BMJ 2013;346:f229 doi: 10.1136/bmj.
f229 (Published 11 January 2013)
Editorials
Preventing and managing violence against women in
India
Requires a systems approach to reforming the culture of the health system
Anita Jain India editor, BMJ
BMJ, India
In 2011, 24 206 cases of rape were reported in India, and an
Indian nationwide survey showed that more than a third of all
women aged 15-49 years had experienced physical or sexual
violence at some point.1 Most women (85%) who experienced
sexual violence told nobody, and only 8% ever sought help.
Sources of help typically included family and friends.
Institutional sources such as the police, medical professionals,
and social organisations seemed to be the last resort, approached
by less than 5% of women facing violence.2 The real picture
may be even worse because of under-reporting and a social
structure that normalises violence in women’s lives. These
statistics beg questions about the systems in place to prevent
violence against Indian women and to offer appropriate support.
The recent violent gang rape of a paramedical student in a
moving bus in New Delhi and her subsequent death have
resulted in widespread outrage throughout India.3 However, it
is crucial that this should propel change beyond punitive
measures against the perpetrators in this particular case and in
the direction of ensuring that systems are in place to offer
appropriate and accessible care and support to women who face
violence.
In 1996, the World Health Assembly recognised prevention of
violence as a public health priority and called for urgent
measures to eliminate violence against women.4 The United
Nations Millennium Declaration avowed to combat all forms
of violence against women by promoting equality between the
sexes and empowerment of women as one of the eight
millennium development goals.5 Prevention of gender based
violence encompasses interventions at three levels. Primary
prevention seeks to prevent perpetration by targeting root causes
such as inequality between the sexes, social norms, parenting
practices, and substance misuse. Secondary prevention includes
immediate response to survivors through services such as
medical treatment, counselling, protection, and legal assistance.
Tertiary prevention encompasses long term responses directed
at rehabilitation and reintegration of survivors and perpetrators.6
Studies in the public health sector in India have documented
that doctors tend to prioritise their forensic role when responding
to survivors of sexual assault over their role in providing
ajain@bmj.com
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Page 1 of 2
EDITORIALS
appropriate care for the victim.7 8 Inadequate training and
prejudiced beliefs result in hesitancy and insensitivity in dealing
with victims. Consent for medicolegal procedures is often
reduced to a formality that documents the patient as being either
“willing” or “not willing” to undergo examination as a whole,
with no option to refuse any part of the examination or police
notification. Hospitals lack uniform treatment protocols and
policies for prioritisation of services, privacy, role of staff, and
interface between departments and external agencies. As such,
inconsistent treatment, delays, forced admission, and multiple
referrals are common. Provision of psychosocial support is
largely absent. In the absence of standard guidelines for the
collection of forensic evidence, inappropriate samples and
inaccurate documentation may undermine the presentation of
a case in court.7-9
The United Nations Convention on Elimination of all Forms of
Discrimination against Women recognised that violence impairs
women’s human rights, including the right to the highest
standard attainable of physical and mental health. India, having
ratified the convention, is legally bound to put its provisions
into practice. These include measures to overcome all forms of
gender based violence; laws that offer adequate protection to
women and respect their integrity and dignity; support services
that include refuges, specially trained health workers,
rehabilitation, and counselling; effective complaints procedures
and remedies including compensation; and ensuring that public
officials are not prejudiced against women.10
Developments in Indian rape laws have largely been catalysed
by women’s movements and, sadly, often only after public
uproar over horrendous cases such as the recent gang rape in
Delhi.
In a landmark judgment in 2009, the Delhi High Court for the
first time recognised the need for care and healing of survivors
and emphasised the collective responsibility of multiple
agencies. It laid down guidelines for police, hospitals, child
welfare committees, and courts. It also led to the establishment
of crisis intervention centres to offer legal counselling and aid.
The use of sexual assault forensic evidence kits was mandated
at all public hospitals. A separate room was to be allocated to
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BMJ 2013;346:f229 doi: 10.1136/bmj.f229 (Published 11 January 2013)
ensure privacy during examination.11 After a directive by the
Supreme Court in 1994, the National Commission for Women
evolved a scheme for financial assistance and support services
for rape survivors. This scheme was to be implemented from
2010; however, bureaucratic procedures still stifle its
realisation.12
Standard templates for forensic examination have been
developed by the Maharashtra and Delhi state governments and
the Indian Medical Association. These, however, continue to
refer to the “moral character” of a woman by requiring doctors
to comment on the size and laxity of the hymen and the finger
test indicating “habituation to sexual intercourse.” These
practices have been proved redundant by science, are prohibited
by Indian law, and violate the woman’s dignity and rights.13 The
Criminal Law (Amendments) Bill, 2012, widens the scope of
the offence of sexual assault. However, the bill fails to deliver
on guidelines for medical examination and care of survivors.14
It is clear that recent changes continue to focus on the forensic
role of doctors, rather than on their remit to provide
comprehensive care to survivors. Comprehensive and sensitive
care must deal with the medical, legal, and psychosocial needs
of the survivor from the first point of contact through to the
final stages of recovery and reintegration.15 Although training
and protocols may lead to some change, a “systems approach”
is needed to achieve broad reforms in health organisations. The
professional culture needs to be reoriented towards convincing
health professionals that violence against women is a health
concern and that responding to it is a part of their job.16 A
Mumbai based non-governmental organisation, Centre for
Enquiry into Health and Allied Themes (CEHAT), has been
engaging with the public health system to institute such systemic
change at the practice and policy level, and it has formulated
guidelines for the Indian healthcare context.17 Integration in
national policy remains the next challenge.
Competing interests: The author has completed the ICMJE uniform
disclosure form at www.icmje.org/coi_disclosure.pdf (available on
request from the corresponding author) and declares: no support from
any organisation for the submitted work; no financial relationships with
For personal use only: See rights and reprints http://www.bmj.com/permissions
Page 2 of 2
EDITORIALS
any organisations that might have an interest in the submitted work in
the previous three years; AJ was employed as research officer at CEHAT
in Mumbai in 2011-12 and worked on health system interventions for
sexual assault survivors.
Provenance: Commissioned not peer reviewed
1 National Crime Records Bureau, Ministry of Home Affairs. Crime in India 2011 report.
Chapter 3. Violent crimes. http://ncrb.nic.in/CD-CII2011/Home.asp.
2 National Family Health Survey India Reports. Chapter 15. Domestic violence. 2005-2006.
http://hetv.org/india/nfhs/index.html.
3 Ballia. As hundreds wail, Delhi gangrape victim’s ashes immersed. The Indian Express
2013 Jan 1. www.indianexpress.com/news/as-hundreds-wail-delhi-gangrape-victims-
ashes-immersed/1052907/0.
4 World Health Assembly. Prevention of violence: a public health priority, WHA49.25.
Resolution of the World Health Assembly, 49th session. 1996. www.who.int/violence_
injury_prevention/resources/publications/en/WHA4925_eng.pdf.
5 WHO Department of Gender, Women and Health. Addressing violence against women
and achieving the millennium development goals. 2005. WHO/FCH/GWH/05.1. www.who.
int/gender/documents/violence/who_fch_gwh_05_1/en/index.html.
6 Loots L, Dartnall L, Jewkes R. Global review of national prevention policies. Sexual
violence research initiative and the South African Medical Research Council. 2011. www.
svri.org/GlobalReview.pdf.
7 Pitre A, Pandey M. Response of health system to sexual violence: study of six health
facilities in two districts of Maharashtra. Centre for Enquiry into Health and Allied Themes,
2009. www.cehat.org/go/ResearchAreas/ItpstPublications.
8 Contractor S, Venkatachalam D, Keni Y, Mukadam R. Responding to sexual assault: a
study of practices of health professionals in a public hospital. Centre for Enquiry into
Health and Allied Themes, 2011. www.cehat.org/go/Publications/Home.
9 Prasad S. Medico-legal response to violence against women in India. Violence Against
Women 1999;5;478-506. http://vaw.sagepub.com/content/5/5/478.abstract
10 Committee on the Elimination of Discrimination against Women. General recommendation
no 19. Violence against women. 11th session. 1992. www.un.org/womenwatch/daw/
cedaw/recommendations/recomm.htm#recom19.
11 Jagadeesh N, Deosthali P, Contractor S, Rege S, Malik S. A comprehensive health sector
response to sexual assault: does the Delhi High Court judgement pave the way? CEHAT
12
working paper no 1. www.cehat.org/go/WorkingPapers.
Dogra CS. Red tape holds up financial support for rape victims. The Hindu 2012 Dec 27.
www.thehindu.com/news/national/red-tape-holds-up-financial-support-for-rape-victims/
13
article4242340.ece.
Human Rights Watch. Dignity on trial. 2010. www.hrw.org/reports/2010/09/06/dignity-trial-
0.
14 Lawyers Collective. BLOG. Comments on the Criminal Law (Amendment) Bill, 2012. 2012.
www.lawyerscollective.org/blog/comments-criminal-law-amendment-bill-2012.html.
15 WHO. Guidelines for medico-legal care for victims of sexual violence. 2003. www.who.
int/violence_injury_prevention/publications/violence/med_leg_guidelines/en/index.html.
16 Population Reference Bureau. The crucial role of health services in responding to
gender-based violence. 2010. www.prb.org/Articles/2010/genderbasedviolencehs.aspx.
17 Centre for Enquiry into Health and Allied Themes. Manual for medical examination of
sexual assault. Revised edition. 2012. www.cehat.org/go/Publications/Home.
Cite this as: BMJ 2013;346:f229
© BMJ Publishing Group Ltd 2013
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