Health Implications of Female
Dignity across the Life Span
Dr. Jameela George MBBS, MIRB
The Center for Bioethics, India
March 7, 2012
Indignity & Health
• Indignity
Humiliation, degrading, or abusive treatment
Offense, as to a person's pride or sense of
dignity
Lack or loss of dignity or honour or self-respect
Injury, injustice, insult
Dishonour, disrespect, discourtesy
Outrage, put down, reproach, snub, taunt
• Health is a state of physical, mental, social wellbeing and not the absence of disease or infirmity
Historical views
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Ancient Greece
China
Rome
English common Law
India
Social funerals of women in India
• Sati: A recently widowed woman would immolate herself
on her husband’s funeral pyre, claimed to be voluntary on
the part of the widow or otherwise
• Buried alive: Widow being buried alive beside her husband,
in ceremonies that are largely the same as those performed
in immolation
• Jauhar: Simultaneous, mass immolation of Rajput women,
children, the elderly and the sick, at the death of their
fighting men and defeat in battle against Muslims
Abortions (Estimates - annual)
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• Worldwide – 42 million abortions
• South and Central Asia – 10.5 million
abortions
• India – 11million abortions
• Two thirds in India are “alternative methods”
such as force, causing risk to mothers
– Nearly 20,000 young mothers die each year caused
by these methods
Male preference
• Traditional patriarchal culture
• Sons inherit property
• Sons carry on the family name
• Sons expected to support aging parents
• Daughter has limited freedom to support parents
• Widow with daughters only will lose late husband’s
property
• Parental preference for boys is common throughout the
world
• It is most obvious in China, Korea and India
Violence in the Life cycle of women
Phase
Pre-birth
Type of violence
Sex-selective abortion; effects of battering during pregnancy on birth
outcomes
Infancy
Female infanticide; physical, sexual and psychological abuse
Girlhood
Child marriage; female genital mutilation; physical, sexual and
psychological abuse; incest; child prostitution and pornography
Adolescence
Dating and courtship violence, Acid attacks, honour killing
Adulthood
Sexual harassment; Sexual abuse in the workplace; rape; forced
prostitution and pornography; trafficking women
partner violence; marital rape;
dowry abuse and murders; partner homicide; psychological abuse;
abuse of women with disabilities; forced pregnancy
Elderly
Sexual, physical and psychological abuse;
Forced “suicide” or homicide of widows for economic reasons
Female Feticide
Female feticide is the practice of
terminating a pregnancy
based upon the predicted female
sex of the baby
• Selectively aborting female
fetuses, thus avoiding the birth
of girls
• Used as a form of
contraception
• Extreme manifestation of
violence against women
Most common in parts of China,
India, Pakistan
Female Feticide –contd.
India
China
Year
Child sex ratio
1991
945
2001
927
2011
914
• About a million female
foetuses are aborted each year
• One child policy enacted in
1979 contributes to this
• Sex ratio at birth (boys born
per 100 girls) >130 in some
provinces
• There could be more than 35
million young "surplus males"
in China
Deviations in sex ratios do not
exist in sub- Saharan Africa,
Latin America & the Caribbean
Special Statistics on Girl Child in India
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12 million girls are born in India
annually
1 out of every 6 girls does not live to
see her 15th birthday
1 million of them are unable to
survive even their first birthday
One-third of these deaths take place at
birth
Every sixth girl child's death is due to
gender discrimination
Females are victimised far more than
males during childhood
300,000 more girls than boys die
every year
Female child mortality exceeds male
mortality in 224 out of 402 districts in
India
Missing women of Asia
This is a shortfall in the number
of women in Asia relative to the
number that would be expected
• European and North American
countries -more women than
men
• Developing countries in Asia
& Middle East, the sex ratio
much lower
• India - 44 million missing
women (UN Estimate 2001)
• China - 50 million women
"missing" - that should be
there but are not
Discrimination in Immunization,
Nutrition & Health care
• Immunization
• Nutrition
• Medical treatment
• Implications
• Girls have a 40% greater risk of ill
health compared to boys
• More girls than boys die of acute
respiratory diseases, infectious &
parasitic diseases and viral
infections
• Anaemia affects >90% of
adolescent girls
Literacy for Girls
• Low enrollment of girls in schools - 2 out of ten girls not enrolled
• High dropout rate of girls from high schools - Fear of PMS/Rape
• Poor School Environment for girls
• Lack of separate toilets for girls
• Lack of female teachers in schools
• Poverty, Bonded Labour and Child Labour Practices
• Older girls taking care of younger siblings
• Dowry a barrier to education
Afghanistan – Girls’ schools were destroyed to prevent girls from being educated
• 65% of the world’s children who do not attend school are girls
• 66% of the world’s illiterate people are women
Literacy
• Differences within India –
– Kerala – 92%
– Madiya – Tribe – 5%
• Low female literacy co-exists
with low female age at
marriage
Languages in India
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National Language – Hindi
Official languages – 22
SIL Ethnologue lists 415
Individual mother tongues in
India – 1652
Women, work, wages
• Gender discrimination in work
load - Women do most of
domestic work, field work/ paid
work
• Gender gap in full time paid
work
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South Korea – 38%
U.K – 18.6%
Japan – 28.3%
France – 16.5%
• Gender difference in employment
5 female CEOs of top 200 (Aus)
• Gender gap in wages
Professionals paid equal
Unskilled labourers
Toilets and indignity
• 1 in 3 women across the world do
not have access to toilet
• 1.25 billion Women - daughters,
sisters, mothers, grandmothers
• Live with discomfort, indignity
and fear
• Risk shame, disease, harassment
and even attack/ violence
• Community toilets is especially
unsafe for women, particularly at
night
• Women, more than men, suffer
the indignity of being forced to
defecate in the open, at risk of
assault or rape
Female genital mutilation
• Types
– Infibulation, Clitoridectomy, Excision, Pricking,
piercing, scraping, cauterizing
• World wide estimate
– 100-140 millions have had FGM
– 3 millions per year
• Practiced in 28 countries of Africa
• Implications
Child Marriage
Children given in marriage before
marriageable age often before
puberty (as young as 4 & 5 years)
• India
• 1500,000 girls <15 years
already married (2001)
• Approximately 300,000 are
mothers to at least one child
• 47.3% of women aged 2024 were married by age 18
(NFHS-III survey)
• Rajasthan - epicentre for
child marriage in India (65.2%)
Child marriage
• India
– 15,00,000 girls < 15 years
– 40% of world’s ch. marriages
• World wide
– Africa, Asia, Middle East,
S. America
• Legal minimum age
• Projection
– 100 million in 10 years
– 25,000 new child brides/day
• Implications
Honor killing
• Causes
• Practiced across
cultures & across
religions
• Suspected
– Global - >20,000/year
– Pakistan – 3 women/day
Trafficking of girls and women
• Worldwide - Victims from 136 countries detected in 118 countries (2007 –
2010)
• No of persons trafficked globally each year – 800,000; (U.S – 17,000)
• No of females trafficked annually – 640,000, more than 70% for sexual
exploitation.
• Australia -about 1,000 women are trafficked each year
• India is a source, destination, and transit country for women, and children
• 21 networks of trafficking have been identified
• 20,000 Nepalese women trafficked to Indian brothels & as servants in
Middle East
• 10% of human trafficking is international, while almost 90% is
interstate
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Implications -
Bride Kidnapping
Also known as marriage by abduction or marriage by capture
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A man who wishes to marry a particular woman abducts her, aided by his friends
and relatives
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She is raped by him until she gives in to the marriage
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Countries practicing Bride kidnapping
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Central Asia, the Caucasus region, and parts of Africa,
Among People s as diverse as
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Hmong in Southeast Asia
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Tzeltal in Mexico
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Romani in Europe
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Bride trafficking in Haryana, India
• Women purchased from far off regions in the garb of marriage
• Cut off from their parents, people, native place and culture forever
• Forced to adjust to local vegetarian food habits
• Denied status & rights of permanent family member
• Not registered in local ration cards or voter lists
• No right to property, involvement in family or social matters
• Kept as bonded farm labourers
• Sexually exploited by all males of the family and by their husband’s
employer
• After their ‘owner’s’ death, they are sold or handed over to others if
childless
Trafficked brides in Haryana are reduced to sex objects and cheap labour
Domestic (Intimate partner) Violence
Domestic violence is universal
Intensity, frequency and prevalence vary
• Less severe physical abuse – punching slapping – 31%
• Severe domestic violence – attack with weapon /
burning – 10% dagger on back
• Physical injury due to violence – sprains, bruises,
dislocation or burns, severe burns, broken bones or
broken teeth and wounds – 12%
• Sexual violence in marriage – forced sex – 8%
(National survey report, India)
Dowry harassment &
Bride burning in India
• Reported no of dowry harassment - 94,000; Conviction
rate just 19% (2010)
• Reported no of dowry deaths - 8618 (2011)
• Approximately 1 dowry death every hour
• Average dowry death reported in Delhi – 1 death in
three days
• Conviction rates in bride burning cases - 34% in 2010.
• Implications:
– Female feticide, infanticide
– Dowry debts, poverty
– Daughter is a burden/liability to the family
Maternal malnutrition
• Anaemia in pregnant women
• India
– 58 %
• Bangladesh
– 40%
• Pakistan
– 45%
• Africa
– 21 – 80%
• Health risks for mother
• Health risks for foetus and new born
• Health risks for the child long term
Maternal Mortality
• World- wide more than 287,000 women die every year
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One maternal death occurs every 90 seconds
• Maternal death burden worldwide (2010)
– Sub- Saharan Africa - 56 %
– South Asia
- 29 %
– Together
- 85 %
• Maternal Mortality Rate (No of maternal deaths per 1, 00,000
live births)
MMR in Pakistan 500
MMR China -37
MMR in India – 212 (2012)
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India
About 57,000 maternal deaths in 2010
Almost 150 women were dying daily
6 every hour
Reproductive servitude
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Fulfil the expectations of husband
and/or orders of in-laws regarding
Number of children
Spacing and timing of their children
Continuing a particular pregnancy or
not depending on
Sex of child
Delivery expected in an inauspicious
month
Delivery inauspicious to parents /
grandparents etc.
No freedom to make decisions
concerning reproduction free of
coercion / violence
Compulsory Sterilization
Compulsory /forced sterilization programs are government policies which attempt to
force people to undergo surgical sterilization, a process of permanently ending
someone's ability to reproduce without his or her consent
• Post natal sterilization without her consent / without her even knowing it
• Bribes used to sterilize women - food and clothing
• Australia - Non-voluntary hysterectomy & Forced sterilization for disabled until
the 1980s
• Sweden and Finland – forced sterilization practiced up until the 1970's
• Uzbekistan- forced and coerced sterilization is current Government policy for
women with two or three children
• India - Sterilization accounts for more than 75% of total contraception
Female sterilization accounts for almost 95% of all sterilizations in India
The right to bodily integrity is violated by compulsory/ forced sterilization
Freedom to decide denied
Reproductive issues
• Infertility – husband azoospermic, but blames wife, wants
divorce
• Reproductive tourism
• Travelling to countries where ova is cheap & unregulated for
IVF
• If ova sale is prohibited, hormones administered, flown and ova
harvested in second country
• Fertilized eggs often travel across international borders to
surrogate mothers
• Commissioning/biological parents travelling for surrogacy to
potential countries
• Implications of Surrogacy
Research Bias
• Assuming erroneously that men’s and women’s biology is similar
• Lab animals are still predominantly male, even in studies of diseases
that disproportionately affect women
• Lack of stratified analysis by sex to assess pharmacokinetics,
effectiveness, adverse effects, dose response, blood concentration
etc
• Lack of evidence that a drug is safe for women
• Over 70% of anti-depressants prescribed to women, but majority of
research conducted on these drugs utilized male subjects
• Research funding for coronary artery disease in men is far greater
than for women
• Cardiovascular research largely conducted on men who suffer at a
lower age group, then applied generalized conclusions to women of
older age group who suffer more morbidity and mortality (without
considering hormonal differences)
Gender bias in health care
provision
• Total joint arthroplasty - Male and female physicians were
more likely to recommend TJA to male patients
• Peripheral Arterial Disease -women are offered surgery less
often in every age group studied for carotid endarterectomy
• Management of stroke in Europe and North America women with stroke were less likely than men to receive
appropriate diagnostic imaging, antithrombotic therapy, or
carotid revascularization
• Gender bias in stroke survivor prescriptions also existed in
the United Kingdom but not in Canada
• Trauma patient triage
• Organ Donation and Transplantation in France
Abuse of Women with Disabilities
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Neglect
Physical abuse
Psychological abuse
Financial exploitation
Sexual abuse
– More than 70% have
been victims of sexual
abuse at some time in
their lives
Abuse of Women with Disabilities
Perpetrators:
Majority of perpetrators are male
caregivers/ paid service providers
Male
family
members-husbands,
dating partners, fathers, brothers are the second
largest perpetrator group
A miniscule percentage of abusers are
strangers
Research needs:
Research on impact of physical or
sexual abuse on survivors (not prevalence)
Research should complement the
insights of survivors themselves
Research to explore the particular
struggles and vulnerabilities that women with
disabilities confront in their own efforts to end
sexual abuse
Women in Disasters
• Gender differentiation at all levels of the disaster process
• Women are more likely to become casualties than men
– Among women aged 20-44, the death rate was 71 per 1000, compared
to 15 per 1000 for men in Bangladesh following cyclone and flood of
1991
• Females are less likely to receive medical, hygienic or psychological
aid when they need it
• Violence against women increases in communities hit by
environmental disasters
– Domestic violence increases after disasters
– Post disaster “flight of men” abandoning women & families, leave
women as sole earners
– In the event of death of husband or son, male relatives confiscate
family land leaving women poverty stricken and destitute
– Women and girls may be coerced into sex for basic needs such as food,
shelter and security
War and Women
As wars have moved from battlefields to villages,
women and girls have become more vulnerable
History
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Social acceptance of rape as part of war in ancient Greece
Rape in wartime an “ancient and customary evil”
World War II comfort women - Chinese & Korean
Mass rapes of Bosnia Herzegovina and the Congo
Forced virginity checks of female protesters in Egypt
For soldiers, rape considered as one of the spoils of war
In Colombia, paramilitary control of some regions often includes sexual
violence and torture of women and girls
• Rwandan genocide- rape was “the rule and its absence the exception”(-UN)
Rape
Rape is generally defined as forced or non-consensual sexual contact
• India– 23,582 reported rape cases; Conviction rate – about 26% (2011)
2 women are raped every hour in India
• South Africa -56,272 rapes; average 154 per day (2010-11)
• US – About 250,000 rape/attempted rape reported annually
685 per day; 28.5 per hour- nearly one every two minutes!
Rape is the destruction of dignity
It is a violation of her right to equality
It is an exertion of power, an act of subjugation and renders her an object
The violator exerts control through the act of unspeakable violence
Causes not only physical harm but also incalculable emotional and
psychological harm
Leads to stigma and rejection by their families and communities
Medical examination for sexual assault
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Blanket consent for the medical examination without adequate information
Gender-insensitive examination of survivors of sexual violence
Undue focus on “habituated to sex”
Over emphasis on genital injuries in cases of rape of women and girls (less
than 30% of them had genital injuries – WHO)
• Flawed views
• “A healthy woman cannot be raped”
• “Working class women are muscular and so can offer resistance”
• “If sexual intercourse is forced, then injuries must be present”
• Medical evidence collection at the expense of providing therapeutic care
• Pakistan – Four male witnesses were needed (Now this has changed)
• Legal proceedings traumatize her further
Widowhood - India
Estimate 40 million widows
• Widowhood is a state of social death
• “husband eater”, “randi” (prostitute)
• Restrictions on food
• Expected to mourn until end of their
lives
• Made to look ugly
• Perceived to be a burden and
inauspicious
• Deprived of their basic dignity as a
kind of atonement for some sin
• It’s the punishment for being a woman
and a widow in India
Widowhood - Africa
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Abandonment by relatives, indifference by friends & society
Accused of being responsible for her husband’s death
Do not have right to inherit land or property
Widows are not allowed to bathe as and when they want
Forced to re-marry her late husband’s brother or forfeit everything her
husband had acquired
Children put through menial excruciating jobs
Husband’s asserts confiscated
Left alone in isolation
Open to sexual abuse
Subjected to dehumanizing rituals
• Shaving of hair on the head
• Taking an oath of innocence – involves drinking bath water of corpse
• Sleeping alone with the corpse