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Miriam is a bright and creative woman in her early thirties who, until recently, had a busy social life and a well-paying job. Now unemployed and living in her parents' basement, Miriam is recovering from a bout of depression and suicidal thoughts that have haunted her at various times since she was sexually abused by an adult family friend at the age of 14.
Almost 20 years after her abuse, Miriam is finally getting the emotional support and treatment she needs to heal her emotional wounds. But she still doesn't feel safe connecting with her feelings of deep sadness, pain and rage. "I guess I'm actually really afraid of myself. I'm afraid I might hurt myself because I really want to hit things," she says, adding that she fears her rage will never end.
Chronic depression is a common response to childhood sexual abuse, says Dr. Patricia Fisher, who studies the relationship between mental illness and child trauma. She adds that people with a history of child sexual abuse are also more likely to develop anxiety disorders, problems with identity and post-traumatic stress disorder (a sense of re-experiencing a past trauma) among other symptoms. One study has found that an overwhelming proportion of adult survivors of childhood sexual abuse have a mental illness: 95%. Half develop post-traumatic stress disorder. And a study monitoring female drug abuse treatment programs nots that 40% of their outpatients report a history of sexual abuse.
A decade-long study carried out in the Department of Preventative Medicine at Kaiser Permanente, in conjunction with the US Centers for Disease Control, has made some startling findings about the relationship between adverse childhood experiences (such as sexual abuse) and adult health. Dr. Vincent Felitti observes that "adverse childhood experiences are common, destructive, and have an effect that often lasts for a lifetime. They are the most important determinant of the health and well-being of our nation."
Fisher's study of women with schizophrenia at Riverview Hospital, British Columbia's psychiatric facility, compared the experiences of inpatients with sexual abuse histories with those of inpatients who hadn't been abused as children.
"The women who had trauma histories on the whole were younger, their illnesses more severe, and they were more likely to have a history of eating disorders, problem drug and alcohol use, depression and suicidal behaviour," Fisher says. She adds that many of the survivors of child trauma went on to experience repeated physical and sexual abuse as adults. "These poor souls are being multiply assaulted in a sense," she says.
Can child sexual abuse cause mental illness? The relationship between mental illness and childhood trauma is too complex to draw such a conclusion, Fisher explains. But a survivor with a family history of mental illness may be more vulnerable to developing the illness and may be more likely to express mental illness much sooner, she says.
At age 14, Miriam never thought her summer-long experiences of abuse could affect her self-esteem or future relationships. "Four months later, I named it as abuse and told myself that I wasn't to blame… so I kind of thought that I didn't have to deal with it anymore."
She says her abuse rarely entered her mind until her feelings resurfaced as a powerful body memory during a sexual experience at age 29. "My whole body shook with pain. I didn't know why this was happening and the only thought in my head was him [her abuser]," Miriam recalls. "Sexual pleasure and everything surrounding that on a physical level is where you get the most triggers," she adds. Now when Miriam remembers her abuse, she gets "real dirty feelings, like spit-it-out, vile, sick-to-your-stomach feelings."
Body memories or flashbacks of the abuse are common symptoms of child sexual abuse, as are feelings of intense shame, distrust, a sense of powerlessness and feelings of isolation and alienation, Fisher says. Some survivors may even experience delusions, amnesia or strange behaviour from the intensity of the trauma.
Because of the shame and distrust, abuse survivors often will not tell their mental health workers about their abuse histories. One review reports that of 1,600 adults with serious mental illnesses, one third of the case managers did not know whether the clients they were serving had been physically and/or sexually abused. Similarly, in sexual abuse treatment settings, the presence and effects of mental health and substance use problems are not addressed either.
The psychological effects of sexual abuse may appear immediately. For example, nearly a quarter of adolescents with a history of sexual abuse make a suicide attempt in a given year. Of course, psychological effects may also take years to surface since many survivors blot the traumatic experiences from their minds.
The effects are even more intense when women have co-occurring mental health and substance use problems and abuse histories. Compared to women with one diagnosis, women with co-occurring disorders and sexual abuse reported more abuse experiences, more suicidal thinking and had more complex diagnoses—often, multiple diagnoses that change over time—and treatment histories.
Without treatment and support, abuse survivors with moderate or severe mental illnesses are more likely to experience physical and sexual assaults as adults, Fisher's study concludes. Nevertheless, few of the survivors at Riverview had reported their abuse and even fewer received any assistance after disclosure. A startling 2005 study adds to this picture, finding that people with severe mental illness are 11 times more likely than the general public to be the victim of a violent crime such as attacks, rapes, or muggings.
"We have a duty of care to address child sexual abuse experiences among adults," Fisher says. "We need to improve quality of life for that person in the here and now."
What is Sexual Abuse?
Sexual abuse consists of any sexual incident of sexual contact between a child less than 14 years of age, or between someone under the age of 18 and a person who is in a position of authority.
Sexual abuse may include:
exhibitionism by an adult
an invitation to touch by an adult
being fondled or molested by an adult
being forced to watch sexual acts or viewing of pornographic videos
being forced to pose for seductive or sexual photos
oral rape, rape, sodomy and/or incest
Child sexual abuse can take place:
within a family by a parent, step-parent, sibling or other relative
outside the home by a friend, neighbour, child care giver, teacher or random molester
Rates of Childhood Sexual Abuse in Adults
general population: at least one in five women and one in ten men
women accessing outpatient mental health services at Riverview Hospital: 36 to 76%
inpatients with schizophrenia at Riverview Hospital: 58% of women and 23% of men had been sexually abused before age 17
The Effects of Sexual Abuse
People with a history of sexual abuse are much more likely to experience:
post-traumatic stress disorder
anxiety disorders
chronic depression
substance use problems
borderline personality disorder
suicidal tendencies
psychotic symptoms (e.g. delusions and hallucinations)
dissociative disorders
hepatitis
heart disease
fractures
diabetes
obesity
problems at work
low self-esteem
self-harm
Treatment for Survivors of Child Sexual Abuse
Individual and group therapies can help survivors heal their childhood wounds and learn to create healthy sexual boundaries as adults. Successful treatments will address the following issues:
guilt: survivors need to be told over and over again that "it's not your fault"; therapies can help them identify and seek alternatives to self-punishing thoughts and behaviours
feelings of being tainted: survivors need to learn that "I am okay physically and in every other way, and not damaged goods"
low self-esteem: survivors need a lot of love and encouragement in believing that they are okay and good, as well as recognition for achieving small goals
trust: group therapies can help a survivor learn to give and take support and gradually trust again
boundaries and empowerment: survivors can learn what healthy boundaries are and practice asserting themselves through peer support and role playing
opportunities to express feelings: in order to protect themselves both during and after the abuse, many survivors have had to stuff intense anger inside of them so it doesn't show; survivors need support and encouragement to express these repressed feelings which can otherwise lead to physical sickness, clinical depression or suicide
Sources
Bartholomew, N.G., Courney, K., Rowan-Szal, G.A. et al. (2005). Sexual abuse history and treatment outcomes among women undergone methadone treatment. Journal of Substance Abuse Treatment, 29(3), 231-235.
Briere, J. & Elliott, D.M. (2003). Prevalence and psychological sequelae of self-reported childhood physical and sexual abuse in a general population sample of men and women. Child Abuse and Neglect, 27(10), 1205-1222.
Felitti, V.J. (2002). The relation between adverse childhood experiences and adult health: Turning gold into lead. Kaiser Permanente's Department of Preventive Medicine and Centers for Disease Control. www.acestudy.org/docs/GoldintoLead.pdf
Fisher, P. (1997). Child and adult trauma histories in women with major mental illnesses. Unpublished paper.
Fisher, P. (1998). Women and mental health issues: The role of trauma. Visions: BC's Mental Health Journal, No. 3, 6-7. www.cmha.bc.ca/files/03.pdf
Janssen, I., Krabbendam, L., Bak, M. et al. (2004). Childhood abuse as a risk factor for psychotic experiences. Acta Psychiatrica Scandinavica, 109(1), 38-45.
McCreary Centre Society. (2005). British Columbia youth health trends: A retrospective, 1992-2003. Burnaby: MCS. www.mcs.bc.ca/pdf/AHS-Trends-2005-report.pdf
Nehls, N. & Sallmann, J. (2005). Women living with a history of physical and/or sexual abuse, substance use, and mental health problems. Qualitative Health Research, 15(3), 365-381.
Newmann, J.P. & Sallmann, J. (2004). Women, trauma histories, and co-occurring disorders: Assessing the scope of the problem. Social Service Review, 78(3), 446-499.
Peleikis, D.E., Mykletun, A. & Dahl, A.A. (2005). Current mental health in women with childhood sexual abuse who had outpatient psychotherapy. European Psychiatry, 20(3), 260-267.
Teplin, L.A., McClelland, G.M., Abram, K.M. et al. (2005). Crime victimization in adults with severe mental illness: Comparison with the National Crime Victimization Survey. Archives of General Psychiatry, 62(8), 911-921.
Links in the Sources section are up to date as of June 2006
