“Mubarak ho, visa hua hai!”.
(Priyam ji)

Six weeks after applying for a visa and going through an emotional rollercoaster of panic and pre-emptive dejection, I read these amazing words whilst sat in clinic. It was decided, I was going to India!

For someone who lacks any real passion for anything in life, my anticipation and excitement for this trip could be directly comparable to a six year old on their way to a fayre with a pit top to the candy floss stand. In fact, I would go as far as saying I would put the six year old to shame.

#gangsta

The total duration was three weeks, which was split not so equally between the Joshi parivar, the Priyamvada clan and Smit bhai et al, with the itinerary looking like: Delhi > Agra > Jaipur > Haridwar > Benares > Delhi > Oxford.

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Delhi 

Ik roz apni rooh se poocha, ke dilli kya hai. 
To yun Jawab me keh gayi,
Ye duniya maano jism hai aur dilli uski jaan
(Mirza Ghalib)

Things to see and do: Akshardham temple, lotus temple, Lal Qallah, Qutb complex, Mehrauli archaeological park, Humayun’s tomb, Zafar mahal, Safdarjung tomb, Banglasahib gurudwara, Lodhi gardens, Connaught place, Chandni Chowk, Hauz Khas village

My love affair with Delhi had begun a few years back after having read Khushwant Singh’s Delhi. By far one of my favourite reads not just for the amazing prose, however, the excellent grip on the psyche and portrayal of key characters in the history of Delhi from those who salvaged the city and those who led to its attempted ruination, alike.

The tourist sites are all secondary things, what strikes one about Delhi is that it a complete gorakh dandha. Its colours and character can be so strange and foreign, yet at other times she becomes truly and exclusively yours, making you fall in love with herself, multiple times, and every as if this is the first. Oh dammit, I promised myself I would not become a literary romantic. Oh, well.

Being a hybrid Pakistani, it was difficult to not compare Delhi to Lahore and indeed, it had so many similarities; like a divided soul of the new and old city with the history at times carefully simmering and rising amongst newer structures; hundreds of people all dotted about in a chaotic manner, yet having a continuous flow of movement and of course…the food! My stomach was catching up with me from the journey from Britain to India, however, BP Market, Noida. How I miss thee, the kalakand and those chicken paratha rolls (love you, R.D). -Le sigh-

My belief of cities, no matter where in the world, is usually that they are a reflection and product of the people that inhabit it. However, like Lahore, Delhi is independent of that. Delhi stands freely with its abundance of history, architecture and heritage. Even the poets I know and have read extensively – a lot of them are known because of Delhi. It is entirely possible that I have a romanticised view of this city, however, it is what it is.

Admittedly I could not have appreciated the wealth of Delhi’s history without the legendary Smit bhai. The first time I met him on an introductions evening in Brasenose College, we were debating something or other about Indo-Pak. He was charged with statistics, economics and current debates. I was preoccupied with chai and craved conflict. Days of relative youth…Any how, the wealth of information this man carries in his brain is amazing enough, however, his anger and frustration at the tour guides (who often are heard giving not only inaccurate, but blatantly wrong information) errs on the side of hilarity. Smit bhai also needs to be given credit for making me realise the lost clinical interests that I have, namely, in occupational medicine particular to those working in industry, but that story can await for some other day.

So let us continue, the personal highlights included Bangla Sahib gurudwara, Jama masjid and Mehrauli.

The gurudwara was initially built as a small shrine during the reign of Shah Alam the Second in 1783. My travel companion, or rather keeping me in line with an orientation program (titled: How now to be an idiot in Delhi), was the beautiful Kanika Joshi. As I have harped on endlessly to everyone who I have mentioned Gurudwaras to, I am in awe of the community work and voluntary services found amongst Sikh communities. Cleanliness is a form of purity and worship, literally and figuratively – and in Bangla Sahib I found this.

 

Whilst on the religious theme, Jama Masjid, you beautiful nutshell of nostalgia! Now, it may have been behavioural conditioning, but it was maghrib and the muezzin was engaged in the adhan.  I found my steps quickening up the steps, awkwardly and angrily glancing at a notice saying “women not allowed after evening prayers”, and then stepping into the courtyard. I felt like I was in the heart of Lahore, inside the Badshahi masjid and some corner of my heart rejoiced. Briefly I was jolted into reality and realised I was in the heart of Purani Dilli and inside the Jama masjid and as such, that very same corner of my heart rejoiced a little more.

The Jama masjid is quite smaller than the Badshahi masjid, however, very similar in architecture. Constructed during the time of the mughal emperor Shah Jahan, it was completed in 1656 AD. Its official name, at least at the time, was Masjid-e-Jahan Numa. After the 1857 revolt, it was also temporarily used as a station to place British soldiers. After some moments of masjid step sitting, we found our way to Karim’s. Every Delhi’ite I have met has made mention of this establishment whenever talks of Purani Dilli have taken place. It is an important establishment. It is a food establishment. It was set up in 1913 by the son of a cook of the mughal kitchen. We had kebabs and rumali roti, the queen of rotis -insert hearts for eyes at this juncture-.

A number of Indians whom I know informed me that Dilli walay are rude and rather unpleasant. I most certainly cannot say I agreed with this, primarily, because it was not an experience I underwent. Either because I did not engage long enough in verbal combat to get a sense of this, or I was equally blasé with humans (as I have often been accused of being). However, there was also not a memorable moment with a local. Agra had Dilshad bhaiyya, Haridwar had LB, Benares had two amazing uncles… the chai walay uncle and then the kachori walay uncle. More on some of these people in further posts.

I guess humans make a significant contribution as to what your personal (or I guess, my personal) experiences are. Having families and their friends with whom I interacted with shaped this journey for the better… I continue talking with some, have some good memories of others and a whole load of positive reflections. Had it been a visit that was very isolated with lone travel, I am not sure I would have had such a positive experience. This reminds me to an excerpt of Khushwant Singh’s City Improbable: Writings on Delhi where he compels you to “draw a balance sheet of what is loveable about Delhi and what is not and you will find that its plus points equal its minus points. So if you happen to be living in Delhi, why uproot yourself and go somewhere else of which you know less, and which may not be worth knowing either?”

So, what of my experience and relationship with Delhi? Well, we coexisted well…and I left with an appreciation of its history, its heritage and above all, its endurance for all the looting, pillaging and plundering it has withstood and is still withstanding, in a contemporary sense, of course. One final word on what I liked the most about it, its sense of humour and irony. It has been the “mistress of conquerors” but it also holds several mausoleums of such invaders. Don’t mess, yo.

Next in this series of India reflections – India and its very many God’s. Well, maybe, lets see.

This post will soon also be available as a podcast as part of the Meer e Karwan series.

Zainab Ansari, a 7 year old child was on her way to Quran recitation classes in Kasur, Pakistan, when she was abducted, raped, strangled and left in a dumpster. Her body was discovered on the 9th January 2018.  Autopsy has yielded that she was most likely held in captivity, where she was tortured. Criminal proceedings are underway and someone has yet to be charged for this.

Child sexual abuse is a horrific reality of the society we live in and Zainab’s case is just one of the few most recent reminders of this. Today’s podcast will focus on definitions, the extent of the problem, signs exhibited by children and further complications secondary to the abuse as well as a brief reflection on prevention and control strategies.

Definition

Child sexual has differing dynamics to those of adult sexual abuse in many parameters ranging from disclosure differences to the symptoms exhibited. Lets begin by defining the problem. The World Health Organisation’s definition of child sexual abuse is:

  • The involvement of a child in sexual activity that he or she does not fully comprehend
  • Is unable to give informed consent to
  • For which the child is not developmentally prepared for
  • Or that violates the laws or social taboos of a society

Sexual abuse in the case of minors is evidenced by any of the above activity between a child and an adult, or another child who by age or development is in a relationship of responsibility, trust or power with the activity being intended to gratify or satisfy the needs of the other people. This may include but is not limited to activities like “intercourse, attempted intercourse, oral-genital contact, fondling of genitals directly or through clothing, exhibitionism or exposing children to adult sexual activity or pornography, and the use of the child for prostitution or pornography.”

Statistics

It is a challenging task to find out the actual number of sexually victimized children due to the fact that the prevalence reported varies across studies and data sources. The WHO in 2002 estimated that 73 million boys and 150 million girls under the age of 18 years had experienced various forms of sexual violence. A meta-analysis conducted in the year 2009 analysed 65 studies in 22 countries and estimated an “overall international figure.” The main findings of the study were:

  • An estimated 7.9% of males and 19.7% of females universally faced sexual abuse before the age of 18 years
  • The highest prevalence rate of CSA was seen in Africa (34.4%)
  • Europe, America, and Asia had prevalence rate of 9.2%, 10.1%, and 23.9%, respectively.

CSA has found to be associated with physical abuse at both younger and older ages and alone is accountable for about one per cent of the global burden of disease, but it is likely to be a risk factor for several other conditions like alcohol consumption, illegal drug usage, development of mental disorders, and spread of sexually transmitted diseases, which when pooled, are accountable for over 20% of the global burden.

India

India has a huge problem of child sexual abuse, in fact, it is home to 19% of the world’s children as well as home to the worlds largest number of abused children. For every 155th minute a child, less than 16 years is raped, for every 13th hour child under 10, and one in every 10 children sexually abused at any point of time. Studies propose that over 7,200 children, including infants, are raped every year and it is believed that several cases go unreported. It is estimated by the government that 40% of India’s children are susceptible to threats like being homeless, trafficking, drug abuse, forced labour, and crime.

United Kingdom

It would be false to believe that the problem exists in poor and developing countries only. Unfortunately, child sexual abuse is found across international borders as well delving deep within all socioeconomic boundaries.

  • 1 in 20 children in the UK have been sexually abused
  • 54,000 sexual offences against children recorded in 2015/6
  • Over 90% of the abused children’s perpetrator was someone they knew
  • Over 2900 children were identified as needing protection from sexual abuse in 2015

Risk factors

Risk factors have been identified, which can make children more vulnerable to abuse. These include:

  1. Unaccompanied children
  2. Children in foster or adopted care
  3. Physically or mentally less abled children
  4. Poverty
  5. Armed conflict
  6. Social isolation
  7. Dysfunctional family life e.g. alcohol, drug dependency

Health consequences

The aftermath of child sexual abuse includes physical and mental complications. The physical issues range from genital injury, genital discharge, bedwetting/soiling, anal complaints (e.g. fissures, pain, bleeding), UTIs and STIs. Psychological and behavioural issues can include behavioural regression, delayed developmental milestones, sleep disturbances, depression, PTSD, poor self-esteem and/or inappropriate sexualised behaviours.

So what is the cause of the problem? Child sexual abuse is multi-dimensional in its cause and complexity, however, cultural and social norms supporting violence are a major issue. These can include the following:

  1. Sexual violence being an acceptable way of punishment/power assertion
  2. Sexual activity (including rape) being a marker of masculinity
  3. Sex and sexuality being taboo as well as shameful for the victim, thus preventing disclosure
  4. Perpetrators having had a history of longstanding sexual abuse

Prevention and control of child sexual abuse

Management of victims of sexual abuse is also, therefore, quite complex and multidimensional. It is important to remember, however, that sexual abuse is preventable and there are a number of steps that can be taken to keeping children safe. On individual levels this includes giving safe spaces to children (online and offline), equipping adults with knowledge and understanding to take action and empowering children to speak out about sexual abuse.

For children already having a history of abuse, there needs to be adequate support. This includes the treatment of physical injuries, STI treatment, HIV prophylaxis, long term counselling and/or psycho-educational intervention. Similarly, the frontline health staff need training in order to pick up the signs of sexual abuse, ask about it in a non-threatening setting and be competent enough to carry out the basic investigations and treatment. Disclosure in children is a multi step process and often is not easy for them to narrate. The health and forensic services must therefore work hand in hand to allow for sensitive information to be gathered from the child.

Education is a key element of control and prevention of child sexual abuse. The learning is imperative for children and families. The children need to be taught in safe environments, which touching and other behaviours are inappropriate and who to report to. They need to be reassured and mentally equipped so that they have a safe person with whom they can communicate.

Implementation of laws and policies is another minefield, which has to be taken into consideration. Control and prevention of abuse cannot work if the laws and policies are not in place, and if society as a whole does not believe in the legal enforceability of these.

References

Guidelines for medico-legal care for victims of sexual abuse. World Health Organisation. http://apps.who.int/iris/bitstream/10665/42788/1/924154628X.pdf

Changing social and cultural norms that support violence. World Health Organisation. http://www.who.int/violence_injury_prevention/violence/norms.pdf

Child sexual abuse. National Society for the Prevention of Cruelty to Children. https://www.nspcc.org.uk/preventing-abuse/child-abuse-and-neglect/child-sexual-abuse/

Singh et al. An epidemiological overview of child sexual abuse. J Family Med Prim Care 2014; 3(4): 430-435.