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 Table of Contents  
FORENSIC FILES
Year : 2021  |  Volume : 1  |  Issue : 1  |  Page : 73-76

Male child sexual abuse: Not as uncommon as you would think


1 Department of Pediatrics, LHMC and Associated Hospitals, New Delhi, India
2 Department of Forensic Medicine and Toxicology, LHMC and Associated Hospitals, New Delhi, India

Date of Submission07-Oct-2020
Date of Decision17-Oct-2020
Date of Acceptance30-Oct-2020
Date of Web Publication27-Feb-2021

Correspondence Address:
Dr. Sandip Ray
202 B, Pocket B, Mayur Vihar Phase 2, New Delhi - 110 091
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ipcares.ipcares_18_21

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How to cite this article:
Ray S, Singh S, Rani M. Male child sexual abuse: Not as uncommon as you would think. Indian Pediatr Case Rep 2021;1:73-6

How to cite this URL:
Ray S, Singh S, Rani M. Male child sexual abuse: Not as uncommon as you would think. Indian Pediatr Case Rep [serial online] 2021 [cited 2023 Feb 3];1:73-6. Available from: http://www.ipcares.org/text.asp?2021/1/1/73/310216



Child sexual abuse (CSA) in boys is quite prevalent worldwide, with rates reported between 3% and 31%.[1] One in every six boys experience at least one sexual assault globally. A systematic review of CSA in the Indian context published a prevalence of 4% to 57% among boys.[2] In all probability, these figures could be greater, as a large proportion are unreported.

As practicing pediatricians, we must be competent enough to suspect, identify, and manage such cases sensitively so that there is minimal trauma to the child and harassment to the family, yet ensuring that all legal evidence is obtained, documented, and sent to the appropriate authorities. This will ensure that justice prevails and we are not penalized for not following proper protocol. This article aims at sensitizing our readers to pertinent aspects related to male CSA by describing a true, but anonymized case.


  Case Study Top


A 15-year-old boy presented to the emergency room accompanied by a police constable. There was a history of him being victim to forceful anal intercourse by a perpetrator 5 days earlier. Apart from the physical symptoms of experiencing pain during defecation, he manifested some issues suggestive of acute mental health illness. He was feeling depressed and had stopped mingling with friends and talking with family members. He had not been eating properly since the event. On probing further about the circumstances, he revealed that the offender was a neighbor and family friend. Both parents were daily wage workers, and he used to remain alone at home till evening after returning from the school. The perpetrator had taken advantage of this. The boy had been too scared to confide in anyone, as he had been threatened with dire consequences. However, after 5 days, the boy could stand it no longer and had gathered courage to go to the nearby police station and narrate the whole incident. The policeman had informed his parents who were at work and had brought him to our hospital for medico-legal examination

The resident on duty registered a MLC. Informed consent was obtained from the child, and the policeman as his parents had still not arrived. The boy was asked whether the clothes worn during the incident were available for collecting evidence. It was learnt that he had immediately taken a bath as he felt “dirty,” and washed his clothes since he didn't want his mother to know. The boy's vitals, general condition, and level of consciousness were normal. However, he appeared anxious, avoided eye contact, and spoke in a monotonous, low voice. Local examination of the anal and peri-anal areas revealed injuries and multiple anal fissures in the posterior and lateral aspects [Figure 1]. There was no active bleeding, but some lesions were exuding pus. Sentinel piles were present at the mucocutaneous junctions, but they did not bleed. Since the area was very tender, internal examination to determine the extent of the fissures was not possible. There were no other injuries elsewhere. A referral was sent to the pediatric surgeon and the findings corroborated. As 5 days had elapsed, no samples could be taken. The final diagnosis in the MLC record was CSA with traumatic anal laceration.
Figure 1: Diagrammatic representation of the injury in the child

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The child and family were counselled as per the standard protocol [Table 1]. Supportive management included warm sitz bath thrice a day, application of 1% Lignocaine gel twice a day, oral intake of laxative powder before bed time and antibiotics for 5 days. Requisite testing for HIV and other sexually transmitted infections (STI) were sent and postexposure prophylaxis was started at the anti-retroviral therapy center. Evaluation of mental health status by a psychiatrist had been initiated and a follow-up plan drawn up.
Table 1: Salient points related to counselling of the victim and family

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  Let's ask the Expert Top


How frequent is an offender known to a victim in male sexual assault? Globally, this is as high as 71%, involving either a family member or an acquaintance. Indian data are unavailable.

Was it unusual for the victim go to the police station without his parents? The self-reporting rate of CSA in boys varies between 3% and 31%.[3] The reasons for the low levels of reporting of CSA result from fear of family breakdown, fear for personal safety, and fear of not being believed.

Who can consent for medicolegal examination (including physical) of a minor? Since a child below 12 years (minor) cannot give consent for medical/surgical procedures, it has to be taken from parents/legal guardian. A child >12 years can give valid consent for physical/medical examination (Indian Penal Code, section 89), but not for any procedure. An individual ≥ 18 years can give valid consent for procedures, termination of pregnancy (MTP Act 1971), donation of blood, and donation of organs (Transplantation of Human Organ Act 1994) as per Indian Majority Act, Guardian and Wards Act, and Indian Contract Act. Since the court is appointed guardians for orphans or children living in the streets, court permission is required for any procedures/treatment. In case of an emergency, when parents/guardians are unavailable to give consent, a person in charge of the child like principal or school teacher can consent for medical treatment (loco parentis). That is the reason why consent for the procedure (per-rectal examination) was taken from the accompanying police constable in this case.

One must remember that the consent should be in the language that the victim understands, preferably in his own handwriting. The statement should be witnessed by a disinterested party as well as the examining doctor.

What are types of sexual abuse seen in male victims? These include manual-genital contact by the perpetrator, oral-genital contact (perpetrator on victim or victim forced on perpetrator), forced anal penetration, or forced vaginal penetration of a female perpetrator.[4]

What are the common examination findings seen in the genital, anal and peri-anal areas of boys who have undergone CSA? This depends on the type of assault. The most common genital injury is prepucial. Others include genital bruises, abrasions, lacerations, “degloving” injuries (avulsion of a part of skin exposing the fibrous shaft circumferentially), bite marks with erythema, rashes, petechiae on the penile shaft, tears of the delicate fold of skin at the ventral base of the foreskin, and urethral discharge. Anal injury varies between 5% and 34% in literature after a single act of abuse. Hence, a normal anal and peri-anal examination does not exclude CSA. Anal injuries can be penetrating or nonpenetrating. The former may lead to anal lacerations, abrasions, and bruising. The most common site is at 12 o'clock or 6 o'clock position. These have a high rate of healing if uncomplicated, and hence, examination of a victim should be done as early as possible. The likelihood of finding a physical injury decreases with time. Samples can be collected from the victim within 4 days, though the yield is much lower.

What kind of emotional reactions can the child experience after the event? Victims of CSA may experience a range of emotional reactions such as difficulty on sleeping, anxiety, nervousness, crying spells, depression, suicidal ideation, anger, and flash backs after an assault. Such reactions are normal after any traumatic episode.

What is the role and responsibilities of the treating physician? After taking history and appropriate consent for examination, the following steps should be performed:[5]

  1. Collection of bodily and genital evidence [Table 2]. Each sample should be packed, sealed, labeled separately, and placed in a bag that is handed over to the police personnel
  2. Treatment of the physical and genital injuries
  3. Assessment of age the victim (if required)
  4. Prophylactic treatment for HIV
  5. Baseline evaluation of mental health and monthly follow-up (for at least 6 months).
  6. Ensure family and crisis counselling [Table 1].
Table 2: Sample to be taken for a male victim of sexual abuse

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Why wasn't the child treated for other STI? According to national guidelines, empirical administration of prophylaxis against other STIs is not recommended for victims of CSA. They undergo requisite testing and are given specific treatment on follow-up if infection is proven.

What were the challenges in this case? Since the boy presented to the hospital 5 days after the incident, the probability of obtaining evidence with good yield percentage was low, though anal injuries were noted. As the boy was a 15-year-old minor, he could consent for physical examination, but not for a procedure (e.g., minor operations, colposcopy, proctoscopy, etc.).


  Legislature: Protection of Children from Sexual Offences Act, 2012 Top


The POSCO Act was a landmark step toward addressing sexual abuse in children in India.[6] It is a gender-neutral legislation that encompasses penetrative and nonpenetrative sexual assault, sexual harassment, using child for pornographic purpose, and trafficking of children for sexual purposes. The Act prescribes stringent punishment according to the gravity of offence; maximum term rigorous life imprisonment with fine and death penalty for aggravated penetrative sexual offences.

Salient features of the Protection of Children from Sexual Offences Act are making provisions to create a child-friendly atmosphere, adhering to the underlying principle of “in the best interest of the child” and avoiding re-victimization, throughout the subsequent judicial process. Emphasis is given to child-friendly mechanisms (for reporting, recording of evidence, and investigation), trial-related issues (fast-track, trial in-camera, concealing identity of the victim, and special courts), and financial compensation for treatment and rehabilitation.

Physicians are considered key persons along with legal personnel to provide comprehensive care to the victim. A doctor should start medical care of the child as soon as he reaches the facility. Involvement of the police and registration of the medico-legal case should be initiated once lifesaving medical care has been started. Failure to report CSA can result in 6-month imprisonment and/or a fine. Section 23 of the criminal law amendment act states that all hospitals are required to provide first-aid or medical treatment, free of cost, to victims of sexual assault. If a health professional finds out that the perpetrator is the parent, it is critical to involve the hospital social worker, who assesses whether the child is in need of protection and care. The social worker will have to speak with the child to determine whom the child trusts, so that the concerned individual can be called. The child may remain admitted in the hospital for a period of 24 h till transfer to a shelter or child welfare home is made.

Through this case, we tried to cover the protocol for standard care to a boy with sexual assault, especially since these are not uncommon presentations to any hospital emergency. Awareness of the frontline physician bears a paramount importance for addressing the child's medical and psychological care, for contributing to timely disbursal of justice to the victim by collecting optimal samples and providing expert opinion as evidence.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Stoltenborgh M, van Ijzendoorn MH, Euser EM, et al. A global perspective on child sexual abuse: Meta-analysis of prevalence around the world. Child Maltreat 2011;16:79-101.  Back to cited text no. 1
    
2.
Choudhry V, Dayal R, Pillai D, et al. Child sexual abuse in India: A systematic review. PLoS One 2018;13:e0205086.  Back to cited text no. 2
    
3.
Doyle Peter S. Prevalence. In: Finkelhor D, editor. A Sourcebook on Child Sexual Abuse. University of New Hampshire, US: SAGE; 1986.  Back to cited text no. 3
    
4.
Holmes WC, Slap GB. Sexual abuse of boys: Definition, prevalence, correlates, sequelae, and management. JAMA 1998;280:1855-62.  Back to cited text no. 4
    
5.
Guidelines and Protocols. Medico-Legal Care for Survivors/Victims of Sexual Violence. Available from: https://main.mohfw.gov.in/sites/default/files/953522324.pdf. [Last accessed on 2020 Oct 20].  Back to cited text no. 5
    
6.
The Protection of Children from Sexual Offences Act; 2012. Available from: http://wcd.nic.in/childact/childprotection31072012.pdf. [Last accessed on 2014? Oct 10].  Back to cited text no. 6
    


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