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To What Extent does Childhood Sexual Abuse Impact the Etiology of Eating Disorders?

By Daniel Castagna
Pyschology 297:  Eating Disorders

     Today's literature estimates that as many as 1 in 3 females and 1 in 7 boys have been the victim of sexual abuse.  There are about 2,000 to 3,000 new cases of incest each year in each major city in the United States.  It is reported by the National Committee to Prevent Child Abuse that in 1993, 2.9 million children were reported to protective services because they were being abused, neglected, or both (Schwartz).  16% of these 2.9 million children had been sexually abused.  It is estimated that there are 60 million survivors of childhood sexual abuse in America today   This childhood sexual abuse has been implicated by some eating disorder experts as a factor in the etiology of anorexia nervosa and bulimia nervosa.  Eating disorder experts are currently engaged in heated debate concerning whether sexual abuse is a specific risk factor or a general risk factor in the development of eating disorders.  Those who propose a specific link hypothesis believe that eating disorders are directly related to early sexual abuse and are a form of gender specific posttraumatic stress disorder.  The proponents of the specific link hypothesis believe that their exists "complex, multiple mediating mechanisms between sexual abuse and disordered eating" (Kearney-Cook, 1994).  They believe that sexual abuse has a direct effect on the victims body image.  There is an emphasis on the "adverse effects of sexual abuse on body esteem, self-regulation, identity, and on interpersonal functioning" (Kearney-Cook, 1994).  Those on the opposite side of the argument believe that eating disorders are not specifically caused by sexual trauma in childhood.  They believe that sexual abuse contributes alongside other factors such as adverse family environment or strained parent-child bonds to the cause of eating disorders.  They argue that it is impossible to infer a single variable model (sexual abuse) to a complex etiological model (eating disorders).  I will attempt to review the scientific literature on this topic. 

Research Review-
                 Glenn Waller (Waller, 1991) conducted a research study that probed whether sexual abuse was a factor in eating disorders.  In his research, Waller presented 67 women who met the DSM-III-R criteria for either anorexia nervosa or bulimia nervosa.  The 67 women were grouped into one of four categories.  The categories included anorexia- restricting subtype, anorexia- purging subtype, bulimia with a history of anorexia, and bulimia with no history of anorexia.  About 36% of the women completed a Sexual Events Questionnaire (SEQ), while the remaining women were asked about the sexual abuse during interviews.  All the women were then interviewed concerning unwanted sexual experiences.  Thirty two (48%) of the 67 reported that they were sexually abused in their childhood.  Scores were compiled for each of the women after they had either taken the SEQ or were clinically interviewed.  The researchers came to the conclusion through statistical analysis that sexual disorders per se do not cause eating disorders.  The researchers believed that sexual abuse may determine the nature of the eating disorder but that this is prompted by other mitigating factors such as family interaction, thus proposing a general link between childhood sexual abuse and eating disorders.
        Another study that was undertaken searched family backround and sexual abuse asociated with eating disorders (Kinzl, et al 1994).  In this study, 202 white female subjects were utilized.  Of these 202 females, 44 were victims of childhood sexual abuse.  The subjects were then asked to fill out a 64 item self report measure called the Eating Disorder Inventory, which measures symptomatic aspects of eating disorders and fundamental personality pathology.  The women were then instructed to complete a Biographic Inventory for Diagnosis of Behavioral Disturbances which is a questionnaire of 97 items related to personal environment, history, and personality.  The participants then filled out a child sexual abuse history questionnaire.  After the data was compiled and assessed, it was found that their was no uniform or significant differences in the scores of the  Eating Disorder Inventory between the women who were sexually abused as children and the women who were not.  The results indicated that the higher the score on the Eating Disorder Inventory the more dysfunctional the woman's family background was and thus scores on the EDI did not correlate with sexual abuse but rather family background.  It was found that there was no significant difference between childhood sexual abuse victims and nonvictims in their risk for developing an eating disorder.  The results did show that women with adverse family backgrounds showed a significantly higher likelihood of developing an eating disorder.  The differences here were independent of whether or not the women had histories of sexual abuse.  The researchers concluded that based on their research, the link between adverse childhood sexual abuse and eating disorders is unlikely to be specific.  They believe that childhood sexual abuse may make an individual contribution to the development of an eating disorder but that it is more of a general link and that an adverse family background may be an even more important etiological factor in the development of an eating disorder.
        A third research study that was conducted sought to find an association between child sexual abuse as a precursor of binge eating in females (Moyer, et al, 1997).  At the onset of this study, it was hypothesized by the researchers that binge eating would be more prevalent among girls in treatment for sexual abuse.  The study recruited girls from five clinics that specialized in the treatment of childhood sexual abuse.  The cohort for the study included 63 girls that met the criteria for childhood sexual abuse and were between the ages of 14 and 18.  The girls all completed four self-administered questionnaires.  The four questionnaires included: (1) Binge Eating Scale-  the BES assessed binge eating behavior among the girls,  (2) Children's Depression Inventory-  which was used to asses depression in the participants,  (3) Children's Self-Concept Scale- which assessed the participants concept of self including anxiety, popularity, and happiness, and (4) Locus of Control Scale-  which tested the participants extent of being externally oriented(reinforcement outside of one's control).   After taking the scores of these four variables, and adjusting for them simultaneously,  the researchers found that childhood sexual abuse was not associated with binge-eating scores.  The strongest correlates of binge-eating scores were depression and body mass index.  The researchers found that child sexual abuse was not a specific link to the etiology binge eating.  The results of this study suggest that the relationship between childhood sexual abuse and binge eating is influenced by several important psychological factors such as depression and locus of control.  This research found that psychological factors such as depression and weight satisfaction are more influential in the relationship to eating disorders then childhood sexual abuse, thus pointing to a general link of childhood sexual abuse in the etiology of eating disorders.
Why the Debate Continues-
    The research reviewed thus far has all pointed toward a general link between eating disorders and childhood sexual abuse, yet there are numerous studies that report contrary results continuing the debate on whether the link between childhood sexual abuse and eating disorders is specific or general.
        One such research study was conducted by Zlotnick, et al which sought to understand the relationship between sexual abuse and eating pathology (Zlotnick, 1996).  This study examined whether patients with a history of childhood sexual assaults presented with a higher degree of eating disorders  than a nonsexually abused control group.  This study utilized 134 female psychiatric inpatients. 92 (69%) reported that they had a history of childhood sexual abuse where the remaining 42 did not.  The participants each completed a self report questionnaire to assess their history of childhood sexual abuse.  The patients then completed the Eating Disorder Inventory (EDI) to assess psychological and behavioral traits common in anorexia and bulimia.  The data on these questionnaires and inventories ware then analyzed.  The researchers found that the complex of EDI subscales was significantly related to a history of childhood sexual abuse.  Those with the highest EDI scores were those participants who admitted to having been sexually abused in their childhood.  The researchers came to the conclusion that there is an association between sexual abuse and eating disorder symptomatology. With this research study, they argue for a more specific link of childhood sexual abuse and eating disorders.  They believe that the findings support their arguement that women with a history of sexual abuse are likely to present with symptomatology of an eating disorder.
Why such mixed research Findings?

    Due to the emergence of contrdictory research findings, it is nearly impossible to make a concrete and factual judgement on whether or not childhood sexual abuse is a specific or general link to the etiology of eating disorders.  A major obstacle with these studies is methodological limitations, methodological problems, and participant willingness and ability to recall memories factually.
        1) One problem with these research findings is the fact that each researcher uses his or her own independent definition of sexual abuse.  In addition, these researchers also use different questionnaires and interviews (from study to study) when recieving information on sexual abuse history, thus leading to a problem in consistency between studies.  To further exacerbate the problem with interviews, the setting of the environment (including the researcher, etc), may significantly influence the rates of reported abuse (Schwartz, 1996). 
        2) More problems lie within the realm of methodology.  For one, these research studies rely very heavily on clinical samples and thus may cause misrepresentation of the population.  Another methodological problem is that in many of these studies linking childhood sexual abuse and eating disorders, there is generally a lack of control groups to compare the findings to.  Also, their are generally small samples of subjects in many of these research studies.
        3)Research findings might be contradictory because the information that is collected regarding the childhood sexual abuse is retrospective and much of it is collected from adult women who are already seeking treatment for an eating disorder.  Accuracy and validity of the sexual abuse is uncertain and may be influenced by the treatment (Moyer, et al, 1997).  Many women may also feel ashamed or embarrassed to disclose information about past sexual abuse which would skew the results as well as any women who were sexually abused but have repressed it and are unable to access it from memory anymore.  
        4) Finally, the memories of the abuse victims may not be accuratly reported.  Memories are not factual and are actively construed and reassimilated over time (Schwartz, 1996).  They are also "subject to childhood misattributions..., developmental idiosyncracies..., and consolidation of memory and memory retrieval distortions" (Schwartz, 1996).

Final Comment-
        All the research cited in this paper finds that childhood sexual abuse is implicated in the etiology of eating disorder symptomatology, whether it be specific or general.  The key is to complete further research with less methodological promblems  and limitations.  Whether or not the link between the two is "specific" or "general" only helps if we can pinpoint the direct effects of childhood sexual abuse on eating disorders and eventually create necessary treatment for suffering patients.  .  

        Schwartz, Mark F. and Cohn, Leigh.  Sexual Abuse and Eating Disorders.  Brunner/Mazel, Publishers, New York: 1996

        Cooke-Kearney, Ann and Striegel-Moore, Ruth H.  (1994).  Treatment of Childhood Sexual Abuse in Anorexia Nervosa and Bulimia Nervosa: A Feminist Psychodynamic Approach.  International Journal Of Eating Disorders, 4, 305 - 319

        Waller, Glenn. (1991).  Sexual Abuse as a Factor in Eating Disorders.  British Journal of Psychiatry, 159, 664 - 671

        Kinzl, Johann F., et al.  (1994).  Family Background and Sexual Abuse Associated with Eating Disorders.  The American Journal of Psychiatry, 151,
1127 - 1130

        Moyer, Diane M, et al. (1997).  Childhood Sexual Abuse and Precursors of Binge Eating in an Adolescent Female Population.  International Journal of Eating Disorders, 21, 23 - 30

        Zlotnick, Caron, et al.  (1996).  The Relationship Between Sexual Abuse and Eating Pathology.  International Journal of Eating Disorders, 20, 129 - 134


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