Medical Procedures and Protocols in Child Sexual Abuse

By Dr. Chhaya Prasad *

As far as the clinical aspect is concerned, a child is defined as one who is less than 12 years of age for obtaining medical care in a Government health facility in India. A request from Indian Academy of Pediatrics to increase the age limit up to 18 years is still under consideration by the Government of India. As the context here is child-rights and child abuse, the legal definition of the child, by age, is important. During the initial census of India, persons below the age of 14 years were defined as children and most of the Government programs on children are still targeted for the age group below 14 years. Thereafter, the UN Convention on the Rights of the Child, 1989 (Article I) defined the child as below 18 years of age. 

In India, the legal definition of child varies from seven years to eighteen years of age, but after the introduction of the Juvenile Justice Care and Protection of Children Act, for all practical purposes, a child is considered as a person below 18 years.

1. The Juvenile Justice (Care and Protection of Children) Act, 2000: “Juvenile” or “Child” means a person who has not completed eighteenth year of age.

2. Family Law (Child Marriage Restraint Act, 1929): „Child. means a person who, if a male, has not completed twenty one years of age, and if a female, has not completed eighteen years of age.

3. Criminal Law (Indian Penal Code, 1860): Nothing is an offence which is done by a child under seven years of age (Section 82). Nothing is an offence which is done by a child above seven years of age under twelve, who has not attained sufficient maturity of understanding to judge the nature and consequence of his conduct on that occasion (Section 83).

4. United Nations Conventions on the Rights of the Child, 1989 (Article I): A child means every human being below the age of eighteen years unless, under the law applicable to the child, majority is attained earlier.

5. Constitution of India, Article 24: Any one below the age of fourteen.

6. The Child Labor (Prohibition and Regulation) Act, 1986: „Child. means a person who has not completed his fourteenth year of age.

Definition of Child Sexual Abuse According to the World Health Organization (Used by Medical practitioners for all practical purposes) 

Child abuse or maltreatment constitutes all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child.s health, survival, development or dignity, in the context of a relationship of responsibility, trust or power (WHO 1999).

Physical abuse of a child is that which results in actual or potential physical harm from an interaction or lack of interaction, which is reasonably within the control of a parent or person in a position of responsibility, power, or trust. There may be single or repeated incidents (WHO 1999). Any non accidental injury resulting from the following actions done with intention to harm a child - punching, hitting, throwing, kicking, chocking, biting, shaking, heating and burning with an object, scalding, banging, etc. 

Child sexual abuse is the involvement of a child in sexual activity that s/he does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared and cannot give consent, or that violate the laws or social taboos of society. Child sexual abuse is evidenced by an activity between a child and an adult or another child who by age or development is in a relationship of responsibility, trust or power; the activity being intended to gratify or satisfy the needs of other person. 

This may include but is not limited to: 

• The inducement or coercion of a child to engage in any unlawful sexual activity
• The exploitative use of a child in prostitution or other unlawful sexual practices
• The exploitative use of children in pornographic performances and materials (WHO, 1999).

At the expense of a child, the involvement of the child in sexual activity intended to gratify the needs of another person: inappropriate kissing, unnecessary touching either directly or through clothing the private body parts of a child for reasons other than hygiene or health care purposes, fondling, exhibitionism, voyeurism, vaginal, oral and anal intercourse, pornography incest, rape, etc. 

Emotional abuse includes the failure to provide a developmentally appropriate, supportive environment, including the availability of a primary attachment figure, so that the child can develop a stable and full range of emotional and social competencies commensurate with his/her personal potential, and in the context of the society in which the child dwells. There may also be acts toward the child that cause or have a high probability of causing harm to the child.s health or physical, mental, spiritual, moral or social development. These acts must be reasonably within the control of the parent or person in a relationship of responsibility, trust or power. Acts include restriction of movement, patterns of belittling, denigrating, scapegoating, threatening, scaring, discriminating, and ridiculing.

Child abuse is a misuse of power by adults over children that endangers or impairs a child.s physical or emotional health and development. Here we are referring to all kind of abuse, physical, sexual or emotional abuse. It is commonly believed that child abuse is a problem of lower socio-economic class and happens to vulnerable children staying in unsafe places but the truth is that most of the abuse occurs to normal children in regular homes. An episode of abuse can occur anywhere, at home, in streets, public places, foster homes, schools, etc. All children can be at risk, whether they are normal children or the vulnerable group. Vulnerable group includes destitute children, orphans, abandoned children, street children; HIV/AIDS affected children, child beggars, substance/drug abusers, child laborers and neglected children. Children of poor parents or with physical, mental or terminal illness, children with a single parent, children of refugees, migrants, construction workers and of prostitutes, rape victims, sex workers also form a part of the vulnerable group. The abusers can be parents, care-givers, teachers, neighbors, family members, frequent visitors, strangers, employers etc. Parents turn abusers if they are immature, have poor parenting skills, personality disorders, mental health problems,

social pressures, are victims of domestic violence, when they single parents or are substance abusers. 

Pediatrician's Response 

A pediatrician's response to a case of child sexual abuse in outpatient and inpatient settings is based on the following cardinal principles. 

1. Child centered and child friendly: It keeps the best interest of child in mind. Safety of the child is considered to be of utmost importance. 

2. Family supportive: Response should provide adequate support to the family as family forms the backbone of the child protection system. Keeping the child permanently in an institution is the last option in child protection. 

3. Provision of legal safety to the Pediatrician managing the case: The management and documentation of the case should be impeccable to avoid professional litigation later. The goal of a pediatrician.s response includes:

1. Short term goal is to ensure safety and provide emergency care if needed.

2. Comprehensive medical assessment including history taking, examination and investigations. To ensure proper documentation.

3. Short term goals include providing immediate emotional (counseling) and social support to the child and family and treating physical problems like injuries, providing immunization, STD prophylaxis and emergency contraception.

4. Long term goals include complete physical and psychosocial well being of the child as well as ensuring reintegration into the family and social system.

When a child is brought with history of unexplained injury or a genital infection, a high index of suspicion should be kept in mind. A detailed medical and social history, including presenting symptoms is mandatory. Any history of fall, fracture or injury (including head injury), unexplained bruises, redness, poor growth and stunting, recurrent UTIs or abdominal/ perineal/ anal pain and mouth and genital sores or discharge should be noted. 


Behavioral History will include:

• Fear of certain people or places, nightmares, trouble sleeping, or other extreme fears without an obvious explanation.
• Loss of appetite, or trouble eating or swallowing or sudden changes in eating habits.
• Sudden mood swings: rage, fear, anger, insecurity or withdrawal, unexplained abdominal pain.
• Bed-wetting or thumb sucking, adult-like sexual activities with toys or other children, new words for private body parts, resistance to bathing, toileting, or removing clothes.
• Talking about a new older friend.
• Inconsistency in history, complaints not correlating with physical findings, previous or repeated similar injuries / complaints of illness but delay in seeking medical help.
• Circumstantial evidence should be noted.

Comprehensive Medical Assessment The presence of a chaperone, preferably a nurse is a must during the assessment. The assessment should be recorded in a special Performa. History taking from the parent or caretaker should be documented separately from that of the child. History should be taken with a sensitive, empathic and nonjudgmental attitude and recorded verbatim. Repeated interviews are avoided. The child and the parents are to be treated with respect and dignity without making accusations. Points to be covered in history include place, time, witness, present and past history, noticeable behavior change, developmental and immunization history. Family history, pedigree chart and social history are extremely important. 

A psycho social history known by the acronym HEEADDSS can be taken directly from an adolescent patient. This includes details regarding home, education, eating behavior, activities and peers, drugs, depression, suicide, sexual history and sleep pattern. To make a final conclusion after discussing the case with seniors, peers, psychologists and probably even NGOs and social worker. 

The responses of a pediatrician to a child abuse case can be broadly classified into the following:

1. Urgent response is needed if the child is brought dead or with a life threatening injury or with acute sexual assault (reports within 72 hours of the abuse). The child will need emergency care and the police would require immediate forensic samples to book a strong case against the abuser. Such cases are best managed in a government hospital setting.

2. Admission to the hospital is needed in all cases of serious injuries. A child may be admitted incase it is felt that there is an immediate threat to his safety at home.

3. Social Services like Child Welfare Committee (CWC) and Child Helpline (#1098) or local NGOs to be contacted if the parents refuse to follow the treatment plan or if there is an immediate threat to safety of other sibs. CWC and Child Helpline can also be contacted in any case where child rights are violated like neglect, child labor, corporal punishment at school, child marriage etc.

4. Planned response is the best. Here a planned interview and examination are performed in a child friendly atmosphere with the appropriate equipment and health personnel (social worker, psychologist, gynecologist if needed). A child friendly atmosphere is one that is sensitive to the needs of the child, where he/she feels comfortable, relaxed and at ease to confide his problems.

Examination Parental and (preferably) the child.s consent are essential for a medical examination. The child may prefer to get examined by a doctor of the same sex. He/she may also choose to have a trustworthy adult during the procedure. The pediatrician may seek the expertise of a forensic physician and a gynecologist while examining a case of sexual abuse. 

The following should be recorded:

1. Resistance to examination, especially in a case of sexual abuse and dissociation (going to sleep during examination)

2. General demeanor (like unkempt appearance in neglect)

3. Vitals and tip-to-toe general physical examination, especially noting pallor, bruises, vitamin deficiencies

4. Height, weight and head circumference to be plotted on growth chart

5. Sexual Maturity Rating for adolescents

6. All injuries are to be marked on anatomical diagrams. Special sites to look for injuries include ears, inside the mouth, soles, genitalia and anus.

7. Systemic examination is done especially to look for other injuries.

8. Examination of genitalia in girls should be done in supine frog leg, knee chest prone and left 

lateral position. 

Details of hymen and injuries are to be noted. If possible, photographic evidence to be recorded. Anal dilatation on a rectal examination indicates sodomy. Presence of discharge, genital ulcers, warts and inguinal lymphadenopathy are to be noted. It is important to note that in 70-85% cases of documented sexual abuse, the physical examination is normal. Examination of clothes of victim for semen stains, struggle tears, trace material etc. should be done.

Investigations The following investigations need to be done. 

Sexually Transmitted Disease screening, including low and high vaginal (in post pubertal girls) swabs and urethral swabs in boys and serology for HIV, Hepatitis B and Syphilis are done in cases of:

• Acute sexual assault
• Penetrative abuse
• Vaginal/ urethral discharge
• STD in abuser
• Pregnancy test is done for an adolescent girl

Forensic samples maintaining the chain of evidence include skin, hair, clothing, saliva, oral and genitourinary secretions are sent in cases of acute sexual assault. Skeletal survey can be done to explain associated multiple unexplained injuries. It is mandatory if the abused child is below 2 years. Multiple bruising entails a detailed hematological profile, including bleeding and coagulation profile. Neuro imaging and Ultrasonography of abdomen are indicated in a case of head and abdominal injury respectively. 

Management


Management should be child friendly and should aim at achieving the short term and long term goals. The current and future plans of action should be discussed with the non offending family members. The need for breaking immediate contact with the abuser if he/she is a known person should be emphasized.

1. Accelerated Hepatitis B vaccination schedule(0,1,2, 12) should be considered if the sexually abused child is not vaccinated. DPT/ DT vaccination should be given in non vaccinated children.

2. STD prophylaxis and Emergency Contraception is to be given to an adolescent with acute sexual assault.

3. Multiple types of abuse may co exist in the same patient and should be looked for. Counseling of the child and family forms the corner stone of the management.

The immediate counselling of the child that can be done by the paediatrician focuses on the following:

1. Believe the child, reassure and absolve feelings of guilt/ blame.

2. Explain about the existence of a medical, family and social support system.

3. Listen carefully to all fears and concerns associated with disclosure.

4. Teach coping and assertive skills.

5. Referrals to appropriate specialties should be made according to the need of the child. 

These will include psychologist, psychiatrist, orthopedic surgeon, surgeon, social services and police. The family members may also need counseling and treatment from mental health professionals.

Medicolegal Aspects: Documentation and Reporting 


Most victims of child abuse are brought directly to hospitals, usually Government hospitals, for medical examination by police. They may be accompanied by Social worker (NGO), but at times are brought by parents / guardians. At times, there can be incidental recognition of child abuse when they are brought for some other medical problem for consultation. The child can also be brought merely for age determination. At present there is no uniformity in text of report, method of examination or prescribed format for documentation. 

Different states follow different practices depending on local laws and procedures. Medical examination is done in a routine matter without proper clinical or forensic screening. Swabs and slides are taken only in sexual assault cases without giving due importance to minute details and injuries. Age determination, which is mandatory as per the Prevention of Immoral Traffic Act, is done only on request and done only in few hospitals. Age range given in reporting is too wide, which often goes against the victim and favors the accused. 


How and what should be documented 


All consultations with the patient should be in hand written notes, with diagrams, body charts, and if possible. 

During examination of a case of sexual abuse, the police need to be informed and consent is a must. Complete examination is necessary. Evidence collection (specimens) is to be done and samples are carefully preserved in refrigerator or suitable place. Photographic documentation should be done wherever possible. It should be understood that both age determination and complete examination requires multidisciplinary references. Their opinions either in person or telephonically should be recorded.

The examining doctor should make sure that important details are not omitted. All aspects of consultation should be documented and detailed notes must be made during the consultation, Patient.s records have to be kept strictly confidential and stored securely. The documentation should be confined to areas of health care expertise only; interpretation of the same has to be

done by a trained person if the examining Medical Officer is not trained in examination of medico-legal cases. 


Consent:


Consent is a voluntary agreement, permission or compliance, it may be

1. Expressed,

2. Implied or

3. Written.

In other words, according to Section 13 of the Indian Contract Act, two or more persons are said to consent, when they agree upon the same thing in the same sense at same time. 


Follow up 


Follow up after 2 weeks is essential to reassess the child. In acute sexual assault of an adolescent girl, a repeat pregnancy test is warranted. A repeat serology for syphilis at 4-6 weeks and for HIV at 3-6 months is required. The long term after-effects of abuse on the physical and mental health are well known, but some children suffer no adverse consequences. 

The outcome is influenced by the following factors:

• Nature, extent and type of abuse
• Age of child, temperament and resilience of the child, relationship of abuser to the child
• Response of the family to abuse and medical management

A single episode of non contact sexual abuse by a stranger may just need reassurance and letting out feelings in one or two counseling sessions. It usually has a good outcome. Prolonged abuse by a close family member requires longer and multiple counseling sessions to heal completely. 

Regular follow up of the abused children includes the following: 

1. To verify if abuse has stopped. 

2. To monitor physical and mental health. 

3. To evaluate development and ensure that it is normal. 

4. To refer for therapy (counseling, cognitive behavior therapy or medication) for delayed presentation of symptoms. 

Child Protection Services


The Existing Services are CHILDLINE, Child Welfare Committee, Local NGOs, National Commission for Protection of Child Rights, and the Police. There is need for a Child Protection Group for Comprehensive Services that includes a Pediatrician, Psychologist, Psychiatrist, Gynecologist, Surgeon, Forensic Expert, Social Worker, Police, and Lawyer. (Source: WHO, UNICEF, CRY, CSWB, DWCD document – 1st National Conference on Child Abuse for Multidisciplinary Professionals in Feb. 2004, Chennai organized by ICCW, Chennai and SRMC, Chennai, Manual on Recognition and Response to Child Abuse: The Indian Scenario, IAP) 

* - Dr Chhaya Prasad is a Developmental and Behavioural Paediatrician, at the Govt. Regional Institute for Mentally Handicapped, Chandigarh. She recently successfully completed her post graduation in Developmental Neurology from the Kerala Univesity.