Womens Health Contemporary Human Rights Issues Martin Donohoe

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

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

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

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

Definitions of Violence Against Women Individual: Any act of verbal or physical force, coercion, or lifethreatening 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 sexual assault/marital rape forced prostitution forced noncompliance with contraception female genital cutting slavery 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) • • • poverty impaired access to employment or education divorce restrictions salary inequalities political marginalization impaired access to reproductive health services

Epidemiology • Lifetime prevalence of assault/sexual abuse – 12% of adolescent girls – 20% of college women – 20% of adult women • 2 - 4 million women assaulted per year • every 15 seconds a woman is beaten; every 2 minutes a woman is sexually assaulted

Epidemiology • 5% of partner abuse is female on male • 22% of men / 7% of women in same sex partnerships report domestic violence • Discrimination against homosexuals legal

Epidemiology of VAW • 2011 CDC study: – 36% of women and 28% of men have experienced rape, physical violence, stalking, or all 3 by their significant other in their lifetimes

Epidemiology of VAW • 2011 CDC study – 18% of women have been raped; 1. 4% of men • Women: 52% by partner; 41% by acquaintance • Men: 52% by acquaintance; 15% by stranger

Dating Violence in Adolescence and Young Adulthood • 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%) – Study included physical violence, but not sexual violence, and did not consider violence not resulting in injuries – Males and females surveyed (under-reporting possible) • Cyber dating abuse increasingly common

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

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

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

Abuse in Pregnancy • 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 – Higher risk for abuse and – Abuse increases risk of post-partum depression

High Risk Occupations: Prostitutes • 80% have been physically assaulted • 80% have been threatened with a knife, gun, or other weapon • 67% have been raped • 1/67 arrested per week in U. S. • 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 • Some prostitutes overseas take furosemide to appear more thin/lose water weight • Prostitute rates of PTSD similar to those of combat veterans and refugees from state-sponsored torture

Prostitution in the U. S. • 0. 6% of men admit to paying for sex in the last year – 17% at some point in their lives (actual percentage likely higher) • 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 18 • Punishment varies among johns, prostitutes, pimps – Different types of regulation exist worldwide (see prostitution paper on website)

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

High Risk Occupations: The Military • 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 – War, rape and genocide

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 1 - 2 million runaway adolescents/year) – association with violence, victimization, STDs, and pregnancy

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

Perpetrators • 1/5 U. S. men reports having been violent against a spouse or significant other • 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

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, 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 • 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 11 -20 serving time for homicide have killed their mother’s abuser

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. . .

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

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

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

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

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

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

Rape • Unwanted, forced penetration (oral/vaginal/anal) • Reported by 33 -46% of women who are physically abused • Annual incidence ³ 80/100, 000 women – 7% of all violent crimes • Lifetime prevalence up to 25% – 1/3 Native Americans/Alaskan Natives victims of attempted rape or rape – Migrants, those in war zones and refugee camps at high risk

Rape • 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 • Underreported • FBI: 8% of rape allegations unfounded • Less than 1% of rapists convicted

Rape 34 states have statutes of limitations on filing charges, ranging from 3 -30 yrs (some exemptions if DNA evidence identifies suspect) • Large backlog of untested rape kits (some estimates as high as 500, 000) • H. R. 4114 and S. B 2376 (Justice for Survivors of Sexual Assault) bills pending in Congress n

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

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

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

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

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

Rape and Pregnancy • 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 – vs. amniocentesis and chorionic villus sampling (1015 weeks, risks to mother and fetus) – May assist mother’s decision to carry vs. terminate pregnancy

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 NEJM 1995; 332: 234 -7 and NEJM 2011; 365: 834 -41

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

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

Physical Examination of Sexual Assault Victims • 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 and NEJM 2011; 365: 834 -41

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

Prophylaxis for Adult Victims of Sexual Assault Prevention of Pregnancy • 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) – Less effective than ulipristal and levonorgestrel • Most effective: copper IUD implanted within 5 days – Nearly 100% effective – Preferred for obese women

Prophylaxis for Adult Victims of Sexual Assault Prevention of Pregnancy • Clinical exam/pregnancy testing not required before EC • Women with contraindications to conventional oral contraceptives may receive any EC regimen • Even within the same menstrual cycle, EC can be used more than once

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

EC and Oregon Pharmacies (2003) • 61% of Oregon hospitals routinely offer EC to rape patients – 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 • Other states are considering similar legislation • Military clinics not required to stock EC • 2013: OTC EC for all children of childbearing age allowed by federal judge

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

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

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

Registered Sex Offenders • 650, 000 in US – 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 – The least likely class of criminals to re-offend (3. 5% recidivism rate within 3 years, recidivism rare after 5 years)

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

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 • Menstrual hygiene management, shaming

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

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

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

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) – hold 20% of legislative seats – receive 10% of global income – own 1% of global property

Economic Gender Disparities: The Bad News • Women make up 45% of the employed global workforce, yet account for 70% of the world’s poor • More patriarchal societies have higher mortality rates for men

Economic Gender Disparities: The Bad News • Women in the U. S. working full-time make $0. 77 $0. 81/$1. 00 males – Those in unions have higher salaries, better benefits – Part-time salary balanced $1. 04/$1. 00 – More than ½ of working mothers get no paid sick leave (some localities passing laws to change this)

Economic Gender Disparities: The Bad News • 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

Economic Gender Disparities: The Bad News • M→F sex change: wages decrease; F→M sex change: wages increase slightly • 2012: IA Supreme Court rules no sex discrimination in case of woman fired for being “irresistible” to her boss • Protections to allow reasonable accommodations for pregnant women lacking in most states

Gender Pay Gap (US)

Gender Disparities: The Bad News • Women account for 22% of legislators worldwide (19% in U. S. ) – U. S. ranks 72 nd in gender equity/65 th in gender pay gap out of 188 countries with national parliaments • 2012: IA Supreme Court rules no sex discrimination in case of woman fired for being “irresistible” to her boss

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 • Lilly Ledbetter Fair Pay Restoration Act of 2009: Now complaint can be filed within 180 of most recent paycheck

Economic Gender Disparities: Health Insurance (pre-PPACA) • Gender rating in 38 states allows insurance companies to charge men and women different rates for the same coverage • Maternity care often excluded – 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

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

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

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

Economic Gender Disparities: The Good News (U. S. ) • 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

Economic Gender Disparities: The Good News (U. S. ) • Fastest growing fields: – Construction – Wholesale trade – Transportation – Communications – Agriculture – Manufacturing

Gender Disparities: Mixed News (U. S. ) • High school sports – 1/3 of girls participate (vs. 1/27 in 1971) – 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) • Women = 1/2 of medical school applicants, 1/2 of medical students, almost 1/2 of residents, and 1/3 of physician workforce • Women under-represented in academic medicine

Gender Disparities in Medicine • Female physicians’ salaries 40% below those of male physicians (2011) – Multifactorial (e. g. , women work 18% fewer hours than men, have fewer years of experience, etc. ) – Salaries 13, 399 lower for researchers of equivalent academic rank (2011)

Gender Disparities in Medicine – When matched for hours worked, female clinicians earned 25% less than males (2006 -2010) • Was 16% between 1996 and 2000

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

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

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

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

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. )

Risk factors which make males susceptible to the “dark side” of porn • 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

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

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

Health Consequences of Violence Against Women Physical Sequelae • • • Alcoholism and Drug Abuse – e. g. rape victims 10 x prevalence of general population – begins after abuse Tobacco abuse High risk sexual behaviors, STDs, recurrent vaginal yeast infections – 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 IBS – symptom severity correlates with severity and duration of abuse GERD Other functional GI disorders

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

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

Health Consequences of Violence Against Women Psychological Sequelae - Long Term • • • PMDD 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

Health Consequences of Violence Against Women • Interference with health care • Delayed health care • Higher hospitalization costs (for 3 years post-violence, then return to baseline)

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

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

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

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

• • • Screening (2011): Percent of Women Ages 18 -44 Who Have Discussed with Their Provider Sexual history: 38% STDs: 28% HIV: 29% Domestic/dating violence: 15% 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 • Abuser – criminal record – alcohol/substance abuse problem – gambling problem – psychiatric disorder • Situational Trigger – job loss – death in family

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

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

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

Domestic Violence Shelters • 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

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

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

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

Violence Against Women in The Developing World • Selective abortion, malnutrition or killing of female children – Normal M: F ratio = 106: 100 – In China = 118: 100 • suicide as “vengeance” against an abusive spouse • post-rape suicide (or homicide) – to “cleanse family honor” – 47% of homicides in Alexandria, Egypt

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

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

Female Genital Cutting • 125 million - 140 million women affected worldwide (3 million girls/year) –mostly in Africa (e. g. 98% of women in Somalia, 80% in Egypt, 50% in Kenya) • Outlawed in Egypt - 2007 –rare in Asia

Female Genital Cutting • 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

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

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

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

Management of Female Genital Cutting • 400, 000 women and girls in US affected • Sensitivity/understand cultural identity issues • Deinfibulation • Immigration Issues

Female Genital Cutting • UN, WHO, and FIGO have condemned • Fear of FGC can be the basis for an asylum claim • Illegal to perform in U. S. under child abuse statutes and 1996 federal law • Girls’ Protection Act of 2011 – To provide penalties for transporting minors in foreign commerce for the purposes of female genital mutilation. – Stuck in committee

Female Genital Cutting • Laws 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

Polygamy • Utah/Mormons – introduced by Joseph Smith (1805 -1844) 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 - 90, 000 today – polygamist clans (e. g. 10, 000 FLDS members, 1, 500 member Kingston clan)

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)

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

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

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

International Issues • 2013 WHO report: 30% of women worldwide have been victims of IPV • Worldwide, 289, 000 women die from childbirth complications each year

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

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

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 • Only minor changes since US invasion – most of country still controlled by Taliban, poppy trade strong

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 – 1 rape/23 s – ¼ South African men say they have committed rape • 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¢ •

International Issues South Africa’s Rape Epidemic • HIV risk – in Johannesburg, 40% of men aged 20 - 29 are HIV+ – 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 • Wives of the gods – Sex slaves at animist shrine in Ghana, Benin and Togo – Sex initiation camps in Malawi

Trafficking • 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 • International sex trade, sex tourism strong US government programs to help victims of sex- and labortrafficking doled out by US Conference of Catholic Bishops, and do not cover reproductive care

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

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

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

Legal approaches • 1994 Violence Against Women Act – New laws, enforcement mechanisms – 2013: Expanded to cover gays, immigrants, Native Americans, and sex-trafficking victims • 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 – Stalled in Congress

Teenage Sexual Activity • 46% of teenage boys and girls have had sexual intercourse (decreasing) • Teen birth rate (2013) = 27/1, 000/yr – Lowest since mid 1940 s – Down from high of 96/1, 000/yr in 1957) – Hispanics and African-Americans = 2 X higher than Whites = 2 X higher than Asians

Teen Pregnancy • 80% of teen pregnancies unintended • Teen pregnancy has decreased 57% since 1991 – But still higher than in many other developed countries

Teen Pregnancy • U. S. rates 3 - 10 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

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 - 4 x higher than among age-matched teenage boys – closer to adult male rates

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

Teenage Sexual Activity • 50% of pregnant teens were not using any form of contraception – 31% of these did not believe they could get pregnant • Contraception use among teens increasing – 80% condom with first intercourse • 16% in combination with hormonal method

Teenage Sexual Activity • STD rates high, testing/treatment/followup poor, long-term risks include PID, infertility • HPV vaccine uptake low – No increased sexual activity with HPV • Inadequate sex education and limited access to reproductive health care likely increases morbidity, mortality

Teen Pregnancy: Worrisome Trends • 1996 “Welfare Reform” Legislation: – 50 million over 5 years allocated to states to teach abstinence – By 2008, annual abstinence-only budget $178 million (vs. 0% for comprehensive sex ed); Obama eliminated program in 2009 – 1988 – 2% of US school districts relied on abstinence-only education – 1999 – 23%

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

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

The American Family • The U. S. is one of the only industrialized countries without paid maternity leave and health benefits guaranteed by law – Exceptions: CA and NJ provide up to 6 wks paid parental leave

The American Family • 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

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 ($40 - 100/week) – 1/8 in day care centers ($70 - 150/week) – poorly regulated, higher worker turnover

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

Perinatal Shackling of Prisoners • Mostly for those convicted of drug crimes • Still permissible for 2/3 of female inmates, despite federal and state directives and laws to eliminate • Applied more frequently to poor and to racial and ethnic minorities

Pregnant Inmates: A High-Risk Obstetrical Population • 31 states allow the shackling of female prisoners while they are giving birth – Despite state and federal regulations designed to limit practice • Some states considering legislation to limit – Detainees of Immigration and Customs Enforcement (ICE) exempt from prohibitions – ACOG, AMA, APHA, ABA (“except in extraordinary circumstances”), UN, Amnesty International oppose

Pregnant Inmates: A High-Risk Obstetrical Population • Shackling pregnant inmates – Risk for falls, difficulty with giving birth (risks to mother and newborn), difficulty with bonding and breast feeding – Dehumanizing, cruel and unusual punishment

Conclusions • Awareness of scope of problem of violence against women • Screen regularly and repeatedly; document; treat; support – Screening reduces IPV, improves health outcomes • Support women’s rights issues, which are health care issues

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