This post is a response to a question on Twitter the other night: Someone asked if there had been any work done on the long-term effects of child sexual abuse. I responded that I have a lecture I give that addresses just that. And I said I’d share my lecture notes. Here they are.
Physical Health Consequences of Child Sexual Abuse
I come with a health warning: you all know that child sexual abuse is far from sexy – it’s a difficult topic. You know that, you’re here because of that. Still, though, some of what I come out with in the next few minutes might touch a nerve. And if it does, please feel free to leave. Good self-care is essential for all of us.
When I first sat down last week to write this paper. I flexed my typing fingers, and said aloud,
‘Now, what should I tell these medical students?’
My daughter was in the room, and she responded:
I think that’s a good place to start.
Meeting patients and clients with kindness is the least – and at the same time, the most – you can do for them. I know that’s probably so obvious a statement that many of you may be irked by it. Still, I think it’s also important enough to bear repeating. The most basic act of kindness, however, we need, as health professionals, is to listen to the people we care for – and to listen with all our senses to what they are telling us. This is where language is important. As medics, you have a language that enables you to speak to each other – to other medical professionals and healthcare providers. That language is often exclusionary to non-medics and it might be useful to be mindful of that when you’re talking to people who don’t have the benefit of your knowledge and education.
Apart from my academic qualifications, I’m also standing in front of you as a survivor of child sexual abuse. I was sexually abused by my father and my two eldest brothers for a total of 15 years. I was trafficked by my father until I was nearly 6 and ‘too old’ for that particular set of child abusers.
I was also – as is common among survivors – re-victimised countless times as a teenager, and a young adult, in my marriages and other intimate relationships. And I want to take a moment to explain that to you, because it can be difficult for people to understand how abused people can end up in situations where they are abused again. And again. I’ve heard – and you probably have, too, that it’s because abuse is what we know, and, therefore, what we gravitate towards. I’d argue that that’s a bit reductive – that revictimization is not quite that simple. People with histories of sexual abuse tend to be revictimized for a few reasons:
- This is one I first came across in Don Hennessey’s 2012 book ‘How He Gets Into Her Head’. Don is Director of the National Domestic Violence Intervention Agency, and he has observed that abused women are kind. And that kindness sees them (us) give second, third, and fourth, chances to people who hurt us.
- Our boundaries are very porous, to say the least, so we’re not always sure when we’re being treated badly, until it’s too late. I used to explain it to myself by saying that I was always wonderful at seeing the tail-lights, but rubbish at seeing the headlights.
- Abusive men are very manipulative. They know which buttons to press to active our guilt. One of the lines I’ve heard more than several times is ‘I’m being punished for another man’s crimes!’ or some variation on that theme. Why? So that they can get their own way.
- Closely linked to that point, is the way we feel we need to be fair. So, we ignore our previous experience in order to be ‘fair’ to the person we’re with. Often, compromising our duty to be ‘fair’ to ourselves.
- Perhaps the sum off all these things is Instinct. As abused children, we stop paying attention to our instinct, because to do so would be dangerous. By the time we’re older children, or teenagers, we have forgotten what our instinct sounds – or feels – like, so we can’t pay attention to it. That’s a skill we need to re-learn.
What is Sexual Abuse?
Sexual abuse according to TUSLA
Sexual abuse occurs when a child is used by another person for his or her gratification or arousal, or for that of others. It includes the child being involved in sexual acts (masturbation, fondling, oral or penetrative sex) or exposing the child to sexual activity directly or through pornography.
Child sexual abuse may cover a wide spectrum of abusive activities. It rarely involves just a single incident and in some instances occurs over a number of years. Child sexual abuse most commonly happens within the family, including older siblings and extended family members.
Examples of child sexual abuse include the following:
- Any sexual act intentionally performed in the presence of a child
- An invitation to sexual touching or intentional touching or molesting of a child’s body whether by a person or object for the purpose of sexual arousal or gratification
- Masturbation in the presence of a child or the involvement of a child in an act of masturbation
- Sexual intercourse with a child, whether oral, vaginal or anal
- Sexual exploitation of a child, which includes:
- Inviting, inducing or coercing a child to engage in prostitution or the production of child pornography [for example, exhibition, modelling or posing for the purpose of sexual arousal, gratification or sexual act, including its recording (on film, videotape or other media) or the manipulation, for those purposes, of an image by computer or other means]
- Inviting, coercing or inducing a child to participate in, or to observe, any sexual, indecent or obscene act
- Showing sexually explicit material to children, which is often a feature of the ‘grooming’ process by perpetrators of abuse
- Exposing a child to inappropriate or abusive material through information and communication technology
- Consensual sexual activity involving an adult and an underage person.
I have a huge problem with this last element of the definition. A child is, under law, incapable of giving consent. So, ‘a person who can’t consent’ can’t consent, so this is a bit problematic, to say the least.
The last time there was any sort of national study undertaken in Ireland to figure out the prevalence of child sexual abuse was in 2002 – the SAVI Report – and it told us that 27% of the population of Ireland reported having been sexually abused before the age of 18.
Dr Rosaleen McElvaney, produced a paper a few years ago that disputed this – and she and her co-author on that piece, Kevin Lalor – are of the belief that it’s probably closer to 1 in 3.
But whether you accept one in three or one in four, you’re still talking about a huge number of people. A large percentage of the people that you come into contact in the course of your every day personal and professional lives will have survived child sexual abuse.
One of the things I do is train midwives and other birthworkers in trauma-informed care for women who were sexually abused; and I advise them to treat every woman they encounter as a survivor of child sexual abuse until they are told otherwise. Not everybody who has been sexually abused will feel comfortable disclosing. Often, people won’t even be aware that their symptoms are attributable to their abuse.
Several things can be attributed to the trauma of abuse that may not be immediately obvious: For example, I cannot remember the last time I went to bed and just went to sleep ‘like a normal person’. I have to bring a book, or the laptop with some work, or Netflix, or – sometimes half a Xanax – because I can’t just drop off. This isn’t unique to me – Greenfield et al (2011) conducted a national survey in the US that found a direct correlation between child abuse and difficulty sleeping as an adult. You don’t have to be a specialist to figure out why – any ideas?
I also suffer with chronic, severe migraines, and by severe, I mean Difene shots, and an anti-emetic if I don’t get Imigran squirted up my nostril quickly enough. Sometimes, a migraine has resulted in my staying in hospital for three days, on stroke watch.
But it’s not just me, researchers have found a link between child sexual abuse and migraines. (Tietjen and Peterlin, 2011; Brennenstuhl and Fuller-Thomson, 2015). The American Headache Society cites several studies demonstrating that childhood abuse makes migraines more likely to develop in later life (American Migraine Foundation, 2013). You won’t be surprised to learn that the more severe the abuse, the stronger the link between it, and migraines.
The reason appears to be that chronic maltreatment in early life alters the brain’s response to stress.
A study of inflammatory blood tests suggests a mechanism for the link. In this study, adults showed higher levels of biomarkers in the bloodstream when they had been exposed to abuse in childhood. Sexual abuse has also been strongly associated with the migraine-depression phenotype if the abuse first occurred before the age of 12 years (Kaleağasi et al., 2009).
I’m not suggesting that you ask every person who presents with a migraine whether or not they have been sexually abused, but it might be no harm to be aware of the links, and to – perhaps – mention them if, and when, it feels appropriate.
I think it’s important to note that CSA can affect people’s perception of their own pain: Dissociation often means that we don’t properly ‘live’ in our bodies. If that makes sense? Somatic integration can be something that doesn’t easily occur for us. It can, therefore, take a bit longer for us to get back into our bodies and explain where, and how something hurts. Logging into our bodies can take a few minutes; which means that, as medics, you may need to exercise a bit of patience with people who seem to be taking forever to tell you what hurts and where. In addition, because we’ve grown up in pain, our thresholds may be higher than other, non-abused, people. We can be a bit stoic, and a bit careless, with our own health and healthcare.
As an example, about ten years ago, I broke my toe. I knew it was broken because the pain of it made me cry. That’s my diagnostic tool, by the way – if a pain makes me cry, it means the offending bone is broken. Anyway, this was January, and I decided I couldn’t face hours in A&E waiting to be told what I already knew – that the toe was broken. So I left it. I was convinced that the two bits of bone would eventually kiss and make up, or a new piece of bone would grow and bridge the gap.
Now, in case you were in any doubt, I clearly don’t have a medical degree….Anyway, by May of that year, when things were still slightly uncomfortable in the general shoe area, I decided it was time to see a doctor. This was prompted, in part, by the fact that I was flying out to India for four months at the end of May: I thought it might be an idea to get the offending digit checked before I left in case things got suddenly worse, and I was over in India, and it suddenly determined that I needed surgery or something, and I had no one to mind my kids. So I hoiked myself off to Tallaght and sat around with a good book until an X-ray and a consultation confirmed that my toe was, in fact, still broken.
My rudimentary – no, sorry! – my non-existent medical training meant that my assumptions of magical healing were based on nothing other than wishful thinking; and my willingness to walk around with a broken toe for nearly half a year points to a deficit in appreciation of pain and its usefulness.
A more obvious physical side-effect is the effect that being sexually abused had on my reproductive ability. I married young, and tried to start a family immediately. Sadly, because I was so young, doctors didn’t take my infertility seriously. I lived in Singapore at the time and I remember remarking bitterly – but still correctly – to my doctor that if I was trying to end a pregnancy, I’d get more help than I was getting while trying to start one. When I eventually found a doctor prepared to investigate, it was discovered that as well as polycystic ovaries, I had a condition known as hydrosalpinx: which basically meant that my fallopian tubes had fused closed – which is neither a congenital nor a genetic occurrence, and a number of doctors indicated to me that it was a result of abuse. In order for me to conceive, my tubes needed to be opened up, and stitched in place. I also had severe endometriosis. After my first round of surgery, I remember the gynaecologist asking me why I’d never said I was in such extreme pain. I hadn’t realised I was in pain. I thought that was just normal.
I did eventually have children and of course, childbirth was profoundly affected by my experiences of sexual abuse. Although my children were born abroad, and in my bedroom, with people who were in attendance by invitation only, the experience of childbirth was still fraught with difficulty. Part of the problem is ignorance, on behalf of birth attendants – whether they are doulas, midwives, doctors, or nurses – around the profound effect that a history of child sexual abuse can have on women. And it’s not just the obvious difficulties around being touched or having procedures performed on us.
For example, women who were sexually abused as children will often, in labour, ‘stop’ at 4cms dilation (Simkin and Klaus, 2011). Labour can actually go backwards, as well, with the cervix closing up again a centimetre or two.
It’s not hard to understand why; but a caregiver who doesn’t know that abuse can cause labour to stop, or reverse, is unlikely to react in a supportive way. It’s possibly useful to note that people who have a history of child abuse have been trained to be compliant. This means, we will often agree to something that we don’t necessarily want to do, in order not to upset the person who is doing the asking, or so we don’t get into trouble. It might, therefore, be worth asking ‘are you sure?’, rather than taking the first ‘yes’ or ‘no’ that you get.
Mammograms, too, can be difficult for women who have been sexually abused as children. Another person touching a woman’s breasts can be triggering, even if it’s for medicinal or diagnostic purposes.
Then there is the dreaded smear. For women without a history of abuse, a smear test is a non-issue. It’s like a trip to the dentist; not something they look forward to, but something they will do as part of looking after themselves, and as preventative, and diagnostic healthcare. For those of us who have been sexually abused, it can bring on an anxiety, or panic attack, it can be triggering, it can be so difficult that many women chose to go without.
I have suggested to the Irish Cancer Society that it might be useful to look at changing how smears and mammograms are offered to women; for example, having SATU-trained nurses deployed in key centres around the county so that women survivors of CSA have access to the kind of consideration and care they need. Small things really can make a difference.
The same can happen around pregnancy – getting pregnant and staying that way. For women who have been abused, the difficulties around conception include everything from receiving fertility treatment to ante-natal appointments and the actual delivery itself. Continuity of care helps, as does a little bit of kindness and understanding.
I have a few tips that work well to ameliorate the difficulties women survivors of CSA can encounter around obs / gynae issues. I won’t go into them here, because of time constraints, and I know you’re not all planning on heading down the Obs-gynae route, but I will send them on to Simon and he can put them up on your version of Loop or Moodle.
In your professional lives, you may find yourselves on the receiving end of disclosure. And that can be very difficult. It’s hard to know what to say to someone, and it can also be really difficult if you are a survivor yourself, or you’re close to someone who is.
I know I said this earlier, but sexual abuse is endemic. Err on the side of caution, and treat all women as survivors until they tell you otherwise.
- Continuity of care is best for women in order to build trust. We are extra vulnerable when pregnant, birthing, and in the peri-natal period.
- If a woman insists on a C-section, listen to that. She may have a much better reason than being ‘too posh to push’. Fear of birth and birthing, of being exposed and vulnerable – particularly in a non-familiar setting (like a hospital) – is understandable in any woman. Even more so in a woman who has lived through CSA.
- Always ask for permission before touching a woman – never assume that your clinical judgement trumps her lived experience.
- Call us by our names. Not ‘Love’ or ‘Sweetheart’. Abusers rarely use our names. Please don’t diminish our personhood.
- Never, ever use the phrase ‘good girl’. We’re not girls. We’re women. Most of us were abused by people who used the phrase ‘good girl’ while they were abusing us, to get us to comply.
- Please don’t use nursery / childish language around us. That can be triggering.
- Don’t tell us to do something, for example, ‘pop up on the bed’. Ask if we’d like to, and explain why you think it is best / necessary.
- Accept ‘no’ as an answer – don’t try and cajole, or persuade us to turn our ‘no’ into a ‘yes’.
- Never tell us you’re going to do something. Ask permission. Our bodies belong to us, even when we’re birthing.
- Never perform a VE unless it’s necessary (hint: during labour, it’s never necessary).
- Be aware that our physiological responses may be different to other women’s, and / or to what’s ‘expected’.
- Don’t rush with interventions because we’re taking ‘too long’. Trust us. Trust our bodies.
- After birth, breastfeeding – no matter how much we want to – may be extremely triggering. Have compassion.
Sticking with the subject of infertility, sometimes women avoid sexual contact, even though they deeply desire a child because of the brutality of orgasms. (link here to the piece I reference: https://www.ourbodiesourselves.org/stories/sexual-abuse-colored-view-men/)
So – what do we do or say when someone discloses?
Well, here’s what not to say: (On the Slide)
Three little words – I believe you – to start with, then something like this: (Next Slide!)
And be prepared, that if someone discloses to you, and you react well, they might continue to disclose. You’re not likely to get a linear, start-to-finish account, but you might get a tentative ‘I have a history of abuse, so this might be hard for me.’
Coming back to the idea of no part of the body being unaffected by CSA, here’s a bit of a list:
This probably seems less obvious, but in an interesting study published in 2016 by Alcalá points to connections between child abuse and cancer. Unfortunately, research into the links is plagued by three inter-related issues:
- There is no agreement as to what actions constitute abuse, and how abuse types – physical, sexual, and emotional – are distinct or inter-related.
- Analytic strategies limit the types of conclusions that can be drawn because of how they treat or measure abuse and related concepts and
- Few theories exist to explain the connection between abuse and cancer.
That said, Coker et at (2009) and Afifi et al (2016), find that reporting sexual abuse is associated with increased odds of reporting cancer – but little work has been done around understanding which types of cancer are related to abuse, and what the potential mediators of this relationship might be. Of course, it’s complicated because abuse is related to lower educational achievement, higher unemployment levels and lower earnings.
These socio-economic factors are also associated with higher risk of some cancers (Banks et al, 2006). Then, of course, we’ve got to consider the fact that sexual abuse can lead to very early exposure to HPV; not just as children, but as a result of the documented risky behaviour that sexually abused people often engage in. This leads to persistent infection, and – therefore – an elevated risk for cervical cancers. Now, if you bear in mind the aversion that sexually abused women have, or can have, to smear tests, you can see that these factors combined push us into the high-risk group.
Bessel Van Der Kolk and Suzanne O’Sullivan have both written extensively about the links between mental and emotional trauma – in particular, but not exclusively, the trauma of CSA – and physical trauma. Van Der Kolk is a psycho-therapist, and O’Sullivan is a neuro-surgeon. Both have found that people presenting with ‘unexplained’ physical difficulties can – upon psychological excavation – find an explanation for these difficulties; and it’s rooted in trauma. Not wanting to sound like a disciple of ‘woo’, but their findings, which make perfect sense to me, indicate that the energy trauma that is not dealt with has to go somewhere, so it invades the body, and presents as physical symptoms. Of course the physical trauma, or pain, or disease, is real, but its origins are not obviously in the physical body.
The Icelandic Research centre has conducted research on women who were sexually abused as children and found correlations between sexual abuse and myriad physical diseases and disorders. CSA survivors report complex physical symptoms without medical explanations, such as stomach ache, colon cramp digestion dysfunction and infection; cardiac arrhythmia, angina and hypertension; dizziness, fainting, glandular dysfunction, problems with the lymphatic and nervous systems, and chronic fatigue. They have had problems with sleep since childhood, and six have been diagnosed with fibromyalgia / ME.
All the women participants have suffered unexplained pain in various parts of the body. All have some kind of eating disorder, and some of them have used alcohol to try to ease their emotional pain. One of their case-studies, a woman called Heather has been very ill and has had many of the symptoms of a dying person; her oxygen levels fell, the lungs were not functioning well, there were disturbances in nerve function and the heart, as if all bodily functions were slowing down. Extensive medical examinations yielded no results (Sigurdardottir, & Hallsorsdottir, 2013).
The most profound difficulties I have, however, are without doubt the ones that affect my mental health. I have recently accepted diagnoses for anxiety, and complex post traumatic stress – which occurs when a person is exposed to emotional trauma over a long period of time, and over which they have no control, and from which there is little or no hope of escape.
Again, having a diagnosis helps me to understand why I feel, and react, the way I do to certain circumstances – and, indeed, people.
Anxiety, for its part, isn’t just being a bit nervous, it’s a physical sensation in my solar plexus that paralyses me. It feels as though a fear like molten-lead has been poured into my core; rendering me terrified to move, and irrationally worried for the people in my life that I love most. It cripples me. It also heightens my emotional responses to things and makes me (feel as though I) become an emotion – rather than just experience an emotion.
In case you start to think that I’m blaming my abuse for everything that ever happened to me, I’d just like to mention that there is empirical evidence for this. A 2012 study by Roberto Maniglio found that child sexual abuse is very much a risk factor for anxiety disorders. His research points to the fact that PTD is more related to child sexual abuse than other anxiety disorders. Male victims are at the same risk as their female counterparts. The risk of developing anxiety, interestingly isn’t linked to the severity of the abuse, or the age of onset. He also found that alterations in brain structure or function information processing biases, parental anxiety disorders family dysfunction, and other forms of child abuse may interact with CSA or act independently to cause anxiety disorders in victims.
What he doesn’t address is how early in life we can expect anxiety to manifest in victims, but that may also be due, in part, to how infrequently – until recently – children were diagnosed with anxiety.
I also spent years self-harming, and I have to confess I adored the sense of psychic relief that the physical pain brought. I was self-harming before the phrase was in use, and the word used back in the 1990s was ‘cutter’ and my goodness, did I apply myself to living up to that title.
My favourite target was my breasts – the most obvious ‘cause’, to my teenaged mind, of my abuse. Part of me thought that if I could just perform a DIY mastectomy, no one would ever sexually assault me, or rape me again. Cysts have formed under the scar tissue of where I cut myself, and sometimes get painful, so there’s another long-term side effect that you don’t automatically associate with child sexual abuse.
Years later, though, I was so glad I hadn’t been successful in chopping my own breasts off. Not only did I breastfeed my own two girls – my youngest until she was five and a half, I contributed daily for over a year to the human milk bank in Fermanagh – helping hundreds of children in the process. I mention this not because I think it makes me a better person, but because it was hugely useful in my own healing journey: My body suddenly doing something ‘right’ suddenly being ‘useful’, suddenly being helpful to others because I chose it to be was empowering.
The other thing I’m really glad I didn’t manage to do was kill myself. I was seven when I learnt the word ‘suicide’, and understood that it described what I’d been trying to do to myself. Suicidal ideation never really left me until October of 2016. I won’t go into details here – for no other reason than it’s a long story…
But October was significant for me, not least because I was so calm about what I saw as my impending death; I saw no way I could make things better. No way that I could improve my situation. No way that I could feel better about myself and the life I was living. I was so overwhelmed by everything. I couldn’t find a way out, and I really didn’t want to. I’d just had enough. I wasn’t sad. I was relieved. Relieved that I had an ‘end date’ in sight. I found I didn’t have the energy, or the desire, or the commitment to my own life, to keep going.
Just as I was getting my affairs in order, small, positive changes started to take place, in quick succession. Maybe it was just pure, dumb, luck, maybe it was Divine Intervention, maybe it was nothing more than coincidence. I’m not going to analyse it too carefully – I’m just glad I’m still here.
But, on that occasion, I didn’t engage with the traditional mental health services, or with my GP, or other medical professionals. On previous occasions, however, I did – and I found that I frustrated the doctors who saw me: Whether that was my own GP or a psychiatrist in a nearby hospital. I didn’t present as expected. I was lucid, logical, crying, but not sobbing. Crying in a way that it appeared my eyes were just leaking, rather than I was ‘upset’. It appeared that there was an incongruity between my words – I was very clearly saying ‘I want to die’, but my body, my demeanour didn’t seem to be translating that in a way that the doctors had been taught, or trained to expect. I can be a challenge, I accept that.
Afterwards, however, after I’d been sent home and after I’d regained a sense of ‘let’s give this living crack another go’, I thought about my experience, and I realised something that could have made a very significant difference very easily, and very early on.
If one person had, rather than ‘what’s wrong with you?’ asked ‘what happened to you?’ the outcome of that particular episode might have been very different. My anguish – if I had felt invited to explain myself, invited to be heard – might well have been diminished quicker, easier, and in a safe, supportive environment.
Still, I survived. And, as I said I’m glad I did. And I’m glad I’m here. I’m glad to be here. Glad to be able to share some of my story with you. Glad to be able to stand here and say to every person in this room who has ever been affected by child sexual abuse; well done. You made it. You’re here, too. And you are not alone. You are never alone.
Alcalá, H.E. 2016, “Making the connection between child abuse and cancer: Definitional, methodological, and theoretical issues”, Social Theory & Health, vol. 14, no. 4, pp. 458-874.
Brennenstuhl, S. and Fuller-Thomson, E. (2015). The Painful Legacy of Childhood Violence: Migraine Headaches Among Adult Survivors of Adverse Childhood Experiences. Headache: The Journal of Head and Face Pain, 55(7), pp.973-983.
Greenfield, E., Lee, C., Friedman, E. and Springer, K. (2011). Childhood Abuse as a Risk Factor for Sleep Problems in Adulthood: Evidence from a U.S. National Study. Annals of Behavioral Medicine, 42(2), pp.245-256.
Irish, L., Kobayashi, I. & Delahanty, D.L. 2010, “Long-term Physical Health Consequences of Childhood Sexual Abuse: A Meta-Analytic Review”, Journal of Pediatric Psychology, vol. 35, no. 5, pp. 450-461.
Kaleağasi, H., Özge, A., Toros, F. And Kar, H. (2009). Migraine type childhood headache aggravated by sexual abuse: case report. AĞRI, 21(2), pp.80-82.
Maniglo, R. 2012, “Child Sexual Abuse in the Etiology of Anxiety Disorders: A Systematic Review of Reviews”, Trauma, Violence, and Abuse, vol. 14, no. 2, pp. 96-112.
McGee, H., Garavan, R., de Barra, M., Byrne, J. and Conroy, R. (2002). The SAVI Report – Sexual Abuse and Violence in Ireland. Dublin: Liffey Press.
Sigurdardottir, S. & Hallsorsdottir, S. 2013, “Repressed and silent suffering: Consequences of childhood sexual abuse for women’s health and well-being”, Nordic college of Caring science, vol. 27, pp. 422-432.
Simkin, P. and Klaus, P. (2011). When survivors give birth. 1st ed. Seattle: Classic Day Publishing.
Tietjen, G. and Peterlin, B. (2011). Childhood Abuse and Migraine: Epidemiology, Sex Differences, and Potential Mechanisms. Headache: The Journal of Head and Face Pain, 51(6), pp.869-879.
Van Der Kolk, B. (2014). The Body Keeps The Score. London: Penguin