Long Term Psychological Sequelae of Abuse Perry Dickinson
Long Term Psychological Sequelae of Abuse Perry Dickinson, MD University of Colorado
Abuse is Common • Occurs in all racial, cultural, and socioeconomic groups • Childhood sexual abuse – prevalence in US primary care settings – Women – 20 to 40% – Men – 12 to 15% • Physical abuse – Women and men about 20 – 25%
Abuse is Common • Overall, US general population – 30 to 40% of adults have had some type of abuse during childhood • Rates in other sites around the world variable, but still very common • Clinicians who believe that abuse does not occur in their patients are just not looking for it
Outline • Perry - Long term mental health consequences of victimization, especially focusing on child abuse • Pam - Health consequences of rape and emotional abuse • Lucy - Long term physical health consequences of abuse • All - Implications of prior abuse on the relationship between the family doctor and the patient
Childhood Sexual Abuse – Mental Health Impact • Childhood sexual abuse (CSA) correlated with multiple mental health symptoms • In general, the more the abuse, the more the mental health impact • However, even “minimal” abuse can cause considerable problems
Childhood Sexual Abuse – Factors Associated with More Problems • • • Higher level of physical contact Intrafamilial abuse Perpetrator in position of power Multiple incidents Violence associated with sexual abuse
Proximate Mental Health Symptoms of CSA • • Generalized shame or guilt Poor self esteem Depression Distorted body image Eating disorder Regressive or pseudo-mature behavior Sleep disturbance
Proximate Mental Health Symptoms of CSA • • Fears and phobias Anger Deterioration in academic performance Sexually provocative or promiscuous behavior • Conduct problems • Running away • Suicide attempts
Adult Survivors of Abuse • Abuse and violence has long term (often lifelong) impact on mental health • Childhood abuse – impact on adult health equal to or greater than that of adult current abuse or other psychological trauma • Many victims of childhood abuse (even severe abuse) do extremely well • However, mental health conditions (full and subthreshold) very common
Adult Survivors of Abuse • Factors Associated with Higher Levels of Mental Health Symptoms – Increased levels of abuse – More episodes – Abuse in both childhood and adulthood – Combined physical and sexual abuse – Family dysfunction – Family violence and sociopathy, especially in family of origin
Adult Survivors of Abuse – PTSD • Post-traumatic stress disorder (PTSD) extremely common in victims of abuse, symptoms may persist for many years • DSM-IV PTSD field trials – victims of early onset interpersonal violence showed higher rates of psychological problems than victims of natural disasters • Complex PTSD – response to multiple severe traumas – symptoms of PTSD plus many symptoms of other mental health conditions
Adult Survivors of Abuse – Depression • Episodes of major depression, dysthymia very common in abuse survivors • Often see chronic pattern of depression • Maintenance therapy with anti-depressants may be indicated in more chronic cases; however, psychotherapy should also be suggested
Adult Survivors of Abuse – Somatization • Medically unexplained physical symptoms common among survivors of abuse – Expression of underlying emotional distress? – Hypervigilance? – Distorted experience of symptoms? • Our study of primary care patients – 2/3 of patients with somatization disorder, 1/2 of patients with subthreshold somatization had history of abuse
Adult Survivors of Abuse – Anxiety Disorders • Clear association between abuse and subsequent panic disorder, generalized anxiety disorder • Possible role of hypervigilance, gearing up of autonomic nervous system • Intermittent panic attacks and anxiety symptoms common - even when full DSM criteria not met
Adult Survivors of Abuse – Substance Abuse • Increased risk for substance abuse also seen in abuse survivors • Genetic? (Parents with substance abuse more likely to abuse, less able to protect child from abuse) • Attempt to numb the pain? • Part of the overall pattern of increased mental health symptoms?
Other MH Issues Associated with Abuse • Bulimia, to a lesser extent anorexia strong relationship with CSA • No clear relationship between abuse and bipolar disorder or schizophrenia
Adult Survivors of Abuse – Dissociation • Dissociation protective defense against very traumatic abuse – go somewhere else mentally • With multiple severe abusive episodes starting early in life – can see more complex walling off of memories of abuse • Can give rise to multiple personality disorder – personalities that experience the abuse split off from core identity • Allows core identity to develop more normally, free from the memories of the abuse • Boundaries between memories often start breaking down at some point, however
Personality Disorders • Personality characteristics adopted as adaptive responses in dealing with abuse can be labeled as personality disorders • Histrionic personality disorder notable example, used as label for characteristics commonly seen in women surviving CSA • Such labels can be more harmful than helpful unless combined with an understanding of the abusive context in which the behaviors arose
Psychosocial Issues Commonly Seen in Abuse Survivors • Difficulty with relationships – especially intimate relationships • Difficulty with trust • Shame, guilt • Sexual issues – discomfort, lack of desire, dyspareunia • Poor self esteem • Anger – internalized or externalized
Family Influences • Abuse and family dysfunction closely tied • Abuse tends to run in families – the abused tend to become abusers or have difficulty protecting their children from abuse • Dysfunction common in families of abuse victims – violence, sociopathy, substance abuse, enmeshment • However, extrafamilial abuse can occur in more functional families – strong family support can ameliorate the impact of the abuse, either in family of origin or in later family setting
Identification of Past Abuse • Victims of childhood abuse seldom volunteer information about the abuse • Many have never shared the story with anyone • Perpetrators often tell the victims that it is their fault; often see long term guilt • Attempts to tell parents or others often not received well – may feel blamed there also • Stories of the abuse often kept hidden – unprocessed, not well understood, surrounded by shame and guilt
Processing of Abuse Memories • Pennebaker – traumatic events need to be processed in order to put them into a frame of reference, achieve some level of understanding of what happened • If events not successfully processed, causes long term mental and physical health problems • Pennebaker disclosure interventions • Memories of abuse tend to go unprocessed – can’t talk about it with other people, difficult to understand or put into a context
Interaction with Clinicians • People willing to talk about abuse histories when asked directly • People almost never will give history in response to vague, general questions • Trust helps, but will often give history on first visit • Tie into review of systems, mental health history, gyn history – may help to give a brief intro to the questions • Don’t ask if you don’t have time to listen to the answer
Questions About Abuse • Direct, specific – series something like this: • Have you ever had anything really bad happen to you? • Have you ever been abused, physically, sexually, or emotionally? • Have you ever been forced to have sex against your wishes?
How to Respond • Manner in which clinician responds to story very important • If patient senses rejection or retreat by clinician, will close down and not give complete story • If not time to go through entire story – clinician should communicate importance of talking through this completely, schedule follow-up ASAP • Clinician should deal with likely shame/guilt – “This was not your fault. It should never have happened to you. ”
Management • Just talking through what happened with supportive clinician can be very therapeutic • Further counseling to process what happened and its impact almost always desirable • Patient may not be ready – offer continued support, open door to discuss, referral for counseling when patient desires
Day to Day Management • Also important to take abuse context into consideration in daily management of patient • Health care can be very scary for abuse survivors – can be re-traumatized • Give patients a lot of control over what happens • Explain everything carefully – especially things that might be traumatic • Explain possible impacts of abuse on the patient’s mental and physical health • Establish therapeutic partnership
Long Term Health Effects of Sexual Violence and Emotional Abuse Pamela M. Mc. Mahon, Ph. D. , M. P. H. Dept. of Family & Community Medicine Tulane University
Challenges • Many forms of violence/abuse co-occur • Lines of research have grown separately • Research often fails to examine cooccurrence • When data are collected on multiple types of trauma, care must be taken to control for effects of other forms of violence on the outcome of interest
How Often Does Sexual Violence Occur? • Estimates vary depending on sample, methodology, definitions, particular questions or wording • National surveys – 27% women report history of child sexual abuse (Finkelhor, et al, 1990) – 15% report rape at some time in their life (Tjaden & Thoennes, 1998) – 20% college females (4% college males) report ever being forced to have sex against their will (Brener, Mc. Mahon, Warren, & Douglas, 1999)
Long-Term Physical Health Sequelae of Sexual and Physical Violence • Cardiopulmonary/neurological (Leserman et al. , 1998) – – – Shortness of breath Palpitations Numbness or tingling Weakness or faintness Blurred or double vision • Musculoskeletal – Muscle aches in neck, ORa= 2. 49, 1. 30 -4. 54 ORa= 2. 42, 1. 39 -4. 28 ORa= 2. 52, 1. 46 -4. 40 ORa= 1. 78, 1. 05 -3. 03 ORa= 2. 35, 1. 26 -4. 53 (Leserman et al. , 1998) ORa= 2. 27, 1. 34 -3. 91 Shoulders, or limbs – Frequent headaches – Pain in eyes or ears ORa= 3. 32, 1. 93 -5. 83 ORa= 2. 05, 1. 16 -3. 71
Long-Term Physical Health Sequelae of Sexual and Physical Violence • Genito-urinary (Leserman et al. , 1998) – – Vaginal discharge/itching Low sexual desire Painful intercourse Pelvic pain ORa= 2. 65, 1. 51 -4. 72 ORa= 2. 45, 1. 37 -4. 46 ORa= 2. 98, 1. 50 -6. 23 ORa= 4. 25, 2. 16 -8. 82 • Skin (Leserman et al. , 1998) – Rash ORa= 2. 18, 1. 25 -3. 87
Long-Term Physical Health Sequelae of Sexual Violence • Women who were raped, as compared to women who experienced no sexual abuse, attempted sexual abuse and contact sexual abuse, report more – – – Pain severity over past 14 days # of days in bed during past 3 months # of surgeries during lifetime Functional disability # of Non-GI symptoms (comparison not different when compared to women who had experienced contact sexual abuse) (Leserman et al. , 1996)
Long-Term Physical Health Sequelae of Sexual Violence • Chronic medical conditions (Ullman & Brecklin, 2003; Koss, 1992) • Pain – – – Chest pain (Stein et al. , 2004) Back pain (Grimstad & Schei, 1998) Facial pain (Koss, 1992) Pelvic Severe headache (Stein et al. , 2004; Koss, 1992) • Overwhelming fatigue (Stein et al. , 2004) • Perceived physical health (Thompson, Arias, Basile, & Desai, 2002) • Sustained serious injury (Thompson, Arias, Basile, & Desai, 2002)
Long-Term Physical Health Sequelae of Sexual Violence • Disordered eating (Ackard & Neumark-Sztainer, 2002; Thompson, Wonderlich, Crosby, & Mitchell, 2001) – Laxative use – Vomiting – Use of diet pills – Binge eating
Reproductive Health Consequences of Sexual Violence • • Excessive menstrual bleeding Genital burning Painful intercourse Medically explained missing 2 periods Medically unexplained dysmenorrhea Menstrual irregularity Lack of sexual pleasure – (Golding, 1996)
Reproductive Health Consequences of Sexual Violence • Unintended pregnancy (Dietz et al, 1999) • Miscarriage or stillbirth (Thompson, Arias, Basile, & Desai, 2002) • HIV (Kimerling, Armistaead, & Forehand, 1999) • Other STDs (Grimstad & Schei, 1999)
Long-Term Reproductive Health Sequelae of Sexual Violence • Behavioral Risk Factors (Cunningham, Stiffman, & Dore, 1994) – Homosexual behavior for males raped during childhood – Choice of partner known to engage in risky behavior – More partners (Grimstad & Schei, 1999) – Involved in or use of prostitutes
Long-Term Reproductive Health Sequelae of Sexual Violence • Behavioral Risk Factors – Younger age at sexual initiation (Grimstad & Schei, 1999) – Unprotected sex – Cigarette use (Nichols & Harlow, 2004; Rodgers et al. , 2004) – Alcohol, or drug use (including during pregnancy)
Long-Term Behavioral Health Sequelae of Sexual Violence • Violent offenses in adolescence and adulthood (Siegel & Williams, 2003) • Running away (Siegel & Williams, 2003) • Drug offenses during adulthood (Siegel & Williams, 2003) • Rape revictimization (Noll et al. , 2003; Ackard & Neumark-Sztainer, 2002; Krahe et al. , 1999; Merrill et al. , 1999) • • Physical victimization (Noll et al. , 2003) Self-harm (Noll et al. , 2003) More lifetime traumas (Noll et al. , 2003) Sexual problems (Fleming et al. , 1999)
Long-Term Behavioral Health Sequelae of Sexual Violence • As compared to those never experiencing rape, college females reporting lifetime experience of rape had an elevated odds of: – – – – – Physical fight with spouse or boyfriend (OR=2. 4) Drove after drinking (OR=1. 5) Thought seriously about attempting suicide (OR=2. 7) Smoked cigarettes (OR=2. 1) Episodic heavy drinking (OR=1. 6) Marijuana use (OR=2. 0) Alcohol or drug use at last sexual intercourse (OR=2. 1) Two/more current sexual partners (OR=2. 5) First sexual intercourse before age 15 (OR=2. 6) (Brenner, Mc. Mahon, Warren, & Douglas, 1999)
Physical Health Sequelae of Sexual Violence within a Violent Intimate Relationship • 7. 7% (7. 75 million) women report rape by intimate partner in their lifetime • 201, 000 women report rape by intimate partner in past year (Tjaden & THonnes, 1998) • 46% of all battered women are forced to have sex by their partner (Campbell & Soeken, 1999) – Higher mean health symptoms score – Increased odds for and greater number of gynecological problems – Number of types of forced sex experiences correlated with depression
Health Care Costs of Child Sexual Abuse • Walker et al. (1999) conducted a survey on child maltreatment experiences with a random sample of 1225 women members of an HMO. • Information on health care costs and use was ascertained from an automated cost-accounting system – Women who reported sexual abuse had median annual health care costs that were $245 greater than costs for women who did not report abuse They also had higher primary care and outpatient costs and more frequent ED visits than women without CSA histories.
What can you do? • When asked directly about sexual abuse by a health care professional, women respond without objection (Weingourt, 1985) • Respond with empathy • Know about and refer to resources in your community • Be alert to consequences
Various Definitions of Psychological/Emotional Abuse • Cruelty demonstrated by verbal and nonverbal acts • Repeated or singular • Intended or not intended • From a close other in a position of power or responsibility over another • Excludes physical or sexual abuse, though may accompany these forms of abuse (Moran, Bufulco, Ball, Jacobs, & Benaim (2002)
Various Definitions of Psychological/Emotional Abuse • Psychological abuse: – willful infliction of mental or emotional anguish by threat, humiliation, or other verbal or nonverbal conduct. (http: //www. preventelderabuse. org/elderabuse/psychological. html) – Insulted or sworn at – Sulking or refusing to talk – Stomped out of the room or house (or yard) – Did or said something to spite – Threatening to hit or throw something – Threw, smashed, hit, or kicked something (Straus, 1979)
Prevalence of Psychological/Emotional Abuse and Emotional Neglect During Childhood • Random Digit Dial Survey in metro-Memphis about emotional abuse and neglect when a child (Scher et al. , 2004) – 12. 1% reported experiencing Emotional Abuse – 5. 1% reported experiencing Emotional Neglect • Of adult female patients in a Family Practice Office seen over 15 days and completing survey Martsolf, Draucker, & Chapman, 2004) – 20. 8% reported Emotional Abuse – 24. 5% reported Emotional Neglect – Approximately the same % as in a primary care practice in NYC (Spertus et al. , 2003)
Impact of Emotional Abuse and Emotional Neglect During Childhood – Trauma Symptoms predicted by emotional abuse and by emotional neglect (Martsolf, Draucker, & Chapman, 2004; Spertus et al. , 2003) • Trauma symptoms predicted – Physical symptoms – Perceived general heatlh – Perceived mental health – Correlated with # of doctor visits (Spertus et al. , 2003) – High Risk Behaviors • Lower age at first consensual intercourse • Failure to use seat belts (Rodgers et al. , 2004)
References • • Ackard, DM & Neumark-Sztainer, D. (2002). Date violence and date rape among adolescents: Associations with disordered eating behaviors and psychological health. Child Abuse & Neglect, 26(5), 455 -473. Brener, N. , Mc. Mahon, P. M. , Warren, C. W. , & Douglas, K. A. (1999). Forced sexual intercourse and associated health-risk behaviors among female college students in the United States. Journal of Consulting and Clinical Psychology, 67, 252 -259. Campbell, JC & Soeken, KL (1999). Forced sex and intimate partner violence: Effects on women’s risk and women’s health. Violence Against Women, 5(9), 1017 -1035. Cunningham, RM, Stiffman, AR, & Dore, P. (1994). The association of physical and sexual abuse with HIV risk behaviors in adolescence and young adulthood: Implications for public health. Child Abuse & Neglect, 18(3), 233 -245. Dietz, PM, Spitz, AM, Anda, RF, Williamson, DF, Mc. Mahon, PM, Santelli, JS, Nordenberg, D, Felitti, VJ, & Kendrick, JS. (1999). Unintended pregnancy among adult women exposed to abuse or household dysfunction during their childhood. Journal of the American Medical Association, 282, 1359 -1364.
References • • Finkelhor, D, Hotaling, G, Lewis, IA, & Smith, C. (1990). Sexual abuse in a national survey of adult men and women: Prevalence, characteristics, and risk factors. Child Abuse & Neglect, 14, 19 -28. Golding, JM. (1996). Sexual assault history and women’s reproductive and sexual health. Psychology of Women Quarterly, 20, 101 -121. Grismstad, H & Schei, B. (1999). Pregnancy and delivery for women with a history of child sexual abuse. Child Abuse & Neglect, 23(1), 8190. Koss, MP, Heise, L, & Russo, NF (1994). The global burden of rape. Psychology of Women Quarterly, 18, 509 -537. Leserman, J, Drossman, DA, Li, Z, Toomey, TC, Nachman, G, & Glogau, L. (1996). Sexual and physical abuse history in gastroenterology practice: How types of abuse impact health status. Psychosomatic Medicine, 58(1), 4 -15. Leserman, J, Li, Z, Drossman, DA, & Hu, YJB. (1998). Selected symptoms associated with sexual and physical abuse history among female patients with gastrointestinal disorders: The impact on subsequent health care visits. Psychological Medicine, 28(2), 417 -425. .
References • • • Martsolf, DS, Draucker, CB, & Chapman, TR (2004). The physical health of women in primary care who were maltreated as children. Journal of Emotional Abuse, 4(1), 39 -59 Merrill, LL, Newell, CE, Thomsen, CJ, Gold, SR, Milner, JS, Koss, MP, & Rosswork, SG. (1999). Childhood abuse and sexual revictimization in a female navy recruit sample. Journal of Traumatic Stress, 12(2), 211225. Morgan, PM, Bifulco, A, Ball, C, Jacobs, C, & Benaim, K. Exploring psychological abuse in childhoos: 1. Developing a new interview scale. Bulletin of the Menninger Clinic, 66(3). Nichols, HB, & Harlow, BL. (2004). Childhood abuse and risk of smoking onset. Journal of Epidemiology and Community Health, 58, 402 -406. Noll, JG, Horowitz, LA, Ponanno, GA, Trickett, PK, & Putnam, FW. (2003). Revictimization and self-harm in females who experienced childhood sexual abuse: Results from a prospective study. Journal of Interpersonal Violence, 18(12), 1452 -1471.
References • • • Rodgers, CS, Lang, AJ, Laffaye, C, Satz, LE, Dresselhous, TR, & Stein, MB. (2004). The impact of individual forms of childhood maltreatment on health behavior. Child Abuse & Neglect, 28, 575 -586. Scher, CD, Forde, DR, Mc. Quaid, JR, & Stein, MB. (2004). Prevalence and demographic correlates of childhood maltreatment in an adult community sample. Child Abuse & Neglect, 28, 167 -180. Siegel, JA & Williams, LM (2003). The relationship between child sexual abuse and female delinquency and crime: A prospective study. Journal of Research in Crime and Delinquency, 40(1), 71 -94. Stein, MB, Lang, AJ, Laffaye, C, Satz, LE. Lenox, RJ, & Dresselhaus, TR. (2004). Relationship of sexual assault history to somatic symptoms and health anxiety in women. General Hospital Psychiatry, 26, 178 -183. Thompson, KM, Wonderlich, SA, Crosby, RD, & Mitchell, JE (2001). Sexual victimization and adolescent weight regulation practices: A test across three community based samples. Child Abuse & Neglect, 25, 291 -305.
References • • Thompson, MP, Arias, I, Basile, KC, & Desai, S. (2002). The association between childhood physical and sexual victimization and health problems in adulthood in a nationally representative sample of women. Journal of Interpersonal Violence, 17(10), 1115 -1129 Tjaden, P & Thonnes, N. (1998). Prevalence, incidence, and consequences of violence against women: Findings from the National Violence Against Women Survey. NCJ Publication No. 172837. Washington DC: US DOJ, NIJ. Ullman, SE & Brecklin, LR. (2003). Psychology of Women Quarterly, 27, 46 -57. Walker, EA, Unutzer, J, Rutter, C, Gelfand, A, Saunders, K, Von. Korff, M, Koss, MP, & Katon, W. (1999). Costs of health care use by women HMO members with a history of child abuse and neglect. Archives of General Psychiatry, 56, 609 -613. Weingourt, R. (1985). Wife rape: Barriers to identification and treatment. Journal of Psychotherapy, 39, 187 -192
The late health consequences of abuse: What do we know? What does it mean for doctors? Lucy M. Candib, M. D. University of Massachusetts Medical School and Family Health Center of Worcester Lcandib@massmed. org
Provocative correlations In every study, where it has been examined…. – Women with more unexplained symptoms are more likely to have a history of more childhood physical and sexual abuse – Women with more unexplained symptoms are more likely to have a history of more adult physical and sexual abuse – Women with sexual symptoms are more likely to have a history of sexual abuse or assault
What do we know? Women with a history of past abuse have poorer self-care – less use of seat-belts – fewer mammograms – less use of Pap smears – less use of safe sex precautions – less use of contraception, teen and adult – more eating disorders – less dental care – less exercise – more likely choice of alcoholic partner
What do we know? • Women with a history of abuse are exposed to more hazards – more substance abuse – more smoking – more high risk sexual activities – earlier initiation of sexual activity – earlier first pregnancy – more exposure to sexual harassment – more exposure to violence
Narrative themes • • Powerlessness Betrayal Stigma/Secrecy/Shame/Guilt Abandonment Violence Loss of self Loss of childhood Traumatized sexuality
What do we know about severity? • Dose-response effect – multiple types of abuse – worse severity of abuse – Worse symptoms – More symptoms – Worse health – More diagnoses
Long-term consequences for women Chronic abdominal pain Chronic GI symptoms Biomedical model Chronic pelvic pain Dyspareunia Multiple abdominal surgeries Painful useless costly revictimizing
Long-term consequences for women Injuries and femicide Substance abuse Revictimization Suicide Disempowerment Psychiatric illness Example: Severe dating victimization of teen girls correlates with substance abuse and risk-taking AND is associated with suicidal ideation and attempts. [Coker, 2000]
Long-term consequences for families Abusive male figure (chosen by abused woman) Sons prone to violence and machismo Repetition in the next generation Disempowered mother Depressed and more easily victimized daughters
Medical consequences for women Early sexual activity Smoking Multiple partners Cervical cancer No condom use Avoidance of Paps RR = 4. 26 of cervical ca among women with IPV [Coker, 2000]
More consequences for women…starting with teens Early sexual activity Poor self-care Disempowerment No condom use Multiple partners Teen pregnancy
Long-term consequences for women Lack of seatbelt use Substance abuse Driving while intoxicated Risk-taking Disempowerment Vulnerability to accidents, trauma
Long-term consequences for women Lack of condom use Substance abuse Substance-abusing partner Exposure to violence Disempowerment/ Revictimization Higher likelihood of HIV More advanced disease than non-victimized
Long term implications • If previously abused women are more likely be overweight, to smoke, drink, use drugs, not use safe sex, not use seat belts, not get pap smears or mammograms, then, in the long run, they should experience: • STDs, HIV, injuries, unintended pregnancies, cervical neoplasia--these have all been documented • But what about advanced breast cancer, diabetes, liver disease, COPD, and CAD? ? ?
Possible health consequences for women Avoidance of mammograms Heavy alcohol use Poor self-care Higher risk of breast cancer Higher likelihood of late diagnosis of breast cancer As yet, hypothetical
Evidence about chronic disease Adverse Childhood Exposure Study • 13, 494 adults at a large HMO; 9, 508 responses (70. 5%) • Seven types of Adverse Exposures – Psychological abuse – Physical abuse – Sexual abuse – Violence against mother substance abusers mentally ill or suicidal – Household members who were: ever imprisoned
What did they find? Adverse Childhood Exposure Study • The seven categories of adverse childhood experiences were strongly interrelated • The number of categories of adverse childhood exposures showed a graded relationship to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease.
Adverse Child Exposures Study Odds ratios for diseases associated with 4 or more categories of adverse exposures in childhood: – ischemic heart disease: 2. 2 – any cancer: 1. 9 – stroke: 2. 4 – COPD: 3. 9 – diabetes: 1. 6 – fracture (ever): 1. 6 – hepatitis or jaundice (ever): 2. 4 (Felitti, 1998)
How does this happen? Smoking nal n o rm io Ho gulat re s y d Lack of exercise COPD Obesity CAD+PVD Poor self-care DM Substance abuse Liver disease
Birth
Another approach to the data: • • Evolving psychiatric terminology Evolving diagnostic methodology Pejorative connotation in medical circles BUT a useful handle for unexplained physical complaints
Ultimate consequences Multiple for women work-ups Poly-pharmacy Iatrogenic illness Frustrated patient Somatization Panoply of symptoms Frustrated doctor High costs Medical revictimization
Somatization: Ultimate consequences Psych Ongoing for women SURG Symptoms Rheum Marked body awareness Ob-gyn GI Ortho FP ID Allergy ENT Side effects, reactions, allergies, “allergies” Pulm Cor Mixed Messages Endo Multiple prescribers Poly-pharmacy DISTRUST
Review • Girls and women experience emotional, physical, and sexual abuse in childhood, adolescence and adulthood • Abuse is associated with poor self-care, higher risk-taking, tobacco and substance abuse • These factors lead to teen pregnancy, unintended adult pregnancy, STDs, and higher risks of cervical neoplasia, HIV, and further revictimization
Review • Abuse is associated with later psychiatric illness, depression, PTSD, overdose, suicide, self-mutilation, etc. • Abuse is associated with poorer health and excess symptoms in multiple systems, i. e. , somatization • Somatization is associated with multiple surgeries, iatrogenic harm, poly-pharmacy, distrust of and conflict with medical providers
Review • Tobacco use, substance abuse, obesity, and poor self-care eventually predispose women to chronic diseases: liver disease, COPD, CAD, DM • Somatization as well is a predictor of chronic disease: 2/3 of women with somatization have either COPD, CAD, or DM
Abuse perpetuates abuse • Individual self-harm after abuse • Revictimization • Propagation of gender roles leads to repetition across generations
Cross-generational data • Girls who witness their mothers being battered experience depression and loss of self-esteem • Boys more likely to act out and exhibit aggressive behaviors • Perpetuation of these gender dynamics in the next generation
Cross-generational data • Mothers of sexually abused girls are more likely to have been sexually abused themselves. • How does this work? – More accepting of domination and abuse – Internalized misogyny – Less able to protect their daughters from an abuser
Cross-generational data • Women battered in pregnancy more likely to have preeclampsia, prematurity, and low birthweight babies; therefore excess biological risk to children of battered women • When battering combined with the impact of limited education and poverty, infants of battered mothers have excess psychosocial risk compared to babies of not-abused mothers
Cross-generational data, global • Children of survivors of atrocity continue to suffer--suffering is passed down • Survivors of atrocities predisposed to inflict violence in retribution • Connection between war and violence against women • Mythology and hatred passed from generation to the next
Conclusions • Victimization produces lasting disempowerment • Disempowerment of girls and young women results in lasting damage to health • Disempowerment crosses generations • Gender roles propagate ongoing abuse • Abusive power self-replicates • War replicates the dynamics into the future
Today’s challenge Where can we intervene? What about men? Where are women’s strengths? What is the evidence? What strategies work? WONCA Family physicians around the world AAFP
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