Sexual Assault or Abuse of Children
These guidelines are limited to the identification and treatment of STIs in prepubertal children. Management of the psychosocial or legal aspects of the sexual assault or abuse of children is beyond the scope of these guidelines.
Identification of STIs in children past the neonatal period strongly indicates sexual abuse (1438). The importance of identifying a sexually transmitted organism for such children as evidence of possible child sexual abuse varies by pathogen. Postnatally acquired gonorrhea, syphilis, chlamydia, and T. vaginalis infection and nontransfusion, nonperinatally acquired HIV infection are indicative of sexual abuse. Sexual abuse should be suspected when anogenital herpes or anogenital warts are diagnosed. Investigation of sexual abuse among children who have an infection that might have been transmitted sexually should be conducted in compliance with recommendations by clinicians who have experience and training in all elements of the evaluation of child abuse, neglect, and assault. The social significance of an infection that might have been acquired sexually varies by the specific organism, as does the threshold for reporting suspected child sexual abuse (Table 8). When any STI has been diagnosed in a child, efforts should be made in consultation with a specialist to evaluate the possibility of sexual abuse, including conducting a history and physical examination for evidence of abuse and diagnostic testing for other commonly occurring STIs (1439–1441).
The general rule that STIs beyond the neonatal period are evidence of sexual abuse has exceptions. For example, genital infection with T. vaginalis (1442) or rectal or genital infection with C. trachomatis among young children might be the result of perinatally acquired infection and has, in certain cases of chlamydial infection, persisted for as long as 2–3 years (1443–1445), although perinatal chlamydial infection is now uncommon because of prenatal screening and treatment of pregnant women. Genital warts have been diagnosed among children who have been sexually abused (1426) but also among children who have no other evidence of sexual abuse (1446,1447); lesions appearing for the first time in a child aged >5 years are more likely to have been caused by sexual transmission (1448). BV has been diagnosed among children who have been abused but its presence alone does not prove sexual abuse. The majority of HBV infections among children result from household exposure to persons who have chronic HBV infection rather than sexual abuse.
All U.S. states and territories have laws that require reporting of child abuse. Although the exact requirements differ by state or territory, if a health care provider has reasonable cause to suspect child abuse, a report must be made (1448). Health care providers should contact their state or local child protection service agency regarding child abuse reporting requirements.
Evaluating Children for STIs
Evaluating children for sexual assault or abuse should be conducted in a manner designed to minimize pain and trauma to the child. Examinations and collection of vaginal specimens in prepubertal girls can be extremely uncomfortable and should be performed by an experienced clinician to avoid psychological and physical trauma to the child. The decision to obtain genital or other specimens from a child to evaluate for STIs should be made on an individual basis. However, children who received a diagnosis of one STI should be screened for other STIs. History and reported type of sexual contact might not be a reliable indicator, and urogenital, pharyngeal, and rectal testing should be considered for preverbal children and children who cannot verbalize details of the assault (1438,1449). Factors that should lead the physician to consider testing for STIs include the following (1449):
- The child has experienced penetration or has evidence of recent or healed penetrative injury to the genitals, anus, or oropharynx.
- The child has been abused by a stranger.
- The child has been abused by an assailant known to be infected with an STI or at high risk for STIs (e.g., injecting drug user, MSM, person with multiple sex partners, or person with a history of STIs).
- The child has a sibling, other relative, or another person in the household with an STI.
- The child lives in an area with a high rate of STIs in the community.
- The child has signs or symptoms of STIs (e.g., vaginal discharge or pain, genital itching or odor, urinary symptoms, or genital lesions or ulcers).
- The child or parent requests STI testing.
- The child is unable to verbalize details of the assault.
If a child has symptoms, signs, or evidence of an infection that might be sexually transmitted, the child should be tested for common STIs before initiation of any treatment that might interfere with diagnosing other STIs. Because of the legal and psychosocial consequences of a false-positive diagnosis, only tests with high specificities should be used. The potential benefit to the child of a reliable STI diagnosis justifies deferring presumptive treatment until specimens for highly specific tests are obtained by providers with experience in evaluating sexually abused and assaulted children.
Evaluations should be performed on a case-by-case basis, according to history of assault or abuse and in a manner that minimizes the possibility for psychological trauma and social stigma. If the initial exposure was recent, the infectious organisms acquired through the exposure might not have produced sufficient concentrations to result in positive test results or examination findings (1450). Alternatively, positive test results after a recent exposure might represent the assailant’s secretions (but would nonetheless be an indication for treatment of the child). A second visit approximately 2–6 weeks after the most recent sexual exposure should be scheduled to include a repeat physical examination and collection of additional specimens to identify any infection that might not have been detected at the time of initial evaluation. A single evaluation might be sufficient if the child was abused for an extended period and if a substantial amount of time elapsed between the last suspected episode of abuse and the medical evaluation. Compliance with follow-up appointments might be improved when law enforcement personnel or child protective services are involved.
Visual inspection of the genital, perianal, and oral areas for genital discharge, odor, bleeding, irritation, warts, and ulcerative lesions should be performed during initial examination. The clinical manifestations of certain STIs are different for children than for adults. For example, typical vesicular lesions might be absent even in the presence of HSV infection. The following should be performed during the initial examination, if STI testing is indicated:
- Testing for N. gonorrhoeae and C. trachomatis can be performed from specimens collected from the pharynx and rectum, as well as the vagina for girls and urine for boys. Cervical specimens are not recommended for prepubertal girls. For boys with a urethral discharge, a meatal specimen discharge is an adequate substitute for an intraurethral swab specimen. Culture or NAAT can be used to test for N. gonorrhoeae and C. trachomatis. Although data regarding NAAT for children are more limited and performance is test dependent (553), no evidence demonstrates that performance of NAAT for detection of N. gonorrhoeae or C. trachomatis among children differs from that among adults. Only FDA-cleared NAAT assays should be used. Consultation with an expert is necessary before using NAAT in this context, both to minimize the possibility of cross-reaction with nongonococcal Neisseria species and other commensals (e.g., N. meningitidis, N. sicca, N. lactamica, N. cinerea, or M. catarrhalis) and to ensure correct interpretation of results. Because of the implications of a diagnosis of N. gonorrhoeae or C. trachomatis infection in a child, only CLIA-validated, FDA-cleared NAATs should be used (837). If culture for the isolation of N. gonorrhoeae or C. trachomatis is performed, only standard culture procedures should be followed. Specimens from the vagina, urethra, pharynx, or rectum should be streaked onto selective media for isolation of N. gonorrhoeae, and all presumptive isolates of N. gonorrhoeae should be identified definitively by at least two tests that involve different approaches (e.g., biochemical, enzyme substrate, or molecular probes). Gram stains are inadequate for evaluating prepubertal children for gonorrhea and should not be used to diagnose or exclude gonorrhea. Specimens (either NAAT or culture, including any isolates) obtained before treatment should be preserved for further validation if needed. When a specimen is positive, the result should be confirmed either by retesting the original specimen or obtaining another. Because of the overall low prevalence of N. gonorrhoeae and C. trachomatis among children, false-positive results can occur, and all specimens that are initially positive should be confirmed.
- Testing for T. vaginalis should not be limited to girls with vaginal discharge if other indications for vaginal testing exist because evidence indicates that asymptomatic sexually abused children might be infected with T. vaginalis and might benefit from treatment (1451,1452). NAAT can be used as an alternative or in addition to culture and wet mount, especially in settings where culture and wet mount of vaginal swab specimens are not obtainable. Data regarding use of NAATs for detection of T. vaginalis among children are limited; however, no evidence indicates that performance of NAAT for detection of T. vaginalis for children would differ from that for adults. Consultation with an expert is necessary before using NAAT in this context to ensure correct interpretation of results. Because of the implications of a diagnosis of T. vaginalis infection in a child, only CLIA-validated, FDA-cleared NAATs should be used (837). POC tests for T. vaginalis have not been validated for prepubertal children and should not be used. In the case of a positive specimen, the result should be confirmed either by retesting the original specimen or obtaining another. Because of the overall low prevalence of T. vaginalis among children, false-positive results can occur, and all specimens that are initially positive should be confirmed.
- HSV can be indicative of sexual abuse; therefore, specimens should be obtained from all vesicular or ulcerative genital or perianal lesions and sent for NAAT or viral culture.
- Wet mount can be used for a vaginal swab specimen for BV if discharge is present.
- Collection of serum samples should be evaluated, preserved for subsequent analysis, and used as a baseline for comparison with follow-up serologic tests. Sera can be tested for antibodies to T. pallidum, HIV, and HBV. Decisions regarding the infectious agents for which to perform serologic tests should be made on a case-by-case basis.
The risk for a child acquiring an STI as a result of sexual abuse or assault has not been well studied. Presumptive treatment for children who have been sexually assaulted or abused is not recommended because the incidence of most STIs among children is low after abuse or assault, prepubertal girls appear to be at lower risk for ascending infection than adolescent or adult women, and regular follow-up of children usually can be ensured. However, certain children or their parent or guardian might be concerned about the possibility of infection with an STI, even if the health care provider has perceived the risk to be low. Such concerns might be an indication for presumptive treatment in certain settings and might be considered after all relevant specimens for diagnostic tests have been collected.
Other Management Considerations
Children who are survivors of sexual assault or abuse are at increased risk for future unsafe sexual practices that have been linked to higher risk for HPV acquisition (1426,1453) and are more likely to engage in these behaviors at an earlier age; therefore, ACIP recommends vaccination of these children at age ≥9 years if they have not initiated or completed HPV vaccination (see Human Papillomavirus Infections, Prevention) (https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hpv.html). Although HPV vaccine will not protect against progression of infection already acquired or promote clearance of the infection, the vaccine protects against HPV types not yet acquired.
If no infections were identified at the initial examination after the last suspected sexual exposure, and if this exposure was recent, a follow-up evaluation approximately 2 weeks after the last exposure can be considered. Likewise, if no physical examination or diagnostic testing was performed at the initial visit, a complete examination can be scheduled approximately 2 weeks after the last exposure to identify any evidence of STIs. In circumstances in which transmission of syphilis, HIV, HBV, or HPV is a concern but baseline tests for syphilis, HIV, and HBV are negative and examinations for genital warts are negative, follow-up serologic testing and examination approximately 6 weeks and <3 months after the last suspected sexual exposure is recommended to allow time for antibodies to develop and signs of infection to appear. In addition, results of HBsAg testing should be interpreted carefully because HBV can be transmitted nonsexually. Decisions regarding which tests should be performed should be made on a case-by-case basis.
Risk for Acquiring HIV Infection
HIV has been reported among children for whom sexual abuse was the only known risk factor. Serologic testing for HIV should be considered for sexually abused children. The decision to test for HIV should involve the family, if possible, and be made on a case-by-case basis depending on the likelihood of infection in the assailant (1448,1454). Although data are insufficient concerning the efficacy of PEP among children, treatment is well tolerated by infants and children with and without HIV, and children have a minimal risk for serious adverse reactions because of the short period recommended for prophylaxis (1455).
Recommendations for Postexposure HIV Risk Assessment of Children <72 Hours After Sexual Assault
Providers should do the following:
- Review local HIV epidemiology, assess risk for HIV in the assailant, and test for HIV.
- Evaluate the circumstances of the assault or abuse that might affect risk for HIV transmission.
- Perform HIV antigen or antibody testing (or antibody testing, if antigen or antibody testing is unavailable) during the original assessment and again at follow-up visits, in accordance with CDC guidelines (https://stacks.cdc.gov/view/cdc/38856). In considering whether to offer PEP, health care providers should consider whether the child can be treated soon after the sexual exposure (i.e., <72 hours), the likelihood that the assailant has HIV infection, and the likelihood of high compliance with the prophylactic regimen (1436). Potential benefit of treating a sexually abused child should be weighed against the risk for adverse reactions.
- Consult with a provider specializing in evaluating or treating children with HIV infection to determine age-appropriate dosing and regimens and baseline laboratory testing, if PEP is being considered.
- Discuss PEP with the caregivers, including its toxicity, unknown efficacy, and possible benefits, for children determined to be at risk for HIV transmission from the assault or abuse.
- Provided adequate doses of medication, if PEP is begun, to last until the follow-up visit 3–7 days after the initial assessment, at which time the child should be reevaluated and tolerance of medication assessed (139).