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General Practice Utilization After Sexual Victimization: A Case Control Study Ask Elklit and Mark Shevlin Violence Against Women 2010 16: 280 originally published online 21 January 2010 DOI: 10.1177/1077801209359531 The online version of this article can be found at: http://vaw.sagepub.com/content/16/3/280

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Article

General Practice Utilization After Sexual Victimization: A Case Control Study

Violence Against Women 16(3) 280–290 © The Author(s) 2010 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/1077801209359531 http://vaw.sagepub.com

Ask Elklit1 and Mark Shevlin2

Abstract There is a growing research literature that indicates that sexual victimization results in increased physical health problems and health service utilization. This study aimed to examine the relationship between attendance at a center for rape victims and frequency of contact with general practitioners. The study used matched case-control design, and information about general practitioner use over a 7-year period was drawn from the Danish Civil Registration System. There was a sustained increase in health care use for those who had used the center for rape victims compared to the control group. Keywords case-control study, health service utilization, sexual victimization

Prevalence estimates of 6% to 14% for sexual assault of women have been reported in large population-based surveys in the United States (Golding, 1999; Sorenson, Stein, Siegel, Golding, & Burnam, 1987). Regan and Kelly (2003) reviewed prevalence estimates of sexual violence against women from European countries and noted variation in estimates from 4.9% to 34%. Although there is some disagreement regarding the prevalence of sexual assault, there is consensus that the consequences for the victim of rape are negative. Research has provided evidence that sexual victimization is associated with a range of psychological and behavioral problems (Resick, 1993), including posttraumatic stress disorder (Bromet, Sonnega, & Kessler, 1998), alcohol abuse (Hankin et al., 1999), disordered eating (Ackard & Neumark-Sztainer, 2002), symptoms of psychosis (Shevlin, Dorahy, & Adamson, 2007), the abuse of prescription and recreational drugs (Kilpatrick, Acierno, Resnick, Saunders & Best, 1997; Sturza & Campbell, 2005), and relationship 1

University of Southern Denmark University of Ulster at Magee, Northern Ireland

2

Corresponding Author: Ask Elklit, National Centre for Psychotraumatology, University of Southern Denmark, Campusvej 55, DK-5230 Odense M, Denmark Email: [email protected]


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dissolutions (Becker, Skinner, Abel, & Treacy, 1982; Burgess & Holmstrom, 1974; Norris & Feldman-Summers, 1981). There is also a growing research literature that indicates that sexual victimization results in increased physical health problems and health service utilization. Koss, Koss, and Woodruff (1991) examined the effects of criminal victimization on women’s health and medical utilization. Interviews were conducted with 413 women who were recruited through random sampling from a worksite-based health maintenance plan. Based on items from the National Crime Survey, an index of severity of victimization was developed. More than half the sample (55%) were classified as either being nonvictimized, mild (experience of noncontact crime), or moderate (experience of bodily harm excluding assaults of a sexual nature). Twenty-four percent of the participants were “severely victimized,” which was defined as having experienced forced and unwanted sexual intercourse. A further 21% of the participants were defined as victims of “multiple victimization,” which was defined as being a victim of forcible rape and physical assault. A significant association between severity of victimization and subsequent service utilization was reported. Women who experienced multiple victimization visited their physician twice as often as nonvictimized women, on average 6.9 visits and 3.5 visits, respectively. Further analysis was conducted on a subsample of 15 participants who were victims of rape. Compared to the average of the preceding 2 years, there was an 18% increase in the average yearly number of physician visits during the year of the rape and a 56% increase for the year following the rape. Eberhard-Gran, Schei, and Eskild (2007) examined the effects of exposure to violence and somatic symptoms in 2,730 Norwegian women. Exposure to violence was assessed using the Abuse Assessment Screen (AAS; Soeken, McFarlane, Parker, & Lominack, 1998), and somatic symptoms were assessed using the Somatic Symptom Scale of the Primary Care Evaluation of Mental Disorders measure (Spitzer et al., 1994). Those women who reported being exposed to sexual violence were significantly more likely to report suffering from a range of physical symptoms compared to nonexposed women; the difference was significant for 12 out of 14 symptoms. There was also a significant dose–response relationship between the severity of sexual violence and the mean number of somatic symptoms. These effects remained significant after controlling for depression and sociodemographic factors. Golding, Stein, Siegel, Burnam, and Sorenson (1988) used data from the Los Angeles (N = 3,132) Epidemiologic Catchment Area Study to investigate the relationship between women’s sexual assault history and medical service use. Sexual assault was assessed using the following question: “In your lifetime, has anyone ever tried to pressure or force you to have sexual contact?” Medical service use was assessed by asking, “How many times altogether did you receive care or treatment from a health professional in an office, clinic, or emergency room in the past 6 months?” Results indicated that assaulted women were significantly more likely to have used medical services. In a similar study, Golding (1999) used data from the Los Angeles (N = 3,132) and North Carolina (N = 2,993) Epidemiologic Catchment Area studies to investigate the relationship between women’s sexual assault history and medical care seeking. Sexual assault was measured


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using a single question about forced sexual contact, and physical symptoms were assessed by means of the Somatization section of the Diagnostic Interview Schedule (Robins, Helzer, Croughan, & Ratcliff, 1981) from which information on 21 symptoms were recorded. The percentage of participants who sought medical care for each symptom was compared for assaulted and nonassaulted women. There was only one significant difference between the groups: Assaulted participants were more likely to seek medical care for abdominal pain. There is also some evidence that suggests that childhood experiences of sexual victimization predict subsequent adult health care costs. Walker et al. (1999) randomly sampled 1,963 women from a large American health maintenance organization (HMO). The Childhood Trauma Questionnaire (Bernstein, Fink, Handelsman, & Foote, 1994) was used to identify three groups: “sexual maltreatment,” “any maltreatment,” and a comparison group who reported subthreshold maltreatment experiences. Health care costs for each participant were recorded every 6-month period for 5 years from the cost-accounting system of the HMO. Total median health costs were significantly higher for the maltreatment and sexual maltreatment groups compared to the reference group. The differences were smaller, but it remained statistically significant when costs of mental health care were controlled for. Similarly, the number of hospital emergency department visits differed significantly between the groups. The women who experienced sexual maltreatment were nearly twice as likely to visit an emergency department compared to the reference group. Overall, a dose–response relationship was found between the degree of maltreatment and health costs. Campbell et al. (2002) conducted a case-control study using a sample of 2,535 female enrollees in an American health maintenance organization. A modified version of the AAS was used to identify victims of physical abuse, sexual abuse (with and without physical abuse), and those who experienced no abuse. Those who were sexually abused without physical abuse reported significantly more chronic stress-related symptoms and central nervous system problems. Those who were sexually abused with and without physical abuse reported the highest levels of gynecological problems. Ruiz-Pérez and Plazaola-Castaño (2005) recruited 1,402 women attending public family practices in Spain. Based on three questions about intimate partner violence, the participants were grouped as “no abuse,” “psychological abuse,” “physical and psychological abuse,” “psychological and sexual abuse,” and “physical, psychological, and sexual abuse.” Self-perceived health was assessed using the question “How would you say your current health status is, compared with your health status last year” with response options “better,” “the same,” and “worse.” There was no significant difference between the psychologically and sexually abused women compared to the nonabused women. However, those who had experienced physical, psychological, and sexual abuse were significantly more likely to have perceived worse health than the nonabused women. Using data from the same sample, Ruiz-Perez, Plazaola-Castano, and del Rio-Lozano (2007) reported that there was no significant difference in physical disease, asthma, diabetes, other diseases, number of days in bed, and number of operations between the psychologically and sexually abused women compared to the nonabused women. The physically, psychologically,


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and sexually abused women were significantly more likely to have reported physical disease as well as other diseases and to have spent more days in bed than the nonabused women. In contrast to other findings, these studies suggest that sexual abuse does not contribute to increased physical health problems above and beyond those accounted for by physical abuse. The present study aimed to examine the relationship between experiences of sexual victimization and health service utilization. We employed a design that combined the strengths of previous research in the area. First, this study used a matched case-control design in which each victim of sexual victimization was matched with controls that were the same age and lived in the same municipality. Second, the use of the Danish Civil Registration System (hereinafter referred to as CRS) allowed for a quasi-prospective element to be incorporated. It was possible to gain information about health service utilization before and after the time of sexual victimization for both victims and controls. Third, instead of relying on self-reported accounts of victimization, this study used an objective behavioral indicator, namely, the recorded annual number of visits to the participant’s general practitioner. Fourth, experience of sexual victimization was assessed by attendance at a center provided to support victims of rape. It was predicted that there would be a sustained increased use of health services, as indicated by frequency of contact with their general practitioner, after visiting the center for rape victims, and this increase would be greater than for the control group.

Method Design and Analysis This study used the CRS. A detailed description of the structure of CRS is provided by Pedersen, Gøtzsche, Møller, and Mortensen (2006). Access to CRS data was through Denmark Statbank (DST), which is the central government agency for statistics. To use CRS data, researchers must apply to DST from an authorized institution and the research proposal must be approved by the office of the Danish Minister of Health. On the basis of the research proposal, DST makes data available on the variables relevant to the researcher, and variables are matched using the individual civil registry number (CPR). The CPR identifies people at the individual level and allows information to be collated across different registries. However, identification of specific individuals is not possible as the 10-digit CPR is scrambled and the data are password protected and requires the correct “time code” that changes every minute provided by a digital key. All female rape survivors visiting the Centre for Rape Victims (CRV) at the University Hospital in Aarhus, Denmark, during the year 2003 were identified and demographic information was added based on their CPR. The CPR data were used to extract a control group of 10 women for each rape victim with the same age and living in the same municipality during the year of rape. Any women who had visited the CRV since 1999 were not eligible for inclusion in the control group. There were 103 women who attended the CRV during 2003, and 1,030 control group participants were selected. Information on the CRV group


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and the control group was also extracted for the 5 years preceding (1999-2002) and 2 years post attendance (2004-2005) at the CRV. The data were analyzed using a mixed ANOVA with seven within-subject levels (annual general practitioner contacts 1999 to 2005) and two between-subject levels (CRV group, controls). A binary variable representing whether a participant spent 1 or more days in hospital during the year preceding the CRV visit (2002) was included as a covariate. The covariate would control for increased frequency of health care use due to severe illness/ accident requiring hospitalization.

Measures Experience of sexual victimization was operationalized by having visited the CRV at any time during 2003, with no previous recorded visits since 1999. No information on the number of visits or details of the rape was available. Health service utilization was operationalized as the number of contacts each woman had with her general practitioner each year from 1999 to 2005. All aspects of general practitioner services are included in this measure, including daytime and evening consultations, visits, phone consultation, and email consultation. Other variables were used to describe the demographic and health characteristics of the sample during the year preceding the CRV visits (2002): living status (0 = married/cohabiting, 1 = single), ethnicity (0 = nonimmigrant, 1 = immigrant/2nd generation), children (0 = no children, 1 = one or more children), employment (0 = partial or 12-month unemployment, 1 = 12-month employment), annual income (DKK), and annual number of bed days in hospital.

Results The females who visited the rape center were aged from 13 to 87 years (M = 26 years, SD = 13.41). The controls were matched for age and municipality. Demographic and health characteristics of the sample (2002) are presented in Table 1. The control sample was significantly different from the CRV group on a number of demographic and health variables. Compared to the control group, the CRV group was less likely to have children, more likely to be single, more likely to have lower income, and more likely to spend more days in hospital. There was a significant main effect for the within-subject factor, F(6, 911) = 9.13, p = .00; a significant between-subject main effect, F(1, 916) = 51.86, p = .00; and the effect for the covariate was significant, F(1, 916) = 60.05, p = .00. The within-subject by betweensubjects interaction was also significant, F(6, 911) = 3.84, p = .00. The estimated marginal means are presented in Table 2. The means in Table 2 show a general increase in the average number of general practitioner contacts for both groups with the means for the CRV group being consistently higher for years 1999 to 2002. There is a marked increase in the means for the CRV group for the year 2003, and the means remain higher for the subsequent 2 years. This pattern is shown in Figure 1.


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Elklit and Shevlin Table 1. Demographic and Health Characteristics of Sample During 2002

Control group n = 1,030

CRV group n = 103

One or more children, n (%) 607 (60.3) 47 (46.1) Immigrant, n (%) 151 (14.7) 9 (8.7) Single, n (%) 344 (34.8) 64 (64.0) Employed, n (%) 979 (97.3) 96 (94.1) Income (DKK), M (SD) 112,042 (103,733) 82,645 (77,426) Hospital, M (SD) 1.27 (3.77) 2.50 (4.17)

c2 (df)

p

7.78 (1) 2.70 (1) 33.09 (1) 3.28 (1) t value (df) 2.47 (823) -3.13 (1,131)

.00 .10 .00 .07 .01 .00

Note: CRV = Centre for Rape Victims.

Table 2. Mean Annual Number of General Practitioner Contacts From 1999 to 2005

Mean Annual General Practitioner contacts

Year

Control group M (SE)

CRV group M (SE)

1999 2000 2001 2002 2003 2004 2005

8.27 (0.30) 8.79 (0.31) 9.39 (0.33) 10.27 (0.37) 10.46 (0.40) 10.95 (0.40) 11.44 (0.42)

12.50 (0.90) 13.79 (0.94) 13.97 (0.99) 14.51 (1.11) 19.47 (1.22) 17.85 (1.20) 19.10 (1.27)

Note: CRV = Centre for Rape Victims.

Discussion This study aimed to examine the relationship between experiences of sexual victimization and health service utilization using a case-control design. The results indicated that general practitioner contacts significantly increased from 1999 to 2005 for both the CRV and the control groups. This pattern is consistent with the temporal trend of increased contact with general practitioners that has been observed in Denmark (Christensen & Olesen, 1998) and other developed countries (Rowlands & Moser, 2002). In addition, the mean annual contact with general practitioners was significantly higher for the CRV group compared to the control group for all years. This suggests that the two groups differ on characteristics that are related to health status other than age and area of residence (the variables that were matched in this study). Previous research has identified low income, being single, and decreased family size as predictors of high contact with general practitioners (Bellón,


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Mean Annual Contact With General Practitioner

20 Group 18

Control CRV

16

14

12

10

8 1999

2000

2001

2002

2003

2004

2005

Year

Figure 1. Mean annual number of general practitioner contacts from 1999 to 2005 for CRV and control groups Note: CRV = Centre for Rape Victims.

Delgado, Luna, & Lardelli, 1999; Carr-Hill, Rice, & Roland, 1996). The two groups differed significantly on these variables in this study also. The main hypothesis was that there would be an increased use of health services, as indicated by frequency of contact with their general practitioner, after visiting the CRV, and this increase would be sustained. There was evidence to support this hypothesis. The increase in the number of contacts by the CRV group was large. From 2002 to 2003, the mean number of visits increased by 34.18%; between 2002 and 2004, the increase was 23.01%. The corresponding increases for the control group were 1.85% and 6.62%, respectively. In Figure 1, there is clear discontinuity in the trend for the CRV group with a sharp increase for the year 2003. The high level of annual contact with general practitioners seems to be sustained through years 2004 and 2005. These findings are consistent with Koss et al. (1991), who identified a sustained increase in health care use after sexual victimization. The psychological impact of rape is well established in the research literature, and there are procedures and interventions available to support victims (Bremsen, Elklit, & Nielsen, 2009). Less attention has been given to the issue of increased physical health needs in


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victims of sexual assault. The results from this study indicate the significant increases in health service use after sexual victimization. Indeed, the findings from this study could be considered a conservative estimate of the health needs of victims as general practitioners in Denmark often represent a “gateway” to additional use of health services with further referrals being made. Kimerling and Calhoun (1994) reviewed the alternative explanations for increased health service use by victims of sexual assault. Previous research has offered explanations based on psychoimmunology, psychological stress being interpreted as somatic symptoms, and presentation to professionals associated with physical (rather than psychological) problems being more socially acceptable. However, more pragmatic explanations should not be discounted. High rates of sexually transmitted infections have been reported in samples of sexual assault victims, and concerns about unwanted pregnancy as a result of the assault have been documented (Kawsar, Anfield, Walters, McCabe, & Forster, 2004). The increased attendance at general practitioners may reflect relatively immediate concerns about possible unwanted pregnancy and longer term concerns related to sexually transmitted infections. This study had some limitations. First, neither was there any independent verification that every woman who attended the CRV had actually been subjected to an attempted or completed rape nor were there details of the nature of the assaults. Importantly, the degree of physical force used in the assaults is unknown. However, attendance at the CRV is an objective behavioral indicator that is likely to be indicative of some type of sexual aggression having been experienced. Second, the control group was matched only on the basis of age and living in the same area. It is not known if the groups differed systematically on potential confounding variables that are related to both family structure and sexual victimization, such as income and socioeconomic status. Third, not all women who experience sexual victimization will have attended the CRV. It may be that married or cohabiting women can find support from their husbands or partners and are therefore less likely to attend the CRV. However, Ullman and Filipas (2001) found that marital status was not a significant predictor of formal help seeking in victims of sexual assault. Fourth, members of the control group may have been victims of sexual victimization but did not attend the CRV.

Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the authorship and/or publication of this article.

Funding The authors received no financial support for the research and/or authorship of this article.

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Bios Ask Elklit, MPsych, is a professor in clinical psychology at the University of Southern Denmark and director of the National Centre for Psychotraumatology. He founded the first Danish


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center for rape victims, is currently the supervisor of three Danish rehabilitation centers for torture victims, and is a board member of the specialist program in psychotraumatology for licensed psychologists. He is a licensed psychologist and a specialist in psychotherapy. Mark Shevlin, PhD, is a senior lecturer in psychology at the University of Ulster and an honorary professor at the University of Aarhus. His research interests are in the areas of trauma, posttraumatic stress disorder, psychosis, and structural equation modeling.
