Violence Against Women

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

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

Violence Against WomenOverview • Recognition and Management • The 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

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 • 15% of college women • 20% of adult women

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)

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

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

High Risk Occupations: Prostitutes • 80% have been physically assaulted • 80% have been threatened with a knife, gun, or other weapon • 67% have been raped

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

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

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)

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

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

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...

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 ofAbuse Victims

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

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, 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%

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 non-spousal rape • not illegal in many U.S. states/other countries

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

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

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

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

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

The Physician’s 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; 332:234-7

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; 332:234-7

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; 332:234-7

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)

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

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

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; 39:1165-79

Factors That Perpetuate Gender-Based ViolenceEconomic • Women’s economic dependence on men • Limited access to cash and credit • Discriminatory laws regarding inheritance, property rights, use of communal lands and maintenance after divorce • Limited access to employment in formal and informal sector • Limited access to education and training for women Soc Sci Med 1994; 39:1165-79

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; 39:1165-79

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 women’s organizations) • Limited participation of women in organized/formal political system Soc Sci Med 1994; 39:1165-79

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) • 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

Economic Gender Disparities:The Bad News • Women make up 46% of the U.S. workforce, but hold < 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

Economic Gender Disparities:The 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)

Gender Disparities:Mixed News (U.S.) • High school sports • 2.5 million female athletes (1999) vs. 300,000 (early 1970s) • But 90% of women’s college sports teams were coached by women when Title IX enacted (1972); 2007 - 42%

Violence Against Women