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Kuldeep Jain
Abha Maheshwari
N. Agarwal
From the Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Shahdra, Delhi 110095, India.
Reprint requests: Dr. Kuldeep Jain, 12, .Anamika Apartment, Plot No. 99, Patparganj, Delhi 110 092, India.
Manuscript received: July 24, 1997; Initial review completed: September 2, 1997; Revision accepted: July 14, 1998.
There are many misconceptions about sexual assault in our society. A common misconception is that the assailant is driven by a strong sexual desire provoked by young women who dress and act seductive. However, sexual assault is a common problem even in young girls (less than 12 yrs) and has been increasing over the last few years throughout the world. Various factors that may be responsible for child abuse are low socio-economic status, inadequate housing facility, antisocial activities,
broken homes, parental disharmony and lack of parental control(1).
The exact magnitude of this problem is difficult to find to
determine as there is paucity of information regarding sexual assault in the pediatric population, especially in India as most of the cases remain unreported for fear of social pressure and embarrassment.
Methods
Case records of all patients with alleged history of sexual assault, who reported to the Gynecology Casualty, GTB Hospital, Delhi, between January 1995 and December 1996 were examined. This hospital drains a population of 8 police districts and caters mainly to the underprivileged section of the society and is situated in the eastern part of the capital city of Delhi. Details such as age of the victim, month, time and location of incident, age of assailant and proximity of asailant to the victim were noted. All the genital and extra-genital injuries, hospital course, duration and the treatment given was also recorded. For the purpose of description, the following classification was employed. However, some injuries could not be classified according to this classification and were grouped separately:
Ist Degree
-
Injuries involving fourchet,
perineal skin and vaginal mucus membrane.
IInd Degree - Vaginal lacerations involving fascia and muscles of perineal body along with skin and mucus membrane.
IIlrd Degree - Involving skin, mucus membrane and perineal body and involving anal sphincter.
IVth Degree - IIlrd degree with extension into rectum.
Other injuries - Colporraxis, vault tear.
Treatment ranged from conservative management in 1st degree perineal tear to laparotomy in more severe cases.
Results
A total of 310 female patients reported with alleged history of sexual assault. Of these, 62 cases (20.32%) were in the below 12 years age group.
All pediatric patients, except 19, were treated on out-patient basis. The age, in these 19 patients, ranged from Ph to 11 years. Most of the children were assaulted in the evening and in almost 50% of cases the child was assaulted by person known to the victim, and near her home. Extra-genital injuries were seen in only 3 patients. The various genital injuries observed are . shown in Table I. Hospital stay varied from 1 to 13 days depending upon the severity of the injury but most of the patients were discharged within 7 days. There were serious injuries in 4 cases, one case required laparotomy, 2 cases required blood transfusion and one patient died before exploration probably due to associated head injury.
TABLE I
Genital Injuries Observed.
Injuries
|
No. of
cases |
Percentage
|
|
Io Perineal tear |
3 |
15.8 |
|
IIo Perineal tear |
12 |
63.1 |
|
IIIo Perineal tear |
1 |
5.3 |
|
Complete perineal tear |
3 |
15.8 |
|
Colporraxis* |
2 |
10.5 |
|
Vault tear* |
2 |
10.5 |
|
* Seen along with other injuries. |
Discussion
Sexual assault is one of the most violent crimes identified. The pediatric age group,
especially below ten years, forms a large and vulnerable group of assault victims as they can be lured easily and offer negligible resistance to the assailant. Although an incidence as high as 83% has been reported(2); the figure in our study was 20.31 % in the pediatric age group, which is similar to some other series(3-4). However, this may not be a true incidence as a large number of sexual assaults go unreported. It is estimated that as few as one in ten victims will report sexual assault(5). Many victims or their parents may hesitate to report sexual assault for fear of becoming involved in complicated police investigations and court proceedings. In addition, feelings of anxiety, guilt, shame and social pressures may prevent a victim or her parent from reporting the crime.
Another fact that has been associated with assault on young girls is the proximity of the assailant to the victim. Mehta et
al.(1) reported that almost 80% assailants were known to the victims. Neighbors constituted 51.5% of the. assailants. In our study, in almost 50% of the cases, the. assailant was known to the victim. Previous studies have reported that 90% sexual assaults are intra-racial rather than inter-racial and the victim and assailant come from a similar social and economic background(6,7). It
has also been reported that in a large number of cases, the
relationship of the molester to the child victim is that of the
parent or parent substitute(8). Child molestations have also been
reported to occur in the victim's or assailant's home and rarely
involve the use of automobile. In the present study, most of the assaults occurred in or near the victim's house.
Studies from the United States(7,9,10) have reported that sexual assaults usually occur in the warmer months. However, no such correlation was noted in the present study. Most of the assaults took place in the evening which can be explained by the fact that children usually go outdoors to play in the evening. However, other studies have reported(7,11) that molestations usually occurred in the afternoon.
Of the 62 cases in the pediatric age group, 19 children required hospital admission whereas none of the 248 patients in age group of more than 12 years required in-patient treatment. Genital injuries were frequently minor and included abrasions or hymenal transections, first degree vaginal tears and perineal
tears. These injuries were almost always painful but were rarely
associated with significant bleeding. In this study, 19 patients
required surgical intervention for their genital injuries, which ranged from suturing of the tear to laparotomy. The position and extent of tear, abrasion .and erythema in previous reports have suggested that introital and perihymenal injuries occur between 3 and 9 O'clock position, most commonly at 6 O'clock position(12).
The role of the physician while attending to a sexual assault victim is manyfold.
Though the primary responsibility is to treat the physical injury,
the emotional stress and trauma which is much more intense in the young victims should also be taken care of. The physician should also try to probe into the assailants background and behavioral and psychological profile so as to provide vital information to the law- enforcement agencies.
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