FOSTERING RESILIENCE IN SURVIVORS OF CHILD SEXUAL ABUSE TO DECREASE VULNERABILITY TO SEXUAL REVICTIMIZATION

Joy Lo, MD, FAAP

FOSTERING RESILIENCE IN SURVIVORS OF CHILD SEXUAL ABUSE TO DECREASE VULNERABILITY TO SEXUAL REVICTIMIZATION  

Joy Lo, MD 

Abstract: Child Sexual Abuse (CSA) is an enormous public health issue worldwide, affecting health outcomes in millions, and the United States is not immune. One significant sequela of CSA is increased vulnerability for sexual revictimization. Each CSA survivor has varying factors that affect their own risks for revictimization, and significant attempts to lower such risks must take into account their complexity. This author seeks to foster resilience in survivors of CSA, utilizing strengths and positive factors which are already part of the survivor as well as those who surround them, and by enhancing or teaching factors of resilience, to decrease sexual revictimization.  

Introduction  

The World Health Organization in 1999 defined child sexual abuse as:  

the involvement of a child in 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, or that violate the laws or social taboos of society. Child sexual abuse is evidenced by this activity between a child and an adult or another child who by age or development is in a relationship of responsibility, trust, or power, the activity being intended to gratify or satisfy the needs of the other person. (p. 15-16)  

Child sexual abuse (CSA) is not a new problem, nor is it likely to disappear any time soon. It occurs in all countries and cultures, and the true prevalence of CSA is likely underrepresented because of the secrecy in which it is enshrouded (Hinton 2019; Lalor & McElvaney, 2010). How have we, as a society, progressed in identification of children individuals who are susceptible and victimized, and how do we care for them? CSA is an enormous public health problem as it affects a significant portion of our children, who often suffer short and long-term emotional, psychological, and physical health issues.  

In the United States, it is estimated that the lifetime prevalence of sexual abuse or assault through the age of 17 years old is 26.6% for girls and 5.1% for boys (Finkelhor et al., 2014). The CDC further estimates that the cost of CSA in the United States in 2015 was $9.3 billion (CDC, 2021). The United States’ National Child Abuse and Neglect Data System (NCANDS) reveals that in 2019, 650,000 victims of child abuse and neglect were reported in the U.S., with 9.3% reported to have experienced CSA. Data was also collected on child sex trafficking victims (up to age 24 years old), and the results revealed of the children who experienced more than one maltreatment type (physical abuse, sexual abuse, neglect, or sex trafficking), 30.7% of female children and 28% of male children who experienced sex trafficking also had a history of CSA (Child Maltreatment, 2019).  

Sequelae of Child Sexual Abuse  

The literature reveals a host of negative outcomes for victims and survivors of CSA, including increased risk for severe mental, physical, and behavioral health problems (Letourneau and Shields, 2016). There is a wealth of data outlining the multiple short- and long-term sequelae of CSA, including anxiety, depression, post-traumatic stress disorder (PTSD), substance use, and suicide attempts (Brier and Elliot, 2003; Hinton, 2019; Lalor & McElvaney, 2010; Letourneau & Shields, 2016). In addition, CSA and physical abuse often result in low self-esteem, anger and aggression, and elevated risk- taking behavior (Briere & Elliott 2003; Letourneau & Shields, 2016). Survivors of CSA are also documented as suffering guilt, shame, fear, helplessness, and grief. They may suffer from feelings of isolation, stigmatization, and negative self-image (Hinton, 2019). Some of these effects may be short-term, but many extend into or worsen in adulthood, often inducing difficulties with relationships, parenting, and sexual functioning (Hinton, 2019; Lalor & McElvaney, 2010). Survivors of CSA are more likely to experience drug and alcohol misuse and participate in self-harm or self- destructive behavior (Lalor & McElvaney, 2010).  

An effect of CSA that is unique, compared to other experiences of childhood trauma, is sexualized behavior that is inappropriate for a child’s developmental age (Cole et al., 2016; Finkelhor & Berliner, 1995). CSA may also lead to high-risk sexual behaviors, such as multiple partners, earlier onset consensual sex, casual sex, changing partners frequently, and group sex (Lalor & McElvaney, 2010). These high-risk sexual behaviors may lead to sexual exploitation and prostitution, multiple STI, teen pregnancy, and increased vulnerability to sexual assault later in life (Lalor & McElvaney, 2010, Cole et al., 2016; Hyman & Williams, 2001). It is because of these specific sequelae of CSA that survivors have a high risk of sexual revictimization.  

According to the CDC (2021), survivors of CSA are two to three times more likely to experience sexual revictimization in adulthood, and two times more likely to experience sexual interpersonal partner violence. Sexual revictimization may include interpersonal violence, sexual assault, pornography, and commercial sexual exploitation. Lalor and McElvaney (2010) found that sexual revictimization in adolescence is associated with being 13.7 times more likely to experience sexual assault as an adult, and those with a history of CSA are 3.5 times more likely to report sexual violence by a non-partner in their lifetime. The more severe the CSA, and with the addition of physical abuse, the higher the risk for sexual revictimization (Hyman & Williams, 2001; Lalor & McElvaney, 2010).  

Ogloff, et al. (2012), also noted an increased risk for subsequent sexual and non- sexual victimization and perpetration among victims of CSA. It is estimated that greater than 90% of children who experience sex trafficking have a history of sexual abuse (Darkness to Light, n.d.). Studies show that a majority of females who are sexually exploited have a history of CSA, especially experiences with more severe abuse, longer duration of abuse, and having experienced CSA at an earlier age (Cole et al., 2016; Lalor & McElvaney, 2010). Lalor & McElvaney (2010), state that 63% of women who had experienced CSA before the age of 14 also experienced rape or attempted rape after 14 years of age, compared with 35% of women with no history of CSA. Breaking the cycle of revictimization is a necessary goal in our treatment of victims of CSA.  

Resilience and Child Sexual Abuse  

However, not all individuals who experience CSA are destined to a lifetime of difficulty. Hinton (2019) states that 40% of those who experience CSA have pathology enough to require therapy in adulthood; but many continue with their lives without significant pathology and live successful lives. It is estimated that 21% to 49% of children who experienced CSA have no short-term effects (Hyman & Williams, 2001; Lalor & McElvaney, 2010). What makes these children different? What makes them able to bounce back, be resilient, resist negative outcomes, and even thrive?  

Several studies have been conducted on resilience and survivors of CSA. Definitions regarding resilience in children who have experienced CSA vary somewhat in the literature, but overall concentrate on strengths-based, positive coping skills in the face of adversity, which is often chronic (Berry-Fletcher, 2013; Gilligan et al., 2014; Hinton, 2019). It is seen as a dynamic process which can be taught, learned, and nurtured (Hinton, 2019; Hyman & Williams 2001). Some definitions of resilience range from being able to competently function in society and lack psychopathology (Domhardt et al., 2015; Hyman & Williams, 2001), while others are more expansive, positing that resilience in such children reflect not only the ability to cope within adversity, but an ability to respond more positively in future stresses, or even thrive despite adversity (Gilligan, et al., 2014; Hinton, 2019). Domhardt et al., (2015) summarize in their review that the 10%-53% of adolescent and adult survivors of CSA show signs of resilience.  

One area that requires more data is resilience in those who experience CSA and seem to have no short-term sequelae, but are triggered in later years, resulting in negative health outcomes. In reviewing the literature, resilience factors can be divided into individual factors, family factors, and community factors (Domhardt et al., 2015; Berry-Fletcher, 2013; Hinton, 2019; Wilcox et al., 2004).  

Individual Factors  

In regard to personal or individual factors, Berry-Fletcher (2013) emphasizes the importance of the developmental stage of the child when the abuse begins and occurs; the more immature a child is in terms of emotional, social, and physical development, the more susceptible the child is to negative impacts from the abuse. While maturity can correlate to chronologic age, it also takes into account individual variability as well as children with disabilities. Berry-Fletcher (2013) states that “children who have had more opportunities to accomplish as many normative developmental tasks as possible are better equipped to manage stress or trauma” (p. 7). Individual or internal factors promoting resilience may include optimism and hope, a sense of self-efficacy, problem- focused coping skills, the ability to externalize the blame of the abuse on the perpetrator, a sense of self-empowerment, higher educational ability, higher emotional intelligence and ability to connect with others, a more secure attachment with one’s family, and spiritual or religious beliefs (Domhardt et al., 2015; Gilligan et al., 2014; Hinton, 2019; Wilcox et al., 2004).  

Some describe resilient CSA survivors to have the qualities of being outgoing and social, possessing certain talents, and the ability to engage in supportive resources (Hinton, 2019). Doing well in school and intelligence are also positively correlated with resilience (Hinton, 2019; Wilcox et al., 2004). In addition, not being arrested, and less deviant or law-breaking activity was found to be associated with resilience in children and adults with a history of CSA. Participation in sports or other activities was shown to be protective (Domhardt et al., 2015). Less aggressive coping skills, less dissociation is also positively correlated with resilience (Lalor & McElvaney, 2010; Spaccarelli & Kim, 1995; Wilcox et al., 2004). Hyman and Williams (2001) also discuss more altruistic behavior in resilient children, such as when they protect their siblings or schoolmates.  

Family Factors  

Family factors understandably have a large impact on how a child experiences sexual abuse, positively and negatively. The closeness of relationship between victim and perpetrator is important (Spaccarelli & Kim, 1995). Ninety percent of CSA victims know their perpetrators and 30% are abused by a family member (Darkness to Light, n.d.). Early emotional support, caring and concern from parents or caregivers are positively correlated with resilience (Domhardt et al., 2015; Lalor & McElvaney, 2010; Spaccarelli & Kim, 1995).  

A stable household with structure, two biological parents and positive parenting, as well as emotional bonds between child and father or mother are protective (Domhardt, et al., 2015). Higher level of caregiver education as well as high expectations from a caring parent have also been predictive of resilience in victims of CSA, and higher SES additionally seems to correlate with more resilience (Domhardt, et al., 2015; Hinton, 2019). On the other hand, disrupted households, instability, frequent moving, substance and alcohol use at home, physical punishment, poor parental attachment, and parental separation can all be negatively correlated with poor outcomes after CSA (Lalor & McElvaney, 2010). A crucial factor is how the parental figures react to the disclosure of abuse; if a child is not believed or listened to regarding CSA, it can cause long term harm (Berry-Fletcher, 2013; Spaccarelli & Kim, 1995; Wilcox et al., 2004). Hyman and Williams (2001) described three characteristics of a family which positively influence resilience: absence of severe physical abuse, stable family, and absence of substance use.  

Community Factors  

Community and environmental factors that may promote resilience include belonging to organizations, participating in sports, and attending school (Domhardt, et al., 2015; Hinton, 2019; Hyman & Williams, 2001; Spaccarelli & Kim, 1995; Wilcox et al., 2004). These offer a sense of belonging, shared experiences, being a part of something larger than oneself, support, a sense of purpose, responsibility, and emotional and physical expression (Hinton, 2019). Having the ability to contribute skills and talents to one’s community fosters resilience and helps one heal. Positive peer relationships and adult relationships outside the family, such as teachers or healthcare professionals, aid in resilience after CSA (Domhardt et al., 2015; Hyman & Wiliams, 2001; Spaccarelli & Kim, 1995; Wilcox, 2004). Hyman and Williams (2001) state that the latter allow the child to believe they are worthy to be loved. These factors may prevent social isolation, thus facilitating the child’s healing process and resilience, and lowering the risk for future revictimization.  

Summary  

The factors found to be most important to outcomes in CSA are severity of abuse, duration of abuse, use of physical force or violence, and not being believed or supported by significant people in the child’s life (Domhardt et al., 2015; Berry-Fletcher, 2013; Lalor & McElvaney, 2010; Spaccarelli & Kim, 1995; Wilcox et al., 2004). Hyman and Williams (2001) present key variables predicting resilience – stable family, no incest, no physical force with the sexual abuse, not being arrested as juvenile, and graduation from high school. Domhardt et al. (2015), state in their review the strongest individual protective factor is education—the ability of the child to engage in and have a positive attitude toward school. Other strong protective factors were the ability to have emotional competence and interpersonal relationships (Domhardt et al., 2015).  

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