Patients' experiences of abuse in health care: a Nordic study on prevalence and associated factors in gynecological patients.

BACKGROUND: In an earlier Swedish study conducted with The NorVold Abuse Questionnaire, we found that one-third of female patients who had experienced adult abuse in health care (AAHC) had a background of childhood emotional, physical and/or sexual abuse (EPSA) ('revictimised'). But since the majority of women with AAHC were 'new victims' without such a background, there might be other factors associated with AAHC. The present study aimed to map prevalence of abuse in health care (AHC), and associated variables among new victims and revictimised patients. METHODS: We carried out a cross-sectional questionnaire study at 5 Nordic gynecological clinics. Associations between AAHC and other variables were tested in a multivariate model in 4 groups of women with adult EPSA, childhood EPSA, childhood and adult EPSA, and no EPSA. RESULTS: The response rate was 77% (n=3,641). The overall prevalence of any lifetime experience of AHC was 13-28%. High educational level, physical complaints, post-traumatic stress symptoms, and sleeping problems were associated with AAHC in women without EPSA (new victims). Poor self-rated health was strongly associated with AAHC in the 3 groups of women with EPSA. CONCLUSION: AHC is commonly reported by gynecological patients in the Nordic countries, but not yet properly explored or understood. The most important factors associated with AAHC were high educational level and poor self-rated health.

Lower urinary tract symptoms after total and subtotal hysterectomy: results of a randomized controlled trial.

The aim of this Danish multicenter trial was to compare the proportion of women with lower urinary tract symptoms after total abdominal hysterectomy (TAH) and subtotal abdominal hysterectomy (SAH) for benign uterine disorders. A total of 319 women were randomized to TAH (n = 158) or SAH (n = 161). Women were followed up for 1 year by strict data collection procedures, including postal questionnaires. Results were analyzed by intention-to-treat analyses. Urinary incontinence was found less often among TAH women than among SAH women. This was due to a larger reduction of the number of women with stress and urinary incontinence in the TAH group. No other differences were found between the two operation methods. The number of women with urinary incontinence and frequency was reduced from study entry for follow-up, while double/triple voiding was increased. Incontinent women had significantly lower quality of life scores than continent women

Genitoanal injury in adult female victims of sexual assault.

OBJECTIVES: To evaluate the presence and extFent of genitoanal injury among sexually assaulted women and to estimate the risk of injury in subgroups according to the type of assault and to the sexually assaulted women's susceptibility to injury. STUDY DESIGN: A case-control study of 249 women exposed to sexual assault. Injury identified by gross visualization. Women with and without injury were compared. Logistic regressions analyses were performed to calculate the risk of injury. RESULTS: Thirty-two percent sustained genitoanal injury. Anal penetration and assaults on women without prior sexual experience were associated with genitoanal injury. CONCLUSIONS: Most women do not have visible genitoanal injuries. The risk of sustaining genitoanal injury during a sexual assault is higher among women without prior sexual intercourse experience and among women exposed to anal penetration. The severity of the assault is a poor predictor of genitoanal injury.

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.

Sexuality after total vs. subtotal hysterectomy.

BACKGROUND: The effect of hysterectomy on sexuality is not fully elucidated and until recently total and subtotal hysterectomies have only been compared in observational studies. AIMS: To compare total abdominal hysterectomy (TAH) to subtotal abdominal hysterectomy (SAH) regarding effects on sexuality. METHODS: In a Danish multicenter trial 319 women were randomized to TAH (n = 158) or SAH (n = 161); 185 women had self-selected TAH (n = 80) or SAH (n = 105) in a simultaneously conducted observational study. Women were followed for 1 year by strict data collection procedures, including postal questionnaires. Results were analyzed by intention to treat (ITT) analyses. RESULTS: No significant differences were observed between TAH and SAH at 1-year follow-up in both the randomized trial and the observational study regarding women's desire for sex, frequency of intercourse, frequency of orgasm, quality of orgasm, localization of orgasm, satisfaction with sexual life, and dyspareunia. None of these sexual variables changed significantly from entry to the 1-year follow-up, apart from dyspareunia, which was significantly (p = 0.009) reduced in both intervention groups. Significant (p < 0.05) predictors for satisfaction with sexual life after hysterectomy were the preoperative satisfaction with sexual life [odds ratio (OR) 32, 95% confidence interval (CI) 10-125], good relationship with partner (OR 50, 95% CI 9-354), physical well-being (OR 0.30, 95% CI 0.09-0.88) and hormone replacement therapy (OR 0.23, 95% CI 0.06-0.78). CONCLUSIONS: Both TAH and SAH significantly reduce dyspareunia without having a negative effect on sexual function. The shift toward SAH seems unwarranted.

Women's experiences of the gynecologic examination: factors associated with discomfort.

BACKGROUND: The aim of this study was to evaluate how women experience the gynecologic examination and to assess possible factors associated with experiencing discomfort during the gynecologic examination. METHODS: Consecutive patients visiting the Department of Obstetrics and Gynecology at Glostrup County Hospital, Denmark, were invited to participate in the study, and received a postal questionnaire that included questions about the index visit, obstetric and gynecologic history and sexual abuse history. The response rate was 80% (n = 798). The degree of discomfort during the gynecologic examination was indicated on a scale from 0 to 10. Experiencing discomfort was defined as a score of 6 or more, based on the 75th percentile. RESULTS: Discomfort during the gynecologic examination was strongly associated with a negative emotional contact with the examiner and young age. Additionally, dissatisfaction with present sexual life, a history of sexual abuse and mental health problems such as depression, anxiety and insomnia were significantly associated with discomfort. CONCLUSION: The emotional contact between patient and examiner seemed to have great importance when focusing on discomfort during the gynecologic examination. Furthermore, we found that discomfort was associated with a number of factors that are seldom known to the gynecologists, such as sexual abuse history, mental health problems and patients' sexual life. Gynecologists need to focus on the emotional contact and to reevaluate issues for communication before the examination.

Adult victims of sexual assault: acute medical response and police reporting among women consulting a center for victims of sexual assault.

BACKGROUND: The medical response to adult sexual assault should comprise: the collection of forensic evidence, the treatment of injuries, and follow-up counselling. In the past, victims of sexual assault reporting directly to the police may not have received this total medical care. The Copenhagen Center for Victims of Sexual Assault at Rigshospitalet, Denmark offers a 24-h service. Medical treatment and psychosocial follow up is offered independent of police reporting. The aim of this study was to assess whether adult sexual assault victims who reported to the police differed from those who did not report to the police. METHODS: Using clinical records, sociodemographics, characteristics of the assault, and type of preventive medical treatment received were obtained for 156 consecutive women consulting the Copenhagen Center (March 1st to December 31st 2000). Comparisons between characteristics of victims who reported to the police or not were determined. RESULTS: Ninety-four (60.2%) of the women reported to the police. Women who sought services within 24 h of the assault, had experienced use of force, were subjected to assault outdoors, and among whom nongenital injuries were observed were more likely to report to the police (p < 0.05). However, in the multivariate model these associations fell below significance, and only the type of perpetrator remained significantly related to police reporting. The adjusted odds ratio for police reporting when the perpetrator was a friend was 0.4 (95% CI 0.17-0.94). There was no statistical difference between the victims who did or did not report to the police to request prophylactic antibiotics or emergency contraception. CONCLUSION: Observed injuries and requests for prophylactic antibiotics or emergency contraception were not influenced by whether the woman did or did not report directly to the police. Hence the need for medical treatment appears to be similar in the two groups, and available specialized care for victims of sexual assault should not be restricted to those who immediately report to the police.

[Sexually transmitted infections and sexual violence against women. Guidelines for examination, prophylactic treatment and follow-up]. / Seksuelt overførte infektioner og seksuel vold mod kvinder. Forslag til undersøgelse, profylaktisk behandling og opfølgning.

Based upon a literature search, but also considering the situation in Denmark, guidelines for examination, prophylactic treatment and follow-up of female victims of sexual assault have been prepared. A pragmatic attitude, looking upon the victim's situation and fear of having acquired a sexually transmitted infection, has been prevailing in order to avoid unnecessary examinations and treatments. The guidelines are directed towards female victims in whom the assault has included vaginal, oral, and/or anal penetration or attempt of penetration. It is concluded that all victims should be screened for and offered prophylactic treatment for chlamydia. Screening for gonorrhea initially and at follow-up is recommended but treatment only if an infection has been established. All victims should be screened for hepatitis B initially and again after three months and vaccination offered if any information indicates that the assailant has an increased risk of hepatitis B. All victims should be screened for HIV initially and again after one and three months. In single cases antiviral HIV prophylaxis must be considered.