Sexual Abuse in Children and Relevance of POCSO Act-A Report of Four Cases.

Sir

The World Health Organization has defined the four main types of child abuse and maltreatment as physical abuse, sexual abuse, emotional abuse, and neglect.[1] Recognizing child sexual abuse (CSA) is really difficult, and maltreatment of children is a major public health crisis.[2] It is estimated that more than 3 million children become victim of abuse every year.[3] It is often difficult to diagnose a case of CSA by either a dermatologist or a pediatrician as the majority of sexually abused children do not display signs of penetrative trauma at the anogenital examination. More often these children present with a variety of dermatological manifestations, and parents or caregivers fail to give relevant history. However, the diagnosis of sexually transmitted infection (STI) in a child is a strong indicator of CSA.[2]

To effectively address the heinous crimes of sexual abuse and sexual exploitation of children through less ambiguous and more stringent legal provisions, the Parliament of India passed the Protection of Children from Sexual Offences (POCSO) act, 2012.[4] POCSO act makes it mandatory for a doctor or other health care professionals to report sexual offenses against children. Failing to report the commission of an offense or failing to record such offenses shall be punishable.[4]

Rule 5 of the POCSO act, 2012 states that emergency medical care is to be provided by any medical facility private or public. Sexual assault in a child is, therefore, a medical emergency.[4]

We report here a case series, where four cases of CSA got detected in the outpatient of a tertiary care center of Kolkata within a span of mere 3 months.

The first case was a 5-year-old girl who reported to us with moist whitish plaques on her anal and perianal areas [Figure 1]. She was accompanied by her grandmother. The girl's parents were separated. Her mother worked as a maid, and she was sent to a neighbor's home in the morning half. She did not have any other lesions. We made a provisional diagnosis of condyloma lata. Her Venereal Disease Research Laboratory (VDRL) test was positive in 1:64, and Treponema pallidum hemagglutination assay (TPHA) was strongly positive. She was, however, HIV nonreactive. She tested positive to penicillin intradermal test. We decided to admit her and did penicillin desensitization and administered penicillin. She had complete clearance in 10 to 14 days. Her VDRL titer became less than 1:8 in 6 weeks.

Figure 1

Condyloma lata in a 5-year-old girl

The second and third cases presented to us were two sisters of 12 and 14 years age. Both presented with condyloma lata following sexual relationship with their male tenant leaving alone [Figures 2 and 3]. Both had strong VDRL positivity - one with 1:64 and younger in 1:32 dilution and TPHA positivity. The first and these two patients were HIV nonreactive. Patients were treated with injection benzathine penicillin. All lesions resolved in 2 weeks and VDRL after 6 weeks was nonreactive.

Figure 2

Condyloma lata in a 12-year-old girl

Figure 3

Condyloma lata in a 14-year-old girl

The fourth case was a 10-year-boy who presented with anal condyloma acuminata and had a history of exposure with multiple partners [Figure 4]. His HIV report was, however, nonreactive.

Figure 4

Condyloma acuminate in a 10-year-old boy

The cases were immediately intimated to the medical superintendent and he, in turn, intimated police for further action.

Our cases reveal that CSA may be much more common than perceived.[5] Issues are further complicated by lower socioeconomic status, overcrowding, single mother, and the popular belief that sex with a child cures sexually transmitted disease.[6] Often parents are completely unaware and unsuspecting; hence, parental history may not reveal much information. As a treating physician, dermatologist role is extremely crucial to suspect and diagnose CSA in children who may have presented with some dermatological conditions. We suggest certain Do's and Don'ts to be followed while examining a suspected case of CSA [Table 1].

Table 1

Instructions to the practitioner tackling a patient of child sexual abuse

Do’s	Don’ts
Be patient and calm.	Don’t pressurize the victim for their story. Don’t speak rapidly.
Let the victim know you are listening. e.g.,:- nod your head.	Don’t look at your watch or cell phone.
Show right attitude.	Do not judge. Do not say “You should not feel this way”
Acknowledge how the victim is feeling.	Do not assume what you think would be best for them.
Give the victim the opportunity to ask what they want. You may ask “How can we help you.”	Wait until the victim has finished talking before asking questions.
Encourage the victim to keep talking. You may ask, “Do you want to tell me more?”	Do not finish the victim’s thoughts.
Allow for silence.	Do not relate to somebody else’s story or even your own experiences.
Stay focused on the victim’s experience and offering them support.
Report all cases of suspected CSA to appropriate authority

We report these cases to underline that CSA is not uncommon in this part of the world, and STI in a child always means CSA.

We also report these cases to highlight that physicians and residents need to be aware of the POCSO act, as not only we have to be vigilant in suspecting a case of CSA but also we need to report the case to appropriate authority, failing which we are liable to be punished with 6-month imprisonment.[4]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.