Sexual Abuse

Sexual abuse and assault are major public health problems that affect many people from all walks of life, including people of all ages and genders, but it is more prevalent in women and girls, with reports of up to 1 in 3 experiencing sexual assault at some time in their life. In addition to psychological consequences, sexual assault can result in unintended pregnancy, STIs, and physical injury. Management includes proper examination, testing, reporting, and psychological support.

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Overview

Definitions

  • Intimate partner violence is a pattern of assaultive and coercive behavior that may include physical injury, psychological abuse, reproductive coercion, and/or sexual assault.
  • Sexual assault is a crime of violence and aggression defined as attempted sexual touching of another person without their consent.
  • Sexual abuse of children is defined as sexual activity for which a child cannot give consent, is unprepared for developmentally, or cannot comprehend, including noncontact abuse.

Epidemiology

  • Affects all communities:
    • All genders
    • All ages
    • All sexual orientations
    • Children from all social, cultural, and economic backgrounds
  • Incidence is much higher in girls and women than in boys and men.
  • Prevalence is difficult to document accurately.
    • Worldwide estimate: 5%–25% of girls and 5%–9% of boys have been exposed to some type of sexual abuse.
    • Often unreported because of:
      • Fear of medical evaluation
      • Shame and embarrassment
      • Privacy concerns
  • Approximately 1 in 3 women have experienced sexual assault during their lifetime.
    • Approximately 1 in 5 women have experienced completed or attempted rape.
    • 33% state that the assault occurred before age 17 years and 12% before age 10 years.
    • 5% of girls who have been sexually assaulted have a STI.
    • Prevalence during pregnancy is approximately 8%. 
  • Approximately 1 in 4 men have experienced sexual violence involving physical contact.
    • Approximately 1 in 38 men have experienced completed or attempted rape.
    • 25% state that the assault occurred before age 17 and 25% before age 10.
  • Perpetrators (according to the Rape, Abuse & Incest National Network):
    • Intimate partner: 33%
    • Acquaintance: 39%
    • Family member: 2.5%
    • Stranger: 19.5% 
  • Special populations at increased risk:
    • Developmentally delayed children
    • Elderly patients with cognitive decline
    • Patients institutionalized with mental health disorders
    • Sexual and gender minority adolescents (gay, lesbian, bisexual, and transgender)

Classification

  • Sexual abuse includes:
    • Sexual intercourse (rape)
    • Sodomy (oral–genital or anal–genital contact)
    • Nonpenetrating sexual contact (fondling)
  • Acquaintance rape/date rape: sexual assault committed by someone known to the victim
  • Statutory rape: consensual sexual intercourse with an individual younger than a specific legal age

Clinical Presentation and Diagnosis

The patient should be approached in a nonjudgmental and respectful manner. In addition to psychological consequences, sexual assault can be associated with unintended pregnancy, STIs, and physical injury.

History

  • Reluctance to talk is common.
  • Children may present with behavioral changes (e.g., imitating sexual acts).
  • Document the location, timing, duration, and type of force.
  • Document other injuries or forms of abuse (e.g., physical abuse).
  • Assess current safety and the presence of an emergency plan.
  • Assess for suicidal ideation.

Physical examination

  • Children may or may not have signs of abuse on physical exam.
  • Vulvovaginitis in girls should elicit consideration for an evaluation of sexual abuse. 
  • May need photos for legal proceedings
  • Anoscopy and colposcopy may be useful for visualizing injuries.
  • Document findings:
    • Hymen trauma or scarring
    • Healed genital injuries (e.g., skin tags or granulation tissue)
    • Ecchymoses
    • Abrasions
    • Vaginal or anal tears
    • Signs of STIs, such as vesicles or condylomatous lesions

Management

Patients who present with a report of sexual assault or abuse need proper examination, testing, and psychological support.

  • Forensic evidence collection (rape kit) should be done within 72 hours.
    • May be falsely positive if delayed
    • Should always be done if there is bleeding or acute injury
    • Specimens obtained for DNA analysis
  • Report to police
  • Offer emergency contraception, if indicated.
  • Consider prophylactic STI treatment.
  • Recommended lab tests:
    • Chlamydia testing of the vagina and anus
    • Gonorrhea testing of the pharynx, vagina, and anus
    • Viral testing of lesions suspicious for herpes simplex
    • Trichomonas and bacterial vaginosis testing
    • HIV serology
    • Hepatitis B and C
    • Syphilis testing (rapid plasma reagin test)
  • Evaluate psychosocial support system and refer as needed.
  • Survivors of sexual abuse may need lifelong mental health care for: 
    • Substance abuse
    • PTSD
    • Major depressive disorder 
    • Suicidality
    • Distorted self-perception
    • Panic disorder

References

  1. Bechtel, K., Bennett, B.L. (2021). Evaluation of sexual abuse in children and adolescents. UpToDate. Retrieved June 7, 2021, from https://www.uptodate.com/contents/evaluation-of-sexual-abuse-in-children-and-adolescents
  2. Sexual Assault Awareness. (2021). Centers for Disease Control and Prevention, Retrieved June 7, 2021, from https://www.cdc.gov/violenceprevention/sexualviolence/index.html
  3. Miller, E., Wiemann, C.M. (2020). Adolescent relationship abuse including physical and sexual teen dating violence. UpToDate. Retrieved June 7, 2021, from https://www.uptodate.com/contents/adolescent-relationship-abuse-including-physical-and-sexual-teen-dating-violence
  4. Rape, Abuse & Incest National Network (n.d.). Perpetrators of sexual violence: Statistics. Retrieved June 10, 2021, from https://www.rainn.org/statistics/perpetrators-sexual-violence
  5. Sackey, M., Murphy-Lavoie, H. (2018). Sexual assault. In Schlamovitz, G.Z. (Ed.), Medscape. Retrieved June 10, 2021, from https://emedicine.medscape.com/article/806120-overview

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