Issues in Mental Health Nursing, 35:41–49, 2014 Copyright © 2014 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2013.836727

Sexual Health and Dissociative Experiences among Abused Women Melissa A. Sutherland, PhD, FNP-BC Boston College, William F. Connell School of Nursing, Chestnut Hill, Massachusetts, USA

Heidi Collins Fantasia, PhD, RN, WHNP-BC University of Massachusetts Lowell, College of Health Sciences, School of Nursing, Lowell, Massachusetts, USA

Lesley Adkison, RN, MSN, PhD candidate Boston College, William F. Connell School of Nursing, Chestnut Hill, Massachusetts, USA

matic stress disorder (Campbell, 2002; Golding, 1999; Iverson, Litwack, Pineles, Suvak, Vaughn, & Resick, 2013; Lindgren & Renck, 2008; Silverman & Loudon, 2010). Given the prevalence of IPV among women and the association with STIs/HIV, it is important to examine factors that support or hinder sexual safety behaviors among women who have experienced IPV. Understanding underexplored psychological variables that affect women’s safer sex behaviors is a necessary first step for designing successful prevention programs. Therefore, the purpose of this study is to (1) describe the dissociative experiences of women who report IPV and (2) examine the ways in which these women describe their own sexual health, particularly how they protect themselves from sexually transmitted infections and HIV.

Sexually transmitted infections are a significant public health issue impacting women. Intimate partner violence (IPV) is one risk factor for STIs/HIV. Women who are the victims of IPV often experience psychological difficulties, including dissociation. Dissociative symptoms may play a role in women’s ability to practice safe sex and negotiate condom use, although this has been underexplored. This mixed methods study examined the dissociative symptoms of 22 women experiencing IPV and examined the ways in which these women described their own sexual health and behaviors as well as how they protected themselves from sexually transmitted infections and HIV.

Sexually transmitted infections (STIs), including HIV, are a major public health issue. A contributing risk factor for STI/HIV acquisition is intimate partner violence (IPV). IPV is defined by the Centers for Disease Control and Prevention (CDC) as a pattern of coercive control of one partner by the other (CDC, 2012a). IPV can include physical and sexual violence, threats of physical or sexual violence, and emotional abuse in the context of physical and sexual violence (CDC, 2012a). Approximately 1.3 to 5.3 million women in the United States experience IPV each year (Tjaden & Thoennes, 2000) and between 22% to 39% of women are estimated to be abused by an intimate partner in their lifetimes (CDC, 2008). Women who experience intimate partner violence are disproportionately at risk for STIs and HIV (Coker, 2007; Dimmitt Champion, Piper, Holden, Korte, & Shain, 2004; Stockman, Campbell, & Celentano, 2010), depression, anxiety disorders, and post trau-

BACKGROUND STIs/HIV Approximately 1.2 million people in the United States are currently living with HIV/AIDS, and 50,000 new people are infected each year (CDC, 2012b). In 2010, women accounted for an estimated 9,500, or 20%, of the estimated 47,500 new HIV infections in the United States (CDC, 2012c). Most of these (84%) were from heterosexual contact with a person known to have, or to be a high risk for, HIV infection (CDC, 2012c). Women are disproportionately affected by STIs, with the rate of infection among women almost three times higher than the rate among men (CDC, 2012d). For women, untreated and undertreated STIs are associated with pelvic inflammatory disease (PID), chronic pelvic pain, infertility, spontaneous abortion, preterm labor and preterm delivery (Hathaway, Mucci, Silverman, Brooks, Mathews, & Pavlos, 2000; Letourneau, Holmes, &

A Boston College Research Incentive Grant, awarded to Melissa A. Sutherland, funded this work. Address correspondence to Melissa A. Sutherland, Boston College, Nursing, 140 Commonwealth Avenue, Chestnut Hill, MA 02467 USA. E-mail: [email protected]

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Chasedunn-Roark, 1999; Wingood, DiClemente, McCree, Harrington, & Davies, 2001). IPV as a Risk Factor for HIV/STIs An increased risk for STIs/HIV among women who have experienced trauma related to IPV has been established by investigations with many different populations and settings using both qualitative and quantitative data (Coker, 2007; Dimmitt Champion et al., 2004; Stockman et al., 2010). A recent study found that IPV was significantly associated with HIV infection, with 11.8% of HIV attributed to IPV in the past year (Sareen, Pagura, & Grant, 2009). In relationships affected by violence, IPV has been linked to an increased risk of STIs through various mechanisms. IPV has been associated with sexual risk-taking among women, including multiple partners, condom non-use, and inconsistent condom use (Coker, 2007; McFarlane et al., 2005). Behaviors of the abusive partner increase a women’s risk; with one study finding that as many as 40% of abused women are forced to have sex with their partners (Campbell & Soeken, 1999). Compared to non-abusers, men who perpetrate IPV have higher rates of condom non-use and partner concurrency (multiple concurrent sexual partners), which place them at greater risk of STI acquisition and transmission to sexual partners (Raj et al., 2006). Despite the well established relationship between women’s experiences of abuse and their risk for HIV and other STIs, HIV/STI prevention strategies generally assume a woman can negotiate for condom use and safely refuse sex—conditions that are often not present for women living with IPV. At least one study has found that women who have experienced IPV can negotiate condom use and safe sex practices (Laughon et al., 2007). In many studies, however, IPV is associated with decreased condom use, decreased ability to negotiate condom use, or increased violence associated with condom use (Beadnell, Baker, Morrison, & Knox, 2000; Gielen, McDonnell, & O’Campo, 2002; Kalichman, Williams, Cherry, Belcher, & Nachimson, 1998; Rickert, Wiemann, Harrykissoon, Berenson, & Kolb, 2002; Wingood, DiClemente, & Raj, 2000; Wu, El-Bassel, Witte, Gilbert, & Chang, 2003). The inability to negotiate safe sex practices, specifically around condom use, may be related to both physical dangers and emotional trauma resulting from the prolonged stress of being involved in a violent relationship (Lindgren & Renck, 2008). Dissociation Women with a history of trauma from IPV experience higher rates of depression, posttraumatic stress disorder, and dissociative symptoms than other women (Cohen et al., 2000; Hansen, Brown, Tsatkin, Zelgowski, & Nightingale, 2012; Iverson et al., 2013; Laughon et al., 2007; Lindgren & Renck, 2008; Maman, Campbell, Sweat, & Gielen, 2000). Researchers have suggested that dissociative symptoms, in particular, may inhibit a woman from engaging in protective sexual health behaviors

and may play an important role in women’s ability to practice safer sex (Malow, Devieux, & Lucenko, 2006; Myers et al., 2006). Dissociation is defined as “a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment” (American Psychiatric Association, 2000, p. 519). It is a psycho-physiological process in which a person experiences altered information processing, resulting in a lack of integration of thoughts and feelings surrounding an event. Dissociation symptoms are seen as existing on a continuum, with “normal” dissociation consisting of day dreaming while “pathological” dissociation consists of significant amnesia or depersonalization (Martinez-Taboas & Bernal, 2000; Moskowitz, 2004). Researchers have proposed investigating dissociation as a possible psychological mechanism interfering with riskreducing behaviors and HIV counseling messages in women who have experienced trauma, including IPV (Hamberger et al., 2004; Hansen et al., 2012; Messman-Moore & Long, 2003), but few have actually measured dissociation. The study reported here is a step towards understanding the role of dissociative experiences and sexual health behaviors among women exposed to IPV. Examining safer sex strategies, particularly in the context of IPV, is essential for HIV/STI prevention (Dworkin & Ehrhardt, 2007; Gollub, French, Latka, Rogers, & Stein, 2001; Logan, Cole, & Leukefeld, 2002; Wingood & DiClemente, 1996). METHODS Design and Sample A multiple methods design was used to describe dissociative symptoms and sexual health for women who were experiencing IPV and at-risk for STIs/HIV. The research was conducted so as to collect quantitative and qualitative data concurrently. Quantitative data did not inform qualitative data and neither method was dominant (Bazeley, 2009; Tashakkori & Teddkie, 1998). The study design, instruments, and forms were all approved by the Institutional Review Board at the participating University prior to data collection. In a community health clinic, all English-speaking women aged 18 or older were asked privately if they would participate in a study to improve women’s health. The study’s purpose was described and participants were given the opportunity to ask questions. After informed consent was obtained by the principal investigator, demographic information was gathered and the women were screened for experiences of violence using the Women’s Experience with Battering (WEB) assessment. Women receiving a score of greater than 20 on the WEB were considered eligible to join the study. Thirty-six women were screened for study eligibility in a private room by the one of the investigators. Women who were not eligible were thanked for their interest, paid $5.00 for participating in the screening process, and provided with a list of resources in the community. They also were informed that the investigators were specifically interested in women who were experiencing violence in their relationships. Twenty-two women screened

SEXUAL HEALTH AMONG ABUSED WOMEN

TABLE 1 Characteristics of the Sample (n = 21) Variable Age (Mean age in years) (Range: 19–62 years) Race (n = 19) African American White Multi-Racial Did not answer Ethnicity (n = 21) Hispanic Non-Hispanic Yearly Income (n = 21) $0–24,999 $25K–49,999 Marital Status (n = 21) Married Living with someone Never married Divorced Widowed

n/% 38.8 (SD = 13) 3 (14.3) 15 (71.4) 1 (4.8) 2 (9.5) 3 (14.3) 18 (85.7) 16 (76.2) 5 (23.8) 9 (42.9) 3 (14.3) 5 (23.8) 3 (14.3) 1 (4.8)

positive, and 21 women completed the subsequent protocol (questionnaires + interview). One woman consented to the study, but was unable to continue at the moment and was lost to follow up. Quantitative Measures Demographic and Personal Information Data on age, race, marital status, current living arrangements (never with partner, with partner, separated from partner), number of children, and gynecological/obstetric history were collected. Sample demographics appear in Table 1. The Women’s Experience with Battering (WEB) The WEB measured emotional intimate partner abuse. The WEB is unique in that it measures the experiences of women in abusive relationships rather than the behaviors of their abusive partners. Instead of focusing on physical abuse, the WEB assesses for emotional abuse by measuring a woman’s perceptions of her vulnerability to physical danger and her sense of loss of power and control in her relationship (Chamberlain & Levenson, 2012). The WEB uses a 10-item scale asking a woman how safe she feels, physically and emotionally, in her relationship. The respondent is asked to rate how much she agrees or disagrees with each of the statements on a Likert-type scale, ranging from 1 (disagree strongly) to 6 (agree strongly). Scores ranging from 10 to 60 were possible, with a score of 20 or greater considered positive for IPV. The cut-off of 20 was derived from sensitivity and specificity analysis (Smith, Earp, & DeVellis, 1995). The

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WEB has an internal consistency (Cronbach’s alpha) ranging from 0.86 to 0.93. The Cronbach’s alpha for this sample was 0.87. Dissociative Experiences Scale (DES) The DES measured the degree to which participants experienced dissociation experiences (Bernstein & Putnam, 1986; Carlson & Putnam, 1993). The DES examines generalized dissociative experiences and does not look at event-specific experiences. For this study the DES was used as a research instrument to describe the type of dissociative symptoms participants experienced. It was not used as a clinical tool to diagnose dissociative disorders. The DES is a widely used measure of dissociation and a meta-analysis of 16 research studies revealed a mean alpha reliability of 0.93 (van Ijzendoorn & Schuengel, 1996). A testretest correlation of 0.84 has been reported in 26 subjects across 4–8 weeks (Bernstein & Putnam, 1986; Carlson & Putnam, 1993). The distribution of DES scores in the general population is skewed to the right with most individuals not considered high dissociators. Carlson and Putnam (1993) suggest a cut-off of 30 to identify those persons who have higher levels of dissociation. The alpha coefficient for this small sample of women was 0.94. Reproductive Coercion Reproductive coercion was measured using the Reproductive Coercion Scale (RCS). The RCS is an 11-item questionnaire that measured experiences of reproductive coercion (pregnancy coercion and birth control sabotage) by male partners. It has been tested in a sample of 1,127 women aged 16–29 from diverse ethnic and racial backgrounds (Miller et al., 2010). Women answer “yes” or “no” to items such as “Made you have sex without a condom so you would get pregnant.” Procedure After the confidential, informed consent process was completed, women completed the set of quantitative measures using a pencil and paper. While women completed the measures, the investigator was present to answer any questions and assess for any distress the women may have experienced related to the sensitive nature of the measures. After the measures were completed, the women were interviewed in a quiet, private location. Qualitative Data Interviews A qualitative descriptive approach, which allows for a direct narrative of the experiences of participants, was used for the qualitative data (Sandelowski, 2000). Single, semi-structured interviews were conducted. An interview guide was created by the researchers based upon previous work with women who had experienced intimate partner violence and child sexual abuse (Sutherland, 2011; Sutherland & Fantasia, 2012). Interviews were audio recorded with the woman’s permission. Confidentiality was maintained in multiple ways. No real names were used. All audio recordings and written study materials were

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stored in a locked file cabinet belonging to the PI. Study consents with participants’ signatures were stored separately from de-identified study materials. All study discussions and interviews with participants were conducted in a private location, and no study information was available in the participant’s health record in the community clinic where recruitment took place. After both the screening questionnaire and interviews, a short debriefing was conducted with each participant using a previously established debriefing protocol (McClain, 2004; McClain, Laughon, Steeves, & Parker, 2007). During the debriefing, warning signs of emotional distress were discussed and participants were given a list of local mental health service resources. Field notes about the environment, process, and tone of the interview and participant demeanor were recorded after each interview.

TABLE 2 Sexual health history Variable Number of pregnanciesa Number of childrena Number of abortionsa Number of miscarriagesa Number of sex partnersa Pain with sexual intercourseb Ever been tested for a STIb History of abnormal pap smearb Use birth control regularlyb a

Data Analysis The quantitative data was entered into SPSS 20.0 for management. Basic descriptive statistics for each of the study variables were obtained and distribution of characteristics was analyzed with univariate statistics. Data collection and analysis occurred simultaneously, consistent with qualitative content analysis techniques (Sandelowski, 2000, 2010). Recruitment continued until saturation was apparent and new data did not provide any unique insights related to the study purpose and aims. The recorded interviews were transcribed verbatim and an audit trail was established that included the recorded interviews, transcripts, and interviewer field notes. Transcripts were read multiple times to achieve data immersion. Conventional content analysis was chosen to analyze the data to ensure that participants’ comments would be reported with minimal inference from the researchers (Sandelowski, 2000, 2010). Units of in vivo coding within and across documents were used to identify broad categories that began to describe the ways in which the participants described their own reproductive health, including control of fertility and protection from sexually transmitted infections and HIV. These broad categories were winnowed into final concepts that contributed to the conceptualization of overall sexual and reproductive health. Two independent researchers with expertise in qualitative data analysis and interview methods verified the study design, methodology, initial coding, data analysis, and final concepts (Graneheim & Lundman, 2004; Sandelowski, 2000, 2010). The results of the qualitative data provide insights into the role of trauma, dissociative symptoms, and sexual health among this sample of women. Descriptive, quantitative data are reported to provide an overall portrayal of the sample. RESULTS Sample Characteristics The sample consisted of 21 women with a mean age of 38.8 years. A majority of the sample (n = 15) identified themselves as white and three women identified as Hispanic. These

n (SD) Range

b

2.6 (SD = 2.1) 0–8 1.5 (SD = 1.4) 0–4 0.60 (SD = 0.9) 0–3 0.48 (SD = 0.9) 0–4 10.5 (SD = 8.5) 0–30 n (%) 9 (42.9%) 16 (76.2%) 9 (42.9%) 5 (25%)

continuous variables – means reported. categorical variables – counts reported.

women were economically disadvantaged, with over 76% reporting yearly incomes of less than $25,000. The mean number of lifetime sex partners was 10.5 and almost half of the women reported pain with sexual intercourse and a history of an abnormal pap smear (Table 2). In general, this sample of women experienced forms of reproductive coercion, Table 3. Women in the sample had a mean score on the WEB of 41.9 and mean DES score of 20.9. Table 4 displays the number of women who reported certain specific dissociative symptoms more than 30% of the time and more than 70% of the time. Dissociative scores as measured by the DES ranged from 2.5–56, with a mean score of 20.9 for the sample. Qualitative Findings The participants in this study spoke of many challenges in their lives, including decisions surrounding first sexual intercourse and relationship dynamics with partners. From these TABLE 3 Reproductive Coercion (n = 21) n (%) Pregnancy Coercion Partner said to use no birth control Partner said would leave if not pregnant Would have baby with other if not pregnant Hurt physically because not pregnant Partner pressured to get pregnant Birth Control Sabotage Partner removed condom Partner made holes in condom Partner purposively broke condom Partner took birth control away Forced sex without condom Reference: Miller et al., 2010.

5 (23.8%) 1 (4.8%) 1 (4.8%) — 2 (9.5%) 1 (4.8%) 1 (4.8%) 1 (4.8%) — 3 (14.3%)

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TABLE 4 Dissociative Experiences (Select Items) Reported ≥ Reported ≥ 30% of time 70% of time Drive, don’t remember (n = 15) In a place, no idea how got there (n = 8) Sense of watching self (n = 4) No memory of important event (n = 6) Accused of lying (n = 10) Do not recognize self in mirror (n = 9) Feel like reliving past events (n = 12) Unsure if events happened (n = 10) Familiar place, but finding it strange and unfamiliar (n = 9) Fantasy/daydream feels real (n = 10) Able to ignore pain (n = 17) Stare off into space (n = 15) When alone, talk out loud (n = 8) Feel like two different people (n = 6) Certain situations able to do things with ease . . . (n = 15) Cannot remember if did something or just thought about doing (n = 13) Have done things, do not remember doing (n = 12) Feel like looking at world through a fog (n = 8)

12 7

3 1

3 5

1 1

7 7

3 2

10

1

8

2

8

1

7

3

14 11 7

3 4 1

6

0

11

4

11

2

10

2

6

2

data, four main categories emerged from the analysis and each category contained specific themes. These categories included disorganized reproductive lives, concern about STIs, contraceptive use, and distancing to escape. Disorganized Reproductive Lives What is meant to be will be. Having a plan for fertility control and spacing of pregnancies was summed up succinctly by one participant who stated that “your life changes according to what you got.” Many participants had a fatalistic view of pregnancy, declaring that “it happened because it was supposed to happen” or that “my whole life wasn’t planned.” Others reported that their pregnancies occurred because “I just didn’t care” or “didn’t know what I wanted.” One participant dismissed the notion of having a plan for fertility control simply because she

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“never gave it that much thought.” Another participant echoed the same thinking and stated, “I never thought of it.” Although the majority of participants spoke of using contraception at first intercourse and having access to reproductive health services, eventual pregnancies were described as “unplanned” and occurring close together, “very soon after” delivering a previous child. Partner interference. In addition to the notion of fate and disorganization contributing to unplanned pregnancies, pressure from partners to become pregnant interfered with the reproductive lives of participants. One participant spoke of overt physical violence and the inability to negotiate for contraception: I mean the beatings went on for the entire ten years we were together . . . well it was roll over I want this . . . and it was always after you got beat that he wants to know what the problem is.

The majority of participants described more subtle and coercive partner behaviors to encourage pregnancy, such as “smooth talk,” “pressure,” “insistence,” and “all these excuses” as to why their partners couldn’t or wouldn’t use condoms to prevent pregnancy and STIs. Women described a pattern of continuous pressure in which agreeing to sex without contraception became “like a habit.” Fear and distrust within violent relationships contributed to an environment in which preventing pregnancy became very difficult: It was more of a control issue . . . a real pressure thing . . . he tricked me. I mean . . . it was like a lockdown [no choice] thing . . . he would say I’ll pull out, I’ll pull out . . . yeah . . . and then he wouldn’t. He didn’t like to use condoms . . . they are just not comfortable . . . and I was always like, “You should wear condoms because I do not want to get pregnant with your child” . . . but I couldn’t really talk to him and tell him what I was thinking because he was such a jerk. I was obviously scared of him.

Awareness of own struggles. Participants often spoke of their reproductive lives with introspect and reflection. Although chaos and disorganization predominated, participants who had not ever been pregnant or had terminated previous pregnancies were able to look forward and decide that they needed to be “financially stable before I can think about somebody else’s life or being responsible for someone else.” There was a stated difference between wanting to “support the child, not only bring the child in the world.” Not wanting any of their own children to face similar social and economic struggles was the primary reason for using contraception, especially within violent relationships. One participant stated: I thought the first boy you are with you would be with forever and then when he turned violent it made me think whether I wanted to stay with him and it made me think about whether I wanted children.

Concern about STIs Youth as protective. Participants spoke of a general awareness of STIs when they were younger, but overall concern for protecting themselves from disease varied depending on their

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age and relationship status. For many women, youth was a time when STIs “weren’t really a big thing” or that “I thought, well, once I am on birth control I am covered.” Participants spoke of being diagnosed with STIs such as trichomoniasis, gonorrhea, cervicitis, and PID and receiving treatment. As these women moved in and out of relationships, concern about STIs and HIV increased as did their awareness of risk and subsequent STI testing. Routinely “getting tested” and asking partners for “their last record of venereal disease” were strategies women used to identify an early infection and possibly protect themselves from future infections. Partner infidelity. Partner concurrency (multiple concurrent sexual partners) was the main factor that increased concern about STIs. There was a heightened awareness of infidelity within abusive relationships. One participant spoke of how “it’s scary because he likes to cheat. He has been with a lot of women and he doesn’t get tested.” Another stated, “I was worried because I felt that he couldn’t be trusted.” Strategies these women used to protect themselves included frequent testing and condom negotiation with partners.

repeated pregnancies with an abusive partner of over ten years and finally reaching a decision to have a tubal ligation:

I could never say “no” . . . after the abuse started I thought that maybe something was going on . . . perhaps he would come home to me and hurt me because he was feeling guilty about something he had done . . . and so then I started telling him, yeah, you better use condoms. . . . I started demanding that he use them . . . and I am lucky that I didn’t get a disease.

So I don’t know sometimes I just daydream about . . . my friends, sometimes about the future.

He did not like to use them [condoms]. But you know he was the type that was very opinionated. He wanted to do things a certain way and he didn’t want to use the condom.

Contraceptive Use Multiple methods. As women’s reproductive lives evolved, they reported using multiple contraceptive methods, depending on their age and ability to negotiate for contraceptive use within specific relationships. Although some participants admitted that they used “no protection” when first sexually active because they were “just being stupid,” consistent contraception use increased over time, often after multiple pregnancies or terminations within a short time span. While some women reported using “just the pill” and condoms, others stated “I have used everything I think” and described how they “started with the pill, and after my children I used an IUD . . . I used the sponges, condoms, and diaphragms, plus the pill.” Permanence with age. Decisions on permanent fertility control were often made after multiple pregnancies and a feeling of “never wanting to do this again.” Having a tubal ligation was described as being done because “it was best to stop” risking another pregnancy and that not having any more children was a way to “protect your children” within an already abusive relationship. It also was a way for participants to protect themselves and advocate for what they wanted by saying, “This is my body and I am not going to have any more.” One participant discussed

After my fourth child I was cut, burned, tied . . . all of that because I did not want any more children . . . I thought I had to deal with that [abuse] because of my children.

Distancing to Escape Escaping present life. Many participants spoke of being “forgetful,” “daydreaming,” or just starting to “drift” off at various points during the day. Participants reflected on “how did I even get here” and stated “it’s kind of hard . . . getting back to normal . . . I don’t really know what normal is right now.” One participant stated that she would occasionally forget pieces of time: “Sometimes driving the car and getting from one place to another. . . . I just drive and I don’t always know how I got there.” Other participants specifically talked about the future without violence: There are times that I dream about what I would like my life to be like and about . . . I dream how I would like things to be.

Escaping intimacy. While some participants spoke of mild dissociative symptoms related to everyday life such as forgetfulness and daydreaming, many others discussed how they were “distancing [themselves] from the situation” during times of intimacy with abusive partners. Sex was often referred to as “coerced a lot” and mentally distancing themselves from the act of intimacy was used as an escape mechanism or “separation thing” because “it got to the point where I didn’t want to do it anymore.” When describing her reproductive health and sexual intimacy, a young participant described how “my mind can detach for a few seconds and something may come up . . . I just drift off . . . like I hear somebody somewhere else.” Another participant described her relationship with her partner as “sexually we were just drifting,” which she specifically attributed to the physical abuse in their relationship. When discussing how she drifted off with her partner during sex she reminisced: “How could you think you do that to me now and then I am going to buddy up to you later . . . I mean, what did he expect?” Similar actions also were reported by others with abusive partners and were described as “[finding] that I go just blank until I catch myself. You think you are having relations and you should do something about it but . . . during the whole thing, I’ll just blank out.” One participant with a long history of IPV stated that during sex “I kind of drift off because I have flashbacks” to earlier episodes of abuse. These descriptions of “escaping,” “drifting,” and “forgetting” are consistent with participants scores on the DES that are presented in Table 4. Participants reported mild dissociation-related symptoms that occurred during daily, routine, tasks and also during intimacy. No severe symptoms, such as overt amnesia or depersonalization, were reported or discussed. Although a

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history of depression can result in cognitive issues such as memory impairment and inability to concentrate, depression was not discussed by participants during interview sessions.

DISCUSSION Our findings emphasize the prevalence of violence in women’s lives and the challenges associated with managing their reproductive health during and after violence exposure. When viewed together, the four main qualitative themes that emerged from the data revealed that the participants had an awareness of STI and pregnancy risks but struggled with implementing consistent plans to protect themselves from infections or unplanned pregnancy and often drifted off in thought during routine, daily, activities and times of intimacy. Reproductive lives and associated plans for managing fertility were particularly disorganized. Although many of the participants were able to describe their plans for having children, rarely did the plan match their situation. Participants described pregnancies as teenagers that were “unplanned” and “just happened” that resulted in an “instant family.” Women discussed how “life changes all the time” and pregnancies were often just part of the relationship, regardless of whether that relationship was healthy and stable. Often many different contraceptive methods were utilized over the reproductive life span. Permanent sterilization occurred after women were able to gain control over their reproductive lives, sometimes as a way to prevent any more children from being exposed to the violent relationship. In addition to a disordered reproductive life, mild dissociative experiences were reported by many participants (Table 4); the severity of dissociation experiences varied among women. The majority of these symptoms occurred during sexual activity when thoughts of violence were “still on my mind.” Participants who scored greater than 30 on the DES and had higher reported dissociation behaviors spoke of the most frequent “distancing” and “drifting” around times of intimacy. This study is important because the research examining the intersection of dissociation and sexual behaviors is very limited. Most recently, Hansen et al. (2012) examined dissociative experiences during sexual behavior in a sample of adults with a history of child sexual abuse (CSA). Unlike this study that used the published version of the DES, Hansen et al. (2012) adapted the DES specifically to examine dissociative experiences during sexual activity. Although Hansen at al. (2012) found that 93% of the women in their sample experienced IPV, the focus of their work was to examine dissociative symptoms during sexual behavior in adults who have experienced CSA. Our findings suggest that mild dissociative symptoms, as measured by the DES and reported in qualitative findings, were common among women in this sample, all of whom who experienced IPV. This mild dissociation, which participants referred to as “distancing” or “drifting,” may have the potential to interfere with the ability to negotiate for sexual consent and condom use or to implement these actions in the moment of sexual activity.

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This is important as the participants in this study reported mild symptoms and “forgetfulness” that may be misinterpreted by patients and health care providers as a component of normal cognition. Although episodes of forgetfulness and daydreaming do not necessarily represent a pathological process, the results of this study revealed that these symptoms occur frequently among women who have experienced IPV. These results must be viewed in terms of the study limitations. A convenience sample was utilized and data were collected from one primary care setting. Therefore, the results and implications for practice are limited in scope. Also, this study represents a beginning exploration of the role of dissociative symptoms in the lives of women experiencing IPV. Causality cannot be inferred from these results. Future research needs to focus on the numerous forms of victimization women experience (e.g., CSA, IPV, sexual assault), dissociative symptoms, and sexual health outcomes. Further testing of the sexual behavior-specific DES adapted by Hansen et al. (2012) to specifically look at dissociation during sexual intimacy is an important next step. Despite these limitations, this study is one of the first to examine the intersection of dissociation, IPV, and sexual health.

Implications Health care providers who work with women that are currently, or have previously been, victims of violence must be aware of potential effects on reproductive and mental health. Asking tailored health history questions, including specific questions about mental health, will allow providers to formulate a health plan that addresses individual patient’s needs and concerns. Providers should consider screening women who have been victims of IPV for dissociative symptoms, anxiety, depression, and PTSD and refer as needed to mental health professionals so these women can develop coping skills to manage symptoms as they arise. Women should be offered a variety of contraceptive methods, including long-acting reversible contraception (LARC) which can be controlled by the women without partner interference. LARCs, such as intrauterine devices and implants, may be a good option for women who report that they frequently “drift” or “forget” and may have more difficulty remembering to correctly use methods that require daily, weekly, or monthly actions. Inquiring about condom use, partner concurrency, and partner characteristics will assist providers in identifying women who are most at risk for STIs and should be offered testing. IPV has been linked to psychosocial disability and mental health complaints, including anxiety, mood disorders, dissociative disorders, and substance abuse (Iverson et al., 2013; Rees et al., 2011). As such, women who have been involved in violent or coercive relationships need access to comprehensive mental health services. Screening for dissociative symptoms, anxiety, depression, and PTSD is an integral part of comprehensive assessment. Development of coping skills aimed at

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symptom management is a crucial element of treatment. Women who are able to recognize precursors to dissociative episodes and utilize coping strategies to manage those episodes effectively may be better able to make empowered choices regarding their reproductive health. Disclosure of IPV is often focused on the assessment of immediate danger and safety planning. Although lethality screening is imperative, clinicians also must consider the longer-term mental health issues that may stem from exposure to violence. Treatment should utilize an interdisciplinary approach that incorporates resources from multiple allied health care providers. CONCLUSION Women affected by IPV are at risk for physical and mental health issues. The ability to care for the self and to effectively manage reproductive choices and sexual activity is critical for women’s ongoing physical and emotional health. Dissociative symptoms may be a consequence of IPV, and could possibly compromise contraceptive consistency and negotiation for safer sex. Health care providers in primary care and mental health must be aware of the need for screening for both IPV and potential mental health issues that can arise from exposure to violence. Women who receive comprehensive health care may be able to recognize and cope with a range of dissociative symptoms, coercion, and partner pressure and may feel an increased ability to make empowered choices. Declaration of interest: Dr. Fantasia is a member of a Women’s Health Advisory Board for Actavis Pharmaceuticals for which she receives financial and travel consideration. REFERENCES American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Bazeley, P. (2009). Intergrating data analysis in mixed methods research. Journal of Mixed Methods Research, 3(3), 203–207. Beadnell, L. K., Baker, S. A., Morrison, D. M., & Knox, K. (2000). HIV/STD risk factors for women with violent male partners. Sex Roles, 42, 661–689. Bernstein, E. M., & Putnam, F. W. (1986). Development, reliability, and validity of a dissociation scale. Journal of Nervous and Mental Disease, 174, 727–735. Campbell, J. C. (2002). Health consequences of intimate partner violence. Lancet, 359, 1331–1336. Campbell, J. C., & Soeken, K. L. (1999). Forced sex and intimate partner violence: Effects on women’s risk and women’s health. Violence Against Women, 5, 1017–1035. Carlson, E. B., & Putnam, F. W. (1993). An update on the Dissociative Experiences Scale. Dissociation, 6(1), 16–27. Centers for Disease Control and Prevention. (2008). Adverse health conditions and health risk behaviors associated with intimate partner violence—United States, 2005. Morbidity and Mortality Weekly Report, 57, 113–117. Centers for Disease Control and Prevention. (2012a). Understanding intimate partner violence. Retrieved from http://www.cdc.gov/ViolencePrevention/ pdf/IPV Factsheet-a.pdf Centers for Disease Control and Prevention. (2012b). Basic Information about HIV and AIDS. Retrieved from http://www.cdc.gov/hiv/topics/basic/ index.htm#spread

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