MAKING THE HEALTH SECTOR RESPONSIVE TO SEXUAL VIOLENCE :LESSONS LEARNT CEHAT: Padma Bhate-Deosthali, Sangeeta Rege Consultant: Jagadeesh Narayan Reddy

Introduction Dual role of health sector: therapeutic and forensic Legal mandate- Criminal Law Amendment 2013 and POCSO 2012 cast the following duties: Immediate treatment, psychological support and appropriate referral for public and private health facilities Mandatory reporting to police Absence of injuries does not mean consent Definition of rape expanded to include all orifices and insertion of penis, finger and object. CEHAT-Bhate-Deosthali, Rege, Consultant-Reddy J,Making health sector responsive to sexual violence-Lessons learnt

TYPICAL MEDICO-LEGAL FORM: Informed Consent Blanket consent taken for all medico legal procedures History Alleged history of rape/ No mention of natural of assault Preoccupation with injuries Description of injuries including prominent mention of no injuries Hymen examination Rupture of hymen with no mention of when it ruptured Size of vaginal opening Two fingers pass, one finger passes, tip of finger passes No mention of activities post assault, use of restraints, delay in reporting Evidence collection Irrespective of nature of assault, irrespective of menstruation /reporting after three months Opinion No medical opinion/no follow up/ no counselling or follow up Insensitive practices and observations which focus on past sexual conduct of the survivor Overemphasis on presence of injuries in medical examination. Mandatory police requisition. Providers attitudes- Poor history taking Absence of reasoned medical opinion. Due to delay or non-receipt of FSL reports final opinion not provided. CEHAT-Bhate-Deosthali, Rege, Consultant-Reddy J,Making health sector responsive to sexual violence-Lessons learnt

Therapeutic care- glaring gap No STP/Treatment advice to the police/ Survivors returned for abortion or burning micturition or for infections Pain killers prescribed for genital injury but doctor write “patient uncooperative” instead of stating that internal examination not possible due to severe pain CEHAT-Bhate-Deosthali, Rege, Consultant-Reddy J,Making health sector responsive to sexual violence-Lessons learnt

Analysis of four forensic textbooks Rape is easiest allegation to make but difficult to prove Types of women who can/cannot resist rape Gait and mental state Determine whether she is habituated to sex- based on examination of vaginal orifice, labia majora, labia minora, breasts and clitoris Hymen and Elasticity of anus and vagina on habituation False allegations CEHAT-Bhate-Deosthali, Rege, Consultant-Reddy J,Making health sector responsive to sexual violence-Lessons learnt

Medical Evidence as perceived & its limitations Limitations of medical evidence Trace evidence: Semen , Spermatozoa, Blood, Hair, cells, Dust, paint, Grass, Lubricant, Faecal matter, Body fluids, Saliva No medical evidence does not mean no sexual violence Gap between the sexual assault and reporting to the health facility Nature of sexual assault Injuries: Body / Genitals, Skin /Mucosa/Abrasions/ Contusions/ Lacerations, Fractures Use of condom Post assault activities STDs/ HIV, Hepatitis, Gonorrhea

Comprehensive health care response to sexual violence CEHAT-Bhate-Deosthali, Rege, Consultant-Reddy J,Making health sector responsive to sexual violence-Lessons learnt

Informed Consent First Aid History Examination Evidence Collection Dry Pack Seal Treatment Discharge Age Estimation Physical Dental Radiological Hand-over to Police Follow-up Documentation Treatment of Injuries STI test and prophylaxis HIV test and prophylaxis Emergency Contraception UPT (if applicable) Counselling Information and Referral to other services Comprehensive health care response to sexual violence: Obtaining informed consent Detailed documentation of history of assault, gender sensitive examination, collection of relevant forensic evidence and provision of a reasoned medical opinion. Provision of medical support free of cost Provision of first contact psychological support Maintaining a clear and fool-proof chain of custody Referral to appropriate agencies such as legal/shelter services etc. CEHAT-Bhate-Deosthali, Rege, Consultant-Reddy J,Making health sector responsive to sexual violence-Lessons learnt

Methods Analysis of medical protocols Cases received from April 2008 to August 2014 Total no of cases: 448 Total for analysis: 411(excluded those reporting consensual sex) Analysis of 17 court judgments Approved by ethics committee for reporting aggregate analysis CEHAT-Bhate-Deosthali, Rege, Consultant-Reddy J,Making health sector responsive to sexual violence-Lessons learnt

Results Genital Injury: 20, Physical Injury: 22, Unwanted pregnancy: 9, Vaginal discharge: 8, Burning micturition: 4 CEHAT-Bhate-Deosthali, Rege, Consultant-Reddy J,Making health sector responsive to sexual violence-Lessons learnt

Three fold increase in reporting: CEHAT-Bhate-Deosthali, Rege, Consultant-Reddy J,Making health sector responsive to sexual violence-Lessons learnt

Age of the survivors CEHAT-Bhate-Deosthali, Rege, Consultant-Reddy J,Making health sector responsive to sexual violence-Lessons learnt

Nature of sexual violence: CEHAT-Bhate-Deosthali, Rege, Consultant-Reddy J,Making health sector responsive to sexual violence-Lessons learnt

Profile of perpetrator: 77% of cases known perpetrator 25% followed up CEHAT-Bhate-Deosthali, Rege, Consultant-Reddy J,Making health sector responsive to sexual violence-Lessons learnt

On examination, no injuries or other findings were seen. Medical Examination findings Deposition by doctor in court 1 Injuries on her face and genitals, and bite marks on her breast. Anal, vaginal and oral swabs taken. When P deposed in court, she only mentioned that she had been raped. The doctor’s documentation of history of forced anal and oral sex and bites on breasts and lips and examination findings were explained by him in court and were honoured as evidence. 2 On examination, no injuries or other findings were seen. the absence of injuries was explained by the fact that the survivor had reported to the hospital over a month after the assault. Court relied on survivor’s testimony alone. CEHAT-Bhate-Deosthali, Rege, Consultant-Reddy J,Making health sector responsive to sexual violence-Lessons learnt

3 No genital or other bodily injuries were seen on examination. Forensic samples negative for semen. Absence of injuries were explained as due to the fact that she was intoxicated. Absence of forensic evidence in the form of semen were explained as due to menstruation and fact that she had washed herself. 4 Soreness on the girl’s labia majora and minora, pain in the lower abdomen and during urination. Doctor testified that the injury may have been caused by pressing of the penis on the genitals. He was asked if it was caused due to penile penetration or venereal disease: he said that he could not conclusively say that it was penile penetration but it cannot be caused due to VD. CEHAT-Bhate-Deosthali, Rege, Consultant-Reddy J,Making health sector responsive to sexual violence-Lessons learnt

Analysis of legal outcomes Factors leading to convictions: Factors leading to acquittal Documentation of history Trace evidence –presence or absence Ejaculation outside the body Detection of lubricant so absence of injuries Menstruation……… Injuries – interpretation of presence or absence of injuries 35 days delay Redness explained as consequence of SV- distinction between this and result of STD Injuries: no interpretation of Trace evidence: lack of evidence not explained Effect of alcohol not explained For an offence of fingering- absence of semen and spermatozoa not explained by prosecution For offence of non-penetrative sexual violence – court asked for semen Social factors: Case withdrawn during trial CEHAT-Bhate-Deosthali, Rege, Consultant-Reddy J,Making health sector responsive to sexual violence-Lessons learnt

Emerging issues for the courts Lesions and vaginal discharge/diseases Investigations for VD/STDs Presence of VD in 5 year old is sign of SV Treatment Burning micturition Treatment of STDs Analgesic for pain relief/EC/force feeding of i-pill by accused CEHAT-Bhate-Deosthali, Rege, Consultant-Reddy J,Making health sector responsive to sexual violence-Lessons learnt

To conclude: Gender sensitivity in examination and treatment Evidence based scientific forensic practice Explanation for absence and/or presence of injuries and evidence can be key to accessing justice Guidance on medical evidence and its limitations for doctors, prosecution, police and judges. Prosecution will be able to push for convictions when they know limits of medical evidence. CEHAT-Bhate-Deosthali, Rege, Consultant-Reddy J,Making health sector responsive to sexual violence-Lessons learnt

Pressing issues: Mandatory reporting vs right to treatment: Informed refusal requires ethical practice Married women reporting marital rape? Transgender and boys reporting sexual violence but more awareness to increase access. CEHAT-Bhate-Deosthali, Rege, Consultant-Reddy J,Making health sector responsive to sexual violence-Lessons learnt

Acknowledgment: Interventionists: Chitra Joshi, Sujata Aiykar, Rashi Vidyasagar, Sangeeta Rege and others Doctors at three public hospitals of the BMC where the model is being run. Research team: Anjali Kadam, Sanjida Arora, Prachi Awlaskar. CEHAT-Bhate-Deosthali, Rege, Consultant-Reddy J,Making health sector responsive to sexual violence-Lessons learnt