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THE HEALTH AND DEVELOPMENT OF THE GIRL CHILD: THE SPECIAL ROLE OF THE CONVENTION ON THE RIGHTS OF THE CHILD

Mark A. Belsey

Formerly (1982-1996), Chief Medical Officer and Programme Manager, Maternal and Child Health and Family Planning, World Health Organization, Geneva, Switzerland

Introduction

The Convention on the Rights of the Child embodies the essential health and developmental needs of children as expressed in the Constitution of the World Health Organization:

"...health is a state of complete physical, mental and social well-being and not merely the absence of disease ... [that] healthy development of the child is of basic importance; the ability to live harmoniously in a changing total environment is essential to such development ... [and that] governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures...."

Preamble of the Constitution of the
World Health Organization

It potently is among the most widely applicable and effective tools for the realization of the goals of the International Summit for Children, and the policies and programme objectives relevant to children and adolescents within the agencies and organizations of the United Nations system. This potential exists, not only because of the comprehensiveness and detail within the Articles of the Convention, but also as a consequence of the procedures adopted by the Committee in reviewing, monitoring and assessing the implementation of the Convention by each country/territory that has become a State Party to the Convention. [A total of 187 countries/territories have ratified the Convention. The United States of America has signed the Convention indicating its intention to ratify, while only Somalia and the Cook Islands have neither ratified nor signed the Convention.]

The process of monitoring and review involves a close working partnership among the agencies and organizations of the UN system, and both international and national nongovernmental organizations. The Committee, in reviewing States Parties' reports, has interpreted the Convention from a public health and child development perspective. Furthermore, it has become a major field of action by the nongovernmental community. There is equal scope and potential for common and complementary action in support of countries by the agencies of the UN system.

Despite a lack of provision for enforcement or sanctions, the Convention on the Rights of the Child is uniquely positioned among the international human rights instruments to be implemented and to effect progress in child and adolescent health and development in countries. It has achieved this potential through its scope and explicitness, by the manner in which the Committee has interpreted the application of its Articles, and as a result of its collaboration with the agencies and organizations of the United Nations system and the nongovernmental organizations. The assessments place a major emphasis on the four main principles of the Convention -- namely, that in all matters related to the Convention:

"... the best interests of the child shall be a primary consideration." (Article 3)

"... respect and ensure the rights set forth ... without discrimination of any kind irrespective of the child's or his or her parent's or legal guardian's race, colour, sex, language, religion, political or other opinion, national, ethnic or social origin, property, disability, birth or other status...." (Article 2)

"... ensure to the maximum extent possible the survival and development...." (Article 6)

"... shall assure to the child who is capable of forming his or her own views the right to express those views freely in all matters affecting the child, the views of the child being given due weight in accordance with the age and maturity of the child." (Article 12)

Determination of the best interests of the child can best be judged by reference to a model of child development -- a model understood to include physical, mental, intellectual, psychological, social, and emotional development.

The Health and Developmental Basis of the Convention on the Rights of the Child

The health implications of the Convention go far beyond the one Article (24) that explicitly addresses the right to "necessary medical assistance and health care to all children with emphasis on the development of primary health care...." Advances in the biomedical, behavioral and social sciences has expanded the knowledge base of public health policy and programmes to include the mental health, cognitive development and lifestyle behaviors of children and adolescents as priority concerns in industrialized and developing countries. Taken together, the Articles of the Convention are a clear expression of the developmental needs of children and adolescents at each age and stage of their growth and maturation. It also spells out the protection required in order that health and psychosocial development are not compromised, but progress under the best of attainable circumstances.

The concept of vulnerability of children has been a sine quo non of policies, programmes and advocacy efforts of community, national and international governmental and nongovernmental organizations and agencies that address the needs of children. What is not always appreciated is that vulnerability is a function of the biophysiological, cognitive, behavioral and social changes that are the defining features of the growth and maturation of infancy, childhood and adolescence. Developmental health encompasses all these dimensions and is attained when the child is provided with an enabling environment for its development (i.e., sufficient nourishment, care and protection, including age-appropriate psychosocial and cognitive stimulation). The interaction of these elements with the genetically pre-programmed endowment of the child will result in the health transition from one stage or phase of development to the next stage. While the potential for a child's development may be disadvantaged even before birth, the human organism has built into it a high level of redundancy and resilience -- if supported -- to compensate for such difficulties.

The Convention serves to codify and provide the legal basis for holding States Parties for action on the scientific knowledge of the growth and developmental needs of children and adolescents. National authorities are obliged to bring their national laws and legal codes into line with the Articles of the Convention and to "undertake such measures to the maximum extent of their available resources, and where needed within the framework of international co-operation" (Article 4). [Examples are provided in Annex 2 of the health and developmental needs of and protection required for children and adolescents according to their age and stage of development.] Pediatricians have a major scientific and moral responsibility to be active participants in this process.

Articles of the Convention on the Rights of the Child of Particular Relevance to the Girl Child

There are four Articles of the Convention that explicitly refer to gender-based discrimination against the girl child, while one (related to health), in referring to traditional practices, implicitly highlights the practices that are particularly harmful to the girl child. The relevant Articles are:

Health and Development Issues of Particular Relevance to the Girl Child

The Committee has become more explicit in its requests to State Parties to provide data on indicators that would allow it to judge whether discrimination in any form is prevalent in their country. The Committee in this regard is not merely addressing the issue of the category of all children, but they are also concerned with the rights of the individual child. They seek information that is disaggregated, including by sex, and includes a number of standard health indicators such as mortality at different ages, nutritional status, specific disease rates, and the use of health services.

Disaggregated Analysis of Changes in Mortality: The Problem of Gender Discrimination and the Health of the Girl Child

Biological differences are universal and vary between countries within ranges of biological variation. In contrast, discrimination against the girl child is neither universal, nor is the variation normally distributed statistically. In a review recently completed by me for WHO, evidence for discrimination is not found in all countries, or even the majority of countries, but is particularly clustered in certain cultures. Furthermore, there is evidence that the pattern is changing.

Differences in the health of girls and boys, as measured by mortality indicators, may be a manifestation of the biological differences between the sexes, the consequences of discrimination against one or the other, or a consequence of the epidemiologic nature of the different diseases in terms of circumstances and modalities of acquisition or transmission of the responsible causative agent or agents.

There is a consistent, although slightly variable, higher ratio of male-to-female births in all countries, ranging from 1.03 to 1.07 male births for every female birth. The exception to this pattern is found in China, where the ratio is 1.10 males for every female birth. Many hypotheses have been put forward to explain these data, including failure to register female births, late registration of births with the result that girl deaths in infancy and childhood are not registered, and/or overt female infanticide.

The normally greater number of male births is counterbalanced by a greater biological advantage for the female to survive childhood. Yet for many years there has been concern that discrimination against women and girls outweighs the biological advantage of the girl child and results in increased levels of morbidity and mortality among girls. In some countries and cultures, there is strong anecdotal evidence that discrimination begins even before birth with the use of modern technologies to identify and terminate female fetuses.

With the exception of China and several countries and areas of the Indian sub-continent, most simple comparisons of the infant or under-five child mortality show a higher survival rate of girls over boys. The question of discrimination against the girl child, however, is not necessarily a question of a significantly higher mortality rate for female children over male children, but of having a higher than expected level of mortality when compared with a biological-epidemiological standard derived from data from settings in which there is little or no social or cultural disadvantage of being a girl such as to affect mortality differentials. Such a reference standard has been developed. The female-to-male sex ratios for infant mortality range from 0.76 to 0.84, for young child mortality from 0.81 to 0.96, and under-five child mortality from 0.77 to 0.90, depending on the overall under-five mortality rate among males.

The lower the overall under-five mortality, the greater the level of female advantage, since the female advantage in mortality is most pronounced in the neonatal period;1 and as over under-five mortality declines, neonatal mortality, being the last and slowest to decline, becomes relatively more important in its contribution to under-five mortality. To distinguish the biological advantage from the social disadvantages affecting the survival of the girl child, a standardized ratio has been used to correct for biological advantage2 in an analysis of data from 35 countries. (Only four countries were in Asia, and they did not include either India or China.) Rather than looking at the absolute rates for child mortality, they observed the median difference between an observed and a standard discrimination ratio. [While the standard female-to-male ratio in infancy was 0.801, the observed ratio for the 35 countries (i.e., an additional 0.05) was attributable to gender discrimination. The Middle East Crescent countries' difference was 0.17, more than three times greater than the differences in Latin America and Africa. The young child female-to-male mortality ratios were 0.15 in sub-Sahara Africa and Latin America and the Caribbean, but 0.25 in the Middle East Crescent countries.]

After demonstrating a variable (generally small -- of the order of five percent -- but consistent survival disadvantage for girl children in all regions but not all countries), Hill and Upchurch2 tried to identify which epidemiological, social or health care factors accounted for the female mortality disadvantage. They were unable to show any association of mortality disadvantage with sex differentials in reported episodes of diarrhoea or acute respiratory illnesses, or in nutritional differences, whether measured in terms of stunting or wasting. Data in the DHS showed on the average among countries there was no difference in the ratio of girls to boys being immunized. The variation in female-to-male ratios for immunization, between countries, accounted for 13% of the variance of the female mortality disadvantage. While girls were less likely to be taken to health providers for respiratory complaints, this was unrelated to female mortality disadvantage. There was an association between female mortality disadvantage and failure to receive treatment from a health care provider for diarrhea. The relationship, however, was paradoxically negative, suggesting that the treatments received were not as effective as those administered at home. The factor most strongly correlated with female mortality disadvantage was the male-to-female differences in primary school enrollment. Despite the statistical significance, each of the health or health care factors adds only a small amount to explaining the variance in the female mortality disadvantage. Only with the addition of education was it possible to explain more than 20% of the variation in female mortality disadvantage.

An analysis was undertaken of the data in the WHO Nutrition database on the percent of stunted children in 81 countries in which disaggregated data were available. This analysis was not able to substantiate a "global" pattern of disadvantage for girls. Quite the contrary: In 61 countries, the rate of stunting in girls was the same as or lower than that in boys. In only ten countries (including Nepal, Bangladesh and Sri Lanka), was the frequency of stunting in girls greater than 7% higher than in boys. In contrast, in 30 countries, the frequency of stunting in boys exceeded that of girls by more than 7%. These included several countries in the Middle East, and a large number in Africa and Latin America. Furthermore, the review of food allocation within families indicates that there is no general pattern of discrimination. A few countries have data indicating that there may be some discrimination, but where discrimination does exist, it relates to adult women and their role to serve family members before they feed themselves.

Distinguishing the role of sex from gender in the susceptibility to, transmissibility of, and case-fatality risk (CFR) from measles has been examined in an analysis of historic data from Germany, and recent outbreaks among unvaccinated children in both developed and developing countries.3-5 Three factors appear to influence the CFR of measles -- namely, the nutritional status of the individual, the coexistence of other illnesses or disorders, and the timeliness and effectiveness of treatment of the potential life-threatening complications.6 Where there are significant differences in the CFR of measles among boys and girls, it is likely to be a function of the epidemiology of transmission and/or gender differences, understood in terms of discrimination, affecting the decision to seek and the timing of medical care.

Marriage

Article 1 of the Convention states that "For the purposes of the present Convention, a child means every human being below the age of eighteen years unless, under the law applicable to the child, majority is attained earlier." Since marriage confers on the individual the age of majority, the Articles of the Convention are no longer applicable to such an individual.

Marriage and child bearing before biological and social maturation persists in many communities. In general, child marriage is more common in rural areas than in urban areas. Its causes are intimately tied up with the image of ideal womanhood. Thus, where a woman is seen primarily as wife and mother, there are culturally defined benefits in starting to mould her personality to suit her husband and his family as early as possible. Other reasons for very early marriage relate to female sexuality, the control exercised over female sexuality in a male-dominated society, and the terrible stigma attached to pregnancy outside marriage. In places where girls marry young, they lost the protection offered by the Convention on the Rights of the Child in their positions as wives and daughters-in-law.

With marriage comes the pressure to bear a child, preferably a son, within a year of consummating the marriage. Unfortunately for young married girls, the capacity for reproduction occurs before full growth is achieved and, more importantly, before the pelvic bones achieve their adult size and dimensions. Pregnancy, without nutritional supplements and before completion of the adolescent growth spurt, will slow or stop further growth. As a result, stunting of the skeletal system leaves the girl at high risk of obstructed labor, leading to vesiculo- or ano-vaginal fistula, infection or death. Young women who have not reached full physical and physiological maturity are almost three times as likely to die from complications in childbirth as older women.

Data from studies in several countries consistently show a higher risk of maternal death among teenage girls compared with women aged 20-34. The risk for very young teenagers (10-14 years) is much greater than for older teenagers (15-19 years). In some countries, in the absence of antenatal care, adolescents under the age of 17 have up to a 5-7% risk of dying. When such "children bearing children" survive, and are still fertile, they face the prospect of a life of complications in future child bearing. If such girls have had the misfortune to have had one or another form of genital mutilation, and survived it, they are doubly at risk.7

In Nigeria, where there is no legal minimum age of marriage, 25% of all women are married by age 14, 50% by 16, and 75% by 18.8 Kelsey Harrison and others have indicated the human cost of adolescent pregnancy in Zaria, Nigeria. Girls younger than age 15 constituted 30% of reported maternal deaths.9 In the United States of America, in 1981, girls under 15 had a maternal mortality rate two-and-a-half times that of women aged 20 to 24.10

Early marriage is also associated with the loss of further educational opportunities in nearly all countries.

Women's education is an important determinant of their own health and that of their children. In every economic setting, the children of literate women have a better chance of survival than those of illiterate women. Educated women tend to marry later, delay the onset of child bearing, and are more likely to practice family planning. They generally have fewer children, with wider spacing between births. Women with no schooling, on average, have almost twice as many children as those with seven or more years of schooling. Discrimination against girls in schooling also results in adverse health consequences if and when such girl children mature and start having their own children.

Divorce and Prostitution

In most traditional societies, sexual activity of girls is normally initiated within marriage, albeit in many before or soon after the onset of menses (at times as young as 10 or 11 years of age). In an adolescent clinic population in Ethiopia, premenarche sexual initiation was noted to occur in 40% of the girls.11 The hazards of sexual activity and child bearing before biological and social maturation have been well documented. In some settings, particularly when the man engages in sexual activity with other women (including prostitutes) outside the marriage, the girls in such marriages have an increased risk of acquiring sexually transmitted diseases on two counts: the increased likelihood of acquiring such infections from their husbands, and their vulnerability to the consequences of such infections due to the relative lack of resistance of the immature reproductive tract. Data from several countries in Africa, for example, have shown higher levels of infertility the earlier the age of onset of sexual activity. Marital discord is also more common with a younger age of marriage, and both circumstances are associated with child prostitution, often as a consequence of the child-wife running away and having no other means than prostitution for supporting herself.

Studies in Ethiopia11 have shown that 42% of prostitutes, as compared with 9% of those still married to their first husbands, had been married before the age of 13. Furthermore, nearly 70% of the women engaged in prostitution were sexually active before menarche, compared with half that number in a control group. Noting that half of all prostitutes were married for less than five years, a large number began prostitution as children.12

Despite very high rates of child marriage, particularly in rural areas, the first coitus was at the time of or after marriage.In a study of the social-cultural background of early child marriage in Ethiopia, Dagne notes four major factors that have historically and continue to sustain the tradition, namely:

In other countries, primary infertility is a significant reason for divorce and an underlying factor in prostitution.14

In some countries, aspects of child prostitution have their roots in historical social and religious traditions. In India, adolescent girls may be wedded to the temple goddess and spend their lives as devadasis (god's servant). Priests and other men sleep with the devadasi to appease the goddess's desires. Young devadasis are highly regarded by some as deities, and then discarded when they grow old. One estimate suggests that 5000 to 10,000 girls a year may be condemned to a life of sexual servitude, and subsequently into prostitution.15

A similar practice, referred to as the Deuki system, is found in regions of Nepal. The Nepalese authorities note that:

"A girl becomes a Deuki when she is brought from a poor family to be offered to the gods ... she cannot marry and often engages in prostitution for economic support. Their children, known as Devis, are accepted in the society, but find it difficult to get married because of a traditional belief that some disaster will strike the husband's family."16

In part based on these traditions and an awareness of other traditions in which poor families sent their daughters to be prostitutes for Kathmandu's ruling elite, traffickers have found it easy to lure large numbers of girls to brothels in India, even with the collusion of the parents who see the wealth that these daughters bring back.

The practice of families placating gods by giving virginal daughters to traditional priests is not limited to Asia. Among the Ewe people of West Africa, a virgin daughter may be given to the shrine of the war god to atone for an ancestral crime. These girls, known as "fetish slaves," or female Trokosi, serve life sentences at the shrines of traditional West African war gods. They are:

"... condemned to a lifetime of hard labour, sexual servitude and perpetual childbearing at the service of the village priest ... At some shrines when the woman dies, the family is expected to replace her with another female virgin ... Fetish slavery is still common in the rural east (of Ghana, as well as areas of Togo and Benin), affecting an estimated 10,000 women and girls...."17

Traditional Practices Affecting the Health of Women and Children: The Example of Female Genital Mutilation

While many traditional practices have no health rationale, they may have a profound health effect, particularly those relating to female children, gender relations, marriage and sexuality. Most societies have evolved norms of care and feeding based on age or life stage and gender. These "norms," referred to as traditional practices, have often been derived from empirical observations that have subsequently become ritualized so as to bear little resemblance to the original objectives. Such practices can be characterized as having a beneficial, harmful, or harmless effect on health.

Female genital mutilation (FGM) is a collective name given to a series of traditional surgical operations performed on female genitals in a number of countries. Its physical and psychological effects on girls and women affects their reproductive health, which lasts all their lives since none of the procedures is reversible. FGM, sometimes referred to as "female circumcision," is not similar to male circumcision, where the cutting is limited to the foreskin which has very limited function. In all types of female circumcision, part or the whole of the clitoris is removed. More severe types of FGM, like excision and infibulation, remove larger parts of the genitals and close off the vagina, leaving only a small hole made of tough scar tissue in place of the supple tissue, thus creating permanent damage and dysfunction.

The operation is usually performed by a traditional practitioner as part of the rites of passage of young girls in cultures where the procedure has become an accepted norm. Among the more affluent, it may be performed, for the same reasons, in a health care facility by qualified medical personnel. Without the procedure, girls are considered unfit for marriage -- so mothers and grandmothers perpetuate the practice.

It is estimated that there are at present around 132 million girls and women worldwide who are genitally mutilated. Most of them live in 26 African countries, a few in Asia, and increasingly in Europe, Canada, Australia, and the United States. The most extreme forms of infibulation are thought to constitute about 15-20% of all FGM, although there are parts of the world, especially in the northeastern countries of Africa, where the incidence is much higher.

The immediate and long-term consequences will vary depending on the procedure performed. The immediate consequences may include hemorrhage, tetanus or sepsis, vesiculo-vaginal fistula. For the most severe form, infibulation, difficulties in intercourse may lead to the cutting or tearing open of the vagina, which is usually required in any event in the course of delivery. As a consequence, though no data exist, it is likely that the risk of maternal death and a stillbirth is greatly increased, particularly in the absence of skilled personnel and appropriate facilities. During child birth, the risk of hemorrhage and infection is greatly increased, and the long-term morbidity becomes cumulative and chronic. Although FGM is practised in many societies with diverse cultures and religions, there is no definitive proof that circumcising girls is required by any religion. It is a culturally contrived problem that causes grave damage to women.

Sexual Abuse

Sexual abuse of children and the commercial sexual exploitation of children (CSEC) serve to illustrate the developmental aspects of risk which vary with age. The stage of sexual maturation is a determining factor in the nature of the targeting of child victims by the perpetrators.9 On the one hand, pedophiles seek less mature children as their victims, whereas sexual violence is more likely in the physically mature, but not necessarily psychologically or socially mature, child. Aside from intrafamilial sexual abuse, sexual violence to boys, as in incidences involving girls, may be circumstantial, such as when children are institutionalized for care by child welfare or juvenile justice services in the absence of sufficient supervisory and monitoring systems.

The capacity for self-protection is also affected by the stage of development and maturation. The more extreme example of the developmental impact on victimization is seen among those individuals who have physical or intellectual limitations. They are unable to protect themselves and are particularly vulnerable to sexual abuse and, in some instances, to commercial sexual exploitation. Another group that would seem to be particularly vulnerable to both sexual abuse and exploitation would be girls who become physically mature at a young age but are socially and psychologically immature.

As Finkelhor points out, the developmental stages of a child interact with the characteristics of the environment they inhabit, affecting the risk of victimization. Children have limited autonomy over their own environments, and as they acquire greater control, "their risk of victimization appears to be less a matter of compulsory circumstances than of personal choices."9 He further notes that a "variety of developmental processes seem to affect these choices, including the formation of personal identities, acquisition of self-esteem, evolution of a personal style in interpersonal relationships, history of academic performance, and prior experience of violence and abuse."9

Based on this formulation, one can identify circumstances in which children are particularly vulnerable to sexual exploitation. For example, children whose developmental progress has been incomplete yet sufficient for the child to continue striving for the accomplishment of development tasks, such as at the stages of preschool and school age when there is a desire to please and a respect for authority. These children may be particularly vulnerable to pedophiles who initially appear to be supporting and caring.

A second group that has been known to be seriously exploited sexually, and perhaps are among the most vulnerable, are children who are placed in residential or foster care because of domestic violence and/or abuse, or the parent(s) was unable to cope with or provide adequate care and protection of the child. The care facilities for such children attract potential pedophiles and organized sexually exploiting groups, particularly as there is often inadequate monitoring and supervision of such services, nor is there sufficient screening or standards in selection of staff. In such settings, as in domestic abuse, and because of the developmental stage, the child is both threatened and made to feel guilty by the perpetrator. That guilt later becomes shame, and the child is reluctant to discuss the abuse. Furthermore, children may perceive that their failure to speak out at the time made them accomplices.18

Commercial Sexual Exploitation of Children

Few doubt, although direct scientific data are very limited, that the sexual exploitation of children results in serious, often life-long, even life-threatening consequences for the physical, psychological, and social health and development of the child. These children become social outcasts. Their future fertility and psychological capacity to establish healthy relationships and their own families is seriously compromised. At a community level, the commercial sexual exploitation of children represents an erosion of human values and rights that threatens the health of society.

Despite the paucity of direct evidence, the indirect evidence of the health consequences of the CSEC is compelling. The evidence draws upon the increasing understanding of such emerging public health issues as sexual abuse in children, the phenomenon of street children, substance abuse by children and within families, and domestic and extra-familial violence. There are the direct health effects of CSEC, and there are the effects of the associated and contributing factors such as child abuse and neglect, sexual abuse, and substance abuse. Intergenerational health and social effects must also be taken into account based on the well-documented risk of intergenerational "transmission" of physical and sexual abuse pathologies to the children of its victims.

The issue of the health aspects of CSEC must also be seen, both in terms of the biological, psychological, and social capacity of the individual to engage in sexual activity, variations in the legal age of consent and of marriage in different countries and the definition of a child according to the Convention on the Rights of the Child.

The Needs of the Adolescent Girl

While Article 5 recognizes the responsibilities of parents and caregivers in providing guidance and direction to the child, it acknowledges that such guidance is exercised in the context of the evolving capacities of the child:

"States Parties shall respect the responsibilities, rights and duties of parents or, where applicable, the members of the extended family or community as provided for by local custom, legal guardians or other persons legally responsible for the child, to provide, in a manner consistent with the evolving capacities of the child, appropriate direction and guidance in the exercise by the child of the rights recognized in the present Convention."

Such a distinction is particularly relevant in addressing the issues of CSEC because adolescence, for convenience and inclusiveness defined by WHO as being from the age of 10 through 19, represents the developmental stage between childhood and adulthood. It is characterized as a period of uneven and non-synchronous transition "characterized by biological development from the onset of puberty to full sexual and reproductive maturity; psychological development from the cognitive and emotional patterns of childhood to adulthood; and, the emergence from the childhood state of total socioeconomic dependence to one of relative independence."7 The discordance of the age at which adolescents attain maturity has implication for their vulnerability to sexual exploitation, particularly with menarche in girls occurring at a younger age, and the age of marriage increasing. The earlier biological maturation (i.e., more mature appearance) of a young female adolescent may lead people to have social expectations of her that she may be neither capable nor ready to fulfil.

Ennew19 notes that although the age of consent for heterosexual acts in England was set at 16 in 1885, after the pressure of child prostitution scandals, the legal age of marriage in England was not changed from 12 years to 16 years until 1929. In the realm of sexuality, different interpretations of evolving capacity are reflected in the variation in the legal age of consent in those countries that have such legislation. In both heterosexual and homosexual relationships, the age of consent may fall within the age definition of a child within the Convention.

The hormonal changes during adolescence confirm the gender identity and prepare the person for reproduction and parenthood. While the biological fact of puberty is unchanged from society to society, albeit its timing influenced by the health and nutritional status of the individual, the tasks and experiences of adolescents are particularly a function of the cultural structuring of adolescence as a period for the preparation for adulthood. While there has been a marked decline in the age of menarche, there is little evidence that this is accompanied by a comparable marked shift in the cognitive, psychological and emotional capacity of children. The lack of synchrony in physical and emotional maturity will often put increased pressures on the adolescent who physically matures at a relatively younger age than his or her peers. Later maturation is generally associated with better affective adjustment. It must also be recognized that adolescence follows childhood, retaining many child-like characteristics, and only gradually achieving social and emotional maturity. The individual experiences physical changes and maturation, brain growth and cognitive development, and self-perceptions.

There are both physical and mental health consequences that are associated with the physiological changes in hormonal and histological changes associated with the rapid physiologic changes of reproductive maturation and appearance of secondary sexual characteristics. During childhood and the transition to adulthood, the reproductive system of girls is particularly vulnerable to infection. The cells and secretions of the physiologically immature reproductive tract are much less able than in adults to resist invasion and damage by sexually transmitted microorganisms.20 The cervical epithelium goes through a process of transformation. The physiologic immaturity is characterized by particular cellular characteristics of columnar and metaplastic cells. These cells provide a poor barrier to invasion by a number of microorganisms, including those associated with pelvic inflammatory disease and its consequences of infertility and ectopic pregnancy and those associated with cervical cancer, namely C. Trachomatis and human papilloma virus (HPV), two of the most common sexually transmitted diseases globally. The risks of these infections is associated with the proportion of the surface the ectocervix covered by these cells, the younger the age of sexual debut and the multiplicity of sexual partners. Under these circumstances, a latter onset of menarche but an earlier onset of sexual activity greatly increases the immediate and long-term consequences of the STDs in these young women. Because the presence of other STDs will also increase the likelihood of HIV infecting an individual, adolescent girls who have a later onset of menarche but early onset of sexual activity will be at even greater increased risk of AIDS as well. Repeated C. Trachomatis, which causes erosion of the normal cervical barriers, further increases the hazards of HPV infection and its subsequent risks of cervical carcinoma.6

Throughout adolescence, self-esteem appears to be affected by competence in certain valued domains -- physical attractiveness, peer acceptance, and perceived support from peers, family, or others. Identity is critical during adolescence. It reflects the formation of a stable, coherent picture of oneself that includes an integration of one's past and present experiences and a sense of where one is headed in the future. The process according to Erikson involves a series of selective narrowing of choices in the realms sexual, occupational, and social roles and a progressive commitment to the choices one makes.

In meeting the health and development needs of adolescents, it is important to recognize the interrelationship between the physiologic and psychosocial changes. Mood changes in adolescents are correlated with the hormonal changes they are experiencing.

Many individual and groups of children face major obstacles or destructive psychological or social circumstances that impede the attainment of the necessary developmental task or distort the development process essential to become a healthy, fully functioning adult. The problems of children in difficult circumstances are only seen in their social and economic context and not the context of their needs and vulnerability in attaining developmental health. Such children should be seen as being potential victims because of their vulnerability at a particular stage of psychosocial and/or cognitive development and their psychological, social, cultural and economic environment. Only recently are health professionals beginning to examine risk-taking behaviors as a public health issue which, in the past, have been crisis-focused rather than developmentally oriented. For example, criminal and juvenile justice systems, as well as political authorities, see juvenile delinquency in terms of social and economic deprivation or the consequences of dysfunctional families. Yet Widom, Finkelhor, and others suggest that a prime cause of delinquency may be the developmental stage of childhood victimization.21,22 "Developmental victimology" examines the developmental dimension of the risk of being a child victim, as well as the developmental aspect of the impact on the child victim.9

Athey and Ahearn,23 in discussing refugee children, make an observation that children may be exposed to "sociocultural risk" in which the environment of the child is lacking in the basic social and psychological necessities for life. Thus, risks can be related either to direct threats or insults to the child or to impoverishment, the absence of opportunities for development.24 "Developmental risk," however, is a statistical, epidemiological concept referring to increased risk of psychiatric morbidity, dysfunctional behavior patterns (such as suicide, drug and alcohol abuse, or delinquency), or "incompetence" in love, work or play. But "risk" is not destiny, and children can and do overcome adversity.10

Poverty, Child Labor, and the Exploitation of Children and the Girl Child

At times poverty, the aspirations of parents for their children, and the naivete of the parents conspire to push children (particularly girls) into highly exploitative and abusive situations, with commercial sexual exploitation of children being the end result. Research on the patterns of child labor in Kenya, by Onyanga and her colleagues, documented a scenario in which girls from rural areas have been sent by their families to relatives or others in urban areas in order to attend school in exchange for "some" domestic service on the part of the child. A large number of these girls are grossly exploited and not infrequently subject to physical and sexual abuse. If they become pregnant, they are turned out of the household, often unable to return to their families, and end up by surviving on the street, through prostitution.

There are many other ways in which children are drawn into CSEC: deception in offering families job opportunities for their children, bonded labor where children may be physically and sexually exploited and abused, and even child sponsorship organizations that have been used for commercial sexual exploitation of children. In the latter instance, Herman10 cites confidential reports of the use of well-known charitable organizations by pedophiles to gain access to and to sexually abuse their "foster child."

In many areas of the world, increasing rural poverty, limited educational opportunities, lack of work and a pattern on bonded labor draw children into the labor market. The pathways of poverty to child prostitution are many and varied, affected to a large extent by cultural traditions of submission to authority and powerlessness. Kaime-Atterhog, et al., describe a number of factors contributing to the sexual exploitation of children through prostitution in Thailand.25 Selling children into prostitution had had an historical precedent in Thailand during the era of slavery when slaves, mistresses, and concubines could be traded as goods and children could be used as collateral for loans. The complexity of relationships and responses by the children themselves is illustrated by the observation that, having entered prostitution against their will, many of the children nonetheless felt that they had fulfilled their obligations for the care and protection given them by their parents in rearing them -- thus gaining merit according to Buddhist principles. Despite the risks of disease and physical abuse, girls who had been sold into prostitution returned home with honor because they had brought money, goods and security to their families.

The new child-centered thinking now informing policymaking generally has had the effect of re-casting child labor as those forms of work that are detrimental to the children involved. Commitment to the elimination of child labor becomes, within the new framework, a commitment to removing children only from those kinds of work or workplaces that are harmful to themselves or to their childhood prospects. This demands a far more subtle and variable response to child work in different settings than does a blanket prohibition against child employment under a certain age. It will as much demand actions to support the physical and psychosocial development of child workers, and require actions to prevent children entering the workplace or expelling them from it. It will certainly require actions to ensure that children forced to abandon work or employment do not end up in a worse situation -- which has been a common experience of the current regulatory and penalizing approach.

An example of the consequences of not having a "best interests of the child" perspective was described by Fatima Badri Zalami at a recent conference on child labor. She presented a case study concerning girls under 15 dismissed from a major export manufacturing garment factory as a result of a British television documentary exposing their employment. The factory was subcontracted to manufacture goods by a supplier to a multinational retailer in England. When filmed evidence of underage workers on the factor floor was shown to the suppliers and retailers, all girls in the factory under age 15 were dismissed by the manufacturer, despite the fact that Moroccan legislation places the minimum working age at 12. From the perspective of the manufacturers, suppliers and retailers, and of the television producers, the whole affair exclusively concerned the company's reputation -- which was duly and acrimoniously tarnished. No consideration by any of these parties was given to the well-being of the girl workers who had lost their jobs or to that of their families.

Zalami's study was based on interviews with 12 of these girls. Their descriptions of their working conditions in the garment factory revealed that they had been systematically exploited, and workplace regulations routinely flouted. They had important reasons for working, however, and its positive rewards (apart from their earnings) more than compensated for its negative aspects. The opportunity to enter the formal employment sector via an apprenticeship was seen as a route to a secure job which education no longer guaranteed, particularly in a setting with high levels of unemployment and a rising age of marriage. For some girls, the factory was perceived as a means of emancipation and autonomy from a constricting family environment. For the families, the textile industry was viewed as an attractive workplace because it was predominantly female, secure, and protective of their girls' morality. They were picked up and returned home by a company bus used exclusively for the girls, thus protecting them from harassment frequently encountered in public transport.

School had taught these girls little of relevance, and they sought another job, preferably in the export sector. Since such opportunities are few, however, many were obliged to enter domestic service or marry at the first opportunity; one girl had gone into prostitution. Some of the families had been unable to make good the loss of incomes from the girls and were in debt or economic difficulty. Meanwhile, the Moroccan government was contemplating raising the minimum working age to 14-15, to withstand the threat of boycotts against goods manufactured for export.

Zalami had examined other possible responses by the parties to the situation. In her view, the multinational company could have obtained the implementation of standard conditions in apprenticeship contracts, put in place a system of vocational training, and insisted on other workplace reforms that would have improved the working girls' life chances. The television company, by failing to examine the complexities of youthful participation in the workforce, had assisted in portraying to British consumers a simplistic view of the nature and reasons for child labor in other countries. Zalami pointed to the need for an improvement in the quality, spread and relevance of education and the need to favor development strategies with a less damaging impact on women and girls. She also called for the establishment of mechanisms to monitor child labor interventions so that impact assessment was not left to chance.

International and National Opportunities to Accelerate Progress in Meeting the Health and Developmental Needs of Children and Adolescents

While the goal of universal ratification has been virtually achieved, the greatest challenge rests in the implementation of the Articles of the Convention and the removal of reservations by States Parties. [As of January 1997, the United States of America has signed the Convention, thereby indicating its intention to ratify it, and only Somalia and the Cook Islands have neither ratified nor signed the Convention.] Some of the Articles are aspirational, to which States Parties are expected to make all due efforts in their realization. Other Articles can and should be put into immediate effect.

Ratification of the Convention has the force of an international treaty. States Parties commit themselves to the implementation of the Articles of the Convention and to report on their progress within two years of their ratification (and subsequently, every five years). The Convention, now ratified by 187 State Parties, has the potential for being one of the most powerful international tools for policy and program development for an integrated and comprehensive approach to meeting the developmental needs of children and adolescents at each phase of the life cycle.

When a country has signed and ratified the Convention, national authorities are obliged to bring their national laws and legal codes into line with the Articles of the Convention. Many countries have prepared such legislation on the family and on health. But civil and penal codes also must be carefully revised to amend the provisions that conflict with the letter or the spirit of the Convention. Pediatrics, as a group, have an important role to play in that process. They must both "act for the best interests of the child" and simultaneously ensure that national policies and programs are based on good science.

The Convention is of relevance to pediatricians in their professional and social capacity, as well as their moral authority as being among the critical guardians of the health, growth, development and well-being of children. The Convention recognizes the child as a legal subject, the health needs of the mother during and after pregnancy, and the need for family planning and services; it provides a unique opportunity "to promote maternal and child health and welfare and to foster the ability to live harmoniously in a changing total environment." The Convention recognizes the diversity of needs and the many dimensions of the changing environment in its Articles of entitlement and its Articles of protection from an array of risks and dangers.

Maternal and child health services are among the few universal social institutions which regularly come in contact with children. Under these circumstances, child health care providers, as individual practitioners and as a group, are in a unique position to assess the adequacy of the national response in meeting the health and developmental needs of children as expressed in the Convention, and to determine circumstances and situations when those needs are threatened or seriously compromised. It is essential, therefore, that they be familiar with the Convention on the Rights of the Child, understand its various Articles in terms of their applicability to the health and developmental needs of children, and take a leadership role as advocates and agents for effecting its application in their communities.

References and Bibliography

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3. Aaby P, Oesterle H, Dietz K, et al. Case-fatality rates in severe measles outbreak in rural Germany in 1861. The Lancet 1992; 340: 1172.

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12. Duncan ME, Tibaux G, et al. A socioeconomic, clinical and serological study in an African city of prostitutes and women still married to their first husband. Social Science Medicine 1994; 39(3): 323-33.

13. Dagne HG. Socio-cultural background of early marriage in Ethiopia. An unpublished document on research on traditional practices for the Inter-African Committee on Traditional Practices Affecting the Health of Women and Children. Geneva (undated).

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15. Gilada, LS (as quoted in Shelly Ngo with Sanjay Sojwal). Sleeping with the goddess. World Vision: February-March 1995 (pp. 3-7).

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17. Brooker E. Slaves of the fetish. Independent on Sunday. The Sunday Review 16 June 1996 (pp. 12-14).

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21. Widom CS. Childhood victimization risk factor for delinquency. In: Colton ME, Gore S, editors. Adolescent stress: Causes and consequences. Hawthorne, New York: Aldine de Gruyter, 1991 (pp. 201-22). As quoted by Finkelhor D (see reference 22).

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23. Athey JL, Ahearn FL Jr. The mental health of refugee children: An overview. In: Ahearn FL Jr, Athey JL, editors. Refugee children: Theory, research and services. Baltimore, Maryland: Johns Hopkins University Press, 1991 (pp 3-19).

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25. Kaime-Atterhog W, Ard-Am O, Sethaput C. A documentary assessment. In: Ard-Am O, Sethaput C, editors. Child prostitution in Thailand: A documentary analysis and estimation of the number of child prostitutes. Bangkok, Thailand: Institute for Population and Social Research, Mahidol University (pp. 37-71).

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