HOW CHILDHOOD SEXUAL ABUSE AFFECTS INTERPERSONAL RELATIONSHIPS
HOW CHILDHOOD SEXUAL ABUSE AFFECTS INTERPERSONAL RELATIONSHIPS
By Neil D. Brick
Copyright 2005 All Rights Reserved
Childhood sexual abuse (CSA) and its effect on symptomology and interpersonal relationships is a relatively new field historically. Legislation has been passed protecting children from rape and sodomy in many European countries. In the 18th and 19th centuries, books advised parents how to prevent child sexual abuse. But child sex abuse was not seen as a major problem in Europe and the United States until fairly recently. Only in the last two decades has childhood sexual abuse been seen in the field of mental health, psychiatry and social work as an important social problem with effects connected to this trauma (Baker, 2003). Though there has been a lot of discussion about how it correlates with a variety of illnesses and psychiatric diagnoses (Styron & Janoff-Bulman, 1997; Gelinas, 1983) there has been little discussion of how childhood sexual abuse actually affects interpersonal relationships directly.
Childhood sexual abuse has been defined in a variety of ways. These different definitions include overt (defined as direct physical abuse or contact) and covert abuse (nonphysical abuse or noncontact), as well as differentiations in each category, including penetration and fondling for overt abuse and spying (or peeping), exposing and inappropriate sexual comments for covert abuse (Collings, 1995).
Interpersonal relationships can be defined as the connection between two people, communicative and physical (which includes touch and body language). Variables that affect interpersonal relationships include emotional states (such as fear or depression), social skill levels, repetition compulsion (including revictimization), trust of others, oneself and life situations, brain damage or conditioning (as seen in Post-Traumatic Stress Disorder or PTSD), styles of relating and attachment, sexual needs, desires and dysfunctions, transference issues, codependency issues, diagnoses and psychopathology and general intimacy and relationship issues.
“How Does Childhood Sexual Abuse Affect Interpersonal Relationships?” and the hypothesis “does childhood sexual abuse have deleterious effects on the variables pertaining to adult interpersonal relationships?” will be discussed by examining each of the various parts of the hypothesis and then by breaking them down into variables. This topic is of great importance because once one can look at the adult symptomology pertaining to childhood sexual abuse, one will be able to make more appropriate diagnoses and interventions of adult pathological symptoms and problems for those patients with abuse histories. Patients with misdiagnoses may not receive appropriate treatment and may not recover as quickly as those that are properly diagnosed (Gelinas, 1983). This article will first discuss the different definitions of childhood sexual abuse (CSA), including the delineations between covert and overt sexual abuse. It will also cover the comparisons of these types of abuse to the deleterious effects they may cause on the variables.
The variables will then be separated by category. These categories will include social problems, psychiatric diagnoses, physiological diagnoses or aspects, sexual dysfunctions or problems and thought problems or perceived disorders. Though there is some overlap between the variables in these categories, these categories have been chosen to divide up the research. This article will cover the views in journal articles, theses and the popular literature. Similarities and discrepancies that arise between these different views and types of presentations will be discussed and compared.
Covert and Overt Sexual Abuse
Contact and noncontact forms of CSA may each have different findings in terms of abuse related effects. Definitional issues may affect the results measured from abuse related effects. Dysfunctional family relationships may also contribute to adult maladjustment (Collings, 1994). A study by Collings (1994), attempted to measure these variables by looking at a nonclinical sample of adult males reporting CSA. It compared them to a nonvictimized sample from the same population and measured their psychological adjustment using certain outcome measures. One pre-research hypothesis explored was that men who had experienced CSA before age 18 were thought to have more psychological difficulties than those with no CSA The subjects were 284 male undergraduates at the University of Natal in South Africa. Two definitions of abuse were used. All were defined as unwanted before the age of 18. One definition involved contact (overt), such as manual genital contact or intercourse. The second definition was defined as noncontact (covert), involving exhibitionism and sexual invitations. The study used the Brief Symptom Inventory (BSI), which is a 53-item self-report checklist, which measures nine main symptom dimensions. These include Psychoticism, Paranoid Ideation, Phobic Anxiety, Hostility, Anxiety, Depression, Interpersonal Sensitivity, Obsessive-Compulsive and Somatization. In addition to the BSI dimensions, two different measures of parental rearing behavior were measured in the study. Two subscales of the EMBU (Swedish initials for own memories of chid-rearing experiences) were used. These subscales were the “Abusive” and “Rejecting” subscales (Collings, 1994). The respondents were divided into three categories: a control group that did not experience CSA, a noncontact CSA group and a contact CSA group. The control group was 71% of the entire sample. The noncontact group was 20% of the sample. The contact abuse group was 9% of the sample. None of the CSA experiences were reported to the police and none of the men sought counseling after the abuse. The noncontact group compared to the control group showed no real significant effect for CSA when the covariates of abusive and rejecting parenting were also looked at. The contact group however showed significant effects for both parenting variables. This group also showed a significant main effect for the history of abuse. All scales of the BSI were significantly elevated, producing a significant increase in the BSI Global Severity Index. The author concludes that the hypothesis that CSA causes later problems in adult psychological adjustment was supported for those with overt (contact) abuse, but not for those with covert (noncontact) abuse (Collings, 1994).
In a review of the CSA research by Browne and Finklehor (1986), it was found that the types of abuse that were the most damaging involved father figures, force and genital contact. This review limited its research to studies to female subjects, due to the fact that at this time few studies had been done with male survivors of CSA. In terms of the duration and frequency of abuse, only four out of the nine studies examined found that duration was connected to greater trauma. Three of the studies found that there was no relationship between the two and two of the studies found some evidence that less trauma was associated with longer duration. Three studies found increased trauma with relatives over nonrelatives. Other studies showed no difference between the abuse impacting family members and others. However, it was found that abuse trauma was greater when perpetrated by fathers or father figures
Browne and Finklehor (1986) discuss a study by Russell where 59% of adult women reporting attempted or completed intercourse, cunnilingus, fellatio, analingus, or anal intercourse stated they were extremely traumatized, where only 36% of women that experienced manual touching of unclothed genitals or breasts and 22% reporting unwanted touching or kissing of clothed body parts reported they were extremely traumatized. Penetration is also found in other studies to be the most powerful variable which explains the strength of one’s mental health impairment. There is disagreement in some studies as to whether penetration and intercourse can be shown to be more serious than manual contact.
Browne and Finklehor’s (1986) review of the research also found that an abuser’s use of force explained more of the variance of the victim’s negative reactions than any other variable. The argument that survivors of forced abuse would have less long-term trauma due to the fact they could more easily blame the abuser does not appear to be backed by empirical studies. They also looked at the age of onset as a factor in measuring the extent of trauma. It has been found in some studies that younger children are somewhat more vulnerable than older children to trauma. It was found that prepubertal CSA experiences correlated with an impact on a woman’s sense of self and long-term relationships with men. Other studies did not find a significant impact between age of onset and impact.
Browne and Finklehor (1986) tempers their findings due to the fact that they claim that body of research is very new. They also state that most of the studies available have methodological problems, including design, sample and measurement problems. These, according to Browne and Finklehor (1986), could invalidate some of these studies’ findings.
Russell (1999) in her study on girls and women discusses whether incest can be nonabusive. She answers the question with “yes,” when related peers engage in mutually desired sex, she considers it to be nonabusive. She defines incestuous abuse as any contact that is exploitative before the victim turns eighteen years old.
Russell (1999) also discusses individuals’ self-reported levels of trauma, as extreme, considerable, some and no trauma in terms of the severity of CSA (incest) and the degree of trauma. She only looks at the overt forms of abuse, from nonforceful kissing to forced rape. She found a statistically significant relationship between how severe the abuse was and strength of trauma reported. Fifty-four percent of very severe incestuous abuse was found to be extremely traumatic. Thirty-five percent of severe abuse was found to be extremely traumatic. Only 19% of the least severe abuse was found to be extremely traumatic. Another study by Browne and Finklehor contradicts the finding that there is a significant relationship between CSA and trauma (Russell, 1999). Russell cites another study by Bagley and Ramsay, with a random sample of 387 women, that found CSA involving any form of penetration to correlate with mental health problems in adulthood.
Russell found an almost perfect linear relationship between trauma and the severity of CSA, when differentiating between extreme trauma, considerable, some and no trauma. This differentiation showed extreme trauma for genital intercourse at 63%, attempted genital intercourse at 50%, fellation, cunnilingus, analingus and anal intercourse – completed and attempted at 40%, genital contact unclothed, which included manual touching or penetration, attempted or completed at 35%, breast contact unclothed or simulated intercourse attempted or completed at 35% and sexual kissing, intentional sexual touching of clothed breasts, genitals, or buttocks, thighs or leg, attempted or completed at 19% (Russell, 1999).
Russell (1999) also found, in contrast to Browne and Finklehor’s 1985 study that there is a statistically significant relationship within the frequency of how often the incestuous abuse occurred and the amount or degree of trauma that was caused. Those that reported a frequency of abuse of only one time reported extreme or considerable trauma 46% of the time as opposed to 54% for those with some or no trauma. Those with a frequency of two to twenty times reported extreme or considerable trauma 61% of the time. And those with more than twenty times reported extreme or considerable trauma 78% of the time. But duration can have an effect over these variables, and the relationship is not totally linear when more discriminating measures are used (Russell, 1999).
When physical force is looked at, there is a statistically significant relationship between the amount of force and the degree of trauma that was reported. This backs up Browne and Finklehor’s 1985 findings and conclusions. Of the violent force group, 100% found this to cause extreme or considerable trauma. Of the forceful group, 74% found this to cause extreme or considerable trauma. Of the nonforceful group, only 46% found the abuse to cause extreme or considerable trauma (Russell, 1999).
Questions about Russell’s (1999) study include the accuracy of self-reported trauma and the low n numbers in some categories, such as seven for violent trauma and five for fellatio, cunnilingus, analingus, and anal intercourse, attempted and completed. However, many of the categories have much higher n counts, such as an overall n count of 181 for all CSA survivors.
The above studies show that for the most part, that overt abuse has stronger deleterious effects than covert abuse. Also, the force used during abuse appears to positively correspond to the amount of damage done during the abuse.
Social problems which correlate with CSA trauma include: conflict resolution, interpersonal sensitivity, adult attachment issues, feelings of isolation and stigma, social alienation, difficulty trusting others, child social relationship problems, relational imbalances, intimacy, tendencies toward revictimization, personality, unstable personal relationships, the victim-perpetrator cycle, social introversion and violence.
Colman and Widom (2004) looked at the effects of child abuse and neglect on
adult intimate relationships. They looked at substantiated cases of neglect and abuse from 1967 to 1971. These cases were followed into adulthood and looked at between 1989 and 1995. A total of 1,196 participants (520 controls and 676 abused and neglected) were given a 2-hour interview test in person. The results were that female and male neglect and abuse victims reported higher rates of divorce, walking out and cohabitation than controls. Neglected and abused females were less likely than controls to be sexually faithful and have a positive perception of their current romantic partner (Colman & Widom, 2004).
The study was designed so that the controls were matched on sex, age, approximate social class and race with those abused and neglected from 1967 – 1971. Case selection of the abused and neglected participants were limited to court substantiated cases of children 11 years of age or younger. The variables measured included marriage, cohabitation and relationship functioning. The functional quality of relationships was measured from the Antisocial Personality Disorder part of the NIMH Diagnostic Interview Schedule – DIS-III-R (Colman & Widom, 2004).
The results were as follows. Victimization in childhood did not significantly diminish the chance that the study’s participants would ever marry. Neglect and abuse did however increase the chance that they would cohabitate. When compared to controls, abused and neglect participants were twice as likely to have walked out on a romantic partner. Also, female and male victims of neglect and abuse had experienced more dysfunctions in their marriages than controls and were twice as likely as controls to experience divorce. Participants with neglect and abuse were more likely than controls to have parents that received food stamps or welfare. When controlling for parental marital status and parents’ receipt of welfare, it was found that the results were very similar to the results obtained before controlling for these variables. With males, child neglect and abuse continued to predict significantly relationship disruption, current involvement in a relationship and the likelihood of cohabitation. For females, neglect and abuse continued to predict sexual faithfulness, divorce, relationship quality, cohabitation and walking out, even when the family background and control variables were considered. Control variables did reduce the impact of abuse and neglect on cheating, bringing it to marginal significance. The relationship between neglect and abuse and current involvement in a relationship became significant for females with controls (Colman & Widom, 2004).
The findings show that when adults were maltreated as children, their intimate relationships differed in quality and stability from controls. This study provides strong support for the hypothesis early childhood maltreatment negatively influences one’s capacity to maintain and form healthy interpersonal relationships. The only influence parents’ receipt of welfare and marital status had on the victims of abuse and neglect was males’ current relationship involvement and females’ sexual faithfulness. It was also found that women with histories of victimization in childhood were vulnerable to relationship dysfunction. Physical abuse, sexual abuse and neglect all increased the risk of infidelity among women (Colman & Widom, 2004).
Colman and Widom (2004) note that having a history of childhood victimization does not necessarily entail that one will have romantic distress and interpersonal dysfunction. Of the neglected and abused people who had married, about 40% of the females and 60% of the males hadn’t had a divorce. Also, 90% of the neglected and abused women did not commit infidelity with multiple partners (Colman & Widom, 2004).
Limitations of the Colman and Widom (2004) study include that their findings might not be generalizable to the entire population of abuse and neglect cases, since they used court-documented cases of children ages 11 or under. This data might not be generalizable to those in abused and neglected in adolescence or those without court involvement. It is also difficult to be sure if these results can be applied to middle class or upper class homes, because maltreating families that come to the attention of the authorities are usually from lower income homes (Colman & Widom, 2004).
Courtois (1988) discusses the aftereffects of incest in her book on adult survivors in therapy. She lists six groupings of effects, including emotional reactions, self-perceptions, physical/somatic effects, sexual effects, interpersonal relating and functioning and social functioning. In this section of the article, the focus will be on the social aspects she discusses in her book. She believes that survivors have a marked impairment in the ability to relate to and to trust others. This is due to the betrayal inherent in the act of incest. The other difficulties a child may have include relating sexually to others, due to conditioning. The child may also experience parentified behavior, where the child acts older than their years and needs to take care of others in the family. The child’s social functioning may include the development of cognitive problems, which may affect social relationships and their behavior in school. As an adult, the survivor may believe they can’t trust anyone, since they couldn’t trust their family. Feelings may be projected onto other people, such as distrust or anger. Survivors may not be able to allow closeness in intimate relationships. The partners chosen may reflect abuse dynamics, such as choosing a partner that can protect oneself, or a partner that one can take of. Feelings may also be projected onto authority figures. Parenting issues may also be affected. Survivors may not have adequate parenting skills due to inappropriate and non-nurturant role models. They may have children at young ages and not have the emotional skills necessary to deal with children (Courtois, 1988).
The social effects of abuse include functioning problems like rebellion, isolation, antisocial behavior and compulsive social interaction. These feelings may be vented in social causes. Other survivors may function well, but yet feel a lack of confidence about their skills (Courtois, 1988).
Hopper (2003) discusses the fact that emotional neglect may be more devastating than child abuse, especially when this occurs in the earliest years of life. He cites the effects of abuse listed by David Lisak in 1994. Some of the variables that may be influenced due to child abuse include: homosexuality issues, fear, anger, isolation and alienation, negative schemas about people and the self, negative childhood peer relationships, problems with sexuality, self blame and guilt and shame and humiliation. (Hopper, 2003) These possible long-term effects of child abuse can affect interpersonal relationships.
Conflict resolution and attachment issues were measured in a study by Styron and Bulman (1997). There is evidence that abused children are more likely to be insecurely attached. Insecure attachment is connected to many psychological concerns, including hostility, a lack of empathy, impulsivity, passivity, antisocial behavior and helplessness. It is argued that insecurely attached children are more likely to be insecurely attached adults. There is empirical support that attachment style remains somewhat stable over time (Styron & Bulman 1997). The Styron and Bulman study examined the correlation between childhood abuse and three adult functioning areas: adult attachment style, depression and conflict resolution behaviors. The study asks, for each of these outcomes, which is the better predictor, childhood abuse or childhood attachment? The researchers expected early attachment to be the stronger predictor.
Those that responded were 879 undergraduates. They used a series of pencil-and-paper self report measures. Forty percent were male and 60% percent were female. Childhood abuse and its frequency, co-occurrence and how much of it was experienced as traumatic was explored by a questionnaire. Trauma levels were measured by a ten-point scale. The attachment styles that were measured were one’s childhood attachment to mother, father and romantic partner. Attachment prototypes were classified as secure or insecure, including avoidant, anxious/ambivalent and fearful (Styron & Bulman 1997).
Fully 26.4 % of the sample reported some kind of childhood abuse. Verbal abuse was 21.8%, physical abuse was 9.8 % and 6.5 % (n = 57) reported CSA. Fifty-one percent of the Abuse group reported an insecure attachment style to their mother and 69.3 % to their father. The No-abuse group reported 19% to their mother and 39.5 % to their father. In regard to adult attachment styles, 63% of the Abuse group and 55% of the No-abuse group’s were classified as insecure. Those in the Abuse group were found to be more likely to use the Insult and Hitting categories of behavior than those in the No-abuse group. In other words, Abuse group members participated in physical violence and insulted their partners more than those in the No-abuse group. The abuse group also reported less secure attachments than the No-abuse group (Styron & Bulman 1997).
Weaknesses of the Styron and Bulman (1997) study include the lack of information collected about abusive experiences, including age, perpetrator relationship and chronicity. Other limitations included the complete reliance on self-report data. The data were retrospective perceptions. It is difficult to know how these may conform to actual childhood experiences. Wanting to be socially desirable and memory distortions may have also affected the data.
Collings (1995) found that interpersonal sensitivity measures on a Brief Symptom Inventory (BSI) were found to be statistically and significantly different when comparing controls to survivors of contact forms of abuse. Comparing the controls to noncontact forms of abuse, interpersonal sensitivity was found to be statistically significant to p <.05, the only category found to be statistically significant from the BSI when comparing the controls to noncontact forms of abuse (Collings, 1995).
Alexander (1993) states that a lot of the long-term effects of CSA are interpersonal in nature. They may also reflect more pervasive disturbances of sense of self, such as borderline personality disorder, avoidant personality disorder or other Axis-II diagnoses (Alexander, 1993). Family variables other than abuse may explain some of the long-term detrimental effects of family issues.
Secure attachment in adults is associated to self-confidence, trust and comfort with negative and positive feelings, a history of warmth, comfort with closeness and support in parents. Preoccupied attachment is connected with confusion, dependency, jealousy, anxiety and worries about being unloved or abandoned. Dismissing attachment is connected to a lack of self-confidence, discomfort with intimacy, loneliness, hostility and a history of rejection by one’s mother. Fearful attachment is connected to a lack of assertiveness, social inhibition and the combination of avoidant and preoccupied traits (Alexander, 1993).
Alexander’s (1993) study examined adult attachment and sexual abuse on several long-term outcomes. The study hypothesized that symptoms reflected by posttrauma would best be predicted by characteristics of the abuse, while personality disorders would best be predicted by attachment. One hundred and twelve women participated in the study. Their perpetrators were 74% fathers or stepfathers, 11% brothers, 4% grandfathers living in the home, and 3% mothers (Alexander, 1993).
Sexual abuse characteristics measured included age of onset of the abuse, type of abuse, degree of coercion and force and relationship to the perpetrator. The Relationship Questionnaire (RQ) measures the four previously discussed attachment styles. Other scales also used include the Beck Depression Inventory, Symptom Checklist-10, Impact of Event Scale and the Millon Clinical Multiaxial Inventory – II. Subjects rated themselves on the RQ as 14% secure, 13% preoccupied, 16% dismissing and 58% as fearful. This differs from the normative sample which correlates as 49%, 12%, 18% and 21% respectively. Current depression was also shown to be predicted significantly by abuse factors (Alexander, 1993).
Subjects in the study (Alexander, 1993) appeared in many ways comparable to a clinical population, even though the sample was derived from the community. Subjects gave responses relating to avoidant and self-defeating personality disorders. The characteristics of abuse severity correlated with the symptoms most frequently connected to PTSD. Basic personality structure was predicted by adult attachment and not abuse characteristics. Limitations of the study include the fact that longitudinal studies may need to be conducted to show that the attachment in adults is continuous with childhood attachment. The study also did not measure extrafamilial abuse and may not necessarily generalize to this (Alexander, 1993).
Miller’s (2004) paper on personality and the development of PTSD discusses how three broad dimensions of personality affect psychopathology. These are positive emotionality (PEM), negative emotionality (NEM) and constraint (CON). PEM is closely aligned with extraversion and social closeness. NEM refers to negative moods and the tendency toward adversarial relationships with others. NEM is connected to neuroticism and traits relating to anxiety, aggression and alienation. CON refers to impulsivity, such as harm-avoidance vs. risk-taking. Genetics studies show these to have substantial heritabilities (Miller, 2004).
Studies have shown the significant connection between pre-trauma NEM and the development of PTSD. Other studies have shown that NEM is the main risk personality risk factor to develop PTSD after trauma exposure (Miller, 2004). Increased vulnerability to PTSD is related to high NEM and low PEM and CON. Resilience to PTSD is related to low NEM and high PEM and CON (Miller, 2004).
Kelly and Ben-Meir’s (1993) paper on the emotional effects of CSA discusses the fact that CSA leads to many harmful effects for the victims. Ritualistic sexual abuse (RSA) children were found to have high levels of negative emotional symptoms. Greater than four-fifths of the children were described by therapists as meeting PTSD criteria. Other emotional effects included aggression, depression and specific fears. (Kelly & Ben-Meir, 1993)
The Lunderberg-Love (1999) study measured the impact of incest on scores obtained on the Minnesota Multiphasic Personality Inventory (MMPI) and the Millon Behavioral Health Inventory (MBHI) at the beginning of treatment and six months and one year after treatment. Previous experience and data showed that CSA survivors would show higher levels of psychological symptoms, including depression, rumination, anxiety, poor self-esteem and social introversion. The study included 103 women who were volunteers. They were divided into four treatment and control groups. Incest victims with a variety of clinical conditions (INC-T, N =29), women entering treatment with no history of CSA (NoINC-T, N = 27), women in a clinical exercise physiological study (EX-C, N = 2) and women in a no-treatment control group in the same exercise physiological study (No-EX-C, N = 15) (Lunderberg-Love, 1999).
Participants were given a 14-page demographic questionnaire asking about age, marriage, ethnicity, educational level, occupation and other variables. Data showed that the higher the socioeconomic status and occupational level of the subject, the higher the age of the onset of sexual abuse. Fifty-seven percent of the abusers were father figures (including grandfathers). Thirty-four percent were abused more than once per week. Fifty-three percent experienced intercourse (Lunderberg-Love, 1999).
Duration of the abuse correlated positively with survivors’ scores on the MMPI scales for Authority Problems and Amorality. This could suggest that the longer the incest occurs the more likely it could be related to behaviors connected to personality disorders, impulsivity or drug abuse. The hypothesis that incest survivors also reported higher levels of symptomology and greater psychological stress than controls was also supported. INC-T scores were higher on a variety of scales, including social introversion. After six months of treatment, there were significant decreases in the INC-T group scores on several variables on the MMPI, including Social Introversion (SI). On the MBHI the INC-T group scored significantly higher than all other groups on the Inhibited and Sensitive styles. The Inhibited scale shows people who tend to be hesitant, shy and ill at ease. The Sensitive scale shows people who may tend to be unpredictable and moody. On the MBHI, the INC-T group scored significantly higher on the Social Alienation, Premorbid Pessimism and Future Despair scales. Early research has shown that CSA can result in strong feelings of social alienation (Lunderberg-Love, 1999).
Dodge (1989) discusses the problems in social relationships children may have. He states that children with poor peer relationships are at risk for later psychological maladjustment and may also have difficulty with academic problems. A lack of good peer relationships is a main feature of several child psychiatric disorders. These diagnoses may range from Social Phobia, Conduct Disorder to Avoidant Personality Disorder (Dodge, 1989).
Gelinas (1983) looks at the range of problems and symptoms seen in previous incest survivors including relational imbalances. Exploitative relational imbalances within the family allowed the incest to occur in the first place (Gelinas, 1983). The relational imbalances of incest hurt the psychological development of the survivor as well as their ability to keep positive relationships with their family of origin, partner, children and friends. Gelinas (1983) believes that incest occurs due to combined family and individual processes. The process of parentification occurs when the child ends up functioning as a parent. The child may take over a variety of parental functions and in other ways may end up taking care of the parents. The child does not help with tasks, but actually does the tasks themselves. The parentified child meets the needs of other family members, without being able to meet their own needs. She ends up putting everyone else’s needs before her own needs. As an adult, the parentified child may not realize that they have needs of their own. Partners carry the relationship imbalances of their own families of origin into their new relationships. Usually these imbalances cause problems when children are born into the new family. The husband may demand more from the wife than she is able to give, due the fact she needs to take care of the children in the family. Incest may occur when the daughter is parentified to fulfill the father’s emotional needs (Gelinas, 1983).
The effects of relational imbalances are that the victim reaches adulthood without the benefits of childhood. Certain personality functions are hyperdeveloped (like her sense of responsibility and care-taking) and other parts are less developed (like social skills, self-esteem, and personal talents). Self-esteem is a major problem, due to the relational imbalances in the original family where they had no rights and nothing was owed to them. Guilt also has a major role, where the survivors may blame themselves for the incest. Younger sisters that have been incested, but not parentified, may show a traumatic neurosis, but do have better self-esteem and less guilt. Incest victims end up being exploited in later relationships. Gelinas lists an Incest Recognition Profile (IRP) which details presenting problems as including depressed mood and affect, guilt, needy depressiveness and very low self-esteem. The complications of a chronic mood disorder include difficulties in parenting and poor relationships (Gelinas, 1983).
The problem with Gelinas’ (1983) work is that it is based partially on cited research and partially on her clinical observations, but it does not appear to be empirically backed through scientific study and testing. Intuitively, her work does appear to make sense and fit. It does contain excellent theories that can be later tested and developed further.
Paolucci, Genuis and Violato (2001) looked at a variety of factors involved in CSA including the victim-perpetrator cycle. A meta-analysis was done for six outcomes, posttraumatic stress disorder (PTSD), depression, suicide, sexual promiscuity the victim-perpetrator cycle and poor academic performance. They found a CSA prevalence rate of about 15 to 20%. They define CSA as any unwanted sexual contact, where the survivor is a child by legal definition and the perpetrator is in a position of power. The study defines the victim-perpetrator cycle as involving acts of sexual victimization directed at others. The studies looked at ranged in publication from 1981 to 1995. There were 37 studies coded, including 88 samples across the six dependent measures. These had 25,367 people at a mean of 634 per study. Most of the studies were longitudinal in nature and assessed participants through questionnaires that were standardized. It was found that a 57% increase in risk of participating in the victim-perpetrator cycle was found after CSA (Paolucci, Genuis, & Violato, 2001).
Their results (Paolucci, Genuis, & Violato, 2001) did not corroborate the findings of other research studies, which found that the type of sexual abuse, age, repetition and perpetrator familiarity had an effect on the development of negative outcomes. They theorize that CSA experiences may be negatively significant in themselves, and these experiences may affect human development consistently. Or, the data they have now may be too imprecise and crude to allow for the detection of some of these differences. There was also no statistical difference in negative outcomes between males and females in the study. Socioeconomic status (SES) did not mediate the results either (Paolucci, Genuis, & Violato, 2001).
Briere’s (1996) book for therapists of CSA survivors discusses some of the interpersonal effects of CSA. These include disturbed relatedness, caused by the exploitative nature of what could be in some instances caring experiences (cuddling, praise). These also include acting out behaviors as opposed to functional or adaptive behaviors. Behaviors that were previously adaptive during the abusive experiences now may be maladaptive (Briere, 1996).
Peed (1995) discusses how incest survivors can create family. Three female incest survivors were interviewed for the study. Incest is discussed as the betrayal of the cultural concept of family as a place of support and nurturance. Incest is a betrayal of dependent and close family relationships. The meaning of family for incest survivors is not often one of belonging and comfort. Many incest survivors, however, have created families for themselves (Peed, 1995).
Peed defines incest as unwanted sexual contact by a relative or step family member. She researched survivors over the age of 24, which had meaningful connections with other people, that had a minimum of 18 months since the last period of self abuse, a three-year minimum since the last psychiatric hospitalization or criminal behavior, and an active recovery program if the participant has any of the previously mentioned problems in young adulthood. One sampling bias inherent in the study is that the study is biased toward those that already have the means to help themselves. This is equal to the selection criteria (Peed, 1995).
The results of Peed’s study looked at relational complexity and its challenges. All three of the participants felt ambivalent about their relationships with their mothers. Two of three women expressed self-doubt at their abilities to create family. Each of the women in the study had difficulty with trust and intimacy. This complicated the problem of creating family. The creation of caring relationships was important to all three in relationship to the creation of family. The limitations of Peed’s (1995) study were the small number of participants (three) and the previously mentioned fact of the sampling bias of those in the study as already receiving some sort of self-help (Peed, 1995).
Other social problems include violence by victims of child abuse. Moskowitz (2004) discusses the correlation between severe dissociation and violence. He discusses the Jekyll and Hide phenomena, where apparently mild-mannered people appear to be prone to committing some of the most heinous crimes (Moskowitz, 2004).
Struve (date unknown) in his paper on working with gay and lesbian survivors of sexual abuse shows the comparisons between being gay and being a survivor of abuse. He details the isolative nature of child abuse vs. the potentially isolative nature of being gay. Abused children are afraid they will not be believed. Often, the person the child needs to get support from is the abuser. So the child is isolated from getting help. Gay and lesbian survivors also isolate themselves from the general population to associate only with other gay and lesbian-oriented people. Other possible commonalities listed between being gay and being abused include secrecy, shame, vulnerability, sexuality, disclosure and hypervigilance (Struve, date unknown).
Certain social problems may also be listed in the DSM-IV-TR under certain specific diagnoses. Avoidant Personality Disorder (American Psychological Association, 2000) is listed as having features are which are described as appearing lonely, isolated, shy or timid. The major problems with suffers of this disorder occur in occupational and social functioning. Sufferers may become socially isolated and not have sufficient networks set up to deal with crises and major problems. Sufferers may want acceptance and affection and fantasize about ideal relationships. The avoidant behavior often begins in adolescence or childhood. Symptoms include the fear of strangers, shyness, isolation and the fear of new situations. Individuals that develop Avoidant Personality Disorder may become increasingly avoidant and shy in early adulthood (American Psychological Association, 2000).
Borderline Personality Disorder (American Psychological Association, 2000) sufferers may also have social problems including unstable personal relationships, self-image or suicidal behaviors. Sufferers of this disorder may feel more secure with inanimate objects or pets than they do in relationships with people. Histories of physical abuse, sexual abuse and neglect are more common in sufferers of this disorder (American Psychological Association, 2000).
Social Phobia (Social Anxiety Disorder) is listed in the DSM-IV-TR and also describes the sufferer’s social problems. Its diagnostic features include marked and persistent fears in which situations where one may be embarrassed. Exposure to the situation creates an anxiety response in the sufferer (American Psychological Association, 2000).
In conclusion, the data shows that there are a variety of deleterious effects associated with CSA. These can be partially mediated by parental attachment style and one’s predetermined genetic personality structure. Most of the studies above showed that a wide range of social problems can be caused or exacerbated by CSA and other forms of child abuse.
The psychiatric diagnoses which correlate with childhood sexual abuse trauma include: chronic traumatic neurosis, obsessive compulsive, depression, dissociation, schizophrenia scores, somatization, phobic anxiety, paranoid ideation and psychoticism scores, chronic trauma disorder (a dual presentation of PTSD and a borderline profile), developmental triggers, dissociative symptoms, dissociative identity disorder, amnesia, eating disorders, avoidant personality disorder and borderline personality disorders (which were previously discussed under social problems).
McGettigan (1992) discusses how amnesia was looked at historically by Janet, which was caused by trauma. Trauma caused the splitting off of the event from the ego, which held the trauma which the ego was unable to integrate. This trauma becomes an “idee fixe” which lives in the subconscious and affects behavior. One’s mental life becomes drained by the increasing power of the traumatic memory. In the beginning, Freud believed his CSA patients. He believed that underneath every case of hysteria there were one or more occurrences of CSA. Freud believed that repression was a defense against overwhelming one’s ego. Some of the symptoms of CSA that Freud listed included a connection to eating disturbances. He mentioned that to cure hysteria one needs to make conscious their unconscious memories. Freud later changed his theory of hysteria to one of sexual fantasies (McGettigan, 1992).
Herman and Hirschman (1981) in their work on father-daughter incest, also
discussed Freud’s work on hysteria and his disavowal of the seduction theory. After this, many clinicians did not mention the subject of incest, until recently. Incest abuse survivors still may be likely to see their stories dismissed as fantasy (Herman & Hirschman, 1981).
Freyd (1996) in her book on betrayal trauma, writes about the reasons why a child would forget child abuse. The reasons she gives are avoidance of pain, terror or overwhelming information. Repression lessens the pain of the abusive incident. Defense mechanisms help survivors keep secrets from themselves (Freyd, 1996).
Whitfield (1995) in his book on memory and abuse writes about how memories can be repressed. He states that since trauma activates and induces many of the parts of our inner life, including our physiology and biochemistry, what we usually get is a painful experience. If one has a safe place to heal and has a healthy support system, one should be able to grieve and heal. But if the family system is dysfunctional or the person is not developmentally healthy, then it is not likely that the survivor of the trauma will be able to work through the trauma to completion. All of the charged material, spiritual, emotional, mental and physical, will remain stuck inside of ourselves, until it can be worked through and released (Whitfield, 1995).
Zurbriggen and Becker-Blease (2003) in their paper on predicting memory for CSA, conclude that there is compelling evidence that some survivors do forget abuse. They believe that adult survivors that are working with new memories need to be believed. They also believe that significant harm can occur from the result of not being believed in adulthood, after the denial and discounting of memories that occurred in childhood (Zurbriggen & Becker-Blease, 2003).
Hopper (2003) discusses the fact that the closer the survivor is to the perpetrator in terms of their relationship and the younger the child is when the incident occurs, the less likely the survivor is to remember the abuse. He cites evidence showing that as many as one-in-three incidents of child abuse are not remembered by those that have experienced them (Hopper, 2003).
Ferenczi, late in his career, believed that CSA was the cause of hysteria. He believed that the ego would split to separate the trauma from the ego state. He believed that if the CSA continued, the splitting would as well. The outcome of this would be what we now called Dissociative Identity Disorder (DID) (McGettigan, 1992).
Moskowitz (2004) writes about how some have argued that mens’ dissociative disorders are missed due to the fact they are in the criminal justice system. PTSD is also closely linked to dissociation. Two of its most prominent symptoms, emotional numbing and flashbacks are dissociative in their nature (Moskowitz, 2004). Moskowitz (2004) believes that Dissociative Identity Disorder (DID) is believed to develop partially in response severe childhood abuse. Others believe that in developing DID, an inborn predisposition to dissociate may contribute to its start. Moskowitz also cites a study by Walter and Ross in 1997 that shows evidence for zero heritability of pathological dissociation (Moskowitz, 2004).
A dissenting view that DID comes from childhood trauma comes from Piper and Merskey’s (2004a, 2004b) review of the literature. They claim that there is no proof that DID comes from childhood trauma. They also believe that it cannot be reliably diagnosed. They also maintain the belief in an iatrogenic theory of development for DID. They claim that association does not cause causation. This is in reference to those that show high rates of severe trauma for the sufferers of DID. They also maintain there is a lack of evidence for the trauma cited in several studies. They claim that certain therapeutic practices reify the alter’s existence and iatrogenically encourage patients to behave as if they have more than one self (Piper & Merskey 2004a, Piper & Merskey 2004b).
Putnam (1989) believes the linkage between childhood trauma and Multiple Personality Disorder (MPD, now called DID in the DSM-IV-TR) has emerged slowly in the clinical literature over the last 100 years. Sexual abuse is the most commonly reported type of childhood trauma in DID patients. He cites the most reported form of sexual abuse as incest. He cites a National Institute of Mental Health (NIMH) survey (with N=100) showing the types of abuse cited by MPD patients. Over 80% of MPD sufferers have experienced sexual abuse, over 70% have experienced physical abuse and approximately 70% have experienced both. He believes that due to his clinical experience, it is obvious that sustained, severe and repeated child abuse is a major element in the development and creation of MPD (Putnam, 1989).
Moskowitz (2004) cites a study by Egeland and Sussman-Stillman in 1996 which showed that higher dissociation scores played a role in the abuse of children abused by their own mothers. It was surmised by the authors that women who dissociated were less likely to have empathy toward their child. Tanay in 1969 (Moskowitz, 2004) found that some offenders that committed crimes switched into dissociative states or altered states of consciousness before their crimes. Moskowitz states that a conservative estimate is that 6% to 21% of sexual or violent offenders are suffering from DID and 14% to 39% are suffering from any dissociative disorder. Another study by Putnam found violent alters in 70 out of 100 DID patients (Moskowitz, 2004).
Moskowitz concludes that in a wide range of populations, where there was an increase in dissociation scores, there was an associated increase in violence. Dissociation has been shown to predict the severity or likelihood of violence in a variety of studies. Dissociation may actually push the cycle of violence. People that are abused and get dissociative symptoms in response are considerably more likely to abuse their children than those that have been abused and do not have such symptoms (Moskowitz, 2004).
Gelinas (1983) discusses chronic traumatic neuroses which appear during the treatment of incest survivors. These neuroses clearly relate to the incest. They are connected to what occurred physically and sexually during the abuse incident. Gelinas believes these emerge only after the incest is disclosed. A client may re-experience the actual events of the trauma or abuse. These can be incorrectly mistaken for psychotic decompensation, due to their intensity. They are the cathartic emergence of long-buried traumatic neuroses. Incestuous abuse causes major trauma for the child. This trauma confuses and threatens the child (Gelinas, 1983).
Traumatic neuroses can occur anytime after an individual experiences a traumatic event. These neuroses tend to continue until they are treated or worked through in a normal developmental process. Incest often is a repeated trauma. The total denial of the incest events may occur or victims may minimize the importance of these events. Patients may use some sort of dissociative defense during the incest experience, such as seeing the event as happening to someone else or self-induced hypnotic anesthesia experiences, so the victim will not consciously feel the event. The tendency of being able to dissociate under stress continues after the incest trauma. This brings up the question of a link between childhood incest and later dissociative disorders, such as multiple personality disorder. Nightmares, hallucinations, recurrent obsessive ideas and panic attacks may also result from the trauma of incestuous abuse (Gelinas, 1983).
Gelinas discusses developmental triggers, which are reminders of early relational imbalances that can cause a precipitation of psychiatric symptoms. The negative consequences of incest can have a time-bomb quality, which can function as developmental triggers. These triggers consist of a normal developmental event that accesses a new area of a survivor’s functioning, which has been damaged due to the incest. These may occur in the areas of a survivor’s sexuality, once the survivor is able to have sexual experiences of their own. These triggers may also precipitate psychiatric symptoms, like depression (Gelinas, 1983).
In a meta-analysis by Jumper (1995) of the relationship of CSA to adult psychological adjustment, it was found that statistically significant relationships exist between CSA experiences and psychological adjustment difficulties when measured with psychological symptomatology, self-esteem and depression. They found that student samples showed less impairments in psychological adjustment than did clinical or community samples (Jumper, 1995).
Twenty-six studies were used in the final meta-analysis. The study found that gender was not an accurate predictor of effect size variance. Jumper’s results showed that women and men that experienced CSA as children did not differ significantly in adult psychological adjustment (Jumper, 1995).
In a paper by Dominguez, Nelke and Perry (2001), the psychosomatic consequences of CSA are discussed. They list a variety of negative short-term effects of CSA that can impact the functioning of a child. It is stated that over 50% of children suffering from child sexual abuse meet at least partial criteria for PTSD. They also state that if PTSD is not effectively addressed, it can become a chronic problem in adulthood as well. They report that more than a third of CSA victims report anxiety and depression. Other symptoms listed include general behavior problems (30%), promiscuity (38%) and poor self-esteem (35%). Family cohesiveness can be a positive buffer for CSA victims. There is a connection between parental stress and child distress (Dominguez, Nelke & Perry, 2001).
Dominguez, Nelke and Perry (2001) state that the evidence suggests that the negative psychological impact of CSA can persist into adulthood. Some of its potential long term effects include anxiety, depression, PTSD, sexual dysfunction and substance abuse. With adult female populations, people with CSA histories were twice as likely to try to kill themselves than nonabused controls (Dominguez, Nelke & Perry, 2001).
In Briere’s (1996) book for therapists of CSA survivors, he writes about research that states that CSA, especially within the family, may produce posttraumatic symptoms when the abuse happens and also later in life. He defines sexual abuse as the actual contact between a child and an adult. The PTSD symptoms Briere describes include a numbing of general responsiveness and autonomic hyperarousal (Briere, 1996).
Myers (date not listed) states that the connections between eating disorders are diverse and sometimes inconclusive. The data suggests that there is a connection between bulimia nervosa and sexual abuse. The data presented in Myers’ paper does not suggest a connection between anorexia nervosa and sexual abuse. CSA survivors in one study (Wonderlich) were found to display significantly more tension reducing behavior, including cigarette smoking, self-mutilation and suicidal gestures. (Myers, date not listed) Though Myers’ paper does come with a full list of citations, it is limited by the fact that it has not been published in a professional journal.
Farber’s (1997) paper discusses the traumatic reenactment of bulimic and self-mutilating behaviors. It is postulated that these acts of self harm are used to narrate what their words can’t say and their minds can’t remember. The author shows a strong association between binge-purging behavior and self-mutilating behavior. Farber discusses Lacy’s work which includes the development of a syndrome, Impulsive Personality Disorder, which includes women with self-damaging and addictive behaviors and a history of sexual abuse. Her article discusses that dissociation of body and mind may be connected to binge-purging and self-mutilation. She postulates that the bulimic behavior in a sexual abuse survivor may be reenactment of the trauma the survivor suffered. The survivor is in control of this reenactment. This is analogous to forced intercourse. The food is stuffed in and then purged out, now all under the control of the survivor. (Farber, 1997) Though Farber does cite a variety of sources and she does provide an interesting theory, more research may be needed to show the connections between traumatic reenactments and self-injurious behaviors.
Collings (1995) previously cited study also looked at somatization, obsessive compulsive, phobic anxiety, depression, paranoid ideation and psychoticism on scales on the Brief Symptom Inventory (BSI) were all found to be significant at least at the p < 0.01 level for those in a control group (who did not report abusive childhood sexual experiences) compared to those in a contact abuse group (defined as those experiencing one of more CSA experiences) (Collings, 1995). Collings’ study shows that child sexual abuse correlates with later several categories of psychological problems.
Styron and Janoff-Bulman’s (1997) previously cited study showed that depression (measured by the Beck Depression Inventory, BDI) was significantly higher in the abuse mean group than the nonabuse mean group. These scores, however, were best accounted for by one’s perceived childhood attachment to their mother and father. Their abuse history did not cause any significant variance past their parental attachment (Styron & Janoff-Bulman, 1997).
Lunderberg-Love’s (1999) previously cited study looked at incest survivors. These survivors scored higher than three other groups of nonsurvivors at clinically significant levels on schizophrenia scores on the MMPI scales. The MMPI measures psychological symptomology via tem clinical scales through 566 true-false items. The INC-T (incest victims with a variety of clinical conditions) scores on the MMPI were significantly higher for the following clinical scales: Hypochondriasis (HS), Psychopathic deviate (Pd), Depression (D), Psychasthenia (Pt), Schizophrenia (Sc) and Social Introversion (Si). Survivors also scored higher on the Anxiety scale and lower on the Ego strength scale than all of the other control groups. Out of 57 MMPI scales, the INC-T group scored higher on 38 or 66% of them (Lunderberg-Love, 1999).
Rauch and Jones (1997) discuss chronic trauma disorder, which as a dual presentation of a PTSD and borderline profile. This disorder has been offered as an alternative explanation to personality disorders or psychosis. Men with long-term abuse histories present with fragile ego structures and a propensity to lash out. Due to being rewarded and abused in an inconsistent manner, these survivors may set double standards up of what they expect of others and from themselves. In group therapy, this may play out as replicating a borderline type of process, where survivors may collude with one another or try to divide the group. They may withdraw or make passive-aggressive comments. Projections, splitting, primitive idealizations, devaluations, diminishment and omnipotence are adaptive defenses to the long-term survival of trauma (Rauch and Jones, 1997).
The problem with Rauch and Jones (1997) paper is that it is basically an opinion paper without citations, apparently based on their observations in group therapy. It is presented here due to their interesting ideas about chronic trauma disorder and how this may be a kind of combination diagnosis of PTSD and Borderline Personality Disorder or borderline traits in survivors.
Apgar (1999) in a mini article on the internet discusses how stressors from childhood that had severe physical or sexual abuse qualities caused the most severe dissociative symptoms. The highest dissociative scores were in clients that were sexually abused by nonfamily and family members and by those that suffered the combination of sexual and physical abuse. Patients whose mothers drank heavily had the highest dissociative symptoms. Repeated victimization appeared to reinforce the dissociative response (Apgar, 1999).
Apgar’s mini article cites a study by Draijer and Langeland (1999) on childhood trauma and the etiology of dissociative symptoms in psychiatric patients. Dissociation is defined as disruptions in the usually integrated functions of consciousness. There is a theoretical assumption that dissociation is connected to overwhelming experiences, especially those in childhood. The research on adult dissociation and childhood trauma has been mainly on CSA and physical abuse. CSA and its being combined with physical abuse have been found to be strongly related to adult dissociation measured on certain scales in many studies. Two studies have found physical abuse to be more important than CSA (Draijer & Langeland 1999).
The methods used by Draijer and Langeland (1999) include the Dissociative Experiences Scale (DES) and the Structured Trauma Interview (STI). Neglect was defined as unavailability of parent or parental dysfunction. Physical abuse was defined as parental aggression that was severe in nature. Sexual abuse was defined as any forced or pressured sexual contact before the age of 16. The study went for a period of 18 months, and all admitted inpatients at a psychiatric hospital were invited to participate. Out of 313 patients, 160 subjects were used (94 women and 66 men) (Draijer & Langeland 1999).
Some childhood experiences were interrelated. Early separation from a parent was related to CSA, physical abuse and witnessing interparental violence. Sexual abuse and physical abuse were also shown to be related. A severity of dissociative symptoms was related to the reported sexual and physical abuse. The severity of sexual abuse was strongly related to the dissociation level. Severity was measured by penetration and abuse lasting more than one year. The highest scores of dissociation came from those that had experienced CSA both outside and inside their families or also those that were both physically and sexually abused. The severeness of the symptoms of dissociation was also related to one’s perceived parental dysfunction. The mother’s level of availability or lack of availability also seems to be an important factor. Several victimizations appear to reinforce a response of dissociation (Draijer & Langeland 1999).
One reason Draijer and Langeland (1999) believe that physical and sexual abuse may be connected to the level of dissociation is that there is denial and secrecy connected to these forms of abuse. They believe that the child may live in a fragmented reality, with limited social support due to the fact that the child is being abused by the people he or she depends on for support. They conclude that the use of CSA as the sole explanation for dissociative and other psychiatric symptoms in adulthood is not correct (Draijer & Langeland 1999).
The limitations of Draijer and Langeland’s study are that the data is being measured in a retrospective manner. Memory bias could also be an issue, with possible under and/or over reporting of trauma. There was no corroborating for evidence sought for child abuse episodes, due to the need for confidentiality. There was also bias in the group, due to the need to skew the study toward the patients that were less psychotic (Draijer & Langeland 1999). Also, since the study is an inpatient study, how applicable is the data to the general population?
Alexander’s previously cited study discusses the long-term effects of CSA, which may not necessarily include PTSD. Instead, many of these effects may be interpersonal in nature or show more pervasive disturbances of self, such as in avoidant and borderline personality disorders or other Axis-II disorders (Alexander, 1993).
Alexander looked at avoidant personality disorder, self-defeating personality disorder, dependent personality disorder and borderline personality disorder. These were measured by the Millon Clinical Multiaxial Inventory – II (MCMI-II). The MCMI-II is a 175-item questionnaire with true/false responses for use with clinical populations. A base score of 75 signifies the presence of a disorder. Alexander found that basic personality structure was not connected to abuse characteristics but instead was predicted by adult attachment (Alexander, 1993).
In a study by Miller and Lisak (1999) adult symptomology was shown to be increased for CSA survivors on portions of the variance for three personality disorder scales on the Personality Diagnostic Questionnaire Revised (PDQ-R). The participants were 584 college age males (mean age = 28.8 years) from a commuter university in the Northeast United States. Each packet given to each participant included a Home Experiences History (HEH) which included a six-item checklist of disruptive family circumstances. The Family Relationship Index (FRI) measures more subtle aspects of family functioning, like Cohesion and Expressiveness. The Family Environmental Scale (FES) contains conflict subscales. The Abuse-Perpetration Inventory (API) looks at the histories of physical and sexual abuse. Personality disorder symptoms were measured using the Passive-Aggressive, Dependent, Avoidant, Narcissistic, Borderline, Antisocial and Schizoid subscales from the PDQ-R. Also used was the Minnesota Multiphasic Personality Inventory – 2 (MMPI-2) scale to measure socially desirable responsible styles (Miller and Lisak, 1999).
In their sample of 584 men, 61.8 % reported no sexual or physical abuse, 10.6% reported sexual abuse only, 17.1 % reported physical abuse only and 10.4 % reported both kinds of abuse. When comparing abused to nonabused men, it was found that men with any sort of abuse history had a greater amount of personality psychopathology connected with the general personality disorder symptoms and Dependent, Avoidant and Borderline (BPD) symptoms. Men with both types of abuse, physical and sexual, showed greater symptomology for Dependent, Borderline and general personality disorder symptoms. There was a relatively strong connection between childhood abuse and BPD symptoms. This supports other empirical work in clinical populations (Miller and Lisak, 1999). The findings for increased Dependent and Avoidant symptoms were found to be of interest due to the masculine gender norms, like self-confidence and self-assurance and autonomy. These scores show that the estrangement of oneself from others can exist among survivors of both sexes (Miller and Lisak, 1999).
The limitations of Miller and Lisak’s study include their relying on past self-report measures to look at and measure abuse histories. The abuse assessment was limited only to physical and sexual abuse. Other important variables not looked at included physical neglect and psychological abuse (Miller and Lisak, 1999).
In Lange’s (1999) study on the long-term effects of CSA, past studies are cited which show CSA correlates with depression, anxiety disorders, borderline personality disorder, dissociative disorders and psychotic symptoms. Certain variables are hypothesized to play a part in the connection between CSA and later psychopathology. These variables include abuse characteristics, the way CSA is processed and experienced, individual victim characteristics and family factors. Factors predictive of adult psychopathology include age of onset of abuse, the nature of the CSA events, frequency of the abuse, relationship to the perpetrator and amount of pressure put on the victim to cooperate. These findings are based on relatively small clinical samples. The negative effects of self-blame for the abuse experiences were found to cause more symptoms of psychopathology. A review by Faust et al. has shown that the emotional atmosphere in the family of origin is connected to the prevalence of abuse. It is also connected later in the survivor’s life in the processing of their traumatic experiences. Reactions to disclosure were also found to predict the severity of internalizing the problems of anxiety and depression (Lange et al., 1999).
Lange et al.’s study used the Questionnaire Unwanted Sexual Experiences in the Past (QUSEP), to assess the subjective and objective characteristics of sexual abuse and its related coping behavior. The QUSEP first identifies unwanted sexual experiences. These experiences are regarded as sexual abuse only if contact took place, not if the respondent only felt sexually unsafe. Other questions include frequency and age of onset of the abuse, the relationship to the perpetrator and the disclosure of the abuse to others. Subjective characteristics were also assessed, like whether the survivor had felt pressured by the perpetrator and how the survivor felt about reactions when disclosing the abuse to others. Then, the respondent is asked about how they coped with the event, including questions around guilt, feelings or responsibility, and feelings about the disclosure of the abuse. The QUSEP also contains questions about the degree they suffer certain symptoms or problems, including memory problems, anxiety, depression, problems concentrating, irritability, somatic complaints, relational problems, suicide attempts or thoughts, eating disorders, parasuicide, gynecological and sexual problems, substance abuse and sleep disorders (Lange et al., 1999).
The Dutch adaptation of the Symptom Checklist-90-R (SCL-90-R) measured present psychopathology. The Dissociation Questionnaire (DIS-Q) measured dissociative symptomology. The Family of Origin Questionnaire (FOQ) measured the atmosphere of the family of origin (Lange et al., 1999).
The final sample had 404 women. Sixty-eight percent of the respondents cited family members as having participated in the abuse. Seventy percent had more than one perpetrator. Seventy-three percent has forced intercourse. The mean age of onset was 11.3 years. Seventy-seven percent responded that they had a lot of pressure to give into the abuser. Eighty percent gave the responsibility of the abuse mainly or entirely to the perpetrator yet, yet 3/4 of the respondents felt guilt when the abuse occurred and almost half still had strong feelings of guilt Family environment was more negative in the incest group and disclosures were more positive in the non-incest group (Lange et al., 1999).
Respondents scored substantially higher on the SCL-90-R (present psychopathology) and the DIS-Q (dissociative symptomology) than those in the general population. The average scores on the psychopathology variables were close to those for psychiatric populations. No difference in psychopathology was found between the incest and non-incest group. Increased and more severe psychopathology was connected to a greater variety of abusive events, higher frequency and longer duration of the abuse (Lange et al., 1999).
Anxiety and depression were shown to be associated with feelings of guilt, the number of abusive events, reactions of others to the survivor’s disclosure and the family of origin’s atmosphere. Characteristics of abuse were also related significantly but less strongly to low self-esteem, somatic complaints, feelings of social insecurity and cognitive dysfunction. Contrary to the expectations of the researchers, no connections were found between psychopathology and the age of onset, the difference in age between the victim and the perpetrator and the relationship between the two. There was a correlation between the severity of the abuse (number of different types of abuse) and dissociation. Duration and the frequency of the abuse and family atmosphere connected amnesia and identity confusion (Lange et al., 1999).
The severity of the abuse and its duration was shown to be more important than whether the abuse was incestuous or not, in terms of developing later psychopathology. In predicting DIS-Q scores (dissociative symptomology), the most important predictor is the number of years passed since the abuse occurred (Lange et al., 1999).
Survivors of CSA may know cognitively that they are not responsible for the abuse, but yet may still have guilt feelings about the abuse. Feelings of guilt were shown to be a significant predictor of psychopathology and dissociation, where feeling responsible for the CSA event was not. Their results also show that early and positive disclosure is important in terms of the survivor’s psychological functioning in later life (Lange et al., 1999).
Limitations of the study include the fact that respondents were sought through national newspapers. This recruitment method may have created a more biased sample, in the direction of increased psychopathology. Possibly, women with more psychiatric symptoms would be more eager to participate than those with fewer symptoms. This may cause overly conservative or low results of the estimate of association between CSA and later psychopathology, due to a lower variance in the sample (Lange et al., 1999).
In conclusion, a variety of studies have shown the connection between CSA and
certain psychological problems. Though there is some dissension about what types of abuse may cause which problems, the overall picture from most resources shows a definite connection between CSA and increased psychopathology.
Physiological diagnoses or aspects
The physiological diagnoses or aspects which correlate with childhood sexual abuse trauma include: adult health and the physiological effects of maltreatment, somatization (also mentioned under psychiatric diagnoses) and substance abuse.
Dallam (2001) cites the physiological effects of child maltreatment. She discusses the neuroendocrine system. The nervous and endochrine systems control the body’s physiological states by decreasing and increasing the activity of hormones and neurotransmitters. The brain’s goal is to maintain equilibrium. A stressful event can change this neurochemical balance. The brain may respond by activating the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system (SNS). This causes the release of endogenous opioids. The SNS’s stimulation results in the release of catecholamines into the blood stream. The HPA axis causes the release of glucocorticoids (mostly cortisol). Cortisol and catecholamines have both been found to be chronically elevated in abused children (Dallam, 2001).
The fight or flight response’s over activation can lead to catecholamines at a chronically elevated level. This can result in abnormalities in cardiovascular regulation, increased startle responses, affect regulation problems, profound sleep disturbances and generalized anxiety (Dallam, 2001). Dissociation or a freeze and surrender response may occur when a child is unable to flee from an abusive situation. It has been suggested that changes in the endogenous opiate system and dopaminergic systems may be involved in dissociative responses. The release of endogenous opioids can cause a strong decrease in arousal, decreased pain awareness and decreased blood pressure and heart rate. Children and females are more likely to dissociate while older children and adults are more likely to use a fight or flight response (Dallam, 2001).
Disorders connected to the dysregulation of the HPA axis include PTSD. PTSD is found in 34% of children that have experienced physical or sexual abuse in one study. For children that have experienced both, this rises to 58% (Dallam, 2001). PTSD that comes from child maltreatment may last for many years and may continue into adulthood. Dissociative disorders are connected to physical and/or sexual abuse that is severe and prolonged. Other disorders connected to the dysregulation of the HPA include depression and stress related disorders affecting the immune system (Dallam, 2001).
The effect of chronic maltreatment on brain growth and brain function has been shown using brain scans. Scans using Magnetic Resonance Imaging (MRI) have shown that maltreated children with PTSD have significantly smaller cerebral and intracranial volumes than controls. Lower brain volumes also correlated with the duration and age of onset and severity of PTSD and dissociative experiences in children (Dallam, 2001). Studies of adults have shown that extreme stress in childhood can cause measurable changes physically in the medial prefrontal cortex and hippocampus. These two areas are connected to emotional and memory responses (Dallam, 2001).
The health consequences of childhood maltreatment may also be significant. It was found that severe sexual trauma in childhood was connected to major reductions in vocational, emotional and physical functioning in adults (Dallam, 2001). Studies show that the stronger the strength of the child maltreatment, the higher the rates of health problems reported in adulthood. Women that report child abuse histories report problems in twice as many body systems as nonabused women. These include depression, genito-urinary disorders (including painful intercourse) and other possible somatic complaints. Chronic pain is also reported as a problem for survivors with histories of physical and/or sexual abuse (Dallam, 2001).
Abused girls were also many times more likely to report that they gave a history of bingeing and purging behavior. Those sexually abused were found to be more likely to engage in risky sexual behaviors than peers. Hermann states that the normal regulation of emotive states is changed by experiences that are traumatic that can repeatedly cause grief, rage and terror. These emotions can be brought up by perceived states of abandonment and can’t be stopped by the ordinary ways of self-soothing (Dallam, 2001).
In a study by Elzinga, Schmahl, Vermetten, van Dyck and Bremner (2004) higher cortisol levels were found following certain traumatic reminders in abuse-related post-traumatic stress disorder (PTSD). A Kessler 1995 study is cited reporting that CSA in women is the most common cause of PTSD, affecting 10% of all women. Soon after a traumatic event, cortisol secretion was found to be enhanced, after a variety of traumatic experiences. In some studies, cortisol secretion has been found to be lower in patients with PTSD compared to controls (Elzinga, Schmahl, Vermetten, van Dyck & Bremner, 2004). PTSD patients suffer from exaggerated stress responses in regard to trauma cues. Exposure to stress in PTSD patients might also result in a larger impairment of declarative memory, when compared to controls (Elzinga, Schmahl, Vermetten, van Dyck & Bremner, 2004).
Elzinga’s et al. (2004) study included 24 women, 12 with and without current PTSD that was related to childhood. PTSD levels were measured by the Clinician-Administered PTSD scale for DSM-IV (CAPS-DX). Baseline dissociation traits were measured by the Dissociative Experiences Scale (DES). The scripts were prepared before the actual test day, and were personalized. The first script was about a severe physical or sexual abuse event. The second script was about when the person felt alone or abandoned. The subject impact of the scripts measured with a 17-item PTSD symptom scale, a Clinician-Administered Dissociative States Scale (CADSS) and a 27-item scales that measures current dissociative states, a Subjective Units of Distress Scale. A Visual Analog Scale assessed anxiety. For memory, paragraph recall was measured by the Wechsler Memory Scale revised Logical Memory Test. To study word recall and the effects of cortisol on encoding, the word recall test was given three days later without the scripts (Elzinga, Schmahl, Vermetten, van Dyck & Bremner, 2004).
It was found that the PTSD patients had 122% higher cortisol levels when exposed to a traumatic script, 69% higher level during their recovery after reading the scripts and 60% higher levels in the period before reading the scripts, compared to controls. The abused subjects showed a strong decrease in cortisol after the script exposure, but the controls didn’t. The abused women with PTSD reported more symptoms that were PTSD like and dissociative and more anxiety than those abused without current PTSD. The abused women with PTSD remembered less emotional words after three days than the controls, but these differences were found to be no longer significant after correction. In both the PTSD patients and the controls after the trauma scripts, memory consolidation was impaired compared to the baseline, but there were no differences in memory performance between the two groups. The higher the cortisol level, the better the story was recalled by the participants (Elzinga, Schmahl, Vermetten, van Dyck & Bremner, 2004).
Limitations of the study include a small sample size (N = 12). One third of the subjects were taking psychotropic medications, which may affect cortisol reactivity. All the subjects had a lifetime diagnosis of PTSD. It is not known if the cortisol responses of women with PTSD can be generalized to those with a history of child abuse without PTSD. No participants were included that had no history or abuse and no PTSD. Possibly, non-abused healthy individuals may show even higher cortisol levels than the two samples in the experiment (Elzinga, Schmahl, Vermetten, van Dyck & Bremner, 2004).
Glaser (2000) discusses how child abuse and neglect effect the brain in a review of the literature. Glaser states that there is a strong association between child maltreatment and cognitive, behavioral, emotional and social adaptational failure and psychopathology in adulthood and childhood. She cites a review by Kendell-Tackett, Williams and Finklehor that states that not all children that are sexually abused end up with problems. The review also states that there is no post child abuse syndrome, which would contain a harmful sequelae showing differences between individuals. In studies of adults abused as children, one study found that any type of severe child abuse was connected to other risk factors in the family, which were connected to negative outcomes as adults. A history of emotional and sexual abuse by a male caregiver was found to be connected to adulthood sexual difficulties (Glaser, 2000).
Glaser (2000) also found that raised levels of dopamine and noradrenaline are positively connected with a dysfunction of the prefrontal cortex. The prefrontal cortex functions include organizing and planning actions using working memory, inhibiting inappropriate instructions and attending to distractions. These raised levels may lead to symptoms recognized as Attention Deficit Hyperactivity Disorder (ADHD). If one is faced with chronic or repeated stress, suppressing stress responses might allow cortisol levels to return to normal limits. Cortisol also affects the amygdala. This may cause problems in reduced cortisol levels. This may cause a less than optimal response to fearful experiences. This is seen in children that have suffered from long-term abuse. In children and adults, high levels of cortisol medication have been shown to affect memory negatively (Glaser, 2000).
Child abuse is a major source of stress on the brain. Glaser believes that trauma and abuse are not necessarily equivalent in meaning. Abuse may be stressful and yet not be seen by the child as traumatic if it is predictable and chronic. Yet, chronic abuse and neglect will probably have a strong effect on a child’s biological and psychological regulatory processes and not PTSD-like conditioned behavioral and emotional responses (Glaser, 2000).
HPA axis responses show that after a review of a number of studies discussing trauma and sexual abuse, lower cortisol levels were found. Hippocampal volume in Bremner’s study was found to be reduced by 12% on the left side in male and female survivors of severe childhood sexual and physical abuse of survivors that now suffer from PTSD, compared to a nonabused group. (Glasser, 2000) But there was no memory impairment shown. Yet there is no conclusive evidence showing a causal explanation of abuse leading to hippocampal damage. In a study by Shaefer, Koustall and Norman, 22 women who had experienced extended and severe CSA also showed a reduced volume of their left hippocampal region on MRI. These same women had both memories of the abuse and memory functioning intact (Glaser, 2000).
Children were found to have cerebral volumes that were 7% smaller, when they had PTSD in a study by Bellis, Chrousos et al. The brain volume was correlated positively with the onset age of the PTSD and negatively with the length of the abuse (Glaser, 2000). Sleep disturbances were found in children before puberty that had been sexually and physically abused and those that had been referred psychiatric treatment, in or out patient. Increased activity during sleep and a difficulty falling asleep were the disturbances found. Glaser concludes that there is considerable evidence for brain function changes in connection to child abuse and neglect (Glaser, 2000).
Perry (2000) in a paper on child trauma and its influence on brain development discusses neurobiological responses to threat. He mentions that when a child is threatened, certain neuroendocrine and neurophysiological responses are started. If these responses persist, there will be what are called use-dependent alterations in important neural systems that are involved in the stress response. The systems include the hypothalmic-pituitary-adrenal (HPA) axis. In animal experiments, the chronic activating of the HPA system when responding to stress, has definite negative consequences. This activating may hurt parts of the body, including the hippocampus. The hippocampus is involved in the arousal, cognition and memory. Martin Teicher is cited as having demonstrated hippocampal/limbic abnormalities in abused children samples (Perry, 2000).
A different set of neural systems that can be hurt by stressful experiences that are repeated are the catecholamine systems, which include the dopaminergic and noradrenergic systems. These systems can be changed after traumatic stress. This can cause changes in attention, sleep, impulse control, fine motor control and other functions. It is possible for a traumatized child to show problems with motor hyperactivity, behavioral impulsivity, anxiety, sleep problems, etc. Perry cites indirect studies backing the theory that following childhood trauma there may be a use-dependent alteration in the catecholamine systems in the brain stem (Perry, 2000).
Courtois (1988) in her book on incest discusses the physical and somatic effects of incest on child and adult survivors of incest. With children, symptoms connected to child abuse include regressive behaviors (like bed wetting), physical pains, lethargy, perceptual disturbances, terror and fear reactions (like averting one’s gaze) and trauma repetition. In adults, physical effects may include trauma-specific effects and discomfort in the parts of the body related to the abuse. Other effects may include trauma related gastrointestinal and respiratory effects due to the locus of the abuse assault, such as gagging (Courtois, 1988).
In conclusion, the research shows a variety of effects on brain physiology due to CSA and child abuse and neglect. Certain biochemical processes may also be altered due to CSA. Memory may also be affected by these changes in brain physiology.
Sexual dysfunctions or problems
Sexual dysfunctions or problems which correlate with childhood sexual abuse trauma include: sexual dysfunctions, repeated sexual victimization, adult sexual relationships, the victim-perpetrator cycle (as previously mentioned under social problems) and feelings around sexuality.
Sorenson, Siegel, Golding and Stein (1991) discussed how repeated sexual victimization may correlate with low adjustment levels, where individuals may be singled out for attack because they are alone or identifiably vulnerable. Some researchers have found that multiple sexual victimization leads to delayed recovery and increased dysfunction. Multiple victimization may also lead to multiple consensual sexual partnerships and unintended pregnancies. Long-term unfavorable mental health problems may occur after a single sexual assault (Sorenson, Siegel, Golding & Stein, 1991).
Sorenson et al. (1991) looked at a variety of studies and found that 24% to 79% of victims were multiply victimized after an initial assault. Women that have experienced two or more rapes report a higher level of assertiveness than women that have experienced only one rape. A study was taken of 3,131 adults, men and women. Sexual assault questions asked about childhood assault (before age 16) and adult assault (after age 16). In the sample mentioned, 13.2% answered “yes” as to whether they were forced or pressured into sexual assault. Incest’s potential differences in the data were not examined due to the small sample size of this category. The average number of adult sexual assaults was 3.2. For any assault (adult or child) there were 4.95 per person. Of the assaults, 46.2 % involved some form of incest, and 62.1 % involved some sort of threat of harm. Of the sample reporting sexual assault, more than 67% reported more than one single assault (Sorenson et al, 1991).
Limitations of Sorenson et al. (1991) study include the fact that they used a broad definition for sexual assault, unlike other studies. These included noncontact forms of sexual assault. Since the study only ask for detail about the most recent event, details of previous events could not be discerned. A strength of the study is that the study looked at a larger population of victims, not only those seeking services for help. Those seeking services for help may be more distressed than the general population, or may differ in other important ways from the general population (Sorenson et al, 1991). The reason this study is listed here in this literature review is because even though it does not specifically deal with incest victims, it shows how an initial victimization of sexual assault correlates with repeated sexual victimizations.
In McGettigan’s (1992) thesis, a discussion of adult sexual relationships from a sample of 42 women showed that multiple perpetrators and experiencing pleasure or arousal during abuse were the aspect of CSA that had the largest impact on the sexual functioning of adults. The different aspects affected by the CSA include: a difficulty achieving orgasm, one’s comfort level while communicating with a partner during sex, and the level of the enjoyment of sexual experiences (McGettigan, 1992).
McGettigan (1992) defines CSA as the sexual contact of a child under the age of 15, with an abuser at least five years older. She lists incident rates from various studies of 20% to 38%, depending on the way abuse is defined and the type of population studied. One studied cited by Meiselman showed that 78% of psychologically disturbed women had gone through CSA before they were 12 years old. The physical symptoms of sexual abuse may include genital and anal injury, sexually transmitted diseases and pregnancy. Behavioral studies show that CSA victims may participate in a variety of delinquent and antisocial behaviors (McGettigan, 1992). Repetition compulsion may be seen in sexual acting out certain parts of the abuse, possibly as an effort to master the trauma. Other studies have shown that abused girls showed greater sexual preoccupation (McGettigan, 1992). Finklehor and Browne report that children may carry an aversion to sex and intimacy into adulthood (McGettigan, 1992). Female survivors may end up distrusting men. Physical symptoms, including genital and pelvic pain have also been noted in the literature (McGettigan, 1992).
McGettigan’s sample was gotten from clinical and nonclinical female samples at a community mental health agency. The criteria set for the participants was that they are 18 years of age, that they are survivors of CSA and that they volunteer to participate in the study. Forty-two women participated in the study. Nine were from the clinical sample and 33 were from the nonclinical sample. Data collection consisted of a self-administered questionnaire which focused on basic biographical details, types of CSA experienced, details about the CSA including frequency and questions about the offender, feelings around the abuse, problems during adulthood, adulthood relationship questions, questions about sex in adulthood and problems with sex in adulthood (McGettigan, 1992).
The findings in McGettigan’s study were as follows. Aspects affecting adult functioning were found to be father-daughter incest, the number of perpetrators, onset of abuse, violence connected to the abuse, child coping methods, cult or ritual abuse, experiencing arousal during the abuse and childhood feelings that were prominent. Variables particularly affected included difficulty achieving orgasm, flashback frequency, seeing oneself as sexually irresistible, aversion to acts committed during CSA, level of comfort of communication during sex, sexual experience pleasure with men, being promiscuous, feeling that sex is being done to one instead of being done with one, and sexual orientation (McGettigan, 1992).
Other findings include the following. Fondling of genitals was the largest form of abuse at 76%. Violence with abuse was found to be used 62% of the time. Prominent adult feelings include anger at 24% and rage at 21%. Adult sequelae due to CSA included high percentages of lacking sexual feelings, feeling pain, difficulty achieving orgasm and being physically numb, all during sex. Cognitive sequelae included high percentages of using alcohol or drugs to have sex, dissociating during sex, having flashbacks during sex and convincing oneself to have sex. Ninety-three percent reported that they had a specific aversion to specific acts of sex. But only 63% mentioned that these were the same acts that had been experienced during CSA. Eighty percent mentioned that sexual abuse had affected their sexual perception and experience. Affective sequelae included high percentages of feeling numb during sex, being able to let go during sex, feeling negative during and after sex and being dissatisfied with one’s sex life. Forty-nine percent reported that they worried they were unable to have deep feelings for another person (McGettigan, 1992).
The partnership qualities people looked for showed that 83% looked for someone they respect and that 81% looked for someone that respected them. Survivors of father-daughter incest showed a significant difference between other survivors in higher frequencies of having sex earlier in relationships than they would have like to. Forty-two percent mentioned that they had felt confused about their sexual orientation. Three-quarters of the women that were not sure of their sexual orientation mentioned that they had experienced cult or ritual abuse. In terms of revictimization frequencies, 79% experienced emotionally abusive relationships, 77% experienced sexual harassment, 60% were promiscuous, 53% had been in sexually abusive relationships and 42% had experienced rape (McGettigan, 1992).
The weaknesses of McGettigan’s study include the low number of participants, 42 and the fact that the nonclinical population (33) was drawn from volunteers from both a woman’s center and 12-step programs and not the general population. It is possible that these populations may be more biased or have leaning opinions toward such questions as sexual orientation and father-daughter incest.
Herman and Hirschman (1981) in their book on father-daughter incest discuss sexual orientation and sexual problems. A minority of the incest victims in their study experimented with lesbian relationships. However, only two of the 40 women in their study were confirmed lesbians and another three thought they were bisexual. The two women that became lesbians did believe that the incest experience had influenced their sexual choices. Over half (55%) of the women in their study complained of impaired sexual enjoyment. Some of the women complained of flashbacks of the incest experience during sex (Herman & Hirschman, 1981).
Gelinas (1983) previously mentioned research also discusses the typical symptoms of incest, including sexual problems. These problems have been seen to include orgasmic dysfunction, difficulty with sexual contact, promiscuity, prostitution and adolescent pregnancy. Other problems may include marital difficulties, emotional and physical abuse toward the children of incest victims and an increased risk of intergenerational incest by the spouse of the incest victim (Gelinas, 1983).
Courtois (1988) in her book on incest survivors writes about the sexual effects on children and adults that have suffered incest. With children, there may be exhibited age-inappropriate sexual behaviors or the awareness of sexual topics beyond their age. Other children may avoid any sort of physical contact with others. They may perceive touch as threatening or negative. As adults, evidence suggests that incest strongly affects the sexual experiences of many survivors of incest (Courtois, 1988). Three areas that may be affected include sexual emergence in early adulthood, sexual orientation and preference and sexual response, arousal and satisfaction (Maltz & Holman, 1987). In terms of emergence, CSA disrupts normal developmental tasks, such as dating and the development of intimacy. Survivors may withdraw from development or may become sexually indiscriminate. CSA may also affect one’s sexual development. Some survivors report that their sexual orientation was affected by abuse while others do not. In comparison studies, survivors have been found to have more sexual problems than non-incest survivors (Courtois, 1988). These disorders include desire, arousal, orgasmic disorders, as well as coital pain, satisfaction and frequency difficulties and qualifying information (like flashbacks). Survivors may also suffer sexual revictimization both outside and inside the family more than nonvictims of abuse (Courtois, 1988).
Maltz and Holman (1987) in their book on incest and sexuality write about how incest affects sexuality. As previously mentioned, three areas that may be affected include sexual emergence in early adulthood, sexual orientation and preference and sexual response, arousal and satisfaction. In terms of sexual emergence, survivors often move toward two extreme sexual lifestyles, withdrawn or promiscuous. In terms of sexual orientation and preference, their study of 12 women had half stating that incest had no bearing on their sexual choice. The first half were lesbians. The second half may have been open to same sex experiences as part of their healing experience. In terms of sexual arousal, response and satisfaction, incest can cause problems in sexual functioning. The women in their study felt several feelings connected to their sexual experiences. These included disgust, anger, hate, loss of control, guilt and helplessness. These negative feelings were reinforced by the sexual abuse experience (Maltz & Holman, 1987).
In conclusion, a wide variety of a person’s sexual aspects may be affected by CSA. CSA is seen in the research as negatively influencing sexual development. Sexual orientation may be influenced by CSA and other factors.
Thought problems and disorders
Thought problems or perceived disorders which correlate with childhood sexual abuse trauma include: depression (as mentioned under psychiatric diagnoses), how the survivor evaluates the incest event, self-blame due to less disclosure and other factors, decreased self-esteem, premorbid pessimism, future despair, suicidal ideation and suicide.
In a study by Feiring, Taska and Chen (2002) that looked at children and adolescents within eight weeks after the discovery of the abuse and one year later, it was found that abuse-specific internal attributions were related consistently to higher levels of psychopathology. Shame was also found to be an important predictor of symptom level. The above sheds light on how the victim evaluates the sexual abuse event, self blame relating to less disclosure and decreased self-esteem (Feiring, Taska & Chen, 2002).
In the same study, research is discussed about how the adult survivor’s attributional style is related to the long-term outcomes of the abuse. Self-blaming attributional styles in women were connected to lower disclosure rates, more severe forms of abuse and more anxiety and depression. The relationships between abuse severity and psychological distress were found to be mediated by self-blaming cognitions. Appraising the abuse experiences as negative, including evaluating oneself negatively, feeling one is negatively evaluated by others and having critical feelings of others has been found to be connected with PTSD and depression symptoms in children and adolescents. Negative evaluations of oneself and others may be seen as related to internalizing symptoms. In adolescents, attributing internally for CSA was associated with lower self-esteem and increased depression. Feiring, Taska and Chen (2002) hypothesized that greater abuse severity would be connected to higher self-blame attributions which are connected to symptomology and shame (Feiring, Taska & Chen, 2002).
Their study consisted of 137 total participants. Eighty were children between eight and 11 years of age and 57 were adolescents between 12 and 15 years of age. CSA was defined as having sexual contact with an adult or juvenile perpetrator. Contact was defined as either contact or nonphysical contact (like exposure to pornography or exhibitionism). All cases were validated by medical findings, substantiated by child protective services, confession or conviction of the offender. Attribution style was measured by a questionnaire asking why the respondents thought certain things had happened. Shame was measured by responses to scaled questions about shame, like “wanting to go away and hide” and “people can tell what happened by looking at me.” Self-esteem was measured by The Self-Perception Profile for Children and Adolescents. This measured global self-worth. Depressive symptoms were measured by the Children’s Depression Inventory (Feiring, Taska & Chen, 2002).
External attributions of the abuse were given approximately half of the time and internal attributions were only about five to seven percent of the time when measured. The other percentage were those that didn’t know why the abuse happened. Number of abuse events, age and gender are related to the outcomes of the questions. Girls showed more hyperarousal and sexual anxiety. Adolescents showed higher depressive symptoms, lower self-esteem and less sexual anxiety than children (Feiring, Taska & Chen, 2002).
The problem with Feiring, Taska and Chen’s (2002) study from the perspective of this article is that the results measure child and adolescent’s reactions to CSA. This differs from the question of how does CSA affect adult interpersonal relationships. However, the results can give us a lot of insight into how attributions of the abuse may translate into later psychopathology and shame.
In Briere’s (2002) paper on treating CSA survivors, he describes one form of child maltreatment as psychological neglect (these are acts of omission). Acts of commission include abusive behaviors directed toward the child, including physical, sexual or psychological abuse. These acts can produce long term interpersonal difficulties, including distorted thinking patterns, posttraumatic stress and emotional disturbances. The occurrences of violence in a child’s life may lead the child to develop defenses that may block out positive attachment interactions as well. It is thought that abuse can affect a child’s internal representations of themselves and others. An abused child may come to see themselves as weak and others as dangerous. These core beliefs may be resistant to change simply by hearing others’ declarations to the contrary. When faced with rejection or abandonment in a relationship, primitive behavior due to the abuse may be activated that is so laden with emotion that even though intended to protect the relationship, it may challenge or destroy the relationship (Briere, 2002).
Other problems that can occur due to child abuse and neglect can be that of poor affect regulation. This refers to one’s ability to control strong negative affect. One that has a history of abuse and neglect may resort to avoidance strategies, like substance abuse, dissociation or external tension-reducing behavior. These avoidance activities may follow or precede repetitive and intrusive cognitive, emotional and sensory experiences (like flashbacks or nightmares). Those that tend to avoid internal access to material that is traumatic, can suffer psychological distress more than those that have less avoidant tendencies. Many survivors of severe neglect and abuse suffer from significant interpersonal difficulties (Briere, 2002).
In the previously mentioned Lunderberg-Love (1999) study, two of the most clinically significant psychogenic stressors or attitudes for incest victims entering treatment for a wide span of clinical conditions (INC-T) were problems for premorbid pessimism and future despair. The INC-T group scored higher on these scales than all other groups. Premorbid Pessimism measured the level of one’s sense of hopelessness and their helplessness, the fact of their feeling powerless. Powerlessness is a traumagenic dynamic that is caused by CSA. The Future Despair scale measures responses to present circumstances and difficulties, which is different than looking at things negatively as a lifelong tendency. Those that score high on this scale do not believe they will have a productive future and may view medical difficulties as possibly life threatening and seriously distressing. Incest survivors may tend not to engage in preventative health care measures due to their future despair. The INC-T group also had high scores for Social Alienation. These survivors scored in the clinically significant scale on this measure. People scoring high on this scale perceive low familial and social support. Other information from this paper includes information on spirituality. It is cited that CSA (incestuous) is often connected with the survivor’s feeling of abandonment by God or other problems with spirituality (Lunderberg-Love, 1999).
In the previously mentioned study of Paolucci, Genuis and Violato (2001) it is mentioned that suicidality is made up of the repeated thoughts of death or suicidal ideation and plans, as well as gestures and attempts of self-harm with death being a possible result. There is a 150% increase in the risk of becoming suicidal or depressed following CSA among the general population when looking at the outcome measures and effect sizes while looking at a meta-analysis of the published research on the effects of CSA (Paolucci, Genuis & Violato, 2001).
Baker’s (2003) thesis, discusses the CSA long-term responses of Hispanic women in midlife. Her thesis showed the nonlinear pathways of internalizing shame, silencing and other struggles of these women. Five Hispanic women were interviewed in-depth, using a semistructured interview schedule. The data was analyzed using the method of narrative analysis. The individuals interviewed were chosen through the researcher’s professional networks and women that had been contacted through the author’s professional contacts who had shown an interest in the study. This helped find some people that may not have participated in formal therapy. The author chose women in midlife (between the ages of 40 and 45) because this appeared to be a strong stage of psychological development. This stage was characterized by the effort to look at the respondent’s past while looking into the future as well as an age of self-reflection (Baker, 2003).
Interpretive summaries were derived from the responses from each of the participants. These were broken down into developmental phases. These observations were backed up by the salient research of the period. The abuse experiences varied from fondling to violent penetration. This research included a study by Briere from 1996 that stated that abuse that combines caring and loving with exploitative behaviors can lead to emotional confusion in children and later lead to confusion and ambivalence in adult intimate relationships (Baker, 2003). In one summary, the survivor used sex to keep herself safe in an abusive relationship. With therapy and growth, this survivor was able to eventually leave this relationship and find healthier relationships. A couple of the survivors married Anglos instead of Hispanics, partly because the Hispanics were too much like their abuser. At times, resistance and/or refusal to visit the abuser(s) as children helped the survivors avoid any future abuse episodes (Baker, 2003).
The women in the study developed more relational complexities and capacities as they got older. The earlier parts of their lives had more accounts of pseudo-connections. These were where the women needed to maintain family connections out of necessity. The abusive parts of their lives were not dealt with during these earlier periods as much. As they got older, they developed more meaningful relationships and grew through these relationships over time. These survivors also grew in other ways. They were able to let go of more caretaking behaviors, set clearer boundaries with their family members and be less resentful and more real in their current relationships (Baker, 2003).
One issue that came up for the women in these discussions was the issue of shame and internalization. Due to the fact that these women were unable to discuss the abuse events as children and be supported and protected, the women responded by blaming themselves and feelings a deep sense of shame. This shame made them feel like they wanted to hide or disappear. The shame intensified during adolescence as each survivor became more aware of their own sexuality. This shame was dealt with in a variety of ways, from using drugs and alcohol, using overly sexual behaviors and suicide attempts. Most of the survivors in the study got married right after high school, so they could leave home in a way that was supported by their culture. All of the women’s relationships involved Anglo men at one time of another (Baker, 2003).
Several resilience factors were mentioned by the women in the study. They had at least one supportive adult in their childhood. They received some sort of positive recognition for whom they were. They worked hard on their achievements and used their intelligence to grow through their adulthood. The abuse was put into perspective in their lives by their strong faith or personal spirituality. They were also able to look at their experiences in midlife (cognitive reappraisal), see the abuse as a challenge and learn to grow from it (Baker, 2003).
The Baker (2003) study also asks questions about the connections between certain variables surrounding the abuse (such as frequency and type of abuse) and the damage these may cause. It is helpful to have the individual’s subjective interpretation of the experience on the abuse. Some of the experiences that appeared to be milder from an outside perspective were experienced by the survivors in the study as damaging (Baker, 2003).
The limitations of the Baker (2003) study are that the data was qualitative and not quantitative. This limits the analysis of the variables, since they are all measured from the perspective of the survivor’s viewpoint. Also, the small sample size of only five survivors and the fact that the study was only about Hispanic women in midlife make the study more difficult to generalize across the rest of the population. There was also no control group in the study, so it is difficult to see how the variables could have been different if the women had not been abused (Baker, 2003).
Herman and Hirschman (1981) in their book on father-daughter incest, discusses the effects of this type of incest on female survivors thought processes. They discuss how the memory of incest has affected survivors relationships with others and their images of themselves. All of the women they talked to felt marked or branded by their experiences. The women felt as if they were separate from other people. The feelings of being an outsider and not normal were strong. They felt as if they had something wrong with them. Even though they may realize they were unable to prevent the incest occurrence, they still felt stigmatized. Some felt they could seduce any man, since they had supposedly seduced their fathers. Sixty percent of the incest victims in their study complained of major depressive symptoms in their adulthood. Thirty-eight percent were so depressed at some point in their lives that they tried to commit suicide. Alcohol and drug dependency affects 20% at some time in their lives. They described these drug episodes as trying to deal with their feelings of depression and loneliness (Herman & Hirschman, 1981).
The women in Herman and Hirschman’s (1981) study also had trouble forming trusting relationships. They felt as if they had been betrayed by both parents. They expected to be abused and disappointed in all of their intimate relationships. They felt as if they would be abandoned, like their mothers abandoned them. Or they felt as if they would be exploited, similar to their experiences with their fathers. The women in the study longed for the nurturance they had not received in childhood. They had learned in childhood that sex was the one way that they could get attention. One third of the women in their study had times in their lives when they were sexually promiscuous. Many of them went between periods of promiscuity and abstinence (Herman & Hirschman, 1981).
The relationships the women in the study (Herman & Hirschman, 1981) did form were very rough. They appeared to choose men that were either unreliable or exploitative. They felt as if their husbands did not respect or value them. They also had trouble choosing someone that they respected. The women also ended up in relationships that were physically abusive. Eleven of the women (out of 40) in Herman and Hirschman’s (1981) study described this. Six of the women had been raped in addition to being beaten. Three of the women had been raped more than once. The women’s reactions to these assaults were that they deserved them. Only a minority felt anger about them. The majority of the incest victims tried to repeat the specialness they felt in their relationship with their father, some had affairs with older men or married men. They saw other women in a hostile manner as potential rivals or inadequate people. This affected their potential for developing friendships with these women. As parents, many of the women felt as if they had to be excellent parents. Some feared having men around their daughters. They often developed a lot of strength and competency in their professional lives, but were often incapable of defending themselves and their own needs (Herman & Hirschman, 1981).
Courtois (1988) discusses the aftereffects of incest in her book on adult survivors in therapy. In two of the categories she writes about, she discusses the emotional reactions and self-perceptions survivors of incest may have. The initial effects of abuse on a child’s emotional reactions can include anxiety, confusion, guilt, fear, depression and anger with grief and loss reactions. Fear and anxiety may show up in ritualized behavior, sleep disturbances and mood swings. She cites Green’s 1983 work where he discusses the development of a traumatic neurosis in children caught in situations of traumatic abuse, which can include ego disorganization and a painful affective state. A child may become psychically closed off from the world (Courtois, 1988).
The child’s self perceptions are also affected. One’s positive sense of self may be weakened and the development of a negative sense of self may occur. Some children may always try to be good, to defend against all of the feelings that come due to the abuse (Courtois, 1988).
As an adult, survivors’ emotional reactions may change in intensity and continuity. These emotions include generalized fear and anxiety and depression (which may become chronic). Adult survivors’ self-perception have been found to be mostly negative. Survivors may self incorporate a strong sense of being bad and feeling shame. Survivors may question why the event happened to them in the first place. They may feel as if they did something to cause the abuse (Courtois, 1988)
Herman (1997) in her later book on trauma and recovery from trauma, discusses the concept of captivity. This is where prolonged, repeated trauma can occur. Repeated trauma occurs when the victim is unable to escape. Battered women and abused children fall into this category. The psychology of the victim in essence becomes shaped by the beliefs and the actions of the perpetrator. To the victim and others, the perpetrator appears normal. The perpetrator needs to enslave the victim. Then, the victim needs to affirm the abuse (Herman,1997).
According to Herman, repeated trauma in childhood deforms a child’s personality. The child must find a way to trust people that are untrustworthy. A child needs to develop extraordinary capacities. This causes the development of abnormal states of consciousness. These states of consciousness then permit the development of an array of a variety of symptoms, including somatic and psychological ones (Herman, 1997).
Survivors of abuse grow up unprepared for the different parts of adult life. The survivor can have problems with initiative, autonomy and trust. In a sense, the survivor is a prisoner of their childhood. Survivors’ intimate relationships are formed by the need for care and protection and the fear of being exploited or abandoned. Survivors have trouble protecting themselves in intimate relationships. Survivors have trouble establishing appropriate boundaries. Survivors also have trouble judging people, due to their self-denigration and idealization of others. This makes it more likely that survivors will be revictimized in adult life (Herman, 1997).
Briere’s previously mentioned book for therapists of CSA survivors also discusses some of the cognitive effects from CSA. These include negative self-evaluation and guilt, helplessness and hopelessness (due to a loss of personal choice), and a distrust of others. Other emotional effects of CSA in adults include anxiety, depression and anger (Briere, 1996).
Gartner (1999) in his book on the psychodynamic treatment of sexually abused men writes about the aftermath of CSA. He states that male survivors of abuse are less likely to seek therapeutic help than female survivors, but are more likely to seek help than nonabused men for issues that are not related to the abuse. Sexually abused men are more likely to desire sexual activity with children than abused women, though most do not become abusers. Sexually abused boys are also more likely to act aggressively as they get older and are more likely to get involved in criminal behavior (Gartner, 1999).
In conclusion, there are a wide variety of effects to a survivor’s thought processes due to CSA. It could be hypothesized that the inability to process and discuss the abuse as children has increased the deleterious effects on CSA survivors as adults, including dealing with additional feelings of guilt and shame, and possibly also having to repeat the abusive cycle, due to the feeling that one somehow deserved the abuse.
This section will discuss the books written by authors for survivors of child abuse and their helpers. These books may occasionally cite journal articles, but are written in a nonscientific manner for the lay person. The opinions of the authors will be discussed in terms of looking at how CSA affects interpersonal relationships.
Ainscough and Toon (2000) discuss the damage caused by CSA in their book
about surviving CSA. They discuss Finklehor’s model for the ways in which child sexual abuse causes problems. These ways include traumatic sexualization, stigmatization, betrayal and powerlessness. In traumatic sexualization, sex becomes associated with bad feelings. Stigmatization occurs when the survivor realizes that what is happening to them is not normal. This can entail keeping the abuse a secret. Betrayal occurs when a survivor’s trust in the perpetrator is broken. Powerlessness is the dynamic that occurs when the child is unable to control the situation (Ainscough and Toon, 2000).
Bass and Davis (1993) in their beginner’s book for survivors of abuse discusses
the emotions of grief and anger that need to be worked through to heal. Anger probably wasn’t allowed to be felt during the abuse experience (Bass & Davis, 1993). In their earlier work written in 1988 about healing from abuse (Bass & Davis, 1988) they write about recognizing the damage done by CSA. This damage includes having one self-esteem diminished and one’s personal power taken away by the abuse situation. The child wasn’t able to process the feelings of rage, pain or terror fully. This was so they could function in daily life. Children may numb or leave their bodies during the abuse experience. The ability for having healthy adult intimacy and sexuality may also have been impaired by the abuse experience (Bass & Davis, 1988).
Davis (1991) in her book for allies of those that are healing from CSA, discusses
how CSA affects children once they grow up. She writes about other life factors having an influence on the child besides abuse, including physical abuse, neglect, alcoholism and the death of a parent. Survivors may be good at one thing, like working, but have trouble in the areas of intimacy. The variables that are affected as an adult include self-esteem, feelings, body awareness, intimacy, parenting and work. An adult may believe that they were responsible for the abuse. This can affect their self esteem. During abusive episodes, feelings may go underground. As adults, a survivor’s feelings may get stuck or be difficult to express. Adult survivors may be disconnected from their bodies, due to the fact they left them or dissociated from them as children. In intimacy, the survivor may be confused about the messages of sex and love as a child. This causes adults problems in relationships. They may either trust too much or too little. As parents, survivors need to learn to be appropriate role models. Survivors may be confused about their choice of avocation, since the survivor may not have had the time to develop their ideas as a child, or they may be following their families ideas about what they should do (Davis, 1991).
Engel (1989) in her book on healing from the trauma of CSA, writes about the
variables that can be affected by CSA. These include the long-term symptoms of damage to self-image and self-esteem, relationship problems, sexual problems, emotional problems and physical problems. Many of these symptoms are discussed in the published scientific literature about CSA and its effects (Engel, 1989). Engel (2000) in her book on families healing in recovery writes about the dysfunctional family dynamics that may occur in the families of survivors. These include denial, unpredictability, lack of empathy, lack of clear boundaries, role reversal, a closed family system, incongruent messages (body language differs from speech) and extremes in conflict (too much conflict may result in abuse, too little may result in hiding problems and not dealing with them) (Engel, 2000).
Frederickson (1992) in her book on repressed memories writes about how PTSD and other symptoms can lie quiet for many years until a triggering event occurs. She describes this as delayed-onset PTSD. These triggers may include a birth, a situation similar to the abuse, a child reaching the age the survivor was when abused, ending an addiction or feeling safe and strong enough in one’s adult life to be able to face the abuse (Frederickson, 1992).
Graber (1991) in his guide for partners of incest survivors writes about the issues of sex in adult relationships. He mentions that usually there are no major problems with sex at the beginning of a relationship, if the survivor is not dealing with their prior abuse. Survivors however need to deal with past memories, and this can put a burden on current sexual relationships. Graber also discusses that some survivors need to put themselves in situations similar to the abuse. This repetition compulsion of survivors might be due to the fact that this is the only way the survivor knows to be sexual. Other survivors may make sure that they are in the dominant position during sex. This repeats learned sexual behavior during the abuse (Graber, 1991).
Grubman-Black (1990) in a book on men recovering from CSA writes about why victims repress their abuse. He mentions, like others, that this is the way that survivors can survive the loss. He considers this a form of denial. He states that those that have survived CSA often have flashbacks. He believes that it is important to deal with these flashbacks and memories to have a better life (Grubman-Black, 1990).
Lew (1988) in his book for male survivors of child abuse, writes about the aftereffects of child abuse. He discusses the losses of childhood. These include the loss of memory of childhood or parts of childhood, the loss of healthy social contact, the losses of playing, learning, control over one’s body and nurturance. He lists many of the issues adult survivors may face, including anxiety, depression, low self-esteem, shame and guilt, the inability to trust, fear of feelings, flashbacks, sleep disorders, amnesia, sexual issues, hypervigilance, intimacy problems, overachievement or underachievement in career, becoming abusers or protectors, having multiple personalities, substance abuse, eating disorders, feelings scared like a child and being very conscious of one’s appearance and body (Lew, 1988).
Oksana (2001) in her guide for ritual abuse survivors writes about healing relationships. She believes that ritual abuse attacks a child sense of self-esteem, feeling of belonging and trust. The problems survivors have include social interactions, familial relationships and intimacy. People that are traumatized lose their ability to keep their sense of self in relation with others. Hypervigilance is part of a dissociated and traumatized self or part. The closer the relationship, the more danger the survivor may feel. Shame and fear from past situations may influence current situations (Oksana, 2001).
Ryder (1992) in his book on ritual abuse writes about the compulsive/addictive characteristics that ritual abuse clients may suffer from. He mentions that as survivors get closer to their memories, they become more obsessive about things like sex, relationships, eating or gambling (Ryder, 1992).
In conclusion, the popular literature looks at a variety of topics that are discussed in the scientific literature. Some of their conclusions, like those on the psychological and sexual aftereffects of abuse are confirmed in the literature. Other factors, such as career over and underachievement, this writer was unable to find any validating scientific confirmation for.
Ainscough, C. & Toon, K. (2000). Surviving childhood sexual abuse. (Rev. ed.) Cambridge, MA: Fisher Books.
Alexander, P. C. (1993). The differential effects of abuse characteristics and attachment in the prediction of long-term effects of sexual abuse. In Journal of Interpersonal Violence. 8(3), 346 – 362.
American Psychological Association (2000). Diagnostic and statistical manual of mental disorders (4th ed. text revision). Washington, D. C: Author.
Apgar, B. (1999) Childhood trauma and dissociation in adulthood – American Family Physician, Sept 1, 1999 retrieved October 19, 2004 from http://www.findarticles.com/p/articles/mi_m3225/is_3_60/ai_56959072.
Azar, S. T. & Wolfe, D. A. (1989) Child abuse and neglect in treatment of childhood disorders In Mash, E. J. & Barkley, R. A. (1989). Treatment of Childhood Disorders. New York: Guilford Press (pp.451- 489).
Baker, J. A.. H. (2003). Long-term responses to childhood sexual abuse: Life histories of Hispanic women in midlife. (Doctoral Dissertation, Case Western Reserve U., 2003). Dissertation Abstracts International. 64(7-A), 2646.
Bass, E., Davis, L. (1993). Beginning to heal : A first book for survivors of child sexual abuse. New York, NY : HarperCollins Pub, Inc.
Bass, E. & Davis, L. (1988) The courage to heal : A guide for women survivors of child sexual abuse. New York, NY : Harper and Row, Pub, Inc.
Briere, J. (1996). Therapy for adults molested as children (2nd ed) New York, NY : Springer Publishing Co.
Briere, J. (2002). Treating adult survivors of severe childhood abuse and neglect: Further development of an integrative model [Electronic Version] In Myers, J. E .B, Berliner, L., Briere, J. Hendrix, C.T., Reid, T. & Jenny, C. (Eds.) (2002). The APSAC handbook on child maltreatment (2nd Ed). Newbury Park, CA: Sage Publications. [Electronic Version] Retrieved October 19, 2004 from http://www.johnbriere.com/STM.pdf.
Browne, A. & Finklehor, D (1986). Impact of child sexual abuse: a review of the research. In Psychological Bulletin. 99(1), 66 -77.
Colman, R.A, Widom, C.S. (2004) Childhood abuse and neglect and adult intimate relationships: A prospective study. Child Abuse Negl 28(11):1133-51.
Courtois, C. A. (1988). Healing the incest wound. New York NY: W. W. Norton & Company.
Dallam, S. J. (2001). The Hidden effects of childhood maltreatment on adult health [Electronic Version] The long-term medical consequences of childhood trauma. In Franey, K., Geffner, R. & Falconer, R. (Eds.), The cost of child maltreatment: Who pays? We all do. (pp. 1-14). San Diego, CA: FVSAI Publications. [Electronic Version] Retrieved October 20, 2004 from http://www.leadershipcouncil.org/Research/Costs/Medical-Costs/medical-costs.html.
Davis, L., (1991). Allies in healing: When the person you love was sexually abused as a child NY : HarperCollins Pub, Inc.
Dodge, K. A. (1989) Problems in social relationships in treatment of childhood disorders In Mash, E. J. & Barkley, R. A. (1989). Treatment of Childhood Disorders. New York: Guilford Press (pp. 222 – 244).
Dominguez, R. Z., Nelke, C. F. Perry, B. D. (2001) Sexual Abuse of Children Its Psychosomatic Consequences [Electronic Version] Retrieved December 8, 2004 from http://www.mgr.org/SexabuseConsequences-1.html
Draijer N, Langeland W. (1999) Childhood trauma and perceived parental dysfunction in the etiology of dissociative symptoms in psychiatric inpatients. In Am J. Psychiatry 156; 379-385
Elzinga, B. M., Schmahl, C. G., Vermetten, E, Dyck, R. V., Bremner, J. D.(2004) Higher cortisol levels following exposure to traumatic Reminders in abuse-related PTSD Retrieved December 4, 2004 from http://www.acnp.org/citations/Npp051602190/default.pdf
Engel, B. (1989). The right to innocence : Healing the trauma of childhood sexual abuse. New York, NY : Ivy Books.
Engel, B. (2000). Families in recovery: Healing the damage of childhood sexual abuse. Lincolnwood, Il: Lowell House.
Farber, S. (1997). Self-medication, traumatic reenactment, and somatic expression in bulimic and self-mutilating behavior. In Clinical Social Work Journal .25 (1), 87-106. Self-medication, traumatic reenactment, and somatic expression in bulimic and self-mutilating behavior [Electronic Version] Retrieved November 20, 2004 from http://www.psychematters.com/papers/farber.htm
Feiring, C., Taska, L. & Chen, K. (2002) Trying to understand why horrible things happen: attribution, shame, and symptom development following sexual abuse. In Child Maltreatment, 7, 1 (2002) 25-39. [Electronic Version] Retrieved October 20, 2004, from http://cmx.sagepub.com/cgi/reprint/7/1/25?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Constance+Dalenberg&searchid=1097070546272_23&stored_search=&FIRSTINDEX=0&sortspec=relevance&journalcode=spcmx.
Frederickson, R. (1992). Repressed memories: A journey to recovery from sexual abuse. New York, NY: Simon and Schuster.
Freyd, J. J. (1996). Betrayal trauma: The logic of forgetting childhood abuse. Cambridge, MA: Harvard University Press.
Gartner, R. (1999). Betrayed as boys: Psychodynamic treatment of sexually abused men. New York, NY: Guilford Press.
Gelinas D. (1983). Persisting negative effects of incest. In Psychiatry. 46(4) 312 – 332.
Glaser, D. J. (2000) Child Abuse and Neglect and the Brain: A Review In Child Psychol. Psychiat. 41, 1; 97-116 [Electronic Version] Retrieved November 29, 2004 from http://fcis.oise.utoronto.ca/~hmcbride/ChildAbuseNeglectBrain.html
Graber, K (1991). Ghosts in the bedroom: A guide for partners of incest survivors. Deerfield Beech, FL : Health Communications, Inc.
Grubman-Black, S. D. (1990). Broken boys/mending men: Recovery from childhood sexual abuse. Blue Ridge Summit, PA: Tab Books.
Herman, J. L. & Hirschman, L. (1981). Father-daughter incest. Cambridge, MA : Harvard University Press
Herman, J. (1997). Trauma and recovery. New York, NY: Basic Books.
Hopper, J. (2003). Sexual abuse of males : Prevalence, possible lasting effects, & resources Retrieved October 14, 2004 from http://www.jimhopper.com/male_ab
Jumper, S. A. (1995). A meta-analysis of the relationship of child sexual abuse to adult psychological adjustment. In Child Abuse and Neglect. 19(6), 715-728.
Kelly, R. J. & Ben-Meir, S. (1993). Emotional effects. In Waterman, J., Kelly, R., Oliveri, M. K. & McCord, J. (1993). Behind the playground walls: Sexual abuse in preschools. New York, NY: Guilford Press. (pp. 106 – 119)
Lange, A., Beurs, E., Dolan, C., Lachnit, T., Sjollema, S. & Hanewald, G., (1999) Long-term effects of childhood sexual abuse: Objective and subjective characteristics of the abuse and psychopathology in later life In Journal of Nervous and Mental Disease,187 (3),150–158. [Electronic Version] Retrieved October 21, 2004 from http://users.fmg.uva.nl/alange/pdf/JNMD1999.pdf.
Lew, M. (1988). Victims no longer : Men recovering from incest and other sexual child abuse. New York, NY: Harper and Row, Pub, Inc.
Lunderberg-Love, P. K. (1999). The resilience of the human psyche : recognition and treatment of the adult survivor of incest. In Paludi, M. A. (1999) The psychology of sexual victimization: A handbook. Westport, CT: Greenwood Press (pp. 1 – 30).
Maltz, W. & Holman, B. (1987). Incest and sexuality: A guide to understanding and healing. Lexington, MA: Lexington Books.
McGettigan, M. L. (1992) Will they always be living this story ?: The impact of childhood sexual abuse on the sexual relationships of women survivors. Unpublished master’s thesis, Smith College School for Social Work, Northampton, MA.
Miller, M. (2004) Personality and the development and expression of PTSD. In PTSD research quarterly 15(3):1 – 3 [Electronic Version] Retrieved December 6, 2004 from http://www.ncptsd.org/publications/rq/rqpdf/V15N3.PDF
Miller, P. M. & Lisak, D. (1999). Associations between childhood abuse and personality disorder symptoms in college males in Journal of interpersonal violence 14(6), 642-656 .
Moskowitz, A. (2004). Dissociation and violence: A review of the literature. In Trauma, Violence and Abuse, 5,1, 21 – 46 Sage Publications [Electronic Version] Retrieved November 19, 2004 from http://tva.sagepub.com/cgi/reprint/s/1/21
Myers, D. (date not listed). The Relationship between sexual abuse and eating disorders Retrieved October 14, 2004 from http://www.vanderbilt.edu/AnS/psychology/health_psychology/PSY297.html
Oksana, C. (2001). Safe passage to healing: A guide for survivors of ritual abuse. Lincoln, NE : IUniverse.com, Inc.
Paolucci, E. O., Genuis, M. L. & Violato, C (2001). Theories of the effects of child sexual abuse . In The journal of psychology, 135(1), 17 – 36 [Electronic Version] Retrieved October 14, 2004 from http://www.ipce.info/library_3/files/paol.htm
Peed, C. A. (1995). How women incest survivors create family. Unpublished master’s thesis, Smith College School for Social Work, Northampton, MA
Perry, B. D. (2000) Traumatized children: how childhood trauma influences brain development (special academy version of an article of Traumatized children: How childhood trauma influences brain development) In: (2000) The Journal of the California Alliance for the Mentally Ill 11:1, 48-51. [Electronic version] Retrieved October 21, 2004 from http://www.childtrauma.org/CTAMATERIALS/trau_CAMI.asp.
Piper, A, Merskey, H. (2004a) The Persistence of Folly: A Critical Examination of Dissociative Identity Disorder. Part I. The Excesses of an Improbable Concept – Can J Psychiatry 49:592-600 [Electronic Version] Retrieved December 3, 2004 from http://www.cpa-apc.org/Publications/Archives/CJP/2004/september/piper.asp
Piper, A, Merskey, H. (2004b) The Persistence of Folly: Critical Examination of Dissociative Identity Disorder. Part II. The Defence and Decline of Multiple Personality or Dissociative Identity Disorder – Can J Psychiatry 49:678-683 [Electronic Version] Retrieved December 3, 2004 from http://www.cpa-apc.org/Publications/Archives/CJP/2004/october/piper.asp
Putnam, F. W. (1989). Diagnosis and treatment of multiple personality disorder. New York: Guilford Publications.
Rauch, M. & Jones, J. W. (1997). Effective Group Therapy with Male Survivors of Sexual Abuse. Retrieved October 23, 2004 from http://www.yesican.org/articles/icanjj.html.
Russell D. E. H. (1999). The secret trauma : Incest in the lives of girls and women (rev. ed.) New York, NY : Basic Books.
Ryder, D. (1992). Breaking the circle of satanic ritual abuse: Recognizing and recovering from the hidden trauma; Minneapolis, MN: CompCarePublishers.
Sorenson, S. B., Siegel, J. M., Golding, J. M. & Stein, J. A (1991). Repeated sexual victimization In Victims and Violence. 6, 4, 299 – 308.
Struve, J. (date unknown) Clinical considerations in working with gay & lesbian sexual abuse survivors. Retrieved October 26, 2004 from http://www.atlantapsychotherapy.com/articles/struve4.htm.
Styron, T. & Janoff-Bulman, R. (1997). Childhood attachment and abuse: long-term effects on adult attachment, depression, and conflict resolution. In Child Abuse and Neglect. 21,10 1015-1023.
Whitfield, C. L. (1995); Memory and abuse: Remembering and healing the effects of trauma. Deerfield Beach, FL: Health Communications, Inc.
Zurbriggen, E. L. & Becker-Blease, K. (2003). Predicting memory for childhood sexual abuse: “non-significant “findings with the potential for significant harm. In Journal of Child Sexual Abuse, 12 (2) New York: Hawthorne Press, Inc. (pp 113-121) [Electronic Version] Retrieved October 21, 2004 from http://www.leadershipcouncil.org/Research/Trauma___Memory/Zurb.pdf.