Women’s Health Contemporary Human Rights Issues

1. Women’s HealthContemporary Human Rights Issues Martin Donohoe, M.D., F.A.C.P.

2. Violence Against WomenOverview • Definitions • Epidemiology • Sexual Assault/Rape • Sequelae of Domestic Violence • Recognition and Management • The Developing World • human rights abuses • female genital cutting

3. Violence Against WomenOverview • Teen Pregnancy • The Family/Single Motherhood/Child Care • Ideals of Beauty & the Historical Subjugation of Women • Abortion • Conclusions

4. Objective • Understand common forms of violence against women • Learn to recognize and manage violence against women • Exposure to national and international issues in women’s rights/reproductive health care

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

9. Epidemiology • Lifetime prevalence of assault/sexual abuse • 12% of adolescent girls • 20% of college women • 20% of adult women • 2 - 4 million women assaulted per year • every 15 seconds a woman is beaten; every 2 minutes a woman is sexually assaulted

10. Epidemiology • 5% of partner abuse is female on male • 22% of men / 7% of women in same sex partnerships report domestic violence • Discrimination against homosexuals legal

11. Epidemiology of VAW • NISVS (National Intimate Partner and Sexual Violence Survey)/CDC (2011) • 19% of women have been raped; 1.7% of men (1999 study found 13% of women, 3% of men) • Women: 52% by partner; 41% by acquaintance • Men: 52% by acquaintance; 15% by stranger

12. Epidemiology of VAW • NISVS (National Intimate Partner and Sexual Violence Survey)/CDC (2011) • 44% of women and 23% of men have experienced rape, physical violence, stalking, or all 3 by their significant other in their lifetimes

13. 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

14. 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

15. Prevalence of Domestic Violence • OB/Gyn • 1/6 women during pregnancy • Abortion Clinics • 12% • Peds • 50 - 70% of mothers of abused children

16. 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

17. 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

18. 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.

19. 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

20. 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

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 18 • Punishment varies among johns, prostitutes, pimps • Different types of regulation exist worldwide (see prostitution paper on website) • WHO, AI, and HRW have called for the decriminalization of prostitution

22. 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

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: • Violence against women in the military • War, rape and genocide

24. 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

25. High Risk GroupsCollege 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

26. 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

27. 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

28. 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

29. 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...

30. 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

31. Common Characteristicsof Abusers • low self-esteem • dependency • jealousy • poor communication skills • unemployed/underemployed

32. Common Characteristicsof 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

33. 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

34. 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

35. 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

36. 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% • 1/3 Native Americans/Alaskan Natives victims of attempted rape or rape • Migrants, those in war zones and refugee camps at high risk

37. High Risk Groups • Persons under age 24 • Prostitutes • Gays, lesbians, bisexuals, transgendered • Alcohol and drug users • The disabled

38. 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

39. 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)

40. Rape • Underreported • FBI: 5% of rape allegations unfounded • Less than 1% of rapists convicted

41. Rape • 34 states have statutes of limitations on filing charges, ranging from 3-30 yrs (some exemptions if DNA evidence identifies suspect) • 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 passed by Congress, awaiting joint committee finalization (late 2016)

42. Rape • Average prison time for those convicted: • rape = 1 year • armed robbery = 3 - 5 years • murder = 8 years • Chemical Castration Laws

43. 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

44. 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

45. Sexual Assault and Rape of Incarcerated Men • Men = 92% of prisoners in US • 1/5 men in state prisons report pressured or forced sex during incarceration; 7% report rape • 4.5% of men in state and federal prisons sexually victimized annually • Rates much higher among non-heterosexual inmates (many engage in “protective” pairing / “protective” prostitution)

46. Rape • 6-7% chance of pregnancy (est. 25,000 pregnancies/yr in US) • 25% chance of acquiring STD • GC = 6 - 12% • Chlamydia = 4 - 17% • Syphillis = 0.5 - 3%

47. Rape and HIV • 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

48. 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 (10-15 weeks, risks to mother and fetus) • May assist mother’s decision to carry vs. terminate pregnancy

49. 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

50. 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