Marital violence may be more widespread than previously estimated, health centre-based interventions necessary: CEHAT report

As per the report, based on data collected from 3,435 women over 19 years, almost half of all women who faced domestic violence were victims of marital rape.

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THE prevalence of marital rape in India might be greater than previously estimated, with nearly half the victims of domestic violence reporting sexual violence in a marital relationship, a report by the Centre for Enquiry into Health and Allied Themes (CEHAT), a not-for-profit research organisation, claims.

The findings are based on 19 years of service records collected during the intake and follow-up sessions of survivors by counsellors from Dilaasa, a hospital-based crisis centre that is a joint initiative between CEHAT and the Brihanmumbai Municipal Corporation, Mumbai to provide psychosocial support to women survivors of domestic violence.

Additionally, an adverse impact of the violence on their mental health was reported by about 92 per cent of the women, with a large majority disclosing having suffered anxiety, depression, loss of sleep, and feelings of nervousness. Almost 32 per cent of the women reported having attempted suicide at some point in life.

Through this recently published report, and its past work in this regard, CEHAT aims to advocate for the implementation of appropriate health facility-based interventions, including building the capacity of healthcare providers, to deal with victims of violence more efficiently.

Often, healthcare providers are the first ones to encounter victims of violence, therefore, data acquired at the level of a health facility is useful in developing interventions for early identification of women facing violence and provision of support-services to them, CEHAT contends.

The Indian Penal Code makes an exception in Section 375 (which defines rape) for husbands, stating, “Sexual intercourse or sexual acts by a man with his own wife, the wife not being under fifteen years of age, is not rape.” The Supreme Court partially struck down this provision in its judgment in Independent Thought versus Union of India (2017), but only to the extent of prohibition on sexual intercourse between a man and his wife aged between 15 and 18 years.

The Supreme Court is scheduled to begin hearing on March 14 a batch of petitions seeking to criminalise marital rape. The appeals before the Supreme Court follow a split decision on the legality of the exception in Section 375 by a division bench of the Delhi High Court delivered in May last year.

Despite non-recognition of marital rape by law, a sensitive enquiry within a health facility can enable disclosure and support-seeking to mitigate sexual violence within marriages,” says the report.

Physical and mental violence

The intake form filled out by the counsellors working under Dilasaa documents information about demographic and socio-economic details of the victim, forms of violence experienced, health consequences (including on mental health), support sought by the survivor, and services provided by the counsellor.

Of the 3,435 women who found their way to Dilaasa to seek intervention services, around half came through the healthcare system, which the report presents as proof of the importance of having hospital-based intervention services. The other half originated from referrals from outside the system such as friends, community members, non-governmental organisations, law enforcement or communication materials.

Most women facing violence who sought out intervention services were within the age group of 18 to 35 years, a majority of whom were married, and either unemployed or employed in low- income/daily wage jobs and hence belonged to economically marginalised groups.

A total of 4,076 women were registered and provided services through Dilaasa in 19 years, with an average rate of about 215 cases per year. Of the 4,076, a total of 3,435 cases were considered for the present study after removing cases with missing information for selected key variables like age, marital status, and years of abuse, among other things.

The most significant finding of the report pertains to the prevalence of sexual violence in marital relationships, which is claimed to be around 49 per cent among all domestic violence victims. This reinforces the findings of the National Family Health Survey-5 (2019-21) which noted, “Among married women aged 18–49 who have ever experienced sexual violence, 82 per cent report their current husband and 14 per cent report a former husband as the perpetrator.

Marital rape was found to be the commonest form of sexual violence reported by women. Some reported being forced by their husbands to watch pornography or even to have sex with other men. Separately, reproductive control was reported to have been exercised in the form of forcing women to have children, not using contraception, and forced abortion.

Victims of physical violence were observed to have suffered injuries such as cuts, bruises and broken bones. Abortions, stillbirths and miscarriages were the other health outcomes of physical violence reported.

All women reported some form of emotional violence, including verbal abuse, which included insults, threats to harm the woman and/or her natal family, infidelity by the husband and restricting mobility. Young girls reported that their families were forcing them into marriages, and preventing them from having a choice of partner.

As mentioned above, the impact of violence on mental health was reported by about 92 per cent of women. Self-harming behaviour, including suicidal ideation and attempts, were recorded as common mental health consequences of domestic violence. Almost 32 per cent of the women reported having attempted suicide at some point in life.

Highlighting an anomaly in the usual healthcare response, the report notes that when women who survive a suicide attempt reach a hospital, the case is invariably recorded as that of ‘accidental consumption of poison’ and women are provided only medical treatment, without probing the underlying factors that triggered the attempt or addressing the mental health aftermath of suicide attempts.

Over the years, this has changed and all women and girls admitted with a history of ‘accidental consumption of poisoning’ are provided suicide prevention counselling and those who disclose a history of domestic violence are registered at Dilaasa for services,” the report claims.

Healthcare-based interventions

For many women, approaching law enforcement agencies or  NGOs may not only be difficult, but it may also put them at additional risk of violence from their abusers, the report notes. To this end, the existence of Dilaasa counselling centres within public hospitals as an out-patient department provides safe and non-stigmatised access of support services to survivors, CEHAT argues.

The majority of the women referred from the health system were in the hospital for assault-related injuries, indicating that the incident of violence had occurred just prior to their reporting in the hospital. Almost an equal percentage of women were admitted for attempted suicide, most commonly by the ingestion of poisonous substances.

The presence of hospital-based intervention services with appropriately trained healthcare providers is critical at this stage, as they may be most receptive to help and services, CEHAT states, making the case for the significance of making several pathways available to women to reach counselling services such as Dilasaa.

Apart from these obvious signs of abuse and violence, covert signs of violence can be identified by trained providers. Some of the most common covert signs included lack of sleep, anxiety, repeated health complaints and unwanted pregnancies.

Highlighting the significance of the early identification of signs of violence, the report notes that women who were referred by healthcare providers were much younger, thereby indicating health system response as an opportunity for early identification. A greater proportion of women (21 per cent) with less than one year of abuse were referred by healthcare providers as compared to women who came directly to Dilaasa (11.1 per cent).

The need for integration of clinical enquiry about violence during pregnancy into routine antenatal care services at healthcare centres is identified as another route to early identification of violence; this suggestion is bolstered by the claim that more than half of the survivors (57.8 per cent) experienced violence during pregnancy.

In nearly 34.4 per cent of the cases in which pregnant women were referred to Dilaasa by healthcare workers, unwanted pregnancy was a primary health complaint of women.

The findings of the…research indicate that training of healthcare providers along with establishing protocols, referral linkages and improving privacy and confidentiality can enable healthcare providers to ask about violence, provide first-line support and make external referrals. Thus, the presence of a facility-based crisis department is indispensable for building a health systems’ response to violence against women,” the report concludes.

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