The Long-Term Effects of Sex Abuse

Overview

Childhood sexual abuse (CSA) is a widespread problem with long-lasting effects on the lives of its victims. According to Putnam (2003), sex abuse covers a diverse number of different activities that range from superficial contact to intimate contact that involves an extreme violation of another individual's well-being. This diverse range of activities also has an impact on the levels of long term harm experienced by each victim. In addition, other factors that vary in their impacts on the victim's long term physical and mental health include the age of the victim, the type of relationship between the victim and the offender, the frequency of incidence of the abuse as well as its duration. As will be seen, CSA can lead to the development of serious mental health problems (Putnam, 2003).

Prevalence

Until the late 1970s, CSA was considered to be a rare occurrence in the US. However, since that time, incidence rates established by official statistics, have shown it to be quite common (Putnam 2003). In fact, international studies of CSA, have shown that its occurrence is found all over the world with varying degrees of intensity (Stoltenborgh, van IJzendoorn, Euser, & Bakermans-Kranenburg, 2011). This increased incidence is likely due to increased reporting. Although there is some research that suggests that incidence rates have been increasing even when improved reporting is taken into account (Putnam, 2003).

In addition, there is some variance in the studies which purport to measure CSA prevalence. Putnam (2003) reports research that shows 12 percent to 35 percent of women and 4 percent to 9 percent of men have been victims of any type of unwanted sexual attention prior to the age of 18. Stoltenborgh, van IJzendoorn, Euser, & Bakermans-Kranenburg (2011) report prevalence rates varying from as low as 0.1 percent to as high as 71 percent, depending on the world areas under study. Chen et al (2010), reporting on research conducted in the US, indicated prevalence rates vary from 4 percent to over one-fifth among adults and from 3 percent to a third among minors.

Sex abuse is associated with a number of risk factors. The most commonly reported risk factors include the victim's gender, age, disability status, and socioeconomic status. CSA studies on gender have found girls had 2.5 times the risk of boys. However, it has become widely acknowledged in recent years that CSA involving boys has been chronically underreported (Putnam 2003). With age, the risk scales up as the child matures, with the lowest risk factor being for those 3 years old and younger. Incidence triples between the ages of 4 and 7 and reaches a peak for children aged 12 and older. Mental or physical disability is a particular risk factor because the victim may be unable to communicate the abuse. While a disproportionately high number of CSA cases have been reported for individuals of low socioeconomic status.

Effects of Sex Abuse review

CSA has been associated with a number of psychiatric problems affecting victims well into adulthood. The types of disorders victims suffer from include of post-traumatic stress disorder (PTSD), borderline personality disorder (BPD), somatization disorder, major depression, bulimia nervosa, substance abuse-related disorders, sleeplessness, suicide ideation, and post-dissociative identity disorder (Santiago, McCall-Perez, Gorcey, & Biegel, 1985; Putnam, 2003; Chen et al., 2010; Hillberg, Hamilton-Giachritsis, & Dixon, L., 2011). Dube et al (2005) found sex abuse victims were more likely to marry an abusive or alcoholic partner. Thus there is a considerable body of research that confirms the long-term effects of sexual abuse.

The association with the above-named disorders was established when individuals seeking professional assistance reported a history of CSA to clinicians. Since the era of initial reporting began, large scale community sample studies (Putnam, 2003) and longitudinal studies (Stoltenborgh, van IJzendoorn, Euser, & Bakermans-Kranenburg, 2011) have been performed. This research has formulated three broad categories of victim response to CSA. These responses are neurobiological dysregulation, dysfunctional behavioral patterns, and psychiatric disorders (Putnam, 2003). It should be noted that much of the available research has demonstrated a gender bias towards females. This is due to the under-representation of males in both research and clinical samples. However, Putnam (2003) reports research that confirms that a significant degree of similarity exists in the effects experienced by male and female CSA victims. Each of the three categories of response will be discussed below.

Neurobiological dysregulation. Research into combat-related PTSD in adults found elevated neurobiological sequelae such as psychophysiological reactivity. This research inspired researchers to seek evidence for similar effects in both adults and children with a history of CSA (Putnam, 2003). This evidence found a group of studies that followed both abused and non-abused girls. The evidence took the form of toxic effects on such areas of the body as the immune system, the sympathetic nervous system, and the hypothalamic-pituitary-adrenal axis or HPA.

Sexually abused girls who were examined in a six-month window of disclosure demonstrated elevated morning serial plasma cortisol in comparison with non-abused cohorts. Similar effects were found in research focusing on adults with documented CSA histories or who had experiences that combined both sexual and non-sexual physical abuse (Putnam 2003). These effects were found to involve adverse changes of a neuroanatomical nature. Three studies that employed magnetic resonance imaging (MRI) indicate lowered hippocampal volume was found of a type previously reported only for military veterans suffering from PTSD. There is also evidence in maltreated children who demonstrated considerably smaller intracranial and cerebral volumes in comparison with their control group counterparts. Also of note, is the lowered "midsagittal section of the middle and posterior corpus callosum (Putnam, 2003 273)." As Putnam writes, "the corpus callosum is a massive fiber tract whose primary function is the transfer of information between the left and right hemispheres (Putnam, 2003, 273)." The reported decreases are very closely aligned with both PTSD and dissociative disorder.

Dysfunctional behavioral patterns. CSA has been found to be associated with a number of different behavioral problems as well. A number of different such problems have been noted in the literature but highly sexualized behaviors have been shown to be most significantly correlated with CSA (Putnam 2003). The research has found that CSA victims demonstrated much more sexualized conduct than their control group counterparts. The reported effects were found to be most apparent in children of a younger age, children who were abused at younger ages, and in children who were clinically examined not long after an abusive incident occurred.

Unlike a history of physical abuse or neglect, a CSA victim history is rather closely associated with an increased likelihood of arrest for sex-related crimes, including prostitution. This trend was observed regardless of the gender of the victim (Putnam, 2003). Studies have also shown that CSA victims are at elevated risk for teen pregnancy. It appears the tendency toward teen pregnancy may be multifactorial. That is, it can include such factors as dissociation and depression.

In addition, the victim may feel they may resolve their emotional needs by producing a child of their own. This tendency toward early pregnancy is particularly concerning to clinicians. This is because pregnant CSA adolescents are at much higher risk for such problems as low-birth-weight infants and premature birth. These problems may be inherent in individuals who are at such a high risk of substance abuse, social isolation, chronic stress, and depression (Putnam, 2003). Finally, CSA is a powerful risk factor for health problems related to the transmission of the human immunodeficiency virus (HIV) and the subsequently acquired immunodeficiency syndrome (AIDS).

Depression. The third and final outcome of CSA is major depression. This particular mental illness is an acknowledged major health problem. In addition, studies have demonstrated a high level of prevalence. Major depression also has considerable outcomes in terms of high mortality and morbidity of those who suffer from it (Putnam, 2003). Thus the illness provides a practical case study of the intersection of evidence connecting a CSA victim with major psychopathological problems in adults.

Such psychiatric problems as dysthymia and major depression have long been correlated with CSA in a number of research studies. For instance, the women with a history of CSA have been shown to have a lifetime risk of major depression that is from three to five times higher than that of women without such a history (Putnam, 2003). Research that controlled for CSA history found that the commonly reported 2 to 1 ratio of female to male depression rates fell to zero.

A history of CSA may also transform how major depression is clinically presented. That is, in a study of over 650 major depression cases, it was found that individuals who had histories of non-sexual physical or sexual abuse, were considerably more likely to experience certain adverse health effects (Putnam, 2003). These health effects included such reversed neurovegetative indicators as hypersomnia, weight gain, and an elevated appetite. These effects were not observed in individuals who didn't share this history.

A CSA history has also been correlated with the earlier in life occurrence of affective episodes. A history of any type of child abuse may negatively impact the victim's response to common treatment methods. In a comparison of recovery rates, Putnam (2003) reported research that showed that women with a history of abuse were prone to significantly protracted depressive episodes. For research that includes children and adolescents, there is accumulating evidence that connects affective disorders to a CSA victim history. This evidence is quite similar to that reported for adults. It includes significantly higher rates of prevalence in children who were abused than in those who were not.

CSA has also been linked with both major depression and other serious psychopathologies in general population studies of children and adolescents. For instance, a 1000 member cohort of children was studied in New Zealand. The study discovered that CSA had significantly raised the odds for certain morbid life outcomes (Putnam, 2003). When non-abused children were compared with CSA victims who had experienced either contact non-intercourse or non-contact abuse, the odds of an outcome of major depression were raised to 4.6. Those abused youths who reported having experienced intercourse had an odds ratio for major depression of 8.1 and an odds ratio for an attempted suicide of 11.8.

What researchers refer to as "contact sexual abuse" produces the worst long-term response to the abuse. As noted earlier, the relationship between the victim and the offender is particularly influential in both outcome and response (Putnam, 2003). Thus the closer the relationship between the offender and victim, then the poorer the victim's outcomes will be. At the same, relationship to the offender is complicated by such intervening factors as the age at which the abuse is initiated, the length of the abuse, and whether physical violence was used.

Furthermore, incest between a father and daughter has been shown to have a notable correlation with both the age at which the abuse is initiated and the length of the abuse. However, the use of violence or physical coercion is less likely in such CSA cases (Putnam, 2003). At the same time, gender may have an influence on how a victim expresses their pathology. Boys are notably worst often than girls in their response and outcomes. This gender differential has also been observed in adult survivors of CSA.

Treatment options

This discussion of the outcomes of CSA would seem to warrant a review of the treatment options. Much of the research has noted that cognitive-behavioral theory (CBT), with a particular emphasis on CSA victims, is the most widely recommended therapy (Putnam, 2003: Chen et al., 2010). Chen (2010) also recommends cognitive processing therapy. A similar intervention is often recommended to the parent that is not involved in the abusive relationship. However, there are limits to the therapy. It has been reported that issues related to aggression and sexually dysfunctional conduct may continue unresolved.

Prevention. In addition, there are a number of interventions that are focused on preventing the problem of CSA from occurring. What intervention works best remains somewhat under discussion by mental health practitioners. One solution is the implementation of education programs based around schools. These programs are designed to provide children with the tools to recognize a possibly abusive situation (Putnam, 2003). The children are then taught to engage in protective strategies and to report the incident to another adult as soon as possible. A meta-study of 16 studies that evaluated such interventions found such programs have a high degree of efficacy. There were also some negative effects on children. These effects involved an increase in anxiety and a heightened sensitivity to touch even from other children. However, Putnam (2003) reports a research study involving 825 participants which found a significant decrease in the likelihood of CSA for those children who receive the intervention.

Home visitation. An alternative intervention is home visitation programs that approach the issue of CSA, and general child neglect, by educating parents who are identified to be most at-risk. The Nurse Home Visitation program is an example of such an intervention (Putnam, 2003). In a 15-year follow-up study, researchers found CSA incidence was about half the rate of a control group. The NHV program was also said to have had a considerable impact on economically disadvantaged and unmarried households.

References

Chen, L.P., Murad, M.H., Paras, M.L., Colbenson, K.M., Sattler, A.L., Goranson, E.N. . . . & Zirakzadeh, A. (2010). Mayo Clinic Proceedings,85(7), 618-629.

Dube, S.R., Anda, R.F., Whitfield, C.L., Brown, D.W., Felitti, V.J., Dong, M., & Giles, W.H. (2005). Long-term consequences of childhood sexual abuse by gender of victim. American Journal of Preventive Medicine, 28(5), 430–438.

Hillberg, T., Hamilton-Giachritsis, C., & Dixon, L. (2011). Review of meta-analyses on the association between child sexual abuse and adult mental health difficulties: A systematic approach. Trauma, Violence, & Abuse, 12(1), 38-49.

Putnam, F.W. (2003). Ten-year research update review: Child sexual abuse. Journal of the American Academy of Child Adolescent Psychiatry, 42(3), 269–278.

Santiago, J.M., McCall-Perez, F., Gorcey, M., & Biegel, A. (1985). Long-term psychological effects of rape in 35 rape victims. The American Journal of Psychiatry, 142(11), 1338-1340.

Stoltenborgh, M., van IJzendoorn, M.H., Euser, E.M. & Bakermans-Kranenburg, M.J. (2011). A Global Perspective on child sexual abuse: Meta-analysis of prevalence around the world. Child Maltreatment, 16(2), 79-101. DOI: 10.1177/1077559511403920.