Wednesday, October 29, 2014

Children needing protection: experience from South Asia

Professor D G Harendra de Silva

Professor Harendra de Silva's contribution to the welfare of children in the country is exceptional. Professor of Paediatrics at the Faculty of Medicine, Ragama, he is the Founder Chairman of the National Child Protection Authority (NCPA) and the Presidential Task Force on Child Protection. A social entrepreneur and an activist against all forms of child abuse, Professor de Silva has been honoured with coveted accolades including Senior Ashoka Fellow of the Ashoka Foundation, Washington DC.   

As in many societies, child abuse is often denied in the Indian subcontinent. Probably one of the oldest recorded tales of child abuse is a 2500‐year‐old Buddhist story called Sopaka.1 A jealous stepfather ties Sopaka to a corpse in a cemetery to be eaten by wolves. Buddha releases the boy and preaches to him, probably one of the earliest recorded instances of counselling. Buddhist scriptures also record the story of the boy Mattakundali,2 whose miserly father neglects him and deprives him of medical care.

Most forms of child abuse have been described in South Asia. In addition, a new form of child abuse – the conscription of children during armed conflict – has emerged relatively recently, especially in Sri Lanka and Nepal.

Physical abuse

In Sri Lanka, there is evidence that the ancient kings Voharika Tissa (214–236 AC), Vijayabahu II (1186–1187) and Vijayabahu III (1232–1236) were influenced by compassion. Non‐violence in Buddhism prohibited any bodily harm, by way of punishment, of children and adults.3However, Sri Lanka went through a phase of denial, acceptance and justification of corporal punishment as a norm for the sake of “discipline” and “education”, an attitude which was especially promoted during the colonial past to facilitate foreign rule,3,4 and which still persists in society today. The Education Ordinance of 1939 of Ceylon,5which was in effect until recently, even after the signing of the United Nations Convention of the Rights of the Child (CRC),6 permitted caning of a child. A new circular in 2001 banning corporal punishment and sent with a booklet to teachers7 by the Ministry of Education Sri Lanka, led to many unpublished controversies within the teaching profession and political circles, including the destruction of the booklet without distribution in some schools.

A high prevalence and frequency of corporal punishment were found in a cross‐sectional study of 1226 school children in Colombo.8 The study indicated that corporal punishment directly predicted to what extent a child would be maladjusted and that non‐parent‐to‐child violence (ie, domestic, school, peer and community violence) significantly affected this psychological damage.8 Although the medical curriculum in Sri Lanka did not include child abuse until recently, it is now being taught in depth.

The first published cases in Sri Lanka recognising physical abuse appeared in the latter half of the 1980s,9,10 and were followed by several case reports.11,12,13 However, the paediatricians who recognised child abuse were faced with a management dilemma as infrastructure and procedures in cases of child abuse were lacking.14There is very little scientific literature on child abuse in other South Asian countries except for some articles based on qualitative data and by non‐governmental organisations (NGOs) on the internet. There have been reports of “ear abuse”15 and physical abuse of street children in India.16,17

Sexual abuse of children

Although not specifically named, child sexual abuse was documented in the case of a tailor named LLJ,18 who was sentenced to death by hanging in 1949 for murdering a 14‐year‐old schoolboy he had previously abused. LLJ had the typical profile of a paedophile, and he lured boys into sex traps in his “fitting room”, attracting boys with the promise of rides on his red “James” motorbike.

During the 1940s, sexual abuse was viewed as being homosexual18 and the child was often considered a criminal contributor rather than a victim. Although the use of young school boys by teachers, hostel wardens, school cadet leaders, sports coaches, and older boys was known to the public, it was not discussed openly, and was considered the norm by some and was completely unknown to others.4 Even at present, there are those who excuse the sexual abuse and exploitation of boys by the justifications “boys do not get pregnant” or “ships don't leave tracks on water” (there is no physical virginity to lose) without realising (or not wanting to know) the long‐term emotional effects of abuse.4

Research in the North West Frontier Province of Pakistan and amongst Afghans (who are tribally similar) revealed that rich men use “attractive beardless” youths, referred to as “Balkay”, for sexual pleasure. One third of adults interviewed in the region did not consider sexual abuse to be “bad” and for many it was a symbol of “power” and “status”.19

The “Devadasi” system in India, although legally banned in 1982, and the “Deuki” system in Western Nepal offer children and women to the temple system to function as sex slaves to pilgrims and priests.20 In the past, Devadasi earnings from prostitution contributed significantly to the temple's earnings for centuries.20 The use of so‐called lower castes and downtrodden women and children for prostitution in South Asia has been “legitimised” by society through religious justification20 and 50% of these women and children are estimated to become commercial sex workers later in life.21

The mean age of entry into prostitution in the Daulotdia brothel in Bangladesh has been estimated to be around 13.5 years.20 A comprehensive report on the commercial sexual exploitation of children in Pakistan has been published.22

Carl Muller, a Sri Lankan author,23,24,25 has written a number of accounts describing the sexual abuse of boys during the 1930s and 1940s in Colombo's “Burgher” community, comprised predominantly of persons of Dutch/European descent, and has also described the hesitant attitude within society towards the sexual abuse of boys.


An initial qualitative study was conducted in homes of safety for children that paradoxically are called “detention” homes in Sri Lanka.26The observations from this study and police data prompted us examine at the incidence of sexual abuse of children in domestic situations. An anonymous questionnaire was administered to 899 students in a university entrance class and to undergraduates. The same questionnaire was also administered to 818 students in the university entrance class who had heard a lecture on child abuse prior to completing the survey.4,14,27

In the initial study,27 85 (18%) boys admitted being sexually abused during childhood and 19 (4.5%) girls had been abused. However, in the group given a prior lecture on child abuse, 21% of the boys and a higher percentage of girls (11%) admitted being sexually abused. A majority of the boys had been abused either by a relative or a neighbour, while others abusers included brothers, teachers and priests. Older women had abused 19 of the boys. Most girls did not divulge the abuser, suggesting that the perpetrator was an immediate family member. A significant finding was that 71% of males who had abused younger children had been abused themselves during childhood.

In a study conducted at a sexually transmitted disease clinic,28 40% of female commercial sex workers had been abused as children, while in promiscuous males 21% admitted paedophilic activity and 64% had been abused as children.

Several social factors may explain why abuse of boys is more common. A girl's virginity is considered important at the time of marriage in traditional Sri Lankan society and since girls can also become pregnant they are more protected than boys. For the same reason, pre‐marital sex is unusual in traditional society. Thus, hormonally primed young adult males may have access only to boys or to pre‐pubertal girls who are less protected.

Sexual exploitation of children by tourists

In the 1970s and 1980s there was an explosion in tourism in Sri Lanka, and foreigners came in increasing numbers for child sex. Early reports of this trend by NGOs and sociologists were presented at meetings but were not scientifically documented.

International gay magazines such as “Spartacus”29 achieved particular notoriety for promoting certain countries such as Sri Lanka, Philippines and Thailand for homosexual tourism, and indirectly highlighting the availability of children.

Tim Bond in a well‐documented report30 estimated the number of commercially exploited boys in Sri Lanka in 1980 (at the peak of unmonitored tourism) to be around 2000. In 1999 Ratnapala31 found 926 youth/child sex workers, of whom 533 were younger than 18 years of age, in the tourist areas of the country. With active surveillance and prosecutions including extra‐territorial trials, numbers are now estimated to be less. However, proper quantitative scientific studies are difficult.

Most sexual abuse occurs as a result of domestic abuse and incest, while a smaller but more visible problem is commercial exploitation of children on the streets and in brothels (fig 1​1).). The tip of the iceberg (fig 2​2)) in countries such as Sri Lanka and the most visible form of abuse, although accounting for the fewest cases, is commercial sexual exploitation by tourists.


The extent of neglect is difficult to evaluate because Asian society has been slow to recognise such neglect as abusive. Mirando,33 a Sri Lankan paediatrician, reported a case of severe neglect in 1965/66, but at that time neglect abuse was attributed to poverty and ignorance and was not recognised by the medical profession as a form of child abuse.

Child labour

The industrial exploitation of children is less of a problem in Sri Lanka than in other countries in the region. The trend of poor adult Sri Lankan women seeking employment in Middle Eastern countries as housemaids, the demand for high wages and the high cost of feeding an adult have made it expensive to employ household help. These conditions contributed to an increase in the domestic employment of children in the 1980s and 1990s. Children's labour is exploited and they are vulnerable to physical and sexual abuse and, almost always, emotional abuse through denigration. These children are also deprived of schooling and proper nutrition.

A study of almost 700 households in urban Southern towns indicated that one in 12 has a child servant, and one third of the domestic labour force consisted of children.34 This study was followed by a media campaign against child labour and prosecution of offenders. A more recent study in 200235 for the International Labour Organization showed a rapid decline in the domestic employment of children with the rates being reduced to 0.5% of households compared to 8% in 1997 in the same area. Tackling the broader economic issues will help address this residual problem.

Child labour in neighbouring India, Nepal, Pakistan and Bangladesh, where there are higher poverty levels, is considerably more common. Unfortunately, scientific studies to determine numbers are scarce; most existing studies are qualitative and carried out by the NGO sector, and are often published on websites. In India estimates indicate that there are 12 million child labourers, with 85% working in rural areas.36

Street children

Children may be born on the street, with their parents living on the streets as beggars or prostitutes or having being mental problems, while children abused physically, sexually or emotionally and experiencing domestic violence may run away from home. The availability of work and food on the street in the commercial areas of cities are the main attractions for children.37

The prevalence of street children in a community is directly related the extent of poverty in that society and the “need” for exploitation for “gain” in the community. These children have to compete for work with other children and also with adults. They require money and food for survival, which may be their only needs. Although there may be a relative dearth of adult labour, the employers' “Mafia” on the street may set the rates of payment, which may only be a meal. Universally all children lack power to ward off abuse and exploitation, but street children are even more vulnerable because they do not have parents to protect them, while absolute poverty nullifies any possibility of protection either by the community or by the state.

Such children are denied appropriate role models and exposed to vice, from picking pockets, prostitution, smoking and drugs, to street violence. The public sees these children not as victims and exploited but as perpetrators of crime and undesirable.

UNICEF's estimate of 11 million street children in India in 1994 is considered to be conservative,38 while in 1996 Human Rights Watch estimated it to be 18 million.16 The health of these children and the problems they faced were reviewed by Nigam in 1994.39 The number of street children in Bangladesh is estimated to be approximately 400000,40 while in Sri Lanka about 600 have been counted in Colombo where most of them work and live.37

Child conscription and armed conflict

The public and the media, even in the West, may not always see armed conflict as detrimental to a child's proper development but may consider the children as heroes or martyrs.41 Sri Lanka has had an ongoing civil war for two decades, and media reports have described child conscripts amongst the militant groups,42,43 which is also an issue in Nepal, which is also affected by civil war.44

Nineteen male child soldiers conscripted before the age of 18 years (mean age 19 years, range 16–24 years) were interviewed using a questionnaire with standardised questions.45,46 The mean age of conscription was 14.5 years. Conscription itself, “the involvement of dependent, developmentally immature children and adolescents in an armed conflict that they do not truly comprehend, to which they are unable to give consent, and which adversely affects their right to unhindered growth and identity as children”, should also be included in the definition of child abuse.45,46

Usually, all conscripts in Sri Lanka, irrespective of age, wear cyanide capsules, which they are trained to bite on during “suicide missions” or when captured.41 The prominent place given to martyrs and the oath taken by the child soldier in which he vows to sacrifice his life are likely contributing factors to this phenomenon. We proposed another definition, “suicide by proxy”: “making a child or adolescent commit suicide, an act he or she cannot comprehend, by a process of persuasion by an adult, for personal, social, economic, or political reasons that the child cannot understand constitutes suicide by proxy”.46,47

Although other forms of child abuse are being challenged globally at a practical level, the impunity of child recruitment has not yet been dealt with. Millions of dollars have been spent on meetings and other forms of advocacy without visible or documented change in prevalence. Compared to other forms of child abuse, which is usually perpetrated by individuals, conscription is carried out by organised groups or dictators who are not answerable to the local population or local lawmakers, or the international community. The international community is more interested in politics, peace and adult human rights while child rights and the conscription of children are not a priority, a situation which makes it easier to abduct children than to abduct adults.47 Political, personal and other hidden agendas within the international community may divert attention away from conscription. The abundant “availability” of poor children for “supply” in a background of poor prospects for education, vocational training or future jobs makes conscription of children more attractive, demonstrating the mutual relationship between supply and demand.

The specific identification of groups and persons responsible for child recruitment, the creation of proper standards in the International War Crimes Tribunal in The Hague and the establishment of local laws are crucial to stopping this plague worldwide. “Peace monitoring” processes by the UN and foreign governments should be for accountability and not merely documentation. “Human rights” and “child rights” should be given the same importance.

Action against child abuse by the government in Sri Lanka

The initial response of professionals, especially a few paediatricians who identified child abuse, was significant in placing the problem on the government's agenda. It is important for other paediatricians in the region to identify child abuse and lobby the administration to set up structures to effectively deal with the issue. Initially, the Penal Code was amendment in 1995.48 The highlight was a provision that strengthened the law governing sexual and other offences against children. It concentrated on (a) defining offences that were previously not defined or described adequately; (b) increasing sentences; and (c) introducing mandatory jail sentences for some offences. In the author's experience, mandatory sentencing considered Draconian in nature has had a negative effect on prosecutions.

In December 1996, the former president of Sri Lanka appointed a task force on child protection. It recommended several legal amendments, including the establishment of a statutory body, the National Child Protection Authority (NCPA).49 The NCPA mandate includes a broad range of objectives and duties such as: advising the government on policy and measures regarding the protection of children and prevention of child abuse; coordinating with relevant ministries and other organisations; recommending legal and other reforms for the effective implementation of policy; monitoring the criminal proceedings in cases of child abuse; recommending measures regarding the rehabilitation, and reintegration, of children affected by armed conflict; receiving complaints from the public; advising the tourism industry, local bodies and NGOs concerning child abuse, and coordinating and promoting campaigns against child abuse with these bodies; and conducting research on child abuse.

The NCPA board of management consists of professionals from various disciplines, including paediatricians, forensic pathologists, psychiatrists, psychologists, a senior police officer, a senior lawyer from the Attorney General's department, and five other members associated with child protection efforts including NGOs. The Commissioners of Labour and Probation and Child Care Services, and the chairperson of the monitoring committee of the CRC are also included. A panel of ex‐officio members from a wide range of relevant ministries has also been appointed. The NCPA had the advantage of reporting directly to the president, and the presence of high‐ranking officials has facilitated the implementation and coordination of mechanisms of action suggested at NCPA meetings. However, for reasons unknown, it has recently been changed to a ministry (2005), which has weakened its mandate. As observed in other countries, lobby groups in Sri Lanka associated with perpetrators are pressurising the authorities50 to soften the action taken by professionals against child abuse, with the replacement of professionals by administrators and politically appointees which will ultimately lead to the downfall of successful work carried out over several years. Another major weakness in the present system is the lack of facilities to care for abused or vulnerable children. The poor financial resources for foster care and the persistent focus on institutional care by administrators makes it difficult to care for these children.

Child protection in most other South Asian countries is by NGOs. Most governments in the region are trying to emulate the NCPA model.



The author would like to thank all the authors/co‐authors (too numerous to be named individually) who helped the author carry out this research.


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Articles from Archives of Disease in Childhood are provided here courtesy of BMJ Group

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