Violence Against Women Martin Donohoe M D F

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

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) n partner abuse n sexual assault/marital rape n forced prostitution n forced noncompliance with contraception n female genital mutilation n slavery n unwanted sexting

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

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

Epidemiology of VAW n Lifetime prevalence of assault/sexual abuse n 12% of adolescent girls n 20 -25% of college women n 20% of adult women

Epidemiology of VAW n NISVS (National Intimate Partner and Sexual Violence Survey)/CDC (2011) n 19% of women have been raped; 1. 7% of men (1999 study found 13% of women, 3% of men) n Women: 52% by partner; 41% by acquaintance n Men: 52% by acquaintance; 15% by stranger

Epidemiology of VAW n NISVS (National Intimate Partner and Sexual Violence Survey)/CDC (2011) n 44% of women and 23% of men have experienced rape, physical violence, stalking, or all 3 by their significant other in their lifetimes

Epidemiology of VAW n 2 - 4 million women assaulted per year n Every 15 seconds a woman is beaten; every 2 minutes a woman is sexually assaulted n 5% of partner abuse is female on male n(homosexual/bisexual abuse also exists)

Dating Violence in Adolescence and Young Adulthood n n 1/3 of 7 th grade girls report “psychological dating violence, ” 1/6 report “physical dating violence” (2012) One study (AJPH 2010; 100: 1737 -1744) showed females more likely than males to be perpetrators (38% vs. 19%) n Study included physical violence, but not sexual violence, and did not consider violence not resulting in injuries n Males and females surveyed (under-reporting possible) Cyber dating abuse increasingly common 1/5 children cyberstalked for sex online (1/22 physically stalked)

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

Prevalence of Domestic Violence OB/Gyn n 1/6 women during pregnancy n Abortion Clinics n n n 12% Peds n 50 - 70% of mothers of abused children

Prevalence of Domestic Violence Orthopedic fracture clinics n 1/6 women n Psych n 1/4 women who attempt suicide n 1/4 women treated for psychiatric symptoms n 55% lifetime prevalence for women with depression n

Abuse in Pregnancy n n Incidence = 8 - 20% (lower than in non-pregnant women) Most common sites of beating are abdomen, head and breasts Increases risk of low birth weight/pre-term labor/delayed prenatal care Post-partum depression n Higher risk for abuse and n Abuse increases risk of post-partum depression

High Risk Occupations: Prostitutes n 80% have been physically assaulted n 80% have been threatened with a knife, gun, or other weapon n 67% have been raped n 1/67 arrested per week in U. S. n 1/33 have sex with a police officer per week in U. S.

High Risk Occupations: Prostitutes High rates of physical assault and abuse by police in Central and Eastern Europe and Central Asia n Some prostitutes overseas take furosemide to appear more thin/lose water weight n Prostitute rates of PTSD similar to those of combat veterans and refugees from statesponsored torture n

Prostitution in the U. S. n 0. 6% of men admit to paying for sex in the last year n 17% at some point in their lives (actual percentage likely higher) n 694 “clients”/prostitute/year average

Prostitution in the U. S. n 1. 6% of women admitted they “had sex with a person [they] paid, or who paid [them] for sex” since age 18 n Punishment varies among johns, prostitutes, pimps n Different types of regulation exist worldwide (see prostitution paper on website) n WHO, AI, and HRW have called for the decriminalization of prostitution

Sex Trafficking and Sex Tourism Sex tourism common in SE Asia, Eastern Europe n 100, 000 children are victims of commercial sexual exploitation in the US each year n Many malnourished forced to take dexamethasone (to gain weight) n Trafficking Victims Protection Act provides some protections n

High Risk Occupations: The Military n See the “Women’s Health” and “War and Peace” pages of the Public Health and Social Justice website for other slide shows and articles covering: Violence against women in the military n War, rape and genocide n

High Risk Groups Runaway and Homeless Youth n Survival sex n the exchange of sex for shelter, food, drugs or money n 28% of street youths, 10% of shelter youth (out of 1 - 2 million runaway adolescents/year) n association with violence, victimization, STDs, and pregnancy

High Risk Groups College Women n 20 -25% incidence of sexual assault over 4 year period n 80% do not report n Highest during first 2 years n Sexual assault resistance programs can cut by almost 1/2

Perpetrators n n n 1/5 U. S. men reports having been violent against a spouse or significant other High risk perpetrators: n Male college athletes n constitute 3. 3% of male student body n involved in 19% of sexual assaults n Fraternities n individual and gang rapes more common Physicians (US gymnastics, USC Student Health)

Deaths from Domestic Violence n 4, 000 domestic violence deaths/year n over 1/2 of women murdered in U. S. are killed by a current or former partner n U. S. has highest rate of IPV homicides among world’s 25 wealthiest countries n 1/2 to 3/4 of the 1, 000 - 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 n Battered women who claim self-defense (the only legally justifiable reason for murder) in criminal trials are acquitted only 25% of the time n 63% of young men aged 11 -20 serving time for homicide have killed their mother’s abuser n

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

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

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

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

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

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

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

Rape n Unwanted, penetration n n Oral/vaginal/anal By penis, other body part, or object Forcible and non-forcible Includes rape of females by females Reported by 33 -46% of women who are physically abused

Rape n Unwanted, forced penetration (oral/vaginal/anal) n Reported by 33 -46% of women who are physically abused n FBI: 5% of rape allegations unfounded

Rape Annual incidence ³ 80/100, 000 women n 7% of all violent crimes n Lifetime prevalence up to 25% n 1/3 Native Americans/Alaskan Natives victims of attempted rape or rape n Migrants, those in war zones and refugee camps at high risk n

High Risk Groups n Persons under age 24 n Prostitutes n Gays, lesbians, bisexuals, transgendered n Alcohol and drug users n The disabled

High Risk Groups n College students n 3/4 of victims incapacitated, usually by alcohol) n 33% reported to counselor, but only 12% reported to law enforcement n Colleges revising policies

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

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

Sexual Assault and Rape of Incarcerated Men • Men = 92% of prisoners in US • 1/5 men in state prisons report pressured or forced sex during incarceration; 7% report rape • 4. 5% of men in state and federal prisons sexually victimized annually – Rates much higher among non-heterosexual inmates (many engage in “protective” pairing / “protective” prostitution)

Rape n 6 -7% chance of pregnancy (est. 25, 000 pregnancies/yr in US) n 25% chance of acquiring STD n GC = 6 - 12% n Chlamydia = 4 - 17% n Syphilis = 0. 5 - 3%

Rape n 1 -2/1, 000 odds of acquiring HIV from HIV+ rapist n 1 -2/100, 000 overall risk of HIV from vaginal penetration n 2 -3/10, 000 from anal penetration

Rape and Pregnancy n Noninvasive prenatal genetic testing through amplification of fetal alleles from maternal blood very accurate for identifying father Can be performed at 8 -14 weeks gestation n vs. amniocentesis and chorionic villus sampling (10 -15 weeks, risks to mother and fetus) n May assist mother’s decision to carry vs. terminate pregnancy n

Rape n n n Underreported (16 -38% notify law enforcement; 17 -43% present for medical evaluation) Only ¼ of reported rapes lead to arrest, 1/5 lead to prosecution, and only ½ of prosecutions result in felony convictions 34 states have statutes of limitations on filing charges, ranging from 3 -30 yrs (some exemptions if DNA evidence identifies suspect)

Rape n Large backlog of untested rape kits (some estimates as high as 500, 000) n H. R. 4114 and S. B 2736 (Justice for Survivors of Sexual Assault) bills passed by Congress, awaiting joint committee finalization (late 2016)

Rape n Average prison time for those convicted: n rape = 1 year n armed robbery = 3 - 5 years n murder = 8 years n Chemical Castration Laws

How We View Women n Montana n 2 nd violation of animal abuse statute n$1, 000 fine + 2 years in jail n 2 nd violation spousal abuse n$500 + 6 months in jail

U. S. Public Funding for Research and Prevention (2013)

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

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

The Physician’s Duties in Caring for Victims of Sexual Assaults n Medical n obtain medical history n evaluate and treat physical injuries n obtain cultures n treat any pre-existing infection NEJM 1995; 332: 234 -7 and NEJM 2011; 365: 834 -41

The Physician’s Duties in Caring for Victims of Sexual Assaults n Medical n offer post-exposure HIV and hepatitis B prophylaxis n offer post-coital contraception (vs. in utero paternity testing f/b selective abortion) n arrange medical followup n provide counseling NEJM 1995; 332: 234 -7 and NEJM 2011; 365: 834 -41

Physical Examination of Sexual Assault Victims Collection of clothing n External/internal evaluation n abrasions, lacerations, ecchymoses, bite marks; colposcopy, toluidine blue staining n Oral cavity n secretions, injuries, collection of samples for culture n Note: time limits for evidence collection vary by state (72 -120 hrs) n NEJM 1995; 332: 234 -7 and NEJM 2011; 365: 834 -41

Physical Examination of Sexual Assault Victims Genitalia n hair combing, hair sampling, vaginal secretions, collection of samples for culture, injuries n Rectum n injuries, collection of samples for culture n NEJM 1995; 332: 234 -7 and NEJM 2011; 365: 834 -41

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

Prophylaxis for Adult Victims of Sexual Assault Prevention of Pregnancy n Most effective oral regimen: 1 dose of 30 mg ulipristal or 1. 5 mg levonorgestrel within 120 hours of unprotected intercourse (ulipristal twice as effective; 0. 9% pregnancy rate vs 1. 7%)

Prophylaxis for Adult Victims of Sexual Assault Prevention of Pregnancy Alternate regimen: 2 doses of 100 mcg ethinyl estradiol plus 0. 5 mg levonorgestrel taken 12 hours apart (plus prn antiemetic) n Most effective: copper IUD implanted within 5 days n n Nearly 100% effective

Previous Limits on Availability of Emergency Contraception 17 states mandate that emergency contraception be available to rape victims n 9 states allow pharmacists to directly prescribe emergency contraception n Other states considering n

EC and Oregon Pharmacies (2003) n n n 61% of Oregon hospitals routinely offer EC to rape patients n Catholic hospitals = non-Catholic hospitals 70% of all pharmacists surveyed reported that their pharmacy stocked emergency contraception. Of those pharmacists who do not stock emergency contraception, 30% will not fill a prescription for the medication due a moral objection.

Changing Limits on Availability of Emergency Contraception Laws in Arkansas, Mississippi, Georgia, and South Dakota explicitly protect pharmacists who refuse to dispense EC n Other states are considering similar legislation n Military clinics not required to stock EC n 2013: OTC EC for all children of childbearing age allowed by federal judge n

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

Factors That Perpetuate Gender-Based Violence From Soc Sci Med 1994; 39: 1165 -79

Factors That Perpetuate Gender-Based Violence Cultural n n n Gender-specific socialization: n Cultural definitions of appropriate sex roles n Expectations of roles with relationships n 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 Menstrual hygiene management, shaming

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

Factors That Perpetuate Gender-Based Violence Legal n n n 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

Factors That Perpetuate Gender-Based Violence Political n n n 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

Patriarchy n Theories: n Hormonal differences, leading to strength differences n Women diverted from power struggles by pregnancy and child-rearing n Menstrual taboos and superstitions isolate women

Patriarchy n Theories: n Power shift to physically stronger males at advent of agriculture 12, 000 yrs ago n Coincided with concept of private property, inheritance via male lineage n Patrilochal residence facilitates patriarchy n Multiple others

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

Economic Gender Disparities: The Bad News n Women make up 45% of the employed global workforce, yet account for 70% of the world’s poor n More patriarchal societies have higher mortality rates for men n Iceland: World’s most gender equal country (women hold 48% of legislative seats, earn $0. 99/$1. 00 for men)

Economic Gender Disparities: The Bad News • n U. S. ranks 72 nd in gender equity/65 th in gender pay gap out of 188 countries with national parliaments Women in the U. S. working full-time make $0. 79/$1. 00 males n Situation better for Asian-Americans ($0. 87), worse for African-Americans ($0. 63) and Latinas ($0. 63) n Those in unions have higher salaries, better benefits n Part-time salary balanced $1. 04/$1. 00 n More than ½ of working mothers get no paid sick leave (some localities passing laws to change this)

Gender Pay Gap n Equal Pay leads to: n Better risk management n Higher profit margins n Higher stock prices n More innovation

Economic Gender Disparities: The Bad News n Women comprise 51% of college graduates, make up 46% of the U. S. workforce, but hold only 5% of CEO positions and less than 20% of corporate director positions in Fortune 500 companies n n Companies with more diverse boards report higher earnings and have higher stock prices Motherhood penalty (lower salary after childbearing)

Gender Discrimination n Pink tax: women charged more than men for virtually identical products and services Applies to 42% of goods, which cost an average of 7% more n Pink Tax Relief Act pending in Congress n n Bystander CPR in public more likely for men than women (45% vs 39%) n 36% vs 35% for CPR at home

Economic Gender Disparities: The Bad News Protections to allow reasonable accommodations for pregnant women lacking in most states n 2012: IA Supreme Court rules no sex discrimination in case of woman fired for being “irresistible” to her boss n

Gender Disparities: The Bad News Women account for 23% of legislators worldwide; 20 heads of state n 25% of U. S. state legislatures; 19% of U. S. House; 23% of U. S. Senate n However, more women ran in 2018 midterms than ever, many female contenders for Democratic presidential nomination n 79% of 2, 400 elected U. S. prosecutors are men n

Economic Gender Disparities n n 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

Economic Gender Disparities n Trump reverses Obama-era executive order forbidding federal contractors from keeping secret sexual harassment and discrimination cases (by requiring that complaints be resolved through arbitration) n Trump repeals other executive orders meant to reduce pay discrimination, including requirement for large employers to submit gender pay data to the EEOC

Economic Gender Disparities: Health Insurance (pre-PPACA) n n Gender rating in 38 states allows insurance companies to charge men and women different rates for the same coverage Maternity care often excluded n 11 states had no private plans that came with maternity coverage n 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(pre-PPACA) C/S can cause rejection of coverage unless woman is subsequently sterilized n Survivors of domestic violence can be rejected in eight states n Rape victims with PTSD may be denied coverage (pre-existing condition) n Rape victims on prophylactic HIV medication could be denied life insurance coverage n

Economic Gender Disparities: Health Insurance (post. PPACA) n No pre-existing conditions n Eliminates gender rating and other forms of health insurance discrimination n Maternity care covered n Some preventive care covered

Economic Gender Disparities: Health Insurance (post. PPACA) n PPACA (Obama. Care) requires insurers to pay full cost of contraception (including EC) n But SCOTUS allows religious exceptions in Hobby Lobby case (2014), citing Religious Freedom Restoration Act of 1993

Trump and Contraceptive Coverage n 2017: Proposed Trump Administration rule would greatly expands the number of employers and insurers that could qualify for exemptions from the mandate by claiming a moral or religious objection, including for-profit, publicly traded corporations

Economic Gender Disparities: The Good News (U. S. ) n n More women than men graduating from college Number of female-owned business increasing dramatically (30% of companies in 2015) Workforce now 50% women Women make 85% of buying decisions or are the “chief purchasing officers” of their households

Gender Disparities: Mixed News (U. S. ) n High school sports n 1/3 of girls participate (vs. 1/27 in 1971) n But 90% of women’s college sports teams were coached by women when Title IX enacted (1972); 2007 - 42%

Gender Disparities in Medicine and Science Women hold < ¼ jobs in STEM fields (science, technology, engineering, and math) n Women = 1/2 of medical school applicants, 1/2 of medical students, almost 1/2 of residents, and 1/3 of physician workforce n Women under-represented in academic medicine, lower-ranked n

Gender Disparities in Medicine n n Female physicians’ salaries 40% below those of male physicians (2011) n Multifactorial (e. g. , women work 18% fewer hours than men, have fewer years of experience, etc. ) n Salaries 13, 399 lower for researchers of equivalent academic rank (2011) Female MD salaries 8% lower in 2016 (after adjustment for age, yrs of experience, specialty, reported work hours, and faculty rank)

Pornography n Multi-billion dollar adult entertainment business n Internet, magazines, movies, clubs, etc. n 2012: LA (home to 80% of the industry) becomes first city to mandate that porn actors wear condoms n Porn actors already regularly tested for STDs

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

Pornography n Sextortion (using personal information, often photos obtained by illicit means, to extort victims into providing more sexually explicit photos/videos) n Revenge porn illegal in 31 states n Intimate Privacy Protection Act pending in Congress

Risk factors which make males susceptible to the “dark side” of porn n n Dysfunctional early home life Delinquent of antisocial behavior or friends A promiscuous attitude which views sex as more of a sport than as part of an intimate relationship “Hostile masculinity” n Narcissistic personality n Hostility against women n Turned on by power over women

Consequences of Excessive Exposure to Pornography n Abnormal ideas regarding normal sexual intimacy n Desensitization n Erectile dysfunction

Violence and Discrimination Against Homosexuals n n n 22% of men / 7% of women in same sex partnerships report domestic violence Gay marriage legal in all 50 states as of 2015 (only 1 state in 2004) Discrimination against homosexuals legal n Laws preventing positive portrayals of LGBTQ individuals in school curricula affect 9 million schoolchildren in 7 states n n Causes……. . GSA, Lambda Legal, etc.

Health Consequences of Violence Against Women Physical Sequelae Trauma: bruises, fractures, lacerations n Traumatic brain injury/chronic traumatic encephalitis n Chronic pain: headaches, AP, pelvic pain, myalgias, LBP, CP n Hyperventilation Syndrome n Eating and sleeping disorders n

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

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

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

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

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

Health Consequences of Violence Against Women n Interference with health care n Delayed health care n Higher health care and hospitalization costs

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

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

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

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

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

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

Screening (2011): Percent of Women Ages 18 -44 Who Have Discussed with Their Provider n Sexual history: 38% n STDs: 28% n HIV: 29% n Domestic/dating violence: 15% n 35%/36% have been tested for an STD/HIV in last 2 years, but 35%/54% assumed such testing was a routine part of the clinical exam

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

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

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

Domestic Violence Shelters n Availability poor n up to 70 - 80% of women and 80% of children turned away on any given night n 4 times as many animal shelters as domestic violence shelters in U. S.

Domestic Violence Shelters Woefully underfunded n Average length of stay = 14 days; most allow 30 day max stay n Over 50% of all homeless women and children are fleeing domestic violence n

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

Physician Failure to Recognize Violence Against Women n. Doctors underestimate the prevalence of domestic violence in their patients/communities n similar to teen sexual activity n. 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 n 1/14 women worldwide has been sexually assaulted at least once by someone who is not an intimate partner nverbal, physical, and sexual abuse n 4 witnesses required for rape conviction in Pakistan ndowry-related murder nbride-burning

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

Violence Against Women in The Developing World n n Selective abortion, malnutrition or killing of female children n Normal M: F ratio = 105: 100 n In China = 118: 100 n China’s one child policy implemented 1979, abandoned 2016 (in favor of two child policy, which is likely to be lifted in 2019) 1/3 young women not involved in either education, training, or employment

Violence Against Women in The Developing World n suicide as “vengeance” against an abusive spouse n post-rape suicide (or homicide) nto “cleanse family honor” n 47% of homicides in Alexandria, Egypt

Female Genital Cutting n See separate slide show on phsj website, Women’s Health page

Polygamy n Utah/Mormons n introduced by Joseph Smith (1805 -1844) who had 50 wives n 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 n Est. 60, 000 - 90, 000 today n n polygamist clans (e. g. 10, 000 FLDS members, 1, 500 member Kingston clan)

Polygamy n n n Utah outlawed “plural marriage” in 1890 in exchange for statehood 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)

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

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

Rape in War n Used for domination, humiliation, control, “soldierly bonding”, and ethnic cleansing n often occurs in front of family members n recognized as a War Crime since Nuremberg n See slide show and article on rape in war on “women’s health” page of phsj website at http: //phsj. org/womens-

International Issues n 2013 WHO report: 30% of women worldwide have been victims of IPV n 2018: More than 600 million women live in countries where sexual violence is not a crime n Worldwide, 289, 000 women die from childbirth complications each

International Issues n n Almost ¼ of Asian man admit to having committed rape n 73% felt “sexually entitled, ” 59% were “seeking entertainment, ” and 38% were “punishing someone” n 55% felt guilty n 23% served prison time Almost ½ of Asian men have committed some type of IPV

International Issues n 80% of refugees and internallydisplaced persons worldwide are female n Indian rape epidemic – one rape every 22 minutes (2012)

International Issues 80% of refugees and internally-displaced persons worldwide are female n Indian rape epidemic – one rape every 22 minutes (2012) n Only 1. 2%/0. 1% of Indian victims of gender-based violence report to police/health care personnel n vs. 2. 6%/1. 1% in Africa n

International Issues Afghanistan Taliban militia took over in 1996 n Human rights abuses n gender-based violence n women denied access to education and health care n female employment rate decreased from 62% to 12% n Maternal mortality among world’s highest n Only minor changes since US invasion – most of country still controlled by Taliban, poppy trade strong n

International Issues South Africa’s Rape Epidemic Official Rape Rate 104/100, 000 people (vs. 34. 4/100, 000 in the U. S. ) n highest rate in the world n 1 rape/23 s n ¼ South African men say they have committed rape n Official annual total = 50, 000, but est. only 1/35 reported n New latex vaginal insert that latches onto a rapist’s penis and requires surgical removal n

International Issues South Africa’s Rape Epidemic n HIV risk n in Johannesburg, 40% of men aged 20 - 29 are HIV+ n post-rape antiretroviral drugs are not available in government hospitals

Other International Issues Mexico City (the most heavily populated city in the world) has one shelter for battered women n Wives of the gods n Sex slaves at animist shrine in Ghana, Benin and Togo n Sex initiation camps in Malawi n

Trafficking n Occurs in 124 countries and all 50 U. S. states n Tens of thousands of women and girls trafficked into US annually to work in sweatshops n Others pay for “transport to US, ” end up in Northern Marianas Islands

Child Marriage n Marriage before age 18 n Affects 60 million women worldwide n 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 n A human rights violation n

Education of Girls and Women n Improvements in length and quality of education lead to: n Fewer children n Increased earning power n Decreased victimization

Legal approaches n Mandatory reporting n History of mandatory reporting (child and elder abuse) n Benefits n Risks n Effectiveness

Legal approaches n 1994 Violence Against Women Act n n n New laws, enforcement mechanisms 2013: Expanded to cover gays, immigrants, Native Americans, and sex-trafficking victims International Violence Against Women Act n n 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

Conclusions Awareness of scope of problem of violence against women n Screen regularly and repeatedly; document; treat; support n n n Screening reduces IPV, improves health outcomes 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): 24 -31. n 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): 313 -319. n

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. http: //www. medscape. com/viewarticle/464 255 n Donohoe MT. Violence against women in the military. Medscape Ob/Gyn and Women’s Health 2005; 10(2): posted 9/13/05. Available at http: //www. medscape. com/viewarticle/512 n

References n Donohoe MT. War, rape and genocide: Never again? Medscape Ob/Gyn and Women’s Health 2004; 9(2): posted 10/22/04. http: //www. medscape. com/viewarticle/491 147

Contact Information Public Health and Social Justice Website http: //www. phsj. org martindonohoe@phsj. org