Worldwide, more than one in three women experiences intimate partner violence (IPV), the most common form of gender-based violence. There are four identified types of IPV; physical violence, sexual violence, stalking, and psychological aggression. According to some sources, women and girls make up even 90% of sexual assault victims. It is recognized that 30% of adolescent girls aged 15–19 worldwide experience partner violence while in a relationship. We aim to summarize the outline of the problems of sexual abuse against adolescents and children, with particular emphasis on that against girls.

Child sexual abuse includes all forms of sexual violence against people under 18 years old. Frighteningly, it is evaluated that even up to 1 billion children aged 2–17 have been victims of emotional, physical, or sexual abuse or neglect in 2019.

Violence is deeply rooted in gender inequality and has severe consequences for physical and mental health, making social relationships difficult and with economic implications. While violence against girls and women is a long-standing problem, responding effectively to it, especially preventing it, has not been widely implemented [1, 2]. Intimate violence by a partner and sexual violence by third parties can result in psychological trauma and stress, physical trauma, and death in extreme cases [3]. Mainly if it occurs already in childhood or adolescence, people who experience sexual violence often have poorer physical health, more mental health problems, and frequent self-destructive behavior [4].

Doctors, as often the first “points” of contact with people exposed to violence, have a legal obligation to report on the phenomenon of violence, which, in some cases, exempts them from medical confidentiality. Therefore, it is vital to educate students, medical students, and doctors about the phenomenon of violence and its aspects, as well as to recognize it, report it correctly, and proceed in medical practice [5].

Child sexual abuse is a new term for the problem existing for thousands of years. According to World Health Organisation (WHO), child sexual abuse involves engaging the child in sexual activity that it does not understand entirely and is not ready for. Nor is she or he able to give conscious consent to it. This activity is inconsistent with passed laws and common acceptance of society. Such activity includes an action between a child and an adult or another older child and is taken to satisfy the needs of the initiator. There are the following forms of such activity mentioned by WHO:

• inducing or forcing into any illegal sexual activity,

• inducing prostitution or other unlawful sexual practices,

• child abuse in pornographic materials [6, 7, 8, 9].

At the root of these cruel acts towards children usually lie problems related to disorders of sexual preference.

Disorders of sexual preferences or paraphilias are defined as conditions in which sexual arousal or sexual satisfaction appears in relation to any unusual stimulus or behaviour that differs from these stimuli that are commonly regarded as sexually arousing and satisfying.

According to the International Statistical Classification of Diseases and Health Problems (ICD-10), paedophilia is a “sexual contact of an adult person with children, mostly at the age before puberty or at the age of puberty. Some people prefer contacts with girls, other people with boys or interested in both sexes”. It is marked with a code F 65.4 and belongs to disorders of sexual preference, including paraphilia F 65 [6, 7, 8]. It is necessary to protect children against violence. For this purpose, it is crucial to disseminate knowledge about symptoms that can signify violence. There are many causes for hiding by children the fact of sexual harassment. Frequently children are intimidated and forced to silence through bribery or blackmail. They feel worse and alienated because of what happened and are afraid of refusal by their parents. Often they are unaware that sexual actions taken by tormentors are not allowed and forbidden—the problem is even more complex in the case of disabled children.

Programme Therapy Animals Supporting Kids recommends the presence of a therapeutic animal (dog) during court hearings of children in connection with sexual abuse to help mitigate children’s discomfort. It was proven that a dog’s presence during a child’s hearing influenced the reduction of cortisol level (cortisol marked from a spit), immunoglobulin A, blood pressure, and heart rate during the hearing [9]. The participation of therapy dogs in the treatment of trauma in children shows a significant reduction of its symptoms, including fear, depression, anger, post-traumatic stress disorder, dissociation, and sexual problems [10].

Symptoms related to disorders of psychosexual development (behaviour disorders, including eating disorders) require cooperation with psycho-sexologists or dieticians. If they are in the form of physical injuries or STDs, they will probably be possible to diagnose only by medical service. They are noticed during nursing care of children, not infrequently disabled children (criminals regard disabled children as especially helpless victims). Severe somatic symptoms require quick medical intervention. For example, injuries of external and internal sex organs—a region of the vulva, crotch: crack of crotch in middle line that can extend from vaginal mucosa to rectum mucosa (vaginal vestibule und rectum as one post-traumatic cavity. Without a doubt, sexual violence leaves an imprint on a child, even if apparent external symptoms are not observed [11, 12, 13].

I. Severe (quick medical intervention is required):

1. Injuries of external and internal sex organs:

$\circ$ region of vulva, crotch: crack of crotch in middle line that can extend from vaginal mucosa to rectum mucosa (vaginal vestibule and rectum as one post-traumatic cavity),

$\circ$ haematomas within the hymen (done with a finger are smaller),

$\circ$ injuries of anus region: lividities, cracks of anus reaching surrounding skin.

2. Injuries of other body regions: lips and mouth cavity (lividities and petechial haemorrhaging on the palate, lower and upper limbs).

3. Wounds that appeared as a result of a bite.

4. Ulcerations and wounds in the course of sexually transmitted diseases.

Severe somatic symptoms are usually infected wounds with irregular edges, contused wounds, crush wounds, and lividities.

CAUTION: Pay extra attention if a child is afraid of saying what circumstances it came to appearing injuries and a person who reports with the child wants to conceal the truth (for example, the mother knows a perpetrator and wants to protect him), also when circumstances of appearing injuries given by the mother or the child are inconsistent or less probable “… she fell on a bicycle frame, clothes horse, edge of a table, tree bough, etc. …”.

II. Chronic:

1. Psychoemotional disorders are foreground [14, 15, 16].

2. Calm, self-confident behaviour of a child during gynaecological examination (Such attitude should raise suspicions of a gynaecologist because a child who is not abused is usually afraid of examination).

3. Loss of hymen (localization of changes should be related to the distribution of hours on a clock face): the lack of hymen under the hypothetic horizontal line between 3:00 and 6:00, loss of healed crack, mostly at 6.00 hour.

4. Permanent broadening anus to a diameter of $>$1.5 cm.

CAUTION: In physical general and gynaecological examination, we do not state any changes in 50–90% of patients, what results from a different way of child sexual abuse, for example touching with sexual character, oral intercourses. After 3 months, it is possible that visible traces will not also remain after vaginal intercourse.

III. Direct:

1. Pregnancy.

2. Sexually transmitted disease (STD) [17].

3. Sperm in the vagina.

4. Hair, blood, spit, and epidermal cells (in the vagina, in the mouth cavity, or under the nails of a victim) that, according to results of molecular analysis of DNA, do not belong to a victim.

Symptoms of sexually transmitted diseases are usually a sign of sexual violence suffered by a child. However, it is worth mentioning here about rare cases when hygiene mistakes appear in viral changes on fingers, and a child can transmit these changes to genital regions. Irrespective of it, in the case of diagnosing STD in a child, it is essential to implement psychological diagnostics to examine if a child is not a victim of violence [18].

• Incorrect leaking liquid from the vulva or penis,

• Pain or burning during urination,

• Itching, rash, papules, or small bladders in the region of mouth and sex organs,

• Pain or bleeding during intercourse or after intercourse [19, 20, 21, 22].

However, symptoms can differ in the case of various infections, and many sexually transmitted diseases are symptomless (for example, some chlamydiosis and gonorrhoea). More than one infection at the same time can also appear in patients.

Besides syphilis and gonorrhoea, which are classic for venereology, they include a range of aerobic and anaerobic bacteria, viruses, protozoans, fungi, and even insects. At the suspicion of STD, the Polish Gynaecological Society recommends essential examinations for the presence of:

• chlamydia,

• gonorrhoea,

• syphilis,

• human immunodeficiency virus (HIV).

Additionally, if symptoms or anamneses indicate it, examinations are conducted for:

• Bacterial vaginosis,

• Mycotic vulvovaginitis,

• Trichomoniasis,

• Genital herpes,

• Scabies,

• Phthiriasis,

• Molluscum contagiosum,

• Inguinal granuloma,

• Viral.

Once more, it is worth emphasizing that inflammations related to STDs can be symptoms of sexual violence toward children—in suspected cases, it is necessary to implement diagnostics, including psychological care [11, 12, 13]. Medical examiners, together with adolescent gynaecologists and paediatricians, estimate not infrequently the biological age of children in materials with pornographic content. The essence of examinations is to indicate persons at age under 15 in materials with pornographic content because possession of pornographic content with sexual abuse of minors is a crime from article 202 of the penal code. As symptoms of sexual violence can be venereal diseases and the complexity of disorders of sexual preference is enormous, it is worth paying attention during estimating this type of material if persons presented in materials do not have symptoms of STD. Pornographic materials are not infrequently aimed at persons with complex, other sexual preferences (ICD 10 F65.6–9).

It is crucial to notice that definitions of “pornography” are diversified. Generally, pornography is verbal or visual material that presents anatomy or sexual activity, and the author’s primary intention is to provoke sexual arousal in the recipient (recipients).

So concerning photos or films: they present erotic scenes or even forms of human sexual behaviours to cause sexual arousal in recipients. “Child pornography” means material containing pornographic content that depicts or presents a child participating in clearly sexual activity or an actual child undergoing such action, including showing intimate places of the child.

In the case of materials, there is suspicion that they are materials containing pornographic content with the participation of persons under 15 complex estimations of the development state of biological features of a child. Due to the complexity of disorders of sexual preference, it is worth pointing out that it is possible to expect that pornographic materials can present persons of various ages with symptoms of venereal diseases in the genital region and oral region (for example, Human papillomavirus (HPV) and other STDs).

Based on the estimation of the development state of biological features, it is possible to determine the so-called development age, i.e., the degree of physical maturity of an organism. We estimate biological age based on the degree of development of teeth bones (bone age), functions of the organism (physiological age), secondary sexual characteristics, and development state of somatic features, i.e., sizes and proportions (morphological age).

In assessing the age of children visible in photos or films, it is impossible to determine bone age and physiological age for obvious reasons. In a few cases, it is achievable to estimate teeth age in limited scope—if a person smiles and features teething front teeth [7, 8].

However, it is possible to assess biological age on the basis of a specific degree of development, taking into consideration the criterium of the age of secondary sexual characteristics and the criterium of morphological age. The scale of children’s physical development, worked out by James Mourilyan Tanner, which is further called Tanner Staging, is acknowledged as the most well-known method of estimating development age for examined age range.

In the case of materials in the form of photos and films, methods of estimation of age can be used in the scope of:

Criterium of morphological age—the figure estimates the physical build and proportions of the body, appearance of the face and facial features, and development of subcutaneous adipose tissue.

Criterium of the age of secondary and tertiary sex characteristics—phase of sexual development is estimated

$\circ$ at girls, among other things development of breasts, development of external sex organs, pubic hair, armpit hair,

$\circ$ at boys, among other things, development of external sex organs, pubic hair, armpit hair, and hair on particular body parts [7, 8].

1. Examination of the general condition of a child for other currently existing diseases: watching skin of the whole body, palpation of the head, auscultation of lunges, heart, etc.

2. During the examination, it is necessary to attempt to make contact, trying to minimize a child’s fear.

3. Symptoms related to sexual violence should be sought first in other regions of the body than sex organs.

4. Examination of sex organs should be conducted at the end. It is worth paying attention to possible symptoms of sexually transmitted diseases that can be as well in the genital and oral regions [7, 12].

The problem of sexual violence toward a child is a complex issue. Symptoms depend on the time of lasting abuse, relationship with the perpetrator, kind of sexual activities, and factors related to child development in the case of disabled children with a type of disability. It is worth mentioning that the rights of minors to sexological healthcare (reproductive healthcare) differ depending on legislation being in force in a given country, and legal provisions in various countries are continuously changed. Undeniably the child is a person and has dignity that should be respected. Sexual violence toward a child’s muscles in the dignity of the person of a child, but also in its innocence. Child sexual abuse is evil—as the worst form of harming them may never become a “forbidden norm” [11].

As well, a child—victim of sexual crime as its carers should be subject to holistic care [17]; supervision of a clinical psychologist is here of special importance. Standards of conduct with a minor victim of sexual violence are worked out and improved. Teams of experts prepare and improve documentation patterns of medical examination of sexual abused minors [12]. Sexual violence is often emphasized as the most severe form of harming a child. Medical help includes not only correct dressing injuries and medical care but also all other activities that accompany conducting operations and are aimed at reducing mental trauma caused by sexual abuse that can unfortunately negatively affect further psychosexual development and functioning in this sphere in adult life. Also, in this context, health-promoting and sexual education are essential. Children should be taught from a young age to take care of their safety and have proper adult supervision [23]. The problem of violence towards children also fits into the philosophical issue of the pain and suffering of human beings, and the contemporary situation of psychological pain related to the pandemic of coronavirus SARS-CoV-2 overlaps it.

KPR, GJB, PM, MPK, DLM, AO, MicP, JOS and MarP—substantial contributions to the conception design of the work, analysis, or interpretation of data for the work, formal analysis. AK, MM, EJ, DL, MWój, MWil, WK and MD—interpretation of data for the work, technical editing, visualization. AP participated in writing or technical editing of the manuscript, visualization. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript.

Not applicable.

Thanks to all the peer reviewers for their opinions and suggestions.

This research received no external funding.

The authors declare no conflict of interest. Katarzyna Plagens-Rotman, Piotr Merks, Małgorzata Wójcik, Grażyna Jarząbek-Bielecka and Maciej Wilczak are serving as one of the Guest editors of this journal. We declare that Katarzyna Plagens-Rotman, Piotr Merks, Małgorzata Wójcik, Grażyna Jarząbek-Bielecka and Maciej Wilczak had no involvement in the peer review of this article and has no access to information regarding its peer review. Full responsibility for the editorial process for this article was delegated to Michael H. Dahan.