Paeds · child-safety-and-social-paediatrics
Child sexual abuse and assault assessment
Also known as Child sexual abuse assessment · Child sexual assault medical examination · Anogenital examination for suspected abuse · Forensic paediatric examination after sexual assault · CSA medical evaluation
A fellowship approach to the medical assessment of a child or adolescent who may have been sexually abused or assaulted: deciding the tempo from acute to non-acute, conducting the trauma-informed forensic history and ano-genital examination, interpreting normal and abnormal findings against the Adams consensus, ordering the right investigations within the correct time windows, assembling the acute management bundle, and discharging the safeguarding, reporting and follow-up duties.
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Target exams
Red flags
- Acute genital bleeding, deep laceration or visceral injury after a disclosed assault — examine urgently and resuscitate first
- A disclosure followed by immediate retraction under family pressure — retraction does not exclude abuse
- Prepubertal child with a sexually transmitted infection in whom vertical and fomite transmission have been excluded
- Acute presentation within the 72-hour forensic window where the evidence kit is being missed or delayed
- An adolescent who discloses assault but is being denied privacy by a controlling accompanying adult
- Suspected abuse in a non-verbal or disabled child who cannot give a history
- Family refusal of examination or removal of the child from care after disclosure
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Child safety and maltreatment
- Current 2026 PREP curriculum — Learning Objective 2.3.1: Recognise and manage child abuse and neglect
- Current 2026 PREP curriculum — Learning Objective 2.3.2: Work effectively with child protection and interagency services
- Renewed curriculum for first-year trainees from 2027 — Learning goal 4: Safeguarding and child protection
- Emergency Medicine
- Clinical Applications — child protection and safeguarding
- Long Cases
- Short Cases
- Communication stations
- 2. Professional skills and knowledge: Safeguarding
- 9. Child protection and safeguarding
- 11. Adolescent health
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- Safeguarding and child protection
- History
- Communication
- Clinical
- Development
- General Pediatrics Content Outline — Domain 8: Child Abuse and Neglect
- General Pediatrics EPA 8: Evaluate suspected child maltreatment
- Adolescent Medicine and Gynecology
- Patient Care 1: History and Physical Examination
- Patient Care 5: Patient Management
- Systems-Based Practice 2: Advocate for patients and populations
- Professionalism 1: Professional Behavior and Ethical Principles
- Advocate
- Professional
- Collaborator
- Pediatrics: Foundations EPA — Assessing suspected child maltreatment
Overview & Definition
A seven-year-old is brought to the emergency department at midnight after disclosing that her mother's partner touched her genitals. The triage nurse asks you what happens next. Your job is not to decide in this moment whether abuse occurred. Your job is to run a safe, staged assessment that protects the child, preserves any evidence that is time-limited, treats what can be treated, and hands the diagnosis to the child-protection and police systems that are built to weigh it. [1] [2]
Child sexual abuse is the involvement of a child in sexual activity that they cannot consent to, cannot understand, or cannot refuse, and that violates the laws or social taboos of the society. The medical assessment is one piece of a multi-agency response, and it answers four questions: is the child medically safe now, what examination and investigation are indicated today, what must be preserved before the forensic window closes, and what safety, reporting and follow-up follow from that. [1]
The single most important idea to hold throughout — and the one examiners probe hardest — is that the physical examination is usually normal. In Adams' landmark study of legally confirmed abuse, the majority of children had normal or nonspecific findings, because hymenal tissue heals rapidly and most contact is non-penetrative or delayed before examination. A normal exam therefore never rules out abuse. The history, taken once and well by a trained forensic interviewer, almost always carries more diagnostic weight than the genital findings. [3]
References14ShowHide
- [1]Adams JA, Kellogg ND, Farst KJ, Harper NS, Palusci VJ, Frasier LD Updated Guidelines for the Medical Assessment and Care of Children Who May Have Been Sexually Abused. Journal of Pediatric and Adolescent Gynecology, 2016.PMID 26220352
- [2]Adams JA Medical evaluation of suspected child sexual abuse: 2011 update. Journal of Child Sexual Abuse, 2011.PMID 21970647
- [3]Adams JA, Harper K, Knudson S, Revilla J Examination findings in legally confirmed child sexual abuse: it's normal to be normal. Pediatrics, 1994.PMID 8065856
- [4]Berenson AB, Heger AH, Hayes JM, Bailey RK, Emans SJ Appearance of the hymen in prepubertal girls. Pediatrics, 1992.PMID 1741209
- [5]Berenson AB Appearance of the hymen at birth and one year of age: a longitudinal study. Pediatrics, 1993.PMID 8464674
- [6]Berenson AB A longitudinal study of hymenal morphology in the first 3 years of life. Pediatrics, 1995.PMID 7700746
- [7]Heger AH, Ticson L, Guerra L, et al. Appearance of the genitalia in girls selected for nonabuse: review of hymenal morphology and nonspecific findings. Journal of Pediatric and Adolescent Gynecology, 2002.PMID 11888807
- [8]Heger A, Ticson L, Velasquez O, Bernier R Children referred for possible sexual abuse: medical findings in 2384 children. Child Abuse & Neglect, 2002.PMID 12201160
- [9]Lamb ME, Orbach Y, Hershkowitz I, Esplin PW, Horowitz D A structured forensic interview protocol improves the quality and informativeness of investigative interviews with children: a review of research using the NICHD Investigative Interview Protocol. Child Abuse & Neglect, 2007.PMID 18023872
- [10]Stoltenborgh M, van Ijzendoorn MH, Euser EM, Bakermans-Kranenburg MJ A global perspective on child sexual abuse: meta-analysis of prevalence around the world. Child Maltreatment, 2011.PMID 21511741
- [11]Barth J, Bermetz L, Heim E, Trelle S, Tonia T The current prevalence of child sexual abuse worldwide: a systematic review and meta-analysis. International Journal of Public Health, 2013.PMID 23178922
- [12]Workowski KA, Bachmann LH, Chan PA Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recommendations and Reports, 2021.PMID 34292926
- [13]Gavril AR, Kellogg ND, Nair P Value of follow-up examinations of children and adolescents evaluated for sexual abuse and assault. Pediatrics, 2012.PMID 22291113
- [14]Norman RE, Byambaa M, De R, Butchart A, Scott J, Vos T The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis. PLoS Medicine, 2012.PMID 23209385