Alessandra H Rellini
A review of 38 studies reported that across methodologies, samples, and measures, child sexual abuse is a risk factor for adult sexual function.1 Comparably, sexual abuse that occurs during adulthood has also been found to affect significantly sexual function.2 Considering that 90 000 children have been reported as having experienced sexual abuse in 2002,3 and that 17.6% of women are at risk of adult sexual abuse,4 an alarmingly large proportion of women is at risk of sexual dysfunctions associated with sexual abuse. This chapter provides a review of the association between sexual dysfunction and sexual abuse, followed by a summary of the direct and indirect effects of sexual abuse on sexual function.
Types of sexual concerns
Although the majority of women show a spontaneous remission within the first 4 years after an assault,5 a large percentage of women continue to report concerns. The prevalence of the sexual dysfunction is highly influenced by the type of sample recruited. While most studies on college students6,7 report no differences in sexual function between abused and control women, clinical studies5,8 are usually at the opposite spectrum and report great differences. Studies conducted on community volunteers9 and random community samples10,11 also tend to show a greater incidence of sexual dysfunctions in sexual abuse survivors than in nonabused women.
Low sexual desire is the sexual concern most commonly reported by women survivors of sexual abuse, followed by decreased sexual arousal, decreased orgasm, decreased satisfaction, and sexual avoidance.8,12-14 Desire is significantly lower in both survivors of adult and child sexual abuse than in women who never experienced sexual abuse.9 Concerns with sexual arousal may be linked to a negative interpretation of physiologic cues typical of the sexual arousal response (e.g., increased heart rate, lubrication). That is, women with a history of sexual abuse may associate cues of the sexual arousal response (i.e., lubrication) with those automatic physiologic responses experienced during the original abuse. Indeed, women with a history of child sexual abuse have reported greater negative affect during increased physiologic sexual arousal induced by sildenafil than controls.15 Additionally, women with a history of child sexual abuse have reported a lack of feelings during sexual activities with their partners, even in the presence of orgasm.16 Orgasm disorders are more common in sexual abuse survivors who experienced both child and adult sexual abuse than in survivors of only child or only adult sexual abuse.14 Researchers have hypothesized that child sexual abuse survivors may have learned at a very young age how to please their partners, but lack experience on how to please their own bodies.17 Sexual satisfaction is often lower in women with a history of child or adult sexual abuse than in controls.18-21 Similarly, the concept of sexual pleasure differs between women with a history of sexual abuse and controls. For example, teenagers with a history of child sexual abuse are more likely to distinguish between physical and mental experiences in their narratives of sexual pleasure than nonabused controls.22 This finding is supported by clinical observations of a separation between body and mind often reported by women with a history of sexual abuse.
In addition to sexual function, sexual risk-taking behaviors are also more common among survivors of child sexual abuse than in women who never experienced sexual abuse. For example, women with a history of child sexual abuse reported more partners and sexual encounters,23 lower condom efficacy,24 and less ability to refuse unwanted sex than controls.25
Sexual concerns are generally associated with guilt, fear of losing control, humiliation,26 sexual self-esteem,27 and perception of severity.28 Post-abuse variables associated with sexual dysfunctions include avoidance of sexual behaviors29,30 and partner’s sexual dysfunction.30 Characteristics of sexual abuse known to affect sexual functioning are penetration or genital fondling during the abuse,31 number of events,7,28 parental incest,28 age,32 and presence of violence at the time of the abuse.33 However, a variable not found to affect sexuality negatively is the level of dysfunction within the survivor’s original family unit.27
The lack of a model specifically developed to explain sexual dysfunction in survivors of sexual abuse can be easily overcome by adapting the trauma model developed by J. Herman.34 This model is particularly useful because it addresses the relation between the self and others as an extension of the original abuse, paralleling the relational nature of female sexuality. Although developed for survivors of child sexual abuse, this model has been extensively used to explain adult sexual abuse. To briefly summarize, survivors of child sexual abuse have to reconcile the perturbing reality that the caregiver is also the cause of their pain and fear. The child often solves the tension between the need to trust the caregiver and the need for selfprotection by assuming responsibility for the pain. The survivor may believe her behavior elicited the sexual abuse. In contrast, she may feel love, attachment, and idealization toward the perpetrator. As previously reviewed, problems with sexual desire have been associated with feeling guilty for provoking the perpetrator’s sexual attention.32 Albeit counterintuitive, this gives the child an apparent sense of control over the situation, but at the expense of low self-worth, reduced trust of others, and inflated feelings of guilt and shame. Although survivors of child and adult sexual abuse are usually able to escape the abusive situation, they often bear a damaged view of the self, as well as a number of psychologic symptoms. Herman emphasizes four key feelings common in survivors of sexual abuse: guilt, lack of safety (difficulty in trusting), disconnection from one’s needs, and a view of the self as unworthy. Accordingly, consequences of sexual abuse can be subdivided into consequences related to the self (intrapersonal functioning) and consequences affecting relationships (interpersonal functioning).
Intrapersonal functioning is one of the most studied aftermaths of sexual abuse and can be further divided into (1) psychologic and psychiatric health, including alcohol/drug abuse and body image, (2) physical health, and (3) cognitive schemas.
Psychologic consequences of trauma
The most common psychologic consequences of sexual abuse are depression, post-traumatic stress disorder (PTSD), dissociation, eating disorders, alcohol/drug abuse, and body dissatisfaction. A study identified depression as the moderator of the relationship between sexual abuse and sexual dysfunction.20 In both studies, the difference in sexual arousal, orgasm, and desire between women with and without a history of child sexual abuse disappeared after controlling for depression. The sense of worthlessness and negative view of the world, both characteristic of depression, may affect the woman’s view of herself as a sexual being. In particular, feeling responsible for the sexual abuse may strengthen a relationship between sexual pleasure and guilt or shame. In fact, child sexual abuse and a less positive sexual schema were found to be closely connected to sexual pain disorders, suggesting that child sexual abuse affects women’s view of their sexual self.35
PTSD, characterized by symptoms of unwanted memories, avoidant behavior, and hyperarousability, has a high comorbidity with sexual abuse. Unwanted memories appear in the form of visual memories (flashbacks or intrusive memories), as well as bodily (fight or flight reaction) and emotional memories (strong feelings of fear or anxiety). Survivors of adult sexual abuse frequently report flashbacks during sexual activities in the first 4 months after the abuse.5 Survivors are often unaware of the triggers that evoke these memories. Empirically validated therapies, such as guided exposure, have been developed to help them assimilate their experiences.36 The goal of guided exposure is to reduce the association between traumatic memories and the fight-or-flight reaction. This is accomplished by guiding the survivor through a detailed recall of the abuse, during which she is encouraged to focus on the details of the memories and the emotions she experienced.36
PTSD has been shown to moderate the relationship between sexual dysfunction and sexual abuse.37,38 In particular, PTSD predicted variance in sexual functioning in sexual abuse survivors even after accounting for other psychologic dysfunctions, characteristics of the abuse, and time elapsed since the abuse.37 In addition, biologic changes specific to PTSD (i.e., increased sympathetic nervous system activity) may play a role in the relationship between physiologic sexual arousal and child sexual abuse. Specifically, increased sympathetic nervous system activity induced by exercise was found to enhance physiologic sexual arousal in healthy controls but had no effect on the physiologic sexual response of women with an impaired hypothalamus-pituitary-adrenal axis.38 Finally, sexual abuse survivors with PTSD reported higher levels of negative affect associated with sexual arousal than controls.33,39 Sexual response can be interpreted by Herman’s model as a sign of the responsibility for having invited the sexual abuse.
Dissociation, a symptom often observed in survivors of severe child sexual abuse, is interpreted in Herman’s model as a method originally used by the child to distance herself from the abuse. This form of self-defense can later become a problem if the survivor continues to use it as a primary coping mechanism. Sex therapists who treat dissociative clients emphasize the importance of using “grounding” techniques to prevent dissociation during sexual encounters.40
Although bulimia is one of the common behavioral consequences of trauma, little is known of its effect on sexual functioning (see review by Wiederman41). Given that women with bulimia are reported to have lower sexual self-esteem than controls,42 bulimics may focus on pleasing their partners more than themselves during sex and this may have a negative impact on their ability to become aroused.43 Unfortunately, the lack of studies on the relationship between sexual functioning, sexual abuse, and bulimia does not provide more than a tentative explanation of this complicated triad.
Alcohol/drug abuse or dependence is common among women with a history of sexual abuse. Sexual pain is the sexual concern most commonly reported by women with a history of child sexual abuse with alcohol/drug problems. Drugs are often used by child sexual abuse survivors during the sexual encounter to reduce negative emotions (i.e., anxiety, depression, reduced self-esteem) through increasing dissociation and emotional detachment.44 However, alcohol also inhibits genital sexual response,45 and this decreases lubrication and may cause more pain due to friction. An additional problem of alcohol is its tendency to make the survivor more prone to further abuse by decreasing her ability to assert her needs during the sexual encounter.
In addition to the link between psychiatric disorders and sexual functioning, the literature also provides evidence for an association between body esteem and sexual functioning in sexual abuse survivors. A variety of clinical observations of abuse survivors pointed to negative feelings toward their bodies, such as detachment, anger, and betrayal. To my knowledge, only one empirical study examined this relationship, and it supported the moderator role of body image in the relationship between adult sexual functioning and childhood sexual abuse.46
In addition to psychologic difficulties, sexual abuse survivors also reported more gynecologic and psychosomatic problems than women who never experienced sexual abuse. Gynecologic complaints were usually associated with lesions and scar tissue in the hymen, in the posterior forchette, and inside the vagina.47 Yeast infections and sexually transmitted diseases were also common among sexual abuse survivors. Despite the higher need for clinical attention, the fear of invasive gynecologic examination often deters the survivor from scheduling an appointment. This avoidant behavior may not only exacerbate anxiety associated with sex, but also have negative repercussions on any untreated health conditions. The psychosomatic complaints most frequently reported were stress related headaches, weight change, and back pain. Particular attention should be given to health profiles of survivors who develop PTSD, since this subgroup tend to experience more severe health problems than the normal population.
Adults with PTSD present with an overactive sympathetic nervous system in combination with a deficiency in cortisol levels,48 indicating an impairment in the negative feedback of the hypothalamus-pituitary-adrenal axis. In healthy individuals, these two systems are responsible for the reaction to stress and the subsequent return to homeostasis. Thus, for a patient with PTSD, the ability to adapt to stress may be impaired. To date, only one study has investigated the relationship between the overactivity of the sympathetic nervous system and sexual functioning in women with PTSD.38 Although the results supported the theory that the sexual response may be negatively affected by the overactive sympathetic nervous system, further studies need to replicate and expand upon these results.
The impact of sexual abuse is not restricted to the behavior and physical health of survivors, but it also infiltrates their self schemas.34 Self-schemas are the blueprints people use to organize information and make sense of the world. Trauma survivors often present an altered schema of the self and the world that keeps them in a state of continuous fear and avoidance. A study using explicit measures of sexual schemas asked women to complete questionnaires on their view of sexuality.35 Women with a history of sexual abuse reported less positive sexual schemas (romantic/passionate and open/direct) than nonabused controls.35 A study that employed implicit measures of self-schemas asked participants to divide sexual words and adjectives into categories. Women with no history of sexual abuse showed similar networks among themselves, while women with a history of child sexual abuse showed dissimilar networks.49 These results point to a disruption in the underlying process of sexual information in child sexual abuse survivors. Interestingly, sexual abuse survivors showed a variety of responses to the disruption caused by the sexual abuse rather than a set pattern. Further studies are needed to delineate the nuances of these networks so that they can be targeted during therapy.
Intrapersonal difficulties associated with sexual abuse are accompanied by interpersonal difficulties, or difficulties the survivor experiences within relationships. Relationships are very important in the quality of life and healing of the survivor. In fact, satisfaction with an intimate relationship prior to the sexual abuse has been found to protect against the development of sexual concerns.10 The main problems that plagued the relationships of sexual abuse survivors were difficulties with emotional communication, power and control imbalances, and issues with trust.30 Sexual communication appeared to be particularly problematic for couples with a history of child sexual abuse (referenced in Compton and Follette50). These problems may arise from relational deficits that often are at the base of survivors’ psychologic symptoms. The survivor may have difficulties expressing her sexual needs because she may not feel she has the right to pleasure and sexual attention. Moreover, intimate communication was found to predict sexual satisfaction in heterosexual couples,51 and therefore it is likely that the survivors’ communication problems may also affect sexual satisfaction.
The sexual problems observed in survivors of sexual abuse should be observed within the context of the relationship, as these dysfunctions may serve a specific function for the patient and her partner. For example, hypoactive sexual desire may be a way of controlling the power dynamic in the relationship. Given that sexual abuse survivors may be more sensitive to controls and power imbalances than women who never experienced sexual abuse, sex may become an effective way to limit the partner’s power in the relationship. Unfortunately, no published studies have investigated the use of sex as a form of control in couples where one partner is a sexual abuse survivor.
In summary, the literature presents evidence that women survivors of sexual abuse are more likely to develop sexual dysfunction than women who never experienced sexual abuse. Since sexuality is a complex bio-psycho-social phenomenon, it is important to take into consideration all aspects of the survivors’ lives when assessing or treating their sexual functioning. An accurate and comprehensive evaluation of the sexual dysfunction of survivors of sexual abuse should include questions addressing potential psychologic, cognitive, and medical functioning consequences of the abuse, as well as questions regarding intimacy and communication with the partner. This chapter points to numerous ways in which sexual abuse can affect sexual function. In particular, it brings to light the need for the development of treatments tailored to address individual differences in the history, meaning, and the impact of the abuse on the survivor’s life.
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