Opinion Providing better medical assistance to survivors of gender-based violence

Chronic exposure to GBV, more so in domestic spaces, negatively impacts women’s participation in society, reduces life quality and hinders growth. Given the global burden of GBV and the enormity of its health consequences, the World Health Organisation (WHO) recognises GBV as a public health issue and recommends an organised response from the health system. Although survivors of GBV likely suffer from immediate health consequences, only one in 5,000 survivors ever seek medical help (NHFS-5).

What is survivor-centric care?

The little available research suggests that survivors of GBV hesitate to seek medical care due to fear of stigma, blame and the process of the criminal justice system. However, global evidence suggests that the provision of medical care through a survivor-centric approach enables survivors of GBV to seek medical care without fear. Survivor-centric medical care includes the provision of safe spaces for disclosure, patient autonomy, informed consent-based medical and mental health care (preventative and curative), consented collection of relevant forensic evidence and consented reporting to the police. The health care workers must maintain confidentiality and uphold the survivor’s dignity throughout the care process. The national medico-legal guidelines for the management of sexual violence, issued by the MoHFW in 2014 following the recommendations of the Justice J S Verma Committee, encompasses most principles of survivor-centred medical care. Yet, the uptake of medical care has not improved since; (NFHS 4 & 5) as the health system does not address the enormous barriers to health care faced by survivors of sexual violence (SV).

Over the years, the health system’s response to SV has evolved from providing medical care with forensic procedures in hospitals to setting up a more organised One Stop Centre (OSC) that provides a minimum package of medical, psychological, forensic, legal and social services. Further, various laws and guidelines governing rape, SV and DV prescribe minimum standards of physical infrastructure, staffing, and training of health care workers and is closely linked to the criminal justice system. While a prescribed minimum care package and quality standard is envisaged, such an exclusive and interdisciplinary care model can only be provided at secondary or tertiary levels of health care.

Policing vs privacy

However, evidence suggests that survivors of GBV greatly rely on the support of close confidants and often prefer to access medical care discreetly. Community-level health systems desist from providing care and tend to refer survivors of SV to higher centres and OSCs due to fear of legal issues and lack of medical training specific to SV. People fear social disclosure of incidents and greater stigma at larger health facilities (and OSCs). Further, doctors tend to mandatorily report the incident to the police, fearing legal prosecution. Currently, seeking or providing medical care without informing the police is not an option for doctors or survivors of rape and SV.

But mandatory police reporting by the health system further compromises confidentiality and ensuing criminal investigation procedures hamper the future of survivors. While survivors of SV may not always seek criminal prosecution, they may only want restoration of their health, dignity and livelihood. Hence, due to a plethora of access barriers to care, survivors of SV may not seek any care or may be forced to pay for service from private clinics or quacks.

Fixing the problem

Given the enormity of the health problem and barriers to accessing care, it may be wise to provide survivor-centric medical care for all survivors of GBV at all levels of the health system. Healthcare workers at all levels may be able to be first responders to all types of GBV. However, such an ambition requires changing the current system of response. In the past year, 30 senior experts from across the country deliberated on enabling the health system to respond better to the public health issue of GBV. Considering global evidence and national experience, the group proposes a seven-point agenda across three domains:

1. Legal reforms to create an enabling environment to seek and provide medical care without fear and interference from the police. All survivors, (including minors and female sex workers) should have full agency to decide on the need and timing of involving the police. Further, healthcare workers should be able to provide survivor-centric medical care, including safe abortion care without the fear of criminal prosecution for non-reporting of cases or noncompliance with forensic procedures.

2. Health system reforms to provide survivor-centric care through simplified medical protocols at the primary care level with referral pathways to higher levels. Secondary-level medical care and all forensic procedures are not required for most survivors of sexual violence. Primary health systems should engage with communities and create access to care by increasing awareness about GBV and its health consequences.

3. Sensitisation and training of all healthcare workers to provide survivor-centric care, which is currently limited to a select group of professionals. In the long run, the medical and nursing teaching curriculum should empower professionals with the requisite knowledge, skills and attitudes to provide quality survivor-centric care. Lastly, an exclusive research ecosystem needs to be nurtured to aid improvements in health systems.

In India, the provision of medical care, and the process of legal recourse and rehabilitation has considerably evolved for survivors of GBV and their families Nevertheless, we have significant evidence of the enormous systemic gaps in survivor-centred care (health, legal and social). We call upon the wider medical academia, legal experts, women rights activists and policymakers to confluence and chalk a pathway towards changing policy and practice in the best interest of the health of the survivors of sexual and gender-based violence in India.

Jagadeesh Narayana Reddy is professor and head, Department of Forensic Medicine, Vydehi Medical College and Research Institute, Bangalore; Padma Bhate-Deosthali is program director (SRH), CREA India; and Himanshu M is medical coordinator, Doctors without Borders, India. Reddy and Bhate-Deosthali are co-authors of the national medico-legal guidelines for the management of sexual violence, MoHFW, 2014