1. Violence Against Women
Martin Donohoe, M.D., F.A.C.P.

2. Violence Against Women Overview
Definitions
Epidemiology
Sexual Assault/Rape
Sequelae of Domestic Violence

3. Violence Against Women Overview
Recognition and Management
The Developing World
human rights abuses
female genital mutilation

4. Objectives Understand common forms of violence against women
Learn to recognize and manage violence against women
Exposure to international issues related to violence against women

5. 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

6. Individual Violence Against Women (examples)
partner abuse
sexual assault/marital rape
forced prostitution
forced noncompliance with contraception
female genital mutilation
slavery
unwanted sexting

7. Definitions of Violence Against Women
Societal:
Structural forms of discrimination or deprivation that affect women as a class

8. Societal Violence Against Women (examples)
poverty
impaired access to employment or education
divorce restrictions
salary inequalities
political marginalization
impaired access to reproductive health services

9. Epidemiology of VAW Lifetime prevalence of assault/sexual abuse
12% of adolescent girls
15% of college women
20% of adult women

10. 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

11. 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

12. Epidemiology of VAW 2 - 4 million women assaulted per year
Every 15 seconds a woman is beaten; every 2 minutes a woman is sexually assaulted
5% of partner abuse is female on male
(homosexual/bisexual abuse also exists)

13. 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: ) 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)

14. 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

15. Prevalence of Domestic Violence
OB/Gyn
1/6 women during pregnancy
Abortion Clinics
12%
Peds
% of mothers of abused children

16. Prevalence of Domestic Violence
Orthopedic fracture clinics
1/6 women
Psych
1/4 women who attempt suicide
1/4 women treated for psychiatric symptoms
55% lifetime prevalence for women with depression

17. Abuse in Pregnancy
Incidence = % (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

18. 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.

19. 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
Prostitute rates of PTSD similar to those of combat veterans and refugees from state-sponsored torture

20. 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

21. 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)

22. 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

23. 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

24. High Risk Groups Runaway 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 million runaway adolescents/year)
association with violence, victimization, STDs, and pregnancy

25. “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

26. 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, ,500 murder suicides per year involve domestic violence
88% of these involve guns

27. 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 serving time for homicide have killed their mother’s abuser

28. 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...

29. 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

30. Common Characteristics of Abusers
low self-esteem
dependency
jealousy
poor communication skills
unemployed/underemployed

31. Common Characteristics of 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

32. 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

33. 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

34. 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

35. Rape Unwanted, penetration
Oral/vaginal/anal
By penis, other body part, or object
Forcible and non-forcible
Includes rape of females by females
Reported by % of women who are physically abused

36. Rape Unwanted, forced penetration (oral/vaginal/anal)
Reported by % of women who are physically abused

37. Rape 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

38. High Risk Groups Prostitutes Gays, lesbians, bisexuals, transgendered
Alcohol and drug users
College students
Persons under age 24

39. 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

40. 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

41. Rape 5% chance of pregnancy (est. 32,000 pregnancies/yr in US)
25% chance of acquiring STD
GC = %
Chlamydia = %
Syphilis = %

42. Rape 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

43. 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

44. Rape
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

45. Rape Large backlog of untested rape kits (over 180,000)
H.R and S.B 2736 (Justice for Survivors of Sexual Assault) bills pending in Congress

46. Rape Average prison time for those convicted: rape = 1 year
armed robbery = years
murder = 8 years
Chemical Castration Laws

47. How We View Women Montana 2nd violation of animal abuse statute
$1,000 fine + 2 years in jail
2nd violation spousal abuse
$ months in jail

48. 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

49. 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)

50. 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

51. 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

52. Physical Examination of Sexual 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 ( hrs)
NEJM 1995; 332:234-7 and NEJM 2011;365:834-41

53. Physical Examination of Sexual 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

54. Prophylaxis for Adult Victims of Sexual Assault Antibiotic Prophylaxis
Ceftriaxone (250 mg IM) or cefixime (2 g po)
PLUS
Doxycycline (100 mg po bid x 7d) or Azithromycin (1 g po x 1)
Metronidazole ( 2 g po x 1)

55. Prophylaxis for Adult Victims of Sexual Assault Prevention of Pregnancy
Most effective oral regimen: 1 dose of 30 mg ulipristal or 1.5 mg levonorgestrel within 120 hours of unprotected intercourse (ulipristal twice as effective; 0.9% pregnancy rate vs 1.7%)

56. Most effective: IUD implanted within 5 days
Prophylaxis for Adult Victims of Sexual Assault Prevention 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

57. 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

58. 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.

59. 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

60. Prophylaxis for Adult Victims of Sexual Assault
HIV Prophylaxis
Consult ID
start up to 72° after rape
Other (as indicated)
tetanus toxoid
Hep B vax/HBIG

61. Factors That Perpetuate Gender-Based Violence Cultural
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:

62. Factors That Perpetuate Gender-Based Violence Economic
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:

63. Factors That Perpetuate Gender-Based Violence Legal
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:

64. Factors That Perpetuate Gender-Based Violence Political
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:

65. 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

66. Economic Gender Disparities: The Bad News
Women make up 45% of the employed global workforce, yet account for 70% of the world’s poor
More patriarchal societies have higher mortality rates for men

67. Economic Gender Disparities: The Bad News
Women in the U.S. working full-time make $ $0.81/$1.00 males
Those in unions have higher salaries, better benefits
Part-time salary balanced $1.04/$1.00
More than ½ of working mothers get no paid sick leave (some localities passing laws to change this)

68. Economic Gender Disparities: The Bad News
Women comprise 51% of college graduates, make up 46% of the U.S. workforce, but hold only 4% of CEO positions and 17% of corporate director positions in Fortune 500 companies

69. 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

70. Gender Disparities: The Bad News
Women account for 22% of legislators worldwide (19% in U.S.)
U.S. ranks 72nd in gender equity out of 188 countries with national parliaments

71. 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

72. 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

73. 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

74. 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)

75. 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

76. 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); %

77. Gender Disparities in Medicine and Science
Women hold < ¼ jobs in STEM fields (science, technology, engineering, and math)
Women = 50% of medical school applicants, 47% of medical students, 44% of residents ( )
Women under-represented in academic medicine

78. 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)

79. Gender Disparities in Medicine
When matched for hours worked, female clinicians earned 25% less than males ( )
Was 16% between 1996 and 2000

80. Pornography 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

81. 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.)

82. 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

83. 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

84. Violence Against Homosexuals
GSA
Gay marriages / civil unions
Discrimination legal
Causes……..

85. Health Consequences of Violence Against Women Physical Sequelae
Trauma: bruises, fractures, lacerations
Chronic pain: headaches, AP, pelvic pain, myalgias, LBP, CP
Hyperventilation Syndrome
Eating and sleeping disorders

86. Health Consequences of Violence Against Women Physical 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

87. Health Consequences of Violence Against Women Physical 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

88. Health Consequences of Violence Against Women Psychological Sequelae - Early
shock
denial
distrust of others
withdrawal
confusion
psychological numbing
sense of vulnerability/hopelessness/loss/betrayal

89. Health Consequences of Violence Against Women Psychological Sequelae - Long Term
depression
anxiety disorders
phobias
anorexia/bulimia
substance abuse

90. Health Consequences of Violence Against Women Psychological 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

91. Health Consequences of Violence Against Women
Interference with health care
Delayed health care
Higher health care and hospitalization costs

92. Health Consequences of Violence Against Women Response to Rape
Initial:
unnaturally calm/detached OR crying/angry
Denial phase
approx. 2 months
Increasing psychological symptoms over several months
Gradual psychological healing

93. Recognition and Management of Domestic 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

94. 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

95. Public Health Approaches to Violence Against Women
Restraining orders prevent recurrent abuse
Batterer treatment programs have had mixed, but generally negative, results

96. 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

97. 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

98. 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

99. Assess Patient for Acutely Increased Danger
Abuser
criminal record
alcohol/substance abuse problem
gambling problem
psychiatric disorder
Situational Trigger
job loss
death in family

100. 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

101. Ensure Victim’s Safety
Social worker involvement
Restraining order
Phone numbers of shelters, hotlines
Safe place to go

102. Domestic Violence Shelters
Availability poor
up to % 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.

103. 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

104. Physician Failure to Recognize Violence 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

105. Physician Failure to Recognize Violence 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

106. Violence Against Women in The Developing World
1/14 women worldwide has been sexually assaulted at least once by someone who is not an intimate partner
verbal, physical, and sexual abuse
4 witnesses required for rape conviction in Pakistan
dowry-related murder
bride-burning

107. Violence Against Women in The Developing World
forced abortion and sterilization
divorce restrictions
forced prostitution
child prostitution

108. Violence Against Women in 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

109. 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”

110. Female Genital Mutilation
125 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
rare in Asia
Found across all socioeconomic strata and in all major religions

111. 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

112. 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

113. 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

114. Female Genital Mutilation Complications/Sequelae
bleeding
infection
dysparevnia
painful neuromas
keloids
dysmenorrhea
infertility
decreased sexual responsiveness
shame
fear
depression

115. Management of Female Genital Mutilation
Sensitivity/understand cultural identity issues
Deinfibulation/clitoral reconstruction
Immigration Issues

116. Female Genital Cutting
UN, WHO, and FIGO have condemned
Fear of FGC can be the basis for an asylum claim
Illegal to perform in U.S. under child abuse statutes and 1996 federal law
Girls’ Protection Act of 2011
To provide penalties for transporting minors in foreign commerce for the purposes of female genital mutilation.
Stuck in committee

117. Female Genital Cutting
Laws 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

118. Polygamy Utah/Mormons
introduced by Joseph Smith ( ) 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 today
polygamist clans (e.g. 10,000 FLDS members, 1,500 member Kingston clan)

119. Polygamy
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)

120. Polygamy Related 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

121. 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

122. 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

123. 2013 WHO report: 30% of women worldwide have been victims of IPV
International Issues
2013 WHO report: 30% of women worldwide have been victims of IPV

124. International Issues
Almost ¼ of Asian man admit to having committed rape
73% felt “sexually entitled,” 59% were “seeking entertainment,” and 38% were “punishing someone”
55% felt guilty
23% served prison time
Almost ½ of Asian men have committed some type of IPV

125. International Issues
80% of refugees and internally-displaced persons worldwide are female
Indian rape epidemic – one rape every 22 minutes (2012)

126. International Issues
80% of refugees and internally-displaced persons worldwide are female
Indian rape epidemic – one rape every 22 minutes (2012)
Only 1.2%/0.1% of Indian victims of gender-based violence report to police/health care personnel
vs. 2.6%/1.1% in Africa

127. International Issues Afghanistan
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

128. International Issues South 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
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¢

129. International Issues South Africa’s Rape Epidemic
HIV risk
in Johannesburg, 40% of men aged are HIV+
post-rape antiretroviral drugs are not available in government hospitals

130. Other International Issues
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
Sex initiation camps in Malawi

131. 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 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

132. Child Marriage Marriage before age 18
Affects 60 million women worldwide
Half occur in south Asia

133. Child Marriage
Associated with no contraceptive use before first childbirth, high fertility, multiple unwanted pregnancies, pregnancy termination, and female sterilization
A human rights violation

134. Education of Girls and Women
Improvements in length and quality of education lead to:
Fewer children
Increased earning power
Decreased victimization

135. Legal approaches Mandatory reporting
History of mandatory reporting (child and elder abuse)
Benefits
Risks
Effectiveness

136. 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

137. Conclusions 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

138. References
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):

139. References
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

140. References
Donohoe MT. War, rape and genocide: Never again? Medscape Ob/Gyn and Women’s Health 2004;9(2): posted 10/22/04.

141. Public Health and Social Justice Website
Contact Information
Public Health and Social Justice Website