Department of Psychiatry, Barts and the London, Queen Marys School of Medicine and Dentistry, University of London
Department of General Practice and Primary Care, Barts and the London, Queen Marys School of Medicine and Dentistry, University of London
Maudsley Hospital, London
Department of General Practice and Primary Care, Barts and the London, Queen Marys School of Medicine and Dentistry, University of London, London
Correspondence: Professor Jeremy Coid, Forensic Psychiatry Research Unit, St Bartholomews Hospital, William Harvey House, 61 Bartholomew Close, London EC1A 7BE, UK. Tel: 020 7601 8138; fax: 020 7601 7969
Declaration of interest None. Funding detailed in Acknowledgements.
See invited commentary, pp.
340341, this
issue.
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ABSTRACT |
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Aims To measure lifetime prevalence of abusive experiences and psychiatric morbidity, and to analyse associations in women primary care attenders.
Method A cross-sectional, self-report survey of 1207 women attending 13 surgeries in the London borough of Hackney, UK. Independent associations between demographic measures, abusive experiences and psychiatric outcome were established using logistic regression.
Results Childhood sexual abuse had few associations with adult mental health measures, in contrast to physical abuse. Sexual assault in adulthood was associated with substance misuse; rape with anxiety, depression and post-traumatic stress disorder but not substance misuse. Domestic violence showed strongest associations with most mental health measures, increased for experiences in the past year.
Conclusions Abuse in childhood and adulthood have differential effects on mental health; effects are increased by recency and severity. Women should be routinely questioned about ongoing and recent experiences as well as childhood.
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INTRODUCTION |
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Most studies of the relationship between early abusive experiences and adult mental health have focused on the role of sexual abuse, although some have attempted to examine the independent contributions of childhood sexual and physical abuse (Mullen et al, 1993; Hill et al, 2000; Dube et al, 2001). Most studies investigating the differential impact of abusive experiences in both childhood and adulthood are characterised by small sample sizes or a limited number of clinical outcome measures. Previous investigators have not been able to differentiate independent effects of multiple abusive experiences over the lifetime on mental health outcomes.
We carried out a survey of adult women attending primary care in east London to:
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METHOD |
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If an adult female patient was eligible to participate, a research assistant introduced the woman to the survey and the purpose of the study was explained. Women were told that participation was voluntary and that all information disclosed would be confidential and would not be given to their doctor or entered in their medical records. Doctors had been given an information pack which detailed local support and housing services for abused women before the start of the study. The survey questionnaire also included an information sheet explaining the study in detail, a list of local support services for women, and a written consent form. Women were encouraged to take the information and support services sheet away with them.
The self-administered questionnaire was specifically developed for this survey and translated into Bengali and Turkish. It included enquiries about demographic details; the Hospital Anxiety and Depression Scale (HADS), rating the presence of anxiety and depression (score of 11 or more) in the past week (Zigmond & Snaith, 1983); the CAGE (Mayfield et al, 1974) questions to assess current and past alcohol misuse; self-reported use of any illicit (street) drugs, and whether the woman had had difficulty reducing or controlling her drug use; and questions about attempted suicide and episodes of self-harm without suicidal intent. Questions on violence in relationships, unwanted sexual experiences in childhood and adulthood, the persons attitude to being questioned by the general practitioner or practice nurse about domestic violence and sexual abuse, and self-reported criteria for DSMIV post-traumatic stress disorder (American Psychiatric Association, 1994) were also included. An algorithm was applied to these PTSD data as developed by Breslau et al (1999), in which a score of four symptoms or more on a seven-symptom screening scale defined positive cases of PTSD.
Six measures of abusive experience included both physical and sexual abuse in childhood and adulthood. These comprised:
Statistical methods
Data analysis was performed using SAS statistical software, version 6.12
(SAS, Institute, 1997).
Logistic regression modelling was used to examine the associations between
demographic variables and mental health measures. A stepwise procedure with
backward elimination was used to select those variables that remained
independently associated with the psychiatric outcome of interest. The
variables selected by the stepwise procedure were used in subsequent analyses
to adjust the associations of abusive experience variables with psychiatric
outcome for any significant demographic characteristics.
Odds ratios relative to a baseline category were estimated for the different levels of categorical variables. The values for odds ratios are such that values greater than 1 indicate an increased risk of a psychiatric outcome and values less than 1 a reduced risk.
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RESULTS |
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Demographic characteristics
The ages of the 1207 women respondents ranged from 16 years to 85 years,
with a mean age of 37.2 years (s.d.=15.9). A total of 569 (49%) reported that
they or their family owned the property in which they lived, and 597 (50%)
owned or lived with someone who owned a car. Four hundred and seventeen (35%)
were born outside the UK, 634 (54%) were White; 443 (38%) were single, 413
(35%) married, 151 (13%) divorced or separated, 35 (3%) widowed, and 123 (11%)
cohabiting; 593 (51%) were currently living with a partner or spouse, 321
(28%) lived alone, and 250 (21%) were living in other circumstances; 730 (61%)
had children.
Prevalence of abusive experiences
Experiences of childhood abuse (at age less than 16 years) included 88 (9%)
women who reported unwanted sexual intercourse; 116 (11%) unwanted sexual
activities, but not intercourse; 48 (5%) severely beaten by a parent or carer
on one occasion and 112 (12%) severely beaten more than once; 53 (5%)
experiencing both unwanted sexual intercourse and other unwanted sexual
activities. Among the women reporting that they had been severely beaten on
more than one occasion, 23 (21%) reported experiencing unwanted sexual
intercourse and 29 (27%) unwanted sexual activities. A total of 17 (2%)
reported all three forms of abusive experience before age 16 years.
Reported adult (16 years and above) abusive and traumatic experiences included 425 (41%) women who fulfilled the study definition for domestic violence, 61 (17%) with more than one partner; 79 (8%) reported that they had been raped; 87 (9%) reported that they had been sexually assaulted (but not raped). Excluding women who reported that they had at some time been forced to have sex by a partner, 33 (4%) reported that they had been raped. The questionnaire did not identify the perpetrator of the rape.
Within the sample surveyed, all childhood abusive experiences were closely interrelated, tending to co-occur in the lives of individual participants: 53 (67%) of the women who had experienced unwanted sexual intercourse prior to age 16 years had also experienced other unwanted sexual activities (OR=30.3; 95% CI 17.752.0; P<0.001); 28 (39%) of the same subgroup had been beaten on one or more occasions (OR=3.5; 95% CI 2.15.8; P<0.001) and 35 (35%) of women who had experienced unwanted sexual activities (not intercourse) before age 16 years had been severely beaten on one or more occasions (OR=3.0; 95% CI 1.94.7; P<0.001). In addition, adult experiences of abuse and trauma co-occurred: 55 (14%) of the women who experienced domestic violence also reported rape (OR=4.7; 95% CI 2.768.11; P<0.001); 54 (14%) sexual assault other than rape (OR=3.34; 95% CI 2.065.41; P<0.001). Forty-one (59%) women who reported being raped reported other forms of sexual assault (OR=30.03; 95% CI 16.9953.09; P<0.001) (Coid et al, 2001).
Prevalence of psychiatric morbidity
A total of 301 (27%) women scored 11 or more on the anxiety scale, and 105
(9%) scored 11 or more on the depression scale of the HADS; 144 (13%) had made
a suicide attempt, and 104 (9%) had deliberately injured themselves, but
without suicidal intention; 708 (62%) reported that they drank alcohol. Of
this latter subgroup, 209 (30%) had at some time felt that they should cut
down on their drinking, 82 (12%) reporting that people had annoyed them by
criticising their drinking; 112 (16%) had at some time felt bad or guilty
about their drinking, and 46 (6%) had drunk alcohol first thing in the morning
to steady their nerves or get rid of a hangover. Within the subgroup of
drinkers, 27 (4%) also reported that they had had a problem with their
drinking in the past 12 months, 35 (5%) before the past 12 months. Of the
total sample of women, 132 (12%) screened positive for alcohol misuse
(affirmative response to two or more of the CAGE questions); 222 (20%) women
reported that they had at some time used illicit (street) drugs. Of these, 31
(14%, which is 3% of the total sample) had at some time been unable to reduce
their use of these drugs. A total of 95 women (8%) were observed to be
suffering from PTSD based on the criteria of Breslau et al
(1999).
Within this population all the mental health measures were closely associated, confirming a high level of comorbidity between anxiety, depression, illicit drug use, alcohol problems, parasuicide, selfharm and PTSD. All associations demonstrated statistical significance at the P<0.001 level, except for depression and illicit use of drugs, for which the association was not significant.
Demographic associations with mental health measures
Table 1 shows the
independent associations between the demographic characteristics of the women
in the survey and mental health measures. All models were adjusted for age,
which was significantly associated only with reported use of illicit drugs
(more prevalent in the 2534 year age group), and alcohol misuse (more
prevalent between the ages of 25 years and 44 years). Marital status had
several important independent associations with mental outcomes: being
divorced or separated was independently associated with anxiety, depression,
PTSD and illicit drug use. Illicit drug use was also associated with single
marital status and cohabitation. Being widowed was associated with a lower
prevalence of anxiety.
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Having further education (more than 13 years) was associated with self-reported use of illicit drugs, but was negatively associated with depression and deliberate self-injury. Living in council or temporary accommodation was associated with anxiety, depression and a history of parasuicide. Women who had been born in the UK were more likely to have deliberately injured themselves and used illicit drugs than women born outside the UK. Black women were less likely to suffer from anxiety or depression than other ethnic groups.
Associations between abusive experiences and mental health
measures
Table 2 demonstrates the
independent associations between abusive experiences reported by the women and
seven mental health outcomes after adjusting for significant demographic
characteristics. Bivariate analyses showed associations with all mental health
measures. Following logistic regression, however, neither form of childhood
sexual abuse was associated with any of the mental health measures, except for
PTSD where women reporting sexual activities before age 16 years were five
times more likely to be rated as a PTSD sufferer. However, being beaten by a
parent or carer in childhood was strongly and independently associated with
several measures: beating on more than one occasion was independently
associated with anxiety, depression, PTSD, parasuicide and deliberate
self-injury, but not drug or alcohol misuse.
Table 2 also highlights the
influence of this repetitive form of childhood physical maltreatment. The odds
ratios are higher for those reporting beating on more than one occasion.
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Independent associations between sexual abuse in adulthood and mental health problems also differed according to the severity of the experience. Table 2 shows contrasts between the odds ratios for sexual assault and rape and individual mental health measures: independent associations with sexual assault included illicit drug and alcohol misuse, but not anxiety, depression, PTSD, parasuicide or deliberate self-injury; rape was independently associated with PTSD and parasuicide, but not with anxiety, depression, deliberate self-injury, or misuse of drugs or alcohol.
Women experiencing domestic violence were more likely to report all forms of psychiatric morbidity except for deliberate self-injury. The effect of current abuse was examined by separating women who reported domestic violence in the past 12 months from those who reported it only in the period prior to the past 12 months. Adjusted odds ratios demonstrated stronger associations with most mental health measures for domestic violence occurring during the past 12 months than for violence occurring prior to the past 12 months, including anxiety (OR=3.6, 95% CI 2.26.0 v. OR=2.4, 95% CI 1.53.9), depression (OR=3.9, 95% CI 1.78.5 v. OR=2.1, 95% CI 0.94.6), PTSD (OR=2.52, 95% CI 1.155.52 v. OR=1.94, 95% CI 0.914.14), parasuicide (OR=2.23, 95% CI 1.144.38 v. OR=1.95, 95% CI 1.013.75) and alcohol misuse (OR=2.58, 95% CI 1.394.79 v. OR=1.86, 95% CI 1.043.33), but with associations in the opposite direction for illicit drug use (OR=1.83, 95% CI 1.013.33 v. OR=2.52, 95% CI 1.494.24).
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DISCUSSION |
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Although a cross-sectional survey cannot determine the direction of causation in adulthood, we found strong associations between certain abusive experiences in both childhood and adulthood and adult mental ill health. Furthermore, we observed important differential effects between individual abusive experiences at different stages in a womans life and over her lifetime on the mental health measures. Severity and repetition of certain abusive experiences also led to increased levels of association with psychiatric morbidity.
Child maltreatment
In contrast to previous research, our study demonstrated that childhood
abuse in the form of a severe beating by a parent or carer was independently
associated with several adverse mental health measures, whereas childhood
sexual abuse was not associated. These findings also confirmed a
doseresponse relationship between repetition of physical abuse and
anxiety, depression, PTSD, parasuicide and other deliberate self-harm. There
is an important divergence between our findings and other studies which found
associations between childhood sexual abuse and psychiatric morbidity in
adulthood (Bagley & Ramsay,
1986; Burnam et al,
1988; Mullen et al,
1988; Peters,
1988; Stein et al,
1988; Winfield et al,
1990; Bifulco et al,
1991; Bushnell et al,
1992; Mullen et al,
1993; Fergusson et
al, 1996; Kessler et
al, 1997; Hill et
al, 2000). It is possible that our measures of childhood
sexual abuse were insufficiently precise and were different from several of
these studies. We obtained our sample from a primary care setting in the
community and did not carry out clinical interviews with the participants to
explore in depth the nature of their abusive experiences. However, previous
studies might have missed a confounding effect of childhood physical abuse,
either by not measuring it (Mullen et
al, 1988; Bushnell et
al, 1992; Fergusson
et al, 1996) or by not including it in a logistic
regression model (Bagley & Ramsay,
1986; Mullen et al,
1993; Fergusson et
al, 1996; Hill et
al, 2000), although some controlled for childhood neglect
(Bifulco et al, 1991;
Mullen et al, 1993;
Fergusson et al,
1996; Kessler et al,
1997). Our results are concordant with a study by Mulder et
al (1998), which found a
relationship between childhood physical abuse and adult dissociative symptoms
but did not find an association with childhood sexual abuse. Similarly, Ernst
et al (1993) found
that adult depression was more strongly associated with a range of early
familial risk factors, including physical abuse, than with early sexual
abuse.
We did not make any prior assumption that childhood sexual abuse was the primary abusive experience associated with the psychopathological symptoms measured in adulthood. The analysis in our study assumed that all abusive experiences had an equal chance of association with these measures. As there was a high level of diagnostic comorbidity, and a marked tendency for the abusive experiences to co-occur over the lifetime for certain participants, it was essential to examine the differential associations. In doing so, the effect of childhood sexual abuse on adult mental health proved to be considerably less important than we had expected.
Associations between childhood sexual abuse and measures of morbidity in previous studies may not reflect causation. Social, family and contextual factors associated with childhood sexual abuse and increased risk of adult psychopathological disorder may have been confounded because childhood sexual abuse is more prevalent in dysfunctional families, with impaired parentchild relationships and parental psychopathology (Mullen et a 1994; Paradise et al, 1994; Stern et al, 1995; Fergusson et al, 1996). Associations between childhood sexual abuse and certain forms of adult psychiatric disorder could have been due to these factors (of which severe beating by carers constituted an additional and more important component) rather than a result of direct effects of sexual abuse. However, studies that have examined the severity of sexual abuse, indicated by attempted or completed penetration, long duration, and where physical violence and restraint are an integral part, tend to show an association with later psychopathological disorder (Mullen et al, 1993; Fergusson et al, 1996; Dinwiddie et al, 2000; Bulik et al, 2001).
An alternative hypothesis could be tested in future research which might explain the absence of the expected association. Both childhood physical and sexual abuse substantially and independently increase the risks of further physical and sexually abusive experiences in adulthood (Coid et al, 2001). The apparent associations found in studies that have not measured adult abusive experiences could therefore be confounded within a three-stage process, in which the childhood abusive experience independently leads to the adult abusive experience, which in turn independently leads to adult psychopathological disorder.
Sexual assault and rape in adulthood
Sexual violence towards women in adulthood contrasted with sexually abusive
experiences in childhood in demonstrating associations with the mental health
outcomes. The more severe experience of rape in adulthood demonstrated
stronger associations than sexual assault. Associations between sexual assault
(but not rape) and substance misuse are consistent with other studies,
suggesting that although substance misuse may be associated with unwanted
physical and sexual experience in adulthood, this is independent of childhood
abusive experiences (Merrill et
al, 1999). It is possible that women who had experienced
sexual assault (but not rape) continued to take more risks than women who had
been raped. It has been observed that sexual encounters characterised by heavy
drinking are more likely to involve sexual aggression
(Muehlenhard & Linton,
1987). Furthermore, women with more sexual partners may be at
increased risk of victimisation through greater contact with a larger number
of men who have the potential to become sexually aggressive
(Koss & Dinero, 1989). We
did not collect data on the sexual behaviour of respondents to test this
hypothesis.
The question remains as to why rape was not associated with substance misuse. There was no difference in the mean age at which rape and sexual assault had occurred in this sample of women, both experiences occurring at a mean age of 21 years. There are two possible explanations. First, women who were raped and women who were sexually assaulted could have constituted two distinct subgroups. This is unlikely, because both experiences cooccurred in the lives of a substantial proportion of the participants, with 59% of those who had been raped reporting that they had been sexually assaulted. Furthermore, the demographic characteristics of women who had experienced these two forms of abuse were similar. The second more likely explanation was that rape, which constituted a more serious trauma in the lives of these women, had led to substantial changes in their subsequent lifestyle, as previously observed by Mezey & Taylor (1988). Presenting symptoms soon after rape do not predict outcome. Some women experience severe impairment, including depression (Ellis et al, 1981; Nadelson et al, 1982), sexual dysfunction (Feldman-Summers et al, 1977), impaired task performance (Burgess & Holmstrom, 1974a,b; Walker & Brodsky, 1976) and social adjustment (Resick et al, 1981). Associations with PTSD and suicide attempts in our respondents who had been raped suggest that many had been unable to resolve and recover from these traumatic experiences, in contrast to women who had been sexually assaulted but not raped. Their psychiatric sequelae are likely to have further impaired their social adjustment, so that they were less likely to engage in social situations that might involve substance misuse. The strong association between parasuicide and rape in this survey underlines the importance of identifying this traumatic experience for future interventions to prevent suicide.
Domestic violence
The findings of our study are generally consistent with a recent
meta-analysis of the literature on intimate partner violence and mental
disorder, which suggests that depression, parasuicide, PTSD, and alcohol and
drug misuse are common among battered women
(Golding, 1999). Domestic
violence was associated with a wider range of mental health measures than any
other abusive experience in this study. Domestic violence had a stronger
association than rape with anxiety and depression. It is possible that these
findings were an artefact, in that the trauma of domestic violence had been
more recent, or was ongoing, at the time of the survey
(McCauley et al,
1995). This contrasted with rape, which had predated the survey by
several years for most women and where some may have shown partial resolution
of their symptoms. Golding
(1999) suggests that
depression tends to remit following cessation of violence, and both depression
and PTSD are influenced by the severity of womens violent
experiences.
The associations between domestic violence and illicit drug use and alcohol misuse are not explained by our study. Substance misuse in this sample could have been the outcome of the domestic violence, but can also be understood in the context of the abusive partners substance misuse. Substance misuse may become a feature of the couples relationship, further increasing the risk of violence between them (Giles-Sims, 1998).
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication February 22, 2002. Revision received January 10, 2003. Accepted for publication February 5, 2003.
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