Pattern of childhood STDs in a major hospital of East Delhi

Introduction

Sexual abuse is a major concern related to STDs in children. The increasing research over last two decades into the prevalence, childhood correlates and later consequences of childhood sexual abuse has established that exposure to some form of unwanted sexual attention during childhood is not uncommon.[2] Transmission of STD pathogens occurs in 2% to 10% of abused children, and it is presumed that when penetration occurs, the risk is even higher.[2] Changes in sexual behaviour, such as premature sexual activity, numerous sex partners and exchange of sex for drugs are some of the factors responsible for the high frequency of STDs. The paucity of reports in literature, particularly from this part of the national capital, prompted us to undertake this study to assess the overall prevalence and the pattern of childhood STDs among hospital attendees. The present study highlights the pattern of STDs in childhood and sexual abuse at a major hospital of East Delhi.

Materials and Methods

Children below 14 years of age, who attended the STD clinic of Guru Teg Bahadur Hospital, Delhi, during the period from January 1998 to December 2000 were subjects of the study. The diagnosis was based on history, clinical examination and relevant laboratory investigations. The data were tabulated according to the age, sex, marital, socio-economic, educational status, pattern of abuse and final diagnosis. This data was then compared with the data for previous two years i.e. January 1996 to December 1997.

Results

Out of a total of 1,12,506 patients who attented the Skin department, 1418 (1.3%) were STD patients and of these 50 (3.4%) were girls. Majority (66%) of these children were in the age group 1 1-14 years [Table - 1]. Only two girls, both aged 14 years, out of 50 children, were married but had not yet started co-habitatinq. 38% of these children were illiterate,, and most of them had a low socioeconomic background.

Congenital syphilis was seen only in 2 boys, aged 2 and 4 months. Parents of both these boys were VDRL positive. The most common acquired STD was secondary syphilis, seen in 20 children (42.6%). Out of these 13 were boys and 7 were girls and all had lesions of condylomata, without a history suggestive of a primary stage of syphilis. The duration of lesions varied from 1-3 months.

Vulvo-vaginitis was the second commonest STD, seen in 9 girls (19.2%). on 10% KOH smear examination, budding hyphae were demonstrated, confirming the diagnosis of candidal vulvovaginitis.

Condyloma acuminata was seen in 5 (10.6%) children (3 boys and 2 girls). The lesions were perianal in all boys and vulva) in the female children.

Four boys (8.5%) had gonococcal urethritis and presented with purulent urethral discharge and burning mictrurition. These boys had history of heterosexual exposure of voluntary nature with commercial sex workers. Diagnosis was confirmed by the presence of Gram-negative intracellular diplococci on Gram staining of urethral smear.

Two girls with genital herpes presented with multiple erosions on erythematous base with polycyclic margins on the labia majora. Similar lesions were seen in 1 boy on the glans penis. Tzanck smear showed presence of multinucleated giant cells in all 3 patients.

Chancroid ulcer was observed in 2 boys (4.3%) in the frenulum area. Both these boys had indulged in heterosexual exposure.

One boy aged 4 years, with history of abuse, had multiple lesions of molluscum contagiosum in the perianal area.

Three children had more than one STD. Mixed ulcer (primary chancre + chancroid) was observed on one boy; Condylomata acuminata and early syphilis were sen in another boy and a girl.

None of these children tested positive for HIV by ELISA technique.

A history of sexual abuse could be elicited in 11 boys and 19 girls on persistent tactful enquiry in private. Amongst perpetrators, the most common were either neighbours or relatives (56%). Further split up demonstrated classmates and friends (24%) and step fathers (20%).

Seven boys had heterosexual contact with commercial sex workers. One boy admitted having heterosexual contact with his girl-friend. Five boys had history of passive homosexual exposure. No boy indulged in active homosexuality. Three boys had strong denial to and kind on sexual exposure even on persistent enquiry.

Discussion

The prevalence of STDs varies from country to country and from place to place in the same country. In the recent times there has been a steady rise in the STDs in children probably as a consequence of increased premature sexual activity′ and increased child abuse because of various prevailing misbeliefs and myths.

Moreover, children′s STDs parallel those in adults. As more adults are infected, the likelihood of children contracting STDs increases, as is evident from our study.

The incidence of STDs in children in our study was 3.4%, which is higher than the previous studies [1],[4] [Table - 2]. An almost four-fold increase in the STD patients in the age group 0-20 years was reported by Khanna et al in 1996.[5] This could be attributed not only to child sexual abuse but also to increased voluntary sexual activity in preadolescent age group.

In our study, there were only 2 cases of congenital syphilis. This is in sharp contrast with earlier studies,[3],[4] where congenital syphilis was reported to be the commonest STD. Thus, there had been a considerable fall in the incidence of congenital syphilis over last few years. This could be because of overall better antenatol care facilities and effective treatment of mother before delivery.

Acquired syphilis (42.6%) was the most common STD and its commonest presentation was condylomata Iota. Oral mucousal patches were not observed in any of these children.

Condyloma acuminatum is most commonly transmitted by sexual assault.[6],[7] All the five children with condylomata acuminata were victims of sexual assault in our study. An incidence of condylomata acuminata in children of 0.15% was reported by Murugan et al in 1995.[8] This also confirms the rising incidence of viral STDs.

History of sexual abuse in 30 children (60%) is quite alarming. The various factors responsible could be low socio-economic status, over-crowding and myths like curing STDs by having sex with a virgin.[9] Girls are more vulnerable than boys, as the female child is an easy prey to adults. Moreover, she is threatened physically and parental force is also used to not to reveal the nature of sexual offence commited against her.[9]

The majority of boys were in the age group 11-14 years. These boys were residing in the resettlement colonies situated at Delhi-Uttar border, which has a sizable mobile population of truck/tempo drivers. These boys act as contact persons between these drivers and the commercial sex workers and at times they are also a party to this trade. This probably explains the high prevalence of STDs in these boys.

This study may only be a tip of the iceberg and lots of efforts are required both at parental and physician level to improve awareness regarding transmission of STDs to their wards and an improved and more patient friendly health care delivery system is required to prevent or at least reduce the further rise of STDs in children.

Evaluation for sexual abuse should be done in all cases. Prevention and treatment of adults are the main steps to prevent these infections in children. It is mandatory to follow up these children for excluding incubating HIV infection.