Herpes infection in two young girls – Is it indicative of child sexual abuse?

Genital Herpes in a pre-pubertal child raises the suspicion of sexual abuse. Two 12-year-old girls presented with multiple painful blisters in the genital area. with a history of alleged sexual abuse. The appearance was very suggestive of herpes infection. Investigations confirmed HSV-1 and HSV-2 infection in the two cases. Presence of herpes without any other positive sexual abuse indicators would make it challenging to prove child sexual abuse. It can also result from non-abusive hand to genital contact. Interpretation of the presence of genital Herpes should be made carefully as it could be challenged at the court of law. a Case Report” given the importance of said clinical findings in paediatric and medico-legal practice, despite the association between genital herpes and sexual abuse being well established in medical literature.


INTRODUCTION
Genital Herpes in a pre-pubertal child presents a unique problem. How likely is it that transmission occurred due to sexual abuse? Genital Herpes in a pre-pubertal child raises the suspicion of sexual abuse. However, the current evidence is too weak to estimate the likelihood of sexual transmission of the virus. Both HSV-1 and HSV-2 are common and contagious. Unlike other incurable diseases, it is not generally associated with long-term deterioration in health but, a new diagnosis is often associated with stress, embarrassment, and concerns about the future of sexual relationships and, in the case of a woman of childbearing age, about childbearing safety. This paper aims to discuss the medico-legal issues encountered in two young girls presented with genital herpes infection acquired through alleged sexual abuse.

CASE REPORT: CASE 1:
In August 2019 a 12-year-old girl presented for medico-legal examination with multiple painful blisters in the genital region. She gave a history of being sexually abused by her step-father on several occasions for past few months. There is no history of penetrative sex but made an allegation of rubbing of the penis of the offender on her genital region. Medico-Legal examination was done on the same day. Clinical examination did not reveal any significant findings other than ruptured and unruptured blisters seen in the genital area. There is no significant past medical history and social history unremarkable. Clinical examination revealed a healthy normal child except for the recent complaint of painful blisters in the genital region. Sample for polymerase chain reaction (PCR) testing by swabbing lesions. The sample was sent to the Medical Research Institution (MRI) in viral transport media.

CASE 2:
In September 2019 a 12-year-old girl presented with a history of single episode of sexual abuse. A known person has allegedly rubbed his penis on her genital area. About a week after, she has developed painful blisters in her genital region. Medico-Legal examination was done on the same day. Clinical examination did not reveal any significant findings other than ruptured and unruptured blisters seen in the genital area. There is no significant past medical history and social history unremarkable. Clinical examination revealed a healthy normal child except for the recent complaint of painful blisters in the genital region. Sample for PCR testing by swabbing lesions. The sample was sent to the MRI in viral transport media. In both cases, ruptured and unruptured vesicular lesions seen in the genital region were very suggestive of herpes infection.

Investigations:
PCR testing at MRI confirmed HSV-1 in case 1 and HSV-2 infection in case 2. In case 2, psychiatric referral revealed the patient to be below the average IQ level with poor school performance. No other significant findings were noted in both these patients.

DISCUSSION:
Definition of Child sexual abuse (CSA) is stated as "contact or interaction between a child and an adult when the child is used for the sexual stimulation of an adult or another person". [1] Child sexual abuse may take many forms. Some types of abuse, like incest, are mostly hidden. [2] In these two cases contracting the disease without any other positive indicators of sexual abuse would make it difficult to defend the opinion of Child sexual abuse in the court of law. It can also result from non-abusive hand to genital contact, such as autoinoculation in a child with active oral lesions or caregivers during bathing and toileting. Therefore, the interpretation of findings depends on the individual case. [3] Genital Herpes can be either sexually or nonsexually acquired. Therefore, the physician should exercise caution in judging how a child has developed such an infection. It is important to exclude sexual abuse in a child with genital Herpes. [4] Pediatricians should have a high index of suspicion when herpes is diagnosed in a child.
The likelihood of child sexual abuse, rather than persistent perinatal transmission, has caused an infection to be strongly considered with several sexually transmitted diseases, including genital Herpes. Although history is unpredictable of sexual abuse episode a significant positive result can be yielded from multiple site isolation method. Usually, children are reluctant to tell the exact history, mostly due to fear and ashamed of what happened. On some occasions, they cannot give all the necessary details due to a lack of knowledge or understanding. Therefore, even checking for infections like N. gonorrhea and C. trachomatis from oral, rectal, and genital sites might provide 'supportive evidence' to prove a case of child sexual abuse. [5] History received from the child always considered to be true and has to be the fundamental means of diagnosis. [6] In these two cases also there is no reason to doubt the history provided by the two victims.
Genital herpes in children is very rare. Occasionally it can present as an acute rash in the diaper region.
In some children it might also present as vulval ulceration. [7] Perinatal transmission contact of the fetus with secretion from the mother carrying a genital infection is considered to be the most common route of HSV transmission. However, the presence of herpes infection in a 12-year-old girl needs another plausible explanation.
In this instance, one victim gives a history of repeated abuse episodes but the other only a single episode of abuse. It is a known fact that multiple exposures make the victim contract the disease more easily. However, a question could be raised in the second case as to whether a single episode of contact is sufficient to transmit the disease.
The increase incidence of asymptomatic HSV-1 infection prevalence in the general population leads to a rise in infections in newborns via the oropharyngeal route. [7,8,9] Increase of HSV-1 prevalence in the community also results in the more frequent transmission of THE disease through a non-sexual mode of infection. Given that genital Herpes in the pre-pubertal period may constitute a sign of sexual abuse, it requires assessment.
Reading et al. [10] evaluated the likelihood that HSV in a child was due to sexual abuse by doing a structured literature search for reports of series of children presenting with genital Herpes for which an assessment for possible sexual transmission of child sexual abuse had been made. Of the five studies reviewed, just over half of reported cases of genital Herpes in children had evidence suggesting a sexual transmission mode.
In these two cases, one had an HSV-1 infection and the other HSV-2. Therefore, it would have been better if the parents and other family members could have been assessed for the presence of these two infections. This would also be important at the trial as it would help establish the assailant's guilt in each case.

CONCLUSIONS:
Sexually transmitted diseases in children always arouse suspicion of child sexual abuse as the underlying cause. However, all findings concerning the case should be thoroughly studied and evaluated before concluding the presence or absence of child sexual abuse. Sri Lankan medicolegal system lacks proper coordination among different groups of professionals managing cases of probable child sexual abuse. In addition, Sri Lankan medical literature also deficient of such case reports which helps medical, legal and other professionals to update their knowledge. Reporting of these cases will also help the medical officers engaged in medico-legal work without proper guidance of specialists in the field.