ARCHIVED: Chapter 2: Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse – Background information

Background Information about Childhood Sexual Abuse

Definitions

While the sexual exploitation of children and adolescents is a criminal act, legal definitions of childhood sexual abuse vary across jurisdictions. There is, however, wide agreement that childhood sexual abuse involves: (a) sexual acts with children and youth who lack the maturity and emotional and cognitive development to understand or to consent; and (b) "an 'abusive condition' such as coercion or a large age gap between participants, indicating lack of consensuality."62p.32 In general, children and younger adolescents are unable to consent to sexual acts with adults because of their lack of maturity and relative lack of power.* An abusive condition implies a difference in power between the perpetrator and the victim. Children can also be abused by other children or adolescents who have more power by virtue of age, physical strength, life experience, intelligence, authority, or social location. The Canadian Incidence Study of Reported Child Abuse and Neglect tracked eight forms of child sexual abuse: penetration (penile, digital or object penetration of vagina or anus), attempted penetration, oral sex, fondling of the genitals, adult exposure of genitals to child, sexual exploitation (e.g., involving child in prostitution or pornography), sex talk (including proposition of a sexual nature and exposing a child to pornographic material), and voyeurism.168p.38-39

An abusive condition implies a difference in power between the perpetrator and the victim.

An extreme and controversial type of abuse is ritual abuse, which has been defined as psychological, sexual, and/or physical assault on an unwilling human victim, committed by one or more individuals, as part of a prescribed ritual that achieves a specific goal or satisfies the perceived needs of their deity.^27,140

Childhood sexual abuse survivors

The great paradox of childhood sexual abuse is that, while it has become more prominent in the public consciousness, it remains shrouded in secrecy. Media coverage of high-profile disclosures and investigations provide evidence that childhood sexual abuse does exist - in "good" families and "trusted" institutions, at all socioeconomic levels, and among all racial and ethnic groups. Frequently we hear and read stories about survivors who are men and women from all walks of life - students, sports figures, clergy, entertainers, educators, police officers, judges, politicians, and health care practitioners. They are our friends and neighbours, our colleagues, and sometimes even ourselves or members of our own families. Despite this prevalence, most childhood sexual abuse survivors are invisible to us, particularly given that it is estimated that fewer than half disclose their abuse to anyone.62,105 Some are silent because they fear reprisal from their abusers; others worry they will not be believed or that they will be blamed or even punished.56,113 Still others say nothing because they harbour the erroneous belief that they are responsible for their abuse.

The most current and reliable lifetime prevalence estimates are that as many as one third of women and 14% of men are survivors of childhood sexual abuse.^25,31,62

Childhood sexual abuse survivors are our friends and neighbours, our colleagues, and sometimes even ourselves or members of our own families.

Perpetrators of childhood sexual abuse

Individuals who are sexually abused as children are, in adulthood, men and women of diverse ages, ethnicity, occupation, education, income level, and marital status.^{16,31,48,73,114,139} Most studies of sexual offending have focused on males as perpetrators. Although the majority of perpetrators of childhood sexual abuse are male,^31,48,49,60 recent research suggests that females engage in sexually abusive behaviour with children more often than has been previously recognized.^31,48,60 Common to all perpetrators is that they have more physical strength, social power, and/or authority than their victims.

As many as one third of women and 14% of men are survivors of childhood sexual abuse.

The most recent report of the Canadian Incidence Study of Reported Child Abuse and Neglect - 2003^168p.53 found that, in contrast to physical abuse of children, non-parental relatives constituted the largest group of perpetrators (35%) of child sexual abuse. Other groups of perpetrators include the child's friend/peer (15%), stepfather (13%), biological father (9%), other acquaintances (9%), parent's boyfriend/girlfriend (5%), and biological mother (5%).

The dynamics of childhood sexual abuse

All sexual encounters with children are intended to meet the needs of the perpetrator, with little consideration for their effect on the child. Some child abusers use physical force or explicit threats of harm to coerce their young victims into compliance, while others develop long-term relationships with their victims and carefully groom them with special attention or gifts. While childhood sexual abuse does not always involve physical injury, it is a violation of body, boundaries, and trust²³ and is typically experienced as traumatic.⁸¹

While people who report a history of childhood sexual abuse are at increased risk for a wide range of difficulties in adulthood, studies suggest that "in the region of 20% to 40% of those describing CSA [childhood sexual abuse] do not have measurable adult dysfunction that could be plausibly be related to abuse."^60p.89,61 A number of factors affect how a particular individual may respond to childhood sexual abuse. Some of these include the gender of the perpetrator, the number of perpetrators, the nature and closeness of the relationship between victim and perpetrator, the duration and frequency of the abuse, characteristics of the abuse itself (e.g., contact vs. noncontact, penetration, etc.), the use of threats or force, and the age of the victim at the time of the abuse.^18,29,31

Childhood sexual abuse and health

While not everyone who reports a history of childhood sexual abuse develops health problems, many live with a variety of chronic physical, behavioural, and psychological problems that bring them into frequent contact with health care practitioners. Because health care practitioners do not routinely inquire about childhood sexual abuse, its long-term effects are under recognized, its related health problems are misdiagnosed, and it is often not met with a sensitive, integrated treatment response.

Childhood sexual abuse often co-occurs with other types of childhood adversity, including physical abuse, marital discord, separation from or loss of parents, parental psychopathology and/or substance abuse, and other types of abuse/neglect.^31,60,108 Even when these other types of adversity are controlled for, childhood sexual abuse remains a powerful predictor of health problems in adulthood.^{30,33,145,183} It is suggested that the underlying mechanism for these difficulties is "that childhood sexual abuse causes disruptions in the child's sense of self, leading to difficulty in relating to others, inability to regulate reactions to stressful events, and other interpersonal and emotional challenges".^108p.753 Kathleen Kendall- Tackett^93p.716 describes behavioural, emotional, social, and cognitive pathways by which childhood abuse affects health, pointing out that "adult survivors can be affected by any or all of these, and the four types influence each other. Indeed, they form a complex matrix of interrelationships, all of which influence health." In addition, research in the fields of immunology, endocrinology, and psychosomatic medicine has demonstrated clear physiological relationships among stress, illness, and disease (e.g.,^{71,95,101,104).}

Because most health care practitioners do not routinely inquire about childhood sexual abuse, its long-term effects are under recognized, its related health problems are misdiagnosed, and it is not met with a sensitive, integrated treatment response.

Table 1 lists the findings of a number of studies that have examined the correlation between histories of childhood sexual abuse and later health and function. Considerably more studies have examined these relationships in women, and when male survivors have been studied, the relationship between past abuse and the mental health of male survivors has been the primary focus. Guy Holmes, Liz Offen, and Glenn Waller⁸⁵ argue that two pervasive myths - that males are rarely sexually abused and that childhood sexual abuse has little effect on males - deter boys and men from disclosing their abuse and, in turn, prevent society from legitimizing it as a problem. The increasing societal recognition of the prevalence and seriousness of sexual abuse of boys is likely to lead to further investigation of physical health correlates.

Two pervasive myths - that males are rarely sexually abused and that childhood sexual abuse has little effect on males - deter boys and men from disclosing their abuse and, in turn, prevent society from legitimizing it as a problem.

TABLE 1 - Correlates of childhood sexual abuse and measures of health and function: A selected list of findings from research studies

In females, a history of childhood sexual abuse or a range of childhood traumas including sexual abuse is correlated with:

• poorer physical and mental health and a lower health-related quality of life than non-traumatized individuals^59,145,176
• chronic pelvic pain ¹²⁹
• gastrointestinal disorders ^53,141
• intractable low back pain ¹⁴⁶
• chronic headache ⁵⁸
• greater functional disability, more physical symptoms, more physician-coded diagnoses, and more health risk behaviours, including driving while intoxicated, unsafe sex, and obesity¹⁷⁶
• ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease ⁵⁹
• high levels of dental fear ^177,185
• greater use of medical services ^{35,87,102,116,150,178}
• drug and alcohol use, self-mutilation, suicide, and disordered eating ¹⁵⁶
• adult onset of 14 mood, anxiety, and substance use disorders ¹⁰⁸
• higher rates of childhood mental disorders, personality disorders, anxiety disorders, and major affective disorders, but not schizophrenia¹⁵⁴
• diagnosis of Borderline Personality Disorder ^79,82,100

In males, a history of childhood sexual abuse is correlated with:

• anxiety, low self-esteem, guilt and shame, depression, post-traumatic stress disorder, withdrawal and isolation, flashbacks, dissociative identity disorder, emotional numbing, anger and aggressiveness, hypervigilance, passivity and an anxious need to please others^{22,28,32,45,147}
• adult onset of five mood, anxiety, and substance use disorders ¹⁰⁸
• substance abuse, self-injury, suicide, depression, rage, strained relationships, problems with self- concept and identity, and a discomfort with sex^{49,54,133,161}
• increased risk of HIV ⁵
• anxiety and confusion about sexual identity and sexual orientation ^85,133
• increased risk of "acting out" aggressively ⁸⁵
• contact with criminal justice system ^85,96

* According to the Criminal Code of Canada, when sexual activity is exploitive (such as sexual activity involving prostitution, pornography, or a relationship of trust, authority or dependency) the age of consent is 18. For sexual activity which is not exploitive, the age of consent is 16 years. The exceptions are that a 12 or 13 year old can consent to engage in non-exploitive sexual activity with another person who is less than 2 years older; and a 14 or 15 year old can consent to engage in non-exploitative sexual activity with another person who is less than 5 years older. A 14 or 15 year old can also consent to engage in sexual activity with a person to whom they are married. These laws governing the age of consent for non-exploitative sexual activity came into force on May 1, 2008. Transitional provisions allow 14 and 15 years old who were in common-law relationships on May 1, 2008, to continue engaging in non-exploitative sexual activity.