Predictors of medical examinations following child and adolescent rapes in a national sample of women.

Childhood rape occurs frequently in our society and is associated with adverse consequences. Despite the severity of these outcomes, there appear to be many obstacles for children to receive postrape medical care. To date, it is unclear what proportion of childhood rape victims receive postrape medical examination or what factors predict receipt of this medical care. This study instigated the factors predicting immediate medica care for women who were raped during childhood. Data for the study were obtained from the final wave of the 2-year, longitudinal National Women's Study. Results indicated that the majority of women did not receive medical care following their childhood rape. Although women raped as adolescents were more likely to receive a postrape exam, logistic regression analyses indicated that rape characteristics (e.g., reporting the assault, concerns about sexually transmitted diseases [STDs]) mediated the relationship between age of victimization and receipt of medical care. Implications of these findings are discussed.

Predictors of post-rape medical care in a national sample of women.

BACKGROUND: Rape has a negative impact on physical and mental health, health-related behaviors, and health service utilization. Timely medical care is important for preventive services. METHODS: Cross-sectional data were obtained from a larger 2-year longitudinal study, the National Women's Study (NWS). A total of 3006 adult women participated in the final data collection wave of the NWS. During a structured telephone interview, women who reported a most-recent or only rape incident during adulthood were asked about rape characteristics, reporting to authorities, medical care, and rape-related concerns. The main outcome measures were receipt and timing of medical care received after an adult rape, and factors influencing whether or not medical care was received. RESULTS: Of the sample, 214 (7.1%) had experienced a most-recent or only rape as an adult (aged >/=18), and 56 (26.2%) received rape-related medical care following that incident. The final model multivariable logistic regression indicated that reporting the crime to police or other authorities (odds ratio [OR], 9.45; 95% confidence interval [CI]=3. 34-26.70) and fear of sexually transmitted diseases (OR, 8.61; 95% CI=3.12-23.72) were significant predictors of receipt of post-rape medical care. CONCLUSIONS: One in five victims reported an adult rape to police or other authorities; these women were nine times more likely to receive medical care than those who did not. Public health efforts are needed to increase the proportion of rape victims who receive immediate post-rape medical care.

Delay in disclosure of childhood rape: results from a national survey.

OBJECTIVE: This study sought to gather representative data regarding the length of time women who were raped before age 18 delayed prior to disclosing such rapes, whom they disclosed to, and variables that predicted disclosure within 1 month. METHOD: Data were gathered from 3,220 Wave II respondents from the National Women's Study (Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993), a nationally representative telephone survey of women's experiences with trauma and mental health. Of these, 288 retrospectively reported at least one rape prior to their 18th birthday. Details of rape experiences were analyzed to identify predictors of disclosure within 1 month. RESULTS: Fully 28% of child rape victims reported that they had never told anyone about their child rape prior to the research interview; 47% did not disclose for over 5 years post-rape. Close friends were the most common confidants. Younger age at the time of rape, family relationship with the perpetrator, and experiencing a series of rapes were associated with disclosure latencies longer than 1 month; shorter delays were associated with stranger rapes. Logistic regression revealed that age at rape and knowing the perpetrator were independently predictive of delayed disclosure. CONCLUSIONS: Delayed disclosure of childhood rape was very common, and long delays were typical. Few variables were identified that successfully predicted disclosure behavior, but older age and rape by a stranger were associated with more rapid disclosure. This suggests that the likelihood of disclosure in a given case is difficult to estimate, and predictions based on single variables are unwarranted.

Risk factors for adolescent substance abuse and dependence: data from a national sample.

A national household probability sample of 4,023 adolescents aged 12 to 17 years was interviewed by telephone about substance use, victimization experiences, familial substance use, and posttraumatic reactions to identify risk factors for Diagnostic and Statistical Manual of Mental Disorders--(4th ed.; American Psychiatric Association, 1994) defined substance abuse/dependence. Age and ethnicity data were available for 3,907 participants. Major findings were (a) adolescents who had been physically assaulted, who had been sexually assaulted, who had witnessed violence, or who had family members with alcohol or drug use problems had increased risk for current substance abuse/dependence; (b) posttraumatic stress disorder independently increased risk of marijuana and hard drug abuse/dependence; and (c) when effects of other variables were controlled, African Americans, but not Hispanics or Native Americans, were at approximately 1/3 the risk of substance abuse/dependence as Caucasians.

The socioeconomic impact of interpersonal violence on women.

Prospective data from a nationally representative sample of women were used to examine 4 objective indexes of social adjustment following direct, interpersonal crime. Household income, marital status, employment, and education level were evaluated as risk factors for and outcomes of victimization. Data were collected in 3 waves at 1-year intervals, and 2,863 women completed all 3 waves. Results indicate that women experience increased risk for victimization when income is below poverty level and when newly divorced. Further, victimization appears to increase women's risk for unemployment, reduced income, and divorce. The cyclical nature of victimization is discussed.

Risk factors for rape, physical assault, and posttraumatic stress disorder in women: examination of differential multivariate relationships.

The National Women's Study, a 2-year, three-wave longitudinal investigation, employed a national probability sample of 3,006 adult women to: (a) identify separate risk factors for rape and physical assault, and (b) identify separate risk factors associated with post-rape posttraumatic stress disorder (PTSD) and post-physical assault PTSD. This investigation differed from previous studies in that it prospectively examined risk factors at the multivariate, as opposed to univariate level. Overall, past victimization, young age, and a diagnosis of active PTSD increased women's risk of being raped. By contrast, past victimization, minority ethnic status, active depression, and drug use were associated with increased risk of being physically assaulted. Risk factors for PTSD following rape included a history of depression, alcohol abuse, or experienced injury during the rape. However, risk factors for PTSD following physical assault included only a history of depression and lower education.

Criminal victimization, posttraumatic stress disorder, and comorbid psychopathology among a community sample of women.

This paper provides information on the relation between victimization status, crime factors, posttraumatic stress disorder (PTSD), and several other psychological disorders among a community sample of women. Results indicated that victims of crime were more likely than nonvictims to suffer from PTSD, major depressive episode, agoraphobia, obsessive-compulsive disorder, social phobia, and simple phobia. Furthermore, life threat was associated with increased risk of major depression, agoraphobia, obsessive-compulsive disorder, and social phobia. Completed rape was strongly related to almost every disorder assessed, while robbery and burglary were not related to any disorder. When demographics, victimization status, and crime factors were entered hierarchically into multivariate logistic regressions with PTSD in the final step, associations between victimization status, other crime characteristics (e.g., life threat, injury), and non-PTSD Axis I disorders were greatly reduced. This suggests that PTSD may be an important mediating factor in the victimization-psychopathology relation for many disorders.

Effects of endometriomas on ooccyte quality, embryo quality, and pregnancy rates in in vitro fertilization cycles: a prospective, case-controlled study.

PURPOSE: The effect of endometriomas on oocyte quality, embryo quality, and pregnancy rates in in vitro fertilization (IVF) cycles was evaluated. METHODS: Forty-five women had "chocolate" cysts aspirated at the time of oocyte retrieval, and cyst fluid CA 125 levels were measured to ascertain presence of "true" endometriomas. Fifty-seven women without any complex cysts at the time of oocyte retrieval served as controls. IVF cycle outcome parameters were compared between the two groups. RESULTS: Women with endometriomas experienced a significantly higher rate of early pregnancy loss compared to controls (47 vs 14%). There was also a trend toward fewer oocytes retrieved and fewer embryos reaching at least the four-cell stage 48 hr after retrieval in patients with true endometriomas vs controls. CONCLUSIONS: The presence of endometriomas at the time of oocyte retrieval is associated with increased rates of early pregnancy losses. The number of oocytes retrieved and the embryo quality may also be affected adversely in the presence of endometriomas.

A 2-year longitudinal analysis of the relationships between violent assault and substance use in women.

Women experience alarming levels of physical and sexual assault, which may lead to escalation of substance use. Reciprocally, evidence from cross-sectional studies indicates that substance use may increase risk of assault. To date, directionality of this relationship remains unclear. This issue is addressed by the present 3-wave longitudinal study in which a national probability sample of 3,006 women were followed for 2 years. Dependent measures were obtained at each wave of the study and included questions about lifetime and new assault status, alcohol abuse, and drug use. Wave 1 use of drugs, but not abuse of alcohol, increased odds of new assault in the subsequent 2 years. Reciprocally, after a new assault, odds of both alcohol abuse and drug use were significantly increased, even among women with no previous use or assault history. For illicit drug use, findings support a vicious cycle relationship in which substance use increases risk of future assault and assault increases risk of subsequent substance use.

Violent assault, posttraumatic stress disorder, and depression. Risk factors for cigarette use among adult women.

Cigarette smoking may be conceptualized as a strategy to cope with negative affect. Therefore, rates of cigarette use might be expected to be greater in individuals experiencing events that produce negative affect, such as assault. To test this hypothesis, a national sample of 3,006 women aged 18 and older was assessed for lifetime and current cigarette use, previous history of physical and sexual assault, lifetime and current incidence of depression, and lifetime and current incidence of PTSD. Results indicated that the odds of active smoking in women with a lifetime history of assault were 1.82 times those of women with no previous history of assault. Similarly, risk of active cigarette use in women with a previous history of depression or PTSD was 2.22 and 1.34 times those of women with no depressive or PTSD history, respectively. Recent assault, current PTSD, or current depression status were not associated with increased cigarette use.

Rape-related pregnancy: estimates and descriptive characteristics from a national sample of women.

OBJECTIVE: We attempted to determine the national rape-related pregnancy rate and provide descriptive characteristics of pregnancies that result from rape. STUDY DESIGN: A national probability sample of 4008 adult American women took part in a 3-year longitudinal survey that assessed the prevalence and incidence of rape and related physical and mental health outcomes. RESULTS: The national rape-related pregnancy rate is 5.0% per rape among victims of reproductive age (aged 12 to 45); among adult women an estimated 32,101 pregnancies result from rape each year. Among 34 cases of rape-related pregnancy, the majority occurred among adolescents and resulted from assault by a known, often related perpetrator. Only 11.7% of these victims received immediate medical attention after the assault, and 47.1% received no medical attention related to the rape. A total 32.4% of these victims did not discover they were pregnant until they had already entered the second trimester; 32.2% opted to keep the infant whereas 50% underwent abortion and 5.9% placed the infant for adoption; an additional 11.8% had spontaneous abortion. CONCLUSIONS: Rape-related pregnancy occurs with significant frequency. It is a cause of many unwanted pregnancies and is closely linked with family and domestic violence. As we address the epidemic of unintended pregnancies in the United States, greater attention and effort should be aimed at preventing and identifying unwanted pregnancies that result from sexual victimization.

Localization and characterization of white blood cell populations within the human ovary throughout the menstrual cycle and menopause.

The purpose of this investigation was to localize and characterize white blood cell populations in the human ovary through its physiological life cycle. Ovaries from 30 women of reproductive age and from three post-menopausal women were embedded in paraffin or frozen. Clinical information and pathology review were used to obtain accurate menstrual cycle information and to ensure the absence of ovarian disease. Tissue sections were stained for leukocyte phenotypes and the numbers of white blood cells in the ovary were semiquantitatively assessed by two separate examiners using a 0-3 plus (+) scoring system. Our results demonstrated that macrophages and T lymphocytes were the primary immune cells of the ovary, the concentrations of which were dependent on the location and stage of development of the structures containing leukocytes. Developing follicles contained few (+) macrophages located in the theca, while atretic follicles possessed moderate (+2) numbers in the granulosa and few (+) to moderate (+2) numbers in the theca. Newly formed corpora lutea contained few (+) macrophages, while regressing corpora lutea contained abundant (+3) numbers. Human leukocyte antigen (HLA)-DR positive cells were located predominantly at sites where macrophages were present. T lymphocytes were generally not present in the developing follicle but focal, small (+) numbers were observed in blood vessels of the theca. Atretic follicles contained few (+) T lymphocytes in the granulosa and few (+) to moderate (+2) numbers in the theca. Few (+) T lymphocytes were present in new corpora lutea, while moderate (+2) to abundant (+3) numbers were present in regressing corpora lutea. T lymphocytes at all sites were UCHL1 positive. The CD4 (T helper) to CD8 (T suppressor) ration in the corpus luteum was 1:1. B-lymphocytes and natural killer cells were generally absent in the pre-menopausal ovary. The post-menopausal ovary, in contrast, only contained few (+) macrophages, T lymphocytes and natural killer cells in the stroma. In conclusion, our results indicate that the human ovary is an immunologically dynamic tissue containing activated macrophages and T lymphocytes which provide an anatomical basis for immunoendocrine interactions within the ovary.

Interleukin-1 alpha and -beta modulation of luteinized human granulosa cell oestrogen and progesterone biosynthesis.

This study was designed to test the hypothesis that interleukin-1 alpha (IL-1 alpha) and beta directly affect progesterone, and oestradiol production in cultures of purified human granulosa cells. Luteinized granulosa cells were obtained from women during in-vitro fertilization cycles. Granulosa cells with and without associated white blood cells were cultured in the presence of IL-1 alpha and IL-1 beta (0.5-50 ng/ml) for 48 h. Media were changed at 24 h intervals and assayed for progesterone and oestradiol. In separate experiments, granulosa cell viability was assessed with the tetrazolium salt reduction assay, haemocytometer cell counts, and Trypan blue dye exclusion. Our results indicate that progesterone synthesis by basal and human chorionic gonadotrophin (HCG)-stimulated granulosa cells co-cultured with white blood cells was inhibited by 5.0 ng/ml of IL-1 alpha and IL-1 beta at 48 h of culture. In the presence of white blood cells, granulosa cell oestradiol synthesis was inhibited by IL-1 beta but not IL-1 alpha. Oestradiol was inhibited after both 24 and 48 h of culture and was maximally affected by 5.0 ng/ml of IL-1 beta. In contrast, basal and HCG-stimulated oestradiol production by granulosa cells cultured free of white blood cells was inhibited only by IL-1 alpha. IL-1 alpha at 5.0 ng/ml produced maximal inhibition of basal oestradiol (57%) and HCG-stimulated oestradiol (41%) production at 48 h of culture. Gonadal steroid inhibition by IL-1 alpha and IL-1 beta was not mediated through cytotoxic or antiproliferative effects on granulosa cells. Specificity of the granulosa cell response to IL-1 alpha and IL-1 beta was demonstrated by abrogation of steroid inhibition with anti-IL-1 alpha and IL-1 beta neutralizing antibodies. In conclusion, IL-1 alpha directly inhibited the production of oestradiol by human ovarian granulosa cells. IL-1 alpha and IL-1 beta also exerted indirect effects on steroid production via white blood cells that are usually present in granulosa cell cultures if steps are not taken to remove them. These data support the hypothesis that cytokines play an important role in intra-ovarian regulation of steroid biosynthesis.

Interferon gamma inhibits luteinized human granulosa cell steroid production in vitro.

OBJECTIVE: The purpose of this study was to determine whether interferon gamma affects luteinized human granulosa cell progesterone, estrone, and estradiol production in the presence and absence of associated white blood cells by either cytotoxic or antiproliferative mechanisms. STUDY DESIGN: Luteinized granulosa cells were isolated by Percoll centrifugation from women during in vitro fertilization cycles. Some cell suspensions were further treated with anti-CD45 magnetic immunobeads to remove associated white blood cells. Granulosa cells with and without white blood cells were cultured in the presence of interferon gamma (0.5 to 50 ng/ml) for 48 hours. Medium was changed at 24-hour intervals, and spent medium was assayed for progesterone, estrone, and estradiol. In separate experiments granulosa cell viability was assessed with the tetrazolium salt reduction assay. RESULTS: Interferon gamma significantly inhibited granulosa cell progesterone production in both basal and human chorionic gonadotropin-stimulated cells cocultured with white blood cells in a concentration-dependent manner, whereas cells cultured free of white blood cells demonstrated less inhibition. In the absence of interferon gamma a more profound increase in granulosa cell progesterone synthesis was found in human chorionic gonadotropin-stimulated cultures without associated white blood cells. Interferon gamma inhibited granulosa cell estrone and estradiol production in basal cultures containing white blood cells in both a time- and concentration-dependent manner. Estrone production was not affected by interferon gamma in human chorionic gonadotropin-stimulated granulosa cell cultures containing white blood cells, whereas estradiol secretion was decreased at 48 hours with 50 ng/ml interferon gamma. Both estrone and estradiol synthesis were inhibited by 50 ng/ml interferon gamma in granulosa cell cultures free of white blood cells. In cultures free of interferon gamma, granulosa cell estrone and estradiol secretion was not affected by human chorionic gonadotropin stimulation compared with basal controls regardless of the presence or absence of white blood cells. All concentrations of interferon gamma used had no effect on granulosa cell viability at any time point tested. CONCLUSIONS: Our data suggest that interferon gamma affects granulosa cell steroid production both independently and in synergy with associated white blood cells and further supports the hypothesis that interferon gamma may be an important intraovarian regulator of ovarian steroid production during the luteal phase.

The reproducibility of the postcoital test: a prospective study.

OBJECTIVE: To determine the reproducibility of the postcoital test among trained observers. METHODS: Twenty-eight infertile patients presenting to the Brigham and Women's Hospital over a 1-year period were recruited for the study. After a standardized collection of specimens for the postcoital test, four fellowship-trained reproductive endocrinologists evaluated six postcoital test characteristics and gave their overall impression of the test. Each observer was blinded to the patients' identities and clinical histories as well as to the ratings of the other observers. The six characteristics included an assessment of the cervical mucus by ferning, cellularity, spinnbarkeit, and consistency, and of sperm by total count per high power field and percent motility. Scoring was adapted from World Health Organization (WHO) criteria for semen-cervical mucus interaction. Statistical analysis included the kappa statistic to determine agreement among observers for postcoital test characteristics and the Mantel-Haenszel test to determine the association between overall impression and the other test characteristics. RESULTS: Agreement among the four observers was best for sperm number and motility (39% of cases) and worst for cellularity, spinnbarkeit, and overall test impression (11, 14, and 14% of cases, respectively). The kappa statistic ranged from a low of 0.13 for cellularity, demonstrating poor reliability (95% confidence interval [CI] 0.03-0.23), to a high of 0.51 for sperm number, demonstrating fair reliability (95% CI 0.41-0.60). Only sperm number and percent motility were significantly associated with the overall impression (P < .001). CONCLUSIONS: In a blinded study, the characteristics of the postcoital test were found to have poor to fair reproducibility among trained observers using a standardized WHO scoring system. The observers' overall impressions of test quality correlated with sperm number and motility only. We question the validity of the postcoital test as a diagnostic tool in the evaluation of infertility.

Modulation of human granulosa cell steroid production in vitro by tumor necrosis factor alpha: implications of white blood cells in culture.

OBJECTIVE: To test the hypothesis that the macrophage cytokine, tumor necrosis factor-alpha (TNF-alpha), directly inhibits progesterone, estrone (E1), and estradiol (E2) synthesis by human granulosa cells in vitro in the presence and absence of white blood cells. METHODS: Granulosa cells from follicle aspirates of patients undergoing in vitro fertilization (IVF) were separated from red blood cells on 50% Percoll columns. Such preparations contained numerous white blood cells (lymphocytes, 40-52%, and macrophages, 6-14%) as determined with immunocytochemistry. In some studies, anti-CD45 magnetic beads followed by an additional adherence step and media change were used to remove white blood cells from granulosa cell cultures. Granulosa cells with and without associated white blood cells were cultured in basal and hCG-supplemented media. Androstenedione (40 ng/mL) and/or recombinant TNF-alpha (0.5-50 ng/mL) were added to triplicate wells. Media were harvested for radioimmunoassay of progesterone, E1, and E2 after 24 and 48 hours of incubation. RESULTS: The effects of TNF-alpha on progesterone production in white blood cell-associated cultures were inconsistent when 0.5 ng/mL TNF-alpha was added under basal conditions. At higher TNF-alpha doses (5-50 ng/mL) and under hCG-stimulated conditions, there was a consistent decrease in progesterone production, but the effect was not clearly dose-dependent. It was possible to remove white blood cells effectively from granulosa cell cultures. In granulosa cell cultures without associated white blood cells, 0.5 ng/mL of TNF-alpha at 48 hours produced an increase in progesterone, whereas 50 ng/mL of TNF-alpha decreased progesterone (P < .001). Estrone and E2 were both decreased by TNF-alpha regardless of whether white blood cells were present in culture, without clear evidence of dose-dependency. Granulosa cell viability and proliferation were unaffected by TNF-alpha as demonstrated by direct cell counts, trypan blue exclusion, and tetrazolium salt viability assays. CONCLUSIONS: In the normal ovary, TNF-alpha may influence the development of the dominant follicle by inhibiting aromatase activity. It may also mediate oocyte maturation disorders and ovarian endocrine dysfunction in some pathologic states. White blood cells can be effectively removed from granulosa cell cultures. Application of this removal technique will facilitate future granulosa cell studies by allowing more precise determination of direct granulosa cell function.

Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women.

Prevalence of crime and noncrime civilian traumatic events, lifetime posttraumatic stress disorder (PTSD), and PTSD in the past 6 months were assessed in a sample of U.S. adult women (N = 4,008). Random digit-dial telephone methods were used to identify study participants. Structured telephone interviews for assessment of specific crime or other traumatic event history and PTSD were conducted by trained female interviewers. Lifetime exposure to any type of traumatic event was 69%, whereas exposure to crimes that included sexual or aggravated assault or homicide of a close relative or friend occurred among 36%. Overall sample prevalence of PTSD was 12.3% lifetime and 4.6% within the past 6 months. The rate of PTSD was significantly higher among crime versus noncrime victims (25.8% vs. 9.4%). History of incidents that included direct threat to life or receipt of injury was a risk factor for PTSD. Findings are compared with data from other epidemiological studies. Results are discussed as they relate to PTSD etiology.

Evaluation of interceed(TC7) for reduction of postoperative adhesions in rabbits.

OBJECTIVE: To evaluate the effectiveness of Interceed(TC7) (Johnson and Johnson, New Brunswick, NJ) in the prevention of postoperative adhesions in a rabbit uterine horn model. Interceed(TC7) was tested in the presence and absence of absorbable suture. DESIGN, SETTING, PARTICIPANTS: Forty-one New Zealand white rabbits had lesions created on bilateral uterine horns at laparotomy. Lesions were randomly allocated to treatment with Interceed(TC7) or control. The effect of Interceed(TC7) was evaluated on sutured lesions (4-0 polyglactin 910; Ethicon, Inc., Somerville, NJ) as well as on open cut lesions (no sutures applied). MAIN OUTCOME MEASURES: Adhesion formation, using a grading system ranging from 0 to 3. RESULTS: Interceed(TC7)-treated animals in the sutured group (average adhesion score +/- SD = 2.15 +/- 1.3) did not differ from controls (average score +/- SD = 2.35 +/- 0.93) in adhesion formation, P = 0.47. Rabbits with open cut lesions treated with Interceed(TC7) (average adhesion score +/- SD = 1.89 +/- 1.1) did not differ from control animals (average score +/- SD = 1.83 +/- 1.2), P = 0.88. CONCLUSIONS: Interceed(TC7) was not an effective adhesioprophylactic agent in the presence or absence of nonreactive absorbable suture.