The self-perceived impact of sexual abuse on daily life and general health - an issue to consider in dental care

Background/Aim: To analyse, from the perspective of adults with a history of sexual abuse, the impact of the experience on their general health and well-being. Material and Methods: The

2][13][14][15][16][17] This link between the experience of abuse and deterioration in health is reported to be related to a disturbance in the body's management of stress hormones, leading to dysfunction of the systems which regulate immune and inflammatory responses. 18,19This relationship is not only strong, but also gradually incremental, that is, repeated molestation is associated with further health impairment. 11,13,15,20WHO has therefore declared that sexual abuse warrants priority in-depth investigation. 4,12The Agenda for Sustainable Development 2030 also includes several goals intended to eliminate sexual violence. 21ysical injuries detected after sexual violence are reported to range from 59% to 80%: thus, in 20%-41% of cases, no visible signs of injuries are recorded. 22,23Of particular relevance for dental personnel is physical injury related to oral abuse.Studies by Riggs et al., 22 Sugar et al. 23 and Karanfil et al. 24 did not report any oral injuries at all.On the other hand, Brew-Graves & Morgan 25 reported few oral injuries (19%), presenting as abrasion, bruising and petechiae: these were classified as 'minor and did not require treatment'.
The authors observed that little specific attention was paid to the mouth area. 25nder-based violence, in particular men's violence towards women, has a huge financial cost.The European Institute for Gender Equality estimated the annual cost of violence in close relationships and gender-related violence in Europe, Australia, Canada and United States.Based on extrapolation of population size and on the 2012 cost level, 26 the estimated costs in Sweden were ~45.5 billion Swedish crowns (SEK) (€ 1 = 11.88SEK, $ 1 = 10.93 SEK, Aug 2023) per year.Most of the cost (59%) was related to an estimated loss of quality of life. 26Thus, as well as physical injuries, it is important to consider other, more insidious aspects of the effects of violence such as personal suffering, fear, pain, premature death, deterioration in quality of life, loss of trust, insecurity and poor interpersonal relationships.These indirect effects are often excluded from calculations. 27ny studies of the correlation between sexual abuse and health are based on analysis of quantitative data.These data lack to some extent the context of the experience.Studies based on qualitative data are suited to analyses of, for example, perceptions, preferences, attitudes and experiences, which can contribute to a more extended knowledge 28 and are appropriate for exploring a particular phenomenon in context. 29,30is interview study is based on interviews with adult survivors of sexual abuse.All had experienced how undergoing dental treatment triggered reminders of sexual abuse, 31 that the dental appointment was a volatile base requiring predictability and a levelling of power to be acceptable to attend 32 and that the sexual abuse experience had negative consequences on oral health. 17The aim of this study was to analyse, from the perspective of adults with a history of sexual abuse, the impact of the experience on their general health and well-being.

| MATERIAL S AND ME THODS
The research team included EW, an endodontist, and author of several previous scientific publications with a qualitative approach.She Eight informants contacted the first author (EW) after listening to a podcast (comprising a conversation between the dentist (interviewer to be) and a psychologist in private practice as to how or if an experience of sexual abuse might have an impact, not only on dental attendance but also on oral and general health).
Alternatively, informants, after reading written information, contacted the psychologist's website.Four informants were recruited through contact with a retired midwife who had specialized in treating drug-addicted, sexually abused women.One informant contacted EW at an official event.Another 5 potential informants were contacted via their therapist or via a contact centre for the sexually abused.Three declined to participate and two did not respond, leaving 13 informants in all.
An initial individual meeting was scheduled (two on Skype), at which each of the 13 informants was provided with verbal and written information.On this occasion the informant was encouraged to ask any question about the study and the interviewer was given the opportunity to confirm that the inclusion criteria were fulfilled, and that sufficient depth could be achieved during the interview.The contact details of each informant's therapist were noted.If the informant did not currently have a therapist, measures were taken to arrange this ahead of the scheduled interview.EW also contacted the therapist in advance of the interview.The offer of two therapy sessions, to be financed by the research grant, was accepted by 4 informants.Another 6 informants scheduled a session with their current therapist, but without burdening the research grant.
EW conducted all the audio-taped interviews in a non-clinical environment, either at the Faculty of Odontology, if convenient for both parties, or at a location chosen by the informant.All informants signed an informed consent form.The interviews were conducted between April 2017 and May 2018.The duration varied from 41 to 93 minutes.The interview topics were: • Please describe, in as much detail as possible, one or more dental appointments at which you were reminded of sexual abuse you have experienced • How do you perceive the effect of sexual abuse on your oral health?
• How do you perceive the effect of sexual abuse on your general health and quality of life?
The interview technique encourages informants to present their specific stories and experiences in their own words and from their own perspectives.Follow-up questions were asked in order to enhance reflection and development.
Qualitative content analysis with an inductive approach was based on principles formulated by Graneheim & Lundman. 33The interviews were transcribed verbatim by an authorized medical secretary.The transcripts were scrutinized and supplemented by EW.
• The transcripts were read through several times to get a sense of the whole • The text was cut at the point at which a change in meaning occurred: meaning units were identified • The meaning units were condensed into succinct formulations by excluding unnecessary words: condensed meaning units were achieved.
The informants´ experience of how the dental setting triggered reminders of episodes of sexual abuse has been reported previously.It was concluded that dental appointments could cause a psychologically stressful reaction, a trauma-related reminder of the abuse.Some of the reactions are easily recognizable for dental staff, suggest that the dental setting be a suitable venue for disclosure of abuse, if questions were to be asked about experience of violence. 31Also reported previously were the informants´ perceptions of the attitudes of dental clinic staff and how they were received in the dental setting. 32With reference to the informants' perceptions of the impact of the sexual abuse experience on their oral health, this also has been reported previously.
It was concluded that maintaining oral health was challenging, not only emotionally but also because of barriers to daily self-care and regular dental attendance which the informants found difficult to surmount. 17e unit of analysis for this study was the perception of the impact of sexual abuse on general health and well-being.The meaning units covering this topic were identified and selected for analysis by EW.In one of the interviews (no.4) the topic of this study was not addressed, an error on the part of the interviewer.The analysis is therefore based on 12 interviews (Figure 1).Each selected condensed meaning unit was analysed, focusing emotions and meanings with links to expressions in the narrative.A code was assigned, reflecting the central meaning of the unit (Table 1).When clustering the codes (EW and GP), varying patterns of the informants' experiences emerged.The interviews were re-read to enable a recontextualization of the identified patterns.This emergent pattern, including variations, was classified into categories and subcategories (EW and GP) to communicate the descriptive (manifest) level of the content.A theme covering the interpretative (latent) level of the content was also identified.The authors reached consensus about the identified pattern via questions, comparisons, and discussion.Quotations from the interviews, which were used as illustrations, were translated into English.The informants were not invited to comment on the transcriptions or provide feedback on the findings.
One informant requested a copy of the transcript of her interview, which was sent to her.She did not, however, request any alteration to the text.The Standard for Reporting Qualitative Research (SRQR) checklist was completed.
The study was conducted in accordance with the 1964 Declaration of Helsinki II (version 2002 revision, www.wma.net).The authorized secretary, who transcribed the interviews, signed a confidentiality form.A requirement from the ethical review board was that all participating informants should have, or be offered, contact with a psychologist or corresponding therapist.This was arranged and the Regional Ethical Review Board, City University, City, Country approved the study, Dnr 2014/780.

| RE SULTS
Ten of the informants were women and two were men.They were aged between 19 and 56 and were single, married or cohabiting, with or without children.They were employees or working in private enterprise, students or early retirees.All informants had to some extent processed the sexual abuse they had been experienced.Some, but not all, described mental health problems such as anorexia, bulimia, self-injury or other challenging issues such as drug abuse, prostitution and imprisonment.All reported dental fear, most often severe.
The informants' experiences of sexual abuse ranged from sexual harassment, single episodes of abuse, or repeated abuse over several years, with or without penetration, to several months of captivity, being subjected to rape and sold for sexual services.Ten informants had been exposed to childhood sexual abuse, two only as adults and eight as both children and adults.The informants reported abuse by one or more perpetrators.Most of the perpetrators were acquainted with the victims.There were female as well as male perpetrators.The analysis identified an overall theme covering the latent content, labelling the impact of sexual abuse on general health and wellbeing to be Sexual abuse experience-limiting long-term consequences, always present in body and mind (Table 2).Sexual abuse, in the form of isolated or repeated episodes, is perceived, explicitly or implicitly, as having a lifelong limiting impact on life and health, both mental and physical.Thus, both life conditions and health can be regarded as being filtered through the abuse experience.The first category covering the manifest content was: 'A lost foothold', which could be described as related to different negative consequences for health: emotional (first subcategory) and physical (second subcategory), all of which permeate daily life long after the abuse has stopped.

| Emotional repercussions
This subcategory contains exclusively negative emotions, notably a lack of security and an apparent lack of self-esteem.( The abuse experience has led to mistrust, especially towards men, due to the harassment in a relationship.The informants described how as adults they lacked enough energy to build a relationship or make a conscious choice to live alone.

Yes ……… In fact, that is what one … in fact one has
felt that one hasn't been able to trust them.And just the fact that there has been maltreatment in these relationships…… The informants also had obvious difficulties in determining their own limits, of accepting that good things can happen or, on the other hand, of feeling that they had no boundaries, and were not able to protect themselves.This subcategory also includes feelings of shame and guilt about being abused, as well as such insecurity that they felt unable to disclose the abuse experience during consultation with a therapist.

| Physical health repercussions
The explicit expression of the abuse experience emerged as neglect of self-care and an unhealthy lifestyle with a negative impact, not only on health, but also with a huge impact on the whole of life.
Informants also described how a sexually suggestive look and comments from the perpetrator about their body were perceived as threats and caused a physical response.
Just the threat of him being able to do something to you.( The physical consequences were described as an enduring suppression of the informant's own physical needs.This could also manifest itself as making things worse for oneself, exposure to danger on repeated occasions or even not allowing oneself to rest.
So that both the fact that I associate the bed with the abuse, but also that in a bed you rest and relax and recover.I haven't been able to allow myself to do that either. ( Muscle tension in different parts of the body was described as a consequence of protracted duration of the abuse.
It is probably more this pain, things like that, I believe.

That the tension in my body and… (…) Especially for
the tension like …. it is in fact….Yes, shoulders, and to …. and then, my head is in fact absolutely tensed up.

You get like tension headache and…. And if you don't breathe properly that can also give you a headache.
Ehh …, so much of this has led to one not feeling well … in your body.

(Interview 6)
Apart from the emotional and physical sequelae of sexual abuse, financial stress was also a common reason for not seeking dental care and thus a barrier to maintaining or attaining oral health.Some informants stated that their oral health had also been directly affected The feeling of being trapped which the informants experienced in the dental chair meant that they ignored recall notices for dental check ups, thus their oral health deteriorated further.

| THE S I G NIFI C AN CE OF D IS TAN CE TO TR AU MA
The second category covering the manifest content was 'The significance of distance to trauma'.The category covers behavioural consequences (first subcategory) with shielding from the traumatic experience and memories, but also to other human beings, physical and emotional in different ways.The category also covers the results of processing the trauma (second subcategory), that is, a better balance and quality of life, facing the consequences and improving well-being.

| Keeping a distance and tending to escape
In order to maintain emotional distance from the trauma, the informants described adopting what might be labelled extreme behaviour.
This could mean unhealthy food, intense focus on herbal remedies and health food products or an eating disorder, in order to achieve the desired result: relieving anxiety.
Drug-induced escape was mentioned in the context of others´ inability to confront and 'see' the informant and also their own wish to neglect their well-being.
I was so afraid that it (the abuse experience) was going to come out.And the heroin had in fact helped a great deal with … That it is in fact the way it is.
[…] The anxiety disappears; your emotions become blunted in that way.
(Interview 2) The informants described an early start to addiction during childhood, in parallel with the early sexual assaults and even multiple use of different strategies to numb their discomfort.(Interview 5) Self-harm of different kinds was described, like not caring at all that something bad might happen or deliberate exposure to danger.
More direct self-harm behaviour was also mentioned, with respect to having sex, cutting oneself and attempts to commit suicide.
The sexual abuse experience was also described as having caused repeated destructive behaviour, repeated relationships with abusive men and also a tendency for the next generation to copy the behaviour.Another way in which the tendency to escape manifested itself was through dissociation, including in everyday life as well as during dental appointments.
In everyday situations, the informants described having a persistent urge to sit close to an exit or to look for escape routes.They also avoided undergoing dental treatment for fear being reminded of the extreme vulnerability that the abuse had entailed.In the dental setting, this could trigger an aggressive outburst, as had happened before.With reference to the dental setting and the urge to escape, the informants stated that during the abuse, they wanted to run away, but were unable to do so.However, with a dental appointment there were some options; you could avoid making an appointment, you could repeatedly leave late cancellations or fail to keep a scheduled appointment, or even leave during treatment when traumatic memories were triggered.
The difficulties associated with close relationships and bodily contact could be addressed by training with a physiotherapist.There were also barriers to having sexual relations with a partner and repeated (surprising and even more unsuccessful) attempts to reject a partner who against all odds was staying.
Informants expressed great sadness at a decision made on the bases of an incorrect initial assumption, taking the initiative to leave one's children in the care of other people.

But just the fact of making a decision from …, from the wrong perspective has probably been that …, the greatest grief and the biggest part… of it. […] … and I felt that
when I couldn't look after myself, then I couldn't care for them either.So it was ……out of love.
(Interview 13) The informants also described many difficulties in daily life, implying that the subject avoided dealing with processing the trauma.The strong need to have control and to search for a balance in life could manifest itself as compulsive behaviour.I have in fact had that (jaw pain) such a lot.Ehh……… And it…., it is also in fact…, one doesn't understand that before you experience how it feels otherwise, or you find out that it shouldn't be like that.….So when it started to ease, I just said "Oh, is this how your jaws are meant to feel?" Yes …… And I am more aware today when I start to feel that I am perhaps not expressing my real truth or don't set boundaries …., and then I tense up immediately. ( The informants also reported that following disclosure and processing of the abuse experience, other conditions such as obesity and diabetes had subsided or abated.( With reference to maintaining sexual health, making an appointment with a gynaecologist could be a tremendous challenge, but could also be overcome after psychotherapy.However, with respect to dental appointments, barriers persisted.

It has taken a long time ………. to come as far as I have. And it …., it has needed many hours of therapy. Ehh… I have in fact had to have ……… therapy in order even to be able to get into the chair for gynaecological examination. […] Now
it works …, much better than going to the dentist. ( Before the traumatic abuse experience had been processed, difficulties also arose with respect to close bodily contact.After several appointments with a physiotherapist, the informant was able to endure bodily contact without discomfort and able to breathe comfortably.
Although having anyone touch their head and face was still repulsive, they reported some progress.
Earlier I would hardly allow anyone even to touch me.I mean, without making a big scene.So that it … yes …… It isn't really like that now.No……, now I can manage to hug at least.

(Interview 12)
There was grief over previously lost friendships but also reassurance that change is possible.
Have sort of lost all my mates and …… Ehh …, it is only now that I am starting to rebuild my life.
(Interview 8) Also clear was a belated realization that, at least in parts of the world, there is some good, after all.
The informants longed for the positive effect of processing past devastating experiences, but there was also awareness of the bodily memories to be dealt with and that the process takes time.
I want it to go more quickly.Ehh …… But my body decides for itself in fact. ( Thus, the informants acknowledged that progress could not be hurried, but they perceived the potential to (re)gain a better quality of life following therapy or processing the trauma experience in other ways.

| DISCUSS ION
The informants' own perspectives disclosed experiences affecting the individual in different ways but also the individual's relationship to the social environment.It was clear that experience of sexual abuse was perceived to have insidious long-term effects and an allembracing impact on emotional and physical health, private life and social activities.Thus, the legacy of sexual abuse pervades all aspects of the survivors' everyday life.However, the interviews also revealed that processing the trauma offered a pathway to eventual relief.This reinforces the opportunity of dental professionals to contribute to facilitating disclosure and to offer trauma-informed care that facilitates for sexually abused persons to receive dental care. 32alth and social consequences of the abuse experience were reported and can be discussed from the perspective that sexual violence is one of the deepest violations of an individual's human rights, 34 partly attributable to a putative difference between bodily and sexual integrity, where the latter is considered to be the most intimate. 35Rape in particular, is therefore often perceived as more humiliating than other forms of physical violence.This might also, in part, explain why an allostatic overload, 36 caused by toxic stress, induced by sexual abuse, is reported to be one mechanism underlying negative health effects, as several body systems such as immune response and hormonal activity are affected. 18,19Toxic stress thus has a detrimental effect on multiple brain structures and functions, resulting in impaired health and well-being, especially if the trauma was experienced during childhood. 37e strategy of keeping ones distance as an escape behaviour can be addressed from different perspectives.Daily living events, usually considered quite normal, were avoided and perceived as somewhat threatening, as previously reported. 38The informants in this study also described emotional escape and attempts to relive anxiety by using, for instance, drugs and unhealthy food.This is in accordance with previous reports. 11Such behaviour could be interpreted in terms of the concept 'protecting armor in daily life', developed by Torp Stensvehagen et al. 38 referring to the strategy of shutting out stressful thoughts and locking in stressful memories and emotions. 38e concept of escape is also relevant to the dental perspective and is reflected in the reported tendency to avoid dental appointments 32 followed by difficulty in maintaining good oral hygiene.The sequelae are poor oral health and difficulty in eating. 17Poor oral health is reported to have a negative impact on quality of life and thus on well-being. 39As mentioned above, both eating disorders and drug abuse are reported to be correlated with poor oral health 40,41 and thus, well-being.These conditions should be considered in relation to dental treatment planning.Failure to take a thorough dental history and not seeking to support sexually abused individuals with dental fear and poor oral heath, might also be regarded as a breach of the requirements of The Swedish Dental Care Act. 42This law stipulates that the goal of dental care is to ensure good dental health and dental care, on equal terms, for the entire population.Dental care must also satisfy the patient's need for security when undergoing care and treatment. 42For adults with a history of sexual abuse, this requirement is not being met.
Dental fear [43][44][45] and poor oral health 46 are well documented in people with a history of sexual abuse 46 hence their dental treatment can be not only more complex but also more time-consuming.This raises the issue of health economics with regards to this patient group.Fees for dental treatment are charged for items of service rather than for interpersonal consultations between patient and dentist. 47For patients with dental fear and a history of sexual abuse, this approach to delivery of dental care is highly questionable.In order to provide a dental experience which is acceptable to the patient, it is essential that the dentist should address the person presenting with the disease and not focus solely on the diseased body part (oral cavity). 32,48,49intaining distance is also considered relevant in daily life after processing the trauma, in an effort to leave difficulties behind, at least partly.This is in accordance with previous research 38 which among women noted three stages of development after an experience of sexual abuse: (1) avoiding and escaping-coping, (2)   accepting and disclosing-starting a process of recovery, (3) reconciling and repossessing-living with the experience.The key factor facilitating progress from Step 1 to Step 2 and subsequently to Step 3, was disclosure of the sexual abuse experience. 38In accordance with previous reports, 34,50 this further reinforces the need for disclosure in order to minimize negative consequences and to support recovery.Thus, not only general health professionals but also dental professionals should question patients about exposure to violence.
This provides an opportunity for appropriate referral for trauma processing.It is reported that neither patients seeking medical 51 nor dental care 52 generally object to questions about exposure to violence.Health care providers are also reported to be more prone to ask questions about an experience of violence if they have received education on the subject. 49The WHO recommends that such education should include basic knowledge of the impact of an experience of violence and also how and when to ask questions. 50 is important to note that it is not enough to ask the patient about experience of violence, a good outcome also requires a clear strategy for following up and referring the victim of violence for adequate support and treatment. 53 access the informants´ subjective perspective of the phenomenon being investigated in a systematic way, qualitative content analysis 33 with an inductive approach was chosen.This approach to analysing qualitative data is reported to provide valuable insights into an individual's experiences. 54The informants´ varied experiences of sexual abuse and molestation, social background and life experience favoured broad access to information.Although the number of informants ( 12) might be considered limited, this does not necessarily invalidate the findings. 55Nor does the size of the selection group determine the transferability of the results: it is, however, essential that the informants have experienced the phenomenon being investigated and can give detailed descriptions. 56Such was the case in the present study: it was considered that and saturation was achieved.Indisputably, the informants' narratives were filtered through experiential lenses developed over time, and as a consequence of such interventions as psychological and sometimes other therapy.However, rather than presenting definitive answers, the results further support earlier research, that experience of sexual abuse should not be considered as an isolated event: it permeates the survivors' entire existence. 6,57xual abuse cannot be understood in isolation, but as a traumatic experience with pervasive, insidious long-term implications for the daily life of the people exposed.In this context the dental team has a potentially important role in facilitating disclosure of abuse, because sooner or later, almost every person visits the dentist.After disclosure and processing of the trauma, the negative effects can be alleviated.

AUTH O R CO NTR I B UTI O N S
EW conceived the study and design, collected the material, contributed to analysis, writing, editing, and critical review; GP contributed to analysis, writing, editing and critical review.

ACK N OWLED G EM ENTS
All the participating informants are gratefully acknowledged for their valuable contribution.The study was supported by grants the following organizations: Faculty of Odontology and Centre for is involved in undergraduate and postgraduate education on the topics of men's violence against women and violence in close relationships, with associated external engagements.GP is a psychologist with extensive research experience in child sexual abuse and experience in research based on qualitative data.The following absolute inclusion criteria were applied for strategic selection of informants: A Has experienced sexual abuse as a child or adult B Is or has been receiving psychological treatment for the sexual abuse experience C >18 years.

16009657, 0 ,
Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/edt.12890by Karlstad University, Wiley Online Library on [03/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License It's there within me, even though it is in fact ……… Yes, it is in fact45 years since I was subjected to it.[…] It is not the sort of life you would wish on anyone else.(Interview 9) 16009657, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/edt.12890by Karlstad University, Wiley Online Library on [03/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License F I G U R E 1 Flow chart of informant recruitment process.
was in fact nothing.I was just a wet patch on the floor.… I had no … self-worth… I didn't love myself and I didn't enjoy life and I just wanted to die.Ehh ………… I spent a lot of time in therapy and was given different pills … for depression and God knows what else.And nothing worked.(Interview 7) The low self-esteem resulted in a general lack of trust, making it impossible to trust other people.It also had the effect of diminishing one's own sense of worth in different situations.I can in fact see it, how … how stagnated and how small I have made myself through all these years.
all my life……………….Partly this feeling of being so totally alienated.So I have really tried to belong all the time, and this has also meant that I have like renounced myself.Yes, I have opened my boundaries completely.Anything just to belong.(Interview 13)

I
have used food, I have used sex, I have used shopping, I have used… In fact I'm addicted to bloody everything.To deaden, to deaden, have a little …, a little….Perhaps a little moment of happiness.

16009657, 0 , 5 . 2 |
Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/edt.12890by Karlstad University, Wiley Online Library on [03/11/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Processing the trauma experience -a struggle towards balance This subcategory revealed the positive effect achievable by disclosure of the sexual abuse and processing the traumatic experience.The informants described experiencing relief from physical ailments, such as muscle tension and pain.

I
feel happy …. *laughs* … that I have made this journey …., and I have lost 75 kg in weight.I have taken the weight of the whole of me off my shoulders.And I'm free of diabetes.

limiting long-term consequences, always present in body and mind The lost foothold The significance of distance to trauma
Qualitative content analysis process used to analyse interviews and extract results.