Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Child sexual abuse presentation and referral
Paediatrics and child health · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Recent assault with acute medical or protection needs
Major bleeding, strangulation symptoms, severe pain, loss of consciousness, intoxication, suicidal crisis, pregnancy risk, possible HIV exposure or immediate access by an alleged perpetrator requires urgent coordinated care.
Action: Stabilise urgent injury and mental-health risk, call senior paediatrics and the regional child sexual assault or paediatric forensic service, and contact children's social care and police through the emergency pathway. Preserve clothing and potential samples without delaying treatment; specialist teams assess forensic timing, emergency contraception, infection prophylaxis and safe placement.
Overview
Respond safely to possible child sexual abuse, hear disclosures without leading, identify urgent medical and forensic needs, obtain specialist examination through the correct pathway, preserve evidence and coordinate protection, treatment and follow-up.
Child sexual abuse includes contact and non-contact acts, online abuse, exploitation and involvement in sexual images or activity that a child does not understand, cannot agree to freely or is not developmentally prepared for. Children may disclose directly, gradually, accidentally or through behaviour. Many never use the word abuse. The clinician's task is to respond supportively, identify immediate needs and activate specialist pathways, not to investigate guilt.
Create privacy without isolating the child unsafely. Establish who accompanied them and whether that person may influence the account. Explain that information cannot be kept secret if someone is unsafe. Use prompts such as 'Tell me more about that' only as necessary to understand urgent medical needs, timing and current access. Avoid naming body parts or actions the child has not used. Document exact words, emotional state, questions and spontaneous corrections.
Practice
Two practice questions
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Question 1 of 2
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Paediatrics and child healthOriginal SBA
Responding to disclosure
A 10-year-old says, 'My uncle touches me where he shouldn't,' and then becomes silent. The child is medically stable. What is the best immediate communication response?
Sources and review status3 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
NICE NG76 Child abuse and neglectNational recommendations inform recognition, supportive communication, referral and therapeutic response after suspected sexual abuse.
Assess ABCDE, pain, bleeding, strangulation, intoxication, ingestion, self-harm and suicidal thinking. Determine whether the event was recent enough for forensic recovery or time-sensitive prophylaxis, but obtain specialist advice rather than relying on a rigid local estimate. Necessary treatment is never postponed to preserve evidence. When safe, avoid washing affected areas and store clothing separately in accordance with police or forensic instructions.
A non-specialist should not undertake an internal genital or anal examination or collect forensic swabs. A general examination may be needed for acute care and other injuries, with consent and chaperoning. Specialist paediatric forensic clinicians decide the nature and timing of examination, photography and samples. The child receives a clear explanation, choices and pauses; assent and competent consent are respected within protection duties.
Sexual-health care is individualised by pubertal status, exposure, time, symptoms and source risk. It can include urine or site-specific nucleic-acid testing, cultures, baseline and later serology, pregnancy testing, emergency contraception, hepatitis B vaccination and HIV post-exposure prophylaxis. Positive results require specialist interpretation because transmission routes and perinatal infection differ. Offer treatment without implying that a normal result disproves the account.
Referral is prompt and coordinated. Children's social care assesses protection, and police coordinate suspected crime and forensic investigation. Identify siblings and other potentially exposed children. Plan how results and appointments will be communicated without unsafe messages or portal access. Long-term care addresses trauma symptoms, education, sexual health and family support, while avoiding repeated retelling and respecting the child's pace.
Key points
Believe the seriousness of the disclosure without declaring facts proven; listen calmly and prioritise the child's immediate safety.
Ask only minimal open questions needed for urgent care and referral, then record the child's words and your questions verbatim.
Do not promise secrecy, confront an alleged perpetrator or ask the child to repeat the account to multiple professionals.
Treat bleeding, strangulation, intoxication, severe pain and mental-health crisis immediately while contacting specialist safeguarding services.
Seek early advice from the regional paediatric sexual assault or forensic medical service before bathing, changing clothes or taking non-essential samples.
A normal genital or anal examination neither disproves abuse nor reduces the importance of the child's account and context.
Specialists assess forensic opportunities, pregnancy, STI testing, hepatitis vaccination, emergency contraception and HIV post-exposure prophylaxis.
Refer to children's social care and coordinate police involvement; arrange trauma-informed follow-up with a named professional and safe communication method.
Aetiology
01
Contact sexual abuse
Touching, penetration and other sexual acts imposed on a child exploit power, developmental vulnerability or inability to give meaningful agreement.
02
Non-contact abuse
Exposure, voyeurism, sexual messaging, grooming, coerced image creation and forced viewing can cause substantial harm without physical contact.
03
Exploitation and trafficking
A child may be exchanged, manipulated or controlled through affection, money, status, debt, threats or movement between locations for sexual purposes.
04
Peer-perpetrated harm
Sexual abuse can be committed by another child; development, coercion, age difference and power imbalance inform safeguarding for everyone involved.
Pathophysiology
1
Tissue injury
Force or penetration can injure genital, anal, oral or other tissues, yet rapid healing and tissue elasticity mean later examination is commonly normal.
2
Infectious exposure
Mucosal contact may transmit bacterial, viral or parasitic infection, with risk varying by act, tissue damage, source and elapsed time.
3
Traumatic stress
Fear, betrayal, secrecy and loss of control can alter arousal, memory, sleep, mood, relationships and bodily symptoms without one uniform presentation.
4
Reproductive consequence
Post-pubertal exposure can cause pregnancy, creating time-sensitive preventive, diagnostic and psychosocial needs within a safeguarding framework.
Clinical features and red flags
Direct or partial disclosure
The child may name an act, unsafe person, secret or fear without providing a complete chronological narrative.
Physical presentation
Genital pain, bleeding, discharge, dysuria, pregnancy or infection can prompt assessment, but absence of signs is common.
Trauma response
Nightmares, avoidance, dissociation, regression, anxiety, self-harm or school decline may follow abuse but remain clinically nonspecific.
Grooming context
Gifts, secrecy, older associates, unexplained travel, multiple devices or coercive messages can indicate manipulation and ongoing access.
Peer sexual harm
Coercion, threats, age or status imbalance and inability to withdraw distinguish harmful behaviour from freely chosen age-appropriate exploration.
Red flags requiring action
A child directly or indirectly describes sexual contact, requests help, names an unsafe adult or communicates through age-incongruent sexualised behaviour.
Genital or anal injury, bleeding, pain, discharge, pregnancy or a sexually transmitted infection may require specialist assessment, although examination is often normal.
Strangulation, sedation, threats, filming, multiple perpetrators, trafficking or exploitation creates additional acute medical and evidential risk.
Assess injury, wellbeing, evidence opportunities and treatment needs sensitively.
Interpretation and limitations
Normal anatomy is frequent after abuse; findings are described objectively and interpreted by appropriately trained clinicians.
02Exposure-directed STI testing
Why
Detect infection at relevant anatomical sites and plan treatment.
Interpretation and limitations
Test choice and timing follow specialist sexual-health protocols; repeat testing may be needed during diagnostic windows.
03Pregnancy assessment
Why
Identify pregnancy risk and provide time-sensitive reproductive healthcare.
Interpretation and limitations
Testing is offered according to pubertal development and exposure, with confidential explanation and safeguarding-sensitive follow-up.
04Baseline and interval serology
Why
Evaluate blood-borne virus exposure and later seroconversion where indicated.
Interpretation and limitations
Negative baseline tests do not exclude recent acquisition; specialists set repeat timing and vaccination or prophylaxis needs.
05Mental-health and safety assessment
Differential diagnosis
01
Accidental genital injury
Straddle injury and other accidents have characteristic histories and distributions; specialist review reconciles anatomy, timing and proposed mechanism.
02
Dermatological or inflammatory disease
Lichen sclerosus, dermatitis, infection and inflammatory bowel disease can cause pain, bleeding or altered appearance requiring clinical treatment.
03
Developmentally expected behaviour
Curiosity and self-touch may be typical, while intrusive, coercive, persistent or age-incongruent behaviour needs broader contextual assessment.
04
Consensual peer relationship
Adolescent sexual activity requires assessment of competence, freedom, age, power, exploitation and law rather than a simple consent label.
Management
01Initial responseListen, stabilise and limit questionsFirst stepA child discloses abuse or presents with acute concerning features.+
1Treat injury, strangulation effects, intoxication and mental-health emergencies.
2Listen calmly and ask only open questions required for safety.
3Record exact words, prompts, timing, companions and observed behaviour.
4Ensure the child is not left with a person who may pose risk.
02Specialist careCoordinate forensic and health needsSexual contact, recent assault, injury or infection risk is possible.+
1Contact the regional child sexual assault service promptly.
2Preserve potential evidence according to specialist and police advice.
3Arrange consent-led examination, testing and time-sensitive prophylaxis.
Complications
01
Injury, infection and pregnancy
Untreated physical consequences may include pain, scarring, sexually transmitted infection and unintended pregnancy with enduring health implications.
02
Trauma-related mental illness
Anxiety, depression, post-traumatic symptoms, dissociation, eating problems, substance use, self-harm and suicidality can develop or recur.
03
Continuing exploitation
Grooming, images, threats, debt and online contact can maintain control after physical separation from an alleged perpetrator.
04
Secondary institutional harm
Disbelief, repeated interviews, avoidable examinations or poor confidentiality can intensify shame and deter future help-seeking from professionals.
Monitoring and follow-up
Arrange repeat infection tests and serology at specialist-defined intervals, assigning responsibility for communicating every result safely.
Review adherence, adverse effects and completion if HIV prophylaxis, antibiotics, vaccination or emergency contraception has been provided.
Assess pain, bleeding, urinary or genital symptoms, pregnancy risk and menstrual concerns at follow-up without requiring repeated disclosure.
Screen sensitively for sleep problems, intrusive memories, avoidance, depression, self-harm, substance use and school disruption over time.
Confirm that online accounts, devices and communication channels are managed within the police and safeguarding plan rather than altered impulsively.
Offer continuity with a named clinician or advocate and adapt appointment timing, location and communication to the child's sense of safety.
Special situations
Normal examination is expected
Rapid healing, elastic tissue and non-contact abuse mean many affected children have no diagnostic physical finding.
Minimal facts protect evidence
Enough information is gathered for urgent health and safety decisions; detailed evidential interviewing belongs to trained investigators.
Consent remains active
Examination is explained step by step, and the child can pause or decline elements unless immediate life-saving care is required.
Digital access can continue harm
Blocking one contact may not remove copied images, alternate accounts, shared passwords or threats to family and peers.
Follow-up should avoid retelling
Professionals can use shared records and focus on current health so the child is not repeatedly asked for an account.
Common pitfalls
01
Asking leading or repeated questions in an attempt to decide whether the allegation is true.
02
Promising confidentiality that conflicts with the duty to share information needed for safety.
03
Performing a non-specialist internal genital examination or taking poorly coordinated forensic samples.
04
Treating a normal examination or negative early infection test as evidence that abuse did not occur.
05
Confronting an alleged perpetrator before multi-agency planning and thereby increasing intimidation or evidence loss.
06
Sending results through a shared portal or telephone number that an unsafe adult can access.
Sudden fear, self-harm, regression, sleep disturbance, school change, avoidance of a person or unexplained gifts can be contextual clues but are not specific alone.
The alleged person retains access to the child, siblings or other children, making immediate multi-agency safety planning essential.
A caregiver's disbelief, pressure to retract or repeated questioning can increase harm and should prompt careful protection of the child's voice.
Why
Identify acute trauma, self-harm, suicidality and coercive control.
Interpretation and limitations
Immediate risk changes supervision and admission plans, while absence of symptoms does not invalidate the safeguarding concern.
4Plan secure result communication and repeat sexual-health follow-up.
03ProtectionRefer and prevent continued accessAbuse is disclosed, suspected or associated with continuing exploitation risk.+
1Refer to children's social care with the child's words and clinical concerns.
2Coordinate police involvement without conducting a parallel detailed interview.
3Assess siblings, devices, online contact and alleged perpetrator access.
4Agree safe placement, communication and trauma-support arrangements before discharge.
Key medicines and prescribing safety1 treatment · regimens, roles and cautions+
Time-sensitive oral emergency contraception for a post-pubertal young person after pregnancy-risk exposure.
Ulipristal acetate emergency contraception
Give 30 mg orally as a single dose within 120 hours of unprotected sexual exposure when clinically appropriate, after specialist assessment of pregnancy risk, interactions and consent.
Discuss copper intrauterine contraception as the most effective option where suitable; check enzyme inducers, severe asthma treated with oral glucocorticoids, breastfeeding advice, vomiting and interaction with subsequent hormonal contraception.