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.