Experience of Pelvic Examination and Uptake of Gynecological Care Following Domestic or Sexual Violence: a Systematic Review

Abstract

Pelvic examination, a routine practice for gynecological care, can cause anxiety and be considered traumatic. This study aimed to define the association between domestic or sexual violence and the experience of pelvic examination, as well as the uptake of gynecological care following domestic or sexual violence. Pubmed, Cochrane Library, ScienceDirect, and Google Scholar were searched, up to April 30, 2023. Cohort, cross-sectional, case-control studies and controlled trials assessing perception of pelvic examination or the use of gynecological care for women with a history of violence were selected and analyzed. Each study underwent a descriptive analysis and was assessed for bias using the Newcastle-Ottawa scale and the RoB2 tool. Twenty-three articles met the inclusion criteria. Eleven studies, including 7,329 women, investigated the experience of pelvic examination following lifetime or childhood sexual violence. Most reported an association between violence and adverse experiences of pelvic examination, such as discomfort, anxiety, distress, and pain perceptions. Ten studies, including 9,248 women, investigated the uptake of gynecological care following domestic or sexual violence and reported mixed results, such as a decreased or an increased uptake, particularly for acute symptoms. Two studies, including 1,304 women, examined both outcomes. The present study highlights the association between violence and adverse experiences of pelvic examination, as well as mixed results on the uptake of gynecological care. It argues for the necessity to screen for violence in consultations, particularly when considering a pelvic examination, to guarantee the utility of pelvic examinations, and to consider the traumatic impact of sexual violence in care.

Keywords

domestic violence sexual assault child abuse

Introduction

Physical, psychological, and sexual violence committed by intimate partners, as well as all forms of sexual violence, are the subject of growing concern. In 2022, the World Health Organization evaluated that 27% of women aged 15 to 49 had been victims of physical or sexual violence during their life, among which 13% during the previous year (Sardinha et al., 2022). Several meta-analyses, systematic reviews, and randomized trials have shown an association between violence during childhood and adulthood and the development of gynecological symptoms and disorders such as pelvic pain (Hassam et al., 2020; Paras et al., 2009), dysmenorrhea (Hassam et al., 2020; Latthe et al., 2006), vaginismus (Tetik et al., 2021), dyspareunia (Hassam et al., 2020; Latthe et al., 2006; Tetik et al., 2021), menorrhagia (Hassam et al., 2020), cervical cancer (Reingle Gonzalez et al., 2018), endometriosis (Harris et al., 2018), menopausal symptoms (Gibson et al., 2019), sexually transmitted infections, including HIV infection (Li et al., 2014), and unwanted pregnancies (Coker, 2007).

Guidelines on well-woman visits issued by the American College of Obstetricians and Gynecologists (ACOG) in 2018 (American College of Obstetricians and Gynecologists [ACOG], 2018a, 2018b), assessed that the interval between two preventive gynecological consultations should be based on women's individual characteristics, which is in line with the guidelines published by the French National College of Obstetricians and Gynecologists in 2023 (Deffieux et al., 2023). In 2012, the ACOG recommended performing pelvic examinations annually in all women aged 21 years and older, as part of the well-woman visit guidelines (ACOG, 2012). In 2021, the ACOG, the American Society for Colposcopy and Cervical Pathology and the Society of Gynecologic Oncology joined the US Preventive Services Task Force in recommending cervical cancer screening beginning at age 21, using cytology or HPV testing, every 3 to 5 years (ACOG, 2021b).

A meta-analysis including seven controlled trials, cross-sectional studies, and case-control studies has demonstrated a lower use of contraception in cases of domestic violence, suggesting a form of reproductive coercion (Maxwell et al., 2015). A US case-control study of 736 participants showed that women with a history of childhood sexual violence were less likely to screen for cervical cancer (Farley et al., 2002). For survivors of violence, healthcare can cause anxiety and traumatic reactivation leading to avoidance of care (Reeves, 2015; Schnur et al., 2017).

Pelvic examination is a routine practice for gynecological and obstetrical care and can cause anxiety, fear, and pain, and even be considered traumatic by women in the general population (O’Laughlin et al., 2021; Tancman et al., 2022). This examination can be difficult or impossible to perform for some patients (Huber et al., 2009). Stress levels during the pelvic examinations are higher for survivors of sexual violence than in parity- and age-matched controls (Leeners et al., 2007) and could lead to avoiding any gynecological examination, even in the presence of symptoms (Razi et al., 2021). Understanding the relationship between domestic or sexual violence and experience of pelvic examination is crucial, as is the uptake of gynecological care following sexual or domestic violence. In the absence of a systematic review on this subject, we aimed to integrate existing knowledge, so that potential gaps could be identified.

Method

Registration and Protocol

The systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020 recommendations) (Page et al., 2021), according to the PRISMA checklist (PRISMA Transparent Reporting of Systematic Reviews and Meta-Analyses., 2021) (Supplemental Figure 1). The protocol was registered in the international prospective register for systematic reviews (PROSPERO, CRD42023427545, June 1, 2023).

Eligibility Criteria

The articles were included if they referred to studies assessing the experience of the pelvic examination (discomfort, anxiety, distress, fear, embarrassment, shame, pain) or seeking gynecological care whatever the reason, routine or emergency, among women who had been victims of domestic violence (physical, psychological, sexual) or sexual violence (regardless of the perpetrator during childhood or adulthood) and were published in English, French, or Spanish. Articles regarding gynecological examination of children or adolescent survivors of sexual violence were eligible. We included randomized trials, case-control studies, cohort studies, cross-sectional analyses, and secondary studies. We excluded reviews, professional guidelines, qualitative studies, case studies, conference communication abstracts, opinion pieces, and studies regarding the use of obstetric care during pregnancy and childbirth that did not provide data on gynecological care.

Data Sources and Search Strategy

A systematic search was conducted using data published in English, French, and Spanish up to April 30, 2023, in Medline/Pubmed, Cochrane Library, ScienceDirect, and Google Scholar.

The following three questions were developed.

- Does a history of domestic or sexual violence affect the perception of the pelvic examination?

- What is the association between a history of domestic or sexual violence and the uptake of gynecological care?

- Is there a relationship between adverse experiences of pelvic examinations following sexual violence and subsequent routine gynecological examinations?

We searched the Medline/PubMed, ScienceDirect, Cochrane Library, and Google Scholar databases using search strategies presented in Table 1.

Table 1.

Databases Search Strategy.

Medline/PubMed
(“childhood abuse*”[All Fields] OR “sexual violence”[All Fields] OR “sexual assault”[All Fields] OR “sexual abuse*”[All Fields] OR “intimate partner violence”[All Fields] OR “domestic violence”[All Fields] OR “sex offense*”[All Fields]) AND (“gynecological exam*”[All Fields] OR “gynaecological exam*”[All Fields] OR “gynecologic exam*”[All Fields] OR “gynaecologic exam*”[All Fields] OR “pelvic exam*”[All Fields] OR “vaginal exam*”[All Fields] OR “vaginal smears/psychology”[MeSH Major Topic] OR “healthcare utilization”[All Fields] OR “gynecological follow up*”[All Fields] OR “gynaecological follow up*”[All Fields] OR “gynecological care*”[All Fields] OR “gynecologic care*”[All Fields] OR “gynaecological care*”[All Fields] OR “gynaecologic care*”[All Fields])
ScienceDirect
(“sexual violence” OR “sexual assault” OR “intimate partner violence” OR “sex abuse”) AND (“gynecological examination” OR “pelvic examination” OR “gynecological care ” OR “Long-term healthcare”)
Cochrane Library
((“childhood abuse*” OR “sexual violence” OR “sexual assault” OR “sexual abuse*” OR “intimate partner violence” OR “domestic violence” OR “sex offenses”) AND (“gynecological exam*” OR “gynaecological exam*” OR “gynecologic exam*” OR “gynaecologic exam*” OR “pelvic exam*” OR “vaginal exam*” OR “ healthcare utilization “ OR “gynecological follow up*” OR “gynaecological follow up*” OR “gynecological care*” OR “gynecologic care*” OR “gynaecological care*” OR “gynaecologic care*”)) in Title Abstract Keyword
Google scholar
allintitle: “pelvic examination” OR “gynecological care” “sexual violence”
allintitle: “pelvic examination” OR “gynecological care” “sexual assault”
allintitle: examinations OR examination discomfort OR embarrassment OR pain OR stress OR distress OR anxiety OR shame OR fear “sexual abuse”

Selection and Data Collection Process

All potentially eligible studies were independently selected based on their title and abstract and were then checked in full text to confirm their inclusion by EI, PC, and JPM.

EI and PC extracted the data using a predefined data extraction table. The differences between researchers were resolved by discussion and mutual agreement. The missing data was collected by contacting the corresponding authors of the reference publications. The patients were not involved in the planification of the development of this systematic review.

Data Items

The country, year of publication, study type, sample size, recruitment context, sociodemographic data, type of violence, experience of pelvic examination, level, and characteristics of gynecological care were collected.

Risk of Bias and Quality Assessment

Two authors (EI and PC) applied the risk of bias assessment tools independently. If the assessment diverged, a consensus was reached following discussion with a third author (JPM). The Newcastle-Ottawa scale (NOS) was used to assess the risk of bias in cohort studies and case-control (Wells et al., n.d.). We used a modified version of NOS for cross-sectional studies (Herzog et al., 2013). The RoB2 tool, which assesses how randomized trials are designed, conducted and analyzed, was used to assess the risk of bias in a randomized trial (Cochrane Methods, 2021).

Synthesis Methods and Effect Measures

The articles were eligible if they dealt with the patient’s perception of the pelvic examination or use of gynecological care, for gynecological motives, contraception, or cervical cancer screening. Studies were excluded if they did not examine the perceptions of gynecological examination by children, adolescents, or adults or if they examined healthcare without specific data on gynecological care or violence other than domestic or sexual violence. The data collected was about the relationship between domestic or sexual violence and the experience of pelvic examination (Table 2) and the relationship between domestic or sexual violence and the uptake of gynecological care (Table 3). The results were presented using prevalence, odds ratios, relative risks, and standard deviations.

Table 2.

Summary of Articles on the Association Between Domestic or Sexual Violence and the Perception of Pelvic Examination.

Authors (year), country	Study design	Time frame	n/Participants	Instruments	Outcomes	Outcome measures
Berger et al. (2023), Germany	Cohort study	2016–2020	49 Women/Department of Forensic Medicine >16 years	Self-questionnaire perceptions of pelvic examination Medical data	Perceptions of pelvic examination among women victims of sexual violence	Prevalence of perception of pelvic examination following sexual violence = additional psychological burden = 52%
Danan et al. (2022), USA	Cohort study/ secondary data	2015	1,049 Women/veterans’ health organizations No sexual assault (Lifetime) N = 433 Sexual assault (Lifetime) N = 616 21–65 years	PHQ-4 screener Veterans health administration’s validated screening questions Medical records	Cervical cancer screening uptake following sexual violence	Higher prevalence of distress, discomfort, and anxiety during pelvic examination in women with a history of sexual violence (p < .001) Higher prevalence of delaying a pelvic examination because of discomfort, anxiety, or distress in women with a history of sexual violence (p < .01) No association between sexual violence history and Papanicolaou (Pap) test completion: OR = 1.35; 95% CI [0.93, 1.97]
Güneş and Karaçam (2017), Turkey	Cross-sectional study	2014–2015	320 Women/maternity and children’s hospital >18 years	PTSDS Self-questionnaire with eight sexual abuse questions Visual analog scale of discomfort	Pelvic examination discomfort among women with psychological violence Pelvic examination discomfort with PTSD for women	Association between history of emotional abuse and discomfort during vaginal examination OR = 4.48; 95% CI [1.42, 14.13] (p = .01) Association between PTSD and discomfort during vaginal examination OR = 1.04; 95% CI [1.01, 1.07] (p = .009)
Hilden et al. (2003), Denmark, Sweden, Norway	Cross-sectional study	1999–2000	798 Women/gynecology department >18 years	Adapted NorAQ	Factors associated with pelvic examination discomfort	Association between sexual violence and discomfort during pelvic examination OR = 1.85; 95% CI [1.19, 2.87]
Khan et al. (2014), USA	Cross-sectional study/ secondary data	2005–2006	40 Women veterans, sexual violence + 18–65 years	Adapted Sexual Experiences Survey CAPS Adapted scale of subjective units of distress	Pelvic examination distress among women with sexual violence and with PTSD	Association between hyperarousal and distress during pelvic examination t = 2.5, R = .40, adjusted R² = .14, p = .02 Association between hypervigilance and distress during pelvic examination Spearman’s rho: r = .54, p < .001
Lee et al. (2007), USA	Cross-sectional study	?	31 Women veterans, sexual violence + 22–68 years	Adapted SUD Scale PCL-C	Pelvic examination anxiety among women with sexual violence, by gender of examiner	Association between anxiety during pelvic examination anxiety and gender of examiner Pelvic examination p < .001 Rectal examination p < .001 Breast examination p < .001 No association between anxiety during pelvic examination and gender of examiner Wilcoxon Signed Rank Test: NS No association between PTSD and pelvic examination anxiety
Leeners et al. (2007), Switzerland, Germany	Cross-sectional study	1999	255 Women recruited by society providing care for sexually abused women (case group) and mothers of kindergartners (control group) Childhood sexual assault +N = 85 childhood sexual assault −N = 170	Self-questionnaire with sexual abuse experiences and gynecological care questions Face-to-face interview	Pelvic examination stressors in women with childhood sexual assault	Association between childhood sexual assault and stressors during pelvic examination p-value Nakedness <.0001 Vaginal examination (TV speculum) <.0001 Endovaginal ultrasound <.0001 Prevalence of women who had memories of the abuse during pelvic examination: 43.5% (lying on the gynecological table, pelvic examinations, a treatment without previous announcement, the feeling of helplessness and pain) Prevalence of suggestions to reduce psychological strain during pelvic examination: 55.8% of women mentioned discussing sexual abuse with the practitioner.
Marks (2009), Australia	Cohort study	2002–2004	71 Children (90% female gender) in child protection unit, CSA + >3 years	Children’s Anxiety and Pain Face Scale Genital examination Distress Scale	Perceptions of the medical examination by children and parents in relation to childhood sexual assault.	Association between children age (>12 years) and distress during pelvic examination p < .01
Robohm and Buttenheim (1996), USA	Case-control study	1993–1994	74 Women recruited in survivors’ newsletters, newspaper advertisements, and flyers childhood sexual assault +N = 44 childhood sexual assault −N = 30 >18 years	Self-questionnaire with violence and gynecological care questions	Perceptions of pelvic examination (anxiety, embarrassment, shame, vulnerability, discomfort, pain) among women with childhood sexual assault	Association between childhood sexual assault and feelings and emotions during the gynecological examination first visit/last visit/usual visit T value first visit/last visit/usual visit Anxiety NS/2.22 (p < .05)/NS Embarrassment 2.83 (p < .01)/3.09 (p < .01)/1.99 (p < .05) Shame 2.96 (p < .01)/3.58 (p < .001)/3.07(p < .01) Sense of vulnerability 3.09 (p < .01)/2.79 (p < .01)/2.35(p < .05) Physical discomfort NS/NS/NS Pain 2.13 (p < .05)/NS/NS Association between childhood sexual assault and discomfort during the gynecological examination stages T value Prior to the examination 3.18 (p < .01) Breast examination 2.70 (p < .01)
						Pelvic examination 3.62 (p < .001)Recto-vaginal examination NS Association between childhood sexual assault and reasons for discomfort during stages of examinationChi-squareBreast examination and physical discomfort χ² = 6.55 (p < .05)Pelvic examination and physical discomfort χ² = 10.15 (p < .001), sexual organ examination 5.35 (p < .05), other reasons χ² = 3.84 (p < .05)Recto-vaginal examination and physical discomfort χ² = 5.13 (p < .05)Association between childhood sexual assault and experiences during visitChi-squareBeing overwhelmed by emotion χ² = 5.71 (p < .05)Intrusive thoughts χ² = 5.87 (p < .05)Memories χ² = 10.24 (p < .001)Body memories χ² = 7.19 (p < .01)Body detachment χ² = 10.69 (p < .001)
Scribano et al. (2010), USA	Cohort study	2006	175 (77% female) CSA +/child Assessment Center8–18 years	MASC-10GEDS	Anxiety during genital examination in children and their parent	Mean difference of anxiety during pre/post-examinationmean pre-T-score = 55.8/mean post-T-score = 53.1 (p < .001).Mean difference of anxiety during pre/post-examination, by ageAge 8–11 years (p = .004)Age 12–18 years (p < .0001)Correlation between coefficients for child’s and parent’s anxiety during pre-examinationPearson correlation coefficient: .32 (p < .0001)Correlation between coefficients for child’s and parent’s anxiety during post-examinationPearson correlation coefficient .34 (p < .0001).
Swahnberg et al. (2011), Sweden	Cross-sectional study		4,384 Women/Departments Of Obstetrics And Gynecology (multicentre)strong discomfort N = 801no discomfort N = 3,583>18 years	NorAQTwo questions on the experience of flashbacksScale of discomfort (0–10)	Discomfort during pelvic examination for women who were abused (physical, psychological, sexual, abuse in healthcare)	Association between physical, psychological, and sexual violence and discomfort during pelvic examinationPsychological violence OR = 1.8; 95% CI [1.2, 2.7]Sexual violence OR = 1.1 95% CI [0.7, 1.7]Psychological and physical violence (PA) OR = 1.7; 95% CI [1.1, 2.6]Sexual violence associated with psychological and physical violence OR = 1.6; 95% CI [1, 2.62] (p = .041)Association between flashbacks during the previous year and pelvic examination discomfort OR = 1.5; 95% CI [1.2, 1.9]Association between negative emotional contact with examiner and pelvic examination discomfort OR = 10.2; 95% CI [7.9, 13.1]Association between combinations violence with abuse in healthcare and pelvic examination discomfort OR = 1.8; 95% CI [1.4, 2.4]
Weitlauf et al. (2008), USA	Cross-sectional study	2005–2006	67 Women veterans/49 completed an assessment for posttraumatic stress disorder approximately 2 weeks later18–65 years	Self-questionnaire with sexual violence and perceptions of pelvic examination questionsPTSD Scale	Anxiety and pain during pelvic examination in women with sexual violence and with PTSD	Difference in median distress during pelvic examination between women who had and had not experienced sexual violence x̃ sexual violence+ = 4.27 (p = .03)Difference in median pain experienced during speculum insertion between women who had and had not experienced sexual violence x̃ 2.5 (p = .04)Difference in median distress during gynecological examination according to whether or not they had experienced sexual violence and whether or not sexual violence was associated (x̃ = 5.50) with PTSD (x̃ 2.44) p = .02No difference between the feeling of pain during gynecological examination according to whether or not they had experienced sexual violence and whether or not the sexual violence was associated with PTSD (p = .35)
Weitlauf et al. (2010), USA	Cross-sectional study	2006–2007	87 Women veterans18–65 years	Short form of the Sexual Experiences Survey.Trauma self-questionnairePCL-CQuestionnaire on perception of pelvic examination	Anxiety, fear, embarrassment and pain during pelvic examination in women with sexual violence and with PTSD	Difference in median fear during pelvic examination according to whether or not (p < .005) they had experienced sexual violence associated with PTSD (p < .001)Kruskal–Wallis test comparing median scorex̃ = 18.8Difference in median discomfort during pelvic examination according to whether or not (p < .005) they had experienced sexual violence associated with PTSD (p < .001)Kruskal–Wallis test comparing median scorex̃ = 21.2Difference in median anxiety during pelvic examination according to whether or not (p < .005) they had experienced sexual violence associated with PTSD Kruskal–Wallis test comparing median scorex̃ = 18.2No difference in median pain during pelvic examination (p = .063)

Note. CAPS = Clinician Administered PTSD Scale; GEDS = Genital Examination Distress Scale; MASC-10 = Multidimensional Anxiety Score for Children; NorAQ = NorVold Abuse Questionnaire; PCL-C = PTSD Checklist-Civilian Version; PHQ = Patient Health Questionnaire; PTSDS = Posttraumatic Stress Disorder Scale-civilian version.

Table 3.

Summary of Articles on the Association Between Domestic or Sexual Violence and the Uptake of Gynecological Care.

Authors (year), country	Study design	Time frame	n/Participants	Instruments	Outcomes	Outcome measures
Bagwell-Gray and Ramaswamy (2022), USA	Cross-sectional study	2019–2020	30 Domestic violence + women’s shelters>18 years	Self-questionnaire for cervical cancer screening and vaccination questionsSVAWSDA	Use of cervical cancer screening in the last 3 years among women with intimate partner violence	Prevalence of never having had a Pap test or having had a Pap test >3 years77%Association between sexual domestic violence and cervical cancer screeningeffect size Cohen’s d = 6.55Association between physical domestic violence and cervical cancer screeningeffect size Cohen’s d = .37Association between sexual domestic violence and cervical cancer screeningeffect size Cohen’s d = .44
Cadman et al. (2012), USA	Exploratory study (cross-sectional)	2010	124 Women victims of violence/website>20 years	Violence self-questionnaire and CCU screening	Use of cervical cancer screening among women with sexual violence	Prevalence of never having had a Pap test or having had a Pap test >5 years45%Prevalence of physical pain or tension during cervical smear tests21%Prevalence of women highlighting the parallels between the cervical smear tests and previous experiences, reporting that it was “exactly like it used to happen when I was abuse15%
Danan et al. (2022), USA	Cohort study/ secondary data	2015	1,049 patients of veterans' health organizationsNo sexual assault history (Lifetime) N = 433Sexual assault history (Lifetime) N = 61621–65 years	PHQ-4 screenerVeterans health administration’s validated screening questionsMedical files	Use of cervical cancer screening among women with sexual violence	No association between sexual violence and Pap test completion (cytology) >3 years or HPV >5 years:OR = 1.35, 95% CI [0.93, 1.97]No association between gynecological examination discomfort, distress, or anxiety and cervical cancer screening > 3 years or HPV >5 yearsOR = .9, 95% CI [0.9, 1]
Denis et al. (2016), France	Cohort study	2010–2012	1,003 women, department of forensic medicineNo previous medical consultation N = 782Any medical consultation N = 221>10 years	Questionnaire with sexual assault and care prior to forensic visitMedical interview	Use of care prior to a forensic visit among women with sexual violence	Prevalence gynecological care: 28%/232 patients followed by 17% by an emergency doctor, 44% by a general practitioner, and 44% by a gynecologist.Prevalence of patients' expectations by consulting a gynecologist: gynecological care (44%), psycho-traumatic care (14%), medico-legal support (15%), and psychological support (6%)Prevalence of medical responses: gynecological care (38%), psycho-traumatic care (12%), forensic support (12%)
Guha et al. (2020), Australia	Cohort study	1964–1995 (cases group)2010–2015 (comparison group)	2,433 Women, department of forensic medicine CSA+>16 yearsComparison group: n = 2,165 (general population)16–61 years	Forensic medical recordsCommonwealth Australian medical data	Subsequent healthcare utilization after childhood sexual assault	No association between children’s sexual abuse and gynecological subsequent healthcare utilizationOR 1.04, 95% CI [0.90, 1.19] p = ,57
Holt et al. (2021), USA	Randomized controlled trial/secondary data	2011–2013	1,490 patients from 40 family planning and abortion clinicsEver delayed clinic visit to avoid pelvic examination + N = 196Ever delayed clinic visit to avoid pelvic examination −N = 1,29418–25 years	Questionnaire with intimate partner violence and avoidance of pelvic examination questions	Delayed contraceptive use and avoidance of pelvic exam among women with intimate partner violence	Association between sexual intimate partner violence and delayed visitOR 3.10, 95% CI [1.39, 6.84]Association between sexual intimate partner violence and avoidance of pelvic examinationOR 2.91, 95% CI [1.57, 5.40]No association between verbal or physical intimate partner violence and delay or avoidance of pelvic examination
Farley et al. (2002), USA	Case-control study		736 Patients/health organizationwomen who had been screened for cervical cancerN = 364women who had not been screened N = 37221–64 years	Childhood TraumaQuestionnaireTrauma History QuestionnairePosttraumatic Stress Disorder Checklist	Cervical cancer screening among women with childhood violence	Prevalence of having had Pap test < 2 years36% with history of rape in childhood50% without history of rape in childhood (p = .05)35% with history of other sexual assault in childhood51% without history of other sexual assault in childhood (p = .05)Association between childhood sexual trauma and having had a Pap test <2 yearsOR = 0.56, 95% CI [0.34, 0.91]No association between PTSD diagnosis and having had a Pap test <2 yearsOR = 1.6,2 95% CI [0.91, 2.90]
Leeners et al. (2007), Switzerland, Germany	Cross-sectional study	1999	255 Women recruited by society providing care for sexually abused women (case group) and mothers of kindergartners (control group)childhood sexual assault +N = 85childhood sexual assault −N = 170	Self-questionnaire with sexual abuse experiences and gynecological care questionsFace-to-face interview	Effects of childhood sexual abuse on gynecological care	Prevalence of utilization of routine gynecological services (NS)70.6% with a history of childhood sexual assault87.6% without a history of childhood sexual assaultPrevalence of treatment for acute symptoms (p < .0001)37.6% with a history of childhood sexual assault20.5% without a history of childhood sexual assault
Olesen et al. (2012), Australia	Cross-sectional study/ secondary data	2003–2004	1,685 Women (random selection)44–68 years64–68 years	Violence, cervical cancer screening and health self-questionnaireAdministrative records	Factors associated with the use of cervical cancer screening	Association between sexual violence in childhood and use of cervical cancer screeningOR = 0.42, 95% CI [0.20, 0.91]
Oscarsson et al. (2008), Sweden	Cross-sectional study	1999–2004	133 Women randomly selected with cervical cancer screening > 5 years16.5% = VS +28–65 years	Register cervical smearsCSQAdapted NorAQDiscomfort self-assessment scale	Factors associated of non-participation in cervical cancer screening	No association between no Pap test screening due to discomfort with gynecological examination, by history of sexual violence
Prosman et al. (2012), Netherlands	Case-control study	2009	100 General practice patientsintimate partner violence +N = 50intimate partner violence −N = 50>18 years	CASMedical files	Use of care by women with intimate partner violence	Association between intimate partner violence and more frequent visits for reproductive health problemsOR = 3.0, 95% CI = [1.3, 6.8]
Razi et al. (2021), Israël	Cross-sectional study	2018–2019	210 ParturientsTwo ethnic groups: Bedouin and Jewish	Sexual Experiences SurveyPosttraumatic Diagnostic ScaleEdinburgh Postnatal Depression ScaleMedical files	Gynecological health behaviors in parturients with sexual violence	Association between sexual violence and avoidance of gynecological care OR = 0.37, 95% CI [0.17, 0.80]Association between sexual violence and sub-optimal gynecological follow-up OR = 2.25, 95% CI [1.19, 4.28]Association between sexual violence and gynecological consultations for acute symptoms OR = 2.11, 95% CI [1.08, 4.11]Association between sexual violence and negative contact with gynecologist OR = 0.36, 95% CI [0.17, 0.75]

Note. CAS = Composite Abuse Scale; CSQ = Cervical Screening Questionnaire; DA = Danger Assessment; NorAQ = NorVold Abuse Questionnaire; PHQ = Patient Health Questionnaire; SVAWS = Severity of Violence Against Women Scales.

Given the methodological and clinical heterogeneity of the studies, each study was subjected to a descriptive analysis according to the synthesis without meta-analysis reporting guideline (Campbell et al., 2020). A narrative approach was used to describe the evidence for each outcome in each domain of interest.

Results

Study Characteristics

The data search identified 251 studies using Medline/PubMed (n = 220), ScienceDirect (n = 24), and Cochrane Library (n = 7). The titles and abstracts enabled the identification of 56 articles in English and French—none in Spanish—after removal of duplicates (n = 18), those that did not pertain to the experience of pelvic examination nor to the uptake of care following domestic or sexual violence (n = 116), those reporting qualitative studies (n = 8), article summaries (n = 1), professional guidelines and reviews (n = 10), editorials, opinion pieces and case reports (n = 43) (Figure 1).

Figure 1.

PRISMA 2020 flowchart. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

After accessing full text, we excluded 36 articles because they reported data on uptake of care without specific reference to gynecological care (n = 18), dealt with genital lesions explored or diagnosed in women (n = 6) and children (n = 11), without mentioning the experience of the gynecological examination (n = 17) and looked into violence other that domestic or sexual violence (n = 1). A Google Scholar search identified 23 additional studies among which 3 were selected (Figure 1).

In total, 23 articles met the inclusion criteria, 11 were about the experience of the pelvic examination, involving 7,329 women (Berger et al., 2023; Güneş & Karaçam, 2017; Hilden et al., 2003; Khan et al., 2014; Lee et al., 2007; Marks et al., 2009; Robohm & Buttenheim, 1996; Scribano et al., 2010; Swahnberg et al., 2011; Weitlauf et al., 2008, 2010) and 10 were about the uptake of gynecological care following domestic or sexual violence, involving 9,248 women (Bagwell-Gray & Ramaswamy, 2022; Cadman et al., 2012; Denis et al., 2016; Farley et al., 2002; Guha et al., 2020; Holt et al., 2021; Olesen et al., 2012; Oscarsson et al., 2008; Prosman et al., 2012; Razi et al., 2021). Two studies were about both the experience of the pelvic examination and the uptake of gynecological care (Danan et al., 2022; Leeners et al., 2007) involving 1,304 women. No study looked into the relationship between the experience of the pelvic examination aimed at identifying lesions following sexual violence and the experience of subsequent pelvic examinations as part of routine gynecological care. The articles, published between 1996 and 2023, originated from the United States (n = 10), Scandinavian countries (n = 3), Turkey (n = 1), Australia (n = 3), Israel (n = 1), France (n = 1), the Netherlands (n = 1), the UK (n = 1), Switzerland, and Germany (n = 2), and included between 30 and 4,436 participants. The articles were case-control studies (n = 3), cohort studies (n = 6), cross-sectional analyses (n = 9), data extracted from secondary studies from a cohort study (n = 1), cross-sectional studies (n = 3), and a randomized controlled trial (n = 1).

Risk of Bias in Studies

The risk of bias assessed using NOS and RoB2 tool is detailed in Supplemental Figures 2 to 5. The cohort, cross-sectional, and case-control studies had a medium quality of 4.90 and a median of 5.00, which indicates a poor to fair quality (Wells et al., n.d.). The risk of bias in the study reporting secondary data from the randomized trial was considered low (Cochrane Methods, 2021).

Synthesis of Results

Relationship Between Violence and the Experience of Pelvic Examination

The articles included case-control studies (n = 1) (Robohm & Buttenheim, 1996), cohort studies (n = 3) (Berger et al., 2023; Marks et al., 2009; Scribano et al., 2010), cross-sectional analyses (n = 7) (Güneş & Karaçam, 2017; Hilden et al., 2003; Lee et al., 2007; Leeners et al., 2007; Swahnberg et al., 2011; Weitlauf et al., 2008, 2010), secondary data from a cohort study (n = 1) (Danan et al., 2022), and cross-sectional studies (n = 1) (Khan et al., 2014).

Lifetime Sexual Violence

A cross-sectional study conducted in Denmark, Norway, and Sweden with 798 women demonstrated that a history of sexual violence was associated with discomfort during pelvic examination (Hilden et al., 2003). A German study of 49 women survivors of sexual violence having consulted in a forensic medical department revealed that half of them felt pelvic examination as an additional psychological burden (Berger et al., 2023). Five studies with US veterans who survived sexual violence showed pain, discomfort, or distress during pelvic examination (Danan et al., 2022; Khan et al., 2014; Lee et al., 2007; Weitlauf et al., 2008, 2010). A study reporting secondary data from a cohort of 1,049 US veterans showed that a history of sexual violence was associated with distress, discomfort, and anxiety during pelvic examination (Danan et al., 2022). A cross-sectional study including 67 US veterans showed higher distress during gynecological examination among survivors of sexual violence, particularly after posttraumatic stress disorder (Weitlauf et al., 2008). This study also reported higher levels of pain during speculum insertion for women declaring sexual violence. The same researchers conducted a cross-sectional study of 167 participants who presented with increased fear, embarrassment, and anxiety levels following sexual violence, particularly in cases of posttraumatic stress disorder (Weitlauf et al., 2010). In both studies, the variations in pain levels during pelvic examination following sexual violence or in cases of posttraumatic stress disorder were not significant. A third cross-sectional study including 40 US veterans with a history of sexual abuse, hyperarousal, and hypervigilance were associated with distress during the pelvic examination (Khan et al., 2014). Conversely, a cross-sectional study conducted with 31 US veterans, posttraumatic stress was not associated with higher anxiety during pelvic examination (Lee et al., 2007).

Childhood Sexual Violence

Three studies revealed an association of childhood sexual violence with negative experiences of gynecological examination. In an Australian cohort of 71 child survivors of sexual violence, 90% of whom were females, being aged over 12 was associated with pain and fear during pelvic examination (Marks et al., 2009). A case-control study including 255 women showed higher stress levels—stress related to nudity, during pelvic examination (vaginal examination, speculum insertion), and during endovaginal ultrasound—for women with a history of childhood sexual abuse (Leeners et al., 2007). A case-control study with 74 participants showed anxiety, embarrassment, shame, vulnerability, discomfort, and pain during pelvic examination following childhood sexual violence. In this study, the discomfort was worsened during the pelvic, recto-vaginal, and breast examinations (Robohm & Buttenheim, 1996). A study conducted in the United States including 175 children with a history of sexual violence after the age of 8, 77% of whom were female, showed less anxiety after genital examination, compared to pre-examination, particularly in survivors aged 12 to 18 (Scribano et al., 2010).

Other Forms of Violence

In two studies, a history of psychological violence appeared to be a significant factor associated with adverse experience of pelvic examination. A cross-sectional study conducted in Sweden with 4,453 women showed an association between discomfort during pelvic examination and a history of psychological violence, associated or not with physical or sexual violence (Swahnberg et al., 2011). No association was found in cases of physical or sexual violence when no psychological violence was reported (Swahnberg et al., 2011). A cross-sectional study conducted in Turkey with 320 women showed that a history of psychological violence and posttraumatic stress disorder was associated with higher risk of discomfort during vaginal examination (Güneş & Karaçam, 2017).

Relationship Between Sexual or Domestic Violence and Uptake of Gynecological Care

The articles included case-control studies (n = 2) (Farley et al., 2002; Prosman et al., 2012), cohort studies (n = 2) (Denis et al., 2016; Guha et al., 2020), cross-sectional analyses (n = 5) (Bagwell-Gray & Ramaswamy, 2022; Cadman et al., 2012; Leeners et al., 2007; Oscarsson et al., 2008; Razi et al., 2021), secondary data extracted from a cohort study (n = 1) (Danan et al., 2022), a cross-sectional study (n = 1) (Olesen et al., 2012), and a randomized trial (n = 1) (Holt et al., 2021).

Absence of Care or Decreased Gynecological Care

Four studies of women with histories of domestic or sexual violence reported absent, sub-optimal, or delayed gynecological care (Cadman et al., 2012; Danan et al., 2022; Holt et al., 2021; Razi et al., 2021). Two studies, one in the United States with 1,480 women consulting for contraception and another in Turkey with 210 women who had given birth, reported sub-optimal routine gynecological follow-up, avoidance, or delayed uptake of care in relation to avoidance of pelvic examination for women with a history of domestic and sexual violence (Holt et al., 2021; Razi et al., 2021). The study by Danan et al. (2022) previously cited reported an association between a history of sexual violence and delayed practice of pelvic examination due to discomfort or distress, but the association between a history of sexual violence and the frequency of cervical cancer screening was not significant. One study in the United States of 30 women with a history of domestic violence, recruited in victim support organizations, found that 77% of women aged 22 to 50 (mean: 41) had never been screened for cervical cancer or had not been screened for cervical cancer in the past 3 years (Cadman et al., 2012).

Three studies reported an association between a history of sexual abuse and an absence of cervical screening (Bagwell-Gray & Ramaswamy, 2022; Farley et al., 2002; Olesen et al., 2012). In a US case-control study of 736 women and a secondary data analysis of a cross-sectional study of 1,685 women, an association was found between a history of childhood sexual abuse and an absence of cervical screening in the past 2 years (Farley et al., 2002; Olesen et al., 2012). In one study in the UK with 124 women with a history of childhood sexual violence recruited in victim support organizations, 42% of women over 25 had never been screened for cervical cancer or had not been screened for 5 years or more (Bagwell-Gray & Ramaswamy, 2022).

Gynecological Care Similar to That Observed in Control Patients

A study of 133 women in Sweden found no difference in non-participation in cervical cancer screening due to discomfort associated with gynecological examinations between women who reported sexual violence and those who did not (Oscarsson et al., 2008). An Australian cohort study including 4,598 women survivors of childhood sexual abuse, recruited in a forensic medical service and the cross-sectional study by Leeners et al. previously cited, which involved 85 women recruited in a society providing care for sexually abused women, did not show a significant difference regarding uptake of gynecological care following violence compared to the general population or to women who reported no history of violence (Guha et al., 2020; Leeners et al., 2007). In the study by Olesen et al., previously cited, no association was found between a history of lifetime sexual abuse and cervical screening in the past 2 years (Olesen et al., 2012).

Increased Gynecological Care

Three studies showed an increased use of gynecological care (Prosman et al., 2012). A case-control study conducted in the Netherlands included 100 women consulting a general practitioner and reported more frequent visits to the clinic for a gynecological issue for women with a history of violence (Prosman et al., 2012). In the studies by Leeners et al. (2007) and Razi et al. (2021), previously cited, women who had experienced sexual violence were more likely to seek gynecological care for acute gynecological symptoms.

First Medical Care Sought After Sexual Violence

A study conducted in a forensic medical department in France assessed the medical care delivered before the forensic consultation for 1,003 women survivors of sexual violence between 2010 and 2012. A total of 28% of the consultations were related to a request for gynecological care. By accessing a gynecologist, the patients’ expectations were gynecological care (44%), trauma care (14%), medical and legal support (15%), and psychological support (6%) (Denis et al., 2016).

Relationship Between the Experience of Pelvic Examination Following Sexual Violence and the Uptake of Routine Gynecological Care

No study investigated the possible association between adverse experiences of pelvic examinations following sexual violence and subsequent routine gynecological examinations.

Discussion

Main Findings

This systematic review synthesizes data from 23 studies on the experiences of pelvic examinations and the uptake of gynecological care among women with histories of domestic or sexual violence. Eleven studies focused on the experiences of pelvic examinations, involving 7,329 women, while 10 studies examined the uptake of gynecological care following violence, involving 9,248 women. Two studies covered both aspects, involving 1,304 women.

This review reports an adverse pelvic examination experience following childhood and adulthood sexual violence. The cohort, cross-sectional, and case-control studies showed an association between exposure to sexual violence and the discomfort, anxiety, distress, pain, embarrassment, and shame experienced during a pelvic examination, especially in cases of posttraumatic stress disorder.

This review reports a discrepancy concerning the increase or decrease in the use of gynecological care following domestic or sexual violence.

Most cohort, cross-sectional, and case-control studies showed an association between a history of domestic or sexual violence and the level of uptake of gynecological care. Following domestic or sexual violence, studies identified a reduced use of gynecological care, e.g. cervical cancer screening, a request for contraception, or conversely, an increased use of gynecological care. In both cases, patients had a higher rate of access to care for acute symptoms following sexual violence.

No studies specifically addressed the relationship between experiences during pelvic examinations following sexual violence and subsequent routine gynecological care, highlighting a gap in the existing literature.

We highlight the main critical findings in Table 4.

Table 4.

Critical Findings.

Focus	Critical findings
Experience of pelvic examination following violence	Most studies reported an association between childhood or lifetime sexual violence and adverse experiences of pelvic examination, such as discomfort, anxiety, distress, and pain perceptions.
Uptake of gynecological care following violence	Studies reported mixed results, such as a decreased or an increased uptake following domestic or sexual violence, particularly for acute symptoms.
Relationship between experiences of pelvic examinations and subsequent routine gynecological examinations	No study investigated the possible association between adverse experiences of pelvic examinations following sexual violence and subsequent routine gynecological examinations.

Strengths and Limitations

This review described the relationship between domestic or sexual violence and the experience of pelvic examination as well as the use of gynecological care following domestic or sexual violence. We examined the association between a history of domestic or sexual violence and the uptake of gynecological care, whereas no systematic review had previously looked at this issue. The very diverse studies identified and included allowed a descriptive approach to multiple forms of violence and experiences of pelvic examination. In most studies, domestic or sexual violence and experience of the gynecological examination were assessed using adaptations of screening scale for violence, posttraumatic stress disorder (PTSD), and examination-related discomfort

Some limitations have been identified. The assessment of experience of a pelvic examination at several time points, the time since the last pelvic examination and the frequency of use of gynecological care were imprecise or inconsistent, and therefore difficult to compare. Unlike the variables on violence and perceptions of pelvic examination, which had validated scales available, there was no scale for assessing the use of gynecological care, which makes this variable difficult to evaluate. Moreover, few studies referred to a specific time frame for the last gynecological consultation or to a time frame of 3 or 5 years, depending on the patient's age and the cervical cancer screening technique used (HPV or cytology). The imprecision of the time of the last consultation or the time of the last cervicovaginal smear may have led to inconsistencies in the way the case-control groups were classified, and to difficulties in comparing gynecological care pathways between studies. Given the disparity between measurement tools and definitions across studies, we could not have a meta-analytic approach.

We did not include any study focusing on the relationship between female genital mutilation and health or gynecological care. However, the existence of a history of female genital mutilation was associated with a higher rate of domestic violence (Salihu et al., 2012) and barriers to accessing prevention (Younas et al., 2024). The discussion on diversity was notably lacking in this review. While age was considered by all of the included studies, characteristics such as sexual orientation, social class, disability, and gender identity were not mentioned. Seven of the included studies, one conducted in Israël (Razi et al., 2021) and six in the United States (Bagwell-Gray & Ramaswamy, 2022; Danan et al., 2022; Farley et al., 2002; Holt et al., 2021; Weitlauf et al., 2008, 2010) collected data on race and ethnicity. Therefore, we cannot extend the validity of the conclusions of this review to the general population.

Most studies had poor to fair quality, which may affect the reliability and validity of the reported results. Some limitations and biases were not always identified by the authors of the articles. The case-control studies presented also a classification bias caused by the shameful and unspeakable nature of domestic or sexual violence. The history of violence, specifically childhood abuse, was not always considered, even though it was likely to influence the relationship between violence and experience of pelvic examination, as well as the uptake of gynecological care. In some studies, the participants had all filed a complaint or accessed a survivor support organization, which is not the case for a majority of survivors (Davidsson et al., 2009). The use of self-administered questionnaires to describe the violence or the gynecological care can be associated with a social desirability bias and did not allow to include allophone women or those with a low literacy level. When the data was self-declared, information regarding the last gynecological consultation or the experience of the last pelvic examination was subject to memory bias.

Three studies exploring the specific experience of pelvic examination for US veterans should be analyzed with caution, due to the lack of consideration of psychotrauma due to other causes than sexual violence, which may have biased the results.

Interpretation

Relationship Between Violence and the Experience of Pelvic Examination

The results of our review on the experience of pelvic examination are consistent with those of a meta-analysis which showed that survivors of violence experience report to severe levels of distress and mild to moderate levels of pain related to gynecological examinations (Coleman et al., 2024). These findings also suggested that survivors of sexual or physical violence experience higher levels of distress than women without a history of violence and that this difference is further accentuated in women with more severe PTSD. Beyond the discomfort, embarrassment, distress, and pain, women may perceive some form of violence during a pelvic examination. A Swedish study of 2,203 women who accessed gynecological care showed that those who declared having been submitted to care perceived to be violent more frequently had a history of childhood abuse than those who did not declare it (Swahnberg et al., 2004). This study was not included in this review due to the lack of precision regarding the nature of the care perceived to be violent, gynecological, or not.

Relationship Between Sexual or Domestic Violence and Uptake of Gynecological Care

Our review showed a divergence in results regarding the increase or decrease in the use of gynecological care related to the history of violence. Most studies showed an association between domestic or sexual violence and lack of gynecological care, whatever the reason for seeking care. Some studies did not, however, identify an association between a history of violence and the use of gynecological care for cervical cancer screening, echoing a meta-analysis (Reingle Gonzalez et al., 2018), which included the previously cited studies by Farley et al. (2002), Cadman et al. (2012), and Olesen et al. (2012). A cross-sectional study carried out in Denmark on 3,539 patients in five gynecological departments showed an association between a history of sexual violence and more frequent medical consultations (>7 consultations per year). In that study, however, the nature of the care—gynecological or other—was not specified (Hilden et al., 2004).

These conclusions strengthen the findings of qualitative studies identifying the differences in levels of uptake of gynecological care in connection with the characteristics of violence and their perceived effect on gynecological health (Ackerson, 2012; Iraola et al., 2023, 2024; Meier et al., 2021). The discrepancy in the results regarding the increase or decrease in the use of gynecological care reflects the heterogeneity in the behavior regarding the use of gynecological care after domestic and sexual violence.

Beyond the acknowledgment of their somatic needs, patients accessing gynecological care expected psychological or psycho-traumatic support. Published medical data showed the relationship between a history of sexual violence and posttraumatic stress disorders (Chen et al., 2010), which might explain the reactivation of the trauma history (Ackerson, 2012).

Relationship Between the Experience of Pelvic Examination Following Sexual Violence and the Uptake of Routine Gynecological Care

No study identified a relationship between the experience of the pelvic examination following sexual violence and the experience of subsequent examinations within the framework of routine gynecological care.

However, we can assume that there is a relationship between undergoing an uncomfortable or traumatic forensic or gynecological examination following violence and the avoidance of any subsequent gynecological consultation and pelvic examination.

Implications for Practice, Policy, and Future Research

This review provides arguments for questioning the utility of pelvic examination and strengthens the need to characterize the adequate conditions and indications of this examination more precisely (ACOG, 2018; Deffieux et al., 2023; Royal College of Obstetricians and Gynaecologists, 2008; Royal Australian and New Zealand College of Obstetricians and Gynaecologists, 2004). Some studies identified the conditions to reduce discomfort for the patient in a general population. As such, self-insertion of the speculum, self-sampling for genital samples, use of lubricant and choice of alternative positions other than gynecological position with stirrups, reduced discomfort for women (Bakker et al., 2017; Nelson et al., 2017; Pergialiotis et al., 2015; Seehusen et al., 2006; Wright et al., 2005). Few studies looked into the conditions of the pelvic examination to prevent or reduce negative experiences of pelvic examination in forensic or gynecological medicine, immediately after sexual and domestic violence, or later in life (Mears et al., 2003; Smith & Smith, 2000). It seems necessary to adapt the conditions of the examination for survivors of violence, particularly for those with a posttraumatic stress disorder (ACOG, 2021a; Ross et al., 2023).

Future research should evaluate the relationship between the experience of pelvic examination following sexual violence and the experience of subsequent examinations as part of routine gynecological care. All health care institutions (including primary care organizations) need to be made aware of violence and its impact on mental or gynecological health and health care utilization The implications for practice, policy, and research are presented in Table 5.

Table 5.

Implications for Practice, Policy, and Research.

Practice	• Healthcare professionals can screen for violence in obstetric and gynecological consultations, particularly when a pelvic examination is being considered.• Healthcare professionals need to guarantee the utility of pelvic examinations.Healthcare professionals can adapt examination conditions for survivors of violence, particularly those with posttraumatic stress disorder.
Policy	• Health care institutions (including primary care organizations) need to be made aware of violence and its impact on mental, and gynecological health and healthcare utilization.
Research	• Future research is needed on the experience of gynecological care following violence, considering all forms of violence.• Future research should evaluate the relationship between the experience of pelvic examination following sexual violence and the experience of subsequent examinations as part of routine gynecological care.• Future research should explore the experience of gynecological care for diverse population groups (all genders, diverse ethnic, and sexual orientations) in wider geographical contexts.

Conclusions

This study highlights the association between violence and adverse experiences of pelvic examination, as well as a decrease or increase in the use of gynecological care following sexual or domestic violence. In both cases, the rate of access to care for acute symptoms was higher after sexual violence. This review argues for the necessity to screen for violence in obstetric and gynecological consultations, particularly when considering a pelvic examination, to guarantee the utility of pelvic examinations, and to consider the traumatic impact of sexual violence in gynecological care.

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Footnotes

Data Availability Statement

Data available on reasonable request from the corresponding author.

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) received no financial support for the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Elisabeth Iraola is a PhD candidate at Sorbonne Paris Nord University and a midwife practicing in reproductive and sexual healthcare. Her research focuses on the links between gynecological health, sexual health, and violence.

Jean-Pierre Menard, MD, PhD in obstetrics and gynecology is a sexual health and sexology specialist. His research focuses on gynecological and sexual health.

Patrick Chariot, MD, PhD, is a full professor of forensic medicine at Sorbonne Paris Nord University. His research interests focus on violence, its consequences for victims, and the role of health professionals in receiving and supporting victims of violence. He has published several books on violence, including one on marital rape.

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