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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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violence against women overview
Violence Against WomenOverview
  • Definitions
  • Epidemiology
  • Sexual Assault/Rape
  • Sequelae of Domestic Violence
  • Recognition and Management
  • The Developing World
    • human rights abuses
    • female genital cutting
violence against women overview3
Violence Against WomenOverview
  • Teen Pregnancy
  • The Family/Single Motherhood/Child Care
  • Ideals of Beauty & the Historical Subjugation of Women
  • Abortion
  • Conclusions
objective
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
Definitions of Violence Against Women

Individual:

Any act of verbal or physical force, coercion, or life-threatening deprivation that causes physical or psychological harm, humiliation, or arbitrary deprivation of liberty, or that perpetuates female subordination

individual violence against women examples
Individual Violence Against Women(examples)
  • partner abuse
  • sexual assault/marital rape
  • forced prostitution
  • forced noncompliance with contraception
  • female genital cutting
  • slavery
definitions of violence against women7
Definitions of Violence Against Women

Societal:

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
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)
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 violence11
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%
  • Most common sites of beating are abdomen, head and breasts
  • Increases risk of low birth weight/pre-term labor/delayed prenatal care
prevalence of domestic violence13
Prevalence of Domestic Violence
  • OB/Gyn
    • 1/6 women during pregnancy
  • Peds
    • 50 - 70% of mothers of abused children
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
prostitution in the u s
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
high risk occupations the military
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
the military
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)
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
  • 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

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
common characteristics of abusers
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
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
slide28
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%
slide29
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
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
slide32
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
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
    • 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

physical examination of sexual assault victims
Physical Examination ofSexual 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

prophylaxis for adult victims of sexual assault antiobiotic prophylaxis
Prophylaxis for Adult Victims ofSexual 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)
prophylaxis for adult victims of sexual assault prevention of pregnancy
Prophylaxis for Adult Victims ofSexual 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
prophylaxis for adult victims of sexual assault
Prophylaxis for Adult Victims ofSexual 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
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
slide39
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
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

Soc Sci 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 Soc Sci 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)
    • receive 10% of global income
    • hold less than 10% of legislative seats
    • own 1% of global property
economic gender disparities the bad news45
Economic Gender Disparities:The Bad News
  • Women make up 45% of the employed global workforce, yet account for 70% of the world’s poor
  • Women in the U.S. working full-time make $0.75/$1.00 males
economic gender disparities the bad news46
Economic Gender Disparities:The Bad News
  • Women make up 46% of the U.S. workforce, but hold < 2% of senior-level management positions in Fortune 500 companies
  • 2002: 5/50 governors are female, 13% of Congresspersons, 4 of the top 21 university presidents
ledbetter v goodyear us supreme court 2006
Ledbetter v GoodyearUS 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
economic gender disparities the good news u s
Economic Gender Disparities: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)
economic gender disparities the good news u s49
Economic Gender Disparities:The Good News (U.S.)
  • Fastest growing fields:
    • Construction
    • Wholesale trade
    • Transportation
    • Communications
    • Agriculture
    • Manufacturing
gender disparities mixed news u s
Gender Disparities: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%
sexual harassment
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
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 physicians53
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
Pornography
  • $4 billion adult entertainment business
  • Per day
    • 23-60 million unique visitors to pornography websites
    • 2-3 million unique visitors to the five largest news sites
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.)
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 sequelae57
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
  • Delayed risk of HTN, arthritis, asthma, stroke, and heart disease
  • IBS
    • symptom severity correlates with severity and duration of abuse
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 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 term60
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
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
screening practices of pcps
Screening Practices of PCPs
  • Self-assessment (1999)
    • routine screening - 79%
    • first visit - 10%
    • periodic checkups - 99%
    • prenatal care - 11%
  • Screening new patients
    • OB/Gyns - 17%
    • Internists - 6%
    • Physicians practicing in HMOs - 1%
    • Physicians practicing in public clinics - 37%
    • no difference by sex
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
  • 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 women71
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
  • forced abortion and sterilization
  • divorce restrictions
  • forced prostitution
  • child prostitution
violence against women in the developing world73
Violence Against Womenin 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
female genital cutting
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 cutting75
Female Genital Cutting
  • Also called female genital mutilation
  • Not female circumcision
    • i.e., male equivalent would be penectomy
female genital cutting76
Female Genital Cutting
  • 100 million women affected worldwide (2 million girls/year)
    • mostly in Africa (e.g. 98% of women in Somalia, 80% in Egypt, 50% in Kenya)
      • Outlawed in Egypt - 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
female genital cutting77
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 cutting78
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

Female Genital CuttingComplications/Sequelae
management of female genital cutting
Management of Female Genital Cutting
  • Sensitivity/understand cultural identity issues
  • Deinfibulation
  • Immigration Issues
female genital cutting81
Female Genital Cutting
  • UN, WHO, and FIGO have condemned
  • Illegal to perform in U.S. under child abuse statutes
    • called “cultural imperialism” by some, although we have also outlawed other “cultural practices”
      • slavery
      • polygamy
      • child labor
      • denial of appropriate, life-saving medical care to sick children
polygamy
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. the 1,500 member Kingston clan)
polygamy83
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
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
international issues afghanistan
International IssuesAfghanistan
  • 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
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
  • 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 epidemic89
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
  • 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
trafficking
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
legal approaches
Legal approaches
  • 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
teen pregnancy
Teen Pregnancy
  • 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)
teen pregnancy94
Teen Pregnancy
  • 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
teen pregnancy95
Teen Pregnancy
  • 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
teen pregnancy the role of adult males
Teen PregnancyThe 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
statutory rape
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
teen pregnancy worrisome trends
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)
    • 1988 – 2% of US school districts relied on abstinence-only education
    • 1999 – 23%
teen pregnancy worrisome trends99
Teen Pregnancy: Worrisome Trends
  • Parental notification laws - consequences:
    • increased 2nd trimester abortions
    • increased abortions in neighboring states
single motherhood
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 American Family
  • The U.S. is one of the only industrialized countries without paid maternity leave and health benefits guaranteed by law
  • The Family and Medical Leave Act (1993) guarantees only unpaid leave and only to individuals working in establishments employing at least 50 workers
    • disproportionately excludes low-wage workers
    • only 56% of working women eligible
child care
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
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
conclusions
Conclusions
  • Awareness of scope of problem of violence against women
  • Screen regularly and repeatedly; document; treat; support
  • Support women’s rights issues, which are health care issues
contact information
Contact Information

Public Health and Social Justice Website

http://www.phsj.org

[email protected]

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