Child Sexual Abuse in Puttalam District, Sri Lanka; A Medico-Legal Analysis

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Introduction Patterns of child sexual abuse are different from country to country and also from area to area within a country. Further, the management should not be confined to medico-legal aspects but ensure psychosocial management o f child and family as a whole. Therefore, this study was conducted to identify and describe the patterns of child sexual abuse and management strategies in a District of Sri Lanka. Methods Retrospective descriptive study was conducted on the victims of child sexual abuse reported to the Base Hospital, Puttalam, Sri Lanka over 20 months from November 2014 to June 2016. Demographic factors, injuries sustained, the abusers" correlates and the management strategies were studied. Results There were 183 victims of Child sexual abuse reported and 168 (91.8%) were females and 15 (8.2%) were males. Ages ranged from 3-18 years and mean age was 12.65 years with SD+/- 3.462. O f them. 123 (67.2%) belonged to 11 -15 years. The distribution of age is shown in Table 1. Forty two (23%) were less than 10 years of age and remaining 141 (77%) were 11-18 years. Table 1. Distribution of Age Age groups Frequency Percent 0-5 10 5.5 6-10 32 17.5 11-15 123 67.2 16-18 18 9.8 Total 183 100.0 There were 164 (89.6%) Sinhalese, 16 (8.7%) Muslims and 3 (1.6%) Tamils. 64 (35%) lived in Urban areas and remaining 119 (65%) belonged to rural areas. At the time of the incident, 53 (29%) had studied up to 5th standard, 127 (69.4%) up to 11th standard and 3 had gone up to Advance Level. In 62 (33.9%) incidents, mother had complaint to police, in 10 the relatives^ in 3 the father and in 4 instances the victim himself. Ninety six (52.5%) incidents had taken place at home and the remaining incidents at places outside home. 37.1% (n=39) of non-relatives and 80% (n=48) of relatives abused their victims at the victinv's home and this difference was significant (x2=28.136, df=l, p=0.000<0.05). But the place of occurrence was not significantly associated with urban or rural living (p=0.317>0.05). | 8. & 6 ) Regarding the time of the incident, 21 (11.5%) in the morning, 40 (21.9%) in the afternoon, 30 (16.4%) in the night, one case in dawn and 91 (49.7%) could not remember the time of the incident. None of them were abused by strangers; 62 (33.9) were relatives and 121 (66.1%) were known non-relatives. Abuser was the father in one instance. All the abusers were male. In 7% (n=l) of male victims and 36% (n=61) of female victims were abused by relatives and this difference was significant (x2=5.402, df=l, p=0.02<0.05). Almost all male children (93%, n=14) were abused by non-relatives. Whereas, one third o f female children (36%, n=61) were abused by relatives. In 52% (n=50) of incidents occurred at home and 14% (n=l2) of incidents occurred at outside were committed by relatives and this difference was significant (x2=29.87, df=l, p=0.000<0.01) Among girls, 94 (51.4%) had crescentic hymen, 36 (19.7%) had annular hymen, 35 (19.1%) had fimbriated hymen and 3 had attenuated hymen. Among less than 10 years girls, most (91%, n=32) had nonfimbriated hymens such as crescentic hymens. In 82% (n=28) o f less than 10 years of age and 50% (n=66) o f over 10 years of age had crescentic hymens and this difference was significant (x2= 11.256, df= 1, p=0.001 <0.05). Among girls, 74(40%) had complete tears, 40(23.8%) had partial tears,5 had notches, 4 had attenuation and 45(26.8%) had no hymenal tears. Three tears were in the anterior half of the hymen and 114 (36.1%) were posterior tears. In 45% (n=16) of less than 10 years of age and 80% (n=107) o f more than 10 years o f age had tears and this difference was significant (x2= 17.049, df=l, p=0.000<0.01 ).Both home (73%, n=66) and outside (73%, n=57) incidents caused tears in hymen. Among all the victims, 92 (50%) had evidence of genital penetration, 51 (28%) had been subjected to both genital and anal penetration, 12had evidence of anal penetration, and 27 (15%) did not have any evidence of penetration. Only one had fresh injuries. Three female victims were pregnant. In 33% (n=5) of males and 34% (n=58) of females had evidence of anal penetration and the difference was not significant (p=0.926>0.05). Five (2.7%) had associated physical abuse as well. Regarding further referrals, 146 (79.8%) were referred to STD clinic and 154 (84.2%) were referred to the psychiatrist. In 37 (20.2%), case conference was organized. Case conferences were not organized in 92% (n=58) of cases with anal penetration. Both, 20% (n=24) of victims with hymenal tears and 18% (n=8) of victims with no hymenal tears were considered for case conference (p=0.800>0.05). Conclusions Physical abuse was rarely associated with child sexual abuse. Majority- of incidents that occurred at home were committed by male relatives. Known non-relatives are the most potential abusers. Girls more than 10 years are most vulnerable for penetration. None were given STI prophylactic treatment. Mere presence of injuries were not indications for case conference. However, the follow-up reports of psycho-social managements were not available.