Sexual Abuse Strongly Linked to Suicidal Behavior

Caroline Cassels

September 23, 2009

September 23, 2009 — Sexual abuse is a significant precursor for suicidal behavior, particularly among women, new research suggests.

A randomized cross-sectional survey of the British population shows that a history of sexual abuse is strongly associated with suicide attempts and suicidal intent and that although the association is higher for women than men, it is substantial for both groups, with odds ratios of 9.6 and 6.7, respectively.

Led by Paul E. Bebbington, PhD, FRCP, FRCPsych, investigators at University College London, United Kingdom, note that based on these findings, the absence of sexual abuse would mean the rate of suicide attempts during a lifetime would drop by 28% in women and by 7% in men.

The study was published online September 1 and will appear in the October print issue of the American Journal of Psychiatry.

Similar Pattern of Suicidal Intent

According to the study, sexual abuse and suicide are more common in women, which led researchers to test the hypothesis that sexual abuse may contribute to suicide risk in females.

Using data from the 2000 British National Survey of Psychiatric Morbidity, the investigators interviewed 8580 randomly selected volunteers aged 16 to 74 years of both sexes from individual households in Great Britain.

Interviewers gathered data on sociodemographics, general health, and intellectual functioning and common mental health problems. Participants were asked specifically about previous suicide attempts. Study subjects were also asked about victimization, which included a question about sexual abuse.

The researchers used the Clinical Interview Schedule–Revised to determine affective disturbance at the time of the interview and found it was a mediator of the relationship between childhood sexual abuse and suicidal behavior.

The study's primary analysis was based on lifetime history of suicide attempt. Secondary outcomes also included analyses of suicidal intent.

Among the respondents, 430 (4.5%) reported at least 1 suicide attempt during the course of their lives, and 50 (0.5%) subjects reported at least 1 suicide attempt in the past year.

The authors note that although women were significantly more likely than men to admit to lifetime suicide attempts, the frequency during the past year was the same between the sexes.

The investigators found a similar pattern for lifetime suicidal intent: 12% of men vs 17% of women, which is a significant difference. However, they report there were no differences between the 2 groups in suicidal intent during the past week or the past year.

Consider Sexual Abuse

Sexual abuse was reported by 3.5% of the study population and was more common in women (5.2%) than men (1.6%). However, say the authors, it is not clear whether these rates are a true reflection of the prevalence of sexual abuse among men and women or whether it is confounded by the fact that men may be less likely to report sexual abuse.

When investigators repeated the analyses using suicidal intent in the past week, in the past year, and during the life course, the results were similar — sexual abuse was strongly related to suicidal intent in all time frames, as it was to suicide attempts.

The authors also report that the Clinical Interview Schedule–Revised total score was strongly associated with both suicide attempts and sexual abuse.

"The implication is that affect strongly mediated the link between sexual abuse and suicidal phenomena. Sexual abuse probably has a tonic effect on increasing dysphoric mood such that sexually abused persons require less deterioration in their affect to place them in danger for suicidality," the investigators write.

They add that when faced with suicidal patients, clinicians should consider the possibility of sexual abuse, which requires focused treatment.

Need for Increased Awareness

In an accompanying editorial, Mindy Thompson Fullilove, MD, a research psychiatrist at New York State Psychiatric Institute and professor of clinical psychiatry and public health at Columbia University, New York City, says one of the study's strengths is in its population-based design.

"A growing body of the evidence from population-based studies is providing a much more reliable estimate of the health problems posed by this trauma of childhood. An interesting feature of this and other large studies is that they are documenting constellations of negative outcomes. In this study, the connections among childhood sexual abuse, gender, affective disturbance and suicide attempt/intent draw our attention to a web of interconnections," Dr. Fullilove writes.

Dr. Fullilove applauds the authors' recommendation that patients with suicidal behaviors be screened for sexual abuse but also notes that previous research has shown that detection of trauma does not always mean this information is incorporated into treatment plans.

One major barrier, writes Dr. Fullilove, is a paucity of well-established treatments. Nevertheless, she says, this and other potential barriers are not reasons not to act and highlight the need for greater public awareness of child sexual abuse and its long-term sequelae.

The authors have disclosed no relevant financial relationships.

Am J Psychiatry. Published online September 1, 2009. Abstract Am J Psychiatry. 2009;166:1090–1092.


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