Patient Safety / Quality

Long-term health outcomes of childhood sexual abuse

Psychological consequences of trauma were first seen in veterans of war and described in the literature as shell shock. By 1980, the diagnosis of post-traumatic stress disorder (PTSD) was listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM), which guides healthcare practitioners with diagnosis, treatment, and reimbursement. For years we have been studying the psychological changes that are the sequelae of childhood trauma. These long-term consequences include a higher incidence of depression, intrusive flashback memories, hypervigilance, maladaptive coping skills, dysfunctional social skills, and an overactive stress response. Research examining the more holistic effect of trauma has exploded due to recent events, such as 9/11, terrorism, and traumatized troops returning from war.

As holistic nurses, we understand that even when the effect seems to be psychological, social or biology is also influenced. The mind and body interact on every level. The ripple effect of early childhood trauma has more than psychological effects. Biology of the brain and immune function are influenced. The child is forever changed. Here we examine the influence of childhood sexual abuse on the long-term health and the nursing care of adult survivors.

Stress

Walter Cannon first described the fight-or-flight response in 1914 as the complex physiological response that prepares the body for fighting or fleeing. The sympathetic nervous system responds to a stressor, suppressing the calming effects of the parasympathetic system. The hypothalamus in the brain secretes hormones that in turn influence the kidneys and the brain. The cascade of chemicals has a ripple effect on many systems, including the respiratory, gastric, cardiovascular, endocrine, renal, and immune. A major part of the brain/hormone/immune interaction, the hypothalamic-pituitary-adrenal axis, becomes involved and further influences physical and psychological functioning.

Adrenocorticotropic hormone is released from the brain and anti-inflammatory steroids such as cortisol suppress the immune system. Ability for healing and even normal cell maintenance is reduced. With altered immune cell levels, the body has increased inflammation, susceptibility to infection, allergic response, and cell mutation. Natural killer cells, for example, whose job it is to correct the cell mutation of cancer, diminish in number. The effect is cumulative: The longer the stress is perceived, the greater the severity of imbalance.

Early trauma changes the brain

When trauma and stress happen early in life, the effects are far more profound and long-lasting. Biological brain development is influenced by genetics, nutrition, social interaction, and experiences. Almost no new brain neurons are formed after birth. There is, instead, a constant rewiring of the existing neurons. New connections are made and old connections are disconnected. This understanding of the plasticity of the brain is what drives rehabilitation after a stroke.

Trauma and early negative experiences affect the development and even structure of the brain. Women who were sexually abused as children show significantly diminished brain volume on brain scans. The structure and function of the hippocampus (responsible for learning and memory), for example, are different when compared to individuals who weren’t traumatized. The medial prefrontal cortex, amygdala, and other neural circuitry of the brain are also changed. The brain shows a sustained and pervasive stress response as the child grows, and this has a long-term effect on immune function. Brain wave patterns change. The brain’s response to inflammation and healing is altered. Neurotransmitter levels adapt to these new abnormal levels. The biological changes in the brain are even more profound if the abuse was early, pervasive, or severe.


Long-term health issues for survivors of childhood sexual abuse

The range of potential adverse health outcomes is extensive and childhood sexual abuse can be seen as a risk factor for many diseases. Those who experienced childhood sexual abuse are one and a half times more likely to report serious health problems.

The figure below shows common long-term sequelae of childhood sexual abuse. Because of the holistic nature, it’s difficult to categorize the conditions into traditional systems or paradigms.

Childhood Sexual Abuse

(Click to download PDF)

Used with permission from Perspectives in Psychiatric Care.

Psychological issues for this population often include anxiety, poor self-esteem, dysfunctional relationships, eating disorders, and PTSD. PTSD results from a threat to self or others accompanied by “intense fear, horror, or helplessness,” according to the Veteran’s Administration National Center for PTSD. Maladaptive coping such as denial is overused. Those with a history of childhood sexual abuse have increased reports of fear, anxiety, insomnia, headaches, aggression, anger, hostility, poor self-esteem, and suicide attempts. Higher rates of depression are reported. Depression has also been shown to be associated with impaired immune functioning. Increased cytokines (inflammation) and cortisol (stress) have been identified as mechanisms by which immune system function is impaired and related to depression. Incidences of dysfunctional relationships, intimate partner violence, and self-destructive behavior are higher.

Higher rates of some physical diseases, such as sexually transmitted diseases, hepatitis, or pelvic inflammatory disease, can be attributed to the common behavioral issues for this population that include promiscuity, substance abuse, and/or sexual dysfunction. But for those traumatized early in life, there exists a clear and increased risk of lung disease, ulcers, cardiac disease, diabetes, and cardiac disorders. The high incidence of inflammatory disorders, such as rheumatoid arthritis and allergies, is an example of the imbalanced immune system’s overreaction. Prolonged stress and exposure to cortisol, for instance, cause wounds to heal slowly, indicating an underreacting immune system.

Autoimmune disease

The role of childhood sexual abuse in the development of autoimmune disease is worthy of special attention. Trauma in early childhood predisposes the individual to autoimmune diseases in later life. Some of the strongest evidence linking autoimmune disease to childhood trauma is a retrospective study of over 15,000 adults who were enrolled in the Adverse Childhood Experiences study. Autoimmune disease processes commonly seen in this population are fibromyalgia, Crohn’s disease, irritable bowel syndrome, type 1 diabetes, and rheumatoid arthritis. Patients with a history of childhood sexual abuse may develop fibromyalgia and use outpatient health services and analgesics more frequently. Adult survivors of childhood sexual abuse also report increased pain associated with other medical conditions. Cardiovascular diseases, such as arteriosclerosis and ischemic heart disease, are directly related to maladaptive immune function and inflammation and occur in higher rates in adult survivors of childhood sexual abuse. It’s important to remember that any of these disease processes can occur in people who weren’t sexually abused as children.

Healing is possible

Healing from childhood sexual abuse is possible at any point in life. Nurses should be familiar with local providers for counseling, stress-management training, and holistic care of these survivors. Nurses should take an active role in advocating for the client in the referral process when the history of childhood sexual abuse is identified. The human cost of healing survivors of childhood sexual abuse is still far greater than the cost of preventing childhood sexual abuse from occurring in the first place. Being sexually abused as a child has a lifelong impact on health. Once again we are reminded that an awareness of the holistic perspective is vital for competent nursing care of victims of childhood sexual abuse.

Now that you have read the article, see how you would handle these example scenarios. There is no one right answer.

Scenario #1 Mrs. B. Raider is a 60-year-old menopausal client who presents at her physician’s office following a stressful event of being laid off from her job. When reviewing her record, the nurse notices that this is Mrs. Raider’s 10th visit to the clinic in the last year. She notes a history of back pain, migraine headaches, depression with use of selective serotonin reuptake inhibitors, irritable bowel syndrome, alcoholism, and fibromyalgia. Mrs. Raider has difficulty making eye contact when asked why she is here today, and states that she has been having persistent pelvic pain. She says she is unmarried, not sexually active, and divorced less than a year.What clues about her history might indicate sexual abuse? What support groups, stress-management training, or nursing interventions may be helpful? Note: To answer the first question, refer to the Childhood Sexual Abuse figure earlier in this article.
Scenario #2 Miss Clarissa Kent is an 18-year-old homeless, obese woman who presents at an urban free clinic with complaints of malodorous vaginal discharge, fever, and pelvic pain for the last 48 hours. She has no contact information, is unaccompanied, and reports a history of I.V. drug abuse. She states she fears she might be HIV-positive. When the nurse inquires about her work-related status, the young woman explains that she recently chose to work for a local escort service to support her drug habit and pay the bills. She reports a long history of poor health and bulimia since she began middle school. She admits to attempting suicide in the past; following the event, she dropped out of school and ran away from home. She says she did this primarily because of the way she was being “treated” by her alcoholic stepfather for most of her life. After sharing this she looks away and states she doesn’t want to talk about it, and asks to see the physician.What might you say to make her more comfortable continuing her story? What resources exist in your community to help this young woman? What might you say and do if she disclosed a history of sexual abuse?
Scenario #3 Mr. Howell accompanies his wife Rebecca to labor and delivery for the birth of their first baby. The nurse notices that Mr. Howell is very protective of his wife, and that his wife isn’t answering many of the questions that are being asked. Rebecca allows her husband to speak on her behalf and is resistant to changing into the hospital gown or letting the nurse put on the fetal monitors. She seems to become tense and pulls away when light touch is used to help her with relaxation. When the nurse tries to explain the need to do a vaginal exam to check the progress of cervical dilation and effacement, the couple admits that they don’t understand what she is referring to and add that they only established prenatal care about a month ago. They haven’t attended any prenatal classes. When the nurse attempts a vaginal exam, Rebecca is unwilling to adequately open her legs or relax her perineum sufficiently. The nurse explains that the female provider Mrs. Howell has seen for the past month isn’t on call and that a male provider will instead attend their birth. Rebecca begins to suddenly sob uncontrollably, as Mr. Howell becomes angry and defensive towards the nurse. What changes and accommodations could the nurse have made that would have been more sensitive to the needs of Rebecca Howell. What behaviors and symptoms might indicate a possible history of sexual abuse?

 

Selected references

Bremner JD. Effects of traumatic stress on brain structure and function: relevance to early responses to trauma. J Trauma Dissociation. 2005;6(2):51-68. doi:10.1300/J229v06n02_06.

Dube SR, Fairweather D, Pearson WS, Felitti VJ, Anda RF, Croft JB. Cumulative childhood stress and autoimmune diseases in adults. Psychosom Med. 2009:71(2):243-250. doi: 10.1097/PSY.0b013e3181907888.

Goodwin RD, Stein MB. Association between childhood trauma and physical disorders among adults in the United States. Psychol Med 2004;34:509–520.

Sachs-Ericsson N, Blazer D, Plant EA, Arnow B. Childhood sexual and physical abuse and the 1-year prevalence of medical problems in the National Comorbidity Survey. Health Psychol. 2005;24(1):32-40.

U.S. Department of Veterans Affairs. (2011). National Center for PTSD. http://www.ptsd.va.gov/professional/pages/forensic-validity-ptsd.asp. Accessed September 20, 2012.

Wilson DR. Health Consequences of childhood sexual abuse. Perspect Psychiatr Care. 2010;46(1):56-64. doi: 10.1177/0123456789123456.

Wilson DR, Warise L. Cytokines and their role in depression. Perspect Psychiatr Care. 2008;44(4):285-289. doi: 10.1111/j.1744-6163.2008.00188.x.

 

Debra Rose Wilson is a professor at Walden University in Minneapolis, Minnesota, and Middle Tennessee State University in Murfreesboro, Tennessee. Mariesa R. Severson is assistant professor at Middle Tennessee State University School of Nursing.

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9 thoughts on “Long-term health outcomes of childhood sexual abuse”

  1. donna says:

    This article is so true.I have fibromyalgia, depression, diabetes, heart disease, insomnia, anxiety,and an unexpressed feeling of constant rage. I was abused as a child from age 5 to age 14. One of my two sisters suffered the same fate before my family moved to another state. We share the same health problems. Reading this article made me want to cry and scream “Not fair”. We shouldn’t have to continue to suffer for what someone else did to us all those years ago. I plan to see a counselor now.

  2. Anonymous says:

    Donna, my heart goes out to you. I am so glad you are seeking help. Cindy

  3. x now but still cares says:

    Boy did this article hit home and it is right on the money. I never knew my x husb was abused until during our divorce process. The last 6 yrs his anxiety skyrocketed, and major depression kicked in, many gasto problems, compulsiveness, reckless, addictive behavior, mixing of many meds, and a lot of rage. Finally culminated in an affair which caused too much damage to the marriage. He was/is never content. Only found out recently about his severe sexual abuse as a child lasting at least a year.

  4. Anonymous says:

    Thank you for this it puts into perspective and understanding of what I’ve gone through for many many years! Thus far the only relief I have found is to self medicate; not so good but to have some sense of normal this is what I do.
    I would prefer finding other methods but do not know where to start.

  5. Debra Rose says:

    Start with what feels right. Therapy? Take stress management classes. Learn self care. Take a class in writing or journaling. If you are a natural writer, start writing it all down. Perhaps some group work for adult survivors? There is support out there in major cities and some nuggets of support in smaller communities too. Choose to change your approach and decide to make progress towards feeling whole again. Take along some peace and love for your healing journey that I send. Breathe

  6. Cin912 says:

    Healing IS possible-don’t let your mind convince you otherwise. Listen to your Heart!

    Thank you, Debra Rose and Mariesa, for a tremendous article! ?

    I experienced CSA and wound up with PTSD and a dissociative order when they manifested 15 years ago (at age 37) after memories surfaced. Therapy, time, and my spiritual practices have helped me thrive. But I am absolutely convinced in CSA’s permanent biological impacts. I now have an autoimmune disease and Fibromyalgia. NOT a coincidence-

  7. Bruisedbutnotbroken says:

    Thank you so much! For years I have struggled and still struggling with the emotions attached to my childhood and multiple forms of abuse I suffered. I have gone so many years just not thinking. About it. I was molested the first time by my fathers half bother at 5 years old. I have so many feelings of shame ,fear anxiety. And I know why I found this article after googling long term effects of child molestation just looking for a clue as to why I am always feeling fear and anxiety jus

  8. Anonymous says:

    I am a survivor of long-term sexual abuse who became a psychotherapist in the long process of learning and healing which continues ever onward. I believe strongly in the power of our own expression of our truth to heal our body-mind-spirit, and scientific research confirms this is so. In recent months, I have taken time out from my private practice and have written every week with an Amherst Method writing group for 1 weekly two-hour session. As the research of James Pennebaker has shown, this has been powerfully effective. My chronic joint pain and all the symptoms associated with my long-term thyroid disorder have disappeared.

    Find a safe place to write with others, a place where you can read out loud or choose to “pass” until you feel ready. When our body-mind can express its pain and shame and truth directly, our bodies can stop having to do all the work (indirectly) for us.

    May we all heal and help others to learn along with us. We have within us what we need to become well. Buried within, we have the capacity to live fully as whole and joyful beings. Let’s help each other do it!

  9. michael says:

    For 2 years now I’ve had progressively worse erectile dysfunction, pain and associated rectal and pelvic pain..much deterioration. .without doctors knowing cause. .I was horribly abused and tortured as an infant and child. by a parent who was clinically psychotic and I even used to black out as an adult. I overcame so much of the abuse several years ago..but now with these new symptoms that will not heal I believe strongly I am reexperiencing the sexual abuse. .as a man it is very humiliating. Best of luck to all…prayer does help

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