1. Resilience, positive capacity building and sexual health promotion in nursing – Couples, families and communities, 3 ECTS Violence against children Anette Häggblom, PhD, senior lecturer Åland University of Applied Sciences (Harstad University College) Tartu May 2014

2. FNs definition,1993Of Violence ”Violence is the intentional use of physical force or power, threatened or actual, against oneself, another person,or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, mal-development or deprivation”. WHO, 2002 Definition of sexual violence “any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work”

3. Defining child abuse and neglect «Child abuse or maltreatment constitutes all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power».

4. Kind of violence Physical violence, Sexual violence, Neglect/maltreatment Emotional abuse/Psychological violence 90% by biological parents

5. Physical abuse Is defined as those acts of commission by a caregiver that cause actual physical harm or have the potential for harm Includes hitting the child with an object, kicking, beating, threatening, burnt … 15% of children

6. Sexual abuse Is defined as those acts where a caregiver uses a child for sexual gratification 9.1% sexually abused (WHO, 2002), 10% USA

7. Neglect/maltreatment Refers to the failure of a parent to provide for the development of the child – where the parent is in a position to do so – in one or more of the following areas: health, education, emotional development, nutrition, shelter and safe living conditions 60% i USA

8. Emotional abuse Includes the failure of a caregiver to provide an appropriate and supportive environment, and includes acts that have an adverse effect on the emotional health and development of a child. Six dimensions (Mitchell, 2005): Persistent hostility, persistent failure to respond to the child’s physical, emotional, intellectual and social needs, seriously unrealistic expectations, inappropriate stimulation of a child’s aggression and /or sexuality, exploitation of a child for the gratification of another’s needs and grossly inconsistent care. Included can be: harsh discipline, conditional parenting, insecure attachment, denigration and emotional unavailability.

9. Fatal abuse / Non-fatal abuse Year 2000, estimates 57 000 deaths of homicide Greatest risk children of 0-4 years old, (most fatalities 86,1% involve younger children than 6 years- USA) The major incidences occurs in the African Region More than 100 000 children are threatened and bullied (Sv)

10. Fatal abuse / Non-fatal abuse Data on non-fatal child abuse and neglect comes from official statistics, case reports and population-based surveys Differs from countries Corporal punishment (aga), hitting, punching (knytnävsslag), kicking or beating (slå/puckla på)

11. Sexual violence in society Rape – in relation (every fifth) Outside: An assault rape (12%) unknown perpetrator Many (gang) perpetrators Entertainment rapes Grooming Trafficking I recognized that this is not a life, I got triplet, they were born too early … I was almost breaking down, I never slept. He should have sex … I felt if he can, all though, his children are weeping and I sleep maybe 3 hours a night, if he can rape me at night, something is wrong…

12. 25% of all women in the world being raped sometimes during their life time Approximately 7/rapes/day in Sweden/BRÅ 60% -less than 30 years, 15% -less than 15 years (2010) Women uncertain if raped (Young women: Don’t know if it was a rape but I felt raped!) 90% raped indoors Of women seeking help only 20% report to police Few turn to hospitals Fear the man (not reporting)

13. Scorpion’s story ‘He also talked about the sexual abuse: ’Yeah, well what he did to me, is that…um…one day, Christ…one day, I was in the bath, and um, he was washing me…and um, he sort of…um, did something what he shouldn’t have done…and I think you already know what, you know…. I was, oh, about seven, you know, I know people bath, bath ya, but like, when you bath somebody, you don’t play with people, and I didn’t know that, because he covered my mouth so I couldn’t talk, and then he…did…you know…you know, that is it…’

14. Consequencies Sexual and reproductive Reproductive health problems Sexual dysfunction Sexually transmitted diseases, including HIV/AIDS Unwanted pregnancy Physical Abdominal/thoracic injuries Brain injuries Bruises and welts Burns Central nervous system injuries Disability Fractures lacerations and abrasions Ocular damage

15. Risk factors/Health consequencies of child abuse Psychological and behavioral Alcohol and drug abuse Cognitive impairment delinquent, violent and other risk-taking behaviors Depression and anxiety Developmental delays Eating and sleeping disorders Feelings of shame and guilt Hyperactivity Poor relationships Poor school performance Poor self-esteem Post-traumatic stress disorder Psychosomatic disorders Suicidal behavior and self- harm

16. Risk factors/Health consequencies of child abuse Other longer-term health consequences Cancer Chronic lung disease Fibromyalgia Irritable bowel syndrome Ischaemic heart disease Liver disease Reproductive health problems such as infertility

17. Consequencies Time after a rape: different Immediate crisis reaction –for some, sleeping difficulties, nightmares, anxiety and cry a lot. Some cannot go out – be among others or be independent Feeling of worthless, feeling of disgust - can result in a destructive behaviour Eating disorder and to harm one self Drug problems Living in sexually destructiveness

18. Consequencies ’flash-backs’ – to re- experience the rape Feeling of deep anxiety Loose self-worth and control The feeling of own body disgusting and dirty Leading to problems with owns sexuality

19. Consequences Fear the perpetrator Living in a bubble Wholly or partially feelings are cut off Repress thoughts Living as nothing has ever happened Don’t tell anybody Long-term consequences: Periods of depression, sleeping disorders or concentration problems

20. To meet – listen, affirm and inform ”The only person who listened to me was this nurse, named Nancy. Her only job was to take my blood. And I’m sitting there and I’m telling her about being sexually assaulted. I was so glad that Nancy listened. It made it all the difference.” To show respect

21. To meet – listen, affirm and inform ”I think there needs to be a relationship, you just don’t go and ask somebody, have you been sexually abused? You know you have to develop a relationship and see some symptomatology that might uh, that you could use in your conversation and say tell me a little bit more about this... You can have a relationship built over several weeks or you can build a relationship over a couple of hours” Affirm feelings and thoughts Give guilt relief Show different solutions Never promise more than you can keep!

22. Prevention Ecological model Microsystem/mesosystem Family support Training in parenting Home visitations and other family support programs Intensive family preservation services Exosystem/macrosystem Health service approaches Screening by health care professionals Training for health care professionals Protective services