CPD Articles

A brief overview of managing prepubertal children who have experienced sexual abuse

Marianne Kotzé, Chika K. Egenasi, Mathew O. Benedict

Received: 20 Oct. 2025; Accepted: 22 Mar. 2026; Published: 08 June 2026

Copyright: © 2026. The Authors. Licensee: AOSIS.
This work is licensed under the Creative Commons Attribution 4.0 International (CC BY 4.0) license (https://creativecommons.org/licenses/by/4.0/).

Abstract

In South Africa, undergraduate medical teaching does not prepare medical and nursing practitioners adequately for the clinical forensic management of patients who have experienced child sexual abuse. Clinicians might be apprehensive when confronted with children who may have experienced sexual abuse. Their insecurities arise from a perceived lack of knowledge and the time-consuming nature of the legal procedures. The high prevalence of the sexual abuse of children demands the involvement of the medical profession. This article aims to allay uncertainty and address the unnecessary barriers to the provision of service and support to vulnerable pre-pubertal children who are victims of abuse.

Keywords: children; sexual abuse; examination; forensic; position.

Introduction

Child sexual abuse (CSA) is a complex public health challenge.¹ When addressing CSA, the best interests of the child take precedence above all else. Safeguarding children’s emotional and physical wellbeing must be prioritised, even above the forensic investigation.² In South Africa, 1 out of 3 children suffers from some form of sexual abuse.³ Medical practitioners’ avoidance of the issue⁴ might disadvantage a significant number of their paediatric patients.

Nature of child sexual abuse

Child sexual abuse is the involvement of a child in sexual activity in circumstances where there is an imbalance in power, which includes monetary, physical strength, emotional, age and intellectual power.⁵ Adults or other children perpetrate the sexual activity, mostly family members or acquaintances.^5,6 They may be male or female from all socio-economic spheres.⁷ Definitions, terminologies and recognition of CSA vary across cultural, legal and social contexts, as norms around childhood, sexuality, consent and acceptable adult–child interactions are socially constructed and embedded within differing legal frameworks.⁸ The sexual activity comprises acts of non-contact sexual abuse, contact non-penetrative sexual acts or sexual penetration.^9,10,11 The perpetrators exert power utilising non-physical coercion such as bribery, threats, seduction or provision of the material or emotional needs of the children. A minority uses physical force.¹²

Consent for the medical examination

Children 12 years and older give consent for their medical examinations when they are of sufficient maturity to understand the nature of the consent.^2,11 For children under 12 or lacking the maturity to understand consent, guardians usually provide consent unless they are unavailable, deceased, suspected offenders, have a mental disability, cannot or will not give timely consent.¹¹ In such cases, under Section 335B of the Criminal Procedure Act, if a magistrate’s consent cannot be obtained, the investigating officer must declare this under oath, the medical practitioner must confirm under oath that the examination is urgent, and only then may the commissioned police officer or the person in charge of the local police station, grant written consent.¹³ Under no circumstances should a child be compelled to undergo the collection of forensic evidence.¹⁴

Timing of the examination

The conduct of the examination depends on medical, safety, emotional and forensic urgency. Emergency examinations must be carried out without delay, while urgent or ‘as soon as possible’ examinations should be completed within 1–7 days.^15,16 In settings where specialised forensic services are not immediately available, initial clinical assessment and essential management should be provided, with urgent referral to specialised services within the recommended time frame. The Child Advocacy Centre (CAC) model exemplifies a multidisciplinary, child-centred approach, integrating investigative, medical and therapeutic services within a single, child-friendly environment to minimise further trauma and support the child’s recovery¹⁷ (Box 1 and Box 2).

Holistic care of child victims of sexual abuse

The care of sexually abused children extends beyond forensic needs, prioritising the child’s best interests. Avoiding secondary trauma is of paramount importance.¹⁸ Children should not be coerced into examinations, as control tactics echo those used by abusers. Offering a toy or gift to comfort them is appropriate if it is unconditional. A child’s sense of control is essential; if they are uncomfortable and no medical urgency exists, the examination should be postponed until they feel safe and comfortable.

History and preparation for the physical examination

Medical history taking in CSA cases involves symptom-focused questions aimed at identifying injuries, infections and immediate health and safeguarding needs to guide clinical care. Forensic interviewing, in contrast, uses open-ended, non-leading questioning to obtain a detailed and legally reliable account of events for investigative and judicial purposes. The HCP must balance the two purposes.

Children’s disclosure of CSA is generally delayed and incremental.¹⁸ Conversations with medical practitioners may add detail to other interviews,^19,20 helping to differentiate symptoms like urogenital discomfort and bleeding from trauma.^21,22,23

All questions posed to the child and their verbatim responses must be carefully documented, and examiners should avoid making assumptions about the child’s meaning. Where appropriate, interviews may be audio- or video-recorded to enhance accuracy.^24,25 Conversations begin with small talk, then transition into open-ended questions about the purpose of the visit and details of the incident. Age-appropriate questions guide ‘where, when, who, and how’, ensuring clarity without leading suggestions.²⁶ Preparation includes explaining that the examination is painless and using dolls or toys to illustrate positions such a frog ‘frog leg’ and a cat stretching out ‘prone knee-chest’ for familiarity and comfort.

General examination

When conducting a medical examination for a child with suspected sexual abuse, it is essential to ensure that the physical environment is safe, private and child-centred, that a chaperone is present to protect the child’s dignity and support the process and that the timing of the examination is determined by clinical need and the urgency of forensic evidence collection.²⁷

A thorough, non-threatening general examination is crucial to building trust and easing children into the anogenital examination. By integrating anogenital and extragenital assessments, the examination normalises all body areas and avoids placing undue emphasis on the anogenital region. The general examination helps identify necessary medical interventions. It establishes a differential diagnosis, guiding decisions on the anogenital exam, further investigations and forensic evidence collection based on the child’s history and findings. Clinicians should ensure that medical forensic examinations are clearly indicated and minimally intrusive, balancing clinical benefit with the need to prevent additional distress and secondary trauma in the child.¹⁰

Anogenital examination

Children’s right to refuse an examination should be honoured if no urgent medical need exists. Proper preparation and clear explanations generally help children feel comfortable. Examiners should guide children through each step and avoid unexpected touch. If children remain tense, the examination becomes technically challenging, and the findings are unreliable.

Positions of the anogenital examination of prepubertal children

It is recommended to utilise multiple examination positions to distinguish structural abnormalities from normal anatomical variants (Box 2).^28,29.

Frog-leg position

The frog-leg position involves placing a child in a supine position with hip flexion and abduction. The outer aspects of the thighs rest on the surface of the examination couch. In this position, the external genitalia are visible.

Prone knee-chest position

To guide a child into a prone knee-chest (PKC) position, they kneel with knees slightly apart, bending forward to rest their ear flat on the examination couch, facing the support person. Arms lie flat beside the head (not resting on the elbows), and the chest is lowered onto the couch to relax the spine. Proper alignment (head on the ear, arms flat, hips at a 90° angle). In this position, the vagina opens under gravity. The posterior rim of the hymen smooths out, allowing for a more accurate diagnosis of anatomical variation and previous trauma of the anus and female genitalia. The anus is visible without touching, and testing for dynamic anal dilatation can be performed.

Supine knee-chest position

In the supine knee-chest (SKC) position, they lie on their backs, knees approaching the chest as comfortably as possible. The SKC position is an excellent examination position for the anal examination of boys since their genitalia are examined in other positions.

Techniques for the anogenital examination of prepubertal children

Labial separation

In the frog-leg position, the labia are gently separated with the touch of the labia majora and lateral movement.The posterior commissure, fossa navicularis, vestibule and hymen become visible, but the margins of the hymen cannot be adequately visualised.^14,28

Labial traction

The labia majora is held bilaterally between the thumbs and forefingers and pulled in the examiner’s direction. Gentle manipulation of the labia allows visualisation of the hymen. The hymenal opening may be better visualised, but the vagina is a potential space, and the edge of the hymen is still relaxed.^14,28

Floating of the hymen with water or saline

The labia minora may adhere, making visualisation difficult. Dropping water at body temperature onto the genitalia breaks the adhesion and allows the structures to float.^14,28

Gluteal separation

Gluteal separation can be done in the frog leg, PKC or SKC and lateral recumbent positions. The best visualisation of the anus is achieved in the PKC and SKC positions. The technique is mainly utilised to test for dynamic anal dilatation.^14,28

Gluteal lift

In the PKC position, the examiner places his hands laterally to the superior aspects of the labia majora and gently pulls upward and outward. The vagina opens under gravitational force. The posterior hymenal rim, the location where structural abnormalities of the hymen occur, is smoothed out, the margins of the hymen can be visualised, and the differentiation between abnormalities and normal anatomical variation can be assessed. The anus is visualised excellently with this position and technique.^14,28

Collection of evidence

Forensic evidence collection is ideally performed within 24 h for prepubertal children and within 72 h for adolescents. In some young children, evidence collection beyond 24 h may still be considered when appropriate.¹⁵ Deoxyribonucleic acid (DNA) retrieval from prepubertal girls’ bodies is extremely rare, with a higher likelihood of evidence recovery from clothing or bed linen.^{22,30,31,32,33} Because of the genital sensitivity and children’s intolerance to hymenal and vestibular contact, evidence collection must be handled with particular care and sensitivity.

Screening for sexually transmitted infections

Physicians should consider sexually transmitted infection (STI) screening in cases involving oral and anogenital penetration, abuse by a stranger, a person known or suspected to have an STI or high infection risk or when a household member has an STI.³⁰ Screening is also advised if the child shows STI signs, lives in a high-STI area, has vaginal discharge or has previously been diagnosed with an STI.^31,32 Diagnosis must meet international quality standards, using confirming culture or serology.³³

Examining under sedation or anaesthesia

Sedation or anaesthesia for examinations should be limited to cases with specific medical indications, such as acute bleeding, lower abdominal tenderness, severe injuries or foreign object use, and not solely for forensic purposes, as anaesthesia carries rare but serious risks.^34,35 For non-acute cases, over 90% of exams in prepubertal children yield normal findings, and the probability of DNA recovery is close to zero.^22,30,31 Procedures with no health benefit expose healthcare providers to legal liability.³⁶

Interpretation of assessment

History

A clear history with details of time, place, sound, smell, touch and sensation and an imbalance of power is suggestive of CSA.^5,22,37

Physical findings

Congenital absence of the hymen does not occur as an isolated anomaly in otherwise normally developed genitalia.³⁸ See Box 3 for more information.

Conclusion

Child sexual abuse among prepubertal children represents a widespread public health crisis. Inadequate awareness, training and specialised skills among healthcare professionals at the primary care level undermine both effective child protection and judicial outcomes. Deficiencies in undergraduate and postgraduate training further contribute to poor quality documentation and testimony. Healthcare professionals should recognise that they are examining children who have experienced sexual abuse, not the abuse itself; the assessment therefore carries a therapeutic responsibility that prioritises the child’s wellbeing while also fulfilling medico-legal obligations.

Acknowledgements

Competing interests

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

CRediT authorship contribution

Marianne Kotzé: Conceptualisation, Project administration, Resources, Writing – original draft, Writing – review & editing. Chika K. Egenasi: Conceptualisation, Project administration, Resources, Writing – review & editing. Mathew O. Benedict: Conceptualisation, Project administration, Resources, Writing – review & editing. All authors reviewed the article, contributed to the discussion of results, approved the final version for submission and publication, and take responsibility for the integrity of its findings.

Ethical considerations

This article followed all ethical standards for research without direct contact with human or animal subjects.

Funding information

The authors received no financial support for the research, authorship and/or publication of this article.

Data availability

All information concerning the review findings is available from the corresponding author, Chika K. Egenasi, upon reasonable request.

Disclaimer

The views and opinions expressed in this article are those of the authors and are the product of professional research. They do not necessarily reflect the official policy or position of any affiliated institution, funder, agency or the publisher. The authors are responsible for this article’s results, findings and content.

References