Men's perceived experiences of abuse in health care: their relationship to childhood abuse.
Adult child sexual abuse victims
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)
|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|
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
Keywords: abuse in health care, emotional abuse, physical abuse, sexual abuse, revictimisation
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?
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.
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).
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
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.
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.
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).
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).
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.
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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: email@example.com
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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