Violence against women – Health perspectives

1. Violence against women – Health perspectives Hassan N. Sallam, MD, FRCOG, PhD (London) Professor in Obstetrics and Gynaecology The University of Alexandria, and Clinical and Scientific Director, Alexandria Fertility Center, Alexandria, Egypt 3rd Congress of Society of Reproductive Medicine, 5 – 9 October 2011, Antalya / Turkey

2. Alexandria, the greatest emporium of the whole world, (Strabo, Geography, book 17, chapter 13, First century AD)

3. Cleopatra Thea Philopator, Queen of Egypt (67-30 BC)

4. Saint Catherine of Alexandria, Caravaggio, c. 1598

5. The Last Judgment, Michelangelo, Sistine Chapel

6. Hypatia of Alexandria, mathematician, philosopher and scientist (370-415 AD)

7. Violence against womenVictimization as part of being female “In all societies, to a greater or lesser degree, women and girls are subjected to physical, sexual and psychological abuse that cuts across lines of income, class and culture” Report of the Fourth World Conference on Women, Beijing, 4-15 September 1995, paragraph 112

8. Violence against women – prevalence A review of studies from 35 countries carried out prior to 1999 indicated that: Between 10% to 52% of women were physically abused at some point in their lives Between10% and 27% of women and girls reported having beensexually abused either as children or adults Data from developing countries was generally lacking. World Health Report 2004: Changing history, WHO 2004

9. WHO Multi-country Study on Violence against Women 24.000 women 15 sites in 10 countries (Bangladesh, Brazil, Ethiopia, Japan, Namibia, Peru, Samoa, Serbia and Montenegro, Thailand and Tanzania) World Health Report 2004: Changing history, WHO 2004

10. WHO Multi-country Study on Violence against Women World Health Report 2004: Changing history, WHO 2004

11. Violence against women 1. Physical 2. Sexual 2. Emotional 3. Verbal 4. Economic

12. Violence against women Selective feticide Female genital mutilation Honor crimes Rape (general, war, marital) Sexual harassment Trafficking in women Mugging senior citizens Domestic (intimate partner) violence

13. Violence against women Selective feticide Female genital mutilation Honor crimes Rape (general, war, marital) Sexual harassment Trafficking in women Mugging senior citizens Domestic (intimate partner) violence

14. The missing females • About 100 million women are missing (44m in China, 37m in India) due to: • Prenatal sex selection/abortion • Discrimination against the female child • Postpartum hemorrhage Sen AK. Missing women, BMJ 304: 586-7, 1992 Sen A. Missing women – revisited, BMJ 367: 185-6, 2003

15. The missing femalesWorld population by sex in 2000 United Nations Report: Population prospects: the 2008 revision, 2009

16. Diagnosis of fetal gender Ultrasonography Amniocentesis

17. Physical complications of abortion Bleeding: hemorrhagic shock Perforation: bowel and bladder injury Cervical lacerations: repeated miscarriages/ preterm delivery Infection: peritonitis, septic shock, deep vein thrombosis Cervical shock: death Dissemination intravascular coagulation (DIC) Infertility/ectopic pregnancy Rh sensitization

18. Complications of abortion in UK10% of which 25% (2.5%) are considered major Infection 27 % Infertility 3 to 5 % Ectopic pregnancy risk increased x 5-8 (12% of all maternal deaths due to ectopic) Cervical damage increase the risks of miscarriage, premature birth x 3-5 times This results in 3000 cases of cerebral palsy among newborns each year Frank, et.al., "Induced Abortion Operations and Their Early Sequelae", J Roy Col Gen Pract 35: 175-180, 1985

19. Complications of abortion increase with the gestational age 8 weeks and under - Less than 1%  8-12 weeks - 1.5-2%  12-13 weeks - 3-6%  Second trimester - Up to 50%, possibly higher Hakim-Elahi E, Tovell HM, Burnhill MS. Complications of first-trimester abortion: a report of 170,000 cases. Obstet Gynecol 76(1):129-35, 1990

20. Abortion-related mortality per 100.000 abortions in the USA Less than 8 weeks: 0.5 From 11-12 weeks: 2.2 From 16-20 weeks: 14 More than 21 weeks: 18 Hakim-Elahi E, Tovell HM, Burnhill MS. Complications of first-trimester abortion: a report of 170,000 cases. Obstet Gynecol 76(1):129-35, 1990

21. Depression Loss of self-esteem Self-destructive behavior Sleep disorders Memory loss Sexual dysfunction Chronic problems with relationships Dramatic personality changes Anxiety attacks Guilt and remorse Difficulty grieving Increased tendency toward violence Chronic crying Difficulty concentrating Flashbacks Loss of interest in previously enjoyed activities and people Difficulty bonding with later children Psychological complications of abortionOver 100 major reactions to abortion have been reported Ashton, The Psychosocial Outcome of Induced Abortion. BJOG 87: 1115-1122, 1980

22. Psychological complications of abortion Increased self-destructive behavior 80% expressed feelings of "self-hatred" 49% reported drug abuse 39% began/increased use of alcohol 14% described themselves as having become "addicted" or "alcoholic" 60% reported suicidal ideation 28% attempted suicide (half of them twice or more) Ashton, The Psychosocial Outcome of Induced Abortion. BJOG 87: 1115-1122, 1980

23. Discrimination against the female child • In treatment • In education • In feeding This Pakistani mother gave birth to twins. She breast-fed the boy and bottle-fed the girl. The girl died the following day this picture was taken.

24. Violence against women Selective feticide Female genital mutilation Honor crimes Rape (general, war, marital) Sexual harassment Trafficking in women Mugging senior citizens Domestic (intimate partner) violence

25. Female genital mutilation (cutting)

27. Female genital mutilation - prevalence About 100 to 140 million women and girls have been subjected to FGM (UNFPA)

28. FGM – medical consequences Pain/shock Severe bleeding/death Reproductive tract infections Urinary tract infections/stones Clitorial cysts Painful intercourse Sexual dysfunction Difficult labor/increased C/S Increased risk to baby Psychological trauma

29. FGM – WHO study 2006 28,393 women in labor in 28 obstetric centers (Burkina Faso, Ghana, Nigeria, Kenya, Senegal and Sudan) Increased risk of death to the baby (15% for Type I, 32% for Type II, and 55% for Type III) Increased risk ofcesarean section (30%) Increased risk of postpartum hemorrhage(70%)

30. Fighting FGM at the Alexandria Regional Center for Women’s Health and Development FGM has no religious basis – Medicalization of FGM is wrong

31. Violence against women Selective feticide Female genital mutilation Honor crimes Rape (general, war, marital) Sexual harassment Trafficking in women Mugging senior citizens Domestic (intimate partner) violence

32. Honor crimes According to the UN in 2002, honor killings were reported in Egypt, Jordan, Lebanon, Morocco, Pakistan, Syria, Turkey, Yemen, and other Mediterranean and Gulf countries, as well as in the immigrant communities in France, Germany and the UK. The United Nations Population Fund (UNFPA) estimates that the annual worldwide total of honor-killing victims may be as high as 5,000 United Nations Reports. Working towards the elimination of crimes against women committed in the name of honor. Report of the Secretary-General, 2 July 2002

33. Honor crimes Refusing to enter into an arranged marriage Loss of virginity/committing adultery or allegedly committing it Being the victim of a sexual assault Seeking a divorce—even from an abusive husband Sometimes, the mere perception that a woman has behaved in a way that "dishonors" her family is sufficient to trigger an attack on her life

34. Violence against women Selective feticide Female genital mutilation Honor crimes Rape (general, war, marital) Sexual harassment Trafficking in women Mugging senior citizens Domestic (intimate partner) violence

35. The rape of Lucretia by Titian, 1571

36. “…and they abused her all night , taking turns in raping her until morning. Finally, just at dawn, they let her go. She fell down at the door of the house and lay there until it was light…found her there, fallen down in front of the door with her hands digging into the threshold… But there was no answer, for she was dead…”Holy Bible: Judges: 19

37. Rape - statistics A UN report from 65 countries showed that more than 250,000 cases of rape or attempted rape are reported annually In the USA, it is estimated thatonly 16% of rapes and sexual assaultsare reported to the police 91% of rape victims are female and 9% are male, with 99% of the offenders being male • The Eighth United Nations Survey on Crime Trends and the Operation of Criminal Justice Systems (2001-2002) • US Department of Justice. Rape in America: A Report to the Nation, 1992

38. Rape/sexual abuse is under-reported World Health Report 2004: Changing history, WHO 2004

39. Rape – medical consequences Trauma/injury Bleeding Unwanted pregnancy/abortion complications Sexually transmitted diseases/AIDS Psychological trauma: acute stress disorder and post-traumatic stress disorder Loss of self esteem/suicide

40. Sexually transmitted diseases In Thailand, researchers found that one in ten victims of rape had contracted a STD STDsincrease a woman’s vulnerability to the HIV/AIDS virus Violent sexual assault increase the risk because resulting tears to delicate vaginal tissue allow the virus easier entry into the bloodstream Women with STDs have a higher risk of complications during pregnancy, including sepsis, spontaneous abortion and premature birth Archavanitkul K, Pramualratana A. Factors affecting women’s health in Thailand. Paper presented at the Workshop on Women’s Health in Southeast Asia, Population Council, Jakarta, October 29-31, 1990

41. Acute stress disorder Depersonalization or dissociation (feeling numb and detached, like being in a daze or a dream, or feeling that the world is strange and unreal) Difficulty remembering details of the assault Reliving the assault through repeated thoughts, memories, ornightmares Avoidance of things, places, thoughts, and/or feelings that remind the victim of the assault Anxietyor increased arousal (difficulty sleeping, concentrating, etc...) Avoidance of social life or place of rape In one third, symptoms continue beyond 6 months (post-traumatic stress disorder) Richard et al. Treating acute stress disorder. Am J Psychiatry 156:1780, 1999

42. Srebrenica Genocide Stone

43. “…from time immemorial, rape has been regarded as spoils of war. Now it will be considered a war crime. We want to send out a strong message that rape is no longer a trophy of war…”Judge Navanethem PillayInternational Criminal Tribunal for Rwanda 1998 Rape as a weapon of war

44. In the Name of Honor, Mukhtaran Mai, 2002 Meerwala, Pakistan

45. Violence against women Selective feticide Female genital mutilation Honor crimes Rape (general, war, marital) Sexual harassment Trafficking in women Mugging senior citizens Domestic (intimate partner) violence

46. Sexual harassment in the work place

47. Sexual harassment in the work place

48. Sexual harassment in educational establishments

49. Sexual harassment in the street

50. Sexual harassment in the street