Sexual Abuse And Eating Disorders

Mark F. Schwartz, Leigh Cohn, Mark F. Schwartz, Leigh Cohn

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781317838876
• Edition: 1
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Sexual Abuse and Eating Disorders is the first book to fully explore the complex relationship between sexual abuse and the eating disorders. The book encom­passes the compelling writings of 26 specialists who thoughtfully consider the numerous questions surrounding this controversial topic: Why would early trauma influence eating behavior? What is the association between eating disorders and sexual abuse? What impact does the controversy surrounding false memory have on the thinking about this association? Working from the premise that children exposed to inescapable stress throughout childhood will be at risk for compulsivity and reenactment of trauma by self-abuse syndromes, this collection provides provocative answers to these and many other questions. Taken as a whole, this book provides an important global view of the topic. Chapters focus attention on the prevalence of sexual abuse among individuals with eating disorders; how a history of sexual violence can serve as a predictor of subsequent food-related syndromes; trauma-based theory, dissociation, abreactive, and ego-states therapy; and a practical and theoretical exploration of the sexual self of an eating-disordered person. New perspectives on body image, feminist approaches to treatment, false memory, and the sexual self, as well as a first-person narrative that powerfully links the two phenomena, round out the discussion. Finally, a dialogue about the controversies surrounding sexual abuse and eating disorders and an examination of false memory syndrome constitute the fitting finale for this stimulating presentation.

PART I

Prevalence and Prevention

1

Is Sexual Abuse a Risk Factor for Developing an Eating Disorder?

JOHAN VANDERLINDEN
WALTER VANDEREYCKEN

Some critical comments are made with regard to the possible relationship between a history of sexual abuse and the development of an eating disorder. In a case of sexual abuse, many factors and variables interacting with one another may play a role in the development of psychiatric sequelae, including eating disorders. The fact that a linear causal link does not exist does not mean that sexual abuse is not a risk factor for eating disorders.

In recent years, more and more reports have appeared about serious traumatic experiences—especially physical and sexual abuse—in anorexia nervosa (AN) and bulimia nervosa (BN) patients (Finn et al., 1986; Gold-farb, 1987; Hall et al., 1989; McFarlane et al., 1988; Oppenheimer et al., 1985; Root & Fallon, 1988; Schechter et al., 1987; Sloan & Leichner, 1986; Torem, 1986; Vanderlinden & Vandereycken, 1993; Waller, 1991; Wooley & Kearney-Cooke, 1986). Traumatic experiences are more frequently reported by bulimics than by restricting anorexics. Systematic inquiry into the occurrence of sexual traumata in eating disorder patients resulted in alarming prevalence figures. Oppenheimer et al. (1985) reported sexual abuse during childhood and/or adolescence in 70% of 78 eating disorder patients. Kearney-Cooke (1988) found 58% with a history of sexual trauma of 75 bulimic patients. Root and Fallon (1988) reported that in a group of 172 eating disorder patients, 65% had been physically abused, 23% raped, 28% sexually abused in childhood, and 23% maltreated in actual relationships. Hall et al. (1989) found 40% sexually abused women in a group of 158 eating disorder patients.

One recent report stands in contrast with these findings. In a systematic study of 112 consecutive referrals of normal-weight bulimic women, Lacey (1990) found that only eight patients (7%) mentioned a history of sexual abuse involving physical contact. Four of these (3.6%) described incest, but only in two cases (1.8%) did the incest occur during childhood. Sexual abuse occurred in those “multi-impulsive” bulimics who also abuse alcohol or drugs. Interestingly, Lacey also mentioned that an additional 18 patients reported “incestuous fantasies.” But on the basis of what kind of considerations and/or methods did the author make this distinction between reality and fantasy, especially since this information was only gained at the initial assessment interview? In cases of serious childhood sexual abuse, there might exist amnesia for the abuse; consequently, the patient will not report it in a first interview. According to the author, however, it is unlikely that actual cases of sexual abuse were missed, since most patients subsequently entered psychotherapy with female therapists and no further cases came to light. But the fact that patients enter psychotherapy does not guarantee that they will disclose sexual abuse. Especially in psychoanalytically oriented psychotherapy, the likelihood that stories about sexual abuse will be interpreted as fantasy or the result of transferential issues cannot be denied. Finally, we are wondering what type of bulimic patients were studied. Except for the DSM-III-R diagnosis, no other information on the patient sample (demographic status and other important clinical characteristics) is presented. In sum, the low prevalence of reported sexual abuse in Lacey’s study may be biased by: 1) the data collection method; 2) the selection of a specific patient sample; and 3) the psychodynamic orientation of the therapists. However, notwithstanding these critical annotations, Lacey’s (1990) conclusion that his therapeutic work confirms his impression that incest and child sexual abuse mostly occurred in multi-impulsive bulimics is consistent, to a great extent, with our own findings (Vanderlinden & Vandereycken, 1993). In our studies on traumatic experiences in eating disorders (Vanderlinden, 1993), we found the highest prevalence of sexual abuse in patients showing both a complex eating pathology (bulimia, vomiting, laxative abuse) and a remarkable comorbidity (depression, alcohol abuse, kleptomania, promiscuity, automutilation), including severe dissociative symptoms (identity confusion, derealization, depersonalization, amnesia).

But a recent paper by Pope and Hudson (1992), reviewing the literature on sexual abuse in BN, questions even more the possible link between sexual abuse and BN. The authors stress that neither controlled nor uncontrolled studies of BN found higher rates of sexual abuse (varying from 7% to 69%) than in studies of the general population (varying from 27% to 67%) that used comparable methods. The differences in sexual abuse rates were partly due to the definition of sexual abuse employed in the various studies. Pope and Hudson conclude that current evidence does not support the hypothesis that childhood sexual abuse is a risk factor for BN. One has to remark, however, that the reported prevalence rates of sexual abuse in the general population of the United States are quite high and even higher than those found in European studies of psychiatric patient samples! The lowest sexual abuse rate reported in the general population of the United States is 27% (Finkelhor et al., 1990). How can these differences be explained? Are sociocultural factors involved in the prevalence of sexual abuse or in the likelihood of reporting it? Overall, these differences demonstrate very clearly the urgent need for both researchers and clinicians to agree on a clear definition of what should be considered sexual abuse and how it can be detected and/or assessed in a reliable way.

Besides this general remark, we believe that Pope and Hudson have used the wrong argument to defend their point of view. If child sexual abuse does not occur more frequently in eating disorder populations than in the general population, why should this mean that it is not a risk factor for BN? Following the authors’ reasoning, one must conclude that sexual abuse is no longer a risk for any of the different psychiatric categories or problems, except for multiple personality disorders. Only in the latter have higher rates of sexual trauma been reported: more than 80% (Putnam, 1989; Ross, 1989). But the relationship between childhood abuse and different forms of psychiatric morbidity has been documented in a number of important studies in recent years (Boon & Draijer, 1993; Briere & Zaidi, 1989; Brown & Anderson, 1991; Bryer et al., 1987; Chu & Dill, 1986; de Wilde et al., 1992; Ensink, 1992; Herman et al., 1989; Margo & McLees, 1991; Morrison, 1989; Mullen et al., 1988; Ogata et al., 1990; Pribor & Dinwiddle, 1992; Ross et al., 1988; Stone et al., 1988; Swett et al., 1990; Wolfe et al., 1989; Zanarini et al., 1989).

In our view, Pope and Hudson (1992) may only conclude that a linear causal link does not exist between sexual abuse in childhood and eating disorders in adults. In the case of sexual abuse, many factors and variables interacting with one another may play a role in the development of psychiatric sequelae: 1) the functioning of the subject prior to the trauma (e.g., age and vulnerability of the child at the time when the abuse occurred); 2) family variables and dynamics; 3) the nature, severity and extent of traumatization (e.g., sexual abuse versus physical abuse alone, or a combination of sexual and physical abuse); 4) the initial response to the trauma (coping resources of the child, parental reactions to the trauma); and 5) longer-term reactions (later triggering events, personality development). Taking these factors into consideration, we believe there is no reasonable argument to question our conviction that sexual and/or physical abuse in childhood place adults at special risk for developing psychological crises and even psychiatric disorders, including anorexia nervosa and bulimia nervosa.

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