Sexually Transmitted Diseases

Sexually transmitted diseases (STD) are discussed in a different sections of this site. We only refer to a few important characteristics with regard to CSA.

STD may be the only medical indicator of sexual abuse in selected cases.

The American Center for Disease Control (CDC) states that the diagnosis of a STD in a child beyond the neonatal period suggests sexual abuse [CDC, 1998].

The interpretation differs according to the respective disease. STDs are diagnosed in 1–5% of abused children. The differences result from factors like type and frequency of the abuse, the age of the victim, the methods for testing and varying regional prevalence. Cultures and smears for STD should only be obtained in selected cases as the yield of positive cultures is very low in asymptomatic children [Ingram et al., 1992; Siegel et al., 1995; AAP, 1999; Muram and Stewart, 2000].

Proposed selection criteria for STD screening include genital discharge at examination or in the recent history, a perpetrator with a known or suspected STD or with high-risk behavior, anogenital findings indicating penetrative abuse, a history of genital-to-genital (or -anal) contact or penetration, concern of the patient or its caretakers or specific genital lesions. The screening includes vaginal and anal cultures for gonorrhea and Chlamydia and a vaginal smear for Trichomonas vaginalis. Prepubertal gonorrhea and chlamydial infections are localized vaginal infections. Swabs should be taken from the vaginal wall beyond the hymen. Cervical swabs are not indicated before adolescence.

Extending the screening to syphilis, hepatitis B and HIV should be done on a case-to-case decision. Adequate and optimal technique of obtaining specimens, choice of testing methods and cultures are of paramount importance due to the forensic implications of positive results. Recently the use of nucleic acid amplification methods has become increasingly popular in testing for STDs. Specific considerations and limitations have to be kept in mind when used for possible prepubertal sexual abuse [Hammerschlag, 2001].

Except in documented congenital infections, confirmed positive cultures for Neisseria gonorrhea in a prepubertal child or serologic proof of an acquired syphilis are definite evidence of sexual abuse. Perinatally acquired infections with Chlamydia trachomatis have been demonstrated to persist as long as 2y ears in the genital area and up to 3 years in the pharynx. Infections appearing after the first 2 years of life are strong indicators of CSA. Infections with T. vaginalis, Herpes genitalis and Condylomata acuminata should raise the suspicion of sexual abuse and warrant further screening [AAP, 1999; Beck-Sagué and Solomon, 1999; Shapiro et al., 1999; Muram and Stewart, 2000; Ingram et al., 2001b].