Gender Violence: The Health Impact – Menstruation: A Biological Process or a Bleeding Curse?

by Aparna Gupta

Gender violence, though often brutally visible, also manifests itself in the most routine acts. In India’s highly patriarchal society, with strict notions of purity and pollution, the routine biological process of menstruation is often viewed as a ‘curse’. Thus, the issues associated with menstruation are never discussed openly, burdening young girls with archaic taboos and restrictions, and even denying them access to basic hygiene and sanitation requirements during their monthly period, thereby reinforcing gender inequities.

One of the worst examples of this is seen in the regressive traditional practices of the Kadu Golla community in Chitradurg District, Karnataka. This community considers a woman to be unclean when she has her monthly period, or after she delivers a baby. Such women have to live outside their villages in derelict buildings or in a hovel the size of a kennel with their newborn without access to medical care or hygienic sanitation facilities. During this time, the women are not supposed to bathe or eat cooked food. The worst sufferers are young girls who are forced to spend a few days away from school and college when they are menstruating, even if it means missing their examinations.[1]

Moreover, such archaic practices are not limited only to remote rural corners of India. According to Aakar Innovations, an NGO that works for the promotion of menstrual hygiene in India, 9 out of 10 women in the country do not have access to hygienic and effective menstrual protection.[2] In addition, according to India’s 2011 census, 89 percent of the nation’s rural population lives in households that lack toilets. The absence of proper sanitation along with the unavailability of affordable sanitary materials for menstrual hygiene results in multiple psychological and physical health problems. For instance, reproductive tract infections are 70 percent more common amongst women who use unhygienic materials during menstruation and an alarming 30 percent of girls drop out of school upon reaching puberty.[3]

Despite such grim realities, menstrual hygiene management has been continuously neglected from programmes for community water and sanitation and hygiene promotion. It is not incorporated into the infrastructural design for toilets and environmental waste disposal policies, or training guidelines for health workers. For instance, the Swaccha Bharat Abhiyan, launched by the new government with much fanfare this year, while recognising the need for proper sanitation facilities and toilets, remains silent on the requirements of menstrual hygiene services.[4]

Thus, the taboos and rituals around menstruation exclude women and girls from various aspects of social and cultural life. They have built a self-reinforcing vicious cycle of silence about the concerns of women, neglect of menstrual hygiene within development initiatives and the lack of participation of women in decision-making.

In 2011, the Central Government created the first initiative for ensuring menstrual hygiene through the launch of the Scheme for Promotion of Menstrual Hygiene among Adolescent Girls in Rural Areas.[5] The scheme aims to increase awareness among adolescent girls on menstrual hygiene, increase access to and use of high-quality sanitary napkins and ensure safe disposal of sanitary napkins in an environmentally friendly manner.[6] However the impact of the scheme is yet to be witnessed at the ground level.

Furthermore, distribution of sanitary napkins, though a crucial part of the solution in a country where 70 percent of girls cannot afford hygienic sanitary products, is not a panacea for the underlying issues that lead to discrimination. Apart from addressing the practical and infrastructural needs of toilets and sanitary napkins, there is an urgent need to promote better awareness in order to overcome the embarrassment, cultural practices and taboos surrounding this biological process, which lead to grave discrimination against women and girls.

Moreover, in order to break the shackles of menstrual taboos that reproduce unequal gender relations, involving men and adolescent boys is of crucial importance. More often than not, men play an important role in the decision-making regarding the provision of menstrual hygiene services, as policymakers, headmasters of schools, or even as the head of the family responsible for the decision to build a toilet at home. Therefore, there is a need to sensitise men and break the silence around menstruation.

[1] ‘Unclean and Outcast’, August 11-24, 2012, Frontline

http://www.frontline.in/static/html/fl2916/stories/20120824291604000.htm

[2] http://yourstory.com/2014/09/aakar-innovations/

[3]‘Sanitation Protection: Every Woman’s Health Right’ , AC Neilsen

http://indiasanitationportal.org/19069

[4] Guidelines for Swaccha Bharat Abhiyan, Ministry of Drinking Water and Sanitation, Government of India

http://www.mdws.gov.in/sites/upload_files/ddws/files/pdfs/Final%20Guidelines%20(English).pdf

[5] National Health Mission, Government of India

http://nrhm.gov.in/nrhm-components/rmnch-a/adolescent-health/menstrual-hygiene-scheme-mhs/schemes.html

[6] http://pib.nic.in/newsite/erelease.aspx?relid=62586

*****

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 – Female Genital Mutilation in India

by Zubeda Hamid

It’s called the haram ki boti: the clitoral hood that is cut away or nicked before a girl reaches puberty. Known primarily as a practice prevalent in some parts of Africa and among immigrant communities in Europe, the United States and Australia, female genital mutilation, cutting or ‘female circumcision’ as it is sometimes known, is practiced in India too. The brutal, non-medical procedure is carried out for a variety of reasons and causes immense physical and psychological damage. It can even be fatal. The World Health Organisation estimates that more than 125 million girls and women alive today have been cut in the 29 countries in Africa and the Middle East where FGM is concentrated.

In India, FGM is practiced by the Dawoodi Bohra community, an Ismaili Shia sect who live primarily in Gujarat, Maharashtra and Rajasthan. The practice probably originated when the community migrated from Yemen, Egypt or other parts of that region to India some centuries ago, or was brought over by a priest and thus gained religious sanction. The community, about 10 lakh strong are mostly wealthy traders and well educated. Due to the intense secrecy in which it is shrouded, it is unclear how many in the community practice FGM.

Said to be done when the girl is seven, the procedure is usually carried out by an older woman in the community, a dai or a midwife with little or no medical training using crude instruments such as blades and no anaesthesia. Of late though, reports suggest some women take their daughters to hospitals and ask for the procedure to be performed by a doctor or get it done at birth. Accounts by women who have been through the procedure, a recent documentary on the subject titled ‘A Pinch of Skin’, several blog posts and online forums all suggest this is the only Muslim community in India to practice ‘khatna’.

According to the World Health Organisation, female genital mutilation comprises all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons. It is classified into four types:

  • Clitoridectomy – partial or total removal of the clitoris
  • Excision which is clitoridectomy and removal of the labia minora with or without excision of the labia majora
  • Narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora
  • All other harmful procedures such as pricking, piercing, incising, scraping and cauterization.

The Dawoodi Bohras practice the first type –clitoridectomy. Cutting off the hood of the clitoris exposes sensitive nerve endings and potentially limits the possibility of sexual pleasure through clitoral stimulation. Women who have undergone it describe female relatives holding down their legs, their fear, the excruciating pain and burning as they scream and the applying of a home remedy afterwards. The procedure is then never mentioned they say, and women are expected to ensure their daughters undergo it too.

A number of reasons are given by the community about the practice according to several posts: claims such as it prevents cancer to reasons such as it is compulsory in Islam and that it is tradition and has to be done in order to be respected in the community. It is also considered a means of ensuring that the girl becomes ‘pure’ and that her marriage goes through.The Quran has no mention of female genital mutilation or circumcision, and its mention in the Hadith is ambiguous at best.

Female genital mutilation has no health benefits, says the World Health Organisation. It can cause a number of health problems including severe pain, bleeding and shock, difficulty in urinating, cysts, infections, abscesses, infertility, difficulties in child birth, HIV, scar tissue formation and genital ulcers among others. This is apart from the psychological damage including post-traumatic stress disorder and long-term sexual effects such as decreased sexual enjoyment and painful sexual intercourse.

What the practice attempts to do, much like communities that kill young men and women for marrying outside their castes, is exercise control over women, specifically over female sexuality. As Tasleem, an activist from within the community who, a few years ago, started a petition against FGM has put it, “This is essentially done to prevent homosexuality, masturbation, and to subdue a girl’s desires so that she doesn’t marry out of the community or have extra-marital relationships.” Tasleem claims 90 per cent of the community continues to practice this custom, and that in many cases, the men are unaware it takes place. Maker of the documentary Priya Goswami has said to DNA: “Since the community was predominantly merchants, men travelled a lot. Removing the haraam ki boti, as it is called, was a way to control the sexual urges of women and keep them from infidelity.”

Not just does FGM constitute an extreme form of discrimination against women in deeply patriarchal societies it is also part of a larger culture where violence against women and in this case, girl children is perhaps the norm. In some parts of Africa, women are cut repeatedly: before puberty, before marriage, and after childbirth, in an attempt not just to reduce the woman’s libido, but also to make her vaginal opening tighter for the enhanced pleasure of men and to discourage illicit sexual intercourse. And while in India this extreme form of FGM is not practiced, the fact that a girl’s genitalia is cut to any degree at all points to the extreme mistrust of female sexuality and the need to maintain control over it.

The immense reluctance of the community to talk about this subject even within families has, to some extent, been broken recently, with Tasleem’s petition. Going only by a first name Tasleem launched a campaign online asking for signatures to petition the community’s high priest, Syedna Mohammad Burhanuddin to ban this custom. The petition was picked up by the ‘Indian Muslim Observer’, a website on Muslim affairs, whose founder-editor Danish Ahmad Khan has also supported the campaign. “The issue of FGM…is surely an important one, particularly when it is being practiced in the name of Islam. This also brings into sharp focus the unholy and absurd role being played by the Bohra clergy…,” a note of his said, adding that awareness was needed to stop this “condemnable practice”. The late Dawoodi Bohra reformist writer Asghar Ali Engineer had also spoken out about the practice, calling it an “attempt to suppress sexuality so that women do not go astray”, in an interview to ‘Outlook’.  As of October 6, 2013, the petition had received 2,500 signatures with a several women who have undergone FGM supporting it. However, so far, the high priest has refused to respond to the petition.

The fact that FGM violates a child’s body makes it an important human rights issue. Globally, there are several campaigns to stop the practice, and many countries have legislations making it an offence. The European Union, the United States, Australia, Ireland, New Zealand, Canada and several other countries have laws against it, while in Africa several countries including Ethiopia, Togo, Uganda, Kenya and Egypt have banned it. In 1993, the United Nations General Assembly included FGM in its resolution on violence against women, and since 2003 has been sponsoring a day on zero tolerance to FGM every year. In 2012, the Assembly adopted a resolution on the elimination of FGM. On October 30 this year, the United Nations secretary general, Ban Ki-moon, announced a global campaign to end it within a generation. Amnesty International runs an ‘End FGM’ campaign and there are many others in several parts of the world.

These organisations have attempted to get religious leaders to speak out against the practice and tell people that it is not compulsory in any religion. While some leaders have proclaimed it un-Islamic, other local clerics continue to sanction it or turn a blind eye. The fact that many African communities believe their daughters are unmarriageable unless cut, adds to the difficulty of stopping the practice. In July this year, ISIS, the Islamist terrorist group allegedly ordered FGM to be carried out on all women in Iraq between the ages of 11 and 46. A UN coordinator said, this potentially affect an estimated four million women. There were later reports that the ISIS dismissed this order, calling it false propaganda.

In India however, a lack of knowledge about this practice, the fact that it seems to be practiced by just one community and the reluctance of the community to speak out against it has allowed it to continue. While there is no law specifically banning the practice in India, it could be punishable under sections of the Indian Penal Code if a complaint is made, ‘Business Line’ has reported. Section 326 – causing grievous hurt, could be used to penalise the parents and person performing FGM if a minor girl is involved, it said.

Will anyone ever use the law though, is debatable. Members of the community have told publications that they fear excommunication if they defy community traditions, and some of whom do not practice it, lie about the fact to avoid trouble. Because, as one father put it in an interview, “Who wants to take up a fight with the community?”

Clearly, more than just laws are needed – a movement to end FGM both within and outside the community are crucial.

Sources:

1. Articles in publications:

Outlook: http://www.outlookindia.com/article/The-Yin-Wounded/279088

DNA: http://www.dnaindia.com/lifestyle/report-a-pinch-of-skin-a-documentary-that-attempts-to-lift-the-silence-on-female-genital-mutilation-1986973

Times of India: http://timesofindia.indiatimes.com/entertainment/hindi/bollywood/news/NID-students-film-on-female-genital mutilation/articleshow/19304011.cms

Hindustan Times: http://www.hindustantimes.com/india-news/mumbai/bohra-women-go-online-to-fight-circumcision-trauma/article1-779782.aspx

Business Line: http://www.youthkiawaaz.com/2012/04/female-genital-mutilation-an-open-secret-in-india/

Dawn: http://www.dawn.com/news/712748/female-circumcision-anger-aired-in-india-fm

New York Times: http://www.nytimes.com/2014/11/17/opinion/fighting-female-genital-mutilation.html?emc=edit_ty_20141117&nl=opinion&nlid=54889929&_r=1

2. Blogs, Facebook posts and online forums/news portals and agencies:

http://breakthesilencespeakthetruth.wordpress.com/

http://indianmuslimobserver.com/2014/04/27/female-genital-mutilation-is-not-circumcision/

https://www.facebook.com/notes/sijo-k-jose/uproar-over-female-genital-mutilation-bohra-muslim-woman-activist-launches-campa/329191643829952

http://www.india.com/whatever/female-genital-mutilation-what-is-fgm-know-more-about-the-brutal-practice-102516/

http://makinghealthmatter.wordpress.com/2011/12/10/fighting-female-genital-mutilation-in-india/

http://www.ipsnews.net/2012/01/pakistan-india-women-expose-secret-genital-cutting-rite/

http://dawoodi-bohras.com/forum/viewforum.php?f=1

http://www.youthkiawaaz.com/2012/04/female-genital-mutilation-an-open-secret-in-india/

3. The petition:

https://www.change.org/p/h-h-dr-syedna-stop-female-circumcision-ladkiyon-par-khatna

4. Campaigns, non-governmental organisations:

http://www.ipu.org/wmn-e/fgm-prov-i.htm

http://www.endfgm.eu/en/

http://www.forwarduk.org.uk/campaigns/end-fgm

http://www.equalitynow.org/fgm

http://www.stop-fgm-now.com/

http://www.actionaid.org.uk/endfgm

5. WHO, UN

http://www.who.int/topics/female_genital_mutilation/en/

http://www.who.int/mediacentre/factsheets/fs241/en/

http://www.who.int/reproductivehealth/topics/fgm/overview/en/

http://www.un.org/en/events/femalegenitalmutilationday/

http://www.unfpa.org/topics/genderissues/fgm

*****

Zubeda Hamid is a correspondent with The Hindu covering health and disability rights.

Gender Violence:The Health Impact – Immediate Medical Care for Burn Victims

by Rishabh Raj

A report by Acid Survivor Trust International (ASTI) aptly says “acid violence rarely kills … [it] always destroys lives.” The very gruesome nature of the violence coupled with the fact that an acid attack takes only five seconds to cause superficial burn and thirty seconds to escalate into  deep burns and that India also accounts for a major share of global burn deaths makes it extremely important to discuss immediate medical care available to burn victims.

Acid attacks inevitably lead to excruciating physical ordeals for the survivors. Upon contact, the acid melts through flesh, muscle, and even bone, until thoroughly washed. Eighty percent of these attacks are directed at women and between 40 per cent and 70 per cent of them target women less than 18 years of age[1].

But acid attacks are not the only form of gendered violence that causes burn injuries. In India, several women are burned alive by their partners, or other close relatives. According to a report by Acid Survivors Foundation of India, this is the most common form of dowry deaths.[2]

In India, about 700,000 to 800,000 people per year sustain significant burns, though very few are looked after in specialist burn units. The highest rates occur in women aged 16-35 years of age[3]. Compare this to the US where annually 500,000 cases receive burn treatment with an average of about 3,300 deaths[4].

Need for appropriate medical care
The medical care available immediately after such an incident is crucial in determining the extent of damage and loss. Hence, it becomes extremely important to understand the complexities of burn injuries and rehabilitation. The most common cause of death for burn patients is infection. The burn skin is very sensitive and can be very easily infected if not taken care and cleaned properly. Hence throughout the course of treatment, strict hygiene measures have to be followed until the wounds are completely healed.

Hospitals not properly equipped
Women who are unable to access proper medical care after the attack could die. Unfortunately, hospitals in India are ill-equipped to handle such complexities. Many hospitals have no facilities to handle acid violence and burn emergencies. Some doctors are not even aware of basic first aid measures such as flushing acid out of the body immediately after the attack. The number of trained burn and plastic surgeons is less than 1100 for more than 1200 million population of India.[5] The situation becomes further grim due to the absence of organized burn care at primary and secondary health care levels, where a woman is most likely to first go after such an incident.[6]

No defined protocol for treating burn victims
In 1998, India was the only country in the world where fire (burns) was classified among the 15 leading causes of death[7].  There is no defined protocol in India for immediate medical attention to burn victims. Burn management remains a relatively new concept here. The concept of legal rights of a burn survivor and the family is also slowly emerging in India.

Under the 11th Five Year Plan, a new initiative was rolled out at the national level to leverage available resources for more effective and standardized delivery of treatment for burn victims. The National Programme for Prevention of Burn Injuries (NPPBI) was started with a goal to ensure capacity building of infrastructure and manpower at all levels of health care delivery system in order to reduce incidence, provide timely and adequate treatment to burn patients to reduce mortality, complications and provide effective rehabilitation to the survivors.

This pilot project was converted into a full-fledged national programme under the 12th Five-Year Plan providing burn management facilities in 67 State Government Medical Colleges at a cost of Rs. 407.21 crore.[8]

It is important to recognize that there is a difference between an accidental burn injury and an acid/dowry burn attack and the approach to medical care has to be based on these factors. While it may be easy for an accidental burn victim to access a health care facility, a victim of acid attack faces intense emotional and psychological fears which hinders the treatment at all the stages.

Finally, burn rehabilitation is an extremely difficult and time-consuming effort. Women have to cope with enormous physical pain and deal, at the same time, with low self-esteem and lack of motivation due to their altered looks and social rejection. Medical care available to the victim in the aftermath of an incident can play a crucial role in minimizing the extent of the loss and needs to be accelerated by the Government as well as the medical professionals in the field with due diligence.

WHO has issued guidelines on burn management broadly outlining the first-aid and a set of checks to estimate the severity of burn. The table below provides a list of Dos and Don’ts for providing immediate relief to a victim.

Do's and Don'ts

[1] Trauma Informed Care, Sourcebook, Acid Survivors Foundation India

[2] http://www.asfi.in/upload/media/SOURCE_BOOK_12_feb.pdf

[3] Burns in developing world and burn disasters – Rajeev B Ahuja

[4] Chapter 4: Prevention of Burn Injuries – Total Burn Care

[5] Arun Goel and Prabhat Srivastav, Post-burn Scars and Scar Contractures, Indian Journal of Plastic Surgery, Medknow Publications, September 2010

[6] National Programme for prevention of burn injuries – JL Gupta, LK Makhija, SP Bajaj – Department of Burns, Safdarjung Hospital, Dr RML Hospital, New Delhi

[7] Burn Mortality : recent trends and socio cultural determinants in rural India

[8] National Programme for Prevention and Management of Burn Injuries, CCEA – Press Information Bureau

*****

Rishabh Raj is currently a fellow with PRS Legislative Research’s Legislative Assistants to Members of Parliament programme. An engineer from IIT Kanpur, Rishabh is interested in finding technological solutions to social problems.

Gender Violence: The Health Impact – The Gendered Nature of Acid Attacks

by Vaibhav Gupta

An acid attack is a form of violence that affects women and girls disproportionately. The Law Commission of India reports that most of the acid attacks registered in India have been against women[1]. A report from the Cornell Law School[2]on combating acid violence published in January 2011 corroborates this. According to this report, 72 per cent of acid and burn attack victims in India are women, clearly indicating the gendered nature of such attacks.

Acid and burn attacks in India need to be understood in the context of the socio-cultural transformation that is taking place across the nation. This requires a study of the reasons behind such attacks and their prevalence in our society. However such a study is difficult to undertake because until recently, India did not even recognise acid attacks as a separate offence.

Trends from neighboring Bangladesh, though, point to a shocking fact: in 78 per cent of acid attacks reported in Bangladesh, the motive behind the crime is cited as the victim’s refusal to marry the perpetrator or her denial of a sexual advance[3].

The 2013 data from India’s National Crime Records Bureau lists 57 cases of acid attacks on women in 2010, 77 in 2011 and 83 in 2012.The upward trend is similar to other gender based offences in India including rape, kidnapping and abduction of women, cruelty by husbands and assault on women.  [4].

Laws against Acid Attacks

India recognised acid attacks as a criminal offence in 2013 when the Parliament passed The Criminal Law (Amendment) Act, 2013. Under the amended legislation, an attempt to throw acid can earn the perpetrator a prison term of five to seven years (Section 326B)[5], while causing permanent or partial damage or deformation can result in a jail sentence of no less than 10 years and up to a maximum of life imprisonment (Section 326A)[6]. The law also stresses that the victim should be compensated by the perpetrator[7]as well as by the respective state government.[8]However, it should be noted that while offenses under Section 326A require the fine imposed to be proportional to the medical expenses incurred by the victim, this is not the case for offences committed under Section 326B.

Implementing Laws: Impossible?

The problem is not just one of legislation, but its implementation and monitoring as well. According to the Supreme Court’s directives[9]on the regulation of acid sales:

1) A buyer must provide a government-issued identity card showing he/she is over 18 years of age
2) Every seller must maintain records of every buyer of acid

However, in practice, this does not seem to be regulated. Individuals are easily able to purchase acid for household purposes bypassing any such process. Even the government seems casual about the severity of these incidences, their investigation, compensation, and punishment; the Delhi High Court in April 2014 highlighted a case where compensation to the victim was delayed for over 6 months. This begs the question: Can the Government afford to be so casual about such a serious crime?

What can be done?

India also lags behind its neighbors in providing protection against acid offences. Bangladesh’s Acid Offences Prevention Act 2002 and the Acid Control Act 2002 banned the open sale of acids, and imposed stringent punishment (including the death penalty) and a fine on offenders. The law further outlays that investigations have to be completed within 30 days and the trial within 90 days. Dedicated Prevention Tribunals have been set up with the sole objective of looking into these crimes. In Pakistan, perpetrators of acid attacks may be punished with a maximum of life imprisonment.

The National Commission for Women prepared a draft proposal in 2008 that specifically dealt with acid attacks in India; in addition to classifying an acid attack as a separate and most heinous form of offence, the law intended to make provisions to:

1) Assist the victim of an acid attack by providing her with medical treatment services;

2) Provide social and psychological support;

3) Provide legal support to survivors;

4) Arrange rehabilitation mechanisms/schemes, taking into account the specific needs of the victim; and

5) Regulate and control acid and other corrosive substances

However, the law was never discussed. We still lack a comprehensive piece of legislation on acid attacks that deals with prevention, regulation of acid sales, punishment, medical care and rehabilitation.

This devastating form of violence continues to take place against the girls and women of this country without stirring the conscience of lawmakers and people in positions of power. As the Cornell Law School report says, ‘Acid attacks are social phenomena deeply embedded in a gender order that has historically privileged patriarchal control over women and justified the use of violence.[10] It is high time policymakers initiate steps to address the issue through advisories, amendments and legal directives.

[1] Law Commission of India Report to Supreme Court on Writ Petition 129 of 2006, Laxmi vs. Union of India

[2]‘Combating Acid Violence in Bangladesh, India and Cambodia’, Cornell Law School, 2011

[3]‘Combating Acid Violence in Bangladesh, India and Cambodia’, Cornell Law School, 2011

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

[5]Sec 326B of IPC

[6]Sec 326A of IPC

[7]Sec 326A of IPC

[8]As per section 357B of Criminal Procedure Code

[9]Law Commission of India Report to Supreme Court on Writ Petition 129 of 2006, Laxmi vs. Union of India

[10]‘Combating Acid Violence in Bangladesh, India and Cambodia’, Cornell Law School, 2011, Foreword by Yakin Erturk

*****

Vaibhav Gupta is currently a fellow with PRS Legislative Research’s Legislative Assistants to Members of Parliament Programme. When he’s not volunteering with organisations that work on everything from education to disability, Vaibhav dreams of building his own start-up in the policy field. 

Gender Violence:The Health Impact – Child Marriage as Gender Violence: Social & Health Consequences

by Mouli Banerjee

It has been argued that law itself, as a political product, doesn’t always have the capacity to pursue ‘justice’, given the qualification that “while many of the juridical forms of power continue to persist, these have gradually been penetrated by quite new mechanisms of power that are probably irreducible to the representation of law”[1]. Child Marriage, as a social practice, is one such example, where laws, even if inadequate, have been put in place, but somehow the practice has continued for decades. However, it is important to understand the legal structure in place against child marriages, in order to tackle the issue properly.

Prohibition of Child Marriage: The System in Place

The current law in place to tackle the crime of child marriage is the Prohibition of Child Marriage Act, 2006 (PCMA). It defines a child, if female, as one who has not completed 18 years of age and if male, as one who has not completed 21 years of age. It includes punitive measures against all those who perform, permit and promote child marriage. The law also has a provision for annulment of a child marriage and gives a separated female the right to have a residence and maintenance costs (from her husband if he is above 18 years of ages, and from her in-laws, if the husband too is a minor), until she is remarried.[2]

However, there are major loopholes in the PCMA.

Most importantly, it makes a distinction, declaring some marriages void (in cases where the marriage is conducted by use of force, fraud, deception, enticement, selling and buying or trafficking) but in other cases simply giving the option that one may declare one’s marriage “voidable” even up to two years after attaining adulthood. This is a contradiction, for if the law doesn’t see a ‘child’ as capable of consent, then every act of child marriage must by definition involve force, fraud, deception or enticement, and thus, must be void.[3] It is obvious that most child marriages, once solemnised, will not be reported and hence will go unchecked.

India is now a part of the UN Resolution on Child, Early and Forced Marriage, and several Action Plans and Policies fielded by the Ministry of Women and Child Development in the last decade have also been geared towards this end.

In this context, it becomes crucial to redefine child marriage as a form of severe gender violence, thus understanding the practice as not just a restriction of a girl child’s choices in marriage, but as violence inflicted on female bodies and minds.

Child Marriage as Gender Violence

The United Nations 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.”[4]

A quick look at the social and health consequences of child marriages promptly validates the assumption of child marriage as an active act of gender violence on many levels.

Threat of violence, coercion or ‘arbitrary deprivation of liberty’

As explained in the previous section, the very fact that a child is not seen as capable of consent makes child marriage an act of coercion. It restricts a girl’s choices on both social and physical levels by taking away her liberty to choose her age of marriage and robbing her of her reproductive rights, long before she has even understood them clearly.

Current statistics suggest that as of 2013, 43% of women aged 20-24 were married before 18. Moreover, UNICEF suggests that there are 23 million child brides in India, and this makes for approximately 40% of the child brides globally.[5]

‘Physical, Sexual or Mental Harm’

The Danger of Marital Rape

While marital rape is a threat all married women face, and legal debates pushing for the criminalisation of marital rape still rage in India, in the context of child marriage, this can be viewed as a contradiction in laws. The Criminal Law (Amendment) Act, 2013, amended Section 375 of the IPC to redefine ‘rape’, but Exception 2 to this amendment states that sexual intercourse or acts by a man with his own wife, the wife not being under 15 years of age, is not rape. Thus, all married women, between the ages of 15 and 18, who are child brides under the PCMA 2006, if subjected to marital rape, cannot consider it a criminal violation. This brings into question the legal concept of ‘consent’ which is considered implicit in a marriage and is incidentally the argument given for not criminalising marital rape.This is in contradiction to the assumption that a ‘child’ is not capable of sexual consent and violates the PCMA 2006 and the Juvenile Justice (Care and Protection of Children) Act, 2000 (which defines a ‘child’ as any person below 18 years).

This contradiction is currently being contested in the Supreme Court by a PIL filed by Independent Thought (www.ithought.in) in a Writ Petition [Independent Thought vs. Union of India (W.P. Civil 382 of 2013)].[6]

Severe Health Consequences of Child Marriages

Apart from the health concerns implicit in any act of sexual violence upon a woman, Child Marriage also has specific health consequences that mandate special attention.

The vicious cycle of Fertility and Sterilisation

A study conducted by NCBI in 2009 suggests that a significantly larger number of women in India married as minors are less likely to use contraception in their first year of marriage (thus leading to higher fertility), when compared to women who married as adults . They have limited or no access to contraception and also displayed higher incidence of rapid repeat childbirths, higher unwanted pregnancies and hence, higher rates of pregnancy terminations (which has health complications of its own). Furthermore, women who have undergone multiple childbirths at a young age are also more likely to get sterilised. Approximately, one in ten women reporting both child marriage and sterilization (9.7%) were sterilized prior to age 18 years. [7]

Thus, child marriage has considerable immediate and long-term impact on the reproductive health of women’s bodies, often causing permanent damage to their health.

Higher Rates of Death at Childbirth

Young girls are at greater risk of death at childbirth than older women. The data from the International Centre for Research on Women shows that girls who are younger than 15 years are five times more likely to die in childbirth than women who are in their 20s. Pregnancy is seen consistently to be one of the leading causes of death for girls ages 15 to 19 worldwide.[8]

Premature labour, Still Births children and New Born Deaths

UNICEF estimates that rates of still births and new-born deaths are 50% higher among mothers under 20 than in mothers who give birth in their 20s. [9] Child marriage often entails a very violent introduction into sexual relations, which can cause long-tern health issues for women.

Obstetric Fistula

This is a dangerous medical condition in which a fistula or a hole develops between the rectum and the vagina or the bladder and the vagina, due to severe or failed childbirth, when proper medical care is not given. Young mothers are consequently at much higher risk of developing this otherwise-preventable condition. A report by the Ministry of Women and Child Development shows that as of 2013 over two million girls and young mothers are affected by this complication in India.[10]

Risk of HIV and other Sexually Transmitted Diseases

Since child brides are often married to older, sexually experienced men, they are also at risk of being affected by sexually transmitted diseases.

Thus Child Marriage is an act of gender violence with severe health consequences, which also has myriad social implications. Marrying as a minor often stultifies one’s education, meaning not just abrogated mental growth but also implying financial dependence on the husband, thus facilitating further oppression of women who are married off before adulthood.

While eradicating the evil of child marriage has been an integral part of the government’s plans- it is a part of the current 12th Five Year Action Plan, the National Population Policy 2000, the National Youth Policy 2003, the National Adolescent Reproductive and Sexual Health Strategy and the National Plan of Action for Children 2005- a lot still needs to be done. Schemes such as the Rajiv Gandhi Scheme for Empowerment of Adolescent Girls (SABLA) aim at eradicating the practice, but as government estimates show, the incidence of child marriage in India has gone down by only around 5% between 1995-96 and 2005-06. This is proof of how much more needs to be done, to increase social awareness and eradicate this practice.

[1] Nivedita Menon. “Rights, Bodies and the Law: Rethinking the Feminist Politics of Justice.”. Gender and Politics in India. New Delhi: OUP, 1999. 262-291.

[2]Prohibition of Child Marriage Act, 2006 (PCMA).  http://wcd.nic.in/cma2006.pdf , accessed in November 2014.

[3] ‘Child Marriage in India: Achievements, Gaps and Challenges’. HAQ: Centre for Child Rights. http://www.ohchr.org/documents/issues/women/wrgs/forcedmarriage/ngo/haqcentreforchildrights1.pdf

[4] ‘Violence Against Women’, Media Center, Updated on October 2013, accessed in November 2014. http://www.who.int/mediacentre/factsheets/fs239/en/

[5] Cf. ‘National Strategy Document on Prevention of Child Marriage, Ministry of Women and Child Development.   http://wcd.nic.in/childwelfare/Strategychildmarrige.pdf (page 1) Data http://www.unicef.org/protection/files/Progress_for_Children‐No.8_EN_081309(1).pdf

[6] Independent Thought vs. Union of India (W.P. Civil 382 of 2013).http://www.ithought.in/download/2014/PIL-Short-Note.pdf

[7] Donta Balaiah, Anita Raj, Niranjan Saggurti,Jay G. Silverman. ‘Prevalence of Child Marriage and its Impact on the Fertility and Fertility Control Behaviors of Young Women in India’. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2759702/

[8] Cf. ICRW, http://www.icrw.org/child-marriage-facts-and-figures

[9] WHO media centre: ‘Child marriages: 39 000 every day’. http://www.who.int/mediacentre/news/releases/2013/child_marriage_20130307/en/

[10] ‘National Strategy Document on Prevention of Child Marriage . http://wcd.nic.in/childwelfare/Strategychildmarrige.pdf

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Mouli Banerjee is currently a fellow with PRS Legislative Research’s Legislative Assistants to Members of Parliament programme. A post graduate in Literature from Delhi University, Mouli is a proud Feminist and LGBTQ rights supporter. 

Gender Violence:The Health Impact – Getting Gender Violence on the Public Health Agenda

by Anupama Srinivasan

The impact of gender violence – and specifically violence against women – extends beyond what a girl or woman endures today, tomorrow or three months from now. Gender violence affects an individual’s ability to go to school, to enter into a relationship with someone of her/his choice, to go out to work, to earn an income, to use public transport and to be financially independent. The threat of violence means that a girl may be withdrawn from school by her parents; that women may lead lives of fear, placing constraints upon their own mobility and that of other girls and women in the family. Most of all, gender violence denies an individual the right to lead a healthy life, free of injury, illness and disease.

In this journey from violence and trauma to (hopefully) healing, healthcare providers – doctors, nurses, hospital administrators, community volunteers – are what the NGO world likes to call ‘key stakeholders’. There is considerable evidence to show that healthcare providers can play a crucial role in responding to gender violence, not just in the provision of health services but also in collecting data on prevalence, risk factors and health consequences; in informing polices to address GBV and in preventing violence[1].

But the fact is, in India, few hospitals (whether in the public or private sector) have in place a comprehensive response system that helps them to identify and support women who have experienced gender and sexual violence. This is despite the fact that globally, gender violence is recognised as a legitimate public health issue, with both immediate and long-term consequences for the health and well-being of women. Violence can potentially impact a woman’s physical, mental, sexual, reproductive and maternal health and ironically, also restrict her access to health care.

Impact of violence on health

VAW Health Impact

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

Rape, domestic violence and intimate partner violence are particularly insidious for women’s health. For those who face abuse at home regularly, severe abrasions, bruises, broken and dislocated bones as well as burn injuries are not uncommon. Rape can and often does result in unwanted pregnancies, which in turn can lead to unsafe abortions as well as, potentially, subsequent infertility.

Women who are raped are vulnerable to HIV and AIDS. Equally common, but far less publicly discussed are sexually transmitted infections, urinary tract infections, genital injuries and pelvic inflammatory disease. Women are often too ashamed or embarrassed to seek help for any pain or injury related to the ‘private’ parts of their bodies; as a result, these infections can remain both undiagnosed and untreated. In addition, women who have been raped (whether by strangers or partners) can develop an aversion to sex, which they are often reluctant to disclose to anyone, including and especially their husbands. This can, in turn, become triggers for a cycle of violence including marital rape and intimate partner violence.

The long-term impact of gender violence is far more nebulous. Recurring anxiety, increased use of alcohol or other forms of substance abuse, eating disorders, frequent menstrual pain, chronic headaches, fatigue, disturbed sleeping patterns, depression and post-traumatic stress disorder or PTSD are all potential mental health consequences of gender violence. Given the dual stigma associated with both mental illness and sexual violence, women are even less likely to seek medical or psychological support, with distressing long-term results.

Forced and early marriages of both boys and girls also result in several health complications that go unacknowledged by families. Young girls, if married before the age of 18, have little knowledge about sex, the threat of STIs or HIV and AIDS. They also have little negotiating power for contraception use. Inevitably, the earlier a girl is married, the younger she is when she gives birth to her first child. And the more likely she is to have more than her fair share of children, with a multitude of long-term consequences for her own health.

Health sector response to gender violence

Over the last few years, I’ve been part of several training programmes for students at different nursing colleges. The objective of these programmes was to help these young women, mostly between the ages of 17 and 25, understand the role they could play as nurses. After all, nurses are often the first point of contact for those who have experienced violence and require care or treatment for themselves or their children. Worryingly – but unsurprisingly – we found that this was the first time these young women had had an opportunity to discuss either gender or sexual violence; several of them were hesitant to even use the words ‘rape’ or ‘sexual harassment’. This experience illustrates a genuine gap in India’s response to gender violence – inadequate training for healthcare professionals.

The irony is that abused women seek and receive more health care than those who have not experienced violence in their lifetime. The public and private health care system in a country therefore can and must play a vital role in recognising, recording, responding to and documenting instances of gender violence.

Right from the moment a woman enters a health facility with a violence-inflicted injury (irrespective of the severity), every department in that facility has a specific responsibility. This includes doctors on duty at the emergency ward, nurses, gynaecologists, obstetricians, forensics specialists, counsellors, psychiatrists and psychologists. In such cases, their job does not end with merely offering the woman the necessary treatment. They must, first of all, learn to recognise gender violence; equally, they must remember that a woman may seek health care for her injuries, but most often, will not choose to disclose an experience of violence. They must know how to respond to a woman who has been raped or abused, by choosing the right words. What can they say? What should they not say? They must understand their role in helping women seek justice through meticulous and sensitive documentation.

In other words, responding to gender and sexual violence is no ordinary or easy task. It requires knowing how to use a rape kit so as not to cause any further trauma. It requires an understanding of the complexities of violence and the emotional impact it has on those who experience it. It requires a non-judgemental attitude; it is not, for instance, the health worker’s responsibility to verify or question the authenticity of an allegation of sexual violence. It demands discretion and respecting an individual’s confidentiality. It needs, therefore, both the right skills and the correct attitudes.

VAW Health Workers

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

The guidelines and protocols exist. In 2003, the World Health Organisation (WHO) published ‘Guidelines for medico-legal care for victims of sexual violence’, outlining the roles and responsibilities of the health sector, particularly in treating rape victims.  It draws attention to the range of services needed, including pregnancy testing, emergency contraception, STI services and psychosocial counselling. It emphasises the responsibility of health care professionals in gathering evidence that can help identify and punish a perpetrator.

In 2013, the WHO published a new set of clinical and policy guidelines on “Responding to intimate partner violence and sexual violence against women”.  At the Sixty-sixth World Health Assembly held in May last year (2013), seven governments – Belgium, India, Mexico, Netherlands, Norway, United States of America, and Zambia – declared violence against women and girls “a major global public health, gender equality and human rights challenge, touching every country and every part of society”.

In India, CEHAT has done pioneering work on health sector responses to sexual violence and assault. Last year, the Government of India issued its own set of guidelines, developed by the Ministry of Health and Family Welfare on medico-legal care for survivors/victims of sexual violence.

All these documents are potential blueprints, waiting to be included in the code of conduct and practices of private hospitals and clinics that operate throughout the country. They are also waiting to be incorporated into medical and nursing college curricula.

The idea that someone who has been raped is shuttled back and forth between the police and the healthcare system is hard to accept. And really, why should we accept it? The act of violence, whether rape or domestic violence or sexual assault, is unjust in the first place. The lack of proper response mechanisms to support someone who has experienced this violence only accentuates the ‘unjustness’ of the situation.

It is well past time to put these guidelines into practice and to move from words to action.

[1] Violence against Women: The Health Sector Responds. WHO (2013). Accessed at http://www.who.int/reproductivehealth/publications/violence/NMH_VIP_PVL_13_1/en/

NB: An earlier version of this post appeared in The Alternative.

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Anupama Srinivasan works on issues related to public health and gender. She’s been Programme Director of the Gender Violence Research and Information Taskforce at Prajnya since 2010. She can be contacted at anupamasrinivasan.prajnya@gmail.com

Gender Violence:The Health Impact – A Blog Symposium

by Anupama Srinivasan, Programme Director, GRIT Prajnya

One of the significant aspects of the Prajnya 16 Days Campaign against Gender Violence is the creation of an indexed source of online material that serves as a compendium of different perspectives on a given issue. This year we have put together a series of blog posts that address the health impact of gender violence and makes the case for getting gender violence onto the public health agenda. Over the next 16 days we will share a series of posts that examine different aspects of the health impacts of gender violence, that reinforce the various responsibilities that healthcare providers have and draws attention to the different protocols that exist. Please read and please share!

This is Prajnya’s third Blog Symposium. The first one was Violence on the Page in 2012 and the second, Unspeakable Inequalities in 2013.