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/

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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.

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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.

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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 – 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