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The evidence base in child protection litigation

BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7560.160 (Published 20 July 2006) Cite this as: BMJ 2006;333:160

Rapid Response:

Re: Child Abuse -Misdiagnosed

Regarding Goodyear-Smith's response to the article by Chadwick, I
would like to submit a correction to one of the citations. The article I
published in The APSAC (American Professional Society on the Abuse of
Children)Advisor (1) contained a table: "Approach to Interpreting Physical
and Laboratory Findings in Suspected Child Sexual Abuse: 2005 Revision".

This table was developed through a process of consensus development and
endorsed by group of physician experts in child sexual abuse medical
evaluation. The wording our group agreed upon for interpreting the
significance of infections caused by gonorrhea, syphilis, Trichomonas
vaginalis, Chlamydia trachomitis and HIV, when perinatal transmission is
ruled out, was: "Presence of Infection Confirms Mucosal Contact with
Infected and Infective Bodily Secretions, Contact Most Likely to Have Been
Sexual in Nature". If there is an explanation for how fresh infected
secretions from an individual with gonococcal vaginitis, urethritis or
conjuctivitis came to be directly deposited on the eye or genitals of a
child in a non-sexual manner, then it may not be necessary to suspect
sexual abuse. With common good hygiene practices, this should not happen,
but in areas where people don't wash their hands between touching their
own infected genitalia or eyes before touching a child's genitalia or
eyes, then such non-sexual transmission probably does occur. The table in
the Advisor article does note that for gonorrhea, syphilis, Chlamydia and
HIV, the most recent guidelines from the American Academy of Pediatrics
Committee on Child Abuse and Neglect (in the Clinical Report authored by
Nancy Kellogg, MD)(2)consider these infections to be diagnostic of sexual
transmission if neonatal transmission is ruled out, however the group of
experts who reviewed the listing of findings did not want to use
"diagnostic" or "clear evidence" terminology.

Alternative modes of transmission, in cases where a child is too young to
give a history of sexual abuse, or who denies such contact, should always
be investigated.

(1) Adams JA. Approach to the interpretation of medical and
laboratory findings in suspected child sexual abuse: A 2005 revision. The
APSAC 2005;17 (3):7-13.

(2) American Academy of Pediatrics, Committee on Child Abuse and
Neglect, & Kellogg NK.(2005). Clinical Report: The evaluation of
sexual abuse of children. Pediatrics, 116 (2):506-512.

Competing interests:
None declared

Competing interests: No competing interests

02 August 2006
Joyce A Adams
Professor of Pediatrics
University of California, San Diego, 200 Arbor Drive, San Diego California 92103-8449