Sexually transmitted diseases in sexually abused girls and adolescents

Pelvic inflammatory disease in the adolescent and young adult: An update

Pelvic inflammatory disease (PID) is an infection of the female upper genital tract that is typically polymicrobial with classic core involvement of Neisseria gonorrhoeae and/or Chlamydia trachomatis, though other endogenous flora from the vagino-cervical areas can be involved as well. It is often a sexually transmitted disease but other etiologic routes are also noted. A variety of risk factors have been identified including adolescence, young adulthood, adolescent cervical ectropion, multiple sexual partners, immature immune system, history of previous PID, risky contraceptive practices and others. An early diagnosis and prompt treatment are necessary to reduce risks of PID complications such as chronic pelvic pain, ectopic pregnancy and infertility. Current management principles of PID are also reviewed. It is important for clinicians to screen sexually active females for common sexually transmitted infections such as Chlamydia trachomatis and provide safer sex education to their adolescent and young adult patients. Clinicians should provide comprehensive management to persons with PID and utilize established guidelines such as those from the US Centers for Disease Control and Prevention (CDC).

Action research improves services for child sexual abuse in one Caribbean nation: An example of good practice

BACKGROUND

Child sexual abuse (CSA) is a multi-dimensional problem. The search for best practice must consider the complexities surrounding CSA and its management in any particular society.

OBJECTIVE

Data previously gathered from service providers on CSA service provision in Trinidad and Tobago identified key deficient issues in policy and practice. In this paper, researchers aimed to bridge the gaps identified, and effect changes to improve services for CSA using an action research methodology.

PARTICIPANTS AND SETTING

Service providers from all sectors in governmental and non-governmental organizations in Trinidad and Tobago, who work with children at risk of CSA were involved in the process.

METHODS

Researchers led the service providers into an awareness of their own practice through critical discussion of, and reflection on, the key deficient issues. The new knowledge generated, with guided input from evidenced-based best practice, led to the development of guidelines for management. Discussion of the practicability of the guidelines by service providers in multiple sectors generated more new knowledge that refined the management approach.

RESULTS

The contextual knowledge obtained from service providers resulted in best practice guidelines for service providers that were culturally relevant and context-sensitive, adaptive and implementable, and allowed a seamless multidisciplinary response to CSA in Trinidad and Tobago within prevailing constraints.

CONCLUSIONS

Action research offers an effective approach to improve services for CSA through mobilization of service providers and changes in policy and practice. It is applicable in any setting and likely to be effective in any socio-cultural context.

Genital and Extragenital Gonorrhea and Chlamydia in Children and Adolescents Evaluated for Sexual Abuse

OBJECTIVE

The aim of this study was to describe the use of a nucleic acid amplification test in detecting genital and extragenital Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) in children and adolescents assessed for sexual abuse/assault.

METHODS

The charts of children aged 0 to 17 years, consecutively evaluated for sexual victimization, in emergency department and outpatient settings were reviewed. Data extracted included age, sex, type of sexual contact, anogenital findings, previous sexual contact, toxicology results, and sites tested for NG and CT.

RESULTS

Of the 1319 patients who were tested, 579 were tested at more than 1 site, and 120 had at least 1 infected site. Chlamydia trachomatis was identified in 104 patients, and NG was found in 33. In bivariate analysis, a positive test was associated with female sex, age older than 11 years, previous sexual contact, acute or healed genital injury, drug/alcohol intoxication, and examination within 72 hours of sexual contact. Fifty-one patients had positive anal tests, and 24 had positive oral tests. More than 75% of patients with positive extragenital tests had additional positive tests or anogenital injury. Most with a positive anal (59%) or oral (77%) test did not report that the assailant's genitals came into contact with that site.

CONCLUSIONS

Positive tests for NG and CT in patients evaluated for sexual victimization may represent infection from sexual contact, contiguous spread of infection, or the presence of infected assailant secretions. Relying on patient reports of symptoms, or types of sexual contact, to determine need for testing may miss NG and CT infections in patients evaluated for sexual victimization.

Updated Guidelines for the Medical Assessment and Care of Children Who May Have Been Sexually Abused

The medical evaluation is an important part of the clinical and legal process when child sexual abuse is suspected. Practitioners who examine children need to be up to date on current recommendations regarding when, how, and by whom these evaluations should be conducted, as well as how the medical findings should be interpreted. A previously published article on guidelines for medical care for sexually abused children has been widely used by physicians, nurses, and nurse practitioners to inform practice guidelines in this field. Since 2007, when the article was published, new research has suggested changes in some of the guidelines and in the table that lists medical and laboratory findings in children evaluated for suspected sexual abuse and suggests how these findings should be interpreted with respect to sexual abuse. A group of specialists in child abuse pediatrics met in person and via online communication from 2011 through 2014 to review published research as well as recommendations from the Centers for Disease Control and Prevention and the American Academy of Pediatrics and to reach consensus on if and how the guidelines and approach to interpretation table should be updated. The revisions are based, when possible, on data from well-designed, unbiased studies published in high-ranking, peer-reviewed, scientific journals that were reviewed and vetted by the authors. When such studies were not available, recommendations were based on expert consensus.

Forensic medical evaluations of child maltreatment: a proposed research agenda

Physicians play an important role in the forensic evaluation of suspected child abuse and neglect. There has been considerable progress in the medical field, helping distinguish findings related to maltreatment from other conditions or circumstances. Nevertheless, important questions remain. This article covers several of these questions and proposes a research agenda concerning five main topics: sexual abuse, neglect, fractures, abusive head trauma, and physicians work in interdisciplinary settings. The suggestions are hardly inclusive, but offer suggestions the authors think are priorities, and ones that research could reasonably address. By providing some background to gaps in our knowledge, this paper should be of interest to a broader audience than just medical professionals.

Gonorrhoea, chlamydia, syphilis and trichomonas in children under 13 years of age: national surveillance in the UK and Republic of Ireland

BACKGROUND

Sexually transmitted infections in children ought to raise concerns about sexual abuse. It is not known how frequently they are identified in the UK and Ireland, nor how well they are investigated.

AIMS

To measure the incidence, mode of presentation, investigations and child protection procedures among children under 13 years and over 12 months of age presenting with infections of Neisseria gonorrhoea, Treponema pallidum, Chlamydia trachomatis or Trichomonas vaginalis in the UK and Republic of Ireland.

METHODS

National surveillance study over 25 months through the British Paediatric Surveillance Unit. All consultant paediatricians in the UK and Republic of Ireland reported laboratory confirmed infections followed by a confidential questionnaire covering clinical details, investigation results and child protection outcomes.

RESULTS

Fifteen cases were reported, giving an overall incidence of these infections of 0.075 cases per 100,000 children per year. Most were identified because they presented with symptoms. Five cases presented with ophthalmic infection. Laboratory investigation and screening for other infections was adequate in most cases. Although only three cases of sexual abuse were confirmed in court or case conference, abuse was suspected in a further seven cases based on clinical factors, family or social history.

CONCLUSIONS

Sexually transmitted infections in children, although rare, are generally well investigated. The findings support current guidance on the management of sexually transmitted infection in young children and the need to maintain a high index of suspicion for sexual abuse. Isolated ophthalmic infection with N gonorrhoeae and C trachomatis occurs beyond infancy, but the mode of transmission is unclear.

Medical evaluation of suspected child sexual abuse: 2011 update

The medical evaluation of children with suspected sexual abuse includes more than just the physical examination of the child. The importance of taking a detailed medical history from the parents and a history from the child about physical sensations following sexual contact has been emphasized in other articles in the medical literature. The examination is important, however, and medical providers who examine children need to be aware of published research on findings in nonabused children, studies of healing of injuries, and studies documenting the association between sexual contact and the diagnosis of sexually transmissible infections in children. This article reviews the current approach to interpreting findings in children who may have been sexually abused and why additional research is needed.

Sexually abused children. Characterization of these girls when adolscents

AIM

To study associations between sexual abuse of girls in childhood and variables affecting life in adolescence.

METHODS

Anonymously, in the class room, all eligible female adolescents 13-18 years old (n = 1,428) in a medium-sized town completed a validated in-depth questionnaire (Q90) with 165 questions. A history of sexual offense was reported by 119 cases (8.3%, mean age 16.0 years). The remaining 1,309 girls (mean age 15.6 years) served as a comparison group.

RESULTS

Questions included body perception, health, including psychosomatic symptoms, depression, suicidal thoughts, psychiatric medication, general questions about present life, peer relations, smoking, alcohol use, delinquent behaviors, and sexual behaviors. In most areas, adolescents with a history of sexual offense responded unfavorably compared with the comparison groups. Some examples were that despite a similar body mass index, 47% of the cases felt overweight as against 31% of the remaining adolescents (p = .0001). Among the sexually abused adolescents, self-perceived depression was more common (60% vs. 37%, p = .0001), as was psychiatric medication (10% vs. 2%, p = .0003). Loneliness was reported by 23% of the cases versus 13% (p = .005). Smoking, alcohol use, and minor criminality showed similar results. Sexual risk behaviors, i.e. multiple sexual partners, unwanted pregnancies, and sexually transmitted infections did not differ between the two groups of girls.

CONCLUSION

Many adolescents with a history of childhood sexual offense feel unhappy, as is evident from the magnitude of the problems. This includes many aspects of adolescent life. It seems likely that the problems are at least partially related to sexual abuse in childhood.

Diagnosis of Trichomonas vaginalis in female children and adolescents evaluated for possible sexual abuse: a comparison of the InPouch TV culture method and wet mount microscopy

STUDY OBJECTIVE

To compare the performance of wet mount microscopy and the InPouch TV culture method in diagnosing Trichomonas vaginalis in a cohort of female children and adolescents evaluated for possible sexual abuse.

DESIGN

A prospective study in which samples for both wet mount and InPouch TV were collected from the vaginal vault of each participant. The wet mount was examined microscopically for the presence of motile trichomonads, and the InPouch TV was analyzed in accordance with manufacturer specifications.

SETTING

A regional, university-affiliated sexual abuse center in Nashville, TN.

PARTICIPANTS

Females (N = 271) aged 10 to 17 years (inclusive) who met screening criteria for sexually transmitted infection testing in accordance with Centers for Disease Control recommendations, and who exhibited evidence of at least partial hymenal estrogenization.

MAIN OUTCOME MEASURES

A Trichomonas vaginalis diagnosis either via detection of motile trichomonads on wet mount or a positive InPouch TV.

RESULTS

The median age of the 271 participants was 13.6 years, 88% (235/268) were genital Tanner stage 4 or 5, and 66% (173/263) were Caucasian. Trichomonas vaginalis was diagnosed by either wet mount or InPouch TV in 4% (12/274) of the possible sexually transmitted infection exposures. The sensitivity of wet mount was 8/12 = 0.67 (95% confidence interval [CI]: 0.39, 0.86) and specificity was 262/262 = 1.00 (95% CI: 0.99, 1.00). The false negative rate of wet mount was 4/12 = 0.33 (95% CI: 0.14, 0.61).

CONCLUSIONS

A culture-based method such as InPouch TV should be considered for Trichomonas vaginalis diagnosis when evaluating children and adolescents in whom sexual abuse is a concern.

Update on child maltreatment

PURPOSE OF REVIEW

Recent literature regarding assessment, management and prevention of child maltreatment will be considered. Unexplained infant and child death will also be reviewed.

RECENT FINDINGS

Controversies in the evaluation of unexpected infant death and inflicted traumatic brain injury are ongoing. Evidence continues to accumulate describing the serious long-term sequelae of child maltreatment. Studies have examined the earliest beginnings of these adverse outcomes commencing in childhood. Despite sustained efforts to develop a variety of training and intervention programs, the deployment of these efforts has been hampered by the lack of evidence that they make any difference in improving recognition of child abuse or in preventing recurrent maltreatment. There is a great need in the child abuse field for more formal, rigorous assessment of all manner of intervention programs.

SUMMARY

Efforts to improve the recognition of and management of child abuse need to be sustained. As our understanding of child maltreatment continues to grow, evidence-based interventions will likely improve outcomes for abused children and their families. General pediatricians are often the first to notice signs and symptoms of possible child maltreatment; collaboration with hospital-based Child Protection Teams is critical when considering the possibility of abuse or neglect.