sexual violence

Health centres are still failing rape survivors, three years after guidelines on unbiased treatment

Doctors are still commenting on past sexual practices, which the guidelines prohibit.

Three years ago, the Ministry of Health and Family Welfare issued guidelines and protocols on how unbiased and sensitive treatment should be provided to survivors of sexual violence. However, our experience based on interactions with doctors across India indicate that these medico-legal guidelines are still not being followed.

Rape survivors continue to be subjected to unscientific medical practices such as irrelevant and invasive swab collections, comments on their past sexual practices and comments raising doubts about their complaints. They continue to face humiliation, delays, insensitivity from health professionals, adding to their trauma. Despite the guidelines stating that survivors need to be given first-line psychological support, health providers continue to restrict themselves to forensic examination with no recognition of therapeutic needs of survivors.

The guidelines were formulated after the December 16, 2012, gangrape and murder in Delhi led to the formation of the Justice Verma Committee, whose report in 2013 highlighted the institutional biases about rape. Taking cognisance of this report, the health ministry took the first steps towards setting its house in order by framing these guidelines.

The health ministry’s guidelines were an outcome of an intensive process led by Keshav Desiraju, who was health secretary at the time. Discussions were held with stakeholders – administrators, forensic experts, clinicians, researchers, lawyers as well as representatives of the Ministry of Women and Child Development, the Home Ministry and the Ministry of Law and Justice. The guidelines were disseminated through a national workshop in collaboration with the World Health Organisation in March 2014 that was attended by senior health functionaries from of all states and union territories. Since then, the health ministry has conducted five regional workshops in collaboration with the WHO for doctors from various states to train them in the skills required to operationalise the guidelines.

The health ministry’s guidelines provide a clear directive to all health facilities to ensure that survivors of all forms of sexual violence, rape and incest – including people who face marginalisation based on disability, sexual orientation, caste, religion and class – have immediate access to healthcare services. They include immediate and follow-up treatment, post-rape care including emergency contraception, post-exposure prophylaxis for HIV prevention and access to safe abortion services, police protection, emergency shelter, documentation of cases, forensic services and referrals for legal aid and other services. They recognise the need to create an enabling environment for survivors where they can speak out about abuse without fear of being blamed, where they can receive empathetic support in their quest for justice and rebuild their lives after the assault.

These guidelines were circulated to all states in April 2014. In the case of Nipun Saxena and Anr vs Union of India and Ors, the Centre submitted to the Supreme Court that all states are expected to adhere to these guidelines. So far, only nine states have issued government orders or circulars stating that health facilities must follow the guidelines. Other states have not even taken this small step.

What is happening at ground level?

The Uttar Pradesh government was one of the first to adopt the guidelines. However, at a workshop organised by WHO and United Nations Population Fund in November 2016, senior Uttar Pradesh health officials said that they were still documenting past sexual practice by commenting on hymen and vaginal introitus (the entrance to the canal), collecting all evidence irrespective of nature of sexual assault or time lapse. Remarks on hymen and vaginal introitus are akin to making comments on the past sexual practices of the survivor and casts aspersions on her character. Such practice is unscientific, irrelevant and banned by law. The current practice of collecting mechanical evidence subjects survivors to unnecessary swab collections which are irrelevant, unnecessary and only add to the burden on forensic science labs with no value.

In Maharashtra, Orissa and Madhya Pradesh, which also claim to have adopted the guidelines, they are not available at health facilities since the state governments have not printed and circulated them.

Kerala’s health department has adopted the health ministry guidelines with modifications that retain unscientific and gender insensitive practices. Their protocol continues to ask doctors to document status of the hymen, status of pubic hair, the person’s height and weight and other characteristics that do not verify or negate the nature of the crime. The department’s manual does not provide guidance on history seeking procedures including documenting activities that lead to loss of medical evidence. The manual also does not say anything about getting informed consent or providing psychological first aid.

What is most disconcerting is the fact that central government hospitals too have not been following the guidelines in toto. The All India Institute of Medical Sciences in New Delhi is using its own protocol, which the institute claims to have been developed in 2014. The hospital guidelines have, in fact, left out the need for doctors to record their medical opinion based on the examination of the survivor.

As per the Criminal Procedure Code and the health ministry guidelines, the doctor’s interpretation of the findings or absence of findings has to be made available. This can assist a court in deciding the case of sexual assault or rape. The non-implementation of these guidelines also allows doctors to escape interpretation of the examination findings where they do not explain the presence or absence of medical evidence.

The Delhi debacle

While this is the reality in states that claim to have adopted the guidelines, other states and union territories have not made any change in their approach even in spirit. The Delhi health department confused the matter by setting up a committee in May 2014, which recommended that “two finger test is necessary in many cases of sexual violence”. The two finger test is a test in which a doctor inserts two fingers into the vagina of the person being examined to test for laxity of the vagina and therefore gauge whether the person is habituated to sex. The health ministry guidelines ban the two finger test as it is rooted in biases about the character of a rape victim and is not any indication of the nature of the crime.

The Delhi government committee had confused the two finger test with a per vaginal examination, which is allowed under the health ministry’s guidelines. A per vaginal exam is a clinical practice, which requires an internal vaginal examination, but is done for diagnosis of infection, injury and presence of a foreign body.

The Delhi government drew severe criticism for the report, which it immediately withdrew, but it has still not adopted the health ministry guidelines. This was evident in the training of doctors organised under the aegis of the Delhi High Court between April and September this year. None of the Delhi public hospitals provide psychological first aid but refer rape survivors to a non-government organisation that is available on call.

What needs to be done

The Criminal Law Amendment 2013 makes it mandatory for all private hospitals to respond to survivors of rape. But while some private medical associations may have conducted training related to the Protection of Children Against Sexual Offences Act, they have not taken any initiative to adopt the health ministry guidelines on sexual assault.

The responsibility of the state cannot end with issuing and circulating an order. Unless concerted efforts are made by state health departments to implement the health ministry’s guidelines in entirety, survivors will continue to receive deficient medico legal care which is a barrier in their rehabilitation as well as access to justice.

As an immediate step, all state governments need to adopt these guidelines and make them available at all levels of the health system. Secondly, health departments need to create action plans for implementing the guidelines and create state-level training plans along with facility level monitoring mechanisms to assess quality of the healthcare response to sexual violence survivors. Healthcare providers need to reorient themselves to an understanding that sexual violence is a critical health issue and good quality health services can enable survivors to heal from trauma and strengthen their resolve to seek justice.

Jagdeesh Reddy is a professor of forensic medicine. Padma Deosthali is an independent researcher and trainer. Sangeeta Rege is coordinator at Centre for Enquiry into Health and Allied Themes.

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Swara Bhasker: Sharp objects has to be on the radar of every woman who is tired of being “nice”

The actress weighs in on what she loves about the show.

This article has been written by award-winning actor Swara Bhasker.

All women growing up in India, South Asia, or anywhere in the world frankly; will remember in some form or the other that gentle girlhood admonishing, “Nice girls don’t do that.” I kept recalling that gently reasoned reproach as I watched Sharp Objects (you can catch it on Hotstar Premium). Adapted from the author of Gone Girl, Gillian Flynn’s debut novel Sharp Objects has been directed by Jean-Marc Vallée, who has my heart since he gave us Big Little Lies. It stars the multiple-Oscar nominee Amy Adams, who delivers a searing performance as Camille Preaker; and Patricia Clarkson, who is magnetic as the dominating and dark Adora Crellin. As an actress myself, it felt great to watch a show driven by its female performers.

The series is woven around a troubled, alcohol-dependent, self-harming, female journalist Camille (single and in her thirties incidentally) who returns to the small town of her birth and childhood, Wind Gap, Missouri, to report on two similarly gruesome murders of teenage girls. While the series is a murder mystery, it equally delves into the psychology, not just of the principal characters, but also of the town, and thus a culture as a whole.

There is a lot that impresses in Sharp Objects — the manner in which the storytelling gently unwraps a plot that is dark, disturbing and shocking, the stellar and crafty control that Jean-Marc Vallée exercises on his narrative, the cinematography that is fluid and still manages to suggest that something sinister lurks within Wind Gap, the editing which keeps this narrative languid yet sharp and consistently evokes a haunting sensation.

Sharp Objects is also liberating (apart from its positive performance on Bechdel parameters) as content — for female actors and for audiences in giving us female centric and female driven shows that do not bear the burden of providing either role-models or even uplifting messages. 

Instead, it presents a world where women are dangerous and dysfunctional but very real — a world where women are neither pure victims, nor pure aggressors. A world where they occupy the grey areas, complex and contradictory as agents in a power play, in which they control some reigns too.

But to me personally, and perhaps to many young women viewers across the world, what makes Sharp Objects particularly impactful, perhaps almost poignant, is the manner in which it unravels the whole idea, the culture, the entire psychology of that childhood admonishment “Nice girls don’t do that.” Sharp Objects explores the sinister and dark possibilities of what the corollary of that thinking could be.

“Nice girls don’t do that.”

“Who does?”

“Bad girls.”

“So I’m a bad girl.”

“You shouldn’t be a bad girl.”

“Why not?”

“Bad girls get in trouble.”

“What trouble? What happens to bad girls?”

“Bad things.”

“What bad things?”

“Very bad things.”

“How bad?”

“Terrible!!!”

“Like what?”

“Like….”

A point the show makes early on is that both the victims of the introductory brutal murders were not your typically nice girly-girls. Camille, the traumatised protagonist carrying a burden from her past was herself not a nice girl. Amma, her deceptive half-sister manipulates the nice girl act to defy her controlling mother. But perhaps the most incisive critique on the whole ‘Be a nice girl’ culture, in fact the whole ‘nice’ culture — nice folks, nice manners, nice homes, nice towns — comes in the form of Adora’s character and the manner in which beneath the whole veneer of nice, a whole town is complicit in damning secrets and not-so-nice acts. At one point early on in the show, Adora tells her firstborn Camille, with whom she has a strained relationship (to put it mildly), “I just want things to be nice with us but maybe I don’t know how..” Interestingly it is this very notion of ‘nice’ that becomes the most oppressive and deceptive experience of young Camille, and later Amma’s growing years.

This ‘Culture of Nice’ is in fact the pervasive ‘Culture of Silence’ that women all over the world, particularly in India, are all too familiar with. 

It takes different forms, but always towards the same goal — to silence the not-so-nice details of what the experiences; sometimes intimate experiences of women might be. This Culture of Silence is propagated from the child’s earliest experience of being parented by society in general. Amongst the values that girls receive in our early years — apart from those of being obedient, dutiful, respectful, homely — we also receive the twin headed Chimera in the form of shame and guilt.

“Have some shame!”

“Oh for shame!”

“Shameless!”

“Shameful!”

“Ashamed.”

“Do not bring shame upon…”

Different phrases in different languages, but always with the same implication. Shameful things happen to girls who are not nice and that brings ‘shame’ on the family or everyone associated with the girl. And nice folks do not talk about these things. Nice folks go on as if nothing has happened.

It is this culture of silence that women across the world today, are calling out in many different ways. Whether it is the #MeToo movement or a show like Sharp Objects; or on a lighter and happier note, even a film like Veere Di Wedding punctures this culture of silence, quite simply by refusing to be silenced and saying the not-nice things, or depicting the so called ‘unspeakable’ things that could happen to girls. By talking about the unspeakable, you rob it of the power to shame you; you disallow the ‘Culture of Nice’ to erase your experience. You stand up for yourself and you build your own identity.

And this to me is the most liberating aspect of being an actor, and even just a girl at a time when shows like Sharp Objects and Big Little Lies (another great show on Hotstar Premium), and films like Veere Di Wedding and Anaarkali Of Aarah are being made.

The next time I hear someone say, “Nice girls don’t do that!”, I know what I’m going to say — I don’t give a shit about nice. I’m just a girl! And that’s okay!

Swara is a an award winning actor of the Hindi film industry. Her last few films, including Veere Di Wedding, Anaarkali of Aaraah and Nil Battey Sannata have earned her both critical and commercial success. Swara is an occasional writer of articles and opinion pieces. The occasions are frequent :).

Watch the trailer of Sharp Objects here:

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This article was published by the Scroll marketing team with Swara Bhasker on behalf of Hotstar Premium and not by the Scroll editorial team.