15 Childhood Sexual Abuse (CSA): Consequences and Holistic Intervention

Introduction

According to the World Health Organization, Child Sexual Abuse (CSA) is a worldwide health problem and it has become increasingly common to view violence from a public health perspective (WHO, 2002). The WHO defines CSA as:

The involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared and cannot give consent, or that violates the laws or social taboos of society. Child sexual abuse is evidenced by this activity between a child and an adult or another child who by age or development is in a relationship of responsibility, trust or power, the activity being intended to gratify or satisfy the needs of the other person. This may include but is not limited to: the inducement or coercion of a child to engage in any unlawful sexual activity; the exploitative use of a child in prostitution or other unlawful sexual practices; the exploitative use of children in a pornographic performance and materials” (WHO, 2003, p. 75).

Violence places a heavy strain on the healthcare systems, social and welfare services (WHO, 2014) because

Unity of Mind and Body

There is no real distinction between the mind and the body because of the communications between the brain, the nervous system, endocrine, and immune systems (Brower, 2006) and psychological trauma, such as after childhood sexual abuse (CSA), has long-term physical health consequences, as research has found that stressful early life experiences can cause immune dysregulation across the lifespan (Fagundes, Glaser & Kiecolt-Glaser, 2013). This means that individuals with CSA experience are at a greater risk for serious illnesses than those without such experience and have increased need for healthcare. This goes hand-in-hand with significantly higher healthcare use such as a greater number of visits to the emergency department, hospital outpatient department, pharmacy, primary care, and specialty care than those without a CSA experience (Bonomi et al., 2008).

Despite the fact that studies have identified childhood sexual abuse (CSA) survivors as a particularly vulnerable group, only a few attempts have been made to study their lived-experience of the health consequences of CSA. Research results indicate that approximately one in every four women and one in every six men have experienced CSA (Sigurdardottir, 2017). This suggests that health care providers, especially in high volume practices, encounter every day multiple women and men who are CSA survivors (Sigurdardottir & Halldorsdottir, 2018).

In this chapter, we will compare and discuss the health consequences of CSA for men and women. When comparing gender similarities and differences, we will use a study on the consequences of CSA for men’s health and well-being from the perspective of male CSA survivors (Sigurdardottir, Halldorsdottir & Bender, 2012) and a study on the consequences of CSA for women’s health and well-being from the perspective of female CSA survivors (Sigurdardottir & Halldorsdottir, 2013). We will also use a case study with a female CSA survivor (Sigurdardottir & Halldorsdottir, 2018). Then we will present the Wellness-Program, designed for female CSA survivors (see Sigurdardottir, Halldorsdottir, Bender & Agnarsdottir, 2016). We will describe this unique multidisciplinary program1 and the professionals working within it, provide certain details of the program, such as the daily schedule, as well as how it was initiated and funded. Finally, we will discuss how it affected the participants.

Trauma and Human Resilience

Not everyone develops PTSD following trauma, which makes the study of resilience interesting (Agaibi & Wilson, 2005). In some individuals, exposure to repeated trauma may increase resilience; in others it can degrade resiliency (Wilson & Drozdek, 2004). What we know of posttraumatic resilience is that it characterizes psycho-biologically healthy survivors; it can be learned and is critical to successful treatment; and, finally, it can be implemented through training programs to reduce the effects of traumatic exposure (Agaibi & Wilson, 2005). What we also know is that parenting influences resilience in adulthood. In a study by Lind et al (2018), the effect of parenting on the association between severe CSA and resilience in adulthood was examined in a large female twin sample (n= 1423). Severe CSA was associated with lower resilience to recent stressors in adulthood. Subscales of the Parental Bonding Instrument were significantly associated with resilience. Specifically, parental warmth was associated with increased resilience while parental protectiveness was associated with decreased resilience. Results suggest that CSA assessment remains important for therapeutic work in adulthood and that addressing parenting may be useful for interventions in children with a CSA history.

Comparing Men’s and Women’s Health Consequences of CSA

Because there is no real distinction between the mind and the body because of the communications between the brain, the nervous system, endocrine, and immune systems the list of the consequences of CSA for both men and women is very long. Psychological trauma, such as after childhood sexual abuse (CSA), has long-term consequences because stressful early life experience cause immune dysregulation across the lifespan (Fagundes, Glaser & Kiecolt-Glaser, 2013). This means that individuals with CSA experience are at a greater risk for serious illnesses than those without such experience. Some of the known consequences for health and well-being that some people are suffering from after CSA include psychological, social and physical consequences shown in Table 1.

Table 1 – Common Health Consequences of CSA

HEALTH CONSEQUENCES OF CSA	EXAMPLES OF HEALTH PROBLEMS
Psychological consequences	Depression, anxiety, phobia, self-destructive behavior, addiction, post-traumatic stress disorder (PTSD), suicidal thoughts and attempts, personal disorders, eating disorders and obesity (Sigurdardottir, 2017).
Physical health consequences	Widespread and chronic pain, sleeping problems, adult onset arthritis, fibromyalgia, long-term fatigue, diabetes, and circulatory-, digestive-, respiratory-, and musculoskeletal problems, as well as neurological and reproductive ones, such as increased problems during pregnancy as well as risk of difficulties during the postpartum period (Sigurdardottir, 2017; Sigurdardottir and Halldorsdottir, 2018).
Social consequences	Re-victimization, antisocial and criminal behavior, difficulties in sex life and in connection with spouse, difficulty trusting mates, marriage problems, anxiety and stress as parents, sexual risk behaviors; having many sexual partners, sexual problems and aggression and more likely to marry an alcoholic (Sigurdardottir, 2017).

When we studied men’s experience of CSA, we found that their experience was characterized by anger and fear, as well as physical and psychological disconnection. In youth, the men were bullied, had learning difficulties, had been hyperactive, displayed criminal behavior, misused alcohol and drugs, and had numerous complex health problems. Their self-identity and self-image was broken. As adults, they had difficulty relating to their spouses and children, had gone through divorce, and were all divorced non-custodial fathers. They lived in silent and painful suffering because of prejudice and did not seek help or talk about the CSA until they were adults (Sigurdardottir et al., 2012).

In a case study with a female CSA survivor, we found that a long trauma history can have serious and destructive effects on physical health. The research participant was still a young child (two to three years old) when her father started to rape her. Since her childhood, she has experienced complex and widespread physical health consequences, such as repeated vaginal and abdominal infections, widespread and chronic pain, sleeping problems, digestive problems, chronic back problems, fibromyalgia, musculoskeletal problems, repeated urinary tract infections, cervical dysplasia, inflammation of the Fallopian tubes, menorrhagia, endometrial hyperplasia, chlamydia, ovarian cysts, ectopic pregnancies, uterus problems, severe adhesions, and ovarian cancer. She disclosed her CSA experience to several health care providers, but they were silent and failed to provide trauma-informed care. She felt she had not been met with adequate understanding and support in the health care system (Sigurdardottir and Halldorsdottir, 2018).

In comparing gender similarities and differences, we found that women had a greater tendency to internalize their emotional suffering, resulting in behavioral and emotional suppression that was later observed in complex physical health problems. The men, however, had a greater tendency to externalize their emotional suffering, which made them more prone to rage, aggressiveness, antisocial behavior, and other behavioral problems. Gender similarities were also found (see Table 2), in that participants all demonstrated poor childhood health and lack of well-being, poor adult health, and lack of well-being, as well as difficulties in relationships and in relating to their children.

Table 2 – Gender similarities regarding the consequences of CSA

Difficulties through the lifespan	Examples of consequences
Poor childhood health and lack of well-being	Emotional pain, dissociation, fear, self-blame, bullying, social isolation and dysfunction, self-harm, insecurity, and physical problems.
Poor adult health and a lack of well-being	Complex health problems, sleeping difficulties, myalgia and muscle pain, self-harm, rejection, sense of being impure, phobias and isolation, emotional numbness and despair, anxiety and depression, as well as deep emotional problems.
Difficulties in relationships and in relating to their children	Trust issues, relationship and touch issues, sexual pleasure issues, postpartum depression, issues regarding touching their children and distrusting others regarding their children

The results of these studies demonstrate that childhood violence, such as CSA, may have extensive and serious consequences for mind and body, and have long-term consequences for both men and women. This means that health professionals, and other professionals working with people, such as in schools and social services, need to be aware that a person presenting a certain health, social, or educational problem may possibly have another story hidden underneath – a story of serious childhood trauma never having reached the surface.

Holistic Intervention: The Wellness-Program

The Wellness-Program (in Icelandic ‘Gæfusporin’) was based on our own research on multifaceted needs of female CSA survivors (Sigurdardottir & Halldorsdottir, 2013). It was also based on the use of some body/mind therapies research findings have indicated were effective when dealing with some of the problems female CSA survivors are faced with. Finally, it was based on the program in Betania Malvik Norway for CSA survivors (Betania Malvik, n.d.; Haugen, 2007). Unfortunately, information about the Betania Malvik program is no longer available on the internet. In the Wellness-Program, the unity of body and mind was recognized, and the program aimed at increasing the women’s health and well-being. The purpose was to develop a person-centered, holistic, traditional and complementary therapy for female CSA survivors, geared to women with complex mental, physical and social health problems that they had not been able to get the help they felt they needed within the healthcare system. The first Wellness-Program was conducted in Akureyri (the “capital of the North” in Iceland) in co-operation with The Vocational Rehabilitation of the North (Starfsendurhæfing Norðurlands) and funded by VIRK – Vocational Rehabilitation Fund in Iceland, whose goal is to systematically decrease the probability that employees lose their jobs due to incapacity and sickness, by increasing their activities and promoting vocational rehabilitation. Table 3 and table 4 provide an overview of the Wellness-Program and the professionals working within the program.

Table 3 – The daily schedule of the Wellness-Program (in all 20 hours per week) Time Monday Tuesday Wednesday Thursday Friday 10:00-12:00   Nursing group therapy, sharing of experiences and empowerment Yoga group     Psychologist: mindfulness –group sessions   Basic body awareness Group teaching about CSA, consequences and health and well-being 12:00-13:00 Lunch Group meeting for planning the week Lunch Diet and nutritional counselling Lunch Getting together and talking Lunch  Lunch Group meeting for closure of the week 13:00-14:00  Psychological therapy: mindfulness –individual sessions Relaxation/ Hypnosis Physical exercise group  (fibromyalgia exercises, walking with walking sticks, water exercises) Psychosomatic therapy (cranio- sacral therapy, reflexology therapy or body orientation therapy with massage) Physical exercise group  (fibromyalgia exercises, walking with walking sticks, water exercises)

(Sigurdardottir et al., 2016, p. 177)

 

Table 4 – An overview of the professionals, their education and their role in the Wellness-Program

PROFESSION	EDUCATION	ROLE/TYPE OF THERAPY
Nurse	B.Sc. in Nursing. MSc. in Health Sciences, Ph.D. student	Supervision, group teaching, relaxation, creation and communication group, getting together group
Family therapist. Manager	M.A. in Family Therapy	Education and personal consultation
Psychologist	M.A. in Psychology	Group therapy and personal consultation with  mindfulness
Social worker (Educational and vocational guide)	B.A. in Social Work	Counselling
Physiotherapist	B.Sc. in Physiotherapy. Diploma in Basic Body Awareness	Basic body awareness
Physiotherapist	B.Sc. in Physiotherapy. MSc in Health Sciences	Psycho-somatic therapy, cranio-sacral therapy
Physiotherapist	B.Sc. in Physiotherapy	Psycho- somatic therapy, cranio-sacral therapy, integrative and therapeutic Yoga practice, exercises in water
Nurse	B.Sc. in Nursing. Diploma in Psychiatric Nursing, Hypnosis Therapist	Hypnosis
Health consultation therapist	Health and Life Coach. Institute for Integrative Nutrition	Diet and nutritional consultation
Physiotherapist	B.Sc. in Physiotherapy	Exercises for fibromyalgia, walking exercises with walking sticks
Nurse. Reflexology therapist	B.Sc. in Nursing. MSc in Health Sciences.  Diploma in Reflexology Therapy	Reflexology, body-oriented therapy with massage
Occupational therapist	B.Sc. in Occupational Therapy	Personal consultation
Reflexology therapist. Alternative and complementary therapist	Diploma in Reflexology and Alternative – and Complementary Therapy	Reflexology

(Sigurdardottir et al., 2016, p. 178)

The Wellness-Program lasted for 10 weeks with organized schedule 20 hours per week (Table 3). A team of health professionals (Table 4) used a holistic approach and provided traditional and complementary individual and group therapy focusing on both mind and body. In-depth phenomenological interviews with the participants were conducted 1 week before and 1 week after the program as well as 12-15 months later. The female survivors who participated in the Wellness-Program were in the beginning of the program socially isolated and had complicated health problems. Their self-esteem was low, they could not work or study and their lack of well-being significantly affected their families and their own quality of life. Positive results were found regarding all these aspects in the participating women 12 to 15 months after the program — all, but one, were active in work, study, or in further rehabilitation. Furthermore, the in-depth interviews showed that their health and well-being, personal life and relationship with partners, family and friends had improved. They felt empowered, more in control, and had developed increased trust towards others. Thus, the Wellness-Program contributed considerably to improved subjective health and well-being of the women (Sigurdardottir et al., 2016).

Participating in the Wellness-program was a challenge for all the women and stressful at times. They had to work with their personal space and boundaries; learn to be “at home” in their own body; learn to go through flashbacks; learn to face “the monster”; and to get rid of self-accusations and self-blame. They sensed positive changes in their relationships with children and mates and some slowly learned to enjoy sex life. They also shared the feeling of being less fearful regarding relationships after the program as well as realizing better their own limits. All the women had been afflicted by some health related problems such as pain, lack of sleep, as well as digestive and uterine problems. In the program the women learned to live with the pain and experienced positive changes regarding sleep and rest, like one participant said:

I’m a completely different person after the Wellness-Program. I still get pain, but not as much as before. I recover much more quickly and the acid reflux is nearly gone. I sleep from dawn till dusk whereas I used to wake up 3-4 times every single night. Now, I just sleep. I can sleep 10 hours straight, which is something I don’t ever remember being able to do.

They also learned to live with fibromyalgia. They all reported a big difference between before and after the program. All the women shared the power of being understood by the group and the therapists and “not being alone” in their suffering. One of them lost 70 kilos; another went back to work after five years of unemployment. They shared that they had more inner peace than ever before and one said the effects of the program was like a “physical, psychological and spiritual resurrection.” (Sigurdardottir et al., 2016) Some of the participants in the Wellness-Program have reached post-traumatic growth since they experienced that their inner change was characterized by improved and deeper relationships with others, increased personal development, positive living, increased self-knowledge, and improved self-esteem which have been found to be the characteristics of post-traumatic growth (Sigurdardottir and Halldorsdottir, 2018). More than one hundred Icelandic women have now been through the Wellness-Program.

Conclusion

CSA can have serious and far-reaching consequences for the health and well-being of both men and women and their suffering can be deep and in fact almost unbearable. It is important for all professionals to be aware of and recognize the symptoms regarding the health consequences of CSA to be better able to provide support and gender-specific care. It is important to continue to develop a holistic program for CSA survivors, for both women and men. Through an organized holistic program, much can be gained for the CSA survivor, the survivor’s family and society as a whole. Finally, yet importantly, public health measures have to be taken in order to prevent children from experiencing such serious trauma as CSA.

Notes

1. A multidisciplinary team is a group of healthcare workers who are members of different professions e.g. nurses, physiotherapists, occupational therapists, psychologists, social workers, each providing specific services to the client.

References

Agaibi, C. E. & Wilson, J. P. (2005). Trauma, PTSD, and resilience: A review of the literature. Trauma, Violence, & Abuse, 6(3), 195-216.

Betania Malvik (n.d.). Behandlingstilbud til personer med traumer efter gjentatte seksuelle overgrep [Treatment options for people who have been traumatized by repeated sexual abuse and violence].

Bonomi, A. E., Anderson, M. L., Rivara, F. P., Cannon, E. A., Fishman, P. A., Carrell, D., Reid, R. J. & Thompson, R. S. (2008). Healthcare utilization and costs associated with childhood abuse. Journal of General and Internal Medicine, 23, 294–299. doi: 10.1007/s11606-008-0516-1.

Brower, V. (2006). Mind-body research moves towards the mainstream. EMBO Reports, 7, 358–361. doi: 10.1038/sj.embor.7400671

Chartier, M. J., Walker, J. R., Naimark, B. (2009). Health risk behavior and mental health problems as mediators of the relationship between childhood abuse and adult health. American Journal of Public Health, 99, 847–854. doi: 10.2105/AJPH.2007.122408

Fagundes, C. P., Glaser, R., Kiecolt-Glaser, J. K. (2013). Stressful early life experiences and immune dysregulation across the lifespan. Brain, Behaviour and Immunity, 27C, 8–12. doi: 10.1016/j.bbi.2012.06.014

Haugen T. (2007). Voksne som ble utsatt for vedvarende seksuelle overgrep i barndommen-problemomrader, behandling og endring. Hovedoppgave i psychology. Norges Teknisk Naturvitenskapelige Universitet. Trondheim, Norway. Open access: http://betaniamalvik.no/traume_enhet/fagstoff/content_1/text_25b99a55-ff4b-4d93-8154-f9677073e5b4/1337669975514/hovedoppgaven_siste_versjon_518190.pdf

Lind, M. J., Brown, R. C., Cheerin, C. M., York, T. P., Myers, J, M., Kendler, K. S., & Amstadter A. B. (2018). Does parenting influence the enduring impact of severe childhood sexual abuse on psychiatric resilience in adulthood? Child Psychiatry & Human Development, 49(1), 33-41.

Sigurdardottir, S. (2017). Childhood sexual abuse: Consequences and holistic intervention (Doctoral dissertation). The School of Health Sciences, Faculty of Nursing, University of Iceland. Open access: https://opinvisindi.is/handle/20.500.11815/317

Sigurdardottir, S., Halldorsdottir, S. & Bender, S. S. (2012). Deep and almost unbearable suffering: Consequences of childhood sexual abuse for men’s health and well-being. Scandinavian Journal of Caring Sciences, 26(4), 688-697. doi: 10.1111/j.1471-6712.2012.00981.x

Sigurdardottir, S., Halldorsdottir, S. & Bender, S. S. (2014). Consequences of childhood sexual abuse for health and well-being: Gender similarities and differences. Scandinavian Journal of Public Health, 42(3), 278-286. doi: 10.1177/1403494813514645.

Sigurdardottir, S., Halldorsdottir, S., Bender S. S. & Agnarsdottir, G. (2016). Personal resurrection: Female childhood sexual abuse survivors’ experience of the Wellness-Program. Scandinavian Journal of Caring Sciences, 30, 175–186. doi: 10.1111/scs.12238.

Sigurdardottir, S. & Halldorsdottir, S. (2013). Repressed and silent suffering: Consequences of childhood sexual abuse for women’s health and well-being. Scandinavian Journal of Caring Sciences, 27(2), 422-432. doi: 10.1111/j.1471-6712.2012.01049.x.

Sigurdardottir, S. & Halldorsdottir, S. (2018). Screaming body and silent healthcare providers. International Journal of Environmental Research and Public Health, 15(1), 94-111. doi:10.3390/ijerph15010094.

Wilson, J. P., & Drozdek, B. (Eds.). (2004). Broken spirits: The treatment of traumatized asylum seekers, refugees and war and torture victims. New York: Brunner/Routledge.

World Health Organisation (WHO) (2002). World report on violence and health. Retrieved from:  http://www.who.int/violence_injury_prevention/violence/world_report/en/full_en.pdf

World Health Organisation (WHO) (2003). Guidelines for medico-legal care for victims of sexual violence. Retrieved from: http://apps.who.int/iris/bitstream/10665/42788/1/924154628X.pdf

World Health Organisation (WHO) (2014). Global status report on violence prevention 2014. Retrieved from:  file:///C:/Users/Lenovo/Downloads/9789241564793_eng.pdf.