Feminist Articles

“I was a kid, I hadn’t grown that much so I was really scared.” Jada was 12 when her father took her to live in Saudi Arabia and started talking about marrying her off. Jada had lived all of her life in New Jersey, in the United States, and marriage had not crossed her mind.

Earlier this month, PBS News Hour shone a light Jada’s story and the American citizens who are taken overseas to be forced into marriage.

Jada immediately sought help from her family back home, texting her half-sister. They soon found out that the U.S. State Department could not intervene to stop a marriage in another country, as American citizens must abide by the laws of the country they are in, and these may allow child marriage.

Jada’s aunt felt powerless: “She’s thousands and thousands miles away […]. It seemed like everybody was saying ‘There is nothing we can do’.” She got in touch with the Tahirih Justice Center, a Girls Not Brides member based in the US that provides legal services to women and girls who face gender-based violence and persecution.

For several months, Tahirih worked with Jada’s aunt and half-sister on strategies to bring her home. Jada eventually flew back to the United States and, with the support of Tahirih, her family requested her full custody. She is now back in school and dreams of attending university.

Watch the full programme

Forced and child marriage in the United States

According to the Tahirih Justice Center, thousands of individuals across the United States may face forced marriages each year. Children in particular are vulnerable to forced marriage and, although there is little nationwide data available, state statistics paint a worrying picture:

• In Virginia, between 2004-2013, nearly 4,500 children were married. Over 200 married at age 15 or younger, and about 90% of underage spouses are girls. • In Maryland, over 3,000 children have been married since 2000.• In Texas between 2009-2013, over 700 children between the ages of 15 and 17 were married.

Puerto Rican rapper, singer, songwriter and rising phenomenon Young Miko casually referred to herself as a “gold star lesbian” in an interview with Cosmopolitan this week. SHOCK! HORROR! Despite her expressing support for every individual faction of the LGBT community in the chat when she didn’t have to, it wasn’t good enough. It’s beginning to feel like lesbians will never be left alone until we apologise for our entire existence. 

Young Miko

This time, the mob wants an “oops, sorry!” for mentioning the fact that she’s never had sex with a man before. Miko didn’t say or imply she was better than lesbians who’ve forced themselves to sleep with men in the past due to heteronormative pressure. Most of us gold stars understand why they do – that’s why we’re so proud we made it through the acid-fire of impressionable young lesbianhood, without doing it to fit in. Heteronormative pressure is felt by all lesbians, gold star included. 

Instagram user @hidden.ruby compares gold star lesbians to nazis in a comment on a post from Gay Times magazine.

“People here haven’t seen how biphobic lesbians get in certain Redit communities. There should be no eugenic rhetorics in lesbianism. Just like how swastika is now a symbol of hate despite the first origin being opposite of harm, the term ‘gold star’ has been a symbol of exclusion and hate in the past. It should be discarded. It’s not the same case as adopting the ‘d*ke’ terminology, which is a derogatory term that was directed from outside the community. You can reclaim the hate word ‘d*ke’ but not gold star.”

This pride is wrong, according to the pitchfork-holders – most of whom are not lesbians at all. Instagram user @hidden.ruby likened the term ‘gold star’ to fascism. Like culty Christians who tell women to always be humble, to never look in the mirror, to never talk highly of oneself, to always consider how our existence might provoke others, lesbians who have never slept with men before are not allowed to talk about that in public because it might make others feel uncomfortable. 

Most late bloomer lesbians – lesbians who came out later in life – wish all lesbians were gold stars. Having sex with men as a lesbian leaves a psychological mark they’d like to prevent. Most anti-gold star witch-hunters are not lesbian at all; instead, they assert that the term is an attack on women who are actually attracted to men. This is why @hidden.ruby mentions it being ‘biphobic’ and ‘eugenics rhetoric’: the user is suggesting that bisexuals are equally lesbian and disagreeing makes you a nazi. They don’t see the issue with questioning female homosexuality. They don’t care that they’re parroting heteropatriarchal beliefs about women supposedly always being capable of finding an attraction to men somewhere deep inside… propaganda that ironically is what coerces many lesbians into denying themselves a gold star life. It’s all connected.

It does not take being a lesbian to figure out why a lesbian would be happy she’s never had sex with men. She is not attracted to them. But it’s become totally normalised WITHIN the LGBT community to question if female homosexuality is a real thing. That’s why so many bisexual women identify as lesbian. Why they feel owed it; why it’s viewed as ‘gatekeepy’ to resist their intrusion. Those who see lesbianism as a feminist competition rather than female homosexuality see ‘gold star’ as aggressive bad sportsmanship. The truth is that lesbians have no interest in men whatsoever, despite what they may have forced themselves to endure. Gold stars represent a hopeful future for lesbians. It’s what our body always wanted.

A lesbian who struggled with accepting herself early in life hopes no lesbian sleeps with men.

“HARD AGREE. As a lesbian who forced myself to sleep with plenty of men (despite not being attracted to any of them) due to some combination of societal pressure, internalized homophobia and self-loathing, I am SO happy for every lesbian who never had to put herself through that. I knew I was attracted to women and I had my first everything with girls, actually! But I felt like I had to at least try to like men and it was traumtic and I would never wish it on another member of our community!”

I’ve spoken to many lesbians who were out during the 80s and 90s, and all of them have said the same thing: the term ‘gold star’ was a tongue-in-cheek joke created by those who are NOT gold stars. As in, “Do you want a gold star for never sleeping with a man before?” It isn’t something lesbians who’ve never slept with a man before coined to refer to themselves as golden, compared to lesbians who have slept with men getting silver or bronze. It’s just been adopted as a casual community term that’s a lot shorter than spelling out the whole thing each time. Gay men have similar terminology – they even use ‘platinum gay’ for those who not only haven’t touched a vagina but were also born via c-section. They didn’t even come out of one! Homosexual humour, everybody. Making it deep due to your insecurities and lack of boundaries with us is sus.

Let’s end this on a knockout DM from an LH follower:

Trying to write this is difficult. I never really thought I would but Wahine Toa Rising and Aunty have supported me to be free of a life I never dreamed I could be free from.

You see, when I was twelve, I was selling myself to men on the streets in New Zealand. I will not say which street. It was a street where many of us congregated and soon realised we could make money for doing what we were already being forced to do for free.

I am not sure you can imagine what it is like to have your head forced down on top of a man’s dick. Night after night… How many times this happened in a night depended on how many people were over or how drunk they all were.

Let us just say it’s gross and disgusting.

They would force my head so hard I would vomit in my mouth. It would splatter everywhere. But the men did not care. They just told me to open wider. I would vomit like this, three or four times. Sometimes I would choke – not only on them, but on my own vomit.

Not a great start to life for a child.

Anyway, I started hanging out on the streets to escape my nightmare of a home. But unbeknown to me, the streets would be even scarier – but at least the men paid.

The Green Men by Tiarna. She says: “One night I wanted to take my own life but instead I used a knife and what paint I could find to paint the ghosts that haunt me.”

I remember the first time a man put his penis into my ass. Fuck it hurt. It was like someone had sawed me in half with a rusty old saw. All I wanted to do was cry but I had already learnt at 12 that crying just turned the men on more and then they would be nastier and more aggressive. So I did not cry. Not until I was alone, and no one could see. Tears were a sign of weakness, and weakness on those streets, meant death.

It was not fun; I was not there because I wanted to be there. I just had nowhere else to go. Home was just as bad. The streets were more home to me because there were others there, who understood, who got me, you know. They did not judge me or spit on me, they were my brothers and sisters. If one of us was in trouble, the others were there. It was a better family than the one I had.

Once I hit 18, I thought I would have enough money to get my own place, but I was wrong. No one wanted to rent to a young, coloured woman, who had no references, no legit job, and no payslips. So, after all those years on the street, this is where I stayed – couch surfing where I could, hotels mostly. By the time I paid for the hotels, and food, clothes, and shoes, there was never much left.

I remember I would often dream of something better, but deep down I always knew it was a dream.

I remember thinking that was it for me. That was where I would be forever, and that was where I would die. Then a friend was talking about a new organisation they had heard of that wanted to support people like me who were in prostitution. I did not believe it. I had been on the street for over 10 years when I heard this and no one had ever wanted to help, not us coloured girls anyway. The white ones, yes, everyone wanted to help the white ones – as if they were more deserving than us, more valuable somehow.

But what the hell! I messaged anyway. And a lady messaged back.

I did not want to talk on social media, so she sent me her number and showed me how I could talk to her through WhatsApp. My phone was not very good, so she organised for me to pick up a phone from a local retailer near me so I could chat to her when I needed to.

She was kind but I still did not trust her. But it was nice to be able to call and talk to someone who was there. Even though she was just a voice, she never once judged me or told me what I needed to do like a lot of organisations would. She just listened. To be honest, that was all I wanted and needed, and it was awesome to have that. Some days I felt like I had a mum, or what I thought a mum would look like.

Life was not easy, but I had learnt when I was being fucked to take myself somewhere else. Places I dreamt I could be if I had been born into a different skin, a different time.

It would be another year before I felt safe enough to ask her to help me get out, to be free…

Flower by Tiarna. “I feel this is how others see me – just a small part of me. If only they would take the time, they would see there’s so much more than what’s on the surface.”

A man who had been coming to see me regularly, asked me to dress up in school clothes. He said he missed the way I was when I was 12. It was more of a turn on, he said. His happy place was a lot happier when I was younger. He said I was coming up to my use-by date, and all I was good for was fucking and once I was not good for that anymore, I should just go and kill myself because no one would want me – not even if I offered it for free.

It was not until he said that, that I realised these guys were creeps. My skin literally crawled. I felt like I had just woken up from a deep sleep, realising the life I had been living was pure and actual hell. I just did not want to be amongst all these creepy men anymore. I had had enough. He was right in a way. I would rather be dead than have to fuck one more guy to survive.

I call the lady on the other end of the phone, Aunty, because I respected her and trusted her.

She asked me what three wishes I would ask for if she had a magic wand. I said (1) to get me out of this hell hole, (2) to go to school, and (3) to get a real job.

I had tried to leave lots of times, but I never had enough money or food. I always had to pay for hotels because I never had a home, so I always had to go back. Sometimes it felt like a trap.

Aunty was amazing. I reckon she did have a magic wand. She gave me the numbers of some people I could turn to – and even though I hated talking, they were different. I was able to put my feelings and emotions into art. I am not bad at it either, I have found.

It really helped me. I have never liked talking. It is too easy for others to twist your words. This is why this is so hard to write. But I trust Aunty that she won’t use it for the wrong things.

She sent me food vouchers and found me somewhere safe to stay. It has not been easy. I have gone back. She has been so patient, and always there. Never pushing, just supporting. I always said to her I wish she were closer or had a refuge. I think I would have left earlier if I had had somewhere to stay, and she was not too far away.

But I have done it. I am studying school stuff. It’s so boring but I know it will be helpful. I didn’t think I could do it, as I had no money for books, or study equipment or anything. That’s when I felt the pull to go back.

But Aunty paid for everything or Wahine Toa Rising did. She said that as long as I was working on myself and trying, really trying, to love myself and my life, she would always be there to help me out. She helps me budget, and I took her zoom shopping so she could show me how to shop healthily but within my budget. Plus, I now have a job. A real legit job, and I am still staying somewhere safe. Some days are still hard, but it helps knowing someone is always in my corner.

Detail of a flower by Tiarna. She started painting when she was still on the streets and wants readers to understand that she had nothing apart from what she could scavenge from skips and the gutter. One of her artworks is painted over an old canvas she found in a bin.

No one had ever said that I was not a sex worker. I had always been told that now I was over 18, it was choice and an empowering choice at that. Now I know it was never a choice. An empowered choice, how? How is choosing to sell myself for sex to strangers as a child vs being fucked at home by so called family for free a choice? What choice is that?

I never had a choice.

Then suddenly the moment I was 18, it was “sex work”. I still did not have a choice, because it was the only life I had known. It was all I was trained to do.

How ironic my training to be a sex worker was being raped everyday as a child to the point I had to leave home and be on the streets. Instead of going to school, I went to rape school every day. Rape school where I was taught how to be the best fuckable, rapeable schoolgirl. Rape school and graduation at 18. I was now a sex worker. Cheapest on the block.

Wow what an experience! What every little girl out there wishes they could be and do.

Craziest thing here in New Zealand, it is all pretty much legal unless of course you are a little white girl – then watch the police and governments lock up the creepies. No such attention for us coloured ones. No one came to help me or ask me if I wanted to escape. No one even came to ask how old I was. The only ones who came up to me were the men who wanted me for sex.

I am just grateful I am out. Aunty reminds me it is one step at a time. She explains it like an AA program. One step. One day. One second, if needed.

As long as I am moving forward, even if it is only every second… I have to remember that I am free and every second I am free is amazing. Hard, but amazing.

I know it won’t be easy. Every time I feel down, all I want to do is go back. Crazy how I didn’t like it there but somehow, I felt safe there too. I like where I am now, but I am also not used to it. I am used to sleeping on the floor, or smelly hotel rooms.

But here I have a really big bed, clean sheets and soft blankets, and pillows, so many pillows. I love it but I also wake up feeling scared and wondering where I am. In these moments I want to go back. I am lucky I have support and someone to talk to even when its late. Many women don’t.

Prostitution when you have been doing it as long as I have becomes addictive like a drug. It’s a bad habit – but one that was the only one I knew. For so long, life without violence was unknown to me. And sometimes it feels scary to know I am safe and sometimes my head tries to tell me otherwise.

I hope I never go back; I won’t say I won’t. But I can say I will try not to and I will always seek out someone to talk to if I ever feel like I want to.

But for now, I am thankful and grateful I have someone who knows and cares.

Thank you, Aunty, and Wahine Toa Rising.

Pedro Pascal will soon be seen in ‘The Last of Us’, which will start airing on HBO on January 15

Pedro Pascal reportedly shares a close relationship with his father José Balmaceda Riera (Frazer Harrison/Getty Images and Instagram/ @pascalispunk)

SANTA ANA, CALIFORNIA: Pedro Pascal is a popular name in the tinsel town now. The Chilean-American actor has starred in many famous shows, like ‘The Mandalorian', ‘Game of Thrones', and ‘The Unbearable Weight of Massive Talent’. Pedro will also be soon seen in ‘The Last of Us’, which will start airing on HBO on January 15.

With his stardom on the rise, the actor's fans are eager to know about his personal details. Pedro is not married yet, and it's his family, especially his parents, who seem to have ignited people's curiosity.

Who are Pedro Pascal's parents?

link

Pedro is the son of Verónica Pascal and José Balmaceda Riera. While his mother is not alive, his fertility doctor father is a controversial figure who was one of many involved in the 1995 UC Irvine fertility scandal. A report by the Orange County Register said that the scandal was about “the switching of frozen embryos of women without their knowledge.”

It also involved tax fraud as “nearly $1 million in clinic income had not been reported. That was believed to include tens of thousands of dollars in cash payments from patients that were allegedly pocketed by doctors.” Eventually, José along with his colleagues Ricardo Hector Asch and Sergio Stone was indicted on mail fraud and income tax evasion charges.

However, before his conviction, the father of the ‘Narcos’ actor fled the US and went back to his home country, Chile. But years later in 2022, he reportedly returned and in a plea deal confessed he “under-reported his taxes in 1991 and 1992, as part of a scheme in which he and other doctors at the UC Irvine fertility clinic took cash from some clients and didn’t report the income,” The Orange County Register stated.

The March 2022 report also added that “Balmaceda’s surrender was the result of negotiations between prosecutors and his attorney, according to the U.S. Attorney’s Office, and he is currently out of custody on a $750,000 bond.”

José is a proud father

Despite the murky past, it seems Pedro and his father are close to each other. In 2021, José reportedly said, “We have a family WhatsApp group called ‘Abuelo Pepe’, where Pedro and the rest of the family communicate. There we discussed things, we send each other photos, we talk from grandchildren to politics.”

Pedro Pascal attends the 'Argentina, 1985' red carpet at the 79th Venice International Film Festival on September 03, 2022 in Venice, Italy (Kate Green/Getty Images)

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.