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The Impact of History of Sexual Abuse on Weight Loss in Gastric Bypass Patients

TO THE EDITOR: We have read the article by Oppong et al.¹ with great interest. It covers a clinically relevant problem of preoperative determination of possible failure of bariatric surgery. It is even more important that this attempt to predict failure or lack of compliance be undertaken in the context of gastric bypass—an operation that can have a serious negative impact on the health of a patient who does not follow the recommendations of the bariatric specialist.^2,3 Therefore, as the authors outline, if obesity is an unconscious method of prevention against renewed sexual abuse in individuals with such a history, one may expect that in the case of inadequate psychological support, the patient may also unconsciously act against the effect of the surgery.⁴

This is the methodological problem we would like to emphasize. The authors use self-report to obtain data on sexual abuse in the past. We strongly believe, on the basis on our experience and the reports of other authors,^5–7 that this form of gathering data concerning such a delicate and hidden matter may have limited validity.

Within our multiprofessional bariatric group, we collaborate with psychologists, who contribute to our 3-month preoperative education and assessment process that all candidates for gastric bypass have to undergo. During this period, the patients learn a lot about the details of the procedure, its inherent risks, and the implications for their postoperative life. The psychologists focus, in particular, on establishing new goals for the patients and obtaining a reliable perspective on factors possibly contributing to their obesity.

It has been observed that the number of patients disclosing sexual abuse during the course of these sessions is significantly higher than might be expected on the basis of self-reports with standard questionnaires.⁵ Also, Roosa et al.⁶ demonstrated that, depending on the methodology used and the definition of sexual abuse applied, the incidence of reported abuse ranges from 5% to 66% in a control population. They proved that using more advanced and sophisticated psychometric tools for evaluation gave 3 times the number of reports of childhood sexual abuse than reported by use of the shorter form of the questionnaire. We therefore challenge the validity of the data obtained by Oppong et al.; we feel that the number of patients victimized by sexual abuse has been underestimated and, in consequence, that the reported lack of association between sexual abuse and bariatric surgery outcome may possibly be attributed to this unrecognized bias.

It should also be emphasized that such a questionnaire, or even a single-question method, could be expected to gather reliable data only if the anonymity of responders is preserved.⁶ In multiple cross-sectional studies, the high degree of the anonymity is emphasized, and precise methodology concerning anonymous data collection is highlighted.^6,7 In clinical bariatric case-controlled studies, such anonymity is not possible, and, moreover, patients are fully aware of that. This fact should be kept in mind when extrapolating the results and methodology of large-sample, cross-sectional studies onto longitudinal, case-controlled ones.

The second problem we would like to address is the possible role of other forms of abuse. A history of mental and emotional abuse and neglect are also often observed in bariatric patients.⁷ We believe that information concerning this problem should also be considered in the context of evaluation of effects of bariatric surgery, although it appears doubtful that it was reported by the patients in the questionnaire utilized by Opong et al.¹ Grilo et al.⁷ reported that 69% of obesity patients revealed childhood maltreatment; of these, 32% were physical sexual abuse. In this study, the information on childhood maltreatment had been collected with The Childhood Trauma Questionnaire, which provided more reliable and better-operationalized data. The use of standardized psychometric tools gives at least the possibility of obtaining data without bias that can arise from different definitions of sexual abuse.⁶

To summarize, we would like to emphasize the role of psychological preparation for bariatric surgery, both in the context of better outcome and more reliable and valid data collection, especially when it concerns issues that can be considered hidden, unconscious, or associated with shame. We regret that these considerations, in many studies concerning problems of sexual and/or emotional abuse in obesity patients, are not taken into account. Fortunately, there is a growing awareness of these issues, resulting in an increase of the number of teams that consider using other methods, which are associated with higher reliability and more patient-centered attitude.⁵

REFERENCES

1. Oppong BA, Nickels MW, Sax HC: The impact of history of sexual abuse on weight loss in gastric bypass patients. Psychosomatics 2006; 47:108–111[Abstract/Free Full Text]
2. Virji A, Murr MM: Caring for patients after bariatric surgery. Am Fam Physician 2006; 73:1403–148[Medline]
3. Malinowski SS: Nutritional and metabolic complications of bariatric surgery. Am J Med Sci 2006; 331:219–225[CrossRef][Medline]
4. Weiderman MW, Sansone RA, Sansone LA: Obesity among sexually abused women: an adaptive function for some? Women and Health 1999; 29:89–100[CrossRef][Medline]
5. Dziurowicz-Kozlowska AH, Wierzbicki Z, Lisik W, et al: The objective of psychological evaluation in the process of qualifying candidates for bariatric surgery. Obes Surg 2006; 16:196–202[CrossRef][Medline]
6. Roosa MW, Reyes L, Reinholtz C, et al: Measurement of women’s child sexual abuse experience: an empirical demonstration of the impact of choice of measure on estimates of incidence rates and of relationship with pathology. J Sex Res 1998; 35:225–233
7. Grilo CM, Masheb RM, Brody M, et al: Childhood maltreatment in extremely obese male and female bariatric surgery candidates. Obes Res 2005; 13:123–130[Medline]

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