Violence Against Women
Martin Donohoe, M.D., F.A.C.P.
Violence Against Women
Overview
 Definitions
 Epidemiology
 Sexual
Assault/Rape
 Sequelae of Domestic
Violence
Violence Against Women
Overview
 Recognition
 The
and Management
Developing World
 human rights abuses
 female genital mutilation
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
Definitions of Violence Against Women
Individual:
Any act of verbal or physical force,
coercion, or life-threatening
deprivation that causes physical or
psychological harm, humiliation, or
arbitrary deprivation of liberty, or that
perpetuates female subordination
Individual Violence Against Women
(examples)
 partner
abuse
 sexual assault/marital rape
 forced prostitution
 forced noncompliance with
contraception
 female genital mutilation
 slavery
 unwanted sexting
Definitions of Violence Against
Women
Societal:
Structural forms of
discrimination or deprivation that
affect women as a class
Societal Violence Against Women
(examples)
poverty
 impaired access to employment or
education
 divorce restrictions
 salary inequalities
 political marginalization
 impaired access to reproductive health
services

Epidemiology of VAW
 Lifetime
prevalence of assault/sexual
abuse
 12% of adolescent girls
 20-25% of college women
 20% of adult women
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
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
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)
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;100:1737-1744) 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)
Cyber dating abuse increasingly common
Prevalence of Domestic Violence


P-care
 1/4 women abused at some point in her
life
 1/7 women abused within preceding 12
months
ER
 1/4 of women seeking care (any reason)
 35% of women treated for trauma
Prevalence of Domestic Violence
OB/Gyn
 1/6 women during pregnancy
 Abortion Clinics



12%
Peds
 50 - 70% of mothers of abused
children
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
Abuse in Pregnancy




Incidence = 8 - 20% (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
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.

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
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
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)

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
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

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 1 - 2 million runaway
adolescents/year)
 association with violence, victimization, STDs,
and pregnancy
High Risk Groups
College Women

20-25% incidence of sexual assault over 4 year
period
 80% do not report
 Highest during first 2 years
 Sexual assault resistance programs can cut by
almost 1/2
Perpetrators
 1/5
U.S. men reports having been violent against a
spouse or significant other
 High risk perpetrators:
 Male college athletes
 constitute 3.3% of male student body
 involved in 19% of sexual assaults
 Fraternities
 individual and gang rapes more common
Deaths from Domestic Violence
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 1,000 - 1,500 murder
suicides per year involve domestic violence
 88% of these involve guns

Victims Who Kill Their Abusers



Between 2,000 and 4,000 women imprisoned for
murdering their abusers
Battered women who claim self-defense (the
only legally justifiable reason for murder) in
criminal trials are acquitted only 25% of the time
63% of young men aged 11-20 serving time for
homicide have killed their mother’s abuser
Race/SES and Domestic Violence



Seen in all age, race, and SES brackets
May be more common in African-American, but
 confounders = lower SES, fewer resources, more
likely to be seen in ER or to use public shelters
May be more common in Latinos, but
 confounders = as above
 However, more women hold more traditional ideas
regarding spousal roles...
Common Characteristics of
Abuse Victims






low self-esteem
guilt
self-blame
denial
traditional attitudes
regarding women’s roles
have children





poor financial resources
few job skills
less education
few friends
history of childhood
abuse
Common Characteristics
of Abusers
low self-esteem
 dependency
 jealousy
 poor communication skills
 unemployed/underemployed

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

Men with Restraining Orders

75% have criminal record

50% have history of violent crime

15% violated R.O. over 6 months

30% arraigned for a violent crime over 6
months
Child Abuse
seen in 1/3 - 1/2 of families where partner abuse
occurs
 in one 3 month study of 146 children who
witnessed partner abuse
 all sons over age 14 attempted to protect their
mothers
 62% were physically injured in the process

Children and Partner Abuse

Children 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
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 33 -46% of women who are
physically abused
Rape

Unwanted, forced penetration
(oral/vaginal/anal)

Reported by 33 -46% of women who are
physically abused

FBI: 8% of rape allegations unfounded
Rape
Annual incidence  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

High Risk Groups
Persons under age 24
 Prostitutes
 Gays, lesbians, bisexuals, transgendered
 Alcohol and drug users

High Risk Groups

College students
 3/4 of victims incapacitated, usually by
alcohol)
 33% reported to counselor, but only
12% reported to law enforcement
 Colleges revising policies
Date Rape



40% of college women report forced sexual contact,
attempted rape, or completed rape
 most common: ignoring victims’ protests
 independent of school demographics
>25% of college males admit to using sexually
coercive behaviors
2/3 of college males report engaging in unwanted
sexual intercourse
 reasons: peer pressure, desire to be liked
Spousal Rape

occurs in 10 - 15% of all marriage

more violent, less frequently reported then nonspousal rape

not illegal in many U.S. states/other countries
Rape
6-7% chance of pregnancy (est. 25,000
pregnancies/yr in US)
 25% chance of acquiring STD
 GC = 6 - 12%
 Chlamydia = 4 - 17%
 Syphilis = 0.5 - 3%

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
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 (1015 weeks, risks to mother and fetus)
 May assist mother’s decision to carry vs. terminate
pregnancy

Rape



Underreported (16-38% notify law enforcement;
17-43% present for medical evaluation)
Only ¼ of reported rapes lead to arrest, 1/5 lead
to prosecution, and only ½ of prosecutions result
in felony convictions
34 states have statutes of limitations on filing
charges, ranging from 3-30 yrs (some exemptions
if DNA evidence identifies suspect)
Rape

Large backlog of untested rape kits (some
estimates as high as 500,000)

H.R. 4114 and S.B 2736 (Justice for Survivors of
Sexual Assault) bills pending in Congress
Rape

Average prison time for those convicted:
 rape = 1 year
 armed robbery = 3 - 5 years
 murder = 8 years

Chemical Castration Laws
How We View Women
 Montana
2nd
violation of animal abuse statute
$1,000 fine + 2 years in jail
2nd violation spousal abuse
$500 + 6 months in jail
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
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)
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
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
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 (72-120 hrs)
NEJM 1995; 332:234-7 and NEJM 2011;365:834-41
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
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)
PLUS
 Metronidazole ( 2 g po x 1)

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%)
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: copper IUD implanted within 5
days

Nearly 100% effective
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
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.
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
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
Factors That Perpetuate
Gender-Based Violence
From Soc Sci Med 1994; 39:1165-79
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
Menstrual hygiene management, shaming
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
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
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
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
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

Economic Gender Disparities:
The Bad News

Women in the U.S. working full-time make
$0.77 - $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)
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
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
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
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
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
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 (preexisting condition)
Rape victims on prophylactic HIV medication could be
denied life insurance coverage
Economic Gender Disparities:
Health Insurance (post-PPACA)
No pre-existing conditions
 Eliminates gender rating and other forms
of health insurance discrimination
 Maternity care covered
 Some preventive care covered

Economic Gender Disparities:
Health Insurance (post-PPACA)

PPACA (ObamaCare) requires insurers to
pay full cost of contraception (including
EC)
 But SCOTUS allows religious exceptions
in Hobby Lobby case (2014), citing
Religious Freedom Restoration Act of
1993
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
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); 2007 - 42%
Gender Disparities in Medicine and
Science



Women hold < ¼ jobs in STEM fields (science,
technology, engineering, and math)
Women = 1/2 of medical school applicants, 1/2
of medical students, almost 1/2 of residents, and
1/3 of physician workforce
Women under-represented in academic
medicine
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)
Gender Disparities in Medicine

When matched for hours worked, female
clinicians earned 25% less than males
(2006-2010)
 Was 16% between 1996 and 2000
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
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.)
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
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
Violence Against Homosexuals
22% of men / 7% of women in same sex
partnerships report domestic violence
 Gay marriages / civil unions
 Discrimination legal
 Causes……..
 GSA, Lambda Legal, etc.

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

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
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
Health Consequences of Violence
Against Women
Psychological Sequelae - Early




withdrawal
confusion
psychological numbing
sense of
vulnerability/hopeless
ness/loss/betrayal



shock
denial
distrust of others
Health Consequences of Violence
Against Women
Psychological Sequelae - Long Term
 depression
 anxiety disorders
 phobias
 anorexia/bulimia
 substance abuse
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
Health Consequences of Violence
Against Women
 Interference with health care
 Delayed health care
 Higher health care and hospitalization
costs
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

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
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
Public Health Approaches to
Violence Against Women
 Restraining
orders prevent recurrent
abuse
 Batterer
treatment programs have had
mixed, but generally negative, results
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
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





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
Assess Patient for Acutely
Increased Danger


Abuser
 criminal record
 alcohol/substance abuse problem
 gambling problem
 psychiatric disorder
Situational Trigger
 job loss
 death in family
Assess for Acutely Increased Danger

Nature of Abuse
 increased severity and frequency of
beatings
 escalation in threats
 stalking
 violent or forced sex
 destruction of property
Ensure Victim’s Safety
Social worker involvement
 Restraining order
 Phone numbers of shelters,
hotlines
 Safe place to go

Domestic Violence Shelters
 Availability
poor
 up to 70 - 80% 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.
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

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

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
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
Violence Against Women
in The Developing World
forced abortion and sterilization
 divorce restrictions
 forced prostitution
 child prostitution

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
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”

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
 rare
in Egypt - 2007
in Asia
 Found across all socioeconomic strata and in
all major religions
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
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
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
Female Genital Mutilation
Complications/Sequelae






bleeding
infection
dysparevnia
painful neuromas
keloids
dysmenorrhea





infertility
decreased sexual
responsiveness
shame
fear
depression
Management of
Female Genital Mutilation
 Sensitivity/understand
cultural identity
issues
 Deinfibulation/clitoral
 Immigration
Issues
reconstruction
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
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
Polygamy

Utah/Mormons
introduced by Joseph Smith (1805-1844) who had 50
wives
 theological justification based on Abraham’s wife Rachel
“giving” him her servant Hagar as a sister wife (Genesis)



Est. 30,000 people in multi-wife families one
generation ago
Est. 60,000 - 90,000 today

polygamist clans (e.g. 10,000 FLDS members, 1,500
member Kingston clan)
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)
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
Covenant Marriages

Can be dissolved only in the case of infidelity, abuse
or felony conviction

Offered since 1997 in Louisiana and Arkansas
 similar measures introduced in 17 other states
Rape in War
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
http://phsj.org/womens-health/

International Issues
 2013
WHO report: 30% of women
worldwide have been victims of IPV
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
International Issues
 80%
of refugees and internally-displaced
persons worldwide are female
 Indian
rape epidemic – one rape every 22
minutes (2012)
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 genderbased violence report to police/health care
personnel
 vs. 2.6%/1.1% in Africa

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
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¢
International Issues
South Africa’s Rape Epidemic
 HIV
risk
 in Johannesburg, 40% of men aged
20 - 29 are HIV+
 post-rape antiretroviral drugs are not
available in government hospitals
Other International Issues
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

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
Child Marriage

Marriage before age 18

Affects 60 million women worldwide

Half occur in south Asia
Child Marriage


Associated with no contraceptive use before
first childbirth, high fertility, multiple unwanted
pregnancies, pregnancy termination, and female
sterilization
A human rights violation
Education of Girls and Women

Improvements in length and quality of
education lead to:
 Fewer children
 Increased earning power
 Decreased victimization
Legal approaches

Mandatory reporting
 History of mandatory reporting (child and
elder abuse)
 Benefits
 Risks
 Effectiveness
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
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
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):313-319.
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.
http://www.medscape.com/viewarticle/464255
Donohoe MT. Violence against women in the
military. Medscape Ob/Gyn and Women’s
Health 2005;10(2): posted 9/13/05. Available at
http://www.medscape.com/viewarticle/512380
References

Donohoe MT. War, rape and genocide: Never
again? Medscape Ob/Gyn and Women’s Health
2004;9(2): posted 10/22/04.
http://www.medscape.com/viewarticle/491147
Contact Information
Public Health and Social Justice Website
http://www.phsj.org
martindonohoe@phsj.org