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
Indian 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 155th minute a child, less than
16years is raped
•For every 13th 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.