Introduction

Assessment of child sexual assault (CSA) requires a dedicated, well-trained and experienced doctor who is able to spend a significant amount of time making an unhurried and thorough assessment and detailed documentation of history and examination findings. The doctor must have an accurate knowledge of genital anatomy, and experience in performing gynaecological examinations. Skills and experience in this field are developed through postgraduate studies, significant case numbers, a knowledge of current literature and involvement in peer-review practices.³

Inexpert assessment of such cases may have a profound negative influence on the child and family. It may potentially lead to inappropriate removal of the child from the family or wrongful imprisonment.⁴

The roles of the emergency physician in this process are:

In the majority of cases, determination of whether or not sexual assault has occurred is not possible within the emergency department (ED). In the majority of cases, physical examination will neither confirm nor refute an allegation of sexual assault. The most important indicator of possible CSA is disclosure by the child.

Definitions

CSA is the use of a child for sexual gratification by an adult or significantly older child/adolescent.⁵ It may involve a range of activities that vary from exposing the child to sexually explicit materials to anal or vaginal penetration of the child. Central to the definition is the limitation of the child to provide truly informed consent for sexual activity with adults.

Sexual play between children of similar age does not fit into this description.

The term ‘assault’ is preferred over ‘abuse’ as it highlights the criminal nature of the activity and avoids minimisation of such abusive acts.

Attitudes/myths surrounding CSA

The subject of CSA is an emotive one. Emergency physicians will often have strongly held opinions and attitudes on this subject. These attitudes may be shaped by past experience and/or social taboos. In order to approach CSA in a calm, non-judgemental and objective manner it is important that emergency physicians are cognisant of their own opinions and emotional responses. In dealing with victims of CSA, expressions of anger, sadness or surprise are not helpful and potentially stigmatising and harmful to the child. With emergency physicians infrequently encountering CSA, it is useful to reflect on the following, sometimes poorly understood, statements.

Epidemiology of CSA

There has been a significant increase in the recognition of CSA,^3,11,12 which has been reflected by a substantial increase in the number of reports made to child protection services across Australia and overseas, particularly in the last 5 years.

Sexual assault has been documented as occurring on children of all ages and both sexes, and is committed predominantly by men, who are commonly members of the child’s family, family friends or other trusted adults in positions of authority.¹¹

Sexual abuse by family members or acquaintances usually involves multiple episodes over periods ranging from a week to years.

Victims of unknown assailants tend to be older than children who are sexually abused by someone they know and are usually only subjected to a single episode of abuse.

The estimated proportion of children exposed to some form of sexual assault varies depending on the definition of sexual abuse and methodology used. In the United States, literature surveys provide estimates of 9–52% for females and 3–10% for males.⁶