Mumbai, India - It is mid-morning at the women and children's block of the KB Bhabha Hospital, one of Mumbai's busiest public hospitals. The hubbub is punctuated by the cries of a baby, and the contented whirring of pigeons settling to roost. A short distance from the row of open consultation cubicles with thickets of women waiting before them is a closed door marked "101".

Inside, a group of women read from files, exchanging tales of unremitting male cruelty: men who bang women's heads against walls. Men who force women to sleep with them, slowly empty out their bank accounts, and then force them to sleep with them again. Men who force women to have unprotected sex with them at night, and force emergency contraceptives down their throats in the morning. Men who rain repeated blows on their wives' swollen abdomens and end their pregnancies. Men who force their wives to watch graphic videos, and then submit them to the painful acts they depict.

Bleak as these stories are, it's unusual that they are being heard at all.

The National Family Health Survey-III (NFHS-III), published in 2005, found that while 37.2 percent of women who had ever been married had faced spousal abuse, only 2 percent sought help from the police. According to the same survey, about half of these women ended up in hospital at some point owing to the violence they experienced.

Over the past few years, social workers and healthcare workers in Mumbai's public hospitals have used this as an opportunity to identify and help women in distress. Some train nurses and doctors to spot signs of abuse; others deploy neighbourhood field workers, usually housewives themselves, to encourage women to seek help at crisis centres like that at KB Bhabha Hospital. Unlike the default option - going to the police and setting off an irreversible, uncontrollable process - this approach ensures that women get the support they need, without the official scrutiny. Giving women agency and privacy, social workers say, could help to arrest the cycle of violence early on, and prevent tragedy.

The socialisation of domestic violence

Many factors make it difficult for women to seek help in India. Foremost among them is that women are socialised early on to submit to unfair treatment and even violence.

"It's ingrained with them from the beginning that they have to 'adjust' to whatever their lot is, because marriage is a must, marriage is for life, that your husband is akin to a god to you, and that without him you're nothing," says Flavia Agnes, a lawyer whose experience of domestic violence inspired her to fight for women's rights.

The programming is so effective that a higher proportion of women, compared with men, find wife-beating justifiable under some circumstances, according to the NHFS-III. Beatings are considered acceptable by more than 50 percent of both sexes. The extenuating circumstances include failing at one's domestic duties, such as not cooking food properly, neglecting one's household and children, and disrespecting one's in-laws.

It's ingrained with them from the beginning that they have to 'adjust' to whatever their lot is, because marriage is a must, marriage is for life, that your husband is akin to a god to you, and that without him you're nothing.

Flavia Agnes, lawyer and women's rights activist

The fact that marital rape is still not a crime is an extension of this logic. "Women are considered good women or bad women according to how well they fulfil their expected duties and responsibilities," says Nayreen Daruwalla, a Mumbai-based counsellor and social worker. "A good wife cooks food, doesn't confront the husband and his family, never speaks up, lets her husband take all important decisions, and allows him to have sex with her whenever he likes."

This reasoning received the tacit endorsement of no less than the Minister of Women and Child Development, Maneka Gandhi, in March this year, when she informed the upper house of Parliament that "the concept of marital rape, as understood internationally, cannot be suitably applied in the Indian context owing to various factors like level of education/illiteracy, poverty, myriad social customs and values, religious beliefs, mindset of the society to treat the marriage as a sacrament". 

She later backtracked on her statement after an angry public response from activists, the media, and lawyers. The former additional solicitor general of India, Indira Jaising, called it "patronising", while a group of actors sent up the absurdity of the stance through a parody sitcom called How I Raped your Mother.

Gandhi's statement served as a reminder of just why the many progressive women-centred laws and amendments passed in recent years have failed to specifically address marital rape. This includes the 2005 Protection of Women from Domestic Violence Act, whose definition of domestic violence included physical, sexual, verbal, emotional and economic abuse, and extended protections to women in "a relationship in the nature of marriage".

But what if the very "nature of marriage" takes a woman's consent for granted? A 2003 study of adolescents in a low-income neighbourhood in Delhi, which documented 32 instances of "serious sexual coercion" across 71 interviews, suggested that this might be the case.

It vividly demonstrates how normative behaviours are enforced in Indian society. The boys act with unfettered aggression and entitlement, while the girls are forced to endure abuse - and be blamed for it, as in the case of a girl whose complaint about being molested was countered by the perpetrator's mother, who blamed her for inviting the attack by choosing not to cover her chest with a chunni (scarf).

A 19-year-old painter described how, when his repeated orders to his new wife to take off her clothes were met with silent, tearful refusal, he "made her keep quiet, took her clothes off and did my work".

Another girl said that her newly married sister endured violent non-consensual sex, and had to be taken to the dispensary the next day as she was in pain. Older female relatives informed girls in the neighbourhood to "accept this situation", or non-consensual sex, as "normal".

Other relationships began as consensual, but led to forced kissing and forced sex, with "subjugation at the start of the relationship [leading] to more severe violence". The report concluded: "Society perpetuates abuse by tolerating certain kinds of coercion, which emboldens boys to become even more aggressive and violent."

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'A good wife cooks food, doesn't confront the husband and his family, never speaks up ... and allows him to have sex with her whenever he likes,' says Nayreen Daruwalla, a Mumbai-based counsellor and social worker, explaining the logic behind why marital rape is still not considered a crime in India [Illustration by Jawahir Hassan Al-Naimi/Al Jazeera]

Why women don't seek help

When women do choose to speak out, reports suggest they are discouraged at every turn.

"Most women first turn to their natal family for help," says Divya Taneja, the co-ordinator of the Special Cell for Women and Children in Mumbai and the greater Konkan region. "But they tell her, 'Oh, you just got married, give yourself time to adjust, when you have a child this will probably go away.' The woman keeps getting pushed back into the family because for society the family is always considered safe. They don't realise how dangerous it is."

When women turn to the police for help, anything short of physical trauma is often dismissed.

"She can say, 'He's abusing me daily, not giving me food, not giving me money,'" Taneja says. "But the police counter that with, 'Physically toh dikhta nahin (We see no physical proof of that).'"

The neighbour, the police both tell her to go back home, as does the priest

Pouruchisti Wadia, a counsellor with SNEHA

Most women have no alternatives: neither safe shelters, nor a family well-off enough or accepting of a potential besmirching of their honour to support them.

"The neighbour, the police both tell her to go back home, as does the priest," says Pouruchisti Wadia, a counsellor with the non-profit Society for Nutrition Education and Health Action (SNEHA), which works out of public hospitals in Dharavi in central Mumbai. "No one tells her, 'No, what's happening with you is not acceptable.'"

Daruwalla, the counsellor who directs SNEHA's programme to prevent violence against women and children, agrees.

"Everyone, from the family members to caste panchayats [community groups mostly made up of older men] and the police tell them, 'Never mind whose fault it is, you two stay together,'" she says.

"This does not resolve the problem."

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Recurring trauma

What it does instead is allow the violence to become chronic.

Last year, Anushka Patel, a psychology graduate student, interviewed 47 women from an east Mumbai suburb who had experienced trauma in an effort to adapt a checklist of symptoms to diagnose Post-Traumatic Stress Disorder (PTSD) to the Indian context.

While analysing her results, she was startled to find that 51 percent of the women reported symptoms of PTSD, an incidence that she noted was 20 percent higher than it was for women who had experienced sexual assault in the US. When she re-read her interviews, she realised just why the figure was so bloated.

"These women were hyper-alert, having negative reminders of the event, bad dreams, being really careful," she recalls. "All symptoms of classic PTSD. But then, unlike a war veteran who freaks out three months after he's returned from combat when he hears a car horn because he thinks it's an IED, all of this is actually very adaptive for these women, because they're all still living in traumatic situations."

These women were hyper-alert, having negative reminders of the event ... All symptoms of classic PTSD.

Anushka Patel, a psychology graduate student researching PTSD in the domestic Indian context

Violence that is allowed to go unchecked can reach extremes.

Daruwalla and her fellow SNEHA counsellors say they often see "the most severe kinds of sexual abuse, which women keep tolerating".

Daruwalla recites a laundry list of such cases: "We see women who have had tomatoes shoved into their vaginas, women who have been bitten all over their body. We see so many who have been made to stand outside their houses for hours, naked, without food."

"No clothes, for some reason, is very common," her colleague Farzeen Faroodi chimes in. "Maybe because it's like taking away their dignity."

The drive to subjugate sometimes reaches a disturbing pitch, with women being forced to consume their husbands' urine during oral sex, and even, in one case, their excrement.

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How hospitals are helping

Not seeking help in time may have dire consequences. But seeking help can also invite unwelcome repercussions for women who remain materially dependent on their abusers.

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Hospitals provide an innocuous pretext for those sequestered in their homes to seek help without drawing any untoward attention. That's why Room 101, the crisis centre in KB Bhabha Hospital, is behind an unobtrusive unmarked door in a bustling block where men are entirely absent. The health non-profit Centre for Enquiry into Health and Allied Themes (CEHAT) set up this centre, which they call Dilaasa (Hindi for "consolation"),15 years ago. It's since become a department run by the hospital, which receives about 300 new cases of domestic violence every year. The success of the model prompted nine more municipal hospitals in Mumbai to open similar centres offering free legal and psychological support.

Such centres don't always slot neatly into the hospital system. Nurses and doctors sometimes face initial resistance and hostility from male colleagues and superiors. One staff nurse, who asked not to be identified, said a top hospital administrator once accused her of splitting up homes, while male colleagues often accused her of wasting time "gossiping" with her patients or wrangling confessions from women who seemed perfectly content to quietly endure their lot. Some other challenges lie in what goes unremarked - and unrecorded.

Before setting up Dilaasa, CEHAT's researchers studied the goings-on in the casualty wards of Mumbai's public hospitals.

While scanning the registers, they noticed that although men and women arrived at the hospitals in equal numbers, the circumstances that brought them there were diametrically different.

"The men mostly got injured due to a fight or an occupational injury, always outside the home," recalls Aarthi Chandrasekhar, a research officer with CEHAT. "But women were reporting with kicks and bites or falls which they would say were accidental."

Consumption of poison can't be accidental. We realised that these cases needed to be probed into.

Aarthi Chandrasekhar, a research officer with CEHAT

Despite the violent nature of these assaults, the files didn't record where they took place, or who the aggressor was. They left those sections blank, or wrote something non-incriminatory, like "assault by known persons". In some cases, the women were recorded to have "accidentally consumed poison", say, mistaken a bottle of floor-cleaning liquid for milk.

"The fact is," Chandrasekhar says, "consumption of poison can't be accidental. We realised that these cases needed to be probed into."

They decided that such categories of cases, which could meaningfully obscure domestic violence, invited automatic vigilance.

When new clients come to these centres, case workers document evidence of adverse incidents, such as scars and dates and times of assaults, as well as clients' health and personal histories. The case workers then explain their choices to them, and support them in the course of action they choose to take.

All women are offered medical and emotional support within the hospital itself. They're also informed about their legal rights, or referred to lawyers and shelters. Some are given the option of filing a non-cognisable police complaint, which, they are assured, cannot put their partners behind bars, but will create a useful paper trail if their situation escalates. This way, they get the treatment and support they require, as well as a hefty rundown of medico-legal evidence, should they later decide to press charges or file for divorce.

Sexual assault cases are often brought to the hospital by the police. In some cases, women turn up on their own, concerned about unwanted pregnancies. But most domestic violence cases are referred to the centre by doctors and nurses.

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When women do choose to speak out, reports suggest they are discouraged at every turn [Illustration by Jawahir Hassan Al-Naimi/Al Jazeera]

Spotting the tell-tale signs of violence

Over the past 15 years, CEHAT has been conducting periodic 10-day workshops for healthcare workers in public hospitals around the city. Doctors and nurses learn about concepts they might see play out among their patients, such as patriarchy, gender and communalism. They are taught how to ask questions sensitively, how to offer psychological first aid, and how to spot tell-tale signs of violence.

"Once you do one of those workshops, you're sensitised," says Rita Pande, an ob-gyn with a private practice who spoke to Al Jazeera under a pseudonym. Pande received CEHAT training while working with a renowned public hospital in south Mumbai.

"You start to look for signs and symptoms where before you just heard health complaints you had to treat, or just mechanically went through a checklist without stopping: Feeling OK? Passed urine? Passed stool?"

Among the tell-tale warning signs she learned to look out for were recurrent white discharges, multiple pregnancies and miscarriages, malnourishment, and prolapsed uteruses.

"About 80 percent of these women will respond and come out with the problem if you spend an extra five minutes with them," she says, "but most doctors don't do that in a crowded out-patient department."

The Dilaasa model helps, she adds, because it "provides a portal for such confessions, and a channel to follow so it's not too time-consuming".

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Pregnant women are among the most vulnerable

To get to head nurse Sneha Sheetal's office, you have to pass a narrow, half-renovated stairwell, through which heavily pregnant women in bright gauzy saris gingerly make their way to the labour ward. Over her 23 years working as a staff nurse in the city's public hospitals, including this one in suburban Mumbai, Sheetal has identified numerous cases of pregnant women facing domestic violence.

What sharpens her scrutiny isn't just the training she received from CEHAT 14 years ago, but also a more personal history.

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Many years ago, her mother, who had five daughters, died while giving birth to the fifth.

"My father's sister and mother had been threatening to get rid of her and get my father remarried if she gave birth to another daughter," she says. "When she realised she did, she bled profusely and died of shock. Today I tell myself, 'If she had a nurse like me, she might have been saved. But, fine, I couldn't save my mummy. I'll save someone else's'."

Her determination to do so has transformed her from someone who only followed a doctor's orders to something of an amateur sleuth.

"Kaaran doondne ke liye nazariya mila (I'm now always on the lookout for back stories)," she says, her eyes sparkling behind rimless glasses. "Before, if we got ladies who showed up at midnight complaining of aching stomachs, we used to give them some pills and send them on their way. Now, we go deep."

Before, if we got ladies who showed up at midnight complaining of aching stomachs, we used to give them some pills and send them on their way. Now, we go deep.

Sneha Sheetal, head nurse at a suburban Mumbai public hospital

According to Pande, suspicious signs abound where pregnant women are concerned. "They tolerate absolutely everything because they can't fend for themselves," she says. 

Sheetal always knows something's up when women's replies are inconsistent and accompanied by poor eye contact, or when they complain of body pain but vehemently resist being examined.

Nothing, however, sets off her alarm bells quicker than falls that take place in the dead of night.

"Most women come in saying they tripped and fell," she says. "But that doesn't explain why their cheeks are black and blue, or why they have bruises on their thighs and private parts. Even when they don't speak, their scars do. They tell us: 'This case is different. This is an assault.'"

A few years ago, a young pregnant woman came into the casualty ward just past midnight, accompanied by her mother-in-law and husband.

"She sat staring at her feet," Sheetal says, "as her husband and mother-in-law told me she fell in the bathroom and started bleeding. Her face was covered by her sari, but I could tell from her body language that she didn't exactly acquiesce to their version of events."

She took the woman aside for a private examination, shutting the door in the increasingly belligerent husband's face. She asked her, "Whatever were you doing in the bathroom this time of night that made you fall?"

The woman responded, "What bathroom? What fall? Those two got together and kicked me in the stomach. They brought me here to find out if the baby was OK."

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Hospitals provide an innocuous pretext for women who want to discreetly seek help. Following the success of the Dilaasa crisis centre, other Mumbai municipal hospitals have opened similar centres to provide women with free legal and psychological support [Illustration by Jawahir Hassan Al-Naimi/Al Jazeera]

Silence about sexual violence

When it comes to cases of sexual violence, women are even less forthcoming.

Sheetal says she often sees women who turn up at the hospital with painful infections.

"And despite that, we know from examining them that they've had sex the previous night," she says. "We ask them, 'How did this happen, by force?' Because their vaginas are so red and inflamed, how would they willingly allow this?"

The women usually stay silent and downcast. So Sheetal calls in their husbands, and tells them to take a course of medication and leave their wives alone for a little while because they're sick and what they have is contagious.

"If we scare them with disease, they'll be quick to act," she says. "But if you say, 'You're hurting this woman,' they'll never listen."

If we scare them [the husbands] with disease, they'll be quick to act ... But if you say, 'You're hurting this woman,' they'll never listen.

Sneha Sheetal, head nurse at a suburban Mumbai public hospital

Faroodi, the counsellor, often sees women come to the hospital with piles or anal injuries.

"It takes a lot of probing for them to admit that they were forced to do it," she says. "And when we ask why they didn't stop it, we get one of two replies: one, he wouldn't listen to me, and two, this is what I was told I had to do to have children."

The problem, she says, is that the women are married off young to far older men.

"And nobody has told them what sex involves," she says, "except that it's something shameful and private, never to be talked about."

The men share that opinion.

"They're orthodox, they don't speak about sex openly," Sheetal says. "They say, 'Only faltu-log (dodgy people) talk about it.' When we try to inform them about safe sexual practices, they look at us funnily, like, 'Who's this deviant, why's she talking about this?' But then," she adds, with a dry laugh, "See what these 'respectable' men do to their women behind four walls."

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Unmarried women

Then, there's the problem of single women.

The hospital setting is not necessarily an advantage in reaching out to them.

Doctors and nurses don't presume to ask whether unmarried women are sexually active, due to the extreme levels of stigma about pre-marital sex. CEHAT, for their part, reminds the doctors and nurses it trains to be "clinical, not moralistic" with the unmarried women who come to them with unwanted pregnancies.

"We tell them, 'Treat them for what they've come to you with, don't pass judgment on them,'" says Chandrasekhar, of CEHAT. "That will prevent them from accessing medical care and they'll end up going to a quack for an abortion."

The women themselves never volunteer such information.

Faroodi, the counsellor, recalls the case of a young woman who showed up at a central Mumbai hospital a few months ago.

"She'd been forced into a sexual relationship but hadn't told anyone about it," she recalls. "When she came to the hospital for her check-up, she lied about when her last period had been. The same female didn't realise what had happened, that the act had been complete. So she came back to us when she was five months' pregnant, by which time we couldn't do anything."

Counsellors across the city have been getting increasingly inundated with a new very tricky category of case - those involving foiled promises of marriage.

The young women who come in with these cases have experienced multiple cruelties. They've had their funds siphoned off, had their heads banged against walls, and have experienced rape many times. But none of these acts of violence drive them to seek help.

"Sex in 'love' relationships is identified by the survivor as violence not because it's not consensual," observed a recent paper, based on an analysis of 58 such cases seen by Mumbai's Special Cell for Women and Children. "It's the refusal of marriage which frames the relationship as violence in retrospect."

Despite the multiple sorts of violence they face, many young women still sought a reconciliation.

The authors observe that the women try their "level best to continue because they have gone against society and fear that their honour would be at stake if the relationship doesn't culminate in marriage". So they refuse to file a police complaint, and occasionally justify the men's violent actions, saying it was their own fault they reeled back and hit a wall, that they weren't hit all that hard after all, and that forced sex was permissible because the relationship was consensual.

In the past few years, a number of factors have increased the rate at which women across India report violence, including more coverage of the issue following the 2012 gang rape of a student in Delhi, and the subsequent passing of various laws concerning the rights of women. But social workers feel that these laws have led the government to focus disproportionately on exceptional instances of sexual violence by strangers - and not the everyday violence that women experience, such as domestic violence, or the kind that hides within stigmatised "love" relationships.

They are convinced that such cases have a much better chance of being reported in centres that are seamlessly integrated into hospitals, rather than the expensive one-stop-crisis centres that the Indian government has been planning to launch in the wake of the 2014 gang rape.

Pande, the ob-gyn, agrees.

"We tell her, do your X-ray at Room 86, give your blood at 42, and speak to someone at 101. So she doesn't feel like she's doing something different, and onlookers don't either. When it's integrated into the system, there's no stigma in wanting to seek such help - and more women will be encouraged to come forward."

Follow Shruti Ravindran on Twitter: @s_ravindran 

Source: Al Jazeera