Caring for Survivors of Childhood Sexual Abuse in Medical Practice

Medicine and Health Rhode Island, Dec 2003 by Jenny, Carole, Roesler, Thomas A

Surveys of adults in 21 countries have shown 7 to 36% of women and 2 to 29% of men reporting unwanted sexual contact in childhood.1 In Rhode Island, the Department of Children, Youth and Families confirmed 310 cases of child sexual abuse in 2001.2 This most likely represents "the tip of the iceberg", since most abused children do not disclose in childhood.

A history of sexual victimization can cause long-term physical and psychological problems for survivors. Adults victimized as children may not volunteer their histories to their physicians. One study of women seeking care in a Seattle primary care clinic found that, when asked, 37% reported sexual abuse in childhood. Although most of the women believed it was appropriate for their physician to ask about sexual victimization, only 4% said they had been asked.3

Childhood sexual abuse is one of the root causes of many subsequent problems. Sexual abuse is experienced by children as a traumatic event, and children are affected by this trauma in many ways. First, since most abusers are known to their victims, the abuse disturbs their relationships. Many children experience this as a profound loss, especially if the abuser is a close family member. Second, the actual abuse events are experienced by the child as physically and psychologically traumatic. Third, the child often experiences prolonged apprehension, guilt and fear between sexual contacts. One expert summarizes the child's experience: ". . . the pervasive, sustained stress . . . (is) . . . most pronounced in domains of self-development, specifically in terms of the development of physical and psychological self-integrity, and the development of self-regulatory processes, particularly regulation of affect and impulse control. Sexual abuse . . . violates the child's basic beliefs about safety and trust in relationships, disturbing both the sense of self and the ability to have satisfying relations in which one feels loved and protected."4

PSYCHOLOGICAL EFFECTS OF SEXUAL ABUSE

The long term effects of child sexual abuse can be broken down into individual physical and emotional components. The following mental processes are often reflected in the abuse survivors' presentation in the medical setting.

Post-traumatic stress disorder (PTSD): Abuse survivors frequently re-experience their trauma through nightmares, flashbacks or intrusive thoughts. Other manifestations of PTSD include avoidance or numbing of general responsiveness and persistent symptoms of increased autonomie arousal.

Cognitive distortions: Adult survivors often blame themselves for their abuse. They can feel hopeless, helpless, and out of control of their lives. Low self esteem is often a problem.

Emotional distress: Depression is much more common among sexual abuse victims than among those not victimized.5 Suicidal behavior, anxiety, phobias and panic attacks are also common.6 Anger, criminal behavior, and sexual offending are more common among victims, especially male victims.

Impaired sense of self: Sexual abuse survivors have an increased rate of victimization as adults. They often lack appropriate boundaries and have an impaired sense of personal risk in interpersonal situations.

Avoidance: The most striking aspect of childhood sexual victimization is its role in the development of dissociative phenomenon and dissociative identity disorder. Children abused at a veiy early age are more likely to develop dissociative states as a coping mechanism for their abuse, and this dysfunctional coping with stress can persist into adulthood. Other avoidant behaviors such as drug abuse and alcohol abuse ("chemical dissociation") are more common in abuse survivors.7 Tension-reducing activities such as self-mutilation and bingeing and purging are also more frequently found in victims of childhood sexual abuse.

Interpersonal difficulties: The lack of ability to trust others can lead to unstable marriages, increased divorce rates, sexual dysfunction and social isolation.8 Sexual objectification can lead to prostitution. In fact, studies of adult prostitutes show that child sexual abuse doubles the risk of a woman becoming a prostitute.9

EFFECTS OF CHILDHOOD SEXUAL ABUSE ON THE NERVOUS SYSTEM AND NEUROENDOCRINE RESPONSES

Recent research suggests that chronic childhood trauma such as sexual abuse can significantly alter the body's response to stress years after the trauma ends. Two mechanisms mediating these effects have been studied, the regulation of the hypothalamic-pituitary adrenal axis and autonomie nervous system, and actual changes in brain volume and function.

DISREGULATION OF THE HYPOTHALAMIC-PITUITARY-ADRENAL AXIS.

Sexually abused girls excrete significantly greater amounts of urinary catecholamines than non-abused girls.10 Women with a history of abuse have been shown to have elevated ACTH levels, higher cortisol production, and higher heart rate increases compared to non-abuse women, when subjected to a psychosocial stress induction exercise, presumably due to hypersecretion of corticotropin-releasing factor.11 Severe early life stress can cause a persistent autonomic stress response. This 'hyper-reactivity' is thought to make adults vulnerable to psychopathology such as anxiety and depression.