Child Sexual Abuse

Definitions (WHO 2009)

Child sexual abuse is the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared and cannot give consent, or that violates the laws or social taboos of society. Child sexual abuse is evidenced by this activity between a child and an adult or another child who by age or development is in a relationship of responsibility, trust or power, the activity being intended to gratify or satisfy the needs of the other person. This may include but is not limited to:

Defilement is unlawful carnal knowledge of a girl 13 or younger (Malawi Penal Code) and requires proof of penetrative sex. Case law suggest penetration is defined as the tip of the penis going beyond the labia majora.

Summary of procedure for dealing with child with possible sexual abuse

Important points in history

**In most cases, the history will be more important than the examination**

Important points on examination

Interpretation of external genitalia findings

Normal and non-specific vaginal findings include:
  • hymenal bumps, ridges and tags
  • v-shaped notches located superior and lateral to the orifice, not extending to base of the hymen;
  • vulvovaginitis
  • labial agglutination
  • vaginal discharge
Anatomical variations or physical conditions that may be misinterpreted or often mistaken for sexual abuse include:
  • lichen sclerosis
  • vaginal and/or anal streptococcal infections
  • failure of midline fusion
  • non-specific vulva ulcerations
  • urethral prolapse
  • unintentional trauma (e.g. straddle injuries) – usually SYMMETRICAL, on mons pubis/ labia majora only
  • labial fusion (adhesions or agglutination)
Findings suggesting or confirming abuse include:
  • acute abrasions, lacerations or bruising of the labia, perihymenal tissues, penis, scrotum or perineum
  • hymenal notch/cleft extending through more than 50% of the width of the hymenal rim (confirmed in knee/ chest as supine view) – usually in ‘4 o’clock to 8 o’clock’
  • scarring or fresh laceration of the posterior fourchette
  • presence of sperm (confirmed on microscopy) or STD

If you are in doubt about the significance of your findings

  • ask for someone with more experience to help
  • refer to Adams et al J Paediatric Adolescent Gynaecology 2007 ‘Guidelines for medical care of children who may have been sexually abused or
  • Guidelines for medico-legal care for victims of sexual violence World Health Organization 2003

Relevant investigations

Reasons for admission


1. Antibiotics to prevent or treat STI
These are NOT generally recommended in pre-pubertal girls. However in our context with high rates of STI they should be prescribed in all children if there is clear evidence that penetration has taken place

2. Post-exposure prophylaxis
PEP should be considered in ALL cases where a naked penis has touched naked skin or mucosa even where there are no physical signs.

The risk is low, but with rape there is often associated violence and genital trauma increasing the rate of transmission

The child is eligible for PEP if the child has presented within 72 hours of the assault and they are HIV negative and the family agree to comply with the treatment

Options are:

!!! A repeat HIV test is required at 3 and 6 months

3. Consider Tetanus Toxoid 0.5ml IM

4. Consider emergency contraception if post-menarchal and <72h from assault

Follow-up/ CSA procedures

Procedures and services for child protection in Malawi are evolving quickly and the up-to-date guidelines should always be adhered to. Currently:
  1. The guardians should be given the stamped medical report form to take back to the referring police station (they should get all the pages – history, examination and report)
  2. All children should be seen at the OSC as soon as possible – preferably the same or next working day.
  3. Keep a copy of all the ‘out of hours’ report forms in the ‘Child Sexual Abuse or defilement’ basket

Guidance for completing the medical report for the police

WRITE A CONCLUSION/ OPINION: (suggestions in italics)