Örebro University School of Medical Sciences Degree project, 15 ECTS
June-Dec 2020
INFLAMMATORY BOWEL
DISEASE AND IRRITABLE
BOWEL SYNDROME IN ADULT
LIFE AFTER EXPERIENCING
CHILDHOOD ABUSE
Author: Myella Cederholm Supervisor: Anna Jinghede, forensic dentist, postgraduate, sergeant
Abstract
Introduction
In a national survey from 2016, 5% of Swedish teenagers reported experience of repeated physical abuse and 6% reported repeated psychological abuse. Childhood abuse has been shown to enhance the risk of both psychiatric and somatic diseases, e.g. Irritable bowel syndrome (IBS) and also general inflammation. One type of inflammatory disease is
inflammatory bowel disease (IBD), which is composed of Ulcerative colitis (UC) and Chron’s disease (CD), but there is limited scientific evidence regarding the correlation of IBD and child abuse.
Objective
The aim of this systematic review is to study the correlation between childhood abuse and IBD in adulthood and compare this to the correlation of child abuse and IBS.
Method
PubMed and Web of Science databases were searched for articles studying childhood maltreatment and adult IBS or IBD. Articles that were not peer reviewed and presented original data or did not study IBD patients were excluded.
Results
342 articles were identified, of which nine met the pre-defined criteria and were included in this review. Eight articles studied the frequency of childhood abuse among IBS and IBD patients and one article studied disease activity in IBD patients that experienced childhood abuse. Childhood abuse was found to be more frequent in both IBS and IBD patients than healthy controls (HC). CD patients that were abused in childhood had elevated disease activity.
Conclusions
Childhood physical abuse was associated with both IBD and IBS. Childhood sexual abuse was associated with IBD, but a stronger association was found with IBS. No conclusions could be drawn regarding childhood psychological abuse.
Abbreviations
ACE’s: Adverse childhood experiences
CCHS-MH: Canadian Community Health Survey - Mental Health CD: Chron’s Disease
CPA: Childhood physical abuse CPS: Child protective services CRP: C-reactive protein CSA: Childhood sexual abuse
DDIS: Dissociative disorders interview schedule FFY: Federal fiscal year
GI: Gastro-intestinal
HBI: Harvey-Bradshaw Index IBD: Inflammatory bowel disease IBS: Irritable bowel syndrome
SBU: Swedish Agency for Health Technology Assessment and Assessment of Social Services
UC: Ulcerative colitis HC: healthy controls
Table of content
Introduction ... 5 Method ... 7 Literature search ... 7 Quality assessment... 7 Ethics... 7 Results ... 7 Articles identified ... 7 Study Characteristics ... 8 Evaluation Methods ... 9Childhood sexual abuse ... 9
Childhood physical abuse...10
Childhood psychological abuse...10
Disease activity ...11 Discussion...11 Risk of bias ...11 Evaluation methods...12 Study groups ...12 Results...13 Conclusion ...14 References...15 Appendix ...18
The questionnaire provided by SBU for assessing risk of bias ...18
Table I ...21
Introduction
During the federal fiscal year (FFY) of 2018 child protective services (CPS) in the US received reports regarding 7,8 million children. Of these, approximately 678,000 cases of child abuse and neglect could be confirmed by the CPS agencies[1]. This is equal to 9,2 in 1000 children. The victimization rate was highest in children younger than one years old (26,7 per 1000) and decreased with rising age. 17-years old’s had a victimization rate at 3,7 per 1000 individuals. The number of child victims were similar for boys (48,5%) and
girls(51,2%)[1]. US Department of Health & Human Services categorize maltreatment into multiple types: physical abuse (CPA), sexual abuse (CSA), emotional abuse and neglect[2]. Data from FFY of 2018 show that most victims (84,5%) were subjected to one single type of maltreatment, of which the majority (60,8%) suffered from neglect only. The remaining 15,5% were polyvictimized and exposed to two or more types of maltreatment[1].
Data from Children´s Welfare Foundation Sweden show that children who suffer from multiple types of abuse have a higher frequency of self-harm, suicide attempts and
psychosomatic symptoms, than those who were never abused or suffered from one or two types of abuse[3]. A Swedish population based survey found that women who experienced severe childhood sexual, physical or psychological abuse were twice as likely to suffer from physical health problems and depression as adults, compared to those who were never abused[4].
In a national survey in Sweden from 2016, 5% of the teenage respondents reported repeated victimization of physical abuse and 6% reported multiple episodes of psychological abuse. The data from this study also indicates a decrease in physical abuse, once or repeated, by parents since 1995, from 35% to 14%[5]. Since 2011, the reported psychological abuse in ninth graders decreased from 12% to 9% in 2016[5]. A national survey from the US also found that the frequency of child abuse is decreasing, and the prevalence of CSA decreased by 62% from 1992 to 2010[6], and CPA decreased from by 56% in the US[6].
It has been shown that adults who experienced childhood abuse have a higher rate of
depression[7], reported pain[8], post-traumatic stress syndrome, general anxiety disorder[9], psychosis[10], eating disorders and suicidal ideation[11]. Apart from the psychological consequences, childhood maltreatment is also linked to the development of several somatic
diseases in adulthood. Studies have shown that children that go through adverse childhood experiences may have a higher risk for lung cancer, which only partly can be explained by smoking behaviors[12]. It has also been shown that children who suffer from maltreatment early in life have a higher risk for musculoskeletal problems, cardiovascular disease, gastrointestinal and metabolic diseases[7].
Multiple studies have found that childhood abuse increases the risk of chronic
inflammation[13,14]. The mechanism of the link between child abuse andassociated long term health outcomes remain unclear, although some of the conditions associated with abuse may be explained by a dysregulated inflammatory immune system [13]. A significant
association has been found between childhood trauma and elevated inflammation markers such as Tumor necrosis factor-α, Interleukin-6 and C-Reactive protein (CRP)[13].
Inflammatory bowel disease (IBD) includes Crohn's disease (CD) and Ulcerative colitis (UC) and is characterized by chronic intestinal inflammation[15],which in most cases is visible during a colonoscopy[16]. Patients with IBD often have high levels of fecal calprotectin, fecal lactoferrin and serum CRP[17]. Some of the environmental risk factors for IBD is smoking, diet, drugs, and social stress[15]. The main symptoms of IBD is diarrhea and abdominal pain, and in ulcerative colitis also perianal bleeding[18].
Irritable bowel syndrome (IBS) is a functional bowel disorder, meaning that no biochemical or structural abnormalities can be seen with current diagnostic methods[19]. The diagnosis relies on that the patient fulfills diagnostic criteria, that is abdominal pain or discomfort associated with diarrhea and/or constipation for more than three days a month in more than six months, and that other causes have been ruled out[19]. Risk factors for IBS include female sex, age >50 years old, stressful life events, sexual or physical abuse, anxiety and
depression[19].
In both IBD and IBS stress is considered a risk factor[15,19]. It has been shown that child abuse and maltreatment are stressors that may increase the risk for long term IBS[20,21]. A lot of the research on IBS and childhood maltreatment uses IBD patients as control group, although there is no evidence that IBD is not linked to child abuse as well. Since childhood trauma is associated with adult inflammation[13,14], it may also be associated with IBD.
The aim of this systematic review is to study the correlation between different types of childhood maltreatment and IBD and compare this to the correlation with IBS. This is
important as a base for further research on the subject and to map out the etiology of IBD, that is currently not fully understood[15]. In addition, understanding the etiology of IBD can improve patient education.
Method
Literature search
A literature search was performed in 2020-11-17 using the databases PubMed and Web of Science. Search terms as “inflammatory bowel disease”, “ulcerative colitis”, “Crohn disease” and “irritable bowel syndrome” were combined with the terms “child sexual abuse”, “child physical abuse” and “child psychological abuse”. Filters were applied to only identify results in English.
Quality assessment
The article's risk of bias was evaluated using a questionnaire provided by the Swedish Agency
for Health Technology Assessment and Assessment of Social Services (SBU)[22]. The risks
of selection bias, performance bias, detection bias, attrition bias, reporting bias, and conflict of interest were evaluated, and the articles were graded high, average, or low risk of bias. See the full questionnaire in the appendix.
Ethics
No ethics approval is needed for this study, since it is a systematic literature review and do not handle any personal, sensitive or confidential information from the study participants. Not all articles studied mentioned an ethical approval, but all articles were peer-reviewed and published on PubMed or Web of Science.
Results
Articles identified
The search produced 342 results. Titles and abstracts were read to identify relevant studies. Articles were included if they were peer reviewed and provided original data about the association of different types of abuse before the age of 18 and any type of inflammatory
bowel disease or Irritable bowel syndrome in adults. 32 articles met the criteria for full-text analysis. Articles not studying any group of IBD patients were excluded and nine articles were included in this systematic literature review[23–31]. The articles that went through this literature search is presented in figure 1.
Figure 1: The process of identification and selection of articles for this review.
Study Characteristics
Table I provides information about the study designs. The full table I with study types, the number of participants, age, sex, study population, control group, variable measured and evaluation method can be seen in the appendix. The number of participants varied from 47[24] to 21852[28]. The mean age ranged from 37,1 to 50,1 years and the study population varied from 0% to 54,4% male. One study was population based[28] and eight were
retrospective cross-sectional cohort studies[23–27,29–31]. Eight out of nine studies measured the frequency of different types of adverse childhood experiences (ACE’s) among different patient groups and/or healthy controls (HC)[24–31] and one study measured the disease activity and quality of life among IBD patients with and without ACE’s[23].
Evaluation Methods
Fuller-Thomson et al. used data from the Canadian Community Health Survey - Mental Health (CCHS-MH), which includes questions about experiences of CPA and CSA [28]. Three studies used the medical history questionnaire to assess recalled physical, sexual, and psychological abuse[26,27,29]. Ross et al. used the Dissociative disorders interview schedule (DDIS), to assess childhood physical and sexual abuse[30]. Hobbis et al. used the abuse history questionnaire, which measures physical and sexual abuse before age 14[31]. Walker et al.(1995) used the Briere Child Maltreatment Interview, which assessed CSA, CPA, and childhood psychological abuse [25]. Walker et al.(1993) used a validated sexual abuse interview for different forms of childhood trauma[24]. Caplan et al. used the Child
maltreatment history self-report to rate childhood sexual and physical abuse, and the Harvey-Bradshaw Index (HBI) and 6-point Mayo score to measure disease activity in CD and UC patients respectively[23].
Table I: A summary of the articles study designs.
UC: Ulcerative colitis, CD: Chron’s disease, EAL: Early life adversities, IBD: Inflammatory bowel disease, IBS: Irritable bowel syndrome, CPA: Childhood physical abuse, CSA:
Childhood sexual abuse
Childhood sexual abuse
The general results of the studies and their risk of bias are presented in table II. For the full table, see the appendix. Seven out of nine articles studied the prevalence of CSA. Fuller-Thomson et al. found that CSA was more frequent in UC patients(21,7%) than in CD
Author, year study population Control group Measurement Caplan et al.[23], 2014 UC and CD patients with EALs UC and CD patients without
EAL Disease Activity Fuller-Thomson et
al.[28], 2015 UC and CD patients
People without
IBD Frequency of CPA and CSA Salmon et al.[29],
2003 IBS patients IBD patients
Frequency of CSA, CPA, and childhood psychological abuse Ross et al.[30], 2005 IBS patients
IBD patients,
other GI-disorders Frequency of CSA Beesley et al.[26],
2010 IBS patients CD patients
Frequency of CSA, CPA, and childhood psychological abuse Hobbis et al.[31],
2002 IBS patients CD patients, HC Frequency of CPA and CSA Walker et al.[25],
1995 IBS patients IBD patients Frequency of CSA and CPA Reilly et al.[27], 1999 IBS patients CD patients
Frequency of CSA, CPA, and childhood psychological abuse Walker et al.[24],
1993 IBS patients IBD patients
Frequency of severe child abuse
patients(4,6%) and HC(5,8%)[28]. Beesley et al. found that CSA was more frequently reported by IBS patients(18,9%) than CD patients(5,3%)[26]. Hobbis et al. did not find a significant difference(p=0,67) in frequency of CSA in IBS patients (26,0%), compared to CD patients (23,5%) and HC (17,0%) [31].
Four studies compared IBS to IBD, and all found a significant difference in the prevalence of CSA[25,27,29,30]. Salmon et al. found that 20,3% of IBS and 4,9% of IBD patients reported CSA[29]. In the study by Ross et al. 37,9% of IBS patients, 9,1% of IBD patients, and 11,6 of patients with another GI-disorder reported CSA[30]. Reilly et al. found that CSA was more frequent among IBS patients(20% of males and 33% of females), compared to IBD patients (5% of males and 10% of females)[27]. Walker et al. (1995) found a significant difference between IBS and IBD patients in reported child rape (24% compared to 8%) and child molestation (43% compared to 18%), but not childhood incest (17% compared to 5%)[25].
Childhood physical abuse
The frequency of CPA was measured in seven studies. Fuller-Thomson et al. found a significant difference in the prevalence of CPA, where UC patients (25,6%) had a higher frequency than CD patients (6,8%) and HC (9,8%), [28]. Beesley et al. found no significant difference in CPA between IBS patients, CD patients, and HC (p>0,05)[26]. Neither Hobbis et al. found any significant difference in CPA between IBS patients (54,0%), CD patients (60,8%) and HC (49,1%), p=0,15[31].
Four studies compared IBS to IBD, whereas two found a significant difference between the groups[27,29]. Salmon et al. found that 35,9% of IBS-patients and 13,1% of IBD patients reported CPA(p<0,01)[29]. Reilly et al. found that 40% of male and female IBS patients and 10% of male and 5% of female IBD patients reported CPA(p<0,01)[27]. Walker et al. (1995) found that 26% of IBS patients and 18% of IBD patients reported CPA, which did not show any significant difference(p>0,05)[25]. Walker et al.(1993) studied severe childhood abuse and found no significant difference(p=0,2) between IBS patients(11%) and IBD
patients(0%)[24].
Childhood psychological abuse
Three studies measured the prevalence of childhood psychological abuse. Beesley et al. found no significant difference between IBS and CD patients(p>0,05)[26]. Salmon et al. studied the prevalence of childhood psychological abuse among IBS and IBD patients and also found no significant difference (39,1%of IBS vs 31,1% of IBD, p>0,05)[29]. Reilly et al. found that
childhood psychological abuse was significantly more frequent reported by IBS-patients (50% of males and 43% of females) than IBD-patients (30% of males, 25% of females),
p<0,001[27].
Disease activity
Caplan et al. was the only study that measured disease activity. The study found that in patients with CD the mean HBI score was 6,1. The mean 6-point Mayo score in UC patients was 0,58. In CD patients more severe abuse was associated with higher HBI score(p=0,026), while in UC patients, more severe abuse was not associated with a higher 6-point Mayo score(p=0,22)[23].
Table II: The concluded results for the reviewed studies.
Author, year Results Caplan et al.[23], 2014
More severe abuse was associated with higher disease activity in CD, but not UC.
Fuller-Thomson et al.[28], 2015
Higher prevalence of CPA and CSA was found in UC, but not CD patients, compared to HC.
Salmon et al.[29], 2003
IBS was associated with a higher frequency of CSA and CPA but not childhood psychological abuse, compared to IBD-patients.
Ross et al.[30], 2005
CSA was more frequent among IBS patients than IBD and other GI patients.
Beesley et al.[26], 2010
IBS patients more frequently than CD patients reported CSA, but not CPA or childhood psychological abuse.
Hobbis et al.[31], 2002
No difference between IBS, CD patients and HC was found in frequency of CPA or CSA.
Walker et al.[25], 1995
Child rape and molestation was more frequent among IBS than IBD patients. No difference was found in CPA and child incest.
Reilly et al.[27], 1999
IBS patients more frequently than IBD patients reported CSA, CPA and Childhood psychological abuse.
Walker et al.[24], 1993 No association between diagnosis and severe child abuse was found.
CD: Chron’s disease, UC: Ulcerative colitis, HC: Healthy controls, IBS: Irritable bowel syndrome, IBD: Inflammatory bowel disease, CPA: Childhood physical abuse, CSA: Childhood sexual abuse, GI: gastro-intestinal
Discussion
Risk of bias
The summarized risk of bias for the studies is presented in table II. In this systematic review, average risk of conflict of interest was observed in all the articles, since no articles presented their funding. Low risk of performance bias and reporting bias was observed in all the studies.
Walker et al. and Ross et al. presented a high risk of selection bias since their study groups significantly varied in age. The prevalence of child abuse has declined since the 1990s[5,6], indicating that abuse was more common when the older study group were children, which may affect the results of the study. Ross et al. utilized various recruitment strategies, resulting in a majority of IBS patients being recruited by newspaper ads compared to IBD patients that were mostly recruited at clinics and hospitals. Group composition may in turn affect the results, as the recruitment methods showed a large heterogeneity with different patient groups being recruited by different recruitment methods. All other studies showed a low risk of selection bias.
Eight studies used an evaluation method only implementing objective measurements, which severely decreased the sensitivity for detection bias and these studies were observed have a low risk of detection bias. However, Walker et al. (1993) used interview followed by a grading of trauma-level by the authors, that were not reported to be blinded . As there were no blinding, the author could manipulate the results, increasing the risk of detection bias.
The risk of attrition bias was observed to be low in seven of the nine studies since they all had an attrition rate of less than 20%. Those with an attrition rate higher than 20%, Hobbis et al. (29%) and Fuller-Thomson et al. (31%), were considered having a high risk of attrition bias, according to SBU’s Guidelines. Hobbis et al. and Fuller Thomson et al. did not report from which group there was attrition, and therefore they both receive high risk of attrition bias. There is a possibility that those who did not complete the study were all in the same study group, which may affect the results.
Evaluation methods
All the articles used different retrospective interviews or questionaries with similar questions to identify childhood maltreatment. The advantages of this method, compared to using a register of reported abuse cases, are that children never noticed by social services could also be included. The disadvantages are the risk of memory error, that may be combined with the suppression of bad memories, and that different individuals may have different definitions of abuse.
Study groups
It can be considered problematic that some of the studies use IBD patients as control group when studying childhood abuse in IBS patients. This because earlier evidence indicates that childhood abuse increases the risk of general inflammation later in life[13], which is
supported by Fuller-Thomson et al. that present a higher frequency of CPA and CSA in UC patients than HC[28] and by Caplan et al. that found an association between severe childhood abuse and disease activity in CD patients.
Results
All six studies that compared IBS to IBD measured CSA and found it more frequent in the IBS group. In CPA two of five studies found that it was more frequent in the IBS group. Caplan et al. did not study frequency but found that CPA was associated with higher disease activity in CD patients and Fuller-Thomson et al. found that CPA and CSA were more frequent in UC than HC. Their results indicate that the results from Walker et al.(1993), Hobbis et al., Walker et al.(1995), and Beesly et al., not showing any link between IBS and CPA, may be underrating the association if both the IBS group and the control group had elevated frequency of child abuse. Contraindicative, Hobbis et al. found no difference in either CPA or CSA in HC, IBS, and CD patients. Considering their number of participants, the result from Fuller-Thomson et al. are more statistically significant. Only one of three studies found childhood psychological abuse more frequent in IBS patients than IBD patients, which none of the studies with HC investigated.
No articles analyzed if a combination of multiple types of abuse was more associated with later IBS and IBD than only one type. This is relevant, since children who suffer from multiple types of abuse suffer more negative consequences in childhood than those who only suffer from one form of maltreatment[3], meaning this is a subject for further research.
Although most of the articles included in this systematic review found an association between IBD and childhood abuse, it is hard to prove causation. Multiple factors can affect both the prevalence of childhood abuse, its consequences, and the risk of IBD. One such factor is depression, since childhood abuse has been linked to adult depression[32] and depression has in turn been linked to both UC and CD[33]. However, childhood abuse is more frequent among those growing up with low socioeconomic status[34] and it is also linked to adult unemployment and poverty[35], but IBD is associated with higher social class[33,36]. To eradicate this, Fuller-Thomson et al. controlled for variables as sociodemographic factors, health behaviors (smoking, physical activity, obesity etc.), depression and anxiety. After adjustment for these factors, CPA and CSA were still more than twice as frequent among UC patients than HC[28].
Considering the fairly small amount of material on this subject, and the variety of the included studies the conclusions of this literature review is limited . A cross-sectional cohort study would be a better contribution to this field of research, ideally comparing children who were abused and those who were not in gastro-intestinal health instead of comparing the abuse frequency among different patient groups. This was not possible under the timeframe for this study.
Conclusion
To conclude, both CPA and CSA were associated with both IBS and IBD, but in CSA data indicates that the link to IBS is stronger than to IBD. No conclusion of the association between childhood psychological abuse and IBD can be drawn in this review since none of the studies that included this had healthy controls. The results indicate that IBD patients should not be used as control group when studying IBS. Further research, that studies the frequency of IBS and IBD among childhood abuse victims compared to those who never experienced abuse, is needed to broaden the understanding of childhood maltreatment and its long-term consequences.
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Appendix
Table I
Table I: A summary of the articles study designs, participant demographics, measurements, and evaluation methods.
UC: Ulcerative colitis, CD: Chron’s disease, EAL: Early life adversities, IBD: Inflammatory bowel disease, IBS: Irritable bowel syndrome, GI: Gastro-intestinal, CPA: Childhood physical abuse, CSA: Childhood sexual abuse, CCHS-MH: Canadian Community Health Survey - Mental Health, DDIS: Dissociative disorders interview schedule
Author,
year study type n participants mean age Sex study population Control
group Measurement Evaluation method Caplan et al.[23], 2014 Cross-sectional cohort study 193 46,3 54,4% male UC and CD patients with EALs UC and CD patients without
EAL Disease Activity
HBI (CD) and 6-point Mayo-score (UC) Fuller-Thomson et al.[28], 2015 Population based study 21852 50 50,2% male UC and CD patients People without IBD Frequency of CPA and CSA CCHS-MH Salmon et al.[29], 2003 Cross-sectional cohort study 125 40,4 39,2% male IBS patients IBD patients Frequency of CSA, CPA, and childhood psychological abuse Medical history questionnaire Ross et al.[30], 2005 Cross-sectional cohort study 105 50,1 37,1% male IBS patients IBD patients, other
GI-disorders Frequency of CSA DDIS Beesley et al.[26], 2010 Cross-sectional cohort study 151 40,2 35,8% male IBS patients CD patients Frequency of CSA, CPA, and childhood psychological abuse Medical history questionnaire Hobbis et al.[31], 2002 Cross-sectional cohort study 207 38,9 0% male IBS patients CD patients, HC Frequency of CPA and CSA
The abuse history questionnaire Walker et al.[25], 1995 Cross-sectional cohort study 111 47,6 15% of IBS, 27% of IBD male IBS patients IBD patients Frequency of CSA and CPA Briere Child Maltreatment Interview Reilly et al.[27], 1999 Cross-sectional cohort study 80 41 25% of IBS, 50% of IBD male IBS patients CD patients Frequency of CSA, CPA, and childhood psychological abuse Medical History Questionnaire Walker et al.[24], 1993 Cross-sectional cohort study 47 37,1 21% of IBS, 47% of IBD male IBS patients IBD patients Frequency of severe child abuse
Sexual trauma interview
Table II
Table II: The concluded results and risk of bias for the reviewed studies.
Author, year Results Statistical significance Risk of bias Caplan et al.[23], 2014
More severe abuse was associated with higher disease activity in CD, but not UC.
P=0,026 Significant results Average risk Fuller-Thomson et al.[28], 2015
Higher prevalence of CPA and CSA was found in UC, but not CD patients, compared to HC. P<0,001. Significant results Average risk Salmon et al.[29], 2003
IBS was associated with a higher frequency of CSA and CPA but not childhood psychological abuse, compared to IBD-patients.
P<0,05 and p<0,01. Significant
results Low risk Ross et
al.[30], 2005
CSA was more frequent among IBS patients than IBD and other GI patients. P<0,05. Significant results Average risk Beesley et al.[26], 2010
IBS patients more frequently than CD patients reported CSA, but not CPA or childhood psychological abuse.
P=0,04. Significant
results Low risk Hobbis
et al.[31], 2002
No difference between IBS, CD patients and HC was found in frequency of CPA or CSA.
P=0,15 and p=0,67. No significant results Average risk Walker et al.[25], 1995
Child rape and molestation was more frequent among IBS than IBD patients. No difference was found in CPA and child incest.
P<0,05. Significant results Average risk Reilly et al.[27], 1999
IBS patients more frequently than IBD patients reported CSA, CPA and Childhood psychological abuse.
P<0,01 and p<0,001. Significant
results Low risk Walker
et al.[24], 1993
No association between diagnosis and severe child abuse was found. P<0,2. No significant results Average risk
CD: Chron’s disease, UC: Ulcerative colitis, HC: Healthy controls, IBS: Irritable bowel syndrome, IBD: Inflammatory bowel disease, CPA: Childhood physical abuse, CSA: Childhood sexual abuse, GI: gastro-intestinal
