I.

INTRODUCTION

Purpose

Within the past 30 years, it has become recognized that there are children

who are harmed by the very people who are expected to protect them. During

this time period there has been a great increase in interest and research in the

problem in developed countries, particularly those of North America and Europe.

On the other hand, in the developing countries much less attention has been

given. There are quite understandable reasons for this discrepancy, to be

discussed later. Nevertheless, child abuse and neglect in their various forms are

now known to be of global importance, affecting the health of a very large number

of children in developing as well as developed countries.

This paper is written for those involved in planning for and assuring child

health in developing countries, reviewing what is known about child abuse and

neglect in those areas, which include most of the world's children. It is hoped

that this information will help those people assess the scope and magnitude of

the problem in their own countries, and to consider new ways of further enhancing

the health of their children.

Background

Few authors have reviewed child abuse and neglect as they occur outside

the developed countries. Gelles and Cornell (1983) included Third-World nations

in their review of family violence including child abuse, although at that time

they were able to find only 10 relevant publications including 2 from India and

6 from Africa. They found that the definitions of abuse and neglect used by
researchers in the Third-World were generally broader than those used elsewhere,

and that there was a higher level of concern over the role of social structures

and institutions in abuse.

Korbin's (1981a) book has provided the most comprehensive look at the topic,

examining eight developing countries. With data collected largely from an an-

thropological viewpoint, the authors consider overall cultural attitudes toward

children, accepted practices which are actually or potentially harmful to children,

occurrence of harmful practices which are not culturally sanctioned. Consistent

with the anthropological perspective, the emphasis is on traditional cultures and

the meaning of abuse within them, rather on worldwide epidemiology.

Methods

A literature search was conducted for all articles and books dealing with

the subjects of child abuse and neglect in developing countries, and indexed in

Index Medicus, Sociological Abstracts, or Psychological Abstracts. Articles in

English, Spanish, or French were accepted. Selected literature on the subjects

of infanticide and abuse against females was also reviewed.

II. ANALYSIS OF LITERATURE

Countries

Tables 1 and 2 show the distribution of the articles by country and region.

Over 25 individual countries are represented, located in all regions of the

developing world.
Table 1. Articles on Abuse and Neglect by Country

Country Number of
Articles
Africa, general 2
Asia, general 2
Bangladesh/Pakistan 1
Bolivia 1
Brazil 1
Chile 1
China 2
Costa Rica 1
East Africa/Kenya 3
Hong Kong 3
India 18
Indonesia 1
Jordan 1
Latin America, general 2
Malaysia 3
Mexico 11
Morocco 1
New Guinea 2
New Zealand 1
Nigeria 7
Peru 1
Philippines 1
Polynesia 1
Singapore 1
South Africa 2
Sri Lanka 1
Taiwan 1
Tunisia 3
Turkey 2
West Indies 1

Table 2. Articles on Abuse and Neglect by Region

Region Number of
Articles
Africa 14
North Africa/Middle East 7
Asia 32
Latin America 18
Oceania 4
International or general 13
Types of article

The articles can be categorized in various ways. Table 3 shows their

distribution according to categories similar to those used by Gelles and Cornell

(1983). When examining these papers it is important to consider what type of

information is being presented and how it has been obtained, and readers are

encouraged to attempt to critically analyze studies which they will encounter in

the future.

Table 3. Articles on Abuse and Neglect by Category

Category Number of

Articles
Position Paper 26
Case Report 16
Surveys/Series 11
Case-Control and Other Epidemiological 6
Studies
Reviews 11
Anthropological Studies 13
Other 3

Position papers

This was the most common type of paper found. The primary focus of such

a paper is the qualitative analysis of one or more aspects of child abuse and

neglect based on general knowledge, the authors' experience and observations,

and previous related research. Opinions are presented regarding the dynamics,

definitions, treatment, and prevention of abuse, but are not closely based on

formal experimental or observational data.

Case reports

Case reports are papers which present one or a few cases of abused or

neglected children, generally as they are diagnosed by a physician. Most of these

papers use the cases as a didactic method to introduce readers to the diagnosis

and treatment of abuse and neglect. Often they are the first papers on the

subject to be published in a given country, and should serve to raise the readers'

level of consciousness toward the existence of the problem. On the other hand,

since they represent only selected instances of abuse, and only a small number,

they cannot be used to make any inferences about the extent or types of abuse

in a given country.

Surveys/Series

Surveys and series are similar to case reports but include a larger number

of cases. Usually the cases are found by retrospectively reviewing records at

one or more medical centers, orphanages, or other agencies. By their inclusion

of many cases, these studies are able to make some generalizations about the

population which was studied. On the other hand, series cannot estimate the

extent of the problem in the general population, or generalize to different groups

of abused children than the ones studied.

For example, Masrour et 81. (1980) looked at 10 cases of battered children

diagnosed at a medical center in Morocco. They found that of the 7 cases with

radiologic studies, 6 had fractures, and 4 had multiple fractures. Although based

on this study we could expect to find fractures in most Moroccan children admitted

to a medical center and diagnosed with abuse, we do not know anything about

children who may be abused but are not admitted to the medical center. Nor can

we compare the abused children with those who are not abused and thus are

not included in the study.

Case-Control and other Epidemiological Studies

This small group of studies group of studies goes beyond series and case

reports by making some attempt to estimate the frequency of abuse in the general
population, or to find risk factors by comparing abused with non-abused children.

Singh et al. (1962) compared various groups of Punjabi villagers, including infants

and females, with regard to (1) the medical care they received for illness, and

(2) their death rates. The results indicated a relative neglect of those groups.

Christoffel et ai. (1981) used WHO data on international death rates to compare

rates of inflicted and non-inflicted deaths in developing and developed countries.

They found that death rates due to inflicted injuries were comparable across

groups of countries and suggested that there may be a type of family violence

which is relatively independent of culture. Caution is required, however, in using

such international data which is quite variable in reliability. It must also be

remembered that deaths due to abuse are not necessarily reported as such. In

a related study Fiala & LaFree (1988) looked at cross-national data on child

homicide in conjunction with various social and economic indices, and concluded

that it is more common in countries where many women are working but have

low social status and where spending on welfare services is low.

Goodall (1979) used a case-control design to compare children with and

without kwashiorkor. She found that the malnourished children were more likely

be living with someone besides the mother, to have parents who were separated,

and to have been sent away from home at the time of weaning (the usual practice

in some African communities).

An informative study from Hong-Kong by Lieh-Mak et al. (1983) compared

characteristics of abused children with those of matched controls who were

pediatric inpatients without trauma. Families of abused children were found to

have a higher prevalence of psychiatric problems, to be more socially isolated,

to report more worries, and to have more marital discord.

 Finally, de Meer (1988) collected data on child mortality in a peasant community

in Peru. The perinatal mortality rate was anomalously high and by its distribution

suggested that infanticide was being practiced especially in families with 2 or

more living children.

It can be seen that even these studies address only indirectly the issues

of child abuse and neglect. Clearly there is a need for further epidemiologic

research before we can begin to estimate the importance of the problem in

quantitative terms, or to compare rates among countries. Meanwhile we are left

with qualitative studies, which though less than ideal do help to give an idea of

the scope of abuse and neglect in certain locations.

Reviews

These papers distill information from previous studies and present it in new

ways or to new audiences. In some cases (e.g. Vicuna, 1981) the sources are

mostly the abuse and neglect literature of the developed countries, with little

that is specific to the developing country. Others, such as de Silva (1981), bring

together existing data in such a way as to provide a coherent picture of the

problem in a given country.

Anthropological studies

The anthropological studies considered here, most of which are found in

Korbin (1981a), are based on intensive observation of participants in a given

culture over a prolonged period of time. These are crucial importance because

of the insights they provide from an insider's point of view. Thus while good

epidemiologic studies could tell us the number of victims of infanticide, they

could never address issues such as the value of the newborn to the mother or

to the village, or the meanings or types of infanticide.

III. OVERVIEW

Despite the variety of approaches and purposes found in the literature,

several important areas of agreement are found. (1) The definition of abuse across

cultures is both important and difficult. (2) There is not enough information at

present to determine the epidemiologic importance of abuse and neglect in any

developing country. (3) Workers in developing countries are concerned with a

wider range of phenomena under the label of "abuse and neglect", some of which

are undoubtedly of greater public health significance in those countries than

are the classic phenomena such as the battered child. (4) Child abuse and neglect

of some kind occurs in most if not all cultures. (5) While the occurrence of CAN

is widespread, the specific forms tend to more specific to a culture. (6) There

are valid reasons for assigning CAN varying priority in different countries.

(7) Certain factors such as urbanization are generally agreed to contribute to

an increase in CAN.

Definitions: what constitutes child abuse and neglect?

One of the most problematic questions in the area of cross cultural child

abuse and neglect is how to define it. In its earliest formulations, such as

"battered child syndrome," it was limited to severe physical injury inflicted by

a parent or caretaker. Over time the definition has become broader, to include

such entities as sexual and emotional abuse. At the same time the definition is

more vague and less concensual. Even within a single society such as North

America there are disagreements over what does or does not constitute abuse or

neglect (Taylor & Newberger, 1983).

Furthermore, while some workers in developing countries use a relatively

narrow definition (e.g. Masrour et a1., 1980; Animashuan, 1977), there has been

a tendency to widen it still further. Bhattacharyya (1983) suggests that

 " .•. child abuse should be defined in a wider sense, as impaired
development of a child for a considerable period or death resulting
from any adverse environmental factor that could otherwise be prevented
to operate on the basis of scientific knowledge and adequate health
services. "

thus implicating all levels of society from parent to government, and including

all sorts of injury. Consistent with this approach, Bhattacharyya cites malnutrition

and associated infections as India's "most alarming" forms of abuse.

Apart from the issue of which levels of actors to include, the main definitional

problem stems from a paradox. On the one hand, any definition of abuse in a

given culture must take into account that culture's values, standards of child

rearing, and adult roles for which the child is being prepared. Thus normative

child rearing practices naturally differ among India, where group orientation and

loyalty are stressed (Poffenberger, 1981), Taiwan and China where the main social

tie is loyalty and obedience to parents (Wu, 1981), and a New Guinea tribe which

values physical endurance and prowess in war (Langness, 1981).

On the other hand, an uncritical acceptance of cultural norms would deny

the existence of any transcendent values such as the child's right to a healthy

life or to life itself. While we need to understand the cultural values and forces

which lead to practices such as child sacrifice, wife burning, and dangerous

child labor, probably none of us would consider them acceptable. Furthermore,

progress in raising the status of women, children, and other groups has often

begun with the efforts of a few directed against cultural norms which they

consider transcendentally wrong.

With this background, we will consider several elements which appear im-

portant in the definition of abuse.

Harm

The most fundamental aspect of child abuse and neglect is that they are

harmful to the child, that is, detrimental in some way to his well-being. While

severe physical injury, severe malnutrition, and death are recognized universally

as harmful, many other circumstances are not. As cultural values (what is good)

vary, so will the concept of harm (what is not good). Likewise even from an

outsiders point of view what may be good for a child in one setting may be

harmful in another. For example, female circumcision and genital mutilation is

practiced in much of Africa. This is unquestionably harmful in terms of immediate

pain, risk of infection, and risk of serious obstetric complications including

maternal and child death (Tevoedjre, 1981). At the same time, a woman who has

not had the procedure performed may not be accepted as a member of her tribe,

and be unmarriageable (LeVine & LeVine, 1981). Thus even educated women may

support the practice as necessary given the cultural context (Lowenstein, 1978;

LeVine & LeVine, 1981).

Intent

Many workers' definitions of abuse include some aspect of intent to cause

harm (e.g. Animashuan, 1977; Masrour 1980; Langness, 1981). One reason for this

is that the there seems to be an important difference between intentional and

unintentional harm, not only from the caretaker's point of view but from the

child's. It has often been observed that what is so destructive about child abuse

and neglect (as opposed to other forms of injury) is that the betrayal of the

child's trust leads to defective socialization (e.g. inability to form close rela-

tionships, defective parenting behavior).

Other workers, perhaps the majority of those in the developing countries,

do not include intent as a criterion of abuse. Thus Johnson (1981) defines abuse
as "any child-rearing technique that results in physical harm or death or

emotionally deprives the child of self-esteem and a sense of competence." However,

if one defines as abusive behaviors or circumstances when there is no intention

of harm, one is saying little else than that they are harmful. Also, without intent

as a criterion one needs to be even more careful to include only clearly harmful

practices, otherwise perhaps nearly all parental behavior could be classed as

abusive from someone's point of view.

Culturally acceptable versus idiosyncratic practices

Korbin (1981a) explores the difference between (1) practices which though

perhaps abusive from an external viewpoint are culturally accepted and (2) those

which are rejected by the culture but occur at the hands of certain caretakers

(who would thus be classed as "deviant"). She points out that it is more clearly

appropriate to consider the deviant behaviors as abusive than those which are

culturally accepted.

Level of control

While early definitions focused in the caretaker's behavior, broader definitions

such as that of Bhattacharyya [above] consider any institution or society as a

whole to be capable of abuse. The problems here are similar to those of intention.

It is certainly true that harm may come to children as a result of parents, school

systems, economic policies, lack of health facilities, international trade problems,

warfare, and a host of other factors. Therefore when considering the welfare of

children from a global standpoint it is essential to consider all these factors.

However to lump all these widely-different problems together under the label of

child abuse and neglect seems to accomplish little beyond calling attention to

them. Clearly the different problems have different bases, different effects on

children, and call for interventions which are not only different in nature but
addressed to distinct levels. Thus there seems to be some value to separating

harm caused by parents and other caretakers of individual children from other

types of harm.

Summary

At one level the question of what constitutes child abuse and neglect is a

semantic question which depends on our purposes. For those working at the

national or international level, broad definitions serve to draw attention to the

ways children suffer because of national and international policies as well as at

lower levels. For others working at a local or regional level, it might be more

important to focus on local customs and idiosyncratic parental practices which

are harmful. It is obvious that deciding to label or not to label a practice as

abusive does not in any way change the practice or the effect it has on the

child.

Lack of data is a general problem

Little is known of the epidemiology of child abuse and neglect in any

developing country, and there are often conflicting claims. The lack of data

should not be surprising since obtaining accurate epidemiologic information is

problematic even in developing countries with great resources to study the issue

(cf. Straus & Gelles, 1986; Stocks 1988). I was unable to find a single study from

which the incidence of any given form of abuse could be semi-accurately estimated

in any developing country.1

There are several reasons for the absence of information. First, in many

countries there is still little interest in or awareness of the problem. De la Torre

1 The exception might be the work done in the area of neglect of females in India,
where a considerable amount of research has been done over a long period of
time. See Miller, 1981.
(1975) attributes this partly to the fundamentally "organic" or biologic focus of

pediatric hospitals in developing countries, with little interest in psychological

and sociological factors. In informal discussions with pediatricians from several

developing countries I have found that none of their training programs dealt

with abuse and neglect.

Even where there is interest, gathering information is difficult. There are

usually problems of communications and travel which impede data collection. In

addition there are generally fewer resources available for large studies. As a

result of these problems, even such gross measures as total mortality rates are

known to be unreliable in many developing countries.

Universality of child abuse and neglect

Though their frequency is difficult to determine and depends on the definition

used, child abuse and neglect can be found in most if not all cultures. In all

cultures there are parents and caretakers who for one reason or another go

beyond their cultures~ recognized child rearing practices in ways which harm

their children. On the other hand, there seems to be a clear concensus, based

on observations in many countries, that this sort of idiosyncratic abuse (e.g. the

classical battered child, or corporal punishment beyond what is accepted in the

culture) is less frequent in most traditional societies than in North America

(Loening, 1981; Poffenberger, 1981; LeVine & LeVine, 1981).

While it may be true that abuse is rare in these situations, there are two

precautions to keep in mind. First is the fact that abuse and neglect always tend

to be hidden (at least the idiosyncratic types do) so that the lack of identified

cases does not imply that no cases exist. For example, Wu (1981) in 1977 could

find no statistics or other records on child abuse in hospitals or other health

agencies in Taiwan, and health workers denied that it could exist in that country.
Cases of abuse were, however, found in newspaper reports. Interestingly the

perpetrating mothers in these cases were generally regarded as being temporarily

insane, a common social explanation for deviant behavior.

Second, even if abuse is rare in traditional societies, many of these societies

are rapidly changing in ways that may make abuse more likely. Urbanization and

the disappearance of the extended family are two of the changes most cited as

contributing to an increase in abuse and neglect. These are discussed below.

Practices more specific to developing countries

Certain types of abuse and neglect seem to be more common in developing

countries than in the developed ones, including child labor and slavery, exploiting

children for begging, and large scale sexual exploitation in certain areas. These

practices are characterized by the fact that, although the caretakers may have

originally exposed the children to these situations, the actual abusers are seldom

the parents. In addition, these practices tend to be more "public" and continuous

than typical forms abuse by parents, and should be subject to control by the

public sector (e.g. by laws regulating child labor). It is significant that similar

types of societal child abuse were prevalent in the Western countries in the past

and were greatly reduced largely through legal reforms.

Abandonment and infanticide may also be more prevalent in certain developing

countries. Both appear to be directed toward freeing the mother (or group) from

a child who is seen as some sort of burden, rather than being punitive. Both

would be expected to be more frequent in communities where poverty is common

and social services are lacking.

Differences in prioritization of problems

In developed countries child abuse and neglect rank high in importance

among problems of children. Many other causes of morbidity and mortality have

been controlled or eliminated, and attention can thus be focused on the minority

of children who are abused. This is not the case in developing countries, where

tremendous numbers of children suffer from malnutrition, infectious diseases,

chronic disabilities, and high rates of accidental injuries. It is not uncommon to

find that over 20% of all children die before the age of five years. For the most

part the problems are well-understood and easily-controlled given adequate

resources. Therefore it is not only understandable but quite appropriate that a

large portion of a country's resources be directed toward these problems.

At the same time, it is clear that in many developing countries neglect and

abuse of children are significant public health problems, and likely to become

greater problems as urbanization continues. Those involved in research and

planning for child health and welfare in those countries should become familiar

with manifestations of abuse and neglect and incorporate prevention and treatment

as much as possible in the fabric of primary health care and social planning.

Contributing problems in developing countries

There appears to be considerable agreement as to some of the factors which

contribute to the occurrence of abuse and neglect in developing countries. Once

again there is little epidemiologic information on which to base these associations.

As already mentioned, the breakup of the extended family and of the support of

closely knit traditional communities has been implicated by many workers. The

process of urbanization has several consequences which are generally believed

to lead to increased abuse and neglect as well to other risks to children. Finally,
 population pressure and poverty are often cited, though their relationship with

abuse is less clear. Each of these factors will be considered separately below,

after a discussion of some important forms of abuse and neglect.

IV. SPECIFIC AREAS OF ABUSE AND NEGLECT

In this section we will look in more depth at some of the forms of child

abuse and neglect which are thought to be important in the developing world.

Undoubtedly their relative importance varies among societies, and no attempt will

be made to generalize in this regard. Planners and other health workers should

be aware of all of these areas in order to be able to consider their importance

in the local context.

/Abandonment

Infants have been abandoned in a wide variety of cultures throughout

history. In some the practice has been condoned or ignored. In Western tradition,

infants both in ancient Greece and Rome could be abandoned as an alternative

to infanticide, as exemplified in the story of Oedipus. Abandonment continues to

be a widespread problem.

A survey of public prosecutions in Turkey showed 3700 prosecutions for

abandonment of newborns over a 6 year period (Gunce & Konanc-Onur, 1983).

The same authors found that a large proportion of children in two institutions

in Ankara had been abandoned. Bhattacharyya (1983) estimated that India has

over one million orphans, many abandoned due to illegitimacy. There have been

increasing reports of abandonment in Mexico and it has been estimated that 25%

of these children die before being found (Retana, 1978). The problem also exists

in east, west, and south Africa (Bwibo, 1972; Loening, 1981; Animashuan, 1977)

and Bwibo says that in East Africa there are "many newborn babies dropped in

pit latrines, dustbins, or left on the wayside."

 Multiple factors lead to abandonment, but fundamentally all have in common

that the child is unwanted. Abandonment and infanticide are both ways of "solving"

the problem of the unwanted child by eliminating her/him from the family.

Animashuan (1977) feels that the response of Nigerian parents to severe stresses

may be to abandon their babies "in the hope of a miracle" while under similar

circumstances parents in "sophisticated societies" may batter their children. It

could also be argued that where abandonment and infanticide are less available

as options, the unwanted child, though remaining physically in the family, becomes

a target for battering and other abuse (cf. Feder, 1978).

Who are the unwanted children? The answer varies among cultures. In many,

the illegitimate child is at great risk. While the extended family and traditional

community may provide considerable protection against abuse for those considered

as members, certain classes of children such as those born outside culturally-

approved marriage bonds are not recognized as valid members of society and

thus are not subject to protection. Furthermore, tremendous pressure may be

placed on the mother to somehow "correct" the problem, leading to the abandonment

of death of a child she might otherwise desire (Gunce & Konanc-Onur, 1983;

Haditono, 1981). Marzouki et a1. (1987) say that the illegitimate child in Tunisia

is, "almost a social non-being ... subject to all sorts of violence without posing

any problem of conscience". They note that even some members of the Tunisian

Human Rights League refused to include the rights of these children in their

charter. Similar observations regarding the illegitimate child's risk of abandonment,

death, and abuse have been made across cultures (Bhattacharyya, 1983; Retana,

1978; Dave et a1., 1982; de Silva, 1981; Lokeshwar et a1., 1979; LeVine & LeVine,

1981).
 Children with physical or mental defects are also frequently unwanted. Even

deformities which may have little or no functional importance, such as an extra

digit or albinism, may lead to abandonment or infanticide. Parents or the community

may act out of superstition, fearing that the deformed child is a manifestation

of an evil power. The community may reject the child simply due to his "dif-

ferentness". In other cases parents may feel they lack the ability and resources

to care for a special child. Especially where life is often a struggle for survival,

the addition of a permanently dependent family member may seem intolerable.

The problem of children with defects may be especially important in developing

countries for at least two reasons. First, many disabilities are relatively frequent

in those areas due to lack of health care. Among them would be deafness (from

prenatal or infant infections), blindness (from trachoma, vitamin A deficiency,

trauma), lameness (from poliomyelitis, trauma, birth defects). In Animashuan's

series in Nigeria, 4 of 24 abandoned children had physical defects, while only 3

of 175 abandoned newborns in India had congenital anomalies (Lokeshwar et al.,

1979). Second, there are far fewer resources for helping such children and their

families. Gunce & Konanc-Onur (1983) state that many of these disabled children

are abandoned due to lack of institutions, and cite the case of a father who kept

his retarded child in a room with windows protected with barbed wire, due to

lack of available institutional care.

Another very important group of unwanted children in some areas are

females. The same series of Lokeshwar and colleagues found that 59% of the

subjects were females. Abuse and neglect of girls is considered separately later.

Twins are also unwanted in some societies (see next section).

 Finally, a child may be unwanted simply because the parent(s) are unable

to care for another child (or even for one). In the urban setting where child

care is lacking and the extended family does not exist, where employment is hard

to find and social services nonexistent, a new child may be unwelcome (d. Retana,

1978).

vI" Infanticide

The practice of killing infants is very similar in many ways to that of

abandonment. Both aim at permanent removal of the unwanted child from the

family. Abandonment of an infant is actually a form of infanticide unless the child

is left where she is sure to be rescued rapidly. In general the risk factors for

abandonment discussed above are also those for infanticide.

The term infanticide often implies killing with some degree of social acceptance,

rather than the idiosyncratic murder of a baby. It has been practiced since

ancient times in all or nearly all societies including the Western ones. Ritual

sacrifice of children was recorded in Biblical times (e.g. 2 Kings 16:3) at least

as early as the second millennium Be and was a capital offense in the Jewish

law (Leviticus 20:1-5). Even in European societies infanticide continued to be

practiced at least through the 19th century, with an estimated 80% of illegitimate

infants in England falling victims (Montag & Montag, 1979). Infanticide has also

been an accepted and widespread practice in the past century in China (Korbin,

1981b), Japan (Wagatsuma, 1981), Africa (LeVine & LeVine, 1981), India (Miller,

1981; Ghosh, 1986). Illegitimacy is still a major reason for infanticide in areas

where illegitimate children are socially rejected (Dave et al., 1982; Haditono, 1981).

In the past infanticide was also used as a means of population control both

at the family and community level (Langness, 1981; Wagatsuma, 1981; Hunton,

1977). Although this reason is now less important due to increased availability
 of contraception and to decreased approval of infanticide, some children are still

killed because of being "excess." In some aboriginal groups the practice is still

accepted or even mandatory (Johnson, 1981; Jenkins, 1988). In the rest of the

world the killing of excess infants is generally not condoned but still occurs in

some situations (e.g. in a rural Peruvian community, [de Meer, 1988], and of

female children in India and China [see below]). The other factors mentioned

above as leading to abandonment, such as defects and economic pressures, are

also important in child homicide and infanticide. Even religious sacrifice of children

still occurs in uncommon instances (Dave et a1., 1982; Bhattacharyya, 1983).

When infanticide is accepted (or quietly ignored) in a culture, there is often

some cultural definition of the victims as not-yet-persons, so not subject to

protection, just as many Western cultures define the fetus as a non-person and

accept abortion. In very adverse conditions where infant and child mortality

rates are extremely high the child might not be fully accepted until the age of

several years (e.g. Langness, 1981). In other cases infanticide is acceptable until

the baby cries (indicating the entry of the spirit) (Wagatsuma, 1981) or nurses

(Johnson, 1981).

VBattering and severe corporal punishment

Different cultures have different standards for how children may be punished

or disciplined. In some corporal punishment is almost nonexistent, at least for

smaller children (e.g. Polynesia). In others children may be severely beaten or

suffer other physical harm in the course of punishment. In part the extent of

punishment depends on the culture's concepts of the child. In the traditional

Turkish culture the child is considered to "a very limited human being who will

grow up at his own pace" (Olson, 1981) and parents do not expect to have complete

control over their children any more than they do over the rest of the natural
environment. When corporal punishment is used it is used "pragmatically" rather

than punitively or to establish the parent as the authority. At the opposite end

of the spectrum is the traditional Chinese view that even very young children

should show devotion and respect to their parents and place their parents'

welfare before their own. The child is expected to obediently endure even the

most severe and unreasonable punishment without complaint (Wu, 1981).

Beating and whipping seem to be the most universal types of corporal

punishments used and accepted. A survey of parents in Tunisia found that 80%

had been beaten at least once in their own childhoods; these parents generally

felt that the punishment had been necessary for their upbringing (Marzouki et

al., 1987). In a survey in Hong Kong over half the respondents had observed

children under 3 years old being beaten and nearly 80% had seen such young

children with marks, bruises, or injuries; 7% had seen children under 3 years

old, and 20% had seen those from 5-10 years old, being hit in the head with an

object (Samuda, 1988). Similar frequencies were found in a survey in Taiwan (Wu,

1981). Four of 30 respondents in that study approved of kicking and beating

5-10 year-olds as punishment, and 3 approved of hitting them in the head. Despite

the close cultural similarity with Taiwan and Hong Kong, physical punishment is

reportedly uncommon in the People's Republic of China, where officially it is

strongly disapproved of in general and strictly prohibited in schools (Korbin,

1981b).

Many other methods of corporal punishment are used around the world, with

varying potential for physical and psychological injury. In some areas of Africa

parents may apply pepper to the child's eyes, anus, or genitals or to cuts

resulting from a beating (LeVine, 1963). In some South American tribes and in

Sri Lanka the child may be whipped with nettles, and in the case of South America
more severe punishments include hallucinogenic drugs and placing the child in

the smoke of a fire, burning hot peppers, until he becomes unconscious (Johnson,

1981; de Silva, 1981). Children in parts of India may be hung by their hands

from a hook on the ceiling as a particularly severe (and terrifying) punishment

(Poffenberger, 1981).

It is difficult to determine where the boundary should be drawn between

acceptable and unacceptable forms of discipline. Clearly the cultural context is

very important. Being caned or whipped in a culture where such punishment is

common and expected carries a different psychological meaning to parents and

child than it does where, for example, spanking is the only approved corporal

punishment. Several authors are careful to point out that even in the cultures

where corporal punishment is relatively frequent and severe, it occurs within

limits rather than out of rage, and i;f does not necessarily reflect a lack of

warmth in the parent-child relationship (Marzouki et 8.1., 1987; LeVine, 1963; Wu,

1981). Parents in many cases believe that the punishments are essential for the

proper socialization of their children and would consider the failure to punish

to be a true form of abuse in the long run (Nathan & Hwang, 1981).

On the other hand, the potential for unintended harm clearly increases with

the severity of the punishment. Social toleration of corporal punishment probably

also increases the risk of serious injury, permanent disability, or death when

the parent does become hostile or loses his control. In the case of the young

child who is beaten, his life depends on the parents "proper technique", so to

speak, since a single blow which is too forceful or in the wrong location can be

fatal. Therefore it seems reasonable for the child advocate to press for the

reduction or elimination of at least the more severe forms of corporal punishment

 in all cultures. Parents may not conceive of any ways of discipline than those

they already use, so the first task may be to introduce alternatives (Nathan &

Hwang, 1981; Arnold, 1982).

J Neglect

Neglect may be thought of as failure to provide whatever care is necessary

for the child's well-being. Furthermore, we need to differentiate situations where

the caretaker is capable of providing the care but fails to do so from those

where she simply does not have the ability or resources to provide proper care.

Thus while it might be neglectful for a middle class mother to leave her infant

at home in the care of a 5 year-old, we would not say the same if the mother

lived alone with her children in an urban slum and had no other resources.

Just as cultures differ as to standards of discipline, so they sometimes

disagree about the standard of care due to children of different ages. American

culture is highly protective and emphasizes personal independence and

achievement, and emotional warmth between parent and child. Neglect in that

context could include failure to provide maximal protection against physical injury,

or to provide a warm and consistent emotional relationship. Among many tribes

in New Guinea personal autonomy is highly valued and warfare and violence are

(or were) nearly continuous, placing the societ.y under pressure to produce

ferociousness, endurance, and independence in its children. Even quite young

children are left to play unsupervised in hazardous situations in the expectation

that this is what is needed for their proper development (Langness, 1981). When

judging the neglectfulness of a behavior we need to consider the cultural "risks"

(that the child's development will be inappropriate for her culture) as well as

physical risks.
 In general neglect has not received much emphasis in the international

literature on child abuse and neglect. Obviously poverty, the breakdown of the

extended family (and even the nuclear family), and the urban situation of many

families around the world make it very difficult for parents to provide for their

children's needs, and hard choices are often made, as in the case of the mother

who leaves her children unsupervised in order to work to provide food for

survival. Given the prevalence of abandonment in some areas, it is logical to

believe that many children are also neglected. LeVine & LeVine (1981) mention

maternal alcoholism as one particular risk factor for disastrous neglect in East

Africa.

Malnutrition is one of the greatest problems of children in developing

countries. In part this is due to simple food shortages, poverty, and maldistribution.

However, there is also evidence that even in areas of poverty much malnutrition

is also associated with parental neglect (e.g. Jinadu, 1980). The neglect may be

as obvious as the failure to feed the child adequate quantities of food, or as

subtle as the withdrawal of the emotional relationship leading to apathy and

depression in the child (Goodall, 1979; Bhattacharyya, 1981, 1983). Therefore it

is important for the health worker to investigate cases of malnutrition for possible

neglect (or unavoidable lack of care) and to include preventive measures in

planning for community health care. For example, adequate day care facilities

and creches can play an important part in avoiding malnutrition (Williams et al.,

1985, p. 229).

In some cases neglect appears to be selective or even intentional. Females,

children with disabilities, and ill children may be given less care than other

children in the same family. Johnson (1981) gives the example of the South

American Indian mother of a sickly infant with chronic diarrhea, who persistently
 ignored its crying and kept pushing it from her breast, and interprets this as
•
an example of "benign neglect" which may be a form of population control. As

noted below, there clearly is selective neglect of girls in parts of India.

On the other hand, we must be extremely careful when we attribute the

mother's failure to provide proper care to her being neglectful, lest we blame

her for circumstances over which she has no control. In extensive fieldwork in

Brazil, Nations & Rebhun (1988) looked at parents in slums who at first might

have appeared to be fatalistic and neglectful toward their sick children. They

found that parents were fatalistic as a rationalizing mechanism after a child's

death, but did not let their children die without doing all in their power to

prevent the death, even at great cost. Rather than the parents being neglectful,

"it was only upper class individuals such as physicians, nurses and government

officials who spoke of neglect leading to death and who used the idea to justify

their own tragic neglect of the impoverished population."

v Sexual abuse and exploitation

Sexual abuse of children is in most countries one of the last forms of abuse

to be "discovered," due to incest taboos, the secrecy of the abuse, and the

feeling that it "could not happen." In the past 10 years there have been several

reports that sexual abuse does occur in developing countries, although there is

no good way to estimate its prevalence. In a series of 1000 abused children in

India, 93 were victims of sexual abuse. Two-thirds of these were adolescent

females, 8 were pre-adolescent females, and 21 were males (Dave et al., 1982). In

Malaysia 3 in a series of 19 abused children had been sexually abused, all were
females and had genital trauma or gonorrhea (Nathan & Hwang, 1981).2 Gunce &

Konanc-Onur (1983) report that in Turkey 31,908 people were tried between 1'981
and 1980 for raping children under 15 years of age.

Information about perpetrators is available from two series. In a study of

183 victims of sexual abuse in Hong Kong, 5% of the perpetrators were relatives

(including 5 fathers), 56% were acquaintances or friends, and 40% were strangers.

Ninety percent of the victims were females (Law, 1979).

In India, a study of 130 cases found that perpetrators included 2 fathers,

8 uncles, and 80 neighbors and friends (Mehta et al., 1979b). Twenty percent of

the victims were less than 13 years old.

While sexual abuse is harmful in itself, the harm is compounded in countries

where the victim is considered disgraced. To some extent this problem of blaming

the victim may be universal. In India, and perhaps in other societies with strict

sexual mores, the disgrace is so strong that the girl is often not accepted back

into her family, becomes a social outcast, and often commits suicide. In Turkey

girls are frequently kidnapped and raped with the perpetrators' intention of

marrying them. After being raped the girl has essentially no one else she may

marry, and Turkish law suspends punishment if the perpetrator marries the girl.

Because of her disgrace, however, she is often subject to later abuse by her

husband or in-laws and lacks the protection of her family. Besides marrying the

perpetrator, prostitution may be the only alternative open to such a girl (Gunce

& Konanc-Onur, 1983; Olson, 1981).

2 Since physical findings are relatively uncommon in sexual abuse in the Western
experience, one suspects that for each of these three cases of sexual abuse there
would be many more undiscovered cases of abuse without physical evidence.
 Sexual exploitation of children for profit occurs in many areas around the

world. Children may be lured by "employment agents" to the city where they

subsequently become essentially enslaved as prostitutes, even to the point of

being kept locked up. Other adolescents and children may become involved more

voluntarily. Child prostitution is said to be significant problem in Thailand and

the Philippines. The customers in those areas are largely from the developed

countries. Peru also has considerable child prostitution in areas where there is

a large population of men developing the Amazon basin. Young boys are also used

for homosexual prostitution, as in the Philippines and Sri Lanka (de Silva, 1981;

Perpinan, 1985; Anti-slavery Society for the Protection of Human Rights, 1985).

Kidnapping girls to use as prostitutes has been described in India (Bhattacharyya,

1983; Mehta et 81., 1979a) and doubtless occurs elsewhere. Sexual exploitation may

also occur on a smaller scale when children are hired out as servants as occurs

in many areas, as their masters may use them sexually (Okeahialam, 1984). Health

workers should be aware of the likelihood of sexual exploitation of children in

urban areas and should advocate necessary legal and social reforms to eliminate

it.

JBegging

The exploitation of children for the purposes of begging has been mentioned

or described at least in Egypt, Niger (Williams et 81., 1985), India (Bhattacharyya,

1983; Mehta et 81., 1979a), Sri Lanka (de Silva, 1981), and Nigeria (Obikeze, 1984;

Jinadu, 1986). In Sri Lanka children or families displaced from the land become

part of a professional beggar group and are taught the "trade" of begging, not

necessarily being exploited. In many other situations however, children are at

the mercy of employers who use their begging as a source of income. The disabled

ones are the most vulnerable. De Silva describes daily auctions where the

"deformed, diseased or malnourished child" can be hired from private "owners"

 or a beggar syndicate. The money collected goes to the entrepreneur while the

child is lucky to receive a small meal. Parents and foster parents sometimes also

use their children in this way.

Even worse than the mere exploitation or enslavement of children for begging,

the "owners" or parents may deliberately disfigure, maim, or starve the children

to make them more pitiable. If the needed resources to care for destitute children

can be mobilized, progress can be made in eliminating these practices, but it is

doubtful that laws alone will be able to do so.

'-"'Child labor

Related to begging is the entire subject of child labor. As in other areas,

there is no clear line between what constitutes child abuse and what does not.

India alone is estimated to have over 16 million child laborers and worldwide

estimates of over 50 million are cited (Mehta et 8.1., 1985). In the context of

poverty and developing countries, child labor in itself should not be considered

abuse, as it can provide income which may be quite necessary for the survival

of the child and his family. There are serious problems often related to child

labor, however.

(1) The child is vulnerable and dependent, therefore easily exploited. The

"employment" may become slavery with no benefit to the child. Parents may be

glad to find even an unpaid job for the child, so as to have one less mouth to

feed, or may use their children simply as a source of income (Mehra, 1985; Gunce

& Konanc-Onur, 1983; Obiako, 1987). To the extent that the child suffers for the

benefit of others, this constitutes abuse.

 (2) Child labor often involves separation of even young children from their

parents and homes. They are deprived of the normal social and emotional rela-

tionships necessary for development.

(3) Employed children may be in the care of people who have no interest

in their well-being. They are thus very prone to physical and sexual abuse.

Because of medical and nutritional neglect by their employers, and because of

harsh working conditions and long hours, they often have serious health problems

and malnutrition. (Nathan & Hwang, 1981; Mehra 1982; Obiako, 1987; Obikeze, 1984;

Nwako, 1974). On the other hand, for some children even moderately harsh

conditions may be preferable to the alternatives. A survey of working children

in India (Mehta et a1., 1985) found that those who received all their meals from

their employers (2/3 of the total) were all fed adequately. Few illnesses or

job-related health problems were encountered.

(4) Child labor frequently prevents the child from being educated. This is

a serious problem since education is crucial both for the child's own sake and

for the well-being of the entire society.

The subject of child labor must thus be considered carefully in each local

context. In many cases the its outright abolition would not be favorable to the

child. At the same time it poses many risks to the child, which need to be

controlled. The best approach will often be to investigate the conditions under

which children are working locally, what their problems are, then to design

appropriate intervention programs and interventions based on the findings. For

example, employers could be required to provide regular health care and education

for all employed children, the number of hours worked could be controlled, and

working conditions could be inspected and regulated by a government agency.

Children below a certain age could be forbidden to work.

Slavery

Slavery could be considered as a type of employment. The distinctive nature

of slavery is that the child is completely under the control of the owner for a

prolonged period of time, the parents having lost or given up their rights to

the child. In India the practice of "jeetha" consists of children being indentured

to the landlord as repayment of the parents' debt. The children are used for

any kind of labor or service desired by the landlord, and often live in very

oppressive conditions. Sathyavathi (1975) found that 3 children in a series of 45

cases of child suicide were in this situation. A similar practice ("pawning") exists

in Nigeria (Obikeze, 1984) where girls are usually the ones involved, and often

become concubines or wives of their masters. In the Turkish institution of

"besleme" orphan girls or those from poor families are taken by more well-to-do

families, who maintain them in return for their labor. Some forms of employment

border on slavery, as when parents send their children away to live with an

employer for an extended period of time, with the parents receiving the wages

(de Silva, 1981).

All the disadvantages of child labor also apply to slavery. As with other

forms of child labor, there may also be advantages to the child in some CIr-

cumstances, as when his survival is at stake. On the other hand, the degree of

control over the child also offers more opportunities for exploitation and abuse.

As with child labor, the situation in each country must be considered on its own

merits, but remembering the goal of promoting the child's emotional, physical,

social, spiritual, and educational welfare.

Cultural abuse

Under the heading of cultural abuse we will consider a range of practices

which exist in various areas which might be considered to be abusive or detrimental

to the child. These practices are characterized by the fact that they are, at least

on the surface, intended to promote the child's welfare. They are not punitive

nor designed (as infanticide) to benefit the community at the expense of the

child. Therefore we can label them as "abuse" only with reservations.

It has been suggested (McKee, 1984) that certain acts become embedded in

the traditions of a culture for the express purpose of reducing the survival of

its children, in order to curtail population growth or to adjust the sex ratio.

Examples of this "progenicide" might include umbilical cord ceremonies such as

application of dirt or dung, initiation rites, differential weaning with males being

breast-fed longer than females, and counterproductive nutritional taboos. It is

characteristic of all these behaviors that they are justified in terms of being

necessary for the survival or well-being of the infant, while actually compromising

that survival. The justification, however, removes the psychological barrier against

harming one's children.

Initiation rites

In various traditional societies around the world there are initiation rites

which involve pain, shame, and sometimes injuries. Generally the males in a group

are subjected to more severe treatment then females. In New Guinea, for example,

practices in various tribes include holding the boys over the fire, forcing them

to drink contaminated water or slaked lime, shooting tiny arrows into the tongue

or up the urethra, and forcing them to have homosexual intercourse with older

males (Langness, 1981). Similar ordeals and a wide variety of others are practiced

in Africa (LeVine & LeVine, 1981) and elsewhere. Although some of these rites

may have the potential for physical and psychological harm or even death, they
are considered to be essential to the development of the child (or new adult).

Although boys may anticipate the experiences with some dread, they also take

pride in the deeper significance of passing into a higher status.

On the other hand, Langness also wonders whether at some level the initiation

practices represent institutionalized expression of hostility against the young

men, and whether certain behaviors "may be considered as 'abusive' irrespective

of context." Once again then, the entire cultural context needs to be looked at

before a single element can be isolated as abusive and needing to be changed.

The risks and benefits of the various practices should be considered, and in

some cases alternatives may be sought.

Ordeals and harmful treatments

Every society has a "health care" system designed to maintain the health

of its members and to cure them when they fall ill. Many of the methods used

are helpful or at least harmless, but some are harmful, causing pain with no

benefit, or putting the child at risk for serious injury or death. A Latin American

folk treatment for an ill infant includes holding him upside down with the top

of his head in hot water, then shaking him vigorously three times while slapping

the soles of his feet. While this might usually be innocuous, it can be fatal due

to the "shaken baby syndrome" of subdural hemorrhage (bleeding around the

brain) (Guarnaschelli et al., 1972). The Machiguenga Indians of South America dip

their babies in river water to stop their crying, and give them scalding baths

and scrape their skin with dogfish teeth to make them fat and able to endure

pain with dignity (Johnson, 1981). In some areas of India newborns are ritually

branded on the abdomen to ensure proper digestion of food and to prevent or

treat respiratory infections; many become ill or die because of complications of

 the burns (Dave et aJ., 1982). Dietary restrictions on ill children, such as giving

a child with measles or diarrhea nothing to eat or drink are frequent and naturally

are the cause of many deaths.

We should not neglect that fact that harmful treatments are also used in

the developed countries and that health care providers in all parts of the world

are sometimes responsible. Some harmful practices such as bottle-feeding were

introduced from the West. Practices such as giving unneeded injections or

performing unnecessary surgery fall into this category of harmful care (except

that the professionals should know better!) (Torrelio & Vargas, 1979).

There are, then, an endless variety of potentially harmful "cures." Obviously

the parents and practitioners should be praised for their attempts to help the

children rather than blamed for the harmful effects we might see, and the focus

of change should be on the provision and demonstration of more efficacious

treatments. We cannot expect changes to occur if we cannot offer better methods

which are accessible, and even then we must remember that change may be slow.

J Removal of child from home

In many parts of Africa the young child is removed from his mother and

his home at some point, often at weaning, or the start of the mother's next

pregnancy (LeVine, 1963). He may be sent to live with a grandparent or with

someone in the mother's clan. There are doubtless many attributed reasons for

this. In the Baganda tribe the explanation is that the child is in danger of being

infected by his mother's abdominal swelling (Goodall, 1979). Whatever the reason,

this practice is generally harmful to the child. The combination of perceived

rejection and withdrawal of mother's affection, the elimination of a clean nutritious

food source, and the loss of other relationships and familiar surroundings can
 cause serious depression and, as Goodall showed, makes him prone to malnutrition.

This is another example of a practice which, though perhaps intended for the

child's good, is actually harmful.

,.../ Abuse against females

Discrimination against females occurs in various forms in many areas of the

world, developed and developing alike, and is a large area of study in its own

right. In this paper we have room only to mention some of the most severe types

of discrimination resulting in death, and the subject of female circumcision. We

have already noted that in some areas girls are in the group of children classed

as "unwanted" or "less wanted", thus they are subject to all sorts of abuse and

neglect. The causes of the discrimination are beyond the scope of this paper but

include may economic factors (females being valued more where they are more

important labor sources), marriage practices such as dowries and hypergamy (a

woman marrying into a higher social class), the valuation of males as warriors,

and many other sociological factors. Most of the research I encountered on severe

abuse and neglect against females is from India, where in some areas there are

far fewer surviving females than males, but to a lesser degree females are

selectively abused and neglected in other parts of the world as well.

Female infanticide, homicide, and severe neglect

The selective killing of girls was relatively frequent in the past in various

areas including East Africa (Bwibo, 1972), and India (Miller, 1981; Jeffery et al.,

1984). Some feel that the practice still continues in the People's Republic of China

where males are highly valued and women are under pressure to have only one

child (Light, 1985). Young brides in India (including teenage ones) are often

victims of homicide or are driven to suicide by their husband or his family, and

a government report from Gujarat in 1966 found that "persistent and calculated
physical and mental torture was employed in some casts to deliberately do away

with the daughter-in-law" (Poffenberger, 1981). The frequent suicides of sexually

abused girls was mentioned above.

More common than the outright killing of females, however, is neglect, which

may be minor or so severe that it can only be intentionally designed to result

in death. It is the more serious forms of neglect which are believed to be

responsible for the overall high death rates in females in India. In the most

severe form of neglect infants are simply abandoned, often dying as a result.

In two series of abandoned children baby girls were abandoned twice as often

as males (Lokeshwar et a1., 1979; Mehta, 1982).

The next most physically damaging form of neglect is probably nutritional.

The child before 3 years of age is nutritionally fragile in the sense that provision

of an adequate amount and quality of food is essential for development. Inadequate

nutrition puts the child at risk for physical and mental developmental delays

and makes her less likely to survive common childhood infections such as measles.

Because of the strong preference given to males, however, girls may not be given

adequate or proper food when food is scarce. In a 10-month observation period

in Northwest India (Punjab) Pettigrew (1986) found abundant examples of such

selective neglect. The food supply was controlled by the mother-in-law who did

not necessarily allocate any milk to pregnant and lactating mothers or to infant

girls. Boys were given breastmilk or buffalo milk as well as other high quality

foods, while girls were given what was left over. A nutritional survey in Punjab

cited by Ghosh (1986) found severe malnutrition to be over twice as frequent in

girls as in boys.
 When girls become ill due to infection, malnutrition, or other causes, they

are less likely than males to be treated (Singh et al., 1962; Ghosh, 1986; Miller,

1984). The lower level of medical attention given to girls is not due to less need

on their part, since the same areas have higher morbidity and mortality rates

in the girls. In one area the female mortality was 30% higher; for every 100 girls

under 5 years old, 2 died who would not be expected to on the basis of the male

mortality rates. One mother succinctly put the justification for this behavior: "A

girl is like a stone and nothing can hurt her but a boy is like a flower and

must be treated with care" (Poffenberger, 1981).

The most recent form of lethal abuse to appear is the selective abortion of

female fetuses after the use of amniocentesis to determine the sex (Jeffery et

al., 1984; Ghosh, 1986).3 While due to the high cost and limited availability it

seems unlikely that the practice will significantly affect the demographics of

India, the demand for the service does illustrate the degree to which females

are unwanted and therefore at risk from the time of birth.

Female circumcision

Female circumcision is a practice with ancient roots, antedating the intro-

duction of Christianity and Islam, which is still widespread in Africa (Tevoedjre,

1981), and is important from a world health standpoint because of the negative

3 Ghosh quotes an advertising flyer for such a service:

Most prospective couples in quest of a male child, as the social set up
in India demands[,] keep on giving birth to a number of female children,
which in a way not only enhances the increasing population but also
leads to a chain reaction of many social, economical and mental stresses
on these families. Amniocentesis and Antenatal sex determination has
come to our rescue and can help in keeping some check over the
accelerating population as well as give relief to the couple requiring
male child [sic] ....
9. Sex determination is done in those patients having one or more than
two [sic] female children.
effects on the health of a very large number of females. "Circumcision" refers

to clitoridectomy, the excision of the clitoris, or to infibulation, a much more

radical procedure consisting of "cutting away all external female genitalia, and

almost closing the vaginal opening" (Lowenstein, 1978). It is usually performed

in children and adolescents. As with male initiation rites, while at deeper levels

the practice may represent institutionalized hostility toward females and their

sexuality, on the surface it is performed as an accepted tradition and a necessary

part of passing into adult life.

Some of the proposed reasons or justifications for the practice are (1)

assurance of chastity before marriage; (2) family planning as intercourse will be

less frequent due to pain or lack of enjoyment; (3) initiation rite; (4) to keep

sexual interest at a minimum, thus discouraging the girl from promiscuity or

prostitution (Lowenstein, 1978). It could also be a form of progenicide as described

above, since it decreases the survival both of the one on whom it is performed

and on her children (at birth).

Problems caused by these procedures go beyond the obvious ones of immediate

severe pain and the likely permanent decrease in sexual enjoyment. Short term

complications include infections which could be fatal. In the long term menstrual

and urinary problems, and sterility may result. Due to scarring there may be

serious or fatal complications during childbirth (Tevoedjre, 1981).

Despite these problems there continues to be much support for the practice

in many areas. Lowenstein (1978) surveyed of Sudanese university students'

attitudes on the subject. The women, all of whom had been infibulated, strongly

supported it, the main re*asons being given that "it is our custom" and "a woman

cannot get a husband without it." While the middle aged men tended to support

it also, young men did not. Thus the circumcision of females is still another
example of a practice which, though harmful in itself, cannot be properly analyzed

outside the context of the cultures in which it occurs. While it is detrimental to

women's health, an individual woman who has not had the procedure may suffer

more in the end as a result of that lack. Therefore changes must occur at a

deeper level, at the level of the values represented. Until women can be assured

that their children will be married and fully incorporated into society without

it, it will continue to be practiced. 4

v. UNDERLYING PROBLEMS

In the final section of this paper we will consider some of the factors which

seem to underlie the occurrence of child abuse and neglect in the developing

world.

Poverty-related factors

Poverty increases the risk of abuse in various ways. It puts pressure on

one or both parents to leave home to work elsewhere, adding to the stress on

the remaining parent; lack of resources to raise a child may lead to her being

abandoned, placed outside the home, or even killed; poverty leads to rationing

of scarce resources, resulting in the differential neglect of some children such

as females; the need for money leads parents to use children as sources of

production (begging; child labor; slavery or indentured apprenticeship). Un-

fortunately the problem of poverty itself is very difficult to solve and the health

worker will be more involved in ameliorating its negative effects than in eliminating

it.

4According to Lowenstein, the practice has been illegal in the Sudan since 1945,
yet all the students in the survey had it performed.
 Urbanization

Urbanization, the move of the population from rural to urban areas, is the

dominant demographic change in most developing countries. Men, women, and

families go to the city in search of employment. Sometimes no jobs are to be

found. Even when there is work, living conditions are often worse than they

were in the home town or village. Housing is cramped, unsanitary, and unaffordable.

Many are forced to live in makeshift squatter towns or slums.

Urbanization leads to the disintegration of traditional family structures which

are a defense against abuse and neglect. It places new stresses on parents and

tends to convert children from an asset (on the family farm) to a liability

(requiring more living space, more expensive food) which may lead to a lower

valuation of children (Olson, 1981). Lack of suitable child care facilities results

, in children being unsupervised at home, supervised by another child, or supervised

by unrelated caretakers, often very young themselves, who have little at stake

in the child and may abuse and neglect him (de Silva, 1981; Okeahialam, 1984;

Jinadu, 1980; Wu, 1981).

While urbanization itself cannot be reversed, some of the effects can be

ameliorated. Perhaps the most practical and important intervention is the provision

of good child care in appropriate locations, with trained (or at least reliable)

staff and good standards of hygiene and nutrition.

Disintegration of family (nuclear and extended)

The extended family and close- knit community are commonly cited as protective

factors against abuse and neglect in traditional societies. Because of the sharing

of child rearing responsibilities the parents themselves are not faced with the

continuous stress themselves; when the pressure builds there are alternatives

such as sending the child to stay in another home for a while (Mehta, 1982;
Langness, 1981). At the same time, others besides the parents are concerned for

the welfare of the child. If the parents begin to go beyond the cultural standards

of care and discipline other relatives or friends may feel free to intervene. (Olson,

1981; Ritchie & Ritchie, 1981; Tevoedjre, 1981; Wu, 1981; Korbin, 1981b).

As traditional societies become urbanized and face other pressures of social

change, there tends to be disintegration of the wide network, and the respon-

sibilities fall on the parents alone. The new pressures, lack of support, and lack

of anyone to intervene combine to make abuse and neglect possible in families

where they might not occur in other circumstances (Fraser & Kilbride, 1980;

Okeahialam, 1984).

Beyond the loss of the extended family, even the nuclear family is under

new stresses. Both men and women are often separated from their spouses and

children for long periods while working in the city or in another country. Men

may have one wife and family in the city and another back home. The resulting

marital discord and single parents are further factors in abuse.

Prevention directed at these factors might be directed toward the

strengthening of a sense of community. For greatest success I suspect that this

should be part of an integrated community development or primary health care

project (not a vertical "child abuse prevention project"5). When designing and

implementing such projects in urban areas the problems of family breakdown and

its impact on children should be kept in mind so as to ameliorate them as far

as possible.

5 Although one of the only child abuse prevention projects to be described in a

developing country was just such a vertical one, involving community volunteers
in a "Neighborhood Protective Strategy for Children", which proved to be fairly
successful (del Castillo, 1985).
Absence of formal support systems

In most developing countries there is a lack of social support systems which

could help prevent, detect, and treat child abuse. Development of these institutions

is hampered by lack of money and personnel and probably also by the failure

to see them as important. Some of the elements of a system to protect children

have been mentioned already. Others would include:

* Placements for unwanted/abused/neglected children. In most countries child

protective, adoption and foster care systems are underdeveloped. Many of the

case histories in the literature the child was returned to the parents even

after the diagnosis of abuse (e.g. Santhanakrishnan et al., 1973; Bhattacharyya,

1983; Hock & Hwang, 1975; Woon et al., 1974). It has even been claimed that

with a "positive approach" "permanent removal of the abused child from the

parental care may hardly be needed" (Santhanakrishnan et al., 1979). In view

of the well-established experience in various countries (including India) that

abused children are likely to suffer further abuse if returned home, such

decisions should be made carefully, and every attempt should be made to

establish safe and healthy homes where children may be kept at least temporarily.

While the governments of developing countries may not be able to directly

support dependent children, adoption can be encouraged and made simple and

accessible. As a good example, Costa Rica recently reorganized its entire system

of institutional care for abandoned children so as to integrate it, to provide

rapid assessment of child and family, to promote family reunification when

possible but also to seek adoption without delay when necessary (Lizano, 1982).

* Support systems for parents. These could include assistance with training or

rehabilitation of disabled children; crisis intervention; and nutritional sup-

plements to high risk women and children.

* Primary health care including care available to working children. Services

should include good, culturally acceptable family planning services and prenatal

care.

* Trained workers. In many areas there are few if any trained social workers

or others who are familiar with or skilled in the issues involved in prevention

and treatment of abuse and neglect (Oyemade, 1980). Governments should

consider providing professional training for a reasonable number of workers.

Meanwhile the shortage of trained social workers and medical personnel mandates

the use of alternative strategies, such as the use of primary health care

system for child protection. Therefore those involved in health care systems

should also identify people who can become special resources in this area.

Children at special risk

We have already discussed many of the categories of children who in some

societies may have little protection, including the illegitimate, the disabled or

deformed, and females. Other risk factors in the child may include prematurity

(Jinadu et al., 1982), and being in any way a "difficult" child, such as having

sleep problems, excessive crying, or feeding problems (Fahaiel & Tabbane, 1974).

Community and child health workers should be familiar with these risk

factors and others which may be important locally. Careful thought should be

given to classes of children who may not be fully integrated into the community

(e.g. servants, certain racial or religious groups, working children) and may thus

be at increased risk of abuse from parents or from others.

Needed changes in law

While legislation is limited in what it can accomplish, in that it cannot

eliminate poverty, stop urbanization, keep families together, or make them love
their children, there are certain ways in which the law can be used to protect

children. The ability of laws to effect changes will naturally depend on the

resources available to implement and enforce them.

* Regulation of child labor. Ways of protecting the working child have been

discussed above.

* Reporting laws. Laws governing the reporting of abuse and neglect need to

be considered. Reporting may be made mandatory, so that defined classes of

people (such as physicians and teachers) are legally obliged to report abuse

or suspected abuse. One reason for this approach is that while sometimes the

case may be handled well without the awareness of an agency or authorities,

in other instances the child will be inadequately protected. Mandatory reporting

makes sense when the agency receiving the reports is more capable of handling

cases than are the reporters.

Confidentiality concerns must also be addressed, as the duties of confidentiality

and reporting may conflict, as in Morocco (Masrour et al., 1980). In any case,

when making decisions about reporting, legislators must keep in mind that

the well-being of the child is the paramount consideration. To avoid discouraging

reporting, the administrative procedures required of the reporters should be

as simple as possible (Nwako, 1974).

* Regulation of child care facilities. In the absence of any regulation, some child

care facilities neglect or abuse children, and some will be unhealthy for other

reasons. Therefore it is reasonable to establish some basic standards and

means of enforcement. For example, the ratio of children to caretakers could

 be limited, and adequate sanitary facilities required. At the same excessive

regulation could be burdensome and counterproductive by restricting the

number of facilities in operation.

* Laws regarding perpetrators. Another issue is the policy of the law toward

those who have abused or neglected children. Again the law should consider

the best interests of the child. In many countries abusing parents are harshly

punished. Factors to consider are the effects this has on the children, and

whether it prevents conscientious workers from reporting abuse (e.g. Masrour

et al., 1980; Nazer, 1988).

* Prohibitions on exploitative practices. It should go without saying that the

law should provide maximal protection against practices such as prostitution

of minors and slavery. The mere existence of laws is not enough, however,

without the political will to do whatever is necessary to end these practices.

Cultural values and standards

Even legal reforms may be of little effect in those aspects of abuse (or harm

to children) where the entire cultural fabric is involved. We have seen how the

customs and values of a culture, such as its views of whether children should

become warriors or farmers, whether young children are capable of obedience,

how to treat illnesses and ensure health, and what sorts of parental discipline

are acceptable, all affect the way children are treated. In some cases a set of

cultural beliefs and values lead to great suffering or death for some members,

such as females in India, illegitimate children in many places, or Afro-Americans

in America. Those whose goals are to promote equity and the well-being of all

have the difficult task of balancing the acceptance of cultural differences with

the need to change some aspects of any culture to more closely reflect those

goals.
 Many of these factors are also associated with other health problems, and

many will be difficult to resolve without overall improvements in economic and

social bases. At the same time, some progress can be made on the basis of

increased public awareness and sensitivity. The process of reforms in the

now-developed countries began when economic conditions were similar to those

in many now-developing countries, and progress was effected not simply because

of increased standard of living but because of changes in values. For this reason

child advocates, health planners, and reformers in the developing countries should

not conclude that the situation is unchangeable, but should press for changes

which can be made in the context of the culture in which they operate.
 REFERENCES

Animashuan A. Abandoned children in Lagos. Nigerian Medical Journal

7:408-411 (1977).

Anti-slavery Society for the Protection of Human Rights. Sexual exploitation

of children. Response to the Victimization of Women and Children 8:13-14 (1985).

Arnold E. The use of corporal punishment in child rearing in the West Indies.
Child Abuse and Neglect 6:141-145 (1982).

Bhattacharyya AK. Nutritional deprivation and related emotional aspects in

Calcutta children. Child Abuse and Neglect 5:467-474 (1981).

Bhattacharyya AK. Child abuse and neglect (CAN): Indian perspective. Indian
Pediatrics 20:803-810 (1983).

Christoffel Kj Liu Kj Stamler J. Epidemiology of fatal child abuse: International

mortality data. Journal of Chronic Diseases 34:57-64 (1981).

vDave ABj Dave PBj Mishra KD. Child abuse and neglect (CAN) practices in
Durg District of Madhya Pradesh. Indian Pediatrics 19:905-912 (1982).

De la Torre JA. [Agression in the pediatric age group. 1. The battered and
underdeveloped child. Gaceta Medica de Mexico 109:215-222 (1975).

De Meer K. Mortality in children among the Aymara Indians of Southern

Peru. Social Science and Medicine 26:253-258 (1988).

J De Silva W. Some cultural and economic factors leading to neglect, abuse

and violence in respect of children within the family in Sri Lanka. Child Abuse
and Neglect 5:391-405 (1981).

JFeder L. [The universality of the preconception conflict (Unwanted children)]

[Spanish]. In: E1 Ma1tratado a los Hijos, Marcovich J, (Ed.), Edicol, Mexico, 1978.
 Fehaiel A; Tabbane C. [Silverman's syndrome: discussion of a case] [French].
Tunisie Medicale 52:223-229 (1974).

Fiala R; LaFree G. Cross-national determinants of child homicide. American

Sociological Review 53:432-445 (1988).

Fraser G; Kilbride PL. Child abuse and neglect -- rare, but perhaps increasing,
phenomena among the Samia of Kenya. Child Abuse and Neglect 4:227-232 (1980).

Gelles RJ; Cornell CPt International Perspectives on Family Violence, D.C.

Heath and Company, Lexington (1983).

Ghosh S. Discrimination begins at birth. Indian Pediatrics 23:9-15 (1986).

Goodall J. Malnutrition and the family: deprivation in kwashiorkor. Proceedings

of the Nutrition Society 38:17-27 (1979).

Guarnaschelli J; Lee J; Pitts F. "Fallen fontanelle" (caida de mollera): A

variant of the battered child syndrome. JAMA 222:1545-1546 (1972).
"
\JGunce G; Konanc-Onur E. Child abuse in Turkey. In: Child Abuse and Neglect
Research and Innovation, Leavitt JE (Ed.), M Nijhoff Publishers, Boston, 1983.

Haditono SR. Prevention and treatment of child abuse and neglect among
children under five years of age in Indonesia. Child Abuse and Neglect 5:97-101
(1981).

Hock YO; Hwang WT. A battered child. Medical Journal of Malaysia 30:43-47
(1975).

Hunton RB. Maori abortion practices in pre and early European Ne",.. Zealand.
New Zealand Medical Journal 86:567-570 (1977).

Jeffery R; Jeffery P; Lyon A. Female infanticide and amniocentesis. Social

Science and Medicine 19:1207-1212 (1984).

Jenkins CL. Health in the early contact period: a contemporary example from
Papua New Guinea. Social Science and Medicine 26:997-1006 (1988).

Jinadu MK. The role of neglect in the aeteology of protein-energy malnutrition

in urban communities of Nigeria. Child Abuse and Neglect 4:233-236 (1980).

Jinadu MK. Combating child abuse and neglect in developing and newly
industrializing countries: a unique primary health care approach. Child Abuse
and Neglect 10:115-120 (1986).
 JJohnson OR. The socioeconomic context of child abuse and neglect in native
South America. In: Child Abuse and Neglect: Cross-Cultural Perspectives, Korbin
J (Ed.). University of California Press, Berkeley, 1981.

Korbin JE. Child Abuse and Neglect: Cross-Cultural Perspectives, University

of California Press, Los Angeles, 1981a.

VKorbin JE. "Very few cases": Child abuse and neglect in the People's Republic
of China. In: Child Abuse and Neglect: Cross-Cultural Perspectives, Korbin J (Ed.).
University of California Press, Berkeley, 1981b.
I
J Langness LL. Child abuse and cultural values: the case of New Guinea. In:
Child Abuse and Neglect: Cross-Cultural Perspectives, Korbin J (Ed.). University
of California Press, Berkeley, 1981.

Law SK. Child molestation: a comparison of Hong Kong and Western findings.
Medicine, Science and the Law 19:55-60 (1979).

v~ Le Vine S; Le Vine R. Child abuse and neglect in Sub-Saharan Africa. In:

Child Abuse and Neglect Cross-Cultural Perspective, Korbin J (Ed.). University
of California Press, Berkeley, 1981.

!../ LeVine RA. Child Rearing in sub-Saharan Africa: an interim report. Bulletin
of the Menninger Clinic 27:245-256 (1963).

Lieh-Mak F; Chung Y; Liu YW. Characteristics of child battering in Hong

Kong: a controlled study. British Journal of Psychiatry 142:89-94 (1983).

Light s. Female infanticide in China. Response to the Victimization of Women

and Children 8:5-6 (1985).

Lizano CZ. For abandoned children: institutions or families. International

Child Welfare Review 55:21-29 (1982).

Loening WEK. Child abuse among the Zulus: a people in cultural transition.
Child Abuse and Neglect 5:3-7 (1981).

\-/ Lowenstein LF. Attitudes and additude differences to female genital mutilation
in the Sudan: Is there a change on the horizon? Social Science and Medicine
12:417-421 (1978).

Marzouki M; Fredj AH; Chelli M. [The battered child and cultural attitudes:
The example of Tunisia] [French]. Child Abuse and Neglect 11:137-141 (1987).
 Masrour Aj Sbihi Aj Outarahout OJ M'Seffer FAj Baroudi TAA. Les enfants
victimes de sevices. A propos de 10 observations. [Battered children. 10 cases].
Maroc Medicale 11:353-365 (1980).

McKee L. Sex differentials in survivorship and the customary treatment of

infants and children. Medical Anthropology 8:91-108 (1984).

Mehra BK. Highlights on abuse in education -- a view from India. Child

Abuse and Neglect 6:225-228 (1982).

Mehta MN. Physical abuse of abandoned children in India. Child Abuse and
Neglect 6:171-175 (1982).

Mehta MNj Bhatt SSj Gore MG. "Kidnapping": A Social Evil. Child Abuse and
Neglect 3:615-621 (1979a)

Mehta MNj Lokeshwar MRj Bhatt SSj Athavale VB; Kulkarni BS. Rape in
children. Child Abuse and Neglect 3:671-678 (1979).

Mehta MN; Prabhu SV; Mistry HN. Child labor in Bombay. Child Abuse and
Neglect 9:107-111 (1985).

Miller BD. The Endangered Sex. Cornell University Press, Ithaca (1981).

Miller BD. Daughter neglect, women's work, and marriage: Pakistan and
Bangladesh compared. Medical Anthropology 8:109-126 (1984).

Montag BA; Montag TW. Infanticide: A historical perspective. Minnesota

Medicine 65:368-372 (1979).

Nathan L; Hwang WT. Child abuse in an urban centre in Malaysia. Child

Abuse and Neglect 5:241-248 (1981).

Nations MKj Rebhun LA. Angels with wet wings won't fly: maternal sentiment
in Brazil and the image of neglect. Culture, Medicine and Psychiatry 12:141-200
(1988).

Nazer Hj Daradkeh Tj Mohamed Sj Shamayleh AQj Marei O. A diagnostic dilemma

in Jordan: Two child abuse case studies. Child Abuse and Neglect 12:593-599
(1988).

Nwako F. Child abuse syndrome in Nigeria. International Surgery 59:613-615

(1974).

Obiako MN. Eardrum perforation as evidence of child abuse. Child Abuse and
Neglect 11:149-151 (1987).
 ;-
v'Obikeze DS. Perspectives on child abuse in Nigeria. International Child Welfare
Review 63:25-32 (1984).
I
J Okeahialam TC. Child abuse in Nigeria. Child Abuse and Neglect 8:69-73 (1984).

\fOlson EA. Socioeconomic and psycho-cultural contexts of child abuse and

neglect in Turkey. In: Child Abuse and Neglect: Cross-Cultural Perspectives,
Korbin J (Ed.). University of California Press, Berkeley, 1981.

JOyemade A. Child care practices in Nigeria -- an urgent plea for social

workers. Child Abuse and Neglect 4:101-103 (1980).

Perpinan MS. Strategies against sexual trafficking. Response to the

Victimization of Women and Children 8:22-22 (1985).

Pettigrew J. Child neglect in rural Punjabi families. Journal of Comparative

Family Studies 17:63-85 (1986).

Poffenberger T. Child rearing and social structure in rural India: Toward

a cross-cultural definition of child abuse and neglect. In: Child Abuse and Neglect:
Cross-Cultural Perspectives, Korbin J (Ed.). University of California Press,
Berkeley, 1981.

\/Retana G. [Abandonment and adoption]. In: El Maltratado a los Hijos,

Ritchie Jj Ritchie J. Child rearing and child abuse: the Polynesian Context. In:
Child Abuse and Neglect: Cross-Cultural Perspectives, Korbin J (Ed.). University
of California Press, Berkeley, 1981.

Samuda GM. Child discipline and abuse in Hong Kong. Child Abuse and Neglect
12:283-287 (1988).

Santhanakrishan BRj Vasantakumar Shetty Mj Raju VP. PITS syndrome. Indian

Pediatrics 10:97-100 (1973).

Santhanakrishnan BRj Sridhar VSj Sriram Rj Shetty MVKj Raju VB. Child
abuse. Indian Pediatrics 16:57-60 (1979).

Sathyavathi K. Suicide among children in Bangalore. Indian Journal of

Pediatrics 42:149-157 (1975).

Singh S; Gordon JE; Wyon JB. Medical care in fatal illness of a rural Punjab
population. Indian Journal of Medical Research 50:865-880 (1962).

Stocks JT. Has family violence decreased? A reassessment of the Straus and
Gelles data. Journal of Marriage and the Family 50:281-291 (1988).
 straus MAj Gelles RJ. Societal change and change in family violence from
1975 to 1985 as revealed by two national surveys. Journal of Marriage and the
Family 48:465-479 (1986).

Taylor Lj Newberger EH. Child abuse in the International Year of the Child.
In: International Perspectives on Family Violence, Gelles RJ & Cornell CP (Eds.).
D. C. Heath & Company, Lexington, 1983.
I
VTevoedjre 1. Violence and the child in the adult world in Africa. CiWd Abuse
and Neglect 5:495-498 (1981).

Torrelio EAj Vargas MC. [The abused child syndrome] [Spanish]. Boletin
Medico Hospital Infantil 36:923-930 (1979).

Vicuna, JR. [The abused child. Epidemiologic, clinical, judicial and social
considerations] [Spanish]. Revist8 Chilena de Pediatria 52:333-341 (1981).

Woon THj Chin Cj Lam KL. Battered child syndrome in a Malaysian hospital.
Medical Journal of Malaysia 28:239-243 (1974).

Wu DYH. Child abuse in Taiwan. In: Child Abuse and Neglect: Cross-Cultural
Perspectives, Korbin J (Ed.). University of California Press, Berkeley, 1981.

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