Circle for both as child and as adult.
As a child (13 and younger) ‚ As an adult (14 and over)
1a. Has anyone ever exposed the sex organs of their body to you when you did not want it? (As a child) Yes No‚ (As an adult) Yes No
lb. Has anyone ever threatened to have sex with you when you did not want it? (As a child) Yes No‚ (As an adult) Yes No
1c. Has anyone ever touched the sex organs of your body when you did not want this? (As a child) Yes No‚ (As an adult) Yes No
1d. Has anyone ever made you touch the sex organs of their body when you did not want this? (As a child) Yes No‚ (As an adult) Yes No
1e. Has anyone ever forced you to have sex when you did not want this? (As a child) Yes No‚ (As an adult) Yes No
1f. Have you had any other unwanted sexual experiences not mentioned above? (As a child) Yes No‚ (As an adult) Yes No
If yes‚ please specify:________________________________________________
Physical Abuse Items on the Questionnaire
2. When you were a child (13 or younger)‚ did an older person do the following:
a. Hit‚ kick‚ or beat you? 0 Never‚ 1 Seldom‚ 2 Occasionally‚ 3 Often
b. Seriously threaten your life 0 Never‚ 1 Seldom‚ 2 Occasionally‚ 3 Often
3. Now that you are an adult (14 or older)‚ has any other adult done the following:
a. Hit‚ kick‚ or beat you? 0 Never‚ 1 Seldom‚ 2 Occasionally‚ 3 Often
b. Seriously threaten your life 0 Never‚ 1 Seldom‚ 2 Occasionally‚ 3 Often
TRAUMA (TRA)
We know that many people have had unwanted “sexual” or violent experiences as children or adults. These experiences may be so upsetting that they may not have been discussed with anyone. Sometimes they are forgotten for long periods of time‚ and sometimes they are frequently brought to mind. Please try to remember whether any of the following has occurred to you.
1. Before your 13th birthday‚ did an adult or someone at least five years older than you ever touch the sex organs of your body when you did not want this? By touch we mean with hands‚ mouth‚ or objects on your sex parts‚ that is (males: penis‚ pubic area or anus; females: breasts‚ vagina‚ pubic area or anus).
0. NO 1. YES
2. Before your 13th birthday‚ did an adult or someone at least five years older than you ever make you touch the sex organs of their body when you did not want this? By touch we mean with hands‚ mouth‚ or objects on their sex parts.
0. NO 1. YES
3. Before your 13th birthday‚ did an adult or someone at least five years older than you ever have sexual intercourse (including vaginal or anal intercourse) with you when you did not want this?
0. NO 1. YES
IF NO TO QUESTIONS 1‚ 2 AND 3 THEN SKIP TO QUESTION 9
4. What was your age the first time any of these unwanted sexual experiences happened?
______ age (0-12 years)
5. What was your age the last time any of these unwanted sexual experiences happened?
______ age (0-12 years)
6. How many times (different days) did this happen before your 13th birthday? Circle number below.
1‚ 2‚ 3‚ 4‚ 5‚ 6‚ 7‚ 8‚ 9‚ 10‚ 11‚ 12‚ 13‚ 14‚ 15 or more
7. And when this happened‚ were you ever afraid that you might be killed or seriously injured? (Indicate for your worst incident)
0. NO 1. YES
8. When this worst incident happened‚ did you suffer:
No physical injuries……………………………………………………………..….. 0
Minor physical injuries (such as bruises and cuts not needing stitches)…………… 1
Serious physical injuries (stitches‚ broken nose‚ broken bones‚ or hospitalization).. 2
9. Since your 13th birthday‚ did anyone ever touch the sex organs of your body by using force or threatening to harm you? By touch we mean with hands‚ mouth‚ or objects on your sex parts‚ that is (males: penis‚ pubic area or anus; females: breasts‚ vagina‚ pubic area or anus).
0. NO 1. YES
10. Since your 13th birthday‚ did anyone ever make you touch the sex organs of their body by using force of threatening to harm you? By touch we mean with hands‚ mouth‚ or objects on their sex parts.
0. NO 1. YES
11. Since your 13th birthday‚ did anyone ever make you have sexual intercourse (vaginal or anal intercourse) by using force or threatening to harm you?
0. NO 1. YES
IF NO TO QUESTIONS 9‚ 10 AND 11 THEN SKIP TO QUESTION 17
12. What was your age (after your13th birthday) the first time any of these forced touching or intercourse experiences happened?
______ age (13 years or older)
13. What was your age the last time any of these forced touching or intercourse experiences happened?
______ age (13 years or older)
14. How many times (different days) did this happen after your 13th birthday? Circle number below.
1‚ 2‚ 3‚ 4‚ 5‚ 6‚ 7‚ 8‚ 9‚ 10‚ 11‚ 12‚ 13‚ 14‚ 15 or more
15. And when this happened‚ were you ever afraid that you might be killed or seriously injured? (Indicate for your worst incident)
0. NO 1. YES
16. When this worst incident happened‚ did you suffer:
No physical injuries……………………………………………………………..….. 0
Minor physical injuries (such as bruises and cuts not needing stitches)…………… 1
Serious physical injuries (stitches‚ broken nose‚ broken bones‚ or ospitalization).. 2
17. Have you had any other forced or unwanted sexual experiences not mentioned above?
NO ………………………….. SKIP TO Question 24……………………………………… 0
YES………………………………………………………………………………………… 1
18. Can you please briefly describe that experience. ________________________________________________
19. What was your age the first time any of these other forced or unwanted experiences happened?
______ age
20. What was your age the last time any of these other forced or unwanted experiences happened?
______ age
21. How many times (different days) did these other forced or unwanted experiences happened? Circle number below.
1‚ 2‚ 3‚ 4‚ 5‚ 6‚ 7‚ 8‚ 9‚ 10‚ 11‚ 12‚ 13‚ 14‚ 15 or more
22. And when this happened‚ were you ever afraid that you might be killed or seriously injured? (Indicate for your worst incident)
0. NO 1. YES
23. When this worst incident happened‚ did you suffer:
No physical injuries……………………………………………………………..….. 0
Minor physical injuries (such as bruises and cuts not needing stitches)…………… 1
Serious physical injuries (stitches‚ broken nose‚ broken bones‚ or hhospitalization) .. 2
24. For any unwanted or forced sexual experiences mentioned so far‚ please indicate who did this.
(Circle all that apply.) If no unwanted or forced sexual experiences‚ go to question 25.
PARENT‚ STEPPARENT‚ GUARDIAN………………………………………..1
OTHER ADULT LIVING IN YOUR HOME (e.g.‚ mother’s boyfriend)………2
SPOUSE/PARTNER (CAN BE AN EX)…………………………‚……………..3
BROTHER………………..…………………………………………..……………..4
OTHER FAMILY MEMBER…………………………………………………….5
BOYFRIEND/GIRLFRIEND…………………………………………………….6
OTHER TEENAGER……………………………………………………….……7
OTHER ADULT YOU KNOW……………………………………………….…8
OTHER ADULT YOU DON’T KNOW…………………………………………9
ANYONE ELSE………………………………………………….………………10
Another type of stressful event people sometimes experience is being physically attacked by another person.
25. Not including physical abuse that may have occurred during the sexual abuse noted previously‚ has anyone‚ including family members or friends‚ ever attacked you with the intent to kill or seriously injure you?
NO ………………………….. SKIP TO Question 31……………………………………… 0
YES…………………………. ………………………………………………………………….. 1
26. Was a weapon used in any attack? A weapon includes any object that could seriously injure someone including a gun‚ knife or other object.
NO WEAPON ………….. ……………………………………………………………………… 0
YES……………………………………………………………………………………………….. 1
27. What was your age the first time any of these attacks happened?
______ age
29. How many times (different days) did these attacks happen? Circle number below.
1‚ 2‚ 3‚ 4‚ 5‚ 6‚ 7‚ 8‚ 9‚ 10‚ 11‚ 12‚ 13‚ 14‚ 15 or more
30. When the worst attack happened‚ did you suffer…
No physical injuries…………………………………………………… ………….……..0
Minor physical injuries (such as bruises and cuts not needing stitches)…….…1
Serious physical injuries (stitches‚ broken nose‚ broken bones‚ or hospitalization) ……….2
31. Not including physical attacks already indicated previously‚ has anyone (including family members or friends) ever beat you up‚ hit you‚ kicked you‚ bit you‚ or burned you? Only include experiences that were outside the range of normal “spanking” or kids fighting.
NO ………………………….. SKIP TO Question 38……………………………………… 0
YES…………………………. ………………………………………………………………….. 1
32. Was a weapon used in any attack? A weapon includes any object that could seriously injure someone including a gun‚ knife or other object.
NO WEAPON ………….. ……………………………………………………………………… 0
YES…………………………. …………………………………………………………………… 1
33. What was your age the first time any of these physical attacks happened?
______ age
34. What was your age the last time any of these physical attacks happened?
______ age
35. How many times (different days) did these physical attacks happen? Circle number below.
1‚ 2‚ 3‚ 4‚ 5‚ 6‚ 7‚ 8‚ 9‚ 10‚ 11‚ 12‚ 13‚ 14‚ 15 or more
36. When this happened‚ were you ever afraid that you might be killed or seriously injured? (Indicate for your worst incident)
0. NO 1. YES
37. When the worst attack happened‚ did you suffer…
No physical injuries…………………………………………………… ………….……..0
Minor physical injuries (such as bruises and cuts not needing stitches)………….…1
Serious physical injuries (stitches‚ broken nose‚ broken bones‚ or hospitalization) ……….2
38. For any physical attacks or beatings mentioned so far‚ who attacked you? (Check all that apply) If no physical attacks‚ skip this question and go to question 39.
PARENT‚ STEPPARENT‚ GUARDIAN……………………………………….. 1
OTHER ADULT LIVING IN YOUR HOME (e.g.‚ mother’s boyfriend)………. 2
SPOUSE/PARTNER (CAN BE AN EX)……………………………………….. 3
BROTHER ………………………………………………………………… 4
OTHER FAMILY MEMBER…………………………………………………… 5
BOYFRIEND/GIRLFRIEND…………………………………………………… 6
MILITARY COMBAT……………………………………….…………………. 7
OTHER CHILD OR TEENAGER…………………………….…………….….. 8
OTHER ADULT YOU KNOW ………………………………………………… 9
OTHER ADULT YOU DON’T KNOW (NOT MILTARY COMBAT)…..….. 10
OTHER (SPECIFY) ____________________________________……………. 11
Attempts: (positive response to any of the 5 items below)
“By using force or threatening to harm you‚ has anyone ever:
1) made you watch a sexual act‚
2) tried to touch the sex parts of your body‚ but did not succeed‚
3) tried to make you touch the sex parts of their body‚ but did not succeed‚
4) tried to make you have sex‚ but he did not succeeded‚ and
5) attempted any other sexual experience not involving contact?”
Touch: (positive response to any of the 5 items below)
“Has anyone ever succeeded in touching the sex parts of your body by using force or threatening to harm you? By touch wemean;
1) with their hands‚ touched or fondled your sexual organs (breast‚ pubic area‚ anus)‚
2) with their mouth or tongue on your vagina or anus (oral sex)‚ and
3) putting fingers or objects in your vagina or anus?
Has anyone ever succeeded in making you touch the sex parts of their body by using force or threatening to harm you? By touchwe mean:
1) made you touch or fondle their genital area‚ and
2) made you put their penis in your mouth (oral sex)?”
Rape: (positive response to any of the 2 items below)
“Has anyone made you have vaginal or anal sex by using force or threatening to harm you? By sex we mean:
1) vaginal intercourse (man putting his penis in your vagina)‚ and
2) anal intercourse (man putting his penis in your anus)?”
Physical
Being beat‚ hit‚ or kicked: (positive response to item below)
“Has anyone—including family members of friends—ever beat you up‚ hit you‚ kicked you‚ bit you‚ or burned you‚ regardless ofwhen it happened or whether you ever reported it or not? (Includeexperiences that were outside the range of normal “spanking”or kids fighting).”
Life threat: (positive response to any of the 2 items below)
1) “Has anyone—including family members of friends—ever attacked you with a gun‚ knife‚ or some other weapon‚ regardlessof when it happened or whether you ever reported it or not?
2) Has anyone—including family members of friends—ever attacked you without a weapon‚ but with the intent to kill or seriously injure you?”
This instrument can be found at: www.karger.com/ProdukteDB/katalogteile/isbn3_8055/_98/_53/suppmat/p41-SPAHQ.pdf
Drossman DA‚ Leserman J. Nachman G‚ Li ZM‚ Gluck H‚ Toomey TC‚ et al. (1990).Sexual and physical abuse in women with functional or organic gastrointestinal disorders. Ann Intern Med. 1990; 113:828-33.
Leserman. Jane‚ Drossman. Douglas A‚ & Li. Zhiming‚. (1995). The reliability and validity of a sexual and physical abuse history questionnaire in female patients with gastrointestinal disorders. Behavioral Medicine‚ 21(3); 141-150.
Leserman J‚ Drossman DA‚ Li Z‚ Toomey TC‚ Nachman G‚ Glogau L. (1996). Sexual and physical abuse history in gastroenterology practice: how types of abuse impact health status. Psychosom Med ;58(1):4-15.
Drossman DA‚ Talley NJ‚ Leserman J‚ Olden KW‚ Barreiro MA. (1995). Sexual and physical abuse and gastrointestinal illness. Review and recommendations. Ann Intern Med. 1995;123(10):782-794.