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Child Sexual Abuse: Level of Awareness among Medical Students in context of the POCSO Act

Objective: Present study aims to analyze the level of awareness about various practical aspects of Child Sexual Abuse (CSA) among MBBS students in context of the Protection of Children from Sexual Offences (POCSO) Act, 2012. Methods: Five hundred eighty six MBBS students studying in a Government Medical College in Maharashtra, India were given a questionnaire testing various aspects of CSA from incidence, prevalence, signs and symptoms, psychological impact, treatment guidelines, to legal remedies available in context of the POCSO Act, 2012. It contained ten Multiple Choice Questions (MCQs) with four options each. The questionnaire was handed over to the students at the beginning of other academic activity (Lecture) and they were asked to mark one correct answer for each MCQ within 15 minutes’ time. There were 277 males and 309 females between 18 to 25 years of age. Five hundred fifty eight students attempted all MCQs. Answers were corrected according to model answer sheet provided. The scores were recorded and results were analyzed. Results: 90 % of the students had scores <5, meaning there is lack of awareness about CSA even among MBBS students. Conclusions: There is scope for conducting workshops / symposia to create awareness about various practical aspects of CSA among MBBS students. It is the need of the hour to include CSA as part of the medical curriculum so that these budding doctors will be sensitized towards CSA and will be future-ready to tackle the ever increasing number of cases of CSA.


Introduction
Child sexual abuse is a widespread phenomenon with life-long consequences on the physical and mental health of the child. India has highest prevalence of CSA cases and the incidence is increasing day by day. 1,2 The POCSO Act defines a child as any person below the age of 18 years and applies to all cases of sexual assault viz; penetrative sexual assault, non-penetrative sexual assault, sexual harassment and use of a child for pornography. 1,2 However, in the existing system, the students and practicing doctors are not methodically trained about various aspects of CSA relevant to the medical fraternity i.e. diagnosis, rational treatment, evidence collection, documentation of injuries and treatment of the child. Many are not aware of the subtle injuries and psychological impact resulting from CSA. This lack of knowledge, may subject many children to repeated victimization. The newly adopted POCSO Act, 2012 deals with all forms of sexual abuse on children and lays down the principles to handle the child in a systematic manner, protocols to be followed by individuals and hospitals for examination and treatment of the child, the manner in which judicial proceedings are to be carried out and is the most elaborate law about this problem. 1,2 However, not many people including medicos are aware of provisions of the law. The current study aims to analyze the level of awareness of MBBS students about various practical aspects of CSA in context of the POCSO Act, 2012.

Methods
Five hundred eighty six Medical (MBBS) students from a Government Medical College in Maharashtra, India participated in the study. Five hundred fifty eight students attempted all MCQs. The age of the participants ranged between 18 to 25 years. There were 277 males and 309 females. They were given a questionnaire containing ten MCQs with four options each at the beginning of other academic activity (Lecture) and asked to mark the answers in 15 minutes' time. The MCQs were structured to objectively assess the participant's knowledge about the incidence and prevalence of CSA, symptoms and signs of child sexual abuse (CSA) including its' psychosocial aspects, what to do when child is suspected to have CSA, case management in practice, related provisions of law, and duties of medical professional in cases of CSA. Each question had four options, out of which they had to choose one correct answer. Answers were marked according to model answer sheet provided. The scores were recorded over a scale of 1 to 10. The results were manually analyzed.
About the questionnaire A two-section questionnaire was used to obtain the data. Section I included information about the student′s age, sex, year of graduation, background -urban or rural and the number of patients seen per week. Section II consisted of ten MCQs regarding CSA to assess the medico′s perception, knowledge and cognitive skills in context to CSA. Questionnaire development comprised of a fivephase process, including -developing the initial item (MCQ ) pool, conducting sample testing, refining the scale based on results of sample testing, building content validity and assessing internal consistency via field testing. The resulting questionnaire [Annexure 1] which displayed construct validity in preliminary testing was used for purpose of the present study. The process of developing the questionnaire extended from January 2018-February 2018; whereas the actual survey was conducted in the month of March 2018. The survey was conducted at the same time for all the participants.

Results
In general, the survey showed that the students were more open in answering the questions than expected. They were more than willing to answer and get to know more about the issue, indicating the gap of knowledge and information in the present medical curriculum. The questionnaire data was filled and MCQs were solved by the students on hard copies provided. The database of 558 records consisting of ten MCQs each, with four different answers (variables) was manually assessed. Percentage of correct answers to each of the MCQ in the questionnaire [Annexure 2 and Graph 1] was used to interpret the results. Only 18 % of the students had scores between 5 to 8 out of 10. Two % of the students had scores >8 and 90 % of the students had scores <5, meaning there is lack of awareness and knowledge about CSA even among MBBS students. Eighty nine percent of medico′s did not know the prevalence of CSA in India. Only 256 % were aware that both boys and girls are almost equally affected. 80 % participants did not know what to do when a child has suffered severe injuries following sexual abuse. Only 20·4 % were aware about the special act to deal with children suffering from CSA. Almost 52·4 % felt the need for including CSA as part of the curriculum form primary school.

Discussion
World Health Organization (WHO) defines CSA as 'the involvement of a child in sexual activity that he or she does not fully comprehend to and is unable to give informed consent to, for which the child is not developmentally prepared, or else that violates the laws or social taboos of society. 3 Child sexual abuse involves touching or fondling a child with sexual intent, forcible kissing, exposing a child to pornographic material, exhibiting ones private body parts before a child, forcing a child to exhibit his / her private body parts (exhibitionism), photographing a child in nude and rape, and sodomy in its ugliest form. 3 India is home to 19% of the world′s children, who constitute 42% of the country's total population. 4,5 Also, India has the world's largest number of CSA cases. 6 According to the survey carried out by Ministry of Women and Child development, Government of India in the year 2007, 53.22% children reported having faced one or the other forms of sexual abuse. 2 States such as Andhra Pradesh, Assam, Bihar, Delhi reported highest percentage of child abuse. Every fifth child has faced critical forms of sexual abuse. 5,6 50% abusers were persons known to the child or in a position of trust and responsibility. 3 As for the mechanisms of abuse, an offender initially befriends with the child and establishes an emotional connection, thus lowering the child's inhibitions; making him or her feel safe, even loved. Usually child grooming is done by giving chocolates and toys or playing with the child. In this manner, the offender, just like a predator, positions himself close to his prey, waiting for the right time to pounce. Based on their profiles the offender may be either situational who simply overpowers and takes advantage of the child's fragility or preferential i.e. a pedophile, who has true sexual interest in children. The offender initiates it; an incident, a series of incidents; an act that leaves an innocent child with consequences too deep to fathom. Not understanding what has happened, the child's emotions are in a mess. The child may exhibit various indirect symptoms and signs like anxiety, depression, low self esteem, post-traumatic stress disorder (PTSD), fear of family breakdown, inability to trust anyone, social isolation, and withdrawal. He / she may present with non-specific behavioral changes, acting out, increased clinginess, distractibility, learning difficulties, cognitive impairment, regression in developmental milestones, new-onset bedwetting, encopresis, excess eating, abusive tendencies in future, and even suicidal tendencies among adolescents. The Protection of Children from Sexual Offences (POCSO) Act came into force from 14 th November, 2012 to effectively address sexual abuse and sexual exploitation of children. In September 2013, the Ministry of Women and Child development formulated Model Guidelines for use of professionals and experts under section 39 of the POCSO act. The act covers children < 18 years of age, who suffers from penetrative and non-penetrative assault, sexual harassment and pornography, and child trafficking for sexual purposes. 1,2 It covers all aspects of CSA in detail. Most importantly, it stresses the need of treating every child sexual abuse case as an emergency. The dignity and self respect of the child must be maintained while examining and treating the child. First and foremost, a medical professional should build a rapport with the child and then elicit the relevant medical history in a facilitating, non-judgmental and empathetic manner. It may be necessary to ask direct questions to elicit history of vaginal or anal pain, bleeding and / or discharge following the event and urinary or fecal incontinence. Both genital and anal regions should be thoroughly examined to diagnose acute or chronic residual trauma and STDs and to collect forensic evidence. Injures present should be meticulously documented. The POCSO Act makes provisions for the medical examination of the child in a manner designed to cause as little distress as possible. The examination should be carried out in presence of the parent or another person whom the child trusts and in case of a female child, by a female doctor. Similarly, all hospitals are required to provide first-aid or medical treatment, free of cost, to the victims of sexual offence. In keeping with the best international child protection standards, reporting of sexual offences is mandatory for doctors. Body samples should be collected as per guidelines and stored appropriately. They should be labeled, sealed and signed before handing them over to the authorities. An inference should be made whether there is evidence of sexual contact and / or recent trauma and if medical history and examination are consistent with sexual abuse. 7 Review article by Adams JA et al has listed all the physical findings of injury/infection and their corroboration, strength and interpretation in CSA. 9 The special article by Seth R and Srivastava RN has elaborated the details to enable pediatricians and all allied medical practitioners to detect and provide immediate and long-term care and support to the victims and their families. 10 From point of view of management, injuries of children are graded using extrapolation of the Perineal Tear Classification since no system of classification of injuries of CSA victims exists so far. 8 Cases with first and second degree injuries are managed non -surgically by thorough local cleaning with antiseptics, use of antibiotics, analgesic and anti-inflammatory drugs; whereas cases with more serious injuries i.e. third and fourth degree injuries usually require surgical management. 8 Thus, the POCSO Act, 2012 is a landmark piece of legislation touching all aspects of CSA in detail. Since the prevalence of CSA in India is very high and the incidence is increasing day by day, 6 all trainee and practicing doctors should be thoroughly trained about the aspects relevant to the medical fraternity i.e. diagnosis, rational treatment, evidence collection, documentation of injuries and treatment of the child in an empathetic manner. Having an in-depth understanding the mechanism of sexual victimization and injuries resulting thereof is crucial. With this aim we conducted the survey among MBBS students, the doctors-in-making. We aimed to sensitize the students to the problem of CSA and analyze their level of awareness about various aspects of CSA in context of the POCSO Act, 2012. The limitation of the present study is that it does not test the actual knowledge of practicing doctors. However, it is an unique, firstever study of this kind in India and across the globe. The questions were especially formulated to cover all aspects of CSA from incidence to legal provisions. They were simple, MCQ type with one correct answer and checked as per the model answer sheet making the assessment objective, non-judgmental and unbiased. A similar study of the actual practicing doctors is underway and would throw more light on the current scenario. Studies published so far are mainly population based studies and have touched upon the incidence and prevalence of CSA in a particular locality, role of gender, sexual abuse and STDs, and psychosocial impact of CSA. However, none of the studies published so far have tested the medical professional's knowledge, their readiness and preparedness to diagnose and treat children suffering from CSA. This is particularly relevant in a country like India where every 155 th minute a child, less than 16 years is raped; every 13 th hour child under 10 years is victimized and one in every 10 children has been sexually abused at any point of time. 6 There is scope for conducting workshops / symposia about CSA in general and the relevant provisions of the POCSO Act, 2012 in Medical Colleges so that these budding doctors will become sensitized towards CSA and will be future-ready to recognize and tackle the ever increasing number of cases of CSA. In fact, CSA should be included as part of the medical curriculum. The medical students should be imparted necessary training and ability to recognize violence against children at an early stage so that they can handle these cases more confidently and with utmost care. Continuing medical education is required to enhance the ability of professionals to detect and manage CSA cases. There is a need of interdisciplinary care involving primary health care workers, police officers, child welfare committee workers, pediatricians, gynecologists, general surgeons, paediatric surgeons, urologists, forensic experts, psychiatric specialists, anesthetists etc. to handle these cases. The entire community should share the responsibility of rehabilitating the lives of these children and their families effectively.