B10. Sexually Transmitted Disease Evaluation and Care



These recommendations are for pediatric examiners on Sexually Transmitted Disease (STD) evaluation and care.

Integrate the evaluation and care of sexually transmitted diseases (STDs) into the medical forensic examination of prepubescent children who disclose sexual abuse or for whom sexual abuse is suspected.[1] Contracting a STD from a perpetrator during sexual abuse is a risk that must be considered for this population.[2] Medical forensic care should include evaluation for STDs for two purposes: (1) to determine if a STD is present, so it can be treated; and (2) to acquire evidence for potential use in legal investigations. Mechanisms should also be in place in any setting where children are examined for STDs to ensure continuity of care, including timely review of test results, and to monitor compliance with and adverse reactions to any therapeutic or prophylactic regimens (CDC, 2010).

Recognize that the diagnosis of a STD in a prepubescent child may be evidence that the child has experienced sexual abuse. The CDC (2015e) noted the identification of sexually transmissible agents in children beyond the neonatal period strongly suggests sexual abuse (Jenny, Crawford-Jakubiak, & Committee on Child Abuse and Neglect, 2013).[3] However, the significance of the identification of a sexually transmitted agent in a child as evidence of possible sexual abuse varies by pathogen (CDC, 2015e): Postnatally acquired Neisseria gonorrhea, [4] syphilis, Chlamydia trachomatis infection,[5] and nontransfusion, nonperinatally acquired HIV[6] are indicative of sexual abuse; and sexual abuse should be suspected when Trichomonas vaginalis, genital herpes, or anogenital warts are diagnosed.[7]

In any case that a prepubescent child presents with a STD, conduct an investigation into the risk factors and contacts, obtain a medical and social history, and evaluate for sexual abuse (Black et al., 2009; CDC, 2015e; Jenny, Crawford-Jakubiak, & Committee on Child Abuse and Neglect, 2013; Girardet et al., 2011). Examiners should be aware of which types of STDs in children need to be reported to law enforcement or child protective services, if the case is not already being investigated as suspected abuse (American College of Emergency Physicians [ACEP], 2013; CDC, 2010).

Provide STD information to children and caregivers (in a manner that is developmentally appropriate for the child and linguistically appropriate for the child and caregiver). As needed in a specific case, examiners should offer information about the risks of STDs for this population, symptoms, the necessity of testing, treatment options upon diagnosis (including benefits and side effects), and follow-up testing and care (adapted from CDC, 2010). As available in a community and appropriate for prepubescent children, examiners should also offer referrals for follow-up services that include free and low-cost testing, counseling, and treatment offered in the community. In addition, children and caregivers should be told that STD testing results will be shared with investigative agencies,[8] and that victim advocates (as available in the community) can provide emotional support, information, and access to/referrals for counseling through follow-up treatment.

On an individual case-by-case basis, consider the need for STD testing. In each sexual abuse case, children should be evaluated for STD risk. They may or may not require diagnostic testing based on their presentation, the examination, and assessment of risk (from sexual abuse and additional exposure that might have occurred since the abuse). (See Appendix 8. Prepubescent STD Testing Algorithm)

Factors that indicate the need for STD testing for prepubescent children, regardless whether the case is acute or nonacute (CDC 2015; Jenny, Crawford-Jakubiak, & Committee on Child Abuse and Neglect, 2013).

  • Child had experienced penetration or there is evidence of recently healed penetrative injury to genitals, anus, or oropharynx
  • Child has been abused by a stranger
  • Child has been abused by a perpetrator known to be infected with a STD or at high risk for STDs[9] (e.g., intravenous drug abusers, men who have sex with men, people with multiple sex partners, and those with histories of STDs)
  • Child has a sibling or other relative or person in the household with a STD
  • Child lives in an area with a high rate of STDs in the community
  • Child has signs or symptoms of STDs (e.g., vaginal discharge or pain, genital itching or odor, urinary symptoms, and genital lesions or ulcers)
  • Child has already been diagnosed with one STD
  • Child or caregiver requests STD testing

 

Test for specific organisms if indicated. (See below) If symptoms, signs, or evidence of a STD are present, the child should be screened for commonly occurring STDs (Black et al., 2009; CDC, 2015e; Girardet et al., 2011). The health and legal implications of test results in prepubescent child sexual abuse cases justify the time, labor, and cost of performing STD tests with high specificities and sensitivity (CDC, 2015e). If diagnostic testing is necessary, examiners should document in the medical record what tests are performed and the results of testing. Follow the designated lab’s policy on identification of the patient from whom the specimen was collected, what specific specimen to collect, and the collection method for different organisms. Legal chain of custody for medical specimens is not required as with evidentiary specimens; the testing lab’s policy should ensure proper patient and specimen identification at both collection and testing, even if the test is sent to an external lab.

General Guidance for Testing for Common STDs[10] (Note HIV is addressed in next section)

Infection

Symptoms

Testing

N gonorrhea (NG)

This infection does not ascend the genitourinary track in prepubescent girls.

This infection IS DIAGNOSTIC of child sexual abuse, once perinatal transmission has been ruled out.

Children with vaginal N gonorrhea can be symptomatic (vaginal discharge) or asymptomatic

Children with pharyngeal and rectal N gonorrhea may be asymptomatic (Matthers & Rein, 2015)

· Nucleic Acid Amplification Testing (NAAT) can be used to screen for N gonorrhea in prepubescent girls (Adams et al., 2015; Black et al., 2009; CDC, 2015e; Papp, Schachter, & Gaydos, 2014).[11] A NAAT urine specimen can be obtained as a “dirty” catch—a random voided, non-clean catch specimen (Black et al., 2009). In the absence of NAAT, obtain culture by swabs from the vulva and beside the vaginal orifice.

· Culture remains the preferred testing method for urethral drainage from boys, as well as anal and oropharyngeal specimens from girls and boys (CDC, 2015e; Papp, Schachter, & Gaydos, 2014).[12]

· Retain all positive specimens at the lab for additional testing (CDC, 2015e). A positive NAAT result should prompt repeat testing by culture or alternate technology NAAT (alternate sequence confirmation).

· Note a positive NAAT persists for weeks after effective treatment (WA, 2012).

C trachomatis (CT)

This infection does not ascend the genitourinary track in prepubescent girls.

 

This infection IS DIAGNOSTIC of child sexual abuse, once perinatal transmission has been ruled out.

 

Vaginal or anal infection is frequently asymptomatic, and can persist for months or years

 

If symptomatic: discharge, dysuria, and abdominal and rectal pain are possible (Amaya & Kellogg, 2011)

Same as for N gonorrhea testing, except:

· Oropharyngeal specimens are not recommended—yield is low, perinatally acquired infection may persist past age 2, and some labs do not distinguish between C trachomatis and Chlamydia pneumonia.

 

Syphilis

This infection IS DIAGNOSTIC of child sexual abuse, once perinatal transmission has been ruled out. Lack of prenatal identification of syphilis in the mother can result in vertical transmission of syphilis for up to 4 years after birth. Children presenting with primary infections after 6 months of age or secondary after 15 months should be presumed sexual abuse victims (Amaya & Kellogg, 2011).

Asymptomatic at primary inoculation on vulva, labia, penile, scrotal, anal, rectal, oral, or extra-genital site signs

 

Secondary cutaneous and constitutional symptoms, but most are asymptomatic (WA, 2012)

· Prevalence in children who have been sexually abused is quite low—testing is recommended only in high-risk situations. Differentiating perinatal from later-acquired syphilis may be challenging.

· Dark field microscopy or direct fluorescent antibody (DFA) testing of exudate or tissue from primary or secondary lesion.

· Serology: In absence of lesions, serologic testing for antibodies to T. pallidum is recommended.

· See CDC (2015e) section on syphilis.

Herpes simplex virus (HSV)

This infection IS SUSPICIOUS of child sexual abuse. Need to rule out self-inoculation (a child with oral herpes may self-inoculate genitalia) or inoculation by an adult with oral or genital herpes during caretaking contact such as diaper changes (WA, 2012).

Dysuria, genital or perianal vesicles/ulcers

 

Primary infection may be accompanied by malaise and fatigue (WA, 2012)

· Obtain specimens from all mucocutaneous lesions and send for viral culture or polymerase chain reaction (PCR) testing (CDC, 2015e). Note culture is rapidly being replaced by PCR in many labs due to cost and improved performance (CDC, 2015e).

· Serology: Serologic testing in the absence of lesions will detect HSV antibody 2 to 3 weeks after infection. Providers should request type-specific HSV-2 and/or HSV-1 serologic assays.

· See CDC (2015e) section on genital HSV infections.

Human papillomavirus (HPV) Condylomaacuminata

This infection IS SUSPICIOUS of child sexual abuse. The older the child, the higher the risk of acquiring HPV via sexual abuse than prenatal or perinatal transmission from mother or postnatal transmission from caregiver. Children over 4 or 5 years of age are likely at higher risk than younger children.

Condyloma presence in oral and/or anogenital areas

 
  • Clinical examination of lesions suspicious for HPV. Histological examination if clinical diagnosis is unclear. Note that biopsy and typing of HPV does not differentiate sexual from nonsexual acquisition.
  • Test for the potential presence of other STDs (Sinclair, Woods, & Sinal, 2011).

T vaginalis (TV)

This infection IS SUSPICIOUS of child sexual abuse. It might be the result of a perinatally acquired infection.

Girls with this vaginal or urethral infection can be symptomatic or asymptomatic
  • Culture for T. vaginalis and wet mount (must distinguish between different species of trichomonas as T. vaginalis is the only species specific to sexual transmission).
  • >Alternately, consider testing a portion of the “dirty” urine specimen for T. vaginalis. There is no evidence suggesting that performance of NAAT for detection ofT. vaginalisin children would differ from that in adults (CDC, 2015e). However, there is not currently an alternate sequence confirmation method available for T. vaginalis.

Consider the timing of initial and follow-up testing (CDC, 2015e). STD test results after a recent exposure are likely to be negative unless the child has a preexisting condition (Day & Pierce-Weeks, 2013).[13] If no infections were identified during the medical forensic examination and the exposure was recent, a repeat examination and testing should be done approximately 2 weeks after the initial testing. (Note that as gonorrhea and chlamydia can clear spontaneously in a prepubescent female, follow-up testing must be done in a timely manner) Decisions regarding which tests should be performed must be made on an individual basis. The initial screening may be sufficient in some cases (e.g., if a substantial amount of time has elapsed between the last suspected episode of abuse and medical forensic care).

In circumstances where the transmission of syphilis, HIV, hepatitis B, or HPV is a concern, but baseline tests for syphilis, HIV, and hepatitis B were negative and examination for genital warts was negative, follow-up serologic testing and an examination approximately 6 week and 3 months after the last sexual exposure is recommended to allow time for antibodies to develop and signs of infection to appear (CDC, 2015). HIV testing is also recommended again at 6 months after the sexual abuse (see next section).

Defer STD treatment until after initial tests are conducted and any positive results are confirmed with follow-up tests (CDC, 2015e). Presumptive treatment is not recommended for several reasons: the incidence of most STDs is low after prepubescent child sexual abuse; prepubescent girls appear to be at lower risk for ascending infection than adolescents or adult women; and regular follow-up testing and treatment of children can usually be ensured (CDC, 2015e). However, some children or caregivers might be concerned about the possibility of STDs, even if the examiner perceives the risk to be low—such concerns might be an appropriate indication for presumptive treatment in some settings and be considered after all relevant specimens for diagnostic tests have been collected (CDC, 2015e). See the CDC STD Treatment Guidelines at www.cdc.gov/std/tg2015/default.htm. (See below for more on treatment and care)

HIV[14]

The risk of the child acquiring HIV as a result of sexual abuse must be considered during medical forensic care. If there is a risk in an individual case, provision of HIV non-occupational post-exposure prophylaxis (nPEP) must be an option. The sooner nPEP is initiated after the exposure, the higher the likelihood that it will prevent HIV transmission, if HIV exposure did occur (Day & Pierce-Weeks, 2013). There is a short timeline to start nPep—no later than 72 hours post-exposure (see below).

 

Understand that the decision to recommend HIV serologic testing, as well as HIV nPEP, depends on local epidemiology, a case-by-case assessment of risk factors of the perpetrator, and details of the contact (WA, 2012). The risk for an individual patient is extremely difficult to calculate, since details about the perpetrator’s risk factors and HIV status are usually unknown (WA, 2012).[15] HIV infection has been reported in children for whom sexual abuse was the only known risk factor. Children might be at higher risk for HIV acquisition than adolescent and adult sexual assault victims because child sexual abuse is frequently associated with multiple episodes of abuse and mucosal trauma might be more likely. Other exposure characteristics might also influence risk, such as the following: penile, anal, or oral penetration; site of exposure to ejaculate; viral load in ejaculate; multiple perpetrators; and the presence of a STD or genital lesions in perpetrators or children (CDC, 2005; Day & Pierce-Weeks, 2013).

Be knowledgeable of current testing and prophylactic recommendations in the field and related CDC guidelines. Examiners should be aware of and able to explain to children and their caregivers, in a way that is developmentally appropriate for children and linguistically appropriate for children and caregivers (drawn in part from Day & Pierce-Weeks, 2013 ESCA-HC, 2011):

  • The risks of HIV infection for child victims of sexual abuse;
  • Benefits (proven and unproven) and toxicities of nPEP;
  • Benefits of adherence to recommended dosage, and costs of regimes; 
  • The importance of follow-up testing and care with a pediatric infectious disease doctor or specialist with HIV knowledge;
  • Medical referrals, including low-cost and free options in various sections of the community; and
  • Where they might obtain assistance with medical expenses (e.g., pharmaceutical patient assistance programs and coupons) and transportation to/from related appointments.

Although data are insufficient concerning the efficacy of nPEP among children, treatment is well tolerated by infants and children with and without HIV infection, and children have a minimal risk for serious adverse reactions because of the short period recommended for prophylaxis (28 days).[16]

Post-Exposure HIV Risk Assessment of Children (within 72 hours of sexual abuse)
  • Review HIV/AIDS local epidemiology, assess risk for HIV infection in the perpetrator, and test for HIV infection.
  • Evaluate circumstances of sexual abuse that might affect risk for HIV transmission (as mentioned above).
  • Consult with a medical specialist who treats children with HIV infection to select age-appropriate dosing and regimens if nPEP is considered. However, nPEP provision should not be delayed due to the lack of availability of a specialist. To this end, it is important for pediatric examiners to have established relationships with infectious disease specialists in their facilities and area, as well as with local HIV clinics. In addition, assistance with post-exposure prophylaxis decisions can be obtained by calling the National Clinician’s Post-Exposure Prophylaxis Hotline (PEPLine), telephone: 888-448-4911. An HIV/AIDs Management “warmline” is available for clinical consultation at 1-800-933-3413. See the Clinical Consultation Center at http://nccc.ucsf.edu/ for more information.
  • For children determined to be at risk for HIV transmission, discuss nPEP with the child and caregiver, including its toxicity, unknown efficacy, and possible benefits. The potential benefit of treating the child should be weighed against the risk for adverse reactions. Another consideration is the likelihood of compliance with the prophylactic regimen, and whether the family has a high concern for HIV infection after discussion of low relative risk.
  • If nPEP is begun, adequate doses of medication should be provided to last until the follow-up visit at 3 to 7 days after the initial assessment,[17] at which time the child should be reevaluated and tolerance of the medication assessed.[18] Consider efficient methods in individual cases to facilitate compliance with the nPEP regimen (e.g., dispensing to the patient a starter pack, incremental dosing, or the full 28-day course of medication up front).
  • If nPEP is started, perform CBC and serum chemistry at baseline. DO NOT wait for lab results to start nPEP.[19]
  • Perform HIV antibody testing during the initial examination and again at 6 weeks, 3 months, and 6 months after the sexual abuse. If the initial test is negative, it should still be repeated at the above intervals. If initial testing was declined during the examination, children and their caregivers should be told they may return for testing.

Also see Appendix 9. HIV Testing nPEP Algorithm.

Follow-Up STD Testing and Care

Follow-up examinations after medical forensic care, either with the child’s primary care provider, the exam facility, or another specialist, provide opportunities to:

·       Detect new infections acquired during or after the abuse;

·       Complete hepatitis B and HPV vaccinations, if indicated;

·       Discuss test results, complete repeat testing as indicated, and start treatment for other STDs if indicated; and

·       Discuss HIV testing results and monitor side effects and adherence to post-exposure prophylactic medication, if prescribed.

Ensure that follow-up communication with children and their caregivers includes a reminder to go to follow-up examinations and receive STD related testing, immunizations, and treatment as directed. Pediatric examiners, child advocacy center staff, and victim advocates may be able to assist patients and caregivers in making follow-up appointments, obtaining transportation to and from appointments, and identifying resources to help pay for expenses involved with follow-up testing and care. Some jurisdictions may cover follow-up treatment as part of initial care through funds such as crime victims’ compensation. In such instances, patients may be more apt to seek follow-up treatment. Advocates may also be able to accompany patients to these follow-up appointments.

Coordinate with other responders. Core responders need to recognize that it is the duty of the pediatric examiner to screen, test, and treat the patient for STDs, as indicated. Examiners can help other responders understand what STD evidence is indicative of sexual abuse and what is not (and consider pre- and perinatal acquisition of STDs). Responders should be educated about the importance of encouraging children who have started a treatment regimen and their caregivers to follow up within the appropriate time frame for required additional doses, as well as any testing needed, and need to be familiar with resources for related referrals to public health and private health care providers, and time frames for treatment/testing.

As mentioned earlier in this chapter, response teams need to protect information related to STDs in a child’s medical record. Investigative agencies, prosecutor’s offices, and multidisciplinary investigative teams should be aware of jurisdictional policies related to legally pressuring suspects in a case to be tested for STDs, whether voluntarily or court ordered (Amaya & Kellogg, 2011).



 Table of Contents B11. Discharge Planning and Follow-Up Care

[1] Much of the information in this chapter was drawn from the CDC’s Sexually Transmitted Diseases Treatment Guidelines (2015)—see www.cdc.gov/STD/treatment/ (CDC general phone: 800-311-3435, TTY: 888-232-6348). The guidelines are updated periodically. Also see the CDC at www.cdc.gov offers information on related research, news, and Internet links.

[2] As for the risk of a prepubescent child acquiring a STD as a result of sexual abuse, the CDC (2015e) indicated that the issue has not been well studied. Black et al. (2009) found that 4.9 percent of prepubescent female sexual abuse victims tested positive for either Chlamydia trachomatis or Neisseria gonorrhea.

[3] The CDC (2015e) provides several examples of exceptions to this general rule. 

[4] Jenny, Crawford-Jakubiak, and the Committee on Child Abuse and Neglect (2013) noted that genital and anal infections with N gonorrhea are rarely acquired perinatally, and, outside the newborn period, are considered likely to be caused by sexual abuse.

[5] The CDC (2015e) and Jenny, Crawford-Jakubiak, and the Committee on Child Abuse and Neglect (2013) indicated that C trachomatis infections might be indicative of sexual abuse in children 3 years of age or older and among those less than 3 years of age, when infection is not likely perinatally acquired.

[6] Jenny, Crawford-Jakubiak, and the Committee on Child Abuse and Neglect (2013) noted HIV infection in children who have not been exposed to the virus perinatally, through blood products, or by needles, are also highly likely to be caused by sexual abuse.

[7] Jenny, Crawford-Jakubiak, and the Committee on Child Abuse and Neglect (2013) noted that herpes simplex virus and genital warts (human papillomavirus or HPV) can be sexually transmitted in children, but these infections are not diagnostic of sexual abuse by themselves.

[8] Formal signed agreements amongst investigative agencies (and the multidisciplinary response team, if one exists) are critical to speak to the scope of information to be shared regarding STDs, especially if it is non-forensic information (e.g., if it was due to perinatal transmission). The investigative team must protect non-forensic medical history and information. The team should consider various scenarios and plan strategies to protect this type of information, so that it is not used inappropriately in the justice system or shared with anyone outside the team who should not have access to it. For example, the team should consider what a child protective service agency might do with non-forensic medical information of a child in a sexual abuse case, how confidential it will be in that child protection system, and implications of its availability in that system across the child’s lifespan. All states and the District of Columbia allow minors 12 years of age and above to consent to STD services (Guttmacher Institute, 2015). However, in most jurisdictions, prepubescent children do not have this right. Health care providers should become familiar with the laws in their jurisdiction. If a caregiver who is a parent/guardian declines STD testing and treatment for their children in cases reported as suspected sexual abuse, health care providers should discuss with legal counsel the options for providing necessary testing and treatment.

[9] For more information on risk for STDs, see CDC’s Sexually Transmitted Disease Surveillance 2014 (in particular the section on special focus profiles) at www.cdc.gov/std/stats14/default.htm. Also see www.cdc.gov/STD/.

[10] The chart was drawn from the CDC (2015e), Day and Pierce-Weeks (2013), and Washington State (2012), as well as others cited. Note that although hepatitis B virus (HBV) may be transmitted to a child during sexual abuse via semen and vaginal fluid, most HBV in children result from household exposure to persons with chronic HBV infection rather than sexual abuse (CDC, 2015e). For that reason, it was not included on this list. If a concern exists about HBV, diagnose via serologic testing (HBsAg). Note that results of HBsAg must be interpreted carefully; HBV can be transmitted nonsexually. HBV vaccine for prophylaxis should be administered in previously unimmunized patients. See CDC (2015e) section on viral hepatitis.

[11] NAAT detects genetic material that is specific for an infecting organism (Esernio-Jenssen & Barnes, 2011). Although cultures have historically been considered the “gold standard” for child sexual abuse evaluations, they are invasive and costly, require stringent transporting and handling, and usually have long turn-around times (Esernio-Jenssen & Barnes, 2011). NAAT on urine, with confirmation by second NAAT or culture, is the “new forensic standard” for diagnosis of gonorrhea and chlamydia in children who disclose sexual abuse or are suspected of being sexually abused (Black et al., 2009). The second NAAT should not be merely a repeat of the first, but instead, a NAAT run by a different amplification sequence (alternate sequence confirmation) (Black et al., 2009; Hammerschlag & Gaydos, 2012). Adams et al. (2015) recognized that NAAT has high sensitivity, allows for collection of sample noninvasively, and can test for gonorrhea and chlamydia with one sample and at a lower cost compared to culture. Due to low prevalence of STDs in the prepubescent population, and the lack of enough large randomized controlled trials for validation, this testing is not yet approved by the Food and Drug Administration for this population. However, the CDC (2015e) discusses the use of NAAT for this population as indicated in protocol recommendations. 

[12] That said, many practitioners find it difficult to access cultures (Adams et al., 2015). NAATS (especially the Strand Displacement Amplification and Transcription Mediated Amplification) have been evaluated in adult studies of pharyngeal and anorectal infections and found to have superior sensitivity to detecting infection at these sites compared to culture and specificity rates (Adams et al., 2015).

[13] CDC (2015e) noted that infectious organisms acquired through a recent exposure might not have produced sufficient concentrations of organisms to result in positive test results or exam findings (Gavril, Kellogg, & Nair, 2012). Also, positive test results after a recent exposure might represent the perpetrator’s secretions.

[14] This section is drawn from the CDC (2015e) unless otherwise indicated.

[15] If the suspected perpetrator is known, examiners should consider if HIV testing of that person is a possibility.

[16] See the CDC (2005) and the Panel on Antiretroviral Therapy and Medical Management of HIV-Infected Children (2012). 

[17] Examiners and heath care facilities are encouraged to collaborate with HIV clinics, insurance companies, pharmacies, justice agencies, victim advocacy programs, victim crime compensation programs, and other relevant entities to help children’s families readily access nPEP medication and manage the costs of this medication.

[18] See Fleming and Wasserheit (1999), Havens and the AAP Committee on Pediatric AIDS (2003), and the Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission (n.d.).

[19] Also, do not wait for HIV tests on the perpetrator, even if arrested. This testing may take weeks to accomplish.