Sexual and Physical Abuse in Women with Functional or Organic Gastrointestinal Disorders Douglas A . Drossman, M D ; Jane Leserman, PhD; Ginette Nachman, M D ; Zhiming Li, M D ; Honi Gluck, M D ; Timothy C. T o o m e y , PhD; and C. Madeline Mitchell, M U R P

Study Objectives: To determine the prevalence of a history of sexual and physical abuse in women seen in a referral-based gastroenterology practice, to determine whether patients with functional gastrointestinal disorders report greater frequencies of abuse than do patients with organic gastrointestinal diseases, and to determine whether a history of abuse is associated with more symptom reporting and health care utilization. Design: A consecutive sample of women seen in a universitybased gastroenterology practice over a 2-month period was asked to complete a brief questionnaire. Measurements: The self-administered questionnaire requested information about demographics, symptoms, health care utilization, and history of abuse. Physicians indicated the primary diagnosis for each patient and whether she had ever discussed having been sexually or physically abused. Results: Of 206 patients, 89 (44%) reported a history of sexual or physical abuse in childhood or later in life; all but 1 of the physically abused patients had been sexually abused. Almost one third of the abused patients had never discussed their experiences with anyone; only 17% had informed their doctors. Patients with functional disorders were more likely than those with organic disease diagnoses to report a history of forced intercourse (odds ratio, 2.08; 95% CI, 1.03 to 4.21) and frequent physical abuse (odds ratio, 11.39; CI, 2.22 to 58.48), chronic or recurrent abdominal pain (odds ratio, 2.06; CI, 1.03 to 4.12), and more lifetime surgeries (2.7 compared with 2.0 surgeries; P < 0.03). Abused patients were more likely than nonabused patients to report pelvic pain (odds ratio, 4.05; CI, 1.41 to 11.69), multiple somatic symptoms (7.1 compared with 5.8 symptoms; P < 0.001), and more lifetime surgeries (2.8 compared with 2.0 surgeries; P < 0.01). Conclusions: We found that a history of sexual and physical abuse is a frequent, yet hidden, experience in women seen in referral-based gastroenterology practice and is particularly common in those with functional gastrointestinal disorders. A history of abuse, regardless of diagnosis, is associated with greater risk for symptom reporting and lifetime surgeries.

l h e functional gastrointestinal disorders (including the irritable bowel syndrome, non-ulcer dyspepsia, and chronic abdominal pain) comprise a common group of 44 disorders with no known structural abnormalities, infectious or metabolic causes" (1). These disorders, occurring primarily in women, have no clearly established pathogenesis or treatment (2, 3). They pose a considerable health and economic burden: They are the most common chronic gastrointestinal diagnoses seen in primary care and gastroenterology practices, and they produce uncertainty and frustration among physicians and patients, at times leading to unnecessary tests and procedures (1, 4-6). Previous research and treatments have focused on the biologic determinants of these disorders, yielding unsatisfactory results. More recently, studies on the irritable bowel syndrome have also shown that psychological disturbance and other behavioral factors are associated with greater symptom reporting and health care utilization (7-9). To develop more effective treatments, investigators and clinicians therefore should identify psychosocial factors that may contribute to the patient's poor health status. In evaluating referred patients with refractory functional bowel disturbance, one of the investigators (DD) has frequently found patients to have a history of sexual and physical abuse. Studies of other referred patients complaining of chronic illness (headaches or pelvic pain) have shown high prevalences of a history of abuse (10, 11). Further, studies have shown that abused patients have a greater tendency to somatize, to see physicians, and to have multiple diagnostic studies (12-16). On the basis of these clinical observations, we decided to study the prevalence of a history of sexual and physical abuse in a university-based gastroenterology clinic. We hypothesized that patients with functional gastrointestinal disorders would report greater frequencies of abuse than would patients with organic gastrointestinal diseases, that a history of abuse would be associated with greater symptom reporting and health care utilization, and that physicians would be largely unaware of their patients' abuse history. Methods Study Sample and Testing Procedure

Annals of Internal Medicine. 1990;113:828-833. From the University of North Carolina School of Medicine, Chapel Hill, North Carolina. For current author addresses, see end of text.

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The study was approved by the committee for the Protection of the Rights of Human Subjects. Between August and September 1989, we administered a questionnaire to a consecutive sample of female patients seen in the gastroenterology clinic of the North Carolina Memorial Hospital. This university-based practice, staffed by 17 gastroenterology faculty and fellows, provides consultative and ongoing care for patients referred

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primarily from physicians within the medical center and the state of North Carolina. The clinic primarily draws patients from rural and semi-urban areas of the central part of the state, with a small proportion of patients coming from the Appalachian mountain and coastal plain areas. Of the 257 patients registered in the clinic, 29 did not meet our inclusion criteria because they were less than 18 or more than 70 years of age (22 patients) or were mentally impaired or unable to understand the questions (7 patients). Of the 228 eligible patients, 26 were seen for a repeat visit during the study period, and they received the questionnaire only on the first visit. At check-in, clinic nurses asked eligible patients to complete a 10-minute, confidential questionnaire containing health-related questions, some of which were of a sensitive or personal nature. After the patients signed a consent form, they completed the questionnaire in a private room and, if unable to read (6 patients), were assisted by the nurse. Those few who were unable to complete the questionnaire were asked to mail in the form. Measurement The questionnaire requested information about age, race, marital status, occupation, and education. Socioeconomic status was calculated from the patient's educational level and occupation (17). Chronic pain was determined by asking 4 'Have you had constant or recurring pain symptoms beginning more than 6 months ago?" We also asked whether patients had frequent (more than 6 times in the past year) upper or lower abdominal pain or pelvic pain. To assess other symptoms (somatization), patients were asked whether they have had any of 12 common nonabdominal symptoms (18): cough, weakness, fatigue, headache, shortness of breath after light work, morning stiffness or aching joints, frequent backaches, unexplained weight loss of over 10 pounds, pains in or near the heart, respiratory infection, unexplained bleeding not caused by injury, and eye or ear infection or irritation. Health care utilization was determined by asking "How many times have you been to the doctor in the last 6 months?," "How many times were you hospitalized in the last 2 years?," and "How many surgeries have you had in your lifetime?" (19). Table 1 indicates the questions we used to measure sexual and physical abuse. Although there is no standard for defining abuse, survey questionnaires that fulfill reliability criteria have been developed (20). The sexual abuse questions that we chose were developed for the National Population Survey of Canada (21). The physical abuse question was previously used in a survey of 251 university women (22). A patient in our study was considered to be in the sexually abused category if she gave a positive score to any item (A through E) during childhood or to any item but sexual exposure (B through E) during adulthood. The patient was considered to be physically abused

Table 1. Questionnaire

if she answered "often" to being kicked or beaten (response 4). This more restrictive definition was chosen to avoid ambiguity, so the behavior would be interpreted as abuse rather than as "discipline." Patients were also asked "Have you ever discussed these experiences with anyone before?" If they responded positively, they indicated with whom they had discussed their experiences, selecting among family, friend, minister or lay counselor, or professional counselor. Patients also indicated whether they were currently seeing a counselor for abuse-related or other emotional concerns. Because the psychological consequences of reporting this information were unknown to us, we made available on-site discussion with a therapist (GN) or referral to an abuse counselor (KM) if requested by the patient. Only one patient was referred for counseling. In addition, to confirm the questionnaire responses and determine any adverse consequences, we sequentially contacted ten patients who had reported sexual abuse (Table 1, categories C, D, or E). They were interviewed by a medical resident and psychotherapist (HG) or psychologist (TT). These patients voiced no concerns about the questionnaire. Many commented on the importance of the issues raised, and some expressed gratitude for the opportunity to discuss these personal issues with an understanding and knowledgeable person. All ten patients confirmed the history of abuse. On the,day of the clinic visit, the patient's physician completed a forced-choice form indicating the principal gastrointestinal diagnosis and its category as either functional (the irritable bowel syndrome, nonulcer dyspepsia, chronic abdominal pain, constipation, or other) or organic (Crohn disease, ulcerative colitis, acid peptic disease, liver disease, or other). In addition, the physician indicated whether the patient had ever discussed having been sexually or physically abused. Statistical Analysis Variables were inspected for violations of normality assumptions, and results indicated normality within an acceptable range for most variables. Because of skewed distribution and outliers in response to the health care utilization questions, these variables were analyzed using log transformed values. In comparing patients who had functional diagnoses with those who had organic diagnoses, analyses of covariance were done for continuous dependent variables, while controlling for age, race, and marital status. For categoric dependent variables, we used logistic regression analysis while controlling for age, race, and marital status. Socioeconomic status was not included in the statistical models because there was neither a significant difference between the main groups nor a significant correlation with the independent and dependent variables, and because of a substantial number of missing values. When abused and nonabused patients were compared, the same types of

Criteria and Frequency of Abuse*

Abuse

During Childhood
6 occasions) 66/88 (75) Lower abdominal pain (on > 6 occasions) 64/86(74) Pelvic pain 14/86 (16) Nonabdominalt Fatigue Headache Shortness of breath Backache Pain around heart Unexplained bleeding Pain or irritation of eyes

72/108(67)

1.85 (0.94 to 3.67)

65/105 (62) 1.68 (0.86 to 3.26)

64/108(59) 1.58 (0.82 to 3.05) 6/108 (6) 4.05 (1.41 to 11.69)

69/80(86) 50/82(61)

70/107(65) 3.32 (1.48 to 7.55) 44/105(42) 2.17 (1.15 to 4.08)

45/85 (53) 46/84(55)

37/105 (35) 2.07 (1.11 to 3.87) 34/103(33) 2.46 (1.30 to 4.66)

35/78(45)

25/99(25) 2.41 (1.22 to 4.79)

41/83 (49)

36/102 (35) 1.79 (0.95 to 3.38)

42/81 (52)

35/103 (34) 2.09 (1.10 to 3.98)

* Logistic regression and analysis of covariance controlling for type of diagnosis (functional or organic), age, race, and marital status. t Five nongastrointestinal symptoms were not significantly different (P > 0.05) and were omitted from the table. Values are expressed as adjusted means (SE).

Discussion We found that sexual and physical abuse is commonly reported by patients in a referral-based gastroenterology practice. Using the same questions in a Canadian national study, Badgley and colleagues (21) found a 34% prevalence of sexual abuse in women. This figure may be compared with data from probability sample surveys in the United States and Canada that show prevalences for sexual abuse to range from 6% to 62% (23). These seemingly high percentages may result from increases in the true prevalence or from the recent

Table 3. Symptoms Organic Diagnoses* Symptom

in Patients

Patients with Functional Diagnoses

with Functional

Patients with Organic Diagnoses

or

Odds Ratio (95% CI)

nIN (%) Chronic or recurring pain 59/74 (80) 81/123 (66) Upper abdominal pain (on > 6 occasions) 62/74(84) 71/122(58) Lower abdominal pain (on > 6 occasions) 60/74 (81) 68/121 (56) Pelvic pain 9/74(12) 11/123(9)

2.06 (1.03 to 4.12) 3.72 (1.80 to 7.70) 3.08 (1.53 to 6.20) 1.58 (0.60 to 4.16)

* Controlling for age, race, and marital status with logistic regression and analysis of covariance.

tendency for persons to report these experiences willingly (24). A large proportion of patients reporting abuse chooses not to discuss or obtain counsel for these experiences. In this study, physicians were aware of the history in only 17% of their abused patients. The finding that almost one third of these patients had never discussed these experiences with anyone is consistent with studies showing that only 20% to 50% of abuse episodes ever come to the attention of authorities (15). Compared with patients with organic disease diagnoses, patients with functional bowel disorders reported significantly more experiences of sexual exposure, threatened sex, incest or rape, and frequent physical abuse. Similarly, previous studies have reported that patients with functional bowel disorders have histories of family deprivation (25) and disrupted family relationships (26-28). The frequency of abuse is similar to that reported in studies of women having laparoscopy-negative chronic pelvic pain (29), many of whom may also have the irritable bowel syndrome (30). The greater frequency of a history of abuse and the reporting of more pain symptoms and surgeries in the group with functional bowel disorders raise questions about the role of psychosocial factors in the illness behaviors of these patients (7, 18, 31-34) and in physicians' responses to these behaviors. We also found that a history of abuse is generally related to greater symptom reporting and health care utilization. When controlling for medical disease, a his-

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Table 5. Health Care Utilization in Abused and Nonabused Patients* Health Care Utilization

Abused Patients

Nonabused Patients

P Value

mean (SE) Number of physician visits per 6 months Number of hospitalizations per 2 years Number of surgeries in lifetime

4.2 (1.12)

3.3(1.10)

0.090

1.1(1.10)

1.0 (1.09)

0.353

2.8(1.10)

2.0 (1.09)

0.009

* Logistic regression and analysis of covariance controlling for type of diagnosis (functional or organic), age, race, and marital status.

tory of abuse was associated with a greater frequency of pelvic and upper abdominal pain (for patients with organic disease) and more lifetime surgeries. There was also a trend for abused patients to see physicians more often. Similarly, studies of abused patients indicate that they often somatize and complain of abdominal pain (13-15). They are 2.5 times as likely as nonabused patients to visit a physician or be hospitalized (16) and are more likely to have invasive diagnostic studies and operations with normal findings (12, 35). The high percentage of patients with a history of abuse may be due to their preferential selection into tertiary care centers. For example, the frequency of the history of abuse among patients seen in pain treatment centers is greater than 50% (10, 14). In one study, 53% of these patients had been physically or sexually abused, and those who had been abused reported more medical problems (predominantly abdominal and pelvic pain) for which they sought treatment (P < 0.005) (14). The clinical implications of these findings are noteworthy. Because of the adverse consequences of abuse and the reluctance of patients to report this history, the physician must actively seek this type of information, particularly when the patient has frequent or severe pain symptoms and a high rate of health care use (12). The conclusions drawn from this study must be regarded as preliminary for several reasons. First, because the data were obtained by survey, validation of the prevalence of abuse using more standardized questionnaires and interviews is needed. Second, these findings from a university-affiliated, referral-based practice should not necessarily be applied to most patients with gastrointestinal disorders seen in primary care or health maintenance practices or among nonclinical populations. Studies are needed to confirm our hypothesis that abuse is less prevalent in nonreferral-based practices. Third, the validity of the data on symptom reporting and health care utilization is open to question, because they were obtained by patient recall. Patients who somatize or exhibit abnormal illness behaviors may also over-report their abuse history, physical complaints, physician visits, or even surgeries. These data need to be corroborated by legal documents, chart review, and prospective assessment. Finally, the relation of abuse to clinical outcomes is likely to be correlated with other factors that were not evaluated in this study. Abuse often exists as part of a disturbed psychosocial milieu in 832

which the psychological, social, and physical consequences are multiple. Multivariate psychosocial assessments using standardized research scales are therefore needed to determine the effect of abuse, relative to these other psychosocial variables, on clinical outcomes. In summary, a history of sexual and physical abuse is a frequent, yet hidden, experience among patients seen in a university-affiliated gastroenterology practice, and a history of abuse may be associated with adverse health consequences. Confirmation of our findings through prospective, multidisciplinary assessment is needed. For the present, we recommend that the physician inquire about a history of abuse, particularly for patients who report chronic severe pain or many symptoms and who overuse health care services. Referral for psychological counseling may ease psychological pain and suffering, minimize unneeded medical treatments, and improve the health outcomes of these patients. Acknowledgments: The authors thank Ms. Liz Merrill, the North Carolina Memorial Hospital clinic nursing staff (Ms. Carol Smith, Ms. Atsie Laws, Ms. Susan Hafer, Ms. Helen Strayhorn, and Ms. Betty Moore), the faculty and fellows of the Division of Digestive Diseases, and Ms. Kit Munson for their assistance. Grant Support: In part by the Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina. Requests for Reprints: Douglas A. Drossman, MD, Division of Digestive Diseases, 420 Burnett-Womack Building, CB #7080, University of North Carolina, Chapel Hill, NC 27599-7080. Current Author Addresses: Drs. Drossman, Leserman, Nachman, Li, and Ms. Mitchell: University of North Carolina School of Medicine, 420 Burnett-Womack Building, CB #7080, Chapel Hill, NC 27599-7080. Dr. Gluck: 11831 Falls Road, Cockeysville, MD 21030. Dr. Toomey: University of North Carolina School of Medicine, Department of Psychiatry, CB #7160, Chapel Hill, NC 27599-7160. References 1. Mitchell CM, Drossman DA. Survey of the AGA membership relating to patients with functional gastrointestinal disorders. Gastroenterology. 1987;92:1282-4. 2. Drossman DA. Clinical research in the functional digestive disorders. Gastroenterology. 1987;92:1267-9. 3. Klein K. Controlled treatment trials in the irritable bowel syndrome: a critique. Gastroenterology. 1988;95:232-41. 4. Mendeloff AI. Epidemiology of functional gastrointestinal disorders. In: Chey WY, ed. Functional Disorders of the Digestive Tract. New York: Raven Press; 1983:13-9. 5. Drossman DA. The physician and the patient: review of the psychosocial gastrointestinal literature with an integrated approach to the patient. In: Sleisenger MH, Fordtran JS, eds. Gastrointestinal Disease: Pathophysiology, Diagnosis, Management. Philadelphia: W.B. Saunders; 1989:3-20. 6. Thompson WG, Dotevall G, Drossman DA, Heaton KW, Kruis W. Irritable bowel syndrome: guidelines for the diagnosis. Gastroenterology International. 1989;2:92-5. 7. Drossman DA, McKee DC, Sandler RS, et al. Psychosocial factors in the irritable bowel syndrome. A multivariate study of patients and nonpatients with irritable bowel syndrome. Gastroenterology. 1988; 95:701-8. 8. Whitehead WE, Bosmajian L, Zonderman AB, Costa PT Jr, Schuster MM. Symptoms of psychologic distress associated with irritable bowel syndrome. Comparison of community and medical clinic samples. Gastroenterology. 1988;95:709-14. 9. Smith RC, Greenbaum DS, Vancouver JB, et al. Psychosocial factors are associated with health care seeking rather than diagnosis in irritable bowel syndrome. Gastroenterology. 1990;98:293-301. 10. Domino JV, Haber JD. Prior physical and sexual abuse in women with chronic headache: clinical correlates. Headache. 1987;27: 310-4. 11. Harrop-Griffiths J, Katon W, Walker E, Holm L, Russo J, Hickok L. The association between chronic pelvic pain, psychiatric diagnoses, and childhood sexual abuse. Obstet Gynecol. 1988;71:589-94. 12. Arnold RP, Rogers D, Cook DA. Medical problems of adults who were sexually abused in childhood. Br Med J. 1990;300:705-8.

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13. Rimsza ME, Berg RA, Locke C. Sexual abuse: somatic and emotional reactions. Child Abuse Negl. 1988;12:201-8. 14. Haber JD, Roos C. Effects of spouse abuse and or sexual abuse in the development and maintenance of chronic pain in women. Advances in Pain Research and Therapy. 1985;9:889-95. 15. Bachmann G, Moeller T, Bennett J. Childhood sexual abuse and the consequence in adult women. Obstet Gynecol. 1988;71:631-42. 16. Sedney MA, Brooks B. Factors associated with a history of childhood sexual experience in a nonclinical female population. J Am Acad Child Adolesc Psychiatry. 1984;23:215-8. 17. Green LW. Manual for scoring socioeconomic status for research on health behavior. Public Health Rep. 1970;85:815-27. 18. Sandler RS, Drossman DA, Nathan HP, McKee DC. Symptom complaints and health care seeking behavior in subjects with bowel dysfunction. Gastroenterology. 1984;87:314-8. 19. Drossman DA, Patrick DL, Mitchell CM, Zagami EW, Appelbaum MI. Health related quality of life in inflammatory bowel disease: functional status and patient worries and concerns. Dig Dis Sci. 1989;34:1379-86. 20. Finkelhor D. A Sourcebook on Child Sexual Abuse. Beverly Hills: Sage Publications; 1986:1. 21. Badgley R, Allard H, McCormick N, et al. Occurrence in the population. In: Sexual Offences against Children, v. 1. Ottawa: Canadian Government Publishing Centre; 1984:175-93. 22. Briere J, Runtz M. Multivariate correlates of childhood psychological and physical maltreatment among university women. Child Abuse Negl. 1988;12:331-41. 23. Peters SD,. Wyatt GE, Finkelhor D. Prevalence. In: Finkelhor D, ed. A Sourcebook on Child Sexual Abuse. Beverly Hills: Sage Publications; 1986:15-59.

24. Leventhal JM. Have there been changes in the epidemiology of sexual abuse of children during the 20th century? Pediatrics. 1988; 82:766-73. 25. Hislop IG. Childhood deprivation: an antecedent of the irritable bowel syndrome. Med J Aust. 1979;1:372-4. 26. Creed F, Craig T, Farmer R. Functional abdominal pain, psychiatric illness and life events. Gut. 1988;29:235-42. 27. Hill OW, Blendis L. Physical and psychological evaluation of "nonorganic" abdominal pain. Gut. 1967;8:221-9. 28. Lowman BC, Drossman DA, Cramer EM, McKee DC. Recollection of childhood events in adults with irritable bowel syndrome. J Clin Gastroenterol. 1987;9:324-30. 29. Walker E, Katon W, Harrop-Grifflths J, Holm L, Russo J, Hickok LR. Relationship of chronic pelvic pain to psychiatric diagnoses and childhood sexual abuse. Am J Psychiatry. 1988;145:75-9. 30. Prior A, Wilson K, Whorwell PJ, Faragher EB. Irritable bowel syndrome in the gynecological clinic. Dig Dis Sci. 1989;34:1820-4. 31. Whitehead WE, Winget C, Fedoravicius AS, Wooley S, Blackwell B. Learned illness behavior in patients with irritable bowel syndrome and peptic ulcer. Dig Dis Sci. 1982;27:202-8. 32. Mitchell CM, Drossman DA. The irritable bowel syndrome: understanding and treating a biopsychosocial illness disorder. Ann Behav Med. 1987;9:13-8. 33. Creed F, Guthrie E. Psychological factors in the irritable bowel syndrome. Gut. 1987;28:1307-18. 34. Langeluddecke PM. Psychological aspects of irritable bowel syndrome. Aust N Z J Psychiatry. 1985;19:218-26. 35. Arnold,RP, Rogers D, Cook DA. Medical problems of adults who were sexually abused in childhood. Br Med J. 1990;300:705-8.

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Sexual and physical abuse in women with functional or organic gastrointestinal disorders.

To determine the prevalence of a history of sexual and physical abuse in women seen in a referral-based gastroenterology practice, to determine whethe...
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