Several studies have reported a possible relationship between chronic pelvic pain and sexual abuse suffered in childhood,1–5 and some1,3,4 suggested a connection between sexual abuse and development of chronic pelvic pain. The question arises whether sexual abuse is associated specifically with development of chronic pelvic pain or with chronic pain in general. According to Engel,6 patients with chronic pain, regardless of the location of pain, typically had childhoods characterized by an atmosphere of violence, physical and sexual abuse, and emotional neglect.
Several methodologic shortcomings of studies have been pointed out.7 Besides the problems resulting from nonuniform definitions of abuse, critical attention has focused on the choice of nonequivalent comparison groups, the neglect of other forms of abuse, and quantification issues. According to Wyatt and Peters8 and Finkelhor and Baron,9 the nature of interview settings and number of questions asked influence reported rates of sexual abuse. Finkelhor and Baron9 found that the rate of reported abuse increased with the number of questions asked, and Wyatt and Peters8 emphasized the higher reliability of confidential interviews.
The aim of the present study was to investigate the specificity of the association between sexual abuse in childhood and development of chronic pelvic pain as an adult. We investigated three groups of women, one group with chronic pelvic pain, one group with chronic low back pain, and a group with no pain complaints. The latter two groups functioned as controls. Factors measured included sexual abuse, violence in the family during childhood, and psychological abuse. Hypotheses investigated were (1) Women with chronic pelvic pain suffered significantly more sexual violence their entire lives than those with chronic low back pain or no pain. (2) Women with chronic pelvic pain suffered significantly more sexual abuse in childhood and adolescence than women with chronic low back pain or no pain. (3) Women with chronic pelvic pain had physical and psychological violence in childhood as frequently as women with chronic low back pain, but more often than pain-free subjects.
Subjects and Methods
Consecutive women who visited the outpatient unit of the Department of Gynecology of the Innsbruck University Hospital from 1996–1998 for pelvic pain were included. Inclusion criteria were pain longer than 6 months, age 18–60 years, adequate knowledge of the German language, and signed written consent. Using the same criteria, consecutive women who suffered from chronic low back pain were examined at the outpatient unit of the Department of Orthopedics. Controls comprised pain-free women who had routine check-ups from their general practitioners.
Gynecologic examination for all women with chronic pelvic pain consisted of sonography, Papanicolaou smears, chlamydia and mycoplasma smears, and laparoscopy when indicated.
Data were collected in semistructured interviews by two women trained in in-depth psychology. Interviews were rated by three psychiatrists according to severity of sexual and physical abuse and emotional neglect. Raters were masked to patients' diagnoses.
The interview covered physical violence and submission, emotional neglect and psychological abuse, guilt, and early and severe experience of loss. Physical abuse included all physical violence against a child by a person in a position of authority.10 Severe physical abuse included repeated blows with the hand without visible injuries such as bruises, and very severe physical abuse included all externally inflicted injuries resulting in tissue damage, as well as threats of severe violence with possible fatality of the child (eg, threat with a knife). Sexual abuse frequently is associated with physical violence or threat of such violence, so physical violence was rated as such only when it was not associated with sexual abuse.
According to the International Conference on Psychological Abuse of Children and Youth,7 the following eight categories comprise psychological abuse: rejecting; degrading or devaluing; terrorizing; isolating; corrupting; exploiting; denying essential stimulation, emotional responsiveness, or availability (emotional neglect); and unreliable or inconsistent parenting. Psychological abuse was assessed as severe when at least one of the factors described was constantly present.
Issues of affection and sexuality within the family were covered with 14 questions11 that ascertained in greater detail possible sexual abuse. When sexual abuse had occurred, women were asked for details on duration, frequency, age at the time of abuse, threat of violence, and age difference and relationship to the perpetrator. Childhood sexual abuse was defined as abuse that occurred before the 15th birthday.3,4 Sexual contact with peers was not defined as abuse if the contact was admitted to have been desired.
For assessment of severity of abuse, raters used Russell's criteria11: (1) least severe sexual abuse, eg, sexual touching of clothed breasts or genitals; (2) severe sexual abuse, eg, genital fondling, simulated intercourse, or digital penetration; and (3) very severe sexual abuse, eg, vaginal, oral, anal intercourse, cunnilingus, or analingus.
Beck's Depression Inventory was used to check for the influence of depression. Because symptoms of pain disorder can be confused with those of depression, we used a two-factor solution, differentiating between somatic symptoms of depression and cognitive-affective factors.12
Classification of women with reference to their social classes was according to Kleining and Moore.13 To calculate the differences between groups, we used non-parametric statistical methods (Mann-Whitney U test, between three groups Kruskal-Wallis tests). Pearson χ2 analyses, continued with binominal tests, were computed for detecting relations between variables. According to Rothman,14 no alpha adjustment was made.
A total of 86 women were enrolled, 43 in the gynecologic and 23 in the orthopedic outpatient units, and 20 in general practitioners' offices. Among women with chronic pelvic pain, two were excluded for lacking adequate knowledge of the German language, and two for missing data. Three women did not want to participate.
There were no significant differences in social class between the three groups. Women with chronic pelvic pain were significantly younger than those with chronic back pain and had been suffering from pain for a shorter time (Table 1). Laparoscopies were done in 22 women with chronic pelvic pain and in 11 of them organic causes of pain were found.
Both groups with chronic pain had nearly the same depression scores according to the Beck Depression Inventory (pelvic pain mean 10.8 ± 10.9, back pain mean 12.6 ± 9.54). Women with chronic pelvic pain had a significantly higher score than the control group of healthy subjects (controls mean 2.2 ± 2.37, Kruskal-Wallis χ2 = 20.711, degrees of freedom [df] = 2, P < .001). There was no change in the results when the cognitive and emotional symptoms of the Beck Depression Inventory were taken into consideration and the somatic factors were excluded. (pelvic pain mean 6.0 ± 6.9, back pain mean 6.6 ± 5.4; controls mean 1.6 ± 1.9, Kruskal-Wallis χ2 = 11.29, df = 2, P < .004).
With regard to sexual abuse among women with chronic pelvic pain, 13 (36%) suffered from sexual abuse at some point, eight before age 15 years (Table 2). In six of those eight women, sexual abuse was assessed as very severe according to Russell's11 criteria. Women with chronic pelvic pain did not differ from controls when sexual abuse experience in childhood and adulthood were considered together. However, significant differences emerged when the groups were compared by sexual abuse in childhood only. Compared with controls, statistically significantly more women with chronic pelvic pain suffered sexual victimization before age 15 (pelvic pain versus back pain P = .019; pelvic pain versus control P = .028).
Women from both pain groups were exposed to physical abuse in childhood with equal frequency (pelvic pain versus back pain P = .385), whereas subjects from the pain-free group were exposed to physical violence less frequently (pelvic pain versus control P = .012, back pain versus control P = .057) (Table 3). As assessed by the raters, patients in the chronic pelvic pain group had significantly more severe psychological abuse than pain-free controls (pelvic pain versus back pain P = .571, pelvic pain versus control P = .018, back pain versus control P = .084).
Because the groups differed in age and duration of pain, we compared those sexually abused and those not abused (Table 4). Among the entire group of subjects, 20 had experienced sexual abuse at some time in their lives. With regard to age and duration of pain, subjects exposed to sexual abuse did not differ from those not exposed to abuse (Table 4). Among women exposed to very severe sexual abuse, there were significant associations with severe physical violence (χ2 = 11.693, P = .002), severe psychological abuse (one-tailed Fisher exact test P < .001), and clinically manifested depression (one-tailed Fisher exact test P = .007).
Although our sample was small, the highly differentiated method used for data collection and inclusion of other forms of abuse, such as physical and emotional abuse, showed a specific association between childhood sexual abuse and development of chronic pelvic pain later in life. Our results indicated a strong association between other traumatic factors, such as physical violence, emotional neglect, and sexual abuse, in childhood for women with chronic pelvic pain. Further studies are required to examine the specific effects of different forms of childhood trauma on development of physical symptoms later in life.
Our results complement and clarify those of Walling et al3 who found a higher rate of sexual abuse over a lifetime in women with chronic pelvic pain than those with chronic headache or healthy controls. With regard to childhood sexual abuse (before age 15 years), women with chronic pelvic pain differed from those with chronic headaches but not from healthy subjects. In contrast, our results point out the effect of sexual abuse in childhood on women with chronic pelvic pain. Walling et al3 conducted telephone interviews, whereas we used face-to-face interviews. As review articles have shown,8,9 the reliability of data can be increased by a trusting interview setting, the number of questions asked, and by paying attention to the individual context in which abuse occurred.
Our study had three limitations, namely, small sample, possible overreporting of abuse experience by women with chronic pain because of their need to find an explanation for the pain, and differences in age between groups. Briere7 and Russell15 found that older women reported less sexual abuse than younger ones. They attribute that to the older women's discomfort with speaking about sexuality. In our study, age was not associated with reported abuse. Nonetheless, further studies with more subjects are necessary to determine the role of age in abuse reporting.
Laparoscopic examinations in patients with chronic pelvic pain often disclose large painful adhesions. Early sexual experiences might lead to pelvic inflammatory disease and, as a consequence, to such adhesions. However, findings such as minor endometriosis, pelvic congestion, or small adhesions often do not sufficiently explain the severity of pain. It is also necessary to consider that the frequency peak of chronic pelvic pain is found in young adults, at a time when sexuality and womanhood are particularly important. The pelvic region is associated closely with female sexuality and identity, so pelvic pain can be considered a psychologic repetition of the trauma for sexual abuse victims and pain occurs where trauma happened.16
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