INCORPORATING ROUTINE SCREENING FOR HISTORY OF CHILDHOOD SEXUAL ABUSE INTO WELL-WOMAN AND MATERNITY CARE

Despite a rapid expansion in the understanding of the incidence and effects of childhood sexual abuse in the mental health disciplines, health care disciplines have only begun to look at the effect of an abuse history on Women's Health. Little is known from research about its influence on a woman's gynecology care or childbearing experience. The literature across disciplines advocates for routine screening for history of childhood sexual abuse. Asking about childhood sexual abuse will benefit women who have been abused and will help build a database from which to gain clinical knowledge about their care. This review presents clinical reasons to screen, discusses barriers and benefits, and emphasizes manageable ways to incorporate asking about childhood sexual abuse into practice.     

Childhood sexual abuse (CSA) experiences: an underestimated factor in perinatal care

BACKGROUND: Childhood sexual abuse can have several negative consequences on pregnancy, birth, and the early neonatal period. However, most obstetricians are not aware if their patients have a history of childhood sexual abuse. We therefore investigated childhood sexual abuse experiences in 226 women three to eight months after delivery of a healthy child. METHODS: 415 women were approached to answer a self-administered questionnaire including obstetrical questions and questions focusing on abuse experiences. 320 women agreed to participate, 226 (69.1% of the women fulfilling inclusion criteria) of which returned a completed questionnaire. Sexual abuse was explored using a modified version of a questionnaire developed by Wyatt. The complete questionnaire was designed in cooperation with the German "Frauennotruf", a society providing care for victims of sexual abuse. RESULTS: The prevalence of childhood sexual abuse was a minimum of 11.5% and a maximum of 14.6% if women who were not sure about such experiences during their childhood were included. Another 1.3% of the women had experienced sexual abuse as an adult. Lifetime sexual abuse prevalence was 12.8% and 15.9%, respectively. Of the women with an experience of childhood sexual abuse, 42.3% mentioned an ongoing abuse situation for at least six months. CONCLUSIONS: As approximately every 9th woman presenting for obstetrical care has experienced childhood sexual abuse, and as those experiences may have a negative impact on fetal and maternal well-being, adequate counseling models should be offered to victims of sexual abuse.     

Prevalence of sexual abuse history in a sample of women seeking treatment for premenstrual syndrome

This study evaluated the prevalence and correlates of sexual abuse history among women seeking treatment for severe premenstrual syndrome (PMS). Of 77 women participating in a randomized clinical trial of non-pharmacological treatments for severe PMS, 42 were interviewed regarding their sexual abuse history. The interviewed women were a mean of 38 years old, and most were of European ancestry, heterosexual, married, employed and well-educated. At least one attempted or completed sexual abuse event was reported by 95% of the women, with 81% reporting completed penetration against their will and 85% of these sustaining physical threat or harm. Compared to prior studies of sexually abused women in general populations, these women were abused earlier in life, more frequently and by similar types of offenders. Most of the abused women (65%) were estimated to have post-traumatic stress disorder (PTSD). Most abused women (83%) had never disclosed the abuse to a health practitioner. The findings suggest that a history of sexual abuse, particularly in childhood or adolescence, may be extremely common among women seeking treatment for severe PMS, and that substantial undiagnosed PTSD may also be present in this population. Implications for patient screening and treatment are discussed.     

The independent and combined effects of physical and sexual abuse on health. Results Of a national survey

Background: Although physical and sexual abuse have been linked to health risk behaviors as well as mental health problems, it is unclear whether those young women who have experienced both physical and sexual abuse are at greatest risk. To examine the independent associations between physical, sexual, and/or both types of abuse and health status, mental health, and health risk behaviors among a national school-aged sample of girls. We hypothesized that the magnitude of risk would be highest for those reporting both types of abuse compared to those reporting neither or one type of abuse. Methods: In 1997, 3,015 girls in grades 5 through 12 participated in the Commonwealth Fund Adolescent Health Survey and responded to both questions inquiring about physical and sexual abuse. This sample was derives from a nationally representative cross-section of 265 public, private, and parochial schools with an oversampling of 32 urban schools to obtain ethnic diversity. Data were analyzed using chi-square and binary or multinomial logistic regression stratified by type of abuse (none, physical abuse, sexual abuse, or both). Results: About 8% (n = 246) of girls reported a past history of only physical abuse, 5% (n = 140) reported only sexual abuse, and 5% (n = 160) reported experiencing both physical and sexual abuse. Logistic regression controlling for demographic characteristics (grade level, ethnicity, family structure, and socioeconomic status) found those who reported both types of abuse as compared to those who did not report any abuse were significantly more likely to experience moderate-to-severe depressive symptoms (OR = 5.1), moderate to high life stress (OR = 3.3), history of bingeing and purging behavior (OR = 4.4), regular smoking (OR = 5.9) regular drinking (3.8), illicit drug use in the past 30 days (RR = 3.5) and fair to poor health status (OR = 1.9). In contrast, lowered adjusted odds ratios (1.8-2. 5) were seen for those reporting one type of abuse as compared to no abuse across most health outcomes.Conclusions: Those experiencing any type of abuse are at risk; however, those adolescent females who report both physical and sexual victimization are at much greater risk.     

Working With Childhood Sexual Abuse Survivors During Pregnancy, Labor, and Birth

It is estimated that approximately 27% of women have a history of childhood sexual abuse. Long-term effects of this abuse include physical and psychologic consequences that can affect the pregnant woman during the prenatal, antenatal, and postpartum periods. Careful screening of all pregnant women and specific interventions during examinations and procedures can help survivors of childhood sexual abuse experience childbearing as healing and empowering. Care providers who are survivors of such abuse can better serve their patients by working therapeutically on their own healing.     

Childhood Abuse and Common Complaints in Pregnancy

Background: Childhood abuse affects adult health. The objective of this study was to examine the prevalence of emotional, physical, and sexual childhood abuse within a large Norwegian cohort of pregnant women and its association with common complaints in pregnancy. Methods: This study is based on the Norwegian Mother and Child Cohort Study (MoBa) conducted by the Norwegian Institute of Public Health. Regression analyses were used to examine associations of childhood abuse and 16 common complaints in pregnancy. Results: Eighteen percent (10,363/55,776) of the women reported some type of childhood abuse. Of all women, 3,870 (6.9%) reported sexual abuse, 3,075 (5.5%) physical abuse, and 7,619 (13.6%) emotional abuse as a child. Of those reporting childhood abuse, 31 percent reported two or more types of abuse. All 16 common complaints in pregnancy were associated with reported childhood abuse. Women reporting three types of childhood abuse reported 5.4 common complaints in pregnancy (mean) compared with 3.7 for women without childhood abuse (p < 0.001). Women reporting childhood abuse are more likely to report seven or more common complaints in pregnancy: adjusted odds ratio (AOR) 1.7 (95% CI 1.6–1.9) for emotional abuse; AOR 2.5 (95% CI 2.0–3.1) for combined physical and sexual abuse; and AOR 3.5 (95% CI 3.0–4.0) for all three kinds of abuse. Sociodemographic characteristics and other risk factors did not explain this graded association. Conclusions: Abuse in childhood is associated with increased reporting of common complaints of pregnancy. Clinicians should consider the possible role of childhood abuse when treating women with many common complaints in pregnancy.     

History of physical and sexual abuse in women with chronic pelvic pain

The history of physical and sexual abuse in childhood and adulthood was assessed in 31 women with chronic pelvic pain, 142 women with chronic pain in other locations, and 32 controls. Thirty-nine percent of patients with chronic pelvic pain had been physically abused in childhood. This percentage was significantly greater than that observed in other chronic-pain patients (18.4%) or controls (9.4%), though the prevalence of childhood sexual abuse did not differ among the groups (19.4, 16.3, and 12.5%, respectively). Abuse in adulthood was less common and was not significantly more likely to have occurred in patients with chronic pelvic pain than in other chronic-pain patients or controls. These data suggest that pelvic pain is unlikely to be specifically and psychodynamically related to sexual abuse but that the pernicious nature of abuse, whether physical or sexual, may promote the chronicity of painful conditions.     

A Practical Approach to Clients Who are Survivors of Childhood Sexual Abuse

Approximately 30% of all women have experienced some form of sexual abuse in childhood or adolescence. This abuse may result in serious long-term sequelae for the survivor, such as depression, low self-esteem, post-traumatic stress disorder, and addictive behaviors. Nurse-midwives are uniquely equipped to provide health care to survivors of childhood sexual abuse because of their commitment to thorough, sensitive history-taking, anticipatory guidance, decreased use of interventions, and in-depth health education. This article draws on current literature and the clinical experience of a nurse-midwife who has cared for many survivors of sexual abuse. It offers suggestions for incorporating identification of survivors into the initial health assessment. Interventions are reviewed including how to approach the physical examination of a survivor and how to provide appropriate care in the intrapartum and postpartum period. Emphasis is given to the development of a referral network.     

Dyspareunia in a Survivor of Childhood Sexual Abuse

Dyspareunia is a frequent chief concern encountered by midwives and other women's health care providers. There are many possible etiologies for dyspareunia, including a history of childhood sexual abuse, and approaching assessment in a holistic manner is necessary to identify the etiology. This case report presents evidence on the importance of screening a woman who presents with dyspareunia in a therapeutic manner to facilitate disclosure of sexual abuse. Best practices for screening for sexual violence, along with recommendations for providing gynecologic care to survivors, are offered. By understanding the long‐term sequelae of sexual abuse and through screening all women, midwives and other women's health care providers can facilitate healing and treatment for survivors.     

The association of sexual abuse with pelvic pain complaints in a primary care population

OBJECTIVE: Our purpose was to determine the prevalence of sexual abuse during childhood and adulthood and its association with pelvic and other pain complaints in a population of reproductive-aged women. STUDY DESIGN: A 10-page questionnaire was administered to 581 nonpregnant women aged 18 to 45 years examined in primary care offices. RESULTS: The reported incidences of childhood and adult sexual abuse were 26% and 28%. In regression analyses, with the exception of irritable bowel syndrome, women with only a history of childhood sexual abuse and no abuse later in life are not more likely than nonabused women to report pain syndromes. By contrast, with the exception of dysmenorrhea, all pain complaints studied were more common in women reporting abuse both as children and as adults. CONCLUSIONS: Sexual abuse that occurs during childhood and again as an adult is strongly associated with pelvic pain complaints.(Am J Obstet Gynecol 1997;177:12)     

History of Sexual and Physical Abuse in Women with Dyspareunia: Association with Pain,Psychosocial Adjustment,and Sexual Functioning

AimDyspareunia is a women's sexual health problem that still often goes undiagnosed despite its high prevalence and its detrimental impact on sexual, relationship, and psychological adjustment. Although sexual and physical abuse may constitute risk factors for the development of dyspareunia, the effects of past abuse on current pain and associated sexual and psychosocial impairments have never been examined. Thus, the aim of this study is to determine the relation between a history of sexual and physical abuse and a series of pain, psychological, dyadic, and sexual functioning variables in a sample of women with dyspareunia.MethodsA hundred and fifty-one women took part in the study via health professional referrals and advertisements in local newspapers. Each participant underwent a standardized gynecological examination and a structured interview in order to confirm the diagnosis of dyspareunia. They also completed self-report questionnaires investigating past sexual and physical abuse, in addition to current pain, psychosocial adjustment, and sexual functioning. Dependent measures included: (i) The Brief Symptom Inventory; (ii) the Sexual History Form; and (iii) the Locke-Wallace Marital Adjustment Scale. Pain was assessed via the McGill Pain Questionnaire and a visual analogue scale.ResultsResults revealed that a history of sexual abuse involving penetration was associated with poorer psychological adjustment and sexual functioning. Additionally, findings showed that women who perceived a link between their dyspareunia and their past sexual abuse reported worse sexual functioning than those who did not. Finally, the experience of sexual abuse was not associated with pain intensity and physical abuse was not associated with any of the outcome measures.ConclusionsFindings suggest that the presence of a sexual abuse history in women with dyspareunia is associated with increased psychological distress and sexual impairment, although there is no relation between a history of physical abuse and these outcomes. Leclerc B, Bergeron S, Binik YM, and Khalifé S. History of sexual and physical abuse in women with dyspareunia: Association with pain, psychosocial adjustment and sexual functioning.     

Domestic violence, lifetime trauma and psychological health of childbearing women

OBJECTIVE: Although histories of abuse are associated with psychiatric illness in women, health professionals rarely enquire directly about such experiences. This study examined the association between physical and sexual violence and lifetime trauma and depressive and posttraumatic stress symptoms in women receiving maternity care. DESIGN: Cross sectional study. SETTING: South London Hospital maternity services. POPULATION: Two hundred women receiving postnatal or antenatal care. METHODS: Two hundred women receiving postnatal or antenatal care at a South London maternity service were screened for lifetime experiences of trauma and domestic violence. Information was obtained about self-harming behaviour, suicidal thoughts and attempts and psychiatric history. Women completed the Edinburgh Postnatal Depression Scale (EPDS) and the Posttraumatic Diagnostic Scale (PTDS). MAIN OUTCOME MEASURES: RESULTS: One hundred and twenty-one (60.5%) women reported at least one traumatic event and two-thirds of these had experienced multiple traumatic events. The most frequent (34%) was witnessing or experiencing physical assault by a family member. Forty-seven (23.5%) women had experienced domestic violence. Physical and sexual abuse commonly co-occurred. Thirteen (10.7%) women with a trauma history had current posttraumatic stress disorder. Severe posttraumatic symptoms were associated with physical and sexual abuse histories and repeat victimisation. Adult and childhood physical and sexual abuse histories were also associated with more severe depressive symptomatology. Significant social factors associated with depression were being single, separated or in a non-cohabiting relationship. CONCLUSION: Traumatic events are under-recognised risk factors in the development of depressive and posttraumatic stress symptoms in childbearing women. Childhood abuse creates a vulnerability to re-traumatisation in adulthood. Awareness of the impact of trauma and abuse on psychological health may enable more appropriate targeting of clinical services and support for women receiving maternity care.     

Demographic and psychosocial characteristics of substance-abusing pregnant women

Women who abuse drugs and alcohol during pregnancy are an elusive population who often remain unidentified to practitioners and researchers and hence have not been well studied. In trying to understand better the characteristics of women who use drugs during pregnancy, the present article relies extensively on information gathered in studies of women in substance abuse treatment who, as epidemiologic studies show, may be more severely impaired than other substance-abusing women and, therefore, may not be typical of substance-abusing women identified in the course of obstetric practice. Yet, those pregnant women who are actually identified by medical providers as substance users are often those whose behavior raises concerns with health providers (such as presenting for labor having had no prenatal care) and thus also may represent only a relatively impaired group of substance-abusing women. The most objective picture available of the universe of women who use drugs during pregnancy comes from blinded urine toxicology screens conducted at samples of representative hospitals across states and across the country. The startling finding to emerge from these studies is that common perceptions of substance abuse as a problem of poor, ethnic minority, and young individuals is inaccurate and that this perception may all too often be acted on by medical providers in a prejudicial manner. These studies show similar rates of substance use during pregnancy by women of different racial, social class, and age categories. Demographic features are only related to type of substance used, with black women and poorer women more likely to use illicit substances, particularly cocaine, and white women and better educated women more likely to use alcohol, the substance whose teratogenic effects have been most clearly documented. Despite the even distribution of substance use across demographic categories, poor women and women of color are far more likely to be reported to health and child welfare authorities for use of substances during pregnancy than are other women, even when their base rates for use of illicit drugs are considered. Data from both epidemiologic studies and samples of women seeking treatment for substance abuse problems indicate that the lives of substance-abusing women are fraught with difficulties past and present. Substance-abusing women are likely to have been raised by parents who were substance abusers, particularly alcoholics. Although the intergenerational patterns of substance abuse may have some genetic basis, there is also ample evidence suggesting problematic relationships in families with a substance-abusing parent that raises concerns about intergenerational transmission of problematic parenting behavior. Perhaps the most startling research finding reported in studies reviewed in this article is the high proportion of substance-abusing women who have experienced early sexual abuse. Although most studies have not had adequate comparison groups of non-substance-abusing women, the fact remains that most studies suggest a third to a half of substance abusing women experienced some kind of sexual abuse during childhood. Substance-abusing women's lives remain complicated as adults. They are commonly involved with men who are also users of drugs, they are often the victims of domestic violence, and they suffer from a variety of psychiatric disorders. Studies of epidemiologic and treatment populations indicate that the majority of substance-abusing women have one or more types of comorbid mental disorders, with depression being the most common and the most elevated compared with substance-abusing men, but antisocial personality being extremely high compared with samples of non-substance-abusing women. These findings are of great concern given a growing body of research with non-substance-abusing women, suggesting that family violence and maternal psychopathology can have a profound effect on women's parenting and development o     

Bad experience, good birthing: Dutch low-risk pregnant women with a history of sexual abuse

OBJECTIVE: The long-term effects on women in childbirth with a history of sexual abuse have only been studied to a limited degree. We estimated the prevalence of lifetime experience among low-risk pregnant women (non-clinical) in The Netherlands as well as the association with (1) psycho-social outcomes, and (2) the birth process. METHODS: Study of 625 randomly selected low-risk pregnant women. At 20-24 weeks gestation, participants completed a questionnaire covering socio-demographic variables, sexual attitude, and psychological determinants. Midwives recorded details of the birth process. RESULTS: Nearly one-in-nine (11.2%) women had experienced sexual abuse. They were on average younger, more likely to smoke, and had lower household income. They reported more conflicting feelings about sex than women who did not report a history of abuse (p = 0.02). Multiparous women with a history of sexual abuse reported more emotional distress (p = 0.037), more internal beliefs concerning health (p = 0.004), and they were also more likely to suffer pelvic pain (p = 0.045). Sexually-abused women reported higher levels of autonomy (p = < 0.001). Referral rates to secondary care were equal. Sexually-abused women were less likely to receive episiotomies (p < 0.005). CONCLUSION: Little difference was observed in major birth-related technical interventions between women with and without a history of sexual abuse.     

Risk of sexual dysfunction in a randomly selected nonclinical sample of the Swedish population

OBJECTIVE: To investigate the risk of sexual dysfunction as a result of childhood sexual abuse or sexual assault in a randomly selected nonclinical sample of men and women. METHODS: In 1996, a randomly selected sample of 2,810 Swedish males and females completed a 322-item interview and questionnaire. Age-adjusted odds ratios (ORs) were calculated to assess risk of sexual dysfunction and analysis of variance was employed to test differences by gender and abuse or assault history in regard to seeking assistance for sexual dysfunction. RESULTS: For females with a history of childhood sexual abuse, an increased risk of anorgasmia for more than 12 months was found for women aged between 31 and 45 years (OR 1.21, P=.009). For females with a history of sexual assault; an increased risk for hypoactive sexual desire disorder was found for women who between the ages of 16 and 30 years (OR 1.51, P=.03), 31 and 45 years (OR 1.28; P=.02), 46 and 60 years (OR 1.21, P=.03), and 61 and 84 years (OR 1.62, P=.04); lubrication problems in the past year for women between 46 and 60 years (OR 1.28, P=.02) and for more than 12 months (OR 1.38, P=.02). No statistically significant increased risk of sexual dysfunction was found for males with a history of childhood sexual abuse. Males who reported a history of sexual assault as an adult had a significant increased risk of retarded ejaculation in the last 12 months if they were between the ages of 31 and 45 years (OR 2.00, P=.008) or 46 and 60 years (OR 2.11, P=.02). Women most often reported sexual dysfunction to their gynecologists (18%) or midwives (8.4%), whereas men reported their sexual dysfunction to their physicians (5.6%) or urologists (4.3%). CONCLUSION: Future research should focus on predictors of sexual dysfunction and resilience subsequent to childhood sexual abuse and sexual assault as an adult. LEVEL OF EVIDENCE: III.     

Effects of Expressive Writing on Sexual Dysfunction,Depression, and PTSD in Women with a History of Childhood Sexual Abuse: Results from a Randomized Clinical Trial

IntroductionWomen with a history of childhood sexual abuse (CSA) have high rates of depression, posttraumatic stress disorder, and sexual problems in adulthood.AimWe tested an expressive writing-based intervention for its effects on psychopathology, sexual function, satisfaction, and distress in women who have a history of CSA.MethodsSeventy women with CSA histories completed five 30-minute sessions of expressive writing, either with a trauma focus or a sexual schema focus.Main Outcome MeasuresValidated self-report measures of psychopathology and sexual function were conducted at posttreatment: 2 weeks, 1 month, and 6 months.ResultsWomen in both writing interventions exhibited improved symptoms of depression and posttraumatic stress disorder (PTSD). Women who were instructed to write about the impact of the abuse on their sexual schema were significantly more likely to recover from sexual dysfunction.ConclusionsExpressive writing may improve depressive and PTSD symptoms in women with CSA histories. Sexual schema-focused expressive writing in particular appears to improve sexual problems, especially for depressed women with CSA histories. Both treatments are accessible, cost-effective, and acceptable to patients. Meston CM, Lorenz TA, and Stephenson KR. Effects of expressive writing on sexual dysfunction, depression, and PTSD in women with a history of childhood sexual abuse: Results from a randomized clinical trial. J Sex Med 2013;10:2177–2189.     

A history of sexual abuse and health: a Nordic multicentre study

OBJECTIVES: To determine if a history of sexual abuse is associated with objective and subjective indicators of health and if certain abusive incidents had a stronger impact on health than others. DESIGN: A cross-sectional, multicentre study. SETTING: Five gynaecological departments in the five Nordic countries. SAMPLE: Three thousand five hundred and thirty-nine gynaecology patients. METHODS: The NorVold Abuse Questionnaire (NorAQ) on abuse history and current health was mailed to all patients who consented to participate. MAIN OUTCOME MEASURES: Reason for index visit at the gynaeocological clinic as well as several questions on health were recorded. General health status was measured as self-estimated health, psychosomatic symptoms (headache, abdominal pain, muscle, weakness, dizziness), number of health care visits and number of periods on sick leave. RESULT: A history of sexual abuse was reported by 20.7% of respondents. A history of sexual abuse was significantly associated with chronic pelvic pain as reason for index visit (P < 0.01), laparoscopic surgery (P < 0.01), psychosomatic symptoms (P < 0.01), self-estimated poor health (P < 0.01), many health care visits (P < 0.01) and high incidence of sick leave (P < 0.01). Several subgroups within the group of sexually abused women were more likely to report poor health: women abused as both children and adults, women who experienced additional emotional and/or physical abuse and women abused by a person they knew. CONCLUSION: Sexual abuse has a profound impact on women's health. Taking a history of sexual abuse seems particularly warranted when the patient presents with chronic pelvic pain or symptoms of a vague and diffuse nature.     

Experiences of physical and sexual abuse and their implications for current health

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.     

Women's perceived experiences of abuse in the health care system: their relationship to childhood abuse

OBJECTIVES: The aim of this study was to determine whether there was an association between any lifetime experiences of emotional, physical and/or sexual abuse and perceived abuse in the health care system. Furthermore, we wanted to ascertain if adult victims of perceived abuse in the health care system reported exposure to childhood emotional, physical and/or sexual abuse more often than non-victims did. DESIGN: A cross sectional questionnaire study. The first hypothesis was tested in the total sample, and the second hypothesis in a case-control analysis. The cases were those women who reported perceived experiences of abuse in the health care system as adults. Exposure was defined as experience of emotional, physical and/or sexual abuse in childhood. SETTINGS: Three Swedish gynaecological clinics. SAMPLE: A total of 2439 gynaecology patients (response rate 81%). METHODS: Postal questionnaire. MAIN OUTCOME MEASURE: Associations between experiences of emotional, physical and/or sexual abuse, and perceived abuse in the health care system; all operationalised in The NorVold Abuse Questionnaire (NorAQ). RESULTS: A general association was found between lifetime experiences of emotional, physical and/or sexual abuse and perceived abuse in the health care system. Adult victims of abuse in the health care system reported experiences of emotional, physical and/or sexual abuse in childhood more often than non-victims did. These findings also held after adjustment for age and educational level. CONCLUSIONS: We found associations between experiences of any lifetime abuse and perceived abuse in the health care system. Adult victimisation in the health care system was associated with childhood exposure to emotional, physical and/or sexual abuse. These associations call for attention and need to be further investigated.     

SEQUELAE OF ABUSE: Health Effects of Childhood Sexual Abuse,Domestic Battering,and Rape

Violence against women is endemic in the United States. One third to one half of all women will experience one or more types of abuse in their lifetime, most often at the hands of a family member or an intimate or formerly intimate partner. One in 12 women is battered during pregnancy. Abuse survivors are disproportionately frequent users of health care services because of acute and chronic physical, somatic, emotional, and behavioral sequelae of abuse. Health care practitioners are often the first contact abuse survivors have with a potentially helping professional. It is, therefore, essential that health care providers learn to identify and to intervene appropriately with survivors of abuse. This article reviews and compares the health effects of three of the most common types of violence against women: childhood sexual abuse, domestic battering, and rape. Sequelae are divided into six categories: physical/medical, somatic, emotional/psychological, social/interpersonal, behavioral/sexual, and pregnancy-related effects. The health effects discussed in this article include research findings, as well as effects noted in clinical practice. Recommendations are made for routine screening of all women for past and current abuse, as well as for intervention strategies.