If you are a gynecologist at a public or private hospital, what should you know about examining a survivor of sexual assault?
If you are a physician in the emergency ward of a hospital, how do you recognize and intervene in cases of domestic violence?
If you are a medical student, what should you know about your curriculum regarding the provision of gender-sensitive medical care?
If you are an intern confronted with your first set of patients, how should you handle cases of abuse?
If you are a nurse or a paramedic or any other first responder, how can you respond sensitively?
These are critical questions about the recognition, screening and intervention to gender-based violence that health systems and the people who populate them often do not ask. An insular approach that treats surface wounds without addressing the underlying causes is the norm and as Dr.Rajani Jagtap puts it, it starts with a bruise and ends in death, with no one being the wiser.
On Thursday, 27th November, Prajnya kick started this years spotlight events on gender violence and public health with a Doctor's Panel at Sri Ramachandra University that looked at all the above questions and shed light on the protocols and guidelines that exist to guide medical professionals in screening and responding to gender violence as well as discussing the mandated roles medical professionals have to play in terms of law and policy.
The panel began with a presentation by Anuradha Kapoor of Swayam who made the case for getting gender violence in all its forms on the public health agenda. She analysed NCRB records and quoted statistics to indicate that not only are a disproportionate number of women facing violence in this country, but also that it has an enormous impact on their physical, psycho-social and reproductive health. She identified the health system as one of the weakest links in the service provider chain, where women are looked at as patients and injuries are treated without dealing with the violence behind it. While discussing the role of health providers, she stressed on the following:
- Creating a safe and secure environment for the survivor to access help and consider options.
- Ensuring privacy and confidentiality to elicit information without fear of reprisals or other consequences.
- Probing the causes behind injuries.
- Being sensitive and not engaging in further victimization.
- While there is a greater emphasis on sexual assault, domestic violence often goes unrecognized. Health providers need to be aware of what the law mandates and understand their roles.
- Health providers should be in touch with local service providers and have referral mechanisms in place to provide the survivor with the help (legal services, shelters etc) she needs.
- Recording and reporting all information clearly. This is also important from the angle of evidence documentation.
- Going beyond response mechanisms and engaging in prevention and support activities.
Sangeeta Rege, Senior Researcher from CEHAT spoke next about the lacunae in implementing standardised protocols for responding to domestic and sexual violence. She began by identifying the lack of serious policy directives in India that recognize violence as a legitimate public health issue. She stated that The National Health Policy of 2002 made no mention of violence and it wasn't until 2008 that the planning commission report recognized violence against women as a health impediment. This has serious implications in terms of delivering a sustained and integrated health care model Some of the barriers to both providing and accessing quality health care for those affected by violence that have existed so far that she pinpointed include:
- The lack of standardised protocols for provision of treatment.
- The fact that violence related injuries are not considered medico-legal emergencies and subsequent lack of 'emergency' care.
- The prevalence of a victim-blaming attitude and engendering secondary cycles of victimization
- The demand for mandatory police requisition that hinders access to immediate health care
- The pervasiveness of insensitive and discriminatory medical practices such as the 2-finger rape test, hymen tests, comments on build and vaginal/anal laxity
- The medical and therapeutic aspects of care are neglected.
Expanding on a public health approach to gender-based violence, the role of Primary Health Centres in screening, awareness and referrals, secondary health centres in establishing hospital-based crisis centres and tertiary centres in incorporating gender into medical education and the need to overhaul curriculum was discussed.
Ms.Rege also outlined a health sector model for sexual assault that comprises of:
- Getting informed consent from the survivor for all procedures to be carried out.
- Implementing a uniform gender sensitive protocol which does away with insensitive practices such as the two-finger test.
- Maintaining chain of custody for medico-legal evidence is critical.
- Standardised treatment guidelines should be followed including screening for STIs, pregnancy tests and provision of emergency contraception within 48-72 hours.
- Providing psychological and social support. Serve as interface with police and other services.
For More Information:
The Government of India issued Guidelines for Medico-Legal Care for Survivors/Victims of Sexual Violence has a comprehensive list of protocols for all health workers.
The WHO Guidelines for Medico-Legal Care for Victims of Sexual Violence is another important resource.
Dr.Rajani Jagtap, Medical Officer at Rajawadi Hospital Mumbai spoke next about the Dilaasa Crisis Centre, a hospital-based screening and response centre for violence against women. The Dilaasa Model comprises of comprehensive training for doctors and other health professionals to repond to VAW and identifies signs and symptoms that are suggestive of Domestic Violence for every department of the hospital. An integrated approach is also provided in terms of outlining a standard proforma and treatment protocols. The Crisis Intervention Department receives referrals from the OPD, IPD and Emergency wards and is staffed with trained counsellors. An interesting aspect of the Dilaasa model is the creation of temporary shelters within the ward which gives women the option of being admitted for 24-72 hours to reflect on the choices available to them. This removes the consequences attached to approaching to other service providers and creates a safe haven for women affected by violence.
Dr.Jagtap shared her experiences of being a part of a hospital-based crisis center and stressed on the importance of screening all patients for potential signs of abuse. She elaborated on the need to go beyond the symptoms and explore possible reasons for them. Even something as simple as anemia could have deeper implications in an abusive household and doctors need to probe for these connections she said. The necessity of recording and documenting all instances of violence and its evidentiary value was also emphasized.
Following the presentations, a serious discussion ensued about the barriers to providing hospital-based care in instances of domestic and sexual violence including the safety of health professionals intervening in these cases. Moving forward, further engagement with the issue via training and capacity building was suggested.
About the Resource Persons:
Anuradha Kapoor is the Founder Director and Managing Trustee of Swayam, a feminist women’s rights organisation addressing the inequalities and violence that women face in our country. She was actively involved in the advocacy that resulted in the passing of the Protection of Women from Domestic Violence Act, 2005, and has since been working on ensuring its effective implementation both at the State and National levels. She has also been a part of the National Consultations on Sexual Assault laws and Marital Property Rights andminitiated the setting up of AMAN Global Voices for Peace in the Home, an international network of organisations working on Domestic Violence.
Sangeeta Rege is a Senior Research Officer working with CEHAT. She has a Masters degree in Social Work and has been involved in developing interventions , conducting training and carrying out researcher on the issue of Violence Against Women and role of the health sector, for the past 13 years. She has published several papers in this regard and has also co- edited a book recently titled ‘Feminist Counselling and Domestic Violence in India’ with Padma Deosthali and Padma Prakash.
Dr. Rajani Jagtap is a doctor practicing at Rajawadi Municipal Hospital in Mumbai. She is a Medical Officer and oversees the Dilaasa centre, the first-hospital based crisis centre responding to Violence Against Women in India. In association with CEHAT, Dr.Rajani also trains doctors and other health care providers in screening and responding to gender violence sensitively.