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

2. Introduction Dual role of health sector: therapeutic and forensic
Legal mandate- Criminal Law Amendment 2013 and POCSO 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

3. 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

4. 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

5. 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

6. 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

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

8. 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

9. 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

10. 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

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

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

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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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