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Sexual Assault and Hysterectomy in Female Veterans

Ryan GL, Summers KM, Mengeling M, Booth BM, Torner J, Sadler AG. Sexual Assault and Hysterectomy in Female Veterans. Paper presented at: AcademyHealth Annual Research Meeting; 2015 Jun 13; Minneapolis, MN.

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Objective: Female veterans are at increased risk of lifetime sexual assault. Previous studies have found links between sexual assault and gynecological symptoms, such as abnormal uterine bleeding and menstrual pain, which are associated with hysterectomy. In addition to plausibly increasing medical need for hysterectomy through association with damage to gynecological organs and pelvis, experienced victimization from sexual assault may influence women's decision-making process. Exposure to sexual assault could be expected to increase voluntary childlessness and avoidance of pelvic exams, potentially further increasing likelihood of hysterectomy. Our objectives were to assess rates of hysterectomy in pre-menopausal female veterans, compare these rates to general population rates, and examine associations between sexual assault, gynecologic symptoms and hysterectomy in the veteran population. Study Design: Bivariate relationships between hysterectomy, sexual assault, demographic and health characteristics were analyzed using chi-square, Wilcoxen-Mann-Whitney, and t-tests. Age adjusted odds ratios were calculated and logistic regression was used to examine the independent contribution of factors to hysterectomy. Population Studied: 989 female veterans 52 years of age and younger computer-assisted telephone interviews. In order to compare rates of hysterectomy within our sample with rates within the general population, we examined both the 2008 Behavioral Risk Factor Surveillance System (BRFSS) dataset and the 2008 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) dataset. Results: Rates of hysterectomy were significantly higher (16.8% vs 12.7%, p < .0001), and mean age at hysterectomy significantly lower (35 yo vs 43 yo, p < .0001), in this sample of female veterans compared to large general population datasets. Completed vaginal sexual assault (VSA) was a significant risk factor for hysterectomy (AOR 1.92), with those experiencing their first VSA in childhood or in military at particular risk. In multivariate analyses, history of gynecologic pain (OR 2.18, 1.37-3.47), history of gynecologic bleeding (OR 2.33, 1.53-3.55), pelvic inflammatory disease (OR 1.97, 1.14-3.55) were associated with hysterectomy. When these factors which were associated with VSA in this population were omitted from the model, VSA (OR 2.07, 1.44-2.97) and history of PTSD (OR 1.49, 1.02-2.18) were associated with hysterectomy. Conclusions: Premenopausal veterans may be at higher risk for hysterectomy and at younger ages than their civilian counterparts. Veterans who have experienced completed vaginal sexual assault in childhood or in military are at particularly high risk of hysterectomy, likely due to their higher risk of gynecologic symptoms and PTSD. These findings have important implications for women's healthcare providers and policy makers both within the VA and civilian healthcare systems.

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