Frenular tear as a sign of non-penetrative sexual assault in a male child: Case report with medicolegal implications

Introduction

Child sexual abuse (CSA) is a serious socio-legal problem. Historically, societal stigma and lack of awareness contributed to underreporting and an inadequate response to such offences. A landmark development in India was the 2012 Protection of Children from Sexual Offences (POCSO) Act, which criminalises a wide range of sexual crimes against children under 18 years of age. It includes child rape, penetrative and non-penetrative sexual assault, aggravated sexual assault, sexual harassment and child pornography. ¹ Sexual assault is categorised into penetrative, non-penetrative (contact without penetration) and non-contact offences. Penetrative sexual assault includes peno-vaginal, penile-oral, penile-anal and digital or object penetration of the vaginal or anal areas, whereas non-penetrative sexual assault involves unwanted sexual contact, physical assault and extragenital injuries, with penile frenular tear being uncommon and underreported. ² We consider a case of non-penetrative sexual assault on a male child, involving active bleeding from a penile frenular tear caused by the forceful pulling of the prepuce skin by the assailant. We also discuss the circumstances, potential mechanisms and forensic examination which are needed to differentiate such injuries from self-inflicted injuries.

Case presentation

A 7-year-old boy presented at the emergency department accompanied by his mother and police who alleged sexual abuse had been perpetrated by his father’s co-worker some 2 hours earlier. The suspected assailant had taken the boy to his home and secured the door, forced the boy to disrobe, after which he forcibly manipulated the prepuce skin of the child’s penis, resulting in a painful rupture of the penile frenulum. The child had screamed instantly, prompting the mother to hasten to his rescue. The assailant rushed out as the child’s mother entered to see her son unclothed and covered with blood from the tip of his penis.

Due to the medico-legal implications, the incident was reported to the police, and a medico-legal case (MLC) was registered. As the case involved a minor under 18 years of age and fell under the POCSO Act, a medical board was constituted, comprising a forensic expert, a paediatric surgeon and a child psychologist. Parental consent was obtained for the medico-legal and medical examinations, treatment and evidence collection for clinical and forensic investigation, accompanied by two independent witnesses.

Examination of the genital area revealed a fresh frenular tear measuring 3 mm × 2 mm, with active oozing of blood and haematoma formation over the glans penis was present (Figure 1(a) and (b)). Dried blood stains were present in multiple areas over the scrotum and the inner aspect of both thighs. Swabs were taken from the penile shaft and frenulum for the detection of DNA of the accused, which turned out to be negative. The patient was admitted and received local wound debridement with betadine and saline, subsequently followed by a compression dressing. Tetanus Toxoid (TT) was administered, analgesics were prescribed, and the patient monitored.

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Figure 1.

(a) Fresh penile frenular tear measuring 3 mm × 2 mm on the dorsal aspect of the tip of the penis, with active oozing of blood. Dried blood stains were also noted on the inner aspects of the thighs. (b) Hematoma formation over the glans penis, observed after retraction of the prepucal skin. Dried blood stains were present in multiple areas over the scrotum and the inner aspects of the thighs.

No other external injuries, such as abrasions, contusions, lacerations, bony fractures or any signs suggestive of struggle or chronic abuse, were present on the child’s body. He had not bathed, douched, urinated or passed stool since the incident. His vitals were stable. There was a history of fondling/touching; however, there was no history or signs suggestive of kissing, licking or sucking, nor a sign of oral sex performed by the assailant on the victim. There was no history of physical assault, such as beating, banging, hair pulling or slapping, nor any evidence or history suggestive of ejaculation or condom use.

Discussion

Child sexual abuse (CSA), a serious public health concern, causes both short and long-term physical and psychological impact on the victim and carries significant legal repercussions. Sexual abuse can take place within the familial context, with the perpetrator potentially being a parent, sibling or relative. It may also be by a family friend, neighbour, caretaker, teacher or acquaintance. ³ The Indian POCSO Act is a gender-neutral law ensuring the safety of all children under 18 years of age and categorises offences into sexual assault, sexual harassment and child pornography. ¹

Non-penetrative sexual abuse can include actions such as kissing, hugging, forced genital manipulation, breast and nipple stimulation, bagpiping, mutual masturbation and intercrural sex. Male child victims frequently have anal or oral injuries, including bruises, fissures, inflammation, or, in severe instances, anal prolapse; nevertheless, the occurrence of strong penile prepuce retraction resulting in frenular tear is less prevalent. Symptoms like pain while walking, bleeding or difficulty urinating should raise suspicions with other causes, such as sports-related injuries and trauma, ruled out.

Dündar et al. ³ found that both penetrative and non-penetrative sexual assaults can lead to short- and long-term psychiatric issues in children. The study also revealed that penetrative sexual assault was more prevalent among boys than girls and was more common in rural areas, whereas non-penetrative assault occurred more frequently in urban settings (as in our case). Sowmya et al. ⁴ in 2012 studied children with a history of sexual abuse at a tertiary care centre in India. They found that contact penetrative abuse was most common (67.5%), followed by contact non-penetrative (30%). Negriff et al. ⁵ classified sexual abuse in young adolescents into penetrative, non-penetrative contact and non-contact types. The study found non-penetrative contact abuse to be the most common, with genital fondling frequently reported as occurred in our case. Approximately 40% encountered penetration and 15% endured non-contact abuse, similar to findings in retrospective studies. Most victims were abused by males but some by females.

The penile frenulum, a soft tissue linking the glans to the shaft, is richly innervated and susceptible to injury. Its tear typically occurs due to vigorous retraction of the prepuce skin, leading to severe pain and haemorrhage. Common causes includes vigorous masturbation, sexual intercourse, tight clothes, cycling, contact sports and injuries sustained during strenuous labour. Over 50% of torn frenulum cases result from vigorous sexual activity, while other causes include self-inflicted, iatrogenic, accidental injuries, zip entrapment and shaving-related cuts. In children, the occurrence of a frenular tear should prompt suspicion of abuse and be seen as a potential indicator of sexual assault. Accidental injuries have been reported in boys, with zip entrapment a predominant cause.^6,7 It can be argued that the injury could be accidental from entrapment, which is more common when zipped up rather than down. There are two entrapment patterns: one involving the mobile head and another where the skin is caught between the interlocking teeth of the zip. Typically, these injuries involve entrapment of the preputial or scrotal skin, leading to minor abrasions or small lacerations, rather than significant haemorrhage and frenular tears, as observed in this case. ⁸

During the court proceedings in our case, the defence lawyer claimed that the child’s frenular tear could be self-inflicted or an accidental injury sustained while zipping/unzipping his pants. The forensic specialist and paediatric surgeon stated the frenular tear strongly indicated sexual assault and that the frenulum is extremely sensitive, making self-inflicted injury unlikely owing to intense pain and it would rarely bleed much. Zipper entrapment usually injures the penile tip or dorsal aspect or scrotal skin, but this frenular tear was beneath the prepuce, making unintentional entrapment unlikely. The haemorrhage and haematoma indicated forceful prepuce skin retraction and squeezing. Moreover, the child’s mother provided an eyewitness account, further supporting the claim of sexual assault. The forensic expert and the paediatric surgeon concluded that the case constituted non-penetrative sexual assault as delineated by Section 7 of the POCSO Act, which states that any individual who, with sexual intent, touches a child’s genitals is culpable of sexual assault. The corresponding punishment under Section 8 prescribes imprisonment for a term of not less than 3 years, extendable up to 5 years, along with a fine.

This case emphasises the need for emergency physicians, paediatricians, surgeons and forensic specialists to remain vigilant in identifying indicators of sexual abuse, particularly in male children who present with genital injuries, both during clinical examinations and autopsies. These experts must thoroughly understand normal genital and perineal anatomy across all age groups, be capable of distinguishing normal variants from abnormalities, and ensure accurate documentation and reporting is carried out. While examining cases of penile frenular tears or prepuce injuries in male children, the possibility of sexual assault must be considered and self-inflicted or accidental injuries ruled out.