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Obstetricians and gynecologists encounter patients with a wide array of symptoms that may be associated with a history of childhood sexual abuse. Frequently, the underlying cause of these symptoms is not recognized by the physician and, in many cases, by the patient. For some survivors of childhood sexual abuse (CSA), there is minimal compromise to their adult functioning. Others will have myriad psychologic, physical, and behavioral symptoms as a result of their abuse (1). Adult CSA survivors have disproportionately high use of health care services, more severe symptoms with more complex patterns of presentation, and often somatic symptoms that do not respond to routine treatment (2-4). These issues can create frustration for women and treatment challenges for their physicians. An understanding of the magnitude and impact of childhood sexual abuse, along with knowledge about screening and intervention methods, can help obstetricians and gynecologists offer appropriate care and support to patients with such histories.

Definitions

Childhood sexual abuse can be defined as any exposure to sexual acts imposed on children who inherently lack the emotional, maturational, and cognitive development to understand or to consent to such acts. These acts do not always involve sexual intercourse or physical force; rather, they involve manipulation and trickery. Authority and power enable the perpetrator to coerce the child into compliance. Characteristics and motivations of perpetrators of childhood sexual abuse vary: some may act out sexually to exert dominance over another individual; others may initiate the abuse for their own sexual gratification (5, 6).

Although specific legal definitions may vary among states, there is widespread agreement that abusive sexual contact can include breast and genital fondling, oral and anal sex, and vaginal intercourse. Definitions have been expanded to include noncontact events such as coercion to watch sexual acts or posing in child pornography (7).

Prevalence

The prevalence of childhood sexual abuse in the United States is unknown. Because of the shame and stigma associated with abuse, many victims never disclose such experiences. Incest was once thought to be so rare that its occurrence was inconsequential. However, in the past 25 years there has been increased recognition that incest and other forms of childhood sexual abuse occur with alarming frequency (8). Researchers have found that victims come from all cultural, racial, and economic groups (9).

Current estimates of incest and other childhood sexual abuse range from 12% to 40% depending on settings and population. Most studies have found that among women, approximately 20% - or 1 in 5 - have experienced childhood sexual abuse (9). Consistent with this range, studies have revealed that:

• Among girls who had sex before they were 13 years old, 22% reported that first sex was nonvoluntary (10).

• Twelve percent of girls in grades 9 through 12 reported they had been sexually abused; 7% of girls in grades 5 through 8 also reported sexual abuse. Of all the girls who experienced sexual abuse, 65% reported the abuse occurred more than once, 57% reported the abuser was a family member, and 53% reported the abuse occurred at home (11).

• Approximately 40% of the women surveyed in a primary care setting had experienced some form of childhood sexual contact; of those, 1 in 6 had been raped as a child (12).

• A national telephone survey on violence against women conducted by the National Institute of Justice and the Centers for Disease Control and Prevention found that 18% of 8,000 women surveyed had experienced a completed or attempted rape at some time in their lives. Of this number, 22% were younger than 12 years and 32% were between 12 and 17 years old when they were first raped (9).

Common Symptoms in Adult Survivors of Childhood Sexual Abuse

Physical Presentations Chronic pelvic pain Gastrointestinal symptoms/distress Musculoskeletal complaints Obesity, eating disorders Insomnia, sleep disorders Pseudocyesis Sexual dysfunction Asthma, respiratory ailments Addiction Chronic headache Chronic back pain Psychologic and Behavioral Presentations Depression and anxiety Posttraumatic stress disorder symptoms Dissociative states Repeated self-injury Suicide attempts Lying, stealing, truancy, running away Poor contraceptive practices Compulsive sexual behaviors Sexual dysfunction Somatizing disorders Eating disorders Poor adherence to medical recommendations Intolerance of or constant search for intimacy Expectation of early death

Although there is no single syndrome that is universally present in adult survivors of childhood sexual abuse, there is an extensive body of research that documents adverse short- and long-term effects of such abuse. To appropriately treat and manage survivors of CSA, it is useful to understand that survivors' symptoms or behavioral sequelae often represent coping strategies employed in response to abnormal, traumatic events. These coping mechanisms are used for protection during the abuse or later to guard against feelings of overwhelming helplessness and terror. Although some of these coping strategies may eventually lead to health problems, if symptoms are evaluated outside their original context, survivors may be misdiagnosed or mislabeled (see box) (5).

In addition to the psychologic distress that may potentiate survivors' symptoms, there is evidence that abuse may result in biophysical changes. For example, one study found that, after controlling for history of psychiatric disturbance, adult survivors had lowered thresholds for pain (13). It also has been suggested that chronic or traumatic stimulation (especially in the pelvic or abdominal region) heightens sensitivity, resulting in persistent pain such as abdominal and pelvic pain or other bowel symptoms (14, 15).

Although responses to sexual abuse vary, there is remarkable consistency in mental health symptoms, especially depression and anxiety. These mental health symptoms may be found alone or more often in tandem with physical and behavioral symptoms. More extreme symptoms are associated with abuse onset at an early age, extended or frequent abuse, incest by a parent, or use of force (4). Responses may be mitigated by such factors as inherent resiliency or supportive responses from individuals who are important to the victim (4). Even without therapeutic intervention, some survivors maintain the outward appearance of being unaffected by their abuse. Most, however, experience pervasive and deleterious consequences (4).

The primary aftereffects of childhood sexual abuse have been divided into seven distinct, but overlapping categories (16):

1. Emotional reactions
2. Symptoms of posttraumatic stress disorder (PTSD)
3. Self-perceptions
4. Physical and biomedical effects
5. Sexual effects
6. Interpersonal effects
7. Social functioning

References

1. McCauley J, Kern DE, Kolodner K, Schroeder AF, DeChant HK, Ryden J, et al. Clinical characteristics of women with a history of childhood abuse: unhealed wounds. JAMA 1997;277:1362-1368

2. Koss MP, Koss PG, Woodruff WJ. Deleterious effects of criminal victimization on women's health and medical utilization. Arch Intern Med 1991;151:342-347

3. Drossman DA, Leserman J, Nachman G, Li ZM, Gluck H, Toomey TC, et al. Sexual and physical abuse in women with functional or organic gastrointestinal disorders. Ann Intern Med 1990;113:828-833

4. American Medical Association. Diagnostic and treatment guidelines on mental health effects of family violence. Chicago: AMA, 1995

5. Hendricks-Matthews M. Long-term consequences of childhood sexual abuse. In: Rosenfeld J, Alley N, Acheson LS, Admire JB, eds. Women's health in primary care. Baltimore: Williams & Wilkins, 1997:267-276

6. Britton H, Hansen K. Sexual abuse. Clin Obstet Gynecol 1997;40:226-240

7. Maltz W. Adult survivors of incest: how to help them overcome the trauma. Med Aspects Hum Sex 1990;24:42-47

8. Hendricks-Matthews MK. Caring for victims of childhood sexual abuse. J Fam Pract 1992;35:501-502

9. Tjaden P, Thoennes N. Prevalence, incidence, and consequences of violence against women: findings from the National Violence Against Women Survey. Research in Brief. Washington, DC: U.S. Dept of Justice, Office of Justice Programs, November 1998, NCJ 172837

10. Moore KA, Driscoll A. Partners, predators, peers, protectors: males and teen pregnancy. New data analysis of the 1995 National Survey of Family Growth. In: Not just for girls: the roles of boys and men in teen pregnancy. Washington, DC: The National Campaign to Prevent Teen Pregnancy, 1997: 7-12

11. Schoen C, Davis K, Collins KS, Greenberg L, Des Roches C, Abrams M. The Commonwealth Fund survey of the health of adolescent girls. New York: The Commonwealth Fund, 1997

12. Walker EA, Torkelson N, Katon WJ, Koss MP. The prevalence rate of sexual trauma in a primary care clinic. J Am Board Fam Pract 1993;6:465-471

13. Scarinci IC, McDonald-Haile J, Bradley LA, Richter JE. Altered pain perception and psychosocial features among women with gastrointestinal disorders and history of abuse: a preliminary model. Am J Med 1994:97:108-118

14. Cervero F, Janig W. Visceral nociceptors: a new world order? Trends Neurosci 1992;15:374-378

15. Drossman DA. Physical and sexual abuse and gastrointestinal illness: what is the link? Am J Med 1994;97:105-107

16. Courtois CA. Adult survivors of sexual abuse. Prim Care 1993;20:433-446

Excerpted from: ACOG Educational Bulletin, No. 259, July 2000. Adult Manifestations of Childhood Sexual Abuse.