III. Shortcomings of Health Services after Gender-Based Violence

Intra-familial or sexual violence can have a profound and lasting effect on physical and psychological health: Colombia’s 2010 demographic and health survey found that 85 percent of women who had suffered domestic violence reported injuries, other physical harm, and psychological harm as a result of the abuse.[95]

Access to adequate medical care after an act of intra-familial or sexual violence is a fundamental human right. Colombian law and its referral pathway aim to guarantee this right by ensuring that all victims of gender-based violence, including the displaced, can access essential health services. But a wide range of obstacles currently prevent them from doing so, including the failure of health facilities to properly implement the relevant laws and policies, inadequate screening for signs of gender-based violence, mistreatment of victims, and arbitrary denial or delays in providing essential services.

Colombia’s laws and policies should ensure women and girls who are victims of gender-based violence—even if internally displaced—have access to health services. But, as a director of an organization in Cali that provides support and training to displaced women told Human Rights Watch, “with health, the law is one thing, but it is difficult to get the care survivors are entitled to.”[96]

Often victims do not know these services exist or that they have a right to access them for free. Worse yet, some health officials do not know this either.

Health Officials Lack Adequate Knowledge or Training of Law and Policies

Health professionals and advocates who accompany women and girls for health services told Human Rights Watch that health providers’ insufficient knowledge or training can impede care for victims. Even when laws and policies are strong, the government has a further obligation to train healthcare professionals to ensure these laws and policies are implemented at the most important point: where victims seek care.

Training should address the mechanics of treating victims of violence, how to identify signs of violence, sensitivity on how to work with victims, what rights victims have, and how to handle referrals. The UN special representative on sexual violence in conflict has noted that emphasis should be placed on building this type of capacity in rural areas.[97] But, Human Rights Watch documentation shows that lack of training is a problem in Colombia’s major cities, and not just limited to rural communities or small municipalities.

Human Rights Watch interviewed health providers in hospitals in Bogotá, Cartagena, and Medellín who said they had not been trained in the laws or protocols governing treatment for victims of gender-based violence. In Bogotá, for example, health care professionals told Human Rights Watch that they were unaware that protocols existed. A health care union representative in Bogotá told Human Rights Watch that its members are in 11 hospitals in Bogotá, but none are aware of any protocol for treating victims of gender-based violence, nor had they received training on it.[98] At one hospital in Bogotá, Human Rights Watch spoke with doctors, nurses, administrators, and social workers in six departments, all of whom claimed that no protocol or referral pathway existed at the hospital for treating victims of sexual or intra-familial violence. Only one social worker in one department had received training, and she said she was working to train colleagues on the new protocol.[99]

Indeed, one consistent exception to the general lack of training was in the ranks of social workers: every hospital visited had at least one social worker who had been trained in the protocols. Even so, training may not be sufficient to ensure that the protocol is implemented correctly. Speaking of the protocol related to Law 1257, one social worker told Human Rights Watch, “I don’t really know this law—it hasn’t been implemented yet. I went to a workshop [in 2011] on this, but it hasn’t been regulated yet.”[100] At the time of the interview, four regulations related to Law 1257 had been issued. Moreover, social workers rely on health care professionals actually seeing patients to refer cases to them, some of whom they claim have not been trained.[101] One health care union organizer explained, “unless the victim herself knows about [her rights under Law 1257], people at the hospitals don’t know”.[102]

Some of these policies are new and training health providers in them will require time. However, some officials and health providers see high rates of turnover as an obstacle to training staff adequately. One [official/health care provider] cited the use of short-term contract workers as an obstacle to adequate training.[103] According to one psychologist in Medellín, ongoing training is needed: “They are trained, [and then leave]. [Then,] there is a new group – they need training all over again.”[104]

Some officials who work with victims of sexual violence also told Human Rights Watch that they were aware of health providers who did not know that the law states that emergency medical care is free in cases of sexual violence. One in Medellín said, “There are clinics and hospitals that don’t know the laws and don’t know it’s free. There needs to be more training so people know it’s free.”[105]

Problems Displaced Women and Girls Experienced When Seeking Health Services after Rape or Intra-familial Violence

Failure to ensure adequate training for health professionals who treat victims of gender-based violence can create obstacles for women and girls seeking services. Displaced women and girls interviewed by Human Rights Watch described a range of obstacles, including inadequate screening for signs of gender-based violence, failure to refer victims to additional services available to them, mistreatment of victims, and arbitrary denial of treatment or delays in providing it.

Inadequate Screening

Screening by health professionals of women who seek treatment helps increase detection of gender-based violence and can help prevent future acts of violence. The Pan-American Health Organization recommends that health providers be trained to ask women about physical, sexual, and psychological violence in direct and indirect ways, whether through routine screening questions, or in response to signs or symptoms of violence or risk of future violence.[106] A 2010 report by the United Nations Fund for Achievement of the Millennium Development Goals—based on interviews with Colombian nurses and doctors—found that most victims of gender-based violence do not present themselves as victims, and are only recognized or identified as victims if a health professional makes appropriate inquiries.[107]

Screening is important because of social obstacles that may prevent a woman from revealing that she is a victim of violence when seeking health services. One health professional explained, “[V]ictims sometimes don’t want to report it [themselves] out of fear, economic dependence, or lack of education.”[108]

New obligations created under Law 1257/2008 require health professionals to report suspected cases of violence or abuse to SISPRO, the public health database maintained by the Ministry of Health.[109] In addition, the law entitles victims of gender-based violence to seek emergency social protection measures from the health system, including temporary housing, food, and transportation services, which requires a risk assessment by medical providers.[110] The law does not, however, specifically require healthcare providers to screen for gender-based violence.

While there are protocols to follow when a victim of violence is identified—and social workers available at many hospitals to work with survivors of violence—health providers do not always detect the symptoms and signs of abuse when they should. One official in Colombia’s Ministry of Health told Human Rights Watch, “Detection is very difficult—it’s really bad here. There remains a lack of knowledge, and sometimes [health providers] want to not see the signs of violence.”[111]

One long-time women’s rights advocate—whose organization has worked with hundreds of victims of gender-based violence—explained to Human Rights Watch that short clinical examinations hinder screening for gender-based violence: “Doctors have about 15 minutes when they see a patient. Most are not specialized in this and they don’t have enough time even to get into it, to know if there is intra-familial violence.”[112]

Obvious cases of abuse, particularly in minors, are easier for health professionals to identify. One social worker in a hospital in Cartagena explained that doctors at her hospital often refer cases to her where there is a young pregnant girl, but they have more difficulty identifying cases where a husband has mistreated his wife:

[Doctors] contact me when they suspect a case … If there is a really young pregnancy, or, say, a 10-year-old with a sexually transmitted infection, they immediately call me and we follow the protocol. What is visible, we report. What isn’t visible, we can’t do anything about. If a husband is limiting a woman’s access to contraception, or forcing her to have sex within the relationship … this we can only identify in an interview.[113]

Even when abuse is visible, because the beatings are severe or cause clear injuries or harm, it appears that some health professionals have failed to identify gender-based violence. Human Rights Watch interviewed several victims of intra-familial violence who had visited health facilities over the period of abuse. Despite bruises or broken bones, they said their health providers had not inquired about domestic violence.[114]

For example, Sofia V., age 37 with two children, said her husband began abusing her after their first displacement in 2003. He beat her so severely during pregnancy that she miscarried in Cali. “I went to the hospital, but I lost the baby, a baby girl,” she told Human Rights Watch.[115] For four and a half more years he continued to beat her severely and she sought treatment at hospitals. “I went to the hospital in Caquetá, in Florencia, in Cali—where I had an operation from the beating, in Quindío, and in Bogotá more than four times…. The hospital[s] knew where the hits came from,” she said. Sofia was sure the health providers recognized she was being abused, but says that none proactively asked her about the abuse.[116] Finally, in October 2008, when she went in for a routine medical appointment in Bogotá, she raised the abuse with her doctor. “I was crying, ‘He hits me, he hits me, I’m not crazy, help me.’”[117] This doctor did refer her for services, and she was placed in a safe home for four months. She left her husband in 2011, after he broke her nose.

Similarly, Dolores G., a 38-year-old woman in Cartagena, also experienced abuse by her husband over seven years.[118] During that time, health officials never discussed intra-familial violence with her—not even when, in 2007, she went to the hospital after a miscarriage. She said that her husband was verbally abusive to her during the miscarriage—blaming her for it. She was visibly distraught and inconsolable at the hospital, but no one screened her for potential abuse. She continued in the relationship. In 2009, he physically abused her during a subsequent high-risk pregnancy. Because the pregnancy was high-risk, she saw health professionals often. Dolores says none of them raised concerns or screened her for possible abuse.[119] 

Mistreatment by Staff in Health Facilities

Mistreatment by staff in health facilities treating victims of gender-based violence sometimes results in denial or delay of care and may deter others from seeking care. Human Rights Watch interviewed displaced survivors of gender-based violence who reported that staff in health facilities mistreated them when they entered health facilities, pressured them not to seek legal abortion after sexual violence, or neglected them.

Hospitals and health centers in Colombia often have a guard or gatekeeper, who questions people wishing to enter the facility. Survivors of gender-based violence, NGOs, and government officials told Human Rights Watch that these guards’ poor treatment of victims seeking help has posed a barrier to services. One healthcare worker in Cartagena explained that security guards and other hospital staff can pose an obstacle for women seeking services because they had not been trained and misinformed victims about costs of treatment. She said, “They ask everyone, ‘What insurance card do you have?’ before they let them pass.”[120]  She said that it is difficult for victims of gender-based violence to get treatment if a security guard, nurse, or an administrator does not know she has a right to be there.[121] 

One displaced woman, Socorro Y., was a victim of sexual violence in 2009 in Bogotá. She said that when she went to a hospital, the guard at the front door asked why she was there, and then yelled down the hall, “This is a raped woman!”[122] Socorro also works with survivors of sexual violence and displaced women, and accompanied another victim of sexual violence to the same hospital over two years later. She said that she was horrified when the same thing happened again.[123]

This treatment is not only humiliating, but it constitutes a breach of confidentiality and jeopardizes the security of the victim. Several victims told Human Rights Watch that they refrained from seeking medical treatment since they feared the facilities would breach confidentiality, and their attackers might find out.[124] Clara V., another victim of sexual violence in 2004 and a human rights defender who accompanies victims regularly in Bogotá, said that many women feel that “unless it is really grave, then it’s better to stay quiet” than risk seeking medical treatment.[125]

Some victims said health providers tried to pressure or shame them into abandoning abortion after rape, or allowed others to do so. Colombia’s Constitutional Court lifted the absolute ban on abortion in 2006—decriminalizing abortion in three instances, including when the pregnancy is the result of rape, sex without consent, or incest.[126] Human Rights Watch spoke with the advocates of Elena L., a 35-year-old displaced woman in Bogotá, who was hospitalized waiting for an abortion after she became pregnant from a rape in 2011. The hospital allowed clergy to visit her room and try to convince her to forego the abortion, according to the advocates.[127] Marleny Y., a 10-year-old girl who was gang raped by members of an armed group in 2011, also sought an abortion for a pregnancy resulting from the rape. According to Marleny’s advocates, while in Colombian Institute of Family Welfare (ICBF) custody—awaiting an abortion to which she had consented— ICBF officials tried to pressure her to cancel the procedure, in contravention of ICBF policy.[128] After receiving additional psycho-social support, Marleny was able to procure the abortion.[129]

Some advocates told Human Rights Watch that they have witnessed doctors ask victims of sexual violence inappropriate questions. Several had heard doctors ask victims what they were doing and wearing when they were raped. They said this is particularly true in the case of women seeking abortions. One advocate explained, “They don’t believe the women. They will ask them questions to see if they are lying about the rape.”[130] Juana C. told Human Rights Watch she has seen similar distrustful behavior on the part of doctors. She experienced such mistreatment when raped in 2001, at age 14, and became pregnant. Her doctor did not believe that she was raped, and asked her what she had done to provoke the attack.[131] Now a human rights defender who accompanies victims to seek health services, she sees similar behavior by medical professionals.

The laws, policies, and protocols set by the Colombian government and health ministry exist to minimize the risk of re-traumatizing patients. Yet, some officials and NGO representatives say healthcare providers fail to follow the guidelines laid out in these documents, including suggestions for how to speak to victims without re-victimizing them, special precautions for children, and explaining the results of exams to patients and the process for follow-up. 

One social worker at a hospital in Bogotá explained to Human Rights Watch, “[t]here are Ministry of Health protocols, they are written, but in reality this is thrown out.…”[132] Health providers can inadvertently mistreat victims of gender-based violence when they fail to follow protocols. Advocates that work with victims told Human Rights Watch that, in their experience, it is rare for violations of protocols to be reported. Victims are often unaware that these protocols or guidelines have been violated. Only extreme failures to follow protocol ever come to light, because the mistreatment of the victim for lack of failing a protocol is so egregious that other government actors are notified or brought into the case to address the poor outcomes for patients.[133]

Arbitrary Delays or Denial of Treatment

Victims of sexual violence need access to some forms of treatment within days of the attack to be effective, including post-exposure prophylaxis for HIV, and emergency contraception to prevent pregnancy. Unfortunately, victims and women’s advocates said that health facilities sometimes moved too slowly for them to be effective.[134] Even for less time-bound services, some victims faced significant delays in accessing services that should be easily available.

The Colombian government has established integrated centers for assisting victims of intra-familial and sexual violence with justice, health, and social services. In Bogotá, for example, the CAIVAS includes a health clinic supported by the mayor’s office. However, a Ministry of Health official said that even in these centers, health services are often delayed:

At CAIVAS [in Bogotá], an integrated center for care, you can see the INMLFC, the attorney general’s office, the ICBF, but when you are sent to the healthcare provider, what happens? They say, “Come back tomorrow.” Even if the 72 hours is running out. This happens in Bogotá sometimes. Imagine what happens in small hospitals.[135]

A few victims described delays in being able to access gynecological care in hospitals or clinics after rape, as well as the failure to inform them about emergency contraception.

Monica N., for example, went to a hospital immediately after she was raped in 2011 in Bogotá, but said she was only given an appointment with the gynecological specialist 10 days later. “Seeking medical attention for the [sexual] violence was difficult. Ten days later, I was finally able to get help,” she said.[136] By the time she did receive treatment, she had developed a fungal infection of the vagina from the rape. She said her doctors told her nothing about the possibility of taking emergency contraception to prevent unwanted pregnancy: “I didn’t receive emergency contraception.”[137] This was not Monica’s first sexual assault, and she has also accompanied other women to health services after rape. Monica reported that she had never seen emergency contraception provided.[138]

Analia C., a 34-year-old human rights defender who works with displaced persons, has been raped five times, and told Human Rights Watch about delays in medical treatment after a rape in January 2012 in Bogotá. A lawyer at the national ombudsman’s office following Analia’s case said that the first hospital she visited sent her away because they were not equipped to provide post-rape services at that time, and that the next hospital gave her an appointment for 10 days later.[139] Some victims, if they had the resources, got faster care at private facilities. Ximena A. obtained timely services at a private hospital after being raped  in 2009 in Bogotá, and explained why she avoided a public hospital: “If you go to a [public institution], it is horrible … the process takes two to three months to get authorization for examination and treatment.”[140] 

The Ministry of Health official that specializes in gender-based violence told Human Rights Watch that while emergency contraception and post-exposure prophylaxis with anti-retroviral (ARV) medications to prevent HIV after rape are widely available, some providers are unaware of this. According to her, emergency contraception supplies should be available to health providers without much difficulty, even in more remote areas. “There are several accepted formulas that can easily be found in major cities and rural areas. The problem is resources and knowledge,” she said. Regional or hospital administrators must know to keep supplies on hand, and doctors and victims need to know that emergency contraception exists as a treatment option. According to the official, accessing ARVs pose similar difficulties, with cost being an additional challenge.[141] Both treatments should be available in post-exposure prophylaxis kits (PEP kits) provided by the Ministry of Health—under law to be administered without cost to the victim, but individual districts and hospitals are in charge of reordering and replenishing the supplies. As are result, “PEP kits are not available in all parts of the country … many of the cases are not in the capitals, for those cases, there is no guarantee of quality services.”[142] According to a Ministry of Health official, “this is particularly true where there is more conflict.”[143]

The director of an organization that accompanies many displaced women seeking services in Cali confirmed with Human Rights Watch that it is difficult for victims to receive emergency contraception in some institutions. According to her, “health providers don’t know the laws—that emergency contraception should be available and free.”[144] When health providers do not know what medication should be available and free, it can lead to a denial of care to victims. Monica, as mentioned above, was not offered any emergency contraception. The doctor did prescribe antibiotics for a fungal infection and anti-retrovirals after her rape, but the hospital did not provide these free of charge. She could not afford both, and had to choose between treatments. She decided to buy medicine for the fungal infection, which was causing her immediate discomfort. This left her vulnerable to contracting HIV.[145] 

The child psychologist in Medellín believes that cost of medicine prevents displaced victims from receiving care. She said she was aware of victims who sought care at smaller health facilities where the staff had not been trained in gender-based violence, and were not aware that the treatment should be free. The psychologist said victims had paid up to US$30 or more for treatment.[146] This is prohibitively expensive for many displaced women and girls, and some therefore forgo treatment.

Interviewees also told Human Rights Watch that supplies may not always be current, and so the medication is no longer effective. A director from an organization in Medellín that works with hundreds of victims of gender-based violence raised concerns with Human Rights Watch that some of the emergency contraception she has seen in hospital supplies are past their expiration date, and she believes that as a result some victims of sexual violence with whom she worked have become pregnant.[147]

Some acts of violence leave injuries that require follow-up treatment not covered by free emergency care. Lupe M., 44, needs continual treatment to heal from an acid attack in 2011 in Cartagena. She does not have insurance, and told Human Rights Watch that she cannot afford the treatment and medication.[148] Due to the pain of the untreated wounds, and to fear of the perpetrator who is still at large, Lupe told Human Rights Watch, “I don’t leave my house now.”[149]

Some victims said they faced delays in health treatment after rape due to ad hoc hospital requirements that strayed from the law and Ministry of Health guidelines. For example, to procure a legal abortion after rape, all that is legally required is a copy of a criminal complaint. This one requisite—filing a criminal complaint—can be a major obstacle to accessing legal abortion.[150] But in some cases, hospitals appear to have required more. For example, Elena L., a 35-year-old displaced woman, sought a legal abortion in Bogotá of a pregnancy resulting from rape.  According to her advocates, she sought the procedure in a public hospital with a copy of her criminal complaint and was held all day for routine tests. Her advocates report that hospital officials then said they could not conduct the procedure for technical reasons, and that a copy of the complaint was not sufficient.[151] The hospital contacted seven other public facilities on her behalf. Six refused to receive her and one required that there be a judicial ruling before providing the services, according to her advocates. She finally procured the abortion at one of the seven facilities after the direct intervention of the district health authority.[152]

Conscientious objection by health providers or institutions—if handled incorrectly—may also lead to an arbitrary denial of health services for victims of gender-based violence. Health providers in Colombia have a legal right to decline to offer treatment such as emergency contraception and abortion services if it is incompatible with their own moral convictions, but there are strict limits for how this should be applied.[153] The Constitutional Court has ruled that only individuals and not an entire institution can invoke the right of conscientious objection.[154] A Ministry of Health decree requires that use of the objection must not create an obstacle or prevent a woman from realizing her sexual or reproductive rights.[155] If no other provider is available to perform the service, the state can revoke the right to object.[156] 

While none of the individual women interviewed by Human Rights Watch said that doctors had denied health services to them on the basis of conscientious objection, advocates who work with victims of gender-based violence said they have witnessed cases where conscientious objection was improperly handled, and resulted in delays or denial of treatment.[157] They said this was especially the case with emergency contraception and abortion services, both legal in Colombia. Advocates working with Rosa L., for example, explained that Rosa experienced an almost month-long delay in accessing legal abortion when one hospital improperly invoked institutional conscientious objection in 2010.[158] A sociologist who works with victims of gender-based violence in one of the largest women’s health NGOs in Cali explained that conscientious objection is most problematic in rural areas because rural doctors do not always know they have to guarantee another provider will perform the services.[159] Another NGO representative who works with hundreds of women told Human Rights Watch that she was aware of some women and girls who were unable to access emergency contraception after rape due to improper handling of conscientious objection.[160]

Failure to Ensure Victims Have Information about Healthcare Options

Most of the displaced women and girls whom Human Rights Watch interviewed never accessed health services after sexual or intra-familial violence; less than half of those interviewed even had enough information to try. Some said they did not know there were treatments that could prevent unwanted pregnancy or infection, and others said they did not know they had a right to such services for free. Health service providers also told Human Rights Watch that they believe victims’ lack of information contributes to low rates of women reporting attacks and seeking services. According to a USAID/Profamilia study, only about a quarter of victims of gender-based violence surveyed reported their case to any authority, including health officials.[161]

A few victims and some human rights defenders who accompany them along the referral pathway told Human Rights Watch that they had no idea that some treatments after rape, such as emergency contraception and post-exposure prophylaxis for HIV, must happen within days of an attack. To maximize effectiveness of these post-rape treatments, survivors must get treatment within 72-120 hours of the incident.[162]

Gloria L., for example, was raped in early 2012 in Medellín. She did not know there was emergency contraception and is now pregnant. She said,

I haven’t told anyone because [the men who raped me] threatened me. Three months … I was waiting for my period and nothing happened … I was pregnant … I don’t know if the baby will be black or white or what, but my husband will know it’s not his … I didn’t know there was medicine that could prevent pregnancy when [a rape] happens.…[163]

Mercedes D., a 44-year-0ld woman also displaced to Medellín, was also unaware that emergency contraception existed. She became pregnant after she was raped in late 2009.[164] No one informed Mercedes that medication existed to prevent unwanted pregnancy, even after her daughter became pregnant from a rape in 2004.[165]

Displaced women human rights defenders play an important role accompanying women and girls in their communities along the referral pathway after gender-based violence. Several of these leaders have attended workshops and trainings organized by NGOs or international organizations regarding the rights of victims. Nevertheless, some grassroots human rights defenders told Human Rights Watch that they did not know the importance of seeking health services in the first 72 hours after sexual violence.[166] Ximena A. is another leader who has accompanied many displaced women in accessing government services, including at least 20 women seeking post-rape services. Yet, she was unaware of time-bound treatments that could prevent pregnancy or HIV infection. “I have a friend who contracted HIV after she was raped. Of 20 women I’ve worked with who were raped, four became pregnant,” Ximena said.[167]

A couple of healthcare workers expressed frustration to Human Rights Watch that more women did not seek care after violence, and felt it was not their role to raise awareness. One healthcare worker said there was a policy in place and the resources for treatment, but that was not sufficient to convince victims of gender-based violence to seek treatment, especially those from marginalized groups like the internally displaced.[168] She said individual health facilities generally do not have the capacity to conduct outreach and public awareness campaigns.

The Colombian government does have an obligation to ensure that accurate health information is available to the public. There are many ways the government could organize such outreach, some of which would include health authorities. This report does not analyze the government’s track record on public awareness efforts concerning health care after gender-based violence, but it is clear from testimonies of victims, advocates, and service providers that greater awareness is needed.

Referral Problems

The referral of victims of gender-based violence from the justice sector to health care providers, between health facilities, or to other services, is vital to ensuring victims are informed about services available to them and to addressing their needs in a timely manner. Referrals are all the more important for displaced victims, who may be unfamiliar with services and agencies in their new communities, and therefore, have less knowledge regarding which services exist.

Colombia’s normative framework and “referral pathway” (described in Chapter I) offer clear guidance on how referrals are supposed to happen. Unfortunately, there are significant problems with ensuring that victims get the referrals they need. As a Ministry of Health gender-based violence specialist told Human Rights Watch, “the referral pathway is great when it works, but it only works 25 percent of the time”.[169] Women interviewed by Human Rights Watch said that healthcare providers often did not provide them any referrals for further care or other available services after violence (for example, psycho-social support, justice, or protection programs), that law enforcement and justice officials sent them for medical forensic testing but made no referrals for health care, or that they were sent to multiple health facilities before receiving care.

Some government officials who work on gender-based violence attributed referral problems to a lack of commitment by institutions that should provide referrals. A representative of the Center for Integrated Care for Victims of Sexual Violence (Centro de Atención Integral a Victimas de Violence Sexual - CAIVAS) said that in agencies in her city, whether or not a referral happens depends on individuals—people willing to make phone calls or search out the right counterpart at other institutions.[170] The Ministry of Health official agreed, saying that if one committed person leaves an institution, “the pathway dies.”[171]

Law enforcement and the justice sector should play an important role in the referral pathways for intra-familial and sexual violence by ensuring that victims who file complaints receive referrals for medical attention, not just forensic testing. A gender advisor at the attorney general’s office confirmed that prosecutors are “obligated to call for medical care” if a victim is in need of it.[172] Unfortunately, health officials and women’s rights advocates told Human Rights Watch that law and justice officials often fail to make these referrals. The Ministry of Health gender-based violence specialist complained that despite trainings, justice officials do not always refer victims for medical care:

We have conducted trainings with officials on this issue. If a victim comes to the prosecutor, [or] if she comes to the INMLCF—[you] take her immediately for health treatment. She has the right to medical attention, as much as to justice…. It doesn’t happen.[173]

Viviana N., a displaced woman living in Cali, reported physical violence by her husband to the prosecutor in 2007 after suffering continued abuse for over four years. After filing her criminal complaint, she was provided no information about other referrals or what happened next, including information about health services: “There was no orientation. No route where I needed to go. No one said what happens at each step.”[174]

Often, prosecutors will refer victims of gender-based violence to the National Institute for Legal Medicine and Forensic Sciences (INMLCF) for forensic exams, but this does not mean they will also receive medical treatment.

Medical doctors at the INMLCF perform forensic exams, but do not provide health services.[175] INMLCF doctors create reports for prosecutors detailing the results of the forensic exam and may include suggested follow-up medical treatment. The internal referral pathway for the INMLCF instructs the examiner to explain to the victim her rights to medical care, including access to emergency contraception and abortion in the case of sexual violence.[176] The agency’s technical guides on sexual crimes and intra-familial violence include forms for referring victims to health services.[177] But the women and girls interviewed who had received a forensic exam after filing a criminal complaint told Human Rights Watch they did not receive such forms at the conclusion of their exams, nor were they counseled about their rights.[178] Few were given a copy of their forensic report. Marta N., a grassroots leader who accompanied a rape victim to the INMLCF in Cartagena, said that “the institute did not talk to us about pregnancy or sexually transmitted infections.”[179] Almost none of the women interviewed by Human Rights Watch who had undergone forensic testing at the INMLCF or had accompanied others for exams said they were given referrals for medical treatment. Andrea A., for example, brought her daughter to the INMLCF in Cartagena after she was raped in February 2011, but she said they told her nothing about where her daughter could be tested for pregnancy or sexually transmitted infections. “They didn’t suggest that we go to other places for testing,” she told Human Rights Watch.[180]

The failure to make timely referrals for health care can cause pain, stress, and other hardship for victims, and when referrals for certain time-bound treatments are missed, it can result in unwanted pregnancies or HIV infection. Lupe M., a 44-year-old displaced woman, said an unknown attacker threw acid at her body, hitting her arms, in 2011. She went to a hospital where she received some emergency care, but was told she needed to have a different insurance card to receive treatment she needed at that hospital. She reported the attack to the police and prosecutor, who referred her to INMLCF. “I went to INMLCF [a day after the prosecutor’s office]. They didn’t give me any medicine,” she told Human Rights Watch.[181] Lupe M. says that they also failed to tell her where to go for the follow-up medical care she needed. Not knowing where to go, Lupe says she did not get any further medical treatment, and ever since has suffered pain. “It feels like ants are always biting me,” she described.[182] She bathes the wound in vinegar to try to ease the pain.[183] 

Officials at the INMLCF are careful to note that the INMLCF’s role is to perform a diagnostic exam that will lead to a successful prosecution.[184] But precisely because the INMLCF’s competency is not medical attention, it should make a concerted effort to ensure that victims are clear about how to obtain health care.

Human Rights Watch found that breakdowns in referrals also happen internally in the health system. For example, Rosa L., a 28-year-old displaced woman, was living in the city of Villavicencio in late 2009, after a previous forced displacement, when she was raped by a man with alleged ties to paramilitary groups.[185] According to a lawyer working with Rosa, on April 2010, she realized she was pregnant and told a nurse what had happened. Rosa’s lawyer then said the nurse referred her to a psychologist who should have sent her to a public hospital for free treatment, but instead sent her to a private clinic.[186] After delays in filing a criminal complaint with the prosecutor,[187] authorities referred her to a public health facility, where she hoped to undergo a legal abortion. But, according to Rosa’s attorney, the facility would not accept her health insurance, and referred her to another public hospital. That hospital denied her treatment on the grounds of conscientious objection, and informally referred her to another facility on the other side of town.[188] She finally was provided the procedure a month after her initial consultation.[189]