[Domestic violence: any progress?]. / Violences conjugales : a-t-on progressé ?

Since the publication of the French national survey of violence against women in 2000, the fight against domestic violence has made steady progress. Knowledge of the phenomenon has significantly improved. A nationwide study of murders and manslaughters perpetrated by one partner of a couple against the other has been published annually since 2006. In 2012, domestic violence resulted in the deaths of 314 persons: 166 women, 31 men, 25 children, 9 collateral victims, 14 rivals, and two former spouses killed by their ex-fathers in law. In addition, 67 perpetrators committed suicide (51 men and3 women). The number of victims fluctuates from year to year but has remained fairly stable since 2006 (n=168). Legislation has improved significantly: eight new laws have been passed since 2004, all designed to protect women and to ensure that violent men are restrained and treated. New measures to inform and protect women have been implemented and others have been improved, such as the anonymous helpline (phone no 3919, "domestic violence information"). An inter-ministerial committee on the protection of women from violence and the prevention of human trafficking (MIPROF) was created on 3 January 2013. A website entitled "Stop violence against women " (Stop violences faites aux femmes) is now available. The "Imminent Danger" mobile phone system, designed to alert police if a suspected or known perpetrator breaches restraint conditions, will be extended to the entire country from January 2014. Referees charged with coordinating comprehensive long-tern care of women victims have been deployed at the county level. Information centers on the rights of women and families (CIDFF) now form a local nationwide network. Routine interviews with a midwife during the fourth month of pregnancy, focusing on the woman's emotional, economic and social conditions, have been implemented in 21 % of maternity units and should gradually be generalized. The authorities who have enforced the law have modified their behavior, as have the victims, although for a lesser extent. Perpetrators are increasingly subject to restraining orders, with an obligation to undergo treatment and to attend awareness sessions. Victims are also more likely to go to the police. Social workers, self-help groups and, since 2006, psychologists are now available for victim support in police stations. Management of perpetrators has improved. Finally, despite the continuing reluctance of many physicians, an encouraging trend is emerging among younger members of the profession. A recent survey of 1472 French medical students showed that, while 90 % of them said they had received no training in this area, 93 % considered that doctors should play a role and 95 % said they felt highly concerned. Specific university diplomas have been created and domestic violence is now included in the midwifery curriculum. The delicate question of prevention remains to be resolved; a program is currently being tested.

[Surrogate pregnancy with regard to marriage between persons of the same sex]. / La gestation pour autrui au regard du mariage entre personnes de même sexe.

After first defining surrogacy, distinguishing between cases in which the pregnancy results from the surrogate's own egg or a donor egg, and examining the different configurations of male homosexual families, the authors outline French and foreign legislation and provide a summary of the literature and of French working group hearings. Arguments for and against lifting the ban on surrogacy for gay couples are examined. The main arguments for lifting the ban are the following: 1) the same-sex couple's desire to start a family from their own gene pool, 2) current obstacles to adoption, 3) the notion of equality between heterosexual and homosexual couples, 4) frequent recourse to surrogacy abroad, which is not only very costly but also leaves the child in a state of legal limbo on its return to France, and 5) the lack of access to therapeutic alternatives. Some arguments against lifting the ban are of a medical nature: (1) physical and psychological risks for the surrogate, 2) the fact that exchanges between the mother and fetus during pregnancy are more complex than previously thought (microchimerism, epigenetics) and never negligible, and 3) the physical and psychological risks for the child. Other arguments are of an ethical nature: 1) surrogacy may undermine the status of motherhood, 2) surrogacy is becoming a societal rather than a medical issue, implying a profound bioethical upheaval, 3) the increasing commercialization of the human body, 4) subjugation of women to men's desires, 5) the risks for the surrogate's own couple and children, and for the host couple, 6) unavoidable financial aspects, and (7) the risk of abuse. The aim of this study is to bring together all the factors potentially influencing the health consequences of surrogacy, for both the mother and the child, especially if surrogacy were to be legalized for male homosexual couples. Surrogacy raises issues far beyond purely medical considerations and is primarily a societal issue that must be settled by the legislator: Short-term and especially long-term physical and psychological risks, particularly for the child, are poorly documented. If it is decided to legalize surrogacy, then a rigorous, objective and strictly regulated program must be set up to assess the related risks.

[Women and HIV/AIDS: stormy beginnings]. / Les femmes et le Sida : de tumultueux prémices.

Following the transfusion of a young woman with two units of blood infected by human immunodeficiency virus (HIV) during a Cesarean section performed at the Obstetrics and Gynecology Unit of Port-Royal Hospital in Paris in 1984, the author realized the danger that this virus would represent for women and their children, at a time when the infection seemed to be confined to homosexuals, drug addicts, hemophiliacs and transfusion recipients. He was confronted with a whole series of issues, including the rejection of HIV-positive women; the need for special precautions in the labor room and operating theater; and the need for these patients to be managed in a single center staffed by skilled and willing healthcare professionals who could help them decide whether or not to continue the pregnancy. The main risks at this time were the onset of life-threatening opportunistic infections during pregnancy and HIV transmission to the child (estimated at 20% to 30%). Other thorny issues included the case of couples wishing to have children when either of the two members was infected, and the question of professional confidentiality when an immunocompromised HIV-seropositive husband stubbornly refused to inform his wife or to use condoms. It seemed important to bring these women together, especially those of African origin, within a self-help group where they could express themselves openly and discuss their difficulties. Screening for HIV antibodies in early pregnancy became necessary to permit preventive treatment of mother-child HIV transmission, and to inform pediatricians. There was also a need to estimate and monitor the seroprevalence of HIV among pregnant women, and this was done by conducting a "sentinel" survey that was subsequently taken over by INSERM and the European Centre for the Epidemiological Monitoring of AIDS. After listing many other issues that were hotly debated over the years, the author describes how, at the beginning of the epidemic, new proposals intended to systematically improve the lives of these women and their children ran into official procrastination, due to the combined pressure of short-sighted doctors, homosexual groups, and a cohort of sociologists and philosophers posing as apostles of human rights and omnipresent in the media.

[Boxing: traumatology and prevention]. / La boxe, sport de combat, de la traumatologie à la prévention.

In 1986, a surgeon who, as an amateur boxer himself was concerned with boxers' health, approached a pioneering Parisian neuroimaging unit. Thus began a study in close cooperation with the French Boxing Federation, spanning 25 years. In a first series of 52 volunteer boxers (13 amateurs and 39 professionals), during which MRI gradually replaced computed tomography, ten risk factors were identified, which notably included boxing style: only one of 40 "stylists" with a good boxing technique had cortical atrophy (4.5 %), compared to 15 % of "sloggers". Changes to the French Boxing Federation rules placed the accent on medical prevention. The second series, of 247 boxers (81 amateurs and 266 professionals), showed a clear improvement, as lesions were suspected in 14 individuals, of which only 4 (1.35 %) were probably due to boxing. The third and fourth series were part of a protocol called "Brain-Boxing-Ageing", which included 76 boxers (11 having suffered KOs) and 120 MRI scans, with reproducible CT and MRI acquisitions (9 sequences with 1.5 T then 3 T, and CT). MRI anomalies secondary to boxing were found in 11 % of amateurs and 38 % of professionals (atrophy, high vascular T2 signal areas, 2 cases of post-KO subdural bleeding). CT revealed sinus damage in 13 % of the amateurs and 19 % of the professionals. The risk of acute and chronic facial and brain damage was underline, along with detailed precautionary measures (organization of bouts, role of the referee and ringside doctor, and application of French Boxing Federation rules).

[Gestational surrogacy]. / La gestation pour autrui.

After defining surrogate pregnancy and distinguishing cases in which the surrogate mother simply bears the child from those in which she is also the egg donor, the authors summarize foreign legislation in this area, together with the task force subs auditions and the literature. They list arguments for and against removing the current coup ban on surrogate motherhood. Arguments for include:--infertility due to the lack of a uterus, either congenitally or following hysterectomy, or to functional destruction of the uterus, repeated failure of in vitro fertilization, and the existence of a disorder that would threatening the future mother's life if she became pregnant;--perception of this infertility and the resulting suffering as an injustice;--the lack of alternative solutions;--the difficulties of adoption, and the fact that the adopted child does not carry the genes of the adopting parents;--the current recourse to surrogate mothers abroad, which is costly and discriminatory and leaves the child in a difficult legal situation on its return to France;--the generally satisfactory observed outcomes. Arguments against include:--the ban on financial exploitation of the human body;--possible exploitation of the surrogate mother;--the risk of undermining the symbolic value of maternity;--psychological and physical risks for the surrogate mother;--psychological and physical risks for the child;--risks for the surrogate mother's couple and her other children;--risks for the infertile couple;--the risk of abuse; and--financial issues. Two particular cases are envisaged: that in which the surrogate mother is also the biological mother, and that in which the surrogate mother is a member of the family. The French National Academy of Medicine considers that surrogate pregnancy is not only a medical matter but one that raises questions for society as a whole and should be dealt with principally by the legislator. In contrast, the Academy considers that it is within its remit to consider the possible complications that might ensue if this practice were to be legalized. The Academy points out that the long-term mental and physical risks are poorly assessed and recommends that, if surrogate pregnancy were to be legalized, the risks should be strictly evaluated, both objectively and transparently, and the practice should be strictly controlled.

[Vaccination against human papillomavirus. Implementation and efficacy against cervical cancer control]. / Les vaccins des papillomavirus humains. Leur place dans la prévention du cancer du col utérin.

The two new HPV vaccines (Gardasil quadrivalent and Cervarix bivalent 16,11) are both effective against HPV types 16 and 18, which are responsible for 70% of cervical cancers, and the quadrivalent vaccine is effective against HPV 6 and 11, responsible for genital warts. Their efficacy is 100% if they are administered before exposure to HPV 16,18. The proven duration of protection against high-grade cervical lesions is currently 5 years, and the need for boosters is unknown. Cervical cancer screening programs must continue, as only 70% of the 15 high-risk HPV types are targeted. The best age for primary vaccination appears to be 11-12 or 14 years, before the outset of sexual activity. Vaccination of older women is less efficacious, and vaccination of males is being discussed. HPV vaccines should be useful in developing countries, if they can be made available. HPV vaccination campaigns require adequate public information.

[Access to personal origins: the new French law]. / Accouchement sous X: les nouvelles dispositions législatives.

The French parliament adopted in January 2002 a law on access to the origins of persons who where adopted at birth. The National Council for access to personal origins (CNAOP) was created in order to apply this new law. The law's purpose was to attempt to conciliate the interests of adults who wish to know their origins, those of pregnant women who want to keep their motherhood secret, and those of children who have the right to live in the best conditions, and obtain the best possible chance of having a happy childhood. In short, the legislator attempted to find a balance between situations of extreme suffering. The new law does not impose on the natural mother to communicate her identity, even confidentially. A woman who requests, at the time of delivery, that her admission and her identity be kept secret, is encouraged to leave, on a voluntary basis, information on her health and that of the father, the origins of the child and the circumstances of birth, as well as her identity, in a sealed envelope. In this sealed envelope, she can specify her name, her date and place of birth. On the cover of the envelope are written the first names that she may have chosen for the child, as well as its sex, date, hour and place of birth. This envelope is stored and can be unsealed only by a member of the CNAOP if this organism is solicited by the child when reaching adulthood, or if the child is minor, by his legal representatives or by himself with these representatives' approval. In this case, CNAOP can search for the mother and contact her. She may maintain or waive the secret of her motherhood. Furthermore, the natural mother can at any time waive the secret of her identity, in the event that the child solicits the CNAOP, but she does not have the right to search for the child. It will take several years to determine whether the effects of these new dispositions are beneficial or not. One of the keys to this problem is improved management of these women in the departments of obstetrics and gynecology.

[Female genital mutilations, forced marriages, and early pregnancies]. / Mutilations génitales féminines, mariages forcés et grossesses précoces.

Female genital mutilations, as well as forcible childhood marriage and their correlate adolescent pregnancies are traditional practices which, not only violate the dignity, but also jeopardize the health, and even the life, of women and their children. The complications of genital mutilations are frequent for a number of reasons: the fact that the clitoris is highly vascularized, the nature of the mutilations, excision or infibulation, and the poor conditions of hygiene. The short term complications are pain, hemorrhage, shock, and urinary retention. Medium term complications include gangrene, septicemia, tetanus, pelvic inflammatory disease, HIV/AIDS, and hepatitis B or C infections. Serious sequelae may occur, including infertility and gynecologic disorders, and sexual life is invariably altered. The main obstetrical complications of genital mutilations are genital lacerations involving the labia minor and the perineum, which can lead to hemorrhage and sequelae such as urinary or anal incontinence, recto-vaginal and vesico-vaginal fistulas. The role of doctors, which is delicate because these customs are entrenched, is to detect genital mutilations, repair them and prevent them, by participating in health education programs. The consequences of forcible childhood marriage are serious, besides the fact that this is a disguised form of rape. The obstetrical risks favored by the underdevelopment of the uterus and the pelvis, include uterine rupture, preeclampsia and eclampsia, and obstetrical hemorrhage. The fetus/neonate are jeopardized by these complications, which can result in perinatal asphyxia and death, as well as the high rates of intrauterine growth retardation and preterm delivery. The impact of genital mutilations on delivery are compounded in childhood pregnancies for anatomical reasons, but also because these adolescents or children are extremely vulnerable and have poor access to perinatal care. In France, as well as in Africa, non-governmental and women's rights organizations are active in preventing these practices. We strongly recommend that these groups should receive aid and encouragement.