Sexual abuse in irritable bowel syndrome : To ask or not to ask – That is the question

Section of Gastroenterology, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba Correspondence and reprints: Dr Alexandra Ilnyckyj, Section of Gastroenterology, 409 Tache Avenue, St Boniface General Hospital, Winnipeg, Manitoba R2H 2A6. Telephone 204-237-2796, fax 204-233-7154, e-mail ailnycky@sbgh.mb.ca Received for publication June 13, 2002. Accepted October 16, 2002 A Ilnyckyj, CN Bernstein. Sexual abuse in irritable bowel syndrome: To ask or not to ask – That is the question. Can J Gastroenterol 2002;16(11):801-805

I rritable bowel syndrome (IBS) is a colossal health care problem in the western world.In Canada, in 1997, the direct costs alone of managing this disorder represented 0.5% of our national health expenditure (1).Pharmacological therapy is limited (2).Despite the much anticipated introduction of the new drug classes binding to the various 5-hydroxytryptamine receptors, these agents have brought disappointment.One agent was withdrawn from the Canadian market, while another has demonstrated limited benefit.Psychological interventions have demonstrated efficacy (3) but are neither widely nor universally available.Since IBS is a considerable personal and societal burden, it is imperative to consider every element of the contemporary management strategy.A current working strategy includes exploring psychosocial stressors and their possible relationship to the onset of IBS (4,5).
The reported prevalence of rates of abuse are highly variable (6% to 62%) depending on the era, selected population, definition of abuse and method of inquiry (6).Among patients with IBS, the incidence of sexual abuse has been documented as 22% in a community sample (7) and as high as 44% in referral centres (8).A history of abuse has been shown to contribute independently to the health status of any individual presenting with gastrointestinal symptoms (9).Specifically, this study demonstrated that patients with functional gastrointestinal disorders had more severe abuse experiences than patients with organic gastrointestinal conditions.
Although no specific pathogenetic link has been developed that directly ties significant life stressors such as sexual abuse with visceral sensation or visceral motor responses, progress has been made in showing altered cortical responses in IBS compared with other gastrointestinal conditions in response to noxious visceral stimuli (10,11).Animal models of noxious rectal stimulation in infancy have been developed, which demonstrate changes in cortical and subcortical activation of the brain (12).It is speculated that altered central pain processing may contribute to the propensity for the disturbed motor and sensory gastrointestinal dysfunction that characterizes some subsets of patients with IBS.
Human studies have explored pain thresholds, coping strategies and psychiatric diagnoses in patients with func-tional disorders and abuse histories.Those who reported abuse had lowered pain thresholds, more maladaptive coping strategies and a higher incidence of psychiatric disorders than those who did not report abuse (13).
The high incidence of abuse among patients with IBS, coupled with the animal and human data, has led opinion leaders to promote abuse inquiry as essential to medical history taking (14).Treatment guidelines have been developed and promoted to assist in conducting an inquiry, specifically in patients presenting with severe symptoms (6).No data exist to support that either disclosure or discussion of abuse leads to measurable outcome benefits.Furthermore, there are no data pertaining to patients' impressions of being queried by a consultant.
While an understanding of the relationship between abuse and IBS must evolve, it is an ethical dilemma at present as to whether physicians should be compelled to inquire into the abuse history of IBS patients.If physicians choose not to ask, are they fulfilling their ethical responsibility to the patient?If physicians are not asking, then it is critical to understand why not.To ask or not to ask -that is the question.

METHODS
Physician practise patterns with regard to abuse inquiry were explored in the fall of 2001, by surveying the membership of the Canadian Association of Gastroenterology (CAG).Members were requested to complete a mailed survey aimed at capturing practice patterns and potential limitations to inquiry.Five potential limitations were hypothesized a priori and presented in the survey.
Respondents were asked to rank the factors they felt limited their inquiry (Figure 1).Only physician members of the CAG were included in the survey if they were in active clinical practice and residents of Canada.

RESULTS
Of the 509 eligible clinicians, 271 (53%) replied and formed the sample.Demographics revealed the following characteristics: gender -86% male; practice type -44% community full-time practice/37.5% academic full-time practice/18.5% academic part-time; 147 (54%) graduated from medical school in 1980 or earlier.There was no association between physician sex or era of graduation with The survey demonstrated that the Canadian gastroenterologist inquires into the abuse history of female IBS patients in only about 50% cases.Approximately one third confine their inquiry to patients with refractory IBS.Abuse inquiry in male IBS patients is less frequent (Table 1).Despite inquiry, 75% reported infrequently gaining disclosure from patients regarding abuse, and 46% estimated that patients were rarely or less than half the time comfortable with the inquiry.
Seventy-one per cent stated that they had limitations to inquiry; the most commonly cited factors were resources, personal comfort and time constraints as opposed to educational background or a view that abuse history is irrelevant to management (Table 2).Overall, inquiry into abuse history in IBS patients is not universally practised in Canada.

INTERPRETATION
The response to the survey of 54% was acceptable.In 1997, the CAG membership was surveyed regarding their use of cyclosporine in ulcerative colitis.Only 34% chose to voice their view on this clinical practice (15).
An implicit assumption of our survey was that a sexual abuse inquiry was of value in assessing patients with IBS.We acknowledge that the benefits of the disclosure and discussion of abuse have not been fully studied.It might be argued that an inquiry into sexual abuse is not of value but this argument was not supported in our survey; only 10% of respondents ranked the view that the abuse history is irrelevant to patient management as their primary barrier to inquiry.
There are no data exploring whether patients with IBS are harmed by inquiry into abuse history.Patients' preferences regarding inquiry of victimization experiences were explored by surveying a general group of community

Type of practice:
Community Full-time Academic Part-time Academic

Year of Medical School Graduation
1.In regard to asking female patients with IBS questions about sexual and/or physical abuse, which best describes your practice?
I always or frequently ask a sexual and/or physical abuse history.
I rarely or infrequently ask a sexual and/or physical abuse history.
I limit my inquiry to refractory patients only.
2. In regard to asking male patients with IBS questions about sexual and/or physical abuse, which best describes your practice?
I always or frequently ask a sexual and/or physical abuse history.
I rarely or infrequently ask a sexual and/or physical abuse history

I limit my inquiry to refractory patients only
If you selected rarely or infrequently for both of the above questions, go directly to question 5.  patients and primary care providers (16).This survey documented that most patients favoured a routine inquiry into physical or sexual abuse and overwhelmingly felt the physician could be of assistance to them.One third of the primary care givers believed inquiry should be routine; however, a minority incorporated this into their practice.The incidence of sexual abuse in the sample was 16%.It should be underscored that in this survey the physician was a primary care provider.Time constraints of the consultations were cited by 25% of gastroenterologists as their most important barrier to inquiry.This may relate to the brevity of the consultant relationship with the patient.Consultation consists of a brief patient-physician interaction.It is both time and frequency limited; consultation usually consists of one meeting.The treatment guidelines acknowledge the importance of establishing a good relationship with the patient before proceeding to an abuse inquiry.Arguably, this may be difficult to attain within the context of a consultation.

If you
With the constraints of current clinical practice, this may underscore the potential value of having nurse clinicians assist in the management and care of patients with IBS.Nurse clinicians or physician assistants can spend more time with a patient.This may promote a stronger relationship, thus facilitating inquiry into abuse.Additionally, the consultant has the option of delegating the inquiry to the referring physician.The consultant can use his or her report as a tool to educate the primary care physician regarding the relationship between abuse and IBS.
Since an inquiry into sexual abuse or handling of disclosure may lengthen consultation time, physicians might consider time constraints as a barrier to inquiry.This position is difficult to defend.Assessment must always be thorough.A physician is expected to inquire into the smoking history of a patient with cough.Disclosure of smoking requires engag-ing in education regarding cessation.This undoubtedly adds to the length of the consultation.Consultants must adapt their use of time to meet the needs of the consultation versus adapting the assessment to meet an arbitrary time allocation.
Another 25% of gastroenterologists cited personal comfort with abuse issues as the primal barrier to inquiry.Certainly one expects physicians to define their personal boundaries and limitations.At the same time, "the health of my patient will be my first consideration" (Hippocratic Oath).Physicians must address their personal discomfort and resolve it.Abuse in Canadian society is common; physicians cannot be excused of involvement due to personal discomfort.
The most commonly cited barrier (33%) was lack of resources for treatment referral; if we can't treat it, we should ignore it.Patients have the right to understand causal or contributing factors to their disorders irrespective of treatment options.There are many examples in modern medicine where resources for treatment are lacking.Every gastroenterologist is aware of the substantial numbers of Canadians who die yearly awaiting liver transplantation.However, physicians expend tremendous resources preparing and educating patients for a treatment option unlikely to come to fruition.Furthermore, in the case of abuse, patients may be encouraged by the link to their illness to help themselves or to seek help outside the health sector.
IBS is a common and costly disorder.It has long been recognized that there is an association between functional disorders and abuse.Increasingly, mechanisms for this link are being proposed.The majority of gastroenterologists are not incorporating an abuse inquiry into their history taking but the barriers they cite are not defensible.Therefore, by not inquiring into abuse, physicians are not fulfilling their ethical obligations.

CONCLUSIONS
Gastroenterologists need to resolve their barriers to abuse inquiry.We need to familiarize ourselves with published treatment recommendations regarding abuse inquiry and systemically include this in our repertoire of history taking in patients with IBS.Ask!That is the answer.
ACKNOWLEDGEMENTS: Dr George Webster, Clinical Ethicist, St Boniface Hospital, University of Manitoba is acknowledged for his contribution in reviewing the manuscript.

5 .
do ask regarding sexual and/or physical abuse, how frequently would you estimate that the patient discloses a positive history?always or most of the time mostly, probably half the time or more sometimes, but less than half the time rarely or never 4. If you do ask regarding sexual and/or physical abuse, in your estimation, how often is the patient comfortable with your inquiry?always or most of the time mostly comfortable, probably half the time or more sometimes comfortable, but less than half the time rarely or never comfortable Which of the following factors limit your inquiry regarding sexual and/or physical abuse?Please check as many factors as apply to you and then rank them (1 being the most important factor limiting you).If you experience no limitations, please omit this question.Rank A) time constraints of the consultation B) my educational background C) personal comfort with abuse issues D) limited resources for referring patient for support or treatment E) I feel the abuse history is irrelevant to patient management.

Figure 1 )
Figure 1) Survey designed to capture practice patterns and potential limitations to inquiry regarding possible sexual or physical abuse