Does Childhood Sexual Abuse Lead to Obesity?

Dr. David Wiss

October 30, 2022

Trauma

I started hearing this early in my career, working with people that had binge eating disorders and I noticed a pattern. A lot of people said, “I was told by my therapist that I gained weight as a protective measure against future revictimization following childhood sexual abuse.”

And the first time I heard it, I was like “wow, these psychodynamic psychologists, they've got some creative ways of connecting dots.” And I was impressed. And then I heard it again and again, and finally, in one case, I leaned into someone, and asked “do you believe that that's true?”

And they sort of scratched their head and were like “I don't know.” And when I became a scholarly individual, one of the things I really enjoy doing is when there is information out there, you scratch your head and ask, “where does it come from?”

Who developed this theory? What's the original paper? What's been the living experience of this information? How has it been disseminated? This is called the production of knowledge. And so, over the years, I started doing a little digging. I saw that in the 1980s, there were some papers that described what they called “barrier weight.”

Interestingly, the principal investigator of the original ACE study (Felitti et al. 1998 [1]) was one of the people that pioneered that thought from a non-psychodynamic standpoint. What they saw was that in 100 women in a weight management program, some people would rapidly gain that weight beyond what was metabolically or physiologically expected, and they were puzzled by it [2,3].

Why is it that after spending six months losing 30 pounds, shortly within two weeks some of them gained it all back? What's the explanation? And so, I think it led to some hypothesis that maybe some people were uncomfortable with the lower weight.

And then they had to think about, why might that be? And then they started doing some digging and figured out that some people felt safer when they were no longer recognized as a candidate for a romantic partner. In my opinion, this assumption that fatness is always unattractive just perpetuates weight stigma, but it was a more socially acceptable opinion in the 1980s and 1990s before weight stigma was a hot topic.

 One of the main arguments that we made in our paper [4] is that this assumption that just because someone is in a larger body means that they're not going to be attractive is not helpful either. Weight stigma is such an important conversation nowadays.

 Around the same time (the late 1980s), psychodynamic psychologists were developing theories about why there was a link between childhood sexual abuse and obesity. And they came up with a similar model. And I do think it’s a good model, at least based on the information they had at that time.

 We recently published a paper called: “Limitations of the Protective Measure Theory in the Role of Childhood Sexual Abuse in Eating Disorders, Addictions, and Obesity: An Updated Model with Emphasis on Biological Embedding” [4]. The main point is that in the 1980s and 90s when they didn't have data on the biological embedding of adversity, they didn't know about the inflammatory cascades and the alterations in the ventral striatum following adversity. They weren't aware of the link between HPA axis dysfunction and weight gain. They were doing the best that they could with the data that they had.

They were trying to piece together information and make sense of the world. They certainly didn't have data on food addiction. Fast forward a few decades. There are several studies that show that childhood adversity increases addiction-like eating and that the protective measure theory, while helpful and useful for many decades, is limited at best.

I think we did a really good job in this paper by making the argument that the processes by which adversity is biologically embedded can set up not only addiction-like eating, but set up eating disorders, including those involving not just bingeing, but purging and other forms of compensatory behaviors, as well as substance use disorder.

My interest is in where those three things cluster: food addiction, substance use disorder, and eating disorders. A lot of people have traits of all three that overlap or oscillate between the three over time. This is such an important intersection in mental health, particularly for people who are binge eating and purging and don’t understand why. 

And some of those conditions are associated with weight gain and some of them are associated with weight suppression. If you take our childhood sexual assault example, let's say someone is a survivor and now they're 15 years old night eating and binge eating.

Let's say that they don't start exercising or purging. Let's say that they start taking Adderall and they move on to crystal meth and soon they're injecting cocaine and doing stimulants all day and their trajectory becomes substance use disorder. At no point during their addiction treatment is someone likely to connect the dots to their body dissatisfaction and those underlying drivers (although this is now changing due to increased awareness of internalized weight bias).

The model that's proposed in this paper looks at childhood sexual abuse as a specific type of trauma, the processes by which that can become biologically embedded, the possibilities of someone then progressing to food addiction, substance use disorder, eating disorders, either one, two, or all three, and how that can affect weight trajectories over time.

A lot of substances lead to weight loss or at least weight suppression. One of the things that we do know is that efforts to suppress weight through dietary restraint and through excess restriction, whether it be from drugs or very low-calorie diets are risk factors for weight gain.

And the body responds to these things by making adaptations, making food taste more delicious, leading to binge eating and more symptoms of food addiction, etc. And so, the model looks at obesity as an outcome but also considers how weight suppression, either deliberately or less deliberately, maybe through drug use or otherwise, can also be a contributor to increased BMI over time.

And then, finally, we do make the argument that a therapist, whether it be a psychodynamic or someone that just picked up that theory along the way, telling someone that they're doing something to be “unattractive” is potentially a way to perpetuate weight stigma and that that's not helpful. I think we can put that one to bed. There are now better ways to explain one’s relationship with food. Let’s find out what is true for you! 

References

1. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, et al. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245–58.

2. Felitti VJ. Childhood Sexual Abuse, Depression, and Family Dysfunction in Adult Obese Patients. Southern Med J. 1993;86(7):732–6.

3. Felitti VJ. Long-term Medical Consequences of Incest, Rape, and Molestation. Southern Med J. 1991;84(3):328–31.

4. Wiss DA, Brewerton TD, Tomiyama AJ. Limitations of the protective measure theory in explaining the role of childhood sexual abuse in eating disorders, addictions, and obesity: an updated model with emphasis on biological embedding. Eat Weight Disord - Stud Anorexia Bulimia Obes. 2021;1–19.