Child sexual abuse medicolegal aspects class

CHILD SEXUAL ABUSE
- Role of Doctors and laws related to
CSA
(Information for Doctors and Health Care Professionals)
Presented by:
Dr. Somashekar C. Assistant professor,
Forensic medicine and Toxicology, DM WIMS

OBJECTIVES of this presentation
 To highlight the existing problem of CSA
 To offer key information to health professionals on
how to prevent, detect and respond to CSA
 To provide insights on the Indian law for the
protection for child victims
 To give inputs to health professionals on how to
manage(counselling, examination, treatment) cases
of CSA: It is ideal to establish Collaborative Child
Response Unit(CCRU)

PROBLEM STATEMENT
 Have you come across a case/cases of child sexual
abuse in your clinical practice or even otherwise?
 How common is Child Sexual Abuse(CSA)?
 What according to you is CSA?
 Do we have an environment (at home or elsewhere)
where sexual problems/abuse can be openly
discussed?

PROBLEM STATEMENT
 India - Largest child population in the world
 Children are vulnerable population
 Steady increase in the sexual crimes against children
(a/c study by Min. WCD in 2007: Over half of children
surveyed reported to have faced some form of sexual abuse;
57% boys, 72% did not report abuse to anyone, 3% reported
to police)
(a/c study by Tulir-NGO, Chennai and Int. Org. Save the
Children in 2005: 48% boys and 38% girls interviewd reported
some forms of CSA; 15% had faced severe forms of abuse)
 Prevalence in Asia: 11.3% girls, 4.1% boys

PROBLEM STATEMENT
 Sexual abuse suffered in childhood is associated with
a broad range of behavioural, psychological and
physical problems that persist into adulthood
 Health sector is an important stake holder in
preventing and responding to CSA

Defining Child Sexual Abuse(CSA)
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
Sexual activity with a child below 18 years of age, boy
or girl is a crime (POCSO Act, 2012)

What acts constitute CSA?
 Actual or attempted penetrative sexual assault
 Non penetrative sexual assault (eg rubbing the penis)
 Sexual harassment (fondling sexual parts,
masturbating, showing sexual parts, photographing a
child in sexual poses, showing pornography or any
pictures of sexual nature, having sexual intercourse in
front of a child etc)
 Exploitative use of child in prostitution, in
pornography
-- POCSO Act 2012

VICTIM PROFILE
Who is the victim of child abuse?
 Only girl child?.. No
 In fact, male children are more abused!!
Why are they vulnerable?
 Tender age, Innocence, not aware, do not
understand an adult’s intent.
 Give unconditioned love and Seek attention
and affection
 Adolescent: curious, rebellious, easily aroused

Where does CSA take place?
Can occur in variety of settings;
 Home
 School or
 Work

Who is the abuser? How to identify?
 Almost always someone the child knows!!!
 In the family.. Parent, step-parent, sibling or other relative
 Can be a friend, neighbour, child care giver, house maid,
teacher or even doctor
 Offenders come from all walks of life and can not be
picked out or identified by appearance
 Attention to be paid to behaviour rather than character

Abuser behaviour…
 Grooming behaviour
 An adult who seems overly interested in a particular child
 Who frequently initiates or creates opportunities to be alone
with a child
 Who becomes fixated on a child
 Who gives special privileges to a child
 Befriends a family and shows more interest in building
relationship with the child than with the adults
 Who caters to the interests of the child, so that child or
patient may feel emotionally depend on the offender

Why do they abuse?
 We do not know!
 May be; they themselves were victims of sexual
abuse in their childhood
 Complex mindset.

Indicators of CSA
PHYSICAL indicators:
 STDs (gonorrhoea)
 Pregnancy
 Pain and itching in the genital area
 Difficulty in walking or sitting
 Repeated unusual injuries
 Pain during urination and/or defecation
 Frequent fungal infections

BEHAVIOURAL indicators:
 Abrupt changes in behaviour
 Refusal to undress for physical examination
 Excessive fear to specific places, men or women
 Fearful or startled response to touching
 Disrespectful behaviour/poor school performance
 Advanced sexual knowledge (more than expected of
that age)

How abused children are affected?
 Confusion
 Guilt
 Shame
 Fear
 Grief
 Anger
 Helplessness
 Depression
Continue to suffer even after the abuse has ended!

How children disclose abuse?
 DISCLOSURE.. Direct or indirect
 BELIEVING AND SUPPORTING THE CHILD
 Appropriate and helpful responses to disclosure are:
 “ I am glad you told me, thank you for trusting me”
 “You are very brave and did the right thing”
 “It was’nt your fault”
 “ I am proud of you for telling me”

DEALING WITH CASES OF
CHILD SEXUAL ABUSE

Medical History taking /
Interview Techniques
 It is important for the doctor to remember that child
sexual abuse is often a diagnosis based on medical
history, rather than on physical findings.
‘Medical history and interview is the KEY’!
 One of its main objectives is to prepare the child for
medical examination
 Place of interview: Child friendly atmosphere
 Interview should begin with questions unrelated to
abuse (eg. Favourite colours, school activities, likes
and dislikes)

Child sexual abuse medicolegal aspects class

 The interview for the medical history should be
developmentally appropriate. Determine child’s verbal
and cognitive abilities, level of comfort, and attention.
(tailored as per the age and understanding of the child
survivor)
 Avoid leading and suggestive questions; instead, maintain
a “tell-me-more” or “and-then-what-happened”
approach.
 Avoid showing strong emotions such as shock or
disbelief

 DONOT ASSUME CHILD CANNOT GIVE
HISTORY!
 REMEMBER ABUSER MAY ACCOMPANY THE
CHILD!
 “ I am glad you told me, thank you for trusting me”
 “You are very brave and did the right thing”
 “It was’nt your fault”
 “ I am proud of you for telling me”

What is to be documented? HISTORY
 Who referred the patient
 Source of information: document all sources of information, including telephone
contacts
 Reason for the concern for sexual abuse
 What information the caregiver obtained from the child
 What specific questions the medical care provider, parent or guardian asked to elicit
information
 Time (hours or days) since last reported sexual contact
 Physical symptoms or signs noted by parent or guardian: itching, bleeding, discharge,
constipation, diarrhea
 Behavioral changes such as anxiety, sleep disturbance, toileting problems
 If the patient has:
 Showered, bathed, cleaned genital-anal area, rinsed mouth, eaten, drank, urinated or defecated since the
alleged abuse
 Changed clothes, gave clothes to police at scene, or brought clothes worn at time of assault to medical setting

EXAMINING THE CHILD…
 Consent for examination, sample collection for clinical
and forensic examination, treatment and police
intimation
 Physical examination: (head to toe)(blood and urine
examination)
 “There may not be physical signs/injuries”
 Forensic evidence collection (only if sexual contact
occurred within 96 hours of examination of child)
 Evidence include blood semen sperm hair skin fragments
etc

Formulating a Diagnosis
 The doctor must keep in mind the following when
formulating his diagnosis:
 Historical details and behavioral indicators reflective of
the abuse
 Symptoms that can be directly associated with the contact
 Acute and healed anal/ genital injuries
 Extragenital trauma
 Forensic evidence
 Sexually transmitted diseases

Differential Diagnosis
 Confirmation of sexual abuse is difficult and there are very
few cases in which such a diagnosis can be made on a stand-
alone basis.
 Anatomical variations, congenital malformations and
infections, or other medical conditions may be confused with
abuse, therefore familiarity with other causes is important.
 In some cases, diagnosis of sexual abuse a medical certainty:
 the presence of semen, sperm, or acid phosphatase;
 a positive culture for gonorrhea; or
 a positive serologic test for syphilis or human immunodeficiency
virus (HIV)

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

Management
 When sexual abuse is seriously suspected or has been
diagnosed, ensure that it is reported to the
appropriate authorities(MANDATORY!)
 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).

Child Protection Unit/ Collaborative
Child Response Unit (CCRU)
Provides a safe interview atmosphere: NOT emergency or labour room
 Safe and neutral
 Child-friendly environment
 No distractions: phones, people’s voices
 Privacy and confidentiality
 Single case manager
 Case conferencing
 Interdisciplinary collaboration(paediatrian, gynecologist, psychiatrist,
psychotherpists, surgeons, forensic experts; social workers and
agencies, interpreters, translators, special needs educators, law
enforcement authorities)
 IDEALLY TO BE ESTABLISHED IN EVERY MEDICAL
INSTITUITION!

CPU/CCRU
 Services provided:
 Medical care of the child
 Child counseling
 Parent and family counseling
 Effective implementation of laws
 Assistance with Police procedures
 Trained lawyers
 Social Interventions

Case Management
Child who has been abused
Social
worker
Private
NGO
CCRU:
Forensic interview
Examination, documentation
Risk assessment. counseling
Follow Up
Information/data

PREVENTION
 Talk to parents about:
 the importance of teaching their children about their
personal space and privacy by 3 years of age.
 teaching their children the concept of “OK and NOT
OK” touching.
 teaching their children to tell if anyone touches their
“private” parts for a reason other than to provide care.
 teaching their children not to keep secrets.

PREVENTION
 limiting the individuals who provide genital, perianal
and bathing care to those who they trust to reduce risk.
 teaching 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.
 Talk to other colleagues in the health care sector
about CSA.

Role of doctors in cases of CSA: Summary
 Suspect and detect abuse cases
 Can play a major role in preventing CSA
 Obtaining a medical history of the child’s experience
and 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

Role of doctors in cases of CSA
 Documenting all diagnosing findings that appear to
be residual to abuse
 Assessing the child’s emotional and physical well-
being and making appropriate referrals
 Formulate a complete and thorough medical report
with diagnosis and recommendations for treatment
 Testifying in court when required

The law on Child Sexual Abuse
 The Protection Of Children from Sexual Offences
Act, 2012 (POCSO Act, 2012) and POCSO rules, 2012
 Came into force in Nov 2012
 Defines different forms of sexual abuse of children
(penetrative/ non penetrative/ aggravated sexual assault,
harassment; pornography)
 Police handling a case (special juvenile police unit/local
PS)
 MANDATORY REPORTING by any adult if s/he has
knowledge that a child has been abused
 Special Courts

Recent Advances ……
 POCSO 2012 – Protection of Children from Sexual
offences Act, 2012 & Rules 2012
 CLA 2013 - Criminal Law Amendment Act, 2013
- changes in IPC, CrPC, IEA……..
 Guidelines from Ministry of H&FW,
Central Government of India, 2014
 Guidelines from Ministry of WCD,
Central Government of India, 2013
 Judgments from Supreme Court & High Court
37

Can you examine without a police
requisition?
 Yes!
 SC in State of Karnataka V Manjanna
( 2000 SC (Crl) 1031/CriLJ3471/2006(6)SCC188 )
 Medicolegal Emergency
– Voluntary reporting to the Hospital
 POCSO Act 2012
- Sec 27 POCSO Act 2012 &
- Rule 5 POCSO Rules 2012
 Section 357 C CrPC
38

Informed Consent/ Informed Refusal?
 I…………………D/o or S/o………………...hereby give my consent for:
a) medical examination for treatment Yes /No
b) this medico legal examination Yes /No
c) sample collection for clinical & forensic examination Yes /No
I also understand that as per law the hospital is required to inform police and this has
been explained to me.
I want the information to be revealed to the police Yes /No
I have understood the purpose and the procedure of the examination including the risk and benefit, explained to
me by the examining doctor. My right to refusethe examination at any stage and the consequence of
such refusal, including that my medical treatment will not be affected by my refusal, has also been explained
and may be recorded. Contents of the above have been explained to me in
……………………………………..…. language with the help of a special educator/interpreter/support
person (circle as appropriate) ……………………..…...
If special educator/interpreter/support person has helped, then his/her
name and signature……………
Name & signature of survivor or parent/Guardian/person in whom the child reposes trust in case of child (<12
yrs) With date, time &place…………………………
Name & signature/thumb impression of Witness With date, time & place …………

Purpose of Medical examination
 Evidence based model –----- TREATMENT model
 Rule 5 POCSO…. Injuries, STDs – HIV, pregnancy,
Emergency Contraception, psychological counseling
 Section 357 C CrPC
….. First aid / treatment, free of cost
 Section 166 B IPC …… 1yr, fine, both
40

Comprehensive care
 Informed Consent & Documentation
 Physical & surgical needs
 Emergency contraceptive & pregnancy advice
 Mental assessment & Counseling
– Rape Trauma Syndrome (PTSD)
- CSA Accommodation syndrome
 STD care including HIV & Hepatitis B
 Rehabilitation – shelter homes / occupation /
monetary relief
 Follow up – delayed injuries / STD
41

Is it mandatory to inform police?
 Mandatory reporting under POCSO Act 2012
Sec 19 … less than 18 yrs (Child cannot
report/complain so responsibility on surrounding
Adult)
 Sec 357C CrPC
42

Is it mandatory to go to Government
hospital for Sexual Assault examination?
 NO!
 Sec 357 C CrPC & WCD guidelines
………..Public or Private
Central Govt, State Govt, Local body, Any person
 Rule 5 POCSO …… Nearest Hospital
 Sec 27 POCSO ….. As per Sec 164 A CrPC
 Sec 164 A CrPC …… Absence of Govt….. Any RMP
44

Is it necessary for a female doctor ONLY
to examine sexual assault victims?
 Liberal interpretation of Section 53 (2) CrPC
 Section 164A CrPC
- any RMP
 Section 27 POCSO Act
- woman doctor for girl survivor
 Guidelines & Protocols, Ministry of HFW, 2014
every possible effort……. If not… male doctor
45

Who can be present while the doctor
conducts examination?
 No other persons – if it’s a Female doctor
 If it’s a Male doctor
Disinterested, Sound, Major, Female
 Sec 27 POCSO Act 2012
- Parent or any person whom she/he trusts - if
not ….. Hospital has to provide
46

How should the examination be?
47

Suspect CSA
As Child often does not complain of CSA
MoHFW Guidelines
 Pain on urination and/or
defecation
 Abdominal pain / generalized
body ache
 Inability to sleep
 Sudden withdrawal from peers
/ adults
 Feelings of anxiety,
nervousness, helplessness
 Weight loss
 Feelings of ending one’s life
MoWCD Guidelines
 Vaginal discharge
 Abdominal pain
 Encopresis (Soiling)
 Enlarged hymenal ring???
48

Is it necessary to do age estimation?
 Only in cases where those documents or certificates
are found to be fabricated or manipulated, the court,
the J.J. Board or the Committee need to go for
medical report for age determination.
{SC judgment in 2013…………Ashwani Kumar
Saxena V State of M.P. 2013(I) OLR(SC)-214}
 Model guidelines by Ministry of WCD, 2013
49

Exercise – What swab to take? Why?
History of
sexual
violence
Type of
swab/s
Purpose Any other
points to
consider?
Peno – Vaginal
Peno- Anal
Peno-Oral
Use of Objects
Use of body
parts (Fingering)
Masturbation

History of
sexual
violence
Type of
swab/s
Purpose Any other points to
consider?
Peno –
Vaginal
Vaginal •Semen / sperm
detection
•Lubricant
•DNA
• whether ejaculation occurred inside
vagina or outside
•Use of Condom
Body •Semen / sperm
detection
•Saliva (in case of
sucking / licking)
•If ejaculation occurred outside
Peno- Anal Anal •Semen / sperm
detection
•Lubricant
•DNA
Faecal matter
• whether ejaculation occurred inside
anus or outside
•Use of Condom
Body •Semen / sperm
detection
•Saliva (in case of
sucking / licking)
•If ejaculation occurred outside

History of
sexual
violence
Type of
swab/s
Purpose Any other
points to
consider?
Peno-Oral Oral •Semen / sperm detection
•DNA
• Saliva
• whether ejaculation
occurred inside mouth or
outside
•Use of Condom
Body •Semen / sperm detection
•Saliva (in case of sucking
/ licking)
•If ejaculation occurred
outside
Use of Objects Swab of the
orifice (anal,
vaginal,oral)
Lubricant Detection of lubricant used
if any
Use of body
parts (Fingering)
Swab of the
orifice (anal,
vaginal,oral)
Lubricant Detection of lubricant used
if any
Masturbation Swab of the
orifice or body
part
•Semen / sperm detection
•DNA
•Lubricant
•whether ejaculation
occurred or not
•If ejaculated in orifice or
body parts

Key messages on CSA
 CSA is a widespread phenomenon and a major public
health concern.
 CSA takes place in all settings: at home, school, in the
community etc.
 Perpetrators are usually people that the child knows
(not strangers).
 The perpetrator builds trust with the child to prevent
disclosure. At times, threats are used to ensure silence
is maintained.

Key messages on CSA
 The child tends to feel a sense of guilt, confusion and
fear as a consequence.
 The impact of abuse will depend on duration and
frequency of abuse, age of child and support network.
 CSA has life long consequences on the physical and
mental health of the child.
 If medical care and mental support are provided a child
can heal and lead a normal life.
 Doctors have a dual role: prevention and response

POCSO
Act, 2012
Criminal Law
Amendment
Act, 2013

You can contact..
Thank You
Child helpline number: 1098

Child sexual abuse medicolegal aspects class

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