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Violence Against Women

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  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 mother’s 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. 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

  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 • >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

  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 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

  37. 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

  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; 332:234-7

  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; 332:234-7

  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; 39:1165-79

  44. 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

  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; 39:1165-79

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

  47. 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

  48. 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

  49. 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)

  50. 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%