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

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

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

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

4 Objectives Understand common forms of violence against women Understand common forms of violence against women Learn to recognize and manage violence against women Learn to recognize and manage violence against women Exposure to international issues related to 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 partner abuse sexual assault/marital rape sexual assault/marital rape forced prostitution forced prostitution forced noncompliance with contraception forced noncompliance with contraception female genital mutilation female genital mutilation slavery slavery unwanted sexting 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 poverty impaired access to employment or education impaired access to employment or education divorce restrictions divorce restrictions salary inequalities salary inequalities political marginalization political marginalization impaired access to reproductive health services impaired access to reproductive health services

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

10 Epidemiology of VAW 2011 CDC study: 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 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 2011 CDC study 18% of women have been raped; 1.4% of men 18% of women have been raped; 1.4% of men Women: 52% by partner; 41% by acquaintance Women: 52% by partner; 41% by acquaintance Men: 52% by acquaintance; 15% by stranger Men: 52% by acquaintance; 15% by stranger

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

13 Dating Violence in Adolescence and Young Adulthood 1/3 of 7 th grade girls report “psychological dating violence,” 1/6 report “physical dating violence” (2012) 1/3 of 7 th 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%) 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 Study included physical violence, but not sexual violence, and did not consider violence not resulting in injuries Males and females surveyed (under-reporting possible) Males and females surveyed (under-reporting possible)

14 Prevalence of Domestic Violence P-care P-care 1/4 women abused at some point in her life 1/4 women abused at some point in her life 1/7 women abused within preceding 12 months 1/7 women abused within preceding 12 months ER ER 1/4 of women seeking care (any reason) 1/4 of women seeking care (any reason) 35% of women treated for trauma 35% of women treated for trauma

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

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

17 Abuse in Pregnancy Incidence = % (lower than in non-pregnant women) Incidence = % (lower than in non-pregnant women) Most common sites of beating are abdomen, head and breasts Most common sites of beating are abdomen, head and breasts Increases risk of low birth weight/pre-term labor/delayed prenatal care Increases risk of low birth weight/pre-term labor/delayed prenatal care Post-partum depression Post-partum depression Higher risk for abuse and Higher risk for abuse and Abuse increases risk of post-partum depression Abuse increases risk of post-partum depression

18 High Risk Occupations: Prostitutes 80% have been physically assaulted 80% have been physically assaulted 80% have been threatened with a knife, gun, or other weapon 80% have been threatened with a knife, gun, or other weapon 67% have been raped 67% have been raped 1/67 arrested per week in U.S. 1/67 arrested per week in U.S. 1/33 have sex with a police officer 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 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 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 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 0.6% of men admit to paying for sex in the last year 17% at some point in their lives (actual percentage likely higher) 17% at some point in their lives (actual percentage likely higher) 694 “clients”/prostitute/year average 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 % 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 Punishment varies among johns, prostitutes, pimps Different types of regulation exist worldwide (see prostitution paper on website) 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 Sex tourism common in SE Asia, Eastern Europe 100,000 children are victims of commercial sexual exploitation in the US each year 100,000 children are victims of commercial sexual exploitation in the US each year Many malnourished forced to take dexamethasone (to gain weight) Many malnourished forced to take dexamethasone (to gain weight) Trafficking Victims Protection Act provides some protections 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: 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 Violence against women in the military War, rape and genocide War, rape and genocide

24 High Risk Groups Runaway and Homeless Youth Survival sex Survival sex the exchange of sex for shelter, food, drugs or money the exchange of sex for shelter, food, drugs or money 28% of street youths, 10% of shelter youth (out of million runaway adolescents/year) 28% of street youths, 10% of shelter youth (out of million runaway adolescents/year) association with violence, victimization, STDs, and pregnancy association with violence, victimization, STDs, and pregnancy

25 “High Risk” Perpetrators Male college athletes Male college athletes constitute 3.3% of male student body constitute 3.3% of male student body involved in 19% of sexual assaults involved in 19% of sexual assaults Fraternities Fraternities individual and gang rapes more common individual and gang rapes more common

26 Deaths from Domestic Violence 4,000 domestic violence deaths/year 4,000 domestic violence deaths/year over 1/2 of women murdered in U.S. are killed by a current or former partner 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 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 1/2 to 3/4 of the 1, ,500 murder suicides per year involve domestic violence 88% of these involve guns 88% of these involve guns

27 Victims Who Kill Their Abusers Between 2,000 and 4,000 women imprisoned for murdering 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 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 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 Seen in all age, race, and SES brackets May be more common in African-American, but 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 confounders = lower SES, fewer resources, more likely to be seen in ER or to use public shelters May be more common in Latinos, but May be more common in Latinos, but confounders = as above confounders = as above However, more women hold more traditional ideas regarding spousal roles... However, more women hold more traditional ideas regarding spousal roles...

29 Common Characteristics of Abuse Victims low self-esteem low self-esteem guilt guilt self-blame self-blame denial denial traditional attitudes regarding women’s roles traditional attitudes regarding women’s roles have children have children poor financial resources few job skills less education few friends history of childhood abuse

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

31 Common Characteristics of Abusers abuse alcohol/other drugs abuse alcohol/other drugs have witnessed or experienced abuse as children have witnessed or experienced abuse as children If immigrants, are more likely to have been victims of political violence If immigrants, are more likely to have been victims of political violence abuse their own children abuse their own children

32 Men with Restraining Orders 75% have criminal record 75% have criminal record 50% have history of violent crime 50% have history of violent crime 15% violated R.O. over 6 months 15% violated R.O. over 6 months 30% arraigned for a violent crime 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 seen in 1/3 - 1/2 of families where partner abuse occurs in one 3 month study of 146 children who witnessed partner abuse in one 3 month study of 146 children who witnessed partner abuse all sons over age 14 attempted to protect their mothers all sons over age 14 attempted to protect their mothers 62% were physically injured in the process 62% were physically injured in the process

34 Children and Partner Abuse Children witness up to 85% of episodes of partner abuse Children witness up to 85% of episodes of partner abuse child abuse child abuse Children of abuse victims show decrements in academic and emotional development and are more likely to become abusers themselves Children of abuse victims show decrements in academic and emotional development and are more likely to become abusers themselves

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

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

37 Rape Annual incidence  80/100,000 women Annual incidence  80/100,000 women 7% of all violent crimes 7% of all violent crimes Lifetime prevalence up to 25% Lifetime prevalence up to 25% 1/3 Native Americans/Alaskan Natives victims of attempted rape or rape 1/3 Native Americans/Alaskan Natives victims of attempted rape or rape Migrants, those in war zones and refugee camps at high risk Migrants, those in war zones and refugee camps at high risk

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

39 Date Rape 40% of college women report forced sexual contact, attempted rape, or completed rape 40% of college women report forced sexual contact, attempted rape, or completed rape most common: ignoring victims’ protests most common: ignoring victims’ protests independent of school demographics independent of school demographics  25% of college males admit to using sexually coercive behaviors  25% of college males admit to using sexually coercive behaviors 2/3 of college males report engaging in unwanted sexual intercourse 2/3 of college males report engaging in unwanted sexual intercourse reasons: peer pressure, desire to be liked reasons: peer pressure, desire to be liked

40 Spousal Rape occurs in % of all marriage occurs in % of all marriage more violent, less frequently reported then non- spousal rape more violent, less frequently reported then non- spousal rape not illegal in many U.S. states/other countries not illegal in many U.S. states/other countries

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

42 Rape 1 -2/1,000 odds of acquiring HIV from HIV+ rapist 1 -2/1,000 odds of acquiring HIV from HIV+ rapist 1-2/100,000 overall risk of HIV from vaginal penetration 1-2/100,000 overall risk of HIV from vaginal penetration 2-3/10,000 from anal 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 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 Can be performed at 8-14 weeks gestation vs. amniocentesis and chorionic villus sampling ( weeks, risks to mother and fetus) vs. amniocentesis and chorionic villus sampling ( weeks, risks to mother and fetus) May assist mother’s decision to carry vs. terminate pregnancy May assist mother’s decision to carry vs. terminate pregnancy

44 Rape Underreported (16-38% notify law enforcement; 17-43% present for medical evaluation) 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 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) 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 H.R and S.B 2736 (Justice for Survivors of Sexual Assault) bills pending in Congress

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

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

48 Sexual Crimes Against Children 81,000 children sexually abused per year in US 81,000 children sexually abused per year in US 93% committed by family member or someone known to victim 93% committed by family member or someone known to victim Child stranger abductions very rare, despite widespread media coverage Child stranger abductions very rare, despite widespread media coverage

49 Registered Sex Offenders 650,000 in US 650,000 in US Covers child molesters, possession of child pornography, solicitation of prostitution, exhibitionism and indecent exposure, voyeurism) 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 In certain jurisdictions also includes anal and oral sex and consensual sex between juveniles or between young adults and juvenilles The least likely class of criminals to re-offend (3.5% recidivism rate within 3 years, recidivism rare after 5 years) The 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 Medical obtain medical history obtain medical history evaluate and treat physical injuries evaluate and treat physical injuries obtain cultures obtain cultures treat any pre-existing infection 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 Medical offer post-exposure HIV and hepatitis B prophylaxis offer post-exposure HIV and hepatitis B prophylaxis offer post-coital contraception (vs. in utero paternity testing f/b selective abortion) offer post-coital contraception (vs. in utero paternity testing f/b selective abortion) arrange medical followup arrange medical followup provide counseling provide counseling NEJM 1995; 332:234-7 and NEJM 2011;365: NEJM 1995; 332:234-7 and NEJM 2011;365:834-41

52 Physical Examination of Sexual Assault Victims Collection of clothing Collection of clothing External/internal evaluation External/internal evaluation abrasions, lacerations, ecchymoses, bite marks; colposcopy, toluidine blue staining abrasions, lacerations, ecchymoses, bite marks; colposcopy, toluidine blue staining Oral cavity Oral cavity secretions, injuries, collection of samples for culture secretions, injuries, collection of samples for culture Note: time limits for evidence collection vary by state ( hrs) 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 Genitalia hair combing, hair sampling, vaginal secretions, collection of samples for culture, injuries hair combing, hair sampling, vaginal secretions, collection of samples for culture, injuries Rectum Rectum injuries, collection of samples for culture injuries, collection of samples for culture NEJM 1995; 332:234-7 and NEJM 2011;365: 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) Ceftriaxone (250 mg IM) or cefixime (2 g po)PLUS Doxycycline (100 mg po bid x 7d) or Azithromycin (1 g po x 1) Doxycycline (100 mg po bid x 7d) or Azithromycin (1 g po x 1)PLUS Metronidazole ( 2 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%) 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 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) 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 Most effective: IUD implanted within 5 days Nearly 100% effective Nearly 100% effective

57 Previous Limits on Availability of Emergency Contraception 17 states mandate that emergency contraception be available to rape victims 17 states mandate that emergency contraception be available to rape victims 9 states allow pharmacists to directly prescribe emergency contraception 9 states allow pharmacists to directly prescribe emergency contraception Other states considering Other states considering

58 EC and Oregon Pharmacies (2003) 61% of Oregon hospitals routinely offer EC to rape patients 61% of Oregon hospitals routinely offer EC to rape patients Catholic hospitals = non-Catholic hospitals Catholic hospitals = non-Catholic hospitals 70% of all pharmacists surveyed reported that their pharmacy stocked emergency contraception. 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. 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 Laws in Arkansas, Mississippi, Georgia, and South Dakota explicitly protect pharmacists who refuse to dispense EC Other states are considering similar legislation Other states are considering similar legislation Military clinics not required to stock EC Military clinics not required to stock EC 2013: OTC EC for all children of childbearing age allowed by federal judge 2013: OTC EC for all children of childbearing age allowed by federal judge

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

61 Factors That Perpetuate Gender-Based Violence Cultural Gender-specific socialization: Gender-specific socialization: Cultural definitions of appropriate sex roles Cultural definitions of appropriate sex roles Expectations of roles with relationships Expectations of roles with relationships Belief in the inherent superiority of males Belief in the inherent superiority of males Values that give men proprietary rights over women Values that give men proprietary rights over women Notions of the family as private/under male control Notions of the family as private/under male control Customs of marriage (bride price/dowry/exogamy) Customs of marriage (bride price/dowry/exogamy) Acceptability/glorification of violence as a means to resolve conflict Acceptability/glorification of violence as a means to resolve conflict S oc Sci Med 1994; 39:

62 Factors That Perpetuate Gender-Based Violence Economic Women’s economic dependence on men Women’s economic dependence on men Limited access to cash and credit Limited access to cash and credit Discriminatory laws regarding inheritance, property rights, use of communal lands and maintenance after divorce 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 employment in formal and informal sector Limited access to education and training for women 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 Plural systems of law: customary, common, religious Lesser legal status of women Lesser legal status of women Laws regarding divorce, child custody, maintenance and inheritance Laws regarding divorce, child custody, maintenance and inheritance Legal definitions of rape and domestic abuse Legal definitions of rape and domestic abuse Low levels of legal literacy among women Low levels of legal literacy among women Insensitive treatment of women by police and judiciary 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 Under-representation of women in power, politics and in legal and medical professions Domestic violence not taken seriously Domestic violence not taken seriously Notions of family being ‘private’ and beyond the control of the state Notions of family being ‘private’ and beyond the control of the state Risk of challenge to status quo/religious laws Risk of challenge to status quo/religious laws Limited organization of women as a political force (e.g. through autonomous women’s organizations) 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: 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) Worldwide, women do 2/3 of the world’s paid and unpaid work (1/3 paid, 2/3 unpaid) hold 20% of legislative seats hold 20% of legislative seats receive 10% of global income receive 10% of global income own 1% of global property 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 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 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 Women in the U.S. working full-time make $ $0.81/$1.00 males Those in unions have higher salaries, better benefits Those in unions have higher salaries, better benefits Part-time salary balanced $1.04/$1.00 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) 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 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 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 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.) Women account for 22% of legislators worldwide (19% in U.S.) U.S. ranks 72 nd in gender equity out of 188 countries with national parliaments U.S. ranks 72 nd 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 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 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 Gender rating in 38 states allows insurance companies to charge men and women different rates for the same coverage Maternity care often excluded Maternity care often excluded 11 states had no private plans that came with maternity coverage 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 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 C/S can cause rejection of coverage unless woman is subsequently sterilized Survivors of domestic violence can be rejected in eight states Survivors of domestic violence can be rejected in eight states Rape victims with PTSD may be denied coverage (pre- existing condition) Rape victims with PTSD may be denied coverage (pre- existing condition) Rape victims on prophylactic HIV medication could be denied life insurance coverage Rape victims on prophylactic HIV medication could be denied life insurance coverage

74 Economic Gender Disparities: Health Insurance (post-PPACA) No pre-existing conditions No pre-existing conditions Eliminates gender rating and other forms of health insurance discrimination Eliminates gender rating and other forms of health insurance discrimination Maternity care covered Maternity care covered Preventive care covered (controversy over birth control) Preventive care covered (controversy over birth control)

75 Economic Gender Disparities: The Good News (U.S.) More women than men graduating from college More women than men graduating from college Number of female-owned business increasing dramatically (29% of companies in 2010) Number of female-owned business increasing dramatically (29% of companies in 2010) Workforce now 50% women Workforce now 50% women Women make 85% of buying decisions or are the “chief purchasing officers” of their households 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 High school sports 1/3 of girls participate (vs. 1/27 in 1971) 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); % 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 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 = 50% of medical school applicants, 47% of medical students, 44% of residents ( ) Women under-represented in academic medicine Women under-represented in academic medicine

78 Gender Disparities in Medicine Female physicians’ salaries 40% below those of male physicians (2011) 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.) 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) 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 ( ) When matched for hours worked, female clinicians earned 25% less than males ( ) Was 16% between 1996 and 2000 Was 16% between 1996 and 2000

80 Pornography Multi-billion dollar adult entertainment business Multi-billion dollar adult entertainment business Internet, magazines, movies, clubs, etc. Internet, magazines, movies, clubs, etc. 2012: LA (home to 80% of the industry) becomes first city to mandate that porn actors wear condoms 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 Porn actors already regularly tested for STDs

81 Pornography and Violence Against Women After viewing pornography, males show After viewing pornography, males show heightened levels of aggression and arousal 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.) 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 Dysfunctional early home life Delinquent of antisocial behavior or friends Delinquent of antisocial behavior or friends A promiscuous attitude which views sex as more of a sport than as part of an intimate relationship 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” “Hostile masculinity” Narcissistic personality Narcissistic personality Hostility against women Hostility against women Turned on by power over women Turned on by power over women

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

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

86 Health Consequences of Violence Against Women Physical Sequelae Alcoholism and Drug Abuse Alcoholism and Drug Abuse e.g. rape victims 10x prevalence of general population e.g. rape victims 10x prevalence of general population begins after abuse begins after abuse Tobacco abuse Tobacco abuse High risk sexual behaviors, STDs, recurrent vaginal yeast infections High risk sexual behaviors, STDs, recurrent vaginal yeast infections Over 3-fold higher risk of being diagnosed with an STD 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 Delayed risk of obesity, HTN, hyperlipidemia, arthritis, asthma, stroke, heart disease, fibromyalgia, psychogenic seizures IBS IBS symptom severity correlates with severity and duration of abuse symptom severity correlates with severity and duration of abuse GERD GERD Other functional GI disorders Other functional GI disorders

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

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

90 Health Consequences of Violence Against Women Psychological Sequelae - Long Term PMDD PMDD PTSD (nightmares/hypervigilance/etc.) PTSD (nightmares/hypervigilance/etc.) Fivefold increased risk of developing a psychiatric disorder Fivefold increased risk of developing a psychiatric disorder 10% of domestic violence victims attempt suicide 10% of domestic violence victims attempt suicide possible recurrence of symptoms in later, healthy relationships possible recurrence of symptoms in later, healthy relationships

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

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

93 Recognition and Management of Domestic Violence Routine, repeated assessments in all settings (ER, clinic, wards) Routine, repeated assessments in all settings (ER, clinic, wards) Maintain supportive, nonjudgmental attitude; avoid victim-blaming Maintain supportive, nonjudgmental attitude; avoid victim-blaming Validate the woman’s experiences, building on her strengths, transfer power and control to her Validate the woman’s experiences, building on her strengths, transfer power and control to her Be available, provide frequent followup Be available, provide frequent followup Involve social work Involve social work

94 Recognition and Management Discover nature and duration of abuse Discover nature and duration of abuse Assess for child abuse Assess for child abuse ensure children’s safety/mandated reporting ensure children’s safety/mandated reporting Keep detailed records, including photographs Keep detailed records, including photographs Testify in court prn Testify in court prn Do not recommend marriage counseling Do not recommend marriage counseling

95 Public Health Approaches to Violence Against Women Restraining orders prevent recurrent abuse Restraining orders prevent recurrent abuse Batterer treatment programs have had mixed, but generally negative, results 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: Evidence-based prevention of familial violence: Increased excise taxes on alcohol Increased excise taxes on alcohol Restricting physical access to alcoholic beverages Restricting physical access to alcoholic beverages Screening and brief intervention for alcohol abuse Screening and brief intervention for alcohol abuse

97 Screening Practices of PCPs Screening new patients Screening new patients OB/Gyns - 17% OB/Gyns - 17% Internists - 6% Internists - 6% Physicians practicing in HMOs - 1% Physicians practicing in HMOs - 1% Physicians practicing in public clinics - 37% Physicians practicing in public clinics - 37% no difference by sex no difference by sex

98 Screening (2011): Percent of Women Ages Who Have Discussed with Their Provider Sexual history: 38% Sexual history: 38% STDs: 28% STDs: 28% HIV: 29% HIV: 29% Domestic/dating violence: 15% 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 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 Abuser criminal record criminal record alcohol/substance abuse problem alcohol/substance abuse problem gambling problem gambling problem psychiatric disorder psychiatric disorder Situational Trigger Situational Trigger job loss job loss death in family death in family

100 Assess for Acutely Increased Danger Nature of Abuse Nature of Abuse increased severity and frequency of beatings increased severity and frequency of beatings escalation in threats escalation in threats stalking stalking violent or forced sex violent or forced sex destruction of property destruction of property

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

102 Domestic Violence Shelters Availability poor Availability poor up to % of women and 80% of children turned away on any given night 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. 4 times as many animal shelters as domestic violence shelters in U.S.

103 Domestic Violence Shelters Woefully underfunded Woefully underfunded Average length of stay = 14 days; most allow 30 day max stay Average length of stay = 14 days; most allow 30 day max stay Over 50% of all homeless women and children are fleeing domestic violence Over 50% of all homeless women and children are fleeing domestic violence

104 Physician Failure to Recognize Violence Against Women Fear of offending Fear of offending feelings of powerlessness feelings of powerlessness time constraints time constraints Pandora’s Box Pandora’s Box low confidence in ability to affect change low confidence in ability to affect change sense of own vulnerability sense of own vulnerability deficits in education and training deficits in education and training

105 Physician Failure to Recognize Violence Against Women Doctors underestimate the prevalence of domestic violence in their patients/communities Doctors underestimate the prevalence of domestic violence in their patients/communities similar to teen sexual activity similar to teen sexual activity Female MDs may be better than male MDs in detecting domestic violence and in taking a more thorough history 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 1/14 women worldwide has been sexually assaulted at least once by someone who is not an intimate partner verbal, physical, and sexual abuse verbal, physical, and sexual abuse 4 witnesses required for rape conviction in Pakistan 4 witnesses required for rape conviction in Pakistan dowry-related murder dowry-related murder bride-burning bride-burning

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

108 Violence Against Women in The Developing World Selective abortion, malnutrition or killing of female children Selective abortion, malnutrition or killing of female children Normal M:F ratio = 105:100 Normal M:F ratio = 105:100 In China = 118:100 In China = 118:100 suicide as “vengeance” against an abusive spouse suicide as “vengeance” against an abusive spouse post-rape suicide (or homicide) post-rape suicide (or homicide) to “cleanse family honor” to “cleanse family honor” 47% of homicides in Alexandria, Egypt 47% of homicides in Alexandria, Egypt

109 Female Genital Mutilation Not female circumcision Not female circumcision i.e., male equivalent would be penectomy 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) 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” surgical “chastity belt”

110 Female Genital Mutilation 125 million women affected worldwide (2 million girls/year) 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) mostly in Africa (e.g. 98% of women in Somalia, 80% in Egypt, 50% in Kenya) Outlawed in Egypt Outlawed in Egypt rare in Asia rare in Asia Found across all socioeconomic strata and in all major religions 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 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 Represents cultural control of women’s sexual pleasure and reproductive capabilities c.f. virginity exams by physicians in Turkey c.f. virginity exams by physicians in Turkey

112 Female Genital Mutilation Type I - removal of clitoris Type I - removal of clitoris Type II - removal of clitoris and part of labia minora Type II - removal of clitoris and part of labia minora Type III - modified infibulation - 2/3 of labia majora sewn together Type III - modified infibulation - 2/3 of labia majora sewn together Type IV - total infibulation Type IV - total infibulation

113 Female Genital Mutilation Most commonly carried out between ages 4 and 10 Most commonly carried out between ages 4 and 10 physicians perform about 12% of operations physicians perform about 12% of operations Often done under non-sterile conditions and without anesthesia Often done under non-sterile conditions and without anesthesia

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

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

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

117 Female Genital Cutting Laws called “cultural imperialism” by some, although we have also outlawed other “cultural practices” Laws called “cultural imperialism” by some, although we have also outlawed other “cultural practices” Slavery Slavery Polygamy Polygamy child labor child labor denial of appropriate, life-saving medical care to sick children denial of appropriate, life-saving medical care to sick children

118 Polygamy Utah/Mormons Utah/Mormons introduced by Joseph Smith ( ) who had 50 wives 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) 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. 30,000 people in multi-wife families one generation ago Est. 60, ,000 today Est. 60, ,000 today polygamist clans (e.g. 10,000 FLDS members, 1,500 member Kingston clan) 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 Utah outlawed “plural marriage” in 1890 in exchange for statehood Not one prosecution in the last 50 years 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) 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 welfare fraud by sister wives claiming single motherhood lapses in medication attention (including lack of prenatal care) lapses in medication attention (including lack of prenatal care) incest and underage sex incest and underage sex girls age 10 forced into marriage girls age 10 forced into marriage women existing in limbo women existing in limbo no birth certificates, drivers’ licenses, or voter registration no birth certificates, drivers’ licenses, or voter registration

121 Covenant Marriages Can be dissolved only in the case of infidelity, abuse or felony conviction Can be dissolved only in the case of infidelity, abuse or felony conviction Offered since 1997 in Louisiana and Arkansas Offered since 1997 in Louisiana and Arkansas similar measures introduced in 17 other states similar measures introduced in 17 other states

122 Rape in War Used for domination, humiliation, control, “soldierly bonding”, and ethnic cleansing Used for domination, humiliation, control, “soldierly bonding”, and ethnic cleansing often occurs in front of family members often occurs in front of family members recognized as a War Crime since Nuremberg 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 See slide show and article on rape in war on “women’s health” page of phsj website at

123 International Issues 2013 WHO report: 30% of women worldwide have been victims of IPV 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 Almost ¼ of Asian man admit to having committed rape 73% felt “sexually entitled,” 59% were “seeking entertainment,” and 38% were “punishing someone” 73% felt “sexually entitled,” 59% were “seeking entertainment,” and 38% were “punishing someone” 55% felt guilty 55% felt guilty 23% served prison time 23% served prison time Almost ½ of Asian men have committed some type of IPV Almost ½ of Asian men have committed some type of IPV

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

126 International Issues 80% of refugees and internally-displaced persons worldwide are female 80% of refugees and internally-displaced persons worldwide are female Indian rape epidemic – one rape every 22 minutes (2012) 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 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 vs. 2.6%/1.1% in Africa

127 International Issues Afghanistan Taliban militia took over in 1996 Taliban militia took over in 1996 Human rights abuses Human rights abuses gender-based violence gender-based violence women denied access to education and health care women denied access to education and health care female employment rate decreased from 62% to 12% female employment rate decreased from 62% to 12% Maternal mortality among world’s highest Maternal mortality among world’s highest Only minor changes since US invasion – most of country still controlled by Taliban, poppy trade strong 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.) Official Rape Rate 104/100,000 people (vs. 34.4/100,000 in the U.S.) highest rate in the world highest rate in the world 1 rape/23 s 1 rape/23 s ¼ South African men say they have committed rape ¼ South African men say they have committed rape Official annual total = 50,000, but est. only 1/35 reported 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¢ 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 HIV risk in Johannesburg, 40% of men aged are HIV+ in Johannesburg, 40% of men aged are HIV+ post-rape antiretroviral drugs are not available in government hospitals 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 Mexico City (the most heavily populated city in the world) has one shelter for battered women Wives of the gods Wives of the gods Sex slaves at animist shrine in Ghana, Benin and Togo Sex slaves at animist shrine in Ghana, Benin and Togo Sex initiation camps in Malawi Sex initiation camps in Malawi

131 Trafficking Tens of thousands of women and girls trafficked into US annually to work in sweatshops 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 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 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 Marriage before age 18 Affects 60 million women worldwide Affects 60 million women worldwide Half occur in south Asia 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 Associated with no contraceptive use before first childbirth, high fertility, multiple unwanted pregnancies, pregnancy termination, and female sterilization A human rights violation A human rights violation

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

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

136 Legal approaches 1994 Violence Against Women Act 1994 Violence Against Women Act New laws, enforcement mechanisms New laws, enforcement mechanisms 2013: Expanded to cover gays, immigrants, Native Americans, and sex-trafficking victims 2013: Expanded to cover gays, immigrants, Native Americans, and sex-trafficking victims International Violence Against Women Act 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 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 Stalled in Congress

137 Conclusions Awareness of scope of problem of violence against women Awareness of scope of problem of violence against women Screen regularly and repeatedly; document; treat; support Screen regularly and repeatedly; document; treat; support Screening reduces IPV, improves health outcomes Screening reduces IPV, improves health outcomes Support women’s rights issues, which are health care issues 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): Donohoe MT. Violence against women: Partner abuse and sexual assault. Hospital Physician 2004;40(10): 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): 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 and human rights abuses against women in the developing world. Medscape Ob/Gyn and Women’s Health 2003;8(2): posted 11/26/03. Donohoe MT. Violence against women in the military. Medscape Ob/Gyn and Women’s Health 2005;10(2): posted 9/13/05. Available at Donohoe MT. 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. Donohoe MT. War, rape and genocide: Never again? Medscape Ob/Gyn and Women’s Health 2004;9(2): posted 10/22/04.

141 Contact Information Public Health and Social Justice Website


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