Violence Against Women Martin Donohoe, M.D., F.A.C.P.

Violence Against Women Overview Definitions Definitions Epidemiology Epidemiology Sexual Assault/Rape Sexual Assault/Rape Sequelae of Domestic Violence Sequelae of Domestic Violence

Violence Against Women Overview Recognition and Management Recognition and Management The Developing World The Developing World human rights abuses human rights abuses female genital mutilation female genital mutilation

Objectives Understand common forms of violence against women Understand common forms of violence against women Learn to recognize and manage violence against women Learn to recognize and manage violence against women Exposure to international issues related to violence against women Exposure to international issues related to violence against women

Definitions of Violence Against Women Individual: Any act of verbal or physical force, coercion, or life-threatening deprivation that causes physical or psychological harm, humiliation, or arbitrary deprivation of liberty, or that perpetuates female subordination

Individual Violence Against Women (examples) partner abuse partner abuse sexual assault/marital rape sexual assault/marital rape forced prostitution forced prostitution forced noncompliance with contraception forced noncompliance with contraception female genital mutilation female genital mutilation slavery slavery

Definitions of Violence Against Women Societal: Structural forms of discrimination or deprivation that affect women as a class

Societal Violence Against Women (examples) poverty poverty impaired access to employment or education impaired access to employment or education divorce restrictions divorce restrictions salary inequalities salary inequalities political marginalization political marginalization impaired access to reproductive health services impaired access to reproductive health services

Epidemiology of VAW Lifetime prevalence of assault/sexual abuse Lifetime prevalence of assault/sexual abuse 12% of adolescent girls 12% of adolescent girls 15% of college women 15% of college women 20% of adult women 20% of adult women

Epidemiology of VAW million women assaulted per year million women assaulted per year every 15 seconds a woman is beaten every 15 seconds a woman is beaten 5% of partner abuse is female on male 5% of partner abuse is female on male (homosexual/bisexual abuse also exists) (homosexual/bisexual abuse also exists)

Dating Violence in Young Adulthood One study (AJPH 2010;100: ) showed females more likely than males to be perpetrators (38% vs. 19%) One study (AJPH 2010;100: ) showed females more likely than males to be perpetrators (38% vs. 19%) Study included physical violence, but not sexual violence, and did not consider violence not resulting in injuries Study included physical violence, but not sexual violence, and did not consider violence not resulting in injuries Males and females surveyed (under-reporting possible) Males and females surveyed (under-reporting possible)

Prevalence of Domestic Violence P-care P-care 1/4 women abused at some point in her life 1/4 women abused at some point in her life 1/7 women abused within preceding 12 months 1/7 women abused within preceding 12 months ER ER 1/4 of women seeking care (any reason) 1/4 of women seeking care (any reason) 35% of women treated for trauma 35% of women treated for trauma

Prevalence of Domestic Violence OB/Gyn OB/Gyn 1/6 women during pregnancy 1/6 women during pregnancy Abortion Clinics Abortion Clinics 12% 12% Peds Peds % of mothers of abused children % of mothers of abused children

Prevalence of Domestic Violence Psych Psych 1/4 women who attempt suicide 1/4 women who attempt suicide 1/4 women treated for psychiatric symptoms 1/4 women treated for psychiatric symptoms 55% lifetime prevalence for women with depression 55% lifetime prevalence for women with depression

Abuse in Pregnancy Incidence = % Incidence = % Most common sites of beating are abdomen, head and breasts Most common sites of beating are abdomen, head and breasts Increases risk of low birth weight/pre-term labor/delayed prenatal care Increases risk of low birth weight/pre-term labor/delayed prenatal care

High Risk Occupations: Prostitutes 80% have been physically assaulted 80% have been physically assaulted 80% have been threatened with a knife, gun, or other weapon 80% have been threatened with a knife, gun, or other weapon 67% have been raped 67% have been raped

Prostitution in the U.S. 0.6% of men admit to paying for sex in the last year 0.6% of men admit to paying for sex in the last year 17% at some point in their lives (actual percentage likely higher) 17% at some point in their lives (actual percentage likely higher) 694 “clients”/prostitute/year average 694 “clients”/prostitute/year average

Prostitution in the U.S. 1.6% of women admitted they “had sex with a person [they] paid, or who paid [them] for sex” since age % of women admitted they “had sex with a person [they] paid, or who paid [them] for sex” since age 18 Punishment varies among johns, prostitutes, pimps Punishment varies among johns, prostitutes, pimps Different types of regulation exist worldwide (see prostitution paper on website) Different types of regulation exist worldwide (see prostitution paper on website)

Sex Trafficking and Sex Tourism Sex tourism common in SE Asia, Eastern Europe Sex tourism common in SE Asia, Eastern Europe 100,000 children are victims of commercial sexual exploitation in the US each year 100,000 children are victims of commercial sexual exploitation in the US each year Trafficking Victims Protection Act provides some protections Trafficking Victims Protection Act provides some protections

High Risk Occupations: The Military Completed and attempted sexual assaults 20 times more common among female soldiers than among other government employees Completed and attempted sexual assaults 20 times more common among female soldiers than among other government employees higher rates of chronic pelvic pain, dysmenorrhea, abnormal periods, PMS, and dissatisfaction with sexual relations higher rates of chronic pelvic pain, dysmenorrhea, abnormal periods, PMS, and dissatisfaction with sexual relations correlate with military sexual trauma history correlate with military sexual trauma history

The Military VA Study (191 inpatients; 411 outpatients) VA Study (191 inpatients; 411 outpatients) 24% under age 50 report domestic violence in the past year (7% over age 50) 24% under age 50 report domestic violence in the past year (7% over age 50) 90% under age 50 report a history of sexual harassment (37% over age 50) 90% under age 50 report a history of sexual harassment (37% over age 50)

High Risk Groups Runaway and Homeless Youth Survival sex Survival sex the exchange of sex for shelter, food, drugs or money the exchange of sex for shelter, food, drugs or money 28% of street youths, 10% of shelter youth (out of million runaway adolescents/year) 28% of street youths, 10% of shelter youth (out of million runaway adolescents/year) association with violence, victimization, STDs, and pregnancy association with violence, victimization, STDs, and pregnancy

“High Risk” Perpetrators Male college athletes Male college athletes constitute 3.3% of male student body constitute 3.3% of male student body involved in 19% of sexual assaults involved in 19% of sexual assaults Fraternities Fraternities individual and gang rapes more common individual and gang rapes more common

Deaths from Domestic Violence 4,000 domestic violence deaths/year 4,000 domestic violence deaths/year over 1/2 of women murdered in U.S. are killed by a current or former partner over 1/2 of women murdered in U.S. are killed by a current or former partner 1/2 to 3/4 of the 1, ,500 murder suicides per year involve domestic violence 1/2 to 3/4 of the 1, ,500 murder suicides per year involve domestic violence

Victims Who Kill Their Abusers Between 2,000 and 4,000 women imprisoned for murdering their abusers Between 2,000 and 4,000 women imprisoned for murdering their abusers Battered women who claim self-defense (the only legally justifiable reason for murder) in criminal trials are acquitted only 25% of the time Battered women who claim self-defense (the only legally justifiable reason for murder) in criminal trials are acquitted only 25% of the time 63% of young men aged serving time for homicide have killed their mother’s abuser 63% of young men aged serving time for homicide have killed their mother’s abuser

Race/SES and Domestic Violence Seen in all age, race, and SES brackets Seen in all age, race, and SES brackets May be more common in African-American, but May be more common in African-American, but confounders = lower SES, fewer resources, more likely to be seen in ER or to use public shelters confounders = lower SES, fewer resources, more likely to be seen in ER or to use public shelters May be more common in Latinos, but May be more common in Latinos, but confounders = as above confounders = as above However, more women hold more traditional ideas regarding spousal roles... However, more women hold more traditional ideas regarding spousal roles...

Common Characteristics of Abuse Victims low self-esteem low self-esteem guilt guilt self-blame self-blame denial denial traditional attitudes regarding women’s roles traditional attitudes regarding women’s roles have children have children poor financial resources few job skills less education few friends history of childhood abuse

Common Characteristics of Abusers low self-esteem low self-esteem dependency dependency jealousy jealousy poor communication skills poor communication skills unemployed/underemployed unemployed/underemployed

Common Characteristics of Abusers abuse alcohol/other drugs abuse alcohol/other drugs have witnessed or experienced abuse as children have witnessed or experienced abuse as children If immigrants, are more likely to have been victims of political violence If immigrants, are more likely to have been victims of political violence abuse their own children abuse their own children

Men with Restraining Orders 75% have criminal record 75% have criminal record 50% have history of violent crime 50% have history of violent crime 15% violated R.O. over 6 months 15% violated R.O. over 6 months 30% arraigned for a violent crime over 6 months 30% arraigned for a violent crime over 6 months

Child Abuse seen in 1/3 - 1/2 of families where partner abuse occurs seen in 1/3 - 1/2 of families where partner abuse occurs in one 3 month study of 146 children who witnessed partner abuse in one 3 month study of 146 children who witnessed partner abuse all sons over age 14 attempted to protect their mothers all sons over age 14 attempted to protect their mothers 62% were physically injured in the process 62% were physically injured in the process

Children and Partner Abuse Children witness up to 85% of episodes of partner abuse Children witness up to 85% of episodes of partner abuse child abuse child abuse Children of abuse victims show decrements in academic and emotional development and are more likely to become abusers themselves Children of abuse victims show decrements in academic and emotional development and are more likely to become abusers themselves

Rape Unwanted, forced penetration (oral/vaginal/anal) Unwanted, forced penetration (oral/vaginal/anal) Reported by % of women who are physically abused Reported by % of women who are physically abused

Rape Annual incidence 300,000  women in US Annual incidence 300,000  women in US 7% of all violent crimes 7% of all violent crimes Additional 3.7 million confronted with unwanted sexual activity Additional 3.7 million confronted with unwanted sexual activity Lifetime prevalence up to 25% Lifetime prevalence up to 25%

Date Rape 40% of college women report forced sexual contact, attempted rape, or completed rape 40% of college women report forced sexual contact, attempted rape, or completed rape most common: ignoring victims’ protests most common: ignoring victims’ protests independent of school demographics independent of school demographics  25% of college males admit to using sexually coercive behaviors  25% of college males admit to using sexually coercive behaviors 2/3 of college males report engaging in unwanted sexual intercourse 2/3 of college males report engaging in unwanted sexual intercourse reasons: peer pressure, desire to be liked reasons: peer pressure, desire to be liked

Spousal Rape occurs in % of all marriage occurs in % of all marriage more violent, less frequently reported then non- spousal rape more violent, less frequently reported then non- spousal rape not illegal in many U.S. states/other countries not illegal in many U.S. states/other countries

Rape 5% chance of pregnancy 5% chance of pregnancy 25% chance of acquiring STD 25% chance of acquiring STD GC = % GC = % Chlamydia = % Chlamydia = % Syphilis = % Syphilis = % 1 -2/1,000 odds of acquiring HIV 1 -2/1,000 odds of acquiring HIV varies varies

Rape Underreported (42% never come to attention of authorities) Underreported (42% never come to attention of authorities) Less than 1% of rapists convicted Less than 1% of rapists convicted Large backlog of untested rape kits (over 180,000) Large backlog of untested rape kits (over 180,000) H.R and S.B 2736 (Justice for Survivors of Sexual Assault) bills pending in Congress H.R and S.B 2736 (Justice for Survivors of Sexual Assault) bills pending in Congress

Rape Average prison time for those convicted: Average prison time for those convicted: rape = 1 year rape = 1 year armed robbery = years armed robbery = years murder = 8 years murder = 8 years Chemical Castration Laws Chemical Castration Laws

How We View Women Montana Montana 2nd violation of animal abuse statute 2nd violation of animal abuse statute $1,000 fine + 2 years in jail $1,000 fine + 2 years in jail 2nd violation spousal abuse 2nd violation spousal abuse $ months in jail $ months in jail

Sexual Crimes Against Children 81,000 children sexually abused per year in US 81,000 children sexually abused per year in US 93% committed by family member or someone known to victim 93% committed by family member or someone known to victim Child stranger abductions very rare, despite widespread media coverage Child stranger abductions very rare, despite widespread media coverage

Registered Sex Offenders 650,000 in US 650,000 in US Covers child molesters, possession of child pornography, solicitation of prostitution, exhibitionism and indecent exposure, voyeurism) Covers child molesters, possession of child pornography, solicitation of prostitution, exhibitionism and indecent exposure, voyeurism) In certain jurisdictions also includes anal and oral sex and consensual sex between juveniles or between young adults and juvenilles In certain jurisdictions also includes anal and oral sex and consensual sex between juveniles or between young adults and juvenilles The least likely class of criminals to re-offend (3.5% recidivism rate within 3 years, recidivism rare after 5 years) The least likely class of criminals to re-offend (3.5% recidivism rate within 3 years, recidivism rare after 5 years)

The Physician’s Duties in Caring for Victims of Sexual Assaults Medical Medical obtain medical history obtain medical history evaluate and treat physical injuries evaluate and treat physical injuries obtain cultures obtain cultures treat any pre-existing infection treat any pre-existing infection NEJM 1995; 332:234-7

The Physician’s Duties in Caring for Victims of Sexual Assaults Medical Medical offer post-exposure HIV prophylaxis offer post-exposure HIV prophylaxis offer post-coital contraception (vs. in utero paternity testing f/b selective abortion) offer post-coital contraception (vs. in utero paternity testing f/b selective abortion) arrange medical followup arrange medical followup provide counseling provide counseling NEJM 1995; 332:234-7

Physical Examination of Sexual Assault Victims Collection of clothing Collection of clothing External evaluation External evaluation abrasions, lacerations, ecchymoses, bite marks abrasions, lacerations, ecchymoses, bite marks Oral cavity Oral cavity secretions, injuries, collection of samples for culture secretions, injuries, collection of samples for culture NEJM 1995; 332:234-7

Physical Examination of Sexual Assault Victims Genitalia Genitalia hair combing, hair sampling, vaginal secretions, collection of samples for culture, injuries hair combing, hair sampling, vaginal secretions, collection of samples for culture, injuries Rectum Rectum injuries, collection of samples for culture injuries, collection of samples for culture NEJM 1995; 332:234-7

Prophylaxis for Adult Victims of Sexual Assault Antibiotic Prophylaxis Ceftriaxone (250 mg IM) or Spectinomycin (2 g IM) Ceftriaxone (250 mg IM) or Spectinomycin (2 g IM)PLUS Doxycycline (100 mg po bid x 7d) or Azithromycin (1 g po x 1) Doxycycline (100 mg po bid x 7d) or Azithromycin (1 g po x 1)PLUS Metronidazole ( 2 g po x 1) Metronidazole ( 2 g po x 1)

Prophylaxis for Adult Victims of Sexual Assault Prevention of Pregnancy 2 OCP tablets (each with 50 mcg ethinyl estradiol) po q12  x 2 2 OCP tablets (each with 50 mcg ethinyl estradiol) po q12  x 2OR 3 OCP tablets (each with 35 mcg ethinyl estradiol) po q12  x 2 3 OCP tablets (each with 35 mcg ethinyl estradiol) po q12  x 2PLUS Antiemetic Antiemetic

Prophylaxis for Adult Victims of Sexual Assault HIV Prophylaxis (studies ongoing) HIV Prophylaxis (studies ongoing) Consult ID Consult ID start up to 72  after rape start up to 72  after rape Other (as indicated) Other (as indicated) tetanus toxoid tetanus toxoid Hep B vax/HBIG Hep B vax/HBIG

Factors That Perpetuate Gender-Based Violence Cultural Gender-specific socialization: Gender-specific socialization: Cultural definitions of appropriate sex roles Cultural definitions of appropriate sex roles Expectations of roles with relationships Expectations of roles with relationships Belief in the inherent superiority of males Belief in the inherent superiority of males Values that give men proprietary rights over women Values that give men proprietary rights over women Notions of the family as private/under male control Notions of the family as private/under male control Customs of marriage (bride price/dowry/exogamy) Customs of marriage (bride price/dowry/exogamy) Acceptability/glorification of violence as a means to resolve conflict Acceptability/glorification of violence as a means to resolve conflict S oc Sci Med 1994; 39:

Factors That Perpetuate Gender-Based Violence Economic Women’s economic dependence on men Women’s economic dependence on men Limited access to cash and credit Limited access to cash and credit Discriminatory laws regarding inheritance, property rights, use of communal lands and maintenance after divorce Discriminatory laws regarding inheritance, property rights, use of communal lands and maintenance after divorce Limited access to employment in formal and informal sector Limited access to employment in formal and informal sector Limited access to education and training for women Limited access to education and training for women Soc Sci Med 1994; 39:

Factors That Perpetuate Gender-Based Violence Legal Plural systems of law: customary, common, religious Plural systems of law: customary, common, religious Lesser legal status of women Lesser legal status of women Laws regarding divorce, child custody, maintenance and inheritance Laws regarding divorce, child custody, maintenance and inheritance Legal definitions of rape and domestic abuse Legal definitions of rape and domestic abuse Low levels of legal literacy among women Low levels of legal literacy among women Insensitive treatment of women by police and judiciary Insensitive treatment of women by police and judiciary Soc Sci Med 1994; 39:

Factors That Perpetuate Gender-Based Violence Political Under-representation of women in power, politics and in legal and medical professions Under-representation of women in power, politics and in legal and medical professions Domestic violence not taken seriously Domestic violence not taken seriously Notions of family being ‘private’ and beyond the control of the state Notions of family being ‘private’ and beyond the control of the state Risk of challenge to status quo/religious laws Risk of challenge to status quo/religious laws Limited organization of women as a political force (e.g. through autonomous women’s organizations) Limited organization of women as a political force (e.g. through autonomous women’s organizations) Limited participation of women in organized/formal political system Soc Sci Med 1994; 39: Limited participation of women in organized/formal political system Soc Sci Med 1994; 39:

Economic Gender Disparities: The Bad News Worldwide, women do 2/3 of the world’s paid and unpaid work (1/3 paid, 2/3 unpaid) Worldwide, women do 2/3 of the world’s paid and unpaid work (1/3 paid, 2/3 unpaid) receive 10% of global income receive 10% of global income hold less than 10% of legislative seats hold less than 10% of legislative seats own 1% of global property own 1% of global property

Economic Gender Disparities: The Bad News Women in the U.S. working full-time make $0.75/$1.00 males Women in the U.S. working full-time make $0.75/$1.00 males Those in unions have higher salaries, better benefits Those in unions have higher salaries, better benefits Women make up 46% of the U.S. workforce, but hold  2% of senior-level management positions in Fortune 500 companies Women make up 46% of the U.S. workforce, but hold  2% of senior-level management positions in Fortune 500 companies 2010: 6/50 governors are female, 74/435 members of the House of Representatives, 17/50 Senators 2010: 6/50 governors are female, 74/435 members of the House of Representatives, 17/50 Senators

Economic Gender Disparities Ledbetter v Goodyear - US Supreme Court, 2006: While the Civil Rights Act forbids pay discrimination on the basis of race, gender or religion, all employees have to lodge a formal complaint within 180 days of the initial discriminatory paycheck – Supreme Court upholds this requirement Ledbetter v Goodyear - US Supreme Court, 2006: While the Civil Rights Act forbids pay discrimination on the basis of race, gender or religion, all employees have to lodge a formal complaint within 180 days of the initial discriminatory paycheck – Supreme Court upholds this requirement Lilly Ledbetter Fair Pay Restoration Act of 2009: Now complaint can be filed within 180 of most recent paycheck Lilly Ledbetter Fair Pay Restoration Act of 2009: Now complaint can be filed within 180 of most recent paycheck

Economic Gender Disparities: Health Insurance Gender rating in 38 states allows insurance companies to charge men and women different rates for the same coverage Gender rating in 38 states allows insurance companies to charge men and women different rates for the same coverage Maternity care often excluded Maternity care often excluded 11 states had no private plans that came with maternity coverage 11 states had no private plans that came with maternity coverage Women pay for additional coverage, which amounts to a few thousand dollars, vs. $7000, the average cost of an uncomplicated birth Women pay for additional coverage, which amounts to a few thousand dollars, vs. $7000, the average cost of an uncomplicated birth

Economic Gender Disparities: Health Insurance C/S can cause rejection of coverage unless woman is subsequently sterilized C/S can cause rejection of coverage unless woman is subsequently sterilized Survivors of domestic violence can be rejected in eight states Survivors of domestic violence can be rejected in eight states Rape victims with PTSD may be denied coverage (pre-existing condition) Rape victims with PTSD may be denied coverage (pre-existing condition) Rape victims on prophylactic HIV medication could be denied life insurance coverage Rape victims on prophylactic HIV medication could be denied life insurance coverage

Economic Gender Disparities: The Good News (U.S.) From : From : # of female-owned firms has doubled (9.1 million) # of female-owned firms has doubled (9.1 million) # of workers employed by such firms has quadrupled (27.5 million) # of workers employed by such firms has quadrupled (27.5 million)

Gender Disparities: Mixed News (U.S.) High school sports High school sports 2.5 million female athletes (1999) vs. 300,000 (early 1970s) 2.5 million female athletes (1999) vs. 300,000 (early 1970s) But 90% of women’s college sports teams were coached by women when Title IX enacted (1972); % But 90% of women’s college sports teams were coached by women when Title IX enacted (1972); %

Gender Disparities: Mixed News (U.S.) – 2006/7 Women = 49% of medical school applicants, 49% of medical students, 44% of residents Women = 49% of medical school applicants, 49% of medical students, 44% of residents 2010: female medical students a majority 2010: female medical students a majority Women in academic medicine Women in academic medicine 17% of full professors 17% of full professors 21% of division chiefs 21% of division chiefs 11% of department chairs 11% of department chairs 33% of associate deans 33% of associate deans 12% of deans 12% of deans

Pornography Multi-billion dollar adult entertainment business Multi-billion dollar adult entertainment business Internet, magazines, movies, clubs, etc. Internet, magazines, movies, clubs, etc.

Pornography and Violence Against Women After viewing pornography, males show After viewing pornography, males show heightened levels of aggression and arousal heightened levels of aggression and arousal increased likelihood of saying that rape is OK under certain circumstances (e.g. woman in sexy clothing, man being “led on”, etc.) increased likelihood of saying that rape is OK under certain circumstances (e.g. woman in sexy clothing, man being “led on”, etc.)

Risk factors which make males susceptible to the “dark side” of porn Dysfunctional early home life Dysfunctional early home life Delinquent of antisocial behavior or friends Delinquent of antisocial behavior or friends A promiscuous attitude which views sex as more of a sport than as part of an intimate relationship A promiscuous attitude which views sex as more of a sport than as part of an intimate relationship

Risk factors which make males susceptible to the “dark side” of porn “Hostile masculinity” “Hostile masculinity” Narcissistic personality Narcissistic personality Hostility against women Hostility against women Turned on by power over women Turned on by power over women

Violence Against Homosexuals GSA GSA Gay marriages / civil unions Gay marriages / civil unions Discrimination legal Discrimination legal Causes…….. Causes……..

Health Consequences of Violence Against Women Physical Sequelae Trauma: bruises, fractures, lacerations Trauma: bruises, fractures, lacerations Chronic pain: headaches, AP, pelvic pain, myalgias, LBP, CP Chronic pain: headaches, AP, pelvic pain, myalgias, LBP, CP Hyperventilation Syndrome Hyperventilation Syndrome Eating and sleeping disorders Eating and sleeping disorders

Health Consequences of Violence Against Women Physical Sequelae Alcoholism and Drug Abuse Alcoholism and Drug Abuse e.g. rape victims 10x prevalence of general population e.g. rape victims 10x prevalence of general population begins after abuse begins after abuse Tobacco abuse Tobacco abuse High risk sexual behaviors, STDs, recurrent vaginal yeast infections High risk sexual behaviors, STDs, recurrent vaginal yeast infections Over 3-fold higher risk of being diagnosed with an STD Over 3-fold higher risk of being diagnosed with an STD

Health Consequences of Violence Against Women Physical Sequelae Delayed risk of obesity, HTN, hyperlipidemia, arthritis, asthma, stroke, heart disease, fibromyalgia, psychogenic seizures Delayed risk of obesity, HTN, hyperlipidemia, arthritis, asthma, stroke, heart disease, fibromyalgia, psychogenic seizures IBS IBS symptom severity correlates with severity and duration of abuse symptom severity correlates with severity and duration of abuse GERD GERD Other functional GI disorders Other functional GI disorders

Health Consequences of Violence Against Women Psychological Sequelae - Early withdrawal withdrawal confusion confusion psychological numbing psychological numbing sense of vulnerability/hopeless ness/loss/betrayal sense of vulnerability/hopeless ness/loss/betrayal shock denial distrust of others

Health Consequences of Violence Against Women Psychological Sequelae - Long Term Health Consequences of Violence Against Women Psychological Sequelae - Long Term depression depression anxiety disorders anxiety disorders phobias phobias anorexia/bulimia anorexia/bulimia substance abuse substance abuse

Health Consequences of Violence Against Women Psychological Sequelae - Long Term PMDD PMDD PTSD (nightmares/hypervigilance/etc.) PTSD (nightmares/hypervigilance/etc.) Fivefold increased risk of developing a psychiatric disorder Fivefold increased risk of developing a psychiatric disorder 10% of domestic violence victims attempt suicide 10% of domestic violence victims attempt suicide possible recurrence of symptoms in later, healthy relationships possible recurrence of symptoms in later, healthy relationships

Health Consequences of Violence Against Women Interference with health care Interference with health care Delayed health care Delayed health care

Health Consequences of Violence Against Women Response to Rape Initial: Initial: unnaturally calm/detached OR crying/angry unnaturally calm/detached OR crying/angry Denial phase Denial phase approx. 2 months approx. 2 months Increasing psychological symptoms over several months Increasing psychological symptoms over several months Gradual psychological healing Gradual psychological healing

Recognition and Management of Domestic Violence Routine, repeated assessments in all settings (ER, clinic, wards) Routine, repeated assessments in all settings (ER, clinic, wards) Maintain supportive, nonjudgmental attitude; avoid victim-blaming Maintain supportive, nonjudgmental attitude; avoid victim-blaming Validate the woman’s experiences, building on her strengths, transfer power and control to her Validate the woman’s experiences, building on her strengths, transfer power and control to her Be available, provide frequent followup Be available, provide frequent followup Involve social work Involve social work

Recognition and Management Discover nature and duration of abuse Discover nature and duration of abuse Assess for child abuse Assess for child abuse ensure children’s safety/mandated reporting ensure children’s safety/mandated reporting Keep detailed records, including photographs Keep detailed records, including photographs Testify in court prn Testify in court prn Do not recommend marriage counseling Do not recommend marriage counseling

Public Health Approaches to Violence Against Women Restraining orders prevent recurrent abuse Restraining orders prevent recurrent abuse Batterer treatment programs have had mixed, but generally negative, results Batterer treatment programs have had mixed, but generally negative, results

Public Health Approaches to Violence Against Women: Alcohol Evidence-based prevention of familial violence: Evidence-based prevention of familial violence: Increased excise taxes on alcohol Increased excise taxes on alcohol Restricting physical access to alcoholic beverages Restricting physical access to alcoholic beverages Screening and brief intervention for alcohol abuse Screening and brief intervention for alcohol abuse

Screening Practices of PCPs Self-assessment (1999) Self-assessment (1999) routine screening - 79% routine screening - 79% first visit - 10% first visit - 10% periodic checkups - 99% periodic checkups - 99% prenatal care - 11% prenatal care - 11%

Screening Practices of PCPs Screening new patients Screening new patients OB/Gyns - 17% OB/Gyns - 17% Internists - 6% Internists - 6% Physicians practicing in HMOs - 1% Physicians practicing in HMOs - 1% Physicians practicing in public clinics - 37% Physicians practicing in public clinics - 37% no difference by sex no difference by sex

Assess Patient for Acutely Increased Danger Abuser Abuser criminal record criminal record alcohol/substance abuse problem alcohol/substance abuse problem gambling problem gambling problem psychiatric disorder psychiatric disorder Situational Trigger Situational Trigger job loss job loss death in family death in family

Assess for Acutely Increased Danger Nature of Abuse Nature of Abuse increased severity and frequency of beatings increased severity and frequency of beatings escalation in threats escalation in threats stalking stalking violent or forced sex violent or forced sex destruction of property destruction of property

Ensure Victim’s Safety Social worker involvement Social worker involvement Restraining order Restraining order Phone numbers of shelters, hotlines Phone numbers of shelters, hotlines Safe place to go Safe place to go

Domestic Violence Shelters Availability poor Availability poor up to % of women and 80% of children turned away on any given night up to % of women and 80% of children turned away on any given night Woefully underfunded Woefully underfunded Average length of stay = 14 days; most allow 30 day max stay Average length of stay = 14 days; most allow 30 day max stay Over 50% of all homeless women and children are fleeing domestic violence Over 50% of all homeless women and children are fleeing domestic violence

Physician Failure to Recognize Violence Against Women Fear of offending Fear of offending feelings of powerlessness feelings of powerlessness time constraints time constraints Pandora’s Box Pandora’s Box low confidence in ability to affect change low confidence in ability to affect change sense of own vulnerability sense of own vulnerability deficits in education and training deficits in education and training

Physician Failure to Recognize Violence Against Women Doctors underestimate the prevalence of domestic violence in their patients/communities Doctors underestimate the prevalence of domestic violence in their patients/communities similar to teen sexual activity similar to teen sexual activity Female MDs may be better than male MDs in detecting domestic violence and in taking a more thorough history Female MDs may be better than male MDs in detecting domestic violence and in taking a more thorough history

Violence Against Women in The Developing World verbal, physical, and sexual abuse verbal, physical, and sexual abuse 4 witnesses required for rape conviction in Pakistan 4 witnesses required for rape conviction in Pakistan dowry-related murder dowry-related murder bride-burning bride-burning

Violence Against Women in The Developing World forced abortion and sterilization forced abortion and sterilization divorce restrictions divorce restrictions forced prostitution forced prostitution child prostitution child prostitution

Violence Against Women in The Developing World Selective abortion, malnutrition or killing of female children Selective abortion, malnutrition or killing of female children M:F ratio of births in China = 119/100 M:F ratio of births in China = 119/100 suicide as “vengeance” against an abusive spouse suicide as “vengeance” against an abusive spouse post-rape suicide (or homicide) post-rape suicide (or homicide) to “cleanse family honor” to “cleanse family honor” 47% of homicides in Alexandria, Egypt 47% of homicides in Alexandria, Egypt

Female Genital Mutilation Not female circumcision Not female circumcision i.e., male equivalent would be penectomy i.e., male equivalent would be penectomy Ranges from clitoridectomy to total infibulation (removal of clitoris and labia minora, stitching labia majora together, and leaving a small opening posterior for urine and menstral blood) Ranges from clitoridectomy to total infibulation (removal of clitoris and labia minora, stitching labia majora together, and leaving a small opening posterior for urine and menstral blood) surgical “chastity belt” surgical “chastity belt”

Female Genital Mutilation 100 million women affected worldwide (2 million girls/year) 100 million women affected worldwide (2 million girls/year) mostly in Africa (e.g. 98% of women in Somalia, 80% in Egypt, 50% in Kenya) mostly in Africa (e.g. 98% of women in Somalia, 80% in Egypt, 50% in Kenya) Outlawed in Egypt Outlawed in Egypt rare in Asia rare in Asia Found across all socioeconomic strata and in all major religions Found across all socioeconomic strata and in all major religions

Female Genital Mutilation Formerly used in U.S. and U.K. as treatment for hysteria (“floating womb”), epilepsy, melancholia, lesbianism, and excessive masturbation Formerly used in U.S. and U.K. as treatment for hysteria (“floating womb”), epilepsy, melancholia, lesbianism, and excessive masturbation Represents cultural control of women’s sexual pleasure and reproductive capabilities Represents cultural control of women’s sexual pleasure and reproductive capabilities c.f. virginity exams by physicians in Turkey c.f. virginity exams by physicians in Turkey

Female Genital Mutilation Type I - removal of clitoris Type I - removal of clitoris Type II - removal of clitoris and part of labia minora Type II - removal of clitoris and part of labia minora Type III - modified infibulation - 2/3 of labia majora sewn together Type III - modified infibulation - 2/3 of labia majora sewn together Type IV - total infibulation Type IV - total infibulation

Female Genital Mutilation Most commonly carried out between ages 4 and 10 Most commonly carried out between ages 4 and 10 physicians perform about 12% of operations physicians perform about 12% of operations Often done under non-sterile conditions and without anesthesia Often done under non-sterile conditions and without anesthesia

Female Genital Mutilation Complications/Sequelae bleeding bleeding infection infection dysparevnia dysparevnia painful neuromas painful neuromas keloids keloids dysmenorrhea dysmenorrhea infertility decreased sexual responsiveness shame fear depression

Management of Female Genital Mutilation Sensitivity/understand cultural identity issues Sensitivity/understand cultural identity issues Deinfibulation Deinfibulation Immigration Issues Immigration Issues

Female Genital Mutilation UN, WHO, and FIGO have condemned UN, WHO, and FIGO have condemned Illegal to perform in U.S. under child abuse statutes Illegal to perform in U.S. under child abuse statutes called “cultural imperialism” by some, although we have also outlawed other “cultural practices” called “cultural imperialism” by some, although we have also outlawed other “cultural practices” slavery slavery polygamy polygamy child labor child labor denial of appropriate, life-saving medical care to sick children denial of appropriate, life-saving medical care to sick children

Polygamy Utah/Mormons Utah/Mormons introduced by Joseph Smith ( ) who had 50 wives introduced by Joseph Smith ( ) who had 50 wives theological justification based on Abraham’s wife Rachel “giving” him her servant Hagar as a sister wife (Genesis) theological justification based on Abraham’s wife Rachel “giving” him her servant Hagar as a sister wife (Genesis) Est. 30,000 people in multi-wife families one generation ago Est. 30,000 people in multi-wife families one generation ago Est. 60, ,000 today Est. 60, ,000 today polygamist clans (e.g. 10,000 FLDS members, 1,500 member Kingston clan) polygamist clans (e.g. 10,000 FLDS members, 1,500 member Kingston clan)

Polygamy Utah outlawed “plural marriage” in 1890 in exchange for statehood Utah outlawed “plural marriage” in 1890 in exchange for statehood Not one prosecution in the last 50 years Not one prosecution in the last 50 years Former EPA Administrator (and former Utah governor) Mike Leavitt (a Mormon descended from a polygamous family) declared constitutional under the U.S. Constitution freedom of speech/religion guarantee (it is not) Former EPA Administrator (and former Utah governor) Mike Leavitt (a Mormon descended from a polygamous family) declared constitutional under the U.S. Constitution freedom of speech/religion guarantee (it is not)

Polygamy Related Offenses welfare fraud by sister wives claiming single motherhood welfare fraud by sister wives claiming single motherhood lapses in medication attention (including lack of prenatal care) lapses in medication attention (including lack of prenatal care) incest and underage sex incest and underage sex girls age 10 forced into marriage girls age 10 forced into marriage women existing in limbo women existing in limbo no birth certificates, drivers’ licenses, or voter registration no birth certificates, drivers’ licenses, or voter registration

Covenant Marriages Can be dissolved only in the case of infidelity, abuse or felony conviction Can be dissolved only in the case of infidelity, abuse or felony conviction Offered since 1997 in Louisiana and Arkansas Offered since 1997 in Louisiana and Arkansas similar measures introduced in 17 other states similar measures introduced in 17 other states

Rape in War Used for domination, humiliation, control, “soldierly bonding”, and ethnic cleansing Used for domination, humiliation, control, “soldierly bonding”, and ethnic cleansing often occurs in front of family members often occurs in front of family members recognized as a War Crime since Nuremberg recognized as a War Crime since Nuremberg

International Issues Afghanistan Taliban militia took over in 1996 Taliban militia took over in 1996 Human rights abuses Human rights abuses gender-based violence gender-based violence women denied access to education and health care women denied access to education and health care female employment rate decreased from 62% to 12% female employment rate decreased from 62% to 12% Maternal mortality among world’s highest Maternal mortality among world’s highest Lowest ranking on U.N. Development and Gender Disparity Indices Lowest ranking on U.N. Development and Gender Disparity Indices

International Issues South Africa’s Rape Epidemic Official Rape Rate 104/100,000 people (vs. 34.4/100,000 in the U.S.) Official Rape Rate 104/100,000 people (vs. 34.4/100,000 in the U.S.) highest rate in the world highest rate in the world ¼ South African men say they have committed rape ¼ South African men say they have committed rape Official annual total = 50,000, but est. only 1/35 reported Official annual total = 50,000, but est. only 1/35 reported New latex vaginal insert that latches onto a rapist’s penis and requires surgical removal available for 35¢ New latex vaginal insert that latches onto a rapist’s penis and requires surgical removal available for 35¢

International Issues South Africa’s Rape Epidemic HIV risk HIV risk in Johannesburg, 40% of men aged are HIV+ in Johannesburg, 40% of men aged are HIV+ post-rape antiretroviral drugs are not available in government hospitals post-rape antiretroviral drugs are not available in government hospitals

Other International Issues 80% of refugees and internally-displaced persons worldwide are female 80% of refugees and internally-displaced persons worldwide are female Mexico City (the most heavily populated city in the world) has one shelter for battered women Mexico City (the most heavily populated city in the world) has one shelter for battered women Wives of the gods Wives of the gods sex slaves at animist shrine in Ghana, Benin and Togo sex slaves at animist shrine in Ghana, Benin and Togo

Trafficking Tens of thousands of women and girls trafficked into US annually to work in sweatshops Tens of thousands of women and girls trafficked into US annually to work in sweatshops Others pay for “transport to US,” end up in Northern Marianas Islands Others pay for “transport to US,” end up in Northern Marianas Islands International sex trade, sex tourism strong US government programs to help victims of sex- and labor-trafficking doled out by US Conference of Catholic Bishops, and do not cover reproductive care International sex trade, sex tourism strong US government programs to help victims of sex- and labor-trafficking doled out by US Conference of Catholic Bishops, and do not cover reproductive care

Child Marriage Marriage before age 18 Marriage before age 18 Affects 60 million women worldwide Affects 60 million women worldwide Half occur in south Asia Half occur in south Asia

Child Marriage Associated with no contraceptive use before first childbirth, high fertility, multiple unwanted pregnancies, pregnancy termination, and female sterilization Associated with no contraceptive use before first childbirth, high fertility, multiple unwanted pregnancies, pregnancy termination, and female sterilization A human rights violation A human rights violation

Legal approaches Mandatory reporting Mandatory reporting History of mandatory reporting (child and elder abuse) History of mandatory reporting (child and elder abuse) Benefits Benefits Risks Risks Effectiveness Effectiveness International Violence Against Women Act International Violence Against Women Act Would require US government to prevent and respond to violence against women and girls as a part of US foreign policy and aid programs Would require US government to prevent and respond to violence against women and girls as a part of US foreign policy and aid programs Stalled in Congress Stalled in Congress

Conclusions Awareness of scope of problem of violence against women Awareness of scope of problem of violence against women Screen regularly and repeatedly; document; treat; support Screen regularly and repeatedly; document; treat; support Support women’s rights issues, which are health care issues Support women’s rights issues, which are health care issues

References Donohoe MT. Violence against women: Partner abuse and sexual assault. Hospital Physician 2004;40(10): Donohoe MT. Violence against women: Partner abuse and sexual assault. Hospital Physician 2004;40(10): Donohoe MT. Individual and societal forms of violence against women in the United States and the developing world: an overview. Curr Women’s Hlth Reports 2002;2(5): Donohoe MT. Individual and societal forms of violence against women in the United States and the developing world: an overview. Curr Women’s Hlth Reports 2002;2(5):

References Donohoe MT. Violence and human rights abuses against women in the developing world. Medscape Ob/Gyn and Women’s Health 2003;8(2): posted 11/26/03. Donohoe MT. Violence and human rights abuses against women in the developing world. Medscape Ob/Gyn and Women’s Health 2003;8(2): posted 11/26/ Donohoe MT. Violence against women in the military. Medscape Ob/Gyn and Women’s Health 2005;10(2): posted 9/13/05. Available at Donohoe MT. Violence against women in the military. Medscape Ob/Gyn and Women’s Health 2005;10(2): posted 9/13/05. Available at

References Donohoe MT. War, rape and genocide: Never again? Medscape Ob/Gyn and Women’s Health 2004;9(2): posted 10/22/04. Donohoe MT. War, rape and genocide: Never again? Medscape Ob/Gyn and Women’s Health 2004;9(2): posted 10/22/

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