Gender Violence: The Health Impact – Blog Symposium Index of Links

A consolidated index of all the posts from the Blog Symposium on Gender Violence and Health that was part of the 2014 Prajnya 16 Days Campaign against Gender Violence can be found below.

Advertisements

Gender Violence:The Health Impact – Sexual Violence in Conflict & Access to Medical Care

by Swetha Shankar

Conflict-Related Sexual Violence

In war as in peace, the identity of women as individuals with agency often gets subsumed by the symbolic ‘woman’ who is varyingly used to represent nations and communities  – as markers of communal boundaries, as  repositories of ethnicity and culture, as the standard bearers of values and morality and as bearers of children. The policing of women’s bodies in these circumstances serves the larger purpose of protecting the integrity of the nation and maintaining the fabric of the patriarchal community. Transgressing from these roles often comes with sanctions that have grave physical, psychological, social and economic consequences for women.

In war, the vulnerability of women to violence is manifold precisely because of what this symbolism represents to the enemy: when conquering armies treat women as the “spoils of war”, it serves the dual purpose of destroying the reproductive capacity of an ethnic group and also emasculating the enemy (Seifert 1994). Apart from being used as a strategy of war, in both international and ethnonational conflicts, the devastation caused by prolonged exposure to armed violence leads to a breakdown of socially sanctioned behaviour and norms resulting in a pervasive violation of human rights that includes sexual violence.

Infographic I

Source: http://www.womenundersiegeproject.org/blog/entry/why-soldiers-rapeand-when-they-dontin-diagrams

Whatever the reasons, in conflict and post-conflict settings, both as a tactic and as a consequence of war, sexual violence affects women disproportionately. However, a neglected and often under-discussed aspect of conflict related sexual violence is that it also claims men and boys as victims. The experiences of sexually assaulted men in conflict often mirror those of women in terms of the physical, reproductive, sexual, psychological and social consequences they face (Sivakumaran 2007). In this context, the gendered characterization of “victor as male and vanquished as female” is also notable. Regardless of their sex, perpetrators are masculinized and victims are feminized. Thus, sexually-assaulted and raped men are gendered as female and face stigma, ostracism and a negation of their masculinity (Goldstein 2001, p.371).

Sexual violence in conflict can take many forms. Women are subject to sexual assault, rape, gang rape, forcible conscription and sexual slavery, enforced prostitution, sex trafficking and forced impregnation. Men are subject to rape, gang rape, forced rape of others, forced fellatio and masturbation, genital violence, forcible conscription and sexual slavery, castration and sexual mutilation. All of these have debilitating short and long-term health consequences and require comprehensive and sustained public health interventions that not only respond and rehabilitate but also prevent and inform.

Sexual Violence in Conflict & Related Health Consequences

Beginning with bruises, wounds, concussions, broken bones and internal injuries and ending in death, the physiological repercussions of sexual violence in conflict are many and varied.  Sexual assault can result in genital injuries, profuse vaginal and anal bleeding, gynecological complications including but not restricted to chronic pelvic pain, pelvic inflammatory disease and urinary tract infections as well as vaginal and rectal fistulas and fibroids.

The devastation of all types of infrastructure during protracted conflicts has an impact on health care as well and results in crumbling health systems, a dearth in health care providers and medical resources. Conflict also creates serious impediments to safe access to medical care. In the immediate aftermath of sexual violence, women are susceptible to both unwanted pregnancies and sexually-transmitted infections including HIV/AIDS. And lack of access to medical care and the stigma associated with accessing medical care for injuries related to sexual violence triggers secondary cycles of health issues such as unsafe and self-induced abortions and an intensification of other physical symptoms due to lack of care (Garcia-Moreno 2014, Amnesty International 2004).

The mental health and psycho-social consequences of sexual violence during and after conflict are particularly disabling. Survivors of sexual violence are vulnerable to many psychological and emotional disorders including anxiety, depression, self-blame, behavioural and eating disorders, post-traumatic stress, traumatic flashbacks and suicide ideation and these feelings are exacerbated by the social stigma, isolation, ostracism and rejection from family and community that they encounter (Alcorn 2014). Studies suggest that survivors of assault are more likely to access health systems frequently due to increased insecurity and a poor perception of their own health. They present with many psychosomatic illnesses and report cardio-pulmonary and neurological symptoms such as migraines, shortness of breath, palpitations, chest pain, hyperventilation, choking sensation, insomnia, fatigue etc (Jina & Thomas 2013, Harris & Freccero 2011, Josse 2010).

The burden placed on health care systems during conflict is enormous and what little remains in terms of resources and persons are found wanting when it comes to both therapeutic and medico-legal interventions for sexual violence. Standardised practices for response and clear, survivor-centric protocols and guidelines while present, are lacking in implementation. This in turn adds another layer to the victimization by obstructing survivors’ access to justice and reinforcing impunity for conflict-related sexual crimes (Cottingham, Garcia-Moreno & Reis 2008).

The Role of the Health Sector

The collapse of political, administrative and essential services during conflict means that the short-term and long-term health needs of women go unmet and this has far reaching public health consequences for women, children, families and communities.

Women (and other survivors of sexual violence) have to overcome monumental challenges to access health care during conflict and many reasons contribute to this:

  • There is a pervasive under-reporting of sexual violence in conflict due to fear of social consequences (Physicians for Human Rights 2008).
  • Physical access to health centres maybe barred and the routes too dangerous, leading to the probability of further violence.
  • In an environment characterized by impunity, survivors often deny themselves health care for fear of violent reprisals and re-victimization (Apple & Martin 2014, Advocacy Forum & ICTJ 2010).
  • In protracted conflicts, the violation of medical neutrality by warring factions causes a high attrition rate amongst health workers and women are left with little or no choice regarding their own reproductive and sexual health (Khandey 2004, Asia Watch & PHR 1993).

 VAW_WHO_Guidelines

Source: http://www.who.int/reproductivehealth/publications/violence/VAW_WHO_Guidelines.jpeg?ua=1

Sexual violence in conflict and the conspiracy of silence that surrounds its treatment, documentation and prosecution has led to an increased focus on creating sustainable, confidential and non-discriminatory response mechanisms.  A growing body of evidence is now available on the development and implementation of accessible, rights-based, survivor-centric health systems and existing guidelines and protocols propose concrete plans for a multi-sectoral, inter-agency, collaborative approach to health that adopt a gendered perspective and comprise of physical, reproductive, psycho-social and medico-legal interventions.

The ‘Guidelines for Gender-Based Violence Interventions in Humanitarian Settings Focusing on Prevention of and Response to Sexual Violence in Emergencies’ (IASC 2005) and ‘The Inter-Agency Field Manual on Reproductive Health in Humanitarian Settings’ (IAWG 2010) are the most comprehensive of their kind and establish minimum standards of care in emergency situations. The IASC Guidelines takes a wide-ranging look at the planning, development and implementation of minimum interventions in the pre-conflict preparedness phase, emphasizes the detailed application of a Minimum Prevention and Response (MPR) program at the peak of the conflict and also provides an overview of the activities to be undertaken in the post-conflict stabilization phase. The IAWG Field Manual incorporates an updated Minimum Initial Service Package (MISP) for reproductive health that includes preventing and managing the consequences of sexual violence in conflict by integrating a comprehensive reproductive health services system into the public health system rather than offering services in isolation. The objectives of the MISP are to identify local organizations to carry out interventions and ensure accessibility of services to women and children and involving community members, especially women, as stakeholders in the process.

The free availability of emergency contraceptives in conflict situations is critical in providing women with options regarding their sexual and reproductive health. Brown (1994) references the ethno-national conflicts in the former Yugoslavia and Bangladesh to highlight the importance of birth control technologies as well as emergency contraceptives in helping women regulate their own reproductive capacities and therefore reduce the potency of rape as a weapon of cultural destruction in conflict. An important resource for health care professionals in this context is ‘The Emergency Contraception for Conflict-Affected Settings’ (RHRC Consortium n.d.).

In addition to developing robust, gender-sensitive health systems to respond to the needs of survivors of sexual violence during conflict and engage in awareness and public education, prevention efforts will be augmented if standardised protocols are implemented for the collection of medico-legal evidence. This will enable women to approach judicial processes with greater confidence and aid in instituting a culture of accountability, reparation and punishment to counter impunity. In this regard, the Clinical Management of Rape Survivors (WHO & UNHCR 2004) and the Guidelines for Medico-Legal Care for Victims of Sexual Violence (WHO 2003) are both useful tools in setting universal standards for the collection, documentation, storage, transfer and use of medical evidence to seek legal recourse. These guidelines also stress on therapeutic interventions including psycho-social care that need to be made available to survivors.

In the Indian context, the Ministry of Health and Family Welfare has released guidelines and protocols for medico-legal care of survivors of sexual violence that are also intended for adaptation and use in situations of communal and caste conflicts and seeks to lay out the components of a comprehensive health care response to sexual violence. Detailed instructions are provided for examining marginalised and special groups including transgender and inter-sex persons, persons of alternate sexual orientation, sex workers, persons with disability and people facing caste, class or religion based discrimination (MoHFW 2014).

The core of health care efforts in the response and prevention of sexual violence in conflict should be grounded in two main pursuits: the provision of physical, sexual and reproductive and psycho-social care for survivors of sexual violence by sensitized and trained health workers and enabling the legitimacy of policy and justice mechanisms in prevention efforts by documenting and establishing broad patterns of sexual violence before, during and after war.

Other Useful Resources

The following websites have a wealth of resources on sexual and gender-based violence and its impact on reproductive and sexual health in conflict settings and address both prevention and response.

References                                       

*****

Swetha Shankar is a trained counselor and works on issues related to gender, conflict and violence. She is the coordinator of the 2014 edition of the Prajnya 16 Days Campaign Against Gender Violence. 

Gender Violence:The Health Impact – Training Health Workers to Respond to GV – The Dilaasa Model

by Rashi Vidyasagar

World over, gender based violence has been accepted as a public health issue. As per the World Health Organisation (WHO), “The principles of public health provide a useful framework for both continuing to investigate and understand the causes and consequences of violence and for preventing violence from occurring through primary prevention programmes, policy interventions and advocacy.” This is because violence has severe physical and mental health consequences – both short term and long term, which includes bruises, cuts, and wounds, lacerations to depression, anxiety, nightmares, pregnancy, STIs, HIV, and even, death. All of these require a visit to the health facility where if proper care and treatment is provided, the survivor can begin the process of healing. Moreover, there is evidence to show that women are more likely to visit a hospital after an episode of violence rather a police station or a counselling centre.

Interventions carried out at the public health level (individual as well as community) can help mitigate violence and help deal with its consequences. However, medical professionals are ill- equipped to sensitively respond to the issue of violence against women. Lack of training and education on this issue, general indifference to dominant societal norms that legitimise violence against women are only some of the reasons for the inability of the professional to respond effectively to the needs of victims of violence. There is evidence that, even when women facing violence are identified within the health care system, providers have a tendency to focus on the physical consequences of abuse, to be condescending and distant, and to blame women for the violence they face. [Campbell and Lewandowski 1997; Kurz and Stark 1988; Layzer et al 1986; Vavarro et al 1993; Warshaw 1989, Daga 1998]. Within the medical context, violence is understood as a social problem and/or private family matter, as it does not fit into the traditional illness model. As noted elsewhere, “The concern for violence is conspicuous by its virtual absence in medical discourses. The special medical needs and rehabilitation of victims and survivors of violence are hardly ever discussed by doctors” (Jesani 1995). Thus, training becomes an integral part of any intervention with the health care system to fill the void left by the medical education.

It was with this view that Dilaasa, a hospital based crisis center was set by Municipal Corporation of Greater Mumbai (MCGM) in collaboration with CEHAT. Today, Dilaasa is a fully functional department within a 400+ bed hospital in the heart of Mumbai.

When CEHAT did the need assessment while setting up Dilaasa, a hospital based crisis centre in 2001, the need to develop a training module emerged clearly. This training was not only for doctors but also for hospital administrators, nurses and every health care professional. Between 2001 -2003, a module of adult peer to peer learning was created. A mixed group of doctors and nurses were selected with the hope that they would go on to train their own cadre. Despite this, referrals were low. This prompted the need to have continuous training of all medical professionals rather a one-time training. In 2006, Dilaasa started expanding and more and more health care providers were interested in providing services, however, the current healthcare system was not able to sustain their interest. It was then when it was decided to set up a training cell. It was formed to share resources and experiences of HCPs dealing with domestic violence, as well as provide them with formal roles of trainers with the aim of mainstreaming the training cell in the current health system.

The impact of this training can be seen in the steady growth of referrals by the health system. Along with training, it was also essential to give certain information-education-communication (IEC) material to these health care providers to supplement their referrals. Visiting cards, brochures, posters, pamphlets with messages of how violence is not their fault or that suicide is not the way out were printed. All of these were displayed prominently in the hospital or given to the doctors. It was realised that doctors don’t necessarily ask women patients about abuse in the OPDs. Women who reported abuse were being referred but no effort was made to draw out those who may have been abused but did not report it. That is when checklists of health consequences for each department and how could they ask about violence were printed and placards were made.

In the 14 years that Dilaasa has been functioning in a public hospital, training has been the cornerstone of the work that is being done. Continuous training with the hospital staff gives them a sense of identification and association with the project. The role of a medical professional is to identify, document and refer a survivor of violence. There should be no ambiguity in the expectations from the training. Training can provide tools that are required to identify the abuse and can also provide an important document if the woman takes the legal road. However, for the provision of comprehensive healthcare, this needs to be supplemented by a counselling centre where the doctors can refer the woman and/or organisations that provide services like shelter, counselling and legal aid to the survivor.

The following case study shows the importance of training all the hospital staff to recognise signs of abuse

Amma was referred to the Occupational Therapy Physiotherapy (OTPT) department by the orthopaedic department for the injuries that she had sustained. Amma had reported that she had fallen and hurt herself. At the OTPT she had received therapy for her hand and shoulder for a week. During this period, the physiotherapist found time with her alone and told her about Dilaasa and what it does. She then asked her if she would like to go there. Amma said, “No, I do not need it”. The following day, the physiotherapist asked her how she had sustained her injuries. Amma repeated the same story about a fall. The physiotherapist suspected abuse but did not want to probe further as she feared that the woman might not come back for treatment. She then asked one of the Dilaasa counsellors to come to OTPT department and speak to her. Amma then talked about the abuse she had suffered and subsequently sought Dilaasa services

Amma’s story is a testimony to the effect that training can have. Since 2001, Dilaasa has responded to over 3000 women, most referred by health care professionals. This has been possible through continuous support of the hospital staff, the trainers and the administrators who have ensured that a comprehensive health care response to survivors can be provided.

More information on setting up Dilaasa, the process of training the health care providers and other work related to Domestic Violence and Sexual violence can be found here: http://cehat.org/

*****

Rashi Vidyasagar is a Criminologist who is currently engaged in research on issues around violence against women including domestic violence and sexual assault. She is a Crisis Interventionist who works with CEHAT (Centre for Enquiry into Health and Allied Themes) in Mumbai.

Gender Violence:The Health Impact – Role of Forensic Evidence in Accessing Justice

by Sheila Jayaprakash

Forensic evidence is a specialised branch of medical jurisprudence wherein material is collected and collated in order to form a body of evidence from which scientifically based deductions may be made. Forensic evidence can be very important in a criminal investigation, and has an impact on the entire criminal justice delivery system. An investigation by the police is aided by the report of forensic experts. These findings are then used by the prosecution or defence lawyers in presenting their case and could be one of the grounds on which the judge acquits or convicts the accused. This brings in the laboratory analyst or scientist as a crucial link into the dispensation of criminal justice. Forensic scientists work closely with the police in gathering material or in the analysis of material sent to their laboratories. Forensic laboratories have been largely set up and run by the government and such laboratories by default become another link in the chain of law enforcement.

Forensic evidence may be used in the analysis of fingerprints or handwriting to identify persons. DNA testing by laboratories has been used to confirm the identity of a deceased victim or parentage in civil cases or to identify perpetrators of homicide, rape or other criminal offences. Autopsies use forensic science to deduce the cause of death and the analysis of toxic substances found in the body of the victim. Forensic experts are also called in for cases involving drugs or the use of firearms. Thus, forensic reports could be the basis of physical evidence in a criminal or civil case; forensic evidence could also be used to form a database outside the criminal system in substantiating statistical deductions.

Forensic evidence has been important in obtaining convictions in rape cases. The identity of the accused has in several cases been based on semen analysis found in or on the clothing of the victim. The collection of this piece of evidence has to be done at the earliest point of time. When a rape complaint is filed with the police, they should immediately take the victim to the nearest hospital. Women’s rights activists have for a long time called for ‘standardised kits for collection of evidence of rape’, with detailed directions for the method of use. Samples collected by the doctor, such as vaginal swabs, are then sent to a laboratory for analysis. This could result in crucial evidence that ultimately leads to a conviction.

The importance of forensic evidence in the justice system places great emphasis on the existence of proper laboratories. They must have well-qualified staff, not only for analysis and reports, but also to give evidence in a court of law when necessary. Moreover, the laboratories must prevent loss or contamination of samples. All law-enforcing agencies must have easy access to such laboratories, while the reporting of forensic evidence must be standardised – the accuracy of such reports has to be maintained because of their evidentiary value. The number of laboratories that offer such services is little, and with the need for more forensic laboratories, private laboratories have begun offering these services.

*****

Sheila Jayapraksash is a prominent Chennai based advocate who is an active women’s lawyer who never minces her
words when it comes to voicing issues of crimes against women. A veteran in her field, she started her career by launching a writ petition on behalf of sex workers in Mumbai. Even as a busy Madras High Court prosecutor, she is one of Chennai’s leading women’s rights activists.

Gender Violence: The Health Impact: Child Sexual Abuse & Health Care Systems

An Interview with Vidya Reddy, Tulir

by Meera Srikant

Despite advancements in medicine in the country, there are not enough mid-level mental health professionals trained to work with children who have experienced sexual violence.

  1. You work with children who have experienced sexual violence. Is our healthcare system equipped to provide them with the required care?

The healthcare system is definitely equipped where treatment of physical injuries is concerned. It is in fact families who are diffident to seek help unless there is blood and gore. If there are no physical injuries, then they do not even seek medical help. They are worried about the stigma attached to those who experience sexual violence

On the other hand, even medical professionals are diffident in our country to deal with sexual violence. Though treating cases of sexual violence is part of medical curriculum, they are not sufficiently trained.

There is a government guideline from the Ministry of Health, Government of India, specifying that private and government hospitals must provide treatment to those coming to them for treatment following sexual violence. The Government of Tamil Nadu has passed an order based on this advising heads of departments of government hospitals about treatment for such cases. However, while it refers to private hospitals in para 2 of the order, in para 3, it only mentions government hospitals. This can cause some confusion and we are bringing it to the notice of the authorities concerned to have this rectified.

This is required because currently, hospitals are too wary to treat children who come to them because of sexual violence. One, because there is diffidence in our society about discussing sexuality itself, and the doctors and nurses  are drawn from this society and have a similar attitude. There is greater diffidence about discussing sexual violence, and even more so when it is with reference to a child! And then the need to deal with courts since every assault case needs to be reported becomes a deterrent.

But while healthcare in our state, especially, may be equipped to handle the consequences of the assault on the body,  the mental health aspects of sexual assault leaves a lot to be desired.

  1. You mean we do not have enough mental health professionals?

We do not have enough mid-level mental health professionals. We have psychiatrists who are pharmacologised in their approach, or counsellors. Anybody in a position to advice is called a counsellor. I think counselling is the most abused word in our country. We have a counsellor for everything, but they don’t have an understanding of the dynamics and effects of sexual violence! One counsellor, for instance, told me that she counselled children who were victims on how to “handle” the situation. They are children, how can they “handle” the situation? The entire society around them needs to be mobilised to give them support and address the situation appropriately, which would also mean making the abuser accountable! The onus should never be on the child.

Even social workers are not trained to deal with cases of sexual violence, and there is also stigma attached to such work. We are a two-member team at Tulir because women who come for interviews back off the moment they hear the work involves sexual violence. They believe their marriage prospects will diminish!

Social sector is dominated with women, with men mostly in managerial positions. Therefore, there are not enough men to address boys experience sexual violence. Sadly, there are almost as many boys as girls who are subjected to sexual violence.

  1. What would you say are some of the challenges today?

Only children under 12 are seen by pediatricians. Girls of any age who experience sexual violence are referred to obstetricians and gynecologists and boys to surgeons, and hopefully a pediatric surgeon if one is around. Pediatricians are seldom trained in providing treatment for children who have experienced sexual violence because they need not just treatment for their physical injury, but a sensitive and understanding approach, which is sadly lacking. The doctors especially in the government hospitals cannot be blamed, though, because they also work under tremendous pressure and often in difficult conditions.

  1. So does Tulir work with professionals on sensitising them?

We do. The results of a pretest that we conduct before starting a workshop can be very enlightening. We realise that even professionals harbour several misconceptions about child sexual violence. Many think only girls experience sexual violence. In fact, the father of a boy who had been sodomised told me, “I am glad I have a son and not a daughter!” They worry more about the consequences of sexual violence, like pregnancy, as that will bring dishonour to the family (spoil the future of the girl). With a boy, that possibility does not exist and so many families do not care.

But what about the boy’s mind, what goes on in there? Sometimes I think if the risk of pregnancy were not there, many would not even bother about such assaults!

  1. So do you see the same stigma attached to children too, like adults?

No, not so much. But there is a reluctance to report cases. Even the police and and allied health professionals discourage the families of the victim from filing cases. They think it will affect their future prospects of marriage.

  1. The media seems to be more active these days in reporting the cases. Do you think that helps?

It is superficial. They do not understand the complexities. Hang a rapist! Most of the times the rapist is a family member. Which child will want him or her hung? Media presents a very skewed picture, does not inform or educate the public, but creates paranoia. They are also the reason why many cases do not get reported, as people fear the news being splashed. As professionals who need to inform and educate the society, they need to become more sensitised and ethical when reporting such incidents.

  1. How do you compare the Indian scenario with other nations?

There are at least 25 specialisations in addressing sexual violence in developed countries! India has a long way to go. In Tulir we do  all 25 rolled into one because we have no specialised systems to fall back on.

  1. How about Tamil Nadu?

I would say our state is far ahead of others in awareness as well as redressal systems. When I go for meetings at the central level, they are discussing issues which our systems have addressed 10 years ago. We are looking to build on these and strengthen the system for better quality of healthcare and support for the children.

*****

Vidya Reddy is the co-founder of Tulir – Centre for the Prevention and Healing of Child Sexual Abuse. Tulir works to support and participate in local, national, and international efforts to promote and protect the rights of the child. Their work involves raising awareness about CSA, improving policy and practice to prevent and respond to CSA, providing direct intervention services as well as undertaking research, documentation and dissemination of information in the area.

Meera Srikant is a writer and a dancer. Violence of any sort disturbs her deeply, and by associating with Prajnya’s 16-day campaign, she hopes to contribute meaningfully for the cause in whatever little way she can.  

Gender Violence:The Health Impact – Adopting a Survivor-Centric Attitude to Medical Care

by Aparna Gupta

Gender-based violence, apart from being a human rights violation, is also a major public health concern. In addition to physical injury that would require immediate medical attention, violence can lead to life-long psychological and physical health problems, along with social and occupational impairment. Therefore, providing effective medical care and support is crucial to mitigate the short- and long-term health effects of gender-based violence on survivors and their families.

Keeping this in mind, it is heartening to note that the State has tried to improve medical care for survivors through various interventions. The Supreme Court in Pt. Parmanand Katara v. Union of India, for example, ruled that doctors in both private and government hospitals have a paramount obligation to extend their services to protect the life of a victim of sexual assault.[i] Taking this judgement forward, the Criminal Law (Amendment) Act, 2013, inserted section 357C in the Code of Criminal Procedure, according to which all hospitals, both public and private, shall have to provide immediate first aid or medical treatment, free of cost, to the victims of sexual violence.[ii]  Refusal of medical care to survivors of sexual violence and acid attacks is a punishable offence under Section 166 B of the Indian Penal Code.

In December 2013, the Ministry of Health and Family Welfare took a significant step by issuing detailed guidelines for providing medico-legal care to survivors of sexual violence.[iii] Briefly, these guidelines include the following:

  1. Compulsory informed consent of the survivor regarding examination, treatment and police intimation
  2. Specific guidelines on dealing with marginalised groups such as persons with disabilities, sex workers, LGBT persons, children, persons facing caste-, class- or religion-based discriminations
  • Ensuring gender sensitivity in the entire procedure and refraining from mentioning the survivor’s past sexual behaviour.
  1. Standard treatment protocols for managing health consequences of sexual violence
  2. Guidelines for provision of first-line psychological support

While commendable, these guidelines must be implemented in letter and spirit, to help in putting an end to the horrendous medical process that victims are subjected to after sexual abuse, and to prevent a miscarriage of justice, by ensuring the proper collection of evidence; laws, policies and guidelines, though a significant part of the solution, cannot guarantee tangible results by their mere existence. Thus, despite the existence of praiseworthy legal tools, survivors of gender violence have been repeatedly denied the much needed compassionate and sensitive post- violence medical care. The first point of contact for any survivor of violence is a medical establishment. However, doctors usually prioritise the collection of forensic evidence, and often insist on filing a police complaint as soon as survivors approach them for medical care, which can intimidate survivors and discourage them from pursuing treatment (Human Rights Watch, 2010)[iv] . Too often, survivors are forced to make gruelling trips from one hospital or ward to another, and receive multiple examinations at each stage. Medical workers frequently collect evidence inadequately, or insensitively, or both. While the provisions of trauma counselling and psychological care for survivors and their families are minimal, even basic medical care such as treatment for injuries or infections is denied to survivors at times (Nita Bhalla, 2013)[v].

Therefore, it is necessary that the existing policies and regulations are supplemented by certain urgent measures. The government should conduct sensitisation programmes in hospitals and for medical practitioners, in order to train them on the possible health consequences of violence against women and how to address such health consequences. The Justice Verma Committee suggested that each district should have a ‘Sexual Assault Crisis Centre’, with at least one female gynaecologist and one professionally qualified counsellor available on the premises. Subject to the survivor’s physical health and choice, their first interaction should be with the counsellor, then the doctor.[vi]

India can draw on the experience of other countries in this regard. For instance, the United Kingdom, the United States and Canada have specialised sexual violence crisis intervention centres equipped and staffed with trained professionals to provide integrated services, with a special focus on the therapeutic needs of survivors. Furthermore, South Africa provides specialised training for medical students on how to treat and examine survivors.

There is a need to recognise that gender violence is a complex problem with varied dimensions, and hence requires multi-sectoral interventions for prevention and management. In the fight against gender violence, strengthening medical health capacities  can go a long way towards providing empathetic and survivor-centric care for addressing survivors’ immediate health concerns and rebuilding their lives after assault.

[i] Pt. Parmananda Katara v. Union of India, 1989 4 SSC 289

[ii] Criminal Law (Amendment) Act, 2013

[iii] Guidelines & Protocols: Medico-legal care for survivors/victims of Sexual violence, Ministry of Health and Family Welfare, Government of India, December 2013.

[iv] ‘Dignity on Trial’, Human Rights Watch, September 2010.

[v] ‘How India’s police and judiciary fail rape victims’, Nita Bhalla, Shakti Vahini, January 2013,

http://shaktivahini.org/shakti-vahini-2/analysis-how-indias-police-and-judiciary-fail-rape-victims.

[vi] ‘Report of the Committee on Amendments to Criminal Law’, Justice J.S Verma, January 2013.

*****

Aparna Gupta is currently a fellow with PRS Legislative Research’s Legislative Assistants to Members of Parliament programme. An engineer by degree, and student of policy by day, Aparna aspires to work in the field of human rights and gender violence.

Gender Violence: The Health Impact: Gender-Based Violence and LGBTQI communities

by L. Ramakrishnan

Background

We understand violence as the “intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation” (Krug et al., 2002). Gender, as a fundamental axis of power difference privileging men over women, serves as a basis for much of the violence we see in the world today.

While gender-based violence has come to signify violence against women, the violence faced by lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI) communities is perpetuated by the same patriarchal rules that work to keep the categories ‘women’ and ‘men’ and the norms and expectations associated with these, separate and unequal (Pharr, 1988).

Glossary

Gay: Persons (usually men) exclusively or predominantly attracted to members of their own gender, regardless of their sexual behavior or relationship status

Lesbian: Women exclusively or predominantly attracted to other women, regardless of their sexual behavior or relationship status

Bisexual: Persons significantly attracted to individuals of more than one gender, regardless of their behaviour or relationship status

Transgender: Persons whose personal gender identification runs contrary to the gender associated with their biological sex assignment, regardless of their sexual behavior, attraction or relationship status

Gender-nonconforming: Individuals, particularly children, who, by their external appearance, mannerisms, behavior or activities, fail to conform to the gender associated with their assigned biological sex. Some gender-nonconforming children may grow into a transgender identity as adults, others lesbian, gay or bisexual, and yet others heterosexual.

Cisgender: Persons who are not transgender

Queer: Often used as an umbrella term for people of non-normative sexualities or genders

Intersex: Persons whose biological sex is intermediate between male and female, as defined with respect to chromosomes, genitals, gonadal tissue and/or typical levels of sex hormones.

For a more detailed explanation of these terms, please click here.

LGBTQI people, by virtue of sex, gender or sexuality, encounter violence of varying intensities, from ridicule to physical, emotional and sexual assault, to murder. Scales of violence range from the inter-personal to the state-sanctioned. Some examples and their impact are below. 

Families

“What will others say?”

 “No son of mine is going to be that way”

Families are often the first sites of violence against LGBTQI people, with many parents perpetuating differential treatment commencing from the moment the child is determined to be a boy or a girl, and enforcing gender-specific expectations on the child at every stage of development.

Embarrassment, shame, anger, emotional and occasionally physical violence meet the child or young adult who is does not conform to the behavior expected of his/her gender, whether a girl-assigned child who does not manifest the nurturing, domestic and compliant qualities required for ascension into traditional heterosexual womanhood and motherhood, or a male-assigned infant who does not grow up to be an athletic boy and dutifully transform into a ‘real’ man a.k.a. breadwinner, husband, and father who will ensure continuity of the family line.

“Paro’s mother reads her personal diary, finds out she has had relationships with women, and calls up all her friends asking them if they have had sexual relations with her…[t]he subsequent shame Paro experiences because of her mother’s action caused the termination of many of these friendships. This episode also triggers a series of physically violent cycles between the mother and the daughter, where Paro is beaten up.” (Fernandez and Gomathy, 2003)

Visibly gender-nonconforming children, or those whose romantic and sexual interests as adolescents or young adults approaching “marriageable” age appear to be directed towards the same gender, are often taken by anxious parents to healthcare providers, in the hope that medical interventions will help restore their children to normative sexuality or gender (Ramakrishnan, 2011).

Perhaps the most insidious violence perpetrated by families of LGBTQI people on those whose romantic/sexual attractions lie elsewhere is forced marriage to individuals of the other sex. This is a crime whose victims extend beyond the gay/lesbian individuals and include their spouses who are often unaware of this incompatibility until after marriage, and – in some cases – children.

Individuals who are same-gender attracted, but who are not otherwise conspicuous with respect to non-conforming gender expression, find it arguably more difficult to have their sexual orientation taken seriously within the family and elsewhere. Invisibility and dismissal by family of one’s orientation as inconsequential, or as a phase that can be overcome by marriage, can be as oppressive as other forms of violence.

Educational Institutions

“[Homophobic bullying] is a moral outrage, a grave violation of human rights and a public health crisis” – UN Secretary-General Ban Ki-moon in 2011

Policing of gender roles and punishment for transgression extends to LGBTQI young people in educational institutions. Bullying from peers disproportionately targets children who are gender-nonconforming, overweight and/or living with disabilities (UNESCO, 2012). Violence may also be perpetrated in the form of physical and sexual abuse from teachers.

In one large-scale longitudinal study of over 9800 youth in the US, childhood gender-nonconformity predicted increased risk for sexual, physical, and psychological abuse and lifetime probable post-traumatic stress disorder (Roberts et al., 2012). Closer to home, a study of kothis (feminine same-gender attracted males) in six cities of India and Bangladesh indicated that 50% of the 240 respondents had experienced harassment and violence from classmates, teachers and non-teaching staff in school and college (Bondyopadhyay & Khan 2005).

Hostile educational environments, coupled with unsupportive families, lead many transgender or gender-nonconforming children to drop out of the educational system, resulting in lost opportunities for gainful employment as adults (MSJE, 2014).

Workplace

Barring community-based organisations, progressive NGOs, and multinational companies that enforce LGBTQI-inclusive diversity and anti-harassment policies, most Indian workplaces are hostile to LGBTQI employees.

Violence against lesbian, gay and bisexual people in the workplace takes the form of homophobic comments and innuendo, directed at individuals who do not flaunt proof of their heterosexuality (Philip, quoted in Sriram, 2014). If the company includes sexual orientation in its diversity policy, individuals who are openly lesbian, gay or bisexual may be dealt with more cautiously for fear of punitive action, but may have to contend with sniggers and homophobic comments behind their back. Individuals who are in the closet may be subjected to the same heterosexist or homophobic water-cooler conversations as their heterosexual colleagues (Pai, 2013).

While very few openly transgender people make it through the educational system and are in a position to enter the formal workforce, anecdotal experiences suggest that transgender individuals trying to transition while employed contend with much resistance and hostility.

“Angel Glady, a transgender woman working in a private software firm in Chennai, … narrated the agony that she had gone through in her initial years as an [transgender] employee living as a man. Despite having disclosed to the Team Leader about her gender identity, she was forced to come to work in male attire. In addition, she also had to undergo physical discomfort such as using the male restroom. She then made a decision to quit after her failed attempts to make the Team Leader understand her situation. But Glady’s hard work and commitment paid off, when she was offered the same position in the same company again, post her transformation to a woman. The second time she made it clear that she would identify herself only as a woman… However, when she got back to work as a woman, she had to endure uncomfortable and piercing stares from her colleagues. Except for a few close friends, the others stayed away from her.” (Kannan and Deepthi, 2011)

Healthcare

Like most other institutions in society, healthcare institutions – including medical education – are grounded in heterosexist assumptions that are reflected in clinical practice. Many Indian medical textbooks echo antiquated and incorrect understandings of homosexuality as pathology or as psychiatric disorder, notions that have been discarded since 1992, when the World Health Organisation removed homosexuality from its International Classification of Diseases (ICD-10).

“Female homosexuality is known as tribadism or lesbianism … [t]he practice is usually indulged in by women who are mental degenerates or those who suffer from nymphomania (excessive sexual desire) … lesbians who are morbidly jealous of one another, when rejected may commit homicide, suicide or both”- excerpt from The Essentials of Forensic Medicine and Toxicology, 21st edition, 2002, by Dr. K. S. Narayan Reddy, MD, DCP, PhD, FAMS, FIMSA, FAFM, FAF Sc., FIAMS, cited in Guha Thakurta, 2014.

Little wonder that those lesbian, gay and bisexual people who can afford to conceal their sexuality when seeking healthcare, do so! This concealment is not without its hazards, though. Gynecologists routinely make assumptions of exclusive heterosexuality while seeing lesbian or bisexual clients and fail to ask vital questions about sexual activity or relationship status. Specialists in sexually transmitted diseases assume heterosexuality when the client appears gender-normative and neglect to assess sexual health and exposure to risk in a comprehensive manner.

Despite decades of scientific evidence confirming that sexual orientation (APA 2009) and gender identity (Lev, 2004) are not amendable to external attempts at modification, ignorant and unscrupulous medical providers in India continue – to this day – to subject LGBTQI adolescents and young adults to psychotropic drugs, electro-shock therapy and other unscientific and discredited practices that  achieve  little more than undermining the physical and mental health of the clients. Such aversion therapy is often carried out at the behest of the parents of the client, but occasionally clients request it for themselves, unable to bear the ordeal of struggling to survive in a homophobic world.

A gay man in Bangalore who was subjected to aversion therapy explained: “She connected some wire to my left hand and tried the machine, but it didn’t work for some time. She repaired it and then asked me to look at man’s photo. I saw the photo for some time and she gave me a shock. Then she asked me to change and look at a woman’s photo. Like this she kept asking me to change and giving me shock when looking at the man’s photo. The shock was very painful. I couldn’t continue after two or three and told her I wanted to stop.” (Mr V, client, cited in Narrain and Chandran, undated)

Treatment meted out by healthcare establishments to transgender clients is worse. It is not uncommon for doctors, upon seeing a transgender woman in the clinic or ward, to summon all colleagues and students, and make the person expose her genitals to the crowd without consent, for a supposedly educational demonstration. Transgender people in India who seek medical (hormonal or surgical) intervention find it an uphill task to locate providers who are both clinically competent and sensitive to their gender issues.

Intersex infants born with ambiguous genitalia face violence through the scalpel of pediatric surgeons who believe they know best for the infant in terms of surgery and gender assignment, despite increasing evidence that the patients, as adults, are often dissatisfied with the outcome of these surgical decisions (Guterman, 2012).

Law

State-sanctioned violence against LGBTQI people is manifested most prominently in Section 377 of the Indian Penal Code. A relic from India’s colonial past, IPC 377 criminalises all forms of penetrative sexual activity that do not involve a penis and vagina. The charge of criminality applies even if these acts involve consenting adults in private, thus undermining the LGBTQI communities’ constitutionally granted rights to freedom, equality, dignity, and privacy. A frequent claim by opponents of LGBTQI rights is that IPC 377 has been infrequently used to prosecute community members. The reality is that it makes the community vulnerable to blackmail and extortion, and to harrassment from the police.

The Delhi High Court, in its path-breaking Naz Foundation verdict of 2009, ruled IPC 377 unconstitutional and asked for it to be read down to exclude consensual adult relationships. However, the Supreme Court reinstated the Section, in its original form, in Dec 2013, after the four-year reprieve granted by the Naz judgement.

A subsequent judgement, NALSA vs. Union of India, passed in April 2014, asserts the rights of transgender people to enjoy full citizenship, and directs all ministries and their state counterparts to ensure inclusion of transgender people within the ambit of their schemes, provisions and entitlements.  Viewed globally as one of the most far-reaching judgements in the domain of transgender law, the NALSA judgement, however, will fall short until it is implemented in its entirety, and as long as IPC 377 continues to be valid, denying sexual rights to many in the transgender community.

Law-enforcement

Violence perpetrated by the law enforcement against LGBTQI people is not limited to use of IPC 377. Community members, especially working class transgender women, are routinely picked up on charges such as ‘public nuisance’ and incarcerated and/or exploited. In 2006,  Pandian/Pandiammal, a transgender person who was repeatedly and brutally sexually abused by the police in Chennai, chose to immolate herself in front of the police station. In their 2007 ruling, Justice AP Shah and Justice P Jyothimani ordered the Government of Tamil Nadu to provide compensation to the next of kin (MSJE, 2014): this case became one of those cited by Justice Shah in his subsequent judgement of 2009.

Way forward

Some strategies to be implemented within the short- and medium- term include:

  • Developing peer- and professional support systems including mental health interventions for LGBTQI people bearing the brunt of violence
  • Instituting psychosocial support for parents of LGBTQI individuals to better understand their children and deal with them in non-violent ways.
  • Strengthening capacities of health care providers to ensure gender- and sexuality-sensitive, stigma-free and clinically competent services to LGBTQI people in need
  • Making conversion therapy a punishable offence
  • Policy advocacy towards zero-tolerance for bullying and other forms of violence in educational institutions, with mechanisms for redressal
  • Decriminalisation of consenting sexual relationships among adults
  • Comprehensive Non-Discrimination laws that include sexuality and gender identity within their scope, and are enforceable across institutions in the public and private sector

In the long term, addressing violence against LGBTQI communities requires one to tackle the root causes of this violence, i.e. the tyranny of gender roles and their imposition across all institutions from family to law and society. All movements engaged in social justice and dismantling oppression have a stake in this, and need to work in solidarity with each other.

References

APA Task Force on Appropriate Therapeutic Responses to Sexual Orientation. 2009. Report of the Task Force on Appropriate Therapeutic Responses to Sexual Orientation. Washington, DC: American Psychological Association.

Bondyopadhyay, A. and S. Khan. 2005. From the front line: A report of a study into the impact of social, legal and judicial impediments to sexual  health promotion, care and support for males who have sex with males in Bangladesh and India. Naz Foundation International

Fernandez, B. and N.B. Gomathy. 2003. The nature of violence faced by lesbian women in India. Mumbai: Research Centre on Violence Against Women, Tata Institute of Social Sciences.

Guha Thakurta, T. 2014. The homophobic doctor. Varta Blog. Online at http://varta2013.blogspot.com/2014/03/the-homophobic-doctor.html

Guterman, L. 2012. Why Are Doctors Still Performing Genital Surgery on Infants? Open Society Foundations blog. Online at http://www.opensocietyfoundations.org/voices/why-are-doctors-still-performing-genital-surgery-on-infants

Kannan, D. and S. Deepthi. 2011. LGBT Voices: Report of a panel discussion held during Chennai Pride 2011. Online at http://orinam.net/lgbt-voices-report-of-a-panel-discussion-held-during-chennai-pride-2011

Krug E.G., L.L. Dahlberg, J.A. Mercy, A.B. Zwi and R. Lozano. Eds. 2002. World report on violence and health. Geneva, World Health Organization

Lev, A.I. 2004. Transgender Emergence: Therapeutic Guidelines for Working with Gender-Variant People and Their Families. Haworth Press.

MSJE, 2014. Report of the Expert Committee on the Issues relating to Transgender Persons. New Delhi, Ministry of Social Justice and Empowerment. Online at http://socialjustice.nic.in/transgenderpersons.php

Narrain, A. and V. Chandran. Undated. “It’s not my job to tell you it’s okay to be gay…” Medicalisation of Homosexuality: A Queer Critique. Manuscript.

Orinam, 2014. Sex, Gender and Sexuality: a primer. Online at http://orinam.net/content/wp-content/uploads/2011/10/Orinam_GSS101.pdf

Pai, N. 2013. Inclusion without Explosion. The Orinam blog. Online at http://orinam.net/inclusion-without-explosion/

Pharr, S. 1988. Homophobia: a weapon of sexism. Arkansas, Chardon Press.

Ramakrishnan, L. 2011. Why Women Need To Ally With The LGBT Cause. Women’s Web. Online at http://www.womensweb.in/articles/women-ally-lgbt-cause/

Roberts, A.L., M. Rosario, H.L. Corliss, K.C. Koenen and S.B. Austin. 2012. Childhood Gender Nonconformity: A Risk Indicator for Childhood Abuse and Posttraumatic Stress in Youth. Pediatrics. http://pediatrics.aappublications.org/content/early/2012/02/15/peds.2011-1804

Sriram, H. 2014. Corporate India is not ready for gay employees as yet. Hindustan Times. Online at http://www.scribd.com/doc/203510405/Hindustan-Times-Delhi-2014-01-29

UNESCO, 2012. Education Sector Responses to Homophobic Bullying. Paris: United Nations Educational, Scientific and Cultural Organization. Online at http://www.lgbt-education.info/doc/unesco/UNESCO_Homophobic_bullying_2012.pdf

*****

L. Ramakrishnan is a biologist by training. He is affiliated with the NGO SAATHII that works towards access to healthcare, legal and social services for marginalised populations, including those affected by the HIV/AIDS epidemic and LGBTQI communities.  

Gender Violence:The Health Impact – Discriminatory & Prejudicial Medical Practices: An Instrument of GV

by Ragamalika Karthikeyan

In the aftermath of a rape, survivors are told to follow certain protocol to ensure that forensic evidence can be collected properly. The National Commission for Women advises women specifically to not take a bath or change their clothes, to tell someone about the incident, file an FIR and get a medical examination done, in that order[1].

However, getting that medical examination is in itself a traumatic experience for most sexual assault survivors in India, as a result of archaic medical practices such as the ‘two-finger test’. Indeed, there are several medical practices in India, not limited to examination of rape survivors, which are themselves instruments of gender violence. We explore some of the most serious discriminatory and prejudicial medical practices in this post.

Pre-natal Sex Determination

Female foeticide is a horrible social reality in India. While the Government of India banned pre-natal sex determination in 1994[2], the female sex ratio is still dangerously low. In fact, while the overall sex ratio increased from 933 females per thousand males in 2001, to 940 in 2011, the child sex ratio has declined from 927 females per thousand males in 2001 to 919 in the latest census[3].

Yet, as per the National Crime Records Bureau (NCRB), only 221 cases of foeticide were registered in the country in the year 2013.[4] According to the NCRB, the rate of crime under this head is ‘negligible’[5].

So, unless we believe natural selection has significantly skewed the numbers against women, we must conclude that there are medical practitioners in the country who still perform sex-selective abortions. Thus, twenty years after the banning of pre-natal sex determination, policy makers and civil society will need to think about how to tackle this menace; moreover, it is imperative that this discussion goes beyond the rhetoric about ‘problems of implementation’. At the same time, the regressive attitudes that lie behind sex-selective abortions must not be confused with the right of a woman to have a safe abortion.

Medical Termination of Pregnancy

Abortions in India are allowed under the Medical Termination of Pregnancy Act, 1971, but conditions apply; because the sex of a foetus can be determined after 12 weeks, the law mandates that terminating a pregnancy between 12 and 20 weeks requires the consent of two qualified medical professionals. For pregnancies under 12 weeks, a woman has to depend on the judgment of a doctor, who has to be convinced, in ‘good faith’, of one of the following scenarios[6]:

  • Risk to life, or physical/mental well-being of the woman
  • Risk to life, or physical/mental well-being of the unborn child
  • Contraceptive failure in case of a married woman
  • Rape, as professed by the woman

Abortion law in India, therefore, is more population control-centric and has very little to offer in terms of rights-based delivery of a medical service. This has left a large population of women vulnerable to unhygienic and unsafe ‘quick fixes’, and expensive and sometimes illegal private healthcare.

Thus, the stigma surrounding pre-marital sex has forced several women to opt for unsafe methods of terminating their pregnancies. According to a study conducted in Manipur on data collected over 5 years, 76 per cent of the women who came in for an abortion of a first-time pregnancy were unmarried[7]. The Report of the Dialogue on Gender, Sex-Selection and Safe Abortion published by CEHAT also talks about the judgmental attitudes of medical service providers on abortions, leading to ‘verbal (and sometimes physical) abuses during service delivery’[8].

Legally, doctors only need the consent of the woman undergoing the procedure for performing an abortion. However, case studies show that several medical practitioners demand the ‘permission’ of the husband for performing the procedures[9], further minimising the right of an adult woman to her own bodily autonomy.

Thousands of woman die every year because of unsafe abortions. Policy makers must recognise this reality, and work towards making the medical termination of pregnancy rights-based, while also creating more awareness about the use of contraceptives.

Sexual Assault and the ‘Two-Finger Test’

Following the gang rape of a young medical professional in Delhi in December 2012, sexual assault laws were modified as per the Criminal Laws (Amendment) Act, 2013. The Act was revolutionary in changing the definition of sexual assault beyond peno-vaginal penetration, as per the recommendations of the Justice Verma Committee. However, despite changes in the law, the medical practices around examination of rape survivors continue to be problematic.

The first issue in this regard is that until recently, there was no standardised protocol for collecting forensic evidence in India. Essentially, the tests done on a survivor depended solely on her doctor. After years of public demand for standardisation of the procedure, the Ministry of Health and Family Welfare came up with guidelines for medical examination of rape survivors in March 2014. For the first time, the guidelines explicitly ban the conduct of a two-finger test in rape examinations; yet, this archaic medical procedure is still practiced in several hospitals across the country.

Over 115 years ago, French jurist L. Thoinot is believed to have been the first person to prescribe the two-finger test to determine the virginity of a woman or a child, in his book, ‘Medico-legal Aspects of Moral Offences’. In the India of 2014, this test is still performed on sexual assault survivors, to determine whether they were sexually active before the purported rape. Essentially, the test involves inserting two fingers into the vagina of the woman to ascertain its ‘elasticity’.

The problem with this medical practice is manifold. Firstly, the very suggestion that the sexual history of a rape survivor is of any value to an investigation of the crime is regressive. Secondly, the two-finger test, or the hymen tear test, is not medically conclusive on whether or not the survivor was raped, or on what the sexual history of a woman is.[10]

Thirdly, and most importantly, medical practitioners do not seek the explicit consent of the survivor for the two-finger test. Consent is sought for a bundle of procedures without informing the survivor of the exact nature of each test. By the very definition of sexual assault, this procedure without the consent of the survivor amounts to rape.

The ‘Not Injured, Not Assaulted’ Myth

Another major issue is that medical examinations of sexual assault survivors perpetuate stereotypes of who can and cannot be a victim. The stress on visible physical injury on the body of the survivor as evidence of whether or not she consented to sex goes against internationally accepted norms. This emphasis on injury fails to recognise that force need not always be physical. Medical examination of survivors does not take into account whether she was blackmailed, or forced to submit by other means.

Sensitisation of Medical Practitioners

Gender Violence is perpetuated by society, and medical practitioners are a part of the society that we live in. Thus, while laws around medical care may not always be discriminatory or prejudicial, in practice, women and girls are at the receiving end of archaic notions about gender and sexuality – even when it comes to something as critical as healthcare, something that not just policy makers, but the medical community and society as a whole needs to work on correcting.

[1] http://ncw.nic.in/MeeraDidiSePoochoEnglish/Chapter02.pdf

[2] Pre-Conception and Pre-Natal Diagnostics Techniques (PCPNDT) Act, 1994

[3] Census 2001, Census 2011

[4] Crime in India-2013, National Crime Records Bureau

[5] Pg 96, Crime in India-2013, National Crime Records Bureau

[6] Medical Termination of Pregnancy Act, 1971

[7] Characteristics of Primigravid Women Seeking Abortion Services at a Referral Center, Manipur. (Ibetombi T Devi, BS Akoijam, N Nabakishore, N Jitendra, Th Nonibala, 2007)

[8] Report of the Dialogue on Gender, Sex-Selection and Safe Abortion, CEHAT 2013

[9] Abortion Needs of Women in India: A Case Study of Rural Maharashtra (Manisha Gupte, Sunita Bandewar, Hemlata Pisal), CEHAT

[10] Dignity on Trial: India’s need for sound standards for conducting and interpreting forensic examinations for rape survivors. Human Rights Watch, 2010

*****

Ragamalika Karthikeyan is a Prajnya volunteer, and currently a fellow with PRS Legislative Research’s Legislative Assistants to Members of Parliament programme. A television journalist before she made the switch to policy research, Ragamalika is interested in issues surrounding gender, social hierarchies, and sanitation.

Gender Violence:The Health Impact – Responding to Domestic and Sexual Violence: An Emergency Health Care Model

by Diksha Choudhary

In a survey conducted in 2010 by the Thomson Reuters Foundation, India won an unenviable tag: that of the worst G20 country in the world to be a woman in[i]. The latest numbers from the National Crime Records Bureau don’t contradict that poll either. In 2013 alone, 309,546 crimes against women were reported, including 118,866 cases of domestic violence, and 33,707 cases of rape[ii]. By average, that’s 92 women who get raped every day, and 848 who have taken the step to report domestic violence, every day.

The statistics paint a gory picture. And gender violence is a crime with serious health consequences. World Health Organization (WHO) defines violence against women as “any act of gender-based violence that results in, or is likely to result in, physical, sexual or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life.”[iii]

Gender-based violence results in physical and psychological trauma on the victims. Physical trauma may include abdominal pain, unwanted pregnancy, sexually transmitted infections, pelvic inflammatory diseases, sexual dysfunction etc. whereas psychological trauma might range from being in shock, denial, numbness, guilt to self- loathing, depression and even suicidal attempts.

So, if a woman who has been abused walks into the emergency ward of a hospital in India, what sort of help can she expect?

In the last few years, India has commenced showing sensitivity towards the issue of emergency medical healthcare. For example, as per Section 357 C of the Code of Criminal Procedure, 1973 (introduced by an amendment in the Criminal Law Amendment Act, 2013), both public and private hospitals are required to provide free treatment to survivors of sexual assault and they cannot be denied such treatment. Refusal to provide medico legal examination and treatment is punishable by imprisonment for up to 1 year as per Section 166B of the Indian Penal Code[iv].

However, so far there is no accepted, standardized and efficient protocol for medical personnel to follow. Until recently, there was no standardized pro-forma for rape examinations across hospitals in India, which was corrected in a guideline issued by the Ministry of Health and Family Welfare in March 2014.[v] While this is an essential first step in strengthening the institutional infrastructure required for an emergency healthcare model, few hospitals follow this protocol.

Incidents like the one in Mysore[vi] where a rape survivor with mental disabilities was made to wait naked for a medical exam reek of insensitivity on the part of medical practitioners. It also raises questions about the training provided to our doctors and nurses. There is an urgent need to implement the training structure as per the new guidelines by the Government to sensitize and educate all medical personnel on how to provide the best medical help to the victims. There is also a need to develop specialized certification training program such as Sexual Assault Nurse Examiner (SANE) in USA to respond to sexual assault patients’ emotional and physical needs as well as forensic evidentiary requirements of the victims.[vii]

Plans to build 600 one stop crisis centres across the country are another step in the right direction[viii]. Models from countries like UK are good examples to emulate, where sexual assault referral centres provide medical care and forensic examination following assault/rape and, in some locations, sexual health services. Medical services provided are free of charge and are provided to women, men, young people and children[ix].

While that’s the wishlist for essential institutional and physical infrastructure needed for emergency healthcare for sexual and domestic violence survivors, here’s an attempt at a ‘model’ model for emergency response: the 3Es to follow for survivors:

  1. Emergency Helpline, or an Emergency Medical Dispatcher (EMD): There is a need for a centralized emergency medical dispatch service in defined zones of every state which provides immediate medical help needed for the victim of sexual violence. This EMD would gather information related to medical emergencies such as information regarding the perpetrator, the wounds inflicted on the victim or information collected from a family member, to provide immediate help prior to the arrival of medical services. It would also dispatch an Emergency medical services team for the aide of the victim[x]. In the United States of America and Canada, 9-1-1 functions as an EMD for all kinds of emergency services. We can develop a similar emergency medical dispatch network to help in the cases of exigencies tailored for medical attention specific to gender violence. Further it is vital that not only government hospitals but private hospitals and nursing homes are included in this program.
  2. Essential Medical Attention: Once a survivor of domestic or sexual violence is brought to a hospital, or a one stop crisis centre, medical practitioners must follow standardized procedures for providing immediate medical care. This must include treatment of physical injuries, detection of sexually transmitted infections, and provision of emergency contraceptives where needed. It must also include psychological counseling of the survivor, and her immediate family or friends where needed.[xi]
  3. Evidence Collection Protocol: An emergency model must also have a proper protocol for forensic evidence collection, and the right methods to do the same. The protocol must expressly forbid prejudicial medical practices like the two-finger test. One-stop crisis centres must have rape kits for doing the necessary tests and for safe storage of evidence. [xii]

[i] http://www.trust.org/item/20120613010100-b7scy/?source=spotlight

[ii] National Crime Records Bureau- http://ncrb.gov.in/ and  http://www.bbc.com/news/world-asia-india-29708612

[iii] WHO Violence against Women- http://www.who.int/topics/gender_based_violence/en/

[iv] http://indiacode.nic.in/acts-in-pdf/132013.pdf

[v] guidelines and protocols to provide medico-legal care for survivors and victims of sexual violence http://uphealth.up.nic.in/med-order-14-15/med2/sexual-vil.pdf

[vi] News Article- http://daily.bhaskar.com/news/BAN-brazen-display-of-insensitivity-rape-victim-made-to-wait-naked-for-3-hours-in-go-4688547-NOR.html

[vii] http://www.vawnet.org/applied-research-papers/print-document.php?doc_id=417

[viii] http://wcd.nic.in/nirbhaya_centre.pdf

[ix] http://www.rapecrisis.org.uk/Referralcentres2.php, http://www.cwhn.ca/en/organization_en/results/taxonomy%3A2998

[x] Wikipedia definition of Emergency Medical Dispatcher -http://en.wikipedia.org/wiki/Emergency_medical_dispatcher,

[xi] http://www.rapecrisis.org.uk/index.php, https://rainn.org/get-help/sexual-assault-and-rape-international-resources, http://www.cwhn.ca/en/organization_en/results/taxonomy%3A2998

[xii] https://www.rainn.org/get-information/sexual-assault-recovery/rape-kit, http://www.casac.ca/, http://www.rapecrisis.org.uk/Policeprocedure2.php, http://uphealth.up.nic.in/med-order-14-15/med2/sexual-vil.pdf

*****

Diksha Choudhary is a former analyst with one of the top consulting firms in the world, and is currently a fellow with PRS Legislative Research’s Legislative Assistants to Members of Parliament programme. In her spare time, Diksha reads French works of fiction.

Gender Violence:The Health Impact – Sexual Assualt, HIV/AIDS & Other STIs

by Jaya Shreedhar

It’s been a good many years, but I remember the waving fields of wheat, the distant bleating of goats and the pungent fragrance of dung at the entrance to Shama Devi’s mud-and- thatch dwelling in Uttar Pradesh. The year is 2005 and Shama, a mother of four, made a brisk living tending to her cows and hens, working the fields for daily wages and scraping together enough to feed her children and herself and even offer a visitor a glass of tea and a couple of biscuits. Not bad for a wisp of a woman, whose crinkled eyes spoke of hours in the sun and at her chula.  Shama was living with HIV. The doctors had tested her when she “went for a health check-up in her third month of pregnancy and now, her infant is due for an HIV test”, she whispers. Kishen, her husband, still sold fruits on the streets of Surat as he had for the past nine years and visits her twice a year. He had tested positive for HIV two years ago. “He got it from women,” Shama adds. “What’s a man to do, with daily earnings burning a hole in his pocket and a body that aches from pushing a heavy cart all day on pitiless streets?”  What indeed.  The National AIDS Control Organization estimated about 2 out of every two dozen female sex workers in the country to be HIV positive at the time, with migrant workers like Kishen forming a huge percentage of their clientele. Over 8% of male migrant workers in India are estimated to be HIV positive. What chance did the Shama Devis have?   Most married women with HIV or STIs continue to be infected by their husbands.  Studies among HIV discordant African couples show that uninfected wives who report sexual violence are more likely to get infected.  Many like Shama Devi, accept their ill health as a matter of course. Few if any, have grouped together to discuss their vulnerabilities or their options for self protection.

Female Sex Workers, a more marginalized and disempowered community took that essential step. The Durbar  Mahila Samanwaya Committee, the country’s first registered co operative society for and by sex workers, went door to door talking about HIV and condoms  in Kolkata’s sprawling red light district of Sonagachi, and negotiated sex workers rights to health information, health care and safe working conditions as crucial to HIV prevention efforts.  Whether a woman’s body may be legitimately traded for cash or goods, and whether that will reduce the occupational hazards of sex work and prevent trafficking and abuse of girls and children is debatable. But the unionization of sex workers served to bring the vulnerability of women to HIV out into the open and catalyzed discussions on rights based approaches to HIV prevention. Female Sex Workers continue to bear a disproportionately high percentage of HIV infections, at an estimated 2.67%.

HIV, Sexually Transmitted Infections, unwanted pregnancies, psychological trauma and chronic vulnerability to ill health are the flip side of the coin of sexual disrespect/violence. The connections are deep and varied, spanning biological and socio-cultural aspects.

The biological connect is direct and easily recognized. Women are physically more at risk of contracting HIV/STIs. Being the receptive partner in sexual intercourse, they receive a larger inoculum of HIV or other infectious agents into their bodies from ejaculated semen and seminal fluid while the vaginal fluids are much less in volume and capacity to infect. The mucosal surface of the vagina offers a larger absorptive surface for pathogens than does the penis. In sexually violent acts such as vaginal or anal rape, particularly among girl children, adolescents and teens, the tender mucosal surfaces may suffer abrasions and tears that serve as gateways for the easy access of STI pathogens and HIV into the blood stream.

In addition to these immediate and direct outcomes, there are studies indicating that the long term risk of acquiring HIV is higher among rape survivors and victims of sexual abuse in childhood.

The third National Family Health Survey found that one in ten married women between the ages of 15 to 49 years suffered sexual violence at the hands of the husband. Contrast that with the finding that only 1 percent of married women had ever initiated violence of any sort against their husband.

On the one hand, the trauma of sexual violence wreaked on oneself by someone who is deemed as protector and provider; on the other, societal and cultural coercion to derecognize the trauma as not trauma at all, but a woman’s normal state of being.  Apprehensions of spousal/partner rape and violence inhibit women from seeking information and health care that can protect them from HIV/STIs, leave alone negotiate condom use.

Structural approaches that reduce the risk of violence in sex, whether marital or transactional and that protect the rights of women, sex workers or otherwise, are critical to the success of HIV prevention. What continues to be missing from the discourse is initiatives for men, particularly perpetrators of physical and sexual violence, that helps them access a better understanding of the roots of violent behavior and its fall out, and interventions that can help them restructure their own perceptions of what male dignity and gender respect mean.

The evidence is clear. Over twenty five years of AIDS interventions in India by health workers and activists show that preventing the spread of HIV and STIs is all about putting the rights of the most vulnerable – particularly women’s rights – first.

References

  1. National Family Health Survey 3 (2005-6)
  2. MC Public Health.2010 Aug 11;10:476. doi: 10.1186/1471-2458-10-476. Violence against female sex workers in Karnataka state, south India: impact on health, and reductions in violence following an intervention program. Beattie TS1Bhattacharjee PRamesh BMGurnani VAnthony JIsac SMohan HLRamakrishnan AWheeler TBradley JBlanchard JFMoses S.
  3. HIV Sentinel Surveillance –A Technical Brief, 2012-13 The National AIDS Control Organization http://naco.gov.in/upload/NACP%20-%20IV/HSS%20TECHNICAL%20BRIEF/HIV%20Sentinel%20Surveillance%20Technical%20Brief.pdf

*****

Dr Jaya Shreedhar is a journalist and medical doctor based in Chennai. She currently works as an independent health communications consultant and teaches Health Journalism at the Asian College of Journalism.