THE PROTECTION OF WOMEN FROM DOMESTIC VIOLENCE ACT, 2005 (‘PWDVA’) is one of the first civil legislations to integrate the role of Healthcare Providers (‘HCPs’) in identifying and responding to domestic violence in India. Despite extensive global evidence on health impacts of domestic violence, there was hardly any policy engagement with health systems to respond to violence. One of the earliest efforts in India was Dilaasa, a public hospital-based crisis intervention department in Mumbai. It was set up in 2000 as a joint initiative between the Centre for Enquiry into Health and Allied Themes (‘CEHAT’), a non-governmental research organisation, and the Brihanmumbai Municipal Corporation (‘BMC’).
Health system interventions are premised on the recognition that violence has many overt and covert health consequences. Healthcare encounters provide a critical window of opportunity to identify and support survivors, particularly when abuse restricts women’s mobility and access to other forms of support. This makes hospitals strategic sites for early identification and timely intervention to disrupt the cycle of violence. The Dilaasa model was the first of its kind to train health professionals to identify survivors during routine clinical care, provide first-line support and information, and refer them to hospital-based counsellors for psychosocial support, crisis intervention, and coordinated linkages to relevant services.
As conversations around the need for a civil law for domestic violence gained momentum in the early 2000s, evidence from models like Dilaasa strengthened the case for recognising domestic violence not just as a social and legal issue but also a critical public health concern. A retrospective review of counselling records between 2001 to 2004 found that among 923 women who sought Dilaasa services, 40 percent were between 15 to 25 years, while 35 percent were 26 to 35 years. One-third of these women presented with physical assault-related injuries, 20 percent were admitted for ‘accidental poisoning’ (most commonly suicide attempts), and 16 percent sought care for reproductive health concerns, including unwanted pregnancies, vaginal discharge, and sexually transmitted infections. These insights highlighted the diverse health manifestations of domestic violence and reinforced the need to integrate the role of health professionals’ within the statutory framework.
The PWDVA recognised public health facilities as service providers and mandated that women experiencing violence must receive free medical treatment as well as information and referral to Protection Officers (‘POs’) where desired. Healthcare providers were expected to identify signs of domestic violence, provide sensitive emergency care, comprehensively document health impacts, and provide survivors with a free copy of their medical records.
The Dilaasa model was scaled-up under the National Urban Health Mission (‘NUHM’) in 2015 across eleven municipal hospitals in Mumbai. This led to the institutionalisation of dedicated infrastructure, human resources, and Standard Operational Protocols, and monitoring mechanisms for responding to gender-based violence under the leadership of the BMC. CEHAT continued to support the BMC as a technical partner to strengthen systems and build capacity of healthcare providers to respond to domestic violence in a survivor-centered manner. Drawing on more than two decades of partnership with the BMC, we seek to examine how the health-sector provisions of the PWDVA have been implemented in practice.
Identification of Survivors in Clinical Settings
An analysis of 19 years of case records from the first hospital where Dilaasa was instituted shows that nearly half of the cases that came to the crisis intervention department were identified by healthcare professionals in casualty or Out Patient Department (‘OPD’) settings. Health consequences like physical assault or attempted homicide by an abusive partner accounted for around 42 percent of healthcare providers’ referrals to Dilaasa. Nearly half of the survivors (48 percent) were identified and referred by doctors and nurses following suicide attempts or other health complaints. This pattern of referral suggests that, when appropriately trained, healthcare providers not only recognise the most overt health consequences, but are also attentive to the signs of violence that may not be obvious.
A senior medical officer at one of the public hospitals recounted, “I treated a woman having maggots inside her hair and asked her to follow up after a week but she came after a month. Someone having maggots will not delay treatment…I felt suspicious and so took her to a private place for an examination and asked her if she had any problem at home. She did not respond to my inquiry at that point. After a few days she came to me and shared about violence she has been facing.”
A senior counselor who has been associated with Dilaasa for nearly two decades observed, “I have seen cases where doctors have played a proactive role. For example, in one case a psychiatrist brought the survivor to us. She was receiving treatment for depression, but comprehensive history-taking by the healthcare provider revealed that domestic violence was one of the major triggers. The doctor thought she would benefit from Dilaasa counseling. In another case, a woman was referred to us by the pediatrics department because her child had been brought to the hospital with repeated fractures. The doctors suspected that the mother and child could be experiencing domestic violence.”
Healthcare providers also routinely refer women presenting with attempted suicide to the crisis intervention department, alongside psychiatric referral. This reflects how years of Dilaasa’s engagement with healthcare providers have shifted clinical understanding towards recognising that suicide attempts among women, particularly younger women, often stem from domestic violence in marital or natal families.
Training has also enabled healthcare providers to understand that signs such as low haemoglobin, poor nutritional status, history of repeated pregnancies, or repeated abortions can also possibly be signs of domestic violence. This has made healthcare providers more vigilant in identifying potential abuse during antenatal checkups and gynaecology consultations.
Providing Information and Enhancing Safety
Healthcare providers are trained to sensitively and privately probe patients in cases where clinical signs and symptoms may not correlate with history given. As a best practice, even if women patients do not disclose violence, healthcare providers inform them about support services and encourage them to visit Dilaasa for further support.
A Matron from one of the public hospitals told The Leaflet:
“Sometimes the nurses may go to the patient for some procedure, or during examination they may find a mark or something on the patient’s body and may ask if she has any problems at home. If the woman says yes, then they refer her to Dilaasa. But if she says no, and the nurse still feels suspicious, she may still refer the patient to Dilaasa.”
CEHAT’s research on domestic violence in pregnancy in 2018 also showed that post-partum women with girl children would often have no visitors at the hospital. These non-clinical signs are also indicative of domestic violence, and trained healthcare providers provide counseling referrals for such patients as well.
Dilaasa staff also conduct regular health talks in outpatient and inpatient departments several times a week and distribute knowledge products that provide information on domestic violence, its health impacts, and how to access Dilaasa services. In the year 2024-2025, nearly 20,000 women who accessed public hospitals in Mumbai were reached through this dissemination process.
The PWDVA recognises that women experiencing violence have diverse needs and may not always be in a position to file a criminal complaint or leave the violent household. As outlined in the SOPs, once survivors are identified and referred to the hospital-based counselling centre, counsellors conduct a safety assessment to evaluate the frequency and severity of violence, the level of risk to the survivor, and its impact on her physical and mental health. The counselors then co-create a safety plan with the survivor, tailored to her needs and resources. The counsellor may share emergency contact numbers, encourage her to inform trusted neighbours, identify safe escape routes in case of physical violence, and advise her to keep aside money and important documents. They also provide survivors with the CEHAT 24x7 helpline number, so that they can reach out in case they are feeling deeply distressed.
At this stage, survivors are also given detailed information regarding the PWDVA and linked with the protection officer, if they wish to pursue a legal route. Counselors also support survivors in approaching the police to register an FIR or NC or to find temporary shelter. In fulfilment of their responsibility to ensure survivors' safety under the PWDVA, hospitals may provide “social admissions” for up to two to three days to women in vulnerable situations, irrespective of whether they require medical treatment or hospitalisation.
Comprehensive Documentation
Clear and complete documentation of health consequences of violence can be crucial evidence for survivors to obtain reliefs under the PWDVA. Under the law, healthcare providers are also empowered to fill the Domestic Incident Report (‘DIR’) and forward the copy to protection officers, but this rarely happens in practice. However, as a part of clinical practice, they create other kinds of medico-legal documentation that may aid the survivor. In case survivors have reported to the hospital with a medical emergency, a medico-legal case paper created at the casualty may document evidence such as injuries. Admission and discharge papers, pathology reports, and bills of medical expenses etc. may be attached to DIRs by protection officers as evidence of violence.
“Medical documentation is important in securing favorable court outcomes for survivors, especially in cases of severe physical violence and chronic illness,” a Protection Officer from Maharashtra told The Leaflet, “Chronic medical conditions such as glaucoma, diabetes, hypertension, and stress-related illnesses may be both consequences of domestic violence and factors that intensify violence against survivors.”
A prominent lawyer from Mumbai who regularly represents women in domestic violence cases explained that “in many cases medico-legal case papers can be helpful for obtaining protection orders and residence orders since judges see such documents as definitive evidence of violence. I have also noticed that a history of chronic illnesses or medical conditions are taken into account by judges for providing monetary relief, and in fact, the relief may be higher when such history is available,” she shared.
However, there remain many gaps that can undermine the evidentiary value of medico-legal documents. Both the protection officers and the lawyer told The Leaflet that in many cases medico-legal case papers lack the name and relationship with the perpetrator. “The MLC (medico-legal certificate) only says ‘history of assault by a known person.’ This is not very useful as evidence of domestic violence,” the lawyer noted.
Another Mumbai-based Protection Officer shared that there are several shortfalls in documenting the mental health consequences of violence. Prolonged emotional abuse and psychological trauma are often inadequately documented by healthcare providers. This leaves survivors without formal records that could aid Protection Officers and the courts in recognising the cumulative impact of domestic violence.
Bolstering Efforts for Institutionalisation
More than two decades after the enactment of the PWDVA, substantial progress has been made in recognising domestic violence as a public health concern. Hospital-based models such as Dilaasa have demonstrated the feasibility of integrating domestic violence response within routine healthcare and informed scale-up across Mumbai and replication in several states like Haryana, Karnataka, Goa, Meghalaya, Gujarat, and Kerala. The recognition of gender-based violence as a public health issue in the National Health Policy (2017) and the envisioning of One Stop Centres as integrated support mechanisms proximal to public health facilities have further strengthened the policy mandate for the health sector to identify, document, and respond to domestic violence.
Although the PWDVA and the National Health Policy recognise the health sector’s role in responding to domestic violence, they are not accompanied by a systematic implementation framework to operationalise these responsibilities across states. Building blocks such as leadership commitment, provider training, standard operating procedures, referral networks, dedicated resources, and systems for documentation and monitoring remain inconsistent across states. This has a real impact on how survivors are able to access the reliefs promised under the PWDVA. Survivors who reach the health system continue to remain invisible. Even when they disclose violence, they frequently do not receive comprehensive psychosocial support, legal referrals, or high-quality medico-legal documentation necessary for care and access to protections under the PWDVA.
A recent study of MLCs in Delhi found that domestic violence was rarely documented explicitly and was often recorded simply as “alleged physical assault,” lending scope for misinterpretations. Research with healthcare providers has identified lack of training, absence of standard operating procedures, and weak institutional support as major barriers to implementation.
Strengthening the implementation of health sector obligations under the PWDVA requires moving beyond legislative recognition towards institutionalisation within routine healthcare. This will require integrating domestic violence-related indicators into Health Management Information Systems (‘HMIS’) to improve identification and documentation. State governments should also establish monitoring and accountability mechanisms for health institutions, similar to those under the Pre-Conception and Pre-Natal Diagnostic Techniques Act, 1994 and the Medical Termination of Pregnancy Act, 1971. Compliance with protocols for responding to domestic violence should form part of hospital quality assessment and accreditation processes. Finally, domestic violence response should be embedded within medical and nursing curricula to equip future healthcare providers with the knowledge and skills to deliver survivor-centred care.
Acknowledgement: The authors sincerely thank the Dilaasa team and Health Care Professionals for their invaluable work and their suggestions while preparing this article. The authors would also like to thank the protection officers and lawyers who provided the important insights that inform this article.
