Poor health system responses to gender-based violence putting lives at risk - Hindustan Times
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Women's Day Special: Poor health system responses to gender-based violence

ByHindustan Times
Mar 08, 2022 11:19 AM IST

The piece has been authored by Leena Menghaney, a lawyer and survivor who works with Médecins Sans Frontières (MSF).

Sexual violence is back in the headlines. The debate in the Delhi High court on the need to recognise sexual violence by an intimate partner (marital rape) as a crime is a step in the right direction. This progress is not standalone. In the last decade, rape or what we now refer to as sexual assault has been re-defined to include different acts and all forms of penetration. Efforts to introduce special procedures for survivors of child sexual abuse and laws to prevent sexual harassment at the workplace have taken shape. Reforms have been hard-fought by the women's movement and survivors triggered by the Mathura custodial rape case in the 1970s; Bhanwari Devi's battle for justice against her sexual assault by upper-caste men at her workplace in the 1990s and the Nirbhaya case in New Delhi in 2012. 

Inadequate responses from the health system to sexual and gender-based violence are putting survivors' health at risk(PTI)
Inadequate responses from the health system to sexual and gender-based violence are putting survivors' health at risk(PTI)

Yet, despite the progress in recognising all forms of sexual violence and reforming the Indian Penal Code, survivors face immense barriers to receiving the medical services and psychological support they need. Sexual Gender-Based Violence (SBGV) has a lifelong impact on the mental health of survivors. The link between violence and mental health is direct, and its scale in India qualifies it as a public health crisis.

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Twenty years ago, there were no readily available services for the sexual violence I faced while returning home from college. The incident remains etched in my mind. I still see women not receiving free and quality psychological support for their violence-related trauma, just like I, as a young college student, could not.

Following the 2012 Delhi gang-rape case, one-stop crisis centres were set up in the public health system aiming to provide women facing sexual violence a single point of contact for support, including medical and psychological aid. Progress has been glacially slow, and the crisis centres in the public health system lack a survivor-centric approach and languish due to under-utilisation of funding and training.

Few humanitarian medical organisations like Medecins Sans Frontieres have also set up a sexual and gender-based violence (SBGV) clinic, to fulfil the existing gaps and provide medical and psychological support to survivors through a community-based clinic in Jahangirpuri northwest Delhi. But they face an uphill task.

The ministry of health's 2014 guidelines on medico-legal care applicable to health care facilities are a progressive step but require careful implementation in the one-stop crisis centres. They recognise situations when survivors of sexual violence may approach a crisis centre or health provider only for treatment and psychological support.

However, the legal requirement that medical practitioners mandatorily inform the police even in cases where the survivor is clearly reluctant and does not consent to the disclosure to authorities can have unintended consequences. Health organisations point out mandatory reporting laws in health settings can have a chilling effect on survivors coming forward to access much-needed medical care and support.

My work in public health and HIV highlights that prevention and treatment interventions in community settings work when we respect a patient's confidentiality, autonomy, and agency. Fear of being 'outed' is deep-rooted, lead to stigmatisation and discrimination within families and communities and needs to be addressed. When communities lack trust, survivors do not come forward to access health services.

The fear of disclosure can discourage women and young people from seeking first aid, psychological treatment, HIV and STI medication, vaccinations and emergency contraception they desperately need in the aftermath of sexual violence. Health care professionals are also reluctant to provide much-needed services to survivors as they are constantly in conflict with the need to comply with mandatory reporting against their ethical duty of maintaining confidentiality.

The decision to report to law enforcement agencies should be determined in healthcare settings based on informed consent and dialogue with the survivor and accompanied with legal aid. 

The ministry of health guidelines allows recording of the survivor's informed refusal if they decide against reporting the sexual violence. Still, these need to be supported by corresponding legal amendments and quality one-stop crisis centres that maximise the accessibility of medical and mental health services to survivors.

The piece has been authored by Leena Menghaney, a lawyer and survivor who works with Médecins Sans Frontières (MSF).

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