Suicide and Life-Threatening Behavior 45 (5) October 2015 © 2014 The American Association of Suicidology DOI: 10.1111/sltb.12148
529
Sexual Assault, Overweight, and Suicide Attempts in U.S. Adolescents LAURA M. ANDERSON, PHD, BRITTANY M. HAYDEN, BA, AND JESSICA L. TOMASULA, PHD
Associations between overweight, sexual assault history, and suicide attempts were examined among 31,540 adolescents from the combined 2009 and 2011 nationally representative Youth Risk Behavior Surveys samples. These variables have not previously been studied concurrently. It was hypothesized that overweight and sexual assault, together, would interact and result in increased suicide attempts. Findings across analyses included (a) no significant associations between sexual assault and overweight in females or males (p = .65 and p = .90, respectively), (b) statistically significant associations between female (but not male) overweight status and suicide attempts (p = .001), (c) a strong association between sexual assault and suicide risk in males (p < .001) and females (p < .001), and (d) an elevated risk for suicide in overweight males with co-occurring sexual assault, with over 33% of males with such histories attempting suicide. Preliminary findings have powerful implications for research and secondary prevention.
Suicide, the third leading cause of adolescent death, continues to be a serious public health issue (Centers for Disease Control and Prevention [CDC], 2012). Research examining (a) overweight and suicide, and (b) sexual assault and suicide has produced inconsistent yet overlapping results, suggesting there may be a common third variable involvement. That is, studies of the relationship between LAURA M. ANDERSON, School of Nursing, University at Buffalo, Buffalo, NY, USA; BRITTANY M. HAYDEN, Department of Counseling School and Educational Psychology, Graduate School of Education, University at Buffalo, Buffalo, NY, USA; JESSICA L. TOMASULA, Department of Psychology, East Carolina University, Greenville, NC, USA. The authors would like to thank the Youth Risk Behavior Surveillance System (YRBSS) team at the Centers for Disease Control and Prevention (Division of Adolescent and School Health) for their hard work and for making YRBSS data publicly available. Address correspondence to Laura M. Anderson, School of Nursing, University at Buffalo, Buffalo, NY 14214; E-mail: pulse@buffalo. edu
obesity and suicide risk in specialized populations (e.g., bariatric samples) have identified sexual abuse as a possible third variable (Chen et al., 2012); however, most studies evaluating these variables in adolescents include depressive mood and/or sadness/ hopelessness as covariates (Kim & Lee, 2010; Zeller, Reiter-Purtill, Jenkins, & Ratcliff, 2013). Sexual assault history is less often considered as a covariate or variable of interest. Further, studies of the relationship between sexual assault history and suicide risk have found results unique to overweight or obese children (Pinhas-Hamiel, Modan-Moses, Herman-Raz, & Reichman, 2009). To date, no published study has examined the three variables (i.e., overweight, suicide attempts, and sexual assault history) concurrently. One recent preliminary study of a national sample of adolescents yielded an alarmingly high rate of suicide attempts in a national sample of overweight adolescents who reported sexual assault histories, particularly among males (Tomasula & Anderson, 2011). That is, for males with no sexual
530 assault history, 3.4% and 3.5% of healthy weight versus overweight adolescents, respectively, reported having attempted suicide. However, among those who reported sexual assault histories, 17.7% of healthy weight males and 39.2% of overweight males indicated suicide attempts in the previous 12 months. These findings inspired this study. With a larger sample of males reporting sexual assault, for example, would this result be replicated? In this study we examined a larger national sample of adolescents (via combining two consecutive cohorts of data from a national survey in 2009 and 2011) to replicate the previously obtained interaction (i.e., nearly 40% of overweight adolescent boys with self-reported sexual assault histories had attempted suicide in the last 12 months; (Tomasula & Anderson, 2011). Was the Tomasula and Anderson result a chance finding from national data in 2007, or might sexual assault history and overweight status be systematically associated with behavioral suicide risk? The answer to this question may inform targeted prevention and intervention. Indeed, results have been mixed when examining suicidality in overweight adolescents. For example, one longitudinal study revealed that body mass index (BMI) did not predict suicidal ideation in adolescents; rather, subsyndromal eating disorder behaviors including overregulation of food intake, and body dissatisfaction were better predictors of suicide, after controlling for depression (Crow, Eisenberg, Story, & Neumark-Sztainer, 2008). Likewise, unhealthy eating behavior, associated with obesity, has been linked to cognitive, affective, or behavioral features such as low self-esteem, depressed mood, and avoidant coping (Crow et al., 2008; Kim & Kim, 2009; Martyn-Nemeth, Penckofer, Gulanick, Velsor-Friedrich, & Bryant, 2009; Pompili, Girardi, Tatarelli, Ruberto, & Tatarelli, 2006; Thompson, Kuruwita, & Foster, 2009). Another recent analysis of a national sample of high school students revealed that adolescents identified as extremely obese (BMI ≥99th percentile for age and gender)
SEXUAL ASSAULT, OVERWEIGHT,
AND
SUICIDE
engaged in suicidal behaviors at rates similar to their average weight peers (Ratcliff, Jenkins, Reiter-Purtill, Noll, & Zeller, 2011). Furthermore, perceived and actual overweight in national studies of adolescents have been linked to suicidal behavior after controlling for potential confounding variables, including but not limited to sexual assault history (Dave & Rashad, 2009; Swahn et al., 2009). Similar variables emerge when examining the biopsychosocial impact of sexual assault or child sexual abuse (Basile et al., 2006; Veldwijk, Proper, Hoeven-Mulder, & Bemelmans, 2012). Outcomes, such as low self-esteem, depressed mood, body dissatisfaction, participation in risky behaviors (e.g., not wearing a seatbelt, using substances), conduct disorder diagnoses, and suicidal behaviors are more evident in adolescents with a history of sexual assault when compared to their peers without such a history (O’Brien, 2013; Tomasula, Anderson, Littleton, & Riley-Tillman, 2012). Brent and Silverstein (2013) have discussed the long-term risks associated with childhood maltreatment (e.g., abuse, trauma, neglect, etc.) on children and adolescents, including both obesity and suicide attempts. Further, one study identified a history of sexual assault as the strongest associated risk factor for suicide attempts in adolescents (Rosenberg et al., 2005). Children and adolescents with sexual abuse histories are 3.5 times more likely to attempt suicide than peers without reported histories (BeckLittle & Catton, 2011). Furthermore, a recent latent class analysis found that high school students who reported forced sexual intercourse were more likely to consider, plan, and attempt suicide than their peers without forced intercourse (Jiang, Perry, & Hesser, 2010). Finally, the association among sexual abuse and suicidal behavior is stronger for adolescents than any other age group (Sandoval & Zadeh, 2008). A few studies have examined sexual abuse and overweight, together, as well as associations with mental health risk. For example, in exploring the association between
ANDERSON
ET AL.
sexual abuse and overweight, researchers in Norway found that obese girls (mean age = 11.9 years) with a history of penetrative sexual abuse were significantly more obese than other obese girls being treated on a hospital unit (Pinhas-Hamiel et al., 2009). Similarly, results of a prospective birth cohort study suggested that BMI and overweight prevalence at age 21 was greater in young women who experienced penetrative childhood sexual abuse (Mamun et al., 2007). More severe mental health symptoms have also been found in overweight girls with sexual abuse histories. Pinhas-Hamiel et al. (2009), specifically, indicated that obese girls with penetrative sexual abuse histories were the most likely to exhibit clinically significant changes in behavior such as newonset enuresis and self-mutilation (PinhasHamiel et al., 2009). Keeshin et al. (2013) have found similar results: Children and adolescents with psychiatric illnesses with sexual abuse histories were significantly more likely to be overweight or obese. Thus, clinicians should be mindful of the possibility of sexual abuse when evaluating markedly obese children who fail to respond to therapy (Pinhas-Hamiel et al., 2009). Aims and Hypotheses Given the mortality of suicidal behavior coupled with inconsistent evidence pertaining to sexual assault, overweight, and suicide risk, researchers recommend new studies that will inform targeted, secondary suicide prevention efforts (Basile et al., 2006; Cleary, 2000; Hussey, Chang, & Kotch, 2006; Kim & Kim, 2009; Needham, 2009; Pompili et al., 2006; Thompson et al., 2009). To date, no published research has analyzed the relationship among overweight status, forced sex, and suicide attempts, concurrently, using a nationally representative sample of adolescents. Our research examined these variables in a large, nationally representative sample of adolescents from 2009 to 2011. One preliminary objective of this research was to examine the relationship
531 among the two predictor variables (e.g., sexual assault and overweight), as well as the association of each predictor variable with suicide risk. We hypothesized, based on existing literature, that a history of sexual assault would be associated with adolescent suicide risk. Because of inconsistent empirical evidence, other preliminary hypotheses were stated in the null. The major aim of this study was to examine whether co-occurring adolescent overweight and sexual assault would result in elevated suicide risk. We hypothesized that overweight adolescents with sexual assault histories would attempt suicide more frequently than all other groups of adolescents. Given the minimal evidence to date, specific a priori predictions about sex differences were not asserted.
METHOD
The secondary data analyses reported here were completed in 2013 with two national cohorts of adolescent data. Because reported male sexual assault occurs at a low base rate (e.g., from 3 to 5% in current samples), the synthesis of data from two administrations, 24 months apart (2009 and 2011), yielded a larger sample of males reporting sexual assault. Data The study, approved with exempt status by the university institutional review board, was an analysis of data from the combined 2009 and 2011 national Youth Risk Behavior Surveys (YRBS). The YRBS was developed to monitor six categories of risk behaviors that contribute to social problems, disability, and mortality in the United States. Detailed YRBS methodology is available for download on the Centers for Disease Control and Prevention (CDC) Web site. Since 1991, the YRBS has been administered biennially, February through May, utilizing a three-stage, cluster sample design.
532
SEXUAL ASSAULT, OVERWEIGHT,
Each active year, a nationally representative sample of students from public and private schools in the 50 states and the District of Columbia complete the selfadministered, anonymous questionnaire. In addition to providing demographic data, students in grades 9–12 respond to questions assessing unintentional injuries, violence, substance use, sexual behaviors, and energy balance behaviors (e.g., eating/ nutrition and physical activity). Parental consent was obtained as per local procedures. School and student response rates, respectively, for 2009 and 2011 were 81% and 88% (CDC, 2009), and 81% and 87% (CDC, 2011). Sample The combined 2009 and 2011 YRBS sample included 31,540 high school students (ages 14–18). Please consult Table 1 for demographic characteristics. Only complete data records were included in analyses of the combined 2009 and 2011 cohorts. Of the 31,540 records, the following were excluded: (a) 2,300 due to missing demographic or BMI information, (b) 881 records missing data on sexual assault, and (c) 3,650 cases missing information about suicide attempts. Adolescents who did not respond to the suicide attempt question were most likely to be African American (e.g., males and females), with nearly 20% omitting this question. Caucasian adolescents showed the highest response rates, with over 93% responding to the item.
AND
SUICIDE
TABLE 1
Combined 2009 and 2011 Youth Risk Behavior Survey Demographic Characteristics Characteristic Gender Females Males Age 14 15 16 17 18 or older Grade 9th 10th 11th 12th Race/Ethnicity Amer Ind/Alaska Native Asian Black/African Amer Nat Hawaiian/Pacific Isl White Hispanic/Latino Multiple Hispanic Multiple non-Hispanic Weight Status Healthy (BMI%tile*
529
Sexual Assault, Overweight, and Suicide Attempts in U.S. Adolescents LAURA M. ANDERSON, PHD, BRITTANY M. HAYDEN, BA, AND JESSICA L. TOMASULA, PHD
Associations between overweight, sexual assault history, and suicide attempts were examined among 31,540 adolescents from the combined 2009 and 2011 nationally representative Youth Risk Behavior Surveys samples. These variables have not previously been studied concurrently. It was hypothesized that overweight and sexual assault, together, would interact and result in increased suicide attempts. Findings across analyses included (a) no significant associations between sexual assault and overweight in females or males (p = .65 and p = .90, respectively), (b) statistically significant associations between female (but not male) overweight status and suicide attempts (p = .001), (c) a strong association between sexual assault and suicide risk in males (p < .001) and females (p < .001), and (d) an elevated risk for suicide in overweight males with co-occurring sexual assault, with over 33% of males with such histories attempting suicide. Preliminary findings have powerful implications for research and secondary prevention.
Suicide, the third leading cause of adolescent death, continues to be a serious public health issue (Centers for Disease Control and Prevention [CDC], 2012). Research examining (a) overweight and suicide, and (b) sexual assault and suicide has produced inconsistent yet overlapping results, suggesting there may be a common third variable involvement. That is, studies of the relationship between LAURA M. ANDERSON, School of Nursing, University at Buffalo, Buffalo, NY, USA; BRITTANY M. HAYDEN, Department of Counseling School and Educational Psychology, Graduate School of Education, University at Buffalo, Buffalo, NY, USA; JESSICA L. TOMASULA, Department of Psychology, East Carolina University, Greenville, NC, USA. The authors would like to thank the Youth Risk Behavior Surveillance System (YRBSS) team at the Centers for Disease Control and Prevention (Division of Adolescent and School Health) for their hard work and for making YRBSS data publicly available. Address correspondence to Laura M. Anderson, School of Nursing, University at Buffalo, Buffalo, NY 14214; E-mail: pulse@buffalo. edu
obesity and suicide risk in specialized populations (e.g., bariatric samples) have identified sexual abuse as a possible third variable (Chen et al., 2012); however, most studies evaluating these variables in adolescents include depressive mood and/or sadness/ hopelessness as covariates (Kim & Lee, 2010; Zeller, Reiter-Purtill, Jenkins, & Ratcliff, 2013). Sexual assault history is less often considered as a covariate or variable of interest. Further, studies of the relationship between sexual assault history and suicide risk have found results unique to overweight or obese children (Pinhas-Hamiel, Modan-Moses, Herman-Raz, & Reichman, 2009). To date, no published study has examined the three variables (i.e., overweight, suicide attempts, and sexual assault history) concurrently. One recent preliminary study of a national sample of adolescents yielded an alarmingly high rate of suicide attempts in a national sample of overweight adolescents who reported sexual assault histories, particularly among males (Tomasula & Anderson, 2011). That is, for males with no sexual
530 assault history, 3.4% and 3.5% of healthy weight versus overweight adolescents, respectively, reported having attempted suicide. However, among those who reported sexual assault histories, 17.7% of healthy weight males and 39.2% of overweight males indicated suicide attempts in the previous 12 months. These findings inspired this study. With a larger sample of males reporting sexual assault, for example, would this result be replicated? In this study we examined a larger national sample of adolescents (via combining two consecutive cohorts of data from a national survey in 2009 and 2011) to replicate the previously obtained interaction (i.e., nearly 40% of overweight adolescent boys with self-reported sexual assault histories had attempted suicide in the last 12 months; (Tomasula & Anderson, 2011). Was the Tomasula and Anderson result a chance finding from national data in 2007, or might sexual assault history and overweight status be systematically associated with behavioral suicide risk? The answer to this question may inform targeted prevention and intervention. Indeed, results have been mixed when examining suicidality in overweight adolescents. For example, one longitudinal study revealed that body mass index (BMI) did not predict suicidal ideation in adolescents; rather, subsyndromal eating disorder behaviors including overregulation of food intake, and body dissatisfaction were better predictors of suicide, after controlling for depression (Crow, Eisenberg, Story, & Neumark-Sztainer, 2008). Likewise, unhealthy eating behavior, associated with obesity, has been linked to cognitive, affective, or behavioral features such as low self-esteem, depressed mood, and avoidant coping (Crow et al., 2008; Kim & Kim, 2009; Martyn-Nemeth, Penckofer, Gulanick, Velsor-Friedrich, & Bryant, 2009; Pompili, Girardi, Tatarelli, Ruberto, & Tatarelli, 2006; Thompson, Kuruwita, & Foster, 2009). Another recent analysis of a national sample of high school students revealed that adolescents identified as extremely obese (BMI ≥99th percentile for age and gender)
SEXUAL ASSAULT, OVERWEIGHT,
AND
SUICIDE
engaged in suicidal behaviors at rates similar to their average weight peers (Ratcliff, Jenkins, Reiter-Purtill, Noll, & Zeller, 2011). Furthermore, perceived and actual overweight in national studies of adolescents have been linked to suicidal behavior after controlling for potential confounding variables, including but not limited to sexual assault history (Dave & Rashad, 2009; Swahn et al., 2009). Similar variables emerge when examining the biopsychosocial impact of sexual assault or child sexual abuse (Basile et al., 2006; Veldwijk, Proper, Hoeven-Mulder, & Bemelmans, 2012). Outcomes, such as low self-esteem, depressed mood, body dissatisfaction, participation in risky behaviors (e.g., not wearing a seatbelt, using substances), conduct disorder diagnoses, and suicidal behaviors are more evident in adolescents with a history of sexual assault when compared to their peers without such a history (O’Brien, 2013; Tomasula, Anderson, Littleton, & Riley-Tillman, 2012). Brent and Silverstein (2013) have discussed the long-term risks associated with childhood maltreatment (e.g., abuse, trauma, neglect, etc.) on children and adolescents, including both obesity and suicide attempts. Further, one study identified a history of sexual assault as the strongest associated risk factor for suicide attempts in adolescents (Rosenberg et al., 2005). Children and adolescents with sexual abuse histories are 3.5 times more likely to attempt suicide than peers without reported histories (BeckLittle & Catton, 2011). Furthermore, a recent latent class analysis found that high school students who reported forced sexual intercourse were more likely to consider, plan, and attempt suicide than their peers without forced intercourse (Jiang, Perry, & Hesser, 2010). Finally, the association among sexual abuse and suicidal behavior is stronger for adolescents than any other age group (Sandoval & Zadeh, 2008). A few studies have examined sexual abuse and overweight, together, as well as associations with mental health risk. For example, in exploring the association between
ANDERSON
ET AL.
sexual abuse and overweight, researchers in Norway found that obese girls (mean age = 11.9 years) with a history of penetrative sexual abuse were significantly more obese than other obese girls being treated on a hospital unit (Pinhas-Hamiel et al., 2009). Similarly, results of a prospective birth cohort study suggested that BMI and overweight prevalence at age 21 was greater in young women who experienced penetrative childhood sexual abuse (Mamun et al., 2007). More severe mental health symptoms have also been found in overweight girls with sexual abuse histories. Pinhas-Hamiel et al. (2009), specifically, indicated that obese girls with penetrative sexual abuse histories were the most likely to exhibit clinically significant changes in behavior such as newonset enuresis and self-mutilation (PinhasHamiel et al., 2009). Keeshin et al. (2013) have found similar results: Children and adolescents with psychiatric illnesses with sexual abuse histories were significantly more likely to be overweight or obese. Thus, clinicians should be mindful of the possibility of sexual abuse when evaluating markedly obese children who fail to respond to therapy (Pinhas-Hamiel et al., 2009). Aims and Hypotheses Given the mortality of suicidal behavior coupled with inconsistent evidence pertaining to sexual assault, overweight, and suicide risk, researchers recommend new studies that will inform targeted, secondary suicide prevention efforts (Basile et al., 2006; Cleary, 2000; Hussey, Chang, & Kotch, 2006; Kim & Kim, 2009; Needham, 2009; Pompili et al., 2006; Thompson et al., 2009). To date, no published research has analyzed the relationship among overweight status, forced sex, and suicide attempts, concurrently, using a nationally representative sample of adolescents. Our research examined these variables in a large, nationally representative sample of adolescents from 2009 to 2011. One preliminary objective of this research was to examine the relationship
531 among the two predictor variables (e.g., sexual assault and overweight), as well as the association of each predictor variable with suicide risk. We hypothesized, based on existing literature, that a history of sexual assault would be associated with adolescent suicide risk. Because of inconsistent empirical evidence, other preliminary hypotheses were stated in the null. The major aim of this study was to examine whether co-occurring adolescent overweight and sexual assault would result in elevated suicide risk. We hypothesized that overweight adolescents with sexual assault histories would attempt suicide more frequently than all other groups of adolescents. Given the minimal evidence to date, specific a priori predictions about sex differences were not asserted.
METHOD
The secondary data analyses reported here were completed in 2013 with two national cohorts of adolescent data. Because reported male sexual assault occurs at a low base rate (e.g., from 3 to 5% in current samples), the synthesis of data from two administrations, 24 months apart (2009 and 2011), yielded a larger sample of males reporting sexual assault. Data The study, approved with exempt status by the university institutional review board, was an analysis of data from the combined 2009 and 2011 national Youth Risk Behavior Surveys (YRBS). The YRBS was developed to monitor six categories of risk behaviors that contribute to social problems, disability, and mortality in the United States. Detailed YRBS methodology is available for download on the Centers for Disease Control and Prevention (CDC) Web site. Since 1991, the YRBS has been administered biennially, February through May, utilizing a three-stage, cluster sample design.
532
SEXUAL ASSAULT, OVERWEIGHT,
Each active year, a nationally representative sample of students from public and private schools in the 50 states and the District of Columbia complete the selfadministered, anonymous questionnaire. In addition to providing demographic data, students in grades 9–12 respond to questions assessing unintentional injuries, violence, substance use, sexual behaviors, and energy balance behaviors (e.g., eating/ nutrition and physical activity). Parental consent was obtained as per local procedures. School and student response rates, respectively, for 2009 and 2011 were 81% and 88% (CDC, 2009), and 81% and 87% (CDC, 2011). Sample The combined 2009 and 2011 YRBS sample included 31,540 high school students (ages 14–18). Please consult Table 1 for demographic characteristics. Only complete data records were included in analyses of the combined 2009 and 2011 cohorts. Of the 31,540 records, the following were excluded: (a) 2,300 due to missing demographic or BMI information, (b) 881 records missing data on sexual assault, and (c) 3,650 cases missing information about suicide attempts. Adolescents who did not respond to the suicide attempt question were most likely to be African American (e.g., males and females), with nearly 20% omitting this question. Caucasian adolescents showed the highest response rates, with over 93% responding to the item.
AND
SUICIDE
TABLE 1
Combined 2009 and 2011 Youth Risk Behavior Survey Demographic Characteristics Characteristic Gender Females Males Age 14 15 16 17 18 or older Grade 9th 10th 11th 12th Race/Ethnicity Amer Ind/Alaska Native Asian Black/African Amer Nat Hawaiian/Pacific Isl White Hispanic/Latino Multiple Hispanic Multiple non-Hispanic Weight Status Healthy (BMI%tile*
