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Women’s Health Contemporary Human Rights Issues

Women’s Health Contemporary Human Rights Issues. Martin Donohoe, M.D., F.A.C.P. Violence Against Women Overview. Definitions Epidemiology Sexual Assault/Rape Sequelae of Domestic Violence Recognition and Management The Developing World human rights abuses female genital cutting.

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Women’s Health Contemporary Human Rights Issues

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

  10. 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

  11. 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

  12. 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)

  13. 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

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

  15. 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

  16. 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

  17. 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.

  18. 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

  19. 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

  20. 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)

  21. 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

  22. 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

  23. 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

  24. “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

  25. 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

  26. 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

  27. 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...

  28. 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

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

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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

  35. Rape • Underreported • Less than 1% of rapists convicted • Large backlog of untested rape kits (over 180,000) • H.R. 4114 and S.B 2376 (Justice for Survivors of Sexual Assault) bills pending in Congress

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

  37. 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

  38. 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

  39. Rape • 5% chance of pregnancy • 25% chance of acquiring STD • GC = 6 - 12% • Chlamydia = 4 - 17% • Syphillis = 0.5 - 3%

  40. 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

  41. 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

  42. 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

  43. 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

  44. Physical Examination ofSexual 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

  45. 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 and NEJM 2011;365:834-41

  46. Prophylaxis for Adult Victims ofSexual AssaultAntibiotic 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)

  47. Prophylaxis for Adult Victims ofSexual AssaultPrevention 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%)

  48. Prophylaxis for Adult Victims ofSexual AssaultPrevention 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: IUD implanted within 5 days • Nearly 100% effective

  49. 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

  50. 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.

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