Case 24

Long-term Physical & Psychological Sequelae of Childhood Sexual Abuse

Objectives:

  1. To highlight the longterm physical and psychological effects of childhood sexual abuse (CSA)
  2. To emphasise the doctor’s important role in identifying patients with a history of CSA so that victim-survivors are treated holistically, using a multifactorial perspective with a biopsychosocial lens, which sees a complex interplay between past and present; physiological, psychological and social factors [1]
  3. To underline that holistic, rather than symptomatic treatment will help prevent retraumatisation of victim-survivors (victims of CSA are much more likely to be raped as adults) [2] as therapy helps them develop a stronger, more positive sense of themselves. Inadvertent iatrogenic retraumatisation by doctors eg with painful Pap smears will also be avoided by doctors who understand the aftermath of CSA

 

Narrative Case:

When Elyse, a 28 year old nurse developed debilitating irritable bowel syndrome (IBS), she went to a new doctor. In response to the doctor’s detailed questions as part of initial assessment, Elyse told her that work was okay but she was having a few problems with her boyfriend. Sex was sometimes painful, but she tried not to show it. She had occasional migraines, her periods were heavy and painful and she was treated with antidepressants for 3 years in her early twenties. She was a binge drinker as a teenager. She’d only ever had one Pap smear 8 years ago and it was excruciating.

The doctor said to Elyse that when women had a range of painful and debilitating symptoms like she did, sometimes something emotionally painful had happened to them in the past – physically or sexually. Elyse, to her surprise, felt safe enough to tell this doctor what she hadn’t told anyone in over 20 years. Then again, no-one had ever asked. Her uncle had sexually abused her: but she couldn’t see how what her uncle had done could be connected to any of her symptoms – it happened over 20 years ago.

After talking about the abuse for the first time, Elyse became anxious. The doctor was very supportive. She told Elyse that she was suffering from a form of posttraumatic stress, likening her experiences to a soldier. She said Elyse must never blame herself; the shame belonged to the perpetrator. Having kept it all in for so long, Elyse had developed a range of physical and psychological symptoms as well as having the emotional pain of abuse to deal with. The doctor said that first they needed a plan to deal with the painful aftermath of disclosure, and then she wanted to see Elyse regularly to make sure that her physical and psychological health were attended to and treated holistically.

Background information

Prevalence: One in three women are affected by a history of SV (in Australia). The overwhelming majority do not tell anyone, including their treating health professionals, for decades, if at all [3].

Learning points and Background

  1. The long-term health consequences of sexual trauma in women include a range of psychosomatic symptoms including IBS, headaches, gynaecological and obstetric problems, various mental health problems and health risk behaviours as well as avoidance of preventative health examinations such as Pap smears. Such avoidance is of concern as these women have an increased risk for sexually transmitted infections, cervical dysplasia, and an increased prevalence of invasive cervical cancer  [2]
  2. Depression, anxiety, stress and posttraumatic stress disorder (PTSD) associated with historical SV may increase affected women’s risk for other problems including alcohol abuse, binge drinking and substance abuse. CSA victim-survivors also have a greater risk for suicide and accidental fatal drug overdose [2]
  3. A biopsychosocial model of diagnosis and treatment conceptualises symptoms such as IBS, vaginismus (pain with sex and/or Pap smears), recurrent headaches and gynaecological symptoms as psychosomatic symptoms: the symptom, expressed in the body (soma), has its origins in mind (psyche) and body and alerts us to painful feelings. Based on this understanding, an integrated approach which addresses painful feelings as well as treating bodily symptoms is required [4]
  4. Patients should be asked about a history of SV if they present with multiple psychosomatic symptoms or health problems, have a history of engaging in health-risk behaviours eg drugs, alcohol or unprotected sex, or avoid or have difficulty with medical examinations or procedures [5] eg pain with Pap smears or avoidance of Pap smears [6]. Given that the biggest risk factor for cervical cancer is not being screened regularly, it is important to ask women if they have had their routine health checks, and if not, find out why not.
  5. Most victim/survivors do not tell their treating practitioners about a history of SV unless they are asked [3]
  6. Patients should only be asked after a good rapport and trust have been established between patient and doctor.
  7. The doctor should only ask if she feels comfortable discussing these sensitive matters and dealing with the aftermath of disclosure. Undergraduate and postgraduate teaching should have modules to help doctors feel competent in this important area of practice [3]. The doctor needs to know of appropriate professionals she can refer to if she is not going to do the counselling herself [5] as well as providing ongoing medical care to treat and prevent health problems.
  8. Many patients think that they should have sex even if it hurts. Some doctors and patients believe that “getting a Pap smear over quickly” will shorten the duration of pain and therefore be helpful. However, doing this can inadvertently re-traumatize a patient who has a history of sexual abuse (iatrogenic traumatic examination). To avoid this, doctors should never proceed with a Pap smear if the patient says it is painful or if she is afraid. Similarly, patients should be encouraged not to participate in painful penetrative sex, whilst still maintaining a sexual relationship. In both cases the pain or fear need to be treated first.

In Australia, a referral can be made to a psychotherapist who can help the patient make connections between the physical (how it feels) and emotional (what has happened/ is happening in her life and how it has affected her). She can also be referred to a specially-trained physiotherapist with skills in patient education (anatomy, physiology of sexual response) and gentle examination. Penetrative sex can be resumes and a Pap smear can be done when the patient feels comfortable emotionally and physically (confident there will be no pain).

References

  1. Boyer SC, Goldfinger C, Thibault-Gagnon S, Pukall CF. Management of female sexual pain disorders. Adv Psychosom Med 2011; 31: 83-104
  2. Taylor,SC, Pugh J, Goodwach R, Coles J. Sexual trauma in women. The importance of identifying a history of sexual violence. Australian Family Physician 2012;41:538-541
  3. Australian Women’s Coalition, Australian Federation of Medical Women, Victorian Medical Women’s Society. Happy Healthy Women Not Just Survivors Consultation Report: Advocating for a long-term model of care for survivors of sexual assault. 2010.
  4. Goodwach,R. Sex Therapy: Historical Evolution, Current Practice. Part 2. ANZJFT 2005; 26,4,178-183
  5. Leserman J. Sexual abuse history: Prevalence, health effects, mediators, and psychological treatment. Psychosom Med. 2005;67:906-15.
  6. Farley M, Golding JM, Minkoff JR. Is a history of trauma associated with a reduced likelihood of cervical cancer screening. J Fam Pract 2002, 51: 827-31

 

Case 22

Domestic violence in a health care professional

Objective: To illustrate the typical excuses of women who keep staying in an abusive relationship

Narrative case:

Nicole is 35, married for 8 years and has two young children. She works as a nurse in a hospital. She comes for an anaesthetic consultation before surgery in the day care unit. She is pretty and healthy with no past medical history of note. As part of clinical examination, she is asked to take off her blouse which has long sleeves and the scarf around her neck but she refused [1]. The female doctor tells her that without examination there is no anesthesia: she is a nurse and she surely understands this fact. She removed her clothes and it is immediately obvious why she was so hesitant: she had many bruises on her arms and around her neck as if somebody had tried to strangle her [2]. She admitted that her husband beats her “but only when he thinks that she has done something wrong”. The doctor says she can give Nicole a medical certificate describing her bruises and advises her to take it to the police station where she lives [3].  She says “I can’t do this because of my two children”. She is counselled that one day her husband will kill her and that she must think about her children’s future. She agreed and left with the certificate. One week later she came back for her anaesthetic and is asked if she has complained at the police office. She said: “No, it was too dangerous for my children but I have always got the certificate”[4]. She has not been seen again.

Learning points:

  1. It is necessary to be concerned about any woman who does not want to take off her clothes for a medical examination by a female doctor. It is important to think about the fact that she does not want the doctor to discover what she wants to hide.
  2. Even healthcare professionals, in this case a female nurse, can try to hide the physical findings which show she has been subject to domestic violence from a female doctor.
  3. It is important to try and convince a woman battered by her husband that she has the right and even the duty (if she has children) to lodge a complaint against him. However, this is often very difficult because she feels guilty about her husband’s behaviour.  
  4. Women subject to domestic violence often do not complain because they have young children and feel they dare not do this for fear of the consequences from their partner.

 

 

 

 

Case 18

Domestic violence is independent of education, economic situation, social class or culture

Objectives

  1.  To show that domestic violence is independent of education, economic situation, social class or culture.
  2.  To show that emotional abuse is often a precursor to serious acts of physical abuse.

Narrative Case

Dr. Bob Smith is a general surgeon and his wife, Dr. Carol Jones, is a general practitioner, both practising in an urban setting.  They have been in practice for ten years. They met in medical school and married in their first year of residency.  They have two children, ages 5 and 7.  [1]

Carol took three weeks off on maternity leave with each child, as her practice was still relatively new at that time and she did not feel she could take the year maternity leave that many of her friends in salaried positions could take. [2]

Things are not going well. Bob is on call every second night since the third general surgeon left for the States last year and the hospital has not been able to attract another surgeon.  He is so tired that he wonders at the completion of some surgeries whether he has done his best.  He is currently in the middle of a legal suit, which is taking so much of his time.  He finds that if he comes home at night and drinks vodka, he feels much more relaxed and yet does not have to worry about the smell of alcohol on his breath if he should get called back. [3] He does not want to seek help in case word of his difficulties negatively influences his medical practice.

Carol is becoming increasingly stressed as well.  Her office is always overbooked, as she has had to cut down to 3 days of office work, to be able to take care of the needs of the children.  She still has the office overhead to contend with, but not the volume of patients to justify the costs.  She is feeling more like a single parent, running the two children to lessons and sports by herself as Bob is always either at the office or the hospital.

On one particularly tiring day, Carol comes home after the children’s swimming lesson to find Bob drunk and asleep on the couch.  After putting the children to bed, Carol awakens Bob and confronts him with his increasing use of alcohol and withdrawal from family duties.  Bob is so angry that he hits Carol and blackens her eye.

At the office the next day, Carol makes up an excuse about a household injury to explain her black eye.  She realizes that Bob is a good husband and that the stress of work, the current litigation, both coupled with alcohol, brought out this atypical behaviour. [4]

After repeated episodes of physical abuse, their relationship deteriorates and Carol tells Bob that she is going to leave him and take the children.  Bob pleads for Carol to go to joint counselling, as he has not been himself and really does love them all.

Carol does not have much hope for success from the counselling, but feels guilty about leaving, so she gives counselling a try.  The female counsellor feels threatened dealing with two physicians.  After six sessions, nothing is resolved and Carol makes plans to leave with the children. [5]

Bob finishes his court case and is found guilty of malpractice.  He wonders what is the point in living—his reputation as a surgeon is tarnished, his wife and children are leaving him and he is exhausted and overworked.  He goes home and drinks.  When he hears Carol and the children driving into the garage, he picks up his hunting rifle, killing them and then turning it on himself. [6]

Learning points

[1] Medical marriages are often difficult.  The woman often has to take second place to her husband in career choice and academic advancement.

[2] Women physicians often have an excessive sense of commitment to make their work successful, just to show that they are capable of “having it all”-career, family, husband, etc.

[3] Bob realizes that he is not coping but as a physician and leader in the community does not want to let anyone know that he needs any help.  He turns to substance abuse.

[4]   Despite having counselled patients against staying in a relationship where there has been physical abuse, Carol makes excuses for Bob’s behaviour.

[5]  Being in a position of authority when seeking personal help is not always an advantage.  The male often presents a more threatening figure than the female and this may affect the performance of the caregiver and consequently the outcome.

[6]  Accustomed to being in control and being an authority figure, Bob cannot cope with all these loses and having humbled himself to go to counselling and that failing, he decides that there is only one alternative.  He struggles with feeling powerless in a society that tells him he should be powerful, with the seeming lack of options and with the socialization that has taught him not to seek help.  All this translates into violence against his female partner

 

Case 17

Domestic Violence in Immigrant Family in Canada

Objective:  To illustrate how adjusting to a new culture conflicts with traditional values and results in violence

Narrative Case

Inderpal was the youngest of three siblings.  She had an older sister and an older brother, both of whom had been born in the Punjab in India.  Her family moved to Surrey, BC, from India, looking for better opportunities for their children.  Inderpal was born when her older siblings were 10 and 12 and she was the only one of the three children born in Canada.  

The family was very traditional and the temple was a big part of their lives.  Despite living in Canada, her older sister and brother thought and acted like their immigrant parents and never caused their parents any grief.  Inderpal was very Canadian and had a multi-ethic group of friends. [1]

In high school, Inderpal liked to go to parties where she would smoke and drink and do drugs.  When she started to date a white boy from College, her family felt that she had overstepped the limits.  Despite their demands to stop dating this boy, Inderpal said she was Canadian and could do what she wanted.  When the family would go to temple, they could see others looking at them and knew they were talking about Inderpal’s behaviour.

Inderpal’s brother felt that she was destroying the honour of the family.  He had given it lots of thought and decided that he must make things right.  One night he waited for her to leave a party, intercepted her and dragged her into the bush, where he promptly stabbed and killed her.  He put her body in the trunk of the car and drove out to a rural area where he could leave her body where it would not be found. [2]

Learning Points

[1]  Despite moving to Canada, assimilation is not easy, as Canada encourages multi-culturism where immigrants are encouraged to live according to their traditions and values.  When immigrants come from very traditional countries, there is often difficulty embracing the more liberal Western way of life.  This often leads to family conflict.

[2]  Honour killings are the term given to murders performed because the victim has brought shame to the family by their behaviour.

Background Information

Honour killings are distinct from domestic violence for three reasons:

  • Honour killings are planned in advance
  • Honour killings can involve multiple family members in the killings
  • Perpetrators of honour killings often do not face negative stigma in their families or communities

In 2000, the United Nations Population Fund (UNFPA) estimated that there were at least 5,000 honour killings world-wide annually, which may be an underestimate because many cases go unreported or are falsely reported as suicides.  Although this practice is currently primarily associated in media reports with certain Arab cultures, variations of harmful cultural practices toward women involving violence based on notions of honour have been known in many cultures world-wide  and in many historical times.

Background:

This reference provides general information and background about Honour Killings, including a basic classification system and consideration of the “reasons” given for this type of violence against women:

http://www.meforum.org/2646/worldwide-trends-in-honor-killings

References

  1. The Canadian Bar Association Service Barriers for Immigrant Women Facing Domestic Violence http://www.cba.org/CBA/conf_women/Women_Newsletters2013/barriers.aspx
  2. Honour Killings on the Rise in Canada http://www.canada.com/life/Honour+killings+rise+Canada+Expert/3165638/story.html
  3. LawNow  A Spotlight on Family Violence and Immigrant Women in Canada
  4. http://www.lawnow.org/family-violence-and-immigrant-women/
  5. Preliminary Examination of So Called Honour Killings in Canada; Prepared for the Canadian Department of Justice
  6. http://www.justice.gc.ca/eng/rp-pr/cj-jp/fv-vf/hk-ch/hk_eng.pdf

Case 16

Domestic Violence in First Nations People on the Vancouver Downtown Eastside and its Connection to the Highway of Tears

Objective:  To illustrate an all too common scenario of domestic and sexual violence involving the First Nations people in Canada.

Narrative Case

Yvonne was a 15 year old First Nations teenager from the Niiska nation in the
province of British Columbia in Canada. She was born on a First Nations reserve
where she was raised in a family where violence was the norm [1]. Her mother and father married at 16 years of age and had six living children and several miscarriages [2].  Her mother was an alcoholic and found it difficult to cope with the duties of motherhood and being a housewife.  She also had tremendous guilt as two of her children had been diagnosed with fetal alcohol syndrome and were extremely difficult to handle. Her father was a labourer and was often away from home working in the oil and gas industry in other parts of the province. When he did come home, he introduced his wife to cocaine, the habit of which he had acquired whilst away [3].  As soon as they were together, there were episodes of verbal abuse often followed by her father beating her mother [4].
As the oldest of the six living children, Yvonne often took on the responsibility for her younger siblings [5]. She frequently had to miss school as she had to look after the house and her brothers and sisters.


At age 14 years, her best friend, Brenda, urged her to move  with her to Vancouver. Brenda’s older sister had moved there a year ago and was making a good living as a waitress. The older sister said she could get them a similar job if they came
down and they could share her accommodation until they had money of their own.
It was hard for Yvonne to tell her mother that she was going to leave, but felt
so hopeless that she thought this would be a chance to get away from her present life which was so miserable [6].


Soon after arriving in Vancouver, Yvonne and Brenda found that things were not
as rosy as Brenda’s sister had promised. The sister’s accommodation consisted of a room with a single bed and a hot plate in a converted old hotel in the Downtown Eastside that the government had provided for those in dire need. The sister’s waitressing job had ended when she repeatedly missed work due to being hung over from using alcohol and drugs the night before. The sister had been befriended by this nice guy who turned out to be a pimp [7]. He kept the sister on drugs.
Yvonne and Brenda could not find work and without work they could not afford to leave the sister’s accommodation. The pimp soon had them working for him as well.
One day, Yvonne decided that she must leave and return home despite all the dangers in doing so.  She did not have the bus fare so was planning to hitchhike back home.  She was never seen again.  Her picture appears on the list of Missing Women– Prostitutes Kidnapped and Presumed Dead while hitchhiking along the Highway of Tears [8].

 

Learning Points

[1] Research indicates that males exposed to domestic violence as children are more likely to engage in domestic violence as adults; similarly, females are more likely to be victims.

[2]  Girls who marry before 18 years are more likely to experience domestic violence than their peers who marry later. Child brides often show signs symptomatic of sexual abuse and post-traumatic stress such as feelings of hopelessness, helplessness and severe depression.

[3] Women who have been abused are fifteen times more likely to abuse alcohol and nine times more likely to abuse drugs than women who have not been abused.

[4]  This is a typical pattern in Domestic Violence: alcohol and/or drug abuse leads to fighting and then reconciliation.  In many cultures a woman had little option but to endure the situation since leaving the man may make her more stigmatized or vulnerable or she may have no economic support without him.

[5]  Female children especially become ‘parentified’, taking on the role of ‘little mother’ in the household.  This pattern of caring for others – no matter how dysfunctional or even abusive they are – becomes entrenched and is repeated in adult life. Generally it is reinforced by cultural prescriptions of appropriate female roles and behaviours.

[6] Most people with this profile are running away from impoverished and/or neglectful and/or abusive families.  They are impulsive and aggressive – they have a fragile sense of self worth and cultural mores of masculinity may dictate that they not acknowledge this fragility but rather that they express aggressive and challenging behaviours.

[7] Adolescent girls who have been abused and neglected are easily attracted to a man who seems able to take care of them and offer protection.  There was also the social imperative that she be attached to a man – in most cultures this is necessary to provide a woman with status and with ‘protection’. In some cultures a woman has no social and/or economic option but to remain with her male partner.

[8] First Nations women disappear while hitchhiking along the Highway of Tears and are never found again.  The communities along the highway share a situation of colonization resulting in experiences of poverty, violence, cultural genocide, residential school impacts, addictions and displacement from land.  In 206 there was a Symposium to raise public awareness and create a call for action.  To see the full Highway of Tears Symposium Recommendations Report, please click here.

Background Information on Domestic Violence

Child marriage directly threatens the health and well-being of girls: complications from pregnancy and childbirth are the main cause of death among adolescent girls aged 15-19 years in developing countries. Girls aged 15 to 20 are twice as likely to die in childbirth as those in their 20s, and girls under the age of 15 are five times as likely to die.

Women who have been abused are fifteen times more likely to abuse alcohol and nine times more likely to abuse drugs than women who have not been abused.  The American Department of Justice, in 2002, found that 36% of victims in domestic violenceprograms also had substance abuse problems.

In a report from Statistics Canada on violent victimisation of Aboriginal women in 2009, 15% of Aboriginal women reported being a victim of spousal violence in the preceding five years compared with 6% of non-Aboriginal women, and 59% were more likely to report injury than the 41% of non-Aboriginal women.

From 1989 to 2006 nine young women went missing or were found murdered along the 724 kilometre length of highway 16 now commonly referred to as the Highway of Tears. All but one of these victims were Aboriginal women.

First Nations women are overrepresented in prostitution, with an especially high number of Canadian youth in prostitution from First Nations.

 

References

  1.  Library and Archives Canada Cataloguing in Publication British Columbia. Missing Women Commission of Inquiry Forsaken [electronic resource] : the report of the Missing Women  Commission of Inquiry / Wally T. Oppal, Commissioner. Complete contents: Vol. I. The women, their lives and the framework of inquiry,  setting the context for understanding and change – v. II. Nobodies, how and why we  failed the missing and murdered women – v. III. Gone, but not forgotten, building the  womens legacy of safety together – v. IV. The Commissions process. – Executive summary. Issued also in printed form Includes bibliographical references. ISBN 978-0-9917299-7-5
  2. Serial murder investigation–British Columbia. 2. Missing persons–Investigation
  3. –British Columbia. 3. Murder victims–British Columbia. 4. Pickton, Robert
  4. William. 5. British Columbia. Missing Women Commission of Inquiry.
  5. Downtown-Eastside (Vancouver, B.C.). 7. Governmental investigations–British
  6. Columbia. I. Oppal, Wallace T II. Title.
  7. HV6762 B75 B75 2012 363.259523209711 C2012-980202-6
  8. http://highwayoftears.org/about-us/highway-of-tears
  9. http://highwayoftears.org/uploads/Highway%20of%20Tears%20Symposium%20Recommendations%20Report%20-%20January%202013.pdf
  10.  Child Marriage
  11. http://www.hrw.org/news/2013/06/14/q-child-marriage-and-violations-girls-rights
  12. http://www.icrw.org/child-marriage-facts-and-figures
  13. http://wcd.nic.in/childact/draftmarrige.pdf
  14. http://en.wikipedia.org/wiki/Child_marriage
  15. http://www.unicef.in/documents/childmarriage.pdf
  16. http://greaterkashmir.com/news/2011/Mar/29/the-practice-of-child-marriage-6.asp
  17. http://www.icrw.org/files/images/Child-Marriage-Fact-Sheet-Domestic-Violence.pdf
  18.  Violent victimization of Aboriginal women in the Canadian provinces, 2009
  19. http://www.statcan.gc.ca/pub/85-002-x/2011001/article/11439-eng.htm
  20. Report on Violence Against Women, Mental Health and Substance Abuse by Canadian Womens Foundation.
  21. http://www.canadianwomen.org/sites/canadianwomen.org/files/PDF%20-%20VP%20Resources%20-%20BCSTH%20CWF%20Report_Final_2011_%20Mental%20Health_Substance%20use.pdf
  22.  Prostitution of Indigenous Women:  Sex Inequality and the colonization of Canadas First Nations Women
  23. http://www.rapereliefshelter.bc.ca/learn/resources/prostitution-indigenous-women-sex-inequality-and-colonization-canadas-first-nations-

Case 10

Lifelong Impact of Childhood Sexual Violence – Joanne’s story

Objectives

  1. To show how childhood sexual violence is kept secret within affected families
  2. To show how the consequences of childhood abuse manifest in physical illness
  3. To discuss impact on multiple health domains over a lifetime

Narrative Case

Joanne is a 53-year-old patient I have known for over 10 years in my family practice. She has had multiple health conditions including severe asthma, migraines, and most importantly, chronic pain as well as depression that was diagnosed as chronic myofascial pain over 20 years ago. She has been treated for the pain and depression for over 20 years. She still frequently rates her pain as 10/10 in severity and describes the major impact it has had on her life, work and marriage. She went on to develop OA of the back including some disc pathology and pinched nerves leading to intractable neuropathic pain, and has had multiple surgeries, carpal tunnel syndrome leading to surgery, elbow tendonitis leading to surgery, ulnar entrapment syndrome leading to surgery, dental pathology and bone loss leading to surgery, and more. Repeatedly the surgeries fail to calm the various pains attributed to multiple orthopaedic pathologies.

Joanne has a family history of mental illness. 5 years ago, Joanne’s sister attempted suicide. In reading her note and talking to her afterwards, Joanne learned that the man with whom they were living had assaulted her sister sexually. When Joanne was 8, her parents divorced and she and her sister lived with an aunt and uncle. From age 9 through 16, whenever her aunt left the house, Joanne (as well as her sister) were repeatedly sexually assaulted by her uncle. He would hold her down with one hand over her face and force oral sex on her. She describes feeling suffocated and this being the start of her asthma. She has been angry about this but had never mentioned it to anyone until her sister’s attempted suicide, not even when she and I directly discussed this over the many years I knew her. Hearing her sister’s story, she acknowledged her own. She drew her courage and confronted the uncle and actually taped his response to her question “Why did you do this to me all these years?” and he replied, “You never stopped me”. She, with the help of counselling from multiple sources, and with much trepidation, ultimately decided to press legal charges against her uncle, a process that took five further years, all the way to the Supreme Court of Canada. Her uncle was ultimately found guilty. Her depression was now more clearly related to her trauma as posttraumatic stress disorder (PTSD). The stress of this confrontation process itself has had huge impact on her health over a period of about five years, both before the disclosure and after. She describes feeling guilty for never having told anyone before and possibly having prevented him from doing this to her sister, to her cousins and his grandchildren. Her anger is always under the surface.

Currently Joanne is using appropriate medication, working hard to take care of herself, yet still feels “totally debilitated” and says she would like to “amputate her painful right arm” She uses willpower to control the pain along with her long acting opioids and feels she will never be able to return to work. Aside from chronic pain and depression, she is having financial problems, social isolation, nightmares and significant dental problems, which she attributes to her sexual abuse directly. Her asthma may also link to the abuse as vocal chord dysfunction. She attributes vaginal warts and anal pain since childhood as well. Most recently she has been attending the “Darkness to Light” program from the Voicefound organization to help her and she still has court issues as the “victim impact” is still being quantified. She is not yet out of the woods for having come forward. She is a survivor and she is able to see it as a positive step towards reclaiming her wellness however.

Learning Points

[1] Girls in Canada are sometimes subjected to repeated rape by family members and will not be able to discuss the past traumatic issues even when asked directly about this. These are well-guarded family secrets and there are many reasons why. There are resources that can help healthcare providers facilitate this necessary but difficult step in the healing process.

[2] Even as physicians who are well aware that childhood sexual assault puts women at higher risk for many different illnesses, chronic pain, marital problems and depression, we will be dealing with patients who are simply unable to tell their story. The index of suspicion of childhood trauma must go up when dealing with comorbidities such as chronic pain, depression, unexplained pelvic or anal pain and many other chronic debilitating conditions. These are described in further depth in the background information that follows

(3) Guilt and anger are very powerful pathogens. Community resources can help a woman understand past events and put them into context. Police services can help. Family services, psychologists, social workers, and other counsellors as well, as this problem needs a village to solve it. A family physician that knows a woman over time can build trust slowly. Even an astute asthma specialist can help identify the problem. Eyes and ears must be open for the underlying story. The practitioner’s index of suspicion can be honed. The office can have reading material that demonstrates this is a topic that would be welcome to discuss. The environment has to be right, the timing as well. Not all stories are told all at once

(4) Telling a story is not the end of the problem but more like a beginning of healing. Community resources like Voicefound can help.

(5) The physician’s patient records that contain detailed clear accounts of childhood abuse are extremely valuable for the adult seeking legal help, and should remain available to those who seek them. Joanne’s case might have taken far less than 5 years if that information had been available to her.

Background information (related to child sexual abuse)

  1. A Review of Child Sexual Abuse Prevalence Studies suggests the child sexual abuse prevalence rate for girls is 10.7% to 17.4%* and the rate for boys is 3.8% to 4.6% .95% will know their perpetrator.
  2. The National Clearinghouse on Family Violence has data on prevalence as well as resources for prevention:
  3. National Clearinghouse on Family Violence
  4. Family Violence Prevention Unit
  5. Public Health Agency of Canada www.phac-aspc.gc.ca/nc-cn
  6. Canadian data on child maltreatment including sexual and physical abuse and neglect can be found at http://www.phac-aspc.gc.ca/ncfv-cnivf/pdfs/nfnts-2006-maltr-eng.pdf

References

  1. Excellent Resources for survivors and for healthcare providers can be found at Voicefound.   http://www.voicefound.ca/
  2. A handbook for health care providers summarizes prevalence, traumogenic illness, and how to approach survivors in practice: http://www.voicefound.ca/wp-content/uploads/2011/03/Handbook-on-Sensitive-Practice.pdf
  3. Darkness to Light sexual abuse prevention training is available at workshops through Voicefound:http://www.voicefound.ca/events-category/stewards-of-children-training/
  4. http://www.d2l.org/site/c.4dICIJOkGcISE/b.6035035/k.8258/Prevent_Child_Sexual_Abuse.htm#.VEW4ibxdWO8

Case 6

Case of First Domestic Violence in Pregnancy

Objective: To show that violence during pregnancy may be a more common problem than conditions for which pregnant women are routinely screened

Narrative Case

Mandy was a 23-year old patient currently 28 weeks pregnant.  I had delivered her and was her only doctor since birth.  I knew her quite well as she had asthma and spent more than the usual time in my office.  I also looked after her mother and sister and grandmother.

She did not do well in school and hung with the rough crowd.  Although we had talked about contraception on previous visits, she was unreliable taking her birth control pills.  Therefore, it was not a surprise to find her presenting to my office for pregnancy care.  Her relationship was unstable but at present she was living with the baby’s father, an El Salvadorian immigrant involved in the drug trade. [1]

The pregnancy was progressing uneventfully until one day Mandy presented with facial bruising and abdominal pain.  Through sobs, Mandy told me that her boyfriend had beaten her up because she refused to have sex with him.  He punched her in the face and kicked her in the belly.  She had called the police and they arrested him overnight but he was being released later that morning. She had been to emergency and found to be physically okay.  She did not know what to do. [2]

Pregnancy-wise, she was fine, but was emotionally distraught and not sure of her options.

I was able to put her in contact with the Ending Violence Association, which is an umbrella organization for services available for victims of domestic and sexual violence.  They were able to get her into a safe house, where counselling and social services were available.  She managed to make a clean break from the relationship and went on to deliver a healthy son, with ongoing support from social services and her family. [3]

Learning Points  

[1]  Many women have a longitudinal relationship with a physician, particularly during pregnancy and well baby visits.  This allows for more opportunities for screening and prevention.  Only about 17% of all pregnancy women are screened for domestic violence at their first visit and 10% at subsequent visits.

[2]  Violence during pregnancy may be a more common problem than conditions for which pregnant women are routinely screened.  It is estimated that one in five women will be abused during pregnancy. As homicide during pregnancy now surpasses the previous leading causes of death (automobile accidents and falls), it is more important than ever that we know the signs and properly screen women for domestic violence.  However, the doctors and emergency room providers need to know the signs of abuse and what to do about them.  

[3]  It is important for primary care providers to have easy access to services for victims of domestic and sexual violence.  It is important to make sure that they are safe from further harm and have access to services that allow them to make choices that are best for them and their baby.

 

References

Centre for Disease Control
Intimate Partner Violence During Pregnancy, A Guide for Clinicians

http://www.cdc.gov/reproductivehealth/violence/intimatepartnerviolence/sld001.htm

Domestic Violence in Pregnancy at about.com

http://pregnancy.about.com/cs/domesticviolence/a/domesticviol.htm