| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
ORIGINAL RESEARCH |
From the Department of Obstetrics and Gynecology, Ludwig-Maximilians-Universität, München, Germany; Violence and Health Research Program, Centre for Research in Women’s Health, Toronto, Ontario, Canada; and National Research Institutes, Watertown, Massachusetts.
Address reprint requests to: Ursula M. Peschers, MD, I. Frauenklinik, Maistraße 11, 80337 München, Germany; E-mail: ursula.peschers{at}fk-i.med.uni-muenchen.de.
 |
ABSTRACT |
|---|
TOP
 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
METHODS: A short anonymous questionnaire was distributed to 1157 women attending a gynecologic outpatient clinic at a large urban teaching hospital. Data collected using the questionnaire included patient characteristics, sexual abuse history, and screening practices. Women who reported that they had been abused were asked if they had ever discussed the issue with their gynecologist.
RESULTS: A total of 1075 questionnaires were returned, for a response rate of 92.9%. Almost half (n = 479 [44.6%]) of the women surveyed reported that they had been the subject of unwanted sexual attention. One fifth (n =216 [20.1%]) had been forced to engage in sexual activities: 6.8% in childhood, 10.3% during adolescence, 6.4% as an adult, and 3.5% across more than one stage. Thirteen women (6%) reported having discussed the abuse with their gynecologist. Sixty-six (30.5%) were too afraid to raise the issue, and 119 (55.1%) stated it was not relevant to their care. Only one woman (0.5%) reported that her gynecologist had asked about sexual abuse.
CONCLUSION: Despite the high prevalence of sexual abuse among women seeking gynecologic care, routine screening does not appear to be part of standardized practice.
International estimates of the prevalence of sexual abuse are startlingly high. Rates in childhood have been reported to be 21% in the United States,1 20% in the United Kingdom,2 13% in Canada,3 20% in Australia,4 13% in Sweden,5 17% in Norway,6 20% in Switzerland,7 9% in Germany,8 22% in Spain,9 30% in Barbados,10 26% in Nicaragua,11 and 8% in Malaysia.12 In two recent American13 and Canadian14 surveys, rape or sexual abuse was reported by 20% and 15% of college and university students, respectively. A survey of 15- to 20-year-olds in Switzerland revealed a similar sexual victimization rate of 19%.15 As well, almost one quarter (24%) of the middle-aged respondents surveyed by Mazza et al16 in Australia had experienced an unwanted sexual experience since the age of 16.
The economic impact of sexual abuse is enormous when both direct and indirect costs are examined.17,18 A recent study found that women with a history of childhood sexual abuse generated significantly higher primary care and outpatient costs than those without. These women were also twice as likely to visit an emergency department.19 This is not surprising, given that the sequelae of sexual abuse include acute and chronic injury as well as persistent stress and fear, which may be manifested in a range of physical and mental health problems. Women with a history of sexual abuse often present with soft tissue injuries, lacerations, and abrasions20–22 and are more likely to suffer from anorexia nervosa,23 bulimia nervosa,24 depression and anxiety,25,26 and posttraumatic stress disorder27 and to attempt suicide.28 Many of these women also present with gynecologic problems such as dysmenorrhea, menorrhaghia, sexual dysfunction,29 chronic pelvic pain,30–33 sexually transmitted infections,34 and unwanted pregnancies.35,36 Golding et al37 found that 95% of women seeking treatment for severe premenstrual syndrome had experienced an attempted or completed sexual assault. There is also clinical evidence to suggest that women with a history of sexual abuse may be retraumatized during pelvic examinations, vaginal ultrasounds, pregnancy, and childbirth.38,39
Despite the strong association of gynecologic symptoms with a history of sexual assault,29–36 little is known about its epidemiology in routine gynecologic practice.2,40–43 The primary purpose of our research, therefore, was to estimate the prevalence of sexual abuse among patients seen in a gynecologic outpatient clinic in Germany. We also sought to investigate whether women who had been forced to engage in unwanted sexual activities 1) had disclosed the abuse to the attending gynecologist and 2) had been asked about the abuse by the attending gynecologist.
|
MATERIALS AND METHODS |
|---|
|
TOP
ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
The questionnaire, written at a basic literacy level, was available in German, Turkish, Serbo-Croatian, and Albanian and consisted of two parts. Part I included three questions on patient characteristics (age, parity, and nationality) and two questions on sexual abuse history. The first of the latter set of questions, "Have you ever been the subject of unwanted sexual attention such as having been propositioned, touched, etc.?," was included to ensure that women differentiated between molestation and sexual abuse. The second question, "Have you ever been forced to have sexual activities that you did not want?," modified from the Abuse Assessment Screen,44 was used in a survey by McGrath et al45 to screen for sexual abuse in urgent care patients. Possible responses to these questions were "yes," "no," or "I don’t know." Those women who answered "yes" to the second question were asked to complete the second part of the questionnaire.
Part II consisted of five questions. The first question asked women when the sexual abuse had occurred: as a child (0–12 years), as an adolescent (13–20 years), and/or as an adult (21 + years). The second question queried women as to the identity of the assailant: father, spouse, relative, friend, or stranger. The third question asked women if they had ever talked to their gynecologist about the abuse. Response options were "yes," "no, because I did not consider the information to be relevant to the gynecologist," and "no, because I was afraid to talk about the subject with the gynecologist." These responses were included because anecdotally they are the most commonly cited reasons for not disclosing an abuse history. Those who answered "yes" were asked to describe the reaction of the gynecologist. Possible responses included interested, helpful, understanding, insecure, uncomprehending, disapproving, indifferent, and unable to handle the situation. The fourth question queried women as to whether their gynecologist had ever asked them if they had been sexually abused. The final question asked women their opinions about screening for abuse during routine gynecologic care. A female gynecologist and a female psychologist were available on site lest a woman became distressed while completing the questionnaire. As well, women were provided with the names and telephone numbers of these professionals in case they wanted to access their services at a later date.
The study was approved by the Research Ethics Board of the Medical Faculty of Ludwig-Maximilians University. A female doctor distributed the questionnaires several days a week throughout the study period. She approached all women in the waiting room who were not accompanied by a man. Those women who were accompanied by a man were excluded to ensure their safety in the event that they were currently in an abusive relationship with the attending man. Women were asked to fill out a brief, anonymous questionnaire on sexual abuse while waiting for their appointment. Completed questionnaires were left in a specially marked and secure box located in the waiting room. A daily log was kept of the number of questionnaires distributed and returned. The data were entered into and analyzed using SPSS 10.0 (SPSS Inc., Chicago, IL). Descriptive statistics were used to estimate the prevalence of unwanted sexual attention and activities and to examine rates of disclosure and screening. Frequencies were calculated for categoric data, and means and standard deviations (SDs) for continuous data.
|
RESULTS |
|---|
|
TOP
ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
More than two fifths (n = 479 [44.4%]) of the women surveyed reported that they had experienced unwanted sexual attention—that is, they had been propositioned, touched, and/or subjected to exhibitionism and/or lewd, sexist jokes or comments. A few women were not sure (n = 33 [3.1%]) or did not answer the question (n= 17 [1.5%]). Half (n = 546 [50.8%]) reported never having experienced any such abuse.
Over one fifth (n = 216 [20.1%]) of respondents indicated that they had been forced to engage in sexual activities. The mean age of these women was 40.2 years (SD = 13.8), and 43 (19.9%) did not hold German citizenship. Of the remaining respondents, 817 (76.0%) reported never having been forced into sexual activities, 18 (1.7%) were not sure, and 24 (2.2%) did not answer the question. The average age of these women was 42.2 years (SD = 16.1).
Table 1
summarizes women’s relationship to the offender. Almost half the respondents forced into sexual activities had been abused by a person known to them: 46 (21.3%) by a spouse, 25 (11.6%) by a father, 29 (13.4%) by another relative, and 65 (30.1%) by a friend. Ninety-two (42.6%) were abused by a stranger, and 47 (21.8%) stated that they had been abused by more than one offender (42 by two and five by three).
|
, forced sexual activities occurred across the life span. Of the total number of women surveyed, 73 (6.8%) stated that they had been abused in childhood, 111 (10.3%) during adolescence, and 69 (6.4%) as an adult. An additional 38 women (3.5%) stated that they had been abused during more than one stage of their life.
|
When the 216 women with sexual abuse histories were asked if they would have liked to have had their gynecologist inquire about the abuse, 67 (31.0%) answered affirmatively, 69 (31.9%) negatively, and 59 (27.3%) were unsure. Twenty-one women (9.7%) did not answer the question.
|
DISCUSSION |
|---|
|
TOP
ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
Our second objective was to examine whether women discuss their experiences of forced sexual activity with health care professionals. In our study, just 6% had disclosed to their gynecologist, suggesting that women may not be prepared to discuss sexual abuse with their physicians. This finding concurs with an Australian study16 that found that less than 10% of women who had been sexually abused had discussed the issue with their general practitioner. As was the case in our study, Mazza et al also reported that 50% of respondents felt that the information was not relevant to care and commented that women may be failing to make the connection between abuse and their health problems. Although this may in part be true, over 30% of women in our study reported being afraid to raise the issue. Their fears may have been justified—of those women who did disclose, almost half described the attending gynecologist’s response as negative and another 15% described it as ambivalent. These results point to the need for medical professionals to be systematically educated about sexual violence so they can respond with greater sensitivity to disclosures.
Our third objective was to assess whether gynecologists screen for sexual abuse as part of routine care. We found that this form of violence was virtually ignored, as only one woman with a sexual abuse history reported that her gynecologist had raised the issue. A study of health care practitioners in Canada47 also revealed that routine screening for sexual abuse was a rare occurrence. Of the 158 gynecologists surveyed, just two reported regularly assessing for sexual abuse, and over 90% stated that it was "difficult" to discuss this issue with patients. According to a survey of 400 American primary care physicians on abuse screening practices for intimate partner violence,48 the most common barriers to identification and referral are 1) the patient’s fear of retaliation by partner, 2) lack of disclosure by the patient, 3) patient-physician cultural differences, 4) the patient’s fear of police involvement, and 5) lack of patient follow-up on referrals. Other barriers that have been identified in the literature include lack of time, lack of education and training, lack of evidence that interventions are effective, and a sense of inefficacy.48–51.
It is possible that those factors that prevent health care providers from screening for intimate partner abuse also prevent them from screening for sexual violence in general. In Germany, education about sexual violence is neither part of the medical school curriculum nor part of the training for residents in any subspecialty. Clinicians have no clear guidelines about how to identify, treat, or counsel a woman with a history of sexual abuse. Anecdotal evidence suggests that in many clinical settings physicians feel that they do not have adequate time to talk to their patients and eliciting information about a sensitive topic like sexual abuse can be a lengthy process. The low reimbursement rate provided by the health care system for counseling may be a further disincentive.
The purpose of our final research question was to assess whether women who have been sexually abused would like to be asked about the experience by their gynecologist. A third of our sample answered affirmatively. A study of women presenting to an emergency department conducted by McLeer and Anwar52 showed that abused women readily answered questions about abuse and were relieved that a triage nurse had inquired directly. Friedman et al53 also found that, regardless of whether a woman herself has been abused, she is likely to endorse routine screening. As primary health care providers, obstetrician-gynecologists can play a critical role in the evaluation, treatment, and prevention of abuse. Each medical encounter provides an opportunity for improving the care provided to women who have been violated. The gynecologic consequences of sexual abuse make it a matter of importance in routine care. The practice of universal screening, however, warrants further investigation. A recent article in The Lancet,54 for example, indicated that it is not feasible in certain settings and may even be dangerous if caregivers lack sufficient training for ensuring women’s safety during and after disclosure.
Several limitations of our study should be acknowledged. The study relied exclusively on self-reported data and examined sexual abuse in a single jurisdiction, among women who reported for outpatient gynecologic care. Moreover, it is not known if our sample is representative of women presenting for gynecologic care, as respondents were not recruited from the clinic list and were excluded if accompanied by a man. Although it can be assumed that most women who completed the survey in the waiting room were patients, it is also possible that some were female companions. Thus, our data may also under- or overestimate the number of women seeking gynecologic care with a history of sexual abuse. Finally, data were collected from a large, economically prosperous urban center and, as such, may not be representative of women in the general German population. Despite these limitations, this study is important as it contributes to the dearth of information on sexual abuse among gynecologic patients and is the first of its kind to examine the issue in Germany. Further research is needed to assess the generalizability of our findings to other patient groups, clinic settings, and geographical locations. Furthermore, studies should inquire about the health-related problems that brought women to seek care in the first place and identify those who are pregnant.
|
Footnotes |
|---|
Received January 23, 2002. Received in revised form May 28, 2002. Accepted July 11, 2002.
|
REFERENCES |
|---|
|
TOP
ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
2. Keane FEA, Young SM, Boyle HM. The prevalence of previous sexual assault among routine female attenders at a department of genitourinary medicine. Int J STD AIDS 1996;7:480–4.[Medline]
3. MacMillian HL, Fleming JE, Trocme N, Boyle MH, Wong M, Racine YA, et al. Prevalence of child physical and sexual abuse in the community. Results from the Ontario Health Supplement. JAMA 1997;278:131–5.[Abstract]
4. Fleming JM. Prevalence of childhood sexual abuse in a community sample of Australian women. Med J Aust 1997;166:65–8.[Medline]
5. Edgardh K, Ormstad K. Prevalence and characteristics of sexual abuse in a national sample of Swedish seventeen-year-old boys and girls. Acta Paediatr 2000;89:310–9.[Medline]
6. Pederson W, Skrondal A. Alcohol and sexual victimization: A longitudinal study of Norwegian girls. Addiction 1996;91:565–81.[Medline]
7. Halperin DS, Bouvier P, Jaffe PD, Mounoud RL, Pawlak CH, Laederach J, et al. Prevalence of child sexual abuse among adolescents in Geneva: Results of a cross sectional survey. BMJ 1996;312:1326–9.
8. Krahe B, Scheinberger-Olwig R, Waizenhofer E, Kolpin S. Childhood sexual abuse and revictimization in adolescence. Child Abuse Negl 1999;23:383–94.[Medline]
9. López F, Carpintero E, Hernandez A, Martin MJ, Fuertes A. Prevalence and sequelae of childhood sexual abuse in Spain. Child Abuse Negl 1995;19:1039–50.[Medline]
10. Heise L, Ellsberg M, Gottemoeller M. Ending violence against women. Population reports, series L, no. 11. Baltimore: Johns Hopkins University School of Public Health, Population Information Program, 1999.
11. Olsson A, Ellsberg M, Berglund S, Herrera A, Zelaya E, Pena R, et al. Sexual abuse during childhood and adolescence among Nicaraguan men and women: A population based anonymous survey. Child Abuse Negl 2000;24: 1579–89.[Medline]
12. Singh HS, Yiing WW, Nurani HN. Prevalence of childhood sexual abuse among Malaysian paramedical students. Child Abuse Negl 1996;20:487–92.[Medline]
13. Brener ND, McMahon PM, Warren CW, Douglas KA Forced sexual intercourse and associated health-risk behaviors among female college students in the United States. J Consult Clin Psychol 1999;67:252–9.[Medline]
14. Newton-Taylor B, DeWit D, Gliksman L. Prevalence and factors associated with physical and sexual assault of female university students in Ontario. Health Care Women Int 1998;19:155–64.[Medline]
15. Tschumper A, Narring F, Meier C, Michaud PA. Sexual victimization in adolescent girls (age 15–20 years) enrolled in post-mandatory schools or professional training programmes in Switzerland. Acta Paediatr 1998;87:212–7.[Medline]
16. Mazza D, Dennerstein L, Ryan V. Physical, sexual and emotional violence against women: A general practice based prevalence study. Med J Aust 1996;164:14–7.[Medline]
17. Greaves L, Hankivsky O, Kingston-Riechers JA. Selected estimates of the costs of violence against women. London, Ontario, Canada: Centre for Research on Violence Against Women and Children, 1995.
18. Koss MP, Heise L, Russo NF. The global health burden of rape. Psychol Women Q 1994;18:509–37.
19. Walker EA, Unutzer J, Rutter C, Gelfand A, Saunders K, VonKorff M, et al. Costs of health care use by women HMO members with a history of childhood abuse and neglect. Arch Gen Psychiatry 1999;56:609–13.
20. Kindermann G, Carsten PM, Maassen V. Ano-genital injuries in female victims of sexual assault. Swiss Surg 1996;1:10–3.
21. Du Mont J, McGregor MJ, Myhr TL, Miller K-L. Predicting legal outcomes from medicolegal findings: An examination of sexual assault in two jurisdictions. J Womens Health Law 2000;1:219–33.
22. Du Mont J, Parnis D. Sexual assault and legal resolution: Querying the medical collection of forensic evidence. Med Law 2000;19:779–92.[Medline]
23. Romans SE, Gendall KA, Martin JL, Mullen PE. Child sexual abuse and later disordered eating: A New Zealand epidemiological study. Int J Eat Disord 2001;29:380–92.[Medline]
24. Wonderlich SA, Brewerton TD, Jocic Z, Dansky BS, Abbott DW. Relationship of childhood sexual abuse and eating disorders. J Am Acad Child Adolesc Psychiatry 1997;36:1107–15.[Medline]
25. Burnam MA, Stein JA, Golding JM, Siegel JM, Sorenson SB, Forsythe AB, et al. Sexual assault and mental disorders in a community population. J Consult Clin Psychol 1988; 56:843–50.[Medline]
26. Cheasty M, Clare AW, Collins C. Relation between sexual abuse in childhood and adult depression: A case-control study. BMJ 1998;316:198–201.
27. Briggs L, Joyce PR. What determines post-traumatic stress disorder symptomatology for survivors of childhood sexual abuse? Child Abuse Negl 1997;21:575–82.[Medline]
28. Davidson JRT, Hughes DC, George LK, Blazer DG. The association of sexual assault and attempted suicide within the community. Arch Gen Psychiatry 1996;53:550–5.[Abstract]
29. Golding JM, Wilsnack SC, Learman LA. Prevalence of sexual assault history among women with common gynecologic symptoms. Am J Obstet Gynecol 1998;179: 1013–9.[Medline]
30. Walling MK, Reiter RC, O’Hara MW, Milburn AK, Lilly G, Vincent SD. Abuse history and chronic pain in women: I. Prevalences of sexual abuse and physical abuse. Obstet Gynecol 1994;84:193–9.
31. Reiter RC, Gambone JC. Demographic and historic variables in women with idiopathic chronic pelvic pain. Obstet Gynecol 1990;75:428–32.
32. Collett BJ, Cordle CJ, Stewart CR, Jagger C. A comparative study of women with chronic pelvic pain, chronic nonpelvic pain and those with no history of pain attending general practitioners. Br J Obstet Gynaecol 1998;105: 87–92.[Medline]
33. Lampe A, Solder E, Ennemoser A, Schubert C, Rumpold G, Sollner W. Chronic pelvic pain and previous sexual abuse. Obstet Gynecol 2000;96:929–33.
34. Jenny C, Hooton TM, Bowers A, Copass MK, Krieger JN, Hillier SL, et al. Sexually transmitted diseases in victims of rape. N Engl J Med 1990;322:713–6.[Abstract]
35. Holmes MM, Resnick HS, Kilpatrick DG, Best CL. Raperelated pregnancy: Estimates and descriptive characteristics from a national sample of women. Am J Obstet Gynecol 1996;175:320–5.[Medline]
36. Glander SS, Moore ML, Michielutte R, Parsons LH. The prevalence of domestic violence among women seeking abortion. Obstet Gynecol 1998;91:1002–6.[Abstract]
37. Golding JM, Taylor DL, Menard L, King MJ. Prevalence of sexual abuse history in a sample of women seeking treatment for premenstrual syndrome. J Psychosom Obstet Gynaecol 2000;21:69–80.[Medline]
38. Mayer L. The severely abused woman in obstetric and gynecologic care. Guidelines for recognition and management. J Reprod Med 1995;40:13–8.[Medline]
39. Weijenborg PT, de Koning BA, van Roosmalen GJ. Individualized obstetrical care for women with a history of sexual abuse. Ned Tijdschr Geneeskd 2001;145:393–6.[Medline]
40. Kirkengen AL, Schei B, Steine S. Indicators of childhood sexual abuse in gynaecological patients in a general practice. Scand J Prim Health Care 1993;11:276–80.[Medline]
41. Ribberink WL, Slurink GE, Everaerd W, Hanewald G The incidence of sexual violence among women with gynecological complaints. J Psychosom Obstet Gynaecol 1989;10 Suppl 10:25.
42. van Lankveld JJ, ter Kuile MM, Kenter GG, van Hall EV, Weijenborg PT. Sexual problems and experiences with sexual and physical violence in gynecological patients. Ned Tijdschr Geneeskd 1996;140:1903–6.[Medline]
43. Moeller TP, Bachmann GA. The combined effects of physical, sexual, and emotional abuse during childhood: Long-term health consequences for women. Child Abuse Negl 1993;17:623–40.[Medline]
44. McFarlane J, Parker B, Soeken K, Bullock L. Assessing for abuse during pregnancy: Severity and frequency of injuries and associated entry into prenatal care. JAMA 1992; 267:3176–8.[Abstract]
45. McGrath ME, Hogan JW, Peipert JF. A prevalence survey of abuse and screening for abuse in urgent care patients. Obstet Gynecol 1998;91:511–4.[Abstract]
46. Beebe DK, Gulledge KM, Lee CM, Replogle W. Prevalence of sexual assault among women patients seen in family practice clinics. Family Pract Res J 1994;14:223–8.[Medline]
47. Maheux B, Haley N, Rivard M, Gervais A. Do physicians assess lifestyle health risks during general medical examinations? A survey of general practitioners and obstetrician-gynecologists in Quebec. CMAJ 1999;160:1830–4.[Abstract]
48. Rodriguez MA, Bauer HM, McLoughlin E, Grumbach K Screening and intervention for intimate partner abuse: Practices and attitudes of primary care physicians. JAMA 1999;282:468–74.
49. Waalen J, Goodwin MM, Spitz AM, Petersen R, Saltzman LE. Screening for intimate partner violence by health care providers: A review of barriers and interventions. Am J Prev Med 2000;19:230–7.[Medline]
50. Garimella R, Plichta SB, Houseman C, Garzon L. Physician beliefs about victims of spouse abuse and about the physician role. J Womens Health Gend Based Med 2000; 9:405–11.[Medline]
51. Parsons LH, Zaccaro D, Wells B, Stovall TG. Methods of and attitudes toward screening obstetrics and gynecology patients for domestic violence. Am J Obstet Gynecol 1995; 173:381–7.[Medline]
52. McLeer SV, Anwar RAH. A study of battered women presenting in an emergency department. Am J Public Health 1989;79:65–6.
53. Friedman LS, Samet JH, Roberts MS, Hudlin M, Hans P Inquiry about victimization experiences. A survey of patient preferences and physician practices. Arch Intern Med 1992;152:1186–90.[Abstract]
54. Garcia-Moreno C. What is an appropriate health service response to intimate partner violence against women? Dilemmas and opportunities. Lancet 2002;359;1509–14.[Medline]
This article has been cited by other articles:
|
|
 |
|
  B. Leeners, R. Stiller, E. Block, G. Gorres, B. Imthurn, and W. Rath Effect of Childhood Sexual Abuse on Gynecologic Care as an Adult Psychosomatics, October 1, 2007; 48(5): 385 - 393. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S G Perez, R J Gelpi, and A M Rancich Doctor-patient sexual relationships in medical oaths J. Med. Ethics, December 1, 2006; 32(12): 702 - 705. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
