Jenny Lisshammar - Thesis submitted in partial fulfilment of the degree of Doctor of Clinical Psychology (DClinPsych)
Keywords: self-harm
gynaecology
women's sexual health
women's psychological health
borderline personality disorder
lifespan psychology
emotionally unstable personality disorder

A Systematic Review of the Research Literature
1. Identified Risks of Retraumatisation in, and Trauma-informed Adaptations to, Routine Secondary Gynaecological Care for Adult Women who have Experienced Sexual Violence: A Narrative Synthesis
Background: Sexual violence against women is associated with post-traumatic sequalae, including retraumatisation where trauma reminders may be present, such as in gynaecological care. Trauma-informed care guidelines remain absent for routine gynaecological care provided by the British National Health Service.
Methodology and Aims: A narrative synthesis was completed, which aimed to document evidence-based care-modifications for reduction of retraumatisation in routine gynaecological care. Full-text, peer-reviewed, English language articles reviewing risks and mitigating factors of retraumatisation in women aged 18+ who had experienced sexual violence, and who were seen in routine gynaecological care settings, were eligible for inclusion. These were identified via Ovid SP, Scopus, and Web of Science between January 2022 and March 2023. Quality assessments were undertaken using The Standard quality assessment criteria for evaluating primary research papers from a variety of fields: Quantitative studies.
Findings: 18 articles were included. 100% employed a survey methodology, with four including case-control comparisons. Prevalence of women with a history of sexual violence was higher in samples than estimated by clinicians, and a history of sexual violence was rarely taken, despite women requesting such a discussion. A multitude of triggers were identified, reflecting their relationship with the individual’s original trauma experiences. However, several common triggers were identified. Clinicians trained and confident in working with women who have experienced sexual violence were found to be the most effective modifier to reduce retraumatisation, alongside discussion about individual triggers and aids to inform modifiable examination procedures.
Discussion: This review contributes a synthesis of evidence-based, trauma-informed modifications to date. It is registered on PROSPERO (CRD42022299821). It is not funded. It identifies the significant positive developments which have occurred in this field over the last two decades. More research, employing a broader methodological range, remains warranted to inform development of accessible and implementable trauma-informed routine care guidelines.

Service Improvement Project
2. Patient Experience of Patient-Clinician Dialogue Concerning Sexual Intimacy: A Qualitative Investigation of Women with Chronic Gynaecological Conditions
Background: Sexual dissatisfaction is common in women living with chronic gynaecological conditions. While increasingly recognised as part of holistic care, it remains infrequently spoken about in clinical consultations. Clinicians attribute this to not recognising its relevance, feeling embarrassed, or feeling insufficiently skilled.
Methodology and Aims: This service improvement project was set at the John Radcliffe Hospital’s Women’s Centre, UK. It sought to understand patients’ experiences of conversations about sexual intimacy. It explored individual and dyadic processes contributing to these experiences. Six patients with chronic gynaecological conditions participated in semi-structured interviews. Their accounts were analysed using Interpretative Phenomenological Analysis.
Results: Four themes were inferred from analysis. ‘Beyond the hospital door’ described the day-to-day impact of participants’ conditions. ‘Ripples of care experiences’ recounted participants care being felt to be a single, continuous journey. ‘The ‘S’ word in clinic’ spoke of absent, but wanted, clinical conversations about sexual intimacy. Lastly, ‘You’re an expert, I’m an expert, too’, identified participants’ beliefs about the meaning of medical expertise, and the value of reciprocal patient-clinician relationships.
Conclusions: Chronic gynaecological conditions significantly impacted women’s sexual lives, which was sometimes felt to be unacknowledged in consultations. Women sought clinicians dialogue and support. Power inequality and social and moral stigma inhibited conversations about sexual intimacy. The clinical relationship was imperative to overcoming this. The service was recommended to; explore these findings within the wider patient pool, increase patient involvement in service development, develop a clinician training module and a clinic pro forma.

Theory-Driven Research Project
3. Differing Self-harm in Younger versus Older People with Emotionally Unstable Personality Disorder Traits; Implications for Cognitive Emotion Regulation Strategies Throughout the Lifespan
Introduction: There remains a paucity of research on emotionally unstable personality traits and emotion dysregulation in older people (65+). Whilst clinical lore suggests that older people with emotion regulation difficulties present markedly differently from younger adults, this remains empirically undocumented. This may account for lower-than-expected diagnostic rates in older people, and result in a lack of comprehensive commissioning for care of older people presenting with emotionally unstable personality traits in National Health Service mental health provision.
Aims: This study aimed to explore emotional regulation strategies across the adult lifespan by establishing differences in self-harm behaviours employed by younger versus older adults with high degree emotionally unstable personality traits; and whether these differences interacted with preferentially employed cognitive emotional regulation strategies. Developmental functionalism theory was introduced as one account of these hypothesised differences.
Methodology: A cross-sectional methodology was employed. 18 younger (age 18-28) and 18 older (65+) (total N = 36) participants, scoring above clinical cut-off on the Borderline Symptom List, completed an adapted version of the Self-Harm Inventory, and the Cognitive Emotional Regulation Questionnaire.
Results: Younger adults were significantly more likely to self-harm using self-injurious means compared to self-neglecting methods, whereas older people where, on average, significantly more likely to use self-neglecting methods preferentially. The frequency of self-neglecting behaviours did not significantly vary between age groups. However, the preferential differences in employment of self-violent behaviours resulted in a significant difference in self-violent methods of self-harm, between age groups. There was no significant difference in cognitive emotional regulation strategies employed, by age or self-harm behaviour.
Conclusions: Non-violent self-harm appears throughout the lifespan in this population. Older people’s preferential use of self-neglecting methods may make self-harm more covert and less sensitive to clinical detection. Self-harm behaviours were unrelated to cognitive emotional regulation strategies employed. A broad definition of self-harm should inform clinical provision, commissioning, and future theoretical models of self-harm in this population across the adult lifespan.