Sexual trauma and physical health correlates among women veterans

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Sexual trauma and physical health correlates among women veterans
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by Linda R. Feldthausen.
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SEXUAL TRAUMA AND PHYSICAL HEALTH CORRELATES
AMONG WOMEN VETERANS














By

LINDA R. FELDTHAUSEN


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA















I would like to dedicate this work to my husband,
Karl Richard Feldthausen,
whose belief in me and unwavering support
has opened the door to endless possibilities.















ACKNOWLEDGMENTS

In the process of crafting this dissertation, I have benefitted from the interest,

guidance, and generous assistance of many people to whom I owe a debt of gratitude. I

wish to thank these colleagues, friends, and family for their support.

I would like to thank the chairman of my supervisory committee, Dr. Mark

Fondacaro, for his willingness to step in and assume leadership at a time when I most

needed him. His flexibility and calm encouragement helped keep me focused on the

central importance of the joy of discovery in research.

I would like to express my appreciation to other members of my supervisory

committee. All have provided boundless support and encouragement, along with

practical advice, in making their unique contributions to this process. Dr. Jaquelyn

Resnick provided a rich understanding of the literature surrounding women's issues and

sexual trauma and has been a positive influence on my professional development. I am

thankful for the critical thinking and broad knowledge of Dr. Keith Berg in sharing his

expertise in developmental psychology. Dr. Alex Piquero has demonstrated not only his

intellectual prowess but also his warmth and good humor in sharing his knowledge of

research design and statistical analyses.

I would also like to thank my colleagues at the V.A. Medical Center: Dr. Lucretia

Mann, who generously shared her research interests and provided continued support, and

Dr. Mary McGuigan, who served as my "in-house" supervisor for the purposes of

gathering data. Both of these women have greatly inspired me in shaping my

iii










professional identity, and I only hope that I can someday attain their level of clinical

expertise.

Finally, I would like to thank my husband, Karl Feldthausen, and my daughters,

Kelly and Kristen, for their patience, their confidence in me, and their willingness to

make many accommodations in their lives to support this project.
















TABLE OF CONTENTS





ACKNOWLEDGMENTS .. ......................... .. ............ iii

LIST OF TABLES...... ................ ...... ........... vii

ABSTRACT .................................................... viii

CHAPTER

1 INTRODUCTION .......... ...... ......... .... ............. 1

Psychological Effects of Sexual Trauma ................................. 1
Physical Effects of Sexual Trauma ................................... 2
Women Veterans and Sexual Trauma ............................. .. 4
Significance of Current Research .. ....... ................. ....... 5

2 REVIEW OF THE LITERATURE ................... ............... 9

Sexual Trauma and Health Perceptions ................... ..... .... 10
Sexual Trauma and Physical Symptoms ................................ 12
Sexual Trauma and Health Care Utilization ........................ 17
Special Concerns of Women Veterans .............................. .. .20
Moderating Variables ....................... .................... 24
Summary and Hypotheses ... .................................. 28

3 METHODOLOGY ........................... ....... ............ 32

Participants .................... ....... ..................... .32
Procedure ............................... .................... 33
Measures .......... ...... ......... ..................... 34
Predictions .......... ....... ................................. 35
Data Analysis ............. ... ... ............................ 36

4 RESULTS ..................................................... 38

Hypothesis 1: Health Perceptions ................................... 39
Hypothesis 2: Health Complaints ................................... .. 40










Hypothesis 3: Healthcare Utilization .................. ........... .. 42
Examination of Moderating Variables .................................. 44
Post Hoc Analyses ..................................... ......... ...49

5 DISCUSSION .............. ............................. 50

Health Outcome Measures ......................................... .51
Moderating Effects of Marital Status and Mental Health Treatment ............. 54
Limitations of the Study ................. ........................... 56
Recommendations for Future Research ................................ .. 59
Conclusion ......... ....................................... 60

APPENDIX WOMEN'S HEALTH QUESTIONNAIRE ....................... 62

REFERENCES ............... ............................. 64

BIOGRAPHICAL SKETCH ................ ........................... 71


































vi















LIST OF TABLES


Table page

4-1. Comparison of means on health perceptions between trauma groups ......... 40

4-2. Comparison of means on health complaints between trauma groups ......... 41

4-3. Comparison of means on healthcare utilization between trauma groups ....... 43

4-4. t-test results for healthcare utilization measures between trauma groups ...... 43

4-5. Correlations between moderating variables, dependent variables, and trauma
history ......... .................... ........... 45

4-6. Logistic regression analysis on health perceptions ...................... 47

4-7. Stepwise linear regression predicting health complaints ................... 47

4-8. Stepwise linear regression predicting medical visits ...................... 47

4-9. Logistic regression analysis on emergency room visits .................... 48

4.10. Stepwise regression predicting number of prescriptions ................... 48















Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

SEXUAL TRAUMA AND PHYSICAL HEALTH CORRELATES
AMONG WOMEN VETERANS

By

Linda R. Feldthausen

May 2003

Chairman: Mark Fondacaro
Major Department: Psychology

This study explored the relationship between experiences of sexual trauma and

subsequent physical health problems among women veterans receiving their healthcare at

a Veterans Affairs Medical Center. The study was designed to test hypotheses about the

impact of sexual trauma on women's perceptions of their own health status, the number

and type of current health complaints, and their utilization of healthcare services. This

study also examined the possible buffering effects of marital status and mental health

interventions on the trauma-health association. Archival records were utilized for this

investigation. Women veterans who enrolled in the Women's Clinic at the V.A. Medical

Center for primary care between April 1999 and May 2000 (N = 210) had been asked to

complete the Women's Health Questionnaire as part of their screening protocol. This

questionnaire captured demographic data and self-reported histories of both childhood

sexual abuse and adult sexual assault, as well as providing ratings of health perceptions

and current physical complaints. These questionnaires were analyzed in connection with










the respondents' medical charts detailing their prescription medicines and the number of

visits to primary care, specialty clinics, mental health providers, and the emergency room

over a two-year period. Results generally supported the hypotheses about sexual trauma

increasing the number of health complaints and resulting in higher utilization of medical

services. Women's self-ratings of their health status were not significantly lower for the

trauma group in general, but were lower among women who had experienced adult

sexual assault. Marital status and mental health interventions were not found to offer any

moderating effect on this relationship. Recommendations for future research included

the use of prospective design and structured interviews in place of self-report

questionnaires. Results are discussed as supporting the bio-psycho-social model of

healthcare, and emphasizing the importance of screening for sexual trauma in healthcare

settings.















CHAPTER 1
INTRODUCTION


Over the past two decades, society has become increasingly aware of the

magnitude of the problem of sexual trauma. Estimates of the prevalence of child sexual

abuse vary, depending upon the definition and setting studied, but range from 5% to 62%

of the women involved in the surveys (Fox & Gilbert, 1994; Longstreth & Wolde-Tsadik,

1993). Similarly, lifetime prevalence rates for sexual assault vary by study, ranging from

13% to 20% (Koss, 1993; National Victim Center, 1992). Concomitant with this

knowledge has been the realization that the victims suffer repercussions of these acts

over many years, both in terms of emotional and physical health problems.

Psychological Effects of Sexual Trauma

A great deal has been learned about the long-term psychological effects of sexual

assault and child sexual abuse on the victims. Previous research focusing on mental

health diagnoses following sexual trauma has clearly established strong correlations

between such a history and posttraumatic stress disorder (Breslau, Davis, Andreski, &

Peterson,1991; Foa & Riggs, 1995; Freedy, Resnick, Kilpatrick, & Dansky, 1994;

Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Norris,1992; Resnick, Kilpatrick,

Dansky, Saunders, & Best, 1993; Resnick, Yehuda, Pittman, & Foy, 1995; Ullman &

Siegel, 1994; Winfield, George, Swartz, & Blazer, 1990). A positive association between

sexual trauma and depression has also been shown to exist (Atkeson, Calhoun, Resick, &

Ellis, 1982; Becker, Skinner, Abel, & Treacy, 1984; Ellis. Atkeson, & Calhoun, 1981;

1










Gidycz & Koss, 1991; Santiago, McCall-Perez, Gorcey, & Beigel, 1985). Additionally,

survivors of sexual abuse and assault are more likely to experience greater fear (Calhoun,

Atkeson, & Resick, 1982; Resick, Veronen, Calhoun & Kilpatrick, 1986; Roth, Wayland,

& Woolsey, 1990; Veronen & Kilpatrick, 1980; Wirtz & Harrell, 1987), and impaired

social adjustment and interpersonal functioning (Cohen & Roth, 1987; Ellis, Atkeson, &

Calhoun, 1981; Resick, Calhoun, Atkeson, & Ellis, 1981) than persons without such

experiences.

Physical Effects of Sexual Trauma

More recently, researchers have turned their attention to the association between

physical health and a history of sexual trauma. Women who have experienced sexual

assault or prior child sexual abuse have been found to report lower ratings of their health

status than nonvictims (Clum, Calhoun, & Kimerling, 2000; Golding, 1994; Golding,

Cooper, & George, 1997; Koss. Woodruff, & Koss, 1990; Waigandt, Wallace, Phelps, &

Miller, 1990). Such victims have also been shown to suffer from a greater number of

physical complaints than women without such histories (Cunningham, Pearce, & Pearce,

1988; Domino & Haber, 1987; Drossman, Talley, Leserman, Olden, & Barreiro, 1995;

Farley & Keaney, 1997; Frayne et al., 1999; Golding, 1996, 1999a; Walker et al., 1988).

Not surprisingly, research has also suggested that these types of victims tend to visit their

primary care doctors more frequently, seek emergency medical services more often, and

receive a larger number of prescription medicines than nonvictimized women (Farley &

Patsalides, 2001; Golding, Stein, Siegel, & Burnam, 1988; Koss, 1994; Sansone,

Wiederman, & Sansone, 1998; Walker, Unutzer, Rutter, Gelfand, Sauners, VonKorff,

Koss & Katon, 1999).









Explanations offered for the assault/health association include (a) psychosomatic

theory, which states that psychological pain is repressed and finds expression through

physical symptoms; (b) that the immune and endocrine systems may be compromised by

psychological stress, resulting in declining health; and (c) victims of sexual violence may

engage in more unhealthy behaviors due to assault-related stress, such as smoking,

excessive alcohol or drug use, or insufficient sleep, diet, and exercise (Resnick, Aciemo,

& Kilpatrick, 1997).

Recently, the question of whether there might be moderating influences on the

association between sexual trauma and physical illness has been raised. Early research

into the role of social support as a protective factor against the risk of sexual assault was

reviewed by Golding (Golding, Wilsnack, & Cooper, 2002), who went on to suggest that

future research was needed to ascertain its role in moderating the assault/health

relationship. Another review article (Ullman, 1999) looked more specifically at the

function of social support in recovery from sexual assault and found mixed evidence.

Some studies showed no significant effect while others claimed positive effects of social

support in recovery from the mental and physical health consequences of this crime.

Another moderating variable that has been considered is the role of mental health

interventions, whether they be in the form of psychotherapy or psychotropic medications.

The findings, thus far, are equivocal. While reasoning would suggest that treatments

aimed at lessening emotional distress would ultimately improve physical health, there is

little empirical support to be found. Investigation into sleep-disordered '-re lh;i.- among

survivors of sexual assault revealed that this particular physical sequelae of sexual

trauma has been unresponsive to traditional mental health treatments of therapy and/or

medications (Krakow et al., 2002). Kimerling and Calhoun (1994) examined the










influence of both social support and mental health service utilization on victims'

recovery from sexual assault. They found that the utilization of mental health services

did not alter the physical health consequences of sexual assault; however, their research

only spanned one year posttrauma. The authors speculated that the benefits of mental

health interventions may become more evident over a longer period of time. They did

find evidence that social support plays a role in moderating the deleterious health effects

of sexual assault. The literature is sparse in this area, and the influences of mental health

treatment and social support in lessening the impact of sexual trauma on physical health

remain open questions.

Women Veterans and Sexual Trauma

The majority of the aforementioned studies have been conducted on civilian

women through large-scale random surveys or via medical contacts within health

maintenance organizations and primary care clinics. A segment of the population that

has received little scrutiny in this area is women veterans of military service. Some

preliminary research has examined women who utilize the Veteran's Administration

healthcare system. Once a significant minority, the number of women veterans has

grown exponentially over the past decade. The rising number of women in the military

has resulted in a burgeoning women veterans' population, measured at over 1.4 million

as of the 2000 census.

Several significant differences between these women and the general population

have been found. In 1998, Skinner and Furey studied the health-related quality of life of

719 female veterans compared to a control group ofnonveteran women and found that

veteran women scored lower on every scale of a 36-item health survey than did

nonveterans. Additionally, a survey conducted among 828 women veterans at a large









urban VA medical center (Coyle, Wolan, & Van Horn, 1996) found that a high

percentage of them reported histories of child sexual abuse (48%) and sexual assault

(41%). While the statistic for sexual abuse is at the high end of the range reported in the

civilian population (5-62%), the sexual assault statistic is double that found among

civilians (13-20%), leading researchers to conclude that abusive experiences are

d. iuri-.ri.j,' common among women veterans."

Equally disturbing were the results of a large survey conducted as part of the VA

Women's Health Project, which was designed to assess the health status of women

veterans. Data analyses from this survey (Frayne et al., 1999; Skinner et al., 2000)

indicated that 23% of the women participating reported having sustained a sexual assault

while in the military (these two studies did not consider any sexual trauma experienced

outside of their military service). A history of sexual assault in the military was

positively associated with a variety of current physical symptoms/medical conditions and

poorer health perceptions in every domain assessed. Thus, women veterans are of

particular interest due to their increasing numbers, higher incidence of reported sexual

trauma, and lower quality of perceived health.

Significance of Current Research

This study attempted to gain new understanding of the relationship between a

history of sexual trauma (both child sexual abuse and sexual assault) and general health

perceptions, physical complaints, and health care utilization among women veterans.

Through the use of a self-report instrument, enrollees at a VA Medical Center Women's

Clinic were classified into one of two groups: those with a history of sexual trauma and

those without such a history. Comparisons were made between the two groups on their

ratings of health perceptions, physical and emotional symptoms, and utilization of health









care resources. The roles of marital status and utilization of mental health services were

examined for possible moderating effects on the assault/health relationships.

A more complete understanding of the association among physical health

symptomatology, medical care utilization, and sexual trauma history would be beneficial

to both the victims of sexual violence and society-at-large. By alerting healthcare

providers to the nature of this association, they may be aided in diagnostic clarification

and more appropriate treatment recommendations. This, in turn, would greatly improve

health care for the victims and reduce the demand on medical providers for appointments

based on vague psychosomatic complaints. Society would benefit from the lower

demand for services through a reduction in healthcare costs, especially in the area of

emergency services and prescription medicines. An additional economic benefit would

be likely in the area of fewer lost work-days in our society's labor force.

Findings from this study may also be useful in advancing scientific knowledge

through confirmation of the sexual trauma/physical health association in the veteran

population, a growing sector of society with a high incidence of sexual trauma. This

study also extends prior understanding of the assault/health relationship by examining the

role of marital status (one form of social support) and mental health interventions as

possible moderating variables. Marital status has been shown in previous research to be

associated with both physical and mental health outcomes, such as self-ratings of health,

mobility limitations (Hughes & Waite, 2002), relapse in breast cancer patients (Declerck,

DeBrabander, Boone, & Gerits, 2002), mortality (Lund et al., 2002), depression (Hughes

& Waite, 2002), and generalized anxiety disorder (Hunt, Issakidis, & Andrews, 2002). It

is possible that the protective factor of a committed relationship extends also to reducing

the ill-health effects of sexual trauma, perhaps by providing an emotional outlet for









psychological pain that might otherwise be repressed, enhancing functioning of the

immune system through reduced stress, or by promoting an increase in positive health

behaviors via a partner's interactions.

The increasing number of women veterans utilizing the V.A. Healthcare system

would especially benefit from this knowledge. These women face additional obstacles in

obtaining appropriate treatment for symptoms associated with being sexually victimized

by males, considering that they are seeking treatment in a traditionally male-focused

healthcare setting. After having served in a predominantly male military, in which for

some the sexual trauma occurred, and being inculcated with repressive dictums about

revealing their victimization, women veterans may find it especially difficult to express

their emotional distress and resort to somatization in order to acquire the needed attention

from healthcare providers. This may be a factor in explaining why women veterans rate

themselves lower on questions assessing their general health than do their civilian

counterparts.

Increased awareness regarding the possible moderating effects of social support

and mental health interventions on the relationship between sexual trauma and physical

health could result in more timely psychological interventions designed to ameliorate or

eliminate such symptoms, further illuminating the mind/body connection and advancing

the field of holistic medicine. These advances in understanding would serve to improve

the delivery of healthcare services to the unfortunate segment of our population who have

been sexually traumatized and are now living with its long-term effects, as well as reduce

costs for unnecessary medical services in an already overburdened healthcare system.

Building on this accumulating body of knowledge, the present study attempts to

further explore the association between sexual trauma and physical health to more fully







8

understand its impact on women veterans, and examine whether the effect is moderated

by marital status or the involvement of mental health services. The following chapter

consists of a review of the literature pertinent to these issues.














CHAPTER 2
REVIEW OF THE LITERATURE

The purpose of this chapter is to review the literature on sexual trauma and

associated physical health complaints in order to clarify the formulation of the research

hypotheses. The experience of sexual trauma appears to be linked with deleterious health

effects in excess of those found following other types of traumatic events, although the

literature is sparse in providing data for direct comparisons. A recent study examined

various types of trauma exposure in relation to physical health among a community-

residing sample of 1,500 New Zealanders (Flett, Kazantzis, Long, MacDonald, & Millar,

2002). Researchers examined three trauma categories: crime (sexual assault, physical

assault, and robbery), hazard (natural disaster and disaster precautions), and accident

(motor vehicle accidents, other accidents, and tragic death), across measures of health

symptoms, chronic limitations, and self-rated health. Results indicated that crime victims

reported the lowest health status, the greatest level of chronic limitations, and the highest

number of physical symptoms compared to the other trauma groups. A few studies have

compared health outcomes among groups of people who reported childhood sexual abuse

versus childhood physical abuse with mixed results. Most have found that the experience

of childhood sexual abuse results in slightly greater subsequent health problems

(Drossman et al., 1995; Farley & Patsalides, 2001; Walker et al., 1999) than physical

abuse; however, one study found no significant differences between the two groups on

measures of physical symptoms, psychological problems and substance abuse (McCauley







10

et al., 1997). Indirect evidence of the increased health risks following sexual trauma can

be found in the literature linking posttraumatic stress disorder (PTSD) with poor physical

health. B -ulcricl. Fomeris, Feldman, & Beckham, 2000; Kimerling, Clum, & Wolfe,

2000; Zoellner, Goodwin, & Foa, 2000). Although there are many types of trauma which

can result in PTSD, interpersonal traumas of a sexual nature are implicated as one of the

highest risk categories for the development of this disorder. Breslau and colleagues

(1991) reported that victims of rape suffer a 49% risk of PTSD development, compared

to 31.9% for victims of severe beatings, 16.8% for victims of serious accidents, 15.4%

for victims of shootings or stabbings, and 3.8% for victims of natural disasters.

This chapter is divided into six sections, with the first three sections detailing

specific studies linking sexual trauma to poor health perceptions, increased physical

symptomatology, and high utilization of medical services. Section four looks at the

particular concerns of women who are veterans of military service and receive their

healthcare through the Veterans Administration Healthcare System. Section five reviews

the literature available on the possible moderating effects of social support and mental

health treatment. The final section summarizes the research hypotheses for this study.

Sexual Trauma and Health Perceptions

It has been shown that, in general, criminal victimization significantly affects

perceived health in female patient populations. Koss et al. (1990) conducted a survey of

2,291 women members of a large health maintenance organization, 57% of whom

reported personally experiencing crime. Using hierarchical multiple regression,

investigators discovered that criminal victimization was an important predictor of lower

ratings of general health. Other variables, including stressful life events with known









links to illness and demographic variables, did not contribute significantly to this

association.

Waigandt and colleagues (1990) investigated the long-term physical health

implications of sexual assault by comparing a group of 51 victims of sexual assault

against a control group of 51 age-matched nonvictims on the Comell Medical Index-

Health Questionnaire. Significant differences were found between the two groups on

perceived current health status, with the victim group assigning themselves lower ratings,

even though no differences were found between the two groups on demographics, family

health history, or past illness symptoms.

The relationship between sexual assault history and perceptions of poor health

was also examined by Jacqueline M. Golding (1994) in her study of 1,610 randomly

selected women living in Los Angeles, California. Of those surveyed, 299 women

(18.6%) reported having been sexually assaulted at some point during their lifetime.

When asked to rate their health status between "excellent, good, fair, or poor," women

with histories of sexual victimization were more likely than nonassaulted women to

report perceptions of poor health, along with functional limitations.

In 1997, Golding et al. expanded this inquiry by performing a meta-analysis of

seven population surveys to evaluate the association between sexual assault history and

health perceptions. Researchers investigated whether characteristics of the assault, such

as identity of the perpetrator, number of assaults, or degree of physical threat or force,

had any impact on this association. The studies they examined had a pooled N of 10,001

(7,550 women and 2,451 men), and the combined results demonstrated a robust

association between sexual assault and poor subjective health (odds ratio = 1.63, 95%

confidence interval = 1.36, 1.95). These findings were consistent across gender and







12

ethnicity. Victims of multiple sexual assaults, or those assaulted by spouses or strangers,

were found to rate themselves lowest on perceptions of their own physical health

compared to those who had experienced only one assault or who had been victimized by

an acquaintance or parent.

Further evidence of the association between sexual trauma and poor subjective

health was found in a large study conducted by the National Center for Injury Prevention

and Control and the National Center for Disease Control and Prevention. Researchers

gathered data from 8,000 women in a random, nationally representative survey

(Thompson, Arias, Basile, & Desai, 2002), of which 299 respondents (18.6%) affirmed

having been sexually abused prior to age 18. Assessments of current health status were

made by asking participants to rate their general health as "excellent, very good, good,

fair, or poor." Responses were then classified into one of two categories: either

excellent, very good, or good (87%), or fair or poor (13%). Women who reported having

been sexually abused as children were more likely than women without such abusive

experience to report poor perceptions of their general health (odds ratio = 1.41, 95%

confidence interval = 1.11, 1.78).

It is apparent that prior sexual trauma, whether experienced as a child or as an

adult, contributes significantly to lower subjective health perceptions among its victims.

Sexual Trauma and Physical Symptoms

In the early 1980s, trauma researchers were noticing the higher-than-average

number of medical complaints in adult survivors of child sexual abuse (Browne &

Finkelhor, 1986; Gross, 1980). A flurry of studies followed, trying to ascertain whether a

greater number of physical symptoms actually presented themselves in these victims and,

if so, what types of symptoms were most common.







13

Cunningham, Pearce, and Pearce (1988) surveyed 60 adult women regarding their

medical complaints. Of these women, 27 acknowledged a history of child sexual abuse,

accounting for 45% of the sample. Researchers found that subjects with a positive

history of trauma had significantly more frequent complaints of a variety of medical

problems. More recently, researchers at Johns Hopkins University School of Medicine

(McCauley et al., 1997) surveyed 1,931 patients in their primary care internal medicine

clinics regarding childhood abuse and health complaints. A total of 424 respondents

(22%) acknowledged having suffered either physical or sexual abuse as a child (15.7%

reported sexual and physical abuse or sexual abuse only, 6.1% reported physical abuse

only). Women who reported abuse as children had more physical symptoms than

nonabused patients (mean = 6.2, sd = 0.2 versus mean = 4.0, sd = 0.9), including back

pain, chronic headaches, pelvic pain, abdominal pain, chest pain, fatigue, gastrointestinal

distress, and shortness of breath.

Walker, Katon, Harrop-Griffiths, and Holm (1988) attempted to distinguish

psychosomatic problems from organic problems by comparing two groups of women,

one with complaints of chronic pelvic pain and the other with specific gynecological

conditions. All subjects were administered structured interviews, in addition to

laparoscopic examination by a gynecologist who was blind to the interview content. No

differences were found between the groups on severity or type of pelvic pathology;

however, the chronic pelvic pain group reported a significantly higher prevalence of

childhood sexual abuse.

Golding (1996) also looked at the issue of sexual trauma and women's

gynecological health by analyzing data from 3,419 women in both Los Angeles and

North Carolina who responded to questionnaires about sexual assault and completed the







14

Diagnostic Interview Schedule. Sexual assault was found to be associated with excessive

menstrual bleeding, genital burning, painful intercourse, menstrual irregularity, and lack

of sexual pleasure. Researchers found that .11, ,'.II, ...l..il i. ,J1 assaults and those

committed by strangers had the strongest correlations to reproductive system problems,

while multiple sexual assaults, date and spousal rape, and completed intercourse were

most strongly related to sexual problems.

The nature of physical complaints associated with sexual trauma is not solely a

gynecological problem. Drossman et al. (1995) attempted to summarize all the pertinent

literature by clinicians and researchers involved in the care of patients with complex

gastrointestinal illness. Their review led to the following conclusions: (a) a robust

association exists between abuse history and gastrointestinal illness, (b) a history of

sexual trauma appears more often among women, (c) this history is not usually known by

the physician, and (d) it is associated with poorer adjustment to illness and adverse health

outcome.

Another study involved female gastroenterology patients who had a reported

history of sexual traumatization (Walker, Gelfand, Gelfand, & Koss, 1995). Following

an interview, 89 women were classified as having experienced either less severe or no

prior sexual trauma (n=46) or severe sexual trauma (n=43). Comparisons between the

two groups revealed that the severely traumatized group had significantly higher

medically unexplained physical symptoms, as well as higher rates of psychiatric

disorders.

Headache pain has also been investigated for its association with sexual abuse.

Domino and Haber first looked at this issue in 1987, using 30 women who presented with

chronic headache pain. After assessment with the Minnesota Multiphasic Personality







15

Inventory li'l i. 66% of the participants reported significant histories of prior physical

or sexual abuse, with an average duration of 8 years. Researchers found that headache

pain developed after the trauma in 100% of the cases; however, participants did not relate

the onset of pain to their trauma. Abused women were found to have significantly more

headaches than nonabused women.

Five general population studies examining the association between headaches and

sexual assault history were synthesized by Golding (1999a). Data from a total of 7,502

subjects contacted in five independent samples of randomly selected community

residents were derived from face-to-face surveys, including three surveys of adults and

two surveys of youth. A robust relationship was shown between sexual assault and

headache, regardless of participants' gender or ethnicity (odds ratio = 1.70). Findings

also suggested that persons sexually assaulted in childhood consistently had greater odds

of headaches than those first assaulted in adulthood.

Another category of physical symptom that has been found to be associated with

sexual trauma is chronic pain. Finestone and colleagues at the London Health Sciences

Center (2000) compared three groups of women on questions of abuse history, pain,

psychological symptomatology, and medical and surgical history. The experimental

group consisted of 26 enrollees of group therapy for individuals who had experienced

child sexual abuse, while the control group was comprised of 33 psychiatric outpatients

and 21 nurses. Their results confirmed that women with histories of sexual abuse were

more likely to experience chronic pain lasting over three months (69% of experimental

group compared to 43% of control group). The abused women also reported a greater

number of painful body areas, more diffuse pain, and more diagnoses of fibromyalgia.









A variety of medical complaints was found to be associated with sexual assault

that occurred during military service in a study of women veterans by Frayne et al. in

1999. While the bulk of this study will be discussed in the section dealing with women

veterans, the findings related to specific health problems should be noted here. A total of

3,543 female veterans responded to a national survey with 805 (23%) reporting a history

of sexual assault while in the military. Information was also requested about a spectrum

of physical symptoms and medical complaints. Comparisons between the women who

had been assaulted and those who had not were made via age-adjusted odds ratios to

lessen the risk of confounding age with medical illness. Researchers found that sexual

assault in the military was correlated with pelvic pain, menstrual problems, chronic

fatigue, back pain, headache, and gastrointestinal symptoms. In addition, they

discovered that certain medical conditions were seen more frequently in the sexually

assaulted group including obesity, irritable bowel syndrome, lost pregnancies,

endometriosis, asthma/emphysema/bronchitis, and hypertension. The severe

symptomatology of this group is also shown by the fact that 26% of the victimized group

endorsed greater than 12 of the possible 24 symptoms, compared to only 11% of the

nonvictimized group.

Golding (1999b) looked at the relationship between sexual assault history and

demand for medical care in order to determine whether or not victimized women actually

have worse physical health than nonvictimized women. She analyzed data from two sites

of the Epidemiologic Catchment Area study, Los Angeles (N = 3,132) and North

Carolina (N = 2,993). Golding's study looked at the association of sexual assault history

with requests for medical care for 21 specific symptoms among randomly selected

community residents age 18 years and older. Results suggested that victimized women









actually have a higher prevalence of symptoms than nonvictimized women versus the

alternative explanation that such persons seek greater care due to a unique pattern of

illness behavior.

It is clear from these studies that the experience of sexual trauma is positively

correlated with an increase in physical symptoms across a wide range of medical

conditions and body systems. Considering this, it should be no surprise that women with

such histories make higher demands on their health care providers.

Sexual Trauma and Health Care Utilization

An early study (Golding et al., 1988) involving 2,560 adult community residents,

343 of whom had been sexually assaulted (13.4%), revealed that women with histories of

sexual trauma were more likely to seek medical care than nonvictimized women.

Researchers found that sexual assault appeared to increase medical use indirectly,

through poor mental and physical health.

Koss (1994) surveyed 413 urban, working women regarding their history of crime

victimization and compared this data against medical records kept by their work site-

based HMO detailing the number of physician's visits and outpatient costs. She found

substantial increases in women's use of medical services by those who had suffered

criminal victimization for up to three years following the crime.

In addition to higher numbers of visits to physicians, Salmon and Calderbank

(1995) found that victims of sexual abuse tend to engage in a greater number of hospital

admissions and surgical procedures in adulthood than nonabused persons. Their study

was conducted using university undergraduates (N = 275) of which 22% reported

experiencing childhood sexual abuse (9% for males and 28% for females).









As referenced earlier, a study by Finestone et al. (2000) compared women with

childhood sexual victimization (n=26) against a control group of women without such

histories (n=54) in a health sciences center in Canada and found that victimized women

had more surgeries, hospitalizations, and visits to physicians.

Farley and Patsalides (2001) compared four groups of women-no abuse,

physical abuse alone, physical and sexual abuse, and unclear memories of abuse-in an

examination of health care utilization from a randomly selected sample of 86 adult

women in a health maintenance organization. Of those, 27 women reported having

experienced both physical and sexual abuse, while 25 reported physical abuse only.

Their findings were consistent with earlier studies, showing that sexually abused women

had the most severe chronic physical symptoms (F = 6.03, p = .001), and a higher

number of medical visits (F = 2.66, p = .05). While victims of physical abuse had higher

numbers of both symptoms and medical visits than nonabused women, the numbers were

substantially lower than in the sexually abused group.

Another study examining the relationship between health care utilization and

sexual trauma looked specifically at childhood sexual abuse. This study examined the

costs of health care services for 1225 women enrolled in a large HMO and found that

women who reported abuse or neglect in childhood had median health care costs $97 per

year greater than women without such histories. Additionally, women with histories of

childhood sexual abuse had median health care costs $245 greater per year than similarly

nonabused women, and these women were nearly twice as likely to visit the emergency

department (Walker et al., 1999).

Interestingly, a study by Sansone, Wiederman, and Sansone (1996) did not

entirely support the above findings. These researchers looked at the medical records of









116 women consecutively recruited during routine gynecological appointments in

association with trauma questionnaires completed by the participants. They found only

moderate correlations between a positive sexual trauma history and physician visits

(r =.25, p <.01) and ongoing prescriptions (r=.27, p < .01), and a negative correlation

with specialist referrals (r= -.02). One of the explanations for the weaker findings in this

study is that their definition of sexual abuse was "any sexual activity against your will,"

which may have diluted the results. Other studies have employed more stringent

definitions of sexual abuse.

With the exception of the study by Sansone and colleagues, all of the research

thus far has substantiated the strong link between a history of sexual trauma and

subsequent declines in physical health and increased utilization of medical services.

There are several possible explanations for this association: (a) victims of sexual trauma

may suffer actual injuries or diseases from the sexual violence that lead to chronic

infection, dysfunction, or systemic disorders; (b) functioning of the immune system may

become impaired due to the subsequent stress of the sexual trauma, leading to increased

infectious diseases; (c) assault-related stress or emotional problems may lead the victim

to engage in risky health behaviors, such as using alcohol, drugs, and tobacco, or to

neglect positive health behaviors, such as proper diet, exercise, and medical check-ups;

(d) inappropriate use of medical services may lead to unnecessary treatments, surgeries,

and prescription medicines which may then cause victims to need restorative treatment,

and (e) victims may interpret their emotional distress as physical symptoms, either due to

repression and resultant somatization, or due to the stigma attached to mental health

problems.









Special Concerns of Women Veterans

As reported earlier in this study, the population of women veterans has proven to

be unique and not merely a representative sample of the general female population in

regards to their health perceptions and sexual trauma histories. Skinner and Furey (1998)

conducted a survey by mail with 719 women veterans randomly selected from active

enrollees in a large VA tertiary care facility near Boston. Their sample ranged in age

from 21 to 93 years, with a mean age of 52.6 years. Only about one-fourth (26%) of the

respondents were married at the time of the survey, and 227 (32%) had never been

married. Nearly two-thirds (65%) of the participants reported their annual income as less

than $20,000. The majority of the women were white (88%), and 65% of them had

completed some college education, with 11% having attained a graduate degree.

Participants were asked to rate their health-related quality of life on a 36-item health

survey that included eight domains: physical functioning, role limitations attributable to

physical problems, bodily pain, general health perceptions, energy and vitality, social

functioning, role limitations attributable to emotional problems, and mental health. The

scores of the veteran women were then compared against a sample of

noninstitutionalized, nonveteran women from the Medical Outcomes Study (Tarlov et al.,

(1989). Veteran women scored lower than their civilian counterparts in every one of the

eight domains, with the largest differences on scales measuring role limitations due to

physical problems, role limitation due to emotional problems, and bodily pain.

Another difference between veteran women and nonveteran women was

highlighted in the study conducted by Coyle, et al. (I I ..''. i. which examined the

prevalence of physical and sexual abuse among women seeking care through the VA

Healthcare System. These authors collected data through an anonymous survey mailed









to 874 veterans receiving care during the last six months of 1994 at the Baltimore VA

Medical Center. A total of 429 completed surveys were returned. Demographic

information reported by those who responded to the survey was compared to data from

the original patient database, revealing no significant differences and confirming the

representative nature of the sample. The majority of women in this sample were under

age 40 years (56.6%), and 49% of them had taken some college courses but not

completed a degree, while 13.5% had earned graduate degrees. At the time of the survey,

only 18.4% were married, while 29.8 reported they had never married. For the purposes

of this study, rape was defined by the question "Have you ever been forced into

unwanted sexual intercourse?" Sexual abuse was defined by asking "Has anyone ever

pressured you into doing something sexual .... could include ... touching your private

parts,. breasts, getting you to touch their private parts, or kissing you in a way that

made you feel threatened or uncomfortable?" They were also asked when the abuse

occurred.

Results of this survey revealed that 178 women veterans (41.5%) reported having

been raped at some point in their lifetime, while another 8 women (1.9%) indicated that

they "did not know" if this had occurred. Regarding sexual abuse, 238 (55.4%)

responded affirmatively, with 5 women (1.2%) saying it was unknown. Of these 238

victims, 22.3% reported that it occurred when they were children, and another 26.5% said

they were sexually abused both as children and adults. Clearly, the prevalence of rape

within this population is much higher than that found in similar surveys of civilian

populations, which report rape prevalence ranging from 13-20%. The 48.8% who

reported they were sexually abused as children is within the range found in civilian

population studies (5-62%). but much closer to the higher end.







22

The authors concluded that a large proportion of these women veterans had been

victimized and "may be psychologically and physically affected by their experiences,"

necessitating better screening, assessment, and treatment by healthcare providers.

Sexual assault sustained during military service (SAIM) is a specific type of

sexual trauma that is particular to the population of women veterans. Figures range from

5% to 13% for the prevalence of this type of assault, depending upon the sample and

definitions used (Freeman, Ryan, & Hendrickson, 1996; Martindale, 1988; Murdock &

Nichol, 1995; Wolfe, Brown, & Kelly, 1993). Sexual assault that occurs during military

service may differ from other sexual assaults due to the unique dynamics of the situation.

Women in the military are usually young adults, and are both living and working with

predominantly male peers. Military training encourages "team-building," which may

serve to discourage reporting or follow-up on reports of sexual violence when it occurs

within the group.

The Veteran's Administration conducted the Women's Health Project, a national

study comprised of a representative sample of women veterans receiving ambulatory care

from a VA facility. Data from this study was used to evaluate the prevalence of SAIM

(Skinner et al., 2000). Out of 6,216 mailed questionnaires, a total of 3,632 (58.4%) were

returned completed. Sexual assault was measured by response to the question, "Did you

ever have an experience where someone used force or the threat of force to have sexual

relations with you against your will while you were in the military?" In response to this

question, 805 women (23%) indicated that they had been sexually assaulted while

serving in the military. Comparisons between those who had been sexually assaulted and

those who had not revealed that the victimized group averaged 6 years younger in age,







23

and were l. I tl. ,..ri i, du i.:.J than their counterparts. There were no significant racial

differences or differences in marital status between the two groups.

Associated researchers (Frayne et al., 1999) looked at this same data set in order

to determine the medical profiles of women veterans who had suffered a sexual assault

while in the military. Results of their analysis were discussed above regarding the

prevalence of specific physical complaints and medical conditions. Researchers

additionally found that the women who had experienced SAIM made more visits to their

healthcare providers in the three months prior to the survey than did nonvictimized

women veterans. The mean number of visits to a mental health specialist was .94 among

women with no history of SAIM and 2.62 (p = .0001) for women who reported SAIM.

The mean number of visits to other healthcare providers (including physician's assistants,

nurse practitioners, nurses, social workers, physical therapists, or chiropractors) was 1.5

for nonvictimized women and 2.3 (p = .0001) for those reporting SAIM.

These studies underline the uniqueness of the population of women veterans.

These women have been shown to report lower ratings of perceived health status and

more physical complaints than their civilian counterparts. They also appear to be at

greater risk for having experienced sexual trauma, both as children and adults. Their

unique circumstance of both living and working in a male-dominated culture places them

particularly at risk for sexual assault while in the military. Since the number of women

veterans is rapidly rising as more and more young women elect to serve in the military, it

is imperative that healthcare service providers understand the specific needs of this

population more clearly.









Moderating Variables

The term "moderator' is used in this study in conformance with the definition

explicated by Baron and Kenny (1986). These researchers explained that a moderating

variable affects the relationship between two variables by interacting with a predictor

variable, which then causes an increase or decrease in the dependent variable. They

distinguish this action from that of a mediating variable, which specifies the mechanism

by which a given effect occurs. Both mental health treatment and marital status are

considered to be possible moderating variables, as they may influence the degree of

impact sexual trauma has on subsequent health status measures, but neither is thought to

be the mechanism by which trauma affects physical health.

While it is clear that women who have been sexually victimized may experience

effects of the trauma through worsening physical health over many years, it is not so

clear how this effect may be moderated. Considering the psychosomatic theory, it would

stand to reason that lessening the emotional distress of these victims would ultimately

improve their physical well-being. The psychosomatic theory simply states that

repressed emotional conflicts are expressed through bodily symptoms. If true, then

strategies aimed at addressing and resolving some of the psychological symptoms that

typically follow sexual trauma may positively influence physical health.

Kimerling and Calhoun (1994) attempted to answer this question in their study of

115 women seen at a rape crisis center following sexual assault. They followed this

group for one year posttrauma. with four follow-up interviews covering areas such as

particular details of their assault, lifetime history of abuse, social support, medical

services utilization, mental health treatment utilization, somatic symptoms, and

psychological disorders. Data gathered from these interviews was compared against a









control group matched for demographic characteristics. While these researchers found

that the sexual assault victims had a higher utilization of medical services over one year

than the nonvictims, there was no evidence that the utilization of mental health services

had any effect in moderating this relationship. These researchers cautioned, however,

that there may have been insignificant findings due to the insensitivity of the

measurement of such services with respect to differentiating between long-term therapy,

a single visit, or call to a rape crisis center. Also, the participants in the two groups of

this study showed no differences in their use of psychological services, even though the

victim group had significantly more psychological symptoms, suggesting that these

victims did not utilize mental health services for their distress. One possible explanation

for this finding is that there is still a stigma attached to mental health treatment which

may encourage victims to identify their emotional distress as physical ailments.

Another route to examining this question was taken by researchers looking at one

particular physical complaint found in a large proportion of sexual assault survivors, that

of sleep-disordered breathing (SLB) (Krakow et al., 2002). Subjects with sleep-

disordered breathing report significantly worse nightmares, sleep quality, anxiety,

depression, PTSD, and impaired quality of life than those without this disorder. When

researchers studied 187 sexual assault survivors, fully 168 of them were diagnosed with

SLB. These subjects reported having suffered an average of 20 years from sleep

problems, which had been unresponsive to traditional treatments such as psychotherapy

and psychotropic medications.

Other research has looked into the role of social support as a possible moderator

of the sexual trauma/health association. One of the theories posed for this association







26

u, i.-. Ihjl ~l~' *. i --. of sexual trauma compromises functioning of the immune system.

Findings from the field of psychoneuroimmunology suggest that psychological stress has

a negative effect on physical health through changes in the immune and endocrine

systems (Kiecolt-Glaser & Glaser, 1992, 1995; Yehuda, Giller, Southwick, Lowy, &

Mason, 1991). Related research has shown that social support can have a positive effect

on these same biological systems (Kiecolt-Glaser, Fisher, Ogrocki, & Stout, 1987;

Uchino, Cacioppo, & Kiecolt-Glaser, 1996; Uchino, Uno, & Holt-Lunstad, 1999). Logic

\ ..uij -u -. I L t-, -. 'ci l support may moderate the effects of sexual trauma on physical

health by reducing the stress-related changes in the immune and endocrine systems.

The study referenced earlier by Kimerling and Calhoun (1994) investigated the

role of social support in moderating somatic symptoms in victims of sexual assault.

Their comparison of 115 sexual assault victims to a matched control group found that

social support provides a moderating effect on the victim/health relationship (F = 2.48,

p<.04), with higher levels of social support associated with better health following sexual

assault. This effect also held true for the association between social support and

subjective health perceptions (F = 2.88, p<.02), with higher ratings of social supports

being associated with better ratings of health following victimization. Interestingly,

however, no significant interaction was found between ratings of social support and

medical care utilization. These researchers reported that a possible explanation for this

finding was that medical care utilization did not begin to increase until 4 months

posttrauma (this study measured effects at 2 weeks, 1 month, 4 months, and 1 year) and

social support may have shown effects if the subjects had been followed for a longer

period of time.









Early research into the role of social support as a protective factor against the

risk of sexual assault was reviewed by Golding ...IJ;n,. et al., 2002) However, none of

these studies examined the moderating effects of social support posttrauma. Golding

suggested that future research was needed to ascertain the role of social support in

moderating the assault/health relationship. Another review article (Ullman, 1999) looked

more specifically at the function of social support in recovery from sexual assault.

Ullman found evidence that social support was related to better self-rated recovery from

sexual assault, reduced psychological symptoms, and reduced fear of crime. However,

two studies in this review reported no significant effect of social support in recovery

from the mental and physical health consequences of sexual assault.

Marital status, as a form of social support, has not been independently evaluated

for its role in moderating the link between sexual trauma and declining health. Previous

research in other fields of inquiry has shown marital status to be associated with both

physical and mental health outcomes. Hughes & Waite (2002) found that married

couples reported better self-rated health, less mobility limitations, and lower rates of

depression than single people in their survey of 8,485 adults aged 51 to 61 years. A

study examining the relationship of marital status and locus of control (LOC) with

relapse in breast cancer patients (Declerck et al., 2002) determined that married patients

with an intermediate LOC (not polarized to either internal or external) had less pathology

and lower levels of stress than their unmarried counterparts. An examination of the

relationship between marital status and mortality (Lund et al., 2002) found that subjects

living alone had significantly increased mortality compared to subjects who were married

or cohabitating. Finally, research into generalized anxiety disorder (GAD) (Hunt,

Issakidis, & Andrews, 2002) found a significant association with marital status, with







28

those subjects who were separated, divorced, or widowed evidencing higher incidence of

GAD than married subjects. These findings suggest that there may be some health

benefits to marriage that may provide a protective buK r. i -.ai- the ill effects of sexual

trauma.

It should be noted that these two variables are being investigated for their role as

"moderators" and not "mediators," as distinguished by Baron and Kenny. As pointed out

by these authors, the two terms are sometimes erroneously used interchangeably. In

actuality, a moderating variable is one that "affects the direction and/or strength of the

relation" between the predictor and criterion variables, whereas a mediating variable

"accounts for the relation between the predictor and the criterion" (Baron & Kenny,

1986). In the present study, marital status and mental health interventions are predicted

to lessen the deleterious health effects that follow traumatic sexual experiences, and they

are not considered to be the mechanism by which the trauma-health relationship occurs;

therefore, they must be considered moderating variables.

Summary and Hypotheses

The research cited above establishes an association between women's health and

sexual trauma, and emphasizes the long-term costs, both in emotional distress and

physical impairment, paid by those victims. Society, too, pays these costs in increased

medical care and loss of work-days. Women who have served in the U.S. military appear

to be especially vulnerable to this risk. With the -r.'. i of women's participation in the

active military and subsequent increasing numbers of women veterans, it becomes

important to understand how sexual trauma, both that experienced prior to their service

and during it, impacts the health perceptions and utilization of medical services of these

veterans. It is important for health care providers to be trained in recognizing and









treating problems associated with sexual victimization in order to provide the victims

with accurate diagnoses and appropriate treatments. As current understanding shifts

away from dualistic mind/body notions and begins to recognize the impact of emotional

distress on somatic conditions, more comprehensive and integrative services can be

offered to alleviate suffering. Understanding the role of social support and mental health

treatment as possible moderators in the assault/health relationship would greatly enhance

delivery of services to trauma victims.

Hypothesis 1: Sexual trauma and health perceptions. Women veterans have been

shown to report lower ratings of their health status compared to their civilian

counterparts. Women veterans also have been shown to have a disproportionately high

number of sexual victimization experiences during their lifetimes, and are uniquely

vulnerable to the experience of sexual assault during military service. Building on the

knowledge gleaned from studies involving civilian populations of women, which

demonstrate a strong relationship between sexual trauma and low subjective ratings of

health, it is hypothesized that women veterans who have been u- ll:, Inr,..i. will

have significantly lower general health perceptions than nonvictimized women veterans.

Hypothesis 2: Sexual trauma and physical symptoms. Women who have

experienced sexual trauma report more chronic physical complaints than their

nonvictimized counterparts, and women veterans who were sexually assaulted in the

military displayed significantly more physical symptoms than veterans without such a

history. Women veterans who have a history of sexual abuse or sexual assault are

predicted to have a greater number of physical complaints, ranging across body systems,

than women veterans without sexual trauma in their backgrounds.







30

Hypothesis 3. Sexual trauma and healthcare utilization. Women with a history of

sexual trauma use medical services at a higher rate than similar women without such

histories. Women veterans who had suffered a sexual assault while in the military were

also shown to visit healthcare providers more frequently than nonassaulted veteran

women. It is predicted that women veterans who have experienced a sexual trauma

during their lifetime will demonstrate higher utilization of healthcare services as

measured by visits to their primary care provider, specialty clinics, emergency room and

urgent care clinic, and by their number of prescription medicines.

Hypothesis 4. Moderating effects of marital status on assault/health association.

Equivocal evidence exists suggesting that social support may moderate the deleterious

effects of sexual assault on physical health. One of the types of social support that has

been recognized as having a positive effect on health is marital status. It is hypothesized

that women veterans who have been sexually traumatized, and are married or in a

committed relationship at the time of the survey, will report higher ratings of their health,

have fewer physical complaints, and demonstrate lower usage of healthcare services, due

to the moderating effects of this type of support on their stress, when compared to

similarly traumatized women veterans without such partners.

Hypothesis 5. Moderating effects of mental health treatment on assault/health

association. The few studies available provide mixed evidence for the efficacy of mental

health treatment in moderating the negative health effects of sexual trauma.

Psychosomatic theory posits that physical illness results from repressed emotional

distress and, if this is true, mental health interventions should serve to alleviate some of

this distress. As an exploratory study, it is .-i r.. i -d that women veterans with sexual

trauma histories, who have engaged in some form of mental health treatment, will







31

demonstrate less of the assault/health association than nontreated, sexually-victimized

women veterans, through higher health ratings, fewer physical complaints, and lower

usage of healthcare services.














CHAPTER 3
METHODOLOGY

The purpose of this study was to examine the relationship between sexual trauma

and physical health in a population of women veterans receiving outpatient care at a

large, tertiary-care VA Medical Center located in the southeastern United States. Two

sources of archived data were accessed for this study: ) the Women's Health

Questionnaire that was completed by new enrollees in a primary care women's clinic,

and (b) medical records for these same patients detailing numbers of visits to healthcare

professionals over a 2-year period of time. Self-reported histories of sexual assault

and/or childhood sexual abuse were studied in relation to ratings of perceived health

status, number and type of physical complaints, and utilization of healthcare services. In

addition, marital status and the utilization of mental health services were examined for

possible moderating effects on the assault/health association.

Participants

In April, 1999, the Women's Clinic for primary care health services was first

opened at the VA Medical Center utilized in this study. Between April 1999 and May

2000, as women enrolled in the clinic, they were asked to complete a screening

questionnaire covering different aspects of their health complaints and history of

interpersonal violence. Of the 247 initial clinic enrollees, seven declined to respond to

questions regarding sexual trauma experiences, and 30 were not veterans of military

service, leaving a subject pool of 210 participants. Respondents were asked to report







33

their age, ethnicity, marital status, and education level. The mean age of this group was

51.9 years (SD = 15.9 years). The majority of participants were Caucasian (80.9%) with

other participants reported as African-American (I n'.. Native American I I.

Asian-American (.5%), Hispanic (3.5%), and other (1%). There were 97 participants

(46.4%) who reported themselves as married or in a committed relationship. Of the

others, 41 had never married (19.6%), 26 were widowed (12.4%), and 45 were divorced

or separated (21.6%). Most of the participants (99%) had completed high school and

43.3% reported having 1 to 3 years of college education. Only 17.6% completed college

and another 8.6% graduated from a trade or technical school. Only two participants

reported that they had not completed high school (1%), and one of these had less than an

8th grade education.

Procedure

Over the course of 1 year between April 1999 and May 2000, as female veterans

enrolled for primary care services through the Women's Clinic, they were asked to

complete a short survey entitled the Women's Health Questionnaire, which asked basic

demographic and health-related questions, in addition to a Trauma Questionnaire. The

purpose for this survey questionnaire was to screen for various physical and mental

health disorders, as well as trauma experiences, in order to provide appropriate treatment

services. These questionnaires were forwarded to the staff psychologist for review and

possible follow-up when deemed necessary.

Information regarding each participant's general health perceptions was obtained

from responses to the question, "Overall, would you say your health is: excellent, very

good, good, fair, or poor." Participants would choose one of the responses to this query.

Their responses to questions regarding medical complaints over the previous 4 weeks







34

were coded according to the ten categories of types of medical problems: gastrointestinal,

neurologic, musculoskeletal, gynecologic, cardiac, depression, anxiety, eating disorders,

substance abuse, and obsessive-compulsive disorders.

The operational definition for sexual assault in this research was based on the

respondent's affirmative reply to the question, "Has anyone ever used force or the threat

of force to have sex with you against your will?" Participants also were asked whether

the sexual assault occurred during military service. Child sexual abuse was defined as

any affirmative response to the question, "Were you ever sexually assaulted or touched in

a sexual way, by a person 5 or more years older than you, when you were younger than

13?" Two independent variables were identified in this study: women who had

experienced sexual trauma via sexual assault or child sexual abuse, and a comparison

group of women with no self-reported sexual trauma.

Medical records of each participant were accessed through the electronic records

system of the VA Medical Center. Beginning with the date of their enrollment in the

Women's Clinic and going forward for two years, the total number of visits to primary

care and specialty clinics, number of visits to the emergency room or Urgent Care clinic,

and the total number of prescription drugs provided to each participant were tabulated.

The type and extent of any mental health services was also determined from this medical

record to include any visits to psychiatrists for psychotropic medications and/or any

sessions of group or individual psychotherapy with mental health professionals.

Measures

The Trauma Questionnaire (TQ) was developed on the national level by the

Women Veterans Comprehensive Health Centers' staffs, and validated at the Durham,

NC Veteran's Administration Medical C.. ,r r i '.1.. I,-, r.. et al., 1999). The TQ is a







35

10-item self-report questionnaire that assesses a woman's history of childhood and adult

sexual trauma, sexual harassment, and domestic violence, along with measures of desire

for mental health services. The Durham researchers compared responses on the TQ to

those given during an interview by experienced clinicians using the K statistic.

Sensitivity and specificity were computed and found to be .89 (sensitivity) and .90

(specificity) for sexual assault items, and .89 (sensitivity) and .97 (specificity) for child

sexual abuse items. The Women's Health Questionnaire, in which the TQ is embedded,

was developed as a screening tool for sexual trauma and major depressive disorder, and

also taps into health perceptions and medical complaints concerning an array of current

or recent physical symptoms and medical conditions spanning all major organ systems.

Predictions

The Women's Health Questionnaire and participants' medical records were used

to test predictions concerning the relationship between a history of sexual trauma and

physical health problems. Based on previous research on this issue, it was predicted that

women with a history of sexual trauma would report lower ratings of their perceived

health than nontraumatized women. Similarly, women with a sexual trauma history

were expected to report a higher number of physical complaints ranging across

physiological systems than women without such a history. The medical records were

expected to yield evidence of higher healthcare utilization among sexually traumatized

participants through their number of visits to primary care, specialty clinics, emergency

room, urgent care clinic, and total number of prescriptions.

It was predicted that women veterans who had been sexually traumatized, but

who had subsequently received some form of mental health services, would rate their

perceived health status as higher than their nontreated, sexually-traumatized peers.









Similarly, this subgroup was predicted to have fewer physical complaints and lower

medical care utilization than the sexually traumatized group who had never engaged in

mental health treatments. Any type of mental health intervention, whether it consisted of

psychotherapy or psychotropic medications, was expected to moderate the ill health

effects that usually follow sexual trauma. Social support in the form of marital status

was also predicted to lessen the effect of sexual trauma on all three physical health

parameters measured in this study: ratings of perceived health status, physical

complaints, and utilization of healthcare services.

Data Analysis

Demographic characteristics were analyzed using standard descriptive statistics,

and were then compared between the two groups. Due to the known association between

advancing age and medical illness, age was entered into the regression models as a

separate variable.

A dichotomous independent variable, .1. u.ii:. ,irju.li.:Le.J or not, was used in

this study, based upon respondents' self-reports of having experienced sexual assault or

child sexual abuse. Dependent measures were (a) respondents' rating of perceived

health, (b) number and type of medical complaints within the past four weeks, (c)

number of visits to health care providers over a 2-year period, (d) number of unscheduled

visits to 'ii l, ,I-i.'ll room or urgent care clinic over a 20-year period, (e) and number

of prescriptions filled for medical conditions. Comparisons between the two groups were

conducted using individual T-tests for each dependent measure.

In addition, two additional variables, marital status and mental health

interventions, were examined for their possible moderating effect on the trauma/health

relationship. Two types of statistical analyses were conducted in this examination. Both







37

linear and binary logistic regression analyses were utilized to investigate the potential

moderating effect of these variables on the dependent measures.















CHAPTER 4
RESULTS

The sample of 210 participants was split into two groups: no sexual trauma and

sexual trauma, based upon their responses to the questions regarding experiences of child

sexual abuse and adult sexual assault. Demographic characteristics were compared

between the two groups, which differed significantly only on age and race. The trauma

group was younger than the no trauma group (mean age 48.4, s.d. 13, vs. 53.8, s.d. 16.9;

t = 2.370, p<.01), and had a slightly higher number of racial minorities (23.9% vs.

16.4%; t = 1.801, p<.04). The two groups did not differ significantly on marital status or

education level. A total of 73 women (34.8%) reported having experienced one or more

forms of sexual trauma in their lifetime.

To test the first three hypotheses identified, individual t-tests were conducted on

the differences between means between the two groups on the measures concerning

health perceptions, health complaints, and healthcare utilization. In c..rdul..ir.L i hc :

analyses, a pattern of different responses was seen between those who had been

traumatized in childhood versus those traumatized as adults. Additional t-tests were

conducted on subgroups of this population: those who had experienced adult sexual

assault (ASA), those who had experienced child sexual abuse (CSA), and those who had

experienced both forms of trauma (both), compared against the "no trauma" group.

Although this last subgroup contained subjects who were also in one of the first two

subgroups, their experience of having experienced sexual trauma in both developmental









phases of life was thought to render their responses as qualitatively different than the

other two groups, necessitating a separate analysis. None of the three subgroups was

compared against the other; all were compared against the "no trauma" group. Child

sexual abuse was reported by 54 women (25.7%), adult sexual assault was reported by 44

women i 2 i". i, and a total of 25 women (11.9%) reported experiencing both forms of

abuse. The final two hypotheses (those relating to potential moderating variables of

marital status and mental health interventions) were analyzed through correlation,

stepwise linear regression, and binary logistic regression.

Hypothesis 1: Health Perceptions

The measure used to capture participants' s if -r. I r, ; of their general health

consisted of a 5-point scale, ranging from 1 = "excellent" to 5 = "poor." Due to a

tendency among participants to select the middle rating (no trauma mean = 2.79, s.d. .99,

vs. trauma mean = 2.96, s.d. .96), the ratings were collapsed into a dichotomous variable

of positive ratings (excellent, very good, and good = 0) and negative ratings (fair and

poor =1) for further analyses. To test the hypothesis that women who have experienced

sexual trauma would assign poorer ratings to their perceptions of health than women

without such experiences, a between-subjects t-test was conducted. While there was a

general trend towards poorer ratings by the sexual trauma group, results of an

independent samples t-test did not support this prediction, t- -1.229, p<.l 1. The

frequency of poor subjective ratings was observed to be greater in two subgroupings:

those who had been sexually assaulted as adults and those who had experienced both

adult and child sexual abuse (34% and 36% respectively versus 21% in the

nontraumatized sample). Therefore. subgroupings of the sexually traumatized sample

were also compared with the nontraumatized group via individual t-tests.









Table 4-1. Comparison of means on health perceptions between trauma groups

Group N Mean Std. deviation
No trauma 135 .21 .41
Any sex trauma 72 .29 .46
Adult sex trauma 43 .35 .48
Child sex trauma 54 .28 .45
Both adult/child 25 .36 .49

Analysis revealed that women who had experienced adult sexual trauma were

significantly more likely to rate their health as "poor" than were nontraumatized women

(t = -1.780, p<.04). Women who had experienced child sexual abuse, and those who had

experienced both adult and child sexual trauma, did not differ significantly from the

nontraumatized sample ( t = -.922, p<.18, and t= -1.569, p<.06 respectively). Therefore,

the prediction that women who had experienced sexual trauma would assign poorer

ratings to their general health status than nontraumatized women held true only for the

subset of this sample who had experienced adult sexual assault.

Hypothesis 2: Health Complaints

Compilation of the total number of health complaints reported by participants in

the 4 weeks preceding their completion of the Women's Health Questionnaire served as

the dependent measure in testing the hypothesis that women who have experienced

sexual trauma would report a greater number of health problems than women without

such experiences. This prediction was supported by comparisons of the mean difference

between the trauma/no trauma groups, as well as between all subgroups. Since the

number of health complaints tended to increase among the trauma groups, all !;li, jr.-

reported at the one-tailed significance level. The first level of comparison made between

the "no trauma" and "trauma" groups revealed that traumatized women reported









significantly more health problems in the preceding four weeks (t = -3.325, p<.00).

Subsequent analyses demonstrated that the group who experienced both forms of abuse

reported the highest number of health complaints (t = -3.141, p<.00 1), followed by the

adult sexual assault group (t = -3.698, p<.001). The child sexual abuse group, while

reporting fewer complaints than the other trauma groups, still had a significantly higher

number than the "no trauma" group (t = -2.776, p<.003).

Table 4-2. Comparison of means on health complaints between trauma groups

Group N Mean Std. deviation
No trauma 137 4.81 3.67
Any sex trauma 73 6.74 4.58
Adult sex trauma 44 7.43 5.21
Child sex trauma 54 6.52 4.22
Both adult/child 25 7.48 5.07

The types of health complaints reported by participants spanned nine categories,

out of which the trauma group endorsed substantially more complaints than the

nontrauma group in six categories. Those included gastrointestinal (54.8% vs. 44.5%),

neurologic (60.3% vs. 42.3%), musculoskeletal (78.1% vs. 69.3%), depression (72.6%

vs. 60.6%), anxiety (61.6% vs. 49.6%), and obsessive-compulsive (19.2% vs. 5.8%).

The research prediction that women who had experienced sexual trauma would report a

greater number of health complaints across a variety of systems than nontraumatized

women was supported. As reported previously, an analysis of subgroups of the

traumatized sample revealed different patterns of responses according to the type of

sexual trauma they had experienced, with women who experienced adult sexual abuse

reporting the highest level of health problems.









1 i. .L *i. I j. l, J i i. j r. I i ll j i ,n

The dependent variable of healthcare utilization was represented by three

different measures assessed over a 2-year period of measurement beginning the date of

their enrollment in the Women's Clinic: (a) the number of medical visits to primary care

or specialty care providers, (b) the number of unscheduled visits to the emergency room

or urgent care clinic, and (c) the number of prescription medicines on record for the

individual. Due to a skewed distribution pattern found in the measures of medical visits

and emergency room visits, these variables were transformed from continuous measures

into categorical measures. Total medical visits were assessed for the entire sample, then

classified into one of four categories of approximately equal proportions (0 = 1 to 7

visits, 1 = 8 to 12 visits, 2 = 13 to 25 visits, and 3 = 26 and over visits). Emergency room

visits were classified dichotomously (0 = no visits and 1 = any visits).

Two of the three dependent measures: medical visits (t = -1.835, p<.034) and

prescriptions (t = -2.569, p<.006). were found to be significantly higher for the trauma

group compared to the nontrauma group. However, there was no significant difference

found between the two groups on utilization of emergency room services ( t = -.529,

p<.30). Again, one-tailed levels of Inl; r~ "L rlk re reported since the higher reported

means on these measures for the groups who had experienced sexual trauma ensures the

reliability of predicting direction of change. Table 4-3 summarizes the mean scores and

standard deviation scores for these three measures of healthcare utilization across all

trauma groups.

The subgroups of adult sexual trauma and child sexual trauma similarly displayed

significantly more medical visits and prescriptions when comparing between these two









groups and the "no trauma" group, but no *,Ii i.IrI Jllli iec in the number of

emergency room visits. However, an analysis of the subgroup of participants who had

experienced both types of abuse did result in significant differences on all three measures

of healthcare utilization. Table 4-4 displays the results of these analyses.

Table 4-3. Comparison of means on healthcare utilization between trauma groups

Group N Mean Std. dev
No trauma 137 1.44 1.16
Any sex trauma 73 1.74 1.08
Medical visits Adult sex trauma 44 1.77 1.08
Child sex trauma 54 1.83 1.08
Both adult/child 25 2.00 1.04
No trauma 137 .31 .46
Any sex trauma 73 .34 .48
ER visits Adult sex trauma 44 .39 .49
Child sex trauma 54 .37 .49
Both adult/child 25 .48 .48
No trauma 137 6.80 6.12
Any sex trauma 73 9.25 7.32
Prescriptions Adult sex trauma 44 9.64 8.25
Child sex trauma 54 9.44 6.75
Both adult/child 25 10.36 7.79

Table 4-4. t-test results for healthcare utilization measures between trauma groups

Trauma Medical visits E.R. visits Prescriptions
group sig. sig. sig.
(1-tailed) (1-tailed) (1-tailed)
Any 1.835* .034 .529 .30 2.569** .006
Adult 1.692* .046 .980 .16 2.441** .008
Child 2.160* .016 .845 .20 2.607** .005
Both 2.257* .013 1.696* .046 2.555** .006
significant at p<.05
** significant at p<.01









Examination of Moderating Variables

Correlational analyses were performed on five dependent measures and the two

moderating variables, marital status and mental health interventions, to examine their

relationship to one another and to sexual history and age of participant. Results indicated

that marital status was not correlated with any of the dependent variables, and was only

weakly correlated with mental health interventions (r= -.15, p<.015, N = 209). Marital

status did differ iL,'ni ~ni. between the trauma subcategories, with the CSA group

evidencing the highest rate of marriage (65.5%), followed by the no trauma group

(46.3%), and with the ASA and both traumas groups reporting the lowest rates of

marriage (36.8% and 36% respectively). One-way analysis of variance between the

trauma categories on marital status resulted in F (2,72)= 3.109, p<.05. Mental health

interventions were found to be most strongly correlated with health complaints

(r = .428, p<.0001, N = 210), and showed weak to moderate correlations with health

perceptions (r = .219, p<.002, N = 207), medical visits (r-.189, p<.006, N = 210),

emergency room visits (r =.20, p<.004, N = 210), and prescriptions (r =.263, p<0001,

N = 210). Age was found to have a negative, moderate association with mental health

interventions, as well as with reported sexual history. Mental health interventions also

showed a moderate correlation with sexual history as indicated on the following page.

Because the distribution of the number of mental health visits over a 2-year

period for this sample was found to be skewed, with a high percentage of participants

reporting no mental health service utilization, this variable was transformed from a

continuous variable to a dichotomous variable (0 = no visits, 1 = any visits). In the

overall sample, only 60 subjects (28.5%) had received any form of mental health

services. Utilization of mental health services was highest among women who had









Table 4-5. Correlations between moderating variables, dependent variables, and trauma history

Mental Marital Health Health Medical
health tx status perceptions complaints visits ER visits Rx's Age Sex history
Mental health tx r 1.000 -.151* .219** .428** .189** .200** .263** -.258** .304**
sig .014 .001 .000 .003 .002 .000 .000 .000
Marital status r -.151* 1.000 -.035 -.056 .051 -.020 -.073 .082 -.060
sig .014 .309 .211 .234 .389 .146 .118 .195
ilth perceptions r .219** -.035 1.000 .406** .244** .189** .190** -.095 .119*
sig .001 .309 .000 .000 .003 .003 .086 .043
Hlth complaints r .428** -.056 .406** 1.000 .320** .189** .350** -.052 .251**
sig .000 .211 .000 .000 .003 .000 .226 .000
Medical visits r .189** .051 .244** .320** 1.000 .365** .606** .139** .142**
sig .003 .234 .000 .000 .000 .000 .022 .020

ER visits r .200** -.020 .189** .189** .365** 1.000 .321** -.073 .084
sig .002 .389 .003 .003 .000 .000 .145 .112

Rx's r .263** -.073 .190** .350** .606** .321** 1.000 .199** .184**
sig .000 .146 .003 .000 .000 .000 .002 .004

Age r -.258** .082 -.095 -.052 .139* -.073 .199** 1.000 -.218**
sig .000 .118 .086 .226 .022 .145 .002 .001
Sex history r .304** -.060 .119* .251** .142* .084 .184** -.218** 1.000
sig .000 .195 .043 .000 .020 .112 .004 .001
Correlation is significant at the 0.05 level (1-tailed).
** Correlation is significant at the 0.01 level (1-tailed).









experienced both child and adult sexual abuse (64%), followed by those who reported

adult abuse (36.8%), child sexual abuse ( I' .. and no sexual trauma (20.4%).

Stepwise linear regression analysis was used to determine whether marital status,

age, and/or mental health interventions moderated the relationships between sexual

trauma history and health complaints, medical visits, and prescriptions. Binary logistic

regression was used to examine the relationships between marital status, age, and mental

health interventions with health perceptions and emergency room visits. The procedure

used was the indicator contrasts method, in which the contrasts indicate the presence or

absence of category membership. This contrast is equivalent to the traditional "dummy

variable" approach. The first category, no sexual trauma history, is the reference

category and, as such, is not included in the model estimation. Sexual trauma history

was analyzed by partitioning the trauma group into subgroup classifications of adult

sexual assault (ASA), child sexual abuse (CSA), and both forms of sexual trauma. No

relationship between marital status and the health-related outcomes was observed. Age

was found to have rillr Fn effects on medical visits and prescriptions. Mental health

interventions, although correlated with the health outcome measures, were not found to

have any significant moderating effect on any of these variables.

As shown in Table 4-6, the use of mental health interventions accounted for only

a small portion of the variance among women's self-ratings of their general health, while

none of the other predictors had any significant effect.

As this model demonstrates, both sexual trauma history and mental health

utilization have significant effects on the number of health complaints, and the utilization

of mental health services appears to be a stronger predictive factor for health complaints

than the other proposed variables.









Table 4-6. Logistic regression analysis on health perceptions

Variable B S.E. Wald Exp(B)
Sex. history 1.1410
CSA -.2782 .5028 .3061 .7571
ASA -.4555 .6508 .4899 .6341
Both .1837 .6756 .0739 1.2016
Mental health .9539 .3730 6.5403** 2.5958
Marital status .0342 .3454 .0098 1.0347
Age -.0039 .0115 .1166 .9961
Constant -1.0587 .7611 1.9349
Chi-square/df: 10.589/6* Nagelkerke R-square: .075
*significant at p=.051
*significant at p<.01

Table 4-7. Stepwise linear regression predicting health complaints

Model B SE Beta R sq.
Step 1 Sex history .973 .26 .251* .06
Step 2 Sex history .51 .25 .133* .20
MH tx 3.50 .59 .388**
Step 3 Sex history .56 .257 .146* .21
MH tx 3.68 .611 .406**
Marital 6.096E-02 .519 .007
Age 2.210E-02 .017 .085
*significant at p<.05
**significant at p<.01

Table 4-8. Stepwise linear regression predicting medical visits

Model B SE Beta R sq.
Step 1 Sex history .153 .074 2.074* .02
Step 2 Sex history .101 .077 .093 .04
MH tx .405 .180 .161*
Step 3 Sex history .138 .076 .128* .09
MH tx .548 .182 .217**
Marital .168 .154 .074
Age 1.546E-02 .005 .213**
*significant at p<.05
**significant at p<.01









Although sexual trauma history, mental health interventions, and age were

significant for their effects on medical visits, only a small portion of the variance could

be accounted for in this model. As shown in Table 4-9, the use of mental health

interventions accounted for only a small portion of the variance among women's use of

emergency room services, while none of the other predictors had any significant effect.

As illustrated in Table 4-10, while sexual trauma history and mental health interventions

were significant, age accounted for more of the variance among this sample's use of

prescription medicines than did either of the other variables.

Table 4-9. Logistic regression analysis on emergency room visits

Variable B S.E. Wald Exp(B)
Sex. history 1.5687
CSA -.2465 .4722 .2726 .7815
ASA -.3640 .5686 .4099 .6949
Both .3661 .4751 .5937 1.4421
Mental health .8578 .3492 6.0339** 2.3579
Marital status .0888 .3153 .0793 1.0928
Age -.0048 .0103 .2214 .9952
Constant -.8228 .6122 1.8062
Chi-square/df: 10.509/6* Nagelkerke R-square: .069
significant at p=.052
,nrGr.i,.a .. i p<.01

Table 4.10. Stepwise regression predicting number of prescriptions

Model B SE Beta R sq.
Step 1 Sex history 1.160 .428 .184** .034
Step 2 Sex history .723 .440 .115* .08
MH tx 3.356 1.027 .228**
Step 3 Sex history 1.017 .425 .162** .17
MH tx 4.224 1.012 .287**
Marital -.611 .860 -.046
Age .133 .028 .315**
*significant at p<.05
**significant at p<.01









Post Hoc Analyses

Additional analyses were conducted on a subgroup of this sample who had

responded affirmatively when asked if their sexual assault had occurred during their

military service. A total of 25 participants indicated they had experienced sexual assault

in the military (SAIM), which accounted for 11.9% of the sample. Descriptive statistics

for this group reveal that they are younger than the other trauma groups, and significantly

younger than the nontraumatized participants (mean age = 44.4 years for SAIM,

s.d. 11.7, vs. 53.8 years for nontraumatized, s.d. 16.9). Other differences noted between

this subgroup and the women who had denied experiencing any sexual trauma were a

higher percentage of minority participants (28% vs. 16.4%), and a greater number were

not married or in a committed relationship (68% vs. 54%). Independent sample t-tests

for mean differences between the SAIM group and the no trauma group on the five

dependent variables revealed a significant difference only on the number of health

complaints (t= 4.062, p<.0001). No other physical health variables were found to be

significantly different. The presence of mental health interventions differed among these

two groups with 48% of the SAIM group using these services versus only 20.4% of the

no trauma group (t = 3.002, p<.002).















CHAPTER 5
DISCUSSION

This study explored the relationship between experiences of sexual trauma and

subsequent physical health problems among women veterans receiving their healthcare at

a Veterans Affairs Medical Center. The study was designed to test hypotheses about the

impact of sexual trauma on women's perceptions of their own health status, the number

and type of current health complaints, and their utilization of healthcare services, along

with an exploration of potential moderating variables. This research is both a replication

and extension of previous investigations into the trauma/health relationship. It serves to

confirm earlier findings on the robust association between sexual trauma and health

perceptions, physical symptoms, and healthcare utilization, while extending the

generalizability of such findings into the population of female military veterans.

Additionally, this study has attempted to explore the possible lbu. lrir effects of marital

status and mental health interventions on the trauma/health relationship. Archival

records were utilized for this investigation.

The results of this study may be interpreted as supporting the existence of a

relationship between sexual trauma and poorer subsequent physical health, beyond what

might be reasonably expected from any actual physical injuries received during the

traumatic experience. Support was not found, however, for either of the predictions that

marital status or mental health interventions would serve to moderate the effects of

sexual trauma on physical health. Although specific types of sexual trauma effects were







51
not predicted, data analysis revealed a pattern of different effects among those victimized

in childhood versus adulthood on measures of health outcomes.

Health Outcome Measures

Health Perceptions

Information regarding each participant's self-rating of her general health was

obtained from her response to the question, "Overall, would you say your health is

excellent, very good, good, fair, or poor." Participants chose one of the responses to this

query, and it was expected that women who had experienced sexual trauma would rate

their health as poorer than nontraumatized women. This prediction was not entirely

supported by the results. As expected, traumatized women did rate themselves slightly

lower on general health but not enough to be r. L ill significant. Further analysis

revealed that most respondents tended to choose the middle response when offered the

five-point scale, with the trauma group displaying more variance. To clarify results, the

five ratings were then collapsed into two categories, good or poor, and reanalyzed. A

higher proportion of the trauma group categorized their health as poor than did the no

trauma group, lending support to this hypothesis. When the trauma group was divided

into subgroupings corresponding to the type of trauma experienced, further details

emerged. The group of women who had experienced adult sexual assault (ASA) rated

their health perceptions significantly lower than nontraumatized women. Those who had

experienced child sexual abuse (CSA) did not. The group who had experienced both

forms of abuse reported lower perceptions of their own health than the CSA group, but

higher than the ASA group.

The implications from this finding suggest that the proximity in time of the sexual

trauma may have an impact on health perceptions. It is possible that adults who were









sexually abused as children have had sufficient time to process their abuse, both

cognitively and emotionally, and the experience does not then influence their self-ratings.

A sexual assault during adulthood would be more contemporaneous to this study and

may, therefore, have had a bigger impact of the individual's perceptions of their own

"wellness." The most surprising finding in this analysis concerned the group who had

experienced both forms of abuse. It was expected that they would provide the lowest

self-ratings due to the cumulative effect of trauma, yet this was not so. These results

might, however, have been the result of low power due to a small sample size (N = 25).

Health Complaints

It was predicted that women who had experienced sexual trauma would report a

higher number of health complaints over a wide variety of body systems than women

without sexual trauma. This was measured through their responses to the Women's

Health Questionnaire on which they were asked to identify which, if any, of 24 possible

health problems they had experienced in the past four weeks. Results were supportive of

this hypothesis, with all categories of trauma victims reporting significantly more health

problems than nontraumatized respondents. The 24 health problems were then collapsed

into nine different categories corresponding to major health systems: gastrointestinal,

neurologic, musculoskeletal, gynecologic, cardiac, depression, anxiety, substance abuse,

and obsessive-compulsive disorder. Subjects who reported a history of sexual trauma

endorsed a significantly higher number of symptoms in six of these nine categories:

gastrointestinal, neurologic, musculoskeletal, depression, anxiety, and obsessive-

compulsive disorder. Surprisingly, there was no difference in the number of gynecologic

symptoms reported between the trauma/no trauma groups. This finding was contrary to

prior research by Golding (1996), who found a strong correlation between gynecologic









problems and sexual assault. This finding may be due to the fact that there were only

two questions focusing on this problem area, rendering it less than optimally assessed.

A small difference in the number of complaints was evident across trauma

subcategories, however this difference was statistically insignificant. Victims of both

types of abuse reported the highest number of problems, followed by the adult sexual

assault group, then the child sexual abuse group. This result is suggestive of the harmful

effects of compounded trauma experiences on health outcomes, and that the proximity in

time of the sexual trauma may have an impact on health complaints. Survivors of adult

sexual assault may still be suffering from actual injuries received during the assault, or

may still perceive themselves as "wounded" due to unresolved emotional problems

related to the assault.

Healthcare Utilization

Medical records were accessed for all participants in order to measure their level

of utilization of healthcare services in three categories: medical visits, emergency visits,

and prescription drugs. Beginning with the date of enrollment in the Women's Clinic,

each record was examined for the total number of visits to primary care, specialty clinics,

urgent care, and the emergency room over a 2-year period. The total number of

prescription medicines on record for each participant was also captured. It was predicted

that women with histories of sexual trauma would demonstrate an increased utilization of

these services over women without such histories. Findings supported this hypothesis in

two of the three categories: medical visits and prescription drugs. Usage of the

emergency room did not differ between the trauma/no trauma groups. However, an

analysis of the subgroup of trauma victims who had experienced both child and adult

abuse did reveal a significantly higher pattern of emergency room visits over the "no







54

trauma" group, again attesting to the severity of health effects in those who have suffered

multiple abuse experiences. These findings are consistent with prior research which

found that women who have been sexually assaulted or sexually abused in childhood

have higher numbers of medical visits and higher healthcare costs (Farley & Patsalides,

2001; Finestone et al., 2000; Golding et al., 1988; Walker et al., 1999).

Moderating Effects of Marital Status and Mental Health Treatment

Marital Status

The idea that women who were currently involved in marriage or a committed

relationship would suffer less ill-health effects from their trauma stemmed from the

literature on the benefits of social support for coping with the aftermath of trauma

(Kimerling & Calhoun, 1994; Ullman, 1999) and on the positive relationship between

marriage and better health (Declerck et al., 2002; Hughes & Waite, 2002; Hunt et al.,

2002). Findings from this study did not support this prediction. Participants were

assigned to one of two categories, married/committed or not, based upon their responses

to demographic questions involving their current status. Although interesting differences

emerged between the trauma categories and the no trauma group (those who had

experienced child sexual abuse were more likely to be in a relationship than those in the

other categories), no significant effect was found for marital status on the measured

health outcomes. Marital status itself may not be a good indicator of social support in

that it only determines the existence of a relationship and not the quality of it. Social

support literature stresses that it is the acceptance, understanding, and availability

implicit in good relationships that eases the trauma burden (Kimerling et al., 1994). It is

also possible that this form of trauma is more likely to disrupt intimate relationships due

to its sexual nature. Partners of victims may have a difficult time reconciling their own









anger, distrust, and/or jealousy after such an experience, negating the stress-reducing

effects of the relationship. Thirdly, it is possible that some of the sexual abuse being

measured in this study could have been perpetrated by the marital partners themselves.

Future research in this area should focus more on the quality of the relationship and the

partners' roles in the aftermath of trauma.

Mental Health Interventions

This study attempted to explore the possibility that mental health treatment would

moderate the effects of sexual trauma on physical health. Little research on this question

was found in the existing literature, although logical reasoning suggested that addressing

emotional problems posttrauma should lessen some of its ill-health effects. Medical

records for each participant were evaluated for utilization of any mental health services

within the 2-year period following their completion of the Women's Health

Questionnaire. Mental health services included appointments with psychiatrists,

psychologists, or any other licensed mental health service provider encompassing

psychotropic medication management, group therapy, and individual therapy. Results of

a comparison between sexual trauma history, mental health service utilization, and health

outcomes did not support this prediction. While mental health was significantly related

to physical health, it did not play a moderating role in the sexual trauma/health

relationship. What did emerge from this analysis was evidence that women who had

experienced both forms of sexual trauma utilized mental health services at a much higher

rate than those in the other trauma categories, 5.9 times the rate of the no trauma group

and about three times the rate of the CSA and ASA groups. While causality cannot be

assessed from this study, these findings underscore the severity of harmful effects, both

mental and physical, that may be related to repeated sexual trauma throughout the







56

lifespan. While utilization of mental health services was not found to have a moderating

effect in this study, it does not negate the ... .. ir:, of such a relationship. The measure

used in this study was necessarily broad and may have poorly targeted the desired

variable. Certainly there are vast qualitative differences between a brief psychiatric

appointment meant to monitor medication and psychotherapy focusing on an individual's

emotional needs. The continuity of treatment and number of visits would likely effect

the outcome of treatment, but were not captured in this study. The dichotomous nature of

this variable, having received any treatment or not, did not allow for these distinctions.

Similarly, in this study, the focus of treatment was not determined, meaning that the topic

of sexual trauma was not necessarily ever addressed in any of these treatment sessions. It

should be expected that, if mental health services are to reduce the ill-health effects of

trauma, the cognitive and emotional processing of the trauma would need to be part of

the treatment. Additionally, due to research design, the temporal relationship between

the trauma and subsequent mental health treatment and the reason for seeking treatment

were not accessed. Future investigations into mental health treatment as a moderator on

the trauma/health relationship should differentiate between types of treatment, duration

and focus of treatment, and when treatment occurs in relation to the trauma.

Limitations of the Study

As with any study that is not a true experimental design, attributions of causality

cannot be made. While there appears to be a relationship between sexual trauma history

and physical health, it is not possible to conclude that the experience of sexual

victimization directly caused diminished health outcomes. As referenced earlier, there

were several aspects of the research design that limited interpretation of the results.







57

Because participants could not be assigned to groups, but rather were categorized

according to their self-report of trauma, several threats to internal validity were

introduced. Women may have been influenced by social desirability when completing

the trauma questionnaires and therefore reluctant to disclose sexual victimization.

Previous work by Widom and Morris (1997) revealed that there is substantial

underreporting by sexually abused women, and the recall rates varied from 41% to 67%.

Other reasons for underreporting may be related to embarrassment, repression, or simple

memory decay. The time between the incident and the survey questionnaire may

influence accuracy of reporting, with longer periods related to more underreporting, as

does the relationship between the victim and perpetrator influence recall (Turner, 1972).

Another aspect of sampling bias that needs to be considered is the how the

\ .rj.l, ,.le Idj.ji group categories were defined. In the field of sexual trauma research,

there is a wide variety of operational definitions given to the terms "child sexual abuse"

and "sexual assault." Definitions vary across age of victimization, age difference

between victim and perpetrator, type of sexual act, and degree of coercion or force used.

This lack of a central definition makes comparisons across studies difficult.

The setting of this study in a V.A. medical center introduces its own sampling

bias. Women who participated had self-selected for some reason to receive all or part of

their medical care through this government entity. The proportion of their care received

through the V.A., and their reasons for choosing this healthcare service (economic,

geographic, or personal preference), were unknown to the researchers and could have

influenced the outcome of this study. This bias is especially important to note when

addressing the issue of sexual assault in the military (SAIM), as it is likely that some

women who were victimized during their military service choose to avoid using V.A.









services due to the setting serving as a reminder of their trauma. Additionally, any

physical or mental health treatment received outside the V.A. could not be accessed in

the available records and, therefore, was not factored into this analysis.

Another limitation to the study is the lack of information about participants' lives

regarding other possible traumatic stressors they may have experienced, such as recent

death of a spouse, interpersonal violence, major accidents, or natural disasters. Effects of

trauma are known to be cumulative and knowledge of past events would enhance the

validity of group comparisons.

The temporal relationship between the sexual trauma and the survey

questionnaire was not assessed. As mentioned above, underreporting of sexual abuse is

strongly related to the elapse of time since the incident. Additionally, having information

about when the trauma occurred would also strengthen validity by controlling for

maturation effects, allowing for comparisons between groups that factor in

developmental stages.

Other limitations to this study include the lack of control over the circumstances

surrounding the collection of the survey data. Because this was archival research,

examining data gathered via medical screenings, the possibility of differential treatment

among participants exists. Women were asked to complete the survey upon enrollment

in the primary care clinic, and differences may exist in the amount of time and privacy

afforded them in completing the questionnaire. Their current health concerns, prompting

them to seek medical treatment, may have influenced their perceptions of their own

health ratings and their compilation of recent symptoms.

Additionally, as reported earlier, the measures used in this study to examine

possible moderating variables did not address the issue of quality. In considering marital









status and mental health treatment, it would be much more useful to understand the

nature of the relationship/treatment than to simply know that it exists. Caution must be

used in interpreting the correlation between mental health treatment and health

complaints in this study, as the measure used to quantify physical symptoms contained

items that overlap between the domains of physical and mental health.

Lastly, these results cannot be generalized to populations differing from the

women participating in this study, who represent middle-aged military veterans who

choose to receive their healthcare through the V.A. system. Previous research suggests

that this population has a higher incidence of reported sexual trauma and lower ratings of

perceived health status than the general population.

Recommendations for Future Research

Because of the limitations and problems referenced earlier in this work, future

research in this area should attempt to employ a prospective design rather than a

retrospective one. Although inherently difficult to accomplish, such a design eliminates

many of the threats to validity. Longitudinal studies, with groups of trauma victims

identified from verifiable records matched against similar nontrauma groups, would

create a powerful design for studying health effects. Carefully examining the operational

definitions of categories of abuse and comparing only between studies with similar,

explicit definitions would also enhance the significance of findings.

Future studies examining the role of marital status in association with trauma and

health would benefit from careful analysis of the quality of the relationship and the

degree of support perceived from it. When inquiring about the status of a "committed

relationship," it should be made explicitly clear that this includes same-sex relationships

as well as heterosexual relationships. *,,ll.,rIr mental health services need to be







60

considered by the type of service rendered, as well as the duration and focus of treatment.

The participant's perception of the quality and usefulness of such treatment would also

be valuable information.

Measures asking for participants' perceptions of their own general health status

would be more powerful if a 4- or 6-point Likert scale were used, instead of a 5-point,

eliminating the possibility of choosing a neutral response. The measure accessed in this

study classified the health status of"good" as the third scale point, rendering it a neutral

response. It is this researcher's opinion that "good" health has a positive valence rather

than neutral, and future instrument design should be constructed accordingly.

Finally, multiple methods of assessing the variables are recommended, utilizing

structured interviews, self-reports, and existing records. Implementation of these

recommendations would go a long way towards increasing the power, scope, validity,

and generalizability of future research in this area.

Conclusion

Subject to the limitations discussed previously, this study is consistent with the

existence of a moderate relationship between a history of sexual trauma and various

deleterious health-related outcomes. At a minimum, it replicates and extends previous

research demonstrating the increase in health complaints and healthcare utilization

among sexually victimized women. While much research remains to be done to clarify

the nature of these relationships, the basic tenets of trauma theory-that highly stressful

events negatively effect both mind and body-continue to be supported by empirical

studies, including the present one.

Within the healthcare field, the study of sexual trauma and its subsequent effect

on physical health has many potential benefits. By alerting healthcare providers to the









nature of this association, they may be aided in d.II ,-I. .. Iri aiif.n and guided in

appropriate treatment planning. This would improve healthcare for the patients, and

potentially reduce the demand on medical providers for appointments based on vague,

psychosomatic complaints. Policies establishing appropriate allocation of finite

resources could be made at the agency level, increasing organizational efficiency and

reducing unnecessary costs. Additional economic benefits would ensue for the general

public through reduced healthcare costs and fewer lost work-days in society's work

force.

Finally, an understanding of the trauma/health association could inform the

process of psychotherapy. Post-trauma therapeutic work aimed at correcting cognitive

distortions and restoring emotional balance would be enhanced by incorporating

acknowledgment of physical health problems into the framework. This process would

assist in moving providers away from the false dichotomy of mind/body dualism, and

closer to the understanding of physical and mental health as contextual and interrelated.

Hopefully, the efforts of all healthcare providers will continue to be informed and

enhanced by ongoing research into health outcomes related to sexual violence.















APPENDIX
WOMEN'S HEALTH QUESTIONNAIRE

INSTRUCTIONS: This questionnaire is an important part of providing you with the best health
care possible. Your answers will help in understanding problems that you may have. Please
answer every question to the best of your ability. It will take approximately 10-15 minutes.

Name: Today's Date:

SSN: DOB: Are you a veteran? Yes No

Marital Ethnicity Education
Married Now Caucasian 8t Grade or Less
Widowed African-American Some High School
_ Separated Native American High School/GED
Divorced Asian-American Trade or Tech School
SNever Married Hispanic 1-3 Years College
Committed Relationship Other Completed College

During the last 4 weeks, have you been bothered A LOT by any of the following problems?
YES NO
1. Stomach Pain
2. Back Pain
3. Pain in your arms, legs, or joints (knees, hips, etc.)
4. Menstrual pain or problems
5. Pain or problems during sexual intercourse
6. Headaches
7. Chest pain
8. Dizziness
9. Fainting spells
10. Feeling your heart pound or race
11. Shortness of breath
12. Constipation, loose bowels, or diarrhea
13. Nausea, gas or indigestion
14. Feeling tired or having ';ril. cn'r ,'
15. Trouble i lh rn. or staying asleep, or sleeping too much
16. Often feel you can't control what or how much you eat
17. Little interest or pleasure in doing things
18. Feeling down, depressed, or hopeless
19. Feeling nervous, anxious, on edge, or worrying about
a lot of different things
20. Had an anxiety attack (suddenly feeling fear or panic)











During the last 4 weeks: YES NO N/A

21. Have you (or someone you know) thought you should
cut down on your drinking of alcohol?
22. Was there a single day in which you had five or more
drinks of beer, wine, or liquor?
23. Do you have ideas, images or impulses that seem silly,
weird, nasty or horrible & that keep coming back to you?
24. Are there things that you do over and over or thoughts
you must think repeatedly in order to get comfortable?
25. Overall, would you say your health is:
Excellent Very Good_ Good__ Fair Poor

PART II
Some women experience traumatic events during their life or in military service. We are
trying to find out about these events and how they affect women's lives. We also want to
find out if women want mental health help addressing these or other concerns.

YES NO
1. Have you ever been involved in a major accident or disaster?
2. Have you ever been physically assaulted or been a victim of
a violent crime?
3. At any time, has a spouse or partner (significant other) ever
threatened to physically hurt you in any way?
4. At any time, has a spouse or partner (significant other) ever hit you,
kicked you, or physically hurt you in any way?
5. Have you ever received uninvited and unwanted sexual attention
(e.g., touching or cornering, pressure for sexual favors, remarks)?
Did this happen to you while you were in the military?
6. Has anyone ever used force or the threat of force to have sex with
you against your will?
Did this happen to you while you were in the military?
7. Were you ever sexually assaulted or touched in a sexual way, by a
person 5 or more years older than you, when younger than 13?
8. Would you like to talk to a mental health worker about any of the
above problems?
9. Do you have any mental health questions or concerns that are not on
this questionnaire?
10. Would you like to talk to a mental health worker about these other
problems?

Thank you for your time. Please give the completed questionnaire to your nurse or
health care provider.















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BIOGRAPHICAL SKETCH

Linda R. Feldthausen was born in Elkhart, Indiana, in 1953. She moved

frequently during her childhood, living in Indiana, Michigan, Iowa, Mississippi,

Arkansas, Arizona, California, and Alaska. She completed her high school education in

Kodiak, Alaska, then went on to a career in law enforcement in Anchorage, Alaska.

Linda attended night classes at the University of Alaska and Alaska Pacific

University while raising a family and working full-time, completing a bachelor of arts

degree in organizational management in 1991. Following her husband's retirement, her

family moved aboard a sailboat and cruised the East Coast and Bahama Islands for one

year, home-schooling her two daughters in the process. After returning to land, she

entered the doctoral program in Counseling Psychology at the University of Florida and

completed a Master of Science in Counseling Psychology in 2000.

Linda lives with her husband, Karl Feldthausen, and daughter, Kristen

Feldthausen, in Gainesville, Florida. Her oldest daughter, Kelly Feldthausen, is currently

serving in the U.S. Air Force. Following graduation, Linda plans to pursue a career in

clinical health psychology with the Veteran's Affairs Medical Center and the University

of Florida Medical Center in Gainesville, Florida.









I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.


Mark R. Fondacaro, Chair
Assistant Professor of Psychology


I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.


J uelyn L. Resnick
Professor of Counselor Education


I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, i scope an
as a dissertation for the degree of Doctor of Philosophy.


wilham Keith Berg
Professor of Psychology


I certify that I have read this study and that in my opt ion it conforms to
acceptable standards of scholarly presentation and is fully equate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.


/Al xis iq ero
Associate Professor of Sociology



This dissertation was submitted to the Graduate Faculty of the Department of
Psychology in the College of Liberal Arts and Sciences and to the Graduate School and
was accepted as partial fulfillment of the requirements for the degree of Doctor of
Philosophy.

May 2003
Dean, Graduate School
















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