Pediatric Acquired Immunodeficiency Syndrome
Barriers to Recognizing the Role of Child Sexual Abuse
Laura T. Gutman, MD; Marcia E. Herman-Giddens, PA, MPH; Ross
The only reportable exposure categories for human
\s=b\
immunodeficiency virus (HIV) infection of children are
vertical transmission from an HIV-infected mother or
receipt of infected blood or blood products. Although sex-
ual transmission of HIV among adults is the subject of
intense concern, sexual transmission of HIV to children
during child sexual abuse has received almost no investiga-
tive attention. This review discusses factors contributing to
the exclusion of sexual transmission of HIV to children from
studies of the epidemiology of HIV infection. Difficulties
occur in screening and confirming abuse in nonselected
populations of children, perceived and real barriers exist to
the evaluation for HIV of sexually abused children, and
problems occur in the assessment for child sexual abuse of
HIV-infected children. Impediments to the understanding of
the relationship between sexual abuse and HIV infection in
sexually abused, HIV-infected children are considered, and
measures that can allow these barriers to be overcome are
discussed.
(AJDC. 1993;147:775-780)
immunodeficiency syndrome (AIDS) classi- is
Acquired
fied L
sexually transmitted disease (STD) of adults,
as a
and the risk of adult heterosexual the
transmission in
United States is reported to be rising.1 All other STDs are
known to be transmittable to children during child sexual
abuse. In the 1988 Presidential Commission on AIDS,
Watkins et al2 anticipated the possibility of AIDS trans¬
mission to children by this exposure category. Subsequent¬
ly, there were two early reports of this occurrence.3-4
For editorial comment see 711.
Nevertheless, in the 7 years since the publication of those
first reports of sexual transmission of human immunode¬
ficiency virus (HIV) to children, almost no data regarding
this exposure category have been developed. The pur¬
poses of this review are (1) to call attention to and exam¬
ine the reasons for the general failure to investigate trans-
Accepted for publication February 4, 1993.
From the Department of Pediatrics, Duke University Medical Center,
Durham, NC.
Reprint requests to Box 3971, Duke University Medical Center,
Durham, NC 27710 (Dr Gutman).
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E. McKinney, Jr, MD
mission of HIV to children by sexual abuse and (2) to ex¬
amine the consequences of inadequate recognition and
treatment of child sexual abuse as they pertain to pediat¬
rie AIDS. Since these two issues are linked biologically,
socially, legally, and politically, it is prudent to examine
them together.
BACKGROUND
The results of prevalence studies of individuals in
groups with possible exposure to HIV represent a power¬
ful and important means of evaluating and following the
HIV epidemic. Between 1988 and 1990,471 seroprevalence
studies involving hundreds of thousands of patients were
conducted in teenagers and adults attending STD clinics,
drug abuse treatment centers, women's reproductive
health clinics, and tuberculosis clinics.5 Hundreds more
studies were conducted in other settings. In contrast, no
seroprevalence study of children known or suspected of
being victims of sexual abuse has been reported.
Numerous reviews and studies of pediatrie HIV infec¬
tions have not mentioned sexual abuse as an expected or
documented means of transmission.6"13 In addition, the
prevention of sexual transmission of HIV to children has
been omitted from recent statements from medical organi¬
zations regarding prevention of HIV infection.14"18 For ex¬
ample, in the 1991 statement by the American Academy of
Pediatrics, "Guidelines for the Evaluation of Sexual Abuse
of Children," HIV infection was omitted from the table
summarizing the implications of STDs for the evaluation,
diagnosis, and reporting of sexual abuse of prepubertal
infants and children.19
In spite of the paucity of data, transmission of HIV dur¬
ing abuse may not be a rare event. Biologic reasons that
young children may be at greater risk than adults of con¬
tracting HIV infection if exposed to infected perpetrators
include the often long-term nature of sexually abusive sit¬
uations, during which multiple exposures usually occur,20
the mucosal trauma that often occurs during invasive
abuse,21 the relative thinness of vaginal epithelia of pre-
menarchal children,22 and the relatively larger extent of
cervical or vaginal ectopy.23 Supporting the relevance of
these concerns, in 1991, a review of the prevalence of iden¬
tified sexual abuse among 96 HIV-positive children re¬
vealed that 14% had been assaulted sexually, and at least
four (4%) of the 96 children were infected through abusive
sexual contact.21 Subsequently, Geliert et al24 elicited re-
 ports from a survey of child protection services in the
United States of 28 children who had acquired HIV infec¬
tion through abusive sexual contact.
The failure to address the sexual transmission of HIV to
children suggests that obstacles exist to recognition and
study. To achieve a better understanding of the problem,
these obstacles will be discussed and methods of their re¬
moval will be described.
GENERAL BARRIERS TO THE DIAGNOSIS
OF SEXUAL ABUSE
Although the elements of diagnosis of child sexual abuse
have been described,20-25'26 numerous barriers exist to the
recognition and reporting of sexual abuse of children (Ta¬
ble 1). Adults may refrain from recognizing or reporting
abuse because of disincentives, which include personal or
professional denial; identification with the adult rather
than the child; concern for possible physical, social, pro¬
fessional, or legal reprisal by the perpetrator or perpetra¬
tor's supporters; reluctance or inabililty to perform a rou¬
tine anal-genital examination; concern that protective
services will fail to protect the child and thereby worsen
the child's situation; reluctance to take a history of abuse
from a verbal child; and ignorance of the legal require¬
ments for reporting.2730
Because of the complexities of the legal system, the
young age of many victims, and the secrecy surrounding
child sexual assaults, the majority of substantiated cases
are not prosecuted, and very few convictions result from
charges of sexual abuse.31 Reabuse has been reported to
occur in one third of identified children who were already
receiving protective services.32 This prosecutorial attrition
and failure of protection further discourages
efforts to
identify abuse. In addition, the child has powerful reasons
to deny abuse or retract a disclosure, due to dynamics for¬
mulated by Summit33 as the "child sexual abuse accom¬
modation syndrome." In fact, except for the child who may
subsequently be protected, in most instances no one is
grateful that a child abuse evaluation has occurred.
BARRIERS TO THE DIAGNOSIS OF HIV INFECTION
IN SEXUALLY ABUSED CHILDREN
There are many barriers to the assessment of sexually
abused children for HIV infection (Table 2). First, there are
no reported studies regarding the prevalence of HIV
infection in populations of children who have been sexu¬
ally abused or of the relationship between specific sexual
acts (penile-oral contact, etc) and HIV transmission. Even
in children with documented STDs, HIV testing and
reports of results have been rare and numbers of studied
children have been very small.34 Consequently, clinicians
caring for children do not know the extent of the problem.
This in turn inhibits the provision of services. Lack of data
has even led to a recommendation that HIV testing not be
done.35
Opinions regarding indications for HIV testing in chil¬
dren undergoing evaluations for abuse or in whom abuse
has been diagnosed vary greatly and are not based on ex¬
perience. One study of the opinions expressed by 65 child
protection teams reported consensus only with regard to
minimal theoretical indications for HIV testing.36 In prac¬
tice, implementation of these indications was infrequent
and erratic and no team had established a protocol. The
characteristics of a child whom the child protection teams
agreed should be tested for HIV infection included a his-
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Table 1.—General Barriers to the Diagnosis
of Sexual Abuse
Inadequate lay recognition and reporting
Professional fear, reluctance, and denial
Identification with the adult (perpetrator) rather than the child
(victim)
Inadequate support of diagnostic services
Inadequate assurance that the child will be protected
Confounding legal system
Dynamics of the child's disclosure
Table 2.—Deterrents to the Assessment of HIV
Infection in Sexually Abused Children*
Lack of data regarding results of examinations for HIV of
abused children
Lack of applicable recommendations for testing
Poor access to information regarding risk status of assailants
Legal barriers to assessment for HIV of abused child and/or
assailant
*HIV indicates human immunodeficiency virus.
tory of known or suspected AIDS/AIDS-related complex,
a high-risk behavioral profile in adolescents, or a parent or
child who was insistent on HIV testing. Information
regarding the risk status of assailants that teams agreed
would trigger HIV testing of the child generally is not ac¬
cessible to child protection services. By these criteria, most
assaulted children would not be tested even if the assail¬
ants) was identified. An example has been published of a
child who was examined on several occasions for docu¬
mented STDs, had probably been infected with HIV dur¬
ing sexual assaults, but was not tested for HIV until after
AIDS-defining infections were diagnosed.37
Wide differences in recommendations from policymak-
ing organizations regarding HIV testing in abused chil¬
dren have added to the confusion. The 1989 recommenda¬
tions from the Centers for Disease Control and Prevention
on the prevention and treatment of STDs state that
testing
of abused children for HIV infection should depend on the
local prevalence of infection and exposure risks.38 This po¬
sition was subsequently reaffirmed.39 A formulation of this
position proposed that HIV testing of abused children
should occur if the perpetrator was at high risk of being
infected with HIV or if the assault was invasive.40 The as¬
sumption that information would be available to the child
protection team regarding assailants is unrealistic. To de¬
pend on the child to identify whether or not sexually in¬
vasive acts occurred is also unrealistic, and the correlation
between the presence of physical findings and invasive
sexual acts is poor.41-42
An alternative policy for HIV testing of abused children,
based on the realization that the investigator of an assault
on a child will know with
accuracy neither the sexual act
nor the medical history of the assailant, would therefore
recommend HIV testing for all children being evaluated
for sexual abuse43 or in whom the diagnosis following
evaluation for abuse is confirmed, probable, or unknown.44
This position has been endorsed by the Surgeon General.45
In summary, the currently recommended circumstances
for screening abused children for HIV infection are widely
divergent.
 Even if testing recommendations are clarified, parents or
caretakers may refuse to permit HIV testing of a child.37
Some states allow a clinician to order HIV testing of a child
without specific parental consent when providing general
medical care, while other states require specific permis¬
sion.
Finally, legal aspects of the assessment of abused chil¬
dren and their assailants for HIV infection have not been
resolved.46 In North Carolina an assailant of a child may be
required to undergo testing for HIV only when an indict¬
ment has been issued for a criminal sexual offense, but
cases of child sexual abuse infrequently
progress to crim¬
inal charges.30,31,47 Nevertheless, testing of the adults who
have access to the child is often essential to ensure a safe
environment for the child. In such an instance, a conflict
may exist between the needs of children for adequate pro¬
tection against assault by an HIV-infected person and the
protection against compulsory testing of persons when in¬
dictments on criminal charges have not been issued. These
legal problems remain unaddressed.31
BARRIERS TO THE DIAGNOSIS OF SEXUAL ABUSE
IN HIV-INFECTED CHILDREN
Risk factors for sexual abuse overlap those for HIV in¬
fection, and the high prevalence of risk factors for abuse in
families with HIV-infected children makes the recognition
of households at enhanced risk of abusing children even
more difficult (Table 3). These risk factors have been for¬
mulated by Finkelhor47 and Moore et al48 to include drug
use or alcoholism in the home, loss of one or both biologic
parents, poverty, chronic illness or disability of the child,
social isolation, and low educational attainment of the
mother. These same factors have been reported in the
homes of many HIV-infected children.21-48"54
Health care workers expend great efforts to provide
medical care for HIV-infected children, some of whom live
in homes in which trust of figures of authority is already
marginal. In this setting, establishing sufficient rapport
with the family to ensure adequate medical care of the
child may be difficult. Thus, a second barrier is the fear that
addressing issues of sexual abuse may lead to adversarial
relationships with some members of a family that could
jeopardize medical care of the child.
A third barrier is the complexity of applying public
health STD control measures to HIV prevention, particu¬
larly with children. Many public health programs have
avoided measures that have been applied to epidemics of
other STDs. The history of the conflicted decisions affect¬
ing current control measures has been recently reviewed
by Bayer,55 Angeli,56 and Wächter.57 Contact tracing, a
standard aspect of the control of most other STDs, has not
been consistently required or practiced in the management
of persons who have acquired HIV sexually. In the context
of child sexual abuse, contact tracing is the identification
of a perpetrator, evaluation of the child and perpetrator for
STDs (in this case HIV infection), evaluation of other chil¬
dren who have been exposed to an infected perpetrator,
and prevention of further abuse of the index child and
other children. In the secret and criminal milieu of adult-
child sexual contact, preventive measures based on contact
tracing, evaluation, and perpetrator therapy would be
even more difficult.
As a further barrier, the current AIDS Pediatrie Confi¬
dential Case Report reporting form of the Centers for Dis¬
ease Control and Prevention does not include child sexual
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abuse as an HIV exposure category. This reporting form is
in the process of revision, but information concerning the
first 12 or more years of the HIV epidemic will have been
collected on a form that has excluded exposure to HIV by
sexual abuse as a possible category. The form collects data
regarding the maternal exposure categories, and vertical
transmission from the mother is the category in which al¬
most all new cases of pediatrie HIV disease are classified.58
However, the maternal exposure categories may be unre¬
lated to the source of the child's disease.
In considering these reporting issues, children who are
1 year of age or younger when they demonstrate HIV-
related disease and whose mothers are infected with HIV
probably acquired the infection vertically. The major areas
of doubt arise when there are inadequate data regarding
the perinatal events and the child is first diagnosed at a
later age. One reported child who acquired HIV by sexual
abuse was only 2Vâ years old at presentation for AIDS.21
The age definition of pediatrie AIDS (age <13 years)
should have a rational basis, but presently it does not. If the
age definition is to be based on the onset of puberty, the
age should be considerably younger than 13 years. Alter¬
natively, the age definition of pediatrie AIDS may be based
on considerations of the sexual transmission of AIDS. In
this event, the definition should include persons younger
than the legal age for consent for sexual intercourse. Since
the current age definition for pediatrie AIDS is 12 years or
less, whereas the age at which a girl may consent to sexual
intercourse is 16 years or higher in the majority of states,59
there is a gap of 3 to 6 years. Consequently, the age defi¬
nition of pediatrie AIDS excludes HIV-infected children
aged 13 through 15 years, ages at which the majority of
states prohibit sexual intercourse, and ages at which types
of sexual abuse that may lead to HIV transmission (penile-
vaginal, penile-oral, penile-anal) are common.60
The transmission of HIV through sexual abuse is a diag¬
nosis that is confirmed if other exposure categories have
been ruled out. If the mother is infected with HIV, vertical
transmission to the child may be very difficult to exclude.
However, approximately 70% of infants born to HIV-
infected mothers are not vertically infected, and perinatal-
Table 3.—Deterrents to the Assessment for Sexual
Abuse of HIV-infected Children*
Common occurrence of dysfunctional homes
Professional concern that an adversarial climate will impair
care of the child
HIV testing of suspected or identified assailants is not an
implemented policy
Tracing child contacts of HIV-infected persons is not an
implemented policy
Child sexual abuse is not a recognized exposure category for
HIV
Disparity between age definitions of pediatrie AIDS and age of
consent for intercourse
Confusion is generated when the child's assailant is probable
source of maternal HIV infection
Professional ambivalence regarding significance of sexual
activity of adolescents
Assumption that the infections of all children whose mothers
are HIV-infected acquired vertically
were
*HIV indicates human
immunodeficiency virus; AIDS, acquired im¬
munodeficiency syndrome.
 Table 4.—Removing Barriers to Understanding
of the Role of Sexual Abuse in the Transmission
of Pediatrie AIDS*
Improve awareness of and response to child sexual abuse
Improve support for child protection services
Foster cooperation among medical, social, and legal systems
Define "child" to include persons below the age of consent
for intercourse
Educate all segments of society to cease condoning child
sexual abuse
Review adequacy of policies and statutes in protecting
children from abuse
Include transmission of HIV through child sexual abuse in
statements of measures necessary to prevent AIDS
Support needed population surveys
Develop data-based policies for testing abused children for
HIV and examining HIV-infected children for child sexual
abuse
Include all identified exposure categories in reports of HIV
infections of children
Educate clinicians of adults in all aspects of child sexual
abuse
*AIDS indicates acquired immunodeficiency syndrome; HIV, human
immunodeficiency virus.
ly exposed but noninfected children may acquire HIV at a
later age. To distinguish vertical transmission from infec¬
tion acquired in later childhood, the diagnosis of HIV in¬
fection must be established or excluded in early infancy.
When this has not occurred and the child presents in later
childhood with HIV infection, the source of infection is
currently attributed to vertical transmission. In actuality
the child may instead have acquired the disease following
delivery.
Finally, medical personnel may exhibit attitudinal lim¬
itations that have contributed to the lack of exploration of
the relationship between early abusive sexual experiences
and initiation of sexual intercourse at an immature age.61"64
Because adolescents are now acquiring AIDS at alarming
rates,65 research has focused on current adolescent sexual
activity without giving adequate study to childhood expe¬
riences, including sexual abuse, that may have led to pre¬
mature entry into promiscuous or unprotected sexual be¬
haviors that appear to be volitional.66-67 The contribution of
misleading terminology to professional confusion and de¬
nial is exemplified in a recent report of a 10-year-old girl
who had acquired an STD and who was described as be¬
ing "sexually active."68 A child of that age who has a his¬
tory of sexual contacts has been the victim of illegal sex acts
and should rather have been described as being chronical¬
ly sexually abused or assaulted.
BARRIER REMOVAL
Children who are infected with HIV through abuse may
present either for medical care of HIV-related conditions or
for evaluation of abuse. We need to overcome general bar¬
riers to the diagnosis of abuse to protect from reabuse
identified children as well as other children exposed to the
perpetrators, to provide therapy for abused children, and
to provide long-term, specific management of perpetra¬
tors. If abuse is to be prevented in settings in which per¬
petrators are also infected with HIV, it is necessary to pre¬
vent abuse in all populations.
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Table 5.—Preliminary Recommendations*
Circumstances in Which HIV Testing Is Recommended
1. Child has another acquired STD
2. Child has an anal vaginal injury or discharge or other
or
mucosal injury suggestive of abuse
3. Child has been documented to have experienced invasive
abuse (penile-oral, penile-vaginal, penile-anal)
4. Child is reported for suspected child sexual abuse and
outcome is confirmed, suspected, or unknown
5. Child is exposed to an HIV-infected perpetrator of abuse of
this or any other child
6. Child is exposed to any perpetrator of abuse of this or any
other child
Circumstances in Which Evaluation of HIV-infected Children
for Sexual Abuse Is Recommended
1. Child has anal-genital or oral physical findings suggestive
of sexual abuse
2. Child has another acquired STD
3. Child first presents for HIV-related disease after early
childhood
4. Siblings or other associated children are known to be or
suspected of being abused
5. Behavioral indicators of suspected abuse are recognized
*HIV indicates human immunodeficiency virus; STD, sexually trans¬
mitted disease.
Measures that could be implemented to enhance the
recognition of abuse include improved support for child
protection services throughout the United States; im¬
proved education of clinicians caring for children regard¬
ing the diagnosis and prevention of sexual abuse; en¬
hanced attention to preventing reabuse; restraining
assailants from further abuse; and increasing the protec¬
tion of other children (Table 4). Cooperation between and
education of the members of law enforcement agencies and
child protection services must be further developed. The
definition of "child" requires attention. For these pur¬
poses, we recommend that it include adolescents below the
age of consent for intercourse. All segments of adult soci¬
ety must cease to condone the sexual abuse and exploita¬
tion of children. The serious problem of the role of profes¬
sional denial in the failure to recognize abuse and in the
obstruction of the improvement of services for abused
children needs further research.
Support should be given for studies of the prevalence of
HIV infection in children who have been assaulted and in
sexual assailants. Formulations by advisory groups of rec¬
ommendations regarding HIV testing and reporting
should be compatible with the uncertainties inherent in
most cases of sexual abuse.
Policies and statutes regarding HIV testing should be
reviewed to determine whether the welfare of children as
well as that of their probable or identified assailants is be¬
ing protected. The prevention of sexual transmission of
HIV to children should be included in public policy state¬
ments of the measures required for preventing AIDS. Lit¬
erature regarding adult sexual behaviors that bring chil¬
dren into the AIDS cycle should be made available to
clinicians who provide care for adults.
Case reporting forms should be revised to reflect the ex¬
posure categories of the child and uncertainties of attribu¬
tion. Definitions of exposure categories for pediatrie HIV
 disease should account for the child's as well as the moth¬
er's exposure categories. Children infected with HIV who
are aged 13 through 15 years should be included in data
regarding pediatrie AIDS. Reporting of sexual abuse as an
exposure category for childhood HIV infection should not
be restricted to instances in which all other exposure cat¬
egories have been excluded. Children who are infected
with HIV and in whom sexual abuse has been confirmed
or suspected should be reported for all known exposure
categories, including sexual abuse.
The implication that sexual intercourse with a child who
is less than 16 years of age is legitimate and socially con¬
doned should be rejected. Laws designed to protect chil¬
dren from sexual exploitation should be reviewed for ad¬
equacy, should be observed, and should be enforced.
The authors recommend that, pending development of
data on each of these issues, consideration be given to ex¬
amining children for abuse or HIV infection on the basis
of the findings in Table 5. Indications for testing are listed
in approximate order of priority.
CONCLUSION
We have described many of the circumstances that have
led to the delay of data development regarding the trans¬
mission of HIV to children through abusive sexual contact.
A set of preliminary recommendations regarding evalua¬
tions of HlV-positive children for abuse or of abused chil¬
dren for HIV infection are suggested and are expected to
be modified when relevant experiences are reported. The
barriers to the development of relevant data are profound.
For children to be protected from sexual abuse and from
this fatal infectious disease, each of the impediments to di¬
agnosis and management of sexual abuse in the context of
HIV infection will have to be overcome.
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