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Violence Against Women. Martin Donohoe , M.D., F.A.C.P. Violence Against Women Overview. Definitions Epidemiology Sexual Assault/Rape Sequelae of Domestic Violence. Violence Against Women Overview. Recognition and Management The Developing World human rights abuses

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violence against women

Violence Against Women

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

violence against women overview
Violence Against WomenOverview
  • Definitions
  • Epidemiology
  • Sexual Assault/Rape
  • Sequelae of Domestic Violence
violence against women overview1
Violence Against WomenOverview
  • Recognition and Management
  • The Developing World
    • human rights abuses
    • female genital mutilation
  • Understand common forms of violence against women
  • Learn to recognize and manage violence against women
  • Exposure to international issues related to violence against women
definitions of violence against women
Definitions of Violence Against Women


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
Individual Violence Against Women(examples)
  • partner abuse
  • sexual assault/marital rape
  • forced prostitution
  • forced noncompliance with contraception
  • female genital mutilation
  • slavery
  • unwanted sexting
definitions of violence against women1
Definitions of Violence Against Women


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

societal violence against women examples
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 of vaw
Epidemiology of VAW
  • Lifetime prevalence of assault/sexual abuse
    • 12% of adolescent girls
    • 15% of college women
    • 20% of adult women
epidemiology of vaw1
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 vaw2
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
epidemiology of vaw3
Epidemiology of VAW
  • 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)
dating violence in adolescence and young adulthood
Dating Violence in Adolescence and Young Adulthood

1/3 of 7th 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)

prevalence of domestic violence
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 violence1
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 violence2
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
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
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 prostitutes1
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

prostitution in the u s
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 s1
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 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
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
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
high risk perpetrators
“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
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
    • U.S. has highest rate of IPV homicides among world’s 25 wealthiest countries
  • 1/2 to 3/4 of the 1,000 - 1,500 murder suicides per year involve domestic violence
victims who kill their abusers
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
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




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
common characteristics of abusers
Common Characteristicsof Abusers
  • low self-esteem
  • dependency
  • jealousy
  • poor communication skills
  • unemployed/underemployed
common characteristics of abusers1
Common Characteristicsof 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
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
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 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
  • Unwanted, penetration
    • 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
  • 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
high risk groups
High Risk Groups


Gays, lesbians, bisexuals, transgendered

Alcohol and drug users

College students

Persons under age 24

date rape
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
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
  • 5% chance of pregnancy (est. 32,000 pregnancies/yr in US)
  • 25% chance of acquiring STD
    • GC = 6 - 12%
    • Chlamydia = 4 - 17%
    • Syphilis = 0.5 - 3%

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
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 (10-15 weeks, risks to mother and fetus)
    • May assist mother’s decision to carry vs. terminate pregnancy
  • Underreported (16-38% notify law enforcement; 17-43% present for medical evaluation)
  • Fewer than ½ of rape cases successfully prosecuted; as few as 1% of rapists convicted

Large backlog of untested rape kits (over 180,000)

H.R. 4114 and S.B 2736 (Justice for Survivors of Sexual Assault) bills pending in Congress

  • Average prison time for those convicted:
    • rape = 1 year
    • armed robbery = 3 - 5 years
    • murder = 8 years
  • Chemical Castration Laws
how we view women
How We View Women
  • Montana
    • 2nd violation of animal abuse statute
      • $1,000 fine + 2 years in jail
    • 2nd violation spousal abuse
      • $500 + 6 months in jail
sexual crimes against children
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
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)
the physician s duties in caring for victims of sexual assaults
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 assaults1
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
Physical Examination ofSexual 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 victims1
Physical Examination ofSexual 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
Prophylaxis for Adult Victims ofSexual AssaultAntibiotic Prophylaxis
  • Ceftriaxone (250 mg IM) or cefixime (2 g po)


  • Doxycycline (100 mg po bid x 7d) or Azithromycin (1 g po x 1)


  • Metronidazole ( 2 g po x 1)
prophylaxis for adult victims of sexual assault prevention of pregnancy
Prophylaxis for Adult Victims ofSexual AssaultPrevention of Pregnancy
  • Most effective oral regimen: 1 dose of 30 mg ulipristal or 1.5 mg levonorgestrelwithin 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 pregnancy1
Prophylaxis for Adult Victims ofSexual AssaultPrevention of Pregnancy
  • Alternate regimen: 2 doses of 100 mcg ethinyl estradiol plus 0.5 mg levonorgestrel taken 12 hours apart (plus prn antiemetic)
  • Most effective: IUD implanted within 5 days
    • Nearly 100% effective
previous limits on availability of emergency contraception
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
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
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
Prophylaxis for Adult Victims ofSexual Assault
  • HIV Prophylaxis
    • Consult ID
    • start up to 72° after rape
  • Other (as indicated)
    • tetanus toxoid
    • Hep B vax/HBIG
factors that perpetuate gender based violence cultural
Factors That Perpetuate 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

factors that perpetuate gender based violence economic
Factors That Perpetuate 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

factors that perpetuate gender based violence legal
Factors That Perpetuate 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

SocSci Med 1994; 39:1165-79

factors that perpetuate gender based violence political
Factors That Perpetuate 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 SocSci Med 1994; 39:1165-79
economic gender disparities the bad news
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
  • Women make up 45% of the employed global workforce, yet account for 70% of the world’s poor
economic gender disparities the bad news1
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
  • Women make up 46% of the U.S. workforce, but hold only 4% of CEO positions and 15% of corporate director positions in Fortune 500 companies
economic gender disparities the bad news2
Economic Gender Disparities:The Bad News

Protections to allow reasonable accommodations for pregnant women lacking in most states

2012: IA Supreme Court rules no sex discrimination in case of woman fired for being “irresistible” to her boss

gender disparities the bad news
Gender Disparities:The Bad News
  • 2011: 6/50 governors are female, 10% of Republican and 25% of Democratic members of the House of Representatives, 17/50 Senators (12 Democrats and 5 Republicans)
    • U.S. ranks 72nd in gender equity out of 188 countries with national parliaments
economic gender disparities
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
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 ppaca1
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 (pre-existing condition)

Rape victims on prophylactic HIV medication could be denied life insurance coverage

economic gender disparities health insurance post ppaca
Economic Gender Disparities:Health Insurance (post-PPACA)

No pre-existing conditions

Eliminates gender rating and other forms of health insurance discrimination

Maternity care covered

Preventive care covered (controversy over birth control)

economic gender disparities the good news u s
Economic Gender Disparities:The Good News (U.S.)
  • More women than men graduating from college
  • Number of female-owned business increasing dramatically (29% of companies in 2010)
  • 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
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
Gender Disparities in Medicine and Science
  • Women hold < ¼ jobs in STEM fields (science, technology, engineering, and math)
  • Women = 49% of medical school applicants, 49% of medical students, 44% of residents (2006-7)
    • 47% of matriculants (2010)
gender disparities in medicine
Gender Disparities in Medicine
  • Women in academic medicine (2006-7)
    • 17% of full professors
    • 21% of division chiefs
    • 11% of department chairs
    • 33% of associate deans
    • 12% of deans
gender disparities in medicine1
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)
  • 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
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
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 porn1
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
violence against homosexuals
Violence Against Homosexuals
  • GSA
  • Gay marriages / civil unions
  • Discrimination legal
  • Causes……..
health consequences of violence against women physical sequelae
Health Consequences of ViolenceAgainst WomenPhysical 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 sequelae1
Health Consequences of ViolenceAgainst 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
    • Over 3-fold higher risk of being diagnosed with an STD
health consequences of violence against women physical sequelae2
Health Consequences of ViolenceAgainst WomenPhysical 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


psychological numbing

sense of vulnerability/hopelessness/loss/betrayal



distrust of others

Health Consequences of ViolenceAgainst WomenPsychological Sequelae - Early
health consequences of violence against women psychological sequelae long term
Health Consequences of ViolenceAgainst WomenPsychological Sequelae - Long Term
  • depression
  • anxiety disorders
  • phobias
  • anorexia/bulimia
  • substance abuse
health consequences of violence against women psychological sequelae long term1
Health Consequences of ViolenceAgainst 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
health consequences of violence against women
Health Consequences of ViolenceAgainst Women
  • Interference with health care
  • Delayed health care
  • Higher health care and hospitalization costs
health consequences of violence against women response to rape
Health Consequences of ViolenceAgainst WomenResponse 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
Recognition and Management ofDomestic 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
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
public health approaches to violence against women
Public Health Approaches to Violence Against Women
  • Restraining orders prevent recurrent abuse
  • Batterer treatment programs have had mixed, but generally negative, results
public health approaches to violence against women alcohol
Public Health Approaches to Violence Against Women: Alcohol
  • Evidence-based prevention of familial violence:
    • Increased excise taxes on alcohol
    • Restricting physical access to alcoholic beverages
    • Screening and brief intervention for alcohol abuse
screening practices of pcps
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
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
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
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
Ensure Victim’s Safety
  • Social worker involvement
  • Restraining order
  • Phone numbers of shelters, hotlines
  • Safe place to go
domestic violence shelters
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 shelters1
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
Physician Failure to RecognizeViolence 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 women1
Physician Failure to RecognizeViolence 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
Violence Against Womenin The Developing World
  • verbal, physical, and sexual abuse
    • 4 witnesses required for rape conviction in Pakistan
  • dowry-related murder
  • bride-burning
violence against women in the developing world1
Violence Against Womenin The Developing World
  • forced abortion and sterilization
  • divorce restrictions
  • forced prostitution
  • child prostitution
violence against women in the developing world2
Violence Against Womenin The Developing World
  • Selective abortion, malnutrition or killing of female children
    • Normal M:F ratio = 105:100
    • 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 mutilation
Female Genital Mutilation
  • Not female circumcision
    • i.e., male equivalent would be penectomy
  • Ranges from clitoridectomy to total infibulation (removal of clitoris and labia minora, stitching labia majora together, and leaving a small opening posterior for urine and menstral blood)
    • surgical “chastity belt”
female genital mutilation1
Female Genital Mutilation
  • 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
female genital mutilation2
Female Genital Mutilation
  • Formerly used in U.S. and U.K. as treatment for hysteria (“floating womb”), epilepsy, melancholia, lesbianism, and excessive masturbation
  • Represents cultural control of women’s sexual pleasure and reproductive capabilities
    • c.f. virginity exams by physicians in Turkey
female genital mutilation3
Female Genital Mutilation
  • 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 mutilation4
Female Genital Mutilation
  • 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 mutilation complications sequelae



painful neuromas




decreased sexual responsiveness




Female Genital MutilationComplications/Sequelae
management of female genital mutilation
Management of Female Genital Mutilation
  • Sensitivity/understand cultural identity issues
  • Deinfibulation
  • Immigration Issues
female genital mutilation5
Female Genital Mutilation
  • 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
  • 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)
  • 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
PolygamyRelated 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
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
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
  • See slide show and article on rape in war on “women’s health” page of phsj website at
international issues afghanistan
International IssuesAfghanistan
  • Taliban militia took over in 1996
  • Kleptocracy in control of some parts of country since invasion
  • Human rights abuses
    • gender-based violence
    • women denied access to education and health care
    • female employment rate decreased from 62% to 12%
  • Maternal mortality among world’s highest
  • Lowest ranking on U.N. Development and Gender Disparity Indices
international issues south africa s rape epidemic
International IssuesSouth 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 (2012)
    • 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 epidemic1
International IssuesSouth 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
Other International Issues
  • Indian rape epidemic – one rape every 22 minutes (2012)
  • 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
  • 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 labor-trafficking doled out by US Conference of Catholic Bishops, and do not cover reproductive care
child marriage
Child Marriage

Marriage before age 18

Affects 60 million women worldwide

Half occur in south Asia

child marriage1
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
Education of Girls and Women
  • Improvements in length and quality of education lead to:
    • Fewer children
    • Increased earning power
    • Decreased victimization
legal approaches
Legal approaches
  • Mandatory reporting
    • History of mandatory reporting (child and elder abuse)
    • Benefits
    • Risks
    • Effectiveness
legal approaches1
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
  • 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
  • Donohoe MT. Violence against women: Partner abuse and sexual assault. Hospital Physician 2004;40(10):24-31.
  • 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.
  • Donohoe MT. Violence and human rights abuses against women in the developing world. Medscape Ob/Gyn and Women’s Health 2003;8(2): posted 11/26/03.
  • Donohoe MT. Violence against women in the military. Medscape Ob/Gyn and Women’s Health 2005;10(2): posted 9/13/05. Available at
  • Donohoe MT. War, rape and genocide: Never again? Medscape Ob/Gyn and Women’s Health 2004;9(2): posted 10/22/04.
contact information
Contact Information

Public Health and Social Justice Website

[email protected]