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.

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

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

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).

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.

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.

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

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.

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

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.

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

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

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.