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Sexual Abuse and Lifetime Diagnosis of Psychiatric Disorders: Systematic Review and Meta-analysis

      OBJECTIVE

      To systematically assess the evidence for an association between sexual abuse and a lifetime diagnosis of psychiatric disorders.

      PATIENTS AND METHODS

      We performed a comprehensive search (from January 1980-December 2008, all age groups, any language, any population) of 9 databases: MEDLINE, EMBASE, CINAHL, Current Contents, PsycINFO, ACP Journal Club, CCTR, CDSR, and DARE. Controlled vocabulary supplemented with keywords was used to define the concept areas of sexual abuse and psychiatric disorders and was limited to epidemiological studies. Six independent reviewers extracted descriptive, quality, and outcome data from eligible longitudinal studies. Odds ratios (ORs) and 95% confidence intervals (CIs) were pooled across studies by using the random-effects model. The I2 statistic was used to assess heterogeneity.

      RESULTS

      The search yielded 37 eligible studies, 17 case-control and 20 cohort, with 3,162,318 participants. There was a statistically significant association between sexual abuse and a lifetime diagnosis of anxiety disorder (OR, 3.09; 95% CI, 2.43-3.94), depression (OR, 2.66; 95% CI, 2.14-3.30), eating disorders (OR, 2.72; 95% CI, 2.04-3.63), posttraumatic stress disorder (OR, 2.34; 95% CI, 1.59-3.43), sleep disorders (OR, 16.17; 95% CI, 2.06-126.76), and suicide attempts (OR, 4.14; 95% CI, 2.98-5.76). Associations persisted regardless of the victim's sex or the age at which abuse occurred. There was no statistically significant association between sexual abuse and a diagnosis of schizophrenia or somatoform disorders. No longitudinal studies that assessed bipolar disorder or obsessive-compulsive disorder were found. Associations between sexual abuse and depression, eating disorders, and posttraumatic stress disorder were strengthened by a history of rape.

      CONCLUSION

      A history of sexual abuse is associated with an increased risk of a lifetime diagnosis of multiple psychiatric disorders.
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      REFERENCES

        • Molnar BE
        • Berkman LF
        • Buka SL
        Psychopathology, childhood sexual abuse and other childhood adversities: relative links to subsequent suicidal behaviour in the US.
        Psychol Med. 2001; 31: 965-977
        • Romans SE
        • Gendall KA
        • Martin JL
        • Mullen PE
        Child sexual abuse and later disordered eating: a New Zealand epidemiological study.
        Int J Eat Disord. 2001; 29: 380-392
        • Coker AL
        • Smith PH
        • Thompson MP
        • McKeown RE
        • Bethea L
        • Davis KE
        Social support protects against the negative effects of partner violence on mental health.
        J Womens Health Gend Based Med. 2002; 11: 465-476
        • Dube SR
        • Anda RF
        • Whitfield CL
        • et al.
        Long-term consequences of childhood sexual abuse by gender of victim.
        Am J Prev Med. 2005; 28: 430-438
        • Haavet OR
        • Straand J
        • Saugstad OD
        • Grünfeld B
        Illness and exposure to negative life experiences in adolescence: Two sides of the same coin? a study of 15-year-olds in Oslo, Norway.
        Acta Paediatr. 2004; 93: 405-411
        • Yang MS
        • Yang MJ
        • Chang SJ
        • Chen SC
        • Ying-Chin K
        Intimate partner violence and minor psychiatric morbidity of aboriginal Taiwanese women.
        Public Health Rep. 2006; 121: 453-459
        • Cheasty M
        • Clare AW
        • Collins C
        Relation between sexual abuse in childhood and adult depression: case-control study.
        BMJ. 1998; 316: 198-201
        • Reza A
        • Breiding MJ
        • Gulaid J
        • et al.
        Sexual violence and its health consequences for female children in Swaziland: a cluster survey study.
        Lancet. 2009; 373: 1966-1972
        • Coid J
        • Petruckevitch A
        • Chung WS
        • Richardson J
        • Moorey S
        • Feder G
        Abusive experiences and psychiatric morbidity in women primary care attenders.
        Br J Psychiatry. 2003; 183: 332-339
        • Greenwood CL
        • Tangalos EG
        • Maruta T
        Prevalence of sexual abuse, physical abuse, and concurrent traumatic life events in a general medical population.
        Mayo Clin Proc. 1990; 65: 1067-1071
        • Jamieson DJ
        • Steege JF
        The association of sexual abuse with pelvic pain complaints in a primary care population.
        Am J Obstet Gynecol. 1997; 177: 1408-1412
        • Mazza D
        • Dennerstein L
        • Ryan V
        Physical, sexual and emotional violence against women: a general practice-based prevalence study.
        Med J Aust. 1996; 164: 14-17
        • Kogan SM
        Disclosing unwanted sexual experiences: results from a national sample of adolescent women.
        Child Abuse Negl. 2004; 28: 147-165
        • Priebe G
        • Svedin CG
        Child sexual abuse is largely hidden from the adult society: an epidemiological study of adolescents' disclosures.
        Child Abuse Negl. 2008; 32: 1095-1108
        • Burgess AW
        • Holmstrom LL
        Rape trauma syndrome.
        Am J Psychiatry. 1974; 131: 981-986
        • Lewis M
        • Sarrel PM
        Some psychological aspects of seduction, incest, and rape in childhood.
        J Am Acad Child Psychiatry. 1969; 8: 606-619
        • Gilbert R
        • Widom CS
        • Browne K
        • Fergusson D
        • Webb E
        • Janson S
        Burden and consequences of child maltreatment in high-income countries.
        Lancet. 2009; 373: 68-81
        • Jumper SA
        A meta-analysis of the relationship of child sexual abuse to adult psychological adjustment.
        Child Abuse Negl. 1995; 19: 715-728
        • Paolucci EO
        • Genuis ML
        • Violato C
        A meta-analysis of the published research on the effects of child sexual abuse.
        J Psychol. 2001; 135: 17-36
        • Smolak L
        • Murnen SK
        A meta-analytic examination of the relationship between child sexual abuse and eating disorders.
        Int J Eat Disord. 2002; 31: 136-150
        • Clark M
        • Oxman AD
        Formulating the problem.
        in: Clark M Oxman AD Cochrane Reviewer's Handbook. Cochrane Collaboration, Oxford, United Kingdom1999 (Section 4.)
        • Stroup DF
        • Berlin JA
        • Morton SC
        • et al.
        Meta-analysis of observational studies in epidemiology: a proposal for reporting: Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group.
        JAMA. 2000; 283: 2008-2012
      1. World Health Organization Krug EG Dahlberg LL Mercy JA Zwi AB Lozano R World Report on Violence and Health. World Health Organization, Geneva, Switzerland2002 (Accessed January 25, 2010.)
        • Wells GA
        • Shea B
        • O'Connell D
        • et al.
        The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottowa Health Research Institute; L'Institut De Recherche en Sante D'Ottowa Web site.
        (Accessed January 25, 2010.)
        • DerSimonian R
        • Laird N
        Meta-analysis in clinical trials.
        Control Clin Trials. 1986; 7: 177-188
        • Higgins JPT
        • Thompson SG
        • Deeks JJ
        • Altman DG
        Measuring inconsistency in meta-analyses.
        BMJ. 2003; 327: 557-560
      2. Comprehensive Meta-analysis [computer program]. 2nd ed. Biostat, Englewood, NJ2005
        • Altman DG
        • Bland JM
        Interaction revisited: the difference between two estimates.
        BMJ. 2003; 326: 219
        • Aglan A
        • Kerfoot M
        • Pickles A
        Pathways from adolescent deliberate self-poisoning to early adult outcomes: a six-year follow-up.
        J Child Psychol Psychiatry. 2008; 49: 508-515
        • Brezo J
        • Paris J
        • Vitaro F
        • Hebert M
        • Tremblay RE
        • Turecki G
        Predicting suicide attempts in young adults with histories of childhood abuse.
        Br J Psychiatry. 2008; 193: 134-139
        • Brown J
        • Cohen P
        • Johnson JG
        • Smailes EM
        Childhood abuse and neglect: specificity of effects on adolescent and young adult depression and suicidality.
        J Am Acad Child Adolesc Psychiatry. 1999; 38: 1490-1496
        • Brown L
        • Russell J
        • Thornton C
        • Dunn S
        Experiences of physical and sexual abuse in Australian general practice attenders and an eating disordered population.
        Aust N Z J Psychiatry. 1997; 31: 398-404
        • Buist A
        • Janson H
        Childhood sexual abuse, parenting and postpartum depression-a 3-year follow-up study.
        Child Abuse Negl. 2001; 25: 909-921
        • Cachelin FM
        • Schug RA
        • Juarez LC
        • Monreal TK
        Sexual abuse and eating disorders in a community sample of Mexican American women.
        Hisp J Behav Sci. 2005; 27: 533-546
        • Cedar Project Partnership
        • Pearce ME
        • Christian WM
        • Paterson K
        • et al.
        The Cedar Project: historical trauma, sexual abuse and HIV risk among young Aboriginal people who use injection and non-injection drugs in two Canadian cities.
        Soc Sci Med. 2008; 66: 2185-2194
        • Chowdhary N
        • Patel V
        The effect of spousal violence on women's health: findings from the Stree Arogya Shodh in Goa, India.
        J Postgrad Med. 2008; 54: 306-312
        • De Bellis MD
        • Chrousos GP
        • Dorn LD
        • et al.
        Hypothalamic-pituitary-adrenal axis dysregulation in sexually abused girls.
        J Clin Endocrinol Metab. 1994; 78: 249-255
        • Deep AL
        • Lilenfeld LR
        • Plotnicov KH
        • Pollice C
        • Kaye WH
        Sexual abuse in eating disorder subtypes and control women: the role of comorbid substance dependence in bulimia nervosa.
        Int J Eat Disord. 1999; 25: 1-10
        • Dinwiddie S
        • Heath AC
        • Dunne MP
        • et al.
        Early sexual abuse and lifetime psychopathology: a co-twin-control study.
        Psychol Med. 2000; 30: 41-52
        • Ernst C
        • Angst J
        • Foldenyi M
        • The Zurich Study, XVII
        Sexual abuse in childhood: frequency and relevance for adult morbidity data of a longitudinal epidemiological study.
        Eur Arch Psychiatry Clin NeuroSci. 1993; 242: 293-300
        • Fergusson DM
        • Boden JM
        • Horwood LJ
        Exposure to childhood sexual and physical abuse and adjustment in early adulthood.
        Child Abuse Negl. 2008; 32: 607-619
        • Fergusson DM
        • Horwood LJ
        • Woodward LJ
        The stability of child abuse reports: a longitudinal study of the reporting behaviour of young adults.
        Psychol Med. 2000; 30: 529-544
        • Fergusson DM
        • Swain-Campbell NR
        • Horwood LJ
        Does sexual violence contribute to elevated rates of anxiety and depression in females?.
        Psychol Med. 2002; 32: 991-996
        • Figueroa EF
        • Silk KR
        • Huth A
        • Lohr NE
        History of childhood sexual abuse and general psychopathology.
        Compr Psychiatry. 1997; 38: 23-30
        • Fiorentine R
        • Pilati ML
        • Hillhouse MP
        Drug treatment outcomes: investigating the long-term effects of sexual and physical abuse histories.
        J Psychoactive Drugs. 1999; 31: 363-372
        • Frank E
        • Anderson BP
        Psychiatric disorders in rape victims: past history and current symptomatology.
        Compr Psychiatry. 1987; 28: 77-82
        • Garnefski N
        • Diekstra RF
        • de Heus P
        A population-based survey of the characteristics of high school students with and without a history of suicidal behavior.
        Acta Psychiatr Scand. 1992; 86: 189-196
        • Gutner CA
        • Rizvi SL
        • Monson CM
        • Resick PA
        Changes in coping strategies, relationship to the perpetrator, and posttraumatic distress in female crime victims.
        J Trauma Stress. 2006; 19: 813-823
        • Harvey EM
        • Rawson RA
        • Obert JL
        History of sexual assault and the treatment of substance abuse disorders.
        J Psychoactive Drugs. 1994; 26: 361-367
        • Kolko DJ
        • Baumann BL
        • Caldwell N
        Child abuse victims' involvement in community agency treatment: service correlates, short-term outcomes, and relationship to reabuse.
        Child Maltreat. 2003; 8: 273-287
        • Pettigrew J
        • Burcham J
        Effects of childhood sexual abuse in adult female psychiatric patients.
        Aust N Z J Psychiatry. 1997; 31: 208-213
        • Plunkett A
        • O'Toole B
        • Swanston H
        • Oates RK
        • Shrimpton S
        • Parkinson P
        Suicide risk following child sexual abuse.
        Ambul Pediatr. 2001; 1: 262-266
        • Price L
        • Maddocks A
        • Davies S
        • Griffiths L
        Somatic and psychological problems in a cohort of sexually abused boys: a six year follow up case-control study.
        Arch Dis Child. 2002; 86: 164-167
        • Rimsza ME
        • Berg RA
        • Locke C
        Sexual abuse: somatic and emotional reactions.
        Child Abuse Negl. 1988; 12: 201-208
        • Roelofs K
        • Keijsers GPJ
        • Hoogduin KAL
        • Naring GWB
        • Moene FC
        Childhood abuse in patients with conversion disorder.
        Am J Psychiatry. 2002; 159: 1908-1913
        • Spataro J
        • Mullen PE
        • Burgess PM
        • Wells DL
        • Moss SA
        Impact of child sexual abuse on mental health: prospective study in males and females.
        Br J Psychiatry. 2004; 184: 416-421
        • Spitzer C
        • Barnow S
        • Gau K
        • Freyberger HJ
        • Grabe HJ
        Childhood maltreatment in patients with somatization disorder.
        Aust N Z J Psychiatry. 2008; 42: 335-341
        • Steiger H
        • Leonard S
        • Kin NMKNY
        • Ladouceur C
        • Ramdoyal D
        • Young SN
        Childhood abuse and platelet tritiated-paroxetine binding in bulimia nervosa: implications of borderline personality disorder.
        J Clin Psychiatry. 2000; 61: 428-435
        • Striegel-Moore RH
        • Dohm F
        • Pike KM
        • Wilfley DE
        • Gairburn CG
        Abuse, bullying, and discrimination as risk factors for binge eating disorder.
        Am J Psychiatry. 2002; 159: 1902-1907
        • Stuart GW
        • Laraia MT
        • Ballenger JC
        • Lydiard RB
        Early family experiences of women with bulimia and depression.
        Arch Psychiatr Nurs. 1990; 4: 43-52
        • Tanskanen A
        • Hintikka J
        • Honkalampi K
        • Haatainen K
        • Koivumaa-Honkanen H
        • Viinamaki H
        Impact of multiple traumatic experiences on the persistence of depressive symptoms-a population-based study.
        Nord J Psychiatry. 2004; 58: 459-464
        • Welch SL
        • Fairburn CG
        Childhood sexual and physical abuse as risk factors for the development of bulimia nervosa: a community-based case control study.
        Child Abuse Negl. 1996; 20: 633-642
        • Widom CS
        Posttraumatic stress disorder in abused and neglected children grown up.
        Am J Psychiatry. 1999; 156: 1223-1229
        • Wise LA
        • Zierler S
        • Krieger N
        • Harlow BL
        Adult onset of major depressive disorder in relation to early life violent victimisation: a case-control study.
        Lancet. 2001; 358: 881-887
        • Paras ML
        • Murad MH
        • Chen LP
        • et al.
        Sexual abuse and lifetime diagnosis of somatic disorders: a systematic review and meta-analysis.
        JAMA. 2009; 302: 550-561
        • Fossati A
        • Madeddu F
        • Maffei C
        Borderline personality disorder and childhood sexual abuse: a meta-analytic study.
        J Pers Disord. 1999; 13: 268-280
        • Goodman GS
        • Ghetti S
        • Quas JA
        • et al.
        A prospective study of memory for child sexual abuse: new findings relevant to the repressed-memory controversy.
        Psychol Sci. 2003; 14: 113-118
        • Widom CS
        • Morris S
        Accuracy of adult recollections of childhood victimization, part 2: childhood sexual abuse.
        Psychol Assess. 1997; 9: 34-46
        • Williams LM
        Recall of childhood trauma: a prospective study of women's memories of child sexual abuse.
        J Consult Clin Psychol. 1994; 62: 1167-1176
        • Lau J
        • Ioannidis JPA
        • Terrin N
        • Schmid CH
        • Olkin I
        The case of the misleading funnel plot.
        BMJ. 2006; 333: 597-600
        • Edwards VJ
        • Holden GW
        • Felitii VJ
        • Anda RF
        Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: results from the adverse childhood experiences study.
        Am J Psychiatry. 2003; 160: 1453-1460
        • Kellogg ND
        • Menard SW
        Violence among family members of children and adolescents evaluated for sexual abuse.
        Child Abuse Negl. 2003; 27: 1367-1376
        • Caspi A
        • Sugden K
        • Moffitt TE
        • et al.
        Influence of life stress on depression: moderation by a polymorphism in the 5-HTT gene.
        Science. 2003; 301: 386-389
        • Kendler KS
        • Kuhn JW
        • Vittum J
        • Prescott CA
        • Riley B
        The interaction of stressful life events and a serotonin transporter polymorphism in the prediction of episodes of major depression: a replication.
        Arch Gen Psychiatry. 2005; 62: 529-535
        • Kaufman J
        • Yang BZ
        • Douglas-Palumberi H
        • et al.
        Brain-derived neurotrophic factor-5-HTTLPR gene interactions and environmental modifiers of depression in children.
        Biol Psychiatry. 2006; 59: 673-680
        • Mandelli L
        • Serretti A
        • Marino E
        • Pirovano A
        • Calati R
        • Colombo C
        Interaction between serotonin transporter gene, catechol-O-methyltransferase gene and stressful life events in mood disorders.
        Int J Neuropsychopharmacol. 2007; 10: 437-447
        • Risch N
        • Herrell R
        • Lehner T
        • et al.
        Interaction between the serotonin transporter gene (5-HTTLPR), stressful life events, and risk of depression: a meta-analysis.
        JAMA. 2009; 301: 2462-2471
        • Grabe HJ
        • Spitzer C
        • Schwahn C
        • et al.
        Serotonin transporter gene (SLC6A4) promoter polymorphisms and the susceptibility to posttraumatic stress disorder in the general population.
        Am J Psychiatry. 2009; 166: 926-933
        • Kilpatrick DG
        • Koenen KC
        • Ruggiero KJ
        • et al.
        The serotonin transporter genotype and social support and moderation of posttraumatic stress disorder and depression in hurricane-exposed adults.
        Am J Psychiatry. 2007; 164: 1693-1699
        • Cicchetti D
        • Rogosch FA
        • Sturge-Apple ML
        Interactions of child maltreatment and serotonin transporter and monoamine oxidase A polymorphisms: depressive symptomatology among adolescents from low socioeconomic status backgrounds.
        Dev Psychopathol. 2007; 19: 1161-1180
        • Bradley RG
        • Binder EB
        • Epstein MP
        • et al.
        Influence of child abuse on adult depression: moderation by the corticotropin-releasing hormone receptor gene.
        Arch Gen Psychiatry. 2008; 65: 190-200
        • Binder EB
        • Bradley RG
        • Liu W
        • et al.
        Association of FKBP5 polymorphisms and childhood abuse with risk of posttraumatic stress disorder symptoms in adults.
        JAMA. 2008; 299: 1291-1305
        • Tang B
        • Jamieson E
        • Boyle M
        • Libby A
        • Gafni A
        • MacMillan H
        The influence of child abuse on the pattern of expenditures in women's adult health service utilization in Ontario, Canada.
        Soc Sci Med. 2006; 63: 1711-1719
        • Hulme PA
        Symptomatology and health care utilization of women primary care patients who experienced childhood sexual abuse.
        Child Abuse Negl. 2000; 24: 1471-1484
        • Bonomi AE
        • Anderson ML
        • Rivara FP
        • et al.
        Health care utilization and costs associated with childhood abuse.
        J Gen Intern Med. 2008; 23: 294-299
        • Suris A
        • Lind L
        • Kashner TM
        • Borman PD
        • Petty F
        Sexual assault in women veterans: an examination of PTSD risk, health care utilization, and cost of care.
        Psychosom Med. 2004; 66: 749-756
        • Walker EA
        • Unutzer J
        • Rutter C
        • et al.
        Costs of health care use by women HMO members with a history of childhood abuse and neglect.
        Arch Gen Psychiatry. 1999; 56: 609-613
        • Chartier MJ
        • Walker JR
        • Naimark B
        Childhood abuse, adult health, and health care utilization: results from a representative community sample.
        Am J Epidemiol. 2007; 165: 1031-1038
        • Finestone HM
        • Stenn P
        • Davies F
        • Stalker C
        • Fry R
        • Koumanis J
        Chronic pain and health care utilization in women with a history of childhood sexual abuse.
        Child Abuse Negl. 2000; 24: 547-556
        • Alexander RW
        • Bradley LA
        • Alarcon GS
        • et al.
        Sexual and physical abuse in women with fibromyalgia: association with outpatient health care utilization and pain medication usage.
        Arthritis Care Res. 1998; 11: 102-115
        • Plichta S
        The effects of woman abuse on health care utilization and health status: a literature review.
        Womens Health Issues. 1992; 2: 154-163
        • Walker EA
        • Katon WJ
        • Roy-Byrne PP
        • Jemelka RP
        • Russo J
        Histories of sexual victimization in patients with irritable bowel syndrome or inflammatory bowel disease.
        Am J Psychiatry. 1993; 150: 1502-1506
        • Wendt E
        • Hildingh C
        • Lidell E
        • Westerstahl A
        • Baigi A
        • Marklund B
        Young women's sexual health and their views on dialogue with health professionals.
        Acta Obstet Gynecol Scand. 2007; 86: 590-595
        • Ryan M
        • Nitsun M
        • Gilbert L
        • Mason H
        A prospective study of the effectiveness of group and individual psychotherapy for women CSA survivors.
        Psychol Psychother. 2005; 78: 465-479
        • Lau M
        • Kristensen E
        Outcome of systemic and analytic group psychotherapy for adult women with history of intrafamilial childhood sexual abuse: a randomized controlled study.
        Acta Psychiatr Scand. 2007; 116: 96-104
        • Kessler MR
        • White MB
        • Nelson BS
        Group treatments for women sexually abused as children: a review of the literature and recommendations for future outcome research.
        Child Abuse Negl. 2003; 27: 1045-1061
        • Smith D
        • Pearce L
        • Pringle M
        • Caplan R
        Adults with a history of child sexual abuse: evaluation of a pilot therapy service.
        BMJ. 1995; 310: 1175-1178
        • Kreidler M
        Group therapy for survivors of childhood sexual abuse who have chronic mental illness.
        Arch Psychiatr Nurs. 2005; 19: 176-183
        • Bradley RG
        • Follingstad DR
        Utilizing disclosure in the treatment of the sequelae of childhood sexual abuse: a theoretical and empirical review.
        Clin Psychol Rev. 2001; 21: 1-32
        • Mendes DD
        • Mello MF
        • Ventura P
        • Passarela Cde M
        • Mari Jde J
        A systematic review on the effectiveness of cognitive behavioral therapy for posttraumatic stress disorder.
        Int J Psychiatry Med. 2008; 38: 241-259
        • House AS
        Increasing the usability of cognitive processing therapy for survivors of child sexual abuse.
        J Child Sex Abus. 2006; 15: 87-103
        • Habigzang LF
        • Stroeher FH
        • Hatzenberger R
        • Cunha RC
        • Ramos Mda S
        • Koller SH
        Cognitive behavioral group therapy for sexually abused girls.
        Rev Saude Publica. 2009; 43: 70-78