ARTICLES

Child and Adolescent Sexual Abuse in

Health Facilities
SURINDER JASWAL

This article reports the findings of an exploratory study conducted in 2001 on the mag-
nitude and patterns of child and adolescent sexual abuse (CSA) reported in a
cross-section of public health facilities near Mumbai. It describes the process of identi-
fying CSA in public health facilities, the health seeking behaviour of those reporting to
health facilities and the handling and management of CSA by health care providers.
The results suggest that reporting of CSA in health facilities is age and sex specific;
and is reported only on appearance of severe symptoms related to the abuse due to
lack of information as well as feelings of guilt, shame and fear. This is compounded by
the attitude and lack of training of health providers on issues related to CSA.

Dr. Surinder Jaswal is Reader, Department of Medical and Psychiatric Social Work,
Tata Institute of Social Sciences, Mumbai. She is also the Associate Editor of the
IJSW.

INTRODUCTION
Child sexual abuse (CSA) can be traced back to the dawn of human
civilisation and has existed in one form or the other in almost all
societies. In traditional societies like ancient Babylon, there is evidence
of culturally accepted liaisons between adults and children. In Hindu
mythology too, an instance is cited wherein Brahma, the creator,
displayed a desire for his daughter, Sandhya (Kakkar, 1988). The
existence of child sexual abuse is thus centuries old.
Child sexual abuse has been defined in a variety of ways. It was first
identified from radiological findings of unexplained multiple fractures.
Among the subsequent clinical accounts, that of Kempe, Silverman,
Steele, Droegemueller and Silver (1962) is noteworthy. Kempe first
defined the 'battered child syndrome' as a clinical condition — meaning
that diagnosable medical and physical symptoms existed — involving
those who have been deliberately injured by a physical assault. Since
then the definitions of abuse have opened up a range of debates on what
could and should be included in the definition of child abuse. In recent
years, there have been attempts to widen the concept of child abuse to
include emotional abuse and neglect, as well as physical abuse.
One of the broader definitions describes child abuse as a complex
social phenomenon in which a caregiver fails to provide for a child's
396 Surinder Jaswal

health and well-being. It involves acts of omission or commission t h a t

can have injurious effects on the child's physical development and
psychosocial well-being. Child sexual abuse constitutes an abuse of
power, whereby an older or more powerful person takes advantage of a
child for the purpose of sexual gratification (Gilgun and Connor, 1989,
cited from Gilgun, 1994). Varied writings acknowledge that CSA,
transgresses against children in ways that clearly threaten children's
development (Gilgun and Connor, 1989, cited from Gilgun, 1994).
Reported forms of CSA today involve child trafficking, sex tourism,
pornography, forced prostitution, and other organised crime,
particularly child rape.

Magnitude of the Problem

Much of the literature in the West, has primarily looked at exploring
linkages between CSA and adult sexual risk in clinical populations, at
understanding short and long-term effects of CSA, estimating
prevalence in general populations and studying disclosure following
CSA (Bagley, 1989; Bagley and Ramsey, 1986; Beitchman, Zucker,
Hood, DaCosta, Akman and Cassavia, 1992; Briere and Elliot, 1994;
Cohen, Spirito, Sterling, Donaldson, Seifer, Plummer, Avila and
Ferrer, 1996; Everett and Gallop, 2001; Finkelhor, 1979; Finkelhor and
Browne, 1988; Finkelhor, Hotaling, Lewis and Smith, 1990; Hyman,
2000; Jaswal, 2002; Koenig, Lynda, O'Leary and Pequegnat, 2004;
Mullen, Martin, Anderson, Romans and Herbison, 1993).
In India, in recent times, CSA has become one of the most emotional
topics in the field of family violence. Though the media repeatedly
reports narration, of long-term and situational incidents of children
being sexually abused by family members, caretakers, or strangers, the
true magnitude of this problem is difficult to assess.
There are no national or state statistics for CSA in India. However,
some data is available from the National Crime Records Bureau
(Caesar, 1997), which shows that in 1991, 1,099 and 2,581 cases of child
and adolescent sexual abuse in the age group below 10 years and 10-16
years, respectively, were reported. It is also acknowledged that like
rape, child molestation is one of the most under-reported crimes in the
nation, and virtually every study of the crime problem acknowledges
the fact that only 1-10 per cent of the incidents are ever disclosed
(National Committee to Prevent Child Abuse, 1996, cited from
Goldstein, 1999). The National Crime Records Bureau (2002) reports
that children account for 19 per cent share of total rapes and the
incidence of rape of children below 10 years has increased by 22.4 per
cent in 2000, as compared to 1996.
It has been conjectured that the problem of CSA is of enormous
dimensions; however, its national dimensions cannot be adequately
measured due to lack of accurate statistics. Several investigative
reports have concluded that the reported incidence (as only a fraction of
 Child and Adolescent Sexual Abuse in Health Facilities 397

the actual cases is reported) is 'only the tip of the iceberg' and that the
actual incidence is far greater than the reports received.
In India the subject is receiving increasingly more attention in
recent times, especially in the popular print media. Research studies
over the last decade have mainly focused on estimating prevalence
(Ganesh, 1994; Rane 1991; SAKSHI, undated), understanding factors
affecting college student's attitude towards disclosure (Vijayalakshmi
and Seshadri, 2001); documentation of special groups such as police
cases of sexually abused girls (Panchal and Shaikh, 1997); children
reporting to health facilities (Jaswal, 2002) and CSA and its sequelae in
children and adult women (Andrew and Patel, 2001; Maitra, 2005).
Some Indian studies (Seshadri, Ganesh and Kumar, 1994, cited from
Caesar, 1997) on a small sample of girls between the age groups of
15-22 years report that 83 per cent of the respondents have
experienced physical eve-teasing, 13 per cent of them when they were
less than 10 years old. Forty-seven per cent of respondents were
molested or experienced sexual overtures and 15 per cent of them were
less than 10 years old. Fifteen per cent of the respondents had
experienced serious forms of sexual abuse, including rape, and 31 per
cent of them were less than 10 years old.

Impact of CSA and Health Outcomes

The invisible nature of CSA makes it next to impossible to look at it
objectively. Child sexual abuse has received considerable attention
since the late 1970s from mental health care professionals; legislative,
judicial and law enforcement personnel; the media; and the lay public
(Rind, Tromovitch and Bauserman, 1998). Much of this attention has
focused on possible effects of CSA on psychological adjustment
(Tromovitch and Bauserman, 1998, cited from Rind, Tromovitch and
Bauserman, 1998).
In a study conducted by Bagley and King (1990) in Canada with
young adult males, those recalling multiple events of abuse (52
individuals, 6.9 per cent of all respondents) were distinguished from
other respondents at a statistically significant level on the following
indicators: emotional abuse in childhood, higher rates of current or
recent depression, anxiety, suicidal feelings and behaviour, and current
sexual interest in or actual behaviour involving minors. Additionally,
two methods of coping with the childhood abuse — dissociation and
somatisation or becoming dysfunctional — were exhibited during
adulthood (Briere and Runtz, 1988, cited from Hyman, 2000; Coons,
Bowman, Pellow and Scheider, 1989, cited from Hyman, 2000). A study
done by Bagley and King (1990) with Canadian and British adolescents
with a known history of sexual abuse revealed that between 18-29 per
cent of the adolescents displayed several features of dissociative
personality implying the possibility of multiple personality disorder.
Zierler, Fringold, Laufer, Velentgas, Kantrowitz-Gordon, and Mayer
398 Surinder Jaswal

(1991, cited from Hyman, 2000) reported that women survivors of CSA
were more likely to engage in behaviour that would put them at risk.
There is some evidence that the severity of the long-term effects of
CSA, are modified by features of the abusive act. The specific features
of whether the perpetrator was a family member or whether force was
employed are associated with increased psychological distress (Bagley
and Ramsay, 1986; Briere, 1992 and Briere and Runtz, 1985, cited from
Hyman, 2000). However, there is a dearth of studies on this issue in
developing countries.
Thus, like rape, CSA/child molestation is one of the most
under-reported crimes in the nation, and virtually every study of the
crime problem acknowledges the fact that (as mentioned above) only
1-10 per cent of the incidents are ever disclosed (National Committee
for Prevention of Child Abuse, 1997, cited from Goldstein, 1999).

Need for Study

The above literature shows that CSA is perplexing, disturbing and
difficult to resolve. Yet, its extent and potentially negative impact —
particularly on children and adolescents involved — has only been fully
recognised in the past two decades (Bagley and Ramsay 1986). Severe
abuse has a serious prognosis. The consequences of less severe abuse
and neglect have not been studied so thoroughly but are likely to be
substantial. Adults who have been abused as children probably have
more psychiatric problems and social difficulties t h a n the general
population and also perform poorly as parents (Rutter and Madge,
1976). The fear of stigmatisation of the victims and the fact that CSA is
a highly sensitive topic and is not discussed openly are only a few
factors that have contributed to this issue being swept under the carpet
for so long. Apart from these issues, the patriarchal family system and
the strictly enforced gender roles have also acted as barriers to an
in-depth understanding of the issue of CSA. It is a public health
problem that needs to be tackled urgently as it is a major threat to the
health and well-being of children and adolescents throughout the
world.

Abuse and Health Facilities

Often, the abused child is first brought to a doctor with an injury that is
alleged to have been caused accidentally. The first access to care is thus
normally through a health care provider. However, it may be difficult to
identify children who are victims of child abuse, as diagnosing child
abuse requires knowledge of child development, an epidemiology of
trauma, understanding the mechanism of injury in children and also a
differential diagnosis of various forms of injury.
Early sexual abuse within the family has severe long-term
implications for mental health in adulthood, unless appropriate
therapeutic intervention is offered. Combinations of sexual abuse with
 Child and Adolescent Sexual Abuse in Health Facilities 399

physical abuse or neglect commenced early in the child's life, have

particularly adverse outcomes (Bagley and Ramsay, 1986). Bagley and
King (1990), in their study conducted with 750 Canadian males aged
18-27 years, found that the combination of emotional abuse in the
respondent's childhood with multiple events of sexual abuse was a
relatively good predictor of both poor mental health, and later sexual
interest in or sexual contact with children. The study underscores the
need for preventive measures, and the prompt identification and
treatment of victims before they enter the victim-to-abuser cycle.
Hence, health care facilities not only play a significant role in helping
identify cases of CSA, but timely intervention by health care providers
can provide invaluable support to those children and adolescents and
can enable the healing process to begin.
Health facilities and health care providers, thus, perform a crucial
role in identifying cases of child abuse and also treating the victim.
However, till recently identification of cases of CSA within and across
different departments in hospitals and also across various health
facilities has been an unexplored area of research.
In India, there was a growing interest in the area of CSA in the early
1970s when many Western researchers, and mental health and child
welfare professionals began recognising this not only as a social
problem, but one with a larger magnitude. In the recent past, there
have been an increasing number of reports of children who are sexually
abused but no national level survey has been conducted so far. A few
studies have been done with small groups of population (SAKSHI,
1999; Seshadri and others, 1994, cited from Caesar, 1997; Sinha,
1990-1992). But it still proves that research in this field is in a stage of
infancy. As mentioned earlier, most of the studies have been prevalence
studies on a small scale and show a high incidence of sexual abuse in
India. These studies have been largely limited in their scope as their
emphasis was on certain forms of CSA like rape and eve-teasing
(Seshadri and others, 1994, cited from Caesar, 1997) and on incidence
rates. No attempt has been made to study vulnerable populations such
as urban communities, especially in the context of health. This article
reports the findings of a research study on CSA conducted in a
cross-section of public health facilities in 2001-2002.

METHODS
The objectives of the current study were to understand and document
the profile and prevalent patterns of cases of CSA that report to
different kinds of health facilities such as urban health posts, clinics
and out patient departments of a hospital. It also sought to understand
the health-seeking behaviour of CSA victims and study the handling
and management of such cases by health care providers at various
health facilities.
400 Surinder Jaswal

The study was based on an exploratory design as this permitted the

researcher to seek new insights into the problem of CSA in urban
populations. The research used a combination of qualitative methods
such as observation, checklists, interview schedule and focus group
discussions (with some groups) to collect data as this would not only
enable the researchers to understand the magnitude and patterns of
abuse reported at health facilities; but, would also give an insight into
how health care providers deal with this sensitive issue.
Setting
The study focused on the health facilities of one municipal
corporation — with eight urban health centres, four maternity
hospitals, four dispensaries, and one corporation hospital catering to
the population residing in the nearby slums. Over the last two decades,
the Thane-Belapur belt has witnessed a growth in industrial and other
developmental activities. This has attracted labour not only from
Mumbai, but also from the rural areas of Maharashtra and other states
of India. Thus, 40 per cent and more of the total population in Thane are
migrants. Most of them work as rag-pickers, domestic workers and
temporary industrial employees. Due to low wages, they are forced to
reside in the low-income shanty towns (slums) in the city. The working
conditions, along with the absence of basic amenities in slums, have
exacerbated the health situation of these people. Thus, given their
socioeconomic status, they largely access the municipal corporation
(public health) health facilities.

Procedure
The health facilities were briefed about the rationale of the study to
enable referrals of pertinent patients. Initially, at the Corporation
Hospital only the Out-Patient Departments (OPDs) of Paediatric and
Skin were monitored, as these two OPDs were likely to receive children
and adolescents reporting with symptoms of sexual abuse (SA). The
history-taking pattern, the doctor—patient non-verbal/verbal cues and
a case profile of the patients reporting to these two OPDs were
observed. At the end of this phase, two male children with a history of
SA were identified.
The pilot study indicated the need for change in data collection
strategies. Firstly, the health providers themselves were reluctant
and/or did not know how to initiate discussion with the accompanying
person/parents on such a sensitive topic. Secondly, the health providers
had a general tendency to only look out for clear-cut cases of CSA. Both
these lacunae could result in loss of data. Therefore, checklists were
distributed in the concerned OPDs at the health facilities for strategic
screening of cases of 'neglected children', 'abandoned babies', and
'battered children' — terms that the health providers were comfortable
with. These cases were then referred by the providers to the research
 Child and Adolescent Sexual Abuse in Health Facilities 401

team to identify and fill basic important information about the 'likely'
SA cases. To get a range of cases, the other OPDs likely to receive 'cases'
of CSA such as the Surgical OPD and Orthopaedic OPD were also
included in the study. Screening of such 'potential' cases proved fruitful
as some of them reported incidents of SA. The Gynaecology OPD was
also targeted so as to assess cases of minor pregnant girls.
This approach enhanced the process of identifying both clear-cut as
well as 'hidden' cases of CSA. A total of four male children and
adolescents in the age group 6-16 years and 16 female children and
adolescents in the age group of 13 months to 15 years were identified as
having been sexually abused/reporting with SA during the period of the
study. All children and adolescents between the ages 1-16 years
reporting to the health facilities over a period of three months were
included in the study.
During the interviews with the parents and the children who were
sexually abused, there was a realisation of reluctance on the part of the
parents not only to impart information, but also to come for medical
follow-ups. Therefore, to get further insights on the issues shrouding
CSA, one focus group discussion each, with male and female children
staying on the streets was conducted; since some of the referrals to the
health facilities were from a local street children's organisation.
Besides, this was an easily identifiable group and one that was also
most vulnerable to abusive situations in urban communities.

FINDINGS AND DISCUSSION

Profile of Respondents
A total of 17 female children and adolescents reported symptoms of SA
compared to only six males during the period of the study in the health
facilities. The age breakup shows that female respondents outnumber
the male respondents in all the age groups (Table 1). Maximum
reporting of cases was in the adolescent age group of 13-16 years where
an almost equal number of five male and seven female adolescents
reported SA symptoms. It is interesting to note that while the number
of female children below five years of age was similar to that of the
number of females reporting SA symptoms in the adolescent category,
no male children were identified/reported SA symptoms in the below
five years of age category. Compared to both these age groups,
reporting of SA was less in the 6-12 years age group. Thus, the findings
indicate that reporting of child sexual abuse is age and sex specific.
Children in the 6-12 years age group are in the primary school when
most educational programmes on growing up or 'sex education' do not
target this age group as they are perceived to be too young to
understand such issues by both parents and educators, alike. Lack of
information, coupled with traditional notions that they are 'too young
to understand issues related to sexuality and abuse' put this age group
402 Surinder Jaswal

at additional risk. Further, lower reporting in males does not

necessarily indicate lower rates of abuse as lack of 'correct information
and notions of masculinity hinder reporting of abuse in male children'
(Jaswal, 2003).

Table 2 shows that an almost equal number of male (3) and female
(4) street children reported symptoms of SA. Significantly, there was no
reporting of CSA below five years in the street children. The findings
from the focus group discussions reveal that most of these children had
left their home or were forced by various circumstances like death of
parents, alcoholic father or physical abuse by parents to leave their
homes. Life on the streets and lack of economic, social and information
support increase this groups' vulnerability to abuse on the streets.

TABLE 2: Type of Residence by Gender of Respondents

Symptoms of Sexual Abuse

The study findings revealed that two types of indicators — physical,
and emotional and behavioural — were indicative of symptoms of SA in
children and adolescents reporting to health facilities.

Physical Indicators of Sexual Abuse

It was observed that the symptoms of SA found in children and
adolescents reporting to Casualty and OPD varied from mild redness,
soreness (erythema) of the vaginal or anal area or penis to severe
maggot infection of the genitals. Table 3 below gives details of the
presenting symptoms at first visit in OPD and Casualty Department of
the health facility. The severity of the symptoms is also presented to
highlight and assess the stage at which symptoms were reported at the
 Child and Adolescent Sexual Abuse in Health Facilities 403

health facility as well as the treatment and prognosis of the reported

symptoms.

TABLE 3: Symptoms of Sexual Abuse Reported by Children at the Health

Facility
Entry First Visit Emergency First Severity
Point Symptoms Visit Symptoms
Street OPD Venereal Disease Severe, even
children Research during the OPD
(Males and Laboratory ratio visit.
Females) high, lesions on This is so because
genitals and the street children
severe maggot are reluctant to
infection, multiple approach a health
molluscum lesions facility and wait till
on the genitals, the last moment to
pregnancy report the symptom
to the social worker.
Slum Casualty Constant PR bleed, Severe. Need in-
(common ulceration due to patient care.
male forceful
residents) penetration, large
perennial ulcers
Females Casualty Ulceration of labia Severe. Needed in-
majora and patient care/
perennial region, treatment.
abscess spreading
upto the anal
canal, burns,
abortion of foetus
within 2 months
Males and OPD Vulval itching, Treatable on OPD
Females vulval redness, basis. Not severe
painful micturation,
blood soaked
panties, hymen
tear, vaginal
introids widened,
dead sperms in the
vagina.

These findings concur with the research studies in the West that
suggest the following to be considered as strong indicators that sexual
activity has occurred:
(1) Hymenal disruption, presenting as scars, tears or abrasions.
(2) Injuries of the posterior forchette in girls (area between the
vagina and the anus).
(3) Significant anal relaxation or the presence of large anal scars.
(4) Presence of sexually transmitted diseases and genital warts.
(5) Chronic irritation about the genitals.
404 Surinder Jaswal

(6) Pregnancy.
.(7) Presence of semen in the vagina, rectum, or mouth or on other
parts of the body.
Other physical/medical symptoms that may, to a lesser degree, point
to SA are painful urination and inability to hold fecal matter, generally
because of injury or relaxation of the sphincter muscle due to acts of
sodomy (Goldstein, 1999).

Indicators Relating to the Genitalia

Some respondents reported with bruises, lacerations of the labia
majora, labia minora and hymen. Some children in the pre-puberscent
age reported of missing or damaged hymen.
Vulva intercourse may cause lacerations to the posterior fourchette,
which can result in scarring in this area or in small perihymenal scars.
In pre-pubescent girls damage to the hymen is significant. An
undisturbed hymen could be between 2 mm and 10 mm, although in
very young girls it should be no more than 3-5 mm (Bamford and
Roberts, 1989).
Assuming the exclusion of genital disease, a damaged hymen in
pre-pubescent girls is regarded with concern because, although
self-injury or accidental injury could be the cause, these are unusual.
The hymen is an internal structure and it is, therefore, unlikely that
vigorous activity would cause any hymenal trauma (contrary to popular
belief) although sudden splits could cause mid-line lacerations of
genital structures (Paul, 1977). It is reported that straddle accidents,
such as falling off a bicycle, a large solid toy or an open cupboard door,
could result in injury to anterio or lateral structures rather than the
interior vaginal introits (Enos, Conrath and Byer, 1986; Heger, 1991;
Hobbs and Wynne, 1987). Research by Herman-Giddens and.
Fronthigham (1987) and Pokorny and Kozinetz (1988) found that
accidents involving the genitals did not cause hymenal injury, although
other researchers indicated that falling on a sharp, penetrating object
could do so (Unuigbe and Giwa-Osagie, 1988). Researchers also report
that not all hymenal abnormalities are indicative of sexual abuse;
absence of the hymen can also be congenital. In the current study,
vaginal swab of one of the female respondents whose hymen was absent
indicated the presence of dead sperms in the vagina. Thus, hymenal
abnormalities, in this particular case were contradicted.

Indicators Relating to the Anal Area

Some male adolescents and children reported of PR bleed, bruising and
laceration to the anus. One street boy reported of severe maggot
infection of the anal region and had to be operated upon.
Other researchers also report that while recent anal penetration
results in the swelling of the anal region which may become rounded
 Child and Adolescent Sexual Abuse in Health Facilities 405

and smooth, t h e r e will b e s m a l l t e a r s a n d fissures w i t h occasional

tearing a n d bleeding of t h e a n u s .

Pregnancy
Four p r e g n a n t t e e n a g e r e s p o n d e n t s r e p o r t e d t h a t t h e y w e r e l u r e d i n t o
or forced into s e x u a l activity by a p e r s o n k n o w n to t h e m , u s u a l l y
h u s b a n d (child m a r r i a g e ) , boyfriend, or s t r a n g e r in c a s e of s t r e e t
adolescents. F i n d i n g s from t h e i n t e r v i e w s h i g h l i g h t t h e i r e x p e r i e n c e s .
I was married off at the age of 15 years. For the first three months,
everything went on smoothly. Though I was hoaxed into sex the first
night itself, I did not like it since it pained a lot. The other times it
was O.K. and always initiated by my husband.
16-year-old married teenager
1
I got acquainted to this boy 1 / 2 years back through one of my close
friends. The first time he raped me after which he promised to marry
me. Based on this promise I totally submitted myself to him. Now I
mentally consider him as my husband. This is the second time I have
got pregnant through him. First time my mother and boyfriend
forced me to abort the baby saying that he will definitely marry me.
This is the second time I have-got pregnant. Again they are doing the
same to me. No one is bothered about me. I want to keep the baby."
16-year-old unwed teenager
Usually, strangers force themselves on girls. Later on they learn to
use it as a mode of earning money.
NGO social worker

One o f t h e m a r r i e d p r e g n a n t t e e n a g e r e s p o n d e n t s a t t e m p t e d suicide
after on-going a b u s e , in t h e process losing a four m o n t h old foetus.
My husband's behaviour was not good even in front of my parents.
He used to scold me and point out trifling mistakes in everything
and whatever I did. Still my parents never intervened though all this
was happening at their house. Just a month back after a quarrel
with my husband in the evening I just got irritated, felt helpless and
did not understand what went wrong with me. On the spur of the
moment I rushed to the kitchen, poured kerosene on my body and set
myself aflame. My parents were present in the house at that time.
All of them came to my rescue and rushed me to the hospital. I
sustained 40% burns on my middle torso and limbs and even lost my
four-month-old foetus.
16-year-old married teenager
A review of 45 s t u d i e s ( K e n d a l l - T a c k e t t a n d o t h e r s , 1993, cited from
Cohen a n d o t h e r s , 1996) concluded t h a t n o one s y m p t o m p a t t e r n w a s
specific to sexually a b u s e d p e r s o n s , a l t h o u g h some s y m p t o m s m a y be
specific to c e r t a i n a g e group like suicidality in adolescence. .
406 Surinder Jaswal

Sexually Transmitted Infections

Sexually transmitted infections (STIs) were reported by a majority of
the street children and adolescents and were not reported by children
and adolescents staying with their parents. Street children and
adolescents reported of soreness of or discharge from the vagina,
genital warts and boils, bleeding and ulceration of the anal region.
According to Swart-Kruger and Richter (1996, cited from Pempelani,
2000), the risk of street children towards STIs and pregnancy is higher
than among other children and adolescents. This is because street
children think they are invulnerable, are sexually active earlier, and
have more partners. Street children and adolescents are also known to
be sexually exploited, engage in survival (or transactual) sex and rarely
use condoms.
Findings from Indian studies (Nayyar and Rajashekhar, 1998) also
indicate that practice of safe sex is rarely heard of amongst street
children and adolescents. It is known that younger children subjected
to forced sodomy are particularly vulnerable to STIs.
I play a passive role now and entertain elderly men, usually
strangers, for money. I do this only if I do not earn enough money
'boot-polishing'. My anal region sometimes bleeds and hurts a lot but
I do not tell anyone about it.
12-year-old street boy
Often, the child fails to realise the medical problem or what exactly
has happened to him/her. Their ignorance and feelings of shame do not
let them seek medical help. Lesions and sores in the anal region further
increase the risk of infections.

Emotional and Behavioural Indicators of Sexual Abuse

Parents of sexually abused children and adolescents reported that the
respondents exhibited behavioural problems like withdrawal, isolation
from other family members and difficulty in concentrating at school.
I do not like playing games that children usually play — running,
skipping, ball, etc. I like playing house-house. I play on my own. I
only cook mutton, wash clothes, utensils. I am an adult.
8-year-old female respondent
I noticed that she is sleeping in an awkward manner as if her genital
area is in discomfort. Even her walking was affected and she was
crawling most of the time. Since the last couple of days she was
stubborn to sleep on my stomach and covers herself with a blanket.
She manifested a lack of appetite and spat out the food if forcibly fed.
She used to eat biscuits but now merely throws it away. She has
become quieter than usual. She is also having fever. A visit to the
toilet is very uncomfortable and she only sits down when told to.
After coming out of the toilet she seems to be clutching her genital
area.
 Child and Adolescent Sexual Abuse in Health Facilities 407

Mother of 2-year-old female respondent

Still the parents denied that such a thing could have occurred to
their child and felt that their child must have engaged in some kind of a
quarrel with other children or had general sickness. Parents said t h a t
the child often did not have the language to describe what had
happened and, therefore, they (parents) could not understand what
was wrong with him/her.
I do not leave the baby unsupervised ever. Our bathroom is inside
only and it's a one room kitchen. So I close the main door, while
having a bath. While washing utensils/clothes outside the house, the
baby is kept inside
13-month-old baby girl respondent's mother
Street children and adolescents exhibited behavioural problems like
preoccupation with sex/erect penis even while attending non-formal
education classes, excessive masturbation (4—5 times a day), being
sexually active amongst themselves, child prostitution/gigolos
(becoming), males acting as female partners thus exhibiting female
behaviour. They also exhibited behavioural problems such as low
attention span, hyperactivity, aggressive behaviour/tendency,
suspicious nature/tendency towards strangers.
There are two boys in this group who are always preoccupied with
sex. They are so preoccupied with it that their concentration level is
less. While the teacher takes non-formal education in the morning,
you can make out from their facial expression and body that they are
preoccupied with it. They will have a drowsy look on their face,
sometimes they bleed through the throat and their penis is always
erect. Before coming over here for the classes in the morning they
masturbate 3-4 times. They even enjoy oral and anal sex with each
other. I tried teaching them meditation, sending them to our unit at
Digha, but of no use. They are still the same. No use. There is
another boy who was not there in the group, who likes to take semen
in his mouth and drink it.
NGO social worker
The situation of girls is still worse. Nobody leaves them. There is the
case of one girl, She is just 12 years of age, she has a younger and an
older sister aged 8 years and 16 years respectively. Her behaviour is so
uncontrollable that she will even spoil her younger sister's life. She
works as a child prostitute now and earns a living for herself. Recently,
i.e. just 2-3 days back, we heard that she went for a movie with a
well-dressed man and robbed him of all his money. She usually does
such things. She even drinks a lot. Now there are three girls at Kurla
station who are pregnant. We will take them to Cama Hospital, Kurla.
NGO social worker
His behaviour has totally become girlish. If he does not earn enough
money from polishing shoes, he goes with elderly men and usually does
a girl's act. Now I think even he has started liking it. This is another
408 Surinder Jaswal

mode of making money for him now. I tried to change him a lot but of
no use.
NGO social worker

Special Issues Related to Street Children

Unapproachable Attitude of the Health Providers

The street children reported of waiting till the last moment for seeking
treatment, as can be clearly seen in the excerpts from interviews, given
below.
Only when they are too serious do they seek a social worker's help.
Then they are taken to the Civil Hospital. The mere mention of a
doctor or hospital scares them, they just run away even if they
suspect that we are going to take them to a health facility.
NGO social worker
Not only did the street children report late to a health facility, but
the health providers were also found to be unapproachable and rude to
the street children.
We forcefully rushed one of the street boys with maggot infection of
the anal region to the hospital. In the Surgical OPD all the doctors
just refused to check him, leave alone touch him. Angry with the
doctors, I took the case to the Dean. Then the doctors laid him on the
OPD bed to remove the maggots. Still they were reluctant and were
pushing each other to do the job. So I and the other street kid with
me took the tweezers from the doctor and removed 32 maggots. After
this, he was admitted in the Surgical Ward. They operated on him.
After discharge he has never come back to us. We have no contacts
with him. We face a lot of problems when it comes to approaching a
health facility. If the boy is dirty they just refuse to touch him and
are quite rude.
NGO social worker

Fear of Exposure
Children have considerable anxiety about the response of adults
towards their abused status. They fear for themselves, including being
punished and ostracised. They may worry that they will not be believed
and be branded as telling lies' in case they were totally forced upon by a
stranger or one of the older peer members.
I was forced into sex by one of the peer members. The first time it
pained a lot and my anal region was bleeding for many days.
Somehow I felt it is not a nice thing to be shared with anyone. Even I
was scared that the boy will harm me more. That is why I never told
even the social workers from the office.
12-year-old street boy
 Child and Adolescent Sexual Abuse in Health Facilities 409

Lack of Information
Lack of information about the consequences of SA prevents the street
children and adolescents from seeking medical help. They try delaying
going to the doctor till the situation gets aggravated.
Sometimes, even their anal region bleeds but they are too negligent
about it and think that somehow things will get back to normal, but
it is not so. I will tell you of one boy who was working in a dhaba. A
few days back, before we took him to the hospital, he used to
regularly come to us. He was very untidy, unkempt and never
changed his clothes. He used to also smell a lot. Even the other
street boys in the group used to run away from him because of the
smell. We decided to clean him, give him a nice wash and forcefully
removed his clothes. The moment we opened his pants, we saw stale
blood on his pants. Then one maggot fell on the ground. Without any
emotions, he picked it up, twisted it around his fingers, and killed it.
NGO social worker
According to Rose-Junines (1993) concern with the health of street
youth has been due to: (i) their exposure to the elements of accidents
and risks, while on the street; (ii) the difficulties that they face in
accessing medical services, including their inability to pay for such
services; and (iii) their ignorance and lack of motivation to use existing
medical facilities.

Shame and Guilt

Sexual abuse involves parts of the body that are associated with a
degree of shame and embarrassment. The cultural norms of the society
label any activity related to the private parts as something dirty,
whether it is mastering bladder and sphincter control or masturbating.
Thus, children harbouring a guilty secret feel embarrased to disclose to
their elders about these activities/experiences.
The first time I was forced upon, my anal region was bleeding for
many days. The other boys in the group knew about this and used to
laugh at my plight, especially when I went to answer nature's call/
evacuate my bowels. I was so ashamed at such times that I did not
want to disclose it to anyone.
12-year-old street boy

CONCLUSIONS AND RECOMMENDATIONS

Child and adolescent sexual abuse, thus, transcends all social, ethnic
and economic groups. The study reveals that children who are isolated
from others, especially the street children who are without adult care,
are the most vulnerable. Both male and female street children reported
their first sexual encounter at about the same age indicating clearly
that children of both sexes are equally vulnerable to abuse in the
absence of protection (parental/ guardian or organisational).
410 Surinder Jaswal

The findings further reveal that reporting of CSA is age- and sex-
specific. In case of females, SA was reported by infants, children and
adolescents alike, while in case of males, SA was reported only by boys
in their early or late childhood. This indicates the need for educating
children of all ages as well as both male and female children. Parents
and guardians too need to be informed about both the symptoms of
'likely' SA as well as its risks to children of all ages and sexes. Besides
inclusion of CSA in formal education curriculum of schools, there is also
an urgent need to address the beliefs and perceptions of guardians and
parents about CSA such as 'only strangers abuse' or 'only girl children
are at risk' or 'very young children cannot be exposed to such sensitive
issues' to provide a safer environment for children and adolescents.
Children find it difficult to break the silence as enforced secrecy and
a child's fear of destroying the privacy and security of the family are
powerful obstacles to disclosure of SA. Thus follow-up of even identified
cases of CSA in the health facilities was very low. The attitude of health
providers added to the discomfort and feelings of shame and guilt felt
by the child and his/her family. Orientation and training of all health
providers at primary (health post), secondary (community clinics) and
tertiary levels (hospitals) to identify, handle and manage CSA at all
levels is thus of utmost importance.
A special group in India is the adolescent — firstly, the married
adolescent who is at the bottom of the hierarchy in the family and has
no access to information; but is expected to shoulder reproductive and
other responsibilities in the family. The low-income urban married
adolescents — both male and female — are particularly vulnerable as
most belong to migrant families which have poor access to economic
and social supports. In the case of the second group — unmarried,
minor expectant mothers — however, due to the stigma and taboo
associated with pregnancy outside marriage both the victim and the
parents were cooperative and could be regularly followed up in the
respective OPD till they were admitted in the pre-natal ward for
abortion.
Thus, in both cases — for married and unmarried adolescents — the
health facilities are the most accessible space. Training of health
providers and provision of facilities such as protocols for identifying
and managing CSA in public health facilities should be a priority in
public health. There is also an urgent need to include modules on life
skill education in primary and secondary schools as well as in outreach
programmes of health posts and Preventive and Social Medicine
department programmes, to reach out of school and street children and
adolescents. Significantly, all minor pregnant girls and street children
reporting CSA had never been to school.
The children who sustained injuries, particularly in their genital
region or developed ailing conditions such as painful mitcuration, boils
and erythema in and of the genital region after the occurrence of SA
 Child and Adolescent Sexual Abuse in Health Facilities 411

were brought immediately to the health facility. Unfortunately, the

parents or the grandparents accompanying the child had no inkling
about the root cause of the medical symptoms of the child. This
ignorance, coupled with the patterns of medical evaluation by the
health providers, created' severe disturbance in the adults
accompanying the child, and their first reaction was denial. Breaking
the 'culture of silence' surrounding SA in both communities and health
facilities through IEC and inclusion in formal training curriculi of
professionals is, thus, important in addressing the issue at the primary
and tertiary levels.

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THE INDIAN JOURNAL OF SOCIAL WORK, Volume 66, Issue 4, October 2005