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					     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
       Violence Against Women
              Overview

• Teen Pregnancy
• The Family/Single Motherhood/Child Care
• Ideals of Beauty & the Historical Subjugation of
  Women
• Abortion
• Conclusions
                      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
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 cutting
  •   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
• 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)
    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 Groups
       Runaway 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...
        Common Characteristics of
            Abuse Victims

• low self-esteem           •   poor financial resources
• guilt                     •   few job skills
• self-blame                •   less education
• denial                    •   few friends
• traditional attitudes     •   history of childhood
  regarding women’s roles       abuse
• have children
          Common Characteristics
              of 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  80/100,000 women
   – 7% of all violent crimes

• lifetime prevalence up to 25%
                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
                     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%
   – Syphillis = 0.5 - 3%
• 1 -2/1,000 odds of acquiring HIV
  – varies
  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
  – 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 of
              Sexual Assault Victims
• Collection of clothing
• External evaluation
   – abrasions, lacerations, ecchymoses, bite marks
• Oral cavity
   – secretions, injuries, collection of samples for culture
• 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 of
            Sexual Assault
               Antiobiotic 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 of
            Sexual Assault
             Prevention 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 of
        Sexual Assault

• HIV Prophylaxis (studies ongoing)
  – Consult ID
  – start up to 72 after rape

• Other (as indicated)
  – tetanus toxoid
  – Hep B vax/HBIG
         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
• 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
         Factors That Perpetuate
         Gender-Based Violence
                          Cultural
• 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 Violence
                      Economic
• 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 Violence
                         Legal
• 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 Violence
                            Political
• 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
    Economic Gender Disparities:
          The Bad News
• Women make up 45% of the employed
  global workforce, yet account for 70%
  of the world’s poor
• 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
          Ledbetter v Goodyear
         US Supreme Court, 2006
• While the Civil Rights Act forbids pay
  discrimination on the basis of race, gender or
  religion, all employees must lodge a formal
  complaint within 180 days of the initial
  discriminatory paycheck
• Women still earn 77 cents to every dollar earned
  by men
    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)
   – sales of these firms have quadrupled ($3.6
     trillion)
       Economic Gender Disparities:
          The Good News (U.S.)
• Fastest growing fields:
  –   Construction
  –   Wholesale trade
  –   Transportation
  –   Communications
  –   Agriculture
  –   Manufacturing
            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%
                 Sexual Harassment


•   quid pro quo
•   hostile environment
•   15,500 cases filed/year ( from 6,900 in 1990)
•   Civil Rights Act
     – prohibits discrimination based on race and sex, but
       not sexual orientation
Gender-Based and Sexual Harassment
   Among U.S. Women Physicians

•4,501 respondents (59% response rate)

•47.7% gender-based harassment

•36.9 sexual harassment


                           Arch Int Med 1998;
 158:352-8
  Gender-Based and Sexual Harassment
     Among U.S. Women Physicians
• med school > internship + residency > practice

• higher rates among those younger, divorced or
  separated, in historically male specialties

• lower rates among Asians, those satisfied with their
  careers, those in government jobs, and the politically
  very conservative
                                       Arch Int Med 1998; 158:352-8
              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
   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.)
   Health Consequences of Violence
           Against Women
                 Physical Sequelae


• trauma: bruises, fractures, lacerations
• chronic pain: headaches, AP, pelvic pain, myalgias,
  LBP, CP
• Hyperventilation Syndrome
• Eating and sleeping disorders
      Health Consequences of Violence
              Against Women
                      Physical 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
       Health Consequences of Violence
               Against Women
                Psychological Sequelae - Early


•   withdrawal                     • shock
•   confusion                      • denial
•   psychological numbing          • distrust of others
•   sense of
    vulnerability/hopelessness/
    loss/betrayal
    Health Consequences of Violence
            Against Women
       Psychological Sequelae - Long Term
•   depression
•   anxiety disorders
•   phobias
•   anorexia/bulimia
•   substance abuse
   Health Consequences of Violence
           Against Women
       Psychological 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
  Health Consequences of Violence
          Against Women
• Interference with health care

• Delayed health care
 Health Consequences of Violence
         Against Women
            Response to Rape

• Initial:
   – unnaturally calm/detached OR crying/angry
• Denial phase
   – approx. 2 months
• Increasing psychological symptoms over
  several months
• Gradual psychological healing
     Recognition and Management of
           Domestic Violence
• Routine, repeated assessments in all settings (ER, clinic,
  wards)
• Maintain supportive, nonjudgmental attitude; avoid
  victim-blaming
• Validate the woman’s experiences, building on her
  strengths, transfer power and control to her
• Be available, provide frequent followup
• Involve social work
 Recognition and Management

• Discover nature and duration of abuse
• Assess for child abuse
   – ensure children’s safety/mandated reporting
• Keep detailed records, including photographs
• Testify in court prn
• Do not recommend marriage counseling
Screening Practices of PCPs
• Self-assessment (1999)
   – routine screening - 79%
   – first visit - 10%
   – periodic checkups - 99%
   – prenatal care - 11%
• Screening new patients
   – OB/Gyns - 17%
   – Internists - 6%
   – Physicians practicing in HMOs - 1%
   – Physicians practicing in public clinics - 37%
   – no difference by sex
Assess Patient for Acutely
    Increased Danger
• Abuser
   – criminal record
   – alcohol/substance abuse problem
   – gambling problem
   – psychiatric disorder
• Situational Trigger
   – job loss
   – death in family
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
   Ensure Victim’s Safety
• Social worker involvement

• Restraining order

• Phone numbers of shelters, hotlines

• Safe place to go
        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
Physician Failure to Recognize
  Violence Against Women

 • Fear of offending
 • feelings of powerlessness
 • time constraints
    –Pandora’s Box
 • low confidence in ability to affect change
 • sense of own vulnerability
 • deficits in education and training
    Physician Failure to Recognize
      Violence 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
         Violence Against Women
         in The Developing World
• verbal, physical, and sexual abuse
   – 4 witnesses required for rape conviction in Pakistan
• dowry-related murder
• bride-burning
• forced abortion and sterilization
• divorce restrictions
• forced prostitution
• child prostitution
           Violence Against Women
           in The Developing World

• Selective abortion, malnutrition or killing of female
  children
   – M:F 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
          Female Genital Cutting
• 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”
• Represents cultural control of women’s sexual
  pleasure and reproductive capabilities
   –c.f. virginity exams by physicians in Turkey
        Female Genital Cutting
• Also called female genital mutilation

• Not female circumcision
  – i.e., male equivalent would be penectomy
           Female Genital Cutting
• 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
• Formerly used in U.S. and U.K. as treatment for hysteria
  (“floating womb”), epilepsy, melancholia, lesbianism,
  and excessive masturbation
            Female Genital Cutting
• 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
           Female Genital Cutting


• Most commonly carried out between ages 4 and 10
  – physicians perform about 12% of operations

• Often done under non-sterile conditions and without
  anesthesia
         Female Genital Cutting
         Complications/Sequelae

•   bleeding           • infertility
•   infection          • decreased sexual
•   dyspareunia          responsiveness
•   painful neuromas   • shame
•   keloids            • fear
•   dysmenorrhea       • depression
          Management of
       Female Genital Cutting

• Sensitivity/understand cultural identity issues

• Deinfibulation

• Immigration Issues
            Female Genital Cutting
• 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
                       Polygamy

• Utah/Mormons
  – introduced by Joseph Smith (1805-1844) who had 50 wives
  – theological justification based on Abraham’s 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)
                   Polygamy

• Utah outlawed “plural marriage” in 1890 in
  exchange for statehood
• Not one prosecution in the last 50 years
• 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)
                    Polygamy
                 Related 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
           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
                  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
              International Issues
                  Afghanistan
• 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 world’s highest
• Only minor changes since US invasion – most of
  country still controlled by Taliban, poppy trade strong
             International Issues
        South Africa’s 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 rapist’s penis
  and requires surgical removal available for 35¢
         International Issues
    South Africa’s Rape Epidemic
• HIV risk
  –in Johannesburg, 40% of men aged
   20 - 29 are HIV+
  –post-rape antiretroviral drugs are not
   available in government hospitals
         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
                 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
                 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
                 Teen Pregnancy
• Birth rate ages 15 - 19 = 55/1,000/year (gradual  since
  1960)
• Greater than 50% of high seniors have had sexual
  intercourse
   – average age at first intercourse: 17 for girls, 16 for
     boys
   – Teen sex, teen STDs decreasing
• Up to 2/3 of teens use condoms (3x as many as in
  1970s)
                 Teen Pregnancy
• U.S. rates 3 - 10x higher than among the industrialized
  nations of Western Europe
   – teen poverty rates higher by a similar magnitude

• 6/7 U.S. teen births are to the 40% of U.S. girls living at
  or below the poverty level

• 2/3 of teen mothers were raped or abused as children
                Teen Pregnancy
• Only 8% of schools provide condoms
   – promotion and distribution does not increase teen
     sexual activity
• Only 20 - 40% of health plans cover all contraceptive
  methods
   – 1/2 - 2/3 refuse to pay for OCPs
   – all methods of contraception more effective and less
     costly than no method
• 1/3 of all plans cover abortions
• 9/10 plans cover sterilization
             Teen Pregnancy
          The Role of Adult Males
• 71% of teen pregnancies in California in 1993
  fathered by adult men (avg. age 22.6 years, or 5 years
  older than the mothers)
   – more births fathered by men over 25 than boys
     under 18
• STD and AIDS rates among teenage girls 2 - 4x
  higher than among age-matched teenage boys
   – closer to adult male rates
                  Statutory Rape
• Underage girls/adult perpetrators or boyfriends
• States evenly split on mandated reporting
• 66% of providers do not routinely report
   – reasons including lack of confidence in criminal
     justice system, confidentiality, deterring health care
     and social services follow-up, risk of physical
     retaliation
Teen Pregnancy: Worrisome Trends

• 1996 “Welfare Reform” Legislation:
   – 50 million over 5 years allocated to states to teach
     abstinence
   – By 2008, annual abstinence-only budget $178
     million (vs. 0% for comprehensive sex ed)
   – 1988 – 2% of US school districts relied on
     abstinence-only education
   – 1999 – 23%
Teen Pregnancy: Worrisome Trends

• Parental notification laws - consequences:
   – increased 2nd trimester abortions
   – increased abortions in neighboring states
              Single Motherhood
• Over 50% of children in solo-mother families live
  below the poverty line
• 21% of U.S. children live in solo-mother families
• Of white children born since 1980, 50% will spend
  some part of their childhood in a single parent family
   – 80% for African-American children
• On average, children from divorced or single parent
  families show poorer school performance,  risk of teen
  pregnancy,  rates of delinquency, and  mental health
           The American Family

• The U.S. is one of the only industrialized
  countries without paid maternity leave and health
  benefits guaranteed by law
• The Family and Medical Leave Act (1993)
  guarantees only unpaid leave and only to
  individuals working in establishments employing
  at least 50 workers
   – disproportionately excludes low-wage workers
   – only 56% of working women eligible
                     Child Care
• 50% of mothers of preschoolers and 70% of mothers of
  school age children work outside the home

• 1/2 of children of working mothers cared for by relatives
   – 3/8 in family day care ($40 - 100/week)
   – 1/8 in day care centers ($70 - 150/week)
   – poorly regulated, higher worker turnover
    Historical Subjugation of Women
• Burning at the stake
• The Chamberlain family and obstetrical forceps
• J. Marion Sims and operative gynecology
   – trials on slaves without anesthesia
• Contrast with slightly delayed use of chloroform for
  obstetrical anesthesia
   – discovered by James Young Simpson, 1847
   – Queen Victoria, Charles Darwin, and Charles Dickens
     used/encouraged
                Conclusions

• Awareness of scope of problem of violence
  against women
• Screen regularly and repeatedly; document;
  treat; support
• Support women’s rights issues, which are health
  care issues
         Contact Information
Public Health and Social Justice Website

         http://www.phsj.org
       martindonohoe@phsj.org

				
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