Women's Health: Contemporary Human Rights Issues

Women’s HealthWomen’s Health
Contemporary Human Rights IssuesContemporary Human Rights Issues
Martin Donohoe, M.D., F.A.C.P.Martin Donohoe, M.D., F.A.C.P.

Violence Against WomenViolence Against Women
OverviewOverview
• DefinitionsDefinitions
• EpidemiologyEpidemiology
• Sexual Assault/RapeSexual Assault/Rape
• Sequelae of Domestic ViolenceSequelae of Domestic Violence
• Recognition and ManagementRecognition and Management
• The Developing WorldThe Developing World
– human rights abuseshuman rights abuses
– female genital cuttingfemale genital cutting

OverviewOverview
• Teen PregnancyTeen Pregnancy
• The Family/Single Motherhood/Child CareThe Family/Single Motherhood/Child Care
• Ideals of Beauty & the Historical Subjugation ofIdeals of Beauty & the Historical Subjugation of
WomenWomen
• AbortionAbortion
• ConclusionsConclusions

ObjectiveObjective
• 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 WomenDefinitions of Violence Against Women
Individual:Individual:
Any act of verbal or physical force, coercion, or life-Any act of verbal or physical force, coercion, or life-
threatening deprivation that causes physical orthreatening deprivation that causes physical or
psychological harm, humiliation, or arbitrarypsychological harm, humiliation, or arbitrary
deprivation of liberty, or that perpetuates femaledeprivation of liberty, or that perpetuates female
subordinationsubordination

Individual Violence Against WomenIndividual Violence Against Women
(examples)(examples)
• partner abusepartner abuse
• sexual assault/marital rapesexual assault/marital rape
• forced prostitutionforced prostitution
• forced noncompliance with contraceptionforced noncompliance with contraception
• female genital cuttingfemale genital cutting
• slaveryslavery
• unwanted sextingunwanted sexting

Definitions of Violence Against WomenDefinitions of Violence Against Women
Societal:Societal:
Structural forms of discrimination orStructural forms of discrimination or
deprivation that affect women as a classdeprivation that affect women as a class

Societal Violence Against WomenSocietal Violence Against Women
(examples)(examples)
• povertypoverty
• impaired access to employment or educationimpaired access to employment or education
• divorce restrictionsdivorce restrictions
• salary inequalitiessalary inequalities
• political marginalizationpolitical marginalization
• impaired access to reproductive health servicesimpaired access to reproductive health services

EpidemiologyEpidemiology
• Lifetime prevalence of assault/sexual abuseLifetime prevalence of assault/sexual abuse
– 12% of adolescent girls12% of adolescent girls
– 20% of college women20% of college women
– 20% of adult women20% of adult women
• 2 - 4 million women assaulted per year2 - 4 million women assaulted per year
• every 15 seconds a woman is beaten; every 2every 15 seconds a woman is beaten; every 2
minutes a woman is sexually assaultedminutes a woman is sexually assaulted

Epidemiology
• 5% of partner abuse is female on male5% of partner abuse is female on male
• 22% of men / 7% of women in same sex22% of men / 7% of women in same sex
partnerships report domestic violencepartnerships report domestic violence
• Discrimination against homosexuals legalDiscrimination against homosexuals legal

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

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

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

Prevalence of Domestic ViolencePrevalence of Domestic Violence
•P-careP-care
– 1/4 women abused at some point in her life1/4 women abused at some point in her life
– 1/7 women abused within preceding 121/7 women abused within preceding 12
monthsmonths
•ERER
– 1/4 of women seeking care (any reason)1/4 of women seeking care (any reason)
– 35% of women treated for trauma35% of women treated for trauma

• OB/GynOB/Gyn
– 1/6 women during pregnancy1/6 women during pregnancy
• Abortion ClinicsAbortion Clinics
– 12%12%
• PedsPeds
– 50 - 70% of mothers of abused children50 - 70% of mothers of abused children

• PsychPsych
–1/4 women who attempt suicide1/4 women who attempt suicide
–1/4 women treated for psychiatric1/4 women treated for psychiatric
symptomssymptoms
• 55% lifetime prevalence for women with55% lifetime prevalence for women with
depressiondepression

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

High Risk Occupations: ProstitutesHigh 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.

High Risk Occupations:High Risk Occupations:
ProstitutesProstitutes
• 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

Prostitution in the U.S.Prostitution in the U.S.
• 0.6% of men admit to paying for sex in the last0.6% of men admit to paying for sex in the last
yearyear
–17% at some point in their lives (actual17% at some point in their lives (actual
percentage likely higher)percentage likely higher)
• 694 “clients”/prostitute/year average694 “clients”/prostitute/year average

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

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

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

High Risk GroupsHigh Risk Groups
Runaway and Homeless YouthRunaway and Homeless Youth
• Survival sexSurvival sex
– the exchange of sex for shelter, food, drugs orthe exchange of sex for shelter, food, drugs or
moneymoney
– 28% of street youths, 10% of shelter youth (out of28% of street youths, 10% of shelter youth (out of
1 - 2 million runaway adolescents/year)1 - 2 million runaway adolescents/year)
– association with violence, victimization, STDs,association with violence, victimization, STDs,
and pregnancyand pregnancy

High Risk Groups
College 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

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

Deaths from Domestic ViolenceDeaths from Domestic Violence
• 4,000 domestic violence deaths/year4,000 domestic violence deaths/year
–over 1/2 of women murdered in U.S. are killedover 1/2 of women murdered in U.S. are killed
by a current or former partnerby a current or former partner
• 1/2 to 3/4 of the 1,000 - 1,500 murder suicides1/2 to 3/4 of the 1,000 - 1,500 murder suicides
per year involve domestic violenceper 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 ViolenceRace/SES and Domestic Violence
• Seen in all age, race, and SES bracketsSeen in all age, race, and SES brackets
• May be more common in African-American, butMay be more common in African-American, but
– confounders = lower SES, fewer resources, moreconfounders = lower SES, fewer resources, more
likely to be seen in ER or to use public shelterslikely to be seen in ER or to use public shelters
• May be more common in Latinos, butMay be more common in Latinos, but
– confounders = as aboveconfounders = as above
– However, more women hold more traditional ideasHowever, more women hold more traditional ideas
regarding spousal roles...regarding spousal roles...

Common Characteristics ofCommon Characteristics of
Abuse VictimsAbuse Victims
• low self-esteemlow self-esteem
• guiltguilt
• self-blameself-blame
• denialdenial
• traditional attitudestraditional attitudes
regarding women’s rolesregarding women’s roles
• have childrenhave children
• poor financial resourcespoor financial resources
• few job skillsfew job skills
• less educationless education
• few friendsfew friends
• history of childhoodhistory of childhood
abuseabuse

Common Characteristics
of Abusers
• low self-esteem
• dependency
• jealousy
• poor communication skills
• unemployed/underemployed

Common Characteristics
of 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

Men with Restraining OrdersMen with Restraining Orders
• 75% have criminal record75% have criminal record
• 50% have history of violent crime50% have history of violent crime
• 15% violated R.O. over 6 months15% violated R.O. over 6 months
• 30% arraigned for a violent crime over 6 months30% arraigned for a violent crime over 6 months

Child AbuseChild Abuse
• seen in 1/3 - 1/2 of families where partner abuse occursseen in 1/3 - 1/2 of families where partner abuse occurs
• in one 3 month study of 146 children who witnessedin one 3 month study of 146 children who witnessed
partner abusepartner abuse
– all sons over age 14 attempted to protect their mothersall sons over age 14 attempted to protect their mothers
– 62% were physically injured in the process62% were physically injured in the process

Children and Partner AbuseChildren and Partner Abuse
• Children witness up to 85% of episodes of partner abuseChildren witness up to 85% of episodes of partner abuse
– child abusechild abuse
• Children of abuse victims show decrements in academicChildren of abuse victims show decrements in academic
and emotional development and are more likely toand emotional development and are more likely to
become abusers themselvesbecome abusers themselves

RapeRape
• Unwanted, forced penetration (oral/vaginal/anal)Unwanted, forced penetration (oral/vaginal/anal)
• Reported by 33 -46% of women who are physicallyReported by 33 -46% of women who are physically
abusedabused
• Annual incidenceAnnual incidence ≥≥ 80/100,000 women80/100,000 women
– 7% of all violent crimes7% of all violent crimes
• Lifetime prevalence up to 25%Lifetime prevalence up to 25%
– 1/3 Native Americans/Alaskan Natives victims of1/3 Native Americans/Alaskan Natives victims of
attempted rape or rapeattempted rape or rape
– Migrants, those in war zones and refugee camps at highMigrants, those in war zones and refugee camps at high
riskrisk

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

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

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)

RapeRape
• UnderreportedUnderreported
• FBI: 5% of rape allegations unfoundedFBI: 5% of rape allegations unfounded
• Less than 1% of rapists convictedLess than 1% of rapists convicted

Rape
 34 states have statutes of limitations on filing34 states have statutes of limitations on filing
charges, ranging from 3-30 yrs (somecharges, ranging from 3-30 yrs (some
exemptions if DNA evidence identifies suspect)exemptions if DNA evidence identifies suspect)
• Large backlog of untested rape kits (someLarge backlog of untested rape kits (some
estimates as high as 500,000)estimates as high as 500,000)
 H.R. 4114 and S.B 2736 (Justice for Survivors ofH.R. 4114 and S.B 2736 (Justice for Survivors of
Sexual Assault) bills passed by Congress, awaitingSexual Assault) bills passed by Congress, awaiting
joint committee finalization (late 2016)joint committee finalization (late 2016)

Rape
• Average prison time for those convicted:Average prison time for those convicted:
– rape = 1 yearrape = 1 year
– armed robbery = 3 - 5 yearsarmed robbery = 3 - 5 years
– murder = 8 yearsmurder = 8 years
• Chemical Castration LawsChemical Castration Laws

Date RapeDate Rape
• 40% of college women report forced sexual contact,40% of college women report forced sexual contact,
attempted rape, or completed rapeattempted rape, or completed rape
– most common: ignoring victims’ protestsmost common: ignoring victims’ protests
– independent of school demographicsindependent of school demographics
− >− >25% of college males admit to using sexually coercive25% of college males admit to using sexually coercive
behaviorsbehaviors
• 2/3 of college males report engaging in unwanted2/3 of college males report engaging in unwanted
sexual intercoursesexual intercourse
– reasons: peer pressure, desire to be likedreasons: peer pressure, desire to be liked

Spousal RapeSpousal Rape
• occurs in 10 - 15% of all marriageoccurs in 10 - 15% of all marriage
• more violent, less frequently reported then non-more violent, less frequently reported then non-
spousal rapespousal rape
• not illegal in many U.S. states/other countriesnot illegal in many U.S. states/other countries

RapeRape
• 6-7% chance of pregnancy (est.6-7% chance of pregnancy (est.
25,000 pregnancies/yr in US)25,000 pregnancies/yr in US)
• 25% chance of acquiring STD25% chance of acquiring STD
–GC = 6 - 12%GC = 6 - 12%
–Chlamydia = 4 - 17%Chlamydia = 4 - 17%
–Syphillis = 0.5 - 3%Syphillis = 0.5 - 3%

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

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

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

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

Physical Examination of
Sexual 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

Physical Examination of
Sexual 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

Prophylaxis for Adult Victims of
Sexual Assault
Antibiotic 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)

Sexual Assault
Prevention 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%)

Sexual Assault
• Alternate regimen: 2 doses of 100 mcg ethinyl
estradiol plus 0.5 mg levonorgestrel taken 12
hours apart (plus prn antiemetic)
– Less effective than ulipristal and levonorgestrel
• Most effective: copper IUD implanted within 5
days
– Nearly 100% effective
– Preferred for obese women

Sexual Assault
• Clinical exam/pregnancy testing not required
before EC
• Women with contraindications to conventional
oral contraceptives may receive any EC regimen
• Even within the same menstrual cycle, EC can
be used more than once

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

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.

Changing Limits on Availability of
Emergency Contraception
• Laws in Arkansas, Mississippi, Georgia, and
South Dakota explicitly protect pharmacists who
refuse to dispense EC
• Other states are considering similar legislation
• Military clinics not required to stock EC
• 2013: OTC EC for all children of childbearing
age allowed by federal judge

Prophylaxis for Adult Victims ofProphylaxis for Adult Victims of
Sexual AssaultSexual 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 WomenHow We View Women
• MontanaMontana
– 2nd violation of animal abuse statute2nd violation of animal abuse statute
• $1,000 fine + 2 years in jail$1,000 fine + 2 years in jail
– 2nd violation spousal abuse2nd violation spousal abuse
• $500 + 6 months in jail$500 + 6 months in jail

U.S. Public Funding for Research andU.S. Public Funding for Research and
Prevention (2013)Prevention (2013)

Sexual Crimes Against Children
• 81,000 children sexually abused per year in US
• 93% committed by family member or someone
known to victim
• Child stranger abductions very rare, despite
widespread media coverage

Registered Sex Offenders
• 650,000 in US
– Covers child molesters, possession of child pornography,
solicitation of prostitution, exhibitionism and indecent
exposure, voyeurism)
– In certain jurisdictions also includes anal and oral sex and
consensual sex between juveniles or between young adults
and juvenilles
– The least likely class of criminals to re-offend (3.5%
recidivism rate within 3 years, recidivism rare after 5 years)

Factors That Perpetuate
Gender-Based Violence
From Soc Sci Med 1994; 39:1165-79

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
• Menstrual hygiene management, shaming

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

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

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

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)
–hold 20% of legislative seats
–receive 10% of global income
–own 1% of global property

The Bad News
• Women make up 45% of the employed
global workforce, yet account for 70% of
the world’s poor
• More patriarchal societies have higher
mortality rates for men

The Bad News
• Women in the U.S. working full-time make $0.77 -
$0.81/$1.00 males
– Those in unions have higher salaries, better benefits
– Part-time salary balanced $1.04/$1.00
– More than ½ of working mothers get no paid sick
leave (some localities passing laws to change this)

The Bad News
• Women comprise 51% of college graduates,
make up 46% of the U.S. workforce, but hold
only 5% of CEO positions and less than 20% of
corporate director positions in Fortune 500
companies

Economic Gender Disparities:Economic Gender Disparities:
The Bad NewsThe Bad News
• M→F sex change: wages decrease; F→M sex
change: wages increase slightly
• 2012: IA Supreme Court rules no sex
discrimination in case of woman fired for being
“irresistible” to her boss
• Protections to allow reasonable accommodations
for pregnant women lacking in most states

Gender Disparities:
The Bad News
• Women account for 22% of legislators
worldwide (19% in U.S.)
– U.S. ranks 72nd
in gender equity/65th
in gender
pay gap out of 188 countries with national
parliaments
• 2012: IA Supreme Court rules no sex discrimination in
case of woman fired for being “irresistible” to her boss

Economic Gender DisparitiesEconomic Gender Disparities
• 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
have to lodge a formal complaint within 180 days of the
initial discriminatory paycheck – Supreme Court
upholds this requirement
• Lilly Ledbetter Fair Pay Restoration Act of 2009: Now
complaint can be filed within 180 of most recent
paycheck

Health Insurance (pre-PPACA)Health Insurance (pre-PPACA)
• Gender rating in 38 states allows insurance companies to charge
men and women different rates for the same coverage
• Maternity care often excluded
– 11 states had no private plans that came with maternity
coverage
– Women pay for additional coverage, which amounts to a few
thousand dollars, vs. $7000, the average cost of an
uncomplicated birth

Health Insurance (pre-PPACA)
• C/S can cause rejection of coverage unless woman is
subsequently sterilized
• Survivors of domestic violence can be rejected in eight
states
• Rape victims with PTSD may be denied coverage (pre-
existing condition)
• Rape victims on prophylactic HIV medication could be
denied life insurance coverage

Health Insurance (post-PPACA)
• No pre-existing conditions
• Eliminates gender rating and other forms of
health insurance discrimination
• Maternity care covered
• Some preventive care covered

Health Insurance (post-PPACA)
• PPACA (ObamaCare) requires insurers to
pay full cost of contraception (including EC)
–But SCOTUS allows religious exceptions
in Hobby Lobby case (2014), citing
Religious Freedom Restoration Act of
1993

The Good News (U.S.)The Good News (U.S.)
• More women than men graduating from collegeMore women than men graduating from college
• Number of female-owned business increasingNumber of female-owned business increasing
dramatically (30% of companies in 2015)dramatically (30% of companies in 2015)
• Workforce now 50% womenWorkforce now 50% women
• Women make 85% of buying decisions or are theWomen make 85% of buying decisions or are the
“chief purchasing officers” of their households“chief purchasing officers” of their households

The Good News (U.S.)The Good News (U.S.)
• Fastest growing fields:Fastest growing fields:
– ConstructionConstruction
– Wholesale tradeWholesale trade
– TransportationTransportation
– CommunicationsCommunications
– AgricultureAgriculture
– ManufacturingManufacturing

Gender Disparities:
Mixed News (U.S.)
• High school sports
–1/3 of girls participate (vs. 1/27 in 1971)
–But 90% of women’s college sports
teams were coached by women when
Title IX enacted (1972); 2007 - 42%

Gender Disparities in Medicine and
Science
• Women hold < ¼ jobs in STEM fields (science,
technology, engineering, and math)
• Women = 1/2 of medical school applicants, 1/2
of medical students, almost 1/2 of residents, and
1/3 of physician workforce
• Women under-represented in academic
medicine, lower ranked

Gender Disparities in Medicine
• Female physicians’ salaries 40% below those of male
physicians (2011)
– Multifactorial (e.g., women work 18% fewer hours
than men, have fewer years of experience, etc.)
– Salaries 13,399 lower for researchers of equivalent
academic rank (2011)
• 8% lower in 2016 (after adjustment for age, yrs of
experience, specialty, reported work hours, and faculty
rank)

Sexual HarassmentSexual Harassment
• quid pro quoquid pro quo
• hostile environmenthostile environment
• 15,500 cases filed/year (15,500 cases filed/year (↓↓ from 6,900 in 1990)from 6,900 in 1990)
• Civil Rights ActCivil Rights Act
–prohibits discrimination based on race and sex,prohibits discrimination based on race and sex,
but not sexual orientationbut not sexual orientation

Gender-Based and Sexual Harassment
Among U.S. Women Physicians
•4,501 respondents (59% response rate)4,501 respondents (59% response rate)
•47.7% gender-based harassment47.7% gender-based harassment
•36.9 sexual harassment36.9 sexual harassment
Arch Int Med 1998;Arch Int Med 1998;
158:352-8158:352-8

Gender-Based and Sexual Harassment
Among U.S. Women Physicians
• med schoolmed school >> internship + residencyinternship + residency >> practicepractice
• higher rates among those younger, divorced orhigher rates among those younger, divorced or
separated, in historically male specialtiesseparated, in historically male specialties
• lower rates among Asians, those satisfied with theirlower rates among Asians, those satisfied with their
careers, those in government jobs, and the politicallycareers, those in government jobs, and the politically
very conservativevery conservative
Arch Int Med 1998; 158:352-8Arch Int Med 1998; 158:352-8

Gender-Based and Sexual Harassment Among
U.S. Female Clinician-Researchers
• 30% women
• 4% men
• JAMA 2016:315(19):2120-1

Pornography
• Multi-billion dollar adult entertainment business
– Internet, magazines, movies, clubs, etc.
– 2012: LA (home to 80% of the industry)
becomes first city to mandate that porn actors
wear condoms
• Porn actors already regularly tested for STDs

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.)

Pornography
• Revenge porn illegal in 31 states
• Excessive pornography exposure can lead to
abnormal ideas regarding normal sexual
intimacy, desensitization, and erectile
dysfunction

Risk factors which make males
susceptible to the “dark side” of porn
• Dysfunctional early home life
• Delinquent of antisocial behavior or friends
• A promiscuous attitude which views sex as more
of a sport than as part of an intimate relationship

Risk factors which make males susceptible to
the “dark side” of porn
• “Hostile masculinity”
– Narcissistic personality
– Hostility against women
– Turned on by power over women

Health Consequences of ViolenceHealth Consequences of Violence
Against WomenAgainst Women
Physical SequelaePhysical Sequelae
• trauma: bruises, fractures, lacerationstrauma: bruises, fractures, lacerations
• chronic pain: headaches, AP, pelvic pain, myalgias,chronic pain: headaches, AP, pelvic pain, myalgias,
LBP, CPLBP, CP
• Hyperventilation SyndromeHyperventilation Syndrome
• Eating and sleeping disordersEating 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
– Over 3-fold higher risk of being diagnosed with an STD

Against Women
Physical Sequelae
• Delayed risk of obesity, HTN, hyperlipidemia,
arthritis, asthma, stroke, heart disease, fibromyalgia,
psychogenic seizures
• IBS
– symptom severity correlates with severity and
duration of abuse
• GERD
• Other functional GI disorders

Psychological Sequelae - EarlyPsychological Sequelae - Early
• withdrawalwithdrawal
• confusionconfusion
• psychological numbingpsychological numbing
• sense ofsense of
vulnerability/hopelessness/vulnerability/hopelessness/
loss/betrayalloss/betrayal
• shockshock
• denialdenial
• distrust of othersdistrust of others

Psychological Sequelae - Long TermPsychological Sequelae - Long Term
• depressiondepression
• anxiety disordersanxiety disorders
• phobiasphobias
• anorexia/bulimiaanorexia/bulimia
• substance abusesubstance abuse

Psychological Sequelae - Long TermPsychological Sequelae - Long Term
• PMDDPMDD
• PTSD (nightmares/hypervigilance/etc.)PTSD (nightmares/hypervigilance/etc.)
• Fivefold increased risk of developing a psychiatricFivefold increased risk of developing a psychiatric
disorderdisorder
• 10% of domestic violence victims attempt suicide10% of domestic violence victims attempt suicide
• possible recurrence of symptoms in later, healthypossible recurrence of symptoms in later, healthy
relationshipsrelationships

Against Women
• Interference with health care
• Delayed health care
• Higher hospitalization costs (for 3
years post-violence, then return to
baseline)

Response to RapeResponse to Rape
• Initial:Initial:
– unnaturally calm/detached ORunnaturally calm/detached OR
crying/angrycrying/angry
• Denial phaseDenial phase
– approx. 2 monthsapprox. 2 months
• Increasing psychological symptoms overIncreasing psychological symptoms over
several monthsseveral months
• Gradual psychological healingGradual psychological healing

Recognition and Management ofRecognition and Management of
Domestic ViolenceDomestic Violence
• Routine, repeated assessments in all settings (ER, clinic,Routine, repeated assessments in all settings (ER, clinic,
wards)wards)
• Maintain supportive, nonjudgmental attitude; avoidMaintain supportive, nonjudgmental attitude; avoid
victim-blamingvictim-blaming
• Validate the woman’s experiences, building on herValidate the woman’s experiences, building on her
strengths, transfer power and control to herstrengths, transfer power and control to her
• Be available, provide frequent followupBe available, provide frequent followup
• Involve social workInvolve social work

Recognition and ManagementRecognition 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 PCPsScreening Practices of PCPs
• Screening new patientsScreening new patients
–OB/Gyns - 17%OB/Gyns - 17%
–Internists - 6%Internists - 6%
–Physicians practicing in HMOs - 1%Physicians practicing in HMOs - 1%
–Physicians practicing in public clinics -Physicians practicing in public clinics -
37%37%
–no difference by sexno difference by sex

Screening (2011):
Percent of Women Ages 18-44 Who Have
Discussed with Their Provider
• Sexual history: 38%
• STDs: 28%
• HIV: 29%
• Domestic/dating violence: 15%
• 35%/36% have been tested for an STD/HIV in
last 2 years, but 35%/54% assumed such testing
was a routine part of the clinical exam

Assess Patient for AcutelyAssess Patient for Acutely
Increased DangerIncreased Danger
• AbuserAbuser
– criminal recordcriminal record
– alcohol/substance abuse problemalcohol/substance abuse problem
– gambling problemgambling problem
– psychiatric disorderpsychiatric disorder
• Situational TriggerSituational Trigger
– job lossjob loss
– death in familydeath in family

Assess for Acutely Increased DangerAssess for Acutely Increased Danger
• Nature of AbuseNature of Abuse
– increased severity and frequency of beatingsincreased severity and frequency of beatings
– escalation in threatsescalation in threats
– stalkingstalking
– violent or forced sexviolent or forced sex
– destruction of propertydestruction of property

Ensure Victim’s SafetyEnsure Victim’s Safety
• Social worker involvementSocial worker involvement
• Restraining orderRestraining order
• Phone numbers of shelters, hotlinesPhone numbers of shelters, hotlines
• Safe place to goSafe place to go

Domestic Violence Shelters
• Availability poor
–up to 70 - 80% of women and 80% of
children turned away on any given night
–4 times as many animal shelters as
domestic violence shelters in U.S.

Domestic Violence Shelters
• 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 RecognizePhysician Failure to Recognize
• Fear of offendingFear of offending
• feelings of powerlessnessfeelings of powerlessness
• time constraintstime constraints
–Pandora’s BoxPandora’s Box
• low confidence in ability to affect changelow confidence in ability to affect change
• sense of own vulnerabilitysense of own vulnerability
• deficits in education and trainingdeficits in education and training

Physician Failure to Recognize
Violence Against Women
•Doctors underestimate the prevalence of domesticDoctors underestimate the prevalence of domestic
violence in their patients/communitiesviolence in their patients/communities
– similar to teen sexual activitysimilar to teen sexual activity
•Female MDs may be better than male MDs in detectingFemale MDs may be better than male MDs in detecting
domestic violence and in taking a more thoroughdomestic violence and in taking a more thorough
historyhistory

in The Developing World
• verbal, physical, and sexual abuseverbal, physical, and sexual abuse
– 4 witnesses required for rape conviction in Pakistan4 witnesses required for rape conviction in Pakistan
• dowry-related murderdowry-related murder
• bride-burningbride-burning
• forced abortion and sterilizationforced abortion and sterilization
• divorce restrictionsdivorce restrictions
• forced prostitutionforced prostitution
• child prostitutionchild prostitution

• Selective abortion, malnutrition or killing of
female children
– Normal M:F ratio = 105:100
– In China = 118:100
– China’s one child policy abandoned in 2016
(after 35 yrs)

• suicide as “vengeance” against an abusive
spouse
• post-rape suicide (or homicide)
–to “cleanse family honor”
–47% of homicides in Alexandria, Egypt

• Selective abortion, malnutrition or killing of female
children
– Normal M:F ratio = 106:100
– In China = 118:100
• suicide as “vengeance” against an abusive spouse
• post-rape suicide (or homicide)
– to “cleanse family honor”
– 47% of homicides in Alexandria, Egypt

Female Genital CuttingFemale Genital Cutting
• See separate slide show on phsj website,See separate slide show on phsj website,
Women’s Health pageWomen’s Health page

PolygamyPolygamy
• Utah outlawed “plural marriage” in 1890 inUtah outlawed “plural marriage” in 1890 in
exchange for statehoodexchange for statehood
• Not one prosecution in the last 50 yearsNot one prosecution in the last 50 years
• EPA Administrator (and former Utah governor)EPA Administrator (and former Utah governor)
Mike Leavitt (a Mormon descended from aMike Leavitt (a Mormon descended from a
polygamous family) declared constitutional underpolygamous family) declared constitutional under
the U.S. Constitution freedom of speech/religionthe U.S. Constitution freedom of speech/religion
guarantee (it is not)guarantee (it is not)

PolygamyPolygamy
Related OffensesRelated Offenses
• welfare fraud by sister wives claiming singlewelfare fraud by sister wives claiming single
motherhoodmotherhood
• lapses in medication attention (including lack of prenatallapses in medication attention (including lack of prenatal
care)care)
• incest and underage sexincest and underage sex
– girls age 10 forced into marriagegirls age 10 forced into marriage
• women existing in limbowomen existing in limbo
– no birth certificates, drivers’ licenses, or voterno birth certificates, drivers’ licenses, or voter
registrationregistration

Covenant MarriagesCovenant Marriages
• Can be dissolved only in the case ofCan be dissolved only in the case of
infidelity, abuse or felony convictioninfidelity, abuse or felony conviction
• Offered since 1997 in Louisiana andOffered since 1997 in Louisiana and
ArkansasArkansas
–similar measures introduced in 17 othersimilar measures introduced in 17 other
statesstates

Rape in WarRape 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
• 2013 WHO report: 30% of women
worldwide have been victims of IPV
• Worldwide, 289,000 women die from
childbirth complications each year

• Almost ¼ of Asian man admit to having committed rape
– 73% felt “sexually entitled,” 59% were “seeking
entertainment,” and 38% were “punishing someone”
– 55% felt guilty
– 23% served prison time
• Almost ½ of Asian men have committed some type of
IPV

• 80% of refugees and internally-displaced persons
worldwide are female
• Indian rape epidemic – one rape every 22 minutes
(2012)
– Only 1.2%/0.1% of Indian victims of gender-based
violence report to police/health care personnel
• vs. 2.6%/1.1% in Africa

International IssuesInternational Issues
AfghanistanAfghanistan
• Taliban militia took over in 1996Taliban militia took over in 1996
• Human rights abusesHuman rights abuses
– gender-based violencegender-based violence
– women denied access to education and health carewomen denied access to education and health care
– female employment rate decreased from 62% to 12%female employment rate decreased from 62% to 12%
• Maternal mortality among world’s highestMaternal mortality among world’s highest
• Only minor changes since US invasion – most ofOnly minor changes since US invasion – most of
country still controlled by Taliban, poppy trade strongcountry still controlled by Taliban, poppy trade strong

South Africa’s Rape EpidemicSouth Africa’s Rape Epidemic
• Official Rape Rate 104/100,000 people (vs. 34.4/100,000Official Rape Rate 104/100,000 people (vs. 34.4/100,000
in the U.S.)in the U.S.)
– highest rate in the worldhighest rate in the world
– 1 rape/23 s1 rape/23 s
– ¼ South African men say they have committed rape¼ South African men say they have committed rape
• Official annual total = 50,000, but est. only 1/35 reportedOfficial annual total = 50,000, but est. only 1/35 reported
• New latex vaginal insert that latches onto a rapist’s penisNew latex vaginal insert that latches onto a rapist’s penis
and requires surgical removal available for 35and requires surgical removal available for 35¢¢

South Africa’s Rape EpidemicSouth Africa’s Rape Epidemic
• HIV riskHIV risk
–in Johannesburg, 40% of men agedin Johannesburg, 40% of men aged
20 - 29 are HIV+20 - 29 are HIV+
–post-rape antiretroviral drugs are notpost-rape antiretroviral drugs are not
available in government hospitalsavailable in government hospitals

Other International Issues
• 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
– Sex initiation camps in Malawi

Trafficking
• Occurs in 124 countries and all 50 U.S.
states
• 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

Child Marriage
• Marriage before age 18
• Affects 60 million women worldwide
• Half occur in south Asia

Child Marriage
• Associated with no contraceptive use before first
childbirth, high fertility, multiple unwanted
pregnancies, pregnancy termination, and female
sterilization
• A human rights violation

Education of Girls and Women
• Improvements in length and quality of
education lead to:
–Fewer children
–Increased earning power
–Decreased victimization

Legal approaches
• Mandatory reporting
– History of mandatory reporting (child and
elder abuse)
– Benefits
– Risks
– Effectiveness

Legal approaches
• 1994 Violence Against Women Act
– New laws, enforcement mechanisms
– 2013: Expanded to cover gays, immigrants, Native
Americans, and sex-trafficking victims
• 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

Teenage Sexual Activity
• 46% of teenage boys and girls have had sexual
intercourse (decreasing)
• Teen birth rate (2013) = 27/1,000/yr
– Lowest since mid 1940s
– Down from high of 96/1,000/yr in 1957)
– Hispanics and African-Americans = 2X higher
than Whites = 2X higher than Asians

Teen Pregnancy
• 80% of teen pregnancies unintended
• Teen pregnancy has decreased 57% since
1991
–But still higher than in many other
developed countries

Teen PregnancyTeen Pregnancy
• U.S. rates 3 - 10x higher than among the industrializedU.S. rates 3 - 10x higher than among the industrialized
nations of Western Europenations of Western Europe
– teen poverty rates higher by a similar magnitudeteen poverty rates higher by a similar magnitude
• 6/7 U.S. teen births are to the 40% of U.S. girls living at6/7 U.S. teen births are to the 40% of U.S. girls living at
or below the poverty levelor below the poverty level
• 2/3 of teen mothers were raped or abused as children2/3 of teen mothers were raped or abused as children

Teen PregnancyTeen Pregnancy
The Role of Adult MalesThe Role of Adult Males
• 71% of teen pregnancies in California in 199371% of teen pregnancies in California in 1993
fathered by adult men (avg. age 22.6 years, or 5 yearsfathered by adult men (avg. age 22.6 years, or 5 years
older than the mothers)older than the mothers)
– more births fathered by men over 25 than boysmore births fathered by men over 25 than boys
under 18under 18
• STD and AIDS rates among teenage girls 2 - 4xSTD and AIDS rates among teenage girls 2 - 4x
higher than among age-matched teenage boyshigher than among age-matched teenage boys
– closer to adult male ratescloser to adult male rates

Statutory Rape
• Underage girls/adult perpetrators or boyfriendsUnderage girls/adult perpetrators or boyfriends
• States evenly split on mandated reportingStates evenly split on mandated reporting
• 66% of providers do not routinely report66% of providers do not routinely report
– reasons including lack of confidence in criminalreasons including lack of confidence in criminal
justice system, confidentiality, deterring health carejustice system, confidentiality, deterring health care
and social services follow-up, risk of physicaland social services follow-up, risk of physical
retaliationretaliation

• 50% of pregnant teens were not using any form
of contraception
– 31% of these did not believe they could get
pregnant
• Contraception use among teens increasing
– 80% condom with first intercourse
• 16% in combination with hormonal method

• STD rates high, testing/treatment/followup poor,
long-term risks include PID, infertility
• HPV vaccine uptake low, despite effectiveness
– No increased sexual activity with HPV
• Inadequate sex education and limited access to
reproductive health care likely increases
morbidity, mortality

Teen Pregnancy: Worrisome TrendsTeen Pregnancy: Worrisome Trends
• 1996 “Welfare Reform” Legislation:1996 “Welfare Reform” Legislation:
– 50 million over 5 years allocated to states to teach50 million over 5 years allocated to states to teach
abstinenceabstinence
– By 2008, annual abstinence-only budget $178By 2008, annual abstinence-only budget $178
million (vs. 0% for comprehensive sex ed); Obamamillion (vs. 0% for comprehensive sex ed); Obama
eliminated program in 2009eliminated program in 2009
– 1988 – 2% of US school districts relied on1988 – 2% of US school districts relied on
abstinence-only educationabstinence-only education
– 1999 – 23%1999 – 23%

Teen Pregnancy: Worrisome TrendsTeen Pregnancy: Worrisome Trends
• Parental notification laws - consequences:Parental notification laws - consequences:
– increased 2nd trimester abortionsincreased 2nd trimester abortions
– increased abortions in neighboring statesincreased abortions in neighboring states

Single MotherhoodSingle Motherhood
• Over 50% of children in solo-mother families liveOver 50% of children in solo-mother families live
below the poverty linebelow the poverty line
• 21% of U.S. children live in solo-mother families21% of U.S. children live in solo-mother families
• Of white children born since 1980, 50% will spendOf white children born since 1980, 50% will spend
some part of their childhood in a single parent familysome part of their childhood in a single parent family
– 80% for African-American children80% for African-American children
• On average, children from divorced or single parentOn average, children from divorced or single parent
families show poorer school performance,families show poorer school performance, ↑↑ risk of teenrisk of teen
pregnancy,pregnancy, ↑↑ rates of delinquency, andrates of delinquency, and ↓↓ mental healthmental health

The American FamilyThe American Family
• The U.S. is the only industrialized country withoutThe U.S. is the only industrialized country without
guaranteed paid maternity leave and health benefitsguaranteed paid maternity leave and health benefits
guaranteed by lawguaranteed by law
– Exceptions: CA and NJ provide up to 6 wks paidExceptions: CA and NJ provide up to 6 wks paid
parental leaveparental leave
• Lack of paid maternity leave linked to lower rates ofLack of paid maternity leave linked to lower rates of
breastfeeding and childhood immunizations, higherbreastfeeding and childhood immunizations, higher
rates of infant and child mortality, and higher rates ofrates of infant and child mortality, and higher rates of
maternal depressionmaternal depression

The American FamilyThe American Family
• The Family and Medical Leave Act (1993)The Family and Medical Leave Act (1993)
guarantees only unpaid leave and only toguarantees only unpaid leave and only to
individuals working in establishmentsindividuals working in establishments
employing at least 50 workersemploying at least 50 workers
– disproportionately excludes low-wage workersdisproportionately excludes low-wage workers
– only 60% of working women eligibleonly 60% of working women eligible

Child CareChild Care
• 50% of mothers of preschoolers and 70% of mothers of50% of mothers of preschoolers and 70% of mothers of
school age children work outside the homeschool age children work outside the home
• 1/2 of children of working mothers cared for by relatives1/2 of children of working mothers cared for by relatives
– 3/8 in family day care ($40 - 100/week)3/8 in family day care ($40 - 100/week)
– 1/8 in day care centers ($70 - 150/week)1/8 in day care centers ($70 - 150/week)
– poorly regulated, higher worker turnoverpoorly regulated, higher worker turnover

Long-Term Care
• Caregivers typically unpaid spouses and
adult daughters
• Caregiving valued at between $234 billion
(CBO, 2011) - $470 billion (AARP, 2013)
• Long-term insurance increasingly
expensive, providers leaving market

Historical Subjugation of WomenHistorical Subjugation of Women
• Burning at the stakeBurning at the stake
• The Chamberlain family and obstetrical forcepsThe Chamberlain family and obstetrical forceps
• J. Marion Sims and operative gynecologyJ. Marion Sims and operative gynecology
– trials on slaves without anesthesiatrials on slaves without anesthesia
• Contrast with slightly delayed use of chloroform forContrast with slightly delayed use of chloroform for
obstetrical anesthesiaobstetrical anesthesia
– discovered by James Young Simpson, 1847discovered by James Young Simpson, 1847
– Queen Victoria, Charles Darwin, and Charles DickensQueen Victoria, Charles Darwin, and Charles Dickens
used/encouragedused/encouraged

Perinatal Shackling of Prisoners
• Mostly for those convicted of drug crimes
• Still permissible for 2/3 of female inmates,
despite federal and state directives and laws to
eliminate
• Applied more frequently to poor and to racial
and ethnic minorities

Pregnant Inmates:
A High-Risk Obstetrical Population
• 31 states allow the shackling of female prisoners while they are
giving birth
– Despite state and federal regulations designed to limit practice
• Some states considering legislation to limit
– Detainees of Immigration and Customs Enforcement (ICE)
exempt from prohibitions
– ACOG, AMA, APHA, ABA (“except in extraordinary
circumstances”), UN, Amnesty International oppose

Pregnant Inmates:
A High-Risk Obstetrical Population
• Shackling pregnant inmates
–Risk for falls, difficulty with giving birth
(risks to mother and newborn), difficulty
with bonding and breast feeding
–Dehumanizing, cruel and unusual
punishment

ConclusionsConclusions
• Awareness of scope of problem of violenceAwareness of scope of problem of violence
against womenagainst women
• Screen regularly and repeatedly; document;Screen regularly and repeatedly; document;
treat; supporttreat; support
– Screening reduces IPV, improves health outcomes
• Support women’s rights issues, which are healthSupport women’s rights issues, which are health
care issuescare issues

Contact Information
Public Health and Social Justice Website
http://www.phsj.org
martindonohoe@phsj.org

Women's Health: Contemporary Human Rights Issues

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