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Traditionally, sexual abuse is under-reported and under-recognized when the victims are boys. A study carried out by the Government of India in 2007 suggests that every second child/adolescent in the country faces some form of sexual abuse and it is nearly equally prevalent in both sexes. The significance of the problem is undermined all the more when the abuse is perpetrated by a peer. Sexual activity between children and adolescents that occurs without consent or as a result of coercion is tantamount to abuse. A majority of the victims do not disclose the occurrence to anyone. This often neglected issue of adolescent male peer sexual abuse in a sexually conservative country like India is highlighted and discussed through this case, which came to light only after the victim developed a venereal disease.
The Government of India published the “Study on Child Abuse: India 2007,” which found that 53.22% of children reported having faced sexual abuse (sample survey of 12,447 children across 13 states of India). Among them, 52.94% were boys. Generalizing these findings, every second child in the country faces some form of sexual abuse and it is nearly equally prevalent in both sexes. Although common, sexual abuse of boys is under-reported, under-recognized and under-treated. Under-reporting is believed to occur due to sex stereotyping, which minimizes male victimization.
Sexual activity between children that occurs without consent or as a result of coercion is tantamount to abuse. This includes when one of the children uses physical force, threats, trickery or emotional manipulation to elicit cooperation. It is differentiated from normative sexual play or anatomical curiosity because of overt and deliberate actions directed at sexual stimulation or orgasm. Peer sexual abuse has been reported to be associated with adverse outcomes. Here, attention is drawn to the neglected issue of adolescent male peer sexual abuse through a case that came to light only after the victim developed a perianal skin lesion.
M, a 13-year-old boy, presented with complaint of small water-filled lesions in the perianal region, which burst to form raw areas, associated with burning pain and bloody discharge. On examination, the lesions were grouped, multiple, superficial with central slough, and peripheral erythema [Figure 1]. Herpes progenitalis was diagnosed (later confirmed by Tzanck smear). Strongly suspecting it to be sexually transmitted, the dermatologist questioned about sexual exposure, which was initially denied by M as well as by his father. On a more tactful enquiry in the absence of his father, M did admit to have been sodomized. The revelation was shocking to his father as he was completely unaware about it. A psychiatric referral was made for psychological evaluation.
History revealed that 10 days back, while roaming around alone in his native village, he was approached by a boy, who was a complete stranger to him. He tried to befriend M, telling him that he was 13 years old and stayed in the neighboring village. He then immediately proposed that he wished to “penetrate” M and promised that the experience would be immensely pleasurable. M gave in to his demand, though with an initial resistance. In an isolated place in the nearby fields, they indulged directly in unprotected peno-anal sex with M being the recipient. Soon after the act began, M felt intense pain and immediately asked to stop, but the boy continued to thrust forcibly. M managed to push him away. He returned home, but could not gather the courage to report it to his parents. He experienced perianal pain for a day, but was asymptomatic thereafter for about 10 days until the appearance of the skin lesion. His father reported that there were no observable emotional or behavioral changes during that period.
Mental status examination did not suggest an overt psychopathology, although it was noted that while narrating the incident, M avoided eye-to-eye contact indicating a sense of guilt and embarrassment attached to it. He also expressed anger toward the perpetrator. He denied having any prior sexual experience. His academic record was good and intelligence was clinically average. He tested negative on Venereal Disease Research Laboratory (VDRL) test, and serological tests for Australia antigen and HIV. He did not come back for follow-up.
As per the study of Government of India, 5.69% children reported penetrative sexually assault, of which 54.4% were boys. Nearly, 72.1% children did not report the occurrence to anyone. Had the child in this case not developed a sexually transmitted disease (STD), he would have probably not reported the assault. Boys are usually less willing to report compared to sexually abused girls. There is fear of being labeled a homosexual. There may be shame and self-blame regarding the inability to prevent what happened. Psychological responses to abuse such as anxiety, denial, dissociation, self-mutilation, and suicidal ideation are common and may result in poor school performance. During the abuse, there appears to be less fondling of boys than girls and the abuser often gets down to the real abusive act as in this case. Abuse of boys frequently occurs outside the home, involves penetration and perpetrators tend to be unrelated males. Male adolescent perpetrators frequently have a history of being victims of sexual abuse themselves; thus, need an equal clinical attention with regard to STDs and possible psychopathology.
Although apparently it appears that the victim in this case indulged in consensual sex, it is obvious that he was tricked into the act, which amounts to abuse. All health-care professionals need to be aware of and sensitive to the possibility of sexual abuse in their male patients. An unassuming, accepting, empathic, and non-judgmental approach is warranted to deal with male victims of sexual abuse. It is needless to emphasize the importance of sex education, which may go a long way in preventing adolescents from indulging in high-risk sexual behaviors. It is worthwhile to acknowledge that boys are as prone to sexual abuse and its repercussions as girls and that it is not always an adult who abuses a child or an adolescent.
The author thanks Dr. Purna Pandya, Dr. Hiren Patel, and Dr. Chetana PR (previously at Department of Dermatology, ESIC Model Hospital, Ahmedabad, India) for reviewing the first draft of the manuscript and giving valuable suggestions.
Source of Support: Nil
Conflict of Interest: None.