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Genital herpes in a prepubertal child presents a child protection clinician with a difficult problem: how likely is it that transmission occurred as a consequence of sexual abuse? Published guidelines on the management of sexually transmitted infections in children provide varying recommendations and refer to a limited literature.
To review the evidence for the likelihood of sexual transmission in a child with proven genital herpes.
Structured literature search for reports of series of children presenting with genital herpes where an assessment for possible sexual transmission or child sexual abuse had been made.
Five suitable papers were identified. Although just over half of reported cases of genital herpes in children had evidence suggestive of a sexual mode of transmission, the quality of assessment of possible sexual abuse was too weak to enable any reliable estimation of its likelihood. Sexual transmission is reported more commonly in older children (aged 5 years), in children presenting with genital lesions alone and where type 2 herpes simplex virus is isolated.
Child protection clinicians should be aware of the weakness of the evidence on the likelihood of sexual transmission of genital herpes in prepubertal children. The US guidance that child sexual abuse is “suspicious” reflects the evidence better than the UK guidance that it is “probable”. A larger, more up‐to‐date, methodologically sound, population based study is required.
Genital herpes in a child not sufficiently mature to engage in consensual sexual activity, proven with culture of herpes simplex virus (HSV), raises the question of whether sexual abuse may have been the mode of transmission. In most cases some form of multidisciplinary child protection investigation will be required. An essential medical contribution is to advise on the likelihood that the infection is sexually transmitted or whether transmission is possible by other means.
There is little evidence on which to base such advice. Culture and typing of the virus is important as rarely other genital lesions can be mistaken for herpes simplex. HSV type 2 in adults is strongly suggestive of sexual transmission, but we do not know whether this also holds true in children, and in the UK the majority of genital herpes infections are type 1 anyway.1
Published guidelines on the management of sexually transmitted infections in children in the United Kingdom stress sexual abuse is a “probable” mode of transmission for genital herpes,2 that is, an intermediate risk for sexual abuse between “possible” and “highly probable”. However, this recommendation is derived from an earlier publication from the Royal College of Physicians in which there is inconsistency between the summary conclusion that sexual transmission is “probable” and the text which describes uncertainty in knowledge about modes of transmission.3 In the US, guidance from the American Academy of Pediatrics4,5 and the Centers for Disease Control and Prevention6 both state that sexual transmission is “suspicious” and describe other possible modes. The primary evidence is rarely cited and where it is, seems to depend largely on a single paper from 1968 reporting six cases.7 We have searched for and reviewed the evidence for the likelihood that transmission has occurred through sexual abuse for a child with proven genital herpes.
Studies were identified in early 2004 and updated in November 2005. Medline (1966–2005), CINAHL (1982–2005) and Embase (1980–2005) were the primary databases searched. Search terms included combinations of herpes simplex, genital, child, sex*, transmi*, abuse, incest, and rape. Using the search terms (herpes simplex), child*, and genital, yielded 265 records. Using (sex* transmi*), child*, and herpes yielded 210 records. Using (child abuse) and (genital herpes) yielded 24 records. Using genital and herpes and (child* or sex*) and (abuse or incest or rape) yielded 97 records. Using herpes and child* and genital yielded 380 records. In order to identify possible studies missed by our primary searches, we searched the social science database ASSIA (1975–2005) and the ISI Web of Science database using combinations of the above terms. We examined additional papers referenced by articles identified by the search strategy. No further relevant papers or studies were identified.
Papers were deemed suitable for review if they described children under 18 years of age presenting with genital herpes simplex where the population included prepubertal children and in whom an assessment for either sexual abuse or sexual transmission had taken place. We included cohort studies, case‐control studies, cross‐sectional incidence studies and case series. Data on cases could be collected prospectively or retrospectively, as long as there was an attempt at complete ascertainment from a population over a time period, and a description of the population was given. In addition, we reviewed papers describing series of children presenting with suspected child sexual abuse in whom genital herpes infection had been considered either clinically or by viral culture. We excluded single case reports and reports of multiple cases in which there was no evidence that all cases presenting over a period of time had been ascertained.
We assessed the quality of included papers in terms of the thoroughness and reliability of the diagnosis of HSV and in terms of the standards for evaluating the mode of transmission. Indicators of high quality HSV diagnosis included viral culture and typing on all cases. Less good, but still adequate was paired type specific sera. Poor quality was indicated by cytology only or no confirmatory investigation and less than complete investigation in all potential cases.1 Quality indicators for the assessment of mode of transmission were less easy to define. There is no gold standard for identifying child sexual abuse. We considered that reasonable standards should include a sensitive history, clinical genital examination, some form of social care assessment which may include information gathering and interviewing child and parent, and a multidisciplinary review of all this evidence. We assessed whether three components of this process (namely history, examination and social enquiry) were carried out and on what proportion of eligible cases. However, it was not possible to assess the depth, thoroughness or consistency of this process from the descriptions given in papers.
One author carried out the searches for abstracts, reviewed the abstracts and identified potential papers (YRE for the initial search, RR for the updated search). Both authors read the papers and selected papers for inclusion and exclusion by consensus. Disagreement was resolved by discussion. Assessment of quality was carried out initially by RR and agreed by discussion. Pre‐agreed forms to score abstracts for eligibility and papers for quality were not used in view of the variable (and generally poor) quality of the evidence.
Of the abstracts retrieved, 13 papers were suitable to be included in the review. Of these, eight papers included series of children presenting consecutively for child protection assessments.8,9,10,11,12,13,14,15 One of these included comparative data from non‐abused controls.12 The other five were series of children with genital herpes infections presenting consecutively either to paediatric departments in hospitals or sexually transmitted infection clinics.7,16,17,18,19
The results of the eight papers are shown in table 11.. The overall results suggest genital herpes is very uncommon in children being evaluated for sexual abuse (8/4117 children). In two of these eight cases no evidence for sexual abuse was found. The other six cases were from clinic populations in whom it was either explicitly stated or assumed that all children had been sexually abused. Hence, these data do not help address the likelihood of sexual transmission in cases of genital herpes because the numerator is heavily biased towards children who have been sexually abused.
Only the study by De Villiers et al routinely cultured samples from all cases for herpes virus. As the others cultured only when clinically indicated, and in some cases not at all, cases may have been missed. Most of the studies included adolescent children who may have been consensually sexually active as well as being abused. The clinical details and ages of the individual cases were often not described. Thus, although the prevalence of genital herpes in children who have been sexually abused is low, this may be over‐ or under‐estimated by the data presented here.
Our search strategy only identified papers where herpes had either been looked for or found. We are aware of other studies where sexually transmitted infections were sought among children being assessed for child sexual abuse but where no mention of herpes was made.20,21,22
We identified five studies of series of children presenting consecutively over a defined period with genital herpes (or who were part of larger clinical populations which would be reliably expected to include all children with genital herpes) in whom enquiries had been made about possible child sexual abuse (table 22).). AS two of these studies were from sexually transmitted infection clinics in India covering highly deprived populations including large groups of young adolescent boys involved in prostitution, it may not be appropriate to generalise the results to different populations. The other series are all small and old with poor quality diagnosis of sexual abuse. We identified one further paper from Chile which appeared to report on around 90 cases of children with genital herpes. However, as there was no information on mode of transmission and our attempts at contacting the authors were unsuccessful, this paper has been excluded from the review.23
Among the studies included, details of the type of history, the quality of physical examination, standards for assessing physical findings, and the extent and nature of further social investigations are scanty. It is clear that these were not investigated systematically in any of the studies. There is no information on which types of sexual contact (ie, genital–genital, oral–genital, hand–genital or anal contact) were considered. The description of the physical findings which were taken to indicate abuse would not be seen as adequate or appropriate now (eg, “hymen was noted to be perforated”7). The paper by Kaplan et al16 has the most thorough and consistent reported assessments. We have provided a description of each study in table 33.
The reported modes of transmission from these five studies is described in the right hand columns of table 22.. Because of the heterogeneity of populations, the age of the studies and the generally poor quality of methods, we have not included a summary meta‐analysis. Extreme caution should be used in interpreting these results, but with this caveat, sexual transmission has been reported more commonly when HSV type 2 has been isolated, in older age groups and when only genital lesions occur. Where both oral and genital lesions occur, especially if in a younger child, the suggestion is that either autoinoculation occurs in the context of a primary infection, or that intimate child care such as nappy changing by an infected adult occurs.
This review confirms the association of genital herpes in children with sexual contact. While a diagnosis of sexual abuse cannot be made on one finding alone, any case of genital herpes should usually result in a multidisciplinary child protection investigation. As part of this process, the child protection clinician will inevitably be asked about the likelihood of sexual transmission. In adults, genital herpes is thought to be transmitted sexually in almost all cases, either by an oro‐genital or a genito‐genital route.1 However, in adults genital herpes is common, sexual activity nearly ubiquitous, and difficult questions about how the infection was contracted can legitimately be answered by the fact that herpes can be clinically asymptomatic in either partner for long periods. In contrast, among children genital herpes is rare, there may be frequent non‐abusive contact with children's genitalia by adults during child care, and there is the theoretical possibility of autoinoculation from an oral lesion during a primary attack. Furthermore, clinically apparent genital herpes in a child may be the result of a primary attack years previously which may or may not have been sexually transmitted.
In this review, we have shown two main findings. First, genital herpes is rarely reported among children being assessed for possible, probable or known sexual abuse. However, few studies universally tested for herpes simplex, so we have no way of knowing how common asymptomatic infection may be. In a review of the transmission of infection after sexual abuse, Hammerschlag called for a large study using sensitive methods of virus identification and non‐abused controls.24
Second, among groups of children identified with genital herpes, it is suggested that sexual transmission occurs in just over half the cases (table 22).). However, this evidence is weak. The series are all small. The reliability of ascertainment of sexual abuse was variable and would not be accepted by current standards. In some studies only clinical history was taken and no reference was made to multidisciplinary social enquiries, while in others there seems an assumption that sexual transmission occurred unless there was convincing evidence otherwise. It is possible that there has been publication bias in favour of studies reporting an association between childhood genital herpes and sexual abuse. Therefore, the overall figure for the likelihood of sexual transmission could be either over‐ or underestimated.
The poor quality of this evidence means it is not possible to estimate the likelihood of sexual transmission in children presenting with genital herpes. This is a much weaker evidence base than that available for gonorrhoea for example, where larger series and a better understanding of the natural history of the disease mean we can be more certain it is sexually transmitted. The US guidance in this respect, reflects the evidence more reliably, where gonorrhoea is described as “highly suspicious” of sexual abuse, while genital herpes is “suspicious”.4,5,6 We propose that the current UK recommendation should be changed to “possible abuse”.
When genital herpes occurs in children, we support the view that a multi‐agency enquiry is required to exclude sexual abuse in the absence of another credible explanation. Both clinically and for research purposes, herpes should be included in any situation where a sexually transmitted infection screen is carried out in children. Although this may be considered over‐investigation clinically, a carefully conducted study of genital examination and genital viral culture in any child presenting with a primary herpes infection elsewhere would help answer many questions about the frequency of autoinoculation, asymptomatic infection and incidental isolation of the virus. A larger, methodologically robust and more up‐to‐date study of children presenting with genital herpes is required in order to be more certain of the implications in a child who is not mature enough to engage in consensual sexual relations. In the meantime this review provides doctors with the evidence on which to base their judgment.
We are grateful to Dr José Cristóbal Paniagua Marrero for translating the Chilean article. We are indebted to Dr Alison Kemp who has provided many helpful comments and advice on earlier drafts of this paper.
Competing interests: None.