The Scottish Government

« Previous | Contents |

Listen

Background

Childhood sexual abuse ( CSA) is associated with vulnerability to a range of mental and physical ill-health, for example: disorders of function without known organic cause, such as irritable bowel syndrome or chronic pelvic pain.

The origins of medically unexplained symptoms ( MUS) in people sexually abused in childhood, and the relationship to their mental health, are disputed or uncertain, affecting patient care. There is a lack of appropriate therapeutic support for the CSA client group with MUS, highlighting significant needs of service users and professionals who work with them.

Aims and methods

This review aims to identify current research and gaps in the research, in order to establish what is known, and to assess what further research is needed to understand these conditions and develop best-practice guidelines.

The review had as its prime focus the implications, for adult survivors of abuse, of any linkages which studies revealed across medically- unexplained symptoms, mental health and child sexual abuse.

Following systematic electronic database searches 110 studies were identified, with 82 retrieved following appraisal of abstracts. With other retrieval through hand-searching, and expert recommendations on unpublished papers, the total was 96. A further 24 narrative reviews or position papers informed relevant parts of the review.

Findings

Survivors were not the primary focus of most studies retrieved. Rather, people with a medically unexplained condition were the focus, and those with CSA history were usually identified after screening of samples. Most researchers were not specialists in CSA, but in these unexplained conditions or in psychosomatic medicine.

No systematic reviews of interventions, nor randomised controlled trials ( RCTs), were identified on MUS and mental health for this specific client group. Most studies were case-control or cohort studies, seeking to identify risk factors for medically unexplained symptoms. There were few prospective studies, studies focussing on males, case history studies, or qualitative studies where service users themselves could contribute their own understandings and experience.

A majority of papers confirm that people with CSA history are at greater risk for MUS, especially for chronic pain and gastrointestinal disorders. The more serious the abuse, the more serious the impact on MUS, functional disability, sick days and healthcare use. A minority of studies conclude the link is unproven, or identify other factors as more significant. Childhood physical abuse and violence experienced in adulthood also emerge as significant influences on MUS.

Despite the lack of intervention studies, many studies within this literature do make general proposals for good practice with CSA survivors. They often suggest that a psychological intervention might prove helpful, that medical professionals should ask patients with certain symptom patterns about a history of sexual or physical abuse, and they recommend good practice on respectful, detailed listening to patients by doctors.

A range of theories underpins explanations about why CSA survivors might be especially prone to MUS. Mental health and personality disturbances are usually seen to occupy an important role in the aetiology and/or presentation of MUS. One frequent assumption is that "somatisation", where emotional pain, suffering and psychosocial stress are translated into bodily symptoms, has taken place. Varying definitions of somatisation, or failure to define it, can obscure clarity and the term has critics within medicine, for encouraging biased attitudes, especially towards women and mentally distressed people.

Other theories are that:

• severe childhood trauma causes changes in the central nervous system, which may amplify physical pain and increase vulnerability to illness
• disruption of early care and attachment leads to increased healthcare-seeking in later life for the "secondary gain" of emotional benefit
• dissociative processes with various effects on the body's expression are involved;
• psychological problems may amplify the sensation of physical symptoms
• injury and infection by abusers directly influence symptoms, especially chronic pain.

Implications for future research

The review finds several problems in the current research literature. An overriding concern with testing which risk factors contribute to which outcomes has produced a repetitive body of case-control and cohort studies which have failed to identify helpful interventions for sexually abused people with MUS. The variables investigated do not always tally with the experience of CSA victims for whom different kinds of abuse and neglect are often inextricably linked. Research collaboration with sexual abuse specialists has not been the norm. The key concept of somatisation is problematic. Ethically, it is unclear how far studies have built in support for participants undergoing numerous probing questionnaires on their trauma history.

The review suggests that to fill gaps in the current literature, adult survivors of CSA require to be the primary focus of study. Research needs to be geared more explicitly towards identifying appropriate therapies and relieving suffering. The design, implementation and interpretation of studies would benefit from collaboration between medical or psychiatric professionals, and statutory/voluntary services experienced in working with abused adults and children.

More specific examples of research which could remedy gaps in the current literature are:

• Qualitative research with adult survivors of sexual abuse who suffer MUS, exploring their experience, knowledge and understanding of possible interconnections, and drawing on their medical records.
• Studies with male survivors of CSA who have MUS.
• Research with major voluntary sector support agencies for CSA in Scotland, to record systematically their practice experience of MUS in adult survivors, and to evaluate interventions which they have found helpful.
• Design of therapeutic interventions, in collaboration with adult survivors and their support agencies, which can be piloted and evaluated.
• Design of a "good practice" interview schedule for use by practitioners on sexual abuse history and MUS, which could be piloted and evaluated.
• Research into direct effects of violence and physical injury and potential connections with MUS in adult survivors. This might usefully include literature reviews of other research areas such as child marriage or political torture, and collaboration with their specialists.
• Research into the concept of "body memories" and its usage in relation to people who suffered childhood sexual or physical trauma.
• Prospective studies with children and young people whose sexual abuse history has been recorded, and with adults who have been sexually assaulted or are victims of domestic violence.

Further details from:

Norma Baldwin

« Previous | Contents |