Consent, not culture, should drive ‘marital rape’ debate

In the last few years, there has been a lot of talk in India about sexual violence, especially stranger rape. Starting with the December 2012 gangrape of Jyoti Singh, the discourse on ‘safety’ and ‘protection’ of women has taken on several dimensions. There are apps that can alert your family if you’re in danger, clothes that make your rapist’s job difficult. There are calls for increased policing, for cutting down on night shifts for women, for not letting women use cell phones to prevent rape… The list is endless. And most items on the list are problematic, because these ‘good intentions’ come from a very flawed understanding of the problem.

Screen Shot 2016-03-11 at 10.41.43 am

Screenshot of written reply given by Minister of Women and Child Development in Rajya Sabha on March 10, 2016. The reply is copied word-for-word from an earlier reply to a different question on marital rape, given by the Ministry of Home Affairs in April 2015.

And it is this same lack of understanding that lies at the root of the Govt’s latest reply in Parliament on maritalrape. “It is considered that the concept of marital rape, as understood internationally, cannot be suitably applied in the Indian context due to various factors e.g. level of education/illiteracy, poverty, myriad social customs and values, religious beliefs, mindset of the society to treat the marriage as a sacrament, etc.,” Union Minister Maneka Gandhi said in a written reply on March 10. This is the entirety of the Minister’s reply on the issue of marital rape. (It’s also exactly the same reply given by the Ministry of Home Affairs to another question on marital rape back in April 2015, so at least, they have been completely consistent in their stand!)

Meanwhile, the Govt is yet to decriminalise consensual gay sex — or indeed any ‘unnatural’ sexual activity including anal sex, oral sex, and the whole gamut of sexual activity that isn’t penis-in-vagina intercourse. While a curative petition is waiting to be heard in the Supreme Court, the Govt has, at the latest instance, refused to take a stand on the issue.

As many have pointed out, right now in India, rape is legal but consensual sex isn’t. And the reason for this is our understanding of rape itself: ‘Indian rape’ is not about consent. It’s not about the mental and physical trauma that the victim undergoes. Instead, it is about the ‘sexual purity’ of a woman, and the honour of her family. Anything that takes away either is wrong — and therefore, as members of the Home Affairs committee said back in 2013, “if the marital rape is brought under the law, the entire family system will be under great stress and the Committee may perhaps be doing more injustice.”

By corollary, ‘Indian sex’ isn’t about consent either. Nor is it about mutual pleasure. Sex within a marriage is about duty, honour and reproduction for a woman. Any sex outside of this definition is not recognised as sex at all, and automatically becomes either ‘unnatural’, or ‘rape’.

While the Minister’s reply in Parliament is infuriating, not just for the views there but also the absolutely flippant nature in which they were presented, outraging about just her, or just this government will not help much. The political class feels that “marital rape has the potential of destroying the institution of marriage” and society doesn’t feel differently. The challenge before civil society and liberal media right now is to shift the debate away from ‘culture’, and steer it towards consent, or the lack of it. The challenge is to stop focusing on ‘family honour’, and start focusing on the physical autonomy of adult women.

Until that happens, until our euphemisms for rape, in all languages, continue to revolve around ‘loss of chastity’, rape and sex will continue to come with unnecessary prefixes.

See Also: Gender Violence in India Report 2014: Rape

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Gender Violence in India Report 2014: Rape

The World Health Organization defines rape as ‘physically forced or otherwise coerced penetration … of the vulva or anus, using a penis, other body parts or an object’.[1] Rape is a subset of sexual assault, which is defined as any sexual act (including but not limited to penetration or intercourse) committed using coercion or without the victim’s consent.[2] People of any gender can be victims of rape and sexual assault, but the majority of victims are women. The Sage Publications Multimedia Encyclopedia of Women in Today’s World notes that most legal definitions of rape involve sexual penetration through force and without consent. The Sage entry, however, also acknowledges that there remains ‘widespread disagreement regarding the meanings of “penetration,” “force,” and “consent”’; definitions and application of the laws on rape vary from country to country, and even from jurisdiction to jurisdiction within a country.[3] Rape victims may thus be left to seek justice amid confusing laws, or be faced with sceptical law enforcement personnel who doubt their claims and experiences.

Another issue related to rape and sexual assault is that of ‘victim blaming’: holding victims of sexual assault responsible for the rape or assault because of their attire, appearance or actions. In India, there have been several documented cases of victim-blaming by politicians, spiritual leaders, lawyers, police officers, and even women’s commission members.[4] A pervasive victim-blaming culture can deter women from reporting rapes, can cause them to fear further victimisation at the hands of law enforcement, and can make it difficult to successfully prosecute those rapes that are reported.

Feminists and advocates combating violence against women have argued that acts previously not recognized as rape should in fact be included in legal definitions. For instance, many countries have included an exception for marital rape, either previously or in current laws, stating that intercourse between a husband and wife cannot be deemed rape regardless of whether one party did not consent.[5] Advocates have also argued against the notion that ‘in order for an encounter to count as rape, the victim must have displayed “utmost” (or even any) physical resistance.[6] Nevertheless, ambiguity remains both in many legal definitions of rape and in enforcement of those laws.

The problem of rape is often compounded by widespread misunderstandings about the nature and incidence of rape and sexual assault. Many believe, for instance, that perpetrators are usually strangers to their victims, that women must have been ‘asking for it’ by behaving promiscuously or going out alone at night, or that lack of overt physical resistance implies consent.[7] In fact, many if not the majority of perpetrators are known to their victims; rapes can occur at any time of day in virtually any context, not just when a woman is along at night; and victims may be unable to resist or choose not to struggle out of fear of even greater violence.

The issue of rape in India has garnered much greater national and international attention in recent years, in large part due to the 2012 Delhi gang rape case that spurred mass protests and an international outcry.

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2012 Delhi Gang Rape: A Case Study

On the evening of December 16, 2012, a 23-year-old physiotherapist and her male friend caught a bus home after seeing a movie in a Delhi suburb. The six men on the bus, including the bus driver, began to taunt the pair for being out late together. The man, to protect his friend, tried to stop the teasing, upon which the situation turned violent. The man was beaten with an iron rod and gagged, while the woman was dragged to the rear of the bus, brutally raped and beaten repeatedly by the six men over the course of several hours. Finally, the men threw the two victims out of the moving bus, leaving them on the side of the road.[8]

The pair was taken to a hospital, where the man began to recover from his injuries. The woman, however, remained in critical condition for several days before dying from her injuries in a Singapore hospital on December 29, 2012.[9]

 

This incident became a watershed in spurring discussion and action on violence against women in India. It provoked national and international outcry over the status of women in India, prompting the Indian government to re-evaluate its procedures for the treatment, prosecution and compensation of gender violence. The Delhi gang rape case catalysed numerous mass demonstrations and increased activism around gender violence in general and the legal system’s handling of it in particular.[10]

In response to public pressure for a speedy trial, the Delhi High Court in December 2012 approved the creation of five fast-tracked courts to prosecute rape and sexual assault cases. It was in one of these courts that five of the men accused of the gang rape were prosecuted on charges of kidnap, rape, murder, attempted murder and destruction of evidence. The sixth man, a minor at the time of the attack, has been prosecuted in the juvenile court system.[11]

In March 2013, one of the accused committed suicide in prison while still on trial. The juvenile offender was sentenced to three years in a reform centre. The remaining four were convicted; the court issued death sentences in all four cases.[12]

In March 2014, the Delhi High Court upheld the verdict of the death sentence for all four convicts. As of mid-July 2014, the execution was stayed pending an appeal by the lawyers of the accused, who alleged that the trial had not been conducted in a ‘free and fair’ manner.[13]

In a wider response to the issue, the national government and state governments of India set up various commissions to better investigate violence against women. On December 22, 2012, the national government commissioned a judicial committee headed by former Chief Justice of India J. S. Verma, to investigate the legal framework and precedents regarding the prosecution of sexual assault as well as to make recommendations for amendments to criminal law. The Justice Verma Committee appealed to lawyers, the non-profit sector, women’s groups, the civil sector and the general public for their input and suggestions.[14] The report, released in February 2013, points to failures of government institutions and the police in recognizing and prosecuting sexual assault in a timely and constitutional manner.[15]

In April 2013, based on the recommendations given by the Justice J. S. Verma Committee, President Pranab Mukherjee gave his assent to the Criminal Law (Amendment) Act, 2013, which made changes to the Indian Penal Code and Indian Evidence Act on laws related to sexual offences.[16]

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Know the Law

The Criminal Law (Amendment) Act, 2013, introduced various amendments to existing laws on rape and sexual assault in the Indian Penal Code (IPC). The Delhi gang rape case and the resultant public outcry were a powerful impetus in amending the laws. As Indian law stands today, the Act describes rape explicitly and exclusively as committed by male perpetrators against female victims. While this does encompass the majority of rape cases, it does not account for rape that occurs between other victim-perpetrator combinations, such as the rape of a man by another man.

Following the amendments introduced by the Criminal Law (Amendment) Act, 2013, Section 375 of the IPC defines rape as non-consensual intercourse, penetration using the penis or ‘any object or a part of the body’, or oral intercourse.[17] The Act also specifies circumstances where consent may be nominally given but not valid, such as: consent obtained through coercion or threats; consent obtained by falsely impersonating the victim’s husband; and consent from a victim ‘unable to understand the nature and consequences’ of what she is agreeing to due to ‘unsoundness of mind or intoxication’. When a victim is below 18 years of age, penetration or intercourse is considered rape regardless of whether consent was given.[18]

The law specifies that mere lack of physical resistance is not sufficient to be regarded as consent. However, it also states that consent may be given ‘by words, gestures or any form of verbal or non-verbal communication’, creating potential ambiguities in determining when a woman has consented to a given sexual activity and possibly making it more difficult to prosecute rape complaints.[19]

Section 376 states that rape is punishable by imprisonment of at least seven years and up to a life sentence, plus a fine.[20] In certain cases, perpetrators are required to receive harsher sentences, such as when the perpetrator is a police officer, public servant or member of the military; when he holds ‘a position of trust or authority towards the woman’; or when the victim is pregnant, disabled or a minor. In these situations, the minimum sentence is ten years, with the possibility of a life sentence, plus a fine.[21] Section 376A prescribes a minimum sentence of twenty years when a perpetrator commits rape or sexual violence that ‘causes the death of the woman or causes the woman to be in a persistent vegetative state’,[22] while under Section 376D, a perpetrator in a gang rape faces a minimum sentence of twenty years, up to life imprisonment, plus a fine.[23]

The Criminal Law (Amendment) Act, 2013, has faced criticism for ignoring the Verma Committee’s recommendations on a number of issues; for example, the Act has raised the age of consent from 16 to 18, and has failed to make changes to the Armed Forces (Special Powers) Act, which currently makes it more difficult to try members of the armed forces for gender-based crimes[24]. The Act also includes an exception for marital rape, stating that ‘sexual intercourse or sexual acts by a man with his own wife … is not rape’.[25] This means that, under Indian law, marital status takes precedence over lack of consent in determining rape and sexual assault cases. The Criminal Law (Amendment) Act, 2013, does criminalise rape committed by a husband against his wife when they are ‘living separately, whether under a decree of separation or otherwise’, and prescribes a sentence of between two and seven years’ imprisonment, plus a fine.[26] For the majority of women assaulted by their husbands, however, there is no legal avenue for a criminal prosecution. The only legal remedy available to wives is the Domestic Violence Act, 2005, which is a civil rather than criminal law that provides for domestic violence reporting mechanisms and monetary compensation for victims.[27] It does not provide for punishment of offenders. Women’s advocates have argued that the marital rape exception prevents India’s criminal laws from adequately protecting women and effectively legalises countless cases of rape and abuse that occur within marriages.

Keeping Count

The National Crime Records Bureau (NCRB) keeps track of cases of rape reported under Section 376 of the Indian Penal Code. The NCRB reported 33,707 cases of rape in 2013, an increase of 35.2% from 2012 (24,923 cases).[28] Although many rapes and sexual assaults are not reported, reports of rapes have increased in recent years as more victims have stepped forward. It is possible that growing public attention towards the issue has emboldened more women to seek justice; it has also been suggested that the actual incidence of rape is increasing, contributing to the growing number of reports.[29] One estimate suggests that in India, a woman is raped on average every 20 mintues.[30]

Table 1 and Figure 1 show the number of rape cases reported between 2009 and 2013 according to the NCRB data.

Table 1: Number of Reported Rape Cases, 2009-2013[31]

Year 2009 2010 2011 2012 2013
Number of reported rape cases 21,397 22,172 24,206 24,923 33,707

Figure 1[32]

Rape I

Note that the NCRB data only includes cases that fall under the Indian Penal Code definition of rape, not other forms of sexual assault that do not meet that definition.

The actual incidence of rape and sexual assault is difficult to determine with accuracy, as experts agree that the majority of rapes worldwide likely go unreported. Estimates of the proportion of unreported rapes vary from 54%[33] to 90%[34] of all rapes.

Of the rapes that are reported, the majority do not result in a successful prosecution. As of 2013, as many as three fourths of the perpetrators of the 24,206 rape cases brought forth in 2011 were either yet to face trial, had been acquitted or had the charges dropped.[35] Many rape and assault victims may decide not to report the assaults because of the fear of indifference or even retaliation from police officers and other law enforcement personnel. Victims have reported being asked demeaning questions by police, feeling as if the questioning procedures were like a second assault, waiting for hours to receive medical attention and being pressurized to marry their attackers or withdraw their complaints.[36]

[1] Jewkes, R., Sen, P. & Garcia-Moreno, C., ‘Chapter 6: Sexual Violence’, World Report on Violence and Health, ed. Krug, E. G. et al, 2002, p. 149, http://whqlibdoc.who.int/hq/2002/9241545615.pdf, accessed 1st December 2014.

[2] Jewkes, R., Sen, P. & Garcia-Moreno, C., ‘Chapter 6: Sexual Violence’, p. 149. See above note 1.

[3] Stange, M. Z., Oyster, C. K. & Sloan, J. E., ‘’Rape, legal definitions of’, The Multimedia Encyclopedia of Women in Today’s World, 2011, http://study.sagepub.com/sites/default/files/Ch09_Legal%20Definitions%20of%20Rape.pdf, accessed 1st December 2014.

[4] ‘NCW Notice to Mirje over Rape Remark’, The New Indian Express, 29th January 2014, http://www.newindianexpress.com/nation/NCW-Notice-to-Mirje-Over-Rape-Remark/2014/01/29/article2026716.ece, accessed 11th December 2014; Hullinger, Jessica, ‘India’s Deadly Gang Rape: 6 Troubling Attempts to Blame the Victim’, The Week, 9th January 2013, http://theweek.com/article/index/238542/indias-deadly-gang-grape-6-troubling-attempts-to-blame-the-victim, accessed 11th December 2014; Bhalla, Abhishek & Vishnu, G., ‘The Rapes Will Go On’, Tehelka Magazine, Vol 9, Issue 15, 14th April 2012, http://archive.tehelka.com/story_main52.asp?filename=Ne140412Coverstory.asp, accessed 11th December 2014.

[5] ‘Feminist perspectives on rape’, Stanford Encyclopedia of Philosophy, http://plato.stanford.edu/entries/feminism-rape/#CriWhaCou, accessed 1st December 2014.

[6] See above note 5.

[7] ‘Common myths about rape’, RapeCrisis, http://www.rapecrisis.org.uk/commonmyths2.php, accessed 1st December 2014.

[8] Bresnehan, S., Udas, S. & Ramgopal, R., ‘”Nirbhaya,” victim of India gang rape fought for justice’, CNN, 16 December 2013, accessed 2nd December 2014.

[9] ‘Delhi gang rape: Chronology of events’, The Hindu, 10 September 2013, http://www.thehindu.com/news/national/delhi-gang-rape-chronology-of-events/article5079321.ece, accessed 2nd December 2014.

[10] Bresnehan, S., Udas, S. & Ramgopal, R., ‘”Nirbhaya,” victim of India gang rape fought for justice’, CNN. See above note 8.

[11] ‘Delhi gang rape: Chronology of events’, The Hindu. See above note 9.

[12] ‘Delhi gang rape: Four sentenced to death’, BBC News India, 13th September 2013, http://www.bbc.com/news/world-asia-india-24078339, accessed 2nd December 2014.

[13] ‘Court puts off execution of two men convicted of 2012 Delhi rape’, Reuters, 14th July 2014, http://www.reuters.com/article/2014/07/14/us-india-gangrape-idUSKBN0FJ16P20140714, accessed 2nd Decemer 2014.

[14] Ed. Sanyal, P., ‘Recommendations of the Justice Verma Committee: 10-point cheat sheet’, NDTV, 24th January 2014, http://www.ndtv.com/article/cheat-sheet/recommendations-of-the-justice-verma-committee-10-point-cheat-sheet-321734, accessed 2nd December 2014.

[15] Justice (retd.) Verma, J.S., Justice (retd.) Seth., L, & Subramanium, G., ‘Report of the committee on amendments ot criminal law’, Justice Verma Committee on Amendments to Criminal Law, January 2013, http://www.thehindu.com/multimedia/archive/01340/Justice_Verma_Comm_1340438a.pdf, accessed 2nd December 2014.

[16] Denyer, S., ‘India gang rape prompts tough new laws on sexual assault’, The Guardian, 5th February 2013, http://www.theguardian.com/world/2013/feb/05/india-gang-rape-stricter-laws, accessed 2nd December 2014.

[17] Criminal Law (Amendment) Act, 2013, Ch. 2(9), http://indiacode.nic.in/acts-in-pdf/132013.pdf, accessed 8th October 2014. Sec. 9 of the Act inserts Sections 375, 376 and 376A-D into the Indian Penal Code. Section 375 defines ‘rape’.

[18] Criminal Law (Amendment) Act, 2013, Ch. 2(9), Sec. 375,. See above note 17. This section defines consent and lists circumstances in which consent may be given but not held to be legally valid.

[19] Criminal Law (Amendment) Act, 2013, Ch. 2(9), Sec. 375. See above note 17.

[20] Criminal Law (Amendment) Act, 2013, Ch. 2(9), Sec. 376(1). See above note 17. This section establishes sentencing rules for rape convictions.

[21] Criminal Law (Amendment) Act, 2013, Ch. 2(9), Sec. 376(2). See above note 17. This section lists circumstances in which a stronger sentence is required.

[22] Criminal Law (Amendment) Act, 2013, Ch. 2(9), Sec. 376A. See above note 17.

[23] Criminal Law (Amendment) Act, 2013, Ch. 2(9), Sec. 376D. See above note 17.

[24] ‘India: Reject New Sexual Violence Ordinance’, Human Rights Watch, 12th Febuary 2013, http://www.hrw.org/news/2013/02/11/india-reject-new-sexual-violence-ordinance, accessed 11th December 2014.

[25] Criminal Law (Amendment) Act, 2013, Ch. 2(9), Sec. 375, Exception 2. See above note 17.

[26] Criminal Law (Amendment) Act, 2013, Ch. 2(9), Sec. 376B. See above note 17.

[27] Protection of Women from Domestic Violence Act, 2005, Section 3, http://wcd.nic.in/wdvact.pdf, accessed 29th October 2014.

[28] ‘Chapter 5: Crimes against Women’, Crime in India 2013, NCRB, p. 81, http://ncrb.gov.in/CD-CII2013/Chapters/5-Crime%20against%20Women.pdf, accessed 26th September 2014.

[29] Special Correspondent, ‘Majority of rape cases go unreported: MPs’, The Hindu, 27th August 2013, http://www.thehindu.com/todays-paper/tp-national/tp-newdelhi/majority-of-rape-cases-go-unreported-mps/article5063089.ece, accessed 2nd December 2014.

[30] Bresnehan, S., Udas, S. & Ramgopal, R., ‘”Nirbhaya,” victim of India gang rape fought for justice’, CNN. See above note 8.

[31] ‘Chapter 5: Crimes against Women’, p. 81. See above note 26.

[32] Figure 1 was generated from the data in Table 1.

[33] Kark, M., ‘Understanding Indian and Pakistani cultural perspectives and analyzing US news coverage of Mukhtar Mai and Jyoti Singh Pandey’, University of North Texas Master’s Thesis, UNT Digital Library, p. 4, http://digital.library.unt.edu/ark:/67531/metadc271840/, accessed 2nd December 2014. Kark quotes a figure from the Rape, Abuse & Incest National Network (RAINN).

[34] Srivastava, M., ‘The iceberg of rape’, India Today, 17th June 2009, http://indiatoday.intoday.in/story/The+iceberg+of+rape/1/46911.html, accessed 2nd December 2014.

[35] Fisher, M., ‘India’s rape problem is also a police problem’, Washington Post, 7th January 2013, http://www.washingtonpost.com/blogs/worldviews/wp/2013/01/07/indias-rape-problem-is-also-a-police-problem/, accessed 2nd December 2014.

[36] Fisher, M., ‘India’s rape problem is also a police problem’. See above note 33.

*****

This series of posts were researched, drafted and edited by Divya Bhat, Shakthi Manickavasagam, Titiksha Pandit and Mitha Nandagopalan.

December 2014

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.

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/

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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.

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.

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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 – 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.

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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 – 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

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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

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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

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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.