Treatment and Follow-up : Sexual Abuse
The medical consequences of sexual abuse may require prophylaxis and treatment of sexually transmitted infections, emergency contraception, and treatment of any injuries resulting from the abuse. In all cases, the emotional and mental health consequences of sexual abuse must be addressed. Similarly, caregivers and other family members may be psychologically traumatized by the event or events of sexual abuse and resources provided as needed.
Using the content below, dot phrases may be created for use in the electronic medical record, enabling the provider to efficiently check commonly required medications and follow-up.
Treatment of Injuries
Most sexually abused children do not present with injuries or sexually transmitted infections and, therefore, most require only supportive care, reassurance, and referral for mental health support as needed. Children and adolescents with post-assault vaginal bleeding require an emergent evaluation for signs of shock and may need emergency treatment by a gynecologist or other surgical subspecialist with expertise in gynecological repair for repair of any genital injuries.
STI Prophylaxis/Empiric Treatment
STI prophylaxis is generally recommended for adolescent victims of child sexual assault, including empiric treatment for common STIs. This differs from the recommendations for prepubertal children where routine presumptive STI treatment is generally not recommended. The risk of a prepubertal child acquiring an STI as the result of a sexual assault is low and adolescent females are at a higher risk of ascending infections.
Key Points
- If a child or caregiver is worried about infection, this may justify starting treatment even if the child is prepubertal.
- Always collect cultures and diagnostic tests before starting antibiotics.
- Sexually active adolescents should be advised to avoid sexual activity until treatment is complete.
Presumptive Antibiotics
For female adolescent sexual assault survivors, the recommended empiric treatment for C. trachomatis, N. gonorrhoeae, and T. vaginalis includes:
- Ceftriaxone 500 mg IM in a single dose (1 g for persons weighing ≥150 kg) plus
- Doxycycline 100 mg orally 2 times/day for 7 days plus
- Metronidazole 500 mg orally 2 times/day for 7 days
- Treatment for trichomoniasis can be delayed (and medications prescribed for later) to minimize drug interactions and potential side effects with co-administration of emergency contraception, or if there is a history of alcohol consumption.
For male adolescent sexual assault survivors, the recommended empiric treatment for T. trachomatis and N. gonorrhoeae includes:
- Ceftriaxone 500 mg IM in a single dose (1 g for persons weighing ≥150 kg) plus
- Doxycycline 100 mg orally 2 times/day for 7 days
For more information on diagnostic tests, see: LABORATORY: Testing for Sexually Transmitted Diseases, Diagnostic Testing.
Treatment Of Viruses
- Hepatitis B
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The CDC guidelines recommend that Hepatitis B vaccination be given for all unvaccinated, uninfected persons who are sexually active with multiple partners or are being evaluated or treated for an STI. The Hepatitis B series includes a vaccine at the initial examination for sexual abuse/assault, and follow-up boosters at 1-2 months and 4-6 months.
For a previously unvaccinated patient:
- If the perpetrator’s Hepatitis B status is unknown: offer the Hepatitis B vaccination (not HBIG) and series.
- If the perpetrator is Hepatitis B surface antigen positive: offer the Hepatitis B vaccination and series and HBIG.
For a previously vaccinated patient:
- If the patient has not had post-vaccination testing (proof of immunity): offer the Hepatitis B vaccine, test for immunity.
- If the patient is partially vaccinated (has an incomplete series): offer the Hepatitis B vaccine and series.
- Hepatitis C
- There is currently no vaccine for Hepatitis C virus prevention and no post-assault empiric treatment. Children and adolescents diagnosed with HCV infection may be treated with a direct acting antiviral. Consultation with an infectious diseases specialists may be needed. For further information, see: American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASLD-IDSA) - HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C.
- Herpes Simplex Virus
- Post-assault presumptive treatment for HSV is generally not recommended. Most patients are not treated with systemic antivirals until the onset of symptoms.
- Human Papilloma Virus (HPV)
- Unvaccinated or incompletely vaccinated male and female children and adolescents aged 9-45 years are recommended to receive HPV vaccination. The vaccine series includes one at the initial examination, follow-up dose at 1–2 months, and one 6 months after the first dose. A 2-dose schedule (0 and 6–12 months) is recommended for persons initiating vaccination before age 15 years. HPV vaccination prevents new infection and does not treat existing infections. See Centers for Disease Control and Prevention - HPV Vaccination Recommendations for the latest recommendations.
- Human Immunodeficiency Virus (HIV)
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HIV Post-Exposure Prophylaxis (PEP) Recommendations
- PEP should be considered on a case-by-case basis depending on the individual’s risk of acquiring HIV.
- Consultation with an HIV specialist is recommended if PEP is being considered.
- Initiate PEP as soon as possible (ideally within 72 hours of the assault) to maximize its effectiveness.
- If PEP is offered:
- Discuss the importance of early initiation, close follow-up, adherence to the regimen, and potential adverse effects. (Severe side effects are rare.)
- Consider providing an initial 3–7-day course of PEP, or the entire 28-day course, at the initial visit. Providing the full course early can help improve adherence.
Factors that increase the risk of HIV infection include:
- Chronic sexual abuse
- Multiple perpetrators
- HIV-positive perpetrator
- High local HIV prevalence
- Perpetrator with a genital lesion
HIV Prophylaxis Checklist
- Check the HIV Guidelines section of New York State Department of Health Aids Institute - HIV Clinical Guidelines Program for updated recommendations.
- Identify local HIV (pediatric infectious disease) experts and whom to call to obtain a consultation on appropriate treatment.
- Check to see that HIV medications are available through the hospital formulary or a local pharmacy.
- Identify whom to contact for NYS Crime Victim Board reimbursement for patient medication.
- Provide a patient packet containing a supply of medications and information regarding the HIV specialist follow-up. Provide written patient education on possible side effects/drug reactions.
For more information on HIV, see: New York State Department of Health Aids Institute - HIV Clinical Guidelines Program and for more information on HIV testing, see: LABORATORY: HIV.
STI Treatment
Treatments for diagnosed STIs are the same as those listed above for presumptive treatment. Commonly contracted STIs may vary based on local epidemiology.
For more information, see: the Centers for Disease Control and Prevention - Sexually Transmitted Infections (STI) Treatment Guidelines or Kimberlin DW, Banerjee R, Barnett ED, Lynfield R, Sawyer MH. Red Book: 2024–2027 Report of the Committee on Infectious Diseases. American Academy of Pediatrics. 2024. (DOI) .
For a CDC chart regarding STI treatment, see: Centers for Disease Control and Prevention - Wall chart regarding STI treatment.
Reporting to the State Central Register
When an STI is diagnosed in a child, sexual abuse must be considered and evaluated. The finding warrants a suspicion of abuse and careful evaluation. In general, children under the age of 12 who have an STI, should be reported to the State Central Register (1-800-635-1522) or local hotline.
When a parent is aware of the child/adolescent's STI but fails to take appropriate and timely steps to ensure medical treatment, there is reasonable cause to suspect maltreatment, and this should be reported to the State Central Register. For more information about how to make a report, see REPORTING: How to Make a Report.
New York State Communicable Diseases Reporting Requirements
Reporting the presence of the STI to the local Health Department is different from reporting to the State Central Register. The purpose is to address public health needs such as for public health as enabling health officials to track disease trends, identify and notify at-risk individuals, and implement infection control measures as needed to prevent further spread. New York State Laws - NY State Sanitary Code Title 10 § 2.1 mandates reporting the following STIs to the local Department of Health:
- Chlamydia trachomatis
- Neisseria gonorrhoeae
- Hepatitis A, B, C
- Herpes infection in infants 60 days and younger
- Syphilis (Treponema Pallidum)
- Chancroid
- Lymphogranuloma venereum
Common infections may vary based on local epidemiology. The primary responsibility for reporting rests with the physician. For a directory of NYS County Health Departments, see: New York State Association of County Health Officials (NYSACHO) - Directory of County Health Offices.
For a complete list of all communicable diseases that require reporting to the NYS Health Department, see: New York State Department of Health - Communicable Disease Reporting
Pregnancy Prevention
Unprotected intercourse exposes females to unplanned pregnancy. Healthcare professionals should educate patients on emergency contraception when pregnancy is not desired.
Ineffective (but not harmful) if the woman is already pregnant.
For more information, see: American College of Obstetricians and Gynecologists. Emergency Contraception. Practice Bulletin No. 152, Reaffirmed 2022. 2010.
Centers for Disease Control and Prevention (CDC). U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR. Morbidity and mortality weekly report. 2024; 73 (4).
Centers for Disease Control and Prevention (CDC). U.S. Selected Practice Recommendations for Contraceptive Use, 2024. MMWR. Morbidity and mortality weekly report. 2024; 73 (3).
Centers for Disease Control and Prevention - Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC)
Counseling and Offering Emergency Contraception
For adolescent sexual assault victims, offer emergency contraception within 120 hours of the assault.
- Discussion should include failure risks and pregnancy management options.
- A baseline urine pregnancy test is recommended.
For more information, see: Braverman PK, Alderman WP, Alderman EM, Breuner CC, Levine DA, Marcell AV, O’Brien RF; COMMITTEE ON ADOLESCENCE. Contraception for adolescents. Pediatrics. 2014; 134 (4) : e1244-56. (DOI) .
Follow-Up Care After Acute Sexual Assault in Children and Adolescents
Why Follow-Up Matters
Follow-up care is critical for children and adolescents after an acute sexual assault. Unfortunately, ensuring this care, particularly after emergency department visits, can be challenging. Proper follow-up offers reassurance, supports emotional recovery, and ensures any injuries or infections are effectively treated.
Goals of Follow-Up Care
- Reassure and Support the Child and Family
Even when there are no visible injuries or infections, a follow-up appointment can reassure the child or adolescent and their caregivers that there is no lasting physical harm. Follow-up care also provides continued emotional support and education for families. - Monitor and Treat Identified Conditions
For those with documented injuries or infections, follow-up ensures appropriate healing and compliance with treatment. - Conduct Additional Testing When Needed
Follow-up in 2 weeks is often recommended by experts, even when empiric treatment for STIs was given.
Recommended Follow-Up Testing for STIs
According to the Centers for Disease Control and Prevention - Sexually Transmitted Infections (STI) Treatment Guidelines, certain tests and evaluations may need to be repeated over time. For example:
- Syphilis, HIV, Hepatitis B: Repeat testing at 4–6 weeks and again at 3 months.
- Symptoms of new infection: Any child who develops new symptoms post-assault should be re-evaluated immediately.
- High-risk exposure: Children evaluated within hours to one week of the assault and considered at increased risk for STIs may need scheduled follow-up testing. For more information, see LABORATORY: Who Should be Tested.
- Hepatitis B vaccine status: Children already vaccinated may require additional booster doses depending on timing and exposure.
Emotional and Psychological Support
A child’s emotional response to abuse may change and intensify over time and the emotional impact of trauma may not be evident initially. Symptoms of short- and long-term trauma can include:
- Depression and low self-esteem
- PTSD
- Behavioral issues
- Difficulties in relationships or school
- Risk of future victimization or acting out abuse
Mental Health Support and Referrals by Healthcare Professionals after Child/Adolescent Sexual Abuse
- Assess the need for urgent mental health support
- Refer to skilled mental health professionals when appropriate
- Ensure that families receive clear written instructions on next steps
- Maintain close follow-up to monitor progress
Settings for Ongoing Follow-Up Care
- Child Advocacy Centers (CACs)
- These offer the most comprehensive multidisciplinary support and may include medical, psychological, legal, and social services under one roof.
- Medical Home
- If a CAC is not accessible due to distance, scheduling, or family preference, the child’s pediatrician or family doctor may be the most practical option for continued care.
