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Child Sexual Abuse

Child Sexual Abuse

                    Child Sexual Abuse on Mental Health

Over the past few years, the discussion on child abuse has caught the attention of academicians and policymakers. ("PBC 2019: Child abuse on the global level", 2019) This may be attributed to the increase of the abuse globally, high report rate and awareness in the media. One of the most common forms of child abuse is child sexual abuse (CSA). In light of this, experiencing CSA has been considered to be a risk factor for mental health. The effects are devastating and they can last throughout the life of the victim. Numerous studies have reported the long-term impact of CSA on the welfare of individual including aspects such as mental health problem. For instance, Jonas et al., (2011) investigated the link between CSA and psychiatric disorder in England. In addition, Bebbington et al., (2009) has also investigated the link between suicide attempt and CSA. From the findings, CSA is associated with high suicide attempt among the women. CSA also affect the brain negatively. For instance, on scans, a significantly diminished brain volume is noted in females who have been victims of CSA, which indicates that early trauma has a direct proportionality to the development and structure of the brain (Bremner et al., 2005). This essay, therefore, seeks to explore the effects of CSA on the mental health. It then follows on to the behavioural aspects of mental health functioning with particular attention to alcohol and substance abuse in child sexual abuse victims and risky behaviours and adjustment difficulties of child sexual abuse victims.
Over the past couple of years, sexual abuse on children has consistently increased across the nations. ("PBC 2019: Child abuse on the global level", 2019) In light of this, different definitions have been accorded to childhood sexual abuse. However, there is an agreement that CSA is a complex phenomenon that occurs for various reasons, various ways and in different relationships. This being said, CSA is a type of child abuse that may occur in different settings such as home, as well as school. As such, CSA is considered as a sexual act, covert or overt in which the adult coerce or seduce the child to participate in this act (Van Hasselt & Hersen, 2000). Moreover, World Health Organisation (1991) contends that CSA takes into account the act of involving a child in sexual acts that he or she lacks the capacity to comprehend is incapable of giving consent. Childhood sexual abuse include activities such as intercourse or attempted intercourse, fondling of genital directly or through clothing as well as oral-genital contact among other activities.  CSA may also comprise of other non-contact activities such as involving the child in watching pornography materials. 
The effects of child sexual abuse (CSA) can be long-term, complex, varied as well as devastating that extend to adulthood. In light of this, CSA has negative impacts on the wellbeing of the victims. 
By clinical psychologists, depression has been reported as the most common mental health issue that is caused by CSA.  In light of this, it is observed that the early onset of depression in the victims can be traced to CSA. In fact, lifetime rates of major depressive disorders have been found to be higher in victims of CSA compared to individuals that have not experienced childhood sexual abuse. (Anda et al. 2006) In addition, survivors of CSA may find it challenging to externalise the abuse, (i.e. verbally express the incident in public) which increases the opportunity of negative thoughts about themselves. Long et al., (2006) opine that after a long duration of negative self-thoughts, the victims of child sexual abuse usually experience the feeling of worthlessness as they tend to believe that they have nothing to offer. Also, individuals who have been sexually abused in early life experience high painful negative emotions.  While trying to cope with these negative emotions, these individuals may engage in behaviours aimed at surpassing the emotions or avoid them, which further aggravate the depression. Trauma in early life has more profound impacts that are long-lasting. In reference to McCann and Pearlman (2015), trauma subsequently leads to overwhelming stress, in which an individual lacks the ability to effectively cope with the emotions that result from a particular event. 
In light of this, childhood trauma can be considered as a contributory factor in the development of depression in victims or survivors of CSA. More specifically, the link between trauma and high risk of adult depression has been confirmed in various cross-section and longitudinal studies. (Deblinger, Mannario, Cohen & Steer, 2006)  For instance, a study by Fergusson et al., (2008) found that both male and female victims of CSA were more likely to develop depression in their adolescence and adulthood compared to those that have not experienced CSA. CSA may cause the trauma to last into adulthood due to the impaired structure as well as the functioning of the cells in the anterior cortex. This is given to the fact that this is the part of the brain that plays a pivotal role when it comes to the regulation of mood as well as emotion. These changes are what that contributes to depression. 
Early childhood sexual abuse is linked to later psychotic disorders. In this view, psychotic disorders like PTSD are considered to be severe mental disorders that lead to abnormal perception as well as thinking. (Deblinger, Mannario, Cohen & Steer, 2006) People with these disorders tend to lose touch with reality. People with mental illness have reported a high prevalence of childhood trauma. Recent studies have linked child sexual abuse with psychotic disorders especially Schizophrenia and delusional disorders. This has been echoed by Cutajar et al., (2010a) that children who have been abused sexual with abuse involving penetration have a high risk of developing psychotic disorders. In this study, a group of 2759 individuals who had documented evidence of child sexual abuse was collected from the Victorian register. From this study, the individual who had experienced CSA had high chances of developing psychotic disorder especially Schizophrenia. Also, factors such as more penetrations, more perpetrators and early age increase the risk of receiving a diagnosis for psychotic disorder. The victims don’t get diagnosed, and in turn, become increasingly self-destructive.
The disturbing nature of CSA and the victim lacking control over the sexual abuse increase the risk of Psychosis. Friedman and Tin (2007) contend that the victim of CSA is forced to internalise the abuse by the society’s demand for secrecy, of which the abuser becomes a symbol. This blocks their social engagement leading to isolation and consequently the development of the psychotic disorder. (Bebbington et al., 2011) Also, children who have experienced sexual abuse at an early age faced the risk of developing this disorder, unlike those that have not experienced CSA at an early age. This means that CSA is a key determinant when it comes to the development of the psychotic disorder.  A study by Gracie et al., (2007) has shown that aspects such as anxiety, negative perception about oneself as well as depression partly mediate the link between CSA and psychotic disorder. Therefore, the above mentioned pathways are a possible mechanism that espouses the link between childhood trauma especially CSA and Psychotic disorder. Also, penetration is a key factor that influences the development of depression among the victims.  For instance, Gracie et al., (2007) contend that severe forms of CSA such as intercourse is associated with severe mental health issues unlike in less severe CSA such as touching. From this, it is evident that the more the abuse the more the victim is likely to develop mental health issues such as depression. From the above discussion, it is evident that CSA is a key contributor for the development as well as an increase of Psychotic Disorder. 
CSA has been associated with has been linked to high incidences of Post Traumatic Stress Disorder or PTSD.  PTSD is a mental health disorder that results from the flashback, uncontrollable thoughts about a particular event, and terrifying events among other factors. Given that CSA causes trauma, the victims have been found to have a high proportion of social anxiety and panic attack. The State-Trait Anxiety Inventory for Children has found self-reported symptoms of both State and Trait anxieties in the victims of CSA. (Deblinger et al. 2006) Research has revealed that women survivors usually experience more severe problems like social anxiety and manic depression as compared to that of men (Ryan et al., 2000). In this light, anxiety disorders in the female are greater when the abuse has been severe and multiple. However, some of the studies have contradictorily revealed that male survivors of CSA may experience severe problems than the female survivors. For instance, a study by Hunters (1991) revealed that anxiety, as well as rumination, is common among the male victims and survivor of CSA. However, a range of meta-analysis has not demonstrated a noteworthy gender difference with respect to mental health problems (Hillberg et al., 2011).  This is consistent with other reports that articulate that male survivors are more likely to internalise the effect of CSA while female are likely to externalize the resulting effect in their behavioural patterns (Dorahy& Clearwater, 2012; Romano & De Luca, 2001). 
 There has also been a positive association between suicide attempt and self-injurious behaviour in both the adolescents and adults.  As such, there have been studies linking CSA with suicidal thoughts, suicide attempt as well as actual suicides. A study that involved approximately 1900 women in primary care reported that CSA was linked to high frequency of attempted suicide in adulthood (Maniglio, 2011). In addition, CSA was found to be a primary etiological factor for self-inflicted injuries. This study has also indicated that sexual victimization in childhood is linked to suicide in adulthood or self-injury. This is true for both female and male victims. This study is in line with Nelson et al., (2002) argument that both suicidal behaviour and non- suicidal kind of self-injury are a common outcomes of CSA survivors. These behaviours are considered as deliberate given that the victims engage in them to minimize stress resulting from the sexual abuse. (Weierich & Nock, 2008) Various studies have also found a strong association between CSA and self-harming behaviour among the CSA survivors. For instance, women DeCamp and Bakken (2016) found that women that have experienced childhood sexual abuse were more likely to engage in self-harming behaviour. In this context, self-harming behaviour facilitates a feeling of relief and also enables the victim to feel control of a previous situation that was unmanageable. By self-harm, the victim reaches the moment of trauma and is released of stress related to the traumatic moment. (Weierich & Nock, 2008)
There has also been a report of attempted suicide that has been reported in primary care sample. Also, a co-twin study by Briere and Elliott (2003) found that suicide attempt was high among the victims and survivors of CSA.  This is unlike the individuals who were not exposed to sexual abuse in their childhood. Dube et al., (2005) has also found the association between CSA and suicidal behaviour or attempt in adulthood. From these studies, it is evident that childhood trauma resulting from CSA can cause suicide or suicide attempt in adulthood. Despite the fact that various studies denote a high rate of suicidal self-injuries among the victim of CSA, there is no consensus concerning the pathways of the association between CSA and suicide. This can be attributed to the limitation of the methodology being applied in regard to the CSA. Impliedly, most of the studies and the literature review are characterized by subjectivity and the quality and validity of data has not been assessed.  
Despite the fact that a plethora of studies has shown the link between CSA and mental health issues, it is of profound importance to note that a considerable number of studies have failed to adequately control for probable confounding factors. These factors may comprise other form of abuse, social-demographic factors as well as family and peer functioning. However, this picture is complex due to various reasons. First, there has been evidence that children who have experienced victimization previously are likely to experience this act again as either adolescents or adults. Secondly, Espejo et al., (2006) has found that that being exposed to childhood adversities such sexual abuses increases the effect of stress in adulthood. For instance, female and male victims with adversities mentioned above were more likely have a mental disorder when faced by a stressful situation than those that do not have these adversities (McLaughlin et al., 2010). These findings are consistent with Finkelhor et al., (2007) that children who were victimized were more likely to show a high level of trauma symptoms. But then, even these studies fail to take into account the multifaceted  confounding factors of social demography and familial and economic situations of the victims. 
Speculation of whether there is a positive correlation between CSA and later development of clinical disorder has continuously persisted. Some of the studies have uncritically accepted that CSA is a risk factor of developing eating disorder in adulthood.  In light of this, some of the common eating disorders such as bulimia nervosa affect women differently and it is believed that they involve a complex feeling of the bodies and this might have originated from the experience of being abused sexually in childhood (Jonas et al., 2011).   From this, a case can perhaps be made that there is a link between individuals suffering from eating disorders and individuals who have experienced sexual abuse in childhood. But it is not a strong one, as individuals suffering from anorexia and bulimia do not necessarily have a history of CSA. The fact that studies have found a correlation does not mean that it indicates the cause. From this, CSA can be considered as a nonspecific factor implying that it can lead to psychiatric problems which include eating disorders. 
Sanci et al., (2008) has reported that CSA is positively associated with eating disorders. In this study, 999 adolescents’ female students with an average age between 14 and 19 were selected for the study. The study participants were followed until they were young adults to establish whether they had developed anorexia nervosa and bulimia nervosa. From the findings, 35 of the students had developed bulimia while 32 had developed anorexia. The researcher then measured sexual abuse in these students and approximately 96% of the students with eating disorders had approximately one episode of sexual abuse while 70 percents were exposed to multiple episodes of abuse.  The study found a strong link between CSA and Bulimia but no link was found between CSA and Anorexia. From the finding, it is evident that CSA is a factor which could predispose to Bulimia. Many people who have experienced CSA usually develop an eating disorder as a means of survival.  This is given that eating disorder tends to convince the victim that behaviours related to eating disorders are healthy. In other words, the victims engage in this behaviour as a way of relieving stress and hence this behaviour appears strong or useful during a stressful event. Therefore, despite the fact that trauma and eating disorder are two distinct issues, the victim tends to understand them as one thing. (Wonderlich et al. 1997) This means that victims tend to feel that eating disorders are a way of coping with stress and trauma. Kendler et al. (2000) also found a link between CSA and Bulimia nervosa. From this, it can be depicted that CSA is a risk factor for eating disorders in adulthood.  Sexual abuse may lead to negative belief about oneself. Therefore, survivors of CSA may struggle with emotions which may trigger impulsive behaviours normally associated with Bulimia Nervosa. Therefore, the trauma caused by CSA and the negative belief about oneself serves as the risk factor of developing eating disorders.
Behavioural aspects of mental health functioning 
Alcohol and substance abuse in CSA victims
A sizeable literature has clearly reported the link between CSA and substance abuse. (Wilsnack et al., 1997; Ullman et al. 2009) The likelihood of developing alcohol disorder among the CSA survivors has also been considered to be high, with the abuse starting an early age (Zlotnik et al., 2006). In reference to population-based studies, alcohol and substance abuse disorders are commonly found among the adolescents and adult when compared with the individuals that have not been the victims of CSA. In fact, Cutajar et al., (2010b) reported that the odd ratio ranges between 1.01 and 8.9. More specifically, the likelihood of CSA survivor of developing alcohol and nicotine dependence has been found to be high (Nelson et al., 2002).  Also, these individuals are likely to struggle with alcohol as well as substance abuse disorder throughout their life. In light of this, a study found that women with a history of CSA who had a lifetime dependency on alcohol were 16 percent compared with 8 percent of those that had not CSA (Molnar et al., 2001). The study also found that 39 percent of male survivors had a lifetime dependency on alcohol compared to 19 percent of the men who were non-victims. However, there are limitations with the study as it takes into account only a limited number of individuals for the survey.
 A history of CSA is considered as a cause of addictive actions among the individuals who abuse alcohol among other substance. Substance abuse among the CSA victim is considered as a coping mechanism for stress as well as negative self-feeling that result from sexual abuse trauma. This is consistent with Lee et al., (2008), that alcohol and substance abuse as a blocking mechanism to the psychological pain given that it allows an individual to disassociate themselves from the traumatic memories of the sexual abuse.  Also, Delima and Vimpani (2011) have articulated the effect of alcohol and other substance on hyper-arousal symptoms.  The author further contends that adolescents use these substances as a form of self-medication to relieve them from traumatic memories of CSA. 
Age is considered as a contributory factor on the likelihood of substance abuse in adulthood.  In light of this, the younger the victim was during the occurrence of sexual abuse, the likelihood to develop abuse among other disorders in adulthood (Lee et al., 2008). However, finding from Clay et al., (2000) contrast stating that the likelihood of younger victims abusing alcohol among other substance is less. CSA Also, the victims who were sexually abused at an early stage tend to develop more depression unlike those that were exposed to abuse at an old age.  Impliedly, sexual abuse at an early age tends to have more devastating effects on the victim.
The gender of the CSA victim is also an influencing factor in respect to substance abuse. For instance, Marcenko et al., (2000) found that female victims and survivors who are in substance treatment centres are victims of childhood sexual abuse. In another study by Berry and Sellman (2001) 51 percent of the participants stated that they had experienced various forms of CSA such as vaginal penetration, anal as well as oral. In contrast to these findings, Rohsenow et al., (1988) reported that alcohol, as well as substance abuse, was not common in male victims of CSA. Instead, the abuse is linked to other variable but not trauma resulting from CSA. However, the high rate of alcohol and substance abuse is likely to be common among the women who were sexually abused in their childhood.  From this, it is evident that gender plays a fundamental role when it comes to the likelihood of alcohol and substance abuse among the victims of CSA. 
When it comes to treatment of alcoholic, those with a history of CSA have low treatment outcomes when compared to those that have not experienced the abuse (Rice et al., 2001).  From this, it is evident that CSA may influence the treatment outcome of the CSA survivors.
A sizeable literature link CSA with risky-sexual behaviour among adolescents and adults.  As such, the neurobiological dysregulation from the CSA and its negative impact on the psychological as well as cognitive development can exacerbate risky sexual behaviour. This is given that CSA tends to create as sense of powerlessness as well as low self-esteem among the victims, which limit an individual ability to negotiate of maintaining a secure relationship or refraining from risky-sexual behaviour. 
CSA has also been found to influence the attitude of women victims with respect to sexuality. In this view, women who are the victims of CSA have been found to be preoccupied with sexual thoughts. This is unlike those that have not experienced the abuse. In addition, women victims have also been found to have permissive attitudes, which influence their sexual behaviour. For instance, they may have a positive attitude in regard to having multiple sex partners or having sex for money (Campbell, et al, 2004). On the other hand, female victims of CSA may also have negative perceptions with respect to their sexuality and some may even believe that sex is frightening. CSA has been linked with the early start of consensual sex, teenage pregnancy, multiple partners as well as unprotected sex among the adolescents (Senn et al., 2008; Upchurch & Kusunoki, 2004). This is also the same among the s adult survivors who have exhibited similar sexual behaviours. For instance, partner swapping as well as group sex is common among the victims and survivors of CSA (Wyatt et al., 1992). However, the extent of engaging in risky-sexual behaviour varies based on the age and genders. In this view, women between the age of 18 and 21 who have experienced CSA showed an increased rate of multiple sexual partners, STI, low off of using condoms, abortions as well as unhappy pregnancies when compared with that had not experienced CSA (van Roode et al., 2009).  Among the men survivor, the study found that multiple partners were more between the age of 2 and 32 and acquiring herpes simplex virus type ranged between the age of 21 and 32. From the above discussion, it is evident that CSA is a risk factor for risky sexual behavior in adulthood. 
CSA victims may use sex as a mechanism of obtaining affection. Also, CSA may change cognitive development, which may trigger the CSA victim to consider risky sexual behaviour in a positive manner (Smith et al., 2004). CSA victims may also result in substance abuse as a coping strategy which may result in risky sexual behaviour given that substance abuse is positively associated with risk-sexual abuse. Wright et al., (2007)  also indicated that CSA survivors may engage in sexually risky behaviour as a means of avoiding emotional distress as well as traumatic memories related to the abuse. Other studies have also espoused that CSA experienced is characterized by a feeling of stigmatization, negative emotional feeling as well as isolation that makes the victim prone to negative sexual experiences. Also, CSA has been found to diminish the victim ability to cope, critical motivational as well as interpersonal factor thereby influencing their sexual behaviour in their adolescent and adulthood. 
From the discussion above, it is evident that sexual abuse on children is linked with detrimental effects to the survivors, which last throughout the life. From the discussion, CSA has been linked to mental problems, such as depression, psychotic disorder, and PTSD, Suicide and self-injurious behaviour as well as eating disorders among the survivors. In this view, CSA trauma has been established a key factor that influences the development of depression developing depression in among both the male and female survivors. This discussion has found that that CSA plays a key role in the development of psychotic disorder especially schizophrenic. This given that the trauma caused by CSA Also, increased the trauma caused by CSA tend to make the victim to lose touch with reality. The number of perpetrators and also the extent of penetration have also been considered o increase the rate of developing psychotic disorder among the survivors. From the discussion, CSA is linked to a high proportion of social anxiety and panic attack among the CSA survivors. In addition, CSA is linked to suicide as well as self-injurious behaviour among the survivors. This can be attributed to trauma caused by CSA. The findings of this paper have also explained a strong association between alcohol abuse and childhood sexual abuse.  This is because substance abuse act as self-medication to block traumatic memories related to CSA. This discussion has established that victim and survivors of CSA are more vulnerable to suffer from a lifetime substance abuse disorder unlike those that have not experienced CSA. A strong link has also been found between CSA and risky sexual behaviour. For instance, CSA is likely to engage in group sex, multiple partners as well as unprotected sex which increase their risk of contracting STIs. To this end, it is deducible that CSA has devastating effects on the mental well being of the victim there the implication on this is that more intervention especially counselling should be made available to the victims. 
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