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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.

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Women s health contemporary human rights issues l.jpg

Women’s HealthContemporary Human Rights Issues

Martin Donohoe, M.D., F.A.C.P.


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Violence Against WomenOverview

  • Definitions

  • Epidemiology

  • Sexual Assault/Rape

  • Sequelae of Domestic Violence

  • Recognition and Management

  • The Developing World

    • human rights abuses

    • female genital cutting


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Violence Against WomenOverview

  • Teen Pregnancy

  • The Family/Single Motherhood/Child Care

  • Ideals of Beauty & the Historical Subjugation of Women

  • Abortion

  • Conclusions


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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


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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


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Individual Violence Against Women(examples)

  • partner abuse

  • sexual assault/marital rape

  • forced prostitution

  • forced noncompliance with contraception

  • female genital cutting

  • slavery


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Definitions of Violence Against Women

Societal:

Structural forms of discrimination or deprivation that affect women as a class


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Societal Violence Against Women(examples)

  • poverty

  • impaired access to employment or education

  • divorce restrictions

  • salary inequalities

  • political marginalization

  • impaired access to reproductive health services


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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)


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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


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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


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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


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Prevalence of Domestic Violence

  • OB/Gyn

    • 1/6 women during pregnancy

  • Peds

    • 50 - 70% of mothers of abused children


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High Risk Occupations: Prostitutes

  • 80% have been physically assaulted

  • 80% have been threatened with a knife, gun, or other weapon

  • 67% have been raped


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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


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    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


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    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)


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    High Risk GroupsRunaway 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


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    “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


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    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


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    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


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    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...


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    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 ofAbuse Victims


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    Common Characteristicsof 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


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    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


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    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


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    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


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    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%


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    Rape

    • Underreported

    • Less than 1% of rapists convicted

    • Average prison time for those convicted:

      • rape = 1 year

      • armed robbery = 3 - 5 years

      • murder = 8 years

    • Chemical Castration Laws


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    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


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    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


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    Rape

    • 5% chance of pregnancy

    • 25% chance of acquiring STD

      • GC = 6 - 12%

      • Chlamydia = 4 - 17%

      • Syphillis = 0.5 - 3%

    • 1 -2/1,000 odds of acquiring HIV

      • varies


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    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


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    Physical Examination of AssaultsSexual 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


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    Prophylaxis for Adult Victims of AssaultsSexual AssaultAntiobiotic 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)

      PLUS

    • Metronidazole ( 2 g po x 1)


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    Prophylaxis for Adult Victims of AssaultsSexual AssaultPrevention 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


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    Prophylaxis for Adult Victims of AssaultsSexual Assault

    • HIV Prophylaxis (studies ongoing)

      • Consult ID

      • start up to 72° after rape

    • Other (as indicated)

      • tetanus toxoid

      • Hep B vax/HBIG


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    How We View Women Assaults

    • Montana

      • 2nd violation of animal abuse statute

        • $1,000 fine + 2 years in jail

      • 2nd violation spousal abuse

        • $500 + 6 months in jail


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    • 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


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    Factors That Perpetuate (“pre-existing condition”)Gender-Based ViolenceCultural

    • 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; 39:1165-79


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    Factors That Perpetuate (“pre-existing condition”)Gender-Based ViolenceEconomic

    • 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; 39:1165-79


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    Factors That Perpetuate (“pre-existing condition”)Gender-Based ViolenceLegal

    • 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; 39:1165-79


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    Factors That Perpetuate (“pre-existing condition”)Gender-Based ViolencePolitical

    • 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; 39:1165-79


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    Economic Gender Disparities: (“pre-existing condition”)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


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    Economic Gender Disparities: (“pre-existing condition”)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


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    Economic Gender Disparities: (“pre-existing condition”)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


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    Ledbetter v Goodyear (“pre-existing condition”)US Supreme Court, 2006

    • While the Civil Rights Act forbids pay discrimination on the basis of race, gender or religion, all employees must lodge a formal complaint within 180 days of the initial discriminatory paycheck

    • Women still earn 77 cents to every dollar earned by men


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    Economic Gender Disparities: (“pre-existing condition”)The Good News (U.S.)

    • From 1987 - 1999:

      • # 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)


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    Economic Gender Disparities: (“pre-existing condition”)The Good News (U.S.)

    • Fastest growing fields:

      • Construction

      • Wholesale trade

      • Transportation

      • Communications

      • Agriculture

      • Manufacturing


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    Gender Disparities: (“pre-existing condition”)Mixed News (U.S.)

    • High school sports

      • 2.5 million female athletes (1999) vs. 300,000 (early 1970s)

      • But 90% of women’s college sports teams were coached by women when Title IX enacted (1972); 2007 - 42%


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    Sexual Harassment (“pre-existing condition”)

    • 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


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    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


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    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


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    Pornography Physicians

    • $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


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    Pornography and Violence Against Women Physicians

    • 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.)


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    Health Consequences of Violence PhysiciansAgainst WomenPhysical Sequelae

    • trauma: bruises, fractures, lacerations

    • chronic pain: headaches, AP, pelvic pain, myalgias, LBP, CP

    • Hyperventilation Syndrome

    • Eating and sleeping disorders


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    Health Consequences of Violence PhysiciansAgainst WomenPhysical Sequelae

    • Alcoholism and Drug Abuse

      • e.g. rape victims 10x prevalence of general population

      • begins after abuse

    • Tobacco abuse

    • High risk sexual behaviors, STDs, recurrent vaginal yeast infections

    • Delayed risk of HTN, arthritis, asthma, stroke, and heart disease

    • IBS

      • symptom severity correlates with severity and duration of abuse


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    withdrawal Physicians

    confusion

    psychological numbing

    sense of vulnerability/hopelessness/loss/betrayal

    shock

    denial

    distrust of others

    Health Consequences of ViolenceAgainst WomenPsychological Sequelae - Early


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    Health Consequences of Violence PhysiciansAgainst WomenPsychological Sequelae - Long Term

    • depression

    • anxiety disorders

    • phobias

    • anorexia/bulimia

    • substance abuse


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    Health Consequences of Violence PhysiciansAgainst WomenPsychological 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


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    Health Consequences of Violence PhysiciansAgainst Women

    • Interference with health care

    • Delayed health care


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    Health Consequences of Violence PhysiciansAgainst WomenResponse to Rape

    • Initial:

      • unnaturally calm/detached OR crying/angry

    • Denial phase

      • approx. 2 months

    • Increasing psychological symptoms over several months

    • Gradual psychological healing


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    Recognition and Management of PhysiciansDomestic 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


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    Recognition and Management Physicians

    • 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


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    Screening Practices of PCPs Physicians

    • 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


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    Assess Patient for Acutely PhysiciansIncreased Danger

    • Abuser

      • criminal record

      • alcohol/substance abuse problem

      • gambling problem

      • psychiatric disorder

    • Situational Trigger

      • job loss

      • death in family


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    Assess for Acutely Increased Danger Physicians

    • Nature of Abuse

      • increased severity and frequency of beatings

      • escalation in threats

      • stalking

      • violent or forced sex

      • destruction of property


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    Ensure Victim’s Safety Physicians

    • Social worker involvement

    • Restraining order

    • Phone numbers of shelters, hotlines

    • Safe place to go


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    Domestic Violence Shelters Physicians

    • Availability poor

      • up to 70 - 80% 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


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    Physician Failure to Recognize PhysiciansViolence 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


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    Physician Failure to Recognize PhysiciansViolence 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


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    Violence Against Women Physiciansin 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


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    Violence Against Women Physiciansin The Developing World

    • Selective abortion, malnutrition or killing of female children

      • M:F ratio of births in China = 119:100

    • suicide as “vengeance” against an abusive spouse

    • post-rape suicide (or homicide)

      • to “cleanse family honor”

      • 47% of homicides in Alexandria, Egypt


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    Female Genital Cutting Physicians

    • 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


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    Female Genital Cutting Physicians

    • Also called female genital mutilation

    • Not female circumcision

      • i.e., male equivalent would be penectomy


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    Female Genital Cutting Physicians

    • 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 - 2007

      • 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


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    Female Genital Cutting Physicians

    • 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


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    Female Genital Cutting Physicians

    • 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 l.jpg

    bleeding Physicians

    infection

    dyspareunia

    painful neuromas

    keloids

    dysmenorrhea

    infertility

    decreased sexual responsiveness

    shame

    fear

    depression

    Female Genital CuttingComplications/Sequelae


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    Management of PhysiciansFemale Genital Cutting

    • Sensitivity/understand cultural identity issues

    • Deinfibulation

    • Immigration Issues


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    Female Genital Cutting Physicians

    • 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


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    Polygamy Physicians

    • 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. the 1,500 member Kingston clan)


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    Polygamy Physicians

    • 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)


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    Polygamy PhysiciansRelated 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


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    Covenant Marriages Physicians

    • 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


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    Rape in War Physicians

    • Used for domination, humiliation, control, “soldierly bonding”, and ethnic cleansing

    • often occurs in front of family members

    • recognized as a War Crime since Nuremberg


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    International Issues PhysiciansAfghanistan

    • 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


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    International Issues PhysiciansSouth 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¢


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    International Issues PhysiciansSouth 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


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    Other International Issues Physicians

    • 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


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    Trafficking Physicians

    • 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


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    Legal approaches Physicians

    • Mandatory reporting

      • History of mandatory reporting (child and elder abuse)

      • Benefits

      • Risks

      • Effectiveness

    • 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


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    Teen Pregnancy Physicians

    • Birth rate ages 15 - 19 = 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)


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    Teen Pregnancy Physicians

    • U.S. rates 3 - 10x 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


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    Teen Pregnancy Physicians

    • Only 8% of schools provide condoms

      • promotion and distribution does not increase teen sexual activity

    • Only 20 - 40% 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


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    Teen Pregnancy PhysiciansThe 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


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    Statutory Rape Physicians

    • 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


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    Teen Pregnancy: Worrisome Trends Physicians

    • 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)

      • 1988 – 2% of US school districts relied on abstinence-only education

      • 1999 – 23%


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    Teen Pregnancy: Worrisome Trends Physicians

    • Parental notification laws - consequences:

      • increased 2nd trimester abortions

      • increased abortions in neighboring states


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    Single Motherhood Physicians

    • 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


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    The American Family Physicians

    • 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


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    Child Care Physicians

    • 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


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    Historical Subjugation of Women Physicians

    • 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


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    Conclusions Physicians

    • 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


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    Contact Information Physicians

    Public Health and Social Justice Website

    http://www.phsj.org

    [email protected]


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