The sexual abuse of Afro-American and white-American women in childhood

Does childhood sexual abuse have an effect on young adults' nicotine disorder (dependence or withdrawal)? Evidence from a birth cohort study

AIMS

To examine whether there is evidence of an independent association between childhood sexual abuse (CSA) and nicotine disorder in youth and to explore the mechanisms underlying this association in a prospective cohort study.

DESIGN

Birth cohort study followed-up to 21 years.

SETTING

One of two major obstetric hospitals in Brisbane, Australia.

PARTICIPANTS

The Mater-University of Queensland Study of Pregnancy involves a prospective birth cohort from a population-based sample involving 7223 singletons whose mothers were enrolled between 1981 and 1984 at the first antenatal visit. The present cohort consisted of a subgroup of 2571 youth who completed the life-time version of the Composite International Diagnostic Interview--computerized version (CIDI-Auto) at the 21-year follow-up.

MEASUREMENTS

Nicotine disorder was measured based on Diagnostic and Statistical Manual version IV (DSM-IV) diagnostic criteria and measures of CSA, including retrospective self-reports of rape, were obtained at 21 years. Results Of 2571 young adults, 16.6% met the criteria for either dependence (12.8%) or withdrawal (8.5%). Non-penetrative sexual abuse was reported by 15.5% of respondents and 8.0% reported penetrative sexual abuse. For any types of sexual abuse including non-penetrative, penetrative and self-reported rape before age 16 years, young adults had significantly higher rates of nicotine disorder than young adults who did not experience CSA. This relationship was independent and appeared direct after adjustment for a range of potential confounding and mediating factors.

CONCLUSIONS

This study shows that CSA is associated with young adult nicotine disorder. The results extend the public health significance of findings in this area and highlight the importance of not only intensifying public health efforts to address substance use problems among those who have experienced CSA, but of early intervention, so that emerging risky behaviours may be targeted in the earliest stages.

Association of childhood sexual abuse with obesity in a community sample of lesbians

OBJECTIVE

Our goal was to examine the association between childhood sexual abuse (CSA) and obesity in a community-based sample of self-identified lesbians.

RESEARCH METHODS AND PROCEDURES

A diverse sample of women who self-identified as lesbian was recruited from the greater Chicago metropolitan area. Women (n=416) were interviewed about sexual abuse experiences that occurred before the age of 18. Self-reported height and weight were used to calculate BMI and categorize women as normal-weight (<25.0 kg/m2), overweight (25.0 to 29.9 kg/m2), obese (30.0 to 39.9 kg/m2), or severely obese (>or=40 kg/m2). The relationship between CSA and BMI was examined using multinomial logistic regression analysis.

RESULTS

Overall, 31% of women in the sample reported CSA, and 57% had BMI>or=25.0 kg/m2. Mean BMI was 27.8 (+/-7.2) kg/m2 and was significantly higher among women who reported CSA than among those who did not report CSA (29.4 vs. 27.1, p<0.01). CSA was significantly related to weight status; 39% of women who reported CSA compared with 25% of women who did not report CSA were obese (p=0.004). After adjusting for age, race/ethnicity, and education, women who reported CSA were more likely to be obese (odds ratio, 1.9; 95% confidence interval, 1.1-3.4) or severely obese (odds ratio, 2.3; 95% confidence interval, 1.1-5.2).

DISCUSSION

Our findings, in conjunction with the available literature, suggest that CSA may be an important risk factor for obesity. Understanding CSA as a factor that may contribute to weight gain or act as a barrier to weight loss or maintenance in lesbians, a high-risk group for both CSA and obesity, is important for developing successful obesity interventions for this group of women.

Self-reported information and pharmacy claims were comparable for lipid-lowering medication exposure

OBJECTIVE

To examine agreement between self-reported exposure to lipid-lowering medications and objective evidence of filling prescribed lipid-lowering medications.

STUDY DESIGN AND SETTING

Using data from 7,918 adults from the Adverse Childhood Experiences (ACE) Study, we calculated the sensitivity, specificity, and positive (PV+) and negative (PV-) predictive values, and likelihood ratios for self-reported exposure to lipid-lowering medications compared to exposure obtained from pharmacy claims (gold standard) both overall and by age, sex, race/ethnicity, education, and ACE Score.

RESULTS

Eight percent (n=655) of adults self-reported lipid-lowering medication exposure, and 379 adults filled at least one lipid-lowering prescription within 60 days of the baseline exam during 1997. The sensitivity of self-reported exposure was nearly 94%; the specificity was 96%; the PV+ was 54%; and the PV- was nearly 100%. Values for sensitivity, specificity, PV+, and PV- were similar across participant characteristics.

CONCLUSION

A self-reported measure of lipid-lowering medication exposure was accurate with high sensitivity and specificity while the PV+ of self-reported lipid-lowering medication exposure was relatively low. These findings suggest that self-reported exposure to lipid-lowering medications may be useful in surveys that examine the prevalence of hyperlipidemia, but may overestimate actual exposure in studies monitoring trends in use of lipid-lowering medications.

Childhood sexual abuse among Black women and White women from two-parent families

Differences in childhood sexual abuse (CSA) between Black women and White women are explored in a community sample of 290 women raised in two-parent families.A self-administered questionnaire and a face-to-face interview assessed CSA characteristics, aftermath, and prevalence as well as family structure and other childhood variables. Siblings served as collateral informants for the occurrence of CSA. Overall, comparisons of the nature, severity, and aftermath of CSA showed similarities by race; some differences, for example, in age of onset, are potentially relevant for the planning of prevention programs. Logistic regression models examined effects of childhood variables on CSA prevalence. Initial analyses showed a higher CSA prevalence among Black women (34.1% [45] of Black women vs. 22.8% [36] of White women) that was attenuated when family structure (e.g., living with two biological parents throughout childhood or not) and social class were considered. Of interest, differences in family structure remained important even among these two-parent families. Understanding the dynamics of abuse by race and family structure will facilitate the design of more targeted CSA prevention programs.

Influence of childhood sexual abuse on pregnancy, delivery, and the early postpartum period in adult women

OBJECTIVE

With a prevalence of around 20%, childhood sexual abuse (CSA) is a relevant problem in obstetric care. The aim of our systematic review was to present the current knowledge on the influence of CSA on pregnancy, delivery, and early parenthood.

DATA SOURCES

All English, French, or German primary and secondary literature from the reference lists found after screening the data banks Pubmed, PsycInfo, and Psyndex for publications that include the terms CSA or childhood traumatization and pregnancy, birth, delivery, labor, childbearing, breast feeding, or postpartum, and published after 1970 were reviewed for relevant data.

METHODS OF STUDY SELECTION

Investigations of psychological/medical data banks and cross references revealed 43 relevant studies. Given the paucity of data on this important subject, we opted to review all of these studies.

TABULATION, INTEGRATION, AND RESULTS

Although research projects on this topic are rare and the methodological quality of studies published to date is generally poor, women with a history of CSA seem to present a variety of long-term sequelae referring to pregnancy, delivery, and early parenthood. These sequelae include risk behaviors during pregnancy and disturbance of delivery by sudden memories of sexual abuse situations. Prenatal care is often complicated by the tendency to avoid situations that can trigger memories.

CONCLUSIONS

As effective treatment programs to improve sequelae of CSA are available today, the question of such abuse experiences should be raised as early as possible and adequate interdisciplinary models to care for victimized patients should be established. However, to improve knowledge on the long-term effect of sexual abuse experiences in obstetrical care, methodologically well-designed research projects focusing on the kind and incidence of sequelae, mediating factors as well as prophylactic and therapeutic options are needed.

Adverse childhood experiences and the association with ever using alcohol and initiating alcohol use during adolescence

PURPOSE

Alcohol is the most common and frequently used drug and has the potential to cause multiple deleterious effects throughout the lifespan. Because early age at initiation of alcohol use increases this potential and programs and laws are in place to attempt to delay the onset of alcohol use, we studied the relationship between multiple adverse childhood experiences (ACEs) and both the likelihood of ever drinking and the age at initiating alcohol use.

METHODS

This was a retrospective cohort study of 8417 adult health maintenance organization (HMO) members in California who completed a survey about ACEs, which included childhood abuse and neglect, growing up with various forms of household dysfunction and alcohol use in adolescence and adulthood. The main outcomes measured were ever drinking and age at initiating alcohol use among ever-drinkers for four age categories: < or = 14 years (early adolescence), 15 to 17 years (mid adolescence), and 18 to 20 years (late adolescence); age > or = 21 years was the referent. The relationship between the total number of adverse childhood experiences (ACE score) and early initiation of alcohol use (< or =14 years) among four birth cohorts dating back to 1900 was also examined.

RESULTS

Eighty-nine percent of the cohort reported ever drinking; all individual ACEs except physical neglect increased the risk of ever using alcohol (p < .05). Among ever drinkers, initiating alcohol use by age 14 years was increased two- to threefold by individual ACEs (p < .05). ACEs also accounted for a 20% to 70% increased likelihood of alcohol use initiated during mid adolescence (15-17 years). The total number of ACEs (ACE score) had a very strong graded relationship to initiating alcohol use during early adolescence and a robust but somewhat less strong relationship to initiation during mid adolescence. For each of the four birth cohorts, the ACE score had a strong, graded relationship to initiating alcohol use by age 14 years (p < .05).

CONCLUSIONS

Adverse childhood experiences are strongly related to ever drinking alcohol and to alcohol initiation in early and mid adolescence, and the ACE score had a graded or "dose-response" relationship to these alcohol use behaviors. The persistent graded relationship between the ACE score and initiation of alcohol use by age 14 for four successive birth cohorts dating back to 1900 suggests that the stressful effects of ACEs transcend secular changes, including the increased availability of alcohol, alcohol advertising, and the recent campaigns and health education programs to prevent alcohol use. These findings strongly suggest that efforts to delay the age of onset of drinking must recognize the contribution of multiple traumatic and stressful events to alcohol-seeking behavior among children and adolescents.

The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology

BACKGROUND

Childhood maltreatment has been linked to a variety of changes in brain structure and function and stress-responsive neurobiological systems. Epidemiological studies have documented the impact of childhood maltreatment on health and emotional well-being.

METHODS

After a brief review of the neurobiology of childhood trauma, we use the Adverse Childhood Experiences (ACE) Study as an epidemiological "case example" of the convergence between epidemiologic and neurobiological evidence of the effects of childhood trauma. The ACE Study included 17,337 adult HMO members and assessed 8 adverse childhood experiences (ACEs) including abuse, witnessing domestic violence, and serious household dysfunction. We used the number of ACEs (ACE score) as a measure of cumulative childhood stress and hypothesized a "dose-response" relationship of the ACE score to 18 selected outcomes and to the total number of these outcomes (comorbidity).

RESULTS

Based upon logistic regression analysis, the risk of every outcome in the affective, somatic, substance abuse, memory, sexual,and aggression-related domains increased in a graded fashion as the ACE score increased (P <0.001). The mean number of comorbid outcomes tripled across the range of the ACE score.

CONCLUSIONS

The graded relationship of the ACE score to 18 different outcomes in multiple domains theoretically parallels the cumulative exposure of the developing brain to the stress response with resulting impairment in multiple brain structures and functions.

Cross-Sectional Predictors of Sexual Assault Perpetration in a Community Sample of Single African American and Caucasian Men

Computer-assisted self-interviews were completed with a random sample of 163 unmarried Caucasian and African American men in a large metropolitan area. Almost a quarter (24.5%) of these men acknowledged committing an act since the age of 14 that met standard legal definitions of attempted or completed rape; an additional 39% had committed another type of sexual assault involving forced sexual contact or verbal coercion. An expanded version of the Malamuth et al. [1991] confluence model was examined using path analysis. The number of sexual assaults perpetrated by participants was associated with the direct or indirect effects of childhood sexual abuse, adolescent delinquency, alcohol problems, sexual dominance, positive attitudes about casual sexual relationships, and pressure from peers to engage in sexual relationships. Additionally, empathy buffered the relationship between sexual dominance and perpetration. The pattern of results was highly similar for African American and Caucasian men. The implications of these findings for sexual assault measurement are discussed and suggestions are made for alternative treatment programs.

Predictors of mental health services use among lesbian and heterosexual women

Studies examining mental health services have identified a series of indicators with demonstrated effects on services access, barriers, and utilization, including gender, race/ethnicity, and socioeconomic status, as well as indicators such as type of insurance, client attitudes toward mental health, and diagnosis. This study identifies predictors of mental health services utilization in a diverse community sample of lesbians and heterosexual women (N=120). Outcomes for study participants are compared to those found in the services utilization literature, and similarities and differences among lesbians and heterosexual women are examined. Suggestions are offered for identifying new factors in mental health service utilization among groups with diverse sexual orientations.

Ethnic differences in symptom presentation of sexually abused girls

Although researchers have begun to examine the issue of ethnic and cultural factors in childhood sexual abuse (CSA), relatively little has been done to look at possible ethnic and cultural differences in psychological symptoms related to CSA. This study investigated the relationship between ethnicity and symptom presentation among Hispanic, African American, and Caucasian sexually abused girls. The study examined the relationship between ethnicity and depression, ethnicity and post-trauma intrusive symptoms, and ethnicity and post-trauma avoidance symptoms. Results indicated that African American girls had significantly higher levels of post-trauma avoidance symptoms than Hispanic girls, but not Caucasian girls. No significant differences were found between ethnic groups for depression or intrusive symptoms.

Intergenerational transmission of sexual abuse? Motherhood in the shadow of incest

The aim of the study was to understand why the dynamic of sexual abuse is perpetuated across successive generations. A qualitative analysis was conducted on therapy session transcripts and diaries written during the therapy of 24 mothers who were survivors of incest, and whose children were the victims of incest. Four types of mothers were defined: the Unaware mother, characterized by a complete lack of cognitive knowledge of the sexual abuse occurring in her home; the Unwitting Accomplice, characterized by latent cooperation with the sexual abuse perpetrated by her husband; the Enabler, characterized by overtly or covertly encouraging her spouse in the raping of her daughter; and the Common Fate mother, characterized by sharing a common fate with her daughters.

The experience of abuse and mental health in the young Thai population A preliminary survey

OBJECTIVES

The aims of this study were to examine the prevalence of child abuse exposure among Thai people in a suburban community and to describe the association of abuse experiences with common mental disorders (CMD), alcohol use disorders and substance use.

METHODS

A population-based cross-sectional survey was conducted in Northern Bangkok on a representative sample of 202 young residents, aged 16-25 years.

RESULTS

Thirty eight percent of the respondents reported experiencing some form of abuse during childhood, with 5.8% having been subjected to sexual penetration, 11.7% having been physically abused and 31.8% emotionally abused. A graded relationship was found between the extent of exposure to abuse during childhood and mental problems. After controlling for potential confounders, CMD remained significantly associated with emotional abuse, and alcohol use disorders remained associated with sexual abuse. Strong but non-significant trends were present for associations between CMD and sexual abuse and all forms of abuse with substance use.

CONCLUSION

Child abuse experiences were common among the respondents. Childhood abuse, particularly sexual abuse, has a potentially devastating impact on adult mental health.

Victimization over the life span: a comparison of lesbian, gay, bisexual, and heterosexual siblings

Lifetime victimization was examined in a primarily European American sample that comprised 557 lesbian/gay, 163 bisexual, and 525 heterosexual adults. Lesbian, gay, and bisexual (LGB) participants were recruited via LGB e-mail lists, periodicals, and organizations; these participants recruited 1 or more siblings for participation in the study (81% heterosexual, 19% LGB). In hierarchical linear modeling analyses, sexual orientation was a significant predictor of most of the victimization variables. Compared with heterosexual participants, LGB participants reported more childhood psychological and physical abuse by parents or caretakers, more childhood sexual abuse, more partner psychological and physical victimization in adulthood, and more sexual assault experiences in adulthood. Sexual orientation differences in sexual victimization were greater among men than among women.

Relationship between emotional numbing and arousal symptoms in American women of Japanese descent who experienced interpersonal victimization

In recent years, studies of veterans and others who experienced various types of trauma have found a strong relationship between emotional numbing and arousal symptoms, challenging the current DSM-IV diagnostic criteria, which combines emotional numbing and avoidance symptoms in a single criterion. In this paper, we investigate emotional numbing symptoms in a community-based random sample of women of Japanese descent who had experienced interpersonal victimization, such as childhood abuse, intimate partner violence, and violence perpetrated by non-intimates (n = 202). Controlling for age, place of birth, and timing and severity of victimization, emotional numbing symptom counts were associated more strongly with arousal than avoidance symptoms, consistent with previous studies of veterans and assaulted women. In addition, emotional numbing symptom counts were significantly associated with age and, to a lesser degree, country of birth. Implications for research and practice are discussed.

Adverse childhood experiences and hallucinations

OBJECTIVE

Little information is available about the contribution of multiple adverse childhood experiences (ACEs) to the likelihood of reporting hallucinations. We used data from the ACE study to assess this relationship.

METHODS

We conducted a survey about childhood abuse and household dysfunction while growing up, with questions about health behaviors and outcomes in adulthood, which was completed by 17,337 adult HMO members in order to assess the independent relationship of 8 adverse childhood experiences and the total number of ACEs (ACE score) to experiencing hallucinations. We used logistic regression to assess the relationship of the ACE score to self-reported hallucinations.

RESULTS

We found a statistically significant and graded relationship between histories of childhood trauma and histories of hallucinations that was independent of a history of substance abuse. Compared to persons with 0 ACEs, those with 7 or more ACEs had a five-fold increase in the risk of reporting hallucinations.

CONCLUSION

These findings suggest that a history of childhood trauma should be looked for among persons with a history of hallucinations.

Predicting long-term outcomes for women sexually abused in childhood: contribution of abuse severity versus family environment

OBJECTIVE

Child sexual abuse (CSA) has been associated with adverse adult psychosocial outcomes, although some reports describe minimal long-term effects. The search for explanations for the heterogeneous outcomes in women with CSA has led to an examination of a range of CSA-related factors, from the severity of individual CSA incidents to the childhood family environment. This study compares three factors for predicting adult outcomes: a multidimensional CSA Severity Scale, the presence or absence of CSA, and family environment.

METHODS

The effect of CSA on adult outcomes was examined among 290 community-dwelling women raised in intact families. Standardized measures and a focused interview were used to collect data, with siblings as collateral informants.

RESULTS

Comparison of a multidimensional CSA Severity Scale to a dichotomous measure of the presence or absence of CSA showed that the Severity Scale did not have greater predictive value for adult outcomes than the dichotomous measure, nor was it as parsimonious. Childhood family environment scales added significantly to the predictive ability of the dichotomous measure.

CONCLUSION

The specific characteristics of a CSA experience may be less important than the occurrence of CSA and the family environment of women for predicting long-term outcomes.

Does a History of Childhood Sexual Abuse Affect Sexual Outcomes in Breast Cancer Survivors?

Purpose

Little is known about a history of childhood sexual abuse (CSA) in breast cancer survivors and its relationship to sexual functioning after cancer. As part of a larger survey study examining sexuality and intimacy in breast cancer survivors, we conducted in-person interviews with a subsample of participants.

Methods

A total of 147 women in Los Angeles, CA, and Washington, DC, completed a structured interview that addressed sexual socialization and a history of sexual abuse. Trained female interviewers conducted the interviews. Descriptive statistics and regression analyses were used to examine the prevalence of CSA, and its potential impact on sexual health and functioning.

Results

One in three women reported at least one CSA incident. Among women who had experienced CSA, 71% reported a single incident, and 22% reported a penetrative form of sexual contact. In multivariate regression analyses examining physical and psychological aspects of sexuality and body image, CSA was not a significant predictor of physical discomfort. However, a history of penetrative CSA was a significant predictor of psychological discomfort (P = .02).

Conclusion

The prevalence of CSA in this sample was similar to the general population literature on this topic. In this small sample, a past history of CSA did not contribute significantly to the physical discomforts associated with sexual intimacy after breast cancer; however, our findings suggest that a past history of penetrative CSA is associated with increased psychological discomfort, and may warrant additional examination in future research.

Epidemiology of multiple childhood traumatic events: child abuse, parental psychopathology, and other family-level stressors

BACKGROUND

Multiple family-level childhood stressors are common and are correlated. It is unknown if clusters of commonly co-occurring stressors are identifiable. The study was designed to explore family-level stressor clustering in the general population, to estimate the prevalence of exposure classes, and to examine the correlation of sociodemographic characteristics with class prevalence.

METHOD

Data were collected from an epidemiological sample and analyzed using latent class regression.

RESULTS

A six-class solution was identified. Classes were characterized by low risk (prevalence=23%), universal high risk (7 %), family conflict (11 %), household substance problems (22 %), non-nuclear family structure (24 %), parent's mental illness (13 %).

CONCLUSIONS

Class prevalence varied with race and welfare status, not gender. Interventions for childhood stressors are person-focused; the analytic approach may uniquely inform resource allocation.

Adverse childhood experiences and the risk of depressive disorders in adulthood

BACKGROUND

Research examining the association between childhood abuse and depressive disorders has frequently assessed abuse categorically, thus not permitting discernment of the cumulative impact of multiple types of abuse. As previous research has documented that adverse childhood experiences (ACEs) are highly interrelated, we examined the association between the number of such experiences (ACE score) and the risk of depressive disorders.

METHODS

Retrospective cohort study of 9460 adult health maintenance organization members in a primary care clinic in San Diego, CA who completed a survey addressing a variety of health-related concerns, which included standardized assessments of lifetime and recent depressive disorders, childhood abuse and household dysfunction.

RESULTS

Lifetime prevalence of depressive disorders was 23%. Childhood emotional abuse increased risk for lifetime depressive disorders, with adjusted odds ratios (ORs) of 2.7 [95% confidence interval (CI), 2.3-3.2] in women and 2.5 (95% CI, 1.9-3.2) in men. We found a strong, dose-response relationship between the ACE score and the probability of lifetime and recent depressive disorders (P<0.0001). This relationship was attenuated slightly when a history of growing up with a mentally ill household member was included in the model, but remained significant (P<0.001).

CONCLUSIONS

The number of ACEs has a graded relationship to both lifetime and recent depressive disorders. These results suggest that exposure to ACEs is associated with increased risk of depressive disorders up to decades after their occurrence. Early recognition of childhood abuse and appropriate intervention may thus play an important role in the prevention of depressive disorders throughout the life span.

Insights Into Causal Pathways for Ischemic Heart Disease

BACKGROUND

The purpose of this study was to assess the relation of adverse childhood experiences (ACEs), including abuse, neglect, and household dysfunction, to the risk of ischemic heart disease (IHD) and to examine the mediating impact on this relation of both traditional IHD risk factors and psychological factors that are associated with ACEs.

METHODS AND RESULTS

Retrospective cohort survey data were collected from 17,337 adult health plan members from 1995 to 1997. Logistic regression adjusted for age, sex, race, and education was used to estimate the strength of the ACE-IHD relation and the mediating impact of IHD risk factors in this relation. Nine of 10 categories of ACEs significantly increased the risk of IHD by 1.3- to 1.7-fold versus persons with no ACEs. The adjusted odds ratios for IHD among persons with > or =7 ACEs was 3.6 (95% CI, 2.4 to 5.3). The ACE-IHD relation was mediated more strongly by individual psychological risk factors commonly associated with ACEs than by traditional IHD risk factors. We observed significant association between increased likelihood of reported IHD (adjusted ORs) and depressed affect (2.1, 1.9 to 2.4) and anger (2.5, 2.1 to 3.0) as well as traditional risk factors (smoking, physical inactivity, obesity, diabetes and hypertension), with ORs ranging from 1.2 to 2.7.

CONCLUSIONS

We found a dose-response relation of ACEs to IHD and a relation between almost all individual ACEs and IHD. Psychological factors appear to be more important than traditional risk factors in mediating the relation of ACEs to the risk of IHD. These findings provide further insights into the potential pathways by which stressful childhood experiences may increase the risk of IHD in adulthood.

The interrelatedness of multiple forms of childhood abuse, neglect, and household dysfunction

OBJECTIVE

Childhood abuse and other adverse childhood experiences (ACEs) have historically been studied individually, and relatively little is known about the co-occurrence of these events. The purpose of this study is to examine the degree to which ACEs co-occur as well as the nature of their co-occurrence.

METHOD

We used data from 8,629 adult members of a health plan who completed a survey about 10 ACEs which included: childhood abuse (emotional, physical, and sexual), neglect (emotional and physical), witnessing domestic violence, parental marital discord, and living with substance abusing, mentally ill, or criminal household members. The bivariate relationship between each of these 10 ACEs was assessed, and multivariate linear regression models were used to describe the interrelatedness of ACEs after adjusting for demographic factors.

RESULTS

Two-thirds of participants reported at least one ACE; 81%-98% of respondents who had experienced one ACE reported at least one additional ACE (median: 87%). The presence of one ACE significantly increased the prevalence of having additional ACEs, elevating the adjusted odds by 2 to 17.7 times (median: 2.8). The observed number of respondents with high ACE scores was notably higher than the expected number under the assumption of independence of ACEs (p <.0001), confirming the statistical interrelatedness of ACEs.

CONCLUSIONS

The study provides strong evidence that ACEs are interrelated rather than occurring independently. Therefore, collecting information about exposure to other ACEs is advisable for studies that focus on the consequences of a specific ACE. Assessment of multiple ACEs allows for the potential assessment of a graded relationship between these childhood exposures and health and social outcomes.

Childhood abuse and its association with mid-aged women's sexual functioning

The aim of this study was to investigate the association of recalled childhood sexual and physical abuse with current sexual functioning in mid-life. The sample was participants in the longitudinal population-based cohort of mid-aged women, The Melbourne Women's Midlife Health Project. Three hundred sixty two of the women (92% of the available cohort) were administered the Violence Questionnaire in the sixth year of follow-up. This included questions on physical abuse and sexual abuse experienced in childhood. We used the Short Personal Experiences Questionnaire (Dennerstein, Anderson-Hunt, & Dudley, 2002) to assess current sexual functioning. Forty eight percent of the women had no experience of childhood sexual abuse, 42% had experienced noncontact sexual abuse, 36% had experienced contact sexual abuse, and 7% had experienced penetrative sexual abuse. Nine percent of the women had experienced physical abuse in childhood. Women who had experienced penetrative childhood sexual abuse were significantly more likely to have fewer children (median 2) than women who had not experienced penetrative childhood sexual abuse (median 3) (P < 0.05). The only area of sexual or relational functioning significantly affected by childhood sexual abuse was that of feelings for partner (P < 0.05). Those who experienced penetrative childhood sexual abuse had, on average, significantly shorter current relationships (P < 0.05). Women who had experienced both childhood sexual and physical abuse reported a lower frequency of current sexual activities (P < 0.05). This study of mid-aged women found that the major impact of childhood sexual abuse is on the quality of relationship with the partner.

Report from the CDC. The Legacy of Child Maltreatment: Long-Term Health Consequences for Women

In 2001, over 903,000 children were victims of physical, sexual, or psychological maltreatment and neglect. Available retrospective and longitudinal data suggest that child maltreatment has a significant negative impact directly on women's physical and mental health in childhood, adolescence, and adulthood. Additionally, childhood maltreatment is a critical risk factor for physical and sexual victimization in adulthood, especially by an intimate partner. The harmful effects of victimization in adulthood among women are substantial, and the negative outcomes of adulthood victimization are especially pronounced when there is a history of childhood maltreatment. Therefore, in addition to the direct effects in childhood, child maltreatment appears to have an indirect effect on women's physical and mental health by increasing the risk for victimization which, in turn, has a direct negative impact on health. The results of existing empirical studies point to the importance of preventing child maltreatment and its short-term and long-term consequences. Intervening at an early stage may reduce a child's likelihood of developing long-term health problems, and also reduce the public health burden of child maltreatment by preventing future health problems and revictimization in adulthood with all its negative health consequences.

Retrospective measurement of childhood sexual abuse: a review of instruments

In this comprehensive review of retrospective childhood sexual abuse (CSA) instruments, instruments from studies published between 1986 and 2001 are examined according to administration method, number and specificity of questions, CSA operational definitions, psychometric properties, and the use of scales. It was found that both self-administered and interview instruments range from the vagueness of a single question to the preciseness of multiple, specific questions. Furthermore, the review demonstrated that CSA instruments generally lack standardization. Many are developed for one-time use and others modified when reused. Descriptive CSA instruments have been preferred by researchers and primarily used to measure CSA dichotomously. However, little consensus exists as to how to operationally define CSA. One positive trend is the development of scales that measure CSA as an interval-level variable, allowing for more extensive psychometric data to be collected.

The association between adverse childhood experiences and adolescent pregnancy, long-term psychosocial consequences, and fetal death

OBJECTIVES

Few reports address the impact of cumulative exposure to childhood abuse and family dysfunction on teen pregnancy and consequences commonly attributed to teen pregnancy. Therefore, we examined whether adolescent pregnancy increased as types of adverse childhood experiences (ACE score) increased and whether ACEs or adolescent pregnancy was the principal source of elevated risk for long-term psychosocial consequences and fetal death.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study of 9159 women aged > or = 18 years (mean 56 years) who attended a primary care clinic in San Diego, California in 1995-1997.

MAIN OUTCOME MEASURE

Adolescent pregnancy, psychosocial consequences, and fetal death, compared by ACE score (emotional, physical, or sexual abuse; exposure to domestic violence, substance abusing, mentally ill, or criminal household member; or separated/divorced parent).

RESULTS

Sixty-six percent (n = 6015) of women reported > or = 1 ACE. Teen pregnancy occurred in 16%, 21%, 26%, 29%, 32%, 40%, 43%, and 53% of those with 0, 1, 2, 3, 4, 5, 6, and 7 to 8 ACEs. As the ACE score rose from zero to 1 to 2, 3 to 4, and > or = 5, odds ratios for each adult consequence increased (family problems: 1.0, 1.5, 2.2, 3.3; financial problems: 1.0, 1.6, 2.3, 2.4; job problems: 1.0, 1.4, 2.3, 2.9; high stress: 1.0, 1.4, 1.9, 2.2; and uncontrollable anger: 1.0, 1.6, 2.8, 4.5, respectively). Adolescent pregnancy was not associated with any of these adult outcomes in the absence of childhood adversity (ACEs: 0). The ACE score was associated with increased fetal death after first pregnancy (odds ratios for 0, 1-2, 3-4, and 5-8 ACEs: 1.0, 1.2, 1.4, and 1.8, respectively); teen pregnancy was not related to fetal death.

CONCLUSIONS

The relationship between ACEs and adolescent pregnancy is strong and graded. Moreover, the negative psychosocial sequelae and fetal deaths commonly attributed to adolescent pregnancy seem to result from underlying ACEs rather than adolescent pregnancy per se.

The child maltreatment log: a computer-based program for describing research samples

The Child Maltreatment Log (CML) is a computer-based program designed to record information about children's maltreatment experiences and associated life events. Addressing concerns posed by scientific panels and grant review panels, the CML was designed to improve upon existing instruments to facilitate collaboration among researchers interested in maltreatment. The CML encourages researchers to collect information from multiple sources and informants concerning children's maltreatment experiences. Rather than classifying types of maltreatment a priori, the CML allows researchers to describe children's experiences using objective descriptors pertaining to potential acts of abuse, potential perpetrators, frequency, onset, consequential injuries, and treatment. The CML can be downloaded by interested agencies and groups without charge.

The effects of trauma history, gender, and race on alcohol use and posttraumatic stress symptoms in a college student sample

The present study examined the extent to which different types of traumatic experiences interact with sex and race to effect alcohol use, posttraumatic stress symptomatology, and general psychological distress among a college student sample. Approximately 600 participants completed measures that assessed for a childhood sexual abuse (CSA) history, alcohol consumption, posttraumatic stress symptoms, and overall psychological functioning. Findings indicated that participants with a history of CSA reported greater psychological distress and posttraumatic stress symptoms compared to participants with a trauma history other than CSA and participants with no trauma history. Despite group differences in psychological distress and posttraumatic stress symptoms, no differences in alcohol use were detected across groups. Gender appeared to affect posttraumatic stress symptoms as a function of group. The implications of the results are discussed.

Child sexual and physical abuse among college students in Singapore and the United States

OBJECTIVES

The purpose of this study was to explore differences in rates and characteristics of child sexual and physical abuse experiences among women in Singapore and the US.

METHOD

Participants (N=153) completed an anonymous questionnaire which assessed experiences of childhood sexual and physical abuse, abuse characteristics (e.g., victimization age, severity), and behavioral and subjective reactions to such experiences (e.g., labeling of experiences as abuse, psychological symptomatology). Exposure to other forms of traumatic life events was also assessed.

RESULTS

In comparison to Singaporean women, US women were more likely to report a history of child sexual abuse, and to report experiencing more severe forms of sexual abuse. Women in Singapore were more likely than women in the US to report a history of child physical abuse, to report experiencing injury as a result of the abuse, and to disclose the abuse. Singaporean women with a history of child sexual abuse reported elevated psychological symptom levels relative to their nonabused peers and to US women with a history of child sexual abuse, even after controlling for exposure to other types of traumatic events. No significant differences in symptomatology with regard to child physical abuse were observed.

CONCLUSIONS

Although preliminary in nature, the present findings are among the first to demonstrate differences in psychological adjustment between sexually abused and nonabused Asian women living in Asia. This study also provides some of the first support for cross-national differences in the psychological adjustment of child sexual abuse survivors.

Prevalence and psychological sequelae of self-reported childhood physical and sexual abuse in a general population sample of men and women

OBJECTIVE

This study examined the prevalence and psychological sequelae of childhood sexual and physical abuse in adults from the general population.

METHOD

A national sampling service generated a geographically stratified, random sample of 1,442 subjects from the United States. Subjects were mailed a questionnaire that included the Traumatic Events Survey (TES) [Traumatic Events Survey, Unpublished Psychological Test, Harbor-UCLA Medical Center, Los Angeles] and the Trauma Symptom Inventory (TSI) [Trauma Symptom Inventory Professional Manual, Psychological Assessment Resources, Odessa, FL]. Of all potential subjects, 935 (64.8%) returned substantially completed surveys.

RESULTS

Sixty-six men and 152 women (14.2% and 32.3%, respectively) reported childhood experiences that satisfied criteria for sexual abuse, and 103 males and 92 females (22.2% and 19.5%, respectively) met criteria for physical abuse. Twenty-one percent of subjects with one type of abuse also had experienced the other type, and both types were associated with subsequent adult victimization. After controlling for demographics, adult history of interpersonal violence, and other child abuse, childhood sexual abuse was associated with all 10 scales of the TSI, and physical abuse was related to all TSI scales except those tapping sexual issues. Sexual abuse predicted more symptom variance than did physical abuse or adult interpersonal victimization. Various aspects of both physical and sexual abuse experiences were predictive of TSI scores. Abuser sex, however, both alone and in interaction with victim sex, was not associated with additional TSI symptomatology.

CONCLUSIONS

Childhood sexual and physical abuse is relatively common in the general population, and is associated with a wide variety of psychological symptoms. These relationships remain even after controlling for relevant background variables.

Lesbians' drinking patterns: beyond the data

Early studies report very high rates of "alcohol abuse" and alcoholism among lesbians. However, serious methodological problems, including nonrepresentative samples that were often recruited in lesbian or gay lesbian bars, limit the validity of findings from these studies. In this article, I briefly review the literature on lesbians' use of alcohol and present findings from a recent study conducted in Chicago (USA). This study recruited a race- and age-diverse sample of lesbians and a demographically matched group of heterosexual women. Rates of "heavy" alcohol use and alcohol-use-related problems among lesbians were much lower in this study than in early studies. However, lesbians were more likely than their heterosexual counterparts to be in recovery and to have been in treatment for alcohol-use-related problems. Further, high rates of childhood sexual abuse, depression, and suicidal ideation reported by lesbians suggest that at least some groups may be at heightened risk for "heavy" drinking and drinking-related problems. Nevertheless, results of this and other studies suggest that reports of heavy drinking and drinking-related problems among lesbians may have been inflated in earlier studies, or that heavy drinking and drinking-related problems may have declined among lesbians.

The impact of adverse childhood experiences on health problems: evidence from four birth cohorts dating back to 1900

BACKGROUND

We examined the relationship of the number of adverse childhood experiences (ACE score) to six health problems among four successive birth cohorts dating back to 1900 to assess the strength and consistency of these relationships in face of secular influences the 20th century brought in changing health behaviors and conditions. We hypothesized that the ACE score/health problem relationship would be relatively "immune" to secular influences, in support of recent studies documenting the negative neurobiologic effects of childhood stressors on the developing brain.

METHODS

A retrospective cohort study of 17,337 adult health maintenance organization (HMO) members who completed a survey about childhood abuse and household dysfunction, as well as their health. We used logistic regression to examine the relationships between ACE score and six health problems (depressed affect, suicide attempts, multiple sexual partners, sexually transmitted diseases, smoking, and alcoholism) across four successive birth cohorts: 1900-1931, 1932-1946, 1947-1961, and 1962-1978.

RESULTS

The ACE score increased the risk for each health problem in a consistent, strong, and graded manner across four birth cohorts (P < 0.05). For each unit increase in the ACE score (range: 0-8), the adjusted odds ratios (ORs) for depressed affect, STDs, and multiple sexual partners were increased within a narrow range (ORs: 1.2-1.3 per unit increase) for each of the birth cohorts; the increase in risk for suicide attempts was stronger but also in a narrow range (ORs: 1.5-1.7).

CONCLUSIONS

Growing up with ACEs increased the risk of numerous health behaviors and outcomes for 20th century birth cohorts, suggesting that the effects of ACEs on the risk of various health problems are unaffected by social or secular changes. Research showing detrimental and lasting neurobiologic effects of child abuse on the developing brain provides a plausible explanation for the consistency and dose-response relationships found for each health problem across birth cohorts, despite changing secular influences.

The relationship between intimate partner violence and PTSD: an application of Cox regression with time-varying covariates

This study uses Cox regression with time-varying covariates to examine the relationship between intimate partner violence and posttraumatic stress disorder (PTSD) in a random sample of Japanese American women and immigrant women from Japan (N = 211). Because applications of survival analysis in trauma research are scarce, this paper presents the utility of this analytical approach by contrasting it with other common methods of analysis (chi-square tests and Cox regression with covariates that do not change over time).

Alleged sexual abuse at a day care center: impact on parents

OBJECTIVE

This report describes the cascade of stressful events and secondary life changes experienced by parents in a case of alleged sexual abuse at a day care program. The study evaluated parents' Posttraumatic Stress Disorder (PTSD) symptoms and general psychological responses to the stressful events 4 years after the alleged abuse, and explored predictive factors of parental distress.

METHODS

A total of 39 parents were interviewed about stressful events, life changes, and social support. Current distress reactions, psychological wellbeing, and locus of control were assessed with a battery of standardized measures.

RESULTS

Hearing about the sexual abuse, testifying in court, hearing the verdict, and being exposed in media reports were all rated by the parents as distressing events. The majority of the parents experienced secondary life changes after the alleged sexual abuse. Four years after the alleged sexual abuse, one-third of the parents reported a high level of PTSD Intrusive symptoms and one-fourth reported a high level of PTSD Avoidance symptoms. There was a significant positive correlation between a measure of psychological wellbeing and PTSD. Secondary life changes and locus of control significantly predicted PTSD.

CONCLUSION

This study demonstrates that the alleged sexual abuse of children in day care and the resulting events in the legal system and the media constitute significant and chronic stressors in the lives of the children's parents. These findings underscore the need to expand the focus of trauma-related sequelae from the child victim to their parents and family.

The role of childhood sexual abuse sequelae in the sexual revictimization of women: an empirical review and theoretical reformulation

There is now widespread empirical evidence that child sexual abuse (CSA) survivors are at greater risk for sexual revictimization in adulthood, but less is known of the mechanisms underlying this relationship. Despite the lack of a conceptual framework to guide research, there has been a recent influx of studies examining explanatory variables, with most focusing on the psychological sequelae of CSA: alcohol and drug use, sexual behavior, dissociation, posttraumatic symptomatology, poor risk recognition, and interpersonal difficulties. With the exception of sexual behavior, the studies reviewed here provide limited or mixed support for the role of intrapersonal factors in revictimization. Future research may benefit from a focus on the function of psychological distress that is expressed as psychological vulnerability, as opposed to individual forms of psychopathology or maladaptive behavior. An ecological framework may be useful as a guide to future investigations, as this model focuses on factors outside of the victim, including childhood factors such as family environment, contextual factors including the behavior of the perpetrator, and societal and cultural factors that impact revictimization. Future investigations should focus on the interaction between victim vulnerability and perpetrator behavior. Implications for prevention programming, clinical intervention, and future research are discussed.

A longitudinal perspective on dating violence among adolescent and college-age women

OBJECTIVES

We investigated physical assault in dating relationships and its co-occurrence with sexual assault from high school through college.

METHODS

Two classes of university women (n = 1569) completed 5 surveys during their 4 years in college.

RESULTS

Women who were physically assaulted as adolescents were at greater risk for revictimization during their freshman year (relative risk = 2.96); each subsequent year, women who have experienced violence remained at greater risk for revictimization than those who have not. Across all years, women who were physically assaulted in any year were significantly more likely to be sexually assaulted that same year. Adolescent victimization was a better predictor of college victimization than was childhood victimization.

CONCLUSIONS

There is a need for dating violence prevention/intervention programs in high school and college and for research on factors that reduce revictimization.

The relationship of exposure to childhood sexual abuse to other forms of abuse, neglect, and household dysfunction during childhood

OBJECTIVE

This study assesses the relationship of childhood sexual abuse (CSA) to nine other categories of Adverse Childhood Experiences (ACEs), including childhood abuse, neglect, and multiple types of household dysfunction.

METHODS

Retrospective cohort study data were collected from 17,337 adult health plan members who responded to a survey questionnaire. Regression models adjusted for age, race, and education were used to estimate the strength of the association of CSA to each of the other nine ACEs and a graded relationship between measures of the severity of CSA and the number of other ACEs (ACE score).

RESULTS

CSA was reported by 25% of women and 16% of men. In comparison with persons who were not exposed to CSA, the likelihood of experiencing each category of ACE increased 2- to 3.4-fold for women and 1.6- to 2.5-fold for men (p < 0.05). The adjusted mean ACE score showed a significant positive graded relationship to the severity, duration, and frequency of CSA and an inverse relationship to age at first occurrence of CSA (p < 0.01).

CONCLUSIONS

CSA is strongly associated with experiencing multiple other forms of ACEs. The strength of this association appears to increase as the measures of severity of the CSA increases. The understanding of the interrelatedness of CSA with multiple ACEs should be considered in the design of studies, treatment, and programs to prevent CSA as well as other forms of ACEs.

Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study

OBJECTIVE

Illicit drug use is identified in Healthy People 2010 as a leading health indicator because it is associated with multiple deleterious health outcomes, such as sexually transmitted diseases, human immunodeficiency virus, viral hepatitis, and numerous social problems among adolescents and adults. Improved understanding of the influence of stressful or traumatic childhood experiences on initiation and development of drug abuse is needed.

METHODS

We examined the relationship between illicit drug use and 10 categories of adverse childhood experiences (ACEs) and total number of ACEs (ACE score). A retrospective cohort study of 8613 adults who attended a primary care clinic in California completed a survey about childhood abuse, neglect, and household dysfunction; illicit drug use; and other health-related issues. The main outcomes measured were self-reported use of illicit drugs, including initiation during 3 age categories: <or=14 years, 15 to 18 years, or as an adult (>or=19 years); lifetime use for each of 4 birth cohorts dating back to 1900; drug use problems; drug addiction; and parenteral drug use.

RESULTS

Each ACE increased the likelihood for early initiation 2- to 4-fold. The ACE score had a strong graded relationship to initiation of drug use in all 3 age categories as well as to drug use problems, drug addiction, and parenteral drug use. Compared with people with 0 ACEs, people with >or=5 ACEs were 7- to 10-fold more likely to report illicit drug use problems, addiction to illicit drugs, and parenteral drug use. The attributable risk fractions as a result of ACEs for each of these illicit drug use problems were 56%, 64%, and 67%, respectively. For each of the 4 birth cohorts examined, the ACE score also had a strong graded relationship to lifetime drug use.

CONCLUSIONS

The ACE score had a strong graded relationship to the risk of drug initiation from early adolescence into adulthood and to problems with drug use, drug addiction, and parenteral use. The persistent graded relationship between the ACE score and initiation of drug use for 4 successive birth cohorts dating back to 1900 suggests that the effects of adverse childhood experiences transcend secular changes such as increased availability of drugs, social attitudes toward drugs, and recent massive expenditures and public information campaigns to prevent drug use. Because ACEs seem to account for one half to two third of serious problems with drug use, progress in meeting the national goals for reducing drug use will necessitate serious attention to these types of common, stressful, and disturbing childhood experiences by pediatric practice.

Social reactions to child sexual abuse disclosures: a critical review

Recent studies have examined disclosure of child sexual abuse to determine the correlates and consequences of telling others about this form of victimization. The present article reviews the current empirical literature on disclosure and reactions to adult survivors to assess what is known about the process of disclosure and whether telling others is therapeutic and leads to positive outcomes. Most studies assessing social reactions in detail have concerned adult survivors retrospectively reporting on their disclosures of child sexual abuse. Few empirical studies have been conducted in this area but research suggests that few victims tell anyone about child sexual abuse as children, and that the type of reactions to disclosure vary according to when disclosure occurs (childhood or adulthood), the extent and nature of the disclosure, and the person to whom one discloses. Clear evidence shows that negative social reactions are harmful to survivors' well-being, but better assessment of specific reactions and their effects are needed in theoretically-based studies to evaluate how these responses affect survivors' recovery in the context of other variables. Suggestions for future research on social reactions of others to adult survivors disclosing child sexual abuse are presented.

A conceptual framework for research on lifetime violence, posttraumatic stress, and childbearing

The objective of this theoretical article is to describe a conceptual framework for research on effects of past and current abuse and posttraumatic stress on childbearing women. The proposed framework builds on an earlier framework proposed by the Centers for Disease Control and Prevention (CDC) for research on violence occurring around the time of pregnancy. Two main adaptations are suggested. First, cumulative lifetime history of abuse trauma is added to the framework in addition to violence occurring around the time of pregnancy. Second, posttraumatic stress disorder (PTSD) is given greater emphasis as a potential factor contributing to adverse maternity outcomes based on the theoretical proposition that PTSD could be a plausible mechanism for adverse outcomes via both behavioral and neuroendocrine pathways. More research is needed on the effects of violence and PTSD on childbearing. This framework for research could be used to facilitate design of studies in which investigators want to consider PTSD as a potential mediator between lifetime exposure to violence and negative childbearing processes and outcomes. It is congruent with a CDC framework for research and could be incorporated into studies designed to meet their recommendations.

Adverse childhood experiences and personal alcohol abuse as an adult

Adult alcohol abuse has been linked to childhood abuse and family dysfunction. However, little information is available about the contribution of multiple adverse childhood experiences (ACEs) in combination with parental alcohol abuse, to the risk of later alcohol abuse. A questionnaire about childhood abuse, parental alcoholism and family dysfunction while growing up was completed by adult HMO members in order to retrospectively assess the independent relationship of eight ACEs to the risk of adult alcohol abuse. The number of ACEs was used in stratified logistic regression models to assess their impact on several adult alcohol problems in the presence or absence of parental alcoholism. Each of the eight individual ACEs was associated with a higher risk alcohol abuse as an adult. Compared to persons with no ACEs, the risk of heavy drinking, self-reported alcoholism, and marrying an alcoholic were increased twofold to fourfold by the presence of multiple ACEs, regardless of parental alcoholism. Prevention of ACEs and treatment of persons affected by them may reduce the occurrence of adult alcohol problems.

Child maltreatment and adulthood violence: the contribution of attachment and drug abuse

This study examined the association between child maltreatment and adult violence in a high-risk sample of women with and without a history of cocaine abuse and the contribution of working models of childhood attachment relationships in understanding this association. Results indicated that whereas childhood physical abuse was associated with adult sexual victimization for cocaine-abusing women, sexual abuse was associated with both partner violence victimization and perpetration for comparison women. Insecure working models of attachment were associated with partner violence victimization for comparison women, independent of the effect of sexual abuse. These findings suggest the importance of research focused on understanding the processes by which child maltreatment may lead to later violence and that examines both childhood and adulthood experiences in understanding pathways to adult violence.

Body weight and obesity in adults and self-reported abuse in childhood

BACKGROUND

Little is known about childhood factors and adult obesity. A previous study found a strong association between childhood neglect and obesity in young adults.

OBJECTIVE

To estimate associations between self-reported abuse in childhood (sexual, verbal, fear of physical abuse and physical) adult body weight, and risk of obesity.

DESIGN

Retrospective cohort study with surveys during 1995-1997.

PATIENTS

A total of 13,177 members of California health maintenance organization aged 19-92 y.

MEASUREMENTS

Body weight measured during clinical examination, followed by mailed survey to recall experiences during first 18 y of life. Estimates adjusted for adult demographic factors and health practices, and characteristics of the childhood household.

RESULTS

Some 66% of participants reported one or more type of abuse. Physical abuse and verbal abuse were most strongly associated with body weight and obesity. Compared with no physical abuse (55%), being 'often hit and injured' (2.5%) had a 4.0 kg (95% confidence interval: 2.4-5.6 kg) higher weight and a 1.4 (1.2-1.6) relative risk (RR) of body mass index (BMI) > or = 30. Compared with no verbal abuse (53%), being 'often verbally abused' (9.5%) had an RR of 1.9 (1.3-2.7) for BMI > or = 40. The abuse associations were not mutually independent, however, because the abuse types strongly co-occurred. Obesity risk increased with number and severity of each type of abuse. The population attributable fraction for 'any mention' of abuse (67%) was 8% (3.4-12.3%) for BMI > or = 30 and 17.3% (-1.0-32.4%) for BMI > or = 40.

CONCLUSIONS

Abuse in childhood is associated with adult obesity. If causal, preventing child abuse may modestly decrease adult obesity. Treatment of obese adults abused as children may benefit from identification of mechanisms that lead to maintenance of adult obesity.