Survivors of sexual assault who encounter negative responses from family members when they disclose their abuse are at higher risk of poor mental health later in life, a new study by UNSW medical researchers has shown.
It is hoped that the study – and subsequent research – can help better inform mental health interventions and strategies to avert the longer-term emotional difficulties and risks that abuse survivors encounter later in life.
“There is ample evidence that sexual abuse is widespread among women – for example, we know that nearly 1 in 5 adult women globally, and approximately 20% of Australian women report exposure to sexual abuse in childhood,” says study lead author Associate Professor Susan Rees from UNSW Medicine’s School of Psychiatry.
“The association between exposure to sexual abuse and a wide range of common mental disorders and adverse psychosocial outcomes is also well established.
“However, there are only few studies that have tried to qualitatively understand the possible range of sexual assault disclosure responses from parents and relatives – girls’ and women’s most likely confidantes – as well as the survivors’ associated emotional reaction, and mental disorder later in life.”
For this study, the researchers conducted interviews with 30 adult female survivors of sexual abuse who sought support from the Royal Prince Alfred Hospital’s Sexual Assault Counselling Service.
To better understand the interpersonal complexity of the survivor’s experiences, the team enabled the survivors to explore their experiences in a confidential one-on-one setting with skilled counselors.
Together, they plotted the survivor’s experience on a visual timeline.
Survivors described the main three toxic responses from family members when they – often as a child – disclosed the sexual assault.
“Women described being ignored, blamed for the abuse or being threatened that some harm would come to them or the family if they speak out,” A/Prof Rees says.
Women who had these negative disclosure experiences then reported a range of adverse psychosocial outcomes experienced later in their lives – including social isolation, taking drugs, recurrent or persisting mental disorder and future risk of abuse, including bullying at school.
“In short, we found that these negative responses are strongly associated with mental disorders and future adversity later in life – particularly if the negative disclosure experience occurred during childhood,” A/Prof Rees said.
The researchers hope that this more nuanced understanding may help to better inform interventions and public campaigns to encourage society to work towards breaking the silence that protects perpetrators and obscures the pervasive harms caused by sexual abuse against children and women.
“For example, parents need to better understand the importance of responding with affirming and caring responses if they are confronted with disclosures, given that the period immediately following a disclosure may be a critical window where survivors are particularly vulnerable,” A/Prof Rees says.
For health professionals, the researchers recommend special training to identify and respond to negative disclosure experiences.
And at a societal level, the researchers say they hope that the contemporary public attention for sexual violence, steered by the #metoo movement, will help promote “public acknowledgment of men’s culpability, rather than women’s responsibility.”
“We need to harness this impetus at the community level to overcome denial and victim blaming in the home, too,” A/Prof Rees concludes.
The study was a collaboration between UNSW Medicine and the Royal Prince Alfred Hospital’s Sexual Assault Counselling Service. The Service is planning future research on this topic.
“Our sample was non-representative and we therefore can’t generalize our findings to the wider population of women who have been sexually abused—so we need more research,” A/Prof Rees says.
Many factors increase the risk of child abuse, including individual, family, environmental, and social factors. Children that have a physical disability, mental disability, or other behavioral disorders are also at higher risk for abuse, especially if the family lacks the socio-economic resources to assist them. 
The following specific factors may increase the risk of abuse:
- Abused as children
- Attachment problems
- Chronic behavior problems
- Frequent moving
- Hostile environment
- Isolation from friends and family
- Low self-esteem
- Medical problems
- Mental or physical disability
- Mental health problems
- Nonbiological relationships
- Poor social network
- Punitive child-rearing styles
- Substance abuse
- Unrealistic expectations
- Young parents
- Acute environmental problems
- Substance abuse
- Perceived need for discipline/punishment
The fourth National Incidence Study on Child Abuse and Neglect found that emotional neglect among American children has significantly increased in recent years. T
he number of neglected children has increased by 101%, from 584,100 in 1993 to 1,173,800 in 2006.
Females between the ages of 12 to 24 have been shown to be the demographic at highest risk of becoming victims of sexual assault and rape.
Greater than 50% of the rapes targeting women happen during childhood, and between 5% and 25% of adults report being victims of child sexual abuse.
Fewer than half of all sexual assaults are ever reported to the police. It is believed that many statistics on child sexual abuse and neglect vastly underestimate its incidence.
History and Physical
Child protection investigators conduct thorough interviews with victims of child sexual abuse, which typically serve as the best source of evidence for prosecutors.
It is therefore important in the emergent setting for healthcare providers to limit their interview of the child to the pertinent medical history that addresses the relevant clinical presentation.
Note the presence or absence of prior genitourinary trauma, urinary tract or anogenital infections, discharge, as well as toileting concerns.
Although the physical exam is often unremarkable in cases of child sexual abuse, a detailed exam is of tremendous value to ensure the present well-being of the child.
Examiners should document the general appearance including the emotional state of the child. The skin, hair, and oropharynx should be carefully inspected for any signs of trauma. Asking the child about any painful areas is essential before palpation.
It is not necessary to perform a speculum examination in the prepubertal patient. A thorough anogenital examination should be done with the patient in a careful positioning in the supine, frog-leg position.
Fully visualize relevant female anatomy to include the labia majora, labia minora, posterior fourchette, clitoris, urethra, hymen, vaginal vault, and fossa navicularis. Any signs of trauma should be clearly documented.
Accidental genital trauma can cause bruising or abrasions to the labia and/or posterior fourchette. However, the hymen is rarely injured as a result of accidental genital trauma due to its anatomical positioning. I
t is therefore essential to detail both the shape and integrity of the hymen.
In male victims of child abuse, the physical exam should detail circumcision status as well as any visible signs of trauma.
Both male and female patients should undergo an anal examination that describes the presence or absence of anal dilatation. Larger than 2 cm anal dilatation should raise suspicion for trauma in cases of suspected sexual abuse.
Between 2% and 12% of child sexual abuse victims have gonorrhea, and up to 10% have been shown to have chlamydia on initial presentation.
As such, it is imperative to test for sexually transmitted infections in the following high-risk situations: patient at high risk for or has sexually transmitted infection (STI), sibling with STI, or parents or patient request testing.
A urine specimen should be sent for nucleic acid amplification technique testing for gonorrhea and chlamydia, and culture should be used to confirm positive test results. Pediatric patients do not typically have vesicles or ulcerations; however, if present they should be swabbed for viral studies.
Guidelines currently recommend forensic evidence collection within 24 hours of sexual contact for prepubescent patients and 72 hours in older adolescents. Some locations have extended the timeframe for evidence collection to 5 to 7 days. Forensic evidence collection kits vary across jurisdictions, and care must be taken to package and label evidence to preserve the chain-of-evidence properly. The Woods light may be a useful adjunct for specimen collection. Clothing including underwear worn at the time of abuse should be placed in a sealed paper bag.
Treatment / Management
An efficient initial assessment is essential to ensure reliable outcomes for the patient and families affected by child sexual abuse. Involving relevant specialists including physicians, nurses, social workers, and mental health professionals is key to providing optimal therapeutic treatment.
Sexually transmitted infection and pregnancy prophylaxis should be considered as part of the management for older female and adolescent patients.
Otherwise, specific treatment should be based on the individual clinical presentation and relevant findings. In emergent settings, it is important that all victims of child sexual abuse have a medical and psychological follow-up in place.
Child sexual abuse can have lifelong effects on both physical and mental health and well-being.
Adolescents are at increased risk for a number of conditions as they enter adulthood including anxiety, depression, low self-esteem, hospitalization for mental health disorders, social phobias, and post-traumatic stress disorder.
Additionally, victims of child sexual abuse are at a higher risk of becoming victims of intimate partner violence as well as sexual assault in adulthood.
Chronic medical illnesses such as irritable bowel syndrome, fibromyalgia, obesity, and sexually transmitted infections also are more prevalent in adult survivors of child sexual abuse.
Studies have revealed child sexual abuse survivors to be more prone to addiction to tobacco, alcohol, and illicit drugs.
More information: Susan Rees et al. Believe #metoo: sexual violence and interpersonal disclosure experiences among women attending a sexual assault service in Australia: a mixed-methods study, BMJ Open (2019). DOI: 10.1136/bmjopen-2018-026773
Journal information: BMJ Open
Provided by University of New South Wales