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Health Sector Response to Child Sexual Abuse

Learn about the medical examination protocol for child sexual abuse cases under the POCSO Act, covering emergency care, forensic evidence collection, and therapeutic support by the health sector. Understand the guidelines for responding to children, ensuring privacy, informed consent, and evidence preservation.

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Health Sector Response to Child Sexual Abuse

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  1. Health Sector Response to Child Sexual Abuse

  2. Protection of Children From Sexual Offences Act 2012 (POCSO) Chapter VI 27(1) The medical examination of a child on whom the offence has been committed under this Act, shall, not withstanding that a First Information Report or complaint has not been registered for the offences under this Act, be conducted in accordance with Section 164 A of the CrPC. (2) In case the victim is a girl child, the medical examination shall be conducted by a woman doctor

  3. (3) Presence of the parent or person in whom the child reposes trust or confidence (privacy) (4) Where the parent or other person cannot be present during the medical examination of the child, it shall be conducted in the presence of a woman nominated by the head of the medical institution

  4. Emergency medical care (POCSO)-Rule 5 The RMP rendering emergency medical care shall attend to the needs to the needs of the child, including: Treatment for cuts, bruises and other injuries including genital injuries if any Treatment for exposure to STDs including prophylaxis for identified STDs Treatment for exposure to HIV including prophylaxis for HIV (where relevant) Possible pregnancy and emergency contraceptives should be discussed with the pubertal child and trusted person Wherever necessary, referral for mental health or other counselling should be made

  5. Role of health sector Dual: FORENSIC AND THERAPEUTIC • Provision of immediate treatment and follow up care • Provision of psychosocial support • Collection of evidence • Medico-legal documentation • Expert witness in court

  6. Components of Medical Evidence • Trace evidence : Semen , Spermatozoa, Blood, Hair, cells, Dust, Paint, Grass, Lubricant, Fecal matter, Body fluids, Saliva • Injuries on body and/ or genitals: Contusions, Lacerations, blunt trauma • Health consequences :HIV, Hepatitis, Gonorrhea, unwanted pregnancies , tenderness , pain etc.

  7. Salient features of the protocol & guidelines Medico-legal care for survivors of sexual violence (MoHFW) • Operationalises informed consent – treatment, examination, evidence collection, police intimation • Specific guidance in responding to marginalised groups – children, LGBT persons, persons facing caste/class/religion-based discrimination • Gender sensitive procedure – no comment on hymen, elasticity of vagina/anus or on built that perpetuate stereotypes

  8. Guidelines for responding to children • Consent must be signed by the person him/herself if above 12 years of age • If accompanying person is suspected of being the abuser, a female appointed by the head of the hospital can be present during examination

  9. History taking • History taking in young children can be facilitated through use of dolls/body charts • History must be documented verbatim/survivor’s own words – evidentiary value in court • Guides examination, treatment and evidence collection • Privacy must be ensure during the process

  10. Children with intellectual disability • In case of mental disability, arrangements for interpreters or special educators must be made (resource list) • Allow time, do not rush the process • Persons with intellectual disabilities are able to give informed consent when explained in a simple manner. In extreme cases, the guardian may provide consent.

  11. Indicators for enquiry – health consequences of sexual violence among children • Pain on urination/ defecation • Abdominal pain/ generalised body ache • Inability to sleep • Sudden withdrawal from peers • Feelings of anxiety, nervousness, helplessness • Weight loss • Suicidal ideation

  12. Standard operating procedures • Any registered medical practitioner can conduct the examination. A minor can choose a person s/he is comfortable with • If a female doctor is not available, a male doctor must conduct the examination in the presence of a female attendant • Police must not be allowed in the examination room while consulting the survivor • There must be no delay in conducting an examination and collecting evidence

  13. Admission must not be insisted upon unless for the purpose of treatment • All services must be provided free of cost – OPD/IPD registration, investigations, UPT, medicines • Copy of all documentation to be provided free of cost • If there is documentary proof, age determination is not required • Setting up a monitoring committee of diverse people (police, doctors, MRO) at the hospital and holding monthly meetings to assess the health set up response

  14. Evidence collection based on science and history – collection of relevant samples • Preservation of evidence and maintaining chain of custody • Standard treatment protocols for managing health consequences of sexual violence • Guidelines for provision of first line psychological support

  15. Factors leading to disclosure about CSA • Child – Caregiver relationship enabled the child to reveal the abuse • Health complaints such as pain in urination, defecation, unwanted pregnancies also were key in disclosing the abuse CEHAT and MCGM collaboration

  16. Recognizes forms and dynamics of sexual violence • Non-penetrative abuse includes: • Kissing • Fondling • Masturbation of the assailant/ by the assailant • Trained healthcare providers are able to elicit circumstances leading to abuse from children CEHAT and MCGM collaboration

  17. Health Consequences 70% of the cases of abuse are reported within a week of the incident • Despite reporting the incident within a week: • Less than 1/4th sustain genital injuries • Even lesser sustain physical injuries • Emerging issue – recognition of health consequences as medical evidence CEHAT and MCGM collaboration

  18. Recognizes activities leading to loss of evidence • Medical evidence rapidly erodes with time and with activities such as Urination/ Defecation, Washing, douching, bathing etc. • Use of condom/ non emission of semen will not provide medical evidence • Medical evidence is not found in all forms of sexual violence • Mucosal injuries heal quickly CEHAT and MCGM collaboration

  19. Relationship to the perpetrator • In 74% of the cases, the perpetrators of abuse are known to the survivors. • 46 of the 238 survivors reported incest • 8 of the 46 survivors were subjected to repeated sexual abuse CEHAT and MCGM collaboration

  20. Continuing challenges in interface with the police • Non recognition by police that survivors can report to hospitals • Unscientific police requisitions to the examining doctors • Whether rape occurred? • Whether the victim is habituated to sexual intercourse? or Was the alleged victim a virgin? • Whether she is capable of sexual intercourse? Guidelines: The health professional must explain the nature of medico-legal evidence, limitations and their role as expert witness. Examination can neither refute nor confirm the forceful sexual intercourse. Circumstantial evidence must be taken into consideration. Rape is a legal term. • Repeat medical examinations if police are not satisfied with medico legal opinion of the doctor Guidelines: Repeat examination must not be carried out just because the police have brought a requisition, this must be explained to the police • Recording FIRs mandatorily despite refusal by survivor and her family Guidelines: In case the survivor does not want to pursue a police case, MLC must be made and the survivor must be informed of her/his right to refuse to file FIR. Informed refusal must be documented

  21. Continuing challenges in interface with the CWC • Biases towards survivors (questioning character) Guidelines: Explain limitations of medical evidence – no medical evidence of sexual violence does not mean the child is lying about sexual abuse

  22. Continuing challenges in interface with the judiciary • Higher likelihood of convictions where injuries present and acquittals where injuries absent Guidelines: Lack of injuries must be interpreted by the doctor (Expert medical witness) based on medical knowledge and details of history shared by the survivor (explain time lapse and other circumstances that led to inability to resist) • Biases and stereotypes about rape Guidelines: Comments on past sexual history, status of vaginal introitus are unscientific It is in contravention to the Indian Evidence Act

  23. The way forward • Need for institutionalization of sensitisation training of healthcare providers in responding to survivors of sexual violence • Need for increased awareness on the therapeutic role of health professionals and training to respond sensitively to children facing violence using the MoHFW guidelines • Recognition of health consequences such as STIs/ unwanted pregnancies / and others as medical evidence of sexual abuse • Need for awareness on the limitations of medical evidence

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