Violence Against Women

1
Violence Against Women

• Martin Donohoe, M.D., F.A.C.P.

2
Violence Against WomenOverview

• Definitions
• Epidemiology
• Sexual Assault/Rape
• Sequelae of Domestic Violence

3
Violence Against WomenOverview

• Recognition and Management
• The Developing World
• human rights abuses
• female genital mutilation

4
Objectives

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

5
Definitions of Violence Against Women

• Individual
• Any act of verbal or physical force, coercion,
  or life-threatening deprivation that causes
  physical or psychological harm, humiliation, or
  arbitrary deprivation of liberty, or that
  perpetuates female subordination

6
Individual Violence Against Women(examples)

• partner abuse
• sexual assault/marital rape
• forced prostitution
• forced noncompliance with contraception
• female genital mutilation
• slavery

7
Definitions of Violence Against Women

• Societal
• Structural forms of discrimination or
  deprivation that affect women as a class

8
Societal Violence Against Women(examples)

• poverty
• impaired access to employment or education
• divorce restrictions
• salary inequalities
• political marginalization
• impaired access to reproductive health services

9
Epidemiology of VAW

• Lifetime prevalence of assault/sexual abuse
• 12 of adolescent girls
• 15 of college women
• 20 of adult women

10
Epidemiology of VAW

• 2 - 4 million women assaulted per year
• every 15 seconds a woman is beaten
• 5 of partner abuse is female on male
• (homosexual/bisexual abuse also exists)

11
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

12
Prevalence of Domestic Violence

• Psych
• 1/4 women who attempt suicide
• 1/4 women treated for psychiatric symptoms
• 55 lifetime prevalence for women with depression

13
Abuse in Pregnancy

• Incidence 8 - 20
• Most common sites of beating are abdomen, head
  and breasts
• Increases risk of low birth weight/pre-term
  labor/delayed prenatal care

14
Prevalence of Domestic Violence

• OB/Gyn
• 1/6 women during pregnancy
• Peds
• 50 - 70 of mothers of abused children

15
High Risk Occupations Prostitutes

• 80 have been physically assaulted
• 80 have been threatened with a knife, gun, or
  other weapon
• 67 have been raped

16
Prostitution in the U.S.

• 0.6 of men admit to paying for sex in the last
  year
• 16.3 at some point in their lives
• 694 clients/prostitute/year average
• 1.6 of women admitted they had sex with a
  person they paid, or who paid them for sex
  since age 18

17
High Risk Occupations The Military

• Completed and attempted sexual assaults 20 times
  more common among female soldiers than among
  other government employees
• higher rates of chronic pelvic pain,
  dysmenorrhea, abnormal periods, PMS, and
  dissatisfaction with sexual relations
• correlate with military sexual trauma history

18
The Military

• VA Study (191 inpatients 411 outpatients)
• 24 under age 50 report domestic violence in the
  past year (7 over age 50)
• 90 under age 50 report a history of sexual
  harassment (37 over age 50)

19
High Risk GroupsRunaway 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

20
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

21
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
• 1/2 to 3/4 of the 1,000 - 1,500 murder suicides
  per year involve domestic violence

22
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 mothers abuser

23
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...

24
Common Characteristics ofAbuse Victims

• low self-esteem
• guilt
• self-blame
• denial
• traditional attitudes regarding womens roles
• have children

• poor financial resources
• few job skills
• less education
• few friends
• history of childhood abuse

25
Common Characteristicsof Abusers

• low self-esteem
• dependency
• jealousy
• poor communication skills
• unemployed/underemployed
• abuse alcohol/other drugs
• have witnessed or experienced abuse as children
• abuse their own children

26
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

27
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

28
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

29
Rape

• Unwanted, forced penetration (oral/vaginal/anal)
• reported by 33 -46 of women who are physically
  abused
• annual incidence ³ 80/100,000 women
• 7 of all violent crimes
• lifetime prevalence up to 25

30
Date Rape

• 40 of college women report forced sexual
  contact, attempted rape, or completed rape
• most common ignoring victims protests
• independent of school demographics
• gt25 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

31
Spousal Rape

• occurs in 10 - 15 of all marriage
• more violent, less frequently reported then
  non-spousal rape
• not illegal in many U.S. states/other countries

32
Rape

• 5 chance of pregnancy
• 25 chance of acquiring STD
• GC 6 - 12
• Chlamydia 4 - 17
• Syphilis 0.5 - 3
• 1 -2/1,000 odds of acquiring HIV
• varies

33
Rape

• Underreported
• Less than 1 of rapists convicted
• Average prison time for those convicted
• rape 1 year
• armed robbery 3 - 5 years
• murder 8 years
• Chemical Castration Laws

34
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

35
Public Policy

• Some health insurers refuse to cover abuse
  victims (pre-existing condition)
• states legislating against this practice
• 2002 Federal funds to fight abuse and neglect
• Elder abuse - 153 million
• Domestic abuse - 520 million
• Child abuse - 6.7 billion

36
The Physicians 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 332234-7

37
The Physicians Duties in Caring for Victims of
Sexual Assaults

• Medical
• offer post-exposure HIV prophylaxis
• offer post-coital contraception (vs. in utero
  paternity testing f/b selective abortion)
• arrange medical followup
• provide counseling
• NEJM 1995 332234-7

38
Physical Examination ofSexual Assault Victims

• Collection of clothing
• External evaluation
• abrasions, lacerations, ecchymoses, bite marks
• Oral cavity
• secretions, injuries, collection of samples for
  culture
• NEJM 1995 332234-7

39
Physical Examination ofSexual Assault Victims

• Genitalia
• hair combing, hair sampling, vaginal secretions,
  collection of samples for culture, injuries
• Rectum
• injuries, collection of samples for culture
• NEJM 1995 332234-7

40
Prophylaxis for Adult Victims ofSexual
AssaultAntibiotic Prophylaxis

• Ceftriaxone (250 mg IM) or Spectinomycin (2 g IM)
• PLUS
• Doxycycline (100 mg po bid x 7d) or Azithromycin
  (1 g po x 1)
• PLUS
• Metronidazole ( 2 g po x 1)

41
Prophylaxis for Adult Victims ofSexual
AssaultPrevention of Pregnancy

• 2 OCP tablets (each with 50 mcg ethinyl
  estradiol) po q12 x 2
• OR
• 3 OCP tablets (each with 35 mcg ethinyl
  estradiol) po q12 x 2
• PLUS
• Antiemetic

42
Prophylaxis for Adult Victims ofSexual Assault

• HIV Prophylaxis (studies ongoing)
• Consult ID
• start up to 72 after rape
• Other (as indicated)
• tetanus toxoid
• Hep B vax/HBIG

43
Factors That Perpetuate Gender-Based
ViolenceCultural

• Gender-specific socialization
• Cultural definitions of appropriate sex roles
• Expectations of roles with relationships
• Belief in the inherent superiority of males
• Values that give men proprietary rights over
  women
• Notions of the family as private/under male
  control
• Customs of marriage (bride price/dowry/exogamy)
• Acceptability/glorification of violence as a
  means to resolve conflict
• Soc Sci Med 1994 391165-79

44
Factors That Perpetuate Gender-Based
ViolenceEconomic

• Womens economic dependence on men
• Limited access to cash and credit
• Discriminatory laws regarding inheritance,
  property rights, use of communal lands and
  maintenance after divorce
• Limited access to employment in formal and
  informal sector
• Limited access to education and training for
  women
• Soc Sci Med 1994 391165-79

45
Factors That Perpetuate Gender-Based
ViolenceLegal

• Plural systems of law customary, common,
  religious
• Lesser legal status of women
• Laws regarding divorce, child custody,
  maintenance and inheritance
• Legal definitions of rape and domestic abuse
• Low levels of legal literacy among women
• Insensitive treatment of women by police and
  judiciary
• Soc Sci Med 1994 391165-79

46
Factors That Perpetuate Gender-Based
ViolencePolitical

• 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 womens
  organizations)
• Limited participation of women in
  organized/formal political system Soc Sci Med
  1994 391165-79

47
Economic Gender DisparitiesThe Bad News

• Worldwide, women do 2/3 of the worlds paid and
  unpaid work (1/3 paid, 2/3 unpaid)
• receive 10 of global income
• hold less than 10 of legislative seats
• own 1 of global property
• Women in the U.S. working full-time make
  0.75/1.00 males

48
Economic Gender DisparitiesThe Bad News

• Women make up 46 of the U.S. workforce, but hold
  lt 2 of senior-level management positions in
  Fortune 500 companies
• 2002 5/50 governors are female, 13 of
  Congresspersons, 4 of the top 21 university
  presidents

49
Economic Gender DisparitiesThe Good News (U.S.)

• From 1987 - 1999
• of female-owned firms has doubled (9.1 million)
• of workers employed by such firms has
  quadrupled (27.5 million)

50
Gender DisparitiesMixed News (U.S.)

• High school sports
• 2.5 million female athletes (1999) vs. 300,000
  (early 1970s)
• But 90 of womens college sports teams were
  coached by women when Title IX enacted (1972)
  2007 - 42

51
Pornography

• 4 billion adult entertainment business
• Per day
• 23-60 million unique visitors to pornography
  websites
• 2-3 million unique visitors to the five largest
  news sites

52
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.)

53
Violence Against Homosexuals

• GSA
• Gay marriages / civil unions
• Discrimination legal
• Causes..

54
Health Consequences of ViolenceAgainst
WomenPhysical Sequelae

• Trauma bruises, fractures, lacerations
• Chronic pain headaches, AP, pelvic pain,
  myalgias, LBP, CP
• Hyperventilation Syndrome
• Eating and sleeping disorders

55
Health Consequences of ViolenceAgainst
WomenPhysical 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
• Delayed risk of HTN, arthritis, asthma, stroke,
  and heart disease
• IBS
• symptom severity correlates with severity and
  duration of abuse

56
Health Consequences of ViolenceAgainst
WomenPsychological Sequelae - Early

• shock
• denial
• distrust of others

• withdrawal
• confusion
• psychological numbing
• sense of vulnerability/hopelessness/loss/betrayal

57
Health Consequences of ViolenceAgainst
WomenPsychological Sequelae - Long Term

• depression
• anxiety disorders
• phobias
• anorexia/bulimia
• substance abuse

58
Health Consequences of ViolenceAgainst
WomenPsychological 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

59
Health Consequences of ViolenceAgainst Women

• Interference with health care
• Delayed health care

60
Health Consequences of ViolenceAgainst
WomenResponse to Rape

• Initial
• unnaturally calm/detached OR crying/angry
• Denial phase
• approx. 2 months
• Increasing psychological symptoms over several
  months
• Gradual psychological healing

61
Recognition and Management ofDomestic Violence

• Routine, repeated assessments in all settings
  (ER, clinic, wards)
• Maintain supportive, nonjudgmental attitude
  avoid victim-blaming
• Validate the womans experiences, building on her
  strengths, transfer power and control to her
• Be available, provide frequent followup
• Involve social work

62
Recognition and Management

• Discover nature and duration of abuse
• Assess for child abuse
• ensure childrens safety/mandated reporting
• Keep detailed records, including photographs
• Testify in court prn
• Do not recommend marriage counseling

63
Public Health Approaches to Violence Against Women

• Restraining orders prevent recurrent abuse
• Batterer treatment programs have had mixed, but
  generally negative, results

64
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

65
Screening Practices of PCPs

• Self-assessment (1999)
• routine screening - 79
• first visit - 10
• periodic checkups - 99
• prenatal care - 11

66
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

67
Assess Patient for Acutely Increased Danger

• Abuser
• criminal record
• alcohol/substance abuse problem
• gambling problem
• psychiatric disorder
• Situational Trigger
• job loss
• death in family

68
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

69
Ensure Victims Safety

• Social worker involvement
• Restraining order
• Phone numbers of shelters, hotlines
• Safe place to go

70
Domestic Violence Shelters

• Availability poor
• up to 70 - 80 of women and 80 of children
  turned away on any given night
• 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

71
Physician Failure to RecognizeViolence Against
Women

• Fear of offending
• feelings of powerlessness
• time constraints
• Pandoras Box
• low confidence in ability to affect change
• sense of own vulnerability
• deficits in education and training

72
Physician Failure to RecognizeViolence 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

73
Violence Against Womenin The Developing World

• verbal, physical, and sexual abuse
• 4 witnesses required for rape conviction in
  Pakistan
• dowry-related murder
• bride-burning

74
Violence Against Womenin The Developing World

• forced abortion and sterilization
• divorce restrictions
• forced prostitution
• child prostitution

75
Violence Against Womenin The Developing World

• Selective abortion, malnutrition or killing of
  female children
• MF ratio of births in China 119/100
• suicide as vengeance against an abusive spouse
• post-rape suicide (or homicide)
• to cleanse family honor
• 47 of homicides in Alexandria, Egypt

76
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

77
Female Genital Mutilation

• 100 million women affected worldwide (2 million
  girls/year)
• mostly in Africa (e.g. 98 of women in Somalia,
  80 in Egypt, 50 in Kenya)
• Outlawed in Egypt - 2007
• rare in Asia
• Found across all socioeconomic strata and in all
  major religions

78
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 womens sexual
  pleasure and reproductive capabilities
• c.f. virginity exams by physicians in Turkey

79
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

80
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

81
Female Genital MutilationComplications/Sequelae

• bleeding
• infection
• dysparevnia
• painful neuromas
• keloids
• dysmenorrhea

• infertility
• decreased sexual responsiveness
• shame
• fear
• depression

82
Management of Female Genital Mutilation

• Sensitivity/understand cultural identity issues
• Deinfibulation
• Immigration Issues

83
Female Genital Mutilation

• UN, WHO, and FIGO have condemned
• Illegal to perform in U.S. under child abuse
  statutes
• 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

84
Polygamy

• Utah/Mormons
• introduced by Joseph Smith (1805-1844) who had 50
  wives
• theological justification based on Abrahams 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. the 1,500 member Kingston
  clan)

85
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)

86
PolygamyRelated 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

87
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

88
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

89
International IssuesAfghanistan

• 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 worlds highest
• Lowest ranking on U.N. Development and Gender
  Disparity Indices

90
International IssuesSouth Africas Rape Epidemic

• Official Rape Rate 104/100,000 people (vs.
  34.4/100,000 in the U.S.)
• highest rate in the world
• Official annual total 50,000, but est. only
  1/35 reported
• New latex vaginal insert that latches onto a
  rapists penis and requires surgical removal
  available for 35

91
International IssuesSouth Africas Rape Epidemic

• HIV risk
• in Johannesburg, 40 of men aged 20 - 29 are HIV
• post-rape antiretroviral drugs are not available
  in government hospitals

92
Other International Issues

• 80 of refugees and internally-displaced persons
  worldwide are female
• 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

93
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

94
Legal approaches

• Mandatory reporting
• History of mandatory reporting (child and elder
  abuse)
• Benefits
• Risks
• Effectiveness
• 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

95
Conclusions

• Awareness of scope of problem of violence against
  women
• Screen regularly and repeatedly document treat
  support
• Support womens rights issues, which are health
  care issues

96
References

• Donohoe MT. Violence against women Partner abuse
  and sexual assault. Hospital Physician
  200440(10)24-31.
• Donohoe MT. Individual and societal forms of
  violence against women in the United States and
  the developing world an overview. Curr Womens
  Hlth Reports 20022(5)313-319.

97
References

• Donohoe MT. Violence and human rights abuses
  against women in the developing world. Medscape
  Ob/Gyn and Womens Health 20038(2) posted
  11/26/03. http//www.medscape.com/viewarticle/4642
  55
• Donohoe MT. Violence against women in the
  military. Medscape Ob/Gyn and Womens Health
  200510(2) posted 9/13/05. Available at
  http//www.medscape.com/viewarticle/512380

98
References

• Donohoe MT. War, rape and genocide Never again?
  Medscape Ob/Gyn and Womens Health 20049(2)
  posted 10/22/04. http//www.medscape.com/viewartic
  le/491147

99
Contact Information

• Public Health and Social Justice Website
• http//www.phsj.org
• martindonohoe_at_phsj.org