A contextual approach to routinely elicit a trauma-oriented history

Thanks to Dr Ingrassia for her recent editorial on the Independent Inquiry into Child Sexual Abuse in the UK with an emphasis on the need for the sensitive and well-informed clinician to proactively and routinely ask about sexual abuse.¹

In our study of child sexual abuse (CSA) history among psychiatric consultations in a general hospital emergency room, we found that 38% of individuals (adults and minors) referred for psychiatric consultation over a 2-year period described having experienced sexual abuse during their childhood.²

We used a semi-structured questionnaire with language that was appropriate to age and cultural background in order to routinely enquire whether the patient had experienced physical, emotional or sexual abuse during their childhood in accordance with a widely accepted definition of sexual abuse.³ This approach is consistent with the research that multiple forms of adverse childhood experiences may coexist.⁴ We believe that a contextual approach like this is more likely to promote a discussion of the person's trauma narrative. Using this paradigm, with appropriate training, it is hoped that medical and paramedical clinicians will be able to sensitively and routinely take a comprehensive trauma-oriented history in every patient. In this way, the patient's presenting problem may be understood and treated with an understanding of ‘what has happened to this person’.

It is worth mentioning that adverse childhood experiences including sexual abuse is not only associated with an increase in lifetime prevalence of mental illness but also of physical illness. There is evidence linking early-life stress to reduced telomere length in a study of physically and psychiatrically healthy adults with or without a reported history of childhood trauma. These early experiences may affect adult health in two ways: either by cumulative damage over time or by the biological embedding of adversities during sensitive developmental periods.⁴ Mediating factors between CSA and physical illness include neuroendocrine dysfunction, metabolic syndrome and chronic inflammation.⁵

To the best of our knowledge our study is the first to investigate CSA history during hospital emergency room psychiatric consultations. It is hoped that there will be an increased awareness of CSA during psychiatric consultations in a general hospital setting.

Interventions for past CSA should include the nature of early-life trauma and its effects on psychobehavioural factors. When healthcare providers counsel victims of childhood abuse, they should consider the long-term psychological and physical well-being necessary to counter adverse responses to abuse such as disordered eating, lack of exercise, sleeping problems and depressive symptoms. They should also promote healthier ways to cope with trauma. Such psychological interventions would have the potential to prevent or reduce physical health problems in later life.⁴