The Need for Training Medical professionals in Child Sexual Abuse

Sir,

Child sexual abuse (CSA) is a problem prevailing worldwide with profound psychological consequences. CSA includes an array of sexual activities like fondling, inviting a child to touch or be touched sexually, intercourse, exhibitionism, involving a child in prostitution or pornography, or online child luring by cyber predators.^{1, 2} The World Health Organization (WHO) defines CSA as follows,

The involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared and cannot give consent, or that violates the laws or social taboos of society. ³

According to 1098 CHILDLINE, a child abuse helpline, India has the world’s largest number of CSA cases: A child less than 16 years is raped every 155th minute; a child under 10 is raped every 13th hour. ⁴ In spite of the magnitude of the problem, there is a profound deficiency of preventive programs. This is especially worrisome in a country like India, where a large population exists with a lacuna in the awareness regarding CSA, coupled with poor knowledge in the medical profession. Although there are organizations working in this direction with the media also playing a role, there is no systematic training at the medical undergraduate and postgraduate level, which has contributed to ignorance and insensitivity to the subject.

Need for training

Residents are most often the first points of contact in emergency as well as out-patient settings, and the child and caregiver must be handled competently and empathetically in order to avoid further trauma. Learning to recognize children’s descriptions as abuse, which may not correspond to the usual accounts, needs guidance and experience, and identifying and managing the long term sequelae which can persist into adulthood and lead to significant behavioral disturbances are also important. Symptomatology and management apart, risk factors and warning signs also need to be recognized, thereby preventing victimization. A survey which included resident program-directors and residents found that more than half of them rated the quality of training for CSA evaluation as less than adequate. ⁵ Although most residents are aware of the basic essentials, they may not have exposure to the finer nuances such as evaluation of the patient without accidently tampering with evidence, detailed documentation, legal responsibility of reporting the perpetrator to authorities, implications for victims and caregivers, and further referral to other medical specialists or to an expert in managing CSA.

Existing and Future Programmes

Considering the global scenario, several effective strategies have been adopted. In USA, a training program for physicians called Safe Environment for Every Kid (SEEK) has been initiated to address the psychosocial risk factors for childhood maltreatment. ⁶ In India too, many organizations are conducting various community and school based awareness programs. The Indian Academy of Pediatrics has started the Child Right and Protection Program (CRPP) under VISION 2007, aimed at providing an impetus for involvement of pediatricians in child protection activities. As part of the CRPP, a module called the “Training of Trainers (TOT) Workshop” for pediatric doctors has been developed. ⁷ The Indian Medical Association, with UNICEF, conducted regional workshops and released information booklets about CSA for doctors. ⁸ Although this is a step in the right direction, identifying and establishing learning needs is important. There is a need to formulate different modules suitable for each group of learners, especially considering that there is a gap in the current knowledge and skills and those that are desired of many students, residents and even practicing doctors. ⁹

For undergraduates, theoretical and clinical material about CSA should be integrated into the medical curriculum. During history-taking training, screening questions could be incorporated to address risk factors and warning signs of CSA. ¹⁰ Demonstration classes for basic interview techniques should be conducted using role-plays along with video demonstrations of correct examination methods. Postgraduate students would benefit more from more structured, intensive methods such as continuing medical education (CME) courses, symposia, expert lectures, multidisciplinary team discussions, and journal reviews, along with hands-on clinical knowledge gained by frequent interactions with survivors. This would help in understanding their own responses, mask discomfort and avoidance and show supportive acknowledgement and reassurance. Structured interview pro forma can be used to avoid missing out on relevant information. There are already well developed training modules to cater to trauma and life threatening emergencies such as basic life support (BLS) and advance cardiovascular life support (ACLS), which have been integrated with the undergraduate and postgraduate medical curriculum; and akin to these, modules for CSA management also need to be put in place.

According to Botash et al, learning requirements of standard residency curricula continue to increase, and incorporating CSA modules may be challenging. Therefore, utilizing a self-paced program independent of faculty skills, case availability or resident time constraints would have potential for success. CMEs are especially suitable for senior residents and practicing consultants and provision of credit points would act as further incentive for active participation. Guided experiences in interviewing and examining abused children may also be of use to improve competency and patient outcomes. ¹¹ Also, providing access to reading material and video tutorials as part of a self-learning course, along with end-of-course self-assessment tests would be more suitable as the flexibility and autonomy would provide impetus for greater involvement. One project proved the effectiveness of self-instructional programs regarding sexual abuse on knowledge of physicians, with > 90% of participants reporting significant knowledge mastery. ¹²

CSA can have diverse symptomatology and its adequate management requires an integrative approach involving psychiatrists, psychologists, obstetricians, surgeons, pediatricians, forensic medicine, and neurologists, and medical professionals are clearly not well equipped to handle a case with CSA in the Indian context. There is considerable need to conduct workshops with compulsory grading system as a part of the medical curriculum. Various school and community programs can be conducted by psychiatry and community medicine postgraduate students, which can possibly aid in reducing the stigma surrounding the reporting of CSA. All medical professionals, irrespective of specialty, should be equipped reasonably well to handle crises such as CSA, and to achieve this, there is a need for robust research on effectiveness of various methods of education about CSA such as structured modules, faculty based teaching, self-learning and assessment, video demonstrations, and incorporation of an emergency response protocol for CSA into the regular medical education curriculum. We need to explore the effectiveness of these modules by measuring the expertise gained, final outcomes for CSA victims and also patient, and caregiver satisfaction, so that, over a period, this will empower and equip the next generation doctors and have a positive impact on the community as well.