The Two-Finger Test Doesn’t Work? No One Told The Medical Colleges

On April 20, 2014, a 14-year-old Dalit girl was gang-raped and thrown off a moving bus in Singrauli, Madhya Pradesh. According to news reports, the accused denied the allegations of rape, stating instead that the teenager had fallen down from the moving bus as the driver refused to take her to her stop. On April 21, the police issued a press release quoting the medical report of a three-member team of the District Hospital: “Pt. [patient] is habituated to sexual intercourse. No external injury seen on body, private parts. No evidence of recent sexual intercourse present.” News of this statement and the fact that the ‘two-finger’ test had been performed on this rape survivor is reported to have caused violence in the town of Rewa.

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Here is a brief excursion into the two-finger test and what the Madhya Pradesh police thought they were saying with perfect justification.

Having conducted the two-finger test, they arrived at the conclusion that the teenager is habituated to sex. The translation: that she has had sexual intercourse before she’s ‘supposed to’, that is, before she was married. The test has a starring role in the special universe of Indian sexual assault investigation, because the general assumption is that a woman habituated to sex may also lie about rape.

There are a few million problems with using sexual history in rape cases, but let us look at the test itself.

The ‘two-finger test’ makes it sound scientific, like the ELISA (for detecting HIV). The truth is that it is about as scientific as those truth-determining tests conducted in the middle ages in Europe when the suspect was held underwater. If she drowned then it was assumed that the ‘test’ showed she was guilty. If she had great lungs or good luck, then she was innocent.

STEP 1

Want to conduct the two-finger test? No medical knowledge is required. You insert two fingers into a vaginal opening.

STEP 2

First object of enquiry. Does the woman have a hymen? The hymen is a tissue that lines the vaginal opening. It has an opening that can be of any size. This allows menstrual blood to flow out. The hymen can be thick or thin. Some women are born with so little hymenal tissue that it is as if they had none. Many stretch their hymens accidentally through sports, riding bicycles or penetrative masturbation so it is as if they had none. Some women have such wide openings to their hymens that they arrive at the gynaecologist pregnant but with hymen intact, leading to many quiet giggles about Immaculate Conception. And yes, a few women have such thick hymenal tissue that sex results in the sensational, much-prized and bloody deflowering of the popular imagination.

So here you are with your two fingers in a vagina and you really can’t be sure whether the woman has had sex before. #fail.

STEP 3

Second object of enquiry. The laxity of the vaginal walls through which you establish whether the woman is habituated to sexual intercourse or not. Ah, the mythic tight vagina. Human civilisation has spent a lot of time obsessing about the hymen and the tight vagina. The myth of the tight vagina assumes that virgins have really up-tight vaginas, married women and women who have a lot of sex have loose, flapping vaginas. Women who have had children, ditto about loose and flapping. As any good gynaecologist will tell you, all of this is subjective. Young women who have had children in their 20s and teens may not display much loosening of the vaginal muscles. Women who have active sexual lives may not display loosening of the vaginal muscles. Anxiety or fear can tighten the muscles and sexual arousal can loosen it temporarily.

So here you are trying to establish whether a woman has had sex before or lots of times. How loose is it supposed to be? You can’t tell? Neither can anyone else. How big are the two fingers supposed to be? How elastic is elastic? Don’t worry that you don’t know. No one does.

STEP 4

Declare the complainant habituated to sex or not. Your guess is as good as any. It might be more useful to ask her about her sexual history, but wait, you can’t. Because the law says it’s irrelevant. As Pratiksha Baxi, Associate Professor at JNU’s Centre for the Study of Law and Governance, writes, “Past sexual history was disallowed in rape trials since 2003. However, the two-finger test by medicalising consent allows past sexual history of the raped survivor to prejudice her testimony.”

Now if you had only known all this before sticking your fingers into people’s vaginas.

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Since December 2012, the conversation around rape has been heated and frequent in India. In March 2014, the government finally passed guidelines for the medical examination of survivors of sexual assault fundamentally saying: do not use the two-finger test. Many well-intentioned and well-framed bits of legislation are passed by the government, but their larger reach into the worlds of law enforcement and medicine is never guaranteed. Often, the different branches of the state – the police, the law, the health apparatus – function in a deeply discordant way. So, has the passing of these regulations snowballed into a greater awareness within the medical community, especially amongst students? Our short answer – and yes, it is a chilling one – is a resounding no.

We began by asking these questions: Are young doctors and medical students prepared to be more sensitive and more professional when they encounter a victim of sexual assault? How are medical students taught to treat survivors of rape? We spoke to 25 medical students in Bangalore, Delhi, Kochi, Hyderabad and Karimnagar.

Students medsplaining the two-finger test

When we asked them about rape survivors, their general chorus ran something like this: “She’s probably lying.” “She might just be accusing someone of rape because she shares a bad relationship with them.” “She might not be telling you the truth.” We heard some minor variations, but an underlying attitude of suspicion towards women who reported sexual assault ran through everything they said. And yes, medical students are not born suspicious – they learn suspicion in college.

A paragraph in the textbook The Essentials of Forensic Medicine and Toxicology (1994) by Dr KS Narayan Reddy, a popular textbook prescribed in many medical colleges, reads like this: “Sometimes, false charges are made by a consenting woman, when the act is discovered by the parents or husband, when she becomes pregnant, or for the purposes of revenge or blackmail.”

We asked the students specifically about the two-finger test. Most of the students we met were confused and uncertain. Most couldn’t say why the test was done; they didn’t know that the government was looking to ban the test either. Others would lose steam halfway through an earnest explanation of the test, sit back in their chairs, and end with an, “I don’t know”, or an, “I’m not really sure”.

It is in their second year that medical students in India study Forensic Science. In this paper, among other things, they are taught the medico-legal procedures involved in dealing with survivors of rape.  This is the first and last time they study forensic science unless they choose it as a specialisation in their post-graduation. Many students forget all about the subject, and even the little they learn is a rather mechanical affair. Rosheen, a third year at Deccan Medical College, Hyderabad laughed and compared studying forensics during an MBBS to studying civics in school. Read: something to mug up without an ounce of thought.

The students we spoke to painted a vivid picture of how forensics class generally goes. The bell goes off. It’s time for one of only two classes on ethics in forensics. More than half the students pick up their stuff and leave. With microbiology and pathology and other subjects weighing down their study loads, they simply don’t have time for something insignificant like ethics. It’s not like the department cares; attendance is pretty chilled-out. Meanwhile, the teacher starts the class with the 10 or 15 students who are present; perhaps a few are interested. He might be enthusiastic as he begins. But with only a handful of students before him, even his energy wears down soon. But at least he tried. At least he wasn’t a pervert like that other teacher who took classes on sexual harassment. The suggestive looks that one gave the women during his lectures didn’t go unnoticed. Because those are so necessary while talking about necrophilia.

Nishant Ohri, currently attending coaching for his PG medical exam in Delhi says, “Forensics is a ‘majboori’ subject.” Construction noises threaten to drown his voice on the phone. Nishant speaks confidently, switching between Hindi and English. He is very aware of the shortcomings in the way medical ethics is taught and he (unlike many of his peers) is keen to discuss them. But he’s also a little resigned. “We learn [about medical examination of rape survivors] only for the 10 mark short note that comes in the [Forensics] exam.” He adds, “We are quite inept to deal with such a case, to tell you the truth. I wouldn’t be able to handle such a situation. Our textbooks which are substandard and old only had definitions of rape, what article of the law it fell into, etc. The class on rape was hardly twenty minutes long.”

One of the main problems in medical education is the low prestige given to forensics as a subject. It’s not a glamorous specialisation like pediatrics or surgery. Not only are the books outdated – some of the citations go back to the 1930s – but the way it’s taught is superficial. “Kuch nahi mila to forensics kar liya. Abroad, the leader of a [police] investigation would be a forensics expert. But not in India. Forensics has no future, therefore no books, and no interest from the side of the students or the management,” says Nishant. There’s just no incentive for doctors in training to remember the procedure for examination of sexual assault victims. This much Nishant makes clear.

Ask a medical student the procedure to be followed when a rape survivor comes in for treatment, and a long list is rattled off, albeit in a shaky, uncertain way. Make sure she’s comfortable; don’t make her say more than she’s willing to. Take her consent before doing any test. Check for injuries on her body. Do a genital area examination. They will then reel off a long list of tests to be done – swab tests, DNA tests, blood tests, pregnancy tests – and then they have to mention the per vaginal examination. A procedure that includes the two-finger test.

We are in the busy universe that is the St John’s College canteen in Bangalore. Roshni, currently an intern, laughs when we first meet her. She’s heard about us from a friend but she’s still hesitant to talk, uncertain and cautious about what she’s saying. It isn’t long before she mentions an exam that requires using fingers to feel for any wounds.

“What’s the reasoning behind this test?” we ask.

She replies quickly and confidently, “To check for any tears, wounds”.

“Can it also be used to check the laxity of the vagina?” we ask.

“And that, yes. In a virgin, the size of the vagina is small, and the hymen isn’t broken,” she says and pauses. “I don’t know how to explain this.”

“Try”, we prompt her.

After a few moments of smiling and stammering, Roshni says, slightly consciously, “I guess it’s to correlate what she’s telling you to what you find, to see if she’s telling the truth or not. If she’s doing this regularly, then she might not be telling you the truth, right? She might be putting the blame on someone.”

The judgment is a common one. Habituation to sex, especially in an unmarried woman, seems to rule out the possibility of rape. It disregards a crucial part of what rape is – the absence of consent.

Here is the imaginary, perfect connection between the two-finger test and a woman’s sexual history. This often ensures the backdoor entry of a woman’s sexual history in a way that is just irrelevant to the case; sexual history begins to precede sexual assault.

Underlying so many of the ‘protocols’ that medical students learn is the idea that women are liars and the system must find ways to catch their lies. That men (or ‘scientifically proven’ medical procedures) could also lie does not appear as a touchstone in forensics class. ‘There must always be a female attendant in case the doctor is male,’ is one of the protocols that students learn. Geetanjali, another medical student, explains the logic behind this and like so much of what we were told, it was laced with a good dose of suspicion. “This to make sure there’s no foul play. So that she doesn’t accuse the doctor of anything,” says Geetanjali. For a profession like medicine, which is about healing, the students seem almost roguishly insensitive. It makes sense for a woman who is uncomfortable with a male doctor to ask for a female one. In case that doesn’t or cannot happen, there is supposed to be an attendant there as witness so ‘false charges’ are not made against the doctor. Underlying the whole procedure is the idea that women lie and falsely accuse as a matter of routine. When we pressed medical students about why they though this, the answer was the same bone-rattling chorus we kept hearing: “this is what we’ve been taught”.

Ashvathy, a third year medical student at Amrita Medical College in Kochi, told us, without any prompting,,“We also need to find out the sexual history.” She then offered ‘proof’ through classist abstraction. “Let me give you a scenario, take a prostitute, for example. Their hymen is torn, so it’s difficult to say if she was raped, or if she’s lying. She might have had a good client, and things could have gone wrong with him, prompting her to file a case of rape. They don’t have much to lose anyway, right?” And if this terrible understanding of sex work wasn’t enough, she continued with more know-it-all offerings: “The two-finger test isn’t enough. But it needs to be done; it’s not a demeaning test. It’s also mentioned in our textbook. We follow VV Pillay’s Textbook of Forensic Medicine and Toxicology.”

Medical students are taught, if nothing else, to look and act sure. We encountered many a defense of the two-finger test – invariably delivered with unnerving confidence – that cited “medical reasons”. Lalit Narayan, a former student of St John’s College, Bangalore, who currently works in the US, laughs as he explains, “As a medical student, you learn that when someone asks you a question, you never say you don’t know. You assume a cloak of competence.”

Why the two-finger test needs to be dumped

We enter Vydehi Medical College in Bangalore just after lunch, hoping to meet a few students and Dr Jagadeesh Reddy, a doctor and professor of forensics at the college. Our first attempt at entering the silent, serious building is unsuccessful – we aren’t allowed. A little while later, having spoken to Dr Reddy over the phone, we’re politely pointed to the staircase. In his small, book-filled office, Dr Reddy seems a little more forgiving than the building had been. He believes that it’s difficult for the students to question these practices. “When their teachers teach the wrong thing, they might disagree. But then the textbooks say the same thing and that leaves them little space to make an argument.”

Along with organisations such as Centre for Enquiry into Health and Allied Themes (CEHAT), Dr Reddy has been working towards eliminating the two-finger test by tackling it’s nasty afterlife in the fields of both medicine and law. He was involved in drafting ‘Guidelines and Protocols: Medico-legal Care for Survivors/Victims of Sexual Violence’, which includes standardised guidelines for the medical fraternity. Talking continuously, he pulls a copy of the guidelines out from a drawer, a slim orange book, pushing it towards us with considerable enthusiasm. It was released in March this year by the Ministry of Health and Family Welfare and the World Health Organisation. And on paper it reads well and comes as much-needed relief in a country where no previous standardised guidelines even existed.

“We are thinking of writing to all the authors to change the texts, to update them according the new guidelines. We are requesting the Health Ministry to send a flyer to all the states and through the states to all the colleges, so that everyone updates the teaching also. The system changes, so will the students, since they will be trained in this new system,” says Dr Reddy.

Shaibya Saldanha, gynaecologist at Acura Hospital and co-founder of Enfold Proactive Health Trust, Bangalore sits before us, smiling at our confused faces. We are at the hospital in an air-conditioned room, and there aren’t too many people waiting outside. Hands folded across the table between us, she patiently waits for us to finish talking. We tell her what we’ve heard about the two-finger test. It’s to check the degree of violence, to see if we can do a per speculum examination, to check for lacerations and whatnot.

She explains, “Rape was considered so obnoxious because it was about the loss of virginity and hence the loss of family honour. If the hymen is torn, then her virginity is gone, and her price in the marriage market would go down. The two-finger test thus came in to check if the hymen is intact or not. That was the extremely crude and gendered concept of the two-finger test.” She picks up her phone, adding, “I’ll show you a picture, promise me you won’t get grossed out.” Pushing the phone towards us, she hold up two fingers and then points. “If you put two fingers in, you damage corroborative evidence. I need to check that area to see if there are any bruises, I need to see it under a light. I can’t see if my fingers are in the way. My gloves will just damage this evidence, the test makes no sense.”

Bhavya Pydi, who recently finished interning at Osmania General Hospital, Hyderabad, says, “The per vaginal examination isn’t allowed on virgins and children, it’s only allowed in older women. This is because people generally have issues with the hymen breaking.” As noble as they might make it sound, we need to look at this carefully. Is a woman worth only her hymen? Many students we spoke to seemed to think so. An ‘intact’ hymen remains so important that some of them believe doing the two-finger test only on unmarried women or those who haven’t been sexually active is wrong. For them, test itself is not the problem, but its hymen ‘breaking’ capacity is. The erroneous logic at the heart of all the hymen-coveting is quite simple: if a woman has had sex before, she must be “habituated” to sex and therefore more likely to offer consent in sex. If we went purely by what medical students were saying to us, the presence or non-presence of a hymen is a key fact in a rape case – with a preternatural ability to determine consent.

More hymen-related gems came our way: “The general exam is done to check the status of the hymen, and give a report based on it,” says Abdul, a third year student at Ambedkar Medical College, Bangalore. He spoke with indifference and confidence at the Ambedkar canteen. Abdul sat with a friend of his who was defiantly quiet, refusing to be interviewed if we recorded the conversation. Abdul seemed to be holding himself back, slightly uncomfortable with the direction of the conversation. Less than ten minutes later, he left. Even others, other than well-meaning Abdul, speak of tests to check if the hymen is broken. Which brings us to a major question – what exactly is rape?

When we asked Abdul this question, he became laconic, presumably because of lack of information. “There are two things that need to be kept in mind. Not sure about the exact details. Just that it is illegal and err…” Many of the students we spoke to had a misplaced definition of rape – especially keeping in mind how the law currently frames rape. For them, rape was a purely penetrative act. None of them mentioned an expanded definition: non-penile-vaginal rape.

And here – yet again – the logic behind the two-finger test falls apart. If there’s no penetration, or if the contact isn’t penile-vaginal, how does the two-finger test even make sense? It succeeds only in bringing in the sexual history of the woman into a case and contributes heavily to the possibility of an unfavourable judgment.

The two-finger test is a problem that needs to be dealt with at many levels, beginning with the judicial system. There are efforts being made by various people and organisations in the medical fraternity and outside to change this system. If brought to the court, the question of a woman’s sexual history needs to be resolutely ignored. If there was willingness, a law could be passed banning the test from medical and judicial practice. And while that will probably take time, doctors should be responsible for spreading negative awareness about the test. Medical students also need to be taught better. Says Dr Saldanha, “What we suggest is that there should be a PCRU [Pediatric Clinial Research Unit] in every hospital where students, after their final year, should be posted. They should be posted in a unit that deals with assault victims. You cannot expose sexual assault victims to junior students. That is also not ethical. So it’s better if it’s done in MD Pediatrics and MD Gynaecology. So we wait till they learn everything and then give them the practical knowledge.”

When classes are conducted to teach medical students, they are taught to be distant and objective – to reduce all knowledge to scientific distillations. Their textbooks make up some of the bedrock from which their worldviews spring. For them, medical textbooks are right because they have dispensed with the messiness of social life in favour of ‘facts’. But have they? Contrary to their own self-perception, medical students are not taught to ignore the social world in favour of everything scientific. Instead, they are taught to perpetuate a particular social vision in which women often appear as yet-to-be-proven liars with potentially dubious sexual histories.

A battle is on get rid of the two-finger test. But scrubbing it out of minds of medical students will not be easy. Changing the outdated the social vision lurking behind their textbooks, tests and protocols will be a good start.

Ila Ananya and Rahul Pillai are interns at The Ladies Finger and students at St. Joseph’s College of Arts & Sciences, Bangalore

Don’t forget to check out: What Can You Do With Two Fingers?