Psychological Sequelae of Childhood Sexual

Psychological Sequelae of Childhood Sexual Abuse

The fact of childhood sexual abuse has become a central area of concern in countries throughout the world and has been described by experts as a "...major public health problem affecting thousands of children and adolescents in the United States each year" (Johnson, 2008). The trauma of childhood abuse of this nature is in itself horrific and innately damaging to the individual. However, the consequence of this abuse, especially if protracted over a long period of time, can have very serious and long-term psychological ramifications. What has become a focus of research on this issue is the question of the sequelae of childhood sexual abuse. This refers especially to the mental and psychological results and consequences of the trauma of childhood abuse.

In essence this chapter will focus on the fact that a child who experiences serious and prolonged sexual abuse can bear the scars of this abuse into adulthood and this can have long lasting and often devastating psychological effects that can seriously impact the quality of life and the ability of respond and relate to others in society.

CSA or childhood sexual abuse has also become a global issue and problem. This is evidenced by recent reports by the World Health Organization (WHO) (2002), which states that the rate of this form of abuse is much higher than many pundits expected. In the World Health report of 2002 the organization has stated that more than 800 million people throughout the world have been the victims of childhood sexual abuse and that than 500 million having experienced contact or intercourse types of abuse. (Johnson, 2008)

There is a large body of literature that has grown in recent years on the impact of sexual abuse. These studies refer to the wide range of different types and kinds of effects that are experienced by the victims. These are usually divided into short to medium term responses as well as to the more lasting affects of the various types of sexual abuse. It should also be noted at the outset that responses to sexual abuse vary according to the individual's psychological makeup and other social and environmental factors. For instance, some children are less affected by the same type of experience than others. However, in this chapter, while allowance will be made for individual variations and fluctuation in the response to abuse, the more typical and general responses will be focused on.

The immediate impact of sexual abuse is often categorized in terms of trauma, depression, anxiety, sleep and eating disturbances, and cognitions such as self-blame and feeling damaged (O'Donohue & Geer, 1992, p. 100). This can have a wide range of concomitant and related sequelae; for example, responses such as physical aggression, sexual aggression, substance abuse, and suicidal behavior. Longer term affects of early sexual abuse can be seen in the relationship to disorders such as PTSD or Post- traumatic stress disorder. This is an aspect that will be explored in detail in this chapter. Other affects or sequelae will also be explored. These include eating disorders such as Anorexia Nervosa and Bulimia, as well as obesity.

In other words, the results or the effects of childhood sexual obesity can manifest themselves across a wide range of disorders and symptoms, which all have a devastating and of psychologically debilitating affects on the individual well after the sexual abuse has terminated.

As one study on this subject points out, an analysis of the findings of various studies on psychological sequelae of this form of abuse "... provide evidence confirming the link between CSA and subsequent negative short- and long-term effects on development, and support the multifaceted model of traumatization rather than a specific sexual abuse syndrome of CSA" (Johnson 2008). This means that understanding the results and the aftermath of childhoods sexual abuse necessitates taking account of a complex and often interrelated set of symptoms and affects.

The above view also refers to the particular way in which many people who have been abused often refuse to acknowledge the psychological trauma the have experienced. This sublimation or denial of the experience is in many cases the precursor to other symptoms and disorders such as dissociation and the secondary results of trauma, such as the inability to have open and healthy sexual and social relationships with others. The following is a statement by a subject named Evelyn who is forty one years of age. Her description of her experiences provides an illuminating insight into the insidious long-term psychological effects of this form of abuse.

It happened so long ago, I wonder if what I remember is real. I have never told anyone the secret that I have carried deep within me. I do not want to believe it is true. Yet, every day I live is another day that I deny what was done to me. It is another day that I feel I deny a part of myself. I have had such a growing need to tell someone. I do not want the secret to die with me (Duncan, 2004, p. 8).

In this particular case the women was repeatedly abused and violated as a child and this had a devastating affect on her life. A common result of this abuse, which was also experienced by this person, was a loss of self-esteem and sense of self-worth; which also caused her to doubt herself and her own integrity. This is turn had a detrimental affect on the choices and on the relationships she made in her life.

Sexual as well as social relationships can be adversely affected by the experience of childhood sexual abuse. The trauma associated with this abuse can negatively impact the trust between social friends and between marriage partners, and also often has an adverse affect on communication within the relationship. It can also make physical intimacy problematic.

Among the sequelae of sexual abuse in children the most immediate affects are usually a feeling of loss of control and powerless, shame and guilt which can lead to a loss of a sense of security (Barker). This in turn often leads to a range of emotional problems and more long-term sequelae; such as secondary and related problems with regard to sexual maladjustment and interpersonal relationships. Among the other sequelae are depression, an inability to experience pleasure, low self-esteem, as well as dissociative symptoms, self-destructive behavior and eating disorders. The following sections will deal with a number of the central psychological sequelae that result from childhood sexual abuse.

Trauma and depression

It goes without saying that sexual abuse is a very harrowing and traumatic experience for the child. However, what are of concern are the effects that the aftermath of such traumatic experience can have on the individual child; which can profoundly influence the child's life and health. The literature is replete with studies about the way that severe trauma as a result of sexual abuse can lead to a wide range of negative outcomes. For example, research shows that children who are abused often have difficulty in regulating their emotions. As a result they may also not be able to form secure relationships and be unable to develop a secure and cohesive sense of self (Sanderson, 2006, p. 170).

The difficulty that abused children have in expressing their emotions can lead to various forms of disassociation and related psychological problems. In other words, their emotions can become blunted and they may become unemotionally responsive. (Sanderson, 2006, p. 170) This in turn may lead to periods of inner anxiety and stress which may culminate in depression.

Depression is often noted in children who have experienced long periods of sexual abuse. This may in some cases lead to suicide attempts. In one study on this subject it was found that "... The rate of lifetime depression among childhood rape survivors was 52% compared to 27% among nonvictims "(Yuan, Koss, and Stone).

There are numerous studies that indicate a positive correlation between sexual abuse in the child and depression with the after- effects extending into later life - although a number of studies add the caveat that this correlation was confined to more severe abuse where there was penetration or attempted penetration (Cheasty M, Clare a. And Collins C., 1998). As one article stresses, studies show that "...children who are abused and neglected are at increased risk of becoming depressed adults,..." (Abused Children Face Depression Risk as Adults)

An insightful study by Arne Cornelius Boudewyn and Joan Huser Liem entitled Childhood sexual abuse as a precursor to depression and self-destructive behavior in adulthood (1995), makes the important point that the duration of sexual abuse is strongly correlated to the severity and the extent of the depression that is experienced by the child and later the adult. "The more frequent and severe the sexual abuse and the longer its duration, the more depression and self-destructiveness reported in adulthood" (Boudewyn and Liem, 1995). In brief, what many other studies and research articles point out is the view that CSA or childhood sexual abuse is a 'predictor' of various forms of self-destructive behavior, including depression. It is also interesting to note that the correlation between depression and childhood sexual abuse was found to be higher among females in many studies.

However, the issue of the relationship between depression and sexual abuse may not be as clear-cut as the above studies suggest. Recent research has begun to question this correlation and has produced findings that suggest that there are many other parameters and variables that should be considered. This is especially the case with regard to the view that childhood sexual abuse necessarily leads to depression in adulthood. As one report claims, "...there is accumulating evidence to contradict these claims" (Roosa,

Reinholtz, (Angelini, 1999). However the majority of studies indicate that there is a strong possibility that children who are sexually abused experience symptoms of depression that can extend into adulthood.

PTSD

3.1. What is PTSD?

Post Traumatic Stress Disorder is a disorder that has shown a marked degree of growth in terms of research and publications in recent years. This increased interest is also due to the fact that PTSD was included in the third edition (1980) of the Diagnostic and Statistical Manual of the American Psychiatric Association (Williams and Sommer, 1994, p.3). This means that PTSD was formally accepted in terms of its etiology and symptoms as a psychological disorder.

In essence, PTSD is a mental health issue which is characterized by "... An individual's exposure to one or more events that involve death, threat to life or limb, or serious injury and a cluster of psychological responses to the memories of those events, consisting of intrusive, avoidant, and hyperarousal symptoms" (Martz, Birks & Blackwell, 2005, p.56).

PTSD has also been compared to and correlated in patients with other psychiatric disorders such as depression as well as substance abuse. Severe and traumatic sexual child abuse is also strongly linked to PTSD.

There are many definitions of this disorder. One of the most common is the following: " Post-traumatic stress disorder...is an intense physical and emotional response to thoughts and reminders of the event that last for many weeks or months after the traumatic event" (Coping With a Traumatic Event). This disorder is described in the DSM-III as a traumatic event and as "...a catastrophic stressor that was outside the range of usual human experience" (Friedman M.J.).

Significantly, previous views and formulations of PTSD referred only to very extreme to unusual events, such as war and nuclear holocaust as defining aspects of the disorder. However this view of PTSD was revised in the DSM-IV and the diagnosis of PTSD was extended to include many other criteria. This is relevant to the present discussion as the first of these criteria refers to the meaning and implications of trauma. A traumatic event is defined as " one in which: (a) the person experienced, witnessed, or was confronted with an event that involved actual or perceived threat to life or physical integrity; and (b) the person's emotional response to this event included horror, helplessness, or intense fear" (Foa & Meadows, 1997. p449).

Both of these aspects can be related to the experiences of many children who face sexual abuse and this has a range of related symptoms and sequelae.

The psychological symptoms of this degree of trauma are categorized into three main groupings; namely the re-experiencing of symptoms, such as nightmares and flashbacks; secondly, symptoms of avoidance of trauma and related stimuli and thirdly, symptoms of increased arousal, which manifest as the inability to sleep and irritability (Foa & Meadows, 1997. p449). In other words, the modern view of PTSD is much more realistic and open to the inclusion of various situations and events, such as sexual abuse, that can initiate the symptoms of the disorder. Among the other commonly referred to symptoms of PTSD are;

Irritability or outbursts of anger

Difficulty concentrating

Hypervigilance, or being constantly "on guard"

An exaggerated startle response, or jumpiness.

Stress Injury to health trauma, PTSD)

3.2. PTSD and Childhood sexual abuse

Recent research has linked PTSD and the symptoms of this disorder to childhood sexual abuse. Studies claim that, " Survivors of childhood sexual trauma are at high risk of posttraumatic stress disorder (PTSD)" (Yuan, Koss, and Stone). This association with PTSD is substantiated by studies that have established a clear link between symptoms of PTSD and the aftermath of childhood sexual abuse. In a recent study it was found that, "... women who reported childhood sexual abuse were five times more likely to be diagnosed with PTSD compared to nonvictims" (Yuan, Koss and Stone). This study indicates that the lifetime rate of a PTSD diagnosis was "...over three times greater among women who were raped in childhood compared to nonvictimized women" (Yuan, Koss and Stone).

The link between PTSD and childhood sexual abuse is also dealt with in an article by Duncan (2004). This study makes the assertion that in fact childhood sexual abuse is a central and leading factor in the development of post-traumatic stress disorder. Many studies indicate that the effects of children abuse have a direct link to PTSD. For instance, a study by Boney-McCoy and Finkelhor (1995) found that "After controlling for family dysfunction, significant associations were found between CSA and increased levels of PTSD symptoms and school difficulties. Abused boys reported significantly more sadness then other children..." (Association between Childhood Sexual Abuse History and Adverse Psychosocial Outcomes in controlled studies)

These findings are also supported by many other studies. Sanderson (2006) states that, " Sexual abuse that occurred during the 15-month interim was associated with PTSD-related symptoms and depression not present prior to the assault" (Sanderson, 2006, p. 159). Sexual abuse can also lead to a range of related symptoms and psychological conditions. For example,

If an individual is in a constant state of high alert, with the physiological danger system activated and yet prevented from discharging built-up energy, energy becomes locked in the body, overloading the system and leading to further numbing and dissociation..." (Sanderson, 2006, p. 159).

Other symptoms include the following: avoidance of people and triggers that are reminders of the trauma, a range of dissociative aspects, detachment, and lack of trust, as well as phobias, obsessive-compulsive disorder, ill health, hopelessness, learned helplessness, affect intolerance, self-injurious behaviors and risk-taking behavior (Forgash, 2004).

3.3. Dissociation central symptom of PTSD that also pertains to the results of sexual abuse during childhood is known as dissociation. Dissociation is understood as a "...splitting of awareness" (Rothschild, 1998). It is also refers to the debate as to whether PTSD can be classified as a dissociative rather than an anxiety disorder, as it is presently classified.

In essence dissociation refers to a separate and split response to a traumatic event. Some experts explain dissociation as a range and continuum of responses by the patient to severe trauma, such as sexual abuse. This continuum can begin with simple forgetting and amnesia and can continue to develop into Multiple Personality Disorder, (Rothschild).

The characteristic symptoms of dissociation in patients with PTSD refer to a range of different variables and aspects. The can include an altered sense of time, reduced sensations of pain, and an absence of terror or horror. The last-mentioned symptom is particularly relevant to the present discussion as it refers to a form of psychological 'freezing' which is often encountered in children who have experienced severe sexual abuse and trauma. This process is described in more depth as follows: (Brain-imaging techniques indicate that the imprint of trauma is located in the right hemi- sphere and the limbic system, where the regulation of emotional states and autonomic arousal occurs...Constant activation of these systems results in loss of self and affect regulation, and the individual is unable to modulate arousal. In addition, the frontal lobes, which are implicated in extracting meaning from experiences, inhibiting in- appropriate behaviour and regulating speech, may be impaired, and the sexually abused child may be unable to think, speak or communicate what is going on. The child also fails to understand that things can change and, therefore, cannot transform the CSA experience or move on Sanderson, 2006, p. 159).

The above analysis is quoted at length as it provides useful insight into PTSD as it might affect the child who has experience severe trauma. In essence, freezing or dissociative behavior can result in a severe paralysis of the psyche of the child and can lead to a sense of existential emptiness and a feeling of nothingness or ennui - which in turn can have other severe behavioral consequences.

The process of dissociation can therefore lead to extensive psychological damage and problems with regard to treatment.

Memories and behaviors associated with the trauma are sometimes stored in fragments and therefore not available for information processing. When the client is cued or triggered, these distressing memories can invade the person's consciousness. These trauma victims suffer from emotional dysregulation and cannot close down the disturbances when triggered (Forgash, 2004).

It is evident from the above quotation that this process can have a confusing and deeply negative psychological affect on the individual who has experienced this trauma.

3.4. Complex PTSD

The concept of complex PTSD was developed and described by Judith Herman (1992). In essence, complex PTSD refers to "profound systemic alterations." In other words, through severe trauma over a period of time the child can show radical and deep-rooted changes in his or her sense of meaning or reality. This can also lead to a sense of hopelessness in life and despair, as well as a severe deterioration in relationships. It can also result in "...failure to protect oneself, isolation, withdrawal..." And "...alterations in perceptions of the perpetrator...power balance, the victim taking on responsibility for abuse..." (Forgash, 2004). This can also lead to deep feelings of guilt and shame as well as a sense of stigma, which have other psychological implications that will be discussed in the section on eating disorders.

Simply stated, complex PTSD differs from short-term trauma"... In the duration and subsequent severity of the PTSD" (Whealin, and Slone). Therefore, this refers to chronic traumas which are repeated over a period of time - as is often the case in childhood sexual abuse. The need for a category such as complex PTSD is due to the fact that, "...Clinicians and researchers have found that the current PTSD diagnosis often does not capture the severe psychological harm that occurs with such prolonged, repeated trauma" (Whealin and Slone).

Dr. Judith Herman of Harvard University put forward this new diagnostic category to better describe the effects of long-term trauma. Chronic and complex trauma and PTSD is therefore associated with various social and psychological aspects such as domestic violence and severe physical and sexual abuse.

The above also relates to a number of general symptoms that are connected to the theory of complex PTSD and which are important to consider in terms of sexual child abuse. These include the following. The individual can experience extreme changes or alterations in the regulation of their emotions. The symptoms that are usually associated with these emotional changes include sadness as well as suicidal thoughts (Whealin and Slone). Change in the consciousness or the thought structure of the individual are also symptomatic of complex PTSD. These can include the forgetting of the abuse and trauma, as was noted in the case above, or the reliving and 'replaying' of the traumatic event. Another related symptom is dissociation or detachment from one's feelings and emotions. A concomitant symptom is the change that often occurs in terms of self-perception and self-worth as a result of the abuse. Shame and a sense of being stigmatized are often reported in cases of abuse.

An important secondary but extremely relevant symptom and outcome of complex PTSD and child abuse is the way that it determines and changes relationships with others. The child often develops a sense of mistrust of others, which can easily become habitual and impact negatively on later relationships. A symptom that is also relevant in this context is the search for a rescuer. This occurs when the child bases his or her relationships on the hope that the individual will be able to help them with their feelings and trauma. This can persist even after the abuse has ended and distort romantic and social relationships with others later in life. These are only a few of the main symptoms that have been noted in research on complex PTSD as it relates to sexual child abuse. Other symptoms refer to self-mutilation and various types of self-harm as well as substance abuse and addiction.

4. Eating disorders

The connection between eating disorders such as Bulimia and Anorexia Nervosa, as well as obesity and over-eating and sexual abuse has received increased attention in recent years. Research indicates that there is a direct link between many types of eating disorders and childhood abuse. "Survivors of childhood sexual abuse have also been shown to be at greater risk of problem alcohol use and eating disorders later in life" (Yuan, Koss and Stone).

Eating disorders such as Anorexia Nervosa are psychologically complex in terms of their causes and origins, which vary from person to person. This also applies to the problem of obesity that is being experienced in many developed countries such as the United States. As one study puts it; "The causes of the current obesity epidemic are multifactorial and include genetic, environmental, and individual factors" (Gustafson and Sarwer, 2004). One of the causative areas that have been identified in relation to the possible genesis of these disorders is childhood sexual abuse. Eating disorders are noted in many studies as one of the central sequela to this form of abuse. As one centre for the treatment of eating disorders points out, "...more than 50% of its patients have experienced trauma in their lives. The trauma is usually sexual, physical and emotional abuse" (Childhood Sexual Abuse, Trauma and Eating Disorders 2008). Of the patients at the Remuda Programs for Eating Disorders, "Forty-nine percent... have experienced childhood sexual abuse...This is about 20% higher than in the general population..." (Childhood Sexual Abuse, Trauma and Eating Disorders 2008). Furthermore, there is also in this particular program a high correlation between these patients and PTSD.

The literature also points out that comparatively few in-depth studies have been done on the relationship between childhood sexual abuse and adult obesity and eating disorders. "... additional research on the relationship between childhood sexual abuse and obesity is clearly needed, not only to address the outstanding empirical issues but also to guide clinical care" (Gustafson and Sarwer, 2004).

In brief, Anorexia Nervosa is a particularly prevalent and pernicious eating disorder that is found mainly among young females. It is described as an often chronic and even life-threatening disorder and in medical terms as "...a refusal to maintain minimal body weight within 15% of an individual's normal weight." (What is Anorexia Nervosa? 2004) Other important symptoms of this disorder include a severe aversion to being overweight, which goes hand in hand with a distorted body image. Anorexia Nervosa is "...characterized by... An intense fear of gaining weight, body image disturbances, and possible amenorrhea or temporary cessation of menstruation" (Harrison1997.p.478).

One of the central factors of this disorder is the cardinal aspect of self-image and self-esteem. It has been found in many of these cases that the individual is suffering from a low or degraded psychological self-image and self-esteem, which are crucial factors that play a decisive role in the way they view themselves. Cases of Anorexia and Bulimia are often more complex and includes social influences such as family and peer pressure. However, in relation to the aspect of sexual child abuse it is obvious that the individuals who suffer this abuse may very easily develop a low and much distorted self-image. It also goes almost without saying that the individual may blame him or her self, as was noted in the case previously mentioned, and this can also result in a very low level of self-esteem. All of these aspects can be precursors to the development of serious and debilitating psychological disorders.

Binge eating and over-eating can also be the result of various social and psychological trauma experienced as a result of childhood sexual abuse. As one study on this particular aspect emphasizes; "Research has shown that childhood sexual abuse increases binge-eating, purging, restricting calories, body shame and body dissatisfaction" (Childhood Sexual Abuse, Trauma and Eating Disorders, 2008). Very often the cause of eating disorders in children who have been sexually abused is an attempt to "help" the victim of the abuse to cope with the shame that he or she may feel. They may also need to modify their body in ways that reduce shame or distress. For example, a woman suffering from trauma and an eating disorder may wish to reduce her breast size in order to appear less feminine and therefore, less appealing to men because of her past sexual abuse" (Childhood Sexual Abuse, Trauma and Eating Disorders, 2008).

5. Alcohol and substance abuse

Many of the causes and features that were referred to with regard to eating disorders and sexual abuse apply to alcohol and substance abuse. There are numerous studies that link alcohol as well as drug abuse to earlier sexual child abuse. For example, a study by Widom and Hiller-Sturmhfel entitled Alcohol Abuse as a Risk Factor for and Consequence of Child Abuse states that, "...the experience of being abused as a child may increase a person's risk for alcohol-related problems as an adult" (Widom C. And Hiller-Sturmhfel). The study also notes that this relationship has been shown to be evident in many women who have been the victims of childhood abuse.