Child sexual abuse laws in India have been enacted as part of the nation's child

protection policies. The Parliament of India passed the 'Protection of Children Against Sexual
Offences Bill, 2011' regarding child sexual abuse on May 22, 2012 into Act.[1][2] The rules
formulated by the government in accordance with the law have also been notified on the
November 2012 and the law has become ready for implementation.[3] Fifty three percent of
children in India face some form of child sexual abuse.[4] The need for stringent law has been felt
many times.[5][6][7]

One in every two children victim of

sexual abuse, says survey
One in every five children do not feel safe because of the fear of being sexually abused.

A survey participated in by more than 45,000 children in the 12- 18 age

group, across 26 states in the country, revealed that one in every two
children is a victim of child sexual abuse.

The survey conducted by humanitarian aid organisation World Vision

India with a sample of 45,844 respondents also revealed that one in every
five do not feel safe because of the fear of being sexually abused.

It also said one in four families do not come forward to report child abuse.

Despite one in every two children being a victim of child sexual abuse,
there continues to be a huge silence. The magnitude of sexual violence
against children is unknown, World Vision India National Director
Cherian Thomas said here while launching a campaign to end child sexual
abuse and exploitation by 2021.

The It Takes the World to End Violence against Children campaign

targets 10 million children across 25 states and one union territory.

The campaign works through our area programmes that deal with
different issues of health care typically -- malnutrition and early illness,
education, child rights and protection and the improvement of resilience in
communities, Thomas said.

The area programmes are based in 186 districts that we operate in, he
added.

Thomas said that the campaign will draw people from all walks of life to
ensure a safe environment for children.

Children are given training in different aspects, where they are taught
about the good touch and the bad touch and various other relevant aspects,
he said.

The National Study reported the following:

53.18 % children in the family environment not going to school reported facing sexual abuse.

49.92% children in schools reported facing sexual abuse.

61.61% children at work (Shop, factory or other places) reported facing sexual abuse.

54.51% children on the streets reported facing sexual abuse.

47.08 % children in institutional care reported facing sexual abuse.

20.90% of all children were subjected to severe forms of sexual abuse that included sexual
assault, making the child fondle private parts, making the child exhibit private body parts and
being photographed in the nude.

50% abusers are persons known to the child or in a position of trust and responsibility.

Sexual violence against children remains a taboo subject in India despite

reports of children being raped, molested and trafficked for sex surging by
almost 70 percent in the latest data, activists and government officials said on
Tuesday.

There were 14,913 reported sex crimes committed against children in 2015
against 8,904 the previous year, says the National Crime Records Bureau
(NCRB), in the most recent published figures. These include rape, molestation,
exploitation for pornography, and trafficking minors for sex.

But in India's socially conservative society, it remains ignored within families

and communities, where victims are afraid to come forward for fear of being
blamed for the abuse.

"From all the types of violence that we talk about when it comes to children's
safety, this is the one that is least mentioned. This is the one with a 'hush hush'
attitude around it," said Razia Ismail from the India Alliance for Child Rights.

"We are told not to talk about it as it will ruin and dishonour the family's
reputation. But if we don't prevent it, doesn't it dishonour our society, doesn't
it dishonour India?"

Ismail, who was speaking at the launch of a campaign by the charity World
Vision to end child sexual abuse in India, called for civil society groups, the
government and the public to break the silence around sexual abuse in order
to end it.

Child sex abuse is widespread in India. A 2007 government survey found that
53 percent of children had faced one or more forms of sexual abuse, but few
reported the assault to anyone.

The NCRB data in 2015 showed that almost 95 percent of child sex abuse
crimes were committed by people known to the victims such as parents,
relatives, neighbours and teachers.
The Indian media has in recent years voraciously reported cases of child rapes
and other incidences of sexual violence against minors, but in most homes and
schools, children are not given any type of sex education, say activists.

World Vision India Director Cherian Thomas said the charity's campaign would
target five million children across India over the next five years.

"A lot of the work will be in the community because a lot of the abuse happens
within the home," said Thomas. It will be in prevention, it will be in awareness,
it will be in getting children to learn to say 'no'."

'Three siblings were subjected to sexual abuse for eight months by their van
driver in New Delhi in September 2010. Three minor girls were raped and
murdered in Mumbai in February 2011'. Most people read about these
incidents and move on to the next news item; believing that 'such incidents'
happen to other children. The incidents listed above are not random
occurrences, but represent the shocking reality of our country, which is home
to 19 per cent of the world's child population.

India has the dubious distinction of having the world's largest number of
sexually abused children; with a child below 16 years raped every 155th
minute, a child below 10 every 13th hour and one in every 10 children sexually
abused at any point of time. A study by the Union Ministry of Women and
Child Development (MWCD) also showed that 53 per cent of the interviewed
children reported having faced some form of sexual abuse and proved that
boys were as vulnerable to abuse as girls.

This state of affairs prompted CHILDLINE India Foundation (CIF) to act, as the
need of the hour is a prevention and awareness program for the community i.e
children, parents and schools.
As we all know the three pillars of Child Protection are Prevention,
Intervention and Rehabilitation. Though CIF plays an important role in all
three, the 1098 service is more geared towards Intervention and
Rehabilitation. Specifically in the case of Child Sexual Abuse (CSA), Prevention
becomes the most important pillar, because if the case reaches the
intervention stage where the child has been abused the damage is already
done. The scars of abuse last a lifetime and affect many areas of the child's life
including relationships, professional life etc. The experience of abuse can lead
to anxiety disorders, substance abuse and depression also.

Though there are already a few programs targeting parents and schools on the
issue of CSA, children, who are at the receiving end of abuse, are mostly
ignored in preventive communication programs. CIF's Program aims to break
the communication barrier about the issue between parents and children and
encourages children to break the silence about a 'touching problem' and
openly communicate on the subject with a trusted adult.

Globally, researches have shown that children who are taught about the
difference between a safe and unsafe touch are empowered to prevent abuse
and also are able to seek help if they find themselves in a situation of an unsafe
touch. This is why age appropriate communication is extremely important in
the fight against CSA.

As far as the clinical aspect is concerned, a child is defined as one who is less
than 12 years of age for obtaining medical care in a Government health facility
in India. A request from Indian Academy of Pediatrics to increase the age limit
up to 18 years is still under consideration by the Government of India. As the
context here is child-rights and child abuse, the legal definition of the child, by
age, is important. During the initial census of India, persons below the age of
14 years were defined as children and most of the Government programs on
children are still targeted for the age group below 14 years. Thereafter, the UN
Convention on the Rights of the Child, 1989 (Article I) defined the child as
below 18 years of age.

In India, the legal definition of child varies from seven years to eighteen years
of age, but after the introduction of the Juvenile Justice Care and Protection of
Children Act, for all practical purposes, a child is considered as a person below
18 years.

The Juvenile Justice (Care and Protection of Children) Act, 2000: "Juvenile" or
"Child" means a person who has not completed eighteenth year of age.

Family Law (Child Marriage Restraint Act, 1929): Child means a person who, if a
male, has not completed twenty one years of age, and if a female, has not
completed eighteen years of age.

Criminal Law (Indian Penal Code, 1860): Nothing is an offence which is done by
a child under seven years of age (Section 82). Nothing is an offence which is
done by a child above seven years of age under twelve, who has not attained
sufficient maturity of understanding to judge the nature and consequence of
his conduct on that occasion (Section 83).

United Nations Conventions on the Rights of the Child, 1989 (Article I): A child
means every human being below the age of eighteen years unless, under the
law applicable to the child, majority is attained earlier.

Constitution of India, Article 24: Any one below the age of fourteen.

The Child Labor (Prohibition and Regulation) Act, 1986: "Child. means a person
who has not completed his fourteenth year of age.

Definition of Child Sexual Abuse According to the World Health Organization

(Used by Medical practitioners for all practical purposes)
Child abuse or maltreatment constitutes all forms of physical and/or emotional
ill-treatment, sexual abuse, neglect or negligent treatment or commercial or
other exploitation, resulting in actual or potential harm to the child's health,
survival, development or dignity, in the context of a relationship of
responsibility, trust or power (WHO 1999).

Physical abuse of a child is that which results in actual or potential physical

harm from an interaction or lack of interaction, which is reasonably within the
control of a parent or person in a position of responsibility, power, or trust.
There may be single or repeated incidents (WHO 1999). Any non accidental
injury resulting from the following actions done with intention to harm a child -
punching, hitting, throwing, kicking, chocking, biting, shaking, heating and
burning with an object, scalding, banging, etc.

Child sexual abuse is the involvement of a child in sexual activity that s/he 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 violate
the laws or social taboos of society. Child sexual abuse is evidenced by an
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 other person.

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 performances and materials

(WHO, 1999).

At the expense of a child, the involvement of the child in sexual activity

intended to gratify the needs of another person: inappropriate kissing,
unnecessary touching either directly or through clothing the private body parts
of a child for reasons other than hygiene or health care purposes, fondling,
exhibitionism, voyeurism, vaginal, oral and anal intercourse, pornography
incest, rape, etc.

Emotional abuse includes the failure to provide a developmentally appropriate,

supportive environment, including the availability of a primary attachment
figure, so that the child can develop a stable and full range of emotional and
social competencies commensurate with his/her personal potential, and in the
context of the society in which the child dwells. There may also be acts toward
the child that cause or have a high probability of causing harm to the child's
health or physical, mental, spiritual, moral or social development. These acts
must be reasonably within the control of the parent or person in a relationship
of responsibility, trust or power. Acts include restriction of movement,
patterns of belittling, denigrating, scapegoating, threatening, scaring,
discriminating, and ridiculing.

Child abuse is a misuse of power by adults over children that endangers or

impairs a child's physical or emotional health and development. Here we are
referring to all kind of abuse, physical, sexual or emotional abuse. It is
commonly believed that child abuse is a problem of lower socio-economic class
and happens to vulnerable children staying in unsafe places but the truth is
that most of the abuse occurs to normal children in regular homes. An episode
of abuse can occur anywhere, at home, in streets, public places, foster homes,
schools, etc. All children can be at risk, whether they are normal children or
the vulnerable group. Vulnerable group includes destitute children, orphans,
abandoned children, street children; HIV/AIDS affected children, child beggars,
substance/drug abusers, child laborers and neglected children. Children of
poor parents or with physical, mental or terminal illness, children with a single
parent, children of refugees, migrants, construction workers and of prostitutes,
rape victims, sex workers also form a part of the vulnerable group. The abusers
can be parents, care-givers, teachers, neighbors, family members, frequent
visitors, strangers, employers etc. Parents turn abusers if they are immature,
have poor parenting skills, personality disorders, mental health problems,
social pressures, are victims of domestic violence, when they single parents or
are substance abusers.

Pediatrician's Response

A pediatrician's response to a case of child sexual abuse in outpatient and

inpatient settings is based on the following cardinal principles.

Child centered and child friendly: It keeps the best interest of child in mind.
Safety of the child is considered to be of utmost importance.

Family supportive: Response should provide adequate support to the family as

family forms the backbone of the child protection system. Keeping the child
permanently in an institution is the last option in child protection.

Provision of legal safety to the Pediatrician managing the case: The

management and documentation of the case should be impeccable to avoid
professional litigation later. The goal of a pediatrician's response includes:

Short term goal is to ensure safety and provide emergency care if needed.

Comprehensive medical assessment including history taking, examination and

investigations. To ensure proper documentation.

Short term goals include providing immediate emotional (counseling) and

social support to the child and family and treating physical problems like
injuries, providing immunization, STD prophylaxis and emergency
contraception.

Long term goals include complete physical and psychosocial well being of the
child as well as ensuring reintegration into the family and social system.

When a child is brought with history of unexplained injury or a genital

infection, a high index of suspicion should be kept in mind. A detailed medical
and social history, including presenting symptoms is mandatory. Any history of
fall, fracture or injury (including head injury), unexplained bruises, redness,
poor growth and stunting, recurrent UTIs or abdominal/ perineal/ anal pain
and mouth and genital sores or discharge should be noted.

Behavioral History will include:

Fear of certain people or places, nightmares, trouble sleeping, or other

extreme fears without an obvious explanation.

Loss of appetite, or trouble eating or swallowing or sudden changes in eating

habits.

Sudden mood swings: rage, fear, anger, insecurity or withdrawal, unexplained

abdominal pain.

Bed-wetting or thumb sucking, adult-like sexual activities with toys or other

children, new words for private body parts, resistance to bathing, toileting, or
removing clothes.

Talking about a new older friend.

Inconsistency in history, complaints not correlating with physical findings,

previous or repeated similar injuries / complaints of illness but delay in seeking
medical help.

Circumstantial evidence should be noted.

Comprehensive Medical Assessment The presence of a chaperone, preferably a

nurse is a must during the assessment. The assessment should be recorded in a
special Performa. History taking from the parent or caretaker should be
documented separately from that of the child. History should be taken with a
sensitive, empathic and nonjudgmental attitude and recorded verbatim.
Repeated interviews are avoided. The child and the parents are to be treated
with respect and dignity without making accusations. Points to be covered in
history include place, time, witness, present and past history, noticeable
behavior change, developmental and immunization history. Family history,
pedigree chart and social history are extremely important.
A psycho social history known by the acronym HEEADDSS can be taken directly
from an adolescent patient. This includes details regarding home, education,
eating behavior, activities and peers, drugs, depression, suicide, sexual history
and sleep pattern. To make a final conclusion after discussing the case with
seniors, peers, psychologists and probably even NGOs and social worker.

The responses of a pediatrician to a child abuse case can be broadly classified

into the following:

Urgent response is needed if the child is brought dead or with a life

threatening injury or with acute sexual assault (reports within 72 hours of the
abuse). The child will need emergency care and the police would require
immediate forensic samples to book a strong case against the abuser. Such
cases are best managed in a government hospital setting.

Admission to the hospital is needed in all cases of serious injuries. A child may
be admitted in case it is felt that there is an immediate threat to his safety at
home.

Social Services like Child Welfare Committee (CWC) and Child Helpline (#1098)
or local NGOs to be contacted if the parents refuse to follow the treatment
plan or if there is an immediate threat to safety of other sibs. CWC and Child
Helpline can also be contacted in any case where child rights are violated like
neglect, child labor, corporal punishment at school, child marriage etc.

Planned response is the best. Here a planned interview and examination are
performed in a child friendly atmosphere with the appropriate equipment and
health personnel (social worker, psychologist, gynecologist if needed). A child
friendly atmosphere is one that is sensitive to the needs of the child, where
he/she feels comfortable, relaxed and at ease to confide his problems.

Examination Parental and (preferably) the child's consent are essential for a
medical examination. The child may prefer to get examined by a doctor of the
same sex. He/she may also choose to have a trustworthy adult during the
procedure. The pediatrician may seek the expertise of a forensic physician and
a gynecologist while examining a case of sexual abuse.

The following should be recorded:

Resistance to examination, especially in a case of sexual abuse and dissociation

(going to sleep during examination)

General demeanor (like unkempt appearance in neglect)

Vitals and tip-to-toe general physical examination, especially noting pallor,

bruises, vitamin deficiencies

Height, weight and head circumference to be plotted on growth chart

Sexual Maturity Rating for adolescents

All injuries are to be marked on anatomical diagrams. Special sites to look for
injuries include ears, inside the mouth, soles, genitalia and anus.

Systemic examination is done especially to look for other injuries.

Examination of genitalia in girls should be done in supine frog leg, knee chest
prone and left lateral position.

Details of hymen and injuries are to be noted. If possible, photographic

evidence to be recorded. Anal dilatation on a rectal examination indicates
sodomy. Presence of discharge, genital ulcers, warts and inguinal
lymphadenopathy are to be noted. It is important to note that in 70-85% cases
of documented sexual abuse, the physical examination is normal. Examination
of clothes of victim for semen stains, struggle tears, trace material etc. should
be done.

Investigations
The following investigations need to be done.

Sexually Transmitted Disease screening, including low and high vaginal (in post
pubertal girls) swabs and urethral swabs in boys and serology for HIV, Hepatitis
B and Syphilis are done in cases of:

Acute sexual assault

Penetrative abuse

Vaginal/ urethral discharge

STD in abuser

Pregnancy test is done for an adolescent girl

Forensic samples maintaining the chain of evidence include skin, hair, clothing,
saliva, oral and genitourinary secretions are sent in cases of acute sexual
assault. Skeletal survey can be done to explain associated multiple unexplained
injuries. It is mandatory if the abused child is below 2 years. Multiple bruising
entails a detailed hematological profile, including bleeding and coagulation
profile. Neuro imaging and Ultrasonography of abdomen are indicated in a
case of head and abdominal injury respectively.

Management

Management should be child friendly and should aim at achieving the short
term and long term goals. The current and future plans of action should be
discussed with the non offending family members. The need for breaking
immediate contact with the abuser if he/she is a known person should be
emphasized.
Accelerated Hepatitis B vaccination schedule (0,1,2, 12) should be considered if
the sexually abused child is not vaccinated. DPT/ DT vaccination should be
given in non vaccinated children.

STD prophylaxis and Emergency Contraception is to be given to an adolescent

with acute sexual assault.

Multiple types of abuse may co exist in the same patient and should be looked
for. Counseling of the child and family forms the corner stone of the
management.

The immediate counselling of the child that can be done by the pediatrician
focuses on the following:

Believe the child, reassure and absolve feelings of guilt/ blame.

Explain about the existence of a medical, family and social support system.

Listen carefully to all fears and concerns associated with disclosure.

Teach coping and assertive skills.

Referrals to appropriate specialties should be made according to the need of

the child.

These will include psychologist, psychiatrist, orthopedic surgeon, surgeon,

social services and police. The family members may also need counseling and
treatment from mental health professionals.

Medicolegal Aspects: Documentation and Reporting

Most victims of child abuse are brought directly to hospitals, usually

Government hospitals, for medical examination by police. They may be
accompanied by Social worker (NGO), but at times are brought by parents /
guardians. At times, there can be incidental recognition of child abuse when
they are brought for some other medical problem for consultation. The child
can also be brought merely for age determination. At present there is no
uniformity in text of report, method of examination or prescribed format for
documentation.

Different states follow different practices depending on local laws and

procedures. Medical examination is done in a routine matter without proper
clinical or forensic screening. Swabs and slides are taken only in sexual assault
cases without giving due importance to minute details and injuries. Age
determination, which is mandatory as per the Prevention of Immoral Traffic
Act, is done only on request and done only in few hospitals. Age range given in
reporting is too wide, which often goes against the victim and favors the
accused.

How and what should be documented

All consultations with the patient should be in hand written notes, with
diagrams, body charts, and if possible. During examination of a case of sexual
abuse, the police need to be informed and consent is a must. Complete
examination is necessary. Evidence collection (specimens) is to be done and
samples are carefully preserved in refrigerator or suitable place. Photographic
documentation should be done wherever possible. It should be understood
that both age determination and complete examination requires
multidisciplinary references. Their opinions either in person or telephonically
should be recorded.

The examining doctor should make sure that important details are not
omitted. All aspects of consultation should be documented and detailed notes
must be made during the consultation, Patient's records have to be kept
strictly confidential and stored securely. The documentation should be
confined to areas of health care expertise only; interpretation of the same has
to be done by a trained person if the examining Medical Officer is not trained
in examination of medico-legal cases.

Consent

Consent is a voluntary agreement, permission or compliance, it may be

Expressed,

Implied or

Written.

In other words, according to Section 13 of the Indian Contract Act, two or more
persons are said to consent, when they agree upon the same thing in the same
sense at same time.

Follow up

Follow up after 2 weeks is essential to reassess the child. In acute sexual

assault of an adolescent girl, a repeat pregnancy test is warranted. A repeat
serology for syphilis at 4-6 weeks and for HIV at 3-6 months is required. The
long term after-effects of abuse on the physical and mental health are well
known, but some children suffer no adverse consequences.

The outcome is influenced by the following factors

Nature, extent and type of abuse

Age of child, temperament and resilience of the child, relationship of abuser to
the child

Response of the family to abuse and medical management

A single episode of non contact sexual abuse by a stranger may just need
reassurance and letting out feelings in one or two counseling sessions. It
usually has a good outcome. Prolonged abuse by a close family member
requires longer and multiple counseling sessions to heal completely.

Regular follow up of the abused children includes the following:

To verify if abuse has stopped.

To monitor physical and mental health.

To evaluate development and ensure that it is normal.

To refer for therapy (counseling, cognitive behavior therapy or medication) for

delayed presentation of symptoms.

Child Protection Services

The Existing Services are CHILDLINE, Child Welfare Committee, Local NGOs,
National Commission for Protection of Child Rights, and the Police. There is
need for a Child Protection Group for Comprehensive Services that includes a
Pediatrician, Psychologist, Psychiatrist, Gynecologist, Surgeon, Forensic Expert,
Social Worker, Police, and Lawyer. (Source: WHO, UNICEF, CRY, CSWB, DWCD
document - 1st National Conference on Child Abuse for Multidisciplinary
Professionals in Feb. 2004, Chennai organized by ICCW, Chennai and SRMC,
Chennai, Manual on Recognition and Response to Child Abuse: The Indian
Scenario, IAP)
* Dr. Chhaya Prasad is a Developmental and Behavioural Pediatrician, at the
Govt. Regional Institute for Mentally Handicapped, Chandigarh. She recently
successfully completed her post graduation in Developmental Neurology from
the Kerala University.