1. Women’s Health Contemporary Human Rights Issues
Martin Donohoe, M.D., F.A.C.P.

2. Violence Against Women Overview
Definitions
Epidemiology
Sexual Assault/Rape
Sequelae of Domestic Violence
Recognition and Management
The Developing World
human rights abuses
female genital cutting

3. Violence Against Women Overview
Teen Pregnancy
The Family/Single Motherhood/Child Care
Ideals of Beauty & the Historical Subjugation of Women
Abortion
Conclusions

4. Objective Understand common forms of violence against women
Learn to recognize and manage violence against women
Exposure to national and international issues in women’s rights/reproductive health care

5. 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

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

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

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

9. Epidemiology Lifetime prevalence of assault/sexual abuse
12% of adolescent girls
15% of college women
20% of adult women
2 - 4 million women assaulted per year
every 15 seconds a woman is beaten
5% of partner abuse is female on male
(homosexual/bisexual abuse also exists)

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

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

12. Abuse in Pregnancy Incidence = 8 - 20%
Most common sites of beating are abdomen, head and breasts
Increases risk of low birth weight/pre-term labor/delayed prenatal care

13. Prevalence of Domestic Violence
OB/Gyn
1/6 women during pregnancy
Peds
% of mothers of abused children

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

15. Prostitution in the U.S.
0.6% of men admit to paying for sex in the last year
16.3% at some point in their lives
694 “clients”/prostitute/year average
1.6% of women admitted they “had sex with a person [they] paid, or who paid [them] for sex” since age 18

16. High Risk Occupations: The Military
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
correlate with military sexual trauma history

17. The Military VA Study (191 inpatients; 411 outpatients)
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)

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

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

20. Deaths from Domestic Violence
4,000 domestic violence deaths/year
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

21. Victims Who Kill 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
63% of young men aged serving time for homicide have killed their mother’s abuser

22. Race/SES and Domestic Violence
Seen in all age, race, and SES brackets
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
May be more common in Latinos, but
confounders = as above
However, more women hold more traditional ideas regarding spousal roles...

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

24. Common Characteristics of Abusers
low self-esteem
dependency
jealousy
poor communication skills
unemployed/underemployed
abuse alcohol/other drugs
have witnessed or experienced abuse as children
abuse their own children

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

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

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

28. Rape Unwanted, forced penetration (oral/vaginal/anal)
reported by % of women who are physically abused
annual incidence ³ 80/100,000 women
7% of all violent crimes
lifetime prevalence up to 25%

29. Rape Underreported Less than 1% of rapists convicted
Average prison time for those convicted:
rape = 1 year
armed robbery = years
murder = 8 years
Chemical Castration Laws

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

31. Spousal Rape occurs in 10 - 15% of all marriage
more violent, less frequently reported then non-spousal rape
not illegal in many U.S. states/other countries

32. Rape 5% chance of pregnancy 25% chance of acquiring STD GC = 6 - 12%
Chlamydia = %
Syphillis = %
1 -2/1,000 odds of acquiring HIV
varies

33. The Physician’s Duties in Caring for Victims of Sexual Assaults
Medical
obtain medical history
evaluate and treat physical injuries
obtain cultures
treat any pre-existing infection
offer post-exposure HIV prophylaxis
offer post-coital contraception (vs. in utero paternity testing f/b selective abortion)
arrange medical followup
provide counseling
NEJM 1995; 332:234-7

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

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

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

37. Prophylaxis for Adult Victims of Sexual Assault
HIV Prophylaxis (studies ongoing)
2 nucleoside analogues + 1 protease inhibitor
start up to 72° after rape
Other (as indicated)
tetanus toxoid
Hep B vax/HBIG

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

39. 2002 Federal funds to fight abuse and neglect:
Some health insurers refuse to cover abuse victims (“pre-existing condition”)
states legislating against this practice
2002 Federal funds to fight abuse and neglect:
Elder abuse - $153 million
Domestic abuse - $520 million
Child abuse - $6.7 billion

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

41. Factors That Perpetuate Gender-Based Violence Economic
Women’s economic dependence on men
Limited access to cash and credit
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 education and training for women
Soc Sci Med 1994; 39:

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

43. Factors That Perpetuate Gender-Based Violence Political
Under-representation of women in power, politics and in legal and medical professions
Domestic violence not taken seriously
Notions of family being ‘private’ and beyond the control of the state
Risk of challenge to status quo/religious laws
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:

44. 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)
receive 10% of global income
hold less than 10% of legislative seats
own 1% of global property

45. Economic Gender Disparities: The Bad News
Women make up 45% of the employed global workforce, yet account for 70% of the world’s poor
Women in the U.S. working full-time make $0.75/$1.00 males

46. Economic Gender Disparities: The Bad News
Women make up 46% of the U.S. workforce, but hold < 2% of senior-level management positions in Fortune 500 companies
2002: 5/50 governors are female, 13% of Congresspersons, 4 of the top 21 university presidents

47. Economic Gender Disparities: The Good News (U.S.)
From :
# of female-owned firms has doubled (9.1 million)
# of workers employed by such firms has quadrupled (27.5 million)
sales of these firms have quadrupled ($3.6 trillion)

48. Economic Gender Disparities: The Good News (U.S.)
Fastest growing fields: construction, wholesale trade, transportation and communications, agriculture and manufacturing
High school sports
2.5 million female athletes (1999) vs. 300,000 (early 1970s)

49. Sexual Harassment quid pro quo hostile environment
15,500 cases filed/year (¯ from 6,900 in 1990)
Civil Rights Act
prohibits discrimination based on race and sex, but not sexual orientation

50. Gender-Based and Sexual Harassment Among U.S. Women Physicians
4,501 respondents (59% response rate)
47.7% gender-based harassment
36.9 sexual harassment
Arch Int Med 1998; 158:352-8

51. Gender-Based and Sexual Harassment Among U.S. Women Physicians
med school > internship + residency > practice
higher rates among those younger, divorced or separated, in historically male specialties
lower rates among Asians, those satisfied with their careers, those in government jobs, and the politically very conservative
Arch Int Med 1998; 158:352-8

52. $4 billion adult entertainment business Per day
Pornography
$4 billion adult entertainment business
Per day
23-60 million unique visitors to pornography websites
2-3 million unique visitors to the five largest news sites

53. Pornography and Violence Against Women
After viewing pornography, males show
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.)

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

55. Health Consequences of Violence Against Women Physical Sequelae
Alcoholism and Drug Abuse
e.g. rape victims 10x prevalence of general population
begins after abuse
STDs, recurrent vaginal yeast infections
Delayed risk of HTN, arthritis, and heart disease
IBS
symptom severity correlates with severity and duration of abuse

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

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

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

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

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

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

62. Screening Practices of PCPs
Self-assessment (1999)
routine screening - 79%
first visit - 10%
periodic checkups - 99%
prenatal care - 11%
Screening new patients
OB/Gyns - 17%
Internists - 6%
Physicians practicing in HMOs - 1%
Physicians practicing in public clinics - 37%
no difference by sex

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

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

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

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

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

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

69. Violence Against Women in The Developing World
verbal, physical, and sexual abuse
4 witnesses required for rape conviction in Pakistan
dowry-related murder
bride-burning
forced abortion and sterilization
divorce restrictions
forced prostitution
child prostitution

70. Violence Against Women in The Developing World
Selective abortion, malnutrition or killing of female children
M:F ratio of births in China = 1.1:1.0
suicide as “vengeance” against an abusive spouse
post-rape suicide (or homicide)
to “cleanse family honor”
47% of homicides in Alexandria, Egypt

71. Female Genital Cutting
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”
Represents cultural control of women’s sexual pleasure and reproductive capabilities
c.f. virginity exams by physicians in Turkey

72. Female Genital Cutting
Also called female genital mutilation
Not female circumcision
i.e., male equivalent would be penectomy

73. Female Genital Cutting
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)
Outlawed in Egypt
rare in Asia
Found across all socioeconomic strata and in all major religions
Formerly used in U.S. and U.K. as treatment for hysteria (“floating womb”), epilepsy, melancholia, lesbianism, and excessive masturbation

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

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

76. Female Genital Cutting Complications/Sequelae
bleeding
infection
dyspareunia
painful neuromas
keloids
dysmenorrhea
infertility
decreased sexual responsiveness
shame
fear
depression

77. Management of Female Genital Cutting
Sensitivity/understand cultural identity issues
Deinfibulation
Immigration Issues

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

79. Polygamy Utah/Mormons
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)
Est. 30,000 people in multi-wife families one generation ago
Est. 60, ,000 today
polygamist clans (e.g. the 1,500 member Kingston clan)

80. Polygamy
Utah outlawed “plural marriage” in 1890 in exchange for statehood
Not one prosecution in the last 50 years
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)

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

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

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

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

85. International Issues South Africa’s Rape Epidemic
Official Rape Rate 104/100,000 people (vs. 34.4/100,000 in the U.S.)
highest rate in the world
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¢

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

87. Other International Issues
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
Wives of the gods
sex slaves at animist shrine in Ghana, Benin and Togo

88. Teen Pregnancy
Birth rate ages = 55/1,000/year (gradual ¯ since 1960)
Greater than 50% of high seniors have had sexual intercourse
average age at first intercourse: 17 for girls, 16 for boys
Teen sex, teen STDs decreasing
Up to 2/3 of teens use condoms (3x as many as in 1970s)

89. Teen Pregnancy
U.S. rates x higher than among the industrialized nations of Western Europe
teen poverty rates higher by a similar magnitude
6/7 U.S. teen births are to the 40% of U.S. girls living at or below the poverty level
2/3 of teen mothers were raped or abused as children

90. Teen Pregnancy Only 8% of schools provide condoms
promotion and distribution does not increase teen sexual activity
Only % of health plans cover all contraceptive methods
1/2 - 2/3 refuse to pay for OCPs
all methods of contraception more effective and less costly than no method
1/3 of all plans cover abortions
9/10 plans cover sterilization

91. Teen Pregnancy The Role of Adult Males
71% of teen pregnancies in California in 1993 fathered by adult men (avg. age 22.6 years, or 5 years older than the mothers)
more births fathered by men over 25 than boys under 18
STD and AIDS rates among teenage girls 2 - 4x higher than among age-matched teenage boys
closer to adult male rates

92. Statutory Rape Underage girls/adult perpetrators or boyfriends
States evenly split on mandated reporting
66% of providers do not routinely report
reasons including lack of confidence in criminal justice system, confidentiality, deterring health care and social services follow-up, risk of physical retaliation

93. Teen Pregnancy: Worrisome Trends
1996 “Welfare Reform” Legislation:
50 million over 5 years allocated to states to teach abstinence
1988 – 2% of US school districts relied on abstinence-only education
1999 – 23%

94. Teen Pregnancy: Worrisome Trends
Parental notification laws - consequences:
increased 2nd trimester abortions
increased abortions in neighboring states

95. Single Motherhood
Over 50% of children in solo-mother families live below the poverty line
21% of U.S. children live in solo-mother families
Of white children born since 1980, 50% will spend some part of their childhood in a single parent family
80% for African-American children
On average, children from divorced or single parent families show poorer school performance, ­ risk of teen pregnancy, ­ rates of delinquency, and ¯ mental health

96. The American Family
The U.S. is one of the only industrialized countries without paid maternity leave and health benefits guaranteed by law
The Family and Medical Leave Act (1993) guarantees only unpaid leave and only to individuals working in establishments employing at least 50 workers
disproportionately excludes low-wage workers
only 56% of working women eligible

97. Child Care
50% of mothers of preschoolers and 70% of mothers of school age children work outside the home
1/2 of children of working mothers cared for by relatives
3/8 in family day care ($ /week)
1/8 in day care centers ($ /week)
poorly regulated, higher worker turnover

98. Historical Subjugation of Women
Burning at the stake
The Chamberlain family and obstetrical forceps
J. Marion Sims and operative gynecology
trials on slaves without anesthesia
Contrast with slightly delayed use of chloroform for obstetrical anesthesia
discovered by James Young Simpson, 1847
Queen Victoria, Charles Darwin, and Charles Dickens used/encouraged

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

100. Public Health and Social Justice Website
Contact Information
Public Health and Social Justice Website