Child sexual abuse. A Medical and health problem

Liset Alfonso Rodríguez1, Dunia Ferrer Lozano2, Jesús Cuéllar Álvarez3

1Psychologist. University Wellbeing Center, Faculty of Social Sciences, "Marta Abreu" Central University of “Las Villas”, Santa Clara, Cuba.
2Dra. Cs. University Wellbeing Center, Faculty of Social Sciences, "Marta Abreu" Central University of “Las Villas”, Santa Clara, Cuba.
3MSc.Policlinic “José Ramón León Acosta” of Santa Clara.

*Corresponding author

*Jesús Cuéllar Álvarez, MSc.Policlinic “José Ramón León Acosta” of Santa Clara


This article analyzes the psychosocial complexity of child sexual abuse from a medical perspective, through a theoretical review of the main considerations on the subject. The lack of preparation of the general medical personnel for the diagnosis and treatment of cases is recognized, as well as in mastering the care protocols for these victims and their families. That is why a group of practical considerations are offered for the care of these children and their families, from primary health care services.  

Keywords: child sexual abuse; primary health care; children; sexual violence


Child sexual abuse is a serious public health problem and a very frequent reason for consultation in primary care. It occurs in all cultures and societies and in any social stratum, constituting a universal and complex problem, which still remains hidden in statistics. Its late disclosure is common, due to the secrecy or "conspiracy of silence" that so frequently surrounds these cases. (1) This situation makes diagnosis and subsequent management difficult, both for the personal physician and for the family itself. (2)

As a form of manifestation of violence, it is a growing phenomenon, turned into a global problem, encompassing complex forms and affecting large population groups. Its consequences have an important impact on the adequate physical and psychological development of the victim who suffers from it and may even lead to death.

Its consequences include signs of distress (crying, fear, shame) and symptoms such as genital or abdominal pain, bruising in intimate areas, sexually transmitted infections, genital injuries (genital, anal or urethral trauma, bleeding, itching, discharge, chronic genital pain, foreign body in the vagina), anal lesions (proctitis, bleeding, pruritus, chronic anal pain, encopresis, painful defecation, foreign body in the rectum), urinary lesions (dysuria, recurrent urinary infection, enuresis and abdominal pain), oral lesions (hematoma on the palate). (3-5)

Mutism, eating disorders, enuresis, loss of interest in attractive activities, as well as different forms of somatization can also appear as consequences. Another consequence is the process called "sacrificial alienation", which is adaptation to the situation, taking into account the dependence of the abuser and the process of submission and manipulation that it imposes (3-5). Adolescents often respond by becoming depressed, experimenting with drugs or alcohol, or running away from home. (6)

The World Health Organization estimates, in terms of prevalence, that in the world approximately 150 million girls and 73 million boys have been victims of some form of sexual abuse before reaching the age of 18. The prevalence rate of some type of sexual abuse of minors in the general population of several countries is 7.4% for boys and 19.2% for girls. (7)

The diversity of ways in which sexual abuse can occur makes conceptualization difficult. In general, it is assumed as that act in which immature and dependent children and adolescents are involved in sexual activities that are not truly understood and for which they are not prepared for their development, not being able to consent responsibly. (8)

The American Academy of Pediatrics highlights in its definition that it supposes the imposition of conduct of sexual content by a person (an adult or another minor) towards a child, in a context of inequality of power, generally through deception, force, lying or manipulation. (9)

According to the World Health Organization, sexual abuse includes advances, touching, harassment, pimping or rape, use of children for sexual purposes or other promises of economic advantage, exhibitionism, voyeurism, obligation to observe sexual acts, offering of pornographic material and, of course, commercial sexual exploitation. Other authors agree with what has been stated. (10)

Regarding the victim of sexual abuse, studies show that girls are abused more severely and with greater violence, in addition to the fact that the age of initiation of abuse is also lower in them. The age of maximum incidence of abuse cases, both in girls and in boys, is usually between 6 and 12 years old. (4)

The organization Save the Children identifies some risk groups in the child population: institutionalized children; children with physical, sensory or mental disabilities; children in poverty; minors living in dysfunctional families; submissive, introverted, calm, isolated children or from families in which cases of this type have already existed. (3)

As a health problem, primary care doctors and nurses are in a favorable position to detect children at risk of sexual abuse, collaborate in the protection of this population and carry out preventive activities. (4-10)

The sensitivity of the subject generates a great emotional impact on these professionals, due to the tension of achieving an objective diagnosis, amidst the confusion, shame and fear of the infants, and then proceed with the respective denunciation of the fact. This justifies the need for a multidisciplinary approach involving doctors, especially pediatricians, but also the nursing service, psychologists and social workers. (1)

The bibliographic review carried out on the management of these cases in primary health care reveals some guidelines to achieve a comprehensive intervention for the victim and their environment, favoring a better prognosis:

  • Health personnel must diagnose abuse, rule out differential diagnoses, inform child protection services, evaluate and treat possible sexually transmitted infections and / or pregnancies. (2)
  • It is important to differentiate sexual abuse from Crohn's disease, Behcet's syndrome, molluscum contagiosum, human papillomavirus, herpes simplex virus, urethral or anal prolapse, anal fissures caused by constipation or straining with defecation.(2-6) Physical lesions must also be differentiated from diaper rash, seborrheic dermatitis, accidental causes such as straddle fall, scratching lesions, scabies, among other physics injuries. (5)
  • It is also the responsibility of these services to provide support to children and their families, as well as to advise parents and children on possible actions to prevent sexual abuse. (2)
  • This process requires establishing a relationship of respect, trust and confidentiality, maintaining a friendly and non-judgmental attitude against the victim or his family, and being aware of the seriousness of his problem. (2,6,9)
  • In the interview with child victims, the use of general, simple and open questions should be tried, not suggestive of possible answers. What the child says in his own words must be recorded correctly. (1) It is advisable not to insist too much on the child with directed questions and to avoid them feeling pressured. (5) You must be empathetic, recognizing the presence of pain, shame, fear and insecurity in the victim. (2,6,9)
  • The process requires the preparation of an accurate medical history and a thorough physical examination of the victim. (2) The diagnosis of sexual abuse should be based on the overall medical history, physical examination, and laboratory findings. (1)
  • The physical examination should be complete and the oral cavity should never be forgotten. (5) However, minors should not be examined more than necessary; therefore, it is recommended that the assessment be carried out by the most experienced physician who is in the service at that time. (3,4,9)
  • It is recommended to carry out the physical examination in the company of a family member or health personnel, asking the consent of the child and his or her. (4,10)
  • The physical examination can be very traumatic for the child. It is important that the child does not assume the physical examination as the equivalent of rape. Family or health team reactions that make the child feel guilty of the abuse should also be avoided. (1)
  • Outpatient management of victims is recommended, as well as guidance to parents for subsequent protection at home and the guarantee of a safe coexistence. (1,8) Hospitalization should be assessed only in necessary cases. The intervention must be done at the time it is requested, because if it is postponed it could imply a retraction on the part of the patient and favor the repetition of the abuse.

The prevention of child sexual abuse should include the training of health professionals and all those who have contact with children and adolescents at risk. (5)

Children's language development, psychosexual development, apprehension, fear and shame can be barriers that hinder the practice of health professionals. It can be embarrassing for these to discuss sexual issues with a child. (1)  Attention to this problem is a challenge for primary care professionals, so it cannot be left to self-preparation. Training processes are needed to allow them to conduct such a complex diagnostic and interventional process.

Conflicts of interest: The authors declare that they have no conflicts of interest.


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