Domestic Violence

Minority Women's Health Cultural Issues

Race and Ethnicity in America

Eating Disorders: Anorexia and Bulimia

Reproductive Health

Based on lecture by:

Alexandra Okun, Ph.D. and former battered patient

• Physical violence against women estimated to be 4 million per year
• A woman is battered every 9 seconds in the United States
• 95% of assaults of intimate partners committed by men against women
• usually boyfriend, husband, former partner
• cuts across all social and economic groups
• battering is the leading cause of injury of women, exceeding combined incidence of rapes, muggings, and aut accidents
• 30% of women in 1 study presenting with injuries to an emergency room had injuries caused by battering
• 42% of murdered women are killed by their intimate male partners
• at highest risk when trying to leave

Tension-building phase

Incident phase

Honeymoon phase

• multiple or bilateral injuries
• delay of help-seeking
• forced sexual encounter
• severity of injury
• behavioral cues
• obstetrics/gynecology
• trauma history
• suicide attempts
• inconsistent description of injuries
• vage and non-specific injuries

For strategies for the treatment and prevention of sexual assault:

http://www.ama-assn.org/public/assault/sa-guide.htm

[The lecturer prefaced her remarks by stating much of what she would cover, students already knew. She avoided the detailed presentation of facts in favor of a more "broad stroke" approach, using anecdotes to illustrate her general remarks.]

• Higher mortality and morbidity from a wide array of diseases higher in minority women, e.g., heart disease, cancer, infant mortality.
• Editorial note: a dramatic example lies in the seroprevalence of HIV by race and gender:

• Impaired access to health care, attitudes toward health care providers and systems, reaction to illness, and difficulty in cross-cultural communication/language may inhibit effective treatment.
• Abstract: "The three leading causes of death in African Americans: barriers to reducing excess disparity and to improving health behaviors." Feldman RH; Fulwood R, J Health Care Poor Underserved, 10(1):45-71 1999 Feb

Health care is a means to an end, not a lifestyle e.g., preventive medicine.

Home remedies maybe used prior to accessing healthcare

Propensity to avoid invasive procedures

Women are the primary child-care givers

Woman usually does not question the man's decision; although with migration to the United States, this changes after exposure either to the workforce or the media.

Women may then desire to know more about their own health issues v. following the advice of a husband or partner.

Myths may influence one's view of health, as may religion (e.g., with issues such as contraception).

History Taking

• Eye contact: challenges authority.
• Opposite gender care-giver maybe uncomfortable with male
• Certain topics not openly discussed with provider.
• May be uncomfortable discussing certain issues with spouse present.

Caveat: difficult to generalize; diverse population of almost 1 billion.

Access:

Spouse job and insurance if applicable.

Transportation

Knowledge of Federal/State programs: women may not be aware of eligibility for programs.

Attitude to health care provider: looks up to and respects physician. In India, physicians are often held up on a pedestal.

Preventive medicine tends not to exist, primarily because of economic issues; food, kids, school, entertaining, building wealth, image tend to be more important.

[A woman in psychotherapy presented her experiences during the first hour of lecture.]

A biopsychosocial approach was presented.

• Hormones
• Evidence to support a role of hormones in women's mental health includes
• mood changes around menstrual cycles (including PMS),
• beginning oral contraceptives (so ask if a woman presenting with depression just began oral contraceptives)
• stabilization of psychiatric disorder during pregnancy
• onset of symptoms postpartum, mood changes perimenopausally (including irritability, depression, fatigue).
• Circuitry
• Neurostructural and neurotransmitter changes exist between men and women.
• genetics
• First degree relatives of women with major depression (1/3) develop depression (v. 1/6 men with first degree depressed relatives);
• Patients with prior depression, chronic pain, or psychological stress are at increased risk of depression.
• Psychological
• Adjusting to secondary sexual characteristics and menses, changing body image during puberty.
• View of one's role in society
• Coping style: passive, learned helplessness, internalizing, obsessive.
• Social
• Conflict between career and family roles.
• Financial stress: majority of people in poverty are women and children. (See reference below.)
• Abuse.
• Living in a de facto (and in some cases de jure) male dominated society.
• Glass ceiling phenomenon: pay and advancement inequities despite similar seniority, experience, education, etc.
• Presence of young children makes women more likely to be depressed, and the more children the greater the risks (even when corrected for socioeconomic status).
• Abstract: "Single mothers, poverty and depression." Brown GW; Moran PM Psychol Med, 27(1):21-33 1997 Jan

The present study set out to examine the relationship between marital status, poverty and depression in a sample of inner-city women. Single and married mothers were followed up over a 2-year period during which time rates of psychosocial risk factors, onset of depression and experience of chronic episodes were measured. Risk of onset was double among single mothers. Single mothers were twice as likely as their married counterparts to be in financial hardship, despite being twice as likely to be in full-time employment. Both of these factors were independently associated with onset in single mothers. The link between them and onset was via their association with humiliating or entrapping severe life events. Single parents were at a much raised risk of experiencing these events. Onset was also more likely to follow such an event when women had poor self-esteem and lack of support, both of which were more common among single mothers. These risk factors were more frequently found among those in financial hardship. Financial hardship was also related to risk of having a chronic episode (lasting at least a year), of which single parents were also at greater risk. The majority of chronic episodes among single mothers had their origins in prior marital difficulties or widowhood and rates of chronicity reduced with length of time spent in single parenthood. Results are discussed in terms of an aetiological model of onset in which financial hardship probably influences outcome at a wide variety of points.

Women are more likely than men to attempt and less likely to complete suicide.

Presence of abuse or neglect (which is much more common in women than men) is a risk factor. Other risk factors include unwanted pregnancy, history of prior attempts, poor social support, presence of major depression or bipolar disorder, and comorbid alcohol or substance abuse.

Note that anorexia nervosa is NOT associated with an increased risk of suicide:

50% of United States pregnancies are unwanted

• 50% of unwanted pregnancies end in abortion
• United States rate of unwanted pregnancies is higher than in any Western country

Overwhelmingly #1 choice of contraception among women is the pill (oral contraceptive); very few Americans use IUD (intrauterine devices) mainly because of bad press received by IUDs in the United States.

Sterilization is the #1 choice in the US for contraception for women in their 30s.

In 1988, 60% of women in the United States age 15-44 were using contraception-

• 7% at risk of pregnant
• 4% trying to get pregnant
• 5% not trying to get pregnant
• 18% not sexually active 

Failure is defined as pregnancies per 100 women years of use. Expected = failure rate under ideal conditions (if used properly); typical (the first #) = observed rates.

Access in the United States is much lower than in many other countries, which don't necessarily require a prescription. Many third party payers refuse to pay for contraception.

Oral Contraception:

Many different preparations, but most are comparable in efficacy, side effects, etc.

• Effective: about 1% failure rate if used properly
• Regular menses
• Decreased menstrual flow
• Protective against:
• Endometrial cancer: nuns, for example, have a high rate of endometrial cancer
• Ovarian cancer
• Ectopic pregnancy
• Rapid return of fertility

Disadvantages:

• Difficult to use; easy to forget to take.
• Hormonal side effects.

Implanted under skin. Can be easily removed

• Very effective, easy to use.
• Useful when OCPs are contraindicated.
• Decreased risk of ectopic pregnancy
• Disadvantages
• Hormonal side effect
• Weight gain
• Dysfunctional bleeding, e.g. spotting, unpredictable bleeding (may have no periods at all)
• Hair loss
• Acne

Dalkon Shield used from 1970-1975 have been implicated in increasing uterine cancer, no longer used in the U.S.

Cheapest - put in and last for years. (Biggest problem is in the first 3 months, but if they do well then they tend to last for years.)

Ease of use, although difficult to insert into the uterus of a women who has never been pregnant.

No hormonal side effects

Disadvantages: increased risk of pelvic inflammatory disease, so not good for women with multiple sexual partners; best for those in the 30s in a monogamous relationship or marriage.

Condoms.

Reality condom = female condom with opening at introitus and other end at the cervix; not easy to find. Many pharmacists will not even know what you are talking about if you request one.

VCF = Vaginal Contraceptive Film with Nonoxyl 9, a spermicide; dissolves quickly in the walls of the vagina; like spermicidal jelly but easier to use.

Cervical cap: analagous to diaghragm

Advantages of barrier contraception:

But messy, not effective.

Tubal ligation: ring is placed on the fallopian tube, interrupting continuity of the tube.

Tubal distruction: burn small segment of tube to end up with disconnected tube.

Permanent.

Increased risk of ectopic pregnancy, perhaps 1 / 300.

Lessens routine gynecological care; since they don't have to come, women may not get routine pap smears, etc.

Abortion: used as a form of contraception in countries with less available contraception, e.g., Japan, in which oral contraceptives are illegal (but Viagra is legal and was rushed through for rapid approval).

Emergency contraception: oral contraceptives - 2 doses within 24 hours following intercourse; not useful long-term, but acutely maybe helpful, e.g., if a condom breaks.

Folic acid supplementation recommended for all women of reproductive age because of high rate of unplanned pregnancy. Women usually don't discover they are pregnant until 6-8 weeks into the pregnancy.

Smoking cessation is important; smoking may cause low birth rate, other complications. Second hand smoke may lead to more respiratory infections in neonates and children, but stopping just for pregnancy is better than nothing.

Stop illicit drug and alcohol use; fetal alcohol syndrome reported even with small amounts of alcohol. Probably should also avoid herbal supplements and other homeopathic remedies.

Avoid sexually transmitted diseases, since risk to fetus also.

For diabetics, optimize blood sugar control.

Continue anitepilectic medications: continue the medications since the risk of a seizure is probably greater than the risk of teratogenic effects of the medications. Compromise: stop if possible during period of organogenesis (first few months).

Can now offer good outcomes to women with complicated medical illness, even transplant recipients for example.

Syphilis

Gonorrhea

Chlamydia

Herpes

Human Papilloma Virus - virus will stay with you for life

Hepatitis

HIV

Chancroid

CMV

Lymphogranuloma venereum

If you define sex as genital-genital intercourse, there really is no such thing. Condom is the cornerstone, but not a cure all. Not effective against herpes, HPV, because you may have lesions in areas not covered by condom.

Spermicides may be helpful although vulva and scrotum are not protected.

Dental dams used for oral sex.

Alternatives to genital-genital intercourse should be considered and discussed with patients. Many providers are embarrassed when discussing sexual matters, but must take the initiative because patients may be even more uncomfortable. Talking about it normalizes it, and allows patients to see that it is O.K. to think about and openly discuss their sexuality. Examples include:

• sexual fantasies
• massages, hugging, body rubbing
• masturbation
• erotic books, conversation, bathing

Minimizing number of partners

Counsel women to get a good partner sexual history, but to take it with a grain of salt.

Stop illicit drug use or needle sharing. Note that cocaine users have higher HIV rates even if not using IV route because of lifestyle (e.g., exchanges of drugs for sex, cultural factors, impairment of judgment).

Perinatal transmission

Violence (see also Domestic Violence)

1.75 women are raped on average per hour in the United States

1 out of 4 women will be victims of sexual assault over their lifetime in the United States

1 out of 12 men in college setting have tried to force a woman to have intercourse; THIS IS RAPE. (Yet most of the men who reported this do not see themselves as rapists.)

3 out of 4 assaults are committed by someone known to the victim, including domestic violence and nonsexual assault.

4 million American women experience domestic violence per year. A woman is much more likely to be killed after leaving or attempting to leave an abusive relationship.

1 out of 3 adult women experience an assault by a partner per lifetime.

1 in 5 women and men report having been sexually abused as children.

• women who were sexually abused as children are more likely to have > 10 partners in a lifetime. May have a different concept of sex and choices made around sex.
• More likely to have sexual dysfunction.
• More likely to become pregnant as adolescents
• 70% of whites, 42% of blacks, and 37% of Hispanics in one series of pregnant adolescents were sexually abused
• victims of abuse are more likely to become teenage parents.
• Victims of childhood abuse may have more difficulty accessing medical care
• M.D.'s may have been part of the problem; they may have minimized or discounted the problem.
• Visits to the doctor may have resulted in punishment or blame. "What were you doing to get Daddy's attention?" "If you were a good girl, this wouldn't have happened to you."
• M.D.s say a lot of the same phrases that the abusers say, e.g., "I'm just going to touch you here," or "This won't hurt."

Many women who have intense anxiety about labor pains or cervical exams were victims of sexual abuse.

As a health care provider, when dealing with a rape victim, e.g., in the emergency room:

• Avoid using terms such as "alleged rape victim." "Alleged" is a legal term; it is not your job to determine if the rape occurred, anyway. We don't say "alleged chest pain" or "alleged motor vehicle accident victim."
• Begin by explaining why a medical history is necessary;
• Keep questions simple, direct, quiet, and gentle, posing those that can be answered briefly;
• Be non-judgmental.
• Remember your objective: to prevent the medical consequences of rape (sexually transmitted diseases and unwanted pregnancy, as well as any injuries such as vaginal tears or incidental bruises, fractures, etc.) while providing emotional and psychological support.
• Be sensitive and supportive. Do not avoid treating the rape victim out of fear of being dragged into court (there is a forensic portion of the rape protocol and you may have to testify in court).
• Be sensitive to your own anxieties and preconceptions about rape and its victims.
• You do not need to get a detailed, blow-by-blow account of the rape.

Injuries frequently resulting from a sexual assault include:

• abrasions and bruises on the upper limbs, head, and neck
• forcible signs of restraint-rope bums, mouth injuries from a gag
• muscle soreness or stiffness in the shoulder, neck, knee, hip, or back from restraint in postures that allow sexual penetration
• broken teeth, swollen jaw or cheekbone, eye injuries from being punched or slapped in the face
• note that bleeding from the penetrated orifice is NOT common.

Note that you may have some reporting obligations, so you cannot reassure the rape victim that you will protect her confidence and not report the crime.

• attempting to prevent sexual assault by getting at its root causes, e.g., societal and cultural norms and attitudes.

• attempting to intervene early by recognizing and responding to the warning signs of sexual abuse

• responding to sexual assault once it has occurred in the hopes of preventing its recurrence.

Causes:

The price of infertility is high:

• "abnormal" in something that others might expect to come easily; becomes a tremendous psychological burden
• "the medical problem": does insurance cover it? Requires testing, multiple trips to the doctor.
• mechanical sex: may lose its pleasure because of requirement to time around cycle, etc. May be humiliating for men also, if e.g., they have to masturbate to generate sperm for artificial insemination.
• other partners, e.g. surrogates, donation of sperm or ova, involving third parties in what should be an intimate activity.
• Financial: $10,000-$20,000 cost per cycle with about a 25% success rate per cycle; some women will have to go through 6 cycles; insurance usually doesn't cover, so only the affluent can access this technology.

Forms of Assisted Fertilization:

Consequences can be dire when one has a large number of fetuses, which is a risk in many forms of fertilization therapy:

Surrogate: this is where a fertile volunteer woman agrees to be inseminated by a man so that he and his wife may have a child. It is very complicated since it involves someone else (who may change her mind about having or giving up the baby), there is no control over what goes into the surrogate's body (e.g., drugs and alcohol) or surrogate's final decision. A case was given in class of a woman who served as a surrogate for a couple who divorced before the child was born. The man, the only one of the two with a genetic link to the child, didn't want the child, nor did the mother. The surrogate didn't either, so it was quite a quandary. Ethical issues such as who decides parental rights, who advocates for the unborn child, whether it's appropriate to use the civil court system to decide the fate of a human being, etc., are all unresolved. Caveat emptor.

Other ethical issues include ownership and control of embryos created for IVF; if the couple divorces, are they the husband's or the wife's or neither?

Adoption: is also expensive, sometimes don't know what you are getting in terms of emotional and physical problems, developmental delays (in the case of neglected Eastern European children adopted by American parents).

As a health care provider, you must grow comfortable talking about sexuality with your patients. You should initiate the discussion, since they often won't.

Decreased sexual desire may be medical, but most commonly is psychological, e.g., history of childhood sexual abuse, stress, marital or relationship tension.

Orgasmic disorders:

Vaginismus: painful, spastic contraction of the pelvic floor muscles with attempted penetration. Usually psychological, e.g., from sexual abuse.

Dyspareunia: pain with vaginal penetration or deep thrusting. Cause is usually organic (infection, vaginal dryness, cyst in upper genital tract) but may be psychological/situational.

(Based on a lecture by Dr. Herbert)

Lesbian women have breast cancer risk factors including: alcohol abuse, obesity, and nulliparity (they tend not to bear children). Their smoking rate, however, is not higher.

Lesbian women tend not to differ from heterosexual women on the basis of socioeconomic status.

Sexually transmitted diseases between females occurs less commonly than from male to female, but most state agencies do not routinely track data on female-female STDs. In general, female-female sex is either not considered a risk factor for transmission of STDs or is lumped under "other risk factors."

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