Epidemiology of Sexually Transmitted Infections in Suspected Child Victims of Sexual Assault
OBJECTIVE: The objective of this study was to describe the epidemiology of Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Treponema pallidum, HIV, and herpes simplex virus type 2 (HSV-2) infection diagnosed by culture or by serologic or microscopic tests and by nucleic acid amplification tests in children who are evaluated for sexual victimization.
METHODS: Children aged 0 to 13 years, evaluated for sexual victimization, who required sexually transmissible infection (STI) testing were enrolled at 4 US tertiary referral centers. Specimens for N gonorrhoeae and C trachomatis cultures, wet mounts for detection of T vaginalis, and serologic tests for syphilis and HIV were collected and processed according to study sites' protocols. Nucleic acid amplification tests for C trachomatis and N gonorrhoeae and serologic tests for HSV-2 were performed blinded to other data.
RESULTS: Of 536 children enrolled, 485 were female. C trachomatis was detected in 15 (3.1%) and N gonorrhoeae in 16 (3.3%) girls. T vaginalis was identified in 5 (5.9%) of 85 girls by wet mount, 1 (0.3%) of 384 children had a positive serologic screen for syphilis, and 0 of 384 had serologic evidence of HIV infection. Of 12 girls who had a specimen for HSV-2 culture, 5 (41.7%) had a positive result; 7 (2.5%) of 283 had antibody evidence of HSV-2 infection. Overall, 40 (8.2%) of 485 girls and 0 of 51 boys (P = .02) had ≥1 STI. Girls with vaginal discharge were more likely to test positive for an STI (13 [24.5%] of 53) than other girls (27 [6.3%] of 432; prevalence ratio = 3.9; P < .001), although 10 girls with STIs had normal physical examinations. Most girls (27 [67.5%]) with a confirmed STI had normal or nonspecific findings on anogenital examination.
CONCLUSIONS: The prevalence of each STI among sexually victimized children is <10%, even when highly sensitive detection methods are used. Most children with STIs have normal or nonspecific findings on physical examination.
In a 2001–2002 survey of >10000 American young adults, 4.5% were reported to be victims of sexual contact before entering the sixth grade, confirming previous reports.1,2 The definition of “sexual contact” in these surveys included fondling as well as penetrating forms of sexual abuse, but data from 1 study indicated that nearly one third of sexually assaulted children were forced to submit to sexual intercourse,3 placing them at risk for infection with a sexually transmissible infection (STI). It has been suggested that the thinness of the vaginal epithelium in prepubertal girls and the likelihood of repeat abuse by the same perpetrator may increase the risk for HIV acquisition after unprotected intercourse,4 and the same may be postulated for other infections; however, published prevalence studies of STIs in sexually abused children have reported rates of infection of <3%.5–8
Citing the low yield of STI testing among asymptomatic prepubertal children, particularly in cases involving only fondling, the American Academy of Pediatrics Committee on Child Abuse and Neglect recommends that the decision to test be based on the type of sexual contact, the time since last sexual contact, whether there are signs/symptoms suggestive of an STI, whether a family member or a sibling has an STI, abuser risk factors for an STI, child or family concern, the prevalence of STIs in the community, and the presence of other examination findings.9,10 Similarly, the Centers for Disease Control and Prevention (CDC) states that the decision to test should be made on an individual basis, taking into account the child's symptoms, the suspected offender's risk for STI infection, any STI infection in a member of the child's immediate environment, patient and parent requests for testing, and evidence of penetration or ejaculation on examination.11 Some authors have suggested that the use of more restrictive testing criteria may identify nearly all infected children while avoiding unnecessary testing for many others.12–14
Low detection rates for STIs in sexually assaulted children may be attributable in part to the limited performance of some diagnostic tests. Cultures have remained the gold standard for diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis in this population because of their high specificities and the potential legal and social implications of a positive result in a child15,16; however, difficulties in maintaining the viability of organisms during transport and, particularly in the case of C trachomatis, low sensitivities limit the utility of cultures.17–21 Culture for Trichomonas vaginalis is not readily available, and the sensitivity of wet mount ranges widely, depending on the expertise of the examiner.22
Nucleic acid amplification tests (NAATs) for the detection of N gonorrhoeae and C trachomatis became widely available in the early 1990s. NAATs offer the advantages of superior sensitivity and ease of specimen collection (urine specimens) as compared with culture, but concerns about both test sensitivity and specificity exist, particularly for detection of N gonorrhoeae.20,21,23 Studies of the use of NAATs in sexually abused children have demonstrated encouraging results but were limited by insufficient sample sizes, as well as mixing of prepubertal and adolescent populations, boys and girls, and/or anatomic sites.24–27
From January 2000 to September 2004, the Centers for Disease Control and Prevention conducted a multicenter study of diagnostic tests for STIs in children who were suspected of being sexually abused. Prevalence data for N gonorrhoeae, C trachomatis, T vaginalis, Treponema pallidum, HIV, and herpes simplex virus type 2 (HSV-2) as detected by traditional methods and noninvasive tests are presented in this report.
The study was conducted at tertiary referral centers for suspected child abuse victims located in New York (4 sites), Georgia (2 sites), Pennsylvania (1 site), and Texas (1 site) between January 2000 and September 2004. Consecutive children from birth through 13 years of age and thought to be at risk for STI were eligible for study participation. Boys and girls were eligible for study participation at the Georgia site; only girls were eligible at the other sites. Children were excluded from study participation when they had no indications for STI testing according to current guidelines10,28 or when they had a history of consensual sexual activity and were 13 years of age. Situations that were deemed to represent a risk for STI were children who had a complaint or suspicion of genital–genital or genital–anal contact, those with anogenital trauma or other physical findings suggestive of sexual contact (eg, anogenital warts or ulcers), those who lived in households with other children who had diagnoses of STIs, and perpetrators who were known to have STIs. All children who had ≥1 of these risk factors were tested for N gonorrhoeae and C trachomatis, and venipuncture for HIV and syphilis tests was offered. Tests for T vaginalis and culture for HSV-2 were performed for children when clinically indicated, as described herein. When the mother of the child was present, the mother's STI history was recorded. Anogenital findings were classified using guidelines published by Adams et al.29
Participation in the study was voluntary. Parents or legal guardians of children who were evaluated for sexual victimization signed written informed consent for their child's participation in the study; assent was obtained from children who were older than 6 years. This study was approved by the institutional review boards of all of the collaborating centers and the Centers for Disease Control and Prevention.
Specimens for N gonorrhoeae and C trachomatis cultures were collected and processed according to study sites' protocols. Positive culture results were confirmed at all sites by Gram stain, oxidase test, enzyme detection, and/or biochemical tests. NAATs for C trachomatis and N gonorrhoeae and serologic tests for HSV-2 were performed blinded to all historical, demographic, and physical examination data. Fifteen milliliters of first-catch urine was collected for NAAT tests for C trachomatis and N gonorrhoeae. For female participants, a vaginal swab specimen was collected for NAAT tests for C trachomatis and N gonorrhoeae. A similar swab specimen was collected from the urethra of boys only when signs or symptoms of inflammation were present. The commercial NAAT tests (strand displacement amplification and transcription-mediated amplification) were performed at the CDC (strand displacement amplification; BD ProbeTec C trachomatis and N gonorrhoeae Amplified DNA assay [Becton Dickinson Microbiology Systems, Sparks, MD]) and transcription-mediated amplification tests at GenProbe Inc, San Diego, CA (Aptima C2). All samples were processed and tested according to manufacturer's protocols. Positive NAAT test results for C trachomatis and N gonorrhoeae were confirmed using a second commercial NAAT test and by in-house polymerase chain reaction tests at the CDC. Additional confirmation of positive NAAT test results for C trachomatis was performed by genotyping analysis.30 Infection with C trachomatis and N gonorrhoeae was defined as either a positive culture or a positive, confirmed NAAT. For children for whom a venipuncture was performed, additional serum was collected for type-specific immunodot enzyme assay for HSV-2 antibodies, using monoclonal antibody inhibition assay (enzyme-linked immunosorbent assay) for confirmation.31 Nontreponemal serologic tests for syphilis and serologic tests for HIV were collected and processed according to study sites' protocols. Wet mounts for detection of T vaginalis were performed when vaginal discharge was present. When indicated by the presence of suspicious lesions, cultures for HSV-2 or other genital ulcer disease pathogens were also performed.
Data were analyzed using EpiInfo software at the CDC.32 Prevalence of each STI was calculated for the total study population and by participant age, gender, center where the child was recruited, and symptoms of STI. Prevalence ratios were calculated to assess strength of association with specific characteristics. The 2-tailed Fisher's exact P values and Kruskal Wallis test for 2 groups were used for significance testing for categorical and continuous variables, respectively.
A total of 543 children who were being evaluated for possible sexual abuse were enrolled (Table 1). Data abstraction forms were lost for 6 children. Older children (aged 11–13 years) represented a greater proportion of study participants in Texas as compared with the other sites (41.0% vs 13.1%–32.5%). The reason for examination was the child's disclosure of genital–genital and/or genital–anal contact for 388 (67%) of the children. Of these, 257 (44.4% of the total children examined) provided a “clear, credible, and detailed description” of molestation. The proportion of children who were examined because the child disclosed sexual contact was greater in Texas than at the other study sites (81.5% vs 53.2%–65.8%). The remaining children were examined because of a report of molestation made by someone else, the presence of vaginal discharge or other physical abnormality, and/or other significant concerns for STI.
Overall, 40 (8.2%) of 485 girls and 0 of 521 boys (P = .02) tested positive for ≥1 STI. C trachomatis was found in 15 (3.1%) girls, 8 of whom received their diagnosis by confirmed NAAT alone. Two children whose specimens were negative by NAAT were also negative by vaginal culture but had a positive anal culture for C trachomatis. One of these 2 girls tested negative for all other STIs tested, and the other tested positive for N gonorrhoeae by vaginal and anal culture and NAAT. N gonorrhoeae was detected in 16 (3.3%) girls, 4 of whom received their diagnosis by confirmed NAAT alone. All children with a positive vaginal culture for N gonorrhoeae had a positive NAAT. Seven (1.4%) girls had positive culture and/or NAAT for both C trachomatis and N gonorrhoeae. Girls who had a culture or NAAT positive for N gonorrhoeae alone were younger (4.9 years) than those with a culture or NAAT positive only for C trachomatis (11.1 years; P = .0012).
Sera from 384 children were tested for syphilis and HIV (enzyme-linked immunosorbent assay); 1 child had serologic confirmation of acquired syphilis, and none had a positive serologic test for HIV. The child with syphilis also had positive cultures and NAATs for N gonorrhoeae. Twelve children had genital ulcers cultured for HSV-2, with 5 positive results. Of the 283 children whose serum was tested for type-specific HSV antibody (IgG), antibody to HSV-1 was detected in 129, and antibody to HSV-2 was detected in 7 (2.5%); however, only 1 of the 5 children with a positive culture for HSV-2 had corresponding positive serology. None of the children who tested positive for HSV-2 had a positive test for N gonorrhoeae, C trachomatis, or syphilis. Of 85 girls for whom a wet mount was performed, T vaginalis was detected on 5 (5.9%). None of the children with T vaginalis had positive tests for N gonorrhoeae, C trachomatis, or syphilis. Of the 40 children who tested positive for ≥1 STI, 7 received their diagnosis by confirmed NAAT only.
Table 2 summarizes STI prevalence data for each study site. The prevalence of N gonorrhoeae genital infection was almost 5 times higher in the Atlanta, Georgia (7.8%), site than in the Houston, Texas site (1.7%), the site with the second highest prevalence (P = .01; Table 2). No other difference in prevalence by site was statistically significant.
Data concerning previous maternal infection was provided by 30 of 35 mothers of children with a diagnosis of C trachomatis, N gonorrhoeae, and/or HSV-2 infection. Previous maternal infection was reported for 6 (25%) children with positive tests for C trachomatis and/or N gonorrhoeae. Among the 6 infected children whose mothers reported previous maternal infection, 4 were older than 3 years at the time of the child's diagnosis. The mothers of two 3-year-old children who received a diagnosis of N gonorrhoeae by both culture and NAATs reported previous C trachomatis infection only. Previous maternal infection was denied for 2 children with N gonorrhoeae and another child with N gonorrhoeae and C trachomatis; all 3 children were younger than 4 years at the time of diagnosis. No mother of a child who received a diagnosis of HSV-2 reported previous maternal herpes.
Thirty-three children had clear evidence of penetrating anogenital trauma on examination (Table 3). The proportion of children who were assessed as having normal or nonspecific findings, suspicious or suggestive findings, or clear evidence of penetrating anogenital trauma on examination differed significantly between study sites, with more children in the clear evidence category at the Texas site (Table 3). An additional 25 children had evidence of sexual contact or abuse as follows: 17 had a positive culture for C trachomatis, a positive culture for N gonorrhoeae, and/or confirmed syphilis; 2 were pregnant; 2 had a previous diagnosis of N gonorrhoeae; and the perpetrators of 4 confessed to the abuse.
Table 4 compares STI prevalence data by examination findings. A history of vaginal discharge was recorded for 53 (10.9%) girls. Among these girls, 4 had a positive culture and 6 had a positive NAAT for C trachomatis; 11 had a positive culture and 13 had a positive NAAT for N gonorrhoeae, and 3 had T vaginalis detected on wet mount. Girls with vaginal discharge were more likely to test positive for a STI (13 [24.5%] of 53) than other girls (27 [6.3%] of 432; prevalence ratio = 3.9; P < .001); however, 8 girls with a positive vaginal or cervical culture and/or NAAT for C trachomatis and 2 with a positive vaginal culture and/or NAAT for N gonorrhoeae did not have vaginal discharge. Of the children with positive tests for C trachomatis and/or N gonorrhoeae but no vaginal discharge, 4 had normal physical examinations. The diagnosis of sexual contact for 1 child was made by NAAT alone.
The prevalence of STI as detected using culture or microscopic or serologic testing methods among 485 prepubertal girls from 4 US regions was low. The use of NAATs increased the detection of C trachomatis by approximately twofold, to 3.1% of children tested, and increased the detection rate for N gonorrhoeae from 2.5% to 3.3%. All positive NAATs were confirmed with a second NAAT. Pharyngeal gonorrhea was not detected in our study, syphilis was rare (1 case), and there was no case of HIV infection. None of the 51 boys in our study had a positive test for an STI. The low prevalence of STIs among prepubertal children may reflect declining rates in US adults. The national decline in STI prevalence has been particularly striking for gonorrhea, which in 2004 reached the lowest number of reported cases since reporting began in 1941.33 In contrast to gonorrhea reporting, reporting of C trachomatis genital infections has increased modestly in the years from 1999 to 2004, attributed to increased testing, increasing use of NAATs for screening in adult and adolescent populations, and continued high population burden.33
The prevalence of C trachomatis and N gonorrhoeae differed significantly by study site, consistent with geographic differences in the general prevalence of these infections during the study period: At the end of 1998, the number of gonorrhea cases per 100000 population reported by Atlanta, 774.9, was >3 times that reported by Houston (228.8) and >4 times that reported by New York City (164.8).34 These differences persisted throughout the study period.35 The proportion of study participants who received a diagnosis of C trachomatis genital infection did not vary as much by city as did gonorrhea, again consistent with rates reported for the general population.36
The classification of physical findings also differed significantly by study site (Table 3). A greater proportion of participants in Texas received a diagnosis of “clear evidence” of blunt force or penetrating anogenital trauma as compared with the other study sites. All participants were examined by pediatricians with specific expertise in child sexual abuse or nurse practitioners working under the supervision of a pediatric expert using the guidelines of Adams et al29 for the classification of anogenital findings. The higher proportion of children with physical findings of trauma in Texas likely reflects the relative predominance at that site of older children and children's making their own disclosures of sexual contact, because more verbally developed children are more likely to provide clear, detailed information; however, we cannot rule out the possibility that examiners may have applied screening guidelines or the criteria of Adams et al differently, because steps to measure interrater reliability between sites were not taken. The American Academy of Pediatrics and CDC screening guidelines leave considerable room for examiner judgment to determine when STI testing is warranted, of necessity, given that many young children are either unable or unwilling to provide detailed accounts of molestation. More than half of the children in our study did not provide a clear disclosure.
Another limitation of our study is that information concerning children who were eligible for study participation but did not enroll was not available for all study sites, raising the possibility of a selection bias. Given that all age and ethnic groups were represented in the study population and that the reasons for STI testing among them were varied, it is not possible to predict the direction in which a possible bias may have influenced our results. Also, changes in expert consensus concerning interpretations of physical findings in sexually abused children since the publication of the 1992 guidelines used in this study may have resulted in the classification of some children with more evidence of penetrating anogenital trauma than would be designated today. For instance, previous references to “enlarged hymenal opening” and “wearing away of the hymen” as indicative of trauma have been removed on the basis of the findings of more recent investigations and expert surveys.29,37,38
Despite the small number of male participants, the lower risk for STI infection among boys versus girls was statistically significant. Penetrative sexual abuse in male children is typically anal or pharyngeal39; having the male victim genitally penetrate the perpetrator may be considerably less common. As such, the use of NAATs exclusively in genital or urine specimens and not in pharyngeal or anorectal specimens would have been less likely to detect STIs in male participants.
Only 1 of 5 children with a positive culture for HSV-2 also had corresponding positive HSV-2 serology. The HSV-2 seronegative status of the other 4 children is consistent with the clinical presentation of the first episode of genital herpes, which usually occurs within days after sexual acquisition of HSV-2 infection but weeks before the appearance of antibody to HSV-2.11,40 The 6 children who had antibody to HSV-2 but did not have genital lesions may represent previous infection. Three girls had antibody to both HSV-1 and HSV-2; it is possible that preexisting antibodies from a previous HSV-1 infection in these children resulted in a milder and unnoticed episode of primary herpes as a result of a cross-protective immune response.41
An important result of our investigation was the proportion of children who were infected with an STI and had normal or nonspecific findings. Vaginal discharge was classified as a “nonspecific” finding, and girls with vaginal discharge were significantly more likely to have an STI than others; however, 10 girls with normal examinations also received a diagnosis of an STI, 1 of whom tested positive for gonorrhea by both culture and confirmed NAAT. A positive test for gonorrhea in a child with normal examination findings was unanticipated from previous studies, which found gonorrhea primarily in symptomatic girls.12–14
This study is the first to describe the epidemiology of STIs in sexually abused children using both NAATs and traditional laboratory tests. Our results demonstrate that the prevalence of STIs among sexually abused children in the United States is low, even when highly sensitive NAAT detection methods are used. The low prevalence and the potential implications of a positive test warrant confirmation of positive STI tests in this population.20,30 Genital STIs are far more common in female abused children than in male counterparts. Most cases of gonorrhea, C trachomatis, and HSV-2 infection occur among girls with nonspecific or absent physical findings.
Funding for this project was provided by the Centers for Disease Control and Prevention Office of Women's Health, Cooperative Agreement Nos. US6/CCU417921-01, US6CCU617918-01, and US6/CCU217922-01, and by the National Center for Infectious Diseases Office of Minority and Women's Health.
- Accepted February 9, 2009.
- Address correspondence to Rebecca G. Girardet, MD, University of Texas-Houston Medical School, 6410 Fannin St, Suite 1425, Houston, TX 77030. E-mail:
The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the funding agency. Brand names are used for informational purposes only and should not be considered as endorsements by the Centers for Disease Control and Prevention or the Department of Health and Human Services.
Financial Disclosure: The authors have indicated they have no financial relationships relevant to this article to disclose. Ms Driebe's current affiliation is TGen North, Translational Genomics Research Institute, Flagstaff, AZ. Dr Sautter's current affiliation is Carolinas Pathology Group, Carolinas Laboratory Network, Carolinas Medical Center, Charlotte, NC.
What's Known on This Subject:
Previous reports of STIs in sexually abused children have reported low prevalence rates. Low detection rates for some STIs in sexually assaulted children are in part attributable to the limited performance of some diagnostic tests.
What This Study Adds:
This report describes a multicenter investigation of the epidemiology of STIs in children who present for sexual abuse, using both standard diagnostic methods and nucleic amplification tests.
- ↵Hussey JM, Chang JJ, Kotch JB. Child maltreatment in the United States: prevalence, risk factors, and adolescent health consequences. Pediatrics.2006;118 (3):933– 942
- ↵Finkelhor D, Dzuiba-Leatherman J. Children as victims of violence: a national survey. Pediatrics.1994;94 (4 pt 1):413– 420
- ↵Siegel JM, Sorenson SB, Golding JM, Burnam MA, Stein JA. The prevalence of childhood sexual assault: the Los Angeles Epidemiologic Catchment Area Project. Am J Epidemiol.1987;126 (6):1141– 1152
- Robinson AJ, Watkeys JE, Ridgway GL. Sexually transmitted organisms in sexually abused children. Arch Dis Child.1998;79 (4):356– 358
- ↵Kellogg N; American Academy of Pediatrics Committee on Child Abuse and Neglect. The evaluation of sexual abuse in children. Pediatrics.2005;116 (2):506– 512
- ↵Guidelines for the evaluation of sexual abuse of children: subject review. American Academy of Pediatrics Committee on Child Abuse and Neglect [published correction appears in Pediatrics. 1999;103(5 pt 1):1049]. Pediatrics.1999;103 (5 pt 1):186– 191
- ↵Siegel R, Schubert CJ, Myers P, 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 (6):1090– 1094
- Ingram DM, Miller WC, Schoenbach VJ, et al. Risk assessment for gonococcal and chlamydial infections in young children undergoing evaluation for sexual abuse. Pediatrics.2001;107 (5). Available at: www.pediatrics.org/cgi/content/full/107/5/e73
- ↵Ingram DL, Everett D, Flick LA, Russell TA, White-Sims ST. Vaginal gonococcal cultures in sexual abuse evaluations: evaluation of selective criteria for preteenaged girls. Pediatrics.1997;99 (6). Available at: www.pediatrics.org/cgi/content/full/99/6/e8
- ↵American Academy of Pediatrics Committee on Child Abuse and Neglect: Guidelines for the evaluation of sexual abuse of children. Pediatrics.1991;87 (2):254– 260
- ↵Black CM. Current methods for the diagnosis of Chlamydia trachomatis infections. Clin Microbiol Rev.1997;10 (1):160– 184
- ↵Girardet RG, McClain N, Lahoti S, Cheung K, Hartwell B, McNeese M. Comparison of the urine-based ligase chain reaction test to culture for detection of Chlamydia trachomatis and Neisseria gonorrhoeae in pediatric sexual abuse victims. Pediatr Infect Dis J.2001;20 (2):144– 147
- Kellogg ND, Baillargeon J, Lukefahr JL, Lawless K, Menard SW. Comparison of nucleic acid amplification tests and culture techniques in the detection of Neisseria gonorrhoeae and Chlamydia trachomatis in victims of suspected child sexual abuse. J Pediatr Adolesc Gynecol.2004;17 (5):331– 339
- ↵Embree JE, Lindsay D, Williams T, Peeling RW, Wood S, Morris M. Acceptability and usefulness of vaginal washes in premenarcheal girls as a diagnostic procedure for sexually transmitted diseases. The Child Protection Centre at the Winnipeg Children's Hospital. Pediatr Infect Dis J. 1996;15 (8):662– 667
- ↵Black CM, Driebe EM, Howard LA, et al. Multicenter study of nucleic acid amplification tests for detection of Chlamydia trachomatis and Neisseria gonorrhoeae in children being evaluated for sexual abuse. Pediatr Infect Dis J.2009 (in press)
- ↵Dean AG, Arner TG, Sangam S. EpiInfo 2000: A Database and Statistics Program for Public Health Professionals for Use on Windows 95, 98, NT, and 2000 Computers. Atlanta, GA: Centers for Disease Control and Prevention; 2000
- ↵Centers for Disease Control and Prevention. Trends in reportable sexually transmitted diseases in the United States, 2006. Available at: www.cdc.gov/std/stats06/pdf/trends2006.pdf. Accessed July 2, 2008
- ↵Centers for Disease Control and Prevention. Division of STD Prevention. Sexually Transmitted Disease Surveillance, 1998. Department of Health and Human Services, Atlanta, GA: US Department of Health and Human Services, September 1999. Available at: www.cdc.gov/std/stats98/98pdf/surv98.pdf. Accessed July 2, 2008
- ↵Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2004. Atlanta, GA: US Department of Health and Human Services; September 2005
- ↵Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2003. Atlanta, GA: US Department of Health and Human Services, September 2004. Available at: www.cdc.gov/std/stats03/tables/table8.htm. Accessed June 4, 2008
- ↵Adams JA. Evolution of a classification scale: medical evaluation of suspected child sexual abuse. Child Maltreat.2001;6 (1):31– 36
- ↵American Academy of Pediatrics. Herpes simplex. In: Pickering LK, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006:361–364
- Copyright © 2009 by the American Academy of Pediatrics