Sexual and Sexualized Behavior in Children : Additional Articles and Resources

The purpose of this clinical report is to provide pediatricians updated research on evidence-based sexual and reproductive health education conducted since the original clinical report on the subject was published by the American Academy of Pediatrics in 2001. Sexuality education is defined as teaching about human sexuality, including intimate relationships, human sexual anatomy, sexual reproduction, sexually transmitted infections, sexual activity, sexual orientation, gender identity, abstinence, contraception, and reproductive rights and responsibilities. Developmentally appropriate and evidence-based education about human sexuality and sexual reproduction over time provided by pediatricians, schools, other professionals, and parents is important to help children and adolescents make informed, positive, and safe choices about healthy relationships, responsible sexual activity, and their reproductive health. Sexuality education has been shown to help to prevent and reduce the risks of adolescent pregnancy, HIV, and sexually transmitted infections for children and adolescents with and without chronic health conditions and disabilities in the United States.

IMPORTANCE: Sexual abuse is increasingly facilitated by technology, but the prevalence and dynamics of such offenses have not been well delineated, making it difficult to design prevention strategies. OBJECTIVE: To examine the frequency and characteristics of online and technology-facilitated sexual abuse against children and youth. DESIGN, SETTING, AND PARTICIPANTS: In this nationally representative online survey study performed from November 19 to December 29, 2021, young adults aged 18 to 28 years were asked retrospectively about their childhood (<18 years) experiences of online and technology-facilitated abuse. The 2639 participants were sampled from an online panel. MAIN OUTCOMES AND MEASURES: Participants were asked questions about 11 different kinds of online and technology-facilitated sexual abuse with follow-up questions about their dynamics and offenders. Prevalence rates were calculated for several cross-cutting concepts (online child sexual abuse, image-based sexual abuse, self-produced child sexual abuse images, nonconsensual sexting, online grooming by adults, revenge pornography, sextortion, and online commercial sexual exploitation). Survey weights were applied to obtain population prevalence estimates. RESULTS: A total of 2639 individuals (48.5% male, 49.8% female, and 1.8% other gender; 23.7% Hispanic, 12.6% non-Hispanic Black, 53.9% non-Hispanic White, 4.8% other race, and 5.0% ≥2 races) were surveyed. Childhood (before 18 years of age) prevalence rates were as follows: online child sexual abuse, 15.6% (SE, 1.0%); image-based sexual abuse, 11.0% (SE, 0.9%); self-produced child sexual abuse images, 7.2% (SE, 0.7%); nonconsensual sexting, 7.2% (SE, 0.7%); online grooming by adults, 5.4% (SE, 0.5%); revenge pornography, 3.1% (SE, 0.5%); sextortion, 3.5% (SE, 0.6%); and online commercial sexual exploitation, 1.7% (SE, 0.3%). The prime age of vulnerability across all categories was 13 to 17 years. Perpetrators in most categories were predominantly dating partners, friends, and acquaintances, not online strangers. CONCLUSIONS AND RELEVANCE: The results of this national survey study suggest that a considerable portion of youth have experienced online child sexual abuse. Professionals planning prevention and intervention strategies for online sexual abuse should understand that dynamics include diverse episodes that are often extensions of dating abuse, sexual bullying, and sexual harassment, not only events perpetrated by adult internet predators.

The present study sought to examine features of sexual abuse cases among a U.S. nationally representative sample of 13,052 children and adolescents, ages 0-17 years. The National Survey of Children's Exposure to Violence was collected in three different years (2008, 2011, and 2014) via telephone interviews. Information about sexual abuse and assault was obtained from youth themselves (ages 10-17) or caregivers (for children ages 0-9) using the Juvenile Victimization Questionnaire. Results indicate most offenses are at the hands of other juveniles (76.7% for males and 70.1% for females), primarily acquaintances, and occurring more frequently for adolescents aged 14-17. Whereas girls are mostly abused by males (88.4%), boys are abused by both males (45.6%) and females (54.4%). In 15% of cases, penetration is part of the abuse. Victims report being very afraid in 37.5% of episodes but not at all afraid in 19.8%. Among 10- to 17-year-olds, 66.3% of episodes are not reported to parents or any adult. Police reports occur for 19.1% of all cases. The results in the present study indicate that children and youth are exposed to sexual abuse and assault in varied ways, which require moving beyond conventional stereotypes of the problem.

STUDY OBJECTIVE: To describe the clinical characteristics of patients referredfor domestic minor sex trafficking (DMST) to improve identification andintervention. DESIGN: Retrospective cohort study. SETTING: The Lawrence A. Aubin,Sr Child Protection Center at Hasbro Children's Hospital where patients areevaluated by child abuse pediatricians in outpatient, emergency department, andinpatient settings. PARTICIPANTS: A total of 41 patients younger than the age of18 years referred for the evaluation of DMST involvement between August 1, 2013and March 30, 2015. INTERVENTIONS AND MAIN OUTCOME MEASURES: We collecteddemographic, social-environmental, medical, and psychiatric variables from themedical records of patients referred for evaluation who have self-disclosed, beenreported with evidence, and/or have histories that place them at high risk forDMST involvement. RESULTS: Children had frequent contact with medical providers,with 81% seen in the year before referral for DMST. Childhood maltreatment andfamily dysfunction were identified (sexual abuse, 21/37 or 57%; parentalsubstance abuse, 22/37 or 60%) in the 41 patients. Children had medical problems(eg, sexually transmitted infection, 13/41 or 32%), psychiatric needs (eg, acutesuicidality, 8/41 or 20%; at least 1 previous psychiatric admission, 19/41 or46%), and substance use (36/41 or 88%). Although 26/41 (63%) had runaway and17/41 (42%) lived in a group home placement, 28/41 (68%) currently lived at homeand 29/41 (71%) presented with a parent/guardian or relative. CONCLUSION:Children referred for DMST present frequently to physicians and have complexmedical and psychiatric needs. Medical providers' increased awareness of thishealth issue would inform victim identification and intervention.

Child sex trafficking and commercial sexual exploitation of children (CSEC) aremajor public health problems in the United States and throughout the world.Despite large numbers of American and foreign youth affected and a plethora ofserious physical and mental health problems associated with CSEC, there islimited information available to pediatricians regarding the nature and scope ofhuman trafficking and how pediatricians and other health care providers may helpprotect children. Knowledge of risk factors, recruitment practices, possibleindicators of CSEC, and common medical and behavioral health problems experiencedby victims will help pediatricians recognize potential victims and respondappropriately. As health care providers, educators, and leaders in childadvocacy, pediatricians play an essential role in addressing the public healthissues faced by child victims of CSEC. Their roles can include working toincrease recognition of CSEC, providing direct care and anticipatory guidancerelated to CSEC, engaging in collaborative efforts with medical and nonmedicalcolleagues to provide for the complex needs of youth, and educating child-servingprofessionals and the public.

PURPOSE OF REVIEW: Sextortion is defined as the act of coercing people into sending explicit images of themselves and subsequently blackmailing victims with the public release of said images. Prosecutions of sextortion cases involving minors have increased almost two-fold in the past 5 years. The purpose of this review is to explore the literature regarding the behavior of both victims and perpetrators, the effects on victims, and the support resources available for clinicians, victims, and parents. RECENT FINDINGS: Sextortion begins as an unassuming request for personal pictures and quickly escalates. Minors targeted by predators fear both punishment by guardians and the social consequences that follow the release of their explicit pictures. This cycle of victimization endangers minors and may lead to mental health problems, such as anxiety and depression. Recently, sextortion cases have risen to the forefront of national attention through the mainstream media with celebrities revealed as both perpetrators and victims. This higher visibility of sextortion highlights the importance of reviewing recent research regarding minors and their online behavior and the tactics of perpetrators. SUMMARY: Sextortion, an extreme form of cyber abuse, endangers minors and may lead to anxiety and depression. Pediatricians should be familiar with the concept of sextortion and discuss its dangers and available resources with parents and minors.

IMPORTANCE: Prepubertal vaginal bleeding outside the neonatal period is always abnormal and is very alarming to parents. A variety of practitioners, including obstetrician-gynecologists and pediatricians, may be asked to see patients with this presenting complaint, yet many do not receive adequate training in pediatric gynecology. EVIDENCE ACQUISITION: Review of the published literature in PubMed, focusing on the last 20 years, regarding the incidence, etiologies, diagnosis, and management strategies for the common causes of prepubertal vaginal bleeding. RESULTS: Careful history taking and pediatric-specific gynecological examination skills, including awareness of normal anatomy across the age spectrum and the ability to identify an estrogenized hymen, are keys to the appropriate assessment of this clinical problem. CONCLUSIONS AND RELEVANCE: Prepubertal vaginal bleeding has many causes and requires a thorough targeted history and pediatric genitourinary examination, requiring knowledge of the variants of normal pediatric genitourinary anatomy. Most causes can be easily treated and are less likely to be due to sexual abuse or malignancy.

This article aims to define and describe female genital anatomy, the changes that occur in the genitalia during growth and puberty, and during sexual response and intercourse. It elaborates the reasons for normal genital examination findings in most female children who have been sexually abused and explains why the absence of findings of genital trauma should not be used to challenge the credibility of the child's history of sexual abuse.

PURPOSE: The objective of this meta-analysis was to provide a synthesis of studies examining the prevalence of unwanted online exposure and solicitation of a sexual nature among youth, and to determine if prevalence varies by youth age, gender, year of study data collection, or study geographical location. METHOD: Eligible studies from January 1990 to January 2016 were identified utilizing a comprehensive search strategy. Included studies examined the prevalence of unwanted online exposure and solicitation in youth who ranged from 12 to 16.5 years. Two independent coders extracted all relevant data. Random-effects meta-analyses were used to derive mean prevalence rates. RESULTS: Thirty-one (37,649 participants) and nine (18,272 participants) samples were included in the syntheses on unwanted online sexual exposure and solicitation, respectively. For online exposure, the mean prevalence rate was 20.3% (95% confidence interval: 17.1-23.4). For online solicitation, the mean prevalence rate was 11.5% (95% confidence interval: 9.4-13.6). Moderator analyses indicated that prevalence rates for unwanted online exposure and solicitation have decreased over time. Prevalence varied as a function of gender (solicitations were higher for males), but not age or geographical location. CONCLUSIONS: Approximately one in five youth experience unwanted online exposure to sexually explicit material and one in nine youth experience online sexual solicitation. Educational campaigns to raise awareness of Internet risks and safety strategies are warranted.

Sexual abuse of children is the involvement of children or adolescents in sexual activities that he or she does not fully understand and can include exhibitionism, fondling, oral-genital contact, and rectal or vaginal penetration. By adulthood, 26% of girls and 5% of boys experience sexual abuse. It is the healthcare provider's responsibility to advise the parents unless they are suspected of abuse and enlist help from other medical specialists or child protective services. A variety of nonspecific presenting symptoms including but not limited to pain, anogenital bleeding, vaginal/urethral discharge, dysuria, urinary tract infection, sexualized behavior, and suicidality are possible. It is also common for the initial presentation of suspected sexual abuse in the absence of any physical symptoms. In such cases, it is important to be mindful that the assailant is often an individual that is close to the victim, such as a close relative or even the parent. All patients presenting within 72 hours of the suspected abuse or presenting with any concerning symptoms should be evaluated emergently, preferably by a sexual assault nurse examiner or child abuse pediatrician if available. In those presenting without symptoms and greater than 72 hours following the suspected abuse, specialized outpatient follow-up should be arranged for further evaluation and treatment. A good understanding of state-specific legislation regarding consent and treatment of minors is essential when treating victims of child sexual abuse.

OBJECTIVE: The implications for sexual abuse investigation of genital herpes in a child are uncertain because of a lack of good quality research evidence. The incidence, presenting features, history of exposure, indicators of child maltreatment and outcomes of child protection investigations in children with genital herpes are described. PATIENTS AND METHODS: Ascertainment of all cases of genital herpes in children <11 years of age first presenting to paediatricians in the UK and Ireland from April 2007 to April 2009 conducted through the British Paediatric Surveillance Unit. RESULTS: 23 cases were notified. The incidence of confirmed and all reported cases was 0.091 and 0.13 per 100,000 children per year, respectively. Of the 16 virologically confirmed cases, 12 were female, 11 were <5 years of age, 14 had herpes simplex type 1, eight were tested for other sexually transmitted infections (STIs), and only one had a full STI screen. Three cases had other clinical features suggestive of sexual abuse. Six cases were referred for child protection investigation, but no sexual abuse was substantiated. CONCLUSIONS: Genital herpes in children under 11 years is rare. Almost a third of children diagnosed with genital herpes did not have appropriate virological investigation and few were screened for other STIs. Around a quarter of cases were referred to child protection agencies for further investigation, which limits any inferences in this study about mode of transmission in children. Sexual abuse guidance should emphasise the need for thorough assessment and investigation in cases of genital herpes in children.

The publicity about online "predators" who prey on naive children using trickery and violence is largely inaccurate. Internet sex crimes involving adults and juveniles more often fit a model of statutory rape--adult offenders who meet, develop relationships with, and openly seduce underage teenagers--than a model of forcible sexual assault or pedophilic child molesting. This is a serious problem, but one that requires approaches different from those in current prevention messages emphasizing parental control and the dangers of divulging personal information. Developmentally appropriate prevention strategies that target youths directly and acknowledge normal adolescent interests in romance and sex are needed. These should provide younger adolescents with awareness and avoidance skills while educating older youths about the pitfalls of sexual relationships with adults and their criminal nature. Particular attention should be paid to higher risk youths, including those with histories of sexual abuse, sexual orientation concerns, and patterns of off- and online risk taking. Mental health practitioners need information about the dynamics of this problem and the characteristics of victims and offenders because they are likely to encounter related issues in a variety of contexts.