The respiratory tract

November 2012

Research

Women survivors of child abuse

Don’t ask, don’t tell

Volume 41, No.11, November 2012 Pages 903-906

Adeline Lee

Jan Coles

Stuart J Lee

Jayashri Kulkarni

Background

Rates of disclosure of child abuse by women survivors are low, and general practitioners seldom ask women about such history. This study explored the experiences of women survivors: child abuse disclosure, GP service use and thoughts on being asked about their abuse experiences.

Methods

A cross-sectional study containing quantitative and qualitative questions was conducted with 108 women child abuse survivors.

Results

Only 5% of the women disclosed their child abuse to their GP and 19% were asked about their child abuse history. More than half of the women (58%) asked reported feeling hopeful or relieved and none reported feeling offended.

Discussion

Rates of child abuse inquiry by GPs and disclosures by women survivors remain low. With the majority of women survivors reporting feeling relieved and none offended when asked about their child abuse experiences, GPs should consider asking women who present to their practice about such experiences: This may facilitate early intervention.

Experiences of child abuse (CA) have been associated with poorer general health, gastrointestinal and gynaecological issues,1–3 an increased risk of depression, post-traumatic stress and anxiety.3–6 Women survivors of CA have higher levels of perceived need for treatment,7 median annual healthcare cost,8 medical doctor visits9 and other professional visits.10

The healthcare costs associated with CA victims in Australia were estimated to be between $91 and $1399.7 million and documented to be the highest for those aged 25–64 years.11 Low rates and often delayed disclosure by survivors of child sexual abuse12,13 further contributes to delays in help-seeking by victims.

A recent study looking at screening for CA in primary care indicated less than one-third of general practitioners screen patients for CA experiences and 25% of GPs rarely or never screen female patients. Even when most GPs believe that screening for CA is helpful and within their role, many cited barriers such as lack of time and concerns about re-traumatising patients.14

While there is a paucity of research exploring women's thoughts on being asked about their CA experience by GPs, patients surveyed from those seeking assistance for substance abuse thought it appropriate to be asked about their CA experience.15 Similarly, research has shown that for most women survivors, talking about their experience as part of participation in research decreased intrusive thoughts16 and provided an opportunity to share their adverse experience.17

Given the increase in health service use and doctor visits by women CA survivors, opportunity exists for GPs to identify survivors who present to their practice and facilitate early intervention by improving case identification.

This study explored a sample of Australian women survivors of CA and describes whether women survivors disclosed their CA, if they disclosed it to GPs, whether women were asked by GPs about their CA experience and their thoughts on being asked about CA experiences by GPs.

Methods

Participants

One-hundred and eight women with CA experience/(s) before the age of 18 years participated in this cross-sectional study containing quantitative and qualitative questions. Participants were recruited via fliers placed at community health centres, hospitals and universities between January 2010 and April 2012.

Procedures

Interested participants contacted the first author (AL) and those who reported child abuse experience before the age of 18 years were provided an explanatory statement. Study completion consisted of either face-to-face interviews or telephone and mail participation to accommodate women who could not travel or felt uncomfortable with face-to-face meetings. All interviews were conducted by the first author (AL). Completion of the study questionnaire implied consent.

Participants were provided with 24-hour crisis telephone helplines and further information for psychological support if interested. Participants who travelled to the face-to-face meetings were compensated $20.

Measures

The key study questions collected:

  • demographic information
  • exposure to CA investigated using the Comprehensive Child Maltreatment Scale for Adults (CCMS-A). The CCMS-A is a self-report instrument, which requires participants to report CA experiences retrospectively. It contains five subscales: sexual abuse, physical abuse, psychological maltreatment, neglect and witnessing family violence, and a total score. It has adequate psychometric properties with internal consistency shown to be a=0.93 for the total score and a=0.66 to 0.88 for the subscales. Test-retest reliability was found to be r=0.75 and moderate to strong correlations with the Child Abuse and Trauma Scale.18 Participants reporting their caregivers at least 'occasionally' engaged in the behaviour listed within the subscales are classified as having experienced the corresponding type of abuse19
  • information on disclosure of CA either to official authorities or 'other' was also collected. Participants provided a free response if they selected 'other'
  • information on general and emotional health services accessed from GPs including age of first access by themselves to explore the opportunity for a GP to ask about CA history and frequency of visits in the past year
  • opinions on being asked about CA by GPs. Women were asked if their GPs ever inquired about their CA experience and how they felt about being asked about CA. If women were never asked about their CA, a hypothetical question asked about how they would have felt if they were asked. Participants could select 'offended', 'indifferent', 'hopeful', 'worried', 'relieved' or 'other' to provide a free response.

Statistical analyses

Data analyses were conducted utilising IBM SPSS Statistics version 20.20 Descriptive analyses such as percentages and means were utilised to demonstrate cumulative responses. Participants provided free responses if they selected 'other' as an answer to questions on CA disclosure or opinions on being asked about CA by GPs. These responses were then thematically coded.

The study procedure was approved by Alfred (304/09), Monash University (CF09/2776 – 2009001597) and Latrobe Regional Hospital (2010–04) human research ethics committees.

Results

Participant characteristics

One-hundred and eight women who reported CA experiences with a mean age of 41 years participated in this study. Table 1 summarises participants' demographics and CCMS-A scores.

Table 1. Participants' characteristics
 Frequency%
Marital status (N=108)
Married/defacto 39 36.1
Divorced/separated/widowed 23 21.3
Single/never married 46 42.6
Living situation (N=108)
Alone/with unrelated others 39 36.1
Spouse/partner no children 31 28.7
Spouse/partner with children 15 13.9
Sole parent with children 8 7.4
Living with parents/other 15 13.9
Education (N=108)
Part of high school 10 9.3
High school completed 8 7.4
Part of trade/TAFE certificate 4 3.7
Trade/TAFE certificate completed 11 10.2
University partially completed 27 25.0
University degree completed 48 44.4
Employment (N=108)
Full-time 24 22.2
Part-time 30 27.8
Student 21 19.4
Self-employed/home duties 11 10.2
Disability/sickness benefits 15 13.9
Aged pension/unemployed 7 6.5
Income (N=107)
Less than $12 000 14 13.1
$12 001 to $40 000 42 39.3
$40 001 to $60 000 19 17.8
$60 001 to $80 000 9 8.4
$80 001+ 23 21.5
CCMS-A (N=108) Mean SD Frequency endorsing abuse %
Emotional child abuse 14.02 7.59 106 98.1
Physical child abuse 5.91 5.57 98 90.7
Witnessing family violence 4.64 2.46 102 94.4
Child neglect 5.39 6.04 84 77.8
Child sexual abuse 12.16 19.34 68 64.8
Total score 42.02 29.34

Abuse disclosure

Of 105 women who provided a valid response, 62 (59.8%) self-disclosed or had their abuse reported including 18 women (16.7%) who had their abuse experiences reported to authorities such as police or child protection agencies. Of the 18 women, four made direct reports to the authorities, while one disclosed abuse to a family member who took her to the authorities. Fifty-seven women (52.8%) disclosed their abuse to others such as relatives, friends, a priest, teachers and health practitioners such as nurses, psychiatrists, psychologists and counsellors; five disclosed to GPs.

Emotional and general health service accessed from GPs

Women sampled accessed GPs for both emotional and general health concerns (Table 2).

Table 2. Emotional and general health services accessed from GPs (N=108)
 Frequency of access (%)Mean age first Accessed (SD)Mean visits in past year (SD)
Emotional health 67   (62) 27.0        (11.4) 4.7 (6.0)
General health 104         (97.2) 13.4        (8.3) 6.7 (7.5)

Thoughts on being asked about abuse experience by GPs

Of the 104 women who sought assistance from GPs, only 20 (19.2%) reported being asked whether they had experienced CA. Response of how women felt when asked are presented in Table 3. One woman could not recall. None reported being offended, with the majority (57.9%) feeling 'hopeful' or 'relieved'. Qualitative responses from six women who answered 'other' were: 'validated', 'understood', 'ashamed', 'embarrassed', 'uncomfortable', 'sad'. Eighty-four women who had seen a GP but were not asked about their CA experience were asked a hypothetical question about how they would have felt if they were asked (Table 3). Five did not provide a valid response. Again, the majority (44.1%) reported that they would have felt 'hopeful' or 'relieved'. Qualitative responses of those who reported 'other' ranged from 'grateful', 'pleased', 'unsure', 'uncomfortable', 'stressed but will still tell what happened', 'surprised as GP often only deal with the immediate presenting physical issues' and 'shocked because wouldn't expect GP to ask but I wish maybe they did'.

Table 3. Participants' thoughts on being asked about child abuse experience by GPs
 Actually asked (N=19)Hypothetical (had GP asked) (N=79)
Frequency (%) Frequency (%)
Offended 0 (0.0) 4    (5.1)
Indifferent 1 (5.3) 13 (16.5)
Hopeful 4 (21.1) 11 (13.9)
Relieved 7 (36.8) 23 (30.2)
Worried 1 (5.3) 10 (29.1)
Other 6 (31.6) 18 (21.4)

Discussion

Results from this study indicated that few women in this sample reported CA to authorities, disclosed CA to a GP or were asked about a history of CA by their GP. The CA disclosure rate of 54% by women survivors is consistent with prior literature.12,13,21 However, CA disclosure rates to authorities and GPs in this study sample was higher than the 10% reported by Flemming.13 This may be due to the sample consisting of women survivors of various types of CA and not solely child sexual abuse.

Almost all women in this study have sought assistance from GPs for general health concerns with more than half also seeking assistance for emotional health. The variability in services accessed and required by women survivors from GPs is not surprising given that GPs are the first point-of-contact22 and the recent reported increased in 'general and unspecified' and 'psychological' problems encountered by GPs in Australia.23 Further, the introduction of Medicare rebates for psychological treatment with implementation of the Better Access initiative in 2006,24 may also explain this high rate of access for emotional health concerns from GPs.

Despite 29% of GPs reporting usually or always screening women patients for CA history,14 only 19% of women in this study sample reported being asked by a GP about their CA experience. This low rate of inquiry is likely due to perceived barriers such as lack of time, not seeing it as part of the GP's role to ask such questions and a fear of re-traumatising patients.14

Of the women asked by GPs regarding their CA history, the majority reported feeling 'hopeful' or 'relieved' and none reported feeling 'offended'. Similarly, of women who were not asked, the majority noted that if they were asked they would feel 'hopeful' or 'relieved'. This is a clear message from this sample of women survivors, which should allay GPs' concerns of offending or re-traumatising patients if they ask about a patient's history of CA. Although GPs may not see it as their role to ask about a CA history, and to some extent patients may not expect to be asked, a case finding approach is warranted. As one woman said, if her GP asked about her CA history she would be 'shocked because wouldn't expect GP to ask but I wish maybe they did'.

Based on the results of this study, we recommend that GPs consider asking patients about CA history if they present with related symptoms such as depression, anxiety, post-traumatic stress, poor general health or gastrointestinal and gynaecological issues. This could be the first step to providing CA survivors with the opportunity to access appropriate intervention for long standing issues related to their experiences.

Strengths and limitations of this study

This is the first study to the authors' knowledge that explored CA disclosure, GP service use and the thoughts of women CA survivors on being asked about their CA history utilising behaviourally specific questions that explored the different types of services accessed from GPs alongside the frequency of visits. Due to the focus on a self-selecting sample of women survivors of CA, results cannot be generalised. Recollection bias may have also resulted in collection of retrospective data, which is unavoidable in this type of research. The sample size was also relatively small due to the nature and length of the interview.

Conclusion

Insights into the disclosure of CA by this sample of Australian women survivors of CA, alongside their patterns of emotional and general health and GP service use, provides further understanding of the needs of women CA survivors. As a result of the variability in presentations to GPs and high rates of GP service use by women CA survivors, GPs are well placed to identify and facilitate early intervention for this vulnerable population.

Results of this study indicating that most women CA survivors were not offended and felt hopeful or relieved when asked about their CA history can be used to guide recommendations for best practice. General practitioners should consider asking patients about their CA history. To provide an accurate picture of the health service needs of CA survivors, further research that considers various types of CA when assessing service use is required. Much research is still needed to understand and reduce the barriers to screening women for a history of CA.

Key points

  • GPs are likely to come in contact with women CA survivors who present with either general or emotional health concerns.
    Most women CA survivors will not be offended if asked about their CA history. As such, GPs should not be fearful and should consider asking women patients about their CA history.
  • A case finding approach for screening women CA survivors is recommended.
  • GPs are best placed to provide early identification and facilitate early intervention for women CA survivors.

Conflict of interest: none declared.

References

  1. Sickel AE, Noll JG, Moore PJ, Putnam FW, Trickett PK. The long-term physical health and healthcare utilization of women who were sexually abused as children. J Health Psychol 2002;7:583–97.
  2. Heitkemper M, Jarrett M, Taylor P, Walker E, Landenburger K, Bond EF. Effect of sexual and physical abuse on symptom experiences in women with irritable bowel syndrome. Nurs Res 2001;50:15–23.
  3. Taylor C, Pugh J, Goodwach R, Coles J. Sexual trauma in women the importance of identifying a history of sexual violence. Aust Fam Physician 2012;41:538–41.
  4. McLaughlin KA, Green JGP, Gruber MJ, Sampson NA, Zaslavsky AM, Kessler RC. Childhood adversities and adult psychiatric disorders in the national comorbidity survey replication II: Associations with persistence of DSM-IV disorders. Arch Gen Psychiatry 2010;67:124–32.
  5. Lang AJ, Aarons GA, Gearity J, et al. Direct and indirect links between childhood maltreatment, posttraumatic stress disorder, and women's health. Behav Med 2008;33:125–35.
  6. Schneider R, Baumrind N, Kimerling R. Exposure to child abuse and risk for mental health problems in women. Violence Vict 2007;22:620–31.
  7. Sareen J, William F, Cox B, Hassard S, Stein M. Childhood adversity and perceived need for mental health care findings from a canadian community sample. The Journal of Nervous and Mental Disease 2005;193:396–404.
  8. Walker E, Unutzer J, Rutter C, et al. Costs of health care use by women HMO members with a history of childhood abuse and neglect. Arch Gen Psychiatry 1999;56:609–13.
  9. Newman MG, Clayton L, Zuellig A, et al. The relationship of childhood sexual abuse and depression with somatic symptoms and medical utilization. Psychological Medicine 2000;30:1063–77.
  10. Chartier MJ, Walker JR, Naimark B. Childhood abuse, adult health, and health care utilization: Results from a representative community sample. Am J Epidemiol 2007;165:1031–8.
  11. Taylor P, Moore P, Pezulla L, Tucci J, Goddard C, De Bortoli L. The cost of child abuse in Australia. Melbourne: Australian Childhood Foundation and Child Abuse Prevention Research Australia, 2008.
  12. Hebert M, Tourigny M, Cyr M, McDuff P, Joly J. Prevalence of childhood sexual abuse and timing of disclosure in a representative sample of adults from quebec. Can J Psychiatry 2009;54:631–9.
  13. Fleming J. Prevalence of childhood sexual abuse in a community sample of australian women. Med J Australia 1997;166:65.
  14. Weinreb L, Savageau, Candib LM, Reed G, Fletcher K, Hargraves J. Screening for childhood trauma in adult primary care patients: a cross-sectional survey. Prim Care Companion J Clin Psychiatry 2010;12.
  15. Department of Human Services USA. Chapter 2: Screening and assessing adults for childhood abuse and neglect. In: Substance Abuse and Mental Health Services Administration, editor. Substance Abuse Treatment for Persons with Child Abuse and Neglect Issues, 2000.
  16. Lugendorf S, Antoni M. Emotional and cognitive processing in a trauma disclosure paradigm. Cognitive Therapy & Research 1999;23:423–40.
  17. Sikweyiya Y, Jewkes R. Perceptions and experiences of research participants on gender-based violence community based survey: implication for ethics guidelines. PlosOne. 2012;7:e35495.
  18. Higgins D, McCabe M. The development of the comprehensive child maltreatment scale. Journal of Family Studies 2001;7:7–28.
  19. Senn T, Carey M. Child maltreatment and women's sexual risk behaviour: childhood sexual abuse as a unique risk factor. Child Maltreat 2010;15:324–35.
  20. IBM Inc. IBM SPSS statistics. Chicago: IBM; 2011.
  21. Smith D, Letourneau E, Saunders B, Kilpatrick D, Resnick H, Best C. Delay in disclosure of childhood rape: results form a national survey. Child Abuse Neglect 2000;24:273–87.
  22. Australian Bureau of Statistics. Australian social trend march 2011 health services: use and patient experience. Australian Bureau of Statistics, Commonwealth of Australia, 2011.
  23. Britt H, Miller G, Charles J, et al. General practice activity in australia 2010–11. General practice series no.30. Sydney: Sydney University Press, 2011.
  24. Crosbie D, Rosenberg S. COAG mental health reform. Mental health and the new medicare services: an analysis of the first six months Mental Health Council of Australia. Mental Health Council of Australia, 2007.

Correspondence afp@racgp.org.au

18 November 2012 01:58

Re: Women survivors of child abuse

Nicholas Silberstein

General Practitioner

Presently volunteer in NGO in Barcelona, Spain.

Congratulations to Lee and colleagues for this article which the authors believe is the first study of disclosure of child abuse to general practitioners and the thoughts of women survivors of child abuse on being asked about histories such as these.

During the thirty plus years that I have been in practice it has certainly become a little easier to directly ask patients about sexual abuse, as well as of physical abuse, drug and alcohol use and suchlike, due I imagine mainly to the increased publicity that these issues have received over recent years.

However doctors remain reticent in many cases. This may be due to concerns that the patient may find such questions objectionable, Lee's study should somewhat put that concern to rest.

The concern that remains is the can of worms that may be opened. In some cases patients may presumably benefit from just being able to share their histories of abuse but for many substantial follow up would be needed. Even with the Better Access programme suitable referral pathways often seem to be difficult to locate.

Did the authors assess reasons that patients may have had for not disclosing histories of abuse?

Yours sincerely,

Nicholas Silberstein

26 November 2012 08:28

Re: Women survivors of child abuse

Adeline Lee

Psychologist and Senior Research Officer

Monash University

Thanks Nicholas for your interest in the article and your comments.

It is very encouraging to hear that practices of some practitioners have changed throughout the years with some directly asking patients about abuse histories.

Unfortunately the concern of opening Pandora’s Box is not a new one and has been cited by many practitioners in previous studies as barriers to asking patients. Asking patients is the first step to identification of survivors and providing early intervention.

A crucial opportunity to challenge this insidious social and health problem is missed by not asking and perpetuates the idea that it is an issue that cannot to be spoken about, further silencing survivors. Although the referral pathways are not ideal, it provides the follow-up that survivors may welcome and may mitigate the long-term consequences of child abuse. Just as the article’s premise that survivors do not get offended when asked about abuse histories and most felt hopeful and relieved.

Unfortunately we did not assess patients’ reasons for not disclosing child abuse histories. This is definitely an area that warrants future research. Previous studies (which focused only on child sexual abuse) have cited factors such as guilt, shame, negative repercussions of abuse disclosures such as ‘social death’ and not being validated when abuse was first disclosed as factors hindering survivors from disclosing abuse.

Please do not hesitate to contact me should you have any further questions about this article.

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