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 Child sexual abuse:
Prevention and response

Preface
The UN Convention on the Rights of the Child (UN CRC), ratified by India in 1992, urges States
to ensure the right of children to protection from abuse, violence, neglect and exploitation.

Available data on child sexual abuse is often not reflecting the real magnitude of the
phenomenon due the taboo and culture of silence around it and the difficulties to research
the subject. Yet, the 2007 Ministry of Women and Child Development Study and other micro-
studies suggests child sexual abuse is an alarming reality in India.

India has recently adopted The Protection of Children from Sexual Offences Act (POSCO),
2012. This is the first comprehensive law on sexual abuse which expands the scope and range
of forms of sexual offences, makes reporting of abuse mandatory and defines guidelines for
child friendly police and procedures. Together with the Juvenile Justice Act, POCSO has
created an opportunity to ensure greater protection to children that have suffered abuse.

Doctors and health care professionals are often the first point of contact with abused children
and their families. They play a keyin detecting abuse and providing immediate and longer
term care and support to children and their families.

The present booklet provides an overview of child sexual abuse prevention, detection and
management of abuse from a legal, medical and mental health angle. It aims to serve as a
guide to ensure a prompt and adequate response to victims of child sexual abuse, not only
for physicians, but all also for allied professionals. It can be used both as a compendium of
information as well as a resource manual for training.

The booklethas been developed through the contributions of a group of experts and
professionals whom IMA and UNICEF would like to thank: Ms. Vidya Reddy; Dr. Jagadeesh
N. Reddy; Dr. Rajesh Sagar; Ms. Hamsa Vijayaraghavan; Dr. Rajeev Seth and Dr. Anandi Lal.

The IMA and UNICEF pledge to exert every future effort in collectively implementingthe
principles of protecting UN child rights, prevention and management of child sexual abuse
in all settings in India.

Dr. Jitendra B.Patel

National President, IMA

Dr. Narendra Saini

Hony. Secretary General, IMA

Dr. Vinay Aggarwal

President,
The Confederation of Medical Associations in
Asia and Oceania (CMAAO) Member,
Medical Council of India

Louis-Georges Arsenault
Representative, UNICEF India
Introduction
India is home to the largest child population in the world, with almost 41 per cent of the
total population under eighteen years of age1. Needless to say, the health and security of
the countrys children is integral to any vision for its progress and development. However,
there has been a steady increase in sexual crimes against children, and according to a study
conducted by the Ministry of Women and Child Development in 2007, over half of the children
surveyed reported having faced some form of sexual abuse2.

Doctors, nurses, and other health sector professionals are important stakeholders in the
prevention and response to sexual violence against children. According to the Adverse
Childhood Experiences (ACE) Study, a major American research project examining the effects
of adverse childhood experiences on adult health and well-being, a powerful relationship
has been established between emotional experiences during childhood and physical and
mental health during adulthood 3 . Sexual abuse is an extremely traumatic experience that
can affect the body as well as the mind, and the reaction of the body and the mind to
such an occurrence could leave a lasting impact on the health conditions for any person at
any age. Studies have consistently demonstrated that sexual abuse suffered in childhood
is associated with a broad range of behavioral, psychological and physical problems that
persist into adulthood; these include anxiety, depression, Post-Traumatic Stress Disorder
(PTSD), self-destructive behavior, dissociation, substance abuse, sexual maladjustment, and
a tendency towards revictimization in subsequent relationships 4 . Adult survivors of childhood
physical, emotional, or sexual abuse are not only at increased risk for depression and other
mental health disorders, but new evidence suggests they are increasingly more likely to
suffer from heart disease, obesity, and other potentially fatal physical conditions. Thus, it is
imperative that the right kind of intervention and opportunity for recovery be provided at the
right time. This is why the role of the health sector is such an important one.

This booklet provides a brief overview on child sexual abuse (CSA). It offers key information
to health professionals (doctors, nurses and mental health professionals) on how to prevent,
detect and respond to abuse. It provides insights on the Indian law for the protection for
child victims and specifies the role for the medical sector. Finally, it gives inputs to health
professionals on how to manage cases of child sexual abuse. A bibliography is available for
further reading.

1
National Cen sus 2001.
2
Ministry of Women and Child Development, Study on Child Abuse
3
http://www.cdc.gov/violenceprevention/acestudy/
4
Browne, & Finkelhor, 1986; Roesler & McKenzie, 1994

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 Child sexual abuse:
Prevention and response

What is meant by sexual offences against

children?
Definition 5
Sexual abuse refers to the involvement of a child in any sexual activity that:

the child does not understand;

the child is unable to give informed consent to;
the child is not developmentally prepared for and cannot give consent to; and,
violates the laws or norms of society.
Under the Protection of Children from Sexual Offences (POCSO) Act, 2012, any sexual
activity with a child below 18 years, whether boy or girl, is a crime.

As defined by the Act, sexual offences include penetrative sexual assault (Section 3),
sexual assault (i.e., non-penetrative) (Section 7), sexual harassment (Section 11), and
use of a child for pornography (Section 13).

Sexual offences under the Act include:

actual or attempted penetrative sexual intercourse with a child;
non-penetrative sexual activity, e.g. rubbing the penis between the childs thighs or
genitals;
fondling a childs sexual parts, i.e. genitals, breasts or buttocks;
oral sex with a child, i.e. mouth to sexual parts;
forcing a child to masturbate another person;
masturbating a child;
the adult showing his or her private parts to the child;
inappropriately watching a child undress or using the bathroom;
photographing a child in sexual poses;
the exploitative use of a child in prostitution or any other unlawful sexual practice;
the exploitative use of children in pornography;
showing pornography or any pictures of a sexual nature to the child that he or she does
not want to see; and
letting the child watch or hear an act of sexual intercourse.

Prevalence of Child Sexual Abuse

Data on CSA is difficult to obtain as it is often based on reporting and is associated with
social taboos and a culture of silence that prevents victims from disclosing. The table below
provides data across regions in the world for females and males, based on surveys conducted
around the globe. On average, Asia has a prevalence rate of 11.3% for females and 4.1% for
males.

5
1999 WHO Consultation on Child Abuse Prevention, quoted in WHO Guidelines for Medico-Legal Care of Victims of Child
Sexual Violence, Chapter 7

3
Findings on the prevalence of child sexual abuse by region from 2 meta-analyses,
Stoltenborgh et al 2011

Region Lifetime prevalence in females Lifetime prevalence in males

Africa 20.2% 19.3%
Asia 11.3% 4.1%
Australia 21.5% 7.5%
Europe 13.5% 5.6%
South America 13.4% 13.8%
USA & Canada 20.1% 8.0%

Data on child sexual abuse in India is scarce for the same reasons outlined above. The table
below provides a few snapshots.

The Statistics on CSA in India

In 2007, the Government of India published its first (and so far, only) report on CSA.
This Report reveals: Of the children interviewed, over 53% reported having faced
some form of CSA
Over 57% of these were boys.
72% said they did not report the abuse to anyone.
Only 3% reported CSA to the police.
In 2005, the international organization Save the Children and the Indian NGO, Tulir -
Centre for Healing and Prevention of Child Sex Abuse, surveyed 2,211 school-going
children from different backgrounds in Chennai.

48 percent of the boys and 39 percent of the girls interviewed said they had faced
some form of CSA
15 percent of these children had faced severe forms of abuse, defined in this study as
oral sex, sexual intercourse, making the child touch the offender's private parts, or
making the children take off their clothes and looking at them or taking their pictures.

Where does CSA take place?

Child sexual abuse can occur in a variety of settings, including home, school, or work (in
places like India, where child labor is common).

Who are the perpetrators?

Child sexual abuse can take place in the family - by a parent, step-parent, sibling or other
relative. It is almost always by someone the child knows ... friend, neighbor, childcare giver,
teacher, etc. The Study on Child Abuse conducted by the Ministry of Women and Child
Development of the Government of India in 2007 found that in most cases, the perpetrator
was known to the child. For example, 31 percent of sexual assaults were committed by the
victims uncle or neighbor.

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 Child sexual abuse:
Prevention and response

Offenders come from all walks of life and cannot be picked out or identified by appearance. It
is therefore essential to pay attention to behaviours (and patterns) and situations that present
risk rather than focusing on an individuals character. Young people can also sexually abuse
younger children or their peers but the dynamics of offending may slight vary.

Vulnerabilities of children
Due to their age and being experientially immature paired with the fact that children are still
developing socially and emotionally, children can be easily confused, controlled & coerced.
Most of them would not be able to interpret or understand an adults intent. Children give
unconditional love and seek attention and affection. In addition to this, socio-cultural norms
mandate that children respect and listen to adults. A person who intends to commit a sexual
offence against a child, or to groom so as to abuse that child sexually, would be able to take
advantage of all these factors.

If the child is an adolescent, his or her vulnerability increases as they are curious, rebellious,
and easily aroused.

Some of the higher risk factors for a child to become a victim of a sexual offence include
isolation (such as children in institutions, children living on the street, working children,
children of families in transition, children with disabilities, and children from dysfunctional
families).

Grooming
Grooming is a method of building trust with a child and adults around the child in an effort to
gain access to the child and increase the chances that the child will not consider the sexual
advances of the perpetrator untoward or improper. However, in extreme cases, offenders
may use threats and physical force to sexually assault or abuse a child.

The purpose of grooming is:

To reduce the likelihood of a disclosure.

To reduce the likelihood of the child being believed.
To reduce the likelihood of being detected.
To manipulate the perceptions of other adults around the child.
To manipulate the child into becoming a cooperating participant/feeling complicit, which
reduces the likelihood of a disclosure and increases the likelihood that the child will
repeatedly return to the offender.

Grooming Behaviour
Although not all child sexual abuse involves grooming, it is a common process used by
offenders.
It usually begins with subtle behaviour that may not initially appear to be inappropriate,
such as paying a lot of attention to the child or being very affectionate.
Many victims of grooming and sexual abuse do not recognize they are being manipulated,
nor do they realize how grooming is part of the abuse process.

5
 Often, the abuser actively encourages the child to keep their interaction a secret.
He/she may also try to isolate the child from persons to whom he or she is close, by saying
that person wouldnt understand their love.
The touching may start in a way that feels vaguely confusing for a child, like tickling or
hugging. For example, they may use touching as a game or introduce sexual touching as
accidental.
They are likely to blur the boundaries of ordinary affection so the child confuses this with
the abuse. This often occurs around the child's normal bathing, dressing and bedroom
routines.
The objective of grooming is to ensure that the child will not protest, and will keep the
secret.

Behaviours that may suggest a potential perpetrators:

An adult who seems overly interested in a particular child.
An adult who frequently initiates or creates opportunities to be alone with a child (or
multiple children).
An adult who becomes fixated on a child.
An adult who gives special privileges to a child (e.g. treats, gifts, etc.).
An adult who befriends a family and shows more interest in building a relationship with
the child than with the adults.
An adult who displays favouritism towards one child within a family.
An adult who caters to the interests of the child, so a child or the parent may feel
emotionally dependent on the offender.
An adult who displays age and gender preferences.
An adult who tests the childs boundaries (and the childs ability to protect him/
herself) through the telling of sexual jokes, playing sexual games(non-sexual touching
to accidental sexual touching, so the child may not identify it as purposeful,
inappropriate touching) in an attempt to see if s/he is at risk to tell someone.

Consequences of child sexual abuse

CSA leads to a range of physical as well as emotional/ mental health consequences. These
depend on a number of factors, such as the duration of abuse, the age of the child, and the
type and availability of support. Below are some of the symptoms and indicators that should
raise an alarm if detected by a medical professional.

Physical Symptoms:
Sexually transmitted diseases,
Pregnancy,
Complaints of pain or itching in the genital area,
Difficulty in walking or sitting,
Repeated unusual injuries,
Pain during urination and/ or defecation, and
Frequent yeast infections.

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 Child sexual abuse:
Prevention and response

Behavioural Indicators:
It is important to pay attention to changes in a childs behaviour as children communicate
how they are feeling through their behaviour. If an adult notices any of manifestations, he/
she should not automatically conclude that s/he has been victimized this may be one of
several possibilities. Rather, he/she should provide support and assistance to help determine
what could be the cause of them. It is important to note that change in a childs behaviour
should be further explored, regardless of whether sexual abuse is believed to be the
reason or not.

Look out for:

Abrupt changes in behaviour,

Refusal to undress for physical examination,
Report of sexual involvement with an adult or child,
Excessive Fear of specific places, men or women,
Fearful or startled response to touching,
Recurrent physical complains without physiological basis,
Tendency to self-harm,
Wearing many layers of clothing regardless of the weather,
Recurrent nightmares or disturbed sleep patterns and fear of the dark,
Regression to more infantile behaviour like bed-wetting, thumb-sucking or excessive
crying,
Poor peer relationships,
Eating disturbances,
Negative coping skills, such as substance abuse and/or self-harm (in older children),
An increase in irritability or temper tantrums,
Fears of a particular person or object,
Disrespectful behaviour and aggression towards others,
Poor school performance, and
Advanced sexual knowledge. This means the child knows more about sexual behaviour
than is expected of a child of that age.
Other behaviours may include:
The child may hate his/her own genitals or demand privacy in an aggressive manner;

The child may dislike being his or her own gender;

The child may use inappropriate language continuously in his or her vocabulary or may

use socially unacceptable slang; and/or

The child may carry out sexualised play (simulating sex with other children).

How does sexual abuse affect children emotionally?

Children who have been sexually abused often continue to suffer even after the abuse has
ended. Some of the psychological harms will be obvious to family members, others may
remain hidden. The effects of abuse may take these forms:

Confusion. Children may have many mixed feelings about what happened to them and
about what happened after they told, depending on the reactions of family and friends.
Guilt. Children may feel guilty, believing they are in some way responsible for the abuse.

7
 Shame. The guilty secret may make them feel worthless.
Fear. If the abuser has threatened that something terrible will happen if they reveal the
secret, they may be afraid.
Grief. Children may stop seeing the world as a safe and friendly place. They may mourn
the loss of their sense of innocence and freedom. They may also mourn the loss of the
relationship with the abuser if there had been a close bond between them.
Anger. They may feel intense, and often uncontrollable anger. Because they cant strike
back at the abuser, they may lash out at another person or they may hurt themselves,
others or a pet.
Helplessness. Because they felt helpless at the time of the abuse, they may feel unable
to resist sexual abuse in the future.
Depression. They may seem sad and less playful. They may lose interest in school,
friends and activities. Depending on how serious the abuse is, and on the childs nature,
these feelings may show up in several ways, for example, physical complaints, problems
in sleeping and eating, irrational fears, an inability to concentrate in school, macho or
seductive behaviour and/or sexual aggression. Even if there are no symptoms, it doesnt
mean that the child doesnt need help it just means that there are no immediate or
outward signs of the abuse.

How Children Disclose Abuse

Disclosure refers to when a child opens up and says that he or she has been sexually
abused. A childs capacity to disclose is impacted by several factors, including the childs
age, sense of safety, available resources and other factors relevant to the particular context.

Often, disclosure of sexual abuse is a process; thus, a child may first give hints about the
abuse to see how an adult reacts before he or she is able to give full disclosure.

Disclosure can be direct, i.e. when the child tells someone about the abuse; or indirect, when
the abuse is discovered as a result of the child becoming pregnant or contracting a Sexually
Transmitted Disease. How the abuse was discovered can impact the childs willingness to
share information about it; some children may be ready to talk, share and receive help while
some children may be afraid to do so.

Why a child may not disclose abuse

He/she is embarrassed Believing and supporting
The child blames himself/ herself and thinks the the child are two of the best
actions to start the healing
abuse is their fault
process. Appropriate and helpful
He/ she does not know if what is happening to
responses to disclosures are as
them is normal or not
follows:
The abuser is a known person and the child does
not want to get them in trouble I am glad you told me, thank you
The abuser told the child to keep it a secret for trusting me.
The child is afraid that no one will believe him/ her You are very brave and did the
The abuser bribes or threatens the child right thing.
He/ she thinks you already know It wasnt your fault.
The child is very young and is not aware that he/ I am proud of you for telling me.
she is experiencing sexual abuse.

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 Child sexual abuse:
Prevention and response

Preventing Child Sexual Abuse

Doctors and other medical professionals can help to prevent CSA by delivering messages on
personal space and privacy to their young patients and their parents. They can do this by:

Talking to parents about the importance of teaching their children about their personal
space and privacy by 3 years of age
Encouraging parents to teach their children the concept of OK and NOT OK touching
and the need to tell if anyone touches their private parts for a reason other than to
provide care.
Encouraging parents to teach their children not to keep secrets.
Telling parents that they should limit the individuals who provide genital, perianal and
bathing care to those who they trust to reduce risk.
Letting parents know that it is best to ensure the children become independent in taking
care of their own genital/perianal care.
Encouraging parents to teach their children the appropriate names for their private parts
so they have the language to communicate.
Looking out for signs that a child is being abused and take necessary action.
Talking to other colleagues in the health care sector about CSA.

The Law on Child Sexual Abuse:

The Protection of Children from Sexual Offences Act, 2012
The POCSO Act came into force in November 2012 to provide for the protection of children
from the offences of sexual assault, sexual harassment and pornography.
The Act defines a child as any person below eighteen years of age. It includes child-
friendly mechanisms for reporting, recording of evidence, investigation and speedy trial
of offences through designated Special Courts.
It defines different forms of sexual abuse, including penetrative and non-penetrative
assault, as well as sexual harassment and pornography.
It deems a sexual assault to be aggravated under certain circumstances, such as when
the abused child is mentally ill or when the abuse is committed by a person in a position of
trust or authority vis-a-vis the child, like a family member, police officer, teacher, or doctor.

Mandatory Reporting
The Act provides for mandatory reporting of sexual offences, so that any adult, including a
doctor or other health care professional, who has knowledge that a child has been sexually
abused is obliged to report the offence, failing which he may be punished with six months
imprisonment and/or fine (Sections 19 and 21 of the POCSO Act).

When reporting, the doctor or other health professional should describe the nature of the
abuse and the involved parties (if he/she is aware of them). He or she should be prepared to
give the name, address, and telephone number of the child and also the name of the parent
or caretaker if known. However, he or she is not expected to investigate the matter, or even
know the name of the perpetrator. This should be left to the police and other investigative
agencies.

9
The report may be made to the Special Juvenile Police Unit, or to the local police station.
Alternatively, a call can be made to the Childline Helpline at 1098 and they can then assist
the reporter in making the report.

"Child sexual abuse is a preventable health problem that has been allowed
to spread unabated due to scientific and social neglect."
-PAUL FINK, SCIENCE, VOL 309, AUGUST 2005

The Act does not lay down that a mandatory reporter has the obligation to inform the
child and/ or his parents or guardian about his duty to report. However, it is good practice
to let parents/guardians know that action to report will be taken. This will help establish
an open relationship and minimize the childs feelings of betrayal if a report needs to be
made. When possible, the medical professional should discuss the need to make a child
abuse report with the family and with the child if in his/best interest, according to the
age and maturity of the child. However, be aware that there are certain situations where
if the family is warned about the assessment process, the child may be at risk for further
abuse, or the family may leave with the child.

Role of Health Professionals under the Act

Doctors have a dual role to play in cases of CSA. They are in a position to detect that a child
has been or is being abused (for example, if they come across a child with an STD); they are
also often the first point of reference in confirming that a child has indeed been the victim of
sexual abuse.

Under Section 27 of the POCSO Act, the doctor must conduct a medical examination as per
the provisions of Section 164A Criminal Penal Code. Where the victim is a girl, the medical
examination is to be conducted by a woman doctor. It is to be conducted in the presence of
the parent of the child or any other person in whom the child reposes trust or confidence;
if such person cannot be present, the examination is to be conducted in the presence of a
woman nominated by the head of the medical institution.

Under Rule 5 of the Act, emergency medical care is to be provided by any medical facility,
private or public; and no magisterial requisition or other document is to be demanded as a
precondition to providing emergency medical care. Such care includes:

treatment for cuts, bruises, and other injuries including genital injuries, if any;
treatment for exposure to sexually transmitted diseases (STDs) including prophylaxis for
identified STDs;
treatment for exposure to Human Immunodeficiency Virus (HIV), including prophylaxis for
HIV after necessary consultation with infectious disease experts;

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 Child sexual abuse:
Prevention and response

possible pregnancy and emergency contraceptives should be discussed with the pubertal
child and her parent or any other person in whom the child has trust and confidence; and,
wherever necessary, a referral or consultation for mental or psychological health or other
counseling.
Further, Rule 7 of the POCSO Act provides that expenses incurred in providing medical care
to the child may be recovered in the compensation awarded to the child.

The role of the doctor may include:

Obtaining a medical history of the childs experience in a facilitating, non-judgmental
and empathetic manner;
Meticulously documenting historical details;
Conducting a detailed examination to diagnose acute and chronic residual trauma
and STDs, and to collect forensic evidence;
Considering a differential diagnosis of behavioural complaints and physical signs that
may mimic sexual abuse;
Documenting all diagnostic findings that appear to be residual to abuse;
Assessing the childs emotional and physical well-being and making appropriate
referrals;
Formulating a complete and thorough medical report with diagnosis and
recommendations for treatment;
Testifying in court when required.

Medical History
It is important to obtain a detailed medical history before examining the child. The medical
history will serve to guide the physical examination. Its objective is not to obtain information
for forensic purposes but for treatment and diagnosis and to ensure the safety of the child.

Taking Medical History

The interview should begin by assessing the childs competence. This can be done by
asking questions unrelated to the abuse, such as favourite colours, school activities, and
likes and dislikes.
The interview should not be an investigative one (this should be left to the police and courts),
but relevant questions should be asked to obtain a detailed pediatric history and a review
of systems.
The questions asked and the childs responses verbatim, as well as their body language,
demeanor and emotional responses to questioning should be documented.
One can begin the conversation by talking about less threatening subjects.
Overall medical history, past incidents of abuse or suspicious injuries, and menstrual history
should be documented.
It is best to avoid leading and suggestive questions; instead, maintain a tell-me-more or
and-then-what-happened approach.
It is best to avoid showing strong emotions such as shock or disbelief.

11
The following should be addressed in the medical history:
A familial psychosocial history;
A detailed medical history of the child with a review of systems focusing on any ano-
genital complaints such as bleeding, discharge, pain, or past genital injury;
The child's history of sexual abuse, ideally obtained without the parent/caregiver present;
and
An adolescent medical history should include age of menarche and date of last menstrual
period.
Additional information to obtain includes changes in the child's behavior, specifically
sexualized behaviors, andespecially in young childrenthe names the child uses for
body parts (e.g., breasts, vagina, penis, and anus).
The child and the parent should be informed and reassured that the pediatric forensic exam
is not invasive or painful and does not routinely include the use of internal instrumentation
or speculum insertion.
The child should be prepared for the physical examination 6.

Child sexual abuse is most often a diagnosis based on history, as opposed

to physical findings.

Examining the Child

Consent
According to the Indian Penal Code, where the child is over twelve years old, consent for the
medical examination should be sought from the child himself or herself 7 . Where he or she is
below the age of twelve, a parent or the guardian may be asked for such consent.

Consent should be taken for the following purposes: examination, sample collection for
clinical and forensic examination, treatment and police intimation.

Informed consent
Consent should be informed, i.e. the person giving the consent should be told about the
purpose, expected risks, side effects, and benefits of the examination, and the amount of
time it will take. This information should be given before the examination is conducted, in a
form, language and manner that the child and his parent/ guardian can understand.

A child that has suffered abuse and his/her family may approach a health facility under three
circumstances, and informed consent must be taken in all:
a) on his/her own only for treatment for effects of assault;
b) with a police requisition after police complaint; or
c) with a court directive.
If the child (and family) has come directly to the hospital without the police requisition,
the hospital is bound to provide treatment and conduct a medical examination with
consent of the survivor/parent/guardian (depending on age).

6
Giardino AP, Finkel MA; Evaluating child sexual abuse. Pediatr Ann. 2005 May
7
Sections 89 and 90, IPC

12
 Child sexual abuse:
Prevention and response

If child (and family) has come on his/her own without the First Information Report (FIR),
s/he may or may not want to lodge a complaint but may require a medical examination
and treatment. Even in such cases the doctor is bound to inform the police as per law.
However neither the court nor the police can force the survivor to undergo medical
examination. In case the survivor does not want to pursue a police case, an MLC must
be made and s/he must be informed that s/he has the right to refuse to file FIR. An
informed refusal must be documented in such cases.
If the child (and family) has come with a police requisition or wishes to lodge a complaint later,
the information about medico-legal case (MLC) number & police station should be recorded.
Police personnel should not be present during any part of the examination.

Physical Examination 8
The general approach to the physical examination follows the standard head-to-toe approach.
Elements of the examination include the following:

Determination of structures of interest Mons pubis, labia majora and minora, clitoris,
urethral meatus, hymen, posterior fourchette, and fossa navicularis in case of girls and
penis, scrotum, and testes in case of boys
Choice of positioning for optimal exposure of prepubertal genital structures Frog-leg
supine position, knee-chest position, or left lateral decubitus position
Calming the child during examination
General observation and inspection of the anogenital area, looking for signs of injury or
infection and noting the childs emotional status
Visualization of the more recessed genital structures, using handheld magnification or
colposcopy as necessary
Collection of specimens for sexually transmitted disease (STD) screening and forensic
evidence collection
Evaluation of any observable findings Although most individuals who have been sexually
abused present with essentially normal examination findings, observable findings may
include (1) those attributable to acute injury or (2) chronic findings that may be residual
effects following repeated episodes of genital contact.
It is important to remember that the results of a physical examination will be within normal
limits in the vast majority of cases of child sexual abuse. The absence of physical findings
can be explained by several factors:

Many forms of sexual abuse do not cause physical injury. Thus, the sexual abuse may be
non-penetrating contact and may involve fondling, oral-genital, genital or anal contact, as
well as genital-genital contact without penetration.
Often, the child and family typically know the perpetrators, and physical force is not often
a major component as in adult sexual assaults.
Mucosal tissue is elastic and may be stretched without injury, and damage to these
mucosal surfaces heals quickly.
Finally, disclosure of abuse is often delayed; many victims of sexual abuse do not seek
medical care for weeks or months after the abuse, and superficial abrasions and fissures
can heal within 24 to 48 hours.
8
Evaluating the Child for Sexual Abuse, SHEELA L. LAHOTI, M.D., NATALIE MCCLAIN, R.N., M.S.N., C.P.N.P., REBECCA
GIRARDET, M.D., MARGARET MCNEESE, M.D., and KIM CHEUNG, M.D., University of Texas Medical School at Houston,
Houston, Texas, Am Fam Physician. 2001 Mar 1

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Diagnosis
Gram stain of vaginal or anal discharge
Genital, anal, and pharyngeal culture for gonorrhea
Genital and anal culture for chlamydia
Serology for syphilis
Wet prep of vaginal discharge for Trichomonas vaginalis
Culture of lesions for herpes virus
Serology for HIV (based on suspected risk)

Other tests that may be considered include the following:

Collection of forensic evidence preferably with a rape kit, wherever available; and
Urine toxicology screen (if the abuse or assault was substance-facilitated).

Management
Medical treatment of CSA follows the diagnosis. Recommendations include the following:

Treat STDs with appropriate medications

In post-menarchal children, consider the possibility of pregnancy and the need for
emergency contraception
Recognize the overriding need for emotional support and attention
When sexual abuse is seriously suspected or has been diagnosed, ensure that it is
reported to the appropriate authorities
Keep well-documented medical records; these are essential in legal proceedings, which
may occur over long periods
A referral to a mental health specialist should be made in all cases. Mental health consultation
is warranted to evaluate and treat acute stress reaction and, later, posttraumatic stress
disorder (PTSD).

The following are the components of a comprehensive health care response to sexual
violence and must be carried out in all cases :

Consent

Age Estimation
First Aid
Physical
Dental
History Radiological Hand-over to Police

Dry
Examination
Pack

Evidence Seal
Collection
Treatment of Injuries STI test
and prophylaxis HIV test
and prophylaxis Emergency Treatment Documentation
Contraception UPT (if
applicable) Counselling
Information and Referral to Discharge Follow-up
other services

14
 Child sexual abuse:
Prevention and response

Forensic Examination
Forensic evidence includes blood, semen, sperm, hair or skin fragments that could link
the assault to an individual person, as well as debris (e.g., carpet fibers) that could link the
assault to a location.
Evidence collection should be performed if sexual contact occurred within 96 hours of the
physical examination.

What is the purpose of a forensic examination?

It is to ascertain:

Whether a sexual act has been attempted or completed. Sexual acts include the slightest
genital, anal or oral penetration by the penis, fingers or other objects as well as any form of
non-consensual sexual touching. However, the absence of injuries does not imply consent.
Whether such a sexual act is recent, and whether any injury has been caused to the childs body.
The age of the survivor, in the case of adolescent girls/boys.
Whether alcohol or drugs have been administered to the child.

Table indicative of type of evidence to be collected 9

History of
sexual Type of Swab Purpose Points to Consider
violence
Peno-vaginal Vaginal Semen/ sperm-detection whether ejaculation
Lubricant occurred inside
DNA vagina or outside
use of condom
Body semen/sperm detection if ejaculation
saliva (in case of occurred Outside
sucking/licking)
Peno-anal Anal Semen/sperm detection whether ejaculation
DNA occurred inside
lubricant anus or outside
faecal matter use of condom
Body semen/sperm detection if ejaculation
saliva (in case of occurred Outside
sucking/licking)
Peno-oral Oral Semen/sperm detection whether ejaculation
DNA occurred inside
saliva mouth or outside
use of condom
Body semen/sperm detection if ejaculation
saliva (in case of occurred Outside
sucking/licking)
Use of Swab of the orifice (anal, Lubricant Detection of lubricant
objects vaginal and/or oral) used if any
Use of Swab of the orifice (anal, Lubricant
body parts vaginal
(fingering) and/or oral)
Masturbation Swab of the orifice or Semen/sperm detection whether ejaculation
body part DNA occurred or not
lubricant if ejaculated in orifice
or body parts

9
Ministry of Health and Family Welfare, Guidelines and Protocols for Medico-Legal Care of Survivors/ Victims of Sexual
Violence, 2014

15
Role of Mental Health Professionals
Throughout the process, mental health professionals play a key role in assisting the child
and his/her family, as highlighted below:

Assessment of Lethality: Usually Interviewing Skills: To begin interviewing

victims of sexual abuse are vulnerable to the child, it is important to create a safe
considerable psychological distress and therapeutic environment where the child
hence may tend towards self-harming feels accepted and validated in herself/
behaviour. Such indicators should be himself. The session flows with the childs
duly noted by professionals not only expression of inner feelings.
for warning family members but also in Assessment of Psycho-social Issues:
providing immediate help to the child it is important to take a detailed history
regarding this. of the family background with specific
Catharsis: Professionals can help the emphasis on parental practices and
child narrate the incident and undergo type of family interactions. This helps
complete catharsis to reduce the burden in assessing any dysfunctional family
of trauma. Also they can provide help in boundaries and communication pattern
handling range of emotional conflicts which may be responsible for CSA.
experienced. An assessment of the childs relative
Psychological Debriefing: this is done strengths and weaknesses may be
by providing emotional and psychological significant for further building ones
support to the child following trauma to coping strategy in therapy.
prevent development of PTSD and other Enquiry should be done in gentle, casual,
forms of negative sequelae. non-confrontational and non-threatening
Normalize the Feelings of Victim: manner.
Professionals should let the child know An assurance of safety, security and
that its absolutely okay to feel the way confidentiality should be provided to
he or she is feeling. This helps to validate the child as otherwise the childs fear of
the childs feelings and unconditionally further harm consequent to disclosure
support them. This will also encourage would impede revelation.
them to emotionally express themselves Professionals should validate and affirm
completely. that she/he did the right thing to reveal
Instilling Hope: It is important to instil the truth.
hope and attempt a positive resolution It is best to void barging the child with too
of the traumatic experiences of child. many questions.
This also helps in reducing obsessive It is important to avoiding trying to gather
deterioration of self-respect when child all the information in one session itself
come to believe and trust that a change and thereby unnecessarily pressurizing
is possible. the child.

16
 Child sexual abuse:
Prevention and response

Who else is involved?

In cases of child sexual abuse, it often happens that the child does not receive adequate legal
assistance as well as proper medical support and counseling, causing the redressal process
to be ineffective and traumatic while heaping physical and mental distress upon the child
and his/her family. There is therefore a need for action that can protect the child from further
abuse and help him deal with his/her trauma and prevent revictimisation. The POCSO Act
envisages a multi-sectoral approach that will be conducive to the justice delivery process,
minimize the risks of health problems, enhance the recovery of the child and prevent further
trauma. This is to be achieved through coordination and convergence between all the key
players. It would therefore be very useful for hospitals and medical professionals to maintain
links with their local police station, Special Juvenile Police Unit, Child Welfare Committees
and District Child Protection Units.

The key organizations and professionals involved in the pre-trial and trial stages to
assist the child are:
Special Juvenile Police Unit or local police: Under the Juvenile Justice Act, each district
has to have police officers especially trained to deal with childrens issues. They form the
Special Juvenile Police Unit.
Health professionals, including those who render emergency medical care, conduct the
medical examination and provide any other medical assistance. In some cases, the doctor
or health care worker may be the first person who detects that the child has been sexually
abused, for example when a child is taken to a paediatrician with a complaint which the
latter then diagnoses as a sexually transmitted infection
Mental Health professionals, such as counsellors, psychologists and psychiatrists to
whom the child is referred for trauma counselling and long-term psycho-social support
Interpreters, translators and special needs educators who may assist the child at various
stages of the process.
Child development experts.
Social workers, support persons and NGO workers who may assist the child through the
process
Members of Child Welfare Committees before whom a child may be presented for
assessment of protection needs (Rule 4[3] of the POCSO Act, 2012).
Advocates, including legal aid lawyers and public prosecutors, involved in prosecuting
the offender.
Judges and staff of Special Courts.
The Model Guidelines under the POCSO Act, published by the Ministry of Women and Child
Development, contain descriptions of the functions of each of these professionals under the
Act, and also lays down guidelines for how these duties are to be discharged.

17
Bibliography
Ministry of Health and Family Welfare, Government of India: Guidelines and Protocols for
Medico-Legal Care of Survivors/ Victims of Sexual Violence, 2014
Ministry of Women and Child Development, Government of India: Model Guidelines under
Section 39 of the Protection of Children from Sexual Offences Act, 2012
Ministry of Women and Child Development, Government of India, 2005: Manual for Medical
Officers dealing with Medico-Legal Cases of Victims of Trafficking for Commercial Sexual
Exploitation and Child Sexual Abuse
Ministry of Women and Child Development, Government of India, 2007: Study on Sexual
Abuse: India
World Health Organization Regional Office for South-East Asia, 2004: Managing Child
Abuse: A Handbook for Medical Officers
World Health Organization, 2003: Guidelines for Medico-Legal Care for Victims of Sexual
Violence
James A. Mercy, 1999: Having New Eyes: Viewing Child Sexual Abuse as a Public Health
Problem, Sage Publications, available at http://sax.sagepub.com/content/11/4/317
Pamela McMahon and Robil Puettl, 1999: Child Sexual Abuse as a Public Health Issue:
Recommendations of an Expert Panel, Sage Publications, available at http://sax.sagepub.
com/content/11/4/257
National Child Traumatic Stress Network and National Childrens Alliance, June 2008,
CAC Directors Guide to Mental Health Services for Abused Children, available at http://
nctsn.org/nctsn_assets/pdfs/CAC_Directors_Guide_Final.pdf
Texas Paediatric Society Committee on Child Abuse and Neglect, 2001: The Medical
Evaluation of Child and Adolescent Sexual Abuse, Available at http://69.89.31.170/~missout9/
safecaremo/wp-content/uploads/2010/05/medical-evaluations-of-sexual-abuse-manual.
pdf
Nancy Kellogg, MD, and the Committee on Child Abuse and Neglect, The Evaluation of
Sexual Abuse in Children, Pediatrics Vol. 116 No. 2 August 1, 2005
Martin A. Finkel, DO, FACOP, FAAP, Child Sexual Abuse Prevention: Addressing Personal
Space and Privacy in Pediatric Practice
David Finkelhor, The Prevention of Childhood Sexual Abuse, available at www.
futureofchildren.org
Adams et al: Guidelines for Care of Children Who May Have Been Abused, J Pediatr
Adolesc Gynecol (2007) 20:163e172
Suzanne P. Starling, MD, Kurt W. Heisler, MS, MPHa,b, James F. Paulson, PhDa, Eren
Youmans, MPH, 2009:: Child Abuse Training and Knowledge: A National Survey of
Emergency Medicine, Family Medicine, and Pediatric Residents and Program Directors",
available at http://www.pediatrics.org/cgi/content/full/123/4/e595
Mary Ranee Leder, MD*; S. Jean Emans, MD; Janet Palmer Hafler, EdD; and Leonard
Alan Rappaport, MD, Pediatrics 1999;104:270 275 Addressing Sexual Abuse in the
Primary Care Setting
Stop it Now Resources, Age-Appropriate Sexual Behaviour
Southern African AIDS Training Programme, 2001: Counselling guidelines on Child Sexual
Abuse

18
 Child sexual abuse:
Prevention and response

Padma Bhate-Deosthali, Indian Journal of Medical Ethics Vol X No 1 January-March 2013:

Moving from evidence to care: ethical responsibility of health professionals in responding
to sexual assault
Jane Leserman, UNC Centre for Functional GI and Motility Disorders, Sexual Abuse: Why
It Is An Important Health Risk Factor
National Crime Victims Research and Treatment Center Medical University of South
Carolina, Final Report: January 15, 2003; Child Physical and Sexual Abuse: Guidelines
for Treatment
Campbell, R., Dworkin, E., & Cabral, G., Trauma, Violence, & Abuse, 10, 225-
246;doi:10.1177/1524838009334456 (2009), An Ecological model of the impact of sexual
assault on womens mental health.
Anne Lazenbatt , 2010, The impact of abuse and neglect on the health and mental health
of children and young people, available at nspcc.org.uk/inform
Stoltenborgh, M van Ijzendoorn, M. Euser, E & Bakermans-Kranenburg, M. (2011) A global
perspective on child sexual abuse : meta analysis of prevalence around the world Child
Maltreatment 16:2, p 79 -101
Adverse Childhood Experiences (ACE) Study, http://www.cdc.gov/violenceprevention/
acestudy/ accessed on May 24, 2014

19
Myths and misconceptions about child sex
abuse
The abuser is usually a stranger: In most cases, the abuser is a person known to the
child. The people most likely to abuse a child are the ones with the most opportunity, most
access, and most trust.
Incest, i.e. sexual abuse by a person related to the child, is not common amongst
well-educated or well-off people: Incest happens in all kinds of families, including
families like ours. It does not depend on class, socio-economic status, education, etc.
Sexual abuse never happened and the child is making it up or exaggerating: Children
rarely make up stories about things that traumatise them. In fact, research shows that
children often minimize and deny, rather than embellish what has happened to them.
No damage is done by the abuse unless the child is visibly physically harmed: Some
acts, like fondling and oral sex, leave no physical traces. Even if the child has not been
physically abused, any kind of sexual abuse causes psychological trauma to the child.
Many children do not reveal sexual abuse because they are enjoying it: The reason
children do not report it is because they are afraid, ashamed, or have been bribed or
threatened.
He looks normal and acts normal, so he cant be a child molester: Sex offenders
are knowledgeable about the importance of their public image, and can hide their
private behaviour from their friends, neighbours, colleagues, and even their own family
members. Some child molesters appear to be charming, socially responsible, caring,
compassionate, morally sound, and sincere and parents and other responsible adults
trust these individuals.
Child molesters molest indiscriminately: Not everyone who comes in contact with a
child molester will be abused. Sex offenders tend to carefully pick and set up their victims
by grooming in which the perpetrator skilfully manipulates the child into participating.
A child says that they have been sexually assaulted and then later says that it didnt
really happen. This clearly means that they are lying: Children may retract an allegation
because of enormous pressure placed on them to make it go away. Disbelieving adults
give the child the idea that if they say it was a lie things will return to normal. However an
offender will not stop abusing and often becomes more aggressive knowing that if the
child says something again people will not believe them.
The victim is always a girl: Just as women can be sex offenders, boys may be victims of
abuse. Unfortunately, child sexual abuse with male victims is underreported due to social
and cultural attitudes: boys are taught to fight back and not let others see vulnerability.
Boys are aware at an early age of the social stigma attached to sexual assault by another
male, and fear appearing weak to others. All of these attitudes make male child victims
less likely to tell of their abuse.
Children are abused because their parents have neglectful style of parenting and
fail to supervise their child properly. Though sometimes absence of sex education in
childhood makes a child an easy traps, however, usually offenders are quite tactful in
manipulating both the caregivers and the child and they are to be essentially blamed for.
Sexual abuse victims are "damaged goods" and their lives are ruined forever: While
sexual abuse is incredibly damaging, victims are not "damaged goods." Healing is easiest
when the intervention is immediate and appropriate therapy is provided. For adults who
have repressed memories, the recovery process can be lengthy. However, all victims of
abuse can become fully functioning, healthy children and adults.

20
INDIAN MEDICAL ASSOCIATION United Nation Childrens Fund
IMA House, I.P. Marg, New Delhi-110 002 Unicef House, 73, Lodi Estate
Tele : +91-011-23370009, 23378680, 23378819 Fax : 23379470 New Delhi - 110003, India
Website : www.ima-india.org, Email : inmedici@gmail.com Email: newdelhi@unicef.org
Website: www.unicef.in