Sexually transmitted infections and child sexual abuse — formative SAQs

SAQ 1 — Interpreting an STI in a prepubertal child (10 marks)

A four-year-old girl presents with vaginal discharge. A vaginal NAAT returns positive for Neisseria gonorrhoeae. There is no disclosure of contact and the examination is non-specific. [1]

Questions

1. How do you grade gonococcal infection in this child as evidence of sexual contact, and which non-sexual routes must you exclude? (4 marks) [1] [6]
2. Outline your targeted history and examination approach, including consent, chaperone and documentation. (3 marks) [1] [2]
3. What is your safety and reporting response, and why does a non-specific examination not exclude abuse? (3 marks) [2] [8]

Model answer

Grading and exclusion (4). Gonococcal infection at a non-conjunctival site in a prepubertal child beyond the neonatal period is a strong marker of sexual contact. The competing route is perinatal acquisition, but persistence of perinatal gonorrhoea beyond infancy is uncommon, making sexual contact the most plausible explanation here — contrast with chlamydia, where perinatal persistence for two to three years materially changes interpretation. The result is graded forensic evidence, not a routine infection, and it is read alongside age, site, perinatal history and examination. [1] [6]

History and examination (3). Take a trauma-informed, child-led history without interrogation, capturing perinatal and maternal history, immunisation status, and bleeding disorder context; the detailed forensic interview belongs to trained child-protection interviewers. Examine in a trained setting with consent and a chaperone, using a colposcope and photo-documentation, and record findings against established normal variants. Document contemporaneously with factual, non-leading, time-stamped notes and chain of custody. [1] [2]

Safety and reporting (3). Make the child-protection notification your jurisdiction requires; do not discharge the child into danger while awaiting results. A normal or non-specific examination is found in most substantiated cases, because healing is rapid and many acts leave no visible mark, so a non-specific exam never overrides a strong-marker STI. Coordinate multidisciplinary follow-up including trauma-informed psychological care, given the long-term mental-health associations of childhood sexual abuse. [2] [8]

SAQ 2 — Acute assault, the evidence window and prophylaxis (10 marks)

A 14-year-old discloses a single episode of vaginal rape eight hours ago by a known contact whose HIV status is unknown. She is distressed but physiologically stable. [7]

Questions

1. Outline your immediate safety and forensic response, including evidence preservation and the timing of sample collection. (4 marks) [7] [4]
2. Describe your HIV post-exposure prophylaxis and STI prophylaxis reasoning, and what else you offer this adolescent. (4 marks) [5] [3]
3. How do you frame confidentiality, and what is your follow-up plan? (2 marks) [2] [8]

Model answer

Immediate safety and forensic (4). Confirm she is safe now and address acute distress and suicidality. Preserve evidence: advise against washing, bathing or changing clothing, and retain any clothing. Collect forensic samples within the evidence window, because forensic yield concentrates in the early hours after assault in prepubertal and adolescent victims, although DNA may recover beyond 24 hours in selected cases. Examine in a trained setting with consent, chaperone and photo-documentation, and maintain chain of custody. Notify child protection per local law and do not discharge into danger. [7] [4]

Prophylaxis (4). Assess HIV post-exposure prophylaxis against source HIV status, exposure type and time since contact; at eight hours she is well within the window where PEP is considered, and the unknown source status pushes toward offering it per local protocol. Provide STI prophylaxis per the CDC STI Treatment Guidelines sexual-assault regimen, update hepatitis B vaccination where indicated, and offer emergency contraception because she is post-menarchal. Confirm exact regimens, windows and weight-based doses from local protocol and product information. [5] [3]

Confidentiality and follow-up (2). Frame confidentiality with its safety limits: what she says stays private unless there is a serious risk of harm to her or others, abuse or exploitation, or a legal duty — and plan any override with her as far as possible. Schedule window-period re-testing and serology at the intervals local protocol sets, and arrange trauma-informed psychological follow-up with a named contact so she is not lost between services. [2] [8]