Cette thèse, développée dans une approche comparatiste et différentialiste de la maltraitance faite à l'enfant (0 à 18 ans), en France et en Syrie, concerne la médecine légale, inscrite dans un contexte d'éthique médicale. La problématique initiale évoque le signalement de la part du médecin, et ses freins, question qui débouche sur l'interrogation suivante : Comment la décision du médecin, toujours première, peut-elle intégrer la dimension psychologique et socioculturelle de la maltraitance, pour que les conséquences du signalement (ou du non signalement) soient au bénéfice de l'enfant et sa famille ? L'Histoire et l'évolution de la maltraitance à enfant sont exposées, pour les deux pays (peu d'informations pour la Syrie). L'enfant, sujet vulnérable, est considéré dans sa globalité psychologique et socioculturelle, face aux données afférant à sa protection. Ensuite, l'approche médicale (tableaux cliniques de maltraitance le plus couramment observés), suivie de la prise en charge globale de l'enfant, dans les sociétés française et syrienne, sont exposées. Enfin, les aspects juridiques de la protection de l'enfant, face au signalement et ses freins, sont présentés comme relevant d'une problématique éthique, située entre médecine et droit, dans des espaces socioculturels spécifiques. Ces données prennent concrètement corps dans des études de cas cliniques, en service de médecine légale : CHU de Dijon, en France, et Centre hospitalier de la région d'Alep, en Syrie (synthèse de Dao sur 249 cas, en 2002, compte tenu de la situation politique actuelle). Via le témoignage du Dr. Catherine Bonnet, cette étude s'ouvre sur un approfondissement des questions du viol et de l'inceste, et met en lumière certaines difficultés à déboucher sur des décisions judiciaires qui, bien que correctes du côté du droit, peuvent s'avérer délétères pour l'enfant et sa famille, sur les plans psychologique, affectif et social ; la situation des deux pays est différenciée, ici aussi. La conclusion, d'ordre moral et éthique, renvoie à la responsabilité de la famille (bientraitance et éducation de l'enfant) et au constat d'une articulation difficile entre le travail du médecin et les décisions judiciaires qui devraient permettre un vrai soin et une protection efficace de l'enfant maltraité, question qui suscite notre interrogation finale : À l'échelon mondial, faudrait-il élaborer une législation commune, spécifique pour l'enfant ? / This research is a comparative and differential approach of child abuse (0-18 years), in France and Syria. It concerns forensic medicine in the context of medical ethics. The initial issue evokes the reporting abuse and its obstacles, and leads to the following question: How the always main decision of the doctor can integrate the psychological and socio-cultural dimension of child abuse in order that the reporting (or the no reporting) benefits the child and family? The history and evolution of child abuse are exposed, for both countries (some information only for Syria). The child, subject vulnerable, is considered as a psychological and sociocultural entity, as to his/her protection. Then, the medical approach (clinical cases of abuse commonly observed), and the medical management of the child are exposed in the French and Syrian societies. Finally, the legal aspects of child protection are reported with its obstacles as part of an ethical issue, between medicine and law, in specific socio-cultural dimensions. These data are updated in the study of clinical cases, in forensic services: CHU of Dijon, in France, and one hospital, in the area of Aleppo, in Syria (Dao’s synthesis of 2002, on 249 cases, given the current political situation). Then, considering the testimony of the Dr Catherine Bonnet, this study opens the reflection on rape and incest, and highlights some difficulties due to certain judicial decisions which, although correct in view of the law, may be deleterious for the child and his family, if we consider a psychological, emotional and social point of view. Both countries situation is differentiated, again. The moral and ethical conclusion refers to the responsibility of the family (welfare and education of the child). It also refers to a difficult relationship between the doctor’s practice and the judicial decisions that should allow a true care and an effective protection of the abused child. This issue arouses our final questioning: at the world level, perhaps it may be necessary to develop a specific legislation for the child ?

Afrikaans text / Hierdie studie bied vanuit 'n ekosistemiese benadering 'n verduideliking van die lewenswereld van die volwasse persoon wat as kind gemolesteer is. Enkele uitgangspunte van die ekosistemiese benadering word bespreek wat dien as vertrekpunt waarvolgens die navorser konstruksies oor die as kind gemolesteerde volwassene konstrueer. Daar word gefokus op die langtermyneffekte van die kindermolestering met spesifieke verwysing na die effek op die • fisiese gedrag van die volwassene; • die aard van die seksuele verhoudings van die volwassene; en • die aard van die interpersoonlike verhoudings van die volwassene. Tydens hierdie bespreking word die oorlewingstrategiee, wat die volwassene aanwend om met die l angtermyneffekte te oorl eef, duidel i k belig. Die he l i ngsproses waardeur 'n vol wassene vol gens sy of haar ei e pas beweeg ten einde die effek van die molestering te verwerk, word volledig bespreek. Die teorie is toegepas in die navorsing om die uitwerking van die kindermolestering op volwassenes te beskryf asook enkele gebeure (events) van die helingsproses waardeur 'n volwassene beweeg het. Gevolgtrekkings en aanbevelings word geformuleer ten einde die bruikbaarheid van hierdie studie in die praktyk aan te dui. / In this study the world of the adult survivor of sexua 1 abuse is described in terms of the eco-systemic approach, as well as certain constructions within the approach. These constructions served as a base on which the researcher construed further constructions of the adult survivor of sexual abuse. The study focuses on the 1 ong term effects of the child abuse with specific reference to the effect on • the physical behaviour of the adult; • the nature of the sexual relationships of the adult; and • the nature of the interpersonal relationships of the adult. The strategies of the adult in surviving with these long term effects are also highlighted in the discussion. The healing process through which the adult survivor passes in healing the sexual trauma according to his or her own pace, is fully discussed. In the empirical research the theory is applied to describe the effect of sexual abuse on the lives of adults as well as on certain events of the healing process. Conclusions and recommendations are formulated to indicate the usefulness of this study for the field. / Social Work / D.Phil. (Maatskaplike Werk)

Afrikaans text / Hierdie studie bied vanuit 'n ekosistemiese benadering 'n verduideliking van die lewenswereld van die volwasse persoon wat as kind gemolesteer is. Enkele uitgangspunte van die ekosistemiese benadering word bespreek wat dien as vertrekpunt waarvolgens die navorser konstruksies oor die as kind gemolesteerde volwassene konstrueer. Daar word gefokus op die langtermyneffekte van die kindermolestering met spesifieke verwysing na die effek op die • fisiese gedrag van die volwassene; • die aard van die seksuele verhoudings van die volwassene; en • die aard van die interpersoonlike verhoudings van die volwassene. Tydens hierdie bespreking word die oorlewingstrategiee, wat die volwassene aanwend om met die l angtermyneffekte te oorl eef, duidel i k belig. Die he l i ngsproses waardeur 'n vol wassene vol gens sy of haar ei e pas beweeg ten einde die effek van die molestering te verwerk, word volledig bespreek. Die teorie is toegepas in die navorsing om die uitwerking van die kindermolestering op volwassenes te beskryf asook enkele gebeure (events) van die helingsproses waardeur 'n volwassene beweeg het. Gevolgtrekkings en aanbevelings word geformuleer ten einde die bruikbaarheid van hierdie studie in die praktyk aan te dui. / In this study the world of the adult survivor of sexua 1 abuse is described in terms of the eco-systemic approach, as well as certain constructions within the approach. These constructions served as a base on which the researcher construed further constructions of the adult survivor of sexual abuse. The study focuses on the 1 ong term effects of the child abuse with specific reference to the effect on • the physical behaviour of the adult; • the nature of the sexual relationships of the adult; and • the nature of the interpersonal relationships of the adult. The strategies of the adult in surviving with these long term effects are also highlighted in the discussion. The healing process through which the adult survivor passes in healing the sexual trauma according to his or her own pace, is fully discussed. In the empirical research the theory is applied to describe the effect of sexual abuse on the lives of adults as well as on certain events of the healing process. Conclusions and recommendations are formulated to indicate the usefulness of this study for the field. / Social Work / D.Phil. (Maatskaplike Werk)

Background: Child abuse in South Africa is a significant public health concern with severe negative outcomes for children; however, little is known about risk and protective factors for child abuse victimisation. This thesis investigates prevalence rates, perpetrators, and locations as well as predictors of physical, emotional and sexual child abuse victimisation. It also examines the influence of potential mediating and moderating variables on the relationships between risk factors and child abuse. Methods: In the first study, a systematic review of correlates of physical, emotional and sexual child abuse victimisation in Africa was conducted. The review synthesised evidence from 23 quantitative studies and was used to inform the epidemiological study. For study two to four, anonymous self-report questionnaires were completed by children aged 10-17 (n=3515, 57% female) using random door-to-door sampling in rural and urban areas in two provinces in South Africa. Children were followed-up a year later (97% retention rate). Abuse was measured using internationally recognised scales. Data were analysed using descriptive statistics, multivariate logistic regressions, and mediator and moderator analyses. Results: The first study, the systematic review, identified high prevalence rates of abuse across all African countries. It identified a number of correlates which were further examined using the study data from South Africa. The second study found lifetime prevalence of abuse to be 54.5% for physical abuse, 35.5% for emotional abuse, 14% for sexual harassment and 9% for contact sexual abuse. Past year prevalence of abuse was found to be 37.9% for physical abuse, 31.6% for emotional abuse, 12% for sexual harassment and 5.9% for contact sexual abuse. A large number of children experienced frequent (monthly or more regular) abuse victimisation with 16% for physical abuse, 22% for emotional abuse, 8.1% for sexual harassment and 2.8% for contact sexual abuse. Incidence for frequent abuse victimisation at follow-up was 12% for physical abuse, 10% for emotional abuse and 3% for contact sexual abuse. Perpetrators of physical and emotional abuse were mostly caregivers; perpetrators of sexual abuse were mostly girlfriends/boyfriends or other peers. The third study found a direct effect of baseline household AIDS-illness on physical and emotional abuse at follow-up. This relationship was mediated by poverty. Poverty and the ill-person’s disability fully mediated the relationship between household other chronic illnesses and physical and emotional abuse, therefore placing children in families with chronic illnesses and high levels of poverty and disability at higher risk of abuse. The fourth study found that contact sexual abuse in girls at follow-up was predicted by baseline school drop-out, physical assault in the community and prior sexual abuse victimisation. Peer social support acted as a protective factor. It also moderated the relationship between baseline physical assault in the community and sexual abuse at follow-up, lowering the risk for sexual abuse victimisation in girls who had been physically assaulted from 2.5/1000 to 1/1000. Conclusion: This thesis shows clear evidence of high levels of physical, emotional and sexual child abuse victimisation in South Africa. It also identified risk and protective factors for child abuse victimisation which can be used to inform evidence-based child abuse prevention interventions.