Child Abuse-or Cultural Norm?-in a Developing Nation

Most of the “Child Abuse-Or Mimic?” cases I have written that appear on this Web site have focused on cases involving children from developed countries. Like many of my colleagues here in the United States, I consider abuse daily in my differential diagnoses.

For the past 20 years, I have been visiting developing nations to deliver health care. Recently, I made a conscious decision to look for a case of child abuse to write about. Late in 2011, during one of my visits to a third world country, I encountered multiple situations that rose to the level of possible child abuse. Here I describe 3 such cases.

The practice of medicine in a developing nation presents a whole new dynamic. On earlier trips, I tended to view myself as a visitor present only to assist with medical issues: my goal was not to attempt to westernize the social climate. I suppose I turned a blind eye to the abuse in developing countries.

Case #1
The first case was that of a 12-year-old girl who had been impregnated by a 50-year-old man. The child presented to the clinic asking for a pregnancy test. She was very quiet and reluctant to give many details of her situation. In the United States, this would be an obvious case of statutory rape. Unfortunately, her situation proved to be more complicated. This child had been sold for a dowry when she was 11 years old-which is the social norm in some countries. She had no choice in this decision. A local nurse, who no longer follows the traditional culture, opined that this is a dreaded fate by young girls. 

There was no way to help this child.

Case #2
The next case was an 11-year-old girl with a possible STI. The child, accompanied by her mother, presented with the complaint of an abnormal vaginal discharge. The mother served as the primary historian. The child sat lifelessly, wearing a blank stare while her mother conveyed the narrative. The mother stated that a local teenage boy raped her daughter as she was gathering firewood. The daughter later confirmed this story. The rape victim and her family had confronted the rapist and his family and were given assurances that this action would not occur again. The two families then “settled” the situation according to their culture-by having a joint feast.

That the child had to attend the settlement feast is unthinkable to western minds . . . yet it pales in comparison to the fact that the rapes had not ceased. This girl and her family live in a very rural area where protective elements such as Child Protective Services or local police were unable to provide any type of service. In their culture, the male suffers no consequences for his actions. The female will be treated as damaged goods for the rest of her life. Minimal advice of protection was applicable in this culture.

Case #3
The third case is another example of a cultural norm that would be viewed with horror in the United States. Children are branded as infants with a hot iron in multiple places (Figure 1). The branding serves two purposes. First, it identifies the child as part of the tribe. Second, it is necessary for acceptance in the tribe. Branding is done under unsterile and unanesthetized conditions to children who have no opportunity to refuse. The scarring it causes is irreversibly disfiguring. 

This practice is tantamount to child labor. Young children as young as 6 or 7 years old are routinely seen tending part of the families’ herd. Although their primary risk of harm comes from animal predators, they are missing their childhood. Missing their childhood robs them of what Americans might view as a chance to dream of a future. They are robbed of the chance to have any other view of the world.

The whole perspective is not negative though. In the government clinics that my colleagues and I staffed, I noticed posters warning of abuse, displayed for what might have been the first time. One poster pointed out the dangers of female genital mutilation (Figure 2) and warned of present and long-term problems. Our interpreter indicated that the poster presented female genital mutilation in a very negative light. Another poster warned of the dangers of domestic abuse (Figure 3). The message to adult females was: go to the hospital if this happens to you. A major problem, though, is that the hospital is a 1- to 2-day walk from most villages.

The outstanding highlight of my trip was a visit to a church-run hospital. The hospital was in the process of opening a child abuse center. The process of training local physicians to identify and refer abused children was just beginning. By report, it was the first such program in the country. 

There is no one-line conclusion about these 3 cases. Was their treatment abuse-or are these simply social norms that are alien to me as a westerner? Or was their treatment an invasion of human rights?

After diligently observing the child abuse climate in a developing country, I fear that such abuse is an international scourge. It is encouraging to see the nascence of a movement in which a country rises to protect its youth. It will be interesting to see how this new trajectory will interact with societal and cultural norms.