Inappropriate use of nonculture tests for the detection of Chlamydia trachomatis in suspected victims of child sexual abuse: A continuing problem

Medical and legal implications of testing for sexually transmitted infections in children

Testing for sexually transmitted infections (STIs) in children presents a number of problems for the practitioner that are not usually faced when testing adults for the same infections. The identification of an STI in a child can have, in addition to medical implications, serious legal implications. The presence of an STI is often used to support the presence or allegations of sexual abuse, and conversely, the identification of an STI in a child will prompt an investigation of possible abuse. The purpose of this paper is to review the epidemiology of child sexual abuse, including the epidemiology of major STIs including Neisseria gonorrhoeae, Chlamydia trachomatis, syphilis, herpes simplex virus (HSV), Trichomonas vaginalis, and human papillomavirus, and the current recommendations for diagnostic testing in this population.

Sexual abuse and sexually transmitted infections in children and adolescents

PURPOSE OF REVIEW

Sexual abuse is unfortunately common in the United States. The presence of a sexually transmitted infection in a child or adolescent should prompt an evaluation to exclude sexual abuse.

RECENT FINDINGS

The present article reviews the demographics of sexual abuse, the prevalence of specific sexually transmitted infections, such as Neisseria gonorrhoeae, Chlamydia trachomatis, HIV, human papillomavirus (HPV) and herpes simplex virus (HSV) and which children and adolescents are at highest risk for contracting such infections. The use of nonculture methods, such as nucleic acid amplification tests (NAATs), to evaluate prepubertal children for N. gonorrhoeae or C. trachomatis, and the use of HIV postexposure prophylaxis are discussed.

SUMMARY

Any child or adolescent with a sexually transmitted infection should be evaluated for sexual abuse. Specific infections in prepubertal children, such as Neisseria gonorrhoeae or Chlamydia trachomatis, are due to abusive contact and should be reported to Child Protective Services. As the modes of transmission of anogenital infections with HPV and HSV are unclear, an evaluation for sexual abuse should be done. Although transmission of HIV after sexual abuse is rare, HIV postexposure prophylaxis must be administered in a timely fashion, and adequate outpatient support provided to facilitate compliance and follow-up.

Sexually transmitted infections in preadolescent children

Pediatric nurse practitioners may be called on to conduct an assessment for sexual abuse of a young child. Depending on the type of sexual contact, a decision may have to be made to obtain cultures for sexually transmitted infections (STIs). Recognizing the symptoms of STIs in preadolescent children, along with having knowledge of the modes of transmission, diagnostics, and treatment, are part of the clinical decision. The impact of STI in preadolescent children has physical and emotional consequences for the child and family, along with legal consequences for an accused perpetrator. Knowledge about types of sexual contact that necessitate STI cultures, incubation periods, and symptomatology is essential. Accurate techniques and appropriate selection of culture materials are necessary. Proper positioning of the child for obtaining cultures can decrease the potential for discomfort during the examination. Gonorrhea, Chlamydia trachomatis, herpes simplex virus, human papillomavirus virus, syphilis, Trichomonas vaginalis, hepatitis B, and HIV are reviewed.

Appropriate use of nonculture tests for the detection of sexually transmitted diseases in children and adolescents

The introduction of nucleic acid amplification tests (NAATs) has been the most important advance in the diagnosis of sexually transmitted diseases (STDs) since tissue culture replaced inoculation of eggs for culture and isolation of Chlamydia trachomatis from clinical specimens. Because nucleic acid amplification is exquisitely sensitive, theoretically capable of detecting as little as a single gene copy, and highly specific, it offers the opportunity to use noninvasive sampling (ie, urine). This ability in turn means that these tests might be used in nontraditional settings, such as schools and in the field, which may be very helpful in providing services to homeless adolescents. However, none of these tests is approved or recommended by the manufacturers for rectal specimens from adults, and they are not approved for rectogenital specimens from children. In addition to medical implications, the identification of a sexually transmitted disease (STD), especially in a young child, also has legal implications. Because of the legal implications, the highest specificity is needed and is more important than is sensitivity in this situation. Data on the use of these tests in prepubertal children are insufficient to permit their use at this time. What may be appropriate for screening a sexually active adult in an STD clinic may not be appropriate for evaluating a child victim of suspected sexual abuse. Although missing possible sexual abuse is a major concern, the ramifications of a false-positive test for an STD, which can lead to erroneous reports of sexual abuse and possibly unjustified prosecution and incarceration, also must be considered.