Ethical Boundaries: Treating Childhood Sexual Trauma

As an overview, the psychological aftereffects of molestation may depend upon one or more of the following variables (adapted from Katz & Mazur, 1979, p. 247):

1. The age of the child is believed to affect the degree to which a child is traumatized. Younger children are considered by many to be more vulnerable to trauma; by contrast, MacFarlane (1978) noted that older children may be hurt more because they are more fully aware of the social stigma that is associated with sexual assault.

2. The psychological condition of the victim: Child victims who have had prior emotional problems (or who are emotionally vulnerable because they come from broken or unstable homes) may experience more pronounced problems as a result of being assaulted, and those problems may be longer lasting.

3. Sexual knowledge or experience: Children who have had no previous sexual experience may be more vulnerable than others.

4. The type of assault: The amount of violence and degree of bodily penetration are positively correlated with trauma. Also, the extent to which the child believes his or her body has been damaged by the event can contribute to the degree of trauma that is experienced by the child.

5. Repeated assaults: Repeated assaults may cause more psychological damage than an isolated assault.

6. Molestation by a stranger versus a known, trusted offender: Sexual assault by someone whom the child knows and trusts is more likely to cause lasting damage than is assault by a stranger.

7. Reactions of others: Negative reactions on the part of police, parents, teachers, peers, and/or family friends or neighbors can contribute to the degree of trauma.

8. Not being believed or supported: Children who are not believed or supported by their parents or adult caretakers suffer more emotional trauma than do those who are.

9. Therapy: As with adults, child victims of sexual assault who receive psychotherapy are more likely to recover from it than are those who do not receive treatment.

The traumatic sequelae of childhood sexual abuse are best described in two categories: 1) symptoms that usually occur in the first two years after the abuse has ceased; and 2) long-term effects. The initial symptoms exhibited by sexually traumatized children will be discussed in detail later in this chapter and can be summarized as follows: fear and anxiety, sleep disturbances, somatic complaints, regressive behavior, poor selfesteem, inability to trust, depression with its underlying anger and hostility, poor school performance, inappropriate sexual behavior, guilt, shame, and/or self-destructive behavior. The longer-term effects, which will be described more fully in Chapter 7 on adults who were assaulted as children, can be summarized as follows: depression, self-destructive or suicidal behavior, anxiety, feelings of isolation and alienation, negative self-concept, impaired interpersonal relationships, vulnerability to revictimization, a propensity to choose abusive mates, problems with sexual adjustment, and/or substance or alcohol abuse.

One cannot review the assessment of the degree to which sexual assault traumatizes children without discussing the persistent controversy about whether or not the traumatic impact of assault has been overstated. In our opinion (in accord with Finkeihor, 1984), one must view the impact that such an event has upon a child in terms of a child's perceptions of pain and trauma. It would be foolish to think of the only "true" trauma as that which leads to impairment in the victim's later adult functioning.

Most people are aware that certain traumatic events in the course of adult life such as rape, serious physical injury, or the loss of a loved one may cause excruciating emotional suffering; the seriousness of such events is accepted, even if they do not emotionally impair the adult when he or she becomes elderly. In fact, most persons would be relieved to learn that such traumatic events may not necessarily scar the rest of a person's life. Why, then, are some so willing to dismiss childhood sexual trauma as not being a serious matter unless it is shown to impair the child's life when he or she grows into adulthood? Clearly the logic does not hold; but what is most disturbing is the reluctance to accept the pain and suffering of childhood as being valid in its own terms.

In conclusion, current research, as well as clinical observation, strongly suggests that children are traumatized and suffer emotionally as a direct result of their being sexually abused. Browne and Finkeihor (1986) put it succinctly:

Because of the general lack of research in this field, clinicians have only recently been able to substantiate their impressions that sexual abuse is traumatic with evidence from strong scientific studies. However, as evidence now accumulates, it conveys a clear suggestion that sexual abuse is a serious mental health problem, consistently associated with very disturbing subsequent problems in some important portion of its victims. (p. 72)

As will be elaborated upon later in this book, the currently available findings of long-term impact are especially persuasive.
- Sullivan-Everstine, Diana, & Louis Everstine, Sexual Trauma in Children and Adolescents: Dynamics and Treatment, Brunner/Mazel Publishers, Inc.: New York, 1989.
The article above contains foundational information. Articles below contain optional updates.

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Personal Reflection Exercise #7
The preceding section contained information about key symptoms in the assessment of sexual trauma. Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 21
How is the traumatic sequelae of childhood sexual abuse thus described by Sullivan? Record the letter of the correct answer the CEU Answer Booklet.