The trauma that never ends

A shocking headline in The Daily Star, claiming "145 children [were] raped in three months!" caught the attention of many recently. The article reported that 145 children in Bangladesh were raped in the first three months of 2017, 50 of whom were killed. Social media was abuzz with discussions around the article, and the general feedback was unanimous - what is happening in our society is despicable, shocking, nauseating. These 145 cases are only the tip of the iceberg - a multitude of sexual abuse cases have likely gone unreported due to societal taboo, shame and stigma.

Have you given a thought about what happens to child abuse victims in the longer term? What influence does child sexual abuse have on a person's physical, psychological, social and interpersonal functioning in later life?

Child sexual abuse can be defined as 'any sexual activity with a child where consent is not or cannot be given'. The perpetrators of sexual abuse are not always adults; sexual contact between an older child and a younger one can also be deemed as abusive if the victim is unable to give informed consent. Acts considered as sexual abuse include penetration and touching, as well as non-contact acts such as voyeurism and exposure; in plain words, any activity that exploits a victim sexually is sexual abuse. Perpetrators may also exploit children online, by prematurely exposing children to pornography, trapping them into having conversations of a sexual nature in chat rooms and manipulating them into sending pornographic photos of their bodies. Sexual abuse is often carried out by someone who the victims trust - the abuse breaks the trust and leaves the abused children believing that the people they trust will end up hurting them.

Childhood sexual abuse occurs in families of all socioeconomic levels, but is most common in families that are socially deprived and disorganised. Dysfunctional marriages, resulting in domestic violence or parental separation, are associated with higher risks of child sexual abuse ("A Study of Potential Risk Factors for Sexual Abuse in Childhood", Child Abuse and Neglect, Vol. 21). There is also increased risk with a step-parent in the family or when a child is put into foster care ("Childhood sexual abuse and psychiatric disorders in young adulthood", Journal of the American Academy of Child and Adolescent Psychiatry, Vol. 35). Social deprivation and dysfunctional family environments are likely to leave children vulnerable due to the lack of adequate care, protection and supervision, leaving them exposed to molesters who display fake interest and affection to take advantage of a child's vulnerability. Studies have suggested that physical maturity, attractiveness, early sexual maturation and socially isolated children with few friends have the highest risk of being sexually abused ("High risk children", A Sourcebook on Child Sexual Abuse). 

Childhood is a time when complex changes occur in a person's physical, social and psychological being - these changes are retarded and perverted when a child is abused, leading to abnormalities in their development. Abuse disrupts a child's self-esteem and sense of mastery of the world, leaving them vulnerable to social and personal deficits in later life. The child loses the sense of the world as a safe and trusting environment, the understanding that relationships can be trusting and intimate; in adult life, this leads to an increased risk of low self-esteem, social insecurity, difficulties with one's sexuality and ability to be intimate, and socio-economic failure. Abused children have lower educational attainment - they are more likely to have lower grades, increased absence from school and lower than average attainment in language and mathematics, all of which persists through adulthood if the right support is not provided (Proceedings of the National Academy of Sciences of the United States). 

 Abuse at an early age, long-term abuse, exploitation by a near relative (such as a parent or sibling) or use of force are more likely to give rise to extreme behavioural symptoms. These behaviours include intense emotional reactions, fear, shame, humiliation, guilt, self-blame, nightmares, flashbacks and poor self-perception. Affected children may develop the belief that they are somehow to blame for the sexual abuse and that they deserved the suffering. The survivor will often take personal responsibility for the abuse, particularly when the abuse is carried out by a trusted adult, as it is difficult for the child to view the loved one in a negative light. Self-esteem is likely to be severely affected - the child may have an increased belief that bad things are likely to happen to them (pessimism) and they may develop a sense that they lack control of their own lives and life events.

Sexual abuse in childhood has been shown to cause significant changes in the brain structure (Proceedings of the National Academy of Sciences of the United States). Researchers have found specific changes in a key part of the brain, the hippocampus, in those who have been maltreated in childhood. Those children who have experienced abuse have been found to have reduction in brain volume in two parts of the hippocampus: the pre-subiculum and subiculum. These brain changes leave a person more vulnerable to anxiety, depression and post-traumatic stress disorder in adulthood. Childhood abuse also leads to high levels of circulating stress hormones that damage regions of the brain that affect the person's ability to cope with stress in later life.

Women who have been sexually abused will often underestimate their own abilities and seek occupations that are below their capacity as a result of their poor self-esteem. In personal relationships, a victim of childhood sexual abuse is more likely to be dissatisfied with their romantic relationships and describe their partners as overly-controlling or uncaring. Unhappiness in intimate relationships is usually due to the victim's lack of trust in others and a poor sense of his/her own sexuality. Child sexual abuse involving penetration is more likely to lead to unsatisfactory adult sexual relationships. Difficulties with sexual performance are also more common in those who have been abused - male victims are more likely to experience low libido, premature ejaculation or erectile dysfunction, while female victims are likely to suffer arousal problems in adulthood ("The long-term effects of childhood sexual abuse: Counseling implications", counsellingoutfitters.com). 

The trauma of childhood sex abuse affects the body's stress system, which lingers on for years after the initial event. The increased level of stress leaves the victim vulnerable to chronic diseases such as hypertension, diabetes, heart attacks and strokes. Victims are also more likely to report chronic pain syndromes such as back pain, unexplained headaches, pelvic pain, poor sleep, gastrointestinal problems and breathing difficulties in adult life ("The long-term effects of child sexual abuse", Australian Institute of Family Studies). A clear link exists between sexual abuse and fibromyalgia, chronic fatigue syndrome and irritable bowel disease. Studies have shown that a victim of sexual assault has double the risk of being confined to bed or restricted in daily activities due to their physical health problems. Eating disorders and body image issues are also common.

The effect of sexual abuse on mental health is profound. The trauma of abuse during childhood leads the victim to direct their shame, despair and anger inwards, which gives rise to psychological distress in adolescence. The denial and repression of the memories of being abused can lead to amnesia of parts of one's childhood, which can be confusing and distressing for the sufferer. There is now a large body of research that links child sexual abuse to high rates of anxiety, depression, suicidal ideation, eating disorders, trauma and substance abuse.

Interestingly, research has shown that long-term problems following child sexual abuse are lower in those victims who have confiding and supportive relationships with their mothers ("Childhood sexual abuse and later psychological problems", Criminal Behaviour and Mental Health, Volume 7). Success in sports and academic achievement at school have been shown to be protective against long-term consequences of sexual abuse as they lead to improvement of one's self-esteem and encourage effective social interaction with peers. 

The long-term effects of childhood sexual abuse can be complex and devastating. Sexual abuse not only leaves the victim vulnerable to mental health problems such as anxiety, depression and anger, but also chronic physical health problems such as chronic pain and gastrointestinal disorders. Survivors need to be supported with empathy, understanding and empowering messages with the aim to improving their self-esteem and re-integrating them in society. Instead of identifying and targeting abuse victims, the effort should be to provide all adolescents the opportunity to participate in social opportunities that increase their self-esteem and mastery in dealing with life. Enabling victims to achieve success in academics, sports and in the workforce greatly reduces the vulnerabilities to developing mental, physical and interpersonal problems in adulthood.

 

The writer is a London-based Adult Psychiatrist working for the National Health Service (NHS), United Kingdom.