The health care experiences of adult survivors of child sexual abuse: a systematic review of evidence on sensitive practice
- HAVIG Kirsten
- Journal article citation:
- Trauma Violence and Abuse, 9(1), January 2008, pp.19-33.
Ten empirically based studies (three based on the same sample) from the medical literature are reviewed to identify lessons about sensitive health care practice with adult survivors of child sexual abuse. Such abuse can influence the experience of care, health behaviours and outcomes. The studies provide patient-based information, which is used as the basis for recommendations to health care providers in two main areas: facilitation of communication and disclosure; and improving the experience of the health care encounter. The implications for research, practice and policy for patients, health care providers and social workers in health care settings are discussed.
- Extended abstract:
The health care experiences of adult survivors of child sexual abuse: a systematic review of evidence on sensitive practice.
Journal citation/publication details
Trauma, Violence and Abuse, 9(1), January 2008, pp.19-33.
This review of ten studies (three based on the same small sample) confirms the significant long term health effects of childhood sexual abuse (CSA), identifying communication and disclosure, and the experience of the physical aspects of health care, as key issues for CSA survivors. Their views form the basis of several recommendations for more sensitive practice, which warrant further investigation. The importance of social workers in the development of an holistic approach to the care of this vulnerable group of patients is noted.
Although a history of CSA often remains hidden, it is recognised to have an impact on the health status, behaviours and experiences of adult survivors. Research studies since the early 1990s have suggested a variety of approaches that health care providers might take to ensure more sensitive and effective assessment/treatment of this patient group. This review looks both at empirical evidence on the health care experiences of CSA survivors and at what assessment/treatment approaches have been evaluated.
What sources were used?
Medline and CINAHL (Cumulative Index to Nursing and Allied Health Literature) were searched, and the reference lists of studies selected for review were checked.
What search terms/strategies were used?
Searches were limited to the period 1990 to October 2006, and conducted in a series of steps using progressive refinement of an initial search on the term ‘child sexual abuse’. The terms used to refine this search were, first, ‘adult health’, followed by ‘health care’, ‘provider’, ‘practitioner’, ‘primary care’ and ‘patient’.
What criteria were used to decide on which studies to include?
The paper does not explicitly list inclusion/exclusion criteria. However, beyond the subject scope implicit in the search strategy, eligible studies were empirical and either explored the health care experiences of CSA survivors or evaluated interventions designed to enhance sensitive and effective health care for this group.
Who decided on their relevance and quality?
The author conducted all procedures, possibly as part of a doctoral thesis. Methodological quality assessment of studies does not appear to have been conducted.
How many studies were included and where were they from?
Ten studies were reviewed, summarised in Table 1, of which six used qualitative methods, three quantitative and one a mixed-method experimental approach. Three studies were based on the same sample of 27 women. Geographical locations are not indicated but most, if not all, studies appear to be North American.
How were the study findings combined?
Study information was recorded on a specially created data extraction form, and a narrative synthesis conducted on the basis of themes.
Findings of the review
Of the ten papers, four focused on communication and disclosure issues for abuse survivors in health care settings, one on a specific intervention and the remaining six on both disclosure and the experience of medical examination or physical aspects of receiving care.
Communication and disclosure
All but one study found that a history of CSA did significantly influence health status, health care-seeking behaviour and compliance with treatment; and that provider knowledge of such a history could have a positive impact on the experience of care, and on health behaviours and outcomes. However, two quantitative studies showed that while survivors wished to disclose their history, providers often did not ask. ‘There is some consensus around the idea that health care providers should initiate’ inquiries of all adult patients, of both genders, about experience of CSA, and that ‘differentiated degrees of disclosure’ are likely to be needed depending on the individual patient. However, there was no clear consensus on how this might be achieved in practice.
In addition, while it is clear that a majority of doctors believed they could help patients deal with the effects of CSA, many survivors had suffered painful experiences as a result of their doctor’s own ‘embarrassment, repulsion, pity, disinterest and avoidance’. Male survivors, and survivors of incest, may be particularly at risk of such reactions. Several studies reported unwillingness to engage with health care treatment because of past negative reactions and labelling as ‘difficult’.
Improving the experience of health care
In addition to more sensitive and non-judgmental communication, including facilitation of disclosure, measures that address the wider environment of the health care encounter can improve the experience. More flexibility to give the patient some choice can be helpful, for example about the gender or age of the person conducting a examination, or about the timing of appointments to allow patients to attend on the day they feel ready to undergo treatment. Several papers also discuss the importance of ‘creating carefully coordinated interdisciplinary care and of making sensitive, confidential, and informed referrals in partnership with the patient’.
In respect of the physical aspects of care, doctors need to be aware that trauma reactions can be triggered by prone positions (as in a dentist’s chair or on an examination couch); physical touch, especially if intrusive (as in the case of oral or gynaecological examination); even the act of undressing. CSA involves inequitable power relations and a loss of control, so that survivors place a particular value on safety and privacy. Practical approaches include conducting examinations and treatments in sound proofed rooms, rather than behind curtains; continuously informing patients about what is to happen throughout the encounter; and giving them the option to halt treatment whenever desired. Simple measures such as providing women with a gown, rather than a drape, during internal examinations can also help.
‘…although few in number, the articles reviewed here reflect the beginnings of a synthesis of the existing knowledge on the health effects of CSA and practical application of this knowledge. There is a great deal of information that is ripe for testing by empirical research.’ The author notes potential limitations of her review, including the search terms used (which are rather limited), the exploration of only medical literature (in a limited number of databases), and the fact that both the number of studies and sample sizes are small. Only one study explored the experiences of male survivors of CSA. All of these factors limit the generalisability of the findings.
Implications for policy or practice
Apart from the practice suggestions contained within the body of the review, the author argues that training for health care providers should encompass ‘the abundance of information now known about the long-term health effects of this particularly damaging form of trauma’. In the same way as knowledge about domestic violence and sexual assault has been incorporated into medical training to promote greater cultural competency in these fields, the evidence about CSA can be disseminated and ‘easily presented in terms of strategies for sensitive care to a distinct patient population’. Cultural competence in this area involves the psychosocial as well as physical needs of patients, and social workers are identified as key professionals in helping to develop a coordinated, holistic package of care.
- Subject terms:
- medical treatment, vulnerable adults, attitudes, child sexual abuse, communication, disclosure, health care;
- Content type:
- systematic review
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