Canadian Guidelines on Sexually Transmitted Infections

Supplementary statement for the management and follow-up of sexual abuse in peripubertal and prepubertal children

October 2014

Key Issue

The Gonococcal Infections chapter has been revised in response to emerging antimicrobial resistance. As a result, the 2010 print and online versions of the Sexual Abuse in Peripubertal and Prepubertal Children chapter of the Canadian Guidelines on Sexually Transmitted Infections are currently under review.

This statement is intended to provide clinicians with high level interim guidance to highlight key changes to screening, management and follow-up of sexually transmitted infections (STI) in cases of suspected or confirmed sexual abuse until such time as updated guidance is available.

Age of Consent to Sexual Activity in Canada

  • Clinicians should refer to the Department of Justice website for information on age of consent in Canada and related exceptions.

Reporting Requirements

  • Every province and territory has statutes in place that require the reporting of child abuse. Although the exact requirements may differ by province/territory, health care professionals should be aware of local reporting requirements and procedures with respect to child abuse and other acts of maltreatment. If reasonable cause to suspect child abuse exists, local child protection services and/or law enforcement agencies must be contacted promptly.

Assessment and Follow-up Recommendations

  • Assessment and follow-up of children who are suspected to be victims of sexual abuse should be carried out with great sensitivity and ideally with the direct involvement of experienced teams or services. When direct referral cannot be made (e.g., in remote areas), every effort should be made to consult with a pediatrician and/or STI expert for guidance on optimal STI specimen collection and prophylactic treatment of victims of sexual abuse. Local and provincial/territorial guidelines should be consulted where available.
  • Clinicians should also consult local or provincial/territorial public health authorities for information on the availability of Referral Centres for peripubertal and prepubertal children.
  • All specimens for forensic evidence should be collected by professionals experienced in these procedures, following established regional/local protocols.

Specimen collection considerations

  • For prepubertal children, testing should be performed if there is any reason to suspect acute or chronic sexual abuse. Clinicians should consult a pediatric specialist or an experienced colleague.
  • The following situations increase the likelihood of a child being exposed to or infected with a STI:
    • presence of symptoms or signs of an STI (e.g., vaginal discharge or pain, genital itching or odour, urinary symptoms, genital ulcers or lesions);
    • when a suspected assailant is known to have an STI or to be at risk for an STI;
    • another child or adult in the household is found to be infected with an STI;
    • when the prevalence of STIs in the community where the abuse occurred is high;
    • when there is physical evidence of genital, oral or anal penetration.
  • Clinicians should be aware that urine testing is the least invasive method for testing prepubertal children for gonorrhea and chlamydia.
  • If a positive NAAT test may be used for medico-legal purposes then this should be confirmed:
    • by sending the positive NAAT samples to another laboratory where a second set of primers would be used; consult with your local laboratory regarding the availability of such testing.
  • Although no NAATs are currently licenced in Canada to detect rectal or pharyngeal infections, individual laboratories may offer NAATs after in-house laboratory validation. Positive specimens need confirmation with culture or a second NAAT which uses an alternate target and has been validated for rectal or oral specimens.
  • Refer to Table 1 in the 2010 chapter for other potential specimen collection sites/serological testing for suspected cases of sexual abuse.

Prophylactic treatment considerations

  • Although the efficacy of antibiotic prophylaxis following sexual abuse has not been well studied, it is routinely recommended in situations where the abuse occurred within 48 hours or where there is a high likelihood of a child being exposed to or infected with a STI (see above). Prophylaxis should be undertaken in consultation with a pediatric specialist or an experienced colleague.
  • If post-exposure prophylaxis is indicated, clinicians should refer to Table 3 in the 2010 chapter for recommendations; for the treatment of gonorrhea, refer to the revised 2013 Gonococcal Infections chapter. Patients treated for gonorrhea should receive combination therapy in response to increasing antimicrobial resistance. This combination therapy also includes effective treatment for chlamydia. Treatment in children under the age of 9 is weight-based; in children 9 years of age or older it is the same as for adults.

Follow-up

  • When a child is diagnosed with an STI, all individuals who are named as suspects in the child sexual abuse investigation should be located and clinically evaluated.
  • Confirmed notifiable STIs should be reported to provincial/territorial authorities as appropriate.
  • Clinicians should consult the relevant chapters of the Guidelines for guidance on infection-specific management issues.
  • Clinicians should refer to the Follow-up section of the 2010 chapter for further suggested follow-up recommendations.
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