The rest of the report

Module A: Country Report

Module B: The Position of Women

Module C: Women's Health (Part 2)

References

Authors

Acronyms

Prepared for the World Health Organization, South East Asia Region Office, January 1998

This module examines the health status of women in Thailand. It seeks to identify areas in which progress has been made in improving women's health, areas in which significant problems remain and newly-emerging problems. Further it seeks to identify the structural framework in which progress has occurred, the reasons for success or failure in various areas, and the ways in which women's health is linked to their social, family, economic and political position within Thai society.

C1: Morbidity and Mortality

(a) Causes of Morbidity and Mortality

(i) Mortality

The trend mortality in Thailand has been decreasing in the past four decades. Simultaneously, life expectancy at birth of both gender has been increasing in the same periods (70). During the past three decades, infant mortality rates per 1,000 live births (IMR) for both gender also decreased over three times, from 84.3 in 1964-65 (73; 24) to 26.1 in 1995-96 (70) Among children in the 1-4 years age group, child mortality was as low as 1.1 per 1,000 in 1994 (67; 44).

Data on major causes of mortality is available to allow consideration of gender differentials for the ten leading causes of death in 1996 Death rates for most causes are higher among men than women reflecting women's 7 year longer life expectancy, on the average, in all previous national surveys of population changes.

The first ten leading causes of mortality per 100,000 population by gender as ICD mortality tabulation list (10th revision) in 1996 encompassed the followings.

Mortality / 100,000 Population

Female Male

1. Diseases of the circulatory system 82.1 134.8

2. External causes of mortality 31.1 78.8

3. Neoplasms 40.6 62.8

4. Diseases of the respiratory system 21.2 46.9

5. Certain infections and parasitic diseases 21.7 40.5

6. Diseases of the nervous system 15.2 28.8

7. Diseases of the digestive system 10.5 25.2

8. Diseases of the blood and blood-forming organ and certain disorders involving the immune mechanism 5.6

20.2 9. Endocrine, nutritional and metabolic diseases 12.0 8.0

10. Diseases of the genitourinary system 8.0 9.3

It is interesting to note that when gender differentials of the above ten leading causes of death are taken into accounted, all rates of female, but endocrine, nutritional and metabolism diseases (cause group number 9), are lower than male in 1996 (67).

(ii) Morbidity

A nationwide survey of health status conducted in 1991-92 (68) using interviews and physical check ups found that of the 41.9 percent of individuals having an acute morbidity during the two weeks prior to the interview, females reported slightly more illnesses than males in every region, in the ratio of 1.2:1.0. Of illnesses identified, 45.1 per cent of females and 38.1 per cent of males were able to report their illness, suggesting a greater awareness of health issues and their own bodies among women (68; 38). In both genders and in almost all age groups urban dwellers had higher acute morbidity rates than rural residents, except in the northeast and south. (68; 39) Housewives were the occupational group with the highest morbidity rate of 50.1 percent (68; 40).

(b) Mental health issues

Although there have been few studies examining issues of women's mental health, or of mental health in Thai society generally, it is broadly agreed that mental health problems are an increasing concern (as discussed in Module A). It would appear that women, who often carry the burden of both income earning, household management and emotional management of family life are particularly at risk (97; 6-7). One extensive survey by Wongpanich (not specifically looking at mental health) found that workers in textile factories suffered a significant range of symptoms which appear to relate to mental health, ranging from bad dreams and hallucinations to suicidal feelings (96h; 65).

As discussed in Module A, suicide rates generally are increasing. They remain considerably higher for males than females, which public opinion generally relates to women being more aware of continuing to try to meet responsibilities, particularly family responsibilities, no matter what the difficulties.

The theory that women try to continue living a normal life despite mental health problems is supported by recently-collected data on the rate of treatment for mental health problems in public hospitals. The number of female inpatients is approximately half that of males, although the number of each gender treated as outpatients is approximately equal (See Table C.1.9.). The fact that over a five-year period these figures show no significant increase in the number of patients treated may be a reflection on the resource limits of the institutions, rather than the level of mental health problems.

(c) Morbidity from certain causes

Malaria remains a significant threat and a major concern of public health programs, although in historical terms, the significance of the problem has been greatly reduced. The reason for ineffective malaria control in Thailand mostly due to internal occupational migration engaged in forest-related activities such as gem-mining along Thailand and Cambodia border, lumbering and rubber-tapping in the East and the South, is a high-risk group. Moreover, it was supplemented by cross-border migration of workers from neighboring countries. Recently, malaria outbreaks have taken place along the Thai-Myanmar border in the western and in the south of Thailand due to the influx of cross-border migrant workers. Adult males in general are at much greater risk of acquiring malaria than adult female. In 1997, the proportion between female to male patients was 1.0:2.0 (229; 1-10). However, in these intense transmission areas infants, young children and pregnant women are also considered as high risk groups and high death rates are observed.

In line with the HIV/AIDS epidemic, tuberculosis become a public health problem in 1990, after years of steady decline (65;20). The death rate from tuberculosis is substantially higher for men than women, with 1994 figures showing rates of 10.0 per 100,000 for males in both the north and north east and 12.1 per 100,000 population in the central region comparing to female rates of less than 5 per 100,000 population in these regions. The rate in the south is considerably lower (7.2/100,000 for males and 2.3 per 100,000 for females). In 1995 the sex ratio of tuberculosis cases between female and male patients was 1.0:2.2 (91).

Leprosy is still a health problem in Thailand with 396 new cases in 1994 (0.67/100,000 population). This rate is however far lower than in the past, and the goal of total eradication of the disease remains in sight. The proportion of female to male cases was 1.0 to 2.0

Regarding non-communicable diseases among population 15 years and older, the prevalence of many diseases was higher in female than of male. For instance, hypertension is 5.6 percent for female and 5.2 percent for male and high blood cholesterol was 13.0 for female and 9.1 for male. Similarly, diabetes in female was 2.7 and 1.9 in male in every region, and anemia was 25.0 percent in female and 17.3 percent in male. Among population ages 30 years and over the prevalence of ischemic heart disease was slighter higher in male than female, 10.7 for the former and 10.4 for the latter.

(a,b) Discrimination in food allocation

With regards to socio-cultural factors affecting nutrition among children, no studies differentiating between girls and boys have been conducted concerning the consumption of nutrient and micronutrient rich foods, including breast milk (96h). Studies in other countries have shown that excessive mortality of female children might be caused by discrimination in food allocation and health care provision for young girls within the household.

A national survey in 1987 noted that girls were slightly more malnourished than boys in the north and northeast (68; 49), but statistics on morbidity and mortality for children throughout Thailand show no evidence of any discrimination, as shown in Table 3. As expected biologically, death rates among young boys are higher than those for girls (96h, 54). A national study on morbidity and mortality in 1985/6 showed no definite patterns of sex difference for infectious diseases among under-fives, with rates of diarrheal diseases, which might demonstrate any discrimination, being almost the same for boys and girls (96h, 55). This is consistent with the low level of sex-preference expressed by parents, as discussed in Module B.

Breastfeeding is an important issue in Thailand, however, with the high level of women's employment outside the home impacting negatively on rates of exclusive breastfeeding during infants' first 4 months. In 1995, the MOPH Nutrition Division of Department of Health (76; 24-25) conducted the assessment on feeding pattern of children 0-24 months of age by interviewing mothers in 10 provinces in 1995 indicated that the percentage of infants exclusively breastfed at 6 weeks was 26.2. However at four months of age the percentage of infant exclusively breastfed significantly dropped to 3.6. The percentage of infant breastfed along with supplementary food at six months was 70.8 at the same period. Data on gender differentials in breast feeding and data on infants breastfed along with supplementary foods at one year of age are not available.

In 1996, a nationwide survey of fertility in Thailand (94) reported that 95.7 percent of ever-married women whose children were under two years of age breastfed their children. Only 4.3 percent of mothers who never breastfed their children. In urban areas, mothers who never breast fed was higher than those in rural areas (7.9 and 3.5 percent, respectively). Interestingly, no regional differentials in breast feeding did exist.. In every region, over 90.0 percent of mothers breast fed their children. In consideration of duration of breast feeding, mothers breastfed for 7.8 months on the average. Mothers in the Northeast breast fed their babies for 9.3 months, longer than any mothers in other regions whereas mothers who lived in Bangkok breastfed for a shorter period of 5.6 months. Urban mothers breastfed in the shorter period than the rural ones, 5.8 months for the former and 9.4 months for the latter (94; 19-20).

The three major reasons for mothers who did not breastfeed were mothers' working (31.5 percent), inadequate breast milk (29.6 percent) and mothers' health problems (18.4 percent). It is worth noting that as high as 41.6 percent of non-breast fed mothers living in Bangkok reported the reason as employment (94; 20). The relatively high rate of supplemented breastfeeding at six months (70.8 percent)(76; 24-25) does indicate, however, that education and promotion programs have encourage mothers to maintain at least some breastfeeding.

(c) Prevalence of underweight children and adolescents

Two National Nutrition Surveys of Thailand in 1986 and 1996 suggested a rapid decline of children under five years who are malnourished in both gender. As assessment by anthropometric measurement using Gomez's classification as a local standard (weight- for- age), the percentage of female malnourished decreased from 43.1 percent in 1986 (92; 87) to 31.6 percent in 1995 (92; 34-36). The percentages of children in the same age group who were underweight were slightly different between the two gender. In 1986, it was 43.1 percent for female and 40.3 for male, but in 1995, the latest data available, it was 31.6 for female and 31.9 for male.

The gender differentials of children under five years who are stunted (height-for-age) were investigated in the two national nutrition surveys in 1986 (92; 34-36 and 1996 (87), respectively (MOPH Nutrition Division, 1986, 1997). No significant difference was observed between female and male in the percentage of children under five years who were stunted in both national nutrition surveys. In 1986 (92; 34-36) survey, the percentage was 21.5 for female and 20.9 for male, whereas it was 14.1 for female and 17.0 for male in 1995 survey (87).

In consideration for urban-rural differentials, the percentages of girls under five years who were stunted were 10.1 for urban areas and 15.0 for rural areas (87). This gender differential of nutritional status was confirmed by the percentage of children in the same age group who are wasted (weight-for-height). The percentage of malnourished females was slightly than male in the past decade. It was 25.3 for female and 22.9 for male in 1986 and it was 10.3 for female and 9.0 for male in 1995 (87).

In 1995, the percentage of malnourished females (weight-for-age) was higher in rural (33.0 percent) than in urban areas (25.4 percent). However, in consideration of weight-for-height, the percentage of malnourished girls in the rural areas was slightly lower in urban areas (10.3 for rural and 11.0 for urban areas) in the same age group and in the same period. Therefore, rural-urban differentials in childhood nutritional problem were unclear (87).

The above shows consistent improvement in children's nutritional status over the past decade. This changes are probably due to the nutritional policies and programs for example the nutritional surveillance project for children under five years old focusing on community participation using village health volunteers to weigh preschool children and collect data every three months under the supervision of health center personnel.

(d) Nutritional Anemia in Women

The most common nutritional deficiency among Thai people is iron deficiency anemia. Both specific data on rates of all women between 15 and 49 years and pregnant women are available, but no gender-segregated data for children is available. Among both pregnant and non-pregnant women the rate of anemia has approximately halved over the past decade (91; 56,87). This is a reflection of both generally improved nutrition rates resulting from improvement in economic conditions and better education and government programs addressing anemia.

Regionally, southern Thailand has the highest level of iron deficiency anemia (Table C.2.1), which may be due to hookworm infestation (particularly prevalent in this region) which further depletes the body's iron supply. Other contributing factors include irregular antenatal attendance (65;15) and traditional food beliefs, which may deny pregnant women access to foods rich in iron and other important nutrients. These may even lead them to decline iron supplements when supplied (as is standard) through government health programs, due to unwarranted fears about these causing large fetuses and complicated deliveries (96h; 56).

(e) Other Micronutrient Deficiencies

(i) Iodine deficiency disorders

The rate of iodine deficiency disorder among primary school children from 1989 to 1994, as measured using thyroid goiter rate as an indicator, is shown in Table C.2.2. The area of highest prevalence is in northern Thailand, an area in which the problem is considered endemic due to low levels of the mineral in soil, water and plant products. Goiter as an indication of iodine deficiency is more common in girls than boys, although the reason for this difference is unclear.

To address the nation's iodine deficiency disorder (IDD) problem among all age groups, under the aegis's of the King's Program on Iodine Deficiency, the MOPH has established laboratories and operation centers as well as launching a campaign to disseminate information on IDD prevention, especially to pregnant women. The campaign has focused on encouraging the use of iodized salt and iodine tablets and testing to assess the status of the newborn infants (96b: 11). The success of this program is shown in the significant reduction in the problem, as shown in Table C.2.2.

(ii) Vitamin A deficiency

In 1990, the MOPH Nutrition Division reported that amongst preschool children in the North and Northeast, 2 to 3 per cent suffered from night blindness, 18 per cent had conjunctival abnormalities and 6 per cent had low levels of serum retinol, all indicators of Vitamin A deficiency (67). No gender-segregated data is available from this study. But one study in the five most southern provinces, which hospital data indicated had a serious problem with Vitamin A deficiency among pre-school children, found there was no significant difference in the level of Vitamin A deficiency between boys and girls (82; 10).

These children had been fed with sweetened-condensed milk without vitamin A supplements. In an attempt to prevent these deficiencies occurring, the MOPH Division of Nutrition has launched a program of community education, distributed high-dose Vitamin A capsules to all children living in high risk areas and has regulated the addition of Vitamin A supplements to sweetened-condensed milk (65; 36). This has been successful in eliminating reported cases of xeropthalmia (nutritional blindness), but subclinical cases remain a problem (65; 37).

(f) Relations of Women's Workload to Nutritional Status

According to the 1993 National Labor Force Survey, 60 per cent of the workforce are employed in the agricultural, fishery and construction sectors, and may be termed "hard labor workers". As noted in Module B, approximately half of these workers are women.

For mothers, pressure to continue work, particularly hard farm work in rural areas, right up until delivery, and to resume work soon after delivery, is an important negative factor for both maternal and baby health. Combined with inadequate nutrition and rest, the effects can be serious, either in themselves, or through leaving mother or baby susceptible to other health problems (97; 7), although no detailed studies have been conducted on this issue.

A study by the MOPH Division of Nutrition to assess the nutritional status of construction workers has been reported. (105) A total of 303 laborers, 224 male, 79 female, were studied. Their average age was 30 years. The nutritional status was assessed using Body Mass Index (BMI) and the study concluded that one third of the female laborers in the study were undernourished, with an average caloric intake of around 1,700 kilocalories, compared to an RDA of 2,000 kilocalories. The study found that about 90 per cent of the subjects ate three meals a day. Half of them reported cooking their own food, while one-third indicated they cooked rice and bought a ready-made dish to eat with it, but it appears that in many cases this diet was inadequate.

Another study, of administrative workers, found they faced the potential of nutritionally-related health problems not from undernutrition, but from an excess of calories. Vichaidit (106) studied 223 administrators living in Bangkok and surrounding areas. The average ages of males and females were 40.9 and 41.9 years respectively. It was reported that 63 per cent of them had normal BMI, while 16 per cent had a BMI below the standard. However, around 20 per cent had a BMI above the standard, leaving them at risk of hyperlipidemia, hypertension, gout and gall stones. Only 19 per cent regularly exercised and 18 per cent reported no exercise. Another study of 3,494 officers of the Electricity Generating Authority found 23.3 per cent of the male and 18.8 per cent of female officers were obese (128; 28).

This study supports another by Smitasiri (129), who found that carbohydrate consumption among urban working women (many in sedentary occupations) was falling as meat and fat intake increased. She found overall mean intakes of Vitamin A, iron and phosphorous were adequate, but mean calcium intake was only 51-54 percent of the Thai RDA.

(a) Maternal Mortality and Morbidity

According to Division of Health Statistics' report, it was found that in 1973, the MMR was 170 per 100,000 live births, declining to 50 in 1984, and approximately 40 in 1987. According to the latest report, the rate was 0.2 per 1000 live birth in 1990. (227; 28). According to the eighth five-year National Health Development Plan (1997-2001), MMR was 23/100,000 live birth in 1996 (227; 3) and expect to be reduced to 20.0/100,000 in 2001 (2278; 8). The ratio of 20 deaths per 100,000 live births is generally regarded as a reasonable estimate. (See Table 3 for a range of the statistics quoted.) What is clear is that the rate of maternal deaths has been falling steadily over the past decade. This is primarily due to improved health services, combined with improving education, nutrition and living conditions of women associated with improving economic conditions.

The cause of death as classified by the International Classification of Disease for 1991 and 1996 shows most deaths are due to hemorrhage and obstructed labor. (See Table C.3.1). The overall increase in numbers recorded between 1991 and 1996 is probably a reflection of better reporting, during a period when the maternal mortality rate was believed to be generally declining. The reduction in deaths due to toxemia appears as evidence of improving health services.

In many cases the underlying cause of maternal deaths is believed to be lack of prenatal care which might otherwise identify high-risk births and ensure adequate care (101; 27). These conclusions were supported by a cross-sectional retrospective maternal mortality study in 1989-90, which found 63.5 per cent of surveyed deaths were in women who had no antenatal care. It found most of the deaths were preventable with adequate care (65; 15).

Despite continuing problems in certain areas, however, the significant decrease in deaths is indicative of the success in spreading appropriate pre-natal, birth and post-natal health services to the bulk of the Thai community. In 1996, over 92 percent of births were attended by a trained attendant, a figure that has remained generally stable throughout the decade, although representing a significant increase from the 1980s. (See Table C.7.1.)

(b) Differential fertility factors

Thailand has been experiencing in a rapid decline in fertility levels in the past two decades. The total fertility rate (TFR) was rather high at 4.9 in 1975, and decreased to 2.7 in 1980 and 2.0 in 1995-96, respectively, as shown in Table C.3.2. This fertility reduction was confirmed by the National Contraceptive Prevalence Survey (CPS96) (89; XIII) indicating a reduction of the average number of children ever born (CBS) for ever-married women aged 15-49 from 3.7 in 1978 to 2.0 in 1996 and that TFR has continued to decline through the 1990s.

For fertility differentials, the same study also indicated that TFR was 1.70 for urban area and 2.08 for rural areas. In addition, TFR for each of the five regions were: Bangkok (1.68), North (1.78), Central (1.92), South (2.09) and Northeast (2.11). Similarly, the same survey shown CEB was slightly lower in urban areas (1.9) than in rural areas (2.1) (89; XIII).

(c) Contraceptive Prevalence

The contraceptive prevalence rate (CPR) has rapidly increased from a low 14.4 per cent in 1970 to 72.2 per cent in 1996 (89; XIII), reflecting a great success of the national family planning program in improving availability and accessibility to family planning services (96b, 9) and the ready acceptance of family planning by the Thai community. The effective family planning IEC programmes promoted a favorable attitudes toward small family size preference among a general public. Consequently, married couples in reproductive age voluntarily adopted birth control to prevent unwanted pregnancies and to prolong birth intervals. A great number of couples considered having many children as an economic burden rather than an asset.

The CPS96 indicated no significant differential CPR in rural and urban areas with the CPR of 72.5 percent and 72.0 percent for rural areas. However, the regional differentials of CPR still exist. The CPR was lowest in the South (61.6 per cent), 70.6 percent for the Northeast and the rates for the other three regions all between 75 and 76 percent.

The national Family Planning Program provides seven alternative birth control methods, namely, female and male sterilization, oral contraceptives, intra-uterine devices (IUDs), injectables (Depomedroxy Progesterone Acetate DMPA), condoms and Norplant. There are differences in methods of contraception used by rural and urban women. It was indicated in the CPS96 that contraceptive pill and female sterilization were more likely to be accepted by urban women whereas injectables were more popular among rural women. Use of the pill was highest among women in Bangkok, injectable use was highest among women in the North and female sterilization use was highest in the Northeast. The use of female sterilization was lowest in the South.

For non-permanent methods, the oral pill has continued to increase in popularity (23.1 per cent of users in 1996). Since 1989 the popularity of injectable contraceptives has doubled. These techniques appear to have largely replaced IUDs, now representing the method of choice of only 3.2 per cent of contraceptive users. (See Table 3)

The low level of male sterilizations, and the relatively high level of the more expensive and difficult female sterilization, is largely a reflection of continuing traditional beliefs which suggest the operation may negatively affect virility and bodily strength. Despite attempts to encourage this practice as being positive for women's health, there remains considerable cultural resistance and misinformation within the community about the procedure (103; 51).

The general figures do, however, hide the fact that agricultural workers and laborers throughout the country are less likely to practice family planning than women in other occupations (96b; 9). This raises questions of how accessible or acceptable methods and services offered are for these groups (96b; 9). For cultural reasons, the Muslim population of southern Thailand also has a relatively low rate of contraceptive acceptance. (96b; 8) The Seventh National Development Plan (1992-1996) sought to develop specific programs promoting contraceptives and providing appropriate services to target groups of these women, together with hill tribe women. (96h; 52) Although the level of contraceptive acceptors has continued to gradually increase, as shown in Table 3, it is unclear if this represents greater use by disadvantaged groups.

There is also concern about continuing low levels of understanding among women about the functioning of their bodies, which may be a barrier to effective contraceptive use. A national survey in 1988 showed only 13 per cent of married women aged 15 to 49 years had accurate knowledge of the time in the menstrual cycle when they were most likely to become pregnant, while a 1992 survey of oral contraceptive users shows a large number did not know what to do if they forgot a pill, or when they should start a new cycle of pills. These facts were reflected in a 1992 nationwide survey which showed one third of pregnancies were unexpected (134; 31).

Despite increasing rates of pre-marital intercourse, family planning information relatively directed towards married women than the single ones. This is supported by traditional beliefs that single women should ideally not know anything about sex intercourse or related topics (96h; 60).

(d) Induced Abortion

Abortion data in Thailand remains very limited, due to the practice's illegality and cultural factors which make this both a very difficult area for researchers to approach. However, the extent of induced abortion problem in Thailand is believed to be increasing.

The only detailed study of health hazards of illegally induced abortion gathering data from hospitals records and reports by Koetsawang (See Table C3.6) found the total abortion in 1984 was 5,701, encompassing 3,700 illegal abortions, 1,227 spontaneous abortions, 750 therapeutic and 24 uncertain abortions. The number of all types of abortion in the North-east, the Central and the North was significantly higher than any other region (see Table C.3.6). For single women, the major reasons for seeking therapeutic abortion were socio-economic problems such as sustaining student status (45.3 percent) and unwanted premarital pregnancies (31.3 percent) (See Table C.3.7). Similarly, most of married women seeking a therapeutic abortions cited socio-economic problems (70.3 percent) and contraceptive failure (16.0 percent) as the reasons for their choice. (See Table C.3.8)

A more recent study, the 1996 Survey of Fertility in Thailand, found that 8.3 percent of ever-married women aged between 15 and 49 had undergone an abortion, Most (6.7 per cent) having only had one (94; 28). In the 15-19 age group, 7.8 percent had undergone an abortion, almost the same rate as the over 40 age groups (94; 28). More data would be needed to determine if this indicates the overall rate of abortion is increasing.

There are ongoing efforts by women's groups to change the abortion law to allow for legal abortions in cases where there is a risk of the fetus suffering from disease or disability, particularly if it may be infected with HIV. These encounter considerable resistance from a number of groups in society on a variety of grounds, most particularly those of religion. However, in light in particular of the rate of HIV infection in Thailand, and on humanitarian grounds, medically-supervised abortions are now reported as being widely available in cases where there is evidence of, or the likelihood of fetal abnormalities or HIV infection. Women's groups are working to develop networks to provide women with effective support, counseling and assistance in accessing these (134; 31). The Medical Council has stated its policy as being that it will consider complaints made to it, but not punish physicians if they are performing abortions for humanitarian reasons (134; 31).

The broader availability of medically-supervised abortions, combined with generally improved health services, is reflected in the fall in the number of deaths reported from abortion. Fourteen cases were reported in 1994, down from 42 cases in 1989 and 24 cases in 1993 (65; 18), although these are certainly underestimates of the total number of deaths. .

The fact that abortion, particularly in cases of HIV infection, is being widely offered (often from the best of motives), while being broadly illegal, presents some particular difficulties. Researchers have recorded cases where couples or women have been pushed to have abortions without appropriate advice or counseling. With the increasing magnitude of the HIV/AIDS problem, discussed below, this issue will present a continuing and increasing challenge to the Thai medical community (186; 118-9). It is generally agreed that a change in the law would be needed to provide the environment to allow appropriate services and support.

(e) Miscarriage and Stillbirth

No completed statistics on miscarriage are available. As mentioned earlier, from 5,701 abortion of all type occurring in hospitals in 1987, as high as 1,227 (21.5 percent) was miscarriage (Table C3.6). However, this number was under-reported due to some hospitals did not report the number of spontaneous abortion.

Stillbirth or late fetal mortality ratio per 1,000 live births are shown in Table 3. Over recent years, between 1991 and 1994, these demonstrate a steady decline from 0.8 in 1991 to 0.3 in 1994 (67), which is certainly reflective of improved maternal health care. However, no systematic investigation of the causes of these deaths has been done. The rate of stillbirths is estimated at 10 per 1,000 livebirths.(65; 18).

(f) Sexually Transmitted Diseases and HIV/AIDS

As in other countries, intensive AIDS prevention programs focusing on condom use and "safer sex" has reduced incidence rates of STD infection in Thailand in recent years. It seems that the rates of STD infection reported in 1991, with prevalence among youth aged 15-19 at 23 per cent, rising to 36 per cent in the 20-24 age group, have since been reduced. (96h, 58) However, figures from 1992 continued to show a high rate of infection among men and women aged between 15 and 24 (with the frequency of male infections 2.5 times greater than female), reflecting difficulties in reaching this group with the "safer sex" message (96h, 10).

The most recent epidemiological survey showed that of sexually transmitted diseases (excluding HIV/AIDS), gonorrhea (42.8 per cent) was the most common, followed by non-specific urethritis and syphilis; 20.1 per cent and 12.9 per cent respectively (Table C.3.9). Among women, commercial sex workers exhibited the highest rate of STDs in 1987-1989, 74.37 and 78.64 per cent respectively. Female laborers were the second largest group of patients (96b, 10).

As noted above, HIV/AIDS is a very significant health concern in Thailand. AIDS surveillance from the MOPH Division of Epidemiology concluded that from the start of the epidemic until October 31, 1997, 59,548 male and 13,227 female AIDS patients were admitted to government and private health service facilities. However, it is hypothesized that many more deaths and illnesses may have occurred without access to the health care system or may be reported as deaths due to other causes, in view of the social stigma still attached to the disease.

Researchers have identified four "waves" of HIV infection in Thailand. The first involved homosexual or bisexual men, many of whom had been in contact with foreigners, while the second was among injecting drug users. It was only in the third wave of infections, among commercial sex workers, and their partners, that women were seriously affected, with the rate of infection among sex workers reaching 27 per cent, according to one survey conducted in June 1994. The fourth wave is being identified now among the wives and girlfriends of men who have visited commercial sex workers (96h, 8-9) and their children. There is also concern about the fate of children whose parents die of AIDS, including children who are not infected with the virus but who may be left as isolated and vulnerable orphans. The growing importance and now dominance of heterosexual transmission is shown in Table C.3.10.

Overall, it is now estimated that infection levels have now reached close to 2 per cent among the population of reproductive age (188; 8). In Chiang Mai (in northern Thailand) the level of HIV infection among pregnant women had reached 7.96 per cent in December 1993. In 1989 46 per cent of pregnant women testing positive to HIV were identified as injecting drug users or commercial sex workers, but by 1992 this figure had fallen to 18 per cent, with heterosexual transmission from husband or boyfriend being reported as responsible for the remaining 82 per cent (189; 24).

Agricultural workers, laborers and other relatively poor socio-economic groups have been hardest hit HIV/AIDS infection (96b, 10). However, increasing rates of infection reported at private hospitals in Bangkok, primarily serving middle and upper class patients, suggest growing levels of infection among higher socio-economic groups (186, 108).

Thailand has been praised for its relatively speedy and effective response to the threat of the HIV/AIDS epidemic. Government programs have focused on a "100 per cent condom use" policy, with a particular use on encouraging condom usage by the clients of commercial sex workers combined with efforts to encourage community -based and home care services. This is generally acknowledged as being broadly successful, with various surveys reporting reduced percentages of Thai men visiting brothels, and reported rates of condom usage with commercial sex workers being high.

A number of problems have, however, emerged. Some commercial sex workers, particularly those working in poor conditions, young workers and those who have been forced into the industry, are often unable to enforce condom usage. Even women aware of the HIV/AIDS risk may, on days with low income, when faced with regular or clean and good looking customers, when receive extra pay from customers for not using condom., when suffering from painful intercourse associated with condoms, or when concerned about extra length of intercourse when condoms are used or acquiesce to unprotected intercourse (190; 47).

Increasing rates of non-commercial pre- or extra-marital sex also put many women at risk. An August 1997 study of nearly 5,000 sexually-experienced male students around Thailand found 72 per cent said they had premarital sex with their girlfriends. Almost half said they did not use condoms during sex with their girlfriends and another 24 per cent said they used them only sometimes. More than one in three (37 per cent) said they had engaged in intercourse with someone they met at an entertainment place. Almost half had engaged in sex with a commercial sex worker, although more than 60 per cent said it was not "okay" to go to commercial sex workers. Of the users of commercial sex services, 84.5 per cent said they used condoms, while 9.3 per cent had used them sometimes. More than one in four agreed with the statement that it was good to have your first sexual experience with a sex worker, in order to learn about sex (140; 6-7).

Due to cultural attitudes which suggest single women should be sexually innocent (as discussed above), women in such relationships are in a very poor position in suggesting or promoting the use of safer sex in the relationship (134; 31), and as the above survey suggests, there is significant danger their boyfriends would put them at risk. Cultural attitudes would make it enormously difficult for women to carry condoms or suggest their use, while one survey found that a significant number of women had never even seen a condom, let alone knew how to use one (96h 60). Similarly, for married women, it is extremely difficult for them to negotiate for condom use within their marriage due to the implied lack of trust and general difficulty in discussing sexual issues. One study of focus groups of housewives in seven provinces found, on average they had intercourse with their husbands three times per week, indicating they are at significant risk (191). Therefore, there is a need for active research on appropriate negotiating strategies married women might use without provoking violence or social risks (225).

In caring for AIDS sufferers, in view of the scale of the problem, Thailand has been seeking to strengthen mechanisms to support community-based services and home-based care.

A further HIV/AIDS issue is childhood infection. It has been estimated that by the year 2000 in Thailand over 160,000 children will have been infected with HIV, and 75,000 will have died from AIDS (192; 6). The transmission rate from HIV-positive mothers to their babies has been broadly estimated at 25 per cent, so there is also the likelihood of large numbers of orphans created by the HIV epidemic. The significant reductions achieved in child mortality in Thailand may thus be threatened by the combined effect of children dying from AIDS and orphans being at risk of poor care, nutrition, vaccinations, health care, etcetera (193; 3)

One way of tackling this problem is to provide appropriate care for HIV-infected pregnant women. This might include ensuring optimal nutrition for the mother, supplying anti-viral agents at key pregnancy-stages, preventing or treating infection with other diseases and taking steps during the birth to prevent infection (ranging from use of drugs in the birth canal to delivery by cesarean section (194; 37). Several Thai studies have shown that use of AZT or similar anti-viral agents at key pregnancy stages can significantly reduce transmission rates, to as low as 8 per cent. At present, however, such treatment has only been available to women involved in clinical trials, those who can gain the support of organizations such as the Red Cross, or who can afford to meet the substantial cost themselves.

(g) Reproductive Cancer

In 1994, the National Cancer Institute found that the most frequent malignancy affecting women was cervical and uterine cancer (33.0 per cent), followed by breast cancer (29.9) (see Table C.3.11). Considering the mortality rate due to cervical cancer and all ovarian cancers from 1970 to 1987, as shown in Table C.3.12, it was reported that the rate increased during 1980 to 1983. As little research has been conducted in the area, the possible reason for this is probably largely due to the improvement of diagnosis and the improvements in the medical record and reporting system.

After 1984, mortality rates from cervical cancer decreased due to a public awareness campaign which sought to encourage women to undergo regular examinations, which led to earlier diagnosis (97; 3). The effectiveness of curative methods also increased, but cervical cancer remains an important problem for women's health and more education and awareness-raising is needed to encourage women to participate in regular screening.

(g) Menstruation and Menopause

There have been only limited studies about the problems associated with the onset or continuation of menstruation among Thai women.

On the average, age of menopause for Thai women is 49 (97; 6). The normal range is 44-52 years (96b; 11). Very limited existing data indicates that 50 per cent of women suffer from negative symptoms of menopause, ranging from mild to severe. Historically, these problems have not been considered or recorded, although the level of discussion has increased in the last few years (96; 10-11).

The findings (See Table C.3.13) suggested that women are likely to suffer most during the middle period of menopause, when they are having irregular menstrual periods. About three-quarters of the women in this group indicated they were suffering from a variety of symptoms, while about half of the menstruating and non-menstruating groups indicated no health problems. Most of the symptoms recorded relate to emotional or psychological state.

As for sexual desire in menopausal housewives of lower education, it was found that 59.4 percent of 1,200 post-menopausal women in Chiang Mai have lost all sexual desire after menopause period (Table C 3.15). Twenty-seven per cent reported reduced libido and 13 per cent reported no change. Only 39.2 per cent still had intercourse with their husbands (135; 28). These findings have important implications for issues of family stability, mental health and the possible transmission on HIV/AIDS.

There has been considerable discussion about hormone replacement therapy, and one survey by the Drug Study Group has shown that most women (largely middle and upper class women as the therapy is relatively expensive) have adopted it without a prescription from a doctor, despite its potential side effects and dangers (136). There has also been concern about the use without prescription of what has been described as a "herbal" medicine, "thyroid hormone" (this is a description some herbalists and doctors reject). Prolonged and inappropriate use of this drug has been linked to uterine cancer, and is also believed to increase the risk of osteoporosis. As yet there is no data available about the incidence of the later condition in Thailand, but increasing lifespans. The relatively low rate of consumption of dairy products and generally sedentary lifestyles among the female urban community suggest this is a health issue which may arise in the future (137).

(h) Infertility

Only limited data on infertility in Thailand is available. A survey of 6,315 currently-married women aged between 15 and 49 years of age, conducted in 1996, found 2.5 per cent had primary infertility and 9.9 per cent secondary infertility. There was no difference in the rates of infertility among rural and urban women, although regionally, women in the south had the highest rates of infertility, women in the north-east the lowest.(195; I)

Another study (195;1) of one clinic providing infertility services in Ubon Ratchatani Province (in the north-east) found that between 1990 to 1997,of 356 clients who are mostly farmers, 90.5 percent suffered from primary infertility. On average the women were aged 28.6 years and had been married for nearly four years, having sexual intercourse on average between two and four times per week. Only five per cent returned to the clinic more than twice. It was unclear if this was because they were successful in becoming pregnant.

Statistics of infertile couple compiled by Infertile Unit, Department of Obstetics and Gynaecology, Faculty of Medicine Ramathibodi Hospital during 1982 to 1987 found that most of female infertility were from abnormality of ovulation (44.9 percent) followed by fallopian tube problems (29.7 per cent), adhesions in the pelvic cavity (28.2 per cent) and cervix (20.3 percent) respectively (see Table C.3.15). Results from diagnoses of 1, 061 infertile couples, revealed that there were only 4.4 percent of male abnormalities, which mostly due to varicscele (1.7 percent), followed by abnormal testis (1.5 percent) (see Table C.3.16).

(i) Reproductive Technologies

For those who can afford to pay, Thailand offers virtually the full range of high-technology reproductive services available in Western nations, including in-vitro fertilization and related technologies. No statistics are available on the usage of this service, but it is likely to be low, as is general knowledge of its availability.

Concerns have also recently begun to be expressed about the application of high-technology medicine, particularly during births. It is known that rates of cesarean section at some Bangkok private hospitals have reached 50 per cent of total births, which by international standards is very high (138) and may be adversely affecting the health of both mother and baby. Those raising concerns about this statistic have tied it to broader issues about the doctor-patient relationship, which still tends to be highly paternalistic and directive.

Unfortunately, no current national or even specific hospital surveys on the overall rate of caesarians is available. A study on birthweights in Thailand (227) which collected data from birth records from the provincial hospitals, four regional MCH centers and four large Bangkok hospitals (Rajvithi, Ramathibodi, Siriraj and Chulalongkorn) from 1979 to 1983 indicated that the incidence of caesarean section of all regions in Thailand varied between 2-7 percent in 1979 and 3-7 percent in 1982, but this has certainly increased significantly.

(a) The household environment:

A 1989 housing evaluation showed that about 40 per cent of housing throughout Thailand was below a basic hygienic quality standard, with more than half of these housing units located in the northeast. However, economic growth has improved this situation. In 1993, 98.6 per cent of the population had access to electricity, 84.5 per cent had sanitary toilets and 77 per cent had a continuous supply of safe drinking water (See Table 3).

Many of the health and lifestyle issues of particular importance to women have thus been addressed, but the continuing existence of substandard housing, particularly "slum" housing in city areas, is no doubt a factor in some health problems. These areas are frequently exposed to toxins and pathogens from industrial production, traffic pollution, garbage and sewage. (187; 14). This particularly affects women because of their responsibility for housework and childcare, and the consequently longer periods they are likely to spend in the household environment.

There have been no studies in Thailand on any risk associated with fuel from cooking stoves, but in view of the Thai climate, and the fact that the majority of cooking is done out-of-doors, this is not generally a significant problem. The exception is in some hill tribe groups (which live in higher, cool areas) in which respiratory illness resulting from cooking fires and poor ventilation may be a problem (65; 28). Similarly, fuel collection is not a serious problem, as a variety of sources, including gas and electricity, are generally available, except to the very poorest groups.

(b) The gender division of labor

In Thai society, factors influencing gender roles have been identified as individual, cultural, economic, and political, or through government policy. All of these factors interrelate in creating a role for women that has particular stress on household responsibilities, both in women's responsibility to provide an appropriate physical environment through good economic management (often of meager resources) and their responsibility in maintaining and managing it. All of these factors influencing women's role are also closely related to women's health status.

(i) Rural and Urban Responsibilities

Thai women, in both rural and urban areas, usually having both household and outside responsibilities. On average, northeastern women spend 11-15 hours a day for household chores, not including time spent for child care, which runs concurrently with these chores (104; 4-2) Another study found that in rural areas women spent an average of 1644 hours per year working in agricultural production, compared to 2294 hours for men. But when women's domestic burdens were seen as "light" and "boring", as well as being solely women's responsibility (104; 3-3).

Women in urban settings have different patterns of domestic responsibility when compared with their rural counterparts. They may face a choice between leisure, child care, housework, work in the informal sector and formal employment. Formal employment in particular is likely to lead to a reduction in the time available for domestic work, which at differing wage levels and social groups may be met by the employment of domestic labor, the use of extended family networks, or by sacrificing leisure time or adopting lower household standards.

The childcare burden, however it may be arranged, is, for both rural and urban women, a substantial barrier to other potential activities, including those related to health. It reduces their exposure to health information campaigns, nutritional information etcetera, particularly through the mass media and indirectly has an impact by preventing them developing their education and skills to obtain better, healthier work or better-paid work which would allow greater expenditure on medicine, nutritious food, accommodation, etcetera.

(ii) Child Care Responsibilities.

Particularly for urban women, usually employed outside the home, child care is often a source of considerable stress and concern. The increase in nuclear families also means that mothers may be removed from traditional sources of advice and information on family planning, and there has been increasing concern that there are no courses in parenting and related skills which might replace the traditional learning method.

(iii) Household Decision-Making

General Thai cultural expectations suggest that women should be responsible for managing household finances, and that in fact they are more responsible and capable in such matters than men. This fact is reflected in Thai law, which requires that both men and women have their spouse sign any loan agreement (103: 52). It also means that Thai women are generally able to direct household expenditure to basic needs such as nutrition and health care, if the resources exist in the household.

This means, however, that women often feel responsible, and are regarded by others as being responsible, if basic household needs cannot be met. This stress often affects a woman's physical and psychological health status, as discussed under section C1. It also means that directing health messages to women will ensure the household manager is being provided with information she may need for her work.

(c) Occupational Health Problems

Occupational health problems can be caused by the physical environment, including factors such as temperature, light, sound, dust, chemicals, and machinery. Other factors are physical conditions of the female workers themselves, their understanding of the work, their health behavior and emotional status, and their readiness to work. It is generally agreed that many of these factors present risks to the health of female workers, although due to the sensitivity of the topic with officials and employers, the difficulty of accessing female workers and identifying work-related illnesses, it is extremely difficult to quantify the problem, or even identify the most significant problem areas.

Another problem which is very difficult to quantify is the threat to women's health, particularly their mental health, from harassment or assault they may suffer in the working environment. Levy and Wegman (196; 482) studied women's status in the workplace among 500 women and found that 42.88 per cent of women workers had been sexually assaulted or harassed at work which, in some cases, resulted in physical and psychological disturbances. Only very recently, in January 1998, was legislation passed prohibiting sexual harassment in the workplace.

(i) Female Agricultural Workers

Chemical use in agriculture poses a great health hazard to the user and environment. In 1985 a study on pesticide poisoning in selected areas of three SEAR (Indonesia, Sri Lanka and Thailand). This study show pesticide poisoning rates of 13.38 per cent, 11.9 per cent and 19.4 per cent respectively in agricultural workers using pesticides (198).

The Division of Epidemiology's report shows that the morbidity of occupational pesticide poisoning in 1987 was 8.6 per 100,000 population (which is almost certainly an under-estimate. Moreover, pesticide residues such as organochlorine were detected which could have direct impact on potable water and its users (probably including many of the workers who applied it).

A 1995 study of the female labor force reported that most of the female laborers hired to spray pesticide were poor, the average age was 20-40 years old and had only elementary education. About 20 per cent of these women have been exposed to pesticides due to poor practices in self-protection. The health problems reported included headache, nausea, vomiting and skin rash. The study also found young children were exposed pesticide residues on their mother's clothes. The women workers were usually unaware of any minor symptoms and unlikely to seek treatment or change their behavior. (199).

Pain-killing drugs are widely used among female workers in the agriculture. It has been reported that 72 per cent of agricultural workers take pain-killing drugs, while 63 per cent take them routinely; without pain killers they would feel fatigue and could not continued working. The consequences include peptic ulcers, addiction, and psychological problems (226, 143).

(ii) Industrial and Non-formal Sector Employment

Industrial workers face a variety of health threats, depending on their industry. Textile workers, more than 90 percent female, face a particular danger from inhaling fiber dust, which can lead to byssinosis. It has been reported that there has been an increasing trend of workers with byssinosis disease applying for the work compensation funds. The occupational Medicine Department reported in 1993 that there was 520 cases of byssinosis, while a study from 1990 to 1994 found that over a ten year period, 30 per cent of workers would develop the disease (96d; 19).

Women in the electronics industry are particularly at risk from exposure to lead, aluminum, trichloroethylene and many other chemicals (96d; 19). Lead is the best-studied of these, with one study finding 36 per cent of female workers of the Seagate Technology (a major manufacturer who might be expected to have better than average safety standards) had blood lead level higher than the standard.

As in agriculture, a problem which is widespread across many industries is the abuse of drugs by workers who find, or feel, that they are essential to their ability to complete the job. Analgesics and amphetamines are particular problems, with the former being used to hide the pain of existing occupationally-related health problems and diseases, and the later being used to enable workers to continue for very long hours (96d;20).

(iii) Female Health Problems in the Construction Industry

About half of the 1,913,900 construction workers in the whole country are female. Most of them are non-skilled laborers and have to work as hard as their male co-workers. After working at the construction site, these female laborers have to take care of their housework and children. A study of the health status of female construction workers in Bangkok found that 17.2 per cent were between 13 and 15 years of age, uneducated, and separated from their families. These workers laboured hard, often worked overtime and reported many emotional and physical problems. Ninety-five per cent said their need for health examinations was not currently being met.

Jirawattanakul (198) studied health problems in female construction workers in the northeast. The results show that the workers spend at least 10 hours per day at the construction site. They encounter similar emotional and physical problems to those of female construction workers in Bangkok. Furthermore, there were reports of work accidents (68 per cent) and traffic accidents (32 per cent).

(a) Domestic Violence

Women within Thailand are most at risk of violence within the family environment (97; 7). Domestic violence is common in Thai society. Its primary cause is seen as a male's right over the body of his subordinate, dependent wife, which legitimizes violent action against her. Many Thai women have internalized or accepted this concept and tolerated it. Thai society, as many other societies, considers this kind of violence as a private problem of the family, rather than the concern of society.

As a result of this lack of social concern, almost no statistics on family violence have been collected. Despite the fact that many female victims of domestic violence have been admitted to hospitals' emergency departments with serious conditions, there is no law or regulation requiring that these cases be reported to the police.

The category of domestic violence has never been recognized in Police Department statistics, although anecdotal evidence suggests thousands of cases of this form of violence have been reported directly to police stations each year. The Public Welfare Department has assisted many women who are abused by their husbands but such cases are similarly not recorded as cases of family violence. Similarly, because of the lack of any comprehensive study on family violence, the impact of this violence against women is not clear (199).

One small-scale study of 400 women attending the outpatients clinic at a central provincial hospital in January 1997 found that 68.8 percent of the women reported they had suffered mental or physical violence. Of those, about one quarter reported being subjected to physical violence, most frequently being described as being pushed or pulled. Over 40 percent reported suffering physical or mental violence from their husbands, and half reported they had been sexually assaulted by a stranger. This is only a limited survey, with limiting methodology, but it certainly illustrates the urgent need for further research and programs. (200)

An earlier study examined the causes of domestic violence. It found the major reason for wife beating and killing is jealousy, followed by economic constraints. Other factors involved are drunkenness and gambling. Some wives were killed just because they refused sexual intercourse with their husbands (201).

(b) Rape and Sexual Assault

Thailand is a country where virginity is valued very highly. Sexual assault is thus especially damaging to its victims. Victims suffer not only from the incident itself, but from the double standard that makes women feel ashamed about the fact that have been violated. Thus they tend to keep the trauma to themselves, rather telling their parents, relatives, friends or going to the courts (202). Victims may also have (well-founded) fears about how they may be treated if they report the case to police. They may fear being treated with disbelief, or subjected to further humiliations.

Ironically, it is very common to find a rape case reported each day on the front page of daily newspapers, with considerable and often lurid coverage. This practice is an important factor in public perceptions that the rate of sexual crimes, including rape, is increasing.

Criminal statistics collected by the Research and Planning Division of the Police Department (shown in Table 3.4.1) indicate the number of rape cases has been steadily increasing over the past 14 years. These figures do not include cases of rape which culminated in murder. On average, two women are raped and killed each month (202).

Out of 139 rape cases reported on the front page of five daily newspapers in 1995, 31 per cent of the victims were raped and killed. Fifty four per cent of the offenders were persons close to the victims (202). However, it has been estimated that reported cases of rape crime in Thailand, as shown in the table above, represent only 5 per cent of the total incidence (203), while the proportion reported in newspapers is smaller again, so it is not possible to draw any real conclusions from these figures, except that they grossly underestimate the scale of the problem. Similarly it is impossible to determine if the increase in the figures above represents an increase in the overall incidence of the crime, or merely a slightly increased willingness to report it. (103; 60)

Although the law allows for very heavy penalties for sexual abuse and rape, it also provides a loophole which allows the involved parties to seek agreement among themselves on the incident. In many cases this is encouraged by police, especially when the offenders have some social status. A middle rank policeman gave an explanation: "rape cases are widely regarded among policemen as easy money-making opportunities. The defendant is willing to pay, and this is why you see all sorts of tactics to discourage the victim to back off ... The attorneys, too, will be co-opted into the process" (139; 29).

Moreover, if the offender is the father of the victim, the child cannot take legal action against her parents. They must depend on the "legal inspector" or attorney to take action for them. On many occasions, these officials do not want to bring a court case against the father as they believe in traditional values that parents should not be accused by their children (204; 266).

Evidence from the court cases in which the Centre for the Protection of Women's Rights has been involved in assisting victims indicates that many rapists are well aware of the many ways in which they may evade the law. Many confessed that they waited until the situation was open for them or sometimes deliberately set up circumstances in which they can both provide for committing the crime and hope to avoid punishment (205).

(c) Sexual and Physical Abuse of Girls

Sexual violence against girls in Thailand can be broadly divided into two forms: incest or rape, and child prostitution. Statistics collected by the Children's Rights Protection Center from newspapers indicate that at least one or two girls under 16 years old is raped, or raped and murdered, or raped and beaten, or assaulted every week. The youngest girl in this study was only one year old.

As with rapes and sexual assaults on adult victims, it is highly likely that these statistics represent only a small percentage of total offenses committed. It is extremely difficult to estimate the number of cases of sexually abused girls not only because the crime is often committed by children's relatives (such as father, brother, grandfather, uncle), or by persons to whom the children are entrusted (such as teacher, male neighbor, and priest), but also because the sexual abuse of girls is usually committed in secret when the sexual offenders are alone with the children. It is, therefore, difficult to find witnesses (199).

One study (199) concluded that the level of child sexual abuse in Thai society is increasing. For example, para-social workers working in four provinces reported that child sexual abuse is one of the most common forms of violence against female Thais at a village level. Children encountering this sort of violence were most likely to combat or cope with the problem alone (206).

In the 139 rape cases reported in newspapers in 1995, (in the study already noted above), 40 percent or 72 victims were girls aged under 15 years, and six of them were aged 0-3 years old. The youngest victim was only eight months old (199). However, despite the incidence of in-family sexual assault, probably the greatest number of girls who are victims of sexual assault in Thailand are individuals who have been trafficked, forced or coerced into prostitution. This issue is discussed in some detail in Section C6.

With regard to battery and other physical abuse of girls, no data is available and no studies have been done within Thailand, although data from throughout the world, suggesting the widespread nature of this problem, indicates that it almost certainly occurs. Due to traditional values about parents rights over their children, this issue has not yet been significantly considered in Thailand.

(d) Health Consequences of Violence against Women

(i) Domestic Violence: Cases of domestic violence which have been published on the front pages of newspapers usually involve severe physical assaults and murders of women. This is primarily because a large number of husbands who beat their wives have used sticks, knives, guns or other weapons, and victims of such attacks are obviously likely to suffer severe health effects. No data is available on the effects of lower levels of violence, but it is obvious that it must affect its victims' health, not only in terms of injuries received, but of the health effects of fear, stress and other emotional trauma.

Another important impact of family violence is that it causes significant damage to even members of the family, including children, who may not be directly injured. Statistics collected by an NGO working with homeless children indicated that almost all children who left their families and were living on streets were from families where mother and children were often beaten by their father (203). In addition, domestic violence in Thai society is likely to happen to women during pregnancy, and may result in pregnancy loss, pre-term birth, low birth-weight, fetal injury and fetal deaths.

4.2 Rape and Sexual Assault: Sexual violence against women causes mental anguish, fear, and other psychological effects, in addition to the physical injury. In addition it is also a form of terrorism against all women. Its threat makes many women refrain from actively participating in social, economic and political activities. Additionally, fear of sexual violence has become a rationale for excluding women from certain public offices and from certain kinds of jobs in the private sector (207).

4.3 Child Prostitution: Young girls and women who are lured or forced into prostitution encounter the torture and exploitation. They are forced to work hard and long hours with little sleep and for very low payment. Brothel owners use violence to control the children, frequently beating them if they refuse to work, sometimes so hard that some children have become handicapped or have been killed. On many occasions, they are drugged with either stimulants or addictive drugs (204).

(e) Policies and Measures taken by the Government and NGOs

(i) Domestic Violence: Since the 1980s, many NGOs have established programs providing assistance to women and children who are victims of the domestic violence. Among these are the Children Rights Protection Centre run by the Foundation for Children, the Emergency Home for Women and Children, run by the Association for Promoting Women's Status, and the Centre for Protection of Women's Rights' and 'Women's Club run by Friend of Women Foundation. However, the Emergency Home for Women and Children is the only refuge specifically aiming to assist battered women and sexually-abused women in Bangkok, and there is none in the rest of the country (199). However, there are two refuges in the North, Baan Taufhun in Chiang Rai and Baan Mareena in Chiang Mai, which provide shelter for women who face with any form of violence or danger, including AIDS, trafficking and domestic violence. Campaigns against domestic violence have been carried out by NGOs, and as noted above, the NCWA recently inaugurated a sub-committee to work on campaigns and new official approaches to the problem.

(ii) Rape and Sexual Assault: The specific problems which rape victims face before, during and after the trials have rarely received attention from the government departments due to the lack of consideration and understanding of the rape crimes. In the last two years, there has, however, been some limited government action. The Police Department, in conjunction with the NCWA, has set up a pilot program, appointing female police officers as investigators at three Bangkok police stations (a position not previously occupied by women), with the expectation that they will be more able to sensitively and effectively deal with the victims of sexual crimes. The program is as yet only small-scale and experimental, but it does represent an acknowledgment of the need for improvements in this area. The NCWA also arranged training for these officers, together with about 60 of their male colleagues, in the investigation of sexual crimes. (103; 60)

In addition, the Office of the Attorney General in association with the NCWA has drafted two proposed new laws which would be of considerable assistance to victims of sexual crimes and investigators seeking to locate and prosecute the offenders. The first is a proposed amendment to the penal code, which would replace current legal definitions of rape (which relate only to penis-vagina contact) and indecent assaults, with a broadly-defined law of sexual assault. This law would focus on the degree of harm to the victim, rather than the nature of the sexual act involved in the offense. (It is broadly in line with the nature of laws already enacted against sexual assault in many Western countries) (104; 23-5).

The Office of the Attorney General has also drafted an amendment to the Criminal Procedure Act which would allow child witnesses and victims to, immediately after being located by police, to make statements and be questioned in a video-taped interview, with a psychologist or social worker present. This would then be presented to the court as their evidence-in-chief. Any questioning during a court case might then be carried out by video-link. For child victims of sexual assault, this would be particularly valuable, as it would remove the need for them to face their attacker in court, or to repeat their story many times. (104; 30-32.)

NGOs have been active in attempting to create increased awareness of the incidence of sexual violence against women and improvements in the treatment of victims. Entrenched social attitudes have made this a difficult task.