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Sexual Assault and Physical Health: Findings From a Population-Based Study of Older Adults

From the Departments of Psychiatry (M.B.S.) and Family and Preventive Medicine (E.B.-C.), School of Medicine, University of California, San Diego, La Jolla; and the VA San Diego Healthcare System (M.B.S.), San Diego, California.

Address reprint requests to: Murray B. Stein, MD, Anxiety and Traumatic Stress Disorders Research Program, Department of Psychiatry (0985), University of California, San Diego, 9500 Gilman Dr., La Jolla, CA 92093-0985. Email: mstein{at}ucsd.edu

	ABSTRACT

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OBJECTIVE: Prior reports have pointed to an adverse effect of sexual assault on subsequent health, particularly depression and obesity, in women. The objective of this study was to determine whether there is an association between self-reported sexual assault history and objective parameters of physical health in a sample of older men and women.

METHODS: We conducted a cross-sectional study of white, middle to upper middle class, older (median age 75 years) men (N = 533) and women (N = 826) within a defined community setting. Sex-specific, age-adjusted risks were calculated for 11 common chronic medical conditions (10 for each sex: coronary heart disease, hypertension, diabetes, osteoporosis, obesity, asthma, migraine, thyroid disease, and arthritis in all subjects; breast cancer in women; and prostate cancer in men) and confirmed by physical or laboratory examination or review of medical records.

RESULTS: Sexual assault was reported by 5.4% of men and 12.7% of women; repeated exposure was reported by 10.3 and 21.9% of sexually assaulted men and women, respectively. In women, a history of sexual assault was associated with an increased risk of 2 of 10 conditions: arthritis (OR = 1.76, 95% CI = 1.13–2.76) and breast cancer (OR = 2.21, 95% CI = 1.12–4.33). A "dose-response" effect was observed: Multiple episodes of sexual assault carried a two- to three-fold increased risk of these diseases compared with a single episode. In men, the only statistically significant association was between sexual assault and thyroid disease (OR = 4.68, 95% CI = 1.08–20.3).

CONCLUSIONS: These data partially replicate findings from other studies of adverse effects of sexual trauma on health, although the specific diseases are different. Causal mechanisms cannot be inferred from these data. Studies in other cohorts are warranted.

Key Words: sexual assault • sexual abuse • chronic medical illness, • health • women.

Abbreviations: CI = confidence interval; OR = odds ratio.

	INTRODUCTION

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Sexual assault (most often defined as any form of unwanted sexual contact obtained by physical force or threat thereof), conservatively estimated to have affected 10 to 30% of women and 5 to 15% of men (1, 2), is associated with serious long-term mental health sequelae (3, 4). A history of childhood sexual assault, in particular, seems to confer increased risk for psychopathology of many forms, including mood and anxiety disorders, dissociative disorders, posttraumatic stress disorder, and substance use disorders (2, 5–8).

The link between sexual trauma and psychiatric illness is well established, and a similar association with physical illness is being increasingly recognized (9–11). Patients with pelvic pain (12, 13) and irritable bowel syndrome (14, 15) report increased rates of sexual abuse exposure compared with control groups. Large-scale studies of women in managed healthcare settings have found an association between history of sexual abuse and rates of pelvic pain, irritable bowel syndrome, obesity, and headaches (16, 17). Studies in other medical settings have also found increased rates of self-reported medical problems in women who have experienced sexual abuse (18–22). The studies are limited, however, by the possibility that sexual trauma leads to increased medical services utilization (21, 22), irrespective of the medical condition under consideration, thereby leading to an ascertainment bias when sampling from medical clinics.

Golding (10), studying a random sample of Los Angeles women surveyed as part of the Epidemiologic Catchment Area Study (1), reported that a history of sexual assault (ie, unwanted sexual contact) was associated with an increase in self-reported chronic diseases such as diabetes and arthritis. In a subsequent national survey, a history of childhood sexual abuse was associated with an increased rate of irritable bowel symptoms (23). Findings from population surveys demonstrating an association between a history of sexual assault and headache (24) and gynecologic symptoms (25) have also been recently reported. A cross-sectional analysis of a nationally representative sample of women veterans using Veterans Administration health services further addressed the relationship between health status and sexual assault (26). In that study, it was found that a history of sexual assault occurring while in the military was reported by 23% of women using Veterans Administration services and was associated with current physical symptoms and self-reported illnesses in every domain assessed. Thus, the population studies support the observations from clinical studies, namely that sexual assault in women is associated with greater likelihood of experiencing various classes of bodily symptoms. Consistent with these findings, women who have been sexually assaulted tend to rate their overall health status as poorer than persons without sexual assault histories (27). From the extant epidemiologic data, however, it is unclear whether objective parameters of health are similarly affected.

The present study was designed to test the hypotheses that prior sexual assault is associated with physical illness in older age, based on a community-dwelling sample of men and women. To our knowledge, this is the first community-based epidemiologic study to report objective parameters of health in both men and women in relation to sexual assault history and to do so in older adults (who are old enough to have experienced these disorders).

	MATERIALS AND METHODS

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Study Population
Between 1972 and 1974, the Rancho Bernardo Heart and Chronic Disease Study surveyed 82% of all adult residents of Rancho Bernardo, a Southern California community, for the prevalence of heart disease risk factors. Beginning in July 1992, as part of a follow-up study of osteoporosis and diabetes, all surviving members of the cohort aged 50 years were invited to come to a clinic for medical examination and interview. About 80% of surviving, locally resident community-dwelling men and women (N = 1359) participated in this visit and completed the sexual assault questionnaire. All participants provided informed, written consent.

More than 85% of participants were middle to upper middle class, based on education and occupation of head of household. At the time of the assessment reported here, the 533 men and 829 women studied were of similar age: 74.0 (SD = 8.7) and 74.6 (SD = 9.1) years, respectively. Seventy percent of subjects were married or living in a married-like situation, 3% were separated or divorced, 24% were widowed, and 3% were never married. Thirty-nine percent of participants were college graduates, 31% had some college education, 26% were high school graduates, and 3% had not completed high school.

Data Collection
Exposure.
The short, standardized, self-administered sexual assault questionnaire was completed during the clinic visit, in private, away from partners or other participants. The questionnaire items were fashioned after those used in the Los Angeles Epidemiologic Catchment Area Study (1), as follows: "In your lifetime, has anyone ever tried to pressure or force you to have unwanted sexual contact? (sexual contact: touching your sexual parts, you touching their sexual parts, or intercourse)." Subjects who responded "yes" were included in the "sexually assaulted" group and were asked whether this was a repeated or isolated event, their age when this first occurred, and whether they had ever received counseling for this experience. Blood pressure, height, weight, and fasting plasma glucose levels were also measured at this index visit.

Outcomes.
Ten specific chronic medical conditions were selected a priori on the basis of having a prevalence rate of 5% in either men or women in this cohort. The following disease categories and diagnostic criteria were used: Coronary heart disease was defined as physician diagnosis of myocardial infarction, Rose Questionnaire (angina pectoris) chest pain, or major Q wave on an electrocardiogram; hypertension was defined as systolic blood pressure 160 mm Hg, diastolic blood pressure 90 mm Hg, or use of antihypertensive medications; diabetes was defined as a physician-made diagnosis, use of diabetic medications, or fasting plasma glucose 126 mg/dl; osteoporosis was defined as a bone mineral density of 2.5 SDs below the sex-specific T score or a history of fracture not associated with major physical trauma; obesity was defined as body mass index 27 kg/m²; asthma, migraine, and arthritis were self-reported with physician evaluation in a subset; fractures, breast cancer, and prostate cancer were confirmed by medical record review; and thyroid disease was based on medication use. Medications were validated by examination of pills and prescriptions brought to the clinic for that purpose. Diseases validated by medical record review were confirmed in 85% (heart disease), 95% (fractures), or 100% (breast and prostate cancer) of cases.

Statistical Analysis
ORs with 95% CIs were calculated to examine the effects of sexual assault exposure on the prevalence of the 10 chronic medical conditions using age-adjusted, sex-specific analyses. When an association with sexual assault was detected for a particular diagnosis, a second set of ORs was calculated comparing persons reporting no sexually assault with persons reporting repeated exposure to estimate a "dose-response" effect. Because this was an exploratory study, Bonferroni correction was not used to control for multiple comparisons; instead, 95% CIs are shown. Analyses were run using PROC FREQ, PROC LOGISTIC, and/or PROC CATMOD from SAS version 6.12 for Windows.

	RESULTS

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Reporting of Sexual Abuse Experiences
The age- and sex-specific rates of reported sexual assault are shown in Table 1. Sexual assault rates were higher in women (12.7%) than men (5.4%). A total of 21.9 and 10.3% of sexually assaulted women and men, respectively, reported having been assaulted repeatedly (ie, more than once). Younger women (and, to a lesser extent, men) were more likely than older women (and men) to report being sexually assaulted (Wald ² = 8.56, df = 1, p < .003).

Sexual Assault and Lifetime Rates of Reported Medical Conditions
The prevalence and lifetime risks of 10 chronic medical conditions (coronary heart disease, hypertension, diabetes, osteoporosis, obesity, asthma, migraine, thyroid disease, and arthritis in all subjects; breast cancer in women; and prostate cancer in men) by sexual assault history are shown in Table 2. In men, a history of sexual assault was associated with a significantly increased risk of thyroid disease (age-adjusted OR = 4.68, 95% CI = 1.08–20.3) only. The number of men exposed to repeated episodes of sexual assault was too small to test for a dose-response effect.

As also shown in Table 2, women who reported being sexually assaulted had more thyroid disease and men who reported being sexually assaulted had more arthritis than their nonassaulted same-sex peers. Thus, the observed differences were consistent, but not statistically significant, in the opposite sex. In other analyses, controlling for gender only, hypertension was significantly less common in sexually assaulted persons. Results were not materially changed in analyses controlling for reported alcohol use and cigarette smoking (rate not shown). Selective survival would also not explain the results because abused persons would not be expected to survive longer with diseases. More than 97% of subjects were followed for vital statistics between 1992 and 1996, with no survival differences by abuse history status.

	DISCUSSION

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The prevalence of sexual assault in this cohort, approximately 5% in men and 13% in women, is similar to that reported in other epidemiologic surveys (1–2). Prevalence rates of the common medical conditions included in this study are also consistent with rates reported in other elderly cohorts (29).

Past sexual assault has been reported to have multiple detrimental effects on the health of women (10–27). In the present study, a history of sexual assault was associated with an increased risk of arthritis and breast cancer in women and thyroid disease in men. The increased risk for arthritis and thyroid disease was seen in both sexes, albeit statistically significant in only one sex, making it less likely that these associations are spurious. More women than men reported multiple episodes of sexual assault, and risks were higher in women who reported multiple episodes.

These associations are impressive in that they were still present in an older adult population, in which it could have been expected that the effects of accruing years, morbidity, and mortality might have obscured any effect of remote sexual abuse on health. The possibility that these associations would have been even stronger if persons whose health was adversely affected were selectively lost due to illness and death is suggested by the decreasing prevalence of reported abuse with increasing age in women. Because the study cohort was well educated and economically advantaged, it is unlikely that effects attributed to abuse were due to the confounding effects of low socioeconomic status on health. In the present study, 98% of subjects had seen a physician at least once in the previous year, making it unlikely that our finding are due to diagnostic detection bias related to access to health care.

Sexual assault, defined here as any unwanted sexual contact, was assessed by self-report using a simple "yes/no" question. One might argue that this method of reporting probably includes more and less severe events (eg, unwanted touching vs. repeated rape). Although some of the exposures could have been "trivial" compared with others, all were recalled by respondents an average of 50 years later; they were thus not trivial to the people reporting them.

Our study, like all studies that have examined the association between prior assault and present health, is based on self-reports of assault history. Misclassification due to underreporting (or to lumping together abuse of varying degrees of severity, as described above) would be expected to weaken the magnitude of the observed associations. More detailed indices of traumatization that take into account frequency and severity of abuse, as well as assess other forms of interpersonal violence, might offer greater explanatory value in terms of health prediction (30–32) and should be used in future studies. Furthermore, although we had insufficient statistical power to determine whether being assaulted within a certain age group (ie, childhood, adolescence, or adulthood) is associated with greater risks for disease, this should be investigated.

Subsequent to the completion of our study, some evidence emerged that the association between adverse health outcomes and emotional trauma may be largely explained by the latter’s association with posttraumatic stress disorder (33, 34). We did not assess posttraumatic stress disorder in our study and are therefore unable to test this hypothesis. Once again, it is recommended that this be considered in future studies. Methodological limitations may have influenced some of our findings. The statistically significant association between thyroid disease and sexual abuse in men but not women may stem from the less specific diagnosis of thyroid disease in women compared with men in Rancho Bernardo (35, 36). One in five women were taking a thyroid hormone, suggesting overdiagnosis and presumptive treatment of malaise, "tiredness," or weight gain (36). Misclassification of thyroid disease among women could have obscured a true association with sexual assault. The failure to find a statistically significant association in men between sexual assault and arthritis may reflect the much smaller number of men (16%) than women (26%) who had arthritis in this sample. Finally, the lower rate of sexual assault in men (compared with women) may have constrained our statistical power to detect associations with physical health in men.

Although these results are consistent with those of prior studies reporting adverse effects of sexual abuse on the health of women, the patterns of association with specific illnesses would not all have been predicted on the basis of previous studies. For example, others have reported an association with obesity or headaches not seen here (16, 17, 19, 22). These differences may reflect the older age of the Rancho Bernardo cohort or their higher socioeconomic status and lower prevalence of obesity. Findings of an increase in breast cancer risk, although not entirely unexpected given the modest association between stress and breast cancer reported in the literature (37), would not have been predicted on the basis of prior studies in sexual assault victims and needs to replicated. Furthermore, the observation of reduced risk for hypertension in the combined cohort of men and women was not at all expected. This finding, in particular, raises the possibility of a survivor bias that might have obscured increased risk for other medical conditions that increase mortality (eg, coronary artery disease, hypertension, and diabetes). This possibility must be addressed in future research.

The possibility of a response bias, in which sexually assaulted respondents might overreport illness, must also be considered. In the Rancho Bernardo study, however, the majority of illnesses were confirmed by physical or laboratory examination or medical record review. For example, all cases of breast cancer were confirmed by record review and/or pathology report. Although this makes it less likely that systematic overreporting of illnesses by sexually assaulted subjects explains the observed associations, it does not exclude the possibility that previously assaulted respondents more often visited doctors, leading to increased opportunities for these diseases to be detected.

The disorders found to be associated with sexual assault in this study do not readily suggest a common pathogenesis. It remains to be established from future research to what extent, and through what mechanism(s) (eg, increases in corticotropin releasing factor, centrally mediated effects on cytokines, or other stress-related hormonal alterations) (38–40), sexual assault is associated with adverse effects on health.

In summary, past sexual assault was associated with an increased risk of breast cancer, arthritis, and thyroid disease in this cohort of older adults. Other studies, using more detailed assessment of the characteristics of the sexual assault (eg, severity, duration) in combination with measurement of "stress markers" such as cytokines, are needed to replicate these findings. If the disease excess in old age noted here reflects remote sexual traumatization with persistent biological consequences, then the potential reduction in this additional burden of illness can be added to the list of societal benefits of preventing sexual assault. It remains to be seen to what extent the systematic assessment of past sexual assault and the provision of counseling will improve the health of persons who were sexually assaulted years ago. In light of the recent demonstration of the impressive health benefits of even a simple psychological intervention in patients with chronic illness (ie, writing about a very stressful experience) (41), the impact of similar interventions on the health of sexual trauma survivors should be systematically evaluated.

	ACKNOWLEDGMENTS

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The authors are grateful to Ricki Bettencourt and Deborah Morton for their assistance with data management and statistical analysis. This research was supported in part by the National Institute of Diabetes, Digestive, and Kidney Diseases (Grant DK-31801) and the National Institute of Aging (Grant AG-07181).

Received for publication February 17, 2000.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Stein, M. B. Articles by Barrett-Connor, E. Search for Related Content PubMed PubMed Citation Articles by Stein, M. B. Articles by Barrett-Connor, E. Related Collections Other Epidemiology General Sexual Medicine Issues