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Sexually transmissible infections (STIs) occupy a unique position in medicine. Like other infections, they are caused by micro-organisms specially adapted to their environment—in their case, to environments involved in human sexual behaviour (the urogenital tract, the oropharynx and the rectum). However, unlike most other infections, they may also be interpreted as evidence of infidelity, immorality or serious criminal offending.
The implications of STIs make disease surveillance difficult, even among adults engaged in consenting sex. Reading et al1 extend surveillance into the most sensitive area of all—childhood. The article follows previous work on genital herpes and attempts to define a population-based incidence for the most common non-viral STI in children.
The validity of the incidence they describe is built on serial assumptions. Children with genital symptoms were brought for healthcare. Their symptoms were adequately assessed. Samples were taken and processed correctly. Positive results were notified to a paediatrician and to the Paediatric Surveillance Unit. All these assumptions are open to challenge. Children may not discuss genital symptoms. Adults may not notice those symptoms or seek treatment. Girls with dysuria may be treated for urine infection with no examination to exclude vulvitis. Routine swabs will not detect chlamydia or trichomonas and will not facilitate survival of gonorrhoea. Syphilis serology will not be performed on a child unless they present with symptoms of primary or secondary disease. If infection is found, the chain of communication may involve microbiology, a primary provider, a sexual health physician and a paediatrician. …