Remembrance of Things Past: the legacy of childhood sexual abuse in midlife women

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by Sari Tudiver, Ph.D, Lynn McClure, N.P., Tuula Heinonen, Ph.D., Christine Kreklewitz, M.A., and Carol Scurfield, M.D

This article is reprinted with permission from A Friend Indeed, Volume XVII No. 4.

 

The prevalence of childhood sexual abuse (CSA) has been described as "shockingly frequent" in both Canada and the United States, with estimates ranging from 12-38% in the female population. [1,2] Some women have sought help to come to terms with the traumas they experienced, others have not.

From statistics and personal narratives, we know that a significant number of women in their menopausal years have experienced such abuse. Yet, almost nothing has been written about the possible effects of childhood sexual abuse on women in the menopausal years and beyond. Other life cycle changes, such as pregnancy and childbirth, raise or trigger associations to past abuse.[3] The transitions of menopause may do so as well. This article looks at some possible implications a CSA history may have for women experiencing menopause and for their heath care providers.

Increasingly, researchers are uncovering some of the emotional, psychological and physical consequences of these experiences. Yet, the implications of these findings are not considered by most health care providers who have not been trained to address the needs of survivors and who do not routinely ask about abuse in a medical history. Ignoring the issue may influence whether a woman receives appropriate diagnosis and treatment. Conditions which may have their origins in a past history of abuse may be missed or misunderstood by a care provider and by the patient, who never discuss the possible deeper causes of, for example, certain respiratory problems or chronic pain. Some survivors of CSA may be particularly fearful of seeking health care because it involves being touched, often in ways that are invasive or confining. Many survivors avoid routine and preventive services, such as PAP smear testing, manual breast examination, mammograms, and preventive dental care. Others seek help for their complaints and suffer in silence when they receive care.

Since 1996, our research team has explored the experiences of some women survivors of childhood sexual abuse in their use of health services.[4] The women discussed difficulties they experienced with invasive examinations and tests and recommended specific improvements in the organization and quality of care provided by health practitioners. In a study of 25 health care providers including physicians, nurses, mammographers and sonographers, dentists and dental hygienists, we explored the professionals' views on, and education about CSA; their experiences with CSA patients and how prepared they felt for such encounters.[5] When asked for recommendations, care providers offered insights into the limitations and barriers to change that they experience and discussed realistic options. Our aim is to encourage appropriate professional bodies and individuals to consider developing new structures (e.g., referral networks), relevant curriculum, and to formulate policies and practice guidelines that would more sensitively meet the needs of women survivors of childhood sexual abuse. Addressing these issues has the potential to improve the quality of care for all women and men. 

Impact of childhood sexual abuse

Childhood sexual abuse is broadly defined as "any sexual activity between a child less than age 18 and a person of power, usually two or more years older, and who has authority over the child".[6] Although the specific behaviours involved in CSA may vary, abuse situations commonly elicit fear in the victim by the perpetrator, whether psychologically through verbal threats, or less often, by physical force, to coerce the vulnerable victim into sexual acts.

Profound, long-term effects may result from such abuse.[7] Several authors link the effects to symptoms of post-traumatic stress disorder, the abuse being the source of the traumatic stress. Women may experience one or more symptoms including: hyper-arousal, flashbacks, insomnia, nightmares, and anger control problems. Some survivors describe intricate sleeping rituals with unusual sleep patterns and feelings of fear, anxiety, feeling dissociated from one's body, nausea, and shame. Often symptoms developed as coping strategies that helped the patient survive the abusive situation, but may have become maladaptive.

Relationship or interpersonal problems may be reflected in sexual dysfunction, difficulty with intimacy, parenting problems, or social isolation. Survivors have had repeated violations of their physical and emotional boundaries and often encounter "boundary confusion", reflected in inappropriate closeness and familiarity, or as perpetual avoidance of any closeness. Concerns of trust and safety are especially sensitive for CSA survivors, who fear losing control.

Some CSA survivors experience depression, low self-esteem and panic attacks. There may also be patterns of self-abuse, such as alcohol or drug abuse, eating disorders, and self-injuries, suicidal gestures or attempts, personality and disassociative disorders.

Ranjan Roy's excellent study of the complex relationship between childhood abuse (including CSA) and chronic pain examines the literature on short term and long term health consequences of childhood abuse and the limitations of the research.[8] He argues that practitioners need to recognize the relevance of childhood abuse to pain complaints, such as chronic pelvic pain and gastrointestinal disorders. "Somatic complaints without organic cause" are also frequently cited in women with a history of CSA. Common somatic (body) complaints include chronic pelvic pain, chronic headache, abdominal pain, and gastro-intestinal complaints. Chest pain, throat pain, respiratory symptoms, musculoskeletal, and neurological symptoms are also cited, but less frequently, by CSA survivors. Several studies have revealed the association between a history of CSA and multiple somatic complaints.

Kendall-Tackett and Marshall studied the association between diabetes and abuse history (sexual or physical abuse) after noting higher rates of health problems in adult survivors of abuse than in the general population. [9]The link between diabetes and CSA survivors was chosen because chronic stress, which is a component of abuse, can lead to an elevation in blood levels of triglycerides, free fatty acids, cholesterol, glucose and insulin. Their study revealed that patients with abuse histories were significantly more likely to have diabetes than their non-abused counterparts. Further research needs to be done in these areas.

Survivors of CSA describe how invasive tests or procedures may lead memories or unresolved anxieties to re-surface. For example, Pap smear tests, use of vaginal probes in ultrasound examinations, touching and compressing the breast in mammograms, or dental care can evoke feelings of powerlessness and depersonalization reminiscent of previous abuse. One sonographer we interviewed identified possible signs of past sexual abuse:

"Body language and how they react to the way you touch them, how they pull away, how they look away, sheets clenched up to their neck, the legs not spreading open. I don't know if they feel bad, they feel dirty, I'm not sure what's going through their mind when they don't want to do that... how they look at you, how they don't look at you, how they are very evasive on answers. I think those are a lot of the key - and you have to learn to read people's reactions..."

Reactions such as these may puzzle and frustrate care providers who are unaware of the causes of such fears and intent on getting the job done. Patients may be blamed or labelled "uncooperative", adding to victimization. Feelings of anxiety and fear -- and the lack of understanding from care providers -- may lead some women to avoid needed tests and preventive care.  

CSA and Menopausal changes

Midlife women with a CSA history, like other menopausal women, may experience a variety of symptoms and complaints, some of which are directly attributable to the hormonal changes of menopause, while causes of other symptoms may be less clear. We don't know whether survivors perceive the normal changes of menopause differently from women without a history of CSA or whether hormonal changes and the process of aging may trigger or exacerbate other symptoms or conditions associated with a history of abuse.

We do know that all aspects of the physical self may be affected by CSA. Sue Blume poignantly wrote that many women with a history of CSA are "at war with their bodies", a description much like the way many women without such a history say they feel about peri-menopausal changes.[10] Negative attitudes about their bodies resulting from CSA (e.g., shame, disgust) and feelings of powerlessness, sexual victimization, violation, and secrecy often result in a woman feeling disconnected or dissociated from her body. Heavy bleeding and other changes in menstrual patterns, hot flashes, and issues of sexuality and perceived body image may be difficult to cope with. Some women survivors may have avoided pregnancy or parenting due to concerns about their own abilities to parent and menopause may be the first time that hormonal changes force them to seek medical care. We can surmise that some CSA survivors are challenged -- more so than other women -- to see their bodies positively, as "normal", and healthy during menopause.

Midlife women often find themselves facing invasive exams (eg. Pap tests and vaginal ultrasounds, mammograms, colonoscopies and rectal exams) for screening or diagnosis of diseases or conditions associated with advancing age. As noted earlier, these experiences may be particularly unsettling for CSA survivors. Another sonographer we interviewed described a midlife woman's disclosure:

"One lady… the doctor had palpated a mass and there was a history of cancer in her family so there was a strong concern for ... ovarian cancer. So he really wanted the internal done and she was one of the ones that was climbing off the back of the table - and I said, 'I really want to do this scan to see what's wrong because the doctor has some really strong suspicions and you have a really strong history. Could you help me? What can I do to make you more comfortable? What can I do to make it easier for you? Do you want to touch the probe yourself while I'm scanning?'... She says, 'You know what? I've been married 25 years, I have three children, I haven't had sex with my husband for 20 years because I can't stand it anymore because my dad used to rape me constantly.' … So yes, she just told me all these things. I said, 'I understand.' And she put her hand on the probe and I said, 'I promise I'll go as fast as I can.' and she sort of laughed and she said 'Okay.' … it was a good thing we did it because there was a suspicious mass, she ended up having surgery and it was removed...She even came back later and thanked me..."

Many women undergo hysterectomy and surgical menopause in the perimenopausal years, experiences which may prove traumatic for women with a CSA history. As Ruth Wukasch notes a hysterectomy might generate memories associated with past abuse.

"...The parallels between a hysterectomy and abusive experience could stir up unresolved feelings from a prior sexual assault; incestual sexual contact is often achieved without force and often there are no outward signs of physical abuse, creating psychic pain and dark secrets. Women with long repressed memories of an abusive experience might have a poor surgical adjustment that includes episodes of depression, panic attacks and or multiple physical complaints. Such problems might be blamed on the surgery alone, especially if the woman has never disclosed the history of CSA to the physician or resolved it with counselling.....The experience from this study indicates women need to be asked specifically about a history of negative sexual experience because information this sensitive is rarely volunteered."[11]

Midlife is also a time of personal reassessment and changing relationships. Partners retire or separate, children leave home, parents become dependent or die. In addition to the physiological/hormonal changes of menopause, unresolved issues and memories may emerge without warning.[12]

Not all women with a history of childhood sexual abuse will experience unusual difficulties during menopause. Counselling or therapy has helped many women come to terms with their past and acknowledge the strengths of being a survivor. However, it is the responsibility of the care provider to be aware of possible long-term effects and alert to signs of distress which women may show.  

Are we opening 'Pandora's box'?

Some care providers fear that asking about past abuse might open a "Pandora's Box" or "can of worms" which they have neither the time nor skills to address. They worry that patients may feel distressed or offended by such questioning or that it is inappropriate in some medical situations, such as when a patient is seen once. In addition to lacking education about CSA, practitioners we spoke with identified other obstacles to disclosure, including lack of privacy in health care settings, lack of time and limited resources for referral.

The general consensus among practitioners and patients, however, is that some form of routine screening for CSA is appropriate and necessary. Evidence shows that failing to ask empowers the abuse situation, contributes to feelings of isolation and conveys the impression that it is irrelevant to current issues or symptoms. [13] As one woman commented, "If your doctor is afraid to talk about it [sexual abuse] then what are you going to feel?"

Researchers suggest that sensitive questions be asked when the patient is fully dressed and sitting, and recommend a task-oriented question such as, "Is there anything about your past experiences that makes this exam particularly difficult for you?" with a follow-up question such as " What can I do to make it easier for you?" This gives the patient control over whether they wish to disclose further details and/or offer practical suggestions to ease their care.

How deeply issues of CSA are explored and addressed depends on the nature of the practitioner's scope of practice. Open-ended questions may be appropriate for nurse practitioners or physicians trying to treat a 50-year-old woman experiencing chronic pelvic pain or gastrointestinal problems with no other determined causes. Understanding how a childhood trauma might affect a woman in midlife may be crucial to accurately diagnosing and treating somatic and psychosomatic complaints. They are in a position to build rapport and trust, laying a basis for disclosure and willingness to engage in appropriate treatment, including counselling.

Mammographers, sonographers and others who perform diagnostic tests and screening, however, usually see a patient only once, and have almost no information beyond what is on a requisition form. As our interviews indicated, they regularly encounter patients with severe anxieties which make it difficult to secure an accurate mammogram or ultrasound. Their challenge is to make the patient feel more relaxed in a short period of time.

Dentists and dental hygienists may see patients regularly or irregularly, with some potential to develop rapport and trust. Yet, oral care is not structured to encourage much discussion between patient and practitioner. The work dentists and hygienists perform is invasive, and for patients who may have experienced oral sexual abuse, preventative or restorative dentistry may create acute anxiety.

Patients highly anxious about invasive tests or procedures benefit from health care providers who acknowledge anxieties and seek ways to make examinations more comfortable. Based on survivors' recommendations, this can be done by increasing the patient's sense of control during exams where touch is required, particularly where a woman feels especially vulnerable. Clinicians are asked to have a respectful, calm, accepting approach, to listen carefully, be sensitive to individual needs, offer choices wherever possible, respect privacy and examine gently, asking permission before touching. Careful and thorough explanations of procedures, warning about pain, encouraging questions, and confirming that the patient can stop the procedure at any time, has been shown to improve experiences of survivors with the health care system. It may help empower women to assert themselves in other areas of their lives and regain some sense of control about what happens to their bodies.[14]

Rather than a 'Pandora's Box', asking questions may lead to new insights for patient and practitioner, and hopefully, appropriate treatment. All patients -- including those without a history of CSA -- have fears and anxieties and will benefit from sensitive clinical practices.  

Some practical suggestions

There is an urgent need for health care providers to be educated about issues related to childhood sexual abuse, in ways appropriate to their practice. This can be done through curriculum development, continuing education programs, development of practice guidelines, informal education, and establishing referral networks. Having childhood sexual abuse survivors involved in these initiatives was suggested as a way to provide powerful, collaborative learning opportunities.

Addressing survivors' needs presupposes an environment in which women feel safe to speak about their past. This requires some flexibility in appointment time, staffing and in how medical settings are structured. Currently, most medical environments are intimidating, rather than accommodating to patients. Women with disabilities, a large proportion of whom have CSA histories, and immigrant and refugee women who may be fearful to speak about their past, encounter particular obstacles in accessing services. Private space for taking histories or for invasive tests should be accommodated in the design and structure of health services. Small changes (cartoons, artwork, music, appropriate health information) can help ensure that an environment feels safe and welcoming. In a time of corporate pressures on health services, even small patient-centered changes are hard won.

There is also a crucial need for research that will help women and care providers understand the possible impacts a CSA history may have on a woman's experiences of menopause and midlife. Do menopausal changes and midlife transitions heighten certain somatic complaints, feelings and emotions rooted in past traumas? Does a CSA history affect the progression of other conditions of aging? Might remembrance of past traumas also lead ultimately to positive re-assessments and new insights about oneself and others? Mid-life is a time for taking stock of one's life, venturing into new activities and relationships, taking risks. A woman with a CSA history may, at such a time, begin a process of reflection (or re-reflection) which others can support.

Alternately, health practitioners and women survivors must not assume a CSA history is the dominant factor in the complex changes associated with menopause. More likely, its significance is subtly woven into the fabric of a woman's life and may emerge in unexpected ways, or at times, not at all. Long hidden from view, CSA and its implications must be acknowledged within diagnosis and therapy, so it does not receive too much or not enough attention.

Sari Tudiver is Associate Editor of A FRIEND INDEED; Lynn McClure is a nurse practitioner in Winnipeg; Tuula Heinonen is Assoc. Prof., Faculty of Social Work, University of Manitoba; Christine Kreklewitz is a Ph.D. candidate in the Dept of Sociology, University of Manitoba; Carol Scurfield is a family physician at the Women's Health Clinic in Winnipeg.

Thanks to Lore Calimente, M.Nsg, for help with the literature review and to the Prairie Women's Health Centre of Excellence for funding the research on which this article is based.

 

ENDNOTES

1. Finkelhor D et al.. Sexual abuse in a national survey of adult men and women: Prevalence, characteristics, and risk factors. Child Abuse and Neglect 1990; (14): 19-28; Roberts S. . The sequelae of childhood sexual abuse: A primary care focus for adult female survivors. The Nurse Practitioner 1996; 21(12): 42-52. back

2. Women consistently show a higher prevalence of CSA than men, but the consequences for both sexes are profound and require more attention and research. back

3. Courtois C., Riley C. Pregnancy and childbirth as triggers for abuse memories: Implications for care. BIRTH 1992; 19(4): 222-223; Kreklewitz C. Parenting themes for incest survivor mothers and daughters. 1995 Unpub. M.A. thesis, Univ. of Manitoba. back

4. Heinonen T, Merrett-Hiley A et al. Perception and utilization of health care services by women survivors of childhood sexual abuse: A preliminary study. Report of research for the Manitoba Research Centre on Family Violence and Violence Against Women, University of Manitoba. 1997. back

5. Tudiver S, McClure L et al. Education and preparation of health care providers for meeting the needs of women survivors of childhood sexual abuse. Prairie Women's Health Centre of Excellence.Winnipeg, Manitoba. 2000. back

6. Holz K. A practical approach to clients who are survivors of childhood sexual abuse. Journal of Nurse-Midwifery 1994; (39)1: 13-18. back

7. An extensive bibliography is available from the authors. See for example, Bala M. Caring for adult survivors of child sexual abuse. Canadian Family Physician 1994; 40: 925-931. back

8. Roy R. Childhood abuse and chronic pain: A curious relationship? University of Toronto Press: Toronto1998.back

9. Kendall-Tackett, K. & Marshall, R.. Victimization and diabetes: An exploratory study. Child Abuse and Neglect 1999; (23)6: 593-596. back

10. Blume ES. Secret survivors: Uncovering incest and its after-effects in women. Ballantine Books, New York; 1990. back

11. Wukasch R. The Impact of a history of rape and incest on the post hysterectomy experience. Hlth Care for Women Internl1996; (17): 53-54. back

12. Courtois C. CSA potential for disruptive and destructive consequences in many aspects of the victim's life. Family Violence and Abusive Relationships, 0095-4543/93: 436. back

13. Seng J., Petersen B. Incorporating routine screening for history of childhood sexual abuse into well-woman and maternity care. Jrnl of Nurse-Midwifery1995; (40)1: 26-30. back

14. Friedman L. et al. Inquiry about victimization experiences: A survey of patient preferences and physician practices. Arch Int Med 1992; 152:1186-1190; Teram E. et al. Opening the doors to disclosure: Childhood sexual abuse survivors reflect on telling physical therapists about their trauma. Physiotherapy 1999; 85 (2): 88-97. back