Rape victims

Caring for Survivors of sexual assault.
By-
Dr KIRAN PANDEY/ Dr PAVIKA LAL

1. CARING FOR SURVIVORS OF SEXUAL ASSAULT I AM A RAPE SURVIVOR. THE TRUTH I HOLD, TOOK YEARS TO UNFOLD, LOCKED UP AND NEVER TOLD NOW , I SPEAK, FOR I AM DONE BEING WEAK. A STORY I WILL TELL, AWAKENING THE PITS OF HELL.

2. DR KIRAN PANDEY ICOG GOVERNING COUNCIL MEMBER(2020-21) UPSC AGOI SECRETARY (2017-2019) FOUNDER PRESIDENT OF KANPUR MENOPAUSAL SOCIETY PROFESSOR & HEAD DEPT. OF OBSTETRICS AND GYNAECOLOGY GSVM MEDICAL COLLEGE KANPUR DR PAVIKA LAL ASSISTANT PROFESSOR DEPT. OF OBSTETRICS AND GYNAECOLOGY GSVM MEDICAL COLLEGE KANPUR

3. INTRODUCTION: The case of a 23 year old girl known as NIRBHAYA provoked unprecedented protests in India . Brutally raped by six men on moving bus in Delhi on December 16, 2012 and died after 13 days. After this news spread,nationwide outrage erupted. Protest movements were led by the commoners. ‘HANG THE RAPIST’ was the vociferous cry of I ndian media

4. Hyderabad Gang Rape, 2019 In November 2019,the gang rape of a 26 year old veterinary doctor near Hyderabad sparked outrage across India. She was gang raped , smothered and burnt beyond recognition. Protesters across India demanded stricter laws against rapists. The government of Andhra Pradesh passed a bill named ‘ DISHA ACT’ to award death penalty for rapists within 21 days after crime commitment.

5. CHILD RAPE: WHO estimated that 73 million boys and 150 million girls under the age of 18 had experienced sexual violence. India is home to 19% of worlds children. Total of 33,098 cases of sexual abuse were reported in 2011. For every 155 th minute a child, less than 16years is raped For every 13 th hour child under 10, and one in every 10 children are sexually abused at any point of time.

6. STATISTICS: The statistics are too scary and dreadful . At any given hour, day or year(one new case of rape is reported every 15 min ). According to NCRB 2013 annual report, 33,707 rape cases were reported,  in more than 94% of cases of rape, the perpetrators were known to the victims. Tragically, many cases go unreported due to concern about stigma or fear of retaliation and humiliation from their communities and families.

7. HEALTH CONSEQUENCES I PUSHED AWAY, FORCED DOWN I AM NOT DEAD, I SURVIVED RAPE SCARE STILL THERE, PEOPLE LOOK AT ME AND STARE I DID SURVIVE LIFE, I TRIED BUT DEFEATED BY MY KNIFE Sexual assault inflicts a life crisis upon the victim and raises the risk of re-victimization and trauma. TRAUMA MENTAL PSYCHOSOCIAL PHYSICAL

8. PHYSICAL HEALTH CONSEQUENCES : Severe abdominal pain. Sexual dysfunction/ Dyspareunia . Menstrual disorders. Urinary tract infections. Unwanted pregnancy. Miscarriage if victim is already pregnant. Exposure to Sexually transmitted diseases. Pelvic inflammatory diseases. Infertility. Unsafe abortion. Mutilated genitalia. Self-mutilation as a result of psychological trauma.

9. MENTAL AND PSYCHOSOCIAL HEALTH CONSEQUENCES : Short term Post traumatic stress disorder (94% of the victims experience PTSD) Emotional distress Intense self-disgust, powerlessness and worthlessness. Feeling of apathy and denial. Social withdrawal (isolation). LONG TERM SHORT TERM

10. Long term- Depression and chronic anxiety. Feeling of vulnerability and self-blame. Prone to addiction. Loss of trust in people. Chronic mental disorders. Suicidal tendencies.

11. RISK FACTORS FOR RE-VICTIMIZATION Females belonging to low socio-economic strata are more prone for re-victimization and becoming habitual sex workers thereafter. Unaccompanied children , children in foster care, adopted children and step children are at high risk of child trafficking . History of past abuse Physically or mentally handicapped children Single parent home Social isolation

12. CARE AND RESPONSIBILITY OF HEALTH PROFESSIONALS International guidelines indicate that a victim should receive adequate and proper forensic, medical and psychological care. They play an important role of providing 3Cs to the survivors: 3C Compassionate (care and concern for whatever they have experienced) Competent (treatment should be appropriate) Confidential

13. It is always important to establish a rapport with the survivor in the beginning: Never say or do anything to suggest disbelief regarding the incident. Do not pass judgemental remarks that might appear unsympathetic. Appreciate the survivor’s strength in coming to the hospital as it can serve to build a bond of trust. Counsel her that: she is not responsible for precipitating the act of rape by any of her actions it is not a loss of honour and it is the perpetrator who should be ashamed.

14. COMPONENTS OF CARE FORENSIC CARE Ensuring good quality , complete and non-judgemental documentation. Conducting a forensic examination by completing a ‘ rape kit ’, which is a pre-assembled box of instructions and containers designed to ensure evidence collection, occurs in a standardized, ordered and thorough manner . Maintaining a clear and fool-proof chain of custody of medical evidence collected.

15. MEDICAL CARE Antibiotics for treatment of STIs as per protocol(These infections include Chlamydia, Gonorrhea , HIV and Syphilis): give the shortest courses available. For post-exposure prophylaxis of HIV transmission: must be started as soon as possible within 72 hours of exposure with a recommendation of 28 days of course. Emergency contraceptive pills and/or copper bearing intrauterine devices within 5 days of unprotected intercourse will reduce the chance of a pregnancy by 56%-93%: Ulipristal 30mg PO once within 120 hrs. Tetanus : Tdap vaccine 0.5 ml IM and tetanus immunoglobulin 250 units IM. Hepatitis B vaccine : administer vaccine series and immunoglobulin within 24 hrs.

16. SURGICAL CARE Victims may have scratches, cuts, bruises, and superficial wounds which should be cleaned and antibiotics may be given to prevent wound from becoming infected. Forced penetration especially in children may lead to perineal tears-dealt with multidisciplinary approach especially with the involvement of pediatric surgeon .

17. PSYCHOLOGICAL CARE Provision of safe and empathetic environment so that women could share their experiences. Active listening , allowing for personal expression of emotions (distress, fright, guilt, shame, anger, depressive and anxious affect) about events. Assessing familial and social consequences. Normalizing women's reactions to reassure that most of the women who have undergone such violence are experiencing similar reactions. Working on coping strategies . Working on acceptance and development of future perspectives and plans. Let her know the available sources of support .

18. EARLY INTERVENTION Assess safety of the survivors . Help survivors understand their psychological responses. Aid survivors in making informed decisions and offer options. Coordinate access to referral resources. Assess for and respond to suicidal tendencies . Provide simple messages to tackle issues of self-blame and guilt. Discuss disclosure to family and friends. Screen those with delayed presentation for psychological indicators of PTSD. Recommend counselling and follow-up. ‘ I was devastated, I was made to give up my phone ‘

19. INTERMEDIATE AND LONG TERM INTERVENTION Focus on the treatments for the three main areas of common psychopathology : PTSD Depression Anxiety Cognitive behavioural therapies are more effective in reducing symptoms of PTSD than counselling

20. LEGAL CARE: In 2009, a new Section 357A was introduced which casts a responsibility on the State Governments to formulate schemes for compensation of victims of crime in coordination with the Central Government. Special fast track courts to strengthen the responsiveness and to shorten the delay in justice. Following widespread agitation after nirbhaya’s case , JUVENILE JUSTICE BILL was passed which permits those between 16 and 18 years of age to be tried as adults for heinous offences. Is it mandatory to go to Government hospital for sexual violence examination?- NO! SECTION 357 CrPC mandates all hospitals- government or private sector the responsibility of providing first aid or medical treatment free of cost; removing barrier which existed earlier of insisting government hospitals only.

21. COMPENSATION: Under Section 357 of the Criminal Procedure Code 1973, courts can award compensation to victims of rape.

22. PUNISHMENT: Thousands of rape victims are being denied justice. The CPS and police must do better. -Ministry of Justice Half of rape survivors drop out of cases even after suspect is identified. Women's rights group sues CPS over failure to pursue rape cases. Thousands of rape reports inaccurately recorded by police. People who report rape face ‘routine’ demands for their mobile data.

23. GUIDELINES FOR CHILDREN Extremely high chances of PTSD, re-victimization, and human trafficking in child sexual abuse cases. Principles of medical examination and treatment for children remains the same as that for adults. Specific points to be considered: If the child is under 12 years of age consent for examination to be sought from the parent or guardian. Do not assume that the child is young he/she will not be able to provide a history. History seeking can be facilitated by dolls or body charts. Believe and confide in what is being reported by the child. Doses of treatment will have to be adjusted as required.

24. CARE BY NGOs, SOCIETY AND GOVERNMENT SECTOR Various social organisations ( Gudiya , Azad, Rahi ) along with the government are playing an instrumental role against this violence. FOGSI has set a wonderful example by adopting Sakshi and sent a exemplary message to change the outlook of the society towards the survivor. Rescue women and children from unsafe environment and rehabilitate them at a safe shelter. Provide vulnerable women with financial support or vocational training to become self-reliant. Provide legal advice to help and understand her rights and initiate the judicial process to attain justice. Provide counselling and psychological rehabilitation.

25.   Mental health care by Psychologists or psychiatrists for survivors who require additional specialized supports. SPECIALISED SERVICES: Basic emotional and practical support by community workers. Social and economic reintegration initiatives NON-SPECIALISED SUPPORTS: Awareness programs to reduce stigma and promote access to services for survivors. STRENGTHNENING COMMUNITY AND FAMILY SUPPORTS : Supporting the inclusion of social/psychosocial considerations in protection , health services, shelter, and sanitation. Safe spaces for those at risk of sexual violence. SOCIAL CONSIDERATIONS IN BASIC SERVICES AND SECURITIES :

26. CONCLUSION: “ PUNISH THE RAPIST..SENSITIZE THE JUDICIARY..ERADICATE RAPE” Violence against women is deeply entrenched in the feudal, patriarchal Indian society. The need of the hour is to improve the crime investigation methodology. make it more scientific and quick as cases take too long to conclude, witnesses gets dissipated, memory frays and conviction becomes tougher. Every rape survivor has right to health, dignity, non-discrimination, information and confidentiality .

27. . Rape is the highest possible attempted crime against a woman and the punishment shall be to remove every point of his reference as a man. To eliminate the horror from the face of the earth, we need to accept capital punishment as an apt punishment for subjecting a woman to such an ordeal. When women are being raped and assaulted ,government and the police demands us to change our behaviour. WHY ARE WOMEN SUPPOSED TO CHANGE THIER LIVES FOR SEX OFFENDERS ? Short skirts don't rape women, nor do dark streets, or clubs, or alcohol, or parties, or sleepovers, or school uniforms.

28. Many candles marched for the rape victim to survive and when she finally did, same society ensured darkness for the rest of her life. If she's alone, Its not your opportunity, Its your Responsibility.