THE AMERICAN JOURNAL OF GASTROENTEROLOGY
1, 2000
© 2000 by Am. Coll. of Gastroenterology
Published by Elsevier Science Inc.
Gender Role and Irritable Bowel Syndrome:
Literature Review and Hypothesis
Brenda B. Toner, Ph.D., and Donna Akman, M.Sc.
Women’s Mental Health Research Section, Centre for Addiction and Mental Health, Toronto,
Ontario, Canada
ABSTRACT
Studies examining the prevalence of irritable bowel syn-
drome (IBS) consistently show that women outnumber men
in both patient and nonpatient populations. However, be-
cause IBS does affect both women and men, it is important
to examine and to understand gender similarities and dif-
ferences in the expression of this complex disorder. Studies
that have explored gender differences have focused their
investigations on prevalence and health seeking behavior,
physical and psychological symptomotology, and abuse his-
tory. This article reviews and summarizes the findings from
those studies. As well, whereas the literature examining
differences between men and women with IBS has focused
on distinctions based on the biological sex of study partic-
ipants, this article offers an alternate approach to the explo-
ration of gender differences. The concept of gender role,
defined as generalizations about appropriate male and fe-
male traits that are associated with masculinity and femi-
ninity, may further our understanding of IBS in both women
and men. (Am J Gastroenterol 2000;95:11–16. © 2000 by
Am. Coll. of Gastroenterology)
INTRODUCTION
Studies examining the prevalence of irritable bowel syn-
drome (IBS) have consistently shown that women outnum-
ber men in both patient and nonpatient populations. Despite
this disproportionate rate of women with IBS, a significant
number of men do receive a diagnosis of IBS. Because IBS
affects both women and men, it is of interest to examine and
to understand the similarities and differences between the
genders with this population. This article will, first, review
the empirical literature in this area and summarize signifi-
cant findings regarding gender differences, and second, dis-
cuss these findings within a framework that considers so-
cialized gender role as critical in the understanding of IBS.
The concept of gender role will be suggested as a possible
contributing factor in the prevalence of IBS for both women
and men, with a particular emphasis on how some of the
main concerns that are expressed by women with IBS may
be related to gender role.
In examining the literature on gender differences in IBS,
it is apparent that most of the research has not tested for
Vol. 95, No.
ISSN 0002-9270/00/$20.00
PII S0002-9270(99)00757-1
these differences in a scientifically rigorous manner. Most
studies on IBS use only women in their samples, and al-
though some studies do include men, there is often no
gender difference analysis performed beyond a description
of sample demographics (1– 4). Studies that do include both
men and women in their sample and that examine for gender
differences have focused their investigations on prevalence
and health seeking behavior, physical symptomotology,
psychological symptomotology, and abuse histories. A re-
view of this literature shows that when statistical signifi-
cance is tested for, few consistent sex differences are found.
The following discussion will focus on findings from studies
that have empirically examined gender differences. The
literature review concentrates on studies that have been
undertaken in the past decade, and only those studies that
specifically examine IBS, as opposed to other functional GI
disorders, are included. Studies included in this review are
those that used both male and female subjects in their
samples, and that conducted a gender difference analysis by
comparing findings for men and women through statistical
analyses to determine whether or not significant differences
exist.
GENDER ISSUES IN SYMPTOMS AND PRESENTATION
Prevalence and Health Seeking Behavior
Irritable bowel syndrome is very common in the North
American adult population, with symptoms compatible with
a diagnosis of IBS in 9 –22% of persons (5– 8). However, the
vast majority of those who have IBS symptoms do not seek
medical attention for those concerns (9). Studies examining
the prevalence of IBS symptoms show that within the non-
patient population (or those who have symptoms but do not
seek medical care for them), the ratio of female to male
sufferers is 2:1 (10). Within the patient population who seek
consultation with primary care physicians, female patients
outnumber male patients by 3:1 (11). In tertiary care set-
tings, female patients are 4 or 5 times more prevalent than
are male patients (9). Gender differences in health-seeking
behavior have been shown by Hochstrasser and Angst (12),
who found that women sought help for GI problems signif-
icantly more often than did men. Thus, prevalence rates for
12 Toner and Akman
IBS in nonpatient, primary care settings and tertiary care
settings consistently show women outnumbering men.
Physical Symptoms
Studies investigating gender differences in physical symp-
tomotology have been undertaken using nonpatient samples
(7–12) and tertiary care samples (13–16). Data on gender
differences in primary care settings was found in only one
study by Longstreth and Wolde-Tsadik (11). Within the
nonpatient literature, severe abdominal pain has been found
to be significantly more often reported by women than by
men (9 –11). In contrast, one study (13) found no significant
gender differences in frequency or severity of pain in a
general sample of adolescents. There have been some stud-
ies showing that women report significantly more constipa-
tion as compared to men (16, 17). Hyams et al. (13) looked
at symptoms of constipation and found that women were
significantly more likely to report straining and bloating.
Talley et al. (17) found that significantly more women than
men report experiencing bloating. In another study (15),
women were initially found to have significantly more con-
stipation, but when the investigators controlled for factors
such as laxative use and a feeling of incomplete evacuation,
the significance disappeared. Hochstrasser and Angst (12)
found significantly more men than women reporting consti-
pation. Two studies examining gender differences in diar-
rhea found opposite results, with Hochstrasser and Angst
(12) showing significantly more women than men having
diarrhea, whereas Talley et al. (17) found that, in their
sample, more men reported diarrhea.
Findings regarding gender differences in overall sympto-
mology compatible with an IBS diagnosis are similarly
inconsistent, with several studies finding no gender differ-
ences (12, 13, 15, 17, 18), whereas other studies (14, 16, 20)
show more women than men reporting symptoms that meet
the Manning criteria for a diagnosis of IBS. In one study that
used a sample of primary care patients (17), initial indica-
tions suggested that female gender was strongly associated
with IBS-type symptoms, but more comprehensive analyses
revealed that female gender was not a significant factor in
the prediction of such symptoms. Levy and Toner (22)
looked further at several studies that examined gender dif-
ferences in the validity of diagnostic criteria for IBS, and
found that the data are not consistent. Smith et al. (23)
examined whether or not gender differences existed when
using the Manning criteria for IBS, comparing ratings on the
Manning criteria with gastroenterologist evaluation. These
investigators found that there was a significant correlation
between the Manning criteria and IBS for women but not for
men. In contrast, Whitehead et al. (24) found that three of
the six Manning symptoms formed a cluster in all sub-
groups, concluding that the Manning criteria have equal
applicability to both men and women. One recent study
found no differences in sensitivity or specificity between the
male and female subjects when comparing Rome criteria to
independent gastroenterologists’ diagnoses (25).
AJG – Vol. 95, No. 1, 2000
Evidence of significant gender differences in tertiary care
settings is scant. One study by Nyhlin et al. (21) found that
abdominal distension was more often experienced by
women than by men. Although these authors investigated
for gender differences in other physical symptomotology,
none were found. Corney and Stanton (19) investigated
physical symptomotology in an IBS patient population, but
although they found several nonsignificant trends in their
gender differences analyses, the only significant finding was
that women reported more time spent in pain per day com-
pared to men. Lembo et al. (1) looked at symptom duration
in male and female patients with IBS, but did not report any
data on gender differences.
In summary, based on the literature to date, no definitive
statements can be made regarding gender similarities and
differences in physical symptomatology. Research in the
area suffers from two important omissions. First, most of the
studies have been undertaken using nonpatient samples
rather than primary or tertiary samples. There may be im-
portant differences both between and within the sexes, de-
pending on the population under study. Second, little can be
said about men’s physical symptomotology because so few
studies have used men as subjects. Thus, to gain clarity with
regard to men’s experience of IBS, and how their experience
is similar to or different from women’s experience, a more
broad survey is needed.
Psychological Symptoms
Although numerous studies on IBS patients have included
measures of psychological functioning in their assessment,
most do not examine results for gender differences. Talley
et al. (3) studied the relationship between personality traits
and nonulcer dyspepsia and IBS in men and women, but did
not do a gender comparison. Walker et al. (4) compared IBS
patients and inflammatory bowel disease (IBD) patients on
measures of psychiatric diagnoses, sexual and physical vic-
timization, and disability, but although their sample in-
cluded both men and women, they did not do any analyses
of gender differences. Lydiard et al. (26) found that indi-
viduals with panic disorder had a significantly higher rate of
endorsing GI symptoms, including those associated with
IBS, compared to those without a psychiatric diagnosis, but
though they used both men and women in their samples,
gender was controlled for in their analyses. A study by
Masand et al. (2) explored the relationship between major
depression and IBS using both male and female psychiatric
patients and non-GI medical patients, but no gender differ-
ence analyses were performed. Blewett et al. (27) examined
psychiatric disorder and outcome in IBS patients, and found
no significant differences between men and women. Corney
and Stanton (19) did include an analysis of gender differ-
ences in psychological functioning in IBS patients, but
although trends were reported indicating that women exhibit
more psychological symptoms such as anxiety and depres-
sion compared to men, the difference did not reach statis-
tical significance.
AJG – January, 2000
Thus, the issue of whether or not there are differences
between men and women in psychological symtomotology
in IBS has not been adequately explored. Until studies use
both male and female subjects in their samples and test for
statistically significant differences, the degree to which men
and women are similar or different in their psychological
profile will remain unknown.
History of Abuse
Studies examining the potential link between a history of
abuse and IBS have consistently found evidence that such an
association does exist. In tertiary care settings, a history of
sexual abuse has been found in up to 50% of IBS patients
(9). However, studies examining this link typically use only
female subjects in their samples (15). There have been some
studies investigating abuse histories that have included men,
and although differences between men and women are
sometimes reported, significant differences are rarely doc-
umented. Talley et al. (28) looked at self-reported abuse and
IBS and found no differences between male and female IBS
patients with regard to a history of sexual, physical, emo-
tional, or verbal abuse. Walker et al. (29) looked at male and
female IBS patients and found that all of the patients who
reported a history of sexual abuse were female. Talley et al.
(30) found that, although more female than male IBS pa-
tients reported a history of sexual and/or physical abuse,
some male IBS patients reported such a history as well.
Longstreth and Wold-Tsadik (11) used a primary care sam-
ple and found that a history of sexual abuse was more
common in women than in men, but these authors did not
differentiate between subjects with no IBS symptoms, less
severe IBS symptoms, or more severe IBS symptoms.
It is clear that there is an association between history of
abuse and IBS. What is less clear is whether or not there are
differences between men and women in terms of the
strength of the link between history of abuse and IBS.
Studies are needed that document the correlation between
having a history of abuse and the onset of IBS symptoms in
both men and women in patient and nonpatient populations.
The Consideration of Gender Role
as a Factor in Irritable Bowel Syndrome
Given that the empirical data in the IBS literature show
mixed results regarding gender differences, it may be im-
portant to shift attention away from how men and women
with IBS are different to how they may be similar. New
perspectives that shed light on the common factors that
those with IBS share, regardless of gender, will likely illu-
minate important directions for the prevention and treatment
of IBS. One area that has been underexplored is the link
between the roles that men and women have in society and
the experience of IBS. The following discussion is intended
to widen the scope by which IBS has traditionally been
conceptualized.
Gender Role and Irritable Bowel Syndrome 13
Gender Role and Irritable Bowel Syndrome
Because the majority of studies have not explored IBS in
males, it is difficult to say very much about those men who
do have IBS. However, findings to date suggest that there
are few significant differences between men and women
with IBS. Thus, it may be that women and men with IBS are
more similar than different. Similarities between women
and men, as well as the higher prevalence of IBS in women,
may be explained in part by considering gender role as an
influential factor in IBS. The literature examining differ-
ences between men and women with IBS has focused on
distinctions based on the biological sex of study partici-
pants. An alternate way of approaching gender differences is
to separate gender role from biological sex (31, 32). Gender
role can be defined as generalizations about appropriate
traits for males and females that are associated with mas-
culinity and femininity. Most conceptualizations of gender
role traits hold that they are acquired through the differential
socialization of boys and girls. This differential socialization
serves to reinforce those behaviors and characteristics that
are considered appropriate and desirable based on the per-
son’s biological sex. Studies examining gender differences,
therefore, should aim to separate the impact of gender role
versus biology. To examine the effects of gender role as
separate from biological sex, what would need to be studied
are the gender-related characteristics of individuals that are
typically associated with one sex but that are exhibited in
both men and women. One example of such a study is that
done by Oliver and Toner (33), which examined the influ-
ence of gender role, rather than biological sex, on the
expression of depressive symptoms. Findings from that
study suggest that depressive symptoms are influenced by
societal expectations. Within the IBS literature, a study by
Ali et al. (34) looked at the relationship between gender role
and illness behavior in IBS and found a correlation between
what are typically viewed as feminine characteristics and
disease conviction in both male and female IBS patients
seen in a tertiary care setting. Specifically, women and men
who show high scores on traits such as nurturance also show
high scores on disease conviction. One important implica-
tion of this finding is that it may be the feminine gender role,
rather than being female, that is influential in affecting
patients’ attributions of their illness. Therefore, interven-
tions that aim to heighten awareness and understanding of
the impact that gender role socialization has on one’s
overall functioning may help to facilitate changes in
illness behavior.
Feminine Gender Role and
Irritable Bowel Syndrome Patients
Based on our clinical work with female IBS patients who
present to a cognitive-behavioral therapy program, we have
identified some common concerns or issues that seem to be
highly salient and meaningful for these women. Future
research will need to identify themes that are salient for men
with IBS to determine similarities and differences between
14 Toner and Akman
men and women. In our research with women, we found that
each of these concerns or issues has, at its core, an injunc-
tion that is based on socially constructed ideology about
appropriate behavior for women.
Women with IBS commonly report concerns over losing
control of their bodily functions. Women and men receive
different messages about bodily functioning, with women
being taught that for them, bodily functions are something to
be kept private and secret, whereas men are more likely to
be taught that their bodily functions do not need to be kept
hidden. One important implication of such teachings is that
for women, bowel functioning becomes a source of shame
and embarassment more so than it does for men. The sanc-
tion against public admission and/or display of bodily func-
tioning in women can be seen as part of the socialization
process that encourages girls and women to be always clean,
neat, fresh, and in control (35). This same socialization
process permits boys and men to be more unrestrained,
messy, and dirty, and even to view their bodily functions as
a source of amusement and pleasure. The result of this
differential treatment of males and females is a paradigm in
which women live their lives experiencing their bowel func-
tioning as secret and shameful, whereas men live their lives
with greater acceptance of their bowel functioning. This
socialization process, which emphasizes self-control, clean-
liness, and dainty behavior in women, has implications for
the quality of life of IBS patients. For many female IBS
patients, the shame and embarrassment associated with
bowel functioning contribute to their physical and emotional
isolation.
The finding that women often score higher on indices of
bloating and constipation can also be discussed as a gender-
related theme. If we consider the impact that bloating and
constipation may have on a woman’s experience of her body
and her perception of her body image, framed within a
cultural emphasis on female beauty, the distress that women
experience from these symptoms gains new clarity. Soci-
ety’s focus on how women look, and its perpetuation of
thinness as a necessary standard of attractiveness (31, 35),
may lead women to experience bloating not only as a source
of physical discomfort, but of psychological distress as well.
For many women, the sensation of being overweight, with
or without an increase in the size of their abdomen, will
evoke worry and shame about their body, and therefore
about themselves. Although most men do not welcome the
sensation of a distended abdomen, they are perhaps less
likely than women to be cognizant or concerned by the
effect that such distention will have on their appearance. To
the degree that women are subjected to being valued and/or
devalued for their physical attractiveness (i.e., thinness),
they will be attentive to and concerned by those IBS symp-
toms that have an impact on how they experience their
bodies.
Higher scores on pain severity in women when compared
to men may be associated with an increased hypervigilance
to bodily sensations. The physical and psychological dis-
AJG – Vol. 95, No. 1, 2000
tress that women may experience with abdominal discom-
fort, coupled with the perception that their pain is being
minimized or trivialized by health care professionals, may
lead women to respond by becoming hypervigilant to any
sign of pain or discomfort. Evidence exists that shows that,
with increased attention to bodily sensations, there is often
increased anxiety and increased physiological arousal, all of
which leads to heightened sensitivity to pain.
Using a selective attention model, IBS patients who be-
lieve that they are suffering from an organic disorder will be
highly attuned to those experiences that confirm their ex-
planatory model of illness. Other experiences, such as life
stressors or intrapersonal conflict, which do not fit with their
hypothesis of an organic disorder, will be selected out or
their importance will be minimized. This selective bias
makes sense given the societal stigmatization and trivializa-
tion of psychological distress, regardless of the manner in
which it is manifested or the impact that it may have on
one’s life. IBS patients who admit to a psychological com-
ponent in the expression of GI symptoms may feel vulner-
able to prevailing attitudes that they are not of strong char-
acter or that they perhaps suffer a personality defect. In our
experience, female IBS patients commonly complain that
their physicians dismiss them with a referral to a psychia-
trist, thereby making them feel “crazy,” or that their physi-
cians recommend that they quit their jobs, indicating little
respect for the importance and value that their work may
hold for them.
Personality characteristics that have traditionally been
associated with femininity have significant implications for
the expression and maintenance of IBS symptoms in
women. For instance, to be nurturing by encouraging, sup-
porting, and validating the experiences of others has been
identified as a female trait, leading to the belief that women
naturally gravitate toward taking care of others before tak-
ing care of themselves (35). This has led to the societal
belief that it is unimportant or even wrong for a woman to
place priority on herself. Thus, women often spend their
lives attending to the needs of their families, friends, and
even coworkers, and feel guilty or selfish if they express a
need of their own. This is important in the treatment of IBS
patients in two major ways. First, health care professionals
should attempt to explore whether some of the symptoms
experienced by female patients are related to stress, includ-
ing the stress of taking care of one’s family while getting
little support for herself. Health care professionals often
assume that women are supposed to be taking care of others,
and rarely question family structures in which women are
often giving more support than they are receiving, much
more readily conceptualizing women’s work roles as a
source of stress that must be altered. In fact, what is often
needed is an alteration in the balance of support that cur-
rently exists in women’s relationships. Secondly, the clini-
cal interpretation of women IBS patients as needy and
demanding is often a misinterpretation of the patients’ pre-
sentation. For many women, the expression of distress about
AJG – January, 2000
their GI symptoms and their demand for treatment may
represent a very rare occurrence in their lives, in which they
are acknowledging their own needs and wish for support.
Although they may communicate these needs in ways that
physicians experience as demanding and difficult, this be-
havior can be reframed as a healthy expression of good
self-care and assertion.
Women are similarly socialized to always be pleasing
others, often at the expense of their own needs (35, 36). In
gastroenterologists’ offices, this may result in patients com-
plying with procedures, examinations and referrals even
when they are not in agreement with the treatment plan. To
some degree, this may contribute to women’s higher rates of
doctor visits and multiple consultations, in that patients who
believe that their physician does not understand their expe-
rience may seek help elsewhere, rather than show displea-
sure with their current physician. This would hold true as
well for those patients who feel unable to be assertive or
angry with their physician, because of the socialized ideal of
women as compliant, understanding, and never overtly an-
gry. Women who express anger, make demands, or question
authority are often given the label “hysteric,” have their
complaints dismissed, or have their femininity called into
question (35). These potential repercussions for women who
express their own wants and needs are often sufficient to
keep women silent. In fact, recent research has illuminated
what Jack (36) refers to as self-silencing, a gender-related
construct associated with societal expectations for women.
According to Jack, women are socialized to behave in cer-
tain ways to maintain safe, intimate relationships. These
social expectations of women can lead to the silencing of
certain thoughts, feelings, and actions rather than jeopardize
relationships that are in place. Two recent studies point to
the relevance of this construct for IBS patients. Ali et al.
(37) compared female IBS patients with female IBD pa-
tients, and found that IBS patients score higher on measures
of self-silencing than do IBD patients. In a separate study,
Ali et al. (34) examined feminine gender role and illness
behavior in male and female IBS patients, and found that
certain characteristics typically associated with femininity,
such as servility and self-subordination, were significantly
associated with certain modes of illness behavior in both
female and male patients. Specifically, results showed sig-
nificant correlations between disease conviction, general
hypochondriasis, and stereotypically feminine traits, inde-
pendent of the sex of the IBS patient. These findings go
counter to conceptualizations of IBS patients as self-cen-
tered and demanding, and instead suggest that they are
actually reluctant to express what they need and want.
Future Directions
Research examining the prevalence and expression of IBS
symptoms in both men and women must consider the role
that gender role socialization may play in both etiology and
treatment. Given that there is little hard evidence of gender
differences in physical or psychological symptoms in IBS
Gender Role and Irritable Bowel Syndrome 15
patients, and given that most of the gender differences that
have been found have been with nonpatient populations, it
seems that efforts to continue to search for gender differ-
ences in IBS, based on biological sex alone, may be mis-
guided. Although there may be important implications of
differences between the sexes in nonpatient or primary care
settings, it seems even more interesting that relatively few
differences exist between the men and women who end up
in gastroenterologists’ offices. The question that becomes
most relevant is that which asks what is common between
men and women who seek treatment for IBS. One possibil-
ity is that gender differences in IBS patients may have more
to do with gender role prescriptives than with biology. It
may be that both male and female IBS patients have certain
characteristics that are commonly associated with the fem-
inine gender role, and that these characteristics are related to
their experience of IBS. Thus, empirical and clinical initi-
atives should be focused on examining common experiences
in the lives of IBS patients, with a particular emphasis on the
impact of gender role socialization. Because it is consis-
tently women who receive a diagnosis of IBS, especially in
tertiary settings, research needs to identify the risk factors in
the lives of women that may contribute to the difference in
prevalence rates. Some of these risk factors have already
been identified, such as a history of abuse and psychiatric
diagnosis. Once these risk factors are identified, research
can then begin to address the degree to which they have
relevance for men who have IBS. Future studies will need to
examine risk factors, such as abuse and psychiatric diag-
noses, in both men and women to disentangle the influence
of gender role, sex, and psychosocial factors. A preventive
model of health care would be concerned with ameliorating
the risk factors associated with IBS. To do so, studies must
begin to incorporate questions about what may be influenc-
ing women’s greater vulnerability to certain risk factors,
such as history of abuse, and higher rates of psychiatric
diagnoses. As well, health care professionals should be
attuned to the degree to which their own ideas about gender
role influence their assumptions about their patients and the
course of treatment being recommended. Finally, studies
should include more male IBS patients in their sample
selection because, until we know more about men who seek
treatment for IBS, we will be unable to make any kind of
definitive statements about similarities or differences be-
tween men and women.
Reprint requests and correspondence: Brenda B. Toner, Ph.D.,
Centre for Addiction and Mental Health Clarke Division, 250
College Street, Toronto, Ontario M5T 1R8, Canada.
Received May 25, 1999; accepted Sep. 22, 1999.
REFERENCES
1. Lembo T, Fullerton S, Diehl D, et al. Symptom duration in
patients with irritable bowel syndrome. Am J Gastroenterol
1996;91:5:898 –905.
16 Toner and Akman
2. Masand PS, Kaplan DS, Gupta S, et al. Major depression and
irritable bowel syndrome: Is there a relationship? J Clin Psy-
chiatry 1995;56:363–7.
3. Talley N, Phillips SF, Bruce B, et al. Relation among person-
ality and symptoms in nonulcer dyspepsia and the irritable
bowel syndrome. Gastroenterology 1990;99:327–33.
4. Walker EA, Gelfand AN, Gelfand MD, et al. Psychiatric
diagnoses, sexual and physical victimization, and disability in
patients with irritable bowel syndrome or inflammatory bowel
disease. Psychol Med 1995;25:1257– 67.
5. Drossman DA, Sandler R, McKee D, et al. Bowel patterns
among subjects not seeking healthcare. Gastroenterology
1982;83:529 –34.
6. Drossman DA, Richter J, Talley N, et al. The functional
gastrointestinal disorders. New York: Little, Brown, 1994.
7. Sandler R. Epidemiology of irritable bowel syndrome in the
U.S. Gastroenterology 1990;90:409 –15.
8. Talley N, Zinsmeister A, Van Dyke C, et al. Epidemiology of
colonic symptoms and the irritable bowel syndrome. Gastro-
enterology 1991;101:927–34.
9. Drossman DA, Creed F, Fava G, et al. Psychosocial aspects of
the functional gastrointestinal disorders. Gastroenterol Int
1995;8:2:47–90.
10. Drossman DA, Li Z, Andruzzi E, et al. US householder survey
of functional gastrointestinal disorders: Prevalence, sociode-
mography and health impact. Dig Dis Sci 1993;38:9:1569 – 80.
11. Longstreth GF, Wolde-Tsadik G. Irritable bowel-type symp-
toms in HMO examinees: Prevalence, demographics, and clin-
ical correlates. Dig Dis Sci 1993;38:9:1581–9.
12. Hochstrasser B, Angst J. The Zurich study: XXII. Epidemi-
ology of gastrointestinal complaints and comorbidity with
anxiety and depression. Eur Arch Psychiatry Clin Neurosci
1996;246:261–72.
13. Hyams J, Burke G, Davis P, et al. Abdominal pain and irritable
bowel syndrome in adolescents: A community-based study.
J Pediatr 1996;129:2:220 – 6.
14. Jones R, Lydeard S. Irritable bowel syndrome in the general
population. Br Med J 1992;304:87–90.
15. Talley N, O’Keefe E, Zinsmeister A, et al. Prevalence of
gastrointestinal symptoms in the elderly: A population-based
study. Gastroenterology 1992;102:895–901.
16. Talley N, Zinsmeister A, Melton L. Irritable bowel syndrome
in a community: Symptom subgroups, risk factors, and health
care utilization. Am J Epidemiol 1995;142:1:76 – 83.
17. Talley N, Zinsmeister A, Van Dyke C, et al. Epidemiology of
colonic symptoms and the irritable bowel syndrome. Gastro-
enterology 1991;101:927–34.
18. Taub E, Cuevas J, Cook E, et al. Irritable bowel syndrome
defined by factor analysis. Gender and race comparisons. Dig
Dis Sci 1995;40:12:2647–55.
19. Corney R, Stanton R. Physical symptom severity, psycholog-
ical and social dysfunction in a series of outpatients with
irritable bowel syndrome. J Psychosom Res 1990;34:5:483–91.
20. Jorgensen L, Jensen K. The epidemiology of irritable bowel
syndrome in a random population: Prevalence, incidence, nat-
ural history and risk factors. J Intern Med 1994;236:23–30.
AJG – Vol. 95, No. 1, 2000
21. Nyhlin H, Ford M, Eastwood J, et al. Non-alimentary aspects
of the irritable bowel syndrome. J Psychosom Res 1993;37:
2:155– 62.
22. Levy R, Toner B. Gender issues in chronic abdominal pain. In:
Olden KW, ed. Chronic abdominal pain: A comprehensive
approach (in press.)
23. Smith RC, Greenbaum DS, Vancouver JB, et al. Gender dif-
ferences in Manning criteria in the irritable bowel syndrome.
Gastroenterology 1991;100:591–5.
24. Whitehead WE, Crowell MD, Robinson JC, et al. Effects of
stressful life events on bowel symptoms: Subjects with irrita-
ble bowel syndrome compared to subjects without bowel dys-
function. Gut 1992;33:825–30.
25. Levy RL, Feld AD, Longstreth GF, et al. Comparison of a
questionnaire incorporating the Rome criteria to gastroenter-
ologists’ clinical judgement. Gastroenterology 1999 (abstract).
26. Lydiard R, Greenwald S, Weissman M, et al. Panic disorder
and gastrointestinal symptoms: Findings from the NIMH ep-
idemiologic catchment area project. Am J Psychiatry 1994;
151:1:64 –70.
27. Blewett A, Allison M, Calcraft B, et al. Psychiatric disorder
and outcome in irritable bowel syndrome. Psychosomatics
1996;37:2:155– 60.
28. Talley N, Fett S, Zinsmeister A. Self-reported abuse and
gastrointestinal disease in outpatients: Association with irrita-
ble bowel-type symptoms. Am J Gastroenterol 1995;90:3:
366 –71.
29. Walker E, Katon W, Roy-Byrne P, et al. Histories of sexual
victimization in patients with irritable bowel syndrome or
inflammatory bowel disease. Am J Psychiatry 1993;150:
1502– 6.
30. Talley N, Helgeson S, Zinsmeister A. Are sexual and physical
abuse linked to functional gastrointestinal disorders? Motility
Nerve-Gut Interact 1992;A523.
31. Lips H. Sex and gender. Mountainview, CA: Mayfield Pub-
lishing, 1997.
32. Worell J, Remer P. Feminist perspectives in therapy: An
empowerment model for women. West Sussex, UK: Wiley,
1992.
33. Oliver S, Toner B. The influence of gender role typing on the
expression of depressive symptoms. Sex Roles 1990;22:11/
12:775–90.
34. Ali A, Richardson D, Toner B. Feminine gender role and
illness behaviour in irritable bowel syndrome. J Gender Cul-
ture Health 1998;3:1:59 – 65.
35. Bepko C, Krestan J. Too good for her own good. New York:
Harper & Row, 1990.
36. Jack D. Silencing the self: Inner dialogues and outer realities.
In: Joiner T, Coyne J, eds. The interactional nature of depres-
sion. Washington, D.C.: American Psychological Association,
1999:221– 46.
37. Ali A, Toner B, Stuckless N, et al. Emotional abuse, self-
blame and self-silencing in women with irritable bowel syn-
drome. Psychosom Med (in press).