REVIEWS OF INFECTIOUS DISEASES • VOL. 12, SUPPLEMENT 6 • JULY-AUGUST 1990
Sexual Assault and Sexually Transmitted Diseases: Detection and Management in Adults and Children Sandra K. Schwarcz and William L. Whittington
From the Division of Sexually Transmitted Diseases, Center for Prevention Services, Centers for Disease Control, Atlanta, Georgia
Sexual assault is a violent crime that affects men, women, and children of all ages. Sexually transmitted diseases (STDs) may be transmitted during sexual assault. In children, the isolation of a sexually transmitted organism may be the first indication that abuse has occurred. Because the presentation, evaluation, interpretation of test results, and treatment differ between children and adults, sexual assault in these two groups will be discussed separately. Sexual Assault in Adults Epidemiology of Assault and Risk of Infection
Rape has an estimated incidence of 73/100,000 population and accounts for 6070 of all violent crimes [1]. It has a seasonal distribution, with peaks occurring in the summer [1-3]. In the majority of assaults, the victims are young women; only 5%-6070 are men [4]. Most assaults - including those against men - are committed by men who regard themselves as heterosexual [5]. Adult victims are often assaulted by strangers and sometimes by more than one assailant [3]. Assault by acquaintances, as in a dating or social situation, has gained increasing recognition in the lay press and has been estimated to occur at least as often as assault by strangers. Sexual assault is an expression of violence; consequently, physical trauma often results [5]. Genital injuries (such as vaginal tears), although often not
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clinically serious, are estimated to occur in 50% of victims [5]. Nongenital injuries are reported in 40070 of sexual assaults [5]. Oral, anal, and vaginal penetration may occur [6]. Few prospective studies have documented the risk of acquiring an STD following sexual assault. Determination of the exact risk of transmission is complicated by several factors. First, it is difficult to distinguish between preexisting infection in the victim and infection acquired during the assault. For example, some authorities believe that infections documented shortly after the assault (in < 24 hours) are likely to represent preexisting conditions [7]. Second, the frequently incomplete follow-up of rape victims, combined with the generally long incubation period of some STDs, have hampered attempts to quantify the risk of acquiring an STD from sexual assault. Other factors that would be expected to influence the risk of disease transmission during rape include the underlying prevalence of STDs (which have distinct geographic and demographic variability) and the type of assault. The chance of transmission is expected to be greater with penetration. The high rates of sexual dysfunction by assailants during assaults may contribute to the relatively low prevalence of STDs found in some studies of rape victims [8]. Previously published reports have found the prevalence of gonorrhea in female assault victims to range between 2070 and 13070 and the rates of syphilis to be usually < 3070 [3,9-11]. These studies are summarized in table 1 and have been reviewed by Glaser et al, [12] and Blackmore et al, [7]. Unfortunately, although other STDs have been described in adult victims of sexual assault [9, 11], studies document-
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Sexual assault is a frequently occurring violent crime. Sexually transmitted diseases (STDs) may be acquired during assault. Reported rates of gonorrhea and syphilis in adult victims range from 6070 to 12070 and from 0% to 3%, respectively. The risk of acquiring other STDs cannot be quantified, although the risk of infection with Chlamydia trachomatis appears highest. In abused children, gonococcal and chlamydial infections are the most frequent findings. In both adults and children, postassault infections with viral agents of STDs, including herpes simplex viruses, hepatitis B virus, and human immunodeficiency virus, have been described. Sensitive, competent care for victims of sexual abuse includes evaluation for STDs soon after the assault and during follow-up.
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Table 1. Prevalence of syphilis and gonorrhea in adult victims of sexual assault. No. tested [reference] 105* [3] i.zoot [9] 50 [10] 46 [11]
No. (%) positive Syphilis
Gonorrhea
3 (2.9) 16 (1.3)
14 (13.3) 55 (4.6) 3 (6.0) 3 (6.5)
o NS*
*
ing the risk of acquiring these infections have not been published. However, it may be reasonable to estimate that the risk of Chlamydia trachomatis infections following assault would be similar to that of gonorrhea; although the prevalence of chlamydial infections is greater than that of gonorrhea, the efficiency of transmission of C trachomatis appears to be lower [13]. The risk of acquiring a viral STD during an assault may be less than the risk of acquiring a bacterial infection because of the episodic nature of viral shedding. Determination of the risk of viral infection after assault may also be hampered by the difficulties involved in isolating a viral agent, the long incubation periods of viral infection, and the frequency of asymptomatic viral infection. Evaluation of tbe Sexually Assaulted Victim
Initial evaluation. The initial evaluation of the victim should be performed as soon after the assault as possible. A thorough history should be taken in a direct and sensitive manner by trained personnel at the outset of the evaluation. The type of assault, including sites of penetration, should be carefully documented. Most adults are capable of providing this kind of information. While the information will be of legal interest, it is important for proper medical management as well. Because the risk of acquiring an STD has not been quantified, the physical examination and laboratory evaluation of the victim should be comprehensive. Although a history of penetration may help orient the clinician, a complete physical examination - with careful inspection of the oral, anal, and genital mucosa for trauma, seminal fluid, or evidence of infection - should be done [12]. Men should undergo careful inspection of their
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* One hundred three persons were tested for syphilis; 105 were tested for gonorrhea. t Adolescents are included. NS = not studied.
oral and anal mucosa and genitalia. A rectal examination should be performed to evaluate the condition of the prostate and the tone of the external sphincter. A lax sphincter may result from anal penetration [12]. Pharyngeal, rectal, and urethral cultures for gonococci and chlamydia may be indicated in men, especially when penetration or attempted penetration has occurred. A gram-stained smear of urethral discharge may be used to assist in an immediate diagnosis. Findings on gram staining should not rule out culture of specimens. As the male victim may have been subjected to fellatio or, in extremely rare cases, to rape by a woman, urethral cultures should not be overlooked. All women should have their external genitalia inspected and have a speculum and bimanual pelvic examination. In addition, women should undergo oral and rectal examinations. Endocervical sites should be cultured for gonococci and chlamydia. Extragenital sites should be cultured in those women from whom a history of penetration or attempted penetration of these sites is elicited or in women whose history is difficult to obtain. The value of tests for gonococcal antigens has not been established for sexual abuse victims of either sex. The use of these tests in this situation is discouraged. Although antigen detection tests are frequently used to screen women for cervical chlamydial infections, these tests have lower sensitivity and specificity than cell culture and are best used in populations with a relatively high prevalence of infection [14]. Furthermore, these tests have not been approved for use on specimens from most extragenital sites [15]. Because of the uncertain risk of STD transmission and the legal consequences surrounding sexual assault, only chlamydial cultures - and not antigen detection tests - are recommended for the detection of C trachomatis. A sample of cervical discharge should be stained and examined microscopically for gram-negative diplococci and white blood cells. A normal saline preparation of vaginal discharge should be evaluated for trichomonads and clue cells. Cultures for trichomonads have been shown to be more sensitive and may be useful in the absence of identification by normal saline preparation [16]. Vaginal pH should be measured, and the presence of an amine odor when the vaginal discharge is mixed with 10070 KOH should be noted. Skin and mucosal surfaces should be carefully in-
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Table 2. Recommended laboratory procedures at initial and follow-up evaluations of sexually abused children (prepubertal) and of adult and adolescent victims of sexual assault. Recommended for
Procedure Gram stain of any genital or anal discharge* Culture for N. gonorrhoeae Culture for C. trachomatis Wet preparation of vaginal secretion for trichomonads, clue cells, and an amine odor when mixed with KOH Vaginal pH Dark-field examination of genital lesions Cultures of lesions for herpes simplex viruses Serologic test for syphilis Serologic test for HIV Frozen serum sample
Children
+
Adolescents/ adults
-§
+ +
+
+
+ + +11 +
+ + +11# +
NOTE. Syphilis and HIV serology should be repeated in 12 weeks. All other tests should be repeated 10-14 days after the initial examination. * Results of gram staining of anal discharge should be interpreted cautiously. t Cultures of pharynx, rectum, and vagina/urethra should be done. :j: Specimens for culture should be obtained from all sites in adolescents whose history is incomplete. In adults, only sites of penetration or attempted penetration need to be cultured. § Vaginal pH testing is not recommended because of the lack of a known standard. II Testing for HIV should be based upon the prevalence of infection and on suspected risk. # Tests for hepatitis B antibody and surface antigen should be considered. .
to be infected with HIV, serologic studies of the victim may be repeated in 24 weeks. Earlier follow-up evaluation may be necessary should symptoms suggestive of infection develop. Recommended tests are listed in table 2. The identity of an STD agent isolated from a victim of sexual assault or from a suspected assailant should be confirmed by recognized laboratory methods [21]. For Neisseria gonorrhoeae, confirmation should include at least two techniques that use different principles, e.g., biochemical and enzyme-substrate or serologic [21]. Isolates should be stored at -70°C for possible future studies; use of the servicesof a reference laboratory to confirm initial findings should be considered.
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spected for evidence of infection in both men and women. Any suspicious lesion should be evaluated by dark-field examination; genital lesions should be cultured for herpes simplex viruses. A serologic test for syphilis should be performed in all cases despite the infrequent occurrence of this disease following sexual assault [12]. Although the risk of pregnancy following assault has been estimated to be low, women should be offered a serum pregnancy test [7]. Infection with hepatitis B virus and the human immunodeficiency virus (HIV) may be transmitted [12, 17]. Questions regarding possible previous exposure to these viral infections should be asked in a sensitive manner. For the evaluation of exposure to hepatitis B in a previously uninfected or unimmunized individual, serum should be tested for hepatitis B surface antigen and antibody. Baseline information regarding HIV exposure may be determined through antibody testing by standard protocols. A sample of serum should be stored at - 70°C for possible future testing [12]. Gastrointestinal STDs have been welldocumented in male homosexuals [18] and therefore may theoretically develop following sexual assault [12]. The pathogens most often associated with these illnesses are Giardia lamblia and Entamoeba histotytica [18]. Since such conditions are rare in heterosexual men and since most rapes, including those of men, are committed by men of heterosexual orientation, transmission seems unlikely. Glaser et ale [12] have recommended the evaluation of men for these pathogens only if symptoms of enteritis, proctocolitis, or proctitis develop. Follow-up evaluation. For victims who are medicallyevaluated shortly after assault (in ~ 24 hours), the initial examination is unlikely to identify STDs that may have resulted from the assault. These infections would be incubating at the initial examination. Infections noted immediately following assault may represent preexisting conditions. Schachter and Dattel [19], in their study of sexually abused and sexuallyactive adolescent girls, found the same prevalence of chlamydial infections in both groups. To identify infections that may have resulted from the assault, all studies except hepatitis B, syphilis, and HIV serology should be repeated 7-14 days after the initial evaluation. Because of the longer incubation periods, syphilis and hepatitis B serologies should be repeated in 8-12 weeks; HIV serology should be repeated in 12 weeks [12, 20]. If the assailant is known
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Sexual Abuse of Children Epidemiology and Risk of Infection
Several factors distinguish sexual assault in children from assault in adults. Children are usually assaulted by someone they know, frequently a male family member [6, 23-32]. There may be multiple episodes of abuse before the child comes to the attention of a health care professional or social worker [29]. Sexual abuse occurs among children of all ages, with the highest rates among adolescents [6, 9, 33]. Although, as in adults, the incidence of sexual abuse is higher among females, the female-to-male ratio is lower than that among adults. Studies of sexually
abused children have found female-to-male ratios of 5:1-7:1 [26, 28]. Sexual abuse among children includes a wide range of activities from fondling to oral and genital contact. Studies of sexual abuse in children have found vaginal penetration in 8%-66070 (counting abused girls only), anal penetration in 2%-30070, and orogenital contact in 3070-16070 [26, 28, 29]. Unlike the situation in adults, in children the presence of an STD may be the first indication that abuse has occurred. However, not all sexually abused children present with genital symptoms. Rather, children may present with other types of physical complaints or behavioral problems [23, 24,34,35]. As many as 50% of children presenting for evaluation of sexual abuse have no physical complaints [28]. In children presenting with complaints not suggestive of abuse, testing may result in the reporting of sexually transmitted organisms. Reported misidentification of organisms such as N. gonorrhoeae, resulting in inappropriate child abuse investigations, underscores the need for confirmation of an organism's identity by at least two procedures that use different principles (for example, as has already been mentioned, biochemical and enzyme-substrate or serologic) [21]. Transmission Routes of STD Pathogens
In general, the identification of a sexually transmitted organism in a specimen from a child suggests the possibility of sexual abuse. The difficulty in assessing a child who presents with an STD lies in distinguishing sexually acquired infections from infections that may have been transmitted through nonsexual means. Nonsexual transmission of sexually transmitted pathogens does occur, usually around the time of delivery. Other types of nonsexual transmission , such as by fomites, autoinoculation, and close physical contact, are rare and probably cannot explain the isolation of a sexually transmitted pathogen from a child [36]. Nonsexual transmission occurs most frequently from an infected woman to her child in utero or at the time of delivery. Infections acquired in utero include syphilis, and, very probably, herpes and HIV infection. Infections transmitted during delivery include gonorrhea, chlamydiosis, herpes, and human papilloma virus (HPV) infection. When acquired at birth, gonorrhea produces con-
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Treatment at the initial evaluation should be given for any infections identified at that time. A presumptive diagnosis of gonorrhea may be based on the observation of gram-negative intracellular diplococci. Prophylactic treatment is recommended only if the assailant is known to be infected, if follow-up of the victim seems unlikely, or if the patient requests it [7, 12]. As the rates of STDs in victims of sexual assault are low, there is little risk in delaying therapy until laboratory results are available. If prophylactic therapy is given, it should be effective against gonorrhea, chlamydial infection, and incubating syphilis [12, 22]. Ceftriaxone (250 mg as a single intramuscular injection) is recommended and will provide coverage for all strains of N. gonorrhoeae [22]. Therapy should be followed by doxycycline (100 mg by mouth twice a day for 7 days) or by tetracycline (500 mg by mouth four times a day for 7 days). If pregnancy is suspected, erythromycin should be given instead of tetracycline. Because the risk of bacterial vaginosis and trichomonas infection in female assault victims is unknown, prophylaxis against these infections is not recommended [12]. Similarly, since the risk of hepatitis B and gastrointestinal infections following assault is not known, prophylaxis is not recommended [12]. No data support the .use of prophylactic antiviral medications. For those patients who have received prophylactic therapy against gonorrhea and chlamydiosis and whose initial cultures are negative, repeated culture is not necessary.
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type 2, either type 1 or type 2 virus may be isolated from the genital tract or the mouth [55]. The possibility of transmission by autoinoculation from an oral lesion to the genitalia has been well described [56]. Transmission by fomites to humans has not been documented. Trichomonas vaginalis is a common sexually transmitted pathogen. Although trichomonads have been shown to survive on toilet sets for up to 45 minutes [57], infections resulting from fomite transmission have not been reported. Bacterial vaginosis (nonspecific vaginitis) is a polymicrobial vaginal infection that appears to be sexually associated. While it has been identified more often in sexually abused children than in nonabused children [58], the possibility of nonsexual acquisition remains [59]. Similarly, the genital mycoplasmas Ureaplasma urealyticum and Mycoplasma hominis have been recovered somewhat more frequently from abused children than from nonabused children, although the presence of these organisms in nonabused children suggests other routes of acquisition [60]. Risk of Infections in Sexually Abused Children
In general, the prevalence of STDs among abused children is relatively low (table 3). Most of the data on the risk of infection following abuse concern gonorrhea and syphilis. Studies indicate that between 0070 and 12070 of sexually abused children may be infected with N. gonorrhoeae [23, 24, 26, 28-30, 32, 61]. As many as 44070 of infected children have asymptomatic gonococcal disease [28]; rectal and pharyngeal infections are frequently asymptomatic [28, 39]. Syphilis has been found much less frequently (0%1.5070) [24, 26, 61]. Chlamydial infection may be the most frequently occurring disease following abuse (table 3). Studies have documented infections in 4070-17070 of abused children [29, 32, 43, 61]. Concurrent chlamydial infection has been found in as many as 27070 of abused children with gonococcal infection [48]. In general, infections are less common among abused prepubertal children than among abused adolescents [19]. The higher rates of gonorrhea and chlamydiosis may reflect consensual sexual activity in adolescents [61]. Other STDs have been identified infrequently. Trichomonas infection has been identified in 607025070 of abused children [26, 58]. However, the small sample sizes in these studies make it difficult to draw conclusions (table 4). Bacterial vaginosis(nonspecific
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junctivitis, although coexisting rectal and nasopharyngeal infection may also be present [37]. In general, oral, anal, and genital infections with N. gonorrhoeae are currently thought to represent sexual transmission [12, 26, 36-39]. C. trachomatis can produce conjunctivitis and pneumonitis and can colonize the nasopharynx, rectum, and vagina of infants [40, 41]. Although the maximal time that this organism may persist has not been established, persistence for up to 2 years has been reported [42]. Studies of chlamydial infections in" children> 2 years old have provided strong evidence of sexual transmission [32, 43-46]. Because the duration of infections acquired at birth is not well understood, there has been some disagreement regarding the point at which sexual abuse should be suspected in a child with a chlamydial infection [19, 32,44,47]. It has been suggested that the identification of C. trachomatis in a child of any age should alert the clinician to the possibility of abuse [19, 44]. However, some authors believe that the isolation of C. trachomatis from the rectum or the genital tract of children> 6 months old merits evaluation of sexual abuse [32, 47]. Other evidence [42] suggests an emphasis on sexual abuse evaluations for children ~ 2 years of age. Condylomata acuminata are caused by specific types of HPV. Types 6, 11, 16, and 18 appear to be associated with genital infections [48]. Genital warts can be transmitted from an infected woman to her child at the time of delivery, and HPV has been reported to cause anal [49], genital [50], and laryngeal papillomas [51]. Because of the variable and long incubation period (6 weeks to 8 months), perinatally acquired condylomata may not be evident immediately after birth, and the source of infection may therefore be difficult to establish [50]. Nonsexual transmission through close physical contact has been suggested, although this route has not been well established [48]. In contrast, sexual transmission of condylomata has been well documented in adults and children [48, 50, 52-54]. Thus the presence of rectal, anal, or perineal warts in a child must alert the clinician to the possibility of sexual abuse. Perinatal transmission of herpes simplex virus has been wellestablished [55]. With an incubation period estimated at 2-20 days (average, 6 days) [55], lesions appearing for the first time in neonates more than 30 days old may not have been acquired by perinatal transmission. Although the majority of genital herpes infections are caused by herpes simplex virus
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Table 3. Prevalence of syphilis, gonorrhea, and chlamydiosis in sexually abused children and adolescents. No. tested [reference]
Syphilis
Gonorrhea
Chlamydiosis
NS* NS
3 (6) 3 (3) 21 (7) 46 (II) 25 (5) 0 9 (10) 5 (10) 10 (20) 15 (12)
6 (13) NS NS NS NS 8 (17) NS 2 (4) 3 (6) 18 (14)
0 6 (I) I (0.2) 0 8 (9) NS NS 0
* NS
= not studied. Twenty-nine children were tested for syphilis; 47 were tested for C. trachomatis.
t
vaginitis) has been identified in 26070 of abused children [58]. Condylomata acuminata and genital herpes have been identified in abused children but only infrequently [28, 62]. The risk of acquiring other, less common infections such as chancroid and lymphogranuloma venereum is not known. Although one report [63] suggests the possible acquisition of HIV during sexual abuse of a lO-year-old girl, insufficient data are available to quantify the risk of HIV infection following sexual assault. Evaluation of the Sexually Abused Child
Initial evaluation. As with adults, a careful, comprehensive history should be obtained in a sensitive manner. Because of the delicate nature of the subject and the difficulty of obtaining an accurate and complete history from abused children, a team approach has been advocated [12]. The type of assault committed and the identity of the perpetrator should be elicited if possible. Table 4. Prevalence of vaginitis in sexually abused children and adolescents. No. evaluated [reference] 409 [26] 25* [28] 31 [58]
Etiology
No. (%) positive
Trichomonads Bacteria Bacteria
4 (I) 3 (12) 8 (26)
* Only patients with signs suggestive of vaginitis were evaluated.
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46 [II 103 [23] 285 [24] 409 [26] 532 [28] 49+ (29] 88 [301 51 [32] 50 [43] 127 [61]
No. (%) positive
In all cases of suspected abuse, children should undergo a complete physical examination. The oral, anal, and genital mucosa should be carefully inspected for signs of trauma or infection. If recent abuse with penetration is suspected, examination for the presence of seminal fluid should be included. In prepubertal girls the condition of the hymen, including evidence of lacerations or scars, should be noted. A speculum examination is not necessary because laboratory specimens may be obtained through aspiration of vaginal contents with a sterile eyedropper [12]or with a moistened Dacron swab [34]. Postpubertal girls should have a speculum and bimanual examination, and cervical and vaginal specimens should be obtained [12]. These examinations should not be painful to the victim, and anesthesia may be considered if the child is unable to cooperate [64]. All boys should have their external genitalia inspected, and urethral specimens should be obtained and cultured. Postpubertal boys should have a digital rectal examination to evaluate the tone of the anal sphincter [12]. Because of the difficulty of obtaining a complete history and the frequency of asymptomatic infection [25, 28], all children should undergo comprehensive laboratory evaluation and have specimens from all potentially infected sites cultured. Any discharge should be stained and examined microscopically [12]. Gonococcal and chlamydial specimens obtained from the throat, rectum, and genitals should be cultured. As was just mentioned, urethral samples from all boys should be cultured. In prepubescent girls who are symptomatic, gonococci and chlamydia produce vulvovaginitis rather than endocervical infection [29, 44]. Consequently, vaginal cultures should be performed in the cases of prepubescent girls and endocervical cultures in the cases of girls who have reached puberty. Antigen detection tests, including enzyme immunoassays and immunofluorescence tests for chlamydiae, may yield false-positive and false-negative results and are not approved for use in evaluation of cases of suspected sexual child abuse [65-67]. Cultures for both N. gonorrhoeae and C trachomatis are the only acceptable diagnostic methods for these cases. Vaginal secretions of pre- and postpubertal girls should be examined for the presence of trichomonads, clue cells, and an amine odor when mixed with KOH. Vaginal pH is not thought to be a useful marker for bacterial vaginosis in the prepubertal girl because of a lack of known standards [59].
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Treatment
Treatment of sexually abused children follows the same principles as treatment of adult victims of sexual assault. The relatively low prevalence of infection in abused children supports the withholding of prophylactic therapy unless the assailant is known to be infected, the child has clinical signs of infection, or the child is not likely to return for follow-up [69]. For children receiving treatment, the dosages should be appropriate in terms of body weight. Tetracycline should not be given to children < 8 years
of age or to pregnant teens. If possible, injections should be avoided to minimize additional trauma to the child.
References 1. U.S. Department of Justice. Uniform crime reports for the
United States, 1987. Publication no. 14. Washington, DC: US Government Printing Office, 1987 2. Michael RP, Zumpe D. Sexual violence in the United States and the role of season. Am J Psychiatry 1983;140:883-6 3. Everett RB, Jimerson GK. The rape victim: a review of 117 consecutive cases. Obstet Gynecol 1977;50:88-90 4. Anderson CL. Males as sexual assault victims: multiple levels of trauma. J Homosex 1982;7:145-62 5. Geist RF. Sexually related trauma. Emerg Med Clin North Am 1988;6:439-66 6. Evrard JR, Gold EM. Epidemiology and management of sexual assault victims. Obstet Gynecol 1979;53:381-7 7. Blackmore CA, Keegan RA, Cates W Jr. Diagnosis and treatment of sexually transmitted diseases in rape victims. Rev Infect Dis 1982;4(Suppl):S877-82 8. Groth AN, Burgess AW. Sexual dysfunction during rape. N Engl J Med 1977;297:764-6 9. Hayman CR, Lanza C. Sexual assault on women and girls. Am J Obstet Gynecol 1971;109;480-6 10. Kaufman A, Vandermeer J, Divasto P, Hilaski S, Odegard W. Follow-up of rape victims in a family practice setting. South Med J 1976;69:1569-71 11. Forster GE, Pritchard J, Munday PE, Goldmeier D. Incidence of sexually transmitted diseases in rape victims during 1984. Genitourin Med 1986;62:267-9 12. Glaser JB, Hamrnerschlag MR, McCormack WM. Sexually transmitted diseases in victims of sexual assault. N Engl J Med 1986;315:625-7 13-. Lycke E, Lowhager G-B, Hallhager G, Johannisson G, Ramstedt K. The risk of transmission of genital Chlamydia trachomatis infection is less than that of genital Neisseria gonorrhoeae infection. Sex Transm Dis 1980;7:6-10 14. Wingerson L. Two new tests for Chlamydia get quick results without culture. JAMA 1983;250:2257-9 15. Alexander ER. Misidentification of sexually transmitted organisms in children: medicolegal implications. Pediatr Infect Dis J 1988;7:1-2 16. Fouts AC, Kraus SJ. Trichomonas vagina/is: reevaluation of its clinical presentation and laboratory diagnosis. J Infect Dis 1980;141:137-43 17. Osterholm MT, MacDonald KL, Danila RN, Henry K. Sexually transmitted diseases in victims of sexual assault [letter]. N Engl J Med 1987;316:1024 18. Quinn Te, Stamm WE, Goodell SE, Mkrtichian E, Benedetti J, Corey L, Schuffler MD, Holmes KK. The polymicrobial origin of intestinal infections in homosexual men. N Engl J Med 1983;309:576-82 19. Schachter J, Dattel BJ. Sexually transmitted diseases in victims of sexual assault [letter]. N Engl J Med 1987;316: 1023-4 20. The Surgeon General's letter on child sexual abuse. Publica-
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Lesions should be carefully evaluated, with the differential diagnosis to include herpes, syphilis, and other, less common genital ulcer diseases such as chancroid and lymphogranuloma venereum. If the risk of syphilis or HIV infection is significant or if a high level of concern about such infection exists, appropriate serologic studies may be done. A serum sample may be frozen for possible additional tests in the future [12]. The identity of an STD agent isolated from a victim of sexual child abuse should be confirmed by recognized laboratory methods [21]. As with adult cases, isolates should be stored at -70°C for possible future studies, and use of the services of a reference laboratory to confirm initial findings should be considered. Fol/ow-up evaluation. All initial studies should be repeated in 7-14 days except for syphilis serology, which should be repeated in 8-12 weeks. The maximal time to the development of detectable antibodies to HIV remains controversial. The Surgeon General's report recommends repetition of HIV serology in 12 weeks [20]. Recommended tests are outlined in table 2. Evaluation of contacts. In cases of established sexual child abuse, all immediate family members and close contacts should be evaluated carefully for possible infection. The presence of infection in a family member is often useful in identifying the perpetrator, but the evidence must be interpreted with caution since other factors may explain the presence of infection. Evaluation of siblings can be important in identifying other abused children [23]. Sexual play with peers may also result in transmission, and follow-up of peer contacts should be considered [68].
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60.
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Oriel D, Ridgway G, Schachter J, Taylor-Robinson D, Ward M, eds. Chlamydial infections. Cambridge, UK: Cambridge University Press, 1986:305-8 Ingram DL, Runyan DK, Collins AD, White ST, Durfee MF, Pearson AW, Occhiuti AR. Vaginal Chlamydia trachomatis infection in children with sexual contact. Pediatr Infect Dis J 1984;3:97-9 Bump RC. Chlamydia trachomatis as a cause of prepubertal vaginitis. Obstet Gynecol 1985;65:384-8 Rettig PJ, Nelson JD. Genital tract infection with Chlamydia trachomatis in prepubertal children. J Pediatr 1981;99: 206-10 Ingram DL, White ST, Occhiuti'AR, Lyna PRo Childhood vaginal infections: association of Chlamydia trachomatis with sexual contact. Pediatr Infect Dis J 1986;5:226-9 Council on Scientific Affairs. AMA diagnostic and treatment guidelines concerning child abuse and neglect. JAMA 1985;254:796-800 Rock B, Naghashfar Z, Barnett N, Buscema J, Woodruff JD, Shah K. Genital tract papillomavirus infection in children. Arch Dermatol 1986;122:1129-32 Eftaiha MS, Amshel AL, Shonberg IL. Condylomata acuminata in an infant and mother: report of a case. Dis Colon Rectum 1978;21:369-71 DeJong AR, Weiss JC, Brent RL. Condyloma acuminata in children. Am J Dis Child 1982;136:704-6 Gissmann L, Wolnik L, Ikenberg H, Koldovsky U, Schniirch HO, Zur Hausen H. Human papillomavirus types 6 and 11 DNA sequences in genital and laryngeal papillomas and in some cervical cancers. Proc Nat! Acad Sci USA 1983; 80:560-3 Fleming KA, Venning V, Evans M. DNA typing of genital warts and diagnosis of sexual abuse of children [letter]. Lancet 1987;2:454 Oriel JD. Natural history of genital warts. Br J Vener Dis 1971;47:1-13 Shelton TB, Jerkins GR, Noe HN. Condylomata acuminata in the pediatric patient. J Urol 1986;135:548-9 Nahmias AJ, Josey WE. Herpes simplex viruses 1 and 2. In: Evans AS, ed. Viral infections of humans: epidemiology and control. New York: Plenum Press, 1982:351-72 Nahmias AJ, Dowdle WR, Naib ZM, Josey WE, Luce CEo Genital infection and Herpesvirus hominis types 1 and 2 in children. Pediatrics 1968;42:659-66 Whittington MJ. Epidemiology of infections with Trichomonas vaginalis in the light of improved diagnostic methods. Br J Vener Dis 1957;33:80-91 Hammerschlag MR, Cummings M, Doraiswamy B, Cox P, McCormack WM. Nonspecific vaginitis following sexual abuse in children. Pediatrics 1985;75:1028-31 Bump RC, Buesching WJ III. Bacterial vaginosis in virginal and sexually active adolescent females: evidence against exclusive sexual transmission. Am J Obstet Gynecol 1988; 158:935-9 Hammerschlag MR, Doraiswamy B, Cox P, Cummings M, McCormack WM. Colonization of sexually abused children with genital mycoplasmas. Sex Transm Dis 1987;14: 23-5 Dattel BJ, Landers DV, Coulter K, Hinton J, Sweet RL, Schachter J. Isolation of Chlamydia trachomatis from sex-
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tion DHHS, HRS-M-CH-13. Washington, DC: US Department of Health and Human Services, 1988 Whittington WL, Rice RJ, Biddle JW, Knapp JS. Incorrect identification of Neisseria gonorrhoeae from infants and children. Pediatr Infect Dis J 1988;7:3-10 Centers for Disease Control. 1989 sexually transmitted diseases treatment guidelines. MMWR 1989;38 (Suppl S-8) Tilelli JA, Turek D, Jaffe AC. Sexual abuse of children: clinical findings and implications for management. N Eng! J Med 1980;302:319-23 Rimsza ME, Niggemann EH. Medical evaluation of sexually abused children: a review of 311 cases. Pediatrics 1982;69:8-14 Miller J, Moeller D, Kaufman A, Divasto D, Pathak D, Cristy J. Recidivism among sex assault victims. Am J Psychiatry 1978;135:1103-4 White ST, Loda FA, Ingram DL, Pearson A. Sexually transmitted diseases in sexually abused children. Pediatrics 1983;72:16-21 Hayman CR, Lanza C, Fuentes R, Algor K. Rape in the District of Columbia. Am J Obstet Gynecol 1972;113:91-7 DeJong AR. Sexually transmitted diseases in sexually abused children. Sex Transm Dis 1986;13:123-6 Fuster CD, Neinstein LS. Vaginal Chlamydia trachomatis prevalence in sexually abused prepubertal girls. Pediatrics 1987;79:235-8 Jaffe AM, Roux P. Sexual abase of children - a hospital-based study. S Afr Med J 1988;74:65-7 Hobbs CJ, Wynne JM. Buggery in childhood-a common syndrome of child abuse. Lancet 1986;2:792-6 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;3:100-4 American Academy of Pediatrics Committee on Adolescence. Rape and the adolescent. Pediatrics 1988;81:595-7 Siedel JS, Elvik SL, Berkowitz CD, Day C. Presentation and evaluation of sexual misuse in the emergency department. Pediatr Emerg Care 1986;2:157-64 Simrel K, Berg R, Thomas J. Crisis management of sexually abused children. Pediatr Ann 1979;8:59-72 Neinstein LS, Goldenring J, Carpenter S. Nonsexual transmission of sexually transmitted diseases: an infrequent occurrence. Pediatrics 1984;74:67-76 Datta P, Laga M, Plummer FA, Ndinya-Achola JO, Piot P, Maitha G, Ronald AR, Brunham RC. Infection and disease after perinatal exposure to Chlamydia trachomatis in Nairobi, Kenya. J Infect Dis 1988;158:524-8 Sgroi S. Kids with clap: gonorrhea as an indication of child sexual abuse. Victimology 1977;2:251-67 Ingram DL, White ST, Durfee MF, Pearson AW. Sexual contact in children with gonorrhea. Am J Dis Child 1982; 136:994-6 Schachter J, Grossman M, Holt J, Sweet R, Spector S. Infection with Chlamydia trachomatis: involvement of multiple anatomic sites in neonates. J Infect Dis 1979;139:232-4 Schachter J. Chlamydial infections, parts 1-3. N Engl J Med 1978;298:428-35, 490-5, 540-9 Bell TA, Stamm WE, Kuo CC, Holmes KK, Grayston JT. Chronic Chlamydia trachomatis infections in infants. In:
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62. 63. 64.
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Failure of direct fluorescent antibody staining to detect Chlamydia trachomatis from genital tract sites of prepubertal children at risk for sexual abuse. Pediatr Infect Dis J 1988;7:660-2 67. Porder K, Sanchez N, Roblin PM, McHugh M, Hammerschlag MR. Lack of specificity of Chlamydiazyme for detection of vaginal chlamydial infection in prepubertal girls. Pediatr Infect Dis J 1989;8:358-60 68. Potterat JJ, Markewich GS, King RD, Merecicky LR. Childto-child transmission of gonorrhea: report of asymptomatic genital infection in a boy. Pediatrics 1986;78:711-2 69. Kramer DG, Jason J. Sexually abused children and sexually transmitted diseases. RevInfect Dis 1982;4(Suppl):S883-90 Downloaded from http://cid.oxfordjournals.org/ at University of Regina on September 7, 2015
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ually abused female adolescents. Obstet Gynecol 1988;72: 240-2 Gardner M, Jones JG. Genital herpes acquired by sexualabuse of children. J Pediatr 1984;104:243-4 Leiderman M, Grimm KT. A child with HIV infection [letter]. JAMA 1986;256:3094 Orr DP, Prietto SV. Emergency management of sexually abused children: the role of the pediatric resident. Am J Dis Child 1979;133:628-31 Hammerschlag MR, Rettig PJ, Shields ME. False positive results with the use of chlamydial antigen detection tests in the evaluation of suspected sexual abuse in children. Pediatr Infect Dis J 1988;7:11-14 Hauger SB, Brown J, Agre F, Sahraie F, Ortiz R, Ellner P.
Schwarcz and Whittington
Sexual Assault and Sexually Transmitted Diseases: Detection and Management in Adults and Children Sandra K. Schwarcz and William L. Whittington
From the Division of Sexually Transmitted Diseases, Center for Prevention Services, Centers for Disease Control, Atlanta, Georgia
Sexual assault is a violent crime that affects men, women, and children of all ages. Sexually transmitted diseases (STDs) may be transmitted during sexual assault. In children, the isolation of a sexually transmitted organism may be the first indication that abuse has occurred. Because the presentation, evaluation, interpretation of test results, and treatment differ between children and adults, sexual assault in these two groups will be discussed separately. Sexual Assault in Adults Epidemiology of Assault and Risk of Infection
Rape has an estimated incidence of 73/100,000 population and accounts for 6070 of all violent crimes [1]. It has a seasonal distribution, with peaks occurring in the summer [1-3]. In the majority of assaults, the victims are young women; only 5%-6070 are men [4]. Most assaults - including those against men - are committed by men who regard themselves as heterosexual [5]. Adult victims are often assaulted by strangers and sometimes by more than one assailant [3]. Assault by acquaintances, as in a dating or social situation, has gained increasing recognition in the lay press and has been estimated to occur at least as often as assault by strangers. Sexual assault is an expression of violence; consequently, physical trauma often results [5]. Genital injuries (such as vaginal tears), although often not
Please address requests for reprints to Technical Information Services, Mail Stop E02, Center for Prevention Services, Centers for Disease Control, Atlanta, Georgia 30333.
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clinically serious, are estimated to occur in 50% of victims [5]. Nongenital injuries are reported in 40070 of sexual assaults [5]. Oral, anal, and vaginal penetration may occur [6]. Few prospective studies have documented the risk of acquiring an STD following sexual assault. Determination of the exact risk of transmission is complicated by several factors. First, it is difficult to distinguish between preexisting infection in the victim and infection acquired during the assault. For example, some authorities believe that infections documented shortly after the assault (in < 24 hours) are likely to represent preexisting conditions [7]. Second, the frequently incomplete follow-up of rape victims, combined with the generally long incubation period of some STDs, have hampered attempts to quantify the risk of acquiring an STD from sexual assault. Other factors that would be expected to influence the risk of disease transmission during rape include the underlying prevalence of STDs (which have distinct geographic and demographic variability) and the type of assault. The chance of transmission is expected to be greater with penetration. The high rates of sexual dysfunction by assailants during assaults may contribute to the relatively low prevalence of STDs found in some studies of rape victims [8]. Previously published reports have found the prevalence of gonorrhea in female assault victims to range between 2070 and 13070 and the rates of syphilis to be usually < 3070 [3,9-11]. These studies are summarized in table 1 and have been reviewed by Glaser et al, [12] and Blackmore et al, [7]. Unfortunately, although other STDs have been described in adult victims of sexual assault [9, 11], studies document-
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Sexual assault is a frequently occurring violent crime. Sexually transmitted diseases (STDs) may be acquired during assault. Reported rates of gonorrhea and syphilis in adult victims range from 6070 to 12070 and from 0% to 3%, respectively. The risk of acquiring other STDs cannot be quantified, although the risk of infection with Chlamydia trachomatis appears highest. In abused children, gonococcal and chlamydial infections are the most frequent findings. In both adults and children, postassault infections with viral agents of STDs, including herpes simplex viruses, hepatitis B virus, and human immunodeficiency virus, have been described. Sensitive, competent care for victims of sexual abuse includes evaluation for STDs soon after the assault and during follow-up.
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Table 1. Prevalence of syphilis and gonorrhea in adult victims of sexual assault. No. tested [reference] 105* [3] i.zoot [9] 50 [10] 46 [11]
No. (%) positive Syphilis
Gonorrhea
3 (2.9) 16 (1.3)
14 (13.3) 55 (4.6) 3 (6.0) 3 (6.5)
o NS*
*
ing the risk of acquiring these infections have not been published. However, it may be reasonable to estimate that the risk of Chlamydia trachomatis infections following assault would be similar to that of gonorrhea; although the prevalence of chlamydial infections is greater than that of gonorrhea, the efficiency of transmission of C trachomatis appears to be lower [13]. The risk of acquiring a viral STD during an assault may be less than the risk of acquiring a bacterial infection because of the episodic nature of viral shedding. Determination of the risk of viral infection after assault may also be hampered by the difficulties involved in isolating a viral agent, the long incubation periods of viral infection, and the frequency of asymptomatic viral infection. Evaluation of tbe Sexually Assaulted Victim
Initial evaluation. The initial evaluation of the victim should be performed as soon after the assault as possible. A thorough history should be taken in a direct and sensitive manner by trained personnel at the outset of the evaluation. The type of assault, including sites of penetration, should be carefully documented. Most adults are capable of providing this kind of information. While the information will be of legal interest, it is important for proper medical management as well. Because the risk of acquiring an STD has not been quantified, the physical examination and laboratory evaluation of the victim should be comprehensive. Although a history of penetration may help orient the clinician, a complete physical examination - with careful inspection of the oral, anal, and genital mucosa for trauma, seminal fluid, or evidence of infection - should be done [12]. Men should undergo careful inspection of their
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* One hundred three persons were tested for syphilis; 105 were tested for gonorrhea. t Adolescents are included. NS = not studied.
oral and anal mucosa and genitalia. A rectal examination should be performed to evaluate the condition of the prostate and the tone of the external sphincter. A lax sphincter may result from anal penetration [12]. Pharyngeal, rectal, and urethral cultures for gonococci and chlamydia may be indicated in men, especially when penetration or attempted penetration has occurred. A gram-stained smear of urethral discharge may be used to assist in an immediate diagnosis. Findings on gram staining should not rule out culture of specimens. As the male victim may have been subjected to fellatio or, in extremely rare cases, to rape by a woman, urethral cultures should not be overlooked. All women should have their external genitalia inspected and have a speculum and bimanual pelvic examination. In addition, women should undergo oral and rectal examinations. Endocervical sites should be cultured for gonococci and chlamydia. Extragenital sites should be cultured in those women from whom a history of penetration or attempted penetration of these sites is elicited or in women whose history is difficult to obtain. The value of tests for gonococcal antigens has not been established for sexual abuse victims of either sex. The use of these tests in this situation is discouraged. Although antigen detection tests are frequently used to screen women for cervical chlamydial infections, these tests have lower sensitivity and specificity than cell culture and are best used in populations with a relatively high prevalence of infection [14]. Furthermore, these tests have not been approved for use on specimens from most extragenital sites [15]. Because of the uncertain risk of STD transmission and the legal consequences surrounding sexual assault, only chlamydial cultures - and not antigen detection tests - are recommended for the detection of C trachomatis. A sample of cervical discharge should be stained and examined microscopically for gram-negative diplococci and white blood cells. A normal saline preparation of vaginal discharge should be evaluated for trichomonads and clue cells. Cultures for trichomonads have been shown to be more sensitive and may be useful in the absence of identification by normal saline preparation [16]. Vaginal pH should be measured, and the presence of an amine odor when the vaginal discharge is mixed with 10070 KOH should be noted. Skin and mucosal surfaces should be carefully in-
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Table 2. Recommended laboratory procedures at initial and follow-up evaluations of sexually abused children (prepubertal) and of adult and adolescent victims of sexual assault. Recommended for
Procedure Gram stain of any genital or anal discharge* Culture for N. gonorrhoeae Culture for C. trachomatis Wet preparation of vaginal secretion for trichomonads, clue cells, and an amine odor when mixed with KOH Vaginal pH Dark-field examination of genital lesions Cultures of lesions for herpes simplex viruses Serologic test for syphilis Serologic test for HIV Frozen serum sample
Children
+
Adolescents/ adults
-§
+ +
+
+
+ + +11 +
+ + +11# +
NOTE. Syphilis and HIV serology should be repeated in 12 weeks. All other tests should be repeated 10-14 days after the initial examination. * Results of gram staining of anal discharge should be interpreted cautiously. t Cultures of pharynx, rectum, and vagina/urethra should be done. :j: Specimens for culture should be obtained from all sites in adolescents whose history is incomplete. In adults, only sites of penetration or attempted penetration need to be cultured. § Vaginal pH testing is not recommended because of the lack of a known standard. II Testing for HIV should be based upon the prevalence of infection and on suspected risk. # Tests for hepatitis B antibody and surface antigen should be considered. .
to be infected with HIV, serologic studies of the victim may be repeated in 24 weeks. Earlier follow-up evaluation may be necessary should symptoms suggestive of infection develop. Recommended tests are listed in table 2. The identity of an STD agent isolated from a victim of sexual assault or from a suspected assailant should be confirmed by recognized laboratory methods [21]. For Neisseria gonorrhoeae, confirmation should include at least two techniques that use different principles, e.g., biochemical and enzyme-substrate or serologic [21]. Isolates should be stored at -70°C for possible future studies; use of the servicesof a reference laboratory to confirm initial findings should be considered.
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spected for evidence of infection in both men and women. Any suspicious lesion should be evaluated by dark-field examination; genital lesions should be cultured for herpes simplex viruses. A serologic test for syphilis should be performed in all cases despite the infrequent occurrence of this disease following sexual assault [12]. Although the risk of pregnancy following assault has been estimated to be low, women should be offered a serum pregnancy test [7]. Infection with hepatitis B virus and the human immunodeficiency virus (HIV) may be transmitted [12, 17]. Questions regarding possible previous exposure to these viral infections should be asked in a sensitive manner. For the evaluation of exposure to hepatitis B in a previously uninfected or unimmunized individual, serum should be tested for hepatitis B surface antigen and antibody. Baseline information regarding HIV exposure may be determined through antibody testing by standard protocols. A sample of serum should be stored at - 70°C for possible future testing [12]. Gastrointestinal STDs have been welldocumented in male homosexuals [18] and therefore may theoretically develop following sexual assault [12]. The pathogens most often associated with these illnesses are Giardia lamblia and Entamoeba histotytica [18]. Since such conditions are rare in heterosexual men and since most rapes, including those of men, are committed by men of heterosexual orientation, transmission seems unlikely. Glaser et ale [12] have recommended the evaluation of men for these pathogens only if symptoms of enteritis, proctocolitis, or proctitis develop. Follow-up evaluation. For victims who are medicallyevaluated shortly after assault (in ~ 24 hours), the initial examination is unlikely to identify STDs that may have resulted from the assault. These infections would be incubating at the initial examination. Infections noted immediately following assault may represent preexisting conditions. Schachter and Dattel [19], in their study of sexually abused and sexuallyactive adolescent girls, found the same prevalence of chlamydial infections in both groups. To identify infections that may have resulted from the assault, all studies except hepatitis B, syphilis, and HIV serology should be repeated 7-14 days after the initial evaluation. Because of the longer incubation periods, syphilis and hepatitis B serologies should be repeated in 8-12 weeks; HIV serology should be repeated in 12 weeks [12, 20]. If the assailant is known
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Sexual Abuse of Children Epidemiology and Risk of Infection
Several factors distinguish sexual assault in children from assault in adults. Children are usually assaulted by someone they know, frequently a male family member [6, 23-32]. There may be multiple episodes of abuse before the child comes to the attention of a health care professional or social worker [29]. Sexual abuse occurs among children of all ages, with the highest rates among adolescents [6, 9, 33]. Although, as in adults, the incidence of sexual abuse is higher among females, the female-to-male ratio is lower than that among adults. Studies of sexually
abused children have found female-to-male ratios of 5:1-7:1 [26, 28]. Sexual abuse among children includes a wide range of activities from fondling to oral and genital contact. Studies of sexual abuse in children have found vaginal penetration in 8%-66070 (counting abused girls only), anal penetration in 2%-30070, and orogenital contact in 3070-16070 [26, 28, 29]. Unlike the situation in adults, in children the presence of an STD may be the first indication that abuse has occurred. However, not all sexually abused children present with genital symptoms. Rather, children may present with other types of physical complaints or behavioral problems [23, 24,34,35]. As many as 50% of children presenting for evaluation of sexual abuse have no physical complaints [28]. In children presenting with complaints not suggestive of abuse, testing may result in the reporting of sexually transmitted organisms. Reported misidentification of organisms such as N. gonorrhoeae, resulting in inappropriate child abuse investigations, underscores the need for confirmation of an organism's identity by at least two procedures that use different principles (for example, as has already been mentioned, biochemical and enzyme-substrate or serologic) [21]. Transmission Routes of STD Pathogens
In general, the identification of a sexually transmitted organism in a specimen from a child suggests the possibility of sexual abuse. The difficulty in assessing a child who presents with an STD lies in distinguishing sexually acquired infections from infections that may have been transmitted through nonsexual means. Nonsexual transmission of sexually transmitted pathogens does occur, usually around the time of delivery. Other types of nonsexual transmission , such as by fomites, autoinoculation, and close physical contact, are rare and probably cannot explain the isolation of a sexually transmitted pathogen from a child [36]. Nonsexual transmission occurs most frequently from an infected woman to her child in utero or at the time of delivery. Infections acquired in utero include syphilis, and, very probably, herpes and HIV infection. Infections transmitted during delivery include gonorrhea, chlamydiosis, herpes, and human papilloma virus (HPV) infection. When acquired at birth, gonorrhea produces con-
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Treatment at the initial evaluation should be given for any infections identified at that time. A presumptive diagnosis of gonorrhea may be based on the observation of gram-negative intracellular diplococci. Prophylactic treatment is recommended only if the assailant is known to be infected, if follow-up of the victim seems unlikely, or if the patient requests it [7, 12]. As the rates of STDs in victims of sexual assault are low, there is little risk in delaying therapy until laboratory results are available. If prophylactic therapy is given, it should be effective against gonorrhea, chlamydial infection, and incubating syphilis [12, 22]. Ceftriaxone (250 mg as a single intramuscular injection) is recommended and will provide coverage for all strains of N. gonorrhoeae [22]. Therapy should be followed by doxycycline (100 mg by mouth twice a day for 7 days) or by tetracycline (500 mg by mouth four times a day for 7 days). If pregnancy is suspected, erythromycin should be given instead of tetracycline. Because the risk of bacterial vaginosis and trichomonas infection in female assault victims is unknown, prophylaxis against these infections is not recommended [12]. Similarly, since the risk of hepatitis B and gastrointestinal infections following assault is not known, prophylaxis is not recommended [12]. No data support the .use of prophylactic antiviral medications. For those patients who have received prophylactic therapy against gonorrhea and chlamydiosis and whose initial cultures are negative, repeated culture is not necessary.
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type 2, either type 1 or type 2 virus may be isolated from the genital tract or the mouth [55]. The possibility of transmission by autoinoculation from an oral lesion to the genitalia has been well described [56]. Transmission by fomites to humans has not been documented. Trichomonas vaginalis is a common sexually transmitted pathogen. Although trichomonads have been shown to survive on toilet sets for up to 45 minutes [57], infections resulting from fomite transmission have not been reported. Bacterial vaginosis (nonspecific vaginitis) is a polymicrobial vaginal infection that appears to be sexually associated. While it has been identified more often in sexually abused children than in nonabused children [58], the possibility of nonsexual acquisition remains [59]. Similarly, the genital mycoplasmas Ureaplasma urealyticum and Mycoplasma hominis have been recovered somewhat more frequently from abused children than from nonabused children, although the presence of these organisms in nonabused children suggests other routes of acquisition [60]. Risk of Infections in Sexually Abused Children
In general, the prevalence of STDs among abused children is relatively low (table 3). Most of the data on the risk of infection following abuse concern gonorrhea and syphilis. Studies indicate that between 0070 and 12070 of sexually abused children may be infected with N. gonorrhoeae [23, 24, 26, 28-30, 32, 61]. As many as 44070 of infected children have asymptomatic gonococcal disease [28]; rectal and pharyngeal infections are frequently asymptomatic [28, 39]. Syphilis has been found much less frequently (0%1.5070) [24, 26, 61]. Chlamydial infection may be the most frequently occurring disease following abuse (table 3). Studies have documented infections in 4070-17070 of abused children [29, 32, 43, 61]. Concurrent chlamydial infection has been found in as many as 27070 of abused children with gonococcal infection [48]. In general, infections are less common among abused prepubertal children than among abused adolescents [19]. The higher rates of gonorrhea and chlamydiosis may reflect consensual sexual activity in adolescents [61]. Other STDs have been identified infrequently. Trichomonas infection has been identified in 607025070 of abused children [26, 58]. However, the small sample sizes in these studies make it difficult to draw conclusions (table 4). Bacterial vaginosis(nonspecific
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junctivitis, although coexisting rectal and nasopharyngeal infection may also be present [37]. In general, oral, anal, and genital infections with N. gonorrhoeae are currently thought to represent sexual transmission [12, 26, 36-39]. C. trachomatis can produce conjunctivitis and pneumonitis and can colonize the nasopharynx, rectum, and vagina of infants [40, 41]. Although the maximal time that this organism may persist has not been established, persistence for up to 2 years has been reported [42]. Studies of chlamydial infections in" children> 2 years old have provided strong evidence of sexual transmission [32, 43-46]. Because the duration of infections acquired at birth is not well understood, there has been some disagreement regarding the point at which sexual abuse should be suspected in a child with a chlamydial infection [19, 32,44,47]. It has been suggested that the identification of C. trachomatis in a child of any age should alert the clinician to the possibility of abuse [19, 44]. However, some authors believe that the isolation of C. trachomatis from the rectum or the genital tract of children> 6 months old merits evaluation of sexual abuse [32, 47]. Other evidence [42] suggests an emphasis on sexual abuse evaluations for children ~ 2 years of age. Condylomata acuminata are caused by specific types of HPV. Types 6, 11, 16, and 18 appear to be associated with genital infections [48]. Genital warts can be transmitted from an infected woman to her child at the time of delivery, and HPV has been reported to cause anal [49], genital [50], and laryngeal papillomas [51]. Because of the variable and long incubation period (6 weeks to 8 months), perinatally acquired condylomata may not be evident immediately after birth, and the source of infection may therefore be difficult to establish [50]. Nonsexual transmission through close physical contact has been suggested, although this route has not been well established [48]. In contrast, sexual transmission of condylomata has been well documented in adults and children [48, 50, 52-54]. Thus the presence of rectal, anal, or perineal warts in a child must alert the clinician to the possibility of sexual abuse. Perinatal transmission of herpes simplex virus has been wellestablished [55]. With an incubation period estimated at 2-20 days (average, 6 days) [55], lesions appearing for the first time in neonates more than 30 days old may not have been acquired by perinatal transmission. Although the majority of genital herpes infections are caused by herpes simplex virus
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Table 3. Prevalence of syphilis, gonorrhea, and chlamydiosis in sexually abused children and adolescents. No. tested [reference]
Syphilis
Gonorrhea
Chlamydiosis
NS* NS
3 (6) 3 (3) 21 (7) 46 (II) 25 (5) 0 9 (10) 5 (10) 10 (20) 15 (12)
6 (13) NS NS NS NS 8 (17) NS 2 (4) 3 (6) 18 (14)
0 6 (I) I (0.2) 0 8 (9) NS NS 0
* NS
= not studied. Twenty-nine children were tested for syphilis; 47 were tested for C. trachomatis.
t
vaginitis) has been identified in 26070 of abused children [58]. Condylomata acuminata and genital herpes have been identified in abused children but only infrequently [28, 62]. The risk of acquiring other, less common infections such as chancroid and lymphogranuloma venereum is not known. Although one report [63] suggests the possible acquisition of HIV during sexual abuse of a lO-year-old girl, insufficient data are available to quantify the risk of HIV infection following sexual assault. Evaluation of the Sexually Abused Child
Initial evaluation. As with adults, a careful, comprehensive history should be obtained in a sensitive manner. Because of the delicate nature of the subject and the difficulty of obtaining an accurate and complete history from abused children, a team approach has been advocated [12]. The type of assault committed and the identity of the perpetrator should be elicited if possible. Table 4. Prevalence of vaginitis in sexually abused children and adolescents. No. evaluated [reference] 409 [26] 25* [28] 31 [58]
Etiology
No. (%) positive
Trichomonads Bacteria Bacteria
4 (I) 3 (12) 8 (26)
* Only patients with signs suggestive of vaginitis were evaluated.
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46 [II 103 [23] 285 [24] 409 [26] 532 [28] 49+ (29] 88 [301 51 [32] 50 [43] 127 [61]
No. (%) positive
In all cases of suspected abuse, children should undergo a complete physical examination. The oral, anal, and genital mucosa should be carefully inspected for signs of trauma or infection. If recent abuse with penetration is suspected, examination for the presence of seminal fluid should be included. In prepubertal girls the condition of the hymen, including evidence of lacerations or scars, should be noted. A speculum examination is not necessary because laboratory specimens may be obtained through aspiration of vaginal contents with a sterile eyedropper [12]or with a moistened Dacron swab [34]. Postpubertal girls should have a speculum and bimanual examination, and cervical and vaginal specimens should be obtained [12]. These examinations should not be painful to the victim, and anesthesia may be considered if the child is unable to cooperate [64]. All boys should have their external genitalia inspected, and urethral specimens should be obtained and cultured. Postpubertal boys should have a digital rectal examination to evaluate the tone of the anal sphincter [12]. Because of the difficulty of obtaining a complete history and the frequency of asymptomatic infection [25, 28], all children should undergo comprehensive laboratory evaluation and have specimens from all potentially infected sites cultured. Any discharge should be stained and examined microscopically [12]. Gonococcal and chlamydial specimens obtained from the throat, rectum, and genitals should be cultured. As was just mentioned, urethral samples from all boys should be cultured. In prepubescent girls who are symptomatic, gonococci and chlamydia produce vulvovaginitis rather than endocervical infection [29, 44]. Consequently, vaginal cultures should be performed in the cases of prepubescent girls and endocervical cultures in the cases of girls who have reached puberty. Antigen detection tests, including enzyme immunoassays and immunofluorescence tests for chlamydiae, may yield false-positive and false-negative results and are not approved for use in evaluation of cases of suspected sexual child abuse [65-67]. Cultures for both N. gonorrhoeae and C trachomatis are the only acceptable diagnostic methods for these cases. Vaginal secretions of pre- and postpubertal girls should be examined for the presence of trichomonads, clue cells, and an amine odor when mixed with KOH. Vaginal pH is not thought to be a useful marker for bacterial vaginosis in the prepubertal girl because of a lack of known standards [59].
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Treatment
Treatment of sexually abused children follows the same principles as treatment of adult victims of sexual assault. The relatively low prevalence of infection in abused children supports the withholding of prophylactic therapy unless the assailant is known to be infected, the child has clinical signs of infection, or the child is not likely to return for follow-up [69]. For children receiving treatment, the dosages should be appropriate in terms of body weight. Tetracycline should not be given to children < 8 years
of age or to pregnant teens. If possible, injections should be avoided to minimize additional trauma to the child.
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