Introduction

Throughout history children, i.e. human beings below the age of eighteen years, have been exposed to violations.’ (1) There is a gradual transition between neglect, maltreatment and torture of children. Corporal punishment by parents, teachers or public authorities, hard labour or misuse as ‘professional’ beggars is still common. New-born infants, especially female babies are constantly left behind or killed. In many places female adolescents and young women are exposed to mandatory virginity testing. (3)

Several kinds of mutilations have been practised, e.g. castration of boys (eunuchs), uvulectorny, female circumcision. The last-mentioned is ‘a hot topic’ at the present timc (4) The sexual exploitation of children is also ancient, as are incest, other forms of assault – rape and prostitut: ion. The specially vulnerable groups are adopted children, disabicd children (5) and, of course, the street children.’ (6) In recent years a cruet effort has been organized, ‘the social and ethnic cleansing operations’, to kill the street children by ‘the death squads,’-the national police, the military or private ‘organisations’. Another horrible ill-treatment is kidnapping of children or ‘voluntary’ sate of children for adoption, labour (slavery), prostitution or organ transplants. At the present time there is an enormous need for organs, especially l’ rom children and young adults and it is really ‘big business’. (7, 8) Furthcrmorc judicial physical punishment e. g. flogging, caning and amputation (nose, hand, foot) is applied to children under the age of eighteen – as is the death pcnaity. (9)

Prosecuted children

Children and adults are persecuted. There are miilions of children as refugees. Several of these are unaccompanied. The serious implications are spectacular: poor nutrition, housing, hygiene, health care, schooling and education. (10) During war several children ‘disappear’ – forced disappearances – some of thcse arc compulsoriiy adopted without Icgal permission, thus forced to assume another identity i. e. false name and birth date. (11) Children witness the raid of their home, arrest. interrogation, assault, rape, torture or execution of parents, other members and friends. In addition, even small children are misused as witnesses in court cases or are retained as hostages. (2, 12, 15) As described by Primo Levi, the former prisoner in a German concentration campl$ uring the World War II: ‘We were not able not to see’. (16)

Children as victims during war

Finally children themselves are arrested. Both boys and girls are interrogated, imprisoned, subjected to the most awful forms of physical torture e. g. tearing out nails, burning including electric torture, amputations, sexual assaults. They are also subjected to psychological forms of torture e. g. threats towards relatives, sham execution, sexual humiliation. (15, 17) Let me again quote Prim0 Levi in relation to this sadism of the torturer: ‘The enemy must not only die, but must die in torment’. (16) There is also evidence of children born in prison or camp of women raped by the police or military staff. Besides being victims the children are, unfortunately, also misused as child soldiers i. e. young combatants under the age of eighteen. Some of these are only ten, thus creating infantile perpetrators. Moreover children, patrioticaIly indoctrinated? are forced to die as martyrs.

The health of child survivors

The health problems for child survivors are multiple. The consequences of extreme violence may be physical signs e.g. wounds, burns, fractures of teeth and bones, amputations or other forms of mutilation, hearing loss and buzzing in the ears or serious neurological sequelae as paralysis, especially because of spinal injuries, and epilepsy.

In the long view we will have a lot of chronic disabled children. It is estimated at for every child killed as a result of involvement in extreme violence, there will be a further three disabled children. The repercussions of extreme violence concerning the mental health are gloomy. Anxiety with intimidating flashbacks, nightmares, depression, introversion living in their own world of fantasy and social withdrawal, dependency and clinging behaviour toward the relatives; and sometimes aggressiveness, nocturnal enuresis, poor appetite, abdominal pain, headache and tics have been noted. (15, 17, 18) The children lose their illusions and become mistrustful and disillusioned without confidence or faith in other human beings (19). Some commit suicide. Longitudinal studies have shown long many-have implemented this decision? standing serious complaints, at times throughout their lives. (20) Prirno Levi has made this laconic observation: References ‘Anyone who has been tortured remains tortured’? In the medical literature this phenomenon or syndrome is described as ‘the post-traumatic stress disorder’.However, in my opinion, the best evidence is presented by the excellent writers e.g. Isabel Allende, (22, 23, 24, 25) Andr Brink (26, 27), Jung Chang (28). Doris Lessin (29) Levi (16) Taslima Nasrin (30) Salman Rushdie (31, 32) Anatolij Rybakov (33, 34) and Elie Wiesel. (35)

Rehabilitation of child survivors

The adult population all over the world has to face these – miserable children. It is a challenge for health professionals and the responsibility is medical as well as psychological, social, ethical and legal.

The children need the help of paediatricians, child psychologists and psychiatrists, nurses, social workers and educators comprising physiotherapy, ergotheraphy, schooling and playing. Legal assistance should be available. It is seldom possible to provide such assistance. Starvation and massacres of children must be tackled pragmatically. Later on the child victims should, if possible, be offered rehabilitation by a team of expert health professionals. In the meantime, and during the entire rehabilitation process, it is important to know that the majority of children do not like excessive sentimentality or pity, they wish to know the authentic truth e. g. on their family, the medical prognosis for themselves or the present situation of their native country. Many children have lost their original faith. They exhibit a realistic outlook to life, as said by Isabel Allende: ‘God helps the good, when they are in majority…’ (24)

Let me also advocate against too importunate or aggressive questioning of the children, because several of these victims prefer to distance themselves from the therapist. The cruel traumas are often connected with shame e.g. sexual assaults, and the children wish to maintain their dignity, honour and pride.

Education on child survivors

Finally, I would like to emphasise the importance of information and education on all aspects of maltreatment of children in order to prevent this phenomenon. This education ought to be obligatory, not only at the Universities and High Schools (36), but must reach the children themselves at .an early time of life, if possible before the age of eight years, hopefully reducing the exploitation and abuse in childhood.

The United Nations Convention on the Rights of the child

The United Nations Convention on the Rights of the Child was established in 1989. Most of the countries in the world has ratified this important document, but how many have implemented this decision?