U.S. Department of Justice

Office of Justice Programs

Office of Juvenile Justice and Delinquency Prevention

Portable Guides to

Investigating Child Abuse

Sexually

Transmitted

Diseases

and Child

Sexual Abuse
Foreword

Investigating allegations of sexual abuse of children is very

difficult for law enforcement. Successful resolution of these

cases is often hampered by victim reluctance or inability to

communicate as well as the scarcity of corroborating evidence.

While the consequences of all abuse of children are of great

concern to us, sexual abuse can be particularly devastating,

especially when a sexually transmitted disease is part of the

tragic legacy of violation.

This guide is designed to present additional investigative

techniques, utilizing the presence of a sexually transmitted

disease, which will assist in identifying or eliminating suspects

in sexual abuse cases. Successful investigations are crucial

because they can be the gateway to treatment for victims and

can help protect them from further victimization. The guide

also seeks to sensitize investigators to the need for personal

precautions when investigating these cases and helps them to

recognize children in need of immediate medical attention.

OJJDP is proud of this offering and urges you to make use

of it as we work to protect our children.

Original Printing June 1996

Second Printing July 1997

Third Printing March 2001

Fourth Printing December 2002

NCJ 160940
1

Sexually transmitted diseases (STD’s) comprise

a wide range of infections and conditions that

are transmitted mainly by sexual activity. The

classic STD’s, gonorrhea and

syphilis, are now being

overshadowed by a new

set of STD’s that are not

only more common, but

are also more difficult

to diagnose and treat.

These new STD’s include

infections caused by Chlamydia

trachomatis (chlamydia), human papilloma virus

(HPV), bacterial vaginosis (BV), and human

immunodeficiency virus (HIV). Rapid application

of new technology to the diagnosis of STD’s has led

to a growing array of diagnostic laboratory tests that

require critical evaluation by clinicians and a critical

review by law enforcement (see table 1).
2

Accurate information about STD’s in victims of sexual abuse

has been hindered by a variety of factors:

✹ The prevalence of sexually transmitted infections may vary

regionally and among different populations within the same

region.

✹ Few studies have attempted to differentiate between infections

existing prior to sexual abuse and those that result from abuse.

The presence of a preexisting infection in adults is usually related

to prior sexual activity. In children, however, preexisting infections

may be related to prolonged colonization after perinatal acquisition

(acquisition immediately before and after birth), inadvertent

nonsexual spread, prior peer sexual activity, or prior sexual abuse.

✹ The incubation periods for STD’s range from a few days for

gonorrhea to several months for HPV. The incubation periods and

the timing of an examination after an episode of abuse are critically

important in detecting infections (see table 1).

When presented with a child with an STD,

law enforcement officials must attempt to

determine absolutely if the infection was

associated with sexual contact and, for

the purposes of prosecution, whether

appropriate diagnostic methods were

used. The following facts should be kept

in mind:

✹ STD’s may be transmitted during sexual assault.

✹ Multiple episodes of abuse increase the risk of STD infection,

probably by increasing the number of contacts with an infected

individual, and rates of infection also vary by the type of assault.

For example, vaginal or rectal penetration is more likely to lead

to detectable STD infection than fondling.

✹ Sexual assault is a violent crime that affects children of all ages,

including infants.

✹ The majority of children who are sexually abused will have no

physical complaints related either to trauma or STD infection.

Most sexually abused children do not indicate that they have

genital pain or problems.

✹ In children the isolation of a sexually transmitted organism may

be the first indication that abuse has occurred.
3

✹ In most cases, the site of infection is consistent with a child’s

history of assault.

✹ Although the presence of a sexually transmissible agent in a

child over the age of 1 month is suggestive of sexual abuse,

exceptions do exist. Rectal and genital chlamydia infections in

young children may be due to a persistent perinatally acquired

infection, which may last for up to 3 years.

The incidence and prevalence of sexual abuse in children are

difficult to estimate.

✹ Most sexual abuse in childhood escapes detection.

✹ Patterns of childhood sexual abuse appear to depend on the sex

and age of the victim.

✹ Between 80 and 90 percent of sexually abused children are female

(average age: 7 to 8 years).

✹ Between 75 and 85 percent of sexually abused children were

abused by a male assailant, an adult or minor known to the child.

This individual is most likely a family member such as the father,

stepfather, mother’s boyfriend, or an uncle or other male relative.

✹ Victims of unknown assailants tend to be older than children

who are sexually abused by someone they know and are usually

only subjected to a single episode of abuse.

✹ Sexual abuse by family members or acquaintances usually

involves multiple episodes over periods ranging from 1 week

to years.

✹ Most victims describe a single type of sexual activity, but over 20

percent have experienced more than one type of forced sexual act.

Vaginal penetration has been reported to occur in approximately

one-half and anal penetration in one-third of female victims of

sexual abuse.

✹ Over 50 percent of male victims of sexual abuse have experienced

anal penetration.

✹ Other types of sexual activity, including oral-genital contact and

fondling, occur in 20 to 50 percent of victims of sexual abuse.

✹ Children who are sexually abused by known assailants usually

experience less physical trauma, including genital trauma, than

victims of assaults by strangers because such trauma might arouse

suspicion that abuse is occurring.
4

STD and Incubation Clinical Transmission Diagnosis

Organism(s) Period Manifestations

1. Culture of N. gonorrhoeae

using selective media

with confirmation by

at least two different

methods using different

principles, e.g., sugar

fermentation, enzyme

substances, serological

or DNA hybridization.

2. Use of DNA probes

or other nonculture

methods, including

Gram-stained smears

or vaginal or urethral

discharges, is not

recommended because

Gonorrhea

Neisseria

gonorrhoeae

3–5 days 1. Vaginitis, urethritis,

pharyngitis, proctitis.

2. Rare: Arthritis,

conjunctivitis.

3. Most pharyngeal

(throat) and rectal

infections and as

many as 50% of

vaginal infections

in children may

be asymptomatic.

1. Through sexual

contact.

2. Exception: Neonatal

conjunctivitis is

acquired by the

infant from his/her

mother at delivery.

3. No evidence of

transmission by

fomites (i.e., via

toilet seats, “dirty”

towels, etc.).

Table 1

Incubation Periods, Clinical Manifestations, Transmission, and Diagnosis of

Sexually Transmitted Diseases (STD’s)*
5

other bacteria may

be misidentified as

N. gonorrhoeae.

1. Isolation of the organism

in tissue culture only

with microscopic

identification of the

characteristic inclusions

with fluorescent

antibody staining.

2. Nonculture methods,

including enzyme

immunoassays (EIA’s),

direct fluorescent

antibody (DFA) tests,

and DNA probes, are

not approved for use in

rectal or genital sites in

children. Use at these

sites has led to many

false-positive tests.

1. Sexually, in children 3

years of age or older.

2. Perinatally acquired

infection (mother-toinfant) may last in the

vagina and rectum for

up to 3 years or longer.

3. No evidence of

transmission by

fomites.

1. Most prevalent sexually

transmitted infection in

the United States.

2. In adults and

adolescents: Urethritis

and mucopurulent

cervicitis, which

can lead to pelvic

inflammatory disease;

however, most infections

in adults and children

are asymptomatic.

5–7 days Chlamydial

infections

Chlamydia

trachomatis
6

STD and Incubation Clinical Transmission Diagnosis

Organism(s) Period Manifestations

1. Primary syphilis:

Chancre, i.e., a painless

ulcer at the site of

inoculation (penis, vulva,

vagina, rectum, etc.).

The chancre heals

spontaneously after

1–2 weeks.

2. Secondary syphilis:

Diffuse rash, fever,

enlarged lymph nodes,

mucous patches.

3. Latent syphilis: Asymptomatic, although positive

serological findings may

persist for years.

1. Through sexual

contact. The chancre

and mucous patches

are very infectious.

2. Infants may acquire

congenital syphilis

from their mothers.

The presentation is

similar to secondary

syphilis.

1. Identification of

T. pallidum in lesions by

dark-field microscopy

or by staining with a

fluorescein-conjugated

monoclonal antibody.

2. The most common

methods used are

serological: Rapid

plasma reagin (RPR)

test; Venereal Disease

Research Laboratory

(VDRL)-reaginic

antibody test; and

fluorescent treponemal

antibody-absorption

Table 1 continued

Incubation Periods, Clinical Manifestations, Transmission, and Diagnosis of

Sexually Transmitted Diseases (STD’s)*

Syphilis

Treponema

pallidum

1. Primary

infection:

10–90 days,

usually 3–4

weeks.

2. Secondary:

6 weeks–6

months after

the primary

lesion heals.
7

(FTA–ABS) test, a

test for a specific antiT. pallidum antibody.

3. Positive results on an

RPR or VDRL test

in a child who does

not have a history of

congenital syphilis.

4. RPR and VDRL test

results will be negative

after effective treatment;

FTA–ABS remains

elevated for the lifetime

of the patient.
8

STD and Incubation Clinical Transmission Diagnosis

Organism(s) Period Manifestations

1. Microscopic identification

of the organism in

vaginal fluid.

2. Culture methods may

be more sensitive, but

not widely available.

3. The finding of

trichomonads in urine

collected for another

purpose is not sufficient

for accurate diagnosis,

as the urine could be

contaminated with

T. hominis, a normal

inhabitant of the bowel

that is not sexually

transmitted.

Table 1 continued

Incubation Periods, Clinical Manifestations, Transmission, and Diagnosis of

Sexually Transmitted Diseases (STD’s)*

Trichomoniasis

Trichomonas

vaginalis

5–28 days 1. Vaginitis.

2. In males, infection

appears to be

asymptomatic,

but T. vaginalis may

cause some cases of

nonspecific urethritis.

1. Through sexual

contact.

2. Has not been found in

children 1 year of age

or older without history

of sexual contact.

3. Infants can acquire

infection from mother

at delivery; can cause

vaginitis.

4. Perinatally acquired

infection may persist

for 6–9 months after

birth.

5. No evidence of

transmission by

fomites.
9

1. Microscopic

identification of

“clue cells,” which are

epithelial cells studded

with bacteria in vaginal

secretions; a positive

“whiff” or amine test,

which is the release of

a very characteristic

fishy odor when 10%

potassium hydroxide

(KOH) is added to the

vaginal fluid; and a

vaginal fluid pH of 

≥4.5.

2. The latter test should

only be done in

adolescents, as there are

no vaginal pH standards

for prepubertal children.

3. Culture of G. vaginalis

is not indicated and is

not diagnostic for BV.

G. vaginalis can be normal

vaginal flora and has

been isolated in 5–15%

of normal children who

have not been abused.

1. Through sexual and

nonsexual contact.

2. Probably related to

poor hygiene in some

young children.

1. BV is not really

an infection, but a

disturbance of the

normal vaginal flora,

which is replaced by

the organisms listed.

2. Clinically presents

as gray, foul-smelling

vaginal discharge, but

may be asymptomatic.

5–28 days Bacterial

vaginosis (BV)

Gardnerella

vaginalis;

Bacteroides

species and

other anaerobic

bacteria; and

Mycoplasma

hominis.
10

STD and Incubation Clinical Transmission Diagnosis

Organism(s) Period Manifestations

Table 1 continued

Incubation Periods, Clinical Manifestations, Transmission, and Diagnosis of

Sexually Transmitted Diseases (STD’s)*

Herpes

Herpes simplex

virus (HSV),

types 1 and 2

2–5 days 1. Painful vesicular lesions

that become ulcers on

the vulva, vagina, penis,

and perirectal area.

2. May be associated

with inguinal

lymphadenopathy

(disease of the lymph

nodes in the groin)

and fever.

1. Through sexual

contact.

2. Primarily HSV–2,

although 10% of

genital herpes in

adults can be due

to HSV–1.

3. Young children

with herpetic

gingivostomatitis

(herpetic infection

of the gum tissues),

a primary, nonsexually

acquired infection

due to HSV–1, may

1. Isolation of the virus

from the lesions.

2. There are no commercially available antibody

tests that will reliably

differentiate between

HSV–1 and HSV–2.
11

autoinoculate (infect

themselves) in the

genital area. There

should be a history

of stomatitis (sores

in the mouth) in the

previous 2 weeks.

1. Sexually, perinatally,

and probably, but

rarely, nonsexually.

2. Major confounding

variable is the long

period after infection

before the lesions

become visible to the

naked eye, which

could be as long as

18 months.

Clinical. HPV

DNA-typing of the

lesions is not generally

available.

Flesh- to purple-colored

papillomatous growths

in the anogenital region.

4–12 weeks, but

may be clinically

inapparent for up

to 18 months.

Condyloma

acuminata,

venereal warts

Human

papilloma

virus (HPV)
12

1. Children who are

HIV positive before

developing AIDS

are asymptomatic.

2. Some individuals

develop an acute

retroviral syndrome,

similar to influenza,

with lymphadenopathy

after infection.

3. Has not been described in

children with acquired

HIV infection.

Seroconversion:

6 weeks after

exposure; more

than 90% of

individuals will

be HIV positive

by 6 months.

Development

of AIDS: 5–10

years.

AIDS

Human

immunodeficiency

virus (HIV)

Serological: Presence

of HIV antibody, detection

of p24 antigen. Child being

evaluated for HIV after

abuse needs to be tested

for 6 months. Consider

HIV testing if the child is

from an area of high HIV

prevalence, if the abuser

is in a high-risk group

(e.g., IVDA, crack user),

or if another STD is

present.

1. Sexually, perinatally,

and via blood

transfusion,

intravenous drug

abuse (IVDA), and

sharing needles.

2. Approximately

30% of infants

born to HIV-positive

mothers will develop

HIV infection but

may not develop

clinical AIDS for

5 years or longer.

STD and Incubation Clinical Transmission Diagnosis

Organism(s) Period Manifestations

Table 1 continued

Incubation Periods, Clinical Manifestations, Transmission, and Diagnosis of

Sexually Transmitted Diseases (STD’s)*
13

3. Acquisition by sexual

abuse needs to be

differentiated from

perinatal infection,

as risk factors for

maternal infection

and sexual abuse

are similar.

*Source: Margaret R. Hammerschlag, M.D.
14

Author

Margaret R. Hammerschlag, M.D.

Professor of Pediatrics and Medicine

Division of Pediatric Infectious

Diseases

State University of New York Health

Science Center at Brooklyn

450 Clarkson Avenue, Box 49

Brooklyn, NY 11203–2098

718–245–4074

Supplemental Reading

Centers for Disease Control and Prevention. 1993 sexually

transmitted diseases treatment guidelines. Morbidity and

Mortality Weekly Report 42:RR–14, 1993.

Child Sexual Abuse: Report of the Twenty-Second Ross Roundtable on

Critical Approaches to Common Pediatric Problems in Collaboration

With the Ambulatory Pediatric Association. Ross Laboratories, 1991.

Evidence Collection Protocol. Texas Department of Health, Bureau

of Emergency Management, Sexual Assault Prevention and

Crisis Services Program, 1990.

Hammerschlag MR. Sexually transmitted diseases in sexually

abused children. Advances in Pediatric Infectious Diseases

3:1–18, 1988.

Hammerschlag MR, Doraiswamy B, Alexander ER, et al. Are

rectogenital chlamydial infections a marker of sexual abuse

in children? Pediatric Infectious Disease Journal 3:100–104, 1984.

Hammerschlag MR, Retting PJ, Shields ME. False positive

results with the use of chlamydial antigen detection tests in

the evaluation of suspected sexual abuse in children. Pediatric

Infectious Disease Journal 7:11–14, 1988.

Jenny C, Hooton TM, Bowers A, et al. Sexually transmitted

diseases in victims of rape. New England Journal of Medicine

322:713–716, 1990.

Sexual Assault: A Hospital/Community Protocol for Forensic and

Medical Examination. U.S. Department of Justice, Office of

Justice Programs, Office for Victims of Crime, 1985.
15

Understanding the Medical Diagnosis of Child Maltreatment: A Guide

for Non-Medical Professionals. The American Humane Association,

American Association for Protection of Children, 1989.

Whitcomb D. When the Victim Is a Child. 2d ed. U.S. Department

of Justice, National Institute of Justice, 1992.

Whittington WL, Rice RJ, Biddle JW, et al. Incorrect

identification of Neisseria gonorrhoeae from infants and children.

Pediatric Infectious Disease Journal 7:3–10, 1988.

Organizations

Missing and Exploited Children’s Training Programs

Fox Valley Technical College

Criminal Justice Grants Department

P.O. Box 2277

1825 North Bluemound Drive

Appleton, WI 54914–2277

800–648–4966

920–735–4757 (fax)

dept.fvtc.edu/ojjdp

Participants are trained in child abuse and exploitation investigative

techniques, covering the following areas:

✹ Recognition of signs of abuse.

✹ Collection and preservation of evidence.

✹ Preparation of cases for prosecution.

✹ Techniques for interviewing victims and offenders.

✹ Liability issues.

Fox Valley also offers an intensive special training for local child investigative

teams. Teams must include representatives from law enforcement, prosecution,

social services, and (optionally) the medical field.

National Children’s Alliance (NCA)

1612 K Street NW., Suite 500

Washington, DC 20006

800–239–9950

202–452–6001

202–452–6002 (fax)

www.nncac.org

Children’s Advocacy Centers (CAC’s) are community-based programs that

bring together representatives from law enforcement, child protective services,

prosecution, mental health, and the medical community in multidisciplinary

teams to address the investigation, treatment, and prosecution of child abuse
16

cases. NCA, formerly the National Network of Children’s Advocacy Centers,

provides leadership and advocacy for these programs on a national level,

including training and publications. The following four Regional Children’s

Advocacy Centers work jointly with NCA, providing information,

consultation, and training and technical assistance to help communities

establish child-focused programs that facilitate and support coordination

among agencies responding to child abuse.

✹ Midwest Regional Children’s Advocacy Center, Midwest Children’s

Resource Center, St. Paul, MN, 888–422–2955, 651–220–6750,

www.nncac.org/mrcac/index.html.

✹ Southern Regional Children’s Advocacy Center, Rainbow City, Alabama,

800–747–8122, 256–413–3158, www.nncac/srcac/index.html.

✹ Northeast Regional Children’s Advocacy Center, Philadelphia Children’s

Alliance, Philadelphia, Pennsylvania, 800–662–4124, 215–387–9500,

www.nncac.org/nrcac/index.html.

✹ Western Regional Children’s Advocacy Center, Lakewood, CO,

800–582–2203, 303–324–8953, www.nncac.org/wrcac/index.html.

Sexual Assault Nurse Examiner (SANE)/

Sexual Assault Response Team (SART)

www.sane-sart.com

Other Titles in This Series

Currently there are 12 other Portable Guides to Investigating

Child Abuse. To obtain a copy of any of the guides listed below

(in order of publication), contact the Office of Juvenile Justice

and Delinquency Prevention’s Juvenile Justice Clearinghouse

by telephone at 800–638–8736 or e-mail at puborder@ncjrs.org.

Recognizing When a Child’s Injury or Illness Is Caused by Abuse,

NCJ 160938

Photodocumentation in the Investigation of Child Abuse, NCJ 160939

Diagnostic Imaging of Child Abuse, NCJ 161235

Battered Child Syndrome: Investigating Physical Abuse and Homicide,

NCJ 161406

Interviewing Child Witnesses and Victims of Sexual Abuse, NCJ 161623

Child Neglect and Munchausen Syndrome by Proxy, NCJ 161841

Criminal Investigation of Child Sexual Abuse, NCJ 162426

Burn Injuries in Child Abuse, NCJ 162424

Law Enforcement Response to Child Abuse, NCJ 162425

Understanding and Investigating Child Sexual Exploitation,

NCJ 162427

Forming a Multidisciplinary Team To Investigate Child Abuse,

NCJ 170020

Use of Computers in the Sexual Exploitation of Children,

NCJ 170021
Additional Resources

American Bar Association

(ABA) Center on Children

and the Law

Washington, DC

202–662–1720

www.abanet.org/child/

home.html

American Humane Association

Englewood, Colorado

800–227–4645

303–792–9900

www.americanhumane.org

American Medical Association

(AMA)

Chicago, Illinois

312–464–5000

www.ama-assn.org

American Professional Society

on the Abuse of Children

(APSAC)

Oklahoma City, OK

405–271–8202

www.apsac.org

Federal Bureau of Investigation

(FBI)

202–324–3000

www.fbi.gov

National Center for the

Analysis of Violent Crime

www.fbi.gov/hq/isd/cirg/

ncavc.htm

Crimes Against Children

Program

www.fbi.gov/hq/cid/cac/

crimesmain.htm

Juvenile Justice Clearinghouse

(JJC)

Rockville, Maryland

800–638–8736

ojjdp.ncjrs.org/about/

clearh.html

Kempe Children’s Center

Denver, Colorado

303–864–5252

www.kempecenter.org

Missing and Exploited

Children’s Training Program

Fox Valley Technical College

Appleton, Wisconsin

800–648–4966

dept.fvtc.edu/ojjdp

National Association of

Medical Examiners

St. Louis, Missouri

314–577–8298

www.thename.org

National Center for Missing

and Exploited Children

(NCMEC)

Alexandria, Virginia

800–THE–LOST

703–274–3900

www.missingkids.com

National Center for Prosecution

of Child Abuse

Alexandria, Virginia

703–549–9222

www.ndaa-apri.org/apri/

programs/ncpca/index.html

National Children’s Alliance

Washington, DC

800–239–9950

202–452–6001

www.nncac.org

National Clearinghouse

on Child Abuse and

Neglect Information

Washington, DC

800–394–3366

703–385–7565

www.calib.com/nccanch/

National SIDS Resource Center

Vienna, Virginia

703–821–8955

www.sidscenter.org

Prevent Child Abuse America

Chicago, Illinois

312–663–3520

www.preventchildabuse.org
U.S. Department of Justice

Office of Justice Programs

Office of Juvenile Justice and Delinquency Prevention

Washington, DC 20531

Official Business

Penalty for Private Use $300

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