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]}