We studied psychiatric patients aged ≥50 years, a group with elevated levels of morbidity (24
). The effects of severe sexual abuse on health indices had clear and compelling clinical significance: the effect on medical illness burden was roughly comparable to adding 8 years of age, and on functional impairment and BP was roughly comparable to adding 20 years. We believe these are the first such estimates to appear in the literature.
Exploratory analyses showed that CSA was strongly associated with increased burden in two of the 12 CIRS subscales, the musculoskeletal/integument and respiratory subscales. Prior epidemiological studies among women with lifetime trauma sexual or physical assault histories have reported increased rates of at least two chronic afflictions in these organ systems, arthritis (25
) and asthma (6
). However, the issue of whether CSA is associated with specific organ-systems or medical conditions is not settled (26
). Finding increased risk for certain medical disorders among older women with lifetime sexual assault histories, Stein and Barrett-Connor (25
) concluded that there was no obvious common pathogenesis for those disorders, but their study design combined childhood and adult sexual assault. Assuming that there are differences in the biological repercussions of severe sexual assault according to the developmental stage of its occurrence—from early to middle childhood into adolescence and adulthood—then illness and disease patterns may vary accordingly.
Interrelated biopsychosocial mechanisms have been posited to explain the sustained, deleterious effects of childhood sexual assault on adult physical health (27
). Early sexual trauma may lead to chronic dysregulation of stress-responsive systems (28
), which in turn increases abused individuals’ “allostatic load” (32
). In a longitudinal prospective study, Danese et al. (27
) found that childhood maltreatment (not confined to sexual abuse) predicted clinically significant biomarkers of inflammation in adulthood, even with adjustments for co-occurring risk factors and potential mediating variables. The investigators hypothesized that inflammation is a likely mediator in the established link between maltreatment and increased risk for many adult diseases.
Sexual abuse can also produce chronic negative emotions (4
), such as shame, that have been linked to disease (4
) and compromised immune function (35
). Similarly, early abuse has implications for personality development (37
), and personality traits have been shown to influence health in older adulthood (38
). Childhood abuse seems to have effects on adult health status only partially mediated by adult psychiatric disorder (39
Beyond the implications of abuse for neuroimmune regulation, neuroendocrine regulation, psychiatric disorder, emotion regulation, and personality, early abuse is associated with high-risk health behaviors (3
), such as smoking and unsafe sex, which in turn influence morbidity (41
). Finally, severe sexual abuse can catalyze a developmental course characterized by significant social morbidity (37
). The interpersonal consequences of early abuse—including low social support, marital instability, and additional interpersonal traumas—may themselves take a physiological toll and contribute to adult disease processes (42
In this relatively small sample, a complex model of interrelated mechanisms could not be tested. Further, this study is limited by a cross-sectional design, which precludes conclusions about causal relations. These findings may not apply to other diagnostic groups, nonclinical samples, younger cohorts, or more racially/ethnically diverse samples. Data on nonparticipants are unavailable. Participants’ retrospective reports regarding CSA were not independently verified; either overreporting or underreporting is possible. Due to sample size limitations, we could not examine gender or age differences. Chief among the study’s strengths is its focus on a vulnerable older psychiatric population. Our approach to the measurement of medical burden and functional impairment effectively rules out the interpretation that the reported associations are spuriously inflated products of shared method variance. The significance of study findings is underscored both by the high rate of reported CSA, 41.7%, that is comparable to other reports (43
) and by the attempt to compare the health effects of abuse with that of age; the latter estimates warrant replication and could generate hypotheses about the potential contribution of early abuse to the aging process.
Study findings may well have important implications for treating patients with sexual abuse histories. Early detection of patients’ abuse histories could inform targeted interventions to prevent or decelerate the progression of morbidity. Given the myriad biological, psychological, social, and economic processes that may engender, exacerbate or stem from childhood abuse, no one form of intervention or single site for intervention could suffice. Educational, psychotherapeutic, pharmacological, and medical interventions across healthcare settings, schools, and workplaces could cast a broad net for detection and treatment. Public health advertisements would increase awareness about both the long-term effects of childhood abuse on health and about available remedies, likely motivating some individuals to divulge trauma histories to their healthcare providers. The physical health effects of trauma have arguably been underemphasized in the public sphere.
At minimum, our findings point to the need for integrated if not colocalized mental health care for these patients when they are seen in primary and specialty care (44
), and for careful medical evaluations when they are seen in mental health settings. Taking the implications of these findings further requires reenvisioning healthcare systems with a prevention focus, including systematic screening for trauma exposure; among identified patients, further screening in physiological, psychological (e.g., depression, posttraumatic stress disorder (PTSD)), behavioral (e.g., smoking, alcohol consumption), and social domains (e.g., domestic violence) that may be affected by exposure to trauma; and, based on screening results, developing individualized treatment plans to address problematic areas through health education, increased medical surveillance and healthcare contacts, behavioral interventions, social service referrals, and mental health care.
Although interventions to identify and address abused adults’ health-risk behaviors (4
) could prevent or decelerate associated morbidity and mortality, some research suggests that adolescent girls and women with sexual assault histories have relatively poor compliance with behavioral-health and medical interventions (45
). Among the reasons for noncompliance is the possibility that invasive medical interventions and the accompanying psychological experience of helplessness stimulate reexperiencing of the traumatic event (49
). Specialized psychological interventions could improve adherence to treatment regimens among medically ill patients with sexual abuse histories (40
), address issues of comfort, trust, and communication with health professionals, and improve a wide range of health outcomes.
Conceivably, effective psychotherapy for PTSD and depression among trauma-exposed individuals could improve not just psychiatric illnesses but also improve health and health-related quality of life (50
). Limitations in our current therapeutic methods suggest that more treatment innovations and research are needed to develop treatment algorithms for the complex health problems of those with sexual assault histories. Some forms of psychotherapy have been found to be useful for PTSD, yet treatment attrition is relatively high (53
). Depression can respond to pharmacotherapy and/or psychotherapy (56
), but remission rates for the chronic, complicated depression that is often associated with CSA leave much room for improvement (58
). Biological outcomes among psychotherapy patients need to be examined.
The impact of CSA is profound even into later life, and future research on the mechanisms and remediation of its effects is warranted. Finally, a society committed to preventing child sexual assault would likely observe dramatic declines in morbidity and mortality.