TREATMENT AND FOLLOW-UP: Sexual AbuseThe medical consequences of sexual abuse require the prophylaxis and treatment of sexual transmitted diseases, emergency contraception, and treatment of any injuries that resulted from the abuse. Children and adolescents with post-assault bleeding require an emergent evaluation for signs of shock and may need emergency treatment by a gynecologist for repair of genital injury. The psychosocial aspects of sexual abuse must also be addressed because appropriate therapeutic follow-up is essential to the child/adolescent's emotional well-being.
Routine prophylaxis for STDs is not generally recommended for sexually abused prepubertal children. The risk of a child acquiring an STD as the result of a sexual assault is low, and prepubertal females are at a lower risk of ascending infections than adolescents and adult women. Some children and their caregivers are concerned about the possibility of infection, and such concerns may be an appropriate indication for presumptive treatment. Initiate prophylaxis only after obtaining the appropriate cultures and diagnostic tests. For more information on diagnostic tests, see LABORATORY: Testing for Sexually Transmitted Diseases, Diagnostic Testing. Always consider prophylaxis for adolescent victims. Before providing antibiotic coverage for adolescents, determine if there is a pre-existing pregnancy. The most common infections are Chlamydia trachomatis, Neiserria gonorrhoea, trichomonas, bacterial vaginosis, Hepatitis B and C, and HIV. In providing prophylaxis for these infections, except Hepatitis B and C and HIV, treat as if the patient were infected. Hepatitis Viruses
The two vaccine-preventable hepatitis viruses, A (HAV) and B (HBV), may be sexually transmitted. Hepatitis A infection has an incubation period of four weeks. It is generally a self-limited disease and does not result in chronic infection. It can be transmitted by sexual contact. Possible fecal-oral contact as in oral sodomy raises the possibility of transmission and infection with HAV. Treatment of the virus is supportive care. HAV Immune Globulin is >85% effective in preventing hepatitis A when administered within two weeks of HAV exposure. The use of HAV vaccine alone is not recommended for post-exposure prophylaxis. Hepatitis B has an incubation period of six weeks to six months from time of exposure via sexual or other contact. Sexual transmission risk increases with a history of unprotected receptive anal intercourse. Treatment of acute HBV infection is supportive. Administer HBIG (Hepatitis B Immune Globulin) if the child/adolescent has not completed the HBV series. The recommended dose of HBIG for children and adults is 0.06 mL/kg. In addition, immunize unvaccinated children and adolescents and those whose previous hepatitis B immunization status is unknown or incomplete within 14 days of exposure. The series should be completed for the incompletely vaccinated child or adolescent. The recommended vaccine doses vary by product and age of recipient. Consider post-vaccination testing (anti-HBs), particularly if the exposure was to a known, chronic HBV carrier. Testing the perpetrator for HBV infection can be considered if it does not delay prophylaxis beyond 14 days. Fully vaccinated persons do not need HBIG or HBV vaccine after sexual assault or rape. The role of sexual activity in the transmission of Hepatitis C virus is controversial. At present there is no vaccine or prophylactic treatment. However, testing is recommended at three and six months post-exposure. Herpes Simplex Virus (HSV)
Presumptive treatment for HSV is generally not recommended. Most patients are not treated with systemic antivirals until the onset of symptoms. HIV
The potential of HIV transmission has been reduced by post-exposure prophylaxis. If a child/adolescent is at risk for HIV transmission from the sexual assault, discuss post-exposure prophylaxis with the caregiver, including the side effects of the treatment and its unknown efficacy in children who are post-assault. Consult a pediatric HIV specialist for recommended HIV post-exposure prophylaxis and treatment and coordinate follow-up with a local pediatric infectious disease center for HIV. See www.hivguidelines.org/ and follow the links for clinical education and then clinical education initiative programs for a list of these programs and contacts. For more information on HIV testing, see LABORATORY: HIV.
In all cases of suspected abuse, obtain appropriate diagnostic tests before giving treatment. It may be appropriate, however, to begin treatment before a definitive diagnosis is made. Adolescents have a greater risk of infection and complications than children, and presumptive treatment may be indicated. Prepubertal children without symptoms should not be treated unless an STD is diagnosed using a "gold standard." For patients requiring treatment, see the CDC website www.cdc.gov/std/treatment/ or the American Academy of Pediatrics Red Book.
Reporting to the State Central Register
When an STD is diagnosed in a child, sexual abuse must be considered and evaluated. Although there is some consensus regarding the certainty of abuse when an STD is diagnosed, the finding always warrants a suspicion of abuse and careful evaluation. In general, children under the age of 12 who have an STD should be reported to the State Central Register (1-800-635-1522) or local hotline. For more information, see DIAGNOSIS: Sexually Transmitted Diseases, The Likelihood of Sexual Transmission of Specific STDs table. When a parent is aware of the child/adolescent's STD but fails to take appropriate and timely steps to ensure medical treatment, there is reasonable cause to suspect maltreatment. This should be reported to the State Central Register. For more information about how to make a report, see REPORTING: How to Make a Report.
New York State Communicable Diseases Reporting Requirements
Reporting the presence of the STD to the local Health Department is different from reporting to the State Central Register. The NY State Sanitary Code (10NYCRR 2.1a) mandates reporting the following STDs to the local Department of Health:
After obtaining a negative ßhCG, offer pregnancy prevention. There are two dedicated products, Preven and Plan B, as well as contraceptive pills approved for emergency contraception. Pregnancy prevention may be offered any time after the assault, but is generally not effective beyond 120 hours. For maximum effectiveness, hormone medications should be taken as soon as possible after the sexual assault, optimally within 12 hours. Plan B is currently the recommended medication because of the lower incidence of gastrointestinal side effects and lower cost. For a descriptive list of options, see Emergency Contraceptive Pills, Appendix K. Obtain a follow-up ßhCG one to two weeks after treatment.
Every child/adolescent who is a victim of sexual abuse should have a follow-up appointment with either his/her own primary care physician or a child abuse specialist, regardless of documented injury or infection. For those without apparent injury or infection, this follow-up appointment and physical exam assures the child/adolescent and family that there is no permanent physical damage. Those with injuries and/or documented infection need close follow-up until the injury or disease has healed. Perform follow-up testing after an acute assault as described below and outlined in Post-Assault Testing and Treatment, Appendix A.