PEDIATRICS Vol. 99 No. 6 June 1997,
p. e8
Copyright ©1997 by the American Academy of Pediatrics
ELECTRONIC ARTICLE:
Vaginal Gonococcal Cultures in Sexual Abuse Evaluations:
Evaluation of Selective Criteria for Preteenaged Girls
David L. Ingram*,
V. Denise Everett*,
Lauren A. R. Flick
,
Theresa A. Russell, and
Susanne T. White-Sims§
From * the Area Health Education Center, Wake Medical Center,
Raleigh, North Carolina and University of North Carolina, School of
Medicine, Department of Pediatrics, Chapel Hill, North Carolina; the
Area Health Education Center, Wake Medical Center, Raleigh, North
Carolina; and § Louisiana State University Medical Center, Department
of Pediatrics, New Orleans, Louisiana.
ABSTRACT
- INTRODUCTION
- METHODS
- RESULTS
- DISCUSSION
- CONCLUSIONS
- ABBREVIATIONS
- REFERENCES
ABSTRACT 
Objective. Accurate selective criteria
could limit the number of vaginal cultures for Neisseria
gonorrhoeae performed on preteenaged girls as part of their
sexual abuse evaluations. This study was performed to determine whether
the published selective criteria by the American Academy of Pediatrics
(AAP) Committee on Child Abuse and Neglect and by Siegel et al would
have accurately detected all cases of vaginal gonococcal infections in
our large study population.
Methods. We prospectively studied girls, ages 1 to 12 years, who were referred to our Child Sexual Abuse Team (CSAT) at Wake Medical Center in Raleigh, NC, between July 1, 1976 to July 1, 1996, for sexual abuse evaluations which were performed using a protocol that
included collecting historical information, a sexual abuse interview,
and a detailed genital examination which included a vaginal culture for
N gonorrhoeae.
Results. Our study population consisted of 2898 girls of
whom 2731 (94%) had vaginal cultures successfully performed for
N gonorrhoeae. There were 84 girls with vaginal gonococcal
infections, 80 of whom had a vaginal discharge. The four girls without
a vaginal discharge included two with a history of having vaginal
intercourse with an alleged perpetrator with gonorrhea, one with
N gonorrhoeae isolated from a urine culture, and one whose
preteenaged sister had gonorrhea. All of the 84 girls would have been
identified using the selective culturing criteria of the AAP Committee
on Child Abuse and Neglect: culturing when epidemiologically indicated (interpreted as the girl having another sexually transmitted disease [STD], a child sibling, child household member, a close child associate or a perpetrator with a known STD) or when the history and/or
physical findings suggest the possibility of oral, genital, or rectal
contact, or Siegel et al's more selective criteria: only culturing
prepubertal girls for N gonorrhoeae if there is a vaginal
discharge at the time of presentation or if there is a high risk for
STD acquisition, defined as having a STD diagnosed, a sibling with a
STD, contact with a perpetrator known to have a STD, contact with
multiple perpetrators, or Tanner stage III or above.
Conclusion. Both the selective criteria of the AAP
Committee on Child Abuse and Neglect and the more selective criteria of Siegel et al as we interpreted them were accurate when applied to
identifying girls with vaginal gonococcal infections in our study
population. Neisseria gonorrhoeae, female children,
sexual abuse evaluation, vaginal cultures.
INTRODUCTION
When evaluating preteenaged girls for sexual abuse, detecting
vaginal gonococcal infections is important information both from a
legal standpoint, as it confirms sexual contact, and from a medical
standpoint, as the child will need treatment and further evaluation for
other sexually transmitted diseases (STDs). Because vaginal gonococcal
infections are being detected in <3% of our study population of girls
ages 1 to 12 years being evaluated for sexual abuse in Raleigh, NC,
selective criteria that could limit the number of girls cultured and
yet not exclude those with vaginal gonococcal infections would be
useful.3 To determine if the selective criteria
suggested by the American Academy of Pediatrics (AAP) Committee on
Child Abuse and Neglect and those of a recent study by Siegel et al
would accomplish this, the following study was performed (Table
1).1,2
|
Table 1.
Selection Criteria for Vaginal Gonococcal Cultures
[View Table]
|
METHODS
In this study, girls ages 1 through 12 years old who were
referred for sexual abuse evaluation to the Wake Medical Center Child
Sexual Abuse Team (CSAT) in Raleigh, NC, between July 1, 1976 to July
1, 1996 had vaginal cultures performed for Neisseria gonorrhoeae by protocol as part of their sexual abuse evaluation. N gonorrhoeae cultures were plated on modified Thayer-Martin
and chocolate agar and immediately processed by the hospital
laboratory. N gonorrhoeae was identified by at least two
confirmatory tests involving different principles, eg, biochemical,
enzyme substrate, or serology. Isolates were further confirmed by the
North Carolina Public Health Laboratory. These girls also had extensive
sexual abuse interviews and physical examinations performed with
special attention given to the genital and rectal areas. The character of their hymenal rings, the transverse hymenal orifice diameters, and
whether they had a vaginal discharge were noted. The examinations were
performed by experienced physicians and interviewers on the CSAT team
who used established protocols in conducting sexual abuse evaluations.
The findings were then examined to determine if all the girls with
vaginal gonococcal infections would have been detected by the selective
culturing criteria of the AAP Committee on Child Abuse and Neglect or
the more selective criteria of Siegel et al (Table 1).1,2
"When epidemiologically indicated" in the AAP recommendations was
interpreted as the girl having another STD or a STD at a different
site, a child sibling, a child household contact, or a child close
associate with a STD, or a sexual contact with a person with a known
STD.
Informed consent to be studied was obtained from all the girls'
parents or guardians. This study was approved by the Wake Medical
Center Institutional Review Committee.
RESULTS
The results of our study are summarized in Table 2. Two
thousand eight hundred ninety-eight girls ages 1 through 12 years were
evaluated for sexual abuse. Of these, 2731 had vaginal cultures performed for N gonorrhoeae. One hundred sixty-seven girls
(6% of the total) did not have vaginal cultures. These girls'
cultures either were improperly processed in outlying clinics and the
girls treated for gonorrhea before referral to us, the cultures died before being fully evaluated, did not arrive in the laboratory after
being performed, or inadvertently were not performed. Eighty-four vaginal cultures were positive for N gonorrhoeae. Eighty
(95%) of these girls with vaginal gonococcal infections had a vaginal discharge. The four girls with vaginal gonococcal infections and without a vaginal discharge had the following histories and findings:
Case 1
A 4-year-old girl was named as a sexual contact by an 8-year-old
boy with urethral gonorrhea who had vaginal intercourse with her. She
also revealed she had vaginal and rectal intercourse with a 25-year-old
man on many occasions, and vaginal intercourse with a 4-year-old boy.
By inspection, the girl's transverse hymenal orifice diameter was 4 mm. There were three hymenal synechiae to the labia minora, a healed
laceration of the hymen at 6 o'clock, marked perihymenal erythema, and
intravaginal synechiae. There was no vaginal discharge. Her vaginal and
rectal cultures were positive for N gonorrhoeae. The rectal
examination was normal.
Case 2
A 9-year-old girl gave a history of vaginal intercourse on a
number of occasions with a 16-year-old male who was known to have
gonococcal urethritis. It was unclear when the last episode occurred.
She never had any symptoms, had a normal genital examination, and had
no vaginal discharge although her vaginal culture was positive for
N gonorrhoeae.
Case 3
A 3-year-old girl presented with 2 days of dysuria and urgency,
and rectal and vaginal itching. A urine culture revealed >100 000 colonies/mL of Gardnerella vaginalis and N gonorrhoeae. Four
days later, vaginal and rectal examinations were normal without a
vaginal discharge, but vaginal and rectal cultures were positive for
N gonorrhoeae. Initial evaluation revealed no history of
sexual contact. She was admitted to the hospital 4 days later and at that time, she had a scant vaginal discharge. Further extensive questioning of the child was hampered by the child's age, and questioning of the family revealed no history of sexual contact.
Case 4
A 4-year-old girl was found locked in her room with the mother and
father who were intoxicated. The child said she was spanked with a belt
and had seen her father nude but denied sexual contact of any kind. Her
vaginal examination was normal with no vaginal discharge. Her vaginal
culture was positive for N gonorrhoeae. Her pharyngeal and
rectal cultures were negative for N gonorrhoeae. Her
preteenaged sister also had a history of having vaginal gonorrhea 11/2 years earlier.
All 84 girls with vaginal gonococcal infections would have been
detected by culturing only the girls who met the selective criteria of
the AAP Committee on Child Abuse and Neglect as we interpreted them, or
the more selective culturing criteria of Siegel et al (Table 1), as
Cases 1 and 2 gave a history of having vaginal intercourse with an
alleged perpetrator known to have gonorrhea, Case 3 had gonococcal
urethritis detected by a urine culture, and Case 4 had a preteenaged
sibling with gonorrhea detected 11/2 years earlier. (Case 4 had
a negative vaginal culture at that time).1,2
DISCUSSION
Current recommendations from authoritative sources about obtaining
vaginal cultures for N gonorrhoeae as part of a sexual abuse
work-up are as follows. In 1991, the Committee on Child Abuse and
Neglect of the American Academy of Pediatrics (AAP) recommended that
"Routine cultures and screening of all children for gonorrhea ... is not recommended. The yield of positive cultures is very low in
asymptomatic prepubertal children, especially those whose history
indicates fondling only. When epidemiologically indicated, or when the
history and/or physical findings suggest the possibility of oral,
genital, or rectal contact, appropriate cultures ... should be
obtained."1 In 1993, the Centers for Disease Control and
Prevention recommended that "The decision to evaluate the child for
STDs must be made on an individual basis. Situations involving a high
risk of STDs and a strong indication for testing include the following:
a suspected offender is known to have a STD or to be at high risk for
STDs (eg, multiple partners or past history of a STD), the child has
symptoms or signs of a STD, or there is a high STD prevalence in the
community."4 In 1994, the Report of the Committee on
Infectious Diseases of the AAP recommended that in evaluating children
for sexual abuse "appropriate tests for gonorrhea ... should be
considered. Some experts advise culturing all children examined for
sexual abuse for ... Neisseria gonorrhoeae because many
children do not disclose the extent of the abuse, and infection with
these agents may be asymptomatic."5
In 1995, a study by Siegel et al did gonococcal vaginal cultures on
children being evaluated for sexual abuse who met what they interpreted
the Committee on Child Abuse and Neglect of the AAP's selective
criteria to be.1,2 These were: that the child had a history
of genital discharge or contact with the perpetrator's genitalia, the
child had a genital discharge or genital trauma on examination, the
child had a history of consensual sexual activity, the child was Tanner
III or greater, the child had sexual contact with a perpetrator known
to have a STD, or there was a family member with a STD. In their study,
of 704 female children ages 3 weeks to 18 years evaluated, 462 met
these criteria. In this group, there were 6 of 249 prepubertal girls
who met these criteria and had vaginal gonococcal infections. All six
also had a vaginal discharge. Based on these six cases and a review of
the literature on the subject, Siegel et al's conclusions and
recommendations were that "in prepubertal girls, cultures for N
gonorrhoeae need only be obtained when a discharge is present at
the time of examination or if the child is felt to be at high risk for
STD acquisition" (defined as having a STD diagnosed, a sibling with a
STD, contact with a perpetrator known to have a STD, or contact with
multiple perpetrators
all girls Tanner stage III or greater should be
tested for STDs).2 Siegel et al felt that the decision to
test may also be influenced by physician experience, presence of
hymenal trauma, and the local epidemiology of STDs.
Having a vaginal discharge would meet the selective criteria of the AAP
Committee on Child Abuse and Neglect and those of Siegel et al for
doing a vaginal culture. The question of whether or not to limit
performing vaginal cultures for N gonorrhoeae is really
confined to whether or not to culture all preteenaged girls being
evaluated for sexual abuse who do not have a vaginal discharge, or
limiting it to certain situations when they do not have a vaginal
discharge. A vaginal gonococcal infection in a girl under age 13 years
without a vaginal discharge is an uncommon situation, being found in
only 5% of 84 girls with vaginal gonococcal infections in our study.
The strength of our study was that it contained preteenaged girls with
the rare situation of having a vaginal gonococcal infection without a
discharge. This enabled us to examine the selective criteria in these
important cases. Despite of its size, the weakness of our study is that
there were only four such cases, making it hard to generalize our
results to the population at large. There are three published reports with a total of nine cases of asymptomatic preteenaged girls with vaginal gonococcal infections.6 It is unclear in these
reports if asymptomatic means no vaginal discharge. Assuming it does, these cases include one reported by Tunnessen and Jastremski, a
two-year-old girl detected when they evaluated the siblings of a
5-year-old girl with a vaginal gonococcal infection and a discharge,
and two reported by Sgroi, sisters ages 5 and 8 years old who were
detected when evaluating the household where a nonrelated 5-year-old
girl with vaginal and conjunctival gonococcal infections (both with a
discharge) had stayed for one week. None of these three children had a
history of sexual contact6,7 Six asymptomatic girls <10
years old were reported by Folland et al8 They were identified because three were sexual contacts of children with symptomatic gonococcal infections, two were relatives of children with
symptomatic gonococcal infections, and one was an associate of children
with asymptomatic gonococcal infection. These nine girls would have
been cultured using the AAP Committee on Child Abuse and Neglect
selective criteria. They all would have been cultured using Siegel et
al's selective criteria if the two cases of Sgroi's (unrelated
household contacts of a child with gonorrhea) and three cases of
Folland et al's (two child relatives and a child associate of children
with gonorrhea) would have been considered siblings by Siegel et
al2,7,8 Dejong, in a study of gonococcal infections in
girls younger than 14 years old, reported that 5 of 15 girls with
vaginal gonococcal infections did not have a vaginal
discharge.9 All were sexually abused. It is not stated if
these five girls were preteenaged, if they had other venereal diseases,
if other siblings in the family had venereal diseases, if there was
genital contact, or anything about their perpetrators, making it hard
to apply the selective criteria of the AAP Committee on Child Abuse and
Neglect or those of Siegel et al to these cases.1,2 It will
take many large studies to collect enough preteenage girls with vaginal
gonococcal infections without a discharge to be certain selective
criteria for culturing girls in this group are very accurate.
CONCLUSIONS
In our study, all 84 girls with vaginal gonococcal infections
would have been detected if we had only done vaginal cultures on girls
being evaluated for sexual abuse who met the selective culturing
criteria of the AAP Committee on Child Abuse and Neglect or the more
selective culturing criteria of Siegel et al (Table 1).1,2 In our review of published studies containing
preteenaged girls with vaginal gonococcal infections, all these girls
would have been cultured using the selective criteria of the AAP
Committee on Child Abuse and Neglect as we interpreted
it.1,6 All also would have been cultured using the
selective criteria of Siegel et al if these criteria are extended to
not only include having a sibling with a STD, but also child relatives,
child household contacts, and child associates with a STD.
All girls being evaluated for sexual abuse and having a vaginal
discharge should have a vaginal culture performed for N
gonorrhoeae. With the current state of knowledge about gonococcal
vaginal infections without a vaginal discharge being so limited, the
final decision as to whether to obtain gonococcal vaginal cultures on
all preteenaged girls being evaluated for sexual abuse who do not have
a vaginal discharge, or to limit culturing based on selective criteria
suggested by the AAP Committee on Child Abuse and Neglect, or those
suggested by Siegel et al (but modified to also include child household contracts, child relatives, or child associates with a STD), will be
based on whether one is willing to risk missing the rare case of a girl
with a vaginal gonococcal infection that does not have a discharge and
may possibly not fit the selected criteria chosen.1,2 It is
a decision each physician will have to make individually, depending on
what he or she feels is best when balancing what the detrimental effect
of missing a rare case of a vaginal gonococcal infection without a
discharge will be on that child versus the beneficial effect of not
doing vaginal cultures on many children who do not need them.
FOOTNOTES
Received for publication Oct 1, 1996; accepted Dec 12, 1996.
Reprint requests to (D.L.I.) Pediatric AHEC, Medical Education
Institute, 3024 New Bern Ave, Suite 307, Raleigh, NC 27610.
ABBREVIATIONS
STD, sexually transmitted disease.
AAP, American
Academy of Pediatrics.
CSAT, Child Sexual Abuse Team.
NC, North
Carolina.
REFERENCES
-
American Academy of Pediatrics Committee on Child Abuse and
Neglect
Guidelines for the evaluation of sexual abuse of children.
Pediatrics
1991;
87:254-260[Abstract/Free Full Text]
-
Siegel RM,
Schubert CJ,
Myers PA,
Shapiro RA
The prevalence of
sexually transmitted diseases in children and adolescents evaluated for
sexual abuse in Cincinnati: rationale for limited STD testing in
prepubertal girls.
Pediatrics
1995;
96:1090-1094 [Medline][Abstract/Free Full Text]
-
Ingram DL,
Everett VD,
Lyna PR,
White SW,
Rockwell LA
Epidemiology of
adult sexually transmitted disease agents in children being evaluated
for sexual abuse.
Pediatr Infect Dis J.
1992;
11:945-950 [Medline][Medline]
-
Centers for Disease Control and Prevention
Centers for Disease Control
1993 sexually transmitted diseases treatment guidelines.
MMWR.
1993;
42:99-100
-
American Academy of Pediatrics. 1994 Red Book. Report of the AAP
Committee on Infectious Diseases. 23rd ed. Elk Grove Village, IL:
American Academy of Pediatrics; 1994:108-109
-
Tunnessen WW,
Jastremski M
Prepubertal gonococcal vaginitis.
Clin Pediatr.
1974;
13:675-676
-
Sgroi SM
"Kids with clap:" gonorrhea as an indicator of child
sexual assault. Victimology:
An Int J.
1977;
2:251-267
-
Folland DS,
Burke RE,
Hinman AR,
Schffner W
Gonorrhea in
preadolescent children: an inquiry into source of infection and mode of
transmission.
Pediatrics
1977;
60:153-156 [Medline][Abstract/Free Full Text]
-
DeJong AR
Sexually transmitted diseases in sexually abused children.
Sex Transm Dis.
1986;
13:123-126
[Medline]
