Obstetrics & Gynecology:
Experiences of Physical and Sexual Abuse and Their Implications for Current Health
Pikarinen, Ulla MD1; Saisto, Terhi MD, PhD2; Schei, Berit MD, PhD3; Swahnberg, Katarina PhD4; Halmesmäki, Erja MD, PhD5
From the 1Department of Obstetrics and Gynecology, South Karelian Central Hospital, Lappeenranta, Finland; 2Department of Obstetrics and Gynecology, Helsinki University Hospital, Jorvi Hospital, Espoo, Finland; 3Women's Health Department of Community Medicine/Department of Obstetrics and Gynecology, St. Olav's Hospital, Trondheim University Hospital, Faculty of Medicine, Trondheim, Norway; 4Division of Gender and Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden; and 5Department of Obstetrics and Gynecology, Helsinki University Hospital, Helsinki, Finland.
Supported by grants from the Medical Research Fund of South Karelian Central Hospital, District of Helsinki and Uusimaa, Helsinki University Central Hospital, Department of Obstetrics and Gynecology, and the Yrjö Janson Foundation.
Corresponding author: Ulla Pikarinen, Department of Obstetrics and Gynecology, South Karelian Central Hospital,Valto Käkelän katu 1, FIN-53100 Lappeenranta, Finland; e-mail: firstname.lastname@example.org.
OBJECTIVE: To estimate the prevalence of a history of physical and sexual abuse in adulthood among gynecological patients and the association with general and reproductive health.
METHODS: A cross-sectional questionnaire study on abusive experiences of gynecologic outpatients in a tertiary hospital. The total sample size was 691.
RESULTS: Of all women, 42.4% had experienced moderate or severe physical or sexual abuse as an adult. One hundred forty-seven (21.6%) women reported physical abuse, 84 (12.3%) sexual abuse, and 58 (8.5%) both. The abused and nonabused women did not differ in mean age, education, or parity. Sexually abused women and those who were both sexually and physically abused reported poor general health significantly more often (P=.005 and P=.001, respectively) than the nonabused. They also rated their sex life as significantly worse than the nonabused women (P=.002 and P=.012, respectively). Over half of abused women had experienced common physical complaints during the previous 12 months compared with one third of the nonabused (P<.001). Two thirds of both the abused and the nonabused women preferred that their gynecologist not ask directly about abuse.
CONCLUSION: Abusive experiences were common in gynecologic outpatients. Women with abusive experiences had ill health and poor sexual life more often than the controls. In contrast to the results of previous studies, most of the women did not want to be asked about abuse by their gynecologist.
LEVEL OF EVIDENCE: II
Violence against women is recognized as a common risk factor impairing women's health. It was claimed to be a crime against humanity by the United Nations. Although striking news presents us with images of cruelty to women and their humiliation during war, the most common violence exists in the everyday lives of the female population.
Abusive experiences have a serious impact on a person's health and quality of life. The prevalence of violent experiences among primary care patients has been reported to be two times higher than among the general population of the area in question.3,4 Sexual violence damages the genitals, causes infections, and later on results in problems with sexual health and desire.5–7 In addition to human suffering and sociological problems, abuse also has economical consequences to society because the victims use health services more than women who are not abused.8
In a Finnish population-based study, it was found that two women out of five had experienced physical or sexual violence or serious threats of such violence during their adulthood.2 Sexual and physical abuse is associated with gynecologic problems such as dysmenorrhea, dyspareunia, and lower abdominal pain.10,11 Hence, the prevalence of abusive experiences could be expected to be high in a sample of gynecologic patients.12
The aim of this study was to estimate the prevalence of a history of physical and sexual abuse in adulthood among gynecologic patients and the associations of such a history with the patients' gynecologic problems, physical complaints, and subjective opinions of their health.
MATERIALS AND METHODS
This Finnish study is part of a Nordic multicenter study of the history of abuse among gynecologic outpatients. Each of the five participating countries (Denmark, Finland, Iceland, Norway, and Sweden) used a similar questionnaire, the NorVold Abuse Questionnaire, which was translated into national languages. The NorVold Abuse Questionnaire was validated in a Swedish female sample and was shown to have good validity and reliability.9 The NorVold Abuse Questionnaire consists of questions about socioeconomic factors (age, marital status, occupation), the reason for the initial visit to the gynecologic clinic, the patient's subjective opinion of her health, specific questions about some common health problems (such as stomach ache, headache, muscular weakness, dizziness), and lifetime experiences of emotional, physical, or sexual violence. The study design was described previously in detail by Wijma et al.12 The classification of violence is presented in Table 1.
The Finnish study also included additional questions about further physical complaints (such as lower abdominal pain, bowel irritation, and dysmenorrhea) and whether the patients would want their gynecologist to ask routinely if they have been exposed to violence. The study took place at Helsinki University, Department of Obstetrics and Gynecology, from November 1999 to January 2000. A referral is usually required for the first visit, apart from acute consultations. Thus, most of the women in this study had already been examined for their complaints by a general practitioner or private gynecologist. Altogether, 1,010 consecutive women over 18 years of age visiting the gynecologic outpatient clinic were asked to participate. These women came for either a first visit or a follow-up visit. They were invited to take part in the study by a nurse who gave them information about the study. Written consent was required.
The NorVold Abuse Questionnaire was sent 1–2 weeks after the initial visit to 817 gynecologic outpatients; 193 patients declined the invitation to participate. This was followed by two reminders 2 weeks apart. The initial response rate was 86% (n=705). After 14 patients had been excluded from the analysis as a result of missing information or being under age, the total sample size was 691 women.
The study women consisted of those reporting being subjected to moderate or severe physical violence (n=147), sexual violence (n=84), or both (n=58) as adults (after their 18th birthday), according to the definitions in the NorVold Abuse Questionnaire (Table 1). The control group included those women who had not experienced such violence as adults (n=402). The sizes of the groups vary slightly in different analyses owing to missing data.
The data were analyzed by using SPSS 10.0 (SPSS Inc, Chicago, IL). We used the Student t test, when appropriate, and the χ2 test when nonparametric tests were concerned, and we chose a level of statistical significance of P<.05. The study was approved by the Ethics Committee of the Department of Obstetrics and Gynecology, Helsinki University Central Hospital.
The total prevalence of abuse (physical, sexual, or both) experienced as an adult was 42.4%. Altogether, 147 (21.6% of those who answered) women reported physical abuse, 84 (12.3%) reported sexual abuse, and 58 (8.5%) reported both. The clinical characteristics and comparison of the abused and the nonabused groups are shown in Table 2.
The reasons for the index visit varied (Table 3), which made the subgroups too small to be reliably compared.
The main results concerning general health and some specific problems are presented in Table 4, and the results concerning reproductive health are shown in Table 5.
Self-estimated general health and quality of sex life during the previous 12 months was estimated on a four-point scale (very good, quite good, quite bad, very bad). Altogether, 22.6% of sexually abused women and 27.6% of both sexually and physically abused women evaluated their general health as being bad or very bad. There were significant differences compared with the controls (11.2%, P=.005 and P=.001, respectively). In the physically abused group, women may also have evaluated their general health as being bad more often than their controls, but the difference was not significant (P=.054) (Table 4). Sexually abused women and both sexually and physically abused women also evaluated their sex lives as being significantly worse than their controls (P=.002 and P=.012, respectively).
More than half of the abused women (all groups) had experienced common physical complaints during the previous 12 months. Only one third of the controls reported such complaints, so the difference was statistically significant (P<.001). The groups did not differ in any other aspect of general heath (admission to hospital for any reason during the previous 12 months, sick leave longer than a fortnight during the previous 12 months, numbers of gynecologic operations other than cesarean deliveries; data not shown). Bowel irritation was significantly more common among all abused women than among the controls (P<.001 in all abused groups). Dysmenorrhea was equally common among all patients (Table 4).
Table 5 shows how abuse was related to the women's reproductive health. Although there was no difference in parity between the groups (Table 2), physically abused women had given birth to their first-borns and last-borns at lower ages (P=.001 and P=.006, respectively) (mean age 24.27±5.17 years and 28.44±5.64 years, respectively) than the control subjects (mean age 26.67±5.89 and 30.84±4.44 years, respectively). Data were missing in the cases of 20–26% of the abused women and in 18–20% of the controls as regards questions concerning miscarriages and legal terminations of pregnancies. The rate of miscarriage was higher among physically abused women than among the controls (P=.020). In addition, legally terminated pregnancies were more common among physically and sexually abused women than in the control group (P=.002 and P=.040, respectively). In an open written text, 11 abused women (5%) stated that they had had a termination of pregnancy as a result of domestic violence.
Only one physically abused patient out of all the abused women had told her gynecologist about her experiences. No one told the gynecologist about having been sexually abused. Altogether, 62% of the patients did not want the gynecologist to ask directly about abuse. There was no difference between the abused and the nonabused patients in this regard.
Experiences of physical and sexual abuse as an adult were very common among consecutively collected Finnish gynecologic patients. Abuse had a strong impact on the women's quality of life. The abused and the nonabused women had similar socioeconomic backgrounds. Sexually abused gynecologic patients and those who were both physically and sexually abused rated their general health and sex life as being bad more often than did the controls. The abused women suffered from irritable colon and other disabling conditions significantly more often than the nonabused women. Physically abused women had lost more pregnancies in miscarriages and physically or sexually abused women in abortions, although parity was similar in all groups.
Our results are in accordance with those of previous studies where the victims of violence have been shown to suffer more long-term problems of health such as stomach pain, digestive disorders, headache, chronic pain, and gynecologic problems.13,14 These might be the result of direct tissue damage or a physiologic response to stress.5,6 Abusive experiences, especially sexual abuse, have been shown to be related to lower abdominal pain in numerous studies.14–16 Smikle et al17 also state that no demographic features identify those women who are at risk of being abused physically or sexually.
Hilden et al18 have shown in the NorVold study that sexual abuse is associated with psychosomatic disorders and poor self-estimated general health. Divergent figures in different studies might be partly the result of national differences, but they mainly arise because of different criteria for cases. Lifelong exposure to violence has been assessed in previous articles, and we studied only the impact of being exposed to moderate or severe violence as an adult. It might be the case that being exposed to violence as a child leads to even more serious consequences.
At least three limitations should be considered when generalizing the findings of this study. First, although the Finnish answering rate (86%) was high, it still leaves the prevalence of abuse unknown in 14% of the patients.12 Ongoing abuse or past traumatic events may affect a woman's willingness to participate in this kind of study. Women in abusive relationships may also fear for their safety when receiving questionnaires or answering questions about violence.20 Second, there is a recall bias in a retrospective study. Violent events may be suppressed and not recalled, although this is more common among adults who have been victims of violence in childhood. In addition, troublesome questions might not be answered. Missing data may make the subgroups small, and this creates some uncertainty in drawing conclusions, for example, as regards questions about sensitive issues such as miscarriages and abortions. Third, the study might not represent gynecologic patients generally because it was carried out in a tertiary clinic where the women's gynecologic complaints can be assumed to be more complex, thus affecting their general health more than in primary or secondary clinics.
Recognizing intimate partner violence and helping the victims demands multidisciplinary cooperation between public social and health care. While discussing intervention strategies, debate often arises about whether female patients should be screened for abuse.19–22 Routine screening of all female patients in primary care is often recommended, with the goal of early intervention and prevention.23 On the other hand, the effectiveness of screening is uncertain.1,24 Routine gynecologic and obstetric visits would provide a natural opportunity for screening. The results of previous surveys indicate that 43–85% of female respondents consider screening acceptable in health care settings,1 but in this study two thirds of our gynecologic patients did not wish to be asked directly about domestic violence by their gynecologist, regardless of whether or not they themselves had been exposed to violence. Unfortunately, we did not ask them whether they would approve of being asked about such experiences by any other person, for example by their general practitioner, with whom they are naturally more familiar.
Domestic violence is screened in Finland at elementary school health examinations and experimentally at maternal health centers. Our results do not favor screening gynecologic outpatients, but there was a high incidence of abusive experiences among the patients suffering from lower abdominal pain and irritable colon, both common causes of gynecologic consultation. It may be correct to ask about violence, at least in patients who have no other evident cause for their symptoms.22 In addition, women seeking abortion, and especially repeated abortion, should be asked about physical and sexual violence.25,26 Eisenstat and Bancroft23 recommend two simple questions: “Do you ever feel unsafe at home?” and “Has anyone at home hit you or tried to injure you in any way?” These questions have a sensitivity of 71% in detecting domestic violence and a specificity of almost 85%.23 However, when asking about violence, the inquirer should be able to provide the victims with the local service programs for abused patients and try to ensure the safety of women living in abusive relationships.
In conclusion, in our cross-sectional study concerning abusive experiences in adulthood in a sample of gynecologic patients, we showed that these experiences were common and that women with abusive experiences had suffered more general ill health and had a poor sex life and disabling general conditions. The patients did not spontaneously tell their gynecologists about their experiences, but most did not want to be questioned about violence.
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