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Child Sexual Abuse

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RaahavendharSugumar

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

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CHILD SEXUAL ABUSE S RAAHAVENDHAR
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)
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.
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.
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
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 childs trust and hide the abuse. The perpetrator is typically a known and trusted caregiver.
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
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.
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
Child Sexual Abuse
Child Sexual Abuse
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
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).
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
GENITO-ANAL FINDINGS: DEFINITIVE OF ABUSE/ SEXUAL CONTACT Sperm or seminal fluid in, or on, the childs 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.
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)
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.
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.
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.
ASSESSMENT AND EXAMINATION
Child Sexual Abuse
ASSESSMENT AND EXAMINATION: HISTORY TAKING Two pronged: 1) Medical history, 2) Interview- Forensic Must be co-ordinated
Child Sexual Abuse
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
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
PHYSICAL EXAMINTAION Ensure privacy Prepare the child Presence of a care-giver
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. Childs sexual development (Tanner) stage
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.
COLLECTION OF EVIDENCE 96 HOURS (INDIAN GUIDELINES) 72 HOURS- SPERMATOZOA IDENTIFICATION SAFE KIT- SEXUAL ASSAULT FORENSIC EVIDENCE KIT
DIAGNOSTIC CONCLUSION DEFINITE ABUSE/ SEXUAL CONTACT PROBABLE ABUSE POSSIBLE ABUSE NO INDICATION OF ABUSE
DIAGNOSTIC CONCLUSION
TREATMENT SEXUALLY TRANSMITTED INFECTIONS HIV AND POST-EXPOSURE PROPHYLAXIS EMERGENCY CONTRACEPTION
SEXUALLY TRANSMITTED INFECTIONS
SEXUALLY TRANSMITTED INFECTIONS Blood sampling for HBsAg Administration of 0.06 ml/kg HBIG immediately (anytime upto 72 hours after sexual act).
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
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
FOLLOW UP AFTER 2 DAYS, 3 WEEKS, 6 WEEKS VDRL REPEAT AFTER 6 WEEKS/ PREGNANCY TESTING/ PSYCHOLOGICAL ASSESSMENT
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.
Child Sexual Abuse
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Child Sexual Abuse

  • 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 childs 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 childs 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.
  • 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. Childs 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
  • 32. TREATMENT SEXUALLY TRANSMITTED INFECTIONS HIV AND POST-EXPOSURE PROPHYLAXIS EMERGENCY CONTRACEPTION
  • 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.