and large stool passing out of the anus can cause

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psychosocial sexual abuse

and with stool passage, further anal tears and a lax anal
sphincter.
Straddle injuries can result in tears of the perineum.
The anus and vagina rarely are penetrated accidentally,
and such penetration usually is through underwear. The
clitoris and penis may be crushed against the symphysis
pubis in a straddle or impact injury. Caretakers of chil-
dren who experience these injuries generally seek imme-
diate medical attention. There may be witnesses to the
event, and the verbal child can give a corresponding
history of the accident.
Familiarity with the normal anatomy of the genitalia
and anus is imperative to determine if trauma has taken
place. Familiarity with anatomy is increased when physi-
cians examine these areas routinely in all physical exami-
Figure 1. Normal preadolescent hymen anatomy. 9ⴝ9 o’clock
nations. A finger or similar-size object may be inserted
position, 3ⴝ3 o’clock position, Aⴝlabia minora, Bⴝurethra,
Cⴝright hymen wall, Dⴝbase of hymen, Eⴝleft hymen wall, for 1 to 2 cm into the vestibule without tearing the
Fⴝfourchette hymen. The perpetrator may perform labial intercourse
or fellatio without resulting trauma to the internal geni-
fissures. An anal tear from the insertion of an object talia. Penetration in the adolescent female may not result
that causes a fissure (Fig. 2) may result in a reluctance in visible trauma, because the hymen is thicker and more
to stool, accumulation of stool that hardens over time, elastic. Therefore, signs of penetration may not be found
when penetration is described. Findings such as gaping
hymenal orifice, vaginal discharge, labial adhesions, fria-
bility of the posterior fourchette, a linea vestibularis, and
vestibule pallor are found in a significant number of
nonabused girls.

Laboratory Findings
Sexual abuse may result in an STD or pregnancy. It is
unusual for the sexually abused preadolescent child to
present with symptoms of a venereal disease. Erythema
and a discharge may be due to poor hygiene, a bubble
bath, or a foreign body. A history of self insertion of
foreign bodies should raise suspicion of sexual abuse.
The sensitivity of the hymen to touch generally precludes
self-induced trauma. If there is a history of genital con-
tact with an orifice, cultures for chlamydia and gonorrhea
and studies for syphilis, hepatitis B, and human immu-
nodeficiency virus (HIV) should be performed. For the
child younger than 3 years of age in whom venereal warts
are newly discovered, the possibility of transmission at
the time of birth must be entertained. Pregnancy in a
child prior to the age of consent is child abuse and should
be reported. Sexually abused children at risk for preg-
nancy should be given preventive treatment according to
the guidelines from the American Academy of Pediatrics
Committee on Adolescence Sexual Assault. Confirmed
venereal diseases should be treated according to the
Figure 2. Acute anal fissures (F). PRⴝperineal raphe (a normal guidelines of the 2003 Red Book Report of the Committee
midline structure) on Infectious Diseases.

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 psychosocial sexual abuse

Clinical Evaluation impression of coercion to those unfamiliar with normal

The History Given to Others child development. For a child whose communication is
A child who recognizes that he or she has had an inap- limited, the interviewer must ascertain if touching
propriate sexual experience may reveal details initially to event(s) took place during toileting or bathing. A parent
a caretaker, friend, teacher, or other trusted adult. The in a custody battle may be convinced that the noncusto-
initial statement may be limited in detail and serve to test dial parent or that parent’s new partner has abused the
the reaction of the person to whom he or she has spoken. child and see a failure to document this as a failure to help
The child may refrain from expanding on the history or protect the child. These parents need guidance to refrain
telling others if the response of the person is a reprimand from doctor shopping and repeated examinations of the
or accusation of lying. Younger children may be confused child. Guidance about how parents can teach children
by the need to repeat this history with more details to the proper names of private parts and the need to tell
other individuals. Threats and bribes, a lack of sophisti- about any uncomfortable experiences to any parts of the
cation about sexual acts, guilt for participation, and fear body is necessary. Normal findings on physical examina-
of reprisal from parents may prevent revelation of details. tion may help assure the parents that no physical trauma
Younger children abused by females or other trusted has occurred. Parents of girls may want to know that the
caretakers may not distinguish inappropriate acts from hymen is “intact.”
hygiene care or health care. Older males abused by males The physician who sees the child initially may elicit
may be reluctant to reveal the activity due to the homo- information from open questioning, but must refrain
sexual nature of the contact. Older males abused by from using the names of suspects or aspects of the history
females may not view the act as abuse. Older females who that are available. A spontaneous answer to the question,
have sex with older males with consent may not consider “Why are you here today?” may elicit a statement that
the acts to be illegal and sexually abusive. results in protection of the child. Questions about touch-
A child who has made a statement about abuse may be ing, rubbing, kissing, or object insertion should not
referred to the private pediatrician by a concerned parent focus on the genitalia or anus. The abuser may have had
or, if a regional diagnostic center is unavailable, by local the child perform acts on her- or himself or the abuser.
children’s services after having been called by a con- Asking children if someone hurt them “down there” may
cerned adult. Parents of abused children are more likely elicit a negative reply because there may have been no
to seek assistance if the suspected abuser is not an imme- pain from the event(s). The question “Why did you wait
diate family member. Sexual activity by siblings, believed to tell?” should be avoided. Children should be told that
to be the most common form of sexual abuse, may not be they are not in trouble, that they are brave for telling
reported by parents. The step-siblings of children arriv- what happened, and that they will be protected. A foren-
ing in newly constituted families may not apply the incest sic evaluation that cannot be challenged effectively in
taboos that they have been taught regarding their own court influences the latter promise. The ideal interview is
siblings to the new arrivals. Foster children may suffer the conducted by a trained interviewer in a clinic where
same situation. A fear of family disruption may interfere members of children’s services, law enforcement, mental
with revelation. health, and the prosecutor’s office are in attendance. This
Caretakers come to the physician desiring a firm diag- system minimizes the need for multiple interviews of the
nosis. Because only 5% of children who are evaluated for child.
suspected abuse have abnormal medical findings, the
forensic interview must be relied on to reach a conclu- The Interview
sion. Unless the child has advanced language skills, the The child should be assured that there will be no shots.
child younger than 3 years of age cannot be interviewed Because the genital examination is not routine for girls,
effectively. At 3 years of age, three-word sentences and a there will be anxiety about the procedure. A physician
vocabulary of fewer than 1,000 words limit answers to familiar to the child may minimize this anxiety. While the
open questions. The young child may be able to respond parent is being interviewed about the medical and social
to the question, “Did anything happen to you that you history, including substance abuse, domestic violence,
didn’t like?” with “He/she hurt my pee pee” or a grasp animal abuse, previous contact with children’s services,
of the genitalia. Further information about the circum- sexual abuse in the family, and mental illness, the child, in
stance, time, and event may not be forthcoming. In another room, should complete a drawing series that can
addition, the child’s short attention span requires addi- be used during the interview. This will put the child at
tional effort to keep the child on track, creating the ease and provide indirect entry to the topic of sexual

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psychosocial sexual abuse

Figure 3. Genital and anal anatomy drawing and report form.

abuse. Having the child draw a person and family doing The interview proceeds to determine what happened,
something is a less formal alternative. The interview of where things happened, the identity of the perpetra-
the child should be private unless the child will not tor(s), frequency, and bribes and threats used. The types
separate from the caretaker. The drawings should be of abuse and their frequency are used by law enforcement
discussed before any formal questions about inappropri- to determine the charges and number of counts. Ques-
ate sexual experiences are broached. Nude figure draw- tions and answers in quotes should be recorded in the
ings appropriately matched to the child’s skin color, race, interview report. Some jurisdictions allow or require
and age are used to determine what words are used to videotaped recordings of the interview.
identify body parts and whether the child recognizes
“private parts” and what to do or say if something The Physical Examination
inappropriate happens to any body part. In young chil- A physical examination should be performed with a
dren, anatomically correct dolls may be substituted. They chaperone present to rule out acute and chronic illness
are best used in the hands of a trained interviewer. An and evidence of medical or dental neglect and physical
open-ended question about private parts is, “What abuse. The anal and female genital examinations are
would you do or say if something happened to a private accomplished best with good lighting, magnification,
part or if someone else asked you to do something to and the ability to photograph findings. On rare occa-
their private part?” If the child says, “I would say no,” the sions, sedation of the child with monitoring is necessary.
next question should be “Have you ever had to say no?” A colposcope, used in referral centers, accomplishes

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 psychosocial sexual abuse

the ampulla. The male genitalia

rarely are injured in sexual abuse
and may be injured nonintention-
ally by zippers and toilet seats. Ac-
cidental injury of the hymen is un-
usual.
Straddle injuries (Fig. 5) gener-
ally traumatize the perineum and
fourchette, and impact injuries gen-
erally injure the clitoris and other
tissue overlying the symphysis pu-
bis. The size and shape of the right,
left, and base walls of the hymen are
inspected. The hymen opening is
measured. The opening size varies
with the examination technique
and the age of the child. Although
sexual abuse may enlarge the open-
ing, the overlap in size with normal
findings prevents a larger-than-
normal opening from being diag-
nostic of sexual abuse. Thick labial
Figure 4. Normal and abnormal adolescent hymens. A. Normal adolescent hymen is adhesions have a variety of causes,
thickened due to hormone effect. Thickening may cause folds that can obscure opening including mechanical irritation. If
and trauma. B. Normal variant. C. Tear in base of hymen at 6 o’clock position. D. Tears in the lateral walls or the base are less
hymen at 4 and 6 o’clock positions. than 1 mm, this is referred to as
attenuated (Fig. 6) and of concern
these ends, but the practitioner may use other bright for possible penetration. Bumps and dents on the hymen
light sources, such as an inexpensive head-mounted light (Fig. 7A) and fenestrated hymens (Fig. 7B) are consid-
and a handheld magnifying glass. A digital camera with ered to be normal. A severely damaged hymen may heal
macro capabilities should record normal and abnormal completely. The finding of a normal hymen may be
findings adequately. Girls generally are examined in the reassuring to the parent but is not an indication that
frog leg position. The labia are grasped by an assistant’s abuse has not taken place. Any hymenal abnormality seen
gloved hands and pulled forward and laterally to reveal in the frog leg position should be confirmed by exami-
the hymen. If tabs obscure the hymen opening, saline is nation in the knee-chest position. Gravity may cause the
dropped into the vestibule to float the tabs. The
fourchette, urethra, and hymen walls should be ob-
served. Findings should be recorded on an anatomic
form (Fig. 3). In the older female, it may be necessary to
examine the hymen edge with a moistened cotton swab
(Fig. 4) or with a Foley catheter inserted through the
hymen opening that is inflated and pulled back against
the hymen wall to detect abnormalities. Bimanual and
speculum examinations are performed on adolescent fe-
males. A speculum is not used with preadolescent fe-
males. The speculum size should be as small as possible.
The anal examination is external. Particular attention
is paid to the opening size, presence of stool, symmetry of
folds, and signs of old or new tissue injury. Midline skin
tags are normal. The anus is considered to be dilated if Figure 5. Straddle injury resulting in tears in the right hymen
the opening is more than 2 cm and no stool is present in wall and fourchette (arrows). Hⴝhymen

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psychosocial sexual abuse

mydia and gonorrhea and testing for HIV, hepatitis B,

and syphilis are preferred. The diagnosis of herpes and
venereal warts can be clinical. Cultures may be obtained
for typing. This is especially valuable if the perpetrator
has active disease. Pregnancy testing and appropriate
pregnancy prevention treatment is recommended in girls
at risk for pregnancy.

Management
Reporting
A verbal report must be made immediately to children’s
services when abuse is suspected. This is followed within
24 to 48 hours by a detailed written report. This report
should include photographs and drawings of abnormal-
ities with measurements of the hymen (Fig. 3) and indi-
cation of examination position. The sagittal drawing of
the genitalia is used to demonstrate how the vestibule
Figure 6. Hymen attenuation (arrows). may be entered without penetrating the hymen. A de-
tailed report may prevent a court appearance by facilitat-
hymen to drop down, assisting in determining the pres- ing a plea bargain.
ence of suspected abnormality.
Rape kits are used to collect samples to detect seminal Therapy
fluid. Seminal fluid can be analyzed to identify a perpe- Venereal disease is treated according to guidelines from
trator. The presence of seminal fluid in the anus, vagina, the Red Book and a recent review by Leder and associates.
mouth, or on clothing is unusual, especially in young Venereal disease prophylaxis may be provided (Table 3).
children, and depends on ejaculation, use of a condom, A pregnancy test is performed when an adolescent victim
bathing, and washing of clothes. Seminal fluid, which is examined. Postcoital emergency contraception
may persist indefinitely on unwashed clothing, may not (levonorgestrel 0.75 mg) should be provided to all at-
be recovered from body orifices after 72 hours. The inner risk adolescent females and be repeated in 12 hours. All
thighs of males and females should be examined for signs victims should be referred for behavior treatment. Family
of bruising. therapy may be needed.

Laboratory Investigation Prognosis and Follow-up

Sexual abuse that occurs less than 72 hours before med- The child should be followed monthly to document
ical attention requires the use of a rape kit and a guaran- healing of any trauma and to assure that he or she is being
tee of a chain of evidence. If there has been contact with protected and that therapeutic interventions are being
the perpetrator’s genitalia or mouth, cultures for chla- followed. Shallow notches or clefts in the inferior rim of
the hymen may be recent tears and
heal over time. If the child must be
removed from the family, disrup-
tion of health care continuity
should be minimized. If possible,
the primary care physician should
be maintained. If this is not possi-
ble, every effort should be made to
transfer medical records to the new
clinician.

Prevention
Figure 7. Normal hymen variations. A. Normal bumps and dents on the hymen. B. Preventive efforts may not be effec-
Fenestrated hymen. tive if they focus on the ability of

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 psychosocial sexual abuse

Prophylaxis for Sexually

Table 3. Some Behavioral
Table 4.

Transmitted Diseases Consequences of Child Sexual

Neisseria gonorrhoeae Abuse
Children and adolescents: Ceftriaxone 125 mg IM in a Child
single dose*
• Anxiety
Chlamydia trachomatis • Behavioral or psychological problems
• Depression
Child <8 years: • Dissociation
Erythromycin 50 mg/kg per day divided into 4 doses • Distress
for 7 days (maximum dose, 500 mg qid) • Emotional problems
Child >8 years and adolescents: • HIV infection
• Homelessness, running away
Azithromycin 1 g PO in a single dose • Hopelessness
OR • Hostility
Doxycycline 100 mg PO bid for 7 days† • Neuroendocrine dysfunction
• Obsessive compulsive behavior
Trichomoniasis and bacterial vaginosis • Paranoid ideation
• Poor academic performance
Adolescents: Metronidazole 2 g PO in a single dose • Pregnancy in adolescence (trend)
Hepatitis B • Psychotic behavior (psychotiscism)
• Posttraumatic stress disorder
Fully vaccinated patient should not be revaccinated. • Sexualized behavior
If not vaccinated: Administer hepatitis B vaccine. • Somatic problems
• Substance abuse
HIV** • Suicide or suicide attempts
Zidovudine (AZT) 200 mg PO tid or 106 mg/m2 per Adult
dose tid for 4 weeks • Adjustment problems (males)
Plus lamivudine 150 mg per dose bid or 4 mg/kg per • Anxiety
dose bid for 4 weeks • Attachment disorder
OR • Binge eating by women
Combination of 300 mg AZT/150 mg lamivudine bid • Bipolar disease
• Children who are sexually abused (the abused
for adolescents person’s own children may be more likely to be
*Ceftriaxone prophylaxis for gonorrhea provides prophylaxis for incu- sexually abused or the abused person eventually may
bating syphilis. abuse children)
†
Doxycycline should not be given during pregnancy. • Chronic urinary retention
**Consider infectious disease consultation. Indications for prophylaxis • Coerced intercourse
are unclear. • Conversion disorder
Sources: Centers for Disease Control and Prevention. 1998 guidelines • Depression
for treatment of sexually transmitted diseases. Morbid Mortal Wkly Rep • Dissociation
MMWR. 1998;47(No. RR-1). • Divorce
American Academy of Pediatrics, Section on Child Abuse and Neglect. • Inadequate or excessive prenatal weight gain
Sexually transmitted disease in child victims of sexual abuse. Newsletter • Irritable bowel syndrome
of Section on Child Abuse and Neglect. 1999;11(3):3 • Less likely to have Pap smear
American Academy of Pediatrics. Sexually transmitted disease. In: • Marital conflict
Pickering LK, ed. 2000 Red Book. Report of the Committee on Infectious • Maternal functioning problems
Diseases. 25th ed. Elk Grove Village, Ill: American Academy of Pediat-
rics; 2000:664
• Medical symptoms
American Academy of Pediatrics. Antiretroviral therapy. In: Pickering
• Panic disorder
LK, ed. 2000 Red Book. Report of the Committee on Infectious Diseases. • Paternity in teen pregnancy
25th ed. Elk Grove Village, Ill: American Academy of Pediatrics; • Pedophilia
2000:679 – 682 • Pelvic pain
• Premenstrual distress
• Posttraumatic stress disorder
• Rape reports
• Sexual abuse offence
children to protect themselves from trusted and more • Sexual dysfunction
• Sexually transmitted disease, including HIV
powerful adults and adolescents. Parents and institutions • Substance abuse
that provide child care and education have a responsibil- • Suicide or suicide attempt
ity to screen all caregivers for a history of sexual abuse. Some studies were unable to distinguish the effects of physical abuse from
Teenage baby sitters may use the child care opportunity those of child sexual abuse due to their coexistence. Separating the comor-
bid effects of poverty, unemployment, alcohol and drug abuse, and other
to experiment with sex. A significant number of pedo- social problems from those of child sexual abuse may not be possible.
philes begin their activity as adolescents. Parents should

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psychosocial sexual abuse

teach children the proper names of all body parts. Chil- be due to trauma, infection, allergy, or irritants. Newly
dren should be encouraged to relate any uncomfortable acquired thumb sucking is a symptom of regression.
experiences to an adult who will listen and respond. School failure has many causes, but both symptoms may
A weekly family roundtable to discuss good and bad be one of the many responses to sexual abuse or the stress
experiences is valuable and minimizes the time from an of divorce. Her sexual acting out is a symptom that
inappropriate experience to revelation. Parents must appropriately led to an interview by the mother and
screen children’s television programs, magazines, and referral into the system. It would be appropriate to see
Internet access to assure healthy content. School pre- Mary for an examination and screening interview if the
vention programs should begin in preschool and pro- clinician is comfortable and skilled. If not, referral should
ceed through high school with age-appropriate con- be made to a specialty clinic that uses a multidisciplinary
tent. team.

Consequences
Sexual abuse results in a variety of acute and chronic
consequences in the child, and consequences may man- Suggested Reading
ifest in adulthood (Table 4). It is hoped that preventive American Academy of Pediatrics. Sexually transmitted disease. In:
Pickering LK, ed. Red Book: Report of the Committee on Infec-
efforts, early recognition and reporting, and prompt and
tious Diseases. 26th ed. Elk Grove Village, Ill: American Acad-
efficacious therapy can prevent or minimize these serious emy of Pediatrics; 2003:157–162
and debilitating consequences. American Academy of Pediatrics, Committee on Adolescence Sex-
ual Assault and the Adolescent. AAP pregnancy prevention
Case Study Denouement guidelines. Pediatrics. 1994;94:761–765
Mary, a child of divorce, is more likely to reveal sexual Budin LE, Johnson CF. Sex abuse prevention programs: offenders’
attitudes about their efficacy. Child Abuse Negl. 1989;13:77– 87
abuse when she is separated from an abuser. Divorce may Elliott M, Browne K, Kilcoyne J. Child sexual abuse prevention:
afford that opportunity. A counterclaim of coercion in- what offenders tell us. Child Abuse Negl. 1995;19:579 –594
tended to change custody may be made by the accused Johnson CF. Child sexual abuse. Lancet. 2004;364:462– 470
caretaker. Masturbation may be a normal behavior or a Leder MR, Emans SJ. Sexual abuse in the child and adolescent. In:
Emans SJ, Laufer MR, Goldstein DR, eds. Pediatric and Ado-
reaction to stress. The mother’s approach to manage-
lescent Gynecology. 5th ed. Philadelphia, Pa: Lippincott, Williams
ment of the behavior is appropriate. Mary’s dysuria may and Wilkins; 2005:939 –976
be due to a variety of causes, but is compatible with a Leder RL, Knight JR, Emans SJ. Sexual abuse: management strat-
history of symptoms after genital trauma. Erythema may egies and legal issues. Contemporary Pediatrics. 2001;18:77–92

26 Pediatrics in Review Vol.27 No.1 January 2006

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 psychosocial sexual abuse

PIR Quiz
Quiz also available online at www.pedsinreview.org.

5. Sexual abuse can be determined definitely only by a:

A. Court.
B. Pediatric health clinician.
C. Physician.
D. Sexual abuse team.
E. Trained investigator.

6. A distinguishing characteristic of the forensic interview of a child suspected of being sexually abused is
the absence of a:
A. Caretaker.
B. Law enforcement official.
C. Physician.
D. Psychologist.
E. Social worker.

7. Use of a rape kit is required if the medical evaluation takes place up to how many hours after the
suspected sexual abuse?
A. 12.
B. 24.
C. 48.
D. 72.
E. 96.

8. Sexual play typically is defined as viewing or touching genitalia, buttocks, or chest by normal
preadolescent children separated in age by no more than how many years?
A. 1.
B. 2.
C. 3.
D. 4.
E. 5.

9. Among the following, the most beneficial approach to beginning the sexual abuse evaluation of a young
or nonverbal victim is by:
A. Asking the child to draw pictures.
B. Detailing what will happen.
C. Explaining the rape kit.
D. Singing songs with happy themes.
E. Telling what is already known.

Pediatrics in Review Vol.27 No.1 January 2006 27

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 Sexual Abuse in Children
Charles Felzen Johnson
Pediatrics in Review 2006;27;17
DOI: 10.1542/pir.27-1-17

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1
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 Sexual Abuse in Children
Charles Felzen Johnson
Pediatrics in Review 2006;27;17
DOI: 10.1542/pir.27-1-17

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
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