Dilaasa: Public Hospital based crisis centre Dr. Seema Malik Project Director, Dilaasa Chief Medical Superintendent, Peripheral Hospitals Municipal Corporation of Greater Mumbai

The Dilaasa Model Joint initiative of the BMC and CEHAT, established in BMC provided infrastructure, staff, commitment to take on running of services once CEHAT withdrew CEHAT provided technical support Model included the following components: Training of health professionals on Gender-based violence IEC material in hospitals in the form of posters, pamphlets, cards Referral to the crisis centre for crisis intervention services Emotional Support, Safety Planning, Social Support, Shelter, Legal Aid, Assistance with filing complaints

Protocols for management of cases Protocols for documentation and evidence collection in cases of sexual violence Standard treatment guidelines for provision of care such as first aid, emergency contraception, access to abortion care, treatment for STIs. Evolved a system of screening women with DV related signs and symptoms (assaults, poisoning, falls, fractures, burns, repeated abortions, among others) and referral to crisis centre. Crisis intervention services developed protocol for providing crisis intervention, developed ethical guidelines as protocol to adhere to high standards of services, trained social workers and nurses to provide services.

Domestic Violence Age profile – 8% 19 or less, 69% yrs, 15% yrs, 9% above 46 yrs. Marital Status - 79% married, 14% separated/widowed/divorced, 7% unmarried Referral – 53% through health system (screening and referral by HCPs), 11% IEC material, 8% ex- clients, 28% Other NGOs. Sexual Violence Age profile – 54% less than 12 yrs, 29% between 13-18, 17% 19 yrs and above. Gender - 97% females, 3% males Marital Status – 87% unmarried, 13% married/separated/divorced. Referral – 44% self (came directly to hospital), 50% police, 6% (referred by NGOs) Dilaasa has provided services to: More than 3000 survivors of DV since 2001 and More than 200 survivors of SV since 2008

Domestic Violence: 19 yrs and below 165 out of 2146 cases of domestic violence were of women 19 yrs and below 48% Married and 49% unmarried, 3% separated/divorced Reporting complaints: Consumption of poison- attempted suicides – 48% Assaults – 18% MTPs/Miscarriage – 7% ANC/PNC/Gynaec complaints – 4% Other complaints – 4% No specific medical complaints, but referred for other needs such as shelter, divorce etc. – 19%

Types of domestic abuse reported Sexual violence reported by 33% of women (both within and outside marriage) - forced sex, not allowing use of any contraception Forced her to marry against her will/ not allowing her to marry person of her choice – reported by 12% women Violence by boyfriend reported by 14% women- failed love affair Abuse from parental family reported by 37% women - restriction on mobility reported by 31% women. High number of attempt to suicide cases

Sexual violence: adolescent survivors 29% of survivors between yrs Perpetrator in two out of three cases in this age group was a known person- neighbour, family member-uncle, cousin Half reported directly to the hospital for treatment, before going to police. In one in four cases, disclosure was due to a health complaint One in five came to the hospital to terminate a pregnancy resulting out of the assault, usually a late abortion. Do not always want to report the case – need to allow access to treatment without making reporting to police mandatory.

A 17 year old girl came to the gynaecology OPD, seeking an abortion. She reported that she was deserted by her husband and could not look after the child, hence wanted an abortion. However, since the girl looked very young, the doctor probed and asked if she was married and if there was more to the history. On this the girl confided in the doctor and told her that she had been raped. She had come to Mumbai 2 years ago and was working as a full-time domestic servant. One Sunday she was out with a friend when two unknown people forcibly got hold of them and raped them both. S did not tell anyone about the incident as she was the only earning member in her family and she was afraid she would lose her job. But when she missed her period she came to the hospital. The doctor assured her that the abortion would be provided irrespective of whether she made a complaint or not. The Dilaasa counsellor helped the girl identify sources of support among friends who she could confide in and together, the possibility of making a police complaint was explored. After providing her reassurance, the girl agreed to file a complaint and Dilaasa facilitated this process. Case Study

Outcomes Health Care professionals feel equipped to identify women facing abuse based on signs and symptoms that they present with. Among adolescents, recognition of complaints such as consumption of poison (attempted suicide), and unwanted pregnancies is critical. Formation of a group of trainers from among health professionals themselves – called the training cell – who conduct capacity building for their peers. Provision of good quality, comprehensive medical and psychological care. Development of a model for counselling survivors of DV, SV and women attempting suicide. Specifically related to sexual violence: Doctors able to operationalize informed consent– recognition of voluntary reporting and that survivors have a right to refuse certain aspects of the procedure. History recording thorough, use of a uniform protocol has helped to identify forms of sexual assault that go beyond penetrative peno-vaginal assault. Evidence of past sexual history is not recorded (such as old tears of hymen, size of introitus, elasticity of vaginal opening) Doctors able to provide a reasoned medical opinion, based on history and examination findings.

Response to GBV at health facility An external evaluation of the Dilaasa model has made valuable recommendations for up-scaling such an initiative. These include: Any response should be integrated into the system –Should NOT be stand-alone Systematically engage with different levels of the healthcare system to establish an integrated system of screening and referral. At the primary care level, auxiliary nurse midwives and medical ofcers may be trained to screen and refer; At the secondary and tertiary level, counselling services as well as referral to legal and other resources may be provided. Crisis centres can be ideally located within secondary hospitals (200 plus beds) with a casualty department in cities or district/rural hospitals more than 60 beds with casualty. Crisis centres can be created as separate departments within a hospital setting OR placed under the social work department or the nursing department – both of which have caring function. Training of in-service personnel in domestic violence (and other issues) should become part of the health system functions – establish a training cell. Efforts must be made to inuence medical and nursing educators/educational institutions and students to integrate violence against women into the curriculum.