The Gender Violence -- Health System Interface: Practices, Guidelines and Protocols

A Report by Ranjitha Gunasekaran

The Gender Violence-Health Systems Interface: A Roundtable

As part of its 2014 16-Day Campaign Against Gender Violence, Prajnya, in association with Friedrich Ebert Stiftung (FES), held a roundtable discussion on November 28, 2014 in Chennai. The roundtable was aimed at highlighting the gender violence as a public health issue and the responsibility of health service providers in identifying, supporting and treating survivors of gender violence. The roundtable featured presentations by Anuradha Kapoor of Swayam, Kolkata, Sangeeta Rege of the Centre for Enquiry into Health and Allied Themes (CEHAT), Mumbai and Dr Rajani Jagtap of the Brihanmumbai Municipal Corporation (BMC), Mumbai. Participants at the roundtable included mental health, medical and nursing professionals as well as journalists and activists. Each presentation was followed by a round of questions and sharing of expertise and experiences by the participants, many of whom looked for guidance on ways in which they could identify and support persons affected by gender violence within their realm of work. The vulnerability of women living with mental illness to violence, the physician’s role in identifying persons affected by violence and the lack of sensitive training provided to medical and nursing professionals in dealing with gender violence are some of the issues that came up for discussion. The out-dated notions describing the physical signs of sexual assault as in some medical textbooks in India were brought up and the effect of such misinformation on the quality of service provided to survivors of sexual violence was highlighted.

Anupama Srinivasan of Prajnya introduced the speakers of the day and started the roundtable with a presentation on the importance of seeing gender violence as a public health issue, while Dr Swarna Rajagopalan of Prajnya introduced the 16 Days Campaign which is in its sixth year. FES was represented by Arti Peter.

Violence against Women - A Public Health Issue: Challenges and Ways Forward

Anuradha Kapoor, Swayam, Kolkata

Kapoor began her presentation by introducing the work of Swayam, a feminist organisation that works with survivors of violence. Swayam supports the survivors through services that range from legal advice and guidance to counselling. According to Kapoor, Swayam aims to help a survivor of violence heal in a holistic way. A great deal of importance is given to mental health support and mental well-being. “We look at women as survivors who can move to become agents of change,” she said. Swayam also works to prevent gender violence through advocacy and community awareness programmes in rural and urban settings.

Kapoor stressed that violence against women was a public health issue. It is pervasive, affecting one in every three women across the world. Citing National Crime Records Bureau data from 2013, she said that 11, 700 women were either murdered or had committed suicide because of violence -- one woman every 45 minutes. Other than death or suicide, such violence can lead to maternal mortality, HIV/AIDS infections as the person lacks control over his or her sexuality, injuries or permanent disabilities. Most violence against women is not reported, she noted, stating that according to the National Family Health Survey 40 per cent of married Indian women faced domestic violence.

Violence against women also affects a woman’s reproductive health, causing her to lose her child, forcing her to seek unsafe abortions or resulting in various gynaecological problems. Further, there is the pervasive but invisible effect on the victim’s mental health -- anxiety, fear, stress, anger, low self-esteem, suspiciousness. Victims even suffer depression leading to suicide or post-traumatic stress disorder (PTSD). Sometimes, these issues manifest as psychosomatic illnesses or affect behaviour of the victim.

These issues demonstrate that violence against women is a public health issue. Health services are the first resort for a woman facing such violence. Doctors and hospitals offer a safe space for victims, a space that it is acceptable for her to approach. However, Kapoor, stated that health services were the weakest link of all the services available to victims of violence. A victim may hide the cause of injury because of shame, fear or lack of trust. Health professionals frequently treat and discharge such victims without making any attempt to find out how the injury occurred. If her injuries are not recorded, then she will have no evidence to support her case when she approaches the legal system, Kapoor pointed out. “The woman needs to be assured that what is happening to her is wrong. Reassurance is important. And referral to services is very important. Whether or not the information is used, it is important to give it to them. For which you need to provide a safe space and privacy and confidentiality,” Kapoor said. She added that protocols on dealing with sexual violence for healthcare providers had been released and that similar protocols were needed to deal with cases of domestic violence.

To help deal with the psychological effects of violence, Swayam provided its clients with mental health support. “The outcome of the legal aspects of her case is not in her hands but she can control herself -- her health and well-being,” Kapoor said. Swayam offered one-on-one as well as group counselling. The latter was very effective with providing the woman with a support system, a reassurance that she was not alone and scale of the problem of domestic violence. Swayam also organised anger management, parenting and self-empowerment workshops for its clients. Some of the clients had started their own theatre and music groups to raise awareness about domestic violence. They also ran a magazine.

Kapoor made the following suggestions to health service providers for dealing with persons who may be victims of gender violence.

• Probe to find the underlying cause of the injury. Be sensitive, create confidentiality, and provide reassurance
• Use Information and Communication Technologies to provide reassuring messages so that victims know that they are in a safe space where they can speak
• Create a list of services that the patient can referred to and provide patients with these referrals -- to therapists, legal services, counsellors, protection officers -- whenever appropriate
• Increase coordination between different medical departments
• It is very important that the medical history is written in such a way that it is supportive to the victim in court
• The Domestic Violence Act has a specific role for health professionals: They are service providers and cannot refuse medical assistance. The medical examiner’s report must be provided free of cost
• It is important that health service providers are trained to screen patients and document their findings appropriately. They should be educated on their roles as described in various laws
• Gender violence needs to be recognised as a public health issue

The discussion that followed Kapoor’s presentation raised the following issues:

• The extent to which Swayam worked with the husbands of the women it helped came up, as did questions of family counselling. Kapoor stated that unless the woman asked for family counselling, Swayam did not provide such support. “We are a safe space for women. If we bring men into that space, it affects them,” she said. Though the organisation worked to promote awareness among boys and men in communities, she stressed that abusers were only brought into the conversation when the women asked that they be included. Some participants suggested, from their experience, that as leaving a marriage was very difficult for women, the couple be counselled and the husband warned against further abuse before they are reunited. Kapoor strongly disagreed with this approach, stating that an organisation could not be certain that the man will not continue to abuse the woman. The possibility of such abuse resulting in her death was too high a risk to late, she said, reiterating that Swayam believed in doing what the woman wanted to do, and supporting her decisions in every way possible. Rege added that we need to move beyond the sanctity of marriage. “It is important to provide an alternative perspective even if she wants to go back to the marriage, that there is life beyond marriage,” she said.
• A social worker who worked with women in prisons asked for clarity on the law regarding women who have murdered their husbands after years of abuse. Kapoor pointed to the precedent provided by the case of Kiranjit Ahluwalia in the UK.
• Medical professionals raised the importance of including the health effects of gender violence in the curricula. Training on how to identify victims of violence as well as how to respond to such situations would be welcome, they said.
• The lack of media reporting of effects of violence on women was raised. Jaya Shreedhar, one of the participants and faculty at Asian College of Journalism, said that she wanted these issues included in the institute’s health journalism course. She also asked if a training curriculum was available for staff at fertility clinics, as the patients at such clinics were often subject to great pressure and stress.
• A question was raised as to how abuse within a natal family was dealt with, specifically with regard to transgender individuals. Kapoor said that Swayam had worked with lesbian women in the past and in such cases, treated the natal family as the abuser.
• A provocative question was raised on false complaints given by some women. Kapoor stated that laws should not be misused but asked why, when almost every law was misused, the handful of cases of false complaints were singled out.

Comprehensive healthcare response to Violence against Women: Lessons learnt

Sangeeta Rege, CEHAT, Mumbai

Rege outlined the efforts of CEHAT in Mumbai in working with health service providers. CEHAT worked largely in urban slums and with secondary and tertiary hospitals. Like Kapoor, Rege stressed that the health system was often the first point of contact for victims of gender violence. She also said that health systems, especially at the primary health centre level, were sites where early intervention and prevention of violence can be promoted. She emphasised the importance of proper medicolegal documentation as mandated by the law.

Rege’s presentation specifically dealt with the Dilaasa crisis centre initiated by CEHAT but functioning through the BMC in Mumbai. Dilaasa involved the training of health service providers and creation of protocols for the crisis intervention department. The project aims to use available resources, thus training nurses rather than doctors. Patients are referred to Dilaasa from the emergency, outpatient or inpatient departments, usually by a doctor or a nurse. The project, now 14 years old, has been replicated in the city. An external evaluation of the project took place in 2009. Rege said that 250 new patients came each year for crisis counselling. An additional 150 met counsellors but chose not to continue counselling. Based on studies of the Dilaasa model and emergency case records, Rege made the following observations and suggestions:

• With 22 per cent of the women who survived abuse being in denial, it was important that the doctor developed the ability to identify persons who may be victims
• With 47 per cent saying that they had experienced violence during pregnancy, it was important to create services that could be accessed by women during ante and post natal care
• Health system and hospitals need to provide victims of gender violence with counselling services
• The hospital could be a safe space for such women - under Dilaasa they can be admitted for three days and can use that time to think, and receive support while deciding their next moves. This was better than moving to a shelter, and provided the women with a sense of security as their hospitalisation would not raise suspicions at home
• Violence Against Women is not recognised as public health issue and is not seen as fitting a biomedical model, according to Rege. This attitude is most evident in medical textbooks, some of which continue to perpetuate myths about sexual violence and feature a fixation on the hymen.
• Further, there is no standard protocol on medico legal examinations in the country
• Medical documentation can include insensitive language such as references to the nutritional status of a woman (as a well-built woman can be assumed to be able to resist assault). Based on this, the woman’s character becomes fair game in court. These archaic views have been challenged in PILs
• As per changes in the law, a survivor can go to a hospital and report abuse, however there is little awareness about this and the therapeutic aspect of care in such circumstances has been neglected.
• Medical examinations are often performed with little sensitivity.
• There is limited recognition of non-peno-vaginal assault
• Doctors are frequently ill-equipped to give a legal opinion and are often unable to separate their legal opinion from their personal opinion
• The medical fraternity continues to entertain several misconceptions with regard to sexual assault. For instance the belief that rape always leaves signs of injuries or that hymenal status is critical to determine sexual assault. Worse, the elasticity of the vagina/anus is considered a determinant of assault. This is a new way to incorporating the two-finger test in the medical examination. Further, absence of medical evidence is seen as absence of rape. Rege stressed that the context of the assault and other variables need to be factored into the medical interpretation

Outlining a model of care to respond to sexual assault, Rege said that hospital-based crisis centres were needed because several young women access these centres within two years of being abused, there is voluntary reporting for treatment and a follow-up rate of more than 60 per cent as visiting a hospital is socially acceptable.

Health service providers had two key roles to play towards victims of gender violence. The first was therapeutic - to provide medical treatment and psychological support. The second was forensic and involved documentation. According to Rege, a comprehensive healthcare response to sexual assault would involve:

• Seeking informed consent from survivor
• A detailed, sensitive medical examination
• Free medical support (by law, both private and public facilities must provide services)
• Psychological support
• Clear and fool proof chain of custody
• Referral to other services

The following issues were raised in the discussion following Rege’s presentation:

• Counselling services provided to families of survivors: Rege said that many are not interested in counselling services though they take the information. This is challenging because counselling becomes associated with the hospital. Further, there is the loss of wages that many family members might face. According to Rege, most who get counselling are those who are also seeking legal redressal. There is better follow up in cases of domestic violence, but numbers drop again when suicide is attempted.
• How to deal with questioning by the police: Police tend to ask doctors questions like, is the victim habituated to sexual intercourse or is the accused capable of intercourse, Rege said. CEHAT asked doctors not to answer such questions and documented them to show the DIG. The response from the police was either denial or an invitation to provide training Rege said. Our role in intervention is to be there for the victim in every way she wants, she added.
• Was informed consent necessary or did the victim have a responsibility to report an assault? Rege explained that the central government had released guidelines on how medico-legal assessment must be done. Informed consent is important though the concept created fear among health professionals. Informed consent is the key in increasing the agency of the survivor. Because of the law on mandatory reporting, Rege added that CEHAT facilitated informed refusal. “We need to be able to approach healthcare as separate from legal issues. What are the compelling reasons for refusal? And are we offering treatment or making it conditional to reporting?” she asked. Survivors need to be provided time, space, respect to survivors before they are treated or examined. Informed consent is particularly important given the amount of power doctors have in a medical context.
• Indian law makes the victim a witness in her own case. Kapoor explained how this often leaves the victim vulnerable. “Because I am witness, i have a right to lawyer but only if Public Prosecutor permits me. This leads to situations where there is unequal competition between overworked PPs and defence lawyers and is hugely problematic thing,” she said.
• Health systems cannot be islands: Rege points out that there are guidelines on how doctors can interact with PPs and defend their findings in court.
• “We need to stop depicting sexual assault as the worst thing that can happen”, Kapoor said responding to a question on how survivors cope after assault. While confidentiality is important, we also say that there should be no stigma attached to victims of sexual assault, and therefore no confidentiality. However, as long as chastity is valued, and it is believed that women would rather die than be raped, there will be stigma. This is a struggle and till then we need to provide support.
• The lack of guidance for private practitioners in dealing with sexual assault cases was raised. Rege pointed out that thanks to the new law, the private sector is awakening to these issues.
• Persistence of potency tests: Jagtap and Rege raised the issue of the forensic community’s obsession with potency tests in the cases of sexual assault even though such tests are legally irrelevant. Kapoor pointed out that the entire system was geared to understand rape in terms of peno-vaginal penetration but with changes in the law, training needs to be imparted to police and members of the judiciary.

Establishing Hospital-based Crises Centres: The Dilaasa Model

Dr Rajani Jagtap, Dilaasa, Brihanmumbai Municipal Corporation

Jagtap argued that as the healthcare provider is the first point of contact for any victim of domestic or sexual violence, it is important that she be sensitised. Doctors may treat injuries and not humans, they may think there is no time to look beyond the injury and arrive at the cause of the injury, she said. Further, doctors are the products of the same society as victims and abusers. She stressed the need for changes in the curricula of medical and paramedical courses before outlining the functioning of the Dilaasa crisis centre.

According to Jagtap, Dilaasa aims to ‘institutionalise’ domestic violence and make the hospital and important reference point for the victim. Every single person that a victim may come in contact with ought to be gender-sensitised and patient-friendly, she said. The idea is to train not only doctors but paramedical staff, social workers and lab staff as well. The guidelines, resources and training was provided by CEHAT in 2001. The superintendent of the peripheral hospital was the project director and initially, staff from different hospitals were trained so that they could return and train their colleagues. They were taught the differences between sex and gender, about gender stereotypes and violence as power play.

The first crisis centre was set up in 2001 and the second was started three years later. The centres operated during hospital hours and by staff were trained to handle the victims. From 2001 to 2006 the project was replicated in all peripheral hospitals, and is now managed by the BMC. From 2010 to 2013, the Dilaasa model has also been replicated in Shillong and Bangalore.

According to Jagtap, the Dilaasa model involves looking beyond the obvious injuries. Even symptoms such as tingling and numbness or chronic anaemia can indicate violence at homes. Sometimes, apparently silly problems may be a front for deeper issues. Jagtap urged doctors to ask what was happening. Sometimes, these lines of enquiry can lead to a breakthrough. Another key factor Jagtap highlighted is privacy and confidentiality. A woman might have come with her abuser or the family of her abuser. Her injuries may be manifested in indirect ways. For instance, a woman with severe abdominal pain was found to have an anal tear from her husband forcing anal sex with her. She urged doctors to be non-judgmental and finally, to tell the patient that what is happening to her is wrong, that action can be taken and that violence is not acceptable. She pointed out that persons with physical and mental disabilities were particularly vulnerable to abuse.

She stressed the importance of documentation and ensuring the safety of the patient, highlighting the option to provide admission for 72 hours so that the victim has shelter from her abuser. After treatment of the patient, referrals must be made, but the victim must be assured that it is not required for her to visit the crisis centre.

The following issues emerged in the discussion that followed Jagtap’s presentation:

• Efforts to educate service providers on violence against gay men or transgender: Rege admitted that within public hospitals, educating staff on same sex couple violence and violence against transgenders posed a huge challenge as staff were very conservative so much so that CEHAT had included training on communal attitudes among staff.
• The importance of ICT: Rege said that when Dilaasa was first set up, none of the doctors were making referrals. When asked why they revealed that they felt very awkward so CEHAT created a set of guidelines and questions -- what to ask and how to ask it with a chart for every department. Now, 10 to 12 per cent of women came to Dilaasa purely on the basis of ICTs, Rege said.
• There are a large number of geriatric women who face abuse from their daughters in law or alcoholic sons. They do not normally come to Dilaasa.
• CEHAT works with secondary level hospitals and Auxiliary Nurse Midwives who take the message into communities.
• Disability renders women doubly vulnerable especially when they are abused by their caregivers and are unable to live independently, a social worker points out. Kapoor says that all circumstances must be considered when dealing with such cases while Rege said that women with mental illness followed up the most. She also highlighted the practice of men having their marriages annulled by certifying their wives mentally ill or retarded. She added that in most cases of domestic violence against the disabled, the woman is brought to the crisis centre by her natal family. When the caregiver is the abuser, situations need to be created to encourage the victim to reveal the abuse.

Postscript from Prajnya:

The discussions at the roundtable drew our attention, once again, to the work that remains to be done if women who experience violence are to receive the support they need from health services. Hospitals need to establish and follow the right protocols - in gathering and documenting evidence, in training health care professionals and in ensuring that they do not impede a woman’s right to justice. Doctors need to unlearn, learn and relearn the required skills and attitudes to respond to a survivor of violence. Medical college curricula needs to be drastically modified to incorporate basic ideas of gender equality and gender justice. In the coming months, we hope to follow up on at least some of the ideas that emerged from the discussions at this programme and take this conversation to a range of healthcare providers in Chennai.

The 2014 Campaign Calendar is up!

After months of brainstorming, as new ideas took shape and old ones came into fruition, we at Prajnya are finally ready to share with you our plans for this year's campaign.

 The 2014 Campaign Calendar is up. Here is a quick sneak peek:

What is this year's Campaign all about?

Every year, the Prajnya 16 Days Campaign against Gender Violence brings together a mix of public events, workshops, seminars and other activities that take place across towns and even, media. This year, we wanted to make a shift away from the notion that the impetus for social change must come mainly from organisations like ours. We wanted to return ownership of campaigns like this to all citizens, to each of us, as individuals. We wanted to say, "No matter what you do, where you are, what your life is like, there is something you can do. And even if it is small, the small things add up!"

We invited 17 individuals to take the lead on this year's campaign by initiating activities and taking action within their immediate spheres. They are our Gender Equality Mobilisers, or as we like to call them, G.E.M.s. The G.E.M.s come from different walks of life; some are more famous than others. Each of them has found a way to show support for this cause--eliminating gender violence--in some way that is meaningful to them and that fits in with their everyday life.

Our SPOTLIGHT this year

This year, we are placing a spotlight on gender violence and public health with a series of programmes and conversations that make the case for getting gender and sexual violence onto the public health agenda as an urgent and legitimate issue.

There is uniform consensus that when a woman experiences violence of any kind, whether once or repeatedly, it has a definitive impact on her physical and mental health. There is considerable research that highlights the association between sexual violence and a long list of health outcomes including HIV infection, sexually transmitted infections (STIs), induced abortions, low birth weight, alcohol use, depression and suicide and physical injuries. Gender and sexual violence deny an individual the right to lead a healthy life, free of injury, illness and disease. There is therefore a real and urgent need to view violence against women as a public health issue, and not merely a criminal or law and order problem.

Programmes in this Spotlight section of the 2014 Campaign will focus on the following key questions:

• How can we build the capacity of health care professionals to respond to violence?
• What are some best practices of health care system responses to gender and sexual violence?
• How can we help establish a sustainable mechanism within the health system to respond to violence?

Resource Creation: 'Gender Violence: The Health Impact' - A Blog Symposium

Resource creation is one of the most important aspects of the Prajnya 16 Days Campaign against Gender Violence. Since 2012, the blog symposium has been an important part of this work. This blog symposium serves as a companion to the Spotlight segment. It seeks to frame gender-based violence in all its forms as a public health issue that affects all sections of the population and analyses its health impact from a physical, reproductive and psychological viewpoint. In addition, the symposium will critically examine the emergency health care responses and protocols that exist to combat gender and sexual violence including the attitudes of health care professionals with a gaze that moves from “what is” to “what should be” and locates this discussion within a framework that is firmly survivor-centric and rights-based.The posts will be featured on the GRIT blog, and indexed there and on the Campaign blog. Look out for them!

What can you do?

 We believe that change begins with each of us and small individual efforts make a large collective impact. If you would like to contribute to the Prajnya 16 Days Campaign, here are some ways to do so:

• Look at our Call for Individual Actions and pick what suits you best. We have many options that you can choose from: Starting from changing your profile picture on social media to our logo to locating and disseminating information on distress services in your city. Do ping us on Twitter or Facebook and tell us what your are doing. We would love to hear from you.
• You can also answer our Call for Videos and send us a  message saying NO to Gender Violence.

 We have some exciting times ahead. Do keep checking in!

Oye! Chennai features Prajnya 16 Days Campaign

As posted on Oye! Chennai on November 27, 2013

 

Focus: Gender Violence Sensitisation

On Day 2 of the Campaign -- Prajnya entered the ‘real world’. We met two groups of women: Journalists and Nurses, and the conversations were definitely not a one way street! The closed group discussions gave everyone an opportunity to speak their minds.

Women journalists interact with senior journalist Ammu Joseph at Chamiers

Nurses at the GH after the gender violence sensitisation training conducted by Brinda Jayaraman and Dr Swarna Rajagopalan

When we speak of gender violence, people in the medical profession are one group who are in a position to help the victims. But are our hospitals prepared? Divya Bhat, the first Shakti Fellow with Prajnya Trust writes:

The role of the doctor within the Indian legal system is to provide the court with documentation of the assault, and to collect any forensic evidence that is on the body.  This entails recording any wounds on the body of the survivor, taking swabs and samples, and getting a detailed account of the assault in the words of the survivor. The ability to collect forensic evidence and accurately record this evidence in legal documents is crucial to prosecuting sexual assault cases; without good forensic evidence, sexual assault cases often rely on character assessments of the survivor.

After sexual assault cases are reported to the police in Chennai, survivors are taken to large government hospitals where a doctor can examine them.  Legally, any female doctor can see any female survivor of sexual assault, but these cases are often taken directly to the obstetrics and gynecology ward due to a lack of trained female forensic doctors.  Gynecologists, however, do not receive sufficient practical and training to collect forensic evidence and fill out the necessary paperwork in the proper and legally admissible way.  Without sound knowledge of forensic protocols or standardized training, doctors can rely on ad hoc and incomplete procedures that compromise the integrity of the forensic evidence.

Another important issue is highlighted by Dr V Kanagasabai, Director Medical Education and Dean, MMC. “Due to their heavy workload, sometimes doctors don't have the time to listen to their patients carefully enough. It is important for us to adopt an empathetic attitude in cases of gender violence, and to identify it for what it is. Doctors and paramedics should be aware of how to treat them. Awareness should also be created for the public on the legal options available, as well as on the punishment for sexual crimes,” he says

Recognising Gender Violence as a Public Health Issue

“Violence against women and girls directly affects individuals while harming our common humanity,” said UN Secretary General Ban Ki-moon, on the International Day for Elimination of All Kinds of Violence Against Women. What it also harms is the health of the survivors.

A recent WHO report says, “Violence against women is a significant public health problem, as well as a fundamental violation of women’s human rights.” But often, we tend to view gender violence simply as individual and isolated incidents – a view that needs to change in order to tackle this massive problem effectively, especially considering the increasing incidence of crimes against women in India.

*Source: NCRB

One of the chief reasons why experts advocate a public health approach to gender violence is to put the thrust on prevention rather than cure. Dr V Kanagasabai, Director Medical Education and Dean, MMC, says the issue needs to be tackled at a policy level. “We have had campaigns in the past to promote women's education, better food habits, educating the girl child etc, which have been fairly successful in achieving their stated goals. We need a similar approach now to tackle gender violence; it must be seen as a public health issue at the policy level,” he says.

Experts believe that recognizing gender violence as a public health issue will also help the Govt achieve some of its existing goals, namely bringing down the Maternal Mortality Rate, which stands at 212 (2008-09).

Dr Kanagasabai says, “Due to their heavy workload, sometimes doctors don't have the time to listen to their patients carefully enough. It is important for us to adopt an empathetic attitude in cases of gender violence, and to identify it for what it is. Doctors and paramedics should be aware of how to treat them. Awareness should also be created for the public on the legal options available, as well as on the punishment for sexual crimes.”

What is also needed is to set up counseling services for victims and their families to help them through the trauma. Every stakeholder must be aware of the gravity of the situation, and treat every individual case with sensitivity.

As the WHO study puts it, “There is a clear need to scale up efforts across a range of sectors, both to prevent violence from happening in the first place and to provide necessary services for women experiencing violence.”

Sexual Assault: Challenges faced by Chennai Hospitals

by Divya Bhat 

In the past year, sexual violence has become a topic of wide public discussion and the roles of government institutions, especially those that prosecute sexual assault cases and work with survivors, have come under increasing scrutiny.  As a Shakti Fellow with The Prajnya Trust, I came to Chennai to learn a bit more about how sexual assault cases move through the legal system, and how doctors and other medical personnel view such cases.  The conversations I had with individuals working within the medico-legal system described inert government institutions that needed streamlining in order to provide timely care for survivors of sexual assault. 

The following blogpost is a brief compilation of some of my findings, especially in regards to the collection of forensic evidence by doctors.  These findings are specific to Tamil Nadu because of state to state variation in protocols for the collection of forensic evidence, although I believe that they reflect some of the broader issues at hand in the national response to sexual assault cases. 

Lack of training and system-wide delays

The role of the doctor within the Indian legal system is to provide the court with documentation of the assault, and to collect any forensic evidence that is on the body.  This entails recording any wounds on the body of the survivor, taking swabs and samples, and getting a detailed account of the assault in the words of the survivor. The ability to collect forensic evidence and accurately record this evidence in legal documents is crucial to prosecuting sexual assault cases; without good forensic evidence, sexual assault cases often rely on character assessments of the survivor.

After sexual assault cases are reported to the police in Chennai, survivors are taken to large government hospitals where a doctor can examine them.  Legally, any female doctor can see any female survivor of sexual assault, but these cases are often taken directly to the obstetrics and gynecology ward due to a lack of trained female forensic doctors.  Gynecologists, however, do not receive sufficient practical and training to collect forensic evidence and fill out the necessary paperwork in the proper and legally admissible way.  Without sound knowledge of forensic protocols or standardized training, doctors can rely on ad hoc and incomplete procedures that compromise the integrity of the forensic evidence.

While completing the forensic examination, the doctor is supposed to use a legal document called a pro forma(provided by the Tamil Nadu state government) in order to guide a doctor in noting down any relevant information.  However, in practice, the pro forma is rarely utilized. Doctors may only fill out only an Accident Register copy, which is a brief assessment that all patients get when coming into the casualty ward.  This document, which provides little room for description of wounds or for the survivor’s account of the attack, often becomes the basis for the medical certificate within the courtroom.

Doctors in government hospitals also face challenges while interacting with other government institutions like the police force and the judicial system.  Most medical professionals expressed frustration with systemic delays that limited the doctor’s ability to collect evidence in a timely manner; nearly every doctor I spoke with suggested that examination of a survivor within 24 hours was crucial to getting the best forensic evidence.  Outside of this time frame, the bodily evidence of assault gets degraded, wounds start to heal, and evidence is washed away. However, survivors of sexual assault must first file a first information report (FIR) with the police before being taken to a government hospital for examination.  Many doctors pointed out that filing an FIR often takes several days, after which time most of the forensic evidence is lost.  Confusion over procedural issues like getting permission from a magistrate to proceed with forensic examinations can also add to further delays.  Finally, in their capacity as government employees, government doctors must make themselves available to provide expert testimony in any medico-legal case. Courts in Chennai suffer from long wait times, delays, and backlogs of cases, so doctors may have to present their medical findings in court years after the initial examination.  

A move to a more therapeutic approach

While I have talked about some of the systemic constraints to providing sensitive care to survivors of sexual assault, doctors can move to a more therapeutic approach to care.  Doctors, particularly gynecologists, are uniquely positioned to provide care to survivors of sexual assault and to collect the necessary forensic evidence.  Nurses, and other medical personnel could also be trained to notice signs of assault and abuse, and to provide emotional support to survivors and their families.  Instead of just treating patients for their immediate wounds and collecting evidence, organizations like CEHAT advocate a more therapeutic approach to care that limits the secondary trauma of reporting a sexual assault case (see CEHAT 2012).  CEHAT suggests that a doctor seeking informed consent to do a forensic examination and discussing the reasons for the examination with the survivor could provide more emotional support and build trust.   Additionally, follow-up with survivors after the initial examination could help assess psychological trauma or further medical complications of an assault. While institutional change within the medico-legal system is certainly required, a move to more therapeutic care will allow patients to feel more comfortable while trying to find justice after an assault.

See: Establishing a Comprehensive Health Sector Response to Sexual Assault. CEHAT, 2012

16 Days 16 Tweets: Day 2, twin focus on media and health

@prajnya: Legal and Press Council guidelines on reporting sexual violence: http://bit.ly/1dsVhAu See also: http://bit.ly/8EHU3T #nosgbv

How to write good reports on SGBV: Guidelines drafted by Chennai reporters http://bit.ly/TN5hdp . Also see, http://bit.ly/1dsVR1a #nosgbv

One WSH case involving journalists has our attention. Here's another :http://bit.ly/1dsWh7x But many more unreported, ignored.#nosgbv

Tahrir Square, 2011, placed spotlight on sexual violence risks faced by women journalists. Starting w: http://abcn.ws/jrSjIj #nosgbv

On women reporting conflict: http://bit.ly/1dsXBav And a survey on dangers faced by women journos: http://bit.ly/1dsXDzh #nosgbv

This safety guide for women journalists: http://bit.ly/1dsXJa5 Works for others too, but is this a solution? #nosgbv

FYI: Women in media networks: @womenandmedia, @NWMIIndia. Others? Also, the Global Media Monitoring Project: http://bit.ly/9raTAD #nosgbv

@prajnya: The impact of gender violence on women’s health by @almostbutnotyet: http://bit.ly/1dsYZdd #nosgbv

WHO report on VAW health impact found 1/3 women experience violence at the hands of their intimate partner. http://bit.ly/1dsZt3e #nosgbv

Why we reach out to nurses and nursing students in our work: http://bit.ly/1dsZJPH #nosgbv

Privacy, confidentiality, patience, not being judgmental, no pressure: good clinical responses. Page 9 of http://bit.ly/1dt0b0n #nosgbv

The health care impact of domestic violence: http://bit.ly/1dt0oRh #nosgbv

Health care costs of VAW calculated for the US: http://bit.ly/1dt0IPV #nosgbv

NFHS-3 (2005-6) on Spousal Violence in India: Chapter 10, pages 95-110, http://bit.ly/1dt10pP#nosgbv

VAW an obstacle to achieving the Millennium Development Goals; the MDGs will help eliminate VAW: http://bit.ly/1dt1bBF #nosgbv

2009 Campaign PR (1/12):Public Health and Gender Violence

Health care professionals – doctors, nurses and others – must be equipped with the skills and the right attitude to handle cases related to gender and sexual violence. This was the theme of a workshop on “Public Health and Gender Violence”, held at Omayal Achi College of Nursing on Tuesday. Facilitated by Prajnya, a Chennai-based non-profit centre for research, public education and networking as part of its 16 Days Campaign against Gender Violence, the workshop was jointly conducted by Dr. Prasanna Poornachandra of International Foundation for Crime Prevention and Victim Care (PCVC) and Nancy Veronica Thomas of Tulir - Centre for the Prevention & Healing of Child Sexual Abuse.

The four-hour session was interactive and included both presentations and anecdotal references to illustrate how and why gender violence is relevant for health care professionals. “The workshop was an attempt to sensitise nursing students on the importance of both physiological and psychological care for victims of gender violence,” said Nancy. “Nurses are the one-point contact in the case of a medical emergency, and have an important role to play in the case of a sexually abused patient,” she added.

The health implications of the various forms of gender violence are many, and include injuries, broken bones, psychological illnesses like neurological disorders, depression, anxiety and long term physiological diseases like arthritis, blood pressure, heart problems and Sexually Transmitted Diseases (STDs). “The role of a health care professional in a gender violence incident is four-fold, and includes: identifying, assessing, documenting and educating,” said Dr. Prasanna during the session. The social costs of gender violence were also discussed at the workshop.

A Response from Omayal Achi

Yesterday, on day seven of the campaign, we organised a workshop on public health and gender violence for nursing students at Omayal Achi College of Nursing. This is the feedback they have since sent us:

Dear Anupama

I am herewith forwarding a complete feed back as written by the students who attended the PH and Gender Violence Workshop.

Comments of the Students

Classes on gender violence was a great thing for us to know about the current status of women in India. Most of the cases which you discussed where new to us and somewhat scaring. But the role of a health care professional in these situations was made to us clearly. it was an eye opening for us to how to handle and take care of a child and women at times of a abuse.

We thank you for your valuable effort put to make people aware of the gender violence.

With regards,

Dr. S. Kanchana M.Sc(N), Ph.D(N)

Principal

Omayal Achi College of Nursing.

Swine & Dandy: What if we did as much to prevent rape as we do to prevent H1N1?

A superb piece from Bitch Magazine, by Meg Stone (Thanks Vidya!): on how the media (and the public health system) has risen to the occasion, in responding to H1N1, ensuring that people know exactly what to do, what not to do, where to go, etc. Meg Stone envisions what could happen if the media and various systems (health, educational, political) responded similarly to rape and sexual violence.

Swine & Dandy: What if we did as much to prevent rape as we do to prevent H1N1?

Science and Politics blog post by Meg Stone, November 3, 2009 - 8:05pm; tagged H1N1, Health care, pandemic, prevention, rape, swine flu.

I spent most of this past spring and summer rolling my eyes every time I heard a news story about the swine flu. Almost every day local reporters got hysterical about 5 or 10 or 20 confirmed cases. Entire schools closed in response to a handful of kids with fevers, and as if there were no war in Afghanistan, no economic crisis, and no other epidemics claiming ten times as many lives, newscasters talked about H1N1 (the proper name for swine flu) for hours.

I have a degree in public health and my work focuses on preventing rape and other acts of violence and supporting survivors in healing from abuse. When I see all the attention swine flu is getting, I’m jealous. Other than intermittent news stories about sex offenders on the loose or why women who accuse professional athletes of rape are lying, sexual violence rarely gets any widespread coverage. Certainly no state of emergency declared by the President of the United States.

Now, I don’t want to diminish the grief of those who have lost loved ones to H1N1. I don’t even want to question the scientific validity of the Center for Disease Control’s decision to declare it a pandemic. But the fact remains that the impact of H1N1 is far less than that of other public health crises that receive a fraction of the attention and resources. The CDC reported just over 43,000 cases of H1N1 between April and July of this year and estimates that it will affect a million people, or 0.3% of the total population of the United States. Compare this to the 2.5% of women and 0.9% of men who reported being raped or sexually assaulted in the past year. The most recent statistics about rape available from the CDC are from last year. Swine flu? Last week.

What would our media, our public discourse, and our institutional responses look like if people cared as much about rape as they do about H1N1?

I imagine the federal government urging colleges to stop the epidemic of rape by developing protocols for quarantining students who have tried to use drugs or alcohol to incapacitate women who would otherwise not consent to sex. Or university officials directing students to stay off campus or out of public areas until they are free of the belief that they are entitled to sex any time they want for a full 24 hours. Sounds pretty good, doesn't it?

I dream of public health departments so inundated with the demand for educational programs that teach kids about healthy relationships that they can’t keep up. Of public outrage that there are not enough doses of self-defense training to inoculate everyone against rape, and of medical experts having to go on television to reassure people that more of these self-defense vaccines are on the way.

Then I wake up to a phone conversation with a principal who tells me there is no dating violence in his school and another with a teacher who desperately wants to offer rape prevention resources to her high school classes but can’t because the entire budget for health education in her district was cut. So much for the dream.

But if I stop resenting H1N1 for getting so much attention for a moment, I realize that what I’m complaining about is actually public health at is best. It is probably true that the coordination of government urgency, media attention, medical system mobilization, and common sense precautions will succeed in thwarting a pandemic. We will probably not look back at 2009 and say it was the beginning of a swine flu crisis that devastated a generation.

What feels like hysteria or over-emphasis is actually the way prevention is supposed to look. It is supposed to be widespread and coordinated. Messages about the importance and seriousness of the public health threat are supposed to be so pervasive that they are almost impossible to ignore. I’m so used to caring about public health crises that don’t get the attention and resources they deserve that I almost can’t recognize what the public health system looks like when it does work.

This kind of focused attention is my wildest dream for our society’s response to HIV, rape, domestic violence, drug addiction, racial health disparities, cancer-causing corporate pollution, food system injustice and every other area of public health that is marginalized.

So why is the public health infrastructure working so well? Because it’s not being undermined by shame, stigma, and denial (you know, the way rape and sexual assault are). Even in the highest drama evening news stories there is almost a complete absence of victim blaming. Personal choices and individual behaviors spread the flu, but our government, our health workers, and our media understand that this crisis is too serious to waste time arguing over whether people who don’t wash their hands or share cubicles with co-workers who fail to stay home from work the recommended 4 to 7 days deserve what they get.

It would be unthinkable for a person to avoid seeking treatment for swine flu because s/he’s afraid that if s/he tells her/his doctor s/he’ll be blamed for touching her/his eyes and nose or lose her/his housing because no parents want to raise their children in a neighborhood where people don’t sneeze into their elbows

As if invoking the finale of High School Musical, when it comes to H1N1, we’re all in this together. Swine flu is not concentrated in any population that people already hate or devalue, so raging debates about whose immoral lifestyle caused it don’t get in the way of an effective public health response. (Even Fox News is posting stories that are sympathetic to people whose jobs don’t have paid sick leave and the hardship they face in missing work as the authorities direct.) Wouldn't it be nice if other health crises were treated the same way?

In watching the rapid mobilization against this virus I know that the public health infrastructure works when our government, our media, and our medical leaders are motivated to mobilize it. H1N1 is not getting any attention it shouldn’t – it’s getting the attention all public health crises should.