The Experiences of Persistent Pain Among Women With a History of Intimate Partner Violence: A Systematic Review

Abstract

Women experience persistent pain at higher rates than men; however, women are less likely to be provided with adequate or appropriate care and more likely to have their pain experiences dismissed. The purpose of this review is to consider the complex interaction of the biopsychosocial factors in the experience of persistent pain in order to inform improved models of care. Given persistent pain is among the most frequently reported health consequences of intimate partner violence (IPV), this review focused on studies exploring the association between persistent pain and IPV. Three reviewers independently and systematically searched seven databases. Qualitative and quantitative studies describing the association between IPV and persistent pain published between January 2000 and June 2018 were included. Twelve studies met the inclusion criteria. The included studies demonstrated that a history of IPV places an additional burden on women who experience persistent pain that cannot be explained by an underlying psychological condition. Health care practitioners should be aware of this phenomena to ensure diagnosis, assessment, and treatment plans are targeted accordingly. Future policy directives and research should account for and seek to elucidate this additional burden.

Keywords

domestic violence perceptions of domestic violence mental health and violence PTSD

Persistent pain, defined as pain lasting longer than 3 months, has a significantly negative impact on quality of life and physical function (Andrews et al., 2018). It is a term used interchangeably with chronic pain. The estimated global prevalence of persistent pain is between 30% and 50% (Andrews et al., 2018; Elzahaf et al., 2012; Fayaz et al., 2016; Goldberg & McGee, 2011). The biopsychosocial model of pain asserts that the experience of persistent pain reflects a complex interplay between social, biological, and psychological factors. These factors interact to influence the experience of persistent pain and play a role in maintaining or worsening symptoms (Engel, 1977). This model is distinct from the biomedical understanding of persistent pain that argues there is a clear pathophysiology for pain symptoms. As some individuals with persistent pain do not have a clear pathological explanation for their pain and the pain experience is not standardized, the biopsychosocial model of persistent pain allows for a more nuanced and holistic approach to management of pain.

The role of gender and sex in persistent pain is well established, such that women disproportionately experience persistent pain when compared to men (Berkley, 1997; Blyth, n.d.; Breivik et al., 2006; Cimmino et al., 2011; Fillingim et al., 2009; Greenspan et al., 2007; Meana et al., 2004; Meisler, 1999; Rovner et al., 2017; Rustøen et al., 2004; Unruh, 1996). Also recognized is the pervasive gender bias in the treatment of persistent pain (Bernardes et al., 2008; Hoffmann & Tarzian, 2001; Racine et al., 2012). In health care settings, women are more likely than men to be undertreated, misdiagnosed, or prescribed inappropriate medication for their persistent pain symptoms (Hoffmann & Tarzian, 2001). A review of the literature found that women’s reports of pain experiences are often labeled by health care professionals as hysterical, fabricated, or nonexistent, resulting in women generally being diagnosed with psychological conditions when they present with persistent pain (Samulowitz et al., 2018). The same review found that women received more prescriptions to psychiatric medication than pain medication (Samulowitz et al., 2018). There is a demonstrated co-occurrence between psychiatric disorders and persistent pain (Defrin et al., 2015; Mostoufi et al., 2014; Velly & Mohit, 2018), which is commonly relied upon to explain women’s symptoms as psychosomatic.

These persisting gender biases in health care and their seeming acceptance (Fillingim et al., 2009; Greenspan et al., 2007; Hoffmann & Tarzian, 2001) are referred to as the “gender paradox of pain” (Hoffmann & Tarzian, 2001). The paradox is such that, despite women experiencing pain at higher rates than men, they are not provided with adequate or appropriate care when they seek help, such as a prescription to analgesics (Wesolowicz et al., 2018). In addition to this, the effect of analgesics has largely only been tested on male models (Beery & Zucker, 2011). Current literature suggests women with persistent pain do not feel believed or understood and have to work hard to be taken seriously (Jackson, 2019; Samulowitz et al., 2018; Werner et al., 2003). Additionally, women have reported that health care encounters left them doubting their pain or feeling they were to blame (Werner et al., 2003). Other barriers to health care disproportionately experienced by women include cost and lack of time (Salganicoff et al., 2014). It has been suggested this chasm exists because the pain is invisible and relies on self-reporting, often with no clear pathology (Samulowitz et al., 2018). In order to address the gender paradox, the complex interplay and interaction of the biopsychosocial factors contributing to the experiences of women with persistent pain must be better understood.

A commonly associated social factor in the persistent pain experience is a history of intimate partner violence (IPV), where IPV is defined as emotional, physical, or sexual harm experienced in a current or former intimate relationship. Various observational studies (Bonomi et al., 2009; Campbell, 2002; Coker et al., 2000; Jamieson & Steege, 1997; Kramer et al., 2004; Leserman et al., 1996; Rapkin et al., 1990; Reiter & Gambone, 1991; Walling et al., 1994) and reviews (Leserman & Drossman, 2007; Plichta, 2004) have established that persistent pain is among the most frequently reported health consequence of IPV. Additionally, women both disproportionately experience IPV and persistent pain (Breivik et al., 2006; Cimmino et al., 2011; Fillingim et al., 2009; Greenspan et al., 2007; Meana et al., 2004; Rovner et al., 2017; Rustøen et al., 2004). Thus, the intersection of persistent pain and IPV is largely experienced by women, as compared to men.

The association between IPV and persistent pain is not limited to physical violence. It includes IPV involving physical or sexual violence, stalking, and psychological aggression such as the use of coercive tactics by a current or former intimate partner (Breiding et al., 2015). That some forms of violence are not immediately apparent to practitioners reflects the frequently missed association between persistent pain and experiences of IPV, resulting in an absence of definitive diagnoses of persistent pain (As-Sanie et al., 2014) and a lack of effective management (Campbell, 2002; Coker et al., 2000; Leserman et al., 1996; Plichta, 2004). Help seeking can also be impacted by stigma associated with IPV (Overstreet & Quinn, 2013) and persistent pain (Balogun-Mwangi et al., 2016), resulting in women not disclosing for fear of being judged or not believed.

Given the complexities in the experience of IPV and its co-occurrence with persistent pain, applying the biopsychosocial model of persistent pain may help practitioners to identify IPV and appreciate the intersection with persistent pain. In order to do so, practitioners must better understand the signs, symptoms, and health conditions that are common in women who have experienced IPV (Campbell et al., 2002) and acknowledge the unique and multifaceted impact of persistent pain on the health and well-being of women who have experienced IPV (Tiwari et al., 2013), both of which must be considered in the context of the gender paradox in the treatment of persistent pain. To better understand the complex interaction of the biopsychosocial factors that contribute to the gender paradox of pain, we undertook a systematic review of the literature examining a history of IPV and persistent pain. The purpose of the review was to identify studies examining the experience of persistent pain among women who have experienced IPV. The review was structured around the following aims: to identify the characteristics of persistent pain among women who have experienced IPV and to describe the impact of persistent pain among women who have experienced IPV.

Method

We conducted a systematic review as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. See Figure 1 for a summary of the study selection process.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analysis diagram.

Search Strategy

The electronic databases searched were Scopus, MEDLINE, CINAHL, ProQuest, PsycINFO, CNKI, VIP, and Wanfang. The search terms included (wife OR wom? n OR female* OR spous* OR partner* OR “battered wi*” OR cisgender OR “same sex” OR lesbian* OR queer OR transg*) AND (“family violence” OR violence/or domestic violence/or intimate partner violence/or physical abuse/or rape/or IPV/OR “gender based violence” OR “partner abuse” or exp Spouse Abuse/OR “conjugal abuse” OR “sexual abuse” OR “sexual violence” OR (partner adj5 (abus* or violence or assault))) AND (pain* OR injury OR trauma* OR chronic pain/or persistent pain/or facial pain/or neck pain/or back pain/or pelvic pain/OR headache* OR migraine* OR “pain syndrome*).

The search was conducted independently by H.H., H.C., and J.S. during February–March 2018. H.H., H.C., and J.S. removed all duplicates and reviewed all publications by screening titles and abstracts. P.C. and N.W. independently reviewed the remaining publications by appraising the full text against the inclusion criteria. The differences were resolved by consensus.

Inclusion and Exclusion Criteria

The inclusion and exclusion criteria were devised by the research team to determine publications that considered the association between IPV and persistent pain when both are experienced by women. The literature identified through the search strategy (see Figure 1) was included or excluded according to the criteria in Table 1. The review focused on the experience of all women who are known to disproportionately experience IPV and persistent pain (Breivik et al., 2006; Cimmino et al., 2011; Fillingim et al., 2009; Greenspan et al., 2007; Meana et al., 2004; Rovner et al., 2017; Rustøen et al., 2004).

Table 1.

Inclusion and Exclusion Criteria.

	Inclusion Criteria	Exclusion Criteria
Topic	Analysis of the prevalence, correlation, causation, or association between IPV and chronic or persistent musculoskeletal pain (i.e. lasting longer than 6 weeks); or IPV as a cause, risk factor, or exposure of chronic or persistent musculoskeletal pain; or chronic or persistent musculoskeletal pain as an outcome of IPV. Observations include any one or a combination of the following elements: screening, identification, documentation, or referral for women who have experienced IPV and chronic or persistent musculoskeletal pain	Treatment or support responses to experiences of IPV and chronic or persistent musculoskeletal pain; studies with a primary focus on mortality or mental health–related morbidity; risk factors of IPV; knowledge, attitudes, and practices of health workers; observations of the correlation between child abuse and chronic or persistent musculoskeletal pain; perceptions of and attitudes toward IPV or chronic or persistent musculoskeletal pain; health care experiences of women who have experienced IPV; validation, reliability, acceptability, or feasibility test of an IPV screening tool
Participants	Women aged 16 years and older, including those identifying as women who have experienced chronic or persistent musculoskeletal pain and IPV	Girls under 16 years old, males, adult survivors of child abuse with no history of IPV
Setting	Any community or clinical setting	N/A
Study design	Primary peer reviewed qualitative or quantitative original observational studies	Intervention studies, non-peer reviewed, editorials, commentary, thesis or dissertation, single-case studies
Timeline	2000–2018	Before 2000
Language	English, Mandarin, or Cantonese	Languages other than English, Mandarin, and Cantonese

Note. IPV = intimate partner violence.

Data Extraction, Quality Appraisal, and Analysis

Each study was reviewed independently, and data were extracted using categories decided on by the principal researchers (N.W., K.B., and P.C.; see Table 2). N.W. and K.B. conducted the quality appraisal. The quality of cohort and case–control studies was assessed against the Newcastle-Ottawa Scale (NOS) and an adapted form of the NOS for cross-sectional studies (Herzog et al., 2013; see Table 3). The NOS tool has been designed to assess the quality of nonrandomized studies (Wells et al., 2019).

Table 2.

Overview of Included Studies.

Author (Year)	Time Period	Setting and Country	Study Design	Population (Inclusion and Exclusion Criteria)	Sample Size	Type of Violence (Physical, Sexual, Psychological)	Measurement of Persistent Pain	Type of Persistent Pain	Main Result	Further Comments on Quality
As-Sanie et al. (2014)	March 2006– September 2007	Michigan, United States. University hospital chronic pelvic pain (CPP) referral clinic	Cross-sectional	Heterogeneous group of women with CPP seen for evaluation and treatment at the clinic. Women had a combination of various pain disorders including but not limited to the pain disorders listed in the study	273 women with CPP (n = 81 history of adolescent or adult physical abuse, n = 89 history of adolescent or adult sexual abuse)	Physical abuse: life threatening physical attack with intent to kill or seriously harm or less severe physical assaults such as being beaten, kicked, bit, or other attacks outside of normal parenting or interpersonal engagement. Sexual abuse: the touching of private body parts by a perpetrator, making the subject similarly touch the perpetrator, or making the subject have vaginal or anal intercourse, with these actions occurring within a context of threat or harm	Brief Pain Inventory (BPI) short form (SF), which measures (1) subjective rating of pain intensity (BPI severity, range 0–10) and (2) pain interference (BPI Interference range 0–10), which is defined as the degree to which a subject reports functional and activity-related disability attributed to pain. Centre for Epidemiological Studies Depression (CES-D) Scale (range, 0–60). Examines self-reported mood and behavior during the previous week	Including but not limited to endometriosis, adenomyosis, pelvic adhesions, ovarian remnants, vulvodynia, interstitial cystitis, irritable bowel syndrome, abdominal and pelvic floor myofascial pain	Pain Severity: There was no difference in pain severity scores when comparing CPP patients with a history of abuse relative to those without a history of abuse. History of adolescent or adult sexual abuse was marginally associated with a higher likelihood of having severe pain (p = .082) although not statistically significant Pain-related disability: CPP patients with a history of physical abuse as an adolescent or adult reported significantly higher pain related disability (BPI interference) when compared to patients reporting no history of abuse in these categories, t(225) = 1.99, p < .05). Depressive symptoms: CPP patients with a history of child physical abuse, t(240) = 2.68, p < .01; child sexual abuse, t(234) = 3.52, p < .01, adolescent or adult physical abuse, t(243) = 4.25, p < .001; and adolescent or adult sexual abuse, t(236) = 3.86, p < .001 reported more depressive symptoms than patients reporting no history of abuse	No direction of causality among significant associations can be ascertained because of cross-sectional study design and correlational statistical analyses. The sample could be biased because patients presenting to a tertiary care referral setting typically will have more severe clinical morbidities. Patient’s self-reported data could be distorted. The abuse categories may be misleading as women experience multiple types of abuse over time, there were no categories where women experienced more than one type of abuse. Abuse was stratified into four groups, reducing the sample size
Bonomi et al. (2009)	Unknown	Washington state and Northern Idaho, United States. Group Health customers inpatient and outpatient records	Cross-sectional	Inclusion: English speaking. Age 18–64. Enrolled in Group Health for at least 3 years. Three most recent adult intimate (heterosexual or homosexual) partners. Exclusion: deceased, too ill, language barrier or hearing impairment, past but not recent (within past year) IPV, enrolled in the health place for less than 3 of the 4 calendar quarters before the study interview.	1,928 women (n = 242 reporting abuse within the past year, n = 1,686 never experienced IPV in their adult lifetime)	IPV. Measured using the Women’s Experience With Battering (WEB) Scale and five questions from the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System (BRFSS) survey on physical (one question), sexual (two questions) and psychological (verbal threats and chronic controlling behavior; two questions)	International Disease Classification, 9th Revision (ICD-9) codes and the Expanded Diagnosis Cluster methods to capture primary and secondary diagnoses documented in inpatient and outpatient records.	Chest pain, abdominal pain, cervical pain syndrome, low back pain	Exposure to IPV within the past year increases a risk of pain related diagnosis. The age adjusted relative risk of a diagnosis associated with IPV exposure includes chest pain (RR = 1.53), abdominal pain (RR = 1.48), cervical pain syndrome (RR = 1.54), low back pain (RR = 1.61)	The results may be biased because women who are insured generally suffer lower rates of IPVA and better health. Additionally, the women in the sample were older, had higher income levels, and were more highly educated compared with all women in the United States. The sample size was too small to adjust for participant characteristics
Campbell et al. (2002)	January 1, 1989, to December 31, 1997	Metropolitan Washington, DC, United States. Health maintenance organization	Case–control	Age 21–55. Continuously enrolled in the health maintenance organization from January 1 1995 to December 31 1997. Health problems that occurred in the 12 months preceding the interview. Abuse occurred anytime from 1989-1997.	441 women (n = 201 physically and/or sexually abused, n = 240 never abused)	Physically and/or sexually abused. Measured by a modified version of the Abuse Assessment Screen that defined IPV as physical and/or sexual assault by a husband, partner, ex-husband, or ex-partner (male or female partner).	General health was measured by the Medical Outcomes Study 36-Item Short-Form Health Survey. Abuse-specific health problems measured by the Miller Abuse Physical Symptom and Injury Scale	Headaches, pelvic pain, abdominal pain, back pain	Women who experienced abuse significantly (p < .05) more frequently reported headaches, pelvic pain and abdominal pain, and significantly (p < .01) more frequently reported back pain compared to women who had never experienced abuse. A significantly higher total number of health problems were reported by abused women (p < .05). comparison of total health problems overall and within health problem clusters indicate that abused women had roughly 60% higher rate of all problems relative to never abused women (incidence rate ratio, 1.58; 95% confidence interval: [1.34, 1.86]; p < .001). A difference in health problems reported was observed between women who experienced sexual abuse (with or without physical abuse) and physical abuse (with no sexual abuse)	No information was gathered on whether the women experienced childhood sexual or physical abuse, this may bias the finding as there is demonstrated to be a relationship between childhood abuse and poor health in adulthood. Additionally, data on trauma over an adult life course were not collected when, like IPV, trauma would affect a woman’s health
Coker et al. (2000)	February 1997–January 1999	South Carolina, United States. University of South Carolina associated family practice clinics	Cross sectional	Women who sought medical care at the clinics. Aged 18–65 years old. Insured either by Medicaid or a managed care provider. An intimate relationship with a man of at least 3 months	1,152 Women (n = 620 ever experienced IPV, n = 532 never experienced IPV, n = 464 experienced physical IPV, n = 156 experienced psychological IPV but not physical)	Psychological (psychological battering or emotional abuse with no sexual or physical violence), sexual and physical IPV. Psychological IPV included psychological battering, characterized by women’s continuous feelings of susceptibility to danger, loss of power and control, and entrapment	Modified the National Health Interview Study (US Public Health Service 1994) to assess prevalence of a range of health outcomes, the age at first occurrence and whether the women currently experienced symptoms	Chronic neck or back pain, arthritis, migraines, and other frequent headaches, chronic pelvic pain	Women who ever experienced IPV (n = 620) had a higher rate of being diagnosed with chronic neck or back pain, arthritis, migraines, other frequent headaches and chronic pelvic pain than women who never experienced IPV (n = 532). Ever experiencing psychological IPV (n = 156) was associated with an increase in risk of developing chronic neck or back pain (RR = 1.91), arthritis (RR = 1.67), migraines (RR=1.54) or other frequent headaches (RR = 1.41) and chronic pelvic pain (RR = 1.62). Ever experiencing physical IPV (n = 464) was associated with an increase in risk of developing chronic neck or back pain (RR = 1.49), arthritis (RR = 1.54), migraines (RR = 1.40) or other frequent headaches (RR = 1.16) and chronic pelvic pain (RR = 1.51). Is consistent with the following trends: repeated physical assaults and resulting injuries result in chronic pain, long-term sexual violence and associated trauma can increase risk of chronic pelvic pain	Cross-sectional study design. Diagnoses were not confirmed with existing medical records therefore may be misclassified. The data may be biased because women who experience IPV may be more likely to access health care services and thus be diagnosed. Health interviews were not conducted for all women screened for IPV and those who could not be recontacted were likely to be in a current violence relationship, therefore, the prevalence of current IPV most likely higher than reported
Humphreys et al. (2011)	n.d.	California, San Francisco, United States. Community sample	Cross-sectional	Women, at least 18 years old, English speaking, with a history of experiencing IPV as an adult but no longer in an abusive relationship (for one year or more)	84 Women	IPV, measured on the Severity of Violence Against Women Scale (SVAWS) and the revised Conflict Tactics Scale (CTS2)	Brief Pain Inventory (BPI)	Pain that lasted 3 months or more	77% of women reported persistent pain. 25% of those women reported mild pain, while the remaining 75% reported moderate to severe pain. Length of time in abusive relationship was linked with experiencing moderate to severe pain	Potential selection bias. Cross-sectional study design limits the exploration of causal mechanisms between IPV and chronic pain. No comparison group. Confounding factors were not measured.
Kendall-Tackett et al. (2003)	n.d.	Northern New England, United States. Adult primary care practice	Case–control	Adult primary care patients from a small community in Northern New England	110 Women (n = 57 abused; n = 27 experienced physical or sexual abuse as children, n = 20 experienced domestic abuse as adults, n = 10 experienced child and domestic abuse; n = 53 non-abused controls)	Child or domestic abuse	Six self-reported pain symptoms combined into a measure of self-reported pain. Responses categories were yes/no	Abdominal pain, pain or stiffness in joints or muscles, pain during urination, arthritis, back pain, or severe headaches	There was no significant difference between the case and control groups when comparing individual symptoms; however, there was a significant difference when the symptoms were combined. Women who experienced child or domestic abuse experienced significantly more pain symptoms than women who did not (p = .017). However, there was no significant difference between women who experienced abuse as a child and adult or only as a child	Abuse may be under reported as it asked patients to identify as victims of domestic abuse rather than whether they had be hit by a spouse or partner. The questionnaire also asked no information about the abuse. The study comments on correlation and treatment options where there is little to no evidence. Small and narrow sample size
Loxton et al. (2017)	16 years	Australia. Data collected from the Australian Longitudinal Study on Women’s Health	Longitudinal cohort	Participants from the Australian Longitudinal Study on Women’s Health (ALSWH). Three birth cohorts; 1973–1978, 1946–1951, 1921–1926. Women who returned all six surveys and had a baseline measure for IPV	16,761 Women (n = 4,820 women born 1973–1978, n = 8,373 women born 1946–1951, n = 3,568 women born 1921–1926)	IPV	Physical and mental pain were measured using the Medical Outcome Study Short Form (SF-36), which measures physical functioning, social functioning, general health, bodily pain, vitality, role physical, role emotional, and mental health	Bodily pain	In all health domains measured by the SF-36, women who experienced IPV in all cohorts recorded significantly poorer health than women who never experienced IPV over the 16-year period	Results are descriptive and measures have not been adjusted for confounding factors. The measure of IPV was conservative and did not take into account different types of abuse, abusive acts, identity of the perpetrator
McCall-Hosenfeld et al. (2014)	February 2005–August 2006	Boston, United States. Urban safety-net hospital.	Cross-sectional	English-speaking patients, 18–60 years old, presenting to primary care clinics with chronic pain	597 (247 men, 350 women)	IPV	Graded Chronic Pain Scale	All types of pain were included	Women reported significantly more severe somatic symptoms than men. Depression was found to be a mediator in the experience of interpersonal trauma (including IPV) and somatic pain severity for women, whereas post-traumatic stress disorder (PTSD) and substance abuse were not. Additionally, there was a direct pathway between interpersonal trauma (including IPV) and somatic symptom severity	Cross-sectional study design limits causality conclusions. Limited sample may not be generalizable
Symes et al. (2013)	7-year study	Texas, United States. District Attorney’s office and shelters	Cross-sectional	English- and Spanish-speaking abused women seeking safe shelter or justice services, specifically a protection order, for the first time, who had at least one child between 18 months and 15 years who lived with the mother at least 50% of the time	300 Women	IPV (physical, sexual and threats) measured by the Severity of Violence Against Women Scale and Danger Assessment Scale	BPI	No type of chronic pain was excluded	Sexual and physical abuse were not significantly associated with the level of pain interference. Higher threats of physical violence were associated with mild to moderate and severe pain interference. All abuse experiences were significantly associated with pain severity. Increased level of pain interference was associated with increased PTSD symptoms, BSI Global scores, BSI-Somatisation, BSI-Anxiety and BSI-Depression. PTSD and depression are significantly associated with pain severity	Sampling from shelters for abused women and the county DA’s office may exclude women who seek shelter at a homeless shelter and women who engage a private lawyer. Self-reporting data may be biased by recall bias
Tiwari et al. (2013)	September 2009–July 2010	Hong Kong. Domestic violence shelters and one community center.	Cross-sectional	Chinese women, aged 18 or older, who were able to understand Cantonese or Putonghua and screened positive for physical, psychological, or sexual abuse by a current or former intimate partner	308 Women	Emotional, physical or sexual abuse by a current or former intimate partner	Pain symptoms for more than 3 months. Chronic pain severity was measured using the Chronic Pain Grade Questionnaire (CPG)	No type of chronic pain was excluded	Psychological abuse severity had a stronger link with chronic pain than sexual coercion and physical assault severity. The effect of psychological abuse severity on chronic pain was mediated by PTSD symptom severity. IPV related injury severity did not have a significant effect on chronic pain severity. Sexual abuse severity had a direct significant effect on chronic pain severity	Cross-sectional study design limits the evaluation of causal relationships between the study variables. The sample population is narrow. Self-report measures could be influenced by bias or limited recall
Vives-Cases et al. (2011)	2006	Spain. Face to face interviews in the home	Cross-sectional	Female, 16 years and older, interviewed in the 2006 Spanish National Health Survey. Women who experienced violence during the previous 12 months by a male intimate partner (i.e., IPV) or a male who was not their intimate partner (i.e. violence against women [VAW]). Nonbattered women: Women who declared not being involved in any kind of violence perpetrated by a male or female	13,094 Women (n = 128 experienced IPV; n = 75 experienced violence perpetrated by other known men, n = 73 by other unknown men, n = 3 by both.)	IPV: any kind of violence perpetrated by a male intimate partner. Other VAW: any kind of violence perpetrated by a male who is not a male intimate partner. Reports of female aggressors were excluded	Physical health indicators were included where they had been diagnosed by a doctor	Chronic back pain, chronic neck pain, and chronic headache	Both IPV and other VAW increased the likelihood of worse chronic neck pain (OR = 2.01 and 1.56), chronic back pain (OR = 2.34 and 2.66) and chronic headaches (OR = 1.49 and 1.59). Similarly, IPV and other VAW increased the probability of poor self-perceived health status (OR = 6.79 and 1.97) and worse mental health. The magnitude of associations were greater for IPV and poor self-perceived health status and psychological distress	IPV may be under reported because asked women one question: if they perceived they were battered. Face-to-face interviews often obtain lower prevalence of IPV than questionnaires. Information bias could have affected the prevalence of VAW. The type of violence experienced (physical, sexual, or emotional) was not reported.
Wuest et al. (2008)	June 2004–January 2006	Ontario, New Brunswick and British Columbia, Canada. Structured interviews by a registered nurse	Longitudinal cross-sectional	Community sample. Separated from an abusive partner for at least 3 months but no more than 3 years before recruitment, and screened positive on the Abuse Assessment Screen	292 Women	IPV: a pattern of physical (assaults or threats of assault using hands, feet, objects or weapons), sexual (any form of nonconsensual or forced sexual activity or touching) and/or emotional violence by an intimate partner in the context of coercive control	Von Korff 7-item Chronic Pain Grade (CPG) Scale (chronic pain severity was measured as a function of pain intensity and pain-related disability)	Back pain, headache, vaginal/pelvic pain, general aches and pains, swollen and painful joints	Pain severity: N = 103 (35.3%) of women experienced high disability, moderately or severely limiting pain on the CPG (III or IV), compared to n = 16 (5.5%) who were pain free. On average women reported pain in three different sites. More than half of the women experienced problematic back pain (n = 187), headaches (n = 185) or general aches and pains (n = 148) in the past month. Less than 20% (n = 51) reported pelvic/vaginal pain. The highest mean degree of interference was for swollen/painful joints (43.2%), then aches and pains, pelvic/vaginal pain and back pain. Abuse History: Women with high disability CPGs reported more severe spousal abuse. Medication use: The average number of prescription medications being taken increased with each pain grade	Recall bias because of retrospective measurement of some variables (e.g., chronic pain). Recall bias was minimized by short periods of time for self-report measures (past month or past week). Cross-sectional design so no causal association can be made

Note. DA's = District Attorney's; DA’s = District Attorney’s

Table 3.

Results of the Quality Appraisal of Included Studies.

Author (Year)	Study Design	Selection (Maximum*****)				Comparability (Maximum**)	Exposure (Maximum***)
Author (Year)	Study Design	Case Definition Adequate?	Representativeness of the Cases	Selection of Controls	Definition of Controls	Based on Design and Analysis	Ascertainment of Exposure	Same Method of Ascertainment for Cases and Controls		Nonresponse Rate
^{Campbell et al. (2002)}	Case–control	*	*	*	*	*	*	*		*
Kendall-Tackett et al. (2003)	Case–control			*	*	*		*
Author (Year)	Study Design	Selection (Maximum****)				Comparability (Maximum**)	Outcome (Maximum***)
Author (Year)	Study Design	Representativeness of Exposed Cohort	Selection of Nonexposed Cohort	Ascertainment of Exposure	Demonstration That Outcome of Interest not Present at Start	Based on Design or Analysis	Assessment of Outcome	Follow-Up Long Enough?		Adequate Follow-Up?
Loxton et al. (2017)	Cohort	*	*	*	*	**	*	*
Author (Year)	Study Design	Selection (Maximum*****)				Comparability (Maximum **)	Outcome (Maximum***)
Author (Year)	Study Design	Representativeness of the Sample	Sample Size	Nonrespondents	Ascertainment of Exposure	Based on Design and Analysis	Assessment of Outcome		Statistical Test
As-Sanie et al. (2014)	Cross-sectional	*	*		**	**	*		*
Bonomi et al. (2009)	Cross-sectional	*	*	*	**	**	*		*
Coker et al. (2000)	Cross-sectional	*	*	*	**	**	*		*
Humphrey et al. (2011)	Cross-sectional	*			**		*		*
McCall-Honsenfeld et al. (2014)	Cross-sectional				**	**	**		*
Symes et al. (2013)	Cross-sectional				**	**	*		*
Tiwari et al. (2013)	Cross-sectional	*	*		**	**	*		*
Vives-Cases et al. (2011)	Cross-sectional	*		*	**	**	*		*
Wuest et al. (2008)	Cross-sectional	*			**	**	*		*

Source: Herzog et al. (2013) and Wells et al. (2019).

Given the broad range of studies included, a narrative synthesis approach was used for analyzng results (Popay et al., 2006). The narrative synthesis process involves iteratively developing a preliminary synthesis of the findings of included studies, exploring relationships in the data and assessing the robustness of the synthesis (Popay et al., 2006). The interpretation of the results was informed by the biopsychosocial model of persistent pain to better understand the individual and contextual influences on persistent pain as it intersects with IPV among women.

Results

Of the studies identified, 12 were included in the final review (see Figure 1). The majority of studies (n = 10) were conducted in English-speaking countries including the United States, Australia, and Canada (As-Sanie et al., 2014; Bonomi et al., 2009; Campbell et al., 2002; Coker et al., 2000; Humphreys et al., 2011; Kendall-Tackett et al., 2003; Loxton et al., 2017; McCall-Hosenfeld et al., 2014; Symes et al., 2013; Wuest et al., 2008). All included studies used quantitative methods. Pain was largely measured using established measurement tools including the Brief Pain Inventory (BPI) short form (SF; As-Sanie et al., 2014; Humphreys et al., 2011; Symes et al., 2013), the Medical Outcomes Study 36-item Short-Form Health Survey (Campbell et al., 2002; Loxton et al., 2017), and the Von Korff 7-item Chronic Pain Grade (CPG) Scale (McCall-Hosenfeld et al., 2014; Tiwari et al., 2013; Wuest et al., 2008). The remaining studies used self-reported pain symptoms (Coker et al., 2000; Kendall-Tackett et al., 2003) and clinical records (Bonomi et al., 2009; Vives-Cases et al., 2011). Detailed characteristics for each study are shown in Table 2.

Methodological Quality Appraisal

Most studies were of moderate to high quality on the NOS Scale (Table 3; Wells et al., 2019). Largely, the studies did not control for the biases present in observational studies such as selection bias and nonparticipation bias or potential confounders such as a history of child abuse. Four of the 11 studies recruited a community sample (Humphreys et al., 2011; Loxton et al., 2017; Vives-Cases et al., 2011; Wuest et al., 2008). The remaining seven studies used clinical samples or a previous diagnosis by a doctor (As-Sanie et al., 2014; Bonomi et al., 2009; Campbell et al., 2002; Coker et al., 2000; Kendall-Tackett et al., 2003; McCall-Hosenfeld et al., 2014; Symes et al., 2013). Conclusions on causality could not be made as all study designs were observational. Additionally, five of the studies did not have a comparison group of women with no history of IPV (Humphreys et al., 2011; Loxton et al., 2017; Symes et al., 2013; Tiwari et al., 2013; Wuest et al., 2008). The majority of the tools used to measure persistent pain relied on self-reported data. All studies except for one (Kendall-Tackett et al., 2003) used a validated measurement tool to measure persistent pain. Only four studies (Bonomi et al., 2009; Campbell et al., 2002; Humphreys et al., 2011; Symes et al., 2013) used a validated IPV measurement tool, and all studies relied on self-reported data. Of the eight cross-sectional studies, only three accounted for nonresponders (Bonomi et al., 2009; Coker et al., 2000; Vives-Cases et al., 2011). Further comments on quality in specific studies are included in Table 2 and critical findings are reported in Table 4.

Table 4.

Critical Findings.

Co-occurring mental health issues were found in both groups, women with a history of IPV and women with no history of IPV.

Higher pain severity, pain-related disability and self-reported health problems were associated with a history of IPV. This suggests a history of IPV places an additional burden on women who experience persistent pain.

Characteristics of Persistent Pain

Type of persistent pain associated with IPV

The studies found associations between IPV and a range of different persistent pain conditions including chest pain (Bonomi et al., 2009), abdominal pain (Bonomi et al., 2009; Campbell et al., 2002), cervical/pelvic pain (Bonomi et al., 2009; Campbell et al., 2002; Coker et al., 2000; Wuest et al., 2008), back pain (Bonomi et al., 2009; Campbell et al., 2002; Coker et al., 2000; Vives-Cases et al., 2011; Wuest et al., 2008), neck pain (Coker et al., 2000; Vives-Cases et al., 2011), arthritis (Coker et al., 2000), and problematic pain or stiffness in joints or muscles (Wuest et al., 2008). All forms of IPV were found to be associated with increased reporting of back pain (Wuest et al., 2008) and frequent headaches/migraines (Campbell et al., 2002; Coker et al., 2000; Vives-Cases et al., 2011; Wuest et al., 2008). Kendall-Tackett et al. (2003) found that women with a history of abuse, including child abuse, reported more persistent pain symptoms than women with no history of abuse. The timing of the abuse, IPV or child abuse, was not found to be associated with increasing persistent pain symptoms.

Severity of pain associated with IPV

An association was found between IPV and pain severity (As-Sanie et al., 2014; Humphreys et al., 2011; McCall-Hosenfeld et al., 2014; Symes et al., 2013; Tiwari et al., 2013; Vives-Cases et al., 2011). Symes et al. (2013) reported that all abuse experiences were significantly associated with higher pain severity, and Humphreys et al. (2011) found that among the women who reported persistent pain, 75% reported moderate to severe pain, compared to 25% who reported mild pain. Additionally, Humphreys et al. (2011) found that increasing length of time in an abusive relationship was positively associated with experiencing moderate to severe pain. Conversely, Tiwari et al. (2013) found that only sexual abuse severity was associated with increased pain severity and that other forms of IPV did not have a significant effect on increasing persistent pain severity.

Impact of Persistent Pain

Pain-related disability associated with IPV

Pain-related disability was only reported on in two studies (As-Sanie et al., 2014; Wuest et al., 2008). Wuest et al. (2008) found an association between high pain–related disability and more severe spousal abuse compared to women who reported low pain–related disability. As-Sanie et al. (2014) similarly reported an association between a history of physical abuse as an adolescent or adult and significantly higher pain–related disability but did not distinguish the impact of child abuse and IPV.

Affective impact of pain associated with IPV

Women with a history of IPV were found to experience worse affective impacts of mental health conditions including post-traumatic stress disorder (PTSD), anxiety and depression, and more severe persistent pain (As-Sanie et al., 2014; Symes et al., 2013; Tiwari et al., 2013; Wuest et al., 2008). As-Sanie et al. (2014) found that adult sexual abuse experienced by women with chronic pelvic pain was associated with more severe depressive symptoms. The authors also noted the importance of understanding the complexities of the relationship between persistent pain and depression and as it impacts pain treatment outcomes, suggesting that depression plays a mediating role in the relationship between a history of IPV and persistent pain. McCall-Hosenfeld et al. (2014) similarly found that depression was a mediating factor in persistent pain severity whereas PTSD was not, and Wuest et al. (2008) found that depressive symptoms co-occur with high disability pain and a history of IPV. In contrast Tiwari et al. (2013) found the co-occurrence of IPV and severity of persistent pain was not mediated by depressive symptom severity but rather PTSD symptom severity. However, the authors noted the positive correlation between worsening depressive symptoms and worsening PTSD symptoms, suggesting an indirect relationship between worsening depressive symptoms and more severe persistent pain.

Discussion

This review elucidated the association between IPV and persistent pain in terms of the characteristics of persistent pain and the factors that impact on the experience of persistent pain symptoms. These findings support literature that has established an association between persistent pain and IPV (Bonomi et al., 2009; Campbell, 2002; Coker et al., 2000; Jamieson & Steege, 1997; Kramer et al., 2004; Leserman et al., 1996; Leserman & Drossman, 2007; Plichta, 2004; Rapkin et al., 1990; Reiter & Gambone, 1991; Walling et al., 1994). In studies with a comparison group of women with no history of IPV, it was demonstrated that persistent pain among women who have experienced IPV is characterized by higher pain severity, higher pain–related disability, and a worsening affective impact of mental health conditions. Taken together, this demonstrates that a history of IPV is associated with a more negative experience of persistent pain and one that is distinguished from the experience of women who have never experienced IPV.

The type of persistent pain associated with a history of IPV varied among the studies, suggesting there is no clear persistent pain etiology associated with IPV. However, the association between persistent abdominal pain and pelvic pain and a history of IPV reflects literature that found a substantial proportion of women who present with abdominal or pelvic pain have a history of sexual abuse (Beck et al., 2009; Cichowski et al., 2013; Mark et al., 2008; Panisch & Tam, 2019; Poleshuck et al., 2005). While a strong association was found between a history of IPV and headaches/migraines or back pain, this could reflect the higher prevalence of back pain and migraines more generally, which are among the leading causes of years lost due to disability (Vos et al., 2017). Determining whether there is a clear persistent pain etiology associated with IPV relies on women disclosing IPV and practitioners adequately identifying this co-occurrence in patients.

Given the gender paradox in the treatment and management of persistent pain, it is likely that women who experience both IPV and persistent pain are not being adequately identified and responded to in clinical settings. To address this, there must be an improved understanding of the patient help seeking and practitioner barriers to effectively managing persistent pain in women with a history of IPV. For example, an established barrier to help seeking is fear of not being heard or believed by practitioners. Women who do not feel heard or believed are more likely to distrust and not depend on practitioners for management of their persistent pain, resulting in fewer diagnoses or regular presentations to clinical settings (Balogun-Mwangi et al., 2016). This fear can be explained by the demonstrated gender bias in the treatment of persistent pain that results in women not being given a diagnosis or appropriate analgesics (Ahlsen et al., 2014).

An additional barrier to help seeking is IPV stigma. Where women experience acute injury as a result of IPV, the fear of IPV stigma may prevent women seeking early intervention for their pain (Overstreet & Quinn, 2013). Delayed treatment, or lack of treatment, is a factor commonly associated with higher persistent pain severity (van Hecke et al., 2013), which could explain the higher pain severity among women who had a history of IPV in studies in our review (As-Sanie et al., 2014; Humphreys et al., 2011; McCall-Hosenfeld et al., 2014; Symes et al., 2013; Tiwari et al., 2013; Vives-Cases et al., 2011). These barriers reinforce the important role practitioners play in ensuring clinical environments are nonjudgmental and do not perpetuate gender biases or stigma around IPV and persistent pain.

Our review supports previous research that establishes the important role of psychological factors, which must be considered by practitioners in the treatment of women with persistent pain and a history of IPV. A systematic review demonstrated an association between a history of IPV and mental health conditions including PTSD, anxiety, and depression, and poorer health outcomes including persistent pain (Dillon et al., 2013). While no causal relationship has been established, there is an association between persistent pain severity and experiencing or worsening mental health conditions (Mostoufi et al., 2014; Velly & Mohit, 2018). It is critical that women’s pain is not dismissed as psychosomatic and instead that psychosocial factors such as experiences of trauma and abuse are considered holistically by practitioners in determining effective management approaches. Further, by understanding the gender paradox of persistent pain, practitioners can be mindful of gender biases when treating women who present with persistent pain and co-occurring mental health conditions.

From a biopsychosocial perspective, higher pain severity may be considered as part of a response to trauma, and there may be co-occurrence with PTSD (Wuest et al., 2010). PTSD is prevalent among women with a history of IPV and has been shown to mediate the relationship between IPV and the development of physical health symptoms including persistent pain (Golding, 1999). Consistent with this, one study in our review found that the type of IPV may be an important factor in this relationship between PTSD and persistent pain (As-Sanie et al., 2014). These findings may be explained by specific psychological factors outlined by Sharp and Harvey (2001) that are thought to maintain and reinforce the relationship between PTSD and persistent pain. These factors include attentional biases toward perceived threats and/or painful stimuli, anxiety sensitivity, persistent reminders of the trauma, avoidant coping styles, depression and an accompanied reduction in physical activity, increased perception of pain, and overwhelmed cognitive resources (Sharp & Harvey, 2001). Additionally, it has been suggested that the attentional bias toward threats and anxiety sensitivity associated with PTSD makes individuals hyper-responsive to pain (Defrin et al., 2015). This literature draws from the biopsychosocial model of persistent pain and asserts that psychological factors, such as those that accompany PTSD, have a modifying effect on persistent pain symptoms, often leading to more severe pain or pain-related disability.

As indicated by the biopsychosocial model, these factors cannot be viewed in isolation and practitioners must appreciate that persistent pain, a history of IPV, and PTSD interact with and influence each other. However, much of the research that investigates mechanisms underlying the co-occurrence of psychosocial factors relevant to PTSD and persistent pain has been done with all male samples or male veterans experiencing combat trauma (Mostoufi et al., 2014). There is a need for gender-sensitive research that focuses on better understanding the relationship between women’s experiences of persistent pain and trauma related to IPV and that specifically considers how this intersects with the gender paradox in the treatment of persistent pain.

Much of our lack of insight into persistent pain among women who have experienced IPV relates to limitations in study design. The literature is largely based on cross-sectional studies, creating difficulty in drawing conclusions on causality between experiences of IPV and persistent pain (As-Sanie et al., 2014). The studies generally refer to women who have experienced abuse, which was inclusive of child abuse, adolescent abuse, and IPV. Not controlling for child abuse potentially introduces bias as it is associated with poorer health outcomes in adulthood (Richmond et al., 2009; Scott-Storey, 2011). However, as child abuse is often associated with IPV in adult life, it is difficult to control for this confounding factor (Rind et al., 1998). The studies also largely relied on a clinical sample or a previous diagnosis by a doctor, thereby excluding women without a definitive diagnosis of persistent pain. As indicated by the gender paradox in the treatment and diagnosis of persistent pain, this is potentially a large cohort of women. Additionally, using clinical samples could introduce bias as patients presenting to clinical settings, in particular tertiary settings, are more likely to have severe symptoms. Community samples and self-reported symptoms should be used to address these limitations and would also result in a more diverse sample of women who may be experiencing additional barriers to health care based on intersecting factors including race, ethnicity, class, and sexuality. As we recognize it is challenging to address these limitations, we suggest a study design that allows for investigation of the biopsychosocial factors that contribute to the lived experience of persistent pain.

Considered together, the included studies do not provide a homogenous report of the experiences of persistent pain among women with a history of IPV; however, they demonstrate that the experience is distinct from women who do not have a history of IPV. These findings argue strongly for the need to better understand the biopsychosocial factors contributing to experiences of persistent pain, in particular the impact of historical and ongoing trauma associated with IPV. Better understanding this complexity could provide greater insight to practitioners in the management of persistent pain for women who have experienced IPV and contribute to addressing the gender paradox in the treatment of persistent pain.

Strengths and Limitations

The review is characterized by the following strengths. Undertaking the analysis through the biopsychosocial lens ensures the application of the findings is not limited by the biomedical understanding of pain. While we have not sought to use the biopsychosocial model to map potential mediators in the relationship between IPV and persistent pain, interpreting the results through this lens contributes to our understanding of co-occurring experiences of persistent pain and IPV. This association, however, is still being understood and represents a complex interplay of factors that may not have been identified yet. For example, the studies we identified as part of this review provided little insight into women’s social identities and experiences. As such, future research in this area would benefit from gaining a deeper and more diverse perspective on women’s lived experience. The biopsychosocial model could be used to explore the association between IPV, pain, and mental health among women with a diversity of experience and social identities. Publication bias was reduced by searching multiple databases in English, Cantonese and Mandarin languages. Bias in study selection was reduced by authors independently screening studies for inclusion and exclusion. Data extraction (N.W., P.C., K.B.) and quality assessment (N.W. and K.B.) were also undertaken independently by authors, thereby reducing bias in the synthesis of evidence and quality appraisal. Any studies written before 2000 and those in a language other than English, Cantonese or Mandarin were excluded; therefore, it is possible that studies have been excluded that may depict the diverse experiences of women. The reliability and validity of the quality appraisal tool, NOS, has been questioned (Hartling et al., 2013; Lo et al., 2014; Margulis et al., 2014; Stang, 2010); however, it was recommended by Cochrane as an effective quality assessment (Rivas et al., 2015). The review is additionally limited as it excluded intervention studies, excluding an analysis of the health care experience of women with persistent pain who have experienced IPV compared to women who have not experienced IPV.

Implications of the Review for Practice, Policy, and Research

Practice

Health care professionals must consider the implications of the association between IPV and persistent pain for screening, diagnosis, and management. This involves being aware of their co-occurrence and how it influences the experience of persistent pain. Health care professionals should use a biopsychosocial approach to pain management, ensuring they treat patients’ pain as a holistic and multifaceted condition. Furthermore, other professionals including social workers, case workers, home visitors, and child advocates must also consider the association between persistent pain and IPV and how this may manifest for their clients. It is imperative that all professionals dealing with women who experience IPV and persistent pain confront gender biases and stigma around both IPV and persistent pain in order to combat the gender paradox in the treatment and management of persistent pain. Professionals must also consider the diverse intersecting experiences and biases of women who experience co-occurring IPV and persistent pain, insofar that every woman may have a unique experience.

Policy

Currently, a majority of pain research is conducted using male samples and generalized to apply to women patients (Jackson, 2019; Mostoufi et al., 2014). As has been demonstrated through the example of IPV, women have a distinct and unique experience of persistent pain. Additionally, the gender paradox in the treatment of persistent pain suggests that women’s needs are not being met by clinicians or that current evidence based practice guidelines are not appropriate for women experiencing persistent pain. As such, policy directives must be inclusive of diverse experiences and include a sex and gender analysis to ensure the clinical and nonclinical differences between the sexes and genders can be accounted for in the screening, treatment, and management of persistent pain. Additionally, language used in policy in reference to IPV and persistent pain must consider the role of deficit discourse (Fogarty et al., 2018) in contributing to reductionist and essentialist solutions to complex issues.

Research

Future research in this area would benefit from gaining a deeper and more diverse perspective on women’s lived experience. For example, exploring the association of IPV and pain and mediators of mental health from diverse perspectives. Engaging diverse communities of women will provide a greater understanding of the varied biopsychosocial factors that influence the co-occurring experience of persistent pain and IPV. A framework such as PROGRESS-Plus could be used to guide the research to ensure that it is conducted through an equity lens (O’Neill et al., 2014). PROGRESS-Plus identifies the factors that contribute to health inequity and encourages researchers to consider their intersection. Additionally, given the stigma and biases associated with persistent pain and IPV, samples should be recruited from the community where possible. It is well established that clinical samples do not necessarily reflect a generalizable experience of persistent pain and IPV as women may not present if they fear they will not be heard or believed (Balogun-Mwangi et al., 2016). Community samples would likely also ensure the experiences of women from diverse communities and cultural backgrounds are included (Tiwari et al., 2013). Studies must also control for confounding factors, in particular child abuse, and should report on both negative and positive aspects of women’s experience to ensure the literature does not promote a deficit discourse.

Conclusion

The review demonstrates the experience of persistent pain and IPV is still largely misunderstood. While it has emerged that an experience of IPV creates an extra burden on women who are experiencing persistent pain, the underlying mechanisms and contributing factors are not clear. Future studies need to be adequately designed to account for the biases in the literature to date and to investigate gaps in current knowledge. Given the gendered prevalence of both IPV and persistent pain, and the gender paradox in the treatment of persistent pain, understanding the co-occurrence of persistent pain and IPV has the potential to illuminate misunderstood complexities in the management of persistent pain. Unless women’s experiences of co-occurring IPV and persistent pain are adequately understood and responded to, the gender paradox will persist, and women will continue to bear a disproportionate burden of persistent pain.

Implications of Review for Practice, Policy, and Research

Health care professionals should be aware of the intersection between IPV and persistent pain, as well as the gender biases in the management and treatment of persistent pain.

Policy makers should be aware of the language used in policy addressing IPV or persistent pain so as not to promote a deficit discourse and thereby encourage reductionist or essentialist strategies. Additionally, policy directives should include a sex and gender approach to address the gender paradox of persistent pain.

A history of IPV creates an additional burden for women who experience persistent pain, but it is not well understood how and why this burden manifests. The focus of future research should consider this question as well as including the perspective of women from diverse communities and cultural backgrounds.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Author, Patricia Cullen received funding from NHMRC Early Career Fellowship (Grant ID APP1158223).

ORCID iDs

Natasha Walker

Jie Shang

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