Psychosomatics 39:561-562, December 1998
© 1998 The Academy of Psychosomatic Medine
Recollection of Childhood Sexual Abuse Following Endotracheal Intubation
Galit Kleiner-Fisman, M.D.,
Stephen Salloway, M.D., Rhode Island Hospital, Providence, RI, and
Sandra N. Fisman, M.B.B.Ch., Children's Hospital of Western Ontario, London, Ontario, Canada
Key Words: Letter • Child Abuse • Intubation
TO THE EDITOR: Incidence and prevalence studies over the past decade have affirmed that sexual victimization in childhood is a common phenomenon in North American society. The 1986 National Incidence Study by the National Center for Child Abuse and Neglect estimated an annual incidence of 2.5 per 1,000 children.1 Community-based surveys have found that 38%–45% of women report having experienced unwanted sexual contact during childhood.2 Given the estimated high prevalence of sexual abuse experiences in the population, it might be expected that persons presenting with unrelated medical problems would have a concurrent history of childhood sexual abuse. The sequelae of the abuse may have an impact on medical investigations and treatment, especially where these represent a reexperiencing of the abuse.
A case is presented in which disclosure of childhood sexual abuse followed a life-sustaining medical procedure.
Case Report
A 42-year-old woman was admitted to our institution with a 2-day history of weakness, choking on food, hoarse voice, and the perception of throat closure. Her past medical history was significant for a recent diagnosis of myasthenia gravis, confirmed by nerve-conduction studies and electromyography, for which she was taking low-dose pyridostigmine. After serial spirometry revealed rapid decline of forced expiratory volumes, the patient was intubated for airway protection and ventilatory support.
On the third hospital day, the patient extubated herself. She confided to the medical team that she could never tolerate intubation again, as it provoked feelings of choking, gagging, and helplesness. She had experienced similar feelings as an 8-year-old child, when forced to perform fellatio on her father. Subsequent careful history revealed that the patient was sexually abused from the ages of 5 to 8. The patient had no conscious awareness of the abuse until many years later, when she began to engage in sexual relations. Her first sexual experience resulted in nausea and vomiting. She subsequently avoided sexual encounters. She reported intermittent, intrusive recollections of the abuse. The patient became conscious of her association between the endotracheal intubation and the early-life sexual trauma as she discussed the issue of reintubation with the medical team.
The patient remained extubated and, following a course of corticosteroids, plasmapheresis, and supportive care, was discharged home on the eleventh hospital day.
Discussion
Sexual abuse experienced in childhood is known to have psychological implications in adulthood. Sequelae of childhood sexual abuse include depression, lowered self-esteem, dissociation, substance abuse, and posttraumatic stress disorder (PTSD). This patient experienced intrusive memories and psychological distress following endotracheal intubation, an event that resembled her original trauma. She also displayed persistent avoidance of stimuli that to her were associated or reminiscent of the trauma. Based on this response, this individual meets established diagnostic criteria for PTSD.3
In this case, the patient appeared functional in her daily life and without significant psychological impairment. However, closer examination revealed a history of chronic anxiety and avoidance of experiences that might re-evoke her more acute symptoms. This pattern is seen commonly in patients with prolonged or repeated traumatic exposures.4 With the retraumatization represented by intubation, this patient's symptoms became more overt and recognizable as symptoms of posttraumatic stress.
There is a paucity of information in the literature on the traumatic effect of medical procedures on childhood sexual abuse survivors.5 Considering the high prevalence of childhood sexual abuse, it is likely that this may be a more common situation than is presently appreciated. It is important for physicians to be aware of a possible history of early trauma and identify patients at risk, thereby lessening the potential for morbidity in these persons.
REFERENCES
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National Center on Child Abuse and Neglect (NCAAN): Study findings: national study of incidence and severity of child abuse and neglect. Washington, DC, Department of Health, Education, and Welfare, 1988
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Russel D: Incidence and prevalence of intrafamilial and extrafamilial sexual abuse of female children. Child Abuse Negl 1983; 7:133–146[Medline]
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American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC, American Psychiatric Association, 1994
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Terr L: Childhood traumas: an outline and overview. Am J Psychiatry 1991; 148:10–20[Abstract/Free Full Text]
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Gruber M, Byrd R: Post-traumatic stress disorder and GI endoscopy: a case study. Gastroenterol Nurs 1993; 16:17–20[Medline]
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