C linical experience has led som e gynaecologists and psychiatrists to conclude that
gynaecological sym ptom s are associated with psychiatric disorder (R ogers, 1950;
Sm ith, 1979; M unro, 1969; Gath et al, 1987; H unter, 1990). G reenberg (1983)
found that sixty-tw o per cent o f w om en referred to a gynaecology clinic w ere
suffering from m ild to m oderate depression (see Chapter 1). At the sam e tim e
it could be argued that an em otional disorder m ay lead a w om an to seek a
hysterectom y (e.g. D ennerstein et al, 1986). For exam ple, psychological state can
affect the horm one levels produced by the ovary through the interm ediary action
o f the pituitary gland (D ennerstein, 1986). ‘C hanges in the production o f
horm ones by the ovary will alter the endom etrium and the m uscles o f the uterus.
T his in turn m ay affect m enstruation by changing either the severity o f
contractions or the am ount o f blood loss’ (op.cit). Thus, treatm ent o f
psychological problem s m ay solve a m enstrual com plaint (D ennerstein).
T herefore hysterectom y m ight be an inappropriate, som atic treatm ent for an
Abuse
D ep ression has been cited as the com m onest sym ptom am ong adults w ith a
h istory o f child sexual abuse (M ullen, R om an-C larkson, W alton & H erbison,
1988; H erm an, 1981; Briere & Runtz, 1988; D raijer, 1989). Sedney & B rooks
(1984) found am ong 301 college students significant differences betw een a control
group and a group o f 51 fem ale students who claim ed to be abused as children.
W ith regard to physical m anifestations, fem ales w ho had been abused w ere tw ice
as likely to attend a doctor and one and a h alf tim es as likely to be hospitalized
than the fem ales in the control group (Sedney & B rooks, 1984 cited in B achm ann,
M oeller & Benett, 1988). The abused fem ales tended to m anifest m ore severe
sym ptom s o f anxiety and depression; 26% had visited a doctor or been
hospitalized for severe anxiety, com pared to 9% o f the control group (op. cit).
A greater num ber o f abused fem ales (18% ) had either attended a doctor or been
hospitalized for depression com pared to those in the control group (4% ). A
sim ilar pattern o f results was reported by M uenzenm aier, M eyer, Struening &
F erber (1993) w ho exam ined the prevalence o f childhood sexual abuse and
p h ysical abuse am ong fem ale outpatients w ith severe and persistent m ental
illness. Forty-five percent o f the patients had been sexually abused, and 51% had
been physically abused. There were higher rates o f depressive and psychotic
sym ptom s and higher rates o f sexual victim ization in adulthood than those w ho
had not experienced abuse (op.cit). In support o f these findings a recent
p leth ora o f studies suggest an association betw een sexual abuse and the
d evelopm en t o f m ajor m edical, psychiatric, and crim inal behaviours (G lod, 1993).
Influences on Patients* Expectations o f Treatment and Desire fo r
140
Hysterectomy
Since there is a problem o f definition o f w hat constitutes sexual abuse (Fry, 1993),
for the purpose o f the present study, sexual abuse w ill be interpreted as: sexual
assault (rape), exposure o f sexual organs, unwanted touching and fondling, w hether com m itted by relatives, acquaintances, or strangers. In 1988 in the U .K . there
w ere 516 prosecutions for incest (C ohen, 1990). OfHcial statistics report 4,600
instances o f rape and 17,400 o f indecent assault against fem ales in E ngland and
W ales in 1993 (H om e O ffice, 1994). H ow ever, such figures on sexual abuse and
rape are w idely accepted as ju st the tip o f the iceberg. A M O R I survey in
B ritain reported that 12% o f fem ales and 8% o f m ales have been sexually abused
before the age o f 16 (Baker & D uncan, 1985). H ere abuse had been defined as
‘exp osu re’ (show ing sexual organs), ‘tou ch in g’ and show ing pornographic
m aterial or talking about sexual things in an erotic w ay. A N ew Z ealand study
reported a rate o f 20% for sexual and physical abuse before the age o f 12, and
a rate o f 13% for genital contact or greater (M ullen, R om ans-C larkson, W alton,
et al, 1988). W est (1988) reports it is likely that as m uch 98% o f childhood
abuse is unreported. H ow ever, it is im portant to rem em ber that rates o f abuse
vary considerably according to how it has been defined (e.g. the age ranges
designated "child” or "adult"), and w hether non-contact cases are included (e.g. confrontations w ith an exposer, involvem ent in erotic talk or view ing
pornography. For exam ple, prevalence rates o f 54% were show n for any sexual
abuse and 38% for abuse involving contact (R ussell, 1984), and B adgley, A llard
& M cC orm ack (1984) reported 39% and 22% respectively (cited in B ifulco,
B row n & A dler, 1991). In A m erica it has been show n in retrospective studies
that adults have recalled sexual abuse as a child, revealing a prevalence from 6%
claim that one in four w om en are survivors o f sexual abuse, yet rarely is this
spontaneously revealed to doctors, although they are m ore likely than non-abused
patients to report m ultisystem ic m edical com plaints (Lechner, V ogel, G arcia-
Shelton, L eichter & Steibel, 1993). T his can lead to m isdiagnosis and m isuse o f
m edical services (op.cit).
A rnold, R ogers & Cook (1990) exam ined the case histories o f seven fem ale
patients betw een the age o f 22 to 39 years o f age. A ll these patients had
experienced child sexual abuse and w ere receiving psychiatric treatm ent, and had
a history o f m edical and surgical procedures. T hey had a m ean o f 18 contacts
with non-psychiatric consultant team s and a m ean o f eight operations o f w hich
66% to 70% revealed norm al findings (A rnold et al, 1990). Further, all the
patients experienced several som atic sym ptom s, w hich eventually led to
investigations and interventions in gynaecology (in 6 o f 7 patients), obstetrics,
gastroenterology, urology, rheum atology, orthopaedics, neurology, and
neuropsychiatry. The researchers reported that the ‘history o f sexual abuse w as
recognized only in the later stages o f m edical and surgical intervention. T he
possibility o f childhood sexual abuse should be considered earlier in such cases
to prevent further unnecessary intervention.’