The World Health Organization (WHO) has released a new guideline document, ‘Responding to Children and Adolescents who have been sexually abused- WHO Clinical Guidelines’.

Background Information:

Child: Any person below the age of 18 years.

Adolescent: Any person aged between 10 and 19 years.

Young Adolescent: A person between 10 and 14 years of age.

Older Adolescent: A person between 15 and 19 years of age.

Child sexual abuse: The involvement of a child or an adolescent in sexual activity that he or she does not fully comprehend and is unable to give informed consent to, or for which the child or adolescent is not developmentally prepared and cannot give consent, or that violates the laws or social taboos of society.

It includes incest which involves abuse by a family member or close relative. Sexual abuse involves the intent to gratify or satisfy the needs of the perpetrator or another third party including that of seeking power over the child.

Three types of child sexual abuse are often distinguished:

1. non-contact sexual abuse (e.g. threats of sexual abuse, verbal sexual
   harassment, sexual solicitation, indecent exposure, exposing the child to pornography);
2. contact sexual abuse involving sexual intercourse (i.e. sexual assault or rape – see below); and
3. contact sexual abuse excluding sexual intercourse but involving other acts such as inappropriate touching, fondling and kissing.

Child sexual abuse is often carried out without physical force, but rather with manipulation (e.g. psychological, emotional or material). It may occur on a frequent basis over weeks or even years, as repeated episodes that become more invasive over time, and it can also occur on a single occasion.

Sexual assault: Use of physical or other force to obtain or attempt sexual penetration. It
includes rape, defined as physically forced or otherwise coerced penetration of the vulva, vagina or anus with a penis, other body part, or object. It also includes oral penetration.

Key Messages:

Sexual abuse, including sexual assault or rape, of children and adolescents, is a major global public health problem, a violation of human rights, and has many health consequences in the short and long term.

A 2011 systematic review and meta-analysis of the prevalence of child sexual abuse around the world places the prevalence among girls at around 20% and among boys at around 8%.

Another 2013 meta-analysis of the current prevalence of child (<18 years of age) sexual abuse worldwide suggests that

• around 9% of girls and 3% of boys experience attempted or completed forced intercourse (oral, vaginal, or anal), and
• 13% of girls and 6% of boys experience some form of contact sexual abuse.

The physical health consequences include injuries and gastrointestinal disorders.

For girls, the sexual and reproductive health consequences of sexual abuse include

• the risk of pregnancy,
• gynaecological disorders such as chronic noncyclical pelvic pain, menstrual irregularities, dysmenorrhoea,
• genital infections and sexually transmitted infections (STIs), including HIV.

Several studies have found that boys and girls who have experienced sexual abuse are more likely to engage in risk-taking behaviours, including

• sexual risk taking and
• abuse of alcohol and drugs later in life,

leading to negative health outcomes in adulthood.

The guidelines include guiding principles, recommendations, and good practice statements.

I. Guiding Principles:

• Attention to the best interests of children or adolescents by promoting and protecting safety; providing sensitive care; and protecting and promoting privacy and confidentiality.
• Addressing the evolving capacities of children or adolescents by providing information that is appropriate to age; seeking informed consent as appropriate; respecting their autonomy and wishes; and offering choices in the course of their medical care, as appropriate.
• Observing non-discrimination in the provision of care, irrespective of their sex, race, ethnicity, religion, sexual orientation, gender identity, disability or socioeconomic status.
• Ensuring the participation of children or adolescents in decisions that have implications for their lives, by soliciting their opinions and taking those into account, and involving them in the design and delivery of care.

II. Recommendations (R):

HIV POST-EXPOSURE PROPHYLAXIS TREATMENT AND ADHERENCE

R1: HIV post-exposure prophylaxis (PEP) should be offered, as appropriate, to children and adolescents who have been raped involving oral, vaginal or anal penetration with a penis, and who present within 72 hours of the incident.

R2: A 28-day prescription of antiretroviral drugs (ARVs) should be provided for HIV PEP, following initial risk assessment.

R3: A triple-therapy regimen (i.e. with three drugs) of ARVs is preferred but a two-drug regimen is also effective.

R4: Adherence counselling should be an important element in the provision of HIV PEP to survivors of sexual assault or rape.

PREGNANCY PREVENTION AND MANAGEMENT AMONG GIRLS WHO HAVE BEEN SEXUALLY ABUSED

R5: Offer emergency contraception to girls who have been raped involving peno-vaginal penetration and who present within 120 hours (5 days) of the incident.

POST-EXPOSURE PROPHYLAXIS FOR CURABLE AND VACCINE-PREVENTABLE SEXUALLY TRANSMITTED INFECTIONS

R6: Presumptive (or prophylactic) treatment for gonorrhoea, chlamydia and syphilis is suggested for children and adolescents who have been sexually abused involving oral,
genital or anal contact with a penis, or oral sex, particularly in settings where laboratory testing is not feasible.

R7: For children and adolescents who have been sexually abused and who present with clinical symptoms, syndromic case management is suggested for vaginal/urethral discharge (gonorrhoea, chlamydia, trichomoniasis), and for genital ulcers
(herpes simplex virus, syphilis and chancroid), particularly in settings where laboratory testing is not feasible.

R8: Hepatitis B vaccination without hepatitis B immunoglobulin should be offered, as per national guidance.

R9: Human papillomavirus vaccination should be offered to girls
in the age group 9–14 years, as per national guidance.

PSYCHOLOGICAL AND MENTAL HEALTH INTERVENTIONS IN THE SHORT TERM AND LONGER TERM

R10: Psychological debriefing should not be used in an attempt to reduce the risk of post-traumatic stress, anxiety or depressive symptoms. (Emphasis added)

R11: Cognitive behavioural therapy (CBT) with a trauma focus should be considered for children and adolescents who have been sexually abused and are experiencing symptoms of post-traumatic stress disorder (PTSD).

R12: When safe and appropriate to involve at least one nonoffending caregiver, CBT with a trauma focus should be considered for both: (i) children and adolescents who have
been sexually abused and are experiencing symptoms of PTSD; and (ii) their non-offending caregiver(s).

R13: Psychological interventions, such as CBT, may be offered to children and adolescents with behavioural disorders, and caregiver skills training to their non-offending caregivers.

R14: Psychological interventions, such as CBT and interpersonal psychotherapy (IPT) may be offered to children and adolescents with emotional disorders, and caregiver skills training to their non-offending caregivers.

In addition to the above, there are several good practice statements that form part of the guidelines.

Useful Links:

Link to the WHO news release:

http://who.int/reproductivehealth/publications/violence/clinical-response-csa/en/

Link to the Guidelines:

http://apps.who.int/iris/bitstream/10665/259270/1/9789241550147-eng.pdf?ua=1