Evidence for sexual transmission of genital herpes in children

The gynecological sequelae of sexual violence in adolescence in the United States: A scoping review

BACKGROUND

Women who engage in sexual acts against their will are at high risk for sexual and reproductive health complications including sexually transmitted infections (STIs), menstruation disturbance, infertility, abnormal uterine bleeding, reproductive cancers, dyspareunia, vaginismus, and chronic pelvic pain. However, the occurrence of these gynecological sequelae in women who experienced sexual violence during their youth has not been scoped in the literature. To map the breadth of gynecological sequelae, corresponding interventions, and associated symptomatology in childhood and adolescence, the researchers conducted a scoping review.

OBJECTIVES

To identify the most common gynecological disease manifestations and symptomatology for patients who have experienced sexual violence in childhood and/or adolescence; to identify existing healthcare interventions indicating promising strategies to mitigate the impact of sexual violence for adolescents; and to provide future recommendations for clinicians and researchers to reduce gaps in care.

SEARCH STRATEGY

A scoping review methodology was chosen and completed in accordance with the PRISMA-ScR. Embase, CINAHL Complete, Web of Science, and MEDLINE PubMed were searched on October 4, 2023. A medical librarian developed, ran, and recorded the search in accordance with PRISMA extension for searching. The search retrieved 11 253 records. After deduplication 7656 articles were screened at the title and abstract levels, of which 212 underwent full text review for eligibility. Ultimately, 92 articles were included.

SELECTION CRITERIA

The following inclusion criteria was used to lead the search and for full-text review: (1) the study focuses on persons with a history of sexual violence prior to adulthood; (2) the study focuses on gynecological interventions from healthcare practitioners; (3) the study is based in the US; (4) the study is published in a peer-reviewed journal; (5) the study was published between 1990 and 2022; and (6) because the patient population resides in the US, the literature is limited to English language. The exclusion criteria that have been identified are: (1) the study focuses on intimate partner violence and/or spousal abuse; (2) the study was published prior to 1990.

DATA COLLECTION AND ANALYSIS

Researchers utilized Research Electronic Data Capture (REDCap) for data collection and analysis. Norming, title-abstract review, and full-text review were conducted in that order among reviewers. The data that were extracted include: (a) author, year of publication, and other background information; (b) research approach (quantitative, qualitative, mixed methods, etc.); (c) type of sexual violence reported in the study; (d) type of gynecological symptoms and/or diagnoses reported in the study. Additional qualitative data points might have been added by the researchers throughout the process of data extraction and charting. The primary researcher then used REDCap to analyze the provided charts and statistics.

MAIN RESULTS

A total of 7656 articles were screened at the title and abstract levels, of which 212 underwent full text review for eligibility. A total of 120 articles were excluded, and 92 articles were included in this review, highlighting the types of sexual violence reported, gynecological intervention, and any gynecological symptoms or diagnoses, with the most prominent being rape, antibiotic therapy, and STIs, respectively.

CONCLUSIONS

Further research to determine the benefit of earlier cervical cancer screening in a subset of women who experienced early lifetime sexual abuse may prevent invasive cervical cancer as an adult and would provide insight for improved management of child sex abuse victims. Consideration of early psychiatry involvement, or pelvic floor therapy referral prior to the onset of psychiatric-related gynecological symptoms secondary to sexual trauma may improve quality of life in adulthood. Finally, a protocol for pharmacologic management following sexual abuse could be considered in the acute setting of sexual trauma, including an algorithm to at least offer HIV prophylaxis, human papillomavirus vaccination, hepatitis B vaccination (HBV) and/or immunoglobulin if the perpetrator is a known intravenous drug user or HBV carrier, tetanus vaccination, antibacterial therapy, and pregnancy prophylaxis in the emergency department setting.

Anogenital HSV in Children: Should Providers Be Concerned for Sexual Abuse?

OBJECTIVE

Anogenital herpes simplex virus (HSV) is most commonly acquired via sexual transmission, although other nonsexual modes of transmission have been proposed. When a child presents with a first-time outbreak of anogenital HSV, providers must consider sexual abuse. There are currently no evidence-based consensus guidelines to inform management of these patients. The purpose of this study was to describe how child abuse pediatricians (CAPs) evaluate children with anogenital HSV infection and determine whether any consistent practice patterns are followed.

PARTICIPANTS AND SETTING

The patients included in this study were children between the ages of 0 and 12 years with a first-time outbreak of anogenital HSV who were medically evaluated by a CAP.

METHODS

Patient charts were retroactively reviewed for the period of January 1 2004 to May 1 2020.

RESULTS

Twenty-two cases were referred for evaluation by a CAP in the chosen time frame. Fifteen were seen in person. Ten of these patients were interviewed, 15 had an anogenital exam with colposcopy, and 14 were tested for at least one other sexually transmitted infection. A diagnosis of sexual abuse was made for 1 patient.

CONCLUSION

This study demonstrates that although nonsexual transmission of anogenital HSV may be possible, providers must still consider sexual abuse. Children with a first-time outbreak of anogenital HSV should have a comprehensive evaluation for sexual abuse, including interview, physical exam, and testing for sexually transmitted infections. Evidence-based concerns for sexual abuse should be reported to child protective services.

Sexual Violence against Adolescents in the State of Espírito Santo, Brazil: An Analysis of Reported Cases

OBJECTIVE

We describe the prevalence of the reported cases of sexual violence against adolescents and analyze their associated factors.

METHODS

A cross-sectional analytical study (n = 561) was conducted with reported data on sexual violence against adolescents in the state of Espírito Santo registered in SINAN between 2011 and 2018 to understand the prevalence and predictors of sexual violence against adolescent victims, as well as to describe the perpetrators and the nature of the aggression. Variables to characterize the victim, aggression, and perpetrator were used. Bivariate analyses were performed using chi-square (χ2) and Fisher's exact tests, and multivariate analyses were conducted using log-binomial models; the results were presented with prevalence ratios. All analyses were stratified by sex.

RESULTS

The prevalence of sexual violence was 32.6%, and 93% of the victims were female. In both males and females, the reported sexual violence was associated with a younger age (10-12 years old), living at home, being related to the perpetrator, and a history of sexual violence. In females, the reported sexual violence was also associated with the number of perpetrators, and in males, with the perpetrator's age.

CONCLUSIONS

Our findings show the high frequency of reporting of sexual violence and the characteristics of the victim, the aggression, and the aggressor as factors associated with its occurrence in both sexes. The importance of health information systems for disseminating data and the need for measures to prevent and treat the violence among adolescents is urgent.

Case Report: Not All Genital Ulcers Are Herpetic

BACKGROUND

The most common cause of genital lesions is herpes simplex virus (HSV) (Pediatr Dermatol. 2012;29:147-153). However, in children and adolescents who are not sexually active, several other causes need to be considered.

CASE

A 13-year-old adolescent girl presented to the emergency department with genital lesions. A gynecologist was consulted at time of presentation for concerns of a primary HSV infection and concurred. Final HSV and sexually transmitted infection testing were subsequently negative. At outpatient follow-up, a child abuse pediatrician made the diagnosis of aphthous genital ulcers (AGUs). Awareness of the diagnosis of AGUs is important because alternate diagnoses such as HSV could imply child abuse. It is critical to include AGUs in the differential diagnosis and to provide the appropriate referrals.

Physical symptoms in very young children assessed for sexual abuse: a mixed method analysis from the ASAC study

So far, a recognizable pattern of clinical symptoms for child sexual abuse (CSA), especially in young male children, is lacking. To improve early recognition of CSA, we reviewed physical complaints, physical examination, and tests on sexually transmitted infections (STIs) in confirmed victims (predominantly preschool boys) of CSA from the Amsterdam sexual abuse case (ASAC). We retrospectively analyzed the outcomes of the primary assessment using mixed methods: descriptive analysis of physical complaints, physical exams, and STI tests from medical files and a qualitative analysis on expert's interpretations of physical complaints and children's behavior during physical examination. We included 54 confirmed CSA victims, median age 3.2 (0-6) years, 43 boys (80%), and 11 girls (20%). Physical complaints were reported in 50%, of which gastrointestinal and anogenital complaints were most common. None of the children showed CSA-specific genital signs at physical examination. Most prominent finding during physical examination was a deviant behavioral response (anxiety, withdrawal, too outgoing) in 15 children (28%), especially in children who experienced anal/vaginal penetration. Testing for STIs was negative.

CONCLUSION

Physical complaints and physical signs at examinations were non-specific for CSA. Deviant behavioral reactions during physical examination were the most prominent finding. Precise observation of a child's behavior during physical examination is needed. What is known • Child sexual abuse (CSA) affects many children on both the short and the long term but remains unrecognized in most cases. • So far, there is a lack of studies on symptom patterns of CSA in male, preschool children. What is new • None of the children showed CSA-specific findings at physical and anogenital examination; STIs were not found in the confirmed victims of CSA. • The most prominent finding was the deviant behavioral response of the children examined, especially in children who experienced anal/vaginal penetration; therefore, precise observation of a child's behavior during physical examination is a crucial part of the evaluation of suspected CSA.

Nucleic acid amplification testing in suspected child sexual abuse

The American Academy of Pediatrics recommends that site-specific cultures be obtained, when indicated, for sexually victimized children. Nucleic acid amplification testing is a highly sensitive and specific methodology for identifying sexually transmitted infections. Nucleic acid amplification tests are also less invasive than culture, and this may provide an efficacious alternative for children suspected of being sexually abused.

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.