VIOLENCE AGAINST WOMEN AND ROLE OF HEALTH PROFESSIONALS

1. VIOLENCE AGAINST WOMEN AND ROLE OF HEALTH PROFESSIONALS Padma Bhate-Deosthali Coordinator, CEHAT www.cehat.org

2. This presentation is based on evidence from interventions and research carried out by CEHAT in collaboration with public hospitals and local organisations : • Establishing Dilaasa-public hospital based crisis centre (Mumbai, Indore, Shillong, Delhi) • Developing a comprehensive health sector model for responding to sexual assault.

3. Reality • Violence not understood as health issue. • Reluctance to document evidence to avoid court appearance. • Absence of health policy/programme/national guidelines. • Cr PC mandates role of medical profession in evidence collection. • Duties of Medical Facility (Rule 17)- PWDVA 2005 • Shall not refuse medical assistance to an aggrieved person if she has not lodged a DIR. • Shall fill in the DIR if not made and refer to Protection Officer. • Shall supply a copy of the medical examination report to the aggrieved person free of cost

4. Providers’ attitudes and the current response: • Domestic violence not recognised as a health issue. • Perceived as a personal and family matter, law and order problem and something that the police must look into. • Understood as a norm and integral part of married life. • Women are blamed for the abuse perpetrated against them. • Domestic Violence is perceived to be more prevalent among the poor, the uneducated, and within religious minority communities.

5. Sexual assault examination ridden with stereotypes against: “Most complaints of rape are false since they must have consented” “It is difficult to rape single handedly a grown up and experienced woman without possible resistance from her” “Instructs doctors to note the previous character of the girl” Preoccupation with integrity of hymen, two finger test and comments on past sexual history Overemphasis on injuries to prove resistance and so on.

6. Identifying Abuse: Screening Method Make Inquiry about DV based on presenting symptom/complaint • Injured women, falls • Accidental poisoning • Look for inconsistencies between history and physical examination • Reproductive health complaints. • Sexual violence is a commonly reported form of violence which can be screened in health settings. 42% of Dilaasa’s clients reported sexual violence of which 67% reported rape within marriage.

7. Outcome: • Accessibility (250 new women registered every year, 50% follow up) • 40% of the women reported that abuse started in the last 5 years. A significant proportion (70%) of women who sought services within one year was screened by health professionals • 60% women had never been to the police, before coming to Dilaasa. • 10% were pregnant when they came to Dilaasa, 60% women reported facing violence during pregnancy • 75% women reported that their partner had no addiction of any kind (alocohol, gambling,etc)

8. Medical evidence in DV crucial HCPs make note of the following on MLC paper: • Detailed history of assault • Date, time and place of assault • Describe the injury, weapon used, • Treatment provided • Assault by whom- Relationship with Perpetrator • Impact of violence on physical and psychological health of woman Evidence stands in court-

9. Outcomes of work on Sexual assault: Establishing a health sector model: • Informed consent • Uniform protocol for collection and documentation of evidence • A clear and fool proof chain of custody that preserves evidence collected • Providing medical care • Providing psychological support • Referral and follow up for further care

10. Emerging issues: • More than half the cases are those of children (<12 years of age) • 45% reported with completed peno-vaginal penetration. Others include fingering, masturbation, attempted penetration, anal penetration, touching of chest etc. • Assailant a known person in majority of cases. Usually a trusted person such as child’s own father, uncle, neighbor, shop keeper neighbour who the child was accustomed to playing with • Disclosure due to health complaint in a majority of cases. (45% had come to hospital directly)

11. Planned Act: Children Promised a toy, or a chocolate, money or simply time to play. Adolescents, promised a job. Adults: Motives such as dispute, robbery, property matters, vulnerability caused due to mental illness • Assault usually occurs in perpetrator’s home, survivor’s home or neighbourhood area. • Restraint or physical force not used in children.

12. Psychosocial Support Services • Emotional Support to survivor – Addressing feelings of guilt, fear, anxiety, sadness, lack of trust. • Support to Caregivers – addressing self-blame, fears of re-occurrence of the assault, apprehensions about child’s future, marriage prospects etc • Safety concerns • Help in registering complaints, negotiation with the police • Legal Aid • Negotiation with other agencies such as CWC

13. Medical Evidence • Only 18 of the 94 (19%) survivors reported bodily/physical injuries and only 36 of the 94 (38%) survivors presented genital injuries.

14. Medical Evidence Contd. • Evidence of Semen/spermatozoa would be seen only in cases where there is emission of semen. • Evidence is lost rapidly with time as well as with activities such as urinating, washing genitals, bathing, defecation. • In these cases, even if the survivor had reached the hospital within 24 hours, the chances of finding evidence may have reduced drastically. Note: Multiple Responses Source: MIS Sexual Assault Intervention, CEHAT 2012.

15. Challenges of Inter-sectoral Coordination • Problems faced with Police • Harassment of survivors • Delay in filing FIR • Multiple Examinations • Problems faced with FSL • Constant engagement required to ensure that reports come back to the hospital • Engagement with Judiciary • Dealing with biases of both PPs and Judges • Misconceptions regarding medical evidence

16. Legal Developments • Passage of Delhi high court order overemphasized the use of SAFE kits • Delhi proformas for sexual assault exam (not on par with WHO standards) • PIL in Nagpur high court (Dr Ranjana Pardhi V/s Union of India) • CEHAT’s intervention petition demands right to treatment including psychosocial and brought in importance of gender sensitive proformas.

17. Recommendations • Clear policy guidelines on VAW as a public health issue and obligation of health professionals and health facilities. • HP’s at PHC need to be trained to screen and refer as well as create community awareness on such services. • At the secondary level, hospitals need to establish crisis centre and provide all the required services to survivors of abuse • At the tertiary level, integration of tools for screening and services for DV. • Need to be integrated in medical and nursing curricula.

18. THANK YOU!