Men's perceived experiences of abuse in health care: their relationship to childhood abuse.
Article Type: Report
Subject: Adult child sexual abuse victims (Psychological aspects)
Adult child sexual abuse victims (Care and treatment)
Medical personnel and patient (Psychological aspects)
Medical personnel and patient (Management)
Medical personnel and patient (Ethical aspects)
Men (Health aspects)
Men (Research)
Authors: Swahnberg, Katarina
Edholm, Simon
Fredman, Kalle
Wijma, Barbro
Pub Date: 06/22/2012
Publication: Name: International Journal of Men's Health Publisher: Men's Studies Press Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 Men's Studies Press ISSN: 1532-6306
Issue: Date: Summer, 2012 Source Volume: 11 Source Issue: 2
Topic: Event Code: 200 Management dynamics; 290 Public affairs; 310 Science & research Advertising Code: 91 Ethics Computer Subject: Company business management
Geographic: Geographic Scope: Sweden Geographic Code: 4EUSW Sweden
Accession Number: 305192591
Full Text: It has previously been shown in a Swedish female patient sample, that there is a statistical correlation between experiences of childhood emotional, physical and/or sexual abuse (EPSA), and perceived abuse in health care (AHC). Our aim was to investigate whether similar correlations exist in a Swedish male sample. The study was based on the male version of NorVold Abuse Questionnaire (m-NorAQ), and performed in a random sample from the Swedish population (n = 2,924), and a patient sample (n = 1,767). Any lifetime EPSA was associated to any lifetime AHC, and victims of adult AHC reported childhood EPSA more often than non-victims. There seems to be a dose-response relationship between childhood EPSA and adult AHC in both female and male samples, i.e. childhood experiences of EPSA is a risk factor for experiencing AHC in adulthood.

Keywords: abuse in health care, emotional abuse, physical abuse, sexual abuse, revictimisation

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A successful caregiver-patient relationship is deeply dependent on trust and respect. Yet, there is often an imbalance of power with the patient's integrity in the hands of the caregiver. It is therefore a delicate relationship which easily can become dysfunctional, leaving the patients feeling mistreated or even abused.

The concept abuse in health care (AHC) is a new area of research and one in which there is still much to be explored. AHC could be defined as any act perceived as abusive by a patient in any health care setting. A medical error can be present but is not a necessity.

AHC can be intentionally or unintentionally on behalf of involved health care staff.

The definition of AHC used in this study is presented in Table 1.

AHC has been operationalized for research purpose by concrete examples in The NorVold Abuse Questionnah'e (NorAQ) (Table 1) (Swahnberg et al., 2007; Swahnberg & Wijma, 2003; Wijma, Schei, & Swahnberg, 2004). Later a male version of the NorAQ was developed (m-NorAQ) (Swahnberg, 2011; Swahnberg, Davidsson, Hearn, & Wijma, 2011; Swahnberg. Hearn, & Wijma, 2009).

What does AHC mean to the patients? Two Swedish qualitative studies, one in a female and one in a male sample, aimed to deepen the understanding of the patients' experiences of AHC (Swahnberg, Thapar-Bjorkert, & Bertero, 2007; Swahnberg, Wijma, Hearn, Thapar-Bjorkert, & Bertero, 2009). The results from these studies revealed a gender difference where the women reported feeling powerless, feeling ignored, experiencing carelessness, and experiencing non-empathy, while the men reported a crisis of confidence, being ignored, and frustration. The two core categories nullified and mentally pinioned encapsulate women's and men's experiences respectively. Both female and male patients suffered from their experiences of AHC, and felt that they had lost their autonomy as well as their value as human beings. However, while male patients became frustrated by the experience, female patient turned their feelings inwards which made them feel diminished and insignificant.

How common is it that patients experience AHC?

In studies on gynecological patients in Sweden, based on NorAQ and the questions in Table 1, the lifetime prevalence of AHC in any health care setting ranged between 14.0 and 19.7 percent in clinical samples, and was 15.5 percent in a Swedish female population sample (Swahnberg et al., 2004). In a larger study, also conducted with NorAQ at one gynecological clinic in each Nordic country, the lifetime prevalence of AHC ranged between 13.2 and 28.1 percent (answering rate 67-85%) (Swahnberg, Schei, et al., 2007).

Swedish studies based on m-NorAQ have estimated the prevalence of AHC to be approximately seven to eight per, gent in male clinical and random population samples (Swahnberg et al., 2011; Swahnberg, Hearn, et al., 2009).

We have earlier shown that any lifetime emotional, physical and/or sexual abuse (EPSA) was associated with an increased risk of any lifetime AHC, and any childhood EPSA was associated with an increased risk of adult AHC in a Swedish female patient sample. Moreover, there was a dose-response relationship, i.e. the more kinds of childhood abuse reported, the higher the risk of experiencing AHC in adulthood. Women who had experienced EPSA in childhood had a nine times higher risk for adult AHC than non-abused women (Swahnberg, Wijma, Wingren, Hilden, & Schei, 2004).

Posttraumatic stress disorder (PTSD) and re-victimization are two mechanisms that can help us understand this strong association between AHC and other kinds of abusive experiences.

THEORY

Posttraumatic Stress Disorder

Experiences of sexual and physical abuse are associated with PTSD (DSM-IV, 1994; Finkelhor & Browne, 1985; Jehu, 1986). A trauma is the first criterion for a PTSD diagnosis, and the main symptoms are grouped into three categories: 1) persistent intrusive re-experiencing of the traumatic event (e.g., flashbacks), 2) persistent avoidance of stimuli associated with the event and numbing of general responsiveness, and 3) increased arousal (DSM-IV, 1994).

A patient with a history of a traumatic event, that has caused posttraumatic stress symptoms, may run a higher risk than others to experience flashbacks during, for example, an examination. If the examination triggers flashbacks, the patient may relive the abusive experience e.g. being forced to do something against his/her will, in present time and maybe even in a sensory way, i.e. the patient might suddenly see, hear, feel, smell or sense the abuse taking place again. Often the patient is overwhelmed by emotions from the traumatic event maybe without understanding from where the feelings came (Jehu, 1992b). These overt reactions may also seem inexplicable to the health care staff if they are unaware of the patient's history of abuse (Jehu, 1992a).

Revictimisation

Several studies on college women have indicated that victimization through childhood EPSA is related to further revictimization (Gidycz, Coble, Latham, & Layman, 1993; Rich, Gidycz, Warkentin, Loh, & Weiland, 2005). Widom et al showed in a sample of both men and women that any type of childhood abuse was associated with an increased risk of lifetime re-victimization, defined as physical and sexual assault/abuse, kidnapping/stalking, and having a family friend murdered or committing suicide (Widom, Czaja, & Dutton, 2008).

Other commentators have formulated theories about the mechanisms behind retraumatisation (Finkelhor & Browne, 1985; Jehu, 1986, 1992a, 1992b), postulating that female victims of childhood sexual abuse often have an altered cognitive schema about relationships with others, thinking, e.g., "I am worthless and I deserve this. Nobody can be trusted." Based on the assumption that childhood sexual abuse creates insecurity, lack of trust and expectations of being traumatised again, also in their contacts with health care, Jehu's theory has the character of "a self-fulfilling prophecy" verifying the victims' worst fears.

We assume that both theories are valid also for male victims and other kinds of abuse than sexual abuse, i.e., also for emotional and physical abuse.

AIM AND HYPOTHESIS

Based on the gender difference in perceiving and handling AHC, we found it interesting to examine if male patients are retraumatized in health care to the same extent as female patients. Our hypotheses were the same as those in the original study among female patients (Swahnberg, Wijma, Wingren, et al., 2004):

1. There is an association between any lifetime EPSA and any lifetime AHC among Swedish men.

2. Adult male victims of AHC have been exposed to childhood EPSA more often than non-victims.

MATERIALS AND METHODS

Measures

NorAQ was originally developed by NorVold, a research network established in 1997 to measure prevalence of perceived experiences of four kinds of abuse: EPSA and AHC (Swahnberg & Wijma, 2003; Wijma et al., 2004; B. Wijma et al., 2003). It is available in all Nordic languages, English, Russian, Hindi and Arabic. m-NorAQ was originally developed for the study in which our clinical sample was collected (Swahnberg, Hearn, et al., 2009). The original questionnaire was changed in obvious ways to target men instead of women, and moreover, four new questions were added; native country, income, and both parents' educational level. The m-NorAQ consists of seven parts with a total of 67 questions. Besides the questions about abuse (Table 1), the m-NorAQ investigates socio-demography, self-estimated health and medical history. Four identically structured sections cover questions about experiences of EPSA and AHC. The content ranges from experiences of mild to severe abuse in childhood, adulthood, or both. Exposure to abuse was defined as having answered "yes" to one or several of the three or four questions about each kind of abuse in m-NorAQ.

Men who reported more than one degree of a specific abuse were categorized according to the most severe abusive act. Both NorAQ and m-NorAQ have been validated in Swedish female and male samples with satisfying results (Swahnberg, Hearn, et al., 2009: Swahnberg & Wijma, 2003).

Samples and Procedure

Clinical sample. The clinical sample was recruited from six departments at the University Hospital of Linkoping, in the County of Ostergotland in southeast Sweden 2005. Inclusion criteria for recruitment were being male, 18 years or older, and understanding the written Swedish language. Consecutive male inpatients and outpatients coming for a consultation were recruited, m-NorAQ was sent out by post, and prepaid envelopes were used in the correspondence. Two reminders were used.

Altogether m-NorAQ was sent to 360 patients in a center for orthopedics, 94 in a center for reconstructive medicine, 1,011 in a center for surgery and oncology (including urological patients), 282 in a dermatological and venerealogy clinic, 479 in a heart center and 137 in an infectious diseases clinic. The overall response rate was 74 percent which gave a total of 1,767 valid answers (Swahnberg, Hearn, et al., 2009).

Population sample. The population sample was collected in 2007. Information letters were sent to a sample of 6000 men randomly selected from the Population Register. Inclusion criteria were being 18 to 64 years old, and living in the county of Ostergotland. One hundred and twenty-two letters were excluded due to an invalid address or other impediments to participation such as not being able to read due to disability or language problems, and 5878 men were eligible. [m]-NorAQ was sent out by post, and prepaid envelopes were used in the correspondence. We used three reminders. The answering rate was 50 percent (n = 2924) (Swahnberg et al., 2011).

The local research ethics committee had approved both studies.

Study Design

The clinical sample consists of 1767 subjects and the population sample of 2924 subjects. These samples combined created a final sample of 4691 subjects which was dichotomized into subjects with or without lifetime EPSA, and subjects with or without lifetime AHC. The first hypothesis was tested in the total material. As in the original study, a subsample was created with a built in time-axis to test the second hypothesis.

The analysis of the second hypothesis was designed as a case control study in which cases were men with experiences of adult AHC and controls were all other men. Exposure was defined as any childhood EPSA (before the age of 18).

To create a time-axis the following groups of respondents were excluded from the subsample (same as in the original study): men reporting EPSA or AHC both in childhood and as adults, men reporting AHC only in childhood, men reporting only adult EPSA, and men with missing answers on EPSA or AHC in childhood or adulthood.

Mild physical abuse (PA) was coded "no abuse" in the original study due to low performance when validated (Swahnberg & Wijma, 2003) (Table 1). One explanation brought forward was that in Sweden smacking your child did not become an unlawful act until the 1970s. Before that time it was not considered abusive by society or by "'perpetrators." Therefore women who had been smacked in childhood and agreed to that item in NorAQ might not have considered it as abusive and therefore answered "no" to the question about physical abuse when asked in the interview that was used a gold standard in the validation study (Swahnberg & Wijma, 2003). Our subsample then consisted of 130 cases and 3555 controls selected from the total sample. The number of men excluded was 1006. The manipulated sample in this study does not have representative prevalence rates anymore.

Statistics

A Pearson's [chi square] test was used to analyze differences in the socio-demographic variables between cases and controls. A crude odds ratio (OR) was calculated to estimate the association between lifetime experiences of AHC and lifetime EPSA, as well as experiences of adult AHC and childhood EPSA. Adjusted OR was calculated in a multivariate model (binary logistic regression) including each kind of abuse (EA, PA and/or SA, alone and in combinations), age, educational level and sample origin. The variable "sample origin" compares subjects from the two samples that we combined to create our study population.

In our subsample of 3685 men, 915 had been exposed to childhood EPSA. There was no difference in prevalence of childhood EPSA between the two samples, but there was a difference in prevalence of adult AHC, which is why we adjusted for sample origin in our statistical calculation. The analyses were performed using the statistical program SPSS (version 17.0). We refer to differences in the text only when the observed differences were statistically significant (p < 0.05).

RESULTS

Background characteristics among men exposed (n = 915) and not exposed (n = 2770) to childhood EPSA are presented in Table 2. Men reporting exposure to childhood EPSA were younger (p < 0.001 ), and had higher education level (p < 0.001 ) than non- exposed men. Students reported higher rates, while men on sick leave/retired or on social support reported less exposure to childhood EPSA. No differences in demographic characteristics were found between cases and controls (Table 3).

The number of cases was higher in the clinical sample than in the population sample (Table 3). The mean age when the first adult AHC occurred was 39.7. Thirty-three men in total (0.9%; n = 3685) reported adult AHC during the past 12 months.

The first hypothesis was supported, i.e. associations were found between any lifetime EPSA and any lifetime AHC in the total sample of 4691 subjects: OR 5.9 (95% CI 4.5-7.6). This was also seen when samples were separated, clinical sample: OR 4.7 (95% CI 3.26.8), population sample: OR 7.3 (95% CI 5.1-10.4)

Also the second hypothesis was supported; 68 of the men who reported adult AHC (n = 130) also reported experiences of childhood EPSA (Table 4-5). Adult AHC was reported by 68 of the exposed (27 mild, 31 moderate, 10 severe), and by 62 of the non-exposed men (27 mild, 22 moderate, 13 severe). There was no difference in the degree of severity of adult AHC among exposed and non-exposed cases (p < 0.001). Adult victims of AHC reported childhood EPSA more often than non-victims, but for sexual abuse alone the OR was not statistically significant (Table 5).

When adjusted for age, educational level and sample origin, OR remained high among cases compared to controls. Emotional abuse showed the strongest association but combinations of abuse had higher OR than any single type of abuse, with the exception of the combination of sexual and emotional abuse. The highest adjusted OR was found for the combination of all three kinds of childhood abuse (Table 5).

DISCUSSION

Both our hypotheses were supported i.e. any lifetime EPSA was associated to any lifetime AHC, and victims of adult AHC reported childhood EPSA more often than non-victims. In accordance with results in the female sample, we found that the associations between experiences of adult AHC and childhood EPSA were stronger if the man had reported more than one kind of abuse (Swahnberg, Wijma, Wingren, et al., 2004). The number of reported kinds of abuse has been proposed to reflect the severity of both male and female victimization (Simmons, Wijma, & Swahnberg, 2012); which might explain why, in both studies, the strongest association was found between adult AHC and the combination of all three kinds of childhood abuse. There seems to be a dose-response relationship between childhood EPSA and adult AHC in both the female and male samples studied.

However, some sex differences were also found. For example, it seems to be a stronger correlation among men than among women between childhood physical abuse and adult AHC. The odds ratios were also higher in the male than in the female sample when the different kinds of abuses were combined, which indicates a higher risk for male than for female former victims of EPSA to be revictimized in health care.

It was also more common that male patients who reported adult AHC were revictimized i.e. had a history of childhood EPSA: one third in the female and half in the male sample had been revictimized in health care. But when adjusted for age and education women had a doubled risk for revictimization in health care compared to men (data not shown). Differences in background variables might also explain why the OR was higher in the male sample.

It has been documented that many examiners find it difficult to ask questions about a history of abuse as a routine (D'Avolio et al., 2001: Parsons, Zaccaro, Well, & Storval, 1995; B. Wijma, et al., 2003). But the focus has solely been on female victimisation, as if there were no male victims or an existing notion that men would not benefit from being asked about abusive experiences.

Furthermore, studies have shown that women with and without a history of abuse in general do not mind being asked about abusive experiences (Robohm & Buttenheim, 1996: Stenson, Saarinen. Heimer, & Siden vall, 2001; Wendt et al., 2007). Similar studies have not been performed in male samples.

Hence, pros and cons about abuse screening of male violence against women has been debated for decades, while little is known about what it would mean to men and how they would react to be screened for abusive experiences.

It is possible that some of these cases of AHC could have been avoided if the patient's background of abuse was known to the caregiver. However, while this hypothesis will have to be tested in future studies, the fact remains that there is no reason not to include male victimization in the research and the debate on screening for abuse.

PA is a very common experience among men. Approximately one third of the men in the current samples reported any lifetime moderate or severe PA (population sample 35 %; clinical sample 29%) (Swahnberg, et al., 2011; Swahnberg, Hearn, et al., 2009). It is likely that it would be more difficult for a male than for a female patient to reveal a history of abuse due to prevailing gender norms, i.e. "a real man is strong, active and capable." Masculinities are constructed in different ways in different contexts, but they have one thing in common; they reject the role of being a victim with few exceptions such as a war hero or a though street fighter (Connell, 1995; Swahnberg. et al., 2011). These notions might also have contributed to the relative high prevalence of physical abuse in our study i.e. social desirability might have introduced a kind of negative report bias for emotional and sexual abuse but not for physical abuse.

Female abuse victims' reports of both physical and emotional abuse have been found to be unrelated to socially desirable responding (Dutton & Hemphill, 1992). There are no equivalent studies in male samples, which is not surprising since the main part of all methodological skills and knowledge is based on research about men's violence against women. This knowledge cannot uncritically be generalized to male samples without empirical evidence.

For both men and women, childhood EPSA is a risk factor with a dose-response pattern for adult AHC. The theories about PTSD and re-victimization offer an important but partial explanation for why some patients feel abused in health care.

Though clues to the mechanisms behind AHC are located with the patient in this study. the responsibility not to hurt patients will always remain with the health care staff.

Moreover, almost half of the males who reported AHC were "new victims," and other risk factors and explanations for incidents of AHC must be further researched.

DOI: 10.3149/jmh.1102.137

REFERENCES

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (DSM-IV). Washington, DC: American Psychiatric Association.

Connell, R.W. (1995). Masculinities. Cambridge: Polity Press.

D'Avolio, D., Hawkins, J.W., Haggerty, L.A., Kelly, U., Barrett, R., Durno Toscano, S.E., et al. (200 I). Screening for abuse: Barriers and opportunities. Health Care for Women International, 22(4), 349-362.

Dutton, D.G., & Hemphill, K.J. (1992). Patterns of socially desirable responding among perpetrators and victims of wife assault. Violence and Victims, 7(1), 29-39.

Finkelhor, D., & Browne, A. (1985). The traumatic impact of child sexual abuse: A conceptualization. The American Journal of Orthopsychiatry, 55(4), 530-541.

Gidycz, C.A., Coble, C.N., Latham, L., & Layman, M.J. (1993). Sexual assault experience in adulthood and prior victimization experiences: A prospective analysis. Psychology of Women Quarterly, l 7, 151-168.

Jehu, D. (1986). Beyond sexual abuse. A sourcebook on child sexual abuse. London: Sage Publications Ltd.

Jehu, D. (1992a). Clinical significance of sexual abuse. In K. Wijma & B. von Schoultz (Eds.), Reproductive life. Advances in research in psychosomatic obstetrics and gynaecology (pp. 508520). Carnforth: The Parthenon Publishing Group.

Jehu. D. (1992b). Long-term consequences of child sexual abuse: Presentation and management in gynaecological practice. In K. Wijma & B. von Schoultz (Eds.), Reproductive life. Advances in research in psychosomatic obstetrics and gynaecology. Camforth: The Parthenon Publishing Group.

Parsons, L.H., Zaccaro, D., Well, B., & Storval, T.G. (1995). Methods of and attitudes toward screening obstetrics and gynecology patients for domestic violence. American Journal of Obstetrics and Gynecology, 173, 381-386.

Rich, C.L., Gidycz, C.A., Warkentin, J.B., Loh, C., & Weiland, P. (2005). Child and adolescent abuse and subsequent victimization: A prospective study. Child Abuse & Neglect, 29, 1373-1394.

Robohm, J.S., & Buttenheim, M. (1996). The gynecological care experience of adult survivors of childhood sexual abuse: A preliminary investigation. Women Health, 24(3), 59-75.

Simmons, J., Wijma, B., & Swahnberg, K. (2012). Family violence, intimate partner violence and violence from acquaintances and strangers: Is there a link? A Swedish Cross-sectional Population Study of Lifetime Violent Experiences among Men and Women. Submitted.

Stenson, K., Saarinen, H., Heimer, G., & Siden vail, B. (2001). Women's attitudes to being asked about exposure to violence. Midwifery. 17, 2-10.

Swahnberg, K. (2011). NorVold Abuse Questionnaire for men (m-NorAQ): Validation of new measures of emotional, physical, and sexual abuse and abuse in health care in male patients. Gender Medicine, 8(2), 69-79.

Swahnberg, K., Davidsson, J., Hearn, J., & Wijma, B. (2012). Men's experiences of emotional, physical and sexual abuse, and abuse in health care: A cross-sectional study of a Swedish random male population sample. Scandinavian Journal of Public Health, 40, 191-202.

Swahnberg, K., Hearn, J., & Wijma, B. (2009). Prevalence of perceived experiences of emotional, physical, sexual, and health care abuse in a Swedish male patient sample Violence and Victims, 24(2), 275-286.

Swahnberg, K., Schei, B., Hilden, M., Halmesmaki, E., Sidenius, K., Steingrimsdottir, T., et al. (2007). Patients' experiences of abuse in health care: A Nordic study on prevalence and associated factors in gynecological patients. Acta Obstetricia et Gynecologica Scandinavica, 86(3), 349-356.

Swahnberg, K., Thapar-Bjorkert, S., & Bertero, C. (2007). Nullified: Women "s perceptions of being abused in health care. Journal of Psychosomatic Obstetrics & Gynecology, 28(3), 161167.

Swahnberg, K., & Wijma, B. (2003). The NorVold Abuse Questionnaire (NorAQ): Validation of new measures of emotional, physical, and sexual abuse, and abuse in the health care system among women. European Journal of Public Health, 13(4), 361-366.

Swahnberg, K., Wijma, B.. Hearn. J., Thapar-Bjorkert, S., & Bertero, C. (2009). Mentally pinioned: Men's perceptions of being abused in health care. International Journal of Men's Health, 8(1), 60-71.

Swahnberg, K., Wijma, B., Schei, B., Hilden, M., Irminger, K., & Wingren, G .B. (2004). Are sociodemographic and regional and sample factors associated with prevalence of abuse? Acta Obstetricia et Gynecologica Scandinavica, 83(3), 276-288.

Swahnberg, K., Wijma, B., Wingren, G., Hilden, M., & Schei, B. (2004). Women's perceived experiences of abuse in the health care system: Their relationship to childhood abuse. BJOG: An International Journal of Obstetrics and Gynaecology, 111 (12), 1429-1436.

Wendt, E., Hildingh, C., Lidell, E., Westerstahl, A., Baigi, A., & Marklund, B. (2007). Young women's sexual health and their views on dialogue with health professionals. Acta Obstetricia et Gynecologica Scandinavica, 86(5), 590-595.

Widom, C.S., Czaja, S.J., & Dutton, M.A. (2008). Childhood victimization and lifetime revictimization. Child Abuse & Neglect, 32 785-796.

Wijma, B., Schei, B., & Swahnberg, K. (2004). NorAQ. The NorVoldAbuse Questionnaire (No. 2). Linkoping: Division of Gender and Medicine, Faculty of Health Sciences, Linkoping University.

Wijma, B., Schei, B., Swahnberg, K., Hilden, M., Offerdal, K., Pikarinen, U., et al. (2003). Emotional, physical, and sexual abuse in patients visiting gynaecology clinics: A Nordic cross-sectional study. The Lancet, 361(9375), 2107-2l13.

KATARINA SWAHNBERG *, R.N., MPH, PH.D., SIMON EDHOLM *, KALLE FREDMAN *, and BARBRO WIJMA *, M.D. PH.D.

* Faculty of Health Sciences. Linkoping University. Sweden.

Financial support for this study came from The Swedish Research Council and The Ostergotland county council.

The NorVold Abuse Questionnaire (NorAQ) was developed by members in NorVold, a research network established in 1997 to explore the prevalence of violence against women and its effects on women's health. The NorVold research network was supported by grants from The Nordic Council of Ministers.

The authors would like to acknowledge and thank Lars-Eric Gustafsson for his participation in creating the hypotheses on which this article is based.

Correspondence concerning this article should be addressed to Katarina Swahnberg, Division of Gender and Medicine, Department of Experimental and Clinical Medicine, Faculty of Health Sciences, Linkoping University, 581 83 Linkoping. Sweden. Email: katarina.swahnberg@liu.se
Table 1

Questions About Abuse in m-NorAQ

                   EMOTIONAL ABUSE

Mild abuse         Have you experienced anybody systematically and
                   for any longer period trying to repress, degrade
                   or humiliate you?

Moderate abuse     Have you experienced anybody systematically and
                   by threat or force trying to limit your contacts
                   with others or totally control what you may and
                   may not do?

Severe abuse       Have you experienced living in fear because
                   somebody systematically and for a longer period
                   has threatened you or somebody close to you?

                   PHYSICAL ABUSE

Mild abuse         Have you experienced anybody hitting you,
                   smacking your face or holding you firmly against
                   your will?

Moderate abuse     Have you experienced anybody hitting you with
                   his/her fist(s) or with a hard object. kicking
                   you, pushing you violently, giving you a beating,
                   thrashing you or doing anything similar to you?

Severe abuse       Have you experienced anybody threatening your
                   life by, for instance, trying to strangle you,
                   showing a weapon or knife, or by any other
                   similar act?

                   SEXUAL ABUSE

Mild abuse, no     Has anybody against your will touched parts of
genital contact    your body other than the genitals in a "sexual
                   way" or forced you to touch other parts of his or
                   her body in a "sexual way"?

Mild abuse,        Have you in any other way been sexually
emotional /        humiliated: e.g. by being forced to watch a
sexual             pornographic movie or similar against your will,
humiliation        forced to participate in a pornographic movie or
                   similar, forced to show your body naked or forced
                   to watch when somebody else showed his/her body
                   naked?

Moderate abuse,    Has anybody against your will touched your
genital contact    genitals, used your body to satisfy him/herself
                   sexually or forced you to touch anybody else's
                   genitals?

Severe abuse,      Has anybody against your will put his penis into
penetration        your mouth or rectum or tried any of this: put in
                   or tried to put an object or other part of the
                   body into your mouth or rectum'?

                   ABUSE IN HEALTH CARE

Mild abuse         Have you ever felt offended or grossly degraded
                   while visiting health services, felt that someone
                   exercised blackmail against you or did not show
                   respect for your opinion--in such a way that you
                   were later disturbed by or suffered from the
                   experience?

Moderate abuse     Have you ever experienced that a "normal" event,
                   while visiting health services suddenly became a
                   really terrible and insulting experience, without
                   you fully knowing how this could happen?

Severe abuse       Have you experienced anybody in health service
                   purposely--as you understood/hurting you
                   physically or mentally, grossly violating you or
                   using your body and your subordinated position to
                   your disadvantage for his/her own purpose?

                   ANSWER ALTERNATIVES (THE SAME FOR ALL QUESTIONS)

                   1 = No
                   2 = Yes, as a child (< 18 years)
                   3 = Yes, as an adult ([greater than
                     or equal to] 18 years)
                   4 = Yes, as a child and as an adult

Table 2

Background Characteristics Among Men Exposed (n = 915) and Not
Exposed  (n = 2,770)  to Childhood EPSA

                                                EXPOSED
                                         (Any childhood EPSA)

                                          n = 915         %
SAMPLE (p = 0.057)
  Clinical sample                           331         36.2
  Population sample                         584         63.8

AGE (p < 0.001)
  18-34                                     239         26.2
  35-49                                     251         27.6
  [greater than or equal to] 50             421         46.2

EDUCATION (p < 0.001)
  <9 years                                  165         18.1
  10-12 years                               340         37.2
  [greater than or equal to] 13 years       408         44.7

CIVIL STATUS (p = 0.189)
  Single                                    227         25.1
  Partner                                   678         74.9

OCCUPATION (p < 0.001)
  Employed                                  622         68.1
  Parental leave                              3          0.3
  Unemployed                                 26          2.8
  Student                                    90          9.8
  Sick lv./retir/social supp. 171                       18.7
  Other                                       2          0.2

                                             NOT EXPOSED      MISSING
                                           (No. childhood
                                                EPSA)

                                         n = 2770    %
SAMPLE (p = 0.057)                                               0
  Clinical sample                          1100     39.7
  Population sample                        1670     60.3

AGE (p < 0.001)                                                  13
  18-34                                     552     20.0
  35-49                                     681     24.7
  [greater than or equal to] 50            1528     55.3

EDUCATION (p < 0.001)                                            9
  <9 years                                  803     29.1
  10-12 years                               987     35.7
  [greater than or equal to] 13 years       973     35.2

CIVIL STATUS (p = 0.189)                                         35
  Single                                    630     23.0
  Partner                                  2115     77.0

OCCUPATION (p < 0.001)                                           8
  Employed                                 1862     67.4
  Parental leave                              6      0.2
  Unemployed                                 62      2.2
  Student                                   168      6.1
  Sick lv./retir/social supp. 171           654     23.7
  Other                                      11      0.4

Statistical significance in background characteristics was
calculated with [chi square]. Men who reported both childhood and
adult EPSA or ABC, childhood AHC or adult EPSA were not included
in the analyses. Mild physical abuse was not regarded as exposure
(coded "no abuse"). Abbreviations: Sick Iv. = on sick leave over
a long period; retir. = retired (temporary disability pension,
disability pension); social supp. = recipient of social assistance.

Table 3

Background Characteristics Among Men Reporting Adult AHC
(Cases n = 130), and Men Not Reporting Adult AHC
(Controls, n = 3,555)

                                             CASES
                                            Adult AHC

                                       n = 130       %
SAMPLE (p = 0.002)

  Clinical sample                        67        51.5
  Population sample                      63        48.5
AGE (p = 0.791)
  18-34                                  25        19.2
  35-49                                  33        25.4
  [greater than or equal to] 50          72        55.4
EDUCATION (p = 0.134)
  <9 years                               25        19.4
  10-12 years                            47        36.4
  13 years                               57        44.2
CIVIL STATUS (p = 0.912)
  Single                                 30        23.1
  Partner                               100        76.9
OCCUPATION (P = 0.299)
  Employed                               78        60.0
  Parental leave                          0         0.0
  Unemployed                              2         1.5
  Student                                12         9.2
  Sick lv./retir/social supp.            38        29.2
  Other                                   0         0.0

                                            CONTROLS        MISSING
                                          No adult AHC

                                       n = 3555      %
SAMPLE (p = 0.002)

  Clinical sample                        1364       38.4       0
  Population sample                      2191       61.6
AGE (p = 0.791)
  18-34                                   766       21.6      13
  35-49                                   899       25.4
  [greater than or equal to] 50          1877       53.0
EDUCATION (p = 0.134)
  <9 years                                943       26.6       9
  10-12 years                            1280       36.1
  13 years                               1324       37.3
CIVIL STATUS (p = 0.912)
  Single                                  827       23.5      35
  Partner                                2693       76.5
OCCUPATION (P = 0.299)
  Employed                               2406       67.8       8
  Parental leave                            9        0.3
  Unemployed                               86        2.4
  Student                                 246        6.9
  Sick lv./retir/social supp.             787       22.2
  Other                                    13        0.4

Statistical significance in background characteristics was
calculated with [chi square]. Men who reported both childhood
and adult EPSA or AHC, childhood AHC or adult EPSA were not
included in the analyses. Abbreviations: Sick Iv. = on sick leave
over a long period; retir. = retired (temporary disability pension,
disability pension); social supp. = recipient of social assistance.

Table 4

Cases of Adult AHC Among Men Exposed/Non-Exposed
to Childhood EPSA

                   Yes (cases)      ADULT AHC       Total
                                  No (controls)
CHILDHOOD EPSA

  Yes                   68             847           915
  No                    62            2708          2770
Total                  130            3555          3685

Table 5

Crude Odds Ratio (OR) and OR Adjusted for Age, Education and Sample
Origin (Adj OR) for Men Reporting Experiences of Adult AHC and of
Having Been Exposed to Childhood EPSA and Controls (N = 3,685)

                                                     ADULT AHC

                      CASES        CONTROLS

                      n (%)         n (%)          OR       95% C1

                      130 (100)     3555 (100)
Non-exposed            62 (47.7)    2708 (76.2)    1.0
Exposed                68 (52.3)     847 (23.8)

ONLY ONE KIND OF CHILDHOOD EPSA (PERCENT OF CASES/CONTROLS)

  Emotional abuse       9 (6.9)      105 (3.0)     3.744   1.812-7.736
  Physical abuse       26 (20.0)     531 (14.9)    2.139   1.340-3.413
  Sexual abuse          1 (0.8)       31 (0.9)     1.409   0.189-10.486

COMBINATION OF DIFFERENT KINDS OF CHILDHOOD EPSA
(PERCENT OF CASES/CONTROLS)

  Emotional +
    physical          24 (18.5)      144 (4.1)     7.280   4.415-12.003
  Emotional +
    sexual             1 (0.8)         7 (0.2)     6.240   0.756-51.484
  Physical + sexual    3 (2.3)        19 (0.5)     6.896   1.989-23.913
  Emotional +
    physical +
    sexual               4(3.1)       10 (0.3)    17.471   5.333-57.230

                      Adj OR       95% Cl

Non-exposed             1.0
Exposed

ONLY ONE KIND OF CHILDHOOD EPSA (PERCENT OF
CASES/CONTROLS)

  Emotional abuse       3.831    1.835-7.998
  Physical abuse        1.981    1.229-3.195
  Sexual abuse          1.361    0.182-10.192

COMBINATION OF DIFFERENT KINDS OF CHILDHOOD
EPSA (PERCENT OF CASES/CONTROLS)

  Emotional +
    physical            7.710   4.632-12.835
  Emotional +
    sexual              5.782   0.685-48.814
  Physical + sexual     5.631   1.590-19.939
  Emotional +
    physical +
    sexual             19.464   5.759-65.782
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