What should doctors do for suspected child abuse by family?

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More than 4,000 cases of child abuse were reported in Pakistan last year. Clinics and emergency rooms in hospitals often receive cases in which children are brought in for some other complaint but during a check-up doctors notice signs of abuse. In a society like ours, how do you flag abuse when it could be the fault of the parents?

Dr Kishwar Enam is working to tackle that. She’s a paediatrician at the Aga Khan University Hospital and heads the recently launched child protection services. She spoke to SAMAA Digital about the need for a separate organised system in which suspected cases of child abuse receive diagnosis and protection.

“We
see a number of cases of child abuse at our hospital. Every suspected case I
saw, I would bring a burden home with me because I could only medically manage
the patient and refer them to psychiatry,” she said. “I would not sleep
that night because I had sent that child back to the same environment.”

These
families never turned up for their follow-up appointments.

So
Dr Enam decided to launch the child protection services. The paediatrics team
worked with the psychiatry department to make a CPS committee. It has five paediatricians,
a nurse and a secretary. The emergency department and obstetrics and gynaecology department
were involved.

When
there’s a suspected child abuse case in the ER or paediatric clinics, the
doctor on call and a psychiatrist are contacted. Signs of neglect can be easily
picked up by paediatricians, says Dr Enam. Identifying sexual abuse is more
complex.

“The
CPS faculty interviews and examines the patient and decides if we need to call
the police and the child protection officer,” explained Dr Enam. “If it is a
suspected rape an obstetrics gynae faculty or fellow would be called, too.”

Communicating
with the child and family in such a harrowing situation can be tough. It
requires special skills to get maximum information and do the least
harm, says Dr Enam.

“In
the majority of physical abuse cases, non-accidental injuries or intentional
injuries can be differentiated easily from maltreatment. Child sexual abuse is
tricky because it can be normal or nonspecific in 80% of the cases.”

Dr
Enam adds that 80% to 90% of the time the perpetrator is known
to the child, so it can be the parent, caregiver, teacher, relative or anyone
in the surroundings where the child lives.

In
its report Cruel Numbers, shared by civil society organisation
Sahil with SAMAA Digital, it was revealed that 47% of
abuse cases were carried out by an acquaintance. Around 23% of these
events took place at an acquaintance’s house and 16% at the victim’s own home.

Between
January and June last year, 1,304 child abuse cases were reported across the
country according to Sahil. This number is also believed to be an
underestimation because most cases are never reported. Sahil concurs with this
in its report.

The legal aspect

Doctors
and healthcare providers are not mandated by law to report child abuse. “When
parents or caregivers tell us that we do not want to register an FIR or have
the involvement of child protection authority, we are helpless,” lamented Dr
Enam.

A
private hospital such as AKUH doesn’t have the authority to deal with
medicolegal cases either. Dr Enam narrated how she had made several trips to
the Sindh health department, social welfare department and the Sindh child
protection authority to get help.

After
some months an MoU was signed with the director-general of the child protection
authority which stated that AKUH would provide medical and
psychiatric treatment and a child protection officer would handle the forensic
and legal aspects of abuse cases.

The
paediatrician believes the situation is improving but many issues remain. “The
police are always reluctant to register an FIR in child rape cases and in some
instances only do so when they get pressure from media and higher authorities.”

There
is little coordination between the police and the SCPA. A justice system
without juvenile courts makes matters worse.

“Worst
of all, the SCPA does not have a shelter,” Dr Enam revealed. “The shelter
has been under construction for 10 years. If a child needs to be rescued to a
safe environment the Sindh government has no place to keep them.”

An
order was passed by the health ministry to all the public hospitals in 2011 to
form child protection committees in their hospitals. This order was never
implemented, said the paediatrician.

They
have requested the health ministry and SCPA to pass it again.

Apart
from setting up a protocol for the suspected child abuse cases, they are
doing workshops for medical and non-medical professionals. They hold
regular lectures for medical students and trainees. They are also
developing a curriculum.

As
for AKUH, Dr Enam hopes one day to form a child abuse advocacy centre there.
The hospital conducts training sessions on “How to be safe” for children and
parents at schools. Soon they will also be carried out at madrassahs.



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