Mental Health

How the opioid epidemic affects women

Opioid use disorder (OUD) has become such a prominent topic in today’s society that it’s hard to go one day without hearing news about new death statistics or pending litigation issues, but one aspect of this ever-growing tragedy that may be overlooked is how OUD affects women specifically.

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When the warrior is a woman

The number of women serving in the United States Armed Forces has increased rapidly over the past decade and a half. The U.S. Department of Veterans Affairs (VA) has been implementing major changes to meet the growing demand for healthcare services after these women have been discharged from the military, as well as for older female Veterans who left the service long ago. This article describes the many and varied types of healthcare services that are available for female Veterans. These services are provided by healthcare professionals, including nurse practitioners, working in VA institutions or in the community.

Women comprise about 15% of active-duty military force members and 18% of National Guard and Reserve force members.Women serve in nearly every area of the military—including as fighter pilots, gunners, warship commanders, and military police— in locations stateside and abroad. They serve in every branch of the military. When they are discharged from the military, they become Veterans. At this time, 2.2 million women in the United States are Veterans.1

How many women use VA healthcare services? How is this population characterized?

Since 2000, the number of female Veterans using healthcare services provided by the U.S. Department of Veterans Affairs (VA) has more than doubled, from nearly 160,000 in fiscal year 2000 to more than 390,000 in fiscal year 2013.This growth has outpaced that of male Veterans. Among all female Veterans who served during Operation Enduring Freedom, Operation Iraqi Freedom, and/or Operation New Dawn (OEF/OIF/OND), 59.7% have received VA healthcare.Of this group who have received VA healthcare, 90.6% have used it more than once and 57.0% have used it 11 times or more. In fiscal year 2013, the average age of VA healthcare users was 48 years for women and 63 years for men.2

The VA serves women in every age bracket.Among female VA healthcare users, 43% are aged 18-44 years, 46% are aged 45-64 years, and the remainder are aged 65 years or older. Reproductive-aged women Veterans receive the gynecologic and obstetric care they need, and those in the menopausal years, many of whom served during the Vietnam or Gulf War eras, can rely on receiving more intensive healthcare because of their age.

In fiscal year 2012, 57% of women Veteran VA patients had some level of service-connected (SC) disability—that is, an injury or illness that occurred or worsened during service in the military.3 If a Veteran receives SC disability status, her SC disability is then assessed and rated for severity from 0% to 100%. In fiscal year 2012, 30% of women Veteran VA patients had an SC disability rating of 50% or higher.2

Women Veterans have higher physical and mental health burdens than their non-Veteran counterparts, as well as health burdens equal to or worse than those of male Veterans.They have substantial chronic disease and mental health problems; top diagnoses include post-traumatic stress disorder (PTSD), hypertension, depression, hyperlipidemia, chronic low back pain, gynecologic problems, and diabetes mellitus (DM). Among female OEF/OIF/OND Veterans, 20% have been diagnosed with PTSD and 20% have responded “yes” when screened for military sexual trauma (MST).1 In addition, women are the fastest growing segment of the homeless Veteran population, and are more likely to be homeless with children.

Recent research shows substantial co-morbidities among women Veterans, with 31% having physical and mental health conditions (vs. 24% of male Veterans). For example, among female Veterans with DM, 45% have a co-morbid serious mental illness or substance use disorder. Among female Veterans with cardiovascular disease, 21% have major depressive disorder.

Certain health risks may depend on the era of service.1,5,6 For example, women who served during the Vietnam War may present with diseases related to exposure to Agent Orange, such as Hodg kin’s disease, multiple myeloma, certain softtissue sarcomas, respiratory cancers, non-Hodgkin’s lymphoma, peripheral neuropathy, type 2 DM, Parkinson’s disease, and ischemic heart disease. Those who served during the Gulf War may present with chronic fatigue syndrome, fibromyalgia, gastrointestinal disorders, fatigue, skin disorders, headache, muscle pain, joint pain, neurologic or neuropsychological signs or symptoms (S/S), sleep disturbances, cardiovascular S/S, abnormal weight loss, or menstrual disorders. OEF/OIF/OND Veterans may be more likely to present with musculoskeletal and connective tissue disorders, mild depression, major depression, and readjustment difficulties.

Do women Veterans seek healthcare outside the VA system? What do providers need to know?

Approximately 83% of women Veterans seek healthcare outside the VA, either exclusively or along with the care that they receive from VA providers.7 Many healthcare providers (HCPs) may not realize that their patients are Veterans. Because such a large proportion of female Veterans receive healthcare outside the VA, either at academic centers or in private community practices, HCPs need to understand these women’s unique needs.

What can HCPs do? Because many female Veterans do not always identify themselves as such, HCPs should ask their patients “Have you served in the military?” If the answer is yes, HCPs should obtain a military history (branch of military, dates of service, occupation, deployment, reason for separation), including a description of their experiences in the military, and be familiar with local VA facilities so that they can refer Veterans appropriately. Women are eligible for VA healthcare if they have an honorable discharge and have completed 2 years of active duty service, were deployed in OEF/OIF/OND, or have experienced MST. A Veteran remains eligible for VA healthcare even if actively serving in the Guard or Reserve. Small copayments for some services are required. The sidebars list services available to women Veterans and additional resources.

How has the VA changed the face of women’s healthcare?

The VA created the Women’s Health Program in 1988 to streamline services for female Veterans in order to provide more cost-effective medical and psychosocial care. At that time, 4.4% of Veterans were women. The program was realigned within the Office of Public Health and Environmental Hazards in 2007, which increased the scope to include all women’s services. When the VA made additional alignment changes in 2011, the Women’s Health Program became part of the Office of Patient Care Services (PCS), The program’s name was changed to Women’s Health Services (WHS) in August 2012. Becoming part of PCS opened opportunities for WHS to collaborate with Primary Care, Mental Health, and Specialty Care.

The motto for WHS is “You served, you deserve the best care anywhere!” Women Veterans using VA healthcare services can expect:

• Women Veterans Program Managers to assist them at every facility;

• Comprehensive primary care, mental health services, and emergency and specialty care delivered by proficient and interested providers;

• Privacy, safety, dignity, and sensitivity to gender-specific needs;

• State-of-the-art healthcare equipment and technology;

and

• Pharmacy services by mail-order and online.1 

The goal of the VA is to ensure that every woman Veteran has access to a VA primary care provider (PCP) who can meet all her primary care needs, including gender- specific care. This approach ensures high-quality healthcare, with special emphasis on continuity of care and a strong relationship between PCP and patient.

Under ideal circumstances, female Veterans should receive complete primary care from one Designated Women’s Health Provider (DWHP) at one location.To provide enough DWHPs, along with nursing support, the national WHS office sponsors a 2.5-day national mini-residency program for PCPs and primary care nurses and offers it several times per year. The VA has also developed online training for core topics in women’s health. Every medical facility, including Medical Centers and Community-Based Outpatient Clinics (CBOCs), should have at least two DWHPs. Currently, all VA healthcare systems and 84% of CBOCs have at least one DWHP. These providers have an interest and special expertise in caring for women Veterans, many of whom have multiple physical and mental health co-morbidities.

The VA is working hard to ensure that every woman Veteran has access to the right kind of care at the right time and place. Facilities across the country are adding specialized equipment (e.g., digital mammography, DEXA scans) for women, updating facilities to ensure privacy and security, and expanding staff to provide convenient, equitable care.6

How is the VA addressing gender differences?

Beginning in 2008, the VA started a Women’s Health improvement initiative to focus on gender disparity data.8 Between 2008 and 2011, the VA saw tremendous reductions in gender disparity for many care measures, including Hypertension in Ischemic Heart Disease, A1C Testing for Diabetes, Retinal Exam in Diabetes, Nephropathy Screening in Diabetes, Pneumococcal Vaccine, Colorectal Cancer Screening, Depression Screening, PTSD Screening, and Alcohol Misuse Screening. Despite nationwide emphasis on gender differences in a variety of physical and mental health issues, gender gaps persisted for achieving these goals: LDL <100 in Ischemic Heart Disease, addressing A1C >9 in Diabetes, LDL <100 in Diabetes, and Influenza Vaccine. Analyses of best practices among VA networks revealed improvement based on education, support of leadership, collaborations among programs (Women’s Health, Primary Care, and Health Promotion Disease Prevention), and systems redesign. Success required multidimensional and multidisciplinary intervention aimed at patients, providers, and systems of care.

Progress is being made. Disparities in the rates of screenings and immunizations given to women and men VA patients are shrinking.8 For example, in 2008, 86% of eligible women Veterans received flu shots versus 94% of men. By 2011, there was only a 1% difference. One hundred percent of VA web pages have at least one topic of interest to women Veterans. Nearly half of these pages link to a facility-specific women’s health page and nearly one-third have images of women.

How does the VA fare with regard to provision of mental health services for women?

The VA provides a comprehensive system of mental health services for all Veterans, including psychological assessment and evaluation, outpatient individual and group psychotherapy, acute inpatient care, and residential-based psychosocial rehabilitation.2 Specialty services target problems such as PTSD, substance use problems, depression, and homelessness.

The VA has outpatient, inpatient, and residential services for women Veterans who have experienced MST and provides free care for all mental and physical health conditions related to MST.2 Veterans may be able to receive this free MST-related healthcare even if they are not eligible for any other VA care. An SC disability rating is not required, nor is the Veteran required to have reported the MST when it happened or have documentation that it happened. Every VA medical center has an MST Coordinator who specializes in this type of care and assists Veterans to access needed care. To accommodate female Veterans who do not feel comfortable in mixedgender treatment settings, many VA medical centers have women only programs or have specialized women’s treatment teams.

The VA offers a variety of programs designed to assist homeless Veterans, including special populations such as women with families.2 Programs include outreach and prevention, temporary and transitional housing, and permanent housing with supportive services. Among the homeless Veteran population, nearly 8% are female.2

The VA has dramatically increased mental health services because of the growing number of women Veterans, who use mental health services in larger numbers than their male counter-parts.Since 2012, more than 1,000 mental healthcare providers and more than 200 administrative support staff were hired, with a goal of hiring 1,600 providers and 300 support staff in 2013 alone.9 Mental health professionals include psychiatrists, psychologists, social workers, mental health nurses, licensed professional mental health counselors, licensed marriage and family therapists, and addiction disorder therapists. In addition, Veterans are being hired as Peer Specialists (up to 800 positions) who provide support to other Veterans. The number of phone lines for the Veteran Crisis Hotline has been increased by 50% to handle the additional volume of phone requests for mental healthcare services.

What type of maternity care does the VA offer?

Many female Veterans who served in OEF/OIF/OND are of reproductive age. Among these women, 81.1% were born in or after 1970 and 54.6% were born in or after 1980.2 With larger numbers of reproductive-aged women Veterans, the VA has recognized the need for expanded maternity care services. Maternity care is provided through outside community providers; costs are paid by the VA.10 The VA covers standard prenatal care, laboratory services, ultrasounds, and delivery costs. If a woman requires specialty care (such as Cardiology) during her pregnancy, her HCP can network within the VA if that service is available. Otherwise, necessary care is handled by other community providers. Each VA Medical Center has a Maternity Care Coordinator who contacts every pregnant Veteran at least every 2 months to review her physical and psychological needs, to ensure that she has the supplies and educational services that she requires, and to keep the Veteran in contact with her primary care and mental healthcare teams as needed. The newborn’s hospital healthcare is covered from birth through 7 days of life.10

What is the VA’s vision with regard to women’s healthcare?

The vision of the VA is to provide the highest quality care to every woman Veteran. Care of the highest quality….

• ensures that each woman Veteran coming to the VA will have her gender-specific primary care needs met by a proficient and interested PCP.

• includes privacy, dignity, and sensitivity to gender-specific needs.

• ensures that healthcare equipment and technology are state-of-the-art.

• ensures gender parity in performance measures.

• provides the right healthcare in the right place at the right time.

• builds necessary efficiencies into the delivery of women’s healthcare.

Each VA facility assesses its needs, strengths, and challenges to create a plan that works for its population of women Veterans, its areas of expertise, and its facilities, equipment, and staffing capacity. The VA is committed to exploring new approaches and pilot programs, all of which are designed to raise the standard to provide the best care anywhere.11 Beyond healthcare, the VA has a full range of benefits for women Veterans, including education and job training, vocational rehabilitation, benefits assistance, home loans, life insurance, and survivor and death/burial benefits.1 The VA is encouraging everyone to rethink the term Veteran (that former warrior might be a woman), to recognize the vital role women play in the military, and to appreciate what it means to be a woman Veteran.

Patrice C. Malena is Women Veterans Program Manager at Hampton VA Medical Center in Hampton, Virginia. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article. The content of this article does not represent the views of the U.S. Department of Veterans Affairs or the United States Government.

References

1. Department of Veterans Affairs. Women Veterans Health Strategic Health Care Group. A Profile of Women Veterans Today. Rethink Veterans: Who is the Woman Veteran? April 2012.

2. Department of Veterans Affairs. Office of Public Affairs Media Relations. Women Veterans Health Care Fact Sheet. Updated July 2014.

3. Department of Veterans Affairs. Sourcebook: Women Veterans in the Veterans Health Administration, Volume2: Sociodemographics and Use of VHA and Non-VA Care (Fee). October 2012.

4. Department of Veterans Affairs. Report of the Under Secretary for Health Workgroup. Provision of Primary Care to Women Veterans. November 2008.

5. Department of Veterans Affairs. Office of Public Affairs. Federal Benefits for Veterans, Dependents and Survivors. Last updated April 21, 2015.

6. Department of Veterans Affairs. Women Veterans Health Strategic Health Care Group. On the Frontlines of VA Women’s Health: Enhancing Services for Women Veterans. August 2011.

7. Women Veterans Health Care. Resources for Non-VA Providers, Medical Students. Page last updated June 3, 2015.

8. Department of Veterans Affairs. Women Veterans Health Strategic Health Care Group, Office of Patient Care Services. Gender Differences in Performance Measures VHA 2008-2011; June 2012.

9. Department of Veterans Affairs. Office of Public and Intergovernmental Affairs. VA Hires More Mental Health Professionals to Expand Access for Veterans. February 11, 2013.

10. Department of Veterans Affairs. Women Veterans Health Care. FAQs. June 3, 2015.

11. Department of Veterans Affairs. Women Veterans Health Strategic Health Care Group. Guide to Moving Forward in Providing Comprehensive Health Care to Women Veterans. August 2008.

Collaboration in practice: A framework for team-based care

Since passage of the Affordable Care Act in 2010, alternate care delivery models such as patient- centered health homes and accountable care organizations have emerged as tools for payment and healthcare delivery system reform. The intent of such clinical integration models is to drive improvement in individual and population health outcomes and in the quality and efficiency of healthcare service delivery.Although these models hold promise in moving our healthcare system from a disjointed paradigm to a seamless, value-driven standard, fragmentation persists at all levels of the healthcare continuum. Establishment of a well-functioning team is one mechanism by which healthcare providers (HCPs) can achieve the goal of patient-centric, well-coordinated, safe, and responsive healthcare.2

Healthcare providers have been challenged to respond to an evolving health policy landscape that demands movement to coordinated, value-driven care models in the face of HCP shortages and shrinking resources. In response to this changing landscape, and, reflective of his own commitment to a team approach to care, John Jennings, ACOG’s 2014 President, chose—as the priority issue of his presidential year—revision of ACOG’s Guidelines for Implementing Collaborative Practice (1995) to better reflect the demands of today’s healthcare system. To meet this charge, ACOG convened an interdisciplinary task force comprising delegates from nine different organizations representing physicians, nurse practitioners, midwives, physician assistants, clinical pharmacists, and consumers. The resulting Collaboration in Practice: Implementing Team-Based Care represents a paradigm shift for healthcare service delivery in which patients are integral participants; all team members are valued equally; and all HCPs are supported in practicing to the full extent of their education, certification, and experience and accept accountability for their practice. To date, this document has been endorsed or supported by 21 national organizations, including NPWH and our sister NP organizations AANP, GAPNA, NAPNAP, and NONPF.3 The Executive Summary of this document is available here.

Team-based care and collaboration

In crafting this document, the writing team worked with the following definitions. Team-based care is defined as the “provision of health services to individuals, families, and/or their communities by at least two healthcare providers who work collaboratively with patients and their families…to accomplish shared goals…”Effective implementation of team-based care requires interprofessional collaborationdefined as “a process involving mutually beneficial participation between autonomous individuals whose relationships are governed by shared norms and visions.”3

The terms team-based care and collaboration have sometimes been used in regulatory policies in a way that places barriers to qualified HCPs’ ability to practice to the full extent of their education, certification, and experience. However, implementing team-based care delivery models does not require team-based licensure or integrated regulatory frameworks. In some cases, linked licensure and restrictive regulations may inhibit the flexibility and innovation required for team-based, patient-centered care. Of note, the ACOG document uses the terms team-based care and collaboration in their truest forms, denoting an equitable practice environment wherein each team member’s knowledge and skills are valued contributions to the team’s work. As such, the terms team-based care and collaboration should not be construed as recommended policy constructs within the context of this document.

Core concepts: Application to women’s health practice

Collaboration in Practice identifies six principles as core components guiding team-based care, all of which are relevant to women’s healthcare and WHNP practice. First and foremost, successful team-based care recognizes the patient and family as central, actively engaged members of the healthcare team.4 In 2008, the National Priorities Partnership identified patient and family engagement as one of six priorities with the most potential to reduce harm, eliminate disparities, decrease disease burden, and remove inefficiencies in healthcare delivery.4 Given the disparities in maternal/child and women’s health outcomes across the lifespan,5 a team-based approach that supports active patient engagement and shared decision making holds merit as one strategy to improve women’s health outcomes.

The second, third, and fourth guiding principles recognize the importance of shared vision, role clarity, and accountability, respectively, as important components of team-based care. These principles underscore the value of mutual respect that recognizes the expertise of each team member. Likewise, there exists an expectation of professional accountability to one’s own practice and to the team. Maintaining competencies through continuous learning is an expectation within an accountable practice. Although regulation of scope of practice resides within the purview of each state, the document urges professional organizations to continue to provide guidance for clinical practice and promote uniform educational requirements and standards of care and conduct. The Women’s Health Nurse Practitioner: Guidelines for Practice and Education, 7th edition (2014), available hereprovides a population-focused framework for WHNPs.

Communication, the fifth guiding principle, underscores the need for clear transfer of information regarding patient status and team tasks. The document recognizes the fluid nature of teams and appreciates evolving trends in healthcare. Teams range from a typical model wherein care is provided at a discrete location by a selected team of HCPs to virtual teams wherein care is provided by multiple HCPs across a variety of settings in disparate locations—in some instances using telehealth as a tool to expand access.The sixth guiding principle recognizes the fluid and dynamic nature of patient-centered care. Team leadership is described as being situational and dynamic. Within this principle, team leadership is determined in response to patient need at any given moment in time, rather than ownership by a specific role or discipline.

Women’s healthcare providers practicing in the maternal/child healthcare field may recognize parallels between team-based care and perinatal regionalization, a concept supported by the maternal/child healthcare community for more than two decades. Perinatal regionalization, which seeks to assure that high-risk pregnant women and/or infants receive the appropriate level of care at the appropriate time in order to optimize patient outcomes in high-risk situations, can be viewed as a key example of a virtual model for team-based care. In this model, communication to facilitate seamless transitions in care among community-based HCPs and perinatal care providers must be established to achieve optimal pregnancy outcomes. In-person or virtual consultation, education, and skill building help support open communication, professional accountability, and fluid team leadership. Just as the team-based care model recognizes the important role of each member, perinatal regionalization recognizes the important role of the community-based team, the perinatal center team, and wraparound service providers, all of whom contribute to an optimal outcome.7,8 Although perinatal regionalization serves as one example of the breadth of a team-based care model, the concept is transferable across a variety of healthcare settings and specialties, within a traditional or a virtual setting.

Conclusion

Women’s healthcare has always been a team-based endeavor recognizing the important role of access to gender-focused care throughout the lifespan, with attention to the realities of women’s lives outside the hospital and clinic walls. In this regard, it is especially fitting that women’s healthcare providers led the way in bringing together a diverse group of HCPs to chart a path applicable across specialties and disciplines. Furthermore, the collaborative process used in developing this document mirrored the equitable, collaborative approach recommended as a pathway to successful implementation of team-based care. NPWH was proud to be part of the working group that helped shape the concepts put forth in this document.

The aforementioned Executive Summary of the Collaboration in Practice document provides an overview of the process and key points. All of the essential elements of the work, including recommendations for implementing an equitable, accessible, reimbursable, patient-centric model of care, are elaborated in the full report. The Collaboration in Practice team invites you to consider how the full report can be used to enhance your practice and improve patient outcomes.

Susan Kendig is a teaching professor and WHNP Emphasis Area Coordinator at the University of Missouri- St. Louis; a consultant at Health Policy Advantage,LLC, in St. Louis, Missouri; and Director of Policy for the National Association of Nurse Practitioners in Women’s Health (NPWH). She served as the NPWH delegate to ACOG’s Collaborative Practice Task Force. She can be reached at 314-629-2372 or at skendig@npwh.org.

References

1. Guterman S, Drake H. Developing innovative payment approaches: finding the path to high performanceThe Commonwealth Fund. May 2010.

2. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.

3. Executive Summary: Collaboration in Practice: Implementing Team-Based Care. Report of the American College of Obstetricians and Gynecologists’ Task Force on Collaborative Practice. Obstet Gynecol. 2016;127(3):612-617.

4. National Priorities Partnership. National Priorities and Goals: Aligning Our Efforts to Transform America’s HealthcareWashington, DC: National Quality Forum; 2008.

5. Kendig S. Women’s health: more than an annual event. Womens Healthcare. 2014;2(3):36-39.

6. ACOG Task Force on Collaborative Practice. Collaboration in Practice: Implementing Team-Based CareWashington, DC: ACOG; 2016.

7. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care, 7th edition. Elk Grove Village, IL: AAP; Washington, DC: ACOG; 2012.

8. Obstetric Care Consensus No. 2: Levels of Maternal Care. Obstet Gynecol. 2015;125(2):502-515.

It’s not just physical: The adverse psychosocial effects of polycystic ovary syndrome in adolescents

 

Management of polycystic ovary syndrome (PCOS) in adolescents entails dealing not only with the physical manifestations but also the troubling psychosocial effects related to these physical manifestations. The author conducted a literature review to ascertain the adverse psychosocial effects of PCOS in adolescents, as well as what nurse practitioners can do to mitigate these effects.

Key words: polycystic ovary syndrome, PCOS, adolescence, psychosocial effects

Polycystic ovary syndrome (PCOS) is a common endocrine disorder that affects 5%-10% of women and typically begins during adolescence.1-5 Common physical manifestations of PCOS—acne, obesity, hirsutism, and anovulation—can have adverse effects on adolescents’ self-image and mood.6,7 As a result, many of these girls may withdraw from their peers because of emotional distress or embarrassment. In addition to lowering self-esteem, obesity and the features of metabolic syndrome can increase the risk for future health complications,8,9 which in turn can provoke anxiety in adolescents who are aware of these risks. With all of these negative forces at play, adolescents with PCOS are also at increased risk for depression.10 In this article, the author shares the results of a literature search on the psychosocial concerns related to PCOS in adolescents and what nurse practitioners can do to address these concerns.

Literature review

The author searched the PubMed, Google Scholar, CINAHL, and JSTOR databases to find articles published between 2002 and 2013 that pertained to the adverse psychosocial effects of PCOS in adolescents, including management of these effects. Key words in the search were polycystic ovarian syndrome, PCOS, adolescence, teens, quality of life,
psychosocial, psychosocial issues, depression, anxiety, eating disorders, hirsutism, obesity, and metabolic syndrome. Other articles were found by hand-searching relevant studies cited in the articles initially found.

Articles met inclusion criteria if they covered psychosocial concerns related to PCOS in adolescents. Articles describing the physical effects of PCOS were included if they served to provide relevant background information. Studies focusing only on adults were excluded unless, again, they provided useful background information or they compared PCOS-related psychosocial concerns in adolescents versus adults.

Psychosocial concerns related to PCOS

Table 1 lists selected studies related to psychosocial concerns in adolescents with PCOS. These concerns include anxiety and depression,1,4 social interaction,11,12 body image,11 body weight,1,11,13,14 eating disorders,15 hirsutism,13 fertility,2,11,13 and decreased quality of life (QOL) related to sexual behavior.2,11 Health-related QOL (HQOL) scores in adolescents have been correlated with the level of PCOS symptomatology.14 A qualitative study showed that a PCOS diagnosis had an adverse impact on HQOL, with emotional and social functioning being more affected than physical health.11

Psychological problems

According to a report by Dowdy,10 adolescents with PCOS commonly use words such as nerd or freak to describe themselves; PCOS changes their bodies, which makes them feel different from other adolescents. A small study showed that adolescents with PCOS, compared with healthy adolescents, had higher anxiety scale scores.4 Dowdy10 reported that anxiety among adolescents with PCOS was related to their appearance, body-image concerns, and fear of future infertility.

Insulin resistance and increased levels of insulin in the bloodstream, which are common in patients with PCOS, have been thought to cause problems with mood.16 Insulin levels in the blood can affect serotonin levels in the brain and vice versa, so it is unclear whether insulin abnormalities initiate depressive symptoms or are the result of them.10

Body weight and body-image disturbances

Overweight/obesity (OW/O) and an elevated body mass index (BMI) are more common in adolescents with PCOS than in those without PCOS.8,14 Excess weight, among all the physical manifestations of PCOS in adolescents, has the greatest adverse impact on HQOL.17,18 One study showed that HQOL scores were inversely proportional to BMI values in teens with PCOS and high BMIs.14 PCOS-related OW/O has been linked to decreased academic achievement and lower income, even after controlling for socio­economic status and intelligence. In addition, many females with OW/O are the recipients of hurtful comments and actions from peers, family members, colleagues, strangers, and even some healthcare providers,19 which can lower their self-esteem.

Other body-image concerns in adolescents with PCOS involve male-pattern hair on the face and body and acne.10 Adolescents with hirsutism, versus those without the condition, have lower HQOL scores and self-esteem and an increased prevalence of anxiety disorders.20 Some adolescents report feeling that hirsutism has robbed them of their female identity.10 PCOS-related insulin resistance increases the risk for developing acanthosis nigricans (a brown to black, poorly defined, velvety hyperpigmentation of the skin),21 another body-image concern because of its physical visibility.

Femininity, fertility, and sexuality concerns

According to the dictionary, feminine means “having the qualities traditionally ascribed to women.”22 Menstruation is an important symbol of femininity; menarche and a normal menstrual cycle serve as rites of passage that prove that a female has the ability to reproduce.4 Adolescents with PCOS, versus their healthy peers, are more likely to have concerns about their future fertility because of their menstrual irregularities.2 Fear of potential infertility has an adverse impact on HQOL.

Adolescents with PCOS, compared with adolescents who do not have PCOS, may feel more self-conscious, less desirable, and less inclined to be outgoing with persons to whom they are attracted.10 A teen with PCOS may feel unsexy or unwomanly because her body has “let her down,” and she may have less sexual interest because of the many PCOS-related stressors with which she must cope.10Eating disorders
Results of a retrospective study showed that adolescents with menstrual disturbances were at greater risk of having an eating disorder.23 Adolescents with OW/O may develop unhealthy eating habits such as binge eating, purging, dieting, and using diuretics or laxatives to lose weight.24 Some adolescents with PCOS feel that their efforts to lose weight are not as successful as those of their peers who do not have PCOS.10

Screening for adverse psychosocial effects of PCOS

Screening for psychosocial concerns related to PCOS should start early in adolescence. Table 2 lists screening tests available for identification of psychosocial problems.25 An evaluation of the Polycystic Ovary Syndrome Questionnaire (PCOSQ) by Jones et al26 found this tool reliable for determining HQOL in women with PCOS. Validity of the tool could be improved with the addition of acne to the questionnaire because of acne’s identification as an important factor involved in HQOL. Although the PCOSQ was first developed based on research conducted on women,27 it has been used in adolescents to assess psychosocial concerns related to PCOS.13

NP role in managing psychosocial effects of PCOS

Goals of therapy for adolescents with PCOS—amelioration of psychological problems, weight loss, reduction of the manifestations of hyperandrogenism, and improvement in body image and self-esteem—are best achieved by a multidisciplinary team that includes NPs.3,4,28 The physical and psychosocial aspects of treatment go hand in hand. Meeting physical management goals (e.g., weight loss, reduction in hyperandrogenism manifestations) can lessen some of the troubling psychosocial effects, and enhancing self-esteem can motivate weight-loss efforts and perhaps even improve adherence to the pharmacotherapeutic regimen. One of the best ways that NPs can help is to supply adolescent patients with information about PCOS and its treatment that they can understand.

Mental health approaches

An open trial of weekly cognitive behavioral therapy sessions and family sessions has shown that these modalities may help treat both depressive symptoms and obesity in adolescents with PCOS.1 Participating in individual and family sessions can help patients develop positive methods of coping with PCOS and find constructive ways to manage their feelings. Support groups that meet in person or online can help motivate adolescents to make and maintain healthy lifestyle choices.29,30 NPs can recommend any or all of these psychotherapeutic approaches.

Lifestyle changes

Weight loss of 5%-10% may not only decrease cardiovascular risks and insulin resistance but also help improve HQOL.8,14,31 NPs should ascertain which weight-loss strategies have worked or not worked in the past, and identify any unsafe weight-loss strategies and eating patterns in which patients may be engaged.24,29 In these cases, NPs should offer patients safe alternatives for losing weight.24

A case–control study showed that, compared with controls, girls with PCOS engaged in physical activities less often (if they did exercise, they did so with less frequency and intensity), and they were less likely to be aware of the beneficial effects of exercise on their health.32 NPs should encourage patients to exercise regularly, which may help increase their self-esteem and overall health.13,19 Yoga may be even more beneficial; results of a recent randomized, controlled trial indicated that yoga effectuated a significantly greater increase in HQOL than did traditional exercise.33

With regard to approaches to counter the effects of hyperandrogenism, unwanted hair can be removed temporarily via shaving, waxing, and/or plucking (which unfortunately may cause other unwanted effects such as irritation, scarring, or folliculitis). Laser treatments can provide more permanent results, but many treatments may be needed and the treatments may be costly.34

Medications

Oral contraceptives (OCs) regulate menstrual cycles and treat hirsutism and acne.28,34 Insulin sensitizers such as metformin can be used to treat underlying insulin resistance.34,35 However, a randomized, placebo-controlled trial showed that adding metformin to a regimen of lifestyle changes and OC use did not lead to a significant improvement in HQOL.13 Anti-androgens such as spironolactone can help manage the hyperandrogenism effects.34,36 Statins are first-line treatments for lowering low-density lipoprotein cholesterol levels.37 Antidepressants and anxiolytics can be used to treat psychiatric disorders related to PCOS; in these cases, NPs may want to consult with a mental health specialist.

Further research

An important topic for future study is the efficacy of implementing a HQOL survey at every primary care visit for adolescents with PCOS. The purpose of this survey would be to assess for psychosocial co-morbidities common in individuals with PCOS. The studies should ascertain whether implementing such a screening would make providers more aware of the adverse psychosocial effects of PCOS, help identify psychosocial symptoms, and facilitate more comprehensive treatment when needed. Additional research should determine the outcomes of losing weight, how other PCOS-specific interventions affect overall HQOL, how to address infertility concerns, and how primary care practitioners can best manage adolescents holistically to help improve HQOL. More research is needed regarding how providers should teach and communicate with adolescents with PCOS.

Conclusion

Polycystic ovary syndrome in adolescents involves a myriad of physical manifestations that can compromise psychosocial health. These adverse psychosocial effects may have a major impact on HQOL. Early diagnosis of PCOS, screening for adverse psychosocial effects, and treatment that reduces physical manifestations of PCOS are important. Lack of attention to these problems can force adolescents to endure adverse psychosocial effects that can lead to further unhealthy behaviors. NPs have an opportunity to educate adolescents about the disease process of PCOS and to implement strategies to treat these patients’ physical and psychosocial problems to improve their HQOL for a lifetime.

Joyce S. Lee is a certified pediatric nurse practitioner who graduated from Columbia University School of Nursing in New York, New York. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

Acknowledgment

The author thanks Rita Marie John, DNP, EdD, CPNP-PC, DCC, for her help, editing, and counsel during the preparation and writing of this article.

References
1. Rofey DL, Szigethy EM, Noll RB, et al. Cognitive–behavioral therapy for physical and emotional disturbances in adolescents with polycystic ovary syndrome: a pilot study. J Pediatr Psychol. 2009;34(2):156-163.

2. Trent ME, Rich M, Austin SB, Gordon CM. Fertility concerns and sexual behavior in adolescent girls with polycystic ovary syndrome: implications for quality of life. J Pediatr Adolesc Gynecol. 2003;16(1):33-37.

3. Bekx MT, Connor EC, Allen DB. Characteristics of adolescents presenting to a multidisciplinary clinic for polycystic ovarian syndrome. J Pediatr Adolesc Gynecol. 2010;23(1):7-10.

4. Laggari V, Diareme S, Christogiorgos S, et al. Anxiety and depression in adolescents with polycystic ovary syndrome and Mayer-Rokitansky-Küster-Hauser syndrome. J Psychosom Obstet Gynaecol. 2009;30(2):83-88.

5. Rachmiel M, Kives S, Atenafu E, Hamilton J. Primary amenorrhea as a manifestation of polycystic ovarian syndrome in adolescents: a unique subgroup? Arch Pediatr Adolesc Med. 2008;162(6):521-525.

6. Perrin JM, Gnanasekaran S, Delahaye J. Psychological aspects of chronic health conditions. Pediatr Rev. 2012;33(3):99-109.

7. Leventhal H, Leventhal EA, Contrada RJ. Self-regulation, health, and behavior: a perceptual-cognitive approach. Psychol Health. 1998; 13(4):717-733.

8. Coviello AD, Legro RS, Dunaif A. Adolescent girls with polycystic ovary syndrome have an increased risk of the metabolic syndrome associated with increasing androgen levels independent of obesity and insulin resistance. J Clin Endocrinol Metab. 2006;91(2):492-497.

9. Snyder BS. Polycystic ovary syndrome (PCOS) in the adolescent patient: recommendations for practice. Pediatr Nurs. 2004;31(5):416-422.

10. Dowdy D. Emotional needs of teens with polycystic ovary syndrome. J Pediatr Nurs. 2012;27(1):55-64.

11. Jones GL, Hall JM, Lashen HL, et al. Health-related quality of life among adolescents with polycystic ovary syndrome. J Obstet Gynecol Neonatal Nurs. 2011;40(5):577-588.

12. Trent ME, Rich M, Austin SB, Gordon CM. Quality of life in adolescent girls with polycystic ovary syndrome. Arch Pediatr Adolesc Med. 2002;156(6):556-560.

13. Harris-Glocker M, Davidson K, Kochman L, et al. Improvement in quality-of-life questionnaire measures in obese adolescent females with polycystic ovary syndrome treated with lifestyle changes and oral contraceptives, with or without metformin. Fertil Steril. 2010;93(3):1016-1019.

14. Trent M, Austin SB, Rich M, Gordon CM. Overweight status of adolescent girls with polycystic ovary syndrome: body mass index as mediator of quality of life. Ambul Pediatr. 2005;5(2):107-111.

15. Wiksten-Almstromer M, Linden-Hirschberg A, Hagenfeldt K. Menstrual disorders and associated factors among adolescent girls visiting a youth clinic. Acta Obstet Gynecol Scand. 2007;86(1):65-72.

16. Weiner CL, Primeau M, Ehrmann DA. Androgens and mood dysfunction in women: comparison of women with polycystic ovarian syndrome to healthy controls. Psychosom Med. 2004;66(3):356-362.

17. Adali E, Yildizhan R, Kurdoglu M, et al. The relationship between clinico-biochemical characteristics and psychiatric distress in young women with polycystic ovary syndrome. J Int Med Res. 2008;36(6):1188-1196.

18. Hoeger KM. Obesity and lifestyle management in polycystic ovary syndrome. Clin Obstet Gynecol. 2007;50(1):277-294.

19. Zidenberg N, Wright S. Care of the overweight adolescent including polycystic ovarian syndrome. Clin Obstet Gynecol. 2008;51(2):249-256.

20. Drosdzol A, Skrzypulec V, Plinta R. Quality of life, mental health and self-esteem in hirsute adolescent females. J Psychosom Obstet Gynaecol. 2010;31(3):168-175.

21. Bhattacharya SM, Ghosh M. Insulin resistance and adolescent girls with polycystic ovary syndrome. J Pediatr Adolesc Gynecol. 2010;23(3):158-161.

22. Steinmetz S, ed. Feminine. In: Random House Webster’s Unabridged Dictionary. 2nd ed. New York, NY: Random House, Inc; 1997:708.

23. Wiksten-Almstromer M, Linden-Hirschberg A, Hagenfeldt K. Menstrual disorders and associated factors among adolescent girls visiting a youth clinic. Acta Obstet Gynecol Scand. 2007;86(1):65-72.

24. Jasik CB, Lustig RH. Adolescent obesity and puberty: the “perfect storm.” Ann N Y Acad Sci. 2008; 1135(1):265-279.

25. Jones GL, Balen AH, Ledger WL. Health-related quality of life in PCOS and related infertility: how can we assess this? Hum Fertil. 2008;11(3):173-185.

26. Jones GL, Benes K, Clark TL, et al. The polycystic ovary syndrome health-related quality of life questionnaire (PCOSQ): a validation. Hum Reprod. 2004;19(2):371-377.

27. Cronin L, Guyatt G, Griffith L, et al. Development of a health-related quality-of-life questionnaire (PCOSQ) for women with polycystic ovary syndrome (PCOS). J Clin Endocrinol Metab. 1998;83(6):1976-1987.

28. Mastorakos G, Lambrinoudaki I, Creatsas G. Polycystic ovary syndrome in adolescents: Current and future treatment options. Paediatr Drugs, 2006;8(5):311-318.

29. Nicandri KF, Hoeger K. Diagnosis and treatment of polycystic ovarian syndrome in adolescents. Curr Opin Endocrinol Diabetes Obes. 2012;19(6):497-504.

30. Yii MF, Lim CED, Luo X, et al. Polycystic ovarian syndrome in adolescence. Gynecol Endocrinol. 2009;25(10):634-639.

31. Wild RA, Carmina E, Diamanti-Kandarakis E, et al. Assessment of cardiovascular risk and prevention of cardiovascular disease in women with the polycystic ovary syndrome: a consensus statement by the Androgen Excess and Polycystic Ovary Syndrome (AE-PCOS) Society. J Clin Endocrinol Metab. 2010;95(5):2038-2049.

32. Eleftheriadou M, Michala L, Stefanidis K, et al. Exercise and sedentary habits among adolescents with PCOS. J Pediatr Adolesc Gynecol. 2012;21(3):172-174.

33. Nidhi R, Padmalatha V, Nagarathna R, Amritanshu R. Effect of yoga program on quality of life in adolescent polycystic ovarian syndrome: a randomized control trial. Appl Res Qual Life. 2013;8(3):373-383.

34. Williams RM, Ong KK, Dunger DB. Polycystic ovarian syndrome during puberty and adolescence. Mol Cell Endocrinol. 2013;373(1-2):61-67.

35. Salmi DJ, Zisser HC, Jovanovic L. Screening for and treatment of polycystic ovary syndrome in teenagers. Exp Biol Med. 2004;229(5):369-377.

36. Arslanian S, Warren-Ulanch J. Treatment of PCOS in adolescence. Best Pract Res Clin Endocrinol Metab. 2006;20(2):311-330.

37. Wild RA. Dyslipidemia in PCOS. Steroids. 2012;77(4):295-299.

Barriers to care for sexual assault survivors of childbearing age: An integrative review

Research indicates that only a small fraction of sexual assault survivors seek comprehensive care—including physical and mental healthcare, forensic evidence collection, victim services, and legal support—after the assault. This integrative review was conducted to identify barriers that may be keeping sexual assault survivors of childbearing age from receiving such comprehensive care.

Key words: sexual assault, barriers to care, comprehensive care

For women in the United States, one of the most likely causes of severe psychological trauma is sexual assault, defined as unwanted sexual contact in any form that occurs without a person’s consent.1,2 Survivors of a completed rape have a 32%-80% incidence of posttraumatic stress disorder (PTSD), versus a rate of 9%-15% in the general population.3-6 In addition to psychological harm, sexual assault survivors may experience physical consequences such as bodily injury, sexually transmitted infections (STIs), and pregnancy. In the immediate aftermath of a sexual assault, about half of survivors show evidence of physical trauma, up to 30% contract an STI, and 5% become pregnant.7,8 Furthermore, survivors are up to 9 times more likely than the average woman to attempt suicide.9 Despite these potential health risks, a major gap exists between reported rates of sexual assault and rates of comprehensive care seeking following the assault.

Statement of the problem

In this country, 1 of every 4-5 women is raped in college,10,11 and lifetime prevalence of rape is 1 in 6-10 women.1,12 Following sexual assault, women may have a need for comprehensive care provided at a rape crisis center or hospital emergency department (ED)—ideally by a specially trained sexual assault nurse examiner (SANE). Recommended comprehensive care following a sexual assault includes treatment of physical injuries and other sequelae, pregnancy prevention, STI screening and treatment, psychological support and care for potential PTSD, forensic evidence collection, victim services, and legal support.1,13-16

Many sexual assault survivors do not receive the comprehensive care they need. In one analysis of post-assault care seeking, only one-third of rape survivors sought assistance from one or more of the following: the legal system, the medical system, the mental healthcare system, a rape crisis center, and/or the religious communi­ty.17 Another report indicated that 4 million U.S. women have not received medical attention focused on preventing or treating the physical and emotional effects of rape.8

The study

The author conducted an integrative literature review to ascertain the barriers that may be keeping childbearing-age women from seeking comprehensive care following sexual assault. The review was focused on survivor, advocate, healthcare provider (HCP), police, and student perspectives.

Method—Five steps were used: problem identification, literature search, data evaluation, data analysis, and presentation.18 An integrative review was appropriate because of the mix of quantitative and qualitative data that were available.18,19Problem identification. The author analyzed empirical studies and national surveys completed between 1990 and 2012. The research question guiding the review was “What are the barriers that may prevent sexual assault survivors of childbearing age from receiving comprehensive care?”

Literature search. The review was conducted at a university library using the search terms sexual assault, rape, barriers to care, barriers, inhibitors, impede, comprehensive care, health care, and health care access. The search utilized a variety of databases. National surveys were identified separately by searching national websites. Only studies whose purpose was to identify barriers to care for sexual assault survivors of childbearing age were included. These studies had to be written in English in the form of scholarly works, dissertations, or qualitative or quantitative research. Excluded were papers unrelated to the research question, commentaries, literature reviews, and papers not written in English.

The initial search elicited 220 articles with the following distribution: Cochrane Database of Systematic Reviews (n = 3), CINAHL (n = 12), EMBASE (n = 101), ISI Web of Knowledge (n = 52), PubMed (n = 37), and PsycINFO (n = 15). Many of these 220 articles were duplicates, and only 11 met all inclusion criteria. By hand-searching the references of these 11 articles, the author found 1 additional article for inclusion, resulting in a total of 12 empirical articles. In addition, 4 national surveys described in 6 different reports met inclusion criteria.

Data evaluation and analysis. Data extraction for the 4 national surveys and 12 empirical studies was conducted with use of a table to identify key components. The author extracted data about the sample, study design, outcomes measured, instruments utilized, results related to the research question, validity, and notes. Results related to the research question were reviewed for common themes using a technique similar to the constant comparative method of analysis outlined by Glaser.20 This technique entailed reading through the results to glean general thoughts, followed by a line-by-line review to evaluate for general themes using a color-coding system. Further review elicited core themes. The data were reviewed again to find commonalities in themes among the studies. Finally, the data were compiled into over­arching themes related to the research question and assessed for the information they represented.

Whittemore and Knafl18 noted that the diverse array of primary sources in an integrative literature review increases the complexity in evaluating the quality of the literature. Also, in an integrative review with a diverse collection of studies, various threats to internal validity must be addressed.19,21 These threats were determined by assessing the studies’ methodology and data relevance.

Results—
National surveys. Four national surveys were reported in 6 different studies (Table 1).1,2,8,10,22,2Empirical studies. Table 2 lists the 12 empirical research studies that met inclusion criteria. As shown in Table 3, these studies used a cross-sectional methodology24-29 or a descriptive or exploratory qualitative method­ology.30-35 All of the studies’ research questions elicited the barriers that prevented sexual assault survivors of childbearing age from accessing community services such as police re­porting,24 mental healthcare,27 medical care,25 and sexual assault centers.26,29Themes. Several themes describing barriers to care emerged. These themes, subdivided into personal and environmental factors, are described in detail using the results from all 18 studies—that is, the 6 reports on national survey data and the 12 empirical studies.

PERSONAL FACTORS. The overarching theme of personal factors encompassed barriers to care inherent to a survivor herself. This broad theme included three subfactors: emotional states, fear of external exposure, and lack of knowledge.

Emotional states. Certain emotional states experienced by a woman after a sexual assault could preclude her from seeking physical, mental, or legal care. These emotional states were identified in 11 (61%) of the 18 studies.1,22,24,26-32,35 Emotional states most commonly cited as barriers were shame,24,28-31 embarrassment or humiliation,1,24,26-29,32,35 guilt,26,28,30,35 and self-blame.22,26Fear of external exposure. Fear of external exposure was described in 12 studies (67%).1,2,8,10,23,24,26,28,29,31,32,35 Fears cited by survivors included bad treatment by the criminal justice system,2,10,23 not being believed,24,28,29 lack of confidentiality,22,24,26,28,29,31,32 going to trial,24 the assailant,1,2,10,23,24,28,31,32,35 and public exposure.8,29 Fears related to the assailant involved fear of retaliation1,10,23,24,28,31,32,35 and, conversely, the possibility of jail for the assailant because the survivor had some type of relationship with the assailant.24 Fear of public exposure was often cited by members of groups such as immigrants, persons with disabilities, sexual minority members, and racial minority members.28 Many of these women feared that their minority status would bring them greater stigma and potentially unfair treatment.

Lack of knowledge. Lack of knowledge regarding post-assault services was identified as a barrier to care in 6 studies (33%).2,23,27,28,31,32 This knowledge deficit encompassed factors such as not knowing which services were needed,31,32 where or how to get services,2,23,28,31,32 and how to pay for services.27,31,32

ENVIRONMENTAL FACTORS. The broad theme of environmental factors captured barriers to care due to outside forces and not within a survivor’s immediate control. These factors were noted in 11 of the 18 studies and included themes of structural/organizational barriers and societal rape myths.

Structural or organizational barriers. Barriers to comprehensive care can include factors related to how these services are accessed. Structural/organization barriers were elicited from 6 studies (33%).25,31-35 For instance, many survivors cited a lack of availability or limited services as a barrier to receiving care.31-33,35 Organizational barriers reported by HCPs included inexperience in treating sexual assault survivors, inadequate time, and personal discomfort.27 Rape victim advocates noted insufficient funding resources as barriers that might compromise survivors’ ability to receive support.33,34Societal myths. Twelve studies (67%) noted the perpetuation of rape myths by society as a factor in preventing survivors from accessing care.1,10,23,24,25,27,29-32,34,35 Many of these myths are propagated through biases related to race, gender, disability, sexual orientation, and class.34 Subsumed within this category is survivors’ perception of the social stigma attached to naming the incident and the belief that the assault was not serious enough to warrant using services.1,10,23,27,29 Societal myths noted by persons in the service sector included police attitudes, including blame and insensitivity24,31,32 and doubt about the validity of the sexual assault accusations.35 Some HCPs perceived that survivors would return to partners who had perpetrated the assault.25Discussion—This review has shown that from survivor, advocate, HCP, police, and student perspectives, numerous barriers to care—encompassing both personal and environmental factors—may prohibit a woman of childbearing age from seeking care after a sexual assault. The overarching theme of personal factors comprised the survivor’s emotional state, her fear as it related to external exposure of the survivor and the assailant, and a lack of knowledge about post-assault services. These results coincide with past research, which has shown that many survivors, especially members of ethnic minorities, lack awareness about post-assault services such as rape crisis centers.17 The broad theme of environmental factors included subthemes of structural/organizational barriers and societal myths. Past research has shown that survivors needed to sit for extended periods of time while they waited to be seen by HCPs who did not have training on the physical or mental aspects of performing a forensic exam.36 In addition, rape myths are known to affect how a survivor deals with an assault, including acquisition of care.37,38 The themes subsumed under environmental factors are long-standing issues that must be addressed using a team approach to improve acquisition of comprehensive care by sexual assault survivors.

Limitations. This review could not completely separate the research articles that dealt with sexual assault and intimate partner violence. One person may be a survivor of both crimes within the same relationship; therefore, many researchers combine the topics. All data were collected via cross-sectional surveys or qualitative interviews and are thus correlational in nature. These data are subject to the possible weaknesses of responses affected by social desirability bias (wherein a respondent wishes to please a researcher) and complicated by the stigma of the topic itself and by problems of recall of traumatic events post-assault.

A limitation specific to the studies in this review was the potential for limited generalizability due to homogenous samples, small sample sizes, and failure to expound on study characteristics. However, the four studies that enrolled college students had fairly heterogeneous samples in terms of age and ethnicity,26,27,29 and most qualitative studies had heterogeneous samples as evidenced by demographic variables and identified themes consistently reported within their study samples.31,32,34

Because a validated and psychometrically sound barriers-to-care scale for sexual assault survivors does not exist, all of the cross-sectional studies used questionnaires specifically created for the purposes of their study. These surveys may not have captured the full range of barriers to care perceived by these survivors.

Strengths. This integrative review demonstrates many strengths within this body of literature. The barriers identified within each individual study, when compared as a group, were consistent. Furthermore, the studies sampled a wide range of individuals. This broad range of participants, coupled with the large geographic region they represent, provides strong evidence for the overall generalizability of the results. Finally, the exploratory and descriptive natures of the included studies have served the purpose of identifying which barriers to care exist for sexual assault survivors of childbearing age.

Implications for practice and research

For nurse practitioners (NPs) working on the front line with survivors of sexual assault, one way to begin to overcome barriers to care is to change the societal atmosphere that perpetuates rape myths. Underlying this atmosphere are patriarchal attitudes and a history of male dominance, both of which support the perpetuation of sexually violent behaviors.

Nurse practitioners need to identify and treat survivors of sexual assault, an all-too-common crime. NPs should consider using screening techniques to identify these survivors, which could simply involve asking about sexual trauma in childhood and adulthood. NPs must also be aware of potential psychological and physical manifestations of past sexual assault, including increased mental health complaints and somatic symptoms, in order to identify hidden survivors who may not freely disclose their history. Universal screening for sexual assault is controversial because of the paucity of research regarding the benefits of early identification and of treatment once a survivor is identified.39 However, NPs do have a responsibility to understand their patients’ histories and their healthcare needs.

In addition, NPs and other HCPs, mental HCPs, and members of the legal system need to know about structural barriers that may exist within their professional realm. One way to surmount these barriers is to promote and expand the use of SANE programs in all EDs. These programs, in which specially trained nurses address survivors’ emotional and medical needs while performing high-quality evidence collection, are a viable alternative to the traditional medical system.13

Nurse practitioners need to advise survivors of their options for pregnancy prevention, STI testing, care of physical injuries, and mental healthcare. And for survivors who have not yet sought post-assault care, NPs can place useful, easy-to-read brochures in public locations such as lavatories, homeless shelters, and community centers. NPs can get brochures and pamphlets from organizations such as the National Sexual Violence Resource Center or the Rape, Abuse & Incest National Network. Additional research is needed to determine the resources that survivors would find most valuable, as well as the easiest ways in which these resources could be provided. For instance, would survivors prefer to receive information about community resources at HCP visits, when they fill prescriptions (e.g., for contraceptives), or through other sources?

Conclusion

Educating women about available resources and recommended care after a sexual assault can help remove personal barriers to care. However, NPs must keep in mind that the community is responsible for minimizing structural barriers. Community members must work together to prevent the occurrence of sexual assault; to provide resources on care, social support, and legal advocacy for instances in which sexual assault has occurred; and to continue to speak with community allies and survivors to determine their needs.

Michelle L. Munro is a research fellow at the University of Michigan School of Nursing in Ann Arbor. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.

Acknowledgment

The author thanks Dr. Julia Seng and Dr. Kimberlee Gretebeck for the comments and support they provided on this manuscript. The author also gratefully acknowledges grant support by the National Institutes of Health and National Institute of Nursing Research, 5 T32 NR007073-19.

References
1. Tjaden PG, Thoennes N. Extent, Nature, and Consequences of Rape Victimization: Findings from the National Violence Against Women Survey. Washington, DC: U.S. Dept. of Justice, Office of Justice Programs, National Institute of Justice; 2006.

2. Wolitzky-Taylor KB, Resnick HS, McCauley JL, et al. Is reporting of rape on the rise? A comparison of women with reported versus unreported rape experiences in the National Women’s Study – replication. J Interpers Violence. 2011;26(4):807-832.

3. Breslau N, Peterson EL, Schultz LR. A second look at prior trauma and the posttraumatic stress disorder effects of subsequent trauma: a pro­spect­ive epidemiological study. Arch Gen Psychiatry. 2008;65(4):431-437.

4. Foa EB, Rothbaum BO. Treating the Trauma of Rape: Cognitive Behavioral Therapy for PTSD. New York, NY: The Guilford Press; 1998.

5. Kilpatrick DG, Saunders BE, Amick-McMullan A, et al. Victim and crime factors associated with the development of crime-related post-traumatic stress disorder. Behav Ther. 1998;20:199-214.

6. Resnick HS, Kilpatrick DG, Dansky BS, et al. Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. J Consult Clin Psychol. 1993;61(6):984-991.

7. Holmes MM, Resnick HS, Kilpatrick DG, Best CL. Rape-related pregnancy: estimates and descriptive characteristics from a national sample of women. Am J Obstet Gynecol. 1996;175(2):320-325.

8. Resnick HS, Holmes MM, Kilpatrick DG, et al. Predictors of post-rape medical care in a national sample of women. Am J Prev Med. 2000;19(4):214-219.

9. Goodman LA, Koss MP, Russo NF. Violence against women: physical and mental health effects. Part I: research findings. Appl Prevent Psychol. 1993;2(2):79-89.

10. Fisher BS, Cullen FT, Turner MG. The Sexual Victimization of College Women. (No. NCJ 182369). Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics; 2000.

11. Koss MP, Gidycz CA, Wisniewski N. The scope of rape: incidence and prevalence of sexual aggression and victimization in a national sample of higher education students. J Consult Clin Psychol. 1987;55(2):162-170.

12. Basile KC, Chen J, Black MC, Saltzman LE. Prevalence and characteristics of sexual violence victimization among U.S. adults, 2001-2003. Violence Vict. 2007;22(4):437-338.

13. Ahrens CE, Campbell R, Wasco SM, et al. Sexual assault nurse examiner (SANE) programs: alternative systems for service delivery for sexual assault victims. J Interpers Violence. 2000;15:921-943.

14. Campbell R, Bybee D, Ford K, Patterson D. Systems Change Analysis of SANE Programs: Identifying the Mediating Mechanisms of Criminal Justice System Impact. (No. 226497). Washington, DC: U.S. Department of Justice; 2008.

15. Campbell R, Patterson D, Lichty LF. The effectiveness of sexual assault nurse examiner (SANE) programs: a review of psychological, medical, legal, and community outcomes. Trauma Violence Abuse. 2005;6:313-329.

16. U.S. Department of Justice, Office on Violence Against Women. A National Protocol for Sexual Assault Medical Forensic Examinations: Adults/Adolescents. (NCJ 206554); 2004. http://www.ncjrs.gov/pdffiles1/ovw/206554.pdf

17. Campbell R, Wasco SM, Ahrens CE, et al. Preventing the “second rape”: Rape survivors’ experience with community service providers. J Interpers Violence. 2001;16(12):1239-1259.

18. Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs. 2005;52(5):546-553.

19. Cooper HM. Synthesizing Research: A Guide for Literature Reviews. 3rd ed. Thousand Oaks, CA: Sage Publications; 1998.

20. Glaser BG. Advances in the Methodology of Grounded Theory: Theoretical Sensitivity. Mill Valley, CA: Sociology Press; 1978.

21. Kirkevold M. Integrative nursing research—an important strategy to further the development of nursing science and nursing practice. J Adv Nurs. 1997;25:977-984.

22. Kilpatrick DG, Edmunds C, Seymour A. Rape in America: A Report to the Nation. Charleston, SC: National Victim Center & the Crime Victims Research and Treatment Center, Medical University of South Carolina; 1992.

23. Kilpatrick DG, Resnick HS, Ruggiero KJ, et al. Drug-Facilitated, Incapacitated, and Forcible Rape: A National Study. (Document No. 219181); 2007. https://www.ncjrs.gov/pdffiles1/nij/grants/219181.pdf

24. Jones JS, Alexander C, Wynn BN, et al. Why women don’t report sexual assault to the police: The influence of psychosocial variables and traumatic injury. J Emerg Med. 2009;36(4):417-424.

25. McGrath ME, Bettacchi A, Duffy SJ, et al. Violence against women: provider barriers to intervention in emergency departments. Acad Emerg Med. 1997;4(4):297-300.

26. Nasta A, Shah B, Brahmanandam S, et al. Sexual victimization: incidence, knowledge and resource use among a population of college women. J Pediatr Adolesc Gynecol. 2005;18(2):91-96.

27. Prospero M, Vohra-Gupta S. The use of mental health services among victims of partner violence on college campuses. J Aggression Maltreat Trauma. 2008;16(4):376-390.

28. Sable MR, Danis F, Mauzy DL, Gallagher SK. Barriers to reporting sexual assault for women and men: Perspectives of college students. J Am Coll Health. 2006;55(3):157-162.

29. Walsh W, Banyard V, Moynihan M, et al. Disclosure and service use on a college campus after an unwanted sexual experience. J Trauma Dissociation. 2010;11(2):134-151.

30. Kelleher C, McGilloway S. ‘Nobody ever chooses this …’: a qualitative study of service providers working in the sexual violence sector – key issues and challenges. Health Soc Care Community. 2009;17(3):295-303.

31. Logan TK, Evans L, Stevenson E, Jordan C. Barriers to services for rural and urban survivors of rape. J Interpers Violence. 2005;20(5):591-616.

32. Logan TK, Stevenson E, Evans L, Leukefeld C. Rural and urban wom­en’s perceptions of barriers to health, mental health, and criminal justice services: implications for victim services. Violence Vict. 2004;19(1):37-62.

33. Muganyizi PS, Nyström L, Axemo P, Emmelin M. Managing in the contemporary world: Rape victims’ and supporters’ experiences of barriers within the police and the health care system in Tanzania. J Interpers Violence. 2011;26(16):3187-3209.

34. Ullman S, Townsend S. Barriers to working with sexual assault survivors: a qualitative study of rape crisis center workers. Violence Against Women. 2007;13(4):412-443.

35. Young CL. Barriers to reporting sexual assault as identified by sexual assault service providers: a qualitative study. Unpublished Doctor of Nursing Science Dissertation. Memphis, TN: University of Tennessee Health Science Center; 2002.

36. Ledray LE. Sexual Assault Nurse Examiner Development & Operation Guide. NCJ 170609; 1999. http://www.ojp.usdoj.gov/ovc/publications/infores/sane/saneguide.pdf

37. DuMont J, Miller KL, Myhr TL. The role of “real rape” and “real victim” stereotypes in the police reporting practices of sexually assaulted women. Violence Against Women. 2003;9(4):466-486.

38. McGee H, O’Higgins M. Garavan R, Conroy R. Rape and child sexual abuse: what beliefs persist about motives, perpetrators, and survivors? J Interpers Violence. 2011;26(17):3580-3593.

39. Basile KC, Smith SG. Sexual violence victimization of women: prevalence, characteristics, and the role of public health prevention. Am J Lifestyle Med. 2011;5:407-417.