Overview
Definition:
Child sexual abuse (CSA) is defined as any sexual activity between an adult and a child, or between two children where one is significantly older or of a sexually mature age
It encompasses various acts, including inappropriate touching, exposure, sexual intercourse, and exploitation.
Epidemiology:
CSA is a significant public health issue with a global prevalence
In India, data suggests a substantial burden, though underreporting is common
Most perpetrators are known to the child, often family members or acquaintances
The incidence varies by region and reporting mechanisms.
Clinical Significance:
Recognizing and managing CSA is critical for pediatricians and other healthcare professionals
Prompt and thorough forensic examination aids in evidence collection for legal proceedings, while appropriate STI prophylaxis and management are vital for the child's immediate health and long-term well-being
Early intervention can mitigate significant psychological and physical sequelae.
Forensic Examination
History Taking:
Obtain a detailed history from the child (if age-appropriate and comfortable) and/or the accompanying adult
Focus on non-leading questions
Inquire about the nature of the abuse, frequency, duration, perpetrator, and any specific acts
Document any injuries or pain reported by the child
Assess for behavioral changes, fear, or withdrawal
Note any disclosure made by the child and the context of disclosure.
Physical Examination:
Conduct a comprehensive, sensitive, and non-traumatizing physical examination in a private and comfortable setting
Use a head-to-toe approach
Pay close attention to the genital, anal, and oral areas
Look for signs of trauma (bruises, lacerations, abrasions), discharge, inflammation, pain, or foreign bodies
Document all findings meticulously with diagrams, photographs (with consent), and detailed descriptions
Use appropriate lighting and magnification
A colposcope may be useful for examining the perineum and introitus
Consider a sexual abuse evaluation kit to collect forensic specimens.
Evidence Collection:
Collect specimens for documentation of potential sexual contact, including semen, epithelial cells, and DNA
Swabs from the genital, anal, and oral areas should be taken
Obtain blood and urine samples for STI testing, pregnancy testing (if applicable), and general health assessment
Collect any clothing or items the child may have had during the assault
All specimens must be handled, packaged, and labeled according to forensic guidelines to maintain chain of custody.
Documentation:
Thorough and accurate documentation is paramount
Use standardized forms
Record the child's demeanor, cooperative level, and any distress during the examination
Photograph injuries with a ruler for scale
Document the timeline of the alleged abuse and examination
The report should be objective, factual, and free of any judgmental language.
Sti Prophylaxis And Management
Risk Assessment:
Assess the risk of STIs based on the type of sexual contact and the known STI status of the perpetrator, if available
High-risk activities include unprotected penetrative intercourse (vaginal, anal, oral).
Screening And Testing:
Perform baseline STI screening for common infections such as Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and Syphilis
HIV testing should also be considered, with appropriate counseling and follow-up
Consider Hepatitis B and C testing
Urine nucleic acid amplification tests (NAATs) are preferred for Chlamydia and Gonorrhea
Serological tests are used for Syphilis, HIV, and Hepatitis B/C.
Prophylactic Treatment:
Initiate empirical prophylactic treatment for STIs based on risk assessment, even if initial tests are negative, as incubation periods can vary
Recommended regimens often include ceftriaxone IM for gonorrhea, azithromycin PO for chlamydia, and metronidazole PO for trichomoniasis
Specific regimens may vary based on local guidelines and antibiotic resistance patterns
For potential HIV exposure, post-exposure prophylaxis (PEP) with antiretroviral drugs should be considered within 72 hours of exposure, following national guidelines.
Contraception And Pregnancy Prevention:
For post-pubertal victims of potential intercourse, consider emergency contraception if pregnancy is a possibility
Discuss and provide options for ongoing contraception if the child is sexually active or at risk.
Follow Up And Retesting:
Schedule follow-up appointments for retesting of STIs, typically 2-4 weeks after the initial exposure and again at 3 months for HIV to confirm negative status
Provide counseling on safe sexual practices and resources for ongoing support.
Supportive Care And Reporting
Psychological Support:
Sexual abuse has profound psychological consequences
Ensure immediate referral to a child psychologist or psychiatrist specializing in trauma
Provide a safe and supportive environment
Address anxiety, depression, PTSD, and behavioral issues
Offer age-appropriate counseling.
Medical Follow Up:
Schedule regular medical follow-ups to monitor for any long-term physical health consequences, including gynecological issues, chronic pain, or other sequelae
Ensure continuity of care.
Mandatory Reporting:
Healthcare professionals have a legal and ethical obligation to report suspected child abuse to the relevant child protective services or law enforcement agencies
Understand and adhere to local reporting laws and procedures
Maintain confidentiality while ensuring the child's safety.
Multidisciplinary Team Approach:
Effective management requires a coordinated effort from a multidisciplinary team, including pediatricians, forensic examiners, social workers, child protection specialists, law enforcement, and mental health professionals
Foster collaboration for comprehensive care.
Legal And Ethical Considerations
Chain Of Custody:
Strict adherence to chain of custody protocols for all forensic evidence is crucial for its admissibility in court
Meticulous documentation of collection, handling, and transfer of evidence is essential.
Informed Consent:
Obtain informed consent for examinations and treatments, considering the child's age and developmental stage
If the child is too young, consent is typically obtained from a parent or guardian
However, in cases of alleged abuse by a parent or guardian, a court order or involvement of child protective services may be necessary to proceed with examination and treatment.
Child Advocacy Centers:
Utilize child advocacy centers (CACs) when available
These centers provide a multidisciplinary approach to the investigation and prosecution of child abuse cases, offering a child-friendly environment for interviews and examinations, and coordinating services for the child and family.
Confidentiality And Disclosure:
Balance the duty of confidentiality with the legal requirement to report suspected abuse
Document all disclosures carefully and report them to appropriate authorities promptly
Ensure the child understands who will be informed about their disclosure.
Key Points
Exam Focus:
Forensic examination must be thorough, sensitive, and well-documented
STI prophylaxis is critical for immediate health
Mandatory reporting is a legal and ethical imperative
Recognize signs of trauma and offer psychological support.
Clinical Pearls:
Always approach a suspected case of CSA with a non-judgmental and child-centered attitude
Use age-appropriate language during history taking and examination
Document everything meticulously, including negative findings
Prioritize the child's safety and well-being above all else.
Common Mistakes:
Failure to conduct a complete forensic exam
Inadequate documentation
Delay in reporting suspected abuse
Incomplete STI prophylaxis or follow-up
Overlooking psychological impact
Treating the physical injuries without addressing the underlying trauma.