BRIEF COMMUNICATION
Correlates of Sexual Abuse in Women with Anorexia Nervosa and Bulimia Nervosa* JANET M. DEGROOT, M.D. I , SIDNEY KENNEDY, M.B?, GARY RODIN, M.D. 3 AND GAIL MCVEY, M.A. 4
Of 184 female outpatients meeting the DSM-lll-R criteria, for anorexia nervosa, bulimia nervosa, or anorexia nervosa with bulimia, approximately 25% reported previous sexual abuse. Furthermore, previous sexual abuse was associated with greater psychological disturbance, measured by the Eating Disorder Inventory and Eating Attitudes Test. Sexual functioning did not differ among women who did or did not report sexual abuse. Thisfinding suggests that sexual abuse or its correlates may affect severity rather than type ofeating disorder.
sexual problems than normal children (10), and women in therapy who report sexual abuse as children describe more difficulties in sexual adjustment than those without such a history (9). A history of CSA has also been associated with greater eating and weight psychopathology in a non clinical sample (11). However, such research does not establish whether or not sexual abuse is a specific risk factor for eating disorders or other psychiatric illnesses. Recent studies have found similar rates of sexual abuse among women with bulimia nervosa and anorexia nervosa (5,6). It is hypothesized that rates of previous sexual abuse might be higher in BN women than in those with AN as self-destructive behaviour, sexual activity and dissatisfaction with sexual experiences have been found to be more common in women with BN (12). We also hypothesized that women with eating disorders who report a history of sexual abuse have more psychopathology. Based on these observations, a pilot survey was undertaken to explore various aspects of reported sexual abuse in an outpatient sample of women with eating disorders. The rates of sexual abuse reported by women diagnosed with AN, BN or both AN and BN were assessed and compared. Unique to this study are an evaluation and comparison of the severity of psychopathology between subjects who did and did not report sexual abuse, to assess whether such a history influences attitudes and behaviour associated with eating disorders. Finally, current sexual behaviour and attitudes were evaluated to determine whether or not these varied with a history of sexual abuse.
I
t is generally agreed that anorexia nervosa (AN) and bulimia nervosa (BN) develop on a multifactorial basis, in relation to multiple risk factors (I). Psychologically and cognitively, women with eating disorders have difficulty meeting the demands of biological maturity, particularly the age-appropriate development of sex-role identity and sexuality during adolescence (1-3). Recently, it has been suggested that a history of sexual abuse may be more prevalent among women with eating disorders than among the general population and may be linked to the development of AN and BN (4-6). However, the reports are inconclusive since they are speculative (7,8) and, except for one study (6), are based on relatively small sample populations (4-5). There is also an increased level of awareness about sexual abuse and the frequency with which it occurs in the general population, particularly among women. It has long term adverse effects and may be a risk factor for psychiatric illness. In this regard, adults with a history of childhood sexual abuse (CSA) are more likely to attempt suicide and engage in self-destructive behaviour than are adults who have not been sexually abused (9). Sexually abused children have more
Method Two hundred and thirty-four consecutive female outpatients who were referred to the Program for Eating Disorders at The Toronto Hospital between January 1, 1987 and December 30, 1989 formed the study population. Diagnoses were determined through interviews with clinicians who were experienced in the field of eating disorders. Subjects were asked to complete several questionnaires: 1. The Diagnostic Schedule for Eating Disorders (DSED), which includes questions about sexual attitudes, experiences and sexual abuse (13). Information about past sexual abuse was obtained from the question "Have you ever been sexually abused against your will (incest, rape)?"; 2. The Eating Attitudes Test (EAT-26), which is a measure of attitudes about eating, weight and shape
*Manuscript received June 1991, revised October 1991. I Assistant Professor, University of Toronto, The Toronto Hospital, Toronto, Ontario. 2Associate Professor, University of Toronto; Head of Eating Disorders, The Toronto Hospital, Toronto, Ontario. 3Professor, University of Toronto; Psychiatrist-in-Chief, The Toronto Hospital, Toronto, Ontario. 4 Ph.D. Student, York University, Toronto, Ontario. Address reprint requests to: Dr. J. deGroot, ECW, 3D-048, The Toronto Hospital, Toronto Western Division, Department of Psychiatry, 399 Bathurst Street, Toronto, Ontario M5T 2S8
Can, J, Psychiatry Vol. 37, September 1992
516
September, 1992
SEXUAL ABUSE IN WOMEN WITH ANOREXIA NERVOSA AND BULIMIA NERVOSA
yielding subscales of oral control, bulimia and dieting (14); 3. The Eating Disorder Inventory (EDI) which provides both psychological and behavioural subscales associated with AN or BN (15). One hundred and eighty-four subjects who met the DSMIII-R criteria for AN, BN or both, and completed the questionnaires were included in the study. Four subjects with a diagnosis of an eating disorder not otherwise specified, 21 with a disorder other than an eating disorder and 25 who did not answer the question related to sexual abuse were excluded from the sample. Fifteen of the women were diagnosed as suffering from AN, 146 with BN and 23 with both. The mean age of the sample was 25.4 years (range from 15 to 64 years), and the average duration of illness was 5.8 years. Multivariate analyses of variance (MANOVA) with two subject factors (eating disorder subtype and presence or absence of sexual abuse) were conducted on the eight EDI subscales and the three EAT-26 subscales. Univariate analyses of variance were used to follow-up significant multivariate effects.
Results Prevalence Forty-five of the 184 subjects (24.4%) reported a history of sexual abuse. Sexual abuse was reported by four women with AN (26.5%), five women with AN and BN (21.7%), and 36 women with BN (22.8%). There were no differences among the three diagnostic groups (chi square = 0.31; p = 0.858).
EDl The MANOVA, using the Wilks Lambda statistic, revealed a significant interaction effect between sexual abuse and diagnosis on the EDI (F(3,181) = 1.68, P
Correlates of Sexual Abuse in Women with Anorexia Nervosa and Bulimia Nervosa* JANET M. DEGROOT, M.D. I , SIDNEY KENNEDY, M.B?, GARY RODIN, M.D. 3 AND GAIL MCVEY, M.A. 4
Of 184 female outpatients meeting the DSM-lll-R criteria, for anorexia nervosa, bulimia nervosa, or anorexia nervosa with bulimia, approximately 25% reported previous sexual abuse. Furthermore, previous sexual abuse was associated with greater psychological disturbance, measured by the Eating Disorder Inventory and Eating Attitudes Test. Sexual functioning did not differ among women who did or did not report sexual abuse. Thisfinding suggests that sexual abuse or its correlates may affect severity rather than type ofeating disorder.
sexual problems than normal children (10), and women in therapy who report sexual abuse as children describe more difficulties in sexual adjustment than those without such a history (9). A history of CSA has also been associated with greater eating and weight psychopathology in a non clinical sample (11). However, such research does not establish whether or not sexual abuse is a specific risk factor for eating disorders or other psychiatric illnesses. Recent studies have found similar rates of sexual abuse among women with bulimia nervosa and anorexia nervosa (5,6). It is hypothesized that rates of previous sexual abuse might be higher in BN women than in those with AN as self-destructive behaviour, sexual activity and dissatisfaction with sexual experiences have been found to be more common in women with BN (12). We also hypothesized that women with eating disorders who report a history of sexual abuse have more psychopathology. Based on these observations, a pilot survey was undertaken to explore various aspects of reported sexual abuse in an outpatient sample of women with eating disorders. The rates of sexual abuse reported by women diagnosed with AN, BN or both AN and BN were assessed and compared. Unique to this study are an evaluation and comparison of the severity of psychopathology between subjects who did and did not report sexual abuse, to assess whether such a history influences attitudes and behaviour associated with eating disorders. Finally, current sexual behaviour and attitudes were evaluated to determine whether or not these varied with a history of sexual abuse.
I
t is generally agreed that anorexia nervosa (AN) and bulimia nervosa (BN) develop on a multifactorial basis, in relation to multiple risk factors (I). Psychologically and cognitively, women with eating disorders have difficulty meeting the demands of biological maturity, particularly the age-appropriate development of sex-role identity and sexuality during adolescence (1-3). Recently, it has been suggested that a history of sexual abuse may be more prevalent among women with eating disorders than among the general population and may be linked to the development of AN and BN (4-6). However, the reports are inconclusive since they are speculative (7,8) and, except for one study (6), are based on relatively small sample populations (4-5). There is also an increased level of awareness about sexual abuse and the frequency with which it occurs in the general population, particularly among women. It has long term adverse effects and may be a risk factor for psychiatric illness. In this regard, adults with a history of childhood sexual abuse (CSA) are more likely to attempt suicide and engage in self-destructive behaviour than are adults who have not been sexually abused (9). Sexually abused children have more
Method Two hundred and thirty-four consecutive female outpatients who were referred to the Program for Eating Disorders at The Toronto Hospital between January 1, 1987 and December 30, 1989 formed the study population. Diagnoses were determined through interviews with clinicians who were experienced in the field of eating disorders. Subjects were asked to complete several questionnaires: 1. The Diagnostic Schedule for Eating Disorders (DSED), which includes questions about sexual attitudes, experiences and sexual abuse (13). Information about past sexual abuse was obtained from the question "Have you ever been sexually abused against your will (incest, rape)?"; 2. The Eating Attitudes Test (EAT-26), which is a measure of attitudes about eating, weight and shape
*Manuscript received June 1991, revised October 1991. I Assistant Professor, University of Toronto, The Toronto Hospital, Toronto, Ontario. 2Associate Professor, University of Toronto; Head of Eating Disorders, The Toronto Hospital, Toronto, Ontario. 3Professor, University of Toronto; Psychiatrist-in-Chief, The Toronto Hospital, Toronto, Ontario. 4 Ph.D. Student, York University, Toronto, Ontario. Address reprint requests to: Dr. J. deGroot, ECW, 3D-048, The Toronto Hospital, Toronto Western Division, Department of Psychiatry, 399 Bathurst Street, Toronto, Ontario M5T 2S8
Can, J, Psychiatry Vol. 37, September 1992
516
September, 1992
SEXUAL ABUSE IN WOMEN WITH ANOREXIA NERVOSA AND BULIMIA NERVOSA
yielding subscales of oral control, bulimia and dieting (14); 3. The Eating Disorder Inventory (EDI) which provides both psychological and behavioural subscales associated with AN or BN (15). One hundred and eighty-four subjects who met the DSMIII-R criteria for AN, BN or both, and completed the questionnaires were included in the study. Four subjects with a diagnosis of an eating disorder not otherwise specified, 21 with a disorder other than an eating disorder and 25 who did not answer the question related to sexual abuse were excluded from the sample. Fifteen of the women were diagnosed as suffering from AN, 146 with BN and 23 with both. The mean age of the sample was 25.4 years (range from 15 to 64 years), and the average duration of illness was 5.8 years. Multivariate analyses of variance (MANOVA) with two subject factors (eating disorder subtype and presence or absence of sexual abuse) were conducted on the eight EDI subscales and the three EAT-26 subscales. Univariate analyses of variance were used to follow-up significant multivariate effects.
Results Prevalence Forty-five of the 184 subjects (24.4%) reported a history of sexual abuse. Sexual abuse was reported by four women with AN (26.5%), five women with AN and BN (21.7%), and 36 women with BN (22.8%). There were no differences among the three diagnostic groups (chi square = 0.31; p = 0.858).
EDl The MANOVA, using the Wilks Lambda statistic, revealed a significant interaction effect between sexual abuse and diagnosis on the EDI (F(3,181) = 1.68, P
