Pediatric Annals

Testing Sexually Abused Children for Sexually Transmitted Diseases: Who to Test, When to Test, and Why

Andrew P Sirotnak, MD

Abstract

Child sexual abuse reports are increasing annually, and pediatricians are confronting this problem more frequently than ever. A multidisciplinary intervention, when available, is often used in cases of child abuse to ensure the safety of the child. Evaluation of the child may be complicated by the possibility of sexually transmitted disease (STD). Who and when do we need to culture for STDs in cases of child sexual abuse? This article reviews what consensus exists regarding these questions and discusses the need for guidelines in the assessment of STD in abused children.

CONSENSUS, CONTROVERSY, AND COST

It is generally agreed on in the medical literature that transmission of STD to infants and children outside the perinatal period by nonsexual means is a rare occurrence.1,2 The increasing incidence of adult STD may indicate that increased perinatal transmission of some STDs may be seen. However, when perinatal transmission of gonorrhea, syphilis, and human immunodeficiency virus (HIV) has been ruled out, the presence of these diseases in children is diagnostic of abuse. Chlamydia trachomatis, herpes simplex virus type 2, Trkhomonas vaginalis, and human papilloma virus infections are likely to be secondary to abuse in children out of infancy. The microbiology and pathology of several of these diseases are reviewed elsewhere in this issue.

Controversy exists regarding when to culture and test for STD in the evaluation of sexually abused children. Most of the studies dealing with this topic have been retrospective reviews of child sexual abuse cases that reported how many "positives* for each disease were found. Very few prospective, and even fewer controlled prospective studies, have been performed.

As more children are evaluated for STD, whether secondary to the increased awareness or to the increased incidence of child sexual abuse, there is a growing concern among child abuse experts that guidelines for instituting these costly evaluations should be adopted.

Culture and serologic tests are too expensive to perform in every case. They can be painful and, at times, traumatic to a sexually abused child. Although STD can be important corroborating forensic evidence of sexual contact, the benefits and the likelihood of a positive test must be weighed against the potential trauma to the child in obtaining such evidence.

The prevalence of STD in children known to be abused varies depending on the criteria and specific microbiologic tests used for diagnosis, the age range of the children examined, and the underlying prevalence of the disease in the community where the children are examined.3

There is general consensus regarding when testing for STD is definitely indicated. Any child with a history of STD symptoms or signs of an STD on examination should be tested. If one STD is diagnosed, test for others. If a child had been molested by an offender known to be at high risk for STD or if there is a high prevalence of an STD in the community, the child should be tested.

NEISSERIA GONORRHOEAE AND CHLAMYDIA TRACHOAiATIS

Neisseria gonorrhoeae and C trachomatis are the most commonly transmitted bacterial STDs in adults and in sexuallly abused children. A great amount of time and money are spent diagnosing diseases caused by these two organisms in abused children.

Gonorrhea is one of the oldest known human illnesses and is contracted by direct oral, genital, or anal contact with infected secretions. Transmission by fomites is a very unlikely occurrence. Chlamydial infections are more commonly transmitted sexually than gonorrhea and are more likely to cause asymptomatic infection. An obligate intracellular organism, C trachomatis is not transmitted by fomites. Although it can be acquired at birth and persist up to 3 years in genital, anal, or…

Child sexual abuse reports are increasing annually, and pediatricians are confronting this problem more frequently than ever. A multidisciplinary intervention, when available, is often used in cases of child abuse to ensure the safety of the child. Evaluation of the child may be complicated by the possibility of sexually transmitted disease (STD). Who and when do we need to culture for STDs in cases of child sexual abuse? This article reviews what consensus exists regarding these questions and discusses the need for guidelines in the assessment of STD in abused children.

CONSENSUS, CONTROVERSY, AND COST

It is generally agreed on in the medical literature that transmission of STD to infants and children outside the perinatal period by nonsexual means is a rare occurrence.1,2 The increasing incidence of adult STD may indicate that increased perinatal transmission of some STDs may be seen. However, when perinatal transmission of gonorrhea, syphilis, and human immunodeficiency virus (HIV) has been ruled out, the presence of these diseases in children is diagnostic of abuse. Chlamydia trachomatis, herpes simplex virus type 2, Trkhomonas vaginalis, and human papilloma virus infections are likely to be secondary to abuse in children out of infancy. The microbiology and pathology of several of these diseases are reviewed elsewhere in this issue.

Controversy exists regarding when to culture and test for STD in the evaluation of sexually abused children. Most of the studies dealing with this topic have been retrospective reviews of child sexual abuse cases that reported how many "positives* for each disease were found. Very few prospective, and even fewer controlled prospective studies, have been performed.

As more children are evaluated for STD, whether secondary to the increased awareness or to the increased incidence of child sexual abuse, there is a growing concern among child abuse experts that guidelines for instituting these costly evaluations should be adopted.

Culture and serologic tests are too expensive to perform in every case. They can be painful and, at times, traumatic to a sexually abused child. Although STD can be important corroborating forensic evidence of sexual contact, the benefits and the likelihood of a positive test must be weighed against the potential trauma to the child in obtaining such evidence.

The prevalence of STD in children known to be abused varies depending on the criteria and specific microbiologic tests used for diagnosis, the age range of the children examined, and the underlying prevalence of the disease in the community where the children are examined.3

There is general consensus regarding when testing for STD is definitely indicated. Any child with a history of STD symptoms or signs of an STD on examination should be tested. If one STD is diagnosed, test for others. If a child had been molested by an offender known to be at high risk for STD or if there is a high prevalence of an STD in the community, the child should be tested.

NEISSERIA GONORRHOEAE AND CHLAMYDIA TRACHOAiATIS

Neisseria gonorrhoeae and C trachomatis are the most commonly transmitted bacterial STDs in adults and in sexuallly abused children. A great amount of time and money are spent diagnosing diseases caused by these two organisms in abused children.

Gonorrhea is one of the oldest known human illnesses and is contracted by direct oral, genital, or anal contact with infected secretions. Transmission by fomites is a very unlikely occurrence. Chlamydial infections are more commonly transmitted sexually than gonorrhea and are more likely to cause asymptomatic infection. An obligate intracellular organism, C trachomatis is not transmitted by fomites. Although it can be acquired at birth and persist up to 3 years in genital, anal, or pharyngeal sites, the presence of C trachomatis in a child older than 3 years can be corroborating evidence of sexual abuse.

Previous retrospective studies have shown a range of incidence of gonorrhea in sexually abused children of 4.7% to 7.4%.4'5 The incidence of C trachomatis in sexually abused children in retrospective studies has been 4% to 6%.6,7 Most studies have been performed in large urban hospitals with established child abuse evaluation teams.

A recent large retrospective study of 622 patients under the age of 12 years seen at a large urban children's hospital for sexual abuse evaluation showed lower incidences of both of these organisms.8 Cases were analyzed for a chief complaint of abuse or vaginal discharge, and for history of either discharge or genital contact. All children had vaginal cultures for N gonorrhoeae and C trachomatis. Vaginal gonorrhea was found in 3.5% and chlamydial infections in 1.3% of the total cases. Of the 22 children with gonorrhea, 21 were seen for a chief complaint of vaginitis and not for sexual abuse. When sexual abuse was the chief complaint, the incidence of gonorrhea was 0.2% and the incidence of Chlamydia was 1.3%. This emphasizes that prepubertal children with a vaginal discharge should have a careful history and physical examination to exclude the diagnosis of sexual abuse.

A recent large prospective study in which 1538 children ages I to 12 years were evaluated for sexual abuse revealed an incidence of 1.2% for C trachomatis and 2.8% for N gonorrhoeae (vaginal/urethral 2.6%, anal 1.8%, and oral 0.14%).9 In this study, 15% of genital gonorrhea and 65% of chlamydial infections were asymptomatic.

Most chlamydial vaginal infections are asymptomatic, but several authors have reported asymptomatic gonorrheal infections of the vagina as well.4,10 The need for culturing asymptomatic children evaluated for sexual abuse with no known exposure to an individual with an STD remains controversial. Most clinicians forego cultures in this population if the history, interview of the verbal child, and physical examination indicate that STD is unlikely. The prevalence of STD in the community of the child is another important consideration when deciding whether to culture for STD in children.

GARDNERELLA VAGINALIS

Bacterial vaginosis is a polymicrobial infection in which Gardnerella vaginalis acts synergistically with other anaerobes in the vaginal flora. It is a clinical diagnosis that is confirmed by the presence of a thin vaginal discharge, clue cells on microscopic examination of the discharge, a pH of greater than 4.5, and a positive "whiff test* (the development of a fishy odor after the addition of 10% potassium hydroxide to the discharge).

Gardnerella also colonizes the vaginal tract of normal adolescents and adults. In both nonabused and sexually abused prepubertal children, there has been controversy over its significance. Several studies have demonstrated an increased incidence of Gardnerella in sexually active adults and in sexually abused children.11'13 However, a recent prospective controlled study of 452 children ages 1 to 12 years showed that the incidence of Gardnerella was not significantly different in three groups of prepubertal children: 1) a group with a history of sexual contact or infection with N gonorrhoeae or C trachomatis, 2) a control group evaluated for sexual abuse but without other infection, and 3) a control group with neither history of sexual abuse nor other vaginal infection.14

Table

TABLE IRisk Factors for Hepatitis B and Human Immunodeficiency Virus Transmission in Child Sexual Abuse

TABLE I

Risk Factors for Hepatitis B and Human Immunodeficiency Virus Transmission in Child Sexual Abuse

Examination of vaginal discharge in a prepubertal child should include whiff test and pH determination and a microscopic examination. The finding of G vaginalis alone in a vaginal culture is not a reliable marker for sexual abuse, but it should alert the physician to take a careful history for the possibility of abuse. Larger multicenter controlled studies of the vaginal flora of nonabused children and of sexually abused children have not been performed. Routine culturing for this organism is probably not appropriate or cost effective.

TRICHOMONAS VAGINALIS

Vaginitis caused by T vaginalis is a common STD in adults. Trichomonas vaginalis can be transmitted to the newborn's nasopharynx and vagina from infected mothers and also has been found in sexually abused prepubertal females. Nonsexual transmission has not been documented.1 Examination of vaginal wet mounts is the commonly performed diagnostic test but cultures are more sensitive. The finding of Trichomonas in a prepubertal girl on wet mount or culture should raise concern about sexual abuse.

Trichomonas hominis is a commensulate motile protozoan that inhabits the colon. It is smaller than T vaginalis, and the two can be distinguished by motility pattern and size. Trichomonas hominis is a nonpathogenic organism, and its presence in a urine specimen from a prepubertal girl may represent contamination of the sample from stool.

HERPES SIMPLEX VIRUS

Herpes simplex virus (HSV) can be acquired in utero or at birth. As in adults, relapsing cutaneous lesions can be seen for years. Any child with genital HSV infection must be examined carefully for possible sexual abuse. Sexual transmission of HSV in child sexual abuse is well documented.15

Both HSV types I and II can be found in the genital area, and children can autoinoculate the genital area from oral HSV infections via their hands. Most HSV in children, however, is sexually transmitted. More studies are needed to determine the incidence of genital HSV in children caused by sexual abuse versus autoinoculation.

Vesicles or pustules in the genital area in boys or girls should be cultured for HSV Scrapings of lesions can be stained to detect multinucleated giant cells (Tzanck preparation), or immunofluorescent stains can be used. Crusted lesions are less likely to yield a positive culture. If a child with suspected herpes virus infection gives a history revealing oral or anal assault or if lesions are present in these areas, cultures should be obtained from these sites as well.

SYPHILIS

In both prospective and retrospective studies, the incidence of syphilis in prepubertal children evaluated for sexual abuse is low.1,,2,10 If congenital transmission of Treponema pallidum can be excluded, the diagnosis of syphilis in a prepubertal child is likely to be caused by sexual abuse. Late congenital syphilis (presenting after die age of 2 years) manifested by the classic bone and teeth findings, keratitis, and eighth nerve deafness is extremely uncommon. A detailed review of syphilis appears in this issue (page 334).

Because the incidence of syphilis in sexually abused children is so low, the benefit of screening every child evaluated is questionable. The sequelae of undiagnosed and untreated syphilis, however, are quite damaging. If the alleged perpetrator of the abused child is known to be infected with an STTA the child evaluated for sexual abuse should be tested for syphilis, especially if the suspected perpetrator is from a group known to be at high risk for syphilis. Ideally, serology should be obtained 12 weeks after the alleged sexual contact to allow antibodies to develop.

HEPATITIS B VIRUS AND HUMAN IMMUNODEFICIENCY VIRUS

The Centers for Disease Control and Prevention (CDC) has not identified sexual abuse as a separate transmission category for national surveillance of pediatric acquired immunodeficiency syndrome (AIDS). There is no accurate information on how many children with AIDS acquired the disease by sexual abuse, but many pediatric HIV programs are collecting such data. During a 2-year period at Duke University, the HIV program confirmed 14 of 96 ( 14-6%) children who tested positive for HIV contracted the disease by sexual abuse.16 All of diese children had multiple risk factors for abuse and neglect. None of the children had gonorrhea or Chlamydia at diagnosis, but one had bacterial vaginosis and one had condylomata acuminata. Three of the identified assailants knew that they were HIV positive at the time the abuse of the children occurred.

Table

TABLE 2Centers for Disease Control and Prevention Recommended Laboratory Evaluation of Sexually Abused Prepubertal Children

TABLE 2

Centers for Disease Control and Prevention Recommended Laboratory Evaluation of Sexually Abused Prepubertal Children

Both hepatitis B virus and HIV can be transmitted through sexual activity, blood or blood product transfusion, or by perinatal acquisition. Many of the social and behavioral risk factors for the transmission of HIV and hepatitis B also can be seen in the history or circumstances surrounding child sexual abuse (Table 1). Considering these factors can be helpful when deciding whether to test sexually abused children for hepatitis B virus and HIV.

Testing for HIV should be encouraged or pursued if the child has symptoms or signs of HIV infection, has another STD, or if evidence of body fluids such as semen, blood, or saliva is found on examination of an assaulted child. If the alleged perpetrator is at risk for HIV transmission, if multiple assailants or a single unknown assailant is involved, or if the assailant has symptoms of AIDS, testing is indicated. The child or parent/guardian may be anxious about AIDS and request testing even if the victim is at low risk of HIV transmission. Thoughtful pre- and posttest counseling is needed every time an HIV test is ordered. Some states require informed consent before testing.

Most children who are acutely infected with hepatitis B virus will have clinical features of hepatitis, and 95% of children with acute hepatitis B infection will recover spontaneously. The earliest detectable serum marker is the rise in hepatitis B surface antigen (HBsAg), which appears 1 to 10 weeks postexposure; HBsAg can be cleared within 6 to 8 months by anti-HBsAg antibody (anti-HBsAg).17

Screening children within 10 weeks after an acute sexual assault with HepBsAg is most cost effective. A child who was sexually abused for more than 6 months prior to evaluation can be screened for anti-HBsAg as well. Routine screening of every child, however, with a complete hepatitis panel is not cost effective because false-positive anti-HBsAg tests are common, and many children are now immunized for hepatitis B. Any child with a positive HBsAg or anti-HBsAg needs a complete hepatitis B serology panel to exclude a false-positive result or to determine the nature of the infection (acute, recovering, carrier, or postinfection).

Finally, screening for hepatitis B infection should be performed when there are supporting epidemiologic risk factors (Table 1) or a clinical history or evidence of infection.

CONCLUSION

The CDC has published recommendations for the diagnosis and treatment of STD in sexually abused children (Table 2).18 They are not based on large population-based studies. Multicenter prospective controlled studies to determine the best laboratory workup for sexually abused children are still needed. Most clinicians in the field of child protection do not adhere to the CDC recommendations verbatim. Each child seen for possible sexual abuse should be evaluated individually. Careful history taking, epidemiologic supporting evidence for STD risk, and a thorough physical examination should guide the physician when deciding to test for STD.

REFERENCES

1. Neinstein LS. Goldenring J, Carpenter S. Nonsexual transmission of sexually transmitted diseases: an infrequent occurrence. Pediatrics. 1984;74:67-76.

2. Paradise JL The medical evaluation of the sexually abused child. Pediatr CIm North Am. 1990;37:839-862.

3. Jenny C. Child sexual abuse and sexually transmitted diseases. In: Holmes KK1 Mardh P, Sparling PF, et al, eds. Sexually Transmitted Diseases. New York, NY: McGraw-Hill; 1990.

4. Dejong AR. Sexually transmitted diseases in sexually abused children. Sex Transiti Dis. 1986;13:123-126.

5. Rimsza ME, Niggernann EH. Medical evaluation of sexually abused children: a review of 311 cases. Pediatrics. 1982;69:8-14.

6. Ingram DL, Runyan DK, Collins AD, et al. Vaginal Chlamydia trachomatis infection in children with sexual contact. Pediatr Infect Dis J. 19843:97-99.

7. Hammerschlag MR, Doraiswamy B, Alexander ER, Cox P, Price W, Gleyzer A, Are rectogenital chlamydial infections a marker of sexual abuse in children,' Pediatr Infect Dis. J 1984;3:100-104.

8. Shapiro RA1 Schubert CJ, Myers PA. Vaginal discharge as an indicator of gonorrhea and Chlamydia infection in girls under 12 years old. Pediatr Emerg Care. 1993;9:341345.

9. Ingram DL, Everett VD, Lyna PR, White ST, Rockwell LA. Epidemiology of adult transmitted disease agents in children being evaluated fot sexual abuse. Pediatr Infect Dis J. 1992:11:945-950.

10. White ST, Loda FA, Ingram DL, Pearson A. Sexually transmitted disease in sexually abused children. Pediatria. 1983;72:16-21.

11. Gardner JJ. Comparison of the vaginal flora in sexually abused and nonabused girls. J Pediatr. 1992;120:872-877.

12. Hammerschlag MR, Cummings M, Doraiswamy B, Cox P, McCormack WM. Nonspecific vaginitis following sexual abuse in children. Pediatrics. 1985;75:10281031.

13. Bartley DL, Morgan L, Rimsza ML Gordnerefla vaginalis in prepubertal girls. Am J Dis Child. 1987;141:1014-1017.

14. Ingram DL, White ST, Lyna PR, et al. Gardnerella vaginalis Infection and sexual contact in female children. CMi Abuse Negl. 1992;16:847-853.

15. Gardner M, Jones JG. Genital herpes acquired by sexual abuse of children. Pediatrics. 1984;104:243-244.

16. Gutman LT, St Claire KK, Weedy C, et al. Human immunodeficiency virus transmission by child sexual abuse. Am J Dis Child. 1991;145:137-141.

17. Balistreri WF. Viral hepatitis. Pediatr Clin North Am. 1988:35:637.639.

18. Centers for Disease Control and Prevention. 1993 sexually transmitted diseases treatment guidelines. MMWR. 1993;42(RR-14):99-102.

TABLE I

Risk Factors for Hepatitis B and Human Immunodeficiency Virus Transmission in Child Sexual Abuse

TABLE 2

Centers for Disease Control and Prevention Recommended Laboratory Evaluation of Sexually Abused Prepubertal Children

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