Recours au soin gynécologique et perceptions de l’examen pelvien après des violences conjugales et sexuelles : du soin gynécologique en suspens aux parcours de soin après des violences

Uptake of gynecological care and perceptions of pelvic examination following domestic and sexual violence

• Auteur / Autrice : Elisabeth Iraola
• Direction : Patrick Chariot
• Type : Thèse de doctorat
• Discipline(s) : Santé et Santé Publique
• Date : Soutenance le 03/12/2024
• Etablissement(s) : Paris 13
• Ecole(s) doctorale(s) : École doctorale Érasme (Villetaneuse, Seine-Saint-Denis)
• Partenaire(s) de recherche : Laboratoire : Institut de recherche interdisciplinaire sur les enjeux sociaux (Paris)
• Jury : Président / Présidente : Christophe Poncelet
• Jury : Examinateurs / Examinatrices : Xavier Deffieux, Virginie Rozée Gomez
• Jury : Rapporteurs / Rapporteuses : Laurent Gaucher, Anne Rousseau

Mots clés

Mots clés contrôlés

Femmes -- Santé et hygiène

Recherche qualitative

Femmes

Suivi médical

Violence conjugale

Mots clés libres

Violences conjugales

Violences sexuelles

Santé gynécologique

Intimate partner violence

Domestic violence

Sexual violence

Résumé

Contexte : Les violences conjugales et sexuelles représentent un problème de santé publique en raison de leur fréquence et du risque de morbidité auquel elles exposent, en matière de santé psychique, gynéco-obstétricale et sexuelle. Elles constituent aussi une violation des droits humains. Cette recherche a reposé sur le modèle hypothético-déductif d'une association entre les antécédents de violences conjugales et sexuelles et l'absence de recours au soin gynécologique qui pourrait s'expliquer par une aversion pour l'examen gynécologique, l'un des temps constitutifs de la consultation gynécologique. Méthodes : Une étude observationnelle cas-témoins impliquant des femmes enceintes consultant pour un suivi de grossesse ou une demande d'interruption volontaire de grossesse, une étude qualitative conduite auprès de femmes victimes de violences conjugales ou sexuelles recrutées par l'intermédiaire d'une association féministe contre les violences sexuelles et d'un centre d'hébergement d'urgence et une revue systématique ont été menées pour caractériser le recours au soin gynécologique et les perceptions de l'examen gynécologique après des violences conjugales ou sexuelles.

Background: Intimate partner violence (IPV) and sexual violence are a public health problem due to their high prevalence and the risk of morbidity affecting mental, gynecological and sexual health. Additionally, they constitute a violation of human rights. This research was based on the hypothetico-deductive model of an association between a history of IPV or sexual violence and the absence of gynecological care, which could be explained by an aversion to the pelvic examination, one of the components of gynecological follow-up.Methods: An observational case-control study of women seeking pregnancy follow-up or abortion care, a qualitative study of women survivors of IPV or sexual violence recruited through a feminist association against sexual violence and an emergency shelter and a systematic review were conducted to understand the uptake of gynecological care and the perceptions of the gynecological examination following IPV and sexual violence.Results: The observational study showed an association between IPV and sexual violence and the absence of a gynecological consultation in the last two years in women continuing their pregnancy (OR 2.13, 95% CI, 1.21-3.73, p = 0.008 and OR 1.92, 95% CI, 1.05-3.49, p = 0.03, respectively), particularly among those who had been sexually abused after the age of 18 (OR 1.95, 95% CI, 1.06-3.56, p = 0.03) and those who had been abused by their ex-partner (OR 2.04, 95% CI, 1.15-3.60, p = 0.01). The absence of a gynecological consultation was associated with IPV or sexual violence and dyspareunia (p < 0.0001 and p < 0.0001, respectively). However, no association between a history of IPV or sexual violence and the absence of gynecological consultation was found among women seeking abortion. The prevalence of sexual violence among pregnant women continuing their pregnancy and those seeking abortion was similar, whereas the prevalence of IPV was higher among women seeking abortion.The qualitative study showed that the uptake of gynecological care following IPV or sexual violence was not characterized exclusively by an absence or reduced uptake of gynecological care. Avoidance of gynecological examination was only one of the factors associated with reduced uptake of gynecological care. Care pathways following IPV or sexual violence were also characterized by annual or regular gynecological visits and frequent or multiple gynecological visits, with the associated factors modulated by the characteristics of the violence and its consequences.The systematic review synthesized data from 23 studies on the experience of pelvic examination and the uptake of gynecological care by women with a history of IPV and sexual violence. Eleven studies focused on the experience of pelvic examination, ten studies examined the uptake of gynecological care after violence, and two studies covered both aspects, involving 7.329, 9.248 and 1.304 women respectively. This review highlights the association between a history of sexual violence and the negative experience of pelvic examination as well as more mixed results regarding the uptake of care after domestic or sexual violence. Regardless of the frequency of usual gynecological follow-up, the use of care for acute symptoms appeared to be higher after sexual violence. No study has examined a relationship between the experience of pelvic examinations following sexual violence and the experience of subsequent examinations as part of routine gynecological care.Conclusion: Our research highlights the impact of IPV and sexual violence on gynecological health, including pain and post-traumatic stress disorder, and their implications for clinical practice in gynecology