A number of previous studies have focused on the relationship among childhood abuse, childhood sexual abuse (CSA), and adulthood health issues, but few have included CAM modalities. To the trained CAM professional looking at the whole person to treat illness, it may be unsurprising that these studies reveal correlations between abuse histories and topics as diverse as risk-taking behavior, headaches, and a range of chronic pain conditions. Despite the prevalence of evidence suggesting that the incidence of childhood abuse can yield a lifetime of chronic ailments and pain, in particular, studies of CAM interventions in treating abuse survivors surprisingly remain in the nascent stages.

The pervasiveness of childhood abuse is a matter of public knowledge, with the US Department of Health and Human Services estimating more than 700,000 cases of child abuse or neglect annually, with a victimization rate of 10.6 per 1000 children abused.¹ The long-term health costs of these numbers are almost unimaginable. In fact, to think that a history of abuse would not influence behavior, health, and general attitudes about the body and self seems a greater stretch than to assume that there will very likely be long-term emotional and physical health consequences. Conditions associated with chronic pain seem to consistently emerge among the top results in studies of abuse survivors. As of this writing, a number of publications exist that investigate the complex relationship between childhood abuse and adult health problems, with the majority focusing on conventional, single-axis approaches to treatments, and still other studies distinguishing long-term health outcomes between types of abuse.² Rather than looking for exact mechanistic relationships between types of abuse and types of pain encountered in adulthood, the authors hope that this synopsis serves as an impetus for future study of holistic approaches to the treatment of chronic pain among childhood abuse survivors. While this is not a meta-review, the authors begin with an overview of existing research, then turn to strategies and suggestions for advancing further research and application, in particular considering how CAM approaches may benefit the treatment of childhood abuse survivors.

Childhood Abuse and Behavior
While the occurrence of childhood abuse certainly influences the behavior of children during the period of trauma, the impact of the trauma may often also remain entrenched in lifelong patterns of risk-taking behaviors, including increased use or abuse of alcohol or  tobacco; patterns of self-neglect, such as increased risks for self-harm, eating disorders, or suicide attempts; increased or chronic stress responses (hyperarousal); greater risk of depression; and numerous behavioral patterns, coping mechanisms, and attitudinal outlooks.^3,4 These long-term responses increase risk factors for a multitude of stress-related conditions, in addition to creating ongoing emotional discomfort for the survivors. Interestingly, the major effects of chronic pain include comparable symptoms, such as "depressed mood, reduced activity and productivity, fatigue, reduced libido, excessive use and abuse of drugs and alcohol, dependent behavior, and disability," and the correlative similarities may provoke exceptional insight with further investigation.⁵ All too easily overlooked by one-dimensional analysis, the emotional attributes of adult childhood abuse survivors are complex phenomena into which a number of studies offer valuable insight regarding the significant role which childhood abuse plays in developing behavioral and emotional patterns that may yield years of suffering with chronic conditions.

Prior studies consistently identify correlations between childhood abuse and myriad specific behavioral outcomes in adulthood. For instance, higher incidence of risk-taking behaviors and subsequent increased risk for HIV, sexual risk behaviors, and long-term risk for revictimization have each been correlated with histories of CSA, in particular.^6-8 There are likely other predictable behavioral results associated with abuse histories. While these emotional and behavioral outcomes can be devastating independently, the literature suggests that long-term consequences of childhood abuse also include a spectrum of physical concerns and chronic health problems.

Childhood Abuse and Adulthood Physical Pain
To date, a vast number of studies have focused their analysis of CSA adult outcomes on sexual functionality, and chronic pelvic pain and sexual dysfunction, yet the topic of CSA and generalized chronic pain is less well established.^9,10 What remains abundantly clear in the somewhat scant literature is that CSA and physical abuse survivors continue to suffer from a staggering variety of physical aches and pains in addition to encountering an array of emotional, behavioral, and chronic stress-related concerns.

On first glance, considering the most widely studied types of physical symptoms and frequency of chronic pain associated with childhood abuse seems to raise more questions than it resolves. Though the mediating factors are yet unclear in reconciling the precise interrelationship among variables like the duration, frequency, type, and extent of abuse as they relate to the diverse characteristics of physical pain, the existence of chronic pain is clearly evidenced by existing studies. Even without a firm understanding of "how the pain works" for abuse survivors, these studies shed helpful light on why the pain exists, and therefore may be helpful to CAM practitioners and researchers who seek to fully address the holistic underpinnings of pain with their patients. Since it seems reasonable to assume that any serious treatment plan must address pain from a combination of mind, body, and energetic perspectives to offer resolution beyond symptom control, integrative medicine may offer an ideal response in such situations.

One 2007 study considered sexual and physical abuse separately, concluding that physical abuse alone was more predictive of chronic pain than CSA.¹¹ However, it is likely premature to generalize from this conclusion, since the complexity of the relationship between traumatic histories and adult chronic pain is not well understood. Minimally, the long-term impact of combined childhood traumas has been verified by other studies. Further, only a handful of studies focus on overall health of adult survivors of CSA, and the results of a later study suggest that the "poorest health status was observed in women with a history of both physical and sexual childhood abuse."¹²

2010 research from the Headache Treatment and Research Program at the University of Toledo reports the association of a broad spectrum of chronic pain conditions with various abuse histories including migraines, headaches, fibromyalgia, IBS, chronic fatigue, and arthritis.¹³ This study offers valuable insight into the myriad questions surrounding the increase in chronic pain conditions among abuse survivors, determining that the intense childhood stress of abuse has a causal relationship that specifically sets the stage for increased pain throughout life.¹⁴ The study also reveals specific conditions associated with certain types of abuse, and yields a multitude of prospects for future study as well as important revelations for treatment paradigms. Significantly, this groundbreaking study establishes the need for enhanced sensitivity to the spectrum of consequences that providers can expect to see associated with childhood abuse.

The research that attempts to link types of abuse histories with specific trajectories of life pain is fairly limited. However useful such data may be, individuals vary wildly in their coping skills, resilience, support systems, emotional strength, and other complicating factors that are likely to influence overall health and outlook. While more research is needed in the field dealing with CAM treatment models, dealing with the general tendencies and improved awareness of the relationship between childhood trauma and chronic pain may be adequate for improving outcomes of care. Our purpose in this writing is primarily to urge CAM researchers and practitioners to take up studies and treatment models that account for a holistic approach to treating pain in abuse survivors of all types, because better treatments for chronic conditions are critically needed.

CAM for Patients with Childhood Abuse Histories
Despite clear evidence that associates adverse events in childhood with issues in adult health, insufficient data support the use of CAM interventions among patients with childhood abuse histories. A few case studies suggest effectiveness in use of CAM approaches for treating various symptoms associated with childhood trauma.^15,16 Additionally, a handful of treatment groups have already implemented holistic intervention programs for abuse survivors utilizing multiple therapies including acupuncture, mind-body formats such as writing workshops and meditation, and therapeutic yoga.¹⁷ It is also worth noting that chronic pain syndrome, common among patients with abuse histories, "is managed best with a multidisciplinary approach" including elements such as "nutrition, physical exercise, yoga, breathing training, meditation, and detoxification along with the use of anti-inflammatory agents and adaptogens," according to internationally regarded naturopathic and Ayurvedic physician Virender Sodhi.¹⁸

Another frequent condition among abuse survivors is posttraumatic stress disorder (PTSD), an anxiety disorder characterized by symptoms relating to reexperiencing trauma (night terrors or bad dreams and sleep disturbances, flashbacks, generalized fear); avoidance symptoms (anxiety, worry, emotional numbness, depression), and increased startle response (hyperarousal, tension, chronic stress). Encouraging findings have come from the results of a 2009 National Institutes of Health (NIH)-funded study of PTSD.¹⁹ The study, carried out at the University of Maryland, evaluated the effectiveness of meditation and yoga interventions for PTSD survivors, and yielded a high rate of success for participants finding relief from depressive and other symptoms associated with PTSD.²⁰ The approach entailed use of a mindfulness based stress reduction plan (MBSR) to treat a range of PTSD symptoms such as depression, sleep disturbances, anxiety, and stress. MBSR techniques have been proved effective in a number of settings and studies, and the application to PTSD provides welcome insights for providers treating patients with childhood trauma histories who may suffer from a multitude of symptoms.²¹

In general, these pilots have offered optimistic results for CAM treatment models and abuse survivors, and a recent meta-review confirms the usefulness of interdisciplinary approaches in treating PTSD.²² The results of one randomized control pilot study suggest that acupuncture offers an effective treatment option for the anxiety and depression associated with PTSD.²³ The National Center for Complementary and Alternative Medicine (NCCAM) also cites a current study of massage investigating its use in the treatment of sexual abuse survivors.²⁴ Since further studies are recommended as a result of the positive potential identified in these pilots, future work will likely take this and other CAM treatment paradigms to broader study and implementation.

Childhood Abuse and Health Care: Considerations for Intervention and Research
Despite the positive results of these studies, simply integrating intensive consideration of childhood abuse histories into therapies may not be sufficient for a balanced approach to care, symptom resolution, or ultimately healing. According to a study on abuse survivors and health care for pregnancy and birth, childhood abuse survivors may associate numerous responses to engagement with health-care practitioners, including helplessness, fear, blame, and others.²⁵ Though to our knowledge this is unsupported by previous research, it may be likely for comparable difficulties in a variety of clinical settings to arise among survivors of abuse in general. Survivors with unresolved emotional issues may have difficulty with boundary setting, self-care, trust and disclosure, or other issues, and may need ongoing psychological and/or social support in addition to CAM therapies.

If abuse survivors face challenges in a variety of health-care settings, it may be helpful to address emotional heath histories in concert with general health histories, which may be more common in integrative approaches to health than within conventional medicine. The relationships among childhood abuse, stressful life events, depression, and the occurrence of chronic pain are complex, and the authors suspect that CAM practitioners are well equipped to create environments in which patients can identify important life events and traumas once the time and trust are cultivated in the provider–patient relationship. Though practitioners are not likely to press their patients about abuse histories, in general CAM clinicians are noted for their exceptional cultivation of communication-driven relationships with patients, often spending more than twice as much time as conventional doctors with their patients.²⁶ Time spent directly with patients has been correlated with patient satisfaction, and the authors propose that this time helps create an environment which may likely also assist in establishing healing environments needed for child abuse survivors.²⁷

Professionally, the ethical duties required of providers working with abuse survivors remain paramount, and may require cautious vigilance in research projects. As with other clients with severe trust issues, the informed consent process may be complex for abuse survivors. In addition to securing consent through standard protocols, particular concerns to address in the consent process with vulnerable popu­lations center on the transparency of any applicable randomization process, and the protection of privacy and confidentiality with regard to any related sharing of data. These details are integral to facilitating the development of a trusting and healing relationship.

It is common for patients of any background to be vulnerable to the persuasive influences of and confident belief in their providers, and to accept recommendations without exercising much inquiry or resistance to treatment. Among abuse survivors who may have self-esteem or related hurdles to overcome, increased attention may be helpful to establish adequate space and time for patients to express their questions and concerns to ensure that their wishes are served and autonomy supported. Additionally, among patients who may have difficulty setting boundaries, providers may need to seek guidance on maintaining consistent, well-understood expectations for therapeutic and research settings. Boundary challenges may occur in either extreme: for instance, patients may expect sessions to be as long as needed or instead may seem overly concerned with the needs of providers, even veering toward self-neglect. As such, providers may need to gently remind patients of the therapeutic process, keep the focus appropriately directed, and act to uphold the best possible healing setting. Every action that providers take to establish healthy boundaries will contribute to an environment of safety that assists the survivor in the therapeutic setting, as well as in his/her overall healing process.

Conclusion
CAM therapies have the potential to vastly improve care delivery and outcomes for abuse survivors. The authors offer that a comprehensive health history would wisely include attention to traumatic histories when patients describe unresolved chronic pain conditions. Certainly, further research is needed in the overlapping areas of chronic pain and childhood abuse as they relate to CAM therapies, and we hope that this overview provides CAM researchers and practitioners with a working knowledge of current trends and considerations in the field, and encourages an integration of CAM perspectives into future studies and work with patients.

Notes
1.   Department of Health and Human Services. Child Maltreatment 2007. Washington, DC: U.S. Government Printing Office; 2009:23. Available at: http://www.acf.hhs.gov/programs/cb/pubs/cm07/cm07.pdf. Accessed March 8, 2010.
2.   Kendall-Tackett K. Bibliography: why family violence makes people sick: new research on the lifetime health effects of adverse childhood experience. Available at: http://uppitysciencechick.com/trauma-health.html. Accessed July 8, 2010.
3.   Lampe A et al. Chronic pain syndromes and their relation to childhood abuse and stressful life events. J Psychosom Res. 2003;4(4):361–367.
4.   Kendall-Tackett K. Why family violence makes people sick: new research on the lifetime health effects of adverse childhood experiences [presentation slides]. http://uppitysciencechick.com/ttuhsc_peds_grand_rounds.pdf. Accessed July 8,2010.
5.   Sodhi V. Chronic pain syndrome and Ayurved. Naturopath Dr News Rev. 2010;6(7):10–13.
6.   Mimiaga MJ et al. Childhood sexual abuse is highly associated with HIV risk-taking behavior and infection among MSM in the EXPLORE Study. J Acquir Immune Defic Syndr. 2009;51(3):340–348.
7.   Senn TE et al. Characteristics of sexual abuse in childhood and adolescence influence sexual risk behavior in adulthood. Arch Sex Behav. 2007;36(5):637–645.
8.   Barnes JE et al. Sexual and physical revictimization among victims of severe childhood sexual abuse. Child Abuse Negl. 2009;33(7):412–420.
9.   Rellini A, Meston C. Sexual function and satisfaction in adults based on the definition of child sexual abuse. J Sex Med. 2007;4(5):1312–1321.
10. Randolph ME, Reddy DM. Sexual abuse and sexual functioning in a chronic pelvic pain sample. J Child Sex Abuse. 2006;15(3):61–78.
11. Walsh C et al. Child abuse and chronic pain in a community survey of women. J Interpers Violence. 2007;22 (12):1536–1554.
12. Bonomi AE et al. Association between self-reported health and physical and/or sexual abuse experienced before age 18. Child Abuse Negl. 2008;32(7):693–701.
13. Goodin K. UT research links childhood abuse to chronic pain [Web article]. University of Toledo News. January 20, 2010. http://utnews.utoledo.edu/index.php/01_20_2010/ut-research-links-childhood-abuse-to-chronic-pain. Accessed April 20, 2010.
14. Goodin, ibid.
15. Aung SKH. Sexual dysfunction: a modern medical acupuncture approach. Med Acupunct. 13(2). Available at: http://www.medicalacupuncture.org/aama_marf/journal/vol13_2/case1.html. Accessed March 2, 2010.
16. Center for Acupuncture and Herbal Medicine. Amenorrhea [Web article]. http://www.acupunctureandherbalmedicine.com/document/link_amenorrhea.pdf. Accessed March 2, 2010.
17. St. Vincent Rape Crisis Program – Manhattan. Fall classes and workshops [Web document]. New York City Alliance Against Sexual Assault. October 17, 2008. http://www.svfreenyc.org/event_883.html. Accessed July 8, 2010.
18. Sodhi, op cit.
19. Kimbrough E et al. Mindfulness intervention for child abuse survivors. J Clin Psychol. 2010;66(1):17–33. Available at: http://www3.interscience.wiley.com/cgi-bin/fulltext/123207015/PDFSTART. Accessed March 9, 2010.
20. Kimbrough E, Magyari T, Langenberg P, Chesney M, Berman B. Mindfulness intervention for child abuse survivors. J Clin Psychol. 2010;66(1):17–33. Available at: http://www3.interscience.wiley.com/cgi-bin/fulltext/123207015/PDFSTART. Accessed March 9, 2010.
21. University of Massachusetts Medical School Center for Mindfulness. Major research findings [Web document]. http://www.umassmed.edu/Content.aspx?id=42426. Accessed March 9, 2010.
22. NHS Evidence. Psychological treatment of post-traumatic stress disorder (PTDS) [Web document]. July 2007. http://www.library.nhs.uk/cam/ViewResource.aspx?resID=238241 Accessed April 12, 2010
23. NCCAM. Acupuncture may help symptoms of post traumatic stress disorder [Web article]. February 22, 2010. Available at: http://nccam.nih.gov/research/results/spotlight/092107.htm. Accessed April 5, 2010.
24. NCCAM. Massage therapy: an introduction [Web document]. June 2009. Available at: http://nccam.nih.gov/health/massage. Accessed April 5, 2010.
25. Coles J, Jones K. 'Universal precautions': perinatal touch and examination after childhood sexual abuse. Birth. 2009;36(3):230–236.
26. Heiligers P et al. Diagnosis and visit length in complementary and mainstream medicine. Biomed Central. January 25, 2010;10(3). Available at: http://www.biomedcentral.com/1472-6882/10/3. Accessed March 23, 2010.
27. Heiligers, ibid.

Laura DeVincentis, ND, LAc, completed her studies in 2001 at National College of Natural Medicine in Portland, Oregon, and joined Preventive Medicine Group in Ohio after graduation. Since 2005, Dr. DeVincentis has served as medical director of CAM PPO of America Inc., a credentialed network of CAM providers serving more than 50,000 members nationally. She can be reached at research@camppoamerica.com.
E. Feigenbaum, PhD, completed a graduate certificate of advanced studies in bioethics and went on to complete a doctoral program focused on applied ethics at Union Institute & University in 2004. A former college instructor in the humanities, Dr. Feigenbaum now serves as director of ethics and research at CAM PPO of America Inc.