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Review | Clinician's Corner

Sexual Abuse and Lifetime Diagnosis of Somatic Disorders:  A Systematic Review and Meta-analysis FREE

Molly L. Paras, BS; Mohammad Hassan Murad, MD; Laura P. Chen, BS; Erin N. Goranson, BS; Amelia L. Sattler, BS; Kristina M. Colbenson, BS; Mohamed B. Elamin, MBBS; Richard J. Seime, PhD; Larry J. Prokop, MLS; Ali Zirakzadeh, MD
[+] Author Affiliations

Author Affiliations: Mayo Clinic College of Medicine (Mss Paras, Chen, Goranson, Sattler, and Colbenson); Division of Preventive Medicine (Dr Murad) and Knowledge and Encounter Research Unit (Drs Murad and Elamin); Department of Psychiatry and Psychology (Dr Seime); Mayo Clinic Libraries (Mr Prokop); and Department of General Internal Medicine (Dr Zirakzadeh), Mayo Clinic, Rochester, Minnesota.


JAMA. 2009;302(5):550-561. doi:10.1001/jama.2009.1091.
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Published online

Context Many patients presenting for general medical care have a history of sexual abuse. The literature suggests an association between a history of sexual abuse and somatic sequelae.

Objective To systematically assess the association between sexual abuse and a lifetime diagnosis of somatic disorders.

Data Sources and Extraction A systematic literature search of electronic databases from January 1980 to December 2008. Pairs of reviewers extracted descriptive, quality, and outcome data from included studies. Odds ratios (ORs) and 95% confidence intervals (CIs) were pooled across studies by using the random-effects model. The I2 statistic was used to assess heterogeneity.

Study Selection Eligible studies were longitudinal (case-control and cohort) and reported somatic outcomes in persons with and without history of sexual abuse.

Results The search identified 23 eligible studies describing 4640 subjects. There was a significant association between a history of sexual abuse and lifetime diagnosis of functional gastrointestinal disorders (OR, 2.43; 95% CI, 1.36-4.31; I2 = 82%; 5 studies), nonspecific chronic pain (OR, 2.20; 95% CI, 1.54-3.15; 1 study), psychogenic seizures (OR, 2.96; 95% CI, 1.12-4.69, I2 = 0%; 3 studies), and chronic pelvic pain (OR, 2.73; 95% CI, 1.73-4.30, I2 = 40%; 10 studies). There was no statistically significant association between sexual abuse and a lifetime diagnosis of fibromyalgia (OR, 1.61; 95% CI, 0.85-3.07, I2 = 0%; 4 studies), obesity (OR, 1.47; 95% CI, 0.88-2.46; I2 = 71%; 2 studies), or headache (OR, 1.49; 95% CI, 0.96-2.31; 1 study). We found no studies that assessed syncope. When analysis was restricted to studies in which sexual abuse was defined as rape, significant associations were observed between rape and a lifetime diagnosis of fibromyalgia (OR, 3.35; 95% CI, 1.51-7.46), chronic pelvic pain (OR, 3.27; 95% CI, 1.02-10.53), and functional gastrointestinal disorders (OR, 4.01; 95% CI, 1.88-8.57).

Conclusion Evidence suggests a history of sexual abuse is associated with lifetime diagnosis of multiple somatic disorders.

Figures in this Article

Many patients seen for general medical care have a history of sexual abuse. In the United States, national population surveys have found the annual incidence of sexual violence to be 2.5% for women and 0.9% for men.1 Additionally, it is estimated that 1 in 15 adults has experienced forced sexual intercourse.1 Retrospective studies have also demonstrated a high prevalence of adult survivors of childhood sexual abuse: 16% of men and 25% of women in the United States.2 Estimates of the prevalence of rape range from 7%-21% for adults and 5%-17% for children.37 These statistics are likely underestimates because the event is frequently underreported.8,9

To date, research on the long-term effects of sexual abuse has primarily focused on mental health outcomes. Strong evidence supports a link between childhood sexual abuse and multiple psychiatric sequelae.10,11 However, studies investigating the association between sexual abuse and somatic outcomes have been less definitive. Initial inquiries date back to the late 1970s, when the link between sexual abuse and “hysterical seizures” was investigated.12 Additional studies evaluating the association of sexual abuse with chronic pelvic pain13,14 and chronic pain15,16 followed in the 1980s. Over time, disorders including fibromyalgia,1719 functional gastrointestinal disorders,5,20,21 and obesity21 have been assessed for their association with sexual abuse.

Epidemiologic studies demonstrate that such disorders are commonly encountered by physicians across a broad spectrum of medical practice. Fibromyalgia occurs in approximately 5% of patients seen in general practices.22,23 Functional gastrointestinal disorders are also highly prevalent, with estimates of 5% to 25% for irritable bowel syndrome in the general population.24,25 As such, physicians are commonly faced with the diagnosis and management of these disorders.

Although several studies have attempted to investigate associations between patient history of sexual abuse and development of somatic disorders, to our knowledge no systematic review has been performed to evaluate the strength of these associations. The objective of this study was to systematically assess and summarize the available evidence regarding the association between a history of sexual abuse and lifetime diagnosis of somatic disorders.

The protocol for this systematic review was developed and executed by physicians and researchers in the disciplines of internal medicine, preventive medicine, epidemiology, statistics, and psychology. The methods described by the Cochrane Collaboration were used in the development of the protocol.26 The reporting of results was based on the recommendations of the Meta-analysis of Observational Studies in Epidemiology group.27

Data Sources and Search Strategies

A comprehensive search of several databases (from January 1980 to December 2008, all age groups, any language, any population), including MEDLINE, EMBASE, CINAHL, Current Contents, PsycINFO, American College of Physicians Journal Club, Cochrane Controlled Trials Registry, Cochrane Database of Systematic Reviews, and Database of Abstracts and Reviews of Effectiveness, was conducted. The search strategy was designed and performed by an experienced librarian (L.J.P.), with input from the study's principal investigator. Controlled vocabulary supplemented with keywords was used to define the concept areas, sexual abuse, and physical/psychological disorders, as well as to limit epidemiologic studies. The complete strategy is available on request from the author.

Study Selection

Eligible studies were longitudinal case-control and cohort studies. Studies were included regardless of publication status, sample size, length of follow-up, or language of publication.

Sexual abuse was categorized into 2 major groups: rape and all forms of sexual abuse. Quiz Ref IDRape was defined as penetration with a body part or foreign object (intravaginal or anal).28All forms of sexual abuse was designed to be broad to capture the wide variety of definitions used to characterize sexual violence. These other forms included, but were not limited to, noncontact exposure of genitals, threatening sexual violence, and contact involving genitals and mouth.28 If a study did not specify that the form of sexual abuse was rape, then it was classified as all forms of sexual abuse.

For studies in which abuse was not further specified, authors were contacted to provide data for that subset of patients with a history of sexual abuse. If studies included data for sexually abused, nonabused, and physically abused individuals, the latter groups were pooled as controls. This practice was adopted to reduce the confounding effect of physical abuse on the outcome as studies have shown childhood physical abuse prevalence rates ranging between 3.8% and 20.6% in the general population.2931

As per protocol, the outcomes investigated in this study were functional gastrointestinal disorders, chronic headache, psychogenic seizure disorder (also called nonepileptic seizure or pseudoseizure), non-neurocardiogenic syncope, fibromyalgia, obesity, chronic pain syndrome, and chronic pelvic pain syndrome. Eligible studies contained an outcome and a nonoutcome group, designated by self-report or clinical identification.

Data Extraction

Teams of reviewers (M.L.P., L.P.C., E.N.G., A.L.S., K.M.C., A.Z.) working independently and in pairs analyzed eligible titles, abstracts, and full-text articles. Data from included studies were extracted in duplicate. Articles in foreign languages (Chinese [1], Czech [1], French [10], German [18], Hungarian [1], Italian [4], Spanish [8], and Turkish [2]) were translated or the author was contacted when available to provide required information.

A description of the type of study and its participants was obtained, including mean age of subjects, sex, and race. If greater than 70% of the study population was of one race, then the study was designated as evaluating that race predominantly. If not further specified, research studies based in Scandinavian countries were assumed to enroll predominantly white participants. The type of sexual abuse (either rape or all forms of sexual abuse) was recorded, along with the age at the abuse. Childhood abuse was defined as abuse occurring at or before age 18 years. Raw data for the exposed, nonexposed, outcome, and nonoutcome groups were obtained when possible. If numbers were not available, then odds ratios (ORs) were recorded, with preference given to adjusted ORs. Authors of eligible articles not presenting raw data or ORs were contacted by e-mail or letters. Authors were requested to provide data required for the analysis that were not printed in the published article.

Quality Assessment

The quality of each eligible study was assessed in duplicate. Disagreements were resolved by mediation, with input from the principal investigator. The Newcastle-Ottawa Quality Assessment Scale was used for case-control studies and cohort studies.32 This scale consists of 8 questions, with a maximum of 10 possible points for each type of study.

Statistical Analysis

Odds ratios were pooled for dichotomous outcomes from each study with the DerSimonian-Laird random-effects model. The 95% confidence interval (CI) for each outcome was estimated to reflect the uncertainty of point estimates.33

An OR of 1.0 indicates no association and OR greater than 1.0 indicates increased risk for the referenced outcome. The I2 statistic was used to estimate the percentage of total variation across studies because of heterogeneity, rather than chance (ie, the percentage of variability of associations across studies that is not due to chance or random error, but rather due to real differences in study patients, design, or outcome definitions).34 I2 values of less than or equal to 25%, 50%, and greater than or equal to 75% represent low, moderate, and high inconsistency, respectively. Statistical analysis was conducted with Comprehensive Meta-Analysis, version 2 (Englewood, New Jersey). P<.05 was set as the threshold for significance.35

Subgroup and Sensitivity Analyses

A priori hypotheses were formed to explore subgroup interactions and explain inconsistency in the direction and magnitude of associations among studies. These included study design (cohort design vs case-control design), the age at which sexual abuse took place (childhood vs adult), sex of the abused person, and race of the abused subject. To test the hypotheses of a subgroup effect, a test of interaction with a predetermined 2-tailed α of .05 was used.36 Meta-regression was used to assess whether study quality affects the strength of reported associations. In the regression model, the natural logarithm of the OR represents the dependent variable and the quality score represents the independent variable.

A sensitivity analysis was planned to determine whether the type of abuse (rape vs all forms of sexual abuse) affects study conclusions.

Publication Bias

To assess the potential effect of publication bias, we planned to inspect funnel plots for asymmetry and use the Duval and Tweedie trim and fill method37 and the Begg and Mazumdar rank correlation test.38

A total of 23 studies met the inclusion criteria and provided data for 4640 subjects (Figure 1). Nineteen of the included studies were case-control design (2778 individuals) and 4 were cohort design (1862 individuals). Sixteen included only female subjects and the remainder evaluated both sexes. Four investigated populations composed of a majority of white subjects, whereas the remaining sample populations were mixed or not specified in terms of race. A total of 11 studies took place in nations outside of the United States. No foreign-language study met inclusion criteria, and no unpublished study met eligibility criteria.

Place holder to copy figure label and caption
Figure 1. Study Selection Process
Graphic Jump Location

The literature review included search for articles with psychiatric outcomes reported elsewhere.

Seven of the studies investigated sexual abuse occurring only in childhood. None of the studies examined abuse only in adulthood. Seven included data for both childhood and adulthood abuse. The remaining studies did not specify the age at which abuse occurred. The included case-control studies ascertained sexual abuse exposure by using self-reporting in questionnaires (11 studies) and interviews (8 studies). Cohort studies confirmed histories of sexual abuse by using legal documentation (3 studies) and interviews (1 study).

Four studies provided data for individuals who had experienced rape. The remaining studies collected data from persons who reported exposure to all forms of sexual abuse. Nineteen of the 23 studies provided definitions used to assess sexual abuse. These included the following: threatening sexual attacks, sexual coercion, unwanted exposure of perpetrator's genitalia, unwanted touching of abused individual's genitals or other sexual parts, and unwanted or forced touching of perpetrator's genitals or other sexual parts. The details of the baseline characteristics of each study are listed in Table 1.

Table Graphic Jump LocationTable 1. Studies Included in Meta-analysis

Each study was assessed for quality according to the population and sampling methods, description of exposure and outcomes, and statistical adjustment of the data (Table 2 and Table 3). Only 5 of 23 studies matched abuse survivors and controls by 2 factors or adjusted for 2 or more confounders simultaneously in their multiple regression models. Among case-control studies, only 13 of 19 studies obtained controls from the same population as cases. Furthermore, only 10 of 19 case-control studies were considered to use rigorous selection criteria of cases (during defined period, throughout defined area, all cases or random/consecutive cases in a defined group).

Table Graphic Jump LocationTable 2. Quality Assessment of Reviewed Case-Control Studiesa
Table Graphic Jump LocationTable 3. Quality Assessment of Reviewed Cohort Studiesa
Meta-analyses

Quiz Ref IDThere was a significant association between a history of sexual abuse and a lifetime diagnosis of functional gastrointestinal disorders (OR, 2.43; 95% CI, 1.36-4.31; I2 = 82%; 5 studies), nonspecific chronic pain (OR, 2.20; 95% CI, 1.54-3.15; I2 = not available; 1 study), psychogenic seizures (OR, 2.96; 95% CI, 1.12-4.69; I2 = 0%; 3 studies), and chronic pelvic pain (OR, 2.73; 95% CI, 1.73-4.30; I2 = 40%; 10 studies).

There was no statistically significant association between a history of sexual abuse and a lifetime diagnosis of fibromyalgia (OR 1.61; 95% CI, 0.85-3.07; I2 = 0%; 4 studies), obesity (OR, 1.47; 95% CI, 0.88-2.46; I2 = 71%; 2 studies), or headache (OR, 1.49; 95% CI, 0.96-2.31; I2 = not available; 1 study). We found no longitudinal studies that assessed the outcome of syncope. The results of meta-analyses are depicted in Figure 2.

Place holder to copy figure label and caption
Figure 2. Odds Ratio for the Association of Sexual Abuse and Somatic Disorders
Graphic Jump Location

CI indicates confidence interval; GI, gastrointestinal.
aNo event total available.

Subgroup Analyses

We found no significant subgroup × strength of association interactions according to the age of abuse (childhood vs adulthood). Only for the outcome of obesity did we find a significant interaction suggesting higher association in studies with case-control design compared with cohort design. This interaction (design × strength of association) was not found for other outcomes. There were insufficient data to conduct subgroup analyses based on the sex or the race of the abused individual. Subgroup analyses are summarized in Table 4. Meta-regression did not reveal a statistically significant association between the quality score and the effect size (P > .05 for all outcomes).

Sensitivity Analysis

To determine the effect of sexual abuse category on the estimated association, we conducted a sensitivity analysis, including only those studies that defined sexual abuse as rape (Figure 3). A significant association was found between a history of rape and a lifetime diagnosis of fibromyalgia (OR, 3.35; 95% CI, 1.51-7.46; I2 = not available; 2 studies), functional gastrointestinal disorders (OR, 4.01; 95% CI, 1.88-8.57; I2 = not available; 1 study), and chronic pelvic pain (OR, 3.27; 95% CI, 1.02-10.53; I2 = not available; 1 study). There were insufficient data to conduct this sensitivity analysis for the other outcomes.

Place holder to copy figure label and caption
Figure 3. Odds Ratio for the Association of Rape With Somatic Disorders
Graphic Jump Location

CI indicates confidence interval; GI, gastrointestinal.

Publication Bias

Inspection of funnel plots and statistical tests for publication bias did not show an obvious effect of publication bias. However, these analyses were underpowered because of the small number of included studies.

We performed a comprehensive systematic review of the literature and meta-analysis to assess the association between sexual abuse and the lifetime prevalence of several somatic disorders. This review found that sexual abuse was associated with a lifetime diagnosis of nonspecific chronic pain, functional gastrointestinal disorders, psychogenic seizures, and chronic pelvic pain. There was no statistically significant association between a history of sexual abuse and the lifetime diagnosis of fibromyalgia, obesity, or headache. No data were available to assess the outcome of syncope. When analysis was restricted to studies in which sexual abuse was defined as rape, significant associations were observed between rape and the lifetime diagnosis of fibromyalgia, chronic pelvic pain, and functional gastrointestinal disorders.

In studies evaluating obesity, case-control studies demonstrated a greater association compared with cohort studies. This observation may be due to type I error or chance. Alternatively, this observation may reflect recall bias in studies of case-control design.

To our knowledge, this is the first attempt to summarize the available data on the association between patient history of sexual abuse and somatic outcomes. Quiz Ref IDPrevious systematic reviews empirically evaluating childhood sexual abuse outcomes have revealed increased psychiatric outcomes, behavior problems, victim-perpetrator cycle, and adult maladjustment.10,11,58 Our systematic review builds on this work by expanding it to include somatic sequelae.

Study Strengths and Limitations

Significant strengths of this study include the exhaustive and reproducible search strategy, attempts to decrease bias by performing selection, review and extraction of data in pairs of reviewers, and communication with authors of original studies to ascertain unpublished or incomplete data. Furthermore, efforts were made to evaluate foreign-language and unpublished studies. Subgroup and sensitivity analyses were conducted to explain heterogeneity.

The principal limitation of this study was the use of evidence susceptible to bias. No studies met all of the Newcastle-Ottawa criteria for quality. Only 2 of 23 studies met at least 8 of the 10 maximum allowed points of the criteria. Analysis with meta-regression did not demonstrate an association between study quality (total number of points for each study) and effect size. This lack of association is consistent with previous literature that revealed that summary scores of clinical trials' quality do not correlate with treatment effect.59 We did not detect publication bias; however, our analysis was underpowered because of the small number of included studies.60 Also, unexplained heterogeneity was demonstrated in analyses of the outcomes of functional gastrointestinal orders and obesity. Imprecision caused by the small number of events could have masked a real association between sexual abuse and the outcomes of obesity, headache, and fibromyalgia. In addition, the associations reported in this review could be overstated because of the use of ORs to estimate the risk of a common event.61 Therefore, the overall level of evidence found by this review may be reduced by methodological limitations, heterogeneity, and imprecision.62

Also, our results may not generalize to men. Sixteen of the 23 studies in this review were restricted to female subjects, whereas no study evaluated male subjects exclusively. These findings may reflect the higher prevalence rates of sexual abuse against females; however, sexual abuse is known to affect males. Further research investigating males would be worthwhile to determine whether similar sequelae also tend to affect male individuals or whether this sex is prone to develop different sets of outcomes.

Another potential limitation of this study is recall bias. Although 3 of the 4 cohort studies obtained data on sexual abuse exposure from medical or legal documentation, all case-control studies relied on self-reporting from either questionnaires or interviews. However, use of questionnaires or interviews to ascertain exposure may be problematic. Previous studies have found notable variability in the percentage of documented survivors of childhood sexual abuse (62%-81%) who recall the abuse as adults.6365 These statistics indicate that questionnaire respondents or interview subjects likely underreport childhood sexual abuse. The effect of this underreporting would be the inclusion of sexual abuse survivors in control groups. This in turn may diminish the effect size of the association between sexual abuse and somatic outcomes.

As an additional point, research shows that emotional, physical, and sexual abuse tend to coexist.29,30 However, only a minority of studies ascertained whether subjects had been exposed to 1 or multiple categories of abuse. To better define outcomes specifically associated with sexual abuse, we recommend that research studies work to better clarify the type of abuse to which patients have been exposed.

Potential Mechanisms and Implications

To our knowledge, there is no validated theory to explain the association between sexual abuse and chronic somatic disorders. Sexual abuse, however, may be an early, inciting environmental factor in a multistep process that culminates in physical dysfunction. Furthermore, neuroendocrine maladaptation may be important to this progression. Animal studies have revealed that early life stress is associated with dysregulation of the hypothalamic pituitary axis.66,67 Hypothalamic-pituitary axis dysregulation has also been measured in women with a history of childhood sexual abuse who experience depression and anxiety. Similar findings of hypothalamic-pituitary axis dysregulation were observed in combat veterans with posttraumatic stress disorder.68,69 Evidence also suggests that neuroendocrine changes caused by stress, including dysregulation of corticotropin-releasing factor, may result in neurologic and behavioral changes.7072 Similar dysregulation of corticotropin-releasing factor has been demonstrated in laboratory animals with colonic dysmotility.7274 However, the role of hypothalamic-pituitary axis dysregulation in chronic pelvic pain and fibromyalgia remains controversial.46,7577 We speculate that the neuroendocrine system mediates the connection between sexual abuse and the development of somatic dysfunction.

Building greater awareness of the association between sexual abuse and somatic disorders may lead to improved health care delivery and outcomes for sexual abuse survivors. Quiz Ref IDAs a group, survivors of abuse have higher medical care use and incur greater costs compared with the general patient population.21,7881 Analysis of expenditures demonstrates that costs are primarily the result of increased use of primary care, specialty medicine, and pharmacy and laboratory services.82,83 Higher medical use may also expose these patients to greater risk without clearly defined benefits, including increased abdominal and pelvic surgeries, adverse effects of medications, and chronic opioid use and dependence.8489

Despite evidence of high health care use among sexual abuse survivors, physicians remain largely unaware of this aspect of their patients' medical history. Only 5% of sexual abuse survivors report a history of abuse to their physician.5 However, heightened awareness of these specific health associations may prompt earlier recognition and improve care for sexual abuse survivors. Quiz Ref IDOne systematic review found that disclosure of childhood sexual abuse memories during psychotherapy may improve posttraumatic stress disorder symptoms, decrease depression, and alleviate anxiety.78 Also, cognitive behavioral therapy and cognitive processing therapy have been found effective in treating posttraumatic stress disorder in survivors of sexual abuse.90,91 We hypothesize that similar therapeutic approaches may be feasible for sexual abuse survivors with somatic sequelae.92 Given evidence of sexual abuse prevalence and related physical and mental health sequelae, we urge physicians to more routinely conduct inquiries about sexual abuse in patients with the identified somatic syndromes. Disclosure of abuse in the clinic setting may allow for earlier consultation with mental health professionals. Prompt recognition of the physical and psychological sequelae of sexual abuse may halt unnecessary medical escalation and provide care better suited to promote recovery.

This review highlights the need for future research to better define the nature and scope of mental and physical health outcomes in sexual abuse survivors. As with previous reviews of sexual abuse and psychiatric sequelae, we were unable to more fully ascertain specific mediators of chronic somatic illness, such as duration of abuse, sex of the victim, and socioeconomic factors (eg, family income, single-parent upbringing, parental alcohol use). To more precisely define the temporal relationship between sexual abuse and somatic outcomes, further studies will be necessary. We recommend a prospective cohort study to evaluate somatic outcomes in survivors of abuse, with focused attention on the potential mediators and modifiers of the associations. This design would also be predicted to better address concerns of potential bias in the literature. Additionally, the premise that disclosure of abuse during psychotherapy improves psychiatric symptoms opens the door to clinical trials to assess the utility of abuse disclosure in the treatment of somatic sequelae. Finally, the success of cognitive behavioral therapy treatment of posttraumatic stress disorder for sexual abuse survivors points to a possible role for this modality for abuse survivors with somatic sequelae.

Sexual abuse remains prevalent and survivors are commonly encountered in general medical practice. Increasingly, it has been shown that survivors of sexual abuse face a spectrum of often challenging health concerns, resulting in greater health care use and cost and significant morbidity. This systematic review and meta-analysis demonstrates an association between sexual abuse and lifetime diagnosis of functional gastrointestinal disorders, chronic nonspecific pain, psychogenic nonepileptic seizure disorder, and chronic pelvic pain. Recognition of this association may have important clinical implications for patients coping with these disorders and their clinicians. Future research should be conducted to better define the epidemiology of this association and improve clinical outcomes for sexual abuse survivors with somatic sequelae.

Corresponding Author: Ali Zirakzadeh, MD, Mayo Clinic Department of General Internal Medicine, 200 First St SW, Rochester, MN 55906 (zirakzadeh.ali@mayo.edu).

Author Contributions: Dr Zirakzadeh had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Paras, Murad, Chen, Colbenson, Elamin, Seime, Zirakzadeh.

Acquisition of data: Paras, Chen, Goranson, Sattler, Colbenson, Prokop, Zirakzadeh.

Analysis and interpretation of data: Paras, Murad, Chen, Elamin, Seime, Zirakzadeh.

Drafting of the manuscript: Paras, Murad, Chen, Prokop, Seime, Zirakzadeh.

Critical revision of the manuscript for important intellectual content: Paras, Murad, Chen, Goranson, Sattler, Colbenson, Elamin, Seime, Zirakzadeh.

Statistical analysis: Murad, Elamin, Zirakzadeh.

Administrative, technical, or material support: Paras, Murad, Chen, Elamin, Zirakzadeh.

Study supervision: Elamin, Seime, Zirakzadeh.

Financial Disclosures: None reported.

Additional Contributions: We thank the Mayo Clinic library staff for their assistance in obtaining the many manuscripts needed to complete this study and also Anne Safley, MD, of University of Iowa Hospitals and Clinics for critical review of the manuscript. We would also like to extend our gratitude to Mary-Ann Fitzcharles, MB, ChB, and Sarah Romans, MD, who returned original data on request.

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Sachs-Ericsson N, Kendall-Tackett K, Hernandez A. Childhood abuse, chronic pain, and depression in the National Comorbidity Survey.  Child Abuse Negl. 2007;31(5):531-547
PubMed   |  Link to Article
Wells GASB, O'Connell D, Peterson J,  et al.  The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. http://www.ohri.ca/programs/clinical_epidemiology/oxford.htm. Accessed June 9, 2009
DerSimonian R, Laird N. Meta-analysis in clinical trials.  Control Clin Trials. 1986;7(3):177-188
PubMed   |  Link to Article
Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses.  BMJ. 2003;327(7414):557-560
PubMed   |  Link to Article
 Comprehensive Meta-Analysis [computer program]. Version 2. Englewood, NJ: Biostat Inc; 2005
Altman DG, Bland JM. Interaction revisited: the difference between two estimates.  BMJ. 2003;326(7382):219
PubMed   |  Link to Article
Duval S, Tweedie R. Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis.  Biometrics. 2000;56(2):455-463
PubMed   |  Link to Article
Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias.  Biometrics. 1994;50(4):1088-1101
PubMed   |  Link to Article
Ciccone DS, Elliott DK, Chandler HK, Nayak S, Raphael KG. Sexual and physical abuse in women with fibromyalgia syndrome: a test of the trauma hypothesis.  Clin J Pain. 2005;21(5):378-386
PubMed   |  Link to Article
Collett BJ, Cordle CJ, Stewart CR, Jagger C. A comparative study of women with chronic pelvic pain, chronic nonpelvic pain and those with no history of pain attending general practitioners.  Br J Obstet Gynaecol. 1998;105(1):87-92
PubMed   |  Link to Article
Delvaux M, Denis P, Allemand H.French Club of Digestive Motility.  Sexual abuse is more frequently reported by IBS patients than by patients with organic digestive diseases or controls.  Eur J Gastroenterol Hepatol. 1997;9(4):345-352
PubMed   |  Link to Article
Dhanaraj M, Rangaraj R, Arulmozhi T, Vengatesan A. Nonepileptic attack disorder among married women.  Neurol India. 2005;53(2):174-177
PubMed   |  Link to Article
Dikel TN, Fennell EB, Gilmore RL. Posttraumatic stress disorder, dissociation, and sexual abuse history in epileptic and nonepileptic seizure patients.  Epilepsy Behav. 2003;4(6):644-650
PubMed   |  Link to Article
Ehlert U, Heim C, Hellhammer D. Chronic pelvic pain as a somatoform disorder.  Psychother Psychosom. 1999;68(2):87-94
PubMed   |  Link to Article
Felitti VJ. Childhood sexual abuse, depression, and family dysfunction in adult obese patients: a case control study.  South Med J. 1993;86(7):732-736
PubMed   |  Link to Article
Heim C, Ehlert U, Hanker JP, Hellhammer DH. Abuse-related posttraumatic stress disorder and alterations of the hypothalamic-pituitary-adrenal axis in women with chronic pelvic pain.  Psychosom Med. 1998;60(3):309-318
PubMed
Koloski NA, Talley NJ, Boyce PM. A history of abuse in community subjects with irritable bowel syndrome and functional dyspepsia: the role of other psychosocial variables.  Digestion. 2005;72(2-3):86-96
PubMed   |  Link to Article
Lampe A, Solder E, Ennemoser A,  et al.  Chronic pelvic pain and previous sexual abuse.  Obstet Gynecol. 2000;96(6):929-933
PubMed   |  Link to Article
Lampe A, Doering S, Rumpold G,  et al.  Chronic pain syndromes and their relation to childhood abuse and stressful life events.  J Psychosom Res. 2003;54(4):361-367
PubMed   |  Link to Article
Rapkin AJ, Kames LD, Darke LL,  et al.  History of physical and sexual abuse in women with chronic pelvic pain.  Obstet Gynecol. 1990;76(1):92-96
PubMed
Reinhard MJ. The Long Term Neuropsychiatric Effects of Early TraumaMalibu, CA: Pepperdine University; 2004
Salmon P, Al-Marzooqi SM, Baker G, Reilly J. Childhood family dysfunction and associated abuse in patients with nonepileptic seizures: towards a causal model.  Psychosom Med. 2003;65(4):695-700
PubMed   |  Link to Article
Walker EA, Katon WJ, Hansom J,  et al.  Psychiatric diagnoses and sexual victimization in women with chronic pelvic pain.  Psychosomatics. 1995;36(6):531-540
PubMed   |  Link to Article
Walker EA, Keegan D, Gardner G,  et al.  Psychosocial factors in fibromyalgia compared with rheumatoid arthritis, II: sexual, physical, and emotional abuse and neglect.  Psychosom Med. 1997;59(6):572-577
PubMed
Noll JG, Zeller MH, Trickett PK, Putnam FW. Obesity risk for female victims of childhood sexual abuse: a prospective study.  Pediatrics. 2007;120(1):e61-e67
PubMed   |  Link to Article
Raphael KG, Widom CS, Lange G. Childhood victimization and pain in adulthood: a prospective investigation.  Pain. 2001;92(1-2):283-293
PubMed   |  Link to Article
Romans S, Belaise C, Martin J, Morris E, Raffi A. Childhood abuse and later medical disorders in women: an epidemiological study.  Psychother Psychosom. 2002;71(3):141-150
PubMed   |  Link to Article
Sachs-Ericsson N, Cromer K, Hernandez A, Kendall-Tackett K. A review of childhood abuse, health, and pain-related problems: the role of psychiatric disorders and current life stress.  J Trauma Dissociation. 2009;10(2):170-188
PubMed   |  Link to Article
Juni P, Witschi A, Bloch R, Egger M. The hazards of scoring the quality of clinical trials for meta-analysis.  JAMA. 1999;282(11):1054-1060
PubMed   |  Link to Article
Lau J, Ioannidis JPA, Terrin N,  et al.  The case of the misleading funnel plot.  BMJ. 2006;333(7568):597-600
PubMed   |  Link to Article
Zhang J, Yu KF. What's the relative risk? a method of correcting the odds ratio in cohort studies of common outcomes.  JAMA. 1998;280(19):1690-1691
PubMed   |  Link to Article
Murad MH, Swiglo BA, Sidawy AN, Ascher E, Montori VM. Methodology for clinical practice guidelines for the management of arteriovenous access.  J Vasc Surg. 2008;48(5):(suppl)  26S-30S
PubMed   |  Link to Article
Widom CS, Morris S. Accuracy of adult recollections of childhood victimization, part 2: childhood sexual abuse.  Psychol Assess. 1997;9(1):34-46
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Williams LM. Recall of childhood trauma: a prospective study of women's memories of child sexual abuse.  J Consult Clin Psychol. 1994;62(6):1167-1176
PubMed   |  Link to Article
Goodman GS, Ghetti S, Quas JA,  et al.  A prospective study of memory for child sexual abuse: new findings relevant to the repressed-memory controversy.  Psychol Sci. 2003;14(2):113-118
PubMed   |  Link to Article
Plotsky PM, Meaney MJ. Early, postnatal experience alters hypothalamic corticotropin-releasing factor (CRF) mRNA, median eminence CRF content and stress-induced release in adult rats.  Brain Res Mol Brain Res. 1993;18(3):195-200
PubMed   |  Link to Article
Nemeroff CB. The preeminent role of early untoward experience on vulnerability to major psychiatric disorders: the nature-nurture controversy revisited and soon to be resolved.  Mol Psychiatry. 1999;4(2):106-108
PubMed   |  Link to Article
Heim C, Newport DJ, Heit S,  et al.  Pituitary-adrenal and autonomic responses to stress in women after sexual and physical abuse in childhood.  JAMA. 2000;284(5):592-597
PubMed   |  Link to Article
Bremner JD, Licinio J, Darnell A,  et al.  Elevated CSF corticotropin-releasing factor concentrations in posttraumatic stress disorder.  Am J Psychiatry. 1997;154(5):624-629
PubMed
Lowry CA, Moore FL. Regulation of behavioral responses by corticotropin-releasing factor.  Gen Comp Endocrinol. 2006;146(1):19-27
PubMed   |  Link to Article
McEuen JG, Beck SG, Bale TL. Failure to mount adaptive responses to stress results in dysregulation and cell death in the midbrain raphe.  J Neurosci. 2008;28(33):8169-8177
PubMed   |  Link to Article
Million M, Wang L, Stenzel-Poore MP,  et al.  Enhanced pelvic responses to stressors in female CRF-overexpressing mice.  Am J Physiol Regul Integr Comp Physiol. 2007;292(4):R1429-R1438
PubMed   |  Link to Article
Martinez V, Wang L, Rivier J,  et al.  Central CRF, urocortins and stress increase colonic transit via CRF1 receptors while activation of CRF2 receptors delays gastric transit in mice.  J Physiol. 2004;556(pt 1):221-234
PubMed   |  Link to Article
Maillot C, Million M, Wei JY, Gauthier A, Tache Y. Peripheral corticotropin-releasing factor and stress-stimulated colonic motor activity involve type 1 receptor in rats.  Gastroenterology. 2000;119(6):1569-1579
PubMed   |  Link to Article
Wingenfeld K, Heim C, Schmidt I, Wagner D, Meinlschmidt G, Hellhammer DH. HPA axis reactivity and lymphocyte glucocorticoid sensitivity in fibromyalgia syndrome and chronic pelvic pain.  Psychosom Med. 2008;70(1):65-72
PubMed   |  Link to Article
Wingenfeld K, Wagner D, Schmidt I, Meinlschmidt G, Hellhammer DH, Heim C. The low-dose dexamethasone suppression test in fibromyalgia.  J Psychosom Res. 2007;62(1):85-91
PubMed   |  Link to Article
Griep EN, Boersma JW, Lentjes EG, Prins AP, van der Korst JK, de Kloet ER. Function of the hypothalamic-pituitary-adrenal axis in patients with fibromyalgia and low back pain.  J Rheumatol. 1998;25(7):1374-1381
PubMed
Bradley RG, Follingstad DR. Utilizing disclosure in the treatment of the sequelae of childhood sexual abuse: a theoretical and empirical review.  Clin Psychol Rev. 2001;21(1):1-32
PubMed   |  Link to Article
Hulme PA. Symptomatology and health care utilization of women primary care patients who experienced childhood sexual abuse.  Child Abuse Negl. 2000;24(11):1471-1484
PubMed   |  Link to Article
Tang B, Jamieson E, Boyle M,  et al.  The influence of child abuse on the pattern of expenditures in women's adult health service utilization in Ontario, Canada.  Soc Sci Med. 2006;63(7):1711-1719
PubMed   |  Link to Article
Walker EA, Unutzer J, Rutter C,  et al.  Costs of health care use by women HMO members with a history of childhood abuse and neglect.  Arch Gen Psychiatry. 1999;56(7):609-613
PubMed   |  Link to Article
Suris A, Lind L, Kashner TM, Borman PD, Petty F. Sexual assault in women veterans: an examination of PTSD risk, health care utilization, and cost of care.  Psychosom Med. 2004;66(5):749-756
PubMed   |  Link to Article
Bonomi AE, Anderson ML, Rivara FP,  et al.  Health care utilization and costs associated with childhood abuse.  J Gen Intern Med. 2008;23(3):294-299
PubMed   |  Link to Article
Reiter RC, Gambone JC. Demographic and historic variables in women with idiopathic chronic pelvic pain.  Obstet Gynecol. 1990;75(3 pt 1):428-432
PubMed
Hasler WL, Schoenfeld P. Systematic review: abdominal and pelvic surgery in patients with irritable bowel syndrome.  Aliment Pharmacol Ther. 2003;17(8):997-1005
PubMed   |  Link to Article
Longstreth GF, Yao JF. Irritable bowel syndrome and surgery: a multivariable analysis.  Gastroenterology. 2004;126(7):1665-1673
PubMed   |  Link to Article
Thompson CA. Novartis suspends tegaserod sales at FDA's request.  Am J Health Syst Pharm. 2007;64(10):1020
PubMed   |  Link to Article
Fishbain DA, Cole B, Lewis J, Rosomoff HL, Rosomoff RS. What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? a structured evidence-based review.  Pain Med. 2008;9(4):444-459
PubMed   |  Link to Article
Chelminski PR, Ives TJ, Felix KM,  et al.  A primary care, multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden of psychiatric comorbidity.  BMC Health Serv Res. 2005;5(1):3
PubMed   |  Link to Article
Resick PA, Nishith P, Griffin MG. How well does cognitive-behavioral therapy treat symptoms of complex PTSD? an examination of child sexual abuse survivors within a clinical trial.  CNS Spectr. 2003;8(5):340-355
PubMed
Resick PA, Nishith P, Weaver TL, Astin MC, Feuer CA. A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims.  J Consult Clin Psychol. 2002;70(4):867-879
PubMed   |  Link to Article
Pennebaker JW. Traumatic experience and psychosomatic disease: exploring the roles of behavioral inhibition, obsession, and confiding.  Can Psychol. 1985;26:82-95
Link to Article

Figures

Place holder to copy figure label and caption
Figure 1. Study Selection Process
Graphic Jump Location

The literature review included search for articles with psychiatric outcomes reported elsewhere.

Place holder to copy figure label and caption
Figure 2. Odds Ratio for the Association of Sexual Abuse and Somatic Disorders
Graphic Jump Location

CI indicates confidence interval; GI, gastrointestinal.
aNo event total available.

Place holder to copy figure label and caption
Figure 3. Odds Ratio for the Association of Rape With Somatic Disorders
Graphic Jump Location

CI indicates confidence interval; GI, gastrointestinal.

Tables

Table Graphic Jump LocationTable 1. Studies Included in Meta-analysis
Table Graphic Jump LocationTable 2. Quality Assessment of Reviewed Case-Control Studiesa
Table Graphic Jump LocationTable 3. Quality Assessment of Reviewed Cohort Studiesa

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Edwards VJ, Holden GW, Felitti VJ, Anda RF. Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents.  Am J Psychiatry. 2003;160(8):1453-1460
PubMed   |  Link to Article
Sachs-Ericsson N, Kendall-Tackett K, Hernandez A. Childhood abuse, chronic pain, and depression in the National Comorbidity Survey.  Child Abuse Negl. 2007;31(5):531-547
PubMed   |  Link to Article
Wells GASB, O'Connell D, Peterson J,  et al.  The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. http://www.ohri.ca/programs/clinical_epidemiology/oxford.htm. Accessed June 9, 2009
DerSimonian R, Laird N. Meta-analysis in clinical trials.  Control Clin Trials. 1986;7(3):177-188
PubMed   |  Link to Article
Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses.  BMJ. 2003;327(7414):557-560
PubMed   |  Link to Article
 Comprehensive Meta-Analysis [computer program]. Version 2. Englewood, NJ: Biostat Inc; 2005
Altman DG, Bland JM. Interaction revisited: the difference between two estimates.  BMJ. 2003;326(7382):219
PubMed   |  Link to Article
Duval S, Tweedie R. Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis.  Biometrics. 2000;56(2):455-463
PubMed   |  Link to Article
Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias.  Biometrics. 1994;50(4):1088-1101
PubMed   |  Link to Article
Ciccone DS, Elliott DK, Chandler HK, Nayak S, Raphael KG. Sexual and physical abuse in women with fibromyalgia syndrome: a test of the trauma hypothesis.  Clin J Pain. 2005;21(5):378-386
PubMed   |  Link to Article
Collett BJ, Cordle CJ, Stewart CR, Jagger C. A comparative study of women with chronic pelvic pain, chronic nonpelvic pain and those with no history of pain attending general practitioners.  Br J Obstet Gynaecol. 1998;105(1):87-92
PubMed   |  Link to Article
Delvaux M, Denis P, Allemand H.French Club of Digestive Motility.  Sexual abuse is more frequently reported by IBS patients than by patients with organic digestive diseases or controls.  Eur J Gastroenterol Hepatol. 1997;9(4):345-352
PubMed   |  Link to Article
Dhanaraj M, Rangaraj R, Arulmozhi T, Vengatesan A. Nonepileptic attack disorder among married women.  Neurol India. 2005;53(2):174-177
PubMed   |  Link to Article
Dikel TN, Fennell EB, Gilmore RL. Posttraumatic stress disorder, dissociation, and sexual abuse history in epileptic and nonepileptic seizure patients.  Epilepsy Behav. 2003;4(6):644-650
PubMed   |  Link to Article
Ehlert U, Heim C, Hellhammer D. Chronic pelvic pain as a somatoform disorder.  Psychother Psychosom. 1999;68(2):87-94
PubMed   |  Link to Article
Felitti VJ. Childhood sexual abuse, depression, and family dysfunction in adult obese patients: a case control study.  South Med J. 1993;86(7):732-736
PubMed   |  Link to Article
Heim C, Ehlert U, Hanker JP, Hellhammer DH. Abuse-related posttraumatic stress disorder and alterations of the hypothalamic-pituitary-adrenal axis in women with chronic pelvic pain.  Psychosom Med. 1998;60(3):309-318
PubMed
Koloski NA, Talley NJ, Boyce PM. A history of abuse in community subjects with irritable bowel syndrome and functional dyspepsia: the role of other psychosocial variables.  Digestion. 2005;72(2-3):86-96
PubMed   |  Link to Article
Lampe A, Solder E, Ennemoser A,  et al.  Chronic pelvic pain and previous sexual abuse.  Obstet Gynecol. 2000;96(6):929-933
PubMed   |  Link to Article
Lampe A, Doering S, Rumpold G,  et al.  Chronic pain syndromes and their relation to childhood abuse and stressful life events.  J Psychosom Res. 2003;54(4):361-367
PubMed   |  Link to Article
Rapkin AJ, Kames LD, Darke LL,  et al.  History of physical and sexual abuse in women with chronic pelvic pain.  Obstet Gynecol. 1990;76(1):92-96
PubMed
Reinhard MJ. The Long Term Neuropsychiatric Effects of Early TraumaMalibu, CA: Pepperdine University; 2004
Salmon P, Al-Marzooqi SM, Baker G, Reilly J. Childhood family dysfunction and associated abuse in patients with nonepileptic seizures: towards a causal model.  Psychosom Med. 2003;65(4):695-700
PubMed   |  Link to Article
Walker EA, Katon WJ, Hansom J,  et al.  Psychiatric diagnoses and sexual victimization in women with chronic pelvic pain.  Psychosomatics. 1995;36(6):531-540
PubMed   |  Link to Article
Walker EA, Keegan D, Gardner G,  et al.  Psychosocial factors in fibromyalgia compared with rheumatoid arthritis, II: sexual, physical, and emotional abuse and neglect.  Psychosom Med. 1997;59(6):572-577
PubMed
Noll JG, Zeller MH, Trickett PK, Putnam FW. Obesity risk for female victims of childhood sexual abuse: a prospective study.  Pediatrics. 2007;120(1):e61-e67
PubMed   |  Link to Article
Raphael KG, Widom CS, Lange G. Childhood victimization and pain in adulthood: a prospective investigation.  Pain. 2001;92(1-2):283-293
PubMed   |  Link to Article
Romans S, Belaise C, Martin J, Morris E, Raffi A. Childhood abuse and later medical disorders in women: an epidemiological study.  Psychother Psychosom. 2002;71(3):141-150
PubMed   |  Link to Article
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