Intended for healthcare professionals

Rapid response to:


The evidence base in child protection litigation

BMJ 2006; 333 doi: (Published 20 July 2006) Cite this as: BMJ 2006;333:160

Rapid Response:

Re: The evidence base in child abuse

Chadwick writes that there is a robust evidence base in child
protection litigation.1 Unfortunately large bodies of evidence may not be
easily accessible to potential medical experts. For example, while it has
always been recognised that Neisseria gonorrhoea is a sexually transmitted
infection,9 there is loss of appreciation that pre-pubertal girls, beyond
the perinatal period, are also susceptible to non-sexual transmission of

American Academy of Paediatrics guidelines state ‘Physicians should
assume that children with gonorrhoea have acquired it by sexual contact
and that most such contacts are sexually abusive’.2 Kellogg claims a
positive culture for N gonorrhoeae makes ‘the diagnosis of sexual abuse a
near medical certainty’ and is diagnostic of sexual abuse ‘if not
perinatally acquired and rare nonsexual vertical transmission is
excluded’.3 Guidelines citing a working party of the Royal College of
Physicians as an evidence source state ‘The bulk of evidence strongly
suggests that gonorrhoea in young people over one year is sexually
transmitted and the isolation of a gonococcal infection is highly
suggestive of sexual abuse’.4 5 Child abuse authorities Sgroi and Adams
write ‘Except in the neonate, gonorrhoea in a child signifies sexual
abuse’’6 and ‘Positive confirmed culture for gonorrhea (from genital area,
anus, throat) in a child outside the neonatal period’ is diagnostic of
sexual contact.7 These various documents either provide no supportive
primary data or refer to a 1985 paper cklaiming to have summarised ‘all
studies of gonococcal infections in children since 1965’8 and concluding
that ‘the bulk of evidence strongly suggests that gonorrhoea in children,
as in adults, is sexually transmitted.’ However a literature search
reveals that this review does not include all studies between 1965 to
1985. Furthermore there are numerous studies of non-sexual transmission
both prior and subsequent to their review.

Prior to the advent of antibiotics, N gonorrhoeae was endemic.
Epidemics of vaginal gonococcal infection was a serious problem in
children’s wards and orphanages, usually through some failure in nursing
care.9 10 The source of infection for an index case might have been sexual
transmission. However once an infected child was admitted, the infection
spread rapidly among other girls within the institution. The literature
records over 40 epidemics involving about 2000 children in Europe and the
United States.9 11-21 Communal baths, towels, bedding and other cloth,
rectal thermometers, enema nozzles, and caregivers’ hands22-2728 were all
identified as agents of transmission. Prior to the advent of penicillin
there was no adequate treatment. While generally causing vulvovaginitis,
to which young girls are particularly susceptible, there were cases of
conjunctivitis and more serious complications including arthritis,
peritonitis and fatality. Epidemics often would continue until strategies
to isolate infected children and identify the transmission source (nurses’
hands or fomites) were implemented. The pattern of spread was clearly due
to contamination not sexual abuse of children within the institutions.

Modern-day epidemics of non-sexually transmitted conjunctival N
gonorrhoeae occur in parts of Africa and Australia where adequate
facilities for diagnosis, treatment and epidemiological surveillance are
lacking.29 In Ethiopia over 9,000 cases of gonococcal conjunctivitis,
particularly affecting children under five years of age, were reported
during eight months in one district.30 Epidemical, surveillance and
clinical data showed no concurrent genital gonorrhoea outbreak - genital
transmission could not explain the community-wide epidemic. Similar
outbreaks occur in Aboriginal communities in rural Australia under
conditions of substandard, overcrowded housing with insufficient water
supply, poor sanitation and sewerage disposal and inadequate food
hygiene.31-35 Children with unwashed faces and/or hands are more likely to
be infected.36 Flies are possible vectors.30 32 37

Many other studies link clusters of family members and associates
having conjunctival or vulvovaginal gonococcal infection with non-sexual
transmission.38-47 48-52 Children may acquire gonococcal infections
through contact with infected towels or bedding.29 48 53-56 Accidental
transmission through freshly contaminated hands of mothers or other
contacts is another mode of infection.49 46 57-59 In some cases it cannot
be established whether transmission was sexual or non-sexual.

Unusual accidental modes of infection include sharing a bed urinal
bottle with an infected fellow-patient,8 ingestion of chocolate agar from
a culture plate,60 being struck in the eye with an infected face mask
strap,61 spraying the eyes with infected fluid62 or bathing them in
contaminated urine.63 Infected toilet seats are an unlikely source of
indirect transmission,64 although contact with contaminated toilet paper
has greater potential to cause infection. 65

While N gonorrhoea is killed by drying or heating, it can survive for
hours if kept warm and damp on towels, bedding and other objects27 39 66-
68 69-71 24 and has .been cultivated from infected bathwater after 24

The prepubertal girl develops vulvovaginitis rather than cervicitis.
She is susceptible to this for many reasons: the vulva lack the protection
of adult labial fat pads and pubic hair and the labia minora tend to open
when the child squats; the vulval skin is thin, delicate and sensitive,
susceptible to irritation, infection, drying, chapping and blistering; the
vagina is an excellent bacterial culture medium being warm, moist and of
neutral pH with an atrophic anoestrogenic mucosa; antibodies that may be
present in adolescents and adults are lacking and children may have poor
local hygiene.73-77

With the advent of antibiotics, gonorrhoea is no longer endemic.
Epidemics in institutions are an event of the past. Gonorrhoea in children
is relatively rare. Knowledge of nonsexual transmission has largely been
lost to modern literature. Medical experts rely on ‘guidelines’ from
leading medical institutions3-5 9 78 rather than referring to primary
sources. Unfortunately these documents are opinion not evidence-based. For
example, Kelly assumes all paediatric cases of gonorrhoea due to sexual
abuse ('the consensus in the Western literature is that genital gonorrhoea
in a child, out of the neonatal period, is a sexually transmitted
disease') with the child requiring urgent placement 'in a safe
household'.79 While some cases may result from sexual abuse, non-sexual
transmission is not considered a possibility. Babies and young children
are taken in to custody and adults prosecuted solely on the finding of
paediatric gonorrhoea. Expert witnesses testify that sexual abuse is a
medical certainty, citing the leading authorities listed above.

Clearly it is important to identify cases of sexual abuse and keep
children safe. Paediatric gonorrhoea is a strong indicator that must be
taken seriously. However denial of the possibility that children may be
infected non-sexually has grave medicolegal implications and may result in
harm and injustice.


1. Chadwick D. The evidence base in child protection litigation. BMJ
2006;333(22 July):160-161.

2. American Academy of Pediatrics. Committee on early childhood aadc.
Gonorrhea in prepubertal children. Pediatrics 1983;71(4):553.

3. Kellogg N, Committee on Child Abuse and Neglect. Clinical Report: the
evaluation of sexual abuse in children. Pediatrics 2005;116(2):506-512.

4. Thomas A, Forster G, Robinson A, Rogstad K, Clinical Effectiveness
Group Association of Genitourinary M, Medical Society for the Study of
Venereal D. National guideline for the management of suspected sexually
transmitted infections in children and young people. Archives of Disease
in Childhood 2003;88(4):303-11.

5. Thomas A, Forster G, Robinson A, Rogstad K, Clinical Effectiveness G.
National guideline for the management of suspected sexually transmitted
infections in children and young people. Sexually Transmitted Infections

6. Sgroi SM. Pediatric gonorrhea and child sexual abuse: the venereal
disease connection. Sexually Transmitted Diseases 1982;9(3):154-6.

7. Adams J. Approach to the Interpretation of Medical and Laboratory
Findings in Suspected Child Sexual Abuse: a 2005 Revision. The APSAC
Advisor, 2005:7-13.

8. Neinstein LS, Goldenring J, Carpenter S. Nonsexual transmission of
sexually transmitted diseases: an infrequent occurrence. Pediatrics

9. Hamilton A. Gonorrheal vulvovaginitis in children with special
reference to an epidemic occurring in scarlet fever wards. Journal of
Infectious Diseases 1908;5:133-157.

10. King A, Nicol C. Veneral diseases. 3rd ed. London: Bailliere Tindall,

11. Gittings C, Mitchell G. Review of the literature of the past five
years on gonovoccus vulvovaginitis in childhood. American Journal of
Diseases in Children 1917;13:438-456.

12. Abt I. Gonorrhea in children. Journal of American Medical Association
1898;31(17 Dec):289-294.

13. Morse J. Five cases of gonorrhoeae in little girls. Achives of
Pediatrics 1894;11: 596-598.

14. Sheffield H. Contribution to the study of infectious vulvo-vaginitis
in children, with remarks upon purulent ophthalmia, and a report of sixty-
five cases. American Medico-Surgical Bulletin 1896;9(30 May):726-731.

15. Cotton A. An epidemic of vulvovaginitis among children. Archives of
Pediatrics & Adolescent Medicine 1905;22(Feb):352-335.

16. Baer J. Epidemic gonorrheal vulvo-vaginitis in young girls. Journal of
Infectious diseases 1904;1(19 March):313.

17. Holt L. Gonococcus infections in children, with especial reference to
their prevalence in institutions and means of prevention. New York Medical
Journal and Philadelphia Medical Journal 1905;81(18 March):589-593.

18. Seippel C. Venereal diseases in children. Illinois Medical Journal

19. Cooperman M. Gonococcus arthritis in infancy. American Journal of
Diseases in Children 1927;33:932.

20. Altchek A. Pediatric vulvovaginitis. Pediatric Clinics of North
America 1972;19(3):559-80.

21. Koplik H. Prohylactic measures to prevent the spread of vulvovaginitis
in hospital services. Archives of Pediatrics 1903;10:735-741.

22. Catterall R. A short textbook of venereology. 2nd ed. London: English
Universities Press, 1975.

23. Wilcox R. Textbook of venereal diseases and treponematoses. 2nd ed.
London: William Heinemann Medical books, 1964.

24. Srivastava AC. Survival of gonococci in urethral secretions with
reference to the nonsexual transmission of gonococcal infection. Journal
of Medical Microbiology 1980;13(4):593-6.

25. Mackie T, Cruickshank R. Mackie & McCartney's handbook of
bacteriology. 10th ed. Edinburough: Livingstone, 1976.
26. Schofield C. Sexually transmitted diseases. 2nd ed. Edinburough:
Churchill Livingstone, 1975.

27. Benson R, Steer A. Vaginitis in children. American Journal of Diseases
of Children 1937;53:806-824.

28. Grimble A. McLachlan's handbook of diagnosis and
treatment of venereal diseases. 5th ed. Edinburough: Livingstone, 1969.

29. Osoba A, Alausa K. Vulvovaginitis in Nigerian children. Nigerian
Journal of Paediatrics 1974;1:26-32.

30. Mikru FS, Molla T, Ersumo M, Henriksen TH, Klungseyr P, Hudson PJ, et
al. Community-wide outbreak of Neisseria gonorrhoeae conjunctivitis in
Konso district, North Omo administrative region. Ethiopian Medical Journal

31. Matters R. Non-sexually transmitted gonococcal conjunctivitis in
Central Australia. Communicable Diseases Intelligence 1981;13:3.

32. Brennan R, Patel M, Hope A. Gonococcal conjunctivitis in Central
Australia. Medical Journal of Australia 1989;150(1):48-9.

33. van Buynder P, Bailey S, Adams J, Talbot J, Sullivan H, Waddingham A,
et al. A cluster of non-sexually transmitted gonococcal conjunctivitis in
the Pilbara, Western Australia. Western Australian Notifiable Diseases
Bulletin 1992;2(6):534-536.

34. Matters R, Wong I, Mak D. An outbreak of non-sexually transmitted
gonococcal conjunctivitis in Central Australia and the Kimberley region.
Communicable Diseases Intelligence 1998;22(4):52-6; discussion 57-8.

35. Anonymous. Gonococcal conjunctivitis outbreak. Communicable Diseases
Intelligence 1998;22(3):39.

36. Merianos A, Condon RJ, Tapsall JW, Jayathissa S, Mulvey G, Lane JM, et
al. Epidemic gonococcal conjunctivitis in central Australia. Medical
Journal of Australia 1995;162(4):178-81.

37. Weinstein P. The Australian bushfly (Musca vetustissima Walker) as a
vector of Neisseria gonorrhoeae conjunctivitis. Medical Journal of
Australia 1991;155(10):717.

38. Folland DS, Burke RE, Hinman AR, Schaffner W. Gonorrhea in
preadolescent children: an inquiry into source of infection and mode of
transmission. Pediatrics 1977;60(2):153-6.

39. Cohn A, Steer A, Adler E. Gonococcal vaginitis: a preliminary report
on one year’s work. Vener Dis Inform 21:208–20 1940;21:208-220.

40. Burry VF, Thurn AN. Gonococcal infections in prepubertal children.
Missouri Medicine 1971;68(9):691-2.

41. Ingram DL, Everett VD, Flick LA, Russell TA, White-Sims ST. Vaginal
gonococcal cultures in sexual abuse evaluations: evaluation of selective
criteria for preteenaged girls. Pediatrics 1997;99(6):E8.

42. Tunnessen WW, Jr., Jastremski M. Prepubescent gonococcal
vulvovaginitis. Clinical Pediatrics 1974;13(8):675-6.

43. Alexander WJ, Griffith H, Housch JG, Holmes JR. Infections in sexual
contacts and associates of children with gonorrhea. Sexually Transmitted
Diseases 1984;11(3):156-8.

44. Ingram DL, White ST, Durfee MF, Pearson AW. Sexual contact in children
with gonorrhea. American Journal of Diseases of Children 1982;136(11):994-

45. Nair P, Glazer-Semmel E, Gould C, Ruff E. Neisseria gonorrhoeae in
asymptomatic prepubertal household contacts of children with gonococcal
infection. Clinical Pediatrics 1986;25(3):160-3.

46. Lowy G. Sexually transmitted diseases in children. Pediatric
Dermatology 1992;9(4):329-34.

47. Dada-Adegbola HO, Oni AA. Review of cases of children with gonorrhoea-
-source of infection. African Journal of Medicine & Medical Sciences

48. Alausa KO, Osoba AO. Epidemiology of gonococcal vulvovaginitis among
children in the tropics. British Journal of Venereal Diseases

49. Shore WB, Winkelstein JA. Nonvenereal transmission of gonococcal
infections to children. Journal of Pediatrics 1971;79(4):661-3.

50. Ismail R, Toh CK, Ngeow YF. Gonococcal vulvovaginitis among female
children in Malaysia. Sexually Transmitted Diseases 1985;12(3):114-6.

51. Low RC, Cho CT, Dudding BA. Gonococcal infections in young children.
Studies on the social, familial, and clinical aspects of 11 instances.
Clinical Pediatrics 1977;16(7):623-6.

52. Frewen TC, Bannatyne RM. Gonococcal vulvovaginitis in prepubertal
girls. Clinical Pediatrics 1979;18(8):491-3.

53. Broso P, Buffetti G, Sacco A. [Non-sexual transmission of sexually
transmissible diseases]. Minerva Ginecologica 1992;44(9):407-13.

54. Lewis LS, Glauser TA, Joffe MD. Gonococcal conjunctivitis in
prepubertal children. American Journal of Diseases of Children

55. Doyle JO. Accidental gonococcal infection of the eyes in children.
British Medical Journal 1972;1(792):88.

56. Doyle JO. Accidental gonococcal infection of a child's eye. Unusual
source of infection. British Journal of Venereal Diseases 1974;50(4):315-

57. Felman YM, William DC, Corsaro MC. Gonococcal infections in children
14 years and younger. Epidemiologic and other lessons drawn from a survey
of 30 instances. Clinical Pediatrics 1978;17(3):252-4.

58. Allue X, Rubio T, Riley HD, Jr. Gonococcal infections in infants and
children. Lessons from fifteen cases. Clinical Pediatrics 1973;12(10):584-

59. Auman GL, Waldenberg LM. Gonococcal periappendicitis and salpingitis
in a prepubertal girl. Pediatrics 1976;58(2):287-8.

60. Lipsitt HJ, Parmet AJ. Nonsexual transmission of gonorrhea to a child.
New England Journal of Medicine 1984;311(7):470.

61. Diena BB, Wallace R, Ashton FE, Johnson W, Platenaude B. Gonococcal
conjunctivitis: accidental infection. Canadian Medical Association Journal

62. Bruins SC, Tight RR. Laboratory-acquired gonococcal conjunctivitis.
JAMA 1979;241(3):274.

63. Valenton MJ, Abendanio R. Gonorrheal conjunctivitis. Complication
after ocular contamination with urine. Canadian Journal of Ophthalmology

64. Gilbaugh JH, Jr., Fuchs PC. The gonococcus and the toilet seat. New
England Journal of Medicine 1979;301(2):91-3.

65. Dayan L. Transmission of Neisseria gonorrhoeae from a toilet seat.
Sexually Transmitted Infections 2004;80(4):327.

66. Cruickshank R, JP D, BP M, RHA S. Chapter 27: Neisseria. Medical
Microbiology: the practice of medical micobiology. 12th ed. Edinburough:
Churchill Livingstone, 1975:399-402.

67. Jordan E, Burrows W. Textbook of bacteriology. 13th ed. Philadelphia
& London: WB Saunders Company, 1941.

68. Bigger J. Handbook of bacteriology. 6th ed. London: Bailliere Tindall
& Cox, 1949.

69. Marshall C. Syphilology and venereal diseases. 3rd ed. London:
Balliere, Tindall & Cox, 1914.

70. Elmros T, Larsson PA. Survival of gonococci outside the body. British
Medical Journal 1972;2(810):403-4.

71. Alausa K, Sogbetun A, Montefiore D. Effect of drying on Neisseria
gonorrhoae in realtion to nonvenereal infection in children. Nigerian
Journal of Paediatrics 1977;4(1):14-18.

72. Leishman W, Keogh A, Melville C. A manual of venereal diseases. 2nd
ed. London: Oxford University Press, 1916.

73. Altchek A. Pediatric vulvovaginitis. Journal of Reproductive Medicine

74. Altchek MA. Gonococcal vaginitis in children. Medical Aspects of Human
Sexuality 1982;16(1):46-51.

75. Robinson AJ. Sexually transmitted organisms in children and child
sexual abuse. International Journal of STD & AIDS 1998;9(9):501-10.

76. Woods CR. Gonococcal infections in neonates and young children.
Seminars in Pediatric Infectious Diseases 2005;16(4):258-70.

77. Rein MF. Nonsexual acquisition of genital gonococcal infection. New
England Journal of Medicine 1979;301(24):1347.

78. American Academy of Pediatrics. Committee on Child A, Neglect.
Guidelines for the evaluation of sexual abuse of children: subject review.
Pediatrics 1999;103(1):186-191.

79. Kelly P. Childhood gonorrhoea in Auckland. New Zealand Medical Journal

Competing interests:
None declared

Competing interests: No competing interests

01 August 2006
Felicity A Goodyear-Smith
Senior Lecturer and GP
Department of General Practice & Primary Health Care, University of Auckland, PB 92019, Auckland NZ