Close encounters with doctors

What is it we talk about when we talk about rape?

Perhaps, now is the time for each of us to ask ourselves this question. A national opera of dread unfolded following 16 December 2012. Fear, fragility, injury—the usual impedimenta of misogyny— were everywhere. Paradoxically, or perhaps not paradoxically, there have been more rapes, more molestations, more murders, since that awful Sunday in Delhi.

What is it we talk about when we talk about rape?

My answer strives to distinguish between act and attitude. Are the two linked? I have no idea. But we do see act and attitude as parallels. Sometimes we think they merge. Sometimes they are indistinguishable: it is only a matter of degree.

There are also moments when they cannot be compared, and perhaps, that too is a matter of degree. While such a distinction may seem of little relevance in conversation, it can be enormously significant in certain positions of responsibility. The police, the judiciary, and the media come immediately to mind.

Not to me. I’m closer to another responsibility in which my training has placed me. I’m a doctor, and when I ask myself what do we talk about when we talk about rape, I am forced to answer from my vantage. My answer may be very different from yours.

Last month, the terrifying gangrape of a journalist in Mumbai seemed almost to mirror the events of Delhi last December. It became what is called a ‘high profile’ case. Hopefully, her first medical encounter was sensitive, and did not traumatise her further. Hopefully, the ‘attitude’ did not echo the ‘act’. The same cannot be said of victims further away from the public eye. Around this time, there was another horrific event in my city. A little girl was raped in a park.

There is something about the rape of a child that defies human reason. It is not just the enormity of rape itself, or even the cruelty of the injuries. Much more than the body of a child is damaged here. The offence is wider, because the rape of a child implodes our understanding of human-ness, of vatsalya, the compulsion to nurture and cherish. Baffled, society retreats into denial or amnesia.

But what of those appointed to help the child survive, what of their attitude?

One afternoon, in the 1980s, I went to hear Germaine Greer. She was well past The Female Eunuch then and veering towards Sex and Destiny, but the audience wanted to talk about that life-altering first book. It had altered their perception of rape.

“Every day, in so many ways, we’re raped,” one earnest speaker claimed. Ms Greer, exhausted by now, smiled patiently.

“It depends on what we talk about when we talk about rape,” she said.

I would have been less diplomatic. I would have told that earnest speaker she didn’t know what she was talking about.

I stayed silent, though, because speaking up would have meant relating what I had witnessed a few hours earlier, and that I wasn’t prepared to do. That morning I had been urgently summoned by a senior colleague. Her cheeks were flushed. Her eyes were shining.

“Come on! There’s a rape case, it’s really exciting!”

I followed her into the ward. A crowd ringed a cot on which, cowering in misery, and pulling her blood-stained frock down tight over her crossed ankles, was a child about the same age as my colleague’s daughter.

The other doctors who surrounded the cot were men. They were chuckling over a joke. The rapist had bitten the child’s face in his frenzy, leaving a gaping hole in one cheek through which her teeth showed. The joke that had the doctors in splits was about that gash.

Once the child’s frock was off, there were other, broader, jokes. They bet on the likely positions the rapist had taken. They rolled her over and inspected her like a piece of meat.

The next day, I went to the police lock-up to speak with the rapist. “Main jaanwar ban gaya thha,” he said.

My colleagues thought nothing of their attitude. It was, one of them spelt it out to me, the only possible response to rape. “It is a sex thing,” he said. “You gotta desensitise.”

The rapist in the lock-up did not know that his crime had given every doctor who examined his victim the freedom to rape her again, repeatedly. Only in word, and in imagination perhaps—but is that any less than in deed? The attitude was indistinguishable from the act.

Desensitisation is a word one hears a lot in medicine. There are rituals and pranks to desensitise the larval doctor towards cadavers, body secretions, bedpans, condoms and other ludic furniture of human urgencies. But these are all inanimate objects. Desensitisation towards the living surely is contrary to the ethic of medicine. And yet, it is the unspoken agenda of the medical curriculum.

That is not the truth—desensitisation is euphemism. The unspoken agenda of the medical curriculum is dehumanisation.

Two entities are dehumanised.

The second is not intended; it is collateral damage.

The intended target is a woman’s body. Dehumanisation begins by investing it with a new name. A woman is now female. Biologically correct, and perfectly acceptable in the clinical context. Until you begin to notice how the word sneaks into opprobrium in nonclinical contexts.

In nonclinical contexts, female is pejorative.

Any woman who is disliked does not need a name: she is that female.

No qualifiers are necessary: the word female encompasses every insult in the speaker’s vocabulary. And the speaker, very often, is female too. That amazes me. How can any woman use the word female with such deep loathing? An earlier generation used the word woman with similar misogyny. Both words code for the most sexist descriptive of a woman: cunt. Surely, at least within the medical curriculum, a woman’s body has a wider gestalt?

But there is collateral damage to be considered. The dehumanisation of a woman’s body has a definite mirror effect.

The examining doctor is dehumanised in tandem. One way or the other, the patient escapes the system, and recovers her humanness. The doctor does not. His (or her) dehumanisation is permanent.

North of the pelvis, things are no different.

I’m reminded of an eminent paediatrician, now happily dead, who lectured us on breast-feeding. At his clinic that day, the subject was a frail young woman, close on starvation. She was practically a living skeleton, her dark skin ashen from anaemia. She had a baby at her breast.

The Professor detached the baby and squeezed the mother’s breast to demonstrate a drop of milk at the nipple.

“Look at the Indian mother!” he raved. “I want you to remember this woman. She is starving. She is dying. But her breast continues to produce excellent milk. This drop has 1.1 per cent protein, 4.1 per cent fat and 7 per cent sugar. She will die with the baby still at her breast and that last drop will be as sweet as this one.” And he licked his finger appreciatively.

The woman snatched the baby from the professor and stormed out, her face burning.

Misogyny in medicine is so deep-rooted it passes without question in women students, in women doctors, in women nurses. You only need to walk into the Gynaecology Out Patient Clinic of a general hospital to experience it.

In teaching hospitals, undergraduates simply follow the lead of the officiating doctor. The patient, resigned to being probed by one gloved hand, now faces a terrifying queue. “Daro mat, yahaan sab doctor hain” is the cheery reassurance as hand after hand clumsily thrusts into her pelvis. If she resists she is an ‘uncooperative female’ and is loudly exhorted to loosen up, sometimes with a slap or two on her thigh. Nobody is shocked. The patient must recover from this humiliation and even thank her doctor for it.

Certainly, most undergraduates feel the outrage. Many assert their own sensitivity and judgment, and go on to become humane and caring doctors. But that is despite the system. The system is hardwired for misogyny.

And it is not as though the medical student needs to feel his/her way into the pelvic cavity. Today, every part of the body, short of the soul, can be imaged in real time.

How did it all get so crass?

As part of the clinical discourse, undergraduates must elicit the patient’s sexual history. The time-honoured phrase is ‘history of contact.’ Nine out of ten students will skip asking this and glibly claim ‘no history of contact’ without being found out. The unwise tenth sometimes gets slapped.

Actually, the question does not relate to the joys and sorrows of the patient’s sex life. It is nothing so intimate. It is meant to discover if the patient has a sexually transmitted disease, and it sounds vague because the last, and telling, phrase is omitted: is there history of contact with a prostitute?

I discovered this, like most undergraduates do, during my stint in the Skin and VD Department. It has a more polite label now, but nothing else has changed.

This particular outpatient clinic was the most degrading perversion of medicine.

Men queued up, unbuttoned and at the ready. The doctor brandished a ruler. It had a red band marking the 6th inch. His gloved fingers stayed strictly north of this. With the distal half he pushed, prodded and flipped the genitals on display.

No matter what he saw, his first question was always the same: Randi ke paas kab gaya thha?

I noticed that most men answered that with relief. The question absolved them of blame.

“Get to the source of infection,” the house surgeon exhorted us. “Get the whores treated. It’s the only way out.”

The hospital was on the fringe of Bombay’s red-light district. The house surgeon’s attitude sounded suspiciously like common sense. But was it? The answer lies in a very present predicament, avidly aired on national television following 16 December 2012.

One of the forensic examinations performed in a case of rape is the insultingly named ‘Two Finger Test’. It has no bearing on diagnosing rape or determining the extent of injury. Besides being an injury in itself, the Two Finger Test is meant to judge if the patient is ‘habituated to sexual intercourse.’ This is downright offensive to the victim.

It is also more than a century old. Forensic textbooks still carry it. Forensic experts still carry it out and courts are quick to dismiss a case of rape in which the victim is reportedly ‘habituated to sexual intercourse.’

Despite a recent Supreme Court ruling [18 July 2013], the test is still far from expunged.

The new ICMR (Indian Council of Medical Research) guidelines state:

The two-finger test of admissibility should not be performed in cases of sexual assault as information about past sexual conduct has been considered irrelevant to the case in several judgments (Sec. 146 of the Indian Evidence Act & deletion of Sub-section (4) of Sec. 155.) Even the test has no scientific validity and is subjective. On the basis of test results doctors should not identify (1) that victim is habituated to sexual intercourse or not.

This has yet to be implemented by forensic experts. For it to percolate into medical textbooks might take a century or more.

The misogyny implicit to the Two Finger Test has a long memory, and like much of our mechanistic protocol, that memory too is British.

The secretive Contagious Diseases Acts of the 1860s were implemented in Indian cantonments long before the British Parliament actually read them for what they were. While the actual wording of these laws and their repeal has been studied and analysed by Indian historians, the shift in medical ethic they brought about has passed without comment. As a result of these laws, Indian women were regimentalised as prostitutes for British soldiers.

In principle, this was meant to control venereal disease in the army. The British farmed Indian women into chaklas (brothels) where they had to present themselves for periodic examinations. The Two Finger Test had its beginnings here. Any woman who seemed suitable could be (and was) spirited away to a chakla by agents, and subjected to this degrading test. Her ‘moral laxity’ confirmed, she was then set to serve the British Army.

Hospitals conducted periodic pelvic examinations on such ‘licensed prostitutes.’

The records of ‘Lock Hospitals,’ written in stiff upper-lipped Imperialese, make heart-rending reading today.

Many doctors, Indian and British, protested angrily against these ugly laws, but the medical curriculum absorbed them eagerly into its system. Without question, these laws changed the way medical students were informed about a woman’s body. The attitude mimicked the Contagious Diseases Act.

Women in medicine, unquestionably, are targets of misogyny themselves, especially those in fields that used to be regarded as male preserves. That is a bitter battle, certainly, but I’m not writing about it here. What I talk about when I talk about rape is the vulnerability of a woman’s body to abuse by the system. Medicine is a protective science. Unless its students are taught to oppose the misogyny in textbooks and routine procedures, they will continue, perhaps in all innocence, to perpetuate rape. Because in medicine, the attitude is the act.

Ishrat Syed and Kalpana Swaminathan are surgeons. They write together as Kalpish Ratna. Their novel The Quarantine Papers is now available in paperback.

Note: A correction was made to this article after it was published