Samples taken from the general community estimate that 12%-35% of women and 4% - 9% of men are victims of unwanted sexual experience prior to age 18. (Read, et al., 2003) Finkelhor and Dziuba-Leatherman (1994) conducted a telephone survey of 2000 children aged 10 to 16 years in the United States. The lifetime prevalence rate for attempted and completed CSA cases was 10.5% for the overall sample. Gorey and Leslie (1997) used a cross-sectional design to investigate 16 community samples. Gorey et al. (1997) adjusted for sample-related variation, response rates and differences in definitions. The calculations showed the prevalence of CSA to be 16.8% for women and 7.9% for men. Both these studies had similar results, thus supporting the notion that CSA is highly prevalent in our society.
There is strong evidence, particularly in our Australian society that CSA is harmful to ones mental state. An Australian study of 1,991 twin pairs found that in twins discordant for CSA, affected twins had significantly higher rates of major depression, attempted suicide, conduct disorder, alcohol dependence, nicotine dependence, social anxiety, rape after age 18 and divorce (Nelson, Heath & Madden, 2002). A second Australian study of 5995 twin pairs which used a single question to assess CSA, found significant odds ratios for CSA and major depression, panic disorder, and alcohol dependence (Dwinwiddie, Heath, Dunne, 2000).
However, CSA is not only found in western societies, it is found to occur across all socioeconomic and ethnic groups in Western cultures, but has been shown to exist globally. Although data from all nations is not always available it appears that the rates of CSA in most countries are reasonably similar (Read, et al.,2003). A review of large sample population based studies in 19 countries found a range of prevalence rates of 7%- 36% for females and 3% to 29% for males ( Finklehor, 1994). The research clearly indicates that far too many women and men in many different societies first experience sex in a context of violence and manipulation rather than love and trust.
In addition to compelling statistics related to the incidence of sexual abuse and assault, there is mounting evidence that early victimisation places persons at risk of subsequent psychological problems. CSA is associated with a variety of adult psychiatric conditions. These include the DSM disorders of major depression, borderline personality disorder, somatisation disorder, substance abuse disorders, posttraumatic stress disorder, and bulimia nervosa (Beitchman, Zucker, Hood, DaCosta & Akman, 1991). Initially the evidence for these associations was based predominantly on findings of high rates of retrospectively reported CSA in clinical samples with the former diagnoses. Increasingly these relationships are being replicated in large community samples. In addition to DSM disorders, CSA has been linked to problematic behaviours and to neurobiological alterations. The scope of this essay limits the discussion of the evidence for this array of outcomes. The evidence shown throughout this paper is best divided into three basic outcomes; psychiatric disorders, neurobiological dysregulation and dysfunctional behaviours.
One of the most debilitating of the discussed psychiatric disorders is that of major depression.. Major depression and dysthymia have been strongly associated with CSA in numerous studies (Beitchman et al. 1991). Lifetime prevalence of major depression in women with a history of CSA is typically three to five times more common than in woman without such a history (Paolucci et al., 2001). There is also evidence that a history of childhood abuse may alter the clinical presentation of major depression. For example, in a sample of 653 cases of major depression, individuals with physical or sexual abuse histories were significantly more likely to have reversed neurovegatative signs such as increased appetite, weight gain, and hypersomnia than individuals without such a history (Levitan, Parikh & Lesage, 1998). Schizophrenia is also believed to be heavily influenced by CSA. Read et al. (2003) cited that among inpatients diagnosed with schizophrenia 60% females and 48% males had suffered from CSA. Read et al. (2003) found that among women at a psychiatric emergency room, 53% of those who had suffered CSA had schizophrenia compared with 25% of those not exposed to CSA. Similar, statistics have been found with those diagnosed with borderline personality disorder (BDP). Zanarini, (2000) states that there is considerable consensus across studies regarding the prevalence of CSA in BDP patients, with rates ranging from 20% to 80%. Zanarnini (2000) cites a study of the psychosocial status of women prison inmates conducted by Jordan (1999). The analyses of early traumatic experiences for inmates with a diagnosis of BDP showed that 32% had been sexually assaulted before the age of 11. Herman and van der Kolk (1987) reported that BDP is related to posttraumatic stress disorder (PTSD) due to the early childhood trauma, including sexual abuse.
The identification of increased psychophysiological reactivity and other neurobiological sequelae in adults with combat – related PTSD stimulated the search for similar effects in maltreated adults and children. In a series a studies with a prospective, longitudinal sample of sexually abused and non abused girls followed by Putnam and Trickett (1997), investigators have identified deleterious effects on the hypothalamic-pituary-adrenal axis (HPA), the sympathetic nervous system, and possibly the immune system. Additional studies cited by Lysaker, Meyer, Evans and Marks (2001) tested the contribution of CSA in the erosion of neuropsychological function in illnesses such as schizophrenia or schizoaffective disorder. The results supported the hypothesis, finding a much graver neurocognitive impairment, working memory and information processing in children with reported histories of CSA.
Victims of CSA often exhibit dysfunctional behaviour. Dysfunctional behaviour is the third and final category of associated outcomes of CSA discussed in this essay. There is a variety of behaviour and conduct problems associated with CSA. Of these behavioural problems, sexualized behaviours have been most closely linked to CSA. Putnam (2003) cited that numerous studies have found that sexually abused children exhibited more sexualized behaviours than various comparison groups, including nonabused psychiatric inpatients. Research indicates that sexually abused adolescents are at increased risk of earlier pregnancy. This could be attributed to many factors, yet Rainey, Stevens-Simon & Kaplan (1995) explained the early pregnancy by a possible desire to conceive, perhaps to fulfill unmet psychological needs resulting from adverse childhood experiences
Another way individuals who suffer from the effects of CSA cope with unmet psychological needs is through alcohol. Langland & Hart van der (2004) found that childhood abuse, more specifically, sexual abuse and combinations of sexual and physical abuse is an important factor in alcoholism. In addition to this, Moseley’s (2004) findings showed that women who were sexually abused as children were 3.8 times more likely to be current smokers that women who did not report abuse.
Not only are victims of CSA more likely to be addicted to alcohol and cigarettes, it has been reported by Theils (2004), that CSA sufferer is at increased risk of developing an eating disorder. Patients with bulimia nervosa suffered more CSA than those with restrictive anorexia nervosa. (Theils, 2004).
Although there is a lot of evidence indicating the children who have been sexually abused have a much higher risk of having psychiatric disorders, neurobiological dysregulations and dysfunctional behaviours, many other factors must be considered. Zanarini (2000) cautions clinicians to be aware that although CSA is common to clients with a mental illness to have been sexually traumatized during childhood, not all women have. It is important for clinicians to keep this in mind, in order to provide an honest, objective prognosis of the client. Zanarini (2000) suggests the etiology is best represented by a multidimensional model, which includes issues of genetic/biological predisposition, adverse environmental/familial factors, possible neurological impairments, and early childhood trauma.
Investigating whether childhood abuse is related to mental-health problems in adulthood is important theoretically, but it also has crucial clinical implications in terms of the accuracy of formulations and the comprehensiveness of treatment planning. The frequency and effects of CSA is often understood by clinicians who have repeatedly seen the manifestation of sexual abuse in the lives of their clients. The manifestation can result in the development of major depression, borderline personality disorder, schizophrenia and alcohol dependence. However, studies show that this knowledge may need further publicity.
Many abuse cases are unidentified by clinicians, and it appears that people with schizophrenia are especially unlikely to be asked about abuse or to receive adequate response when they disclose abuse. This is due to clinicians holding strong biogenetic causal beliefs of schizophrenia (Putnam, 2003). One study found that support during hospitalisation was considered for only 12% of CSA cases. Overall, 12% were referred to post-discharge abuse counseling, but referral was not even considered for any of the patients diagnosed schizophrenic (cited in Read et al, 2003).
Many researchers have recommended routine abuse inquiry in all mental-health settings. Training of clinicians in how to diagnose and treat abuse histories will benefit clients. Knowing the risk factors, the outcomes and successful therapies would be advantageous to clinicians. Research and availability of treatments is another area psychologists and the society at large would benefit greatly from. Not only would the research help CSA survivors, it could be integrated with trauma models for abuse survivors in general (Read et al, 2003).
Before one can make statements about the direction of research and need of training, one must consider where the motivation and economical support will come from. These can only be found through education and therefore awareness of the prevalence and effects of CSA. Awareness must be directed at both clinicians and the general public. By targeting clinicians, one not only educates, but hopefully inspires others to specialise in the treatment of sexually abused clients. This can be through academia or practical measures. Education of the public can be through school and higher education facility based education programs and general community programs.
Research shows that programs that explicitly focus on self-protection skills training with sufficient time to integrate this material into a behavioural repertoire are most effective (Putnam, 2003). In the first long-term evaluation, a recent survey of 825 female undergraduates found that those who had participated in school-based sexual abuse prevention programs were significantly less likely to have been sexually abused (Gibson and Leitenberg, 2000).It is also important to note that a study cited by (Finkelhor, 1998) showed that the risk of CSA increases with age. Data from 1996 indicated that 10% of victims are between the ages of 0 and 3. Between ages of 4 and 7 years, the percentage almost triples. Therefore CSA education should be exposed to children possibly younger than originally thought. However, in addition to benefits some negative effects were noted, especially to those who were younger in age. These include increased anxiety, feeling less in control for younger children, and feeling more discomfort with normal touch in older children (Putnam, 2003).
There is a need for further research in order to establish the most appropriate age group to target with CSA education. In addition to this, future research involving males needs to be conducted. Many studies conducted have only included women, completely ignoring male CSA victims. This underrepresentation also happens in studies involving males, especially older boys who may be reluctant to disclose information due to social pressures (Putnam, 2003).
The studies have shown that sexual abuse is prevalent and has extremely damaging effects. Compared with other psychiatric patients, those who experienced physical CSA not only are more likely to commit suicide, but also have earlier first admissions and longer and more frequent hospitalizations, spend more time in seclusion and exhibit higher symptom severity (Levitan et al., 1998).
The significant impact of childhood abuse is unquestionable. This impact, however, speaks not only to the individual child victim of the crime, but also to the mental health community. Despite the magnitude of the child abuse problem in general, and its contribution to serious public health issues such as major depression, schizophrenia and borderline personality disorder, research support is still lacking. If education and awareness programs are put into place, this would promote support and thus create funding. Psychologists are responsible to the public to instigate the overcoming of disbelief with understanding, indifference and indignance, and reluctance to intervene with an intolerance of the victimisation of children. Tragic as it is, child abuse has a great deal to teach us about etiology, outcome, and intervention for psychiatric disorders, neurobiological dysregulation and dysfunctional behaviours.
