Sexual Assault Victimization Across the Life Span 2e, Volume 1: Investigation, Diagnosis, and the Multidisciplinary Team

By Angelo P. Giardino, MD, PhD, Diana Faugno, MS, RN, CPN, Mary J. Spencer, MD and 2 more

462 pages, 192 images, 38 contributors

This first volume serves as a complete guide for multidisciplinary team members involved in the investigation of sexual assault. It includes comprehensive medical guides for the diagnosis and treatment of assaultive trauma; legal guides to investigation and prosecution; and guidelines for the role of first responders in cases of sexual assault, including EMS and law enforcement professionals.

Supplemented by nearly 200 full-color photographs, this new title offers an excellent visual reference for professionals in the field, in addition to in-depth guidelines for diagnostic and investigative procedures in response to sexual assault.

• Language: English
• Publisher: STM Learning
• Release date: Jan 15, 2017
• ISBN: 9781936590476

Angelo P. Giardino, MD, PhD

Angelo P. Giardino, MD, PhD, MPH, FAAP is the medical director of Texas Children's Health Plan, a clinical associate professor of pediatrics at Baylor College of Medicine, and an attending physician for the Texas Children's Hospital's forensic pediatrics service at the Children's Assessment Center in Houston, Texas.

Book preview

Chapter 1

HEALTH CONSEQUENCES OF SEXUAL TRAUMA ACROSS THE LIFE SPAN

Elizabeth Lee, PhD, APN, ACNS-BC

Patricia M Speck, DNSc, APN, FNP-BC, DF-IAFN, FAAFS, FAAN

PURPOSE OF CHAPTER

Sexual trauma experienced in childhood or as an adult has impact beyond temporal bruises, soft tissue injury, or broken bones.¹ The wounded psyche, left unhealed, can yield detrimental health consequences throughout life.² Not all negative health outcomes result from learned self-destructive lifestyle choices of trauma survivors; spontaneous unmitigated and functioning psychological and physical changes, possibly permanent, occur after trauma exposure. The purpose of this chapter is to present normal physical, psychological, and behavioral outcomes of sexual trauma in both genders across the life span. As scientific knowledge of the internal biological changes wrought by all trauma expands, including natural and human-born disaster, future evidence-based care must challenge the entrenched habits of blaming victims of traumatic sexual abuse for their own suffering and focus on providing hope, evidence-based insight and viable options for empowered healing.

OBJECTIVES

By the end of this chapter, the reader will be able to:

—Define child abuse and maltreatment, domestic violence (DV), intimate partner violence (IPV), elder abuse, rape, and sexual violence.

—Relate the history of trauma to vulnerable populations.

—Describe the long-term functional biobehavioral outcomes of trauma exposure.

—Review current interdisciplinary strategies to prevent and treat traumatic exposure and consequences of abuse in vulnerable populations.

KEY POINTS

1.Not all negative health outcomes result from learned self-destructive lifestyle choices of trauma survivors; spontaneous unmitigated and functioning psychological and physical changes, possibly permanent, occur after trauma exposure.

2.Irrespective of gender, sexual abuse, assault, and rape can and does occur in children, adolescents, adults, elderly, and intimate partners in any population, regardless of culture and socioeconomic status.

3.An increasing body of sexual trauma research supports association or relationship with a plethora of physical, psychological, and behavioral disorders.

4.Increased awareness of long-term and lingering health outcomes after sexual trauma is needed in the community of health care providers and other sexual response team members.

5.Providing a trauma focused care from professionals responding to sexual trauma survivors can diminish the predictable cascade of negative health outcomes experienced through the life span.

KEY TERMS

—The adverse childhood experiences (ACE) instrument is a tool that measures self-reported personal childhood emotional and physical abuse and neglect, childhood sexual abuse, along with a history of household illicit drug use, maternal battering, parental separation or divorce, and family member mental illness, incarceration, or attempted suicide.³

—Child abuse includes any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child.⁴

—Child sexual abuse is the involvement of a child in a sexual activity that he or she does not fully comprehend, is unable to give informed consent to or for which the child is not developmentally prepared and cannot give consent to, or that violates the laws or social taboos of society.⁵

—A cultural group is a specific religious, racial, or ethnic group and any other group with its own distinct values, beliefs, and practices, such as senior citizens, deaf and hard-of-hearing communities, populations with differing sexual orientations, the homeless, military personnel and their dependents, adolescents, prison inmates, and victims of sex trafficking.⁶

—Elder abuse is a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person.⁷

—A first responder is a professional who responds in an official capacity to an initial disclosure of a sexual assault.⁶

—Intimate partner violence is physical, sexual, or psychological harm by a current or former intimate partner or spouse.⁸

—Military sexual trauma (MST) is defined as psychological trauma, which in the judgment of a mental health professional employed by the Department [of Veteran Affairs], resulted from a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment which occurred while the Veteran was serving on active duty or active duty for training.⁹

—Rape is defined as nonconsensual oral, anal, or vaginal penetration of the victim by body parts or objects using force, threats of bodily harm, or by taking advantage of a victim who is incapacitated or otherwise incapable of giving consent.¹⁰

—Sexual assault forensic examiner (SAFE) is a broad term for all health care providers (ie, physicians, physician assistants, nurses, or advance practice nurses [APNs]) who received specialized education and clinical training to conduct a forensic medical examination (FME) following sexual assault.¹¹

—Sexual assault nurse examiner (SANE) is defined as a registered nurse who has advanced education in FME of sexual assault victims.¹²

—Sexual assault response team (SART) is a team of individuals, typically the SANE or SAFE, rape crisis center advocate, and law enforcement and emergency room (ER) medical personnel, who either work as a team at the time of the sexual assault examination or provide services independently but communicate frequently about cases.¹²

—Sexual harassment is repeated, unsolicited verbal or physical contact of a sexual nature, which is threatening in character.⁹

—Sexual violence is defined by the World Health Organization (WHO) as, any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic women’s sexuality, using coercion, threats of harm or physical force, by any person regardless of relationship to the victim, in any setting, including but not limited to home and work.⁵

—Survivor is a sexual assault victim who is involved in long-term healing.⁶

—Trauma refers to a serious or critical emotional distress that threatens self-perception and identity, fundamental assumptions about the world, and connection to people and activities that were once meaningful.¹³

—Vulnerable groups are individuals at greater risk of sexual assault and include women who are alone or single parents; children of all ages, especially those in foster care; all individuals in an abusive relationship or with a previous history of sexual abuse; individuals with physical or mental disabilities or drug or alcohol problems; incarcerated individuals; and those involved in prostitution, victims of war, and homeless populations.⁵

HISTORY

Murder, incest, and rape with associated personal and social consequences are clearly described in some of the earliest accounts of human behavior (Genesis 19 and 32; Judges 19 [New International Version]). Although trauma from physical and sexual assault can be traced throughout the history of human life, legal action to protect children and the elderly from abuse was not established in the United States until late in the twentieth century.¹⁴ The first Federal legislation to protect children was enacted in 1974 by passage of the Child Abuse Prevention and Treatment Act (CAPTA), Public Law 93-247.¹⁵ The United States (US) Surgeon General C. Everett Koop declared violence a public health problem and intimate partner violence (IPV) an epidemic in 1985.¹⁶,¹⁷ Another decade and years of congressional hearings occurred before the Violence Against Women Act (VAWA) of 1994 was signed into law to protect women and their children from rape, IPV, and stalking.¹⁸ Public Law 102-585, Veterans Health Care Act of 1992, was amended by Public Law 103-452, Veterans Health Programs Extension Act of 1994, to establish programs to offer counseling and treatment for victims of military sexual trauma (MST).⁹ The Older Americans Act of 1965 established the Administration on Aging and laid groundwork for Title VII which provides state funding for protecting elders as a vulnerable population from abuse, neglect, and exploitation.¹⁹,²⁰ Although attempts have been made to solidify general risk factors for abuse and neglect, sexual assault can happen to anyone of any age and gender (Table 1-1). Thus, enactment and enforcement of legal protection for those at greatest risk of traumatic abuse continues to evolve in the US and globally.

Often hidden, early childhood and adolescent abuse is widespread and creates insidious lifetime potential for a plethora of adverse health outcomes.²⁵ The World Health Organization (WHO) found 1% to 21% of women experienced child sexual abuse before 15 years of age.²⁶ The National Intimate Partner and Sexual Violence Survey (NISVS) reported 1 out of 5 women and 1 out of 7 men in the United States experienced rape and the first rape often occurred before adulthood.²⁷ In the Nurse’s Health Study II, 54% of registered nurses reported physical abuse and 34% acknowledged sexual abuse occurred during childhood or adolescence.²⁸ Conversely, 18.4% of insured men reported childhood physical or sexual abuse.²⁹ In the longstanding Adverse Childhood Experience (ACE) studies of health maintenance organization (HMO) enrollees, the frequency of childhood sexual abuse in females and males was lower, 25% and 16% respectively.³⁰ Public awareness of child abuse was bolstered by publication of an article on the battered child syndrome.³¹ The Centers for Disease Control and Prevention (CDC) established definitions and guidelines that promote uniformity of data collected from research on violence.³² Increasing evidence of association between self-reported childhood abuse and detrimental health is strongly supported by numerous ongoing studies of adults spanning several decades²¹,²⁵,³³ (Table 1-2).

Table1-1Table1-1aTable1-2Table1-2aTable1-2b

Abuse may be an isolated event or occur in cyclic waves throughout the life span. According to WHO, 13% to 61% of women sampled worldwide admitted experiencing physical violence and 6% to 59% reported sexual violence by a partner during life.²⁶ In 1997, the CDC announced IPV as the leading cause of death in young women aged 15 through 24 years of age.¹⁶ Of adult women surveyed, 53.6% experienced physical or psychological IPV, or both, in their lives.³⁵ Older women were not immune from IPV with 5.5% remaining in an abusive relationship,³⁶ while 35.5% of those aged 50 through 56 years of age admitted IPV occurred sometime in adulthood³⁷ and 26% of those aged 65 years or older also had lifetime IPV prevalence.³⁸ Men reported 28% lifetime exposure to either physical contact abuse or nonphysical angry threats and control, but only 1% reported sexual IPV.²⁹ Although female gender correlated with higher trauma scores than male gender,³⁹ IPV occurred among diverse social, racial, and ethnic groups of all ages.⁴⁰

Consistent with civilian reports, traumatic sexual abuse in the military occurs more among females than males. A larger percentage of female than male reservists reported military sexual harassment (60% versus 27.2%) and sexual assault (13.1% versus 1.6%).⁴¹ Abuse is not limited to a stereotypical weak victim; it can affect anyone targeted by an opportunistic or anger driven perpetrator. Long-term negative health consequences are strongly associated with MST.⁴²

REVIEW OF THE LITERATURE

The intent of this literature review is to create awareness among multidisciplinary teams, especially health care providers, about how sexual assault affects the victim’s health immediately and beyond. Long-term health effects associated with rape and sexual abuse have often gone unrecognized and untreated, even in premiere health care settings. The physical, neurobiological, mental health, and behavioral consequences of trauma are supported by research from numerous disciplines. The intent of the following section is to provide a quick reference for concerned professionals wanting to improve both personal and professional knowledge and trauma-informed care skills and to knowledgably respond to individual questions from survivors of sexual abuse who are on a quest to mitigate lingering effects of rape.

PHYSICAL HEALTH CONSEQUENCES OF TRAUMA

General Health Function

Sexual, physical, and emotional abuse can affect the function of each body system and erode general health. As shown in Table 1-3, there are many physical health consequences of sexual trauma and the list is growing as researchers begin to understand the neurobiology of trauma across the life span. Diminished quality of life and perception of poorer general health occurs in adolescents and adults who experienced childhood sexual abuse (CSA) and other forms of childhood maltreatment. Adults of all ages who reported CSA had a combined significant and sustained decrease in health-related quality of life (P < .05) compared to adults who reported no childhood physical or emotional abuse or neglect.⁴³ Adolescents and young adults who reported CSA were more than twice as likely to report fair to poor health (P < .001) than those who did not report any form of abuse or neglect.⁴⁴ Adult HMO members who reported CSA (22%) also reported high rates of childhood psychological (47%) and physical (44%) abuse and household dysfunction (ie, 34% substance abuse, 37% mental illness, 41% maternal battering, and 40% incarceration). A significant dose- response relationship was found between the number and duration of adverse childhood experiences (ACEs) and risk factors for the leading causes of death in adults.⁴⁵ Life expectancy decreased by 20 years (60.6 years versus 79.1 years) with exposure to 6 or more ACEs in HMO enrollees tracked over a decade.⁴⁶

Although more studies have been conducted with women, adults of both genders who experienced IPV reported poor health. In a seminal study of both genders, the National Violence Against Women Survey found more sexual assault (24%) and stalking (47%) among women who experienced extensive, multifaceted violence from an intimate partner and reported higher odds of self-perceived poor health in this group compared to women without systematic abuse.⁴⁸ Sexual assault (0.1%) and stalking (16%) were less frequent and poor health was reported less in men classified with systematic IPV compared to females surveyed. Reports of fair to poor general health were more common in women with both physical and sexual IPV than controls with no abuse.⁴⁹ Women with history of IPV reported significantly more total health problems than women without abuse (P < .05), and women with sexual abuse were more likely to have more stress-induced physical health problems.⁶⁴ In women seeking treatment, traumatic sexual assault and severity of posttraumatic stress disorder (PTSD) were predictive of the presence of physical symptoms (P < .001).⁶⁵ In women with severe PTSD following sexual, physical, or emotional abuse and neglect, the odds for fatigue was 9 times greater compared to women without PTSD.⁵¹ Traumatic abuse, with or without PTSD, drains energy and contributes to a worse perception of personal health in both genders.

Table1-3Table1-3aTable1-3bTable1-3cTable1-3d

Trauma in the military, including sexual harassment and sexual assault, can contribute to lower energy, poorer health, and increased disability. Female veterans serving from Vietnam to the Gulf Wars were interviewed for violent military experiences (41% rape, physical assault, or both); those with repeated violent events had significantly poorer health and experienced more outpatient visits (P < .05) than those who had single or no violence exposure.⁶⁶ Female veterans who reported military sexual trauma were twice as likely to have chronic fatigue than veterans without MST.⁵³ For both genders of US reservists, odds of somatic complaints (pain, gastrointestinal [GI], psychoneurological, and sexual symptoms) and medical conditions (diabetes, hypertension, arthritis, and cancer) increased with sexual harassment alone, but sexual assault increased symptoms more.⁴¹ Veterans of both genders with a history of MST also had significantly more service-connected disability than counterparts with MST (P < .001).⁵⁰ Female veterans with PTSD following traumas (including those with sexual trauma) reported more problems with general health and physical symptoms than female veterans without PTSD.⁶⁷,⁶⁸

NEUROLOGIC AND COGNITIVE FUNCTION

The ability to produce neurons and neural stem cells is affected by environmental conditions,⁶⁹ and for some, the environment is toxic. Childhood trauma from physical or sexual abuse can alter the limbic system (eg, amygdala, hippocampus, cingulated gyrus, thalamus, hypothalamus, and putamen) and related structures (eg, cerebellar vermis, prefrontal cortex, and visual and parietal cortex)⁷⁰ and decrease memory and cognitive function. Total corpus callosum area was smaller (15%) on magnetic resonance imaging (MRI) in abused or neglected children (P = .0001) compared to healthy controls; smaller corpus callosum size in girls was strongly related to sexual abuse.⁷¹ In sexually or physically abused and neglected children and adolescents, smaller corpus callosum size correlated with age of onset of PTSD (P < .05) with the corpus callosum and cerebral volume smaller in males than females.⁷² Maltreated children and adolescents also had larger total lateral ventricles, prefrontal lobe cerebral spinal fluid, intracranial volume, and a larger left hippocampus volume on MRI than controls; symptoms of intrusion, avoidance, hyperarrousal, and dissociation positively correlated with ventricular volume (P < .05 all).⁷²

Brain changes in some victims of trauma can persist into adulthood. Ten women with PTSD following CSA had significant increase in blood flow to the posterior cingulated, anterolateral prefrontal cortex, and left motor cortex, but significant decrease in medial prefrontal cortex, supramarginal gyrus, right hippocampus, visual association cortex, fusiform gyrus/inferior temporal gyrus, and dorsolateral prefrontal cortex (P < .001 all) while they listened to scripts related to their abuse compared to women with a history including CSA but not PTSD.⁷³ Compared to healthy adults, adult survivors of long-lasting (15 year mean) CSA and lifetime PTSD had smaller (12%) left hippocampal volume (P < .05) MRI regardless of gender and significantly lower verbal immediate recall (P < .0006), delayed recall (P = .0001), and memory retention (P = .024).⁷⁴ Adults with a greater number of exposures to childhood sexual and physical abuse had lower scores on a general achievement test.⁷⁵ Women with a history of CSA self-reported significantly more trouble learning, difficulty concentrating, memory lapses, and memory loss (P < .001 all) than women without CSA.⁷⁶ In a prospective study of women who experienced CSA, 38% did not even remember the traumatic abuse that was documented (mean = 17 years) earlier.⁷⁷ Self-reported neurological problems were more significant (P = .01) in women with CSA compared to women who reported no abuse.⁷⁸

Sexual trauma in the military, PTSD from violent events, and comorbid mental health disorders can complicate memory and cognitive performance in veterans. Female veterans with a history of MST had double, and male veterans had quadruple, the risk for attention deficit disorder (ADD) and both genders had triple the risk of impulse control problems compared to same-gender veterans with a negative MST history (P < .01).⁵⁰ Whether deployed or not, Gulf War veterans with current PTSD reported significantly more neurologic symptoms and conditions (P < .001) than those without PTSD.⁷⁹ Vietnam veterans with trauma exposure and PTSD had more episodes of blank spots in memory (P < .01) or forgetfulness (P < .05) than those without PTSD.⁶⁸ Veterans with chronic PTSD with comorbid dissociative disorder had significantly more PTSD avoidance symptoms (P = .008), worse attention span (P = .007), diminished word recall (P = .002), and decreased autobiographical memory (P = .049) compared to veterans with only chronic PTSD.⁸⁰ Aberrant size and function of the amygdala have also been implicated in borderline personality,⁸¹ bipolar disorder,⁸² and schizophrenia and other psychoses,⁸³ but trauma history was not monitored.

Alterations in brain function from stress and trauma create a cascade of neuroendocrine changes that affect lifelong health outcomes. Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis from chronically elevated corticotrophin-releasing factor (CRF) can occur with abuse.⁷⁰ Women with a history of childhood abuse and current depression exhibited a sixfold hypersecretion of adrenocorticotropin hormone (ACTH) with stress compared to controls (P = .001).⁸⁴ ACTH can prolong inflation of cortisol levels which impairs nerve growth, development, and function and results in neuronal death.⁸⁵ A malfunctioning prefrontal cortex fails to buffer overstimulation of the amygdala, and PTSD symptoms (eg, hypervigilance, exaggerated startle reflex, flashbacks, intrusive memories, and over-responsiveness to perceived threats) can occur.⁸⁶,⁸⁷ Prolonged cortisol and glutamate exposure can decrease memory processing and contribute to amnesia, dissociation, and numbing.⁸⁸ The adrenal gland releases epinephrine, which can trigger panic attacks and trauma flashbacks,⁸⁹ and norepinephrine, which can induce hypervigilance, anxiety, exaggerated startle, irritability, sleep problems, and nightmares.⁸⁸ Chronic traumatic stress can deplete serotonin levels with accompanying depression, aggression, and suicidal ideation and also increase dopamine with associated hypervigilance, inattention, paranoia, and psychosis.⁹⁰ Higher levels of substance P, which heightens pain perception, have been found in spinal fluids of abuse victims.⁹¹ Trauma at an early age can influence the severity of damage that occurs.⁹²

Pain Perception

Location of increased pain perception across the life span appears to vary by study and severity of trauma. Most civilian studies focus on pain in women. Women who reported childhood physical, sexual, or physical and sexual abuse had significantly more fatigue (P < .001) and pain in the face (P < .02), chest (P < .005), back, abdomen, pelvis, and genitals, including breasts (P < .001 all).⁹³ Women with CSA had significantly increased lower abdominal pain (P < .01)⁷⁶ and current pelvic pain⁵² than women without CSA. Women with CSA (P = .008) reported significantly increased chronic fatigue, while women with adult sexual abuse reported both chronic fatigue (P = .004) and pelvic pain (P = .002) compared to women without sexual abuse.⁹⁴ Higher trauma scores were significantly associated with chronic pain (P < .0001) but not familial or genetic ties in a study of monozygotic and dizygotic twins.³⁹ Generalized or regional pain can occur with traumatic abuse irrespective of genetic coding.

Studies of traumatized veterans give insight into gender differences in pain perception and introduce the influence of PTSD into the pain experience. Female veterans with PTSD reported significantly more aches and pains (P < .01) than males.⁹⁵ Female veterans with PTSD from mixed trauma seen in a veterans affairs (VA) medical hospital had more bodily pain (P < .05) and less vitality (P < .01) than those without PTSD.⁶⁷ Female Vietnam veterans with exposure to different types of trauma who had PTSD reported more fatigue and muscle weakness (P < .05) than those without PTSD.⁶⁸ Female veterans who reported MST were more likely to have back pain, knee pain, foot pain, and chronic pelvic pain.⁵³ MST appears to be associated with diverse locations of pain perception.

Headaches

Increased headaches, including migraines, and dizziness, can occur with abuse in civilian and veteran populations. McCauley et al⁹³ reported women with childhood physical abuse, sexual abuse, or both had significantly more headaches (P < .001) than women with no childhood abuse, while Romans et al⁹⁴ found women who experienced adult physical abuse (n = 0.05) had significantly more headaches and migraines (P = .05) than controls (n = 181) but headaches were not significantly associated with CSA.⁹⁴ Women with moderate and severe PTSD with a history of childhood sexual, physical, and emotional abuse had increased risk for dizziness, numbness, and headaches compared to women without PTSD.⁵¹ Female veterans with MST were twice as likely to have severe headaches or migraines compared to those without MST,⁵³ and female veterans with PTSD had significantly more dizziness (P < .001) and headaches (P < .001) than males with PTSD.⁹⁵

MUSCULOSKELETAL FUNCTION

Musculoskeletal complaints are common among adult survivors of child abuse. Women with a history of CSA had significantly increased reports of muscle soreness (P < .001), generalized weakness (P < .001), heaviness in extremities (P < .05), and backaches (P < .01) than other women.⁷⁶ From the National Comorbidity Survey, CSA increased the risk of adult arthritis.⁵⁷ According to the ACE Study, adult health risks in individuals aged 19 through 91 years of age, showed significant dose-response relationship between the number of exposures to ACEs and skeletal fractures (P < .05).⁴⁵ Development of PTSD after traumatization adds to the risk of musculoskeletal complications. Women with moderate to severe PTSD (related to dose response to sexual, physical, and emotional trauma) had increased odds for temporomandibular disorders and joint or back pain compared to women without PTSD.⁵¹ Civilian women with PTSD from mainly sexual assault, and men with PTSD from predominately combat and violence, were at greater risk of arthritis and joint problems compared to female and male adults without PTSD.⁵⁴ Female veterans with MST had almost double the risk for arthritis and more than double the risk for reporting a broken hip than those without MST.⁵³ Female veterans with PTSD, from traumas including sexual abuse, were 3 times more likely to have musculoskeletal diagnoses than those without PTSD,⁵⁵ and reports of fibromyalgia also tripled in women with PTSD from trauma types that included MST compared to women without PTSD.⁵⁶ PTSD may play a role in enhancing perception of musculoskeletal pain.

IMPAIRED AUDITORY AND VISUAL FUNCTION

Abuse can diminish vision and hearing. According to the National Comorbidity Survey, civilian women with PTSD from predominately sexual trauma⁹⁶ were at increased risk of vision or hearing loss compared to females who reported no PTSD⁵⁴; but men with PTSD, from mainly combat and violence exposure,⁹⁶ were also at increased risk of vision and hearing loss compared to men without PTSD.⁵⁴ Female veterans who reported MST were also more likely to have vision and hearing problems.⁵³

GASTROINTESTINAL FUNCTION

Early research provided foundational support for the effect of highly stressful life events on GI function. Patients with irritable bowel syndrome (IBS) reported significantly more stressful life events than normal controls (P < .05).⁹⁷ Self-reported GI problems were more significant (P < .001) in women with CSA compared to women who reported no abuse.⁷⁸ Women who reported childhood physical abuse, sexual abuse, or both had significantly more problems with choking sensation (P < .004), loss of appetite (P < .006), constipation (P < .001), and diarrhea (P < .001) compared to women with no history of abuse.⁹² Women with a history of CSA self-reported significantly more nausea and vomiting (P < .05), stomach pain (P < .001), and constipation (P < .01).⁷⁶ Childhood sexual abuse almost doubled the risk of stomach ulcers in both men and women compared to non-abused gender controls.⁵⁷ Risk of ulcers doubled in both genders with PTSD following abuse that included CSA.⁵⁴ PTSD from emotional, physical, and sexual childhood abuse in women increased odds tenfold for nausea, tripled the risk for diarrhea, and quadrupled the risk for constipation, when compared to women with no PTSD.⁵¹ PTSD following sexual trauma may magnify deleterious effects on the GI tract.

The same pattern of GI disorders can be seen in veterans traumatized from sexual abuse or other threatening events. Compared to female veterans without MST, those who reported MST had almost double the risk of stomach ulcers or gastritis and more than double the risk of having IBS or spastic colon and problems with gas or bloating, swallowing, and bowel function.⁵³ Female veterans with PTSD, over half of whom reported sexual assault, were twice as likely to have stomach cramps and gas compared to those without PTSD.⁶⁸ Female veterans with PTSD from various traumas, including sexual trauma, were almost 3 times more likely to have IBS compared to women without PTSD.⁵⁶ Gastrointestinal symptoms appear to be amplified by PTSD.

LIVER FUNCTION

A small group of studies explored the association of liver disorders with sexual trauma. The ACE Study on childhood abuse showed a significant dose-response relationship between the number of exposures to abuse and development of hepatitis or jaundice in adulthood (P < .05).⁴⁵ Eight risky behaviors (ie, use of oral or injected street drugs; present or previous heavy alcohol consumption, or a combination of the 2; intercourse before 15 years of age; more than 50 sexual partners; having a sexually transmitted infection (STI); or being at risk for acquired immune deficiency syndrome [AIDS]) account for a significant amount of liver disease (P < .001) with a history of alcoholism plus family drug use increasing the risk of liver disease over tenfold.⁹⁸ Hepatitis B or C (39%) and liver disease (17%) were frequently reported in a sample of drug court clients that included victims of sexual abuse.⁹⁹ A sevenfold increase in kidney or liver disease was found in civilian women and men with PTSD following traumas, including sexual assault.⁵⁴

Veteran men with MST had almost double and veteran women with MST had slightly greater odds of developing liver disease when compared to their counterparts with no MST (P < .01).⁵⁰ Excessive use of alcohol in the military to numb trauma pain has been suggested as a contributing factor to the increase of liver disease in traumatized veterans.

URINARY FUNCTION

Trauma, especially sexual abuse of women, can impair urinary function, and this impairment appears to be accelerated with the presence of PTSD. Women who reported childhood physical, sexual, or physical and sexual abuse had significantly more problems with dysuria (P < .02),⁹³ and women with a history of CSA had significantly more bladder problems (P < .001) compared to women without abuse.⁷⁶ Women who reported severe CSA had greater odds of lifetime functional dyspareunia than women with less severe or no CSA.⁵² Women with moderate and severe PTSD with history of sexual, physical, emotional abuse, had greater odds for dyspareunia compared to no PTSD.⁵¹ Both men and women who had an anxiety disorder plus PTSD, with forced sexual contact or rape the most common trauma, were 3 times as likely to report kidney disease than those without PTSD.⁵⁸ Impaired urinary function was also found in veterans. Female veterans with MST were twice as likely to have problems with urinary infections, bladder control, and limiting bladder problems compared to those without MST.⁵³

ENDOCRINE FUNCTION

Abuse in childhood or adulthood can lead to neuroendocrine disruption.¹⁰⁰ Initially with trauma exposure, a functioning hypothalamic-pituitary-adrenal (HPA) axis provides compensatory hormonal balancing or allostasis. However, repeated traumatic stress through actual or relived experience wears the body down, erodes the ability to maintain dynamic balance, and progresses to a depleted state of allostatic loading with HPA dysregulation.¹⁰¹ Women with CSA and major depression had a sixfold increase in corticotropin levels in response to laboratory-controlled stressors (eg, public speaking and arithmetic) compared to women without childhood abuse or major depression.⁸⁴ Endocrine disruption is not limited to the HPA axis, but can involve other endocrine organs.

Elevated levels of thyroid hormones, triiodothyronine (T3) and thyroxine (T4), have been found in civilian and military adults of both genders following trauma. Women with PTSD following CSA had significant large elevations of total T3 (P = .001) and the ratio of total T3 to free T4 (P = .004), with significant moderate reductions of TSH (P = .05), compared to a control group.¹⁰² Elevated T3 and T4 levels in women with sexual abuse–related PTSD can be compared to elevations found in combat veterans with PTSD.¹⁰³,¹⁰⁴ Changes in endocrine function that occur with traumatic stress can progress to thyroid dysfunction later in life.

Prolonged abuse can affect glucose metabolism and lead to diabetes mellitus. Women with CSA exposure reported significantly more problems with low blood glucose (P < .01) compared to women with no CSA.⁷⁶ Civilian women with PTSD from mainly sexual abuse had double the risk of having diabetes compared to women without PTSD.⁵⁴ Women with a history of sexual assault were at increased risk of having diabetes compared to women without sexual abuse; two-thirds of women with CSA and diabetes had an elevated body mass index.²⁸ Conversely an increased risk of diabetes in adults was found with a history of childhood neglect but not with CSA.⁵⁷ Diabetes was also diagnosed more in female veterans who had PTSD, from traumas that included MST, compared to those without PTSD.⁵⁶ Eating habits associated with sexual abuse and PTSD may be more related to development of diabetes than endocrine dysfunction.

Reproductive Function

The profound influence of traumatic abuse on endocrine function is manifest as a variety of reproductive disorders in women. Lower estrodial levels and higher follicle-stimulating hormone levels were found in women, in their forties not on birth control pills, who had a history of CSA compared to never-harmed women.¹⁰⁰ Women with a history of CSA self-reported significantly more pelvic pain (P < .01), dysmenorrhea (P < .05), vaginal yeast (P < .01), and coitophobia (P < .001),⁷⁶ and vaginal discharge occurred more often with a history of physical abuse, sexual abuse, or both (P < .001)⁹³ when compared to women without abuse. Women who reported severe CSA had greater odds of decreased libido and inhibited orgasm than women with less severe or no abuse.⁵² Women with moderate and severe PTSD from sexual, physical, or emotional abuse or combination of abuses were at increased risk for having premenstrual distress, sexual anhendonia, and anorgasmia compared to women with no PTSD.⁵¹ Both gynecological pain and sexual dysfunction occur more with sexual abuse.

Veterans of both genders with sexual trauma or PTSD are at greater risk of having problems with sexual function. Veteran women and men with MST had a significantly increased risk of having sexual dysfunction compared to same gender counterparts with no MST (P < .01 both).⁵⁰ Female veterans who reported MST were more likely to have problems with severe, debilitating premenstrual symptoms, dysmenorrhea, endometriosis, and severe menopausal symptoms.⁵³ Female veterans with MST exposure were almost twice as likely to have a hysterectomy before aged 40 years than those without MST.⁵⁹ Women who were treated at a VA medical center for PTSD, from exposure to traumatic events like MST, were more likely to have chronic pelvic pain, premenstrual syndrome, polycystic ovary disease, cervical cancer, and hysterectomy compared to women without abuse.⁵⁶ Sexual abuse and PTSD can affect future sexual health.

Problems with pregnancy are associated with history of abuse. Women with 4 or more ACEs were more likely to become pregnant at an early age.¹⁰⁵ According to the National Violence Against Women Survey, women who experienced systematic abuse, including sexual abuse (24%) by an intimate partner, were twice as likely to miscarry.⁴⁸ In a Denmark population study of single-fetus pregnancies, women with a high level of stress had 80% higher risk of having a stillborn infant compared to women with intermediate stress levels.¹⁰⁶ Female veterans with MST reported more problems becoming pregnant.⁵³

SEXUALLY TRANSMITTED INFECTIONS

Sexual abuse and having PTSD are associated with increased risk of acquiring STIs. The presence of 3 ACEs doubled the risk of acquiring a sexually transmitted infection for both men and women,⁶⁰ and this trend was consistent for several decades.³⁴ Odds of lifetime STIs were greater in women seen at a VA medical center with PTSD from traumas that included sexual assault compared to women without PTSD.⁵⁶ Veteran men had much greater odds of acquiring AIDS and veteran women with MST had slightly greater odds of AIDS when compared to their counterparts without MST (P < .01).⁵⁰

IMMUNE AND HEMATOLOGIC FUNCTION

Childhood maltreatment causes immune activation and chronic inflammation⁹⁰ that can persist through adulthood. Patients with two or more ACEs had almost twice the risk of hospitalization with Th1 (eg, insulin-dependent diabetes mellitus, idiopathic pulmonary fibrosis, irritable bowel syndrome, idiopathic myocarditis, and Wegener’s granulomatosis) or Th2 (eg, rheumatoid arthritis, thrombocytopenia purpura, systemic lupus erythematosus, dermatomyositis, Graves’ disease, Hashimoto’s thyroiditis, myasthenia gravis, scleroderma, and Sjogren disease) autoimmune diseases.⁶¹ From the National Comorbidity Survey, US adults had a fourfold increase of autoimmune disease with childhood neglect but not with CSA.⁵⁷ Conversely, civilian women with PTSD from mainly sexual assault were at greater risk for autoimmune disease compared to women without PTSD.⁵⁴ Both genders who had PTSD, with sexual assault as the most common trauma, were more likely to report anemia than those without PTSD.⁵⁸ Women who reported childhood physical, sexual, or physical and sexual abuse had significantly more frequent or serious bruising (P < .05).⁹³

The risk of all types of cancer doubled with exposure and an ACE score of 4 or more types of abuse.⁴⁵ Suggestive of a diminished immune system, women who experienced abuse an average of 6 years had a higher mean total white blood counts (P = .022), granulocytes (P = .04), and eosinophils (P = .49), and a higher median total thymus-dependent cell (T-cell), human immunodeficiency virus (HIV) cluster of differentiation four (CD4; helper cell), CD8 (HIV suppressor cell), and CD19 positive bone marrow derived (B-cell absolute counts) compared to controls.¹⁰⁷ The relative risk of lung cancer in adults doubled with an ACE score of 4 or 5.⁶² Physical or sexual victimization were significant predictor variables for the number of PTSD symptoms (P < .01) in women with cancer.¹⁰⁸ Impaired immune function is suggested with sexual abuse, but research evidence is still evolving.

RESPIRATORY FUNCTION

An array of respiratory symptoms may be attributable to abuse and associated PTSD. Women who reported childhood physical, sexual, or physical and sexual abuse had significantly more episode of shortness of breath (P < .006) than women without abuse⁹³ and women with CSA reported more asthma (P = .04).⁹⁴ Respiratory problems were more self-reported as more significant (P = .002) in women with CSA compared to women who reported no abuse.⁷⁸ In adults of both genders, there was a significant dose-response relationship between the number of exposures to abuse and chronic bronchitis or emphysema (P < .05),⁴⁵ early smoking (P < .001), and lung cancer (P = .001).⁶² An ACE score of 5 or more in HMO employees was associated with more than double the risk of chronic obstructive pulmonary disease and hospitalizations than that of coworkers with no history of abuse.⁶³ With women with moderate and severe PTSD from sexual, physical, and emotional abuse, odds for shortness of breath were increased,⁵¹ and both males and females who had PTSD, with sexual assault as most common, were more likely to report lung disease compared to those without PTSD.⁵⁸

Increased respiratory problems were also seen with sexual abuse in veterans. Female veterans who reported MST were more likely to have allergies or head congestion, report lung problems including asthma, emphysema, and bronchitis,⁵³ be current smokers compared to those without MST.⁵⁹ Emphysema and asthma were seen more often in women with PTSD that included trauma from MST compared to women without PTSD.⁵⁶ Increased association of smoking with MST may be a key to the increased likelihood of lung disorders with MST exposure.

CARDIOVASCULAR FUNCTION

Increased cardiac symptoms and cardiovascular disease were found with sexual abuse history in several studies. Women who reported childhood physical, sexual, or physical and sexual abuse reported significantly more problems with chest pain (P = .005).⁹³ CSA survivors reported more chest pain (P < .001), palpitations (P < .05), and dizziness or presyncope (P < .001),⁷⁶ and heart problems (P = .03)⁹⁴ than women with no abuse in their history. CSA in both genders was associated with over 3 times the risk of cardiac disease, but sexual abuse in females carried a sixfold increased risk of cardiac disease compared to respective genders without CSA.⁵⁷ In the ACE Study, there was a significant dose-response relationship with the number of childhood abuse exposures and development of ischemic heart disease (P < .05)⁴⁵; the risk of coronary artery disease increased by 20% for each increase in ACE score.¹⁰⁹ Women with moderate and severe PTSD and a history including sexual, physical, or emotional abuse had increased odds for chest pain.⁵¹ PTSD associated with sexual abuse may enhance cardiac symptoms.

Increased cardiac risk factors and cardiac problems were identified in veterans with MST and with PTSD. Cardiac risk factors and symptoms were found more in female veterans with MST exposure, including hypertension, obesity, smoking, excessive alcohol use, and sedentary lifestyle.⁵⁹ Female veterans with MST reported more chest pain and heart problems, including heart attack within the last year, than those without MST.⁵³ Female veterans with PTSD, one-fourth with MST, were more likely to have documented cardiovascular diagnoses than those without.⁵⁵ Veteran women with PTSD, mainly related to MST, were at greater risk of hypertension compared to female veterans without PTSD,⁵⁴ and other female veterans with PTSD that included MST had a greater risk of stroke compared to veteran women without PTSD.⁵⁶

Arrhythmias

A biological response to abuse may increase the risk of arrhythmias in survivors where attribution of psychological disorders as a cause of arrhythmias in women occurs more often than in men. Paroxysmal supraventricular tachycardia was misdiagnosed as psychiatric problems in women more often than in men (P < .04), and symptoms previously attributed to panic disorder resolved after ablation in 86% of patients.¹¹⁰ Heart rate variability, a precursor to arrhythmia development, was significantly lower by time domain measures, the standard deviation of all normal sinus R-R intervals and the root mean square of the sum of differences between successive normal sinus R-R intervals (P < .001), in female veterans with MST exposure treated for cardiac complaints compared to contemporaries without MST history; veterans with MST were on average 10 years younger, and 80% had PTSD.¹¹¹ Additionally, female veterans with PTSD and rape-MST had lower heart rate variability than female veterans with PTSD associated with other traumas, including combat trauma.¹¹²

PREMATURE MORTALITY

Abuse, through the acute or chronic allostatic load compounded by age and health status, can result in the ultimate physical outcome of immediate or premature death. Almost 1800 child fatalities from abuse occurred in the US in 2009.¹¹³ Adults with a history of childhood abuse documented by an ACE score of 6 or more died in adulthood almost 20 years earlier than those without a history of exposure to abuses.⁴⁶ Risk for femicide increased if the abuser was unemployed, had access to a firearm, and used illicit drugs and also increased after the victim separated from an abuser.¹¹⁴

SUMMARY AND IMPLICATIONS

Sexual trauma is associated with diverse long-term physical, mental, and social health consequences that often manifest in clusters (eg, migraines, fibromyalgia, IBS, dysmenorrhea, and palpitations; mental health diagnoses; and behaviors that isolate the individual from their family and loved ones). A health care provider should use trauma-informed care principles with motivational interviewing by asking open-ended questions of patients presenting with multiple health issues, Tell me about your childhood... your adolescence... your relationships. The term abuse conjures a personal perception of the word, not only in the patient but also in the provider, so when asking about abuse histories, providers should avoid language like child abuse and rape. Rather, they should ask, Are you afraid of anyone? If asking about a history of rape or child abuse, providers should ask, Has anyone ever touched your private areas without your permission? If the answer is yes, then they should continue, Do you feel comfortable telling me about those times? Screening for IPV and other traumas with validated tools reveals specific traumas experienced in the life-trajectory of the patient. Again, health providers should ask about specific behaviors (ie, In your relationships, have you ever been hit, kicked pushed?). In order to be successful with the interview about traumatic life experiences, the environment must be safe and nonjudgmental. Questions about abuse should never be asked if the abuser may be present. Victim responses to intentional trauma are unique, and responses will vary. Some will not remember the abuse, while others will angrily deny it. Those who choose to share their abuse history with a knowledgeable and therapeutic health care provider often express a sense of release or peace upon disclosure and may even exhibit physical and emotional improvement at subsequent visits. The victim’s state of acceptance and the complex manifestations of stress in an individual across a life’s trajectory will help the thoughtful health care provider prioritize a plethora of treatments and recommendations to address the mental and physical health effects of sexual abuse.

PSYCHOLOGICAL CONSEQUENCES OF TRAUMA

EMOTIONAL FUNCTION

Changes in the HPA axis and repeated and chronic norepinephrine release from the stress response with prolonged childhood abuse can lead to sustained mental health disorders after childhood.⁹⁰ Table 1-4 shows a variety of mental health disorders associated with sexual abuse. Women who reported childhood physical, sexual, or physical and sexual abuse had significantly more hospitalizations for emotional or psychiatric problems (P < .001) than women without abuse.⁹³ Self-reported mental health problems were more significant (P = .001) in women with CSA compared to women who reported no abuse.⁷⁸ Women with a history of CSA reported significantly more mood swings, extreme anger, rage, trust issues, fear, terror, feelings of guilt, and lower self-esteem (P < .001).⁷⁶ Both genders with more than 4 ACEs were 3 times more likely to report emotional distress (ie, depressed effect, panic reaction, and anger) than those with no ACEs.¹¹⁵ The risk of having uncontrollable anger almost tripled in women with 3 or 4 ACEs.¹¹⁶ Adults had significantly lower mental health score if they came from abusive families and experienced a number of abuse types (ie, sexual, physical, witnessing maternal battering) (P < .03).¹¹⁷ The National Violence Against Women Survey revealed women who experienced sexual and physical assault by an intimate partner were over 3 times more likely to have a mental health disability than women without abuse.⁴⁸ Veterans of both genders with a history of MST had triple the odds of having a mental disorder compared to same-gender counterparts with no MST (P < .01 both).⁵⁰ However, female veterans reported more fear (P < .001), MST (P < .001), and severity of PTSD symptoms (P < .02) than male veterans.¹¹⁸ Whether experienced as a child or as an adult, sexual, physical, and emotional abuse deeply impact the mental and emotional health of men and women.

ANXIETY DISORDERS

Sexual abuse increases the risk for developing anxiety disorders throughout the life span. Having 4 or more ACEs more than doubled the risk of both genders reporting anxiety in adulthood.⁴⁷ In a large prospective study of Australian children, the trauma of CSA more than tripled the relative risk of anxiety in both genders equally (P < .001).¹²⁰ However, McCauley et al⁹³ found women who reported CSA had significantly more anxiety (P < .001). Contrastingly, a smaller study found men who experienced CSA had significantly more anxiety (P < .01) than women.¹³⁰ A study of twins found social anxiety was twice as likely for those with a history including CSA compared to those without CSA.¹¹⁹ Both veteran women and men with MST had over twice the odds of reportable anxiety disorders when compared to gender-matched veterans with no MST (P < .01 both).⁵⁰ Sexual abuse increases the risk of having anxiety disorders for both genders.

Table1-4Table1-4aTable1-4b

POSTTRAUMATIC STRESS DISORDER

Risk for lifetime PTSD is increased after sexual assault. Sexual abuse was highly significant (p < 0.001) in predicting PTSD symptoms, and risk for PTSD more than doubled in adults of both genders 20 years after CSA compared to those without CSA.¹²¹ Development of PTSD was associated with exposure to a greater number of traumatic events¹³¹ and female gender¹³² instead of familial or genetic vulnerability.³⁹ Meta-analysis of 3 decades of research supports that women had more childhood and adult sexual assault (P < .001) while men experienced more diverse types of trauma (P = .002), but gender differences in severity of PTSD were smallest when males also reported exposure to childhood or adult sexual abuse.¹³³

In addition to gender, the type or number of traumatic events encountered may influence development of PTSD. According to the National Comorbidity Survey, women with PTSD reported rape (29.9%) and molestation (19.1%) as the worst trauma types, while men with PTSD listed combat (28.8%) and seeing another harmed or killed (24.3%) as the most traumatic.⁹⁶ Women with PTSD reported a mean of 9.7 trauma exposures compared to 4.2 exposures in those without PTSD.¹³¹ In women with sexual assault and PTSD, re-experiencing symptoms were significantly predictive of the presence of physical symptoms and medical utilization (P < .001).⁶⁵ PTSD activation of fight-or-flight response is supported by exaggerated startle reflex, as well as with increased heart rate and eye blink in female sexual assault survivors with PTSD¹³⁴ and by increased urinary norepinephrine and epinephrine levels in hospitalized patients with PTSD compared to patients with other mental disorders.¹³⁵ Having PTSD more than doubled the risk of having a medical condition in civilians of both genders compared to corresponding genders without PTSD.⁵⁴

PTSD has been documented following diverse traumatic events encountered while in the military. Risk of PTSD in female veterans increased ninefold with MST, sevenfold with CSA, and more than fourfold with civilian adult sexual assault when compared to those without sexual assault history (P < .0001 all).¹²² MST significantly predicted development of PTSD (P = .001) in female veterans more than other traumas (P = .02).¹³⁶ Veteran women with MST had almost 12 times, and veteran men with MST had 4 times the odds of developing PTSD, when compared to their counterparts with no MST (P < .01 both).⁵⁰ Compared to controls, PTSD was about 6 times more likely with sexual assault in veterans of both genders, and a dose-response was exhibited with progression from no MST to harassment, to assault, to both forms of MST (P < .0001).¹²³ PTSD was significantly predictive of physical symptoms and health perception (P < .01) in female veterans, 60% of whom had a sexual assault history,⁶⁸ and female veterans with PTSD had more mental health problems (P < .001) than those without PTSD.⁶⁷ Female veterans had significantly higher PTSD scores (P < .01) than males; however, the degree of PTSD symptoms was predictive of health problems 2 years later in both genders (P < .001).⁹⁵ PTSD can contribute to development of comorbid physical and mental disorders.

PHOBIA AND PANIC DISORDERS

Sexual abuse in childhood contributes to risk of phobia and panic disorder. A small study of adults who experienced CSA reported men had significantly more phobic anxiety (P < .01) than women.¹³⁰ Women who reported severe CSA had 6 times the odds of having a phobia and almost 50 times increased risk for panic disorders than women with less severe or no abuse.⁵² Having 4 or more ACEs doubled the risk of panic reactions in both genders.⁴⁷ Female veterans with PTSD from trauma that included sexual abuse were more than 20 times more likely to have panic disorder than those without PTSD.⁵⁶ Having phobias or panic attacks is common in survivors of sexual assault; however, panic disorder may occur more frequently than social phobia.¹³⁷

DEPRESSION

Risk of depression increased fourfold in both genders with exposure to 4 or more ACEs,³ and an almost fourfold increase was consistent across 7 decades.³³ A significant dose relationship was evident between the number of ACEs and probability of lifetime depression and recent depression (P < .0001) in both genders.¹³⁸ Men who experienced CSA had more depression (P < .001) than women.¹³⁰ Homosexual and bisexual men reported double the risk of depression with CSA, triple with adult nonconsensual sex, and 6 times the risk with juvenile prostitution.¹²⁴ Women who reported childhood physical, sexual, or physical and sexual abuse had significantly more depression (P < .001) than women without abuse.⁹³ Women with a history of CSA had significantly more health care visits for feeling depressed (P < .001),⁷⁶ and women with severe CSA had greater odds of lifetime major depression than women with less severe or no abuse.⁵² According to data from the National Violence Against Women Survey, women who experienced systematic IPV, one-fourth of whom had sexual abuse, were 3 times as likely to have depression and take an antidepressant.⁴⁸ Women exposed to IPV sexual abuse had double the risk for depression and triple the risk for severe depression compared to women with no history of IPV.⁴⁹ Depression is common among survivors of sexual abuse.

Depression can also occur in veterans who were sexually abused. Women with military sexual assault were 3 times more likely to report current depression than women without MST,¹²⁵ and both genders with MST, harassment or assault, had more than twice the odds of having depressive disorders when compared to gender-matched veterans with no MST (P < .01 both).⁵⁰ Odds of depression doubled with sexual harassment but increased almost fivefold for both male and female reservists who experienced sexual assault.⁴¹ Major depression was almost 19 times more likely in female veterans with PTSD, from traumas that included sexual assault, compared to women without PTSD.⁵⁶ Depression occurs frequently with MST and has been reported as high as 89% in female veterans.¹¹¹

DISASSOCIATION

Younger age¹³⁹ and threat to life at time of sexual assault¹⁴⁰ have been suggested as predictors of disassociation. Preteen girls who experienced CSA were 8 times more likely to have disassociation and almost 4 times more likely to have PTSD.¹²⁷ Adults who experienced attempted or actual rape in childhood were 4 times more likely to have dissociation than those without history of CSA, and those with dissociation were 5 times more likely to have an anxiety disorder and almost 8 times more likely to have PTSD.¹²⁶ Veteran women with MST had 7 times the risk, and veteran men with MST had almost 6 times the risk of dissociative disorders compared to corresponding gender veterans with no MST (P < .01 both).⁵⁰

SOMATIZATION

Somatization is the physical manifestation of psychological distress through multiple pain, GI, sexual, and neurological or dissociative symptoms.¹⁴¹ The risk of having 6 or more somatic symptoms involving at least 2 different organ systems more than doubled with 4 or more ACEs (P < .001).⁴⁷ Women who reported severe CSA had greater odds of somatization than women with less severe or no abuse.⁵² Women who reported childhood physical, sexual, or both physical and sexual abuse had 3 times more somatization (P < .001) than women with no abuse.⁹³ Female and male veterans with MST had more than double the risk of somatoform disorder and the risk of psychogenic disorders when compared to corresponding gender veterans with no MST (P < .01 both).⁵⁰ Women treated at a VA medical center with PTSD from trauma that included sexual abuse were more than 5 times as likely to exhibit somatization than those without PTSD.⁵⁶

PERSONALITY DISORDER

Childhood sexual or physical abuse and neglect increased the odds sixfold for early adulthood personality disorder.¹²⁸ Veteran women with MST had almost 5 times and veteran men with MST had almost 6 times the odds of having personality disorders when compared to their counterparts with no MST (P < .01 both).⁵⁰ Comparing men and women with borderline personality disorder who had no significant difference in rates of childhood physical and sexual abuse, women had significantly more PTSD, eating disorders, and substance abuse disorders, while men had significantly more schizotypal, narcissistic, and antisocial disorders (p ≤ 0.005 all).¹⁴² PTSD was almost 3 times as likely and substance abuse 4 times more likely to occur in patients with borderline personality disorder compared to patients with another axis II disorder.¹⁴³

SCHIZOPHRENIA AND PSYCHOSES

Childhood sexual abuse more than doubled the risk for psychosis and the risk for schizophrenia in both genders.¹²⁹ Having 4 or more ACEs increase the risk of hallucinations in adults of both genders.⁴⁷ Female gender doubled and male gender tripled the risk of schizophrenia and psychoses in veterans with MST compared to corresponding gender veterans with no MST (P < .01 both).⁵⁰

BIPOLAR DISORDER

History of childhood physical and sexual assault was significantly associated with development of bipolar disorder (P < .001), earlier onset of bipolar symptoms (P < .001), increased severity of mania (P = .002), and faster cycling frequency (P = .03) in both genders.¹⁴⁴ Adult males and females with a history of childhood sexual abuse and subsequent bipolar disorder were 3 times more likely to commit suicide¹⁴⁵ and had significantly more use of drugs (P ≥ .001) and alcohol (P = .02) than those without childhood abuse.¹⁴⁴ Female veterans with MST had 3 times and male veterans with MST had 4 times the risk of bipolar disorder when compared to female veterans with no MST (P < .01 both).⁵⁰ Like many other mental disorders associated with sexual trauma, bipolar disorder is often connected with negative behavioral consequences.

SUMMARY AND IMPLICATIONS

Psychological consequences of sexual trauma can be diverse and longstanding. The most common psychological consequence of trauma, PTSD, may occur alone or coexist with numerous other psychological disorders, making treatment more complex. Preventive benefits of counseling should be shared with sexual assault victims. Early intervention following rape may avert some of the long-term psychological consequences; however, sexual abuse may not be reported for several years after the event. The health care provider has a responsibility to offer referral for counseling as soon as sexual trauma is disclosed.

BEHAVIORAL CONSEQUENCES OF TRAUMA

Trauma victims who have not recovered psychologically tend to exhibit risky behaviors and enter similar traumatic situations unconsciously in a futile attempt to change the outcome through a process called reenactments or repetition compulsions.¹⁴⁶ Table 1-5 provides evidence of increased negative behavioral consequences associated with sexual abuse. Attempts to temporarily numb the lingering emotional pain of sexual abuse through use of illicit drugs, alcohol, or risky sexual behavior is often passed from one generation to the next.¹⁴⁷

SUBSTANCE ABUSE

Many sexual trauma victims choose to numb the painful memory of abuse until they are addicted or incarcerated or both.⁹⁹ Smoking almost doubled, alcoholism increased sevenfold, and illicit drug use quadrupled with a score of 4 or more ACEs in both genders.⁴⁷ Increased risk of substance abuse with childhood trauma remained consistent across age groups spanning 7 decades.³³,¹⁴⁹ Adults with 3 ACEs were 3 times more likely to begin smoking early in life and were twice as likely to be current smokers and smoke 2 packs per day.¹⁴⁸ History of abuse documented by any ACE significantly increased the risk of adult alcoholism (P < .05) for both men and women (P < .0001).¹⁵⁶ Risk of alcohol abuse was increased in homosexual and bisexual men who had a history of CSA, juvenile prostitution, and adult nonconsensual sex.¹²⁴ Females with childhood physical and sexual abuse were more than twice as likely to have a past and current history of alcohol and street drug abuse (P < .001 all).⁹³ Women with a history of CSA reported significantly more heavy drinking (P < .01)⁷⁶ and had 6 times the odds of using illicit drugs.⁵² Severe IPV, that included sexual abuse of one-fourth of the women, doubled the risk for alcohol or street drugs and for use of prescription tranquilizers, sleeping pills, sedatives, antidepressants, and pain pills.⁴⁸ Adults of both genders with 5 or more ACEs were 7 times more likely to report drug addiction and 10 times more likely to use intravenous (IV) drugs.¹⁴⁹ Seeking temporary relief from the pain of sexual abuse through use of alcohol and drugs is common in both genders. Drug courts across the US were created to address the association of substance addiction with increased crime in these vulnerable populations.⁹⁹

Table1-5Table1-5aTable1-5bTable1-5c

Tendency toward substance abuse is also found in veterans of both genders with sexual trauma or PTSD. Female veterans with MST were almost twice as likely to be current smokers, have a history of problems with alcohol,⁵⁹ and report current alcohol abuse compared to those without MST exposure.¹²⁵ Dobie et al⁵⁶ found women with MST had about two-thirds greater risk of alcohol problems; however, Kimerling et al⁵⁰ found female veterans with MST had 3 times the risk of alcohol abuse and drug abuse, and male MST survivors had over twice the risk of alcohol abuse and triple the risk of drug abuse compared to matched-gender veterans without MST (P < .01). Women seen at a VA with PTSD, some of whom reported sexual assault, had twice the risk of smoking and triple the risk of using drugs compared to women without PTSD.⁵⁶ Even though sexual assault was on average 16 years earlier, MST continued to have significant impact on the lives of female veterans admitted for PTSD treatment,