Sexual abuse can take many forms and definitions vary by location. Common types of sexual offenses include rape, unlawful sexual intercourse with a minor, indecent assault, indecent exposure, indecency with children, incest, and certain homosexual acts. Sexual abuse has serious physical and psychological impacts on victims. Forensic evidence collection and treatment of any injuries or sexually transmitted infections is important. Ongoing counseling and support is also needed to help victims process the trauma over time.

1. SEXUAL ABUSE
(children & adults)
RAYYAN MKAHAL,MED 5
‫مكحل‬ ‫ريان‬

2. INTRODUCTION:
legal definitions of particular sexual offences will vary from country to country, the classification
of illegal sexual acts is relatively standard, even though the names of various offences may
differ.
Types of sexual offences-
1. Rape
 It is the most serious sexual assault.
 it can be committed by a biological male, but victim can be of either sex.
 It's a non-consensual penetration of vagina or anus by a penis or intercourse with a
sleeping individual under the effect of alcohol or drugs, or intercourse under a fear-force-
fraud consent.
 law applies to boys over age of 14 yrs because English law presumes that a boy under
that age is incapable of rape, this is medically untrue but can't be challenged in England
although it may be in Scotland
 Individuals with severe mental impairment under Mental Health Act of 1983 can't give
valid consent to sexual intercourse whatever their age.
2.Unlawful sexual intercourse
Below the age of 16 or 18 according to the country law, a girl can't give legal consent for
sexual intercourse; hence any act of intercourse is termed unlawful
3.Indecent assault
 It covers a wide spectrum of acts performed by members of either sex on victims of either
sex.
 These acts may range from a failed attempt at penile penetration of the vagina/anus to
actual penetration of the vagina /anus with a finger or an object, or penetration of mouth
by penis (forced fellatio), to touching of foundling of the buttock, breasts, thighs,
perineum, penis, or putting a hand up a woman's shirt or inside a man's trousers.
 Only the more serious penetrative forms of indecent assault are likely to have physical
medical aspects unless other injuries are caused as bruises, bite marks and abrasions .
 All these acts leave the victims psychologically traumatized.
4.indescent exposure
 when a person usually a male displays his genitals in public to the annoyance and
embracement of members.
 This is physically harmless to victim and may cause them psychological distress.
5.Indecency with children

3.  When men and women encourage a child to handle or masturbate the offender's
sexual organs.
 In England and Wales, a special law was passed in 1960 to make this behavior illegal
with a child below 14 yrs of age
6.Incest
 It is not universally considered to be a criminal offense; indeed, it was (and is) a socially
acceptable part of normal behavior in some cultures.
 the most common situation occurs when a father has sexual intercourse with his own
teenage daughter when his wife was in later stages of pregnancy or in puerperium.
 The extinct of this varies from country to country and even between religion and secular
codes in same country.
7.Homosexual offences
 In many countries, all sexual acts between men are illegal. In England and Wales , the
Sexual Offense Act(1967) allowed for homosexual acts in private between consenting
males over the age of 21 yrs, but with special exclusion of members of the armed forces
or merchant seamen.
Age of consent has now reduced to 18 yrs, and there is considerable pressure to reduce it
to 16 yrs to match heterosexual age of consent for females. In Scotland and Ireland, no
such act was introduced.
 Homosexual acts between females have never been a criminal offence unless they offend
against public decency.
SO, any sexual act performed on a person without his/ her consent is classified as sexual assault
the includes any unwanted genital, anal, or oral penetration by a part of the attacker's body or by
any object. Rape; on the other hand, is a violent attack that may or may not stem from the
perpetrator's sexual desire. Very often, the perpetrator uses sex as a mean of control over another
person . During any act or rape, the victim's predominant feelings is one of fear for her life or
fear of her mutilation.
Sexual assault in adults
women of all ages, ethnicities and socioeconomic groups can be victims of sexual assault;
although very young, the mentally and physically disabeled, and the elderly are more vulnerable.
Nearly 75% of assaults are perpetrated by someone known to the victim, such as
husbands(marital or partner rape), boyfriend(date rape), fathers(incest), mother's boyfriend and
other relatives, or work associates.
The American Medical Association reports that 20% of women younger than 21 yrs have been
sexually assaulted. 41% of women of all ages have been victims of actual or attempted sexual
assault and that 50% of these have been victims more than once.

4. Death occur in about 1% of sexual assaults( including rape) and serious injuries occur in 4%.
In Arab no specific statistics was reported.
Sexual Assault in Children
Approximately 25% of girls and 10% of boys in the USA will be sexually abused at the some
point during their childhood. Pediatricians may play a number of different roles, reporting to
CPS, testing for and treating STDs, and providing support and reassurance to children and
families. They also advice parents and children about ways to help keep safe from sexual abuse.
Sexual abuse may be defined as any sexual behavior toward a child that is unwanted or
exploitative. It's important to note that sexual abuse doesn't have to involve direct touching or
contact by the perpetrator. Showing pornography to a child in sexually explicit poses, and
encouraging or forcing one child to perform sex acts on another also contribute sexual abuse.
Diagnostic and Legal Aspect
In adults
Ideally, the examination needs to be performed as soon as possible after the incident, but this is
not always possible due to delayed reporting by the victim simple because the victim does not
feel able to be examined; thus medical consultation should be proceeded only after a supportive,
caring relationship has been established.
Examination of the victim must be performed in a suitable and well-equipped room, which may
now be a specially constructed suite at a police station or hospital or in a medical room at the
police station or in a hospital casualty department. wherever the examination is to be performed
,there must be guarantee of privacy for the individual who is to be examined, and adequate
lighting and other facilities for the doctor performing the examination.
Usually during the interview and examination phases, a chaperon or patient advocate should be
present.

5. It is imperative that informed consent is obtained and that the doctor explains the limit of
confidentiality of this examination. In particular, the doctor must explain that no absolute
guarantee of confidentiality can be given because he may be ordered by a court to disclose
anything that is said or seen during the course of the examination; this applies equally to the
victim and the accused. The individual must be aware that he or she can stop the examination at
anytime.
The victim will normally have been interviewed by the police or other legal officer to ascertain
the sequence of events and the acts that were committed. The doctor if necessary ask the victim
some additional questions in order to clarify particular aspects.
The adult/ adolescent woman should be actively involved in the consultation so that she may
regain a feeling of control over what has happened to her. The purpose of the consultation are
threefold: a-to provide hr acute medical care
b-to gather evidence
c-to transition her into the long-term care she will need for psychological recovery from
the extreme loss of control and great fear of death that nearly every rape victim suffers.
These objectives should be explained to her, and she should be allowed to dictate the pace of the
questioning and the order of examination.
Careful attention must be paid to the rules governing the chain to maintain the legal integrity and
utility of all the specimens, photos, and other materials collected. Information about her recent
menstrual history, use of medications, recent immunization, contraceptive use, and past medical
and surgical history is important.
The physical examination will commence with a general examination concentrating on evidence
of injury and disease, and all abnormalities should be noted and the injuries described and
measured. Samples of hair and fingernails, blood and urine should be obtained. The specific
anogenital examination will depend on each individual case.
A thorough physical examination is needed is evaluate possible injuries because 40% of all
women who are sexually assaulted sustain injuries. I possible photographs or sketches should be
obtained of the injured areas. CDC recommended routine testing :
 gonorrhea and chlamydia from specimens collected from any site of penetration or
attempted penetration
 Wet mount and culture for trichomonas are routine
 microscopic evaluation for bacterial vaginosis and candidiasis is prudent in a woman with
a vaginal discharge.
 Serum testing for HIV, hepatitis A and syphilis are needed for baseline evaluation.

6. Positive HIV status can be another clue to identify victims of abuse.
Examination of anus,
after examining for acquired and congenital abnormalities and diseases, swabs should be taken
from the perianal region, the anal canal and the lower rectum and foreign material, including
lubricant, condoms or other objects, should be swabbed or recovered. The anus and the anal
canal and the rectum should then be inspected for injury, using a proctoscope if this will be
tolerated by the individual. Damage to the anal mucosa may be referred to by a number of
different names, including fissures, tears or lacerations. It is important to remember that damage
to the anus may be the result of factors other than direct trauma.
In children
For some children, behavioral changes are the first indication that something went wrong. Non-
specific behavior changes such as social withdrawal, acting out, increased clinginess or
fearfulness, distractibility, and learning difficulties may be attributed to a variety of life changes
or stressors. Regression in developmental milestones, including new-onset bed wetting or
encopresis, is another behavior that caregivers may overlook as an indicator of sexual abuse.
Teenagers may respond by becoming depressed, experimenting with drugs or alcohol, or running
away from home. Because nonspecific symptoms are very common among children who have
been sexually abused, it should nearly always be included in one's differential diagnosis of child
behavior changes.
Some children may not exhibit behavioral changes or provide any other indication that
something is wrong. For these children, sexual abuse may be discovered when another person
witnesses the abuse or discovers evidence such as sexually explicit photographs or videos.
Pregnancy may be another way that sexual abuse is identified. There are also children, some with
and others without symptoms, that will not be identified at any point during their childhood.
Before determining where and how a child with suspected sexual abuse is evaluated, it is
important to assess for and rule out any medical problems that can be confused with abuse. A

7. number of genital findings may raise concern about abuse but often have non-abusive
explanations. For example, genital redness in a prepubertal child is more often caused by non-
specific vulvovaginitis, eczema, or infection with staphylococcus, group A streptococcus,
hemophilus, neisseria or yeast. Vaginal bleeding can be caused by uretheral prolapse, vaginal
foreign body, accidental trauma, and vaginal tumor.
When other medical conditions are not under consideration, have been ruled out, or less likely
than abuse, the triage process for suspected sexual abuse should be activated.
For the prepubertal child, if abuse has occurred in the previous 72 hrs, forensic evidence
collection (e.g. , external genital, vaginal, anal, and oral swabs, sometimes referred to as "rape
kit") is often indicated. If the last incident of abuse occurred more than 72 hrs prior, the
likelihood of recovering forensic is extremely low, and forensic collection is not necessary.
For postpubertal females, many experts recommended forensic evidence collection up to 120hrs
following the abuse-the same limit as for adult women.
Children with suspected sexual abuse may present to the pediatrician's office with a clear
disclosure of abuse or more subtle indicators. In this situation, a private conservation between
pediatrician and child can provide an opportunity for the child to speak his or her own words
without parent speaking for him or her. Doing this may be especially important when the
caregiver doesn't believe the child, or unwilling or unable to offer emotional support and
protection.
When speaking with the child, experts recommended establishing rapport by starting with
general and open-ended questions:"Can u tell me more about what happened ?" that will allow
the child to clarify in his or her words. It is not necessary to obtain extensive information about
what happened because the child will usually have a forensic interview once a report is made to
CPS and an investigation begins. In very young children, caregiver's history is reported to CPS.
Many children do not disclose abuse until days, weeks, months, or even years after the abuse has
occurred. Because genital injuries heal rapidly, injuries are often completely healed by the time a

8. child presents for medical evaluation. A normal genital exam doesn't rule out the possibility of
abuse, and should not influence the decision to report to CPS.
Few findings on the genital examination are diagnostic for physical abuse. In the acute time
frame, lacerations or bruising of the labia, penis, scrotum, perianal tissues, or perineum are
indicative of trauma. Likewise, hymenal bruising and lacerations, and perianal lacerations
extending deep to the external anal sphincter indicate penetrating trauma. Severe nonacute
findings are also concerning for sexual abuse. A complete transection of the hymen to the base
between the 4 and 8 o'clock positions is considered diagnostic for trauma. For all these findings,
the cause of injury must be elucidated through the child and the caregiver history. If there is any
concern that the finding may be the result of sexual abuse, CPS should be notified and a medical
evaluation should be performed by an experienced child abuse pediatrician.
Testing for sexually transmitted infections is not indicative for all children, but is warranted in
the situations listed in table below:
Culture is still considered the gold standard for diagnosis of gonorrhea, and chlamydia in
children. Because obtaining vaginal swabs can be uncomfortable for prepubertal children, a urine
specimen for nucleic acid amplification testing(NAAT) can be collected for screening. However,
if only NAAT testing is done, the child should not receive presumptive treatment at the time of
testing. Instead, a NAAT test should be confirmed by culture prior to treatment.
A number of sexually transmitted infections should raise concern for abuse:

9. Management
CDC does not recommend prophylaxis for STDs in asymptomatic prepubertal children who are
evaluated for possible child sexual abuse. In contrast, the CDC recommends that teenaged
patients and adults who are sexually abused or assaulted should receive antibiotic prophylaxis for
STDs
In children
 Treat STDs with appropriate medications based on the infection and the child's age and weight.
 In postmenarcheal children, consider the possibility of pregnancy.
 Recognize the overriding need for emotional support and attention to the psychosocial crisis in
which the child and family now find themselves.
In adults
Prophylaxis is suggested as preventive therapy. This includes hepatitis B vaccination(if
previously unvaccinated), and appropriate antibiotics for sexually transmitted infection. It is
critical to provide any woman at risk for pregnancy with emergency contraception. If
prophylaxis for HIV is considered necessary, consultation with an HIV specialist is
recommended. Tetanus toxoid should be administered to an unprotected, injured woman.
Psychological Sequelae of Sexual Assault
Sexual assault is almost always associated with both immediate and long term effects on
victims. These effects have been termed the rape trauma syndrome and involve the following
two phases:
1.Acute and disorganization phase: This phase lasts days to weeks. Immediately after the
experience, victims frequently appear calm, although preoccupied and inattentive. Among those

10. expected in the acute phase of adjustment are irritability, tension, anxiety, depression, fatigue,
and persistent ruminations. Somatic symptoms of a general nature may occur, such as
headaches and persistent bowel syndrome, or symptoms may be more specific to the
reproductive system, such as vaginal irritation or discharge. Behavioral problems, such as
overeating and alcohol or substance abuse have been evident in the past. Long term sequelae
include changes in lifestyle, the occurrence of disturbing dreams and nightmares, and the
persistence of phobic reactions. Fear persists as the predominant feeling.
2.Integration and resolution phase: During this phase, victims begin to accept the assault, but
problems at work or with relationships may persist. The management of the sexual assault
victim in the acute phase influences long term adjustment.50% of rape victims may manifest
posttraumatic stress disorder.
Long term reactions involve nightmares phobic reactions, and sexual fears. Flashbacks may also
occur during pelvic examination. Loss of libido is a common response to stressful or traumatic
circumstances of any kind. Other complains include vaginismus, impaired vaginal lubrication,
and loss of orgasmic capacity. Giving permission for a lower than usual sexual drive during the
period following the assault may remove some performance anxiety. Explaining how anxiety
and stress can inhibit sexual responsiveness and providing ways in which this can be overcome
are also important.
Finally, careful follow-up must be arranged.

11. References
 Essentials of Obstetrics and Gynecology
 Nelson Textbook of Pediatrics
 Simpson's Forensic Medicine
 Medscape