violence against women – health perspectives hassan n. sallam, md, frcog, phd (london) professor...

Violence against women – Health perspectives

Hassan N. Sallam, MD, FRCOG, PhD (London)

Professor in Obstetrics and GynaecologyThe University of Alexandria, and

Clinical and Scientific Director, AlexandriaFertility Center, Alexandria, Egypt

3rd Congress of Society of Reproductive Medicine, 5 – 9 October

2011, Antalya / Turkey

Alexandria, the greatest emporium of the whole world, (Strabo, Geography, book

17, chapter 13, First century AD)

Cleopatra Thea Philopator, Queen of Egypt (67-30 BC)

Saint Catherine of Alexandria, Caravaggio, c. 1598

http://en.wikipedia.org/wiki/Image:Michelangelo_Caravaggio_060.jpg

The Last Judgment, Michelangelo, Sistine Chapel

Hypatia of Alexandria, mathematician, philosopher and scientist (370-415 AD)

Violence against womenVictimization as part of being female

“In all societies, to a greater or lesser degree, women and girls are subjected to physical,

sexual and psychological abuse that cuts across lines of income, class and culture”

Report of the Fourth World Conference on Women, Beijing, 4-15 September 1995,

paragraph 112

Violence against women – prevalence

A review of studies from 35 countries carried out

prior to 1999 indicated that:

• Between 10% to 52% of women were physically abused at some point in their

lives• Between 10% and 27% of women and

girls reported having been sexually abused either as children or adults

• Data from developing countries was generally lacking.

World Health Report 2004: Changing history, WHO 2004

WHO Multi-country Study on Violence against Women

24.000 women 15 sites in 10 countries

(Bangladesh, Brazil, Ethiopia, Japan, Namibia, Peru, Samoa, Serbia and

Montenegro, Thailand and Tanzania)


WHO Multi-country Study on Violence against Women


Violence against women

1. Physical2. Sexual

2. Emotional 3. Verbal

4. Economic


Selective feticideFemale genital mutilation

Honor crimesRape (general, war, marital)

Sexual harassmentTrafficking in women

Mugging senior citizensDomestic (intimate partner)

violence

Sen AK. Missing women, BMJ 304: 586-7, 1992 Sen A. Missing women – revisited, BMJ 367: 185-6, 2003

The missing females

About 100 million women are missing (44m in China, 37m

in India) due to:

• Prenatal sex selection/abortion

• Discrimination against the female child

• Postpartum hemorrhage

Population in thousands

Males Females

World 3 442 851 3 386 510

High income 451 069 464 797

Low and Middle income

2 594 306 2 535 000

The missing femalesWorld population by sex in 2000

United Nations Report: Population prospects: the 2008 revision, 2009

Diagnosis of fetal gender

Ultrasonography Amniocentesis

Physical complications of abortion

• Bleeding: hemorrhagic shock• Perforation: bowel and bladder injury

• Cervical lacerations: repeated miscarriages/ preterm delivery

• Infection: peritonitis, septic shock, deep vein thrombosis

• Cervical shock: death• Dissemination intravascular

coagulation (DIC)• Infertility/ectopic pregnancy

• Rh sensitization

• Infection 27 %• Infertility 3 to 5 %

• Ectopic pregnancy risk increased x 5-8 (12% of all maternal deaths due

to ectopic)• Cervical damage increase the risks of miscarriage, premature birth x 3-5 times• This results in 3000 cases of cerebral

palsy among newborns each year

Complications of abortion in UK

10% of which 25% (2.5%) are considered major

Frank, et.al., "Induced Abortion Operations and Their Early Sequelae", J Roy Col Gen Pract 35: 175-180, 1985

Complications of abortion increase with the gestational

age

Hakim-Elahi E, Tovell HM, Burnhill MS. Complications of first-trimester abortion: a report of 170,000 cases. Obstet Gynecol 76(1):129-35,

1990

• 8 weeks and under - Less than 1%

• 8-12 weeks - 1.5-2% • 12-13 weeks - 3-6%

• Second trimester - Up to 50%, possibly higher

Abortion-related mortality per 100.000 abortions in the USA

Less than 8 weeks: 0.5 From 11-12 weeks: 2.2 From 16-20 weeks: 14 More than 21 weeks: 18

Hakim-Elahi E, Tovell HM, Burnhill MS. Complications of first-trimester abortion: a report of 170,000 cases. Obstet Gynecol 76(1):129-35,

1990

Psychological complications of abortionOver 100 major reactions to abortion have been

reported

Depression Loss of self-esteem

Self-destructive behavior

Sleep disorders Memory loss

Sexual dysfunction Chronic problems with

relationships Dramatic personality

changes Anxiety attacks

Guilt and remorse Difficulty grieving

Increased tendency toward violence

Chronic crying Difficulty concentrating

Flashbacks Loss of interest in previously enjoyed

activities and people Difficulty bonding with

later children

Ashton, The Psychosocial Outcome of Induced Abortion. BJOG 87: 1115-1122, 1980

Psychological complications of abortion Increased self-destructive

behavior

• 80% expressed feelings of "self-hatred" • 49% reported drug abuse

• 39% began/increased use of alcohol • 14% described themselves as having

become "addicted" or "alcoholic" • 60% reported suicidal ideation

• 28% attempted suicide (half of them twice or more)

Ashton, The Psychosocial Outcome of Induced Abortion. BJOG 87: 1115-1122, 1980

Discrimination against the female child

This Pakistani mother gave birth to twins. She breast-fed the boy and bottle-fed the girl. The girl died the following day this

picture was taken.

• In treatment

• In education

• In feeding






violence

Female genital mutilation (cutting)

http://www.dw-world.de/dw/article/0,1564,1188662,00.html

Female genital mutilation - prevalence

About 100 to 140 million women and girls have been subjected to FGM (UNFPA)

FGM – medical consequences

• Pain/shock• Severe bleeding/death

• Reproductive tract infections• Urinary tract infections/stones

• Clitorial cysts• Painful intercourse• Sexual dysfunction

• Difficult labor/increased C/S• Increased risk to baby• Psychological trauma

FGM – WHO study 2006

• 28,393 women in labor in 28 obstetric centers (Burkina Faso, Ghana, Nigeria, Kenya, Senegal

and Sudan)• Increased risk of death to the baby (15% for Type I, 32% for Type II, and 55% for Type III)• Increased risk of cesarean

section (30%)• Increased risk of postpartum

hemorrhage (70%)

Fighting FGM at the Alexandria Regional Center for Women’s Health and

Development

FGM has no religious basis – Medicalization of FGM is wrong






violence

Honor crimes

According to the UN in 2002, honor killings were reported in Egypt, Jordan,

Lebanon, Morocco, Pakistan, Syria, Turkey, Yemen, and other Mediterranean

and Gulf countries, as well as in the immigrant communities in France,

Germany and the UK.

The United Nations Population Fund (UNFPA) estimates that the annual

worldwide total of honor-killing victims may be as high as 5,000

United Nations Reports. Working towards the elimination of crimes against women committed in the name of honor. Report of the

Secretary-General, 2 July 2002

Honor crimes

• Refusing to enter into an arranged marriage

• Loss of virginity/committing adultery or allegedly committing it

• Being the victim of a sexual assault • Seeking a divorce—even from an

abusive husband

Sometimes, the mere perception that a woman has behaved in a way that

"dishonors" her family is sufficient to trigger an attack on her life






violence

The rape of Lucretia by Titian, 1571

“…and they abused her all night , taking turns in raping her until

morning. Finally, just at dawn, they let her go. She fell down at the door of the house and lay there until it was light…found her there, fallen down in front of the door with her hands digging into

the threshold… But there was no answer, for she was dead…”

Holy Bible: Judges: 19

Rape - statistics

• A UN report from 65 countries showed that more than 250,000 cases of rape or attempted

rape are reported annually

• In the USA, it is estimated that only 16% of rapes and sexual assaults are reported to the

police

• 91% of rape victims are female and 9% are male, with 99% of the offenders being male

• The Eighth United Nations Survey on Crime Trends and the Operation of Criminal Justice Systems (2001-2002)

• US Department of Justice. Rape in America: A Report to the Nation, 1992

Rape/sexual abuse is under-reported


Rape – medical consequences

• Trauma/injury• Bleeding

• Unwanted pregnancy/abortion complications

• Sexually transmitted diseases/AIDS• Psychological trauma: acute stress disorder and post-traumatic stress

disorder• Loss of self esteem/suicide

Sexually transmitted diseases

• In Thailand, researchers found that one in ten victims of rape had contracted a STD

• STDs increase a woman’s vulnerability to the HIV/AIDS virus

• Violent sexual assault increase the risk because resulting tears to delicate vaginal tissue allow the

virus easier entry into the bloodstream • Women with STDs have a higher risk of

complications during pregnancy, including sepsis, spontaneous abortion and premature birth

Archavanitkul K, Pramualratana A. Factors affecting women’s health in Thailand. Paper

presented at the Workshop on Women’s Health in Southeast Asia, Population Council, Jakarta, October 29-31, 1990

Acute stress disorder• Depersonalization or dissociation (feeling numb and detached, like being in a daze or a dream, or

feeling that the world is strange and unreal) • Difficulty remembering details of the assault

• Reliving the assault through repeated thoughts, memories, or nightmares

• Avoidance of things, places, thoughts, and/or feelings that remind the victim of the assault

• Anxiety or increased arousal (difficulty sleeping, concentrating, etc...)

• Avoidance of social life or place of rape• In one third, symptoms continue beyond 6 months

(post-traumatic stress disorder)

Richard et al. Treating acute stress disorder. Am J Psychiatry 156:1780, 1999

Srebrenica Genocide Stone

http://upload.wikimedia.org/wikipedia/en/c/ca/SrebrenicaStone.jpg

“…from time immemorial, rape has been regarded as spoils of war. Now it will be

considered a war crime. We want to send out a strong message that rape is no longer

a trophy of war…”

Judge Navanethem PillayInternational Criminal Tribunal for Rwanda

1998

Rape as a weapon of war

In the Name of Honor, Mukhtaran Mai, 2002Meerwala, Pakistan






violence

Sexual harassment in the work place

Sexual harassment in educational establishments

Sexual harassment in the street

Sexual harassment in public transportation

Sexual harassment• Sexual harassment has a negative

impact on women's physical and emotional health, and the more severe the harassment, the more severe the

reaction • The reactions reported by women include anxiety, depression, sleep

disturbance, weight loss or gain, loss of appetite, and headaches

• There is a link between sexual harassment and post-traumatic stress

disorder• Sexual harassment in the workplace in the European Union.

European Commission, Directorate-General for Employment, Industrial Relations and Social Affairs, 1998

• Louise F. Fitzgerald, Sexual Harassment: Violence Against Women in the Workplace, American Psychologist 48: 1070-1072, 1993






violence

Trafficking in women


1. Selling newborn babies2. Slave workers

3. Domestic workers4. Sex industry

Trafficking in babies and young girls

Trafficking in women – physical health

• Women were “intentionally hurt” since they left home. The majority of reported injuries and

illness were the result of abuse• Broken bones, contusions, pain, loss of consciousness, headaches, high fevers,

gastrointestinal problems, undiagnosed pelvic pain, complications from abortions,

dermatological problems (e.g., rashes, scabies, and lice), unhealthy weight loss, and dental and

oral health problems• Women were deprived of food, human contact, valued activities and items, and held in solitary

confinementLondon School of Hygiene & Tropical Medicine. The health risks and consequences of trafficking in women and adolescents: findings

from a European study, 2003.

Trafficking in women – reproductive health

• All women reported having been sexually abused and coerced into involuntary sexual acts, including rape, forced anal and oral sex, forced

unprotected sex, and gang rape• Gynaecological complications were the most

common• Only 20% of women knew where to go for

medical care• 25 % of women had at least one unintended

pregnancy and a subsequent abortion. One woman nearly died from complications

• Most women who worked as sex workers reported having 10 to 25 clients per night, while

some had as many as 40 to 50 • 25% of women did not use condoms regularly or

at allLondon School of Hygiene & Tropical Medicine. The health risks and consequences of trafficking in women and adolescents: findings


Trafficking in women – psychological health

• 75% of women reported having at least half of 21 negative mental health symptoms in the

questionnaire• The most common reported symptoms

were: feeling easily tired; crying more than usual; experiencing frequent headaches,

frequently feeling unhappy or sad; and feeling as though they were not as good as other

people or permanently damaged• One third of women thought of committing

suicide• Two third of women resorted to/were forced

to use drugs or alcohol (none of them had consumed alcohol in their home country)

London School of Hygiene & Tropical Medicine. The health risks and consequences of trafficking in women and adolescents: findings







violence

Mugging senior citizens

US Department of Justice. Bureau of Justice Statistics

http://www.ojp.usdoj.gov/bjs/glance/tables/vagetab.htm

Mugging senior citizens – Ingratitude at its worst






violence

Domestic violence – when home is no longer safe

Partner versus non-partner violence


Physical violence

• Slapping or throwing something that could hurt

• Pushing or shoving• Hitting with a fist or something else

thatcould hurt

• Kicking, dragging or beating up• Choking or burning on purpose

• Threatening with, or actually using a gun,

knife or other weaponWorld Health Report 2004: Changing history, WHO

2004

Sexual violence

• Being physically forced to have sexual intercourse against her will

• Having sexual intercourse because she was afraid of what her partner might do

• Being forced to do something sexual she found degrading or humiliating


Emotional violence

• Being insulted or made to feel bad about oneself

• Being humiliated or belittled in front of others

• Being intimidated or scared on purpose(for example by a partner yelling and

smashing things)• Being threatened with harm (directly orindirectly in the form of a threat to hurtsomeone the respondent cared about)

• Can be more devastating than physical abuse



Few battered women seek help

Domestic (intimate partner) violence Health consequences

• Physical health consequences• Psychological health

consequences• Public health consequences

Serious injuries(Bruises, fractures, chronic disabilities)

• Research in Cambodia found that 50% of all women reporting abuse had sustained

injuries

• Canada’s national survey on violence against women revealed that 45% of wife

assault incidents resulted in injuries, and of the injured women, 40% subsequently

visited a doctor or a nurse• Nelson E, Zimmerman C. Household survey on domestic violence in Cambodia. Ministry of Women’s Affairs, Project Against Domestic

Violence, Cambodia, 1996• Rodgers K. Wife assault: the findings of a national survey. Juristat

service bulletin, Statistics Canada, 1994, 14(9)

Homicide

Most women who die of homicide are killed by their partner or ex-partner

A study of 249 court records in Zimbabwerevealed that 59% of homicides of womenwere committed by the intimate partner

ofthe victim

Watts C, Osam S, Win E. The private is public: a study of violence against women in Southern Africa, Zimbabwe, Women in Law and

Development in Africa, 1995

Injuries during pregnancy

In a three-year study of 1203 pregnantwomen in hospitals in Houston andBoston, United States, abuse during

pregnancy was a significant risk factor for

low birth weight, low maternal weight gain,

infections and anemiaParker B, McFarlane J, Soeken K. Abuse during pregnancy: effects on maternal complications and birth weight in adult and teenage women.

Obstetricsand gynecology, 1994, 84(3):323-328.

Injuries to children

• Children in violent families may also be victims of abuse. Frequently, children

are injured while trying to defend their mothers

• In one study of abused women in Bogotá, Colombia, 49% reported that their children

had also been beaten

Berenguer A. Alternativas desde la medicina legal y experiéncias sobre la violencia intrafamiliar. In: Corporación de la Mujer. Violencia

en la Intimidad. Bogotá, Corporación de la Mujer, 1984.

Psychological health consequences

Domestic violence is a chronic and recurrent type of violence.

Wounds of the body heal sooner or later leaving only scars.

Wounds of the soul take much longer to heal, and can bleed

again any time

Fathalla M. Victimization as part of being female. In: Issues in women’s health and rights, p. 251. IPPF Press 2008.

Mental health problems

• Severe depression• Anxiety

• Post-traumatic stress disorder• Chronic fatigue

• Inability to sleep / nightmares• Eating disorders

• Use of alcohol and drugs• Becoming isolated and withdrawn

Stark E, Flitcraft A. Spouse abuse. In: Rosenburg M, Fenley M, eds. Violence in America: a public health approach. New York,

Oxford University Press, 1991.

Suicide

Research in the United States has shown that battered women, as compared to

women not living with violent men, are five times more likely to commit suicide

Stark E, Flitcraft A. Spouse abuse. In: Rosenburg M, Fenley M, eds. Violence in America: a public health approach. New York,

Oxford University Press, 1991.

Mental health problems

•In one study in León, Nicaragua, researchers

found that abused women were six times more likely to report experiencing mental

distress than non-abused women

•In the United States, women battered by their partners have been found to be

between four and five times more likely to require psychiatric treatment than non-

abused women• Ellsberg M, Peña R, Herrera A, Liljestrand J, Winkvist A. Candies in hell: women's experiences of violence in Nicaragua Soc Sci Med 51(11):1595-

610, 2000• Stark E, Flitcraft A. Spouse abuse, In: Rosenburg M, Fenley M, eds,

Violence in America: A Public Health Approach. New York, Oxford University Press, 1991.

Effects of witnessing violence on children• Children who witness domestic violence often

suffer many of the same symptoms as children who have been physically or sexually abused

themselves

• Girls who witness their father’s violent treatment of their mother are more likely to accept violence as a normal part of marriage

• Boys who have witnessed the same violence,are more likely to be violent to their partners as

adultsVung ND, Krantz G. Childhood experiences of inter-parental violence as a risk factor for intimate partner violence: a

population-based study from northern Vietnam. J Epidemiol Community Health 63(9):708-14, 2009

A study in León, Nicaragua reported thatchildren who had regularly witnessed theirmothers being hit or humiliated, comparedto other children, were at least five times

more likely to experience serious emotional

and behavioral difficulties.

Ellsberg M, et al. Confites en el infierno: prevalencia y características de la violencia conyugal hacia las mujeres en Nicaragua. Asociación

de Mujeres Profesiocales por la Democracia en el Desarrollo, Managua, 1996.

Effects of witnessing violence on children

VAW is a public health issue Added health costs

• Treating serious physical injury • Treating psychological problems• Police, courts and legal services

• Treatment programs for offenders• Social service costs

• Child protection services

One study in the United States showed that care for women

with a history of sexual or physical assault costs two and a half times as much as care for

other women

Koss M, Koss P, Woodruff J. Deleterious effects of criminal victimization on women’s health and medical utilization. Archives of internal

medicine, 1991, 151:342-347

VAW is a public health issue Added health costs

VAW is a public health issue Effects on productivity and employment

• Victims of VAW have a reduced contribution to society and to their own potential self-realization• Victims of VAW are more likely to be anxious or depressed, and unable to perform to their best

• Because of their bad experience, the world may become a threatening place where they avoid

challenges of any kind• If abused by their teachers, girls may stay away

from school• Parents, who fear that their daughters will be

sexuallyassaulted, may keep them at home until marriage

Day T. The health related costs of violence against women in Canada: the tip of the iceberg. London, Ontario, Centre of Research on Violence

Against Women and Children, 1995

VAW – Burden of disease

A World Bank report estimated that rape and

domestic violence account for about 5% of the total disease burden among women aged

15-44 in developing countries

World Bank. World development Report. Investing in health. Oxford University Press, p.50, 1993

Conclusions

Violence against women is a universal phenomenon and takes many forms. Besides being a violation of human

rights, it has far reaching medical and psychological effects on battered

women and their children and is also a community health issue. By exposing

this evil phenomenon and implementing the proper measures, we can curb it

further and maybe one day eradicate it all together

Stop Violence Against Women !

by Amril Nuryan

Bibliotheca Alexandrina

Violence against women – Health perspectives

Hassan N. Sallam, MD, FRCOG, PhD (London)

Professor in Obstetrics and GynaecologyThe University of Alexandria, and

Clinical and Scientific Director, AlexandriaFertility Center, Alexandria, Egypt

3rd Congress of Society of Reproductive Medicine, 5 – 9 October

2011, Antalya / Turkey

The Suzanne Mubarak Regional Centre for

Women's Health and Development

Rape - Acute stress disorder

Injuries of the body can heal quickly but injuries of the soul take longer to heal and can bleed again at any

time

Professor Mahmoud Fathalla, Issues in women’s health,

2008

violence against women – health perspectives hassan n. sallam, md, frcog, phd (london) professor...

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