21 Dec, 12 | by BMJ
As a brutal rape attack in Delhi has outraged masses and spurred the demand for urgent action, my thoughts turn to to the thousands of cases every year that suffer in silence. I do hope this spirit of intolerance for violence sustains. While calls for the death penalty, chemical castration, faster court trials, and heightened vigilance demonstrate the disgust and anger we feel; they also affirm to a sense of helplessness—what could have been done to prevent such suffering and further, offer solace?
I am reminded of counselling sessions with sexual assault survivors in my role as a crisis interventionist. One particular memory that has stayed with me is of meeting a single mother who had been molested by a group of men. She was refused care at a private clinic on the premise that it was a police case and further by a government health centre citing lack of gynaecologists, when by law any registered medical practitioner may examine sexual assault survivors. At last she made it to a public hospital where she was further delayed as treatment was made conditional to registering a police case and getting admitted. Giving in to these demands of the system, she finally managed to get examined and receive first aid.
At the counselling session, I observed that she was astute and had many questions about what samples had been collected for forensic tests and how would these nail the culprits, about police interrogation and court trials, and seeking protection for herself and her child. What struck me as remarkable were her desire for justice and her willingness to fight so others don’t face a similar situation. Most survivors I have met often deal with feelings of guilt, fear, and shame, and they would want to erase the incident from their memory. She stood out as somewhat different. For her to heal, it was important to see the perpetrators punished.
This made me realise the importance of understanding what your patient wants and enabling an informed choice. Their needs may vary from treatment, counselling, an abortion, financial compensation, an interpreter, legal justice, protection, the time to decide, and no police investigation among others. And the law grants them the option to choose any and all of these. As the first point of contact, it is pertinent you explain these, respect the survivor’s autonomy to decide, and then facilitate their choice.
Doctors sometimes label survivors as “false cases” based on their judgement that there are no injuries; or that she is habituated to sexual intercourse; she presented in an intoxicated state and was dressed provocatively; etc. Proving the veracity of the survivor’s complaints does not really lie in the purview of a doctor’s responsibilities and should be left to the courts.
A pre-occupation with medico-legal aspects tends to divert from the primary responsibility of providing treatment. Coupled with tenacious administrative procedures, this may lead to secondary victimization of the survivor. I remember meeting the father of a child who had been assaulted. On Day 1, he had wanted to pursue legal recourse. But by Day 3 of forced hospitalisation, running from one department to another, multiple interrogations, loss of daily wages, and no semblance of privacy or confidentiality so that everyone from the ward boy to visitors knew who the “rape case” was—all the father wanted was to take his daughter home, and then move to another city for good.
It is possible to create systems that facilitate care for survivors at your hospital. Streamlining investigations, inter-departmental coordination, providing free treatment, linking with social support agencies, training nurses or para-medical staff to assist the survivor and protect her privacy, and other such initiatives may be pursued. Further, doctors sometimes fear legal procedures and court deposition. One must realise however, that this is a responsibility that accompanies the professional privileges of being a doctor. Staying updated on developments in law and medical procedures vis-à-vis sexual assault is essential. A document on “Legal changes towards justice for sexual assault victims” published in the Indian Journal of Medical Ethics may be useful.
As you take a lead, it may help you go beyond candlelight vigils and Facebook posts proclaiming solidarity to actually playing a role in healing the survivor.
Thank you to CEHAT (Centre for Enquiry into Health and Allied Themes), Mumbai, for their help with this article.
Anita Jain is the India editor, BMJ.