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Chapter One: Child Sexual Abuse and its Impact
Definition of Child Sexual Abuse
A formal definition, from Scottish child protection guidelines, says child sexual abuse happens " When any person, by design or neglect, exploits the child … in any activity intended to lead to the sexual arousal or other forms of gratification of that person or any other person(s), including organised networks. This definition holds whether or not there has been genital contact and whether or not the child is said to have initiated, or consented to, the behaviour."1
Sexual abuse is also physically and emotionally abusive. It breaches the personal boundaries to which all human beings are entitled. Child sexual abuse is always wrong and involves the misuse of power and control.
What Does Child Sexual Abuse Involve?
"Today I live with a rage and sadness that rules my life. I feel I shall never be a whole human being. My mum used to say you shouldn't live in the past. I don't. The past lives in me."
Many people imagine child sexual abuse is 'a bit of fondling that shouldn't happen' or 'inappropriate touching'. In considering the effects which people may be left with for the rest of their lives, it's important to realise that CSA often involves serious and very degrading assault. It may include:
- 'Non-contact abuse' Although sometimes regarded as insignificant, this can include: being watched (often daily) in private situations, like going to the toilet or having a bath; being forced to watch the abuser masturbating; being made to watch group sex or pornography, and a range of other perverse acts, including sex with animals, young children or even babies.
- 'Contact abuse' can include vaginal, oral and anal assault by one abuser or a group; penetration with objects or weapons; forced participation in group sexual activities; forced acts with animals; involvement in child prostitution and pornography; forced abuse of other children; being urinated on, and other forms of ritual humiliation.
- Additional physical violence during abuse which survivors have reported includes burning, scalding, electrocution, pulling of hair, use of weapons, beatings, having their wrists and ankles tied, being isolated, drugged, or deprived of sleep, food or drink.
The abusive acts and additional physical violence, or perverse scenarios, might be filmed for the purpose of making and selling pornography. Captured internet child pornography reveals that these acts may be inflicted on very young children and babies, as well as on older victims.
The Impact of Child Sexual Abuse
Many people who experienced sexual abuse as children live successful lives, despite their adverse experiences. Being sexually abused does NOT mean people will necessarily suffer the problems referred to below. Survivors of child sexual abuse can be affected to very different degrees, and some might only have difficulties in one particular area. However, child sexual abuse can have lasting, serious and wide-ranging effects, such as those discussed below. It is important to remember that not all people who manifest these symptoms will be survivors of childhood sexual abuse. The list provides a guide but staff are reminded that they are listeners, not therapists, and your role therefore is not to diagnose but to listen and validate what the person is saying.
In general, the most pervasive effect of childhood sexual abuse is the destruction of self-esteem and the generation of a sense of worthlessness. It is not hard to understand why people who have been sexually abused might feel worthless: they have been used as objects, purely for the gratification of others. Their own feelings counted for nothing. They have often been ritually humiliated and repeatedly degraded because others find this exciting. Their personal privacy has been profoundly invaded. Their abuse has often been as a result of betrayal by those they trust, love and depend upon, which may include one or both of their parents.
"I used drugs to get away in my head. I didn't care at all about myself. I thought nothing of myself ... you reach so much desperation."
Some Major Effects
The major effects of CSA have been widely researched and documented. We can only summarise here some key issues which you may want to read about in more depth. The impact of sexual abuse does not make a person abnormal - the effects listed below can be common and normal responses to trauma. It is when they persist and cause problems in survivors' lives that treatment and support are valuable. The voices of survivors quoted below give a better appreciation and understanding of the physical and emotional costs of abuse, and an insight into the behaviour of some survivors.
There is good research evidence that people experiencing particular mental health problems, including post traumatic stress symptoms ( PTS), borderline personality disorder, depression, problems with food, suicide/attempted suicide and self harm, severe substance misuse, anxiety disorders and loss of self esteem, are more likely than others to report a history of childhood sexual abuse. Sometimes the associations are very strong. For instance, many people with histories of CSA trauma have consistently been found in those diagnosed with borderline personality disorder.
Depression is a widespread problem in society, and there are many contributory causes. It is very common for survivors of sexual abuse to suffer debilitating bouts of depression during their lives, especially at times of particular stress, or when experiences trigger memories of abuse. For women, one of these trigger points can be pregnancy (which often involves intimate examinations) and the birth of a child. An unrecognised history of sexual abuse can make response to treatment more difficult, and hinder recovery; focusing on the trauma can aid recovery.
"I thought this is terrible, I have a lovely baby, what's the matter with me? Feeling terrified for what would happen to my children, that someone else might abuse them…I felt suicidal the whole time. Childbirth brought up floods of memories."
- Post traumatic stress ( PTS) symptoms, such as flashbacks, night terrors, phobias, anxiety states or panic attacks
Post-traumatic stress symptoms are familiar not just to sexual abuse survivors, but to people who have experienced many forms of trauma. These symptoms can include flashbacks to the traumatic incident, and avoidance of situations associated with the trauma. These are normal responses to abnormal events, not signs of weakness or irrationality. What is perhaps more difficult to appreciate is just how disruptive, distracting and disturbing PTS symptoms can be to survivors' everyday lives, to the performance of everyday tasks, and to their physical health. Survivors may live continually on edge, what therapists call 'hypervigilance'. The symptoms are exhausting! They can also lead people into sometimes desperate attempts at self-medication.
In addition to avoidance of feared situations or objects, some survivors experience phobias related to their abuse, such as agoraphobia or claustrophobia. While their phobia may initially sound irrational, sensitive enquiry can sometimes reveal that the person has good reason to be scared: they may, for instance, have developed a fear of the dark after being locked alone in a cupboard for days. They may have a generalised anxiety that leaves them with no self confidence. They may have bouts of being unable to work, with panic attacks, a sense of not wanting to be seen, and sometimes even agoraphobia. Survivors may have difficulty sleeping, need to sleep with the light on, and may wake up panicky or depressed.
- Self-harm and self-mutilation:
Self-mutilation (cutting, burning or otherwise physically injuring yourself) is strongly linked to childhood trauma, including sexual, physical and/or emotional abuse. Self-harm and self-mutilation are particularly hard for other people to understand and often make them feel upset or disgusted. This revulsion can sometimes result in great unkindness to distressed survivors. What may be a coping mechanism for the survivor is sometimes wrongly seen as attention-seeking (although most of it actually takes place unseen and in private). It is helpful for workers to read as much as possible about the causes of self-mutilation, in order to develop more understanding and to work with survivors on constructive ways to reduce their self-mutilation. NHS Health Scotland has a booklet about this.
Self-mutilation can be quite distinct from attempted suicide. Indeed the person may see it as one means of survival. The causes are complex and can be about several things, including: attempts to regulate overwhelming feelings; self-hatred and self-punishment; a sense that abusers are ordering them to do it; or compulsive re-enactment of an abusive experience. For instance, one survivor in Beyond Trauma kept inflicting very severe burns on her arm before recalling that, as a child, her abuser had repeatedly burned her arm on the cooker. Self-mutilation can bring temporary relief from distressing thoughts or feelings, or a feeling of euphoria.
"It's a desperation, an absolute desperation, where you're feeling so much pain within you, and there's other times when I felt so dulled I couldn't feel anything at all, and wanted to feel something. There was so much pain within me that I almost needed to do something really extreme to relieve it."
Self-harm in a wider sense can take many forms. For males especially, it can involve compulsive risk-taking, heavy drink and drug misuse, and/or extreme lack of self-care.
- Suicidal behaviour and thoughts:
We will never know the exact relationship between child sexual abuse and suicide because so many people's histories remain secret. However, those who work with people who have experienced CSA cannot fail to be struck by how often suicide or attempted suicide is a feature. For instance, 50% of the interviewees in the Beyond Trauma2 study revealed that they had tried to kill themselves - sometimes repeatedly. Some survivors may experience such serious and persistent distress that they feel like they want to go to sleep and never wake up, and may take overdoses of drugs in order to dull or deaden the pain they experience.
Suicidal behaviour among male CSA survivors is also common, and life-threatening forms of risk-taking behaviour are often more extreme for men than for women. Most male survivors interviewed for the Lothian needs assessment 3 had attempted suicide, sometimes several times: "Actually I tried at the ages of 6, 16 and 17, and it wasn't picked up…"
Indirect Murder
When all is said and done,
As if it ever could be,
The issue of suicide is not one
That rates much sympathy.
Murder, for some reason, is more
Written about and understood.
To the box office, glorified gore
Is artistically valued and good.
Murders and murdered are news. Fame
Or even notoriety is their lot.
Suicide is looked upon with shame
As something it's better we all forgot.
Yet suicide is murder in disguise,
Caused by some unremembered crime,
Not understood by our present eyes,
For it has its roots in an earlier time.
Because we don't know the beginning
Of such long-term murder, we see
Suicides as people who are sinning
And reject them accordingly.
Those untouched by such murder, in resentment
Or fear, not knowing enough about
It, come up with some facile comment
Such as 'suicide is the coward's way out'.
Like primitive man, who saw
No relation between sex and birth,
And later man, whose immature and raw
Greed fatally threatens the earth,
We seem totally unable to relate
Effect to a cause that isn't obvious to see
Or to realise that a suicide's state
Is murder rooted in personal history.
Not by something as obvious as a knife
Or a gun, but by acts that the perpetrator
Cannot recognise as threatening to life
Because the dying happens years later.
Brenda Nicklinson
With grateful thanks to Malone C. Farthing L. Marce L. (eds) 1996.
The Memory Bird: Survivors of Sexual Abuse. London, Virago
Many people in our culture, especially young adults, misuse drink or drugs. But prolonged, repeated and intractable misuse, repeated failures to detox, and misuse at an early age should alert workers to the possibility that this person is self-medicating in an attempt to deal with effects of a trauma, such as sexual abuse. (It is also important to remember that the misuse can be of prescription drugs.) In particular, it may be an attempt to get rid of flashbacks, nightmares, frightening memories, intrusive thoughts or the hearing of voices. Alcohol and drug misuse is also connected with self-harm and lack of self-care. Additional services may be required to enable adult survivors to give up alcohol and drugs when they are being used to manage difficulties relating to the early trauma.
"I think I just felt desperately unhappy … you would drink and drink and drink, just to blot everything out. I started having - like blackouts - things were happening, like (my) shop got smashed up and I thought someone had broken in, and it was probably me … there was glass everywhere. I started drinking a couple of bottles a day … neat gin … I was getting into more and more debt, and I started going downhill rapidly."
Anger and aggression are particular problems for survivors and can be internally or externally expressed. As a male survivor recalls:
"I felt I was taking 20 years of aggression out on somebody in the pub. Men can be torn up with anger. If they are forced to suppress it all, they are likely to explode. They could find themselves doing a long (prison) sentence for attacking someone … you have this aggressive body language, swearing, and the physical pain too, which can make people very angry and frustrated, very uncomfortable."
Another remembers:
"It took over my life. I was so determined that it wouldn't happen to me again, so afraid, I beat other people up. I was violent, I ended up in prison many times. Other people remember the records they played at that time - I remember the fights."
When faced with institutions (hospitals, prisons and other places with formal procedures), a survivor can feel a loss of control and power: there is little or no personal space, no privacy, and no escape. This is like a replay of the abuse situation, and can result in a great deal of fear, anger and hostility. This can be misjudged as the person being a 'difficult customer', but it makes a lot of sense when traced to the underlying cause.
A significant number of survivors have problems with food and with eating for a variety of reasons. Causes can include a determination to exercise some control over one's powerless life; self-hatred; reactions to oral assault or to the forced ingestion of noxious substances; self-comfort in compulsive eating; attempts to be unattractive to abusers, or to avoid sexual relationships generally; the wish (with anorexia) to prevent pregnancy, or sometimes a wish to die.
"It's wanting to reclaim some sort of power over my body, because my body hasn't been mine for so long, but also because there was a lot of self-hatred."
"Food issues were always around the abuse. They were kind of inseparable. For instance, the dish of sweets as a reward … the link has persisted with me."
Physical effects of CSA can include genital and anal damage, sexually transmitted diseases (some of which can also reduce fertility), pelvic inflammatory disease, and gynaecological problems. Some of the psychological effects of sexual abuse, such as eating problems, suicide attempts, substance misuse, and depression, can also seriously affect physical health and self-care. Chronic pain is common, and can come from the effects of injury, or from the physical expression of emotional pain. Survivors may present often at their GPs over long periods, with no apparent reason found for troublesome, disabling physical symptoms ( e.g. recurrent chest pains, breathing problems).
Symptoms of PTS, such as continually disrupted sleep, can be exhausting. Survivors who run away from abusive homes can have their physical health jeopardised by the unhealthy and dangerous environments they encounter while living on the streets. Many survivors also suffer medically-unexplained conditions, such as irritable bowel syndrome.
Physical ill-health also results from declining or avoiding preventative checks. This frequently includes the reproductive areas for both sexes, ante and post natal checks, smears and dental checks.
"Self-hatred has made it impossible at times to listen to myself or believe I am important enough to have health needs. Denial has made me simply cut off physical sensation, dismiss pain as being silly. Social isolation has … cut me off from care, support and feedback about my health … illnesses have dogged my life."
- Relationship problems and dysfunctional sexual relationships:
Many men and women who have been sexually abused may need to re-learn appropriate boundaries which keep them safe in their relationships. They may acquiesce to things they are unhappy about and may be unclear about what is or is not acceptable behaviour. As a result they are vulnerable to being 'walked over', exploited, disrespected or transgressed physically or emotionally. In extreme situations this difficulty in creating and maintaining appropriate boundaries can lead to re-victimisation or to survivors ending up with abusive or bullying partners. Expecting no better for themselves, they put up with aggressive or controlling behaviour, believing that this is the norm or that they deserve to be treated badly. Some survivors have not had good role models for relationships, and consequently accept unreasonable or inappropriate behaviour from those around them, while others may act inappropriately themselves, perhaps continuing the patterns of violence they experienced in their own childhood.
It also is not uncommon for survivors to have some confusion about, or difficulty with, sexual feelings or behaviour. Most of us can understand how experiencing sexual abuse might turn some people off sex altogether or cause various other problems such as unpleasant intrusive flashbacks during sex or avoidance of physical intimacy, even with trusted partners. It can be more difficult to understand survivors turning to apparent 'promiscuity' or sexual risk-taking. Teenagers, in particular, are often stigmatised for this, instead of their behaviour indicating possible abuse and a need for protection. Such behaviour can result from feelings of worthlessness and self-hatred, from experience of only being valued for sex, or from a lack of appropriate physical contact and care in childhood:
"I used to go to Calton Hill and go with any man, and do disgusting things, the lowest things I could, because I felt so totally bad about myself. But it didn't actually help, in fact it made me feel even worse afterwards. But it was like a compulsion."
Many survivors also experience some confusion about their sexual orientation. Those who are as adults attracted to people of the same sex may worry that the abuse 'made them' gay, lesbian or bisexual, and consequently can feel bad about their sexual feelings, while heterosexual male survivors abused by men may worry that their abuser thought they were gay and chose to abuse them as a result. Linked to this, they may develop homophobic feelings or present as very macho. Survivors can also feel enormous guilt and confusion about sexuality if they had a sexual response to the abuse, perhaps assuming that this must mean they enjoyed the abuse or wanted it to happen. In fact, a sexual response to being abused can be a result of the high adrenaline caused by fear and anxiety or a normal physiological response of the body unrelated to sexual enjoyment.
In wider relationships, it is also very common for adult survivors to have disrupted relationships with non-abusive members of their families. This can be a cause of continuing sadness and loss for all concerned. Many feel bitter and perplexed that their mothers, or other adults, did not intervene to stop the abuse. Survivors who 'blow the whistle' on abusing relatives can sometimes find themselves isolated in the family - other abused members of the family may feel unable to speak out and support them. On the other hand, many survivors have also had very rewarding experiences of repairing family relationships after the abuse has been brought into the open.
Abused people who themselves become parents can be overprotective of their children, unable to leave them with babysitters or with non-abusing family members. They may be particularly anxious when their child reaches the age they themselves were first abused, as this can bring up many unpleasant memories or flashbacks. Parents may also worry about their own parenting and can be very concerned about abusing or neglecting their children. Sometimes they might avoid appropriate physical contact or routine care out of this concern. They may find it very hard to display affection to their children, although this doesn't mean that they don't care.
Reactions to overwhelming, traumatic situations are often described as fight, flight or freeze responses. Where children can't escape their situation or fight back they may freeze, with their bodies and minds 'switching off' or 'going elsewhere' for the duration of the trauma. This is a form of dissociation. For example, some survivors recollect feeling distant from their bodies while the abuse was happening, viewing it as if it was happening to someone else.
Dissociation happens when some thoughts, emotions, sensations or memories are separated from the rest of our conscious awareness. It exists along a continuum from feeling slightly disconnected and distant through to memory blackouts and an inability to recall significant periods of time. Some degree of dissociation is normal. For example, most of us can't recall what we've been thinking about during a long train journey: our minds are simply 'elsewhere'. Some memory gaps about parts of our childhood are also common. However, severe and problematic dissociation in adults is more frequently found amongst people who have experienced different kinds of abuse and trauma in childhood.
The most common forms of dissociation are depersonalisation and derealization. This is where things seem unreal - the survivor might feel detached from their body or from their surroundings, experiencing things in a slightly vague, distant and dreamlike way. Sometimes survivors have described this as feeling as if their life was a film they were watching rather than something really happening to them. Dissociative Identity Disorder, formerly called Multiple Personality Disorder, is where the mind is thought to split into several personalities, who may or may not have awareness of one another. This is the most controversial form of dissociative disorder. While some mental health professionals doubt its authenticity as a disorder others believe it is a response to overwhelming trauma, with the mind splitting off parts it is otherwise unable to cope with.
In adult life dissociation can sometimes be behind apparent mood swings or personality shifts, forgetfulness, dreamlike states, inattention or memory loss for periods of time. It can be frightening and distressing for survivors if they can't remember where they were or what they were doing for some hours.
It is helpful for survivors who experience dissociation to work with a trained professional to find ways of 'grounding' themselves in order to improve their psychological contact with themselves and the world.
There are a range of recognised personality disorders, including Borderline Personality Disorder and Antisocial Personality Disorder. Research suggests there is a relatively high prevalence of diagnosed personality disorders among people who experienced traumatic neglect and abuse in childhood. As infants and young children we are totally dependent on our care-givers to meet our needs for survival and for comfort. We also begin to develop a sense of who we are in the world through these early relationships. Unfortunately some care-givers behave in a neglectful, inconsistent, inappropriate or abusive way, which can affect our sense of identity as well as the way we relate to others in adult life. Personality disorders are characterised by long-lasting inflexible patterns of thought and behaviour which cause significant difficulty in adult life and relationships.
For survivors, these diagnoses raise problems as the label of personality disorder is experienced as stigmatising. For many, the diagnosis of personality disorder has become a 'dustbin diagnosis' for people who behave 'badly', abuse substances, self-harm frequently, or are considered 'hard to treat'. This can result in services, or hospital admission, being denied because of a belief that there are no effective treatments for personality disorders, or that the person is simply attention-seeking. It is hard for staff and volunteers to perceive the extent of post-traumatic distress and suffering beneath the apparently exasperating behaviour. This can lead to survivors spinning through the 'revolving doors' of prison, psychiatric hospital, streets and A&E.
In recent years, with increasing dialogue between scientists and clinicians, there is a greater understanding of the development of personality difficulties, the neuropsychological implications of the problems and the existence of successful psychological and pharmacological treatment interventions. See page 50 for some information on the Scottish Personality Disorder Network.
Survivors with personality disorders can be challenging to work with: because of their difficult childhood experiences they may relate to others in ways which are very difficult to cope with. They may be mistrustful and suspicious, apparently uninterested in relationships, or may swing between being very needy or dependent at one time and hating us at another. Self harm is common, as is dissociation (see previous section).
It is vital that you provide safe, appropriate and consistent relationships in these situations. You need to respond to the distress rather than to behaviour which may appear provocative. This requires compassionate but firm professional boundaries around time, contact and our role. You are not there to be a substitute for friendship or for other relationships, but this does not mean you act coldly. Survivors may never have experienced a caring person who acts appropriately, does what they say they will do and doesn't go beyond what is appropriate to their role and competence.
Providing this kind of relationship can create an opportunity for survivors to experience people differently - not as abusive and rejecting, or collusive and cloying, but as responsible adults. This means you need to be able to tolerate being loved and/or being hated, without taking it too much to heart or changing our own behaviour and response to the survivor as a result. Over time this can help survivors change their sense of self and their behaviour.
One female survivor diagnosed with Borderline Personality Disorder recalls a nurse whose skilled therapeutic help enabled her to change her life:
"I was totally outrageous. Throwing myself on her, pleading and begging with her, lying on the floor: I don't know how she survived. Yet she never overstepped the boundaries, but not once was she ever cold, she always behaved in a warm kind way … I think when things got intolerable, I must have been hell to work with."
Some survivors experience what may appear to be psychotic episodes at stressful points in their lives, or during flashbacks of abuse. Some hear the voice of their abuser(s) or experience intrusive thoughts about their abuser's derogatory comments. There can be confusion between post traumatic stress and psychotic episodes, although the two can also occur together. It can require a skilled and trained person to make these distinctions accurately, and frontline staff should seek advice when they are concerned about the significance of psychotic episodes.
Reflection
The list of effects discussed above reveals the pain and distress which many survivors of CSA have had to live with since childhood, whether or not their silence has been broken.
Looking at the effects of abuse, it is difficult to understand why so many people appear sincerely to believe survivors are somehow all right, and stable, left as they are, and that trying to help them by addressing the issues would make them "worse". It is very important to be honest with ourselves and ask whom this notion protects. There is an anxiety that trying to help survivors explore issues can worsen things and in some situations they may indeed feel worse before they feel better. However, people who try to kill or mutilate themselves, seek oblivion in drink or drugs, sometimes lose their children into care as a result, suffer frightening hallucinations, have endless nightmares and flashbacks, or chronic physical pain, are not feeling OK. They are also trying to tell us something, and it is hard to imagine what more they have to do. As one experienced CSA counsellor remarked with regards to the clients that came forward for this work : "Survivors don't talk about the can of worms, because for them it's already open and they're in the middle of it".
You Want a Witness?
Telling it as it is
Would you
listen
if I
really
told
you
what
it's
like
Could
you
cope
if I
said
there is
no
happy
endings
Only death
Would you
listen
if I saidthe pain
is constant
that it
interferes
that it
destroys
concentration
Or
would
you
say
I
can't
hear
the
pain
Tell
me
about
your
strength
Would
you
listen
If
I
told
you
I
was
afraid
of
sleep
of
my
body
or
would
you
say
I
can't
you
are
a
survivor
Listen
now
I am
sick
of
surviving
Now
I
will
tell
you
the
terror
the
sickness
are
always
with
me
I
just
hide
it
because
others
want
happy
endings
Rebecca Mott
With grateful thanks to Malone, C., Farthing, L., & Marce, L. (Eds) 1996.
The Memory Bird: Survivors of Sexual Abuse. London, Virago
Don't forget the positives!
It is important to understand the range of possible effects of child sexual abuse discussed in this chapter. This understanding encourages empathy, but it inevitably gives a very negative picture. All staff and volunteers need to remember that survivors of sexual abuse have particular strengths and resilience. These strengths can be built upon in any support work. Survivors are essential allies in their own recovery, in the training of professionals, in informing service provision and service delivery, in issues of criminal justice, and in campaigns to reduce sexual abuse in the wider society.
- Survivors have used great resourcefulness as children and teenagers, often for many years, to find ways of enduring, escaping or reporting their ordeal.
- They have shown great courage and endurance to survive severe, often prolonged, sexual, physical and emotional trauma.
- Survivors have detailed knowledge and experience about the patterns of behaviour of their own abusers.
- Survivors are often incredibly perceptive about signals given off by others, and the motivations, intentions and qualities of others.
How do services respond?
This chapter has described ways in which CSA is a risk factor for a range of life problems. Relevant services, such as those working with drug misuse, homelessness or self-harm, are already building in ways of exploring for the problem, or train and support their staff to work with it. It is important to strengthen this.
It is important to address symptoms, and some service users will, in any case, wish to do no more than that. It is also important, when appropriate, to tackle the underlying causes as this might prove less costly and more effective. It is also important to address survivors' complaints that for years no-one actually asked them what was wrong.
The next chapter explores the barriers to strengthening services' responses. These include: silence among survivors; assumptions and anxieties among workers; and staff not expecting that they should have to deal with the mental health consequences of CSA, and the limitations staff themselves impose on what they can deal with.
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