Prevalence of Functional Gastrointestinal Disorders in Women Who Report Domestic Violence to the Police

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1 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2005;3: ORIGINAL ARTICLES Prevalence of Functional Gastrointestinal Disorders in Women Who Report Domestic Violence to the Police MÓNICA PERONA,* RUTH BENASAYAG,* ANTONIA PERELLÓ,* JAVIER SANTOS, NATALIA ZÁRATE,* PATRICIA ZÁRATE, and FERMÍN MEARIN* *Institute of Functional and Motor Digestive Disorders, Centro Médico Teknon, Gastroenterology Department, Hospital Vall D Hebrón, and National Police Department, Barcelona, Spain Background & Aims: Retrospective studies found an association between past sexual, physical, or psychological abuse and functional gastrointestinal disorders (FGIDs). However, there are no studies evaluating such an association concurrently with the ongoing abuse. Our aim was to investigate the prevalence of the main FGIDs, functional dyspepsia and irritable bowel syndrome, in 70 women reporting a situation of domestic violence to the police and to evaluate the level of psychological distress and its relationship with the presence of FGID. Methods: Through an interview between a social worker and the woman reporting abuse, digestive symptoms, psychological status, and type of abuse were recorded. These data were matched against police records. Functional dyspepsia and irritable bowel syndrome were diagnosed according to Rome II criteria. Results: Seventy-one percent of the women had an FGID: 67% functional dyspepsia, 47% irritable bowel syndrome, and 43% both. In two thirds of the cases, FGID onset occurred simultaneously with or soon after abuse onset. Only 34% of the women had sought medical attention for FGID symptoms. No differences were found between women with or without FGID regarding age and type or duration of abuse; psychological distress tended to be more severe in the group of women with FGIDs. Conclusions: Most women who suffer domestic violence (reported to the police) have functional dyspepsia and/or irritable bowel syndrome and also have elevated psychological distress. This has important implications, not only for comprehensive health care of women in a situation of abuse, but also for medical treatment of women with FGIDs. Functional gastrointestinal disorders (FGIDs) include a group of digestive diseases produced as a result of altered gastrointestinal motility or sensitivity in the absence of an organic illness and manifested as the presence of symptoms that follow a chronic or recurrent course. 1 Irritable bowel syndrome (IBS) and functional dyspepsia (FD) are the most frequent FGIDs. IBS is characterized by the presence of abdominal pain/discomfort associated with an alteration in the consistency or frequency of defecation. 2 FD is defined as chronic or recurrent pain/discomfort in the upper abdomen and is commonly associated with postprandial fullness, abdominal bloating, early satiety, or nausea. 3 These syndromes lack any biologic diagnostic marker; therefore, in some cases diagnosis requires organic diseases to be ruled out. On the other hand, clinical criteria have been developed with the purpose of obtaining a positive diagnosis of functional digestive disorders. 1 These criteria have been widely accepted to standardize the diagnosis not only in medical care, but also in conducting epidemiologic studies 4,5 and clinical trials. 6 Despite the fact that the etiology is not completely understood, at present the pathogenesis of FGID is explained by the biopsychosocial model in which different factors participate in the origin of symptoms, biologic factors such as dysregulation in mechanicosensitive function and psychosocial factors such as psychological status, social environment, and stress. 7,8 Abuse is one of the most stressful events a person can be subjected to. Unfortunately, at present, domestic violence constitutes a social problem of huge dimensions with significant legal, social, and health repercussions for the victims Data of a Spanish survey conducted in 1999 showed that 1.8 million women (12.4% of the adult female population) had suffered some type of domestic maltreatment during the previous year, and that 640,000 (approximately 4.2%) considered themselves victims of domestic violence. During the same year, only 3372 complaints to the police for domestic abuse were regis- Abbreviations used in this paper: FD, functional dyspepsia; FGID, functional gastrointestinal disorder; HAD, hospital anxiety and depression scale; IBS, irritable bowel syndrome by the American Gastroenterological Association /05/$30.00 PII: /S (04)

2 May 2005 DOMESTIC ABUSE AND FUNCTIONAL GUT DISORDERS 437 tered. 12 Moreover, in 2002 seventy women died as a result of this type of violence. Therefore, it is becoming accepted that increased resources should be invested for the multiple consequences of abuse to be recognized as a first step toward the comprehensive attention to this group. 13 Patients with functional digestive disorders have a greater prevalence of a history of physical or sexual abuse than patients with organic diseases However, we are not aware of the existence of any study covering the issue from the opposite way: How many adults suffering maltreatment have FGID? For these reasons, our aim was to investigate the prevalence of FD and IBS among women who report current domestic violence to the police and explore the severity of their psychological distress and its relationship with the presence of FGID. Materials and Methods The study was performed at the Women s Attention Services located in the National Police Department in Barcelona, Spain, between May 2001 and October A social worker, in close collaboration with the police, proposed anonymous participation in the study to every woman reporting domestic violence at the police station. No compensation was given for participation in this study. Approval for the study was obtained from the local research ethics committee and by the Chief of Police in Catalonia. Domestic violence was defined as that committed by an intimate partner or family member against another. Physical maltreatment included any injury such as blows, beatings, acute trauma, burns, or cuts. Psychological abuse included verbal threats, humiliations, coercion, demand for obedience, insults, public humiliations, destruction of personal belongings, physical maltreatment of pets, and socioeconomic damages such as not providing financial support for the children in common or not adhering to scheduled visits. Women reporting aggressions of a sexual nature were attended to by a different police section; as a consequence, this particular type of violence was not included in our study. Data were obtained in a systematic manner via a questionnaire consisting of 3 parts. The first part recorded the presence of each FD and IBS symptom according to Rome II criteria; time elapsed from the beginning of the abdominal pain or discomfort until the time of interview (less than 6 months, between 6 months and 2 years, more than 2 years), its intensity (mild/moderate/severe), and whether the subject needed to consult a doctor for these symptoms. The second part evaluated anxiety-depression levels by using the hospital anxiety and depressive scale (HAD) questionnaire. The third part collected demographic data (age and nationality), socioeconomic data (marital and employment status and number of children), and variables related to maltreatment: number of official complaints, duration of the abuse situation, relationship with the aggressor, and form of abuse (psychological, physical, or both). Women were also asked if they believed there was a relationship between their digestive symptoms and the situation of abuse they were suffering. Once the questionnaire had been completed at the police station, participants were requested to fill out a second identical questionnaire at home (or any place other than the police station) within the following 7 days and return it to the social worker by mail. Our intention was to detect whether the situation of high stress as a result of the recent abuse situation could influence responses. The information obtained in the third part of the questionnaire regarding the number of abuse reports to the police, relationship with the aggressor, and maltreatment characteristics was checked confidentially by a police officer with the corresponding police reports. Physical abuse was corroborated by medical reports. Rome II criteria were used to diagnose IBS and FD, 2,3 and women known to have Crohn s disease, ulcerative colitis, celiac disease, colon cancer, or who had undergone major digestive surgery were excluded from the analysis. Evaluation of Psychological Status The HAD questionnaire has been extensively used to evaluate anxiety and depression in stressful situations and has been validated in the Spanish population. 17 A self-administered questionnaire with 14 items designed by Zigmond and Snaith 18 in 1983, it consists of 2 subscales of 7 items each: one that measures anxiety, based on the scale of anxiety by Hamilton, and another that evaluates depression, centered on the anhedonia area or loss of pleasure. The intensity or frequency of each item is evaluated on a Likert scale of 4 points (0 3). Each subscale has a range of 0 21 points; 0 7 points is consistent with a normal result, between 8 and 10 is inconclusive, and greater than 10 is indicative of significant anxiety or depression. For the global score, the range is from Different cutoff points have been used to consider significant psychological distress or abnormal HAD in relation to the context in which HAD is being used. For patients with symptoms unexplained by an organic illness (somatic patients), a HAD score greater than 12 indicates the presence of psychological disturbance with a sensitivity of 0.79 and specificity of On the other hand, Le Fevre et al 20 concluded that in seriously ill patients who are close to death, the best HAD cutoff value to identify significant depression was 20 (sensitivity, 0.77; specificity, 0.85). Statistical Analysis This was performed by using SPSS 11.0 version (SPSS Inc, Chicago, IL) software. For comparisons, Student t test for independent data was used for quantitative variables and the 2 test for qualitative variables. Data are expressed as mean standard deviation. Differences were considered significant when P value was less than.05. HAD score concordance between the 2 measurements (first and

3 438 PERONA ET AL CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 3, No. 5 Table 1. Variables Related to the Abuse Situation in the Global Sample (n 70 Women) Number of reports to the police, n (%) 1 47 (67) 1 23 (33) Beginning of maltreatment, n (%) 6 mo 16 (23) 6 mo 2 y 13 (19) 2 y 31 (44) No reply 10 (14) Relation to aggressor, n (%) Partner 41 (59) Ex-partner 16 (23) Direct family member 3 (4) No reply 10 (14) Form of abuse, n (%) Physical 3 (4) Psychological 20 (29) Both 47 (67) second questionnaires) was assessed by the intraclass correlation coefficient (Ri). Results Eighty-seven women agreed to participate in the study; of these, only 11 returned the second questionnaire. In all 17 women were excluded, 13 because of a lack of information essential to the objective of the study and 4 (also including 1 of the 11 with a second questionnaire) because of organic gastrointestinal disease (3 ulcerative colitis and 1 colon cancer). Therefore, the final sample consisted of 70 women with a mean age of years (range, years). Seventy percent were Spanish, and the remainder were from different Latin American countries. Thirtyfour women (48%) were married or with a stable partner, 21 (30%) were single, 13 (18.5%) were separated or divorced, and in 1 case the woman was a widow. The majority of women (57.1%) had more than 1 child, 28.6% had 1 child, and 8 women had no children. At the time of the study, 34 (48.5%) were actively working, 19 (27.1%) were unemployed, 8 (11.4%) were off work or had retired, and 2 (3%) were housewives. In 67% of cases, this was the first official complaint to the police. The duration of the current abuse situation was less than 6 months in 16 women, between 6 months and 2 years in 13, and longer than 2 years in 31. Ten women were not able to respond precisely to this question. In most cases the aggressor was the current partner or ex-partner of the victim. The most frequent form of maltreatment was a situation of physical injury accompanied by psychological abuse. In one fourth of cases maltreatment corresponded only to one of the forms defined as psychological abuse (Table 1). The global psychological distress score obtained by the HAD questionnaire was Both the subscale scores for anxiety ( ) and for depression ( ) were above normal values, with anxiety being significantly higher than depression (P.05). All but 3 women in our sample presented a global HAD score above the cutoff value of 12 and could thus be considered to have high psychological distress. If the cutoff value of 20 points would be applied, 52 women (76.5%) would be suffering from a high level of distress. The concordance between HAD score obtained inside and outside the police station was excellent in the 10 cases in which these data were available (Ri for anxiety subscale, 0.94; Ri for depression subscale, 0.90). FGID prevalence was 71% (50 women); 3 (4%) had IBS, 17 (24%) had FD, and both disorders were present in 30 (43%). Thus, total FD prevalence was 67%, and total IBS prevalence was 47%. Of the total of 33 women with IBS, 9 belonged to the diarrhea subtype, 12 to the constipation subtype, and 12 to the alternating diarrhea/ constipation subtype. FGID onset occurred simultaneously with or soon after abuse had started. In 24 women (48%), the beginning of abuse and the onset of the abdominal symptoms coincided in the same period of time; in 12 women (24%), the gastrointestinal symptoms started after at least 6 months of ongoing abuse; and in 4 cases the victim referred to suffering FGID before the beginning of the abuse situation. In 10 cases it was impossible to determine the temporal relationship between the abuse and the FGID. Eighty percent of the women responded affirmatively to the question, Do you think that your digestive problems are related to the abuse situation you are suffering? The intensity of abdominal pain was mild in 7 cases, moderate in 25, and severe in 17, and in 1 case the intensity scale was not filled in. No relationship was observed between time elapsed from the beginning of the maltreatment situation and intensity of the abdominal pain or discomfort. Time elapsed from the onset of abdominal symptoms was 6 months in 15 women, from 6 months to 2 years in another 15, the time was longer than 2 years in 17 women, and for 3 women these data were not available. Sixty-four percent (32) of women with FGID had not consulted their doctor for gastrointestinal symptoms, 34% (17) had, and only 1 woman did not answer the question. Of the women who had consulted a physician, 14 had done so at least 5 times, 2 between 5 10 times, and 1 woman more than 10 times.

4 May 2005 DOMESTIC ABUSE AND FUNCTIONAL GUT DISORDERS 439 Table 2. Characteristics of Women With FGID Whether or not They Consulted a Physician Women with FGID a Consulted physician (n 17) Did not consult (n 32) P value Age (y) NS Anxiety score NS Depression score NS Subjective perception of an association between FGID and abuse (%) NS Intensity of pain (%) Mild Moderate Severe Time of FGID evolution (%) Less than 6 mo Between 6 mo and 2 y y NS a One woman did not answer the question. No significant differences were found among the women who saw a physician and those who did not regarding age, form and duration of abuse, and anxietydepression levels. The subjective perception of a positive association between their digestive discomfort and the abuse situation was similar in both groups. The women who consulted their physician had higher pain intensity (P.044) (Table 2). Women with a diagnosis of both FD and IBS consulted the doctor significantly more (46.7%) compared with women with FD, who consulted in 12.5% of cases (P.02). Comparison Between Women With and Without Functional Disorders When the group of women who had FGID was compared with those who did not, no differences were found in age, socioeconomic variables, form of abuse received, time of subjection to abuse situation, or anxiety subscale score. Global HAD score, depression subscale score, and percentage of cases with a high level of psychological distress trended toward being higher in the group of women with FGID, but these differences did not reach statistical significance (Table 3). Discussion Previous studies are consistent with the hypothesis that a history of abuse significantly increases the risk of FGID. This fact was first described in 1990, showing that a history of sexual or physical abuse was more prevalent in patients with FGID than in patients with organic gastrointestinal disorder in the same population. 16 In a population-based study in which 26% of participants referred to having suffered some form of abuse (emotional, physical, or sexual), it was calculated that abuse during childhood or adulthood increased the risk of FGID 2-fold, and that when maltreatment was present in both periods of life, the risk of suffering FGID increased 3-fold. 14 Different forms of abuse might be related differently to FGID, as shown in a subsequent study in gastroenterologic outpatients, in whom only severe forms of abuse such as rape and life threats were related to FGID. 21 Conversely, other authors found that emotional abuse per se is also related to IBS. 10,14 In all these previous studies, maltreatment was retrospectively assessed as a history of abuse. Information on the presence of gastrointestinal symptoms while the maltreatment is ongoing is scant. Interestingly, in one study, Table 3. Characteristics of Women According to the Presence of FGID Women with FGID (n 50) Women without FGID (n 20) P value Age (y) a NS Anxiety score a NS Depression score a HAD global score a % of high psychological distress (HAD 20) Form of abuse, n (%) Physical 1 (2%) 1 (5%) Psychological 15 (30%) 6 (30%) Both 34 (68%) 13 (65%) NS a Mean standard deviation.

5 440 PERONA ET AL CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 3, No. 5 women under current abuse had greater gastrointestinal and mental health disturbances than women with past abuse and similar symptoms as the group of persons who had suffered childhood abuse. 22 Unlike previous studies we selected a population suffering a current situation of maltreatment severe enough to be reported to the police. It should be noted that the forms of abuse evaluated are psychological or physical domestic violence. Women reporting sexual aggressions were not included in this study. The present study reveals for the first time how the majority of women who report a situation of domestic violence to the police present chronic digestive discomfort consistent with FD or IBS. Both FD prevalence of 67% and IBS prevalence of 47% were considerably higher compared to the general female population of Spain, in whom the prevalence of FD is 24% and of IBS between 4.6% and 13.6%, depending on the criteria used to define IBS. 23,24 Furthermore, in our study it was possible to analyze the temporal relationship between the abuse situation and the appearance of FGID; in 72% of our sample the beginning of abuse coincided with or had started before the onset of symptoms. At the same time, the majority of women related their digestive symptoms to the situation of abuse. The concept of patient perceptions regarding the origin of symptoms has not often been evaluated in the literature and should be taken into account in the context of functional as in other disorders. Drossman et al 15 proposed that psychological distress would be the mediator for the development of FGID in abuse situations. In this respect, the women in our study presented higher levels of anxiety and depression than what could be regarded as normal, and the development of FGID was associated with higher levels of psychological distress. Thus we believe that the high level of psychological distress is indeed a mediator for the development of FGID in women suffering domestic violence. Unfortunately our results are not definitive, because differences did not reach statistical significance. The reasons could be related to the limitations of our study. One of the limitations is that the situation of a police report might represent per se an acute stressful situation that introduces a bias in the analysis of the data, although we consider that any violent event is more stressful than the fact of reporting it to the police, especially when a social worker accompanies the woman in the process. Also in the few cases with HAD score collected outside the police station, concordance with the first questionnaire was excellent. The majority of maltreatments to women are perpetrated by their partners or ex-partners, as is the case in our study, and nearly half occur at the victim s or at the couple s home. We think that the low rate of received second questionnaires could be related to this fact. It must be hard to answer our questionnaire where the maltreatment usually takes place. Another limitation to be considered is that the same questionnaire was not applied in other populations of persons reporting to the police for other reasons, which would have served as a control group. In comparing the other variables between women with and without FGID, no differences were found concerning age, type of abuse received, or duration of the maltreatment situation. Furthermore, the intensity of abdominal pain or discomfort did not depend on the duration of the abuse situation. Therefore, we could not identify any factor other than psychological distress that might influence the development of FGID. It might be hypothesized that the stress-inducing events might have a different effect on each person, according to individual vulnerability related to genetic factors, 25 previous gastrointestinal infections, 26 different coping skills, 27 and other conditioning psychosocial factors. 28 Taking into account that one of the characteristics of patients with FGID is their high frequency of consultation to the doctor, which implies a high health cost, 29 in this study the low frequency of medical consultation for FGID symptoms is clearly signaled. Medical consultation had no relationship with the duration of gastrointestinal symptoms or with psychological status. Instead, pain intensity was higher in women who had sought medical care. These results suggest, in concordance with a previous study, 30 that symptom severity was the most important predictor of seeking health care in the present study. It is known that two thirds of IBS sufferers are women. Either in the general population or in gastroenterology practice, all forms of abuse or maltreatment are more frequent in the female population We believe that higher abuse rates could contribute to the greater prevalence of FGID in women than in men, and that this gender difference should not be underestimated in FGID. In summary, these results demonstrate that a relationship exists between the abuse a woman suffers and the appearance of functional digestive disorders. This relationship might be mediated through the high levels of psychological distress to which these women are subjected. They experience a complex negative situation with anxiety, socioeconomic and legal problems, and injuries and also have a high risk of suffering a chronic disorder such as FGID that impairs their quality of life.

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Predictors of health care seeking for irritable bowel syndrome: a population based-study. Gut 1997;41: Address requests for reprints to: Fermín Mearin, MD, Institute of Functional and Motor Digestive Disorders, Servicio de Aparato Digestivo, Centro Médico Teknon, C/Vilana 12, Barcelona, Spain. mearin@dr.teknon.es; fax: ( 34) Supported by a grant from Astra-Zeneca Spain. The authors thank Ms Mariví Foronda, the social worker, for her participation in this study, and we also thank Ms Christine O Hara, who helped to prepare the manuscript.