1 Introduction

The mapping which follows was conducted over a period of six weeks during February and March 2003, including one week of preparation and one week of report writing. Regional working group members of Save the Children Sweden - Denmark (SCSD) in the respective countries took the responsibility for identifying and contacting organisations and individuals who are working to combat CSA, particularly those providing psychosocial support to children affected by abuse. A total of 34 organisations and individuals were met. Six days were spent in each country, except in Afghanistan, where only three days were spent. The six locations were Peshawar, Islamabad and Karachi.

Organisations met included those working on child sexual exploitation and sexual health, and those working with communities of street children, MSM (men who have sex with men), and trafficked women and girls. Many groups could not be visited due to time limitations. Non-governmental organisations (NGOs), university psychology departments, community-based organisations (CBOs), international non-governmental organisations (INGOs) and donor agencies, as well as

independent research consultants and a theatre animator | | | were amongst the contacts met. Interviews were held | | | with those at management level, heads of organisations, | | | coordinators of child protection units, trainers, | | | programme officers, field workers, therapists and | | | counsellors. Wherever possible, counsellors, therapists | | | and caregivers working directly with children were | | | interviewed. | 1 | | | | |

Objectives

The objectives were to:

* collect and compile information on organisations working on community-based approaches to combat CSA and to assess their level of psychosocial support, including their structures and mechanisms; and

* map sexual health education projects which relate to children affected by CSA.

1.1 Methodology and Focus

The study was conducted primarily through meetings and semi-structured interviews with individuals and organisations. The discussions focussed on several key areas:

• Healing processes adopted for children affected

| by CSA | | • Models and approaches to counselling | | • Community-based interventions for preventing | | CSA or healing children affected by CSA | | • Child participation and child-centred approaches | 2 | • Approaches for working on sexuality with girls | and boys

Discussions lasted between one hour and three hours, depending on the availability of the staff member and the time constraints of the consultant. Information was recorded in note form. In Bangladesh and Pakistan, interviews were conducted with assistance from SC country office staff and volunteers. Discussions were informal and centred around questions to ascertain:

• how CSA is perceived in the country and the barriers and challenges encountered to providing psychosocial care for children affected by CSA;

• the type, quality and efficacy of psychosocial services being provided;

* the emerging models of healing environments; and

* good practices emerging from the region.

In the preparation week leading up to the mapping, secondary data from the internet on CSA issues in the region were collected, some of which have been included in the following country reports. Secondary data in the form of training manuals, reports, research documents, pamphlets and a film, all collected from the organisations met, have also informed the overall findings of this report.

Data were collected from a gender and non-discrimination perspective. The interviews were mostly conducted in English and the compiled findings, which were largely of a qualitative nature, were then analysed while writing the final report.

1.2 Challenges, Limitations and

Achievements

Firstly, a major limitation while conducting the mapping was lack of time. This made it difficult to get a full understanding of each organisation and the quality of their work. A minimum of one day with each organisation would have perhaps have improved the data collected. Secondly, meetings with many organisations were limited to interviews with the heads of those organisations. Although this was valuable for getting insights into the visions and perspectives of each

organisation, without meeting persons involved with the delivery of psychosocial support, it was difficult to get an idea of quality of counselling and other mechanisms of support. When both the head and counsellor/caseworker were met, more in-depth data were obtained. Thirdly, it was not possible to meet either the clients or those involved in policy-making. This is a major gap in the study.

Some other challenges faced by the consultant included:

* The 20 years of conflict in Afghanistan has significantly affected the social milieu, and thus it was difficult to contextualise psychosocial support on CSA. *
At times, bias may have entered the reporting when the interviewee thought that the consultant was a donor.

* A few times, details of information were lost in the translation of the discussions.

Despite these limitations, a great deal of information came to light as information was given wholeheartedly and enthusiastically. Those interviewed were very accommodating with their time and resource materials, and above all were extremely warm and hospitable. Logistically, the study was managed excellently, with superb coordination at the regional level and between country offices. This helped the consultant enormously with meeting the needs of her assignment.

2 Summary

2.1 Child Sexual Abuse in the Home

The majority of organisations have encountered obstacles in working on child sexual abuse within the family. Most people said families were difficult to access, since the family is private terrain, which culturally cannot be questioned or looked into. Challenging these norms however were, organisation like Breaking the Silence (Bangladesh), Sahil (Pakistan) and Rozan (Pakistan). By working in schools and providing anonymous counselling through help-lines, email and postal mail, they seemed to be successful in reaching out to children within their homes.

In all countries visited, it was found that women were the primary target group in terms of psychosocial support and protection for children from abusers both within and outside the family. Talking to mothers on how to protect their children was considered to be a concrete step towards both prevention and reducing further abuse. Male members of families rarely came to centres for counselling, and no interventions were identified that focussed on working with fathers or other male family members. A study conducted by Sahil,

called ‘Conversations with Mothers about Child Sexual Abuse’ investigated the family as a potential site of sexual violence.

Some interesting findings about family relationships and

children’s views of violence can also be found in ‘The 5 Children of Kabul: Discussions with Afghan Families’,

an as yet unpublished report by SC US, Afghanistan. It was seen that CSA was rarely addressed from a gender perspective. As well, few organisations made a concentrated effort to work with existing or prospective perpetrators.

2.2 The Impact of Cultural/Social Perceptions of CSA on Service Provision

Possibly one of the biggest barriers to providing psychosocial or protection services to children affected by CSA is the cultural silence that exists around sexuality. Child sexual abuse is viewed as something which should not be talked about, even if it is known and happening in close proximity.

Non-participation of children in the family is one of the reasons why sexual abuse often goes unnoticed. Children are rarely asked their opinions, even on non-contentious issues such as disliking school or on decisions that are being made within the family. If a child expresses discomfort with a particular person in the family, the discomfort will often be overlooked.

The taboos that surround CSA directly affect disclosure and consequently service use. Families and individuals are reluctant to seek services that openly work on CSA. Several organisations said that their local community views ‘shelters’ or projects for trafficked or sexually-abused girls as homes for ‘bad’ girls. Much of this stems from cultural notions of shame and family honour. While these notions are found throughout the region, they are particularly strong in Pakistan and Afghanistan,

6 where maintenance of family honour can be literally a matter of life and death, especially for girls.

Across the region, little scientific work has been done on child sexual abuse, and research is limited. Areas that clearly need to be researched include culture-based definitions of ‘child’ and ‘sexual abuse’, and perceptions of sexual maturation. Clarity on these is fundamental for assessing service use and provision for several reasons: 1) children are often viewed as compliant to abuse; 2) sexual abuse is often viewed as only rape and sodomy; 3) man to boy sexuality is widespread and, in some areas, legitimated; and 4) though it is clear that sexual abuse socially impacts girls and boys differently, perceptions also prevail that boys are less psychologically impacted than girls. These assumptions are common and

directly affect the way psychosocial services are accessed and provided.

2.3 Psychosocial Support in the Region

Most psychosocial support in the region for children affected by CSA is in the form of counselling services and rehabilitation and reintegration programmes. Rehabilitation and reintegration are both terms that need clarification. They are generally understood to include shelter, education, practical skills training, medical and legal aid, and social activities. Services are generally either centre-based or shelter-based, although very few children who are abused in the home are reached by such services. Some organisations interviewed, including Bandhu Social Welfare Society and INCIDIN in Bangladesh and Azad Foundation and AMAL in Pakistan, deliver counselling services at the community level for communities of MSM (men who have sex with men) and street children.

Counselling is understood differently depending on the level of expertise and training undergone by staff. Some notable examples of training programmes on psychosocial support were found to exist in Nepal (CVICT) and Pakistan (Rozan). The CVICT course is a model that can be adopted in other countries as it takes in many cultural specificities in the way trauma is experienced, expressed and dealt with South Asia. A good example of capacity building for psychosocial care at the community level was observed in Pakistan (SACH), where young women from far-flung areas of the country are currently engaged in the first year of a

course on psychosocial counselling, in order to go back and create support services in their communities.

The word ‘counselling’ is applied to a wide range of activities, from information-giving and advice-giving to client-centred approaches. Most organisations professed to offer client-centred approaches. In some organizations, mechanisms of support were directed at providing reassurance and giving comfort, rather than working with deeper issues of trauma. Here, there was a tendency to view the child as a victim, rather than a person with resilience and capacity to heal. Approaches to counselling varied.

Individual and group counselling were common. Many organisations applied different approaches depending on the age group, but few varied their approaches according to gender. Very few said they adopted different approaches for boys. One or two organisations said that boys expressed themselves differently, and applied action-orientated approaches for boys such as physical games to release expression.

Some interesting peer group support models existed in Pakistan (Dost Foundation) and Nepal (CWIN), where it was found that children and adults initially expressed themselves about childhood violations easier with each other than on a one-to-one basis with a counsellor. Peer activities were found to build trust and help clients understand that they were not the ‘only one’ who had been sexually abused. One-to-one counselling was also seen as culturally inappropriate in Afghanistan, where sitting alone with a person while talking about ‘confidential’ matters was deemed suspicious.

Notable examples of psychosocial work with perpetrators of CSA were found in Pakistan (Dost Foundation and Hamdard University Department of Psychiatry). Rozan in Pakistan has initiated the White Ribbon Campaign, in which a group of young men talk to male lorry drivers in petrol stations about gender violence. It was found that the use of religious messages from the Quran to talk to men about CSA was a highly effective way to help men acknowledge responsibility for perpetrating sexual abuse on children and to prevent further abuse.

Some other points that emerged from the study and are expanded upon in this report include:

* Need for expanded rights-based perspectives in interventions, with emphasis on non- discrimination, gender and diversity. | 7 |

* Limited understanding of and attention to root causes of sexual abuse.

* A lack of understanding of the impact of institutionalisation on social integration, especially for girls and young women.

* The ‘rescue’ approach predominating over a child-centred approach.

* Lack of child participation in psychosocial support, and lack of understanding by organisations on how to promote child participation.

• Inappropriate identification of orientation programmes as ‘counsellor training’, resulting in untrained persons engaging in ‘counselling’, with the danger of further traumatising the child.

• Only a few organisations having supervision structures to monitor the quality of counselling activities.

| • Care-for-caregivers not being recognized as an area | | of need. | | • Lack of clinical practice in counselling courses. | | • Lack of minimum operational standards for | | caregiving facilities. | 8 | • Undeveloped mechanisms to enter and support | families. • Lack of accountability of the majority of duty bearers.

• Shortage of experts with capacity to work on CSA (many go abroad following training).

• Limited professionalism, procedures, protocols, extensive training inputs and infrastructure to provide comprehensive healing environments.

• Misuse of the term ‘counselling’; lack of conceptual clarity about psychosocial support; lack of knowledge about caregiver roles, i.e., including counsellor, para-counsellor, guidance counsellor, social worker, etc.

2.4 Definitions

Counselling

Counselling is a two-way process for the benefit of child survivors, helping them to understand and work with feelings of depression, low self-esteem, sadness and hopelessness, for example. It is a process of listening and responding to a child in a non-judgmental way, assisting when they need to ventilate or express feelings, and providing support through non-verbal and verbal means. Complementing verbal counselling, experiential therapies use methods such as art, music and play to help children to project their feelings, and receive affirmative love or care.

The traumatic past of a child who has been sexually abused should not be delved into in this type of general counselling. The depth and manifestation of trauma can possibly be worsened by non-professional intervention. Discussion of traumatic events should only be conducted by a professionally trained person with sufficient clinical experience who can help the child re-look at things that have happened in her/his life, and assist in managing the trauma surrounding her/his experiences.

2.5 Roles in Caregiving Facilities

Professionals

Long-term training, including clinical experience, as specialists in a particular discipline. These include physicians, psychiatrists, psychologists, counsellors, lawyers, and social workers. Their tasks include medical assessment, psychosocial response to acute trauma, family assessment and legal intervention, for example.

Para-professionals

Persons with a comprehensive but medium-length training and clinical practice (four months to two years) in a specific discipline. These could include para-counsellors, para-medics and para-legal workers. They provide the majority of specialised tasks in a caregiving environment, such as general counselling for non-acute emotional problems, family assessment and problem-solving, first aid and emergency care, and routine legal preparatory activities. This cadre should, however, acknowledge their limitations and provide referral of acute problems to trained professionals.

Support Staff

These comprise the largest proportion of staff in caregiving facilities of organisations in the region. Support staff have the vital role of providing support, companionship and guidance to clients. As the persons most in contact with the abused child, they are essential for assisting in the development of self-esteem, providing stress management and conflict resolution, and helping clients clarify their needs and hopes for the future.

9

10

3 PAKISTAN
Country Report

6.1 Background

Despite media reports of 4078 cases of sexual assault by men on 2309 children between 1997 and 199931, child sexual abuse continues to be a largely unacknowledged phenomenon in Pakistan. Prevalence appears to be high. In a study conducted in 2002 with 100 adults from three psychiatric units in Karachi, 33 persons had experienced CSA32 . In another report carried out in the North-western Frontier Provinces (NWFP), 47% of male respondents believed that the practice of men keeping boys for sexual services was a common practice. During the current study trip, one organisation reported that 16 out of 20 children in their care had been sexually abused33 , while in a school-based study 20% of the children interviewed had reported facing one or more forms of sexual abuse34 .

Though there has been scant scientific work on child sexual abuse in Pakistan, there has recently been considerable response from the government, NGOs and some dedicated legal and medical professionals to put child sexual abuse on the map. Pakistan has ratified the Convention on the Rights of the Child and is a

signatory to the Stockholm Agenda and Plan of Action against Sexual Exploitation of Children. The Stockholm Agenda demands that signatories strengthen strategies, promote attitudes and facilitate practices to ensure child rights.
45

A national consultation was held in 2001 for developing a Policy and Plan of Action against Child Sexual Abuse in Pakistan. The National Commission on Child Welfare and Development, the Pakistan Paediatric Association and Save the Children Sweden - Denmark sponsored the consultation, inviting experts from non-government organisations, health practitioners, lawyers, psychologists and government functionaries. It was the first time that such a consultation has been organised by the government.

Social understanding of what comprises child sexual abuse is often limited to rape and sodomy. There is no legislation specifically dealing with CSA35 . Lack of information and procedures regarding lodging police complaints for cases of CSA exacerbates the problem.

The provisions of juvenile legislation are frequently unknown to the police and lawyers. The impact of this is the further traumatisation of the child.

The educational system does not permit any discussion of the issue, for many reasons. In addition, there is no safe space for disclosure. Police are largely insensitive to the impact of CSA, and many medical professionals do not comprehend the gravity of the offence and often uphold the dominant ideology of family stability and privacy. There are few counsellors available for survivors. The state legal system is unaware and often unwilling to be proactive to the issue.

Direct action against domestic and commercial sexual abuse of children in Pakistan is minimal. Children remain at high risk in their own homes and in public

46 places like video centres, video game shops, snooker clubs, cinema halls, bus terminals and roadside hotels36 . The transport industry is an institution where child sexual abuse thrives and roadside hotels are places where children in difficult circumstances can be easily trapped into sexual service and abuse. In some areas, religious shrines have been identified as high-risk places37 .

There has been no research in Pakistan to ascertain the impact, responses to and reasons for CSA in terms of gender. Research by Sahil found that though male children are regularly subjected to sexual assault (in 1999, 44% of the total known victims were male children),38 the print media generally reports incidents of sexual abuse of girls due to the fact that the female body is seen as a sex object, as more vulnerable. Girls

are ‘dishonoured’ by men as a public act of revenge to settle outstanding scores with rivals.

However, hundreds of young boys work in workshops and sordid hotels near bus stations, such as the Pirwadhai bus station in Rawalpindi39 . Here, local hotel owners promote the trade by employing children who are used to attract customers. According to several organisations, the North-western Frontier Provinces and other tribal regions of the country are well known for men keeping boys specifically for sex. This strictly male-to-male practice increases the status and prestige of the man, depending on the number of ‘good-looking’ boys he has with him. There are no cultural or social mechanisms to check this practice. On the contrary, it is publicly visible, unlike sexual abuse of girls, which is hidden and outwardly condemned.

All this seems to be a result of the rigid segregation of men and women in Pakistan, which is most seriously enforced in the Pashtun areas of the North. Under Pashtun culture it is very difficult for a young man to interact with the opposite sex, particularly in the rural areas. Thus, young boys become the targets of abuse.

Another important aspect of child sexual abuse is incest. Generally, it is perceived that this phenomenon is non-existent or negligible in Pakistan society. Sahil data show 70 cases of incest during 1997 to 1999. In these cases, the predominant abusers were fathers. For the most part, the mother was the one who took action and approached the police. In all the reported cases the crime was rape. Interestingly, all the victims were female

children and there was not a single reported case where a father or brother had sexually assaulted a male child. Father-to-son abuse was however reported by relief workers in refugee camps in Peshawar40 . The indisputable status that a husband enjoys and the fact that families are dependent economically and socially on the male head of the family make it exceedingly unlikely that cases of incest will get reported to the authorities.

6.2 How CSA is Viewed in Pakistan

Child sexual abuse is a complex issue in Pakistan, for a number of reasons. The language of sexuality is restricted, especially for girls and women, definitions of the child are unclear, and children are all too often not given space to express their concerns. Demonstrative homo-affectionate behaviours can easily become blurred with sexually abusive ones, and male power and space tend to violate the personhood of the less powerful. These are constantly legitimated and reiterated at all levels of society.

Most people are aware that child sexual abuse exists, although they are not vocal about it, may deny it exists in Pakistan, may dispute that it happens in families, or may even condone it. In one study in the NWFP, 1800 men were interviewed about their feelings about child sexual abuse. One third of the respondents said they did not consider it to be bad, let alone a ‘crime’ or a ‘sin’. At one organisation met during this study, counsellors reported that many men they come in contact with are not aware that the sexual abuse they had committed was

wrong41 . According to the men, it was a part of life. Said another person interviewed, ‘abuse is not seen by most men as wrong. It is normalised and they express neither pleasure nor guilt. They express it as ‘killing time’.42

Regarding women’s views, in a survey conducted by the | | | NGO Sahil43 , 99% of mothers were aware of child | | | sexual abuse, though most women believed that it | | | happened more outside of the family, and that Maulvis | | | (religious leaders) were to blame for sexual abuse rather | | | than male relatives. Children are time and again viewed | | | as compliant, or worse, are to be blamed for the abuse. | | | In the same study, 19% of the women reported to have | | | a negative attitude toward abused girls, and 17% | | | towards abused boys, confirming that many children are | | | held responsible and further victimised by their own | 47 | | families. | | |

Social norms, particularly those surrounding virginity and family honour, tend to normalise rather than denounce child sexual abuse. The notion of honour (and its contrary, shame) deeply informs most social practices and norms in Pakistan. Transgression of these norms, whether it be in the form of violence, child sexual abuse or consensual arrangements (i.e., sex outside of marriage, multiple partners or same-sex relationships) are all ruthlessly stigmatised if publicly displayed. If disclosed, such behaviours bring immeasurable shame upon the child and more importantly upon her or his family.

Thus, it becomes imperative that all sexual behaviours which defy norms or question the foundations of what

constitutes ‘family’ remain firmly hidden from public inquiry and therefore unchallenged. Embedded in the protection of the family is male superordination and the institutionalised silencing of women and children. Within this climate, child sexual abuse goes unchecked.

Due to widespread child marriage and the placing of adult responsibilities on children at an early age, the child is held sexually accountable when the police, court or society confronts a child sexual abuser. Abused girls are deemed to be ‘damaged goods’, losing their opportunity for marriage, whereas boys can still get married, and their individual and familial honour can remain intact. Honour killings are evidence of this. A few points have emerged from organisations that have interacted with both boys and girls on the issue of sexual abuse. For example, boys were found to be dealing with

48 fear of marriage, sexual performance, homosexuality, anger, guilt and confusion about whether excessive masturbation was linked to abuse. On the other hand, girls were grappling with virginity issues, confusion over whether abuse may have made them pregnant, and concerns over eligibility for marriage.

Some counsellors found that boys could channelise their experience much better through physical activities and that they were more conducive to rehabilitation than girls44 . This was ascribed to boys getting more support from the family and to the supposition that girls were more likely than boys to feel that abuse was their fault. Girls were more often found to be subdued and were harder to access, being hidden by the family. Boys generally had more access to resources of recovery than

girls, and were less constrained by issues relating to family honour. Some organisations tried to promote mixed gatherings to discuss the issue of CSA, and one organisation found that different verses of the Quran could be used to help girls overcome shameful feelings45 .

6.3 Organisations Providing Psychosocial Support to Children Affected by CSA

The situation of psychiatric and psychological education in Pakistan is severely hampered by a lack of courses in behavioural sciences, lack of opportunities for clinical training, and lack of recognised institutions with postgraduate training. This has resulted in a shortage of trained professionals in mental health across the nation. For instance, Karachi, with a population of 9.33 million only has a total number of 72 practicing psychiatrists.46 This has particular significance when it comes to psychosocial support for child sexual abuse, a gap recognised in the National Plan of Action and many of the organisations visited.

Engaged in diverse psychosocial support and reintegration programmes, the organisations visited work with varied populations including juvenile offenders, refugee children, out-of-school children, street children, employed children, school-going youth, and trafficked and sexually exploited children. Levels and structures of support differed greatly, and all organisations have a multi-disciplinary approach to working in the area of child sexual abuse.

Aahung, Karachi, conducts programmes to train

teachers and health service providers on sexual health issues and CSA. They are actively pursuing the inclusion of sex education in the curriculum of schools. Working with Save the Children UK, the organisation has developed a life skills curriculum that seeks to raise Pakistani adolescents’ awareness of sexuality and reproduction, build their self-esteem, and increase their access to quality sexual health services. The curriculum makes a special effort to ensure sensitivity to issues of gender.

AMAL, Islamabad, works primarily in awareness raising about HIV/AIDS. AMAL has worked mainly in outreach to young people in Gawal Mandi, a district of Rawalpindi where child labour and child sexual abuse is highly prevalent. They have initiated peer education projects in areas that have a concentration of truck repair workshops where there is a significant population of young boys. In the process of awareness raising, the high prevalence of CSA emerged as a crucial issue. In collaboration with UNICEF they are producing a life skills training manual aimed at linking and integrating CSA into life skills for children. Though they don’t have institutionalised psychosocial support structures, they have included psychosocial intervention in their work on the street.

Azad Foundation conducts direct interventions with street children and youth. Through long-term relationships with the children they raise awareness on street children’s rights, as well as arranging activities affirming childhood, such as picnics. In their experience, 90% of the boy street children report sexual abuse. Sexual abuse cases are referred to the

Foundation’s resident psychologist. The Azad Foundation works with families with the aim of providing traditional support for street children, and has started a project to record data on street children, in order to assist families in locating their missing children.

Dost Foundation in Peshawar is a drug rehabilitation | | | centre. The target constituency is adult and juvenile | | | offenders within the prison system. This has inevitably | | | led to address issues of CSA because 90% of child | | | substance abusers report histories of child sexual abuse. | | | They have found that substance abuse and crime are | | | inextricably linked to CSA. They have a wide range of | | | interventions which include skills training, counselling, | | | therapy and de-addiction. Interventions are conducted | | | both from the centre and in the prisons. Dost | 49 | | Foundation also works with abuse perpetrators, and | | | conducts sensitisation programmes for the police on CRC and CEDAW.

Dost Foundation’s Therapeutic Community Model for juvenile offenders is located in the juvenile barracks of Peshawar Central Jail and caters to the rehabilitation and reintegration needs of young offenders. Though there is no specific programme on CSA, they recognise the linkages between sexual abuse, drug abuse and crime, and adopt a holistic approach with the young people. Interventions are conducted by a team which includes psychologists, caseworkers, vocational trainers and teachers. They also offer a similar therapeutic community for women and children in Peshawar Central Jail.

Hamdard University Hospital Day Care Centre, Karachi, was established by the Psychiatric Department of the University. They have a day care centre designed for psychosocial support for child and adult survivors of sexual abuse. The primary focus of intervention is the family, and they work with perpetrators as well. They are aiming to do work on CSA with the mullahs (religious leaders).

Lawyers for Human Rights and Legal Aid (LHRLA), Karachi, is a legal intervention NGO working to secure justice and support for survivors of violence and sexual abuse. They litigate and use training as a tool of advocacy with the community and the Nasims (the local mediators). The organisation is working towards elimination of discriminatory practices, such as the repeal of the Hudood Ordinance, a law that victimises

50 female rape victims. LHRLA has succeeded in getting acquittal for many women unjustly indicted in Hudood cases.

The majority of the people who approach LHRLA to seek help or initiate proceedings also need counselling or/and crisis intervention. LHRLA provides the service of trained clinical psychologists for the benefit of legal clients. LHRLA has also initiated a help line, and refer psychosocial cases to professionals. In addition, they have an outreach programme in Korangi, which has a high population of migrants.

The organisation Rozan’s Aangan Project in Islamabad works on issues of CSA and the emotional well-being of children and women. The Aangan Project has five

programmes: children and violence; women and mental health; gender sensitisation for communities and institutions like the police; a youth help line; and school packages designed to sensitise teachers on CSA and other child development issues. Aangan focuses on domestic CSA rather than commercial sexual abuse of children.

The Aangan Project provides psychosocial support also in the form of counselling and therapy, although given the social seclusion of Pakistan children do not have the freedom or opportunity to physically meet counsellors to discuss their CSA experiences. Children who attend school workshops or counselling camps are given the Aangan Project address, email address and help line numbers so that they can contact counsellors to discuss CSA incidents. Many correspond with the project by letter, developing rapport with counsellors in writing. According to a project coordinator, both girls (55%) and boys (44%) access the services.

Struggle for Change (SACH), Islamabad, conducts community-based programmes with refugees and internally displaced children, and provides shelter to women and children who have endured domestic physical or sexual violence. This affords an entry point for providing support and raising awareness about CSA through education programmes. SACH has been working with torture victims since 1994, and has shelter homes for victims of torture and abuse. They conduct programmes for sensitising the police, and actively engage with the Law Ministry and the Women’s Ministry. They have a psychosocial rehabilitation team consisting of a doctor, psychologist, physiotherapist and

several counsellors. They have long-term training programmes in counselling skills for women in distant districts to enable them to work in their areas.

Sahil was the first organisations in Pakistan to work solely on the prevention and treatment of CSA in the family. They conduct identification of CSA, counselling interventions and prevention through awareness. Though based in Islamabad, they have programmes in the conservative areas of Baluchistan, Chilas and the NWFP. Awareness and advocacy activities are conducted through the media, communities and schools. Activities are also directed at the government, including the sensitisation of the police.

Sahil has recently set up a counselling centre, called the Jeet Healing Centre, in response to the need recognised during their awareness-raising work in the schools. The centre is based in a shopping centre and a board outside openly publicises the organisation as working against child sexual abuse. Sahil’s focus is on reaching children who face sexual abuse at home, and reach out to children through a help line which is advertised widely in the print media and on the radio around Islamabad. Professional clinical psychologists offer free therapy and providing email counselling for both children and adult survivors.

Save the Children UK, Peshawar, is an organisation working on child protection in the North-western Frontier Provinces (NWFP) of Pakistan. Their present work on CSA has evolved largely from their experiences with children in Afghan/Pashtun refugees camps within

Pakistan. The organisation does training in child development, including stages of sexual development and the indicators and consequences of CSA. They have initiated and are the hub of a referral network of individuals and organisations for the protection of children in the NWFP. In the Kotkey Afghan refugee camp, SC UK has conducted a programme to sensitise doctors about the special requirements of CSA cases. Feedback from the programme indicates that the mothers of CSA victims are actively involved in supporting their children. Save the Children UK is also working in Torkham, a tribal community with a high prevalence of child labour. Here, an all-male team is working to raise awareness of CSA of young boys. Activities include forming peer groups of children, and sensitising children and mothers regarding CSA.

6.4 Qualitative Analysis of the Support | 51 |

All organisations visited, with the exception of the Azad Foundation, had ‘teams’ of psychologists working with children. They also had staff (‘counsellors’) who had undergone some form of training or orientation on psychosocial counselling, usually short-term courses and sometimes delivered by experts from abroad.

The 15-member team at Hamdard University Hospital Day Care Centre has received specialised training on trauma management from Karachi University. The Dost Foundation, Rozan, Sahil and SACH all have in-house specialised training on CSA and supervision structures for all newly-appointed psychosocial staff. As well, they all had a policy of appointing only professional

psychologists to work with abused children. As in other countries, reports revealed that the term ‘counselling’ was a misused term in Pakistan, predominantly coming from the model of family planning motivational counselling.

Counselling sexually abused children, as reported by the organisations, included placing emphasis on the child’s ability to heal; helping the child understand that abuse was not her/his fault and should not have happened; ensuring confidentiality; and explaining to the child that sexual abuse happens to others. That values and attitudes should be kept out of counselling processes is endorsed as a priority condition for effective counselling.

Using various tools and techniques depending on the 52 clients’ age, class, personality and behaviours was considered vital by the organisations. Many groups adopted methods of puppetry, story-telling and games when working with young clients. One method found useful in working with older clients was telling them about famous people who are also sexual abuse survivors. Many organisations said children require varying degrees of help in recovery from sexual abuse.

Some counsellors reported children only needing ‘support’, and counselling techniques were used primarily to provide relief and space for ventilation. Several organisations in Pakistan use support group techniques with boys, girls, mothers, teachers and perpetrators. These activities explore issues like blocking feelings and grieving, as well as using cathartic approaches like letter writing to the abuser.

Hamdard Centre organises therapeutic groups based on supportive psychotherapy models for parents and children together, as well as a therapeutic group for perpetrators. They work mostly with sexually abused girls. Activities include imparting skills in self-protection, including karate training, and showing films on CSA. With younger children, they provide the mother with knowledge of how to empower the child. Removal of the child from the family for protection reasons by social workers and lawyers is adopted as a strategy, but has been very difficult to put into practice.

When Rozan works with children accompanied by their parents, they begin with taking a history of the abuse from the parents and noting how they are coping with the situation. Sessions with children at Rozan cover rapport building and affirming confidentiality both to the child and the parents. Ongoing counselling processes involve dealing with feelings of guilt, anger, helplessness and mistrust, working on self-esteem, developing a positive body image, and providing information on protection. Individual meetings with parents are conducted regularly to help them deal with their own feelings about the traumatised child.

Sahil’s approach is to offer six sessions without disclosure of sexual abuse, after which clients are referred to other services if their issues are not related to sexual abuse. Their counselling facility is also open to adults, though they prefer to refer perpetrators and clients with severe problems to outside professionals. At Sahil, art therapy, play therapy, story telling, colour therapy, Reiki healing, yoga and meditation are offered

in conjunction with counselling. They have adapted techniques of TAT (pyshological-test) using animals instead of humans in pictures if there is a low level of literacy or if the child is very young.

The Dost Foundation uses an entirely different approach to counselling: a ‘therapeutic community’, which means creating a supportive environment through peer group support. The ‘healing family’ allows young people to talk and support each other in their problems. They find that peer counselling initially works more effectively as the child doesn’t readily open up with the counsellor about sexual abuse. After the child feels more comfortable through recounting her/his experiences to another child, it is easier to develop a relationship with a counsellor. Stress management techniques are also imparted. Dost counsellors work extensively with children on feelings of guilt. Dost sees a clear link between guilt, continuation of drug abuse, and psychological problems such as depression and behavioural disorders.

AMAL mixes behavioural therapy with local adaptations of experiential therapies. One example is ‘reading therapy’, which begins with a small lecture on sexual abuse, after which the child is invited to read in more detail about the subject. After a day or two she/he is invited for a session to talk about the topic. If the child identifies with the issue she/he can enter into a counselling process. In AMAL’s street interventions, psychosocial processes were incorporated with protection and negotiation skills. Most important, the child is given the necessary skills to report the abuse to someone older.

Many organisations used HIV/AIDS and CRC Article 34 (sexual exploitation) as entry points to discuss sexual abuse. Several organisations used verses from the Quran, prayer, relaxation and Wooso (a ritual cleansing process), finding them helpful in overcoming guilt and feelings of pollution from the abuse, as well as preventing further abuse by perpetrators.

6.5 Sex Education

Pakistan is a society with tremendous reserve about discussing sexuality, and little research is available. The education system and media are both excellent avenues to impart information on sexuality issues to young people, but the common belief is that such information would lead young people into promiscuity. As children grow up, the craving for information results

in children being misinformed about sexuality by 53 visiting hakims, reading pornographic stories, and

seeing pornography in videos and on the internet. In Pakistan today there is a growing movement among organisations to bring sexuality issues to the forefront. Much of the urgency to talk about sexual issues comes with increasing concerns about HIV/AIDS and sexual violence.

Most of the organisations are convinced about the importance of equipping the child with skills of body protection, disclosure to an adult, and negotiating sexual advances from the adult world. The organisations do this through body mapping techniques, theatre and story-telling, among other tools.

One of the challenges faced by many of the organisations interviewed is getting sex education into the school curriculum. AMAL has worked with this in conjunction with UNESCO, and has produced a life skills manual. However, they have come across significant resistance from the government. The government decided that certain pictorial information pertaining to sexual / reproductive organs had to be removed as it did not fit the ‘cultural context’. AMAL say this has been quite detrimental to teaching children about their bodies and sexual functions.

Aahung has also found resistance in their work to get schools to integrate sex education into their curriculum. Aahung is currently affiliated with a teacher training institute which works with seven schools. They report that teachers agree that adolescents

54 need sex education but are unwilling to take a stand on it. Teachers’ fear what parents will say, and fear being blamed for promoting irresponsible sexual behaviours.

Rozan imparts information on sex education through their help line and by correspondence with children. Their communications cover sex education, and normalising sexual feelings, experiences and behaviours. SACH also said they have imparted teacher training in sex education that included ‘health and hygiene’, HIV/AIDS and reproductive health. Azad Foundation said that through rapport building with street children

over the last three years, talking with them about sexuality and child sexual abuse issues is now easy. Other organisations visited in the study expressed great reluctance to talk about sexuality in their work on CSA. SC UK said they adopted methods such as story-telling as a way to open up, for example, the topic of puberty.

6.6 Good Practises

Good practices observed in one or more of the Pakistan organizations include providing support group activities as a follow-up to CSA workshops for teachers, mothers and children, use of Theatre for Development as an awareness-raising tool with adolescent sexual abuse survivors, promoting mixed gender gatherings to discuss the issue of CSA;

initiating the ‘White Ribbon Campaign’47 with young men in Islamabad to address issues of gender violence, and organizing a boys’ peer group, the ‘mechanics group’, which developed a tool kit on rights and CSA. Other notable practices include working with Mullahs, raising awareness about CSA by quoting from the Holy Quran, and connecting the process of counselling to religious rituals, conducting legal awareness on CSA with Nasims, providing awareness training on CSA to teachers, social welfare officers and doctors, training teachers and parents in how to identify CSA, and forming committees in the community to advocate for the prevention of CSA.

| | | | | | | | | 6.7 Barriers and Challenges | | | | | | | | | | | | | Following are a few identified by the organisations: | | | | | | • Lack of reporting of child sexual abuse; | | | | | | • Parents further victimising the child after disclosure; | | | | | | • Parental attempts to get children to change their statement after reporting CSA; | | | | | | • Women’s dependence on men’s preventive activities to stop abuse; | | | | | | • No definition of sexual abuse in Pakistani context; | | | | | | • Parental discomfort with sexualised behaviours of the child; | | | | | | • General discomfort with the issues, resulting in trivialising or denial of CSA; | | | | | | • Lack of trained expertise on CSA; | | | | | | • Poor medical and legal procedures which may further violate the child; | | | | | | | | | | | | • Lack of awareness amongst lawyers about CSA; | | | | | | • Lack of legal remedies or specific legislation for different forms of CSA; | | | | | | • Inability of children to access protective and healing services without their parents; | | | | | | • Key persons in contact with children (teachers, parents, etc.) lack knowledge on how to identify child | | | | | | sexual abuse; | | | | | | • Difficulty in talking about CSA in awareness-raising programmes; | | | | | | • Limited public knowledge on lodging of police reports on CSA; | | | | | | • Lack of CSA networks in Pakistan; | | | | | | • Insufficient time and resources spent on capacity building; and | | | | | | • Inadequate support for caregivers working with abused children. | | | | | | | | | | | | | | | | | |

7 Recommendations

Recommendations

Save the Children is committed to protecting children from child sexual abuse by addressing the issue from a child rights-based approach. ‘Child Rights Programming (CRP) means using the principles of child rights to plan, manage, implement and monitor programmes with the overall goal of strengthening the rights of the child as defined in international law.’48

Working on CSA from a CRP perspective means addressing the root causes of child sexual abuse, including patriarchal power structures and unequal power relations between children and adults, and recognising children as rights holders and social actors. It means giving priority to children, creating child-friendly environments and providing child-friendly information on child sexual abuse and sexuality.

Governments should be recognised as primary duty bearers, accountable for addressing and taking action against CSA. Parents and families are seen as the primary caregivers and protectors, and must be supported in this role. Using participatory and empowering approaches, partnerships and alliances

must be created to promote the rights of the child for | | | addressing CSA. | | | Research | | | | | | | • Areas that need to be researched include culture- | 57 | | based definitions of the child and sexual abuse and | | | | | | perceptions of the sexual maturation of girls and | | | boys. This will help to clarify misconceptions | | | which are constraints to addressing the issue, | | | such as ‘only girls can be sexually abused’, | | | ‘children are compliant with abuse’, and ‘the only | | | kind of sexual abuse is rape’. | | |

* In order to develop appropriate psychosocial interventions, research is needed to better understand the social and cultural context
(family and community structures, norms and values, such as the notions of shame and honour). This will allow interventions to be built on positive, supportive and child-friendly values, structures and mechanisms. It is important to

learn more about the family systems, as well as about families’ and children’s own coping mechanisms.

* In countries where child sexual abuse is not ‘accepted’ as an issue or concern, quantitative research is necessary to determine the magnitude of the problem, in order to raise public awareness and to lobby governments to address the problem, including promoting the development of psychosocial support mechanisms.

* It would be helpful to conduct research on children’s own perception of child sexual abuse (who abuses them, why they think adults abuse children, what can be done to prevent and address child sexual abuse, etc.). This 58 | understanding will assist in developing | | appropriate psychosocial interventions. |

* Research on gender relations, masculinities and sexuality will increase understanding of the taboos and barriers that need to be addressed. It will help in the development of psychosocial support mechanisms that are gender sensitive and help children develop their personal sexual identity.

* More research needs to be done on how CSA affects children of various backgrounds, especially children with various forms of disabilities. This research needs to be conducted from a gender perspective to clarify how interventions to address CSA affect boys and girl from various backgrounds. *
Lack of children’s participation is one of the root causes of child sexual abuse. Sexually abused children are typically reluctant to disclose their experiences due to feelings of guilt and shame, dependency upon the perpetrator, inability to understand the sexual meaning of the abuse, and other reasons. Research on children’s participation in the family and other social institutions

(educational, religious, etc.) can identify situations in which girls and boys are able to express themselves and circumstances in which their views are taken into consideration. This will help in developing appropriate psychosocial support mechanisms with the involvement of children, and in promoting a society that respects children’s views and acts according to children’s agendas.

* Research on girls’ and boys’ resilience, including case studies of boys and girls who have been able to overcome the negative experience/trauma of sexual abuse, will help in designing interventions that build on and develop children’s resilience and coping mechanisms.

* Research and study of best practices on community-based approaches for addressing various forms of trauma (for example, the trauma of children affected by armed conflict) can provide important information for developing community-based psychosocial interventions for addressing CSA.

* More study and information is needed on ‘young perpetrators’ and their psychosocial needs.

Prevention

* It is important to strengthen and develop professionals through schools of social work, departments of psychology, etc. and to ensure that CSA issues become part of university curricula and clinical training. University training should provide a clear child focus, and clinical practice should be part of the curriculum for all persons who will work with CSA.

* Awareness of the extent and the impact of the problem is an important component of any strategy to address child sexual abuse. Various stakeholders need to be aware and to accept that child sexual abuse does exist and that it can happen to any girl or boy. On the other hand, to initiate awareness campaigns on child sexual abuse without having appropriate psychosocial support and interventions in place to address the problem will create unfulfilled expectations and might create further distress for children who have been sexually abused.

* Awareness campaigns on child sexual abuse needs to be specifically targeted at fathers, teachers, mothers, decision-makers, etc. The information needs to be age, gender and diversity sensitive, relating to girls and boys of various backgrounds and ages. Children should be involved in designing and field-testing information materials, including child-friendly information materials for girls and boys. Many information materials are

available (globally as well as in South and Central Asia) that can be adapted and translated into local languages. Positive religious values that condemn child sexual abuse can be incorporated into the messages of the awareness campaigns.

* Awareness and education on life skills (negotiation skills, assertion skills, etc.), sexuality, sex education, gender roles and relations, power relations responsible sexual behaviour, etc. will not only help to prevent abuse, but will also help children recognize that they have been abused. Appropriate and age-specific information will also help the child to develop a strong sexual identity as part of the healing process. It is also important

to make the public aware that both girls and boys 59 can be sexually abused.

* Promote programmes for young men on parenting and stress the benefits of all male members of society playing a more active role in nurturing their children and abandoning the culture of violence and abuse as a proof of masculinity.

* It is important to increase knowledge of gender issues and child sexual abuse among professionals, such as teachers, medical doctors, lawyers, police and law enforcement institutes, and to include working against CSA in school and teacher-training curricula.

* The majority of the perpetrators are men, it is therefore important to work with boys and men in order to challenge gender discrimination and to address child sexual abuse. Working with boys and men to promote gender equality and child participation is essential for bringing about a paradigm shift in socialization processes and institutions. This will lead to a more inclusive and participatory culture that respects the rights of all human beings and denounces all forms of violence against children and women. Boys and men can learn from initiatives where they are mobilized to challenge violence against girls and women, such as the White Ribbon Campaign.

* It is important to share and analyze good practices of working with boys and men to promote

60 gender equality and to prevent child sexual abuse. It is also important to identify boys and men who break traditional stereotypical behaviours and internalize gender equality, and to engage them in programmes addressing violence and child abuse.

Interventions

* It is recommended to develop family-centred, community-based psychosocial approaches. Many organizations tend to withdraw the child from the family rather than trying to address abuse in the family setting. Both male and female family members should be involved through family counselling, and by developing family-based and community-based supportive structures and mechanisms. *
The word counselling is understood and applied in various ways. Conceptual clarity needs to be created in relation to the role of various caregivers, including counsellors, para-counsellors, guidance counsellors, social workers, etc. It is important to develop minimum standards for the levels of psychosocial support, including counselling, provided by various professionals. It is also recommended to establish supervisory structures to monitor the quality of counselling activities.

* It is important to develop various stakeholders’ capacity to address child sexual abuse. Caregivers need to have appropriate knowledge on what support they can and cannot provide, as well as access to professionals to whom they can refer children with acute psychological concerns.

* In many countries, families and individuals are reluctant to seek services that openly address CSA. It is important to break cultural barriers that restrict access to services and to seek alternatives where services, such as individual counselling and shelter homes, are considered culturally inappropriate. Concepts such as rehabilitation and reintegration also need to be clarified.

* Organisations providing psychosocial support need to be trained on child-centred and child-friendly mechanisms and methodologies.

* Very few organisations target the perpetrators, since child sexual abuse is a very sensitive issue and

family members tend to protect the abuser. There is a strong need to find mechanisms to approach the abuser in order to stop the abuse. It is also important to work with men and boys on sexuality and dominant forms of masculinities as well as with girls and boys on gender roles and relations in order to prevent the recurrence of child sexual abuse.

* It is important to encourage the development and application of child protection policies as well as gender and diversity policies within organisations in order to prevent child sexual abuse.

Policy And Law Enforcement

* Few laws against child sexual abuse exist, and if they do exist the laws are seldom implemented. In some countries, legislation only applies to the sexual abuse of girls, since it is perceived that boys are able to protect themselves. It is important to lobby for the implementation of laws against CSA, in order to demonstrate to society that CSA is unacceptable. There is a need to be sensitive to the ways in which laws are implemented, since a child may be reluctant to report CSA if she/he is afraid that her/his close relative might go to jail.

Addressing CSA from a rights-based approach means:

• Addressing the root causes of child sexual abuse, including patriarchal power structures and unequal | | | | | | power relations between children and adults; | | | | | |

* Putting children at the centre, and recognising them as rights holders and social actors;

* Giving priority to children, creating child-friendly environments and providing child-friendly information on child sexual abuse and sexuality;

* Recognising governments as primary duty bearers, accountable for addressing and taking action against CSA;

* Seeing parents and families as the primary caregiver and protectors, and supporting them in this role;

* Using participatory, empowering approaches and creating partnerships and alliances to promote the rights of the child for addressing CSA; and

* Providing long-term goals that are clearly set out in international legal frameworks, and encouraging legal and other reforms, such as the establishment of regular monitoring mechanisms, that bring about sustainable change.

References

Aahung. (2001). Body, Mind and Spirit in Sexual Health. National Conference Report. Aahung.

Breaking the Silence. (1997). Non-Commercial Sexual Abuse of Children in Bangladesh: A Case Study Report.

Breaking the Silence Group.

Campbell, S. (2001). Lost Chances: The Changing Situation of Children in Afghanistan, 1990-2000. Global Movement for Children Afghanistan and UNICEF. | 67 | | | | | De Berry, J., et alia. (no date). The Children of Kabul: Discussions with Afghan Families. (Unpublished report). Save | | | | | | the Children US. | | | Frederick, J. (editor). (2002). Creating a Healing Environment, Volumes I and II. ILO-IPEC Nepal. | | | Frederick, J. (2002). ‘Human Resources Development for the Care of the Sexually Abused and Sexually Exploited: A | | | Resource Document on Training Programmes’. In Creating a Healing Environment, Vol. II, Technical Papers. ILO- | | | IPEC Nepal. | | | Heiberg, T. (2001). Commodities in Stigma and Shame: An International Overview of Save the Children’s Work | | | against Child Sexual Abuse and Exploitation. Save the Children. | | | Heissler, K. (2001). Background Paper on Good Practices and Priorities to Combat Sexual Abuse and Exploitation of | | | Children in Bangladesh. UNICEF. | | | Jordans, M.J.D., et alia. (2002). ‘Training of Psychosocial Counselors in a Non-Western Context: The CVICT | | | Approach’. In Creating a Healing Environment, Vol. II, Technical Papers. ILO-IPEC Nepal. | | | Jordans, M.J.D. (2002). ILO/IPEC Specialised Training Manual on Psychosocial Counselling for Trafficked Youth. | | | CVICT and ILO-IPEC. | | |

Kabir, R. (2002). Report on Findings from Consultations with Children on Sexual Abuse and Exploitation. Save the

Children Alliance and UNICEF Bangladesh.

Karlsson. L and Karkara. R (2003), Discussion Paper: Working with Boys and Men to End Gender Discrimination

and Sexual Abuse of Girls and Boys, Save the Children Sweden - Denmark.

Khalid, N. (2003). ‘The Characteristics of Childhood Sexual Abuse among Psychiatric Patients in Karachi’. Journal

of Pakistan Psychiatric Society. Vol. 1. No. 1.

NGO Coalition on Child Rights. (no date). Community Perceptions of Male Child Sexual Abuse in the North Western

Frontier Provinces, Pakistan. UNICEF.

Pakistan Pediatrics Association and Save the Children Sweden. (2000). Confronting Reality: Sexual Exploitation and

Abuse of Children in Pakistan, A Situational Analysis. Child Rights and Abuses Committee, Pakistan Pediatrics Association and Save the Children Sweden.

Premjee, S. Gender in the Bedroom: Negotiating Sexual Relations within Marital Unions. Aahung. Protacio-Marcelino, E., et alia. (1998). An Analysis of the Training Needs of Caregivers in Relation to the Provision of
Bio-psychosocial Help to Sexually Exploited Children in Nepal. ECPAT International.

Rozan, Aangan Project. (no date). Transforming Childhood: The Story of the First Six Years. Rozan. 68 | Rozan, Angaan Project. (no date). Our Bodies Our Selves. Rozan. | | | | | | Sahil. (no date). Conversations with Mothers on Child Sexual Abuse. Sahil. | | | | | | Seshadri, S. (2002). ‘Addressing Child Sexual Abuse: Dimensions, Directions and Good Practice Parameters for the | | | Care Setting.’ In Creating a Healing Environment, Vol.II, Technical Papers. ILO-IPEC Nepal. | |