Child Sexual Abuse and the Role of Health Promotion in India: An Analysis of a Case Study

Sharma, Bhattacharya, and Singh: Child Sexual Abuse and the Role of Health Promotion in India: An Analysis of a Case Study

Authors

INTRODUCTION

‘Child abuse’ or ‘Child maltreatment’ is defined as “physical, sexual or psychological maltreatment or neglect of a child or children, especially by a parent or other caregiver. It may include any act or failure to act by a parent or other caregiver that results in actual or potential harm to a child and can occur in a child’s home or in the organizations, schools or communities the child interacts with.”

Child abuse and neglect, i.e. maltreatment usually common to under 18 children globally. It varies from physical, mental and social ill-treatment which harms the child. It has short-term and lifelong consequences which can ultimately slow down the countries social and economic development indirectly.1

In this case study we described our experiences of a child who experienced sexual abuse by a bus conductor of a school, which was completely preventable. Our case also highlighted the lacunae from different sector, which aggravated the situation.

Burden of child sexual abuse

Sexual abuse is a worldwide problem. Children are the soft targets and often they are not even realised about their condition. Due to social and cultural pressure, often we ignore this issue and conceal it. Child protection laws are not stringent enough. Parents are not confident enough to tackle this issue due to various reasons.

Data suggests that 1/4th of all adults had been sexually abused during their childhood. It is estimated that 1 in every 5th women and 1 in 13th men reported being sexually abused during their childhood globally. In India, more than 53% of children have probably been sexually abused.1

Though various national surveys regarding child abuse have been conducted in low and middle-income countries still, data from most countries are still unavailable due to the complexity of this issue.2

Description of the case

The researcher met the mother of 6-year-old girl child sexual abuse in a clinic. The mother of the girl child narrated the whole episode of her turmoil as under - The family of the girl child is quite affluent. Her bringing up was in a strict environment as most of the Indian girl children are raised. A girl named “X” is studying in a convent school. Her parents had enrolled her to commute by school bus. She goes to school in the morning at 7 .30 am and is back home at 1 pm. The bus picks and drops girl at home. In the evening, she plays with children in the park under the supervision of her mother. Her mother told a researcher that usually in the evening she goes for a walk along with her two women neighbours and ‘X’ plays with the sons of her neighbours. The age of one of the boy is 5 years old (‘Y’) and other is 7-year-old (‘Z’).

One day ‘X’ took the ‘Z’ behind the swings and said-“‘Let’s play a secret game but only two people can play, we will not play with ‘Y’.” But ‘Z’ did not listen to her and said that he was more interested in swings. Then she approached the ‘Y’ who was younger to her ‘Y’ you come with me otherwise I will not talk to you ever. ‘Y’ listened to her threatening voice and went with her. She and ‘Y’ went behind bushes for hiding. She told the boy “I will teach you a new game, which is known as love-love but for that, you have to take off your pants”. ‘Y’ ran to his mother and told her “mom she doing my puppy shame.” This comment alerted the boy’s mother and she talked to the mother of “X”. The mother of “X” started thrashing ‘X’ and said, ‘girls should not play with boys’, “she plays with boys and must have seen something on TV.” “She plays with your sons, boys are boys, after all”. She blamed the mothers of the boys for unusual behaviour of her daughter.

It was hard for the other women to convince her that girl child was displaying unusual sexual behavior. This was not due to the exposure of sexually explicit videos. She did not consider the possibility of abuse.

But on being requested, she agreed to interrogate the child with love and affection gently. It was a shock for the mother of “X” when the girl child told her that the bus driver and conductor misbehaved with her when she commuted in a school bus.

The home of the girl child was the last stoppage of the bus. She told that the driver stopped the bus in a secluded place and conductor used to take her behind the bushes and sexually abused the child.

Mother also told that ‘X’ used to complain of constipation and pain in urination and for last two months. She told that she thought that she does not take required quantity of water hence there must be burning micturation and complaint of constipation.

She told researcher that she could not think in her wild of wildest dreams that something like this could happen to her daughter as keeps strict supervision and she is overprotected.

She told researcher for last two months school bus comes late as there was annual function rehearsal going in the school.

Next morning, parents of the girl child and her relatives went to meet the school authorities to report the matter. School Principal told these bus services are outsourced. They assured that in future one school staff member would accompany students every day in the bus.

DISCUSSION

Child abuse is a complicated subject. It is a social issue and multiple stakeholders are involved in it.3 The estimates from different countries are varied due to following factors:4

  1. The definitions vary from country to country regarding child abuse;

  2. The ethnicity of the child has been studied;

  3. Extent of reporting and quality of data;

Child abuse is closely linked with homicide. It is estimated that 41000 homicidal deaths have occurred in under 15 children globally. Still, these data actually underestimate the true extent of the problem (child abuse), as a large percentage of mortality due to child abuse are wrongly ascribed to injuries and other causes.5

In warfare and refugee settings, girls are particularly very much prone to sexual exploitation by armed forces, aid workers and others.6

Inappropriate sexual behaviour with a child is known as sexual abuse or maltreatment. It varied from touching a child’s genitals, forcing the child to rub the adult’s genitals, to intercourse ultimately ended sexual exploitation. If a person commits these acts, it is considered a crime and dealt in criminal courts.7 Sexual exploitation invokes the images of ‘stranger danger’. Unfortunately, most of cases children are sexually exploited by their known person/relatives.8

Child sexual abuse victims need to be supported in their recovery and healing process through child-specific, compassionate and appropriate care and treatment. There are various approaches for addressing the addressing the care of the victim. UNICEF has recommended three key components of care for child survivors of sexual abuse, i.e.9

  1. Child-centric case management care

  2. Specialized clinical and treatment care

  3. Psychological counselling care

In Indian families’ parents are very protective for their daughters from the day one they are born. Parents keep their daughters under close supervision throughout the day. If any sexual, incident occurs; parents do not report issues of abuse to authorities. Even they avoid taking the child to doctor for preventive health care services are never considered. It is the tendency of every Indian to hide incidences of child sexual abuse cases especially girl child.10-11 This paper highlights the role of health promotion approach in dealing with the issue of a girl child sexual abuse while commuting by school bus and through a case study.

Analysis of the case study

Stages of Sexual abuse: To understand the case study progressive nature of the sexual abuse has been applied:

1. Sting phase: That crook (bus conductor) started the interaction with the child by offering particular attention or affection. The offender (bus conductor) used the opportunity to build the relationship with the child during the bus journey.12

2. Sexual dealing stage: As soon as the child responded positively to the distinct attention, some form of sexual activity began by the bus conductor in connivance with the driver.

Gradually, it progressed toward more obvious sexual behaviours, often fondling with the genitals of a child.12

3. Secrecy stage: To maintain the secrecy:

  • Threatening the child that no-one will believe if she told someone;

  • Threatening the child that he (bus conductor) will not play with her, a girl child was said that he is making her learn a new game called “pyar pyar” (lovemaking).12

4. Disclosure: It occurred when the secret was discovered and later told by girl child.12

5. Suppression: The family member (mother) punished the child and tries to dismiss the allegations. Later she reacted by expressing concern and responded protectively. But it was tough for her to maintain this attitude throughout. She was undergoing periods of uncertainty where she did not know what is right and what is wrong and this uncertainty had both cognitive and emotional aspects.12 “How could happen this to my daughter, I will not leave her alone for even 1 minute, I will change school. She will not play now onwards ,she has played enough.”

6. Reactions to the disclosure: Offenders (Bus driver and conductor) reacted with alarm and almost denied the allegation.12

After listening to the complaint of parents, the school authorities ordered one school faculty to accompany the students, the driver and conductor asked the school representative “What is the issue, is there any complaint?”

Indicators of sexual abuse13-14

Medical signs:

-Itching in urethral, vaginal and rectal areas

-Constipation

-Burning Micturition

Behavioural indicators:

-Noticeable personality changes

-Sudden fears, phobias

-Drawings of an explicit nature

-Age inappropriate sexual play

No medical examination of the girl child and other children who were used to board the bus was conducted and not even considered by parents or school authorities. Medical examination of the child was necessary as there were clear indicators of child abuse. School authorities were more concerned about the reputation of their school and parents were interested in hiding the incidence, as they were more concerned about family reputation.

Safety of child

The safety of the child is a prime concern which requires regular assessment and evaluation

The driver and bus conductor can harm the child as they fear for action against them. The same day when the parents went to meet school authorities and they ordered a school faculty to accompany the school students the girl child told her mom “Mom when conductor uncle saw that school faculty is sitting in the bus then he patted lightly on my head.” The mother was unable to afford protection and mental backing for her child as she cannot believe that something horrible like this was happening to her daughter. As there was not much corroborating physical sign to support the child’s disclosure, the mother was left alone to defend the child in front of school authorities and front of her husband/in-laws. The validity of the child’s claim becomes the arena for a power struggle between the abuser’s denial and the child’s version due to lack of substantial evidence.

Role of Health Promotion
Level 1

Policy and Law:

In India the ‘Protection of Children against Sexual Offences Bill, 2011’ came into force to protect child abuse.8 Under this act variety of offences by the accused can be punished. The Act makes abetment of child sexual abuse an offence. Under this Act. There are various procedural reforms has been made, to make the trial considerably easier for children in India. Though like other Acts it was also criticised regarding age limit. Now the age limit is 18. It has helped a lot to curb the situation.15

Values:

The cultural and social norms in India, sexuality is not discussed openly. Parents are quite hesitant to discuss with their children about sexuality as well as physical and emotional changes which take place during childhood or adolescence. Child sexual abuse is still a taboo in India. For this reason, it is under-reported. The situation is so pathetic that a girl is unable to tell her mother about the sexual exploitation by her uncle or neighbour. Most of the time children do not even realise that they are sexually exploited. There is a need to change the existing social and deep-rooted cultural values. Now a day’s sexual abuse should not be considered a stigma for the victim.16-17

Escort:

Family profile of the driver, the conductor, should be considered. There should be complete scrutiny of the record before recruiting for the job. Monitoring of the bus services should be ensured. School faculty should commute with students. For example, as per state government policy in Mumbai woman attendant should be present on the bus along with school children. The timing of the school bus of picking and dropping kids should be monitored. Surprise checks should be done by school authorities.

Education:

Parents need to aware regarding such happening. Children should be pampered enough to discuss their issues openly. School authorities should appoint counsellor and health team personnel for educating and dealing with such incidences.18

Level 2
Secondary prevention meant for the victims of sexual abuse (Special protection)-

Prevention of HIV: The survivor should be referred to receive HIV post-exposure prophylaxis within 72 hours. Thus, the risk of HIV can be reduced.19

Medical treatment of acute health problems: Depending on the severity and nature of the injury (i.e., wounds or internal genital organ injuries), emergency medical treatment should be started.19

Prevention of pregnancy: The risk for unwanted pregnancy can be reduced by providing emergency contraception.19

Evidence collection: It is better to collect the evidence for legal purposes and medical examination should be arranged and recorded as soon as possible (within 48 hrs).19

Level 3

Treating symptoms: Treatment of symptoms (perineal injury, fistula, etc.) are out most important. Vaccination of Hepatitis-B should be given. Treatment for any infection is also considered necessary. Anti-anxiety and anti-depressants are required in case of mental trauma.

Lastly medical termination of pregnancy can be done up to 22 weeks.19

Level 4

Mental health services: This plays paramount in rehabilitation as children goes through the phases of mental shock. After addressing the child’s immediate health and safety needs psychosocial assessment should be advised. Psychological rehabilitation of victims needs to be ensured through counselling and parental care. Care should be provided by supporting and non-offending parent/caregiver. Skills for managing anxiety and stress for the victims need to be stressed upon by counsellor and parents need to be taught regarding these skills.19

CONCLUSION AND RECOMMENDATIONS

  • Sexual abuse to children is worldwide prevalent and indeed it is a very complex issue.

  • Underreporting is also a problem due to cultural and social barriers.

  • The outcomes of this issue can sluggish a country’s economic and social development, indirectly.

  • However, since implementation of laws depends much on the social attitudes, legislation, in itself, cannot bring about social change.

  • Preventing of sexual abuse to the children requires a long-term multisectoral (parenting, schooling, judiciary) approach and most importantly we need to change our mindset.20-23

ACKNOWLEDGEMENT

We do acknowledge all participants for their kind inputs.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

ABBREVIATIONS

UNICEF

United Nations Children’s Fund

PC-PNDT Act 1994

The Pre-Conception and Pre-Natal Diagnostic Techniques (Prohibition Of Sex Selection) Act 1994.

SUMMARY

Child abuse usually common to under eighteen children globally. It varies from physical, mental and social ill-treatment which harms the child. It has short-term and lifelong consequences. This case study describes how a school girl was sexually exploited in north India.

We conclude that- 1) Sexual abuse of children is prevalent worldwide. 2) This issue is very complex. 3) Under-reporting is also a problem. 4) Implementation of laws in itself, cannot bring about social change since it depends much on the social attitudes. We also recommend that-Preventing sexual abuse of children requires a long-term multi sectoral (parenting, schooling, judiciary) approach. Most importantly we need to change our mindset

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