Women's victimization history and surgical intervention

AORN Journal,  Jan, 2003  by Debra Pilling Hastings,  Glenda Kaufman Kantor

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Violence against women by an intimate partner is recognized widely as a significant health problem and is believed by many to have reached epidemic proportions in the United States today. An intimate partner is defined as a spouse, ex-spouse, boyfriend, ex-boyfriend, girlfriend, ex-girlfriend, or date. (1) Intimate partner violence (IPV) is the reason an estimated 25% to 50% of all women present for treatment in emergency rooms. (2) Women who have been battered or sexually assaulted use health care services at much higher rates than women who have not experienced abuse, (3) and they have health care needs that go beyond the original trauma. Women who are abused are more likely to suffer from a range of chronic and acute illnesses than women who are not abused, yet few studies have considered the possibility of associations between victimization-related illnesses and surgery for abused women.

Recently, the trauma committee of the American College of Surgeons (ACS) issued a formal statement of its recognition that IPV is a major public health problem and acknowledged that victims frequently are in need of surgical care. (4) According to the ACS, surgeons regularly treat women with injuries ranging from minor lacerations to severe blunt and penetrating wounds without an awareness of their patients' victimization status. The ACS statement suggests that IPV be viewed as causally related to these injuries. A practitioner who fails to diagnose IPV may be unsuccessful in the identification of a disease process that can be chronic.

THE RELATIONSHIP BETWEEN VICTIMIZATION AND POOR HEALTH

One group of researchers found significant results in their study of the relationship between abuse in childhood and negative health outcomes in adults. (5) Self-reporting female participants (n = 1,225) were selected randomly from a health maintenance organization in the northwest and grouped according to the amount and type of childhood maltreatment experienced. A history of abuse and neglect during childhood was acknowledged by nearly half (ie, 43%) of these women. History of childhood victimization was associated significantly with adverse physical health outcomes experienced as adults. The number of different types of maltreatment experienced was correlated significantly with the number of physical symptoms identified, diagnoses by physicians, increased functional disability, and health risks. The physical symptoms included nausea, diarrhea, constipation, fatigue, insomnia, abdominal pain, back pain, and chest pain. There was no specific analysis of surgical intervention in this study, however. The researchers suggest that knowledge of a possible connection between history of childhood maltreatment and poorer health status during adulthood should be taken into consideration when caring for women who may have survived such treatment as children.

In addition to the acute physical trauma and injury, the consequences of victimization can include increased susceptibility to depression, post-traumatic stress disorder (PTSD), and other psychological symptoms in both children and adults, which may lead to greater use of health care services related to these disorders. (6) Few studies have taken into account the cumulative effect of multiple victimizations (ie, abuse as a child and IPV experienced as an adult) on health care service use. Most studies to date have focused only on IPV, and little research has examined possible links between victimization and surgery. Consequently, the focus of this study is the cumulative effects of women's victimization and the need for surgical intervention throughout a lifetime.

HEALTH CONSEQUENCES OF VICTIMIZATION

Physical assault on women by intimate partners is recognized widely as a leading cause of injury to women in the United States. (7) In addition, some studies suggest that many women who are victims of IPV report being sexually abused by their partners. (8) Intimate partner violence may be part of a system of domination and control that includes emotional, verbal, and economic abuse, as well as sexual assault, coercion, or injury. (9)

Acute health consequences. Intimate partner violence is a significant risk factor for many injuries and systemic disorders and diseases. Facial lacerations and skull, neck, and orbital trauma can occur as a result of direct force or assault to the head, neck, and face. (10) Various types of fractures have been documented in women either from direct force or as the result of victims' attempts to defend themselves from physical assault. Direct force to the chest can produce pneumothorax. Internal injuries to the spleen, liver, and kidney occur when patients are punched or kicked in the abdomen or back. Forced sexual intercourse can cause vaginal bleeding and vaginal or anal tearing, or it may lead to development of hemorrhoids.

Chronic health symptoms. Chronic complaints, such as headaches, abdominal pain, fatigue, and musculoskeletal or soft tissue pain, and multiple admissions for undefined conditions could be indicative of ongoing violence in a relationship. (11) The effects of victimization on gynecologic symptoms, such as pelvic pain, bladder infection, and dyspareunia, (12) and gastrointestinal diseases, such as dyspepsia, abdominal pain, or irritable bowel syndrome, (13) also have been examined.