(3) Hofvander 27-34 27 Upsala J Med Sci 111 (1): 27–34, 2006 Violations against Children in a National and International Perspective Yngve Hofvander Department of Women´s and Childrens Health, Uppsala University In his writings, Rosén does not at all discuss violations against children, although this cer- tainly was common in his time. Actually, children have been beaten and maltreated since times immemorial - in their homes, as servants and in schools (1). Flogging used to be a corporal punishment in schools and was found to be a valuable disciplinary and pedagogic means. In the Swedish school laws from 1611 it was stated, however, that due consideration should be given to those children who were intellectually or physically defect. In 1918 corporal punishment or abusive treatment became forbidden against older chil- dren but for younger children this could continue until 1958! Not until 1979 Sweden introduced as the first country in the world a law forbidding cor- poral punishment at home and in 1990 Sweden ratified the UN Convention of the rights of the child. The Article 19 in this document states:“…to protect the child from all forms of physical or mental violence, injury or abuse, neglect or neglient treatment, maltreatment or exploitation including sexual abuse…” However, Article 14 neutralises to some extent this strong statement by saying that …”state parties shall respect the rights and duties of the parents to provide direction to the child in the excercise of his or her right”. In other words the parents may still have the right to corporal punishment if considered fit according to tradition or religion. Maltreatment of children has been much in focus (mass media) in recent years. In 1999 in Sweden no less than 879 abused children 0-6 years were reported to the police and 5040 in the 7-14 age group (1). Most of these were not severe – but probably a large number are never reported. However, it would seem that it has decreased compared to the 1970s corporal punish- ment from about half of all children to about 1/5. In absolute number this is of course alarmingly many children, some of whom may retain painful memories to later in life. Received 17 October 2005 Accepted 28 October 2005 Sexual intercourse with children (usually defined as less than 12 years) has over the centuries been considered the same as rape and being a very serious crime, resulting in death penalty, at least until the end of the 18th century (2). In these days there was a very marked male dominance and the head of household had a legitimate power over wife, children and servants, which also included the right for corporal punishment. Sexual abuse of young girl servants was certainly common, impossible to report – and resulting in expulsion and not seldom illegitimate abortion or infanticide with cata- strophic consequences for the mother(2). IMPLEMENTATION OF THE CONVENTION OF THE RIGHTS OF THE CHILD In article 24.3 is stated that …” States parties shall take all effective and appropriate measures with a view to abolish traditional practices prejudicial to the health of children”. Practices which are listed which should be reviewed in the light of the Convention include “ all forms of genital mutilation and circumcision, binding, scarring, burning, initiation ceremonies e.g. forced holding under water, preferential care of male children, lack of care of disabled children, food taboos, beating chil- dren, early marriage” – et cetera… This horrible list of abuse could be made much longer! In general we believe that parents always do the right thing for their children, the best they can and always to the benefit of the children. Is that true? I am inclined to answer in the negative – it is not, there are many examples that show that parents may cause harm to their children to serve other purposes, mainly their own, but also purpose of religion, of tradition or a mixture of the two (3). In the following a number of examples are given on violations against children´s integrity and which may be causing much suffering and harm (3). FOOT BINDING In China, about 1000 years ago, parents started to bind girls´ feet to prevent them from growing to more than about 10 cm, starting at the age of about 5 years and continuing for 2-3 years. This caused much pain, often infection and the girl became unable to walk and work. The custom started in the royal courts, became a fashion spreading to other sectors among the well-to-do, a sign of beauty, submis- sion and chastity. The parents could thus offer for marriage a girl who was definite- ly a virgin, thereby resulting in a substantially higher bride price for the benefit of the parents (4). Foot binding was forbidden during the 20th century but it is still possible to see elderly women in the streets demonstrating what happened with them in the past. 28 SELECTIVE ABORTIONS In most cultures there has been and still is a preference for boys. In China and India this has taken extreme forms. The physiological sex ration at birth is 100 girls to about 104 boys. Since the 1960s – at the time when the one- child policy was put into action in China – the ratio has become more and more skewed, to some 117 boys ( Table 1) and for multipara and in some remote areas even up to 135 to 100. (5). Ultrasound investigation for foetal sex determination is readily available although forbidden, but there are many ways to get around this. Recently the one-child policy seems to have become less rigidly upheld. CIRCUMCISION OF GIRLS – FEMALE GENITAL MUTILATION (FGM) FGM is practiced to a horrifying great extent and shows no tendency to decrease with the exception of small areas where intensive educational and motivational pro- grammes have started. It is basically an African phenomenon and is practiced in varying extent in those countries that form a belt across Africa (Table 2). In Somalia, Sudan and Ethiopia practically all girls undergo FGM, at least in the traditional society. But also in well educated circles FGM is considered to be a decree in the Koran. In a study in Somalia (6), a country where the tradition is strongest, among girls where 43 % had secondary school or higher education, no less than 70 % believed that this was a decree in the Koran. About 2 million girls undergo FGM annually and more than 130 million currently living girls and females have experienced this mutilating operation (7). Tens of thou- sands of them are presently living in the US and in Europe, constituting new med- ical, ethical and legal problems in these countries. It is illegal in these Western coun- 29 Table 1. Development of sex ratio at birth in China. The normal biological sex ratio is 100 girls to 102-104 boys (5). Years Girls Boys <1980 100 106 1981 100 109 1986 100 111 1889 100 114 2000 100 117 (130-135) tries to perform the operation and to restore the circumcision after delivery. In Swe- den it is also illegal to perform the operation abroad. However, so far not a single case has been brought to court in any Western country, respect for the parents or oth- er relatives has been given as the reason. Instead the mutilated girl is sacrificed! (8) The operation takes different forms of severity. The most simple is excision of the prepuce and part or all of the clitoris. This may be extended to comprise the labia minora. In the most severe form , infibulation, also part or all of the external geni- talia are excised and the orifice of the vaginal opening is stitched ( traditionally with a thorn) or scraped, leaving only sufficient room for urine and menstrual blood. A wide variety of immediate and long term complications have been reported – bleedings, infections, sexual problems, delivery complications and infertility (9). It is indeed understandable that marital problems will arise when the bride is infibulated and the vaginal orifice has to be cut open with a knife by a piece of glass! And it is indeed difficult to understand how this mutilating practice, severely affect- ing half the population in many countries, is allowed to continue, showing only mod- est signs of decreasing frequency. The international organisations including the NGOs have been remarkably inactive, in view of the enormous suffering that is affecting millions of girls and women. However, suffering from the female genital area is usually silent and accepted in the name of chastity and marital honour! In Sweden with some 30.000 immigrants from Somalia, it is estimated that possibly up to some 50 girls annually are subjected to FGM, the operation being performed Country Percent FGM Somalia Sudan 80-100 Ethiopia Egypt Liberia Kenya 40-80 Nigeria Guinea Bissau 30 Table 2.Rate of female genital mutilation (FMG) in selected African countries (7). 31 abroad (Martina Frank, RISK, personal communication). In a number of cases this has been suspected but so far none has been brought to court (risking a sentence of up to 10 years). MALE CIRCUMCISION – MALE GENITAL MUTILATION, MGM Male circumcision is usually associated with a practice originating from the tales in the Old Testament – Abraham going into a covenant with God, prescribing that he had to circumcise himself ( 90 years old!) and all his male household and in exchange should get a multitude of off springs which should populate the land. Also we have learnt that Jesus was brought to the temple on his 8th day to be cir- cumcised. Since then circumcision is one of the traditional rites in Jewish life, at least until recently. However, circumcision was practiced in Egypt long before that, its background being obscure. The Jewish circumcision is in minority, though, as is seen in Table 3. In the Moslem sphere it is estimated that some 12 million boys are circumcised annually, some time during the period 2 – 14 years. The claim is that this is a command in the Koran (which is not true) or in the hadiths (the tales and sayings from the Prophet’s time). The operation is often done by laymen, barbers and similar, is cruel and painful, sometimes made as a mass operation, e.g. in the market place, the boy dressed up like a prince, the whole event continued with a big fiesta, the boys being given sweets and gifts – a party which may cost several times more than the operation itself (8). In Sweden it is estimated that some 3000 boys are circumcised annually. A number of severe complications have been reported including in recent years one death (10) . Background Target group No circ/YR Religious Jews 100.000 Religious Moslem 12 million Traditional Africa/S Sahara 9 million Neonatal USA+ 1.2 million Table 3. Estimated number of male circumcisions performed annually for religious, traditional or other reasons assuming 80% in the first 3 groups and about 60 % in the 4th group (10). Less than 1000 of these operations are performed by the county council health service. We know only little where the remaining are done, by whom and how (11). In 2001 the Swedish Parliament issued a law, stating that the operation must be done by a doctor and appropriate anesthetics given. An exception was made for the Jewish circumcision done by a lay person – a doctor or a nurse had to be present and give the anesthetics. As is obvious from the above the large majority of circumcisions are per- formed without any control at all from the health service and thereby the law has not much effect as it cannot be implemented. In the traditional African setting, mainly South of the Sahara and in West Africa, it is estimated that some 9 million MGM are being done annually as an initiation rite to manhood. Again these operations are done by lay people such as barbers, are done en masse (“the boy shall go out in the bush”) and are an introduction to big parties. Under- standably the complication rate may be high. In 1995 in the Cape province in South Africa 34 boys had died, 12 had got the whole penis amputated and 743 boys had to be admitted to hospital for treatment of septic infections (12). Finally, in the USA and other Anglo-Saxon countries about 1 million circumcisions annually are done, practically all in the neonatal period and in hospital or other safe set- tings. This tradition started (in Germany!) with the idea that it should prevent or stop masturbation. Little by little up to more than one hundred indications were added – ranging from asthma to epilepsy. By 1960 about 80 % of all boys underwent circumci- sion. The figure now is about 57 % and continues to decrease, particularly in areas where the public health service is not paying for the operation (8). A large number of medical professional organisations have stated over and over again that circumcision does not bring with it any medical advantages ( ’’… data are not sufficient to recommend routine neonatal circumcision”) (10). Lately a number of studies seem to have indicated that the HIV rate should be lower in circumcised African men, presumably because the hardened surface at the glans penis better would withstand penetration of the HIV. However, still of course the HIV infection rate also in circumcised men is alarmingly high and constitutes an enormous medical and social disaster in Africa. CIRCUMCISION AND THE CONVENTION OF THE RIGHTS OF THE CHILD There is a UN committee located in Geneva, consisting of representatives from 18 different countries which shall implement the Convention. Hearings are arranged about every 3-5 years. Genital mutilation – although performed on a massive scale on more than 20 mil- lion boys and girls annually and being a medically unnecessary operation – has not been a prominent issue in these hearings. MGM, although listed in the Implementa- tion handbook to be reviewed (13) apparently has been totally removed from the agenda and no explanation is given for that (attorney Steven Svoboda, NOCIRC, Los Angeles, personal communication). Contributing to that may be what is stated in 32 Article 14 in the Convention …”Freedom to manifest one´s religion or beliefs may be subjected only to such limitation as are prescribed by law, a text which could be interpreted as contrary to the text in Article 24.3, which is quoted above. Over and over again in the Convention is stated that all action taken in relation to the child always shall be “for the best of the child”. With due respect for tradition and religious preferences and wants and considering that the child has no say and the risk for complications which may have life long effects - then it is indeed strange that the Swedish government has not acted to the effect that this violation against the child must be abolished. REFERENCES 1. Jansson S. Children and maltreatment (in Swedish). Report on corporal punishment and other maltreatment in Sweden at the end of the 20th century. SOU 2001:18, ISBN 91-38-21411-3 2. Bergenheim A. Brottet, offret och förövaren: Vetenskapen och det svenska rättsväsendets syn på sexuella övergrepp mot kvinnor och barn 1850-2000. ( in Swedish). Carlsson, Stockholm, 2005 3. Hofvander Y. The world´s children – the children´s world. Acta Paediatr 93:1414-9, 2004 4. Fang HSY, Yu FYK Foot binding in Chinese women, Canad J Surg 1960;3:195-202 5. Plafker T Sex selection in China sees 117 boys for every 100 girls. Brit Med J 2002;324:1233 6. Dirie M, Lindmark G. Female circumcision in Somalia and women´s motives. Arch Obstetr Gyn Scand 1991;70 (7-8):58-65 7. Female genital mutilation. Report of a WHO technical working group meeting. Geneva: 17-19 July, 1995. Geneva, WHO, 1996 8. The 8th international symposium on circumcision and human rights. An anthropological, med- ical, legal and ethical analysis. 2-4 September 2004. To be published. 9. Almroth L Genital mutilation of girls in Sudan. Doctoral dissertation. Karolinska Institute, Stockholm, 2005. 10. Hofvander Y Circumcision in boys: time for doctors to reconsider World hospitals and health service vol 38, no 2; 2002 11. Hofvander Y Circumcision of boys in Sweden performed within the county health service system. Report (in Swedish). Uppsala county council, 2004. 12. Sidley P Botched circumcision leads to arrest for murder. BMJ 1966;313:647 13. Implementation handbook for the Convention of the rights of the child. UNICEF, New York, 1998 Corresponding author: Yngve Hofvander Department of Women´s and Children´s Health University Hospital SE-751 85 Uppsala, Sweden 33 34