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Health effects of experiences

of sexual violence for women
with abusive partners
a b
Kimberly K. Eby MA , Jacquelyn C. Campbell
c a
RN, MSN, PhD , Cris M. Sullivan PhD & William
a
S. Davidson II, PhD
a
Michigan State University , East Lansing,
Michigan, USA
b
Department of Psychology , Tulane University ,
Percival Stern Hall, New Orleans, LA, 70118–5698,
USA E-mail:
c
School of Nursing , Johns Hopkins University ,
Baltimore, Maryland, USA
Published online: 14 Aug 2009.

To cite this article: Kimberly K. Eby MA , Jacquelyn C. Campbell RN, MSN,

PhD , Cris M. Sullivan PhD & William S. Davidson II, PhD (1995) Health effects of
experiences of sexual violence for women with abusive partners, Health Care for
Women International, 16:6, 563-576, DOI: 10.1080/07399339509516210

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 HEALTH EFFECTS OF EXPERIENCES OF SEXUAL
VIOLENCE FOR WOMEN WITH ABUSIVE PARTNERS

Kimberly K. Eby, MA
Michigan State University, East Lansing, Michigan, USA

Jacquelyn C. Campbell, RN, MSN, PhD

School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA

Cris M. Sullivan, PhD, and William S. Davidson II, PhD

Michigan State University, East Lansing, Michigan, USA
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We assessed the incidence of sexual violence, physical violence, phys-

ical health symptoms, gynecological symptoms, and risk behaviors for
contracting an STD or HIV infection in women who had used a shelter
for women with abusive partners. In addition, we investigated the
relationships between sexual violence and the frequency of physical
health symptoms, including specific gynecological symptoms.
Results indicated that one fourth of the women interviewed had
experienced sexual violence and nearly two thirds of the women had
experienced physical violence in the past 6 months. The incidence of
physical health symptoms, gynecological symptoms, and risk behav-
iors for exposure to STDs and HIV infection are presented. The cor-
relations among sexual violence, physical violence, and experiences
of physical health symptoms are also reported. This study is particu-
larly valuable because previous research has not documented the
relationship between sexual violence and physical health symptoms.

REVIEW OF THE LITERATURE ON THE RELATIONSHIP

BETWEEN WOMEN'S HEALTH AND THEIR EXPERIENCE
OF SEXUAL VIOLENCE

Recently, increased attention has been paid to the issue of sexual vio-
lence both within and outside of ongoing, intimate relationships. Although

Received 21 October 1993; accepted 1 December 1994.

We would like to acknowledge Maureen H. Rumptz for her generous assistance, encour-
agement, and enthusiasm in conducting this research study.
Address correspondence to Kimberly K. Eby, Department of Psychology, Tulane
University, Percival Stern Hall, New Orleans, LA 70118-5698, USA. E-mail may be sent to
ebykimbe@aol.com.

Health Care for Women International, 16:563-576,1995 563

Copyright © 1995 Taylor & Francis
0739-9332/95 $10.00 + .00
 564 K. K. Eby et al.

sexual abuse is not always a part of a battering relationship, it is one of the

several potential forms of domestic violence. It has been estimated that
sexual abuse occurs in approximately 40% of all cases of battering
(Campbell, 1989; Finkelhor & Yllo, 1985; Shields & Hanneke, 1983;
Stark & Hitcraft, 1982).
Researchers have found that sexual assaults by husbands are reported
two to eight times as frequently as sexual assaults by a stranger (Finkelhor
& Yllo, 1985; Flitcraft, 1978; Russell, 1982). Shields and Hanneke
(1983) investigated reactions to marital rape. Forty-one percent of the
women in their sample reported rape as well as alternate forms of vio-
lence, while 48% reported nonsexual violence only. They concluded
that (a) sexual violence in a relationship was rarely an isolated incident,
(b) the severity of a woman's reaction to marital rape was directly re-
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lated to the number of incidents of marital rape, and (c) marital rape
occurred with severe forms of nonsexual violence. Campbell (1989)
found that approximately half (49.9%) of the physically abused women
in her sample were sexually abused, most of them experiencing ongoing
violence.
With strong evidence that a substantial proportion of women in abu-
sive relationships are experiencing sexual violence, it is important to
explore the impact of sexual violence on women's health. Campbell and
Alford (1989) reported that the two most frequently recounted health
concerns of maritally raped women were painful intercourse (72%) and
vaginal pain (63%). Additional problems women attributed to their sex-
ual abuse included bladder infections, vaginal and anal bleeding, mis-
carriages and stillbirths, and STDs.
In 1974, Burgess and Holmstrom identified "rape trauma syndrome."
In the first phase of the syndrome, women experience a multitude of
somatic reactions in addition to the initial physical trauma. In the second
phase, they are at risk of developing phobias and nightmares related to
the trauma. Therefore, it is imperative to examine the potential relation-
ships between women's experiences of relationship sexual violence and
their experiences of physical health symptoms, particularly gynecological
symptoms. Although some researchers have assessed sexual violence and
the presence of gynecological symptoms, no study to date has documented
the relationship between sexual violence and physical health symptoms,
including gynecological symptoms. There is increasing evidence that
assessing risk for contracting an STD or HIV infection should be includ-
ed in health evaluations for women with abusive partners. The potential
for rape increases women's chances of exposure to an STD or HIV infec-
tion. The potential use and abuse of alcohol and drugs by women with
abusive partners may also result in substantial medical risks. A small pro-
portion of Campbell and Alford's (1989) sample (6.5%) reported that
 Health Effects 565

they had contracted an STD as a result of their sexual abuse. Rodriguez

(1989) found that women with abusive partners repeatedly cited expo-
sure to HIV when asked about their immediate health concerns.

THE PRESENT STUDY

Our purpose in conducting the present study was twofold. First, we

assessed the incidence of sexual violence, physical violence, physical
health symptoms, gynecological symptoms, and risk behaviors for con-
tracting an STD or HIV infection. Second, we investigated the relation-
ships between the incidence of sexual violence and the frequency of
physical health symptoms in women with abusive partners.
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METHOD

Setting

The present study was part of a larger, longitudinal research investiga-

tion of the effects of an advocacy intervention (Sullivan et al., 1992,
1994). Women were recruited from the local shelter for women with
abusive partners and were interviewed seven times over a 2-year period.
Participation in the project was completely confidential.

Research Participants

The participants in this study were the first 110 women who were
scheduled for regular project interviews beginning January 1992. The
women were asked at the beginning of their interviews if they would be
willing to answer additional questions regarding their physical health.
All of the women who were interviewed consented to complete the
health section of the interview.
Relevant demographic information regarding the research participants
is presented in Table 1. Ages ranged from 17 to 61 years (M = 28).
Forty-nine percent of the women were White, 42% were African
American, 5% were Latina, and 4% were Native American. The major-
ity (70%) of the women were currently unemployed, and 71% were
receiving some form of governmental assistance. A small percentage
(17%) were students. Forty-one percent of the women had not completed
high school, 22% had received their high school diploma or general
equivalency diploma, and 24% had some college education.
More than two thirds (69%) of the women had children currently liv-
ing with them (the mean number of children was two). Seventy-nine per-
cent of the women reported that they had ended or were ending their
 566 K.K.Ebyetal.

Table 1. Demographics of Research Participants (N= 110)

Characteristic %

Age
17-19 years 13
20-29 years 51
30-39 years 26
Over 40 years 10
Race
African American 42
White 49
Latina 5
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Native American 4
Been employed in last 6 months 41
Education level
Less than high school 41
High school graduate/general equivalency diploma 22
Some college 24
College graduate/professional degree 8
Trade school 5
Receiving governmental aid 71
Children living with them 69
Currently in relationship with assailant 21

relationship with their assailant. The average length of their relationship

with their assailant was 6 years, and the average number of previous sep-
arations was 8. Only 23% of the women had never had a previous sepa-
ration from their assailant. The participants were demographically simi-
lar to the participants of the larger project and of other studies involving
shelter residents (Finn, 1985; Gondolf, 1988; Mitchell & Hodson, 1983;
Okun, 1986;Pagelow, 1981).

Procedure
Interview training. Undergraduate students were recruited on an
ongoing basis to conduct face-to-face interviews after a term of rigorous
training. The training used written material, films, and discussions about
the nature and dynamics of woman abuse. The interviewers learned
appropriate interview protocol through a written interviewer's handbook,
class discussion, and role-play interviews weekly throughout training.
 Health Effects 567

Interrater agreement was calculated by having all of the interviewers lis-

ten to and code the same interview. The number of items coded correctly
was divided by the total number of health items to determine percent
agreement, which ranged from 89% to 100% by the end of training.

Data collection. All of the interviews began with an explanation of

the purpose of the interview. With the participants' consent, the inter-
views were tape-recorded for verification purposes. The women were
paid for their participation.

Measures
Presence of sexual violence. The presence of sexual violence in the
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past 6 months was measured by three dichotomously scored items. One

of these items, "being forced into sexual activity," was taken from the
project-modified version of the Conflict Tactics Scale (CTS; Straus,
1979). The other two items were taken from research by Shields and
Hanneke (1983) and inquired into whether the women's partners had
used threats to have sex with them and whether the women's partners
had used physical force to have sex with them in the past 6 months. The
internal consistency estimate, alpha (Cronbach, 1951), for this three-item
scale was .81.

Frequency of physical abuse. Physical abuse was measured using a

modified version of Straus's (1979) Violence subscale of the CTS. The
revised CTS (16 items) was used to measure frequency of abuse on a 6-
point scale from never to more than four times a week. The items mea-
sured how often the women's assailant had engaged in different acts of
violence in the past 6 months. Of the 16 items, 12 items were combined
to form the final Frequency of Physical Abuse scale. (Four items were
dropped because of their individual item characteristics and the results
from a reliability analysis.) The internal consistency estimate for the 12-
item scale was .93.

Physical health symptoms. Physical health symptoms were measured

using an adaptation of the 35-item Cohen-Hoberman Inventory of Phy-
sical Symptoms (CHIPS; Cohen & Hoberman, 1983). The modification
included physical health symptoms predominant in populations of
women with abusive partners, such as high blood pressure, ulcers, and
menstrual problems (Rodriguez, 1989). Women rated how often they
had been bothered by each of the physical health symptoms in the past 6
months. An examination of item characteristics and the results of a relia-
bility analysis led to the construction of a 29-item scale. The internal
consistency estimate for this scale was .95.
 568 K. K. Eby et a!.

The women were also asked about various gynecological symptoms,

including pelvic pain, vaginal bleeding or discharge other than a period,
missed menstrual periods, unwanted pregnancies, painful intercourse,
infertility, rectal bleeding, bladder infections, and painful urination or
passing of water (Campbell & Alford, 1989). For each of the health
symptoms, gynecological or otherwise, the women were asked to indi-
cate whether they believed it was a result of abuse.

Risk for contracting STDs and HIV infection. The women's risk for
contracting STDs and HIV infection was assessed using a modified ver-
sion of the 17-item Risk Assessment Questionnaire currently used by the
county Health Department. The questionnaire included items relating to
the number of sex partners in the last year, use of alcohol or drugs during
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sex, use of condoms and foam during sexual activity, and knowledge of
partners' drug use. These items represent behaviors that put people at
risk for contracting an STD or HIV infection. Risk for contracting STDs
and HIV infection was scored item by item, such that responding posi-
tively to any one of the risk behaviors suggested being at risk for con-
tracting an STD or HIV infection. Correlational analyses were per-
formed on individual items, not on the total scale.

RESULTS
Sexual Abuse
Approximately one fourth (27%) of the women interviewed had expe-
rienced at least one type of sexual abuse. Eighteen percent of the women
indicated they had experienced "forced sexual activity." Twenty-two per-
cent reported that their partner had used threats to try to have sex with
them in the past 6 months and that their partner had used force to try to
have sex with them in the past 6 months.

Frequency of Physical Abuse

Nearly two thirds (63%) of the participants had experienced at least
one incident of physical violence in the past 6 months. Violent acts
ranged from being pushed or shoved (48%) to being hit with a fist (22%)
and being threatened with a gun or knife (14%). Almost half (45%) of
the women reported experiencing violence in the past 6 months that fell
within the category of severe abuse.

Physical Health Symptoms

Nearly all (99%) of the women reported experiencing at least one
physical health symptom. Physical health problems reported most fre-
 Health Effects 569

Table 2. Percentage of Women Who Experienced Each Physical

Health Symptom in the Past 6 Months and the Percentage
of Women Who Considered the Symptom (if Endorsed) a Result
of the Abuse They Experienced (N = 110)

%Who %Who
experienced considered it
Physical health symptom symptom a result of abuse

Low energy 88 57
Sleep problems 77 73
Headaches 77 71
Muscle tension/soreness 73 61
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Constant fatigue 68 65
Weight change 67 65
Back pain 63 62
Nightmares 62 66
Dizziness 61 52
Poor appetite 61 69
Migraine headaches 60 70
Acid stomach or indigestion 60 52
Feeling weak all over 59 62
Stomach pain 57 56
Heart pounding or racing 55 72
Muscle cramps 54 42
Hands trembling 53 64
Severe aches and pains 51 61
Numbness/tingling in body 51 43
Pains in heart or chest 49 72
Shortness of breath 48 53
Blurred vision 46 53
Constipation 46 39
Nausea and/or vomiting 44 50
Ringing in ears 44 44
Hot or cold spells 43 40
Faintness 40 57
Diarrhea 39 51
Pelvic pain 38 36

quently were low energy (88%), sleep problems (77%), and headaches
(77%). In addition, for the majority of the health symptoms, at least half
of the women believed that the abuse had contributed to their experienc-
ing the symptom. Physical health problems most often thought to be a
result of abuse were sleep problems (73%), pains in the heart or chest
(72%), heart pounding or racing (72%), and headaches (71%). Table 2
 570 K. K. Eby et al.

presents the percentage of women who expertenced each of the health

symptoms and the percentage of women who considered each symptom
to be a consequence of their abuse.

Gynecological Symptoms

Pelvic pain was the most frequently reported gynecological symptom

(38% of the women), and infertility was the least reported (5% of the
women). Not surprisingly, painful intercourse was the gynecological
symptom women most often attributed to abuse (52%). Table 3 presents
the percentage of women who experienced each of the gynecological
symptoms and the percentage of women who considered each symptom a
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result of abuse. Also reported in Table 3 is the incidence of miscarriages.

Potential Exposure to STDs or HIV Infection

Although the majority of women did not engage in drug-related

behavior that would increase their chances of being exposed to the HIV,
other risky behaviors did emerge. Most notable was the lack of use of
condoms and spermicides during sexual intercourse (62%). Further a lit-
tle more than half (54%) of the women reported that they had ever been

Table 3. Percentage of Women Who Experienced Each

Gynecological Symptom in the Past 6 Months and the Percentage
of Women Who Considered the Symptom (if Endorsed) a Result
of the Abuse They Experienced (N = 110)

% Who
%Who considered
experienced it a result
Gynecological symptom symptom of abuse

Pelvic pain 38 36
Bladder infection 25 37
Missed menstrual periods 25 33
Vaginal bleeding/discharge 22 29
Painful intercourse 21 52
Painful urination 16 29
Unwanted pregnancy 6 29
Rectal bleeding 6 17
Infertility 5 40
Miscarriages 15
(not only in past 6 months)
 Health Effects 571

tested for HIV infection, and 52% of the women reported that they had
been tested within the past 6 months.

Additional Analyses

We examined the relationships between experiences of sexual violence

and the presence of various gynecological symptoms: pelvic pain, vaginal
bleeding or discharge other than periods, missed menstrual periods,
unwanted pregnancies, painful intercourse, painful urination, bladder infec-
tions, infertility, rectal bleeding, and miscarriages. Moderate correlations
were found between experiencing sexual violence in the past 6 months and
the gynecological variables pelvic pain, vaginal bleeding or discharge,
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painful intercourse, miscarriages, bladder infections, painful urination, and

rectal bleeding. These correlations were significant at the .05 level. No
significant correlations were found between the experience of sexual vio-
lence and missed menstrual periods, unwanted pregnancies, and infertility.
We also used correlational analysis to explore the relationships
between (a) sexual violence and physical health symptoms, (b) physical
violence and physical health symptoms, and (c) sexual violence and
physical violence. There was a moderate to high correlation between sex-
ual abuse and physical health symptoms (r = .58, p < .05). Furthermore,
there was a moderate correlation between physical abuse and health
symptoms (r = .50, p < .05). These results indicate that the women's
experiences of abuse, both sexual and physical, were related to their
experiencing of various health symptoms. However, because of the
extremely high correlation between sexual violence and physical violence
(r = .86, p < .05), it was impossible to determine the independent effects
of these two variables on women's physical health.
We conducted f-tests to examine whether sexually abused women
were more seriously physically abused by their partners than women
who experienced solely physical abuse, and if they scored higher on the
physical health symptom scale. The results indicated that women who
were sexually abused did have significantly higher scores on the physi-
cal abuse scale, r(31) = 4.20, p < .05, and on the physical health symp-
tom scale, f(40) = 3.23, p < .05.
Finally, we conducted f-tests to examine whether women's involve-
ment with their assailant had an impact on their experiences of sexual
abuse, physical abuse, and physical health symptoms. The results indi-
cated that women's involvement with their assailant was significantly
related to higher scores on the sexual violence scale, t(63) = 2.55, p <
.05, and on the physical violence scale, t(59) = 3.73, p < .05. However,
involvement with the assailant was not significantly related to group dif-
ferences in scores on the physical health symptom scale.
 572 K. K. Eby et al.

DISCUSSION

Woman battering continues to be a widespread social problem in the

United States and around the world. Advocates in the women's move-
ment and researchers are focusing increased attention on the multiple
needs, including physical health needs, of women with abusive partners.
Health care leaders have recently called on doctors and nurses to recog-
nize woman battering as a new public health priority. The results of the
present study justify the need for this priority.
Of the 69 women who had experienced some form of physical abuse,
28 had also experienced at least one form of sexual violence in the past 6
months, such that approximately 41% of the physically abused women
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had also been sexually abused. These results corroborate previous find-
ings that marital rape occurs in approximately 40% of cases of battering
(Campbell, 1989; Campbell & Alford, 1989; Shields & Hanneke, 1983;
Stark & Flitcraft, 1982). It is imperative to note that the women were
asked to report only on the past 6 months.
Participants also reported being frequently bothered by physical
health symptoms. Again, it is important to remember that women were
asked to think about only the past 6 months. The physical health symp-
toms reported by the women support other researchers' findings that
women with abusive partners are often bothered by these health prob-
lems (Kerouac et al., 1986; Rodriguez, 1989; Straus & Gelles, 1987).
Several of the health symptoms that the women attributed to abuse,
such as back pain and weight changes, have not yet appeared in the
medical literature as important symptoms to assess in women with abusive
partners. Disseminating this information to health care professionals is
vital so that women are not misdiagnosed and the true etiology of their
health problems is not overlooked. There is also a constellation of symp-
toms suggesting neurological damage (headaches, blurred vision, ringing
in ears, and dizziness) that, singly, would often be attributed to psycho-
somatic causes. Finally, another constellation of symptoms (nightmares,
difficulty sleeping, heart pounding, trembling, and shortness of breath)
is often associated with posttraumatic stress disorder, a diagnosis only
recently associated with battered women (Dutton, 1992; Woods &
Campbell, 1993).
A substantial group of women reported various gynecological symp-
toms, ranging from pelvic pain to missed menstrual periods to painful
intercourse. Interestingly, women appeared more reluctant to attribute
their gynecological symptoms than their other physical health symptoms
to their abuse. Not surprisingly, painful intercourse was the gynecologi-
cal symptom the women most often considered to be a result of abusive
experiences.
 Health Effects 573

Overall, the risk behavior that emerged most frequently among the
women was the lack of condom and spermicide use while engaging in
sexual intercourse. Within the past 6 months, nearly two thirds of the
women who had been sexually active did not use condoms or spermi-
cides for protection from STD or HIV infection. For the participants who
had multiple casual sex partners (11%) or one-time, anonymous partners
(4%) or who paid or received money for sex (7%), the risk for contract-
ing an STD or HIV may have substantially increased. Furthermore, the
threat of a sexual assault is quite high for women with abusive partners,
even when they are separated from their assailant. Separation also
increases the probability that the assailant has been sexually active with
someone else and therefore contributes to women's risk.
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Aside from the lack of use of protection during sexual intercourse, the
vast majority of women did not appear to be engaging in behaviors that
would elevate their risk for contracting an STD or HIV infection, such as
sharing needles to shoot drugs, using dirty needles, or having sexual
partners who shot drugs. A factor that would certainly influence partici-
pants' risk but was not measured thoroughly was the risky behaviors and/
or sexual habits of the women's partners. For example, if the women's
partners changed partners frequently or engaged in unprotected sex, the
women's risk of contracting an STD or HIV infection would increase.
Finally, another factor that could elevate the risk of contracting an STD
or HIV infection for women with abusive partners is that their partners
may refuse to wear condoms or may threaten the women if they try to
force the issue.
Whereas the sexual violence scale was significantly correlated with
the overall physical health symptom scale, it was significantly correlated
with only some of the symptoms on the gynecological scale. The
strongest relationships were found between sexual violence and pelvic
pain, vaginal bleeding or discharge, and painful intercourse; moderate
relationships were found between sexual violence and miscarriages,
bladder infections, painful urination, and rectal bleeding. These results
support Campbell and Alford's (1989) finding that marital rape victims
reported extreme problems with painful intercourse and vaginal pain.
The evidence of strong relationships between sexual abuse and physi-
cal abuse and the physical health symptom scale indicated that there
indeed may be long-term health consequences for women in abusive
relationships. Although it was impossible to determine conclusively
whether experiences of sexual violence independently contributed to the
women's experiencing more frequent physical health symptoms, the
women who were sexually abused were also more severely physically
abused and experienced an increase in physical health symptomatology.
This suggests that the presence of sexual violence in an abusive relation-
 574 K. K. Eby et al.

ship is predictive of more severe physical abuse and increased physical

health symptoms.
Although involvement with the assailant was significantly related to
more frequent physical abuse and greater likelihood of experiencing sex-
ual violence, it was not significantly related to physical health symp-
toms. This finding provides support for the contention that woman bat-
tering has long-term effects on women's health, such that physical health
symptoms may persist even after the abuse has ended.
The present study is one of the first to attempt to link women's experi-
ences of sexual violence with their physical health status. The results sug-
gest that women's physical health has indeed been overlooked in the
research on women with abusive partners. We did find relationships
between women's experiences of sexual abuse and their experiences of
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physical health symptoms, particularly specific gynecological symptoms.

These results emphasize the necessity of paying more attention to the
physical health needs of women with abusive partners. Other than the
identification of injuries as a direct result of the abuse, the potential rela-
tionships between abuse and physical health have largely been ignored.
More research designed to examine these critical relationships is essen-
tial. In particular, longitudinal research that tracks changes in experi-
ences of abuse over time as well as changes in physical health over time
is needed so that the nature of this relationship is understood more thor-
oughly.
Finally, there is the question of how health care professionals should
intervene on behalf of women with abusive partners. One solution is to
educate the professionals who are treating women about the nature and
dynamics of woman abuse (Campbell & Humphreys, 1993). Conducting
educational workshops and/or in-services that provide information on
warning signs and cues to look for in identifying women with abusive
partners is a start. With this information, health care professionals would
be able to conduct a more complete assessment of women's health status
and would also be able to make appropriate referrals to community
resources. Medical records that contain documentation of past or recent
abuse would be useful for women in the event that they pressed charges,
filed for a restraining order in the future, or needed evidence in child
custody disputes.
Another intervention might occur in the shelter targeted specifically
for abused women. Weekly evening meetings are conducted in most
shelters to provide women with support and information specific to dif-
ferent situations that they may encounter. These meetings include legal
workshops, support groups, and parenting groups. It would be possible
to structure a similar group addressing women's health issues. The phys-
ical health symptoms that often result from women's experiences of
 Health Effects 575

abuse, as well as other health issues of importance, could be discussed.

Sexual abuse issues may be difficult to address in a group setting, but
abused women need to have this topic brought up in either individual or
group sessions—they will probably be reluctant to initiate it on their
own. Nurses could be effective group leaders and could also provide
information to shelter workers, enabling them to be more effective advo-
cates for women with physical health concerns.
The future should bring a comprehensive plan of action, one that
includes multiple interventions targeted at both women and health care
professionals. If this action is combined with additional research on the
relationship between women's experiences of abuse and their physical
health, this long-ignored threat to women's health can begin to be ade-
quately addressed as the public health problem it is.
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