Every case of sexual assault is a medical emergency for which free treatment is mandatory at government or private medical facilities, and no document or precondition is necessary for providing emergency medical care.A survivor of CSA may approach a health facility directly for treatment, with a police requisition after police complaint, or with a court directive. The hospital is bound to provide treatment and conduct a medical examination with consent of the child/parent/guardian, depending upon the age of the child. The survivor may or may not want to lodge a complaint, but requires medical examination and treatment. In such cases, the doctor is bound to inform the police as per law. However, neither court nor the police can force the survivor to undergo medical examination without an informed consent of the child/parent/guardian. If the victim does not want to pursue a police case, a medico-legal case (MLC) must be made and an informed refusal documented. If the victim has reported with a police requisition or wishes to lodge a complaint later, the information about MLC number and police station must be recorded.

An informed consent must be obtained, which is required for examination, collection of samples for forensic examination, treatment and police intimation. If the child is over 12 years of age, consent should be sought from the child. For those below the age of 12 years, a parent or guardian is required to provide it. Such consent should be informed and the person providing the consent should be clearly explained the purpose, expected risks, benefits and any adverse effects of the examination, and the amount of time it will consume. This information should be provided before the examination is conducted.

The diagnosis of CSA is most often based on the history, as opposed to physical findings; and thus obtaining a meticulous history of the child’s experience is crucial.The interview should be conducted in a facilitative, non-judgmental and empathetic manner and should not have an investigative tone, which is the domain of the police and courts.The interview process & seeking answers to:

• The family’s psychosocial background.
• The child’s developmental level.
• The questions and the child’s responses are recorded verbatim.
• The body language, demeanour and emotional responses are noted.
• The likelihood of behavioural complaints and physical findings that may suggest sexual abuse should be considered.
• Past medical history, incidents of abuse or suspicious injuries, and menstrual history should be documented.
• Information is obtained about the child’s behaviour, specially sexualized behaviours and in young children, the names the child uses for body parts (breasts, vagina, penis, anus).

Leading and suggestive questions are avoided and expression of strong emotional responses such as shock or disbelief is resisted. A review of systems is done focusing on any anal and genital complaints such as bleeding, discharge, pain, or past genital injury. The history of sexual abuse is ideally obtained without the presence of the parent or caregiver. The child and the parents should be informed and reassured that the paediatric forensic examination is not invasive or painful and that internal instrumentation or speculum insertion is carried out only when considered essential.

Doctors are legally bound to examine and provide treatment to survivors of sexual violence. Timely reporting, documentation and collection of forensic evidence are important toward investigation of the crime. Police personnel should not be present during any part of the examination.Where the victim is a girl, the medical examination has to be conducted by a woman doctor in the presence of the parent of the child or any other person in whom the child reposes trust or confidence. If such a person cannot be present, the examination is conducted in the presence of a woman nominated by the head of the medical institution. The elements of physical examination include particular attention to the following

• calming the child during examination
• positioning for optimal exposure of prepubertal genital structures: frog-leg supine position, knee-chest or left lateral decubitus position
• general observation and inspection of the anogenital area, looking for signs of injury or infection and noting the child’s emotional status.
• examination of mons pubis, labia majora and minora, clitoris, urethral meatus, hymen, posterior fourchette, and fossa navicularis.
• visualization of the more recessed genital structures, using handheld magnification or colposcopy as necessary.
• collection of specimens for sexually transmitted disease (STD) screening and forensic evidence collection.

It is important to realize that physical examination in CSA is very likely to be within normal limits in most cases. The absence of abnormal findings can be explained by several factors. Many forms of sexual abuse do not cause physical injury. Thus, sexual abuse may be non-penetrating contact and may involve fondling, oral-genital, genital or anal contact, as well as genital-genital contact without penetration. Mucosal tissue is elastic and may be stretched without injury, and superficial abrasions and fissures can heal within a few days. The perpetrators are often known to the child and family and the use of physical force is rarely a major component in CSA as in adult sexual assaults. Disclosure of abuse is often delayed for weeks or months, and by that time any physical evidence may be absent. The abnormal findings observed may be attributable to acute injury incurred during the recent episode or indicative of residual effects following repeated episodes of genital contact in the past.

The following investigations are routinely carried out:

• Gram stain of vaginal or anal discharge
• Genital, anal, and pharyngeal culture for Gonorrhea
• Genital and anal culture for Chlamydia.
• Serology for syphilis
• Wet preparation of vaginal discharge for Trichomonas vaginalis
• Culture of lesions for herpes virus
• Serology for HIV (based on suspected risk)

Collection of forensic evidence employing the Rape Kit and Urine toxicology screen (if the abuse or assault was likely to be substance-facilitated) may be required.

Forensic evidence includes blood, semen, sperm, hair or skin fragments that could link the assault to an individual person, as well as debris (e.g., carpet fibers) that could help to identify the location. Collection of specimens and material should be done if sexual contact has occurred within 96 hours of the physical examination. The purpose of a forensic examination is to ascertain the following:

• whether a sexual act has been attempted or completed. Sexual acts include the slightest genital, anal or oral penetration by the penis, fingers or other objects as well as any form of sexual touching. The absence of injuries does not imply consent of the victim for the act.
• whether the sexual act is recent and if any injury has been caused to the child’s body.
• the age of the survivor in cases involving of adolescents.
• whether alcohol or any other intoxicating substances have been administered to the child.

Emergency medical care must be provided in a case of CSA. Police or magisterial requisition is not required for that purpose. The management of CSA includes the following:

• Treatment of sexually transmitted diseases (STDs) is carried out with appropriate medications.
• In post-menarcheal girls, the likelihood of pregnancy and the need for emergency contraception is considered.
• Emotional support is provided.
• CSA, whether confirmed or strongly suspected, must be reported to the appropriate authorities.
• Detailed, well-documented medical records must be kept, since these are crucial in legal proceedings, which may take place after a lapse of long periods.
• Referral to a mental health specialist should be made in all cases, which is required for evaluation and treatment of acute stress reaction, and subsequently posttraumatic stress disorder (PTSD). Referral to other specialists should be made as required.

Proper collection of material, depending upon the history of sexual violence, is of utmost importance for medicolegal purposes. Such assault can be peno-vaginal, peno-anal, peno-oral, masturbation and use objects for penetration. Thus the material can be semen, faecal matter, lubricant, saliva and hairs. Detailed instructions about collecting forensic evidence are provided by the Ministry of Health & Family Welfare, Government of India. The material should be properly packed, sealed, labelled and sent to the police.The Ministry of Women & Child Development, Govt. of India is establishing One Stop Centres (OSC) to provide support and assistance to survivors of gender violence . Thus, comprehensive services, including medical, police, psychosocial counselling, legal aid, shelter, referral and facilities for video-conferencing are provided ‘under one roof’. For those below 18 years, these are undertaken in coordination with authorities under the Juvenile Justice Act, 2011 and the POCSO Act, 2012. The scheme is centrally sponsored with 100% financial assistance.