A Qualitative Assessment of their Health Needs and Available Services

The national reports describe a range of serious physical, social and psychological consequences for children of sexual abuse and sexual exploitation. Key elements of the reports’ findings are summarized below.

1. Consequences of sexual abuse

The basic premise that children have a fundamental right to their personal integrity and to freedom from exploitation and abuse follows not only from international and national laws in the countries of South Asia, but also from the certainty that violation of these rights damages the children concerned. The most distressing consequences include physical and developmental problems and profound psychological and emotional disturbances.

2. Physical problems

Physical problems encountered by victims of child sexual abuse and exploitation can be categorized into two forms. The first form consists of those ailments directly linked to the abuse. The second consists of problems indirectly linked to the abuse of resulting from the victim’s poor socio-economic situation.

a. Physical problems include bruises and bite marks on breasts and buttocks, unwanted preganncies and lesions or infections in the vagina or anus. Victims also report frequent back problems. Illegal abortions are a common problem, particularly those performed by unqualified health practicioners resulting in vaginal bleeding and even infertility. Often, there is vaginal discharge indicating infection. Various skin infections, such as scabies, were also found among the victims.
b. Most victims of sexual exploitation and abuse seemed to have frequent fits of coughing, colds, fevers and nasal tract infections. Some suffered from tuberculosis. Other complaints included intestinal problems, worms and lice. Frequent headaches were also common, though these may be attributable to other problems such as malnutrition and stress.

3. Sexually Transmitted Diseases (STD)

All national studies make reference to the presence of STDs among victims of sexual abuse and exploitation. The level of information, however, varies greatly from study to study. In Pakistan, for example, none of the children in the study were tested for STDs, even though almost none of the children even used confoms to protect themelves. However, when the victims were asked whether they had experience vaginal discharge, ulcers, pain during the intercourse or pain in their lower back, almost one third of those interviewed in Kaarachi said they had expeienced some of these symptoms.

The Indian study refers to the presence of STDs, including HIV/AIDS, but provides no statistical information. The Nepal study states that girls in a CWIN home all had at least one STD. Most of them had suffered from STDs such as syphilis, gonorrhea, venereal warts, and infections of the urinary tract at least once in their lives. HIV infection and AIDS were also found among the victims of sexual exploitation in Nepal. Health care workers have reported that around four per cent of the high-risk sex workers in Nepal suffer from HIV/AIDS.

According to an integrated community and industrial development initiative study conducted under the ESCAP project, a survey of commercially sexually exploited street children in Bangladesh found that 69 per cent had STDs, with 54 per cent suffering from syphilis and 17 per cent from skin diseases. There was also a prevalence of abdominal pain, vaginal discharge and infections of the sex organs. The Sri Lankan report refers to HIV/AIDS cases as well, though it does not provide any indication of the scope of this or other STDs.

The information in the national studies points to the need for greater awareness of the dangers of STDs, and HIV/AIDS in particular, including how people can best protect themelves. In addition, condoms should be freely distributed as widely as possible in order to remind people of their importance and encourage their use.

4. Psychological and emotional impact

Child sexual abuse and exploitation, whatever their forms have a profound impact on the lives of victims – both as children and as adults later on. AS the Bangladesh study points out, “any abused child is a traumatized child and that is an inescapable fact.” The psychological consequences of sexual abuse of children can be even more dangerous than the physical effects. The children in the studies were often found to be suffering from psychological problems, reflected in falling grades, staring into space and difficulty in communicating. They also showed other behavioural problems such as temper tantrums, aggression, anxiety, guilty feelings and depression.

For the most part, the psychologocal and emotional effects of sexual abuse and sexual exploitation are similar, with the noted exception of children who are abused by a aprent or close relative. In these cases there is the additional trauma of having been abused by someone the child trusted. Pained by the sense of betrayal, these children often have difficulty building trusting relationships later in their lives.

Child sexual abuse and exploitation involve violations of the victim’s body privacy, honor and rights to independence and autonomy. Such violations have immediate and long-lasting effects. The issues are repressed anger and hostility and the failure to accomplish normal developmental tasks are al particularly significant. Unless the victims receive appropriate help and support, their prospects for avoiding the destructive consequences of abuse and exploitation are poor.

The treatment and reintegration of victims is a highly technical and demanding task. Many experts believe that the profound psychological impact of sexual abuse on the children may render them more likely to abuse other children in the future. Treatment is also, therefore, a means of prevention, reducing the risk of victims becoming perpetrators.

In order for victims to recover and be reintegrated into their families and society, they need professional counseling. Such counseling may need to be supported by medical treatment to bring the children back to health. There is also a strong need for respect and acceptance (as opposed to stigmatization) within their communities. In the case of victims of sexual abuse, there is also the need to be believes. All victims need to be provided with viable alternative job opportunities through education and vocational training. Finally, all the victims need unconditional love and acceptance, particularly as they are often judged to be responsible for their own abuse and as a result feel dirty, low and rejected.

B. Health and Social Services

The level of services available in the subregion varies greatly from country to country. Most national health services are aimed at addressing the physical problems of the victims and at preventing the spread of infections and STDs. In all the countries in the stude there is recognition of the need to develop a greater capacity to deal with the recovery and reintegration of victims of sexual abuse and exploitation and to build on existing services. These good intentions, however, are hampered by limited resources. Perhaps the most important development in this area is the recognition of the problem and the needs that flow from it.

The services provided by NGOs and other members of the public also vary greatly from country to country. There appears to be a stronger presence of NGOs dealing with the recovery and reintegration of victims in Bangladesh, India and Nepal, whereas organizations addressing these issues appear to be fewer in Pakistan and Sri Lanka. In Nepal for example, the majority of NGOs and reintegration centers had both counseling and treatment facilities for sexually exploited and abused children. In Sri Lanka only seven organizations nationwide were identified in the report that provided such care services.

1. Physical problems

In all the countries in the study, the national health services, NGOs and private practitioners cater to the physical needs of children who have been sexually abused or exploited. The main issues revolving around these services are their quality and scope, and the need for the provision of services at low cost since the victims are rarely in a position to seek expensive treatment. Many victims of sexual abuse and exploitation seek the help of unqualified practitioners because of the prohibitive cost of professional services.

Another issue is the tendency for victims not to seek medical assistance until the symptoms of their problem are acute. This is linked to the fear that their abuse or exloitation will become known as well as their fear of the law due to the illegal nature of sex work. There is a need to find the means to enable the victims to feel more comfortable in seeking medical assistance and to ensure them of the confidentiality of such treatment.

2. Psychological and emotional impact

Perhaps the area needing the greatest development is the provision of services addressing the psychological and emotional needs of child victims of sexual abuse and exploitation. Though some excellent services are available in all countries in the subregion, it may be concluded from the study that the availability, cost and quality of these services could be significantly improved.

In Sri Lanka, for example, few NGOs provide institutional or residential rehabilitative care for victims of sexual exploitation. Those that do provide such services generally do not have sufficiently qualified counselors or adequate infrastructure. These institutions are also unable due to limited finances and expertise, to provide the vocational training necessary to provide alternatives to the sex trade. It is important that the Sri Lankan Government focus on this aspect of reintegration as the Department of Probation and Childcare Services has generally tended to concentrate more on "probation," rather than on "childcare services."

In Nepal, on the other hand, the majority of NGOs and reintegration centers observed had their own health clinics in which health assistants and nurses provided general services to the children. Most NGOs and reintegration centers provided food, clothing and shelter to the children who stayed there. They also provided recreation, such as indoor games, music and dancing. Some of the children who had music and dance training in the centers were able to find employment in hotels and restaurants and could earn money to support themselves and their families.

Some of the children received psychological treatment aimed at reintegrating them into their families and society, we well as giving them confidence about their social and economic needs. That being said, institutions providing such services are still too few and too ill equipped to meet the needs of a growing number of victims.

In India, services are available to meet some of the needs of the victims, but there are gaps in these services. They are generally of a curative nature and may succeed in meeting the victim's medical needs. They provide counseling, education and vocational guidance. In some of the organizations doing commendable work, however, the quality of the services depends largely on the skills of individual workers. The services provided would suffer if these key workers left the organization.

In Pakistan, there are a few organizations providing recovery and reintegration services to victims of sexual abuse and exploitation, though various human rights groups and NGOs provide shelter and legal advice. There is a great need to build the capacity to provide health and psychosocial services that address the growing needs of the victims, at least in the major cities.

The Bangladesh report highlights the lack of awareness of sexual abuse, particularly among public service providers. It goes on to express the need for training and building human resources to help address the issues of sexual abuse and exploitation. It also notes the marked differences in attitudes between the public service providers and NGOs, with the latter appearing to have a greater awareness of the issues and a greater commitment to addressing them.

There is a clear need across the subregion to strengthen the services provided to child victims of sexual abuse and exploitation. The capacity of public agencies and NGOs must be improved so that they will be able to provide children with food, shelter, education and health care. Counseling and assistance with reintegration into their families and society should also be emphasized and supported. Finally, service providers should be able to offer career counseling and vocational training so that sexually abused and exploited children will be able to earn a livelihood outside the sex trade.