Feminist Articles

Cherise Doyley was in labor in 2024 when the hospital sought an emergency hearing to force her to have a C-section. Doyley, who was a professional birthing doula, now focuses more on providing postpartum depression resources. “I don’t think I will ever attend another birth as a doula. It’s too traumatizing for me.”

Reporting Highlights

Unequal Rights: Pregnant women in some states have fewer rights than other mentally competent adults to refuse medical treatment, including surgery.

Constitutional Questions: The rise of fetal personhood policies has some legal experts worried about an increase in court-ordered medical care.

Florida Disparities: Florida has gone further than other states to guarantee medical freedom for those who decline vaccines, but it also has restricted the medical freedom of pregnant women.

These highlights were written by the reporters and editors who worked on this story.

On the afternoon of Sept. 9, 2024, Cherise Doyley was in her 12th hour of contractions at University of Florida Health in downtown Jacksonville when a nurse came in with a bedsheet and told her to cover up. A supervisor brought a tablet to Doyley’s bedside. Gathered on the screen were a judge in a black robe and several lawyers, doctors and hospital staff.

“It’s a real judge in there?” Doyley asked the nurse at the beginning of what would be a three-hour hearing. “Now this is the craziest thing I’ve ever seen.”

Doyley hadn’t asked for the hearing. The hospital had sought it. Doyley had mere minutes to prepare. She had no lawyer and no advocate — no one to explain to her what, exactly, was going on.

Judge Michael Kalil informed her that the state had filed an emergency petition at the hospital’s behest — not out of concern for Doyley, per se, but in the interest of her unborn child. He described the circumstances as “extraordinary.”

The hospital and state attorney’s office wanted to force Doyley to undergo a cesarean section. Doyley, a professional birthing doula, didn’t want that and had been firm about it. She’d had three prior C-sections, one that resulted in a hemorrhage, and hoped to avoid another serious complication and lengthy recovery. She was aware that doctors were concerned about the risk of uterine rupture, a potentially deadly complication for her and her baby. She would say during the hearing that she understood the risk to be less than 2% and didn’t want to agree to a C-section unless there was an emergency.

But the choice would not be hers. The judge would decide how she would give birth.

Watch How a Court Hearing Was Convened in Cherise Doyley’s Hospital Room

Obtained by ProPublica

Mentally competent patients typically have the right to choose their medical care — or refuse it. But there is one notable exception: pregnant patients. That inconsistency is particularly striking in Florida, a state that has pushed to expand medical freedom for those who wish to avoid vaccines or fluoridated water, while constricting the rights of people in various stages of pregnancy.

“There aren’t any other instances where you would invade the body of one person in order to save the life of another,” said Lois Shepherd, a bioethics expert at the University of Virginia School of Law.

In Florida and many other states, court-ordered medical procedures are just one of the ways pregnant patients’ rights are restricted. The effort to chip away at those rights is rooted in the concept of fetal personhood — that a fetus has equal and, in some cases, more rights than the woman sustaining it.

The link between fetal personhood and court-ordered C-sections dates back to the 1980s, when courts started ruling that hospitals can override patients’ decisions in favor of the health of unborn children.

In the years since, proponents of fetal personhood began to push for even broader legal protections. In 1986, Minnesota was the first state to recognize fetuses as victims in homicide cases. Some states have imprisoned pregnant women for exposing their fetuses to drugs. Nearly 30 states have passed laws that allow hospitals to invalidate pregnant patients’ advance directives, which outline the kinds of life-sustaining treatment a person wants after a catastrophic illness or accident. At least one, Alabama, extended the concept of personhood all the way to the earliest stages of fertilization and conception by giving frozen embryos the same legal status as children, though the Legislature later said the law couldn’t be enforced.

And the fetal personhood movement has accelerated in the past several years, supercharged by the U.S. Supreme Court decision to reverse the abortion rights that had been protected by Roe v. Wade.

Florida has long been at the forefront of fetal personhood policies. The state was one of the first in the country to prosecute a woman for “delivering” drugs to her fetus during pregnancy in 1989, although the Florida Supreme Court later overturned her conviction. And after advocates twice failed to get a fetal personhood amendment on the state ballot, the Legislature is now considering a bill that would enshrine the concept in state law by giving embryos and fetuses the same legal status as people in wrongful death suits.

For women in labor, the potential impact of the bill is clear: Experts anticipate their medical needs could be further diminished in favor of the fetuses’.

Several legal experts told ProPublica they are alarmed by Doyley’s case and the legislation’s potential to allow for more court interventions during childbirth. Lawyers who represent women in fetal personhood cases already have identified a higher number of forced C-sections in Florida than other states.

The state attorney’s office for the 4th Judicial Circuit declined to comment on Doyley’s case, saying a response would violate her medical privacy. But in an email, a spokesperson noted why, in general, the office would intervene: “The courts have held that the State has a compelling interest in the preservation of the life of an unborn child and the protection of innocent third parties who may be harmed by the parental refusal to allow or consent to life-saving medical treatment.”

C-sections account for nearly a third of all deliveries in the United States. They can be necessary when babies are breech, or in the wrong position for birth, as well as in cases of maternal or fetal emergency. But in other cases, such as slow laboring or prior C-sections, the need for the surgery is less clear.

Surveys have found that more than 10% of women feel pressured into C-sections and other procedures by doctors worried about injuries to the baby. Patients generally don’t challenge doctors who say they’re necessary, and it is uncommon for someone to hold out and for the hospital to turn to the courts.

It is so rare, in fact, that advocates for the rights of pregnant women were shocked to discover that the same thing that happened to Doyley had happened to another Florida woman just a year and a half earlier.

The similarities in their cases were striking. Both women had three prior C-sections. They had questioned the need for their previous surgeries and arrived prepared to fight for vaginal births. And both women are Black.

They had argued that compelling them to have C-sections violated their rights to make medical decisions. Hospital staff said their medical decisions threatened the health of the fetus. It would be up to the courts to decide which one mattered more.

Doyley enjoys time with her 1-year-old daughter, Arewa, on their porch.

Brianna Bennett with her 2-year-old daughter, Aubree. Like Doyley, Bennett was forced to have a court-ordered C-section.

Asked to consider the constitutionality of court-ordered C-sections, the U.S. Supreme Court declined in 1994, leaving a patchwork of decisions that vary by state.

In the early 1980s, a hospital in Georgia won a court order to force a woman with a dangerous pregnancy complication to have a C-section. Then, in 1987, a judge in Washington, D.C., approved a request to perform surgery on a pregnant woman dying from cancer without her consent. Later, a higher court reversed that ruling and held that hospitals should not override medical decisions. An Illinois appellate court in 1993 refused to order a woman to undergo a C-section.

Not long after, a patient named Laura Pemberton, who did not want a C-section, left a hospital in Tallahassee, Florida, against medical advice. A local judge sent law enforcement to her house to bring her back. Once she returned to the hospital, the judge ordered her to have a C-section, which doctors carried out. She later sued in federal court and lost. The 1999 decision by a federal district judge found that the state had a right to override her wishes.

“Whatever the scope of Ms. Pemberton’s personal Constitutional rights in this situation, they clearly did not outweigh the interests of the State of Florida in preserving the life of the unborn child,” the decision said. The decision marked a legal turning point in prioritizing fetal rights over the religious freedom and bodily autonomy of the mother.

In 2009, Samantha Burton arrived at the same hospital at 25 weeks pregnant, after going into premature labor. Doctors told her she needed to remain on bed rest, but she wanted to leave and go home to her children. The hospital got a court order for her to remain in the hospital and undergo any treatment doctors deemed necessary to save the fetus. She had an emergency C-section, and the baby was stillborn.

She appealed the ruling granting the emergency order, and a Florida appeals court ruled in her favor. They said the circuit judge should have required the hospital to prove the baby was viable before imposing unwanted treatment, but the court stopped short of saying it was unacceptable to override the medical decisions of pregnant women in all situations.

Pregnancy is the only condition where Florida courts have ruled that a patient can be forced to undergo unwanted treatment. Even a state prisoner on a hunger strike has more rights to make medical decisions.

Those rulings give the state vast control over pregnant women.

“All of it essentially is about the state’s ability to decide that a fetus, at any point during a pregnancy, is more important than the person who’s pregnant,” said Rutgers University law professor Kimberly Mutcherson.

Doyley decorates her home with decals of butterflies. She says she likes how they represent transformation.

One-year-old Arewa plays on the family porch.

Bennett’s 2-year-old daughter, Aubree, pretends the floor is lava.

In March 2023, more than a year before Doyley’s court-ordered C-section, Brianna Bennett arrived in labor at Tallahassee Memorial Hospital — the same hospital where the women in the 1999 and 2009 lawsuits had given birth.

Over the preceding years, Bennett had come to question the medical reasoning behind her three prior C-sections. Each recovery had been harder than the last, leaving her so incapacitated after the third that for two weeks she couldn’t even go to the bathroom without help.

At the time Bennett went into labor with her fourth, her mother’s hip problems had gotten so bad that she needed a wheelchair and required some help from Bennett to function. Bennett did not think she could care for all her family members while in recovery from abdominal surgery, so she insisted on trying for a vaginal birth.

Bennett researched and weighed birthing options before going into labor.

Tallahassee Memorial Hospital had specialists on staff and a neonatal intensive care unit equipped to serve critically ill babies. Bennett believed it offered the kind of support she needed to be able to follow her birth plan. The hospital has handled a lot of high-risk pregnancies.

As Bennett’s labor stretched past 24 hours, a doctor confronted her about agreeing to a C-section, Bennett said. She continued to refuse, so the hospital reached out to the state attorney. In an email, Jack Campbell, state attorney for the 2nd Judicial Circuit, responded that the court needed to act quickly.

“I plan to file an emergency motion with the Court to allow TMH to take whatever steps medically necessary to protect the life of the child and mother,” he wrote.

Bennett, in the red dress, prepares lunch with her children, from left, Alannah, 16, Aubree, 2, Ayden, 11, and Ava, 7. After her three prior C-sections, she was worried about recovering from a fourth while taking care of a newborn and other family members.

During the hearing, 15 to 20 people squeezed into Bennett’s hospital room. As would later happen with Doyley, she found herself in front of a tablet with a judge on the screen.

Bennett said she found it offensive that so many people were concerned about the method of her delivery without taking into consideration how difficult it would be to take care of both herself and her baby while recovering from a C-section. “Are any of you gonna help me bathe or shower? Are you gonna help change my pad? Are you gonna help lift the baby out of the bed and put me in the bed because I can’t lift my legs? Is anyone going to help me?”

Campbell told ProPublica that he felt the hearing was necessary to save two lives, Bennett’s and her baby’s. “I’m real comfortable with what we did here,” Campbell said. “I hate the fact that she’s upset about it.”

A spokesperson for Tallahassee Memorial Hospital declined to comment on Bennett’s case, even though she signed a waiver allowing the hospital to do so. “We will not be able to discuss specific patients or cases,” the spokesperson wrote in an email. The hospital did not respond to questions about its history of seeking court intervention in multiple women’s medical decisions while giving birth.

Bennett said she tried to remain calm, but inside she was panicking. During the hearing, her baby’s heart rate spiked. The judge ordered her to have a C-section, and doctors wheeled her into surgery. The operation lasted two and a half hours and the surgical team had to cut around existing scar tissue and avoid her bladder. Her incision looked like an upside-down T and required a wound vac, a portable machine that helps incisions close more quickly.

She said a doctor who visited her room during recovery told her she should never get pregnant again, according to a civil rights complaint filed with federal regulators.The complaint is still under investigation, but lawyers for Bennett said they haven’t heard from investigators in more than a year. The U.S. Department of Health and Human Services did not comment on the complaint.

“I cried every single day,” Bennett said. “I felt like I was supposed to be happy. I’m supposed to be thankful that I have a new life and that the Lord has blessed me to see this new baby. And I’m not even happy.”

Bennett’s daughters Aubree and Ava play on a swing set.

Aubree looks at a photo of her mother holding her after a court-ordered C-section.

A year and a half later in Jacksonville, Doyley faced a situation eerily similar to Bennett’s.

She noted as her hearing began that she was the only Black person on the screen. About a dozen faces, most of them white, had gathered to challenge her medical decisions. She said it made her feel as if her race had something to do with the fact that she was thrust into the intrusive hearing.

“I have 20 white people against me, and because I am informed and I am making an informed decision, they are trying to take my rights away from me by force,” Doyley told the people on the screen, requesting a Black nurse or doctor.

“I don’t find that race really has much to do with this, ma’am,” the judge responded.

Dr. Erin Burnett said during the hearing that she did not think Doyley could successfully give birth vaginally because she had a history of stalled labors. A long labor after prior C-sections could increase the risk of uterine rupture, which could kill Doyley and the child, she said.

She said the baby’s heart rate showed some signs of distress and told Doyley it would be better to have a C-section before it became an emergency. If the baby’s heart stopped or if she lost oxygen during delivery, the baby could suffer a brain injury or death.

Dr. John Davis, the chair of the obstetrics and gynecology department, testified that the hospital had been recognized for its low C-section rate and did not perform unnecessary surgeries. Doyley’s condition required intervention, he said.

Burnett and Davis did not respond to requests for comment, and the hospital declined ProPublica’s requests to interview them and others involved in Doyley’s care. Doyley signed a waiver allowing the hospital to discuss her case with ProPublica, but a spokesperson for University of Florida Health in Jacksonville would not comment, citing patient privacy. Nor did the hospital respond to questions about Doyley’s claim that race played a role in the decision to involve the court.

The research on the risks of uterine rupture after prior C-sections is unclear. Studies have found that 0.15% to 2.3% of these labors resulted in a rupture, depending on a number of factors such as body mass, a history of successful vaginal births and whether the labor was spontaneous or had to be induced.

Doyley, who felt comfortable with her odds and wanted to continue laboring, argued during the hearing that C-sections carry their own dangers — including a risk of death.

“A lot of that comes from medical negligence and medical racism, where we have a group of white doctors that think that they know what is best for Black bodies and Black babies,” Doyley said in the hearing.

Doyley’s children — from left, Aganju, 7, Akilah, 11, and Arewa, 1 — sit on the porch at their home.

Both the doctors and Doyley mentioned recommendations from the American College of Obstetricians and Gynecologists. However, neither one cited the organization’s stance on court-ordered C-sections, which the group has deemed to be “ethically impermissible.”

After three hours of testimony — all while Doyley lay in her hospital bed — the judge ruled that she could keep laboring unless there was an emergency. If that happened, the hospital could operate, whether she wanted it or not. The judge would reconvene the hearing in the morning.

In response to questions from ProPublica, Kalil wrote in an email that the judicial code of conduct prohibits judges from commenting on cases. “These ethical standards exist to protect the integrity of the judicial process, ensure fairness to all parties, and preserve the Court’s neutrality,” he wrote.

Overnight, doctors said the baby’s heart rate dropped for seven minutes. Doyley woke to her hospital bed being wheeled into surgery. She called out to her sister who was asleep in the hospital room.

“I had to tell her, ‘Hey, wake up,’” Doyley said. “‘Something is going on.’ She’s trying to put on her shoes. I’m like, ‘Girl, leave the shoes. Let’s go.’”

Doyley recalled reciting a short prayer as her sister scrambled into the operating room. The baby was delivered by C-section. Although Doyley’s daughter was initially limp, she perked up and became responsive within a few minutes. Doctors took her to the NICU while Doyley went to recover. And to get ready to face the judge again.

At the 8 a.m. hearing, Doyley looked pained and groggy. She told the judge she still hadn’t been allowed to see her daughter and asked if he could help. A doctor testified that the baby had been brought to the NICU in respiratory distress and placed on a continuous positive airway pressure machine to help with her breathing.

Kalil said he couldn’t order the hospital to do anything. The matter he had been appointed to hear involved only her unborn baby. He had no authority over the child in the nursery.

Kalil wished her well and quickly closed the case.

We are glad that our paper (1) raised discussions on the relations between sex and the brain and on our new methodological approach. Clearly, sex affects the brain, as evidenced in differences between brains from females and brains from males in both macroscopic and microscopic features. However, the fact that sex affects the brain does not necessarily entail that there are two distinct types of brains, “male brains” and “female brains,” as there are two distinct types of genitalia (2–4). Answering this question was the aim of our study.

Assessing Internal Consistency and Substantial Variability

The rational for our method of analysis was derived from animal studies demonstrating that in contrast to sex effects on genital organs, sex effects on brain features may be opposite under different environmental conditions. That is, what is typical in one sex category (e.g., females) under some conditions may be typical in the other sex category under other conditions (reviewed in refs. 2 and 3). As a result, brains are expected to be composed of both features more common in males compared with females and features more common in females compared with males, a situation that rarely occurs in genitalia. When it does occur, the genitalia are classified as “intersex” and not as “male” or “female” (5). Our analysis was designed to assess how common this “mixture” of features is in the human brain.

We found that there are many more “substantially variable” brains, that is, brains with both features that are more common in males compared with females (“male-end” features) and features more common in females compared with males (“female-end” features), than “internally consistent” brains, that is, brains with only “male-end” or only “female-end” features. The finding that substantial variability is more prevalent than internal consistency was robust across different samples, age groups, type of magnetic resonance imaging, method of analysis, and the cutoff used to define the “male-end” and “female-end” zones (table S2 in ref. 1) and led to the conclusion that human brains do not belong to one of two distinct categories: “male brain”/“female brain”.

Del Giudice et al. (6) provide an elegant validation of our method of analysis, by demonstrating that internal consistency is higher than substantial variability when distinct populations (facial morphology of different primate species) are assessed. Thus, with a cutoff of 33%, internal consistency was found in 1.1–5.1% of profiles (depending on the pair of primates assessed) and substantial variability in 0% (6), compared with 0–8.2% internally consistent brains and 23–53% substantially variable brains [depending on the dataset (1)]. This comparison also reveals a degree of “mosaicism” in brains that is much higher than that found in primate species and provides further support to our conclusion that human brains do not belong to two distinct populations.

Using simulations in which they systematically varied the size of sex/gender differences and of correlations between variables, Del Giudice et al. (6) further demonstrated that our method of analysis returns more substantially variable profiles than internally consistent profiles, unless correlations and/or sex/gender differences become extremely large. These simulations corroborate our simulations (1), in which we systematically varied the mean random noise added to an otherwise internally consistent “brain.” Although the correlations between variables change as random noise is added, the multivariate distribution of variables created this way differs from that of the variables created by Del Giudice et al. (6). Indeed, for similarly sized correlations (0.7–0.8) and sex differences (0.70 < d ≤ 0.84) our simulation revealed more internally consistent “brains” than substantially variable “brains” (1), whereas Del Giudice et al. (6) found the reverse (less internally consistent “brains” than substantially variable “brains”). Together, these simulations demonstrate that our method of analysis can differentiate between an internally consistent system with some degree of random noise (our simulated data) and a system in which there are similar correlations between variables but with no underlying internal consistency [the simulated data of Del Giudice et al. (6)].

We hope future studies on the effects of sex on additional systems in which sex/gender differences were found (e.g., the immune system) will use our method to reveal whether the relations between sex and other systems are more similar to the relations between sex and the brain (substantial variability more prevalent than internal consistency under several cutoffs) or to the relations between sex and the genitalia (internal consistency more prevalent than substantial variability under several cutoffs).

Do Brains Belong to Two Distinct Types?

The high degree of overlap in the form of brain features between females and males combined with the prevalence of mosaicism within brains are at variance with the assumption that sex divides human brains into two separate populations. Moreover, the fact that the large majority of brains consist of unique mosaics of “male-end,” “female-end,” and intermediate (i.e., common in both females and males) features precludes any attempt to predict an individual’s unique brain mosaic on the basis of sex category (2–4). However, the existence of group-level differences between brains of females and brains of males is sufficient to make the reverse prediction, that is, to predict with accuracy above chance an individual’s sex category on the basis of the individual’s brain mosaic (2). For example, in the two voxel-based morphometry (VBM) datasets, one’s sex category can be predicted with ∼70% accuracy by comparing the number of “male-end” and “female-end” features (figures 1F and 2A in ref. 1). This also means that one’s sex category predicts with ∼70% accuracy whether s/he has more “female-end” than “male-end” characteristics, or vice versa. However, the reduction of the original 10-dimensional space (volume of each of 10 brain regions) to a 2D space (number of “female-end” and “male-end” features) results in the loss of information about the identity of the “female-end,” “male-end,” and intermediate features of each brain. As a result, sex category cannot predict a person’s number and specific combination of “male-end,” “female-end,” and intermediate characteristics. Moreover, “similarity” in the 2D space may have no biological meaning. Consider, for example, three individuals: A with a large (“female-end”) left hippocampus and all other regions in the intermediate form; B with a large (“female-end”) left hippocampus, small (“male-end”) left and right caudate, and all other regions in the intermediate form; and C with a small (“male-end”) left hippocampus, large (“female-end”) left and right caudate, large (“female-end”) left and right gyrus rectus, and all other regions in the intermediate form. In the 2D space (number of “female-end” and “male-end” features), A and C fall on the “female” side, whereas B falls on the “male” side. However, by the details of their brain mosaic, A seems to be more similar to B than to C.

Del Giudice et al. (6), Rosenblatt (7), and Chekroud et al. (8) achieved better accuracy in predicting an individual’s sex category on the basis of brain form, using supervised learning over all brain measures to find the space in which brains of females and brains of males are most separated. Specifically, using linear discriminant analysis on our different datasets, Del Giudice et al. (6) correctly identified an individual’s sex category about 69–77% of the time (depending on the dataset); using linear support vector machines (SVM) on our VBM data, Rosenblatt (7) correctly identified an individual’s sex category about 80% of the time (depending on the random split); using penalized logistic regression on cortical thickness and subcortical volume calculated using FreeSurfer (a technique that does not “correct” for differences in brain size), Chekroud et al. (8) correctly identified an individual’s sex category about 89.5–95% of the time, but accuracy dropped to 65–74% when head-size-related measurements were regressed out. This latter finding is in line with previous reports that observed sex/gender differences are largely attributed to differences in brain size (9, 10) (see also figure S4 in ref. 1). Although the different supervised learning methods achieve better accuracy in predicting sex category than the simple method described above, they have the same conceptual problem, namely, it is unclear what the biological meaning of the new space is and in what sense brains that seem close in this space are more similar than brains that seem distant. Moreover, it is unclear whether the brain variability that is represented in the new space is related to sex or rather to physiological, psychological, or social variables that correlate with sex (e.g., weight, socioeconomic status, or type of education) or to a chance difference between the males and females in the sample (2, 4). One way to answer this question is by checking whether a model created to predict sex category in one dataset can accurately predict sex category in another dataset. Using SVM, we found that accuracy may drop dramatically (sometimes to less than 50%) when a model created using a dataset from one geographical region (Tel-Aviv, Beijing, or Cambridge) was tested on the other datasets.

Conclusion

Lisa Bul/ASSOCIATED PRESS Robert Kosilek sits on trial for the May 1990 murder of his wife in Bristol County Superior Court, in New Bedford, Mass., on Jan. 15, 1993.

BOSTON — A federal judge on Tuesday ordered state prison officials to provide a taxpayer-funded sex-reassignment surgery to a transgender inmate serving life in prison for murder.

U.S. District Judge Mark Wolf ruled in the case of Michelle Kosilek, who was born as a man but has received hormone treatments and lives as a woman in an all-male prison. Robert Kosilek was convicted of murder in the killing of his wife in 1990.

Wolf is believed to be the first federal judge to order prison officials to provide the surgery for a transgender inmate.

Kosilek first sued the Massachusetts Department of Correction 12 years ago. Two years later, Wolf ruled that Kosilek was entitled to treatment for gender-identity disorder, but stopped short of ordering surgery. Kosilek sued again in 2005, arguing that the surgery is a medical necessity.

In his ruling Tuesday, Wolf found that surgery is the “only adequate treatment” for Kosilek’s “serious medical need.”

“The court finds that there is no less intrusive means to correct the prolonged violation of Kosilek’s Eighth Amendment right to adequate medical care,” Wolf wrote in his 126-page ruling.

Prison officials have repeatedly cited security risks in the case, saying that allowing her to have the surgery would make her a target for sexual assaults by other inmates.

Gynecologic surgeries, particularly hysterectomy (uterus removal), oophorectomy (ovary removal) and C-section, are the top overused procedures in the U.S. Only a small percentage of hysterectomies and oophorectomies are considered necessary since gynecologic cancers are rare. According to this JAMA Surgery article on 2007 inpatient procedures, “Two operations on the female genital system, hysterectomy and oophorectomy, accounted for a total of 930,000 procedures (89.3% and 84.6%, respectively, were elective).” These figures do not include the roughly 300,000 outpatient hysterectomies and oophorectomies done in 2007. This graph (graph B) of indications for hysterectomy is a good visual of how few are done for cancer (~50,000) indicated by the gray line. However, it is misleading in that it appears that hysterectomies have steadily declined since it only includes inpatient procedures. Outpatient hysterectomies have steadily increased since about 2002 and reached 40% of these surgeries in 2012, the last year for which I could find data. The 89.3% “elective” rate would indicate that these surgeries are “restorative” or at least harmless, but medical literature and women’s experiences prove otherwise.

A few years ago, I began writing for Hormones Matter about the consequences of hysterectomy and oophorectomy. Year after year, these posts generate tens of thousands of views and hundreds of comments. The comments inevitably follow the same pattern of unwarranted removal of organ(s), sometimes without informed consent, and ensuing declining health. We are publishing a series of articles highlighting women’s comments. This is the third of the series. The first article is about the lack of informed consent and can be found here. The second one talks about how our “exterior” settles / collapses after the uterus is removed leading to an altered figure and back, hip, and leg problems in the long run.

Bladder and Bowel Problems

Bladder and bowel problems are common after hysterectomy and usually permanent and progressive. A number of mechanisms seem to be at play – organ displacement, severed nerves and blood vessels, adhesions. Prolapse and risk of urinary and fecal incontinence are increased especially in the long-term. Bowel obstructions can occur many years after hysterectomy due to displacement of the bowel as well as adhesions which, according to this article, develop in 93% to 100% of patients who undergo abdominal surgery. This article cites “matted” versus “band” adhesions as more likely to develop after surgeries done via a vertical incision as well as colorectal surgeries. Matted adhesions are more apt to cause obstruction recurrences than are band adhesions. Here is my article that addresses the impact of hysterectomy on the pelvic floor and bladder and bowel function.

The non-profit HERS Foundation did a survey of 1,000 hysterectomized women. Urinary and bowel problems were frequently reported. The five complaints below were the most commonly cited:

constipation = 43.8%

urinary frequency = 39.5%

urinary incontinence = 31.1%

bladder infection = 24.5%

diarrhea = 20.8%

There are quite a few other complaints related to urinary, bowel and digestive issues as well as many other problems. Here is the complete list broken out by hysterectomy only, hysterectomy with one ovary removed, and hysterectomy with both ovaries removed.

Dysfunction of Other Organs / Glands

Studies have shown that other organs are negatively impacted by hysterectomy. Multiple studies show an increased risk of renal cell cancer after hysterectomy. This article states that risk to be “nearly 2-fold” and conjectures unintentional damage to ureter(s) as the primary mechanism. Thyroid cancer risk is also elevated regardless of whether or not ovaries are removed. According to this Finnish study, both rectal and thyroid cancer risks are increased in hysterectomized women.

Gallbladder disease seems to be fairly common after hysterectomy. However, according to this article exogenous estrogen (estrogen replacement) is the culprit.

Contrary to what many women are told or led to believe, ovarian function is oftentimes compromised once the uterus is removed and even more so if one ovary is removed. This makes sense when one considers that the uterus, ovaries, and Fallopian tubes work together as a system. This study determined that 39% of hysterectomized women showed signs of ovarian failure. This cohort study showed a nearly 2-fold increased risk when both ovaries were preserved and nearly 3-fold when only one was preserved.

The main purpose of this article is to report women’s experiences with bladder and bowel changes after hysterectomy. As such, below are comments from some of my articles that are evidence of these problems.

F De wazieres writes:

“…prolapsed bowl, severe constipation… the list is endless…”

Michelle:

“….  Most recently I’m having bladder issues…”

Rachel:

“I had a total hysterectomy August 13, 2007 a few weeks later I kept getting nauseous. I suffer from IBD and I fluctuate between constipation and diarrhea.”

Rebecca:

“hysterectomy on 6th February 2014 recovery ok. Sex life non-existent major loss of feeling, weak pelvic floor – leaking pee when exercise, sneeze, rarely laugh”

Nicole:

“I have also had some bad kidney infections.”

Nikki:

“I had a total hysterectomy and ureter repair two days later. This was 3 years ago. I have pain in my right side from time to time. I also experience problems urinating. I go ALL the time. I think I am finished, I wipe and when I stand up, I have leakage.”

ATH:

“After surgery I began getting chronic UTI’s, experiencing severe lower back pain, diarrhea and weight loss.”

Ann:

“Everyday is a struggle with bladder pain, constipation and pelvic blood vessel pain.”

SharonJ:

“urinary & bowl issues. … I even had an InterStim device placed in my upper buttocks with the hope that it would help with urinary issues and pain (it didn’t).”

KA:

“always constipated”

Julie:

“my bowel movements changed forever it’s never been the same.”

Lyn:

“I certainly feel and experience of incontinence and leakage of urine and stool.”

SharonJ:

“urinary & bowl issues”

Georgina:

“I can relate i had a hysterectomy in 2006. Today I’m experiencing pain in my stomach that takes my breath away.then i have pressure when i urinate.”

Karen Wood:

“When I work on my feet I have to be aware of holding my muscles tight so I don’t have incontinence!”

Shirley Davis:

“I had my partial in 2003 and since then I’ve had constant bloating and lack of bowel elimination at times it never donned on me until now that it may be from my hysterectomy, I’ve tried practically everything to ease the discomfort but nothing is working.”

Lisa:

“I have had hundreds of problems with my bladder, have to use my hands as a sphincter muscle otherwise the poo doesn’t come out and I have stomach pain for hours and cant sleep.”

Rene:

“I had a hysterectomy in 2004 and I have suffered with swelling in my stomach ever since I look like I’m 9 months pregnant, have trouble going to the bathroom had my gallbladder removed since then i stay in pain my stomach…”

Sue:

“I had a hysterectomy in 2007 and my health has slowly declined ever since to the point that the last few yrs. have been debilitating. My first symptom was constipation, then came…. I can’t go to the bathroom with out some sort of laxative and now they don’t even work at times. I have on and off pain under my right rib, have been to every doctor I can think of.”

Ashley:

“I had a hysterectomy Aug 30th and now my gallbladder is acting up have to go see a surgeon tomorrow”

KME:

“The first thing that became a problem post-op was chronic constipation. No matter what I do, I am always constipated and so much so that I always have a build up of and pass a huge amount of mucus (sometimes just mucus). This has affected my entire gastrointestinal tract of course and I have intermittent issues with enough gas to float a blimp, nausea, heartburn, etc. Over the last two years, I have definitely noticed my intestines shifting down and I may have a rectal prolapse as a result.”

Julie in Texas:

“My grandmother had a hysterectomy sometime in the mid to late 60’s. She had already undergone menopause. She was so humiliated by it that she didn’t speak about it for nearly 20 years. I do not know when her complications set in… she apparently experienced all the horrors of pelvic organ prolapse. …I remember that she had multiple bladder stapling surgeries, one of which I swear was reported to have been to staple it to her backbone! What she didn’t confess until years later was that her doctor, frustrated by these many surgeries on what he considered to be just some ancient, obese woman, decided that the best way to treat her organ prolapse, pelvic floor problems, incontinence, etc., was to sew up her vagina! He did not discuss this with her beforehand.”

Irene:

“LAST 3 YEARS I HAVE HAD STRESS INCONTINENCE AND OCCASIONAL PROBLEMS TRYING TO POO AS ITS HARD TO PUSH OUT DUE TO BOWELL PRESSING ON MY VAGINA. Gynecologist told me a month ago that normally the uterus holds the bladder the vagina and the bowel in place as they are all connected. He said when uterus is removed the other organs often become unstable often swinging in the wind and after on average 6 years after hysterectomy women start having problems. I am a week out of major surgery after having a bladder sling repair and an anterior and posteria vagina repair. If I hadn’t had a hysterectomy I wouldn’t have needed this surgery as I was very fit and every thing was where it should have been. If I knew what I know now i would have just had the one ovary removed.”

Sue:

“Hysterectomy in 2007. Chronic constipation ever since. Now laxatives aren’t even working…. My life has been horrible since.”

Joan:

“I am 13 weeks post hysterectomy and I am sorry I had it done. I was a very active women, always running around from 6am till 9pm. It has slowed me down I am incapable of standing for too long and sitting down hurts me as I constantly feel there is something stuck in my rectum.”

Kelisi:

“Lisa, in my case it also improved a lot, though I experienced some incontinence for a while. But the improvement lasted exactly three years and since then its got worse and my life is devastated, not only sexually. I am now in the 6th year post.”

Michelle:

“It’s been a year since my surgery. Most recently I’m having bladder issues and….”

Jadedkrystals:

“I had a complete hysterectomy (including both ovaries) when I was 30 yrs old (am now 49)…. since then have had loose stools and bowel problems w/ pain in stomach, also had my gall bladder out 8 yrs ago, now I have more bowel issues…. now I am having constant pain in flank area all the way around on both sides burning & cool sensations in back around kidney area and tenderness in my belly area, fullness/bloating under my rib cage on both sides after I eat.”

Jen:

“I had TAH kept my ovaries (boy, that was a battle)… had it Aug 2013. I have had so many problems since. … I have been having issues since day 4 post hysterectomy…. I also have severe rib pain right and left. I have bowel problems too and the nausea and fatigue is hell. … It’s interesting talking about loose stools because that has been happening….”

Kimberly Furino:

“I have had a Laparoscopic hysterectomy in February with just my uterus taken out. Since my surgery, I have been nauseous and have bowel problems. I have had every test they can possibly do and no one can figure out what is causing this.”

Ginger:

“I had cervical cancer…. I have my ovaries tacked up high,it hurts, had bladder surgery after that did not work suffered terribly, I have lbaf constipation.”

Lynn:

“7 years ago I had a full hysterectomy. (Cervix, Fallopian tubes, uterus and left ovary) during this surgery I also had a bladder suspension. Three years ago I had to have a bladder sling. The suspension lifted my bladder. And the most recent was the sling which pulled my bladder forward. So right now I currently have both the suspension and the sling. As of now I have developed vaginal prolapse to the point where my intestines bulges out from my vagina and I have to push it back in. If I walk for more then half our or so my insides feel like they are just hanging inside. To the point where it hurts and I have to lay down on my back. I can’t explain it any other way then it feels like I have to push as though I am in labor. The pressure on the pubic bone and the pressure on my pelvic floor.”

Stephanie:

“I’ve had pain in my upper stomacher ever science the server. I had the belly button one done on me.I’ve had like a big rock in my upper ABS but now its huge and I’m bleeding from vagina.I’m so scared.”

Nonhlanhla:

“I had partial hysterectomy in 2008 ,I was 32yrs old I was ok till 4 months back am having severe lower abdominal pain and candida which is getting worse I consulted the dr with no effect I am so confused what is wrong with me?”

WS:

“I also developed rather severe diarrhea.”

I caution any woman who is told she needs a hysterectomy and/or oophorectomy or is considering one to heed these comments. With the gross overuse of these surgeries, chances are she’s being sold a false bill of goods. It’s not always a good idea to rely solely on your doctor’s advice as Someone Who Cares cautions:

“After 40 years of enduring this “disabled” existence, it breaks my heart that no matter how many of us try to warn other women, in various ways, the number of these destructive surgeries continues to increase, not decrease.”

Texas man harasses woman thinking she was a man (Dallas Observer)

A Texas woman captured her harassment at the hands of an unidentified man for using the womens' bathroom because of her apparel, the Dallas Observer reported.

The encounter took place while Jessica Rush was using the restroom at Baylor Medical Center in Frisco on Thursday. She told the Observer that she was wearing basketball shorts and a Texas Tech t-shirt when the man approached her.

"You didn't look like a girl when I saw you enter," the man tells Rush in the video, adding, "I thought you was --"

"A boy?" Rush replies.

"Yeah, it was kind of confusing. It's difficult. You're dressed like a man," the man responds before walking away.

"That's the shit we deal with," can be heard saying as the man leaves.

Rush also filmed her second encounter with the man, inside the office lobby.

"I was confused when I see somebody entering the woman's bathroom looking like a man," the man says in the second video. "I was with my mom, so I wanted to make sure she was going to the right place."

Rush said she has been harassed at both Hobby Lobby and 24 Hour Fitness in similar fashion because her hair is styled in a fauxhawk, leading people to assume she is not a woman.

"I look very much like a girl," she said. "I'm not trying to transition, nothing like that."

Rush's encounter with the man near the bathroom can be seen below.

There's a removed video here.

The encounter inside the lobby can be seen here.

Leading facts and statistics on homicide and injury from domestic violence.

Infographic

While the country focuses on death and injury from auto accidents, health ailments and drug abuse, a shocking number of deaths and injuries are the result of domestic and intimate partner violence. Almost one-third of all female homicide victims are killed by an intimate partner. Tens of thousands of women and men have died, and hundreds of thousands of been injured, at the hands of their abuser over the last few decades.

Almost one out of five or 16.3% of murder victims in the U.S. were killed by an intimate partner; women account for two out of three murder victims killed by an intimate partner.Source: Homicide Trends in the United States, 1980-2008. Nov., 2011. U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.

Almost one-third of female homicide victims that are reported in police records are killed by an intimate partner. Source: Federal Bureau of Investigation, Uniform Crime Reports “Crime in the United States, 2000,” (2001).

In 70-80% of intimate partner homicides, no matter which partner was killed, the man physically abused the woman before the murder. Source: Campbell, et al. (2003). “Assessing Risk Factors for Intimate Partner Homicide.” Intimate Partner Homicide, NIJ Journal, 250, 14-19. Washington, D.C.: National Institute of Justice, U.S. Department of Justice.

Access to firearms yields a more than five-fold increase in risk of intimate partner homicide when considering other factors of abuse, according to a recent study, suggesting that abusers who possess guns tend to inflict the most severe abuse on their partners. Abstract: Jacquelyn C. Campbell et al., Risk Factors For Femicide in Abusive Relationships: Results From A Multi-Site Case Control Study, 93 Am. J. of Public Health 1089, 1092 (2003).

Less than one-fifth of victims reporting an injury from intimate partner violence sought medical treatment following the injury. Source: U.S. Department of Justice, Bureau of Justice Statistics, “Intimate Partner Violence in the United States,” December 2006.

Intimate partner violence results in more than 18.5 million mental health care visits each year. Source: Costs of Intimate Partner Violence Against Women in the United States. 2003. Centers for Disease Control and Prevention, National Centers for Injury Prevention and Control, Atlanta, GA.

The most common forms of physical violence against women who have experienced intimate partner violence in their lifetime are being pushed or shoved (27.5%), slapped (20.4), slammed against something (17.2%), hit with fist or something hard (14.2%) and being beaten (11.2%). Source: National Intimate Partner and Sexual Violence Survey, 2010 Summary Report. National Center for Injury Prevention and Control, Division of Violence Prevention, Atlanta, GA, and Control of the Centers for Disease Control and Prevention.

Asthma, irritable bowel syndrome, frequent headaches, chronic pain, difficulty sleeping, and poor physical or mental health are nearly twice as common among women with a history of rape or stalking by any perpetrator, or physical violence by an intimate partner, compared to women without a history of these forms of violence. Source: National Intimate Partner and Sexual Violence Survey, 2010 Summary Report. National Center for Injury Prevention and Control, Division of Violence Prevention, Atlanta, GA, and Control of the Centers for Disease Control and Prevention.

A deeper look into how the brain works reveals that addictions to harmful substances like tobacco have striking similarities to porn compulsion, including impaired decision-making.

On the surface, tobacco and porn don’t seem to have much in common. Because of its well-known harmful effects, tobacco is kept behind the counter at the gas station and requires an adult I.D. to purchase.

Porn, however, is available almost anywhere with an internet connection. Tobacco can quickly become an expensive habit, while a porn habit can be completely free.

But is a habit like smoking tobacco at all similar to consuming porn? The simple answer: absolutely, yes. The more complicated answer: still yes, but with a caveat.

At a certain point, a direct comparison between the effects of drugs and the effects of porn starts to break down, as we’ll talk about later in this article. But at its core, if you understand the basic science of how addiction works, addiction to tobacco and addiction to pornography consumption are remarkably similar.

And it all starts in the brain.

The reward center

In case you’re not a neurosurgeon, here’s a crash course on how a few parts of the brain work.

Deep inside the brain, there’s something called a reward center. You’ve got one. Your dog’s got one. A monkey’s got one. The reward center’s job is to release a pleasure chemical called dopamine into our brains in response to behaviors that we perceive as positive, like eating tasty food, getting in a good workout, or enjoying a kiss.

Dopamine tells our brain, “Hey, this is a good thing! Keep doing this thing!” And it sends that message in such a powerful way, we become hardwired to do whatever things trigger this process. Normally, it’s a great system. The problem, however, is that this process can be hijacked.

When someone uses an addictive drug, that drug uses the same dopamine process as part of the high, flooding your brain with feelings of pleasure and positive reinforcement. Your hardworking brain then immediately starts doing its job: developing a preference for whatever produced those feelings and rewiring itself to find and experience those feelings again. This creates a feedback loop that leads us to develop and seek out preferred ways of triggering that flood of happy-making chemicals.

Ironic, right? The very thing that is supposed to reinforce healthy actions and behaviors is being co-opted for a drug’s high—and that’s not even the worst part.

The more the dopamine process is stimulated, the more it can begin to warp an individual’s perception of the world around them. Seemingly everyday items and situations—maybe particular smells, images, or places—can become triggers that spike the desire and cravings for whatever brings on the next high.

Want to know what else can spark this same process in the brain? You got it: porn.

Porn can trigger this process endlessly because it is endlessly available. Just like addictive products such as tobacco, porn can create pathways within the brain that lead to cravings, and those cravings can push consumers to search longer and more diligently for the same level of “high.” What’s worse is that the amount of dopamine that floods the brain only increases with repeated consumption. Each time a consumer turns to porn, they increase their cravings for more. But as the consumer’s brain is gaining this increased desire, it’s losing something else.

Hypofrontality

Like we talked about earlier, your brain’s reward center is something you share with most mammals. Now let’s talk about the part of the brain that makes you uniquely human: the prefrontal cortex.

While the reward center is largely responsible for wanting, the prefrontal cortex is largely responsible for putting the brakes on those wants when needed. Let’s say you’re watching Netflix late on a weeknight. When your reward center is firing, you might find yourself thinking, “Just one more episode, this show is so good!” But once your prefrontal cortex kicks in, you might think, “Hold on, it’s already after midnight, and I have school tomorrow—I should probably get some sleep.” Any time you weigh the consequences of a decision, put off instant gratification for a long-term goal, or think your way through a problem, you’re using your prefrontal cortex. And yes, while a hungry little reward center might be common to all animals on our little blue planet, a well-developed prefrontal cortex is a uniquely human advantage.

Under normal circumstances, your prefrontal cortex would disrupt unhealthy patterns such as an escalating porn habit—and for many people, it does. Many will notice intensifying cravings and recognize the potential for an unhealthy habit, and change their behavior accordingly. But a sizable percentage of the porn-consuming population will struggle to understand the level of risk, or to control their impulses.

This impaired decision-making ability is known as hypofrontality. “Hypo” simply means “less than normal” and “frontal” refers to your prefrontal cortex. So as the name implies, hypofrontality involves decreased frontal control over the brain’s impulses. In some cases, brain scans have actually shown decreased frontal brain matter.

Hypofrontality is such a key part of the addictive experience, it’s considered one of the four main markers for addiction (the others being sensitization, desensitization, and dysfunctional stress).

In other words, for something to be considered addictive, it must be shown to cause hypofrontality. As of the time this article was published, over 150 studies have demonstrated hypofrontality in internet addiction, including more than a dozen studies that have demonstrated its presence in the brains of porn consumers.

One interesting study, for example, was divided into two parts. In the first part, heavy porn consumers were shown to be less capable of valuing long-term rewards over short-term. But in a clever twist, the researchers divided those participants into two groups for the second part of the study. Half were asked to abstain from porn for two weeks. The other half were asked to abstain from their favorite food. Even though both groups were exercising self-control for two weeks, only those who abstained from porn improved their scores in their ability to appreciate long-term rewards, showing that porn uniquely affects consumers’ patterns of self-control. In other words, self-control was not the key factor—porn was the key factor. The implication is that porn consumption did not simply correlate to hypofrontality. Porn consumption caused hypofrontality.

So not only can porn create a feedback loop of cravings and desire, it can simultaneously decrease the brain’s ability to keep those cravings in check.

The good news is, change is possible! Research and the experiences of thousands of people have demonstrated that the negative effects of pornography can be managed and largely reversed.2122 In fact, even in cases of serious substance and other addictions, research shows that the brain can heal over time with sustained effort. Research also indicates that, while guilt can motivate healthy change, shame actually fuels problematic porn habits. So if you’re trying to give up porn, be kind to yourself and be patient with your progress. Because of neuroplasticity, the amazing human brain has the ability to change itself in both directions.

Romi Gonen speaks to 'Uvda,' in a program aired December 25, 2025. (Video screenshot, Channel 12)

Former hostage Romi Gonen tells Channel 12’s “Uvda” program about her harrowing ordeal in Gaza. Gonen says she was sexually assaulted by four different men during her time as a hostage.

She says the first assault happened on her fourth day in captivity, the abuser being a doctor who was tasked with caring for her injuries sustained during the Hamas-led October 7 attack and her abduction.

Gonen says she was allowed to take a shower, and the man followed her in “because he’s a nurse and he came to ‘help’ me in the shower.”

“I was injured, I had no power, and I was in a situation in which I couldn’t do anything,” she says.

“He took everything from me,” she says. “Afterward, I had to continue living with him in the house.”

Gonen says her next attacker was a cameraman who filmed clips of her for propaganda purposes. When she was moved homes, she was forced to stay alone with man, Muhammad, who then began touching her. Gonen says she told him to stop and went to another room, but that the next day Muhammad told her he would be beside her from then on out. “And that’s how my ordeal in that house began,” she says.

She says that for many days, Muhammad and a second man, Ibrahim, assaulted her.

“I’m sitting on the bed. Ibrahim comes and sits next to me, and harasses me. Everything happens in the room, in complete silence. I start crying insanely. Everything is quiet, and he says, ‘Be careful, if you don’t calm down, I’ll get angry.’ And that’s how the days pass: I go to the bathroom and Muhammad is with me, and he watches me. I pee, and with one hand I pull down my pants. I sit on the toilet so that God forbid he won’t see anything of me. Ibrahim keeps bothering me endlessly. They grab my leg and move up to my thigh. I kick. It went on for 16 days… Those were by far the worst 16 days of my captivity.”

But Gonen says the worst single attack came later, when another captor in another house followed her into the toilet and assaulted her for some 30 minutes.

“I remember this one moment when I looked — there was a kind of window there, a small square like a picture frame — and I looked through the window and said to myself: ‘Wow. Blue skies, birds chirping, and this is the situation I’m in right now.’ The dissonance between life outside, the beautiful, normal, clean life, and the filth and brutality and utter disgust that’s happening here inside the bathroom — It’s a moment I will never forget in my life,” she says.

The whole world needs to hear the courageous testimony of Romi Gonen, who survived Hamas captivity, about the horrific sexual violence she endured there!@Uvda_tweet pic.twitter.com/9m1fhySeOG — יוסף חדאד – Yoseph Haddad (@YosephHaddad) December 25, 2025

Gonen says she was weeping throughout the assault, while her abuser “was at the peak of his life. He got a gift for life.”

Afterward, she says the world was spinning. “All that went through my head was: ‘Romi, everyone in Israel thinks you’re dead, and you’re going to be a sex slave in captivity.’”

The suspect pushed the door open before the victim could lock herself in

FILE image.

ON Saturday, October 17, at around 1:30pm, a male suspect was arrested for rape on Ampere Road, Chloorkop.

“It is alleged that the victim, a female aged 50, was attacked while in the bathroom at her workplace. The suspect allegedly pushed the bathroom door open before the victim could lock it,” explained Norkem Park SAPS spokesman Capt Lesibana Molokomme.

The victim told police that the suspect pushed her and forcefully undressed her before raping her.

Banished and Forgotten: Life in Exile for the Women of Ghana’s “Witch Camps”

In Ghana’s remote north, centuries-old fears and superstitions have sentenced women to exile. Now, a new law offers hope—but can justice overcome belief?

* This reporting was supported by the Pulitzer Center

July 2025

From ghouls and goblins to fairies and ogres, mythical creatures have long stirred the imaginations of children. Tales of wizards and witches—one often symbolizing wisdom and power, the other evil and danger—remain especially enduring, kept alive through books, films, and folklore.

But in northern Ghana, witches are not confined to fairy tales. Belief in witchcraft remains widespread and deeply entrenched, with devastating consequences—particularly for women.

This belief can be deadly. In July 2020, 90-year-old Akua Denteh was brutally lynched in a public market after being accused of witchcraft. Her killing, filmed and widely circulated, shocked the nation and galvanized calls for legal reform. Her death became a symbol of the deadly intersection of superstition and gender-based violence.

To be accused of witchcraft in Ghana is to face exile, persecution, and even death. These accusations—often directed at older, vulnerable women—can be triggered by personal misfortunes: the death of a relative, failed crops, illness, or jealousy over a woman’s independence. Even a child’s success at school can spark suspicions of a mother’s “spell.” For those deemed “guilty,” banishment to one of northern Ghana’s six so-called witch camps is often the only means of survival.

A woman accused of witchcraft sits on the ground outside her small, windowless hut in exile, alongside around 80 other banished women.

I first visited the Gambaga camp in 2008 and returned in 2012, witnessing firsthand the stark realities the women endure. While interviewing one elderly woman, I asked if she believed she was a witch. Before she could respond, my translator—related to the local chief—interrupted: “Of course she’s a witch. Why else would she be here?” The question was never translated. Her answer was lost, her voice dismissed before it could even be heard.

A cluster of round, thatched huts forms the heart of the Gambaga camp—a place that serves as both sanctuary and prison. Accusations often lead to a traditional “trial”—a ritual involving the slaughter of a chicken or guinea fowl, with the manner of its death interpreted as spiritual evidence. But in many cases, the accusation alone is enough to seal a woman’s fate. Regardless of the ritual’s outcome, she may be cast out by her community—her judgment delivered not by spirits, but by neighbors.

A woman accused of witchcraft sits outside her hut in a remote camp where roughly 80 other women, all banished from their communities, now live in exile.

“A man saw me in a dream, and the next day I was accused of being a witch… I went to the bush and wanted to kill myself.”

When I returned to northern Ghana in May 2025, I met Matis Awola, a widow who had been banished from her home just a month earlier. For her, a man’s dream became a living nightmare.

“A man saw me in a dream, and the next day I was accused of being a witch,” she tells me. “I went to the bush and wanted to kill myself.”

In April 2025, her son brought her to Gambaga, where she now lives in a tiny, windowless hut among approximately 80 other accused women. She survives by working on a local farm in exchange for food, clinging to the hope that she might one day return to her family.

Life in the camps is marked by relentless hardship. The women live in poverty and bear the burden of societal rejection—often ostracized even by their own families. They sleep on dirt floors in makeshift huts, relying on sparse donations from NGOs, churches, or well-wishers. Access to clean water, healthcare, and food is unreliable. Children who accompany their mothers or grandmothers are often bullied in school or pulled into street work, stigmatized as “witches’ children.”

Bachalbanueya has spent more than forty years in exile. Now in her eighties, she sits quietly outside her crumbling mud-brick hut. She was banished after her husband’s co-wife accused her of witchcraft following his death—grief weaponized into a lifetime of isolation.

Stories like hers are tragically common.

Bachalbanueya has lived in exile in Gambaga camp for women accused of witchcraft for forty-five years. She was banished after her husband’s co-wife accused her of witchcraft following his death.

“It is violence against women—a demonization of women,” says Professor John Azumah, Executive Director of The Sanneh Institute in Accra, which has long supported survivors and is part of a coalition pushing for legal reform.

Even in Western usage, the term ‘witch hunt’ reflects long-standing cultural beliefs that associate witches with evil—and overwhelmingly with women. While men can also be accused, accusations most often target women. Witchcraft itself is not always seen as evil, Azumah explains—but when it is believed to reside in a woman, it becomes feared and condemned. Male witches, by contrast, are often thought to use their powers for good.

Accused of witchcraft, women gather beneath a mango tree in the Gnani camp in northern Ghana on May 11, 2025. The camp is home to roughly 130 women and numerous children.

In the Kpatinga camp in northern Ghana, women accused of witchcraft crack groundnuts for a local farmer. Banished from their communities, they survive on informal labour, permitted to eat a portion of the nuts they shell.

Most of the women banished to camps are among society’s most vulnerable. “These women are the poorest of the poor,” says Azumah. “They have no child or relative well-off enough to speak for them—that’s why they’re languishing there. Women with educated children—those children get their mothers out. But these women have no one. They are truly the voiceless.”

Lamnatu Adam, Executive Director of Songtaba, a women’s rights organization in northern Ghana, echoes this view. “When men are spiritually strong, it’s said they use their power to protect the community and family,” she says. “But when women are known to be spiritually strong, it’s said they use it to cause harm, illness, and disaster.”

As a result, women—particularly older women—disproportionately bear the burden of accusation and exile.

“About 90% of the women who are accused are over 60 and without education,” says Adam. “They are very poor. Most don’t have children, and about 80% are widows.”

Barikisu Winbie was banished to Kpatinga camp in northern Ghana two months ago after being accused of witchcraft by her step-daughter.

Bachalbanueya has lived in the Gambaga camp for 45 years. After her husband died, the children of his other wife accused her of being a witch. Today, she is the longest-standing resident of the Gambaga camp in Ghana’s Northern Region..

Abdulia Meili, 68, has lived in the Kpatinga camp for women accused of witchcraft for almost five years.

One of the leaders of Gambaga camp, Zenabu Bogei, sits at the entrance of her makeshift hut, where she lives in exile alongside roughly 80 other women. All have been accused of witchcraft and cast out from their homes and communities, forced to seek refuge in this remote settlement.

Wudana Takura is pictured inside her hut at the Gambaga camp, one of Ghana’s oldest settlements for women accused of witchcraft.

Memonatu Yaw is pictured at the Kpatinga camp for women accused of witchcraft. The camp is home to around 40 women, all of whom have been banished from their communities following accusations. Isolated and impoverished, the women here live without access to their families or the freedoms they once knew—a stark reminder of the deep social stigma and injustice they continue to face.

Azumah traces the pattern of accusations to a blend of spiritual belief and calculated social exclusion. “It’s the oldest conspiracy theory of humankind,” he says. “And it is a form of misogyny.” Even a woman’s success—such as a bountiful harvest—can provoke jealousy. “They accuse her just to get her out of the community, then they take over her land.”

Sometimes, the danger comes from within the family. “Young men may genuinely believe their mothers are sabotaging their lives,” he adds. “They truly believe it.” In the end, he says, it’s scapegoating: “a conspiracy theory that has been used—and still is.”

Memonatu Yaw sits with the grandchild of a fellow resident at the Kpatinga camp, where around 40 women live in exile after being accused of witchcraft. Banished from their communities, these women endure poverty, isolation, and the enduring stigma of accusations that have stripped them of their families, freedoms, and rightful place in society. The stigma often extends to the children and grandchildren of the accused, as it is widely believed that spiritual powers can be inherited through birth, leaving generations marked by fear and discrimination.

Refuge or Prison?

There are now approximately six unofficial “witch camps” remaining in northern Ghana, situated near remote villages like Gambaga, Kpatinga, Gnani, and Kukuo. While these settlements may offer refuge from immediate danger, they also stand as stark reminders of social exclusion and the unresolved injustice the women continue to face.

As Professor Azumha puts it: “The camps are neither a refuge nor a prison, they are something in between.”

There are no fences or gates, yet most women do not feel free to leave. Many believe that returning home would bring illness, misfortune, or even death. Some were violently attacked before fleeing; others were quietly cast out by relatives seeking to rid the family of perceived spiritual danger. Beneath each case lies a deeply patriarchal worldview—one in which women, especially widows or those without male protectors, are easily targeted.

“There are no physical barriers keeping the women inside,” says Professor John Azumah. “But cultural and psychological ones are deeply entrenched. The women are made to believe that if they leave the camp, the spirits will kill them.”

The emotional toll is profound.

“I’m not happy because my children are not with me…. I just want to go home.”

Fusheina, a widow and mother of five, has lived in the Gnani camp for the past six years. She was accused of witchcraft by the chief of her village after the sudden death of her nephew. Expelled immediately, she now lives alone. “I’m not happy because my children are not with me,” she says sorrowfully. “I just want to go home.” But returning is not an option—she fears the villagers would harm her.

Life in the camp is extremely difficult, Fusheina adds. “There is no work. We don’t have a farm here, so we have no way of earning money.” She hasn’t seen her children in over two years.

Gambaga offers a more hopeful example. There, the Presbyterian Church has worked for decades to help restore dignity and agency, says Reverend Gladys Lariba Mahama, a minister who has supported the women since 1997. “In the past, when women were banished, no one asked about them,” she says. “But because of the church’s intervention, people now know them—and the whole world knows their story.”

“This place was established out of love and sympathy,” she continues. Referring to the camp as a “home,” Reverend Gladys explains that it was founded decades ago, when a local religious leader intervened to protect women accused of witchcraft. “Whenever they were accused, they would send them to the execution field to kill them. So this man—he was the imam of Gambaga—pleaded that they come here instead.”

Since the early 1960s, the Presbyterian Church of Ghana has supported the women by providing food, second-hand clothing, and helping to repair their modest homes. “Around 1994, the Church saw that they could do more,” she says. “So they came up with a proposal—the main purpose was to reintegrate the women into their original communities, ensure their health needs are met, send their children to school, and make life more comfortable for them here.”

Access to healthcare has also improved. “In the past, it was very difficult,” says Reverend Gladys. “But now, they can go to the health clinic, and no one even identifies them.”

Reverend Gladys Lariba delivers donations of second-hand clothing to the women of Gambaga camp.

Unlike other camps where tension or suspicion lingers between the women and local authorities, Gambaga stands apart. The women clearly trust Reverend Gladys. She moves easily through the compound, greeting them by name, exchanging warm smiles, and translating their stories with care.

“We are here every morning,” she says, just as an elderly woman approaches her with a gentle smile and a handshake. “We’re working hard now on the reintegration program. Many women travel home to visit and return. Some of their family members even come here to see them.”

Still, stigma remains. For most of the women, their families refuse to visit.

Gambaga’s central location—at the heart of the village rather than tucked away—offers a greater degree of integration. “They’re well integrated into Gambaga and the surrounding communities,” she says. “But sometimes, because of the humiliation and trauma they’ve endured, when you ask if they want to go home, some will say no.”

The Cost of Going Home

Reintegration comes at a cost—both symbolic and financial. For the few women who eventually return—sometimes years or even decades after being accused—the process depends on a traditional “cleansing” ritual intended to absolve them of alleged witchcraft. Performed by spiritual leaders, it typically involves the slaughter of a ram and a chicken and can cost over 1,000 Ghanaian Cedis (about $100 USD)—a prohibitive sum for many.

But even with support, reintegration is far from straightforward. In many cases, no amount of spiritual absolution or mediation is enough to convince families to accept a woman back. “Most of the communities say, ‘Even the exorcism—we don’t believe in it, because once a witch, forever a witch,’” says Professor John Azumah. “They believe in the diagnosis, but not the cure. When the same priest declares a woman a witch, they believe him. But when he says, ‘I can perform a ritual to free her of the spirit,’ they don’t believe that part.”

In Gambaga, the church often steps in. “When a woman wants to try to return home, we work on it,” says Reverend Gladys Lariba Mahama. “First, she has to go through purification. Then she can return to her community.”

For Ama Somani, a mother of eight, the church’s support changed everything.

“I wanted death because it was too painful,” she says, recalling her exile. She had been accused by her niece, who blamed her for a mysterious illness. A traditional ritual involving the slaughter of a guinea fowl found her guilty. With no one to defend her—her husband, a landlord in their community, remained absent—Ama spent four years in Gambaga, isolated and uncertain.

In April 2025, with help from the Presbyterian Church, she was finally reintegrated into her extended family in a nearby village. The church provided food rations and negotiated her return. Life remains difficult, she says—but she is overjoyed to be reunited with her children and loved ones.

Alongside the church, Professor Azumah and the Sanneh Institute—together with NGOs and human rights advocates—have worked tirelessly to reintegrate women across northern Ghana.

“Sometimes the accuser has died, or the situation in the village has changed, and the woman can safely return,” Azumah explains. “Sometimes the community regrets the accusation. They admit it came from jealousy or envy. They want the woman to come back. But first, she has to pay what I call the ‘discharge fee’—the cost of rituals to release her.”

These rituals, he adds, are what keep many women trapped. “Most can’t afford them. So even when they could return safely, they’re stuck—because they can’t pay for the ceremony that would set them free.” In some cases, as NGOs have stepped in to help, community leaders have raised prices, hoping donors will cover the costs. “They’ve inflated the fees astronomically,” says Azumah. “And so, the cycle continues.”

Ama Somani enters her home, where she now lives with her children after spending four years living in exile in Gambaga camp.

There are more photos after this but I can only add 30 to a post.

Despite these obstacles, organizations like ActionAid Ghana and Songtaba have helped reintegrate hundreds of women. “Overall, we’ve reintegrated not less than 600 people into their communities over the past 15 years,” says Esther Boateng, ActionAid’s Regional Manager for the Northern, Northeast, and Savannah Regions. “We identify their home communities, engage families, and involve the entire community—because it’s the same community that accused them.”

In 2014, ActionAid worked with the Ministry of Gender to shut down the Bonyasi camp in Central Gonja District after successfully reintegrating all of its residents. “We had to ensure their safety, so we combined community sensitization, radio education, and events like Mother’s Day celebrations to build acceptance,” says Boateng. “We even built houses for some women returning home. It was a fully integrated program—and today, Bonyasi camp no longer exists.”

Exploitation in Plain Sight

While witchcraft accusations are common across Ghana, and many other countries, the practice of banishing women to isolated camps is less prevalent. “Witchcraft is not just a Ghanaian thing. It’s very strong in Nigeria, in East Africa, Tanzania, South Africa. What is unique about Ghana is the camps in the north, says Professor Azumah.

Despite being established to provide a place of refuge for vulnerable women, sadly the camps are also sites of exploitation and abuse. “I don’t call it a refuge,” stresses Professor Azumah. “These are places of exploitation – the women there are exploited. Some of them are sexually abused, physically molested.”

Some women are forced to work without pay, fetching water or farming for community leaders and priests. There are credible reports of sexual abuse, and in at least one documented case, a priest fathered children with multiple women in a camp.

“People are making money out of it” adds Professor Azumah. “It has become an industry – it is a huge business for people there. The women are used for free labor by the community leaders in the rainy season, they make them go to their farms and cultivate their farms. They do all the work manually and all they get is whatever food they can give them there to eat that day to do the work, that’s all. They are not paid anything.”

Even humanitarian aid does not always reach its intended recipients. Community leaders—who often control the camps—have been accused of diverting food and money for personal use.

“These are not safe havens,” says Azumah. “They are places where society has abandoned its most vulnerable.”

Lamnatu Adam, Executive Director of Songtaba, a women’s rights organization in northern Ghana, speaks to Mohammed Abdulai, Chief of Gnani Camp for Alleged Witches during a visit to the camp to celebrate the twentieth anniversary of Songtaba.

A Glimpse into Belief: Spirits, Sickness, and Superstition

The persistence of witchcraft accusations in Ghana cannot be understood without acknowledging the deep-rooted belief in spirits, possession, and supernatural causality—beliefs that shape how many Ghanaians interpret illness, misfortune, and conflict.

During a visit to the stilt village of Nzulezu in Ghana’s Western Region in 2012, I witnessed just how deeply these convictions are held. One night, the wooden platform beneath me shuddered, waking me from sleep. Under a moonlit sky, I stepped outside the homestay hut and onto the creaking boardwalk. Across the water, silhouetted figures had gathered. Women wailed and chanted, a plume of smoke rising among them. A small child, wrapped in a blanket, was being passed gently from one person to another.

Curious and concerned, I asked what was happening. I was told the child had been possessed by an evil spirit.

Later, a man approached and asked if I could help. Unsure what to say, I suggested we take the child to the hospital to be tested for malaria. “No, no,” he replied, shaking his head. “We need to take out the evil spirit.” The ritual continued through the night.

The next morning, I saw a relative of the boy and asked how he was doing. With a broad smile of relief, the man said, “He’s much better.” I asked what had been wrong with him. “Malaria!” he answered.

This brief encounter has stayed with me for years. It revealed how central spiritual explanations are to daily life—and how illness and affliction are often viewed through a supernatural lens. In that context, it becomes easier to understand how, in moments of unexplained tragedy or fear, suspicion turns toward someone believed to possess malevolent power. Often, that someone is an older woman without protection.

Belief in witchcraft is very strong, explains Professor Azumah. “Medical doctors believe it, police officers believe it. Even judges believe it.”

Hope, and a Way Forward

What has struck me most on each visit to the camps is the remarkable resilience of the women who live there. Despite the extreme hardship and the isolation of exile—not just from society, but often from their own families—they maintain a quiet strength. Even amid rejection and poverty, the joyful spirit so beautifully woven into Ghanaian culture endures. “Happiness is free,” one woman told me with a smile.

Now, for the first time in years, there is a glimmer of hope. In March 2025, Ghana’s Parliament reintroduced a landmark piece of legislation: the Anti-Witchcraft Bill. If passed, it would outlaw the naming or accusing of someone as a witch, criminalize the spiritual consultations that often lead to accusations, hold ritual practitioners legally accountable, and empower police and social workers to intervene. Crucially, it also lays the groundwork for reintegration programs to support survivors returning to society.

The bill had previously passed Parliament in July 2023 as an amendment to the Criminal Offences Act, 1960, but Ghana’s former president refused to sign it into law. Reintroduced under a new administration, the bill is now scheduled for debate—what campaigners describe as a final, pivotal opportunity for change.

According to the bill, its primary objective is “to address the unfortunate beliefs and thinking in some communities that make Madam Akua Denteh’s case possible.” Her brutal murder in 2020 sparked national outrage and galvanized public support for reform.

The bill acknowledges that belief in witchcraft is not unique to Ghana. It cites England’s 1735 Witchcraft Act, which criminalized accusing someone of magical powers, and underscores the importance of public education and cultural transformation: “Now witchcraft is not illegal in the UK, but the level of enlightenment is such that witchcraft is generally viewed with amusement, if not ridicule.”

Civil society organizations such as ActionAid Ghana, Songtaba, and The Sanneh Institute have long championed these reforms, providing everything from public awareness campaigns to safe housing for survivors. Amnesty International has also urged Parliament to pass the bill without delay, warning that inaction continues to put hundreds of women at risk.

While many are hopeful that the current president will sign the bill if passed again, doubts persist. “It’s not a vote winner,” says Professor John Azumah.

Even after the widespread condemnation that followed Akua Denteh’s murder, resistance to reform remains entrenched. “We have our own conspiracy theories,” Azumah says when I ask why the previous president declined to sign the bill. “We believe there are powerful religious figures and some chiefs working behind the scenes to block it.”

Those fears haven’t disappeared. “That’s our concern with the current president too,” he continues. “If the bill is passed again and those chiefs and religious leaders start to pressure him behind closed doors, we might never even know. Politicians want votes. And they fear that pushing this through could hurt them in the next election.”

Among advocates, there is cautious optimism. Passing the bill is only the beginning. Real change will require coordinated implementation, sustained funding, and a long-term commitment from both government and civil society.

Even the bill itself acknowledges these challenges: “Legislation on such a subject may not immediately eliminate the problem, but it provides an awareness and a deterrent, which, if handled with the requisite public education and sensitisation, can eradicate the practice.”

“I think the passage of the legislation will significantly reduce the accusations,” says Azumah. “And over time, it will die out.”

“The accusation is the beginning of everything,” he adds. “If we stop it at the source, we can begin to address the issue. We’re not going to relent. We will keep pushing until this bill becomes law.”

A Nation at a Crossroads

Ghana now stands at a crossroads. The debate over the Anti-Witchcraft Bill is not just about superstition—it is about women’s rights, state responsibility, and the power of law to reshape cultural norms.

For survivors like Bachalbanueya, the bill may come too late to reclaim what was lost. But whether Ghana chooses to act now—or allows fear and silence to prevail—will determine not only the fate of women like her, but the moral direction of the nation itself.

PENDING REVISION 2024

Introduction: Pelvic Pain

Pelvic pain in transgender men can be a clinical challenge and has a broad differential diagnosis. Pelvic pain less than 6 months of duration is considered acute. Chronic pelvic pain, which is continuous or episodic pain in the lower abdomen or pelvis lasting more than 6 months, has a large differential.[1] History is a critical component to assessment and diagnosis. Key to the history is a detailed description of pain including onset, precipitating and palliating features, quality, radiation, severity and timing. A pain diary can be helpful to elucidate pain pattern and features and there are many available online.

The general approach to the workup of pelvic pain in transgender men is similar to that for non-transgender women. An anatomic approach to history gathering that considers urological, gynecologic, gastrointestinal, musculoskeletal, and psychological components is critical. Specific etiologies may be multifactorial, such as post-surgical adhesions with or without gastrointestinal symptoms, or endometriosis and/or pelvic floor muscle dysfunction. It is also critical to assess quality of life impact and determine what the patient would consider a favorable outcome. Most evaluation and treatment guidelines stress that chronic pelvic pain can be a diagnostic and therapeutic challenge, and success will depend on comprehensive and customized evaluation and multidisciplinary care.[2,3]

Etiologies

Specific medical etiologies to consider in transgender men include: atrophic or infectious vaginitis, cervicitis, cystitis, STIs, adhesions, post-surgical sequelae, musculoskeletal disorders, and neurogenic. Specific behavioral etiologies to consider include: depression, history of emotional trauma (including sexual assault or abuse, adverse childhood events),[4] and post-traumatic stress disorder. The use of testosterone has a dose dependent effect on vaginal tissue by inducing a hypoestrogenic state which promotes atrophy, increases vaginal pH and thus increases the risk of vaginitis and cervicitis. Additionally, transgender men may have decreased access to or utilization of screening and therefore treatment for cervicitis and sexually transmitted infections.[5-7] Prior surgery may cause adhesions, scar tissue, bladder dysfunction, or nerve injury, which may lead to a lack of visceral mobility and contribute to pain.[8] It is unclear to what extent post-surgical adhesions cause pain independently, or via secondary mechanisms such as constriction or incarceration of other organs. Transgender men who have pelvic pain after hysterectomy but have retained one or both ovaries/gonads should be screened for a gonadal pathology. The interaction between a genotypic female skeleton and increased muscle mass as a result of testosterone therapy may result in changes in postural carriage. Additionally, recent and/or history of sexual trauma may be exacerbated among those with gender minority status. Engaging with medical professionals can be re-traumatizing in this setting; in all cases a trauma informed approach external site (opens in a new window) should be taken.[9]

Taking a pelvic pain history

The initial history should include a menstrual history including age of onset, frequency of menses or cyclical menstrual-like symptoms even if amenorrheic, duration of menses, last menstrual period, and if amenorrheic, for how long. Also assess for use of pain medication, and any association with testosterone dosing cycles. A comprehensive sexual history, including assessing for specific behaviors with other individuals such as (vaginal-vaginal), vaginal or anal or receptive penile sex, recognizing that many transgender men may engage in receptive vaginal sex.[10] Assess for potential risk of pregnancy and ectopic pregnancy; transgender men who have receptive vaginal sex with a partner with sperm are at risk for unintended pregnancy, including ovulation and conception without preceding menstrual bleeding. Also note any history of pelvic inflammatory disease. A surgical history should note for history of an open, laparoscopic or vaginal approach to inform suspicions of scar tissue and adhesions and subsequent symptomatology. Note any specific risks such as a ruptured appendix or history of pelvic inflammatory disease (PID). Other history should include screens for adverse childhood events, current domestic violence, and for substance use and overuse, including tobacco.

Physical exam

On exam assess for involvement of various abdominopelvic organs, including a check for costo-vertebral angle tenderness, palpation of the abdominal wall, noting any particular tenderness along prior surgical scars or point tenderness along scars or the abdominal wall in general. Palpate the bladder for localized sensitivity, and palpate the abdomen for visceral organ involvement. Consider a speculum exam only if clearly indicated, noting vaginal discharge or any evidence of vaginitis, and assess the general condition of vaginal tissues and the cervix. If a pelvic exam is necessary, consider starting with a pediatric speculum. If a bimanual exam is performed, note any cervical, adnexal or ovarian tenderness to palpation.[5] Also assess sensation in the vulvar area with cotton tipped nerve testing as well as sharp/dull differentiation, and examine of the pelvic floor via palpation of the obturator internus (two-digit exam with palpation of muscles at 4 to 5 o'clock and 7 to 8 o'clock; pain on flexion of the two fingers at these locations suggests pelvic floor dysfunction). Also if indicated consider a rectal exam, noting masses, tenderness, or hardened stool. Laboratory testing includes a urinalysis and culture, testing for Chlamydia and gonorrhea, vaginal pH, vaginal wet mount and KOH prep, and possibly a vaginal culture. A pregnancy test should be considered, however some patients who are not sexually active with someone capable of insemination may be offended by the suggestion of this test. It is best to explain to patients in advance that this test is part of a standard protocol, and if it is certain that pregnancy is not possible based on sexual behaviors, a pregnancy test may be omitted. Imaging should be performed using transabdominal or transvaginal ultrasound; in those men who have had a vaginectomy, a transrectal ultrasound may be an option. Some transgender men may decline vaginal ultrasound and/or bimanual exams due to potential exacerbation of gender dysphoria. These patients should not be forced to undergo a pelvic examination. In these cases proceed with an abdominal exam as well as laboratory and transabdominal ultrasound for the initial workup. Specifically for transgender men, critical components of the assessment include timing of pain and associated symptoms in relation to initiation of testosterone therapy, moliminal timing (symptoms in relation to an expected menstrual cycle) even in the presence of amenorrhea, and a detailed history of prior surgeries and related organ inventory.

Testosterone-induced dyspareunia, vaginitis, and cervicitis

The use of testosterone often results in estrogen deficient, atrophic vaginal tissues akin to a post-menopausal state in cisgender women.[11-13] These atrophic vaginal tissues represent a decline in tissue resilience, skin barrier function, and increased susceptibility to altered microbial environment and resistance which may result in bacterial vaginosis, cystitis, or cervicitis.[14] Additionally, thin atrophic vaginal tissues are more susceptible to traumatic irritation from friction and sexual contact,[13] which may result in atrophic dyspareunia or vaginitis. Symptoms are often described as "rough" "sand-paper" and "burning" or "dry" vaginal irritation. Visual inspection consistent with atrophy will demonstrate thin pale tissues, a loss of rugae, loss of elasticity, friability, and dryness. It is also possible to find hyperemic, deep red vaginal tissue. Bacterial vaginosis is more common in the estrogen-deprived state. Wet mount, vaginal culture, vaginal pH and STI testing can aid in directing treatment. Interstitial cystitis should be considered when infectious causes have been rules out and symptoms localize to the urinary bladder. Vaginal estrogen to treat underlying atrophy may be warranted and a short course may be successful in restoring comfort. Patients may be reassured that vaginal estrogen is associated with minimal systemic absorption and should not interfere with the desired effects of Testosterone. Other therapeutic approaches may include vaginal lubricants or vaginal moisturizers.[15]

Cyclic symptoms relating to testosterone dosing

Transgender men on testosterone may complain of pain that is associated with cyclical testosterone dosing, pelvic, and/or vaginal pain with penetration (with penis, fingers, dildo, etc.), or orgasmic pain. The etiology of post-testosterone administration cramping is unclear. In one cross-sectional study 20% of respondents had a hysterectomy to decrease post-testosterone cramping and another 22% to stop "extreme bleeding and cramping."[16] Trauma informed care can be effective, as are other treatments used for chronic pelvic pain such as pelvic floor therapy, vaginal lubrication with unscented products, or the use of tricyclic antidepressants.

Co-occurring mental health conditions

As with any pain syndrome, patients with chronic pelvic pain should be evaluated for depression and post-traumatic stress disorder (PTSD). These conditions may be simultaneously present in up to 35% of non-transgender female patients with chronic pelvic pain.[1] Multiple studies link adverse childhood events with increased incidence of chronic pain and depression. Pre-existing depression may exacerbate pelvic pain. Conversely, pelvic pain and living with a chronic pain condition may result in depression. A high percentage of those who have undergone sexual assault develop PTSD, and many of those who have PTSD may develop pelvic floor muscle dysfunction and pain.[17,18] The presence of pelvic pain as well as the related workup and evaluation may trigger PTSD, especially if such trauma relates to a prior sexual assault or otherwise involves the lower abdomen and pelvis. These symptoms may be even greater in transgender men for whom examination of genital and reproductive organs may be particularly challenging and triggering of gender dysphoria, and result in avoidance of pelvic exams.[19] Collaboration with a specialist in mental health can be an important adjunct to pathophysiological evaluation and treatment.

Pharmacologic management

The initial approach to management should include NSAIDS, with other pain management medications used as indicated and appropriate. Changing to a more even testosterone transdermal testosterone regimen, or adding a progestogen such as the levonorgestrel IUD may address underlying hormonal causes.

Role of hysterectomy

In addition to non-surgical approaches, in some cases hysterectomy may have a role in the management of pelvic pain. Depending on the preferences and reproductive goals of an individual patient, gynecologists may revise their therapeutic approach to consider hysterectomy earlier than they might in non-transgender women (Grading: X C S). At the same time hysterectomy should not be viewed as a cure-all, and in some cases is not effective in improving pain. For this reason, transgender men with pelvic pain must be evaluated on a case-by-case basis due to the lack of evidence-based guidance at this time. Decision to perform oophorectomy should be based on the etiology of pelvic pain, presence of comorbidities, future fertility desires, and any future plans to stop taking testosterone.

Management of specific symptoms and syndromes

If pain is vulvar and there are no identifiable lesions or infections, Consider the use of topical 2-5% topical lidocaine placed on soaked cotton-ball and left in the vestibule overnight for general pain relief, or for 30 minutes prior to sexual activity as desired.

If pain is vulvar and exam is consistent with vaginal atrophy in the setting of testosterone administration, consider a short course of vaginal estrogen in doses and administration similar to that used for post-menopausal non-transgender women. Patients who are uncomfortable with intravaginal use may be instructed to place treatment cream on their external genitalia. Choice between tablets, creams, and rings depends on patient preference and formulary considerations.[20]

If pain is triggered by pelvic floor muscle palpation, consider referral to pelvic floor physical therapy, pelvic floor relaxation exercises, and even guided instruction on massage using self or partner's fingers or a massage tool.

If pain is abdominal, present in the abdominal wall or associated with abdominal scar tissue, consider treatment with 1% lidocaine instilled at trigger points in repeated administration.

If transvaginal ultrasound is required, consider a low-dose benzodiazepine such as lorazepam 0.5mg orally, 30 minutes prior to the procedure, in coordination with administration of 2-5% lidocaine ointment applied to the vulva and vagina 10 minutes prior to the procedure. Some patients may feel safer and more comfortable placing the ultrasound probe intra-vaginally themselves. These approaches may also be used in advance of a pelvic examination.

Introduction: Persistent menses and unexpected vaginal bleeding

Many transgender men chose not to undergo hysterectomy, oophorectomy and/or gender affirming genital procedures.[19,21,22] For transgender men of reproductive age undergoing transition without hormones, or those whom have used testosterone and later discontinued it due to unwanted side effects such as balding, menses would be expected to be within standard reference ranges from 21-35 days between cycles with no inter-menstrual bleeding and lasting on average 2-6 days and ceasing on average at age 49.[23] Variation from these ranges warrants further gynecological investigation.

For those transgender men using physiologic doses of testosterone, cessation of menses is expected, typically within 6 months. Cessation of menses is driven by a combination of testosterone induced ovulation suppression, which may be incomplete, and endometrial atrophy.[12] However, the time to cessation of menses may vary. Factors that affect time to cessation of menses likely include: dose of testosterone, route of administration, frequency of testosterone administration, presence and functioning of ovaries, body habitus, and the presence of other structural or non-structural medical conditions of the uterus or ovaries. Transgender men with a history of abnormal cycles prior to initiating testosterone (e.g. frequent cycles, heavy irregular bleeding) may have underlying pathology, which could result in a prolonged or complicated path to cessation of menses once on testosterone. Therefore in patients with risk factors for endometrial hyperplasia and a degree of clinical suspicion, evaluation for and elimination of known causes of irregular bleeding should be considered concurrent with testosterone administration; those with pre-existing amenorrhea or oligomenorrhea may require evaluation for endometrial abnormalities prior to initiating testosterone. This includes ruling out pregnancy in transmen who are sexually active with partners who produce sperm.

Etiologies

Abnormal uterine bleeding (AUB) may be considered present in those who have continued bleeding after 6-12 months of male-range testosterone levels and suppressed LH and FSH. AUB may be related to a variety of structural and non-structural causes. These causes can be summarized by the internationally recognized Federation of Gynecology and Obstetrics (FIGO) PALM-COEIN classification system.[24] Structural causes of AUB include: endometrial polyps, adenomyosis, leiomyomata, endometrial hyperplasia, or malignancy. As a group these are best evaluated with imaging and endometrial biopsy. Despite prior suggestions that endometrial cancer risk may be increased in transgender men on testosterone,[25] longer-term data do not support this risk.[26] Non-structural causes of AUB include: pregnancy, coagulopathy, ovulatory dysfunction, endometrial, or iatrogenic causes. While the gold standard for pelvic imaging is transvaginal ultrasound, other approaches such as a sonohysterogram, transabdominal ultrasound, CT scan, or MRI may be warranted. Both structural and non-structural causes should be investigated in consultation with a gynecologist. The decision to pursue transvaginal ultrasonography or endometrial biopsy should not be taken lightly in transgender men who may find these procedures invasive. Noninvasive diagnostic approaches such as watchful waiting for induction of amenorrhea 6 months after initiation of testosterone, observing for a withdrawal bleed after a progestin challenge, or use of a transabdominal approach to ultrasonography should all be considered. Persistent menses despite testosterone may also be related to body habitus; those with higher levels of body adipose tissue have higher endogenous estrogen levels and increased conversion of testosterone to estradiol through the peripheral aromatization process.

Therapeutic approaches based on etiology

Increasing the dosage and frequency of dosing (1 and 2 weeks) of intramuscular testosterone has been found to be positively correlated with rapidity of amenorrhea induction.[27] The time to cessation of menses has been reported as ranging from 1-13 months [27-31] and in addition to individual genetic and physiologic factors may very well depend on the formulation or route of testosterone administration.[28]

Physiologically, amenorrhea induction rates should correlate to increased testosterone levels (to physiologic male range) as well as possible decreased estrogen levels seen with androgen therapy, however many will achieve amenorrhea despite elevated estrogen levels and sub-physiologic male testosterone levels. For example, one study of transgender men presenting for initiation of cross-sex hormones found that 84% of those completing the study were amenorrheic at 6 months. This was despite many only 58% achieving physiologic male total testosterone levels and 68% achieving physiologic male free testosterone levels.[30] However in the setting of persistent menses, adjustment of hormone regimen and dosing may be appropriate. The addition of an oral, injected, implanted, or intrauterine (IUD) progestogen may serve as an adjunct to induction of amenorrhea. Endometrial ablation can be considered [31] for those transgender men who do not desire future fertility and who also either decline hysterectomy or have surgical complications. The levonorgestrel intrauterine system (IUS/IUD), which in non-transgender women can either significantly decrease menstrual flow or fully induce amenorrhea, has the added contraceptive benefit for those at risk since some may still ovulate despite male physiologic testosterone levels.[32]

Aromatase inhibitors (AIs) such as anastrazole or letrozole may be considered as short-term adjunctive therapy in achieving amenorrhea for those with persistent menses on testosterone. Aromatase is expressed throughout the body including the ovaries, endometrium, skin, bone, breast, brain and adipose tissue. AIs have been used for the treatment of estrogen receptor positive breast cancer, endometriosis, and ovulation induction. AIs have also been shown to reduce vaginal bleeding and pelvic pain in combination with other hormone therapies such as progestins or combined oral contraceptives.[33-35] In non-transgender women, treatment with AIs without add-back estrogen therapy has led to symptoms of medical menopause: hot-flashes, arthralgias, mood disturbances, fatigue, vaginal dryness, decreased bone mineral density, and fractures.[36] In transgender men concurrently using testosterone, these symptoms may be attenuated or even absent.

ABSTRACT We initiated this research in order to address some of the issues that have arisen in discussions about the nature of prostitution. In particular: is prostitution just a job or is it a violation of human rights? From the authors' perspective, prostitution is an act of violence against women; it is an act which is intrinsically traumatizing to the person being prostituted. We interviewed 475 people (including women, men and the transgendered) currently and recently prostituted in five countries (South Africa, Thailand, Turkey, USA, Zambia). In response to questionnaires which inquired about current and lifetime history of physical and sexual violence, what was needed in order to leave prostitution and current symptoms of post-traumatic stress disorder (PTSD) we found that violence marked the lives of these prostituted people. Across countries, 73 percent reported physical assault in prostitution, 62 percent reported having been raped since entering prostitution, 67 percent met criteria for a diagnosis of PTSD. On average, 92 percent stated that they wanted to leave prostitution. We investigated effects of race, and whether the person was prostituted on the street or in a brothel. Despite limitations of sample selection, these findings suggest that the harm of prostitution is not culture-bound. Prostitution is discussed as violence and human rights violation.

INTRODUCTION In an effort to document the experiences of women in prostitution, we interviewed and administered psychological tests to 475 people currently and recently prostituted in five countries (South Africa, Thailand, Turkey, USA, Zambia). These people live in social and legal contexts defining them variously as hated and filthy women, criminals and 'sex workers'. We inquired about respondents' histories of violence in childhood, and in adult prostitution. For many, these two historical periods overlapped. Since violence is associated with psychological trauma, we also inquired about the severity of current symptoms of posttraumatic stress disorder (PTSD). We began this work from the perspective that prostitution itself is violence against women. The authors understand prostitution to be a sequela of childhood sexual abuse; understand that racism is inextricably connected to sexism in prostitution; understand that prostitution is domestic violence, and in many instances -- slavery or debt bondage; and we also understand the need for asylum and culturally relevant treatment when considering escape or treatment options for those in prostitution. The perspective that prostitution is violence against women and other political perspectives on prostitution have been described and critiqued by Jeffreys (1997). Another viewpoint considers prostitution to be an issue which primarily involves economic and sexual determination (Bell, 1994). Prostitutes' rights advocates understand prostitution as just another job, a vocation that they should have a choice to make, and as sexual liberation. Alexander (1996) commented on the advantage to the prostitutes' rights movement brought about by the AIDS epidemic. HIV has indirectly facilitated the growth of the commercial sex industry by funding outreach programs which provide sex workers with a safesex education, condoms, union-style organizing and by legitimizing prostitution as commercial sex work. Customers' anxieties about contracting HIV from those in prostitution has further created a vast pool of research and education monies. The contribution of this study to these differing perspectives will be discussed later.

Sexual and other physical violence is the normative experience for women in prostitution. This has been clinically noted by all four authors, and reported by others (Baldwin, 1992; Farley and Barkan, 1998; Hunter, 1994; McKeganey and Barnard, 1996; Silbert and Pines, 1982; Vanwesenbeeck, 1994). Noting 'everpresent' violence against 361 prostituted women in Glasgow, UK, McKeganey and Barnard (1996) described a range of violent behaviors against women in prostitution ranging from name-calling to physical assault, rape and murder. Of the prostituted women interviewed by Hoigard and Finstad (1992) in Norway, 73 percent were exposed to acts of violence -- physical assaults, rapes, confinement and threats of murder. The remaining 27 percent spoke of the extreme violence which had victimized their friends. The Council for Prostitution Alternatives in Portland, Oregon, USA, reported that prostituted women were raped about once a week (Hunter, 1994). A Canadian report on prostitution and pornography found that women and girls in prostitution had a mortality rate 40 times higher than the national average (Baldwin, 1992). The diagnosis of PTSD describes psychological symptoms which result from violent trauma. In the language of the American Psychiatric Association (1994), PTSD can result when people have experienced:

. . . extreme traumatic stressors involving direct personal experience of an event that involves actual or threatened death or serious injury; or other threat to one's personal integrity; or witnessing an event that involves death, injury or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate.

In response to these events, the person with PTSD experiences fear and helplessness.

Exposure to any of these events may lead to the formation of symptoms of PTSD. These symptoms are grouped into three categories: symptoms of traumatic re- experiencing (items 1-4 in Table 1); efforts to avoid stimuli which are similar to the trauma as well as a general numbing of responsiveness (items 5-11); and symptoms of autonomic nervous system hyperarousal (items 12-17).

Authors of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) comment that PTSD may be especially severe or long-lasting when the stressor is of human design (e.g. torture, rape).

The following are two examples of symptoms of PTSD: many years after escaping from prostitution, an Okinawan woman who was purchased by US military personnel during the Vietnam War became extremely agitated and had flashbacks of sexual assaults on the 15th and 30th of each month -- those days which were US military paydays (Sturdevant and Stoltzfus, 1992). Describing symptoms which were ignored by her counselor, a survivor of prostitution from the USA stated:

I wonder why I keep going to therapists and telling them I can't sleep, and I have nightmares. They pass right over the fact that I was a prostitute and I was beaten with 2 x 4 boards, I had my fingers and toes broken by a pimp, and I was raped more than 30 times. Why do they ignore that? (Farley and Barkan, 1998).

The symptoms of PTSD may be cumulative over one's lifetime. Several studies report a positive correlation between a history of childhood sexual assault and symptoms of PTSD in adult women (Farley and Keaney, 1994, 1997; Rodriguez et al., 1997). Since almost all prostituted women have histories of childhood sexual abuse, this undoubtedly contributes to their current symptoms of post-traumatic stress.

Prolonged and repeated trauma usually precedes entry into prostitution. From 55 to 90 percent of those in prostitution report a childhood sexual abuse history (Bagley and Young, 1987; Belton, 1992; Farley and Barkan, 1998; Harlan et al., 1981; James and Meyerding, 1977; Silbert and Pines, 1981, 1983; Simons and Whitbeck, 1991). Silbert and Pines (1981, 1983) noted that 70 percent of their sample told them that the earlier sexual abuse had an influence on the later ,choice' to become a prostitute. A conservative estimate of the average age of recruitment into prostitution in the USA is 13-14 years (Silbert and Pines, 1982; Weisberg, 1985). Any distinction between prostitution of children and prostitution of adults is arbitrary, and obscures this lengthy history of trauma. The 15-year-old in prostitution eventually turns 18, but she has not suddenly made a new vocational choice. She simply continues to be exploited by customers and pimps.

A number of authors (e.g. Barry, 1995; Hoigard and Finstad, 1992; Leidholdt, 1993; Ross et al., 1990; Vanwesenbeeck, 1994) have described the psychological defenses which are necessitated by the experience of prostitution, and which frequently persist: splitting off certain kinds of awareness and memories, disembodiment, dissociation, amnesia, hiding one's real self (often until the nonprostituted self begins to blur), depersonalization, denial. One woman said, 'Only my head belongs to me now. I've left my body on the street' (Hoigard and Finstad, 1992).

Some have criticized the application of any psychiatric terminology to women who have been harmed by the sexism, racism or class prejudice which comprises male supremacy. There is an assumption that the oppression is dismissed once a psychiatric diagnosis is applied. Pejorative terms such as 'masochistic', 'deviant' or 'borderline' have certainly caused pain and sometimes additional harm to women in prostitution.

On the other hand, the concept of PTSD has been important in describing the psychological symptoms suffered by combat veterans, sexual abuse survivors, concentration camp survivors -- and it may also be useful in describing the psychological harm of prostitution. The authors' experience is that when the trauma- related symptoms of PTSD are discussed, survivors of prostitution feel less stigmatized, less 'crazy' and may experience relief at having their symptoms named. Attaching a name to symptoms associated with severe trauma makes it possible for survivors of prostitution to learn about their own and others' experiences. Further, it becomes possible for survivors to organize politically around their own health needs, just as gay men have organized around HIV.

The diagnosis of PTSD is a departure both from the biological viewpoint that psychological symptoms are essentially biochemical in origin and from the psychoanalytic notion that psychological symptoms result from intrapsychic turmoil. The diagnosis of PTSD requires an external stressor, clearly implying that psychological symptoms result from material conditions that oppress women. The diagnosis of PTSD alone, however, does not completely articulate the extent of the psychological harm caused by prostitution. Over time, the constant violence of prostitution, the constant humiliation, and the social indignity and misogyny, result in personality changes. Herman (1992) described long-term changes in trauma survivors' emotional regulation, changes in consciousness, changes in self- perception, changes in perception of perpetrator(s), changes in relations with others, and changes in systems of meaning. These personality changes have been called complex PTSD by Herman and others. Describing prostitution, one woman said: It's a process. The first year was like a big party, but eventually progressed downward to the emptiest void of hopelessness. I ended up desensitized, completely deadened, not able to have good feelings because I was on 'void' all the time.

Herman saw these symptoms as resulting from a history of subjection to totalitarian control over a prolonged period, and noted that organized sexual exploitation may be one cause of complex PTSD. The violence of pimps is aimed not only at punishment and control of women in prostitution, but at establishing their worthlessness and invisibility (Dworkin, 1997; Patterson, 1982). The hatred and contempt aimed at those in prostitution is ultimately internalized. The resulting self-hatred and lack of self-respect are extremely long-lasting.

Graham et al. (1994) have also described the psychological consequences of being in prostitution. The Stockholm syndrome -- a psychological strategy for survival in captivity -- is useful in explaining the traumatic bonding which occurs between women in prostitution and their pimps/captors. When a person holds life-or-death power over another, small kindnesses are perceived with immense gratitude. In order to survive on a day-to-day basis, it is necessary to deny the extent of harm which pimps and customers are capable of inflicting. Survival of the person in prostitution depends on her ability to predict others' behavior. So she develops a vigilant attention to the pimp's needs and may ultimately identify with his view of the world. This increases her chances for survival, as did Patty Hearst's identification with her captors' ideology. Graham described other behaviors which are typical of the Stockholm syndrome: extreme difficulty leaving one's captor and a long-term fear of retaliation.

Barry (1995) and Giobbe et al. (1990) estimate that at least 90 percent of prostitution is pimp-controlled. Sexual and physical abuse and torture are used by pimps to keep women from escaping prostitution (Barry, 1995; Dworkin, 1997; Hunter, 1994; MacKinnon, 1993). Pimps in Washington, DC, USA, employ ,catchers' -- thugs who stand guard at the borders of their turf and 'catch' girls trying to escape from prostitution (Michelle J. Anderson, personal communication, 1996).

Houskamp and Foy (199 1) suggested that a primary etiological variable for the development of PTSD in battered women is the extent of violence to which they have been subjected. Giobbe et al. (1990) compared prostitution to other forms of domestic violence. They described methods of coercive control exercised by pimps and customers over women in prostitution which are identical to the methods used by battering men to control women: isolation, verbal abuse, economic control, threats and physical intimidation, denial of harm and sexual assault used as a means of control.

Although the incidence of PTSD has been investigated among battered women, and ranges from 45 percent to as high as 84 percent (Houskamp and Foy, 1991; Kemp et al., 1991; Saunders, 1994) -- the frequency of the diagnosis has not been investigated among prostituted women, who are exposed to the same violence as battered women.

PTSD has been assessed in people from non-Western cultures, such as Southeast Asian refugees, Latin American disaster survivors, Navajo and Sioux Vietnam veterans (Marsella et al., 1996). A recent review of the PTSD literature noted that its major limitation is that many of the most traumatized populations have not been studied (de Girolamo and McFarlane, 1996; Keane et al., 1996). Our study documents, across several cultures, some of the violence and traumatic stress which result from being prostituted.

METHOD

Brief structured interviews of people in prostitution were conducted in San Francisco, CA, USA; in two cities in Thailand; in Lusaka, Zambia; in Istanbul, Turkey; and in two cities in South Africa. These countries were included in the study in part because of the first author's wish to include a majority of women of color, since globally prostitution exploits vast numbers of women of color. Second, all four authors shared a commitment to the project of documenting the experiences of women in prostitution, and to providing options for escape.

If respondents indicated that they were working as prostitutes, they were asked to respond to a 23-item questionnaire which asked about the following: physical and sexual assault in prostitution; lifetime history of physical and sexual violence; and the use of or making of pornography during prostitution. The questionnaire asked whether respondents wished to leave prostitution and what they needed in order to leave. We asked if they had been homeless; if they had physical health problems; and if they had a problem with drugs or alcohol or both.

Respondents also completed the PCL, a 17-item scale which assesses DSM-IV symptoms of PTSD (Weathers et al., 1993). Respondents were asked to rate the 17 symptoms of PTSD (see Table 1) on a scale where: I = not at all; 2 = a little bit; 3 = moderately; 4 = quite a bit; and 5 = extremely. Weathers et al. (1993) report PCL test-retest reliability of .96; internal consistency, as measured by an alpha coefficient, was .97 for all 17 items. Validity of the scale is reflected in its strong correlations with the Mississippi Scale (.93); the PK scale of the MMPI-2 (.77); and the Impact of Event Scale (.90). The PCL has functioned comparably across ethnic subcultures in the USA (Keane et al., 1996).

We measured symptoms of PTSD in three ways. First, using a procedure established by the authors of the scale, we generated a measure of overall PTSD symptom severity by summing respondents' ratings across all 17 items.

Second, using Weathers et al.'s (1993) scoring suggestion, we considered a score of 3 or above on a given PCL item to be a symptom of PTSD. Using those scores of 3 or above, we then noted whether each respondent met criteria for a diagnosis of PTSD. PTSD consists of three kinds of symptoms: persistent, intrusive re- experiencing of trauma (B symptoms); numbing of responsiveness and persistent avoidance of stimuli associated with trauma (C symptoms); and persistent autonomic hyperarousal (D symptoms). A diagnosis of PTSD requires at least one B symptom, three C symptoms, and two D symptoms. We report the numbers and percentages of respondents who qualified for a diagnosis of PTSD in each country.

Third, we measured partial PTSD, following Houskamp and Foy (1991) who investigated PTSD among battered women. These authors suggested that if a person meets at least two of the three foregoing criteria for PTSD, a significant degree of psychological impairment exists. We report the numbers and percentages of respondents who qualified for a diagnosis of partial PTSD in each country. The two questionnaires were translated into Thai and Turkish. In Zambia, interviewers translated verbally as needed -most participants spoke some English. The authors either administered or directly supervised the administration of all questionnaires.

In San Francisco, we interviewed 130 respondents on the street who verbally confirmed that they were prostituting. We interviewed respondents in four different areas in San Francisco where people worked as prostitutes.

In Thailand, we interviewed several of the I 10 respondents on the street, but found that pimps did not allow those they controlled to answer our questions. We interviewed some respondents at a beauty parlor which offered a supportive atmosphere. The majority of the Thai respondents were interviewed at an agency in northern Thailand that offered nonjudgmental support and job training.

We interviewed 68 prostituted people in Johannesburg and Capetown, South Africa, in brothels, on the street and at a drop-in center.

We interviewed 117 women currently and formerly prostituted at TASINTHA in Lusaka, Zambia. TASINTHA is a nongovernmental organization which offers food, vocational training and community to approximately 600 prostituted women a week.

In Turkey, some women work legally in brothels which are privately owned and controlled by local commissions composed of physicians, police and others who are 'in charge of public morality'. We were not permitted to interview women in brothels, so we interviewed 50 prostituted women who were brought to a hospital in Istanbul by police for the purpose of venereal disease control.

In two of the five countries, respondents were racially diverse. In the USA, 39 percent (51) of the 130 interviewees were white European/American, 33 percent (43) were African American, 18 percent (24) were Latina, 6 percent (8) were Asian or Pacific Islander and 5 percent (4) described themselves as of mixed race or left the question blank. In South Africa, 50 percent (34) were white European; 29 percent (20) were African or Black; 12 percent (8) described themselves as Colored or Brown or of mixed race; 3 percent (2) were Indian; 6 percent (4) left the question blank.

We included transgendered people in this study because they represent a significant minority of those in prostitution. A previous study (Farley and Barkan, 1998) found that transgendered persons experienced the same degree of physical assaults and rapes as did women in prostitution. These authors concluded that to be female, or to appear female, was to be targeted for violence in prostitution. In Turkey and Zambia, all respondents were women. Table 2 below describes gender of respondents in South Africa, Thailand, and the USA.

The most daunting challenge in cross-cultural research is sample selection. Were the 475 people we interviewed representative of all women in prostitution? We attempted, as McKeganey and Barnard (1996) did in Glasgow, UK, to contact as broad as possible a range of those in prostitution: women of diverse races, cultures, ages, location where working, and including gender differences. However, 'there is quite simply no such thing as a representative sample of women selling sex' (McKeganey and Barnard, 1996). Given the illegality of prostitution in most places, it was necessary to interview those people to whom we had access. In most cases, researchers have access only to people prostituting on the street. We were fortunate that, in South Africa, we were able to interview 25 people in brothel prostitution.

Should it become possible to interview those in massage parlors, escort services, stripping, or others who are in brothel prostitution -- the authors would immediately include these people in a future expansion of this work. We will also share our questionnaires with researchers who have access to these groups of people.

There were differences in the ways the samples were selected. In all cases, we interviewed people who were either currently in prostitution or had recently been prostituted. In the USA and South Africa, all were currently prostituting, whereas a higher proportion of respondents in Thailand and Zambia were actively attempting to leave prostitution and find other employment. Respondents in Turkey were interviewed after they were brought to a clinic by police for STD testing. In Istanbul, as elsewhere in this study, women in prostitution were freely offered STD testing, but other acute and chronic health problems were rarely addressed.

Part Two of Three

RESULTS

In most countries, regardless of the legal status of prostitution, interviewing of people in this study was periodically obstructed by others who controlled their lives, whether brothel operators (Turkey) or pimps/boyfriends (USA), or older women hired to guard those in prostitution (Thailand). Thus recruitment was necessarily opportunistic, relying on the discovery and utilization of sites where these prostituted people were away from the supervision of those who pimped them. This opportunistic sampling means that these samples may or may not be representative of the actual populations of those prostituted in each country. Nevertheless, comparisons of the results from the different countries suggest some noteworthy similarities, as well as differences.

Violence marked the lives of these prostituted people from five countries (see Tables 4 and 5). Since not everyone answered every question, the numbers of responses to a given item varied. Averaging across countries, 81 percent reported being physically threatened in prostitution; 73 percent had been physically assaulted in prostitution; and 68 percent had been threatened with a weapon. In Istanbul, 46 percent of these respondents reported physical assaults by police e.g. being kicked, beaten, or hit with a nightstick.

An average of 62 percent of the respondents from five countries told us that they had been raped since entering prostitution. Of those who were raped, 46 percent had been raped more than five times. Of these 475 respondents, 41 percent reported that they had been upset by attempts to coerce them into imitating pornography and 46 percent had pornography made of them while in prostitution.

An average of 54 percent of these interviewees reported that as children they were beaten by a caregiver to the point of injury. And 58 percent reported sexual abuse as children, with an average of four perpetrators.

Of these respondents, 72 percent reported current or past homelessness, with 61 percent reporting a current physical health problem; 52 percent reported a problem with alcohol addiction; and 45 percent reported a problem with drug addiction. In some of the countries, these percentages were much higher (see Table 5).

We found differences in lifetime and current experiences of violence, based on country. There were statistically significant differences in the experience of physical threat in prostitution (chi square = 105.37; d.f. = 4; p = .000); also in the experience of physical assault in prostitution (chi square = 27.30; d.f. = 4; p = .000); and in rape in prostitution (chi square = 17.79; d.f. = 4; p = .001). Similarly, there were significant differences, by country, in report of childhood physical abuse (chi square = 20.73; d.f. = 4; p = .000) and childhood sexual abuse (chi square = 47.43; d.f. = 4; p = .000). The mean PTSD severities fell in a narrow range from 51 (Thailand) to 56 (South Africa) (see Table 6). Differences between the five countries' mean PTSD severities were not statistically significant (F = 1.33; d.f. = 4, 397; p = .41). Average PTSD severities across the five countries were slightly higher than treatment-seeking US Vietnam veterans (Weathers et al., 1993).

A person must have at least one of the four B symptoms of intrusive reexperiencing of trauma symptoms, at least three of the seven C symptoms of numbing and avoidance of trauma, and at least two D symptoms of physiologic hyperarousal in order to meet criteria for a diagnosis of PTSD (see Table 1). Across the five countries, an average of 67 percent of these 475 respondents met criteria for a diagnosis of PTSD. Of people currently or recently in prostitution, 75 percent in South Africa, 50 percent in Thailand, 66 percent in Turkey, 68 percent in the USA and 76 percent in Zambia met criteria for a diagnosis of PTSD. The differences between these percentages of people in each country with PTSD were statistically significant (chi square = 19.8; d.f. = 4; p = .001). When the Thai respondents, who were administered the questionnaires in a large group, were excluded from the analysis, the differences between the remaining four countries were not significantly different (chi square = 2.66; d.f. = 3; p = .45).

In order to qualify for a diagnosis of partial PTSD, respondents must meet two of the three foregoing criteria for B, C, and D symptoms. Across the five countries, 85 percent of our respondents met criteria for partial PTSD, which suggests a significant degree of psychological distress. Of people currently or recently in prostitution, 87 percent in South Africa, 72 percent in Thailand, 86 percent in Turkey, 83 percent in the USA and 96 percent in Zambia met criteria for a diagnosis of partial PTSD. The differences between these percentages of people in each country with partial PTSD were statistically significant (chi square = 25.7; d.f. = 4; p = .000). When the Thai respondents, who were administered the questionnaires in a large group, were excluded from the analysis, the differences between the remaining four countries were not significant (chi square 4.24; d.f. = 3; p = .24).

We investigated differences in PTSD associated with race in South Africa and the USA. There were no differences between racial groups in South Africa (chi square = 1.56; d.f. = 3; p = .67) or in the USA (chi square = 3.98; d.f. = 4; P = .41). We also investigated differences in PTSD associated with gender. In the USA, differences in PTSD incidence among women, men and the transgendered were not statistically significant (chi square = 2.48; d.f. = 2; p = .29). In Thailand, differences between women and the transgendered were not statistically significant (chi square = 1.31; d.f. = 1; p = .25). In South Africa, differences between women and men were not significant (chi square = .2 1; d.f. = 1; p = .65).

In South Africa, 25 of our respondents prostituted in brothels and 43 prostituted on the street. There was more violence in the lives of those in street prostitution than brothel prostitution. We found significant differences in the incidence of physical assault in brothels as compared with street prostitution (Fisher's Exact Test, p = .000) and rapes in brothels as compared with street prostitution (Fisher's Exact Test, p = .000). There were no differences in histories of childhood physical and sexual abuse, based on whether the person was prostituted in a brothel or on the street. We investigated the relation between PTSD and whether the person was prostituted in a brothel or on the street. There was no statistically significant difference in incidence of PTSD between brothel and street prostitution (Fisher's Exact Test, p = .25).

There were differences in the availability of support services. All of the women at TASINTHA, in Lusaka, Zambia, and most of the women in northern Thailand, were interviewed at agencies which offered support and job training. These agencies not only advocated but actually provided alternatives to prostitution. This level of support and vocational training was not available in San Francisco at the time of this study. Little governmental or nongovernmental funding in the USA is dedicated to services for those escaping prostitution. In the USA, there is widespread acceptance of the notion that prostitution is a reasonable job choice for women, and there is denial of the extent of prostitution in that country. On the other hand, European NGOs are more actively involved in providing support services for prostituted women in Asia and Africa.

There were also very few services for those in prostitution in South Africa. A drop-in center in Johannesburg, the House, advocated escape from prostitution for drug- addicted teenagers, and provided emergency services. SWEAT was a peer support agency in Capetown which promoted both safe sex and the sex industry. We asked respondents what they needed (see Table 7). On average, 92 percent stated that they wanted to leave prostitution; 73 percent needed a physical place of asylum; 70 percent needed job training; 59 percent needed health care; 55 percent wanted individual counseling; and 49 percent wanted peer support; 47 percent needed child care; 45 percent wanted self-defense training; 38 percent needed drug or alcohol addiction treatment; 24 percent thought that prostitution should be legalized.

In South Africa and Zambia, we asked whether respondents believed that legalizing prostitution would decrease violence in prostitution.' In reply 62 percent of respondents in South Africa and 73 percent in Zambia stated that they did not believe that legalization of prostitution would decrease violence in prostitution. It should be noted that at the time the question was asked in South Africa (1996), there was a national political movement promoting legalization of prostitution.

Part Three of Three

DISCUSSION, ACKNOWLEDGMENTS, NOTES, REFERENCES

DISCUSSION

Our data indicate that violence and PTSD are widely prevalent among 475 prostituted people in five countries. Physical assault, rape and homelessness were common. Despite differences in sample selection, and despite major cultural differences, we found no differences in overall PTSD severity in five countries. There was no difference in the incidence of PTSD in four of the five countries. The traumatic experience of prostitution is a more potent variable than race, gender or state where one was born. These findings suggest that the harm of prostitution is not a culture-bound phenomenon.

We found differences in reports of childhood sexual and physical abuse, and also in physical assault and rape in prostitution. In spite of these differences in current and past violence, the experience of prostitution itself caused acute psychological distress and symptoms of PTSD. Our respondents reported a history of childhood sexual abuse on average 58 percent of the time. Based on previous research, we believe that our figure is lower than the actual incidence of childhood sexual abuse. This may be a result of several factors. First, in the midst of ongoing trauma, reviewing childhood abuse was probably too painful. Second, we did not have the time to establish rapport with interviewees. In Zambia, where 83 percent of respondents indicated a history of childhood sexual abuse, interviewers had previously established relationships with interviewees. Thus the Zambian data on child abuse may be more indicative of its actual occurrence than data from other countries.

In figures comparable to those discussed here, Vanwesenbeeck (1994) found that 40 percent of her respondents reported physical or sexual abuse in childhood; 40 percent had been forced into prostitution or had experienced sexual abuse by an acquaintance; 70 percent had been verbally threatened in prostitution; 60 percent had been physically assaulted; and 40 percent had been sexually assaulted in prostitution in the Netherlands. Vanwesenbeeck reported that 90 percent of prostituted respondents in the Netherlands reported 'nervousness', with a slightly lower 75-80 percent reporting depression, aggression, distrust and guilt. Multiple physical complaints were also common.

It is often assumed that street prostitution is qualitatively different from escort or brothel prostitution. Our data shed some light on this assumption. We found significantly more physical violence in street, as opposed to brothel, prostitution. However, there was no difference in the incidence of PTSD in these two types of prostitution. This suggests that psychological trauma is intrinsic to the act of prostitution. Whether the person was being prostituted in a brothel or on the street seemed to make as little difference in incidence of PTSD as the distinction based on the country in which the person lived.

When we asked those interviewed in South Africa and Zambia if they thought that legalizing prostitution would make them physically safer, a significant majority (62 percent in South Africa and 73 percent in Zambia) told us 'no'. They viewed prostitution as an activity which always involved physical and sexual assault -- legal or not.

In addition to prostitution, other factors may have contributed to the incidence and severity of PTSD seen here. The unemployment rate in Zambia was 90 per cent at the time of this study. Many of the women we interviewed, and their children, were hungry.'

It is likely that the PTSD score elevations from South Africa and the USA are a result of culture-wide violence, as well as from the harm of prostitution. We are in the process of obtaining a nonprostituted sample of people matched for age, race and class in order to compare their responses to those described here.

Some of the lower Thai scores may have resulted from the fact that most of the Thai respondents answered these questions in a large group. (In all countries except Thailand, questionnaires were administered individually.) Although the measures had been translated into Thai, our assistants, who roamed the large room and offered to help read or write, were not able to provide the personal attention offered in the other countries.

There was no difference in the severity of PTSD symptoms across countries, despite sample selection and cultural differences. The 67 percent incidence of 475 respondents meeting criteria for a diagnosis of PTSD may be compared to battered women seeking shelter (45 percent, Houskamp and Foy, 1991; 84 percent, Kemp et a]., 1991); rape victims from Northern Ireland (70 percent, Bownes et al., 1991); and refugees surviving state-organized violence who attended a torture treatment center (51 percent, Ramsay et al., 1993).

Respondents in this study endorsed similar statements when asked what they needed, regardless of country. A vast majority desired to leave prostitution (92 percent), and in order to do that needed asylum (73 percent), job training (70 percent) and health care (59 percent). Like others who have looked at this question, we found that those in prostitution want what everyone else does -- a home, an education, a job, health care, a partner and a community (Hoigard and Finstad, 1992; El-Bassel et al., 1997). The question raised by this study is not 'Should one have the choice to be a prostitute?' rather: 'Does one have the right not to be a prostitute?'

Much of the current medical and psychological literature fails to address the physical and emotional harm which is intrinsic to prostitution. In a 1994 literature review, Vanwesenbeeck commented: 'Researchers seem to identify more easily with clients than with prostitutes.' A recent editorial (Lancet, 1996) concluded that 'the health risks of street prostitution are likely to remain small'. HIV transmission is the sole 'health risk' discussed in much of the current literature. Pedersen (1994) suggested that an interest in controlling the spread of HIV has motivated a trend toward legitimizing prostitution as just another job.

Legalization or decriminalization of prostitution would normalize prostitution. We do not think that legalization of prostitution -would improve the lives of women in prostitution -- in fact, according to some of our interviewees, legalization makes their lives worse. Legalization of prostitution puts the state in the role of the pimp, and in the role of ensuring that customers are provided with people who are HIV- and STD- free.

Although we advocate depenalization of prostitution for the person being prostituted, we support vigorous prosecution of customers of prostitutes, and pimps, brothel owners and traffickers. Decriminalization of prostitution primarily benefits customers and pimps, not those in prostitution.

Three of the women in the USA had worked in a locale where prostitution is legal. Preferring to work on the streets of San Francisco, they all stated that their lives in legal brothels were unbearable. Hoigard and Finstad (1992) noted that the systematized degradation inflicted on women in brothels is in many ways worse than street prostitution. The women we interviewed who had left brothels stated that they were completely under the control of the brothel's pimp/owners: they were not permitted to refuse customers; they were usually not allowed to leave the brothel for eight consecutive days; they were not permitted to choose their own physicians -- and were regularly sexually assaulted by physicians who practiced in brothels.

Apologists for prostitution legitimize it as a freely made and glamorous career choice. We are told that people in prostitution choose their customers as well as the type of sex acts in which they engage. Bell (1994) suggested that prostitution is a form of sexual liberation for women. We are also told that 'high-class' prostitution is different, and much safer than street prostitution. Referring to prostitutes in general, Leigh said 'most of us are middle class' (in Bell, 1994).

None of these assertions was supported by this study. Our data show that almost all of those in prostitution are poor. The incidence of homelessness (72 percent) among our respondents, and their desire to get out of prostitution (92 percent) reflects their poverty and lack of options for escape. Globally, very few of those in prostitution are middle class. Prostitution is considered a reasonable job choice for poor women, indigenous women and women of color, instead of being seen as exploitation and human rights violation. Indigenous women are at the bottom of a brutal gender and race hierarchy. They have the fewest options, and are least able to escape the sex industry once in it. For example, it has been estimated that 80 percent of the street prostituted women in Vancouver, Canada, are indigenous women (Lynne, 1998).

The appearance of choice to work as a prostitute is profoundly deceptive. 'If prostitution is a free choice, why are the women with the fewest choices the ones most often found doing it?' (MacKinnon, 1993). In Amsterdam, a woman described prostitution as 'volunteer slavery', clearly articulating both the appearance of choice and the overwhelming coercion behind that choice (Vanwesenbeeck, 1994).

In prostitution, male dominance is disguised as sexuality (Dworkin, 1997). For the vast majority of the world's women, prostitution is the experience of being hunted, being dominated, being sexually assaulted, and being physically and verbally battered. Intrinsic to prostitution are numerous violations of human rights: sexual harassment, economic servitude, educational deprivation, job discrimination, domestic violence, racism, classism (being treated as if you are worthless because you are poor), vulnerability to frequent physical and sexual assault, and being subjected to body invasions which are equivalent to torture. From the perspective of those we interviewed in five countries, prostitution might at best be called a means of survival: if one wants a place to sleep, food to eat and a way to briefly get off the street, one allows oneself to be sexually assaulted. At its worst, prostitution is kidnapping, torture and sale of parts of the person for sex by third parties.

What is needed is public education regarding the intrinsic violence of prostitution to those in it, and programs which offer options for escape to those in prostitution. In order to offer genuine choices, programs must offer more than condoms, unions and safe-sex training. It is necessary to scrutinize the vast array of social conditions in women's lives which eliminate meaningful choices. Psychological treatment is necessary for both acute PTSD resulting from sexual violence and captivity in prostitution, as well as for the long-term harm resulting from childhood abuse and neglect. Drug and alcohol addiction treatment and health care must be integral to programs offered to people escaping prostitution. We must offer asylum and job training to women who are prostituted and who wish to escape prostitution.

We urge feminist researchers to continue to report -- and protest -- the experiences of women in prostitution.

ACKNOWLEDGMENTS

Roma Guy, at the Bay Area Homelessness Program, San Francisco State University, made vital contributions to this project. Her support helped initiate this work.

Zoe Holder was an interviewer in the USA. Norma Hotaling was coresearcher in the USA. Ilse Puaw assisted with interviews in Capetown. Catherine Mubanga, Theresa Kosheni, Mary Mompela, Clara Kabamba and Annie Kashano were interviewers in Lusaka.

The South African data were collected with support and assistance from Adele du Plessis and Jean du Plessis, without whose contribution this project could not have been completed in South Africa.

Tracy Cohen provided invaluable help in South Africa. Shane Petzer (SWEAT) was generous with his time and assistance.

Amporn Leininger translated the questionnaires into Thai, and also assisted with translating responses from Thai to English.

The Thai data could not have been collected without the generous time and energy contributed by Toi Taylor, Joi Taylor and Ellen Keller, and with assistance from Patricia Green. Toi Taylor translated extensively.

Howard Barkan, DrPH provided statistical analysis and consultation, as well as editorial suggestions.

Erica Boddie organized the coding and data entry phase of the project. Data entry was provided with the generous help of- Mandy Benson, Erica Boddie, Marilyn Davis, Ruth Lankster and Gail McCann.

Michelle J. Anderson, JD and Jonathan Shay, MD, PhD offered editorial suggestions.

The Turkish data were presented at a symposium at International Society for Traumatic Stress Studies, Jerusalem, March 1996.

A paper which described a portion of the USA research was presented by Melissa Farley and Norma Hotaling at the Fourth World Conference on Women, Beijing, China, 1995. NOTES

I . The item from the prostitution questionnaire: 'Do you think that if prostitution were legal, sex workers would be any safer? (for example, from rape and assault)' was contributed by Tracy Cohen, Johannesburg, South Africa.

No Peace Without Justice (NPWJ) mourns with profound grief the assassination of Yanar Mohammed, one of the most courageous and consequential women’s rights defenders of our time, who was shot dead outside her home in Baghdad earlier today.

Yanar Mohammed spent her life building the world she believed Iraqi women deserved. As the founder of the Organization of Women’s Freedom in Iraq (OWFI), she established the country’s first shelters for survivors of “honour” killings and trafficking, published the feminist newspaper *Al-Mousawat*, and gave voice — at grave personal risk — to hundreds of women waiting for the promise of state protection to become a reality. A Gruber Prize laureate, Rafto Prize recipient, and BBC 100 Women honouree, she was, above all, a woman who returned to Iraq despite exile and death threats because her devotion to her country outweighed her concern for her own safety.

*”Yanar Mohammed was assassinated for her commitment to the women of Iraq. I knew her for her bravery in exposing exploitation and hypocrisy, and I am certain that her voice cannot be silenced by those who ordered her killing. We will not rest until there is accountability for this heinous crime.”* — Tara O’Grady, President, No Peace Without Justice

NPWJ unequivocally condemns this killing as a targeted assassination of a feminist leader — a calculated act of terror aimed not only at one woman, but at every person in Iraq who dares to demand equality, safety, and dignity.

We call on the Iraqi authorities to immediately launch a full, independent, and transparent investigation into Yanar Mohammed’s assassination. It is imperative that those responsible — both the perpetrators and those who ordered this crime — are identified, prosecuted, and held to account through the very institutional mechanisms she spent her life defending. We further call on the international community and the United Nations to stand in solidarity with the people of Iraq, lending their full support to ensure that accountability for this crime is swift and certain.

When it comes to sex traits, brains are consistently inconsistent

Male or female? Turns out there's no distinction. PASIEKA/Science Photo Library/Corbis

Are differences between men and women reflected in their brains? For centuries, scientists would have said yes—and they’ve been searching for evidence of those differences since long before the invention of the MRI.

Now, the debate has taken an interesting twist: New research suggests that though there are brain differences between the sexes, there’s no such thing as a male or female brain, reports Stephanie Pappas for LiveScience.

The study is the first to look at sex differences in the whole brain, rather than just variations in different areas, writes Pappas. For a brain to be considered gendered, it must display multiple structures that can be identified as "male" or "female"—differences that in turn are consistently distinct between males and females themselves.

"Consider the peacock, with its sexually dimorphic tail," writes Pappas. "The difference in color and size is consistent between the sexes – there's no subset of peahens brandishing iridescent purple feathers."

To suss out whether such consistent differences exist, lead researcher Daphna Joel and her team examined over 1,400 MRI images of males and females. They identified 29 regions that often exhibit size differences and patterns of connectivity in individuals of different sexes, then looked for consistent differences in those brain regions across the sample MRIs.

That’s where the theory that brain differences are consistent across the sexes began to fall apart. Very few of the samples—six percent in a study of 281 brains from males and females and 2.4 percent in a study of over 600 brains—were internally consistent as “male” or “female.” Surprisingly, each brain studied had its own unique pattern of “maleness” and “femaleness.”

“Internal consistency is rare and is much less common than substantial variability,” the team writes. That turns stereotypes of brain differences on its head—and raises intriguing questions about the concept of gender. Psychologist John Barker tells New Scientist that “the study is very helpful in providing biological support for something that we’ve known for some time—that gender isn’t binary.”

But brain structure isn’t the whole story, writes Pappas: Rather, there’s mounting evidence that brain development in both genders responds to a mishmash of inputs like environment, genetics and external factors.

Reporting from Vacaville — Lyralisa Stevens, who was born male but lives as a female, is serving 50 years to life in a California prison for killing a San Bernardino County woman with a shotgun in a dispute over clothes.

Stevens is one of more than 300 inmates in the state prison system diagnosed with Gender Identity Disorder, a psychiatric condition addressed in free society with hormone replacement therapy and, in some cases, sex reassignment surgery.

Prison officials have provided female hormones for Stevens since her incarceration in 2003. But now she is asking the 1st District Court of Appeal in San Francisco to require the state to pay for a sex-change operation.

Stevens, 42, and her expert witnesses say that surgery is medically necessary, and that removal of her penis and testicles and transfer to a women’s prison are the best way to protect her from rape and abuse by male inmates.

As prison officials have struggled to address chronic overcrowding, the constant threat of gang violence and a health system that federal judges have equated with “cruel and unusual” punishment, they have also gone to court multiple times to answer allegations that they failed to properly treat and protect transgender inmates.

Judges have sided with transgender prisoners — who according to a UC Irvine study are 13 times more likely to suffer sexual assault than other inmates — on some significant cases. In 2009, the California Supreme Court ruled that an inmate could sue guards for failing to protect her from repeated rapes and beatings by her cellmate. In 1999, an appeals court ordered prison officials to provide hormone therapy to inmates who were already taking them when they arrived. The treatments cost about $1,000 a year per prisoner.

A ruling in Stevens’ favor would make California the first place in the country required to provide reassignment surgery for an inmate, according to lawyers for the receiver appointed to oversee California’s troubled prison health system. They argue that the state should be required to provide only “minimally adequate care,” not sex-change operations that cost $15,000 to $50,000.

Stevens, who has a slight build — 5-foot-6 and about 115 pounds — and entered prison with silicon injections in her breasts and hips to feminize her physique, said in a court filing that she feels like she’s under threat of sexual assault in the men’s facility and wants the surgery, in part, so she’ll be sent to a women’s institution.

“The male inmate is not expecting to see breasts … in the shower next to him,” Stevens wrote. The situation can lead to violent disputes among the men and sparks attacks against transgender inmates, who may have less upper body strength because of the hormone therapy, Stevens said.

In a court filing supporting Stevens’ petition, psychotherapist Lin Fraser said she has “grave concerns” for Stevens’ safety because she “had been put alone in cells all night long with men who threatened and abused her.”

California law requires prison administrators to assign the state’s nearly 162,000 inmates to men’s or women’s institutions based on “gender,” which officials determine solely by a prisoner’s genitals. Richard Masbruch, who tried multiple times to castrate himself while in a Texas prison and eventually succeeded, is in the California Institution for Women inChino. Masbruch, who goes by the name Sherri, was transferred from Texas to serve 40 years for a 1991 rape in Fresno.

While confronting complaints and lawsuits by transgender inmates challenging their housing assignments during the mid-2000s, the California prison system commissioned a study by UC Irvine sociologists to help them understand the small, uniquely vulnerable population. The study found that 59% of transgender inmates said they had been raped or otherwise sexually assaulted behind bars, compared with 4.4% of the general prison population, lead researcher Valerie Jenness told the state Senate Public Safety Committee.

Despite those numbers, 59% of transgender inmates said they did not want to move to a women’s institution.

“The advantages of being in a men’s prison include the pursuit of sex and the possibility of securing a male partner,” Jenness said. “Concern about safety is not a main factor in predicting [housing] preferences.”

Stevens declined to join a group of transgender inmates interviewed by The Times recently at the prison system’s main medical facility in Vacaville. But six others — of the 30 to 50 transgender inmates housed there at any given time — spoke candidly about their lives in prison.

Thomas Strawn, 52, who uses the name Lisa and is serving a life sentence after a third-strike conviction for burglary, said she is in a committed relationship with the man in the next cell and would not want to move.

“I stayed single for an entire year when I got here,” Strawn said. “But now I got with somebody and I’ve been with him now two years.”

Others, such as convicted killer David, or Bella, Birrell, 58, who said she had been raped in prison, would like to be transferred to a women’s facility. “You don’t have to worry about the constant harassment like you get from the men here,” she said.

Only two of the six said they would be interested in a sex change operation if a court order compelled the state to pay the costs.

“I had made plans to try to get [the surgery] done before I committed the crime that I did,” said Steve Alamillo, 39, who goes by Nikkas and is serving life for first-degree murder. “If the state can do that stuff, absolutely.”

Willie Murphy, 47, who is also known as Mena and is serving life on a third-strike conviction for burglary, was among the majority, preferring to “keep what I got.”

Surgery is where the California Department of Corrections and Rehabilitation draws the line.

“A prison is not required by law to give a prisoner medical care that is as good as he would receive if he were a free person, let alone an affluent free person,” attorney Steven J. Bechtold, who represents the receiver, wrote in the state’s response to Stevens’ petition for the operation.

The prison system has lost on a similar point before. The state provides hormone therapy today because a federal court found in a 1999 case that failing to continue treatment for inmates who were on hormones before coming to prison amounted to cruel and unusual punishment.

“We regularly get questions about why we are treating these patients,” said Dr. Joseph Bick, chief medical officer at Vacaville. “The bottom line is, not only is it appropriate, but it’s mandated by federal courts.”

Stevens, who has fathered three children, argues in her court case that the cocktail of estrogen and testosterone-blockers the state has provided since her incarceration in 2003 are no longer adequate to combat her emotional distress. Failing to provide surgery could increase her “risk of future self-harm,” wrote Dr. Denise Taylor, a medical expert who filed a brief on Stevens’ behalf.

Taylor also argued that leaving Stevens on estrogen therapy could lead to the reemergence of a benign tumor removed from her brain in 2005.

Bick, who filed a declaration with the court in January defending the state’s position, said the previous tumor was not believed to be caused by estrogen therapy. He said Stevens’ treatment in prison has been “adequate and successful.”

Perhaps the biggest threat to Stevens’ case is the state’s budget crisis, in the view of several transgender inmates interviewed. They worried that a judge might be reluctant to rule in her favor with the state facing hard times.

“If I were out there, I wouldn’t understand, especially if I was unemployed or trying to support a family,” Birrell said.

A female worker sprays herbicide in a palm oil plantation in Sumatra, Indonesia, on Saturday, Sept. 8, 2018. Many women are hired by subcontractors on a day-to-day basis without benefits, performing the same jobs for the same companies for years and even decades. They often work without pay to help their husbands meet otherwise impossible daily quotas. (AP Photo/Binsar Bakkara)

SUMATRA, Indonesia (AP) — With his hand clamped tightly over her mouth, she could not scream, the 16-year-old girl recalls – and no one was around to hear her anyway. She describes how her boss raped her amid the tall trees on an Indonesian palm oil plantation that feeds into some of the world’s best-known cosmetic brands. He then put an ax to her throat and warned her: Do not tell.

At another plantation, a woman named Ola complains of fevers, coughing and nose bleeds after years of spraying dangerous pesticides with no protective gear. Making just $2 a day, with no health benefits, she can’t afford to see a doctor.

Hundreds of miles away, Ita, a young wife, mourns the two babies she lost in the third trimester. She regularly lugged loads several times her weight throughout both pregnancies, fearing she would be fired if she did not.

These are the invisible women of the palm oil industry, among the millions of daughters, mothers and grandmothers who toil on vast plantations across Indonesia and neighboring Malaysia, which together produce 85 percent of the world’s most versatile vegetable oil.

Palm oil is found in everything from potato chips and pills to pet food, and also ends up in the supply chains of some of the biggest names in the $530 billion beauty business, including L’Oréal, Unilever, Procter & Gamble, Avon and Johnson & Johnson, helping women around the world feel pampered and beautiful.

The Associated Press conducted the first comprehensive investigation focusing on the brutal treatment of women in the production of palm oil, including the hidden scourge of sexual abuse, ranging from verbal harassment and threats to rape. It’s part of a larger in-depth look at the industry that exposed widespread abuses in the two countries, including human trafficking, child labor and outright slavery.

Women are burdened with some of the industry’s most difficult and dangerous jobs, spending hours waist-deep in water tainted by chemical runoff and carrying loads so heavy that, over time, their wombs can collapse and protrude. Many are hired by subcontractors on a day-to-day basis without benefits, performing the same jobs for the same companies for years – even decades. They often work without pay to help their husbands meet otherwise impossible daily quotas.

“Almost every plantation has problems related to labor,” said Hotler Parsaoran of the Indonesian nonprofit group Sawit Watch, which has conducted extensive investigations into abuses in the palm oil sector. “But the conditions of female workers are far worse than men.”

Parsaoran said it’s the responsibility of governments, growers, big multinational buyers and banks that help finance plantation expansion to tackle issues related to palm oil, which is listed under more than 200 ingredient names and contained in nearly three out of four personal-care products – everything from mascara and bubble bath to anti-wrinkle creams.

The AP interviewed more than three dozen women and girls from at least 12 companies across Indonesia and Malaysia. Because previous reports have resulted in retaliation against workers, they are being identified only by partial names or nicknames. They met with female AP reporters secretly within their barracks or at hotels, coffee shops or churches, sometimes late at night, usually with no men present so they could speak openly.

The Malaysian government said it had received no reports about rapes on plantations, but Indonesia acknowledged physical and sexual abuse appears to be a growing problem, with most victims afraid to speak out. Still, the AP was able to corroborate a number of the women’s stories by reviewing police reports, legal documents, complaints filed with union representatives and local media accounts.

Reporters also interviewed nearly 200 other workers, activists, government officials and lawyers, including some who helped trapped girls and women escape, who confirmed that abuses regularly occur.

Indonesia is the world’s biggest palm oil producer, with an estimated 7.6 million women working in its fields, about half the total workforce, according to the female empowerment ministry. In much-smaller Malaysia, the figures are harder to nail down due to the large number of foreign migrants working off the books.

In both countries, the AP found generations of women from the same families who have served as part of the industry’s backbone. Some started working as children alongside their parents, gathering loose kernels and clearing brush from the trees with machetes, never learning to read or write.

And others, like a woman who gave the name Indra, dropped out of school as teenagers. She took a job at Malaysia’s Sime Darby Plantations, one of the world’s biggest palm oil companies. Years later, she says her boss started harassing her, saying things like “Come sleep with me. I will give you a baby.” He would lurk behind her in the fields, even when she went to the bathroom.

Now 27, Indra dreams of leaving, but it’s hard to build another life with no education and no other skills. Women in her family have worked on the same Malaysian plantation since her great-grandmother left India as a baby in the early 1900s. Like many laborers in both countries, they can’t afford to give up the company’s basic subsidized housing, which often consists of rows of dilapidated shacks without running water.

That ensures the generational cycle endures, maintaining a cheap, built-in workforce.

“I feel it’s already normal,” Indra said. “From birth until now, I am still on a plantation.”

Out of sight, hidden by a sea of palms, women have worked on plantations since European colonizers brought the first trees from West Africa more than a century ago. As punishment in Indonesia back then, some so-called female “coolies” were bound to posts outside the boss’ house with finely ground chili pepper rubbed into their vaginas.

As the decades passed, palm oil became an essential ingredient for the food industry, which saw it as a substitute for unhealthy trans fats. And cosmetic companies, which were shifting away from animal- or petroleum-based ingredients, were captivated by its miracle properties: It foams in toothpaste and shaving gel, moisturizes soaps and lathers in shampoo.

New workers are constantly needed to meet the relentless demand, which has quadrupled in the last 20 years alone. Women in Indonesia are often “casual” workers – hired day to day, with their jobs and pay never guaranteed. Men receive nearly all the full-time permanent positions, harvesting the heavy, spiky fruit bunches and working in processing mills.

On almost every plantation, men also are the supervisors, opening the door for sexual harassment and abuse.

The 16-year-old girl who described being raped by her boss – a man old enough to be her grandfather – started working on the plantation at age 6 to help her family make ends meet.

The day she was attacked in 2017, she said the boss took her to a remote part of the estate, where her job was to ferry wheelbarrows laden with the bright orange palm oil fruits he hacked from the trees. Suddenly, she said, he grabbed her arm and started pawing her breasts, throwing her to the jungle floor. Afterward, she said, he held the ax to her throat.

“He threatened to kill me,” she said softly. “He threatened to kill my whole family.”

Then, she said, he stood up and spit on her.

Nine months later, after she says he raped her four more times, she sat by a wrinkled 2-week-old boy. She made no effort to comfort him when he cried, struggling to even look at his face.

The family filed a report with police, but the complaint was dropped, citing lack of evidence.

“I want him to be punished,” the girl said after a long silence. “I want him to be arrested and punished because he didn’t care about the baby … he didn’t take any responsibility.”

The AP heard about similar incidents on plantations big and small in both countries. Union representatives, health workers, government officials and lawyers said some of the worst examples they encountered involved gang rapes and children as young as 12 being taken into the fields and sexually assaulted by plantation foremen.

One example involved an Indonesian teen who was trafficked to Malaysia as a sex slave, where she was passed between drunk palm oil workers living under plastic tarps in the jungle, eventually escaping ravaged by chlamydia. And in a rare high-profile case that sparked outrage last year, a female preacher working at a Christian church inside an Indonesian estate was tied up among the trees, sexually assaulted by two workers and then strangled. The men were sentenced to life in prison.

While Indonesia has laws in place to protect women from abuse and discrimination, Rafail Walangitan of the Ministry of Women Empowerment and Child Protection said he was aware of many problems identified by the AP on palm oil plantations, including child labor and sexual harassment.

“We have to work hard on this,” he said, noting the government still has a long way to go.

Malaysia’s Ministry of Women, Family and Community Development said it hadn’t received complaints about the treatment of women laborers so had no comment. And Nageeb Wahab, head of the Malaysian Palm Oil Association, said workers are covered by the country’s labor laws, with the ability to file grievances.

Those familiar with the complexities of plantation life say the subject of sexual abuse has never drawn much attention and that female workers often believe little can be done about it.

“They are thinking it happens everywhere, so there’s nothing to complain about,” said Saurlin Siagan, an Indonesian activist and researcher.

Many families living on plantations struggle to earn enough to cover basic costs, like electricity and rice. Desperate women are sometimes coerced into using their bodies to pay back loans from supervisors or other workers. And younger females, especially those considered attractive, occasionally are given less demanding jobs like cleaning the boss’ house, with sex expected in exchange.

In the few cases where victims do speak out, companies often don’t take action or police charges are either dropped or not filed because it usually comes down to the accuser’s word against the man’s.

“The location of palm oil plantations makes them an ideal crime scene for rape,” said Aini Fitri, an Indonesian official from the government’s women and children’s office in West Kalimantan province. “It could be dangerous in the darkness for people, especially for women, but also because it is so quiet and remote. So even in the middle of the day, the crime can happen.”

Many beauty and personal goods companies have largely remained silent when it comes to the plight of female workers, but it’s not due to lack of knowledge.

A powerful global industry group, the Consumer Goods Forum, published a 2018 report alerting the network’s 400 CEOs that women on plantations were exposed to dangerous chemicals and “subject to the worst conditions among all palm oil workers.” It also noted that a few local groups had cited examples of women being forced to provide sex to secure or keep jobs, but said few workers were willing to discuss the sensitive issue.

Even so, almost all of the pressure aimed at palm oil companies has focused on land grabs, the destruction of rainforests and the killing of endangered species such as orangutans.

Those concerns led to the 2004 formation of the Roundtable on Sustainable Palm Oil, an association that promotes and certifies ethical production, including provisions to safeguard laborers. Its members include growers, buyers, traders and environmental watchdogs. But of the nearly 100 grievances lodged in Indonesia and Malaysia in the last decade, most have not focused on labor until recently. And women are almost never mentioned.

The AP reached out to representatives affiliated with every cosmetic and personal goods maker mentioned in this story. Some didn’t comment, but most defended their use of palm oil and its derivatives, with many attempting to show how little they use compared to the roughly 80 million tons produced annually worldwide. Others said they were working with local nonprofits, pointed to pledges on their websites about commitments to sustainability and human rights, or noted efforts to be transparent about the processing mills in their supply chains.

But the AP found that labor abuses regularly occur industrywide, even from mills that source from plantations bearing the RSPO’s green palm stamp.

That includes Indonesian companies like London Sumatra, which withdrew from the RSPO last year after the association cited it for a series of labor abuses. London Sumatra told the AP that it adheres to labor laws and takes “the health of our workers very seriously.”

In some cases, women working at various palm oil companies illegally said they were ordered to hide in the jungle when sustainability auditors arrived, while others were told to smile if they encountered any visitors.

The AP used U.S. Customs records, product ingredient lists and the most recently published data from producers, traders and buyers to link the laborers’ palm oil and its derivatives from the mills that process it to the Western brands’ supply chains – including some that source from mills fed by plantations where women said they were raped and young girls toiled in the fields.

Abuses also were linked to product lines sought out by conscientious consumers like Tom’s of Maine and Kiehl’s, through the supply chains of their giant parent companies Colgate-Palmolive and L’Oréal. And Bath & Body Works was connected through its main supplier, Cargill, one of the world’s biggest palm oil traders.

Coty Inc., which owns global staples like CoverGirl and is tapping into partnerships with Gen Z newcomers like Kylie Cosmetics, did not respond to multiple AP calls and emails. And Estee Lauder Companies Inc., owner of Clinique and Aveda, acknowledged struggling with traceability issues in its RSPO filing. When asked by AP whether specific products used palm oil or its derivatives, there was no response.

Both companies, along with Shiseido and Clorox, which owns Burt’s Bees Inc., keep the names of their mills and suppliers secret. Clorox said it would raise the allegations of abuses with its suppliers, calling AP’s findings “incredibly disturbing.”

Johnson & Johnson makes its mill list public, but refused to say whether its iconic baby lotion contains palm oil derivatives.

One case uncovered by the AP involved a widow named Maria who said her supervisor began sexually harassing her when she first started working at a Malaysian-owned company in Indonesia. She said she successfully fought off his advances until she returned home one night to find him inside, waiting for her.

“I tried to remind him about his wife and his children in the village, but he hugged me tighter while pulling my pants down. Then he raped me,” she said. “After that, he left me. But almost two hours later, he came back and raped me a second time.”

She said she stayed quiet at first because he threatened her life and her job. But the attacks continued, she said, including once when he jumped her while she was working in the field “crushing me so that I couldn’t move.”

That time, she said, she kept a semen-filled tissue as evidence. She later confronted the man and his wife and also complained to company and union officials. She attempted to file a police report, but instead was directed to seek compensation directly from the man, a union representative said. She was never paid and ended up moving to another plantation to get away from the boss, who has since quit.

Rosita Nengsih, the director of the Women, Children and Family Legal Aid Institution in the Indonesian province of West Kalimantan, said most victims are reluctant to report rapes to authorities, adding it’s typical to settle complaints through so-called “peace solutions” in which the victim’s family may be paid off. Sometimes parents force their daughter to marry her rapist to lessen the shame, often after pregnancy occurs.

The province where Nengsih works borders Malaysia on the island of Borneo, which is shared by the two countries. It is a porous corridor for Indonesian workers, including women and young girls hoping to earn enough in the wealthier neighboring country to pull themselves out of poverty. Many travel there illegally, sometimes falsifying documents or lying about their ages, leaving them vulnerable to exploitation.

Nengsih recalled a case involving two Indonesian girls as young as 13 who were working on a Malaysian plantation with their parents and said they were repeatedly raped by the same supervisor until both became pregnant four months apart.

“Nothing happened to the foreman,” she said. “He’s still free.”

The conditions these workers endure stand in stark contrast to female empowerment messages promoted by industry leaders such as L’Oréal, one of the world’s top cosmetic companies, and Unilever, one of the biggest palm oil buyers for consumer goods, which sources from more than 1,500 mills.

As Unilever’s popular soap brand proclaims: “Dove believes that beauty is for everyone.” And L’Oréal says it is working to stamp out sexual harassment “because we are all worth it.”

In a global industry expected to reach $800 billion within the next five years, cosmetic legacy brands – together with fast-growing celebrity and niche startups – proudly tout $300 anti-wrinkle creams or glittery eyeshadows as sustainable and free of labor abuses, with little or no evidence.

In response, L’Oréal said it “has put particular emphasis on supporting and empowering women, who are the first victims of many of the social and environmental challenges our world faces.” Unilever said progress needs to be made more quickly, but that “the safety of women in global agricultural supply chains … including in the palm oil industry, remains a key concern.”

The women in Southeast Asia’s rugged, steamy plantations are a world away. Some haul tanks of toxic chemicals on their backs weighing more than 13 kilograms (30 pounds), dispensing 80 gallons each day – enough to fill a bathtub.

“Our lives are so hard,” said Ola, who has been employed as a day worker in Indonesia for 10 years and wakes each day aching from repeatedly lifting heavy loads. “After spraying, my nose bleeds occasionally. I think it’s connected to the pesticide.”

She doesn’t wear a mask because it’s too hot to breathe. She said the company doesn’t provide medical care to casual workers, and she has no money for a doctor.

Paraquat, one of the chemicals Ola and others spray, has been banned by the European Union and many other countries over possible links to a wide range of health issues, including an increased chance of developing Parkinson’s disease.

Glyphosate, the active ingredient in popular weedkiller Roundup, also is commonly used. Roundup’s parent company, Bayer, agreed earlier this year to pay more than $10 billion to end tens of thousands of lawsuits filed in the U.S. alleging the chemical caused serious illnesses, including cancer.

Some palm oil workers who use agrochemicals daily showed the AP raw webbing between their fingers and toes, along with destroyed nails. Others had milky or red eyes and complained of dizzy spells, trouble breathing and blurry vision. Activists reported that some totally lost their sight.

The workers said pesticides routinely blow back into their faces, splash onto their backs and seep into the sweaty skin on their stomachs.

“If the liquid shakes and spills out, it’s also running into my private area. Almost all women are suffering the same itching and burning,” said Marodot, whose five children also work to help their father meet his daily target. “I have to keep going until I finish working, and then clean it up with water. There’s too many men around.”

She said she has trouble seeing, and her face is dark and cracked from years in the sun.

When handed a $20 lipstick by a journalist, a worker named Defrida was told it contained palm oil. She twisted the silver case and stared at the glistening pink stick – first with intrigue, then with disgust.

Noting she would have to spray pesticide on 30 acres of rough jungle terrain just to afford a single tube, she pleaded with women who buy products containing palm oil: “Oh, my God!” she said. “Please pay attention to our lives.”

She, along with nearly all the women interviewed, complained of pelvic pain and explained how almost every phase of their reproductive health is affected.

Some women are forced to undergo humiliating checks to prove they are bleeding in order to take leave during their periods.

Others suffering from collapsed uteruses – caused by the weakening of the pelvic floor from repeatedly squatting and carrying overweight loads – create makeshift braces by tightly wrapping scarves or old motorbike tire tubes around their mid-sections. Some workers described the pain as so agonizing that they could find relief only by lying on their backs with their legs in the air.

Despite a national health care program launched by the Indonesian government, many palm oil workers still don’t have access to medical services and, even when basic care is available, it typically is not extended to female day workers. The nearest clinics can be more than a day’s drive by motorbike, so most workers just use aspirin, balms or home remedies when they’re sick.

Still, they are better off in many ways than migrant women working without papers in Malaysia, mostly in the bordering states of Sarawak and Sabah on the island of Borneo.

The AP confirmed a horrific story involving a pregnant Indonesian woman who escaped captivity on a Malaysian estate owned by state-run Felda, one of the world’s biggest palm oil companies. She gave birth in the jungle and foraged for food before finally being rescued. In September, U.S. Customs and Border Protection banned all palm oil imports from FGV Holdings Berhad, which is closely affiliated with Felda, after finding indications of child and forced labor and other abuses on its plantations.

Even on a day-to-day basis in Malaysia, migrant women fear arrest and deportation. Many rarely leave their plantations, even to give birth, at times risking their own lives and their babies’. And those who do venture out during emergencies can be held for weeks at the hospital until family members can collect enough money to pay exorbitant rates.

At one government facility in a border town, a menu of maternity ward prices was posted on a blue bulletin board. A natural birth costs foreign migrants about $630 – several times more than it would cost a Malaysian citizen, an amount that could take some women at least a year to pay back.

And that’s if they’re able to conceive and carry their babies to full term.

Groups of women interviewed by the AP in Indonesia wondered whether their arduous jobs, combined with the chemicals they handle and breathe, caused their infertility, miscarriages and stillbirths.

Ita was among those who said her work affected her ability to deliver healthy babies. She said she hid two pregnancies from her boss, knowing she likely wouldn’t be called for daily work otherwise. With two children already at home to feed, she had no choice but to keep working for $5 a day. In contrast, a permanent full-time female worker is entitled to three months of paid maternity leave.

Every day, as her belly grew, Ita said she continued to carry back-breaking loads over acres of fields, spreading 400 kilograms (880 pounds) of fertilizer – nearly a half-ton – over the course of a day. She lost both babies in her third trimester and, with no health insurance, was left with medical bills she couldn’t pay.

“The first time I miscarried, and the doctor had to pull the baby out,” said Ita, who has worked on the plantation alongside her mother since the age of 15. “The second time, I gave birth at seven months and it was in critical condition, and they put it in an incubator. It died after 30 hours.

“I kept working,” she said. “I never stopped after the baby died.”

2 of 20 | A 17-year-old mother gives a bottle to her 2-week-old baby, whom she says was bom as a result of a rape in Sumatra, Indonesia, Sunday, Sept. 9, 2018. She started working on a plantation as a young child to help her family survive, never going to school or learning how to read or write. One day she said her boss took her alone to a quiet part of the estate. After the attack, while still half-naked, she said the man held a blade to her throat. "He threatened to kill me with an ax. … He threatened to kill my whole family." Then, she said, he stood up, spit on her and walked away. (AP Photo)

3 of 20 | Babies and toddlers of female palm oil workers nap in a makeshift daycare center in Sumatra, Indonesia, Tuesday, Nov. 14, 2017, as their parents work Most mothers who work on palm oil plantations do not have access to childcare, forcing them to take their young children with them into the fields. (AP Photo/Binsar Bakkara)

4 of 20 | Ranging in age from 6 to 102, women in a family that has worked on a palm oil plantation for five generations hold out the palms of their hands in Malaysia, on Wednesday, Nov. 11, 2020. Like many laborers, they can't afford to give up the company's basic subsidized housing, creating a generational cycle the helps ensure a cheap, built-in labor force. (AP Photo)

5 of 20 | Indonesian women deported from Malaysia for working illegally, wait to be processed by Indonesian immigration officers at Nunukan, Indonesia, Thursday, Dec. 6, 2018. The porous border in Borneo, an island shared by Malaysia and Indonesia, serves as a corridor for opportunistic Indonesian workers, including women and young girls hoping to pull themselves out of poverty. Many go illegally, sometimes falsifying documents or lying about their age, leaving them vulnerable to exploitation. (AP Photo/Binsar Bakkara)

6 of 20 | A little girl helps her parents work on a palm oil plantation in Sabah, Malaysia, Monday, Dec. 10, 2018. Many children gather loose kernels and clear brush from the trees with machetes, never learning to read or write. (AP Photo/Binsar Bakkara)

7 of 20 | A tool used for harvesting palm oil rests on thorny fruit bunches in Sabah, Malaysia, Monday Dec. 10, 2018. (AP Photo/Binsar Bakkara)

8 of 20 | A woman who sprays pesticides in a palm oil plantation displays the raw, irritated skin on her foot and damaged toenails she blames on the chemicals, in Sumatra, Indonesia, Saturday, Sep. 16, 2017. Many female workers spray toxic chemicals, including some banned in many countries, and spread fertilizers without wearing any protective gear. (AP Photo/ Margie Mason)

9 of 20 | A female worker carries a bag of fertilizer in a palm oil plantation in Sumatra, Indonesia, on Tuesday, Nov. 14, 2017. Some women say they suffer from fallen womb, caused by the weakening of the pelvic floor from repeatedly squatting and carrying overweight loads. They sometimes create makeshift braces by tightly wrapping scarves or old motorbike tire tubes around their mid-sections. (AP Photo/Binsar Bakkara)

10 of 20 | A casual worker removes floating aquatic plants from a canal in a palm oil plantation in Sumatra, Indonesia, Thursday, Feb. 22, 2018. Women sometimes must work submerged up to their waists in water often filled with snakes and agrochemical runoff. (AP Photo/Binsar Bakkara)

11 of 20 | This combination of November 2020 photos shows the hands of five generations of women from a family that has worked on the same palm oil plantation sime the early 1900s, ranging in age from 6 to 102. They each hold products made by iconic Westem companies that source palm oil from Indonesia and Malaysia. (AP Photo)

12 of 20 | A woman who sprays pesticides in a palm oil plantation blames her red, irritated eyes on the chemicals she works with, in Sumatra, Indonesia, Saturday, Sep. 16, 2017. Many female workers spray toxic chemicals and spread fertilizers without wearing any protective gear. (AP Photo/Margie Mason)

13 of 20 | A female worker walks with a pesticide sprayer on her back at a palm oil plantation in Surnatra, Indonesia, Saturday, Sept. 8, 2018. Some workers use a yellow paste made of rice powder and a local root as a sunblock. (AP Photo/Binsar Bakkara)

14 of 20 | A woman walks with a sack of fertilizer to be spread in a palm oil plantation in Sumatra, Indonesia, Nov. 14, 2017. Some workers who suffer from collapsed uteruses, caused by the weakening of the pelvic floor from repeatedly squatting and carrying overweight loads, create makeshift braces by tightly wrapping scarves or old motorbike tire tubes around their mid- sections. (AP Photo/Binsar Bakkara)

15 of 20 | A woman helps load palm oil fruit into a wheelbarrow, navigating barefoot through the rough jungle floor in Sumatra, Indonesia, Wednesday, Feb. 21, 2018. Women are often "casual" workers, hired day to day, with their jobs and pay never guaranteed. Men receive nearly all the full-time permanent positions, harvesting the heavy, spiky fruit bunches and working in processing mills. (AP Photo/Binsar Bakkara)

16 of 20 | A child collects palm kernels from the ground ata palm oil plantation in Sumatra, Indonesia, Monday, Nov. 13, 2017. Children often work to help parents to reach their targets set by the vast plantations across Indonesia and neighboring Malaysia. (AP Photo/Binsar Bakkara)

17 of 20 | A woman rides a motorbike with a container full of iEticide on her back in a palm oil plantation in Sumatra, Indonesia, Monday, Nov. 13, 2017. Female workers carry loads so heavy that, over time, their wombs can collapse and protrude from their bodies. In some cases, they spray toxic chemicals banned in many countries and linked to serious health problems. (AP Photo/Binsar Bakkara)

18 of 20 | Female workers carry heavy loads of fertilizer at a palm oil plantation in Sumatra, Indonesia, Tuesday, Nov. 14, 2017. Some women spread up to 880 pounds of fertilizer, nearly a half-ton, over the course of a day. (AP Photo/Binsar Bakkara)

19 of 20 | A woman who works in a palm oil plantation speaks during an interview in Sumatra, Indonesia, on Friday, Sept. 7, 2018. She worked as both a pesticide sprayer and spreader of fertilizer and said she suffered from a series of health issues, from respiratory and skin issues to a condition known as fallen womb. (AP Photo/Binsar Bakkara)