It is a pecularity of Pakistan’s criminal justice system that it has treated children as miniature adults, not just in the way their crimes are prosecuted but in how the victims themselves are perceived.

“We handle a four-year-old child through the same protocols used for an 18-year-old boy, a 16-year-old girl, or even a 30-year-old man,” said Police Surgeon Dr Sumaiyya Syed. She is part of the government effort to open the country’s pilot Child-Friendly Medicolegal Clinic at the Office of the Police Surgeon as part of the Anti-Rape Crisis Cell. It was inaugurated last week and fulfils a requirement of the Sindh Medico-Legal Act.

In the case of bodily harm, a medico-legal certificate or report needs to be prepared as evidence. The child has to be brought to a government facility where one of its doctors will examine the child and document injuries, their severity and probable cause. The ML certificate is the bridge between medicine and the courts.

Every year, Sahil, a nonprofit organisation working on child protection since 1996, publishes its Cruel Numbers report, tracking child sexual abuse, abduction, missing children and child marriage across Pakistan. Last year, at least 2,003 child sexual abuse cases were recorded, with 1,549 (77 per cent) in Punjab, 330 (16pc) in Sindh, 91 (4pc) in Khyber Pakhtunkhwa, and 33 (3pc) across other areas.

The figures are widely cited, but they barely reflect the full problem. Sahil compiles its data through secondary collection, using reports published in over 80 newspapers. But so much more never makes it to press. Families and communities suppress cases more often than they report them.

Dr Syed said she’s pushing to have violence against women and children recognised as a public health crisis. “It would change our protocols, our entire approach. Until we recognise it as a crisis, we will just keep working randomly.”

The child-friendly approach

It is not easy to open up in a government hospital or police station if you have been sexually assaulted or worse regardless of your age. But at the new clinic some effort has been made to create an environment to put children at ease with toys and snacks.

Dolls and figure diagrams help children indicate what happened. Children used to be examined lying down, but the approach now is to adapt to their comfort, even if that means examining them while they sit in a parent’s lap.

A system of psychosocial support is integrated, connecting children to shelters when needed, and making sure case workers follow up on their care. A psychologist is stationed at the clinic, though currently only during working hours. There is also a case worker, and children can be referred for psychological support either before or after the medico-legal examination, depending on what they need. The idea is to have clear referral pathways so care doesn’t stop at the examination. “The benefit of the case worker is that, without involving me, they can coordinate with the Sindh Child Protection Authority, Dar-ul-Aman, or other shelter homes,” said Dr Syed.

“In the second phase, there is also a plan for a safe room where children who need to stay overnight can remain in a secure environment, ideally with their mother, instead of being sent back immediately or handed over to police,” she said. “At present, we request hospitals to admit the child because we cannot send them back.”

The clinic also caters to minors in custody who are brought in by police for examination or age assessment. For girls who have reached puberty, an ethical priority would be to provide emergency contraception. “If a survivor presents within three days, it should be given immediately,” added Dr Syed.

Adolescent girls are frequently brought in for age determination in cases shaped by family pressure, early marriage or disputes over legal age. Since consent under 18 is not legally recognised, such cases are often referred through police, courts or FIRs to establish a child’s age and legal status. It has to be determined with medical and forensic assessments, including physical examinations, radiology and dental X-rays. In such situations, children were often questioned in the presence of adults or in ways that may be damaging to their emotional state.

And then there are children who are refugees or have been rescued from trafficking or experienced repeated abuse. Here, the initial clinical concern is the risk of HIV and sexually transmitted infections. While tests like VDRL are used for STI screening, HIV prevention is also addressed through post-exposure prophylaxis (PEP). If the child is suspected of being exposed to HIV, PEP is started immediately to reduce the risk of infection.

These protocols are being formalised in a 20-page manual prepared under the Sindh Medico-Legal Act. The document builds on earlier guidelines, including the anti-rape crisis cell manual, and is intended to guide doctors on how to provide structured, child-sensitive care in such cases.

The usual suspects

Abdul Mateen is the psychologist at the clinic and has over a decade of experience working with children and young people dealing with drug addiction, including at Punjab’s Life Care Hospital. He and the police officers are extra vigilant as to how information unfolds during an examination.

“Sometimes cases are presented in a certain way by parents or others, but the reality is different,” he said. “It may turn out that the alleged abuse involves someone close to the child, a neighbour or someone known to them.”

NGO Sahil has clearly said that for children below five, the majority of abusers are indeed acquaintances, which means children are most vulnerable to people they know but are not closely related to. This can include guards, religious teachers, shopkeepers, neighbours, or even uncles.

Dr Kishwer Enam, a paediatrician at Karachi’s Aga Khan University Hospital, said child-friendly medicolegal clinics are essential because children who arrive for examinations are in a very fragile state. “These tests can be extremely distressing for a child,” she said. “You have to do all of this very carefully and very empathetically, without causing the child further distress or harm.”

The physical environment should feel safe and reassuring, especially for younger children, so that they are not further intimidated by the process. Equally important is the behaviour of staff. “In the past, the environment in typical medicolegal offices was often very harsh,” she said. “Sometimes, staff would scold or speak to patients rudely. That is not the way to do it.”

Lawyer Ahrar Soomro gives the example of a child’s case from Lyari in which the uncle was suspected of abuse. The investigation was at risk of being compromised because the child’s father was not interested in pursuing it. In order to record the child’s account, those involved created a more familiar setting. A family member with whom the child was comfortable was introduced to him as a “police officer” and asked to pose the questions, while the actual investigating officer sat alongside and listened. The idea was to create a situation in which the child felt he was speaking to someone he trusted, rather than being directly questioned by unfamiliar police personnel.

What do child abuse laws say?

For a long time, Pakistani law barely acknowledged child sexual abuse. There was one provision that covered sexual offences, a single section of the Pakistan Penal Code that applied equally to acts committed against humans and animals. Convictions were rare.

“We didn’t even like to talk about it,” said lawyer Miqdad Mehdi, who has over 18 years of experience working on child rights. “It was a completely ignored area.”

It began to change in 2015, when police in Kasur’s Ganda Singh area booked a gang of fifteen suspects on charges of sodomy, extortion, and blackmail. Their victims, hundreds of boys and girls from Hussain Khanwala village, had been filmed and threatened into silence. Three years later, the murder of seven-year-old Zainab Ansari in the same district triggered a wave of public outrage and renewed scrutiny of child sexual abuse in Pakistan.

Legislators responded. Two new sections, 377A and 377B, were added to the Pakistan Penal Code, dedicated exclusively to child sexual abuse for the first time. Where the law had previously offered only vague, borrowed language, it now named specific offences: fondling, exhibitionism, voyeurism, bad touch. Each carried defined punishments.

The Criminal Law Amendment followed in 2016. Then, in 2021, the Anti-Rape Act, first introduced as an ordinance, then passed into law, brought the most comprehensive overhaul yet. It covered all forms of sexual offences against both women and children, and addressed procedure, not just punishment.

Under the Act, Special Sexual Offences Investigation Units were to be established. Trials would be held in camera, away from public view. Victims would not be made to face their accused in open court. Psychosocial support would be made available. Survivors’ rights, for the first time, were written into the process itself.

In 2025, further amendments tightened the framework. Medical examinations in such cases must now be conducted within 24 hours. Bail for the person accused of child sexual abuse cases has been restricted. And rape cases involving child victims can now also be tried in juvenile courts.

However, as Imtiaz Soomro, a lawyer who works with Sahil, put it, Pakistan has plenty of good laws, yet there is no naam o nishaan of their implementation.