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Monday, July 23, 2018

Checking for Vital Signs

The rights of a victim at a hospital,and if the medical community is respecting that

Published: December 15, 2013 5:33:49 am

by Pritha Chatterjee

In the aftermath of the December 16 gang rape,the recommendations of the Justice JS Verma Committee brought into effect a new stringent law in April,to empower victims of sexual offences. The Criminal Law (Amendment) Act replaced “rape” with the broader ambit of “sexual assault” to include not just penile-vaginal intercourse,but stalking,e-stalking,and voyeurism as non-bailable offences. It also broadened the legal definition of rape,with all kinds of penetration covered under the ambit of rape. Acts like forcing someone to touch or apply their mouth on private parts was also made a sexual offence.

But at hospitals,often the first institution that a sexual assault victim encounters,both for the purpose of evidence and treatment,the amendments have created a confusion in parts. “The lack of any government-drafted protocol for doctors to manage victims of sexual violence,particularly after changes in the law,has meant many doctors don’t know the kind of evidence needed in the broader ambit of sexual violence,” says Dr SK Gupta,head,forensic medicine,All India Institute of Medical Sciences (AIIMS),Delhi.

The Union health ministry has been working on releasing guidelines on medical examination for over a year. “We have tried to get inputs from all stakeholders,including National AIDS Control Organisation (NACO),civil society groups,lawyers and have consulted several international guidelines. We expect to release them sometime next year,” a health ministry official said.

In the meanwhile,hospitals are trying to sensitise their staff to the nature of grievous injuries that may be associated with sexual assault. Dr BD Athani,medical superintendent of Safdarjung hospital,Delhi,where the December 16 victim was first brought and treated,says the case has been a learning experience for his doctors. “Our doctors were alert enough to conduct an X-ray of her abdomen,despite there being no obvious indications besides the genital bleeding,and she was rushed to her first surgery. That’s when we realised the extent of her intestinal injuries,” says Athani. So grievous and extensive were those,that it required the intervention of several intensivists,surgeons and gynaecologists.

Despite the stir created by the case,Gupta says there is still ambiguity in grasping the concept of holistic medical examination among doctors. “It is the right of the victim to get prophylactic treatment against sexually transmitted diseases,and I-pills for prevention of pregnancy if there is sexual intercourse. If a victim does not have visible injuries but gives a history of insertion of objects,scans must be conducted and examination done under anaesthesia if required,” he says.

But doctors say necessary tools like kits to give prophylactic treatments is often missing in hospitals. A gynaecologist from Lok Nayak hospital in Delhi said,“There has been no supply of STI kits for almost two years now from NACO,even though we see the sexual assault cases.”

The victim,as per the law,has a right to free first aid and/or medical treatment. In several cases of grievous assault where there are internal injuries,the victim has a right to free surgical intervention,even if it requires multiple surgeries over a period of time. Any victim brought to a hospital also has the right to seek free psychiatric treatment and counselling,and sustained follow-ups to deal with her trauma. But in the legal process of evidence gathering and ensuring immediate physical well-being like avoiding STDs and infection,the psychological trauma of the victim and her family often gets lost.

Despite a new law to protect children against sexual assault,PCSOA,child victims continue to face a particularly tough time. Months after the December 16 case,a five-year-old girl was gang-raped in east Delhi. At the municipality-run Swami Dayanand hospital,doctors,after initial assesments,rushed her to an X-ray and then an examination under anaesthesia. “We found an oil bottle,pieces of broken candles. Even though we did not have a pediatric anaesthetist or a surgeon,we had no option but to do an examination. As a government hospital,we get many cases of sexual assault and many minor victims. But we don’t have any pediatricians and since there are no guidelines,we conduct the examinations,” says a senior doctor on condition of anonymity.

Raj Mangal Prasad from Pratidhi,an NGO in Delhi working with victims of sexual crisis,particularly children,says,“In the past one year,we have had several instances where parents have been talked into refusing medical examination of their children by doctors. Instead of explaining the examination as a necessary part of evidence gathering,doctors scare parents. In cases where there is no penile penetration,doctors don’t check for a history of other forms of assault. We need to have dedicated guidelines for medical examination of child victims.” He talks of a case in which doctors were recommending drug-induced abortion to a minor sexual assault victim who had become pregnant. It would have killed all evidence,but the doctors were not sure about the protocol of preserving DNA samples of the foetus for evidence.

The controversial per vaginal examination commonly known as the Two-Finger Test (TFT) has been banned by the Supreme Court; states like Maharashtra and Delhi have issued advisories directing doctors not to conduct it. The insertion of one,two or three fingers into the vagina was used as evidence to state a woman’s habituality to sexual intercourse. This was often used by the defence to establish the woman’s complicity. But despite the ban,many hospitals continue to do the test.

Forensic specialists say doctors also need training in collection of samples: clothing,oral or vaginal swabs,for evidence. “Government supply of kits is short,and investigating officers refuse to take samples otherwise. We try to collect samples in cotton swabs,and preserve them inside test tubes. We are yet to have a guideline on this,” a gynaecologist from AIIMS says.

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