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Adult Manifestations of Childhood Sexual Abuse

Adult Manifestations of Childhood Sexual Abuse
Full PDF article and figures can be found here:
http://publichealth.lacounty.gov/wwwfiles/ph/media/media/TPH-409.pdf

Background

While childhood sexual abuse (CSA) continues to be a major public health problem, an equally severe and silent epidemic are the estimated 39 million adult survivors of childhood sexual abuse in the United States who continue to exhibit aftereffects of CSA that predispose them to adverse psychosocial outcomes throughout their adolescent and adult life.

Early childhood traumas such as sexual abuse can have lifelong effects throughout adulthood, and the cost to society is high. Ninety percent of cases go unreported and untreated, as the symptoms of CSA are often misdiagnosed and unappreciated.

This article attempts to provide clinicians with awareness of the neurodevelopmental effects of CSA, the adult clinical symptoms, and the adverse psychosocial outcomes of CSA. It will also present tools to help identify the aftereffects of CSA in adulthood and provide mandated reporting protocols.

Definition

Sexual abuse is defined as any sexual activity that a child cannot comprehend or consent to. It includes acts such as fondling, oral-genital contact, and genital and anal intercourse, as well as exhibitionism, voyeurism, and exposure to pornography. A central characteristic of any abuse is the dominant position of an adult that allows him or her to force or coerce a child into sexual activity. Researchers have determined that child sexual abuse victims come from all cultural, racial, and economic groups. The lack of a universal definition of CSA contributes to the complexity of data collection and estimates.

Incidence and Prevalence

Currently, CSA prevalence in the U.S. is not known, but estimates vary from 12% to 40%. Incidence studies suggest that while on average 5.5 children per 10,000 enrolled in day care are sexually abused, a greater number of children (8.9 children per 10,000) are sexually abused in their home. Further CSA studies suggest that 53% of the abuse occurs in the home, 57% report the perpetrator was a family member, and 65% report repeated abuse. Overall, studies show that 1 in 3 females, and 1 in 6 males have experienced childhood sexual abuse by the age of 18.

While nearly 90,000 cases of child sexual abuse are reported each year in the U.S., between 88%-90% of CSA cases are estimated to be unreported and interestingly, between 21%-49% of CSA victims appear asymptomatic following victimization. The lack of disclosing a history of sexual abuse contributes to the lifelong effects of the abuse.

Neurodevelopmental Damage of CSA

Controlled studies have shown that adult survivors of child sexual abuse (ASCSA) are more likely to exhibit adverse psychopathologies in adulthood, and neuroimaging studies confirm that exposure to sexual abuse in childhood alters the neurobiology and neurostructures in the brain, leading to scarring, an abnormal neurohormonal response to future stressors, and predisposes the victim to a lifetime of negative consequences.

Neurological damage from sexual abuse alters early brain development, increasing the risk for psychopathology in adolescence and adulthood (Table 1). The hippocampus, responsible for new learning and memory, plays a critical role in recording emotions that are attached to a stressful event such as sexual abuse. The hippocampus is known to be very sensitive to stress. During stress, high levels of glucocorticoids are released, and over time (as observed among CSA victims, including those re-victimized) elevated levels of glucocorticoids damage neurons in the CA3 region of the hippocampus and lead to atrophy. While the hippocampus has been shown to regenerate neurons, stress inhibits neurogenesis.

Abnormalities of the hippocampus have been shown to be associated with pathological fear, mood imbalances, and anxiety reactions in trauma-related disorders (also hallmarks among ASCSA).

Magnetic resonance imaging (MRI) studies have demonstrated a 12% left hippocampal volume size reduction among adults who have been sexually abused in childhood as compared to healthy controls (Figure 1). Similar reductions are exhibited among subjects with trauma-spectrum disorders such as depression, dissociation, PTSD, and borderline personality disorder. In addition, the amygdala, responsible for emotional and fear regulation, is affected by early sexual trauma, resulting in similar psychopathologies.

Studies suggest sexually traumatized children are also less able to utilize both brain hemispheres to process experiences. The corpus callosum, a longitudinal fissure that connects the left and right cerebral hemispheres, is shown to be abnormal in sexually abused children. Generally, the left side of the brain processes positive emotions and logical thinking, and the right processes negative emotions such as fear. When the corpus callosum is not operating properly these processes are unable to function at the same time, thus supporting theories why many abused individuals divide people into “all good” or “all bad” and exhibit mood swings, as observed in borderline patients.

Adult Manifestations of CSA

There is no adopted definition to identify the symptoms exhibited among ASCSA; however, evidence-based research has confirmed long-term effects of CSA in adolescence and into adulthood. Later in their lives, many ASCSA, whether reported or not, exhibit psychopathology, acting-out behaviors (social dysfunction), relationship problems (interpersonally), somatic symptoms, and sexual disorders.

CSA survivor studies suggest that ASCSA use health care services more often than the general population, are shown to exhibit more somatic symptoms that do not respond to medical treatment, and present more severe and complex symptoms.The response to sexual abuse during childhood varies, and is largely dependent on 1) age at onset; 2) severity; 3) duration; 4) relationship to the perpetrator; 5) the child’s resiliency; and 6) stability of and support from the family.

Childhood survivors might initially seem unaffected by the trauma; however, by adolescence and adulthood, the consequences eventually become symptomatic, resulting in eating disorders, dissociation, phobias, obsessions, borderline personality disorder, depression, anxiety, bulimia, obesity, post traumatic stress disorder, hallucinations, conduct disorder, substance abuse disorder, panic disorder, antisocial personality disorder, affective disorder, and impaired sense of self.

Behavioral Effects of CSA 

Acting out

Children are limited in their physical, cognitive, and emotional development and, thus, dependent upon adult and often sibling caregivers to provide love, trust, and support. Once a child is violated however, shame and stigma often follow, as well as fear that disclosing the abuse will result in re-victimization, loneliness and isolation, physical violence, and death. Poor coping skills are common among this cohort, such as substance abuse, tobacco use, overeating, addiction, lying/stealing, poor academic performance, expectation of early death, poor adherence to medical treatment, suicide, anger, prostitution, and increased risk of sex crimes.

Relationship problems

Controlled studies identify an association between childhood sexual abuse and adult relationship problems. Adult manifestations of CSA increase the risk of intimate partner violence victimization and perpetration, rape after 18 years of age, low self-esteem, intimate relationship problems, divorce, interpersonal problems, victim-perpetrator cycle, superficial idealization of sexual relationships, and the inability to trust others.

Somatic symptoms

Evidence illustrates that CSA also results in biophysical changes. ASCSA show a decreased threshold for pain. Other effects include a heightened sensitivity in the pelvic or abdominal region, various bowel symptoms, musculoskeletal disorders, back pain, severe headaches, gastrointestinal problems, sleep disorders, asthma, and pseudocyesis.

Sexual disorders

Adult manifestations of CSA increase adolescent and adult risk of exposure to sexually transmitted diseases, compulsive sexual behaviors, early sexual activity, extreme masturbation, sexual promiscuity, poor sexual adjustment, poor contraceptive practices, and teen pregnancy.

Functional amnesia

Functional amnesia (dissociative amnesia–dissociative disorders) can develop after severe trauma, such as child sexual trauma. This is especially true among children experiencing severe sexual trauma or in those aged 5 years or younger. Functional amnesia among CSA cases varies widely, from 19% to 88%. While theories about amnesia and delayed recall of CSA vary and may be controversial due to false memories, it is important to recognize that later in adolescence or adulthood, the victim may not recall the experience. Additionally, if the abuse occurred in middle childhood, ages 6-12, the victim may 1) develop false memories that the abuse ever occurred; 2) be in denial; or 3) be unaware that the type of experience was determined to be sexual abuse. 

Role of the Clinician

The clinician plays an important role in caring for adult survivors of childhood sexual abuse. Because the presenting symptoms can be somatic in nature, the role of CSA in the patient’s illness or presenting symptoms can be overlooked.

Despite never reporting the abuse, 85% of adult survivors of child sexual abuse favor physician screening. Directly asking patients about the occurrence of abuse has been shown to elicit more positive responses compared to self-reporting, 29% versus 7% respectively. Further, especially among adolescent patients, it is important to remember that early disclosure of sexual abuse by the victim is critical to reducing the effects of CSA and to helping reduce psychological distress later in life. Symptoms of ASCSA can vary greatly and, in fact, the patient can be asymptomatic.

Evidence-based research suggests that many interventions can be useful in this population. For example, coping-skill interventions seem to help diminish or prevent post traumatic stress disorder and related adult aftereffects of CSA. Physicians can use the SAVE universal screening tool (Table-2) for childhood sexual abuse in adulthood, developed by the Florida Council Against Sexual Violence. This useful tool screens patients for sexual violence.

Physicians should also be familiar with their own hospital, clinic, or HMO policies and procedures regarding sexual violence reporting, as well as the use of specific reporting forms. The California Medical Training Center develops instructional materials and conducts training in clinical forensic medicine techniques for physician and other health care professionals, social workers, and related reporters.

 

James M. DeCarli, MPH, MPA, CHES
Injury and Violence Prevention Program
Los Angeles County Department of Public Health

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Effects of Childhood Sexual Abuse, Part 6

Effects of abuse on children, part 6
By Paul Irby Special to the Abilenian
Abilene Reporter-News
Posted June 10, 2009 at 3:25 p.m.

Over the last five months we have examined the possible effects of childhood sexual abuse on its victims. These effects were considered with regard to the impacts on cognitive, emotional and behavioral dimensions. In this article bringing a close to this series, I would like to address some common myths or misconceptions prevalent in our society.

The first misconception to be addressed is the narrow definition often assigned to sexual abuse. A complete conception of sexual abuse should also include exposure to graphic sexual material. Exposure can include Internet, magazines and video, as well as witnessing adults engaging in sexual acts. It should be clarified that a child who accidentally wanders in on parents having sex one time will not be forever psychologically damaged. Exposure becomes damaging and abusive when sex and sexual material is available frequently, without discrimination and/or purposely targeted to the child.

The second misconception to be addressed is the notion that victims of sexual abuse are somehow destined to perpetrate the abuse on other children. While it cannot be denied that the vast majority of abusers were abused themselves, it cannot and should not be assumed that the majority of abused children will become abusers. It is understandable how this misconception can be perpetuated given the increased likelihood that most abuses (physical, emotional and neglect) are handed down intergenerationally. Physical and emotional abuse are most likely to be handed down from generation to generation because they are usually impulsively expressed through anger and modeled frequently. Neglect is a more passive abuse, and is usually intergenerational because of lack of education and intervention. Sexual abuse is different in that it usually requires premeditation and incremental “grooming.” It is this premeditative nature of sexual abuse that decreases the likelihood of intergenerational transference compared to other abuses. It should also be noted that no victim of any form of abuse is destined to repeat it.

Lastly, I would like to offer some insight to parents who might be wondering how to best respond to their child who has been sexually abused. Typically there are two extreme responses parents can have, both of which are not best for the children. The first extreme is to “sweep” the abuse “under the carpet” after the initial disclosure, the family seeks to reduce the anxiety and awkwardness of talking about the abuse modeling an unwritten rule that this subject is now somehow taboo. The other extreme is when parents begin to define their child by the abuse, and consistently bring up the subject either in direct conversation or by initiating new rules for the child, such as not being alone with friends, going to friends’ houses and not being able to spend the night with friends. The best response parents can have is to resume normalcy in the routine at home and to let the child know that the parent is concerned about how the child might be dealing with being abused and is willing to listen if the child ever desires to talk about it.

I would like to personally thank executive director Kirk Hancock and the Mental Health Association of Abilene for allowing me to contribute these articles that I hope can be used as part of the healing dialogue in our community.

Paul Irby, M.A., is a licensed professional counselor with the Ministry of Counseling and Enrichment. Mental Health Matters is facilitated by the Mental Health Association in Abilene.

Original article found here:
http://www.reporternews.com/news/2009/jun/10/effects-abuse-children-part-6/

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Effects of Childhood Sexual Abuse, Part 4

April is Abuse Prevention Month
By Paul Irby Special to the Abilenian
Abilene Reporter-News
Posted April 1, 2009 at 5:26 p.m.

April is designated as abuse prevention month for the state of Texas. Therefore, the Mental Health Association of Abilene, felt it more than appropriate to run its latest installment of the “Effects of Abuse Series.” This installment is in two parts, because there is much to consider. In the previous two articles we considered the mental and emotional impacts of abuse, respectively. The third dimension to be examined is the behavioral dimension. What kinds of behaviors are “typical” of a person who has been sexually abused? The easy and disappointing answer is that there are no “typical” behaviors, and the behaviors that will be discussed are ambiguous enough that they should not be the sole determining factor in assessing if one has been abused. However, it is a fact that the behaviors are the first thing we notice in people that cause us alarm or concern. It is also important to clarify that behaviors are the end result of the “chain reaction” we have been discussing between thoughts/beliefs, feelings and behaviors.

The underlying belief that fuels those feelings of depression, anxiety, fear, anger, shame and doubt is the belief that he/she is “different” from others; that he/she is alone in this struggle and if anyone truly knew his/her plight, they would not value him/her. One of the most common manifestations of these beliefs and emotional responses is in the abused creating a persona of anger and aggression. This persona is in reality a wall meant to communicate to the world, “keep out!” and “if you don’t stay away, I’ll make sure you regret trying to get close.” Males will tend to be more physically aggressive while the females are more likely to be more verbally aggressive. Both are the result of a brooding anger which ultimately can be traced back to the fear of being betrayed, hurt, exploited and victimized again.

Depression and anxiety can lead to behavior manifestations like withdrawal, self-injury and suicidal ideations and attempts. Withdrawal is a common behavior in abuse victims. If the abuse begins at an early age and is chronic, this withdrawal may go unnoticed and explained away as a personality trait. Withdrawal is more noticeable in children between the ages of 8-18 because there is an already established pattern of social interaction. Self-injury is most common in adolescent females and takes the form of surface-level cuts on the forearms, abdomen, pelvis, or underneath the breast. The purpose of the self-injury is usually to achieve a sense of release reinforced by the initial shot of pain and subsequent presentation of blood. Many who engage in this behavior find it difficult or unacceptable to cry because crying leaves one with feelings of vulnerability, which is interpreted as weakness. Crying can also become uncontrollable, which again frightens the abuse victim, who often desires to have control in a life that seems so chaotic. The child who engages in self-injury believes they can control the cutting and therefore believe it to be a safe alternative. The self-injury then becomes another secret that has to be hidden and protected. In some ways this can relate back to the aspect of control, the cutter has control over the secret, but ultimately it becomes one more stressor which maintains the need to alleviate that stress. Self-injury can also be used as a form of self-punishment motivated by feelings of worthlessness. These feelings of worthlessness, when coupled with pent-up anxiety, depression, and fear, can lead to thoughts and attempts at suicide.

In the next installment we will look inside the possible sexual manifestations of a sexually abused child and how abuse can lead to substance and process addictions.

Paul Irby, M.A., is a licensed professional counselor with the Ministry of Counseling and Enrichment. Mental Health Matters is facilitated by the Mental Health Association in Abilene.

Original Article found here:
http://www.reporternews.com/news/2009/apr/01/april-abuse-prevention-month/

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Effects of Childhood Sexual Abuse, Part 3

Effects of abuse, part 3
By Paul Irby Special to the Abilenian
Abilene Reporter-News
Posted February 4, 2009 at 1:08 p.m.

This third article in the series of six reflects what can be called a continuation of a chain reaction beginning with the cognitive impacts discussed last month, which lead to the emotional experiences discussed in this article. The most common emotional experiences a sexually abused child encounters include fear, anxiety, anger, guilt and shame.

Fear and anxiety are closely related emotions. Many of their physiological and psychological experiences are identical. Fears and anxieties experienced by an abused child can be specific to gender, age range, status or race. When these fears are category-specific it is most likely tied to associations with the abuser. Fears and anxieties can also be more broad and general. Common generalized fears of abused children include the fear of their secret being found out, being rejected by peers and being emotionally vulnerable which would ultimately lead to being betrayed by someone else.

I recall working with a 23-year-old man who had been sexually abused by his mother from the age of 6 until the age of 21. One of the main reasons for his desire to seek therapy was “feeling angry all the time.”

I explained to my client that when I hear someone make such an assertion that my mind immediately returns to what I know to be the nature of anger. Anger is a secondary emotion. Quite literally, what that means is that anger is what we feel second in the sequence of emotional experience. Most often what is felt first is some kind of fear. This is only true of genuine anger, not frustration or irritation.

Think back to your own experience of being cut off in traffic. We can easily identify the feelings of anger toward that driver and our subsequent desires to express that anger. If someone were to ask you how you felt after being cut off, you would probably frame this experience as one that prompted anger. However, if we were to trace back the very first emotional experience, it would be one of fear. For the driver, it is the fear that the vehicle or self might be hurt, and the fear quickly manifests itself into anger. So, when I heard my client contend that he was “angry all the time,” we began a discussion of what fears are present that lead to his consistent feelings of anger. In reality one who has been abused, who walks around angry “all the time,” is living with pervasive fear. Anger was the way in which this person chose to protect himself from the fears becoming a reality.

Guilt and shame are often used interchangeably in our language, but an important distinction was made to me by one of my wise clients. He defined guilt as “believing you did something bad” and shame as “believing you are a bad person.” When considered in the framework of one who was sexually abused as a child, this is one of the biggest lies he or she can believe. While much of our society can look from the outside in to another’s experience and logically make a case finding fault in the abused child’s reactions or responses, these outsiders are wrong. Often they will say things like, “well you shouldn’t have kept it a secret so long,” not recognizing the power of intimidation, fear and humiliation that maintains the secret. Abusers use sick “logic” to rationalize abuse, claiming that the child “flirted” with them or “wanted it as much as they did.” These abusers fail to recognize their humane responsibility as adults to the welfare of children, and often confuse affection for sexual advancement.

Survivors of abuse will internalize these inaccurate beliefs that result in feelings of guilt and shame. Children should never be blamed for abuse perpetrated against them.

Paul Irby, M.A., is a licensed professional counselor with the Ministry of Counseling and Enrichment. Mental Health Matters is facilitated by the Mental Health Association in Abilene.

The original article can be found here:
http://www.reporternews.com/news/2009/feb/04/effects-abuse-part-3/

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Effects of Childhood Sexual Abuse, Part 1

April is designated as abuse prevention month for the state of Texas.  Therefore, the majority of posts for this month will orbit around childhood abuse and the effects of such abuse.  I pray that our world can come to a place where no child is ever abused again!

Effects of abuse, part 1
By Paul Irby Special to the Abilenian
Abilene Reporter-News
Posted December 3, 2008 at 11:21 a.m.

It seems the sexual abuse of children is an epidemic in our society. This evil respects no boundaries of gender, race, ethnicity or socioeconomic status. The Mental Health Association of Abilene recognizes thousands of people in the Big Country have been impacted by this epidemic. Therefore, executive director Kirk Hancock has commissioned the penning of six articles over the course of six months for the purpose of educating the general public regarding the potential developmental impacts of sexual abuse on its victims.

When approaching the discussion of this subject, it is important to note there are no standard or predictable outcomes, and some seem to adjust better post-abuse than others.

For the next five months, Mental Health Matters will have articles highlighting how specific dimensions of a person can be impacted by sexual abuse. These articles will take a “shotgun” approach to describing potential impacts. It should be noted not all survivors of sexual abuse will experience all the effects discussed, and the intensity with which others endure their respective impacts will differ. Therefore, it stands to reason that we first answer the question of what factors influence the intensity of the adverse developmental impacts on a child who has been sexually abused.

The duration and frequency of the abuse is one important component to consider. Some children experience the abuse on a daily, weekly or monthly frequency for a duration of months or years. Others have endured less chronic or isolated instances of abuse. It is this latter group that has the least amount of susceptibility to adverse consequences down the road.

Another consideration is the kind of abuse perpetrated. Survivors with the most intense developmental impacts are those who sustained penetration orally, anally or vaginally. The invasive nature of these acts adds to the already deep sense of violation, both physically and psychologically. Sexual abuse can include less invasive, yet still horrific, forms such as manual stimulation and groping over the clothes.

The response of adults to the child’s disclosure of the abuse is another vital piece to understanding the resilience of some abused children.

Common mistakes parents and other significant adults make when a child musters the courage to disclose the abuse are not believing the child, blaming the child or defining the child by the abuse. The lack of support, blame and even punishment of the child can have just as devastating impacts as the actual abuse.

Other factors include the age and temperament of the child, the presence of violence or intimidation, along with the sexual abuse and the relationship of the abuser to the abused.

While nothing positive exists in an abusive situation, there are “best case” scenarios. Bear in mind, even children who come from a “worst case” scenario who access quality professional help and have a solid social support system can not only survive, but thrive.

Next month we will explore possible mental or cognitive impacts sexual abuse can have on a child.

Paul Irby, M.A., is a licensed professional counselor with the Ministry of Counseling and Enrichment. Mental Health Matters is facilitated by the Mental Health Association in Abilene.

Original article found here:
http://www.reporternews.com/news/2008/dec/03/effects-abuse-part-1it-seems-sexual-abuse-children/