Preventing and managing violence against women in IndiaBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f229 (Published 11 January 2013) Cite this as: BMJ 2013;346:f229
In 2011, 24 206 cases of rape were reported in India, and an Indian nationwide survey showed that more than a third of all women aged 15-49 years had experienced physical or sexual violence at some point.1 Most women (85%) who experienced sexual violence told nobody, and only 8% ever sought help. Sources of help typically included family and friends. Institutional sources such as the police, medical professionals, and social organisations seemed to be the last resort, approached by less than 5% of women facing violence.2 The real picture may be even worse because of under-reporting and a social structure that normalises violence in women’s lives. These statistics beg questions about the systems in place to prevent violence against Indian women and to offer appropriate support. The recent violent gang rape of a paramedical student in a moving bus in New Delhi and her subsequent death have resulted in widespread outrage throughout India.3 However, it is crucial that this should propel change beyond punitive measures against the perpetrators in this particular case and in the direction of ensuring that systems are in place to offer appropriate and accessible care and support to women who face violence.
In 1996, the World Health Assembly recognised prevention of violence as a public health priority and called for urgent measures to eliminate violence against women.4 The United Nations Millennium Declaration avowed to combat all forms of violence against women by promoting equality between the sexes and empowerment of women as one of the eight millennium development goals.5 Prevention of gender based violence encompasses interventions at three levels. Primary prevention seeks to prevent perpetration by targeting root causes such as inequality between the sexes, social norms, parenting practices, and substance misuse. Secondary prevention includes immediate response to survivors through services such as medical treatment, counselling, protection, and legal assistance. Tertiary prevention encompasses long term responses directed at rehabilitation and reintegration of survivors and perpetrators.6
Studies in the public health sector in India have documented that doctors tend to prioritise their forensic role when responding to survivors of sexual assault over their role in providing appropriate care for the victim.7 8 Inadequate training and prejudiced beliefs result in hesitancy and insensitivity in dealing with victims. Consent for medicolegal procedures is often reduced to a formality that documents the patient as being either “willing” or “not willing” to undergo examination as a whole, with no option to refuse any part of the examination or police notification. Hospitals lack uniform treatment protocols and policies for prioritisation of services, privacy, role of staff, and interface between departments and external agencies. As such, inconsistent treatment, delays, forced admission, and multiple referrals are common. Provision of psychosocial support is largely absent. In the absence of standard guidelines for the collection of forensic evidence, inappropriate samples and inaccurate documentation may undermine the presentation of a case in court.7 8 9
The United Nations Convention on Elimination of all Forms of Discrimination against Women recognised that violence impairs women’s human rights, including the right to the highest standard attainable of physical and mental health. India, having ratified the convention, is legally bound to put its provisions into practice. These include measures to overcome all forms of gender based violence; laws that offer adequate protection to women and respect their integrity and dignity; support services that include refuges, specially trained health workers, rehabilitation, and counselling; effective complaints procedures and remedies including compensation; and ensuring that public officials are not prejudiced against women.10
Developments in Indian rape laws have largely been catalysed by women’s movements and, sadly, often only after public uproar over horrendous cases such as the recent gang rape in Delhi.
In a landmark judgment in 2009, the Delhi High Court for the first time recognised the need for care and healing of survivors and emphasised the collective responsibility of multiple agencies. It laid down guidelines for police, hospitals, child welfare committees, and courts. It also led to the establishment of crisis intervention centres to offer legal counselling and aid. The use of sexual assault forensic evidence kits was mandated at all public hospitals. A separate room was to be allocated to ensure privacy during examination.11 After a directive by the Supreme Court in 1994, the National Commission for Women evolved a scheme for financial assistance and support services for rape survivors. This scheme was to be implemented from 2010; however, bureaucratic procedures still stifle its realisation.12
Standard templates for forensic examination have been developed by the Maharashtra and Delhi state governments and the Indian Medical Association. These, however, continue to refer to the “moral character” of a woman by requiring doctors to comment on the size and laxity of the hymen and the finger test indicating “habituation to sexual intercourse.” These practices have been proved redundant by science, are prohibited by Indian law, and violate the woman’s dignity and rights.13 The Criminal Law (Amendments) Bill, 2012, widens the scope of the offence of sexual assault. However, the bill fails to deliver on guidelines for medical examination and care of survivors.14
It is clear that recent changes continue to focus on the forensic role of doctors, rather than on their remit to provide comprehensive care to survivors. Comprehensive and sensitive care must deal with the medical, legal, and psychosocial needs of the survivor from the first point of contact through to the final stages of recovery and reintegration.15 Although training and protocols may lead to some change, a “systems approach” is needed to achieve broad reforms in health organisations. The professional culture needs to be reoriented towards convincing health professionals that violence against women is a health concern and that responding to it is a part of their job.16 A Mumbai based non-governmental organisation, Centre for Enquiry into Health and Allied Themes (CEHAT), has been engaging with the public health system to institute such systemic change at the practice and policy level, and it has formulated guidelines for the Indian healthcare context.17 Integration in national policy remains the next challenge.
Cite this as: BMJ 2013;346:f229
Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; AJ was employed as research officer at CEHAT in Mumbai in 2011-12 and worked on health system interventions for sexual assault survivors.
Provenance: Commissioned not peer reviewed