SEXUAL ABUSE, CANCER, AND SEXUAL HEALTH

Abstract

BACKGROUND: Victims of sexual violence – both sexual abuse and intimate partner violence - report a significant decrease in sexual and general health. There exist national screening guidelines for sexual violence in healthcare due to the short and long-term physical and psychological consequences of sexual abuse. However, there is still a gap between the healthcare provided and the needs among women with a history of sexual abuse. Exposure to sexual violence may increase a woman’s risk of susceptibility to high-risk human papilloma- associated cancers, particularly cervical cancer. Globally, one in three women has experienced intimate partner violence, including sexual violence, and the numbers are increasing due to the COVID-19 pandemic. Less than 40 percent of women exposed to intimate partner violence are actively searching for help. There is evidence for a significant correlation between intimate partner violence victims, sexual abuse, and cervical cancer. In the oncology setting, exposure to previous or current intimate partner violence a history of childhood sexual abuse lowers cancer-related well-being. Screening for sexual abuse on a large scale both overall in healthcare and the oncology setting is of absolute importance to improve or women’s cancer-related quality of life. There is limited research into how far sexual health is affected by pelvic radiotherapy-induced site effects among women with a history of sexual abuse. One previous study found a significant synergistic effect for superficial dyspareunia in cervical cancer survivors after pelvic radiation compared to healthy controls. AIM: The thesis aims to examine sexual and general health among female cancer survivors with a history of pelvic radiotherapy. Further, additional aim was to assess the proportion and the level of severity of women with a history of sexual abuse who have undergone 2 pelvic radiotherapy with curative intent for gynecological, anal, and rectal cancer suffer from sexual dysfunction compared to women without reported history of sexual abuse. METHOD: Women were recruited from both a population-based cohort and patients referred to the pelvic rehabilitation clinic by other healthcare providers. All participants were female, over 18 years old, treated with pelvic radiotherapy at Sahlgrenska University hospital between 2007 to 2016. The participants completed a study-specific questionnaire including aspects addressing sexual health, sexual abuse, and well-being. For this thesis, a subgroup of study participants with experience of sexual abuse of any degree (mild, moderate, severe) was identified. Participants grouped as “experience of sexual abuse” or “no experience of sexual abuse.” Chi-Square tests and Fisher’s exact test was used for statistical analysis of categorical variables and, Analysis of Variance (ANOVA) for standard continuous variables were used to compare the two groups’ characteristics. Characteristics of sociodemographic data and sexual health aspects were compared. Also, an assessment of well-being was carried out to estimate women’s self- reported quality of life. Numeric rating scales of 0-7 were used to grade levels of depression and anxiety. Data on cancer diagnosis and treatment modality were collected from medical records. The results are presented in tables and descriptively by means, medians, percentages, and relative risks. The significance level was set at p <0.05. RESULTS: In total, 570 women participated in the study. 435 self-reported questionnaires were analyzed from the cohort and 135 from a referred patient group. The overall most common diagnosis was endometrial cancer N=203 (35.6%), followed by rectal cancer N=138 (24.2%). Cervical and anal cancer was the most common diagnosis among women with experience of sexual abuse compared to women without such an experience (32.3% vs. 21.5% p=<0.063) (17.7% vs. 12.4%, p=<0.063). In total, 62 (11%) of women reported previous experience of sexual abuse. A higher proportion of women reporting experience of 3 sexual abuse was referred from other health care providers to the pelvic rehabilitation clinic compared to women with no experience of sexual abuse (33.9% vs. 22.4% p=<0.066). On average, women with experience of sexual abuse were younger compared to women without experience of sexual abuse (57.2 years vs. 64.0 years, p<0.001). More women with than without experience of sexual abuse were in a depressed mood (19 % vs. 9 %, p=0.007), anxious (23 % vs. 12 %, p=0.007), and had vaginal pain during sexual activity (52 % vs. 25 %, p=0.011, RR 2.07, CI 1.24-3.16). In the total study cohort, vaginal pain during sexual activity was associated with vaginal shortness (68 % vs. 31 % p=<0.001) and vaginal inelasticity (67 % vs. 33 %, p=<0.001). Three-quarters of all women in the study cohort said they would be very distressed if problems with their sexual life persisted. CONCLUSIONS: Sexual abuse significantly affects the sexual health outcomes and other aspects of well-being for female cancer survivors after pelvic radiotherapy. The results highlight the importance of screening for sexual abuse in oncology settings before, during, and after cancer treatment. These routine changes challenge healthcare to prevent further traumatization and provide appropriate interventions and support. Impaired sexual and general health after pelvic radiotherapy – shown in this thesis – reflects some of the long-term consequences of sexual abuse underlying the importance of developing individually targeted rehabilitation for oncology patients with previous experience of sexual abuse.