Psychiatry and Clinical Neurosciences (2001), 55, 333–340
Regular Article
Physical and sexual abuse histories in patients with
eating disorders:A comparison of Japanese and
American patients
TOSHIHIKO NAGATA, md, phd,1 WALTER H. KAYE, md,2 NOBUO KIRIIKE, md, phd,1
RADHIKA RAO, ms,2 CLAIRE McCONAHA, bsn2 AND
KATHERINE H. PLOTNICOV, phd2
1
Department of Neuropsychiatry, Osaka City University Medical School, Osaka Japan and 2Department of
Psychiatry, University of Pittsburgh School of Medicine, Pennsylvania, USA
Abstract
Physical and sexual abuse among patients with eating disorders has been a focus of attention
in Western countries, however, there is no study comparing the incidence of these factors in
Western and Asian countries. Japanese subjects consisted of 38 patients with anorexia nervosa
restricting type (AN-R), 46 patients with anorexia nervosa binge eating/purging type (AN-BP),
76 patients with bulimia nervosa purging type (BN) and 99 controls. Subjects from the USA consisted of 29 AN-R, 34 AN-BP and 16 BN. The Physical and Sexual Abuse Questionnaire was
administered to all subjects. Minor sexual abuse such as confronting exhibitionism or being
fondled by a stranger tended to be more prevalent among Japanese subjects, while victimization
by rape or incest was more prevalent among USA subjects. Conversely, physical abuse history
was similarly distributed across each diagnostic subgroup in both countries. Events related to
physical abuse, such as an abusive family background, may contribute whether eating disorder
patients are restricting or bulimic and regardless of culture.
Key words
eating disorders, physical abuse, sexual abuse.
INTRODUCTION
In recent years, there have been an increasing number
of reports concerning serious traumatic experiences,
especially physical and sexual abuse in general psychiatric patients1 and in anorexia nervosa and bulimia
nervosa patients2–5 in Western countries. Results of
recent studies suggest that the link between abuse histories and eating disorder is not specific nor straightforward, but such histories are risk factors for bulimia
nervosa with significant comorbidity.6–10
Although anorexia nervosa and bulimia nervosa
have been considered a prototype for investigations of cross-cultural differences and psychiatric
Correspondence address: Toshihiko Nagata, Department of
Neuropsychiatry, Osaka City University School of Medicine,
1-4-3 Asahimachi, Abenoku, Osaka 545-8585, Japan. Email:
TOSHI@med.osaka-cu.ac.jp
Received 9 August 2000; revised 20 November 2000; accepted 5
December 2000.
diagnoses,11 only Pope et al. compared abuse rates
reported by normal-weight bulimics among countries
(USA, Austria, and Brazil), but failed to find significant differences.12 Moreover, these rates did not
appear to be any greater than those reported in comparable studies of women in the general population.
However, American and Brazilian society mainly consists of immigrants from European countries, so that
these societies have relatively similar cultures. Conversely, Japan is a highly industrialized country, but
has a very different culture from that of Western
countries. Few Japanese patients with eating disorders
have reported traumatic experiences during their
childhood,13 although their clinical features show a
similar degree of severity compared with patients in
Western countries with regard to prevalence14 and
stress-coping strategies.15 Furthermore, anecdotal evidence also suggests that Japanese male patients with
alcoholism frequently report being physically abused
in childhood. Therefore, a cross-cultural study, especially in very different cultures, is essential to improve
T. Nagata et al.
334
understanding of eating disorder psychopathology
and etiology.
This study compares the prevalence of sexual and
physical abuse histories in Japanese and USA patients
with eating disorders to examine the hypothesis
that Japanese patients were less frequently sexually
abused, but might have been physically abused more
frequently.
METHOD
Subjects
Japanese subjects consisted of 38 patients with
anorexia nervosa restricting type (AN-R), 46 patients
with anorexia nervosa binge eating/purging type
(AN-BP), 76 patients with bulimia nervosa purging
type (BN) and 99 female controls. Findings regarding
some of these Japanese subjects were previously published elsewhere, one study focused relationship traumatic events and impulsive behaviors,13 while another
study reported obsessional symptoms in bulimic
patients.16 Subjects from the USA consisted of 29 ANR, 34 AN-BP and 16 BN. Patients with eating disorder
not otherwise specified were excluded from this study.
Diagnoses were made according to DSM-IV criteria,17
and all subjects were females.
All Japanese patients were outpatients of the
Department of Neuropsychiatry, Osaka City University Hospital, Osaka, Japan. Questionnaires were
administered during the initial evaluation, and some
patients were hospitalized in our unit if necessary.
Japanese controls were female students attending a
nursing school in Osaka. In a psychiatry class, 120
students were asked to complete our inventory on
a voluntary basis and to return the questionnaire
anonymously by mail. Although 103 students (86%)
responded, four students were excluded from this
study because they reported a history of eating disorders (n = 2), the minimum body mass index (BMI)
was less than 17.5 (n = 1, BMI of one student was
16.6),18 or the questionnaire was incomplete (n = 1).
All subjects in the USA were inpatients at the
Center of Overcoming Problem Eating (COPE) unit
of Western Psychiatric Institute and Clinic, Pittsburgh,
PA, USA. All US subjects were female Caucasians,
and questionnaires were administered at admission.
Inventories
We expected that Japanese subjects would not
respond about sensitive issues in direct interviews,
therefore a self-reporting questionnaire was used to
assess abuse histories.
The Physical and Sexual Abuse Questionnaire
(PSA)13 was originally developed in both languages
by the authors to assess in detail the presence of
sexual or physical abuse (an English version can be
obtained upon request). Sexual abuse was defined as
unwanted sexual contact prior to the age of 18 years,
ranging from body contact such as fondling to intercourse and oral sex.19 Confronting exhibitionism was
considered separately in analyzing the results.
Physical abuse focused on histories of excessive
physical punishment by parents.20 These physical punishment items ask for responses of ‘never’, ‘sometimes’ or ‘often’. However, only ‘often’ was counted as
a history of physical punishment.
The preliminary validity and reliability of PSA was
evaluated by comparing questionnaire results when
the patient first visited our outpatient clinic with the
interviewing results during inpatient treatment in 15
Japanese patients. Kappa statistics of physical punishment questions (first to sixth items) were 0.68, 0.62,
0.66, 1.00, 0.66, 0.56, respectively. If only ‘often’ was
counted, the results of outpatients and inpatients
were the same, indicating that kappa statistics were
1.00 for all six items. Similarly, kappa statistics of
sexual abuse contents in terms of who was involved
and what happened, were the same (indicating that
kappa for both were 1.00). Thus, preliminary validity
and reliability had been demonstrated.
This PSA and Eating Disorders Inventory
(EDI)21,22 were administered to all subjects.
Statistics
Two-way analysis of variance (ANOVA) and Scheffe’s
multiple comparison, Student’s t-test with Levene’s
test for equality of variances, c2 test, and Fisher’s
exact test were used for analyses (SPSS software,
Chicago, IL, USA). On post-hoc Fisher’s exact test,
alpha was reduced to.016 by Bonferroni correction.
RESULTS
Table 1 shows the demographics of the subjects. Data
were analyzed by two-way ANOVA. Patients in Japan
and the USA were similar in age, however, patients
from the USA had significantly earlier onset and
had been ill for a significantly longer period compared with Japanese patients. Conversely, Japanese
patients showed a significantly lower BMI, however,
bulimic patients in both countries showed a similar
BMI. Among Japanese patients, 15 AN-R, 18 AN-BP
and 18 BN patients had a history of inpatient treatment due to eating disorders or were admitted our
unit.
Cross-cultural study of abuse histories in eating disorder patients
335
Table 1. Demographics of Japanese (Jp) and American (USA) subjects with anorexia nervosa restricting type (AN-R),
anorexia nervosa binge eating purging type (AN-BP), bulimia nervosa purging type (BN) and controls (C, Japanese only)
Nationality
Subject number
Jp
USA
Age
Jp
USA
Age of onset
Jp
USA
Duration of illness
Jp
USA
Body mass index
Jp
USA
Minimal body mass index
Jp
USA
AN-R
AN-BP
BN
Statistics
38 (15)1
29
46 (18)
34
76 (18)
16
22.5 ± 6.3
18.8 ± 4.9
24.8 ± 4.7
25.5 ± 9.0
22.3 ± 4.3
22.8 ± 5.0
F(N) = 0.7, P = 0.4
F(D) = 12, P < 0.001,AN-BP > AN-R,BN
19.3 ± 4.5
15.4 ± 4.6
18.9 ± 3.4
16.2 ± 6.4
18.3 ± 3.8
14.9 ± 3.2
F(N) = 27, P < 0.001
F(D) = 0.8, P = 0.4
NA
3.2 ± 4.1
3.4 ± 5.2
5.9 ± 4.4
9.7 ± 9.7
4.0 ± 3.9
7.8 ± 5.6
F(N) = 11, P = 0.001
F(D) = 13, P < 0.001,AN-BP > AN-R,BN
NA
13.4 ± 1.7
15.3 ± 2.4
15.3 ± 2.9
15.2 ± 2.3
20.6 ± 2.6
20.2 ± 3.9
F(N) = 1.4, P = 0.2
F(D) = 92, P < 0.001,AN-R,N-BP < BN
20.0 ± 3.0
NA
12.6 ± 1.5
14.8 ± 2.4
13.0 ± 2.2
13.7 ± 2.3
16.6 ± 2.3
16.3 ± 3.4
F(N) = 7, P = 0.01
F(D) = 171, P < 0.001,AN-R,AN-BP < BN
19.2 ± 2.0
NA
F(N): effect of country difference
F(D): effect of diagnostic subtype
Controls
99
0
20.8 ± 2.5
NA
NA: not available. 1 number in parentheses indicates patients with inpatient treatment history, degree of freedom for age,
age of onset, duration of illness, BMI and minimal BMI is 5, 233.
All Japanese patients were outpatients and all
patients from the USA were inpatients, thus we compared demographics, EDI scores, physical and sexual
abuse history between Japanese patients with and
without inpatient treatment (including our unit)
history. However, there are no significant differences
in sexual or physical abuse history in any diagnostic
subgroup such as AN-R, AN-BP or BN, or in the total
Japanese patient group. For example, physical punishment history (as defined below) in Japanese total
eating disorder patients, with and without inpatient
treatment history were 10 (20%) versus 14 (13%)
(P = 0.34 by Fisher’s exact test). Victims of rape among
these Japanese patients, with and without inpatient
treatment history were 0 versus 4 (4%), respectively
(P = 0.31 by Fisher’s exact test). However, among
demographics values, Japanese AN-BP patients with
an inpatient treatment history were significantly older
(26.9 ± 5.2 vs 23.5 ± 3.9, t = 2.5 P = 0.015), had a longer
duration of illness (8.7 ± 4.5 vs 4.1 ± 3.4, t = 4.0 P <
0.001), lower minimal BMI after menarche (12.0 ± 1.9
vs 13.7 ± 2.1, t = 2.7, P = 0.01), and showed significantly
lower drive for thinness (7.7 ± 5.8 vs 12.3 ± 6.1, t = 2.2, P
= 0.03) and bulimia (4.5 ± 4.8 vs 10.5 ± 6.7, t = 3.0, P =
0.006) scores on EDI compared to those without such
history. Therefore, Japanese patients with and without
inpatients treatment history were combined into one
group in analyzing abuse histories.
Results of sexual abuse histories are summarized in
Table 2. Some Japanese patients and controls reported
histories of confronting exhibitionism, although no
patient from the USA reported this. Likewise,
Japanese AN-R patients reported minor sexual abuse
history (sexual abuse history other than rape) significantly frequently compared with the AN-R patients
from the USA, and similarly Japanese AN-BP and
BN patients. However, there were no AN-R patients
in either country who had been raped or victimized
by incest. Similar substantial numbers of patients with
AN-BP and BN in both countries were sexually
abused, although two major differences between the
countries were identified. First, most of the perpetrators of Japanese patients were strangers, while in the
patients from the USA, perpetrators were known to
some degree. This difference between the two countries reached significance in the AN-R and AN-BP
groups. Second, victims of rape or incest, including
attempts, were significantly more frequent among
AN-BP and BN patients from the USA than among
their Japanese counterparts.
Histories of physical punishment are presented in
Table 3. Only responses of ‘often’ were counted as a
history of abuse in Table 3. Similar to results of sexual
abuse histories, none of the Japanese or American
patients with AN-R were physically punished by their
parents in their childhood. Japanese patients with
T. Nagata et al.
1.00
0.02
0.57
0.76
0.12
1.00
5 (31%)
0
1 (6%)
10 (29%)
0
2 (6%)
1
Number in parentheses indicates percentage. 2 by Fisher’s exact test.
14 (30%)
7 (15%)
1 (2%)
2 (7%)
0
0
12 (34%)
9 (24%)
0
0.009
0.04
0.35
0.008
2 (13%)
4 (25%)
38 (38%)
28 (28%)
1 (1%)
19 (25%)
14 (18%)
2 (3%)
0.18
0.03
5 (15%)
7 (20%)
13 (28%)
2 (4%)
2 (7%)
0
12 (34%)
0
0.009
0.21
0.55
0
6 (38%)
0
12 (35%)
1 (2%)1
15 (33%)
0
2 (7%)
Confronting exhibitionism
Sexual abuse history (exc. exhibition)
Rape or not
Other than rape
Rape or incest (inc. attempt)
Extra-familial or intra-familial
Extra-familial
By unknown person
Intra-familial
0
12 (34%)
0.009
38 (38%)
1 (1%)
19 (25%)
2 (3%)
1.00
0.81
P
AN-BP
USA
AN-R
USA
P2
Jp
BN
USA
18 (18%)
39 (39%)
11 (15%)
21 (28%)
P
DISCUSSION
C
Jp
Jp
AN-R seemed less likely to be physically punished,
even compared with controls, although there were
no controls from the USA for statistical comparison.
There were no significantly differences between USA
and Japanese patients for any item or in any diagnostic subgroup (P = 0.39–1.00 by Fisher’s exact test). We
provisionally defined physical punishment histories as
any of the following: often locked in a closet, often hit
with the hands, often kicked, or often hit with something other than the hands. Surprisingly, a very similar
percentage of AN-BP and BN patients from both
countries reported to have had a physical punishment
history. AN-BP and BN groups in Japan and the ANBP group in the USA experienced significantly more
frequently these physical punishment histories than
AN-R patients.
Jp
Table 2. Sexual abuse at least including physical contacts and confronting exhibitionism of Japanese (Jp) and American (USA) subjects with anorexia nervosa
restricting type (AN-R), anorexia nervosa binge eating purging type (AN-BP), bulimia nervosa purging type (BN) and controls (C, Japanese only)
336
To our knowledge, this is the first study to directly
compare the sexual and physical abuse histories
in eating disorder patients of Western and Asian
countries.
Although methodologies varied considerably, the
study demonstrated a childhood sexual abuse rate of
approximately 30% in eating disordered individuals
in clinical settings.3,23 Therefore, the results from both
countries are consistent with previously reported percentages of patients with such sexual abuse histories.
However, there are two major differences between
two countries. First, is the high rate of victimization
by rape or incest among the AN-BP and BN patients
from the USA. Second, is the significantly higher rate
of minor sexual abuse by strangers among Japanese
patients, especially in Japanese patients with AN-R
and AN-BP, compared to the rate among patients
from the USA. However, this issue has been discussed
elsewhere as a ‘Chikan’ (a Japanese word meaning a
person who commits minor sexual crimes such as
among rush-hour subway users).13 In addition,
Japanese people might be more shameful of sexual
events and difficulties, although our results did not
agree with Schmidt’s hypothesis24 that patients with
anorexia nervosa had significantly more pudicity
events before onset than BN patients or controls.
Rates of rape or incest in AN-BP or BN patients
from the USA were significantly higher than those
among their Japanese counterparts (around fivefold
higher). There were no controls from the USA in the
present study, however, we used questions similar to
Finkelhor et al.’s telephone interview survey,25 and
victimization by rape or incest (including attempts)
has been reported to be 14.6% among the general
population of the USA, and this rate is consistent
Cross-cultural study of abuse histories in eating disorder patients
337
Table 3. Physical punishment histories in Japanese (Jp) and American (USA) patients with anorexia nervosa restricting type
(AN-R), anorexia nervosa binge eating purging type (AN-BP), bulimia nervosa purging type (BN) and controls (C, Japanese
only)
Subjects
AN-R
AN-BP
BN
c2 (P)
C
Jp
USA
Jp
USA
Jp
USA
Jp
USA
Jp
USA
Jp
USA
Jp
USA
0
0
0
0
0
0
0
0
0
0
0
0
0
0
4 (9%)
7 (21%)*
2 (4%)
2 (6%)
9 (20%)*
5 (15%)
1 (2%)
2 (6%)
1 (2%)
2 (6%)
2 (4%)
4 (12%)
10 (22%)*
8 (24%)*
8 (11%)
2 (13%)
4 (5%)
0 (0%)
8 (11%)
3 (19%)
4 (5%)
1 (6%)
8 (11%)
1 (6%)
8 (11%)
2 (13%)
14 (18%)*
3 (19%)
4.2 (0.12)
6.6 (0.04)
2.0 (0.37)
2.7(0.26)
8.4 (0.02)
5.4 (0.07)
2.5 (0.29)
1.8 (0.40)
6.7 (0.03)
1.8 (0.40)
5.2 (0.08)
3.8 (0.15)
9.0 (0.01)
7.6 (0.02)
0
NA
2 (2%)
NA
6 (6%)
NA
2 (2%)
NA
2 (2%)
NA
2 (2%)
NA
9 (9%)
NA
Did your parents use physical discipline with you?
(Often)
When your parents got angry with you, did they ever
lock you in a closet? (Often)
When your parents got angry with you, did they ever hit
you with their hands (other than spanking)? (Often)
When your parents got angry with you, did they ever
punch you? (Often)
When your parents got angry with you, did they ever
kick you? (Often)
When your parents got angry with you, did they ever
hit you with something other than their hands? (Often)
Physical punishment history (often locked in closet,
often hit with hands, often kicked, or often hit with
something other than hands).
NA, not available; d.f. = 2 for all c2; * P < 0.016, compared with AN-R by Fisher’s exact test.
with the results of a recent study.26 Therefore, victimization involving unwanted sexual intercourse among
the general population of the USA is obviously
higher than among the Japanese control group in this
study (only 1%), although the sample size of the
Japanese controls was too small and sampling was
biased (all nursing school students) to represent the
Japanese general population. Victimization by rape or
incest among AN-BP or BN patients from the USA
appears to be comparable with the rate in the general
American population.
These discrepancies between two countries cannot
be explained by the high criminal rate in the USA
because all perpetrators in the USA were known to
the person. In addition, the majority of perpetrators
were strangers to the Japanese patients. These discrepancies may be explained by cultural attitudes
toward sexual matters and the high-divorce rate in
USA.27 Our results clearly show that sexual abuse
history is not a necessary and sufficient causal variable for eating disorders, although these events might
be related to refractory and chronicity of illness.
Conversely, rates of physical punishment history in
every diagnostic subgroup were very similar between
the two countries. The impact of a physically abusive
childhood is profound. These include psychopathology such as post-traumatic stress disorder, depression,
and alcoholism;28–31 and the intergenerational transmission of impaired parenting.32
Few studies have examined the relationship
between eating disorders and a physical abuse history.
Rorty et al. found that women with bulimia nervosa
reported significantly more physical punishment than
did controls.33 McCarthy et al. reported that dissociation appeared to be linked to physical rather than
sexual abuse in bulimic patients.34 However, Folsom et
al. reported that there were no significant differences
in the rates of physical and sexual abuse between
eating disordered patients and the general psychiatric
group.7 We found a significantly higher prevalence of
physical punishment in bulimic anorexic and bulimic
patients than in the restricting anorexic sample in
both countries. Although there were no controls from
the USA, AN-BP and BN patients tended to have
been physically punished more frequently than controls in Japan. Whether childhood sexual abuse is
more linked to bulimic than restricting anorexics
currently remains controversial (among controlled
studies, two support35,36 and two do not37,38). However,
there are no available data on whether childhood
physical abuse is more linked to bulimic than restricting anorexics. Our study is the first one to show that
physical abuse history tends to be linked with bulimic
behaviors even in very different cultures.
However, it would be inappropriate to conclude
that physical abuse as a traumatic event causes the
bulimia. Because physical forms of child abuse are
generally intrafamilial, it may be argued that many of
the apparent associations between childhood physical
abuse and later adjustment reflect the social and
family context within which the abuse occurs rather
than the direct traumatic effects of abuse on individ-
T. Nagata et al.
338
ual adjustment.39 Even sexual abuse is not randomly
distributed through the community but is more likely
to be found in disrupted and disturbed families and
in those families subject to economic and social
disadvantage.40 Therefore, it seems to be natural for
physical abuse to be clearly linked with family disadvantages. Indeed, in the bulimia nervosa group,
increased levels of physical punishment were associated with greater global family pathology.33 The elevated rates of adjustment problems in physically
abused subjects may have been largely or wholly
due to the social environment and context in which
physical punishment/maltreatment occurred.41 Even
in terms of sexual abuse, there were data that adverse
family background may be a more important etiological factor for bulimia nervosa than the sexual abuse
itself.42 Therefore, physical abuse may only be an indicator of family background. Moreover, physical abuse
may be related to a factor that decides whether eating
disorder patients are restricting or bulimic, rather
than a causal factor of eating disorders.
There were some limitations in the present study.
First, the relatively small number of subjects from the
USA, especially normal-weight bulimics and absence
of American control subjects were serious shortcomings of this study. Most interesting is how prevalent
abuse and eating disorders are in the general populations of the two countries. Further study needs to
clarify this point.
Second, inpatients usually have a more severe form
of illness than outpatients in regard to some clinical
symptoms, and all the patients from the USA in our
study were inpatients. Chronicity of the subjects from
the USA was probably due to this difference, because
Japanese AN-BP patients with inpatient treatment
history showed a degree of chronicity similar to that
of patients from the USA. However, there were no
significant differences in physical or sexual abuse
history between Japanese in- and outpatients. Similarly, Favaro et al. found that the prevalence of sexual
and physical abuse did not differ significantly between
the in- and outpatients.43
Third, the degree to which a self-reporting questionnaires can accurately identify childhood histories
of abuse remains unclear. Many factors could potentially lower the rate of reported abuse (e.g. the degree
of honesty, dissociation or repression of traumatic
memory). Many investigators believe patients commonly do not report histories of abuse, especially
sexual abuse, until they are well into their psychotherapy. However, Waller found no difference between
clinical interview and self-reports in eliciting a history
of sexual abuse in eating disordered subjects,36 similar
to our results in a small number of inpatients. The
number of patients admitting to stealing in selfreporting questionnaire also did not change after
2 months of intensive treatment.44 In addition, other
groups in Japan45 reported that there were no differences in reporting sexual abuse history for female
eating disorder patients whether the interviewer was
male or female.
Taken as a whole, differences in sexual abuse histories suggest that these two cultures and two societies
are very different. Despite these differences, we found
a very similar physical punishment history between
patients in these countries. It would be oversimplifying to conclude that physical abuse is the essential
trauma causing bulimic behaviors because we found
that only around one-fifth of the bulimic patients had
such childhood histories, even though we included
mild forms of physical punishment. Therefore, physical abuse might be related to whether patients are
restricting or bulimic, even in different cultures, rather
than a risk factor for developing eating disorders.
Further cross-cultural study, including family environment, childhood disruptive behaviors and temperament using general population sample, will help us
better understand etiology and psychopathology of
eating disorders.
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