SPECIAL ARTICLE

Child Sexual Abuse: Management and Prevention, and Protection of

Children from Sexual Offences (POCSO) Act
*RAJEEV SETH AND #RN SRIVASTAVA
From *Max Super Speciality Hospital, and #Indraprastha Apollo Hospital; New Delhi, India.
Correspondence to:Dr RN Srivastava, Indraprastha Apollo Hospital, New Delhi, India. [email protected]
Received: June 01, 2017; Initial Review: June 05, 2017; Accepted: September 05, 2017.

Child Sexual Abuse is an alarming reality and is being increasingly reportedin India as well as globally. Pediatricians and allied medical
professionals are often the first point of contact with abused children and their families. They have a key role in detecting Child Sexual
Abuse, providing immediate and long-term care and support to the victims and their families. India has adopted the Protection of Children
from Sexual Offences Act (POCSO) in 2012. It is a 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 the examination of victims. Pediatricians and health care
professionals need to acquire necessary expertise for clinical evaluation of child sexual abuse, and its prevention, management and
reporting.
Keywords:Child Abuse, Legislation, Management, Prevention.

C
hild sexual abuse (CSA) includes all types of equally affected and more than 20% were subjected to
sexual victimization of children – penetrative severe forms of abuse. 10,854 cases of child rape were
or non-penetrative sexual intercourse, reported from India in 2015, according to National Crime
pornography, sexual harassment, commercial Records Bureau. Several reports indicate that
sexual exploitation, sex tourism and online exploitation neighbours, friends, close relatives, and acquaintances
[1]. In India, the Protection of Children from Sexual and employers at workplaces are the most common
Offences (POCSO) Act, 2012 (that regards any sexual abusers. The Delhi High Court observed that in 2014, of
activity with a child below 18 years a crime), describes the 1704 cases of rape registered in the Capital, 215 cases
various forms of sexual offences [2]. In recent years, were instances of incestuous rape. Acts of CSA are
CSA has assumed global concern [3,4]. Whereas CSA has usually repeated over varying periods and may cause
been mostly reported from economically affluent serious short- and long- term adverse effects [6].
countries, it may be more common in developing
A majority of health care professionals are not trained
countries. A recent epidemiological study mentions that
to examine and manage a case of CSA. It isimportant that
the prevalence rates of CSA in Europe, America and Asia
they acquire the necessary expertise. This communi-
were 9.2%, 10.1% and 23.9%, respectively [4]. CSA is
cation describes the management of CSA, focusing on
influenced by socio-cultural practices and frequently
medical history, physical examination and forensic
goes unreported, as a culture of secrecy, fear of indignity
aspects. Physicians also need to be aware of prevention of
and social embarrassment prevents disclosure of such
CSA and the POCSO Act, which clearly mentions their
offences. Moreover, minor forms of CSA are mostly
responsibility in the management of CSA.
ignored.
INITIAL MANAGEMENT OF CHILD SEXUAL ABUSE
Sexual violence takes place in all settings: at home,
Every case of sexual assault is a medical emergency for
schools, child care institutions, places of work and in the
which free treatment is mandatory at government or
community. Information on the prevalence and forms of
private medical facilities, and no document or
CSA is very scarce and difficult to obtain. In a study
precondition is necessary for providing emergency
carried out under the aegis of the Ministry of Women and
medical care.
Child Development (2007) interviewing 1,25,000
children in 13 Indian states, it was found that sexual abuse A victim of CSA may approach a health facility
had taken place in about half of them [5]. Boys were directly for treatment, with a police requisition after

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SETH AND SRIVASTAVA CHILD SEXUAL ABUSE

police complaint, or with a court directive. The hospital is or past genital injury. The history of sexual abuse is
bound to provide treatment and conduct a medical ideally obtained without the presence of the parent or
examination with consent of the child/parent/guardian, caregiver. The child and the parents should be informed
depending upon the age of the child. The victim may or and reassured that the pediatric forensic examination is
may not want to lodge a complaint, but requires medical not invasive or painful and that internal instrumentation
examination and treatment. In such cases, the doctor is or speculum insertion is carried out only when considered
bound to inform the police as per law. However, neither essential.
court nor the police can force the survivor to undergo
Examination
medical examination without an informed consent of the
child/parent/guardian. If the victim does not want to Doctors are legally bound to examine and provide
pursue a police case, a medico-legal case (MLC) must be treatment to survivors of sexual violence. Timely
made and an informed refusal documented.If the victim reporting, documentation and collection of forensic
has reported with a police requisition or wishes to lodge a evidence are important toward investigation of the crime.
complaint later, the information about MLC number and Police personnel should not be present during any part of
police station must be recorded. the examination.Where the victim is a girl, the medical
examination has to be conducted by a woman doctor in
MEDICAL EVALUATION OF A CHILD SUBJECTED TO
the presence of the parent of the child or any other person
SEXUAL ABUSE
in whom the child reposes trust or confidence. If such a
An informed consent must be obtained, which is required person cannot be present, the examination is conducted in
for examination, collection of samples for forensic the presence of a woman nominated by the head of the
examination, treatment and police intimation. If the child medical institution.The elements of physical examination
is over 12 years of age, consent should be sought from the include particular attention to the following
child. For those below the age of 12 years, a parent or the
• calming the child during examination
guardian is required to providing it. Such consent should
be informed and the person providing the consent should • positioning for optimal exposure of prepubertal genital
be clearly explained the purpose, expected risks, benefits structures: frog-leg supine position, knee-chest or left
and any adverse effects of the examination, and the lateral decubitus position
amount of time it will consume. This information should • general observation and inspection of the anogenital
be provided before the examination is conducted [7-9]. area, looking for signs of injury or infection and noting
Medical History the child’s emotional status.

The diagnosis of CSA is most often based on the history, • examination of mons pubis, labia majora and minora,
as opposed to physical findings; and thus obtaining a clitoris, urethral meatus, hymen, posterior fourchette,
meticulous history of the child’s experience is crucial. and fossa navicularis.
The interview should be conducted in a facilitative, non- • visualization of the more recessed genital structures,
judgmental and empathetic manner and should not have using handheld magnification or colposcopy as
an investigative tone, which is the domain of the police necessary.
and courts. The history includes the family’s psychosocial
• collection of specimens for sexually transmitted
background. The child’s developmental level is assessed.
disease (STD) screening and forensic evidence
The questions and the child’s responses are recorded
collection.
verbatim. The body language, demeanor and emotional
responses are noted. The likelihood of behavioral It is important realize that physical examination in
complaints and physical findings that may suggest sexual CSA is very likely to be within normal limits in most
abuse should be considered. Past medical history, cases. The absence of abnormal findings can be explained
incidents of abuse or suspicious injuries, and menstrual by several factors. Many forms of sexual abuse do not
history should be documented. Information is obtained cause physical injury. Thus, sexual abuse may be non-
about the child’s behavior, specially sexualized behaviors penetrating contact and may involve fondling, oral-
and in young children, the names the child uses for body genital, genital or anal contact, as well as genital-genital
parts (breasts, vagina, penis,anus). Leading and contact without penetration. Mucosal tissue is elastic and
suggestive questions are avoided and expression of may be stretched without injury, and superficial abrasions
strong emotional responses such as shock or disbelief is and fissures can heal within a few days. The perpetrators
resisted. A review of systems is done focusing on any anal are very often known to the child and family and the use
and genital complaints such as bleeding, discharge, pain, of physical force is rarely a major component in CSA as in

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adult sexual assaults. Disclosure of abuse is often delayed carried out with appropriate medications.
for weeks or months, and by that time any physical • In post-menarchal girls, the likelihood of pregnancy
evidence may be absent. The abnormal findings observed and the need for emergency contraception is
may be attributable to acute injury incurred during the considered.
recent episode or indicative of residual effects following
repeated episodes of genital contact in the past. • Emotional support is provided.
• CSA, whether confirmed or strongly suspected, must
Investigations be reported to the appropriate authorities.
The following investigations are routinely carried out: • Detailed, well-documented medical records must be
• Gram stain of vaginal or anal discharge kept, since these are crucial in legal proceedings,
which may take place after a lapse of long periods.
• Genital, anal, and pharyngeal culture for Gonorrhea
• Referral to a mental health specialist should be made in
• Genital and anal culture for Chlamydia. all cases, which is required for evaluation and
• Serology for syphilis treatment of acute stress reaction, and subsequently
• Wet preparation of vaginal discharge for Trichomonas posttraumatic stress disorder (PTSD). Referral to other
vaginalis specialists should be made as required.
• Culture of lesions for herpes virus Proper collection of material, depending upon the
history of sexual violence, is of utmost importance for
• Serology for HIV (based on suspected risk)
medicolegal purposes. Such assault can be peno-vaginal,
Collection of forensic evidence employing the Rape peno-anal, peno-oral, masturbation and use objects for
Kit and Urine toxicology screen (if the abuse or assault penetration. Thus the material can be semen, fecal matter,
was likely to be substance-facilitated) may be required. lubricant, saliva and hairs. Detailed instructions about
collecting forensic evidence are provided by the Ministry
FORENSIC EXAMINATION
of Health & Family Welfare, Government of India [9,10].
Forensic evidence includes blood, semen, sperm, hair or The material should be properly packed, sealed, labeled
skin fragments that could link the assault to an individual and sent to the police.
person, as well as debris (e.g., carpet fibers) that could
One Stop Centers (OSC)
help to identify the location. Collection of specimens and
material should be done if sexual contact has occurred The Ministry of Women & Child Development, Govt. of
within 96 hours of the physical examination. The purpose India is establishing One Stop Centers (OSC) to provide
of a forensic examination is to ascertain the following: support and assistance to victims of gender violence [11].
Thus, comprehensive services, including medical, police,
• whether a sexual act has been attempted or completed.
psychosocial counseling, legal aid, shelter, referral and
Sexual acts include the slightest genital, anal or oral
facilities for video-conferencing are provided ‘under one
penetration by the penis, fingers or other objects as
roof.’ For those below 18 years, these are undertaken in
well as any form of sexual touching. The absence of
coordination with authorities under the Juvenile Justice
injuries does not imply consent of the victim for the
Act, 2011 and the POCSO Act, 2012. The scheme is
act.
centrally sponsored with 100% financial assistance.
• whether the sexual act is recent and if any injury has
been caused to the child’s body. Role of Mental Health Professionals
• the age of the survivor in cases involving of Mental health professionals have an important role in
adolescents. assisting the child and the family during examination and
for comprehensive management of CSA. Victims of CSA
• whether alcohol or any other intoxicating substances
are vulnerable topsychoemotional distress and may have
have been administered to the child.
a tendency to self-harming behavior. Experts can counsel
MANAGEMENT the child and help to reduce the emotional burden of
trauma. Appropriate measures must be taken to prevent
Emergency medical care must be provided in a case of
further abuse, trauma and re-victimization.
CSA. Police or magisterial requisition is not required for
that purpose. The management of CSA includes the PREVENTION OF CHILD SEXUAL ABUSE
following:
CSA should be considered a preventable crime. The
• Treatment of sexually transmitted diseases (STDs) is society must shed old traditions of silence, shame and

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SETH AND SRIVASTAVA CHILD SEXUAL ABUSE

embarrassment and act against this most reprehensible provide for protection of children from the offences of
violation of child right and dignity. Whereas the parents sexual assault and safeguarding the interest and well
have the chief responsibility of protecting their children, being of children [2]. It clearly describes various forms of
they must be supported by the civil society. Information sexual misconducts including actual or attempted sexual
about the prevalence of CSA, its occurrence in all societies intercourse, oral sex, fondling sexual parts, pornography
and particularly who are the common perpetrators, legal and inappropriately photographing. POCSO is a
aspects and the ways for its prevention should be widely comprehensive law, which besides expanding the scope
disseminated.The parents should know the facts about and range of forms of CSA, makes its reporting
CSA and take every care to watch over the child and never mandatory and gives guidelines for various actions by the
leave them unsupervised. The child aged between 3-5 police and at courts. Physicians are made responsible for
years can be told what is ‘good’ touch or ‘okay touch’ and ensuring prompt and adequate response to child victims.
‘bad touch’, and places over the body where nobody
except the mother can touch or clean. Older children The Act includes child-friendly mechanisms for
should be informed about body parts, differences between reporting, recording of evidence, investigation and
boys and girls, and issues of privacy. Such communication speedy trial of offences through designated Special
may appear difficult, particularly when using expressions Courts. It deems a sexual assault to be ‘aggravated’ when
for body parts and ‘how babies are born’, but most parents abuse is committed by a person in a position of trust or
find their own ways once they understand the importance authority vis-a-vis the child, such as a family member,
of empowering the child. Brochures, graphic descriptions police officer, teacher, or doctor [1,2]. Different levels of
and parental guides are available to help them [10]. punishment are included, which are more stringent in
cases of aggravated assault.
Adolescents need more detailed knowledge of body
physiology, sexual intercourse, pregnancy, healthy Mandatory Reporting
relationships and sexual violence, which is best provided The Act calls for mandatory reporting of sexual offences
at schools by trained teachers. This information can be so that the doctor or any other health care professional
packaged as health and family life education, thus who has the knowledge that a child has been sexually
avoiding the term ‘sex education’. The parents should ask abused is obliged to report the offence, failing which he
the child to report any unusual behavior by adults or older may face legal punishment (6 months imprisonment and/
children. Their accounts must not be ignored and the or fine (Sections 19 and 21 of the POCSO Act).It does not
child never made to feel guilty. lay down that the mandatory reporter has an obligation to
CSA is frequently reported from Children’s Homes, inform the child or his parents or guardian about his duty
work places and schools. Institutions must be closely to report. While making the mandatory report, the doctor
supervised by independent agencies and records of their or other health professional should describe the nature of
inspections maintained. The staff at these homes should be the abuse and all involved parties. The reporter is not
carefully selected. School authorities and teachers should expected to investigate the matter, or even know the
be informed about CSA and strict vigilance needs to be identity of the perpetrator, which are left to the police and
maintained. Improper use of internet and mobile phones other investigative agencies.
may put the children at the risk of sexual misconduct. Multidisciplinary Approach
CHILDLINE 1098: This is an emergency telephonic The POCSO Act envisages a multidisciplinary approach
helpline, which can link children in situations of abuse that will be conducive to medical care and justice
and neglect with sociolegal services. It is operational in delivery for a sexually abused child. This can be achieved
more than 400 cities and districts across the country through coordination and convergence between all key
(India) and has proven to be of great help. Medical stakeholders such as Juvenile Police Units, Child Welfare
professionals and others should be aware of this Committees, District Child Protection Units, health
telephone helpline, and call it to refer cases of known or professionals, mental health professionals including
suspected child abuse or neglect. Clinics and hospitals psychiatrist, psychologist and counsellors, child
should prominently display the Childline telephone developmental experts, medical social workers,
number (1098). advocates, magistrates and members of legal profession.
THE LAW ON CHILD SEXUAL ABUSE The components of comprehensive health care response
to sexual violence, as per Guidelines & Protocols of the
In November 2012, India adopted The Protection of Ministry of Health and Family Welfare [8], include first
Children from Sexual Offences Act (POCSO) meant to aid, informed consent, history and examination,

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SETH AND SRIVASTAVA CHILD SEXUAL ABUSE

collection of forensic material and its further handling. Srivastava RN, Seth R, Van Niekerk J, editors. Child
Appropriate treatment of injuries is carried out along with Abuse and Neglect: Challenges and Opportunities. New
management of sexually transmitted infections, HIV Delhi:Jaypee Brothers, 2013.p.62-70.
testing and prophylaxis, and emergency contraception if 2. The Protection of Children from Sexual Offences Act
2012. Available from:wcd.nic.in/childact/child protection
indicated. Referral to other specialists is made if required.
31072012.pdf. Accessed May 30, 2017.
WHO GUIDELINES 3. Roylance R, Foley S, Manzel K. International perspectives
on child sexual abuse. In: Srivastava RN, Seth R, Van
The World Health Organization has recently published Niekerk J, editors. Child Abuse and Neglect: Challenges
guidelines providing evidence-based, quality, trauma- and Opportunities. New Delhi:Jaypee Brothers, 2013.
informed care to children and adolescents who have been p.40-50.
sexually abused [12]. Their observations and 4. Wihbey J. Global Prevalence of Child Sexual Abuse, 2013.
recommendations are particularly aimed to assist front-line Available from: Journalistresource.org/studies/./global-
healthworkers in low-resource settings. prevalence-child-sexual-abuse.Accessed May 30, 2017.
5. Study on Child Abuse: India (2007). Ministry of Women
CONCLUSIONS and Child Development, Government of India.Available
from:www.wcd.nic.in/childabuse.pdf. Accessed May 30,
CSA is a particularly reprehensible criminal act. The 2017.
practice is globally prevalent and occurs in all societies. 6. Cashmore J, Shackel R. The Long Term Effects of Child
Pediatricians and other health care professionals are often Sexual Abuse. Child Family Community Australia, 2013,
the first contact for CSA victims and thus need to have the Paper No 11.
expertise for its adequate clinical evaluation and treatment, 7. Finkel MA. Medical evaluation of child sexual abuse. In:
and be knowledgeable of the legal aspects. A multi- Srivastava RN, Seth R, Van Niekerk J, editors. Child Abuse
disciplinary response is necessary for comprehensive and Neglect: Challenges and Opportunities. New
Delhi:Jaypee Brothers, 2013.p.62-70.
management that includes psychological support to the
8. Finkel MA. The Evaluation. In: Finkel MA, Giardino AP,
victim and the family. The Government of India’s Act for editors. Medical Evaluation of Child Sexual Abuse: A
Prevention of Children from Sexual offences Act (POCSO, Practical Guide. 3rd ed. Elk Grove Village, IL: American
2012) defines CSA and lays down responsibilities of Academy of Pediatrics. 2009.p.19-52.
physicians and gives management guidelines and legal 9. UNICEF and Indian Medical Association. Child Sexual
procedures. Parents, school teachers and the civil society at Abuse: Prevention and Response. Information for Doctors
large must overcome the traditional inimical attitudes of and Health Care Professionals (2015).
silence and shame and take appropriate educative measures 10. Guidelines and Protocols. Medicolegal Care of Survivors/
to prevent CSA. Victims of Sexual Violence, 2014. Available from: http://
mohfw.nic.in.Accessed May 30, 2017.
Contributors: Both authors contributed to literature search, 11. Ministry of Women and Child Development. One Stop
manuscript writing and its approval. Centres. Available from: www.wcdhry.gov.in/oscg.pdf.
Funding: None.Competing interest: None stated. Accessed September 7, 2017.
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