Experiences of Physical and Sexual Abuse
and Their Implications for Current Health
Ulla Pikarinen, MD, Terhi Saisto, MD, PhD, Berit Schei,
and Erja Halmesmäki, MD, PhD
OBJECTIVE: To estimate the prevalence of a history of
physical and sexual abuse in adulthood among gyneco-
logical patients and the association with general and
reproductive health.
METHODS: A cross-sectional questionnaire study on
abusive experiences of gynecologic outpatients in a ter-
tiary hospital. The total sample size was 691.
RESULTS: Of all women, 42.4% had experienced mod-
erate or severe physical or sexual abuse as an adult. One
hundred forty-seven (21.6%) women reported physical
abuse, 84 (12.3%) sexual abuse, and 58 (8.5%) both. The
abused and nonabused women did not differ in mean
age, education, or parity. Sexually abused women and
those who were both sexually and physically abused
reported poor general health significantly more often
(Pⴝ.005 and Pⴝ.001, respectively) than the nonabused.
They also rated their sex life as significantly worse than
the nonabused women (Pⴝ.002 and Pⴝ.012, respec-
tively). Over half of abused women had experienced
common physical complaints during the previous 12
months compared with one third of the nonabused
(P<.001). Two thirds of both the abused and the non-
abused women preferred that their gynecologist not ask
directly about abuse.
From the Department of Obstetrics and Gynecology, South Karelian Central
Hospital, Lappeenranta, Finland; Department of Obstetrics and Gynecology,
Helsinki University Hospital, Jorvi Hospital, Espoo, Finland; Women’s Health
Department of Community Medicine/Department of Obstetrics and Gynecology,
St. Olav’s Hospital, Trondheim University Hospital, Faculty of Medicine,
Trondheim, Norway; Division of Gender and Medicine, Faculty of Health
Sciences, Linköping University, Linköping, Sweden; and Department of Obstet-
rics and Gynecology, Helsinki University Hospital, Helsinki, Finland.
Supported by grants from the Medical Research Fund of South Karelian Central
Hospital, District of Helsinki and Uusimaa, Helsinki University Central
Hospital, Department of Obstetrics and Gynecology, and the Yrjö Janson
Foundation.
Corresponding author: Ulla Pikarinen, Department of Obstetrics and Gynecol-
ogy, South Karelian Central Hospital,Valto Käkelän katu 1, FIN-53100
Lappeenranta, Finland; e-mail: ulla.pikarinen@fimnet.fi.
© 2007 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/07
1116 VOL. 109, NO. 5, MAY 2007
MD, PhD, Katarina Swahnberg, PhD,
CONCLUSION: Abusive experiences were common in
gynecologic outpatients. Women with abusive experi-
ences had ill health and poor sexual life more often than
the controls. In contrast to the results of previous studies,
most of the women did not want to be asked about abuse
by their gynecologist.
(Obstet Gynecol 2007;109:1116–22)
LEVEL OF EVIDENCE: II
V iolence against women is recognized as a com-
mon risk factor impairing women’s health. It was
claimed to be a crime against humanity by the United
Nations. Although striking news presents us with
images of cruelty to women and their humiliation
during war, the most common violence exists in the
everyday lives of the female population.
Abusive experiences have a serious impact on a
person’s health and quality of life. The prevalence of
violent experiences among primary care patients has
been reported to be two times higher than among the
general population of the area in question.3,4 Sexual
violence damages the genitals, causes infections, and
later on results in problems with sexual health and
desire.5–7 In addition to human suffering and socio-
logical problems, abuse also has economical conse-
quences to society because the victims use health
services more than women who are not abused.8
In a Finnish population-based study, it was found
that two women out of five had experienced physical
or sexual violence or serious threats of such violence
during their adulthood.2 Sexual and physical abuse is
associated with gynecologic problems such as dys-
menorrhea, dyspareunia, and lower abdominal
pain.10,11 Hence, the prevalence of abusive experi-
ences could be expected to be high in a sample of
gynecologic patients.12
The aim of this study was to estimate the preva-
lence of a history of physical and sexual abuse in
adulthood among gynecologic patients and the asso-
ciations of such a history with the patients’ gyneco-
OBSTETRICS & GYNECOLOGY
logic problems, physical complaints, and subjective
opinions of their health.
MATERIALS AND METHODS
This Finnish study is part of a Nordic multicenter
study of the history of abuse among gynecologic
outpatients. Each of the five participating countries
(Denmark, Finland, Iceland, Norway, and Sweden)
used a similar questionnaire, the NorVold Abuse
Questionnaire, which was translated into national
languages. The NorVold Abuse Questionnaire was
validated in a Swedish female sample and was shown
to have good validity and reliability.9 The NorVold
Abuse Questionnaire consists of questions about so-
cioeconomic factors (age, marital status, occupation),
the reason for the initial visit to the gynecologic clinic,
the patient’s subjective opinion of her health, specific
questions about some common health problems (such
as stomach ache, headache, muscular weakness, diz-
ziness), and lifetime experiences of emotional, physi-
cal, or sexual violence. The study design was de-
scribed previously in detail by Wijma et al.12 The
classification of violence is presented in Table 1.
The Finnish study also included additional ques-
tions about further physical complaints (such as lower
abdominal pain, bowel irritation, and dysmenorrhea)
and whether the patients would want their gynecolo-
gist to ask routinely if they have been exposed to
violence. The study took place at Helsinki University,
Department of Obstetrics and Gynecology, from No-
vember 1999 to January 2000. A referral is usually
required for the first visit, apart from acute consulta-
tions. Thus, most of the women in this study had
already been examined for their complaints by a
general practitioner or private gynecologist. Alto-
gether, 1,010 consecutive women over 18 years of age
visiting the gynecologic outpatient clinic were asked
to participate. These women came for either a first
visit or a follow-up visit. They were invited to take
part in the study by a nurse who gave them informa-
tion about the study. Written consent was required.
The NorVold Abuse Questionnaire was sent 1–2
weeks after the initial visit to 817 gynecologic outpa-
tients; 193 patients declined the invitation to partici-
pate. This was followed by two reminders 2 weeks
apart. The initial response rate was 86% (n⫽705).
After 14 patients had been excluded from the analysis
as a result of missing information or being under age,
the total sample size was 691 women.
The study women consisted of those reporting
being subjected to moderate or severe physical vio-
lence (n⫽147), sexual violence (n⫽84), or both
(n⫽58) as adults (after their 18th birthday), according
to the definitions in the NorVold Abuse Question-
naire (Table 1). The control group included those
women who had not experienced such violence as
adults (n⫽402). The sizes of the groups vary slightly in
different analyses owing to missing data.
The data were analyzed by using SPSS 10.0 (SPSS
Inc, Chicago, IL). We used the Student t test, when
appropriate, and the ␹2 test when nonparametric tests
were concerned, and we chose a level of statistical
significance of P⬍.05. The study was approved by the
Ethics Committee of the Department of Obstetrics

Table 1. Classification of Physical and Sexual Violence by the NorVold Abuse Questionnaire*
Mild abuse
Moderate abuse
Severe abuse
Mild abuse, no genital contact
Mild abuse, emotional/sexual humiliation
Moderate abuse, genital contact
Severe abuse, penetration
* Moderate and severe abuse as an adult were analyzed in this Finnish study.
Physical Abuse
Have you experienced anybody hitting you, smacking your face, or holding you
firmly against your will?
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?
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?
Has anybody against your will touched parts of 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⬙?
Have you in any other way been sexually humiliated, eg, by being forced to
watch a pornographic or similar movie against your will, forced to participate
in a pornographic or similar movie, forced to show your body naked or forced
to watch when somebody else showed his/her body naked?
Has anybody against your will touched your genitals, used your body to satisfy
him/herself sexually, or forced you to touch anybody else’s genitals?
Has anybody against your will put his penis into your vagina, mouth, or rectum
or tried any of this: put or tried to put an object or other part of the body into
your vagina, mouth, or rectum?

VOL. 109, NO. 5, MAY 2007 Pikarinen et al Experiences of Physical and Sexual Abuse 1117
and Gynecology, Helsinki University Central Table 3. Reason for Index Visit (nⴝ576)
Hospital. n (%)

RESULTS Lower abdominal pain, less than 3 months 23 (4.0)

The total prevalence of abuse (physical, sexual, or
both) experienced as an adult was 42.4%. Altogether,
147 (21.6% of those who answered) women reported
physical abuse, 84 (12.3%) reported sexual abuse, and
58 (8.5%) reported both. The clinical characteristics
and comparison of the abused and the nonabused
groups are shown in Table 2.
The reasons for the index visit varied (Table 3),
which made the subgroups too small to be reliably
compared.
The main results concerning general health and
some specific problems are presented in Table 4, and
the results concerning reproductive health are shown
in Table 5.
Self-estimated general health and quality of sex
life during the previous 12 months was estimated on a
four-point scale (very good, quite good, quite bad,
very bad). Altogether, 22.6% of sexually abused
women and 27.6% of both sexually and physically
abused women evaluated their general health as being
bad or very bad. There were significant differences
compared with the controls (11.2%, P⫽.005 and
P⫽.001, respectively). In the physically abused group,
women may also have evaluated their general health
as being bad more often than their controls, but the
difference was not significant (P⫽.054) (Table 4).
Sexually abused women and both sexually and phys-
ically abused women also evaluated their sex lives as
being significantly worse than their controls (P⫽.002
and P⫽.012, respectively).
More than half of the abused women (all groups)
had experienced common physical complaints during
the previous 12 months. Only one third of the con-
Lower abdominal pain over 3 months 36 (6.3)
Cervical smear 75 (13.0)
Miscarriage 36 (6.3)
Urogynecologic problems 38 (6.6)
Termination of pregnancy 21 (3.6)
Infertility 81 (14.1)
Abnormal bleeding 42 (7.3)
Gynecological cancer 52 (9.0)
Leiomyoma, ovarian cyst, or genital descendence 55 (9.5)
Preoperative control 57 (9.9)
Various 60 (10.4)
trols reported such complaints, so the difference was
statistically significant (P⬍.001). The groups did not
differ in any other aspect of general heath (admission
to hospital for any reason during the previous 12
months, sick leave longer than a fortnight during the
previous 12 months, numbers of gynecologic opera-
tions other than cesarean deliveries; data not shown).
Bowel irritation was significantly more common
among all abused women than among the controls
(P⬍.001 in all abused groups). Dysmenorrhea was
equally common among all patients (Table 4).
Table 5 shows how abuse was related to the
women’s reproductive health. Although there was no
difference in parity between the groups (Table 2),
physically abused women had given birth to their
first-borns and last-borns at lower ages (P⫽.001 and
P⫽.006, respectively) (mean age 24.27⫾5.17 years
and 28.44⫾5.64 years, respectively) than the control
subjects (mean age 26.67⫾5.89 and 30.84⫾4.44
years, respectively). Data were missing in the cases of
20 –26% of the abused women and in 18 –20% of the
controls as regards questions concerning miscarriages

Table 2. Socioeconomic Characteristics of the Study Groups

Education (y)*

Age (y) 9 or Less 10–12 13 or More Parity: 1 or More†

Controls (n⫽402) 42.05⫾14.87 46 (11.5) 94 (23.5) 260 (65.0) 224 (56.4)
Physically abused (n⫽147) 40.37⫾12.45 17 (11.6) 39 (26.7) 90 (61.6) 80 (54.4)
P‡ NS NS NS NS NS
Sexually abused (n⫽84) 40.82⫾12.33 8 (9.5) 25 (29.8) 51 (60.7) 47 (56.6)
P‡ NS NS NS NS NS
Physically and sexually abused (n⫽58) 40.26⫾12.41 7 (12.1) 20 (34.5) 31 (53.4) 32 (55.2)
P‡ NS NS NS NS NS
NS, not significant.
Data are expressed as mean⫾standard deviation or n (%).
* Data missing from two controls and one physically abused subject.
†
Data missing from five controls and one sexually abused subject.
‡
Compared with control subjects.

1118 Pikarinen et al Experiences of Physical and Sexual Abuse OBSTETRICS & GYNECOLOGY
VOL. 109, NO. 5, MAY 2007
Table 4. Results 1: Self-Estimated Health, Impairing Symptoms During Latest 12 Months, and Frequency of Abdominal Operations
Self-Estimated Self-Estimated Disabling Physical
General Health: Quality of Sex Life: Complaints Nonspecific Frequency of
Very Bad or Very Bad or Quite During Last 12 Lower Bowel Laparoscopic Frequency of
Quite Bad* Bad* Months† Abdominal Pain Dysmenorrhea Irritation Operations Laparotomies
Controls (n⫽402) 45 (11.2)‡ 56 (13.4)‡ 121 (30.1)‡ 79 (19.7)§ 165 (41.0)兩兩 86 (21.4)兩兩 121 (30.1)¶ 96 (23.9)兩兩
Physically abused (n⫽147) 26 (17.7)‡ 27 (18.3) 77 (52.4) 44 (30.0)‡ 64 (44.8)‡ 51 (34.7)‡ 46 (31.3)§ 37 (25.2)‡
P# NS NS ⬍.001 .020 NS ⬍.001 NS NS
Sexually abused (n⫽84) 19 (22.6) 25 (29.8) 44 (52.4) 28 (33.3)‡ 38 (46.3)‡ 39 (46.3)‡ 29 (34.5)‡ 22 (26.1)‡
P# .005 .002 ⬍.001 .007 NS ⬍.001 NS NS
Physically and sexually
abused (n⫽58) 16 (27.6) 17 (29.3) 36 (62.0) 20 (35.1)‡ 28 (50.0)‡ 26 (44.8)‡ 21 (36.2)‡ 14 (24.1)

Pikarinen et al
P# .001 .012 ⬍.001 .011 NS ⬍.001 NS NS
NS, not significant.
* Scale: very good, quite good, quite bad, very bad.
†
Stomachache, headache, muscular weakness, dizziness.
‡
Data missing from 1–5 cases or control subjects.
§
Data missing from 6–9 cases or control subjects.
兩兩
Data missing from 12–15 cases or control subjects.
¶
Data missing from 19–21cases or control subjects.
#
Compared with control subjects.

Experiences of Physical and Sexual Abuse

1119
Table 5. Results 2: Age at Delivery, Frequency of Miscarriages, Legal Terminations of Pregnancy
Mean Age at First
Delivery (y)
Controls 26.67⫾5.89 (n⫽224)
Physically abused 24.27⫾5.17 (n⫽79)
P* .001
Sexually abused 24.98⫾5.09 (n⫽47)
P* NS
Physically and sexually 25.00⫾5.57 (n⫽32)
abused
P* NS
NS, not significant.
Data are expressed as mean⫾standard deviation, n, or n (%).
* Compared with control subjects.
and legal terminations of pregnancies. The rate of
miscarriage was higher among physically abused
women than among the controls (P⫽.020). In addi-
tion, legally terminated pregnancies were more com-
mon among physically and sexually abused women
than in the control group (P⫽.002 and P⫽.040, re-
spectively). In an open written text, 11 abused women
(5%) stated that they had had a termination of preg-
nancy as a result of domestic violence.
Only one physically abused patient out of all the
abused women had told her gynecologist about her
experiences. No one told the gynecologist about
having been sexually abused. Altogether, 62% of the
patients did not want the gynecologist to ask directly
about abuse. There was no difference between the
abused and the nonabused patients in this regard.
DISCUSSION
Experiences of physical and sexual abuse as an adult
were very common among consecutively collected
Finnish gynecologic patients. Abuse had a strong
impact on the women’s quality of life. The abused and
the nonabused women had similar socioeconomic
backgrounds. Sexually abused gynecologic patients
and those who were both physically and sexually
abused rated their general health and sex life as being
bad more often than did the controls. The abused
women suffered from irritable colon and other dis-
abling conditions significantly more often than the
nonabused women. Physically abused women had
lost more pregnancies in miscarriages and physically
or sexually abused women in abortions, although
parity was similar in all groups.
Our results are in accordance with those of
previous studies where the victims of violence have
been shown to suffer more long-term problems of
1120 Pikarinen et al Experiences of Physical and Sexual Abuse
Mean Age at Latest Legal Terminations of
Delivery (y) Miscarriages Pregnancy
30.84⫾4.44 (n⫽134) 72 (n⫽402) Data missing 69 (n⫽402) Data missing
from 78 controls from 81 controls
28.44⫾5.64 (n⫽54) 39 (26.5) (n⫽147) Data 43 (29.3) (n⫽147) Data
missing from 38 cases missing from 34 cases
.006 .020 .002
29.43⫾6.03 (n⫽30) 22 (26.2) (n⫽84) Data 22 (26.2) (n⫽84) Data
missing from 20 cases missing from 20 cases
NS NS .04
28.33⫾6.28 (n⫽18) 16 (27.6) (n⫽58) Data 15 (25.9) (n⫽58) Data
missing from 14 cases missing from 15 cases
.035 NS NS
health such as stomach pain, digestive disorders,
headache, chronic pain, and gynecologic prob-
lems.13,14 These might be the result of direct tissue
damage or a physiologic response to stress.5,6 Abusive
experiences, especially sexual abuse, have been
shown to be related to lower abdominal pain in
numerous studies.14 –16 Smikle et al17 also state that no
demographic features identify those women who are
at risk of being abused physically or sexually.
Hilden et al18 have shown in the NorVold study
that sexual abuse is associated with psychosomatic
disorders and poor self-estimated general health. Di-
vergent figures in different studies might be partly the
result of national differences, but they mainly arise
because of different criteria for cases. Lifelong expo-
sure to violence has been assessed in previous articles,
and we studied only the impact of being exposed to
moderate or severe violence as an adult. It might be
the case that being exposed to violence as a child
leads to even more serious consequences.
At least three limitations should be considered
when generalizing the findings of this study. First,
although the Finnish answering rate (86%) was high, it
still leaves the prevalence of abuse unknown in 14%
of the patients.12 Ongoing abuse or past traumatic
events may affect a woman’s willingness to participate
in this kind of study. Women in abusive relationships
may also fear for their safety when receiving question-
naires or answering questions about violence.20 Sec-
ond, there is a recall bias in a retrospective study.
Violent events may be suppressed and not recalled,
although this is more common among adults who
have been victims of violence in childhood. In addi-
tion, troublesome questions might not be answered.
Missing data may make the subgroups small, and this
creates some uncertainty in drawing conclusions, for
OBSTETRICS & GYNECOLOGY
example, as regards questions about sensitive issues
such as miscarriages and abortions. Third, the study
might not represent gynecologic patients generally
because it was carried out in a tertiary clinic where the
women’s gynecologic complaints can be assumed to
be more complex, thus affecting their general health
more than in primary or secondary clinics.
Recognizing intimate partner violence and help-
ing the victims demands multidisciplinary coopera-
tion between public social and health care. While
discussing intervention strategies, debate often arises
about whether female patients should be screened for
abuse.19 –22 Routine screening of all female patients in
primary care is often recommended, with the goal of
early intervention and prevention.23 On the other
hand, the effectiveness of screening is uncertain.1,24
Routine gynecologic and obstetric visits would pro-
vide a natural opportunity for screening. The results
of previous surveys indicate that 43– 85% of female
respondents consider screening acceptable in health
care settings,1 but in this study two thirds of our
gynecologic patients did not wish to be asked directly
about domestic violence by their gynecologist, re-
gardless of whether or not they themselves had been
exposed to violence. Unfortunately, we did not ask
them whether they would approve of being asked
about such experiences by any other person, for
example by their general practitioner, with whom
they are naturally more familiar.
Domestic violence is screened in Finland at ele-
mentary school health examinations and experimen-
tally at maternal health centers. Our results do not
favor screening gynecologic outpatients, but there was
a high incidence of abusive experiences among the
patients suffering from lower abdominal pain and
irritable colon, both common causes of gynecologic
consultation. It may be correct to ask about violence,
at least in patients who have no other evident cause
for their symptoms.22 In addition, women seeking
abortion, and especially repeated abortion, should be
asked about physical and sexual violence.25,26 Eisen-
stat and Bancroft23 recommend two simple questions:
“Do you ever feel unsafe at home?” and “Has anyone
at home hit you or tried to injure you in any way?”
These questions have a sensitivity of 71% in detecting
domestic violence and a specificity of almost 85%.23
However, when asking about violence, the inquirer
should be able to provide the victims with the local
service programs for abused patients and try to ensure
the safety of women living in abusive relationships.
In conclusion, in our cross-sectional study con-
cerning abusive experiences in adulthood in a sample
of gynecologic patients, we showed that these experi-
VOL. 109, NO. 5, MAY 2007 Pikarinen et al
ences were common and that women with abusive
experiences had suffered more general ill health and
had a poor sex life and disabling general conditions.
The patients did not spontaneously tell their gynecol-
ogists about their experiences, but most did not want
to be questioned about violence.
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