Childhood sexual abuse is one of the most harmful experiences an individual can go through in their entire life. Often covered up and denied, by both the offender, and society at large, we’ve made great strides in exposing these wounds to the light and developing better treatments for those who have experienced this suffering.
This article reviews a number of elements in the understanding and treatment of child sexual abuse. Because most of the resources on sexual abuse examine women exclusively or primarily, they will be the focus of this article. I hope to write one on male survivors of sexual abuse soon.
Defining Child Sexual Abuse
The World Health Organization (WHO) defines child sexual abuse 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, or else that violate the laws or social taboos of society” (WHO, 2006)
Prevalence of Child Sexual Abuse
In Canada, the rate of sexual assault of those under 18 is approximately 201 per 100,000 (Statistics Canada, 2008), while an Ontario study identified approximately 13% of females and 5% of males had reported sexual abuse. (MacMillan, et. al., 1997) US studies began in the 1950s and reported between 20 and 30% of men and women reported sexual contact with children. (Draucker & Martsolf, 2006; p. 2)
Impact of Child Sexual Abuse
Child sexual abuse has been associated with life-long emotional health challenges including “the development of a range of psychiatric difficulties, including depression…self-harm…anxiety disorders…and post-traumatic stress disorder” (Barrera, Calderon & Bell, 2013) Other negative impacts can include substance abuse (Sartor, et. al., 2013) and risky sexual behaviour. (Roemmele, & Messman-Moore, 2011)
As well, survivors of childhood sexual abuse are also at greater risk for developing physical health issues, with Moeller et. al. (1993) reporting that women who were abused reported “significantly more hospitalizations for illnesses, a greater number of physical and psychological problems, and lower ratings of their overall health” than non-abused women.
False and Recovered Memories
There is a controversy in the treatment of survivors of sexual abuse about the potential for recovered memories, “the recall of traumatic events not previously remembered” (Draucker & Martsolf, 2006; p. 15) and false memories, allegedly implanted by the therapist using improper or even fraudulent techniques.
The general scientific consensus (e.g. as summed up by Ilsley (1998) is that while false memories can occur, they are the exception rather than the rule. Therefore care must be taken to avoid introducing these memories, but survivors of sexual abuse should be believed in the absence of information suggesting otherwise. This does not mean that criminal prosecution should adopt a different standard (indeed, many individuals who receive treatment for sexual abuse could never secure convictions) but merely that the potential for false memories should not dissuade a therapist from providing treatment.
The research is continuing and therefore counsellors should keep themselves informed on the latest developments in this area.
Phase Model for Treatment of Child Sexual Abuse
A phase-based model is a method of treating childhood sexual abuse that is focused on multiple distinct stages of the treatment, with specific goals for each stage. The following example of phase-treatment comes from Courtois (2004):
The goals of phase 1 are to explore the client’s motivation to get better, ensure informed consent (including the client’s rights and responsibilities), and educating the client on what psychotherapy is. This is also the time to establish an effective therapeutic alliance with the client, so that they can ensure the most success.
As Courtois notes, phase 1 doesn’t look much different from other forms of psychotherapy, though it may take much longer to establish in sexual abuse than other presenting problems. The acronym RICH is used as a short-hand for the four goals of phase 1:
Building life skills is also a significant component of phase 1. These skills can include techniques like deep breathing, communicating one’s needs, identifying one’s emotional state, coping skills, and a variety of others that may depend on the specific client deficits.
The goals of phase 2 are to begin the process of developing an integrated understanding of the abuse. The client begins to construct a narrative to objectively describe the abuse in terms of the who, what, where, why, and their own reactions to the experience.
Desensitization through graduated exposure therapy is used to help reduce the impact of dissociation and allow the client to separate themselves from the abuse experience. This has been found to be an effective way of increasing the client’s ability to control their emotional regulation and decrease other symptoms. (Cloitre, 2002)
The final phase involves fine-tuning the skills developed in stage 1 and begins to build a new life post-abuse. At this point the client can begin tackling elements typical or a more normal range of experiences including “the development of trustworthy relationships and intimacy, sexual functioning, parenting, career and other life decisions, ongoing decisions/ discussions with abusive others, and so forth.” (Courtois, 2004)
Implications for Crisis Intervention
Helpline callers or chat and text visitor may disclosure historical sexual abuse to you. If they do, there are some things you should keep in mind to respond most effectively:
- Check for immediate safety if it is not clear the abuse was in the past – this is especially important in a situation where the person is still young
- Adopt a supportive tone without gawking or getting shocked. This can further stigmatize the individual and heighten their sense of isolation
- Consider supportive responses as noted by Draucker & Martsolf (2006; p. 44):
- Acknowledging the difficult step of disclosing
- Offering support and indicating one’s availability after the session during which the client disclosed
- Inviting the client to discuss the abuse at his or her own pace
- Evaluating the client’s mental status and determining any immediate safety concerns (e.g. suicidal thoughts)
- On the phone, watch for symptoms of dissociation or Dissociative Identity Disorder (DID)
- If the individual starts to dissociate, try a grounding exercise: have them identify things they can see, hear (including your voice), or smell in the room. This will help them stay focused
- If a person appears to switch personalities, remain calm but do not breach confidentiality. Treat the second personality as another person but work to get them medical assistance as soon as possible
The free e-course “Addressing Past Sexual Assault in Clinical Settings” is provided by Women’s College Hospital in Toronto and funded by the Government of Ontario.
The book Counselling Survivors of Childhood Sexual Abuse provides a comprehensive review of the assessment and treatment of sexual abuse in children.
The office of Juvenile Justice and Deliquency Prevention hosted a webinar titled “Male Survivors of Sexual Abuse” which will hopefully be available on their website for viewing soon.
Barrera, M., Calderón, L., & Bell, V. (2013). The Cognitive Impact of Sexual Abuse and PTSD in Children: A Neuropsychological Study. Journal Of Child Sexual Abuse, 22(6), 625-638. doi:10.1080/10538712.2013.811141
Cloitre, M., Koenen, K. C., Cohen, L. R., & Han, H. (2002). Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to childhood abuse. Journal Of Consulting And Clinical Psychology, 70(5), 1067-1074. doi:10.1037/0022-006X.70.5.1067
Courtois, C.A. (2004) Complex Trauma, Complex Reactions: Assessment and Treatment. Psychotherapy. 41(4) 214-425. DOI 10.1037/0033-322.214.171.1242. Retrieved on October 8, 2016 from http://www.dhss.delaware.gov/dsamh/files/si10_1396_article1.pdf
Draucker, C.B. & Martsolf, D.S. (2006) Counselling Survivors of Childhood Sexual Abuse. 3rd Ed. London: SAGE Publications.
Ilsley, J. K. (1998). Recovered memories of childhood abuse : We must tell patients that they were not to blame. BMJ : British Medical Journal, 317(7164), 1012.
MacMillan, H.L., Fleming, J.E., Trocme, N., Boyle, M.H., Wong, M., Racine, Y.A., Bearslee, W.R. & Offord, D.R. (1997) JAMA. Prevalence of Child Physical and Sexual Abuse in the Community. 278(2). 131-135
Moeller, T. P., Bachmann, G. A., & Moeller, J. R. (1993). The combined effects of physical, sexual, and emotional abuse during childhood: long-term health consequences for women. Child Abuse And Neglect, (5), 623.
Roemmele, M., & Messman-Moore, T. L. (2011). Child Abuse, Early Maladaptive Schemas, and Risky Sexual Behavior in College Women.Journal Of Child Sexual Abuse, 20(3), 264-283. doi:10.1080/10538712.2011.575445
Sartor, C. E., Waldron, M., Duncan, A. E., Grant, J. D., McCutcheon, V. V., Nelson, E. C., & Heath, A. C. (2013). Childhood sexual abuse and early substance use in adolescent girls: the role of familial influences. Addiction, 108(5), 993-1000. doi:10.1111/add.12115
Statistics Canada. (2008) Child and Youth Victims of Police-reported Violent Crime, 2008. Retrieved on October 8, 2016 from http://www.statcan.gc.ca/pub/85f0033m/2010023/part-partie1-eng.htm
World Health Organisation (WHO). (2006) Preventing child maltreatment: a guide to taking and generating evidence. Retrieved on October 8, 2016 from http://apps.who.int/iris/bitstream/10665/43499/1/9241594365_eng.pdf. Geneva: World Health Organisation (WHO).