Management of Childhood Sexual Assault
Children who have been sexually assaulted require immediate comprehensive care that prioritizes physical safety, medical treatment including STI prophylaxis and emergency contraception when indicated, and trauma-focused cognitive behavioral therapy (TF-CBT) as the first-line psychological intervention, with SSRIs reserved only for cases where psychotherapy alone is insufficient.
Immediate Assessment and Safety
Ensure the child's immediate physical safety and provide emotional support in a calm, private environment while treating any life-threatening or serious physical injuries first 1, 2.
Notify child protective services and law enforcement immediately, as mandatory reporting is legally required in all jurisdictions for child sexual abuse cases 1, 2.
Obtain consent from the parent/guardian (and assent from the child when appropriate) before proceeding with examination, while maintaining a trauma-informed approach 1.
Instruct the child not to change clothes, bathe, eat, drink, or use the bathroom until forensic examination is complete to preserve evidence 1, 2.
Medical Evaluation and Forensic Evidence Collection
Perform a thorough physical examination to assess for both genital and non-genital injuries, documenting all findings meticulously with diagrams and photographs when possible 1.
Collect forensic evidence according to local protocols, ideally with a Sexual Assault Nurse Examiner (SANE) or Sexual Assault Forensic Examiner (SAFE), as DNA evidence remains viable for at least 72 hours and potentially up to 4-7 days post-assault 1, 2.
Use high-resolution video colposcopy or equivalent imaging systems for real-time documentation of anogenital findings 2.
Most sexually assaulted children will have unremarkable anogenital examinations, so absence of physical findings does not rule out assault 1.
Collect specimens from all sites of reported contact (cervical/urethral, vaginal, anorectal, blood) for STI testing including gonorrhea, chlamydia, and trichomoniasis using nucleic acid amplification tests (NAATs) 1, 2.
Obtain baseline urine pregnancy testing and serologic screening for HIV, hepatitis B, and syphilis 2.
STI Prophylaxis and Immunizations
Administer empiric STI prophylaxis immediately, regardless of the child's age:
Ceftriaxone 125 mg intramuscularly for gonorrhea prophylaxis 1, 2
Metronidazole 2 g orally once for trichomoniasis and bacterial vaginosis 1, 2
Azithromycin 1 g orally once (preferred) OR doxycycline 100 mg twice daily for 7 days for chlamydia prophylaxis 1, 2
Initiate hepatitis B vaccination if not previously immunized 1, 2
Emergency Contraception and HIV Prophylaxis
Offer emergency contraception to any adolescent with possible vaginal penetration, regardless of menstrual cycle phase, as the risk of pregnancy is significant 2.
Assess risk factors for HIV post-exposure prophylaxis (PEP), including multiple perpetrators, HIV-positive perpetrator, high HIV prevalence area, or perpetrator with genital lesions 1.
Initiate HIV PEP within 72 hours if indicated, following CDC recommendations and consulting with a specialist in HIV treatment 3, 1, 2.
Psychological Support and Mental Health Management
Immediate Psychological Assessment
Screen immediately for suicidal ideation, homicidal ideation, and self-harm behaviors, as adolescents who experience sexual assault have markedly higher rates of depression, suicide attempts, and self-injurious behavior 2, 4.
Provide age-appropriate reassurance that the assault was not the child's fault 1, 2.
Address acute anxiety with grounding techniques in a calm environment before proceeding with invasive examinations 2.
First-Line Psychotherapy: Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
Trauma-focused psychotherapy, specifically TF-CBT, should be the primary treatment for PTSD and trauma-related symptoms, providing superior and more durable outcomes with 40-87% of patients no longer meeting PTSD criteria after 9-15 sessions 4.
TF-CBT is the evidence-based treatment specifically designed and validated for children and adolescents with sexual abuse histories 3, 4.
TF-CBT has been shown to be effective in multiple randomized controlled trials for sexually abused children, with sustained improvements at 6 and 12 months post-treatment 5, 6, 7, 8.
The TF-CBT model includes components summarized by the acronym PRACTICE: Psychoeducation, Parenting skills, Relaxation skills, Affective modulation skills, Cognitive coping skills, Trauma narrative and cognitive processing, In vivo mastery of trauma reminders, Conjoint child-parent sessions, and Enhancing safety 5.
Eight sessions of TF-CBT that include the trauma narrative component appear to be the most effective and efficient means of ameliorating abuse-related symptoms 6.
Alternative trauma-focused options include Eye Movement Desensitization and Reprocessing (EMDR), Prolonged Exposure, or Cognitive Processing Therapy, all showing equivalent efficacy 4.
Critical Pitfalls in Psychological Management
Do not delay trauma-focused treatment based on severity of symptoms, attachment disruption, or aggressive behavior—these factors do not predict worse outcomes or increased dropout 4.
Emotion regulation deficits and aggressive behavior improve directly through trauma-focused treatment without requiring separate stabilization interventions first 4.
Childhood sexual abuse history does not negatively affect treatment response or increase dropout rates in trauma-focused psychotherapy 4.
Role of Pharmacotherapy (SSRIs)
Psychotropic medications, including SSRIs such as fluoxetine, may be required in some instances when psychotherapy alone is insufficient 3.
Medication should be considered as an adjunct rather than first-line treatment, with trauma-focused psychotherapy remaining the primary intervention 4.
Assess treatment response after 8 weeks of psychotherapy; if symptom reduction is inadequate despite good adherence, consider switching trauma-focused modalities before adding medication 4.
Follow-Up Care
Schedule follow-up within 1-2 weeks of the initial presentation to assess injury healing, medication adherence, and the child's mental health functioning 3, 1, 2.
Repeat STI testing at 2 weeks if initial prophylaxis was not given or if the child has had consensual sexual activity since the assault 1, 2.
Repeat syphilis and HIV testing at 6 weeks, 3 months, and 6 months if initial results were negative and infection in the assailant could not be ruled out 3, 1, 2.
Ensure ongoing psychological support and counseling with mental health professionals experienced in childhood trauma 3, 1, 2.
Monitor for PTSD symptoms using standardized measures at regular intervals 4.
Continue to assess for suicidal ideation throughout treatment given the severity of trauma history 4.
Documentation and Legal Considerations
Document the history using the child's own words when possible, with precise anatomical terminology and avoiding value-laden language 1, 2.
Medical records will likely be subpoenaed for legal proceedings, so thorough documentation is essential 1, 2.
Secure the adolescent's consent before communicating with the primary care provider, respecting confidentiality laws while encouraging involvement of a trusted adult for support 3.
Common Pitfalls to Avoid
Failing to report suspected abuse to appropriate authorities 1
Inadequate documentation of physical findings 1
Delaying medical examination while waiting for police arrival—medical needs take absolute priority 2
Omitting STI prophylaxis due to young age 1
Neglecting the psychological impact and failing to arrange prompt mental health follow-up 1
Assuming that lack of physical findings means no assault occurred 1
Delaying trauma-focused psychotherapy in favor of "stabilization" interventions 4