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Child abuse in Chandigarh, India, and its implications
J O U R N A L
Journal of Clinical Forensic Medicine 11 (2004) 248–256
O F
CLINICAL FORENSIC MEDICINE www.elsevier.com/locate/jcfm
Original communication
Child abuse in Chandigarh, India, and its implications B.R. Sharma *, Manisha Gupta Department of Forensic Medicine and Toxicology, Government Medical College and Hospital, #1156-B, Sector 32 B, Chandigarh 160030, India Available online 28 March 2004
Abstract Few abuses of human rights are so universally condemned but at the same time so universally practiced as child abuse. Over the centuries, children have been subjected to physical, sexual and emotional abuse as well as neglect. By any objective measures, this issue should rank high on the global agenda but in practice it is surrounded by a wall of silence and perpetuated by ignorance. Child sexual abuse is a dark reality that routinely inflicts our daily lives but in a majority of cases it goes unnoticed and unreported on account of the innocence of the victim, stigma attached to the act, callousness and insensitivity of the investigating and the law enforcement agencies, etc. A child who has been sexually abused is traumatized for life but it is only much later in life when the emotional and psychological trauma aggravates that such people seek medical help. There is an urgent need to take up the problem as a larger social issue where the society has a responsibility to help the victims overcome their trauma and move on with life as normally as possible. We report a retrospective review of children (age < 16 years) referred for medicolegal examination, an autopsy in Chandigarh, India, between 2000 and 2003. 2004 Elsevier Ltd and AFP. All rights reserved. Keywords: Child abuse; Child sexual abuse; Caffey syndrome; Atrocities on children; Cruelty on children
1. Introduction Based on the classification of the psychologists, childhood is from conception to the chronological age of thirteen years. In India, according to Juvenile Justice Act 1986 Section 2 (h), juvenile means a boy who has not attained the age of 16 years or a girl who has not attained the age of eighteen years. According to Immoral Traffic (Prevention) Act, 1956 Section 2 (aa), a child is defined as a person who has not completed the age of 16 years. Psychology, Sociology and Jurisprudence define a child as a human being up to fourteen years of age.1 Cruelty to children is not something new. Destruction of unborn and new-born infants, stringent measures including physical torture at home and in teaching institutions to introduce discipline and teaching program, child labor systems, all may extend up to cruelty on
*
Corresponding author. Tel.: +91-172-665545; fax: +91-172-608488. E-mail address: [email protected] (B.R. Sharma).
children. The problem was highlighted by Silverman (1953) and Wooley and Evans (1955) in its exact shape, magnitude and significance, who established the deliberate trauma character of certain specific types of pathological lesions, earlier detected by J. Caffey (1946) a pediatric radiologist (CaffeyÕs Syndrome).2 Many recent studies from the western countries have reported adverse effects of childhood abuse on physical and mental health in adult life.6–17 In India; however, child abuse still remains to be an ill identified entity. Recently, the Government of India has decided to constitute a National Commission for Children that would be a statutory body setup by an Act of Parliament to give further protection to children and act as an ombudsman for them. The commission will have certain judicial powers, will guide policy on children related subjects and take effective steps for review and better implementation of laws and programs meant for the survival, development and protection of children. It would also oversee the overall and proper implementation of the laws and programs relating to children in the country. The implementation of legislation, policy and
1353-1131/$ - see front matter 2004 Elsevier Ltd and AFP. All rights reserved. doi:10.1016/j.jcfm.2004.01.009
B.R. Sharma, M. Gupta / Journal of Clinical Forensic Medicine 11 (2004) 248–256
programs for children is extremely inter-sectoral, and is dispersed across eight departments both at the center and in the states – mainly the departments of Family welfare, Education, Labor, Social Justice and Empowerment, Water and Sanitation, Youth Affairs, Woman and Child Development, Information and Broadcasting and encompasses jurisdiction of the Center and States/ Union Territories, often with the participation of the non-governmental sector.18 Here the question arises that if any welfare program to be implemented is to be routed through so many channels what will actually reach the needy – welfare or farewell?
2. Material and methods We retrospectively reviewed 117 cases of children below 16 years of age, referred for medicolegal examination/autopsy from January 2000 to June 2003 to Government Medical College Hospital Chandigarh, India – a tertiary care center receiving patients from the North Indian States of Punjab, Haryana, Himachal Pradesh and Jammu and Kashmir in addition to patients from the Union Territory of Chandigarh. The case records from the Medical Records Department of the hospital as well as the Investigating Agencies were analyzed with regards to data that included the profile of the victims and the perpetrators, nature of the offence, how and where it happened, disclosure to whom and how long after the abuse, reason for the disclosure and the presenting clinical features.
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Fondling was the commonest sexual abuse reported in 14 (38.9%) cases followed by sexual intercourse in 8 (22.2%) and insertion of finger in the vagina in 6 (16.6%). Sodomy was reported in 3 (8.3%) cases. The most common place where the sexual abuse occurred was in the home of either the victim 14 (38.9%) or the perpetrator 9 (25%) (Table 3). The victim of sexual abuse in 30 (83.3%) of cases knew the perpetrator. The most common age group to which the perpetrators belonged was 31–40 years. The majority of perpetrators 31 (86.1%) belonged to a low socioeconomic group with a low literacy rate (Table 4). Mother at home 17 (47.2%) and the hospital staff outside the home 12 (33.3%) were most preferred to disclose the sexual abuse by a victim. Eleven (30.55%) victims disclosed the abuse within one day of the act while 8 (22.2%) took one day to one week for disclosure. Disclosure was made in 16 (44.4%) cases on being questioned by the parents and in 13 (36.1%) cases on account of pain in private parts (Table 5). Emotional disturbances in the form of fears, nightmares, insomnia, feeling of something wrong and crying spells at the time of disclosure were observed in 19 (62.7%) cases. Eleven (30.5%) presented with pain in the genital area of which 4 (11.1%) had associated perennial tear with bleeding per vagina. Behavioral disturbances in the form of playing with the private parts of the adults were reported in 4 (11.1%) cases as presenting problem (Table 6).
4. Discussion 3. Results During the period of study, a total of 117 children below the age of 16 years were referred to the hospital for medicolegal examination, of which 6 were referred for medicolegal autopsy. 81 (69%) were the cases of physical abuse whereas 36 (30.77%) were that of sexual abuse. 73 (62%) were referred by the police whereas 44 (37.6%) were brought by their parents either for treatment of injuries in case of physical abuse or complaints like pain abdomen/private parts of the child but on examination were found to be sexually abused. The youngest sexually abused child was 2 years of age. Girls 28 (77.8%) were more at risk of sexual abuse than boys (22.2%) whereas physical abuse was more common in case of boys. Physical as well as the sexual abuse was more common among the children from lower socioeconomic group forced to work as child labors (Table 1). Twenty-four (29.6%) cases were of physical violence at the hands of parent/guardian at home, 3 (3.7%) at school by the teachers and 54 (66.6%) at the work place and the perpetrators were either employer or senior coworkers (Table 2).
Incidents of cruelty may not remain limited to assault and injury only – physical abuse. It may be, for example, providing the child insufficient food, inadequate care, protection and education – neglect. Reports of not only child labor but also child slavery (though banned) are available in this part of the world. Kidnapping or seducing a girl child for immoral traffic and sexual assault on young girls are the other examples of atrocities on children. In China, infanticide was an acceptable method of family planning. Greeks and Romans used to kill their weak and deformed children in the belief that only the strong should survive. In the USA, each year nearly 3 million children are reported to child protective services as alleged victims of maltreatment.3 Although early childhood maltreatment has been associated with many psychological sequelae,4 Maltreatment of children has been justified for centuries with the belief that severe physical punishment was necessary to maintain discipline and to transmit educational ideas and the same has been often justified by quoting the Biblical aphorism, ‘‘He that spareth the rod hateth his son.’’5 Child abuse is intentional harm or threat of harm to a child by an adult.19 It may be described as a medico-social
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Table 1 Profile of the victim Type of case
No. of cases Physical abuse Male
Sexual abuse Female
Total
Male
Female
Total
Total
No.
%
No.
%
No.
%
No.
%
No.
%
No.
%
No.
Medicolegal examination Referred by police Referred by parents Medicolegal autopsies
42 28 14 04
54.55 60.87 45.16 100
35 18 17 00
45.45 39.13 54.84 00.00
77 46 31 04
95.06 56.79 38.27 04.94
07 03 04 01
20.59 14.29 30.77 50.00
27 18 09 01
79.41 85.71 69.23 50.00
34 21 13 02
94.44 58.33 36.11 05.56
111 67 44 06
Total
46
56.79
35
43.21
81
69.23
08
22.22
28
77.78
36
30.77
117
Age of victim 1–2 2–4 4–6 6–8 8–10 10–12 12–14 14–16
01 02 06 03 03 06 09 16
02.17 04.35 13.04 06.52 06.52 13.04 19.57 34.78
00 01 03 02 04 05 08 12
00.00 2.86 08.57 05.71 11.43 14.29 22.86 34.29
01 03 09 05 07 11 17 28
01.24 03.70 11.11 06.17 08.64 13.58 20.99 34.57
00 00 00 02 03 01 02 00
00.00 00.00 00.00 25.00 37.50 12.50 25.00 00.00
01 01 00 03 04 05 07 07
03.57 03.57 00.00 10.71 14.29 17.86 25.00 25.00
01 01 00 05 07 06 09 07
02.78 02.78 00.00 13.89 19.44 16.67 25.00 19.44
02 04 09 10 14 17 26 35
Total
46
56.79
35
43.21
81
64.23
08
22.22
28
77.78
36
30.77
117
Occupation of the victim
No.
%
At home Student Domestic help Small scale factory worker Auto repair shop worker Road-side tea stall worker
38 03 13 23 25 15
32.48 02.56 11.11 19.66 21.37 12.82
Table 2 Profile of physical abuse
% 94.87 57.27 37.61 05.13 100.0 01.70 03.42 07.69 08.55 11.97 14.53 22.22 29.91 100.0
Table 3 Profile of sexual abuse No.
%
Perpetrator of physical abuse Father Mother Step mother Uncle Aunt Grandparent Teacher Senior colleague at work Employer
07 03 09 03 01 01 03 33 21
08.64 03.70 11.11 03.70 01.24 01.24 03.70 40.74 25.93
Site of physical abuse Home School Workplace
24 3 54
29.63 03.70 66.67
disease, prevalent all over world, commonly divided into four categories – physical, sexual, and emotional and neglect. In the USA there are more than 300,000 instances of child abuse reported annually. The types of child abuse and neglect reported in literature are approximately 70% physical, 25% sexual and 5% emotional but the incidence of sexual abuse in reality is much higher than reported or
No.
%
Type of sexual act Fondling Insertion of finger into vagina Sexual intercourse Sodomy Oral sex
14 6 8 3 5
38.89 16.67 22.22 08.33 13.89
Site of sexual act Home of perpetrator Home of victim Play ground near the house Quiet area near the house
9 14 2 4
25.00 38.39 05.56 11.11
5 2
13.89 05.56
Away from home Store room of a shop Amusement centers
presumed as it is rarely revealed, because of the childÕs ignorance, shame, guilt feeling and insistence of evidence by the courts.20 The 1986 National Incidence and Prevalence study of the National Center on Child Abuse and Neglect reported that 22.6 per 1000 children were maltreated.21 Studies report that the childhood homicide rate tripled in the US between 1950 and 1993.22
B.R. Sharma, M. Gupta / Journal of Clinical Forensic Medicine 11 (2004) 248–256 Table 4 Profile of the perpetrator of child sexual abuse No.
%
Relationship to the victim Uncle Tenant Domestic help Step father Father Grand father
15 8 3 3 1 6
41.67 22.22 08.33 08.33 02.78 16.67
Age of the perpetrator <20 21–30 31–40 41–50 51–60 >60
3 9 16 4 3 1
08.33 25.00 44.44 11.11 08.33 02.78
8 6 6 3 3 2 3 5
22.22 16.67 16.67 08.33 08.33 05.56 08.33 13.89
Occupation of the perpetrator Factory worker Bus driver Cleaner Welder Security guard Painter Tutor Shopkeeper
Table 5 Disclosure of sexual abuse No.
%
Relationship to the victim Mother Father Aunt Friend Teacher Hospital staff
17 2 3 1 1 12
47.22 05.56 08.33 02.78 02.78 33.34
Duration of sexual abuse before disclosure 1 day 1 day to 1 week 1 week to 1 month 1 month to 1 year 1 year to 10 years >10 years
11 8 6 3 5 3
30.55 22.22 16.67 08.33 13.89 08.33
Reason of disclosure Questioned by parents or relatives Pain in private parts Fear of perpetrator Felt it wrong
16 13 6 1
44.44 36.11 16.67 02.78
Problems at presentation
No.
%
Emotional Physical Behavioral Shock due to hemorrhage following perennial tear Smothering during sodomy
19 11 04 01
62.78 30.56 11.11 02.78
01
02.78
Table 6 Presenting problems
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Physical abuse. Battered Baby Syndrome is the term used to define a clinical condition in young children, who have received non-accidental violence or injury, on one or more occasions, at the hands of an adult in a position of trust, generally a parent, guardian or foster parent. The precipitating factor being usually a cry which interferes with either a parentÕs sleep or their television program or the outing. Exact incidence of baby battering is not known due to reporting biases and investigatory procedural constraints. Inconsistencies are common between the history offered of a minor accident and the physical findings of a major injury. From a study conducted by Cameron23 in 1966, some of the explanations offered by guardians or parents in cases of Battered Child Syndrome, that continue to be same even today are tabulated below (Table 7). Child labor is a harsh reality in this part of the world and most of the working children are found in unorganized sector. The status of girls in the labor market is different than the boys and they are considered to be more productive in the household activities. The deep routed gender bias in the minds of people also leads to more female child labor. Harmful effects of child labor are long lasting in that the children who spend considerable part of their time in gainful employment are deprived of education that is not only a loss to the children but also to the nation in the future. Lately the trend of teenaged commercial sex workers among girls has been reported to be on rise. According to a report,24 there are about 10 million commercially sexually exploited women in India, of which one fifth are under the age of 18 years. As the average age of girls at the entry to commercial sex trade is 16–18 years, most of them tend to loose market appeal by the time they are aged 30–35 years. At this stage they develop behavioral disorders and many of them become drug abusers, they may also initiate their own daughters into the trade so as to ensure the continuance of economic support. Child sexual abuse is a dark reality that routinely inflicts our daily lives, though the truth regarding the same is often kept under wraps. Child sexual abuse refers to wide varieties of acts, subtle or gross, which adult individuals indulge in, in order to derive sexual pleasure through the medium of children. It may take the form of acts like obscene talks, exposure, and voyeurism, touching or fondling of genitals of the child or asking the child to fondle the adultÕs genitals. Sexual intercourse includes vaginal, oral or rectal penetration on a non-assaultive basis. Less than 10% of the sexual abuse is reported to be assaultive.25 Statistics tell a chilling tale of how widespread this abuse is. As per official statistics of the Government of India, 20% of IndiaÕs population under 15 years is susceptible to child sexual abuse but some studies peg the figures much higher. The World Health Organization reports that one in ten children is sexually abused in India while some Non Government
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Table 7 Victims of physical assault vis-a-vis history furnished Presenting history
Probable truth
Fell from pram and caught ear on handle Fell and caught stomach against door Fell downstairs Fell from settee and head struck table Tripped whilst carrying baby Mother fell downstairs whilst carrying baby Fell off bed Must have strayed too near the fire Split hot water over herself Toppled backwards while sitting in a chair
Blows on face and/or bounced on floor Kicked over stomach Kicked and struck with broom handle Blow with hand behind left ear Threw him to the floor Thrown downstairs Dropped child on head Multiple blows and held against electric fire Ill-treatment with very hot water Blows on head and face
Organizations report that five out of every ten girls and three out of every ten boys are sexually abused.26 A steep rise in cases of sexual offences particularly rape from 10,068 in 1990 to 15,033 in 1998 has been reported,27 but the more disturbing feature of this report is that 25–30% of the victims were children (Table 8). These figures, despite of the fact that sexual offences against children are one of the most under-reported crimes in India, speak for themselves. It has been argued that for every case reported against children there are a hundred, which are not reported because in majority of the cases, the abuser is a person whom the child knows and mostly trusts, like a family friend or acquaintance, a domestic help, a relative or in the most tragic and traumatic of the cases a member of the immediate family like the father, brother or grand father. Ironically this is also the reason why child sexual abuse is many a times allowed to continue despite getting detected. In cases of involvement of close family members, the childÕs allegations of misconduct against the same might not be believed because any acknowledgement of such a behavior is likely to lead not only to a familial rift but also to a social scandal. So a child in such circumstances is sacrificed at the altar of family unity and prestige. In other cases, when people other than the family member are involved, the fact of child sexual abuse is relatively easier to acknowledge and confront. But here too
complex social and cultural factors make it extremely difficult for the affected party to take up cudgels against the guilty. To begin with in a society like ours, the victim is often the one who carries the cross of shame. It is the victim who becomes the target of mocking eyes, slandering tongues and a butt of lewd jokes. The stigma of sexual assault and victimization continues long enough to even hamper the marital prospects of the girl child in question. Thus silence regarding the crime is often the most advised and frequently followed recourse to the problem of child sexual abuse. A study based on interview of 350 Delhi schoolgirls found that a family member had abused 63% of them. Another study on 1000 middle and upper class women, revealed that 71% had been abused by the people they knew.26 Friedrich (1988), documented disturbances in sexual behavior in a controlled study, which revealed a higher incidence of sexual behavior problems in 20 sexually abused boys between 4 and 7 years old than in a comparison group of 23 non-abused boys with a history of conduct disorder.28 The National Crime Records Bureau of India in its report – 2000, reported an alarming 26.6% increase in the incidence of child rape where victims are below 10 years of age.29 In a study of sexual offences in South Delhi, out of a total 13 reported cases of sodomy on males, 12 belonged to the age group of 5– 15 years whereas 27 of the 67 reported female victims of
Table 8 Victims of sexual assault by age groups Year
1990 1991 1992 1993 1994 1995 1996 1997 1998
Age in years Below 10
10–16
16–30
Above 30
394 1099 532 634 734 747 608 770 626
2105 2630 2581 2759 3244 3220 3475 3644 3433
6028 5377 7000 7038 7442 7752 8281 8612 8414
1541 1319 1621 1792 1798 1955 2485 2310 2560
Source: National Crime Records Bureau11 1996, 1998.
Total
% of child rape
10,068 10,426 11,734 12,223 13,218 13,674 14,849 15,336 15,033
24.8 35.8 26.5 27.8 30.2 29.5 27.5 28.8 27.4
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sexual offences belonged to the same age group, i.e., 5– 15 years.30 Much of the sexual abuse is perpetrated within the family or household although a wide variation has been reported by studies. Bentovin (1987) found that 75% of the cases were sexually abused within the household whereas the Northern Ireland Incidence Study (1990) reported that although 85% of children knew their abusers, only 31% had been abused within the household while 54% were abused by a known person not living in the house. Incidence of sexual child abuse by strangers was reported to be only 5%.31 Non-clinical studies suggest that the difference in rates of sexual abuse between boys and girls is about 2.5:1 whereas most of the clinical studies suggest a female:male ratio of 5:1. The difference in the gender ratio between clinical and non-clinical studies is suggestive of lack of reporting of male child sex abuse as well as homosexual nature of the abuse.32 Sodomy, the commonest of the sexual offences, may be homosexual or heterosexual in nature, but the active agent in both cases is a male. As for all active agents and those passive agents who enjoy their participation, there might be some background having psychological influence on them which may be either unusual passion for the same sex or just the reverse, a cryptic hatred nurtured by them against their own sex, which is expressed through such sexual activity. This might have some bearing of childhood environment and experiences.31 According to a study,33 the risk of sexually abused boys in early adolescence abusing other children may be associated with experiences in early life that are independent of sexual victimization; exposure to persistent violence within the family may be particularly important risk factor; and management of sexually abused boys should take into account the impact of early life experiences that may be associated with increased risk with a view to the secondary prevention of sexually abusive behavior. Primary care physicians often deal with the fallout of childhood abuse and neglect. Each year, an estimated 18,000 children are severely disabled as a result of abuse, and 30,000–40,000 additional children require immediate medical attention to prevent long term impairment from abuse or neglect.34;35 A survey of 1225 women36 reveals the broad array of adverse adult health outcomes with which childhood sexual and physical abuse are associated, including disturbances in emotional, social and role functioning; mental health problems; risky health practices including substance abuse; physical symptoms and health disorders reaching clinical threshold. Another study,37 reported a strong relation between exposure to abusive or neglectful conditions in childhood and risk for certain adult disorders, including ischaemic heart disease, cancer, chronic lung diseases, liver diseases and skeletal fractures.
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These findings call out for explanation as to how do abusive and neglectful family environments in childhood affect mental and physical health decades later. An important route involves alterations in autonomic and endocrine responses to stressful circumstances. The consequences of early exposure to abuse or neglect appear to be potentially irreversible disruptions in biological systems that may, perhaps also in conjunction with genetic predisposition, produce large differences in susceptibility to stress, to biological markers of the cumulative effects of stress, and to stress related physical and mental health disorders.38 These include elevated blood pressure and heart rate responses, as well as prolonged sympathetic responses to stress. Alterations in hypothalamic pituitary adrenocortical reactivity in response to stress also appear to be related to adverse family history. In families characterized by conflict, anger and aggression, there may be disruption of the normal rise and fall of serum cortisol levels in response to acutely stressful circumstances, such that a protracted cortisol response or in extreme cases a flattened cortisol response may develop. In contrast, a warm and supportive family environment may actually foster a less elevated cortisol response to potentially stressful circumstances or one that rapidly habituates to stress.39 There is evidence for serotonergic dysregulation in offspring in abusive and neglectful families. Difficulty in moderating aggressive impulses, problem in developing and maintaining social relationships, and risky health related behaviors, especially substance abuse, are among the outcomes consistently seen. Deficit in appropriate emotion regulation and social regulation skills take their toll on adult health in at least four ways. First, people who lack these vital skills interact poorly in the social environment. As adults, they may have difficulty forming long term social relationships and compromise their work-related relationships as well. Second, social isolation and lack of social support have been associated with a greater risk of mortality from all causes, as well as more protracted courses of illness and recovery from several acute and chronic disorders.40 Third, poor emotion regulation is also a risk factor for mental illness. Emotion dysregulation is implicated in more than half of the DSM – IV axis I psychiatric disorders and in almost the entire axis II disorders, as described by the American Psychiatric Association. Fourth, emotion dysregulation and low social competence, in turn, increase the likelihood of substance abuse, aggression, risky behavior and other poor health habits.
5. What can be done? The role of a medical practitioner though limited, can be significant if the following suggestions are incorporated in regular practice:
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1. Parents at high risk for being unable to love and care for their offspring adequately can be identified early if attention is given to such things as abuse of previous child, drug addiction, negative parental comments about the newborn, lack of evidence of maternal attachment to a newborn or severe neglect of infant hygiene. Physical abuse and neglect may be prevented by proper counseling of such parents. It needs to be borne in mind that the people may have violent thoughts or fantasies but unless they loose control, thoughts do not become acts. Any condition that produces increased aggressive impulses in the context of diminished control may produce violent acts and as such, the children who are premature, mentally retarded or physically disabled and those who cry aggressively or are unusually demanding – the so called Ôdifficult childÕ may be at high risk of physical abuse or neglect. Gladstone,41 in a study, viewed the syndrome of physical child abuse as a result of parentÕs attempt to cope with internal conflicts, poverty, domestic demands, social isolation, etc. to discharge the intra-psychic tension. 2. Improving training in medical schools/colleges and residencies on the correct process of identification and management of the forensic patients.42 While it would be inappropriate to label a child as potential abuser just because he has been exposed to intrafamilial violence but relatively greater support may need to be given to the boys at high risk with a view to averting future abusive behavior. 3. Awareness of the link between childhood abuse/maltreatment and adverse health outcomes may sensitize the community in general and the primary health care providers in particular to identify and report the cases. 4. Continuing development, implementation and evaluation of systematic, continuous child health review programs and to report on a regular basis the contribution of maltreatment to childrenÕs health problems and death. 5. It is unacceptable not to know how many children are killed each year by their caregivers. The effort in the 1980s to bring consistency to coding of abuse fatalities was an important step in improving child abuse fatality ascertainment. Now, with the increased understanding of child abuse dynamics and expanded epidemiology of child injury mortality, appropriate revision of rules for coding child abuse fatality globally may be considered. 6. Creating a child-specific injury/death certificate with prompts so that available space could be used to capture information, including socio-demographic data pertinent to children. 7. Many of the cases of child sexual abuse are disclosed after a delay of weeks, months or even years. It has been argued that persuasive or suggestive psychother-
apeutic techniques designed to unearth sexual abuse can not be relied upon.43 However, the central question here is: can someone endure a seemingly unforgettable traumatic experience, such as repeated rape, and then expel the memory completely from conscientious awareness for many years?44 The following Important legal issues related to child sexual abuse need to be resolved: 1. Usually there is a long interim period lasting many months or even years before the Judicial proceedings are completed and justice meted out. In this period, it is always the child victim who is taken away from its home in the name of protection, while the perpetrator roams free. It gives an impression to the child that he or she is being removed because it is in the wrong. It is therefore, recommended that medico-legal action has to be prompt and complete, as also all the other investigations concerned so that the judicial proceedings in the case be completed as early as possible and the perpetrator punished. Meanwhile the accused may be kept in custody, away from the child and its environment, to stop any further sexual violence against the defenseless young victims. 2. To minimize distress to the child victims through multiple interviews by various professionals a coordinated and specialized team of professionals should conduct interviews with the child victims, especially the first, which should be video recorded. This would reduce the need for repeated interviews of the child by different professionals, i.e., police, social workers, doctors, etc. The video recording can also be used as evidence in Court and the need for the child to testify in Court is thus minimized. 3. If the child has to go to Court to testify, then the stress for the child can be reduced by a number of means, including the use of videotaped interviews, frequent breaks during the hearings, exclusion of spectators in Court and the option for the child not to physically face the accused. Once the evidence for prosecution is available, Court proceedings should be expedited so that further trauma for the child is reduced. 4. To support the child victims throughout the Court process Ôtrained social workersÕ may be assigned to help the child victims/witnesses to testify in Court. The assigned worker would befriend and familiarize the child with the Court proceedings and offer emotional support to the child before and during the Court case. These workers should not discuss evidence and facts of the case with the child or its family, but only act as guides to help through the Court proceedings. 5. Competency and credibility are the two essential pre requisites for the child to give testimony in Court. According to Weissman, 199145 the four main criteria to establish competency of the child to testify in Court
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in a reliable and meaningful manner are the capacity to: • perceive facts accurately, i.e., the ability to observe or receive accurate impressions of the incident. • recollect and recall, i.e., memory sufficient to retain an independent recollection of the occurrence. • understand the oath, i.e., the ability to tell truth from falsehood and to understand the consequences of not telling the truth. • communicate based on personal knowledge or the facts, i.e., ability to communicate the memory of the observation and to understand simple questions about the occurrence.
6. Conclusion The solution to the problems like physical abuse and child labor lies in recognition of the ÔRights of the ChildrenÕ incorporated in the Geneva Declaration of Rights of Child 1924 and the Universal Declaration of Human Rights 1948. It must be stressed that the rights and duties are two sides of being human. Proper performance of duties by the parents, teachers and the community at large is equally necessary, as is the strict implementation of relevant laws enacted from time to time. Primary prevention of sexual abuse includes encouraging children to Ônot keep secretsÕ, Ôsay noÕ and to Ôtell someoneÕ. The parents often fail to equip children with vocabulary that the child can use to report sexual abuse. The child may exhibit other abuse related signs like anxiety, isolation, depression, regression, avoidance of particular individuals, difficulty in concentration, display of explicit behavior, infections in the throat, anal and genital areas etc. But these signs may be lost on ignorant, unsuspecting or non-communicative parents. Counseling of young parents in this regard along with the antenatal care can be of great help. There is a paucity of studies on child abuse in Asian countries. Much of the information and data used here is derived from case studies and references from the west. There is a need to identify potential risk factors for baby battering, child labor, child sexual abuse etc., so as to better understand the problem, improve the treatment of the victim as well as perpetrator and take preventive steps to restrict the incidence of child abuse. Announcements of new legislation, commissions or programs by the respective governments in the absence of the will to implement the same has nothing more than politically motivated ornamental values. A societal awareness to boldly report the cases, honest and scientific investigation by the Investigating Agencies and speedy delivery of justice by the Courts is all that is required in addition to a change in the attitude of the community towards the victim.
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References 1. Muthuswamy S. Rights of the children. Soc Welfare 2000;46(10):35–7. 2. Nandy A. Principles of forensic medicine. 1st ed. New Central Book Agency (P) Ltd.; 1995. p. 352–357. 3. US Department of Health and Human Services, National Center on Child Abuse and Neglect. Child Abuse and Neglect Case – Level Data 1993. Working Paper I. Washington DC: US Government Printing Office; 1996. 4. Beitchman JH, Zucker KJ, Hood JE, et al. A review of the longterm effects of child sexual abuse. Child Abuse Negl 1992;16:101–18. 5. Vyas NJ, Ahuja N. Postgraduate psychiatry. 1st ed. BI Churchill Livingstone; 1992. p. 399–402. 6. Rimsza ME, Berg RA. Sexual abuse: somatic and emotional reactions. Child Abuse Negl 1988;12:201–8. 7. Walker E, Katon W, Harrop J, et al. Relationship of chronic pelvic pain to psychiatric diagnosis and childhood sexual abuse. Am J Psychiatr 1988;145:75–80. 8. Arnold RP, Rogers D, Cook DA. Medical problems of adults who were sexually abused in childhood. BMJ 1990;300:705–8. 9. Koss MP, Koss PG, Woodruf WJ. Deleterious effects of criminal victimization on womenÕs health. Arch Intern Med 1991;151:342–7. 10. Walker EA, Katon WJ, Roy-Byrne PP. Histories of sexual victimization in patients with irritable bowel syndrome or inflammatory bowel disease. Am J Psychiatr 1993;150:1502–6. 11. Moeller TP, Bachmann GA, Moeller JR. The combined effects of physical, sexual and emotional abuse during childhood: long term health consequences for women. Child Abuse Negl 1993;17:623–40. 12. Lodico MA, DiClemente RJ. The association between child hood sexual abuse and prevalence of HIV related risk behaviors. Clin Pediatr 1994:498–502. 13. Golding JM. Sexual assault history and physical health in randomly selected Los Angeles women. Health Psychol 1994;13:130–8. 14. Taylor ML, Trotter DR, Csuka ME. The prevalence of sexual abuse in women with fibromyalgia. Arthritis Rheum 1995;38:229– 34. 15. Golding JM. Sexual assault history and womenÕs reproductive and sexual health. Psychol Women Quart 1996;20:101–21. 16. Golding JM. Sexual assault history and limitations in physical functioning in two general population samples. Res Nurs Health 1996;19:33–44. 17. McCauley J, Kern DE, Kolodner K, et al. Clinical characteristics of women with a history of childhood abuse: unhealed wounds. JAMA 1997;277:1362–8. 18. Gurtu Arvind. National Commission for children. Soc Welfare 2003;50(3):22–3. 19. Wissow LS. Child abuse and neglect. N Eng J Med 1995;332(21):1425–31. 20. Ahuja D. Community action against child exploitation. Soc Welfare 2000;47(4):66–70. 21. Kaplan SJ. Child and adolescent psychiatry. 2nd ed. Williams & Wilkins; 1996. p. 1033–1054. 22. Romain N, Michaud K, Horisberger B, et al. Childhood homicide: a 1990–2000 retrospective study at the Institute of Legal Medicine in Lausanne, Switzerland. Med Sci Law 2003;43(3):203–6. 23. Parikh CK. ParikhÕs text book of medical jurisprudence and toxicology. 5th ed. CBS Publications; 1992. p. 503–505. 24. Patnam V, Bagul M. Teenage sex workers – aspirations and interest. Soc Welfare 2002;49(8):8–14. 25. Behrman RE. Nelson text book of pediatrics. 14th ed. WB Saunders Company; 1992. p. 78–83. 26. Bakhshi J. Innocence abused. The Tribune 2003;123(192):1. 27. The National Crime Records Bureau, Ministry of Home Affairs, Government of India, Report for the year 1996, 1998.
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28. Skuse D, Bentovin A, Hodges J, et al. Risk factors for development of sexually abusive behavior in sexually victimized adolescent boys: cross sectional study. BMJ 1998;317:175–9. 29. The National Crime Records Bureau, Ministry of Home Affairs, Govenment of India, Report for the year 2000. 30. Bhardwaj DN, Sharma RK, Sagar MS. Study of sexual offence victims in South Delhi. J Forensic Med Toxicol 1996;12(4):9–15. 31. American Humane Association, National Incidence Survey, 1990 and 1993. 32. Smith M, Bentovin A. Child and adolescent psychiatry – modern approaches. 3rd ed. Blackwell Scientific Publications; 1994. p. 230– 247. 33. Gallup GH, Moore DW, Schussel R. Disciplining children in America: a Gallup Poll Report. Princeton, NJ: The Gallup Organization; 1995. 34. Emery RE, Laumann BL. An overview of the nature, causes and consequences of abusive family relationships. Am Psychol 1998;53:121–35. 35. Friedrich WN. Behavioral problems in sexually abused children, an adaptational perspective. In: Wyatt GE, Powel GJ, editors. Lasting effects of child sexual abuse. Baveerly Hills: Sage; 1988. 36. Walker EA, Gelfand A, Katon WJ. Adult health status of women with histories of childhood abuse and neglect. Am J Med 1999;107:332–9.
37. Felitti VJ, Anda RF, Nordenberg D. Relation ship of childhood abuse and household dysfunction to many of the leading causes of death in adults. Am J Prevent Med 1998;14: 245–58. 38. McEwen BS. Protective and damaging effects of stress mediators. N Eng J Med 1998;338:171–9. 39. Gunnar MR. Quality of early care and buffering of neuroendocrine stress reactions: potential effects on the developing human brain. Prevent Med 1998;27:208–11. 40. Seeman TE. Social ties and health. Am J Epidemiol 1996;6:442– 51. 41. Gladstone R. Observations on children who have been physically abused. Am J Psychiatr 1965;122:440–3. 42. Sharma BR. Clinical forensic medicine – management of crime victims from trauma to trial. J Clin Forensic Med 2003;10(4):267– 73. 43. Pope HG. Recovered memories of childhood sexual abuse. BMJ 1998;316:488–9. 44. Yiming C, Fung D. Child sexual abuse in Singapore with special reference to medicolegal implications: a review of 38 cases. Med Sci Law 2003;43(3):260–6. 45. Weissman HN. Forensic psychological examination of the child witness in cases of alleged sexual abuse. Am J Orthopsychiatr 1991;61(1):48–58.
Journal of Clinical Forensic Medicine 11 (2004) 248–256
O F
CLINICAL FORENSIC MEDICINE www.elsevier.com/locate/jcfm
Original communication
Child abuse in Chandigarh, India, and its implications B.R. Sharma *, Manisha Gupta Department of Forensic Medicine and Toxicology, Government Medical College and Hospital, #1156-B, Sector 32 B, Chandigarh 160030, India Available online 28 March 2004
Abstract Few abuses of human rights are so universally condemned but at the same time so universally practiced as child abuse. Over the centuries, children have been subjected to physical, sexual and emotional abuse as well as neglect. By any objective measures, this issue should rank high on the global agenda but in practice it is surrounded by a wall of silence and perpetuated by ignorance. Child sexual abuse is a dark reality that routinely inflicts our daily lives but in a majority of cases it goes unnoticed and unreported on account of the innocence of the victim, stigma attached to the act, callousness and insensitivity of the investigating and the law enforcement agencies, etc. A child who has been sexually abused is traumatized for life but it is only much later in life when the emotional and psychological trauma aggravates that such people seek medical help. There is an urgent need to take up the problem as a larger social issue where the society has a responsibility to help the victims overcome their trauma and move on with life as normally as possible. We report a retrospective review of children (age < 16 years) referred for medicolegal examination, an autopsy in Chandigarh, India, between 2000 and 2003. 2004 Elsevier Ltd and AFP. All rights reserved. Keywords: Child abuse; Child sexual abuse; Caffey syndrome; Atrocities on children; Cruelty on children
1. Introduction Based on the classification of the psychologists, childhood is from conception to the chronological age of thirteen years. In India, according to Juvenile Justice Act 1986 Section 2 (h), juvenile means a boy who has not attained the age of 16 years or a girl who has not attained the age of eighteen years. According to Immoral Traffic (Prevention) Act, 1956 Section 2 (aa), a child is defined as a person who has not completed the age of 16 years. Psychology, Sociology and Jurisprudence define a child as a human being up to fourteen years of age.1 Cruelty to children is not something new. Destruction of unborn and new-born infants, stringent measures including physical torture at home and in teaching institutions to introduce discipline and teaching program, child labor systems, all may extend up to cruelty on
*
Corresponding author. Tel.: +91-172-665545; fax: +91-172-608488. E-mail address: [email protected] (B.R. Sharma).
children. The problem was highlighted by Silverman (1953) and Wooley and Evans (1955) in its exact shape, magnitude and significance, who established the deliberate trauma character of certain specific types of pathological lesions, earlier detected by J. Caffey (1946) a pediatric radiologist (CaffeyÕs Syndrome).2 Many recent studies from the western countries have reported adverse effects of childhood abuse on physical and mental health in adult life.6–17 In India; however, child abuse still remains to be an ill identified entity. Recently, the Government of India has decided to constitute a National Commission for Children that would be a statutory body setup by an Act of Parliament to give further protection to children and act as an ombudsman for them. The commission will have certain judicial powers, will guide policy on children related subjects and take effective steps for review and better implementation of laws and programs meant for the survival, development and protection of children. It would also oversee the overall and proper implementation of the laws and programs relating to children in the country. The implementation of legislation, policy and
1353-1131/$ - see front matter 2004 Elsevier Ltd and AFP. All rights reserved. doi:10.1016/j.jcfm.2004.01.009
B.R. Sharma, M. Gupta / Journal of Clinical Forensic Medicine 11 (2004) 248–256
programs for children is extremely inter-sectoral, and is dispersed across eight departments both at the center and in the states – mainly the departments of Family welfare, Education, Labor, Social Justice and Empowerment, Water and Sanitation, Youth Affairs, Woman and Child Development, Information and Broadcasting and encompasses jurisdiction of the Center and States/ Union Territories, often with the participation of the non-governmental sector.18 Here the question arises that if any welfare program to be implemented is to be routed through so many channels what will actually reach the needy – welfare or farewell?
2. Material and methods We retrospectively reviewed 117 cases of children below 16 years of age, referred for medicolegal examination/autopsy from January 2000 to June 2003 to Government Medical College Hospital Chandigarh, India – a tertiary care center receiving patients from the North Indian States of Punjab, Haryana, Himachal Pradesh and Jammu and Kashmir in addition to patients from the Union Territory of Chandigarh. The case records from the Medical Records Department of the hospital as well as the Investigating Agencies were analyzed with regards to data that included the profile of the victims and the perpetrators, nature of the offence, how and where it happened, disclosure to whom and how long after the abuse, reason for the disclosure and the presenting clinical features.
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Fondling was the commonest sexual abuse reported in 14 (38.9%) cases followed by sexual intercourse in 8 (22.2%) and insertion of finger in the vagina in 6 (16.6%). Sodomy was reported in 3 (8.3%) cases. The most common place where the sexual abuse occurred was in the home of either the victim 14 (38.9%) or the perpetrator 9 (25%) (Table 3). The victim of sexual abuse in 30 (83.3%) of cases knew the perpetrator. The most common age group to which the perpetrators belonged was 31–40 years. The majority of perpetrators 31 (86.1%) belonged to a low socioeconomic group with a low literacy rate (Table 4). Mother at home 17 (47.2%) and the hospital staff outside the home 12 (33.3%) were most preferred to disclose the sexual abuse by a victim. Eleven (30.55%) victims disclosed the abuse within one day of the act while 8 (22.2%) took one day to one week for disclosure. Disclosure was made in 16 (44.4%) cases on being questioned by the parents and in 13 (36.1%) cases on account of pain in private parts (Table 5). Emotional disturbances in the form of fears, nightmares, insomnia, feeling of something wrong and crying spells at the time of disclosure were observed in 19 (62.7%) cases. Eleven (30.5%) presented with pain in the genital area of which 4 (11.1%) had associated perennial tear with bleeding per vagina. Behavioral disturbances in the form of playing with the private parts of the adults were reported in 4 (11.1%) cases as presenting problem (Table 6).
4. Discussion 3. Results During the period of study, a total of 117 children below the age of 16 years were referred to the hospital for medicolegal examination, of which 6 were referred for medicolegal autopsy. 81 (69%) were the cases of physical abuse whereas 36 (30.77%) were that of sexual abuse. 73 (62%) were referred by the police whereas 44 (37.6%) were brought by their parents either for treatment of injuries in case of physical abuse or complaints like pain abdomen/private parts of the child but on examination were found to be sexually abused. The youngest sexually abused child was 2 years of age. Girls 28 (77.8%) were more at risk of sexual abuse than boys (22.2%) whereas physical abuse was more common in case of boys. Physical as well as the sexual abuse was more common among the children from lower socioeconomic group forced to work as child labors (Table 1). Twenty-four (29.6%) cases were of physical violence at the hands of parent/guardian at home, 3 (3.7%) at school by the teachers and 54 (66.6%) at the work place and the perpetrators were either employer or senior coworkers (Table 2).
Incidents of cruelty may not remain limited to assault and injury only – physical abuse. It may be, for example, providing the child insufficient food, inadequate care, protection and education – neglect. Reports of not only child labor but also child slavery (though banned) are available in this part of the world. Kidnapping or seducing a girl child for immoral traffic and sexual assault on young girls are the other examples of atrocities on children. In China, infanticide was an acceptable method of family planning. Greeks and Romans used to kill their weak and deformed children in the belief that only the strong should survive. In the USA, each year nearly 3 million children are reported to child protective services as alleged victims of maltreatment.3 Although early childhood maltreatment has been associated with many psychological sequelae,4 Maltreatment of children has been justified for centuries with the belief that severe physical punishment was necessary to maintain discipline and to transmit educational ideas and the same has been often justified by quoting the Biblical aphorism, ‘‘He that spareth the rod hateth his son.’’5 Child abuse is intentional harm or threat of harm to a child by an adult.19 It may be described as a medico-social
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Table 1 Profile of the victim Type of case
No. of cases Physical abuse Male
Sexual abuse Female
Total
Male
Female
Total
Total
No.
%
No.
%
No.
%
No.
%
No.
%
No.
%
No.
Medicolegal examination Referred by police Referred by parents Medicolegal autopsies
42 28 14 04
54.55 60.87 45.16 100
35 18 17 00
45.45 39.13 54.84 00.00
77 46 31 04
95.06 56.79 38.27 04.94
07 03 04 01
20.59 14.29 30.77 50.00
27 18 09 01
79.41 85.71 69.23 50.00
34 21 13 02
94.44 58.33 36.11 05.56
111 67 44 06
Total
46
56.79
35
43.21
81
69.23
08
22.22
28
77.78
36
30.77
117
Age of victim 1–2 2–4 4–6 6–8 8–10 10–12 12–14 14–16
01 02 06 03 03 06 09 16
02.17 04.35 13.04 06.52 06.52 13.04 19.57 34.78
00 01 03 02 04 05 08 12
00.00 2.86 08.57 05.71 11.43 14.29 22.86 34.29
01 03 09 05 07 11 17 28
01.24 03.70 11.11 06.17 08.64 13.58 20.99 34.57
00 00 00 02 03 01 02 00
00.00 00.00 00.00 25.00 37.50 12.50 25.00 00.00
01 01 00 03 04 05 07 07
03.57 03.57 00.00 10.71 14.29 17.86 25.00 25.00
01 01 00 05 07 06 09 07
02.78 02.78 00.00 13.89 19.44 16.67 25.00 19.44
02 04 09 10 14 17 26 35
Total
46
56.79
35
43.21
81
64.23
08
22.22
28
77.78
36
30.77
117
Occupation of the victim
No.
%
At home Student Domestic help Small scale factory worker Auto repair shop worker Road-side tea stall worker
38 03 13 23 25 15
32.48 02.56 11.11 19.66 21.37 12.82
Table 2 Profile of physical abuse
% 94.87 57.27 37.61 05.13 100.0 01.70 03.42 07.69 08.55 11.97 14.53 22.22 29.91 100.0
Table 3 Profile of sexual abuse No.
%
Perpetrator of physical abuse Father Mother Step mother Uncle Aunt Grandparent Teacher Senior colleague at work Employer
07 03 09 03 01 01 03 33 21
08.64 03.70 11.11 03.70 01.24 01.24 03.70 40.74 25.93
Site of physical abuse Home School Workplace
24 3 54
29.63 03.70 66.67
disease, prevalent all over world, commonly divided into four categories – physical, sexual, and emotional and neglect. In the USA there are more than 300,000 instances of child abuse reported annually. The types of child abuse and neglect reported in literature are approximately 70% physical, 25% sexual and 5% emotional but the incidence of sexual abuse in reality is much higher than reported or
No.
%
Type of sexual act Fondling Insertion of finger into vagina Sexual intercourse Sodomy Oral sex
14 6 8 3 5
38.89 16.67 22.22 08.33 13.89
Site of sexual act Home of perpetrator Home of victim Play ground near the house Quiet area near the house
9 14 2 4
25.00 38.39 05.56 11.11
5 2
13.89 05.56
Away from home Store room of a shop Amusement centers
presumed as it is rarely revealed, because of the childÕs ignorance, shame, guilt feeling and insistence of evidence by the courts.20 The 1986 National Incidence and Prevalence study of the National Center on Child Abuse and Neglect reported that 22.6 per 1000 children were maltreated.21 Studies report that the childhood homicide rate tripled in the US between 1950 and 1993.22
B.R. Sharma, M. Gupta / Journal of Clinical Forensic Medicine 11 (2004) 248–256 Table 4 Profile of the perpetrator of child sexual abuse No.
%
Relationship to the victim Uncle Tenant Domestic help Step father Father Grand father
15 8 3 3 1 6
41.67 22.22 08.33 08.33 02.78 16.67
Age of the perpetrator <20 21–30 31–40 41–50 51–60 >60
3 9 16 4 3 1
08.33 25.00 44.44 11.11 08.33 02.78
8 6 6 3 3 2 3 5
22.22 16.67 16.67 08.33 08.33 05.56 08.33 13.89
Occupation of the perpetrator Factory worker Bus driver Cleaner Welder Security guard Painter Tutor Shopkeeper
Table 5 Disclosure of sexual abuse No.
%
Relationship to the victim Mother Father Aunt Friend Teacher Hospital staff
17 2 3 1 1 12
47.22 05.56 08.33 02.78 02.78 33.34
Duration of sexual abuse before disclosure 1 day 1 day to 1 week 1 week to 1 month 1 month to 1 year 1 year to 10 years >10 years
11 8 6 3 5 3
30.55 22.22 16.67 08.33 13.89 08.33
Reason of disclosure Questioned by parents or relatives Pain in private parts Fear of perpetrator Felt it wrong
16 13 6 1
44.44 36.11 16.67 02.78
Problems at presentation
No.
%
Emotional Physical Behavioral Shock due to hemorrhage following perennial tear Smothering during sodomy
19 11 04 01
62.78 30.56 11.11 02.78
01
02.78
Table 6 Presenting problems
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Physical abuse. Battered Baby Syndrome is the term used to define a clinical condition in young children, who have received non-accidental violence or injury, on one or more occasions, at the hands of an adult in a position of trust, generally a parent, guardian or foster parent. The precipitating factor being usually a cry which interferes with either a parentÕs sleep or their television program or the outing. Exact incidence of baby battering is not known due to reporting biases and investigatory procedural constraints. Inconsistencies are common between the history offered of a minor accident and the physical findings of a major injury. From a study conducted by Cameron23 in 1966, some of the explanations offered by guardians or parents in cases of Battered Child Syndrome, that continue to be same even today are tabulated below (Table 7). Child labor is a harsh reality in this part of the world and most of the working children are found in unorganized sector. The status of girls in the labor market is different than the boys and they are considered to be more productive in the household activities. The deep routed gender bias in the minds of people also leads to more female child labor. Harmful effects of child labor are long lasting in that the children who spend considerable part of their time in gainful employment are deprived of education that is not only a loss to the children but also to the nation in the future. Lately the trend of teenaged commercial sex workers among girls has been reported to be on rise. According to a report,24 there are about 10 million commercially sexually exploited women in India, of which one fifth are under the age of 18 years. As the average age of girls at the entry to commercial sex trade is 16–18 years, most of them tend to loose market appeal by the time they are aged 30–35 years. At this stage they develop behavioral disorders and many of them become drug abusers, they may also initiate their own daughters into the trade so as to ensure the continuance of economic support. Child sexual abuse is a dark reality that routinely inflicts our daily lives, though the truth regarding the same is often kept under wraps. Child sexual abuse refers to wide varieties of acts, subtle or gross, which adult individuals indulge in, in order to derive sexual pleasure through the medium of children. It may take the form of acts like obscene talks, exposure, and voyeurism, touching or fondling of genitals of the child or asking the child to fondle the adultÕs genitals. Sexual intercourse includes vaginal, oral or rectal penetration on a non-assaultive basis. Less than 10% of the sexual abuse is reported to be assaultive.25 Statistics tell a chilling tale of how widespread this abuse is. As per official statistics of the Government of India, 20% of IndiaÕs population under 15 years is susceptible to child sexual abuse but some studies peg the figures much higher. The World Health Organization reports that one in ten children is sexually abused in India while some Non Government
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Table 7 Victims of physical assault vis-a-vis history furnished Presenting history
Probable truth
Fell from pram and caught ear on handle Fell and caught stomach against door Fell downstairs Fell from settee and head struck table Tripped whilst carrying baby Mother fell downstairs whilst carrying baby Fell off bed Must have strayed too near the fire Split hot water over herself Toppled backwards while sitting in a chair
Blows on face and/or bounced on floor Kicked over stomach Kicked and struck with broom handle Blow with hand behind left ear Threw him to the floor Thrown downstairs Dropped child on head Multiple blows and held against electric fire Ill-treatment with very hot water Blows on head and face
Organizations report that five out of every ten girls and three out of every ten boys are sexually abused.26 A steep rise in cases of sexual offences particularly rape from 10,068 in 1990 to 15,033 in 1998 has been reported,27 but the more disturbing feature of this report is that 25–30% of the victims were children (Table 8). These figures, despite of the fact that sexual offences against children are one of the most under-reported crimes in India, speak for themselves. It has been argued that for every case reported against children there are a hundred, which are not reported because in majority of the cases, the abuser is a person whom the child knows and mostly trusts, like a family friend or acquaintance, a domestic help, a relative or in the most tragic and traumatic of the cases a member of the immediate family like the father, brother or grand father. Ironically this is also the reason why child sexual abuse is many a times allowed to continue despite getting detected. In cases of involvement of close family members, the childÕs allegations of misconduct against the same might not be believed because any acknowledgement of such a behavior is likely to lead not only to a familial rift but also to a social scandal. So a child in such circumstances is sacrificed at the altar of family unity and prestige. In other cases, when people other than the family member are involved, the fact of child sexual abuse is relatively easier to acknowledge and confront. But here too
complex social and cultural factors make it extremely difficult for the affected party to take up cudgels against the guilty. To begin with in a society like ours, the victim is often the one who carries the cross of shame. It is the victim who becomes the target of mocking eyes, slandering tongues and a butt of lewd jokes. The stigma of sexual assault and victimization continues long enough to even hamper the marital prospects of the girl child in question. Thus silence regarding the crime is often the most advised and frequently followed recourse to the problem of child sexual abuse. A study based on interview of 350 Delhi schoolgirls found that a family member had abused 63% of them. Another study on 1000 middle and upper class women, revealed that 71% had been abused by the people they knew.26 Friedrich (1988), documented disturbances in sexual behavior in a controlled study, which revealed a higher incidence of sexual behavior problems in 20 sexually abused boys between 4 and 7 years old than in a comparison group of 23 non-abused boys with a history of conduct disorder.28 The National Crime Records Bureau of India in its report – 2000, reported an alarming 26.6% increase in the incidence of child rape where victims are below 10 years of age.29 In a study of sexual offences in South Delhi, out of a total 13 reported cases of sodomy on males, 12 belonged to the age group of 5– 15 years whereas 27 of the 67 reported female victims of
Table 8 Victims of sexual assault by age groups Year
1990 1991 1992 1993 1994 1995 1996 1997 1998
Age in years Below 10
10–16
16–30
Above 30
394 1099 532 634 734 747 608 770 626
2105 2630 2581 2759 3244 3220 3475 3644 3433
6028 5377 7000 7038 7442 7752 8281 8612 8414
1541 1319 1621 1792 1798 1955 2485 2310 2560
Source: National Crime Records Bureau11 1996, 1998.
Total
% of child rape
10,068 10,426 11,734 12,223 13,218 13,674 14,849 15,336 15,033
24.8 35.8 26.5 27.8 30.2 29.5 27.5 28.8 27.4
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sexual offences belonged to the same age group, i.e., 5– 15 years.30 Much of the sexual abuse is perpetrated within the family or household although a wide variation has been reported by studies. Bentovin (1987) found that 75% of the cases were sexually abused within the household whereas the Northern Ireland Incidence Study (1990) reported that although 85% of children knew their abusers, only 31% had been abused within the household while 54% were abused by a known person not living in the house. Incidence of sexual child abuse by strangers was reported to be only 5%.31 Non-clinical studies suggest that the difference in rates of sexual abuse between boys and girls is about 2.5:1 whereas most of the clinical studies suggest a female:male ratio of 5:1. The difference in the gender ratio between clinical and non-clinical studies is suggestive of lack of reporting of male child sex abuse as well as homosexual nature of the abuse.32 Sodomy, the commonest of the sexual offences, may be homosexual or heterosexual in nature, but the active agent in both cases is a male. As for all active agents and those passive agents who enjoy their participation, there might be some background having psychological influence on them which may be either unusual passion for the same sex or just the reverse, a cryptic hatred nurtured by them against their own sex, which is expressed through such sexual activity. This might have some bearing of childhood environment and experiences.31 According to a study,33 the risk of sexually abused boys in early adolescence abusing other children may be associated with experiences in early life that are independent of sexual victimization; exposure to persistent violence within the family may be particularly important risk factor; and management of sexually abused boys should take into account the impact of early life experiences that may be associated with increased risk with a view to the secondary prevention of sexually abusive behavior. Primary care physicians often deal with the fallout of childhood abuse and neglect. Each year, an estimated 18,000 children are severely disabled as a result of abuse, and 30,000–40,000 additional children require immediate medical attention to prevent long term impairment from abuse or neglect.34;35 A survey of 1225 women36 reveals the broad array of adverse adult health outcomes with which childhood sexual and physical abuse are associated, including disturbances in emotional, social and role functioning; mental health problems; risky health practices including substance abuse; physical symptoms and health disorders reaching clinical threshold. Another study,37 reported a strong relation between exposure to abusive or neglectful conditions in childhood and risk for certain adult disorders, including ischaemic heart disease, cancer, chronic lung diseases, liver diseases and skeletal fractures.
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These findings call out for explanation as to how do abusive and neglectful family environments in childhood affect mental and physical health decades later. An important route involves alterations in autonomic and endocrine responses to stressful circumstances. The consequences of early exposure to abuse or neglect appear to be potentially irreversible disruptions in biological systems that may, perhaps also in conjunction with genetic predisposition, produce large differences in susceptibility to stress, to biological markers of the cumulative effects of stress, and to stress related physical and mental health disorders.38 These include elevated blood pressure and heart rate responses, as well as prolonged sympathetic responses to stress. Alterations in hypothalamic pituitary adrenocortical reactivity in response to stress also appear to be related to adverse family history. In families characterized by conflict, anger and aggression, there may be disruption of the normal rise and fall of serum cortisol levels in response to acutely stressful circumstances, such that a protracted cortisol response or in extreme cases a flattened cortisol response may develop. In contrast, a warm and supportive family environment may actually foster a less elevated cortisol response to potentially stressful circumstances or one that rapidly habituates to stress.39 There is evidence for serotonergic dysregulation in offspring in abusive and neglectful families. Difficulty in moderating aggressive impulses, problem in developing and maintaining social relationships, and risky health related behaviors, especially substance abuse, are among the outcomes consistently seen. Deficit in appropriate emotion regulation and social regulation skills take their toll on adult health in at least four ways. First, people who lack these vital skills interact poorly in the social environment. As adults, they may have difficulty forming long term social relationships and compromise their work-related relationships as well. Second, social isolation and lack of social support have been associated with a greater risk of mortality from all causes, as well as more protracted courses of illness and recovery from several acute and chronic disorders.40 Third, poor emotion regulation is also a risk factor for mental illness. Emotion dysregulation is implicated in more than half of the DSM – IV axis I psychiatric disorders and in almost the entire axis II disorders, as described by the American Psychiatric Association. Fourth, emotion dysregulation and low social competence, in turn, increase the likelihood of substance abuse, aggression, risky behavior and other poor health habits.
5. What can be done? The role of a medical practitioner though limited, can be significant if the following suggestions are incorporated in regular practice:
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1. Parents at high risk for being unable to love and care for their offspring adequately can be identified early if attention is given to such things as abuse of previous child, drug addiction, negative parental comments about the newborn, lack of evidence of maternal attachment to a newborn or severe neglect of infant hygiene. Physical abuse and neglect may be prevented by proper counseling of such parents. It needs to be borne in mind that the people may have violent thoughts or fantasies but unless they loose control, thoughts do not become acts. Any condition that produces increased aggressive impulses in the context of diminished control may produce violent acts and as such, the children who are premature, mentally retarded or physically disabled and those who cry aggressively or are unusually demanding – the so called Ôdifficult childÕ may be at high risk of physical abuse or neglect. Gladstone,41 in a study, viewed the syndrome of physical child abuse as a result of parentÕs attempt to cope with internal conflicts, poverty, domestic demands, social isolation, etc. to discharge the intra-psychic tension. 2. Improving training in medical schools/colleges and residencies on the correct process of identification and management of the forensic patients.42 While it would be inappropriate to label a child as potential abuser just because he has been exposed to intrafamilial violence but relatively greater support may need to be given to the boys at high risk with a view to averting future abusive behavior. 3. Awareness of the link between childhood abuse/maltreatment and adverse health outcomes may sensitize the community in general and the primary health care providers in particular to identify and report the cases. 4. Continuing development, implementation and evaluation of systematic, continuous child health review programs and to report on a regular basis the contribution of maltreatment to childrenÕs health problems and death. 5. It is unacceptable not to know how many children are killed each year by their caregivers. The effort in the 1980s to bring consistency to coding of abuse fatalities was an important step in improving child abuse fatality ascertainment. Now, with the increased understanding of child abuse dynamics and expanded epidemiology of child injury mortality, appropriate revision of rules for coding child abuse fatality globally may be considered. 6. Creating a child-specific injury/death certificate with prompts so that available space could be used to capture information, including socio-demographic data pertinent to children. 7. Many of the cases of child sexual abuse are disclosed after a delay of weeks, months or even years. It has been argued that persuasive or suggestive psychother-
apeutic techniques designed to unearth sexual abuse can not be relied upon.43 However, the central question here is: can someone endure a seemingly unforgettable traumatic experience, such as repeated rape, and then expel the memory completely from conscientious awareness for many years?44 The following Important legal issues related to child sexual abuse need to be resolved: 1. Usually there is a long interim period lasting many months or even years before the Judicial proceedings are completed and justice meted out. In this period, it is always the child victim who is taken away from its home in the name of protection, while the perpetrator roams free. It gives an impression to the child that he or she is being removed because it is in the wrong. It is therefore, recommended that medico-legal action has to be prompt and complete, as also all the other investigations concerned so that the judicial proceedings in the case be completed as early as possible and the perpetrator punished. Meanwhile the accused may be kept in custody, away from the child and its environment, to stop any further sexual violence against the defenseless young victims. 2. To minimize distress to the child victims through multiple interviews by various professionals a coordinated and specialized team of professionals should conduct interviews with the child victims, especially the first, which should be video recorded. This would reduce the need for repeated interviews of the child by different professionals, i.e., police, social workers, doctors, etc. The video recording can also be used as evidence in Court and the need for the child to testify in Court is thus minimized. 3. If the child has to go to Court to testify, then the stress for the child can be reduced by a number of means, including the use of videotaped interviews, frequent breaks during the hearings, exclusion of spectators in Court and the option for the child not to physically face the accused. Once the evidence for prosecution is available, Court proceedings should be expedited so that further trauma for the child is reduced. 4. To support the child victims throughout the Court process Ôtrained social workersÕ may be assigned to help the child victims/witnesses to testify in Court. The assigned worker would befriend and familiarize the child with the Court proceedings and offer emotional support to the child before and during the Court case. These workers should not discuss evidence and facts of the case with the child or its family, but only act as guides to help through the Court proceedings. 5. Competency and credibility are the two essential pre requisites for the child to give testimony in Court. According to Weissman, 199145 the four main criteria to establish competency of the child to testify in Court
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in a reliable and meaningful manner are the capacity to: • perceive facts accurately, i.e., the ability to observe or receive accurate impressions of the incident. • recollect and recall, i.e., memory sufficient to retain an independent recollection of the occurrence. • understand the oath, i.e., the ability to tell truth from falsehood and to understand the consequences of not telling the truth. • communicate based on personal knowledge or the facts, i.e., ability to communicate the memory of the observation and to understand simple questions about the occurrence.
6. Conclusion The solution to the problems like physical abuse and child labor lies in recognition of the ÔRights of the ChildrenÕ incorporated in the Geneva Declaration of Rights of Child 1924 and the Universal Declaration of Human Rights 1948. It must be stressed that the rights and duties are two sides of being human. Proper performance of duties by the parents, teachers and the community at large is equally necessary, as is the strict implementation of relevant laws enacted from time to time. Primary prevention of sexual abuse includes encouraging children to Ônot keep secretsÕ, Ôsay noÕ and to Ôtell someoneÕ. The parents often fail to equip children with vocabulary that the child can use to report sexual abuse. The child may exhibit other abuse related signs like anxiety, isolation, depression, regression, avoidance of particular individuals, difficulty in concentration, display of explicit behavior, infections in the throat, anal and genital areas etc. But these signs may be lost on ignorant, unsuspecting or non-communicative parents. Counseling of young parents in this regard along with the antenatal care can be of great help. There is a paucity of studies on child abuse in Asian countries. Much of the information and data used here is derived from case studies and references from the west. There is a need to identify potential risk factors for baby battering, child labor, child sexual abuse etc., so as to better understand the problem, improve the treatment of the victim as well as perpetrator and take preventive steps to restrict the incidence of child abuse. Announcements of new legislation, commissions or programs by the respective governments in the absence of the will to implement the same has nothing more than politically motivated ornamental values. A societal awareness to boldly report the cases, honest and scientific investigation by the Investigating Agencies and speedy delivery of justice by the Courts is all that is required in addition to a change in the attitude of the community towards the victim.
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