Friday, October 31, 2014

The Psychological Impact of the Armed Conflict in Sri Lanka

Dr. Ruwan M Jayatunge M.D.

The Sri Lankan society experienced a 30 year prolonged armed conflict that changed the psychological landscape of the Islanders. A large number of combatants, civilians and the members of the LTTE underwent the detrimental repercussions of combat trauma. Following the armed conflict in Sri Lanka over 90,000 people lost their lives and thousands of families are still grieving. A large numbers became physical and psychological casualties of the war.  The war trauma still echoes in the Sri Lankan society. 

War has serious consequences for both short-term survival and longer-term recovery and development (Sørensen, 1998). War trauma represents a horrendous experience to the Sri Lankans. The Sri Lankan society is still struggling with the negative aftermath of the 30 year armed conflict.  If not addressed effectively the psychological scars following combat can stay behind for many years. It can change the psychological markup of people making them more dysfunctional.

Londoño and colleagues (2012) indicate that exposure to violence in general and to armed conflict in particular has been consistently associated with an increased prevalence of mental illness.  Although mental disorders are a major public health problem, the development of mental health services has been a low priority everywhere, particularly in low- and middle-income countries (Minas, 2012).

War trauma has impacted the Sri Lankan society in every level. The social fabric has been severely damaged. It has become a part of social experience and memory.  As the Salvadorian psychologist Martin-Baro wrote of his own country, what was left traumatized were not just Salvadorian individuals, but Salvadorian society. This expression is totally applicable to Sri Lanka.  

During the post war period interpersonal violence, child abuse, rape, alcohol and drug abuse, social violence have been increased in significant numbers. Many of these social maladies have direct or indirect connections with war trauma.  Deplorably Psychological wounds of the Eelam war were not adequately addressed and the deleterious effect of combat trauma impacts the post war Sri Lankan society. 

 Brief History of the Conflict
The armed clashes in Sri Lanka dates back to as far as 1972. In 1972, a group of undercover Tamil militants planted several bombs at the   Duraiappah Stadium in Jaffna. In 1974, a hand bomb was thrown at the Kankesanturai Police Station.  On the 27th  of July 1975, the Mayor of Jaffna Mr. Alfred Duraiappah  was gunned downed by the LTTE  leader Velupillai Prabhakaran,The tension was escalating in the North and the security forces were repeatedly on high alert.

The Eelam War started in 1983 and lasted until 2009. Over the years, the Sri Lankans saw a bloody war that destroyed thousands of lives. Many civilians as well as the members of the armed forces became the physical and psychological casualties of the war.

From Independence in 1948 to until 1971, Sri Lanka had a relatively small Army that was less professional and regarded as a ceremonial army.  With the 1971 JVP insurgency, the Armed Forces had been mobilized for combat operations for the first time. The Northern conflict demanded more manpower to the Armed Forces. In late 1987, the army had a total estimated strength of 40,000 troops, about evenly divided between regular army personnel and reservists on active duty. The approximately 20,000 regular army troops represented a significant increase over the 1983 strength of only 12,000. Aggressive recruitment campaigns following the 1983 riots raised this number to 16,000 by early 1985. (Global In the year 1986, the Sri Lanka Army had 30,000 personnel.  By 2008, the Sri Lanka Army had force strength of 162,000. 

From 1981, the LTTE intensified its attacks on the security forces. In 1981, the LTTE killed two members of the Sri Lanka Army on the Kankesanturai road in Jaffna. In 1983, the LTTE ambushed a Sri Lanka Army patrol killing 13 soldiers.  The LTTE launched its first suicide attack in 1987 at the Sri Lanka Army camp in Nelliady killing 40 soldiers. The Sri Lankan Armed Forces launched a number of military operations against the Tamil Tigers. On May 26th  1987 the Operation Liberation (Vadamarachchi Operation) was launched against the LTTE.

 The Nature of the Sri Lankan Conflict
The Sri Lankan Conflict was the longest-running armed conflict in Asia.  It was a conflict between the Government Forces and a rebel separatist group better known as the LTTE (The Liberation Tigers of Tamil Eelam).  The LTTE was regarded as the most lethal terrorist group in the world. In the subsequent years the LTTE was banned in UK, US and in Canada. The LTTE   attacked   the Sri Lankan armed forces with modern high tech weapons. In addition the LTTE used numerous unconventional methods to fight the Sri Lankan Forces using child soldiers and suicide bombers. The Northern conflict consumed many lives and caused damage to the property worth of billions of dollars. 

Sri Lankan Combatants and War Trauma
Sri Lankan military forces deployed its entire bayonet strength for nearly 30 years.  During this critical period the Sri Lankan military launched nearly 20 major military operations against the LTTE. Over 200,000 members of the Sri Lanka armed forces and Police had been directly or indirectly exposed to combat events during these years.  They were exposed to hostile battle conditions and many soldiers underwent traumatic battle events outside the range of usual human experience.

In 2009 May the Sri Lankan government declared that the country won the war against the LTTE. Although the armed forces were able to gain a decisive victory it came with a huge social cost. The Eelam war affected the psychosocial health of the combatants. Significant numbers are still impacted by combat trauma. During the post war era high numbers of desertions and suicides have been reported among the combatants.  According to the Military Spokesperson of the Sri Lanka Army from 2009 to 2012 postwar period nearly 400 soldiers had committed suicide (Sriyananda, 2012).

The Social Impact of Combat Related PTSD

The experts believe that the circumstance of war can produce a range of emotional, psychological and behavioral stress reactions among soldiers and officers that can lead to a condition known as PTSD (Post Traumatic Stress Disorder). Posttraumatic stress disorder (PTSD) is a condition that engenders both symptomatic distress and severe disruption in interpersonal and social functioning (robertson et al. 2004).

During the Eelam War many soldiers experienced combat related psychologically distressing traumatic reactions. Most of these acute traumatic reactions were not appropriately diagnosed or treated. Some soldiers were emotionally overwhelmed as a result of war trauma. There were no apparatus to identify these distressing reactions and offer psychological first aid without delay. Some soldiers lived with the traumatic ruminations for years while serving in the operational areas. These victims were later diagnosed with combat related PTSD.

For a number of years the Sri Lankan authorities were reluctant to believe that combat related PTSD was emerging in the military. PTSD was regarded as an American illness and there was an unofficial taboo to use the term PTSD. The tension of combat trauma was mounting in the military over the years and there had been suicides, and self-harms reported from the battle fields. The soldiers affected by war trauma had behavioral problems and their productivity was plummeting. Many soldiers who had positive features of combat related PTSD without any physical wounds were compelled to serve in the operational areas and engage in active combat. In the early days of the war soldiers were sometimes charged with malingering when they tried to seek medical attention. Many traumatized veterans deserted the army or joined underworld criminal gangs. Until 2005 the Sri Lanka Army did not medically discharge any combatant on psychological grounds especially PTSD.

Combat related PTSD has impacted combatants hugely.  The wounds that they received from war were not confined to the battlefield. It was not an individual trauma anymore.  The war trauma frequently transformed to their domestic environments. Domestic and community violence, child abuse addiction issues, self harm etc. became massive social problems. War trauma has turned in to a vicious cycle affecting   individuals as well as the entire society.

The Residual Effect of Combat Trauma
It is important to know that in the post war era late reactions of combat related PTSD can emerge. Combat stress has residual effect on some veterans. For some soldiers combat related traumatic reactions can emerge at a later date. Posttraumatic stress disorder (PTSD) may develop as a serious long-term consequence of traumatic experiences, even many years after trauma exposure (Lecic-Tosevski et al. 2013). There is a risk of emergence of late reactions of combat related PTSD in the post war Sri Lankan society.

Palali Syndrome
A new form of battle stress began in Sri Lanka mainly after 1983. Many Psychiatrists point out that a number of psychiatric illnesses have been increased as a result of the Northern Conflict. For a combat soldier in World War 2 who served for 4 years the average time spent in actual combat was approximately 40 days. In Vietnam, soldiers spent an average of about two thirds of their 12 or 13-month tours over 250 days in combat. But in Sri Lanka a large number of soldiers have spent 10-15 years in combat with short intervals.

For nearly three decades, Sri Lanka experienced a social calamity following an armed conflict and people were deeply traumatized. The echoes of the war trauma will affect Sri Lanka for generations. Although the origin and the history of this conflict was very complicated and carries many versions and explanations, after all it is a collective trauma for the Islanders. The North and South suffered from this conflict creating a large number of physically and psychologically traumatized victims. The combatants who experienced the war firsthand became profoundly affected by the physical and psychological consequences of the armed conflict. Many became the victims of the Palali syndrome. Unfortunately the International media has overlooked the magnitude of combat trauma experienced by the Sri Lankan combatants and often portrayed them as the perpetrators of violence.   

Palali Syndrome describes post traumatic reactions and post war re-adjustment problems experienced by some Sri Lankan combatants.  It narrates the psychological aftermath of the Eelam War in Sri Lanka. Even though the Eelam War is over  combat trauma is still hounding the Sri Lankan society rising as social violence, political violence, political extremism, criminal activities, domestic violence, suicides, homicides, alcohol and drug abuse, cruelty to children and various other forms.

Combat Related PTSD Study in Sri Lanka
The first combat related PTSD study in Sri Lanka was conducted during 2002 – 2006 period at the Military Hospital Colombo. This study was headed by Dr. Neil J Fernando Consultant Psychiatrist of the Sri Lanka Army and the former acting Director of Mental Health – Ministry of Health Sri Lanka.
From August 2002 to March 2006, 824 members of Army infantry and services units who were referred to the Psychiatric ward Military Hospital Colombo were interviewed. This study was conducted while the soldiers were still on active duty. The study group included 824 soldiers and officers. These soldiers were administered the PTSD Check List based on DSM 4 with a structured interview. This schedule designed from similar trauma questionnaires used elsewhere in the world to detect PTSD. The presence or absence of PTSD was evaluated with the use of the PTSD Checklist. 

This was a convenient sample that was referred to the Psychiatric Unit Military Hospital Colombo. Mainly the referrals were done by the medical officers of the OPD, Consultants in the Medical and Surgical units, Palali Military Hospital, Victory Army Hospital Anuradhapura and other military treatment centers. The affected combatants had behavioral problems, psychosomatic ailments, depression and anxiety related symptoms, self-harm, attempted suicides, alcohol and substance abuse, and misconduct stress behaviors.

In this study among the 824 Sri Lankan combatants 56 were found with full blown symptoms of PTSD and 6 soldiers were found with partial PTSD. The PTSD rate was found as 6.7% following analysis of DSM 4 based questionnaire.

Combat Trauma among the ex LTTE Carders

Combat Trauma among the ex LTTE Carders is least discussed. Very few studies are available on the mental health factors relating to the ex militants. Many surviving members of the former LTTE either now live in Sri Lanka or live abroad. Most of these ex militants joined the movement as children and throughout the war they underwent the harsh realities of war trauma.

As children these members witnessed and engaged in violence. While spending time in the battlefield they turned in to adults. As adults they continuously lived through battle stress until the end of the conflict in 2009.

Mental health experts believe that psychological trauma experienced by people during their childhood have a higher tendency to manifest mental health problems in later life.   According to several mental health experts some of the ex LTTE members suffer from malignant PTSD (Disorders of Extreme Stress Not Otherwise Specified or DESNOS). These victims live with rage, guilt, alienation and suicidal ideation. They lack social skills and unable form families due to lack of parental skills and intimacy. Although a number of rehabilitation projects were launched by the Sri Lankan government to rehabilitate the former militants some of them still live with scarred minds. Those who managed to flee and live as refuges in the Western countries do not receive culturally fitting psychological rehabilitation therapy. These individuals need psychosocial rehabilitation in order to re integrate in to society.

The Child soldiers in the Sri Lankan Conflict 
Over 7000 children were forcibly recruited and sent to war by the LTTE during 1983 – 2009 (Human Rights Watch). Children were abducted and forced into weapon training and they were subjected to torture, indoctrination, sleep deprivation and often forced to commit atrocities.   During the Eelam War these children witnessed absolute carnage that would impact their future adult lives. 

Former child soldiers have numerous mental health issues. Children who survive traumatic events exhibit   diverse set of symptoms and physical signs   often meet with diagnostic criteria for attention-deficit hyperactivity disorder, anxiety disorder etc (Perry, 2003). 

In 2009 the Sri Lankan Government liberated all the child soldiers that were held by the Tamil Tigers. These child soldiers were reunited with their families and they were offered rehabilitation.  Among   the conflict ridden countries Sri Lanka became the first state to free all the child soldiers that were held by the rebel group.  Today Sri Lanka is free of child soldier menace.  This is a major victory to the civilized world that sternly condemns the military use of children.

Today these ex-child soldiers undergo rehabilitation. Most of them go to schools and receive vocational training.  But still many are trapped with their dreaded combat memories. According to the local clinicians a considerable numbers of Sri Lankana child soldiers   are suffering from depression, PTSD, somatization and adjustment disorders. They need effective long term rehabilitation and acceptance by the society.

The Civilians Affected by the War  
In armed conflicts civilians have little protection from collateral or incidental damage and often they become vulnerable. Among the consequences of war, the impact on the mental health of the civilian population is one of the most significant (Srinivasa Murthi & Laksminarayana , 2006). The recent military conflicts in Afghanistan and Iraq had a large numbers of civilian casualties.  The Eelam war in Sri Lanka was no exception. A large number of civilians from the North and South   became innocent victims of the war in Sri Lanka. Many became casualties due to the colorectal damage following military offensives against the rebels (in the North) and due to suicide bombing by the LTTE (in the South). 

According to the International Institute for Strategic Studies (2003) between 1980 and 2000, the LTTE carried out 168 suicide attacks causing heavy damage on civilian, economic and military targets. Suicide bombings and other form of explosions can cause long-term repercussions on survivors. Bashir and colleagues (2013) highlight that  civilian victims of suicidal and improvised bombings present with a wide range of neurological symptoms and injury patterns, which often differ from the neurological injuries incurred by military personnel in similar situations, and thereby often require individualized care.

The Sri Lankan conflict caused mass displacements. At the end of 2006, at least 520,000 people in Sri Lanka were victims of conflict-induced displacement in a country of 20 million, making up one of the largest displacement crises in Asia in absolute terms and particularly in terms of the proportion of the population displaced (Civilians in the way of conflict: Displaced people in Sri Lanka September 2007).  Many civilians who became displaced   lived in shelters for long years and fled the country. Adverse mental health consequences have been reported among the displaced people.

The war trauma in Sri Lanka destroyed the social fabric and a large number of civilians underwent hardships of war. People lost their loved ones. They lost their property and livelihoods.  It affected individual as well as in collective level.  For the most of the Sri Lankans the war became a collective trauma. Tens of thousands of Sri Lankans still face the bitter consequences of the war. They live with their traumas suffering silently.

The civil society has been degraded by war trauma. Hostility, suspicion, alienation, emotional numbing, indifference, scapegoating became the common components in the war ridden Sri Lankan society. Empathy, tolerance and compassion gradually disappeared as the war progressed. There is a noticeable lack of quality in civil society, partly due to the crippling brain drain, but also due to the devastating effect of the war. There is also widely reported perception in northern Sri Lanka that there has been a marked deterioration in social values evidenced by changing sexual and social behaviours. (Somasundaram 2007) 

The researches indicate that armed conflict can have long term consequences. Nandi (2013) investigated to what extent the soldiers and young women of World War II were affected by PTSD symptoms over the course of their lives and in this study the researchers recruited 52 male and 20 female Germans aged 81-95 years and interviewed regarding war experiences and PTSD symptoms. Of the men 2 % and 7 % met the criteria for current and lifetime PTSD diagnoses, respectively, as compared to 10 % and 30 % of the women, respectively. These researches show that the impact of war trauma can affect the Sri Lankan society for long years.

The Eelam War and the War Widows
One harsh reality of the war is that the every soldier killed in war leaves behind grieving family and relatives. It has been a reality since the Trojan War. The women who were left widows as a result of the Sri Lankan conflict are facing radically altered circumstances. There are estimated thousands of war widows who still experience grief reactions. Many widows young and with the death of their husbands these women have become a psychologically and socially vulnerable group. Most of the women who underwent severe emotional pain still have not completely recovered. Many have become the victims of pathological grief and were clinically diagnosed with Prolonged Grief Disorder or PGD.

They are unable to work through their grief despite the passage of time. With the widowhood, they experience identity change, role adjustment and change in social status.

Many researches concur that the mental trauma of the war widows can last for long years. Depressive reactions are common among the Sri Lanka war widows. Many LTTE carders who died in action left their wives in grief-stricken situations. The war widows of the Northern part of Sri Lanka too experience the similar plight. 

In the conservative Asian societies, widows face social, economic and legal handicaps. Widow as its name denotes is associated with some form of socio-cultural stigma and humiliation. They are considered as bad omen in many Sri Lankan rural areas. They are marginalized by their own communities. These   factors affect their self-esteem. In some events, the accusations were made by the in laws stating that the husband’s death occurred because of the unluckiness of the wife and they are partially answerable for the husband’s death. They experience lack of social support and loss of their social possession in their own family circles.

The war widows face a number of mental health problems. They have suffered bereavement as a result of the violent deaths of their husbands and these traumatic memories hound them for long years. They are often subjected to extreme forms of discrimination and physical, sexual, and mental abuse. Therefore, widowhood represents a form of “social death” for these women.

Treating  Trauma Victims based on Cultural Components

In the modern day Sri Lanka, the psychological victims of   trauma are treated with Allopathic medicine, traditional Ayurvedic medicine, Psychotherapy and Spiritual therapies. Psychiatrists treat the war trauma victims with depression and PTSD and other anxiety related disorders with SSRIs (Selective serotonin re-uptake inhibitors) and sometimes combine antipsychotics when there are signs of severe disturbed behavior with psychotic manifestations. Ayurvedic specialists use various types of traditional remedies to ease the anxiety. Psychologists and Psychotherapists often use Person-centered (Rogerian) therapy, Cognitive behavior therapy and EMDR.  

Spiritual therapy frequently helps the war victims to reduce their depression and anxiety related symptoms. Many Sri Lankan clinicians have observed that the spiritual therapy diminishes the suicidal ideation in combat trauma victims. Many combatants and civilians with war trauma are encouraged to practice meditation and yoga. Meditation methods such as Methha Meditation (Meditation of loving-kindness), Vipassanna meditation (mindfulness mediation) are widely used in rehabilitation centers.  

Sri Lanka faced a prolonged armed conflict that caused paralyzing impact on the society. War trauma in Sri Lanka has generated a large number of victims with PTSD and other forms of psychological ailments. A study done with the Sri Lanka Army servicemen during 2002-2006 reveals that combat related PTSD is prevailing among the members of the armed forces. The victims of war trauma experience problems in their living, working, learning, and social environments. In Sri Lanka there are numerous measures to treat the war victims using traditional and modern treatment measures. In overall effective psychosocial measures have to be implemented to treat victims of the Sri Lankan armed conflict.

War Trauma Presentation : (contains graphic images) Link 


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Baro, M. (1994) . Writings for a liberation psychology, Harvard University Press.

Bashir, M.U., Tahir, M.Z., Bari, E., Mumtaz, S. (2013).Craniocerebral injuries in war against terrorism --- a contemporary series from Pakistan. Chin J Traumatol.  16(3):149-57. 

Batista, P. & Wiese, E. ( 2010) .   Culture and Migration: Psychological Trauma in Children and Adolescents.  Traumatology   16: 142-152

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Fernando, N. & Jayatunge, R (2011) . Combat Related PTSD among the Sri Lankan Army Servicemen. Retrieved from

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Jayatunge, R. (2004) . PTSD Sri Lankan Experience , ANL Publishers Colombo.

Lecic-Tosevski, D.,Pejuskovic, B., Miladinovic, T., Toskovic, O., Priebe, S.2013). Posttraumatic stress disorder in a serbian community: seven years after trauma exposure.J Nerv Ment Dis. 040-4. doi: 10.1097/NMD.0000000000000051.

Londoño,A,.   Romero,P.,    Casas , G.(2012).The association between armed conflict, violence and mental health: a cross sectional study comparing two populations in Cundinamarca department, Colombia.Confl Health.6: 12. 

Minas,H (2012). The Centre for International Mental Health Approach to Mental Health System Development. Harv Rev Psychiatry.20(1): 37–46.

Nandi,C. (2013).War trauma and PTSD among German war survivors : A comparison of former soldiers and women of World War.

Perry, B.D. (2003) Effects of Traumatic Events on Children. Retrieved from

Robertson, M., Rushton, P.J., Bartrum, D., Ray ,R. (2004).Group-based interpersonal psychotherapy for posttraumatic stress disorder: theoretical and clinical aspects.

Somasundaram , D. (2007) .  Collective trauma in northern Sri Lanka: a qualitative psychosocial-ecological study.   International Journal of Mental Health Systems 2007, 1:5

Sørensen, B. (1998).  Women and Post-Conflict Reconstruction.  Retrieved from$FILE/opw3.pdf

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Watters,  E. (2010) . Crazy Like Us: The Globalization of the American Psyche.  Free Press.

Wednesday, October 29, 2014

Children needing protection: experience from South Asia

Professor D G Harendra de Silva

Professor Harendra de Silva's contribution to the welfare of children in the country is exceptional. Professor of Paediatrics at the Faculty of Medicine, Ragama, he is the Founder Chairman of the National Child Protection Authority (NCPA) and the Presidential Task Force on Child Protection. A social entrepreneur and an activist against all forms of child abuse, Professor de Silva has been honoured with coveted accolades including Senior Ashoka Fellow of the Ashoka Foundation, Washington DC.   

As in many societies, child abuse is often denied in the Indian subcontinent. Probably one of the oldest recorded tales of child abuse is a 2500‐year‐old Buddhist story called Sopaka.1 A jealous stepfather ties Sopaka to a corpse in a cemetery to be eaten by wolves. Buddha releases the boy and preaches to him, probably one of the earliest recorded instances of counselling. Buddhist scriptures also record the story of the boy Mattakundali,2 whose miserly father neglects him and deprives him of medical care.

Most forms of child abuse have been described in South Asia. In addition, a new form of child abuse – the conscription of children during armed conflict – has emerged relatively recently, especially in Sri Lanka and Nepal.

Physical abuse

In Sri Lanka, there is evidence that the ancient kings Voharika Tissa (214–236 AC), Vijayabahu II (1186–1187) and Vijayabahu III (1232–1236) were influenced by compassion. Non‐violence in Buddhism prohibited any bodily harm, by way of punishment, of children and adults.3However, Sri Lanka went through a phase of denial, acceptance and justification of corporal punishment as a norm for the sake of “discipline” and “education”, an attitude which was especially promoted during the colonial past to facilitate foreign rule,3,4 and which still persists in society today. The Education Ordinance of 1939 of Ceylon,5which was in effect until recently, even after the signing of the United Nations Convention of the Rights of the Child (CRC),6 permitted caning of a child. A new circular in 2001 banning corporal punishment and sent with a booklet to teachers7 by the Ministry of Education Sri Lanka, led to many unpublished controversies within the teaching profession and political circles, including the destruction of the booklet without distribution in some schools.

A high prevalence and frequency of corporal punishment were found in a cross‐sectional study of 1226 school children in Colombo.8 The study indicated that corporal punishment directly predicted to what extent a child would be maladjusted and that non‐parent‐to‐child violence (ie, domestic, school, peer and community violence) significantly affected this psychological damage.8 Although the medical curriculum in Sri Lanka did not include child abuse until recently, it is now being taught in depth.

The first published cases in Sri Lanka recognising physical abuse appeared in the latter half of the 1980s,9,10 and were followed by several case reports.11,12,13 However, the paediatricians who recognised child abuse were faced with a management dilemma as infrastructure and procedures in cases of child abuse were lacking.14There is very little scientific literature on child abuse in other South Asian countries except for some articles based on qualitative data and by non‐governmental organisations (NGOs) on the internet. There have been reports of “ear abuse”15 and physical abuse of street children in India.16,17

Sexual abuse of children

Although not specifically named, child sexual abuse was documented in the case of a tailor named LLJ,18 who was sentenced to death by hanging in 1949 for murdering a 14‐year‐old schoolboy he had previously abused. LLJ had the typical profile of a paedophile, and he lured boys into sex traps in his “fitting room”, attracting boys with the promise of rides on his red “James” motorbike.

During the 1940s, sexual abuse was viewed as being homosexual18 and the child was often considered a criminal contributor rather than a victim. Although the use of young school boys by teachers, hostel wardens, school cadet leaders, sports coaches, and older boys was known to the public, it was not discussed openly, and was considered the norm by some and was completely unknown to others.4 Even at present, there are those who excuse the sexual abuse and exploitation of boys by the justifications “boys do not get pregnant” or “ships don't leave tracks on water” (there is no physical virginity to lose) without realising (or not wanting to know) the long‐term emotional effects of abuse.4

Research in the North West Frontier Province of Pakistan and amongst Afghans (who are tribally similar) revealed that rich men use “attractive beardless” youths, referred to as “Balkay”, for sexual pleasure. One third of adults interviewed in the region did not consider sexual abuse to be “bad” and for many it was a symbol of “power” and “status”.19

The “Devadasi” system in India, although legally banned in 1982, and the “Deuki” system in Western Nepal offer children and women to the temple system to function as sex slaves to pilgrims and priests.20 In the past, Devadasi earnings from prostitution contributed significantly to the temple's earnings for centuries.20 The use of so‐called lower castes and downtrodden women and children for prostitution in South Asia has been “legitimised” by society through religious justification20 and 50% of these women and children are estimated to become commercial sex workers later in life.21

The mean age of entry into prostitution in the Daulotdia brothel in Bangladesh has been estimated to be around 13.5 years.20 A comprehensive report on the commercial sexual exploitation of children in Pakistan has been published.22

Carl Muller, a Sri Lankan author,23,24,25 has written a number of accounts describing the sexual abuse of boys during the 1930s and 1940s in Colombo's “Burgher” community, comprised predominantly of persons of Dutch/European descent, and has also described the hesitant attitude within society towards the sexual abuse of boys.


An initial qualitative study was conducted in homes of safety for children that paradoxically are called “detention” homes in Sri Lanka.26The observations from this study and police data prompted us examine at the incidence of sexual abuse of children in domestic situations. An anonymous questionnaire was administered to 899 students in a university entrance class and to undergraduates. The same questionnaire was also administered to 818 students in the university entrance class who had heard a lecture on child abuse prior to completing the survey.4,14,27

In the initial study,27 85 (18%) boys admitted being sexually abused during childhood and 19 (4.5%) girls had been abused. However, in the group given a prior lecture on child abuse, 21% of the boys and a higher percentage of girls (11%) admitted being sexually abused. A majority of the boys had been abused either by a relative or a neighbour, while others abusers included brothers, teachers and priests. Older women had abused 19 of the boys. Most girls did not divulge the abuser, suggesting that the perpetrator was an immediate family member. A significant finding was that 71% of males who had abused younger children had been abused themselves during childhood.

In a study conducted at a sexually transmitted disease clinic,28 40% of female commercial sex workers had been abused as children, while in promiscuous males 21% admitted paedophilic activity and 64% had been abused as children.

Several social factors may explain why abuse of boys is more common. A girl's virginity is considered important at the time of marriage in traditional Sri Lankan society and since girls can also become pregnant they are more protected than boys. For the same reason, pre‐marital sex is unusual in traditional society. Thus, hormonally primed young adult males may have access only to boys or to pre‐pubertal girls who are less protected.

Sexual exploitation of children by tourists

In the 1970s and 1980s there was an explosion in tourism in Sri Lanka, and foreigners came in increasing numbers for child sex. Early reports of this trend by NGOs and sociologists were presented at meetings but were not scientifically documented.

International gay magazines such as “Spartacus”29 achieved particular notoriety for promoting certain countries such as Sri Lanka, Philippines and Thailand for homosexual tourism, and indirectly highlighting the availability of children.

Tim Bond in a well‐documented report30 estimated the number of commercially exploited boys in Sri Lanka in 1980 (at the peak of unmonitored tourism) to be around 2000. In 1999 Ratnapala31 found 926 youth/child sex workers, of whom 533 were younger than 18 years of age, in the tourist areas of the country. With active surveillance and prosecutions including extra‐territorial trials, numbers are now estimated to be less. However, proper quantitative scientific studies are difficult.

Most sexual abuse occurs as a result of domestic abuse and incest, while a smaller but more visible problem is commercial exploitation of children on the streets and in brothels (fig 1​1).). The tip of the iceberg (fig 2​2)) in countries such as Sri Lanka and the most visible form of abuse, although accounting for the fewest cases, is commercial sexual exploitation by tourists.


The extent of neglect is difficult to evaluate because Asian society has been slow to recognise such neglect as abusive. Mirando,33 a Sri Lankan paediatrician, reported a case of severe neglect in 1965/66, but at that time neglect abuse was attributed to poverty and ignorance and was not recognised by the medical profession as a form of child abuse.

Child labour

The industrial exploitation of children is less of a problem in Sri Lanka than in other countries in the region. The trend of poor adult Sri Lankan women seeking employment in Middle Eastern countries as housemaids, the demand for high wages and the high cost of feeding an adult have made it expensive to employ household help. These conditions contributed to an increase in the domestic employment of children in the 1980s and 1990s. Children's labour is exploited and they are vulnerable to physical and sexual abuse and, almost always, emotional abuse through denigration. These children are also deprived of schooling and proper nutrition.

A study of almost 700 households in urban Southern towns indicated that one in 12 has a child servant, and one third of the domestic labour force consisted of children.34 This study was followed by a media campaign against child labour and prosecution of offenders. A more recent study in 200235 for the International Labour Organization showed a rapid decline in the domestic employment of children with the rates being reduced to 0.5% of households compared to 8% in 1997 in the same area. Tackling the broader economic issues will help address this residual problem.

Child labour in neighbouring India, Nepal, Pakistan and Bangladesh, where there are higher poverty levels, is considerably more common. Unfortunately, scientific studies to determine numbers are scarce; most existing studies are qualitative and carried out by the NGO sector, and are often published on websites. In India estimates indicate that there are 12 million child labourers, with 85% working in rural areas.36

Street children

Children may be born on the street, with their parents living on the streets as beggars or prostitutes or having being mental problems, while children abused physically, sexually or emotionally and experiencing domestic violence may run away from home. The availability of work and food on the street in the commercial areas of cities are the main attractions for children.37

The prevalence of street children in a community is directly related the extent of poverty in that society and the “need” for exploitation for “gain” in the community. These children have to compete for work with other children and also with adults. They require money and food for survival, which may be their only needs. Although there may be a relative dearth of adult labour, the employers' “Mafia” on the street may set the rates of payment, which may only be a meal. Universally all children lack power to ward off abuse and exploitation, but street children are even more vulnerable because they do not have parents to protect them, while absolute poverty nullifies any possibility of protection either by the community or by the state.

Such children are denied appropriate role models and exposed to vice, from picking pockets, prostitution, smoking and drugs, to street violence. The public sees these children not as victims and exploited but as perpetrators of crime and undesirable.

UNICEF's estimate of 11 million street children in India in 1994 is considered to be conservative,38 while in 1996 Human Rights Watch estimated it to be 18 million.16 The health of these children and the problems they faced were reviewed by Nigam in 1994.39 The number of street children in Bangladesh is estimated to be approximately 400000,40 while in Sri Lanka about 600 have been counted in Colombo where most of them work and live.37

Child conscription and armed conflict

The public and the media, even in the West, may not always see armed conflict as detrimental to a child's proper development but may consider the children as heroes or martyrs.41 Sri Lanka has had an ongoing civil war for two decades, and media reports have described child conscripts amongst the militant groups,42,43 which is also an issue in Nepal, which is also affected by civil war.44

Nineteen male child soldiers conscripted before the age of 18 years (mean age 19 years, range 16–24 years) were interviewed using a questionnaire with standardised questions.45,46 The mean age of conscription was 14.5 years. Conscription itself, “the involvement of dependent, developmentally immature children and adolescents in an armed conflict that they do not truly comprehend, to which they are unable to give consent, and which adversely affects their right to unhindered growth and identity as children”, should also be included in the definition of child abuse.45,46

Usually, all conscripts in Sri Lanka, irrespective of age, wear cyanide capsules, which they are trained to bite on during “suicide missions” or when captured.41 The prominent place given to martyrs and the oath taken by the child soldier in which he vows to sacrifice his life are likely contributing factors to this phenomenon. We proposed another definition, “suicide by proxy”: “making a child or adolescent commit suicide, an act he or she cannot comprehend, by a process of persuasion by an adult, for personal, social, economic, or political reasons that the child cannot understand constitutes suicide by proxy”.46,47

Although other forms of child abuse are being challenged globally at a practical level, the impunity of child recruitment has not yet been dealt with. Millions of dollars have been spent on meetings and other forms of advocacy without visible or documented change in prevalence. Compared to other forms of child abuse, which is usually perpetrated by individuals, conscription is carried out by organised groups or dictators who are not answerable to the local population or local lawmakers, or the international community. The international community is more interested in politics, peace and adult human rights while child rights and the conscription of children are not a priority, a situation which makes it easier to abduct children than to abduct adults.47 Political, personal and other hidden agendas within the international community may divert attention away from conscription. The abundant “availability” of poor children for “supply” in a background of poor prospects for education, vocational training or future jobs makes conscription of children more attractive, demonstrating the mutual relationship between supply and demand.

The specific identification of groups and persons responsible for child recruitment, the creation of proper standards in the International War Crimes Tribunal in The Hague and the establishment of local laws are crucial to stopping this plague worldwide. “Peace monitoring” processes by the UN and foreign governments should be for accountability and not merely documentation. “Human rights” and “child rights” should be given the same importance.

Action against child abuse by the government in Sri Lanka

The initial response of professionals, especially a few paediatricians who identified child abuse, was significant in placing the problem on the government's agenda. It is important for other paediatricians in the region to identify child abuse and lobby the administration to set up structures to effectively deal with the issue. Initially, the Penal Code was amendment in 1995.48 The highlight was a provision that strengthened the law governing sexual and other offences against children. It concentrated on (a) defining offences that were previously not defined or described adequately; (b) increasing sentences; and (c) introducing mandatory jail sentences for some offences. In the author's experience, mandatory sentencing considered Draconian in nature has had a negative effect on prosecutions.

In December 1996, the former president of Sri Lanka appointed a task force on child protection. It recommended several legal amendments, including the establishment of a statutory body, the National Child Protection Authority (NCPA).49 The NCPA mandate includes a broad range of objectives and duties such as: advising the government on policy and measures regarding the protection of children and prevention of child abuse; coordinating with relevant ministries and other organisations; recommending legal and other reforms for the effective implementation of policy; monitoring the criminal proceedings in cases of child abuse; recommending measures regarding the rehabilitation, and reintegration, of children affected by armed conflict; receiving complaints from the public; advising the tourism industry, local bodies and NGOs concerning child abuse, and coordinating and promoting campaigns against child abuse with these bodies; and conducting research on child abuse.

The NCPA board of management consists of professionals from various disciplines, including paediatricians, forensic pathologists, psychiatrists, psychologists, a senior police officer, a senior lawyer from the Attorney General's department, and five other members associated with child protection efforts including NGOs. The Commissioners of Labour and Probation and Child Care Services, and the chairperson of the monitoring committee of the CRC are also included. A panel of ex‐officio members from a wide range of relevant ministries has also been appointed. The NCPA had the advantage of reporting directly to the president, and the presence of high‐ranking officials has facilitated the implementation and coordination of mechanisms of action suggested at NCPA meetings. However, for reasons unknown, it has recently been changed to a ministry (2005), which has weakened its mandate. As observed in other countries, lobby groups in Sri Lanka associated with perpetrators are pressurising the authorities50 to soften the action taken by professionals against child abuse, with the replacement of professionals by administrators and politically appointees which will ultimately lead to the downfall of successful work carried out over several years. Another major weakness in the present system is the lack of facilities to care for abused or vulnerable children. The poor financial resources for foster care and the persistent focus on institutional care by administrators makes it difficult to care for these children.

Child protection in most other South Asian countries is by NGOs. Most governments in the region are trying to emulate the NCPA model.



The author would like to thank all the authors/co‐authors (too numerous to be named individually) who helped the author carry out this research.


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Articles from Archives of Disease in Childhood are provided here courtesy of BMJ Group

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