Medical and Psychosocial Consequences of Childhood Sexual Abuse

1. Medical and Psychosocial Consequences of Childhood Sexual Abuse Laura S. Brown, Ph.D. Argosy University Seattle Lbrown@argosyu.edu

2. What is sexual abuse of children? • CSA (Childhood Sexual Abuse) ranges on a continuum, and includes: • Any sexual contact between an adult and minor child, including exposing self to the child, voyeurism of the child, use of child for pornography • Sexual contact between a much older (six+ years) minor and a younger, minor child • Violent sexual assault of a child by a person of any age

3. What is sexual abuse of children? • CSA may happen once to a child (most common when perpetrator is a stranger) or be a repeated event that happens regularly over many years of the child’s lifetime (most common when perpetrator is a trusted family member, teacher, clergy, coach or other person with regular sanctioned contact- this form is frequently accompanied by other forms of family dysfunction) • CSA occurs across culture, social class and ethnicity; it is an equal opportunity problem

4. Why Does CSA Happen • CSA reflects deeply held cultural norms about children as the possessions of adults, as well as the eroticization of youthfulness, dependency, and helplessness. • Perpetrators act from many motives • Pedophilic arousal (the minority) • Inability to acknowledge child as separate person • Anger at child or at another person (frequently the mother of the child)

5. How common is CSA? • Studies of the general population, using broad definitions, find that around 38% of women and 25% of men report a history of CSA. Using more narrow definition that involve only contact CSA, around 25% of women and 19% of men report CSA. • In clinical populations, these rates increase. For example, among a random sample of psychiatric patients, 75% had a CSA history • In prison populations, rates are also high. At the Washington Women’s Correctional Center, 85% of the women reported a history of such victimization in a survey conducted by the state.

6. Who are the victims and perpetrators? • CSA cuts across all lines of race, class and gender. Girls and boys are both victimized. • Perpetrators also come from all backgrounds, although 95% of known perpetrators are male. Of female perpetrators, a large number are co-perpetrators with men • Most perpetrators are known to the child; a family member, family friend, teacher, pediatrician or other health care provider, coach, clergy person.

7. Who are the victims and perpetrators? • CSA is a crime of access to children. Many perpetrators of CSA identify themselves as heterosexual, are married, and have a history of normal sexual functioning. • Only a small percentage are “fixed” pedophiles who are sexually attracted only or primarily to children. Most perpetrators do not have a history of CSA. • CSA is largely about power, and only rarely about the sexual arousal of the perpetrator (see the work of Anna Salter for more data on perpetrators)

8. What are the effects of CSA? • The effects of CSA are complex. They depend on: • the age and developmental stage (or stages) at which the CSA occurred • the age when CSA ended, • the frequency of sexual acts • whether or not penetration occurred • the relationship of the perpetrator to the victim (how much betrayal of trust occurred) • the presence or absence of parental support • the nature of the family context • Chaotic family context or other co-occurring forms of maltreatment will increase the risk loading of CSA

9. What are the effects of CSA? • There is no one symptom or syndrome, either physical or psychological, that results from CSA. Many of the problems for which CSA is a risk factor can have other comorbid risk factors. • Because CSA is a complex stressor and occurs at many different developmental points, there are multiple trajectories, biologically and psychosocially, for survivors

10. CS A Effects in Children • Children who have been sexually abused may manifest a range of behavioral problems, including loss of toilet training and other age-regressed behaviors, excessive masturbation to the point of self-harm, sexualized and inappropriate behaviors with peers and adults, depression, anxiety, and fearfulness. • However, the child who dissociates CSA may be asymptomatic, or develop symptoms long after CSA has ended. Prospective longitudinal studies suggest that this is a common trajectory post-abuse.

11. What are the effects of CSA? • Long-term effects in adolescent and adult survivors include psychiatric disorders (Depression, anxiety disorders, dissociative and post-traumatic disorders, specific phobias, personality disorders) as well as medical illness (increased rates of IBS, chronic pelvic pain, genitourinary complaints, autoimmune disorders). • Recent research indicates long-term neurobiological effects of childhood maltreatment are responsible for both psychological and psychosomatic disorders arising from a CSA history • Specific areas of current research include cortisol levels, changes to brain structure (hippocampal volume), effects on HPA axis functioning

12. CSA in a Medical Patient Population • People with a history of severe childhood maltreatment utilize medical care services at extremely high rates. The patient with frequent, vague complaints, autoimmune disorders, or difficult to diagnose problems is frequently a person with a history of CSA.

13. What are the effects of CSA? • Pregnancy in adolescents is highly correlated with a history of CSA. Pregnant CSA survivors of any age may face special emotional challenges related to pregnancy and childbirth (see work of Julia Seng). • People who have difficulties practicing safer sex are likely to have higher rates of CSA histories

14. Compulsive Coping Strategies • Adults with a history of CSA frequently use compulsive behaviors- substance abuse, disordered eating, compulsive sexuality, compulsive overwork- as coping strategies for handling their emotional distress. Thus, they may have appeared to be high-functioning both in childhood and in some parts of adulthood, especially if overwork was the preferred coping strategy.

15. Effects of CSA • Because many of these coping strategies have health risks associated with them, physicians will frequently make attempts to intervene at the behavioral level (e.g., counseling to stop smoking or eat less) • Patients who experience anxiety or depression when attempting to reduce compulsive behaviors may be CSA survivors • CSA survivors may experience extreme challenges in stopping health risk behaviors

16. Findings of longitudinal prospective studies • Putnam (1998) studied 77 CSA children, compared with 15 maltreatment/no CSA and 72 no maltreatment children over 20 year period • Assessed psychologically and physiologically at 2 year intervals • Described “sleeper effects”

17. “Sleeper Effects” of CSA • ADHD in later childhood • By adolescence • Alcoholism • Anxiety disorders • Depression • Suicidality • Self-harm • Hypersexuality • Earlier age of first intercourse • Multiple somatic problems, including pain complaints • These are the children who appeared to be asymptomatic immediately post-abuse

18. More longitudinal studies • Widom (1999) followed sample of 1575 poverty-class children, majority Caucasian for 20 year period; 96 had CSA • Compared to physically abused, neglected, and no-maltreatment children in sample, CSA survivors were • More suicidal • More depression • More substance abusing • More lifetime and current PTSD

19. Can people not remember CSA? • Yes. Although the underlying mechanism is unknown post-traumatic amnesia, for CSA and other trauma, is a well-documented phenomenon. • There is no relationship between a memory being continuous, and how accurate it is. • Patients who present with somatoform dissociative symptoms (e.g., psychogenic pain) commonly have unacknowledged CSA histories

20. Memory for Abuse • Most reports of long-delayed recalls of CSA can be corroborated and many have been (for an interesting list of cases, check out the Recovered Memory Website, at:www.brown.edu/Departments/Taubman_Center/Recovmem/Archive.html) • However, is it also possible to believe that abuse happened when it did not (although there are few completely erroneous reports, and there is not a False memory syndrome)

21. Do children ever make false reports? • Infrequently, but yes. Most completely false reports occur in the context of child custody evaluations • Some children misinterpret, or are misinterpreted when they describe behavior that is not CSA. Careful evaluation usually leads to clarity in such cases. • Despite media reports, most erroneous reports are not due to suggestive interviewing, and current interview techniques (for instance, the Cognitive Interview) carefully guard against suggestion.

22. What does treatment involve? • Somatic treatment, such as antidepressant, mood stablizing or anxiolytic medications- these are frequently prescribed by the primary care provider, not psychiatrists • Psychotherapy, including EMDR and Prolonged Exposure • Group therapy • Self-help groups • Treatment can be highly effective in assisting people to recover from effects of CSA • Treatment for children will commonly involve the family

23. What is the job of the primary care MD? • If a child reports CSA, you must call Children’s Protective Services within 48 hours in Washington State; times will vary elsewhere • If you suspect CSA, you must call CPS within 48 hours. Your suspicion can be based on a number of things; physical signs (a child with an STD, torn anal or vulva tissues, unusual redness in the genital areas) or because a child shows many possible CSA effects behaviorally.

24. What is the job of the primary care MD? • It is never the job of the physician or other primary health care provider to ascertain the accuracy of the report. Non-reporting when there is reasonable suspicion is a violation of law. • For good patient care, it is helpful to let parents know that you are calling CPS, even, or especially, when a child has accused one of the parents of committing CSA • If an adult reports a history of CSA, you must determine whether the perpetrator has current access to children. If so, a CPS report may also be in order. However, in general, adult retrospective reports of CSA do not trigger a CPS report

25. References • Putnam, F. (1998, March). Developmental pathways in sexually abused girls. Presented at Psychological Trauma: Maturational processes and psychotherapeutic interventions, Harvard Medical School, Boston MA. • Widom, K.S. (1999) Posttraumatic stress disorder in abused and neglected children. American J. of Psychiatry, 156, 1223-1229.