ARCHIVED: Chapter 3: Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse – What survivors bring to health care encounters

What Childhood Sexual Abuse Survivors Bring to Health Care Encounters

Gender socialization: Women's experiences

Gender socialization affects both children's responses to sexual abuse and how the experience affects them in adulthood. Throughout the research for this handbook, survivor participants described ways in which gender socialization shaped their interactions with health care practitioners.

Although many would argue that gender socialization has changed considerably in the past century, many female children continue to be encouraged to be non- aggressive, submissive, and "nice." They receive multiple messages that to be female is to be less valued and less powerful than males, and that the appropriate role for females is to please others, especially males. Rebecca Bolen states,

Socialization to be submissive coupled with children's normative tendency to blame themselves for negative experiences involving adults leaves many female survivors believing that they are "bad" people who are responsible for the abuse.

Females develop a sense of their lack of entitlement and vulnerability to the more powerful members of society. Females internalize this message ... they are socialized to be less powerful than, and to defer to, the more powerful and more entitled males.^{26 p.146}

These aspects of normative female socialization may exacerbate girls' tendency to be submissive and to blame themselves for negative experiences involving adults, which can leave many female survivors believing that they are "bad" people who are responsible for the abuse and that their bodies, which they have come to hate, somehow caused the abuse:

“Most survivors I know hate their body, disown their body ... become disconnected from it”. (Woman survivor)

A female abuse survivor may also be mistrustful of authority figures, which stems from having been betrayed by the trusted adult who abused her. This helps to explain the difficulty that some survivors have trusting health care practitioners and why they experience health care encounters as distressing. It also helps explain why so many female survivors report symptoms of depression and anxiety:

“I didn't want to state what my needs were because ... [with] the abuse ... you don't get to choose what happens to you. What happens to you happens to you, you just accept it and that's the way I thought for a long time. I still probably think that way but I'm trying to change the way I think because I do have choice now”. (Woman survivor)

Girls learn that it is important for females to be objects of male sexual desire and that appearing young and innocent is sexually appealing. "We dress fashion models up to look child-like and sexually provocative and set this standard for all women," writes Calgary social worker Lois Sapsford.138p.76 Girls may also learn that, to be valued, they must be sexually "pure"; at the same time, they receive the contradictory message that they should be not only beautiful but also "sexy." Sexual abuse objectifies a girl's body to serve the needs of her abuser and may leave her believing that her sole value is as a sexual object. The message that females should be sexually "pure" along with the stigma attached to sexual abuse contributes to some female survivors' perceptions of themselves as "damaged goods" and to the shame and guilt that many describe. This may be manifested in a survivor's ambivalence about her body and reticence to seek care for health problems:

“The other thing is the big shame and the secret ... We may have an ailment that could be addressed ... [early] but let it go and let it go until ... it takes longer to mend or to heal”. (Woman survivor)

The historical and current societal factors that encourage people in our society to deny or minimize the significance of child sexual abuse also affect female survivors' perceptions about the wisdom of disclosing their experience. Many women participants talked about their fear of not being believed; some gave examples of being told directly that they must be lying or imagining things. Another aspect of female gender socialization is the message that it is the female who is responsible for setting limits on sexual behaviour, which contributes to women survivors fearing that they will be blamed for what happened, even though the sexual behaviour occurred when they were children and the perpetrator was older and more powerful. One health care practitioner responded to a woman's disclosure of past abuse by asking, "How did you let it happen?" These societal messages strongly discourage women survivors from sharing their experience with health care practitioners, which in turn impedes the clinician's ability to assess all factors that may contribute to health problems.

The stigma attached to sexual abuse contributes to some female survivors' perceptions of them-selves as "damaged goods," as well as their ambivalence about their bodies and reticence to seek care for health problems.

Gender socialization: Men's experiences

The men in our studies repeatedly reported feeling invisible as survivors of childhood sexual abuse. Among the major factors contributing to the invisibility of male childhood sexual abuse survivors are: (a) the widespread lack of knowledge about the prevalence of childhood sexual abuse of boys; (b) incongruence between society's notions of masculinity and victimhood; and (c) the fact that services for childhood sexual abuse survivors, which grew out of the second wave of feminism, were historically designed for women and not for men.

For a man to acknowledge that he has been sexually abused is an admission of vulnerability in a society that has few models for the expression of masculine vulnerability. Indeed, applying the label victim of sexual abuse to a man juxtaposes vulnerability with masculinity, an uneasy pairing that further contributes to the under recognition and underreporting of childhood sexual abuse among boys and men.^{3,43,52,86,105}

For a man to acknowledge that he has been sexually abused is an admission of vulnerability in a society that has few models for the expression of masculine vulnerability.

The socialization of men to be strong and independent^15,85 complicates the situation for male survivors who consider sharing their history of abuse with a health care practitioner.¹⁶⁵ As Michel Dorais puts it in his book Don't Tell: The Sexual Abuse of Boys, the "masculine conception of virility is incompatible with the factual experience of having been a victim of sexual abuse, or needing help following such a trauma"^52p.17 (see also O'Leary¹¹⁷). Men in our study spoke about their need to appear "tough" and "in control" despite feeling anxious and fearful during encounters with health care practitioners:

“Men are tough. Men are macho. Men don't need [help]. All we have to do is to get over it! Get over it be a man! You know, men don't cry”. (Man survivor)^167p.509

Some participants also spoke about their difficulty in identifying and expressing their feelings:

“Women appear to me more aware of the names of things. Such as I'm feeling depressed or I've been having a real struggle for the past couple of weeks and these are the circumstances. I don't know what half of that stuff is called”. (Man survivor)^167p.510

The participants suggested that health care practitioners are sceptical about men who disclose sexual abuse and tend to take their experiences less seriously than those of their female counterparts.

There is a pervasive belief that boys and men are rarely victimized and that a central feature of masculinity is the ability to protect oneself (Mendel as cited in Lab, Feigenbaum, & De Silva96); failure to do so is seen as evidence of weakness and can be a source of great male shame. Thus, the "dissonance between the male role expectation and the experience of victimisation"117p.83 may seriously compromise the health care of male survivors, often because their feelings of shame and unworthiness affect their ability to seek care:

“One of the reasons why for a long time I didn't go [to a health care practitioner was that] ... quite frankly, I just didn't feel worthy ... Worthy of the care, the attention. I mean doctors are busy”. (Man survivor)

Most of the men in our studies expressed the belief that different reactions to male and female childhood sexual abuse survivors shape their help-seeking behaviours and, in turn, influence how health care practitioners treat them. In general, the participants suggested that health care providers are sceptical about men who disclose sexual abuse and tend to take their experiences less seriously than those of their female counterparts. In addition, some regard sexual abuse by a woman as something that the "fortunate" male survivor should have enjoyed. Ramona Alaggia³ and Guy Holmes and colleagues⁸⁵ reiterate that such perceptions are common. The media also contribute to these views by framing the sexual abuse of boys by adult women as a "sexual relationship" (e.g., ). The fact that boys are more often sexually abused by a female than girls³¹ may fuel the myth that sex between boys and women is normative rather than abusive and perpetuates the "male gender role of seeking early sexual experiences with women."^15p.225

Notwithstanding the general progress made in addressing homophobia in our society, some of the men in our study talked about their fear that health care practitioners would think they were homosexual if they revealed their history of childhood sexual abuse. Others talked about how their abuse experiences had led them to develop strong negative feelings about individuals (including health care practitioners) whom they perceived to be homosexual:

“I had to go into the hospital where I had a problem with some medication I had [taken] and there was a male nurse there and he was obviously very effeminate, and he had to give me an IV, I refused him because I didn't want him touching me”. (Man survivor)^167p.506

Such reactions can be seen as internalized homophobia. These fears may also reflect the pervasiveness of the myth in our society that childhood sexual abuse causes boys and girls to become gay or lesbian.¹³²

Societal myths about the cycle of violence

The emotional cost of childhood victimization is intensified especially for male survivors by the societal belief that it is only a matter of time before they become abusers themselves, if they have not already done so. The media typically give more attention to the erroneous belief that male survivors will likely become perpetrators⁴³ than to information that disputes this belief.¹¹⁷ Despite the lack of conclusive evidence regarding this causal link ^68,137) and the fact that many male perpetrators do not report a history of childhood sexual abuse,⁹⁹ the public and even some male survivors themselves continue to fear that they are destined to become perpetrators.^85,117,133 Some female survivors may also fear that they will sexually abuse children or that others will see them as potential offenders.

Transference and counter-transference

The concepts of transference and counter- transference were originally identified by Freud in the context of psychoanalysis, and refer to common human experiences that are important for everyone working in human service to understand. Transference is said to occur when an individual displaces thoughts, feelings, and/ or beliefs about past situations onto a present experience. It is widely agreed that we all engage in transference to some extent. While transference can be positive or neutral, it can also be negative and may interfere with healthy and adaptive functioning. For example, an adult who was constantly criticized by an authority figure may grow up expecting all authority figures to be critical and may hear criticism where none is intended. Similarly, survivors of childhood sexual abuse may react negatively towards a health care practitioner whose appearance, gender, or mannerisms are reminiscent of someone who abused them. The dynamics of transference help explain why a survivor may respond to an interaction with a health care practitioner in ways that are unrelated to the encounter or to the specific health care practitioner. Understanding transference may also help health care practitioners to avoid taking patients' negative responses personally.

The media typically give more attention to the erroneous belief that male survivors will likely become perpetrators than to information that disputes this belief.

Counter-transference involves the same dynamics as transference, but occurs when a health care practitioner responds to a patient with thoughts, feelings, and/or beliefs associated with his or her own past. For example, a patient who reminds a practitioner of an angry and demanding teacher may evoke feelings of anxiety that seem out of proportion to the current situation.

Counter-transference can also refer to the health care practitioner's expectable emotional reaction to a patient's behaviour - in particular, when the patient is transferring experiences from the past. For example, a survivor may engage in transference by behaving in a hostile manner towards a practitioner whom he incorrectly believes does not care about him just as his parents did not seem to care about his wellbeing. A health care practitioner who responds with anger and defensiveness can be said to be allowing counter-transference feelings to be expressed.

While it is understandable that health care providers have negative feelings in response to a patient's negative transference, they must strive to contain these feelings and respond professionally. Inquiring about the reasons for the patient's hostility, for example, is likely to be more productive than responding with anger. Health care providers have an ethical obligation to work continuously at being self-aware and to reflect critically on their practice in order to recognize when they may be responding harmfully to a patient's transference or experiencing counter- transference. Further, health care providers need to remind themselves repeatedly of their obligation to respond to a patient professionally, even when they believe they have been judged harshly, have been provoked, experience negative feelings about the patient or are personally upset. When practitioners have difficulty meeting these ethical requirements, they need to reflect on the situation and the reasons for their responses and take appropriate steps to prevent harming their patients directly or indirectly. If a health care practitioner notices a recurring strong reaction to a particular individual or to certain behaviours, personal characteristics, or events, it may be useful to talk to a supervisor or trusted colleague about it.

Specific behaviours and feelings arising during health care encounters

Distrust of authority figures. Throughout this project, survivors told us how, as children, they experienced violation at the hands of an authority figure and how the distrust from these past experiences affects their interactions with health care practitioners. Although this distrust originates in the past and should not be taken as a personal affront, survivors constantly scrutinize health care providers for evidence that they are taking active and ongoing steps to demonstrate their trustworthiness. It is crucial to recognize that some survivors may associate a health care practitioner's attempts to verbally assure them that they are safe with the perpetrator's empty assurance of safety during their abuse.

While it is understandable that health care practi-tioners have negative feelings in response to a patient's negative transference, they must strive to contain these feelings and respond professionally.

Fear and anxiety. Many survivors spoke at length about their tremendous fear and anxiety during health care encounters. The experiences of waiting, being in close contact with authority figures, and not knowing what is to come all resonated with past abuse. Some survivor participants said that they were even afraid of being abused by the health care practitioner:

“[In the clinic waiting room, I felt] nervous, apprehensive, not exactly knowing what was going to happen ... as far as clothing was concerned or ... touch, just not knowing”. (Woman survivor)^143p.252

Discomfort with persons who are the same gender as their abuser(s). For some survivors, the gender of a person in a position of authority is a powerful "trigger" that can leave them feeling vulnerable and unsafe. This strong reaction prevents some survivors from seeking care from practitioners who are the same gender as their abuser:

“[A male health care provider and assistant were] in the room with me, and I had my pants off, and this guy's putting [ultrasound] gel on my leg. And I felt really uncomfortable ... even though ... probably nothing could have happened, but I just didn't like the fact that I was in a room by myself with my pants off, with two men. That was really eerie”. (Woman survivor)

“My abuser was my mother. I don't like to be touched by women, especially strange women”. (Man survivor)

Triggers. Examinations or treatments may "trigger" or precipitate flashbacks, a specific memory or overwhelming emotions such as fear, anxiety, terror, grief, or anger. A flashback is the experience of reliving something that happened in the past and usually involves intense emotion. Some survivors are particularly susceptible to flashbacks and some are overwhelmed by them:

“And the goop that they put on me for the ultrasound gave me flashbacks, nightmares, insomnia; I just couldn't deal with it”. (Woman survivor)^143p.257

For some survivors, the gender of a person in a position of authority is a powerful trigger that can leave them feeling vulnerable and unsafe.

Dissociation. Survivor participants also spoke about dissociating during interactions with health care providers. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (Text Revised) (DSM-IV-TR) ^11p.519 explains dissociation as "a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment" that may be sudden or gradual, transient or chronic. Some authors (e.g.,^120,155) liken it to a state of divided consciousness in which aspects of the self that are normally integrated become fragmented. Dissociation is also understood to be a process that exists on a continuum,¹²⁰ with one end being "common experiences such as daydreaming and lapses in attention, through déjà vu phenomena ... [and the other end of the continuum involving] a pathological failure to integrate thoughts, feelings, and actions."^111p.806

DSM-IV-TR states that "dissociative states are a common and accepted expression of cultural activities or religious experience in many societies"^11p.519 and in these cases they do not usually lead to the "significant distress, impairment, or help-seeking behaviour"^11p.519 that is required for them to be diagnosed as a disorder. A common experience of dissociation that most of us can relate to is highway hypnosis, in which an individual driving a car suddenly realizes that he or she cannot remember all or part of the trip.¹²¹

The International Society for the Study of Trauma and Dissociation⁸⁹ takes the position that traumatic experiences play an important role in the development of various pathological dissociative disorders. Many believe that dissociation is an effective strategy for coping (in the immediate situation) with extreme stress such as childhood sexual abuse. However, if it becomes a long-term coping mechanism, it may contribute to a variety of mental health problems and interfere with relationships, self-concept, identity development, and adaptive functioning.^4,77

A number of the survivor participants told us that they do not have consistent control over this mechanism through which they "escape" from a current (usually stressful) situation; some even report that for many years they were unaware of their tendency to dissociate. When they are in a dissociative state, some individuals experience themselves as being outside their bodies, watching the present situation from a distance. Others simply go silent, stare blankly into the distance, or seem unaware of their surroundings. When the dissociative episode is over, individuals may have no memory of what occurred and may have difficulty orienting themselves back to the present:

“[In a physical therapy session] I would just get that same dread feeling inside, and I would do the same coping that I would have done when I was abused ... just trying to not feel my arms and not really be there”. (Woman survivor)^158p.182

Physical pain. For some survivors, the experience of acute and/or chronic physical pain may be associated with past abuse. This association can manifest itself in various ways (e.g., some individual have learned to ignore or dissociate from pain, while others are hypersensitive to it):

“I think sometimes when survivors are in pain, and coming for physical therapy, it hooks us back into our childhood where we were in pain and ... no one responded. And if you did indicate you were in pain ... the pain was trivialized or you were threatened [so that you did not tell] anyone”. (Woman survivor)^143p.256

Examination or treatment may "trigger" or precipitate flashbacks or overwhelming emotions such as fear, anxiety, terror, grief, or anger.

Ambivalence about the body. Many survivors feel hate, shame, and guilt about their bodies. As children, many believed that something about them or their bodies invited or caused the abuse. This belief is reinforced if the survivor enjoyed some aspects of the abuse (e.g., special attention, physiological arousal).^85,133 This shame and guilt may lead some survivors to feel ambivalent about and disconnected from their bodies:

“And [the amount of attention that I give to my body] ebbs and flows too, depending on where I'm at and how well I'm choosing to take care of my body. Which is a very difficult thing for me physically to do, because when you don't live there, it's just sort of a vehicle to get around”. (Woman survivor)^143p.255

The conflict between the need to seek health care for a physical problem and the ambivalence or dislike of one's body can affect treatment. For example, an individual may ignore symptoms that might contribute to an accurate diagnosis, explain an individual's response to treatment, or interfere with the ability to self-monitor effects of an intervention or medication.

Conditioning to be passive. Abuse can teach children to avoid speaking up or questioning authority figures. In adulthood, survivors may then have difficulty expressing their needs to a health care practitioner who is perceived as an authority figure.

“[The health care practitioner did something and] I really freaked but ... I didn't show her I was freaking, because our history is that you don't let on if things are a problem for you. You just deal with it however you can ... by dissociating or what have you”. (Woman survivor)^143p.254

Self-harm. Self-harm (e.g., scratching, cutting, or burning the skin) is a way that some survivors attempt to cope with long-term feelings of distress. Health care practitioners may see evidence of self-harm in the form of injuries or scars on the arms, legs, or abdomen. Self-harm may take more subtle forms as well, such as ignoring health teachings or recommendations for treatment or symptom management (e.g., refusing to pace one's activity in response to pain or fatigue, or failing to adhere to a diabetic treatment regime).

Abuse can teach children to avoid speaking up or questioning authority figures. In adulthood, survivors may then have difficulty expressing their needs to a health care practitioner who is perceived as an authority figure.

There are many reasons why survivors harm themselves. It may serve to distract them from emotional pain, focus the pain to one area of the body, or interrupt an episode of dissociation or numbness. Some survivors may harm themselves to regain a sense of control or ownership of their bodies. For others, it may be a punishment or an effort to atone for wrongs they believe they have committed.⁴⁷ Dusty Miller ¹⁰⁷ argues that self-harm is one example of a range of self- destructive behaviours that can be thought of as an unconscious effort to reenact past trauma.

Questions about sexuality and sexual orientation

Survivors of child sexual abuse, like many other people in our society, may have questions about their sexuality or sexual orientation. Some male participants who had been abused by men said they had struggled with uncertainty about their own sexual orientation:

“I just realized in sexual abuse, it seems very, very common that the issue of homosexuality when dealing with a male [survivor] of sexual abuse comes up. It's an issue: Am I a homosexual? ” (Man survivor)

Some women survivors report similar struggles:

“Female survivors of female- perpetrated abuse also experience this confusion around their sexual identity and orientation”. (Woman survivor)

For participants who self- identified as gay, public assumptions about the "cause" of their sexual orientation and about their potential to be abusers were also problematic:

“They assume that because it was your mother [who abused you] that's why you're gay. Because it was a woman doesn't make much sense. Or that then because you're gay, you were abused, you're going to be a pedophile yourself. These attitudes come out from others that I've disclosed to. Lots of layers there; biases would be one of the big problems there with health practitioners. They're going to make assumptions”. (Man survivor)

Relatively few survivor participants raised the issue of sexual orientation in the context of their interactions with health care practitioners. However, a number of health care practitioner participants who commented on drafts of the Handbook pointed out that the phenomena of sexual identity and sexual orientation are often overlooked or ignored by health care practitioners. Certainly, it is important to recognize that women and men who have been sexually abused in childhood may experience challenges around sexuality and intimacy in general. This is true of a proportion of survivors in heterosexual relationships as well as for some in same-sex relationships and for some survivors who identify as gay, lesbian, bisexual or transgendered.

Because of the general societal perception that being gay, lesbian, bisexual, or transgendered (GLBT) is "abnormal" or "wrong," abuse survivors (and health care practitioners) may sometimes attribute their same-sex attraction to past sexual abuse. Shoshana Pollack, professor of social work at Wilfrid Laurier University, notes that "fostering this assumption in patients misses the important point that childhood sexual abuse involves traumatic sexualization and often leaves survivors confused about how to engage sexually in general, what their sexual preferences are (not only gender, but practices), what it means if they experience same sex attraction, what it means if they don't experience it but as a child their abuser was the same sex etc." (2007, personal communication).

No research has supported the idea that childhood sexual abuse is associated with the development of GLBT identity.

Participants who were abused as children and who are (or have been) involved in same- sex relationships often have to deal with negative thoughts about themselves based on negative societal stereotypes. For example, some may think, "I'm bad because I was abused," or "I am really bad because I was abused and it made me be attracted to the same sex." These thoughts should be recognized as internalized heterosexist and homophobic social attitudes that need to be challenged and worked through. (Shoshana Pollack, 2007, personal communication)

No research studies have supported the claim that childhood sexual abuse is associated with the development of GLBT identity.¹³² In an online questionnaire study of lesbian and bisexual women between 18 and 23 years old, fewer than half of those who had experienced childhood sexual abuse thought that the childhood sexual abuse had affected their feelings about their sexuality or how they "came out." Among those who did identify effects on their feelings about their sexuality and coming out process, some said that the abuse had not affected their feelings about their sexual orientation, which they believed was unconnected to the childhood sexual abuse experience.

The conflict between the need to seek health care for a physical problem and difficulty in caring for one's body often affects treatment.