Introduction
Child sexual abuse is a form of child abuse in which a child is abused for the sexual gratification of an adult or older adolescent.
- There is physical, sexual or emotional abuse in childhood in all countries and social classes.
- Estimates of the prevalence of childhood sexual abuse among the general population varies from 7% to 38%.
- Among gynaecological patients rates are generally between 15% and 20%.
- Rates are highest among women with chronic pelvic pain and those who have had gynaecological surgery.
- Childhood sexual abuse may cause adult depression, somatisation or neurological changes.
- Gynaecologists should remember that childhood sexual abuse is common.
- Empathic questioning about the possibility should be routinely included. Failure to do so may lead to inappropriate treatment, including unnecessary surgery.
- Women distressed by childhood sexual abuse should be offered appropriate referral.
- Child abuse is a broad term that encompasses neglect as well as physical, sexual and emotional abuse.
- Childhood sexual abuse includes any exposure to sexual acts imposed upon children.
- It does not always involve penetration or physical force. Studies in at least 21 countries have confirmed that it is a worldwide problem, the prevalence in most being similar to that found in the USA (where most of the research on childhood sexual abuse has been carried out).
- In general, girls are 1.5–3.0 times more likely to be sexually abused than boys.9401
Prevalence
Estimates of the prevalence of childhood sexual abuse and molestation among females in the general population vary from 7% to 38%. Rates of up to 62% have been reported when abuse not involving contact is included (such as exhibitionism or obscene phone calls).
Although childhood sexual abuse occurs among all socio-economic groups, more severe forms are associated with lower socio-economic status. After the age of 10 years there is a sharp increase in vaginal intercourse, violent assaults and abuse by strangers. Fathers are often cited as the main perpetrators but other relatives may account for 20–70% of childhood sexual abuse occurring within the family.
Childhood sexual abuse was reported by 25% of women and 16% of men, and was strongly associated with adverse childhood experiences, such as neglect and other forms of abuse. There has been a decline in childhood sexual abuse in the past decade in the USA, and a study in Australia 0301 also found evidence of a decline.
Prevalence among gynaecological patients
In a Scandinavian study of 4729 women, 0302 the lifetime prevalence was 38–66% for physical abuse, 19–37% for emotional abuse and 17–33% for sexual abuse. Only 2–6% of women had discussed the abuse with their gynaecologist.
In a German study of 1157 women attending a gynaecological clinic,0303 almost 50% reported unwanted sexual attention and 20.1% had experienced forced sexual activity: 6.8% was in childhood,10.3% during adolescence, 6.4% as an adult and 3.5% across more than one stage. Only 0.5% of these women had discussed their abuse with the gynaecologist. The others were either afraid to do so or stated that it was not relevant to their case. Only one woman reported that her gynaecologist had asked about sexual abuse.
Long-term effects of childhood sexual abuse
Childhood sexual abuse may have long-term effects on health and is particularly associated with adult depression,0304 which is more likely to be resistant to treatment.
In a study in Ireland9801 involving interviews with 237 female general practice patients, 37% of interviewees who were depressed and 23% who were not, reported sexual abuse under the age of 16 years. All nine women who had experienced penetration and 12 of the 14 women who had experienced attempted penetration were depressed as adults. Childhood sexual abuse was also associated with sexual dysfunction, housing problems and problems with their own children at school.
Besides depression, anxiety, low self-esteem and sexual problems, childhood sexual abuse may also contribute to multiple chronic complaints in adulthood including incontinence. Arnold et al.9001 described seven women who had experienced a mean of 18 contacts with non-psychiatric consultant teams and a mean of eight operations, with a high rate of normal findings. They had encountered consultant teams in several specialties including gynaecology, gastroenterology, urology, rheumatology, haematology, orthopaedics and neurology, but the history of childhood sexual abuse was recognised only in the later stages of these interventions.
Effects of child sexual abuse also include propensity to re-victimization in adulthood, and physical injury to the child, among other problems.Sexual abuse by a family member is a form of incest, and can result in more serious and long-term psychological trauma, especially in the case of parental incest.
Long term negative effects on development leading to re-victimization in adulthood are also associated with child sexual abuse. Studies have established a causal relationship between childhood sexual abuse and certain specific areas of adult psychopathology, including suicide, antisocial behaviour, anxiety and alcoholism.
A 2009 study from Canada0901 has demonstrated that after childhood sexual abuse there is:-
- anorexia nervosa
- depression
- bulimia nervosa
- reduced self-esteem
and those affected might benefit from a more specialized focus on their emotional responses to the abuse including counselling.
Gynaecological conditions associated with childhood sexual abuse
Most research has focused on the association between childhood sexual abuse and chronic pelvic pain.
Childhood sexual abuse may, however, be associated with other gynaecological symptoms.
Chronic pelvic pain
Chronic pain in general is correlated with childhood abuse, stress and depression.
A 2003 study comparing women suffering from chronic back and pelvic pain with a pain-free group found that childhood physical abuse, stress and depression affected chronic pain but that childhood sexual abuse was correlated only with pelvic pain.0305
In a Norwegian study of gynaecological patients in general practice,0306 childhood sexual abuse (which was reported by 28% of women) was strongly associated with a history of pelvic pain or gynaecological surgery.
Other gynaecological symptoms
Springs and Friedrich9201 investigated 511 women from a family practice in Midwestern USA. Women who had been sexually abused formed 22% of the sample and had more pelvic inflammatory disease, yeast infections and pregnancy complications than women who had not been abused. There was a relationship between severity of abuse and number of gynaecological problems. Fewer than 2% of the women who had been abused had discussed the abuse with a doctor.
Moeller et al.9301 studied 668 middle-class women from a US gynaecological practice. One in five recounted exposure to abuse in childhood but the study made no distinction between sexual, physical and emotional abuse. Women who had suffered abuse were more likely than women who had not been abused to suffer from:
- severe premenstrual syndrome,
- frequent (unspecified) gynaecological problems and
- frequent vaginal infections.
- They were also more likely to be dissatisfied with their sex life.
A study in 1998 by Golding et al.9802 investigated women with one or more symptoms of dysmenorrhoea , menorrhagia and sexual dysfunction. In a randomly selected population of 4094 women, 622 (15%) reported previous sexual assault. Each of these three gynaecological symptoms carried increased odds of a history of sexual assault and these odds approximately doubled with each additional symptom. This association was noticed only in women aged under 45 years and over 54years and not in perimenopausal women. Again, this study did not distinguish between childhood and adult sexual assault.
When Walker et al.9901 investigated 1225 women in Washington State, USA, by means of a questionnaire,18% reported a history of childhood sexual abuse. They had a higher incidence of
- dyspareunia,
- premenstrual distress,
- sexual anhedonia (anhedonia is an inability to experience pleasure from normally pleasurable life events such as eating, exercise, and social or sexual interaction),
- and anorgasmia
- and a significantly higher number of pain disorders, including, among others, dysmenorrhoea.
compared with women who had not been abused.
These findings, however, are not universal. Dalton et al.0201 compared women with and without vulval pain (classified as vulvar dysaesthesia/vestibulodynia). Women with vulval pain were more likely to be married, white, and with a higher household income than the controls, but they were no more likely to have suffered sexual assault.
How does childhood sexual abuse lead to gynaecological symptoms in adults?
Several hypotheses have been put forward to explain the underlying mechanism linking childhood sexual abuse with problems in adulthood. The links may be physical, social or psychological. One possibility is that the act of sexual abuse causes physical damage to the female pelvic anatomy that manifests itself later in gynaecologicalsymptoms. Another direct effect could be the acquisition of a sexually transmitted infection that may remain hidden until adult life.
Victims of childhood sexual abuse engage in more health risk behaviours, such as illicit drug use, smoking and promiscuity, than women who have not been abused.17 This may lead to subsequent gynaecological problems; for example, smoking and multiple sexual partners are risk factors for cervical cancer. Other hypotheses relate to the psychological consequences of childhood sexual abuse.
UK studies have shown that victims of childhood sexual abuse have higher frequencies of hospital admissions and surgical procedures (including gynaecological procedures) inadulthood. Identifying those who have experienced childhood sexual abuse should reduce the number of unnecessary operations. This would help the NHS economically as well as provide major benefits for the woman.
How should the doctor react when someone discloses a history of childhood sexual abuse?
The woman may feel guilty and must be reminded that she is the victim and has not brought these problems upon herself. The doctor should make it clear that she has been heard and believed, and that her symptoms make sense in the light of what she has experienced. It takes a great deal of courage to disclose childhood sexual abuse. She should be asked if she has ever talked to anyone about her experience. She may not want further counselling and this wish should be respected, but women who have experienced childhood sexual abuse generally benefit from mental health care. Routine psychiatric referral is not appropriate and every effort should be made to refer to a practitioner who is familiar with the issues common to women who have experienced childhood sexual abuse.2,28 Sadly, not all areas of the country have adequate provision of support groups or colleagues with relevant experience.
Conclusion
Although the prevalence of childhood sexual abuse is decreasing in some countries, it still remains common. It does not always lead to medical problems in adulthood but may underlie some gynaecological complaints.
Gynaecologists are consistently missing the diagnosis by failing to ask appropriate questions. When childhood sexual abuse is diagnosed, unnecessary medical or surgical treatment may be avoided and victims may be helped through counselling. There is a need for more training and a UK guideline on this subject.
