Sexual violence (SV) includes all forms of sexual assault, rape, attempted rape, contact and noncontact sexual violence and childhood sexual assault. It refers to unwanted and nonconsenting sexual activity in childhood, adolescence and adulthood. Sexual trauma encompasses both the event and its impact on the individual.
One in three women in Australia in 2002–03 reported experiencing SV over their lifetime and 29% experienced physical and/or SV before the age of 16 years.1
It is also estimated that one in 6 men have a history of SV, predominantly as childhood sexual abuse or SV in early adolescence.2 However, unlike women, there is a low incidence of SV for males in adulthood.
General practitioners will inevitably see patients for the health problems associated with sexual trauma,3,4 many without being aware of the SV, because most survivors do not disclose their experiences to health professionals.1,5–7 Additionally, some GPs may not broach this sensitive subject with their patients.8 It is important that GPs are aware of the long term physical and psychosocial sequelae of SV and the relevant intervention skills required to treat these patients holistically to avoid inadvertent retraumatisation.9
Although this article provides an overview of the evidence, issues and implications of sexual trauma in women, some of the findings are also relevant to male survivors of sexual trauma.
Long term health sequelae of sexual trauma
Over the past 3 decades, most English language research on the long term health sequelae of SV in women has reported on cross-sectional studies of community residents, college students and military personnel in the United States, relying mainly on self reported data. As such, a causal relationship between SV and health problems cannot be confirmed and more research is needed in this area. Researchers have often reported aggregated data for physical and/or SV, rather than SV in isolation, and have often included data on intimate partner violence. Nonetheless, the evidence across a number of studies using large, representative samples suggests that SV in women is associated with long term physical and psychological health problems. Those seeking health services may present with a range of symptoms and medical conditions that diminish their quality of life. These may be comparable to chronic diseases such as diabetes and heart disease,10 impair daily functioning and disrupt the strength and quality of social relationships.7,11
The adult health sequelae of childhood sexual abuse alone may present as psychosomatic symptoms, which may confound both survivors and health professionals, resulting in underdetection, misdiagnosis and ineffective treatment.12 Sexual trauma is associated with a range of physical health problems,13,14 persistent urogynaecological and obstetric problems,6,15,16 mental health problems10,12,17–21 and health risk behaviours,22 as well as avoidance of preventive health examinations.13,23,24 Table 1 lists the long term health problems associated with sexual trauma in women.
Table 1. Long term health problems associated with a history of sexual trauma in women
Physical health problems13,14
- Irritable bowel syndrome
- Abdominal pain
- Vaginal pain
- Breast pain
- Headaches
- Musculoskeletal pain
|
Urogynaecological and obstetric problems6,15,16
- Pelvic pain and pelvic inflammatory disease
- Dysmenorrhoea
- Menorrhagia
- Sexual dysfunction
- Nonmenstrual vaginal bleeding or discharge
- Rectal bleeding
- Bladder infection
- Dysuria
|
Mental health problems10,12,17–21
- Anxiety
- Depressive symptoms
- Major depressive episodes
- Post-traumatic stress disorder
|
Health risk behaviours associated with childhood sexual abuse22
- Smoking
- Alcohol use
- Drug use
- Obesity and inactivity
- Early intercourse and multiple partners
|
Avoidance of preventive healthcare13,23,24
- Pap tests
- Breast examinations
|
Considerations for GPs
Women with a lifetime history of SV use health services more than nonvictimised women,3,15 but are often reluctant to disclose their experiences of SV to health professionals, including GPs.1,5–7 As a result, these women may not receive timely and appropriate intervention to detect, treat and/or prevent health problems.
In particular, women with a lifetime history of sexual trauma tend to avoid preventive healthcare such as Pap smears and early antenatal care.13,23,24 This is concerning as women with a lifetime history of SV, including childhood sexual abuse, rape and sexual intimate partner violence, have an increased risk for sexually transmissible infections, cervical dysplasia and an increased prevalence of invasive cervical cancer.25
The evaluation of common gynaecological problems also places these women at risk for retraumatisation (eg. triggered memories or dissociation) during gynaecological and breast examinations.6,26,27 Retraumatisation may also occur in the context of perinatal care of women and/or their babies.28
The ongoing impact of sexual trauma on mental health is an important consideration for GPs. Depression, anxiety, stress and post-traumatic stress disorder (PTSD) may also increase the risk for alcohol abuse,29 binge drinking30,31 and substance abuse.20,31 Moreover, PTSD is a risk factor for revictimisation,20 as is childhood sexual abuse,1,32,33 and substance abuse and/or heavy alcohol consumption in specific populations, including female adolescents and college students.34–37 Compared to the general population, childhood sexual abuse victim-survivors also have a greater risk for suicide and accidental fatal drug overdose.38
What can GPs do?
General practitioners need to be aware of the long term health sequelae of SV. However, to date, undergraduate and graduate entry medical programs in Australia have focused mainly on recent sexual assault and/or sexual abuse.39 Both the health impact and the community costs of sexual trauma in women could potentially be reduced by early identification, allowing for timely and appropriate intervention to treat and prevent health problems.40 Importantly, the overwhelming majority of women with a past history of SV do not tell their doctors what happened to them unless they are specifically asked. Instead, they present over time with a range of physical and/or psychological symptoms, as outlined in Table 1. Therefore, GPs who connect a woman's symptoms to historical SV are better placed to provide holistic treatment to the woman.7
The Royal Australian College of General Practitioners Guidelines for preventive activities in general practice41 (section on identification of psychosocial problems), and consensus guidelines for primary care physicians managing the family unit in the presence of intimate partner violence,42 advocate personal and professional attributes similar to those required to care for women with historical SV.
In terms of when to ask about SV, questioning is indicated if the patient presents with multiple or chronic health problems, expresses feelings of helplessness, shame or guilt, or avoids or has difficulty with medical examinations or procedures.43 Before asking about a history of SV however, GPs should establish rapport and trust with their patient; monitor their own personal and professional attitudes and beliefs; be nonjudgemental and open to discussing sexual trauma; be prepared to acknowledge and validate the disclosure; make the patient feel safe and protected; ensure confidentiality; provide sufficient consultation time for discussion; and be able to refer the patient to culturally appropriate, affordable treatment, and psychological or specialist services when needed.7,42–44 Staff training, confidentiality of patient records and clinic protocols for monitoring patient safety are also important.
Summary
Women with a lifetime history of SV can be opportunistically identified by GPs, as they are likely to present more frequently than other patients with multiple or chronic health problems, have poor health status or display health risk behaviours. Many of these women will be reluctant to disclose their experiences unless they already feel comfortable with their doctor.
As one in three women are affected by a history of SV, there is a pressing need to improve GP knowledge of the long term physical, psychological, behavioural and social sequelae in victim-survivors in order to build practitioners' capacity to sensitively, safely and effectively meet the needs of these women over their lifetime.
Evidence for the health impacts of a lifetime history of SV and skills in the sensitive and appropriate management of these issues should be included in both undergraduate and postgraduate medical curricula.
Guidelines for preventive activities in general practice should cover the identification of a history of SV and the appropriate interventions and counselling techniques and referral options.
Conflict of interest: none declared.