Madhura M Khanapur, an ophthalmologist, made her way into the chaotic outpatient department at the Bowring and Lady Curzon Hospital in Bengaluru, Karnataka. Its various departments are scattered across several buildings, some of which date back to the colonial era.

Khanapur walked through corridors where hundreds of patients jostled for space, a dozen medical students in white coats clamoured for a professor’s attention and nurses and peons wandered between departments. Doctors sat across patients in the ophthalmology department, which had four interconnected rooms. It was a frenzy of activity: consultations, eye tests, examinations, dilations.

Khanapur settled into her routine and began to listen in on some cases. She watched a junior doctor examine a female patient. Khanapur noticed that there was a moon-shaped blood clot under the woman’s eye. “Hey, what happened?” Khanapur said. “Did you fall or did someone hit you? Come on, you can tell us.”

The patient hesitantly responded that she had been hit by her partner. Khanapur’s hunch changed the trajectory of healthcare the woman received: after the check-up, she was referred to a Muktha centre, a consultation room next to the hospital’s casualty department. This is a kind of crisis centre found in certain government hospitals in Karnataka for survivors of gender-based violence, as part of a programme launched in 2021.

At the centre, staff conducted a safety assessment through a questionnaire, to understand the extent of threat to the woman. They then counselled her on precautions she could take to stay safe, gave her emergency contact numbers she could call in case she was in danger, and chalked out plans for safe spaces she could retreat to if the violence at her home peaked, such as her maternal home or a friend’s house. She was assured that her case would be kept confidential, and was advised to return for further counselling.

Karnataka opened Muktha centres in four government hospitals in Bengaluru and one in Chikkaballapur district in 2021. Key staff at these hospitals, including doctors and nurses, were first trained by forensic experts, social workers, psychologists and others; they then further trained others at their hospitals, to recognise signs of gender-based violence, and to provide healthcare and other support that is sensitive to the needs of survivors. In all, so far, around 400 hospital staffers, including 129 doctors and 227 nurses, have been trained under the programme.

Other states have set up similar hospital-based crisis centres, beginning with Maharashtra, which launched a programme called Dilaasa in 2000, and established its first centre in Mumbai’s KB Bhabha Hospital. The programme was spearheaded by the NGO Centre for Enquiry Into Health and Allied Themes, or CEHAT – it is currently present in 11 major hospitals run by the Municipal Corporation of Greater Mumbai, or MCGM. Data accessed by Scroll showed that the 11 Dilaasa centres in Mumbai, which have the ability to reach over 75% of Mumbai’s population, responded to 6,285 survivors of violence in 2022, or 17.2 per day.

Since then, CEHAT has been a technical partner in introducing variations of the Dilaasa model at the state level in Haryana, Kerala, Karnataka, Maharashtra, Meghalaya, and Goa. There have also been efforts by other nonprofits and civil society organisations to start local initiatives in Gujarat, Odisha, Jharkhand, and Bihar.

Junior doctors at the Bowring and Lady Curzon Hospital’s ophthalmology department. The Muktha programme trains doctors in various departments to spot signs of gender-based violence. Photo: Mahima Jain

The need for such programmes is evident from data on violence against women. Globally, one in three women have suffered at least one instance of physical or sexual violence. In India, 29% of women aged between 18 and 49 have suffered at least one instance of sexual or physical violence, and 32% of ever-married women have suffered at least one instance of spousal violence, according to the recent National Family Health Survey, labelled NFHS-5. Of the women who have experienced gender-based violence, 98% don’t seek healthcare because they fear that the matter will be reported to the police and due to the “absence of comprehensive medical care available in close proximity to vulnerable groups.” Only 2% of women who suffer violence ever seek help from a doctor or other medical professional, or a lawyer.

The WHO terms gender-based violence a public health crisis, and notes that healthcare providers are often the first – and sometimes the only – individuals the survivors come into contact with outside the family.

In a majority of cases, these personnel treat survivors’ injuries and symptoms without enquiring into deeper causes behind them. “You don’t ask why it happened, how it happened,” explained Sylvia Karpagam, an independent public health researcher and scientist. “Somehow doctors see it as outside their domain.”

But, Kiran Bhatia, formerly regional advisor with the United Nations Population Fund, noted, “Doctors need to look beyond the medical implications of violence.”

To ensure that at least those women who contact doctors and healthcare workers receive broader support to tackle the violence they face, it is essential that these personnel are trained to respond to such cases beyond simply treating them medically. spoke to over 30 counsellors, nursing staff, and doctors in eight public hospitals across Maharashtra, Karnataka, and Gujarat. These doctors and nurses – from various specialties, including obstetrics and gynaecology, psychiatry, emergency, general surgery, dentistry, and orthopaedics – were trained as part of initiatives to detect signs of gender-based violence in patients, provide first-line counselling, and referrals for further systemic support to them to deal with it.

Doctors told Scroll that their training had helped them offer support to survivors of different forms violence in cases that they might earlier have overlooked. “It is very important to have an integrated response,” Anisa Sayed, administrator at the Bhabha Hospital.

While women may visit all departments, Sayed said, the department of obstetrics and gynaecology, followed by casualty, play an important role in identifying survivors. This is also evident from data from Muktha. Since 2021, 40% of cases of gender-based violence were identified by the obstetrics and gynaecological departments, and 37% by casualty departments.

While these healthcare providers are not expected to rehabilitate survivors or resolve their problems completely, Sangeeta Rege, director at CEHAT explained, they help identify signs and symptoms of violence, provide an immediate therapeutic response, and build a survivor’s capacity to be able to access another service. “That’s really the common minimum plan for a health system,” Rege said.

This story is part of Common Ground, our in-depth and investigative reporting project. Sign up here to get a fresh story in your inbox every Wednesday.

Shraddha Bhone, a consultant and general surgeon at the Bhabha Hospital, explained that there were broadly two kinds of signs and symptoms of gender-based violence: those that were obvious and those that were subtle. “Some patients tell us if they were abused, but others do not,” said Bhone.

Even in cases where patients do not readily share information, doctors can look for several subtle signs and symptoms to detect violence, she explained.

To begin with, injuries that are inconsistent with a patient’s description of an incident are a clear indication of violence, said Bhone.

Bhaveshdan N Gadhavi, a medical officer at Radhanpur Sub-District Hospital, Gujarat, echoed this idea. The Radhanpur hospital is one of three secondary and tertiary hospitals in Patan district with hospital-based crisis centres set up by Society for Women’s Action and Training Initiative, or SWATI, an Ahmedabad-based nonprofit that works to strengthen the response of rural health systems to gender-based violence. “You’re saying that you fell a certain way, but the way I see it is different from the way you see it,” he explained, referring to the difference between a doctor’s understanding and a layperson’s. “I’m looking at an injury, you say it’s a cut, but it doesn’t look like that to me,” he added.

As S Prabhu, the head of the department of medicine, at Bowring, noted, “It’s not just a doctor’s job, it’s like a detective agency.”

Several doctors noted that repeated fractures or bruises, cigarette burns, shattered eardrums, broken teeth, and injuries to the jaw and cheekbones are signs that the woman was pushed or hit, burnt, slapped or punched.

The significance they ascribed to these injuries is consistent with NFHS data on violent attacks by husbands against their wives. According to this data, 25% of all husbands slapped their wives or ex-wives; 12% shoved them or threw objects at them; 10% twisted or pulled their hair; 8% punched, beat, kicked or dragged them; 2% choked or burned them; and 1% attacked them with a weapon.

Doctors at Bengaluru’s HSIS Gosha Hospital, which has a Muktha centre. Among the signs of violence that doctors look for are repeated fractures, cigarette burns and shattered eardrums. Photo: Mahima Jain

In some instances, patients themselves approach healthcare personnel to report violence. Such was the case with Nisha, a survivor of domestic violence in Mumbai, who is in her late thirties, and whom I met at a Dilaasa centre in the city. (Nisha is being referred to by a pseudonym for this story.)

After her marriage, Nisha said she suffered physical violence at the hands of her husband, who beat her often, didn’t support her financially, and cheated on her. In 2018, in a fit of rage, he threw the lid of a pressure cooker at her. The sharp edge of the lid pierced her thigh and left a deep wound. She was rushed to a government hospital in Mumbai.

Nisha recalled that her sister-in-law accompanied her to the hospital, and did not leave her side there, constantly intervening to answer the doctor’s questions. “If she had even left me for a minute, I would have told the doctors the truth, and asked to file a complaint,” said Nisha, who had to undergo surgery to treat the injury.

Khanapur explained that perpetrators or family members often accompany the survivors to the hospital and pressure them to remain silent.

In such situations, doctors told Scroll, they look for non-verbal cues and observe the relationship between the patient and the persons accompanying them. If they notice something incongruous, they either take such patients aside or ask the attendees to leave the room on the pretext that the patient needed to be physically examined in private.

Nisha, however, sought help of her own volition. Her initial medical report noted that the injury was an accident. The cooker lid or her husband were not mentioned. But when Nisha returned to the hospital for a follow-up, she learned about Dilaasa, and decided to seek more information about it. She visited the centre at the hospital, and spoke to staff, following which they took up her case, offered her counselling, a safety plan, and other forms of support. They continue to work with her, she said. She added that while there are many social and legal complexities to work through, the counselling and the attention given to her by the doctors and counsellors has helped her put an end to the physical violence.

“There are many times, I felt like I couldn’t live,” Nisha said, her voice quivering, and her eyes tearing up. “But after coming here, Dilaasa gave me the courage to live on. I feel like I have someone supporting me.”

In some cases, violence progresses much further before women reach hospitals. Bhone, who began working at Bhabha in 2009, recounted that the first case of gender-based violence that she encountered was at the casualty department at the hospital, when a woman was brought in with 90% burns. The patient’s husband had suffered burns on his hands too. The woman told Bhone that her husband had set her on fire. Bhone made a formal record of her statement, and a case was filed. Soon after, the woman succumbed to her extensive injuries.

In court, the lawyer defending the husband said that he had been trying to save his wife. The scars on his hands were proof, he reasoned.

Bhone testified that this couldn’t be the case. First, she argued, the burn patterns on the husband’s hands were consistent with the possibility that he had set fire to her. Second, she said, the victim’s statement was a dying declaration – under Section-32(1) of the Indian Evidence Act, such declarations can serve as crucial evidence courts. On the basis of these and other pieces of evidence the man was convicted.

Gadhavi, from Radhanpur, explained that women with burn injuries often tell him they sustained burns while cooking food or making tea. But these explanations are often inconsistent with the nature of the injuries. “If you spill it on yourself, it will only fall to a certain extent, either on your body or on your feet,” he said. “How will it fall on your breast or chest area?”

It is particularly crucial for doctors to scrutinise such cases closely given the grim statistics on burn incidents in India. According to estimates from the National Burns Programme, ten women die of burn injuries every hour in the country. One 2016 study found that of an estimated 1,40,000 burn-related fatalities annually, 65% are of women.

Doctors across the eight hospitals noted that they also have to look out for cases of poisoning in which women attempt to take their own lives, and investigate whether they were sparked by violence.

Here, too, data reveals a disturbing picture of women’s suffering. In 2020, of 44,498 suicide deaths among women, married women accounted for 63.1%, an analysis published in The Lancet in 2023 showed. Of these 50% of the women were housewives, and the leading reason for the suicides was found to be family problems.

Studies show that women commonly use drugs or chemicals, such as cleaning agents, in attempts to take their own lives. Chitra Joshi, former community development officer and counsellor at the Dilaasa centre in the Bhabha Hospital, noted that women who drink cleaning liquids or phenol in an attempt to end their lives sometimes claim they mistook it for water or milk. “You can take one sip by mistake, but if you are drinking an entire bottle it has to be deliberate,” Joshi explained.

She added, “When women come to the casualty, they say: I took the poison or overdose by mistake. They don’t say that it’s a consequence of someone hitting me or because of verbal abuse.”

In some cases, doctors and nurses explained, violence does not manifest in the form of physical injuries.

One afternoon in May, amidst the rush of patients, Asha Nadager, a senior nursing staff at Bengaluru’s HSIS Gosha Hospital, stopped to chat with a young woman in the corridor. The patient was barely 20 years old and was carrying an infant in her arms. She was alone, and her medical file was squeezed between the baby and her frail body. Her deep-set kohl-lined eyes were tired. Her clothes, several sizes too big for her, swept the floor. Nadager examined the young mother’s eyes and nails, and asked: “You aren’t eating well, are you? Who’s taking care of you post-pregnancy? Where’s your husband or family member?”

Nadager later explained that the patient had had two female children within two years, and that no family members had accompanied her to the hospital for the checkup on that particular day. She was also anaemic and undernourished. Nadager suspected that she was neglected by her husband and his family.

After a brief chat and a look at her file, Nadager advised the use of contraceptives and tried to convince the woman to meet her and talk to her again on the woman’s next visit.

In some cases, violence does not manifest in the form of physical injuries. Rather, doctors look out for less obvious signs, such as repeated abortions and undernourishment in pregnant women. Photo: Mahima Jain

Chronic undernourishment in pregnant women points to stress from or neglect by family members, experts told Scroll.

Arati Kulwal, medical superintendent and gynaecologist at the District Women’s Hospital in Akola, Maharashtra, explained that multiple pregnancies within short gaps are also often an indicator that a woman is facing multiple types of violence at home. Women with repeated abortions or complaints of miscarriages, bleeding, vaginal white discharge, and pelvic fractures should all be suspected to be survivors of violence, she added.

Hemalatha P, senior specialist, obstetrics and gynaecology department and nodal officer for Muktha at Gosha Hospital, explained that in some cases of unwanted pregnancies, women who are under stress at their homes choose to undergo abortions using over-the-counter pills, as a result of which “they may have excessive bleeding, and then they come to the gynaecologist”. In several cases, she added, such unwanted pregnancies are linked to either sexual or physical abuse by the partner.

Jashodaben Bhil, a counsellor at the Sub-District Government Hospital in Radhanpur, recollected encountering women over the years who had given birth to more than three or four girls, and were under pressure to have a boy.

“They were fed up with having sex with their partners and were very tired,” she said. As experts noted, such pressures are exacerbated by the fact that marital rape is not a crime under Indian law.

In some cases, women even seek drastic medical interventions to try and put a stop to this kind of violence at home. Gadhavi, the medical officer in Radhanpur said that some women in their mid-twenties and thirties ask for hysterectomies to avoid becoming pregnant repeatedly. “Patients tell me, make up a medical reason and just remove my uterus,” he said.

Bhatia noted, “That’s the ultimate violence that a woman has to go through: to remove her reproductive organs because of the complete lack of control and confidence on how this will impact her health.”

Nisha, who I met at the Dilaasa Centre in Mumbai, explained that though with the centre’s help, she has managed to contain her husband’s physical violence, he has continued to inflict economic, emotional and mental abuse on her. He continues to visit sex workers, she said, and makes no effort to speak to her even though they share a small flat. He also limits the money he gives her to run their household of four, to just Rs 200 a day. “I know that if I work, even as a domestic helper or cook, I can make some money,” she said. “But he doesn’t let me do that either,” she said.

As a result, she is constantly stressed and has to ration the food in their home. A large portion of the food goes to her two growing children and her husband. She eats last, and often in insufficient quantities. She suffers from hypertension, anxiety and anaemia.

Research has found close links between domestic violence, psychological health and physical health. A study by the Harvard School of Public Health found that survivors of domestic violence face prolonged psychological stress, which has negative impacts on the immune system. Doctors explained that due to this survivors may complain of a range of long-term health issues such as anaemia, fevers, stomach aches, sleeplessness, fatigue, and loss of appetite.

Poor immunity may also make survivors more susceptible to tuberculosis and other chronic infections, Prabhu pointed out.

Studies in other countries have shown that survivors of gender-based violence demonstrate a significant risk for developing atopic diseases, which are caused by hypersensitivity to certain allergens – such diseases include asthma, eczema and allergic rhinoconjunctivitis.

In such cases, where the effects of violence manifest in less obvious ways, it is often nurses who are key to identifying potential victims of violence. Nurses at different hospitals explained that during rounds, they look for women in distressed states, who seem lonely, lost or dishevelled, and who are undernourished.

Kalpana Thomas Khandagle, sister-in-charge, of the MCGM-run 500-bedded Babasaheb Ambedkar Hospital, in Mumbai’s Kandivali, noted that many patients are more comfortable talking to nurses than doctors.

Christina Carol, nursing officer at the female medical ward, Bowring Hospital, echoed this observation. She explained that she tells women, “ “If you trust me, can I ask some questions?” She added, “I try to gain their confidence.”

The senior nursing staff at the Ambedkar Hospital and Bhabha Hospital, who have been working with Dilaasa for several years now, explained that they are now able to identify and refer dozens of survivors every month. “Earlier, I didn’t know how to help such women even if I knew they may be suffering from violence,” Khandagle said. “Now I know.”

Experts note that without training, medical professionals may make key missteps when they encounter survivors of gender-based violence.

For one, they miss cues and evidence of such violence. Further, they treat symptoms such as anaemia and undernourishment without looking deeper at underlying causes and taking any steps to resolve them.

But even when doctors do identify survivors, Karpagam noted, they can lack sensitivity in communicating with and treating them. For instance, they may insist that the survivor take certain measures, such as filing a police complaint, which they believe can counter the underlying problem. “Even when doctors pick up cases of gender-based violence, there’s a lot of morality that all of us participate in,” explained Karpagam. “We can’t just expect her to admit that she is suffering violence and then go file a police complaint.”

Karpagam explained that in such cases, medical professionals often fail to understand that women cannot easily leave situations such as marriages, or take strong actions against perpetrators – there are various reasons for this, including financial dependence, the risk of social stigma, and the lack of support systems.

Training can ensure that medical personnel handle patients with sensitivity, and do not insist that they take certain measures, such as leave an abusive marriage or file a police complaint. Photo: Mahima Jain

Under programmes like Dilaasa, healthcare providers are trained to deal with survivors of violence without imposing their personal judgements on the women.

But as many doctors, nurses and social workers noted, to truly change the perspective of the medical community would need a much deeper overhaul.

One reason that such problems remain prevalent is that the Indian medical school curriculum does not treat gender as an important lens through which healthcare should be viewed. Rege noted that the current medical curriculum “does make some mention of gender here and there,” but that a lot more needed to be done. She pointed out that gender is embedded in medical education in countries such as the United States, the United Kingdom, Thailand and Malaysia.

In India, she added, “It’s really left to individual medical colleges or deans to generate that kind of interest.”

Harsh Haran is a recent graduate from a medical college in Gujarat, who is posted as a medical officer at a primary health centre in a village in Patan district, Gujarat.

Haran explained that he regularly encountered cases in which women appeared to be survivors of gender-based violence, but that his medical training had not equipped him to identify or intervene in such cases.

Rather, it was training by SWATI that provided him with the necessary skills to offer the women support. “Such training should be part of the medical college curriculum,” Haran said.

CEHAT, along with the Directorate of Medical Education and Research and Maharashtra University of Health Sciences has developed gender-sensitive modules for the undergraduate curriculum. Rege noted that several other states, such as Karnataka, have shown interest in similar curricular changes. Apart from teaching students about gender as a social determinant of health, these changes include training in responding to and treating cases of sexual assault and sensitisation on the needs of LGBTQIA+ communities.

“These modules are a kind of package which is readily available and possible to integrate,” Rege said. “And this has sparked interest in different medical colleges.”

Even the ministry of health and family welfare has been advocating for such training. The 2017 National Health Policy calls for strengthening the health system’s response to gender-based violence and “ensuring that the staff have orientation to gender-sensitivity issues.” It further “notes with concern the serious and wide ranging consequences” to gender-based violence.

However, the success of such interventions will remain limited by the fact that India’s health systems are overburdened and understaffed: in 2018, there were 6.78 doctors for every 10,000 patients in India, whereas the ratio recommended by the World Health Organization is ten doctors for every 10,000 patients. The shortage of nurses is even more stark.

“The caseload is so high,” Prabhu pointed out. “If we have more time we can spend more time with patients and identify more cases.”

Rege explained that another problem such programmes can face is that officials in different state health departments don’t always view gender-based violence as a health issue. This, she added, results in insufficient funds being allocated to the programmes.

In most states no funds are allocated at all for such work. Even in states, like Maharashtra, where health system-based crisis centres do exist, funds are often short of requested amounts – while CEHAT estimates that the cost of running a Dilaasa centre for a year is Rs 7.2 lakh, in 2016-’17, the NHM provided for a little under Rs 5.5 lakh for each centre, or 76% of the requested funds. Muktha does not currently have any specific funds allocated to it, but is run under the NHM funding provided to individual hospitals.

Rege explained that there was a need for the Central government and the ministry of health and family welfare to more broadly introduce such programmes across states. A protocol for care for survivors of sexual violence, drafted by the health ministry in 2014, has only been implemented in seven states, Rege pointed out. “The health system continues to believe that it’s largely a women and child issue, a social welfare issue, or a civil-criminal-justice issue,” she said. “So they will often turn to these other departments to do the job.”

But, as Sayed from Bhabha Hospital pointed out, the health system has a vital role to play in tackling the problem. “The society we belong to has this problem,” she said. “So if we, doctors, are not there for them, then who will be there? Where will they go?”

This story was supported by the Pulitzer Center.