Suicide prevention in primary care should include questions on intrafamilial sexual abuse (incest)
British Medical Journal : Published 17 August 2010
Dr Louis Jehel MD, PhD, Responsable de l'Unité de Psychiatrie, Dr Piere Levy MD; Dr Heather Payne MB, BS, FRCPCH; Isabelle Aubry President of Face à l'inceste ; Dr Catherine Bonnet MD, Urgence-Psychotraumatologie-Addictologie.
Gunnell and Miller (1) identify strategies to prevent suicide attempts as an important public health measure to reduce premature mortality. We report a new association of suicide attempts with long term sequelae of childhood intrafamilial sexual abuse or incest.
Incest is not rare: 15% of US college students surveyed in 1991 reported an unwanted sexual experience in childhood (2), and a 1992 Scandinavian study showed that children suffering incest (intrafamilial abuse, by a trusted family member) experience more comorbidity (3). Recent US and European studies consistently show a similarly high proportion of children reporting unwanted sexual experiences (4),(5) . Despite this, identification of the sequelae of incest is not routinely taught in medical schools, even though epidemiological studies have begun to identify its long term consequences (6).
In 2009 the International Association of Incest Victims (AIVI3), initiated an epidemiological survey in France. IPSOS surveyed 931 individuals sampled from the general population and showed that 3% of the adult population have been subjected to incest.(7) A further IPSOS survey assessed the impact of incest on health and daily life, by comparing samples of those who had been subjected to incest (n=341 Face à l'inceste members) (Association International des Victimes de l'Inceste)with non abused individuals, using 12 questions derived from the Adverse Childhood Experience study (8) and the Trauma Screening Questionnaire (9). The internal consistency of the questionnaire as constructed was adequate (Cronbach's alpha 0.79).
A multivariate logistic regression was applied to the 1287 individuals of this survey. This showed 91% [95% CI, 87-95] of women and 76% [71-81] of men who answered "yes" (current or past) to three questions had experienced incest. These three questions relate to presence of:
- eating disorder (Q1),
- suicidal ideation and impulses (Q6),
- social phobia (afraid of others or of saying no) (Q9).
A "yes" response to all these three questions gave a positive predictive value of identifying past incest (PPV) of 91% for women and of 76% for men, and a negative predictive value of 82% for women and 97% for men. (In other words, when at least one response to the three questions is "no", 82% of women and 97% of men have not experienced incest.)
Responses to an additional 24 self-reported questions were gathered from the 341 respondents who had experienced incest. This revealed that chronic health symptoms related to incest remained unexplained for an average of 16 years until spontaneous disclosure (7).
The US based ACE study demonstrated a strong graduated relationship between the accumulation of adverse childhood experiences and multiple risk factors for public health problems.(10) Our French study is much smaller, however our results were unexpected and they appear significant. Suicidal ideation has not previously been systematically identified in relation to incest, but this triad of features (suicidal ideation, social phobia and eating disorder) represents a potentially simple and cheap clinical screening test to identify individuals at risk of mental health problems following experiences of incest, allowing appropriate intervention. Disclosure of incest may occur spontaneously, but unless physicians ask these three simple questions , the hidden risk is likely to last an average of 16 years.
To increase the chances of identifying suicide risk (and eating disorders) related to incest experiences we suggest that primary and emergency room carers use the presence of one of the triad as a prompt to ask these three simple questions (11). Early identification of this "triad" may be a valuable tool for screening for mental health trauma following incest.
Dr Louis Jehel MD, PhD, APHP, Psychiatrie, INSERM U669, Paris, France; Dr Pierre Levy MD, APHP, INSERM UMR-S 707; Dr Heather Payne MB, BS, FRCPCH; Isabelle Aubry President of Face à l'inceste ; Dr Catherine Bonnet MD, consultant in child and adolescence psychiatry, Chevalier dans l'Ordre de la Legion d'honneur
References:
1. Editorial: D Gunnell and M Miller Strategies to prevent suicide BMJ 2010; 341: c3054 (6 July) http://www.bmj.com/cgi/content/full/341/jul06_1/c3054
2. Erickson PI and Rapkin AJ Unwanted sexual experiences among middle and high school youth Journal of Adolescent Health 12 (4 ) 319-325 (June 1991 ) http://www.jahonline.org/article/0197-0070(91)90007-9/abstract
3. J. A. Bushnell , J. E. Wells, M. A. Oakley-Browne Long-term effects of intrafamilial sexual abuse in childhood, Acta Psychiatrica Scandinavia 85 (2) 136-142 Feb 1992 (published online 23 AUG 2007) DOI: 10.1111/j.1600-0447.1992.tb01458.x
4. Finkelhor D The international epidemiology of child sexual abuse Child Abuse and neglect May 1994 18(5) 409-417 Available online 22 June 2002.
5. May-Chahel C, Hercoz M. Child sexual abuse in Europe. Strasbourg 2003. Council of Europe Publishing. http://www.coe.int/t/transversalprojects/children/violence/SexualAbuse_en.asp
6. Darves Bornoz JM, Berger C, Degiovanni A, Gaillard P, Lapine JP. Similarities and differences between incestuous and non-incestuous rape in a French follow-up study. Journal of Traumatic Stress 1999;12:4, 613-623. http://www.darves-bornoz.net/img/b.pdf
7. IPSOS. Etat des lieux de la situation des personnes victimes d'inceste: vecu, etat de sante et impact sur la vie quotidienne. Sondage aupres des victimes d'inceste et des francais. 2010. www.aivi.org
8. http://www.acestudy.org/index.html
9. Serre L, Jehel L, Le depistage de l'etat de stress post- traumatique en consultation de medecine generale. evaluation de la version francaise du trauma screening questionnaire, Medical Thesis, Rennes University, 2009
10. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine. 1998;14:245-258.
11. Edwards VJ, Dube SR, Felitti VJ, Anda RF. It's ok to ask about past abuse. Am Psychol. 2007-Jun; 62 (4):327-8
Competing interests: Isabelle Aubry is President and Dr Bonnet is a membe of Face à l'inceste (Association of Incest Victims International)
Heather Payne and Catherine Bonnet are members of PACA (Professionals against Child Abuse)