Psychosomatics 48:385-393, September-October
doi: 10.1176/appi.psy.48.5.385
© 2007 Academy of Psychosomatic Medicine
Effect of Childhood Sexual Abuse on Gynecologic Care as an Adult
Brigitte Leeners, M.D.,
Ruth Stiller, M.D.,
Emina Block,
Gisela Görres,
Bruno Imthurn, M.D., and
Werner Rath, M.D.
Received August 10, 2006; revised September 29, 2006; accepted October 3, 2006. From the Dept. of Gynecology and Obstetrics, University Hospital, Zurich, Switzerland; the Dept. of Gynecology and Obstetrics, University Hospital, Aachen, Germany; and the Support Center for Women Exposed to Sexual Abuse (Frauennotruf Aachen, Germany). Send correspondence and reprint requests to Brigitte Leeners, M.D., Dept. of Gynecology and Obstetrics, Clinic for Endocrinology, Frauenklinikstr. 10, CH 8091 Zürich, Switzerland. e-mail: Brigitte.Leeners{at}usz.ch
© 2007 The Academy of Psychosomatic Medicine
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ABSTRACT
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The study sought to evaluate whether childhood sexual abuse (CSA) experiences significantly affect the gynecologic care received as an adult. A self-administered questionnaire including eight questions on CSA was completed by 85 women exposed to CSA and 170 matched-control women. Women exposed to CSA experienced gynecologic examinations as anxiety-provoking significantly more often and sought more treatment for acute gynecologic problems; 43.5% of these women experienced memories of the original abuse situation during gynecologic consultations. Gynecologic care is particularly distressing for women exposed to CSA.
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INTRODUCTION
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About 20% of all women have experienced childhood sexual abuse (CSA),1 depending on how it is defined; the definitions of CSA vary greatly. Some surveys ask only about rape or attempted rape, whereas others include questions about other types of "contact abuse" (e.g., fondling), as well as non-contact abusive experiences, such as genital exposure. Definitions of CSA also vary according to the age-period considered as childhood (most surveys use either age 16 or 18 as cutoffs), whether or not the respondent is asked to self-define the experience as sexual abuse, and whether differences in age between the respondent and the perpetrator are used to define CSA.2 Research concerning the long-term consequences of sexual abuse suggests that abuse has a strong negative impact on women’s overall health and psychological functioning later in life,3 with up to 96% of women presenting with long-term disturbances.4,5 Healthcare utilization and sick-leave are higher in women with CSA experiences; they rate their health lower and have a greater number of physical symptoms than women who have not had such experiences.3,6–8
A history of CSA has been associated with an increased risk for chronic pelvic pain,7,9,10 dysmenorrhea,8,11 premenstrual dysphoric disorder,12,13 menorrhagia,11 bladder dysfunction,14 sexual dysfunction,11,15,16 sexually transmitted diseases,17 and pelvic inflammatory disease.18 Difficulties with contraception and adolescent pregnancy19,20 have also been associated with CSA. In a study from Golding et al.,13 95% of women with severe premenstrual syndrome reported attempted or completed sexual assaults. CSA has also been associated with an increased number of pelvic surgeries and breast disease as an adult.7,18 Dissociation might lead to affected women dismissing the first symptoms of gynecologic disease, and, as a result, gynecologic care might be sought at a more advanced stage of disease. Furthermore, women with CSA experiences seem to refrain from regular screening for cervical cancer.21 The number of known gynecologic sequelae of CSA experiences is increasing steadily. Also, pelvic organs are associated with sexual abuse and are, at the same time, the clinical focus of gynecologists.22 However, data on how women with a positive history of CSA deal with gynecologic care are sparse.
Early studies regarding psychological aspects of gynecologic examinations were conducted in the late 1970s.3 Researchers found that, independent from sexual abuse, 30%–35% of women rated gynecologic examinations as more problematic than other medical procedures because women felt shame and distress and feared that serious pathology would be discovered.23 Women’s reluctance to see gynecologists may result in delay or avoidance of gynecologic examinations, with potentially harmful health effects.24 It seems likely that these difficulties are particularly strong for women with a positive history of CSA. Therefore, this study seeks to determine 1) the long-term effects of CSA on gynecologic care; 2) the specific factors that lead to increased stress during gynecologic care in women who have experienced CSA; and 3) possibilities for improving gynecologic care for women with CSA experiences.
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METHOD
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Study Design
The study was designed as a case–control study, comparing data from 85 women with CSA experiences receiving psychological support with those of 170 matched-control women.
Sample Inclusion criteria for cases were a history of CSA and receiving psychological support to handle the experiences of CSA. Women were excluded if they had a major communication, cognitive, or psychiatric disorder that prevented informed consent and/or understanding of the questionnaire. Control-group women were only included when there was no history of sexual abuse and when their age, as well as the number and age of their children, matched with one of the women with CSA experiences. This matching was selected because we also sought to investigate experiences with obstetric care.
Procedures Recruitment of study participants was performed in cooperation with the German "Frauennotruf," a society providing care for sexually abused women. The Frauennotruf operates regional support centers in all large cities in Germany, focusing on women exposed to sexual abuse. The research leaders developed the project in cooperation with the local committee, and all other centers were invited to support the study. Aims and methods of the study were explained by a staff member, and all women presenting with a history of CSA who asked for support to deal with these experiences at the support center within an 18-month study period were asked to participate. During the interview, we determined whether knowledge of the German language was sufficient for participation in the study. Also, each woman had an intensive, nonstructured interview lasting at least 3 hours, which focused on the abuse situation, with a sexual-abuse treatment specialist who worked at the support center. One hundred thirty-two women who had sought support from a center were invited to participate in the study. We emphasized that participation was voluntary; 111 women agreed to complete the questionnaire; the remaining 21 gave "lack of time" as the reason for not participating. After they gave verbal agreement, the questionnaire, with a detailed explanation of the study’s objectives and a prepaid envelope, was given to the participant of the study. All questionnaires were returned anonymously. To keep the questionnaires anonymous, no reminders were sent.
Control subjects were recruited in cooperation with various local kindergartens. Visiting kindergarten mothers were asked to participate in the study. Kindergartens were chosen because nearly every child goes to kindergarten in Germany, so that selection bias from social status differences could be excluded. Two control subjects for every women exposed to CSA were selected; 191 matched-control women were approached in order to yield two matched-controls for every woman with a positive history for CSA (89% response rate). Mothers of kindergartners who mentioned CSA experiences were excluded from the control group (N=25). The study was approved by the local ethics committee, and subjects gave their informed consent for participation. Table 1 shows the sociodemographic characteristics of cases and control subjects. Women with CSA experiences were significantly more likely to be laborers or managers, whereas there were significantly more mid-level employees in the control group. Control-group women were also significantly more likely to be married or cohabiting.
Instruments In cooperation with the German Frauennotruf, we designed a self-administered questionnaire comprising sexual abuse experiences and their correlation with gynecologic care. The Frauennotruf operates regional support centers for sexually abused women in all large cities in Germany. All women had contacted the support center to deal with emotional problems thought to be a result of their CSA experiences. Sexual abuse had been investigated in face-to-face interviews as part of the psychological support the women received from the center. CSA experiences were investigated by use of a modified version of questions developed by Wyatt.25 The eight specific questions focusing on abuse experiences from the Wyatt questionnaire used in the present study ask for the following unintended sexual experiences: 1) exposure of genital organs to the child/adolescent; 2) masturbation in front of the child/adolescent; 3) touching or fondling of the child’s/adolescent’s body, including breasts or genitals; attempt by someone to arouse the child/adolescent sexually; 4) having the child/adolescent arouse the offender; touching the offender’s body in a sexual way; 5) rubbing genitals against the child’s/adolescent’s body in a sexual way; 6) attempting to have intercourse with the child/adolescent; 7) having intercourse with the child/adolescent; and 8) any other sexual experience involving a relative, family friend, or stranger. CSA was defined as any undesired body contact of a sexual nature, ranging from fondling to attempted or completed intercourse, with someone of any age or relationship to the respondent. Masturbation in front of the child was also defined as abuse. Sexual abuse occurring before the 18th birthday was considered as CSA.
Further questions focused on details of the abuse situation, such as age at the beginning of sexual abuse, duration of CSA situations (6 predefined answers, plus "I do not know" and free-text answer), number of offenders, relationships with perpetrators (13 predefined answers, plus "I do not know" and free-text answer), age difference with perpetrators (5 predefined categories, plus "I do not know"), use of force during sexual abuse (Yes/No/Don’t know), use of alcohol/drugs during abuse (Yes/No/Don’t know), physical consequences of abuse (4 predefined answers, plus "I do not know"), disclosure of abuse (7 predefined answers, plus free-text answer).
Social/psychological support was investigated by asking for persons/groups that provided support (i.e., nobody, parents, doctors, teachers, police, support groups for children/women with CSA experiences, self-help groups, and others) during the time of abuse experiences or shortly afterward. Women were asked to report whether they had received any professional help (Yes/No), by whom (support group, self-help group, psychotherapist, others), the duration of professional support at the patient’s age, the type of support (individual psychotherapy, group psychotherapy, treatment in psychosomatic clinic, treatment in a department of psychiatry, others) and whether the treatment was completed or still ongoing. Physical abuse in women with CSA experiences and control subjects was assessed by asking for physical abuse experiences in general (Yes/No) and during pregnancy (Yes/No). The authors also investigated whether physical force was used in combination with sexual abuse (Yes/No). Also, the women were asked to report whether they experienced any tension, pain, bruises, cuts, and/or fractures due to physical abuse. Additional questions investigated whether women exposed to CSA had always been able to remember their CSA experiences (Yes/No).
Women with a positive history for CSA were asked to give more detailed information on whether they generally thought that CSA experiences had an influence on their gynecologic care (Yes/No), whether they had memories of the original abuse situations during gynecologic care (Never, Sometimes, Always), whether there were specific triggers for such memories (free-text answer), and whether they thought that informing the gynecologist about their background would be helpful (Yes/No). All other questions on experiences with gynecologic care (i.e., general difficulties in going to the gynecologist [5-point Likert scale]), frequency of routine and emergency gynecologic care, favoring a female over a male gynecologist (Yes/No), and stressors experienced during gynecologic consultations were asked of all study participants. We explored specific difficulties with gynecologic care with four predefined parameters (difficulties with nakedness, conversation about intimate details, vaginal examinations [speculum/palpation], and transvaginal ultrasound. The intensity of each of this potential problems was rated on a 3-point Likert scale. Also, further difficulties could be listed in a free-text answer. Suggestions for the improvement of gynecologic care for women with CSA experiences were also collected as free-text responses. The authors used free-text answers to obtain as much understanding as possible about the women’s experiences with gynecologic care. Additional questions focused on obstetric and dental care; these data will be presented separately.
A first version of the questionnaire was tested by 15 women with abuse experiences for aspects of understanding and clarity. For the final questionnaire, several questions focusing on details of those abuse situations tested in the pre-study were excluded because most of the women having experienced CSA found these questions very hard to answer in a self-administered questionnaire. Although specific questions had been used in other studies,26 the cooperation with the support centers reduced the possibility of re-traumatization, which we consider an important aspect of this study design; it led to the exclusion of questions deemed to risk such re-traumatization, according to the experiences of the women participating in the pre-study. As a result of the cooperation with the support centers, the inclusion criteria might have been much more strict than those of other research groups. From the free-text answers, specific aspects were isolated, using content analysis, and these were offered as predefined answers in the final questionnaire when more than three women in the pilot study mentioned that specific aspect. The data from the pilot study have not been included in the results presented here.
With every questionnaire, the women received addresses and phone numbers for seeking help. All subjects were encouraged to contact one of the healthcare providers listed in the accompanying letter if filling in the questionnaires provoked negative emotions.
Statistical Analysis
Only women with complete data sets on main outcome measures and potential confounders were included in the study. The data were collected within an ACCESS database. Participants’ free-text answers were analyzed by content analysis (conceptual analysis). For each question, responses were systematically reviewed for typical aspects by two members of the research team (BL and PN-W). There was agreement on classification in 97.3% of all cases. In turn, specific aspects were coded in the database to prepare statistical evaluations. Only when both investigators agreed on the classification was the mentioned aspect used for analysis.
The Student t-test and Wilcoxon test were used to compare group differences in continuous variables such as age, number of children, and number of gynecologic visits. Differences between proportions for nationality, professional status, marital status, distress with gynecologic care, routine and emergency care, specific stressors during gynecologic treatment, and preference for a female over a male gynecologist were analyzed by chi-square and Fisher’s exact test. A p value less than 0.05 was considered statistically significant. Data analysis was performed with SPSS Advanced Statistics 4.0. With one degree of freedom (df) and an effect size of 0.8, power of the analysis for the comparison of Cases and Controls was above 0.90.
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RESULTS
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We received 85 completed questionnaires from women contacted through members of the support centers (76.6%). Lack of time was the main reason mentioned for refusing participation in the study. All women had experienced abuse before age 18. Of those 85 women with a history of CSA, 66% experienced a combination of sexual and physical abuse. Table 2 shows the characteristics of the sexual abuse experiences. The 85 women with CSA experiences reported a total number of 183 perpetrators. Although 15.4% could not give any information on the number of perpetrators involved in a single abuse situation, those women remembering the perpetrators mentioned between one and nine perpetrators in a single abuse situation (one: 67%; two: 7.7%; three: 5.1%; four: 2.5%; and nine: 2.5%). Investigating the lifetime number of perpetrators: 12.8% of the women had a single, 12.8% two, 36% three, and 12.6% more than six perpetrators. For the remaining 25.8%, no information on the total number of offenders was available.
Social/Psychological Support
Of the women with CSA experiences, 69 (81.2%) reported having received no support during or shortly after the abuse. Of the 16 (18.8%) women who obtained help during this time, 4 (4.7%) were supported by parents, 3 (3.5%) by support groups, 3 (3.5%) by self-help groups, 2 (2.4%) by medical doctors, 1 (1.2%) by her teacher, 1 (1.2%) by the police, and 10 (11.7%) by others (friends, sisters, other relatives, or psychologists). All of the women with a history of CSA in the study had received professional support as an adult. Of these women, 34 (40%) had participated in a self-help group; 26 (30.6%) had psychotherapy with a male, and 61 (71.7%) with a female therapist. The mean duration of professional support was 4.4 years (SD: 4.5), and it varied between 3 months and 24 years. A total of 80 women (94.1%) had had individual psychotherapy; 19 (22.4%) had had group psychotherapy; 18 (21.2%) had been treated in a psychosomatic, and 4 (4.7%) in a psychiatric clinic. In 50 women (58.8%), therapy was still ongoing; 21 (24.7%) had completed, and 12 (14.1%) had terminated or interrupted therapy.
Long-Term Effects of Childhood Sexual Abuse on Gynecologic Care
More than half of these women showing a positive history of CSA (52.9%) report that these experiences continue to influence their gynecologic care. A significantly higher percentage of women with CSA experiences, as compared with control-group women, assumed that a visit to the gynecologist would cause an important psychological strain (37.7% versus 3.5%; p<0.0001). Minor or no difficulties when going to the gynecologist were reported significantly more often by control-group women (31.8% versus 64.2%; p<0.0001). A history of CSA did not result in the anticipated decreased utilization of routine gynecologic services as an adult (70.6% versus 87.6%; NS); however, more women with CSA experiences sought treatment for acute gynecologic problems than did those in the control group: 37.6% and 20.5%, respectively (p<0.0001).
Social support during or shortly after abuse situations had no effect on gynecological care as an adult ("gynecological exam causes important psychological strain:" 40.6% versus 18.8%; NS; minor or no difficulties with gynecological exam: 27.5% versus 37.5%; NS; number of routine gynecological care visits during 3 years before study period: 3.6 versus 3.7; NS; number of visits due to gynecological problems during same period: 2.3 versus 0.8; NS) Socioeconomic status (professional status) showed no correlation with gynecological care (data not shown).
Specific Factors Leading to Stress During Gynecologic Care
Specific difficulties during a gynecologic consultation are summarized in Table 3. Fewer than three women (3.5%) mentioned examinations of the breast, an impersonal relationship with the gynecologist, touching without announcement, and a feeling of helplessness as important stressors. During a gynecologic evaluation, 37 of the women with a history of CSA (43.5%) had experienced memories of the original abuse situation. Triggers for such memories were sentences such as "it will not hurt" (1; 2.7%), lying on the gynecologic table (4; 10.8%), pelvic examinations (4; 10.8%), a treatment without previous announcement (2; 5.4%), the feeling of helplessness (7; 18.9%), and pain (3; 8.1%).
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DISCUSSION
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Suggestions for Improvement of Gynecologic Care
Only 21 women (24.7%) who had experienced CSA felt that disclosing their CSA history to their gynecologist would be helpful. Table 4 shows factors in reducing psychological strain during gynecologic care regarded as important by 52 women with a positive history of CSA. A female gynecologist was preferred over a male gynecologist by 54 of the women after CSA (63.5%) and 45 (26.5%) of the women without such experiences (p<0.0001).
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TABLE 4. Suggestions Made by Women After Childhood Sexual Abuse to Reduce Psychological Strain During Gynecological Consultations (N=52)
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Although CSA is a risk factor for many gynecologic diseases7–20 and although the CSA influences the practice of regular prophylactic gynecologic examinations,21 those results from the study undertaken here and from one other study27 are the only ones focusing on the correlation between CSA and experiences with gynecologic care. According to the results obtained, a history of CSA influences gynecologic care even several decades after the abuse took place. In accordance with the findings of other authors3,24,28 a significantly higher number of women exposed to CSA perceive a visit to the gynecologist as anxiety-provoking and distressing. Results of the same research project on dental care show that women exposed to CSA also more often show major psychological strain during dental treatment, as compared with control subjects (36.5% versus 18.8%; p<0.005; Leeners et al., unpublished), although the results presented show a stronger correlation between CSA experiences and difficulties with gynecological care.
This correlation can partly be explained by aspects of gynecologic care, which are reminiscent of the abuse situation; these include a disparity in power between the gynecologist and the women, the removal of clothing, vulnerability, and potential pain. Because part of these features are also present in dental care, stress seems to be associated with the general situation during a consultation and is not limited to potential stressors such as an pelvic examination. However, a gynecologic examination might be a trigger for memories of sexual abuse. During a gynecologic consultation, 43.5% of the women with a history of CSA (as investigated in this study) experienced memories of the original abuse situation. Triggers for such memories were sentences such as "it will not hurt," which had also been used by a former offender; lying on the gynecologic table; a treatment without previous announcement; the general feeling of helplessness; and pain, all of which represent characteristic features of the original abuse situation.
These results obtained do not confirm results from other authors, who found a trend toward the underutilization of regular gynecologic services in women who had faced CSA experiences.18,28 However, because these data were self-reported, they have to be interpreted with caution. The high frequency of prophylactic gynecologic examinations in women with CSA experiences is likely to be supported by specific features of the German healthcare system, where regular gynecologic examinations are paid for by the health insurance provider. Also, regular gynecologic exams are required in order to receive hormonal contraceptives. However, comparable results have been found for prenatal care. The mean number of prenatal consultations (9.4 versus 10.4; NS) or prenatal ultrasound consultations (4.8 versus 5.5; NS) was not significantly different between women exposed to CSA and control subjects (Leeners et al., unpublished). Although we found no difference between the number of prophylactic consultations in women after CSA and control subjects, the first went significantly more often to see the gynecologist as a result of an acute gynecologic problem. On one hand, this might be explained by a significantly higher number of gynecologic problems;7–18 on the other hand, it might be explained by insecurity regarding gynecologic symptoms resulting from a reduced confidence in her own body, often described as a consequence of sexual abuse.3,6
Although long-term consequences are known to be influenced by social status and the psychosocial support provided, especially during the time of or shortly after abuse,29 these confounders showed no significant influence on the results of the present study.
In accordance with other results,28,30 women with a positive history of CSA had significantly more difficulties with conversations on intimate details of gynecologic care and vaginal examinations, but not with breast examinations. Women with a history of CSA rated the stress level associated with conversation on intimate details, nakedness, and vaginal (ultrasound) examinations significantly higher than control-group women (Table 3). Although increasing experience with pelvic examinations seems to reduce anxiety,31 the pelvic examination remains one of the most anxiety-provoking medical procedures.32 However, having to remain motionless throughout dental treatment was also classified more often by women with CSA as equally intensely stressful (29.4% versus 6.5%; p<0.0001) as a pelvic exam (29.4% versus 3.5%; p<0.0001; Leeners et al., unpublished).
Unfortunately, the patient’s risk of experiencing pelvic examination as a traumatic situation may be increased if her history of abuse is not known to the gynecologist.1 Fewer than 10% of gynecologists discuss sexual abuse experiences when taking patients’ history.33–35 Fewer than 15% of women who have experienced CSA inform a gynecologist about this history,34,36 and only 24.7% of the women in the current study consider conveying this information to their gynecologist as being helpful. This may be due to the fact that nearly half (46.2%) of the women who try to discuss their sexual abuse history with their gynecologist receive a negative reaction.6,34 Women with CSA experiences may also be failing to make the connection between abuse and their present health problems.35
Women in the study with a positive history of CSA assume that most gynecologists would benefit from training focusing on potential sequelae of CSA and specific needs of women with CSA experiences. In Germany, education about sexual violence is neither part of the medical school curriculum nor part of the training for residents in any subspecialty.34 Gynecologists have no clear guidelines on how to identify, treat, or counsel a woman with a history of sexual abuse.34 Women with CSA experiences want their gynecologist to be particularly friendly, patient, sensible, and sympathetic. More than half of the women (55.8%) want to discuss their experiences with their gynecologist and would appreciate either a question from the gynecologist or an indirect investigation of such experiences, for example, with a questionnaire. However, although directly asking about CSA experiences strongly increases the rate of disclosure,37 the gynecologist needs to ask about women's difficulties with gynecologic care in a way that allows the women with CSA experiences to voice known problems without having to disclose past abuse.38
According to our results, women with CSA experience prefer a female gynecologist. However, given that the perpetrator may also have been female, women gynecologists have to be aware that they may not generally perceived as "safer" than a male gynecologist. According to the suggestions of these and other women with CSA, they may benefit from anything that increases their feelings of control, especially during vaginal examinations.3 Examinations should be carefully explained; the atmosphere should be adapted to patient needs; and, at each step of the examination, the women should be asked for permission. At any time during the examination, they should be able to have it stop when they reach their personal limits. Sentences that might also have been used in the abuse situation (e.g., "it will not hurt" or "please relax") should be avoided. For some women, continuous verbal contact to help stay in the actual situation is helpful.33 In case of a positive history of CSA, there is also an increased risk for current abuse.39 Therefore, it is important to exclude current abuse, which should always be done in the absence of a possible abuser. Because the risk for abuse and life-threatening injuries is particularly high when leaving an abusive partner, such a step has to be intensively anticipated.
Generalization of these results are limited by several factors: Compared with other groups of sexually traumatized women, this study group includes a particularly high number of women with risk factors for long-term sequelae, such as an early beginning and a long duration of abuse experiences, as well as a close relationship with the perpetrator.7 This finding is in accordance with the fact that all traumatized women in this investigation sought help from a support center in order to overcome actual problems resulting from the abuse experiences. As a result, the correlation between CSA and experiences with gynecologic care found in our study will probably not be representative of all women with a positive history of CSA.
Women having experienced CSA may deny or even not remember these experiences, thereby adding "false negatives" to the control group. The implication for the present study is that actual between-group differences may have been underestimated.
The cross-sectional design of the present study implies that analyses provide associations but not causal relationships. Despite matching for several confounders, there were more laborers and managers in the case group, whereas control-group women were more often mid-level employees. As expected, women after traumatization were significantly more likely to be separated.39 Therefore, we cannot excluded the possibility that part of the difference can be attributed to differences in socioeconomic level. However, differences in socioeconomic level by professional status showed no correlation with measures of gynecological care.
To our knowledge, there are no validated questionnaires focusing on experiences with gynecologic care after CSA. Therefore we had to develop a questionnaire for this study. Because there are no data on validity and reliability of our questionnaire, the results have to be interpreted with caution. Also, there are no data on reliability and validity for the Wyatt instrument.
The strength of this study is that diagnoses of CSA history were investigated in a therapeutic setting and, therefore, are very reliable. Also, the presented case group represents only women who experienced sexual abuse during childhood. Another strength of the study is the use of a control group. Because women with CSA and control-group women were matched for age, differences between groups cannot be explained by bias resulting from the time since childhood (i.e., experience in dealing with the CSA history). Often, women with a history of CSA have less confidence in their abilities as a mother,40 so that they more often decide against having a family, which provides for more homogeneous groups, as with the one presented here, where subjects gave birth to at least one child. The fact that nearly 100% of the women in both groups are Caucasian further adds to the homogeneity of the study group.
Women with a positive history of CSA differ from control-group women in their experiences with gynecologic care. The consultation, communication with the gynecologist, and the vaginal examination are particularly difficult for women exposed to CSA. The gynecologic sequelae of CSA experiences emphasize its importance in routine gynecologic care. Gynecologists should be systematically educated in dealing with sexual violence so that they can respond with sensitivity to disclosures and offer established counseling structures to give these women the support they need to implement adequate gynecologic care.
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ACKNOWLEDGMENTS
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The first and second author have contributed equally to the manuscript.
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ABSTRACT
INTRODUCTION
