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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: 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
gonorrhoea.

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
hours.72

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.

References

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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