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Joan Arehart-Treichel

Young women with bulimia nervosa share both emotional secrecy and profound
guilt with many victims of sexual abuse. For some bulimia patients, this
emotional style may begin with sex abuse.

As psychiatrists know only too well, childhood sexual abuse can devastate
young people psychologically and thus render them vulnerable to a spate of
mental illnesses-alcohol abuse, depression, drug abuse, panic disorder,
posttraumatic stress disorder, and suicide attempts (Psychiatric News,
August 3, 2007; August 17, 2007).

Bulimia nervosa can be added to the list of unfavorable outcomes as well,
some studies have suggested. Now a new one does too. It was headed by Lena
Sanci, Ph.D., a senior lecturer in general practice at the University of
Melbourne in Australia. Results were published in the March Archives of
Pediatrics and Adolescent Medicine.

Sanci and her coworkers randomly selected some 1,000 female students,
average age 15, from 44 public, Catholic, or private schools to participate
in their study. They followed their subjects until they were young adults to
see whether they developed bulimia nervosa or anorexia nervosa. Thirty-five
were found to have acquired bulimia and 32 anorexia during that age span.

At age 24, the subjects were asked certain questions to determine whether
they had experienced sexual abuse before age 16.

"We measured childhood sexual abuse in adulthood because our state has a
statutory requirement to report all abuse in children younger than 17 years
to government services," Sanci and her coworkers explained in their study
report. "To have informed parents and participants of this at the time
carried a risk of selective refusal for those with abuse histories.
Furthermore, participation... required parental and school consent.
Inclusion of childhood sexual abuse questions may have reduced our response
rates. By the age of 24 years, we believed participants would be
sufficiently comfortable to encounter these questions, yet not as removed
from the experience as to limit recall."

Ninety-six of the subjects reported one episode of sexual abuse, and 70
reported two or more episodes. The researchers then looked to see whether
there were any links between subjects' retrospective reports of having been
abused sexually as a child and their later developing bulimia or anorexia.
During this analysis, subjects' background differences-say, their parents'
educational levels and whether their parents were divorced-were considered.

Sanci and her colleagues found no link between reports of having been
sexually abused in childhood and developing anorexia, but they did find a
link with bulimia. Compared with subjects who had experienced no childhood
sexual abuse, the incidence of bulimia was three times higher among those
who reported one episode and five times higher among those who reported two
or more episodes. Furthermore, even when some possibly confounding factors
such as subjects' anxiety, depression, or dieting behavior before developing
an eating disorder were considered, it reduced the association between
childhood sexual abuse and bulimia only a little.

Thus, "Childhood sexual abuse seems to be a risk factor for the development
of bulimic syndromes, not necessarily mediated by psychiatric morbidity or
severe dieting," Sanci and her group concluded in their report.

Their findings largely jive with those obtained by other investigators, they
pointed out. In four different studies, investigators were able to link
childhood sexual abuse with both bulimia and anorexia, but the links they
found were much stronger for bulimia.

Sanci told Psychiatric News, "I was surprised that we found such a clear
association between childhood sexual abuse and bulimia symptoms, as there
has been so much controversy in the past [about whether such a connection
exists]."

"This paper takes us a step further in confirming suspicions that clinicians
have long had that childhood sexual abuse is common in young women with
bulimia," George Patton, M.D., a professor of psychiatry at the University
of Melbourne and senior investigator of the study, added. "The paper [also]
takes us a step further by suggesting that sexual abuse may initiate a
pattern of dealing with emotional distress that brings a high likelihood of
bulimia. Young bulimics share both emotional secrecy and profound guilt with
many victims of sexual abuse. It is possible that for some patients, this
emotional style begins with the abusive experience. This psychological style
may be an important focus for psychotherapy."

The study was funded by the Australian National Health and Medical Research
Council, the Australian Center for Excellence in Eating Disorders, and a
research grant from the Australian National Depression Initiative.