Violence and Human Rights Abuses Against Women in the Developing World

Martin Donohoe, MD, FACP

Disclosures

November 26, 2003

Over the past decade, there has been an increasing focus in American medicine and public health on identifying victims of domestic violence and preventing intimate partner violence. However, much less attention has been focused on the problem of individual and societal violence against women in the developing world.[1] This first essay for the column "Women's Health in Context" focuses on individual violence against women and girls in the developing world. Future issues will examine some of the societal forces that subjugate and marginalize women in the United States and abroad and that sustain a milieu in which high levels of interpersonal violence are tolerated or accepted.

Women worldwide suffer verbal, emotional, physical, and sexual abuse, along with their sequelae, such as traumatic injuries, sexually transmitted diseases, chronic pain, eating and sleeping disorders, other psychiatric conditions, and alcohol and drug abuse. Globally, it has been estimated that 1 woman in 3 has been beaten, forced into sex, or otherwise abused in her lifetime.[2] In many nations today, women are still considered their husband's property, wife-beating is justifiable, and spousal rape is legal. Because of the limited availability of healthcare and the lack of social support services for women and their children (eg, Mexico City, the fourth most heavily populated city in the world, had only 1 domestic violence shelter as recently as 1996[3]), many women suffer in silence, both physically and emotionally. Social forces serve to limit victims' access to safe spaces and, simultaneously, perpetuate intimate partner violence. These forces include excess poverty, impaired access to employment and education, divorce restrictions, salary inequalities, political and legal marginalization, and limited access to reproductive health services.[1,2,4]

Types of individual violence against women seen more frequently in the developing world than in the United States include dowry-related murder (sometimes in response to an "insultingly low" bride price), bride burning (in which the wife is voluntarily or forcibly immolated so that she can accompany her mate to the afterlife), honor killings (In some countries, particularly in the Middle East and parts of South Asia, women who bring dishonor to their families because of sexual indiscretions may be beaten or killed by a male family member) forced abortion and sterilization, forced prostitution, and child prostitution and sex slavery.[1,2,5,6] Selective abortion, malnutrition, and killing of female infants are common and may account for the excess of male to female births in China and for higher infant mortality rates among girls in numerous poorer nations.[7] A future issue of this column will address female genital mutilation, also (incorrectly) referred to as female "circumcision."

In Sub-Saharan Africa, Turkey, and some Middle Eastern countries, girls and young women undergo "virginity exams," which evaluate intactness of the hymen, a notoriously unscientific and inaccurate method of determining whether or not one has had sexual intercourse.[8] Physicians occasionally conduct these exams. Those girls and women who "fail" are considered impure and are ostracized by their families and communities; their chances for marriage plummet. They often turn to prostitution for economic survival. On the other hand, those "passing" may be vulnerable to unwanted sexual advances. Local myth in some parts of Sub-Saharan Africa, for example, promotes the idea that sexual intercourse with a virgin can cure AIDS in an HIV-infected man.[9] Given rates of HIV infection as high as 40%, the extremely limited availability of antiretroviral medications, and the extremely high rape rates (eg, South Africa currently has the highest rape rate in the world -- 1 million women and children are raped annually[9,10]), this belief has been a death sentence for babies, girls, and young women in this region.[9]

Between 1 and 2 million women and girls are trafficked annually around the world for the purposes of forced labor, prostitution, and involuntary marriage.[11] In Southeast Asia, many young girls leave their rural homes for the cities, lured by the promise of moderate wage jobs that may allow them to support themselves and their families. Finding few such options available, and having inadequate economic and social support, many turn to prostitution. Their customers are not only locals but well-to-do foreigners, including Americans and Europeans on international sex tours. Laws against child abuse and child prostitution are weak, and when present, often ignored. In addition, a recent article highlights the difficult situation that organizations find themselves in their efforts to "rescue" prostitutes.[12] Organizations have been criticized for "saving" prostitutes against their will -- usually by the sex workers themselves, who either feel that they have been "ruined" by prostitution and as a result cannot envision any other life or realize that there is no economically viable alternative outside the brothels that will enable them to support themselves and their families.

A common consequence of rape and prostitution is unwanted pregnancy, especially in places where condoms and other forms of birth control are not available or are too expensive. As such, many women turn to abortion. Worldwide, there are 36 to 53 million abortions performed per year.[13] Abortion on request is permitted in only 22% of all countries and in only 6% of those in the developing world. One third of developing countries either prohibit abortion or allow it only in cases of rape or incest or to save the mother's life. Seventy thousand women (8 per hour) die annually from abortions (13% of all maternal deaths).[14] A lack of contraceptive services and impaired access to abortion lead many desperate women to choose self-induced or other unsafe pregnancy termination options. In Latin America, one quarter to one half of maternal deaths are due to unsafe abortions.[14] Worldwide, for every single abortion death, there are 30 infections or injuries.[14] Many more women suffer and die as a result of inadequate prenatal and perinatal care. A recent report from the World Health Organization, the UNICEF children's agency, and the U.N. Population Fund states that women in Sub-Saharan Africa are 175 times more likely to die from complications in pregnancy and childbirth than women in rich countries; in Africa at large, 1 in 16 women do not survive a pregnancy.[15]

In 2001, the Bush Administration reinstituted the "global gag rule," which blocks foreign nongovernmental organizations (NGOs) that receive US family planning assistance from performing abortions, except in cases of rape, incest, or a threat to the woman's life; from providing counseling or referral for abortions; and from advocating for safe and legal abortion in their respective countries.[16] This policy has hampered the efforts of NGOs to provide not only pregnancy terminations, but also contraceptive and anti-HIV services, and has undoubtedly led to an increase in the numbers of unsafe abortions and HIV-infected individuals. The Catholic Church's ongoing, unscientific renunciation of condoms further exacerbates the problems of unwanted pregnancies and sexually transmitted diseases, including HIV.[17]

Physicians in the United States and the rest of the developed world must educate themselves regarding the effects of violence against women in their own countries and internationally. Some doctors will work overseas; many others will see immigrant patients, whose histories of abuse, if not addressed, will have profound, negative effects on their long-term physical and mental health. Given their privileged position in society, doctors should advocate individually and collectively (through national and international organizations) for equal rights for women, tougher laws (and enforcement of existing laws) against abusers, social services to protect victims and their children, and enhanced access to employment, education, and reproductive health services for women of all ages.

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