To the Editor,

We read with interest the article by Davy (2006), titled "The Endoscopy Patient With a History of Sexual Abuse: Strategies for Compassionate Care," which revealed that medical procedures such as colonoscopy and endoscopy in patients with a history of physical or sexual abuse can invoke stress reactions and exacerbate fear during and after the procedures. Because of this, these patients demand ample attention and compassion from doctors and nurses (Davy, 2006). This article is of particular interest with the frequently unappreciated prevalence of sexual abuse. It is critical that healthcare providers are aware that interventional procedures can invoke stress reactions. Healthcare providers should also be aware that frequent noncompliance with scheduled invasive procedures may be a reflection of a history of sexual abuse.

We report a case of a woman with unrecognized history of sexual abuse who repeatedly scheduled and cancelled a recommended upper endoscopy. A 49-year-old woman with history of hypertension controlled with medications was referred for evaluation of abdominal pain and anemia. Her physical examination was significant for abdominal tenderness. She was empirically treated with a proton pump inhibitor. An upper gastrointestinal tract evaluation was recommended, and she elected to proceed with an upper endoscopy. The patient did not come for her scheduled procedure. She was contacted and was found to have persistent symptoms despite treatment. Another upper endoscopy was scheduled; however, the patient did not come for her second scheduled procedure.

The patient was then contacted and asked to come to the office for an evaluation. During her assessment, it was learned that she had a history of sexual abuse that she had not previously admitted. Addressing the patient's concerns and providing a safe environment enabled the patient to undergo the procedure. The upper endoscopy identified a duodenal ulcer that had evidence of a recent bleed. Her ulcer disease was treated and the patient remained in stable condition.

More than 100,000 children are estimated to be victims of sexual abuse annually (Department of Health and Human Services, 1998). It has also been speculated that the actual incidence of child sexual abuse exceeds this estimate because of underreporting by victims. Researchers have suggested that approximately 20% of North American women may have been sexually abused during childhood (Finkelhor, 1994). In addition, individuals who have been victims of abuse have been reported to have a higher frequency of medical utilization than do individuals with no history of abuse, due to somatic symptoms resulting from the psychological and physical manifestations of abuse (Arnow et al., 1999).

We are in agreement with Davy (2006) that with the substantive prevalence of sexual abuse in the United States, healthcare providers should enhance their ability to identify those who have been victims of abuse. Using an individual's verbal and nonverbal cues, healthcare providers should be able to adequately address and manage the fears and concerns that patients have about endoscopic procedures. The upper endoscopy in our patient provided important diagnostic information and enabled her to receive appropriate treatment. Although individuals who have a history of abuse may seek medical care more frequently and have stress reactions during and after procedures, they can also have significant noncompliance with procedures. It is important that physicians and nurses address patients' concerns enabling them to receive optimum medical intervention. All patients with noncompliance for endoscopic procedures should be surveyed for history of sexual abuse and treated with utmost patience and empathy given the significant impact that their sexual abuse has on their decisions regarding medical interventions.

Marie L. Borum, MD, EdD, MPH

Enaruna Igiehon, BS

Shervin Shafa, MD

Division of Gastroenterology and Liver Diseases, George Washington University, Washington, DC

REFERENCES