Needs Assessment: Sexual and physical abuse of women is occurring in epidemic proportions. There appear to be major health consequences of abuse, particularly gastrointestinal and pelvic pain disorders, both of which tend to be refractory to treatment. Abuse history, however, tends to remain hidden from healthcare providers. It is important to provide the research evidence documenting the effects of abuse on gastrointestinal and pelvic pain as well as a discussion of when and how to ask about abuse history.
• Provide research evidence that sexual and physical abuse and partner violence are strongly and consistently associated with gastrointestinal and pelvic pain disorders and symptoms.
• List the circumstances when it is reasonable to ask patients about their abuse history and give examples of how to ask patients about previous abuse.
CME Accreditation Statement: This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the Mount Sinai School of Medicine and MBL Communications, Inc. The Mount Sinai School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.
Faculty Disclosure Policy Statement: It is the policy of the Mount Sinai School of Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. This information will be available as part of the course material.
This activity has been peer-reviewed and approved by Eric Hollander, MD, chair at the Mount Sinai School of Medicine, and Norman Sussman, MD, editor of Primary Psychiatry and professor of psychiatry at New York University School of Medicine. Review Date: March 20, 2007.
Drs. Hollander and Sussman report no affiliation with or financial interest in any organization that may pose a conflict of interest.
To receive credit for this activity: Read this article and the two CME-designated accompanying articles, reflect on the information presented, and then complete the CME quiz. To obtain credits, you should score 70% or better. Early submission of this posttest is encouraged to measure outcomes for this CME activity. Please submit this posttest by April 1, 2009 to be eligible for credit. Release date: April 1, 2007. Termination date: April 30, 2009. The estimated time to complete all three articles and the quiz is 3 hours.
Primary Psychiatry. 2007;14(4):58-63
Dr. Leserman is professor in the Department of Psychiatry at the University of North Carolina School of Medicine in Chapel Hill.
Disclosure: Dr. Leserman receives grant support from the National Institutes of Health.
Please direct all correspondence to: Jane Leserman, PhD, Department of Psychiatry, CB 7160, Medical School Wing C, Room 233, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7160; Tel: 919-966-4755; Fax: 919-966-4180; E-mail: JLes@med.unc.edu.
There is no question that sexual and physical abuse and intimate partner violence are occurring in epidemic proportions. Furthermore, such violence has been associated with poor health outcome, although not all types of medical conditions appear to be at greater risk. This article reviews the evidence that links sexual and physical abuse and intimate partner violence with functional gastrointestinal and pelvic pain symptoms and disorders. In addition, this article briefly explores some psychological mechanisms that might mediate these relationships, and reviews whether, when, and how to discuss abuse with patients.
Despite the lack of a gold standard for measuring sexual and physical abuse, most studies indicate that abuse is occurring in epidemic proportions. Prevalence estimates of lifetime sexual abuse range between 15% and 25% in the general female population.1-3 However, estimates of sexual abuse are even higher when surveying female patients with unexplained or functional pain (eg, irritable bowel syndrome [IBS], pelvic pain of unknown origin).4,5 Childhood physical abuse has been estimated at approximately 15% among women,6,7 with intimate partner violence (IPV) (excluding forced sexual abuse) occurring in 22% to 30% of cases.7-9 Despite discrepancies in how sexual and physical abuse have been measured, these experiences have consistently been associated with increased risk for many physical health disorders, even years after the abuse.6,10,11
Although sexual and physical abuse history is associated with poor long-term health, not all somatic symptoms are equally affected. Abuse has been consistently linked to greater reporting of abdominal pain, pelvic pain, and a host of gastrointestinal (GI) and gynecologic symptoms.4,6,11-15 The primary goal of this article is to review the evidence that links sexual and physical abuse with functional GI and pelvic pain disorders. Psychological mechanisms that might mediate these relationships are briefly discussed, and whether, when, and how to discuss abuse with patients is reviewed.
Functional Gastrointestinal Disorders
Functional gastrointestinal disorders (FGIDs) include those with no known or identifiable structural abnormalities, or no known infectious, biochemical, or metabolic causes; they are exclusionary diagnoses reached after ruling out organic diseases. Specific diagnostic standards for FGIDs have been developed by consensus (Rome III criteria).16 Common types of FGIDs include IBS and chronic abdominal pain. IBS is characterized by persistent or recurrent abdominal pain or discomfort, altered bowel function (eg, constipation and/or diarrhea), and bloating or abdominal distention. It is estimated to affect 10% to 15% of the population,4 with far greater prevalence in women than men.17
Patients with IBS report impaired health-related quality of life, more pain, and more healthcare visits compared to normal controls and patients with other serious diseases (eg, diabetes, end-stage renal disease, asthma).5,17,18 In addition, these patients tend to be refractory to treatment, often get unnecessary tests and procedures, comprise a large portion of gastroenterology practice, and contribute to high healthcare costs.
Chronic Pelvic Pain
Chronic pelvic pain (CPP) is a catch-all heterogeneous diagnosis including many types of chronic pain in the abdominal region, pelvis, lower back, and vulva (eg, diffuse abdominal/pelvic pain, painful sexual intercourse, painful menstruation).19 Similar to IBS, those with CPP usually have no known or identifiable structural abnormalities, nor any infectious, biochemical, or metabolic causes of their pain. Both IBS and the most common type of CPP include abdominal pain. In fact, studies show an overlap between IBS and CPP; 35% to 39% of patients with CPP have IBS,20,21 and 35% of those with IBS have CPP.22 IBS patients are more likely to have CPP than patients with other GI diseases.22 The prevalence of CPP (15% in the general population) is similar to IBS.23
Women with CPP tend to have poor health-related quality of life, high healthcare utilization, and psychological dysfunction.20,23 Compared to women with specific gynecologic conditions (eg, infertility, tubal ligation), CPP patients tend to have more psychological and somatic symptoms.24-26 Furthermore, women with both IBS and CPP are more likely to have psychiatric and somatization disorders compared to women with only IBS.22 Examining subtypes of CPP, Leserman and colleagues27 showed that patients with diffuse abdominal pain tended to have the worst physical functioning and pain as well as the most medical symptoms and lifetime surgeries compared to women with more focused types of CPP. Like IBS, patients with CPP tend to have poor response to treatment, resulting in unnecessary tests and procedures.19 Because of the overlap between FGIDs and CPP, the effects of sexual and physical abuse on both of these disorders will be examined.
Association Between Abuse and Gastrointestinal Disorders
Abuse history has been associated with approximately 1.5–2.0 times the risk of reporting GI complaints in large probability-based studies.4,6,11,14,15 Studying primary care practices, McCauley and colleagues6 found that women who were sexually and/or physically abused in childhood reported more abdominal pain (46%), diarrhea (36%), and constipation (39%) compared to the non-abused, respectively (28%, 24%, and 26%). Women health maintenance organization (HMO) members with sexual maltreatment reported more abdominal pain (OR=1.3) compared to those with no maltreatment; diarrhea and constipation did not differ between groups.11 Sexual abuse was associated with twice the risk of IBS in a random survey of men and women in one Minnesota county.4 Abuse history increased the likelihood of seeing a physician for GI complaints. Although physical abuse was not associated with increased risk of GI disorders, the measure of physical abuse lacked validation.28 Sexually assaulted women in a Los Angeles, California survey had approximately twice the risk of reporting GI symptoms such as abdominal pain, diarrhea, and bloating (41%) compared to non-assaulted women (26%).14 Finally, a random survey of one large primary care clinic found that women sexually abused in childhood were more likely to report being bothered by stomach pain (33%), lower belly pain (20%), and painful stools (26%) compared to non-abused women (13%, 8%, and 14%, respectively).15 These and other studies using non-probability primary care samples12,13 provide substantial evidence that abuse—particularly sexual abuse—is associated with robust and persistent effects on GI health.
Intimate Partner Violence and Gastrointestinal Disorders
Compared to sexual abuse, there has been less research on IPV and GI disorders. A large study from two family practice clinics found more digestive tract conditions (eg, constipation, diarrhea) among women experiencing IPV compared to no abuse.9 Another study found that victims of IPV had more abdominal pain and digestive problems than case controls.29 A 1-year retrospective study of one county found that women who had filed a protection order had twice the risk of a hospitalization for a digestive system disease compared to a non-abused cohort control.30 Finally, in an uncontrolled study of 70 women reporting IPV to the police, 47% met Rome II criteria for IBS—rates much higher than the general population.31
Functional Versus Organic Gastrointestinal Disorders
In several studies of women in a referral-based GI clinic, Drossman and colleagues5,32 found that patients with functional disorders reported more severe types of abuse (eg, rape [33%] or life-threatening physical abuse [37%]) than patients with organic disorders (20% and 23%, respectively). Additionally, functional disorders were associated with poorer health status (eg, pain, dysfunction, healthcare use).5,33 In another study of eight university hospitals, researchers reported more sexual abuse (31.6%) in patients with IBS versus patients with organic GI diseases (14.0%) or healthy controls (7.6%).34 Patients with IBS had higher rates of physical symptoms and disability than those with inflammatory bowel disease (an organic disorder).35,36 To the contrary, Talley and colleagues37 found no differences in abuse between patients with functional versus organic GI disease; however, sexually abused patients were more likely to have IBS-type symptoms than non-abused patients.
Relationships Between Health Status and Abuse Among Patients with Gastrointestinal Disorders
There is also evidence that among those with GI disorders, abuse history—especially more invasive abuse—is associated with poorer health status on a variety of measures. In studying a referral-based gastroenterology clinic, Leserman and colleagues33 reported that women with sexual and or physical abuse history had significantly more health-related physical dysfunction, pain, non-GI somatic symptoms, and lifetime surgeries. Severe abuse (eg, rape, multiple life threats, and injury) was related to worse health status,38 and the severely abused had on average eight more doctor visits during 1-year follow-up compared to those without abuse.39 A similar finding was shown in a study of patients with upper abdominal or chest pain.40 Furthermore, Talley and colleagues4 showed an additive effect of abuse, so that those with both child and adult abuse had more physician visits and diagnoses of IBS compared to those with only adult or child abuse. Finally, in a study of patients with severe IBS, sexual abuse was associated with more pain and physical dysfunction.41
Association Between Abuse and Pelvic Pain
Sexual and physical abuse has been consistently related to greater reporting of CPP, including symptoms of painful intercourse (dyspareunia) and painful menstruation (dysmenorrhea). A large study by McCauley and colleagues6 of several primary care practices found that women who were sexually and/or physically abused in childhood had approximately double the risk of reporting pelvic pain (24%) compared to women who had never been abused (11%). A random sample of a primary care clinic showed that women sexually abused in childhood had approximately twice the risk of menstrual problems and greater likelihood of having pelvic pain as their chief complaint compared to non-abused women.15 In consecutive sampling of a primary healthcare center, patients reporting a child sexual abuse history were significantly more likely to have surgical evaluation of pelvic pain (22%) compared to non-abused (13%).12 A study of 511 women from a family practice clinic also showed the risk of pelvic pain was twice that in women with sexual abuse history compared to no abuse.42
Examining specific CPP symptoms in a national probability sample of women, those with child sexual abuse had almost twice the risk of reporting pain that prevented intercourse (32%) compared to the non-abused (20%).43 In a random survey of two communities, sexually assaulted women had more than twice the risk of reporting medically unexplained painful menstruation and pain during intercourse compared to non-assaulted women.44 Analyzing three random surveys, Golding and colleagues45 reported that the number of gynecologic complaints (eg, dysmenorrhea, sexual dysfunction) was related to increased odds of having a history of sexual abuse. Finally, a random sample of HMO members showed more dyspareunia (18%) and premenstrual distress (42%) in those with sexual maltreatment compared to those without (7% and 26%, respectively).11
Two studies sampling consecutive female patients with GI disorders found that sexually and/or physically abused women had four times the risk of reporting pelvic pain than non-abused women.32,39 In another study, women with both IBS and CPP were more likely to have childhood sexual abuse compared to women with only IBS.22
Abuse Comparisons of Pelvic Pain Versus Other Disorders
In a study of patients with CPP, Leserman and colleagues27 showed greater likelihood of trauma history, including sexual and/or physical abuse, in patients with diffuse abdominal pelvic pain compared to those with more focused vulvar pain disorders. Likewise, women with CPP were significantly more likely to have a history of sexual abuse compared to those with specific gynecologic conditions (eg, infertility, tubal ligation).24,25 Furthermore, a large consecutive sample of patients from five gynecology departments in Norway found that patients with CPP were more likely to have been sexually abused compared to those with other gynecologic disorders, especially when the sexual abuse involved penetration.26 Walling and colleagues46 found that women with CPP had higher prevalence of sexual and physical abuse—especially more invasive abuse—compared to those with headache pain and pain-free controls.
Intimate Partner Violence and Pelvic Pain
Studies have also investigated the effects of IPV on CPP. A large study of two family practice clinics found an approximately 50% increased risk of CPP among women experiencing IPV compared to no partner violence.9 A case control study of an HMO showed that women experiencing IPV had more pelvic pain and painful intercourse than controls.29 In two studies of gynecology clinic patients, IPV was associated with greater risk for abdominal pain, painful menstruation, painful intercourse, and pelvic pain.47,48
Do Psychological Variables Mediate the Health Effects of Abuse?
There are many possible physiologic and psychological mechanisms that might explain why abuse history may influence the onset, clinical expression, and perpetuation of GI and pelvic pain symptoms. Studies have shown that posttraumatic stress disorder (PTSD) and depression mediate, at least in part, the health effects associated with trauma.49,50 In a population-based study, Talley and colleagues51 showed that the association of abuse with IBS was largely explained by neuroticism and other psychological comorbidities. A high prevalence of PTSD has been found among patients diagnosed with IBS and pelvic pain.50,52 It is plausible that psychiatric comorbidities like depression and PTSD, and the dysregulation of the autonomic nervous system and hypothalamic-pituitary-adrenal axis associated with these psychiatric disorders,53 are mechanisms that might contribute to GI and pelvic pain symptoms among patients with abuse history.
Whether to Ask About Abuse
Compelling evidence has been presented for the long-term detrimental health effects of abuse, particularly increased risk of CPP, IBS, and GI symptoms. Despite these health effects, relatively few patients discuss abuse history with their physicians, and few physicians acknowledge routinely asking about abuse.54-56 One study showed that if physicians asked about abuse, the vast majority of abused women accepted psychological referrals for psychotherapy.57
It may make sense to ask about abuse when the patient has numerous painful chronic health symptoms; psychiatric symptoms consistent with PTSD, panic, depression, or dissociation; difficulty establishing trust, with feelings of helplessness, shame, or guilt; and extreme difficulty with medical procedures.58 Health practitioners should not ask about abuse if they have not established rapport and trust with the patient; do not feel comfortable discussing the topic; cannot provide an environment where the patient feels safe; do not have sufficient time during the medical visit; think that this information will not help improve the patient’s care; and do not have access to psychological/psychiatric referral resources. If the patient is <18 years of age, the healthcare provider is mandated to report sexual or physical abuse to the Department of Social Services.
How to Ask About Abuse
There is no one right way to ask about sexual abuse history. It has been suggested that one start with a general inquiry (eg, “Are there any experiences not yet discussed that have been particularly difficult or painful for you?”).58 As a prelude to asking more specific questions about abuse, it is a good idea to normalize these experiences. An introduction like the following may be helpful: “We know that many people have had unwanted sexual or violent experiences as children or adults. These experiences may be so upsetting that they may not have been discussed with anyone. Sometimes they are forgotten for long periods of time, and sometimes they are frequently brought to mind. These experiences may have an impact on your current health and may help us suggest treatment for you, so we would like to know about them.” After such an introduction, the following questions may be helpful: “It is not uncommon for people to have been sexually or physically victimized at some time in their lives. Has this ever happened to you? Has anyone ever touched the sex parts of your body (your breasts, vagina, anus) when you did not want them to? Has anyone ever made you touch the sex parts of their body when you did not want to? Have you ever felt unsafe at home? Have you ever been or are you presently afraid of your partner? Has anyone, including family members or friends, ever beat you up, hit you, kicked you, bitten you, or burned you?” Research has shown that using behaviorally-specific questions is more useful than asking generic questions (eg, “Have you ever been abused?”).57,59 Drossman and colleagues58 provide a more thorough discussion of how and when to talk with patients about abuse.
Sexual and physical abuse are common experiences, particularly among patients with functional GI and pelvic pain disorders. These patients with abuse history tend to have the poorest health status, to use the most healthcare resources, and to be refractory to treatment. Despite the high prevalence and detrimental health effects associated with abuse, this history often remains hidden from most healthcare practitioners. Continuing education of physicians and more support systems (eg, case management, referral systems) might help physicians feel more comfortable dealing with issues of abuse. More research is needed examining psychiatric and psychological treatments that might be efficacious in treating these functional health disorders that are often seen in victimized patients. PP
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