Childhood sexual abuse (CSA)
How does childhood sexual abuse affect HIV prevention?
What is childhood sexual abuse?Childhood sexual abuse may be defined in many ways, but this fact sheet refers to unwanted sexual body contact prior to age 18, the age of consent to engage in sex. CSA is a painful experience on many levels that can have a profound and devastating effect on later physiological, psychosocial and emotional development. CSA experiences can vary with respect to duration (multiple experiences with the same perpetrator), degree of force/coercion or degree of physical intrusion (from fondling to digital penetration to attempted or completed oral, anal or vaginal sex). The identity of the perpetrator–ranging from a stranger to a trusted figure or family member–may also impact the long-term consequences for individuals. To distinguish CSA from exploratory sexual experimentation, the contact should be unwanted/coerced or there should be a clear power difference between the victim and perpetrator, often defined as the perpetrator being at least 5 years older than the victim. Many more children are sexually abused than are reported to authorities.1 Estimates of the prevalence of CSA in the US are about 33% for females under the age of 18 and 10% in males under 18 years of age.2 Men are significantly less likely than women to report CSA when it occurs.3 CSA is more likely to occur in families under duress. Children are at risk for CSA in families that experience stress, poverty, violence and substance abuse and whose parents and relatives have histories of CSA.
Does CSA affect HIV risk?Yes. Because childhood and early adolescence are critical times in a person’s sexual, social and personal development, CSA can distort survivors’ physical, mental and sexual images of themselves. These distortions, combined with coping mechanisms adopted to offset the trauma of CSA, can lead CSA survivors into high-risk sexual and drug-using behaviors that increase the likelihood of HIV infection.4 Persons who experience CSA may feel powerless over their sexuality and sexual communication and decision-making as adults because they were not given the opportunity to make their own decisions about their sexuality as children or adolescents. As a result, they may engage in more high-risk sexual behavior, be unable to refuse sexually aggressive partners and have less sexual satisfaction in relationships. CSA survivors may have difficulties forming attachments and long term relationships and may dissociate from their feelings, resulting in having multiple sexual partners, “one night stands” and short-term sexual relationships. Adults who perceive positive aspects of their own CSA (such as gaining attention) may also use sex as a soothing or comforting strategy, which can lead to promiscuity and compulsive sexual patterns.5 The effects of CSA may be different for adult men and women. Female survivors of CSA may have lower condom self-efficacy with partners, use condoms less frequently, exhibit more sexual passivity and attract or be attracted to overly controlling partners.6 Male survivors of CSA may experience higher levels of eroticism, exhibit aggressive, hostile behavior and victimize others.7 Adults with CSA histories may use dissociation and other coping efforts to avoid negative thoughts, emotions and memories associated with the abuse. One of the most common dissociation methods is alcohol and drug abuse. A study of men and women with a history of substance abuse found that 34% had experienced CSA. CSA survivors with substance abuse problems were more likely than substance abusers who had not experienced CSA to exchange sex for money or drugs, have an HIV+ or high-risk partner and not use condoms.8 Sexual revictimization can also influence high-risk sexual behavior. One study of African American and white women found that CSA survivors who experience revictimization as adults had more unintended pregnancies, abortions, STDs and high-risk sexual behaviors than those who experienced only CSA.9
What’s being done?There are many resources for CSA survivors, but few programs exist to reduce HIV-related sexual and drug-using risk behaviors and increase psychological well being. Most of these programs focus on women; there are even fewer programs for male CSA survivors. Good-Touch/Bad-Touch is a comprehensive child abuse prevention intervention designed for pre-school and kindergarten through sixth grade students. The program uses a variety of materials to teach children prevention skills including personal body safety rules, what abuse is and what action to take if threatened.10 The Children’s Medical Center in Dallas, TX, provides HIV/STD prevention for young female sexual abuse victims at a child abuse clinic. Adolescent females between 12 and 16 years old receive one-on-one evaluation and personalized education from an adolescent-focused HIV/STD counselor. Providing sensitive counseling close to the time of recognition of abuse can be a good method for prevention education.11 At Stanford University, CA, a trauma-focused group therapy intervention seeks to reduce HIV risk behavior and revictimization among adult women survivors of CSA. The groups focus on survivors’ memories of CSA to see if this helps increase safer behaviors and reduce stress. The women also receive case management.12 The Visiting Nurse Service of New York offers comprehensive in-home services to HIV-infected families. The children in these families are at high risk for repeating the histories and behaviors of their parents, including HIV infection, substance abuse, sexual abuse and mental illness. The program provides home-based interventions that include play therapy, health and safe sex education, family and individual counseling, relapse prevention for the parent and drug awareness and prevention for the children. Helping the child deal with anger and resentment towards the parent lessens the likelihood that their anger will be displaced on themselves, thus repeating the behavior of the parent. Supporting each family member is key to breaking the cycle of HIV and abuse in these families.13 At the University of California, Los Angeles, and King-Drew University, CA, a psychoeducational intervention aims to increase healthy behavior and decrease HIV risk behaviors in HIV+ women with histories of CSA. Women are taught communication and problem-solving tools and link CSA experiences to past and current areas of risk.14
What needs to be done?Although dealing with CSA may seem like a daunting task for many HIV prevention programs, there are a variety of usable approaches to address CSA in adults. Programs can: include questions on abuse during routine client screening, reassess clients over time, provide basic education on the effects of CSA and offer referrals for substance abuse and mental health services. Program staff need basic training and support to help cope with the effects of CSA counseling and the relative high prevalence in certain populations.15 Persons who are likely to interact with CSA survivors such as medical and other health professionals, religious and peer counselors, including alcohol, substance abuse and rape counselors, and probation officers need to be educated on the effects of CSA on sexual and drug risk behaviors. They also need training on how to recognize symptoms of CSA and how to address these issues or provide appropriate referrals for treatment. Professionals should look beyond CSA symptoms and inquire about other childhood experiences that may have been problematic. CSA survivors often are forced to contend with other types of abuse and a dysfunctional family environment. A poor family environment may set the tone for abuse to occur and leave the survivor with little support to cope with the experience.
Says who?1. Green AH. Overview of child sexual abuse. In SJ Kaplan (ed.), Family violence: A clinical and legal guide. Washington, DC: American Psychiatric Press. 1996;73-104. 2. Finkelhor D. The international epidemiology of child sexual abuse. Child Abuse & Neglect. 1994;18:409-417. 3. Roesler TA, McKenzie N. Effects of childhood trauma on psychological functioning in adults sexually abused as children. Journal of Nervous and Mental Disease. 1994;182:145-150. 4. Prillo KM, Freeman RC, Collier C, et al. Association between early sexual abuse and adult HIV-risky behaviors among community-recruited women. Child Abuse & Neglect. 2001;25:335-346. 5. Paul, J. Understanding childhood sexual abuse as a predictor of sexual risk-taking among men who have sex with men: The Urban Men’s Health Study. Child Abuse & Neglect. 2001;125:557-584. 6. Watkins B, Bentovim A. The sexual abuse of male children and adolescents: a review of current research. Journal of Child Psychology & Psychiatry & Allied Disciplines. 1992;33:197–248. 7. Wyatt GE, Guthrie D, Notgrass CM. Differential effects of women’s child sexual abuse and subsequent revictimization. Journal of Consulting and Clinical Psychology. 1992;60:167-173. 8. Morrill AC, Kasten L, Urato M, et al. Abuse, addiction and depression as pathways to sexual risk in women and men with a history of substance use. Journal of Substance Abuse. 2001;13:169-184. 9. Wyatt GE, Myers HF, Williams JK, et al. Does a history of trauma contribute to HIV risk for women of color? Implications for prevention and policy. American Journal of Public Health. 2002;92:1-7. 10. Harvey P, Forehand R, Brown C, et al. The prevention of sexual abuse: Examination of the effectiveness of a program with kindergarten-age children. Behavior Therapy. 1988;19:429-435. 11. Squires J, Persaud DI, Graper JK. HIV and STD prevention counseling for adolescent girls seen in a child abuse clinic. Presented at the 14th International AIDS Conference, Barcelona, Spain. 2002. Abst # TuPeF5249. 12. Group Interventions to Prevent HIV in High Risk Women.www.med.stanford.edu/school/ Psychiatry/PSTreatLab/TraumaStudy.php 13. Mills R, Samuels KD, Bob-Semple N, et al. Breakin the cycle: multigenerational dysfunction in families affected with HIV/AIDS. Presented at the 14th International AIDS Conference, Barcelona, Spain. 2002. Abst #. ThPeE7828. 14. Wyatt GE, Myers H, Longshore D, et al. Examining the effects of trauma on HIV risk reduction: the women’s health intervention. Presented at the International Conference on AIDS, Barcelona, Spain. 2002. Abst# WePeF6853. 15. Paul JP. Coerced childhood sexual episodes and adult HIV prevention. FOCUS. 2003;18:1-4
Prepared by Gail Wyatt PhD, Tamra Loeb PhD, Inna Rivkin PhD, Jennifer Carmona PhD, Dorothy Chin PhD, John Williams MD, Hector Myers PhD, Douglas Longshore PhD and Charlotte Sykora PhD UCLA Women’s Health Project September 2003. Fact Sheet #52E Special thanks to the following reviewers of this Fact Sheet: Ruth Kelley, Jay Paul, Elizabeth Radhert.
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