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The effects of child sexual abuse
MacIntyre, Deirdre; Carr, Alan
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1999
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Journal of Child Centred Practice, 6 (1): 87-126
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Irish Society for the Prevention of Cruelty to Children
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MacIntyre, D. & Carr, A. (1999).The effects of child sexual abuse. Journal of
Child Centred Practice, 6, (1), 87-126.
36
Prevention of CSA
THE EFFECTS OF CHILD SEXUAL ABUSE
A substantial body of empirical evidence now shows that child sexual abuse has
profound effects on the psychological adjustment of children (Kendall-Tackett,
Williams & Finkelhor, 1993) and these effects in some instances continue on into
adulthood (Beitchman, Zucker, Hood, Da Costa & Akman, 1991). A wide range
of factors mediate the impact of abuse on adjustment (Spacarelli, 1994). In this
chapter the impact of sexual abuse on children and adults will be addressed with
reference to the empirical literature in the field and the implications of this for
prevention considered.
DOMAINS AFFECTED BY SEXUAL ABUSE
Sexual abuse can affect children's functioning in the following domains:
behavioural adjustment; attachment; intrapsychic integration and dissociation;
and physiological functioning.
Effects of CSA
37
Behavioural adjustment
Sexually abused children exhibit more behavioural problems compared with
their non-abused counterparts (e.g. Cohen & Mannarino, 1988; Gomes-Schwartz
et al, 1990; Tong, Oates & McDowell, 1987; Kendall-Tackett, Williams &
Finkelhor, 1993). Sexually abused children typically become either more
withdrawn, depressed, disinterested in school and other activities or they become
angry, aggressive and disruptive. That is, they may display both internalising and
externalising behaviour problems (Achenbach, 1984). In addition a proportion
show inappropriate sexual behaviour. (e.g. Gale, Thompson, Moran & Sack;
1988, Friedrich & Leucke, 1988). This is uniquely related to the process of
premature sexualisation inherent in the abuse. Explicit sexual behaviours among
non-abused children are rare but are exhibited by a significant proportion of child
sexual abuse victims.
Sexually abused children tend to display compulsive
sexual behaviours and may also engage in sexual behaviour imitative of adult
sexual activity (Friedrich, Grambsch, Damon et al, 1992). In adulthood,
psychosexual difficulties are common among survivors of child sexual abuse
(e.g. Browne & Finkelhor, 1986; Courtois, 1988).
Attachment disruption
Children victimised at an early age by their primary caregivers develop insecure
attachments (Carlson, Cicchetti, Barnett & Braunwald, 1989). These early
attachment difficulties lay the foundation for relationship difficulties at later
stages of development (Cicchetti & Lynch, 1993). There is substantial evidence
that difficulties in interpersonal relationships are reported by both children
(Friedrich, Beilka & Urquiza, 1987) and adults who have been sexually abused
(Courtois, 1988; Elliot, 1994).
Insecure attachments may also predate and
increase vulnerability to abuse or previously secure relationships may be
disrupted by the trauma of abuse. For instance, the reaction of parents to a
38
Prevention of CSA
disclosure may destroy trust and compound the child's sense of betrayal and the
effects of the abuse (e.g. Conte & Schuerman, 1987b; Elliot & Briere, 1994;
Gomes-Schwartz et al, 1990).
Alexander (1992) has identified rejection; premature parentification; and
the integenerational transmission of trauma as three attachment-related processes
common in abusive families. The process of rejection results in avoidant
attachment and is often determined by parents' own impoverished experiences of
attachment and care. One critical consequence of rejection is that parents do not
respond appropriately to children's distress. Children then learn that these
feelings fall outside the realm of shareable experiences and so are apt to deny
their own feelings of distress and related needs for safety and security. This
dynamic explains the increased vulnerability of such children to revictimisation
(e.g. Gomes-Schwartz et al, 1990). The second attachment-related process
described by Alexander (1992) is premature parentification. This role reversal
process is commonly observed in sexually abusive families (e.g. Levang, 1989).
Again, this premature parentification deprives the child of the support and
nurturance they need before and after the trauma of sexual abuse and leads them
to construct maladaptive internal working models for relationships which persist
into other developmental stages. The multigenerational transmission of fear and
unresolved trauma evident in abusive families is the third attachment-related
process identified by Alexander (1992). Here the attachment history of the parent
is recapitulated in their relationship with the child. This dynamic is consistent
with empirical evidence on risk factors which contribute to sexual abusive
behaviour (Friedrich, 1990).
Intrapsychic integration and dissociation
Summit (1983) described how sexually abused children trapped in secrecy and
helplessness adapt to abuse by engaging in denial and dissociation. Dissociation
Effects of CSA
39
is typically used by children as a defense mechanism to protect themselves from
overwhelming anxiety. Dissociation
reduces anxiety by
psychologically
negating the pain of the immediate impact of the abuse. In order to cope with
sexual abuse, children may split themselves off from an awareness of what is
happening by dissociating from abuse-related physical sensations or they may
cope by pretending the lower part of their body does not exist. Prolonged abuse
forces the child to routinely rely upon dissociation and so a dissociative response
pattern becomes entrenched (Putnam, 1990). Children victimised during the preschool period are particularly likely to use dissociation as a defence mechanism
and to develop a chronic pattern of dissociation (Kirby, Chu & Dill, 1993). These
same defence mechanisms which facilitate psychic survival in childhood are
serious obstacles to effective psychological integration in later life. Dissociation
may
present in adulthood
disengagement,
as psychic numbing, depersonalisation,
amnesia for the abuse, borderline personality disorder, and
multiple personality disorder (Briere & Conte, 1993; Elliot & Briere, 1995;
Williams, 1994; Herman & Schatzow, 1987; Barnard & Hirsh, 1985; Bryer et al,
1987; Bliss, 1984; Coons & Milstein, 1986; Anderson, Yasenik & Ross, 1993).
Multiple personality disorder, the most dysfunctional outcome of a chronic
pattern of dissociation, is associated with severe forms of victimisation such as
co-occurring sexual and physical abuse prior to age eight (Kluft, 1990).
Physiological functioning
Severe chronic sexual abuse may have long-term effects on neuroendocrine
functioning (Herman & Van Der Kolk, 1989; Pitman, Orr, Forgue, De Jong &
Claiborn, 1987). Putnam and Trickett (1993) found that abnormal levels of
cortisol occur in preadolescent sexually abused girls. Neuroendocrine
40
Prevention of CSA
abnormalities have also been detected in pre-pubescent boys who were victims of
physical and sexual abuse (Jensen, Pease, Ten Bensel & Garfinkel, 1991).
Sexual abuse may also lead to earlier onset of puberty (Herman-Giddens, Sandler
& Friedman, 1988; Trickett & Putnam, 1993).
THE DEVELOPMENTAL COURSE OF SYMPTOMS
In the immediate aftermath of victimisation between one fifth and two fifths of
abused children seen by clinicians show significant psychological adjustment
problems (e.g. Gomes-Schwartz et al, 1990; Mian, Marton & Le Baron, 1996;
Tufts, 1984). As adults, between one fifth a quarter of victims of sexual abuse
experience considerably more impairment than non-victims (e.g. Kendall-Tackett
et al, 1993; Finkelhor et al, 1990; Browne & Finkelhor, 1986). Extreme longterm effects are not inevitable and a majority of victims appear to recover and
function adequately (Bentovim, Von Elberg & Boston, 1988; Gomes-Schwartz et
al, 1990; Lanktree & Briere, 1995).
Fluctuating patterns of symptoms following sexual abuse have also been
observed.
Mannarino et al's (1989) found a significant reduction in the
internalising but not externalising behaviour problems over time and Friedrich
and Reams (1987) reported a rise in sexual preoccupation among preadolescents.
Some long-term effects may be delayed and only appear when the individual
matures
or
life
events
precipitate
the
emergence
of
abuse-related
symptomatology. This sleeper effect occurred in a study by Kinzl and Biebl
(1992) who found that the onset of severe psychological problems in female
survivors of child sexual abuse was precipitated when their own children reached
the age at which they were first victimised.
Sexual abuse may have different effects on children at different
developmental stages (Kendall-Tackett et al, 1993). Abuse related depression for
instance, may be expressed as clingy behaviour in a pre-schooler, as disruptive
behaviour during pre-adolescence, and as a major mood disorder with suicidal
Effects of CSA
41
ideation and self-injurious behaviour in adolescence. Abuse related symptom
patterns common among pre-schoolers, pre-adolescents and adolescents deserve
particular mention and will be outlined below.
Pre-schoolers
While some early studies of sexually abused pre-schoolers appeared to indicate
they were less behaviourally disturbed than older children (Adams-Tucker, 1982;
Gomes-Schwartz, Horowitz & Sauzier, 1985), subsequent findings have not
borne this out (Friedrich et al, 1986; Mian et al, 1986).
The short-term effects
documented as most characteristic of sexually abused pre-school children include
inappropriate sexual behaviour (Friedrich, Beilke & Urquiza, 1988; Friedrich &
Luecke, 1988; Gale, Thompson, Moran & Sack, 1988; Jampole & Weber, 1987)
and excessive internalizing behaviour problems such as tearfulness, nightmares,
clinginess and anxiety (Fagot, Hagan, Youngblade & Potter, 1989; Friedrich,
Urquiza & Beilke, 1986).
Pre-adolescent children
Behavioural and academic problems at school are commonly reported symptoms
among preadolescent children with a history of sexual abuse (Adams-Tucker,
1982; Black, Dubowitz & Harrington, 1994; Elwell & Ephross, 1987; Johnston,
1979; Tong, Oates, & McDowell, 1987). For instance, Tong et al (1987) found
that teachers rated sexually abused children as performing significantly less well
in school work than other non-abused children. However, it is possible that
cognitive deficits may pre-date the trauma of the abuse since the presence of
42
Prevention of CSA
learning difficulties and developmental delays
are
risk factors for
sexual
victimisation (Gomes-Schwartz et al, 1985; Senn, 1988).
Increased internalizing behaviour
problems including depression,
anxiety, poor self-esteem, and post-traumatic stress disorder have also been noted
in this age group (Mannarino, Cohen, Smith & Moore-Motily, 1991; McLeer,
Deblinger, Atkins, Foa & Ralphe, 1988) ). Sexually inappropriate aggressive
behaviour while less manifest in this age group than in sexually abused preschoolers or adolescents is still significantly more frequent among preadolescent
victims than among any non-abused controls (Hewitt & Friedrich, 1990;
Friedrich, 1993; Friedrich, Grambasch, Broughton , Kuiper & Beilke, 1991).
Adolescents
Sexually abused adolescents show a wide range of internalizing behaviour
problems including depression, anxiety, low self-esteem, suicidal ideation, self
injurious behaviour, post-traumatic stress disorder and eating disorders such as
bulimia (Gomes-Schwartz et al, 1985; Sansonnet-Hayden, Haley, Marriage &
Fine, 1987: Lindberg & Distad, 1985; Hibbard et al, 1990; Kendall-Tackett et al,
1993). Higher levels of all these symptoms are reported even in non-clinical
samples of sexually abused adolescents (Gidycz & Koss, 1989). Externalizing
behaviour problems such as running away, truanting and substance abuse are
frequently reported sequelae of sexual abuse among adolescents (Briere & Runtz,
1987; Burgess, Hartman & McCormack, 1987; Gomes-Schwartz et al, 1990;
Lindberg & Distad, 1985).
Increased sexual behaviour among adolescents is manifested as promiscuity
(Gomes-Schwartz et al, 1985; Chandy, Blum & Resnick, 1996), involvement in
prostitution or gender identity disturbance (Bagley & Young, 1987) and sexual
confusion (Friedrich, Beilke & Urquiza, 1987; Sansonnet-Hayden et al, 1987).
Particularly among adolescent males, abuse-related sexualized behaviour may be
Effects of CSA
43
expressed as sexually abusive behaviour towards younger children (Gil &
Johnson, 1993; Green, 1993)
EFFECTS OF CHILD SEXUAL ABUSE ON ADULTS
At least a fifth of sexually abused children suffer
psychological harm (Browne & Finkelhor, 1986).
serious long-term
However, the effects of
childhood sexual abuse on adult adjustment are far from uniform. In adults,
childhood sexual abuse has been found to lead to a wide variety of adjustment
problems including anxiety, post-traumatic stress disorder (PTSD) and
dissociative states; depression and self-injurious behaviour; relationship and
sexuality difficulties; antisocial behaviour and sexual offending; and parenting
problems (Beitchman et al, 1992; Polusny & Follette, 1995).
Anxiety
Anxiety is one of the most common responses to the trauma of child sexual abuse
(Donaldson & Gardner, 1985; Peters, 1988). Sexual abuse survivors in the
general population are more likely than non-victims to suffer from agoraphobia,
panic disorder, obsessive compulsive disorder and social phobia (Ernst, Angst &
Foldenyi, 1993). The extent to which the experience of child sexual abuse
predisposes adult survivors to chronic anxiety is shown by the finding that they
are five times more likely to be diagnosed with an anxiety disorder than their
non-abused peers (Saunders, Villeponteaux, Lipovsky & Kilpatrick, 1992a; Stein
et al, 1988).
Furthermore, in clinical samples, chronic or severe anxiety is
44
Prevention of CSA
correlated with repeated violent sexually abusive experiences (Briere & Runtz,
1987; Herman & Schatzow, 1987).
Post-Traumatic Stress Disorder (PTSD)
Anxiety and fear stemming from the trauma of early sexually abuse may also
manifest itself in the development of post-traumatic stress disorder (e.g. Briere,
1992; Briere & Runtz, 1991; Rowan, Foy, Rodriquez & Ryan, 1994). Child
sexual abuse has been shown to result in PTSD in as many as 36% of adult
survivors and is particularly prevalent in victims reporting contact sexual abuse
and child rape ((Donaldson & Gardner, 1985; Saunders et al, 1992a, 1992b).
While not all victims of child sexual abuse go on to develop full blown PTSD,
the experience of both intrusive traumatic memories and attempts at avoidance of
these memories are common (Elliot & Briere, 1995). A history of concurrent
physical and sexual abuse during childhood may increase the risk of PTSD (e.g.
Rodriguez, Ryan & Foy, 1992).
Dissociation
Dissociation occurs commonly among adult survivors of sexual abuse (Briere &
Runtz, 1987; Chu & Dill, 1990; Kluft, 1990; Putnam, 1990). As has already been
noted,
dissociation
presents
as
psychic
numbing,
depersonalisation,
disengagement, amnesia for the abuse, borderline personality disorder,
or
multiple personality disorder. A significant proportion of child sexual abuse
victims report partial or complete amnesia for their abuse experiences (Briere &
Conte, 1993; Elliot & Briere, 1995; Williams, 1994). This phenomenon was also
noted by Groth and Burgess (1979) among sex offenders asked about childhood
abuse. Many did not deny the experience but were not sure if something had
happened. Dissociation of abuse related memories appears to be correlated with
chronic and violent maltreatment with an early age of onset (Briere & Conte,
Effects of CSA
45
1993; Herman & Schatzow, 1987). An association between borderline personality
disorder and child sexual abuse has been reported by several authors (Barnard &
Hirsh, 1985; Bryer et al, 1987). Multiple personality disorder, the most extreme
manifestation of dissociation, is associated with extremely severe and concurrent
physical and sexual abuse (Bliss, 1984; Coons & Milstein, 1986; Anderson,
Yasenik & Ross, 1993).
Depression and self-injurious behaviour
Depression is consistently reported as the most common long-term effect of child
sexual abuse and has been documented in a variety of clinical and non-clinical
studies (Briere & Runtz, 1988; Browne & Finkelhor, 1986; Mullen et al, 1996;
Russell, 1986; Silverman, Reinherz & Giacona, 1996; Wyatt & Powell, 1988;
Beitchman et al,1992). Stein et al (1988) in a large scale community survey
found that sexual abuse victims have as much as a fourfold greater lifetime risk
for major depression than non-victims. Victims of sexual abuse are more likely to
be identified as requiring treatment, usually for depression (Mullen, RomansClarkson, Walton and Herbison, 1988) and the degree of depression is directly
related to the severity of the abuse (Peters, 1988).
In studies of clinical
populations higher rates of depression have been found in female patients with
histories of sexual abuse compared to psychiatric control groups (Margo &
McLees, 1991; Pribor & Dinwiddie, 1992). Recovery from a major depressive
episode is also negatively affected by a history of child sexual abuse. For
instance, Zlotnik, Ryan, Miller and Keitner (1995) reported that women without a
history of child sexual abuse were three times more likely to have recovered from
depressive episodes by 12 months. Given the strength of the association between
a history of child sexual abuse and depression, it is not surprising that increased
suicidal ideation and self-injurious behaviours have also been linked to sexual
abuse in studies of both community and clinical populations (Bagley & Ramsay,
46
Prevention of CSA
1986; Briere & Runtz, 1986; Bryer, Nelson, Miller & Krol, 1987; Silverman et al,
1996; Briere & Zaidi, 1989; Ernst et al, 1993).
Interpersonal relationships and sexuality
Women who have been sexually abused in childhood report a greater fear of both
men and women (Briere & Runtz, 1988). They report difficulty trusting others
and are more likely to have a history of failed relationships or marriages than
non-abused women (deYoung, 1982; Russell, 1986). They are more likely to
have fewer friends (Gold, 1986), experience less satisfaction in their relationships
and have more maladaptive interpersonal patterns (Elliot, 1994). Sexual
maladjustment has been found to be associated with a childhood history of sexual
abuse in both clinical (e.g. Briere & Runtz, 1988) and non-clinical samples (e.g.
Saunders et al, 1992b). Saunders et al (1992b) found that 32% of sexually
abused subjects, compared to 16% of non abused subjects, met diagnostic criteria
for a psychosexual disorder at the time of interview. Briere and Runtz (1988)
reported that 45% of sexual abuse survivors, compared to 15% of non-abused
clients at a walk-in counselling centre reported sexual problems.
In adulthood, victims of child sexual abuse have been found to engage in
more promiscuous or indiscriminate sexual behaviour (Briere & Runtz, 1991;
Herman, 1981; Courtois, 1988). Such promiscuous behaviour is associated with
higher rates of HIV infection among adult survivors of child sexual abuse
(Zierler, Feingold et al, 1991). Wyatt et al (1993) concluded that the severity of
sexual abuse experiences contributes to the higher frequency of sexual activity
observed during adulthood thus increasing the chance of exposure to HIV
infection and other sexually transmitted diseases.
Another form of high risk behaviour associated with a history of sexual
victimisation in childhood is prostitution which is even more common among
male victims than females (Silbert & Pines, 1981; Zierler, Feingold et al, 1991).
Effects of CSA
47
Just as sexual abuse increases the risk of subsequent sexual victimisation for
children (Gomes-Schwartz et al, 1990) adult victims of child sexual abuse also
show a greater vulnerability to revictimisation, both physical and sexual later in
life (Wind & Silvern, 1992). In summary, child sexual abuse appears to have a
devastating effect on adult sexuality for a significant proportion of victims, these
effects include impaired sexual satisfaction and functioning, promiscuous
behaviour, higher rates of HIV infection, prostitution and a greater vulnerability
for revictimisation which may involve sexual assaults or physical violence.
Anger, antisocial behaviour and sexual offending
Chronic irritability, uncontrollable rage and fear of their own anger are common
complaints among adult survivors of child sexual abuse (Briere & Runtz, 1987;
Donaldson & Gardner, 1985). Survivors are nearly twice as likely to have
problems with anger than non-victims (Briere & Runtz, 1988).
experienced by
The rage
former victims of sexual abuse can intensify when it is
restimulated by interpersonal events which parallel the original experience of
child abuse (e.g. Kinzl & Biebl, 1992). This anger may be internalised as selfinjurious behaviour (e.g. Courtois, 1988) or externalised as antisocial behaviours
including the perpetration of abuse (e.g. Briere & Runtz, 1988; Herman, 1988).
A small proportion of victims externalise their rage by sexually abusing others.
Approximately 30% of offenders report having been sexually abused as children
(Murphy & Smith, 1996) and there is some evidence to suggest that this group of
offenders have higher overall levels of sexual deviancy and increase levels of
psychological disturbances (Langevin, Wortzman, Wright & Handy, 1989). One
hypothesis is that the victim who becomes a victimiser is identifying with the
aggressor and by taking on the abusive role. This identification with the aggressor
may have a number of pay-offs including reducing the sense of powerlessness
associated with the original trauma.
48
Prevention of CSA
Parenting
Women who were sexually abused as children, particularly victims of incest, may
have difficulty parenting their own children and creating a safe and secure home
environment for their offspring
Cole and Woolger (1989) found that female
incest survivors, compared to survivors of extrafamilial abuse, had excessive
expectations of autonomy for their children; were less accepting or supportive of
their children; and also reported greater conflict with their children. Children of
mothers who experienced incest have been found to be at risk for maltreatment
(Cole, Woolger, Power & Smith, 1992). Also, the children of adult victims of
child sexual abuse have a higher
risk for intrafamilial sexual victimisation
(Cohen, 1995; Gelinas, 1983).
MEDIATING VARIABLES
A variety of variables mediate the effects of sexual abuse and these include age
of onset of the abuse; the frequency and duration of the abuse; the degree of
violence involved in the abuse; the nature of the abusive acts; the relationship to
the abuser; the gender of the victim; the child's cognitive appraisal and coping
style; family support; and the context of the disclosure
Age of onset.
Results of empirical studies on the impact of age of onset of abuse on later
psychological adjustment are far from clear-cut (Beitchman et al, 1992 ; KendallTackett et al, 1993). For example, in studies of children Zivney, Nash and Hulsey
(1988) found that those victims with early age of onset were most likely to show
psychological adjustment problem. However, findings from other studies show
Effects of CSA
49
that children abused during pre-teenage and teenage years show the greatest
levels of disturbance (Adams-Tucker, 1982; Sirles, Smith & Kusama, 1989). The
picture emerging from studies of adult survivors is also equivocal. While some
studies have reported a clear association between younger age and greater
adjustment problems (e.g. Courtois, 1979; Meiselman, 1978: Ussher &
Dewberry, 1995; Sedney & Brooks, 1984; Murphy, Kilpatrick et al, 1988), other
have found no significant association (Finkelhor, 1979; Langmade, 1983;
Russell, 1986). Bagley and Ramsay (1986) reported that when the traumatic
effect of penetrative abuse was controlled for, the effect of age of onset of abuse
was no longer significantly associated with the degree of later maladjustment.
The major difficulty in assessing the independent contribution of age of
onset to outcome is that this variable is connected with several other abuse
specific variables.
Older children and adolescents are more likely to be
subjected to penetrative abuse (e.g. Murphy, Kilpatrick et al, 1988) while
younger children are more likely to be abused by a father or stepfather (e.g.
Russell, 1986). Both these variables are associated with high levels of trauma and
harm. Age of onset may also be correlated with duration of abuse which again is
associated with severity of impact. Furthermore, because the full extent of the
aftermath of the abuse may not be evident when children are first assessed the
effects of the abuse may be underestimated (Gomes - Schwartz et al, 1990) .
It is also probable that severe and repeated sexual, has a more detrimental
effect on psychological adjustment if it begins when the child is very young
because it disrupts the child's sense of safety and security and may lead the child
to adopt dissociation as a defence mechanism (Cole & Putnam, 1992). In contrast
it is also probable that less severe forms of abuse, particularly abuse that does not
involve physical contact such as exhibitionism or voyeurism has a less marked
effect on younger children since they are less likely to appraise such abuse as
particularly threatening, whereas older children may perceive it as a major threat
to their well being. Clearly, questions remain to be answered about the
relationship of age of onset of abuse to later psychological adjustment.
50
Prevention of CSA
Frequency and duration
The frequency and duration of child sexual abuse is associated with both shortterm and long-term psychological adjustment problems (Beitchman et al, 1992,;
Kendall-Tackett et al, 1993). Briere and Runtz (1985) and Conte and Schuerman
(1987a) in studies of clinical populations of adults and children respectively,
found that the duration of abuse was the factor most strongly associated with
degree of maladjustment. The findings of several non-clinical studies all support
the increased traumatising effect of abuse of extended duration (Bagley &
Ramsay 1986; Peters, 1988; Russell, 1986; Tsai, Feldman-Summers & Edgar,
1979) . These results are particularly persuasive because they are based on
community samples of adults and so represent a wide spectrum of frequency and
severity of abuse. Sexual abuse by multiple perpetrators has also been associated
with more severe outcome in both children and adults (e.g. Friedrich et al, 1986;
Wind & Silvern, 1992).
Violence
In studies of sexually abused children, sexual abuse involving violence has
consistently been found to lead to more profound psychological problems (e.g.
Conte & Schuerman, 1987a; Cohen and Mannarino, 1988; Elwell & Ephross,
1987). This finding parallels the trends reported in studies of adult survivors of
sexual abuse (e.g. Gold, 1986; Mullen et al, 1988; Peters, 1988; Russell, 1986).
In Elwell and Ephross’ (1987) sample of school-age sexual abuse victims,
the most severe symptoms were associated with physical injury to the child, the
use of force by the perpetrator and sexual abuse involving penetration. Cohen
and Mannarino (1988) found that children who experienced abuse involving
physical force or vaginal penetration subsequently engaged in a high level of
aggression and externalising behaviour problems.
This suggests that more
Effects of CSA
51
violent assaults may result in more subsequent aggressive behaviour by the
victim.
Beitchman (1992) in his review of long-term effects of child sexual abuse,
asserts that the interaction of violence and aggression with sexual abuse may
produce effects specific to this combination which do not occur or are rarely
associated with the presence of either aggression or sexual abuse alone. These
effects include Multiple Personality Disorder and suicidality. Studies such as
those by Mullen et al (1996) and Gold (1986) indicate that the concurrent
experience of multiple forms of abuse produce higher levels of psychopathology
and poorer outcome patterns among survivors.
Type of sexually abusive act
While the literature is clear on the impact of violent sexual assault during
childhood, whether the type of abusive act consistently influences trauma is less
certain (e.g. Finkelhor, 1979). The results of some studies which focused on
short-term effects of abuse, such as those by Elwell and Ephross (1987) and
Mian, Marton and Le Baron (1996), suggest that experiences which involve
penetration do result in more severe symptomatology in childhood. Most of the
available research on adult survivors of sexual abuse also implicate more serious
sexual abuse, including anal or vaginal penetration as a major factor in producing
serious long-term psychological problems (e.g. Bagley & Ramsay, 1986; Russell,
1986; Wind & Silvern, 1992). Studies which failed to find an association between
the severity of the abusive acts and degree of adjustment problems (e.g.
Finkelhor, 1979; Fromuth, 1986) had very low rates of actual or attempted
intercourse among sample participants, limiting the scope of these studies in
terms of assessing this particular variable. The available evidence from studies
where abuse involving penetration was frequent enough to permit valid
conclusions to be drawn, suggests that more invasive abuse is associated with
52
Prevention of CSA
more traumatic impact in the short-term (e.g. Black, Dubowitz & Harrington,
1994) and in adulthood (e.g. Mullen et al,1988).
Relationship to Offender
The most devastating violation of trust occurs when the perpetrator is closely
related to the victim (e.g. Kendall -Tackett et al, 1993; Beitchman et al, 1992).
Studies investigating the relationship between the identity of the perpetrator and
victim distress have consistently found that abuse by a father or stepfather is
associated with the most serious sequelae in both children and adults (e.g.
Adams-Tucker, 1982; Friedrich et al, 1986; Mian et al, 1996; Peters, 1988;
Russell, 1986; Sirles et al, 1989; Ussher & Dewberry, 1995). Few studies have
examined the differential impact of abuse by fathers compared with stepfathers
but Gomes-Schwartz et al (1990) found that children abused by a parent
substitute (e.g. step-father or mother’s live-in partner) were the most severely
distressed. These children also had the least supportive mothers. These findings
highlight the significance of family intactness and the interaction of maternal
support with the identity of the offender in some cases of sexual abuse.
The consequences for the child and family are likely to be particularly
traumatic when intrafamilial rather then extrafamilial abuse is disclosed. Unlike
extrafamilial abuse, intrafamilial abuse may
lead to
family break-up and
imprisonment of the abuser or disbelief and scapegoating of the abused child.
The frequency and duration of the abuse is also likely to be of greater
significance when the perpetrator is a family member compared with cases of
extrafamilial abuse (e.g. Bagley & Ramsay,1986). Thus, the association of abuse
by a close family member, particularly a father or father figure, with the most
severe outcomes is complex
since other variables are involved including
frequency and duration of abuse; anticipated consequences of disclosure; and
actual consequences of disclosure.
Effects of CSA
53
Gender of the victim
The gender of the victim is associated with both the nature of the sexual abuse
experienced and subsequent psychological adjustment problems. Pierce and
Pierce (1985) in a chart review of 15 male and 180 female victims of child sexual
abuse found that boys were more likely to be abused by a stepfather and girls
were more likely to be abused by their natural fathers. According to these
authors force and violence were more likely to be used against male victims.
Other studies have found that the co-occurrence of physical abuse is more
common in male victims (e.g. Sansonnet-Hayden et al, 1987; Sirles et al, 1989).
While Adams-Tucker (1982) reported that girls were more likely to suffer
multiple sexual victimisations and abuse of longer duration. These studies show
that the experience of abuse may differ for males and females.
Briere et al (1988) and Seidner, Calhoun and Kilpatrick (1985) found
higher levels of maladjustment in male victims as compared with female victims.
Chandy, Blum and Resnick (1996) examined gender differences in outcomes of
sexually abused youngsters and found that female adolescents with a history of
child sexual abuse engaged in more internalising behaviour problems while males
displayed a tendency to show more externalising behaviour problems. Males
were at higher risk than females of poor school performance, delinquent activities
and sexual risk taking.
Conversely female adolescents were more likely to
develop suicidal ideation, self-injurious behaviour and eating disorders. Among
the sequelae specifically associated with males are sexual preoccupations and
compulsiveness (Singer et al, 1989), gender identity confusion and sexual
orientation confusion (Finkelhor, 1979). Finkelhor (1979) found that males who
had been sexually abused prior to age 13 by an older male were four times more
likely to be homosexually active. The high rate of child sexual abuse histories
among sex offenders (approximately 30%) demonstrates the long-term impact of
child sexual abuse on adult male sexual adjustment (e.g. Becker, 1988).
54
Prevention of CSA
Cognitive appraisal and coping
Victims' appraisals of abusive experiences, their attribution of blame and their
understanding of the social and interpersonal meaning of abuse, as well as the
coping strategies they use to deal with trauma account for some of the individual
differences in the impact of similar traumatic experiences on different victims
(Spaccarelli, 1994). Younger children’s lack of understanding may buffer them
from the immediate impact of trauma, although realisation in retrospect can have
very negative consequences (Gelinas, 1983). Higher levels of cognitive
functioning are correlated with greater reported distress (Shapiro, Leifer, Marton
& Kassem, 1990). This may be because older children or those with more
sophisticated cognitive functioning are more aware of the implications of the
abuse. Changing cognitive appraisals may also effect willingness to disclose
abuse (Finkelhor, 1995). For instance, boys become more reluctant to disclose
abuse as they approach puberty due to an increased awareness of the stigma
related to homosexuality ( Urquiza & Keating 1990; Watkins & Bentovim, 1992).
Among the abuse related cognitions reported by children are self-blame,
perceptions of the self as different to peers, and reduced interpersonal trust
(Mannarino, Cohen & Berman, 1994 ). It is not surprising that many adult
survivors of abuse continue to experience abuse-related cognitions in the form of
self-blame, low self-esteem, lack of a sense of self-efficacy, feelings of
helplessness and perceptions of life as threatening or hopeless (Gold, 1986; Jehu,
1988). These negative appraisals are associated with impaired psychological
functioning in adults and adolescents (Drauker, 1989; Morrow, 1991). Greater
distrust in children is associated with a global, stable and internal attributions for
abusive experiences reflecting a sense of self-blame as constant across time and
situations (Wolfe, Gentile & Wolfe, 1989) .
The coping strategy which appears to be associated with the most severe
symptomatology is avoidant coping, represented by denial, dissociation and
suppression (e.g. Johnson & Kenkel, 1991; Leitenberg, Greenwald & Cado,
Effects of CSA
55
1992). Active coping strategies such as disclosure and support seeking are
associated with better long-term adjustment, although purposeful disclosure may
be associated with increased distress initially (Gomes-Schwartz et al, 1990;
Wyatt & Newcomb, 1990).
However the positive impact of active coping
strategies is likely to be mediated by the response to disclosure of significant
members of the child's network and the amount of support available, particularly
from non-abusing parents and family members.
Family factors
A number of specific features of the family environment are risk factors for
sexual abuse (Beitchman et al, 1991). These include family breakdown and
dysfunction (Mian et al, 1986);
parental psychopathology and violence
(Friedrich & Leucke, 1988); and parental substance abuse (Burgess et al, 1987).
Significantly, a history of sexual abuse in the mothers of sexually abused children
has been reported in a number of studies (Friedrich & Reams, 1987; SansonnetHayden et al, 1987; Smith & Israel, 1987). This implies the possibility of an
inter-generational transmission of sexual abuse.
In addition to increasing the likelihood of intrafamilial sexual abuse,
family dysfunction may also exacerbate the effects of the abuse (Alexander,
1992; Courtois, 1988). Higher levels of distress are found in children whose
families
are
characterised
by
communication
problems,
organizational
difficulties, high levels of conflict and low levels of cohesion (Friedrich &
Reams, 1987; Mian et al, 1996).
Maternal support and belief in the child’s disclosure of sexual abuse and
warmth toward the child promotes recovery and helps to mitigate the impact of
trauma (Conte & Schuerman, 1987b; Everson, Hunter, Runyan, Edelson &
Coulter, 1989; Peters, 1988). Maternal support is compromised most often when
the perpetrator is a step-father or boyfriend (Elliot & Briere, 1994; GomesSchwartz et al, 1990). Children who lack maternal support are more likely to
56
Prevention of CSA
recant an abuse accusation (Elliot & Briere, 1994) and to experience an out-ofhome placement (Hunter, Coulter, Runyan & Everson, 1990).
The context of disclosure
The way disclosure occurs and the context of the revelation are important
predictors of both short and long-term consequences for the victims of child
sexual abuse (Everson et al, 1989; Gomes-Schwartz et al, 1990; Sauzier, 1989;
Wyatt & Mickey, 1988; Russell,1986). Most sexual abuse is never disclosed
(Finkelhor, 1990; Russell, 1986) and only a minority of abuse is ever reported to
authorities subsequent to disclosure (e.g. Saunders et al, 1992a; Wyatt & Mickey,
1988). Among adult survivors of child sexual abuse, nondisclosure of abuse has
consistently been found to be associated with more profound psychological
adjustment problems in adulthood (e.g. Wyatt & Mickey, 1988; Wyatt &
Newcomb, 1990). For children the lowest levels of distress are found among
those who did not disclose abuse but whose abuse was discovered accidentally
(e.g. Sauzier, 1989). Taken together, these findings suggest that disclosure is
inherently stressful and results in increased levels of symptomatology in the
short-term but may lead to enhanced recovery in the longer-term.
The levels of stress and trauma associated with disclosure are strongly
associated with family dynamics and the anticipated and actual reactions of
caretakers and others to the revelation of the abuse. (Sauzier, 1989; Lawson &
Chaffin, 1992; Sorenson & Snow, 1991). As mentioned previously, support from
non-abusing parents and their belief in the child’s disclosure is a critical factor in
the child’s adaptation to sexual abuse (Everson et al, 1989; Gomes-Schwartz et
al, 1990; Wyatt & Mickey ,1988). Children who are well supported show fewer
adjustment problems.
Believing a child’s disclosure, offering protection and support and
refraining from blame or pressure are considered crucial to the child’s recovery.
However, as Lawson and Chaffin (1992) point out, parental attitude to disclosure
Effects of CSA
57
is not a discrete post-disclosure event but may be explicitly or covertly manifest
prior to the disclosure itself. It may therefore influence not only post-disclosure
adjustment but also the child’s decision to reveal the abuse. Lawson and Chaffin
(1992) studied 18 children who were not previously suspected of being sexually
abused, and for whom there were only physical indicators of possible abuse (i.e.
sexually transmitted disease). They found that children whose caretakers
accepted the possibility of sexual abuse disclosed at a rate 3.5 times that of those
whose caretakers denied any possibility of abuse.
Professional interventions following disclosure and the nature of the legal
process in which the child participates may influence the impact of abuse on the
child's psychological adjustment. For example, multiple interviews by different
personnel are associated with greater psychological adjustment problems
(Tedesco & Schnell, 1987), although repeated interviews by the same person may
not increase distress. The specific effects of court involvement and testimony
have been investigated in a small number of longitudinal studies. For example,
Runyan et al (1988) reported that poorer recovery was
associated with
participation in protracted legal proceedings. Williams (1991) demonstrated that
some of the adverse effects of court testimony could be mitigated by giving
videotaped evidence or using closed-circuit televisions systems. Overall, while
certain types of court proceedings appear to delay recovery, these aspects are
open to modification and consequently, much of the negative impact associated
with legal proceedings is preventable.
CHILD SEXUAL ABUSE ACCOMODATION SYNDROME
Summit (1983) argues that child sexual abuse, its effects and the dynamics of
unsuccessful disclosure may be conceptualized as an accommodation syndrome
with
five
distinctive
features:
secrecy;
helplessness;
entrapment
accommodation; delayed and unconvincing disclosure; and retraction.
and
58
Prevention of CSA
Secrecy
CSA is predicated upon secrecy. The secrecy surrounding the sexually abusive
incident serves both as a source of fear and a promise of safety. The child is
terrified of the implied or explicit consequences of the secret being discovered
and so is intimidated into silence. The child also experiences a sense of safety
from reassurances given by a perpetrator that, as long as the secrecy is
maintained, the child will be all right. So the abused child rarely discloses. The
power of secrecy is demonstrated by retrospective surveys which indicate the
majority of victims never told anyone during their childhood. Summit concludes
that children must be helped to expect a supportive, nonpunitive response to the
disclosure before they will be able to share the secret.
Helplessness
Summit points out that a child is three times more likely to be molested by a
recognized trusted adult than by a stranger. Given the authority of the adult and
the dependence of the child, the victim is easily rendered helpless. It is this
terrified helplessness which is often misconstrued as consent, or compliance. The
child is unable to protest, unable to resist and frequently unable to escape. Adults
may despise helplessness because it runs counter to the cherished adult sense of
free will and are quick to attribute blame to children who submit to abuse.
Summit contends that children need to have their helplessness and noncomplicity
acknowledged and their innocence affirmed if they are not to become filled with
guilt and self-hate for somehow inviting the sexual victimization.
Entrapment and accommodation
Effects of CSA
59
Constrained by the demands of secrecy and rendered helpless by the power
imbalance in their relationship, the sexually abused child has little choice but to
accept the situation in an attempt to survive. The child must find a way to
accommodate to the experience which often entails not only intrusive sexual
demands, but also a need to view the perpetrator as an idealized authority. That
accommodation may entail the child assuming a sense of power and control over
the situation, such that the child accepts responsibility and blame for the sexually
abusive relationship. The normal moral order is reversed. Disclosure becomes a
sin greater than the abuse. Accommodation mechanisms used by children to cope
with this way of viewing their abusive situation include splitting of reality,
altered consciousness, hysterical phenomena, delinquency and self-mutilation.
Delayed, conflicted and unconvincing disclosure
The form which disclosure takes and the factors which trigger it can mitigate
against the youngster being believed. Confronted with an angry and rebellious
adolescent, many adults assume that a disclosure is a revolutionary response
against a parent’s attempt to achieve reasonable control and discipline. Denial
also operates strongly when a child or adolescent who has demonstrated no
outward conflict or behaviour problems discloses sexual abuse. The fact that the
child did not talk before now and showed no signs of abuse can be used to
invalidate the disclosure, or to attribute responsibility for its occurrence to the
victim. Summit concludes that specialists must help skeptics overcome their
disbelief.
Retraction
60
Prevention of CSA
Retraction is described by Summit as an escape route often taken by children and
adolescents in the chaotic aftermath of disclosure. Children can feel revictimised
by the process surrounding validation. Their families may be fragmented and the
perpetrator’s threats may appear to be fulfilled. Retraction restores the family's
equilibrium. The child bears the burden of either preserving or destroying the
family. In the absence of immediate support and strategic interventions to force
the offender to take responsibility for the abuse and its aftermath, the child will
usually retract, thereby undermining the credibility of the original disclosure.
Summit's model highlights that the very dynamics of the Sexual Abuse
Accommodation Syndrome reinforce the victimization of children and society's
complacency and denial of its destructiveness.
Only by challenging and
interrupting the accommodation process can the chain of abuse be broken.
Summit's model is an important framework for understanding some of the effects
of child sexual abuse and the dynamics surrounding chronic abuse and
unsuccessful disclosure. The model highlights the adaptive role of some of the
effects of abuse (e.g., splitting, self-mutilation) and disclosure related difficulties
(e.g. retraction). as being important for the victim’s survival from the victim's
perspective.
TRAUMAGENIC DYNAMICS MODEL
Like Summit, Finkelhor and Browne (1985) have developed a conceptual
framework within which to conceptualize the many effects of CSA. They argue
that sexual abuse traumatises children through four distinctive mechanisms,
which in turn, account for the variety of outcomes experienced by victims. The
four traumagenic dynamics are (a) traumatic sexualisation, or experience of
developmentally inappropriate sexual behaviours; (b) powerlessness, or feelings
resulting from the contravention of the child’s will and domination by
the
abuser; (c) stigmatisation, or the shame, self-blame and negative connotations of
the abuse which the victim internalises; and (d) betrayal , or the shattering of the
child’s belief that trusted adults will protect and not harm them. These key
dynamics, alter a child’s cognitive or emotional orientation to the world and
Effects of CSA
61
distort the child’s self-concept, world view or affective capacities, leading to the
psychological and behavioural problems characteristic of child victims and adult
survivors of sexual abuse.
Traumatic Sexualisation
Traumatic sexualisation is the process involved in the inappropriate conditioning
of the child’s sexual responsiveness and the socialisation of the victim into
distorted beliefs and assumptions about sexual behaviour.
Several distinct
processes mediate the dynamic of traumatic sexualisation. These include the
manner in which sexual behaviour, inappropriate to the child’s level of maturity,
is rewarded and the fact that parts of the child’s body become fetishised by the
abuser and thus acquires distorted importance and meaning for the victim. The
distorted views of sexual behaviour and morality transmitted by the offender also
contribute to traumatic sexualisation as do other frightening aspects of the
abusive experience which may become strongly associated with sexual activity.
Traumatic sexualisation increases the salience of sexual issues (e.g. Gale
et al, 1988) results in confusion about sexual norms or identity (e.g. SansonnetHayden et al, 1987) and accounts for abuse outcomes such as sexual precocity,
compulsive sexuality and sexual aversion or dysfunction (e.g. Burgess, Hartman
& McCormack, 1987; Courtois, 1988), as well as aggressive sexual behaviours
(Friedrich & Leucke, 1988). The impact of traumatic sexualisation is manifest in
the symptomatic behaviour of pre-schoolers in their sexualised play, compulsive
masturbation and age-inappropriate sexual knowledge (e.g. Gale, Thompson,
Moran & Sack, 1988; Friedrich, Grambsch, Broughton, Kuiper & Beilke, 1991).
In older pre-adolescent children, sexual preoccupation, sexual aggression and
other inappropriate behaviours are again more common in sexually abused
children than their non abused counterparts (e.g. Deblinger, McLeer, Atkins,
Ralphe & Foa, 1989; Friedrich & Leucke, 1988). Adolescents may manifest the
impact of this dynamic through promiscuity, prostitution or sexual aggression
62
Prevention of CSA
(e.g. Burgess, Hartman & McCormack, 1987; Sansonnet-Hayden et al, 1987).
Gender identity problems are also found in adolescent victims (e.g. Johnson &
Shrier, 1985; Sansonnet-Hayden et al, 1987). In adulthood, traumatic
sexualization is manifested
as sexual dysfunction or sexual offending (e.g.
Courtois, 1979; Gelinas, 1983).
Betrayal
The traumagenic dynamic of betrayal arises from the child’s realisation that a
trusted person has used, manipulated and failed to protect them. It may involve
the shattering of the child’s confidence in the most fundamental of relationships,
with their parents and thus may destroy or impair their subsequent ability to trust
others (e.g. Mannarino et al, 1994). This betrayal may occur in a variety of ways:
directly, at the hands of the abuser, when the child realises the callous disregard
inherent in the sexual abuse; or betrayal may involve the realisation that others
have colluded with or failed to protect them from the abuser. It may also stem
from the reactions of others to the disclosure of abuse.
Children who are
disbelieved, blamed, or ostracised, experience a double betrayal, in the sense that
the impact of the abuse is compounded by the negative reaction to disclosure
(Finkelhor & Browne, 1985).
The dynamic of betrayal is linked to feelings such as grief, depression,
heightened dependency, mistrust and anger. It is associated with clinging
behaviour, vulnerability to further abuse, intimacy problems and conduct
problems, all well documented sequelae among child victims and adult survivors
of child sexual abuse (Kendall-Tackett et al, 1993; Beitchman et al,1992 ). The
prevalence of depression in survivors of child sexual abuse (e.g. Peters, 1985)
may reasonably be seen as an attenuated grief reaction in the wake of betrayal.
The heightened dependency seen in some young victims (e.g. Mian et al, 1996)
may emerge as a constant search for a redeeming relationship in adulthood which
increases their vulnerability to physical, sexual and psychological revictimisation
Effects of CSA
63
(e.g. Wind & Silvern, 1992; Wyatt & Newcomb, 1990). Difficulty in intimacy
also operates as a form of protection (e.g. Elliot, 1994). At the opposite end of
the spectrum of reactions to betrayal, are hostility and anger
rather than
dependence. The anger and hostility shown by a significant proportion of victims
may be a primitive attempt to protect the self from further betrayal and distress
(e.g. Briere & Runtz, 1988; Donaldson & Gardner, 1985 ). Antisocial behaviour
and offending behaviour are forms of retaliation for the original betrayal (e.g.
Herman, 1988; Gil & Johnson, 1993).
Stigmatisation
The dynamic of stigmatisation relates to the isolation and sense of differentness
experienced by many victims. Keeping the secret of the abuse increases the
victims sense of isolation (e.g. Wyatt & Newcomb, 199o) and diminishes their
self-esteem (e.g. Mannarino et al, 1991; Zivney et al, 1988) leading to negative
self-evaluations. Stigmatisation covers all of the mechanisms which operate to
undermine the child’s positive self image; the sense of shame that is instilled; the
accompanying self-blame; the ostracism suffered; and the negative stereotypes
acquired from society (Kendall-Tackett et al, 1993). These are linked to sequelae
such as social marginalism , for example involvement in drug addiction or
criminal activities or prostitution (Bagley & King, 1990; Silbert & Pines, 1981).
At its most extreme,
the dynamic of stigmatisation
leads to self-injurious
behaviour and suicide (Briere & Runtz, 1987 ; Saunders et al, 1992b).
Powerlessness
The traumagenic dynamic of powerlessness is related to a constellation of effects,
including fear, anxiety and aggression (Finkelhor & Browne, 1985). Symptoms
64
Prevention of CSA
of fear and anxiety, such as nightmares, phobias and somatic complaints which
reflect powerlessness are among the most common reactions noted in sexually
abused children (Adams-Tucker 1981; Tufts, 1984; Kolko, Moser & Weldy,
1988).
Anxiety is also common in adults along with eating disorders (e.g.
Palmer, Chaloner & Oppenheimer, 1992) and dissociation (Briere & Runtz,
1987). The experience of powerlessness impairs the child’s sense of mastery,
competence and their coping skills (Black et al, 1994; Silverman et al, 1996). For
example, Silverman et al (1996) found that sexually abused adolescents showed
an impaired sense of self-efficacy,
learning problems, school
difficulties,
depression and anxiety. Studies of adult survivors of child sexual abuse also
support this association. For instance, the high rates of revictimisation reported
in several studies (e.g. Russell, 1986; Sorenson, Siegel, Golding & Stein, 1991)
suggest that for some victims the feelings of powerlessness associated with the
original abuse persist across time, situations, and relationships and render them
vulnerable to further abuse. Aggression may occur as a compensatory reaction to
the experience of powerlessness. A need to control and dominate typical of male
victims (Silverman et al, 1996) which results in antisocial behaviour (e.g. Bagley
& King, 1990) or at its most extreme, sexual offending (e.g. Gil & Johnson,
1993) arises from the dynamic of powerlessness.
From the preceding account of Finkelhor and Browne’s (1985)
traumagenic dynamics model of child sexual abuse it can be seen that this
conceptualisation provides a comprehensive and multifaceted description of the
multiple processes involved in traumatisation.
CONCLUSIONS
From this discussion it may be concluded that child sexual abuse has a
devastating effect on behaviour, attachment, intrapsychic integration and
physiological functioning which persists throughout childhood and into
adulthood for a significant proportion of victims. Broadly speaking, this review
Effects of CSA
65
shows that with respect to behaviour, child sexual abuse may lead to an increase
in internalizing and externalizing behaviour problems and an increase in
inappropriate sexualized behaviour. At an interpersonal level, sexual abuse may
disrupt parent-child attachment and this in turn may compromise children's
capacity to make and maintain supportive relationships with peers and other
adults. At an intrapsychic level, children may cope with sexual abuse through
dissociation and subsequently develop a dissociative response set which
compromises psychological integration. In the most severe cases this may lead to
the development of multiple personality disorder. At a physiological level, sexual
abuse may lead to abnormal neuroendocrine functioning.
The impact of child sexual abuse shows a developmental trajectory in that
both the nature and severity of symptoms vary with age. Developmentally
specific problems following sexual abuse occur in pre-school children,
preadolescent children, and adolescents. For example, pre-schoolers may show
clingyness, tantrums and frequent masturbation; preadolescents may show
underachievment at school, nightmares and peer relationship problems; while
adolescents may engage in truanting, drug abuse, sexual abuse of others and
prostitution. In adults sexual abuse has been found to lead to anxiety disorders
including PTSD, dissociative states, depression, self-injurious behaviour,
psychosexual adjustment difficulties, antisocial behaviour, sexual offending and
parenting skills deficits.
The impact of sexual victimisation during childhood is mediated by the
age of onset of the abuse; the frequency and duration of the abuse; the cooccurrence of violence; the nature of the abusive act; the relationship of the
victim to the perpetrator and the gender of the victim. Broadly speaking, poorer
psychological adjustment occurs in boys and is associated with intrafamilial,
frequent, chronic abuse which began at an early age and involved penetration
and violence.
The impact of child sexual abuse is also mediated by the types of coping
strategies used, the availability of social support, and the way in which the family
and professionals respond to disclosure. Better psychological adjustment occurs
66
Prevention of CSA
in cases where children do not attribute the cause of the abuse to themselves;
cope with the abuse by disclosing it to a trusted peer or adult; receive support and
warmth from the non-abusing parent and other members of their social network;
and engage in a brief minimally intrusive legal process. Poorer psychological
adjustment occurs where children blame themselves for the abuse; use denial,
dissociation and avoidant strategies to cope with the abuse and other life
difficulties; and do not disclose the abuse to adults. In cases where children make
disclosures about the abuse, poorer adjustment occurs where children find that
the non-abusing parent or others disbelieve them and are forced to engage in
multiple forensic interviews with different interviewers and participate in
protracted legal proceedings.
Finkelhor and Browne's (1985) traumagenic dynamics model offers a
parsimonious yet comprehensive framework for conceptualising the complex and
multi-dimensional nature of the effects of child sexual abuse. Within this model
the traumatization process in cases of sexual abuse may be conceptualized as
being underpinned by four distinct mechanisms: traumatic sexualization,
powerlessness, stigmatization and betrayal. Traumatic sexualization accounts for
the inappropriate sexual behaviour
shown by victims of sexual abuse. The
dynamic of betrayal accounts for subsequent attachment and relationship
difficulties. Negative self-evaluation, depression and self-injurious behaviour are
accounted for by the dynamic of stigmatization. Excessive anxiety on the one
hand and excessive anger on the other are accounted for the dynamic of
powerlessness within Finkelhor and Browne's model.
The devastating effects of child sexual abuse provide grounds for the
development of and evaluation child abuse prevention programmes. The
multifaceted nature of abuse the and factors which mediate its impact suggest that
prevention programmes should be multisystemic and target not only children but
also significant members of their social networks including parents and teachers.
That is, prevention programmes should aim to help children develop safety skills.
However such programmes should also aim to help parents and teachers create a
Effects of CSA
67
supportive context within which children's use of safety skills is encouraged and
children's disclosures of abuse are believed.
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