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Cumulative Abuse: Do Things Add Up? An Evaluation of the Conceptualization, Operationalization, and Methodological Approaches in the Study of the Phenomenon of Cumulative Abuse

Kelly Scott-Storey1

Abstract For women, any one type of abuse rarely occurs in isolation of other types, and a single abusive experience is often the exception rather than the norm. The importance of this concept of the cumulative nature of abuse and its negative impact on health has been well recognized within the empirical literature, however there has been little consensus on what to call this phenomenon or how to study it. For the most part researchers have operated on the premise that it is the sheer number of different types of cumulating abuse experiences that is primarily responsible for worse health outcomes among women. And although this simplistic ‘more is worse’ approach to conceptualizing and operationalizing cumulative abuse has proven to be a powerful predictor of poorer health, it contradicts growing empirical evidence that suggests not all victimizations are created equal and that some victimizations may have a more deleterious effect on health than others. Embedded in abuse histories are individual and abuse characteristics as well as other life adversities that need to be considered in order to fully understand the spectrum and magnitude of cumulative abuse and its impact on women’s health. Furthermore, given the long-term and persistent effects of abuse on health it becomes imperative to not only evaluate recent abusive experiences, but rather all abuse experiences occurring across the lifespan. This review highlights and evaluates the conceptual, operational, and methodological challenges posed by our current methods of studying and understanding the phenomenon of cumulative abuse and suggests that this phenomenon and its relationship to health is much more complex than research is currently portraying. This paper calls for the urgent need for interdisciplinary collaboration in order to more effectively and innovatively study the phenomenon of cumulative abuse.

Keywords violence exposure, child abuse, domestic violence, mental health and violence, sexual assault

Insight into the effects of abuse on women’s health has

emerged primarily from research examining one or two types

of abuse on a small number of health outcomes (Bohn & Holz,

1996; Eby, Campbell, Sullivan, & Davidson, 1995; Letour-

neau, Holmes, & Chasedunn-Roark, 1999; Ratner, 1993). This

approach limits insight into the abuse–health relationship, as it

does not take into account the reality that one type of abuse

rarely occurs in isolation of others, or that a single abusive

experience is often the exception rather than the norm

(Finkelhor, Ormrod, Turner, & Hamby, 2005; Golding, 1999;

Kira et al., 2008). There are significant detrimental effects on

health for any one type of abuse (i.e., sexual, physical, or psy-

chological/emotional abuse), however health consequences

may be incrementally worse for victims experiencing multiple

types of abuse, either cooccurring, or compounding over a life-

time (Alvarez et al., 2009; Banyard, Williams, Saunders, &

Fitzgerald, 2008; Campbell, Greeson, Bybee, & Raja, 2008).

The focus of this article is to review and evaluate current

knowledge regarding the effects of cumulative experiences of

abuse on women’s health. In particular, to explore how the

premise of ‘‘cumulative abuse’’ has been conceptualized and

operationalized, particularly in studies focusing on health out-

comes. As well, this article will evaluate the designs, methodo-

logical, and analytic approaches used to examine the health

effects of cumulative abuse. First and foremost, the author

acknowledges and commends the important and painstaking

1 Department of Interdisciplinary Studies, University of New Brunswick,

Fredericton, NB, Canada

Corresponding Author:

Kelly Scott-Storey, Department of Interdisciplinary Studies, University of New

Brunswick, Sir Howard Douglas Hall, Box 4400, Fredericton, NB, Canada, E3B 5A3

Email: [email protected]

TRAUMA, VIOLENCE, & ABUSE 000(00) 1-16 ª The Author(s) 2011 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1524838011404253 http://tva.sagepub.com

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work that has been conducted in the field of violence against

women to better understand the relationships between abuse

history and health outcomes. This work has had significant

implications for research, policy, and clinical practice directed

at helping women who have experienced abuse. The intent of

this scholarly work is not to negatively critique past research

but to hopefully provide a comprehensive review of our current

understanding of cumulative abuse and offer a point of depar-

ture to build upon for future research.1

Abuse and Health

Abuse is a major social problem and a significant health issue

for women (World Health Organization [WHO], 2005). Con-

servative estimates from the National Violence Against

Women Survey (NVAWS) indicates lifetime prevalence rates

of physical abuse among women to be 52%, with lifetime rates

of sexual abuse at 18% (Tjaden & Thoennes, 2000). These data

also suggest that many women first experience abuse during

childhood, with nearly 40% reporting childhood physical abuse

and 9% reporting childhood sexual abuse (Tjaden & Thoennes,

2000). Even though physical and sexual abuse are most com-

monly studied, research has more recently demonstrated that

they are often accompanied by psychological/emotional abuse,

although true prevalence estimates of the latter are more diffi-

cult to obtain because of the entangled relationship with the

other types of abuse (Pico-Alfonso, 2005; WHO, 2002).

The past 30 years of research has provided a growing

awareness of the pervasive effects of abuse in undermining

women’s physical and mental health and abuse is now recog-

nized as having substantial long-term negative health conse-

quences for survivors, even after the abuse has ended

(Campbell, 2002; Crofford, 2007; Kendall-Tackett, 2005;

Koss, Koss, & Woodruff, 1991; WHO, 2002). Although not

an exhaustive list, beyond death and physical injury, abuse

has been linked to an extensive array of physical health prob-

lems such as: gastrointestinal problems (Drossman et al.,

2000; Frayne et al., 1999); sleep disturbances (McCauley

et al., 1995); chronic pain (Kendall-Tackett, Marshall, &

Ness, 2003; Wuest et al., 2008); heart disease (Breiding,

Black, & Ryan, 2008; Frayne et al., 1999); obesity (Bonomi

et al., 2006); severe headaches, migraines, chronic fatigue

(Frayne et al., 1999); pulmonary problems (Anda et al.,

2008; Frayne et al., 1999); autoimmune diseases (Breiding

et al., 2008; Dube et al., 2009); diabetes (Romans,

Belaise, Martin, Morris, & Raffi, 2002); sexually transmitted

diseases, human immunodeficiency virus (Zierler, Witbeck,

& Mayer, 1996); somatic syndromes (Crofford, 2007); and

a disproportionately higher use of health care services (Bohn

& Holz, 1996).

The most common psychological health sequelae of abuse

are depression and posttraumatic stress disorder (PTSD; Clum,

Calhoun, & Kimerling, 2000; Golding, 1999; Mechanic,

Weaver, & Resick, 2008). Further to PTSD and depression

being outcomes of abuse, a growing body of research suggests

that PTSD and depression may also influence the extent to

which abuse negatively compromises a women’s physical

health, thus positioning psychological health as a mediator

between abuse and physical health outcomes (Schnurr &

Green, 2004; Sutherland, Bybee, & Sullivan, 2002; Weaver

& Resnick, 2004). As well, health risk behaviors such as

smoking, alcohol and drugs use, and engaging in unpro-

tected sex have also been found to be more prevalent among

women with abusive histories, suggesting that abuse and

negative health outcomes are partially mediated through

these health risk behaviors (Breiding et al., 2008; Eby,

2004; Golding, 1999; Mechanic, 2004; Rheingold, Acierno,

& Resnick, 2003).

The mechanisms by which abuse can impact health are

multifaceted and not well defined (Bohn & Holz, 1996).

Obvious are the immediate and direct harms sustained from

physical injury that may result in long-term disability. But

beyond these direct and rather obvious physical effects, the

traumatic experience of abuse can result in enduring chronic

psychological stress that is believed to have long-term nega-

tive mental and physical health consequences (Bremner,

2002; Kendall-Tackett, 2005; Plichta, 2004). Chronic psycho-

logical stress can accumulate and compound over time to

produce significant and long-term physiological changes

within the body (Breiding et al., 2008; Carlson, 1997;

McEwen, 1998; Sapolsky, 1994). These changes are believed

to create a state of vulnerability leading to the etiology of

many chronic diseases and illnesses that may exist or

present long after the abuse has ended (Bohn & Holz, 1996;

Kendall-Tackett, 2005; McEwen, 1998; Sapolsky, 1994). The

cost of these diseases and illnesses are profound in terms of both

money and human suffering and situates abuse as one of the pri-

mary health issues facing women today (Kendall-Tackett, 2003b;

Lesserman & Drossman, 1995).

Conceptualization

What we name a phenomenon both reflects and determines

how we conceptualize it and subsequently how we operationa-

lize it (McHugh & Hanson-Frieze, 2006). However, within the

abuse literature there appears to be little consensus on what to

call this phenomenon of accumulating abusive experiences

(what will be referred to as ‘‘cumulative abuse’’) and its unique

contribution to health. Variability in terms used among many

disciplines and researchers has made examining this phenom-

enon a complex task. Terms commonly used include: accumu-

lated trauma or exposures to violence (Briere, Kaltman, &

Green, 2008; Brown, Hill, & Lambert, 2005); retraumatization

(Banyard, Williams, & Siegel, 2001); revictimizaiton

(Arata, 2000; Casey & Nurius, 2005); cooccurrence

(Campbell et al., 2008); cumulative exposure/effects

(Alvarez et al., 2009; Banyard et al., 2008); lifetime trauma

(Krause, Shaw, & Cairney, 2004); lifespan victimizations

(Macmillan & Kruttschnitt, 2005); polytraumatization

(Gustafsson, Nilsson, & Svedin, 2009); and polyvictimiza-

tion (Finkelhor et al., 2005). Upon closer examination each

of these terms seemingly refers to the same phenomenon:

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more experiences of abuse, whether repetition of the same

type, differing types, or a combination of both, result in

health outcomes that differ from those associated with an

isolated experience of abuse. So why are so many different

terms used to describe the same phenomenon? Part of the

reason may stem from the research silos that we have cre-

ated, where different disciplines and even different fields

within the same discipline seemingly lack effective commu-

nication about research interests. This became evident while

reviewing the literature. Unfortunately, the result is the par-

allel examination of the same phenomenon and the use of

multiple terms to describe it, inevitably creating confusion

within the literature.

Another part of the difficulty in conceptualizing the phe-

nomenon of cumulative abuse is that the conceptualization of

‘‘abuse against women’’ itself has changed considerably over

the years (McHugh & Hanson-Frieze, 2006; Murray &

Graybeal, 2007). Abuse is grounded in historical, economic,

cultural, social, and political factors that has lead to consider-

able fluctuations in the definitions of abuse, and little consen-

sus of what constitutes abuse (McHugh & Hanson-Frieze,

2006; WHO, 2002). As what we conceptualize as constituting

abuse changes, so does our conceptualization of what cumula-

tive abuse encompasses.

Recognizing that the development of the concept of cumu-

lative abuse has not happened in consecutive time frames and

that it has varied depending on the discipline conducting the

research, the following is a general presentation of an overall

pattern in which the conceptualization and operationalization

of cumulative experiences of abuse has changed over time.

An extensive search of the literature was conducted. Primary

search terms included: cumulative abuse/violence, multiple

abuse/violence, revictimization, multiple traumatization, retrau-

matization, lifetime abuse/violence, lifespan abuse/

violence, and multiple victimization. From these primary search-

ers, secondary searches were conducted based on new terminol-

ogy uncovered in the reviewed body of literature. Search

criteria were limited to English-only articles and research involv-

ing humans. Despite the multiple terms used to describe the phe-

nomenon of cumulative abuse, in reviewing the literature

essentially four categories emerged through an inductive process

that allowed the author to capture all the different ways in which

the concept has been studied; revictimization, cooccurrence of

types of abuse, lifetime abuse perspective, and cumulative

patterns.

Singular Abuse Categories

Much of our early understanding of the relationship between

abuse and health was based on women being broadly categor-

ized as either ‘‘abused’’ or ‘‘not abused,’’ with findings consis-

tently showing a higher prevalence of detrimental physical and

mental health effects for those women with abuse histories

(Eby et al., 1995; Hathaway et al., 2000; Letorneau Holmes,

& Chasedunn-Roark, 1999; Ratner, 1993). Extending from this

simplistic categorization, came studies examining specific

‘‘types’’ of abuse and their unique impact on health (e.g., Bach-

mann, Moeller, & Benett, 1988; Plichta, 1992), as well as stud-

ies contrasting health outcomes from one type of abuse against

those from another type (e.g., Bohn & Holz, 1996; Kolko,

Moser, & Weldy, 1988; Lesserman et al., 1996). Although

these studies have been successful in illuminating the deleter-

ious impact of abuse on health and have contributed greatly

to our understanding of the abuse–health relationship, they did

not consider the potential cumulative effects that the cooccur-

rence of multiple types of abuse or repeated abuse experiences

across the lifespan may have on health.

Revictimization

Early conceptualization of the phenomenon of cumulative

abuse emerged within the sexual revictimization literature.

At this time, researchers began shifting focus beyond health

outcomes of singular incidences of abuse or violence (e.g.,

rape) to that of repeated experiences of the same type of

abuse (e.g., sexual abuse; Messman-Moore, Long, &

Siegfried, 2000). The empirical evidence at the time sug-

gested that women who experienced sexual abuse during

childhood were at an increased risk for being revictimized

as adults (Gidycz, Coble, Latham, & Layman, 1993; Wyatt,

Guthrie, & Notgrass, 1992). Revictimization research took

into consideration a temporal component to incidences of

repeated abuse and conceptualized cumulative abuse as hav-

ing an experience of child sexual abuse and a separate inci-

dent of adult sexual victimization. Since this time, findings

have rather consistently demonstrated that women with

repeated victimizations have poorer health compared to those

exposed only in childhood or only in adulthood (Arata, 2000;

Banyard et al., 2001; Fogarty, Fredman, Heeren, &

Liebschutz, 2008; Messman-Moore et al., 2000).

The bulk of revictimization research has focused predomi-

nantly on sexual revictimization, with only a few studies examin-

ing revictimization involving physical abuse despite evidence of

its high cooccurrence with sexual abuse (e.g., Desai, Arias,

Thompson, & Basile, 2002; Fogarty et al., 2008; Kimerling,

Alvarez, Pavao, Kaminski, & Baumrind, 2007; McGuigan &

Middlemiss, 2005). As Humphreys, Sharps, and Campbell

(2005) stated ‘‘studies that focus on single forms of abuse may

wrongly attribute long-term negative health sequelae solely to a

certain type of abuse, overlooking the cumulative impact of con-

textual factors and multiple types of abuse’’ (p. 183). As well, only

examining a single type of abuse could conceal the potentially

augmented effects from combined types of abuse on health out-

comes (Basile, Arias, Desai, & Thompson, 2004). This highlights

the limitation of conceptualizing cumulative abuse so narrowly,

and underscores the importance of factoring in other cooccurring

types of abuse.

Cooccurrence of Types of Abuse

With the evolving conceptualization of what constitutes abuse

and with researchers being more aware of the risks associated

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with examining singular types of abuse in isolation of others,

we began to see the incorporation of additional types of abuse

into the conceptualization of ‘‘cumulative abuse’’ (Briere &

Jordon, 2004). For example, research has illuminated a broad

array of abuse types including psychological abuse (Basile

et al., 2004; Coker, Smith, Bethea, King, & McKeown, 2000;

Mechanic et al., 2008; Pico-Alfonso et al., 2006), stalking and

harassment (Basile et al., 2004; Mechanic et al., 2008;

Moracco, Runyan, Bowling, & Earp, 2007; Tjaden &

Thoennes, 1998), workplace bullying (Dewa, Lesage, Goering,

& Caveen, 2004; MacIntosh, 2005), and witnessing violence

(Felitti et al., 1998) that have all been found to independently

contribute to poorer health. This growing awareness that acts

of abuse tend to cooccur began to complicate research into

health outcomes and spurred interest in the examination of the

cumulative impact of multiple types of cooccurring abuse

(Briere & Elliott, 2003; Coker et al., 2000; Eby et al., 1995).

Many of the early studies that examined the unique impact

of cooccurring types of abuse on health did not explicitly con-

ceptualize cumulative abuse per se, but findings rather consis-

tently suggested that children and women who had experienced

more than one ‘‘type’’ of abuse, primarily physical and sexual

abuse, were at risk for more severe symptomatology and more

health problems than those who experienced only one ‘‘type’’

of abuse (Hart, Mader, Griffith, & deMendonca, 1989; Shields

& Janneke, 1983; Walker, 1984). Although a few of the more

recent studies have done a better job of explicitly conceptualiz-

ing the phenomenon of cumulative abuse by conceptualizing it

as ‘‘the greater number of different types of abuse experi-

enced,’’ many continue not to do this, creating much confusion

within the cumulative literature. In essence though, regardless

of whether the concept has been implicitly or explicitly concep-

tualized and despite different terms used, research has consis-

tently supported that the more types of abuse experienced, or

cumulative experiences, the worse the health outcomes (Basile

et al., 2004; Thompson, Arias, Basile, & Desai, 2002).

Some researchers have diverged from solely including abu-

sive experiences to take on a broader cumulative adversity per-

spective in examining the concept of cooccurrence, in which

cumulative experiences are conceptualized as an accumulation

of a multitude of adversities, inclusive of, but not limited to abuse

(Felitti et al., 1998; Turner & Lloyd, 1995). This appreciation for

the broader impact of both abusive and nonabusive adversities

has been in part a reflection of conceptual and methodological

advances in the study of childhood stress and trauma

(Schilling, Aseltine, & Gore, 2008). One of the more seminal

works in this area has been the Adverse Childhood Experi-

ences (ACE) study conducted by Felitti and colleagues

(1998). This large-scale epidemiological study of 9,508 adults

sought to examine a broad array of adversities experienced

before the age of 18 years and their associations with risk

behaviors and diseases in adulthood. Adversities extended

beyond the traditional types of abuse (emotional, physical, or

sexual abuse) to include witnessing domestic violence, parental

marital discord, growing up with mentally ill, substance abus-

ing, or criminal household members, all of which have been

independently associated with poorer physical and mental

health outcomes. The researchers acknowledged that adverse

experiences rarely occur in isolation and are highly interre-

lated, thus conceptualizing cumulative effects as being the

total number of adverse experiences. Consistent with their

hypothesis, the greater number of cumulative experiences

resulted in even more pronounced negative effects on health

outcomes, supporting a strong cumulative dose–response rela-

tionship between the number of childhood adversities and

many diseases in adulthood.

Numerous other studies have since conceptualized

cumulative experiences in a similar way further supporting this

dose–response relationship (e.g., Briere et al., 2008; Moeller,

Bachmann, & Moeller, 1993). For example, Edwards, Holden,

Felitti, and Anda (2003) in their examination of multiple

forms of childhood maltreatment and their relationship to

adult mental health outcomes conceptualized cumulative abuse

as ‘‘multi-category maltreatment experiences,’’ and found

that a greater number of women within the multicategory

maltreatment groups exhibited worse mental health scores in

a dose–response fashion compared to those in the single

category abuse group. Follette, Polusny, Bechtle, and Naugle

(1996) in their study of the relationship between trauma

symptoms and a history of child sexual abuse, adult sexual

assault, and adult physical abuse conceptualized cumulative

trauma as ‘‘multiple traumatic experiences’’ believing

that as the number of different types of traumas increased,

symptomatology would also increase.

More recently, terms such as polyvictimization and

polytraumatization have emerged, which although termed dif-

ferently, essentially conceptualize cumulative experiences in

a similar fashion claiming that high-cumulative levels of a

broad array of multiple types of victimizations or traumas

exert a compounded risk on health. However, this way of

conceptualizing cumulative experiences is more concerned

with the number of different adversities regardless of the broader

‘‘category’’ or ‘‘type’’ of experience (Finkelhor, Ormrod, &

Turner, 2007; Finkelhor et al., 2005; Gustafsson et al., 2009;

Richmond, Elliott, Pierce, Aspelmeier, & Alexander, 2009;

Sabina & Straus, 2008). Regardless of the terms used, the

findings have remained consistent: the cumulative number of

different abusive or adverse events is highly predictive of worse

health outcomes beyond that accounted for by any single type of

victimization or adversity (Briere et al., 2008; Edwards et al.,

2003; Finkelhor et al., 2007; Gustafsson et al., 2009; Richmond

et al., 2009).

Lifetime Abuse Perspective

Despite support for a dose–response type of relationship, a sig-

nificant portion of the aforementioned studies have confined

their examination of abuse to a distinct period of time or devel-

opment, such as childhood or adulthood, thereby negating a

lifespan perspective (e.g., Basile et al., 2004; Bonomi,

Anderson, Rivara, & Thompson, 2007; Briere et al., 2008;

Edwards et al., 2003; Felitti et al., 1998; Moeller et al.,

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1993). This approach is a notable caveat in how cumulative

abuse has for the most part been conceptualized; it violates the

basic premise of the theory of chronic stress, in which the

effects of abuse are pervasive and can have chronic, long-

lasting physiological implications for health (Dutton et al.,

2006; McEwen, 1998; Sapolsky, 1994). Given the persistent

and long-term effects of abuse on health, it becomes imperative

to not only include recent abusive experiences or experiences

of a single type of abuse in research but rather all abuse

experiences occurring across the lifespan (Campbell, 2002;

Kilpatrick, 2004; Richmond et al., 2009).

Out of this noted limitation emerged a lifespan perspective

in which the basic conceptualization of cumulative abuse was

expanded to include cumulative exposure to a number of differ-

ent types of abuse and/or adversities across the lifespan. Col-

lectively, findings from lifespan studies have supported the

dose–response relationship, highlighting the value of examin-

ing an entire life history of abuse so not to falsely attribute

health outcomes to abuse sustained at specific points in time

(Alvarez et al., 2009; Banyard et al., 2008; Follette et al.,

1996; Krause et al., 2004; Woods & Wineman, 2004). Impor-

tantly, a lifespan perspective has suggested that women do not

habituate to repeated abuse but rather exhibit increasing levels

of symptomatology (Follette et al., 1996). Unfortunately, many

of these studies have only examined a few types of abuse, so

what remains unclear in the cumulative literature is whether

every different type of abuse or experience of abuse has an

incrementally worse impact on health? Or does there come a

point when the cumulative impact on health becomes capped,

in which no differences are seen?

Although the lifespan perspective has contributed to our

understanding of the importance of examining cumulative abuse

over a lifetime, caution must be taken when appraising the litera-

ture as some researchers use the term ‘‘lifetime’’ in their concep-

tualization of cumulative abuse but in actuality they are only

examining lifetime experiences of a particular form or type of

abuse, such as intimate partner violence, and not any other abu-

sive experiences at any other point in the women’s lives (e.g.,

Bonomi et al., 2007). As well, many studies continue to concep-

tualize cumulative abuse as involving only one or two types of

abuse across the lifespan without controlling for, or including,

other potentially cooccurring types (e.g., McGuigan & Middle-

miss, 2005; Polusny, Dickinson, Murdoch, & Thuras, 2008).

Another critique in continuing to conceptualize cumulative

abuse as simply ‘‘the greater the number of types of abuse, the

worse the impact on health’’ is that it assumes abuse experi-

ences are homogenous and that individual abuse characteristics

are insignificant (Banyard et al., 2008; Bogart, Levendosky, &

von Eye, 2005). However, there is considerable empirical evi-

dence to suggest that an independent dose–response relation-

ship exists between abuse characteristics and health, in which

greater severity, duration, and frequency of abuse, as well as

recency of the experience, relationship to the perpetrator, and

number of perpetrators, have all been implicated as powerful

predictors of worse health outcomes among women (Arata,

2000; Bogart et al., 2005; Bonomi et al., 2006; Cloitre, Cohen,

Edelman, & Han, 2001; Finkelhor et al., 2007; Ford-Gilboe

et al., 2009; Kaysen, Resick, & Wise, 2003; Kendall-Tackett,

2003a; McNutt, Carlson, Persaud, & Postmus, 2002; Pico-

Alfonso, 2005).

Messman-Moore and colleagues (2000) provided an excel-

lent example of the potential influence of abuse characteristic

in examining health outcomes. When both revictimization

(child sexual abuse and adult sexual abuse, physical abuse, or

both) and cooccurrence (physical and sexual abuse in adulthood

only) were examined within the same study, health outcomes var-

ied depending on these two different ways of viewing cumulative

abuse. So what becomes unclear is to what extent recency of

abuse (e.g., cooccurrence of abuse in adulthood only vs. lifetime

child and adulthood revictimization) interacts to produce the var-

iations in these health outcomes. This underscores the importance

of considering abuse characteristics to provide a more compre-

hensive understanding of the reality of the cumulative abuse expe-

rience and its full impact on women’s health.

A further limitation has been the lack of attention given to

the unique influence of individual types of abuse within the

cumulative relationship. The individual type of abuse experi-

enced has been found to produce different health outcomes. For

example, physical abuse results more commonly in physical

injuries (Arias, 2004); sexual abuse has been associated

uniquely with sexually transmitted diseases (Molina &

Basinait-Smith, 1998); and psychological abuse has been found

to be more strongly associated with an increased risk for poor

health, depressive symptoms, substance use, and developing a

chronic disease than that of physical abuse (Coker et al., 2002).

Furthermore, Woods and colleagues (2005) found varying

alterations in immune status depending on the different type

of abuse examined. Bonomi and colleagues (2007) established

that sexual intimate partner violence, either with or without

physical abuse, resulted in increased depressive symptoms

compared to women with a history of only physical abuse, sug-

gesting that the presence of sexual abuse adds something worse

to health effects. There is also limited information available to

determine whether certain combinations of types of abuse

result in worse health outcomes than others (Edwards et al.,

2003). These findings emphasize the limits of conceptualizing

cumulative abuse as simply the cumulative impact of each

additional type of abuse on health and suggests the importance

of distinguishing and disentangling not only the different types

of abuse within a cumulative relationship but also paying atten-

tion to the patterns of cumulative abuse to look at possible

interactive effects of different types of abuse on health. In other

words, it is necessary to understand the important and unique

contribution of each type of abuse within a cumulative relation-

ship in order to fully appreciate the value of a more profile-

centered approach in examining the combination of different

types of abuse and abuse characteristics.

Cumulative Patterns of Abuse

‘‘Life histories of victimization vary tremendously—ranging

from a lone incident to a series of chronic related events over

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time to multiple discreet, unrelated events unfolding across a

life course’’ (Pimlott-Kubiak & Cortina, 2003, p. 528) and

these different configuration of experiences can result in differ-

ent health outcomes (Kira et al., 2008). This awareness of

the variability in abuse experiences lead to a shift in the

late 2000s, when researchers became interested in examining

the heterogeneous patterns within the context of cumulative

experiences of abuse. Although not explicitly defined, these

studies conceptualize cumulative abuse as the impact of differ-

ent patterns of collective abuse experiences on mental and

physical health (Campbell et al., 2008; Carbone-López,

Kruttschnitt, & Macmillan, 2006; Cavanaugh et al., 2009; Dut-

ton, Kaltman, Goodman, Weinfurt, & Vankos, 2005). Together

these studies have demonstrated that not only do patterns

reflecting a greater cumulative number of types of abuse (sum-

mative score) contribute to poorer health outcomes but also the

configuration of abuse types within the patterns uniquely influ-

ence health outcomes. For example, in a study conducted by

Campbell and colleagues (2008) higher levels of sexual abuse

were found to be particularly detrimental to health above and

beyond the sheer cumulative number of types of abuse.

These patterning studies have been successful in advancing

our understanding of the variability of the cumulative experi-

ences of abuse and have attempted to take into account abuse

characteristics such as severity and duration, as well as extract-

ing the unique influence of individual types of abuse (e.g.,

Dutton et al., 2005). However, to date these studies too have

often encountered reoccurring problems commonly seen in the

cumulative literature, such as not systematically including all

types of abuse across the lifespan.

Summary

The overall importance of the phenomenon of cumulative

abuse has been well-recognized within the empirical arena.

However, very few studies have adequately conceptualized the

concept of cumulative abuse. More commonly, the concept has

been implicitly threaded throughout research studies and its

impact highlighted in the findings section. The reason for this

may lie in the subtle nuances of how different researchers and

disciplines have conceptualized cumulative abuse over time,

which has lead to great confusion and a general lack of consen-

sus of what the phenomenon should entail and be called. None-

theless, research has supported the notion that ‘‘more is worse’’

in terms of the sheer number of different types of abuse experi-

ences. Yet, the empirical literature also suggests that the phe-

nomenon of cumulative abuse and its relationship to health is

much more complex than simply conceptualizing it as the sum

of victimization experiences. Embedded in abuse histories are

both individual and abuse characteristics as well as other life

adversities that need to be considered in order to fully under-

stand the spectrum and magnitude of cumulative abuse and its

impact on women’s health. This review highlights the need for

researchers across disciplines to work collaboratively to come

to some consensus on how cumulative abuse should be defined

and conceptualized, so that there is consistency in how this

phenomenon is researched in the future.

Operationalization

Despite evolution in how cumulative abuse has been concep-

tualized, how it has been operationalized has remained fairly

simplistic and consistent over time. The evidence that the

greater the number of accumulated types of abuse experienced,

the worse the health outcomes has resulted in the operationali-

zation of this concept as simply ‘‘the sum of the total number of

different abuse experiences’’ (Casey & Nurius, 2005; Felitti

et al., 1998).

The most basic approach to operationalizing cumulative

abuse has been to categorize women according to their experi-

ence of either a singular type of abuse (e.g., physical or sexual)

or their experiences of two or more types of abuse (physical

and sexual) at one point in time (e.g., childhood or adulthood),

hypothesizing that the category with the combined experiences

would capture the effects of cumulative abuse on desired health

outcomes (Bonomi et al., 2007; Sabina, Strause, et al., 2008;

Thompson et al., 2002). Others have taken this one step further

combining categories based on developmental or temporal

parameters to capture the importance of a lifespan perspective

(e.g., Arata, 2000; Kimerling et al., 2007; McGuigan &

Middlemiss, 2005; McNutt et al., 2002; Messman-Moore

et al., 2000). For example, Fogarty and colleagues (2008) oper-

ationalized cumulative experiences of physical and sexual

abuse by creating four categories of variables: no abuse, child-

hood abuse, adulthood experiences of abuse, and a combination

of both child and adult experiences. Operationalizing cumula-

tive abuse is this manner allowed for the differentiation

between childhood abuse, versus adult victimization, versus

lifespan cumulative effects of both childhood and adult expo-

sures on health outcomes.

Another approach has been to operationalize cumulative

experiences in a more continuous fashion, in which the

unweighted sum of all scores indicating the number of different

types of abuse have been summed to create a total ‘‘count’’ of

experiences (Alvarez et al., 2009; Banyard et al., 2008; Briere

et al., 2008; Edwards et al., 2003; Felitti et al., 1998; Finkelhor

et al., 2007; Follette et al., 1996; Gustafsson et al., 2009;

Krause et al., 2004; Polusny et al., 2008; Richmond et al.,

2009; Turner & Lloyd, 1995; Woods & Wineman, 2004). For

example, Briere and colleagues (2008) summed up the number

of affirmative responses from a list of multiple childhood trau-

matic events creating a score ranging from 0 (no reports) up to

8 (indicating experiencing a total of eight identified traumas).

Although these ‘‘count’’ studies provide evidence that

‘‘more is worse,’’ a notable limitation is that again homogene-

ity within abuse experiences is assumed. Therefore a drawback

to this manner of operationalizing cumulative abuse is that it

negates the influence of abuse characteristics, such as severity,

duration, and frequency, on health outcomes as previously

noted in the conceptualization section. Although there has been

some indication in the literature (e.g., Haller & Miles, 2004)

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that ‘‘counts’’ of types of abuse are positively associated with

severity of abuse, and thus potentially serve as a proxy for

severity and chronicity, much more work needs to be done in

this area. Moreover, others have found that number of types

of abuse experienced and severity of abuse have an interactive

effect to predict greater levels of symptomatology, which high-

lights the importance of considering both abuse types and abuse

characteristics in research involving survivors of abuse

(Clemmons, Walsh, DiLillo, & Messman-Moore, 2007).

Furthermore, although a simple count of the number of dif-

ferent types of abuse appears to be a powerful predictor of neg-

ative health outcomes, using the unweighted sum of scores

contradicts the growing empirical evidence that suggests not all

victimizations are created equal and that some victimizations

are more deleterious than others (Bonomi et al., 2007; Boxer

& Terranova, 2008; Finkelhor et al., 2005). In order to address

this, weighting techniques would need to be used in analysis,

which poses considerable complexities and has yet to be done

with much success (Finkelhor et al., 2005). Moreover, simply

applying weights to different ‘‘types’’ of abuse still does not

take into consideration the aforementioned abuse characteris-

tics (e.g., severity, duration, frequency, etc.) that may, in part,

be responsible for the outcomes seen.

With interest mounting in the heterogeneity of abuse experi-

ences (nature and types), there has recently been a shift in how

cumulative experiences have been operationalized to that

beyond a simple summative count. Within studies that have

examined abuse patterns, the importance of cumulative abuse

continues to be recognized, however, cumulative abuse for the

most part has not been explicitly operationalized. Rather more

implicitly, the concept is inherent in the premise of examining

the cumulative patterns or clusters of victimizations and the

belief that the relationships between each cluster is generally

characterized by greater probabilities for more cumulative

types and severity of abuse (Campbell et al., 2008;

Carbone-López et al., 2006; Dutton et al., 2005; Macmillan

& Kruttschnitt, 2005). In order to promote a clearer understand-

ing of the concept of cumulative abuse within studies that

examine patterns of cumulative abuse, a better job needs to

be done of explicitly operationalizing the concept.

Summary

Very little consideration has been given to the variety of ways

in which cumulative abuse has been operationalized or how

these variations affect study results, a position supported by

Schilling and colleagues (2008). Furthermore, as Finkelhor and

colleagues (2007) pointed out, it is still unclear whether each

additional adversity or cumulative experience makes the out-

come worse, or whether some adversities potentate the harmful

effects of other adversities. Future improvements into the study

of cumulative abuse requires an interdisciplinary effort to

examine the potential ways in which the concept of cumulative

abuse can most appropriately be operationalized that best

reflects the experience of abuse in the lives of women. This

involves not only summing different experiences of types of

abuse but also appreciating both the influence of abuse charac-

teristics and the heterogeneity of abuse experiences.

Design, Methodology, and Analytical Approaches

Design

Cross-sectional, retrospective, descriptive correlational

designs have been the most commonly used design for

describing the phenomenon of cumulative abuse and its

potential relationship to health. Although not without its

value and place within violence research, such designs are

limited as they can only demonstrate associations thereby

precluding definitive temporal and causal inferences (Arata,

2000; Bonomi et al., 2007; McNutt et al., 2002; Sabina &

Straus, 2008). Also critiques have frequently identified

intrinsic problems in the validity and reliability of retrospec-

tive designs, primarily with respect to recall bias and issues

in accuracy and meaning (Spatz-Widom, Raphael, &

DuMont, 2004). As such, Spatz-Widom and colleagues

(2004) argued for the need for prospective longitudinal

studies especially when the research interest is in disentan-

gling some of the complexities in relationships between

abuse history and subsequent outcomes. This is especially

relevant given the obvious complexities inherent in

researching cumulative abuse.

Of the limited number of longitudinal studies conducted

examining the concept of cumulative abuse, even though there

has been support of a dose–response type of relationship

between the number of types of abuse and worse health out-

comes, only a few of these studies truly allow for the examina-

tion of cumulative abuse in a longitudinal fashion (e.g.,

Banyard et al., 2008). For example, some researchers have used

data pertaining to the concept of cumulative abuse and health

outcomes that were measured only in a single wave, thus

voiding the benefits of the longitudinal design (e.g., Dutton

et al., 2005; Krause et al., 2004). Although longitudinal

designs are not exempt from problems, such as considerable

costs and the challenges of following participants over time,

prospective and longitudinal approaches are important for

exposing the complex causal relationship between cumula-

tive abuse and health.

Many of the limitations addressed in how cumulative

abuse has been conceptualized and operationalized carry

over into problems in how research studies have been

designed. For example, very little attention has been given

to how the multitude of ways in which abuse has been

defined has affected what we know about cumulative abuse

and its impact on health. As well, there are a plethora of

studies that have documented the unique impact of abuse

characteristics such as severity, duration, type, and so forth

on health outcomes, suggesting the importance of incorpor-

ating these characteristics, or controlling for them in analy-

sis (Arata, 2000; Bonomi et al., 2006; Cloitre et al., 2001;

Schilling et al., 2008). However, only a handful of studies

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specifically examining cumulative abuse have attempted to

do so, and of those that have, many have only taken into

consideration a few of the characteristics (e.g., Campbell

et al., 2008; Carbone-López et al., 2006; McNutt et al.,

2002). Thus, the risk continues to lie in falsely contributing

health outcomes to the sheer number of different types of

abusive experiences, rather than a more complex interrela-

tionship between the number of types of experiences and

abuse characteristics.

Another important critique in how cumulative abuse has

been studied has been the underuse of mediators and

moderators in investigating the relationship between abuse and

health. Not all women who experience abuse exhibit negative

health outcomes and rarely is there a simple cause and

effect relationship between abuse and health (Bogart et al.,

2005; WHO, 2002). For example, resilience, coping, and social

supports have long been recognized as important mediators

and moderators in terms of health outcomes but have been

relatively understudied in the cumulative abuse–health

relationship. A better understanding of their role could lead

to a clearer picture of not only etiology of negative health

outcomes but also enrich interventions, and help to more

accurately inform policy and practice. While some researchers

are becoming increasingly sensitive to the role of mediators

and moderators within the context of cumulative abuse (e.g.,

Banyard et al., 2008; McGuigan & Middlemiss, 2005), it

is apparent that much more research is needed to fully

understand their influence within the cumulative abuse–health

relationship.

Sampling

What we know about cumulative abuse and its relationship to

health has come from an impressive array of clinical, nonclini-

cal, military, university, community, and national-based sam-

ples of women (e.g., Banyard et al., 2008; Bonomi et al.,

2007; Kimerling et al., 2007; Sabina & Straus, 2008; Thomp-

son et al., 2002; Woods & Wineman, 2004). The majority of

these samples have been convenience samples, which risks

homogeneity within the sample and limits generalizability of

findings (Polit & Beck, 2004). Despite this, sample sizes for the

most part have been adequate, especially the large national

population-based studies, providing greater confidence in the

findings (Carbone-López et al., 2006; Finkelhor et al., 2005;

Fogarty et al., 2008; Thompson et al., 2002).

Data Collection Methods

Abuse history data have primarily been collected through indi-

vidual self-reports (e.g., Arata, 2000; Bonomi et al., 2007;

Felitti et al., 1998; Messman-Moore et al., 2000). A drawback

to this widespread use of retrospective self-reports is the con-

cern with recall bias, in which factors such as the passing of

time, current psychological health, and stress may influence

accurate recall (Briere, 1992; Briere & Elliott, 1995; Maughan

& Rutter, 1997; Spatz-Widom et al., 2004). However, findings

from longitudinal studies in which documented cases of child-

hood abuse have been available have suggested that, in general,

adults’ retrospective recall of childhood abuse is likely to

underestimate actual occurrence rather than overestimate

(Banyard et al., 2001; Williams 1995). As well, it is widely

accepted that all types of abuse are underreported to authorities,

thus official documented cases likely underrepresent the true

prevalence (Bohn & Holz, 1996). Furthermore, as some

researchers have suggested, what is really of importance is how

women remember and attribute past abusive experiences and

therefore self-reports should be considered a valid form of

inquiry (Miller, Downs, & Testa, 1993).

Measurement

The scales and instruments used to measure abuse vary tremen-

dously in the literature, making it difficult to report collectively

on reliability and validity of such instruments, or to make com-

parisons between studies. What may be of benefit, or at least a

beneficial next step, would be a systematic review of the cumu-

lative abuse literature in which methodological quality of stud-

ies (reliability and validity) could be more thoroughly

critiqued. Furthermore, comparisons among measures are

impeded by the use of a multitude of abuse definitions. As

such, the use of narrow definitions of abuse versus broad defi-

nitions may partially reflect differences in outcomes observed.

For example, sexual assault being narrowly defined to mean

rape would not capture any other acts of sexual violence or

coercion against the woman (DeKeseredy & Schwartz, 2001;

Mahoney, Williams, & West, 2001; Murray & Graybeal,

2007). Failure to achieve consensus on what constitutes abuse

adds to the complexity of studying and measuring cumulative

abuse.

Also worth noting is that either by virtue of design choice or

instruments used, some studies have used a limited time frame

for measuring an abusive history, for example, physical and

sexual abuse within the last 12 months (e.g., Dutton et al.,

2005) or emotional abuse within the 12 months (e.g., McNutt

et al., 2002). Although these studies may allow for the exami-

nation of many types of abuse and their cumulative impact,

there continues to be the risk of attributing health outcomes

to abuse experiences within these limited time frames, negating

the unmeasured effects of experiences outside such time

frames.

Data Quality

The response rates among studies have fluctuated tremen-

dously, and with few exceptions lean toward the low side,

which is not uncommon in abuse research given the sensitive

nature of the topic (WHO, 2002). As low response rates can

introduce biases into study findings and affect quality of the

results, it is important when possible to compare characteristics

of those who decline participation against characteristics of

those who do participate (Fogliani, 1999; Templeton, Deehan,

Taylor, Drummond, & Strang, 1997). And while a few studies

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have done so (e.g., Bonomi et al., 2007; Edwards et al., 2003),

most have not which raises concern about possible inherent dif-

ferences among these two groups of women. This can poten-

tially further impact our understanding of the impact of abuse

on health and restricts the generalizability of findings.

Abuse affects women of every race and ethnicity, yet it is

known that some women have additional vulnerabilities based

on social, economic, and political barriers entrenched in race,

ethnicity, and culture (Gunter, 2007; Humphreys et al.,

2005). Research efforts examining the effects of abuse on

health have done a rather adequate job in having diverse popu-

lations represented through national, epidemiological, and clin-

ical studies (e.g., Banyard et al., 2001; Finkelhor et al., 2007;

Hedtke et al., 2008; McGuigan & Middlemiss, 2005). How-

ever, it must be noted that the majority of the samples are still

predominantly English-speaking Caucasian women (e.g.,

Hedtke et al., 2008). Also, to date there remains limited

research that examines the influence of race, ethnicity, and cul-

ture specifically on health outcomes especially within the con-

text of cumulative abuse. Forging ahead in an attempt to better

understand the concept of cumulative abuse, it becomes

imperative to design studies that are sensitive to race, ethnicity,

and culture.

Statistical Control

If the interest is in deconstructing cumulative abuse to examine

the unique impact of one particular type of abuse on health,

then it becomes imperative to control for other types. However,

if the interest is in examining the effects of cumulative abuse on

health, then it is necessary to include a broad array of abuse

types across the lifespan so that findings do not wrongly attri-

bute health outcomes to a handful of specific types of abuse at a

specific period of time rather than the cumulative impact of all

forms of abuse across a lifetime (Felitti et al., 1998; Saunders,

2003). Further adding to the complexity is a growing awareness

that other nonabusive adversities (such as witnessing violence,

unstable family life, illness, serious accidents, divorce, and so

forth) are often embedded in the larger context of abuse and can

interact to produce negative effects on health as well (McEwen

& Lasley, 2002; Turner, Finkelhor, & Ormrod, 2006). These

are concepts that need to be included in the larger theoretical

model. And while a greater number of researchers are including

or controlling for these more diverse adversities (e.g., Briere

et al., 2008; Felitti et al., 1998; Finkelhor et al., 2005), many

are not resulting in the need to cautiously interpret health out-

comes when they are related to only a few types of abuse/

adversities.

When the interest is explaining variability in health out-

comes, decades of research has clearly demonstrated the need

to control for potential confounding extraneous factors such

as age, race/ethnicity, socioeconomic status, and educational

level (Gunter, 2007; Schnurr & Green, 2004; Sorenson, 1996;

Weaver & Resnick, 2004). Yet, it is apparent that not all studies

consistently control for these confounding factors, which may

result in an overestimation of the strength of the relationship

between cumulative abuse and health outcomes (Roosa, Rein-

holtz, & Angelini, 1999; Saunders, 2003). Moreover, when

comparison groups have been used, they have not always been

designed in the most advantageous manner. If truly respectful

of the basic premise of cumulative abuse, in which adverse

events over a lifetime can accumulate and compound leading

to greater negative health outcomes, then the importance of

using a comparative group that has no lifetime abuse history

becomes obvious. However, some researchers use a compara-

tive group in which abuse has not been experienced within a

certain time frame, for example, within the last 12 months

(e.g., McGuigan & Middlemiss, 2005) which negates the

impact of an abuse history prior to 12 months and may inadver-

tently lead to the examination of the differences between distal

and proximal abuse rather than abuse versus no abuse.

Analytic Techniques

A cumulative classification model has probably been the most

predominantly used model in guiding analytic techniques. This

model is congruent with how the majority of researchers have

operationalized cumulative abuse; that the sheer number of

experiences is what is important in predicting negative out-

comes not the presence of any specific type of experiences

(Boxer & Terranova, 2008). Within this model, some research-

ers have used bivariate statistical analyses such as analysis of

variance (ANOVA) and correlations, while the majority have

progressed to using more complex multivariate analytic

approaches such as logistic and multiple regression analyses,

analysis of covariance (ANCOVA), multiple analysis of covar-

iance (MANCOVA), and structural equation modeling (e.g.,

Arata, 2000; Banyard et al., 2001; Briere et al., 2008; Campbell

et al., 2008; Finkelhor et al., 2007; Kimerling et al., 2007;

McGuigan & Middlemiss, 2005; Messman-Moore et al.,

2000; Thompson et al., 2002).

Collectively, these analytic approaches within a cumulative

classification model have provided utility in examining the

concept of cumulative abuse and have supported a dose–

response type of relationship in which more cumulative abuse

is related to poorer health outcomes. However, a shortcoming

of this model is that it does not operate on the premise that

some types of abuse are inherently more detrimental than oth-

ers, or that certain combinations of abuse may produce worse

outcomes than others (Boxer & Terranova, 2008). In order to

address this, weighing techniques would need to be used as out-

lined previously, however, simply applying weights to different

‘‘types’’ of abuse still does not take into consideration other

factors such as abuse characteristics (e.g., severity, duration,

frequency, etc.) that may, in part, be responsible for the out-

comes seen. Schilling and colleagues (2008) poignantly high-

lighted this in their study of the impact of cumulative

childhood adversity on the mental health outcomes of high

school students in which they caution against simply assuming

that a basic linear association exists between cumulative adver-

sity and health outcomes. In their analysis, both a linear and a

quadratic model approach were used. Findings from the linear

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model falsely lead to the assumption that a simple cumulative

impact of each additional adversity existed on mental health.

The quadratic model, however, further revealed that ‘‘this

acceleration effect was an artifact of the confounding of high

cumulative adversity scores with the experience of more severe

events’’ (p. 1148). Thus, respondents with higher total cumula-

tive scores had disproportionally poorer mental health scores in

part because of the severity of the adversities, not solely

because of the cumulative number of different types of adver-

sities experienced. This again underscores the complexity of

examining cumulative experiences and the importance of

including abuse characteristics such as severity in order to pro-

vide a clearer picture of the cumulative impact of abuse on

health.

A major drawback of the aforementioned analytic

approaches is that for the most part they have been rooted in

a variable-oriented approach, which assumes that samples

being investigated are sufficiently homogeneous so that infor-

mation on overall trends of relationships among variables of

interest can be created (Nurius & Macy, 2008). However, this

approach has its limitations as it does not take into account the

complexity and heterogeneity of abuse nor the cooccurrence of

multiple types of abuse that is often a reality for many women.

In contrast, a person-oriented approach assumes that meaning-

ful subgroups exist within any sample that is drawn from a

population (Bogart et al., 2005; Nurius & Macy, 2008).

‘‘Person-oriented methods are based on varying statistical

approaches to clustering or classifying groups of people based

on the comparability of their values or locations on an array of

variables’’ (Nurius & Macy, 2008, p. 396).

This appreciation of the heterogeneity of abuse coupled with

methodological advances has lead to the recent use of cluster-

ing techniques, such as latent class analysis (e.g., Carbone-

López et al., 2006; Cavanaugh et al., 2009; Macmillan &

Kruttschnitt, 2005) and hierarchical and iterative cluster analy-

sis (e.g., Campbell et al., 2008; Dutton et al., 2005) to examine

the relationships among cumulative abuse and health. An

important statistical advantage to such a method is that it

allows researchers to take into consideration multidimensional

abuse characteristics as well as the cooccurrence of different

types of abuse (Carbone-López et al., 2006). In other words,

‘‘count studies’’ may expose a group of women who have all

experienced three types of abuse, but not necessarily the same

three types, whereas clustering techniques would reveal groups

with high probabilities of similar types of abuse histories

(Cavanaugh et al., 2009). However, it must be cautioned that

just because such analytic techniques allows for the creation

of various subgroups, does not always mean they are meaning-

ful. Therefore it is imperative that researchers use theoretical

rational to decide the meaning and utility of the groups/clusters

formed.

Recently, there has been a surge in the use of these clus-

tering/patterning techniques in the study of abuse and health

(e.g., Campbell et al., 2008; Carbone-López et al., 2006;

Cavanaugh et al., 2009; Dutton et al., 2005; Macmillan &

Kruttschnitt, 2005). Together these studies have not only

provided greater evidence for heterogeneous patterns of

abuse among women but have also demonstrated that health

outcomes actually differ according to various abuse patterns

(Cavanaugh et al., 2009). Further, and of particular impor-

tance, has been the empirical evidence to suggest the cumu-

lative effects of either increasing number of types of abuse,

or increasing severity of abuse, or a combination of both,

exist and have an unique influence on health outcomes

(Cavanaugh et al., 2009). As suggested by Nurius and Macy

(2008), being able to identify meaningful subgroups with

variations in cumulative abuse patterns and understanding

differences in health outcomes has important implications

for the future direction of health prevention and treatment

programs as it pushes health care professionals to consider

the heterogeneity of cumulative abuse experiences.

The complexity of trying to incorporate all abuse charac-

teristics and potential mediators and/or moderators into a

research study is obvious and continues to be an obstacle for

researchers. Currently there are no perfect solutions or ana-

lytic techniques that can accommodate all the intricacies of

examining cumulative abuse, and designing one study that

would do so would be impractical at best. For cumulative

abuse research to advance and further contribute to our

understanding of the complex interrelationships between

abuse and health, researchers need to be aware of methodo-

logical problems that have plagued studies to date, address

limitations, try not to repeat past mistakes, and work

together regardless of individual disciplines to devise crea-

tive and innovate new ways to study the phenomenon of

cumulative abuse.

Limitations

The present review has limitations that should be considered.

It is important to acknowledge that this critical review and eva-

luation of how cumulative abuse has been historically concep-

tualized, operationalized, studied, and the ‘‘categories’’

deduced to frame the article is from the perspective of one

scholar, and so other ways to categorize and historicize articles

may be argued. It is also acknowledged that a few studies used

to construct this article had primary focuses that were not

necessarily the relationship between abuse histories and health.

In such cases, these studies examined health outcomes as a sec-

ondary aim, which may have lead to the researchers operatio-

nalizing and analyzing abuse experiences differently than in

research focused on health as the primary outcomes of interest.

Future Directions

This review came about from my own attempts to grapple with

the phenomenon of cumulative abuse and how to study and

measure it in my own research. Although answers per se are not

provided, nor would it be appropriate to do so, this review has

laid the foundational work as a starting point for researchers

and scholars to move our understanding of this phenomenon

and all its complexities forward. For me, insights gained that

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seem to be most promising include a better understanding the

critical need for a cumulative life history of abuse when study-

ing abuse in the lives of women and the risks that are inherent

in not doing so. Also appreciating the complexities in trying to

operationalize cumulative abuse and in deciding methodolo-

gies to best examine it. For example, using person-centered

analytical techniques that allows taking into account abuse

characteristics, begins to address some of the historical limita-

tions seen with traditional ‘‘count’’ studies and is a promising

step forward.

Overall, it appears to be one of those unique situations

whereby the theory is far ahead of the methodology. This is not

unlike what we have seen in the study of ‘‘change’’ in longitu-

dinal research. Researchers for generations have been fasci-

nated with studying ‘‘change’’ across time in an infinite

number of concepts (e.g., depression, attachment, relation-

ships, etc.). However, it has only been in the last 30 years or

so that methodology has been developed to be able to study

change well (Singer & Willett, 2003). It appears as though the

phenomenon of cumulative abuse is at the same crossroads

which gives hope that with intense efforts and interdisciplinary

collaboration, we too can overcome current obstacles. In under-

standing this, it becomes reasonable that this article creates

many more questions than there are currently answers for. For

example, how do we move toward agreement across and within

disciplines in conceptualizing and operationalizing cumulative

abuse? How might researchers better capture cumulative abuse

inclusive of not only types but also abuse characteristics? How

do we more accurately analyze this phenomenon? What theo-

retical frameworks should be considered in moving toward

person-centered analytical techniques? What mediators/mod-

erators are important to pay attention to in the cumulative

abuse–health relationship?

Conclusion

While the magnitude of this phenomenon of cumulative abuse

is striking and its impact on health is of notable importance, it is

surprising how underdeveloped the concept is and the relative

lack of attention it has received in the literature. At the most

basic level, literature on the phenomenon of cumulative abuse

has consistently supported the premise that ‘‘more is worse’’ in

terms of health outcomes. However, this review highlights that

conceptualizing, operationalizing, and analyzing cumulative

abuse as such remains too simplistic and that more work needs

to be done. Definite progress has been made and our under-

standing of the importance of considering a cumulative abuse

history over the entire lifespan has been a turning point in how

abuse is studied. Yet, there is much to still learn and even if it is

not yet possible to design the ‘‘perfect’’ study, researchers can

continue to design better studies that will incrementally move

our understanding forward. More specifically, future research

into cumulative abuse needs to further elucidate the intercon-

nections among types of abuse, other life adversities, abuse

characteristics and individual characteristics, as well as the role

of mediators and moderators within these relationships.

Finally, too many disciplines and fields of study are see-

mingly examining the same phenomenon, just calling it some-

thing different. It is time that researchers from all disciplines

who are interested in the study of abuse and its effects on health

work collaboratively in an interdisciplinary manner to discuss

this phenomenon of cumulative abuse and how it should be

conceptualized, operationalized, and studied. In moving for-

ward, a greater understanding of the cumulative impact of

abuse exposure on health will serve to better inform service

provision for individuals and meaningfully inform public pol-

icy and secondary prevention efforts. Hopefully, this review

has offered a point of departure by which researchers can col-

laboratively work from to address some of the historical limita-

tions of studying cumulative abuse and has prompted interest to

build upon the important cumulative abuse research that has

been conducted to date.

Critical findings

� Women’s experiences of being victimized are often cumu-

lative and heterogeneous.

� Cumulating experiences of abuse have a serious deleterious

impact on health.

� Despite recognition of the importance of considering the

cumulative nature of abuse in evaluating health outcomes,

there is little consensus on what to call this phenomenon or

how to study it.

� The current conceptual, operational, and methodological

approaches to understanding cumulative abuse have serious

limitations that undermine our understanding of this impor-

tant phenomenon. Continuing to research cumulative abuse

in the same way risks falsely contributing health outcomes

to the sheer number of different types of abusive experi-

ences, rather than a more complex interrelationship

between the number of experiences, individual and abuse

characteristics, and life adversities.

Implications for practice, policy, and research

� Researchers from all disciplines who are interested in the

study of abuse and its effects on health need to work colla-

boratively and in an interdisciplinary manner to discuss the

phenomenon of cumulative abuse and how it should be bet-

ter conceptualized, operationalized, and studied in order to

provide a more comprehensive understanding of this com-

plex phenomenon.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to

the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, author-

ship, and/or publication of this article.

Scott-Storey 11

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Note

1. Often the terms violence and abuse are used interchangeably and

with little conceptual clarity. For the purpose of this article, the

term ‘‘abuse’’ will be used to denote both violence and abusive acts

against women.

References

Alvarez, J., Pavao, J., Mack, K., Chow, J., Baumrind, N., &

Kimerling, R. (2009). Lifetime interpersonal violence and self-

reported Chlamydia trachomatis diagnosis among California

women. Journal of Women’s Health, 18, 57-63.

Anda, R., Brown, D., Dube, S., Bremner, J., Felitti, V., & Giles, W.

(2008). Adverse childhood experiences and chronic obstructive

pulmonary disease in adults. American Journal of Preventive Med-

icine, 34, 396-403.

Arata, C. (2000). From child victim to adult victim: A model for

predicting sexual revictimization. Child Maltreatment, 5, 28-38.

Arias, I. (2004). The legacy of child maltreatment: Long-term health

consequences for women. Journal of Women’s Health, 13, 468-473.

Bachmann, G., Moeller, T., & Benett, J. (1988). Childhood sexual

abuse and the consequences in adult women. Obstetrics &

Gynecology, 71, 631-642.

Banyard, V., Williams, L., Saunders, B., & Fitzgerald, M. (2008). The

complexity of trauma types in the lives of women in families

referred for family violence: Multiple mediators of mental health.

American Journal of Orthopsychiatry, 78, 394-404.

Banyard, V., Williams, L., & Siegel, J. (2001). The long-term mental

health consequences of child sexual abuse: An exploratory study of

the impact of multiple traumas in a sample of women. Journal of

Traumatic Stress, 14, 697-715.

Basile, K., Arias, I., Desai, S., & Thompson, M. (2004). The differen-

tial association of intimate partner physical, sexual, psychological,

and stalking violence and posttraumatic stress symptoms in a

nationally representative sample of women. Journal of Traumatic

Stress, 17, 413-421.

Bogart, A., Levendosky, A., & von Eye, A. (2005). The future of

research on intimate partner violence: Person-oriented and

variable-oriented perspectives. American Journal of Community

Psychology, 36, 49-70.

Bohn, D., & Holz, K. (1996). Sequelae of abuse: Health effects of

childhood sexual abuse, domestic battering, and rape. Journal of

Nurse Midwifery, 41, 442-456.

Bonomi, A., Anderson, M., Rivara, F., & Thompson, R. (2007). Health

outcomes in women with physical and sexual intimate partner

violence exposure. Journal of Women’s Health, 16, 987-997.

Bonomi, A., Thompson, R., Anderson, M., Reid, R., Carrell, D.,

Dimer, J., & Rivara, F. P. (2006). Intimate partner violence and

women’s physical, mental, and social functioning. American Jour-

nal of Preventive Medicine, 30, 458-466.

Boxer, P., & Terranova, A. (2008). Effects of multiple maltreatment

experiences among psychiatrically hospitalized youth. Child Abuse

& Neglect, 32, 637-637.

Breiding, M., Black, M., & Ryan, G. (2008). Chronic disease and

health risk behaviors associated with intimate partner violence – 18

U.S. states/territories, 2005. Annals of Epidemiology, 18, 538-544.

Bremner, J. D. (2002). Does stress damage the brain? New York, NY:

W. W. Norton.

Briere, J. (1992). Methodological issues in the study of sexual abuse

effects. Journal of Consulting and Clinical Psychology, 60, 196-203.

Briere, J., & Elliott, D. (1995). Posttraumatic stress associated with

delayed recall of sexual abuse: A general population study. Journal

of Traumatic Stress, 8, 629-647.

Briere, J., & Elliott, D. (2003). Prevalence and psychological sequelae

of self-reported childhood physical and sexual abuse in general

population sample of men and women. Child Abuse & Neglect,

27, 1205-1222.

Briere, J., & Jordon, C. (2004). Violence against women: Outcome

complexity and implications for assessment and treatment. Journal

of Interpersonal Violence, 19, 1252-1276.

Briere, J., Kaltman, S., & Green, B. (2008). Accumulated childhood

trauma and symptom complexity. Journal of Traumatic Stress,

21, 223-226.

Brown, J., Hill, H., & Lambert, S. (2005). Traumatic stress symptoms

in women exposed to community and partner violence. Journal of

Interpersonal Violence, 20, 1478-1494.

Campbell, J. (2002). Health consequences of intimate partner

violence. The Lancet, 359, 1331-1336.

Campbell, R., Greeson, M., Bybee, D., & Raja, S. (2008). The

co-occurrence of childhood sexual abuse, adult sexual assault, inti-

mate partner violence, and sexual harassment: A meditational

model of posttraumatic stress disorder and physical health

outcomes. Journal of Consulting Psychology, 76, 194-207.

Carbone-López, K., Kruttschnitt, C., & Macmillan, R. (2006). Patterns

of intimate partner violence and their associations with physical

health, psychological distress, and substance use. Public Health

Reports, 121, 382-392.

Carlson, B. (1997). A stress and coping approach to intervention with

abused women. Family Relations, 46, 291-298.

Casey, E., & Nurius, P. (2005). Trauma exposure and sexual revicti-

mization risk: Comparisons across single, multiple incident, and

multiple perpetrator victimizations. Violence Against Women, 11,

505-530.

Cavanaugh, C., Messing, J., Fowler, B., Lareina, L., Kub, J., Agnew,

J., Campbell, J. (2009). Patterns of violence exposure among

female nurses: A latent class analysis. Manuscript in preparation.

Clemmons, J., Walsh, L., DiLillo, D., & Messman-Moore, T. (2007).

Unique and combined contributions of multiple child abuse types

and abuse severity to adult trauma symptomatology. Child

Maltreatment, 12, 172-181.

Cloitre, M., Cohen, L., Edelman, R., & Han, H. (2001). Posttraumatic

stress disorder and extent of trauma exposure as correlates of

medical problems and perceived health among women with

childhood abuse. Women & Health, 34, 1-17.

Clum, G., Calhoun, K., & Kimerling, R. (2000). Associations among

symptoms of depression and posttraumatic stress disorder and

self-reported health in sexually assaulted women. The Journal of

Nervous and Mental Disease, 188, 671-678.

Coker, A., Davis, K., Arias, I., Desai, S., Sanderson, M., Brandt, H., &

Smith, P. H. (2002). Physical and mental health effects of intimate

partner violence for men and women. American Journal of

Preventive Medicine, 23, 260-268.

12 TRAUMA, VIOLENCE, & ABUSE 000(00)

at PENNSYLVANIA STATE UNIV on March 5, 2016tva.sagepub.comDownloaded from

Coker, A., Smith, P., Bethea, L., King, M., & McKeown, R. (2000).

Physical health consequences of physical and psychological

intimate partner violence. Archives of Family Medicine, 9,

451-457.

Crofford, L. (2007). Violence, stress, and somatic syndromes.

Trauma, Violence, & Abuse, 8, 299-313.

DeKeseredy, W., & Schwartz, M. (2001). Definitional issues. In

C. Renzetti, J. Edleson, & R. Kennedy-Bergen (Eds.), Source-

book on violence against women (pp. 23-34). Thousand Oaks,

CA: Sage.

Desai, S., Arias, I., Thompson, M., & Basile, K. (2002). Childhood

victimization and subsequent adult revictimization assessed in a

nationally representative sample of women and men. Violence and

Victims, 17, 639-653.

Dewa, C., Lesage, A., Goering, P., & Caveen, M. (2004). Nature and

prevalence of mental illness in the workplace. Healthcare Papers,

5, 12-25.

Drossman, D., Leserman, J., Li, Z., Keefe, F., Hu, Y., & Toomey, T.

(2000). Effects of coping on health outcomes among women with

gastrointestinal disorders. Psychosomatic Medicine, 62, 309-317.

Dube, S., Fairweather, D., Pearson, W., Felitti, V., Anda, R., &

Croft, J. (2009). Cumulative childhood stress and autoimmune

disease in adults. Psychosomatic Medicine, 71, 243-250.

Dutton, M., Green, B., Kaltman, S., Roesch, D., Zeffiro, T., &

Krause, E. (2006). Intimate partner violence, PTSD, and adverse

health outcomes. Journal of Interpersonal Violence, 21, 955-968.

Dutton, M., Kaltman, S., Goodman, L., Weinfurt, K., & Vankos, N.

(2005). Patterns of intimate partner violence: Correlates and

outcomes. Violence and Victims, 20, 483-497.

Eby, K. (2004). Exploring the stressors of low-income women with

abusive partners: Understanding their needs and developing

effective community responses. Journal of Family Violence, 19,

221-232.

Eby, K., Campbell, J., Sullivan, C., & Davidson, W. (1995). Health

effects of experiences of sexual violence for women with abusive

partners. Health Care Women International, 16, 563-576.

Edwards, V., Holden, G., Felitti, V., & Anda, R. (2003). Relationship

between multiple forms of childhood maltreatment and adult men-

tal health in community respondents: Results for the Adverse

Childhood Experiences Study. American Journal of Psychiatry,

160, 1453-1460.

Felitti, V., Anda, R., Nordenberg, D., Williamson, D., Spitz, A.,

Edwards, V., . . . Marks, J. S. (1998). Relationship of

childhood abuse and household dysfunction to many of the

leading causes of death in adults; The Adverse Childhood

Experiences (ACE) Study. The American Journal of Preventive

Medicine, 14, 245-258.

Finkelhor, D., Ormrod, R., & Turner, H. (2007). Polyvictimization and

trauma in a national longitudinal cohort. Development and

Psychopathology, 19, 149-166.

Finkelhor, D., Ormrod, R., Turner, H., & Hamby, S. (2005).

Measuring poly-victimization using the Juvenile Victimization

Questionnaire. Child Abuse & Neglect, 29, 1297-1312.

Fogarty, C., Fredman, L., Heeren, T., & Liebschutz, J. (2008).

Synergistic effects of child abuse and intimate partner violence on

depressive symptoms in women. Preventive medicine, 46, 463-469.

Fogliani, M. (1999, November). Low response rates and their effects

on survey results. Paper presented at the meeting of the

Government Statistical Service Methodology Advisory Committee,

Adelaide, Australia.

Follette, V., Polusny, M., Bechtle, A., & Naugle, A. (1996).

Cumulative trauma: The impact of child sexual abuse, adult

sexual assault, and spouse abuse. Journal of Traumatic Stress,

9, 25-35.

Ford-Gilboe, M., Wuest, J., Varcoe, C., Davies, L., Merritt-Grey, M.,

Campbell, J., & Wilk, P. (2009). Modelling the effects of intimate

partner violence and access to resources on women’s health in the

early years after leaving an abusive partner. Social Sciences &

Medicine, 68, 1021-1029.

Frayne, S., Skinner, K., Sullivan, L., Tripp, T., Hankin, C.,

Kressin, N., & Miller, D. R. (1999). Medical profile of women vet-

erans administration outpatients who report a history of sexual

assault occurring while in the military. Journal of Women’s Health

& Gender-Based Medicine, 8, 835-845.

Gidycz, C., Coble, C., Latham, L., & Layman, M. (1993). Sexual

assault experience in adulthood and prior victimization experi-

ences: A prospective analysis. Psychological of Women Quarterly,

19, 5-29.

Golding, J. M. (1999). Intimate partner violence as a risk factor for

mental disorders: A meta-analysis. Journal of Family Violence,

14, 99-132.

Gunter, J. (2007). Intimate partner violence. Obstetrics & Gynecology

Clinics of North American, 34, 367-388.

Gustafsson, P., Nilsson, D., & Svedin, C. (2009). Polytraumatization

and psychological symptoms in children and adolescents. Eur-

opean Child & Adolescent Psychiatry, 18, 274-283.

Haller, D., & Miles, D. (2004). Personality disturbances in drug-

dependent women: Relationship to child abuse. The American

Journal of Drug and Alcohol Abuse, 30, 269-286.

Hart, L., Mader, L., Griffith, K., & deMendonca, M. (1989). Effects of

sexual and physical abuse: A comparison of adolescent inpatients.

Child Psychiatry and Human Development, 20, 49-57.

Hathaway, J., Mucci, L., Silverman, J., Brooks, D., Mathews, R., &

Pavlos, C. (2000). Health status and health care use of Massachu-

setts women reporting partner abuse. American Journal of Preven-

tive Medicine, 19, 302-307.

Hedtke, K., Ruggiero, K., Fitzgerald, M., Zinzow, H., Saunders, B.,

Resnick, H., & Kilpatrick, D. G. (2008). A longitudinal investiga-

tion of interpersonal violence in relation to mental health and sub-

stance use. Journal of Consulting and Clinical Psychology, 76,

633-647.

Humphreys, J., Sharps, P., & Campbell, J. (2005). What we know and

what we still need to learn. Journal of Interpersonal Violence, 26,

182-187.

Kaysen, D., Resick, P., & Wise, D. (2003). Living in danger: The

impact of chronic traumatization and the traumatic context on post-

traumatic stress disorder. Trauma, Violence, & Abuse, 4, 247-264.

Kendall-Tackett, K. (2003a). Health consequences of abuse in the

family: A clinical guide for evidence-based practice. Washington,

DC: American Psychological Association.

Kendall-Tackett, K. (2003b). Treating the lifetime health effects of

childhood victimization. Kingston, NJ: Civic Research Institute.

Scott-Storey 13

at PENNSYLVANIA STATE UNIV on March 5, 2016tva.sagepub.comDownloaded from

Kendall-Tackett, K. (Ed.). (2005). Handbook of women, stress, and

trauma. New York, NY: Brunner-Routledge.

Kendall-Tackett, K., Marshall, R., & Ness, K. (2003). Chronic pain

syndromes and violence against women. Women and Therapy,

26, 45-56.

Kilpatrick, D. (2004). What is violence against women? Defining and

measuring the problem. Journal of Interpersonal Violence, 19,

1209-1234.

Kimerling, R., Alvarez, J., Pavao, J., Kaminski, A., & Baumrind, N.

(2007). Epidemiology and consequences of women’s revictimiza-

tion. Women’s Health Issues, 17, 101-106.

Kira, I., Lewandowski, L., Templin, T., Ramaswamy, V., Ozkan, B.,

& Mohanesh, J. (2008). Measuring cumulative trauma dose, types,

and profiles using a development-based taxonomy of traumas.

Traumatology, 14, 62-87.

Kolko, D., Moser, J., & Weldy, S. (1988). Behavioral/emotional

indicators of sexual abuse in child psychiatric inpatients: A con-

trolled comparison with physical abuse. Child Abuse & Neglect,

12, 529-541.

Koss, M., Koss, P., & Woodruff, W. (1991). Deleterious effects of

criminal victimization on women’s health and medical utilization.

Archives of Internal Medicine, 151, 342-347.

Krause, N., Shaw, B., & Cairney, J. (2004). A descriptive epidemiol-

ogy of lifetime trauma and physical health status of older adults.

Psychology and Aging, 19, 637-648.

Lesserman, J., & Drossman, D. A. (1995). Sexual and physical abuse

history and medical practice. General Hospital Psychiatry, 17,

71-74.

Lesserman, J., Drossman, D., Li, Z., Toomey, T., Nachman, G., &

Glogau, L. (1996). Sexual and physical abuse history in gastroen-

terology practice: How types of abuse impact health status.

Psychosomatic Medicine, 58, 4-15.

Letourneau, E., Holmes, M., & Chasedunn-Roark, J. (1999). Gyneco-

logic health consequences to victims of interpersonal violence.

Jacobs Institute of Women’s Health, 9, 115-120.

MacIntosh, J. (2005). Experiences with workplace bullying in a rural

area. Issues in Mental Health Nursing, 26, 893-910.

Macmillan, R., & Kruttschnitt, C. (2005). Patterns of violence against

women: Risk factors and consequences. Washington, DC: U.S.

Department of Justice.

Mahoney, P., Williams, L., & West, C. (2001). Violence against

women by intimate relationship partners. In C. Renzetti, J. Edle-

son, & R. Kennedy-Bergen (Eds.), Sourcebook on violence against

women (pp. 143-174). Thousand Oaks, CA: Sage.

Maughan, B., & Rutter, M. (1997). Retrospective reporting of child-

hood adversity: Issues in assessing long-term recall. Journal of

Personality Disorders, 11, 19-33.

McCauley, J., Kern, D., Kolodner, K., Dill, L., Schroeder, A.,

DeChant, H., . . . Derogatis, L. R. (1995). The ‘‘battering

syndrome’’: Prevalence and clinical characteristics of domestic

violence in primary care internal medicine practices. Annals of

Internal Medicine, 123, 737-746.

McEwen, B. S. (1998). Stress, adaptation, and disease: Allostasis

and allostatic load. Annals New York Academy of Science, 840, 33-44.

McEwen, B. S., & Lasley, E. (2002). The end of stress as we know it.

Washington, DC: Joseph Henry Press.

McGuigan, W., & Middlemiss, W. (2005). Sexual abuse in childhood

and interpersonal violence in adulthood. Journal of Interpersonal

Violence, 20, 1271-1287.

McHugh, M., & Hanson-Frieze, I. (2006). Intimate partner violence:

New directions. Annals of the New York Academy of Sciences,

1087, 121-141.

McNutt, L., Carlson, B., Persaud, M., & Postmus, J. (2002). Cumula-

tive abuse experiences, physical health and health behaviors.

Annals of Epidemiology, 12, 123-130.

Mechanic, M. (2004). Beyond PTSD: Mental health consequences of

violence against women. Journal of Interpersonal Violence, 19,

1283-1289.

Mechanic, M., Weaver, T., & Resick, P. (2008). Mental health conse-

quences of intimate partner abuse: A multidimensional assessment

of four different forms of abuse. Violence Against Women, 14,

634-654.

Messman-Moore, T., Long, P., & Siegfried, N. (2000). The

revictimization of child sexual abuse survivors: An examination

of the adjustment of college women with child sexual abuse, adult

sexual assault, and adult physical abuse. Child Maltreatment, 5,

18-27.

Miller, B., Downs, W., & Testa, M. (1993). Interrelationships between

victimization experiences and women’s alcohol use. Journal of

Studies on Alcohol, 11, 109-117.

Moeller, T., Bachmann, G., & Moeller, J. (1993). The combined

effects of physical, sexual, and emotional abuse during childhood:

Long-term health consequences for women. Child Abuse &

Neglect, 17, 623-640.

Molina, L. S., & Basinait-Smith, C. (1998). Revisiting the intersection

between domestic abuse and HIV risk. American Journal of Public

Health, 88, 1267-1268.

Moracco, K., Runyan, C., Bowling, M., & Earp, J. (2007). Women’s

experiences with violence: A national study. Women’s Health

Issues, 17, 3-12.

Murray, C., & Graybeal, J. (2007). Methodological review of intimate

partner violence prevention research. Journal of Interpersonal Vio-

lence, 22, 1250-1269.

Nurius, P., & Macy, R. (2008). Heterogeneity among violence

exposed women: Applying person-oriented research methods.

Journal of Interpersonal Violence, 23, 389-415.

Pico-Alfonso, M. (2005). Psychological intimate partner violence:

The major predictor of posttraumatic stress disorder in

abused women. Neuroscience and Biobehavioral Reviews, 29,

181-193.

Pico-Alfonso, M., Garcia-Linares, M., Celda-Navarro, N., Biasco-

Ros, C., Echeburúa, E., & Martinez, M. (2006). The impact of

physical, psychological, and sexual intimate male partner violence

on women’s mental health: Depressive symptoms, posttraumatic

stress disorder, state anxiety, and suicide. Journal of Women’s

Health, 15, 599-611.

Pimlott-Kubiak, S., & Cortina, L. (2003). Gender, victimization, and

outcomes: Reconceptualizing risk. Journal of Consulting and Clin-

ical Psychology, 17, 528-539.

Plichta, S. (1992). The effects of woman abuse on health care utiliza-

tion and health status: A literature review. The Jacobs Institute of

Women’s Health, 2, 154-163.

14 TRAUMA, VIOLENCE, & ABUSE 000(00)

at PENNSYLVANIA STATE UNIV on March 5, 2016tva.sagepub.comDownloaded from

Plichta, S. (2004). Intimate partner violence and physical health con-

sequences: Policy and practice implications. Journal of Interperso-

nal Violence, 19, 1296-1323.

Polit, D., & Beck, C. (2004). Nursing research: Principles and meth-

ods (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Polusny, M., Dickinson, K., Murdoch, M., & Thuras, P. (2008).

The role of cumulative sexual trauma and difficulties identify-

ing feelings in understanding female veterans’ physical health

outcomes. General Hospital Psychiatry, 30, 162-170.

Ratner, P. (1993). The incidence of wife abuse and mental health sta-

tus in abused wives in Edmonton, Alberta. Canadian Journal of

Public Health, 84, 246-249.

Rheingold, A., Acierno, R., & Resnick, H. (2003). Trauma, PTSD, and

health risk behaviors. In P. P. Schnurr, & B. L. Green (Eds.),

Trauma and health: Physical health consequences of exposure to

extreme stress (pp. 247-275). Washington, DC: American Psycho-

logical Association.

Richmond, J., Elliott, A., Pierce, T., Aspelmeier, J., & Alexander, A.

(2009). Polyvictimization, childhood victimization and psycholo-

gical distress in college women. Child Maltreatment, 14, 127-147.

Romans, S., Belaise, C., Martin, J., Morris, E., & Raffi, A. (2002). Child-

hood abuse and later medical disorders in women: An epidemiologi-

cal study. Psychotherapy and psychosomatics, 71, 141-150.

Roosa, M., Reinholtz, C., & Angelini, P. (1999). The relation of

child sexual abuse and depression in young women: Comparisons

across four ethnic groups. Journal of Abnormal Child Psychology,

27, 65-76.

Sabina, C., & Straus, M. (2008). Polyvictimization by dating partners

and mental health among U.S college students. Violence and

Victims, 23, 667-682.

Sapolsky, R. M. (1994). Why zebras don’t get ulcers: A guide to stress,

stress-related disease, and coping. New York, NY: W.H. Freeman.

Saunders, B. (2003). Understanding children exposed to violence:

Toward an integration of overlapping fields. Journal of Interperso-

nal Violence, 18, 356-376.

Schilling, E., Aseltine, R., & Gore, S. (2008). The impact of cumulative

childhood adversity on youth adult mental health: Measures, models,

and interpretations. Social Science & Medicine, 66, 1140-1151.

Schnurr, P., & Green, B. (Eds.). (2004). Trauma and health: Physical

health consequences of exposure to extreme stress. Washington,

DC: American Psychological Association.

Shields, N., & Janneke, C. (1983). Battered wives’ reactions to martial rape.

In D. Finkelhor, R. J. Gelles, G. T. Hotaling, & M. A. Straus (Eds.), The

dark side of families (pp. 132-148). Beverly Hills, CA: Sage.

Singer, J., & Willett, J. (2003). Applied longitudinal data analysis:

Modeling change and event occurrence. New York, NY: Oxford

University Press.

Sorenson, S. B. (1996). Violence against women: Examining ethnic

differences and commonalities. Evaluation Review, 20, 123-145.

Spatz-Widom, C., Raphael, K., & DuMont, K. (2004). The case for

prospective longitudinal studies in child maltreatment research:

Commentary on Dube, Williamson, Thompson, Felitti, and Anda

(2004). Child Abuse & Neglect, 28, 715-722.

Sutherland, C., Bybee, D., & Sullivan, C. (2002). Beyond bruises and bro-

ken bones: The joint effects of stress and injuries on battered women’s

health. American Journal of Community Psychology, 30, 609-636.

Templeton, L., Deehan, A., Taylor, C., Drummond, C., & Strang, J.

(1997). Surveying general practitioners: Does a low response rate

matter? British Journal of General Practice, 47, 91-95.

Thompson, M., Arias, I., Basile, K., & Desai, S. (2002). The associa-

tion between childhood physical and sexual victimization and

health problems in adulthood in a nationally representative sample

of women. Journal of Interpersonal Violence, 17, 1115-1129.

Tjaden, P., & Thoennes, N. (1998). Prevalence, incidence and

consequences of violence against women: Findings from the

National Violence Against Women Survey. Washington, DC:

U.S. Department of Justice.

Tjaden, P., & Thoennes, N. (2000). Full report of the prevalence,

incidence, and consequences of violence against women: Findings

from the National Violence Against Women survey. Washington,

DC: U.S. Department of Justice.

Turner, H., Finkelhor, D., & Ormrod, R. (2006). The effect of lifetime

victimization on the mental health of children and adolescents.

Social Science & Medicine, 62, 13-27.

Turner, R., & Lloyd, D. (1995). Lifetime traumas and mental health:

The significance of cumulative adversity. Journal of Health and

Social Behavior, 36, 360-376.

Walker, L. (1984). The battered woman syndrome. New York, NY:

Harper & Row.

Weaver, T., & Resnick, H. (2004). Towards developing complex mul-

tivariate models for examining intimate partner violence-physical

health relationship: Commentary on Plichta. Journal of Interperso-

nal Violence, 19, 1342-1349.

Williams, L. M. (1995). Recovered memories of abuse in women with

documented child sexual victimization histories. Journal of Trau-

matic Stress, 8, 649-673.

Woods, S., & Wineman, M. (2004). Trauma, posttraumatic stress dis-

order, symptom clusters, and physical health symptoms in post-

abused women. Archives of Psychiatric Nursing, XVII, 26-34.

Woods, S., Wineman, M., Page, G., Hall, R., Alexander, T., &

Campbell, J. (2005). Predicting immune status in women from

PTSD and childhood and adult violence. Advances in Nursing Sci-

ence, 28, 306-319.

World Health Organization. (2002). World report on violence and

health. Geneva: Author .

World Health Organization. (2005). WHO multi-country study on

women’s health and domestic violence: Report of initial results on pre-

valence, health outcomes, and women’s reponses. Geneva: Auhtor.

Wuest, J., Merritt-Gray, M., Ford-Gilboe, M., Lent, B., Varcoe, C., &

Campbell, J. (2008). Chronic pain in women survivors of intimate

partner violence. The Journal of Pain, 9, 1049-1057.

Wyatt, G., Guthrie, D., & Notgrass, C. (1992). Differential effects of

women’s child sexual abuse and subsequent sexual revictimiza-

tion. Journal of Consulting and Clinical Psychology, 60, 167-173.

Zierler, S., Witbeck, B., & Mayer, K. (1996). Sexual violence against

women living with or at risk for HIV infection. American Journal

of Preventive Medicine, 12, 304-310.

Bios

Kelly Scott-Storey, MN PhD(c), is currently a full time

Interdisciplinary PhD student at the University of New Brunswick,

Scott-Storey 15

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New Brunswick, Canada. Career wise, Kelly has been a Cardiac

Care Nurse, a Nursing Instructor, a Program Coordinator for a

Cardiac Rehabilitation Program, and a Clinical Nurse Specialist

in Cardiac Health and Wellness. In 2008, concurrent with her PhD

studies, Kelly was accepted into a very prestigious Cardiovascular

Nurse Scientist Training Program supported by CIHR called the

FUTURE program. As well, in 2010 she was accepted into the

CIHR Institute of Gender and Health Summer Training Institute.

Kelly currently holds a CIHR Regional Partnership Program

Doctoral Award (2009-2012), a President’s Doctoral Tuition

Award (2008-2011), a New Brunswick Innovation Foundation

(NBIF) Research Assistantship Award (2008-2010), and a

Graduate Research Assistantship (2009-2012). Her research and

clinical interests lie broadly within cardiovascular health, and more

specifically within understanding the cardiovascular risk of women

who have experienced abuse.

16 TRAUMA, VIOLENCE, & ABUSE 000(00)

at PENNSYLVANIA STATE UNIV on March 5, 2016tva.sagepub.comDownloaded from

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