Gender-based violence is a term used to denote harm inflicted upon individuals and groups, connected to normative understandings of their gender. Gender based violence is an umbrella term that is inclusive various heinous acts (punishable by law) that include rape, domestic violence, sexual harassment, acid throwing, reproductive coercion, female infanticide, prenatal sex selection, obstetric violence and mob violence. It also encomapsses harmful customary or traditional practices such as honor killings and dowry violence. The Indian framework assigns lawful protection against these heinous crimes only for women and children (boys and girls).
Medication examinations of survivors
Prior to Supreme Court’s judgement in 2000, the procedure for medical examination of rape victims was lax and doctors would proceed with the examination only after the request of the police. This made it necessary for rape victims to file an FIR before being able to get proper medical treatment. This attitude towards the rape victims was considered to be deeply unjust since it essentially ignored the survivors actual experience, focused instead only upon the procedural aspects and took away the survivors agency to have medical tests done or not. It was only in 2005, an amendment in Cr.P.C. with the insertion of 164A that made the medical procedure strict and clear. The Criminal Law Amendment Act, 2013, lays emphasis on examination, treatment both physical and psychological in addition to mere evidence collection that was the case earlier. Section 164A, Criminal Procedure Code says:
- The woman against whom the offence of rape has been committed shall be sent for medical examination within 24 hours of receiving the complaint.
- The medical examination shall be conducted with the consent of the victim or with the consent of a competent person on her behalf.
What is crucial to keep in mind is that beside medical consequences, such as sexually transmitted diseases or unwanted pregnancies, sexual violence, and rape in particular, may lead to long-lasting trauma and suffering. Sometimes this may take the shape of mental health disorders (such as depression, post-traumatic stress disorder, schizophrenia or bipolar disorder) whereas at other times it surfaces in less obvious ways such as shame, guilt, sleeping problems, difficulties in daily functioning and withdrawal.
Taking a sensitive approach
According to the World Health Organization, care for victims of sexual violence must be guided by the individual’s wishes and needs. The care should be provided sensitively in a coordinated and timely fashion to avoid the need for multiple service visits. Although this is the approach used in most developed countries, some research shows that the mental health needs of patients are often the least well met in low resource or conflict settings. In the Indian scenario, we do see guidelines and provisions for medico-legal care but it fails to address the need of mental health care comprehensively, as part of the medical examination. Guidelines were proposed by the Ministry of Health and Family Welfare in 2014 and cover the following: basic details and consent; identification marks; menstrual and vaccination history; history of incidence; general physical examination; examination of injuries; examination of genitals and orifices; collecting samples; urine samples; blood test and post-examination among the comprehensive examination guidelines. The ministry provision mentions: “Doctor’s first priority should be to provide first aid and treat bleeding injuries and address anxiety of the survivor/victim”.
Managing the mental health consequences
Provisions also state that emotional trauma from sexual violence can be tremendous. Doctors are mentioned as responsible to deal with survivors’ feelings of self blame and anger and provide the required emotional and psychological support. Survivors are recommended to be referred to professional counsellors for this purpose.
Some other available provisions that are applicable for rape victims / survivors includes the following, as outlined in the Diagnostic and Statistical Manual of Mental Disorders:
- provision of safe and empathetic environment so women could share their experiences;
- active listening, allowing for expression of emotions, distress, fright, guilt, shame, anger, depressive and anxious affect;
- allowing expression of personal views about events and distress, including cultural representations;
- assessing familial and social consequences;
- normalizing women’s reactions to reassure that most of the women who have undergone such violence are experiencing similar reactions;
- working on coping strategies; and
- working on acceptance and development of future perspectives and plans.
Some psychologically supportive provisions which are already in practice when it comes to medical examination of cases of sexual assault also include:
- A mental health practitioner or forensic professional is present during the physical examination of cases of sexual assault.
- Counsellors are present in the department in case of referral for psychological or emotional challenges.
- Mental health professionals are also present during the examination of children (minors).
- Both ethically and legally, a doctor cannot examine any survivor / victim without seeking their informed consent. Informed consent should be sought in a language that the survivor / victim understands.
- The entire procedure of examination, collection of evidence from body and genitals and treatment modalities available should be explained to the survivor / victim.
- Proper documentation of written informed consent should be taken after explaining the above procedures.
- Wherever barriers exist in terms of age, mental maturity, language, physical and mental disabilities, consent should be sought from legally authorized individuals such as parent/guardian or with the help of an interpreter, special educator, support person (whoever is applicable).
Some challenges within the medical sector
There are, of course still some challenges in with the way medical professionals are managing such cases. The guidelines by Ministry of Health and Family Welfare (2014) and the Mental Health Care Act (2017) both emphasize the training of medical health professionals in fundamental mental health but there is barely any evidence to show that this actually happens. In fact, there have been instances that do indicate that there is still a need for training and psychoeducation for medical health professionals in the realm of mental health.
It is impirtnat that there must be a psychiatric and psychological evaluation compulsorily present in liaison with the medical team when medical examination happens in order to early identify and treat mental health issues that are commonly prevalent among survivors of sexual violence. It is important to note that 80-90% of survivors of sexual assault develop a psychological or psychiatric problems and so mental health support must be available before, during and after the medical examination of survivors. The psychological well-being of the survivor is most important and that must be kept in mind and strictly cooperated with before and during any medical examination too. Finally, there is also a need for greater community mental health workers who can also act as the first line of help available to survivors.
It is clear that there is a need for a liaison-based professional relationship between the medical and mental health teams in order to address the medical and psychological needs of survivors of gender-based violence better than they are currently being managed.