Childhood Sexual Abuse
Introduction
It would be difficult to find a clinician that has not seen a child or adult who has been sexually abused. A longitudinal study of adverse childhood events estimates that 1 in 4 girls and 1 in 6 boys are sexually abused before the age of 18. (ACE study, n.d.). Thirty to forty percent of these children are abused by a family member, and another fifty percent are abused by someone outside of the family whom they know and trust (Frawley, 1990; Kilpatrick, Saunders & Smith, 2003). As distressing as these statistics are, these figures do not account for others who keep the abuse secret throughout their lifetimes. Abuse has a significant effect on interpersonal functioning and self-esteem. Individuals who have been sexually abused may seek help for a variety of difficulties including depression, suicidal tendencies, phobias, eating disorders, drug addictions and self-destructive behaviors (Day, Thurlow, & Woolliscroft, 2003; Molnar, Buka & Kessler, 2001; Saunders et. al., 1999).
Traumatic experience is a pivotal organizing feature in the survivor's life. It presents many therapeutic challenges that stem from the emotional and family dynamics of abuse. Survivors of interfamilial sexual abuse generally come dysfunctional or chaotic early environments. Conscious and unconscious mechanisms, such as denial and avoidance, are used to contradict the reality of the traumatic event. Many respond to overwhelming feelings about the abuse with dissociation and depersonalization. Abusive behavior is also repeated: victims are at risk of being victimized again or victimizing others. Other therapeutic challenges include concealment of the abuse, hesitant disclosure, disguised presentation and resistance to treatment.
Unlike other forms of trauma (war, disaster, crime) sexual abuse often occurs early in development, is perpetuated by a trusted other and may be prolonged —sometimes lasting years. Childhood sexual abuse results in a sense of stigmatization and powerlessness. The child incorporates the negative connotations associated with the abuse experience into his or her developing self-concept. The outcome of the experience is pervasive feelings of guilt, shame, anger, fear, and shattered self-esteem. Because traumatizing events are often repeated and interrupt important developmental needs, abuse can result in severe forms of post-traumatic stress disorder (PTSD).
This course will examine the impact of sexual abuse on children and adult survivors. It will review ways to help individuals heal from these early experiences.
Objectives:
After finishing this course, the participant will be able to:
-Define Sexual Abuse -Compare and contrast acute and chronic trauma
-Discuss the effects of sexual abuse -List the symptoms of PTSD -Discuss core issues in the treatment of sexual abuse survivors ---Describe a treatment approach
Definition of Sexual Abuse
The American Medical Association defines child sexual abuse as "the engagement of a child in sexual activities for which the child is developmentally unprepared and cannot give informed consent” (American Medical Association, 1992). “Incest” is sexual abuse by a family member. Every state has its own definition of child sexual abuse, which is often more specific and included under the state’s child protection laws. Additionally mental health clinicians need to be aware of mandated reporting statutes, which are now a requirement in all states.
The most significant feature of child sexual abuse is that the dominant position of an adult allows him or her to coerce the child into sexual activity (American Psychological Association, 2001). Child sexual abuse may include fondling a child's genitals, masturbation, oral-genital contact, digital penetration, or vaginal and anal intercourse. Child sexual abuse is not solely restricted to physical contact; such abuse could include noncontact abuse, such as making a child watch pornography or look at an adult’s genitals. Sexual abuse may also include abuse by a child’s peer.
Russell (1986) provides a continuum of sexual abuse severity in which specific activities can be classified on a continuum of severity. In general, the more severe the sexual abuse, the more serious the impact, although any form of sexual abuse is psychologically harmful. Among clinical samples, over 60% of those surveyed reported having been abused at the very severe level (Russell, 1986). The following is a description of this continuum.
Very severe sexual abuse: Attempted or completed, forcible or non-forcible, genital or anal intercourse, fellatio, cunnilingus, analingus.
Severe sexual abuse: Attempted or completed, forcible or non-forcible, manual touching or penetration, simulated sexual intercourse, or breast contact (unclothed).
Least severe sexual abuse: Forcible or non-forcible sexual kissing, intentional sexual touching of buttocks, thighs, legs, or clothed breasts or genitals.
In addition to the classification above, researchers note that there are additional factors that mediate the effects of sexual abuse (Evans & Sullivan, 1995). They have found that the effects of sexual abuse are most adverse when:
1. Incidents are frequent.
2. The inappropriate sexual activity occurs over a long period of time.
3. The abuse is unpredictable.
4. The sexual activities are wide-ranging and extensive.
5. There is more than one perpetrator.
6. The sexual abuse involves physical violation and force.
7. The relationship of the child or adolescent to the perpetrator is close.
These descriptors are starting points in assessing for and working with sexual abuse. It is also valuable for clinicians to be aware of the patterns of sexual victimization.
Stages of Sexual Victimization
Often sexual abuse follows a predictable pattern. This pattern is helpful to understand
especially when working with children and families, or with those who have been more recently
abused. Delaplane, D. and A. Delaplane. (n.d.) describe the stages in the process of sexual
victimization:
1. The Approach
This is the stage in which the perpetrator makes initial overtures towards the child. Child sexual abuse is planned activity and is often perpetrated by someone known to the child. Children tend to accept adult authorities particularly that of adults close to them. Additionally, the in the initial stages of the abuse process, the perpetrator may pay attention to the child, or suggest a relatively harmless activity such as an outing or other activity. This initial gentleness may be difficult for the victim to reconcile once the abuse has progressed in nature. Alternately abuse can involve intimidation or threats as part of the initial contact.
2. Sexual Interaction
The next stage of sexual abuse involves an increase in sexual interaction. Child abuse is often progressive. It may start with the abuser looking at the child, progress to some form of touching or fondling and eventually lead to penetration. It is important to note that all of these behaviors are boundary violations and can lead to confusion and emotional injury to the child.
3. Secrecy
Keeping the abuse a secret is another almost universal dynamic in sexual abuse. Many experts believe that sexual abuse is the most under-reported form of child maltreatment because of the secrecy or "conspiracy of silence" that so characterizes these cases. Victims of sexual abuse may not disclose the secret until years after the abuse has occurred. Another component of sexual abuse related to the idea of secrecy is repression of memories of the abuse.
4. Disclosure
Although disclosure of sexual abuse may be voluntary, often disclosure is involuntary. Survivors of intra-familial sexual abuse often conceal the abuse experience or disclose it hesitantly due to strong feelings of family loyalty. Disclosure may come through observations of caretakers or others who recognize behaviors or signs of sexual abuse. In children these may include bed-wetting, a significant change in behavior, compulsive masturbation, fears or avoidance, or victimization of others.
5. Suppression
It is not uncommon that families of children who are abused suppress the abuse and do not disclose it to appropriate authorities. They may do so due to the misperception that the child will be more scarred by needing to discuss the abuse or by a desire to protect the perpetrator. They may also minimize the abuse, assuming that the child will simply “get over it.” Suppression of abuse and has serious emotional consequences for the victim and may lead the victim to minimize hir or her own experience.
6. Repression or Recovery
If child sexual abuse is suppressed, some adjustments may be made in the family, however these may not be sufficient to avoid further abuse. There is also a strong probability that the offender may repeat the abuse with another child. Alternately, recovery involves seeking treatment for the child. If the abuser is a family member, treatment must also treatment for the offender.
The process above is seen in the histories of many children who are sexually abused.
Important components of treatment for children involve having them feel supported by caretakers
and others following the abuse, as well as disclosing aspects of what they have been through in
order to move towards healing.
Defining Trauma
Clearly sexual abuse is a traumatic experience in the life of a child or adult survivor.
Unfortunately, the term “trauma” has become somewhat overused in popular language. For
purposes of this discussion of trauma, we will adapt Judith Herman’s definition. In her seminal
work on psychological trauma, Trauma and Recovery, Judith Herman describes trauma in this
way:
"Traumatic events are extraordinary, not because they occur rarely, but
because they overwhelm the ordinary human adaptations to life. Unlike
commonplace misfortunes, traumatic events generally involve threats to life or bodily
integrity, or a close personal encounter with violence or death. They confront human
beings with the extremities of helplessness and terror and evoke the responses of
catastrophe (Herman, 1992)."
Herman’s book discusses many types of trauma, including sexual abuse, war,
natural disasters and crimes including rape. Although she points out that all types of trauma can be damaging, sexual abuse is particularly damaging due to its ongoing nature as well as the often close relationship of the perpetrator to the person who has been abused..
Stressful events may be loosely characterized as acute or chronic. Acute stress results from sudden, intense events, such as rape or other violent crimes. Chronic stresses are more constant, such as incest or sexual abuse, physical abuse, or neglect. In households where a person is sexually abused, there may often be a combination of acute and chronic traumas or multiple traumatic stressors. When faced only with acute stress individuals display a relatively similar set of responses (that is, the symptoms of post-traumatic stress disorder or PTSD). This is not always the case for those experiencing chronic stressors.
The picture for individuals who experience long-term stressors varies. Some individuals do display PTSD symptoms. Others develop a wider range of difficulties including substance abuse, eating disorders, deliberate self-abuse, social phobias, depression, and anxiety. The aftereffects of chronic stressors intrude on many life spheres: social and vocational; psychological or emotional; physical; sexual; family; sense of self; and relations with others. These stressors often result in a sense of stigmatization and powerlessness. When they occur early in life, a child may incorporate the negative connotations associated with these experiences into his/her developing self-concept.
Post Traumatic Stress Disorder and Trauma Responses
Post Traumatic Stress Disorder is listed in the DSM-IV as an anxiety disorder (American Psychiatric Association, 1994). The characteristic features of this disorder are fear, particularly in the absence of a current threat to safety, and avoidance behaviors. Anxiety responses can range from mild apprehensiveness, to episodes of acute anxiety, commonly associated with situations that recall the traumatic experience.
A diagnosis of PTSD requires that four criteria be met (American Psychiatric Association, 1994). First, the individual must have been exposed to a traumatic event, such as having been sexually abused. Second, the individual must re-experience the event in some way. This can include recurrent dreams, intrusive thoughts about the event, flash backs of the event, or body memories, which are a somatic re-experiencing of the trauma. The later is often quite confusing, and individuals may not be willing to initially disclose that they are feeling the abuse in their bodies. The third criterion for PTSD is the persistent avoidance of events related to the trauma, trauma specific fears, and emotional numbing. An example would be a woman who was sexually abused as a child developing fears of men and avoiding intimate relationships.
Fourth are co morbid symptoms of anxiety and arousal. This may include chronic tension and irritability, or a sense of hyper arousal, often accompanied by feelings of fatigue, insomnia, inability to tolerate noise, and the complaint "I just can't seem to relax," which is related to the "fight or flight" response. When stress is intense or prolonged, hyper arousal may result in a variety of
somatic problems including migraines, urinary and bowel dysfunction, sleeplessness, trembling, and increased menstrual discomfort (Dickson et. al., 1999). Some Individuals with PTSD may attempt to reduce this arousal through alcohol or drug use, or through overeating or restricting food intake. Clinically we may also see impaired concentration and memory (that may lead to accident proneness) and depression.
Post-traumatic stress is considered chronic if it lasts more than six months. Delayed reactions, in which symptoms do not occur until long after the experience are also possible. Some survivors of childhood trauma, for example, report that they have fared relatively well until faced with an event that in some way recalls the trauma (e.g., seeing an abusive parent, having their own child reach the age at which their abuse occurred); they then develop PTSD symptoms at this point. This reaction may be particularly painful because the individual feels that they already "overcome" the childhood stressor.
Other related symptoms often seen in those who have been abused include repetition of the event either directly or symbolically. In a person with a sexual abuse history clinicians may see a direct reenactment, such as promiscuity or compulsive sexual behaviors, or a more symbolic repetition, such as purging in a person who has experienced oral sexual abuse. Dusty Miller (1994) applies the concept of repetition to women with a broad range of self-harm behaviors (eating disorders, self-mutilation, and drug and alcohol abuse). This syndrome, which she terms “Trauma Reenactment Syndrome,” also has clinical applicability for men who have been sexually abused. Those with Trauma Reenactment Syndrome "reenact the harm done to them as children and reinforce their belief that they are incapable of protecting themselves because they were not protected as children." Miller suggests if clinicians focus only on symptoms the treatment will not be successful. The abuse must be integrated into the psyche and worked through.