Key points

Introduction

Child sexual abuse is a worldwide public health issue with significant long-lasting negative effects on the physical and mental health of children and their caregivers. According to Child Maltreatment 2022, 10.6% of child maltreatment cases that were substantiated by child protective services nationally were for child sexual abuse. The Centers for Disease Control (CDC) reports that 1 in 4 girls and 1 in 20 boys are victims of child sexual abuse. The World Health Organization reports similar statistics.

Child sexual abuse is defined as involvement of a child or an adolescent (<18 years old) in sexual activity that he or she does not fully comprehend and is unable to give informed consent to, or for which the child or adolescent is not developmentally prepared and cannot give consent, or that violates the laws or social taboos of society. It involves sexual gratification and/or satisfaction to the offender. It may also include coercion and exploitation (eg, sexual solicitation in reality and/or on media platforms).

Typically, we think of child sexual abuse involving contact with the child; however, child sexual abuse can also involve incidents of noncontact. Types of noncontact abuse include threats of sexual abuse, verbal sexual harassment, sexual solicitation, indecent exposure, or exposing the child to sexual materials. Contact sexual abuse can be nonpenetrative acts (touching, fondling, masturbation) or penetrative acts (penetration of the vagina, mouth, or anus).

Given the legal concerns that accompany child sexual abuse, it is important to understand the difference between nonconsensual and consensual sexual activity. All pediatric clinicians should be familiar with their state laws regarding the age of legal consent and the presence of so-called “Romeo & Juliet” clauses. These clauses are built into many states’ statutory rape laws to address consensual sexual contact between adolescents of similar ages who are all under the age of legal consent. Regardless, pediatric clinicians should always report all nonconsensual or abusive sexual activity. All pediatric clinicians are mandated reporters and are required to report any suspected and known cases of child maltreatment, including child sexual abuse.

Risk factors

A recent meta-analysis showed several child and childcare system factors that increase the risk for child sexual abuse. The largest effect sizes were seen for prior sexual abuse victimization of the child and/or siblings, prior/current nonsexual abuse (eg, physical abuse, psychological abuse) in the home, nonnuclear family structure, parental psychiatric or physical problems, parental substance abuse, female child, child with chronic physical or mental conditions, problems in family systems functioning, parental history of child abuse victimization, low family socioeconomic status, and low parental education. It is important to acknowledge that even though these factors have strong associations with children being victims of sexual abuse, any child can be a victim of child sexual abuse.

Approximately 90% of offenders of child sexual abuse are known and/or trusted by the child. Despite data showing various risk factors associated with being an offender of child sexual abuse, it is important to understand that there is no one standard offender profile. Offenders come from diverse socioeconomic, ethnic, and educational backgrounds. They may or may not have a personal history of sexual abuse or other types of adverse childhood experiences.

Presentation

Children who have been sexually abused present for medical evaluation with a variety of chief complaints: (1) child discloses sexual abuse; (2) child has concerning behaviors; (3) there was a witnessed incident of child sexual abuse; and (4) child has symptoms concerning sexually transmitted infections such as dysuria, genital itching, and genital rash. Children can present with caregivers, child protective services, or law enforcement. The components of the medical evaluation will depend on presenting symptoms/concern and the acuity of the incident. Whether an incident is deemed an emergent or non-emergent case is typically based on the laws and practices in each locale which determines when forensic evidence can be collected. Pediatric clinicians should learn the referral process for both acute (emergent cases) and non-acute (non-emergent cases) medical evaluations.

Disclosure

The diagnosis of child sexual abuse relies primarily on the child’s disclosure. Objective findings on physical examination or laboratory tests rarely contribute to the diagnosis of child sexual abuse. A child’s disclosure of sexual abuse can be purposeful or accidental. A purposeful disclosure is when a child makes a conscious decision to make someone aware of the event(s). Accidental disclosure is when a child spontaneously discloses after a triggering event or when others become aware of the abuse unintentionally (eg, witnessing or reading about abuse in a personal journal).

Disclosure is a process that unfolds overtime in different circumstances and not as a singular event. A disclosure can involve multiple stages. These stages may include (1) denial, in which a child might indicate abuse did not occur despite the event being witnessed or diagnosis of a sexually transmitted infection; (2) partial disclosure, in which a child gives a tentative/incomplete account of what occurred; (3) full disclosure, in which a child gives a full account of the abuse; (4) recantation or retraction in which a child withdraws some or all of their disclosure; and (5) reaffirmation or reassertion of their disclosure. Reasons for recantation include pressure from the offender, pressure from caregivers, fear of “getting into trouble” or negative personal consequences, knowledge that their disclosure is videotaped, and involvement of authorities such as child protective services and/or law enforcement. A child may experience one, some, or all the stages of disclosure and can move between these stages at any time throughout the process.

Several studies have examined the timing of child sexual abuse disclosures. One study showed that approximately 30% of children and adolescents disclose immediately after the abusive event(s), 30% delayed their disclosure up to 5 years from the initial onset of the abusive event(s), and 30% disclosed as an older child or an adult. Another showed that a child’s environment affects the timing of disclosures of sexual abuse. These include the stability of family relationships, having a protective caregiver, child’s gender, feelings of culpability, societal and cultural norms, the relationship between the child and the offender, and the response of the person the child discloses to. Kellogg and colleagues showed that child factors such as young age (<11 years) at abuse onset and fear of consequences to self were common reasons for delayed disclosures in both preadolescent and adolescent children. Self-blame, severity of abuse, and an adult offender were associated with delayed disclosure in preadolescent girls only. Landberg and colleagues noted that it was more common for girls to disclose sexual abuse than boys: 68.3% and 36.8%, respectively. This study also showed both boys and girls disclosed sexual abuse to someone in their age group more often than to an adult.

Child sexual behaviors/genital-focused behaviors

Child sexual behaviors or genital-focused behaviors in children are common, occurring in 42% to 73% of children by the age of 13 years. ^, These behaviors range from normal or developmentally expected to problematic, abusive, and violent. Many caregivers perceive child sexual behaviors as concerning for child sexual abuse even if they are developmentally expected. Sexual behaviors are part of normal childhood development. The motivation for these behaviors includes but is not limited to curiosity, anxiety, imitation, attention-seeking, or self-soothing. These behaviors can be prompted or modified by factors such as caregiver’s reaction to the behavior, caregiver’s perception of sexuality, environment (home vs school/daycare), family stressors, social/cultural norms, and access to sexual materials and/or acts (family nudity, television, social media, and the Internet).

The type and frequency of genital-focused behaviors vary with the age of the child. Sexual behaviors can occur as a solo act or involve other persons. Prior to the age of 2 years, sexual behavior is rare other than hand-to-genital contact as children become aware of their body parts. Between the ages of 2 and 5 years, common developmentally expected sexual behaviors include touching genitals at home and/or public, touching mother’s breast, trying to look at persons when they are nude, or standing/sitting too close to other persons. Between the ages of 6 and 9 years, common normal sexual behaviors include the behaviors listed for ages 2 to 5 years with the addition of increasing interest in sexual topics and exploring different gender roles. Self-touching of genitals occurs mostly at home or in isolation. Between the ages of 10 and 12 years, common developmentally expected sexual behaviors include the behaviors listed for ages 6 to 9 years with the addition of further exploration of same/other sex romantic relationships, gender roles, and behaviors, increasing interest in sexual topics with more explicit discussion with others, and increasing interest in viewing nudity using various accessible media.

Sexual behaviors occur on a spectrum where behaviors range from developmentally expected genital-focused behaviors to problematic sexual behaviors (PSBs). Common, normal, age-appropriate sexual behavior can become problematic if they are disruptive and coercive and not easily redirected. PSBs typically involve (1) any sexual behavior that involves children who are aged more 4 years apart; (2) a variety of sexual behaviors displayed on a daily basis; (3) sexual behavior that results in emotional distress or physical pain in at least one child; (4) a child coercing or threatening another child into participation; (5) sexual behaviors that are persistent, are resistant to caregiver redirection, and cause a child to become angry if distracted from the sexual behavior; (6) sexual behavior displaying explicit repetitive acts such as actual penetration of the genitals/anus or oral-to-genital contact; and (7) a child asking an adult to perform a sexual act. These behaviors warrant additional evaluation and referral to child protective services if abuse or neglect is suspected.

Current research on sexual behaviors in children shows that most children with PSBs have not been sexually abused. These behaviors have a stronger association with other emotional and behavioral disorders in childhood such as conduct disorder, attention-deficit hyperactivity disorder, or oppositional defiant disorder as well as with other forms of child maltreatment such as emotional and physical abuse. ^,

Physical examination

If child sexual abuse is suspected, a thorough head-to-toe physical examination including an anogenital examination should be performed to assess for current and/or past injuries as well as to reassure the child and caregiver that their body is healthy. A pediatric clinician with education and experience on how to conduct these examinations should perform the medical evaluation. The examination should be child focused to minimize re-traumatization. The purpose of the steps of the examination should be explained to both the child and caregiver, and they should be given opportunities to ask questions throughout the entire process. A chaperone in the examination room is recommended.

During the head-to-toe examination for suspected child sexual abuse, it is important to identify nongenital findings that could have occurred during the abusive event or that could indicate other medical problems. Nongenital findings related to child sexual abuse include suction ecchymoses (“hickeys”), grab marks, palatal petechiae, strangulation injuries, and tattoos/brands. Supplemental lighting and magnification should be used to optimize visualization of all details on the examination. Photo documentation should be performed during child sexual abuse evaluations. Photo documentation allows for a robust peer-review process and decreases the need for additional examinations. Familiarity with anogenital anatomy, sexual maturity rating, and the descriptive terminology is important for all pediatric clinicians but especially so for those conducting medical evaluations due to concerns for child sexual abuse. The term “normal” is insufficient as it does not consider that genitalia have many components and the appearance of “normal” varies from child to child and by age. During child sexual abuse evaluations for children and adolescents, visualization past the hymen or use of a speculum is rarely necessary unless there is an acute injury that cannot be visualized. In those cases, a specialty consult with general surgery or gynecology is needed. Depending on the age and comfort of the child, an examination with anesthesia may be warranted.

Suspected victims of child sexual abuse should be offered a complete examination and comprehensive testing for sexually transmitted infection regardless of the forensic utility. Per the American Academy of Pediatrics’ Council on Child Abuse and Neglect (AAP COCAN) and the CDC, considerations for testing for sexually transmitted infection in preadolescent children include situations where (1) a child experienced penetration of the genitals, anus, or oropharynx; (2) a child was abused by a stranger; (3) a child was abused by an offender with a known sexually transmitted infection or is at high risk for a sexually transmitted infection; (4) a child has a sibling or other relative in the household with a sexually transmitted infection; (5) a child discloses sexual abuse and lives in an area with a high rate of sexually transmitted infections in the community; (6) a child has symptoms or signs of a sexually transmitted infection; (7) a child who already was diagnosed with one sexually transmitted infection; (8) a child or their caregiver requests testing for sexually transmitted infection; (9) a child cannot verbalize details of the sexual assault; (10) the child sexual abusive event was witnessed or documented with photos/videos. ^, All adolescents should have comprehensive testing for sexually transmitted infection as part of their child sexual abuse evaluation. Comprehensive testing includes pregnancy test for pubertal female individuals and testing for chlamydia, gonorrhea, trichomonas, syphilis, and human immunodeficiency virus (HIV). Any positive sexually transmitted infection should be confirmed. Prophylactic medication per the CDC guidelines and discussion of emergency contraception should be provided to adolescents who present after an acute event. If there is high clinical suspicion for HIV transmission, HIV post-exposure prophylaxis and a referral to the health department or an infectious disease clinician are needed.

In a primary care setting, the medical evaluation described earlier does not need to be completed. The main goal of a physical examination when a child presents in a primary care setting with concerns for sexual abuse is to ensure that the child does not have any acute injuries, or lesions/symptoms concerning for a sexually transmitted infection that requires immediate medical intervention.

Immediate medical intervention is indicated if the sexual abuse incident was considered emergent/acute by state laws, if there are concerns for an acute injury, if there are significant abnormal physical or psychiatric symptoms, if there are concerns regarding the safety of the child or family, if there is caregiver anxiety/worry, or if there is need for prophylactic treatment of infection or pregnancy, or forensic evidence collection.

Examination findings

A majority of anogenital examinations in children with concerns of child sexual abuse are normal. Multiple studies demonstrated that anogenital examinations are 95% to 98% normal in this population. ^, Penetrating injury or trauma to the hymen is rarely present. One small study looked at 36 pregnant adolescents and only 2 cases had definitive findings of penetration. The presence of injury has been associated with many variables such as the degree of force, the object used to inflict injury, the type of sexual contact, and if there is a history of penetration. There are several reasons why these examinations are usually normal. Sexual contact may not be injurious, such as after genital fondling or rubbing of genital tissues or if lubricants are used. Additionally, injury to the genital mucosal tissue can heal quickly even when children present for an examination soon after the incident.

When there are anogenital findings, they can be broadly categorized as diagnostic for sexual contact, highly concerning for sexual contact, nonspecific for sexual contact (findings that can be from either sexual or nonsexual contact), and not related to sexual contact. Currently, there are 2 findings that are diagnostic of sexual contact: pregnancy and semen identified in the forensic specimens taken directly from the child’s body. Studies show that identification of forensic evidence varies (3%–80%). ^, Time since the assault is a key factor when deciding whether to collect or not collect forensic evidence. Guidelines on timing of evidence collection vary from state to state. However, the highest rate of positive forensic findings is within 24 hours of sexual assault. However, forensic evidence has been found up to 96 hours post assault. ^, Most forensic evidence in prepubertal children was found on clothing and linens. The AAP recommends that “children who have had recent sexual contact involving exchange of bodily fluids be immediately referred to a specialized clinic or emergency department capable of collecting evidence using a forensic evidence kit.” The ability to detect evidence decreases rapidly with time, regardless of the age of the child.

In general, examination findings that are concerning for sexual contact include trauma and sexually transmitted infections. Traumatic anogenital findings include acute laceration or bruising to the genital/anal tissues and/or residual or healing injuries to the genital/anal tissues. A review of the child’s history to rule out possible accidental anogenital trauma such as a straddle injury or prior surgical interventions is important. Infections that are highly concerning for sexual contact include Neisseria gonorrhea , syphilis, Chlamydia trachomatis , Trichomonas vaginalis, and HIV. The prevalence of sexually transmitted infections in children who are evaluated for sexual abuse/assault is low: 7.9% for Chlamydia trachomatis and 2.5% for N gonorrhea . If one of these infections is positive, a review of the child’s history to rule out perinatal transmission is important in younger children.

Infections that can be transmitted sexually or nonsexually include herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2), molluscum contagiosum, and condyloma accuminata (or human papillomavirus [HPV]) in the genital/anal tissues. If these findings are present, additional history such as close contact with an infected person/body part, presence of the infection elsewhere on the body, or a sexual abuse disclosure is needed to determine the level of concern for sexual abuse.

Lastly, there are findings that have low specificity or can be mistaken for child sexual abuse. These include anatomic features such as hymenal variants (septate hymen, annular hymen, etc.) or failure of midline fusion. There are also genital/anal skin conditions that mimic child sexual abuse such as labial adhesions or genital/anal erythema/inflammation caused by Streptococcus .

Please refer to the Interpretation of Medical findings in Suspected Child Sexual Abuse for details.

Outcomes of sexual abuse

Child sexual abuse can have profound lifelong adverse effects on a developing child as well as adolescents transitioning to adulthood. Children who experience sexual abuse can develop high-risk behaviors such as running away, substance abuse, and suicidal/homicidal ideation. The behaviors can then increase the risk of being involved in commercial sexual exploitation. They are also at risk for developing one or multiple psychiatric disorders such as post-traumatic stress disorder, major depression, anxiety disorders, bulimia, or sexual dysfunction. ^, Not all children who experience sexual abuse go on to engage in high-risk behaviors or have psychiatric disorders. Their environment and their support system can be protective factors. Protective factors include the presence of supportive caregivers and engagement in an effective therapeutic relationship. ^, A referral to outpatient psychological services should be provided to all children, adolescents, and their caregivers who were affected by sexual abuse so they can adequately address the issues post-abuse. The treatment modality that is most effective for this patient population and has been shown to reduce the potential for continuing the cycle of child sexual abuse and sexually reactive behaviors is trauma-focused cognitive behavioral therapy.

Prevention

With education, pediatric clinicians can play an important role in preventing child sexual abuse. One limited survey aimed at exploring caregivers’ perceived knowledge and perspectives regarding child sexual abuse and how prevention information should be presented to the public showed that over 90% of caregivers agreed that pediatricians played a critical role in child sexual abuse prevention. Prevention efforts should be initiated early and continued throughout childhood and adolescence.

Pediatric clinicians can support caregivers by emphasizing goals for healthy child sexual development that includes privacy, open communication, empathy, and accountability. Consider introducing the following topics with caregivers as early as the 2 or 3 year well visits (1) information regarding personal space and the topic of privacy; (2) limiting the number of individuals who provide genital, perianal, and bathing care to their child to reduce risk; (3) use of appropriate anatomic names for genitals for ease of communication with other caregivers outside of their home; (4) establishing rules regarding who is able to touch their child’s body such as a caregiver during bath or toilet time and the pediatric clinician with the caregiver in the examination room; (5) establishing rules on what to do when genitals are touched in a context other than providing appropriate care; (6) discouraging caregivers’ co-bathing with their child; (7) emphasizing that it is never OK for a child to have a “secret” and if anyone tells them a secret or to keep a secret, the child should tell at least 2 adults; and (8) explaining the concept of privacy when a child walks into a bedroom or bathroom during private moment.

For adolescents who have experienced sexual abuse/assault, there are challenging and difficult issues that arise when providing medical care. It is important to consistently empower adolescents with knowledge and transparency regarding their health care at each clinic visit. Clinicians should continue to encourage confidential discussion about the adolescent’s health separate from their caregiver during health care visits keeping in the mind the limits of confidentiality if the adolescent discloses concerning information. These confidential discussions are appropriate times to provide anticipatory guidance regarding healthy and safe sexual activity. Adolescents should be screened for high-risk behaviors and the presence of intimate partner and/or dating violence. Prevention strategies that have shown to reduce the risk of involvement in unsafe relationships include teaching the adolescent healthy relationship skills, engaging of influential peers and adults, creating protective environments, and supporting survivors to increase safety and reduce harm. Clinicians should consider informing adolescents of the legal definition of consensual sexual activity and what to do when they have concerns about their safety. Discussions about safe social media use include the use of caution before sending text messages, photos, or videos with explicit sexual material.

Child sexual abuse myths

There are several misconceptions about the diagnosis of, diagnostic testing for, and examination findings of child sexual abuse. These misconceptions have been studied and have been proven inaccurate.

Myth #1: The hymen is a membranous tissue that completely covers the vaginal orifice. Fact: The hymen is a membranous tissue that surrounds the vaginal orifice and its appearance changes with age. Historically, the size of the vaginal orifice was thought to be an indicator of child sexual abuse; however, measurements of the vaginal orifice are variable. It is rare that the hymen completely covers the vaginal opening and when it does (imperforate hymen) require medical intervention. The appearance of the hymen is variable and is affected by pubertal development.

Myth #2: Visualizing an “intact” hymen indicates no prior sexual activity. Blood seen on bedsheets after the first event of sexual intercourse means the hymen is “broken.”

Fact: Most changes to the hymenal tissue do not indicate consensual or nonconsensual sexual activity. The hymen in postpubertal female individuals can stretch and accommodate to allow vaginal penetration with minimal to no injury. One study compared hymenal morphology in adolescent female individuals with and without a history of sexual activity and found that 52% of those who admitted to prior sexual activity did not have identifiable changes to the hymen. Reasons for bleeding could include forced penetration or lack of lubrication. The hymen in prepubertal female individuals is smaller and less elastic. If there is a history of penetrative injury, trauma to the hymen and other anogenital structures is more likely to be evident. Pediatric clinicians should avoid using terms such as “intact” or “broken” when describing hymen morphology as there is no correlation between the hymen’s appearance and reported history of prior sexual activity.

Myth #3: Children lie about sexual abuse .

Fact: Most allegations of child sexual abuse are true. There have been many studies researching false allegations of sexual abuse. However, the literature varies greatly with regard to how the data were obtained and have unclear criteria on how the truthfulness of a child’s disclosure was judged. With these known limitations, approximately 2% to 5% of disclosures of child sexual abuse may be untrue. Overall, the more details a child gives, the more negatively the child feels about their experience, and the more a child describes sexual acts that exceed in maturity and sophistication for that child’s psychosocial development are important aspects of the disclosure to consider.

Myth #4: There are many nonsexual ways to get a sexually transmitted infection .

Fact: Fomite transmission of many sexually transmitted infections is highly unlikely. Chlamydia trachomatis infection due to vertical transmission can still be present up to age 2 to 3 years according to some studies, ^, but it remains exceedingly rare (<2%). Some studies show that gonococcal and chlamydia species can survive up to 24 hours on fomites (toilet seats, towels) in moist purulent secretions. However, the evidence for nonsexual fomite transmission is lacking in rigorous study design. The most frequent cause of gonococcal and chlamydial infections in infants, children, and adolescents remains sexual contact.

Approach to child sexual abuse

If a child presents with concerns for sexual abuse, it is important to approach the child and caregiver’s concerns in a calm, nonjudgmental, and compassionate manner. A pediatric clinician should attempt to obtain a medically relevant history prior to a physical examination to guide appropriate medical management. Medically relevant history includes (1) what the child disclosed and to whom and in what context; (2) who the alleged offender is and do they have continued access to the child; (3) the last date of known or possible (last time when child was alone with the alleged offender) sexual contact; and (4) current or previous symptoms of injuries and/or sexually transmitted infections.

If the pediatric clinician speaks with the child, they should speak with the child alone and employ open-ended questions such as “Tell me what happened.” If a child discloses sexual abuse, clinicians should believe what the child is saying. The child should be allowed to talk without interruption and speak in their own words. Pediatric clinicians should document what is said in the child’s own words. Reassure the child that they did the right thing by telling what happened and that it is not their fault. Next, clinicians should contact child protective services and law enforcement. If a pediatric clinician has difficulty deciding the next steps, they should contact the local child protection team and/or child abuse pediatrician.

Pediatric clinicians play a critical role in differentiating between normal and PSB as they can provide reassurance, referrals for psychological evaluation and intervention, or report to child protective services and law enforcement if there are concerns of child sexual abuse. Incorporating discussion about normal childhood sexual development during health maintenance visits can provide numerable benefits. A detailed history can assist in differentiating between normal and PSBs. Components of the detailed history should include the ages of the child and/or person(s) involved, type of behavior, frequency of behavior, emotional demeanor of the child during the behavior, recent stressors in the child’s environment, access to nudity or pornographic materials, and if coercion or force was used regarding the sexual behavior. Clinicians should gauge the caregiver’s thoughts about this topic and provide anticipatory guidance when appropriate. Referrals for additional psychological evaluation should be made if there are concerns for an underlying behavioral problem and reports to child protective services and law enforcement if there are concerns of child sexual abuse or other forms of child maltreatment.

Once a pediatric clinician makes the decision to report, it is important to communicate this decision to caregivers in a calm and non-accusatory manner. The primary responsibility of the clinician is the protection of the child. If there are concerns that the caregivers are non-supportive or the child could be in danger, the pediatric clinician can delay informing the caregivers of the report.

Summary

Child sexual abuse is a public health issue that can have negative outcomes; recognizing it and working on prevention strategies are important. This is why all pediatric clinicians should become familiar with this challenging topic and know how to provide an appropriate and timely response. The diagnosis of child sexual abuse relies primarily on the child’s disclosure. Pediatric clinicians should believe a child’s disclosure as they play a pivotal role in that child’s journey toward healing. The pediatric clinician’s role is not to be an investigator, but to provide reassurance or assistance to address a child’s physical and mental well-being.

Clinics care points

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  Child sexual abuse is a common and challenging public health problem.

  
  
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  Child sexual abuse is defined as involvement of a child or an adolescent (<18 years old) in sexual activity that he or she does not fully comprehend and is unable to give informed consent to, or for which the child or adolescent is not developmentally prepared and cannot give consent, or that violates the laws or social taboos of society.

  
  
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  Approximately 90% of child sexual abuse offenders are known/trusted by the child.

  
  
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  The diagnosis of child sexual abuse relies primarily on the child’s disclosure. Pediatric clinicians should approach the child and/or caregiver in a calm, nonjudgmental, and compassionate manner.

  
  
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  Disclosure of child sexual abuse is a process.

  
  
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  Most anogenital examinations and testing for sexually transmitted infections are normal or negative.

  
  
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  Pediatric clinicians should avoid using words like “intact” or “broken” when describing the hymen.

  
  
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  The need for forensic evidence collection is based on state laws.

  
  
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  Pediatric clinicians play an important role in assessing child sexual behaviors.

  
  
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  Child sexual abuse can have profound lifelong adverse effects on the child and caregiver. The mainstay of treatment is trauma-focused cognitive behavioral therapy.

  
  
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  Prevention efforts start in the pediatric clinician’s office. Prevention topics should be introduced early and continue throughout childhood and adolescence.

  
  
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  If a pediatric clinician has difficulty deciding the next steps after having concerns for child sexual abuse, they should contact the local child protection team and/or child abuse pediatrician.

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