The Supreme Court on October 31 criticised the two-finger test that continues to be carried out on survivors of sexual violence “to determine whether they are habituated to sexual intercourse” and said that doctors who conduct such an examination would be considered guilty of misconduct.

Justices DY Chandrachud and Hima Kohli said the test is rooted in a “patriarchal and sexist mindset”. The judges called it invasive and unscientific and that it also “re-victimises and re-traumatises” the survivor.

While the judgement deserves applause for explicitly stating that the two-finger test is medical misconduct, is the court’s position on this archaic test something new?

Legal, policy changes

Months after the gangrape and murder of a 22-year-old woman in New Delhi in 2012, there were a flurry of legal amendments to build a comprehensive gender-sensitive framework to respond to sexual violence against women.

The Criminal Law (Amendment) Act of 2013 made changes to Section 53A of the Indian Evidence Act to include the irrelevance of any information aimed to determine character or the previous sexual experience of the survivor. In April 2013, a Supreme Court bench of Justices BS Chauhan and Fakkir Mohamed Kalifulla held that the two-finger test violates the right of rape survivors to privacy as well as physical and mental integrity and dignity.

In the guidelines and protocol on the medicolegal care for survivors of sexual violence, 2014, the Union Ministry of Health and Family Welfare states that the test is not to be conducted on survivors. The guidelines also say that no comment is to be made about sexual experience or habituation to sexual intercourse as it has no bearing on a case of sexual violence.

Why then, almost a decade after its ban, do doctors still carry out this test? The fractured Indian medical education system can help answer this, partly.

Curricular issues in medical education

In 2019, after 21 years, the National Medical Council revised the undergraduate curriculum for the Bachelor of Medicine and Bachelor of Surgery degree.

But this was just old wine in a new bottle as the core content remained unchanged despite the many legal and policy advances made for the care of survivors of sexual violence

Medical systems have historically sought to control women’s bodies and this has resulted in the creation of medical knowledge that is deeply sexist. In part, it manifests as the multiple signs sought to assess virginity – size of vaginal introitus, or opening, laxity of vaginal walls, tags and tears in the hymen, gaping fourchette and more.

In fact, the competencies associated with sexual offences under the subject of forensic medicine and toxicology included “discussing the medico-legal importance of hymen” and “defining virginity”. This not only perpetuates gender-biased attitudes among future doctors, but is also in contradiction with the many legal amendments made before the development of the new curriculum.

In October 2021, following the directives of Madras High Court, the National Medical Council issued an advisory for all medical institutes and universities to adhere to scientific literature, government guidelines and court directives while teaching students about virginity testing.

An expert committee in August also drafted revised competencies explicitly stating how “signs of virginity”, including those of the two-finger test, are unscientific and discriminatory. It also includes teaching students how to appraise courts about the unscientific nature of the test, should they order it. The persistence of these tests despite frequent court rulings reiterating their ban, however, raises questions on whether these revisions are really operationalised in medical education.

During a study conducted by the Centre for Enquiry into Health and Allied Themes, forensic medicine and toxicology educators highlighted how textbooks are not updated with legislations or amendments made to laws, possibly leading to inaccurate and outdated information being conveyed to students, which in turn explains the prevalence of such practices. (The author of this article is associated with the Centre for Enquiry into Health and Allied Themes.)

In the context of sexual violence survivors specifically, it is seen that they are referred to tertiary care public hospitals, many of which do not use the prescribed government proforma for documenting the findings from medicolegal examination. How does one expect students to learn the correct practice if teaching hospitals do not practice it themselves?

Lack of gender perspective

For a profession that is about dealing with human beings, medical training in India places a lot of focus on viewing cases as a mere juxtaposition of pathologies. As far back as 2003, the World Health Organization had focused on training the health workforce in the social determinants of health, including gender.

It is critical that doctors appreciate gender as a system of power that influences vulnerabilities, health-seeking behaviours, doctor-patient relationships and consequent health outcomes. The two-finger test is one of many gender-biased practices that are still rampant in medical institutions in India.

The Centre for Enquiry into Health and Allied Themes, during its work with medical education in teaching hospitals, found a slew of clinical practices that raise concern – from the insistence of spousal or parental consent for abortion in cases of adult women to hesitation in mounting a clinical enquiry of violence.

The medical establishment should recognise the importance of developing competencies relating to comprehensive gender-informed practices, just as equally as those relating to aetiology – the investigation of what causes diseases – and the pharmacological management of diseases.

This is imperative to attain the goal of making medical education more “patient-centric and gender-sensitive”, as stated in the preamble of the recently introduced competency-based medical education.

Social scientists and gender experts have, for long, critiqued the field of medicine as androcentric, or male-centered. Incorporating perspectives from this rich body of knowledge could be the answer to ridding health systems of many gender-blind medical practices.

Incorporating social realities

While the Supreme Court judgement advised curricular reforms in medical schools to do away with the two-finger test, this might only act as a stop-gap solution to the larger problem of the lack of social perspectives in medical education.

Through the many trainings the Centre for Enquiry into Health and Allied Themes has conducted for educators, it found that medical education places disproportionate emphasis on the biomedical health paradigm, with no recognition of the social realities. The biomedical health paradigm assumes that an illness is caused only due to medical reasons.

Exposing students to sociocultural, ethical and legal issues surrounding medical practices like virginity testing, sex verification tests, assisted reproductive technologies, conversion therapies and more, can help create a more gender-informed cadre of health providers in the future.

While the introduction of an attitude-ethics-communication curriculum is a step in the right direction, there is an urgent need to operationalise its pedagogy and also include gender perspectives from medical humanities. Faculty development programmes should include training in topics such as the gendered social, ethical and legal aspects of medicine.

It is crucial that medical educators be open to unlearning and relearning from a myriad of stakeholders including social scientists, lawyers, civil society organisations and most importantly, the larger public.

Mukul Bhowmick is Senior Research Associate at the Centre for Enquiry into Health and Allied Themes (CEHAT), Mumbai. His Twitter handle is @drmukulbhowmick.

The author acknowledges comments and feedback from Sangeeta Rege and Amruta Bavadekar that shaped this article.