Case 2: Green vaginal discharge in a 7-year-old girl

A seven-year-old girl accompanied by her mother presents to your community clinic with a three-day history of green vaginal discharge. She reports no other symptoms. You perform a full history and physical examination, including inspection of the external genitalia. The genital examination is entirely normal. A swab of the discharge is sent for culture and comes back positive for Neisseria gonorrhoeae. You discuss the findings and the possibility of sexual transmission with the patient’s mother, who has no concerns of sexual abuse. You report the findings to public health and the local child welfare agency. Joint investigation by child welfare and the police is inconclusive (the child denies any inappropriate sexual contact). You treat her infection and screen for other sexually transmitted infections (STIs) including chlamydia, hepatitis, syphilis and HIV. At a follow-up visit, the mother asks if she can speak with you in private. She says she doesn’t believe that anything has happened to her daughter because she seems fine. On further questioning, however, she does report that her daughter has recently had a few episodes of crying out in the night. How would you counsel this mother and child?

CASE 2 DIAGNOSIS:

Interpretation of the case and counselling of the mother

Most genital examinations in children who have been sexually abused are normal because inappropriate genital contact may occur without causing injury, and those injuries that do occur heal quickly and without residual scarring (1). A normal examination, therefore, does not rule out the possibility of sexual abuse. It is important to explain to this mother and the child welfare workers that gonorrhea infection is strongly indicative of sexual abuse, despite the lack of disclosure by the child. All potential contacts should be tested for STIs.

Vaginal cultures are recommended for STI testing in prepubertal children. If cultures are unavailable, nucleic acid amplification tests (NAAT) may be used. Positive tests should be confirmed using culture or a second type of NAAT test.

Delayed disclosure is extremely common in children who have been sexually abused, with nondisclosure continuing into adulthood in many victims. Factors associated with delayed disclosure include increasing age, familiarity with the perpetrator, severity and number of abusive events, and parental fear or shame (2). The majority of childhood sexual abuse is intrafamilial. Children who do disclose most commonly tell friends or adults other than their parents (2). In the present case, the mother should be assured of the normalcy of this response and encouraged to continue to support her daughter.

Following sexual abuse, children are often initially asymptomatic. Potential adverse consequences include substance abuse, poor school performance, headaches, asthma, gastrointestinal disturbances, post-traumatic stress disorder (PTSD) and other mental illnesses (3). Symptoms of trauma include flashbacks, insomnia, inability to focus and avoidance of triggers (3). Screening tools, such as the University of California at Los Angeles PTSD Reaction Index, can be administered quickly in the office setting (3). It is important to inform parents that the effect of abuse on children is variable, and is dependent on age and development, and may change over time. In the present case, the crying out in the night may be a trauma symptom. Management includes educating the family about symptoms, teaching relaxation techniques to cope with arousal symptoms and promoting mental health treatment processes (3). Community health providers may seek training in treatment models effective for PTSD management such as cognitive behavioural therapy.

Discussion with the parent(s) should not take place in front of the child. Repeated questioning of the child by the parent should be discouraged. The parent(s) require significant support to cope with the impact of the disclosure on themselves, the child and the family. Maintaining normal routines and being supportive of the child are of the greatest importance. It is critical to help the non-offending parent(s) to understand that their response contributes significantly to how the child will cope with sexual abuse, and is a primary predictor of the child’s prognosis. Referral of the parent to a social worker, psychologist or other mental health specialist might help a parent who is struggling (2).

By playing a trusting role in a child’s life, paediatricians are ideally suited to respond to the disclosure of a traumatic event and provide supportive care (3). The paediatrician’s response to what has happened can impact the child’s and parents’ perception of the event. Questioning of the child to elicit a history of the event should be left to child welfare and the police, unless it is necessary for medical treatment. If the child discloses information, responding in a calm, supportive, reassuring and nonjudgmental manner is recommended. The paediatrician’s role includes follow-up and monitoring for health problems and PTSD symptoms. Any subsequent disclosures to the paediatrician must be reported to child welfare. Referrals to other health care professionals for psychosocial support should be initiated as needed (3).

CLINICAL PEARLS

• Nondisclosure or delayed disclosure of childhood sexual abuse is common.

• A normal genital examination does not rule out the possibility of sexual abuse.

• Gonorrhea is considered to be diagnostic for sexual abuse in prepubertal children outside of the newborn transmission period.

• Children who have been sexually abused may have no behavioural or emotional symptoms, although they are at risk for a variety of post-traumatic adverse effects.

• The paediatrician’s role includes educating the parent(s) about the range of effects of abuse on children, the importance of providing a believing and supportive response to their child, monitoring the child’s health, reporting to child welfare and public health, and referring to mental health services when appropriate.