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Sexual and Physical Abuse Hrstory in Gastroenterology Practice: How Types of

Abuse Impact Health Status


JANE LESERMAN, PHD, DOUGLAS A. DROSSMAN, MD, ZHIMING LI, MD, TIMOTHY C. TOOMEY,
PHD, GINETTE NACHMAN, MD, AND LOUISE GLOGAU, BA
Objective: There is an increasing amount of literature pointing to a relationship between sexual and/or
physical abuse history and poor health status, although few studies provide evidence concerning which
aspects of abuse may impact on health. In female patients with gastrointestinal (GI) disorders, the present
study examined the effects on health status of: 1) history of sexual abuse and physical abuse, 2) invasiveness
or seriousness of sexual abuse and physical abuse, and 3) age at first sexual and physical abuse. Method: The
sample included 239 female patients from a referral gastroenterology clinic who were interviewed to assess
sexual and physical abuse history. Results: We found the following: 1) 66.5% of patients experienced some
type of sexual and/or physical abuse; 2) women with sexual abuse history had more pain, non-GI somatic
symptoms, bed disability days, lifetime surgeries, psychological distress, and functional disability compared
to those without sexual abuse; 3) women with physical abuse also had worse health outcome on most health
status indicators; 4) rape (intercourse) and life-threatening physical abuse seem to have worse health effects
than less serious physical violence, and sexual abuse involving attempts and touch; and 5) those with first
abuse in childhood did not appear to differ on health from those whose first abuse was as adults. Conclusions:
The authors conclude that asking about abuse should be integrated into history taking within referral-based
gastroenterology practices.
Key words: Sexual abuse, physical abuse, health status, pain, psychological distress, gastrointestinal disorder,
gastroenterology.
INTRODUCTION
In the first study to document the high prevalence
of sexual and physical abuse among female patients
in a referral gastroenterology clinic, it was found that
44% of women reported some type of sexual and/or
physical abuse (1). Those with abuse history had a
4-fold greater risk of pelvic pain, two to three times
more nonabdominal symptoms (eg, headaches, back-
aches, fatigue), as well as more lifetime surgeries.
These findings among patients with gastrointestinal
(GI) disorders have now been replicated by other
researchers (2,3). In addition, there is presently an
abundance of research examining the psychological
(4-7) and somatic (8-12) correlates of past sexual
and physical abuse among those in normal popula-
tions, primary care practice, and among those with a
variety of pain and chronic disorders.
From the Department of Psychiatry (J.L., D.A.D., T.C.T.), and
Division of Digestive Diseases, Department of Medicine (J.L.,
D.A.D., Z.L., G.N., L.G.}, University of North Carolina School of
Medicine, Chapel Hill, North Carolina
Address reprint requests to: Jane Leserman, PhD, Departments
of Psychiatry and Medicine, CB #7160, University of North
Carolina, Chapel Hill, NC 27599-7160.
Received for publication March 17, 1995; revision received
May 16, 1995.
Despite the profusion of research, there is little
clarity or evidence concerning which aspects of
abuse may impact on health status. Few studies
systematically look at the separate effects of sexual
vs. physical abuse, the independent contributions of
more invasive types of abuse, and the relative im-
portance of first abuse in childhood vs. adulthood. In
addressing these three issues among women patients
in a referral gastroenterology clinic, the present
paper will follow-up and extend our initial observa-
tions, using more reliable and valid methods of
assessment.
Studies of primary care patients and general pop-
ulation surveys have consistently documented a
relationship of sexual abuse history with GI symp-
toms and disorders (8,13-16). Only two of these
studies examined the separate effects of physical and
sexual abuse on GI disorders (13,14). In both studies,
those with irritable bowel syndrome (IBS), a com-
mon chronic GI illness, were more likely to have
been sexually abused compared with those without
this disorder. However, in only one study was phys-
ical abuse history found to differ between those with
IBS compared with those without IBS (13). These
studies of physical abuse and GI disorders did not
inquire about experiences involving life threat.
In addition to GI disorders, studies have also
shown a preponderance of pelvic and abdominal
pain compared to other types of pain in patients with
Psychosomatic Medicine 58:4-15 (1996)
SEXUAL AND PHYSICAL ABUSE HISTORY
sexual and/or physical abuse history (11,17-20).
One study examined the separate effects of physical
and sexual abuse, and found that only physical
abuse, particularly that occurring in childhood, dif-
ferentiated women with pelvic pain from those with
other types of pain or no pain (19).
Women with sexual and/or physical abuse histo-
ries have also been shown to have a large array of
other medical symptoms, and other indicators of
poor health, compared with those without abuse
(10,12,21). These have included more: functional
disability (2,15), non-GI somatic symptoms
(1-3,8,15,16,22-25), pain (15), lower pain thresholds
(2), psychiatric illness (2-4), physician visits (16),
and hospitalization or surgeries (1,22,24). Only four
of the above studies investigated physical abuse
(1,2,24,25), and only one analyzed the effects of
physical abuse separately from sexual abuse (25). In
this study of pain and nonpain patients, physical
abuse, particularly in childhood, was more consis-
tently predictive of physical and psychological dis-
tress than was sexual abuse.
Although many studies have looked at the rela-
tionship of sexual abuse history to poor health, our
review of available literature shows that few have
examined the health impact of physical abuse, over
and above sexual abuse. Furthermore, we could find
only a few health outcome studies that examined
invasiveness of sexual abuse and none that focused
on seriousness of physical abuse. Among women in
a rural family practice clinic, those with penetration
experiences (defined as actual or attempted sexual
intercourse, and objects in the vagina) were reported
to have more medical symptoms and higher somati-
zation scores than women with less severe abuse
(22). Other studies report no effect on health out-
come of invasive sexual abuse (intercourse) com-
pared with less invasive abuse (18,23).
Finally, few studies have assessed how age of
abuse onset may affect health status. Wallings and
colleagues (25) have shown that both childhood
physical abuse and adult abuse (sexual and/or phys-
ical) were related to worse psychological and so-
matic symptoms among women with and without
pain. Childhood sexual abuse was unrelated to psy-
chological status or somatization, however, inade-
quate power may have accounted for their findings.
Rapkin et al. (19) showed that pelvic pain patients
had more child abuse (particularly physical abuse),
but not adult abuse, compared with those with other
or no pain. Other studies have not found consistent
differences in health outcome based on age when
abuse occurred (11,14,18,23).
In patients seen in a gastroenterology clinic, we
determined the effects on health status of the follow-
ing: 1) history of sexual abuse and physical abuse, 2)
invasiveness or seriousness of sexual abuse and
physical abuse, and 3) age at first sexual and physi-
cal abuse. We hypothesized that poorer health status
would be associated with history of both sexual and
physical abuse, and with more invasive abuse.
Health status is conceptualized to include pain,
somatic symptoms, days in bed due to disability,
number of lifetime surgeries, functional disability,
and psychological distress.
METHODS
Sample and Procedure
Data were collected on 239 women patients seen at the Uni-
versity of North Carolina, referral gastroenterology clinic. While
waiting to see their physicians in the clinic, all English-speaking
women patients between ages 18 and 70 were asked consecutively
to fill out a brief questionnaire and to enroll in a longitudinal
study. The study was approved by our Institutional Review Board,
and all subjects signed a written informed consent before partic-
ipating in the study. Those agreeing to the longer study returned
for a full-day visit where they filled out questionnaires and were
administered a structured interview concerning sexual and phys-
ical abuse history. Data were collected over a 2-year period. Of the
731 women who met eligibility requirements and were asked to be
in the study, 506 women completed the brief clinic questionnaire
(69% of those eligible); of these, 239 (33% of eligible) returned for
a full-day visit. The latter group are the subjects analyzed for the
present study.
Measurement
Sexual abuse. A structured interview was developed to assess
in detail the presence of sexual and physical abuse history, as well
as the nature of the abuse. The Structured Abuse Interview was
based on the work of many researchers working in this field
including: Kilpatrick et al. (26,27), Jacobson and Richardson (28),
Russell (29), and Koss et al. (30,31). The structured interview was
conducted by clinical psychology graduate students (G.N. or
L.G.), who were extensively trained in administering and scoring
the instrument.
Clear rules were written and conferences with senior investi-
gators (J.L., T.C.T., D.A.D.) were held to decide on whether
ambiguous experiences met our criteria for abuse. To meet criteria
for sexual abuse incidents in adults, there had to be clear throat of
harm or force; feeling pressured to have sex was not sufficient. To
meet criteria for sexual abuse in children, the threat of force did
not have to be as clearly established; "unwanted" incidents
sufficed where threat of force was implied by the age differential
between perpetrator and victim. Subjects who indicated that they
may have been abused, but were not sure, were not considered to
have abuse history.
Sexual abuse was defined as any of three types of sexual
experiences: those involving attempts; those involving forced
sexual touching with hand, mouth, or objects; and lastly, those in
which vaginal or anal intercourse (rape) occurred. Table 1 shows
Psychosomatic Medicine 58:4-15 (1996)
|. LESERMAN et al.
TABLE 1. Sexual and Physical Abuse Interview Items
Sexual*
Attempts: (positive response to any of the 5 items below)
"By using force or threatening to harm you, has anyone ever:
1) made you watch a sexual act,
2) tried to touch the sex parts of your body, but did not suc-
ceed,
3) tried to make you touch the sex parts of their body, but did
not succeed,
4) tried to make you have sex, but he did not succeeded, and
5) attempted any other sexual experience not involving con-
tact?"
Touch: (positive response to any of the 5 items below)
"Has anyone ever succeeded in touching the sex parts of your
body by using force or threatening to harm you? By touch we
mean;
1) with their hands, touched or fondled your sexual organs
(breast, pubic area, anus),
2) with their mouth or tongue on your vagina or anus (oral
sex), and
3) putting fingers or objects in your vagina or anus?
Has anyone ever succeeded in making you touch the sex parts of
their body by using force or threatening to harm you? By touch
we mean:
1) made you touch or fondle their genital area, and
2) made you put their penis in your mouth (oral sex)?"
Rape: (positive response to any of the 2 items below)
"Has anyone made you have vaginal or anal sex by using force or
threatening to harm you? By sex we mean:
1) vaginal intercourse (man putting his penis in your vagina),
and
2) anal intercourse (man putting his penis in your anus)?"
Physical
Being beat, hit, or kicked: (positive response to item below)
"Has anyoneincluding family members of friendsever beat
you up, hit you, kicked you, bit you, or burned you, regardless of
when it happened or whether you ever reported it or not? (In-
clude experiences that were outside the range of normal "spank-
ing" or kids fighting)."
Life threat: (positive response to any of the 2 items below)
1) "Has anyoneincluding family members of friendsever at-
tacked you with a gun, knife, or some other weapon, regard-
less of when it happened or whether you ever reported it or
not?
2) Has anyoneincluding family members of friendsever at-
tacked you without a weapon, but with the intent to kill or
seriously injure you?"
* To meet criteria for sexual abuse in children, threat of force did not
have to be as clearly established; "unwanted" incidents sufficed where
threat of force was implied by the age differential between perpetrator
and victim.
the exact wording of the questions in these three categories. We
considered these three types of abusive experiences to be hierar-
chical in invasiveness, that is, rape (intercourse) being more
serious than touch, and touch being more serious than an attempt.
Because it is likely that touch experiences occur during rape, we
coded only the most invasive type of experience for each discrete
abuse event. When more than one abuse event occurred we coded
the most invasive type for each event. For purposes of data
analyses, subjects were given sexual abuse scores based on their
most invasive sexual abuse experience. Thus, sexual abuse was
defined in terms of four mutually exclusive and hierarchical
categories: No sexual abuse, attempts only (no touch or rape),
touch (touch with or without attempts, no rape), and rape (rape
with or without other types of abuse).
Researchers have included a variety of types of sexual encoun-
ters in their criteria of sexual abuse. "Noncontact" sexual abuse,
(sexual experiences that do not involve physical contact), have
included encounters with exhibitionists, and unsolicited sexual
advances (without force). These experiences have been catego-
rized in the present study and by others (32,33) as "attempted"
sexual abuse only if they occurred in childhood and met criteria
of "unwanted" events. Another type of "attempt" experience is
attempted rape or attempted sexual touching, when force is used
or threatened but sexual contact does not occur. Being threatened
with rape and then escaping before any sexual touching occurs is
an example of an experience we categorized as "attempted" or
"noncontact" sexual abuse. "Contact" abuse included both touch
and rape abuse.
There is no empirical evidence to indicate which age separates
child from adult abuse; age limits for child abuse range from 12 to
17 (33). For comparative purposes we chose the most commonly
used age cutoff of 14 (1,31), inasmuch as it is the statutory age for
rape in most states.
To compare the abuse history of full participants to those
answering only the clinic questionnaire, the questionnaire admin-
istered in the gastroenterology clinic also included items on
sexual and physical abuse. These sexual abuse items were
adapted from the National Population Survey of Canada (34); and
have been described in detail previously (1). Briefly, the question-
naire included the paraphrased items below. When you did not
want it, has anyone ever: exposed the sex organs of their body to
you (childhood only), threatened to have sex with you, touched
the sex organs of your body, made you touch the sex organs of
their body, forced you to have sex, or have you had any other
unwanted sexual experience?
Physical abuse. Using the same interview for sexual abuse, we
also included questions concerning physical abuse. Since by
definition, many types of sexual abuse involve physical abuse, we
counted physical abuse only when it occurred as an event outside
the sexual abuse incident. Thus, physical abuse in this study was
counted only if the incident did not involve sexual abuse. Phys-
ical abuse was divided into two categories: beat, hit, or kicked,
and life threat. Table 1 shows the exact wording of items in the
structured interview measuring these two categories of physical
abuse.
Like sexual abuse, the categories of physical abuse (beat up and
life threat) were considered hierarchical, so that being beat, hit, or
kicked was not recorded, if in the same incident the person was
attacked severely enough to have had their life threatened. For
purposes of data analyses, subjects were given physical abuse
scores based on their most serious abuse experience, so if more
than one incident of physical abuse occurred, then we coded the
most invasive type. Thus, physical abuse was defined in terms of
three mutually exclusive and hierarchical categories: No physical
abuse, beat up (beat, hit or kicked only, no worse physical
violence), and life threat (with or without a weapon, regardless of
lesser violence).
Physical abuse was measured on the clinic questionnaire with
a positive response to either of the following items, "When you
were a child (13 or younger), did an older person . . . seriously
threaten your life?", or "Now that you are an adult (14 and older),
has any other adult. . . seriously threatened your life?"
Health status variables. Health status covers a broad array of
concepts. To be inclusive, we used six different summary mea-
Psychosomatic Medicine 58:4-15 (1996)
SEXUAL AND PHYSICAL ABUSE HISTORY
sures including: pain severity averaged over 14 days, number of
non-GI medical symptoms, number of days spent in bed during
the previous 3 months, number of lifetime surgeries, psychologi-
cal distress, and overall functional disability. For all health status
variables, a high score indicated worse overall health.
The pain measure was a visual analogue scale (VAS) (100 mm
line) in response to the item, "place a vertical mark that indicates
the amount of pain you felt today?" (Scores could range from none
(0) to very severe (100)). Patients were given the pain diary card at
their day long visit. They were asked to mark the amount of pain
they experienced everyday for the 14 days after their visit. These
14 pain ratings were averaged. For subjects who missed days, the
available days were averaged, except those missing more than 7
days were omitted. The VAS approach has been shown to be
sensitive to changes in pain intensity (35).
Number of non-GI medical symptoms for the past 6 months is
derived from a list of 32 medical symptoms that patients indicate
"yes" or "no" to their presence. Possible range is thus from 0 to 32.
Symptoms include such problems as frequent headaches, fre-
quent backaches, feeling tired or fatigued, rash, etc. Symptoms
were chosen from other symptom checklists and verified as
commonly occurring among women by the National Ambulatory
Medical Care Survey (36).
Number of days in bed or bed-disability days was measured by
the following item, "How many days during the past 3 months did
you stay in bed (more than half the day) because of illness?
Include any days you stayed in the hospital." This item was
adapted from the Epidemiological Catchment Area survey for
North Carolina (37). Number of lifetime surgeries was measured
by the item, "How many surgeries have you had in your lifetime?"
This item has been used in our previous research (1).
We measured psychological distress with the Global Symptom
Index (GSI) of the SCL-90 (38). This is a 90-item questionnaire
including 8 subscales (depression, anxiety, hostility, obsessive
compulsion, phobic anxiety, interpersonal sensitivity, somatiza-
tion, and psychoticism). For the present study, we used the raw
score from the summary measure of all 90 items ranging from 0
(low distress) to 4 (high distress). This instrument has been used
widely and has been shown to be highly reliable and valid (38).
The overall summary scale of the Sickness Impact Profile (SIP)
was used as a measure of functional disability (39). The SIP has
become a standard assessment tool to assess daily functioning in
12 areas of activity (eg, mobility, body care, social interaction,
alertness, eating).
Demographic data were obtained by questionnaire. Primary
diagnosis (functional vs. organic) was determined by patient's
physicians. One of the authors (D.A.D.) reviewed the medical
records of patients where diagnosis was in question. Functional
diagnoses include those conditions with no known structural or
biochemical basis to explain symptoms (eg, IBS, functional ab-
dominal pain, functional dyspepsia). Organic disease includes
disorders such as ulcerative colitis, Crohn's disease, and liver,
pancreatic-biliary, and acid peptic disease.
Data Analysis
To determine the representativeness of our sample, we com-
pared the 239 women who completed the full-day interview study
to those who did not participate in the full study, but completed
only a brief questionnaire while waiting in the clinic [N = 267).
For continuous dependent variables (eg, education, age), we
performed a t test for independent samples (two-tailed), and for
bivariate dependent variables (eg, diagnosis, abuse, race), we
performed a z-test of proportional differences between indepen-
dent samples (two-tailed).
Several health status measures had one extreme outlier score.
These were truncated (given a score 1 unit higher than the next
highest score) to avoid problems of undue influence. All data
analyses used two-tailed tests.
To examine whether sexual and physical abuse were related to
health status, we performed an analysis of covariance (ANCOVA)
where sexual abuse (coded in four mutually exclusive and hier-
archical categories) and physical abuse (coded in three mutually
exclusive and hierarchical categories) were treated as class vari-
ables. Age, education, race, and diagnosis (functional vs. organic)
were entered into equations first as control variables. These
variables were controlled in this and all other ANCOVA proce-
dures to eliminate possible confounding effects on the relation-
ship between abuse and health status. In the text, we cite the
overall p values from ANCOVA associated with the four category
sexual abuse variable and the three-level physical abuse variable,
holding constant each other and the control measures. All re-
ported means for each category of sexual and physical abuse were
adjusted for the covariates (least squared means from the General
Linear Model). We performed pairwise comparisons [t tests)
among all adjusted means within each class variable only when
the F test for the abuse variable was significant in the model. The
reported increment to R
2
is the explained variance of the full
model minus the R
2
of the model with control variables only.
Because those with "attempted" sexual abuse and physical abuse
involving beatings were never significantly different on health
status from no abuse, these categories were merged with "no
abuse" for subsequent analyses, unless otherwise indicated.
In further specifying our model, we were interested in separat-
ing more invasive touching (eg, oral sex. fingers/objects in vagina)
from less invasive touching (eg, touching with hands). We ran the
ANCOVA model with control variables and one sexual abuse
variable including four categories (none/attempted, less invasive
touch, more invasive touch, and rape). Since the F test for sexual
abuse was significant in all cases, we performed two pairwise
comparisons (t tests) of adjusted means: more vs. less invasive
touch, and rape vs. invasive touch.
Using ANCOVA, we examined the possible confounding role of
multiple abuse in predictions of the health status variables.
Equations included control variables and one sexual abuse class
variable with five categories: no/attempted sexual abuse, one
touch, more than one touch, one rape, and multiple rape/contact
abuse (more than one rape or one rape and at least one touch). We
performed four pairwise comparisons [t tests) of adjusted means:
one rape vs. multiple rape/contact abuse, one touch vs. more than
one touch, one touch vs. one rape, and more than one touch vs.
multiple rape/contact abuse. In six separate ANCOVA equations
with the health status dependent variables, we examined a phys-
ical abuse class variable divided into five categories: no physical
abuse, one beating, more than one beating, one life threat, and
multiple severe abuse (more than one life threat, or one life threat
and at least one beating). We performed four pairwise compari-
sons of adjusted means (adjusting for control variables): one life
threat vs. multiple severe abuse, one beating vs. more than one
beating, one beating vs. one life threat, and more than one beating
vs. multiple severe abuse.
We examined the effects of age of first abuse on health status
using ANCOVA. In addition to the control variables, we included
three class variables: touch (no touch, child touch abuse, adult
touch abuse), rape (no rape, child rape, adult rape) and life threat
(no life threat, child life threat, adult life threat). We performed
pairwise comparisons (f tests) among all adjusted means within
Psychosomatic Medicine 58:4-15 (1996)
oach class variable only when the F test for the abuse variable was
significant in the model. The reported increment to R
2
is the
explained variance of the full model minus the R
2
of the model
with control variables only.
RESULTS
Comparison of Study Subjects to Nonparticipants
To determine the representativeness of our sam-
ple, we compared the 239 women completing the
study (full participants) to the 267 who completed
only the clinic questionnaire. In other words, we
were interested in whether participants in the full-
day study differed from those filling out only the
clinic questionnaire. We found that full participants
and clinic participants did not differ on race (z = .37,
p = .71, N = 506), having functional vs. organic
illness (z = 1.44, p = .15, N = 470), estimation of
health status (1 = poor to 5 = excellent) ( = .39, p =
.70, N = 503), and perception of well-being (1 = poor
to 5 = excellent) {t = 1.11, p = .27, AT = 497). Full
participants were on average 4 years younger (t =
3.39, p = .001, N = 506), and had 1 more year of
education [t = 3.99, p = .0001, N = 505) than clinic
participants. Furthermore, on a brief questionnaire
measure of abuse (1), full participants reported
somewhat more sexual abuse (49.4%) compared
with clinic participants (38.2%) (z = 2.53, p = .011,
N = 506), but the groups did not significantly differ
on serious life threat (28.0% for participants and
22.1% for clinic patients, z = 1.52, p= .13, N= 503).
J. LESERMAN et al.
TABLE 2. Demographic and Abuse Variables [N = 239)
Mean age (SD)
Mean education (SD)
Race
White
Nonwhite
Diagnosis
Functional
Organic
Sexual abuse
None
Attempted
Touch
Rape
Total sexual abuse
"Contact" sexual (rape + touch)
Physical abuse
None
Beat up
Life threat
Total physical abuse
Sexual and/or physical abuse
Any
Physical/"Contact" sexual
Age at first "contact" sexual abuse {N = 99)
Childhood (<14 years)
Adulthood
Age at first life threat physical abuse (N = 68)
Childhood (<14 years)
Adulthood
%
39.4 (12.3)
14.0 (2.8)
83.7
16.3
38.5
61.5
44.8
13.8
16.3
25.1
55.2
41.4
51.5
20 1
28.4
48.5
66.5
60.2
38.4
61.6
27.9
72.1
some type of "contact" sexual and/or life threatening
physical abuse. As indicated in Table 2, the majority
of women had their first abuse experience at age 14
and above.
Description of the Study Group
Table 2 shows the demographic and abuse history
characteristics of women in our study. The average
age was 39.4 years (SD = 12.3), with a range from 18
to 70, and mean education was 14.0 years (SD = 2.8).
The racial distribution was 83.7% white, and 16.3%
nonwhite (11.7% African-American and 4.6% other
racial/ethnic groups). The majority of patients have a
primary GI diagnosis of organic disease (61.5%).
Fully 55.2% of patients have experienced some
type of sexual abuse (attempt, touch or rape), with
41.4% having a history of "contact" sexual abuse
(touch or rape). Almost half of the women have a
physical abuse history (48.5%). Taken together,
66.5% have had some type of sexual and/or physical
abuse, and about two thirds of women with sexual
abuse history have been physically abused (67.4%).
In addition, 60.2% have had "contact" sexual abuse
and/or physical abuse, and half (50.6%) have had
Sexual and Physical Abuse With Health Status
The relationship of abuse variables to the six
health status measures was studied controlling for
demographic variables and diagnosis (functional vs.
organic). Overall, sexual abuse, (coded none, at-
tempt, touch and rape), was significantly related to
all health status variables, so that women with this
history had more pain [p = .008), more non-GI
somatic symptoms (p = .003), more bed-disability
days (p = .0004), more lifetime surgeries (p = .004),
more psychological distress [p = .0004), and worse
functional status (p = .0001) compared with those
without sexual abuse. Physical abuse history, (coded
none, beat, and life threat), was associated with more
pain (p = .005), more non-GI somatic symptoms (p =
.01), more surgeries (p = .01), and poorer functional
status (p = .05). The trend for those with physical
abuse to have more psychological distress (p = .12)
Psychosomatic Medicine 58:4-15 (1996)
SEXUAL AND PHYSICAL ABUSE HISTORY
became significant when the "beat up" category was
combined with the "no abuse" group [p = .05). Over
and above the control variables, the sexual and
physical abuse measures combined explained from
11% to 17% of the variance on these health status
variables (Table 3]. There were virtually no signifi-
cant interactions of sexual or physical abuse with
diagnosis, so functional and organic groups were
combined for all analyses.
Having shown that sexual and physical abuse
overall were associated with health status, we then
analyzed which types of abuse were associated with
poor health. Table 3 shows the significance of each
type of abuse experience holding constant all other
types of abuse and the control variables. Note that
those with rape history (forced intercourse) had
worse health on all variables compared to those with
no sexual abuse. Those with rape histories reported
on average three more non-GI medical symptoms,
over twice the bed-disability days, over one and
one-half times more surgeries, almost twice the func-
tional disability, and considerably more pain and
psychological distress as those without sexual abuse
history. Women with forced touching as their most
invasive sexual abuse had worse psychological dis-
tress and non-GI somatic symptoms than the non-
abused; rape was significantly more predictive than
touch abuse on all other health status variables.
Women having experienced only attempted abuse
were not different from those with no abuse history
on any health measure. Furthermore, those with rape
history had worse health on all variables compared
with those whose worst sexual abuse involved at-
tempts. Women with forced touching as their most
invasive sexual abuse had worse psychological dis-
tress and functional disability compared with those
with attempted sexual abuse. Inasmuch as attempted
sexual abuse was not predictive of any health status
variable, over and above other types of abuse, these
noncontact experiences were categorized with no
abuse in subsequent analyses.
Table 3 also shows that physical abuse involving
life-threatening force was the only significant pre-
dictor of health status. Compared with women with
no physical abuse history, women whose life had
been threatened (over and above physical assault
during any sexual abuse) had worse pain, somatic
symptoms, surgeries, and functional disability.
(Note, as indicated above, that those with life threat
had significantly more psychological distress than
those not physically abused, when the "beaten"
category was collapsed into the "no abuse" catego-
ry.) Being beat up was not related to worse overall
health, holding constant all other types of abuse and
the control variables. Although having a life threat
was the only significant physical abuse predictor,
those having this experience were not significantly
different in health status from those having been
beaten, except on number of surgeries. (There were
trends for life threat to be worse than being beat up
TABLE 3. Health Status With Sexual and Physical Abuse Variables*
Abuse
Sexual
None
At t empt
Touch
Rape
Physical
None
Beat
Life threat
Increment R
2
Pain
Adj . mean
25.4
25. 0
23.5
36. l "
a W3 CC
21.6
28.1
32. 8
M
13%
(SE)
(2.3)
(3.4)
(3.2)
(2.7)
(2.1)
(2.9)
(2 5)
No. iof Non-CI
Symptoms
Adj.
r
.
(SE)
mean
10.6
11.2
13.7'
13.8'
11.0
12.1
13.9

(0.64)
(0.95)
(0.88)
"'' (0 75)
(0.60)
(0.80)
" (0.72)
15%
No. of Days
Disability
Adj. mean
7.0
5.1
7.1
1 7 J-iobbcc
6.8
8.8
12.1
14%
(SE)
(1-8)
(2.7)
(2.5)
(2.1)
(1.7)
(2.2)
(2.0)
No. of Suq
Adj .
mean
3.6
4.1
3.5
5 .s
Mbcc
4.1
3.4
5.4
aW>
11%
56N6S
(SE)
(0.40)
(0.62)
(0.57)
(0.48)
(0.38)
(0.51)
(0.46)
Psychol ogi cal
Distress
Adj .
mean
.67 (0.06)
.62 (0.09)
. 92
i l b
(0.09)
1. 03"' *' ' (0.07)
.73 (0.06)
.78 (0.08)
.92 (0 07)
13%
Functi onal
Di sabi l i t y
Adj . mean
7.3
6.4
10.2'
J
14,0-
n
'
i Wj c
8.2
8.7
11. 5
an
17%
(SE)
(0.9)
(1.4)
(1.3)
(1.1)
(0.9)
(1.2)
(1.1)
* Table results are from six ANCOVA equations including the following variables: age, education, race, diagnosis (functional vs. organic), sexual
abuse, and physical abuse. Means are adjusted for other variables in the model. Incremental R
2
equals percent variance explained by abuse
variables only. N = 239 for number of surgeries and functional disability. Due to missing data, N = 238 for psychological distress, N = 238 for
bed-disability days, N = 235 for number of non-GI symptoms, and N = 231 for pain.
11
f test p <= .05 different from no abuse.
1111
f test p <= .01 different from no abuse.
'' t test p <= .05 different from attempted sexual abuse (or "beat" physical abuse).
hh
f test p < = 01 different from attempted sexual abuse (or "beat" physical abuse).
c
t test p < = .05 different from touch sexual abuse.
cc
f test p < .01 different from touch sexual abuse.
Psychosomatic Medicine 58:4-15 (1996)
J. LESERMAN et al.
on number of non-GI somatic symptoms (p = .09)
and functional status (p = .06)).
Invasive vs. Less Invasive Touch
Originally we had hypothesized that rape (vaginal
or anal intercourse) was more invasive than all types
of abuse involving touch, including oral sex and
vaginal/anal penetration with fingers or objects.
Other researchers have not made a distinction be-
tween invasive types of touch and rape. Holding
constant demographic characteristics and diagnosis,
we examined the relationship to health status mea-
sures of the following four groups: no sexual abuse
or attempted abuse only (JV = 140), less invasive
touch (eg, forced touching with hands only) (JV =
22), more invasive touch (eg, oral sex, or fingers/
objects in vagina) (JV = 17), and rape (JV = 60). The
more invasive touch group was not significantly
different from the less invasive touch group on any
health measure (p ranged from .16 to .99), and all
trends showed the less invasive group to have worse
health. Furthermore, women with rape history
scored significantly worse (p ranged from .04 to .006)
than those whose worst experience was invasive
touch on all health status variables except number of
non-GI somatic symptoms. As noted above, touch
abuse and rape were both related to more non-GI
somatic symptoms. Our data provided evidence that
the effects of invasive touching were more similar to
the effects of lesser touching than to sexual abuse
involving vaginal or anal intercourse.
Single Incident vs. Multiple Abuse
One possible caveat of our findings concerned our
hierarchical and mutually exclusive categorization
of abuse where those with a touch and rape experi-
ence were included in the rape category. By defini-
tion, those with a rape experience may also have had
a touch experience and thus may have more multiple
abuse than those experiencing only touch abuse. To
determine if multiple sexual abuse experiences
might explain the more predictive effects of rape
compared with touch (on pain, bed disability, sur-
geries and functional status), we compared the fol-
lowing groups: no abuse or attempted abuse (JV =
140), one touch experience (JV = 18), more than one
touch (JV = 21), one rape (JV = 10), and multiple
rape/contact abuse (more than one rape or one rape
and at least one touch experience) (JV = 50). The
small numbers, especially in the "one rape" cate-
gory, made it difficult to determine the possible
confounding effects of multiple abuse. Despite this
problem, we found that in no instance did those with
one rape differ significantly on health status from
those with multiple/rape contact abuse. Those with
one touch experience did not significantly differ
from those with more than one touch experience on
any health status measure. Furthermore, those
with one rape experience tended to rate worse
than those with one touch experience on bed-
disability days (p = .0006), pain [p = .02), and
number of surgeries (p = .07). Those with multiple
rape/contact abuse differed from those with mul-
tiple touch on functional status (p = .01), number
of surgeries (p = .006), bed-disability days (p =
.01), and pain (p = .02). Thus, it seemed that
differences between touch and rape abuse hold
when controlling for multiple sexual abuse. Those
with multiple sexual abuse did not appear to have
worse health status compared with those with a
single episode of abuse.
We were also concerned about whether multiple
physical violence might explain the trend for those
with life-threatening experiences to have worse
health (on surgeries, functional status, and non-GI
symptoms) compared with those reporting incidents
of being beaten, hit, or kicked. Using the same
approach as for sexual abuse, we categorized sub-
jects into the following categories: no abuse (JV =
123), one incident of being beaten (JV = 17), more
than one time of being beaten (JV = 31), one life
threat (JV = 13), and multiple severe abuse (more
than one life threat or one life threat and at least one
incident of being beaten) (JV = 55). Again, the small
numbers in some categories make it difficult to
determine the possible confounding effects of mul-
tiple abuse. On surgeries, functional status and
non-GI symptoms, those with one life threat did not
significantly differ from those with multiple severe
abuse, and those with one experience of being beaten
did not significantly differ from those with more
than such one experience. Furthermore, those with
multiple severe abuse significantly differed from
those with multiple times of being beaten on number
of surgeries (p = .0009), functional status (p = .05),
and non-GI symptoms (p = .005). Thus, it seems that
multiple experiences do not explain why life threat
physical abuse tended to be more predictive of some
health status indicators than being beaten. Since
being beaten up, hit, or kicked was never predictive
of health status over and above other types of abuse,
these experiences were categorized with no abuse in
subsequent analyses.
10
Psychosomatic Medicine 58:4-15 (1996)
SEXUAL AND PHYSICAL ABUSE HISTORY
Child vs. Adult First Abuse
To answer our last question, whether age of first
abuse differentially affects health status, we exam-
ined the following variables: 1) touchincluding no
touch abuse [N = 200), child touch abuse [N = 23),
adult touch abuse [N = 16), 2) rapeincluding no
rape abuse [N = 179), child rape abuse (AT = 15),
adult rape abuse [N - 45), and 3) life threat
including no life threat abuse [N = 171), child life
threat abuse [N= 19), adult life threat abuse [N = 49)
(Table 4). Women whose sexual abuse involved
touching that occurred in childhood (<14 years old)
had more non-GI somatic symptoms than those with
no such abuse. Those whose touch sexual abuse first
occurred in adulthood (14 or more years) had more
somatic symptoms and psychological distress com-
pared with those without touch abuse. Both those
raped in childhood and adulthood had worse health
on all variables compared with not experiencing
rape. In no case did women with abuse first occur-
ring in childhood (either touch or rape) differ on
health status from those with abuse first occurring in
adulthood. It seems that first abuse in both child-
hood and adulthood contribute about equally to
health.
In terms of the age when subjects first had serious
physical abuse, we noted that those who first had a
life threat as an adult had more somatic symptoms,
pain, and surgeries, and those who first had a life
threat as a child had more somatic symptoms com-
pared with those without life-threatening experi-
ences. In no case did those whose first life threat
occurred during childhood differ on health status
from those whose first life threat happened in adult-
hood.
Our definition of first abuse during childhood did
not take into consideration later adult abuse. Ideally,
we would have analyzed three groups: those with
childhood-only abuse, adult-only abuse and both
childhood and adult abuse. We were unable to do
this type of analysis because almost all of those
whose worst first experience was touch sexual abuse
in childhood, only had touch abuse as children
(19/23), whereas, few of those with childhood rape
as their first abuse had only this abuse as children
(3/15). Likewise, with physical abuse, few of those
whose first abuse was life threat in childhood had
only life-threatening experiences as children (3/19).
Thus, we were unable to examine the effects on
health status of abuse occurring only during child-
hood. The results in Table 4 for child rape and
life-threatening physical abuse, refer mostly to those
whose first abuse occurred in childhood but later
had abuse in adulthood.
Abuse occurring in adulthood (either first or last)
was more common among those who had been raped
TABLE 4. Health Status by Child and Adult First Abuse*
Abuse
Sexual
Touch
None
Child
Adult
Rape
None
Child
Adult
Physical
Life threat
None
Child
Adult
Increment R
2
Adj .
mean
35.5
28.8
43.3
25.8
45.8
a
36.0'
1
31.3
35.6
40.7
Pain
(SE)
(2.16)
(4.72)
(5.25)
(2.65)
(5.46)
(3.81)
(3.39)
(4.72)
(3.67)
15%
No. of Non-GI
Symptoms
Adj .
(SE)
mean
13.6
16.5
16.7
13.7
16.3
17.0
13.6
17.4
15.8
(0.62)
b
(1.30)
" (1.50)
(0.75)
(1.56)
(1.08)
(0.96)
(1 -35)
b
(1.04)
15%
No. of Days
Disability
Adj .
mean
15.2
16.9
15.8
7.2
22.4
a
18.3
a
14.1
14.2
19.5
(SE)
(1.73)
(3.65)
(4.21)
(2.11)
(4.37)
(3 00)
(2.69)
(3.78)
(2.92)
14%
No. of Surgeries
Adj .
mean
57
4.8
6.3
4.2
6.5"
6. 1
a
4.6
5.8
6.4'
1
(SE)
(0.40)
(0.84)
(0.97)
(0.49)
(1.00)
(0.69)
(0.62)
(0.87)
(0.67)
11%
Psychological
Distress
Adj .
mean
1.0
1.2
1.4
a
.9
1.5"
1.2
a
1.1
1.3
1.2
(SE)
(0.06)
(0.13)
(0.15)
(0.07)
(0.15)
(0 11)
(0.09)
(0.13)
(0.10)
14%
Functional
Disability
Adj .
mean
13.1
15.4
17.4
10.2
18.9
a
16 8'
1
13.3
16.4
16.1
(SE)
(0.91)
(1.91)
(2.20)
(1.10)
(2.29)
(1.57)
(1.40)
(1.98)
(1.53)
17%
' Table results are from six ANCOVA equations including the following variables: age, education, race, diagnosis (functional vs. organic), touch
sexual abuse, rape sexual abuse, and life threat physical abuse. Means are adjusted for other variables in the model. Incremental R
2
equals percent
variance explained by the three abuse variables only. N = 239 for number of surgeries and functional disability. Due to missing data, N = 238
for psychological distress and bed-disability days, N = 235 for number of non-CI symptoms and N = 231 for pain.
" t test p < = .01 different from no abuse.
h
t test p < = .05 different from no abuse.
c
t test p < = .10 different from no abuse.
Psychosomatic Medicine 58:4-15 (1996) 11
J. LESERMAN et al.
(95%) or had their life threatened (95%) than among
those who had forced touch (51%) or beatings (76%).
Due to this possible age bias, we reexamined the
findings in Table 3. We repeated the ANCOVA in
Table 3, excluding those whose abuse occurred only
in childhood or the few whose age of last abuse was
unknown. We were, therefore, interested in compar-
ing the health status of women with a history of: 1)
adult rape, adult touch abuse, and no (or only
attempted) sexual abuse, and 2) adult life threat,
adult beatings, and no physical abuse. The pattern of
findings in Table 3 were upheld among those with
adult abuse. The potential age bias of more serious
abuse being more likely to occur in adulthood, did
not seem to affect our basic conclusions.
DISCUSSION
Sexual and physical abuse history seem to be
common among women in a referral-based gastroen-
terology clinic. Fully 50.6% of our sample had
experienced forced touch, rape, and/or life-threaten-
ing physical abuse. As many as 66.5% of women in
our study report sexual or physical abuse when
using a broader definition (including also attempted
sexual abuse and experiences of being beaten, hit,
kicked, burned, or otherwise hurt). Like other stud-
ies (1,3,13), we find that those with a history of
sexual abuse, also tend to have been physically
abused (about two thirds). Most women have had
these experiences in adulthood (age 14 and above).
How representative are these and other findings of
the women choosing to enter the study compared to
a referral-based GI clinic? To answer this question,
we compared full study participants to women who
chose not to participate, but did complete a ques-
tionnaire given in the clinic. Patients participating in
the clinic questionnaire study represented 69% of
those eligible to participate. We found that the two
groups did not differ on race, having functional vs.
organic illness, estimation of health status or well-
being, and experience of a serious life threat. Beyond
assessing well-being, we did not compare partici-
pants and refusers on psychological variables such
as psychiatric illness, so we do not know the extent
of participation bias on this dimension. Full partic-
ipants were on average 4 years younger, had 1 more
year of education, and reported about 11% more
sexual abuse than those answering only the clinic
questionnaire. The younger age of participants may
have resulted from older and sicker patients being
unable or unwilling to come back for a full study
day. The greater frequency of sexual abuse history
among full-day participants may have been due to: 1)
the greater desire of those with abuse to participate
in the study, and/or 2) the tendency of those not
willing to communicate about abuse history to refuse
study participation. In fact, 28 (12%) study patients
initially indicated no sexual abuse on the clinic
questionnaire, but later acknowledged sexual abuse
on the same questionnaire administered at the study
visit. When asked about this discrepancy, patients
indicated to interviewers (G.N., L.G.) their unwill-
ingness to report abuse on the clinic questionnaire,
until they decided whether to participate in the full
study. Alternatively, it may be that patients with
sexual abuse history were interested in our study
after completing the clinic questionnaire, and thus
we had a better response rate from those with abuse.
To be conservative, we must assume that our esti-
mates of abuse history, based on the interview of full
participants, may be slightly inflated and thus bias
our sample. Our estimates of abuse, however, are
consistent with other estimates among patients with
GI disorders (2,3). Our study may not, however, be
generalizable to patients seen outside of referral
gastroenterology practice.
Another potential bias of our study is the recently
documented phenomenon of false memories of sex-
ual abuse being recovered by patients in response to
therapist's pressures and expectations (40,41). Al-
though we acknowledge this as a possible source of
error, we believe this to be minimal among our
patients for several reasons. We only included
women who were sure of their abuse in our abuse
category, our interview was not coercive or leading,
and only 38% of those acknowledging sexual abuse
had ever discussed their abuse with a therapist.
Our findings consistently show a strong relation-
ship of prior sexual abuse with current poor health,
so that women with sexual abuse history report more
pain, more non-GI somatic symptoms, more bed-
disability days, more lifetime surgeries, more psy-
chological distress, and worse functional disability.
Physical abuse history was also associated with
poorer health status on all measures except bed
disability days. Thus, both sexual and physical
abuse history were independently related to health
status. The present study joins a growing literature
pointing to the association of sexual and physical
abuse with long-term medical sequelae
(1,10,13,20,21,42), and in particular worse health
among those with gastrointestinal disorders (1,2,12-
14). Our findings are particularly striking because
patients at gastroenterology referral centers generally
have high baseline frequencies on most health status
indicators (eg, psychologic disturbance, functional
12 Psychosomatic Medicine 58:4-15 (1996)
SEXUAL AND PHYSICAL ABUSE HISTORY
impairment, and medical symptoms), resulting in
high rates of health care utilization (43-45). Despite
the high levels of disturbance, abuse history seems to
be independently related to psychological and phys-
ical distress, impaired quality of life, more days in
bed, and even more lifetime number of surgeries.
Many explanations have been proposed to explain
the relationship between abuse history and health
outcome. From a methodological point of view, it is
possible that recall bias may affect or amplify this
relationship, so that women who are more likely to
remember abuse are also the ones more likely to
endorse psychological distress and illness behaviors.
From a physiologic standpoint, traumatic stimula-
tion of the genitals might downregulate the sensation
thresholds of visceral nociceptors, thereby increas-
ing sensitivity to abdominal/pelvic pain or other
bowel symptoms (46). From a psychodynamic per-
spective, sexual abuse may produce feelings of guilt
and shame that may then be expiated through phys-
ical pain or suffering (47). From a cognitive perspec-
tive, negative cognitions and ineffective coping style
may lead to a maladaptive adjustment to illness,
thereby increasing pain reporting and behavior (14).
One study among patients with gastroesophageal
reflux found that abused women tended to report
lower cutaneous sensation thresholds (2). Low sen-
sation threshold was explained primarily by the
tendency to set low standards for judging stimuli as
noxious (response bias, a psychologic factor) rather
than by differences in cutaneous discriminating ca-
pability (nociception, a physiological factor). This
hypervigilance to pain was accompanied by abused
women's tendency to report more non- GI related
pain, to cope poorly with pain (eg, self-blame, cata-
strophizing), to have more psychiatric morbidity and
psychosocial functional disability. From a psychiat-
ric perspective, the association between abuse his-
tory and certain psychiatric diagnoses, including the
anxiety and somatoform disorders (3,23,48,49) may
lead to communicating psychological distress via
bodily symptoms. Finally, from a behavioral per-
spective, increased attention paid to illness com-
plaints early in life may lead to reinforcement of
illness behaviors (5052), setting up a vicious cycle
of continued symptoms, disability, and health care
utilization.
The types of abuse associated with poor health, in
order of predictive ability, were rape, life-threaten-
ing physical abuse, and forced touching. Those with
rape histories reported on average three more non-GI
medical symptoms, over twice the bed-disability
days, over one and one-half times more surgeries,
and almost twice the functional disability as those
without sexual abuse history. Women having expe-
rienced only "attempted" sexual abuse or being
beaten, hit, or kicked (without having their life
threatened) were not different from those with no
abuse history on any health status variable. Despite
the lack of association with current health status
variables, attempted sexual abuse and being beaten
should still be considered abusive.
Other researchers have not made a distinction
between invasive types of touch and rape (inter-
course), and thus have included vaginal or anal sex,
oral sex, or penetration of the subject's vagina or
anus with fingers or objects in their definition of
rape or penetration (30,53). As conceptualized in the
present study, the category of rape was reserved for
sexual intercourse (vaginal or anal). We found that
the health correlates of invasive touching (eg, oral
sex, objects in vagina) were more similar to those of
lesser touching than to sexual abuse involving vagi-
nal or anal intercourse. Thus, our data provided
empirical evidence for our theoretical division of
abuse into two categories, forced touch and inter-
course (rape).
Our definition of sexual and physical abuse his-
tory was hierarchical, so that women with several
types of abuse were categorized as having their most
severe abuse. By definition, those with the most
severe abuse were more likely to have multiple
abuse. Despite this possible caveat, the association of
poor health status with rape and life-threatening
physical abuse, was not accounted for by multiple
abuse experiences. These findings are preliminary,
given the small numbers in some cells of this
analysis.
Finally, we were interested in whether age of first
abuse would affect health status. The small numbers
in some cells of the analysis also make these findings
preliminary. In no case did women who reported
abuse first occurring in childhood (either touch or
rape) differ on health measures from those with
abuse first occurring in adulthood. Childhood and
adult abuse history both appear to be related to
health status.
Due to small numbers and the poor distribution of
cases, we were unable to examine the effects on
health status of abuse occurring only in childhood.
Most who report abuse during childhood, also had
experienced abuse as adults (particularly for those
who had been raped, or had their life threatened).
We did attempt to control for the possible confound-
ing effects of age at last abuse on the relationship
between severity of abuse and health measures.
Excluding those whose abuse occurred only in child-
hood or whose age of last abuse was unknown, we
Psychosomatic Medicine 58:4-15 (1996)
13
j . LESERMAN et al.
examined differences in severity of adult abuse (eg,
no sexual abuse, adult rape, adult touch) on health
status. The potential age bias of more serious abuse
being more likely to occur in adulthood, did not
seem to affect our basic conclusions. Future research
with more abuse cases should examine the effects on
health of those having only childhood abuse, those
with childhood and adult abuse, and those with only
adult abuse. It is consistent with other research that
women who have been raped or had their life threat-
ened in childhood, tend to have this experience
again in adulthood (1,14).
Despite the high percentages of abuse history and
the association of poor health and higher utilization
of health care among those experiencing abuse, stud-
ies consistently show that health practitioners are
unaware of their patients' histories of abuse. Our
previous studies in the GI clinic found that physi-
cians seeing these patients were aware of this abuse
history among only 17% of the abused women; and
that 30% of the abused had never discussed their
abuse with anyone (l). The present study found that
the gastroenterologists seeing these patients ac-
knowledged discussing abuse history with only 17%
of the women having any sexual and/or physical
abuse (using broader or more narrow definitions of
abuse). In a recent national probability survey, 92%
of women who were physically abused by a partner,
did not discuss these incidents with their physi-
cians; 57% did not discuss them with anyone (54).
Furthermore, in one family practice clinic, 25% of
women in relationships were assaulted by a partner
in the past year, however, less than 2% of women
had been asked about physical assault by their phy-
sicians during their most recent extended office visit
(55). Thus, despite the epidemic of sexual and phys-
ical abuse, these experiences tend to remain hidden
from practitioners treating women patients, and as a
result women tend not to be referred for psycholog-
ical counseling or services to help them address the
psychological and physical consequences of abuse.
The relationship of abuse history with long-term
medical sequelae points to a larger theoretical model
which is at the heart of psychosomatic and behav-
ioral medicine, and consultation liaison psychiatry;
that is the relationship of stress and health. As one
category of stresses, sexual and physical abuse have
clearly been associated with a wide variety of nega-
tive health consequences. In light of this relation-
ship, it is reasonable, that asking about present and
past abuse become an essential part of history taking
in medical practice, and that referral for psycholog-
ical services be made available when appropriate.
This work was supported in part by the National
Institutes of Health grant no. MH46959. The authors
would like to thank Gary Koch, the biostatistician on
this project, for his help and thoughtful review of this
paper.
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