Pitfalls in the diagnosis of child sexual abuse

delta-Storage pool disease: a pitfall in the forensic investigation of sudden anal blood loss in children: a case report

We present the case of a 3.5-year-old boy with sudden anal blood loss at school. Sexual abuse was suspected, and, apart from anal fissures seen on sigmoidoscopy, no other clinical signs of any sort of disorder were present. As no medical explanation for the blood loss could be given, penetrating anal trauma was suggested. During follow-up consultations, there were complaints of occasional blood loss. Platelet aggregation tests and electron microscopy finally helped diagnose a delta-storage pool disease which is a rare haemostatic disorder involving the dense granules of the platelets. Although exclusion of well-known blood diseases through routine laboratory testing is a common practice in children with sudden blood loss, this case illustrates the value of more specialised investigation both from a diagnostic and forensic point of view.

Victims of violence: an Asian scenario

The term 'violence' is difficult to define. Aggressive behaviour with actual use of physical force may result in some form of physical and emotional trauma to an individual and this could be considered as violence against the person. The trauma may range from minimal physical injury to death. It is also relevant to note that in some jurisdictions if members of the law enforcement agencies with appropriate authority resort to certain acts of 'violence' for lawful purposes, then such acts of violence may be excluded from this category. However, if the law enforcement personnel exceed their limits of authority, or resort to various unacceptable and unauthorized methods of violence, then certainly such acts will become violence against the person. In today's context the word violence has expanded to encompass many issues, besides the usual physical violence such as assault. Rape, child sexual abuse, other forms of sexual abuse, non-accidental injury to children, battered wife, assault in custody, torture, victims of war, civil unrest and ethnic violence are all considered under 'violence'. While general violence is almost endemic in many countries, assault in custody, torture, political and ethnic violence are serious problems in some of the developing world. In these countries, particularly, the law enforcement agencies and other unlawful groups who are backed by politicians may inflict politically motivated violence against its citizens. In such cases attempts are often made to cover up such crimes. Forensic physicians and forensic pathologists who examine these cases may be placed in difficult positions at times owing to various 'pressures' being brought upon them to issue 'favourable' reports. On the other hand there is also a general dearth of suitably trained forensic physicians and forensic pathologists in many of these countries. Medical officers without any training in forensic medicine often undertake the examination of victims of violence, both living and fatal cases. Lack of training makes them more vulnerable to political and other forms of 'pressure'. The objective of this article is to highlight some of the common problems that are encountered, particularly in developing countries.