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Laboratory : Testing for Sexually Transmitted Infections in Children and Adolescents

Symptoms of STIs 

The CDC defines the term “sexually transmitted infection” (STI) where infection refers to a pathogen causing infection through sexual contact. The term “sexually transmitted disease” (STD) refers to a recognizable disease state that has developed from an infection. This website will use the term sexually transmitted infection. The symptoms and illnesses caused by STIs vary according to the specific infection, the age and sex of the child/adolescent, and the site of the infection.

A non-exhaustive list of symptoms may include:

Generalized Symptoms:
  • Fever or flu-like symptoms, muscle pains, chills, sweats
  • Weight loss
  • Rash, including pruritic lesions
  • Abdominal and/or pelvic pain
  • Lymphadenopathy (particularly inguinal), may be painless or painful
Ano-Genital Symptoms:
  • Vaginal discharge (change in color, odor, thickness)
  • Vaginal bleeding, spotting, or irregular periods
  • Urethral discharge (or penile discharge)
  • Pelvic inflammatory disease (PID) symptoms, including abdominal pain
  • Dysuria, frequency, burning
  • Blisters or ulcers
  • Rash
  • Anorectal pain, discharge or other symptoms 
Other
  • Dyspareunia (possible complaint in sexually active adolescents)
  • Generalized rash or lesions in areas other than the genital area
  • Sore throat, dysphagia

Recommended Tests

For adolescents, empiric treatment for potential STIs may be provided, particularly if follow-up from initial testing cannot be assured. For pre-pubertal children, and where compliance with follow-up may have more oversight by child protective services, testing for STIs prior to any empiric treatment may be a prudent approach.

A non-exhaustive list of infections transmitted via sexual abuse or assault may include:

  • Bacterial vaginosis (BV)
  • Candidiasis
  • Chlamydia
  • Gonorrhea
  • Herpes from herpes simplex virus (HSV)
  • Hepatitis from hepatitis B viruses (HBV)
  • Hepatitis from hepatitis C virus (HCV)
  • Human papillomavirus (HPV)
  • Syphilis
  • Trichomoniasis

Per the 2021 CDC Guidelines for Sexually Transmitted Infections Treatment, https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf, tests for post-sexual assault sites where sexual transmission may have occurred include the following:

  • Nucleic Acid Amplification Tests, or NAATs, for C. trachomatis and N. gonorrhoeae.
  • NAAT for T. vaginalis, BV from Gardnerella vaginalis or other bacterial overgrowth, and candidiasis, can be obtained via a urine or vaginal specimen for females. Testing for T. vaginalis should not be limited only to girls with vaginal discharge. Asymptomatic sexually abused children may be infected and benefit from treatment. 
  • A serum sample for HIV, HBV, and syphilis (Treponema pallidum) infection. Note, in NYS, HIV testing must be offered at least once as a routine part of health care to all patients aged 13 or older receiving primary care services at an outpatient clinic or primary care services from a physician, physician assistant, nurse practitioner or midwife. See: https://www.health.ny.gov/diseases/aids/providers/testing/docs/testing_fact_sheet.pdf
  • Many experts in child abuse pediatrics currently test for HCV at least once (and may test concurrently with subsequent testing for HIV and HBV) as part of the post-assault serum testing. If there concern for HIV co-infection (in the potential perpetrator or patient) or a history suggestive of men who have had sex with men, screening for HCV antibody during the initial HIV evaluation is recommended. A positive HSV antibody warrants follow-up HSV RNA testing. For more information about hepatitis C, see https://www.hcvguidelines.org/.

New York State implemented universal hepatitis C screening in May 2024 (Public Health Law § 2171 and § 2500-L). Anyone younger than age 18 where there is risk of hepatis C exposure should be offered screening. Risks of exposure are like HIV risk. For more information see: https://www.hivguidelines.org/guideline/hcv-testing/.

If lesions specific for infections are observed, such as herpes vesicles, chancroid ulcers from Haemophilus ducreyi, lymphogranuloma venereum (LGV) from a specific strain of chlamydia (Herring & Richens 2006), and others, specific tests may be warranted. See: Sexual Assault and Abuse STIs, Adolescents and Adults, beginning on page 128. https://pmc.ncbi.nlm.nih.gov/articles/PMC8344968/pdf/rr7004a1.pdf.

Who Should Be Tested

Depending on the local epidemiology of sexually transmitted diseases, the majority of child sexual abuse victims will not have an STI and the decision to test for STIs should be determined on a case-by-case basis. Because many STIs are asymptomatic, testing should be considered even if there are no symptoms. Providers should also recognize that children’s disclosures may be nonspecific or incomplete and oral, genital, and anal testing (all sites) may need to be considered for testing when sexual abuse is suspected.

The possibility of a sexually transmitted infection increases in some circumstances, such as when:

  • A sibling or household contact was recently diagnosed with an STI
  • The patient had a previous STI
  • There is concern for human trafficking. For more information see: Trafficking: Child Victims of Human Trafficking https://champprogram.com/trafficking.php .
  • The patient discloses prior unprotected sexual contact (consensual or non-consensual)
  • The abuse involved multiple perpetrators
  • The abuse involved a perpetrator with high-risk behaviors, such as drug use, commercial sex-work, multiple partners, or a history of STIs

Testing should be considered when there is a history of or examination findings consistent with symptoms of sexually transmitted infections, such as:

  • Vaginal or urethral discharge or bleeding
  • Rectal pain or discharge
  • Genital ulcers, sores, or warts
  • Physical indications of vaginal or rectal penetration or a genital injury
  • Findings of another STI
  • Or other symptoms as listed in the section on Symptoms of STIs

If there is a concern for lack of follow-up, for example if there is a suspicion of human trafficking and concern that the patient may not return for testing or treatment, strongly consider testing for STIs.

The child/adolescent may not offer a reliable enough history to adequately determine risk factors. In cases such as this, individualize the testing based on the information available. A referral to a Child Advocacy Center or other specialized center or child abuse expert for further evaluation is recommended.

Collecting Specimens

Identification of an STI requires an adequate sample, careful specimen handling, and a qualified laboratory. False negative and false positive cultures and tests can occur if errors are made.

Check with your laboratory to ensure the use of appropriate swabs, handling of the specimens, and requirements for storage, if needed. See Diagnostic Methods below for additional information regarding needs for FDA approved tests.

Diagnostic Testing

In cases of suspected sexual abuse, it is critical that the tests used to diagnose STIs are recognized as "gold standards." While cultures for N. gonorrhoeae and C. trachomatis were once the "gold standard" for sexual abuse evaluations, nucleic acid amplification tests have generally been found to be sensitive and specific for these infections, as well as for herpes simplex virus (HSV), T. pallidum, and human papillomavirus (HPV) tests.

NAAT vaginal and urine specimens from biologic females and urine in biologic males are recommended. Despite limited data, the use of NAATs for specimens from extragenital sites (rectum and pharynx) in prepubertal children, is often the most practical. NAAT performance for detecting C. trachomatis for extragenital sites among children is anticipated to be similar to performance of these tests in adults.

Only CLIA-validated, FDA-cleared NAAT should be used for extragenital site specimens. The use of NAATs, including review of sensitivity and specificity in children in your lab, should be reviewed with your local laboratory. See Brownell A, et al: https://pubmed.ncbi.nlm.nih.gov/30466791/.

Confirmatory testing is indicated in situations with a positive NAAT, and this may include scheduling a follow-up for a repeat test prior to treatment.

Human Immunodeficiency Virus (HIV)

There are various types of tests for human immunodeficiency virus (HIV), including antibody tests, antigen/antibody tests, and nucleic acid tests (NAT). The window period, the time between HIV exposure and when a test can detect HIV in the body, varies based on type of test. A child/adolescent should be tested for human immunodeficiency virus (HIV) when significant exposure may have occurred. Exposure to HIV is considered to be a medical emergency as the virus for HIV replicates rapidly and the antiretroviral medications used to prevent this replication (Post Exposure Prophylaxis or PEP) must be given as soon as possible and recommended within the first 36 hours after exposure. (https://www.health.ny.gov/diseases/aids/general/pep/). Note that CDC guidelines recommend testing within 72 hours. https://www.cdc.gov/hivnexus/hcp/pep/.

In New York State, the Department of Health protocol for HIV currently recommends testing and prophylaxis for all victims of sexual assault who are evaluated within 36 hours of the incident. Provide all patients being tested for HIV antibodies with pre- and post-test counseling in compliance with New York State HIV Confidentiality Law (Article 27-F) and obtain written, informed consent. For more information on NYS testing including an algorithm, see https://www.hivguidelines.org/guideline/hiv-testing/ and https://www.health.ny.gov/diseases/aids/providers/testing/docs/testing_toolkit.pdf.

In addition to the baseline test for HIV, it is recommended by the CDC, prior to post-exposure prophylaxis, to perform serum liver enzyme tests, pregnancy testing, BUN/creatinine tests, STI screening, hepatitis B (HBV) test, including HBV surface antigen, surface antibody, and core antibody. Depending on risk factors, a hepatitis C (HCV) antibody test may also be included in serum tests. Follow-up HIV testing should be performed at one month and three months post exposure. See: https://www.cdc.gov/hivnexus/hcp/pep/.

Considerations Regarding HIV Testing

  • The incidence of developing HIV infection from a single episode of sexual abuse is very low.
  • Recommend HIV post-exposure prophylaxis (PEP) to patients reporting sexual assault in which significant exposure may have occurred. Offer PEP as soon as possible following exposure, ideally within one hour and not more than 36 hours after exposure.
  • Perform baseline HIV testing prior to administration of post-exposure prophylaxis.
  • Provide counseling to both the adolescent and parent unless the adolescent is determined to have the ability to understand the risks and benefits of testing and treatment. In those situations, ask the adolescent if he/she wishes the parent involved with the counseling.
  • After counseling and obtaining permission, draw blood and process it per the healthcare facility's policies.
  • For more comprehensive information, see the New York State Department of Health website: https://www.health.state.ny.us/diseases/aids/.

For HIV Clinical Practice Guidelines, see: https://clinicalinfo.hiv.gov/.

For information about HIV prophylaxis, see: TREATMENT AND FOLLOW-UP: Sexual Abuse, STD Prophylaxis, HIV.

Follow-up for an Acute Assault

In the weeks following an acute assault:

  • A serum pregnancy test should be performed in a follow-up visit in one to two weeks of the incident.
  • Test for syphilis, HBV & C and HIV six weeks after the suspected exposure to allow time for antibodies to infectious agents to develop.
  • Test for HIV at 3 months after suspected exposure.
  • Follow-up with serologic tests for syphilis and hepatitis B and C viruses at 3 months.
  • Refer for support and counseling as needed.
  • If the patient is a resident of NYS, consider referral to a NYS designated pediatric HIV or infectious disease center.

Make the choice of tests on a case-by-case basis and discuss the estimated risk of infection with the parent or adolescent. Consider further post-assault testing for STIs or pregnancy in the context of the presence of symptoms, genital lesions, or a history of intercurrent sexual contact.

Testing for Sexually Transmitted Infections in Children and Adolescents

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