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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.

Another issue seen in individuals who have been traumatized is that they may withdraw from social contact and refrain from experiences that cause them to become overly stimulated. This is commonly seen in avoidance of interpersonal involvement (feeling detached from others), or a loss of interest in previously enjoyed activities, similar to that seen in depressed people (Levine, 1990). There may also be difficulties with healthy attachment, with some vacillating between attachment and ambivalence (Levy, 2005).

Lenore Terr (1994) is another researcher who has focused extensively on the effects of childhood trauma, including longitudinal studies of children who have undergone traumatic events. Terr has found that all victims of childhood trauma experience symptoms including body memories, repetitive reenactments, trauma specific fears, and changed attitudes (such as pessimism). Terr further categorizes survivors as Type I or Type II survivors depending on the nature of their symptoms.

Type I survivors have full memories of the abuse. Despite this, they do often show some issues of reality testing such as a preoccupation with omens, or misperceptions about the intentions of others. Type II survivors do not have full memories of the trauma. There may be denial about what happened to them or to the fact that it was harmful. They may also display

defensive mechanisms including self-hypnosis, depersonalization and dissociation, psychic numbing. Lastly there is often rage, turned outward toward others or inward toward the self.

As Terr suggests, some individuals who experience chronic stressors develop ways to deal with the overwhelming nature of the stress. For example, they may push it out of their awareness (repress or "lose" memories) or may split it off into a separate part of themselves (dissociate it). Such compartmentalization helps to the individual to get beyond the pain of the experience but may result in the person feeling fragmented. Other responses are numbing out the abuse (e.g., through drugs or alcohol), and reacting with rage turned outward toward others or inward toward the self (Allen, Coyne & Huntoon (1998; Herman, 1992).

A number of recent studies (i.e., Briere & Zaidi, 1989; van der Kolk, Hostetler, Herron, & Fisler, 1994; Weaver & Clum, 1993) demonstrate a significant link between a borderline diagnosis and childhood trauma. Hallmarks of Borderline Personality Disorder include diffuse self-concept, unstable moods and interpersonal relations, feelings of emptiness, interpersonal attachment problems, a tendency to decompensate under stress, physically self-harmful destructive acts (including self-mutilation and suicidal tendencies), splitting and abandonment concerns.

Factors That Influence an Individual’s Reaction to Stress

Many clinicians are faced with client situations in which an individual experiences a traumatic stressor and develops less severe symptoms in comparison with others they have treated with a similar set of circumstances. There are a number of factors that influence an individual’s reaction to stress. These include:

1. Intensity and duration of the stress. In general, the more intense or prolonged the stressful event, the more serious the stress reaction will be. The intensity of the traumatic reaction is also dependent on the suddenness of the event and the degree to which the situation is life threatening.

2. Presence of other stress. Each source of stress produces its own reactions in the individual and makes the individual more vulnerable to other stress.

3. Characteristics of the individual. Some people are more reactive to stress and others more resilient.

4. Social support. Adequate social support mitigates stress to some degree.

5. Personal control. The degree to which the individual can predict or control the stressful event also influences their reaction. Symptoms of stress may persist because the person's sense of self-confidence has been undermined. Once a stressful event occurs, an individual may be on the lookout for other stressors.

Effects of Trauma and Sexual Abuse

There are a number of effects of childhood sexual abuse. These include those related to emotional/psychological health, physical health and social issues. Although an exhaustive discussion of these issues is not possible given the scope of this training manual, the primary effects of sexual will be discussed below.

Sexual abuse affects the survivor’s sense of safety and well-being. As a result, those who have been sexually victimized are more likely to develop psychological problems. The most common of these are disorders along the depressive spectrum, including major depressive disorder and dysthymia (Molnar, Buka & Kessler, 2001) and anxiety disorders (Levitan, et. al., 2003)." Depressive disorders may or may not be co morbid with PTSD, thus an individual’s abuse history may not be immediately evident. In child populations, depressive disorders may present with sadness, acting-out behaviors and school problems. Children who have been victims of sexual abuse exhibit long-term and more behavioral problems, particularly inappropriate sexual behaviors (Browne, & Finkelhor, 1986; Day, Thurlow, & Woolliscroft, 2003).

Victims of child sexual abuse are also at higher risk for developing addictive behaviors including substance abuse problems (Day, Thurlow, & Woolliscroft, 2003) and eating disorders (Kendler et. al., 2000). There are many reasons for this. Adolescents who abuse substances often talk about the numbing/sedating quality of drugs and alcohol. Thus, substances may be used as a way to modulate emotions or to decrease painful feelings. They may also be used to discharge anger or to maintain a sense of identity and self-esteem, such as through identification with a peer group. Young men and women who develop eating disorders often describe similar functions to the disorder. In addition, eating disorders such as anorexia, bulimia and compulsive eating may also be a way to maintain helplessness, establish a sense of control and power and establishment psychological space. Sexual abuse survivors may also use eating disorders in an attempt to “purify” the self or to create a large/small body for protection (Schwartz & Gay, 1996).

In child populations, those who have been victims of sexual abuse are more likely to experience physical health problems (e.g., headaches, stomachaches, irritable bowel syndrome). These problems are also frequently seen in adult survivors of child sexual abuse and can lead to expensive medical testing and utilization of medical services.

Sexual abuse also has societal effects. Victims of child sexual abuse are more likely to be sexually promiscuous and 3 times more likely to become pregnant before age 18 (Kellogg Hoffman, & Taylor, 1999). Adolescents who suffer violent victimization are at risk for being victims or perpetrators of felony assault, domestic violence, and property offense as adults (Beitchman, et. al., 1992).

Another are that is important to consider are the relational aspects of sexual abuse. Few would disagree that sexual abuse damages the human connection. Experiences such as sexual abuse and family violence interfere with the child’s ability to internalize a sense of safety and trust in relationships. Jean Baker Miller and Irene Stiver propose that psychological problems result

from situations in which one person or group has “more power over another and can thereby create and enforce disconnections and violations” (Miller & Stiver, 1997,

p. 50). Disconnections occur when relationships are not mutually empathic or mutually empowering. Violation of another is the antithesis of empathy; if one person is empathic to another, he or she will not engage in the kind of disconnection or mistreatment that hurts or violates that person and the relationship.

Clearly childhood sexual abuse has wide ranging effects. Treating the effects of childhood trauma will allow individuals to become more functional and productive.

Summary of Core Issues

Evans and Sullivan (1995) outline the following core issues for survivors of sexual abuse. Many of these have been mentioned previously, but this is a nice summary of the factors to be addressed before turning to treatment issues.

Strong need to be in control

Tendency to be overly sensitive and to take things personally

Difficulty trusting others

Distorted sense of responsibility

Trouble being appropriately assertive and dealing with anger

Tendency to reenact or repeat self-defeating behavior

Sexual and somatic problems

Alienation from self and others

Frequent use of denial or dissociation to deal with problems

In some, repression—pushing out of awareness of painful memories and feelings

Treatment of Childhood Sexual Abuse

Treatment of childhood sexual abuse is challenging for the clinician. In order for treatment to be effective it must help the individual address the feelings related to childhood abuse as well as the ways that the sexual abuse has affected and continues to affect the person. Treatment varies somewhat based on whether the clinician is treating a child or an adult survivor.

In child populations, there are a number of both individual and family treatment goals (Jongsma, et. al, 2006). Individual treatment goals include ensuring the patient’s safety, particularly that there is no further sexual victimization of the client. This goal may include the involvement of social services. The clinician must also help the child to work successfully through the issue of sexual abuse with consequent understanding and control of feelings and behavior. Often children express feelings through negative means, such as acting out behaviors, including sexual acting-out. Children must also be taught to resolve the issues surrounding the sexual

abuse, resulting in an ability to establish and maintain close interpersonal relationships. Work on self-esteem and sense of empowerment is also important.

Family work is also critical for the treatment of child survivors of sexual abuse. The primary goal is to eliminate denial in the family, placing responsibility for the abuse on the perpetrator and allowing the survivor to feel supported. Additionally the clinician must help the family to establish appropriate boundaries and generational lines in the family to greatly minimize the risk of sexual abuse occurring again in the future.

There have been many models proposed for treating adult survivors of childhood sexual abuse. Most of these have some similar components, and many clinicians utilize a combination of approaches in treatment. Such approaches include psychodynamic treatment (e.g., Frawley, 1990), which enables the client to see how early experiences have affected them and provides ways to minimize defensive reactions and trauma reenactments, cognitive behavioral approaches (e.g., Dancu, 1999), which focus on providing skills to cope with anxiety, manage trauma symptoms, cope with anger and address stress responses, eye movement desensitization and reprocessing (EMDR) (Shapiro, 2004), which utilizes bilateral eye movements to help clients process disturbing memories. A treatment model which has been highly effective for clients with self-harming or impulsive behaviors or for those with borderline personality disorder is dialectical behavior therapy (Linehan, 1993). Linehan utilizes a skills-based approach to teach clients mindfulness, interpersonal effective skills and affect modulation techniques.

Another approach is a Herman’s (1994) stage-specific model that is applicable to the treatment of sexual abuse as well as other traumatic events. The stages of this model are:

Safety

Remembrance and mourning

Reconnection

Using this model, the first stage of treatment involves creating safety, both physical and emotional. Although safety is a basic right of all individuals, those who have been sexually victimized were deprived of this right. Feeling safe, however, is key to the healing process. At its most basic level, the clinician must ensure that there is no further sexual victimization of the client (a goal appropriate to child and adults, who may be in sexually victimizing relationships. Creating safety also involves teaching survivors to establish appropriate boundaries with others. Clinicians may also find it helpful to establish the frame of not acting out physically or emotionally. If there are self-harm behaviors, such as cutting, eating disorders, or drug and alcohol issues a basic level of abstinence from these behaviors or diligent work on these harmful symptoms.

In the remembrance and mourning stage clients remember and explore their traumas and grieve the many losses they have experienced. This stage challenges the client to break old patterns of silence and secrecy, the conditions under which the abuse took place. Two techniques are used: flooding and testimony. After being taught relaxation techniques the client is asked to

recall the traumatic event. Testimony involves keeping a detailed record of the traumatic experience. At the conclusion of this stage, clients are encouraged to grieve losses, such as the loss of innocence or the loss of a loving and protecting parent.

Finally reconnection involves taking on a new identity in which the person feels empowered rather than victimized. Some trauma survivors, for example, may choose to do some kind of social advocacy work or other mission that enables them to move on from the trauma as a survivor rather than a victim.

Conclusion

Childhood sexual abuse is a traumatic experience that has ranging and lasting effects. Due to the prevalence of childhood sexual abuse, clinicians with encounter clients who have been victimized as children. It is important to understand and address childhood sexual abuse. There are many techniques and approaches that can be useful in doing so. Helping clients address these issues will enable them to lead fuller and more functional lives.

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