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Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. Acknowledgements
  9. Principal investigators
  10. Coordinator
  11. Local investigators
  12. Financial support
  13. References

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.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. Acknowledgements
  9. Principal investigators
  10. Coordinator
  11. Local investigators
  12. Financial support
  13. References

Occasionally, patients feel violated in the health care system.1 The traumatic event may be one that anybody would perceive as traumatic, such as a life-threatening emergency situation. The event may also be a more ordinary procedure, during which the physician/nurse perceived that nothing special happened, while the patient experienced the situation as frightening, insulting or disrespectful.

Why do these things happen to some patients and not to others? What characterises those patients who have such traumatic experiences?

In our clinical work with victims of abuse, we have empirically found that victims of emotional, physical and/or sexual abuse have often felt violated in the health care system. Jehu1–3 and Finkelhor and Browne4 postulated that childhood victims are prone to be retraumatised in the health care system. Victims of childhood sexual abuse often alter their cognitive schemata about relationships with others after the abusive experience(s) thinking: “I am worthless and I deserve this. Nobody can be trusted.” Everybody may be suspected of maltreating, exploiting or hurting them. Information is filtered accordingly, and only information that fits into the preformed schemata is included in the memory. Events are interpreted according to the schemata and generalised. Victims may even appear to provoke those around them to act in a way that verifies their worst suspicions. Former victims will then be able to conclude that their suspicions were correct. Jehu's theory therefore becomes ‘a self-fulfilling prophecy’, on the assumption that the childhood sexual abuse creates a basic insecurity, lack of trust and expectations of being traumatised again. These feelings constitute the victims' schemata for appraising relationships with others and of their anticipated dangers.

According to this theory, it may be hypothesised that victims of emotional, physical and/or sexual abuse in childhood would be over-represented among those who experience violations in the health care system as adults. It seems logical to assume that the theory cited above would also be valid for other kinds of abuse, such as physical and emotional abuse in childhood.

We decided to test our hypotheses with female patients coming to three departments of obstetrics and gynaecology in southeast Sweden in two steps: firstly in general and then according to the above theory. This generates the following hypotheses:

  • 1
    There is an xassociation between any lifetime emotional, physical and/or sexual abuse and abuse in the health care system.
  • 2
    If Hypothesis 1 is confirmed: adult victims of abuse in the health care system have been exposed to emotional, physical and/or sexual abuse as children more often than non-victims.

METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. Acknowledgements
  9. Principal investigators
  10. Coordinator
  11. Local investigators
  12. Financial support
  13. References

The study subjects were 3000 consecutive acute and non-acute patients >18 years old, coming for gynaecological consultations at three Departments of Obstetrics and Gynaecology in southeastern Sweden: the University Hospital, Linköping, which serves three counties; Ryhov Hospital, Jönköping (county hospital); and Västervik Hospital (local hospital). Most patients had an outpatient appointment, and a minority were admitted to a ward. Patients who claimed that they did not speak or understand the Swedish language properly were excluded. The recruitment period lasted from 1 October 1999 until 28 February 2000, with a four- to seven-week break for the Christmas holidays. The patients were orally invited and given an information letter from the head of the clinic and the local investigator which also included information on further assistance. One or two weeks after their visit to the gynaecological department, the 3000 participants received the NorVold Abuse Questionnaire (NorAQ)5,6 by post. Two reminders were sent out at two-week intervals.

The local ethical committee approved the study.

A more detailed description of material and procedure has been presented earlier together with data on the prevalence of emotional, physical and sexual abuse and abuse in the health care system and associations with regional and socio-demographic variables.7

We tested the first hypothesis in the complete sample, which was dichotomised into any or no lifetime emotional, physical and/or sexual abuse, and any or no lifetime abuse in the health care system.

The second hypothesis demanded that we created a subsample with a built-in time axis providing us with the opportunity to perform case–control analysis. In a case–control analysis, the odds of exposure versus non-exposure are compared for cases and controls.8 In our analysis, cases were those women who reported experiences of abuse in the health care system as adults. Exposure was defined as emotional, physical and/or sexual abuse in childhood. Mild physical abuse was classified as non-exposure as this question had low likelihood ratio in an earlier study on the validity of the questions of abuse in NorAQ.5 Women who reported both adult and childhood abuse of any kind were excluded in the analyses, as were women reporting only childhood abuse in the health care system.

NorAQ was developed for a Nordic study on gender violence.9 It is available in all Nordic languages and English.6 In NorAQ the topic of abuse is represented by 13 questions divided into four kinds of abuse: emotional, physical, sexual abuse and abuse in the health care system (Fig. 1). Abuse might have occurred in childhood (age <18), adulthood or both. The content of the questions ranges from mild to severe lifetime abuse, allowing an approximate classification of the severity of any abusive act. Women who reported more than one degree of a specific abuse were categorised according to the most severe abusive act. Exposure to abuse was defined as having answered ‘yes’ to one or several of the three or four questions about each kind of abuse in NorAQ.

imageimage

Figure 1. Questions about abuse in NorAQ.

The definition of abuse in the health care system included acts by any health care personnel at any health care institution. The act might have been perceived as abusive from an emotional, physical or sexual aspect. The character of the abusive act was not investigated further in this study.

According to our definition, mild abuse was any kind of offence, degradation, blackmail or disrespect that had caused later disturbance or suffering.

Moderate abuse was defined as having experienced a normal event in the health services, that was perceived terrible and insulting experience, without the patient fully understanding how this could happen.

Severe abuse in the health care system was defined as having felt purposely hurt physically or mentally or grossly violated, or as having felt that one's body was used to one's disadvantage for someone else's purpose.

NorAQ has been validated in a randomised cross sectional study population with interviews of women with and without earlier abusive experiences. With the exception mentioned above (mild physical abuse), we found that the questions about abuse in NorAQ had good reliability and validity.5

A Pearson χ2 test was used to analyse differences in socio-demographic variables between cases and controls. A crude odds ratio (OR) was calculated to estimate the association between firstly, lifetime experiences of abuse in the health care system and lifetime emotional, physical and/or sexual abuse at each clinic, and secondly, experiences of abuse in the health care system as an adult and childhood emotional, physical and/or sexual abuse.

Adjusted OR was calculated in a multivariate model (binary logistic regression) including each kind of abuse (emotional, physical and/or sexual alone or in combinations), age and educational level. The descriptive analyses, crude and adjusted OR, were performed using the statistics program SPSS (version 11.0).

We refer to differences in the text only when the observed differences were statistically significant (P < 0.05).

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. Acknowledgements
  9. Principal investigators
  10. Coordinator
  11. Local investigators
  12. Financial support
  13. References

The original sample consisted of 2439 women from three gynaecological clinics (response rate 81%): 831 from Jönköping, 842 from Linköping and 766 from Västervik.

There were associations between any lifetime emotional, physical and/or sexual abuse and abuse in the health care system in each of the samples from the three clinics: Jönköping: OR 4.4 (95% CI 2.8–6.7); Linköping: OR 3.3 (95% CI 2.3–4.8); Västervik: OR 4.9 (95% CI 3.1–7.5).

To test our second hypothesis, we selected 277 cases and 1926 controls from the total sample. In the new sample of 2203 women, 359 women had been exposed to emotional, physical and/or sexual abuse in childhood.

We found no differences in the prevalence of childhood emotional, physical or sexual abuse or adult abuse in the health care system between the women from the three clinics in our new sample. In the further analyses we therefore treat the samples from the three clinics as one sample (n= 2203).

Background characteristics among women exposed (n= 359) and not exposed (n= 1844) to childhood abuse are presented in Table 1. Women reporting exposure to emotional, physical and/or sexual abuse in childhood were younger (P < 0.05) and had higher educational level (P < 0.05) than non-exposed women.

Table 1.  Background characteristics among women exposed (n= 359) and not exposed (n= 1844) to childhood abuse.
 ExposedNot exposedMissing
Any childhood abuseNo childhood abuse
n= 359% exposedn= 1844% not exposed
  1. Statistical significance in background characteristics was calculated with χ2 for the three clinical samples.

  2. Women who reported both adult and childhood abuse of any kind were not included in the analyses, nor were women reporting only childhood abuse in the health care system.

  3. Abbreviations: sick lv. = on sick leave over a long period; retir. = retired (temporary disability pension, disability pension); social supp. = recipient of social assistance.

Site (P= 0.944)0
Linköping11832.962233.7 
Jönköping12534.863934.7 
Västervik11632.358331.6 
 
Age (P= 0.015)9
18–3411030.649226.8 
35–4912033.453229.0 
≥5012935.981144.2 
 
Education (P= 0.011)10
<9 years8022.352928.8 
10–12 years12234.164335.0 
≥13 years15643.666336.1 
 
Civil status (P= 0.557)16
Partner30284.8157586.0 
Single5415.225614.0 
 
Parity (P= 0.125)21
≥126875.5144679.1 
08724.538120.9 
 
Occupation (P= 0.326)10
Employed24067.0124067.6 
Housewife41.1462.5 
Pregnant/parent leave154.2683.7 
Unemployed92.5713.9 
Student287.81035.6 
Sick lv./retir./social supp.6117.030416.6 
Other10.330.2 

Women reporting adult abuse in the health care system (cases) were also younger and had a higher educational level than those not reporting such abuse (controls) (P < 0.001, see Table 2). There were more students and fewer employed among cases than controls (Table 2).

Table 2.  Background characteristics among women reporting abuse in the health care system as adults (cases, n= 277), and women not reporting adult or childhood abuse in the health care system (controls, n= 1926).
 CasesControlsMissing
Abused in the health care system as adultsNot abused in the health care system
n= 277% of casesn= 1926% of controls
  1. Statistical significance in background characteristics was calculated with χ2 for the three clinical samples.

  2. Women who reported both childhood and adult abuse of any kind were not included in the analyses, nor were women reporting mild physical abuse or childhood abuse in the health care system.

  3. Abbreviations: sick lv. = on sick leave over a long period; retir. = retired (temporary disability pension, disability pension); social supp. = recipient of social assistance.

Site (P= 0.095)0
Linköping10939.463132.8 
Jönköping8831.867635.1 
Västervik8028.961932.1 
 
Age (P < 0.001)9
18–349433.350826.5 
35–4910638.354628.5 
≥507727.886345.0 
 
Education (P < 0.001)10
<9 years5620.255328.9 
10–12 years8631.067935.4 
≥13 years13548.768435.7 
 
Civil status (P= 0.095)16
Partner22782.5165086.3 
Single4817.526213.7 
 
Parity (P= 0.363)21
≥121176.4150378.9 
06523.640321.1 
 
Occupation (P= 0.001)10
Employed16057.8132068.9 
Housewife41.4462.4 
Pregnant/parent leave186.5653.4 
Unemployed134.7673.5 
Student279.71045.4 
Sick lv./retir./social supp.5419.531116.2 
Other10.430.2 

The mean age when the first abuse in the health care system occurred was 29.5. Fifty-three women (2.4%; n= 2203) reported abuse in the health care system during the past 12 months.

Adult abuse in the health care system was reported by 99 of the exposed (29 mild, 44 moderate, 26 severe), and by 178 of the non-exposed women (62 mild, 82 moderate, 34 severe) (Table 3). There was no difference in the degree of severity of abuse in the health care system among exposed and non-exposed cases (χ2= 2.1, df= 2, NS).

Table 3.  Cases of adult abuse in the health care system among women exposed/non-exposed to childhood emotional, physical and/or sexual abuse.
 Adult abuse in the health care system 
Yes (cases)No (controls)
Emotional, physical and/or sexual abuse in childhoodYes99260359
No17816661844
 2771926 

Adult victims of abuse in the health care system reported emotional, physical and/or sexual abuse in childhood more often than non-victims (Table 4), but for childhood physical abuse, the OR was not statistically significant. However, in combination with emotional or sexual abuse or both, the association was statistically significant. When adjusted for age and educational level, OR remained high among cases compared with controls. The highest OR was found for the combination of all three kinds of childhood abuse.

Table 4.  Crude and adjusted (for age and education) odds ratio (OR and adj OR) for women reporting experiences of adult abuse in the health care system of having been exposed to emotional, physical, sexual abuse in childhood (total sample 2203). Values are expressed as n (%) unless otherwise indicated.
 Adult abuse in the health care system
CasesControlsOR95% CIAdj OR95% CI
 277 (100)1926 (100)    
Non-exposed178 (64.3)1666 (86.5)1.0 1.0 
Exposed99 (35.7)260 (13.5)    
 
Only one kind of childhood abuse
Emotional abuse15 (5.4)29 (1.5)4.842.55–9.203.9032.031–7.502
Physical abuse16 (5.8)89 (4.6)1.680.97–2.931.7060.974–2.987
Sexual abuse33 (11.9)82 (4.3)3.772.44–5.803.5302.275–5.478
 
Combination of different kinds of childhood abuse
Emotional + physical7 (2.5)20 (1.0)3.281.37–7.853.0491.250–7.441
Emotional + sexual11 (4.0)18 (0.9)5.722.66–12.305.1862.369–11.355
Physical + sexual9 (3.2)13 (0.7)6.482.73–15.376.5792.724–15.889
Emotional + physical + sexual8 (2.9)9 (0.5)8.323.17–21.838.9143.310–24.003

One-third of the women who reported adult abuse in the health care system also reported experiences of emotional, physical and/or sexual childhood abuse.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. Acknowledgements
  9. Principal investigators
  10. Coordinator
  11. Local investigators
  12. Financial support
  13. References

Both our hypotheses were confirmed. There was a general association between any lifetime emotional, physical and/or sexual abuse and abuse in the health care system. Victims who reported experiences of abuse in the health care system as adults reported events of emotional, physical and/or sexual abuse in childhood more often than adult non-victims did, which strengthened our theory about revictimisation. This association was found in the sample of gynaecology patients. There is good evidence that the prevalence of abuse is high among women who present with gynaecological symptoms which raises the question of selection bias in the present study.10–13 However, we found no statistically significant differences in prevalences of the four kinds of abuse when NorAQ was used in a randomised Swedish population study, and the estimated prevalences were compared in multivariate analyses with the Linköping patient sample in the present study.7

Abuse in the health care system could have been experienced in any health care setting. When the associations between abuse in the health care system and different kinds of abuse were compared, emotional abuse showed the strongest association.

The association between abuse in the health care system in adulthood and childhood abuse became stronger when the women reported more than one kind of abuse. NorAQ measures experiences of actual acts. When women report more than one kind of abuse, we do not know whether it was one act with emotional and sexual aspects, for instance, or if abuse has occurred several times. Dividing abuse into separate categories, such as emotional, physical and sexual, is therefore an artificial construct. For example, sexual assault is often a physical as well as an emotional abuse. Our interpretation of the results is that women who do report an event of sexual assault as sexual and physical and emotional abuse (for example) may have experienced more severe trauma than women who report an abusive event as ‘only’ one kind of abuse.

To allow for an assessment of the risk of having been exposed to prior emotional, physical and/or sexual abuse, women in our cross sectional study had to be clearly identified as having experienced either pure childhood abuse (the exposure) or pure adult abuse in the health care system (the outcome). Therefore, all women who reported both childhood and adult abuse were excluded.

If a majority of non-participants had experiences of adult abuse in health care but not childhood emotional, physical and/or sexual abuse, the association between childhood emotional, physical and/or sexual abuse and adult abuse in the health care system might be exaggerated. One possible explanation for that hypothesis could be that these women were so disappointed with the health care system that they did not bother to answer a questionnaire like ours.

Cases were younger and had a higher educational level than controls. Consequently, there were more students and fewer employed women among cases than among the controls. One can only speculate about the reason for these differences. It is possible that the authority of the health care system earlier was so powerful that some patients found it difficult to question what happens to them. Perhaps it is easier to be critical of a system if you have some sort of authority yourself, such as, for instance, a higher educational level. It is also likely that a person with authority is less prone to accept the traditional patient role.

Adjusted OR revealed no confounding effects, either of age or of education. These two factors are known to be associated with physical and sexual abuse.14

Several studies have documented the association between childhood physical and/or sexual abuse and adult experiences of physical and/or sexual abuse (i.e. revictimisation).15–20 Cloitre et al.16 found that women with a history of childhood physical abuse alone or childhood physical and sexual abuse combined were 3.1 times more likely to have experienced adult sexual assault than women without abusive experiences in childhood. We have not found any study investigating associations between childhood emotional, physical and/or sexual abuse and adult experiences of abuse in the health care system.

What is the clinical implication of our findings? Considering the small number of exposed cases, our results have to be interpreted with caution. Still, our hypotheses were confirmed. It might be useful for the clinician to bear in mind that a patient with strong reactions to routine interventions, or a patient who feels grossly offended, might have been exposed to emotional, physical and/or sexual abuse in the past.

Two thirds of the women who reported adult abuse in the health care system did not report any experiences of emotional, physical and/or sexual childhood abuse. Thus, our findings may indicate two kinds of abuse in the health care system: revictimisation or a first time experience or victimisation, which might need to be handled with a different strategy.

In future studies, it would be valuable to describe the character of those events that patients have perceived as abuse in the health care system, and what those events signified for them.

Another important field of research is to analyse what went wrong in the traumatic events, both according to the patient's experiences and from an ethical and theoretical perspective. Results from studies on revictimisation and first time victimisation may offer new ways to advance empirical and theoretical knowledge about how to prevent perceived experiences of abuse in the health care system.

CONCLUSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. Acknowledgements
  9. Principal investigators
  10. Coordinator
  11. Local investigators
  12. Financial support
  13. References

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 explored.

Acknowledgements

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. Acknowledgements
  9. Principal investigators
  10. Coordinator
  11. Local investigators
  12. Financial support
  13. References

The NorVold Abuse Questionnaire (NorAQ) was developed by members in NorVold, a research network established in 1997 to explore the prevalence of violence against women and its effects on women's health. The NorVold research network was supported by grants from the Nordic Minister Council.

Finland: Erja Halmesmäki, Ulla Pikkarinen.

Iceland: Tora Steingrimsdottir.

Norway: Berit Schei, Hildegunn Stoum-Hinsverk, Kristin Offerdal.

Sweden: Barbro Wijma, Katarina Swahnberg.

The authors would like to thank all the participants and the health care staff who made this study possible.

References

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSION
  8. Acknowledgements
  9. Principal investigators
  10. Coordinator
  11. Local investigators
  12. Financial support
  13. References
  • 1
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Accepted 6 May 2004