VAW, Law and US!

Abstract

Aims and Objectives

To evaluate presentation, trends and management of violence against women and children at a tertiary referral center in Mumbai and to suggest ways to optimize handling of sexual assault cases.

Design

Retrospective descriptive case study.

Setting

Department of Obstetrics and Gynaecology, HBTMC, and Dr. R. N. Cooper Hospital, Mumbai (tertiary teaching hospital).

Sample Size

A total of 1449 cases of alleged sexual assault from January 2015 to December 2019.

Methods

A retrospective descriptive study was conducted, of all the reported incidents of alleged sexual violence managed by department of OBGY from January 2015 to December 2019 at a tertiary teaching hospital in Mumbai.

Results

During the study duration 1449 cases of alleged sexual assault were seen in our facility. A steady rise in the number of incidents of sexual assault over the past 5 years was noted. In our study, we found one-third of the survivors were children below 15 years of age. Forensic samples were collected in 21% cases. Counseling by onsite NGO showed positive trend over the years.

Discussion

There is growing recognition that violence against women has a health impact, in addition to being a gross violation of women’s human rights. There was a steady increase in the number of cases coming to us; increasing awareness of the law, collaboration with NGOs, and provision of services under one roof may be the reason for this.

Conclusion

Violence against women is a public health problem of epidemic proportion. There is urgent need to integrate these issues into clinical training for health-care providers. All efforts need to be made to ensure the right of the survivors to healthcare is upheld and appropriate physical and mental health services are available without discrimination and are accessible, acceptable and of good quality.

#METOO - Barrier To Reproductive Health

VIOLENCE AGAINST WOMEN AND CHILDREN - Current Scenario In Tertiary Institute In Mumbai.

Introduction

March 8, International Women’s Day is a global day meant to celebrate the social, economic, cultural, and political achievements of women. This celebration cannot be complete if women are not able to enjoy their rights to sexual and reproductive health. Violence against women and children is a barrier to reproductive health.

The United Nations defines violence against women as ‘any act of gender-based violence that results in, or is likely to result in, physical, sexual, or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life.’ Sexual violence is ‘any sexual act, attempt to obtain a sexual act, or other act directed against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting. It includes rape, defined as the physically forced or otherwise coerced penetration of the vulva or anus with a penis, other body part or object, attempted rape, unwanted sexual touching and other non-contact forms.’ The term ‘violence against women (VAW)’ encompasses many forms of violence, including violence by an intimate partner (intimate partner violence) as well as non-partner sexual violence [1]. Estimates by the World Health Organization (WHO) indicate that about 1 in 3 (35 percent) of women and girls worldwide have experienced physical and/or sexual intimate partner violence or non-partner sexual violence in their lifetime [2]. These numbers—shocking as they are, only tell part of the story. VAW negatively affects women’s general well-being and prevents women from fully participating in society. It is rightly said, VAW has an impact on the lives of many beyond the survivors—it impacts their families, their community, and the country at large.

Health providers are in unique position to identify women subjected to violence, provide them with appropriate care, connect them to other support services, thus potentially contributing to preventing future harm.

Progress has been made on many important fronts in recent times, though much greater efforts are needed to tackle VAW, in-depth study of the cases of sexual violence will help us in evolving systems that support respectful, caring, and effective response to women who experience violence.

Aims and Objectives

To evaluate presentation, trends and management of violence against women and children at a tertiary referral center in Mumbai and to suggest ways to optimize handling of sexual assault cases.

Methods

A retrospective descriptive study was conducted, of all the reported incidents of alleged sexual violence managed by Department of Obstetrics and Gynecology from January 2015 to December 2019 at a tertiary teaching hospital in Mumbai. Department of Obstetrics and Gynecology is the nodal department for alleged sexual violence cases. Standard Operating Procedure (SOP) for management of cases of sexual violence based on guidelines and protocols for medico-legal care for survivors/victims of sexual violence laid by Ministry of Health and Family Welfare, Government of India (MOHFW) was followed [3]. Sexual assault evidence collection (collection of specimens and documenting injuries of sexual assault victims to be used in the court of law) was done as per the MOHFW protocols. Sexual Assault Forensic Evidence (SAFE) Kit was used for collecting and preserving physical evidence following a sexual violence. Support and other services like emergency services, OPD/inpatient registration, sexual and reproductive health services like antenatal care, family planning, post-abortion care, urine pregnancy test, emergency contraception, HIV testing and post-exposure prophylaxis (PEP), laboratory and radiology investigations and medicines are provided free of cost. Counseling is provided by onsite NGO team.

The data for this study were collected from our database for 5 years (January 2015 to December 2019). Data were analyzed to assess alleged sexual assault cases with respect to demographics and follow-up.

Results

In the duration of study, 1449 survivors reported to our facility. The total numbers of survivors who reported to our institute increased from 237 in the year 2015 to 370 in 2019 (ref Table 1 | Fig. 1). 56% increase was noted over 5 years as seen in Fig. 1. The highest number of cases was seen in 2019—370 cases.

Table 1.

(Ref Fig. 1)

Number of cases—yearly
Year	2015	2016	2017	2018	2019
Cases	237	213	300	329	370

Fig. 1.

Number of cases—yearly

The age-wise distribution of the survivors is depicted in Fig. 2 (ref Table 2 | Fig. 2). It is worthwhile to note 78% of the survivors were young, i.e., less than 25 years of age, and 31% were less than 15 years of age. 11 survivors were more than 45 years of age. 18% were between 26 and 45 years of age.

Fig. 2.

Age-wise distribution of survivors

Table 2.

(Ref Fig. 2)]

Age-wise Distribution of Survivors
	< 15	16–25	26–30	31–45	46–60	> 60	Age not mentioned
2015	53	129	30	22	1	0	2
2016	55	90	28	20	1	0	19
2017	96	150	26	22	2	0	4
2018	117	145	17	28	3	1	18
2019	139	161	30	37	3	0	0

Percentage of samples collected year-wise is depicted in Fig. 3 (ref Table 3 | Fig. 3). In the duration of our study among the survivors who reported to our facility over 5 years, samples could be collected in 21% of the cases (Fig. 3). It should be noted as per the MOHFW guidelines, the survivor or the guardian has the right to refuse either medico-legal examination or collection of evidence or both. Collection of evidence should be decided after careful assessment of the case taking into consideration the nature of the assault, time elapsed between the assault and examination and if the survivor has bathed/ washed herself since the assault.

Fig. 3.

Samples collected—yearly

Table 3.

(Ref Fig. 3)

Samples collected—yearly
	2015	2016	2017	2018	2019
Samples collected	82	41	65	63	63
Not collected	155	94	232	266	307
Details not available	–	78	3	–	–
Total cases	237	213	300	329	370

Since onsite counseling of survivors by dedicated NGO was started in 2016, 38% of the survivors underwent counseling in the year 2016 which increased over the years; 67% survivors completed counseling in the year 2019. Over 4 years, 73% of the survivors completed counseling session by onsite counseling team (ref Table 4 | Fig. 4).

Table 4.

(Ref Fig. 4)

Number of survivors counseled—yearly
	2015	2016	2017	2018	2019
Completed		81	232	319	248
Not completed		52	6	10	122
Details not available	237	80	62
Total cases	237	213	300	329	370

Bold values denote survivors who completed necessary counselling sessions

Fig. 4.

Number of survivors counseled—yearly

Discussion

The results of this study indicate a steady rise in the incidents of sexual assault that were reported to us over the past 5 years (56% increase over 5 years). This can be partly attributed to increased incidence of assaults, but more likely to increased awareness among survivors and access to help.

The brutal Nirbhaya case and the outrage that followed led to changes in India’s legal system and generated awareness among the society at large. The shame, blame and humiliation that were earlier associated with the reporting of sexual assaults seem to have been replaced by courage, dignity and respect with some help from social movements like the #MeToo. This is reflected as, though the number of sexual offences committed against women in India is not less, the increase over period of 5 years (2015–2019) has been less than 1% (0.83%) as per the data released by the National Crime Records Bureau. Close collaboration with the law enforcement agencies and onsite NGO team, and provision of all the services under one roof may be among the reasons of increased number of cases coming to us (56% increase over 5 years).

It was noted during our study, majority of the survivors of sexual assaults (80%) were young people, as defined by WHO (age 25 or below). In our study, we found one-third of the survivors were children below 15 years of age (33.5%); considering POCSO, all become statutory rape. We even had a few menopausal women; one of them was above 60. It is important that the age of the survivor needs to be verified in the case of adolescent girls/boys. In case the child is under 12 years of age, consent for examination needs to be sought from the parent or guardian.

According to the NCRB figures, 126 incidents of crimes included under ‘Protection of Children from Sexual Offences Act (POCSO)’ were reported every day in 2019. Child sexual abuse is a serious problem that often results in immediate negative effects on children, followed by the potential for numerous problems throughout the lifespan [4–7]. It is well documented that CSA may hinder proper growth and development and place children at risk for a host of mental health disorders [8–11]. As per the NCRB statistics for the last few years, the legislative framework in India—the POCSO Act, 2012, has resulted in increased reporting of CSA incidents. However, the lack of clarity of legislation among professionals (health-care workers and police), issues related to mandatory reporting of the CSA incidents, and general lack of professional support for victims of CSA create potential problems in its implementation which need to be looked at [12]. Some interventions suggested to improve it include: improve training for pediatricians and gynecologists on recognizing and handling cases of CSA, including by developing a mandatory gender-sensitive training module for medical students on treating and examining victims of child sexual abuse, developed in consultation with lawyers and experts on women’s, children’s, and health rights [13], and also development and dissemination of guidelines for school administrators and teaching staff on protecting children from sexual abuse, recognizing abuse, appropriately speaking to victims, handling disclosure of abuse, and taking appropriate action when such incidents come to light [13].

Though there is no perfect time to report an assault, except for when the victim is ready to come forward, it plays an important role in collection of samples. One-fifth presented of the victims within the time to collect forensic samples for testing, this remained unchanged over the years study was conducted. Samples were collected if the survivor reports within 96 h (4 days) of the assault as per the MOHF guidelines, after the survivor (or the legal guardian in case the survivor is a minor) gives written and verbal consent for it [3]. The likelihood of finding evidence after 72 h (3 days) is greatly reduced; however, it is better to collect evidence up to 96 h in case the survivor may be unsure of the number of hours lapsed since the assault [3]. The cases being reported have increased over the last few years; the conviction rates, unfortunately, seem to have remained stagnant to slightly falling [14, 15]. Health professionals play a dual role in responding to the survivors of sexual assault. The first is to provide the required medical treatment and psychological support, and the second is to assist survivors in their medico-legal proceedings by collecting evidence and ensuring a good quality documentation. Collection of forensic samples is an important step in ensuring better conviction rates. We need to increase awareness in the society, to ensure the victims of sexual assault reach a health-care facility in time to collect forensic samples to ensure justice is delivered to the survivors of sexual assaults. Examination and evidence collection should be done by following the protocols, using the ‘Sexual Assault Forensic Evidence (SAFE) Kit’ as per the ‘Guidelines & Protocols For Medico-Legal Care For Survivors/Victims Of Sexual Violence’ laid by the Ministry Of Health and Family Welfare, Government of India (MOHFW). The nature of swabs taken is determined to a large extent by the history and nature of assault and time lapse between incident and examination. The fact that sample collection (including genital examination) may be uncomfortable but is necessary for legal purposes should be explained to the survivor.

There was steady rise in the number of victims that were willing to undergo counseling; of the 842 survivors that reported to our facility over 4 years, counseling was done in majority of the cases (73%). In the later part of the duration of our study, almost all the survivors (97%) underwent the counseling. Onsite counseling post-incident is important as the victim can experience psychological reactions as well as behavioral and somatic manifestations, a condition known as rape trauma syndrome (RTS). RTS is now recognized as a type of post-traumatic stress disorder (PTSD). Onsite counseling post-incident will help them cope the trauma and put them on a path of healing and restoration. It is important to note if mental health professionals or crisis counselors are available on site that is ideal, but their absence cannot be an excuse; every physician dealing with sexual assault survivors needs to learn basic counseling skills.

Conclusion

Violence against women is a global public health problem of epidemic proportion, requiring urgent action. There is growing recognition that violence against women has a health impact, in addition to being a gross violation of women’s human rights [16]. Health-care providers (HCPs) are in a unique position to address the health and psychosocial needs of women who have experienced violence. WHO’s new clinical and policy guidelines on the health sector response to partner and sexual violence against women emphasize the urgent need to integrate these issues into clinical training for health-care providers [2]. Our center conducts regular in-house training programs for HCPs and also for other peripheral centers affiliated to us to ensure all the HCPs have requisite competencies and skills. The key elements of a health sector response to violence against women include women-centered care, identification and care for survivors, clinical care for survivors, training of health-care providers on intimate partner violence and sexual violence, health-care policy and provision care for women experiencing intimate partner violence and sexual assault and mandatory reporting of intimate partner violence. Our center is doing training, facilitation of reporting and collaborating with councilors; hence, we are having increased number of survivors coming to us.

All medico-legal examinations and procedures must respect the privacy and dignity of the survivor. To realize the right to healthcare of survivors/victims, health professionals must be trained to respond appropriately to their needs, in a sensitive and non-discriminatory manner respectful of the privacy, dignity and autonomy of each survivor. Health workers cannot refuse treatment or discriminate on the basis of gender, sexual orientation, disability, caste, religion, tribe, language, marital status, occupation, political belief, or other status.

All efforts need to be made to ensure the right of the survivors to healthcare is upheld and appropriate physical and mental health services are available without discrimination and are accessible, acceptable and of good quality.

Important points to note [3]

• Any registered medical practitioner can conduct the examination, and it is not mandatory for a gynecologist to examine such a case.

• In case of a girl or woman, every possible effort should be made to find a female doctor but the absence of availability of lady doctor should not deny or delay the treatment and examination.

• If a person has come directly to the hospital without the police requisition, the hospital is bound to provide treatment and conduct a medical examination with the consent of the survivor/parent/guardian (depending on age). A police requisition is not required for this.

• If a person has come on his/her own without FIR, s/he may or may not want to lodge a complaint but requires a medical examination and treatment. Even in such cases the doctor is bound to inform the police as per law. However, neither court nor police can force the survivor to undergo medical examination. It has to be with the informed consent of the survivor/ parent/ guardian (depending on the age). In case the survivor does not want to pursue a police case, an MLC must be made and she must be informed that she has the right to refuse to file FIR. An informed refusal must be documented in such cases.

• Police personnel must not be allowed in the examination room during the consultation with the survivor. If the survivor requests, her relative may be present while the examination is done.

• There must be no delay in conducting an examination and collecting evidence.

• Providing treatment and necessary medical investigations is the prime responsibility of the examining doctor. Admission, evidence collection or filing a police complaint is not mandatory for providing treatment.

• Specific needs of children must be kept in mind while providing care to child survivors.

• Make arrangements for interpreters or special educators in case the person has a speech/hearing or cognitive disability.

• Admission should not be insisted upon unless the survivor requires indoor stay for observation/treatment.

• Survivors of sexual violence should receive all services completely free of cost.

• A copy of all documentation (including that pertaining to medico-legal examination and treatment) must be provided to the survivor free of cost.

• The Criminal Law Amendment Act 2013, in Section 357C Cr.PC, says that both private and public health professionals are obligated to provide treatment. Denial of treatment of rape survivors is punishable under Section 166B IPC with imprisonment for a term which may extend to one year or with fine or with both [17].

Reena Wani

(MD, FRCOG, FICOG, DNBE, FCPS, DGO, DFP). Chairperson FOGSI Perinatology Committee 2015–2017. Core Committee Member FOGSI Violence against Women Cell, Member, Managing Committee MOGS, UNESCO Bio-Ethics, President MBPC, Section Editor TIP, Peer Reviewer JOGI, Professor Addl. & Head of Unit, Obstetrics & Gynaecology, HBTMC and RN Cooper Hospital, Juhu, Mumbai. Correspondence: reena.wani@rediffmail.com

Funding

None.

Declarations

Conflict of interest

Authors declare that they have no conflict of interest.

Ethical approval

Ethical permission has been taken from institutional ethics committee (IEC)—consent waiver requested and approved by IEC.

Informed consent

Since it was not a study or research setup, but a treatment program, which was retrospectively analyzed, waiver of patient consent was sought from institutional ethics committee (IEC) which was approved by IEC; letter of the same is attached in this file.