A presentation on child sexual abuse based on WHO module and Ministry of Health and Family Welfare of India guidelines.

1. CHILD SEXUAL ABUSE
S RAAHAVENDHAR

2. People staging a road block agitation at Thudiyalur on Wednesday
demanding the arrest of the accused involved in the sexual assault
and murder of a seven-year-old girl from Kasthurinaickenpalayam in
Coimbatore. (COIMBATORE, MARCH 27, 2019 23:06 IST, THE
HINDU)

3. DEFINITION (WHO 1999)
 Involvement of a child in sexual activity
 that he or she 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 violates the laws or social taboos of society.
 Child sexual abuse is evidenced by this 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 the
other person.

4. DEFINITION…
 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 performance and
materials.

5. INDIAN SCENARIO
 MINISTRY OF WOMEN AND CHILD DEVELOPMENT STUDY IN 13
STATES- >12000 CHILDREN: 53% ABUSED, 22% SEVERELY ABUSED;
57% WERE BOYS.
 NATIONAL CRIME RECORDS BUREAU (NCRB):
 CHILD RAPE: MORE THAN 10,000 CASES PER YEAR

6. DYNAMICS OF CHILD SEXUAL ABUSE
 The sexual abuse of children is a unique phenomenon.
 Physical force/violence is very rarely used; rather the perpetrator tries to manipulate the child’s
trust and hide the abuse.
 The perpetrator is typically a known and trusted caregiver.

7. DYNAMICS OF CHILD SEXUAL ABUSE
 Often occurs over many weeks or even years.
 Frequently occurs as repeated episodes that become more invasive with time. Perpetrators
usually engage the child in a gradual process of sexualizing the relationship over time (i.e.
grooming).
 Incest/intrafamilial abuse accounts for about one third of all child sexual abuse cases

8. RISK FACTORS FOR VICTIMIZATION
 Female sex (though in some developing
countries male children constitute a large
proportion of child victims)
 Unaccompanied children
 Children in foster care, adopted children,
stepchildren
 Physically or mentally handicapped children
 History of past abuse
 Poverty
 War/armed conflict
 Psychological or cognitive vulnerability
 Single parent homes/broken homes
 Social isolation (e.g. Lacking an emotional support
network)
 Parent(s) with mental illness, or alcohol or drug
dependency.

9. DYNAMICS OF DISCOSURE
 ‘Child sexual abuse accommodation syndrome’
 Can be purposeful or accidental
 Usually a ‘process’ than a single event
 Usually to the mother, close friend, peer or teacher

12. GENITO-ANAL FINDINGS
Normal and non-specific vaginal findings
include:
 hymenal bumps, ridges and tags
 v-shaped notches located superior and
lateral to the hymen, not extending to base
of the hymen
 Vulvovaginitis
 labial agglutination.
Normal and non-specific anal changes include:
 Erythema
 Fissures
 midline skin tags or folds
 venous congestion
 minor anal dilatation
 lichen sclerosis

13. GENITO-ANAL FINDINGS…
Anatomical variations or physical conditions that may be misinterpreted or often
mistaken for sexual abuse include:
 lichen sclerosis
 vaginal and/or anal streptococcal infections
 failure of midline fusion
 non-specific vulval ulcerations
 urethral prolapse
 female genital mutilation
 unintentional trauma (e.g. straddle injuries)
 labial fusion (adhesions or agglutination).

14. GENITO-ANAL FINDINGS: SUGGESTIVE
OF ABUSE
 Acute abrasions, lacerations or bruising of the labia, perihymenal tissues, penis, scrotum or
perineum
 Hymenal notch/cleft extending through more than 50% of the width of the hymenal rim
 Scarring or fresh laceration of the posterior fourchette not involving the hymen (but
unintentional trauma must be ruled out)
 Condyloma in children over the age of 2 years
 Significant anal dilatation or scarring

15. GENITO-ANAL FINDINGS: DEFINITIVE
OF ABUSE/ SEXUAL CONTACT
 Sperm or seminal fluid in, or on, the child’s body
 Positive culture for N. gonorrhoeae or serologic confirmation of
acquired syphilis (when perinatal and iatrogenic transmission can be
ruled out)
 Intentional, blunt penetrating injury to the vaginal or anal orifice.

16. HEALTH CONSEQUENCES
PHYSICAL:
 Gastrointestinal disorders (e.g. irritable bowel syndrome, non-ulcer dyspepsia, chronic abdominal
pain)
 Gynecological disorders (e.g. chronic pelvic pain, dysmenorrhea, menstrual irregularities)
 Somatization (attributed to a preoccupation with bodily processes)

17. HEALTH CONSEQUENCES
BEHAVIOURAL:
 Depressive symptoms, anxiety, low self-esteem, symptoms associated
with PTSD such as re-experiencing, avoidance/ numbing,
hyperarousal; increased or inappropriate sexual behaviour, loss of
social competence, cognitive impairment, body image concerns,
substance abuse.

18. ASSESSMENT AND EXAMINATION
SCENARIOS WE MAY FACE:
1. A child sexual abuse allegation has been reported and there is a request for an examination by
the child protection authorities and/or the police.
2. The child is brought by a family member or referred by a health care professional because an
allegation has been made but not reported to authorities.
3. Behavioural or physical indicators have been identified (e.g. by a caregiver, health care
professional, teacher) and a further evaluation has been requested.

19.  Doctors are legally bound to examine and provide treatment to
survivors of sexual abuse.
 The timely reporting, documentation and collection of forensic
evidence may assist the investigation of the crime.
 Police personnel should not be present during any part of the
examination.

20. ASSESSMENT AND EXAMINATION

22. ASSESSMENT AND EXAMINATION:
HISTORY TAKING
 Two pronged: 1) Medical history, 2) Interview- Forensic
 Must be co-ordinated

24. CONTEXT QUESTIONS
Last occurrence of alleged abuse When do you say this happened?
First time the alleged abuse occurred. When is the first time you remember this
happening?
Threats that were made
Nature of the assault, i.e. anal, vaginal and/or oral
penetration.
What area of
your body did you say was touched or hurt?
Whether or not the child noticed any injuries or
complained of pain

25. CONTEXT QUESTIONS
Vaginal or anal pain, bleeding and/or discharge
following the event.
Do you have any pain in your bottom or genital area?
Is there any blood in your panties or
in the toilet?
Any difficulty or pain with voiding or defecating. Does it hurt when you go to the bathroom?
Any urinary or faecal incontinence.
Details of prior sexual activity (explain why you need
to ask about this).
Have you had sex with someone because you wanted
to?
History of washing/bathing since (a recent) assault.
First menstrual period and date of last menstrual
period

26. PHYSICAL EXAMINTAION
 Ensure privacy
 Prepare the child
 Presence of a care-giver

27. PHYSICAL EXAMINATION: POINTS TO
BE NOTED
 Height and weight (neglect may co-exist with sexual abuse).
 Bruises, burns, scars or rashes on the skin.
 In the mouth/pharynx, petechiae of the palate or posterior pharynx,
and tears to the frenulum/ Breast injury
 Any signs that force and/or restraints were used, particularly around
the neck and in the extremities.
 Child’s sexual development (Tanner) stage

28. PHYSICAL EXAMINATION
 Non-invasive and painless examination methods to be preferred.
 Speculums or anoscopes and digital or bimanual examinations to be
avoided, if medically not indicated. (Sedation or anaesthesia for
speculum examination should be strongly considered)
 Digital rectal examination only if medically indicated, as the invasive
examination may mimic the abuse.

29. COLLECTION OF EVIDENCE
 96 HOURS (INDIAN GUIDELINES)
 72 HOURS- SPERMATOZOA IDENTIFICATION
 ‘SAFE’ KIT- ‘SEXUAL ASSAULT FORENSIC EVIDENCE’ KIT

30. DIAGNOSTIC CONCLUSION
 DEFINITE ABUSE/ SEXUAL CONTACT
 PROBABLE ABUSE
 POSSIBLE ABUSE
 NO INDICATION OF ABUSE

31. DIAGNOSTIC CONCLUSION

32. TREATMENT
 SEXUALLY TRANSMITTED INFECTIONS
 HIV AND POST-EXPOSURE PROPHYLAXIS
 EMERGENCY CONTRACEPTION

33. SEXUALLY TRANSMITTED INFECTIONS

34. SEXUALLY TRANSMITTED INFECTIONS
 Blood sampling for HBsAg
 Administration of 0.06 ml/kg HBIG immediately (anytime upto 72
hours after sexual act).

35. HIV AND POST-EXPOSURE
PROPHYLAXIS
 IF THE CHILD PRESENTS WITHIN 72 HOURS
 IF THE PERPETRATOR IS HIGH-RISK INDIVIDUAL
 IF COMPLIANCE WOULD BE HIGH
 IF POSSIBLE AFTER CONSULTATION WITH A HIV SPECIALIST

36. EMERGENCY CONTRACEPTION
 WITHIN 5 DAYS (WITHIN 3 DAYS MOST EFFICACIOUS)
 LEVONORGESTREL 750 MCG 2 TABLETS STAT
(OR)
MALA-D (ETHINYL ESTRADIOL+ LEVONORGESTREL)- 2+2 (IN 12 HOURS)
 PREGNANCY ASSESSMENT DURING FOLLOW UP

37. FOLLOW UP
 AFTER 2 DAYS, 3 WEEKS, 6 WEEKS
 VDRL REPEAT AFTER 6 WEEKS/ PREGNANCY TESTING/
PSYCHOLOGICAL ASSESSMENT

38. PSYCHOSOCIAL CARE
 Making the child believe that recovery from abuse is possible
 Strategies such as good touch and bad touch can be taught
 Restricting child's mobility such as not being allowed to play with friends, not allowed to go to
school, not allowed to visit friends, may be perceived by the child as punishment for something
the child had no control on.
 Encourage the child to carry on with his/ her daily routine.
 Follow up with crisis counselling so that the child is able to deal with negative feelings and also
heal from the abuse.

40. THANK YOU