This comprehensive systematic review and meta-analysis of 37 longitudinal observational comparative studies including 3,162,318 participants found an association between a history of sexual abuse and a lifetime diagnosis of anxiety, depression, eating disorders, PTSD, sleep disorders, and suicide attempts. There was no statistically significant association between a history of sexual abuse and a lifetime diagnosis of schizophrenia or somatoform disorders. Association between sexual abuse and psychiatric disorders persisted regardless of sex of the abuse survivor or age at which abuse occurred. History of rape strengthened the associations between history of abuse and depression, eating disorders, and PTSD. No data were available to assess the outcomes of bipolar or obsessive-compulsive disorder.
Analyses appeared robust with regard to the statistical model and were associated with a low level of heterogeneity. Exceptions included the outcomes of depression and suicide attempts. Residual unexplained heterogeneity may be attributable to other study-level or patient-level covariates that could not be evaluated in this meta-analysis.
Using methodology similar to that in our current study, we recently conducted a systematic review and meta-analysis that found an association between a history of sexual abuse and several somatic disorders, including functional gastrointestinal disorders, chronic pelvic pain, psychogenic seizures, and nonspecific chronic pain.
65 Taken together with the results presented in the current meta-analysis, these findings lead us to conclude that a number of psychiatric and somatic disorders are associated with a history of sexual abuse. Many of these associations persist regardless of the age at which the sexual abuse occurred or the sex of the abuse survivor. Furthermore, some of the associations are strengthened by the occurrence of rape.
Several other meta-analyses have assessed the association of sexual abuse and psychiatric outcomes. Paolucci et al
19 reviewed published and unpublished research from 1981 to 1995 to assess the link between childhood sexual abuse and depression, PTSD, and suicide. The authors found a significant association between childhood sexual abuse and depression, PTSD, and suicide, even after adjustment for socioeconomic status, type of abuse, relationship to abuser, and number of abuse episodes. Other systematic reviews have focused on individual diagnoses from the
Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition). In 1995, Jumper
18 conducted a meta-analysis including adults with a history of childhood sexual abuse and demonstrated an association between childhood sexual abuse and depression. In 1999, Fossati et al
66 found no association between childhood sexual abuse and borderline personality disorder in a review of observational studies. In 2002, Smolak and Murnen
20 conducted a meta-analysis of 53 studies and described an association between childhood sexual abuse and eating disorders.
More recently, Gilbert et al
17 performed a systematic review of longitudinal studies of childhood maltreatment and mental health outcomes between 2000 and 2008. This study found an association between childhood maltreatment and depression, PTSD, and suicide attempts. However, the authors did not perform a meta-analysis specific for the association of sexual abuse and mental health outcomes.
Our study builds on the previous literature and expands on prior systematic reviews by updating and presenting the best available evidence for the association between a history of sexual abuse and psychiatric disorders most commonly encountered in general medical practice. Previous study searches were limited to fewer databases and explored reference lists, whereas we performed a comprehensive, systematic search of 9 databases. Our review was also more temporally inclusive, searching articles from 1980 to 2008. Other reviews were limited by focusing solely on childhood abuse and by including a few psychiatric diagnoses. We expanded the scope to include both childhood and adulthood sexual abuse and their association with 10 common psychiatric disorders. In addition, we performed subgroup analyses based on the victim's race, sex, and age at which abuse occurred, as well as a sensitivity analysis for rape. Also, in contrast to previous systematic reviews, we excluded cross-sectional studies from our analysis. Such studies are prone to quality-of-evidence problems, and their results cannot infer causality.
Important strengths of the current study are its comprehensive and reproducible search strategy and its exhaustive selection process. Furthermore, we attempted to decrease bias by performing data extraction in pairs of independent reviewers and by communicating with authors of original studies to obtain unpublished or incomplete data. Efforts were made to evaluate foreign-language and unpublished studies.
The main limitation of the current study is the use of data susceptible to bias. No studies met all the Newcastle-Ottawa criteria for study quality. Only 6 of 37 studies fulfilled more than half of the criteria. Among case-control studies, only Wise et al
64 provided independent validation of cases. All other studies used self-reporting from questionnaires or interviews. Notably, self-reporting in case-control studies may lead to recall bias. As an example, self-reporting of childhood sexual abuse is thought to lead to significant underreporting. Previous studies show significant variability in the percentage of documented survivors (62%-81%) who recall the abuse as adults.
67-69 The effect of underreporting would be to include survivors of sexual abuse in the control group, potentially decreasing the effect size of the association between abuse and psychiatric outcomes.
Attempts were also made to minimize publication bias by requesting unpublished data in the form of graduate-level theses and dissertations, conference abstracts, and foreign-language studies. However, no unpublished studies met eligibility criteria. Although review of funnel plots showed no obvious publication bias, the impact of such bias remains difficult to measure.
70In addition, previous research has shown that emotional, physical, and sexual abuse tend to coexist.
71,72 In the current review, only 18 of 37 studies assessed multiple categories of abuse, including physical and verbal violence. Thus, sexual abuse survivors may also have been exposed to other types of abuse, which may have affected the observed association.
No well-validated theory currently exists to explain the association between a history of sexual abuse and psychiatric outcomes. However, growing evidence supports the hypothesis of a gene-environment interaction in which genetic vulnerability alters an individual's ability to respond to stress. The serotonin transporter gene and its association with depression have been the focus of many such studies. Original work by Caspi et al
73 in a large New Zealand birth cohort demonstrated that people homozygous for the short form of the serotonin transporter gene promoter region polymorphism (
5HTTLPR) are at higher risk of depression than people with other genotypes if they experience childhood maltreatment. The study also demonstrated that people homozygous for the long form of
5HTTLPR who have a history of childhood maltreatment are at lower risk of developing depression than people with other genotypes. This result was replicated by many additional independent studies, including work by Kendler et al.
74 Kaufman et al
75 demonstrated that
5HTTLPR and brain-derived neurotrophic factor (
BDNF) gene polymorphisms interact to increase the severity of depression in children exposed to adverse events. Another study also demonstrated the interaction between
5HTTLPR and catechol O-methyltransferase (COMT) in increasing the risk of depression.
76 However, a recent meta-analysis of the
5HTTLPR genotype alone or combined with stressful life events found no association with the risk of depression,
77 indicating the challenge of drawing genetic associations in mental health research.
Evidence is emerging to support the effect of serotonin transporter (
5-HTT) gene-environment interactions on a wide range of psychiatric disorders other than depression. Recent data suggest that
5-HTT gene polymorphisms influence the development of PTSD in trauma survivors.
78,79 Polymorphisms in
5-HTT have also been implicated in the development of anxiety and somatic symptoms in victims of childhood sexual abuse.
80 These studies strengthen the traditional hypothesis that the serotonin pathway plays a common role in the development of several psychiatric disorders.
Other studies have shown that genes involved in the hypothalamic-pituitary-adrenal axis are involved in the development of psychiatric disorders such as depression and PTSD. Genetic variants in the corticotropin-releasing hormone receptor (
CRHR1) gene polymorphisms were found to both predict and protect for the development of depression in persons with a history of trauma.
81 Another study found that the FK506 binding protein (
FKBP5) polymorphisms were associated with adult PTSD symptoms in patients with a history of childhood abuse, although interestingly,
CRHR1 polymorphisms were not found to be associated with PTSD in the same population.
82As aforementioned, early evidence suggests that sexual abuse may potentiate the development of psychiatric disorders in genetically vulnerable individuals. Further research regarding this gene-environment interaction is necessary to identify which genes play a role in the development of specific psychiatric disorders and what stressful life events play a role.
Building greater awareness of the association between a history of sexual abuse and multiple psychiatric disorders will, it is hoped, lead to improved treatment and outcomes for survivors of sexual abuse. Studies have shown that survivors of sexual abuse use more medical care and incur greater costs than the general patient population. Health statistics show that abuse survivors incur 10% to 40% greater primary care costs and 13% to 43% greater total health care costs.
83-87 Greater health care use reflects increased emergency department visits; greater number of hospitalizations; and more generalist, subspecialty, and psychiatric evaluations.
85,86,88-91 Despite this increased health care use, the topic of abuse is seldom addressed between patient and physician. Only 5% of sexual abuse survivors report a history of abuse to their physicians.
92 Studies demonstrate that patients consider it appropriate for physicians to inquire about abuse history, but such questions are not routinely asked.
93Early evidence suggests that heightened awareness of the association between sexual abuse and mental health disorders may improve health outcomes for abuse survivors. Both group therapy and individual psychotherapy have been shown to improve psychological symptoms among sexual abuse survivors.
94-98 A recent systematic review found that disclosure of childhood sexual abuse during psychotherapy may improve PTSD symptoms.
99 Cognitive behavioral therapy and cognitive processing therapy have also been found to be effective in treating PTSD in survivors of sexual abuse.
100,101 Furthermore, a recently published study demonstrated the efficacy of cognitive behavioral therapy in reducing symptoms of depression, anxiety, and PTSD in sexually abused girls.
102 Given the evidence for the high prevalence of sexual abuse, its association with mental health disorders, and available psychotherapeutic options, we encourage physicians to routinely inquire about sexual abuse history in patients with psychiatric symptoms. We speculate that greater awareness of the link between sexual abuse and mental health disorders will prompt earlier and more effective treatment strategies.
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