The Impact of Childhood Sexual Abuse on Women’s Sexuality
An Integrative Literature Review
Notre Dame de Namur University
I would like to acknowledge and thank my professor, Dr. John Astin, Dr. Adam Rodriguez, Mary Wegman, Director of NDNU Library and its staff and Kate Mills of the Tutoring Center, and Dr. Deborah Brenner-Liss for their help, support and advice.
Table of Contents
- Statement of purpose
- Introduction 5-7
- CSA defined 5
- Methodology 8
- Sexual functioning 1-18
- Sexual functioning in mid-life and beyond 20-21
- Sexual functioning in couples seeking therapy 21-22
- Sexual schemas 21-23
- Severity of CSA 24-25
- Intimacy 25-26
- Revictimization 26-28
- Sexual Risk-taking 28-30
- Prostitution, porn industry and human trafficking 30-32
- Women Military Veterans 32-34
- Gynecological issues 34-37
- Therapeutic Implications 37-40
- Suggested Future Research 41
- Conclusion 41-43
- References 44-48
The purpose of this capstone is to provide a further understanding of the impact of Childhood Sexual Abuse (CSA) on women’s sexual lives, sexual schemas, sexual functioning and satisfaction, as well as gynecological problems and psychological treatment of sexual problems. According to the US National Library of Medicine and the National Institutes of Health (2014),
Child sexual abuse is the involvement of children and adolescents in sexual activities that they cannot fully comprehend and to which they cannot consent as a fully equal, self-determining participant, because of their early stage of development. Social taboos are violated, and the offending adults exploit the difference of age and power through verbal persuasion and/or physical compulsion. The intent, on the part of adults, to use children for their own sexual stimulation and satisfaction is the central feature of child sexual abuse. The spectrum ranges from noninvasive activities that do not involve any touching of the child (hands-off contacts) all the way to rape. (p. xx)
Given that women exposed to CSA may be more vulnerable to mental health problems, but especially so to sexual difficulties and STIs, including HIV/AIDS, (Doll, Koenig & Purcell, 2003), CSA represents an important public health issue. It is important for health professionals to be aware of the symptoms and consequences of child sexual abuse in order to provide support, appropriate care and treatment for the survivors. Finally, preventive and long lasting public health measures have to be taken in order to prevent children from experiencing such serious trauma.
Almost 20% of adult women have experienced CSA (Perada, Guilera, Forns & Gomez-Benito, 2009). Among the population of women reporting sexual difficulties, important differences have emerged between survivors with and without a history of CSA. With such a high percentage of women having experienced childhood sexual abuse, it is likely that many women seeking therapy will have histories that include sexual abuse. It is imperative that therapists are aware of and familiar with the symptoms and long-term effects associated with childhood sexual abuse to help gain a deeper understanding of what is needed in therapy. For example, women with a history of CSA tend to exhibit weaker associations between sexual impairment and subjective sexual distress than non-abused women (Stephenson, Hughan & Meston, 2012). Additionally, women with a history of CSA respond differently from their non-abused counterparts to treatments for sexual problems (Brotto, Seal, & Rellini, 2012; Maltz, 2002).
In addition, Coker (2007) and Lemieux & Byers (2008) have linked the experience of CSA to an increased risk of engaging in subsequent high-risk sexual behaviors such as engaging in consensual sex at a younger age, having a higher number of sexual partners, a higher frequency of unprotected sex, less sexual satisfaction, greater likelihood of contracting a sexually transmitted infection (STI), greater gynecological problems and using drugs or alcohol during sexual activities.
This capstone will provide an overview of the impact of CSA on women’s sexuality to inform the therapeutic community and health professionals of the prevalence of CSA, its effects on sexual function, and therapeutic strategies that evidence suggests may be most beneficial for these populations.
The following databases were used to conduct an exhaustive search of the literature related to the impact of CSA on women’s sexuality: EBSCO, PsycArticles, PsycInfo, Social Sciences Full Text, Google, Google Scholar, PubMed, TRIP database. In total, approximately 50 academic journal articles were referenced to gain further understanding of the impact of CSA on women’s sexual lives, sexual schemas, sexual functioning and satisfaction, gynecological problems and their subsequent psychological treatment for these conditions.
The following key search words were used to find literature associated with CSA and women’s sexuality: adulthood sexual victimization (ASV), adult sexual assault (ASA), childhood sexual abuse (CSA), complex PTSD, sexuality, sexual function, sexual risk, sexual schema, sexual avoidance, sexual compulsivity, sexually transmitted disease (STD), sex therapy, sexual schemas, intimacy, revictimization, sexual risk-taking, prostitution, porn industry, human trafficking, women military veterans, gynecological issues, therapeutic implications, inter-partner violence (IPV), CBT therapy, marriage and cohabitation, sex therapy for couples.
This critical analysis of journal articles was assembled using different perspectives. The review begins with 5 key longitudinal studies; the first examined victimization and self-harm from childhood, adolescence to early adulthood. The second longitudinal study explored adult sexual behaviors and outcomes, the third examined substantiated adolescent and young adult-female reports of traumatic sexual and physical experiences (revictimizations); the fourth longitudinal study focused on research examining the relationships between sexual victimization occurring in different developmental stages – (childhood and adolescence) as well as sexual appraisals. Finally, the fifth study examined the associations between childhood exposure to sexual abuse and intimate relationship outcomes at 30 years. Categories for the articles examined include sexual functioning; sexual functioning in mid-life and beyond; sexual functioning in couples who seek sex therapy; sexual schemas; severity of CSA; intimacy; revictimizations; sexual risk-taking; prostitution, the porn industry and human trafficking; women military veterans; gynecological issues. The therapeutic implications as well as opportunities for future research based on the results of the studies will be examined.
Noll, Horowitz, Bonanno, Trickett & Putnam (2003) conducted a study of child samples from the reporting of sexual abuse in childhood through adolescence and into early adulthood on victimization and self-harm rates for women from low to middle socioeconomic status, including comparison females. This was the first prospective study following a child sample from the reporting of sexual abuse in childhood through adolescence and into early adulthood on victimization and self-harm rates. Compared to non-abused participants, sexually abused participants were twice as likely to have been raped or sexually assaulted as adults, almost four times as likely to have inflicted subsequent self-harm such as suicide attempts and self-mutilation. In addition, there were higher rates of physical revictimization such as domestic violence, and also a greater number of self-reported lifetime traumas of adults, than comparison participants. Results also indicated that sexual preoccupation was positively associated with being raped, sexually assaulted, and was not a unique predictor of sexual revictimization. Being sexually abused was by far the strongest predictor of self-harm even when compared with other forms of child abuse. Results also indicated that being sexually active or believing that sexual activity is allowable, can increase one’s vulnerability for physical abuse. This was the first study of its kind and provided important data on the prevalence and onset of revictimization and self-harm. It is crucial that therapists and other professionals be aware of these risks. The sample may not have been representative of the entire population of women experiencing CSA; it may have been biased as the requirement included all participants go to child protective services and have a non-abusing caretaker as a willing participant; and also included potential difficulties with memory recall.
Van Roode, Dickson, Herbison & Paul (2009) examined the impact of CSA on adult sexual behaviors and outcomes over three age periods with women from 18 to 21, 21 to 26, and 26 to 32. While a substantial number of women answered questions about CSA, contact CSA was reported by 30.3% of women. CSA women were found to have significantly increased rates for number of sexual partners, unhappy pregnancies, abortion, and sexually transmitted infections from age 18 to 21. Findings showed that gender and age were critical when considering the impact of CSA. Using a longitudinal design based on a community sample with exceptionally high follow-up, similar questions on sexual behavior were consistent at all stages of the age period. The use of a computer-based questionnaire and the trust established over a long period of time were crucial for disclosure. This study did not include older women and did not include the impact of CSA on sexual satisfaction at different stages of life course. Furthermore, the study relied on self-report data and retrospective collection of CSA data which potentially increases bias and lack of memory recall.
The purpose of the fifteen-year prospective, longitudinal study by Barnes, Noll, Putnam & Trickett (2010) was to examine substantiated adolescent and young adult-female reports of traumatic sexual and physical experiences (revictimizations) occurring after CSA. Abused females’ revictimizations were also more likely to have been perpetrated by older, non-peers and characterized by physical injury. The reported accuracy by abuse victims of their past was validated, and substantiated sexual abuse was determined by protective service records and somewhat consistent with past research (Fergusson et al., 2000). Abused females were accompanied by a non-abusing caregiver who was more supportive and able to engage in the study. Limitations included an exclusive focus on familial abuse and the sample being drawn from a Mid-Atlantic metropolitan region with certain ethnic and cultural characteristics not addressed. Finally, the study did not address individual differences in revictimization.
Kelly and Gidycz (2015) examined the potential relationships between sexual victimization occurring in different developmental stages (i.e. childhood, adolescence, or both states) and sexual appraisals (i.e. sexual schemas, sexual self-esteem and erotophobia-erotophilia) with a group of college women from a midsized Midwestern University including non-abused women. Results indicated that a history of CSA was uniquely related to lower sexual self-esteem, whereas history of adolescent sexual assault was uniquely related to greater erotophilia and more positive romantic/passionate sexual self-image yet lower attractiveness, moral judgment and sexual self-esteem. Sexual victimization can result in altered perceptions and cognitions related to one’s sexuality. Results suggested that identifying the developmental stage during which the sexual abuse occurred can have implications for treatment of sexual abuse survivors. The findings were consistent with previous literature (Messman-Moore et al., 2000). The surveys were completed for course work only with a small number of women with CSA. Furthermore, the findings were only for college aged women rather than the general population. Finally, the study was based on self-reports retrospectively which could be biased, and the researchers did not assess for the frequency or chronicity of sexual abuse.
In a 30 longitudinal study by Friesen, Woodward, Horwood & Fergusson (2010) data from the Christchurch Health and Development Study (CHDS) were used to examine the association between childhood exposure to sexual abuse and intimate relationship outcomes from birth to thirty years. This study included children born in Christchurch and studied at regular intervals from birth to age 30. Exposure to more severe forms of CSA was associated with earlier and more frequent cohabitation, higher rates of perpetrated inter-partner violence (IPV), early parenthood, lower relational satisfaction and investment. During adolescence, CSA was associated with a history of early consensual sexual intercourse, higher number of sexual partnerships and low self-esteem as well as IPV. This could result in later self-reported acts of aggression and hostility in young adulthood. Future research is suggested to assess the extent to which these factors apply to other cultures and groups. Study findings supported a causal relationship whereby early childhood and family factors place some individuals at risk. In addition, identifying this process provides important clues for those designing intervention programs and treatment strategies. This study is subject to recall and reporting events and fails to report direct effects of CSA on other areas of intimate relationship functioning and lack of generalizability.
In a study by Easton, Coohey, O’Leary, & Hua (2011) examined whether and how characteristics of CSA and disclosure influenced emotional, behavioral and evaluative categories during adulthood. The researchers also examined the influence of disclosure on the relationship between severity and psychosexual functioning. The sample included adults who were sexually abused as children. Being older at the time of the abuse increased the likelihood of being afraid of sex and feeling guilty during sex and increased the likelihood of being dissatisfied with sex during adulthood. With disclosure, the adult respondents who were older at the time of the first abuse were 14 times more likely to experience fear of sex, problems with touch, and problems with arousal than participants who were not abused. Findings also suggest that avoiding emotional pain associated with past abuse may contribute to problems with touch and problems with arousal. Incest increased the likelihood of having problems with touch. When these acts of affection and care are intermingled with acts of sexual abuse in family life, it is likely lack of trust and lack of boundaries which may impair an adult’s ability to differentiate between sexual and non-sexual physical touch. The results indicate that practitioners who treat adults with CSA histories for sexual functioning problems should assess all three dimensions of psychosexual functioning (emotional, behavioral and evaluative). Thus, to decrease problems with touch and arousal and to increase satisfaction with sex, practitioners may need to address the underlying emotional aspects such as fear of sex and guilt during sex. The results suggest that characteristics of abuse and disclosure need to be addressed as well as addressing more than one dimension of psychosexual functioning. Retrospective accounts and self-reports without validation from other sources and potential issues related to memory deterioration and recall bias could have affected the accuracy of the reports.
In a study by Vaillancourt-Morel et al. (2016), a sample of adults were examined. These participants were currently involved in a close relationship and completed online self-report computerized questionnaires. Prevalence of CSA was 21.5% in women. Results indicated that CSA survivors who have attained a relationship status (i.e. marriage) are more likely to report sexual avoidance. In comparison, single survivors are more likely to evidence sexual compulsivity, whereas cohabiting survivors report a mixture of sexual avoidance and compulsivity. Overall, these findings suggest that both avoidant and compulsive sexuality are relevant intervention targets with couples in which one or both partners are CSA survivors. This is the first study suggesting that, in CSA survivors, these two forms of sexual functioning are associated with couple satisfaction. An intervention might attempt to help survivors understand how CSA can lead to maladaptive sexual behaviors due to difficulty with managing intimacy or how one sees oneself and others. A better understanding of the role of CSA in different sexual behaviors may promote the development of efficient targeted treatments for distinct subgroups of CSA survivors. For clinicians in particular, the need for assessment of both partner’s sexual abuse history and severity through face-to-face interviews and detailed questionnaires is paramount. The results were consistent with their clinical hypotheses, and provide a more complex picture of sexual responses to CSA. The study’s cross-sectional nature, failure to assess sexual orientation, socioeconomic status, level of sexual experience before marriage and exclusive reliance were not evaluated. This study was based on retrospective self-report measures only, which can introduce biases, under-reporting, over-reporting and recall issues of the survivor.
Staples, Rellini & Roberts (2012) examined participants with and without a history of sexual abuse who were recruited prior to age 16 years from a medium-sized urban community. A significant interaction between CSA and avoidance tendencies was found for orgasm function, with the combination of sexual abuse and avoidance tendencies explaining lower orgasm function. These findings suggest that for women with a history of early sexual abuse, the tendency to avoid interpersonal closeness and avoid emotional involvement predicts orgasm function. Furthermore, pursuing of a relationship had a positive effect on arousal function but only with mild or no CSA. Therapeutic interventions for sexual difficulties include addressing a survivor’s tendency to avoid sexual experiences at times and their commitment to relationships. A study limitation was that the investigators failed to examine the relationship between pursuing, distancing and high risk sexual behavior for survivors.
Najman et al. (2005) examined a representative sample of the Australian population aged eighteen to fifty-nine years, who were selected from the electoral roll for Australian states and territories in April 2000. More than one-third of women reported a history of CSA. There was a significant association between CSA and symptoms of sexual dysfunction. CSA was not, however associated with the level of physical or emotional satisfaction respondents experienced with their sexual activity. Women who had experienced penetrative sexual abuse were substantially more likely to report many symptoms of sexual dysfunction (oversexualization and undersexualization.) The total number of lifetime sexual partners and promiscuity was significantly and positively associated with CSA. The results are comparable to previous studies (Bauserman & Find, 1997, Holmes & Slap, 1998, Briere et al., 1998, and Roesler & McKenzie, 1994). Limitations were selection bias which may have underestimated the true prevalence of CSA, as well as the validity of respondents’ answers, and the failure to adjust for other factors such as the child’s family environment.
Bird, Seehaus, Clifton & Rellini (2012) examined women with CSA and non-CSA recruited from the community. Participants were asked to indicate the frequency and intensity of their experience in two dissociation subgroups, derealization and depersonalization, during sex with their partner and in their daily life. Participants in their study with CSA histories indicated more depersonalization during their daily life than women in the NSA group. Both the NSA and CSA group had more derealization when considering dissociation and sexual function. Mental health professionals should focus on changes in bodily perception and not merely changes in the environment. Furthermore, the authors suggest future studies on the causes and intensity of depersonalization during sex may lead to clarification of its relationship to female sexual arousal functioning. Findings were not in agreement with some previous research which indicates a longer period of sexual abuse and higher number of perpetrators associated with higher levels of dissociation during sex. Severity of abuse and co-occurring types of abuse were not examined. In addition, the study did not separate CSA women who experienced revictimitization during adulthood from those who experienced sexual abuse during childhood.
Katz & Tirone (2008) focused on CSA survivors’ risk for nonviolent, unwanted sexual interactions with romantic partners and how these interactions impact adult sexual functioning. A sample of young college women completed self-report measures examining these conditions. About 24% of the sample reported CSA. Past CSA determined greater compliance with partners and more frequent use of manipulation in their sexual contact, particularly after their saying “no”. Therefore women with CSA histories were more likely than other women to report reduced sexual satisfaction in their romantic relationships. Women who had racial/ethnic differences were likely to report experiencing unwanted sexual encounters with partners. Study limitations included non-representativeness of the sample which was primarily college based and Caucasian, and reliance on self-report measures that may not account for bias and issues with memory recall.
Lorenz & Meston (2012) investigated language differences, comparing women with CSA and without CSA (NSA). When participants wrote about their daily life and their beliefs about sexual and sexual experiences, compared to the NSA group, women with CSA histories used fewer first person pronouns in the writing about their daily life, but more in the sexual essay, suggesting women with CSA histories have greater self-focus when thinking about sexuality. Women who reported CSA used more intimacy words and more language consistent with psychological distancing in the sexual essay than did individuals with no CSA history. The findings support the view that language use differs between women with CSA history and no history. These differences related to sexual functioning and satisfaction. These findings may help to inform clinicians about treatments using CPT therapy. Study limitations included some differences in the groups, namely ethnicity, type of relationship and sexual orientation and the possibility that there were other demographics not assessed in their findings. The researchers only investigated word categories for which there was previous research which suggests possible differences between groups. In addition, CSA survivors were offered a treatment for relationship problems while NSA women were not.
Contrary to previous studies, Seehuus, Clifton & Rellini’s cross-sectional study (2015) of heterosexual women (ages 18-25) explored how multiple forms of abuse (i.e. physical, emotional and sexual), rather than sexual abuse alone, could influence the development of adult sexuality. Findings from this study suggest that family environment, childhood abuse, sexual schemas and romantic relationship quality were all related to sexual function and satisfaction, with each factor relating to the other factor. Unlike previous studies, Seehuus et al. found that the quality of the current romantic relationship, although related to sexual function and satisfaction was not significantly associated with childhood abuse. The limitations of this study were its cross-sectional nature and reliance on self-report which may not have accounted for memory bias and recall issues. Additionally, the identity of the perpetrator of the abuse by its participants (e.g. family member versus non-family member) was not examined, and the age group was limited to ages 18-25.
In another study that conflicted with prior research, Dunlop et al. (2015) examined English speaking adults (18-75) of chronically depressed outpatients across eight academic sites between 2002 and 2006. CSA was significantly greater among women, blacks, and Hispanics. All aspects of sexual function (drive, arousal and orgasm) were negatively associated with the degree of CSA. Findings predicted lower relationship and sexual satisfaction among depressed adults and the long-term effects of CSA appear to be mediated by depressive and anxious symptoms. Findings suggest the importance of focusing on symptoms of both depression and anxiety as these factors may be fueling the effects of childhood abuse on adult sexual health and thereby addressing these precursors may promote improvements in mood and hence, sexual functioning. The study did not include a comparison group of non-chronically depressed patients or any information on the partner’s perception of sexuality and relationship. Lack of clarity regarding whether depression symptoms precede or follow CSA points to the need for a longitudinal study.
Sexual functioning in couples seeking therapy
Berthelot, Godbout, Hebert, Goulet & Bergeron (2014) studied adults receiving sex therapy (sexual dysfunction, sexual dissatisfaction) from a wide variety of medical clinics or general services of hospitals. The prevalence of CSA was high in women (56%) and clients with a history of CSA were more likely to report psychological and relationship problems. Findings reveal that those who have experienced abuse involving penetration are more likely to have couple functioning issues. In addition, the various sexual behaviors with a couple might be experienced by some victims as particularly intrusive and might trigger negative transference. Findings show that clinicians need to be aware of the need to assess sexual trauma and the effects of these traumas. Furthermore, the treatment offered will face important resistances that may hamper effectiveness and slow down progress. Brief therapy of standard sex therapy might not be well suited for CSA survivors. Indeed, CSA may not hamper therapy but using adaptations of the traditional sex therapies with CSA survivors may enhance treatment. Participants were from diverse clinical settings which represents general services offered to the population. A limitation, however, was that clients from distinct clinics may show differences in history, clinical presentation and motives for coming to therapy.
In a pilot study by Anderson & Miller (2006) explored the impact of CSA on couples who sought therapy for relationship problems, as well as reported a history of CSA in one partner. Groups were compared using self-report and therapist-rated measures of individual and couple distress. Results indicated that although there were some statistically significant differences between couples reporting CSA and those not reporting CSA at the onset of therapy, those differences do not appear to affect the therapist’s perception of the outcome of therapy. Husbands in couples reporting CSA rate themselves as being more distressed than the comparison group. Furthermore, therapists rated husbands and wives as being more distressed when they are part of couples reporting CSA and therapists perceived therapy to be just as effective regardless of the severity of abuse. The results showed that CSA affects both partners, not only the partner who was actually victimized. In addition, psychoeducation focusing on the effects of CSA may be a particularly important intervention with this population. Although the symptoms for which the couple sought therapy were resolved, different symptoms arose because the underlying problem still remained. Hence the need arises for future studies, using a larger sample size, including six-month and one-year follow-ups. Because of low post-test participation, the measures of effectiveness of therapy are all from the point of the therapist; this sample was not a random sample, and was seen through the eyes of student therapists.
Sexual functioning in mid-life and beyond
Dennerstein, Guthrie & Alford (2004) surveyed the association of recalled child sexual abuse with current sexual functioning in women who were mid-aged between 51 and 62. The authors reported that for this population, the major impact of CSA was the quality of the relationship with the partner. Those who experienced penetrative CSA had, on average, shorter current relationships and were significantly more likely to have fewer children than the comparison group. This study used a population base of middle-aged women, and included a longitudinal component which was more rigorous than many prior studies in both measurement of sexual function and childhood experience of violence. Findings suggest that clinicians should be alerted to inquire about CSA during history-taking with their clients. The researchers only used the questionnaire as a measure of sexual functioning in the first follow-up year; however there was missing data that year because they modified the questionnaire. In addition, women only between 51 and 62 years were examined.
Godbout, Sabourin, & Lussier (2009) examined the presence or absence of CSA related to level of force, relationship with perpetrator, number of abusive experiences. The nature of the assault was examined in order to predict possibly later marital, attachment and psychological issues. CSA may be an important risk factor to consider that may develop couple’s difficulties and marital distress, regardless of the severity of the trauma. The results showed that couple problems associated with CSA was not significantly hampered by the use of a sophisticated measure of CSA; however, their findings contribute to a large body of evidence examining survivors with more severe abuse. Retrospective self-reports can often lead to under-reporting biases or distortions in the recall of traumatic events, and furthermore, the results of this study should not necessarily be generalized to clinical populations.
Niehaus, Jackson & Davies study (2010) examined female undergraduate students who were recruited through the research pool at a large southeastern university. The study indicated that a history of CSA impacted the way women viewed themselves as a sexual person. CSA survivors were found to view themselves as more open and possessing more immoral/irresponsible cognitions about sexuality as compared to women who did not have a CSA history. In addition, the CSA survivors perceived less embarrassment and passionate/romantic views of their sexual selves. Survivors were more likely to view themselves as more sexually open and less conservative than non-victims; however, they associated their sexuality in a more negative framework (e.g. immoral and dirty as opposed to loving.) The interaction of CSA severity and sexual self-schemas explained the difference in adolescent sexual assault experiences over and above the severity of CSA history and risky sexual behavior. It will be important for future studies to examine relationships with abuse severity and a broader range of abuse experiences. The retrospective nature of this study suggests possible issues with memory recall and bias. Because of its correlational design, it was also not possible to determine a causal relationship. Furthermore, the study used a sample of mostly white, heterosexual, well-educated women who are not representative of the general population of CSA survivors.
Walker, Sheffield, Larson & Holman (2011) examined couples from 1999 to 2006. Their study explored the relationship between a history of CSA for one or both members of a romantic couple and perceptions of contempt and defensiveness for self and partner. The findings suggest that CSA is a risk factor for relational challenges of satisfaction and stability for survivors and partners. The presence of CSA for either partner increased the likelihood that one will perceive themselves and their partner as somewhat more defensive and contemptuous. Findings suggested that assessment and treatment of CSA should include both members of a romantic couple for communication problems. Given the damaging effects of contempt and defensiveness in the relationships studied, these issues should be a primary target of therapeutic interventions. For couples who are both survivors of CSA, there is a probability that in conflict resolution or problem-solving both may be triggered by their own trauma. The study also helped couples to distinguish the past from the present and helped couples build empathy and compassion for each other. The sample was lacking in diversity in terms of race, ethnicity, education and income and did not include measures such as duration, number of perpetrators, presence of other types of abuse, or age at which abuse occurred. Data were collected in the early stages of relationships (engaged or seriously dating) and did not take into consideration more mature couples later in marriage.
Rellini & Meston (2011) in their study of women with CSA and no CSA history were recruited from two medium sized towns in the North East and South West of the United States with a variety of ethnic backgrounds between ages 25 and 35. The findings showed evidence that sexual self-schemas predicted negative affect prior to exposure to sexual stimulation, which, in turn, partially explained the lower sexual arousal function and sexual satisfaction. Future studies should include an examination of the ways CSA survivors experience more negative affect prior to exposure to sexual stimulation.
A study using grounded theory conducted by Roller, Martsolf, Draucker & Ross (2011) explored the process in which CSA influences the sexuality of women. This process was labeled “Determining My Sexual Being” by the researchers. Four core questions addressed the participants’ experience of coming to terms with the effort, time and frustration in understanding the cause of the abuse and why it happened to them specifically, the sexual effects of CSA, and empowerment in claiming their sexuality. The researchers reported that positive resolution of CSA involved a stage of “increasing knowledge of sexual abuse.” The findings are comparable to previous studies which show how CSA survivors can recover or heal from the experience. In addition, it can provide health care professionals a different way to conceptualize survivor’s responses to CSA as they move through the stages tailored to the stage that reflects the survivors’ current experiences.
Severity of CSA
Senn, Carey, Vanable, Coury-Doniger, & Urban’s study (2007) investigated the associations between sexual abuse characteristics and later sexual risk behavior. The study included women participants from an STD clinic. Those who reported sexual abuse involving penetration and/or force reported more adult sexual risk behavior, including the number of lifetime partners and number of previous STD diagnoses, compared with no sexual abuse and those who were abused without force or penetration. The women who reported abuse with penetration, regardless of whether the abuse involved force, reported the most episodes of sex trading. Thus individuals who experienced more severe forms of sexual abuse may use drugs or alcohol to cope, which in turn may lead to exchange of sex for money or drugs, and/or a greater number of sexual partners and episodes of unprotected sex. The researchers obtained a larger, more diverse sample than other studies, but the survey failed to address other aspects of sexual abuse such as duration, frequency and relationship to the perpetrator, and outcomes in their adult life. Participants were recruited by a sexually transmitted disease clinic only and were included because they were currently engaging in sexual behavior that showed risk for contracting an STD.
A study by Vaillancout-Morel et al. (2016) tested a model investigating CSA severity and negative sexual outcomes (i.e. sexual avoidance and compulsivity) with relationship status (single, cohabitating and married couples). CSA abuse severity was associated with higher sexual compulsivity in single individuals, both higher sexual avoidance and compulsivity in cohabitating individuals and higher sexual avoidance in married individuals. Furthermore, the findings suggest that sexual avoidance and sexual compulsivity are dependent on relationship status. The results suggest the need for assessment of both partners’ sexual abuse and its severity, using face to face interviews and detailed questionnaires. Couple interventions that address the underlying conditions of compulsive and avoidance sexual symptoms will greatly benefit abuse survivors. Current findings are generalizable across gender, age and relationship duration. Exploration and consequent processing of the emotional issues underlying the survivor’s history and partner’s perspective will enhance the patients’ and therapists’ understanding of the sexual difficulties. There is additional research needed on gender similarity and gender differences with regards to sexual outcomes of the survivor. The cross-sectional design did not allow for causal conclusions, which they suggest can only be confirmed by longitudinal studies. In addition, differences due to sexual orientation, socioeconomic status and participants’ level of sexual experience prior to marriage were not evaluated. Retrospective self-report measures may be colored by bias and issues with memory recall and the researchers did not account for other types of child abuse or neglect and childhood.
Meston, Rellini & Heiman (2006) examined differences between survivors of CSA and non-survivors in the way they viewed themselves as a sexual person with unwanted sexual experiences, and later their adult sexuality. CSA survivors were found to view themselves as less romantic and passionate compared with non-CSA women above and beyond the effect of depression and anxiety. Furthermore, CSA survivors in relationships were observed to have higher levels of negative sexual affect as compared with non-CSA women. A possible explanation for this was that women who have experienced CSA are less able to view themselves as passionate and romantic because sexuality has become linked to negative affect. Future studies should include a combination of questionnaires and various other types of methods needed to explore negative sexual affect and impaired romantic/passionate responses of CSA survivors. Compared to previous studies, the researchers used a community sample with higher mean age (28 years) and higher (approximately 50%) of reported unwanted sexual touching as well as more severe forms of sexual abuse. Only women 21-40 years of age were used and self-report measures are open to bias and repressed memory.
A study done by Cherlin, Hurt, Burton & Purvin (2004) on low-income families in Boston, Chicago and San Antonio examined the pattern of union and experience of sexual experience for a random-sample of children and caregivers in adulthood. Additional children and families recruited non-randomly in the same neighborhood were used. Findings showed that women who experienced sexual abuse beginning in childhood were less likely to be in sustained marriages or stable cohabitating relationships, and instead were more likely to experience multiple short-term, mostly cohabiting unions with brief intervals between. Women who had been abused as children and experienced revictimization were less likely to withdraw from relationships, instead use short-term relationships, often with strained relationships with families and friends and therefore fewer emotional and materials resources. Their study suggests that abuse is a widespread and serious problem to which women have been responding by pursuing other options than marriage. Low-income women judge potential partners using similar cultural standards as middle class women. This was a three-city study, with varied measurements for abuse with high a number of participants. Participants who came from low-income families were not compared with other groups.
Lacelle, Hebert, Lavoie, Vitaro &Tremblay (2012) examined the association between CSA and sexual health with a sample of young women from Quebec. Participants were assessed annually from the age of 6 to 12 years adolescence and early adulthood (mean 21.2 years). Results from the study revealed that a history of CSA was associated with greater risk of reporting other forms of childhood victimization, including exposure to multiple victimization. Furthermore, women with a history of exposure to both CSA and multiple victimizations were more likely to report greater adverse outcomes including more sexual risk behaviors, sexual problems and negative sexual self-concept and revictimization compared to women without CSA. Exposure to CSA combined with other forms of childhood victimization leads to more negative sexual health consequences than just CSA alone. The longitudinal nature of the study and using a large sample of young adult women from a community setting, including various measures of prior victimization and exposure to parental victimization were used. The results highlight the need for early intervention to reduce the long-term health impact of CSA. Whilst their findings are supported by previous studies, other recent studies do not support this (Senn, & Carey, 2010) and women with more severe forms of physical and psychological abuse should be included in future studies.
The study by Messman-Moore, Walsh & Dilillo (2010) examined emotional dysregulation in participants who were college students at a mid-sized Midwest public university. Findings showed that CSA was associated with increased risk for adolescent/adult rape and that risky sexual behavior is a significant risk factor for revictimization. Number of lifetime sexual partners was the strongest predictor of adolescent/adult rape, although frequency of risky sex with a stranger and with a regular dating partner also predicted revictimization. Emotional dysregulation was linked only to number of sexual partners and risky sexual behavior with a stranger, yet CSA was only associated with risky sexual behavior with a regular dating partner. This is the first study to specifically assess emotion dysregulation and to predict high risk behaviors that impact sexual revictimization. Additional studies need to examine revictimization in relation to other causes and should include multiple and mixed method approaches to assess aspects of emotional dysregulation. Since only self-reported questionnaires were included in the study, recall and bias should be taken into account. In a study by Daigneault, Hebert and McDuff (2009) assessed IPV in CSA women and their partners in adulthood. The study showed consistently predicted IPV for women. Being younger or being in a more recent relationship, being limited to either physical, mental conditions or chronic illness were also predictors of adult victimization for the female sex. Women reported almost four times more CSA and almost eight times more sexual IPV. Therefore, CSA is associated with an elevated risk of being sexually revictimized by an intimate partner for Canadian women. The researchers’ results were based on women’s risks of IPV and did not consider characteristics of participants and their current partners. Future studies should include assessing violence and risk factors, including use of CPS records and refined definitions of childhood abuse. This study was based on self-report measures, which did not allow for memory recall and bias.
A study by Lemieux & Byers (2008) examined female community college and university students at a mid-sized Canadian university for the positive and negative aspects of CSA associated with women’s sexual well-being. The women who had experienced CSA involving sexual penetration or attempted sexual penetration were more likely to be sexually revictimized in adulthood and more likely to have engaged in casual sex, unprotected sex, and voluntary sexual abstinence. They also reported fewer sexual rewards, more sexual costs, and lower sexual self-esteem, more negative and less positive sexual functioning. Multiple types of victimization and women who had experienced adulthood sexual victimization (ASV) tend to report some of the same sexual difficulties as women with a history of CSA, including sexual avoidance, problems with sexual desire, arousal, orgasm and lower sexual satisfaction. Only young heterosexual students, with a high percentage of the sample married or cohabitating were included.
Schloredt & Hellman (2003) examined women with abuse histories who reported more negative affect during sexual arousal and reported more lifetime vaginal intercourse partners than non-abused women. The researchers also found that participants with a history of CSA, alone or in combination with physical abuse, reported more sexual risk taking than did non-abused individuals. CSA survivors experienced more negative affect (e.g. fear, anger, and disgust) during their sexual arousal and had nearly three times more sexual partners than did non-abused individuals. Results were consistent with previous studies; however this study was unique in its attempt to explore sexuality by incorporating reports of behavior and self-perceptions. There were only a small number of CSA participants and the study was based on self-reporting which did not allow for possible distortion or poor recall.
In another longitudinal study, Testa, VanZile-Tamsen & Livingston (2006) examined women across three years with twelve months apart. This study was unique in suggesting that the high sexual risk status of adult survivors, including higher numbers of sexual partners and higher rates of STI, can be at least partially explained by the quality of women’s intimate relationships. Across many relationships, CSA was associated with more aggressive and more sexually risky partners. Partner sexual risk characteristics were associated with women’s risk of sexually transmitted infection from current partner. The study suggests that the higher levels of sexual risk behaviors and negative sexual outcomes among CSA survivors may be resolved by addressing women difficulties in establishing and maintaining safe and stable relationships. Addressing HIV risk education in CSA survivors through increasing sexual assertiveness may improve the quality and help women be more discerning in entering a new relationship. This was a large representative sample and longitudinal in nature, addressing CSA women with issues of trust and communication directly. Reports of CSA were made retrospectively, at 1st, 2nd and 3rd years and may not be stable over time with partner behavior based solely on the women’s reports which could be inaccurate or biased. The findings also showed the pattern of some CSA women seeking sexual risky behavior and others, avoidance behavior which does not fit the experience of all CSA women.
Prostitution, porn industry and human trafficking
Wilson & Widom (2008) examined links between childhood maltreatment (including CSA) and risky sexual behavior (early sexual contact, promiscuity, prostitution). Prospective evidence showed that maltreated children were more likely to report sexual contact before age 15, then engage in prostitution by young adulthood, and test positive for HIV in middle adulthood. Physically abused and neglected children, and not just those who have been identified as sexual abuse victims, were more vulnerable to these early sexual experiences. The results contribute to the understanding of long-term behavioral health consequences of CSA and therefore have important implications for public health service professionals. Not only victims of sexual abuse, but physically and emotionally abused children would benefit from interventions and early evaluations to reduce sexual risk-taking. This study did not account for possible risky sexual behaviors that may have led to HIV infection and that there were cases of abuse and neglect which did not come to the attention of authorities. Since the sample was taken from the lower end of the socioeconomic spectrum, results cannot be generalized to all cases.
Griffith, Mitchell, Hart, Adams & Gu (2013) compared the self-reports of porn actresses to a sample of women matched on age, ethnicity, and marital status. Comparisons were conducted on sexual behaviors and attitudes, self-esteem and quality of life and drug use. Porn actresses were more likely to identify as bisexual, first had sex at an earlier age, had more sexual partners, were more concerned about contracting a sexually transmitted disease (STD) and enjoyed sex more than the matched sample. Porn actresses had higher levels of self-esteem, positive feelings, social support, sexual satisfaction and spirituality, although porn actresses had a history of more drug use. The findings suggest that one can make a more informed decision about porn actresses instead of stereotyping and basing their perception based on the “damaged goods theory.” Random sampling was not used in both groups and since pornography actress participation was unknown, and the size of the population was largely unknown, this reduces the generalization of their findings. Furthermore, the definition of a pornography actress was based on the internet and traditional sex industry and was therefore unclear.
A study by Muftic & Finn (2013) identified the relationship of risk factors of physical, sexual, and mental health outcomes involving international trafficking victims, domestic trafficking victims, and non-trafficked sex workers. Findings suggest that the experiences in sex work of domestic women displayed poorer health outcomes compared to the international group. In terms of risk factors, a higher percentage of women involved in street prostitution reported sexual health problems, co-occurring health issues and addiction compared to the international group. Finally a greater percentage of domestic trafficking victims reported having experienced physical and/or sexual abuse as a child compared to the international group. Very few women, regardless of group, reported using birth control (beyond infrequent condom use). Relatively large percentages of women reported becoming pregnant. Women reported a higher incidence of sexually transmitted infections than women who engaged in prostitution elsewhere (e.g., clubs, escort agencies, massage parlors). The domestic trafficking group was usually older (on average 10 years older), non-white, and had experienced physical or sexual abuse as a child, and had been involved in street prostitution compared with the international group. Whilst the researchers examined the relationship of various risk factors identified in prior research to the adverse health outcomes among the sample of sexually exploited women, future research is needed on the cumulative risk factors on health outcomes for workers in the sex trade. Future research should identify risk factors which will help the public health and criminology sectors. The sample was small and used non-representative cases obtained through convenience sampling and their measurement was determined by whether or not an exploited woman experienced the prevalence of a particular health outcome and its incidence.
Female Military Veterans
In a study by Schultz, Bell, Naugle & Polousny (2006) female military veterans with CSA and civilian community members were investigated for adulthood sexual victimization (ASV), and adulthood sexual assault experiences. Although comparable rates of CSA and ASV were found across groups, veterans more frequently reported having been sexually abused by a parental figure, reported longer durations of CSA, and significantly greater severity of ASV than civilians. Given the high rates of CSA and ASV associated with a female veteran population, preventative efforts should also be addressed with women in the military. When treating female veterans or active military duty military personnel, CSA and ASV history should be assessed, and include emotional functioning for revicimitization. Preventative efforts should also be addressed such as emotional issues, awareness of risky situations, and impact of substance abuse. This research needed a larger representative sample, with no information available on the non-responders.
In another study conducted by Merrill, Guimond, Thomsen & Miller (2003) examined U.S. female Navy recruits in their first week of training. Only sexually abused single women who had never been married were recruited, as sexual behavior is likely to differ as a function of marital status. Women who experienced CSA of greater severity (e.g., involving intercourse, use of force, father-figure as a perpetrator, multiple perpetrators and incidents) reported greater use of both avoidant and self-destructive coping strategies than did those who experienced less severe CSA. Their results suggest that sexually abused women are likely to have relatively higher or lower number of sex partners depending on whether they are more reliant on self-destructive or avoidant coping strategies. The findings also suggest a decrease in self-destructive coping may reduce high-risk behavior. In addition, the researchers found that learning adaptive coping strategies may teach women other ways to cope with their CSA other than through sex or being revictimized. The researchers focused on participants who were single as opposed to combining single and married participants. In addition, their sample came from a nonclinical, nonstudent population with a wide range of socioeconomic backgrounds, and included minorities. The diversity of their sample increased the generalizability of the findings to other female recruits, however, not to the general population as those who enlist in the military may be different from those who are in the workforce, or who choose to attend college.
Kelly, Skelton, Patel & Bradley (2011) of CSA, examined military sexual trauma (MST), interpersonal violence and mental health in women. Future research and particular attention needs to understanding why some female veterans with pre-military service function well (i.e. resilient, do not require intervention) compared to others who display a range of mental and physical health problems. In the future this will enable more effective health care to be delivered to this population and can facilitate access to appropriate and effective trauma care, particularly those with MST and CSA. Exposure to early life adverse experiences contributes significantly to both physical and mental health problems and particularly across the lifespan of a veteran. The sample was comprised of primarily African-Americans and used only women veterans, from a cross-sectional, single-site.
Campbell, Greeson, Bybee & Raja (2007) examined the co-occurrence of CSA, adult sexual assault (ASA), intimate partner violence (IPV) and sexual harassment (SH) in a mostly low-income African-American sample of female veterans randomly sampled from a VA hospital women’s clinic. The results suggest that African-American female veterans may experience more violence than their white counterparts, but their experiences are not dramatically different from other low-income African-American women. The more forms of violence women had experienced, the worse off their health; in addition, the amount of sexual violence was detrimental to women’s mental and physical heath. All of the measures assessing violence were reliable, valid, short and behavior-specific; however their findings stress the need for early identification and intervention of victims of violence before physical problems start. This was only a short-form assessments of behavior and did not include measures of stalking or childhood physical abuse though both have been linked to IPV. In addition, non-sex crime victimizations should have been assessed and no control group was used.
Campbell et al. (2002) conducted a study of intimate partner violence and physical health consequences by using a case-control study of enrollees in a multisite metropolitan HMO. Their findings indicated that a history of CSA, regardless of diagnosis, is associated with greater risk for symptom reporting and lifetime surgeries. Abused women had a 50 to 70 percent increase in gynecological problems such as sexually transmitted diseases, vaginal bleeding, vaginal infections, pelvic pain, painful intercourse, urinary tract infections. Abused women also had more gynecological, chronic stress-related, central nervous system (back pains, headaches etc.), and total health problems. Physicians need to routinely screen for abuse and IPV (forced sex), as well as a physical examination for assessing severity of timing of trauma, injuries and gynecological problems. They also need to know that abused women remain less healthy over time and that this occurs even after the relationship has ended. In addition, physicians who mostly see higher-income working women should be aware that these patients are also at risk for short and long term negative health consequences of IPV. Information about the women’s physical or sexual abuse during childhood needs to be evaluated as well as the lack of IPV and trauma history over the life course. Furthermore, sexually controlling behaviors, such as affairs and unsafe sex needs to be evaluated.
Cichowski, Dunivan, Komesu & Rogers (2014) examined sexual abuse history and pelvic floor disorders (PFDs) in women. The researchers found that the CSA was associated with a history of chronic pelvic pain but not with other PFDs. Their study does not support other studies which demonstrated a direct link between history of sexual abuse and a diagnosis of painful bladder syndrome. The researchers grouped the list of PFDs into four categories and their findings were consistent with previous studies which explored the relation between sexual abuse and chronic pelvic pain. The study used a large sample. The researchers included standardized histories and physical examination, with a significant representation of Hispanic women and women with anal incontinence was included. The questionnaire was administered by the physician and hence could include bias, and the researchers did not define the type, duration, or extent of abuse in the questionnaire. Non-English speakers were not included and underreporting of sexual abuse history may be due to some patients not willing to report.
Randolph & Reddy (2006) examined sexual abuse and sexual functioning in a chronic pelvic pain sample. Women with more extensive adolescent/adult sexual abuse histories reported lower sexual drive and satisfaction with sexual relationships when they were single as opposed to being married or cohabitating. Being married or cohabitating was related to lower sexual arousal, but not after controlling for age. In addition, women with chronic pelvic pain and histories of CSA viewed their physical health and functioning as impaired. Future studies should assess the relationship of sexual abuse and sexual functioning in terms of extent or severity of abuse in chronic pain populations and whether they indulge in risky sexual behavior. Treatment programs for chronic pain and for sexual dysfunction could also benefit from using measuring the extent or severity of abuse. There was no group of women who had no sexual abuse history, yet had pelvic pain disorder.
Paras et al. (2009) performed a comprehensive systematic review of the literature and meta-analysis to assess the association between sexual abuse and the lifetime prevalence of several somatic disorders. This review found that sexual abuse was associated with a lifetime diagnosis of nonspecific chronic pain, functional gastrointestinal disorders, psychogenic seizures, and chronic pelvic pain. This was the first attempt to summarize the available data with association between patient history of sexual abuse and somatic outcomes. Attempts were made to decrease bias by performing selection, review and having data examined by pairs of reviewers. Efforts were made to evaluate foreign language as well as unpublished studies. This research highlighted that building greater awareness of the association between sexual abuse and somatic disorders may lead to improved health care delivery and outcomes for sexual abuse survivors.
A study by Leeners et al. (2007) examined CSA experiences of women and its potential effect on the gynecologic care they received as adults. Women exposed to CSA experienced gynecological examinations as anxiety-provoking more often, and sought more treatment for acute gynecological problems with many re-experiencing memories of the original abuse. Furthermore, gynecologic care was particularly distressing for women exposed to CSA as compared to the control group. CSA women rated the stress level associated with conversations with their gynecologist about intimate details, nakedness and vaginal (ultrasound exams) significantly higher than control-group women. These findings suggest that most gynecologists would benefit from training focusing on CSA disclosure, sequence, health problems and the specific needs of CSA survivors. In addition, the physicians need to be more aware and more sensitive to those women who have been traumatized.
In a longitudinal cohort design study, Calvert, Kellett & Hagan (2015) examined CSA patients who were treated with twenty-four sessions of group cognitive analytic therapy (GCAT). This was the first attempt to evaluate GCAT for highly distressed female survivors of CSA in routine clinical practice. The results generally suggest that GCAT can be an effective approach for those patients completing therapy, including care provided in a secondary mental health setting. Acceptance of treatment was encouraging for survivors who endured ongoing adversity, and that initial evidence for GCAT appears an acceptable and moderately effective treatment with highly distressed female survivors. Patients with severe and complex difficulties required lengthier group treatment. Further research indicates coordinating strategies to improve the overall care of women struggling with the emotional consequences of CSA. There was no systematic recording of other interventions from health services and the study could have been improved with more CSA-specific outcome measures, and utilization of a measure of therapist adherence.
A study by Chard (2005) compared the effectiveness of CBT for sexual abuse survivors (CBT-SA) who were assessed at pretreatment and three times during post treatment, with a wait-listed control group. These findings suggest that CPT-SA shows promise as an alternative form of treatment with clients reporting higher statistical and clinical gains on dissociation and PTSD. No differences were found for treatment outcome response based on age of onset of abuse, chronicity, time between last abuse and treatment or relationship to the perpetrator. Future studies might include treatment comparisons of other therapies with the same duration of time, as well as updated assessments that include guilt, anger, sexual intimacy, severity of abuse and complex PTSD. The sample underrepresented minorities so the findings may have limited generalizability.
Resick, Nishith & Griffin (2010) studied female rape victims, most of whom had extensive histories of trauma. Subjects were randomly assigned to cognitive-processing therapy, prolonged exposure, or a delayed treatment waiting-list condition. Both groups of CSA women and non-CSA women improved significantly over the course of treatment with regards to the symptoms of complex PTSD as measured by the Trauma Symptom Inventory. CBT, CPT and prolonged exposure implemented over a 6-week period were highly effective in reducing, not only chronic PTSD and depressive symptoms, but more insidious symptoms, such as dissociation, low self-esteem, dysfunctional sexual behavior and tension reduction behaviors. Further research is needed using other instruments with CSA survivors with complex histories, as well as longer follow-ups to determine whether improvements are sustained.
Brotto, Basson & Luria (2008) examined women using elements of education, CBT, sexual therapy, relationship therapy and mindfulness in a group setting, with homework exercises between sessions. A follow-up comparison of women with and without a sexual abuse history revealed that women with a sexual abuse history improved significantly more than those without such history on mental sexual excitement, genital tingling/throbbing, arousal, overall sexual function and sexual distress. Participant feedback indicated that mindfulness was the most effective form of treatment. Future research might specifically target women with sexual concerns who also have a history of sexual abuse. CSA survivors improved more than women without such a history on laboratory-based and at-home sexual arousal, overall sexual function and sexual distress and had greater improvements with mindfulness techniques. This study only included women who sought help for a sexual concern. Indeed, they found that more active participation by the partner in the homework exercises was needed.
Brotto et al. (2012) examined women for CBT treatment with their partners for sexual difficulties and sexual distress. The study included two sessions of either a CBT or mindfulness-based group treatment (MBT) with women 22-54 years of age. Women in the MBT group experienced a significantly greater subjective sexual arousal response to the same level of genital arousal compared to the CBT group and to pre-treatment. Both groups also experienced a significant decrease in sexual distress. Their findings showed that mindfulness-based approaches may improve sexual distress in the treatment of sexual difficulties. Women learned about the aspects of nonjudgment in group work, and found they had additional support in the group. This study did not include a wait-list or no treatment control group, nor a detailed history of sexual abuse and PTSD symptoms.
A study by Pulverman, Boyd, Stanton,& Meston (2016) examined women with a CSA history. The participants completed a five-session expressive writing treatment which focused on 7 items of sexual self-schemas: family and development, virginity, abuse, relationship, sexual activity, attraction and existentialism. CSA survivors showed changes in their use of certain sexual self-schema themes, and a decrease in their use of the abuse, family and development, virginity and attraction schemas, and an increase in their use of the existentialism schema. Future research with larger samples of women is needed to further explore women’s sexual self-schemas for this population. The expressive writing treatment may help survivors process their abuse, and explore the importance of sexual self-schema themes. Therapists in particular may be helped in working with these survivors by using the treatment at home in an effort to process their abuse and improve sexual functioning and mental health. The sample was relatively small and non-random, with no control group and therefore cannot be generalized.
Suggestions for Future Research
The following areas represent suggested areas for future research to create a more comprehensive picture of the impact of CSA on women’s sexuality.
- Repressed memories and CSA
- Comparison of sexuality and relationships in Twelve-Step and non-Twelve-Step recovery programs
- Differences in healing of CSA histories with somatic versus talk therapy
- Differences in outcomes for women who were abused at home compared with those abused outside of the home
- Potential differential treatment effects for men as compared with women
- CS as a predictor of later-life sexual offending
- CSA and its impact on women’s spirituality
- CSA and its effects among incarcerated women
- CSA in women military veterans
- Effects of CSA in women with chronic health issues
- Role of CSA in relationships and revictimization
- Pornography actresses and CSA
- Effects of sexual abuse on sexual cognition/fantasy
- Gender differences with regards to sexual outcomes of survivors
- Personality differences including personality disorders and attachment
Recent research shows that almost 20 percent of adult women have experienced CSA (Perada, Guilera, Forns & Gomez-Benito, 2009), and among the population of women reporting sexual difficulties, important differences have emerged between survivors with and without a history of CSA. Women exposed to CSA may be more vulnerable to mental health problems, but especially so to sexual difficulties and STIs, including HIV/AIDS, (Doll, Koenig & Purcell, 2003). Furthermore, research has shown a link between the experience of CSA and an increased risk of engaging in subsequent high-risk sexual behaviors such as consensual sex at a younger age, having a higher number of sexual partners, a higher frequency of unprotected sex, less sexual satisfaction, greater likelihood of contracting a sexually transmitted infection (STI), experiencing greater gynecological problems and using drugs or alcohol during sexual activities.
Indeed, CSA represents an important public health issue. Health professionals (particularly physicians and gynecologists) need to be aware of the symptoms and consequences of child sexual abuse in order to provide support, appropriate care and treatment for the survivors. Paras et al. (2009) showed that sexual abuse was associated with a lifetime diagnosis of nonspecific chronic pain, functional gastrointestinal disorders, psychogenic seizures, and chronic pelvic pain. With regards to medical treatment, research (Leeners et al. 2007) indicates that gynecologists would benefit from improved training focusing on CSA disclosure, sequence, health problems and the specific needs of CSA survivors. Finally, preventive and long lasting public health measures have to be taken in order to prevent children from experiencing such serious trauma.
With such a high percentage of women having experienced childhood sexual abuse, it is likely that many women seeking therapy will have histories that include sexual abuse. It is imperative then, that therapists are aware of and familiar with the symptoms and long-term effects associated with childhood sexual abuse in order to gain a deeper understanding of what is needed in therapy. Symptoms include increased risk of engaging in high-risk sexual behaviors, having a higher number of sexual partners, a higher frequency of unprotected sex, less sexual satisfaction, greater likelihood of contracting a sexually transmitted infection (STI), greater gynecological problems and using drugs or alcohol during sexual activities. Additionally, women with a history of CSA respond differently from their non-abused counterparts to treatments for sexual problems (Brotto, Seal, & Rellini, 2012; Maltz, 2002). With regards to clinical treatment, evidence-based practices such as cognitive behavioral therapy (CBT) for women with CSA show significant promise (Resick, Nishith, Griffin, 2010). However, the combination of education, CBT, sexual therapy, relationship therapy and mindfulness in group settings or in individual treatment work has demonstrated significantly better outcomes. Brotto, Basson & Luria’s (2008) findings are consistent with previous studies showing that this type of treatment is associated with enhanced sexual functioning, improved emotional and physical health.
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