Sexual violence : epidemiology, treatment and access to health care

Sammanfattning: Sexual violence is recognized by the World Health Organization as a “… global public health problem of epidemic proportions, requiring urgent action” [1]. In Sweden, the estimated incidence of penetrative sexual violence is 45 000 per year [2-4] . Whilst anyone may be exposed to sexual violence, the vast majority of victims are girls and women. Access to good quality health care for victims of sexual violence is hence a prerequisite for gender-equal health care. The overarching aim of this thesis is to increase the epidemiological knowledge about the health consequences of sexual violence, the access to good quality health care among victims of sexual violence in Sweden, and to identify key factors with the potential to increase the access to good quality health care for victims of sexual violence. More specifically to: 1) Quantify and compare comorbidities, number of visits and prescribed medicines among individuals with a recorded diagnosis of sexual violence compared to those without such a registration; 2) Analyze patient and sexual violence characteristics, diagnoses and perceived access to good quality health care among patients at a specialist clinic for victims of sexual violence; 3) Evaluate a one-session treatment method for posttraumatic stress disorder (PTSD) after penetrative sexual violence. Three different data sources and five different study designs were used to cover the aims. Using register data from the Stockholm Regional Healthcare Data Warehouse (VAL), one cross sectional study, one case-control study and one cohort study were performed. Journal data from a non-emergency specialist clinic for victims of sexual violence were used for a descriptive study with the construction of a tool for analysis of health care access for victims of sexual violence, and finally, self-rating data were used to analyze treatment outcomes in a randomized controlled treatment study. The results from the register-based studies revealed high burdens of disease and different health care seeking patterns among individuals with a registration of sexual violence as compared with individuals without such a registration. For example, ORs > 19 for alcohol violence, and > 15 for psychotic disorders, were found for adults with a registration of sexual violence, as compared to adults without such a registration. ORs for suicide attempts among adolescent girls 1 year prior to the first registration of sexual violence in the journal record were 15.5 (7.9–30.5) and 26.4 (12.7–55.0) the year after the registration, as compared to same-aged girls from the same neighborhood without such a registration. The descriptive data confirmed the high burden of disease and high risk for suicide attempts found in the register-based studies. The descriptive data also revealed large difficulties in the access to good quality health care: 82% of the patients had tried to get access to good health care prior to admission to the specialist clinic, but felt their needs had not been met. Furthermore, at the intake visit, 90% of the patients scored for PTSD or/and depression regardless of prior health care access. A two-dimensional gatekeeping model was constructed and proposed as a tool for evaluation of factors directly impacting health care access for victims of sexual violence. By facilitating accountability and enabling patients to claim their rights the gatekeeping model also promotes a human rights-based approach. The self-rating data were collected from a pilot study (n=36), where the method Lifespan Integration (LI) was modified (MLI) and tested as a one-session treatment of PTSD symptoms after rape. In the study, 72% of participants in the treatment arm no longer scored for PTSD at follow up, with an mean score reduction of 50% on the Impact of Event Scale after the intervention, while the waiting list arm IES-scores were essentially unchanged. No drop-out rates or adverse effects were reported and the results were stable at the six-month follow up. In conclusion, the burden of disease is high and access to good quality health care is very limited for victims of sexual violence in Sweden. This violation of a universal human right hinders progression towards gender-equal health care access. Specialist clinics and treatment methods adapted to the needs of victims of sexual abuse are two key factors for change. The gatekeeping model for health care access and the MLI PTSD-protocol are promising and may be developed to increase access and lower costs for good quality healthcare for victims of sexual violence.