Childhood Sexual Abuse As a Risk Factor for the Development of an Eating Disorder in Adolescent Girls:
A Systematic Review
Rebecca van der Hout – 10650539
Bachelorthesis
University of Amsterdam
Date: 30-01-2017
Words: 5402
Table of Contents
Abstract………...3
CSA as a Risk Factor for the Development of an Eating Disorder in Adolescent Girls……4
Method……….8
Results………..8
CSA as a Risk Factor for Anorexia………..9
CSA as a Risk Factor for Bulimia………...11
CSA as a Risk Factor for Binge Eating Disorder………15
Conclusion and Discussion……….17
Abstract
This systematic review uses the results of 20 studies to determine if childhood sexual abuse is a specific risk factor for the development of eating disorders in adolescent girls. The
reviewed studies were all published between 1999 and 2016 and were written in English. Studies were summarized in this systematic review if they included both key factors: childhood sexual abuse and anorexia nervosa or bulimia or binge eating. All studies were retrospective and used a sample of female participants. Results show that childhood sexual abuse is a specific risk factor for anorexia nervosa, bulimia nervosa and binge eating disorder in adolescent girls. Therefore, this systematic review shows that childhood sexual abuse is a specific risk factor for the development of eating disorders in adolescent girls. However, there are several limitations to this systematic review. First of all, all instruments that were used to assess CSA were retrospective. Secondly, many studies examined small sample sizes. Finally, the results of this systematic review were only based on female participants, which made it impossible to examine possible gender differences. Therefore, it is important to conduct more specific research about the relation between childhood sexual abuse and eating disorders. Results can be used to develop or enhance interventions to minimalize the number of adolescents that suffer from sexual abuse in childhood and an eating disorder in
adolescence.
Childhood Sexual Abuse As a Risk Factor for the Development of an Eating Disorder in Adolescent Girls:
A Systematic Review
Almost 8.3% of American women reports to have experienced Childhood Sexual Abuse (CSA) before the age of 16 years (U.S. Department of Health and Human Services [HHS], 2014). CSA is a severe form of child abuse and is defined as any activity with a child before the age of legal consent that is for the sexual gratification of an adult or a substantially older child (Johnson, 2004). The activities include oral-genital, genital-genital, genital-rectal, hand-genital, hand-rectal or hand-breast contact; exposure of sexual anatomy; forced viewing of sexual anatomy; and showing pornography to a child or using a child in the production of pornography (Behrman, Kliegman, & Jenson, 2001). CSA is a specific and malignant form of trauma that can negatively influence the life and development of children (Brewerton, 2007).
An important period of time in the development of children is adolescence, between ages 12 and 18 years (Christie & Viner, 2005). Adolescence is the period of developmental transition between childhood and adulthood, and is characterized by the development of a sexually dimorphic body shape and the awareness of sexuality and body image (Christie & Viner, 2005; Steinberg & Morris, 2001). Body image and self-awareness are therefore especially vulnerable in adolescence, and research shows that adolescent girls are even more aware of their body image than adolescent boys (Clay, Vignoles, & Van Dittmar, 2005; Jones, 2004). Since the function of the female body is often seen as being attractive and sexually pleasing to men, adolescent girls seem to show a greater investment in body image than boys (Smolak, 2004). Moreover, adolescent girls show a higher prevalence of poor body image than boys, which can be explained by their tendency to exhibit lower levels of self-esteem (Ata, Ludden, & Lally, 2007).
by a history of CSA (Eubanks, Kenkel, & Gardner, 2006). Adolescence of girls that have suffered from CSA is characterized by a negatively affected personal integrity, a negative self-image, and less self-esteem in comparison to peers (Thompson & Stice, 2001). These features all reinforce the development of a negative body image (Ata et al., 2007). A negative or poor body image can have a great impact on the life of adolescents, and is strongly
associated with the development of eating disorders (Levine & Murnen, 2009).
The development of an eating disorder in females often starts in late adolescence, between ages 15 and 19 (Fairburn & Harrison, 2003). An eating disorder is a mental disorder that is characterized by abnormal eating habits that negatively affect a person’s physical or mental health (Fairburn & Harrison, 2003). The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013) defines three types of eating disorders: anorexia nervosa, bulimia nervosa and binge eating disorder. Anorexia is characterized by a restriction of energy intake leading to a significantly low body weight (i.e., weight that is less than minimally expected for adolescents) and an intense fear of gaining weight or becoming fat. Moreover, adolescents suffering from anorexia show persistent behavior that interferes with weight gain, a persistent disturbance in the way in which one’s body weight or shape is experienced, and a persistent lack of recognition of the seriousness of the current low body weight (APA, 2013). Bulimia is identified as having recurrent episodes of binge eating and recurrent inappropriate compensatory behaviors in order to prevent weight gain (e.g., self-induced vomiting, misuse of laxatives, diuretics, fasting, excessive exercise or other medicines). An episode of binge eating is characterized by eating an amount of food that is larger than what most individuals would eat in a discrete amount of time and a sense of lack of control over eating during the episode (APA, 2013). Binge eating disorder is characterized by recurrent episodes of binge eating which are associated with three (or more) of the following: eating much more rapidly than normal,
eating until feeling uncomfortably full, eating large amounts of food when not feeling physically hungry, eating alone because of feeling embarrassed by how much one is eating, and feeling disgusted with oneself, depressed or very guilty afterwards (APA, 2013). These binge eating episodes are not associated with recurrent use of inappropriate compensatory behavior as in bulimia nervosa (APA, 2013).
Between 30 and 50% of females with an eating disorder also reports a history of unwanted sexual experiences in childhood (Tripp & Petrie, 2001). In addition, non-eating disordered individuals with a history of CSA typically share certain features with eating disordered individuals. These shared features include an intense feelings of shame, a low self-esteem, and body image disparagement (Carter, Bewell, Blackmore, & Woodside, 2006). Research therefore suggests there is a strong association between a history of CSA and the development of an eating disorder in adolescent girls (Preti et al., 2006).
The hypothesized association between CSA and eating disorders in adolescent girls can be explained in several ways. First of all, females who have suffered from CSA often experience an element of coercive control in the episode of abuse, which profoundly affects their self-esteem and body image (Clarke & Griffin, 2008). The control over the body in the form of dieting or weight management is associated with a struggle for power over their own body, that they have experienced to be powerless during the event of CSA (Clarke & Griffin, 2008). The need to gain back control, and physically and psychologically feel in control over the body is strongly associated with the eating disorder anorexia nervosa (Stice & Shaw, 2002). Secondly, research by Cachelin, Schug, Juarez and Monreal (2005) shows that females often experience feelings of vulnerability after the event of CSA. These feelings result in dissociative coping styles that can be displayed as binge eating or bulimic behaviors (Cachelin et al., 2005). Also, unhealthy eating and dieting is seen as a coping strategy for negative emotional states, which are related to the experience of CSA (Logio, 2003).
The role of CSA as a risk factor for the development of eating disorders has gained considerable empirical and clinical interest in research and literature in the last few years, but is in need of more research (Kendall-Tacket, 2002; Gilbert et al., 2009; Preti et al., 2006; Sansone & Sansone, 2007). Elevated rates of child abuse have consistently been identified in samples of females with an eating disorder, when compared to females without an eating disorder (Jacobi, Hayward, De Zwaan, Kraemer, & Agras, 2004; Thompson & Wonderlich, 2004). Moreover, several studies have shown that a significant proportion of individuals suffering from an eating disorder also reports a history of CSA (Preti et al., 2006;
Wonderlich, Brewerton, Jocic, Dansky, & Abbott, 1997; Treuer, Kóperdak, Rósza, & Füredi, 2005). Research has also found different associations for the three types of eating disorders in relation to CSA (Jacobi et al., 2004; Smolak & Murnen, 2002; Wonderlich et al., 1997). Although the results of different studies have been inconsistent, the general results in studies of females with an eating disorder, abuse victims, community-based samples and nationally representative samples have all showed associations between a history of CSA and eating disturbances (Wonderlich et al., 1997). However, the different results have not yet been incorporated into one article. This overview of results can provide insight in the different associations and can determine if CSA is a specific risk factor for the development of eating disorders in adolescence.
Therefore, the goal of this systematic review is to create an overview of recent literature about the different types of eating disorders in relation to CSA in female
adolescents. Furthermore, the goal is to provide insight in the role of CSA as a specific risk factor for the development of eating disorders in female adolescents. This will be examined by investigating the existing literature on the three types of eating disorders and their association with CSA. This systematic review will clarify what is known about the possible associations. Moreover, this review will show which associations are in need of more
research. This information can be used as a guideline for new (longitudinal) studies about CSA and eating disorders. By determining for which eating disorders CSA is a risk factor, interventions can be developed or enhanced to help the females suffering from eating disorders. Also, by confirming CSA as a risk factor in eating disorders, prevention methods can be created to minimalize the risk of developing an eating disorder when a female has suffered from a history of CSA.
Method
A systematic review was conducted by using the following combination of terms in the literature search: (“sexual abuse”) AND (child*) AND (“anorexia nervosa”) OR
(“bulimia”) OR (“binge eating”) The databases PsychINFO, MEDLINE and ERIC were used to find relevant articles for this systematic review.
All articles that were included in this systematic reviewed were published between 1999 and 2016. Only articles written in English were included in this review. Moreover, only articles were included that used both key factors: sexual abuse and anorexia/bulimia/binge eating. Furthermore, studies that investigated the relationship between CSA and eating disorders for boys were not included in this systematic review.
In the beginning, 42 articles were found through database searching. Based on the inclusion criteria above, the eligibility of the articles was assessed. A total number of 17 studies were eligible for the systematic review. The reference lists of these 17 studies were reviewed to identify studies that were eligible based on the inclusion criteria, but did not show in the database search. Three more studies were found through the reference lists.
Results
This systematic review summarizes the results of 20 articles to determine if CSA is a risk factor for the development of eating disorders in adolescent girls. First of all, the results of the studies about CSA and anorexia will be discussed. Secondly, the studies about bulimia
in relation to CSA will be explored. Lastly, the found results about binge eating and CSA will be examined.
CSA as a Risk Factor for Anorexia Nervosa
The relation between CSA and anorexia nervosa was reviewed in eight articles (Carter et al., 2006; Castellini et al., 2013; Deep, Lilenfeld, Plotnicov, Pollice, & Kaye, 1999;
Johnson, Cohen, Kasen, & Brook, 2002; Karwautz et al., 2001; LaPorte & Guttman, 2001; Nagata et al., 2001; Wentz, Gillberg, Gillberg, & Råstam, 2005). All studies included a clinical group of women that were diagnosed with anorexia nervosa based on the DSM-IV or DSM-III classifications. Moreover, all used studies were retrospective studies. This means the participants were asked at an older age to answer questions regarding their eating disorder and the experience of CSA. Estimates of CSA in females with anorexia nervosa ranged from 7% to 48%.
When CSA was assessed in a group of clinically diagnosed females different
estimates of CSA were found (Carter et al., 2006; Castellini et al., 2013; Nagata et al., 2001). Only 7% of the 29 American females reported to have experienced CSA, when estimates of CSA in American females with anorexia were compared to Japanese females who suffered from anorexia (Nagata et al., 2001). However, in a sample of 27 American females who suffered from anorexia, 22.2% reported a history of CSA. Furthermore, approximately 48% of the 77 females who suffered from anorexia reported an experience with CSA before the onset of anorexia (Carter et al., 2006). This does suggest that CSA might be a risk factor for the development of anorexia in adolescence.
However, when females with anorexia were compared to a non-clinical control group contradictory results were found (Deep et al., 1999; LaPorte & Guttman, 2001; Karwautz et al., 2001). One study showed that females who suffered from anorexia did not differ
of the females with anorexia reported to have experienced sexual abuse in childhood, in comparison to the 9% in the control group. However, two studies did find significant differences when comparing females who suffered from anorexia to a non-clinical control group (Deep et al., 1999; Karwautz et al., 2001). One study found that the reports of a history of CSA were significantly higher for the females who suffered from anorexia (Deep et al., 1999). Furthermore, results differed significantly between a clinically diagnosed sample of females who suffered from anorexia when they were compared to their sisters, who had no history of any eating disorder (Karwautz et al., 1999). Thirty-six percent of the sisters with anorexia reported to have experienced CSA, which was a significantly higher percentage when compared to the 11% of the sisters without any history of eating disorders (Karwautz et al., 2001).
Furthermore, results of two longitudinal studies also confirm the association between reports of CSA and the development of anorexia in adolescence (Johnson et al., 2000; Wentz et al., 2005). Females who suffered from anorexia reported significantly more CSA than a non-clinical control group (Wentz et al., 2005). Approximately 16.2% of the women with anorexia reported to have experienced a history of CSA. In addition, females who were followed throughout their adolescence showed elevated risks for the development of anorexia when they reported an episode of CSA (Johnson et al., 2000). Twenty-seven percent of the females who suffered from CSA developed anorexia in adolescence (Johnson et al., 2000). Seven percent of the females that experienced CSA did not develop an eating disorder in adolescence. These results also provide evidence that CSA might a risk factor for the development of anorexia in adolescence.
In addition, when the influence of the extent of CSA on the development of anorexia was assessed, results showed a positive association (Wentz et al., 2005). Females who suffered from anorexia reported to experience more repeated CSA than females who did not
suffer from anorexia in adolescence. This suggests that the extent of CSA might also influence the development of anorexia. Females who experienced one or more episodes of CSA were more likely to develop anorexia in adolescence than the females who experienced one or no episodes of CSA (Wentz et al., 2005).
To sum up, all studies found a positive association between CSA and the development of anorexia in adolescence. The found associations were relatively high when compared to the American national percentage of 8.3% (HHS, 2014). This strongly suggests that CSA is a risk factor for the development of anorexia nervosa in adolescence. One study did not show significant differences between a clinically diagnosed group of women and a non-clinical control group (LaPorte & Guttman, 2001). However, most studies did show a significant difference when CSA was assessed in a clinically diagnosed group of females and compared to a non-clinical control group. Moreover, one study also found a strong association between the extent of CSA and the development of anorexia, showing that a higher number of
episodes of CSA leads to a higher risk of the development of anorexia (Wentz et al., 2005) Furthermore, two longitudinal studies about the association between CSA and anorexia show that significantly more females who experienced CSA also developed anorexia (Johnson et al., 2000; Wentz et al., 2005). These results provide a solid body of support for the
hypothesized association between CSA and the development of anorexia in adolescent girls. The results of this systematic review therefore give sufficient evidence that confirms CSA as a risk factor for the development of anorexia nervosa in adolescent girls.
CSA as a Risk Factor for Bulimia Nervosa
A growing empirical body of evidence confirms the association between CSA and bulimia in female adolescents. The association between bulimia and CSA was reviewed in twelve studies (Anderson, LaPorte, & Crawford, 2000; Bulik, Prescott, & Kendler, 2008; Castellini et al., 2013; Claes & Vandereycken, 2007; Deep et al., 1999; Groth-Marnat &
Michel, 2000; Hartt & Waller, 2002; Matsunaga et al., 1999; Sanci, Coffey, Dip Epi, & Olsson, 2007; Steiger et al., 2001; Van Gerko, Hughes, Hamill, & Waller, 2004; Waller et al., 2001). All used studies were retrospective and the participants were clinically diagnosed with bulimia based on the criteria of the DSM-III and DSM-IV. Ten studies examined a group of clinically diagnosed females with bulimia and assessed the reports of CSA. Two studies compared this clinical group of females to a non-clinical comparison group. Estimates of CSA in females who suffered from bulimia ranged from 12.9% to 74.3%.
When CSA was assessed in a group of clinically diagnosed females, the found proportions differed (Castellini et al., 2013; Claes & Vandereycken, 2007; Matsunaga et al., 1999; Van Gerko et al., 2004; Waller et al., 2001). In a group of 31 females who were diagnosed with bulimia, a relatively small proportion of 12.9% reported a history of CSA (Castellini et al., 2013). Three studies show that moderate percentages of the females who suffered from anorexia reported a history of CSA, ranging from 30.4 to 45% of the females (Matsunaga et al., 1999; Van Gerko et al., 2004; Waller et al., 2001). Moreover, one study found a relatively high proportion of 67.9% of females who reported a history of CSA before the onset of anorexia. However, this study examined a relatively small sample of 28 female participants (Claes & Vandereycken, 2007).
Furthermore, this positive association between CSA and bulimia is also confirmed when a clinically diagnosed sample of females was compared to a non-clinical control group (Deep et al., 1999; Groth-Marnat, & Michel. 2000; Steiger et al., 2001). Females who
suffered from bulimia reported a history of CSA significantly more in comparison to the non-clinical control group, with estimates ranging from 37 to 74.3% (Deep et al., 1999; Groth-Marnat, & Michel. 2000; Steiger et al., 2001).
One study divided the experience of CSA in specific predictors to examine which predictor could be significant for the development of bulimia (Bulik et al., 2008). When CSA
was divided in seven different predictors, only one predictor showed to be significant for the development of bulimia (Bulik et al., 2008). Females answered questions about CSA on seven scales corresponding to the seven predictors: age at time of first abuse, the number of perpetrators, age of the perpetrator, gender of the perpetrator, whether the perpetrator was a relative, the use of force and threats and how much the incident influenced the victim. The scale ‘the use of force and threats’ when experiencing CSA showed to be a significant risk factor for the development of bulimia in adolescence (Bulik et al., 2008). This suggests that not the experience of CSA as a whole, but the level of force and threats during an episode of CSA can influence the development of bulimia in adolescent girls. However, when a similar predictor (use of forece) was examined in relation to the severity of bulimic symptoms, the predictor ‘use of force’ did not seem to influence the severity significantly (Anderson et al., 2000). This suggests that females who experience a high level of force and threats during an episode of CSA are more likely to develop bulimia, but not more likely to develop more severe symptoms than women who did not report a high level of force and threats (Anderson et al., 2000; Bulik et al., 2008).
When CSA was compared to other forms of abuse in relation to the development of bulimia, a non-significant relation between CSA and bulimia was found (Hartt & Waller, 2002; Steiger et al., 2002). When CSA was compared to a history of emotional or physical abuse, results showed that significantly more females with a history of physical abuse reported to have suffered from bulimia in adolescence in comparison to a history of CSA (Hartt, & Waller, 2002). Moreover, when sexual abuse was compared to physical abuse only, no significant differences were indicated for females who suffered from bulimia and females who did not suffer from bulimia (Steiger et al., 2001). Results even show that bulimia was only significantly associated with physical abuse (Steiger et al., 2001). This suggests that physical abuse might be a stronger predictor for the development of bulimia in adolescent
girls than a history of CSA (Anderson et al., 2000; Steiger et al., 2002). However, still a relatively high proportion of 41% of the females who suffered from bulimia reported a history of CSA (Steiger et al., 2002). This does suggest that CSA is a risk factor for the development of bulimia.
Results about the extent of CSA in relation to the development of bulimia are
contradictory (Anderson et al., 2000; Sanci et al., 2008). One study examined if the severity of bulimic symtpoms differed when sexual abuse characteristics were considered (Anderson et al., 2000). CSA was divided into six possible predictors for severity of bulimic symptoms: identity of the perpetrator, number of incidents of abuse, age at the time of abuse, presence of physical abuse and, nature of disclosure (Anderson et al., 2000). Results show that none of these predictors significantly influenced the severity of bulimic symptoms in the female participants, suggesting that the extent of CSA (e.g. number of incidents) does not influence the severity of bulimic symptoms (Anderson et al., 2000). However, when the severity of CSA was assessed in a longitudinal study, results suggest that the extent of CSA does influence the development of bulimia (Sanci et al., 2008). Results of this longitudinal study show that the incidence of bulimia was 2.5 times higher for females who were classified with one report of CSA, compared to females who did not report CSA. Moreover, the incidence was 4.9 times higher for the females who reported two or more episodes of CSA, compared to the females who did not report CSA (Sanci et al., 2008). The longitudinal prospective design provides strong evidence that the extent of CSA does influence the development of bulimia in adolescence (Sanci et al., 2008).
In conclusion, most studies show that a relatively high proportion of females with bulimia reports to have suffered from CSA. However, a prospective longitudinal study showed that CSA is not a specific risk factor for the development of bulimia, but only the use of force and threats during an episode of CSA is a significant predictor for the development
of bulimia. This predictor does not seem to influence the severity of bulimic symptoms. The studies that examined the extent of CSA in relation to the severity of bulimia show
contradictory results. One study showed that the extent and duration of CSA did not influence the severity of bulimic symptoms. However, when the incidence of bulimia was examined in a longitudinal study, results show that a higher incidence bulimia was reported by females who suffered from more episodes of CSA. All studies showed that relatively high proportion of females who suffered from bulimia reported a history of CSA, when compared to the American national percentage of 8.3% (HHS). Therefore, the results of these studies provide sufficient evidence that CSA can be determined as a risk factor for the development of bulimia in adolescent girls.
CSA as a Risk Factor for Binge Eating Disorder
There is a lack of information on the relation between CSA and binge eating disorder. Binge eating disorder is a relatively new disorder, added in the DSM-IV. Therefore, not many studies have focused on the relation between binge eating and CSA. Three articles that
examined this association were found by database searching (Grilo & Masheb, 2001;
Rodriguez-Srednicki, 2008; Van Gerko et al., 2005). All studies were retrospective and binge eating disorder was diagnosed when the criteria of the DSM-IV or the DSM-5 were met. Two articles used a clinical group and one article used a non-clinical group to investigate the possible association.
A moderate proportion of females suffering from binge eating disorder reported a history of CSA (Grilo & Masheb, 2001; Van Gerko et al., 2005). Approximately 22.2% of the females who were diagnosed with binge eating disorder also reported to have experienced an event of CSA. However, this study examined a relatively small sample size of 29 female participants (Van Gerko et al., 2005). In a bigger sample size of 90 female participants, reports of sexual abuse were two to three times higher for women who suffered from binge
eating disorder when compared to a non-clinical control group (Grilo & Masheb, 2005). These studies show that a relatively high proportion of females with binge eating disorder reports CSA compared to a non-clinical control group. This suggests that CSA might be a risk factor for the development of binge eating disorder in adolescence.
Furthermore, one study examined the difference in reports of self-destructive
behaviors in group of females who reported CSA and a group of females who did not report CSA (Rodriguez-Srednicki, 2008). Females who reported a history of CSA had a significant higher incidence of binge eating episodes in adolescence than the females who did not report a history of CSA. Results suggest that a history of CSA is related to more binge eating episodes in adolescence (Rodriguez-Srednicki, 2008). This provides evidence that a history of CSA can influence the severity of the symptoms of binge eating disorder..
To sum up, only a limited number of studies have examined the relation between CSA and binge eating disorder in adolescence. Due to this limited number of studies, any
conclusions based on the results are preliminary and should be interpreted with caution. Important to note is that no studies used a longitudinal design to examine the association, which limits any prospective findings. However, all the studies that were reviewed showed a positive and relatively high association between CSA and binge eating disorder, when
compared to the American national percentage of 8.3% (HHS, 2014). Two studies have found that a relatively high proportion of females who suffered from binge eating disorder also reports a history of CSA. Moreover, when a group of females who suffered from binge eating disorder was compared to a non-clinical control group, significant differences were found. Furthermore, one study showed that the experience of CSA is also a predictor for the incidence of binge eating episodes in adolescence. Although limited studies have been reviewed, results do provide sufficient evidence to confirm CSA as a risk factor for the development of binge eating disorder in adolescence.
Conclusion and Discussion
The goal of this systematic review was to create an overview of recent literature about the different types of eating disorders in relation to CSA, and to clarify CSA as a specific risk factor for the development of an eating disorder in adolescent girls. Based on the results of this systematic review three conclusions can be drawn. First of all, CSA is a specific risk factor for the development of anorexia nervosa in adolescent girls. Second, CSA can be considered as a specific risk factor for the development of bulimia in adolescence. Lastly, results also suggest CSA is a specific risk factor for the development of binge eating disorder in adolescent girls. These results provide sufficient evidence for a final conclusion that can be drawn from the three sub-conclusions: CSA is a specific risk factor for the development of eating disorders in adolescent girls.
The results of this systematic review expand upon existing research on the association between CSA and the development of eating disorders (Jacobi et al., 2004; Smolak &
Murnen, 2002; Thompson & Wonderlich, 2004; Treuer et al., 2005 Wonderlich et al., 1997). However, important to keep in mind is that only limited information was available about the association between binge eating disorder and CSA. This association is in need of more research. Therefore, the final conclusion of this systematic review is preliminary and should be used as a guideline for future research.
The results of this systematic review can be explained by a few alternative explanations. First of all, the association between CSA and eating disorders could be mediated by other conditions, such as post-traumatic stress disorder (PTSD) (Brewerton, 2007). Brewerton (2007) shows that a history of trauma in females who suffered from an eating disorder can be associated with significant psychiatric comorbidity, which is especially true when there is a current or lifetime history of PTSD. The mediating role of PTSD could therefore explain the strong association between the eating disorders and a history of CSA.
Secondly, the found associations could be influenced by an underlying biological mechanism. Research by Moneteleone et al. (2015) shows that a history of traumatic stress is marked by a dysregulation of the endogenous stress response system. Consequently, symptoms of an eating disorder are often characterized by a lack of regulation of stress (Adam & Epel, 2007). Monteleone et al. (2015) suggest that the development of eating disorders is caused by this dysregulation. The strong association between CSA and the development of eating disorders, could therefore be explained and mediated by this dysregulation of the endogenous stress response system (Adam & Epel, 2007; Monteleone et al., 2015). A final explanation for the results could be the overlap in bulimia and binge eating disorder. A main symptom of both bulimia nervosa and binge eating disorder is the binge eating episodes (APA, 2015). This suggest that a history of CSA is a predictor for symptoms of an eating disorder (binge eating episodes), and not purely for full eating disorder syndromes (Jacobi et al., 2004). Therefore, the strong association between CSA and bulimia or binge eating disorder might be caused by the mutual symptom of binge eating episodes.
Furthermore, this systematic review has several important limitations that should be considered when interpreting the results. First of all, the information about the experience of CSA was entirely gathered by retrospective instruments. This required the female participants to recollect a memory of events that might have occurred many years ago. The reliability of these reports could therefore have been influenced by a memory delay, elaboration of events or finding closure after the events of CSA. However, due to ethical reasons it is almost impossible to use a non-retrospective instrument to assess CSA. A second limitation is that the samples sizes of all reviewed studies were relatively small. The small sample sizes may have resulted in a reduced statistical power of the studies, and the inability to detect actual group differences. A final limitation is that only the results female participants were incorporated in this systematic review. Gender differences could influence the found
association between CSA and the development of eating disorders. However, only few studies have examined the association between CSA and the development of eating disorders in adolescent boys, which made it impossible to incorporate these results in the systematic review and examine gender differences.
Hence, based on these alternative explanations and limitations, some suggestions can be made for future research. First of all, this systematic review suggests possible mediating factors in the association between CSA and the development of eating disorders. Future research should examine the possible mediating role of PTSD and the endogenous stress response system. Secondly, future research should focus at the possible association between CSA and binge eating episodes to examine if CSA is a risk factor for binge eating episodes only. Thirdly, future research should also include results samples of adolescent boys. Still a lot is unknown about the association between CSA and eating disorder in adolescent boys, but found results do suggest there is an association. Therefore, it is important to investigate this association further, to determine possible gender differences. Finally, future research should try to include bigger sample sizes. By including bigger sample sizes, results can be generalized to a larger population and the reliability of the results can be enhanced
In conclusion, several studies have tried to investigate the relation between CSA and the development of eating disorders in adolescence. Due to the comprehensive search strategy and article selection, only high-quality articles with reliable assessment methods were reviewed in this systematic review. This systematic review has incorporated the results of these studies and had provided sufficient evidence that CSA is a specific risk factor for the development of eating disorders in adolescent girls. The conclusions of this systematic review are in line with previous studies about the association between CSA and the
development of eating disorders in adolescence. Results can be used to enhance and develop interventions, which in turn can be used to minimalize the number of girls suffering from
both sexual abuse in their childhood and the development of an eating disorder in
adolescence. It is very important to keep examining this association, because early screening of survivors of CSA might lead to better interventions and prevention methods for the development of eating disorders in adolescence.
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