(There is a new blog page with a glossary of terms related to sexual abuse that may be helpful in reading this post. The terms in the glossary are underlined.)
This blog title is from a song by Craig Finn. He describes in his song-story telling way his distancing from a self-destructive friend who once helped him when he first came to New York. The title, and the pain in the song, remind me of a subject I dealt with too often both professionally and personally- the sequelae of child sexual abuse (CSA). While my experience is large, I wanted to find serious, academic material on this painful subject.
CSA does not appear in the pyschological or medical literature in any meaningful way until the early 21st century. There are papers from the 1980s, but few. These papers are limited by relatively small sample sizes and problems with long-term follow-up, as well as the type and duration of abuse and the background setting of family dysfunction.
Since I do not provide care for children, my major interest and experience has been with the adult sequelae of CSA. In my practice, these women have usually stood out. Their reactions to Gyn exams are unusual, with decathection and excessive fear common. Many of these women have somaticization (the expression of emotion as physical complaints), and some sexualize the exam.
Since sexual abuse was something not spoken of in public until the late, late 20th century, many women with CSA histories have kept them secret, or are profoundly ashamed of their stories. Self-blaming is common, especially since the sexualization of a relationship with a child brings the child attention they enjoy. The power dynamic distortion and conflicts about sexuality lead to many adult manifestations of CSA besides unusual reactions to exams.
As a group, CSA survivors have more sexual partners and less relational stability. Short relationships and divorces are common, with divorce rates exceeding 70% in most papers. Multiple divorces are also common, as these women tend to make poor relational choices. The reasons for this are not clear. What is clear is that CSA can often not be readily separated from familial dysfunctions like drug and alcohol abuse, and other forms of abuse such as verbal and physical injuries.
Women with a pure history of CSA, without other forms of abuse or continuation into adolescence, actually have little different lives than most women. The most damaged, and most complex cases, are in those women where abuse continued into adolescence or recurred with different abusers. Thus the woman abused as a child, then raped as a teen has a far, far worse outcome than the woman abused as a child who has no further abuse contacts.
Unlike news stories, women are the perpetrators in 5-20% of CSA. The most common perpetrators are mothers and teachers. Mothers show little sexual preference in their victims, abusing daughters as much as sons, while teachers show a marked preference for male targets. In broad studies of Catholic church abuses the only stories reported are about priests, but nuns were 5% of perpetrators.
Psychiatric diagnoses are common among CSA survivors. Common ones include PTSD, depression, anxiety, dissociative disorders, schizoid symptoms (Schneiderian symptoms), somatiform disorders, and conversion symptoms. In one paper the incidence of dissociative symptoms was 88%, with 51% fulfilling the criteria for dissociative personality disorder. Among women with CSA there are many more claims of ESP, supernatural abilities such as being able to 'see' demons and 'Evil', and many associated physical complaints without objective basis (somatiform complaints) such as migraines and generalized aches and pains. Predictably, certain other diagnoses often used as catch-alls for such symptoms are much more common, such as chronic fatigue syndrome and fibromyalgia. Self-mutilation is also much more common. Borderline personality traits are far more common as well.
For women with CSA histories, female role-defining events can evoke depression, marked anxiety and worse. These include marriage, childbirth, menopause, aging changes, and menarche.
Sexuality is often greatly affected. Decathection or even dissociation during sex is common, with traumatized partners 'zoning out' or 'disconnecting'. Orgasm may be difficult or impossible via intercourse, and achieved only by masturbation during sex or alone. The dissociation so prevalent among abused women, combined with the common seeking of comfort from multiple partners, leads to women who are often found 'flirtatious' or 'sexy' but who are mechanical and detached during sex itself. They are often described as 'clinical' in their sexuality, objective and even cold rather than interpersonal. Sex may be viewed by these women as what they are good for, a duty they must fulfill, a way of gaining affection, or an unpleasant chore. Regardless, sexual dysfunction and relational dysfunction are extremely common.
Fear of abandonment is much more common in these women. Despite this, the multiple relational and sexual dysfunctions leads to numerous, short relationships, thus confirming and extending fears of abandonment. Patience is universally advised when interacting with these women, as the process of recovery commonly takes years. Sadly, most intimate partners will not stick around that long to work through these women's pervasive social and sexual problems, or they withdraw emotionally.
Treatment for these individuals is severely lacking in quantity and quality. Insurance coverage of psychiatric counseling is poor, leading to use of unqualified counselors with agendas beyond helping their clients. Church or religious counseling is a common resort, but most of these 'counselors' have no training in dealing with the many psychiatric and sexual problems with which these people present. Their nostrums generally include exhortations to conform to social and religious paradigms that may put greater psycho-social stress on the patient and confirm their already bad self-image. Unusual religious beliefs or cultish experiences are also common, as these individuals seek some kind of source of emotional and spiritual comfort. Gurus, self-help books, 'therapy' sessions with spiritual guides, etc, etc are sadly common and unhelpful. Most psychiatric 'care' consists of brief medication appointments to deal with symptomatology rather than causation, leading CSA survivors to doubt or reject their diagnoses and claim they are well, further removing them from therapeutic options.
The intimate partners of these women typically cannot endure the repeated withdrawals, aggression and dissociative actions of survivors of CSA. Like Craig Finn's song, whose speaker cannot keep saying thank you for a favor done years ago, the intimate partners of these women often cannot remain in relationships where they are repeatedly abandoned, attacked, and criticized. They withdraw in self-protection, leaving the abused woman feeling even worse than before and reinforcing her distorted relational beliefs.
All of this is so sad and painful that society does not want to recognize or address the problem in any meaningful way. CSA is like the lightning that hits a tree when it is young. The tree may survive, but its shape and growth are altered forever. In just this way, CSA alters lives throughout life. If a person is to become emotionally or sexually involved with a survivor of CSA, it is important to recognize there will be many unpleasant and apparently inexplicable behaviors. The relationship will be variable and often very unstable. Prolonged therapy of high quality will be necessary for these individuals, and even then their relationships and responses are likely to be altered compared to unabused individuals.
Here are links to selected high-quality studies on this problem-
-https://www.ncbi.nlm.nih.gov/pubmed/8221221
-https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1401228/
-https://www.goodtherapy.org/blog/impact-of-childhood-abuse-on-womens--adult-relationships-0925122
-https://www.psychologytoday.com/us/blog/all-about-sex/201610/childhood-sexual-abuse-how-men-can-help-women-recover
-https://aifs.gov.au/cfca/publications/long-term-effects-child-sexual-abuse/interpersonal-outcomes
-https://www.ncbi.nlm.nih.gov/pubmed/15159068
-https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3142010/
Ted
This blog title is from a song by Craig Finn. He describes in his song-story telling way his distancing from a self-destructive friend who once helped him when he first came to New York. The title, and the pain in the song, remind me of a subject I dealt with too often both professionally and personally- the sequelae of child sexual abuse (CSA). While my experience is large, I wanted to find serious, academic material on this painful subject.
CSA does not appear in the pyschological or medical literature in any meaningful way until the early 21st century. There are papers from the 1980s, but few. These papers are limited by relatively small sample sizes and problems with long-term follow-up, as well as the type and duration of abuse and the background setting of family dysfunction.
Since I do not provide care for children, my major interest and experience has been with the adult sequelae of CSA. In my practice, these women have usually stood out. Their reactions to Gyn exams are unusual, with decathection and excessive fear common. Many of these women have somaticization (the expression of emotion as physical complaints), and some sexualize the exam.
Since sexual abuse was something not spoken of in public until the late, late 20th century, many women with CSA histories have kept them secret, or are profoundly ashamed of their stories. Self-blaming is common, especially since the sexualization of a relationship with a child brings the child attention they enjoy. The power dynamic distortion and conflicts about sexuality lead to many adult manifestations of CSA besides unusual reactions to exams.
As a group, CSA survivors have more sexual partners and less relational stability. Short relationships and divorces are common, with divorce rates exceeding 70% in most papers. Multiple divorces are also common, as these women tend to make poor relational choices. The reasons for this are not clear. What is clear is that CSA can often not be readily separated from familial dysfunctions like drug and alcohol abuse, and other forms of abuse such as verbal and physical injuries.
Women with a pure history of CSA, without other forms of abuse or continuation into adolescence, actually have little different lives than most women. The most damaged, and most complex cases, are in those women where abuse continued into adolescence or recurred with different abusers. Thus the woman abused as a child, then raped as a teen has a far, far worse outcome than the woman abused as a child who has no further abuse contacts.
Unlike news stories, women are the perpetrators in 5-20% of CSA. The most common perpetrators are mothers and teachers. Mothers show little sexual preference in their victims, abusing daughters as much as sons, while teachers show a marked preference for male targets. In broad studies of Catholic church abuses the only stories reported are about priests, but nuns were 5% of perpetrators.
Psychiatric diagnoses are common among CSA survivors. Common ones include PTSD, depression, anxiety, dissociative disorders, schizoid symptoms (Schneiderian symptoms), somatiform disorders, and conversion symptoms. In one paper the incidence of dissociative symptoms was 88%, with 51% fulfilling the criteria for dissociative personality disorder. Among women with CSA there are many more claims of ESP, supernatural abilities such as being able to 'see' demons and 'Evil', and many associated physical complaints without objective basis (somatiform complaints) such as migraines and generalized aches and pains. Predictably, certain other diagnoses often used as catch-alls for such symptoms are much more common, such as chronic fatigue syndrome and fibromyalgia. Self-mutilation is also much more common. Borderline personality traits are far more common as well.
For women with CSA histories, female role-defining events can evoke depression, marked anxiety and worse. These include marriage, childbirth, menopause, aging changes, and menarche.
Sexuality is often greatly affected. Decathection or even dissociation during sex is common, with traumatized partners 'zoning out' or 'disconnecting'. Orgasm may be difficult or impossible via intercourse, and achieved only by masturbation during sex or alone. The dissociation so prevalent among abused women, combined with the common seeking of comfort from multiple partners, leads to women who are often found 'flirtatious' or 'sexy' but who are mechanical and detached during sex itself. They are often described as 'clinical' in their sexuality, objective and even cold rather than interpersonal. Sex may be viewed by these women as what they are good for, a duty they must fulfill, a way of gaining affection, or an unpleasant chore. Regardless, sexual dysfunction and relational dysfunction are extremely common.
Fear of abandonment is much more common in these women. Despite this, the multiple relational and sexual dysfunctions leads to numerous, short relationships, thus confirming and extending fears of abandonment. Patience is universally advised when interacting with these women, as the process of recovery commonly takes years. Sadly, most intimate partners will not stick around that long to work through these women's pervasive social and sexual problems, or they withdraw emotionally.
Treatment for these individuals is severely lacking in quantity and quality. Insurance coverage of psychiatric counseling is poor, leading to use of unqualified counselors with agendas beyond helping their clients. Church or religious counseling is a common resort, but most of these 'counselors' have no training in dealing with the many psychiatric and sexual problems with which these people present. Their nostrums generally include exhortations to conform to social and religious paradigms that may put greater psycho-social stress on the patient and confirm their already bad self-image. Unusual religious beliefs or cultish experiences are also common, as these individuals seek some kind of source of emotional and spiritual comfort. Gurus, self-help books, 'therapy' sessions with spiritual guides, etc, etc are sadly common and unhelpful. Most psychiatric 'care' consists of brief medication appointments to deal with symptomatology rather than causation, leading CSA survivors to doubt or reject their diagnoses and claim they are well, further removing them from therapeutic options.
The intimate partners of these women typically cannot endure the repeated withdrawals, aggression and dissociative actions of survivors of CSA. Like Craig Finn's song, whose speaker cannot keep saying thank you for a favor done years ago, the intimate partners of these women often cannot remain in relationships where they are repeatedly abandoned, attacked, and criticized. They withdraw in self-protection, leaving the abused woman feeling even worse than before and reinforcing her distorted relational beliefs.
All of this is so sad and painful that society does not want to recognize or address the problem in any meaningful way. CSA is like the lightning that hits a tree when it is young. The tree may survive, but its shape and growth are altered forever. In just this way, CSA alters lives throughout life. If a person is to become emotionally or sexually involved with a survivor of CSA, it is important to recognize there will be many unpleasant and apparently inexplicable behaviors. The relationship will be variable and often very unstable. Prolonged therapy of high quality will be necessary for these individuals, and even then their relationships and responses are likely to be altered compared to unabused individuals.
Here are links to selected high-quality studies on this problem-
-https://www.ncbi.nlm.nih.gov/pubmed/8221221
-https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1401228/
-https://www.goodtherapy.org/blog/impact-of-childhood-abuse-on-womens--adult-relationships-0925122
-https://www.psychologytoday.com/us/blog/all-about-sex/201610/childhood-sexual-abuse-how-men-can-help-women-recover
-https://aifs.gov.au/cfca/publications/long-term-effects-child-sexual-abuse/interpersonal-outcomes
-https://www.ncbi.nlm.nih.gov/pubmed/15159068
-https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3142010/
Ted
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