The Impacts of Lifetime Violence on Women's Current Sexual Health

Background: Intimate partner violence (IPV), nonpartner sexual violence (SV), child sexual and physical abuse, and neglect have detrimental impacts on women's reproductive and sexual health. More empirical studies are needed to investigate the negative impacts of lifetime violence, including physical or sexual child abuse, nonpartner SV, physical, sexual, and psychological IPV on women's sexual health to better understand long-term impacts from IPV and physical or sexual child abuse. Materials and Methods: We used data from Wellness, Health and You, an ongoing health registry. A total of 1,213 women were included in data analysis. Our aim was to investigate the associations between lifetime IPV, nonpartner SV, child abuse, and women's current sexual health defined using Patient-Reported Outcomes Measurement Information System (PROMIS) measures of sexual health (e.g., sexual satisfaction, interest, and functioning), sexual assertiveness, female sexual subjectivity, and use of online resources to address sexual needs. Multivariate analysis of covariance was used to investigate demographic factors (e.g., age and current relationship) as potential correlates of current sexual health. Results: Women with lifetime experiences of physical, sexual, or psychological IPV, nonpartner SV, and child physical or sexual abuse reported lower sexual satisfaction compared to women with no history of lifetime violence (p < 0.0001). However, lifetime violence was not correlated with sexual interest, sexual functioning, sexual subjectivity, nor sexual assertiveness. Conclusion: Lifetime experiences of violence (i.e., IPV, nonpartner SV, child abuse) are associated with poorer sexual health. Asking questions about past sexual and physical violence/abuse in ways that support disclosure is important toward improving women's physical and sexual health and wellbeing.


Introduction
Globally, nearly 30% of women have experienced either physical and/or sexual intimate partner violence (IPV) or nonpartner sexual violence (SV) in their lifetime. 1In the United States, over 36.4% of women experience sexual and physical IPV, stalking, and psychological aggression by an intimate partner in their lifetime. 2hese experiences often occur earlier, with more than one in seven children exposed to physical, sexual, and emotional abuse or neglect (Center for Disease Control and Prevention, 2022), and nearly 20% of women experience sexual abuse before 18 years of age. 3,4PV, nonpartner SV, and child physical abuse and neglect, specifically child sexual abuse (CSA), have detrimental impacts on women's reproductive and sexual health.][7][8][9] Specifically, female sexual dysfunction involves distress over problems with sexual desire, arousal, orgasm, or sexual pain. 4,10Results of a systematic review show that physical and sexual IPV are associated with experiencing lower sexual desire, less pleasurable sex, sexual dissatisfaction, sexual pain, and chronic pelvic pain among women. 11Recent systematic review results indicate that sexual and emotional IPV are associated with dyspareunia, vaginal dryness, and vaginal irritation. 12omen with a history of SV and severe clinical symptoms of posttraumatic stress disorder (PTSD) experience vaginal dryness, vaginal irritation, and dyspareunia. 13imilarly, CSA is associated with sexual dysfunction, including sexual avoidance, lower sexual satisfaction, vaginismus, dyspareunia, and sexual anxiety in adult women. 14,150][21] This complex interplay involves hormones such as testosterone that may be able to mediate sexual functioning. 22This becomes particularly important in the experience of trauma.For example, a condition of the hypothalamic pituitary ovary gland is often seen in patients after PTSD due to the inhibitory effect of increased cortisol level on hypothalamic pituitary ovary glad suppression. 23Therefore, a reduction of testosterone production, as observed in hypothalamic amenorrhea conditions, could have a negative impact on sexuality, particularly sexual desire and arousal.
Several mechanisms could explain different pathways between lifetime sexual or physical violence experienced as a child or an adult and negative sexual health outcomes.For instance, the biological mechanism and structural and functional changes in the brain may cause alterations in the hypothalamic-pituitary-adrenal (HPA) axis, as the primary system involved in the physiological stress response.It is well-established that the HPA axis is dysregulated by chronic stress. 24Experiencing higher levels of psychological distress caused by violence resulting from trauma may lead to dysregulations in the HPA axis. 25When the HPA-axis is dysregulated, individuals face difficulty with decision-making and often experience dissociative states that could interfere with sexual decision-making and enjoyment.
Therefore, posttraumatic symptomatology or traumatic stress symptoms (e.g., PTSD) from lifetime violence experience may act as a mediator between lifetime violence exposure and sexual dysfunction among women, 26,27 and thereby women with a history of lifetime sexual or physical violence exposure are more likely to report poorer sexual health compared to women with no history of lifetime violence.
While prior studies demonstrate the association between sexual health problems and IPV and CSA, empirical studies are needed to investigate the negative impacts of lifetime violence, including physical or sexual child abuse, nonpartner SV, physical, sexual, and psychological IPV on women's sexual health to better understand long-term impacts from lifetime violence.
Our specific aim was to investigate the associations between lifetime IPV, nonpartner SV, child abuse, and women's current sexual health defined using Patient-Reported Outcomes Measurement Information System (PROMIS) 28 measures of sexual health (e.g., sexual satisfaction, interest, and functioning), sexual assertiveness, 29 female sexual subjectivity, 30 and use of online resources to address sexual needs.

Materials and Methods
We used data from Wellness, Health and You (WHY), an ongoing health registry which includes annual surveys from a convenience sample (N = 5,447) in a southern state in the United States.For the purposes of this analysis, longitudinal data were aggregated across survey years to identify any potential exposure to child abuse or adult physical or sexual or psychological IPV.Among those who completed the sexual health survey, only one record per participant was included in the current analysis.The design for this investigation was cross-sectional where the exposure to violence (i.e., child abuse or adult physical or sexual or psychological IPV or nonpartner SV) was collected retrospectively and sexual health was assessed related to the status of their sexual health at the time of data collection.The WHY research protocol has been approved by University of Kentucky Institutional Review Board (protocol no.43533).

Measurement
Lifetime interpersonal violence: adult IPV, adult nonpartner SV, child physical and/or sexual abuse.The following six lifetime violence experience questions (sexual, physical, or psychological IPV, adult nonpartner SV, and CSA or physical abuse) were based on items included in the Behavioral Risk Factor Surveillance System. 31Lifetime IPV exposure was measured using three questions that solicited a yes or no response: (1) sexual IPV ''Has an intimate partner used force [like hitting, holding down, or using a weapon] to make you have sex [any sex act, not just intercourse]?'';(2) physical IPV ''Has an intimate partner hit, kicked, punched, or otherwise hurt you?''; and (3) psychological IPV ''Has an intimate partner made serious threats, tried to control you, or humiliated you on purpose.''Adult nonpartner SV was measured with the following question that solicited a yes or no response: ''Has anyone, other than an intimate partner or anyone else, used force-such as hitting, holding down, or using a weapon to make you have sex, any sex act, not just intercourse?.''Child physical and sexual abuse were measured using the following BRFSS questions that solicited a yes or no response: (1) ''Did a parent, stepparent, or guardian ever hit, kick, punch, or otherwise hurt you?; and (2) Did a parent, stepparent, or guardian ever make you have sex [any sex act, not just intercourse] by using force or by threatening to harm you or someone close to you?.''Because SV has been associated with poorer sexual health, we used a hierarchical approach to prioritized SV, measured as adult partner SV, adult nonpartner SV, or CSA.
Specifically, (1) those experiencing any form of SV, regardless of physical or psychosocial violence, were grouped together, (2) those experiencing physical violence as an adult or child, yet no SV, were grouped regardless of psychologic IPV, (3) and those experiencing psychologic IPV ''alone'' were grouped together.For these three groups experiencing violence, the referent group were those not experiencing violence or abuse.
Sexual health measures (primary outcomes).Three existing scales were used to measure indicators of sexual health.The scales included the PROMIS Sexual Health module, the Female Sexual Subjectivity Inventory (FSSI), and the Sexual Assertiveness Questionnaire (SAQ-12).The PROMIS sexual health module 31,32 was adapted to include three subscales: sexual satisfaction (5 items, 1 factor, variance explained [VE] = 3.63, Cronbach's a = 0.903), sexual interest (5 items, 1 factor VE = 3.19, a = 0.87), and sexual functioning (5 items, 1 factor, VE = 3.43, a = 0.78).Our adaptation was changing the time reference period from the past 7 days to the past month depicted in Supplementary A, Supplementary Table S1 for PROMIS sexual health measures.
A 4-item subscale of the FSSI 30 was included as an indicator of a woman's sense of entitlement to sexual pleasure and safety from a partner (1 Factor, n = 1,191, VE = 3.29; a = 0.928) see Supplementary A, Supplementary Table S2.Twelve items from the SAQ 29 were included as measures of communications about sexual initiation and satisfaction (a = 0.866; 12 items, Range: 0-55) 1 Factor, n = 1,191, VE = 5.58).See Supplementary A, Supplementary Table S3.
A 4-item measure assessing the frequency participants visited or used online resources to address sexual needs was created for this research (M.K.M., A.L.C.).The items addressed visits to websites dedicated to (1) sexual health information such as contraception, sexually transmitted infections, and pregnancy; (2) sexual pleasure information such as orgasm technique, mindfulness during sex, and mutual pleasure, but would not be considered pornography; (3) pornography such as depictions of genitals touching, mouths on genitals, and genitals being penetrated; (4) dating apps or websites such as Tinder, Grinder, Bumble, and Match.Response options ranged from Daily ( = 10), Weekly ( = 4), Once in the Past Month ( = 1), and Never or not applicable ( = 0) (1 factor, VE = 1.79, a = 0.575).
Demographic data collected included current age (based on the participant's most recently completed survey), race (self-reported, then grouped as White, Black, Asian, Hispanic, or Other), sex assigned at birth (restricted to female for the current analyses), current employment status, highest education, (based on the participant's most recently completed survey).See Table 2 for the demographic attribute categorizations.

Statistical analysis
Sample size.A total of 1,274 WHY participants completed the sexual health module.Eleven men were excluded from analysis for not being women and 21 women were excluded due to missing responses for adult violence (n = 21) and 29 with incomplete responses for sexual health items outside the scale range of 4-25.A total of 1,213 women with no missing data on adult violence or sexual health measures were included in the final analysis.
Confounder assessment.Demographic attributes of WHY participants were investigated as correlates of lifetime violence experiences (primary exposure).Test of differences in proportions for demographics by lifetime violence rates were used (Chi-square, Table 2).Because current sexual health was the primary outcome, as assessed using the three PROMIS subscales, the FSSI, and SAQ-12, we opted to evaluate current demographic attributes as potential confounders of association between lifetime violence and sexual health.Multivariate analysis of covariance (MANCOVA) was used to investigate demographic factors (e.g., age and current relationship) as potential correlates of current sexual health.Demographic factors associated with violence were included in subsequent models as potential confounders.To investigate the association between timing (child or adult), types of violence exposure (e.g., physical or sexual or psychological IPV or nonpartner SV, three sets of measures were included in MANCOVA. Hypothesis testing.The p-values associated with Wilks' Lambda for MANCOVA were significant ( p < 0.05) indicating that these five dependent variables were correlated and use of MANCOVA was deemed appropriate.The following indicators of current sexual health were included in one MANCOVA model as dependent variables: (1) PROMIS sexual interest, (2) PROMIS sexual function, (3) FSSI, (4) SAQ-12, and (5) use of online resources to address sexual needs.Because the PROMIS measure of satisfaction was asked for those currently in a relationship, this outcome was included in a separate model of participants who were in a relationship at the time of data collection.
The interpersonal violence exposure measures were included in separate MANCOVA analyses to determine the associated between the form and timing of interpersonal violence and the six indicators of sexual health.

Results
Among the 1,213 women included in this analysis, 41.9% (n = 508) disclosed lifetime abuse as a child (16.9%) or in adulthood (IPV: 31.3%, nonpartner SV: 11.8%; Table 1).Psychological IPV (21.4%) was the most commonly disclosed form of violence or abuse, and Psychological IPV alone without sexual or physical IPV was 10%.Among women experiencing lifetime IPV, 9% disclosed sexual IPV and 18.6% physical IPV.While 11.8% disclosed nonpartner SV (i.e., SV by someone other than a partner), 10.9% of women disclosed physical abuse, and 8.2% sexual abuse as a child; and 20% experienced both two forms of sexual abuse as a child or in adulthood (partner or nonpartner).
In an attempt to identify potential confounders for the association between lifetime violence or abuse and current sexual health indicators, lifetime violence rates were correlated with available demographic characteristics.Depicted in Table 2, lifetime violence rates were higher among WHY participants who had less education or were divorced or separated, and were older.
Based on this analysis of potential confounders, only age was correlated with lifetime violence ( p < 0.008).Current sexual relationship status, and education were additionally included in subsequent modeling as strong correlates of sexual satisfaction.
As hypothesized, lifetime sexual and physical violence experiences, defined hierarchically to prioritize lifetime SV, then physical violence, as a child or an adult, and finally, psychological IPV, were associated with lower current sexual satisfaction ( p < 0.0001, see Table 3, 1st column).In general, lifetime SV was associated with lower sexual satisfaction for those experiencing SV as a child or adult (IPV) ( p £ 0.0001).This pattern held across all interpersonal violence experi-ences in adulthood, yet, not childhood.Lifetime SV, IPV, or child abuse was not correlated with sexual interest, sexual function, sexual subjectivity, nor sexual assertiveness.Experiencing lifetime physical or sexual IPV or psychological IPV or nonpartner SV or child abuse was not associated with an increased use of online resources for sexual health.

Discussion
We found that lifetime sexual and physical violence was consistently associated with lower sexual satisfaction across all combinations of lifetime violence experienced as an adult or child.Since the initial call from scholars 11 for research to address the impacts of IPV on women's current sexual health, there has been limited examination of the associations between negative sexual health outcomes and lifetime interpersonal violence (i.e., child physical and sexual abuse, adult nonpartner SV, and physical and sexual IPV and psychological IPV) among women.To our knowledge, this investigation into the current sexual health of women who have experienced lifetime sexual or physical violence or psychological IPV is unique in its size (N = 902 adult women) and in the comprehensive  measures of lifetime violence and sexual health to include sexual interest, sexual satisfaction and functioning, sexual assertiveness, and female sexual subjectivity.Lifetime experiences of sexual, physical, and psychological IPV are associated with poorer sexual health.Results of a recent study showed that women with lifetime experiences of emotional, physical, or sexual IPV reported increased levels of worry and stress related to their current sex life, and sexual dysfunctions, including problems with sexual desire, orgasm, and sexual pain. 335][36] Our findings show that women with lifetime experiences of physical, sexual or psychological IPV, nonpartner SV, and child physical or sexual abuse reported lower sexual satisfaction (41.9%) compared to women with no history of lifetime violence.
Although we found significant associations between lifetime experiences of physical or SV as an adult or child and current sexual satisfaction, and the extent to which women used online resources for their sexual health needs were not significantly associated with lifetime sexual or physical violence.Those in the process of recovering from physical or SV may not yet be interested in pursuing online resources for satisfying and pleasurable sexual experience.Future research is needed to expand our results and investigate the confounding factors related to lifetime experiences of physical or sexual IPV or psychological IPV and child physical and sexual abuse on positive sexuality and sexual assertiveness among women.While primary prevention of sexual and physical violence victimization is essential, investigating approaches to mitigating the effect of violence/abuse on current sexual health defined to include positive sexuality, sexual functioning, and satisfaction also remain important to improving sexual health and wellbeing.
Some qualitative research has explored sexual pleasure and wellbeing after experiencing sexual trauma.Specifically, one finding of this body of work was that empathetic partner responses to disclosure of prior sexual trauma that are respectful of boundaries and allowed the survivor to lead the conversation were helpful for finding space to explore satisfying and pleasurable sexual relationships postsexual trauma. 37In addition, there are several strategies that women have reported being effective in establishing a healthy and satisfying sex life after experiencing sexual trauma, such as engagement in self-care, building social support, or communicating with their partner as concerns arise. 38oreover, the disclosure to a trusted partner in itself is helpful for healing improve symptoms or perceptions. 39Testing a multidimensional quantitative model that identifies the strongest predictors of sexual satisfaction and pleasure while healing from sexual trauma would be an ideal next step in this body of research.We observed greater use of online resources to address sexual needs among those who experienced violence in adulthood, yet, no association with seeking online resources for those experiencing violence in childhood.This observation provides support for discerning potentially different needs for healing based on whether the SV took place during childhood or adulthood as important distinction that can guide treatment of sexual trauma.

Implications
Sexual health problems associated with lifetime experiences of physical and SV as an adult or child are extensive. 5Therefore, health care providers may ask questions about past or current experiences of sexual and physical violence/abuse in ways that support disclosure.This remains a unique and strategically important tool toward improving women's physical and sexual health and wellbeing.Health care providers may also ask patients not only about their sexual health but also their sexual interest and satisfaction as both are key to physical health and emotional connections with their partners.

Limitations
Those participating in WHY are disproportionately middle-aged, well-educated women and may, therefore, not be representative of the general population or those who may be at greatest risk of nonpartner SV or IPV.Nonetheless, even in this more privileged population, rates of sexual and physical violence were comparable to national estimates, 2 and the effect of lifetime sexual and physical violence were consistently associated with poorer current sexual satisfaction.All data were collected through self-reports using reliable measures as indicated by strong psychometric properties for the majority of the current sexual health indicators.Self-reported data can be biased; however, for both past violence and current sexual health, the research participant is the only valid source of these data.
The potential for differential misclassification of current sexual health given violence experiences is unlikely, as questions regarding past violence or abuse were asked in prior surveys often years before the sexual health module was launched in 2020.We may have underestimated the effect of past violence or abuse on current sexual health because we did not have data to characterize receipt of services to address CSA or physical abuse, adult physical or sexual or psychological IPV, or nonpartner SV.We were able to adjust our analyses for potential confounding factors, including education and age, which may be associated with receipt of services.We were limited to data from cisgender women in this analysis and, therefore, future research should investigate the impact of lifetime physical or SV or current sexual health among nonbinary, transgender, or genderqueer people in addition to cisgender men.

Conclusions
Findings of this investigation highlight the importance of asking questions about lifetime experiences of interpersonal violence (i.e., child physical and sexual abuse, adult nonpartner SV, and physical and sexual and psychological IPV) to improve positive sexual health outcomes.Additional research is needed to investigate the effects of interpersonal violence on positive sexuality and sexual assertiveness among people who are from diverse socioeconomic and cultural backgrounds.While primary prevention of sexual and physical violence victimization is essential, the prevalence rates remain relatively high.Thus, investigating approaches to mitigating the effect of an array of violence/abuse on women's current sexual health (e.g., positive sexuality, sexual functioning and satisfaction) proves to be an important piece of addressing health holistically.

Table 1 .
Frequency of Lifetime Partner Violence, Sexual Violence, and Childhood Sexual and/or Physical Abuse (N = 1,213) a Form of violence.CSA, child sexual abuse; IPV, intimate partner violence; SV, sexual violence.

Table 3 .
Multivariate Analysis of Covariance Results Assessing Lifetime Interpersonal Violence and Current Sexual Health Indicators (Sexual Satisfaction, Interest, and Function), Use of Online Resources, Sexual Subjectivity, and Sexual Assertiveness (N *Modules adjusting for age, current relationship status (in a relationship or not), Education (<college, college graduate, postbaccalaureate), Wilks' Lambda