Entre Nous: the European magazine for sexual and reproductive health: no. 21: child abuse: special issue on society's ugly little secret

ENTRENous The European Family Planning Magazine No. 21/November 1992 1 htld sexual abuse ENTRE Nous Sexuality and Family Planning Unit WHO Regional Office for Europe Scherfigsvej 8 DK 2100 Copenhagen 0 Denmark Tel.: 39171451 or39171426 Fax : 39 17 18 50 Coordinator Dr Daniel Pierotti Editor John Bland Administrator Dominique Dalsgaard ISSN 1014-8485 ENTRE NOUS is funded by the United Nations Popw.lation Fund (UNFPA), New York, with the assistance of the World Health Organization's Regional office for Europe, Copenhagen. It is produced an? distributed three times a year in Englisfu and French by the sexwality and Family Planning Unit of the WHO Regional Office for Europe. Present distribution figures stand at 3400 English, 1350 French, 2000 Spanish, 2000 Portuguese, 500 Hungarian. 2 ENTRE NOUS is produced in: Spanish by the Instituto d� la Mujer, Ministerio de Asuntos Soc1ales, Alma­ gro 36, 28010 Madrid, Spain Portuguese by the General Directorate for Primary Health Care, Ministry of Health, Lisbon, Portugal Hungarian by me Department of Ob­ stetrics and Gynaecology, University Medical School ofDebrecen, P.O. Box 37, Debrecen, Hm1gary The Spanish and PortNguese issues are distributed through UNFPA repres­ entatives and WHO Regional Offices to Portuguese-speaking countries in Africa and South America. Material from ENTRE NOUS may be freely translated into any national lang­ uage and reprinted in journals, magazines and newspapers, provided due acknowl­ edgment is made to ENTRE NOUS, UNFPA and the WHO Regional Office for Europe. Articles appearing in ENTRE NOUS do not necessarily reflect the views of UNFPA or WHO. Please address en­ quiries to the authors of signed articles. For information on WHO-supported activities and WHO documents, contact the Sexl!lality and Family Planning Unit at the address given above. Please order WHO publications direct from tlhe WHO sales agent in each coun­ try or from Distribution and Sales, WHO, 1211 Geneva 27, Switzerland. Young victims A taboo subject until recent times, child sexual abuse is as old as human history but has been swept under the carpet, out of sight. It is a social malaise that will not go away, but it can at last be brought into the open, discussed and perhaps within limits - treated. We offer a short overview of the situa­ tion in a few European countries, which reflects a broad range of awareness of, opinions about and approaches to the problem. Commonly, the health and so­ cial services seem to have been firmly resolved not to confront the "can of worms" that infant and child sexuality, incest and child abuse embody. Some ten years ago, the lid began to come off, and the few cases that reached the police coµrts could be seen as the tip of a very large iceberg: a chilling history of large numbers of young victims, abused by adults over many years, often by close relatives and worse still by their own parents. Many abusers were previously abused as children, so their acts perpetu­ ate a vicious spiral of cause, effect and cause again. Almost never were there facilities for teating the abused, only futile jail sentences for the abuser. Entre Nous recognises that a single issue must leave scores of questions un­ answered. Can society face up to bring­ ing incest into the light of day? What can the wealthy do about child prostitu­ tion and its ugly corollary of "sex tour­ ism." Is child rape and murder really on the increase, or are we seeing a new bru­ talism in newspaper reporting practices? How can society weed out the corrup­ ters? Who will protect the world "street children" - and how? If this issue only serves to trigger open debate about child sexual abuse, it will have made its small contribution. John Bland Thanks! Entre Nous wishes to say thank you to Diana Gibson, Editor of the magazine for the past two years. She has now relinquished the post in order to concentrate on freelance journalism. Contents I EDITORIAL Guest Editorial: The picture of child sexual abuse in Europe by Michele Elliott............................... 3 FEATURES Controlling abuse - an effort doomed to failure, by Catherine Mameffe . . . . . . . 4 Poland: a society in transition by Danuta Golec and Irena Namyslowska ............................ 5 Switzerland drags its feet, by Odette Masson............................... 6 Finland's problem areas, by Heikki Sariola.. .. .. .. . . .. .. ...... .. .. ... .. .. . 7 Let's break the conspiracy of silence, by Belen Nogueiras Garcfa ................ 8 France: belated recognition of the problem, by Caroline Mignot ............. 9 The role of alcohol, by David F. Duncan ............................ 10 An unknown dimension in Turkey, by Ayten Egemen ............................... 11 Lines of escape in the United Kingdom, by Michele Elliott... ........... 12 WHO and child sexual abuse, by John Orley ..................................... 13 Ireland: Child rape case undermines abortion ban ........................................ 14 •I } MOTHERHOOD More children born out of wedlock .... 14 Towards safer motherhood in Turkey by Diana G. Smith .............................. 15 UN AGENCIES Keeping prices low for the UN by Michel Amiot ................................ 16 UN Nuptiality Chart 1991 .................. 16 Condoms rate poorly in preventing disease .............................. 16 Larger families in Ireland ................... 16 OBITUARIES Discoverer of kwashiorkor Dr Cicely Williams ............................. 17 Populariser of the Pill Dr Eleanor Mears ............................... 17 Women at risk in their own home ....... 17 WHO FILE World fertility rates fall sharply ......... 18 Managing STDs .................................. 18 IUDs more popular ............................. 18 RESOURCES Books .................................................. 18 Documents ...... � ................................... 19 Slide set .............................................. 19 Magazines/Newsletters ....................... 19 Diary ................................................... 20 Cover photo: WHO Logo (facing page) created by Peter Davies ENTRE NOUS 21, Novenber 1992 © World Health Organization 1992 GUEST EDITORIAL The picture of child sexual abuse in Europe by Michele Elliott Incest has been "a fact of · life" since long before Oedipus begot a child on his mother, and Lot's daughters prevailed on their father to sleep with them. Throughout human history it has also been one of the great social taboos, characterised by determined and even desperate efforts by the parties con- cerned to "keep it within the family." Today, the lid is coming off the subject of incest, and off the related issue of child sexual abuse. This issue of Entre Nous will peer briefly under that lid in an attempt to show that the problem knows no national frontiers, but that there is as yet no consensus on just what to do about it. In 1985, the European Regional Office of WHO called together a group of "experts" from several countries to report on the problem of child sexual abuse. They met in Copenhagen and their report, published in 1986, was one of the first international attempts to bring together the collective knowledge of this problem. Since then, many countries have conti- nued to investigate the extent of child sexual abuse and have found it shocking. Others have held back, either out of fear, ignorance or the proverbial "lack of re- sources". The reality is that it seems to be happening everywhere, but is only being acknowledged here and there as a major social problem. The statistics frankly tell us little. Is there a correlation between the incidence of child sexual abuse and, say, income levels, or intelligence quotients, or un- employment, or a country's economic development? We don't know, and may never truly know. Almost certainly child sexual abuse, in all countries, is massi- vely under-reported. Perhaps the best that the health, social, education and legal professions can hope to do is to drive the subject into the open, get it publicly discussed, educate children to under- stand better how they might be at risk, and instruct the police in the most effe- ctive ways of treating abusive situations. The reader will find a wide variety of opinions presented here. From Belgium, for example, Dr Marneffe adopts a con- ciliatory, non-judgmental tone in the face of child abuse within the family. Many readers will find this controversial, but they can hardly remain indifferent to her argument. She points out that profes- sionals are poorly prepared to deal with the problem, and roundly declares that ENTRE NOUS 21, Novenber 1992 child sexual abuse is an outcome of re- pression in sexual relationships and of punitive tendencies in our societies. She concludes that present methods to con- trol it are "doomed to failure." Idealised society Sometimes circumstances have been beyoncNhe control of professionals. In Poland, for example, the former commu- nist government presented an idealised society to the world - free from abuse, drugs, alcohol, suicide and so forth. Our contributors point out the great risk that the problem of child sexual abuse will "catch the existing services totally un- prepared." In Turkey apparently, sexual abuse of children is not talked about and there is no obligatory recording of cases, through a survey in 1985 did reveal that a small percentage of cases coming before the criminal courts were of sexual abuse. In Spain too, sexual abuse and incest still constitute a "secret trauma". The article calls on women in particular to break the silence. In Switzerland, little therapeutic inter- vention is available to abused children and their families. Two centres were recently closed down, making it even more difficult to get the necessary help. In England, too, where the problem is widely discussed and more and more cases are coming to light, there is tre- mendous need for more funding, trai- ning and human resources to help the victims or - better still - to warn children before they become victims. France, we learn, lagged several years behind other countries before recognising that there was a problem and taking steps to tackle it. Dr Mignot is critical of the telephone help-lines, finding the system both costly and ineffective. Other countries ("Stichting Kindertelefoon" in the Netherlands, "11 Telefono Azzurro" in Italy, "Childline" in the UK) have re- ported more positively on their usefulness. Finland made a serious attempt to obtain reliable statistics in 1988, when youngsters aged 15 to 16 were asked about their sexual experiences with adults; this suggested that seven per cent of the girls and three per cent of the boys had experienced sexual abuse, while incest by father or stepfather was reported by 0.5 per cent of the girls. But where does "abuse" begin? To what extent do 15- and 16-year-olds tend to exaggerate, on the one hand, or to conceal painful facts on the other? As so often, new Poor classwork can be a source of grief for any child. It may also reflect a r;/,arker secret back home. Photo WHO/ Jean Mohr · answers suggest new questions. Treatment of both abused and abuser is another area of vagueness and uncertain- ty throughout Europe. For the survivors of abuse, whether children or adults, resources are severely limited. Waiting lists for therapy can be as long as six months. In countries where the onset of therapy depends upon the completion of court cases, some families must wait for over two years, by which time the child's problems will have multiplied. Abusers are often given short sentences or parole, without therapy. As a result, they are soon able to resume the abuse. Perhaps we should take a leaf from work being done in parts of the United States, where the abusers are ordered by the courts to receive treatment and to pay for it themselves; refusal earns them a much longer prison sentence. Less dogma The good news is that we have come a long way from the "denial and blame the victim" stage of a few years ago. Pre- vention programmes are in operation widely in France, Germany, Netherlands, the United Kingdom and the Scandinavian countries. We are looking at the entire picture of child sexual abuse with less dogma and more openness. For instance, Kidscape in England recently held the first national conference on female sexual abuse, and has now recorded over 2,000 cases of adults reporting child sexual abuse by women. Is this another taboo subject coming into the daylight? • 3 CHILD SEXUAL ABUSE Controlling abuse - an effort doomed to failure? by Catherine Marneffe Child sexual abuse is an area of concern that is dif- ficult to approach objecti- vely and analytically. It is a phenomenon that arouses moral outrage and other intense emotions associ- ated with a number of poorly understood prejudices and anxieties. Even leading workers in this area, who characteristi- cally are willing to find many reasons to excuse abusing parents, cannot bring themselves to view the sexual offender as another victim of social forces beyond his or her control or to understand why what has taken place happened. The code of practice is a legal one: child sexual abuse is seen as a crime, and it is therefore understandable that many furiously call for immediate prose- cution and severe punishment. What stri- kes one about this attitude is the absence of a broader analysis and the lack of a theoretical basis. In fact, disclosure of sexual abuse is still relatively rare and professionals are poorly prepared to deal with it. They subject the family to close scrutiny and involve the police from the outset, considering the protection of the sexually abused victim as a much more Continued from page 3 Other issues are scarcely touched on here: that of sexual abuse of boys; that of brother-sister incest (who is the abused and who the abuser?); that of rape and murder of a child. All of these unhealthy situations cry out for studies and possible solutions. A single issue of Entre Nous is not going to improve the situation. But the lid is off this particular subject, progress is being made, and our children are to that degree better protected. People working in this field may sometimes feel their efforts are in vain. But as Edmund Burke said two centuries ago: "No man ever made a greater mistake than he who did nothing because he could only do a little." 4 Mrs Michele Elliott worked as a child psychologist in the United States before settling in London, where she founded Kidscape,·a UK organization seeking to prevent child abuse before it happens, through education. important goal than the need to help the child and family at a time of crisis when they are most likely to benefit from therapeutic interventions. We have to stop thinking of child sexual abuse in terms of crime and prosecution and to concentrate rather on the capacity of society as a whole to modify aggressi- ve and moralizing attitudes toward vio- lent families. The energy spent in control, repression and crying scandal should be directed instead towards an attitude of compassion, comprehension and solida- rity. This changing process first concerns the welfare and health system, which should be more concerned about offering help than about controlling violent families. Confronted with the risk that present interventions might be more detrimental t:min beneficial to the child and family, the Confidential Doctor Centre at the Free University Hospital in Brussels developed four years ago an alternative approach to child abuse in general, in- cluding child sexual abuse. This approach was essentially based on the notion that parents with difficulties or having endangered their children should be able to come spontaneously, and of their own free will, to an agency which they are confident would give them help without the risk of being judged or prosecuted. At the Centre, a multi-disciplinary team offers help to the abused child and its parents independently from judicial aut- horities, anonymously, 24 hours a days, seven days a week and without payment. Since 1986, no fewer than 2, 104 abused children, of whom 512 were sexually abused, came to the Centre. The children are being followed for a period of five years. Only five per cent of cases rea- ched the courts, there has been no repeti- tion of the abuse, and above all no child has died. Overcomming repression Child sexual abuse is an outcome of repression in sexual relationships, of punitive tendencies in our societies, of gender inequality and of upside-down structures in family relationships. Prevention of child sexual abuse thus consists of overcoming repression and punitive attitudes - not only in the families we see, but in the wider social context. Perhaps to start with, we in the health system should be looking at our own professional controlling attitudes. If we can have confidence in our patients' ability to take responsibility for themsel- ves and their families, they will live up to it. Maybe then, and only then - we will find more loving relationships be- tween husbands and wives, fathers and mothers, and less abuse of children. Without such an approach, efforts to control abuse are doomed to failure. Dr Catherine Marneffe is a child psychiatrist and Director of the Department of Medical Psychology and the Confidential Doctor Centre, Free University Hospital, Laarbeeklaan 101, 1090-Brussels, Belgium. A psychotherapist tries to probe the mind of a child. What are her secret troubles? Photo WHO ENTRE NOUS 21, Novenber 1992 CHILD SEXUAL ABUSE Poland: A society in transition by Danuta Golec and Irena Namyslowska Until the end of the 1970s, the problem of child physi- cal and sexual abuse was almost never mentioned in Poland. It figured neither in the mass media, in medical reports nor in the public consciousness. Several factors contributed to this situation, including certain political aspects which are typical for other East European countries. Communist ideology tended to present society as free from any form of social pathology: drug dependency, prostitution, suicide and child abuse. Only alcoholism could not be denied because of the magnitude of the problem. Statistics were not pub- lished; studies and research were not supported. But it would be a great over-simplifica- tion to attribute the silence around child abuse solely to political reasons. There are other factors, of a historical and psychosocial nature. The family has al- ways played a crucial role in Polish his- tory as a means of preserving and protec- ting important values, particularly when the national identity was threatened in the 19th century by invaders. After the Second World War, the family was the bastion of the strongest resistance against the communist ideology. Such circumstances made it very difficult for us to accept that family members could abuse physically, or even worse - sexually, their own children. In addition, Poles tend to see themselves as helpless victims of external circum- stances, and blame the authorities for anything wrong that happens. This unwillingness to take responsibility makes it easier to deny the existence of problems we feel uneasy about. The situation has changed recently. The newly gained freedom has opened a different view on social and family pathology. Very slowly, the idea of child physical and sexual abuse is fighting its way into public consciousness. British and American films have brought the subject to television screens and the pro- blem is discussed in the press. 'I Fidt statistics In May 1992, the Foundation for Pre- vention of Cruelty to Children convened its second seminar, addressed primarily to paediatricians and paediatric surgeons. What is striking is that some 600 invita- tions sent to doctors and their organiza- tions in Poland produced virtually no response. The seminar heard the first statistics to estimate the problem of child abuse in Poland, which can be summed up as fol- lows: Sexual molestation under the age of 15 Women Men Sexual contacts 2.5% 0.8% with parents 2.4% 2.5% with siblings 3.3% 1.9% with other members of the family 7.5% 17.2% with people from outside the family 6.6% 1.6% attempted rape 3.9% 1.4% rape committed Of those victims, 90% never spoke to A battered child in Poland. The risk is that bringing the problem of child abuse into the open may catch the existing services totally unprepared. Photo WHO/]. Jozefiak ENTRE NOUS 21, Novenber 1992 anybody about it and never sought any help. The President of the Foundation, Dr Kordacki, estimates that in Poland 200,000 children each year suffer child abuse and 4% of them die. Professionals working in the field of child protection say the range of the problem is similar to the western countries. But certain cir- cumstances typical for Poland make the problem of child abuse more dramatic - and attempts to protect the children less effective. One is alcoholism, which is a social plague. (Hundreds of thousands of children in Poland live in alcoholic families). Another burning issue is the constant shortage of flats. Even divorced people have to live under one roof for many years, and it is practically impossi- ble to evict a parent who is abusive and aggressive. Apart from the Foundation, one of the very few agencies working to prevent child abuse is the Synapsis Foundation )n Warsaw; in its view, schoolteachers ,are the most sensitive to the violation of 'children rights and are the first to alert the authorities, with the medical and legal professions falling far behind. Poland at P,resent faces the great risk that when the problem of child abuse is brought into the open it will catch the existing services totally unprepared. There are few agencies dealing with this problem, there is no money to support projects, a foster care system is almost non-existent, family therapists are not prepared to work with abusing families and abused children, and the legal proce- dures are lengthy and unclear. Poland is at present undergoing a dif- ficult time of transition in every aspect of life - political, economic and cultural - and the speed of those changes puts tremendous strain on the families. Growing unemployment and the profound change in the value system have already resulted in an upsurge of aggression. It is not hard to imagine that the child could be the easiest target of that aggression, with minimal l<igal and ethical consequences. It may take time but we hope that we will finally manage to work out ways of effectively prote- cting the child and preventing child abu- se. The first steps have already been taken. Danuta Golec and Irena Namyslowska are with the Polish Institute of Psychiatry and Neurology, 119 Sobieskiego Street, 02-957 Warsaw, Poland. 5 CHILD SEXUAL ABUSE Switzerland drags its feet by Odette Masson Civil and penal laws in Switzerland are intended to detect cases of maltreat- ment of minors and protect the individuals concerned. Sexual acts committed against children under 16 years of age are punished by reclusion or imprisonment (for "crimes" or "offences" respectively). When committed by a re- lative or guardian on a minor aged be- tween 16 and 18, acts of a sexual nature are punished by imprisonment. Penal measures are considered as distinct from civil measures aimed at protecting the · victims.A federal law passed in 1991 regarding aid to the victims of crime should give abused children greater access to therapeutic treatment. Information about child abuse is still of a limited kind. In 1985, the Council for International Organizations of Medi- cal Sciences (CIOMS) and WHO hel9 a congress in Berne on the subject of bat- tered children. Among other recommen- dations, it proposed changes in professi- onal training, the creation of therapeutic programmes and the involvement of government authorities in drawing up national projects for prevention and treatment. Since 1987, Switzerland has been the host to six international con- gresses on incest and two congresses devoted to sexual abuse and the coordi- nation of counter-measures. The media contribute little towards removing the taboos concerning violence to children. And while a growing flood of articles and books describe the pheno- mena of abuse and the possible counter-measures, only rarely do they report on therapeutic activities and still less on follow-up analyses. University-level and professional trai- ning of those who are concerned about violence to children only occasionally include structured theoretical teaching on this subject. Still rarer are centres where people can acquire both theoretical and clinical knowledge, linked with training in trans-institutional collaborati- on. Two university units of paediatric psychiatry which fulfilled these functions had to close down their activities by decision of the authorities, at Basle in 1982 and at Lausanne in 1990s after three and 16 years of work respectively. The main reason given for closing these two preventive units was that they functioned in ways that were not compatible with other psychosocial units. Detection of sexual abuse is mainly left to the police, a special police unit taking care of abused and delinquent children, the social services and about ten private help-lines; very few cases are brought to light by physicians. Only the police keep national statistics which, 6 in 1990, recorded that 1,495 sexual crimes committed on minors under the age of 16. In the absence of any federal health statistics, it is not possible to estimate the progress made in detecting sexual abuse in this country. However, by refe- rence to police statistics and to the pro- spective study, we can state that detecti- on paints a rose-coloured picture by con- trast with the true incidence of sexual abuse and maltreatment in general. Back in 1984, the Children's News Agency estimateQ, by extrapolation from the cri- minal statistics available, that the total numlier of children sexually abused in Switzerland approached 45,000. Appropriate follow-up The institutional networks, although thick on the ground, are slow to reorga- nize themselves in ways that will ensure coherent treatment and follow-up ap- propriate to the needs of the victims, their families and of the abusers themselves. The principal changes that are needed to ensure treatment of cases of sexual abuse and to prevent them include: pre- and post-graduate training of ihe professionals who deal with children and their families; • training psychotherapists to deal with complex cases at the individual, family and network levels; making provision for treating those who commit abuse so as to prevent them doing so again. To sum up, Switzerland has fallen seriously behind as regards the preventi- on and treatment of child sexual abuse, by comparison with the observable prog- ress in countries where the government authorities (Belgium and France) or regi- onal authorities (Spain and Italy) support such treatment. Swiss professionals in this field are more and more aware of this, and are looking for ways of making psychiatric, medical and social practice even more effective. Lifting the taboos on sexual abuse and setting in train new programmes of treat- ment by a thorough revision of instituti- onal practices will call for a new politi- cal awateness and the introduction of projects at the national level. This is pre- cisely the line advocated by a Report on the Abused Child in Switzerland, which a group of experts is submitting this year to the Federal Council in Berne. Dr Odette Masson is a Paediatric Psychiatrist and Privat docent at the Faculty of Medicine in Lausanne, Chatelard sur Lutry, CH-1095 Switzerland. Lifting the taboos on sexual abuse will ~all for new political awareness. Photo 1Yorld Council of Churches, Geneva Street children and drug abuse A week-long meeting in February held at WHO Headquarters in Geneva exami- ned the largely disregarded problem of street children and drug abuse. During the meeting, estimates of the number of street children in the world were put forward which ranged from 10 million to 100 million, depending on the definition that is used. Most of these children live in poor city environments, and are increasingly exposed to malnutrition, infectious diseases, accidents, physical and sexual abuse, prostitution and drug abuse. Illicit drug use is one of the tragic consequences of life on the street, to which the children tum as a means of coping with the stress of daily survival, and the lack of emotio- nal support, food and shelter. The avera- ge age at which they first use these sub- stances varies considerably, but many reports speak of 11-year-olds using drugs. A pilot project.is to be undertaken aimed at harnessing the local communi- ty, but also involving the street children themselves in making decisions about how to manage their problems. The pro- ject will be field-tested in Brazil, Egypt, Honduras, India, Mexico, the Philippines and Zambia. ENTRE NOUS 21, Novenber 1992 Finland's problem areas by Heikki Sariola Sexual abuse of children came to the public's consciousness in Finland during the early 1980s. Discussion was provoked by the international media's attention to the subject. The Central Union for Child Welfare, together with the National Agency for Welfare and Health, carried out a state-wide survey targeted to all operational units of the social and health services. They reported all known cases of sexual abuse and incest, the particu- lars of each case, the circumstances of discovery and so forth. The results were published in 1985. The survey uncovered 132 cases of sexual abuse and 222 suspected cases over a two-year period in this country of five million inhabitants. The families where cases of incest were known to the officials were often violent, multi-pro- blem families. Another type of incest family uncovered by the survey tended to lead regular but isolated lives. Another survey, in 1988, was conducted among 7 ,500 youngsters aged from 15 to 16. A nationally representative sample was asked about their sexual experiences with adults. This survey is one of the most comprehensive of its kind in the world. Seven per cent of the girls and three per cent of the boys had experien- ced sexual abuse. Father-daughter or stepfather-daughter incest was reported by 0.5 per cent of the girls. Child prostitution in Finland is unorganized and rare. All Finnish officials are required to report child abuse to the local social authorities, who are responsible for providing the needed diagnosis and care for the child and the family. Social or health officials counsel the whole family about the situation. Often the child is taken to hospital during the investigation, and if need be, she or he is removed from the home temporarily or permanently. The general intention is to return the child to the family whenever her or his safety can be guaranteed. A number of psychologists, social workers and doctors have been educated in sexual abuse of children following mainly British and North American models. The child usually receives indi- vidual therapy, and family therapy is also used. The least amount of help is available for the offender, in Finland as well as in other countries. After the mid- 1980s, many cities and towns establis- hed multi-professional cooperation groups to treat sexual abuse cases. These groups coordinate the work regionally and locally. ENTRE NOUS 21, Novenber 1992 Legal sllortcomings All abuse cases do not end up in the courts, even though they usually involve breaking the law. For instance, if a step-parent has had intercourse with a child, the other parent becomes a plaintiff in the case; so the suit may not come to court even though it would clearly benefit the child. At present, the courts cannot require an offender to seek therapy. But the process of changing the criminal law is under way. Among the most serious problem areas are: ., • jdentifying and diagnosing possible sexual abuse cases. Too few people have adequate experience in this field. • The almost total lack of treatment of abusers; The need for a central sexual abuse centre, to give prompt, practical advice to officials who have to deal with cases. Mr Heikki Sariola is a social science researcher with the Central Union for Child Welfare, Annfeltintie 1, Sf'-00150 Helsinki, Finland. Many countries today have free phone services where young people can seek help and guidance - like Switzerland's La Main Tendue (the helping hand). Photo WHO/La main tendue CHILD SEXUAL ABUSE Quis custodiet ips- os custodes? C.J.E. was a compulsive child molester who set up in business as a provider of free childminding for problem families . When he was tried for assaulting child- ren in his charge, the court was not informed of his criminal record. He suc- cessfully claimed that he was a chari- table man who had been "framed" for other people's dirty deeds, and was acquitted. Some time later he murdered one of his child victims. Father M.C., a deputy housemaster at a boys' boarding school with a religious foundation, was jailed for nine months for molesting a 12-year-old boy. Press stories on similar lines to these have come to be almost commonplace in all European countries. They raise the question that the Roman poet and satirist Juvenal posed in about the year 100 AD: "Sed quis custodiet ipsos custodes?•- But who is to guard the guards themselves?" The manager of a clinic offering therapy to abusers says cynically that this experience has taught him "that men who want to be with children are highly suspect: teachers, social workers, scout masters, vicars, youth club leaders, kindly uncles, Father Christmases - men in general." , Administrators of health, education and 1social services have a heavy responsibili- ty to examine most carefully the creden- tials and past history of every person they appoint to supervise the welfare of orphans, children in care and young people in general. Although children can occasionally be motivated by malice, those administrators should investigate meticulously any instance where youngsters make allegations of miscon- duct, however timidly or guardedly the allegations may be expressed. Treatment or jail? Approaches to child sex abusers differ widely in different countries. In the Netherlands only a small proportion of child abusers are prosecuted; instead help is offered to the victim, the family and the perpetrator. In Belgium, Germany, Italy and Sweden, abusers are more likely to receive voluntary long-term therapy than imprisonment. • In the United Kingdom, on the other hand, the trend is more often to prosecute and imprison the offender. The National Association for the Care and Resettle- ment of Offenders issued a report in July suggesting that jailing sex abusers could make the plight of child victims worse. The prospect of prosecution and imprisonment might deter abusers from admitting their guilt; and victims were less likely to report incidents if they thought this might lead to their home- life breaking up. 7 CHILD SEXUAL ABUSE Let's break the conspiracy of silence by Belen Nogueiras Garcia Thanks to the work of the feminist movement, socie- ty and its institutions have started to take notice of the serious problems related to sexual violence: rape and ill-treatment. How- ever, incest and sexual abuse still have not received political, health and social attention in Spain, where these themes still continue to be "the secret trauma". Current legislation also reflects the non-recognition of the gravity of the problem and its consequences. The Penal Code explicitly mentions the rape of · minors up to the age of 12, which is punishable - even though there has been no force or intimidation - with the same penalties as for rape. However, if there is no penetration, whether vaginal, anal or oral, nor introduction of objects, nor "use of degrading or annoying means, methods or instruments", the penalty is considerably less. The traumatic effects are still greater when the abuse is com- mitted by a family member or an acqua- intance, yet the legislation does not recognise this. Paradoxically, for persons aged between 12 and 18 years, the concept of "ravishment" has been dreamed up instead of rape, in such cases reducing the penalty by a half. Reform of the Penal Code which is now under way must take account of the special characteristics of child sexual abuse and increase the penalties for incest, bearing in mind the harm caused to the victim and not just the type of act committed or the use of force. Conscious of the present social, politi- cal, health and legislative vacuum, the Association of Women for Health conve- ned a seminar in January 1991 aimed at professionals in the fields of education, health, social work, the law and women's policies. Women experts in the subject from other countries were invited, including representatives from the Cen- tre for Support against Incest in Oslo. As a result of this seminar, we decided to give high priority to this subject and to call for further studies. So we set up a pilot programme under our "Women-to- Women Health Space" activities, which was intended to offer support and care to women who had suffered sexual abuse in childhood or adolescence. Most of the women who took part in this programme have turned to "Women to Women" seeking help because they feel depressed or have been beaten. Since it was set up, we have found that some 20% of these women have been victims, during infancy or adolescence, of sexual abuse by a member of the family or a person known to them. 8 . The young child is a delicate creature. There are those among us who would wish to crush it. .. Photo WH0/1.P. Martel Lifelong consequences We have discovered that the lack of awareness and social recognition of the problem - "the conspiracy of silence" - means that the girls and women who have undergone such experiences neither recognize them nor consider them as the origin of many later problems in the area of sexuality, self-esteem, interpersonal relations and general state of health and well-being. Yet the effects continue. Women who have been victims of sexual abuse have a higher probability of being abused again. They have physical and emotional health problems, without even realising that these are the results of growing up in a climate where they have been abused and misused instead of being loved and protected. It is urgent that we start to recognise the gravity and extent of the problem, that the existence of sexual abuse be dis- cussed in the communication media. Only in this way can women break the silence. Specific programmes of rehabilitation must be set up for women who have been victims of abuse. We must take action against all the factors which contribute to sexual abuse, such as sexist education, advertising which makes sex-objects of children, and pornography. Girls must be educated to be autonom- ous, to learn to say "No" to what they do not like, to feel the right to the privacy oftheir body and its intimacy, the right to feel safe, to learn to protect and defend themselves, to love and esteem them- selves, to be strong and free. Mrs Belen Nogueiras Garcia is a member of "Women-to-Women Health Space" (Espacio de Salud para Mujeres Entre Nosotras), Avenida Alfonso 13 XIII, 118, Madrid 28016 Spain. A mother at .age 11 An Italian girl aged 11 gave birth in May to a baby girl weighing 4.1 kilograms at Ovada Hospital near Turin. According to Agence France-Presse, the mother was still attending primary school and had hidden her pregnancy from her parents until shortly before the birth. The father - a 22-year-old mason - went spontane- ously to the police admitting the rela- tionship but declaring that he had no idea the girl was so young. A provisional charge was laid against him of doing violence to a minor aged less than 14. ENTRE NOUS 21, Novenber 1992 CHILD SEXUAL ABUSE France: belated recognition of the problem by Caroline Mignot The problem of sexual abuse was recognised and measures were taken to deal with it nearly ten years ago in the United States and other Anglo- Saxon countries, while in France it was still considered as having only marginal importance. Recognition that this problem exists has been trum- peted by the press and TV media, but it arose from the converging interests of concerned health and education professi- . onals and the feminist movements. Today - although it has only relatively recently been brought to light - sexual abuse is regarded as an integral aspect of the maltreatment of children. It was in 1988 that the public authoriti- es in France began a national campaign with the slogan: "Sexual abuse - it really exists", finally lifting the veil on a prob- lem hitherto shrouded in silence. This campaign developed along several diffe- rent lines. Firstly, it sought to inform and train those 'professionals who are involved with protecting children. A technical dossier, drawn up by special- ists from many disciplines and given wide distribution as a summary of every- thing that had been learnt on the subject, served as a basic primer for the teams working in this field. The second phase was preventive work among schoolchildren aged 6 to 12 years. Screening of the Canadian film "My body is mine" served to alert child- ren to the possible risks and to keep them informed. And the third phase was the installation of a national telephone number, called the "green phone" because it is free. This listening service is at the disposal of children, professionals and families and works 24 hours a day on an anony- mous basis. Although the "green phone" receives hundreds of calls each day, the great majority cannot be followed up, either because they have nothing to do with the problem, or because they are just rude phone calls. A small fraction of calls come from professionals who ask for advice or need help with a decision. Frankly, very few cases of abuse or of hitherto '1nknown risk are brought to light through the medium of the "green phone", and the system is very costly. Today there is better professional diagnosis of cases; better knowledge of the elements that may traumatise the child; better acceptance of what a child says, at whatever age. People have at last been forced to admit that children rarely lie, except to protect someone. Despite some brave pilot efforts, actual treatment of cases is still in its infancy. Since this problem has come out into the open, some real progress has been made, but the gaps in our under- standing of the psycho-dynamics of trauma due to child sexual abuse make it hard to identify clearly just what compe- tence is needed to bring about successful treatment. There is an urgent need for new working methods, which in tum will encourage an evolution in practical action and the development of innovati- ve measures to deal with abused and abusers alike. Dr Caroline Mignot is a Paediatrician at the Hopital des Enfants Malades, 149 rue de Sevres, 75015 Paris, France. Appraisal, appreciation, admiration - or abuse? Photo WHO/Zafar ENTRE NOUS 21, Novenber 1992 ILS NE SONT PAS TOUJOURS DE TAILLE A SE DEFENDRE •• • - ~)) ,rl, A L INITIATIVE OU SECRETARIAT D' ETAT CHARGE DE LA FAM ILLE ET DES CONSEJLS GENERAUX "'"""''"'"''"'"'"" .. , .. , .. , They aren't always big enough to defend themselves. Poster from the French Com- mittee for Health Education France's "green phone" was inspired !PY Italy's experiences with its own · "telefono azzurro" and is more formal- ly know as SNATEM, the National Telephone Service for Abused Child- ren. Its financing is shared equally between the state and the French departments. It operates 24 hours a day, with 33 listeners and two coordi- nators, receiving some 600 calls a day; in 1991, a total of 210,604 calls. As Dr Mignot says, apart from 3.6% of requests for information, 25% of callers remained silent, and 66% of the calls consisted of hoaxes, swearing or schoolkids fooling about. SNATEM is still in an exploratory phase; children have yet to take it seriously. Real calls for help, because of bea- ting or sexual abuse, made up 5% of the total. Many could not be followed up because no name or address was given. But in 1991, 1,649 cases were conveyed to the department concerned for action'to be taken. Of these, 53% concerned girls and 47% boys; 24% were children under six, 40% children aged six to 12, and 31 % youngsters aged 12 to 18. The person complained about was the stepfather or mother's lover (one case in 14), the father (one in four) and the mother (one in every two cases). Early evaluation of SNATEM suggests that it has succeeded in bringing to light cases of childhood maltreatment which would otherwise have remained unde- tected by local services. Further re- search - social and epidemiological - is being undertaken to try to improve methods that will better serve to protect the child and prevent abuse. 9 The role of alcohol by David F. Duncan Childhood sexual abuse has gained recognition over the past few decades as being a serious problem in the United States. Esti- mates of its prevalence in our population range from 3% to 31 % of all boys and from 6% to 62% of all girls (D. Finkelhor, 1987). C. Bagley's (1989) findings for the Canadi- an population, that 8.2% of all boys and 17 .6% of all girls were victims of sexual abuse, would probably apply equally to the U.S. population. In general, the data suggest that girls are at least twice as likely as boys to be sexually abused, and that they are more likely to be abused by a member of their own family - most often their father, stepfather or other father-substitute - while boys are more likely to be abused by a non-family acquaintance, such as a neighbour or teacher. Looking only at father-daughter (or father substitute-daughter) incest, what role does alcohol play in sexual abuse cases? What role does alcohol play in sexual abuse cases? Photo WHO/Zafar Susan was an attractive 15-year-old girl, living with her grandparents after her parents died in an automobile acci- dent. One afternoon, while her grand- mother was away, her alcoholic grand- father drunkenly assaulted and raped When four-year-old Wendy was asked by staff in a Belgian hospital to draw her father, this is how she saw him. 10 her. 'For nearly a year afterward, until she finally ran away from home, she had to fear a repetition of the assault when- never her grandfather got drunk. Susan is a teal person, but she could have been a composite of the American media's image of incest: a simple formula of pretty teenager plus drunken father/ stepfather/grandfather plus absent or re- jecting mother equals incest. That image is to be found in popular novels, women's magazines and television soap-operas. To what extent is this image representati- ve of the truth? There is no .simple answer. J.P. Martin (1978), for instance, noted - that many accounts of family violence mention the disinhibiting effects of alco- hol. He concluded that alcohol frequent- ly appeared to be a factor which enabled latent violence and sexual aggression to be expressed in the family. The problem with basing any conclusi- ons on these clinical reports is that we don't know how likely incest would be in alcoholism-free families or vice-versa. Comparative studies of incest case families and matched control families were clearly called for. In a comparison of incestuous fathers to a control group of non-incestuous fathers, G.E. Edwall · and N.G. Hoffman (1988) found that 46% of the former and 39% of the latter were alcoholics. The difference in these proportions is not statistically signifi- cant. So while paternal drunkenness may play a role in some individual incidents such as Susan's, paternalalco- holism does not appear to play any ,J } general role in the causation of father- daughter incest. Interesting enough, however, maternal alcoholism might be more directly invol- ved. Edwall and Hoffman - in contrast to their negative findings for fathers - found that the mother was alcoholic in 27% of the incestuous families and in only 12% of a control group of families. How might maternal alcoholism contribute to father-daughter incest? First, the alcoholic mother is likely to be an unsatisfactory sex partner for her husband. Second, the mother's drunken- ness may contribute to the environment of abuse by eliminating her as a restrai- ning factor. Third, her alcoholism may help the mother. to "tum a blind eye" to the developing incestuous situation. Finally, it has been suggested that alcohol and other drug abuse is a com- mon long-term effect of incest on the victim. Studies of adult women who had been sexually abused as children have shown that they are twice as likely to be heavy drinkers as women who were not so abused. Dr David F. Duncan, is a Research Fellow at the Center for Alcohol and Addiction Studies, Brown University, Providence, Rhode Island, USA. ENTRE NOUS 21, Novenber 1992 .. An unknown dimension in Turkey by Ayten Egemen_ ... Child abuse and neglect, defined as exposing chil- dren to intended or unin- tended insults by parents or other individuals, is an undesirable situation in any society, since it prevents the normal emotional, mental, physical and sexual development of the recipients. In general, people instinctively give affec- tion, love and care to the younger gene- ration in accordance with inherited and established customs, but unfortunately child abuse is becoming an increasingly important problem in many countries. Child abuse for sexual satisfaction can occur in different ways, i.e. with or without physical contact or by brutal action. Cultural differences make the detection of cases a complex task, and it is difficult to establish the degree of damage caused and whether the insults are continuous or isolated; there are al~o differences in individual and cultural perceptions of sex. Since there is no obligatory recording system for child abuse cases in Turkey, the dimension of the problem is not known. Turkish people are bashful about speaking openly about sex. This conser- vative attitude and the concept of family privacy and intimacy prevent the objecti- ve investigation of cases. However, some research has been carried out in recent years and, by evaluating the information available, it may be concluded that child abuse is not very common. Families in Turkey still attribute importance to virgi- nity and to remaining a virgin until mar- riage, so this to some extent acts as a preventive against sexual exploitation. Certainly Turkish people are very sen- sitive about sexual abuse of children. and react more severely towards this offence than to any other. The Turkish judicial system includes preventive measures on this issue in the Turkish penal code and the labour laws, Offenders in Turkey are mostly relatives or near neighbours, and many are from the low socio-cultural group. PhotoJLOIWHO in addition to actions that may be taken by social welfare and other institutions for the protection of children, and by the Children's Court. Under Turkish law, prosecution is possible even though the abuse is not habitual. Such offences are dealt with by the criminal court, and the Turkish penal code imposes not less than five years' imprisonment for offences against children under the age of 15. A survey carried out on all such cases filed with criminal courts in 1985-1986, to discover the types and quantitative dimensions of cases of child abuse in different socio-economic and cultural Trying to find the reason why The Gracewell Institute and Clinic near Birmingham specialises in the study of child sexual abuse. It was founded about four years ago by a wealthy businessman and a retired probation officer, and now enjoys funding from local and central government as well as full charity status. Some 20 paedophiles at a time spend "time out" - in some cases from prison ENTRE NOUS 21, Novenber 1992 sentences undergoing therapy with trained professionals who try - if not to cure their charges - at least to understand what made them act. Over 1100 inci- dents of gross indecency with a child were reported in the UK last year, but the country's prisons held only about 200 convicted abusers on 31 March this year. The Gracewell Institute is the only groups in three metropolitan areas (Istanbul, Ankara, Izmir), showed that 701 (46%) cases were of sexual abuse, 479 (68.3%) were ofrape and attempted rape, and 10 (1.4%) were of incitement to prostitution. The results also showed that the offenders were all men, and that 54.1 % of the victims were girls and 45.9% boys. Their ages were below seven years for boys and above seven for girls. As for the offenders, 32.8% were aged under 18 and 47.2% under 21. Offenders are mostly relatives or near neighbours and they rarely act savagely, but it has been noted that a considerable number of cases are from the low socio- cultural group. At present there are no institutions or rehabilitation programmes for physically or emotionally damaged children who become social outcasts as a result of sexual abuse. However, in 1986 a group of people sensitive to the issue establis- hed a private association, the Turkish Association of Child Abuse and Neglect. Its main activity is to educate families and train specialists concerned with the h<ialth and care of children. There is no formal sex education in Turkish schools, and the main source of information remains within the family. A final comment: those dealing with the problem of protecting children against sexual abuse should not overlook the tra- ditional approach to children of parents, relatives and close friends in countries where touching, kissing, hugging and caressing are considered perfectly natural behaviour. Dr Ayten Egemen is Professor of Public Health in the Department of Public Health, Hacettepe University School of Medicine, Ankara, Turkey, and a member of the Executive Committee of the Association of Child Abuse and Neglect. place in the UK where men can receive specialist long-term, full-time therapy within the community, whether or not they have been convicted of their crime. Of the 50 men who have so far passed through Gracewell, all but one were sexually abused as children. 11 CHILD SEXUAL ABUSE Lines of escape in the UK by Michele Elliott Between February and July of 1987, in Cleveland, a county in the north of England, 121 children were diagnosed by two hospital paediatricians as having been sexually abused. The children, and their brothers and sisters, were suddenly removed from their homes amidst great publicity. The ensuing outcry led to the Cleveland Inquiry which lasted five months and called 137 witnesses at a total cost of£ 4 million. The vast majority of the children were returned to their homes, and the inquiry made it clear that proper proce- dures had not been followed. How many of the children were actually abused and how many were not is still a matter of controversy. The Cleveland Inquiry became critical in the national debate about abused'chil- dren. It affected government guidelines and legislation. It cast doubt on the vali- dity of anal dilation reflex as a test for possible abuse. But it also affected the way the public looked at child sexual abuse. The real problem, according to many people, lay with the professionals who saw child abuse everywhere. Subsequently, there have been even more widely publicised cases of "Sata- nic ritual abuse" against children, again resulting in children being abruptly remo- ved from their parents for long periods. Recognition that child sexual abuse is a problem has increased in the UK in the past seven years, and these recent cases focused the nation's attention on it in a major and negative way. Children were not listened to when they said abuse had not happened, interviews reflected badly on the training of social workers, and there was bitterness and recrimination. The director of one county's social ser- vices department said frankly: "Child care law in this country is a mess." The debate which grew out of the "mess" did, however, result in positive legislation and specific guidelines for protecting children and their parents. Th~ Children Act came into force in October 1991 and was much heralded as the best child care legislation ever intro- duced in the UK. Children may no longer be removed from home without proper procedures, and parents have the right to be informed and involved in the proceedings, if this is appropriate for the child's welfare. That's the good news. The bad news is that social workers are still seen as anathema to the public. They cannot win: if a child dies or is harmed, they should have taken steps sooner. If a child is removed from home, why did they act in such a heartless wa'y? As a result, the social workers are feeling beleaguered and are leaving the profession. Preventing abuse One innovative initiative in preventing abuse has been the introduction into schools of the KIDSCAPE Child Protec- tion Programmes. These programmes, for under-fives, five-to-elevens and teen One million children in the UK have been "Kidscaped" - instilled with the notion that they have a right not to be touched in ways they don't like. Photo Kidscape 12 agers, have begun to instill in children the idea that they do have the right to be safe, not to be touched in ways which make them uncomfortable or which are secret (even if they feel good), and that they should try to tell if anyone is abusing them. The programmes are intro- duced to schools either by individual headteachers or parents, or by the local authorities. KIDSCAPE grew from a one-person campaign started in 1984 into a charity which has now "kidscaped" over one million children in the UK. It is the only organization in the UK working to prevent child abuse before it happens, through education. Another important initiative was the introduction five years ago of the first free phone help-line for children, Child- Line. Open 24 hours a day, this line has taken many thousands of calls and coun- selled more than 215,000 children since it opened. ChildLine, onei of several organizations which help to pick up the pieces for abused children, receives some government funding, but 94% of its income is given by the public. The success of KIDSCAPE and ChildLine shows that initiatives aimed at curbing child abuse can make a difference. Mrs Michele Elliott is a psychologist and Director of KIDSCAPE, 152 Buckingham Palace Road, London SWl W9TR, United Kingdom. ENTRE NOUS 21, Novenber 1992 CHILD SEXUAL ABUSE WHO and child sexual abuse by John Orley Although child sexual abuse is increasingly recognised as a problem worldwide, WHO has no concerted action in this field. Nevertheless a num- ber of programmes within the Organization do concern themselves with this issue. In the new (tenth) edition of the International Classification of Diseases (ICD-0), sexual abuse of child- ren is now clearly identified as a conditi- on to be recorded within the "Z codes" - psychosocial factors influencing health and contact with health services. For the purposes of the classification, sexual abuse is divided into abuse within the family (including all household mem- bers) and that by persons outside the family. Although probably difficult to convey, the idea is to distinguish cases where an overtly sexual relationship is imposed on a normally non-sexual fami- ly relationship from cases where an out- sider assaults a child. This latter is treated more as a single traumatic life event ( or a series of such events). It is recognised, however, that sexual abuse of children is often carried out by people in a position of trust (even though not in the family), with the sex distorting that relationship of trust and thus affecting the child's development. As part of WHO's activities in produ- cing a multiaxial classification of child psychiatric disorder, a classification of associated abnormal psychosocial situa- tions has been developed as one axis, in which the components are selected from the Z codes of ICD-0. This classification is accompanied by glossary descriptions and diagnostic guidelines for each of the items. The criteria for classifying a sexual incident as "abuse" are defined (thus a single incident of genital exposu- re by an adult, but at a distance, would be insufficient to count since there is no evidence of any lasting adverse health effects caused by this). Sexual incidents involving children are common, and indeed it is likely that most minor inci- dents are of little psychological signifi- cance. Sexual play and exploratory play between children can however merge into abuse. The WHO diagnostic guidelines are built on the presumption that the degree of psychiatric risk is influenced by such factors as the extent to which the incident directly involves the child, the degree of sexual intrusion, and the regularity of the sexual activity. As part of another activity within the WHO Mental Health Programme, aimed at promoting the teaching of behavioural science to medical students, a set of learning modules has been developed ENTRE NOUS 21, Novenber 1992 A child's sense of trust in adults can easily be distorted, thus affecting the child's later development. Photo WHO!R. Laszlo , which includes one of the identification and as\5essment of children suspected of being victims of physical and of sexual abuse. In 1985 in Berne, Switzerland, WHO jointly organized a meeting with the Council for International Organizations of Medical Sciences (CIOMS) on batte- red children and child abuse. One of the sessions was devoted to sexual abuse and child prostitution. The inclusion of child prostitution continued some earlier WHO work from within the Division of Family Health on child labour, which included studies of child prostitution, the sexual abuse of working children (especially those working as domestic servants) and the sexual exploitation of children, particularly in developing countries. Dr John Orley is Senior Medical Officer in the Division of Mental Health, WHO, 1211 Geneva 27, Switzerland. Sex abuse - by children The number of children who sexually abuse other children is much higher than was previously thought, according to a report published in April by the National Children's home in the UK. A commit- tee of inquiry set up in October 1990 found that OJle in three cases of sexual abuse involved abusers under the age of 18, and that children as young as three have been known to display "sexually Bullying at school When the UK education department and ChildLine ran an experimental Boarding School Line for six months last year, more than 1,000 schoolchildren phoned to complain of bullying and sexual abuse, often by teachers. Bullying accounted for 20% of the inappropriate behaviour." The chairman of the National Child- ren's home, Mr Tom White, said that cases of sexual abuse by children on other children had tended to J;ie ignored or were put down to childhood experi- mentation. The committee found that, if offenders went untreated, they were likely to continue to sexually abuse into adulthood. cases, while 15% concerned sexual abuse, including allegations involving head teachers. More than a quarter of the alleged sexual abuse cases were said to have lasted for more than a year, and 53% of the alleged perpetrators were male teachers. 13 CHILD SEXUAL ABUSE Traditional patterns of family life in Europe are changing. Photo WHO/Manfred Kraiise Ireland: Child rape case undermines abortion ban Ireland, a staunchly Roman Catholic country, has long forbidden by law not only abortion but the use of contracep- tives as well. As a consequence, for many decades large numbers of women - at least 5,000 a year - have crossed the Irish Sea to the United Kingdom in order to have safe, clinical abortions. Now a change seems imminent, as a result of a case which appeared to rock the very Constitution. Early this year, a pregnant 14-year-old girl was prevented, first by the Irish police and then by the Attorney-General's injunction, from leaving the country to go to England in order to have an abor- tion. She claimed she had been raped by the father of a schoolfriend, and sub- sequently sexually assaulted over a period of two years. The Irish Supreme Court upheld the injunction, even though the girl was reported to be talking of sui- cide, and ruled that the risk of her taking her own life was "much less and of a different order of magnitude than the certainty that the life of the unborn will be terminated if the order is not made." This provoked a national outcry. 14 Thousands of demonstrators marched in Dublin demanding the right to abortion information and the right of Irish women - pregnant or otherwise - to travel when and where they wished. Abortion had been illegal since 1861, and in 1963 this ban was built into the Irish Constitution when a referendum voted "yes" to an amendment pledging to protect the unborn. A new referendum in 1983 endorsed this viewpoint by a vote two to one in favour of "the right to life of the unborn." But now sympathy for the young girl's plight resulted in public opinion polls showing 66 per cent of those questioned in favour of abortion in limited circums- tances. Narrowly in time for the pregnant girl to go to England within the legal limit for abortions in the United Kingdom, the Supreme Court finally acceded to the right of pregnant Irish women to travel outside the country, and to the limited right of suicidal Irish mothers to abortion. Subsequently, a 42-year-old Dublin man was charged with sex offences against the girl between 1990 and 1991. More children born out of wedlock More children are being born out of wedlock than ever before in Western Europe, according to the statistical office of the European Commission. A recent report, Population and Social Conditions, details a breakdown in traditional patterns of family life across 19 countries of the European Community and the European Free Trade Associati- on. It shows also that more Europeans than ever are either shunning marriage or divorcing. In Iceland more than half of the children are born to unmarried mothers, while in Sweden the figure is 48.2% and in Denmark 46.4%. The UK has almost 30% of births outside marriage compa- red with an average within the EC coun- tries of 19.8%, a rate in Switzerland of 6.1 % and Greece of only 2%. The UK also has the highest divorce rate of all the Western European countries, one- third higher than in France and six times higher than Italy. The report, which is the first to collate population statistics on the 379 million people living in the European Economic Area, predicts that the trend towards an older European population will continue. The 19 countries covered by the report already have the highest proportion of elderly people in the world. Marriage and Divorce Marriages Divorces per year per year per 1000 per 1000 population population Austria 5.6 2.1 Belgium 6.1 2.1 Denmark 6.0 2.5 Germany 5.7 2.2 Finland 4.7 2.6 Greece 6.1 0.6 Spain 5.6 • 0.6 France 4.9 1.9 Iceland 4.8 2.1 Ireland 4.8 - Italy 5.4 0.5 Liechtenstein 12.1 1.2 Luxembourg 6.7 2.0 Netherlands 6.3 1.9 . Norway 4.8 2.4 Portugal 7.3 1.1 Sweden 4.2 2.3 I• Switzerland 6.8 2.0 United Kingdom 6.8 2.9 Source: Eurostat ENTRE NOUS 21, Novenber 1992 MOTHERHOOD Towards safer motherhood in Turkey by Diana G. Smith The opportunity to talk to women about their own health comes when they bring their children to our clinics, says Profes- sor Dr Tomris Tiirmen, until recently Director General of Mother and Child Health and Family Planning in the Mini- stry of Health of Turkey. She has now taken over as Director of WHO's Divi- sion of Family Health in Geneva, re- placing Dr Angle Petros-Barvazian, who has retired. "We try to approach a mother through her child because we know she would never come to the clinic just for family planning," Dr Tiirmen told Entre Nous shortly before she took up her post in Switzerland. "When she comes for the immunization of her child, we give her advice on women's health and family . planning as well as on the health of her child." She commented that Turkey has high infant.and maternal mortality rates (IMR 59 per 1,000 infants aged under one year and MMR 104 per 100,000 live births). With 62% of the Turkish population comprising women of childbearing age or children under 14 years, maternal and child health and family planning are pri- ority issues. "We are taking an integrated approach to women's health, child health and family planning, and our health cen- tres and district hospitals in Turkey now provide all three services together." The approach works well both from the point of view of boosting maternal and child health and family planning as part of MCH services, and from the point of view of support from the international agencies. Turkey's Ministry of Health is working with the three agencies simultaneously - WHO for the promo- tion of Safe Motherhood, UNFPA for the development of a strategy for family planning services, and UNICEF for care of the newborn baby. "In this way, we are able to benefit from expertise in all three areas." Speaking at a recent meeting on Safe Motherhood at WHO headquarters in Geneva, Dr Tiirmen said that maternal mortality in Turkey was now falling as a result of the new high priority that the Ministry of Health has been giving to family planning. "We offer a free choice of condoms, IUDs, the contraceptive pill and sterilisation - and we encourage male involvement by inviting husbands to come with their wives to the clinics," she explained. Lower maternal mortality rates have also been achieved as a result of the legalisation of abortion in 1983. "We are ENTRE NOUS 21, Novenber 1992 seeing fewer deaths from unsafe aborti- on," she said. Although abortion was not considered a family planning method by her Ministry, she nevertheless still felt that much more could and should be . done in Turkey to reduce the maternal mortality associated with childbirth. There should be greater promotion of Safe Motherhood, including program- mes to eni:;ourage the sterile, healthy birth process with the help of trained medical personnel. "Although we do not have maternal mortality rates as high as Bangladesh and Africa (about 800 maternal deaths per 100,000 live births), the countries of Central and Eastern Europe - Turkey for example, with 104 deaths per 100,000 live births - have health parameters which are very different from Sweden (five maternal deaths per 100,000)," she concluded. Miss Diana G. Smith is a freelance journalist based in London and specialising in women health and development in the Third World. She is the Editor of WHO's newsletter Safe Motherhood, Division of Family Health, WHO, 1211 Geneva 27, Switzerland. ·1· · , ~ . '. . ~ . - t Dr Tomris Turmen, Director of the Divi- sion of Family Health, WHO, Geneva ·I } "Much more should be done in Turkey to reduce maternal mortality, and greater pro- motion of Safe Motherhood." Photo WHOIT. Urban 15 I UN AGENCIES Keeping prices low for the UN by Michel Amiot The Inter-Agency Procurement Services Office (IAPSO) is a coordinating office which· serves as a focal point for the United Nations system of organizations. Based in Copenhagen, it collects, analyses and distributes procurement data on common-user items with a view to identifying opportunities for economies, improved delivery terms and new procurement sources. Its primary concern is to assist the UN system in its efforts to procure equipment and services at the lowest possible cost, consistent with the maintenance of adequate standards. The restructuring of the economic and social sectors of the UN system during 1977 called for the establishment of a "common procurement system". To this end, the UNDP Governing Council cre- ated the Inter-Agency Procurement Ser- vices Unit (IAPSU), serving as a chan- nel for collecting, analysing and circula- ting procurement data on equipment in common use. Originally based in New York, IAPSU moved to Geneva at the beginning of 1982 to strengthen its ope- rating viability and effectiveness. In July 1989, IAPSU relocated to Copenhagen and became the Inter-Agency Procure- ment Services Office or IAPSO. This move was in direct response to a decision made by UNDP's Governing Council in 1988 stipulating that concrete measures be taken to achieve more equi- table geographic distribution of procure- ment through greater use of supply sour- ces from under-used donor countries, in partioolar the Nordic Countries. Major donor countries such as Canada, Denmark, Finland, the Netherlands, Norway and Sweden are considered "under-utilized" when voluntary contri- butions are compared to UN business- generated return flows. Consequently IAPSO is active in collecting data on potential suppliers within those countries. Information about under-used major donor countries is updated on a continual basis and catalogues are published annually. Identifying viable and verified potential suppliers of common-user items in developing countries is one of th~ important priorities within IAPSO's work programme. In collaboration with national trade promotion organizations UN Nuptiality Chart 1991 The Population Division of the UN Secretariat's Department of International Economic and Social Affairs has produ- ced the United Nations Nuptiality Chart 1991. Printed in full colour, the chart records the average age at first marriage for every country in the world, and the distribution of countries by legal age at marriage. The countries are then shown region by region, with detailed informa- tion on whether or not there is parental consent to the marriage (females and males), the year of the census of survey, and the percentage of females and males located within developing countries, IAPSO prepares special catalogues identifying procurement sources within the target country. As part of the requirement to dissemi- nate timely and reliable information on business opportunities, IAPSO's publi- cation "General Business Guide for Potential Suppliers of Goods and Services" (GBG) provides information concerning the procurement activities and requirements of the UN system of organizations. The GBG is available in English, French or Spanish upon request. The 1991 fiscal year saw IAPSO pro- cess 2,800 requests for advisory services and award 2,300 purchase orders total- ling some US$ 38.5 million . . Mr Michel Amiot was until recently ·I the Senior Business Liaison Officer ,. with IAPSO, based in Copenhagen. He is now Regional Adviser with the UN Drug Control Programme in the Caribbean, based in Barbados. who have ever married at ages 15-19, and at age 50, plus the average age at first marriage. Inquiries should be addressed to The Director, Population Division, UN Secretariat, New York, NY 10017, USA. Condoms rate poorly in preventing disease Female barrier methods of contraception, such as the diaphragm and the contra- ceptive sponge, provide better protection against sexually transmitted diseases than the condom. A study of 4,000 American women attending an STD cli- nic showed that those using the dia- phragm or the sponge ran less than half the risk of catching gonorrhoea than tho- se whose partners used a condom. Rates for other diseases such as chla- mydia and trichomoniasis were also much lower among those using female barrier methods. Transmission of the HIV virus was not studied. The findings, reported in the American Journal of Public Health, were adjusted for risk factors such as the number of Larger families in Ireland Women in Ireland have more children than those in any other European Com- munity country. They had on average 2.14 children each in 1990, according to Population Trends, published by the OPCS, Stationary Office, in London earlier this year. Women in the UK were 16 the surprising runners-up, with 1.84 children, followed by France with 1.8. Outside the EC, women in Sweden have 2.14 children and, in the former Soviet Union, 2.26. The survey of fertility trends in Europe showed that the UK's fertility partners. They bear out earlier studies and call in question the emphasis by sex education and AIDS prevention program- mes on the importance of condoms in preventing the spread of•disease. The authors say a likely explanation for the findings is that condoms are often used wrongly or intermittently, especially among those at highest risk. rate for those aged 15 to 19 was higher than for any other Western European country, at 32 births per 1,000 in 1990, compared with under 10 per 1,000 in Denmark, France, Netherlands and Switzerland. ENTRE NOUS 21, Novenber 1992 OBITUARIES Discoverer of kwashiorkor Dr Cicely Williams, the first adviser in maternal and child health to the World Health Organization in 1948, died in July at the age of 98. Her long and active life began in Jamaica in 1893. In her childhood, she watched her mother run- ning a local clinic on the verandah of her home. She was struck by the extraordi- nary ability of the poorest Jamaican mothers to care for their children in spite of poverty, frequent infections and inadequate nutrition. She was among the first women medical students to be admitted to Oxfotd Uni- versity and, after qualifying as a doctor, · she joined the British Colonial Service and went to work in mother and child clinics in Ghana - then the Gold Coast. She rejected the current belief that curative and preventive care were to be kept separate, and made sure that her clinics provided both. She also encouraged mothers to stay at the clinics with their sick children; "a cuddle is worth a lot of medicine." In writing up the results of this work for a postgraduate Oxford doctorate, she included a first description of the protein-calorie deficiency disease which she called "kwashiorkor'' from the Ghanaian word for "the deposed one" - meaning the child who is displaced from the mother's breast, and is consequently malnourished, when a new baby arrives. Dr Williams next postings were to Singapore and Malaya (now Malaysia). The invading Japanese in 1942 rounded her up with other civilians and military men, and she began three years of internment in Changi prison camp. Her knowledge of nutrition helped many of the pHsoners to survive, thanks to the fresh green vegetables which she was able to grow. She was proud of the fact that all 20 infants born under her care were successfully breastfed and thrived. After the war, she began her years with WHO, including work at the South-East Asia regional office in New Delhi. Later she went to the Department of Human Nutrition at the London School of Hygi- ene and Tropical Medicine, and was one of the first advisers to the Family Plan- ning Association of the UK. Populariser of the Pill Dr Eleanor Mears: campaigner for legalised abortion Dr Eleanor Mears, a pioneer advocate for the contraceptive pill, died in May at the age of 74. A Scotswoman, she was medical secretary of the UK Family Planning Association in the early 1960s when the Pill came to public attention. She did much to ensure its safe introduc- tion in general use and to overcome pre- judice against it. She developed a unique understanding of the effects of different brands of oral and intra-uterine contra- ceptives, and passed this knowledge on to other doctors by setting up FPA trai- ning programmes and advising govern- ments internationally. As a medical student at Edinburgh University, she began to appreciate the Women at risk in their own home Susan's husband broke her jaw with his fist so it had to be wired shut at hospital. Later her husband and another man, over drinks in a bar, decided that her jaw had been wired for long enough. So they held her down over the kitchen table and pulled out the wires with a pair of pliers. She didn't report that incident to the police at the time; she couldn't because her husband had taken all her ENTRE NOUS 21, Novenber 1992 clothes, leaving her naked. This was just one of the cases reported to the Domestic Violence Unit at a pol- ice station in north London. The officers there deal with about 900 cases of vio- lence a year, and 97 per cent of the victims are women. According to statistics from the United Kingdom's Home Office, about 50,000 cases of domestic violence are reported Dr Cicely Williams: "a cuddle is worth a lot of medicine." appalling consequences for women who lacked a safe and reliable method of birth control. She herself had an abortion after her third child was born, and subsequently campaigned vigorously and successfully in the 1960s for to be legalised abortion in the UK. At the end of World War II, she practi- sed in Christchurch, New Zealand, re- turning to London in 1956 and becoming a leading authority in women's medici- ne, with particular accent on infertility. She was the author of Marriage - a con- tinuing relationship, and was a medical adviser to the Marriage Guidance Council in its early days. to police each year, and about 100 women are killed by their partners. Princess Ann, the Princess Royal - as patron of Victim Support - launched a campaign earlier this year for the creation of a nati- onal telephone help-line, like the net- work already in place for abused chil- dren, and for greater light to be shed on domestic crime. 17 WHO FILE World fertility rates fall sharply The total number of contraceptive user in the developing world has risen tenfold in the past 25 years, to over 380 million users. Fertility rates in those countries have correspondingly dropped, from 6.1 children per woman to 3.9 over the past 20 years. These figures were among the positive findings of "Reproductive health, a key to a brighter future," a report compiled to mark the 20th anni- versary of WHO's Special Programme of Research, Development and Research Training (HRP). Set up in 1972, HRP is co-sponsored by the UN Development Programme, the UN Population Fund and the World Bank. On the negative side, the report says that some 300 million couples, who do not want any more children, still do not have access to family planning services. Each year more than half a million women die from complications of preg- nancy and childbirth. And there are"still more than 60 million infertile couples in the world. The report can be ordered from Distribution and Sales, WHO, 1211 Geneva 27, Switzerland. Managing STDs "Whether for diarrhoeal diseases, tuberculosis or STD, effective patient management remains the cornerstone of control programmes," declares the introduction to Management of Patients with Sexually Transmitted Diseases, No. 810 in WHO's Technical Report Series. The many obstacles to STD control, such as limitations of trained personnel and laboratory facilities, oblige a large proportion of STD patients to resort to self-treatment or traditional healers and drug vendors. The booklet - reporting the findings of a WHO Study Group - suggeSJis the best means of identifying pat\ents (and their sexual contacts), managing their illness properly and referring them, if necessary, to a higher level. Order from: Distribution and Sales, WHO, 1211 Geneva 27, Switzer- land. Price 14 Swiss francs; in develo- ping countries 9.80 francs. RES.OURCES Books Abused children: 12 per 10,000 Child Sexual Abuse in Northern Ireland is a 188-page report of a large-scale sur- vey made in 1987 by a group called The Research Team. It defines child abuse very broadly, ranging from "talking about sexual things in an erotic way" to sexual intercourse. And it considers as a child someone under the age of 17 years - the age of consent in Northern Ireland. The team estimated the incidence of reported cases over one year at 12 per 10,000 children. Men were most com- monly the abuser and girls most frequently the abused, although the incidence among younger boys was relatively high. The team recommends that child care centres should be established by each Health and Social Services Board in the country to deal with suspected cases, to train workers in this field and to form useful links with other agencies. Price £18, published in Northern Ireland by Greystone Books. International strategies Adolescent sexuality: health education strategies is the title of a 100-page report published by the Centre International de 18 l'Enfance in Paris on a Workshop held in July 1991. The report is intended to serve as a teaching tool for all professionals concerned with adolescents. It presents the experiences and strategies deployed in such countries as Brazil, Canada, Ethi- opia, France, Germany, Jamaica, Mexico, Netherlands, Senegal, Switzerland and the UK. At present published in French only, it costs 90 French francs plus 25 francs postage and packing. ISBN 2 900 498-17-1. Write to: Centre International de l'Enfance, Service Information, Chateau de Longchamp, 75016 Paris. And after abortion? IPAS announces the publication of a monograph entitled Meeting women's needs for post-abortion family planning: framing the questions. The authors ex- plore the myriad obstacles that prevent women in many parts of the world from receiving the family planning services they need to break the cycle of repeated unwanted pregnancies and unsafe aborti- on. They examine the factors relating to health system design, clinical practice, and national and international laws and policies that impede access, and express the hope that this publication will serve as a catalyst for much-needed policy IUDs more popular The intra-uterine device or IUD is making a comeback after years of con- troversy in some parts of the world. In terms of efficacy and safety, the latest generation of IUD differs dramatically from that of 20 years ago, and pregnan- cy failure rates have improved six-fold over the earliest devices, falling to 0.5% per year. Health care providers in many countries increasingly consider IUDs as one of the most effective reversible methods of family planning. WHO has carried out in-depth exami- nations of different aspects of IUD safe- ty and efficacy over nearly 20 years, involving some 23,000 users. One result has been that the effective lifespan of specific copper devices has been extended to at least eight years of use. The studies related particularly to the rare, but potentially serious, complicati- on of pelvic inflammatory disease (PID), which can lead to chronic pain and infertility. The findings indicate that the PID risk is minimal in women who are at low risk for sexually transmitted diseases - in other words, among couples ,in monogamous sexual relationships. change. IPAS - International Projects Assistance Services - is an international non-profit organization. For further information, contact: IPAS, P.O. Box 100, Carrboro, N.C. 27510, USA. Tel 919.967.7052. Fax 919.929.0258. Guide for pharmacists The Family Planning Association in the UK has published a new reference guide to family planning methods and services specifically for pharmacists. The Contra- ceptive Handbook provides pharmacists with a convenient and comprehensive reference source on family planning met- hods and services. It includes sections on all methods of contraception (including efficacy rates, advantages and dis- advantages, contra-indications and side- effects), details of new methods (the fe- male condom, vaginal ring and implants), emergency contraception, pregnancy testing, abortion, guidelines on legal and ethical issues, and addresses of useful organizations. The Handbook is issued free to UK pharmacies under the Phar- macy Healthcare Scheme. Copies are available (price £12.99 plus £2.50 postage and packing) from FPA, 27-35 Mortimer Street, London WIN 7RJ. Tel 071.580.2333. Fax 071.436.3288. ENTRE NOUS 21, Novenber 1992 Documents Hub of Europe The Swiss Association for Family Plan- ning Counsellors (ASCPF~ - co~s~io~s of Switzerland's geographic position m the centre of Europe, now produces bro- chures on ways of using different meth- ods of family planning in eight langua- ges - French, German, Italian, Spanish, Portuguese, English, Turkish an~ Serbo- Croat. Simply expressed ~d with clear illustrations, the brochures mclude the familiar Swiss slogan Stop SIDA (Stop AIDS) replacing the O by ~ rolled . condom. Inquiries to: Danielle Terzi, Avenue des Boveresses 71, CH-1010 Lausanne, Switzerland. Parents as sex educators Parents need all the help and support they can get in order to become effective sex educators of their children. This booklet results from a study initiated by the Sexuality and Family Planning Unit of the WHO Regional Office for Europe. Authors Mary Porter, Karen Akhoej and Danuta Duch contacted nearly 70 profes- sionals active in the field of sex educati- on in 21 European countries (see reJ?Ort in issue No. 17 of Entre Nous). Avail- able from SFP Unit, WHO Regional Office for Europe, Scherfigsvej 8, DK- 2100 Copenhagen 0, Denmark. SEX EDUCATION PROGRAMMES FOR PARENTS Psychosexual services in selected European countries Issue No. 18 of Entre Nous included an article by Dr John Sketchley explaining how the WHO Regional Office for Europe made its survey of psychosex~al counselling services in certain countnes. In commending this booklet, Dr Jacques Waynberg, Director of the Institute of Sexology in Paris, points out how difficult it is for anyone who want~ to . embark on international collaboration m this field to obtain information in a convenient form. Members of the public too whatever their nationality, need to ha~e access to the right kind of adviser. ENTRE NOUS 21, Novenber 1992 Dr Waynberg comments that, i~ com- . paring on equal terms the m~age g~id- ance counsellors, centres of mformation on sex problems and family planni~g,. sex therapists and social workers withm the cultural patchwork that make up the European scene, WHO reaffirms ~h~ . basic homogeneity of European civilisa- tion. The booklet, he adds, is also a pow- erful tool for those professionals who want to break out of their isolation, and for the general public which is always clamouring for more information and better treatment in this intimate field of health. PSYCHOSEXUAL SERVICES IN SELECTED EUROPEAN COUNTRIES Less of an ordeal The gynaecological consultation can be something of an ordeal for many women. With the aim of putting them 1!1ore at . ease, the Institute for Women m Madnd has compiled a little booklet called f:a consulta ginecol6gica. Illustrated with . little cartoons, line drawings or anatomi- cal sketches on each page, the 54 pages inform women about how their bodies function, the warning signs that may need a gynaecologist's attention, a~d useful tips about premenstrual tension, self-inspection and clinical "etiquette." In Spanish only, the booklet can be ordered from: Instituto de la Mujer, Ministerio de Asuntos Sociales, Almagro 36, 28010 Madrid, Spain. Health promotion in Wales The Welsh Health Planning Forum is producing a series of Health Gains . documents aimed at health and social service departments, local authorities and community health councils to e'.'- plain the long-term goals of the National Health Service in Wales. "Maternal and Child Health" was followed by "Emotio- nal Health and Relationships," and others are planned on HIV/AIDS, STDs, family planning and teenager pregnan- cies. For further information contact: Dr A.M. George, Deputy Chief Medical Officer, Welsh Office NHS Directorate (The Welsh Health Planning Forum), Cathays Park, Cardiff CFl 3NQ, UK. Tel 0222.825.111. Fax 0222.823.204. Slide Set The Role of Informed Choice in Family Planning is a new slide show prepared for family planning personnel, program- me managers and policy-makers by the Johns Hopkins University in the USA._ Taking about 20 minutes to present, with 68 slides this new resource stems from the prov;n finding from many studies that when people choose a method and it is properly explained to them, they are. more likely to use it correctly and conti- nue practising family planning over time. The slides can be ordered (free of charge in developing countries) from: The Johns Hopkins University, Center for Communication Programs, 527 St. Paul Place, Baltimore, MD 21202, USA. Magazines/ newsletters The Brussels-based International Health Foundation recently published the first issue of its new Newsletter. A non-profit organization carrying out research and providing information in the field of contraception and the menopause, the Foundation plans to publish the newslet- ter four times a year, reporting recen~ ·9-evelopments in research and educat10n- lu activities. It will be sent to researchers, gynaecologists, journalists a~d health educators in different countnes. From: International Health Foundation, Don Boscolaan 8, 1150 Brussels, Belgium. Tel (32) 2. 771.9598. Fax (32) ' 2.771.9287. Tabou-Sante is the eyecatching title of a little "newspaper" aimed at youngsters aged between 15 and 20, and publish~d in Paris by Jeunes et Sante - an associa- tion which is itself over 90 years of age. The first issue deals with AIDS (starting with the headline "That's enough blether about AIDS"), the second about drugs ("Neither angel nor devil") and the third about diet. Further information from: Tabou-Sante, 24 rue de Tanger, 75019 Paris. Tel:(33) 1.4034.5219. Fax (33) 1.4034.0534. It is not too early to start planning for 1994, the International Year of the Fam- ily. Henryk J. Sokalski, co-.ordinator for IYF writes in the first issue of The Fa~ily: "The family is neith~r a sta~ic institution nor an abstract notion. Neither is it gender neutral. It is a living entity, functioning in specific realities." Under- lining the need for its concepts to be based on the various international instru- ments enshrining human rights, he adds: "Hence the motto for the Year: Building the smallest democracy at the heart of society." The IYF Bulletin The F_amily is published by the UN Office at Vienna, IYF Secretariat, P.O. Box 500, A-1400 Vienna, Austria. Tel. 431.21131.4223. Fax 431.237497. 19 DIARY Weekend conference on Medical Abortion Services: European perspe- ctives on anti-progestins (Frankfurt, Germany,5-6 December 1992). Details from: Caroline Robinson, IPPF Europe Region, Regents College, Inner Circle, Regents Park, London NWl 4NS, UK. Tel (071) 486.0741. Francophone Congress on Sexology, Fertility and Infectiology (Marrakesh, Morocco, 20-23 December 1992). Details from: Secretariat du Congres, B.P. 15851 Casa Principale, Casablanca, Morocco. Tel (212) 226.2959. Fax (212) 226.2894. Short course on Population and Development, Centre for Development Studies, University of Wales (Swansea, UK, January to March 1993). Details from: The Admissions Secretary, Centre for Development Studies, University of Wales, Swansea, Singleton Park, Swan- sea SA2 8PP, Wales, UK. Tel (0792). 295332. Fax(0792) 295682. International course on the Health of Mother and Child (Paris, 11 January to 2 April 1993). Details from: Dr Michel Pechevis, Centre International de Editar: Annette Kaplun Publish«! in collaboration IVlth l'Enfance, Chateau de Longchamp, Bois de Boulogne, 75016 Paris. Tel (33)1.4520.7992. Fax (33)1.4525.7367. Applied Training to meet Statistical Development Needs: 32 different trai- ning options during 1992-93 (Was- hington, DC, USA). Further details from: Chief, International Statistical Pro- grams Center, U.S. Bureau of the Cen- sus, Washington, DC, 20233, USA. Tel (301)763.2856. Fax (301)763.7589. Health Education and Mass Media: how to communicate effectively. Third European Conference on Health Edu- cation (Amsterdam, Netherlands, 24- 26 May 1993). Contact: Ms Marianne Smit, Dutch Centre for Health Education and Health Promotion, P.O. Box 5104, 3502 JC Utrecht, Nether- lands. F..;ix (31) 30.964082. I POSTAGE - WILL YOU HELP? Entre Nous is free, but our handling costs are very high. If you can afford it, we should very much appreciate it if you could contribute 50 Danish kroner per year ( or the same amount in another currency) as a handling fee. Please send your cheque-made payable to World Health Organizati- on (documents)- to: Entre Nous, WHO Regional Office for Europe, Scherfigsvej 8, DK-2100 Copen- hagen 0, Denmark. WHO Regional Office for Europe The post of Technical Officer at the Sex- uality and Family Planning Unit is vacant. The postholder will be responsible, in col- laboration with the Regional officer for Sexuality and Family Planning, for the project formulation, implementation and monitoring of country projects within the Region, mainly in Central and Eastern Europe and Turkey as well as for inter- country projects. The qualifications required: a degree in public health or health education or medi- cine from a recognized institution; trai- ning and/or experience in family planning including supervision and management of MCH/FP and IEC programmes and rela- ted advisory and teaching experience, pre- ferably at international level; good know- ledge of spoken and written English, knowledge of other European languages an asset, in particular French. The World Health Organization (WHO) is the speciali- zed agency of the United Nations with primary r<>c sponsibility for international health matters and public health. Based in Copenhagen, Denmark, its Regional Office for Europe works to improve the health of peo- ple in the Member States of the Region. Candidates should have the ability to thrive and inno- vate within a rapidly changing, multicultural environ- ment. Applications from women are encouraged. It should be noted that the Office has a smoke-free envi- ronment. Please send your detailed curriculum vitae within three weeks of publication of this advertisement to Personnel, World Health Organization, Regional Office for Europe, Scherfigsvej 8, 2100 Copenhagen 0, Denmark (Fax: +45-31-18-11-20) stating the post for I which you wish to be considered and the name of this journal. Chronic illness With the subtitle "Discovering a new quality of health," Health promotion and chronic illness is essential reading for all who want personal and public health carers to think more positively about chronic conditions. Underlying the book are the principles of the Ottawa Charter for Health Promotion, with its emphasis on encouraging a positive and active attitude to health, whatever the state of health of the individual. Edited by Annette Kaplun, with contributions from some 70 specialists in different fields, the 460-page work is published - in collaboration with the Federal Centre for Health Education, Cologne, Germany - as WHO Regional Publication, European Series, No. 44. A German edition is in preparation to complement the English version. It can be ordered from: ISBN 92 890 1307 9 Price: Sw.fr. 68.- or US$ 61.20 The Federal Centre for Health Education, Cologne Distribution and Sales World Health Organization CH-1211 Geneva 27 Switzerland In developing countries: Sw.fr. 47.00 WHO llaponal Public.,""" Eu,opo.,A ...,... No. <W Order No. 131 0044 ENTRE NOUS 21, Novenber 1992 Q) E "' :;;; Q) a: E :::, 0:: en "fil ~ ~ ~ iii E c: Q) Cl .!: "O ~ ;r