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Health Implications of Female Dignity across the Life Span

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1 Health Implications of Female Dignity across the Life Span
Dr. Jameela George MBBS, MIRB The Center for Bioethics, India March 7, 2012

2 Indignity & Health Indignity
Humiliation, degrading, or abusive treatment Offense, as to a person's pride or sense of dignity Lack or loss of dignity or honour or self-respect Injury, injustice, insult Dishonour, disrespect, discourtesy Outrage, put down, reproach, snub, taunt Health is a state of physical, mental, social well- being and not the absence of disease or infirmity

3 Historical views Ancient Greece China Rome English common Law India

4 Social funerals of women in India
Sati: A recently widowed woman would immolate herself on her husband’s funeral pyre, claimed to be voluntary on the part of the widow or otherwise Buried alive: Widow being buried alive beside her husband, in ceremonies that are largely the same as those performed in immolation Jauhar: Simultaneous, mass immolation of Rajput women, children, the elderly and the sick, at the death of their fighting men and defeat in battle against Muslims

5 Abortions (Estimates - annual)
Worldwide – 42 million abortions South and Central Asia – 10.5 million abortions India – 11million abortions Two thirds in India are “alternative methods” such as force, causing risk to mothers Nearly 20,000 young mothers die each year caused by these methods

6 Traditional patriarchal culture Sons inherit property
Male preference Traditional patriarchal culture Sons inherit property Sons carry on the family name Sons expected to support aging parents Daughter has limited freedom to support parents Widow with daughters only will lose late husband’s property Parental preference for boys is common throughout the world It is most obvious in China, Korea and India

7 Violence in the Life cycle of women
Phase Type of violence Pre-birth Sex-selective abortion; effects of battering during pregnancy on birth outcomes Infancy Female infanticide; physical, sexual and psychological abuse Girlhood Child marriage; female genital mutilation; physical, sexual and psychological abuse; incest; child prostitution and pornography Adolescence Dating and courtship violence, Acid attacks, honour killing Adulthood Sexual harassment; Sexual abuse in the workplace; rape; forced prostitution and pornography; trafficking women partner violence; marital rape; dowry abuse and murders; partner homicide; psychological abuse; abuse of women with disabilities; forced pregnancy Elderly Sexual, physical and psychological abuse; Forced “suicide” or homicide of widows for economic reasons

8 Most common in parts of China, India, Pakistan
Female Feticide Female feticide is the practice of terminating a pregnancy based upon the predicted female sex of the baby  Selectively aborting female fetuses, thus avoiding the birth of girls Used as a form of contraception  Extreme manifestation of violence against women Most common in parts of China, India, Pakistan

9 Female Feticide –contd.
India China Year Child sex ratio 1991 945 2001 927 2011 914 About a million female foetuses are aborted each year One child policy enacted in 1979 contributes to this Sex ratio at birth (boys born per 100 girls) >130 in some provinces There could be more than 35 million young "surplus males" in China Deviations in sex ratios do not exist in sub- Saharan Africa, Latin America & the Caribbean

10 Special Statistics on Girl Child in India
12 million girls are born in India annually 1 out of every 6 girls does not live to see her 15th birthday 1 million of them are unable to survive even their first birthday One-third of these deaths take place at birth Every sixth girl child's death is due to gender discrimination Females are victimised far more than males during childhood 300,000 more girls than boys die every year Female child mortality exceeds male mortality in 224 out of 402 districts in India

11 Missing women of Asia This is a shortfall in the number of women in Asia relative to the number that would be expected European and North American countries -more women than men Developing countries in Asia & Middle East, the sex ratio much lower India - 44 million missing women (UN Estimate 2001) China - 50 million women "missing" - that should be there but are not

12 Discrimination in Immunization, Nutrition & Health care
Medical treatment Implications Girls have a 40% greater risk of ill health compared to boys More girls than boys die of acute respiratory diseases, infectious & parasitic diseases and viral infections Anaemia affects >90% of adolescent girls

13 Literacy for Girls Low enrollment of girls in schools - 2 out of ten girls not enrolled High dropout rate of girls from high schools - Fear of PMS/Rape Poor School Environment for girls Lack of separate toilets for girls Lack of female teachers in schools Poverty, Bonded Labour and Child Labour Practices Older girls taking care of younger siblings Dowry a barrier to education  Afghanistan – Girls’ schools were destroyed to prevent girls from being educated 65% of the world’s children who do not attend school are girls 66% of the world’s illiterate people are women

14 Literacy Differences within India –
Kerala – 92% Madiya – Tribe – 5% Low female literacy co-exists with low female age at marriage Languages in India National Language – Hindi Official languages – 22 SIL Ethnologue lists 415 Individual mother tongues in India – 1652

15 Women, work, wages Gender discrimination in work load - Women do most of domestic work, field work/ paid work Gender gap in full time paid work South Korea – 38% U.K – 18.6% Japan – 28.3% France – 16.5% Gender difference in employment 5 female CEOs of top 200 (Aus)  Gender gap in wages Professionals paid equal Unskilled labourers

16 Toilets and indignity 1 in 3 women across the world do not have access to toilet 1.25 billion Women - daughters, sisters, mothers, grandmothers Live with discomfort, indignity and fear Risk shame, disease, harassment and even attack/ violence Community toilets is especially unsafe for women, particularly at night  Women, more than men, suffer the indignity of being forced to defecate in the open, at risk of assault or rape

17 Female genital mutilation
Types Infibulation, Clitoridectomy, Excision, Pricking, piercing, scraping, cauterizing World wide estimate millions have had FGM 3 millions per year Practiced in 28 countries of Africa Implications

18 Child Marriage Children given in marriage before marriageable age often before puberty (as young as 4 & 5 years) India 1500,000 girls <15 years already married (2001) Approximately 300,000 are mothers to at least one child 47.3% of women aged were married by age 18 (NFHS-III survey) Rajasthan - epicentre for child marriage in India (65.2%)

19 Child marriage India World wide Legal minimum age Projection
15,00,000 girls < 15 years 40% of world’s ch. marriages World wide Africa, Asia, Middle East, S. America Legal minimum age Projection 100 million in 10 years 25,000 new child brides/day Implications

20 Honor killing Causes Practiced across cultures & across religions
Suspected Global - >20,000/year Pakistan – 3 women/day

21 Trafficking of girls and women
Worldwide - Victims from 136 countries detected in 118 countries (2007 – 2010) No of persons trafficked globally each year – 800,000; (U.S – 17,000) No of females trafficked annually – 640,000, more than 70% for sexual exploitation. Australia -about 1,000 women are trafficked each year India is a source, destination, and transit country for women, and children 21 networks of trafficking have been identified 20,000 Nepalese women trafficked to Indian brothels & as servants in Middle East 10% of human trafficking is international, while almost 90% is interstate Implications -

22 Also known as marriage by abduction or marriage by capture
Bride Kidnapping Also known as marriage by abduction or marriage by capture A man who wishes to marry a particular woman abducts her, aided by his friends and relatives She is raped by him until she gives in to the marriage Countries practicing Bride kidnapping Central Asia, the Caucasus region, and parts of Africa, Among People s as diverse as Hmong in Southeast Asia Tzeltal in Mexico Romani in Europe

23 Bride trafficking in Haryana, India
Women purchased from far off regions in the garb of marriage Cut off from their parents, people, native place and culture forever Forced to adjust to local vegetarian food habits Denied status & rights of permanent family member Not registered in local ration cards or voter lists No right to property, involvement in family or social matters Kept as bonded farm labourers Sexually exploited by all males of the family and by their husband’s employer After their ‘owner’s’ death, they are sold or handed over to others if childless Trafficked brides in Haryana are reduced to sex objects and cheap labour

24 Domestic (Intimate partner) Violence
Domestic violence is universal Intensity, frequency and prevalence vary Less severe physical abuse – punching slapping – 31% Severe domestic violence – attack with weapon / burning – 10% dagger on back Physical injury due to violence – sprains, bruises, dislocation or burns, severe burns, broken bones or broken teeth and wounds – 12% Sexual violence in marriage – forced sex – 8% (National survey report, India)

25 Dowry harassment & Bride burning in India
Reported no of dowry harassment - 94,000; Conviction rate just 19% (2010) Reported no of dowry deaths (2011) Approximately 1 dowry death every hour Average dowry death reported in Delhi – 1 death in three days Conviction rates in bride burning cases - 34% in 2010.  Implications: Female feticide, infanticide Dowry debts, poverty Daughter is a burden/liability to the family

26 Maternal malnutrition
Anaemia in pregnant women India – 58 % Bangladesh – 40% Pakistan – 45% Africa – 21 – 80% Health risks for mother Health risks for foetus and new born Health risks for the child long term

27 Maternal Mortality World- wide more than 287,000 women die every year
One maternal death occurs every 90 seconds Maternal death burden worldwide (2010) Sub- Saharan Africa - 56 % South Asia % Together % Maternal Mortality Rate (No of maternal deaths per 1, 00,000 live births) MMR in Pakistan 500 MMR China -37 MMR in India – 212 (2012) India About 57,000 maternal deaths in 2010 Almost 150 women were dying daily 6 every hour

28 Reproductive servitude
 Fulfil the expectations of husband and/or orders of in-laws regarding Number of children Spacing and timing of their children Continuing a particular pregnancy or not depending on Sex of child Delivery expected in an inauspicious month Delivery inauspicious to parents / grandparents etc. No freedom to make decisions concerning reproduction free of coercion / violence

29 Compulsory Sterilization
Compulsory /forced sterilization programs are government policies which attempt to force people to undergo surgical sterilization, a process of permanently ending someone's ability to reproduce without his or her consent Post natal sterilization without her consent / without her even knowing it Bribes used to sterilize women - food and clothing Australia - Non-voluntary hysterectomy & Forced sterilization for disabled until the 1980s Sweden and Finland – forced sterilization practiced up until the 1970's Uzbekistan- forced and coerced sterilization is current Government policy for women with two or three children  India - Sterilization accounts for more than 75% of total contraception Female sterilization accounts for almost 95% of all sterilizations in India  The right to bodily integrity is violated by compulsory/ forced sterilization Freedom to decide denied

30 Reproductive issues Infertility – husband azoospermic, but blames wife, wants divorce Reproductive tourism Travelling to countries where ova is cheap & unregulated for IVF If ova sale is prohibited, hormones administered, flown and ova harvested in second country Fertilized eggs often travel across international borders to surrogate mothers Commissioning/biological parents travelling for surrogacy to potential countries Implications of Surrogacy

31 Research Bias Assuming erroneously that men’s and women’s biology is similar Lab animals are still predominantly male, even in studies of diseases that disproportionately affect women Lack of stratified analysis by sex to assess pharmacokinetics, effectiveness, adverse effects, dose response, blood concentration etc Lack of evidence that a drug is safe for women Over 70% of anti-depressants prescribed to women, but majority of research conducted on these drugs utilized male subjects Research funding for coronary artery disease in men is far greater than for women Cardiovascular research largely conducted on men who suffer at a lower age group, then applied generalized conclusions to women of older age group who suffer more morbidity and mortality (without considering hormonal differences)

32 Gender bias in health care provision
 Total joint arthroplasty - Male and female physicians were more likely to recommend TJA to male patients  Peripheral Arterial Disease -women are offered surgery less often in every age group studied for carotid endarterectomy Management of stroke in Europe and North America - women with stroke were less likely than men to receive appropriate diagnostic imaging, antithrombotic therapy, or carotid revascularization Gender bias in stroke survivor prescriptions also existed in the United Kingdom but not in Canada Trauma patient triage   Organ Donation and Transplantation in France

33 Abuse of Women with Disabilities
Neglect Physical abuse Psychological abuse Financial exploitation Sexual abuse More than 70% have been victims of sexual abuse at some time in their lives

34 Abuse of Women with Disabilities
Perpetrators: Majority of perpetrators are male caregivers/ paid service providers Male family members-husbands, dating partners, fathers, brothers are the second largest perpetrator group A miniscule percentage of abusers are strangers Research needs: Research on impact of physical or sexual abuse on survivors (not prevalence) Research should complement the insights of survivors themselves Research to explore the particular struggles and vulnerabilities that women with disabilities confront in their own efforts to end sexual abuse

35 Women in Disasters Gender differentiation at all levels of the disaster process Women are more likely to become casualties than men Among women aged 20-44, the death rate was 71 per 1000, compared to 15 per 1000 for men in Bangladesh following cyclone and flood of 1991 Females are less likely to receive medical, hygienic or psychological aid when they need it Violence against women increases in communities hit by environmental disasters Domestic violence increases after disasters Post disaster “flight of men” abandoning women & families, leave women as sole earners In the event of death of husband or son, male relatives confiscate family land leaving women poverty stricken and destitute Women and girls may be coerced into sex for basic needs such as food, shelter and security

36 War and Women  As wars have moved from battlefields to villages, women and girls have become more vulnerable History Social acceptance of rape as part of war in ancient Greece Rape in wartime an “ancient and customary evil” World War II comfort women - Chinese & Korean Mass rapes of Bosnia Herzegovina and the Congo Forced virginity checks of female protesters in Egypt For soldiers, rape considered as one of the spoils of war In Colombia, paramilitary control of some regions often includes sexual violence and torture of women and girls Rwandan genocide- rape was “the rule and its absence the exception”(-UN)

37 Rape Rape is generally defined as forced or non-consensual sexual contact India– 23,582 reported rape cases; Conviction rate – about 26% (2011) 2 women are raped every hour in India  South Africa -56,272 rapes; average 154 per day ( )  US – About 250,000 rape/attempted rape reported annually 685 per day; 28.5 per hour- nearly one every two minutes!  Rape is the destruction of dignity It is a violation of her right to equality It is an exertion of power, an act of subjugation and renders her an object The violator exerts control through the act of unspeakable violence Causes not only physical harm but also incalculable emotional and psychological harm Leads to stigma and rejection by their families and communities

38 Medical examination for sexual assault
Blanket consent for the medical examination without adequate information Gender-insensitive examination of survivors of sexual violence  Undue focus on “habituated to sex” Over emphasis on genital injuries in cases of rape of women and girls (less than 30% of them had genital injuries – WHO) Flawed views “A healthy woman cannot be raped” “Working class women are muscular and so can offer resistance” “If sexual intercourse is forced, then injuries must be present” Medical evidence collection at the expense of providing therapeutic care Pakistan – Four male witnesses were needed (Now this has changed) Legal proceedings traumatize her further

39 Estimate 40 million widows
Widowhood - India Estimate 40 million widows Widowhood is a state of social death “husband eater”, “randi” (prostitute)  Restrictions on food Expected to mourn until end of their lives Made to look ugly Perceived to be a burden and inauspicious Deprived of their basic dignity as a kind of atonement for some sin It’s the punishment for being a woman and a widow in India  

40 Widowhood - Africa Abandonment by relatives, indifference by friends & society Accused of being responsible for her husband’s death Do not have right to inherit land or property Widows are not allowed to bathe as and when they want Forced to re-marry her late husband’s brother or forfeit everything her husband had acquired Children put through menial excruciating jobs Husband’s asserts confiscated Left alone in isolation Open to sexual abuse Subjected to dehumanizing rituals Shaving of hair on the head Taking an oath of innocence – involves drinking bath water of corpse Sleeping alone with the corpse

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