Sexually transmitted diseases : A significant complication of childhood sexual abuse

D LINDSAY, J EMBREE. Sexually transmitted diseases: A significant complication of childhood sexual abuse. Can J Infect Dis 1992;3(3):122-128. The acqui sition of one or more sexually transmitted diseases (STD) is a significant complication of sexual assau lt of chi ldren . The risk of infection by pathogens varies from less than 1 to 50% depending on the nature of the assault, the organism studied and the background prevalence of STD in the general community. The correct diagnosis of STD in children depends upon optimal collection and appropriate laboratory testing of clinical specimens. Diagnosing STD will a llow for treatment and follow-up to ensure cure of these infections as well as to monitor for re-infection . It will also help confirm that sexual activity involving the child has occurred. This can be exi.remely important, particularly when there are minimal other physical findings of abuse or if the child has limited verbal skills and thus cannot provide a complete disclosure. All physicians who care for children should be knowledgeable about the methods of STD diagnosis and the cuITently recommended treatment regimens.

S EXUAL ABUSE OF CHILDREN IS A DISTURBING SUBJECT TO most of us.The increasing awaren ess of this problem over the past two decades has led to numerous studies by medical, legal and related researchers concerning the prevalence of abuse , characteristics of offenders, victims and families, tl1e physical findings in abused childr en, credibility of allegations, the legal issues pertaining to the child and court.and acquisition of sex'Ually transmitted diseases (STD) by children through sexual abuse (1)(2)(3)(4)(5)(6)(7)(8).In this article, the body of this knowledge will be reviewed as it relates to the acquisition, diagnosis and management of these infections in this population.

BACKGROUND
Sexual abuse refers to the sexual exploitation of a child by another person , and encompasses both direct physical acts, such as fondling and digital or penile penetration of the vagina, as well as nonphysical acts such as exhibitionism or procuring.The Badgely Commission Report released in 1984 (5) suggested tl1at as many as one in two females and one in three males have been victims of a sex'Ual offence at some time in their lives.Most offences occur prior to the age of 21 years; acts of exposure are tl1e largest category of offences against youth.By the age of 16 years.however, as many as 5 to 9 % of males and 15 to 20% of females have experienced some form of unwanted sexual touching, with intercourse occurring in 1 to 3%.Based upon reporting trends across Nortl1 America over tl1e past 10 to 15 years.the numbers of reported cases of child abuse.and the percentage which are sexual in nature, are increasing (1,7,9).At the Child Protection Centre in Winnipeg, Manitoba, tl1e number of referrals for child abuse have increased from 372 in 1982 to 1157 in 1990, with an increase from 30.6 to 58.8% of cases being sexual in nature.This likely reflects an increase in both public and professional awareness resulting in a corresponding increase in recognition and reporting, since the actual number of cases in relation to population growth has remained at a relatively constant level (5).
Sexual abuse in ch ildren is a widespread problem: however, certain trends and generalities have been identified.Many victims have previously been living with nonbiological parents. in homes where alcohol and/or drugs are abused, in families already known to child welfare agencies or in families with a history of physical abuse (2,3) .Family units in which adolescent males spend prolonged unsupervised time with young children are considered higher risk.A large percentage of victims are children of parents who were themselves the victims of childhood sexual abuse.The majority of children seen currently (80 to 90%) are female victims of male offenders: however, many retrospective studies have shown that a much larger number of males than expected describe sexual abuse in childhood (2.3,5) .Usually offenders are known to the child eitl1er as a STD in child sexual abuse family member, friend or acquaintance, or guardian; only a small percentage (1 to 17%) are strangers (2,4 ,5).Most a llegations are substantiated; false allegations which are often initiated by an a dult make up 6 to 11 % of unsubstantiated cases (5 , 10).On ly app roximately 40% of cases will result in charges being laid (5).

EPIDEMIOLOGY
The reported prevalences of the sexually transmitted pathogens found in abused children vary considerably (Table 1).This is partly due to differences in study population definition.Differences related to using an absolute age limit for prepubescence (hence including some early pubertal children) versus Tanner staging are important, since significant changes occur in the pathogenesis of many vaginal infections, in particular Chlamydia trachomatis and Neisseria go11orrhoeae, once puberty begins ( 11 , 12).The identity of the abuser is significant, as family members who do not engage in sexual activity outside the family are less likely to pass on STD .For exan1ple, the number of children diagnosed with gonorrhea is lower iftl1e offender was tl1e father or stepfather as opposed to another relative or a family friend (7).In families where tl1ere is drug or alcohol abuse, the risk is increased as STD are more prevalent in tl1is adult population (12).The type of abuse also plays a role .Sexual activities such as exhibitionism are unlikely to lead to tl1e transmission of STD since tl1ere is little opportunity for passage of infected genital secretions to tl1e child.The risk of infection is greater with actual sexual intercourse, but penetration need not take place for STD transmission to occur.The sexual abuser who masturbates and ejaculates, and tl1en fondles the child .may transmit the organism in that fashion .Victims of repeated episodes of abuse have a greater risk of infection than those experiencing only a single episode (8).There may also be clustering of STD if more tl1an one child is sexually abused by an infected individual (13)(14)(15)(16) .The prevalence of STD varies from community to community.In communities where there is a high endemic rate of gonoIThea, tl1ere is an equally high rate of gonorrheal isolation among sexually abused children (7).Finally, many studies have not considered the full spectrum of etiological agents due to difficulty in collecting multiple, good samples from a female child, since prior to maturation of tl1e genital tissue, the introitus is quite sensitive to touch .
Determining tl1at an infection is sexually transmitted, isolated because of prolonged perinatal carriage, or acquired in a nonsexual fashion, may be difficult but is in1portant.For example , Gard11erella vagi11alis is not exclusively sexually transmitted in young children (17); tl1us.its isolation may not be indicative of sexual abuse if no other findings of abuse are present.Lack of suitable control populations have interfered with interpretation of tl1e large studies designed to examine this problem.Control groups have often comprised clinic patients felt not to have been sexually abused or previously abu sed patients, and so m ay not truly reflect the 'normal' population (18)(19)(20).Also, the numbers of children studied are often insufficient to show moderate differences in prevalence.Duration of colonization of perinatally acquired STD is not !mownfo r the m ajority of pathogens.Perinatally acquired gonorrh ea is not thought to persist past the neonatal period (15).Chlamydia was not detected in a sample of 131 children at one year of age who were born to culture positive mothers (21).However, untreated adult women may carry the organism for up to two years (12).Trichomonas vaginalis has only rarely been isolated after one month of age (22).While the prevalences of genital mycoplasmas are low in prepubertal age groups (range 4 to 22%). the duration of perinatal colonization is unknown (18 ,23).No genital mycoplasmas were isolated from children followed beyond one year of life in one study (24).The acquisition of anaerobic bacterial vaginosis at delivery by infants h as not been studied.
Uncertainty concerning the frequency of duration of the latency period of human papillomavirus complicates the diagnosis of sexual abuse in the child who presents with condyloma acuminatum.Although an average latency period of three months has been quoted, incubation periods oflonger duration are likely (25).Since the lesions may persist for many years without treatment, perinatal transmission could be the mode of acquisition in the older child (older than two years) who is found to have genital warts during a physical examination.However, this should not preclude evaluation for other evidence of sexual abuse (25 ,26).
Another controversy centres on nonsexual transmission of STD, in particular gonorrhea, after the perinatal period.Although gonorrhea has been isolated in fomites and on porcelain toilet bowls, this mode of transmission has never been implicated in the transmission of N gonorrhoeae.Most care givers assume that children acquire gonorrhea through sexual contact (27) .This includes children who acquire gonorrhea from a sibling or playmate of the same age through

Syphilis
Human immunodefic ienc y virus Hepatitis B Frozen sample t o be saved sexual play acting: one of the children has been sexually abused.although not necessarily the index child (13)(14)(15)(16).A potential nonsexual transmission scenario has been suggested by Shore and Winkelstein (28) who investigated Inuit children in which all family members shared the same bed and in which gonorrhea was found in a very high proportion of the children.Based only on the lack of a history of sexual abuse Shore and Winkelstein concluded that sexual transmission was not the mode of gonococcal acquisition.Four of the infected children had gonococcal conjunctivitis which implied hand-to-eye transmission.However, the crowded conditions in this study are unique to the population studied, and the conclu s ions drawn by the authors, even if correct, cannot be generalized .

DIAGNOSIS AND MANAGEMENT
The diagnosis of STD in abused children is complicated by difficulty in obtaining the necessary specimens from prepubertal children.and the lack of sensitivity and specificity of tests used to detect or isolate the different pathogens.Ideally, the approach to diagnosis of STD should involve testing for all potential pathogens if sexual abuse of a nature allowing transmission of STD in child sexual abuse STD is suspected.The availability of laboratory facilities m ay limit this approach.
A careful genital examination, including STD testing, in a calm, relaxed child should cause little or no discomfort.Often, however, the abused child is afraid , anxious or uncooperative, resulting in an examination which is uncomfortable, particularly during specimen collection.Time spent in preparing the child for the examination will alleviate many of the anxieties and allow for an easier examination.At many sexual abuse clinics a child life therapist spends time with the patient prior to the actual examination.Simple things such as an explanation of equipment, allowing a child to examine a doll with medical equipment, and letting a child touch swabs (dry and wet) may alleviate some fears.
The actual examination should consist initially of maneuvres which are both familiar to a child and nonhurtful, such as listening to the chest.This enables tl1e child to become familiar and comfortable witl1 the examining procedures.The genital examination is best done with the child in the supine position , with the legs bent at the knee and abducted at the hip -tl1e 'frog-leg position'.An alternate position is with the child on the parent's lap with the parent helping to abduct the legs.Slight traction of the vulva towards the examiner and slightly down will allow for the best visualization of the introitus.In the relaxed child, this position will enable the vaginal orifice to open.With care, a small moistened Calgi type I swab can then be inserted tl1rough the orifice.If the hymenal ring is not touched, there is usually little sensation associated with the swabs.A speculum examination is only rarely required and in this age group is best done under general anesthetic.
Sites which should be cultured for each STD are shown in Table 2.Because most prepubertal children are seen well after the episode(s) of abuse, a single sample taken for STD at the time of assessment will suffice.For chil dren seen in1mediately after an acute episode.initial cult ures may be negative and should be repeated in two to three weeks.Neisseria gonorrhoeae: Asymptomatic infection with N gonoTThoeae frequently occurs: thus, reliability of vaginal, rectal or pharyngeal exudates as an indication of likely infection is poor ( 14, 15,29 ,30).
Adequate specimens of exudate or swabs of mucosal surfaces should be obtained and plated immediately onto antibiotic-containing selective media (such as modified Thayer-Martin media) and incubated to maximize the chances of recovery of the organism.Several Neisseria species may be falsely identified as N gonorrhoeae and may thus lead to false allegations of sexual abuse (31).Isolates should be identified using more than one identification procedure and should ideally be fowarded to a reference laboratory for confirmation.
Empiric treatment for chlamydia infection may be warranted while awaiting results of culture , since as many as one-third of cases of gonorrhea are complicated by concomitant infection with chlamydia (32).
Repeat cultures of infected sites for 'test of cure' a re recommended for all patients ,vith gonorrhea.Particular attention should be given to children with U1e organism isolated from the throat.as eradication of infection at this site is difficult.A throat swab for N gonorrhoeae should be included in the initial investigation of gen ital or rectal gonorrh ea.The •test of cure• cu ltures for gonorrhea should be done four to five days following completion of the antibiotic treatment course .Chlamydia: Chlamydia may also be isolated from young girls with symptomatic vaginitis, but its role as a causative agent in this condition remains unclear {18, 19.32-34).Currently, a controversy exists regarding the sensitivity and specificity of rapid diagnostic testing methods for C trachomatis when used in the abused child population.The successful use of enzyme assays or fluorescent antibody tests for rapid culture-ind ependent diagnosis of chlamydia infections in adult patients led to testing of these products in ch ildren (35).There are significant problems when these tests a re used for specimens obtained from the genitourinary tract or the rectum of children, due to false positive results when specimens contain other bacterial elements (36)(37)(38)(39)(40). Mathematical calculations based on the theoretical performance of existing tests on populations of low seroprevalence indicate that currently used tests have a positive predictive value of only 50% in situations of child a buse (41).Manufacturers of these products are examining laboratory man ipulations such as blocking antibodies in the test system to obviate most.if not all.false positive reactions.
At present. the diagnosis of gen ital or rectal chlamydia infections in prepubertal children is dependent on isolation of the organism from the vagina.urethra or rectum.Dacron swabs may be toxic to chlamydia; tl1erefore , Calgi swabs are used to collect cells from tl1e lining of the vagina or urethra.Less invasive procedures such as early phase voided urine specimens or vaginal washes are under assessment.Samples should be placed in chlamydia transport media and transported on wet ice to the laboratory.Specific arrangements regarding appropiiate handling of chlamydia culture specimens should be made witl1 the laboratory if there will be a delay of greater tl1an 4 h in specimen transport.Vaginitis: Children who present with symptoms or signs of vaginitis such as vulvar or vaginal itching, uiinary frequency or painful urination , vulvar or vaginal inflammation.or vaginal discharge , should be investi-<fated for STD and non-STD pathogens (42,43).Samples of vaginal secretions can be obtained using a swab from ilie vagina suspended in saline or an aspirate of vaginal secretions (possibly diluted with sterile saline).These samples should be studied under the microscope for the presence of trichomonads, candida and 'clue cells•.
Suspension of a drop of ilie sample mixed witl1 10% potassium hydroxide will give off a distinctive offensive fishy an1ine odour if anaerob ic organisms producing vaginitis are present (44).The chocolate agar of tl1e modified Thayer-Martin split plate often used for detection of gonococci should be a dequate to isolate an aerobic non -STD bacterial cause of vaginitis such as streptococci, staphylococci or enterobacteiiaceae.Candida may also be recovered from tl1is culture.
Cultures for N gonorrhoeae and C trachomatis should be obtained as described previously.Examination for pinworm infection may b e warranted.Treatment of non -STD aerobic organisms or candida will depend upon culture results and the patient's underlying condition.Genital ulcer disease: If present, genital ulcers should be tested for detection of h e rpes simplex virus .n-eponema pallidum, Haemophilus ducreyi (if chancroid is present in the community) and aerobic non -STD pailiogens.The initial differential diagnosis will depend upon the appearance of ilie ulcer and ilie presence of pain or other symptoms.Classic ally, the primary chancre of syphilis is painless, whereas genital ulcers ,vith other etiologies are usually extremely painful.
The ulcer base should be cleaned and swabs taken for ilie diagnostic specimen.Material should be sent in viral transport media to a virology laboratory for herpes simplex virus isolation and typing if possible.If syphilis is suspected.a swab of tl1e base should be tested imm ediately by fluorescent darkfield examination.The diagnosis of H ducreyi involves the use of specialized media; the sample should be plated immediately on tl1is media (45).Genital warts: Diagnosis is by inspection of ilie genital area.The wart may be biopsied and DNA hybridization or polymerase chain reaction testing for STD strains performed if tl1ere is doubt concerning the type of wart.Treatment depends upon the location and size of ilie warts and may involve the use of topical agents such as podophyllin or liquid nitrogen, or may necessitate surgical removal (25.26).Podophyllin is often not well tolerated.Recurrences are frequent despite therapy.Use of interferon alpha-2b is currently under investigation (25).Inapparent infections -Latent syphilis, HIV, hepatitis B: These infections are diagnosed using serological tests .Testing is at the discretion of the physician and is based upon the risk of acquisition of the illness.The risk of syphilis is estimated to be less tl1an 1 % in areas of low prevalence of this disease in U1e adult population.and only a few cases of human immunodeficiency virus (HIV) or hepatitis B transmission have been described {7,8,46).If testing is done, tl1e rapid plasma reagin (RPR) or VDRL screening tests should be confirmed witl1 an additional test (usually T pallidum hemagglutination).An initially positive HIV antibody test should also be repeated to confirm the diagnosis.Both syphilis and HIV have latent periods .and so. in h igh risk s ituations.the tests need to be repeated if the initial on e is negative (six weeks for syphilis.six mo n ths for HIV) .Treatment fo r syphilis is dependen t upon disease stage and requires fo llow-u p serological testin g a t three-m onth intervals u n til the VDRL or RPR tests b ecome nonreactive .Managem ent of children with HN infection involves emotional s u pport, p reven tion of opportu n istic infection, and a dministration of antiviral agents to delay progress ion of the illn ess on ce immune s u ppression occurs .
There is no specific treatment fo r h epa titis B infection .A s ummary of an tibiotic treatment regim ens for children is found in Table 3.In addition to the suggested therapies, tetracycline or doxycycline a re alternative antibiotic treatments for syphilis, gonorrhea and ch lan1ydial infections in children n ine years or older.Empiric treatment for STD in instances of acu te assault is at the discretion of the physician.If done.treatment should b e directed against syphilis , gonorrhea a n d ch lan1ydia.Test of cure' specimens should be obtain ed following this th erapy.

SUMMARY
The importance of correct diagnosis of the presence of STD in ab used children cannot be overem ph asized.nor can the n ecessity of testing for additional STD pa thogens fo llowing the identification of one STD be ignored.Of prime importance is that identification of STD allows for appropriate treatment and fo llow-up.As well the presen ce of one or more STD helps confirm th at sexual activity has occu rred.This may be e>-1:remely important, particula rly in the ch ild with minin1al physical findin gs suggestive of abuse, or in the child with limited verbal skills who is unable to give complete disclosure.As knowledge of STD epidemiology.diagnosis and optimal m a n agem ent of infected children in the abused population grows, so will clinician ability to use this infom1ation to h elp unravel the often complicated problem of the diagnosis of sexual a buse of children.
Neisseria g onorrh oeae c ulture Chlamydia trac homatis c ulture Herpes simplex virus c ulture Urine Examine for Tric homonas vagina/is Vagina Neisseria gonorrh oeae culture Chlam ydia trac homatis c ulture Aerobic bac terial c ulture Microsc op ic examina tio n of wet mount preparatio n/ exudate fo r: Trichomonas vagina /is C lue c ells Yeast Amine od our Herpes simple x virus c ulture Genital ulcers Aerob ic bac terial c ulture Herpes simplex virus c ulture Hemophilus duc re yi c ulture Examination o f exudate fo r Treponema pal/idum Genital warts

TABLE 1
Reported prevalences of sexually transmitted diseases in abused children

TABLE 3
Treatment of sexually transmitted pathogens in children Human papillomavirus Podophyllin, liquid nitrogen, surgery Interferon alpha-2b (investigational) CAN J INFECT DIS VOL 3 No 3 M AY/J UNE 1992 STD in child sexual abuse