Skip to main content
Download PDF

Health care providers’ responses to sexually abused children and adolescents: a systematic review

BMC Health Services Research volume 22, Article number: 441 (2022) Cite this article

Abstract

Background

Sexual abuse of children and adolescents is a significant health concern worldwide. Appropriate and timely health services for victims can prevent severe and long-term consequences. This study identified and categorized diagnostic and treatment services needed for sexually abused children and adolescents.

Methods

Several databases, including MEDLINE, Web of Science, Scopus, Science Direct, ProQuest, and Google Scholar, were searched to retrieve studies on the topic and clinical guidelines in English covering the literature from 2010 to 2020 using search terms. Primary studies and guidelines were reviewed to identify treatment strategies and medical interventions related to sexually abused children and adolescents.

Results

Twenty-one studies and guidelines were selected and analyzed narratively. The quality of evidence was relatively good. We identified that effective health care systems for sexually abused children include the following: interview and obtain medical history, physical and anogenital examination, collecting forensic and DNA evidence, documenting all the findings, prevention and termination of pregnancy, diagnostic tests, prophylaxis for HIV and other STIs, vaccinations, and psychological intervention.

Conclusions

This review provides up-to-date evidence about adequate health care services for children and adolescent victims of sexual abuse. We conclude that recent studies have focused more on prophylaxis against HIV and other STIs, studies on vaccinating against HPV for victims are still limited, and future research in this area is needed.

Peer Review reports

Background

Child Sexual Abuse (CSA) is a pervasive concern for public health and human rights [1]. The World Health Organization (WHO) has defined sexual abuse against children and adolescents as “involving a child in a sexual activity that he or she does not fully understand and has no informed consent because of the child’s intellectual development and immaturity.” Either it is an act that is not clear to the child or a violation of society’s laws or social restrictions [2]. The prevalence of child and adolescent sexual abuse is alarming. Three meta-analyses have been conducted to determine world-wide prevalence rates. A systematic review and meta-analysis in 2011 reported that the prevalence of CSA among girls to be 20% and among boys at around 8% [3]. Another 2013 meta-analysis about the prevalence of CSA reported that 9% of girls and 3% of boys had experienced forced oral, vaginal, or anal intercourse [4]. Meta-analyses by Stoltenberg et al. in 2015 reported that 8% of boys and approximately 18% of girls during their childhood had experienced sexual abuse [5]. Studies on children and adolescents exposed to sexual abuse confirm wide ranges of short- and long-term destructive health consequences [6, 7]. Sexual abuse can affect children and adolescents’ physical, sexual, reproductive, and mental health and need to be addressed [2]. Survivors of CSA may experience significant lifetime consequences in mental health, including depression, post-traumatic stress, anxiety, eating disorders, externalizing symptoms, problems with relationships, sleep disorders, and suicidal ideation and behaviors [7,8,9]. Studies have reported that children and adolescents who have been sexually abused are more likely to engage in high-risk behaviors such as risky sexual behaviors and drug and alcohol abuse, leading to adverse health consequences in adulthood [10,11,12]. Many survivors of sexual abuse can overcome such adverse health conditions as long as support services are provided and the confidentiality of their information and treatments insured [13,14,15].

Health care providers play an essential role in early access to services and care for child and adolescent victims of sexual abuse [16]. These victims need effective and immediate medical, psychological and legal services [17]. According to the World Health Organization, the rate of abused children presenting to medical and legal centers varies from country to country. For example, the rate of children with sexual abuse seeking help from health or legal centers in Swaziland was 24%, while in Kenya, it was only 2% for boys and 6.8% for girls [2]. These data indicate that there is a need to increase awareness in communities about the diagnosis and treatment options and provide timely services to victims of sexual abuse [15].

Although a recent systematic review by the World Health Organization (2017) explored the literature on good practice considerations for initial health system response to child and adolescent victims of sexual abuse [18], it only focused on how the provision of care to survivors should be implemented. In addition, this review did not synthesize the evidence on diagnostic and treatment services. Also, WHO 2017 guidelines need to be updated, as it does not include Tetanus vaccinations for high-risk children, laboratory tests for Hepatitis C, or the Papanicolaou test (Pap smear) for adolescent girls. Thus, the purpose of this review was to identify and categorize diagnostic and treatment services that are needed for sexually abused children and adolescents.

Methods

Design

This was a systematic review of the literature. We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.

Search strategy

Six electronic databases, including MEDLINE; Web of Science; Scopus; Science Direct; ProQuest, and Google Scholar, were searched. We also searched databases such as Guidelines International Network (GIN), Agency for Healthcare Research and Quality (AHRQ), National Institute for Clinical Excellence (NICE), Unicef Guidelines, and World Health Organization (WHO), to retrieve clinical guidelines related to the research. Then, the keyword was adjusted based on the concept in the research question. These concepts consist of “Children” OR “child” OR “Minors” AND “Adolescent” OR “Adolescents” OR “Teenagers” AND “Sexual Abuse” OR “Sexual Assault” OR “Sex Offenses” OR “Rape” OR “Child Molestation” OR “Sexual Molestation” AND “Guideline” OR “Practice guideline” OR “Intervention” OR “Program” AND “Medico-legal assessment” and “Medico-legal intervention.” The final keywords were reviewed by a public health expert and two reproductive health experts. Studies published in English languages between 2010 and 2020 were included. The citations were transferred to the Mendeley Reference Management Software.

Inclusion/exclusion criteria

Articles, guidelines and clinical and treatment protocols were included in this review if they met the following criteria: (1) Studies on sexually abused children and adolescents under 18 years of age of both sexes (boys, girls); (2) Studies that were conducted to identify treatment strategies and medical interventions related to sexually abused children and adolescents; (3) Studies on the legal interventions for victims of sexual abuse; or (4) Studies focusing on the rehabilitation and treatment of long-term consequences of sexual abuse.

Exclusion criteria for studies consisted of: (1) Studies on the prevention and protection of children from sexual abuse; (2) Studies on the characteristics and epidemiological distribution of sexual abuse in children and adolescents; (3) Resources on adults who have experienced sexual abuse in their childhood; (4) Studies focusing on other forms of child and adolescent abuse, such as physical or psychological violence; (5) Studies on the treatment and characteristics of sexual abuse perpetrators; (6) meta-analyses, and systematic reviews; and (7) Studies with transgender participants, disabilities, and other underlying diseases.

Study selection process

The studies were classified, and then the full text of selected articles from the initial screening stage was searched and reviewed again by two authors. According to the inclusion and exclusion criteria, the first two authors conducted a primary title and abstract screening individually. Two reviewers (MR and SS) made separate judgments about the searched studies, and in case of disagreement, the third author (AM) made the final decision. Articles with study inclusion criteria were maintained for the quality assessment and data extraction stage.

Quality assessment and risk of Bias

Studies were evaluated for scientific quality using the Mixed Methods Appraisal Tool (MMAT) version 2018 and its associated scoring system [19]. In brief, studies were scored based on five criteria as indicated by the guideline. Studies were rated as low quality if they met only 2 criteria and were excluded from the review. The remaining studies were rated medium if they met 3 criteria and high if they met 4 or 5 criteria. These studies were included in the review. In addition, the selected treatment guidelines for sexually abused children and adolescents also were assessed with the Appraisal of Guidelines, Research and Evaluation II (AGREE II) instrument [20]. The instrument contains 23 items divided into six sections. Scores on each section are independent. Guidelines with low quality (low scores on all sections or 4 out of six sections) were excluded. The remaining guidelines were rated medium if fulfilled adequate scores for 3 out of 6 sections, and high if fulfilled adequate scores for 4 or more sections.

Data extraction process and data synthesis

The data extracted consists of: (1) general characteristics, (2) article summary, and (3) results of studies related to this review questions. General characteristics consisted of participant (Child or/and Adolescent), participant’s age and sex, and study location. The article summary included objective, research question, the methodology of studies (qualitative, quantitative; sample size), and main findings. The results included physical, psychological, forensic assessment and intervention, and follow-up services.

The studies included in this review were diverse in design, interventions, and primary and secondary outcome measures. As a result, meta-analysis was not applicable. The results were synthesized narratively as the best procedure for describing, comparing, and combining study findings.

Results

Search results

The PRISMA flow diagram (Fig. 1) shows that the preliminary search yielded 1680 articles and 66 protocols or guidelines that potentially met the inclusion criteria. After excluding duplicates, 1161 articles and protocols were reviewed for the title and abstract. Consequently, 793 articles and protocols were excluded from the study. Then, the full text of 368 articles and protocols were assessed for eligibility. Out of 368 studies, 273 studies were excluded for the following reasons: focused on the epidemiological features of the child sexual abuse (n = 88), legal and medical measures against perpetrators of sexual abuse were examined (n = 71), the age of the sample was over 18 years (n = 43), assessed the prevalence and consequences of sexual abuse (n = 59), and the full text was not available (n = 12). In addition, 74 articles were excluded due to low quality. Finally, 21 articles and protocols were included in the review.

Fig. 1
figure 1

PRISMA diagram for Process of articles selection

Full size image

Characteristics of studies under review

Out of twenty-one studies, 11 studies were clinical protocols for the management of child and adolescent sexual abuse [2, 21,22,23,24,25,26,27,28,29,30] (Table 1), 8 were quantitative [31,32,33,34,35,36,37,38], one was qualitative [39], and one article described a quality improvement project [40] (Table 2). The majority of the studies were conducted in high-income countries. Most quantitative studies were retrospectively conducted on sexually abused children and adolescents. Protocols or guidelines were developed by experts in child sexual abuse. One quantitative study was performed prospectively on 5 children with large anogenital ruptures [34]. The ages of children and adolescents in most studies were under 18 or 21 years old [2, 25, 26, 31, 32, 35,36,37,38,39,40], but in some studies, only the words “child” or “adolescent” were used, and exact age was not mentioned [23,24,25, 28, 30]. Two studies mentioned the combined care of adolescents and adults [21]. Data collection in two studies was in-depth interviews with children and their parents [37, 39]. Although most contents included all medical, psychological, forensic, and legal services for victims of sexual abuse, some addressed only one of the psychological [37], forensic [33], or HPV (Human Papilloma Virus) vaccination measures [36]. The quality of evidence was relatively good as can be seen in Tables 1 and 2. Overall, we identified seven services provided for children and adolescent victims of sexual abuse that were addressed by the studies under review. The findings are briefly described as follows.

Table 1 Characteristics of quantitative and quantitative studies included in this review
Full size table
Table 2 Characteristics of clinical guidelines or protocols included in this review
Full size table

Principles for interviewing and obtaining medical history

General principles for interviewing children and adolescents who have been sexually abused include the following: use interviewers who have been trained in forensic medicine for forensic disclosure [2, 21, 23, 25, 27,28,29,30], build rapport with victims [2, 21, 22, 24, 26, 28, 29, 31, 38, 39], obtain informed consent from victims and their parents (except in cases where the parents are abusive), the examiner should be aware that any injured children may have been sexually abused, so a thorough examination of the relevant evidence is necessary for protect these victims [2, 21, 24, 26, 27, 34, 39], provide sufficient and clear explanations regarding all stages of the examination [2, 21, 23, 24, 26, 28, 30], provide a private and child-friendly place for interviews and ensure the safety of victims [2, 23, 24, 27, 28], preserve victims’ autonomy and avoid coercion [2, 21, 24, 25, 29], provide non-judgmental responses and support [2, 22, 25, 27], assurance regarding the confidentiality of information [2, 24, 39], use the child’s and adolescent’s language and give age-appropriate information [2, 24, 28], conduct interviews alone with victims [2, 23, 24, 39], use open-ended or general questions about themselves and events before the legal interview [2, 25, 27, 29, 39], record and document evidence [2, 21, 25, 29, 35], and ask for past medical and social history of all victims [2, 21, 22, 25]. The purpose of obtaining the medical history of victims is to check their health status, record the injuries, and ultimately address their health problems [2, 22, 24]. Also, to achieve the best treatment for children and adolescents, the examiner should attempt to obtain victims’ past medical records [2, 24, 25, 27] since such information may affect subsequent interventions, for example, victims who have previously received mental health interventions maybe need immediate psychiatric care [2, 27] .

Recommendations for physical and Anogenital examinations

Findings from 15 studies confirmed that when sexual abuse is discovered, the examiner should perform a complete physical examination to document any injuries. This examination is the first step in identifying and treating the injuries [2, 21,22,23,24,25,26, 28, 29, 31, 34, 38, 39]. it is difficult for the examiner to decide which child needs immediate sexual abuse examination and which case needs a referral to legal centers for more specialized examinations [25]. studies confirmed the conduct ofcomprehensive physical examinations and to avoid delay of examinations of the victims [2, 23, 25, 26, 28, 34, 35, 39]. Medical interventions to prevent complications in victims of sexual abuse depends on the early referral of sexual victims [26, 40]. Few studies have talked about victims’ fears and anxiety about physical and forensic examinations and have suggested that victims should have a sense of control and choice in examinations [2, 27,28,29, 39]. Four studies indicate that the presence of a supportive and empathetic caregiver or supportive person in the examination room can be useful for the child’s comfort [2, 25, 28, 29].

Physical examination

Studies show that in cases of child sexual abuse, the physical examination does not end only in the anogenital area, but a complete and comprehensive examination should be performed of all body parts [2, 21, 22, 28, 30]. Health care providers conduct a head-to-toe examination in the first stage of care [28,29,30]. Studies confirm that it is better to determine the stage of sexual maturity according to the Tanner stages. Then an anogenital examination is performed based on the stage of development [2, 21, 22, 28, 29]. Four clinical guidelines have recommended that every injury in all the skin surfaces, consisting of the soles of the legs, behind the ears, the eyes, the axilla, and the oral cavity, must be evaluated [2, 22, 28, 29]. If the victim’s interview reveals that oral penetration has also occurred, the victim’s oral cavity should also be sampled with swabs, and the swabs should be kept for microscopic investigation [21, 27, 28]. Any injuries to the victim’s body should be recorded [2, 22, 28, 29].

Genital and anal examination

To perform genital and anal examinations, visual aids can be useful for explaining the steps and position of the examination [2, 29]. Studies recommend that speculum, anoscope, and colposcope are not used to examine prepubescent girls. If the injury is severe and under anesthesia or sedation, then these instruments can be used [2, 24, 27,28,29,30, 34]. However, two studies indicate that a speculum can be used for intra-vaginal investigation [2, 25]. Most of the mentioned studies have suggested both supine (frog leg) and the knee-chest positions are better for genital and anal examination in both genders [2, 24, 27,28,29,30, 34, 39]. The genitals examination included examining the penis and scrotum in boys, and the labia and contents of the vestibule of girls, then documenting any injuries or scarring and other defects [25, 29]. Examiner should be checking any signs of injury or disease in victims and recognize whether this finding is normal or not [24, 29, 34] Then, first aid should treat minor injuries and, if necessary, refer to the hospital setting [24].

Collecting forensic and DNA evidence for forensic evaluation

Three studies confirmed that the time between the last event and evaluation is critical [26,27,28]. Most studies have stated that the best time to collect samples and identify the perpetrator is less than 72 h after the rape or sexual abuse [21, 25, 27,28,29, 35]. However, two studies from the USA reported that the time for the gathering of beneficial forensic evidence might be prolonged beyond the present 72-h standards if DNA testing is used for analyzing forensic specimens [26, 27] Samples, including blood, hair, semen fluid, and other likely foreign material can be obtained from the victim’s clothing and body skin, genitals, anus, and mouth by using swabs [21, 24, 27, 28].

Documenting findings from medical history and physical and forensic investigation

After observation and examination of victims, the examiner should completely and correctly document medical history findings, physical and forensic examination, and any other relevant evidence [2, 22, 24, 27,28,29,30]. Studies have even suggested that any examinations and injuries can be recorded with photo and videography [21, 22, 24,25,26,27,28,29,30, 34]. As a component of the informed consent process during the examination, consent to take video photography should be required [2, 29]. A national protocol for treating sexual abuse in children and adolescents recommended that video or audio recording during the medical history process not be used [29]; however, the WHO Clinical Guide recommended recording verbatim statements for perfect and comprehensive documentation [2]. The recorded documents must be securely stored in a safe setting [2, 29, 30].

Prevention and termination of pregnancy in sexually abused adolescent girls

Adolescent girls who have been sexually abused are at risk for unwanted pregnancies if they have attained menarche or are of reproductive age [2, 21, 22, 39]. Two studies report that pregnancy can signify sexual abuse in adolescent girls [23, 30]. Prevention of pregnancy can include emergency contraception for prophylaxis and termination of pregnancy [24]. Some studies state that after the contact sexual abuse in post-pubertal girls, emergency contraception for pregnancy should be given as soon as possible, preferably within 72 h after sexual abuse [21, 23,24,25,26, 28]. Some of the mentioned studies considered 120 h or 5 days after sexual abuse [2, 22, 25, 26, 35]. The initial response varied based on how much time has passed since the contact sexual abuse occurred [25]. One study in 2011 suggested that hormonal contraception is the only selective approach for pregnancy prevention in adolescent victims of acute sexual abuse [26]. But in WHO’s 2017 clinical guidelines for response to child and adolescent sexual abuse, intra-uterine devices such as copper-bearing intra-uterine device (Cu-IUD) are allowed if there is a low risk of STI [2].

Based on the recommendations of three clinical guidelines about abortion for pregnant adolescents, that decision should be based upon the local laws of each country [2, 22, 28].

Diagnostic tests

Children and adolescents who are victims of sexual abuse may need diagnostic tests based on their evidence and physical examinations. Based on the review of studies, these tests consist of the following:

  1. a.

    HIV (Human Immunodeficiency Virus): Since the frequency of HIV in prepubescent children and adolescents who have been sexually abused varies, diagnosis of these infections is recommended by almost all of the literature [2, 22,23,24,25,26,27,28, 30, 31, 35, 39]. However, two studies in the USA and UK suggest syphilis and HIV analysis should only be done in high prevalence populations or when the victims requested these tests [24, 35]. According to the result of a study in the USA, testing for HIV and other STI depended on the patient’s age, history of the abuse, timing of the medical examination, and perpetrator’s characteristics [26]. If warranted, HIV rapid testing (definitive results within 2 h) should be done. If the initial test results for HIV were negative, victims should repeat the test at 6, 12, and 24 weeks after the abuse [22, 28, 29].

  2. b.

    STI (Sexual Transmitted Infections): Studies confirm that identification of STI in pre-pubertal children can help to diagnose child sexual abuse, because it can be one of the possible signs of concealed sexual abuse [22, 28,29,30, 35]. Based on the review of studies, the most common STIs reported in victims of sexual abuse consist of chlamydia, gonorrhea, and trichomoniasis [22, 23, 26, 29, 30]. In this regard, some studies recommend vaginal culture in girls [26, 29, 35] or obtaining “dirty” (non-sterile) urine sample to detect Trichomoniasis [22]. Also, nucleic acid amplification test can be used to diagnose chlamydia, gonorrhea, and Trichomonas on vaginal swabs or urine samples during the first 72 h after abuse [2, 26, 28,29,30]. Furthermore, Chlamydia, Gonorrhea, syphilis, human papillomavirus, and herpes simplex can be identified employing serology [2, 22, 28, 29, 35].

  3. c.

    Hepatitis B, C and Syphilis: In addition, studies recommend testing for hepatitis B in unimmunized children and adolescent victims of sexual abuse [2, 27,28,29,30, 35]. Syphilis and Hepatitis B serologic testing must be repeated 6 weeks and 3 months later [29]. Testing for Hepatitis C should also be done [29].

  4. d.

    Pregnancy test: According to two clinical guidelines, the pregnancy test should be performed only in adolescent girls with delayed menstruation [2, 22].

  5. e.

    Cervical cytologic analysis: Carole et al., in their study, suggested that adolescent girls should have the first cervical cytologic analysis at the age of 21, except there are special conditions, such as HIV infection or immune suppression [25].

Prophylaxis for HIV and other STIs

A total of 12 studies suggested that children and adolescents who have been sexually abused, especially with oral, vaginal, or anal penetration, should receive early HIV Post-Exposure Prophylaxis (PEP) at the first 72 h after the last sexual abuse [2, 23,24,25,26,27,28, 30, 31, 39]. Sexually abused victims presenting later than 72 h are no longer indicated for antiviral prophylaxis [2, 29, 35]. HIV PEP should be started within 72 h of the sexual abuse and continued for 28 days [2, 22, 24, 26, 29]. According to two clinical guidelines, drug programs for PEP in adolscents are determined by local or national conventions [2, 22]. The latest WHO guidelines recommended two or three antiviral drugs for HIV PEP [2]. As mentioned in most studies, children and adolescents who have suffered sexual abuse may be infected with an STI [2, 23,24,25,26,27,28, 30, 31, 39]. Prophylaxis for bacterial and viral infection in sexually abused children and adolescence is needed, especially in settings where laboratory testing is not possible [2, 24]. According to the two Clinical Guidelines, drugs used as prophylaxis depend on the local protocol [2, 22]. The recommended antibiotics for prophylaxis in some studies consist of oral cefixime 400 mg or ceftriaxone, azithromycin 1 g, and Metronidazole 500 mg (for gonorrhea, chlamydia, and trichomoniasis respectively), followed by screening 2 weeks later [24, 27, 28]. Studies recommended that prophylaxis should be given within the first 72 h after the sexual abuse [22, 24, 25, 27, 28, 35].

Vaccinations

One study from the UK confirms that in countries with low childhood vaccination rates for tetanus and high prevalence of tetanus, prophylaxis against tetanus is recommended [24]. In addition, other studies reported that if there were mucosal or skin damages, a suitable tetanus toxoid (td) must be administered [22, 39]. Especially in unvaccinated and unprotected children, it may be necessary to administer anti-tetanus serum and a course of tetanus toxoid vaccine [22]. Some reviewed studies have suggested that unvaccinated children who have been sexually abused should be administered hepatitis B vaccination within 6 weeks of the last event [2, 22, 24, 29]. Vaccine first dose should be initiated at the time of examination, and then should be advised to complete three doses and a booster dose 12 months later [22, 24].

Furthermore, the national clinical practice guidelines suggested HPV vaccination is needed after child sexual abuse [29]. Two studies on child victims of sexual abuse also showed the effectiveness and importance of the HPV vaccine in post-rape care [36, 40]. HPV vaccination should be given to children between the ages of 9–14 years [2, 29].

Psychological intervention and follow up

Child and adolescent sexual abuse is a serious health concern with many short and long-term health consequences, negatively impacting the victim’s life [2, 24, 28,29,30, 32]. Some of these consequences based on the review of studies consist of: Post-Traumatic Stress Disorder (PTSD), low self-esteem, anxiety, decreased personal well-being, reduced school performance, loss of social competency, inappropriate sexual behavior, depression, substance abuse, and suicidal ideation [2, 21, 23, 27,28,29,30, 32,33,34, 37, 38]. The choice of behavioral or psychological intervention depends on victims’ ages and developmental stages and the behavioral and emotional problems [2, 37]. Based on the review of studies, psychological interventions used in children and adolescent victims of sexual abuse included:

  1. a.

    Psychological and social support and risk assessment of vulnerabilities, including domestic violence or self-harm, and practical support should be provided depending on victims’ needs [2, 24, 37],

  2. b.

    Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and follow-up for at least 6 months for sexually abused children and adolescents who had symptoms of Post-Traumatic Stress Disorder (PTSD) [2, 37]. Stress management may be useful for children and adolescents with PTSD [2].

  3. c.

    CBT and Interpersonal Psychotherapy (IPT) for children and adolescents with emotional disorders [2] and training care skills to parents and caregivers [2, 24].

Discussion

Findings from the current systematic review provided a summary of the clinical interventions associated with providing care to child and adolescent victims of sexual abuse. These findings are mainly from studies conducted in middle- and high-income countries focusing on improving the care provided to victims.

In our study, both valid guidelines and articles on sexual abuse of children and adolescents were systematically examined. Through studies, we have found that providing timely and early care to children and adolescents who are victims of sexual abuse can reduce the short- and long-term effects of sexual abuse and thus improve their living conditions and adaptation.

In this study, by reviewing clinical guidelines and related studies on providing clinical care to children and adolescents victims of sexual abuse, it was found that the clinical services to victims of sexual abuse have undergone positive and efficient changes over time. Thus it is believed that in addition to other measures in the collection of evidence related to sexual abuse, newer tests such as DNA testing will increase the likelihood of obtaining evidence from aggressors even after the standard 72 h [26, 27]. Similarly, new studies reported that effective time in preventing unwanted pregnancies in female victims has increased from less than 72 h to 120 h after rape [2, 22, 25, 26, 35]. Likewise, whereasolder studies only focused on tetanus and hepatitis B vaccination, newer studies emphasize HPV vaccination in sexually abused children and adolescents [2, 29, 36, 40].

While the focus of this review was to provide evidence on clinical management and interventions to care for child and adolescent victims of sexual abuse, planning in health systems is needed to minimize harm to such victims. These plans include training health care approaches to health care providers, coordination mechanisms between the centers involved, monitoring and evaluation of systems, and the establishment of counseling and prevention services [18]. Resources, training, and an environment of supportive health systems are needed to provide trauma-informed care and critical early response. In fact, creating a supportive health environment enables health care providers to offer effective care and minimize victims’ feelings of shame, anxiety, and fear during interviews and examinations.

The strengths of this study include the extent of resources sought and the use of appropriate search methods and narrative synthesis to integrate the findings. The heterogeneity of the studies reviewed and the use of different quality assessment methods are limitations of our study.

Conclusions

Suggestions for sexually abused children and adolescents include a set of evidence-based interventions. Many of these interventions are the same for sexually abused boys and girls. Also, these services for victims should be provided as soon as possible after sexual abuse, preferably less than 72 to 120 h. According to the results of this review, more studies have focused on prophylaxis against HIV and other STIs. Studies on vaccinating victims against HPV are limited, and future research in this area is recommended. The findings of the present review can be used by clinical development experts in child abuse and sexual violence against children and adolescents. Also, the recommendations of this study in 7 areas of care are in line with the principles derived from international human rights instruments such as the Convention on the Rights of the Child (CRC) and The Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), which provide normative and protective standards to protect children and women from violence.

Availability of data and materials

In this review all data are available from the referenced articles. The open access articles used for analysis during the current study are available from the corresponding author.

References

  1. Choudhary V, Satapathy S, Sagar R. Qualitative study on the impact of child sexual abuse: perspectives of children, caregivers, and professionals in Indian context. J Child Sex Abus. 2019;28(4):489–510. https://doi.org/10.1080/10538712.2018.1563262http://www.ncbi.nlm.nih.gov/pubmed/30681937.

    Article  PubMed  Google Scholar 

  2. Responding to children and adolescents who have been sexually abused. WHO clinical guidelines. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO

    Google Scholar 

  3. 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 Maltreat. 2011;16(2):79–101. https://doi.org/10.1177/1077559511403920https://pubmed.ncbi.nlm.nih.gov/21511741/.

    Article  PubMed  Google Scholar 

  4. Barth J, Bermetz L, Heim E, Trelle S, Tonia T. The current prevalence of child sexual abuse worldwide: a systematic review and meta-analysis. Int J Public Health. 2013;58(3):469–83. https://doi.org/10.1007/s00038-012-0426-1https://pubmed.ncbi.nlm.nih.gov/23178922/.

    Article  CAS  PubMed  Google Scholar 

  5. Marian MS, J. Bakermans-KranenburgLenneke R. A. Alink Marinus H. vanIJzendoorn. The prevalence of ChildMaltreatment across theGlobe: review of a Seriesof Meta-analyses. Child Abuse Rev. 2015;24:37–50. https://doi.org/10.1002/car.2353.

    Article  Google Scholar 

  6. Sewanee SH, Finkelhor D, Turner H. Teen dating violence: co-occurrence with other victimizations in the National Survey of Children’s exposure to violence (NatSCEV). 2012; https://psycnet.apa.org/journals/vio/2/2/111.html?uid=2012-03614-001.

    Google Scholar 

  7. Maniglio R. The impact of child sexual abuse on health: a systematic review of reviews. Clin Psychol Rev. 2009;29(7):647–57. https://doi.org/10.1016/j.cpr.2009.08.003https://doi.org/10.1016/j.cpr.2009.08.003.

    Article  PubMed  Google Scholar 

  8. Chen LP, Murad MH, Paras ML, Colbenson KM, Sattler AL, Goranson EN, et al. Sexual abuse and lifetime diagnosis of psychiatric disorders: systematic review and meta-analysis. Mayo Clin Proc. 2010;85(7):618–29. https://doi.org/10.4065/mcp.2009.0583.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Koola MM, Ahmed AO, Sebastian J, Duncan EJ. Childhood physical and sexual abuse predicts suicide risk in a large cohort of veterans. Prim Care companion CNS Disord. 2018;20(4). https://doi.org/10.4088/pcc.18m02317https://pubmed.ncbi.nlm.nih.gov/30152644/.

  10. Richter L, Komárek A, Desmond C, Celentano D, Morin S, Sweat M, et al. Reported physical and sexual abuse in childhood and adult HIV risk behaviour in three African countries: findings from project accept (HPTN-043). AIDS Behav. 2014;18(2):381–9. https://doi.org/10.1007/s10461-013-0439-7.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Senn TE, Carey MP, Vanable PA. Childhood and adolescent sexual abuse and subsequent sexual risk behavior: evidence from controlled studies, methodological critique, and suggestions for research. Clin Psychol Rev. 2008;28(5):711–35. https://doi.org/10.1016/j.cpr.2007.10.002.

    Article  PubMed  Google Scholar 

  12. Zierler S, Feingold L, Laufer D, Velentgas P, Kantrowitz-Gordon I, Mayer K. Adult survivors of childhood sexual abuse and subsequent risk of HIV infection. Am J Public Health. 1991;81(5):572–5. https://doi.org/10.2105/ajph.81.5.572.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Kress VE, Adamson NA, Yensel J. The use of therapeutic stories in counseling child and adolescent sexual abuse survivors. J Creat Ment Health. 2010;5(3):243–59. https://doi.org/10.1080/15401383.2010.507657.

    Article  Google Scholar 

  14. Walker EC, Holman TB, Busby DM. Childhood sexual abuse, other childhood factors, and pathways to survivors’ adult relationship quality. J Fam Violence. 2009;24(6):397–406. https://doi.org/10.1007/s10896-009-9242-7.

    Article  Google Scholar 

  15. Ligiéro DP, Fassinger R, McCauley M, Moore J, Lyytinen N. Childhood sexual abuse, culture, and coping: a qualitative study of latinas. Psychol Women Q. 2009;33(1):67–80. https://doi.org/10.1111/j.1471-6402.2008.01475.x.

    Article  Google Scholar 

  16. Blanco L, Nydegger LA, Camarillo G, Trinidad DR, Schramm E, Ames SL. Neurological changes in brain structure and functions among individuals with a history of childhood sexual abuse: A review. Neurosci Biobehav Rev. 2015;57:63–9. https://doi.org/10.1016/j.neubiorev.2015.07.013.

    Article  PubMed  Google Scholar 

  17. Veenema TG, Thornton CP, Corley A. The public health crisis of child sexual abuse in low and middle income countries: an integrative review of the literature. Int J Nurs Stud. 2015;52(4):864–81. https://doi.org/10.1016/j.ijnurstu.2014.10.017.

    Article  PubMed  Google Scholar 

  18. Broaddus-Shea ET, Scott K, Reijnders M, Amin A. A review of the literature on good practice considerations for initial health system response to child and adolescent sexual abuse. Child Abuse Negl. 2019. https://doi.org/10.1016/j.chiabu.2019.104225.

  19. Hong QN, Fàbregues S, Bartlett G, Boardman F, Cargo M, Dagenais P, et al. The mixed methods appraisal tool (MMAT) version 2018 for information professionals and researchers. Educ Inf. 2018;34(4):285–91. https://doi.org/10.3233/EFI-180221.

    Article  Google Scholar 

  20. Brouwers M, Kho M, Browman G, Burger J, Cluzeau F, Feder G, et al. AGREE II: advancing guideline development, reporting and evaluation in healthcare. Can Med Assoc J. 2010;182(18):839–42.

    Article  Google Scholar 

  21. Ludes B, Geraut A, Väli M, Cusack D, Ferrara D, Keller E, et al. Guidelines examination of victims of sexual assault harmonization of forensic and medico-legal examination of persons. Int J Legal Med. 2018;132(6):1671–4 http://www.ncbi.nlm.nih.gov/pubmed/29468380.

    Article  CAS  Google Scholar 

  22. Day K and JP-Weeks. The Clinical Management of Children and Adolescents Who Have Experienced Sexual Violence: Technical Considerations for PEPFAR Programs. Arlington, VA: USAID’s AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1. 2013.

  23. Adams JA, Kellogg ND, Farst KJ, Harper NS, Palusci VJ, Frasier LD, et al. Updated guidelines for the medical assessment and Care of Children who may Have Been Sexually Abused. J Pediatr Adolesc Gynecol. 2016;29(2):81–7 http://www.ncbi.nlm.nih.gov/pubmed/26220352.

    Article  Google Scholar 

  24. Cybulska B. Immediate medical care after sexual assault. Best Pract Res Clin Obstet Gynaecol. 2013;27(1):141–9. https://doi.org/10.1016/j.bpobgyn.2012.08.013.

    Article  PubMed  Google Scholar 

  25. Jenny C, Crawford-Jakubiak JE. The evaluation of children in the primary care setting when sexual abuse is suspected. Pediatrics. 2013;132(2) https://pubmed.ncbi.nlm.nih.gov/23897912/.

  26. Cindy CW. Timing of the medical examination. J Child Sex Abus. 2011;20(5):505–20. https://doi.org/10.1080/10538712.2011.607424.

    Article  Google Scholar 

  27. Crawford-Jakubiak JE, Alderman EM, Leventhal JM, Flaherty EG, Idzerda S, Legano L, et al. Care of the adolescent after an acute sexual assault. Am Acad Pediatr. 2017;139(3). https://doi.org/10.1542/peds.2016-4243 https://pediatrics.aappublications.org/content/139/3/e20164243.short.

  28. Department of Health K. Province of KWAZULU-NATAL ISIFUNDAZWE SAKWAZULU-natali guidelines for the medical examination and management. 2017; KZN department of health. Available from: http://www.kznhealth.gov.za.

  29. Department of Justice U, on Violence Against Women O. April 2016 A National Protocol for Sexual Abuse Medical Forensic Examinations Pediatric. 2016.

  30. Vrolijk-Bosschaart TF, Brilleslijper-Kater SN, Benninga MA, Lindauer RJL, Teeuw AH. Clinical practice: recognizing child sexual abuse—what makes it so difficult? Eur J Pediatr. 2018;177(9):1343–50. https://doi.org/10.1007/s00431-018-3193-z.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Harrison RE, Pearson L, Vere M, Chonzi P, Hove BT, Mabaya S, et al. Care requirements for clients who present after rape and clients who presented after consensual sex as a minor at a clinic in Harare, Zimbabwe, from 2011 to 2014. PLoS One. 2017;12(9). https://doi.org/10.1371/journal.pone.0184634https://pubmed.ncbi.nlm.nih.gov/28934344/.

  32. Hornor G, Thackeray J, Scribano P, Curran S, Benzinger E. Pediatric sexual assault nurse examiner care: trace forensic evidence, ano-genital injury, and judicial outcomes. J Forensic Nurs. 2012;8(3):105–11. https://doi.org/10.1111/j.1939-3938.2011.01131.xhttp://www.ncbi.nlm.nih.gov/pubmed/22925125.

    Article  PubMed  Google Scholar 

  33. Thackeray JD, Hornor G, Benzinger EA, Scribano PV. Forensic evidence collection and DNA identification in acute child sexual assault. Pediatrics. 2011;128(2):227–32. https://doi.org/10.1542/peds.2010-3498.

    Article  PubMed  Google Scholar 

  34. Sham M, Singh D, Wankhede U, Wadate A. Management of child victims of acute sexual assault: surgical repair and beyond. J Indian Assoc Pediatr Surg. 2013;18(3):105–11. https://doi.org/10.4103/0971-9261.116043http://www.ncbi.nlm.nih.gov/pubmed/24019641.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Schilling S, Samuels-Kalow M, Gerber JS, Scribano PV, French B, Wood JN. Testing and treatment after adolescent sexual assault in pediatric emergency departments. Pediatrics. 2015;136(6):e1495–503. https://doi.org/10.1542/peds.2015-2093.

    Article  PubMed  Google Scholar 

  36. Deutsch SA, Benyo S, Xie S, Carlin E, Andalaro B, Clagg B, et al. Addressing human papillomavirus prevention during pediatric acute sexual assault care. J Forensic Nurs. 2018;14(3):154–61. https://doi.org/10.1097/JFN.0000000000000209.

    Article  PubMed  PubMed Central  Google Scholar 

  37. van Duin EM, Verlinden E, Vrolijk-Bosschaart TF, Diehle J, Verhoeff AP, Brilleslijper-Kater SN, et al. Sexual abuse in very young children: a psychological assessment in the Amsterdam sexual abuse case study. Eur J Psychotraumatol. 2018;9(1):1503524. https://doi.org/10.1080/20008198.2018.1503524.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Zerbo S, Milone L, Scalici E, Procaccianti S, Nardello R, Ventura Spagnolo E, et al. Medico legal procedures related to sexual assault: a 10-year retrospective experience of a Daphne protocol application. Egypt J Forensic Sci. 2018;8(1). https://doi.org/10.1186/s41935-018-0039-9.

  39. Wangamati CK, Thorsen VC, Gele AA, Sundby J. Postrape care services to minors in Kenya: are the services healing or hurting survivors? Int J Women's Health. 2016;8:249–59. https://doi.org/10.2147/IJWH.S108316.

    Article  Google Scholar 

  40. Goodman EA, Goodpasture M. Human papilloma virus vaccination after pediatric sexual abuse evaluations in the outpatient child sexual abuse subspecialty clinic: A quality improvement project. J Forensic Nurs. 2020;16(1):16–21. https://doi.org/10.1097/JFN.0000000000000251.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

We would like to thank Tarbiat Modares University for their financial support for this project. This systematic review recorded by the International Prospective Register of Systematic Reviews (PROSPERO) on 15 January 2019 with registration number: CRD42020165598.

Funding

This research is funded by Tarbiat Modares University, Tehran, Iran (Grant no. 1398–230).

Author information

Authors and Affiliations

  1. Department of Reproductive Health and Midwifery, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran

    Mona Rahnavardi & Shadab Shahali

  2. Health Metrics Research Center, Institute for Health Sciences Research, ACECR, Tehran, Iran

    Ali Montazeri

  3. Faculty of Humanity Sciences, University of Science &Culture, Tehran, Iran

    Ali Montazeri

  4. Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran

    Fazlollah Ahmadi

Authors
  1. Mona Rahnavardi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Shadab Shahali
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ali Montazeri
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Fazlollah Ahmadi
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

MR and SS were involved in study conception, and conducted primary search in databases. SS supervised and coordinated the research process. MR and SS conducted primary title and abstract screening and made separate judgments about the searched studies, and in case of disagreement, the third author AM and FA get the consensus. AM and FA were advisors for this study, and contributed to wrting process and interpreting the results. MR and SS conducted screening, quality assessment, and data extraction. MR drafted the manuscript. All authors read and accepted the last version of manuscript.

Corresponding author

Correspondence to Shadab Shahali.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declared there are no potential conflicts of interest

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Rahnavardi, M., Shahali, S., Montazeri, A. et al. Health care providers’ responses to sexually abused children and adolescents: a systematic review. BMC Health Serv Res 22, 441 (2022). https://doi.org/10.1186/s12913-022-07814-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12913-022-07814-9

Keywords

BMC Health Services Research

ISSN: 1472-6963

Contact us