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STDs and Sexual Assault

Our courses fulfill continuing nursing education requirements in all 50 states. For more accreditation information, click here. Nurse practitioners may apply these contact hours to pharmacy continuing education and prescriptive authorization.

Wild Iris Medical Education has adapted the material for this course from guidelines published by the Centers for Disease Control and Prevention (CDC). The original material was published by the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Division of STD Prevention. The post test and learning objectives were prepared by Sharon A. Sanders, RN.

Sexually Transmitted Diseases Treatment Guidelines, 2006 was prepared for the CDC by Kimberly A. Workowski, MD, and Stuart M. Berman, MD. References may be viewed at http://www.cdc.gov/std/treatment/2006/rr5511.pdf.

These guidelines for the treatment of people who have sexually transmitted diseases (STDs) were developed by Centers for Disease Control and Prevention (CDC) after consultation with professionals knowledgeable in the field who met in Atlanta April 19–21, 2005. The information in this report updates the 2002 Sexually Transmitted Diseases Treatment Guidelines (CDC, 2002).

Included in these updated guidelines are:

• An expanded diagnostic evaluation for cervicitis and trichomoniasis
• New antimicrobial recommendations for trichomoniasis
• Additional data on the clinical efficacy of azithromycin for chlamydial infections in pregnancy
• Discussion of the role of Mycoplasma genitalium and trichomoniasis in urethritis/cervicitis with treatment-related implications
• Emergence of lymphogranuloma venereum proctocolitis among men who have sex with men (MSM)
• Expanded discussion of the criteria for spinal fluid examination to evaluate for neurosyphilis
• The emergence of azithromycin-resistant Treponema pallidum
• Increasing prevalence of quinolone-resistant Neisseria gonorrhoeae in MSM
• Revised discussion concerning the sexual transmission of hepatitis C
• Postexposure prophylaxis after sexual assault
• An expanded discussion of STD prevention approaches

Wild Iris Medical Education has divided this material into four courses: (1) STDs: detection, referral, and counseling; (2) STDs affecting the reproductive system; (3) STDs: hepatitis, proctitis, and ectoparasitic infections; and (4) STDs related to sexual assault.

ASSAULTS ON ADULTS AND ADOLESCENTS

This course focuses on the identification, prophylaxis, and treatment of STDs as well as the conditions commonly seen with such infections. Documentation of findings, collection of specimens for forensic purposes, and management of potential pregnancy or physical/psychological trauma are beyond the scope of this course. Survivors of sexual assault should be examined by an experienced clinician in a way that minimizes further trauma. Clinicians decide to obtain genital or other specimens for STD diagnosis on an individual basis.

Care systems for survivors should be designed to ensure continuity (including timely review of test results), support adherence, and monitor for adverse reactions to any therapeutic or prophylactic regimens prescribed at initial examination.

Laws in all fifty states strictly limit the use of a survivor's previous sexual history, including evidence of previously acquired STDs, to undermine the credibility of the survivor's testimony. Most states enforce evidentiary privilege against revealing any aspect of the examination or treatment. In unanticipated and exceptional situations, STD diagnoses may later be admitted, and so the survivor and clinician may opt to defer testing for this reason.

However, collection of specimens for laboratory diagnosis at initial examination gives the survivor and clinician the option to defer prophylactic treatment. Among sexually active adults, the identification of sexually transmitted infection after an assault might be more important for the psychological and medical management of the patient than for legal purposes because the infection could have been acquired before the assault.

Trichomoniasis, bacterial vaginosis (BV), gonorrhea, and chlamydia are the most frequently diagnosed infections among women who have been sexually assaulted. Because the prevalence of these infections is high among sexually active women, their presence after an assault does not necessarily signify acquisition during the assault. A post assault examination is, however, an opportunity to identify or prevent sexually transmitted infections, regardless of whether they were acquired during an assault. Chlamydial and gonococcal infections in women are of particular concern because of the possibility of ascending infection. In addition, HBV infection might be prevented by postexposure administration of hepatitis B vaccine. Reproductive-aged female survivors should be evaluated for pregnancy, if appropriate.

Evaluation for Sexually Transmitted Infections

INITIAL EXAMINATION

An initial examination should include the following procedures:

• Testing for N. gonorrhoeae and C. trachomatis from specimens collected from any sites of penetration or attempted penetration
• Culture or FDA-cleared nucleic acid amplification tests (NAAT) for either N. gonorrhoeae or C. trachomatis. NAAT offers the advantage of increased sensitivity in detection of C. trachomatis
• Wet mount and culture of a vaginal swab specimen for T. vaginalis infection. If vaginal discharge, malodor, or itching is evident, the wet mount also should be examined for evidence of BV and candidiasis
• Collection of a serum sample for immediate evaluation for HIV, hepatitis B, and syphilis

FOLLOWUP EXAMINATIONS

After the initial post-assault examination, followup examinations provide an opportunity to (1) detect new infections acquired during or after the assault; (2) complete hepatitis B immunization, if indicated; (3) complete counseling and treatment for other STDs; and (4) monitor side effects and adherence to postexposure prophylactic medication, if prescribed.

Examination for STDs should be repeated within 1 to 2 weeks of the assault. Because infectious agents acquired through assault might not have produced sufficient concentrations of organisms to result in positive test results initially, testing should be repeated during the followup visit unless prophylactic treatment was provided. If treatment was provided, testing should be conducted only if the patient reports having symptoms.

If treatment was not provided, followup examination should be conducted within 1week to ensure prompt discussion of positive test results so that treatment can begin. Serologic tests for syphilis and HIV should be repeated 6 weeks, 3 months, and 6 months after the assault if initial test results were negative and infection in the assailant could not be ruled out.

PROPHYLAXIS

Many specialists recommend routine preventive therapy after a sexual assault because followup of survivors of sexual assault can be problematic. The following prophylactic regimen is suggested as preventive therapy:

• Give hepatitis B vaccination, without HBIG, which should protect against HBV infection. The vaccine is administered to sexual assault survivors at the time of the initial examination if they have not been previously vaccinated. Followup doses of vaccine should be administered 1 to 2 and 4 to 6 months after the first dose.
• Institute an antimicrobial regimen for chlamydia, gonorrhea, trichomonas, and BV.
• Emergency contraception should be offered if the assault could result in pregnancy.

The efficacy of these regimens in preventing infections after sexual assault has not been evaluated. Clinicians should counsel patients regarding the possible benefits and toxicities associated with these treatment regimens; gastrointestinal side effects can occur with this combination. Providers might also consider anti-emetic medications, particularly if emergency contraception is provided.

OTHER CONSIDERATIONS

At the initial examination and if indicated at followup examinations, patients should be counseled regarding (1) symptoms of STDs and the need for immediate examination if symptoms occur, and (2) abstinence from sexual intercourse until treatment is completed.

Risk for Acquiring HIV Infection

HIV seroconversion has occurred in individuals whose only known risk factor was sexual assault or sexual abuse, but the frequency of this occurrence is probably low. In consensual sex, the risk for HIV transmission from vaginal intercourse is 0.1% to 0.2% and for receptive rectal intercourse, 0.5% to 3%. The risk for HIV transmission from oral sex is substantially lower.

Specific circumstances of an assault might increase risk for HIV transmission (eg, trauma, including bleeding) with vaginal, anal, or oral penetration; site of exposure to ejaculate; viral load in ejaculate; and the presence of an STD or genital lesions in the assailant or the survivor. Children might be at higher risk for transmission because child sexual abuse is frequently associated with multiple episodes of assault and might result in mucosal trauma (see below under Assault or Abuse of Children).

Postexposure therapy with zidovudine has been associated with a reduced risk for acquiring HIV in a study of healthcare workers who had percutaneous exposures to HIV-infected blood. On the basis of these results and the results of animal studies, postexposure prophylaxis (PEP) has been recommended for healthcare workers who have occupational exposures to HIV. These findings have been extrapolated to other types of HIV exposure, including sexual assault.

If HIV exposure has occurred, initiation of PEP as soon as possible after the exposure likely increases benefit. Although a definitive statement of benefit cannot be made regarding PEP after sexual assault, the possibility of HIV exposure from the assault should be assessed at the time of the post-assault examination. The possible benefit of PEP in preventing HIV infection also should be discussed with the assault survivor if risk exists for HIV exposure from the assault.

The likelihood of the assailant having HIV, any exposure characteristics that might increase the risk for HIV transmission, the time elapsed after the event, and potential benefits and risks from the PEP are all factors that impact its recommendation and impact the assault survivor's acceptance of it. Determination of assailant's HIV status at the time of the initial examination is usually impossible; therefore, the healthcare provider needs to assess any available information concerning HIV-risk behaviors of the assailant(s) (eg, MSM, use of injection-drugs or crack cocaine), local epidemiology of HIV/AIDS, and exposure characteristics of the assault.

When an assailant's HIV status is unknown, factors to consider in determining whether an increased risk for HIV transmission exists include:

• Whether vaginal or anal penetration occurred
• Whether ejaculation occurred on mucous membranes
• Whether multiple assailants were involved
• Whether mucosal lesions are present in the assailant or survivor
• Other characteristics of the assault, survivor, or assailant that might increase risk for HIV transmission.

When offering PEP, discuss with the patient the:

• Unproven benefit and known toxicities of antiretrovirals
• Close followup that will be necessary
• Benefit of adherence to recommended dosing
• Necessity of early treatment to optimize potential benefits (ie, as soon as possible after and up to 72 hours after the assault)

Providers should emphasize that PEP appears to be well-tolerated in both adults and children and that severe adverse effects are rare. Implement clinical management of the survivor as follows. If there was possible HIV exposure during the assault, consult a specialist on PEP regimens. The sooner PEP is initiated after the exposure, the higher the likelihood that it will prevent HIV transmission; however, distress after an assault may prevent the survivor from accurately weighing risks and benefits and making an informed decision to start PEP. If use of PEP is judged to be warranted, offer the survivor a 3- to 5-day supply of PEP and schedule a followup visit for additional counseling after several days.

ASSAULT OR ABUSE OF CHILDREN

Again, recommendations here are limited to the identification and treatment of STDs. Management of the psychosocial aspects of the sexual assault or abuse of children is beyond the scope of this course.

The identification of sexually transmissible agents in children beyond the neonatal period suggests sexual abuse. Significance of the identification in such children as evidence of sexual abuse varies by pathogen. Postnatally acquired gonorrhea, syphilis, and nontransfusion-acquired HIV that was not perinatally acquired are usually diagnostic of sexual abuse. Suspect sexual abuse when genital herpes is present.

Investigation of sexual abuse among children who may have sexually transmitted infection is conducted by clinicians who have experience and training in the evaluation of child abuse, neglect, and assault. The social consequence of a sexually transmitted infection and the reporting of suspected sexual abuse varies by specific organism (see table below). In all cases in which a sexually transmitted (ST) infection has been diagnosed in a child, healthcare professionals must look for evidence of sexual abuse; this includes diagnostic testing for sexually associated (SA) infections.

IMPLICATIONS OF ST OR SA INFECTIONS IN CHILDREN

ST/SA confirmed	Evidence for sexual abuse	Suggested action
Gonorrhea*	Diagnostic**	Report †
Syphilis*	Diagnostic	Report †
Human immunodeficiency virus ††	Diagnostic	Report †
Chlamydia trachomatis*	Diagnostic**	Report †
Trichomonas vaginalis	Highly suspicious	Report †
Condylomata acuminata (anogenital warts)*	Suspicious	Report †
Genital herpes*	Suspicious	Report † unless a clear history of autoinoculation is evident
Bacterial vaginosis	Inconclusive	Medical followup
* If not likely to be perinatally acquired and rare nonsexual vertical transmission is excluded. ** Although culture is the gold standard, current studies are investigating the use of NAAT as an alternative diagnostic method. † Report to the agency mandated to receive reports of suspected child abuse. †† If not likely to be acquired perinatally or through transfusion. Source: Adapted from Kellogg, 2005.

The general rule that sexually transmissible infections beyond the neonatal period are evidence of sexual abuse has exceptions. For example, rectal or genital infection with C. trachomatis among young children might be the result of perinatally acquired infection and has, in some cases, persisted for as long as 2 to 3 years. Genital warts have been diagnosed in children who have been sexually abused, but also in children who have no other evidence of sexual abuse. Bacterial vaginosis has been diagnosed in children who have been abused, but its presence alone does not prove sexual abuse. The majority of HBV infections in children result from household exposure to individuals who have chronic HBV infection.

The possibility of sexual abuse should be strongly considered if no conclusive explanation for nonsexual transmission of an STD can be identified. When the only evidence of sexual abuse is the isolation of an organism or the detection of antibodies to a sexually transmissible agent, clinicians must confirm the findings and consider the implications carefully.

Evaluating Children for STDs

Examinations of children for sexual assault or abuse should be designed to minimize pain and trauma. Collection of vaginal specimens in prepubertal children can be very uncomfortable and should be performed by an experienced clinician to avoid psychological and physical trauma. The decision to obtain genital or other specimens from a child in order to conduct an STD evaluation must be made on an individual basis. The following situations involve a high risk for STDs and constitute a strong indication for testing:

• The child has or has had symptoms or signs of an STD or of an infection that can be sexually transmitted, even in the absence of suspicion of sexual abuse. Among the signs that are associated with a confirmed STD diagnosis are vaginal discharge or pain, genital itching or odor, urinary symptoms, and genital ulcers or lesions.
• A suspected assailant is known to have an STD or to be at high risk for STDs (eg, has multiple sex partners or a history of STDs).
• A sibling or another child or adult in the household or child's immediate environment has an STD.
• The patient or parent requests testing.
• Evidence of genital, oral, or anal penetration or ejaculation is present.

If a child has symptoms, signs, or evidence of an infection that might be sexually transmitted, the child should be tested for other common STDs before initiating any treatment that could interfere with the diagnosis of those other STDs. Because of the legal and psychosocial consequences of a false-positive diagnosis, choose tests with high specificities. The potential benefit to the child of a reliable diagnosis of an STD justifies deferring treatment until specimens for highly specific tests are obtained by providers with experience in evaluating sexually abused and assaulted children.

The scheduling of an examination should depend on the history of assault or abuse. If the initial exposure was recent, the infectious agents acquired through the exposure might not have produced sufficient concentrations of organisms to result in positive test results. A followup visit 2 weeks after the most recent sexual exposure may include a repeat physical examination and collection of additional specimens.

To allow sufficient time for antibodies to develop, another followup visit 12 weeks after the most recent sexual exposure may be necessary to collect sera. A single examination might be sufficient if the child was abused for an extended period and if the last suspected episode of abuse occurred substantially before the child received medical evaluation.

The following recommendations for scheduling examinations serve as a general guide. The exact timing and nature of followup examinations should be determined on an individual basis and performed to minimize the possibility for psychological trauma and social stigma. Compliance with followup appointments may be improved with involvement of law enforcement personnel or child protective services.

Initial and Two-Week Followup Examinations

The initial examination and two-week followup (if indicated) include the following.

Inspect the genital, perianal, and oral areas for genital discharge, odor, bleeding, irritation, warts, and ulcerative lesions. Clinical manifestations of some STDs are different in children than in adults. For example, typical vesicular lesions might not be seen in the presence of HSV infection. Because this infection is suspicious for sexual abuse, specimens should be obtained from all vesicular or ulcerative genital or perianal lesions compatible with genital herpes and sent for viral culture.

Collect specimens for culture for N. gonorrhoeae from the pharynx and anus in both boys and girls, the vagina in girls, and the urethra in boys. Cervical specimens are not recommended for prepubertal girls. For boys with a urethral discharge, a meatal specimen is an adequate substitute for an intraurethral swab.

Use only standard culture systems for the isolation of N. gonorrhoeae. All presumptive isolates of N. gonorrhoeae should be confirmed by at least two tests that involve different principles (ie, biochemical, enzyme substrate, serologic, or nucleic acid hybridization test methods). Isolates and specimens should be retained or preserved in case additional or repeated testing is needed. Gram stains are inadequate to evaluate prepubertal children for gonorrhea.

Collect specimens for culture for C. trachomatis from the anus in both boys and girls and from the vagina in girls. Some data suggest that the likelihood of recovering C. trachomatis from the urethra of prepubertal boys is too low to justify the trauma involved in obtaining an intraurethral specimen. However, a meatal specimen should be obtained if urethral discharge is present.

Pharyngeal specimens for C. trachomatis are not recommended for children of either sex because the yield is low, perinatally acquired infection might persist beyond infancy, and culture systems in some laboratories do not distinguish between C. trachomatis and C. pneumoniae. Only standard culture systems for the isolation of C. trachomatis should be used.

Confirm isolation of C. trachomatis by microscopic identification of inclusions by staining with fluorescein-conjugated monoclonal antibody specific for C. trachomatis; EIAs are not acceptable confirmatory methods. Isolates should be preserved. Nonculture tests for chlamydia (eg, nonamplified probes, EIAs, and DFA) are not sufficiently specific for use in circumstances involving possible child abuse or assault.

Data are insufficient about the usefulness of NAAT in evaluating children who may have been sexually abused, but these tests might be an alternative if confirmation is available and culture systems for C. trachomatis are unavailable. Confirmation tests should consist of a second FDA-cleared NAAT that targets a different sequence from the initial test.

Collect specimens for culture and wet mount of a vaginal swab specimen for T. vaginalis infection and BV.

Collect serum samples to be evaluated immediately, preserved for subsequent analysis, and used as a baseline for comparison with followup serologic tests. Sera should be tested immediately for antibodies to sexually transmitted agents. Agents for which suitable tests are available include T. pallidum, HIV, and HBV. Decisions regarding which agents to use for serologic tests should be made case by case.

HIV infection has been reported in children whose only known risk factor was sexual abuse. Serologic testing for HIV infection should be considered for abused children. The decision to test for HIV infection is made case by case, depending on the likelihood of assailant infection. Data are insufficient concerning the efficacy and safety of PEP among both children and adults. However, antiretroviral treatment is well-tolerated by infants and children with and without HIV infection. In addition, children who receive such treatment have a minimal risk for serious adverse reactions because of the short period recommended for prophylaxis.

In deciding whether to offer antiretroviral PEP, healthcare professionals should consider whether the child can be treated soon after the sexual exposure (ie, within 72 hours), the likelihood that the assailant is at risk for HIV infection, and the likelihood of high compliance with the prophylactic regimen. The potential benefit of treating a sexually abused child should be weighed against the risk for adverse reactions. If antiretroviral PEP is being considered, a professional specializing in HIV-infected children should be consulted.

Followup Examination After Assault

When transmission of syphilis, HIV, or hepatitis B is a concern but baseline tests are negative, an examination approximately 6 weeks, 3 months, and 6 months after the last suspected sexual exposure is recommended to allow time for antibodies to infectious agents to develop. In addition, results of HBsAg testing must be interpreted carefully, because HBV can be transmitted nonsexually. Decisions regarding which tests should be performed are made on an individual basis.

Presumptive Treatment

The risk of a child's acquiring an STD 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 (1) the incidence of the majority of STDs in children is low after abuse/assault, (2) prepubertal girls appear to be at lower risk for ascending infection than adolescent or adult women, and (3) regular followup of children usually can be ensured. However, some children or their parent(s) or guardian(s) might be concerned about the possibility of infection with an STD, even if the risk is perceived to be low by the healthcare provider. Such concerns might be an appropriate indication for presumptive treatment in some settings and may be considered after all relevant specimens have been collected.

Reporting Child Abuse or Assault

States and territories of the United States have laws that require reporting child abuse. Although the requirements differ by state, when there is reasonable cause to suspect child abuse, the healthcare provider must report it. Contact your state or local child protection agency to determine child abuse reporting requirements in your area.

ILLITERACY AND HEALTH

Illiteracy is often silent, yet it is a potentially deadly problem in healthcare. In a field where vocabulary is unfamiliar to many and information is often presented at the college level (despite the fact that the average American reads at the eighth-grade level!) a client who has difficulty reading or calculating numbers is at a terrible disadvantage when it comes to understanding what they need to be healthy (Marcus, 2006).

A client's language difficulties, which may range from poor skills to no skills, may be the result of:

• Never having acquired reading and calculating skills
• Having had them but lost them due to an illness or accident
• Possessing them only in another language

The problem is frequently made worse by the shame and embarrassment that research has shown often accompanies illiteracy. It is a situation requiring tact and understanding on the part of healthcare staff (Marcus, 2006).

All clients benefit when healthcare providers:

• Develop an awareness of signs that may indicate a patient cannot read
• Learn simple tests to quietly confirm that suspicion
• Work out alternative methods to convey medical information

The lack of reading or calculating skills should be considered in when a client is noncompliant, and staff should be alert when clients repeatedly say they cannot fill out a form because they "forgot their reading glasses" or "have a headache." Once aware of a possible problem, diagnostic techniques can be as simple as handing a client an instruction sheet upside down and asking them to read it out loud, watching to see if they turn it right side up before they begin (Ratnayake, 2006).

Alternative methods for delivering information requires adapting the information to the needs of clients. Be aware that even simple pictures do not always have shared meanings. Healthcare providers need to familiarize themselves with the literature on the subject and the resources that are currently available. For example, Medlineplus, an online medical information provider, includes over 160 strictly audio/video presentations on common illnesses, tests, and procedures (Doyle, 2003).

Remember too that office staff are often in a position to notice any problems clients may have with forms (Marcus, 2006). Be sure to share your knowledge!

Posted November 10, 2006

Expires December 1, 2008

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