Columbia University, School of Public Health, April 11th 2002.

Conference, Global Health Problems of Prostituted Children.

Fundación Renacer, Bogotá, Colombia.

Timothy Ross

The children and adolescents with whom we work in the Fundación Renacer in
Colombia are among the most stigmatized, excluded and high risk members of
a society that is already a very high risk environment – because of the political
conflict and resulting displacement, trauma and destruction of families and
traditional cultures, because of leakage onto local markets from the illicit drugs
business of large amounts of pure and very cheap cocaine, heroin,
benzodiazepines, and synthetics including ecstasy and methylamphetamine,
and because of the exceptional levels of street crime, violence and murder that
are not related to either insurgency or organized trafficking, but are just part of
the ordinary facts of Colombian life . . and death. The homicide rate, by the
most conservative estimates, is about nine times that of the U.S. and more than
40 times the European average. Less than 1 murder in 90 goes ends up with a
conviction, and the scandals of official corruption and misuse of power that
make up a major part of the daily news coverage rarely lead to any real
sanctions or controls.
For Colombian children in sexual exploitation, this environment only
meets the expectations they have grown to expect through personal histories
filled with abuse, neglect and abandonment. Their perceptions of the macro-
society, the authorities and most adults are of alien hostile forces, to be
contended with, avoided or, in turn, manipulated and exploited. Extreme
violence, disease and early death are seen as part of the natural order of things.
So a key early focus of therapeutic interventions with this population is
generating change in perceptions of self and society that allows them to value
themselves, their health and their lives. Unfortunately the available resources
for attending this population are not the low-threshold, client-centered structures
required to engage them.
An illustrative vignette: at last Thursday’s free clinic in Renacer’s central
Bogotá day center 15 year old Rosa Maria arrived with her nine week old baby.
Possibly because of first trimester drug consumption the baby displayed some
poor reflexes, as well as minor dermatological infections. On leaving Rosa
Maria vaguely said she wanted to ask about something else, a vaginal
discharge – so she came back in for a gynecological examination, that revealed
an IUD in an eroded cervix with a heavy discharge and signs and symptoms of
PID. It turned out that in one of the supposedly better women’s clinics an IUD
had been installed, despite an existing and incompletely treated STD, despite
knowing she was in engaged in street prostitution and at high risk of further
infections and that she would clearly have difficulty in raising further money for
appointments and therefore would be unlikely to return for follow-up
consultations. Because of serious pain and inflammation it was decided to
remove the IUD on the spot and to arrange for a hospital appointment for lab
tests and PID treatment. Despite the fact that one of the two volunteer doctors
attending was from the STD/HIV program of a large Bogotá hospital, the best
we could arrange was for Rosa Maria to go the next day, 45 minutes by bus, to
register for an appointment, which would probably be two to seven days later, at
which she would be a given a further appointment to return for lab tests, which
she would collect 2 to 4 days later and then request a new appointment with the
gynecologist for treatment.
This much is only possible because Rosa Maria already has an identity
card, and as she had previously spent some weeks in a Renacer residential
home, had been registered under the Child Care authorities as eligible for
subsidized health care, including medications that may be prescribed. Without
this coverage she could still get attention but would be given medications
prescriptions to pay for herself – impossible for most street youth whose every
last cent goes on drugs and survival. But if she had no identity papers, city
health department regulations would ban the hospital from offering treatment.
Despite the daunting prospect of multiple trips and bus fares, we think
Rosa may manage to comply, as in her sporadic day center treatment over the
past seven months she has stopped her chaotic drug use, substantially reduced
prostitution and improved her self-perception and self-care.
For most of the sexually exploited children on the street the chances of
getting treatment are fewer. A majority do not have identity papers – in one
sample of high risk youth and young adults I found almost 80% without papers,
and 97% with no kind of health cover. Even with ID papers and a referral letter
from the foundation they are frequently turned away by public hospitals, but
more important is the lack of sense of self-efficacy, expectation of rejection and
fear of all forms of official structures, coupled with chaotic drug use and
unwillingness to leave the dubious safety of their bounded territories, that mean
that about half of those referred on never arrive for their appointments, even
when initially presenting with serious and painful complaints