STDs under the microscope: a reply
Genital gonorrhoea in an adult is a sexually transmitted disease. In a recent article in NZLawyer, Dr Goodyear-Smith argues that, in pre-pubertal children, this is not necessarily the case. Two New Zealand experts on childhood gonorrhoea, Dr Janet Say and Dr Patrick Kelly, respond to this assertion
Dr Goodyear-Smith is described as the author of a “controversial new study” which has uncovered evidence from a systematic review of past scientific literature that is so “shocking” that Dr Goodyear-Smith was “blown away”.
Dr Goodyear-Smith’s evidence should be placed in a proper scientific context. Firstly, her “systematic review” is not, in fact, what it claims to be. The term has a very precise meaning in evidence-based medicine, where a series of systematic steps have been developed to minimise bias and random errors. The standard for such reviews is set by the Cochrane Collaboration, and includes the establishment of a review team, a workshop which leads to the preparation and subsequent publication of a protocol, and work on the main review. At all stages of the process, the work is carefully checked by members of the Cochrane editorial team and by external referees to ensure its quality. None of these processes have been followed by Dr Goodyear-Smith.
Secondly, from the perspective of practising physicians, most of the literature reviewed is extremely old. We accept that old literature may still be relevant. However, it is important to acknowledge the deficiencies of the methods available to the authors of microbiological papers written in the late nineteenth and early twentieth centuries.
In particular, these papers were published before reliable diagnostic tests for Neisseria gonorrhoeae became available. The sugar tests used for reliable identification of this organism were developed in the mid-1930s. There are many other organisms which can be mistaken for N.gonorrhoeae, and no laboratory today would rely on the methods used in the papers cited by Dr Goodyear-Smith. Consequently, there are many other bacteria which may have been responsible for the outbreaks described in institutions, hospitals, and children’s homes. For example, acinetobacter species is a common environmental contaminant, which can colonise wounds and mucous membranes, and is found in damp hospital environments and on poorly disinfected fomites.
It is interesting that all these outbreaks stopped after the 1930s, but before the widespread availability of antibiotics. Diagnostic microbiology has advanced since the nineteenth century, and we have not seen any outbreaks of genital gonorrhoea in the last 50 years, even in undeveloped countries with poor hygiene, lack of medical facilities, and limited knowledge of the risks of cross-infection.
Thirdly, many of the papers and cases reviewed by Dr Goodyear-Smith, both old and new, refer to the non-sexual transmission of childhood conjunctivitis. This has never been considered a sexually transmitted disease. The eye (anatomically, immunologically, and physiologically) is different from the genitalia. Without good scientific evidence for such an assertion, one cannot argue that non-sexual transmission to the eye is proof of the possibility of non-sexual transmission to the genitalia.
Fourthly, the fact that an organism can be demonstrated to survive on inanimate objects does not answer the question as to whether it will infect and cause disease in someone who comes into contact with that object.
Lastly, numerous scientific studies over the last 30 years have made clear the prevalence of child sexual abuse, both in families and in institutional care. Possibilities for sexual transmission within institutions include sexual contact between patients, or between patients and staff. It would not be possible to publish a paper on a suggested epidemic of genital gonorrhoea in childhood today without very careful exclusion of these possibilities.
The dialogue repeated
We agree with Dr Goodyear-Smith that “sexual transmission should be immediately considered whenever gonorrhoea is found in a pre-pubertal child – and that in the majority of cases it really is sexually transmitted and the likelihood of this should be considered on a case-by-case basis”.
However, for the reasons we have already outlined, Dr Goodyear-Smith has provided no evidence which would make it easier, on the basis of sound science, to diagnose non-sexual transmission in a pre-pubertal child. There is no new “dialogue” within the scientific community on this issue because Dr Goodyear-Smith has provided no reliable data on which such a dialogue could be based.
We acknowledge that there are cases where it may be impossible to be certain exactly how the child acquired genital gonorrhoea. We are very aware of the potential consequences of an incorrect diagnosis of child sexual abuse. We regularly see children where adults are concerned about sexual abuse, but our examination reveals an innocent explanation for the child’s genital symptoms. However, we also deal on a regular basis with cases of child and adolescent sexual abuse, where a failure to make the diagnosis and intervene in time has resulted in serious and possibly lifelong consequences.
Dr Goodyear-Smith, the article states, “refuses to accept the guidelines that have been set down by Doctors For Sexual Abuse Care (DSAC), which she describes as being “ideological”. In her article in the Journal of Forensic and Legal Medicine, Dr Goodyear-Smith states: “In New Zealand, the finding of gonorrhoeal infection in a pre-pubertal child beyond the neonatal period is considered diagnostic of sexual abuse”. She attributes this statement erroneously to the DSAC Manual. In fact, the chapter on Sexually Transmitted Infection in the DSAC Manual on the Medical Management of Sexual Abuse (2002) states “The detection of N. gonorrhoea in a child without prior peer sexual activity should alert the examiner to the high likelihood of sexual abuse”, a position which would appear to be the same as her own.
Dr Goodyear-Smith’s quote on the significance of childhood gonorrhoea in New Zealand is, in fact, taken from a local inter-agency guideline on the management of childhood gonorrhoea, where it accurately reflects the scientific consensus. It echoes the position statement of the Committee on Child Abuse and Neglect of the American Academy of Pediatrics, and is essentially the same as the position of the United States Department of Health and Human Services, Centers for Disease Control and Prevention.
The guideline was developed not by DSAC, but by Dr Kelly and Starship Hospital in collaboration with the Police and the Department of Child Youth and Family Services. Dr Kelly’s series of 14 cases over 11 years was published in order to demonstrate the often poor quality of inter-agency practice in these cases. For example, it could take up to 15 months for a child with gonorrhoea to be interviewed. In many cases, potential sexual contacts were never screened for infection, or screened so late in the process that the results were of no value in determining the source. Such a process was often inconclusive, left a cloud of uncertainty hanging over families, and may well have left several children at ongoing risk. For example, the source was never identified in case 10, a three year old with both gonorrhoea and chlamydia. She continued living in her extended family setting, and at one routine follow-up visit was found to have sperm in the vagina. In contrast, it is notable that since the introduction of these guidelines, we have had several cases in which a child has made a disclosure, or a perpetrator has confessed to sexual abuse.
A critic ignored
Dr Goodyear-Smith’s credentials are described as “excellent”. We acknowledge Dr Goodyear-Smith’s many publications as a reviewer of the medical literature. She has reviewed a wide range of subjects, including the safety of genetically modified foods, the palliative care of patients with motor neurone disease, and the value of corticosteroid injections for painful shoulder. However, it is important to appreciate that she has not been employed to perform an examination on a child for alleged sexual abuse for over 20 years, and would not be regarded as qualified to manage a sexually transmitted infection in a child.
Dr Goodyear-Smith states, with regard to the 14 children described in the Starship paper: “there was no consideration that they might not have been [sexually abused], and it is this that she objects to: the presumption of guilt”. She surmises that in some of these cases “a terrible miscarriage of justice” may have occurred. Dr Goodyear-Smith was not involved in the clinical management of any of these children, has no knowledge of the explanations advanced for their infections, and no knowledge of the context for each case. She is in no position whatsoever to comment on what alternatives were considered by the clinicians involved, nor on the quality of justice delivered by the legal system for those cases which proceeded to court. It would appear that Dr Goodyear-Smith’s surmise is based on something other than evidence.
Suffice it to say that doctors trained by DSAC, and paediatricians employed by Te Puaruruhau, practise on the basis of the evidence and not ideology. All cases seen in Starship are diagnosed by the New Zealand STD reference laboratory, using state-of-the-art methods according to the highest international standards. All these cases are reviewed rigorously by a team of practising consultant paediatricians, who consider all means of transmission for which reasonable scientific evidence exists. We certainly make no presumption as to the guilt or innocence of any possible offenders. Our duty is to provide the highest quality of medical care to the child, and to leave any determination of guilt or innocence to a court.
Dr Janet Say is a Fellow of the Australasian Chapter of Sexual Health Medicine of the Royal Australasian College of Physicians and a Fellow of the Royal College of Pathologists. Dr Say was previously a clinical microbiologist at Auckland Hospital. She is also a senior practising Sexual Health Physician at Auckland City Hospital, and has been on the Auckland Police roster for sexual assault for nearly 20 years.
Dr Patrick Kelly is a Fellow of the Royal Australasian College of Physicians, and Honorary Clinical Senior Lecturer in Paediatrics in the University of Auckland Faculty of Medicine and Health Sciences, where he is responsible for the undergraduate and postgraduate curriculum on child abuse. Dr Kelly is a consultant general paediatrician at Starship Children’s Hospital, and Clinical Director of Te Puaruruhau, the team affiliated to Starship which deals with allegations of abuse in children and young people. He has been on the Auckland Police roster for child and adolescent sexual assault for 14 years.
NZLawyer, issue 77, 9 November 2007