32 A practical guide to the Istanbul Protocol – for medical doctors PART D EXAMINATION OF CHILDREN1 Many cases of torture of children have been documented by human rights organisations, and it is feared that those cases form only the tip of the iceberg (Amnesty International, 2000). Yet there is a general disbelief that torture can be perpetrated against children. Torture and sexual abuse of children is widespread, particularly in conflicts dominated by ethnicity (Southall & Kamran, 1998). The girl child is doubly susceptible to violence, because of her gender and because of her age (Chinkin, 1998). Children may be secondary torture victims because of the violence or torture perpetrated against one or more of their relatives. They may also be primary victims. Since there are many reports on how children have been subjected to the same torture methods as adults, it may be expected that they present similar physical symptoms as adults. Still, very little is known about the physical consequences of torture that are typical for children. What are the implications of torture for a growing body? How does torture affect the development of a child? Children should be examined in a way appropriate for their age. Nevertheless, the health professional should realise that for many of the world’s children, childhood ends long before they reach the age of eighteen, the age when according to most international standards they become adults. Their stories of the violence suffered by them should be respected and taken seriously. However, they often prefer to stay silent, move away and hide and bury their experiences (Protacio-Marcelino, de la Cruz, Balanon, Camacho, & Yacat, 2000). Children may react to trauma with depression, sleep disturbances, nightmares, anxiety, fears, learning problems, post-traumatic 1. The definition of a “child” in the UN Convention on the Rights of the Child states “For the purpose of the present Convention, a ‘child’ means every human being below the age of eighteen years, unless, under the law applicable to the child, majority is attained earlier.”